Inverse relationship between body mass index and mortality in older nursing home residents: a meta‐analysis of 19,538 elderly subjects

Body mass index (BMI) and mortality in old adults from the general population have been related in a U‐shaped or J‐shaped curve. However, limited information is available for elderly nursing home populations, particularly about specific cause of death. A systematic PubMed/EMBASE/CINAHL/SCOPUS search until 31 May 2014 without language restrictions was conducted. As no published study reported mortality in standard BMI groups (<18.5, 18.5–24.9, 25–29.9, ≥30 kg/m²), the most adjusted hazard ratios (HRs) according to a pre‐defined list of covariates were obtained from authors and pooled by random‐effect model across each BMI category. Out of 342 hits, 20 studies including 19,538 older nursing home residents with 5,223 deaths during a median of 2 years of follow‐up were meta‐analysed. Compared with normal weight, all‐cause mortality HRs were 1.41 (95% CI = 1.26–1.58) for underweight, 0.85 (95% CI = 0.73–0.99) for overweight and 0.74 (95% CI = 0.57–0.96) for obesity. Underweight was a risk factor for higher mortality caused by infections (HR = 1.65 [95% CI = 1.13–2.40]). RR results corroborated primary HR results, with additionally lower infection‐related mortality in overweight and obese than in normal‐weight individuals. Like in the general population, underweight is a risk factor for mortality in old nursing home residents. However, uniquely, not only overweight but also obesity is protective, which has relevant nutritional goal implications in this population/setting.     

Older people's mortality index: Development of a practical model for prediction of mortality in nursing homes (Kahrizak Elderly Study)

Aims: In the elderly, mortality prediction models are important for clinical decision‐making and planning of services required. Methods: A total of 247 Kahrizak Charity Foundation (KCF) residents aged ≥65 years were followed up for approximately 39 months. At the baseline, the questionnaires of Barthel Index (BI), Mini‐Mental State Examination, Geriatric Depression Scale, Mini Nutritional Assessment and Norton Index was given. Medical history was recorded and anthropometric values were also measured at the baseline. Fasting blood samples were collected at baseline. Mortality and its causes were recorded during the study. Results: A total of 30% (74) of participants died during the study. The variables that had a significant association with mortality in the Cox regression hazard model were entered into the principal components analysis (PCA). The older people's mortality index (OPMI) was developed by four variables extracted from PCA, including BI, age, hemoglobin and mid‐arm circumference. Cut‐points of these components were calculated using ROC curve analysis. Based on neural network analysis, there was no significant difference in relative importance of OPMI components. OPMI was correlated to mortality (r = ?0.351, P = 0.000) and survival (r = ?0.355, P = 0.000). OPMI score was defined as the number of adverse predictors present. An increasing hazard ratio for mortality was observed from scores 1 to 4 (2.10, 4.56, 7.12 and 13.85, respectively). Conclusion: Our suggested model could predict mortality in KCF residents well. The new developed model could be a practical, easy and non‐expensive index for mortality prediction in elderly care facilities. Geriatr Gerontol Int 2012; 12: 36–45.     

Australia's use of the Cornell scale to screen for depression in nursing homes

Aim: To examine the utility of the Cornell scale for depression in dementia (CSDD), following its introduction as a routine measure in nursing homes. Methods: The CSDD is administered in Australian nursing homes as section 10 of the Aged Care Funding Instrument. CSDD, cognitive and behavioural ratings, and medication use, recorded in three Sydney nursing homes in 2008–2009 were reviewed. Staff discussed what actions were taken if CSDD scores indicated depression. Results: Of 223 residents, 23% scored >12 on the CSDD, indicating probable depression. Another 21% were possibly depressed and 29% not depressed. The CSDD had not been completed for 27%, commonly because preliminary screening indicated no depression, but sometimes because severe cognitive impairment made various CSDD items impossible to rate. Second CSDD assessments had usually not been made. Conclusion: Nursing homes need to document policies that will ensure best use is made of CSDD findings.     

Body mass index (BMI), body composition and mortality of nursing home elderly residents

The body mass index (BMI) is a key marker of nutritional status among older patients, but does not reflect changes in body composition, The aim of the present study was to investigate BMI levels and body composition in a sample of disabled nursing home residents, and to study possible interrelations between BMI, fat-free body mass (FFM), body fat mass (BFM), skeletal muscle mass (SMM) and 1-year mortality rates. FFM and SMM were assessed by 24-h urine creatinine excretion and BFM as the difference between BMI and FFM. We calculated relative risk (RR) and odds ratio (OR) of 1-year mortality, associated with different levels of BMI, FFM index (where index = value/height²), SMM index and BFM index in 82 disabled institutionalized elderly patients. One-year mortality rate was 29.3%. Adjusted relative risk of mortality of low BMI patients was 1.45 (95% CI = 0.73-2.89; OR = 1.73) and 0.63 (95% CI = 0.33-1.60; OR = 0.72) in high BMI. Risk of mortality was higher in those having low FMM index or SMM index (RR = 2.42, 95% CI = 0.36-16.18; OR = 2.55 and RR = 3.22, 95% CI = 0.78-13.32; OR = 3.67, respectively). It is concluded that low FFM and SMM indexes among disabled nursing home residents are far better predictors than BMI for 1-year mortality estimation.     

Retention and survival of hostel residents – a 12 year study

Abstract Background: The admission of a proportion of disabled people to hostels is inevitably followed by their transfer to nursing homes. Our hypothesis was that such admissions are justified in terms of quality of life and the cost to the community, notwithstanding the necessity of subsequent transfer. Aims: To test this hypothesis by measuring the retention and survival times of residents in hostel and in nursing home; to consider the relevance of these factors to the future policy of the two institutions. Methods: A retrospective study was made of 159 residents admitted over a period of 12 years to a hostel with 32 places. Times spent in the hostel and in the nursing home were recorded. Probabilities of survival in hostel and in nursing home were calculated according to the Kaplan-Meier method. Comparison with the expected survival of a matched cohort of the total population was determined. Estimation was made, using the SAS software package, of the likely number of places needed in nursing homes for residents following transfer. Results: Although the majority of hostel residents eventually needed nursing home care, a worthwhile proportion of their total institutional time (approximately two-thirds) was spent in the hostel. Ongoing support from the personnel in a geriatric service is likely to increase retention time in the hostel. Because of the ultimate outcome for the majority of residents, planning for hostel care should include consideration of places needed in nursing homes.     

Inpatient multidisciplinary rehabilitation after hip fracture for residents of nursing homes: A randomised trial

Objective: To determine the effectiveness of interdisciplinary rehabilitation for women with hip fracture who were residents of nursing homes. Design: Randomised controlled trial. Subjects: Eleven cognitively impaired women with hip fracture who were previously ambulant. Methods: Participants were randomly allocated to usual care (discharge back to the nursing home soon after surgery to the hip fracture) or an inpatient interdisciplinary rehabilitation program. Results: Participants were severely cognitively impaired and the majority used a walking aid prior to fracturing their hip. There was one early death, and at final follow up (4 months after hip fracture) median (range) Barthel Index was 28 (0–82) for control group and 68 (0–88) for the intervention group. Conclusion: No definite conclusion can be drawn about the effectiveness of the intervention because of its premature termination. However, the study established that it is feasible to provide an interdisciplinary rehabilitation for older people with hip fracture and severe disablement.     

Nursing assistants' use of best practices and pain in older adults living in nursing homes

Background

Inadequate pain management persists in nursing homes. Nursing assistants provide the most direct care in nursing homes, and significantly improving the quality of care requires their adoption of best care practices informed by the best available evidence. We assessed the association between nursing assistants' use of best practices and residents' pain levels.

Methods

We performed a cross-sectional analysis of data collected between September 2019 and February 2020 from a stratified random sample of 87 urban nursing homes in western Canada. We linked administrative data (the Resident Assessment Instrument-Minimum Data Set [RAI-MDS], 2.0) for 10,093 residents and survey data for 3547 nursing assistants (response rate: 74.2%) at the care unit level. Outcome of interest was residents' pain level, measured by the pain scale derived from RAI-MDS, 2.0. The exposure variable was nursing assistants' use of best practices, measured with validated self-report scales and aggregated to the unit level. Two-level random-intercept multinomial logistic regression accounted for the clustering effect of residents within care units. Covariates included resident demographics and clinical characteristics and characteristics of nursing assistants, unit, and nursing home.

Results

Of the residents, 3305 (30.3%) were identified as having pain. On resident care units with higher levels of best practice use among nursing assistants, residents had 32% higher odds of having mild pain (odds ratio, 1.32; 95% confidence interval, 1.01–1.71; p = 0.040), compared with residents on care units with lower levels of best practice use among nursing assistants. The care units did not differ in reported moderate or severe pain among residents.

Conclusions

We observed that higher unit-level best practice use among nursing assistants was associated with mild resident pain. This association warrants further research to identify key individual and organizational factors that promote effective pain assessment and management.     

Intensified rehabilitation therapy and transitions to skilled nursing facilities in community‐living seniors with acute medical illnesses

Aim: To examine whether rehabilitation therapy type would be associated with transitions to skilled nursing facilities (SNF) in community‐living seniors with acute medical illnesses. Methods: Using administrative and clinical data, multivariate regression analysis examined the relationship between the extent of rehabilitation therapy and transitions to SNF in all participants, as well as participants by physical function at admission. Results: In all participants (n = 929), the intensified rehabilitation therapy was associated with a lower probability of transitions to SNF (14% vs 21%; odds ratio [OR] 0.59; 95% confidence intervals [CI] 0.22–0.96; P = 0.02). In participants with mild physical limitations (n = 270), less frequent transitions to SNF occurred when patients received intensified rehabilitation therapy [16% vs 23%; OR 0.46; 95% CI 0.17–0.94; P = 0.01]. In participants with moderate to severe physical limitations (n = 265), the decreased frequency of transitions to SNF associated with rehabilitation therapy became more pronounced (18% vs 28%; OR 0.34; 95% CI 0.07–0.89; P = 0.004). By contrast, in participants without physical limitation (n = 394), the number of transitions to SNF did not change significantly when they received intensified rehabilitation therapy (P = 0.53). Conclusions: We found a significant relationship between intensified rehabilitation therapy and the decrease of transitions to SNF in community‐living seniors with acute medical illness. The magnitude of this relationship increased in participants with more physical limitations, but not in participants without physical limitations at admission. Geriatr Gerontol Int 2013; 13: 547–554.     

Development and validation of a multidimensional prognostic index for one-year mortality from comprehensive geriatric assessment in hospitalized older patients

Our objective was to construct and validate a Multidimensional Prognostic Index (MPI) for 1-year mortality from a Comprehensive Geriatric Assessment (CGA) routinely carried out in elderly patients in a geriatric acute ward. The CGA included clinical, cognitive, functional, nutritional, and social parameters and was carried out using six standardized scales and information on medications and social support network, for a total of 63 items in eight domains. A MPI was developed from CGA data by aggregating the total scores of the eight domains and expressing it as a score from 0 to 1. Three grades of MPI were identified: low risk, 0.0-0.33; moderate risk, 0.34-0.66; and severe risk, 0.67-1.0. Using the proportional hazard models, we studied the predictive value of the MPI for all causes of mortality over a 12-month follow-up period. MPI was then validated in a different cohort of consecutively hospitalized patients. The development cohort included 838 and the validation cohort 857 elderly hospitalized patients. Of the patients in the two cohorts, 53.3 and 54.9% were classified in the low-risk group, respectively (MPI mean value, 0.18 +/- 0.09 and 0.18 +/- 0.09); 31.2 and 30.6% in the moderate-risk group (0.48 +/- 0.09 and 0.49 +/- 0.09); 15.4 and 14.2% in the severe-risk group (0.77 +/- 0.08 and 0.75 +/- 0.07). In both cohorts, higher MPI scores were significantly associated with older age (p = 0.0001), female sex (p = 0.0001), lower educational level (p = 0.0001), and higher mortality (p = 0.0001). In both cohorts, a close agreement was found between the estimated mortality and the observed mortality after both 6 months and 1 year of follow-up. The discrimination of the MPI was also good, with a ROC area of 0.751 (95%CI, 0.70-0.80) at 6 months and 0.751 (95%CI, 0.71-0.80) at 1 year of follow-up. We conclude that this MPI, calculated from information collected in a standardized CGA, accurately stratifies hospitalized elderly patients into groups at varying risk of mortality.     

Comorbidity and 1-year mortality risks in nursing home residents

OBJECTIVES: To investigate the effect of chronic diseases and disease combinations on 1-year mortality in nursing home residents. DESIGN: Retrospective cohort study using electronically submitted Minimum Data Set (MDS) information and Missouri death certificate data. SETTING: Five hundred twenty-two nursing homes in Missouri. PARTICIPANTS: Forty-three thousand five hundred ten nursing home residents with a full MDS assessment in 1999. MEASUREMENTS: Information about chronic diseases, age, sex, and performance in activities of daily living (ADLs) available from the first full MDS 2.0 assessment in 1999; death within 1 year after the first full MDS-assessment in 1999. RESULTS: After adjustment for age and sex, eight variables were predictive for 1-year mortality: seven chronic diseases (dementia, cancer, heart failure, renal failure, emphysema/chronic obstructive pulmonary disease, diabetes mellitus, and anemia) and an interaction variable containing age and cancer. Adding terms for disease combinations (e.g., diabetes mellitus and heart failure) did not enhance survival prediction. When there was also adjustment for ADL performance as measured using the MDS-ADL Short Form, dementia and anemia were not included, because they had no prognostic value above that of the other variables. CONCLUSION: Several chronic diseases were associated with 1-year mortality in the institutionalized elderly after adjustment for ADL performance, age, and sex. Evidence of a synergistic effect of disease combinations on mortality is lacking.