Resident and facility characteristics associated with care‐need level deterioration in long‐term care welfare facilities in Japan

Aim

To determine the resident and facility characteristics associated with residents’ care‐need level deterioration in long‐term care welfare facilities in Japan.

Methods

A nationally representative sample of 358 886 residents who lived in 3774 long‐term care welfare facilities for at least 1 year from October 2012 was obtained from long‐term care insurance claims data. Facility characteristics were linked with a survey of institutions and establishments for long‐term care in 2012. We used a multilevel logistic regression according to the inclusion and exclusion of lost to follow‐up to define the resident and facility characteristics associated with resident care‐need level deteriorations (lost to follow‐up: the majority were hospitalized residents or had died; were treated as deterioration in the including loss to follow‐up model).

Results

Adjusting for the covariates, at the resident level, older age and lower care‐need level at baseline were more likely to show deterioration in the care‐need level. At the facility level, metropolitan facilities, unit model (all private room settings) and mixed‐model facilities (partly private room settings) were less likely to experience care‐need level deterioration. A higher proportion of registered nurses among all nurses was negatively related to care‐need level deterioration only in the model including lost to follow‐up. A higher proportion of registered dietitians among all dietitians and the facilities in business for fewer years were negatively associated with care‐need level deterioration only in the model excluding lost to follow‐up.

Conclusions

The present study could help identify residents who are at risk of care‐need level deterioration, and could contribute to improvements in provider quality performance and enhance competence in the market. Geriatr Gerontol Int 2018; 18: 758–766 .

     

What is a common factor in different areas?: The case of depression among caregivers of the frail elderly in Sapporo and Kochi,Japan

Aim: Depression affecting caregivers is a risk factor for discontinuing at‐home care. The present cross‐sectional study was conducted to evaluate factors related to depression among family caregivers. Methods: A cross‐sectional study was conducted to evaluate factors related to depression among family caregivers of the frail elderly. The study included caregivers whose relatives received periodic visits from a nurse from one of seven Sapporo‐based home‐visiting nursing service stations in October 2008 or from one of nine Kochi‐based home‐visiting nursing service stations between June 2009 and March 2010. Caregivers were asked to answer a self‐administered questionnaire about various factors that might affect their depression and to complete a Center for Epidemiologic Studies Depression Scale evaluation. We analyzed 127 pairs of responses in total. Results: After we adjusted the results for the caregivers' gender and age, the factors that decreased the risk of depression in the Sapporo group related to relieving the stress that results from being a caregiver (OR = 0.12, 95%CI = [0.03, 0.42]) and the ability to independently pay more than ¥10 000 for part of care service costs (OR = 0.17, 95%CI = [0.05, 0.58]). In contrast, feeling ill was a factor that increased caregivers' risk of depression in the Kochi group (OR = 4.23, 95%CI = [1.29, 13.9]), but not in Sapporo group (OR = 2.53, 95%CI = [0.91, 7.08]). Caregivers in the Sapporo group were more likely to feel ill (P < 0.01) than their counterparts in Kochi. Conclusion: The Japanese government should take measures to reduce caregivers' depression. Otherwise family members will increasingly discontinue to provide at‐home care. Geriatr Gerontol Int 2012; 12: 230–237.     

Norovirus Infections in Long‐Term Care Facilities

Noroviruses have emerged as one of the leading causes of viral gastroenteritis worldwide, affecting community‐dwelling and institutionalized older adults. Recent global epidemics present a growing challenge to the healthcare system and to long‐term care facilities. Noroviruses spread readily and rapidly through multiple routes (e.g., person‐to‐person contact, contact with contaminated surfaces, airborne dissemination of vomitus) and thus are able to sustain an epidemic efficiently and successfully. Although norovirus gastroenteritis is a short self‐limited illness in healthy immunocompetent individuals, it can result in significant morbidity and mortality in vulnerable compromised persons such as frail elderly persons and older residents of nursing homes. Diagnosis is made by clinical assessment and confirmed primarily by stool evaluation using polymerase chain reaction. Treatment is confined to supportive measures. Public health prevention and control strategies provide guidance regarding surveillance and the necessary steps to curb the clinical effect and spread of norovirus infections in various settings, including long‐term care.     

Comprehensive geriatric functional analysis of elderly populations in four categories of the long‐term care insurance system in a rural,depopulated and aging town in Japan

Aim: The aim of this study was to show which dimensions of functions differ among community‐dwelling elderly participants in four different certification levels of the current long‐term care insurance system (LTCI) in a rural, depopulated and aging town in Japan, with special consideration for strengths and weaknesses of the LTCI. Methods: The study population consisted of 1077 community‐dwelling elderly participants aged 65 years and older, with LTCI certification comprising 542 uncertified elderly (Ippan‐Koureisya), 437 specified elderly (Tokutei‐Koreisha), 57 support‐level elderly (Youshien‐Koureisha) and 41 care‐level elderly (Youkaigo‐Ninteisha). Each participant was rated regarding their health status, with question topics including basic activities of daily living (ADL), the Tokyo Metropolitan Institute of Gerontology Index of Competence (TMIG‐IC), the 15‐item Geriatric Depression Scale (GDS‐15), 21‐item Fall Risk Index (FRI‐21), the quantitative subjective quality of life (QOL), current medical situation, past medical histories and social backgrounds. Results: The scores in basic ADL, each item of the TMIG‐IC and five items of the quantitative subjective QOL were significantly lower, and the scores in GDS‐15 and in FRI‐21 were significantly higher according to certification level, in order of uncertified, specified, support‐level and care‐level elderly in a dose–response manner. Exercise and drinking habits were significantly less common in support‐ or care‐level elderly than in specified or uncertified elderly. The prevalence of taking antihypertensive, antihyperlipidemia, antidepressant or sleeping medications was significantly higher in the support‐ or care‐level elderly than in uncertified or specified elderly people. Support‐ or care‐level elderly also had a significantly higher prevalence of past medical histories of stroke, bone fractures, osteoarthropathy, heart disease and cancer than uncertified or specified elderly people. Conclusion: Actual standardized quantitative and qualitative geriatric functions of the elderly among four categories in newly revised LTCI system were shown in a depopulated and aging town in Japan. Based on the actual situation of functions of the elderly, the strengths and weaknesses of the current LTCI system were reconsidered. Further research on the measures to prevent future dependency among the specified and support‐level elderly is required. Geriatr Gerontol Int 2013; 13: 63–69 .     

Innovation in a Learning Health Care System: Veteran‐Directed Home‐ and Community‐Based Services

A path‐breaking example of the interplay between geriatrics and learning healthcare systems is the Veterans Health Administration's (VHA's) planned roll‐out of a program for providing participant‐directed home‐ and community‐based services to veterans with cognitive and functional limitations. We describe the design of a large‐scale, stepped‐wedge, cluster‐randomized trial of the Veteran‐Directed Home‐ and Community‐Based Services (VD‐HCBS) program. From March 2017 through December 2019, up to 77 Veterans Affairs Medical Centers will be randomized to times to begin offering VD‐HCBS to veterans at risk of nursing home placement. Services will be provided to community‐dwelling participants with support from Aging and Disability Network Agencies. The VHA Partnered Evidence‐based Policy Resource Center (PEPReC) is coordinating the evaluation, which includes collaboration from operational stakeholders from the VHA and Administration for Community Living and interdisciplinary researchers from the Center of Innovation in Long‐Term Services and Supports and the Center for Health Services Research in Primary Care. For older veterans with functional limitations who are eligible for VD‐HCBS, we will evaluate health outcomes (hospitalizations, emergency department visits, nursing home admissions, days at home) and healthcare costs associated with VD‐HCBS availability. Learning healthcare systems facilitate diffusion of innovation while enabling rigorous evaluation of effects on patient outcomes. The VHA's randomized rollout of VD‐HCBS to veterans at risk of nursing home placement is an example of how to achieve these goals simultaneously. PEPReC's experience designing an evaluation with researchers and operations stakeholders may serve as a framework for others seeking to develop rapid, rigorous, large‐scale evaluations of delivery system innovations targeted to older adults.     

B‐type natriuretic peptide is predictive of hospitalization in community‐dwelling elderly without heart diseases

Aim: To examine prospectively the relationship between plasma B‐type natriuretic peptide (BNP) levels in community‐dwelling elderly and their hospitalization. Methods: A total number of 644 subjects aged 65 years or older were recruited from the annual community health examinations. Those with a history of stroke or neurological findings were not included. After excluding those with old myocardial infarction, left ventricular dysfunction, moderate or severe valvular disorders, atrial fibrillation, renal insufficiency, and history of hospitalization within 1 year, 602 participants (226 men, 376 women; mean age, 80.3 ± 6.2 years) remained eligible for this study. Antihypertensive medications, activities of daily living (ADL) score and history of hospitalization were assessed by annual interview. Measurement of casual blood pressure, Mini‐Mental State Examination, electrocardiography and echocardiography were performed. Plasma BNP, serum creatinine, total cholesterol, albumin and hemoglobin A1c levels were also examined. A follow‐up survey was performed for the occurrence and reasons for hospitalization. Results: During a median follow up of 37 months, 112 subjects were hospitalized. After adjustment for conventional risk factors of hospitalization using the Cox proportional hazard model, each increment of 1 standard deviation in log BNP levels was associated with a 36% increase in the risk of hospitalization (P = 0.02). Plasma BNP levels were significantly higher in the hospitalized subjects due to stroke, heart diseases, dementia, pneumonia and also difficulty to live alone than those of the subjects without hospitalization. Conclusion: Plasma BNP level is a very useful biochemical marker predictive of future hospitalization in community‐dwelling independent elderly people without apparent heart diseases.     

Prediction of mortality in community-living frail elderly people with long-term care needs

OBJECTIVES: To develop and validate a prognostic index for mortality in community‐living, frail elderly people. DESIGN: Cohort study of Program of All‐Inclusive Care for the Elderly (PACE) participants enrolled between 1988 and 1996. SETTING: Eleven PACE sites, a community‐based long‐term care program that cares for frail, chronically ill elderly people who meet criteria for nursing home placement. PARTICIPANTS: Three thousand eight hundred ninety‐nine PACE enrollees. The index was developed in 2,232 participants and validated in 1,667. MEASUREMENTS: Time to death was predicted using risk factors obtained from a geriatric assessment performed by the PACE interdisciplinary team at the time of enrollment. Risk factors included demographic characteristics, comorbid conditions, and functional status. RESULTS: The development cohort had a mean age of 79 (68% female, 40% white). The validation cohort had a mean age of 79 (76% female, 65% white). In the development cohort, eight independent risk factors of mortality were identified and weighted, using Cox regression, to create a risk score: male sex, 2 points; age (75–79, 2 points; 80–84, 2 points; ≥85, 3 points); dependence in toileting, 1 point; dependence in dressing (partial dependence, 1 point; full dependence, 3 points); malignant neoplasm, 2 points; congestive heart failure, 3 points; chronic obstructive pulmonary disease, 1 point; and renal insufficiency, 3 points. In the development cohort, respective 1‐ and 3‐year mortality rates were 6% and 21% in the lowest‐risk group (0–3 points), 12% and 36% in the middle‐risk group (4–5 points), and 21% and 54% in the highest‐risk group (>5 points). In the validation cohort, respective 1‐ and 3‐year mortality rates were 7% and 18% in the lowest‐risk group, 11% and 36% in the middle‐risk group, and 22% and 55% in the highest‐risk group. The area under the receiver operating characteristic curve for the point score was 0.66 and 0.69 in the development and validation cohorts, respectively. CONCLUSION: A multidimensional prognostic index was developed and validated using age, sex, functional status, and comorbidities that effectively stratifies frail, community‐living elderly people into groups at varying risk of mortality.     

Association of care recipients’ care‐need level with family caregiver participation in health check‐ups in Japan

Aim

The public mandatory long‐term care insurance system in Japan has supposedly mitigated the care burden for family caregivers of older adults, whereas family caregivers still play a considerable role in providing care. The effect of informal caregiving on the caregiver's health has been of great interest. We investigated the relationship between the amplitude of informal caregiving and caregiver participation in health check‐ups in Japan.

Methods

The present study was a cross‐sectional analysis of nationally representative data in Japan (2010 Comprehensive Survey of Living Conditions). We investigated the relationship between care recipients’ care‐need level and in‐home caregiver participation in health check‐ups during the last year of the survey for caregivers.

Results

A total of 3354 caregiver/recipient pairs were included in the study. Crude proportions of caregivers completing a health check‐up by care‐need level were 68.4% (support required 1 and 2), 63.5% (care required 1–3) and 60.3% (care required 4 and 5). Higher care‐need level was negatively associated with caregiver participation in health check‐ups (support required 1 and 2as reference, care required 1–3: odds ratio 0.82, 95% confidence interval 0.75–0.90), care required 4 and 5: odds ratio 0.76, 95% confidence interval 0.74–0.79) after adjustment for possible confounders. Inclusion of the caregiver time devoted to care per day and caregiver self‐rating of health as independent variables did not change the result.

Conclusions

These results suggest that facilitating health check‐up participation for family caregivers of care recipients with higher care‐need levels might be an effective intervention for decreasing the gap in health behavior possibly caused by informal caregiving. Geriatr Gerontol Int 2018; 18: 26–32 .     

Predictors of eligibility for long‐term care funding for older people in Japan

Aim: To determine the predictors of Japanese long‐term care insurance system (LTCI) certification. Methods: Care needs of 784 persons aged 65–84 were followed through LTCI over 5 years. Each participant's score was divided into quartiles according to handgrip strength and one‐leg standing time with eyes open. Cox proportional hazard models were conducted for the onset of certification of LTCI. Results: Over the 5‐year period 64 women (14%) and 30 men (9%) were certified. Adjusted hazard ratios for certification were significantly higher for those of the lowest groups of one‐leg standing time with eyes open at baseline than those in the highest groups, but no significance was found for handgrip strength. Other predictors were age and low social activity for women; and living alone and diabetes for men. Conclusions: One‐leg standing time with eyes open predicts the onset of care‐need certification in older people.     

Preliminary Data from the Caring for Older Adults and Caregivers at Home (COACH) Program: A Care Coordination Program for Home‐Based Dementia Care and Caregiver Support in a Veterans Affairs Medical Center

Caring for Older Adults and Caregivers at Home (COACH) is an innovative care coordination program of the Durham Veteran's Affairs Medical Center in Durham, North Carolina, that provides home‐based dementia care and caregiver support for individuals with dementia and their family caregivers, including attention to behavioral symptoms, functional impairment, and home safety, on a consultation basis. The objectives of this study were to describe the COACH program in its first 2 years of operation, assess alignment of program components with quality measures, report characteristics of program participants, and compare rates of placement outside the home with those of a nontreatment comparison group using a retrospective cohort design. Participants were community‐dwelling individuals with dementia aged 65 and older who received primary care in the medical center's outpatient clinics and their family caregivers, who were enrolled as dyads (n = 133), and a control group of dyads who were referred to the program and met clinical eligibility criteria but did not enroll (n = 29). Measures included alignment with Dementia Management Quality Measures and time to placement outside the home during 12 months of follow‐up after referral to COACH. Results of the evaluation demonstrated that COACH aligns with nine of 10 clinical process measures identified using quality measures and that COACH delivers several other valuable services to enhance care. Mean time to placement outside the home was 29.6 ± 14.3 weeks for both groups (P = .99). The present study demonstrates the successful implementation of a home‐based care coordination intervention for persons with dementia and their family caregivers that is strongly aligned with quality measures.     

Prognostic Significance of Electrocardiographic Abnormalities in Diphtheritic Myocarditis After Hospital Discharge: A Long‐Term Follow‐Up Study

Objective: We aimed to investigate the long‐term cardiac mortality and the relationship between cardiac mortality and electrocardiographic abnormalities in patients with diphtheritic myocarditis who survived after hospital discharge. Materials and Methods: Between 1991 and 1996, 32 patients (all males, mean age 21.00 ± 3.77 years) surviving diphtheritic myocarditis were included in the study and they were followed up for an average of 16.3 months (range 10.3–26.8 months) after hospital discharge. Clinical evaluation, ECG, and echocardiography were performed on admission, daily while in hospital and at the time of discharge. ECG changes were permanent during the follow‐up period. The causes of death of the patients during follow‐up period were inferred from the death records of the patients and talking to the people witnessing cardiac arrest. Results: We observed that the patients with left bundle branch block (LBBB) and T wave inversion at hospital discharge had lower survival rates than that of the patients without these ECG changes in the long term. Although univariate Cox regression analysis identified LBBB (P = 0.001) and T wave inversion (P = 0.014) as the predictors of survival, only LBBB was an independent predictor of survival in multivariate Cox regression analysis. Adjusted hazard ratio was calculated as 13.67 for LBBB (P = 0.001; CI = 2.81–66.28). Conclusion: Diphtheritic myocarditis does not only demonstrate a malignant clinical course during acute phase of the disease, but also during the long‐term follow‐up period, especially in patients with LBBB and T wave inversion. Besides, T wave inversion and LBBB can help us to predict survival rate of the patients in long term. Moreover, LBBB is an independent predictor of long‐term survival in diphtheritic myocarditis.     

‘The rollercoaster of follow‐up care’ after bariatric surgery: a rapid review and qualitative synthesis

Benefits of bariatric surgery for obesity related comorbidities are well established. However, in the longer term, patients can become vulnerable to procedure specific problems, experience weight regain and continue to need monitoring and management of comorbidities. Effective longer term follow‐up is vital due to these complex needs post‐surgery. Current guidance recommends annual long‐term follow‐up after bariatric surgery. However, attendance can be low, and failure to attend is associated with poorer outcomes. Understanding patients' experiences and needs is central to the delivery of effective care. This rapid review has synthesized the current qualitative literature on patient experiences of healthcare professional (HCP) led follow‐up from 12 months after bariatric surgery. A recurring theme was the need for more and extended follow‐up care, particularly psychological support. Enablers to attending follow‐up care were patient self‐efficacy as well as HCP factors such as a non‐judgemental attitude, knowledge and continuity of care. Barriers included unrealistic patient expectations and perceived lack of HCP expertise. Some preferences were expressed including patient initiated access to HCPs and more information preoperatively to prepare for potential post‐surgery issues. Insights gained from this work will help identify areas for improvement to care in order to optimize longer term outcomes.     

Comparison of five‐year outcome in African Americans versus Caucasians following percutaneous coronary intervention

Background: Studies regarding short‐term outcomes after percutaneous coronary intervention (PCI) have reported no ethnic differences and data on long‐term follow‐up is conflicting and sparse. Methods: 730 consecutive patients (67% African American) undergoing PCI from January 1999 to December 2000 at a tertiary care center in Detroit, MI, were followed up. End points studied included either all cause mortality collected from Social Security Death Index or first hospital admission after the index procedure due to myocardial infarction(MI), congestive heart failure(CHF), and revascularization (PCI or coronary artery bypass graft surgery). Results: African‐Americans undergoing PCI had significant differences in baseline cardiovascular co‐morbidity and were more likely to present with acute myocardial infarction than Caucasians. On Kaplan Meier survival analysis and log rank test, each ethnic group had equivalent survival for cumulative end points upto 6‐month follow‐up, however longer follow‐up to 5 year was characterized by lower survival rate in African Americans compared to Caucasians (41% vs. 54%, log rank P 0.01). After adjustment for potential confounders, AA ethnicity (Adjusted HR 1.62, 95% CI 1.01–1.28, P 0.04) remained a predictor of adverse cardiac outcome (Death/MI/CHF) at five‐year follow‐up (Cox regression propensity adjusted hazard analysis). Conclusions: African American patients undergoing PCI had unfavorable baseline cardiovascular characteristics but comparable short‐term outcome compared to whites. However, at 5‐year follow‐up, African Americans had worse clinical outcome, higher incidence of acute myocardial infarction, congestive heart failure and significantly lower long‐term survival. © 2008 Wiley‐Liss, Inc.     

The association between demographic and oral health‐related quality of life factors and dental care attendance among underprivileged older people

Aim: In order to identify whether demographic and oral health‐related quality of life factors are associated with dental care attendance among an underprivileged older population, a comparison was performed between people who have and have not attended dental care. Methods: A cross‐sectional purposive sample of 344 older underprivileged people comprised the study population. The dependent variable was dental care attendance. The 14‐item version of the Oral Health Impact Profile index (OHIP‐14) was used as the independent variable, together with other social and general variables, using a structured interview. Results: The variables that were significantly associated with dental care attendance were family status (not married, the highest attendance), dwelling location (living at home, the highest attendance), caregiver (family member, the highest attendance), place of birth (Western countries, the highest attendance) and income (pension, the highest attendance). Sex, welfare support, functional ability, education, age and OHIP‐14 were not associated with dental care attendance. Conclusions: Attending dental care was not associated with oral health‐related quality of life measured by OHIP‐14. Several socioeconomic variables were strongly associated.     

Community‐based exercise program reduces chronic knee pain in elderly Japanese women at high risk of requiring long‐term care: A non‐randomized controlled trial

Aim: To estimate the prevalence of low back pain and/or knee pain among the elderly at high risk of requiring long‐term care, and to determine the effectiveness of a community‐based exercise program provided in accordance with the Motor Function Improvement Program for improving low back and/or knee pain. Methods: The target population of this study was 320 residents aged ≥65 years who were eligible for the exercise program. For the intervention group, weekly exercise classes of 120 min duration were held 12 times over 3 months. The main outcome measures were changes between the baseline and 3‐month follow up in visual analog scale (VAS) scores for pain and in the Western Ontario McMaster Osteoarthritis Index (WOMAC) pain for severity of knee pain. Results: The number of participants reporting chronic low back and/or knee pain was 252 with a prevalence of 78.8%. Among them, 68 who were allocated to the intervention group and 125 to the control group completed the study, and were stratified by sex. In women, change in the VAS scores of low back pain was −17.5 ± 23.2 for the intervention group and −7.2 ± 23.4 for the control group (between‐group differences P = 0.03). For knee pain, significant changes in the VAS scores (between‐group differences P = 0.04) and WOMAC pain (P < 0.001) were observed; −14.9 ± 24.9 and −0.6 ± 3.1 for the intervention group, and −0.2 ± 28.5 and 2.2 ± 3.2 for the control group, respectively. No significant difference was observed in men. Conclusion: Community‐based exercise programs might reduce prevalent knee pain in elderly women at high risk of requiring long‐term care. Geriatr Gerontol Int 2013; 13: 167–174.     

Suicide in Older Adults in Long‐Term Care: 1990 to 2005

OBJECTIVES: To describe the characteristics associated with suicide in older persons residing in long‐term care (LTC) facilities, to compare the characteristics of suicide cases in LTC with those of cases in the community, and to evaluate trends in suicide in these settings over the past 15 years. SETTING: The New York City (NYC) Office of the Chief Medical Examiner (OCME). PARTICIPANTS: Suicide deaths in NYC from 1990 to 2005. MEASUREMENTS: Location and method of suicide death reported by OCME. METHODS: Suicides in older persons in LTC and community‐dwelling older adults were compared in terms of demographic characteristics and method used. Trends in suicide rate ratios (RRs) were examined using zero‐inflated Poisson regression. RESULTS: Over the study period, there were 1,771 suicides among NYC residents aged 60 and older: 47 in LTC and 1,724 in the community. Cases in LTC tended to be older (P<.02) but did not differ from community cases in terms of race or sex. Suicides in LTC were significantly less likely (RR=0.05, P<.002) to be due to firearms and 2.49 times as likely to be due to a long fall (P<.002) as community cases. Over the 15‐year period, there was a significant decrease in the relative rate of suicide in community‐dwelling adults (RR=0.97, P<.001) but no change in residents of LTC (RR=1.05, P<.17). CONCLUSIONS: Suicide risk in community‐dwelling older adults has declined over the past 15 years but has not changed in LTC facilities. This suggests that prevention efforts may not be reaching this population effectively.     

Impact of informal care levels on discontinuation of living at home in community-dwelling dependent elderly using various community-based services

The aim of the study was to examine the effect of informal care levels on overall discontinuation of living at home, all-cause death, hospital admission, and long-term care placement for community-dwelling older people using various community-based services during a 3-year period. Prospective cohort study of 1582 community-dwelling disabled elderly and paired informal caregivers was conducted. Baseline data included the recipients and caregivers’ demographic characteristics, comorbidities, informal care levels (sufficient, moderate, and insufficient care), which were evaluated by trained visiting nurses, and the level of formal community-based service use. Among 1582 participants, 97 died at home, 692 were admitted to hospitals, 318 died during their hospital stay, and 117 were institutionalized in long-term care facilities during 3 years of follow-up. A multivariate Cox hazard model demonstrated that when compared with a sufficient informal care level, an insufficient informal care level was associated with overall discontinuation of living at home, all-cause mortality, hospitalization, and institutionalization during 3 years of follow-up (hazard ratio: 1.65, 95% confidence interval: 1.15-2.36; 1.98, 1.17-3.34; 1.56, 1.04-2.35; 2.93, 1.25-6.86, respectively). The results suggested that informal caregiving is an important factor in the prevention of overall discontinuation of living at home in a population of disabled older people.     

Factors associated with polypharmacy in elderly home‐care patients

Aim

Polypharmacy, which is often observed in elderly patients, has been associated with several unfavorable outcomes, including an increased risk of potentially inappropriate medications, medication non‐adherence, drug duplication, drug–drug interactions, higher healthcare costs and adverse drug reactions. A significant association between polypharmacy and adverse outcomes among older people living in the community has also been confirmed. A reduction in the number of medications should thus be pursued for many older individuals. Nevertheless, the factors associated with polypharmacy in elderly home‐care patients have not been reported. Here, we investigated those factors in elderly home‐care patients in Japan.

Methods

We used the data of the participants in the Observational Study of Nagoya Elderly with Home Medical investigation. Polypharmacy was defined as the current use of six or more different medications. We carried out univariate and multivariate logistic regression analyses to assess the associations between polypharmacy and each of several factors.

Results

A total of 153 home‐care patients were registered. The mean number of medications used per patient was 5.9, and 51.5% of the patients belonged to the polypharmacy group. The multivariate model showed that the patients’ scores on the Charlson Comorbidity Index and the Mini‐Nutrition Assessment Short Form were inversely associated with polypharmacy, and potentially inappropriate medication was most strongly associated with polypharmacy (odds ratio 4.992).

Conclusions

The present findings showed that polypharmacy was quite common among the elderly home‐care patients, and they suggest that home‐care physicians should prescribe fewer medications in accord with the deterioration of home‐care patients’ general condition. Geriatr Gerontol Int 2018; 18: 33–41 .     

Long‐term clinical outcomes of real‐world experience using sirolimus‐eluting stents in saphenous vein graft disease

Objective : To evaluate the long‐term clinical outcomes of patients undergoing percutaneous coronary intervention for saphenous vein graft (SVG) disease. Specifically, we compared clinical endpoints of patients who received sirolimus‐eluting stents (SES) versus bare‐metal stents (BMS) for SVG disease. Background : A recent small randomized‐controlled trial (RCT) reported increased mortality with the use of SES in SVG disease. Methods : We retrospectively identified patients who underwent SES placement for a SVG lesion(s) at our institutions over a 4‐year period. The procedural and medical records were reviewed to identify predetermined clinical outcomes. Results : 318 patients who underwent SES placement for a SVG lesion were identified. 7 patients were lost to follow‐up. 141/311 patients (45%) received SES, while 170/311 (55%) received BMS. At a mean follow‐up of 34 months, there was a reduction in target lesion revascularization (TLR) (7% vs. 14%, P = 0.07) without an increased risk of mortality (6% vs. 12%, P = 0.06) in patients who received SES compared to patients who received BMS. When compared to the recent RCT's SES patients at long‐term follow‐up, our SES patients had significantly less mortality; rates of myocardial infarction, TLR, target vessel revascularization, and major adverse cardiac events; and were more likely to be taking dual antiplatelet and statin medications. Conclusion : Our results support that SES used in SVG lesions result in a reduction in TLR without an increased risk of mortality, and therefore may be an equally safe and feasible technique for revascularization with excellent long‐term clinical outcomes. These patients may benefit from prolonged dual antiplatelet and statin medication regimens. © 2008 Wiley‐Liss, Inc.     

Predicting Discharge to Institutional Long‐Term Care After Stroke: A Systematic Review and Metaanalysis

Background/Objectives

Stroke is a leading cause of disability worldwide, and a significant proportion of stroke survivors require long‐term institutional care. Understanding who cannot be discharged home is important for health and social care planning. Our aim was to establish predictive factors for discharge to institutional care after hospitalization for stroke.

Design

We registered and conducted a systematic review and meta‐analysis (PROSPERO: CRD42015023497) of observational studies. We searched MEDLINE, EMBASE, and CINAHL Plus to February 2017. Quantitative synthesis was performed where data allowed.

Setting

Acute and rehabilitation hospitals.

Participants

Adults hospitalized for stroke who were newly admitted directly to long‐term institutional care at the time of hospital discharge.

Measurements

Factors associated with new institutionalization.

Results

From 10,420 records, we included 18 studies (n = 32,139 participants). The studies were heterogeneous and conducted in Europe, North America, and East Asia. Eight studies were at high risk of selection bias. The proportion of those surviving to discharge who were newly discharged to long‐term care varied from 7% to 39% (median 17%, interquartile range 12%), and the model of care received in the long‐term care setting was not defined. Older age and greater stroke severity had a consistently positive association with the need for long‐term care admission. Individuals who had a severe stroke were 26 times as likely to be admitted to long‐term care than those who had a minor stroke. Individuals aged 65 and older had a risk of stroke that was three times as great as that of younger individuals. Potentially modifiable factors were rarely examined.

Conclusion

Age and stroke severity are important predictors of institutional long‐term care admission directly from the hospital after an acute stroke. Potentially modifiable factors should be the target of future research. Stroke outcome studies should report discharge destination, defining the model of care provided in the long‐term care setting.