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1.
Himali Weerahandi Li Li Haikun Bao Jeph Herrin Kumar Dharmarajan Joseph S. Ross Kunhee Lucy Kim Simon Jones Leora I. Horwitz 《Journal of the American Medical Directors Association》2019,20(4):432-437
Objective
Discharge to skilled nursing facilities (SNFs) is common in patients with heart failure (HF). It is unknown whether the transition from SNF to home is risky for these patients. Our objective was to study outcomes for the 30 days after discharge from SNF to home among Medicare patients hospitalized with HF who had subsequent SNF stays of 30 days or less.Design
Retrospective cohort study.Setting and participants
All Medicare fee-for-service beneficiaries 65 and older admitted during 2012-2015 with a HF diagnosis discharged to SNF then subsequently discharged home.Measures
Patients were followed for 30 days following SNF discharge. We categorized patients by SNF length of stay: 1 to 6 days, 7 to 13 days, and 14 to 30 days. For each group, we modeled time to a composite outcome of unplanned readmission or death after SNF discharge. Our model examined 0-2 days and 3-30 days post-SNF discharge.Results
Our study included 67,585 HF hospitalizations discharged to SNF and subsequently discharged home. Overall, 16,333 (24.2%) SNF discharges to home were readmitted within 30 days of SNF discharge. The hazard rate of the composite outcome for each group was significantly increased on days 0 to 2 after SNF discharge compared to days 3 to 30, as reflected in their hazard rate ratios: for patients with SNF length of stay 1 to 6 days, 4.60 (4.23-5.00); SNF length of stay 7 to 13 days, 2.61 (2.45-2.78); SNF length of stay 14 to 30 days, 1.70 (1.62-1.78).Conclusions/implications
The hazard rate of readmission after SNF discharge following HF hospitalization is highest during the first 2 days home. This risk attenuated with longer SNF length of stay. Interventions to improve postdischarge outcomes have primarily focused on hospital discharge. This evidence suggests that interventions to reduce readmissions may be more effective if they also incorporate the SNF-to-home transition. 相似文献2.
Anupam Chandra Parvez A. Rahman Amelia Sneve Rozalina G. McCoy Bjorg Thorsteinsdottir Rajeev Chaudhry Curtis B. Storlie Dennis H. Murphree Gregory J. Hanson Paul Y. Takahashi 《Journal of the American Medical Directors Association》2019,20(4):444-450.e2
Objectives
Patients discharged to a skilled nursing facility (SNF) for post-acute care have a high risk of hospital readmission. We aimed to develop and validate a risk-prediction model to prospectively quantify the risk of 30-day hospital readmission at the time of discharge to a SNF.Design
Retrospective cohort study.Setting
Ten independent SNFs affiliated with the post-acute care practice of an integrated health care delivery system.Participants
We evaluated 6032 patients who were discharged to SNFs for post-acute care after hospitalization.Measurements
The primary outcome was all-cause 30-day hospital readmission. Patient demographics, medical comorbidity, prior use of health care, and clinical parameters during the index hospitalization were analyzed by using gradient boosting machine multivariable analysis to build a predictive model for 30-day hospital readmission. Area under the receiver operating characteristic curve (AUC) was assessed on out-of-sample observations under 10-fold cross-validation.Results
Among 8616 discharges to SNFs from January 1, 2009, through June 30, 2014, a total of 1568 (18.2%) were readmitted to the hospital within 30 days. The 30-day hospital readmission prediction model had an AUC of 0.69, a 16% improvement over risk assessment using the Charlson Comorbidity Index alone. The final model included length of stay, abnormal laboratory parameters, and need for intensive care during the index hospitalization; comorbid status; and number of emergency department and hospital visits within the preceding 6 months.Conclusions and implications
We developed and validated a risk-prediction model for 30-day hospital readmission in patients discharged to a SNF for post-acute care. This prediction tool can be used to risk stratify the complex population of hospitalized patients who are discharged to SNFs to prioritize interventions and potentially improve the quality, safety, and cost-effectiveness of care. 相似文献3.
George A. Heckman John P. Hirdes Paul C. Hébert Anne Morinville Andre C.K.B. Amaral Andrew Costa Robert S. McKelvie 《Journal of the American Medical Directors Association》2019,20(4):438-443
Objectives
To understand how a heart failure diagnosis and admission health instability predict health transitions and outcomes among newly admitted nursing home residents.Design
Retrospective cohort study of linked administrative data, including the Continuing Care Report System MDS 2.0 for nursing homes, the Discharge Abstract Database for hospitalized patients, and National Ambulatory Care Reporting System to track emergency department visits.Setting and participants
Older adults, aged 65 years and above, admitted to nursing homes in Ontario, Alberta, and British Columbia, Canada, from 2010 to 2016.Measures
Mortality and hospitalization were plotted over 1 year. Multistate Markov models were used to estimate adjusted odds ratios (ORs) for transitions to different states of health in stability, hospitalization, and death, stratified by heart failure diagnosis and by interRAI Changes in Health and End-stage disease Signs and Symptoms (CHESS) score, at 90 days following admission to a nursing home.Results
The final sample included 143,067 residents. Adverse events were most common in the first 90 days. A diagnosis of heart failure predicted worsening health instability, hospitalizations, and mortality. The effect of heart failure on hospitalizations and death was strongest for low baseline health instability (CHESS = 0; OR 1.63, 95% confidence interval (CI) 1.58-1.68, and OR 1.71, 95% CI 1.57-1.86, respectively), versus moderate instability (CHESS = 1-2; OR 1.36, 95% CI 1.32-1.39, and OR 1.48, 95% CI 1.41-1.55), versus high instability (CHESS = 3; OR 1.12, 95% CI 1.03-1.23, and OR 1.21, 95% CI 1.11-1.32). The magnitude of the impact of a heart failure diagnosis was greatest for lower baseline health instability. Residents with the highest degree of health instability were also most likely to die in hospital.Conclusions and implications
A diagnosis of heart failure and health instability provide complementary information to predict transfers, deaths, and adverse outcomes. Clearly identifying these at-risk patients may be useful in targeting interventions in nursing homes. 相似文献4.
Chong-Han Kua Vivienne S.L. Mak Shaun Wen Huey Lee 《Journal of the American Medical Directors Association》2019,20(3):362-372.e11
Objectives
Deprescribing is effective in addressing concerns relating to polypharmacy in residents of nursing homes. However, the clinical outcomes of deprescribing interventions among residents in nursing homes are not well understood. We evaluated the impact of deprescribing interventions by health care professionals on clinical outcomes among the older residents in nursing homes.Design
Systematic review and meta-analysis of randomized controlled trials. CINAHL, International Pharmaceutical Abstracts, MEDLINE, EMBASE, and Cochrane Library were searched from inception until September 2017; manual searches of reference lists of systematic reviews identified in the electronic search; and online trial registries for unpublished, ongoing, or planned trials. (PROSPERO CRD42016050028).Setting and Participants
Randomized controlled trials in a nursing home setting that included participants of at least 60 years of age.Measures
Falls, all-cause mortality, hospitalization, and potentially inappropriate medication were assessed in the meta-analysis.Results
A total of 41 randomized clinical studies (18,408 residents) that examined deprescribing (defined as either medication discontinuation, substitution, or reduction) in nursing were identified. Deprescribing interventions significantly reduced the number of residents with potentially inappropriate medications by 59% (odds ratio [OR] 0.41, 95% confidence interval [CI] 0.19–0.89). In subgroup analysis, medication review–directed deprescribing interventions reduced all-cause mortality by 26% (OR 0.74, 95% CI 0.65–0.84), as well as the number of fallers by 24% (OR 0.76, 95% CI 0.62–0.93).Conclusions
Compared to other deprescribing interventions, medication review–directed deprescribing had significant benefits on older residents in nursing homes. Further research is required to elicit other clinical benefits of medication review–directed deprescribing practice. 相似文献5.
Helena Temkin-Greener Tiffany Lee Thomas Caprio Shubing Cai 《Journal of the American Medical Directors Association》2019,20(4):476-480.e1
Objective
Ultrahigh therapy use has increased in SNFs without concomitant increases in residents' characteristics. It has been suggested that this trend may also have influenced the provision of high-intensity rehabilitation therapies to residents who are at the end of life (EOL). Motivated by lack of evidence, we examined therapy use and intensity among long-stay EOL residents.Design
An observational study covering a time period 2012-2016.Setting and participants
New York State nursing homes (N = 647) and their long-stay decedent residents (N = 55,691).Methods
Data sources included Minimum Data Set assessments, vital statistics, Nursing Home Compare website, LTCfocus, and Area Health Resource File.Therapy intensity in the last month of life was the outcome measure. Individual-level covariates were used to adjust for health conditions. Facility-level covariates were the key independent variables of interest. Multinomial logistic regression models with facility random effects were estimated.Results
Overall, 13.6% (n = 7600) of long-stay decedent residents had some therapy in the last month of life, 0% to 45% across facilities. Of those, almost 16% had very high/ultrahigh therapy intensity (>500 minutes) prior to death. Adjusting for individual-level covariates, decedents in the for-profit facilities had 18% higher risk of low/medium therapy [relative risk ratio (RRR) = 1.182, P < .001], and more than double the risk of high/ultrahigh therapy (RRR = 2.126, P < .001), compared to those with no therapy use in the last month of life. In facilities with higher physical therapy staffing, decedents had higher risk (RRR = 16.180, P = .002) of high/ultrahigh therapy, but not of low/medium therapy intensity. The use of high/ultrahigh therapy in this population has increased over time.Conclusions and Relevance
This is a first study to empirically demonstrate that facility characteristics are associated with the provision of therapy intensity to EOL residents. Findings suggest that facilities with a for-profit mission, and with higher staffing of therapists, may be more incentivized to maximize therapy use, even among the sickest of the residents. 相似文献6.
Adam Simning Thomas V. Caprio Christopher L. Seplaki Yeates Conwell 《Journal of the American Medical Directors Association》2019,20(4):492-496
Objectives
Our article's primary objective is to examine whether rehabilitation providers can predict which patients discharged from skilled nursing facility (SNF) rehabilitation will be successful in their transition to home, controlling for sociodemographic factors and physical, mental, and social health characteristics.Design
Longitudinal cohort study.Setting and Participants
One hundred-twelve English-speaking adults aged 65 years and older admitted to 2 SNF rehabilitation units.Measures
Our outcome is time to “failed transition to home,” which identified SNF rehabilitation patients who did not successfully transition from the SNF to home during the study. Our primary independent variable consisted of the prediction of medical providers, occupational therapists, physical therapists, and social workers about the likely success of their patients' SNF-to-home transition. We also examined the association of sociodemographic factors and physical, mental, and social health with a failed transition to home.Results
The predictions of occupational and physical therapists were associated with whether patients successfully transitioned from the SNF to their homes in bivariate [hazard ratio (HR) = 4.96, P = .014; HR = 10.91, P = .002, respectively] and multivariate (HR = 5.07, P = .036; HR = 53.33, P = .004) analyses. The predictions of medical providers and social workers, however, were not associated with our outcome in either bivariate (HR = 1.44, P = .512; HR = 0.84, P = .794, respectively) or multivariate (HR = 0.57, P = .487; HR = 0.54, P = .665) analyses. Living alone, more medical conditions, lower physical functioning scores, and greater depression scores were also associated with time to failed transition to home.Conclusions/Implications
These findings suggest that occupational and physical therapists may be better able to predict post-SNF discharge outcomes than are other rehabilitation providers. Why occupational and physical therapists' predictions are associated with the SNF-to-home outcome whereas the predictions of medical providers and social workers are not is uncertain. A better understanding of the factors informing the postdischarge predictions of occupational and physical therapists may help identify ways to improve the SNF-to-home discharge planning process. 相似文献7.
Teresa Botigué Olga Masot Jèssica Miranda Carmen Nuin Maria Viladrosa Ana Lavedán Sandra Zwakhalen 《Journal of the American Medical Directors Association》2019,20(3):317-322
Objective
The aim of this study was to determine the prevalence of low fluid intake in institutionalized older residents and the associated factors.Design
This was a cross-sectional study.Setting and Participants
The study was carried out at a nursing home with a capacity for 156 residents, all of whom were older than 65 years.Measures
Data were collected on the fluids consumed by each resident over a period of 1 week. Information relating to sociodemographic variables and to residents' health, nutrition, and hydration status was also collected.Results
Of 53 residents, 34% ingested less than 1500 mL/d. The factors with the greatest correlation associated with low fluid intake were cognitive and functional impairment, the risk of suffering pressure ulcers, being undernourished, a texture-modified diet, dysphagia, impaired swallowing safety, and BUN:creatinine ratio.Conclusions/Implications
The results obtained highlight the scale of low fluid intake in nursing homes and also aid to identify and understand the factors associated with this problem. The findings could help us to develop specific strategies to promote the intake of liquids and thereby reduce the incidence of dehydration in nursing homes. 相似文献8.
Hanna-Maria Roitto Hannu Kautiainen Ulla L. Aalto Hannareeta Öhman Jouko Laurila Kaisu H. Pitkälä 《Journal of the American Medical Directors Association》2019,20(3):305-311
Objectives
The use of psychotropic drugs in long-term care (LTC) is very common, despite their known adverse effects. The prevalence of opioid use is growing among older adults. This study aimed to investigate trends in the prevalence of psychotropics, opioids, and sedative load in a LTC setting over a 14-year period. We also explored the interaction of psychotropic and opioid use according to residents’ dementia status in nursing home (NH) and assisted living facility (ALF) settings.Design
Four cross-sectional studies.Setting
Institutional settings in Helsinki, Finland.Participants
Older residents in NHs in 2003 (n = 1987), 2011 (n = 1576), and 2017 (n = 791) and in ALFs in 2007 (n = 1377), 2011 (n = 1586), and 2017 (n = 1624).Measures
Comparable assessments were conducted among LTC residents at 4 time points over 14 years. The prevalence of regular psychotropics, opioids, and other sedatives and data on demographics and diagnoses were collected from medical records.Results
Disabilities and severity of dementia increased in both settings over time. The prevalence of all psychotropics decreased significantly in NHs (from 81% in 2003 to 61% in 2017), whereas in ALFs there was no similar linear trend (65% in 2007 and 64% in 2017). There was a significant increase in the prevalence of opioids in both settings (30% in NHs and 22% in AFLs in 2017). Residents with dementia used less psychotropics and opioids than those without dementia in both settings and at each time point.Conclusions/Implications
NHs show a favorable trend in psychotropic drug use, but the rates of psychotropic use remain high in both NHs and ALFs. In addition, the rates of opioid use have almost tripled, leading to a high sedative load among LTC residents. Clinicians should carefully consider the risk-to-benefit ratio when prescribing in LTC. 相似文献9.
Jiancheng Wang Huiyuan Guo Tengfei Lin Yun Song Hao Zhang Binyan Wang Yan Zhang Jianping Li Yong Huo Xiaobin Wang Xianhui Qin Xiping Xu 《Journal of the Academy of Nutrition and Dietetics》2019,119(5):769-781
Background
Evidence from epidemiologic studies has been inconsistent regarding the role of vitamin E in cancer incidence risk.Objective
The aim of this study was to evaluate the prospective association between baseline plasma vitamin E levels and subsequent cancer risk in Chinese adults with hypertension, and to identify effect modifiers.Design
A nested, case–control study was conducted from 20,702 hypertensive participants in the China Stroke Primary Prevention Trial, a randomized, double-blind, controlled trial, conducted from May 2008 to August 2013.Participants
The current study included 229 new cancer cases and 229 controls matched for age (±1 year), sex, treatment group, and study site.Main outcome measures
Plasma vitamin E was measured by liquid chromatography with tandem quadrupole mass spectrometers and plasma selenium was measured by inductively coupled plasma mass spectrometry using Thermo Fisher iCAP Q ICP-MS.Statistical analyses
Odds ratios (OR) of cancer in relation to plasma concentrations of vitamin E were calculated using conditional logistic regression models.Results
Median follow-up duration was 4.5 years. Overall, vitamin E was not associated with subsequent risk of total cancer (per 1-mg/L [2.3 μmol/L] increase: OR 1.01, 95% CI 0.93 to 1.09) and non-gastrointestinal cancer (OR 1.10, 95% CI 0.98 to 1.24). However, there was a significant, inverse association between vitamin E and gastrointestinal cancer (OR 0.86, 95% CI 0.75 to 0.99), particularly esophageal cancer (OR 0.67, 95% CI 0.48 to 0.95). Moreover, high vitamin E decreased the risk of total cancer (OR 0.91, 95% CI 0.84 to 0.99) and gastrointestinal cancer (OR 0.83, 95% CI 0.73 to 0.95) among patients with high selenium levels (median≥83.7 μg/L [1.1 μmol/L]), and increased the risk of total cancer (OR 1.13, 95% CI 1.00 to 1.26) and non-gastrointestinal cancer (OR 1.25, 95% CI 1.03 to 1.50) among those with low selenium levels (<83.7 μg/L [1.1 μmol/L]).Conclusions
This study suggests that higher levels of plasma vitamin E are associated with reduced risk of gastrointestinal cancer. High vitamin E decreased the risk of total cancer among patients with high selenium levels, but increased the risk of total cancer among those with low selenium levels. 相似文献10.
Joyce Y.C. Chan Karen K.L. Yiu Timothy C.Y. Kwok Samuel Y.S. Wong Kelvin K.F. Tsoi 《Journal of the American Medical Directors Association》2019,20(3):279-286.e1
Objective
To investigate whether depression and/or antidepressants can be a potential risk factor for the development of dementia and mild cognitive impairment (MCI).Design
Systematic review and meta-analysis of longitudinal studies.Setting and Participants
Community or clinical settings. Participants included patients with depression, antidepressant users, and the general population.Measures
Longitudinal studies evaluating the risks of dementia or MCI in patients with depression and/or antidepressant users were identified from the OVID database. The outcomes were the number of patients who developed dementia or MCI among the antidepressant users and nonusers. Relative risk (RR) with 95% confidence interval (95% CI) was used to evaluate the association between the use of antidepressants and the risk of dementia and MCI. Meta-analysis was used for combining the effect sizes of individual studies, and the heterogeneity test was performed. Risk of bias and reporting quality of included studies was assessed. Subgroup analyses were conducted for different types of antidepressants.Results
A total of 18 studies with 2,119,627 participants with mean age ranging from 55 to 81 years were included. Among patients with depression, antidepressant users showed a significantly higher risk of dementia (RR = 1.37, 95% CI = 1.11-1.70) and MCI (RR = 1.20, 95% CI = 1.02-1.42) than the nonusers. Besides, patients with depression who used antidepressants and who did not use antidepressants also showed significantly higher risk of dementia than the general population (RR = 1.50, 95% CI = 1.26-1.78, and RR = 1.31, 95% CI = 1.15-1.51, respectively).Conclusions/Implications
Patients with depression are associated with a higher risk of dementia, and the use of antidepressants is not shown to be a protective factor of dementia. Further large-scale trials are required for investigation of the benefit-risk ratio between depression relapse and dementia when prescribing antidepressants. 相似文献11.
Masahiro Waza Keisuke Maeda Chihiro Katsuragawa Atsuko Sugita Ryotarou Tanaka Asako Ohtsuka Tomo Matsui Keiko Kitagawa Taiki Kishimoto Hiroko Fukui Katsuhisa Kawai Masahiko Yamamoto Michio Isono 《Journal of the American Medical Directors Association》2019,20(4):426-431
Objective
To determine the influence of the Kuchi-kara Taberu (KT) index on rehabilitation outcomes during hospitalized convalescent rehabilitation.Design
A historical controlled study.Setting and Participants
A rehabilitation hospital.Participants
Patients who were admitted to a convalescent rehabilitation ward from June 2014 to May 2017.Measures
Patients’ background characteristics included age, sex, nutritional status, activities of daily living (ADL) assessed using the Functional Impedance Measure (FIM), dysphagia assessed using the Functional Oral Intake Scale (FOIS), and reasons for rehabilitation. The following values before (control group) and after initiation of the KT index intervention period (intervention group) were compared: gain of FIM, length of stay, accumulated rehabilitation time, discharge destination, gain of FOIS, gain of body weight (BW), and nutritional intake (energy and protein).Results
Mean age was 76.4 ± 12.3 years (n = 233). There were no significant differences in the baseline characteristics of the patients at admission between the control and intervention groups, except for reason of rehabilitation. The intervention group demonstrated statistically higher values for the total (P = .004) and motor FIM gain (P = .003), total (P = .018) and motor FIM efficiency (P = .016), and FOIS gain (P < .001), compared with values in the control group. The proportion of patients returning home was statistically more frequent in the intervention group compared with that in the control group (73.4% vs 85.5%, odds ratio 2.135, 95% confidence interval [CI] 1.108-4.113, P = .022). Multivariate analyses indicated that intervention using the KT index was a significant independent factor for increased FIM gain (β coefficient = 0.163, 95% CI 1.379-8.329, P = .006) and returning home (adjusted odds ratio 2.570, 95% CI 1.154-5.724, P = .021).Conclusions/Implications
A rehabilitation program using the KT index may lead to improvement of inpatient outcomes in post-acute care. Further prospective research is warranted to confirm the efficacy of this program. 相似文献12.
Hillary Lum Oluyomi Obafemi Joanna Dukes Molly Nowels Kristina Samon Rebecca S. Boxer 《Journal of the American Medical Directors Association》2017,18(10):885-890
Background
Individuals with heart failure (HF) who are hospitalized and admitted to skilled nursing facilities (SNFs) are at high risk for rehospitalization and death. The care preferences of this high-risk population have not been studied.Objectives
To describe care preferences of patients with HF admitted to SNFs for rehabilitation based on Medical Orders for Scope of Treatment (MOST) documentation, and evaluate goal-concordant care based on MOST documentation, emergency department (ED) visits, and hospitalization.Design, setting, and participants
Retrospective study of patients with HF in 35 SNFs enrolled in a randomized controlled trial of HF-disease management versus usual care between July 2014 and May 2016.Measurements
Validity of MOST forms, care preference documentation, and ED visits/hospitalizations within 60 days of SNF admission.Results
Of 370 patients (mean age 78.6 years, 58% women, 25% systolic HF), 278 (75%) had a MOST form in the SNF chart, of which 96 forms (35%) were invalid. The most common reason for an invalid MOST form was missing date accompanying patient or provider signature. Of 182 valid MOST forms, 47% of patients chose no cardiopulmonary resuscitation (“No CPR”), 58% selected “Full Treatment,” 17% chose “Selective Treatment,” and 23% chose “Comfort-Focused Treatment.” Patients who were older [odds ratio (OR) = 1.50, 95% confidence interval (CI) = 1.25, 1.81] and female (OR = 2.33, 95% CI = 1.18, 4.59) had higher odds of choosing “No CPR.” Sixty-six of 182 patients (36%) with valid MOST forms had an ED/hospital visit within 60 days of SNF admission; only 3 patients received medical care that was potentially discordant: all 3 chose “Comfort-Focused Treatment” and were hospitalized for more than symptom management.Conclusion
Seventy-five percent of patients with HF admitted to SNFs had care preferences documented using the MOST form, and 95% received goal-concordant care based on care preferences documented during the SNF admission. Clinicaltrials.gov # NCT01822912. 相似文献13.
Paolo Dionigi Rossi Sarah Damanti Carolina Nani Mauro Pluderi Giulio Bertani Daniela Mari Matteo Cesari Dario Consonni Diego Spagnoli 《Journal of the American Medical Directors Association》2019,20(3):373-376.e3
Objectives
To evaluate the effects of repeated cerebrospinal fluid (CSF) tap procedures in idiopathic normal pressure hydrocephalus (iNPH) patients ineligible for surgical treatment.Design
Prospective, monocentric, pilot study.Setting
University hospital.Participants
Thirty-nine patients aged 75 years and older, ineligible for shunting surgical intervention.Intervention
Repeated CSF taps.Measurements
All patients underwent a comprehensive geriatric assessment before and after each CSF tap. Adverse events were recorded.Results
No major side effect was reported. Eleven patients showed no response to the first CSF tap test and were excluded. In the remaining 28 patients, all physical and cognitive functions improved after the drainage procedures, except for continence (which seemed poorly influenced). According to clinical judgment, the mean time frame of benefit between CSF taps was 7 months. Patients withdrawing from the protocol during the clinical follow-up showed a worsening of functional and cognitive performances after the interruption.Conclusions/Implications
Periodic CSF therapeutic taps are safe, allow a better control of iNPH symptoms, and prevent functional decline in geriatric patients. 相似文献14.
Thierry Bautrant Michel Grino Corinne Peloso Frédéric Schiettecatte Magali Planelles Charles Oliver Caroline Franqui 《Journal of the American Medical Directors Association》2019,20(3):377-381
Objectives
To determine whether environmental rearrangements of the long-term care nursing home can affect disruptive behavioral and psychological symptoms of dementia (BPSD) in residents with dementia.Design
Prospective 6-month study.Setting
The study was conducted before (phase 1) and after (phase 2) environmental rearrangements [skylike ceiling tiles in part of the shared premises, progressive decrease of the illuminance at night together with soothing streaming music, reinforcement of the illuminance during the day, walls painted in light beige, oversized clocks in corridors, and night team clothes color (dark blue) different from that of the day team (sky blue)].Participants
All of the patients (n = 19) of the protected unit were included in the study. They were aged 65 years or older and had an estimated life expectancy above 3 months.Measures
Number and duration of disruptive BPSD were systematically collected and analyzed over 24 hours or during late hours (6:00-12:00 pm) during each 3-month period.Results
There was no significant change in the patients' dependency, risk of fall, cognitive or depression indexes, or treatment between phase 1 and 2. Agitation/aggression and screaming were observed mainly outside the late hours as opposed to wandering episodes that were noticed essentially within the late hours. The number of patients showing wandering was significantly lower over 24 hours during phase 2. The number of agitation/physical aggression, wandering, and screaming and the mean duration of wandering episodes were significantly (P = .039, .002, .025, and .026 respectively) decreased over 24 hours following environmental rearrangements. Similarly, a significant reduction in the number and mean duration of wandering was noticed during the late hours (P = .031 and .007, respectively).Conclusions
Our study demonstrates that BPSD prevalence can be reduced following plain environmental rearrangements aimed at improving spatial and temporal orientation. 相似文献15.
Silvia Gonella Ines Basso Valerio Dimonte Barbara Martin Paola Berchialla Sara Campagna Paola Di Giulio 《Journal of the American Medical Directors Association》2019,20(3):249-261
Objective
Less aggressive end-of-life (EOL) care has been observed when health care professionals discuss approaching EOL and preferences about life-sustaining treatments with nursing home (NH) residents or their families. We performed a comprehensive systematic review to evaluate the association between health care professionals–residents and health care professionals–family EOL conversations and EOL care outcomes.Design
Systematic review with meta-analysis.Setting and Participants
Seven databases were searched in December 2017 to find studies that focused on health care professionals–residents (without oncologic disease) and health care professionals–family EOL conversations and aimed to explore the impact of EOL conversations on resident's or family's EOL care outcomes.Measures
Random effects meta-analyses with subsequent quality sensitivity analysis and meta-regression were performed to assess the effects of EOL conversations on the decision to limit or withdraw life-sustaining treatments. A funnel plot and Eagger test were used to assess publication bias.Results
16 studies were included in the qualitative and 7 in the quantitative synthesis. Health care professionals–family EOL conversations were positively associated with the family's decision to limit or withdraw life-sustaining treatments (odds ratio = 2.23, 95% confidence interval: 1.58-3.14).The overall effect of health care professionals–family EOL conversations on the family's decision to limit or withdraw life-sustaining treatments remained stable in the quality sensitivity analysis. In the meta-regression, family members with a higher level of education were less influenced by EOL conversations with health care professionals when making decisions about limiting or withdrawing life-sustaining treatments. No publication bias was detected (P = .4483).Conclusions/Implications
This systematic review shows that EOL conversations promote palliative care. Structured conversations aimed at exploring NH resident preferences about EOL treatment should become routine. NH administrators should offer health care professionals regular training on EOL conversations, and resident-centered care that involves residents and their families in a shared decision-making process at EOL needs to be promoted. 相似文献16.
Shubing Cai Susan C. Miller Ira B. Wilson 《Journal of the American Medical Directors Association》2019,20(4):497-502
Objective(s)
To examine the change in physical functional status among persons living with HIV (PLWH) in nursing homes (NHs) and how change varies with age and dementia.Design
Retrospective cohort study.Setting
NHs in 14 states in the United States.Participants
PLWH who were admitted to NHs between 2001 and 2010 and had stays of ≥90 days (N = 3550).Measurements
We linked Medicaid Analytic eXtract (MAX) and Minimum Data Set (MDS) data for NH residents in the sampled states and years and used them to determine HIV infection. The main outcome was improvement in physical functional status, defined as a decrease of at least 4 points in the activities of daily living (ADL) score within 90 days of NH admission. Independent variables of interest were age and dementia (Alzheimer's disease or other dementia). Multivariate logistic regression was used, adjusting for individual-level covariates.Results
The average age on NH admission of PLWH was 58. Dementia prevalence ranged from 14.5% in the youngest age group (age <40 years) to 38.9% in the oldest group (age ≥70 years). Overall, 44% of the PLWH experienced ADL improvement in NHs. Controlling for covariates, dementia was related to a significantly lower likelihood of ADL improvement among PLWH in the oldest age group only: the adjusted probability of improvement was 40.6% among those without dementia and 29.3% among those with dementia (P < .01).Conclusions/relevance
PLWH, especially younger persons, may be able to improve their ADL function after being admitted into NHs. However, with older age, PLWH with dementia are more physically dependent and vulnerable to deterioration of physical functioning in NHs. More and/or specialized care may be needed to maintain physical functioning among this population. Findings from this study provide NHs with information on care needs of PLWH and inform future research on developing interventions to improve care for PLWH in NHs. 相似文献17.
Hylco Bouwstra Ewout B. Smit Elizabeth M. Wattel Johannes C. van der Wouden Cees M.P.M. Hertogh Berend Terluin Caroline B. Terwee 《Journal of the American Medical Directors Association》2019,20(4):420-425.e1
Objective
The Barthel index (BI) is a widely used observer-based instrument to measure physical function. Our objective is to assess the structural validity, reliability, and interpretability of the BI in the geriatric rehabilitation setting.Design
Two studies were performed. First, a prospective cohort study was performed in which the attending nurses completed the BI at admittance and discharge (n = 207). At discharge, patients rated their change in physical function on a 5-point Likert rating scale. To assess the internal structure of the BI, a confirmatory factor analysis was performed. Unidimensionality was defined by comparative fit index and Tucker-Lewis index of >0.95, and root mean square error of approximation of <0.06. To evaluate interpretability, floor/ceiling effects and the minimal important change (MIC) were assessed. Predictive modeling was used to calculate the MIC. The MIC was defined as going home and minimal patient-reported improvement defined as slightly or much improved physical function, which served as anchors to obtain a clinical- and patient-based MIC. A second group of 37 geriatric rehabilitation patients were repeatedly assessed by 2 attending nurses to assess reliability of the BI. The intraclass correlation coefficient, standard error of measurement, and smallest detectable change were calculated.Setting and Participants
Patients receiving inpatient geriatric rehabilitation admitted to 11 Dutch nursing homes (n = 244).Results
Confirmatory factor analysis showed partly acceptable fit of a unidimensional model (comparative fit index 0.96, Tucker-Lewis index 0.95, and root mean square error of approximation 0.12). The clinical-based MIC was 3.1 [95% confidence interval (CI) 2.0–4.2] and the patient-based MIC was 3.6 (95% CI 2.8–4.3). The intraclass correlation coefficient was 0.96 (95% CI 0.93–0.98). The standard error of measurement and smallest detectable change were 1.1 and 3.0 points, respectively.Conclusions/Implications
The structural validity, reliability, and interpretability of the BI are considered sufficient for measuring and interpreting changes in physical function of geriatric rehabilitation patients. 相似文献18.
Joseph Carson Stephanie Gottheil Sherri Lawson Tim Rice 《Journal of the American Medical Directors Association》2019,20(4):481-486
Background
Long-term care (LTC) homes expressed concern that patients had experienced medication incidents after hospital discharge as a result of poor coordination of care.Objective
The London Transfer Project aimed to reduce LTC medication incidents by 50% within 48 hours of discharge from general medicine units at the London Health Sciences Centre.Design
This quality improvement study involved 2 hospitals and 5 LTC homes in London, Ontario, Canada. The baseline prevalence of medication incidents was measured and explored for root causes. Two change ideas were tested on general medicine units to improve transfer communication: (1) expediting medication reconciliation and (2) faxing medication plans before discharge.Measures
Evaluation involved time-series measurement and a comparison of baseline and intervention periods. The primary outcome was medication incidents by omission or commission within 48 hours of discharge, which was determined by dual chart reviews in hospital and LTC homes. Process measures included medication reconciliation and fax completion times. Hospital discharge times were included as a balance measure of the new communication process.Results
Four hundred seventy-seven LTC transfers were reviewed between 2016 and 2017; 92 transfers were reviewed for medication incidents in participating homes at baseline (January-April 2016) and implementation (January-April 2017). Medication incidents decreased significantly by 56%, from 44% (22/50) at baseline to 19% (8/42) during implementation (P = .006). Medication reconciliation completion by noon increased from 56% (28/50) to 74% (31/42) but not significantly (P = .076). Faxes sent before discharge increased significantly from 4% (2/50) to 67% (28/42, P = .015). There was no significant change in hospital discharge time.Conclusions/Implications
Medication incidents can be significantly reduced during care transitions by taking a systems perspective to explore quality gaps and redesign communication processes. This solution will be scaled to other inpatient services with a high proportion of LTC residents. 相似文献19.
Jennifer L. Carnahan James E. Slaven Christopher M. Callahan Wanzhu Tu Alexia M. Torke 《Journal of the American Medical Directors Association》2017,18(10):853-859
Background
Many adults are discharged to skilled nursing facilities (SNFs) prior to returning home from the hospital. Patient characteristics and factors that can help to prevent postdischarge adverse outcomes are poorly understood.Objective
To identify whether early post–SNF discharge care reduces likelihood of 30-day hospital readmissions.Design
Secondary data analysis using the Electronic Medical Record, Medicare, Medicaid and the Minimum Data Set.Participants/setting
Older (age > 65 years), community-dwelling adults admitted to a safety net hospital in the Midwest for 3 or more nights and discharged home after an SNF stay (n = 1543).Measurements
The primary outcome was hospital readmission within 30 days of SNF discharge. The primary independent variables were either a home health visit or an outpatient provider visit within a week of SNF discharge.Results
Out of 8754 community-dwelling, hospitalized older adults, 3025 (34.6%) were discharged to an SNF, of whom 1543 (51.0%) returned home. Among the SNF to home group, a home health visit within a week of SNF discharge was associated with reduced hazard of 30-day hospital readmission [adjusted hazard ratio (aHR) 0.61, P < .001] but outpatient provider visits were not associated with reduced risk of hospital readmission (aHR = 0.67, P = .821).Conclusion
For patients discharged from an SNF to home, the finding that a home health visit within a week of discharge is associated with reduced hazard of 30-day hospital readmissions suggests a potential avenue for intervention. 相似文献20.
Jing-Hong Liang Jia-Yu Li Rui-Xia Jia Ying-Quan Wang Rong-Kun Wu Hong-Bo Zhang Lei Hang Yong Xu Chen-Wei Pan 《Journal of the American Medical Directors Association》2019,20(3):347-355