Exploring Antipsychotic Prescribing Behaviors for Nursing Home Residents With Dementia: A Qualitative Study

Objectives

Caution is advised when prescribing antipsychotics to people with dementia. This study explored the determinants of appropriate, evidence-based antipsychotic prescribing behaviors for nursing home residents with dementia, with a view to informing future quality improvement efforts and behavior change interventions.

Quality of Post-Acute Care in Skilled Nursing Facilities That Disproportionately Serve Hispanics With Dementia

ObjectivesAs the number of Hispanics with dementia continues to increase, greater use of post-acute care in nursing home settings will be required. Little is known about the quality of skilled nursing facilities (SNFs) that disproportionately serve Hispanic patients with dementia and whether the quality of SNF care varies by the concentration of Medicare Advantage (MA) patients with dementia admitted to these SNFs.DesignCross-sectional study using 2016 data from Medicare certified providers.Setting and ParticipantsOur cohort included 177,396 beneficiaries with probable dementia from 8884 SNFs.MethodsWe examined facility-level quality of care among facilities with high and low proportions of Hispanic beneficiaries with probable dementia enrolled in MA and fee-for-service (FFS) using data from Medicare-certified providers. Three facility-level measures were used to assess quality of care: (1) 30-day rehospitalization rate; (2) successful discharge from the facility to the community; and (3) Medicare 5-star quality ratings.ResultsAbout 20% of residents were admitted to 1615 facilities with a resident population that was more than 15% Hispanic. Facilities with a higher share of Hispanic residents had a lower proportion of 4- or 5-star facilities by an average of 14% to 15% compared with facilities with little to no Hispanics. In addition, these facilities had a 1% higher readmission rate. There were also some differences in the quality of facilities with high (>26.5%) and low (<26.5%) proportions of MA beneficiaries. On average, SNFs with a high concentration of MA patients have lower readmission rates and higher successful discharge, but lower star ratings.Conclusions and ImplicationsAchieving better quality of care for people with dementia may require efforts to improve the quality of care among facilities with a high concentration of Hispanic residents.     

Effectiveness of Powerful Tools for Caregivers on Caregiver Burden and on Care Recipient Behavioral and Psychological Symptoms of Dementia: A Randomized Controlled Trial

ObjectiveThe aim of this study was to evaluate the effectiveness of a psychoeducational intervention, Powerful Tools for Caregivers (PTC), for family caregivers of individuals with dementia.DesignA pragmatic, 2-arm randomized controlled trial compared the PTC intervention, as delivered in practice, to usual care. Participants randomized to usual care functioned as a control group and then received the PTC intervention.InterventionPTC is a 6-week manualized program that includes weekly 2-hour classes in a group setting facilitated by 2 trained and certified leaders. The educational program helps caregivers to enhance self-care practices and manage emotional distress.Setting and participantsTwo stakeholder organizations delivered the intervention in community settings. Participants were family caregivers of individuals with dementia recruited from the community in Florida.MethodsPrimary outcomes were caregiver burden and behavioral and psychological symptoms of dementia of the care recipient. Secondary outcomes included caregiver depressive symptoms, self-efficacy, self-rated health, and life satisfaction. Measures were collected at baseline (n = 60 participants), postintervention (n = 55), and at 6-week follow-up (n = 44).ResultsIntent-to-treat analyses found PTC reduced caregiver burden (d = −0.48) and depressive symptoms (d = −0.53), and increased self-confidence (d = 0.68), but found no significant benefit for behavioral and psychological symptoms of dementia in care recipients. PTC was rated highly by participants and program attrition was low, with 94% of caregivers completing at least 4 of the 6 classes.Conclusions and implicationsAlthough no significant effects were found for behavioral and psychological symptoms of dementia, this trial supports the effectiveness of PTC to improve caregiver outcomes as delivered in the community.     

Music Compared with Auditory Books: A Randomized Controlled Study Among Long-Term Care Residents with Alzheimer's Disease or Related Dementia

BackgroundOver 5 million Americans age 65 years and older were diagnosed with Alzheimer's disease and/or related dementia (ADRD), a majority of whom exhibit behavioral and psychological symptoms leading to placement in long-term care settings. These facilities need nonmedical interventions, and music-based programs have received supportive evidence.SettingThirteen long-term care facilities were among a wave of facilities that volunteered to be trained and to administer a music-based intervention. The residents within were randomized into intervention or control groups (intervention/music, n = 103; control/audiobook, n = 55).DesignThis team used a pragmatic trial to randomly embed music and control (audiobooks) into 13 long-term care facilities to compare the effects on agitation in people with ADRD.MethodsMeasures included a demographic survey; the Mini-Mental Status Examination, used to assess cognitive status; and the Cohen-Mansfield Agitation Inventory with 4 subscales, used to measure agitation. These measures were implemented at baseline and every 2 weeks for 8 weeks. Mixed-effects models were used to evaluate change in agitation measures while addressing dependencies of scores within participants and facility.ResultsDecreases in agitation were attributable to both music and audiobooks in 3 of 4 agitation subscales. In the fourth, physical agitation, which was not directed toward staff, initially, it decreased given music, and increased thereafter; and generally, it increased with the audiobooks.Conclusion and ImplicationsBoth music and control audiobooks delivered by headphones after personalized selection reduced some aspects of agitation in residents diagnosed with ADRD. The effects of music were greater initially then diminished.     

Impact of Prior Home Care on Length of Stay in Residential Care for Australians With Dementia

ObjectivesTo assess the impact of home care on length-of-stay within residential care.DesignA retrospective observational data-linkage study.Setting and ParticipantsIn total there were 3151 participants from the 45 and Up Study in New South Wales, Australia with dementia who entered residential care between 2010 and 2014.MethodsSurvey data collected from 2006‒2009 were linked to administrative data for 2006‒2016. The highest level of home care a person accessed prior to residential care was defined as no home care, home support, low-level home care, and high-level home care. Multinomial logistic regression and Cox proportional hazards were used to investigate differences in activities of daily living, behavioral, and complex healthcare scales at entering residential care; and length-of-stay in residential care.ResultsPeople with prior high-level home care entered residential care needing higher assistance compared with the no home care group: activities of daily living [odds ratio (OR) 3.41, 95% confidence interval (CI) 2.14‒5.44], behavior (OR 2.61, 95% CI 1.69‒4.03), and complex healthcare (OR 2.02, 95% CI 1.06‒3.84). They had a higher death rate, meaning shorter length-of-stay in residential care (<2 years after entry: hazard ratio 1.12; 95% CI 0.89‒1.42; 2-4 years: hazard ratio 1.49; 95% CI 1.01‒2.21). Those using low-level home care were less likely to enter residential care needing high assistance compared to the no home care group (activities of daily living: OR 0.61, 95% CI 0.45‒0.81; behavioral: OR 0.72, 95% CI 0.54‒0.95; complex healthcare: OR 0.51, 95% CI 0.33‒0.77). There was no difference between the home support and no home care groups.ConclusionsHigh-level home care prior to residential care may help those with dementia stay at home for longer, but the low-level care group entered residential care at low assistance levels, possibly signaling lack of informal care and barriers in accessing higher-level home care.ImplicationsBetter transition options from low-level home care, including more timely availability of high-level care packages, may help people with dementia remain at home longer.     

The Course of Quality of Life and Its Predictors in Nursing Home Residents With Young-Onset Dementia

ObjectiveTo explore the course of quality of life (QoL) and possible resident-related predictors associated with this course in institutionalized people with young-onset dementia (YOD).DesignAn observational longitudinal study.Setting and ParticipantsA total of 278 residents with YOD were recruited from 13 YOD special care units in the Netherlands.MethodsSecondary analyses were conducted with longitudinal data from the Behavior and Evolution in Young-ONset Dementia (BEYOND)-II study. QoL was assessed with proxy ratings, using the Quality of Life in Dementia (QUALIDEM) questionnaire at 4 assessment points over 18 months. Predictors included age, gender, dementia subtype, length of stay, dementia severity, neuropsychiatric symptoms, and psychotropic drug use at baseline. Multilevel modeling was used to adjust for the correlation of measurements within residents and clustering of residents within nursing homes.ResultsThe total QUALIDEM score (range: 0-111) decreased over 18 months with a small change of 0.65 (95% confidence interval −1.27, −0.04) points per 6 months. An increase in several domains of QoL regarding care relationship, positive self-image, and feeling at home was seen over time, whereas a decline was observed in the subscales positive affect, social relations, and having something to do. Residents with higher levels of QoL and more advanced dementia at baseline showed a more progressive decline in QoL over time. Sensitivity analyses indicated a more progressive decline in QoL for residents who died during the follow-up.Conclusion and ImplicationsThis study shows that although overall QoL in nursing home residents with YOD was relatively stable over 18 months, there were multidirectional changes in the QoL subscales that could be clinically relevant. Higher levels of QoL and more advanced stages of dementia at baseline predicted a more progressive decline in QoL over time. More longitudinal studies are needed to verify factors influencing QoL in YOD.     

Autonomy Support of Nursing Home Residents With Dementia in Staff-Resident Interactions: Observations of Care

ObjectivesPeople with dementia living in nursing homes benefit from a social environment that fully supports their autonomy. Yet, it is unknown to what extent this is supported in daily practice. This study aimed to explore to which extent autonomy is supported within staff–resident interactions.DesignAn exploratory, cross-sectional study.Setting and ParticipantsIn total, interactions between 57 nursing home residents with dementia and staff from 9 different psychogeriatric wards in the Netherlands were observed.MethodsStructured observations were carried out to assess the support of resident autonomy within staff–resident interactions. Observations were performed during morning care and consisted of 4 main categories: getting up, physical care, physical appearance, and breakfast. For each morning care activity, the observers consecutively scored who initiated the care activity, how staff facilitated autonomy, how residents responded to staff, and how staff reacted to residents’ responses. Each resident was observed during 3 different mornings. In addition, qualitative field notes were taken to include environment and ambience.ResultsIn total, 1770 care interactions were observed. Results show that autonomy seemed to be supported by staff in 60% of the interactions. However, missed opportunities to engage residents in choice were frequently observed. These mainly seem to occur during interactions in which staff members took over tasks and seemed insensitive to residents’ needs and wishes. Differences between staff approach, working procedures, and physical environment were observed across nursing home locations.Conclusions and ImplicationsThe findings of this study indicate that staff members support resident autonomy in more than one-half of the cases during care interactions. Nonetheless, improvements are needed to support resident autonomy. Staff should be encouraged to share and increase knowledge in dementia care to better address residents’ individual needs. Especially for residents with severe dementia, it seems important that staff develop skills to support their autonomy.     

Quality of Nursing Homes and Admission of Residents With Alzheimer's Disease and Related Dementias: The Potential Influence of Market Factors and State Policies

ObjectivesThis study aimed to examine the associations between nursing home (NH) quality and prevalence of newly admitted NH residents with Alzheimer's disease and related dementias (ADRD), and to assess the extent to which market-level wages for certified nursing assistants (CNAs) and state Medicaid behavioral and mental health add-on policy may influence such associations.DesignRetrospective cohort study.Setting and ParticipantsThe analytical sample included 2777 NHs with either high or low quality, located in urban areas of 41 states from 2011 to 2014.MethodsThe outcome variable was the prevalence of ADRD among newly admitted NH residents. NH quality was defined as dichotomous, based on the Nursing Home Compare (NHC) star rating system. We considered an NH with 5-star rating as having high quality and with 1-star rating as having low quality. Information on county-level CNA wages and state Medicaid behavioral and mental health add-on policies was included. Linear regression models with NH random effects and robust standard errors were estimated. A set of sensitivity analyses were performed.ResultsAfter accounting for NH-level aggregated resident characteristics and market/state-level factors, the prevalence of ADRD among newly admitted residents was 3% lower in high-quality NHs compared with low-quality NHs (P < .01). A 1-dollar increase in CNA hourly wage was associated with a 0.9–percentage point decrease in the prevalence of ADRD among newly admitted residents (P < .01). State Medicaid behavioral and mental health add-on policy was associated with a 2.5–percentage point increase in the prevalence of ADRD in high-quality NHs (P < .05), but not in low-quality NHs.Conclusions and ImplicationsOur findings suggest that high-quality NHs are less likely to admit residents with ADRD. The effect size of this relationship is modest and may be influenced by state Medicaid behavioral and mental health add-on policies. Future studies are needed to better understand reasons leading to these associations so that effective interventions can be developed to incentivize high-quality NHs to more readily serve residents with ADRD.     

Preventable Hospitalizations Among Nursing Home Residents With Dementia and Behavioral Health Disorders

ObjectiveNursing home (NH) residents with Alzheimer's disease/related dementias (ADRD) and/or behavioral health disorders (BHD) are at high risk of hospitalizations, many of which are potentially avoidable. Empirical evidence regarding potentially avoidable hospitalizations (PAHs) among these residents is quite sparse and mixed. The objectives of this study were to (1) examine the risk of PAH among residents with ADRD only, BHD only, ADRD and BHD compared to residents with neither and (2) identify associations between individual- and facility-level factors and PAH in these subgroups.DesignRetrospective, CY2014-2015.Setting and ParticipantsLong-term residents age 65+ (N = 807,630) residing in 15,234 NHs.MethodsWe employed the Minimum Data Set, MedPAR, Medicare beneficiary summary, and Nursing Home Compare. Hospitalization risk was the outcome of interest. Individual-level covariates were used to adjust for health conditions. Facility-level covariates and state dummies were included. Multinomial logistic regression models were fit to estimate the risk of PAH and non–potentially avoidable hospitalizations (N-PAH).ResultsCompared to residents without ADRD or BHD, those with ADRD had at least a 10% lower relative risk ratio (RRR) of N-PAH and a significantly lower risk of PAH, at 16% (P < .0001). Residents with BHD only had a statistically higher, but clinically very modest (RRR = 1.03) risk of N-PAH, with no difference in the risk of PAH. Focusing on specific BHD conditions, we found no difference in N-PAH or PAH among residents with depression, lower PAH risk among those with schizophrenia/psychosis (RRR = 0.92), and an increased risk of both N-PAH (RRR = 1.15) and PAH (RRR = 1.09) among residents with bipolar disorders.Conclusions and RelevanceWe observed a lower risk of PAH and N-PAH among residents with ADRD, with the risk for residents with BHD varying by condition. Substantial variations in PAH and N-PAH were evident across states. Future research is needed to identify state-level modifiable factors that explain these variations.     

A Cluster Randomized Controlled Trial Testing the Impact of Function and Behavior Focused Care for Nursing Home Residents With Dementia

ObjectiveThe purpose of this study was to test the effectiveness of the Function and Behavior Focused Care for the Cognitively Impaired (FBFC-CI) intervention on function, physical activity, and behavioral symptoms among nursing home residents with dementia, and to explore the adoption of the intervention at the facility level.DesignThis study was a clustered, randomized controlled trial with a repeated measures design that was implemented in 12 nursing homes randomized to either treatment (FBFC-CI) or educational control [Function and Behavior Focused Care Education (FBFC-ED)].Setting and ParticipantsTwelve nursing homes (6 treatment and 6 control) and 336 residents (173 treatment and 163 control) with moderate to severe cognitive impairment.MeasuresOutcomes included functional ability (Barthel Index), physical activity (actigraphy and survey), behavioral symptoms (Resistiveness to Care Scale, Cohen-Mansfield Agitation Inventory, Cornell Scale for Depression in Dementia), and psychotropic medication use.ResultsThe participants were 82.6 (SD = 10.1) years of age, mostly female, and were moderate to severely cognitively impaired (Mini-Mental State Exam of 7.8, SD = 5.1). There was a significantly greater increase in time spent in total activity (P = .004), moderate activity (P = .012), light activity (P = .002), and a decrease in resistiveness to care (P = .004) in the treatment versus control group at 4 months. There was no change in mood, agitation, and the use of psychotropic medications. There was some evidence of adoption of the intervention at treatment sites.Conclusions and ImplicationsThis study provides some support for the use of the FBFC-CI Intervention to increase time spent in physical activity and decrease resistive behaviors during care commonly noted among nursing home residents with moderate to severe cognitive impairment.     

Structured Care Protocols to Reduce Behavior That Challenges in People With Dementia: A Systematic Review

ObjectivesPeople with dementia often express behavior that challenges, such as agitation and aggression. Structured care protocols aim to identify common causes of behavior and facilitate the selection of appropriate treatments. The protocols comprise different steps including specific assessments and related nonpharmacologic and pharmacologic treatments. We aim to assess the effects of such protocols to reduce behavior that challenges.DesignSystematic review according to the methods of Cochrane and registered in PROSPERO (CRD42020155706).Setting and ParticipantsPeople with dementia living in nursing homes.MethodsThe systematic search (September 2020) included databases (MEDLINE, CINAHL, Cochrane Library) and other sources. Two reviewers independently performed the study selection, data extraction, and quality assessment for all included studies. A narrative synthesis was conducted owing to the small number of studies and the heterogeneity of instruments.ResultsFour studies with 596 participants were included. Three studies compared a version of the Serial Trial Intervention, with control groups receiving education about behavior that challenges. One study compared 2 versions of the intervention. The methodologic quality was moderate. For behavior that challenges, there was little to no effect of structured care protocols (4 studies). Two studies found little to no effect on pain and quality of life. Structured care protocols may reduce discomfort (2 studies). None of the studies reported adverse effects. The certainty of evidence was low to moderate. Implementation fidelity of the structured care protocols was limited, although this was not assessed in all of the studies.Conclusion and ImplicationsStructured care protocols seem not to be more beneficial than education for reducing behavior that challenges or pain, but may reduce discomfort in people with dementia in nursing homes. Based on the small number of studies, the results should be interpreted with caution. Further research should focus on the feasibility and implementation of structured care protocols.     

Pragmatic Trial of Personalized Music for Agitation and Antipsychotic Use in Nursing Home Residents With Dementia

ObjectiveTo test the effect of a personalized music intervention on agitated behaviors and medication use among long-stay nursing home residents with dementia.DesignPragmatic, cluster-randomized controlled trial of a personalized music intervention. Staff in intervention facilities identified residents' early music preferences and offered music at early signs of agitation or when disruptive behaviors typically occur. Usual care in control facilities may include ambient or group music.Setting and ParticipantsThe study was conducted between June 2019 and February 2020 at 54 nursing homes (27 intervention and 27 control) in 10 states owned by 4 corporations.MethodsFour-month outcomes were measured for each resident. The primary outcome was frequency of agitated behaviors using the Cohen-Mansfield Agitation Inventory. Secondary outcomes included frequency of agitated behaviors reported in the Minimum Data Set and the proportion of residents using antipsychotic, antidepressant, or antianxiety medications.ResultsThe study included 976 residents with dementia [483 treatment and 493 control; mean age = 80.3 years (SD 12.3), 69% female, 25% African American]. CMAI scores were not significantly different (treatment: 50.67, SE 1.94; control: 49.34, SE 1.68) [average marginal effect (AME) 1.33, SE 1.38, 95% CI ?1.37 to 4.03]. Minimum Data Set–based behavior scores were also not significantly different (treatment: 0.35, SE 0.13; control: 0.46, SE 0.11) (AME –0.11, SE 0.10, 95% CI ?0.30 to 0.08). Fewer residents in intervention facilities used antipsychotics in the past week compared with controls (treatment: 26.2, SE 1.4; control: 29.6, SE 1.3) (AME –3.61, SE 1.85, 95% CI ?7.22 to 0.00), but neither this nor other measures of psychotropic drug use were statistically significant.Conclusions and ImplicationsPersonalized music was not significantly effective in reducing agitated behaviors or psychotropic drug use among long-stay residents with dementia. Barriers to full implementation included engaging frontline nursing staff and identifying resident's preferred music.     

Influences on Decision-Making Regarding Antipsychotic Prescribing in Nursing Home Residents With Dementia: A Systematic Review and Synthesis of Qualitative Evidence

Background

Antipsychotic prescribing is prevalent in nursing homes for the management of behavioral and psychological symptoms of dementia (BPSD), despite the known risks and limited effectiveness. Many studies have attempted to understand this continuing phenomenon, using qualitative research methods, and have generated varied and sometimes conflicting findings. To date, the totality of this qualitative evidence has not been systematically collated and synthesized.

Association Between Home Health Services and Facility Admission in Older Adults With and Without Alzheimer's Disease

ObjectivesTo evaluate the association between home health (HH) services, including skilled nursing (SN), physical therapy (PT), occupational therapy, social work (SW), and homemaking aide assistance with the hazard of unplanned facility admissions among Medicare patients with and without Alzheimer's disease and related dementias (ADRD).DesignAnalysis of the Outcome and Assessment Information Set and billing records.SettingA not-for-profit HH agency serving multiple counties in New York State.ParticipantsAdults ≥65 years old who received HH from January 1, 2017 to December 31, 2017.MeasuresOutcome was time from HH start of care to an unplanned facility admission of any type, including the hospital, nursing home, and rehabilitation facility. Independent variables included weekly intensity (visits/week, hours/week) of SN, PT, occupational therapy, SW, and, homemaking aide assistance separately. ADRD was identified by diagnosis (International Classification of Diseases, Tenth Revision codes in billing records) and cognitive impairment assessment (Outcome and Assessment Information Set).ResultsOf the sample (N = 6153), 14.9% had an unplanned facility admission. In multivariable Cox proportional hazard models that adjusted for time-varying effects of HH intensity and covariates, receiving the highest intensity of SN (3.3 visits of 2.78 hours per week) and PT (2.5 visits of 2 hours per week) was related to up to a 54% and 86% decrease, respectively, in the hazard of unplanned facility admission among patients with ADRD (n = 1525), and decreases of 56% and 90%, respectively, among patients without ADRD (n = 4628). Receiving any SW was related to 40% decreased in the hazard of facility admission in patients without ADRD only. Other HH services were not consistently related to the risk of facility admission.Conclusions and ImplicationsReceiving a higher intensity of SN and PT was associated with reduced hazards of unplanned facility admission among HH patients with and without ADRD. Policies should ensure that patients with ADRD receive a sufficient amount and appropriate mix of HH services.