Obesity in nursing homes: an escalating problem

OBJECTIVES: To estimate trends in the prevalence of obesity in nursing homes, to characterize the obese nursing home population, and to evaluate the extent to which estimates of the prevalence of obesity varied by facility and geographic location. DESIGN: Cross-sectional. SETTING: One thousand six hundred twenty-five nursing homes in Kansas, Maine, Mississippi, New York, and South Dakota from 1992 to 2002; 16,110 nursing homes in the United States in 2002. PARTICIPANTS: Newly admitted residents between 1992 and 2002 (n=847,601) in selected states and 1,448,046 residents newly admitted to a U.S. nursing home in 2002 with height and weight documented on the Minimum Data Set (MDS) assessment. MEASUREMENTS: Data were from the Systematic Assessment of Geriatric Drug Use via Epidemiology database. Residents were classified as having a body mass index of less than 18.5 kg/m2, 18.5 to 24.9 kg/m2, 25.0 to 29.9 kg/m2, 30 to 34.9 kg/m2, or 35.0 kg/m2 or greater. RESULTS: Adjusting for sociodemographics, in Kansas, Maine, Mississippi, New York, and South Dakota, fewer than 15% of newly admitted residents were obese in 1992, rising to more than 25% in 2002. In U.S. nursing homes, the distribution of obese residents is not shared equally across facilities. Nearly 30% of residents with a BMI of 35 kg/m2 or greater are younger than 65, and a disproportionate percentage of obese residents are non-Hispanic black. Residents identified as obese had a higher likelihood of comorbid conditions (e.g., diabetes mellitus, arthritis, hypertension, depression, and allergies). CONCLUSION: Increasing prevalence of obesity in nursing homes and substantial variation of obesity prevalence within facilities raise concerns about nursing home preparedness and access.     

Pain assessment and management in cognitively impaired nursing home residents: association of certified nursing assistant pain report,Minimum Data Set pain report,and analgesic medication use

OBJECTIVES: The primary purpose of this preliminary study was to investigate the associations between certified nursing assistant (CNA) report of pain, Minimum Data Set (MDS) report of pain, and analgesic medication use in cognitively impaired nursing home residents. DESIGN: Correlational study. SETTING: Three nursing homes in the greater Birmingham, Alabama area. PARTICIPANTS: Fifty-seven cognitively impaired nursing home residents with a mean Mini-Mental State Examination (MMSE) score of 11.1. MEASUREMENTS: Pain was assessed using a three-item proxy pain questionnaire (PPQ), developed by the researchers and administered to the residents' primary CNA. MDS and analgesic medication data corresponding with the time of PPQ data collection were gathered from medical records. Cognitive status was measured with the MMSE. RESULTS: The PPQ elicited substantially higher estimates of pain prevalence than the MDS (48% versus 20%), and the PPQ and the MDS were not well correlated (pain frequency: r=.19, P=.18; pain intensity: r=.22, P=.11). The PPQ was also more strongly associated with analgesic medication use than the MDS. Cognitive status was significantly associated with pain report on the PPQ but not on the MDS. Test-retest reliability coefficients for the three items of the PPQ were excellent, ranging from.84 to.87 (P 相似文献   

Indwelling device use and antibiotic resistance in nursing homes: identifying a high-risk group

OBJECTIVES: To quantify the relationship between indwelling devices (urinary catheters, feeding tubes, and peripherally inserted central catheters) and carriage of antimicrobial-resistant pathogens in nursing home residents.
DESIGN: Cross-sectional.
SETTING: Community nursing home in Southeast Michigan.
PARTICIPANTS: Residents with indwelling devices (n=100) and randomly selected control residents (n=100) in 14 nursing homes.
MEASUREMENTS: Data on age, functional status, and Charlson comorbidity score were collected. Samples were obtained from nares, oropharynx, groin, wounds, perianal area, and enteral feeding tube site. Standard microbiological methods were used to identify methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant enterococci (VRE), and ceftazidime-resistant (CTZ-R) gram-negative bacteria (GNB).
RESULTS: Use of indwelling devices was associated with colonization with MRSA at any site (odds ratio (OR)=2.0, P =.04), groin (OR=4.8, P =.006), and perianal area (OR=3.6, P =.01) and CTZ-R GNB at any site (OR=5.6, P =.003). Use of enteral feeding tubes was associated with MRSA colonization in the oropharynx (OR=3.3, P =.02).
CONCLUSION: Use of indwelling devices is associated with greater colonization with antimicrobial-resistant pathogens. This study serves as an initial step in defining a high-risk group that merits intensive infection control efforts.     

Rural-urban differences in medical care for nursing home residents with severe dementia at the end of life

OBJECTIVES: To identify factors associated with the use of selected medical services near the end of life in cognitively impaired residents of rural and urban nursing homes. DESIGN: Retrospective cohort study using Centers for Medicare and Medicaid Services administrative data for 1998 through 2002. SETTING: Minnesota and Texas nursing homes. PARTICIPANTS: Nursing home residents aged 65 and older with severe cognitive impairment who subsequently died during 2000/01. MEASUREMENTS: Minimum Data Set and Medicare Provider Analysis and Review, Hospice, and Denominator files were used to identify subjects and to assess medical service use. U.S. Department of Agriculture metro-nonmetro continuum county codes defined rural (codes 6-9) and urban (codes 0-2) nursing homes. Nursing home residents with hospice or health maintenance organization benefits were excluded. Use of hospital services at the end of life was adjusted for use of corresponding services before the last year of life. Outcome variables were feeding tube use, any hospitalization, more than 10 days of hospitalization, and intensive care unit (ICU) admission. RESULTS: The population included 3,710 subjects (1,886 rural, 1,824 urban). In multivariable logistic regression analyses (all P<.05), feeding tube use was more common in urban nursing home residents, whereas rural nursing home residents were at greater risk for hospitalization. CONCLUSION: Rural residence was also associated with lower risk of more than 10 days of hospitalization and ICU admission. Nonwhite race and stroke were associated with higher use of all services. Rural nursing home residence is associated with lower likelihood of use of the most-intensive medical services at the end of life.     

Evaluation of a risk-adjustment model for pressure ulcer development using the Minimum Data Set

OBJECTIVE: To validate a previously derived risk-adjustment model for pressure ulcer development in a separate sample of nursing home residents and to determine the extent to which use of this model affects judgments of nursing home performance. DESIGN: Retrospective observational study using Minimum Data Set (MDS) data from 1998. SETTING: A large, for-profit, nursing home chain. PARTICIPANTS: Twenty-nine thousand and forty observations were made on 13,457 nursing home residents who were without a pressure ulcer on an index assessment. MEASUREMENTS: We used logistic regression in our validation sample to calculate new coefficients for the 17 previously identified predictors of pressure ulcer development. Coefficients from this new sample were compared with those previously derived. Expected rates of pressure ulcer development were determined for 108 nursing homes. Unadjusted and risk-adjusted rates of pressure ulcer development from these homes were also calculated and outlier identification using these two approaches was compared. RESULTS: Predictors of pressure ulcer development in the derivation sample generally showed similar effects in the validation sample. The model c-statistic was also unchanged at 0.73, but it was not calibrated as well in the validation sample. On applying the model to the nursing homes, expected rates of ulcer development ranged from 1.1% to 3.2% (P <.001). The observed rates ranged from 0% to 12.1% (P <.001). There were 12 outliers using unadjusted rates and 15 using adjusted performance. Ten nursing homes were identified as outliers using both approaches. CONCLUSIONS: Our MDS risk-adjustment model for pressure ulcer development performed well in this new sample. Nursing homes differ significantly in their expected rates of pressure ulcer development. Outlier identification also differs depending on whether unadjusted or risk-adjusted performance is evaluated.     

Accuracy and bias of licensed practical nurse and nursing assistant ratings of nursing home residents' pain.

BACKGROUND: This study evaluated the accuracy of licensed practical nurses' (LPN) and nursing assistants' (NA) Minimum Data Set (MDS) pain ratings of nursing home residents and evaluated the bias in pain ratings associated with residents' race, gender, mental status, function, depression, or disruptive behavior. METHODS: Data were obtained on the same day directly from residents, LPNs, and NAs by trained interviewers in two safety-net nursing homes. A total of 252 residents were included in this study: 79% were Black, and 60% were men. MDS items J2a and J2b evaluated pain frequency and pain intensity during the last 7 days (weekly pain frequency and weekly pain intensity). A parallel question evaluated pain intensity on the day of the interview (daily pain intensity). MDS data were obtained for the MDS Cognition Scale, the MDS Activities of Daily Living-Long Form Scale, the MDS Depression Rating Scale, and the MDS Disruptive Behavior Scale. RESULTS: Kappa coefficients documented fair to good resident-LPN (K =.70,.56, and.50) and resident-NA (K =.72,.58, and.60) agreement for weekly pain frequency, weekly pain intensity, and daily pain intensity ratings. LPNs and NAs underestimated residents' weekly pain frequency (p <.001 for LPNs, and p <.001 for NAs), weekly pain intensity (p <.001 for LPNs, and p <.001 for NAs), and daily pain intensity (p <.001 for LPNs, and p =.002 for NAs). LPNs underestimated weekly and daily pain intensity more than NAs did (p =.016 for weekly pain intensity, and p =.035 for daily pain intensity). LPN and NA pain ratings were not biased by resident race, gender, mental status, function, depression, or disruptive behavior. CONCLUSIONS: Results documented that (i) LPNs and NAs underestimated residents' pain frequency and pain intensity, (ii) NAs were more accurate than LPNs for pain intensity, and (iii) resident characteristics did not bias LPN or NA pain ratings.     

Does hospice have a role in nursing home care at the end of life?

OBJECTIVES: To assess the possible benefits and challenges of hospice involvement in nursing home care by comparing the survival and needs for palliative care of hospice patients in long-term care facilities with those living in the community. DESIGN: Retrospective review of computerized clinical care records. SETTING: A metropolitan nonprofit hospice. PARTICIPANTS: The records of 1,692 patients were searched, and 1,142 patients age 65 and older were identified. Of these, 167 lived in nursing homes and 975 lived in the community. MEASUREMENTS: Patient characteristics, needs for palliative care, and survival. RESULTS: At the time of enrollment, nursing home residents were more likely to have a Do Not Resuscitate order (90% vs 73%; P < .001) and a durable power of attorney for health care (22% vs 10%; P < .001) than were those living in the community. Nursing home residents also had different admitting diagnoses, most notably a lower prevalence of cancer (44% vs 74%; P < .032). Several needs for palliative care were less common among nursing home residents, including constipation (1% vs 5%; P = .02), pain (25% vs 41%; P < .001), and anticipatory grief (1% vs 9%; P < .001). Overall, nursing home residents had fewer needs for care (median 0, range 0-3 vs median 1, range 0-5; rank sum test P < .001). Nursing home residents had a significantly shorter survival (median 11 vs 19 days; log rank test of survivor functions P < .001) and were less likely to withdraw from hospice voluntarily (8% vs 14%; P = .03). However, there was no difference in the likelihood of becoming ineligible during hospice enrollment (6% for both groups). CONCLUSIONS: These results suggest that hospices identify needs for palliative care in a substantial proportion of nursing home residents who are referred to hospice, although nursing home residents may have fewer identifiable needs for care than do community-dwelling older people. However, the finding that nursing home residents' survival is shorter may be of concern to hospices that are considering partnerships with nursing homes. An increased emphasis on hospice care in nursing homes should be accompanied by targeted educational efforts to encourage early referral.     

The minimum data set prevalence of restraint quality indicator: does it reflect differences in care?

PURPOSE: This study investigated whether the use of restraining devices and related measures of care quality are different in nursing homes that score in the upper and lower quartiles on the Minimum Data Set (MDS) "prevalence of restraint" quality indicator, which assesses daily use of restraining devices when residents are out of bed. DESIGN AND METHODS: The study was a cross-sectional study, with 413 residents in 14 nursing facilities. Eight homes scored in the lower quartile (25th percentile; low prevalence, 0-5%) on the MDS restraint prevalence quality indicator, and six homes scored in the upper quartile (75th percentile; high prevalence, 28-48%). Eight care processes related to the management of restraints and gait and balance problems were defined and operationalized into clinical indicators. Research staff conducted direct observations during three 12-hr days (7 a.m.-7 p.m.) to determine the prevalence of restraining devices and identify resident and staff behaviors that may be affected by restraint use. RESULTS: Residents in high-restraint homes were in bed during the day on more observations than residents in low-restraint homes (44% vs. 33%; p <.001), were more frequently observed with bed rails in use (74% of residents vs. 64% of residents; p <.03), and received less feeding assistance during meals (2.7 min vs. 4.1 min; p <.001). There were no differences between homes in the use of out-of-bed restraints, nor were there any differences on any care process measure related to the management of restraints, gait and balance problems, or measures of physical or social activity. IMPLICATIONS: A home's score on the MDS-generated prevalence of restraint quality indicator was not associated with differences in the use of restraints, physical activity, or any care process measure when residents were out of bed. However, there were differences in the use of in-bed restraining devices, and residents in high-restraint homes were in bed more often during the day. These differences were associated with poor feeding assistance and reflect important differences in quality of care between homes, even though these differences are not what the restraint prevalence quality indicator purports to measure. Methods to monitor and improve the quality of care related to exercise, in-bed times, and resident freedom of movement are discussed.     

Measurement sensitivity and the Minimum Data Set depression quality indicator

PURPOSE: The purpose of this study was to determine the accuracy of the prevalence rating of depression in nursing homes as flagged on the Minimum Data Set (MDS) quality indicator report. DESIGN AND METHODS: Research Staff measured depression symptoms and compared the results with the prevalence of disturbed mood symptoms documented by nursing home (NH) staff on the MDS in two samples of residents living in different NHs. The homes had been flagged on the nationally mandated MDS quality indicator report as having unusually low (Site 1) or high (Site 2) prevalence rates of depression. RESULTS: The percentages of residents determined by research staff interview assessments to have probable depression in the two resident samples were not significantly different (49% vs. 55%, respectively) between homes. The staff in the home flagged on the MDS quality indicator report as having a high depression prevalence rate identified significantly more residents who also had scores indicative of probable depression on the resident interviews for follow-up mood assessments than did the home with a low quality indicator prevalence rate (78% vs. 25%, respectively). IMPLICATIONS: The prevalence of the depression quality indicator may be more reflective of measurement processes than of depression outcomes. Factors that may affect the difference in detection rates are discussed.     

Tube Feeding Preferences Among Nursing Home Residents

OBJECTIVE: To determine the preferences of nursing home residents regarding the use of tube feedings and to characterize the clinical, functional, and psychosocial factors that are associated with preferences. DESIGN: In-person survey. SETTING: Forty-nine randomly selected nursing homes. PATIENTS/PARTICIPANTS: Three hundred seventy-nine randomly selected, decisionally capable, nursing home residents. MAIN RESULTS: Thirty-three percent of participants would prefer tube feedings if no longer able to eat because of permanent brain damage. Factors positively associated with preferences for tube feedings include male gender, African-American race, never having discussed treatment preferences with family members or health care providers, never having signed an advance directive, and believing that tube feeding preferences will be respected by the nursing home staff. Twenty-five percent of the participants changed from preferring tube feedings to not preferring tube feedings on learning that physical restraints are sometimes applied during the tube feeding process. CONCLUSIONS: Demographic and social factors are associated with preferences for tube feedings. The provision of information about the potential use of physical restraint altered a proportion of nursing home residents' treatment preferences.     

The management of depression in older nursing home residents

OBJECTIVES: Depression remains underrecognized and undertreated in older people. We estimated the prevalence of depression in older nursing home (NH) residents and described its pharmacological management. DESIGN: Cross-sectional study. SETTING: Residents in 1,492 NHs in five states (Kansas, Maine, Mississippi, New York, South Dakota). PARTICIPANTS: Forty-two thousand nine hundred one residents aged 65 and older with depression documented as an active clinical condition on the Minimum Data Set (MDS) assessment. MEASUREMENTS: Data were from the Systematic Assessment of Geriatric drug use via Epidemiology database. We grouped antidepressant medications by class: tricyclic antidepressants (TCAs), tetracyclics, selective serotonin reuptake inhibitors (SSRIs), monoamine oxidase inhibitors, and others. Logistic regression models revealed predictors of receipt of any antidepressant and, among those treated, predictors of receipt of an SSRI. RESULTS: Eleven percent of the residents were identified as depressed on the MDS. Of these, 55% received antidepressant therapy. Of depressed residents receiving antidepressant therapy, 32% received doses less than the manufacturers' recommended minimum effective dose for treating depression, with residents on TCAs more likely to receive less than the recommended dose for treating depression. The oldest-old (> or = 85 years) (odds ratio (OR) = 0.93, 95% confidence interval (CI) = 0.88-0.98), black residents (OR = 0.83, 95% CI = 0.75-0.92), and those with severe cognitive impairment (OR = 0.69, 95% CI = 0.64-0.75) were the least likely to receive an antidepressant. In those treated, cardiovascular diseases were associated with an increased likelihood of SSRI use. Despite control for comorbid conditions, women were less likely than men to receive an SSRI (OR = 0.77, 95% CI = 0.72-0.82). CONCLUSIONS: Although depression is a treatable illness, the majority of NH residents may be inadequately treated.     

Evaluating the accuracy of minimum data set bed-mobility ratings against independent performance assessments: systematic error and directions for improvement

PURPOSE: The Minimum Data Set (MDS) Activities of Daily Living (ADL) bed-mobility item, which rates the staff-assistance level necessary for bed movement, is used to target scheduled repositioning interventions and to identify physical function changes in nursing home residents; however, accuracy of the item is uncertain. The purpose of this study was to evaluate the accuracy of the MDS ADL bed-mobility item as completed by nursing home nurses with independent performance assessments conducted by research staff. DESIGN AND METHODS: A convenience sample of 197 long-stay residents from 26 California nursing homes participating in a larger project was used in this cross-sectional study to compare independent research-staff performance assessments (using graduated assistance protocols of residents' ability to move in bed) and nursing home nurse MDS bed-mobility ratings. Participants also wore movement monitors to verify performance assessments. RESULTS: Poor agreement existed between the nursing home nurse MDS bed-mobility ratings and the research-staff performance assessments across all assistance levels (kappa range, kappa = 0.007, p =.918 to kappa = 0.484, p <.001), with better agreement seen in totally dependent participants and with fewer elapsed days between MDS ratings and performance assessments. The odds of nursing home nurse errors (underestimating or overestimating dependency) on the MDS bed-mobility item were 2.1 times higher for participants judged independent by research staff compared with participants judged as requiring physical assistance by research staff (95% confidence interval, 1.14-4.03) when adjusted for number of days between nurse MDS ratings and research-staff performance assessments. IMPLICATIONS: Nursing home nurses overestimated resident dependency in bed mobility. The systematic inaccuracies in MDS bed-mobility ratings have implications for their use as a basis for targeting residents for repositioning programs and determining changes in residents' physical function. Performance assessments utilizing graduated assistance protocols are recommended as a method of improving the accuracy of MDS bed-mobility ratings.     

Discussion as a Factor in Racial Disparity in Advance Directive Completion at Nursing Home Admission

Studies have consistently shown racial disparities in advance directive completion for nursing home residents but have not examined whether this disparity is due to differences in interactions with healthcare providers. This study had two aims: to determine whether the racial disparity in advance directive completion by nursing home residents is related to differences in discussion of treatment restrictions with healthcare providers and to examine whether there is a racial disparity in perceptions of residents' significant others that additional discussions would be helpful. Participants were 2,171 white or black (16% of sample) residents newly admitted to 59 nursing homes. Data were collected from structured interviews with residents' significant others and review of nursing home charts. Questions included whether advance directives were completed, whether treatment restrictions were discussed with the resident or family, and whether more discussion would have been helpful. Frequencies according to race were determined for each question; P -values and logistic regression models were obtained. Black residents were less likely to have completed any advance directives ( P <.001), and they ( P <.001) and their family members ( P <.001) were less likely than whites to have discussed treatment restrictions with healthcare providers. Logistic regression models indicated that disparity in treatment restrictions narrowed when these discussions occurred. Significant others of black residents were more likely than those of white residents to consider further discussion helpful ( P <.001), especially with physicians. Racial disparity in treatment restrictions may be due in part to a difference in discussion with healthcare providers; increasing discussion may narrow this disparity.     

Do Financial Incentives of Introducing Case Mix Reimbursement Increase Feeding Tube Use in Nursing Home Residents?

OBJECTIVES: To determine whether adoption of Medicaid case mix reimbursement is associated with greater prevalence of feeding tube use in nursing home (NH) residents.
DESIGN: Secondary analysis of longitudinal administrative data about the prevalence of feeding tube insertion and surveys of states' adoption of case mix reimbursement.
SETTING: NHs in the United States.
PARTICIPANTS: NH residents at the time of NH inspection between 1993 and 2004.
MEASUREMENTS: Facility prevalence of feeding tubes reported at the state inspection of NHs reported in the Online Survey, Certification and Reporting database and interviews with state policy makers regarding the adoption of case mix reimbursement.
RESULTS: Between 1993 and 2004, 16 states adopted Resource Utilization Group case mix reimbursement. States varied in the prevalence of feeding tubes in their NHs. Although the use of feeding tube increased substantially over the years of the study, once temporal trends and facility fixed effects were accounted for, case mix reimbursement was not associated with greater prevalence of feeding tube use.
CONCLUSION: The adoption of Medicaid case mix reimbursement was not associated with an increase in the prevalence of feeding tube use.     

The minimum data set depression quality indicator: does it reflect differences in care processes?

PURPOSE: The objective of this work was to determine if nursing homes that score differently on prevalence of depression, according to the Minimum Data Set (MDS) quality indicator, also provide different processes of care related to depression. DESIGN AND METHODS: A cross-sectional study with 396 long-term residents in 14 skilled nursing facilities was conducted: 10 homes in the lower (25th percentile: low prevalence 0-2%) quartile and 4 homes in the upper (75th percentile: high prevalence 12-14%) quartile on the MDS depression quality indicator. Ten care processes related to depression were defined and operationalized into clinical indicators. Measurement of nursing home staff implementation of each care process and the assessment of depressive symptoms were conducted by trained research staff during 3 consecutive 12-hr days (7 a.m. to 7 p.m.), which included resident interviews (Geriatric Depression Scale), direct observations, and medical record review using standardized protocols. RESULTS: The prevalence of depressive symptoms according to independent assessments was significantly higher than prevalence based on the MDS quality indicator and comparable between homes reporting low versus high rates of depression (46% and 41%, respectively). Documentation of depressive symptoms was significantly more common in homes reporting a high prevalence rate; however, documentation of symptoms on the MDS did not result in better treatment or management of depression according to any care-process measure. Psychosocial prevention and intervention efforts, such as resident participation in organized social group activities, were not widely used within either group of homes. IMPLICATIONS: The MDS depression quality indicator underestimates the prevalence of depressive symptoms in all homes but, in particular, among those reporting low or nonexistent rates. The indicator may be more reflective of measurement processes related to detection of symptoms than of prevention, intervention, or management of depression outcomes. A depression quality indicator should not be eliminated from MDS reports because of the importance and prevalence of the condition. However, efforts to improve nursing home staff detection of depressive symptoms should be initiated prior to the use of any MDS-based depression indicator for improvement purposes. Homes that report a low prevalence of depression according to the nationally publicized MDS quality indicator should not be regarded as providing better care.