Development and validation of a prognostic index for 2‐year mortality in Chinese older residents living in nursing homes

Aim: There is no mortality prediction index for Chinese nursing home older residents. The objective of this study was to derive and validate a 2‐year mortality prognostic index for them. Methods: We carried out a prospective cohort study on 1120 older residents from 12 nursing homes of Hong Kong. We obtained potential predictors of mortality and carried out updated functional assessment. Each risk factor associated independently with 2‐year mortality in a derivation cohort was assigned a score based on the odds ratio, and risk scores were calculated for each participant by adding the points of risk factors present. Similar analysis was carried out on the validation cohort. Results: Independent predictors of mortality included: aged 86–90 years (3 points); aged ≥91 years (4 points); Charlson comorbidity index ≥4 (6 points); Barthel Index 5–60 (5 points); Barthel Index 0 (10 points); number of hospitalizations in the preceding year (Adbefore) 1 (4 points); Adbefore 2 (5 points) and Adbefore ≥3 (6 points). In the derivation cohort, 2‐year mortality was 10.8% in the low‐risk group (≤4 points) and 59.9% in the high‐risk group (≥14 points). In the validation cohort, 2‐year mortality was 11.8% in the low‐risk group and 60.4% in the high‐risk group. The receiver–operator characteristic curve area was 0.761 for the derivation cohort and 0.742 for the validation cohort. Conclusions: Our prognostic index had satisfactory discrimination and calibration in an independent sample of Chinese nursing home older residents. It can be used to identify older residents with a high risk for poor outcomes, who need a different level of care. Geriatr Gerontol Int 2012; 12: 555–562.     

Development of a minimum data set-based depression rating scale for use in nursing homes

BACKGROUND: depression is common but under-diagnosed in nursing-home residents. There is a need for a standardized screening instrument which incorporates daily observations of nursing-home staff. AIM: to develop and validate a screening instrument for depression using items from the Minimum Data Set of the Resident Assessment Instrument. METHODS: we conducted semi-structured interviews with 108 residents from two nursing homes to obtain depression ratings using the 17-item Hamilton Depression Rating Scale and the Cornell Scale for Depression in Dementia. Nursing staff completed Minimum Data Set assessments. In a randomly assigned derivation sample (n = 81), we identified Minimum Data Set mood items that were correlated (P < 0.05) with Hamilton and Cornell ratings. These items were factored using an oblique rotation to yield five conceptually distinct factors. Using linear regression, each set of factored items was regressed against Hamilton and Cornell ratings to identify a core set of seven Minimum Data Set mood items which comprise the Minimum Data Set Depression Rating Scale. We then tested the performance of the Minimum Data Set Depression Rating Scale against accepted cut-offs and psychiatric diagnoses. RESULTS: a cutpoint score of 3 on the Minimum Data Set Depression Rating Scale maximized sensitivity (94% for Hamilton, 78% for Cornell) with minimal loss of specificity (72% for Hamilton, 77% for Cornell) when tested against cut-offs for mild to moderate depression in the derivation sample. Results were similar in the validation sample. When tested against diagnoses of major or non-major depression in a subset of 82 subjects, sensitivity was 91% and specificity was 69%. Performance compared favourably with the 15-item Geriatric Depression Scale. CONCLUSION: items from the Minimum Data Set can be organized to screen for depression in nursing-home residents. Further testing of the instrument is now needed.     

Interventions to reduce hospitalizations from nursing homes: evaluation of the INTERACT II collaborative quality improvement project

A substantial proportion of hospitalizations of nursing home (NH) residents may be avoidable. Medicare payment reforms, such as bundled payments for episodes of care and value-based purchasing, will change incentives that favor hospitalization but could result in care quality problems if NHs lack the resources and training to identify and manage acute conditions proactively. Interventions to Reduce Acute Care Transfers (INTERACT) II is a quality improvement intervention that includes a set of tools and strategies designed to assist NH staff in early identification, assessment, communication, and documentation about changes in resident status. INTERACT II was evaluated in 25 NHs in three states in a 6-month quality improvement initiative that provided tools, on-site education, and teleconferences every 2 weeks facilitated by an experienced nurse practitioner. There was a 17% reduction in self-reported hospital admissions in these 25 NHs from the same 6-month period in the previous year. The group of 17 NHs rated as engaged in the initiative had a 24% reduction, compared with 6% in the group of eight NHs rated as not engaged and 3% in a comparison group of 11 NHs. The average cost of the 6-month implementation was $7,700 per NH. The projected savings to Medicare in a 100-bed NH were approximately $125,000 per year. Despite challenges in implementation and caveats about the accuracy of self-reported hospitalization rates and the characteristics of the participating NHs, the trends in these results suggest that INTERACT II should be further evaluated in randomized controlled trials to determine its effect on avoidable hospitalizations and their related morbidity and cost.     

Unrecognized tuberculosis in a nursing home causing death with spread of tuberculosis to the community

OBJECTIVES: To determine the reason for an increase in tuberculin skin test (TST) conversion in employees in a nursing home and to determine the source case responsible for spread of tuberculosis (TB) in two nursing homes and a hospital in a rural part of Arkansas using molecular and traditional epidemiological methods. DESIGN: TB contact investigation of residents and employees of two nursing homes and a hospital. SETTING: Two nursing homes and a hospital in rural part of Arkansas. PARTICIPANTS: One hundred fifty-seven employees and 117 residents of two nursing homes and 211 employees of a hospital in rural part of Arkansas. MEASUREMENTS: Tuberculin skin test. RESULTS: Analysis of room and work assignments of residents and employees who converted their TSTs in Nursing Home A showed that residents and employees in the same wing as the suspect source case were significantly more likely to have converted their TST than residents and employees in other wings (P = .01). A nurse from the local hospital where the suspected source case had been sent developed a tuberculous cervical abscess, and one employee in Nursing Home A developed pulmonary TB. A visitor to Nursing Home A was diagnosed with culture-positive pulmonary TB 2 years later. Genotyping of the Mycobacterium tuberculosis isolates from the four secondary cases showed identical patterns. CONCLUSION: Molecular and traditional epidemiological studies revealed an outbreak of TB that began in a nursing home and spread to a second nursing home, a local hospital, and the community.     

A training program to enhance recognition of depression in nursing homes,assisted living,and other long-term care settings: Description and evaluation

ABSTRACT

Low levels of symptom recognition by staff have been “gateway” barriers to the management of depression in long-term care. The study aims were to refine a depression training program for front-line staff in long-term care and provide evaluative knowledge outcome data. Three primary training modules provide an overview of depression symptoms; a review of causes and situational and environmental contributing factors; and communication strategies, medications, and clinical treatment strategies. McNemar’s chi-square tests and paired t-tests were used to examine change in knowledge. Data were analyzed for up to 143 staff members, the majority from nursing. Significant changes (p < .001) in knowledge were observed for all modules, with an average change of between 2 and 3 points. Evidence was provided that participants acquired desired information in the recognition, detection, and differential diagnosis and treatment strategies for those persons at significant risk for a depressive disorder.     

Application of the Haddon matrix to COVID-19 prevention and containment in nursing homes

COVID-19 has exacted a disproportionate toll on the health of persons living in nursing homes. Healthcare providers and other decision-makers in those settings must refer to multiple evolving sources of guidance to coordinate care delivery in such a way as to minimize the introduction and spread of the causal virus, SARS-CoV-2. It is essential that guidance be presented in an accessible and usable format to facilitate its translation into evidence-based best practice. In this article, we propose the Haddon matrix as a tool well-suited to this task. The Haddon matrix is a conceptual model that organizes influencing factors into pre-event, event, and post-event phases, and into host, agent, and environment domains akin to the components of the epidemiologic triad. The Haddon matrix has previously been applied to topics relevant to the care of older persons, such as fall prevention, as well as to pandemic planning and response. Presented here is a novel application of the Haddon matrix to pandemic response in nursing homes, with practical applications for nursing home decision-makers in their efforts to prevent and contain COVID-19.     

Experts recommend strategies for strengthening the use of advanced practice nurses in nursing homes

In 2003, The John A. Hartford Foundation Institute for Geriatric Nursing, New York University Division of Nursing, convened an expert panel to explore the potential for developing recommendations for the caseloads of advanced practice nurses (APNs) in nursing homes and to provide substantive and detailed strategies to strengthen the use of APNs in nursing homes. The panel, consisting of nationally recognized experts in geriatric practice, education, research, public policy, and long-term care, developed six recommendations related to caseloads for APNs in nursing homes. The recommendations address educational preparation of APNs; average reimbursable APN visits per day; factors affecting APNs caseload parameters, including provider characteristics, practice models, resident acuity, and facility factors; changes in Medicare reimbursement to acknowledge nonbillable time spent in resident care; and technical assistance to promote a climate conducive to APN practice in nursing homes. Detailed research findings and clinical expertise underpin each recommendation. These recommendations provide practitioners, payers, regulators, and consumers with a rationale and details of current advanced practice nursing models and caseload parameters, preferred geriatric education, reimbursement strategies, and a range of technical assistance necessary to strengthen, enhance, and increase APNs' participation in the care of nursing home residents.     

Use of oseltamivir during influenza outbreaks in Ontario nursing homes, 1999-2000

OBJECTIVES: To describe the experience of Ontario long-term care facilities that used oseltamivir during influenza outbreaks in 1999/2000. DESIGN: Case series. SETTING: Ten Ontario long-term care facilities for older people and their residents. PARTICIPANTS: Older residents of long-term care facilities. INTERVENTION: Oseltamivir for treatment or prophylaxis during 11 influenza outbreaks in 1999/2000. MEASUREMENTS: Control of outbreaks; pneumonia, hospitalization, and death complicating acute influenza. RESULTS: All outbreaks were due to influenza A//H3N2/Sydney/05/97. One facility elected to use oseltamivir for treatment and amantadine for prophylaxis. The remaining nine facilities (10 outbreaks) recommended oseltamivir for treatment and prophylaxis (after amantadine failure in five and as primary prophylaxis in five). Use of oseltamivir was associated with termination of the outbreak in all eight evaluable outbreaks. Overall, 178/185 (96%) case-residents met the case definition of influenza and had complete data for evaluation. Of these, 63 (35%) were treated with antibiotics, 37 (21%) were diagnosed with pneumonia, 19 (11%) were hospitalized, and 16 (9%) died. Compared with residents receiving no therapy or who became ill while taking amantadine, residents who received oseltamivir within 48 hours of the onset of symptoms were less likely to be prescribed antibiotics, to be hospitalized, or to die (P <.05 for each outcome). These differences persisted and remained statistically significant when corrected for influenza immunization status. A total of 730 residents received oseltamivir prophylaxis for a median of 9 days (range 5-12). Of these, side effects were identified in 30 (4.1%), the most common being diarrhea (12 residents, 1.6%), cough (5, 0.7%), confusion (4, 0.5%) and nausea (4, 0.5%). CONCLUSIONS: Oseltamivir is safe and appears to be effective when used as treatment or prophylaxis to control outbreaks of influenza in older nursing home residents.     

Depression in older patients admitted for postacute nursing home rehabilitation

OBJECTIVES: To describe the prevalence, recognition, and persistence of depression in older adults undergoing postacute rehabilitation in a nursing home (NH) setting and to explore the effect of depression on rehabilitation outcomes. DESIGN: Prospective cohort study. SETTING: One rehabilitative NH in the Los Angeles area. PARTICIPANTS: One hundred fifty-eight patients (aged >/=65) admitted for postacute rehabilitation over a 9-month recruitment period. MEASUREMENTS: Depression was assessed using the 15-item Geriatric Depression Scale (GDS-15) or the Cornell Scale for Depression (in participants with dementia). Medical records were reviewed for documentation of depression and antidepressant use before and during the rehabilitative NH stay. Rehabilitation process was assessed using total amount of successfully completed therapy (minutes). Rehabilitation outcome was assessed using the motor component of the Functional Independence Measure (mFIM). Measures were performed at admission and 2 months later. RESULTS: Of the 646 potentially eligible patients admitted during the study, 158 consented, and 151 were screened for depression. Forty-two (27.8%) had depressive symptoms (GDS=6 or Cornell=5). Of these, only 15 had a documented diagnosis of depression, and 12 were receiving antidepressants. Depression was associated with longer NH stay but not with discharge mFIM score. Two months later, depression persisted in 24 participants and was associated with worse mFIM (55.5+/-22.7 vs 67.0+/-23.7, depressed vs nondepressed; P=.03). CONCLUSION: Depression was common, underrecognized, and undertreated in these postacute rehabilitation patients. Depression generally persisted and was associated with worse functional status at 2-month follow-up.     

Recognition of late-life depression in home care: accuracy of the outcome and assessment information set

This study evaluated the accuracy of home care nurses' ratings of the Outcome and Assessment Information Set (OASIS) depression items. The accuracy of home care nurses' depression assessments was studied by comparing nurse ratings of OASIS depression items with a research diagnostic assessment based on the Structured Clinical Interview for Axis I Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (SCID). The setting for this study was a nonprofit, Medicare-certified, voluntary home healthcare agency. Sixty-four home care nurses assessed 220 patients aged 65 and older with the OASIS upon admission. Of the 220 patients, using standard SCID criteria, 35 cases of major or minor depression were identified. The home care nurses accurately documented the presence of depression in 13 of 35 cases (sensitivity=37.1%; positive predictive value=0.56). Of the 220 patients, 185 had no SCID-identified major or minor depression. The nurses agreed on the absence of depression in 175 of 185 cases (specificity=94.6%; negative predictive value=88.8%). This study indicates that home care nurses often do not accurately rate OASIS depression items for older adult patients.     

Falls documentation in nursing homes: agreement between the minimum data set and chart abstractions of medical and nursing documentation

OBJECTIVES: To assess the agreement between falls as recorded in the Minimum Data Set (MDS) and fall events abstracted from chart documentation of elderly nursing home (NH) residents. DESIGN: Secondary analysis of data from a longitudinal panel study. SETTING: Fifty-six randomly selected NHs in Maryland stratified by facility size and geographic region. PARTICIPANTS: Four hundred sixty-two NH residents, aged 65 and older, in NHs for 1 year. MEASUREMENTS: Falls were abstracted from resident charts and compared with MDS fall variables. Fall events data obtained from other sources of chart documentation were matched for the corresponding periods of 30 and 180 days before the 1-year MDS assessment date. RESULTS: For a 30-day period, concordance between the MDS and chart abstractions of falls occurred in 65% of cases, with a kappa coefficient of 0.29 (P<.001), indicating fair agreement. Concordance occurred between the sources for 75% of cases for a 180-day period, with a kappa of 0.50 (P<.001), indicating moderate agreement. During the 180-day period, chart abstractions showed that 49% of the sample fell, whereas the MDS revealed that only 28% fell. An analysis of residents whose falls the MDS missed indicated that these residents had significantly more activity of daily living impairment and significantly less unsteady gait and cane/walker use. CONCLUSION: The MDS underreported falls. Nurses completing MDS assessments must carefully review residents' medical records for falls documentation. Future studies should use caution when employing MDS data as the only indicator of falls.     

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

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

The management of adverse clinical events in nursing homes: a 1-year survey study

OBJECTIVE: In Italian nursing homes (NHs), care delivery at night and during holidays is not regulated by regional laws; some facilities employ staff physicians, others employ physicians engaged from year to year (temporary physicians), and others employ publicly funded National Health System (NHS) physicians. This study was designed to determine whether the use of different kinds of physicians leads to different outcomes with regard to the rate of hospitalization and appropriateness of the management of adverse clinical events. DESIGN: Prospective, nonrandomized-survey data collection. SETTING: Ten nonprofit nursing facilities in Italy. PARTICIPANTS: Three hundred and fifty-two NH residents, staff physicians, temporary physicians, and NHS physicians. MEASUREMENTS: Medical intervention during adverse clinical events occurring at night and during holidays. RESULTS: Three hundred and fifty-two residents experienced 551 adverse clinical events; 78 were hospitalized. The hospitalization rate of NHS physicians was about two times that of the temporary physicians and six times that of the staff physicians. Staff physicians' diagnoses and management were appropriate in the majority of cases; NHS diagnosis and management were doubtful or incorrect in about one-third of all cases. CONCLUSIONS: NH residents frequently experience adverse clinical events; physician characteristics influence the rate of hospitalization and the quality of medical interventions.     

Prevention of falls in nursing homes: subgroup analyses of a randomized fall prevention trial

OBJECTIVES: To evaluate the effectiveness of a multifactorial fall prevention program in prespecified subgroups of nursing home residents.
DESIGN: Secondary analysis of a cluster-randomized, controlled trial.
SETTING: Six nursing homes in Germany.
PARTICIPANTS: Seven hundred twenty-five long-stay residents; median age 86; 80% female.
INTERVENTION: Staff and resident education on fall prevention, advice on environmental adaptations, recommendation to wear hip protectors, and progressive balance and resistance training.
MEASUREMENTS: Time to first fall and the number of falls. Falls were assessed during the 12-month intervention period. Univariate regression analyses were performed, including a confirmatory test of interaction.
RESULTS: The intervention was more effective in people with cognitive impairment (hazard ratio (HR)=0.49, 95% confidence interval (CI)=0.35–0.69) than in those who were cognitively intact (HR=0.91, 95% CI=0.68–1.22), in people with a prior history of falls (HR=0.47, 95% CI=0.33–0.67) than in those with no prior fall history (HR=0.77, 95% CI=0.58–1.01), in people with urinary incontinence (HR=0.59, 95% CI=0.45–0.77) than in those with no urinary incontinence (HR=0.98, 95% CI=0.68–1.42), and in people with no mood problems (incidence rate ratio (IRR)=0.41, 95% CI=0.27–0.61) than in those with mood problems (IRR=0.74, 95% CI=0.51–1.09).
CONCLUSION: The effectiveness of a multifactorial fall prevention program differed between subgroups of nursing home residents. Cognitive impairment, a history of falls, urinary incontinence, and depressed mood were important in determining response.