Hospitalization risk following admission to an academic nursing home

OBJECTIVES: Nursing home residents are at risk for experiencing acute illness and hospitalization early in nursing home stay. The objectives of this study were (1) to measure the probability of hospitalization over time from nursing home admission, and (2) to determine resident risk factors for early hospitalization. DESIGN: Prospective observational study. SETTING: 409-bed urban, not-for-profit academic nursing home. PARTICIPANTS: 204 consecutive newly admitted residents who did not previously reside in the nursing home. MEASUREMENTS: Demographic profile, chronic comorbidity, physical function, recent medical events, admission condition and anticipated length of stay were ascertained on admission to the nursing home. Hospitalization and acute illness were recorded each week after nursing home admission. Data were collected primarily by chart review except for acute illness, which was identified by nurse report and chart review according to previously established criteria. RESULTS: Subjects were 69% female and 62% white. The mean age was 83. The percentage of residents experiencing their first hospitalization peaked 2 and 7 weeks after nursing home admission and after 14 weeks plateaued at a low rate. The percentage with acute illness (commonly gastroenteritis, urinary tract infection, and pneumonia) paralleled that of hospitalization. In multivariate proportional hazards analysis, resident factors independently associated with early first hospitalization were atrial fibrillation (21% of subjects, 2.6 risk ratio), history of stroke (26%, 2.5), history of depression (25%, 1.9), absence of dementia (62%, 2.3), and receiving antibiotics on admission (23%, 3.3). Residents with 0, 1, 2,> or = 3 of these characteristics had 9%, 19%, 34% and 62% probability, respectively, of being hospitalized in the first 8 weeks of nursing home stay. CONCLUSIONS: In a large, urban, academic nursing home, residents' risk of hospitalization varied over time from admission and among different subgroups of residents. These results can be used to develop interventions to prevent acute illness and hospitalization early in nursing home stay and to enhance the communication of prognostic risk to nursing home residents, their caregivers and medical providers.     

Reducing antihypertensive medication use in nursing home patients

Of the 1.5 million nursing home residents, about 40% are aged 85 years or older, and a similar percentage have hypertension. The rates of incorrect diagnoses from the "white coat" effect and from errors in blood pressure evaluation are as frequent in older persons as in younger persons. The benefits of antihypertensive treatment and the risks of lowering blood pressures in the very old (> or = 85 years) are uncertain. Elderly patients experience adverse effects from drug treatment that are unique to their age group and that complicate management problems associated with polypharmacy and multiple comorbid conditions. Trials to withdraw or lower the dosage of antihypertensive medications have been successful in up to 40% of elderly persons when combined with salt restriction and weight loss, but such studies are lacking in nursing home patients. The management of hypertension should be reevaluated in nursing home patients.     

Effects of horticulture therapy on nursing home older adults in southern Taiwan

Purpose

This study aimed to test the effects of horticulture therapy on activities of daily living, happiness, meaning of life, and interpersonal intimacy of nursing home older adults in southern Taiwan.

Methods

A quasi-experimental study was applied. Eighty-five older adults aged 65 or older who lived in nursing homes in southern Taiwan were recruited conveniently. All participants completed the study: experimental group (n = 41) and control group (n = 44). The experimental group received horticulture therapy for 1 h once a week for 8 weeks, while the control group continued their routine daily activities. The following questionnaires were administered before and after the intervention period: (1) Barthel Index (BI), (2) Chinese Happiness Inventory short version (CHI), (3) Meaning of Life Scale (MLS), and (4) Interpersonal Intimacy Scale (IIS).

Results

The BI, CHI, MLS, and IIS scores significantly improved in the experimental group (p < .05). After 8 weeks of horticulture therapy, the BI, CHI, and IIS scores of experimental group participants were significantly better than the scores of control group participants (p < .05); however, the MLS scores of two groups showed no significant differences (p = .738).

Conclusions

Horticulture therapy improved activities of daily living, happiness, and interpersonal intimacy of older adults in nursing homes. We recommend that nursing homes recruit and train personnel to lead horticultural therapy and to incorporate the therapy as routine daily activities in the facilities.

     

Clinical causes of death of 2372 older persons in a nursing home during 15-year follow-up

OBJECTIVE: To investigate the causes of death in older persons in a nursing home. DESIGN: The major clinical cause of death of all persons aged 60 years older residing in a nursing home during a 15-year period was investigated in a prospective study. The author carefully reviewed the major cause of death with the physicians who took care of all persons who died either in the nursing home or after transfer to a general hospital. SETTING: A large nursing home in which 2372 of 3164 older persons (75%) died during a 15-year period. PATIENTS: The 2372 persons who died included 766 men and 1606 women, mean age 81 +/- 8 years. MEASUREMENTS AND MAIN RESULTS: A total of 2372 of 3164 persons (75%) died during the 15-year period,. Seven hundred sixty-six of 1023 men (75%) and 1606 of 2141 women (75%) died (P not significant). The major cause of death in these 2372 persons was sudden cardiac death in 25%, myocardial infarction in 18%, refractory congestive heart failure in 11%, thromboembolic stroke in 6%, cerebral hemorrhage in 1%, pulmonary embolism in 2%, mesenteric vascular infarction diagnosed at surgery in 1%, peripheral vascular disease, including dissecting aneurysm of aorta and ruptured abdominal aneurysm, in <1%, pneumonia in 15%, urosepsis in 4%, bacterial endocarditis in 1%, sepsis from abdominal abscess or gastrointestinal or biliary tract in 1%, sepsis from decubiti, gangrene of lower extremity, and osteomyelitis in <1%, cancer in 9%, renal failure in 3%, gastrointestinal or liver disease in 2%, hematologic disorders in 1%, and chronic obstructive pulmonary disease in 1% of persons. CONCLUSIONS: The major cause of death of persons in the nursing home was cardiovascular disease, which accounted for 63% of deaths. The second major cause of death was infectious disease, accounting for 21% of deaths. Cancer accounted for 9% of deaths, renal failure for 3% of deaths, gastrointestinal or liver disease for 2% of deaths, hematologic disorders for 1% of deaths, and chronic obstructive pulmonary disease for 1% of deaths.     

Low serum concentrations of 25-hydroxyvitamin D in older persons and the risk of nursing home admission

BACKGROUND: The prevalence of vitamin D deficiency in nursing home patients is high. OBJECTIVE: We aimed to ascertain whether lower serum 25-hydroxyvitamin D [25(OH)D] concentrations increase the risk of future nursing home admission and early death. DESIGN: We included 1260 independent, community-dwelling persons aged > or =65 y who were participating in the Longitudinal Aging Study Amsterdam (1995-1996). Study outcomes were time to nursing home admission during 6 y of follow-up and time to death until 1 April 2003. RESULTS: Vitamin D deficiency [25(OH)D < 25 nmol/L] and insufficiency [25(OH)D = 25-49.9 nmol/L] were present in 127 (10.1%) and 462 (36.7%) subjects, respectively. During follow-up, 138 subjects (11.0%) were admitted to nursing homes, and 380 subjects (30.2%) died. The risk of nursing home admission for participants with 25(OH)D deficiency was 53 cases per 1000 person-years higher than that for those with high 25(OH)D (> or =75 nmol/L) concentrations (58 compared with 5 cases). After adjustment for potential confounders, the hazard ratio (95% CI) of nursing home admission was 3.48 (1.39, 8.75) for vitamin D-deficient, 2.77 (1.17, 6.55) for vitamin D-insufficient, and 1.92 (0.79, 4.66) for vitamin D-borderline persons as compared with persons with high 25(OH)D (P for trend = 0.002). The results remained after additional adjustment for frailty indicators. Lower 25(OH)D was associated with higher mortality risk, but this association was not significant after adjustment for frailty indicators. CONCLUSION: Lower serum 25(OH)D concentrations in older persons are associated with a greater risk of future nursing home admission and may be associated with mortality.     

The downstream financial effects of a nursing home practice on an academic medical center

OBJECTIVE: To determine the financial impact of a nursing home practice on an academic medical center. DESIGN: Retrospective cohort design. SETTING: Middle-sized Midwestern community with fee-for-service Medicare population. SAMPLE: One hundred seventy-six nursing home residents followed by faculty and residents of a medical school department of family and community medicine. MEASUREMENTS: Billings and collections for professional and hospital services delivered by the academic medical center during fiscal year 1998. RESULTS: One hundred forty-four patient-years of service resulted in over 1 million dollars in billed charges. For every 1 dollar billed by family medicine, consulting physicians billed 2 dollars and the hospital billed 10 dollars. This amounted to over 4000 dollars per patient per year in reimbursement. This practice generated a wide variety of clinical problems (37 different diagnosis-related groups (DRGs) for the 61 admissions to the hospital). CONCLUSIONS: There is a significant downstream financial effect of a nursing home practice on an academic health center. For this and other reasons, this practice may be worthy of institutional support.     

Trust in older persons: A quantitative analysis of alignment in triads of older persons,informal carers and home care nurses

Self‐management by older persons could be influenced by the level of trust found in triads of informal carers, formal care providers and care recipient, the older person. Little research has been done on care providers’ trust in older persons. This study aims to explore the level of trust that informal carers and home care nurses have in older persons, the extent of alignment in triads and the relationship between trust in older persons and self‐management. We conducted a cross‐sectional survey study in the Netherlands, sampling 133 older persons, 64 informal carers and 72 nurses, which resulted in 39 triads. Alignment level was analysed through Intraclass Correlation Coefficient 1 scores and absolute and mean difference scores. Correlation analysis and one‐way analysis of variance measured the relationship between trust and self‐management. The results show that triads contain both alignment and misalignment. Misalignment occurs mostly when informal carers and nurses have little trust in the older person while this person views their own behaviour towards their caregivers positively. Care providers’ trust levels relate significantly to their perception of the person's ability to self‐manage, but not to the person's self‐rated ability. This could be explained by care providers not communicating their intrinsic trust in the older person to them. Trust building could be enhanced by organising discussions of mutual expectations of trust and both formal and informal care providers could benefit from compassionate assessment training, to learn how to openly express their trust in the older person.     

Sarcopenia and mortality among older nursing home residents

Background and AimsSarcopenia has been indicated as a reliable marker of frailty and poor prognosis among the oldest individuals. At present, no data are available on sarcopenia in the nursing home population. The aim of the current study was to explore the relationship between sarcopenia and all-cause mortality in a population of elderly persons aged 70 years and older living in a nursing home in Italy.MethodsThis study was conducted among all subjects (n = 122) aged 70 years and older who lived in the teaching nursing home of Catholic University of Rome between August 1, 2010, and September 30, 2010. According to the European Working Group on Sarcopenia in Older People (EWGSOP), sarcopenia was diagnosed in presence of low muscle mass plus either low muscle strength or low physical performance. The primary outcome measure was survival after 6 months.ResultsForty residents (32.8%) were indentified as affected by sarcopenia. This condition was more common in men (68%) than in women (21%). During the follow-up period, 26 (21.3%) patients died. After adjusting for age, gender, cerebrovascular diseases, osteoarthritis, chronic obstructive pulmonary disease, activity of daily living impairment, and body mass index, residents with sarcopenia were more likely to die compared with those without sarcopenia (adjusted hazard ratio 2.34; 95% confidence interval 1.04–5.24).ConclusionsThe present study suggests that among subjects living in a nursing home, sarcopenia is highly prevalent and is associated with a significantly increased risk of all-cause death. The current findings support the possibility that sarcopenia has an independent effect on survival among nursing home residents.     

IV drug use, dementia, and nursing home care for PWAs (persons with AIDS)

Despite the usual focus on daily costs, because PWAs have higher costs per day than other SNF residents, LOS and days of care are important cost indices. Data on LOS for 102 admissions and annual days of care for 90 PWAs show average 64-day LOS and 67 days of care. Regression analysis and survival analysis show dementias and IV drug use to mean longer LOS and more days of care. Higher PWA costs must be sustained over longer periods for PWAs with dementias and for IV drug users, who may claim increasing shares of the SNF care provided to PWAs.