Characteristics Associated with Feeding Tube Placement: Retrospective Cohort Study of Texas Nursing Home Residents with Advanced Dementia

ObjectivesTo investigate resident-level, provider-type, nursing home (NH), and regional factors associated with feeding tube (FT) placement in advanced dementia.DesignRetrospective cohort study.Setting and ParticipantsNH residents in Texas with dementia diagnosis and severe cognitive impairment (N = 20,582).MethodsThis study used 2011-2016 Texas Medicare data to identify NH residents with a stay of at least 120 days who had a diagnosis of dementia on Long Term Care Minimum Data Set (MDS) evaluation and severe cognitive impairment on clinical score. Multivariable repeated measures analyses were conducted to identify associations between FT placement and resident-level, provider-type, NH, and regional factors.ResultsThe prevalence of FT placement in advanced dementia in Texas between 2011 and 2016 ranged from 12.5% to 16.1% with a nonlinear trend. At the resident level, the prevalence of FT decreased with age [age > 85 years, prevalence ratio (PR) 0.60, 95% confidence interval (CI) 0.52-0.69] and increased among residents who are black (2.74, 95% CI 2.48-3.03) or Hispanic (PR 1.91, 95% CI 1.71-2.13). Residents cared for by a nurse practitioner or physician assistant were less likely to have an FT (PR 0.90, 95% CI 0.85-0.96). No facility characteristics were associated with prevalence of FT placement in advanced dementia. There were regional differences in FT placement with the highest use areas on the Texas-Mexico border and in South and East Texas (Harlingen border area, PR 4.26, 95% CI 3.69-4.86; San Antonio border area, PR 3.93, 95% CI 3.04-4.93; Houston, PR 2.17, 95% CI 1.87-2.50), and in metro areas (PR 1.36, 95% CI 1.22-1.50).Conclusions and ImplicationsRegional, race, and ethnic variations in prevalence of FT use among NH residents suggest opportunities for clinicians and policy makers to improve the quality of end-of-life care by especially considering other palliative care measures for minorities living in border towns.     

Polypharmacy and Mortality Among Nursing Home Residents With Advanced Cognitive Impairment: Results From the Shelter Study

IntroductionOlder adults with advanced cognitive impairment have a limited life expectancy and the use of multiple drugs is of questionable benefit in this population. The aim of the present study was to assess if, in a sample of nursing home (NH) residents with advanced cognitive impairment, the effect of polypharmacy on mortality differs depending on estimated life expectancy.MethodsData were from the Services and Health for Elderly in Long TERm care (SHELTER) project, a study collecting information on residents admitted to 57 NHs in 8 European countries. Polypharmacy was defined as the concomitant use of 10 or more drugs. Limited life expectancy was estimated based on an Advanced Dementia Prognostic Tool (ADEPT) score of 13.5 or more. A Cognitive Performance Scale score of 5 or more was used to define advanced cognitive impairment. Participants were followed for 1 year.ResultsMean age of 822 residents with advanced cognitive impairment entering the study was 84.6 (SD 8.0) years, and 630 (86.6%) were women. Overall, 123 participants (15.0%) had an ADEPT score of 13.5 or more (indicating limited life expectancy) and 114 (13.9%) were on polypharmacy. Relative to residents with ADEPT score less than 13.5, those with ADEPT score of 13.5 or higher had a lower use of benzodiazepines, antidementia drugs, and statins but a higher use of beta-blockers, digoxin, and antibiotics. Polypharmacy was associated with increased mortality among residents with ADEPT score of 13.5 or more (adjusted hazard ratio [HR] 2.19, 95% confidence interval [CI]: 1.15–4.17), but not among those with ADEPT score less than 13.5 (adjusted HR 1.10, 95% CI: 0.71–1.71).DiscussionPolypharmacy is associated with increased mortality in NH residents with advanced cognitive impairment at the end of life.ConclusionThese findings underline the need to assess life expectancy in older adults to improve the prescribing process and to simplify drug regimens.     

The Minimum Data Set Agitated and Reactive Behavior Scale: Measuring Behaviors in Nursing Home Residents With Dementia

ObjectivesInterventions aimed at managing agitated and aggressive behaviors in dementia without the use of antipsychotics are currently being tested in nursing homes (NHs). Researchers and clinicians require a measure that can capture the severity of residents’ behaviors. We test the internal consistency and construct validity of the Agitated and Reactive Behavior Scale (ARBS), a measure created using data from mandatory NH assessments.DesignCross-sectional.Setting and ParticipantsThe 2016 national sample of 15,326 Centers for Medicare and Medicaid Services-certified NHs. The analytic sample included 489,854 new admissions and 765,367 long-stay residents (at least 90 days in NH). All participants have a dementia diagnosis.MethodsMinimum Data Set (MDS), version 3.0. The ARBS is a composite measure of (1) physical behavioral symptoms directed at other people; (2) verbal behavioral symptoms directed at other people; (3) other behavioral symptoms not directed at other people; and (4) rejection of care. Variables used to establish construct validity included degree of cognitive impairment, use of medications for managing agitation and aggression, and co-occurring conditions associated with agitated and aggressive behaviors (eg, schizophrenia, depression, or delirium).ResultsThis report has 3 important findings: (1) the ARBS score has borderline-adequate internal consistency (α = .64-.71) in the national population NH residents with dementia; (2) only 18% of new admissions and 21% of long-stay residents with dementia evidence any agitated or aggressive behaviors in the last week, as rated in the MDS assessment; and (3) the ARBS demonstrates good construct validity; it increases with cognitive impairment, treatment with relevant medications, and co-occurring psychiatric conditions and symptoms.DiscussionNationally available MDS data may significantly underestimate the prevalence of agitated and aggressive behaviors among NH residents with dementia.Conclusions and ImplicationsResearchers conducting pragmatic trials of non-pharmaceutical interventions to manage behaviors in NH residents with dementia should consider the likely underdetection of these behaviors in the available MDS data.     

Facility Characteristics Associated With Intensity of Care of Nursing Homes and Hospital Referral Regions

ObjectivesIntensity of care, such as hospital transfers and tube feeding of residents with advanced dementia varies by nursing home (NH) within and across regions. Little work has been done to understand how these 2 levels of influence relate. This study's objectives are to identify facility factors associated with NHs providing high-intensity care to residents with advanced dementia and determine whether these factors differ within and across hospital referral regions (HRRs).DesignCross-sectional analysis.Setting and Participants1449 NHs.MethodsNationwide 2016–2017 Minimum Data Set was used to categorize NHs and HRRs into 4 levels of care intensity based on rates of hospital transfers and tube feeding among residents with advanced dementia: low-intensity NH in a low-intensity HRR, high-intensity NH in a low-intensity HRR, low-intensity NH in a high-intensity HRR, and a high-intensity NH in a high-intensity HRR.ResultsIn high-intensity HRRs, high-vs low-intensity NHs were more likely to be urban, lack a dementia unit, have a nurse practitioner or physician (NP or PA) on staff, and have a higher proportion of residents who were male, aged <65 years, Black, had pressure ulcers, and shorter hospice stays. In low-intensity HRRs, higher proportion of Black residents was the only characteristic associated with being a high-intensity NH.Conclusions and ImplicationsThese findings suggest that within high-intensity HRRs, there are potentially modifiable factors that could be targeted to reduce burdensome care in advanced dementia, including having a dementia unit, palliative care training for NPs and PAs, and increased use of hospice care.     

Nursing Home Residents Dying With Dementia in Flanders,Belgium: A Nationwide Postmortem Study on Clinical Characteristics and Quality of Dying

ObjectivesThere is a lack of large-scale, nationwide data describing clinical characteristics and quality of dying of nursing home residents dying with dementia. We set out to investigate quality of end-of-life care and quality of dying of nursing home residents with dementia in Flanders, Belgium.Design/Setting/ParticipantsTo obtain representativity, we conducted a postmortem study (2010) using random cluster sampling. In selected nursing homes, all deceased residents with dementia in a period of 3 months were reported. For each case, a structured questionnaire was filled in by the nurse most involved in care, the family physician, and the nursing home administrator. We used the Cognitive Performance Scale and Global Deterioration Scale to assess dementia. Main outcome measures were health status, clinical complications, symptoms at the end of life, and quality of dying.MeasurementsHealth status, clinical complications, symptoms at the end of life, and quality of dying.ResultsWe identified 198 deceased residents with dementia in 69 nursing homes (58% response rate). Age distribution was the same as all deceased residents with dementia in Flanders, 2010. Fifty-four percent had advanced dementia. In the last month of life, 95.5% had 1 or more sentinel events (eg, eating/drinking problems, febrile episodes, or pneumonia); most frequently reported symptoms were pain, fear, anxiety, agitation, and resistance to care. In the last week, difficulty swallowing and pain were reported most frequently. Pressure sores were present in 26.9%, incontinence in 89.2%, and cachexia in 45.8%. Physical restraints were used in 21.4% of cases, and 10.0% died outside the home. Comparing stages of dementia revealed few differences between groups regarding clinical complications, symptoms, or quality of dying.ConclusionRegardless of the dementia stage, many nursing home residents develop serious clinical complications and symptoms in the last phase of life, posing major challenges to the provision of optimum end-of-life care.     

Epidemiology of Antibiotic Use for Urinary Tract Infection in Nursing Home Residents

ObjectivesDescribe antibiotic use for urinary tract infection (UTI) among a large cohort of US nursing home residents.DesignAnalysis of data from a multistate, 1-day point prevalence survey of antimicrobial use performed between April and October 2017.Setting and participantsResidents of 161 nursing homes in 10 US states of the Emerging Infections Program (EIP).MethodsEIP staff reviewed nursing home medical records to collect data on systemic antimicrobial drugs received by residents, including therapeutic site, rationale for use, and planned duration. For drugs with the therapeutic site documented as urinary tract, pooled mean and nursing home–specific prevalence rates were calculated per 100 nursing home residents, and proportion of drugs by selected characteristics were reported. Data were analyzed in SAS, version 9.4.ResultsAmong 15,276 residents, 407 received 424 antibiotics for UTI. The pooled mean prevalence rate of antibiotic use for UTI was 2.66 per 100 residents; nursing home–specific rates ranged from 0 to 13.6. One-quarter of antibiotics were prescribed for UTI prophylaxis, with a median planned duration of 111 days compared with 7 days when prescribed for UTI treatment (P < .001). Fluoroquinolones were the most common (18%) drug class used.Conclusions and ImplicationsOne in 38 residents was receiving an antibiotic for UTI on a given day, and nursing home–specific prevalence rates varied by more than 10-fold. UTI prophylaxis was common with a long planned duration, despite limited evidence to support this practice among older persons in nursing homes. The planned duration was ≥7 days for half of antibiotics prescribed for treatment of a UTI. Fluoroquinolones were the most commonly used antibiotics, despite their association with significant adverse events, particularly in a frail and older adult population. These findings help to identify priority practices for nursing home antibiotic stewardship.     

Cognition and Screening for Hearing Loss in Nursing Home Residents

ObjectivesTo compare hearing screening results using pure tones and distortion product otoacoustic emissions (DPOAEs) with nursing home residents who have dementia and explore the relationship of hearing impairment and cognitive function using the Mini- Mental Status Evaluation (MMSE).Design and SettingA correlational design was implemented to evaluate residents in a large inner city nursing home.ParticipantsOne hundred one nursing home residents 65–108 years.MeasurementsDPOAEs and pure tone screenings were conducted at 30 dB HL and 40 dB HL at 1, 2, and 3 kHz. Pure tone thresholds at 1, 2, and 3 kHz were obtained. The MMSE was administered to all participants.ResultsResults showed that all residents failed the DPOAE screen, 97.1% failed at 30 dB HL, and 90.0% failed at 40 dB HL. Kendall’s tau, phi correlation, linear by linear association, and χ² results indicated no significant relationship for any of the screening protocols and cognitive status other than a significant finding with left ear screening at 40 dB HL. Logistic regression analysis indicated that individuals who passed the screen had better MMSE scores. Results of the t test and Mann-Whitney U test revealed a significant difference in cognitive function for residents with a mild hearing loss compared with those with a more significant hearing loss.ConclusionFor screening nursing home residents, 40 dB HL screening level or DPOAEs can be used. The significant finding that residents with greater than a mild hearing loss have poorer cognitive function reinforces the importance of identifying residents with a hearing loss and providing rehabilitation and follow-up.     

Predictors of hospitalization in Italian nursing home residents: the U.L.I.S.S.E. project

ObjectiveTo examine resident and facility characteristics associated with hospitalization in a cohort of Italian older nursing home residents.DesignA longitudinal observational study.SettingThe nursing homes participating in the U.L.I.S.S.E. study, a project evaluating the quality of care for older persons in Italy.Setting ParticipantsNursing home residents in 31 Italian nursing homes.MeasurementEach resident underwent a comprehensive geriatric assessment at baseline, and after 6 months and 1 year by means of the RAI MDS 2.0. Facility characteristics were collected using an ad hoc designed questionnaire. Hospitalizations were self-reported by facilities.ResultsA total of 170 (11.6%) of 1466 nursing home residents were admitted to the hospital at least once during the study period. Female gender and higher physician, nurse, and nursing assistant hours per resident were predictive of a lower probability to be admitted to the hospital, whereas a diagnosis of arrhythmia, a previous urinary tract infection, and polypharmacy were associated with a higher probability of being hospitalized.ConclusionThese findings suggest that a reduction of hospitalization of nursing home residents could be achieved by providing an adequate amount of care and optimizing the management of chronic diseases and polypharmacy. This hypothesis should be tested in future clinical trials.     

General practitioners’ perspectives on discontinuation of long-term antidepressants in nursing homes

BackgroundLong-term use of antidepressant drugs (AD), much longer than recommended by guidelines, in nursing homes (NH) is common. NH home residents may have a relatively higher risk of adverse events. Moreover, in an NH setting nursing staff and relatives are intensively involved in the decision-making process. In many countries, General Practitioners’ (GPs) provide care for residents in NHs. Little is known about GPs’ perspectives on discontinuation of long-term AD in NH residents.ObjectivesTo explore GPs’ views of discontinuing long-term AD in NH residents.MethodsAn exploratory qualitative study, with semi-structured interviews, was conducted with a purposive sample of 20 Belgian GPs. Interviews, conducted over six months in 2019, were analysed by thematic analysis.ResultsTwenty interviews were conducted until data saturation. The first theme, ‘reluctance to rock the boat: not worth taking the risk’, describes that GPs perceive discontinuation as an unpredictable risk without clear benefits. GPs’ main concern was the risk of destabilising the fragile balance in an older patient. Second, ‘it takes at least three to tango’, captures the unspoken alliance between GPs, nursing staff and relatives and suggests that agreement of at least these three partners is required. The third, ‘Opening the door: triggers to discontinue’, points to severe health problems and dementia as strong facilitators for discontinuation.ConclusionDiscontinuation of long-term AD in NHs is a complex process for GPs. More evidence and attention to the role nursing staff and relatives play are needed to better guide the discontinuation of AD in older NH patients.     

Factors Associated With Antimicrobial Use in Nursing Home Residents With Advanced Dementia

ObjectivesWidespread antimicrobial misuse among nursing home (NH) residents with advanced dementia raises concerns regarding the emergence of multidrug-resistant organisms and avoidable treatment burden in this vulnerable population. The objective of this report was to identify facility and resident level characteristics associated with receipt of antimicrobials in this population.DesignCross-sectional analysis of baseline data from the Trial to Reduce Antimicrobial use in Nursing home residents with Alzheimer's disease and other Dementias (TRAIN-AD).Setting and ParticipantsTwenty-eight Boston area NHs, 430 long stay NH residents with advanced dementia.MeasuresThe outcome was the proportion of residents who received any antimicrobials during the 2 months prior to the start of TRAIN-AD determined by chart review. Multivariable logistic regression was used to identify resident and facility characteristics associated with this outcome.ResultsA total of 13.7% of NH residents with advanced dementia received antimicrobials in the 2 months prior to the start of TRAIN-AD. Residents in facilities with the following characteristics were significantly more likely to receive antimicrobials: having a full time nurse practitioner/physician assistant on staff [adjusted odds ratio (aOR) 3.02; 95% confidence interval (CI), 1.54, 5.94], fewer existing infectious disease practices (eg, antimicrobial stewardship programs, established algorithms for infection management) (aOR, 2.35; 95% CI 1.14, 4.84), and having fewer residents with severely cognitively impaired residents (aOR 1.96; 95% CI 1.12, 3.40). No resident characteristics were independently associated with receipt of antimicrobials.Conclusions and ImplicationsFacility-level characteristics are associated with the receipt of antimicrobials among residents with advanced dementia. Implementation of more intense infectious disease practices and targeting the prescribing practices of nurse practitioners/physician assistants may be critical targets for interventions aimed at reducing antimicrobial use in this population.     

Functional outcomes of nursing home residents in relation to features of the environment: validity of the Professional Environmental Assessment Protocol

ObjectivesThe aim of this article was to examine associations between specific dimensions of nursing home environments and the functional ability (walking and eating) of residents with dementia, and to contribute to the ongoing psychometric development of the Professional Environmental Assessment Protocol (PEAP).DesignOne-year prospective cohort study.SettingFifteen nursing homes in a western Canadian province.ParticipantsConvenience sample of 120 nursing home residents with middle-stage dementia.MeasurementsEvery 2 weeks we observed residents’ abilities to walk to the dining room and to feed themselves. At the end of a year of observation and immediately following a brief interview with the unit managers, we used the PEAP to measure the extent to which 9 specific dimensions of nursing home environments support the ability of residents with dementia to walk and to eat. Cox proportional hazards models were used to evaluate the effect of specific environmental features on residents’ walking and eating disability.Results“Support of functional ability” was associated with a reduced hazard of both walking and eating disability. The environmental dimensions of “maximizing awareness and orientation” and better “quality of stimulation” were associated specifically with reduced hazard of walking disability, whereas the dimensions of the nursing home environment specifically associated with a reduced hazard of eating disability included improved “safety and security,” “opportunities for personal control,” and “regulation of stimulation.” The Cox proportional hazards models using the 13-point PEAP scale were not significantly different from nested models using the 5-point PEAP scale, indicating that the 2 scales did not differ in their ability to discriminate between more and less supportive environments for residents with dementia.ConclusionsSpecific dimensions of the nursing home environment reduced the hazard of walking disability, whereas others reduced the hazard of eating disability. Modifying specific features of nursing home environments may reduce disability in nursing home residents with dementia. The 5-point PEAP scale is able to discriminate between nursing home environments as well as the 13-point scale.     

Feasibility of Routine Quality of Life Measurement for People Living With Dementia in Long-Term Care

ObjectivesMaximizing quality of life (QoL) is the ultimate goal of long-term dementia care. However, routine QoL measurement is rare in nursing home (NH) and assisted living (AL) facilities. Routine QoL measurement might lead to improvements in resident QoL. Our objective was to assess the feasibility of using DEMQOL-CH, completed by long-term care staff in video calls with researchers, to assess health-related quality of life (HrQoL) of NH and AL residents with dementia or other cognitive impairment.DesignCross-sectional study.Setting and ParticipantsWe included a convenience sample of 5 NHs and 5 AL facilities in the Canadian province of Alberta. Forty-two care staff who had worked in the facility for ≥3 months completed DEMQOL-CH assessments of 183 residents who had lived in the facility for 3 months or more and were aged ≥65 years. Sixteen residents were assessed independently by 2 care staff to assess inter-rater reliability.MethodsWe assessed HrQoL in people with dementia or other cognitive impairment using DEMQOL-CH, and assessed time to complete, inter-rater reliability, internal consistency reliability, and care staff ratings of feasibility of completing the DEMQOL-CH.ResultsAverage time to complete DEMQOL-CH was <5 minutes. Staff characteristics were not associated with time to complete or DEMQOL-CH scores. Inter-rater reliability [0.735, 95% confidence interval (CI): 0.712-0.780] and internal consistency reliability (0.834, 95% CI: 0.779-0.864) were high. The DEMQOL-CH score varied across residents (mean = 84.8, standard deviation = 11.20, 95% CI: 83.2-86.4). Care aides and managers rated use of the DEMQOL-CH as highly feasible, acceptable, and valuable.Conclusions and ImplicationsThis study provides a proof of concept that DEMQOL-CH can be used to assess HrQoL in NH and AL residents and provides initial indications of feasibility and resources required. DEMQOL-CH may be used to support actions to improve the QoL of residents.     

Cost of Diagnosing and Treating Cognitive Complaints: One-year Cost-evaluation Study in a Patient Cohort from a Slovenian Memory Clinic

IntroductionDementias present a global health challenge and give rise to significant economic costs. This study aims to evaluate the economic impact of one-year outpatient healthcare, nursing home, and formal and informal home help costs for all patients referred to the Centre for Cognitive Impairments at the Department of Neurology, Ljubljana University Medical Centre, Slovenia.MethodsData was acquired retrospectively from physicians’ records and the costs for 2015 were calculated. Total costs were estimated by means of a bottom-up calculation of outpatient visits, diagnostic examinations and anti-dementia medication. In a subgroup of 120 patients with dementia, the Resource Utilization in Dementia questionnaire was used to estimate formal and informal care costs.ResultsA total of 720 patients visited the memory clinic in 2015. Diagnosis at first visit was subjective cognitive or mild cognitive impairment (SCI/ MCI) for 322 patients, dementia for 258 patients, and psychiatric or other disorders for 140 patients. The average annual cost per patient was EUR 578. It was highest for patients with dementia (EUR 751), EUR 550 for patients with SCI/MCI, and lowest for patients with psychiatric and other disorders (EUR 324). Monthly informal and social care costs were between EUR 1,037 and EUR 3,369, depending on the methodology used.ConclusionThe cost of diagnosing a cognitive disorder depends on how extensive the diagnosis is. With an estimated prevalence of 34,137 persons with dementia in Slovenia, basic diagnostic investigations incur costs of approximately EUR 7 million. Direct medical costs represent a smaller portion of total dementia costs; this is because annual costs for formal and informal home help are estimated at EUR 265 million and nursing home placements at EUR 105 million.