Reconstruction of the long term care insurance system in Japan

The Japanese long term care insurance has started since 2000. After 5 years' experience, it is scheduled to change in 2006, the most important point is preventive care which means to stop the deterioration of ADL or cognitive function. Prevention is thought to be best way to cut the cost of care services. The preventive care system will start in April, 2006, over 1 million people with supportive care needs will receive muscle training or oral care and nutritional support from care workers in the community. New comprehensive community centers will open and these should which make assessments for preventive care, and provide consultations for care givers and families, and comprehensive care management in the community, and protect the dignity of the elderly will newly start. To improve quality of care services is important, and each prefecture has to evaluate all services and to publish the data with internet, so that everybody can see it and select the most appropriate care or company. Also, the government will start a new system of community based services including group homes, small and multifunctional care services, and day care services for people with dementia. These services should have one room available for each individual.     

Impact of long term care and mortality risk in community care and nursing homes populations

ObjectivesTo identify the survival time, the mortality risk factors and the individuals’ characteristics associated with cognitive and physical status at discharge, among the Portuguese long-term care (LTC) populations.SettingsHome-and-Community-Based Services (HCBS) and three types of Nursing Homes (NH).Participants20,984 individuals admitted and discharged in 2015.MeasurementsThe Kaplan-Meier survival analysis and the Cox Proportional Hazards Models were used to study the mortality risk; the Wilcoxon signed-rank test to identify the number of individuals with cognitive and physical changes between admission and discharge; two cumulative odds ordinal logistic regressions to predict the cognitive and physical dependence levels at dischargeResultsThe mortality rate at HCBS was 30%, and 17% at the NH, with a median survival time of 173 and 200 days, respectively. The main factors associated with higher mortality were older age, male gender, family/neighbour support, neoplasms and cognitive/physical dependence at admission. In NH/HCBS, 26%/18% of individuals improve their cognitive status, while in physical status the proportion was 38%/27%, respectively. Finally, older age, being illiterate and being classified at the lowest cognitive and physical status at admission decrease the likelihood of achieving a higher level of cognitive and physical independence at discharge.ConclusionsThe adoption of a robust and complete assessment tool, the definition of guidelines to enable a periodical assessment of individuals’ autonomy and the adoption of benchmark metrics allowing the comparison of results between similar units are some of the main goals to be taken into account for future developments of this care in Portugal.     

Cardiac remodeling after long term norepinephrine treatment in rats.

OBJECTIVE: In this study we have tested the hypothesis that degradation of collagen by matrix metalloproteinase 2 (MMP-2) precedes the deposition of extracellular matrix (ECM) after long term norepinephrine (NE) treatment. METHODS: Female Sprague-Dawley rats received continuous i.v. infusion of NE (0.1 mg/kg.h) for 1, 2, 3, 4 and 14 days. Heart function and weight as well as expression of cardiac colligin and of collagen I and III were examined. Furthermore, we have assessed the degradation pathway of collagen by measuring the mRNA and activity of myocardial MMP-2 and tissue inhibitor of metalloproteinase 2 (TIMP-2) as well as the protein level of TIMP-2. RESULTS: NE induced hypertrophy predominantly of the left ventricle (LV) in a time-dependent manner. It increased the mRNAs of colligin, collagen I and III, and of MMP-2 and TIMP-2 as well as MMP-2 activity in two phases: In the initial phase, at 3 and 4 days, the mRNA of colligin and of collagen I and III was elevated predominantly in the LV, MMP-2 and TIMP-2 mRNA, as well as TIMP-2 protein and MMP-activity were increased in both ventricles. The second phase, after 14 days, was characterized by a less pronounced increase in colligin, collagen I and III and in MMP-2 activity which occurred exclusively in the LV. Finally, long-term treatment with NE induced a 37% increase in interstitial fibrosis which was shown to occur exclusively in the LV after 14 days. CONCLUSION: NE treatment induced fibrosis exclusively in the LV which was associated with hypertrophy predominantly of the LV. The elevated MMP-2 activity seems to be necessary for the ECM to adapt to the enlargement of myocytes and to reduce overproduction of collagen.     

Bacteremia in a long term care facility

Episodes of bacteremia identified in a long term care facility over a seven and a half-year period from July 1984 to December 1991 were reviewed. Twenty-nine episodes of bacteremia were identified, a rate of 4.35/100,000 patient-days. The most common infecting organisms were Escherichia coli (11 episodes), Streptococcus pneumoniae (four), Proteus mirabilis (three), Staphylococcus aureus (three) and Bacteroides species (two). The source of bacteremia was urinary in 45% of patients, gastrointestinal in 17%, pneumonia in 14%, skin in 14% and unknown in 10%. The overall case fatality rate was 24%, but for the final six years of the review the case fatality rate was only 9.5%. These observations report a rate of bacteremia 10-fold lower than reported from other North American long term care facilities and, potentially, a lower case fatality rate. The primary site of bacteremia, however, in long term care facilities is the urinary tract.     

Impact of serious mental illness online training for certified nursing assistants in long term care

ABSTRACT

Certified nurse assistants (CNAs) spend the most staff time with nursing home residents, yet they receive little training in addressing the mental health needs of residents with serious mental illness (SMI). Forty CNAs from four long-term-care facilities took the online interactive CARES-^® Serious Mental Illness^? training consisting of two modules guided by the Recovery Movement philosophy of care. Responses from pre–post testing, Likert-type items, and open-ended questions indicated that CNAs gained information, changed their perspectives, and had more confidence in dealing with SMI. Although there were minor concerns regarding length, clarity of content, and technical issues, CNAs found the online format acceptable and easy to use, and many said they would recommend the training. CARES Serious Mental Illness online training appears to be a viable way of helping CNAs address the mental health needs of long term care residents. Additional testing on CARES Serious Mental Illness is planned.     

Cholinesterase inhibitor therapy in long term care settings

PURPOSE: Cholinesterase Inhibitors (ChEIs) have proven efficacy in outpatients with mild to moderate Alzheimer's Disease (AD). The benefits of maintaining this treatment once patients are institutionalised remain controversial. The aim of this study was to present current therapeutic strategies regarding ChEIs use in long-term care settings (LTC). METHODS: A multicentric, retrospective, observational study was conducted on currently available ChEIs (donezepil, rivastigmine, galantamine) prescribed in LTC. Data were obtained from medical records. Judgement was based on three criteria: ChEIs indication, follow-up, and justification for maintenance of treatment. RESULTS: Among the 1,373 patients evaluated, 6% (N=81) were receiving ChEIs. They represented various stages of the disease, with cognitive and functional decline ranging from severe (18%) to very mild (10%). Among patients receiving ChEIs, 29% met neither the indication for which these drugs were approved, nor professional guidelines. Patient evaluation at entry was of high quality, with 90% of records including cognitive, functional and behavioural evaluation. Follow-up evaluations were weaker, with at least one assessment domain missing in 40% of the medical records. ChEIs treatment was maintained, although almost half of patients experienced a worsening of their clinical state. CONCLUSION: This study shows that follow-up of institutionalised patients receiving ChEIs could be improved. While treatment maintenance seems to be the rule, it should be questioned on ethical, efficacy, and economic grounds. The rationale for use and discontinuation of these therapeutic strategies in institutional settings requires urgent review.     

Evaluation and treatment of urinary incontinence in long term care

All elderly patients with established urinary incontinence residing in an intermediate care facility during one year were evaluated for medical and urological conditions contributing to the incontinence; treatment was initiated for all diagnosed problems if possible. Unstable detrusor function (65%), sphincter weakness (13%), and overflow incontinence (10%) were all frequent urological causes, although several patients required extensive testing in addition to cystometrics to establish a complete diagnosis. Frequent nonurological causes of incontinence included behavioral problems (53%), immobility (45%), medication problems (24%), diabetes (18%), and local pathology (47%). Thirty-seven percent had three or more conditions identified. Treatment aimed at nonurological causes was more successful in ameliorating incontinence than urological medication; side effects were significant limitations to urological treatment success. Of the 22 patients who completed evaluation, treatment, and follow-up, five patients (23%) were cured, three (14%) showed at least a 65% decrease in incontinence, four (18%) showed at least a 30% decrease in incontinence, and 10 (45%) showed no change or worsened. We conclude that nonurological problems frequently contribute to urinary incontinence in long term care facilities; incontinence in some of these patients can be improved without urological therapy. Nonurological problems need careful definition and treatment; patients whose incontinence persists require comprehensive urological evaluation and therapy. A complete solution to incontinence in this setting may require safer drugs and better understanding of urinary pathophysiology.     

The educational impact of a computer-based training tutorial on dementia in long term care for licensed practice nursing students

The purpose of this study was to examine whether training with a multimedia tutorial would have an impact on LPN students' knowledge of dementia care, attitudes toward dementia care, and self-efficacy ratings. A total of 38 nursing students participated. Pre-post comparisons of outcome measures revealed significant improvements in knowledge, attitudes, and self-efficacy ratings. Results of post-training satisfaction and usability questionnaires indicate that participants found the tutorials easy to understand and easy to use. These data support the effectiveness of the dementia tutorial and the use of computer-based training in educating our long-term care workforce.     

Use of antiviral prophylaxis in influenza outbreaks in long term care facilities

Influenza is a major cause of illness and death in residents of long term care facilities for the elderly, in part because residents'' age and underlying illness increase the risk of serious complications, and in part because institutional living increases the risk of influenza outbreaks. The administration of antiviral medications active against influenza to persons exposed to influenza has been shown to protect them effectively from illness, and mass antiviral prophylaxis of residents is an effective means of terminating influenza A outbreaks in long term care facilities. The only antiviral currently licensed in Canada for influenza prophylaxis is amantadine, a medication active against influenza A but not influenza B. The National Advisory Committee on Immunization recommends that amantadine prophylaxis be offered to residents when influenza A outbreaks occur in long term care facilities. However, there remain a number of unanswered questions about how best to use amantadine for controlling influenza A outbreaks in long term care facilities. In addition, two members of a new class of antivirals called neuraminidase inhibitors have recently been licensed in Canada for the treatment of influenza, and are effective in prophylaxis. Issues in the use of amantadine in the control of outbreaks of influenza A in long term care facilities for the elderly are reviewed, and the potential uses of neuraminidase inhibitors in this setting are discussed.Key Words: Amantadine, Influenza, Long term care, Neuraminidase inhibitor, OutbreakDespite the fact that more than 90% of residents of long term care facilities in Canada are vaccinated against influenza annually, almost half of such facilities report detecting at least one influenza outbreak each year (1,2). Although there are no randomized, controlled trials assessing the effectiveness of antiviral prophylaxis in the control of outbreaks, amantadine has been shown to be effective in preventing influenza A in exposed persons (3,4), and numerous reports document its success in terminating influenza A spread in the long term care setting (1,2,5-9). Thus, both American and Canadian expert advisory committees recommend antiviral prophylaxis for residents for the control of influenza A outbreaks (10,11), and such prophylaxis has become a standard part of outbreak management in Canadian long term care facilities (1,2). There are, however, numerous areas of disagreement about how best to manage mass prophylaxis, and the advent of neuraminidase inhibitors offers new challenges in selecting the best options for prevention of influenza in this setting. In the present paper, we discuss issues surrounding the initiation and discontinuation of prophylaxis, the use of amantadine and the potential place of neuraminidase inhibitors in outbreak control.