The effect of raloxifene on markers of bone turnover in older women living in long-term care facilities

OBJECTIVES: To examine the effect of raloxifene on bone turnover in elderly women. DESIGN: Clinical intervention. SETTING: Long-term care facilities. PARTICIPANTS: Nineteen women completed the study, mean age 85 (range 76-99). INTERVENTION: Raloxifene 60 mg was given daily for 12 weeks. MEASUREMENTS: Markers of bone turnover were plasma C-telopeptides of type I collagen (CTx), urine cross-linked N-telopeptides of type I collagen (NTx) and serum tartrate-resistant acid phosphatase (TRAP 5b), plasma osteocalcin, and serum bone alkaline phosphatase. Other markers were serum 25-OH vitamin D, parathyroid hormone, ionized calcium, and phosphate. Markers were measured at baseline, after calcium and vitamin D had been taken for 6 weeks, after raloxifene had been taken for 12 weeks, and 6 weeks after raloxifene had been stopped. Paired sample t test was used to examine changes in markers at each time point. RESULTS: Plasma CTx decreased on average by 31%, urinary NTx by 35%, plasma osteocalcin by 25%, serum bone alkaline phosphatase by 15% (P<.01), and serum TRAP 5b by 10% (P<.05) on treatment. CONCLUSION: Raloxifene reduces bone turnover in elderly women living in long-term care facilities. The effect of raloxifene on bone turnover is comparable with that seen in younger postmenopausal women.     

Consumer satisfaction in long-term care: state initiatives in nursing homes and assisted living facilities

PURPOSE: We report the results of a survey of state initiatives that measure resident satisfaction in nursing homes and assisted living facilities, and we describe several model programs for legislators and public administrators contemplating the initiation of their own state programs. DESIGN AND METHODS: Data on state initiatives and programs were collected during March and April 2000 through a mailed questionnaire and follow-up telephone interviews and were current as of September 2002. RESULTS: Of the 50 states surveyed, 50 responses were received (response rate = 100%); 12 states (24%) reported the use of consumer satisfaction measures, and 7 (Florida, Iowa, Ohio, Oregon, Texas, Vermont, and Wisconsin) reported using resident satisfaction data within their consumer information systems for nursing homes or assisted living facilities. Additionally, 2 states (Iowa and Wisconsin) use resident satisfaction data for facility licensing and recertification. The design of the instruments and collection methods vary in these states, as do the reported response rates, per-resident cost, and the purpose for satisfaction data collection. IMPLICATIONS: State satisfaction efforts are in an early stage of development. Well-produced, easily understandable reports on nursing home and assisted living quality could provide information and guidance for patients and families contemplating the utilization of long-term care services. Dissemination of quality information may also facilitate sustained quality and efficiency improvements in long-term care facilities and thus enhance the quality of care for and quality of life of long-term care residents.     

Nutrition risk factors for survival in the elderly living in Canadian long-term care facilities

OBJECTIVES: To determine the role of nutritional parameters in influencing the risk of mortality in institutionalized elderly. DESIGN: A prospective cohort study in which subjects had several nutritional parameters measured at baseline and were followed for 19 months. Time to death and mortality were recorded starting immediately after enrollment. SETTING: Fourteen long-term care facilities (LTCFs). PARTICIPANTS: Four hundred eight elderly long-term care residents aged 60 and older who resided in the facility for more than 6 weeks. MEASUREMENTS: At baseline, knee height, weight, mid-arm circumference (MAC), skin-fold thickness, and fat-free mass using bioelectric impedance analysis were measured. Covariates included demographic factors, length of stay in the facility, functional status, and medical diagnoses. Cox proportional hazards regression analysis was used to identify independent predictors of mortality. Results are reported as mean+/-standard error of the mean (SEM). RESULTS: Overall, mortality rate was 28.4%. Univariate predictors included male sex, body mass index, MAC, and triceps skin fold. In multivariate analysis, male sex (hazard ratio (HR)=1.7, 95% confidence interval (CI)=1.2-2.7, P=.0096) and MAC less than 26 cm were significantly associated with increased risk of mortality (HR=4.8, 95% CI: 2.8-8.3, P<.0001). CONCLUSION: Among this elderly population living in LTCFs, MAC is the best nutritional predictor of mortality.     

Use of diagnostic tests for presumed lower respiratory tract infection in long-term care facilities

OBJECTIVES: To describe the current use of diagnostic tests for management of presumed lower respiratory tract infection in selected long-term care facilities (LTCFs) in Canada and to correlate test use with facility and resident characteristics. DESIGN: Prospective, 12-month multicenter cohort study. SETTING: A convenience sample of 21 LTCFs in Canada. PARTICIPANTS: LTCF residents prescribed antimicrobial therapy for presumed lower respiratory tract infection. MEASUREMENTS: Data collection included facility characteristics, patient demographics, level of care, comorbidities, clinical presentations, diagnostic testing, and outcomes. Diagnostic test use was correlated with facility access and resident and episode characteristics. RESULTS: Forty-two percent of 1,702 episodes had chest radiography obtained, 28.5% had pulse oximetry, 23.8% had peripheral leukocyte count, and 3.3% had sputum culture. On-site access correlated with obtaining chest radiography (odds ratio (OR)=4.4; 95% confidence interval (CI)=3.2-6.0) and oximetry (OR=30.3; 95% CI=16.4-55.8). Analyses stratified according to facility found that greater test use was associated with greater premorbid functional impairment and more-severe presentations. Advance directives, time to stabilization, and mortality did not correlate with test use. In multivariate analysis, significant variability between facilities for chest radiography and oximetry remained after incorporating differences in access to diagnostic testing and other facility or resident variables. CONCLUSION: The use of diagnostic tests in the management of presumed lower respiratory tract infection in these Canadian LTCFs is highly variable. Access to diagnostic tests and severity of presentations correlate with test use but do not fully explain the variability in use in institutions.     

Cognitive interventions in patients with dementia living in long-term care facilities: Systematic review and meta-analysis

BackgroundPrevious reviews and meta-analyses demonstrated effects of cognitive interventions in dementia, but none specifically considered residents with dementia in long-term care (LTC) facilities.ObjectiveTo analyse the efficacy of cognitive interventions in institutionalised individuals with dementia.MethodsAfter identifying 27 articles, a systematic review was performed. A meta-analysis was calculated for 15 studies of the randomized controlled trials regarding effects on relevant outcomes. Fixed-effects meta-analyses were conducted using standardized mean differences (SMD) of changes from baseline pooled using the inverse variance method.ResultsWhen comparing cognitive interventions to passive control groups, the meta-analysis revealed significant moderate effects on global cognition (SMD = 0.47, 95% CI 0.27–0.67), autobiographical memory (0.67, 0.02–1.31), and behavioral and psychological symptoms in dementia (BPSD; 0.71, 0.06–1.36). Significant small effects were detected for quality of life (QoL; 0.37, 0.05–0.70). Moderate effects on activities of daily living (0.28; −0.02 to 0.58) failed to reach significance; no effects were found on depression (0.22; −0.08 to 0.51). Significant moderate effects of global cognition (0.55; 0.22–0.89) and depression (0.64; 0.21–1.07) were also found for cognitive interventions contrasting active control groups. No harmful events related to the participation in the interventions were observed.ConclusionCognitive interventions are safe and effective for residents with dementia in LTC. However, while it seems clear that cognitive benefits can specifially be assigned to these forms of intervention, further research is necessary to clarify whether the effects on BPSD and QoL reflect unspecific changes due to additional attention. Furthermore, future studies will have to determine which intervention type yields the largest benefits.     

Infection control program disparities between acute and long-term care facilities in Maryland

BACKGROUND: In January 2003, the Maryland State Department of Health and Mental Hygiene (DHMH) surveyed, for the first time, all acute care hospitals (ACHs), long-term care facilities (LTCFs), and specialty hospital (acute rehabilitation and behavioral health) facilities in the state to determine the current state of infection control resources and practices in Maryland. Federal health care facilities in Maryland were not surveyed. METHODS: A self-administered questionnaire was sent to all 40 ACHs, 247 LTCFs, and 20 specialty hospitals in the state. The senior infection control professional (ICP) in the facility completed the questionnaire. RESULTS: The response rates were 85% for ACHs, 39% for LTCFs, and 95% for specialty hospitals. Data were analyzed separately for each type of facility. The ICPs in acute care reported 1.2 full-time equivalent positions (FTEs) for each 200 acute care beds, whereas ICPs in LTCFs reported 0.3 FTEs per 200 LTCF beds. Ninety percent of acute care ICPs reported taking some type of basic infection control course, whereas only 3% of long-term care ICPs reported taking a basic infection control course. CONCLUSION: In this survey of ICPs in Maryland, striking differences were noted between ACHs and LTCFs in the ratio of ICP FTEs to beds and in basic infection control educational preparation for ICPs. These findings suggest that Maryland LTCFs could benefit from basic infection control training and from regulatory actions addressing staff-to-resident ratios.     

Sleep of children living in institutional care facilities

Purpose

To describe sleep patterns and problems among institutionalized children.

Methods

In this cross-sectional study, the caregivers of 118 children, aged 4?C12?years from six institutional care facilities completed the Children??s Sleep Habits Questionnaire (CSHQ).

Results

The mean (±SD) of night bedtime was 21:05?±?2:52, mean morning wake-up time was 06:58?±?0:31, mean total sleep duration was 10?±?1.1?h, and mean night-sleep duration was 9.5?±?0.9?h. The percentage of children who took a daytime nap was 34.7% (n?=?41) and the mean duration of nap was 0.5?±?0.7?h. The most frequently reported sleep problems were bedtime resistance, daytime sleepiness and night awakening. Children with bedtime at or after 9?PM, night-sleep duration less than 10?h and daytime napping had more disturbed sleep.

Conclusions

Sleep problems are common among this sample of institutionalized children.     

Pneumonia in nursing homes and long-term care facilities

This article reviews the epidemiology of pneumonia in residents of nursing homes and other long-term care facilities (LTCFs). Streptococcus pneumoniae is the most important cause of pneumonia in residents of nursing homes and LTCFs. Factors suggestive of aspiration are the most important risk factors for pneumonia in this population. The clinical presentation of pneumonia among long-term care facility residents is challenging; residents tend to be older and more debilitated than their elderly community-dwelling counterparts. Data on optimal antimicrobial therapy in this setting is sparse. Functional status is an important predictor of outcome in this population. There are key management issues, such as site of care, which remain unresolved. Immunization with influenza and pneumococcal vaccines remains the mainstay of prevention.     

The effects of animal-assisted therapy on loneliness in an elderly population in long-term care facilities

BACKGROUND: Animal-assisted therapy (AAT) is claimed to have a variety of benefits, but almost all published results are anecdotal. We characterized the resident population in long-term care facilities desiring AAT and determined whether AAT can objectively improve loneliness. METHODS: Of 62 residents, 45 met inclusion criteria for the study. These 45 residents were administered the Demographic and Pet History Questionnaire (DPHQ) and Version 3 of the UCLA Loneliness Scale (UCLA-LS). They were then randomized into three groups (no AAT; AAT once/week; AAT three times/week; n = 15/group) and retested with the UCLA-LS near the end of the 6-week study. RESULTS: Use of the DPHQ showed residents volunteering for the study had a strong life-history of emotional intimacy with pets and wished that they currently had a pet. AAT was shown by analysis of covariance followed by pairwise comparison to have significantly reduced loneliness scores in comparison with the no AAT group. CONCLUSIONS: The desire for AAT strongly correlates with previous pet ownership. AAT reduces loneliness in residents of long-term care facilities.     

养老机构老年人日常活动能力与焦虑状况

目的探讨城市养老机构老年人日常活动能力(ADL)及其焦虑的现状及其影响因素。方法应用改良版巴氏指数量表、老年人焦虑量表调查A城市养老机构老年人的ADL及焦虑状况,并分析影响因素。结果 69%的养老机构老年人ADL受损,5.5%的老年人有患焦虑症的风险。不同年龄、月收入、运动情况、爱好情况、慢性病患病情况的老年人ADL差异有统计学意义(P<0.05);不同年龄、文化程度、月收入、运动情况、爱好情况、慢性病患病情况、入住养老机构类型的老年人焦虑状况差异有统计学意义(P<0.05);养老机构老年人的ADL与其焦虑情况呈现负相关(r=-0.489,P<0.01)。结论养老机构老年人ADL越高,其焦虑水平越低。提高养老机构老年人ADL有助于改善老年人的精神状态,减轻焦虑水平。     

The relationship between lower body strength and obstructed gait in community-dwelling older adults

OBJECTIVES: To determine the relationship between lower body strength of community-dwelling older adults and the time to negotiate obstructed gait tasks. DESIGN: A correlational study. SETTING: The Biomechanics Laboratory, Deakin University, Australia. PARTICIPANTS: Twenty-nine women and 16 men aged 62 to 88 were recruited using advertisements placed in local newspapers. The participants were independent community dwellers, healthy and functionally mobile. MEASUREMENTS: Maximal isometric strength of the knee extensors and dynamic strength of the hip extensors, hip flexors, hip adductors, hip abductors, knee extensors, knee flexors, and ankle plantar flexors were assessed. The times to negotiate four obstructed gait tasks at three progressively challenging levels on an obstacle course and to complete the course were recorded. The relationship between strength and the crossing times was explored using linear regression models. RESULTS: Significant associations between the seven strength measures and the times to negotiate each gait task and to walk the entire course at each level were obtained (r = -0.38 to -0.55; P < .05). In addition, the percentage of the variance explained by strength (R(2)), consistently increased as a function of the progressively challenging level. This increase was particularly marked for the stepping over task (R(2) = 19.3%, 25.0%, and 27.2%, for levels 1, 2, and 3, respectively) and the raised surface condition (R2 = 17.1%, 21.1%, and 30.8%, for levels 1, 2, and 3, respectively). CONCLUSION: The findings of the study showed that strength is a critical requirement for obstructed locomotion. That the magnitude of the association increased as a function of the challenging levels suggests that intervention programs aimed at improving strength would potentially be effective in helping community-dwelling older adults negotiate environmental gait challenges.     

Antibiotic and infection tracking in Minnesota long-term care facilities

OBJECTIVES: To describe current systems used to track infections, antibiotic use, and antibiotic-resistant infections in Minnesota long-term care facilities (LTCFs). DESIGN: Self-administered multiple-choice survey assessing the methods, frequency, content, and dissemination of information used to track infections and antibiotic use. SETTING: Licensed Minnesota LTCFs providing skilled nursing care to geriatric residents as of June 2005. PARTICIPANTS: Surveys addressed to the director of nursing at 393 eligible LTCFs. MEASUREMENTS: Responses to survey questions, assessed by percentage of all responders. Of the 345 surveys returned, the majority had a system to track infections (94.1%), antibiotics prescribed (80.6%), and antibiotic-resistant infections (86.2%). Most facilities used only a nonelectronic format to track antibiotic use (73.4%) and antibiotic-resistant infections (72.4%). Respondents collected information on antibiotic susceptibility results from cultures of blood (49.0%), urine (53.0%), sputum (50.0%), or wounds (50.0%). One third of attending clinicians were routinely informed of trends in facility antibiotic use. In 42% of facilities, less than 5 hours per month of paid time for an infection control practitioner was provided. Two-thirds of responders (64.2%) described their systems as not or somewhat effective at optimizing appropriate antibiotic use in their facilities. CONCLUSION: Most facilities in Minnesota have a system in place to track infections, antibiotic use, and antibiotic resistance. These systems may not collect or disseminate information effectively enough to identify or address the development of antibiotic resistance. Paid infection control practitioner time is limited.     

A hospital-based multidisciplinary approach improves nutritional status of the elderly living in long-term care facilities in middle Taiwan

Improvement in nutritional status using two different care models was assessed in 374 elderly people (mean ± S.D. age = 78.8±7.2 years) living in eight long-term care facilities in middle Taiwan. The subjects were divided into two groups using randomized block design; a hospital-based multidisciplinary team was responsible for the care of the intervention group, and the control group received usual care for 6 months. A structured questionnaire, anthropometric measurements, and biomedical markers were checked for each subject before and after the intervention. No significant differences were observed in age, height, weight, body mass index, hemoglobin, and albumin between the intervention (n = 125) and control (n = 249) groups at baseline. After 6 months of intervention, 83 subjects in the intervention group and 182 subjects in the control group had completed the study. The change in albumin level was greater in the intervention group (1.58 g/l) than in the control group (0.15 g/l, p < 0.05). The prevalence of hypoalbuminemia (albumin < 35 g/l) decreased from 69.2% to 52.9% in the intervention group and from 70.3% to 67.0% in the control group. In conclusion, a hospital-based multidisciplinary care effectively improved the nutritional status of elderly patients living in long-term care facilities in middle Taiwan.     

Risk factors for pneumonia and other lower respiratory tract infections in elderly residents of long-term care facilities.

BACKGROUND: Little is known about the risk factors, outcome, and impact of pneumonia and other lower respiratory tract infections (LRTIs) in residents of long-term care facilities. OBJECTIVE: To determine the risk factors and the effect of these infections on functional status and clinical course. METHODS: Active surveillance for these infections was conducted for 475 residents in 5 nursing homes from July 1, 1993, through June 30, 1996. Information regarding potential risk factors for these infections, functional status, transfers to hospital, and death was also obtained. RESULTS: Two hundred seventy-two episodes of pneumonia and other LRTIs occurred in 170 residents during 228 757 days of surveillance for an incidence of 1.2 episodes per 1000 resident-days. Multivariable analysis revealed that older age (odds ratio [OR], 1.7; 95% confidence interval [CI], 1.1-2.6 per 10-year interval; P = .01), male sex (OR, 1.9; 95% CI, 1.1-3.5; P = .03), swallowing difficulty (OR, 2.0; 95% CI, 1.2-3.3; P = .01), and the inability to take oral medications (OR, 8.3; 95% CI, 1.4-50.3; P = .02) were significant risk factors for pneumonia; receipt of influenza vaccine (OR, 0.4; 95% CI, 0.3-0.5; P = .01) was protective. Age (OR, 1.6 [95% CI, 1.0-2.5] per 10-year interval; P = .05) and immobility (OR, 2.6; 95% CI, 1.8-3.8; P = .01) were significant risk factors for other LRTIs, and influenza vaccination was protective (OR, 0.3; 95% CI, 0.2-0.4; P = .01). Residents with pneumonia (OR, 0.7; 95% CI, 0.3-1.4; P = .31) or with other LRTIs (OR, 0.5; 95% CI, 0.2-1.1; P = .43) were no more likely to have a deterioration in functional status than individuals in whom infection did not develop. CONCLUSIONS: Swallowing difficulty and lack of influenza vaccination are important, modifiable risks for pneumonia and other LRTIs in elderly residents of long-term care facilities. Our findings challenge the commonly held belief that pneumonia leads to long-term decline in functional status in this population.     

Hand hygiene practices of health care workers in long-term care facilities

Little is known about hand hygiene practice in the long-term care setting. In this study, we observed 459 hand hygiene opportunities in 2 long-term care facilities in Hamilton, Ontario. Overall hand hygiene adherence was 14.7%, with a mean handwashing time of 15.9 seconds. Adherence varied by activity performed and the presence or absence of a sink.     

Management of heart failure in Canadian long-term care facilities

BACKGROUND: In long-term care (LTC) facilities, heart failure is common but undertreated. No Canadian studies of heart failure in LTC facilities have been reported. OBJECTIVES: To estimate the prevalence of heart failure in Canadian LTC facilities; to document the management of heart failure in LTC; and to describe characteristics of LTC residents with heart failure and predictors of adherence to treatment guidelines. METHODS: Cross-sectional survey in eight LTC facilities lodging 1223 residents. RESULTS: The prevalence of heart failure was 20%. LTC residents with heart failure were older, more often women, and more functionally impaired and burdened by comorbidity than were participants in heart failure trials. Documentation supporting the heart failure diagnosis was inadequate, with some symptoms possibly misattributed to chronic obstructive pulmonary disease. Angiotensin-converting enzyme (ACE) inhibitors were prescribed to 55% of residents, although only 45% received appropriate doses. Residents with hypertension or diabetes mellitus, using nitrates or who were male were more likely to receive ACE inhibitors. Appropriate ACE inhibitor doses were associated with functional impairment, nitrate use and recent hospitalization. Documentation of systolic dysfunction was associated with a greater likelihood of ACE inhibitor use. Beta-blockers were prescribed to 25% of residents, who were more likely to be using nitrates, have ischemic heart disease or had been recently hospitalized, and less likely to have chronic obstructive pulmonary disease. Residents with atrial fibrillation were more likely to be prescribed digoxin. Potentially hazardous regimens were prescribed to 43% of residents. CONCLUSIONS: Heart failure is common in Canadian LTC facilities. Management of heart failure in LTC does not conform to guidelines. Improved diagnostic methods tailored for frail elderly patients must be developed. Studies are needed to understand and identify factors influencing prescribing for heart failure medication in LTC.