Cognitive Change Among Nursing Home Residents: CogRisk-NH Scale Development to Predict Decline

ObjectivesExamine cognitive changes over time among nursing home residents and develop a risk model for identifying predictors of cognitive decline.DesignUsing secondary analysis design with Minimum Data Set data, cognitive status was based on the Cognitive Performance Scale (CPS).Setting and ParticipantsBaseline and 7 quarterly follow-up analyses of US and Canadian interRAI data (N = 1,257,832) were completed.MethodsLogistic regression analyses identified predictors of decline to form the CogRisk-NH scale.ResultsAt baseline, about 15% of residents were cognitively intact (CPS = 0), and 11.2% borderline intact (CPS = 1). The remaining more intact, with mild impairment (CPS = 2), included 15.0%. Approximately 59% residents fell into CPS categories 3 to 6 (moderate to severe impairment). Over time, increasing proportions of residents declined: 17.1% at 6 months, 21.6% at 9 months, and 34.0% at 21 months. Baseline CPS score was a strong predictor of decline. Categories 0 to 2 had 3-month decline rates in midteens, and categories 3 to 5 had an average decline rate about 9%. Consequently, a 2-submodel construction was employed—one for CPS categories 0 to 2 and the other for categories 3 to 5. Both models were integrated into a 6-category risk scale (CogRisk-NH). CogRisk-NH scale score distribution had 15.9% in category 1, 26.84% in category 2, and 36.7% in category 3. Three higher-risk categories (ie, 4-6) represented 20.6% of residents. Mean decline rates at the 3-month assessment ranged from 4.4% to 28.3%. Over time, differentiation among risk categories continued: 6.9% to 38.4.% at 6 months, 11.0% to 51.0% at 1 year, and 16.2% to 61.4% at 21 months, providing internal validation of the prediction model.Conclusions and ImplicationsCognitive decline rates were higher among residents in less-impaired CPS categories. CogRisk-NH scale differentiates those with low likelihood of decline from those with moderate likelihood and, finally, much higher likelihood of decline. Knowledge of resident risk for cognitive decline enables allocation of resources targeting amenable factors and potential interventions to mitigate continuing decline.     

Anticholinergic Drug Use and Negative Outcomes Among the Frail Elderly Population Living in a Nursing Home

AimIncreasing evidence from experimental studies and clinical observations suggests that drugs with anticholinergic properties can cause physical and mental impairment. The aim of the present study was to evaluate the relationship between the use of drugs with anticholinergic activity and negative outcomes in older nursing home residents.MethodsWe used data from the database of the U.L.I.S.S.E project (Un Link Informatico sui Servizi Sanitari Esistenti per l'Anziani), a prospective multicenter observational study. Patients from 31 facilities in Italy were assessed at baseline and at 6 and 12 months by trained personnel, using the Minimum Data Set for Nursing Home (MDS-NH). The only exclusion criterion was age younger than 65 years. The Anticholinergic Risk Scale (ARS), a list of commonly prescribed drugs with potential anticholinergic effects, was used to calculate the anticholinergic load.ResultsA total population of 1490 patients was analyzed; almost half of the sample (48%) was using drugs with anticholinergic properties. The population of patients with ARS 1 or higher had a higher comorbidity index (P < .003) and greater cognitive impairment (CPS 5–6) (P < .007). They were more likely to suffer from heart failure, Parkinson disease, depression, anxiety, and schizophrenia. In multivariate analysis, a higher score in the ARS scale was associated with a greater likelihood of functional decline (described as the loss of ≥1 ADL point) (odds ratio [OR] 1.13; confidence interval [CI] 1.03–1.23), to a higher rate of falls (OR 1.26; CI 1.13–1.41), and to a higher incidence of delirium (OR 1.16; CI 1.02–1.32) during a 1-year follow-up.ConclusionsThe use of medications with anticholinergic properties is common among older nursing home residents. Our results suggest that among older nursing home residents the use of anticholinergic drugs is associated with important negative outcomes, such as functional decline, falls, and delirium.     

Attitudes Toward Sexuality Among Nursing Home Residents

There is a paucity of data regarding sexuality among nursing home residents. The aim of the present study was to evaluate sexual attitudes in a group of independent residents in a large urban nursing home. Ten items covering different aspects of sexual attitude were scored by two board certified psychiatrists following a semistructured interview. The study was undertaken at a large 1,200-bed nursing home providing services to both healthy independent elderly as well as geriatric patients. Subjects were 31 volunteers: 15 men and 16 women (mean age: 82.4 and 74.1 years, respectively), who consented to participate. Participants were cognitively intact and living independently at the nursing home. Exclusion criteria were: a) current major psychiatric morbidity, b) drug or alcohol abuse, c) Geriatric Depression Scale (short version) score 5, and d) Clinical Dementia Rating >0. A hierarchy of basic functions was constructed wherein each function was graded on a 5-point Likert-like scale reflecting its endorsed importance. The majority (23/31) felt that sexuality should be openly discussed with the elderly by health professionals. Twenty-one of 31 expressed willingness to receive medical consultation and treatment for sexual dysfunction as needed and 20/31 expressed a similar attitude if their partner so needed. The hierarchy of needs was rated by the participants (men and women, respectively) as follows: Mood (4.4; 4.3), Memory (4.2; 4.2), Sleep (3.8; 3.9), Sex (3.5; 2.8), and Appetite (2.8; 2.6). Sex is graded as moderately important among nursing home residents, more so in males. The majority of residents expressed positive attitudes towards open discussion of sexual matters and willingness to accept therapeutic interventions when needed.     

The Use of Humor in Addressing the Sexuality of Elderly Nursing Home Residents

This paper is drawn from a large phenomenologically based study which investigated the nursing home carers' experiences of elderly residents' sexuality. Joking and teasing with the residents was an acknowledged way for staff to deal with sexuality in the nursing home. Whilst humor can be used in a therapeutic way to establish and maintain rapport, as well as to deal with incidents which are uncomfortable, joking is also known to be an effective way to manipulate and control people. Teasing can be used as an effective strategy to discourage certain types of behavior.     

Prevalence and Correlates of Cardiovascular Medication Use Among Nursing Home Residents With Ischemic Heart Disease: Results From the SHELTER Study

ObjectivesDespite being the highest group of users of many medications, older individuals remain underrepresented in clinical trials. This leaves a gap in evidence to guide management of many conditions, such as ischemic heart disease (IHD), in this population. This study aimed to describe factors associated with IHD medication use among nursing home residents in 7 European countries and Israel to depict challenges facing disease management in this population.DesignThis study was a retrospective cohort analysis.Setting and ParticipantsThe sample included 4156 nursing home residents in the SHELTER study.MeasurementAll residents were assessed using the interRAI Long-Term Care Facility (LTCF) instrument. Use of angiotensin-converting enzyme inhibitor (ACEi) and/or angiotensin receptor blocker (ARB), beta-blocker (BB), antiaggregants (including acetylsalicylic acid [ASA]) and statins was analyzed. Based on the use of these medications, residents were classified into groups by medication use (as nonusers, 1–2 medications, or 3–4 medications). Generalized Estimation Equation modeling was used to explore predictors of medication use from items on the LTCF instrument as well as facility questionnaire.ResultsOf the 1050 residents with IHD, medication use was 77.7% overall, but only 16.9% were receiving 3 to 4 medications. Use of antiaggregants was highest at 51.7% and variations in medication use were observed by country (highest in France and lowest in Italy). Functional disability was the strongest predictor of medication use, reducing the likelihood of any or optimal management. Severe cognitive impairment also reduced the likelihood of optimal management, and comorbidity generally increased the likelihood of medication use. Polypharmacy reduced the likelihood of use of 3 to 4 medications for IHD.ConclusionOptimal management of IHD in nursing home residents was low and varied by country. Individual characteristics seemed to predict IHD medication use, suggesting prescribing bias and an effect of population differences from clinical trial cohorts.     

Hospice Use Among Nursing Home Patients

ObjectivesAmong hospice patients who lived in nursing homes, we sought to: (1) report trends in hospice use over time, (2) describe factors associated with very long hospice stays (>6 months), and (3) describe hospice utilization patterns.Design, setting, and participantsWe conducted a retrospective study from an urban, Midwest cohort of hospice patients, aged ≥65 years, who lived in nursing homes between 1999 and 2008.MeasurementsDemographic data, clinical characteristics, and health care utilization were collected from Medicare claims, Medicaid claims, and Minimum Data Set assessments. Patients with overlapping nursing home and hospice stays were identified. χ² and t tests were used to compare patients with less than or longer than a 6-month hospice stay. Logistic regression was used to model the likelihood of being on hospice longer than 6 months.ResultsA total of 1452 patients received hospice services while living in nursing homes. The proportion of patients with noncancer primary hospice diagnoses increased over time; the mean length of hospice stay (114 days) remained high throughout the 10-year period. More than 90% of all patients had 3 or more comorbid diagnoses. Nearly 20% of patients had hospice stays longer than 6 months. The hospice patients with stays longer than 6 months were observed to have a smaller percentage of cancer (25% vs 30%) as a primary hospice diagnosis. The two groups did not differ by mean cognitive status scores, number of comorbidities, or activities of daily living impairments. The greater than 6 months group was much more likely to disenroll before death: 33.9% compared with 13.8% (P < .0001). A variety of patterns of utilization of hospice across settings were observed; 21% of patients spent some of their hospice stay in the community.ConclusionsAny policy proposals that impact the hospice benefit in nursing homes should take into account the difficulty in predicting the clinical course of these patients, varying utilization patterns and transitions across settings, and the importance of supporting multiple approaches for delivery of palliative care in this setting.     

Nursing Home Star Ratings and New Onset of Depression in Long-Stay Nursing Home Residents

ObjectivesTo examine the association between nursing home (NH) quality and new onset of depression and severity of depressive symptoms in a national cohort of long-stay NH residents in the United States.DesignCohort study.Setting and participants129,837 long-stay residents without indicators of depression admitted to 13,921 NHs.MethodsNH quality was measured by Nursing Home Compare star ratings (overall, health inspection, staffing, quality measures) closest to admission. Study outcomes at 90 days from the Minimum Data Set 3.0 included depression diagnosis and severity of depressive symptoms (minimal; mild; moderate; moderately severe/severe). Symptoms were measured by resident self-report Patient Health Questionnaire (PHQ-9) or a staff-report observational version (PHQ-9-OV). Logistic and multinomial logistic models with generalized estimating equations were used to estimate adjusted odds ratios (aORs) and 95% confidence intervals (CIs).ResultsAt 90 days postadmission, 14.1% of residents had a new diagnosis of depression, and odds did not differ across star ratings. Nearly 90% of these residents had minimal depressive symptoms, with only 8.5% reporting mild symptoms and 2.6% with moderate to severe symptoms. Using minimal depressive symptoms as the reference, residents in NHs with 5-star overall ratings were 12% less likely than those in 3-star NHs to experience mild (95% CI: 0.81-0.96) and 31% less likely to experience moderate symptoms (95% CI: 0.58-0.82). In NHs with 1-star staffing compared to 3-star, residents had 37% higher odds of moderate symptoms (95% CI: 1.14-1.64) and 57% higher odds of moderately severe to severe depressive symptoms (95% CI: 1.17-2.12). The odds of any above-minimal depressive symptoms decreased as quality measure ratings increased.Conclusions/ImplicationsLower NH quality ratings were associated with more severe depressive symptoms. Further investigation is warranted to identify potential mechanisms for a targeted intervention to improve quality and provide more equitable care.     

Prediction of the Incidence of Falls and Deaths Among Elderly Nursing Home Residents: The SENIOR Study

Objective

The objective of this study was to evaluate, among nursing home residents, the extent to which the various operational definitions of frailty predict mortality and falls at 1 year.

Pain Treatments After Hip Fracture Among Older Nursing Home Residents

Objectives

To examine the association between use of opioids versus other analgesics with death and functioning after hip fracture in older nursing home (NH) residents.

Geographic Variation in Anticoagulant Use and Resident,Nursing Home,and County Characteristics Associated With Treatment Among US Nursing Home Residents

ObjectivesTo quantify geographic variation in anticoagulant use and explore what resident, nursing home, and county characteristics were associated with anticoagulant use in a clinically complex population.DesignA repeated cross-sectional design was used to estimate current oral anticoagulant use on December 31, 2014, 2015, and 2016.Setting and ParticipantsSecondary data for United States nursing home residents during the period 2014-2016 were drawn from the Minimum Data Set 3.0 and Medicare Parts A and D. Nursing home residents (≥65 years) with a diagnosis of atrial fibrillation and ≥6 months of Medicare fee-for-service enrollment were eligible for inclusion. Residents in a coma or on hospice were excluded.MethodsMultilevel logistic models evaluated the extent to which variation in anticoagulant use between counties could be explained by resident, nursing home, and county characteristics and state of residence. Proportional changes in cluster variation (PCVs), intraclass correlation coefficients (ICCs), and adjusted odds ratios (aORs) were estimated.ResultsAmong 86,736 nursing home residents from 11,860 nursing homes and 1694 counties, 45% used oral anticoagulants. The odds of oral anticoagulant use were 18% higher in 2016 than 2014 (aOR: 1.18; 95% confidence interval: 1.14-1.22). Most states had counties in the highest (51.3-58.9%) and lowest (31.1%-41.4%) deciles of anticoagulant use. Compared with the null model, adjustment for resident characteristics explained one-third of the variation between counties (PCV: 34.8%). The full model explained 65.5% of between-county variation. Within-county correlation was a small proportion (ICC < 2.2%) of total variation.Conclusions and ImplicationsIn this older adult population at high risk for ischemic stroke, less than half of the residents received treatment with anticoagulants. Variation in treatment across counties was partially attributable to the characteristics of residents, nursing homes, and counties. Comparative evidence and refinement of predictive algorithms specific to the nursing home setting may be warranted.     

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.     

Cognitive Decline After Entering a Nursing Home: A 22-Year Follow-Up Study of Institutionalized and Noninstitutionalized Elderly People

ObjectiveThe objective of this study is to compare cognitive decline of elderly people after entering an institution with that of elders living in the community with similar clinical conditions.DesignThe Personnes Agées QUID (PAQUID) cohort is a prospective population-based study which included, at baseline, 3777 community-dwelling people aged 65 years and older. Participants were followed-up for 22 years. Among those who were nondemented and living at home at baseline, 2 groups were compared: participants who entered a nursing home during study follow-up (n = 558) and those who remained living at home (n = 3117). Cognitive decline was assessed with Mini-Mental State Examination (MMSE), Benton visual retention test, and verbal fluency Isaacs Set Test.ResultsAfter controlling for numerous potential confounders, including baseline MMSE and instrumental activities of daily living scores, incident dementia, depressive symptoms, and chronic diseases, nursing home placement was significantly associated with a lower score on MMSE between the last visit before and after institutionalization (difference of 2.8 points, P < .0001) and greater further cognitive decline after institutionalization (difference of 0.7 point per year, P < .0001). Similar results were found for the Benton memory test. In a second series of analysis in which the persons who became demented over the study follow-up were excluded, the results remained unchanged.ConclusionsThe present study suggests that institutionalized elderly people present a greater cognitive decline than persons remaining in the community. The reasons of that decline remain unclear and may be related to physical and psychological effects of institutionalization in elderly people.