Background:The U.S. Surgeon General recently put renewed focus on loneliness and isolation as fundamental determinants of health. Objective:To estimate the incidence of depression among established long-stay residents in relation to contextual isolation. Design:Retrospective cohort study. Setting:US nursing homes. Participants:490,523 residents who lived in the same home for at least one year between 2010 and 2019. Measurements:Using data from the Minimum Data Set 3.0, we identified residents who were newly diagnosed with depression. We assessed contextual isolation for each resident with regard to 31 socially salient characteristics relative to their co-residents. Results:The incidence proportion of diagnosed depression from 3-12 months was 21.3% among residents not contextually isolated, 21.0% among residents contextually isolated on a single characteristic, and 22.2% among residents contextually isolated on multiple characteristics. After adjustment for several potential effect modifiers (gender, age group, race/ethnicity, use of translation services), the 3-12 month incidence proportion was 8% higher among residents experiencing contextual isolation on multiple characteristics (95% confidence interval 6% to 10%). Conclusion:Contextual isolation modestly increases the risk of newly diagnosed depression among long-stay residents after they have settled into the nursing home setting. Entry to a nursing home represents an opportunity to make new connections. Helping residents make novel connections may be particularly important for residents whose background or other socially salient characteristics leave them as outsiders to the mainstream of a given nursing home.
BACKGROUND: The PureWick™ System (PureWick) is intended for non-invasive urine output management in female patients.PureWick is comprised of the PureWick™ Female External Catheter and the PureWick™ Urine Collection System.OBJECTIVES: The objectives were: (i) to observe how PureWick impacts caregivers and patients, in the care/nursing home setting and at home, and (ii) to compare PureWick with other urinary incontinence management systems (incontinence pads and Foley catheters).The impact of PureWick on care/nursing home patients was evaluated by comparing the number of incontinence interventions (pad checks, pad changes, other observations such as bed pan/bed linen/clothing change or wash) when using PureWick compared with pads or Foley catheters.Care/nursing home and home users provided Patient-Reported Outcomes Measurements (PROMs) feedback on user experience of comfort, ease of use, efficacy, impact on daily living and quality of life when using PureWick compared with pads or Foley catheters.The impact of PureWick on carers was evaluated in the PROMs questionnaire by asking how much continence care they had given the user while using PureWick compared with pads.Carers were also given the opportunity to provide any additional comments.STUDY DESIGN, SETTING AND PARTICIPANTS: Staff in care/nursing homes identified female incontinent residents using pads or indwelling Foley catheters who met the eligibility criteria for the study.Participants (25) ranging from 31 to 107 years (mean age 75.7 years) of age enrolled in the observational study: 11 from care/nursing homes and 14 home-based users.MEASUREMENTS: Baseline continence information was collected for 10-14 days, then for 10-14 days using PureWick.Care staff recorded the daily intervention data which was then collated.This was an observational study, and due to the sample size of 25 participants across two different data gathering approaches, statistical analysis methods were not applied.RESULTS:Notably fewer pad-only changes were recorded during the PureWick trial compared with baseline (103 vs 522).Night-time interventions that disturb the patient reduced by 65%, with an 89% reduction in participant-reported disturbance of sleep.88% of PROMS respondents reported that PureWick kept them dry all or most of the time, and 52% said that PureWick never caused them skin irritation.56% reported that PureWick never caused them to worry about smell; only 16% said this of pads or catheters.PureWick was rated 7.2/10 for comfort compared to 5.7/10 for either pads or catheters.CONCLUSIONS: PureWick has user-reported benefits (including improved independence, dignity and quality of life) over other continence products for some users.The overall opinion of PureWick was positive compared with pads, with 64% of care/nursing home users choosing to continue using PureWick beyond the trial period, and all home users choosing to continue using PureWick following their trial.
Background: Drugs with anticholinergic properties have many adverse effects that can affect nutritional status.Methods: An observational cross-sectional study was conducted on data from the IDEM study (N=585) to explore the link between nutritional status and anticholinergic burden as well as other factors among older nursing home residents.Nutritional status was determined using the Mini Nutritional Assessment.Multivariate logistic mixed regression was used.Results: Half of residents (N=293) had an impaired nutritional status.After adjusting for potential confounders, there was no significant association between high anticholinergic burden and impaired nutritional status.However, the impaired nutritional status was significantly higher for women (OR=1.90,95CI=[1.15-3.15]),patients with a high Charlson Comorbidity Index score (OR=2.22,),history of fracture (OR=1.62,95CI = [1.03-2.54])or abnormal one-leg standing test (OR=1.99,95CI=[1.04-3.78]), a low cognitive score (OR=0.95,95CI=[0.91-1.00]),with a low autonomy scale (GIR) (OR=0.69,95CI=[0.57-0.85])and with a poor Quality of Life-Alzheimer's Disease assessment (OR=0.90,95CI=[0.86-0.94]).Conclusions: We found no significant association between anticholinergic exposure and nutritional status in older residents living in nursing homes.The use of existing scales in clinical practice remains a challenge because of the complexity of calculating anticholinergic exposure.
The purpose was to investigate the association between mortality in nursing home residents (NHR) and multimorbidity, dependence and their interaction.This study was an 18-month prospective, observational study, that included a subgroup of 5527 NHR residing in 163 nursing homes located in France between May and July 2011.A Cox proportional hazard model was used to perform multivariate survival analysis.Independent variables of interest were baseline multimorbidity, baseline dependence, and the interaction between multimorbidity and dependence.NHR were very dependent at baseline and the median Charlson Index score was 2. In multivariate survival analysis, multimorbidity and dependence were both significantly associated with an increased 18-month mortality (HR=1.10;CI 95% [1.04 -1.17] and HR=1.30;CI 95% [1.22 -1.38], respectively).Higher multimorbidity and higher dependence were both independently associated with a higher 18-month mortality in NHR.Clinicians could use these two simple indicators to identify NHR requiring palliative care.
effort in human history. The drama experienced in longterm care facilities (LTCFs) during the epidemic period must however raise questions about the ability of the scientific community to find specific solutions for the oldest and most vulnerable people living in LTCFs in a timely manner. Many epidemiological works carried out in developed countries such as France, the United States, Spain, Italy, Canada alarmed the medical community on a major number of deaths due to SARS-CoV-2 in LTCFs (1). Schematically, about 30% of all deaths due to SARS-CoV-2 concern residents of LTCFs (2,3). This high percentage of deaths within a very minority subgroup of the population (1% of the French population) contrasts with the low number of scientific studies involving residents of LTCFs. A quick search on the PudMed. gov website proves it. By filtering on the research carried out on “humans”, only 694 references emerge by associating the keywords “nursing home” and “COVID-19” (less with “longterm care facility”). This number is derisory (around 0.49%) compared to the 141,237 results obtained with the keyword “COVID-19” alone. To put it another way, 1 in approximately 200 COVID-related manuscripts to date relate to residents of LTCFs. Of course, this observation can be balanced by the research which, without focusing specially on the population living in LTCFs, has led to advances in the care of people living in LTCFs. Research on vaccination is one example among others. However, should we not again be surprised that before the massive and priority vaccination of the residents of LTCFs, none were included in the original work that led to the implementation of the vaccination against SARS-Cov-19 in all institution worldwide? To date, only 5 Randomized Controlled Trial (RCT) have been published on COVID-19 in “nursing home”. In the initial phase, the preventive measures implemented in the LTCFs relied on common sense and were mainly empirical (4). Yet, the severity of the epidemic in the LTCFs due to (i) the specificities of the population but also (ii) the organizational characteristics of the institutions justify a strong commitment for research work to bring improved geriatric medicine and quality of care in LTC during the pandemic. The very high age of the residents, their multiple morbidities, their undernutrition explain their immunosuppression and the high rate of deaths. The very high prevalence of neuro-degenerative diseases in LTCFs, often at severe stage and complicated with psychobehavioral disorders such as wandering compromise the feasibility in applying protective measures and in particular in wearing the mask. Finally, community life, in closed spaces, sometimes old and poorly ventilated, is conducive to the spread of the virus. The conjunction of these three factors (patients at very high risk of severe COVID-19/impossibility of applying health rules/promiscuity of many individuals in a closed place), made it possible, from the start of the pandemic in spring 2020, to announce a disaster in LTCFs. To this observation must be added the insufficient number of health care professional, their low level of training and equipment and sometimes the insufficient support provided by hospital staff overwhelmed by the workload in the emergency room. Despite the need for research data in LTCF, many challenges must be overcome to conduct high-quality research in LTCF. More than ever, evidence-based medicine should guide the practices of caregivers in LTCFs and improve the care of residents. However, the pandemic has added challenges to an already difficult research to conduct in LTCF. In a systematic review, Lam et al. (5) report the multiples challenges, constraints and specificities of research in LTCFs. Among the challenges to be met, it is worth mentioning the increased costs of research in LTCFs compared to the community and few funding opportunities for research projects, the high turnover of health care professionals and residents, the heterogeneity of residents, the difficulty of recruitment to participate in research and in particular the obstacles to obtaining consent and assent of residents (in cognitively impaired residents with or without legal guard, among other ethical challenges), barriers related to relatives who are afraid of research and who do not want their relatives to be involved in clinical research, poor or complicated access to imaging or lab exams, low number and overloaded health care professional. Moreover, the directors and administrative officers of the LTCFs do not know the world of research and show little interest. Research in LTCF also generates concern that the data collected from residents and health care professional may lead to criticism or even controls of regulatory guardianship (6). In randomized placeboEDITORIAL
The rapid increase in antimicrobial resistance is a great concern in safeguarding the nursing home population. Improving inappropriate prescribing is the main agenda of antimicrobial stewardship. It is complicated to articulate the appropriateness of antimicrobial prescribed in nursing home residents, especially the prophylaxis. It is tricky because most of the residents are often on multiple medications, and there are no guidelines available for prescribers to decide on the appropriateness. Except for urinary tract infections, prescribing instructions rarely exists for other infections in nursing homes. Very few studies discuss prophylactic prescribing, and most of them are prevalence studies. These studies showed the urinary tract, respiratory tract, and skin-related problem as the most common cause of antimicrobial prophylaxis. However, this information is presented as total proportion without disaggregated analysis of conditions and types of the urinary and respiratory tract and skin-related infections. Further, the definition used is vague, and significant risk factors of antimicrobial prophylaxis and precision about the use remain unanswered. Lack of appropriate definition and unanswered questions are potentially challenging for stewardship in nursing homes. This review summarizes the current situation of antimicrobial prophylaxis and discusses gaps in the literature and pertinent areas for moving forward for antimicrobial stewardship in nursing home settings.
Background:About 29.2% of American adults ≥ 65 years of age have diabetes mellitus, but details regarding diabetes management especially among nursing home residents are dated.Objectives:Evaluate the prevalence of antihyperglycemic agents in residents with diabetes mellitus and describe resident characteristics using major drug classes.Design:cross-sectional study.Setting:virtually all United States nursing homes.Participants:141,636 residents with diabetes mellitus.Measurements:Minimum Data Set (2016) and Medicare Part D claims determined use of metformin, sulfonylureas, meglitinide analogs, alpha-glucosidase inhibitors, TZDs, DPP4 inhibitors, SGLT2 inhibitors, GLP1 agonists, as monotherapy and with basal insulin.Results:Seventy-two percent received antihyperglycemic drugs [most common: basal insulins (53.9% total; 46.9% with other non-insulin agents), metformin (35.5% total; 14.2% monotherapy), sulfonylureas (19.6% total; 6.3% monotherapy), and DPP4 inhibitors (12.2% total; 2.2% monotherapy)]. Sixty-three percent of meglitinide monotherapy versus 34.1% of metformin monotherapy users; and 38.3% meglitinide-basal insulin versus 22.2% metformin-basal insulin users were ≥85 years. Obesity was greater among users of GLP1 agonists compared to those receiving other agents (monotherapy: 60.5% versus 33-42%; with basal insulin: 76.2% versus 50-58%). End-stage renal disease was least prevalent among metformin users (monotherapy: 6.6%; with basal insulin: 8.8%) and most common among meglitinide monotherapy (19.6%) and GLP1 agonists with basal insulin (22%) users.Conclusions:There is heterogeneity of diabetes treatment in nursing homes. Use of antihyperglycemic drugs with a higher risk of hypoglycemia, such as insulin with sulfonylureas or meglitinides, continue in nursing home residents.
Background/Objectives: To identify which infection prevention and control (IPC) precautions in long-term care facilities (LTCF) were associated with reduced COVID-19 incidence and mortality among residents and reduced COVID-19 incidence in health care professionals (HCP). Design: Retrospective data on self-assessment of adherence to 101 IPC measures collected via an online questionnaire sent to 825 nursing homes in France in December 2020. Setting and participants: Medical and administrative staff jointly reported data on IPC measures, characteristics of LTCF, counts of residents’ COVID-19 deaths and cases, and counts of HCP cases. Measurements: Random forest models were used to identify the most important IPC measures associated with reduced number of COVID-19 deaths and cases in residents and cases in HCP. The identified variables were then included in linear regression models to estimate the association between levels of adherence to each selected IPC measure and COVID-19 deaths and cases. No data on time of IPC measures implementation were collected. Results: Data from 307 LTCF (37.2%) were collected, accounting for 22,214 residents. A higher number of COVID-19 deaths in residents was associated with a better adherence to physical distancing in group activity rooms. A better adherence by HCP to physical distancing during their mealtimes and break times was associated with fewer COVID-19 cases among residents and HCP. Other IPC measures were not significantly associated with COVID-19 cases or deaths. Conclusion: Physical distancing between residents was more implemented when LTCF had been confronted with COVID-19 deaths. Physical distancing between HCP was associated with fewer COVID-19 cases in residents and HCP, suggesting it may prevent significantly COVID-19 spreading in LTCF. HCP should particularly adhere to physical distancing measures during their mealtimes and break times. A higher adherence to such preventive measures does not require extra material or human resources and may be easily achievable.
Objectives: Elderly patients requiring emergency general surgery (EGS) are at high risk for complications due to preexisting malnutrition. Thus, correcting nutritional deficits perioperatively is essential to improve outcomes. However, even in patients unable to tolerate enteral nutrition, initiation of parenteral nutrition (PN) is often delayed due to concerns of associated complications. In this study, we hypothesized that in elderly EGS patients with relative short-term contraindications to enteral nutrition, early administration of PN is as safe as delayed administration. Furthermore, early PN may improve outcomes by enhancing caloric intake and combatting malnutrition in the immediate perioperative period. Design and Setting: A single-institution, retrospective review was performed at a quaternary academic medical center. Participants: Participants consisted of 58 elderly patients >65 years of age admitted to the EGS service who required PN between July 2017 and July 2020. Measurements: Postoperative outcomes of patients started on PN on hospital day 0-3 (early initiation) were compared to patients started on PN on hospital day 4 or later (late initiation). Bivariate analysis was conducted using the Chi-square or Fisher’s exact test for categorical variables and the Wilcoxon-Mann-Whitney test and F-test for continuous variables. Results: Fifty-eight patients met inclusion criteria, with 27 (46.6%) patients receiving early PN and 31 (53.4%) receiving late PN. Both groups shared similar baseline characteristics, including degree of frailty, body mass index, and nutritional status at time of admission. Complications associated with PN administration were negligible, with no instances of central venous catheter insertion-related complications, catheter-associated bloodstream infection, or factors leading to early termination of PN therapy. A significantly higher proportion of patients in the early administration group met 60% of their caloric goal within 72 hours of admission (62.9% versus 19.5%, p=0.0007). Patients receiving late PN demonstrated a significantly higher rate of unplanned admission to the intensive care unit (38.7% versus 14.8%, p=0.04). Moreover, there was a 21.5% reduction in mortality among patients in the early initiation group compared to patients in the late initiation group (33.3% versus 54.8%, p=0.10). Conclusions: Early initiation of PN in hospitalized elderly EGS patients was not associated with increased adverse events compared to patients undergoing delayed PN administration. Furthermore, patients receiving early PN demonstrated a 2.6-fold decrease in the rate of unplanned admission to the intensive care unit and trended toward improved mortality. Based on these results, further prospective studies are warranted to further explore the safety and potential benefits of early PN administration in elderly surgical patients unable to receive enteral nutrition.
Background: Residents of nursing homes frequently report loneliness and isolation, despite being in an environment shared with other residents and staff. Objective: To describe, among long-stay US nursing home residents living with Alzheimer’s disease and/or related dementias (ADRD), group activity participation in relation to contextual isolation: living in a nursing home where fewer than 20% of residents share socially salient characteristic(s). Design: A cross-sectional evaluation of group activity participation in relation to contextual isolation across 20 characteristics based on demographic characteristics, habits and interests, and clinical and care dimensions. Setting: US nursing homes. Participants: We included 335,421 residents with ADRD aged ≥50 years with a Minimum Data Set 3.0 annual assessment in 2016 reporting their preference for group activity participation, and 94,735 with participation observed by staff. Measurements: We identified 827,823 annual (any anniversary) assessments performed on nursing home residents in 2016, selecting one at random for each resident, after prioritizing the assessment with the least missing data (n=795,038). MDS 3.0 item F0500e assesses resident interest in group activities. Results: When considering all potential sources of contextual isolation considered, 30.7% were contextually isolated on the basis of a single characteristic and 13.7% were contextually isolated on the basis of two or more characteristics. Among residents reporting importance of group activity, 81% of those not contextually isolated reported that group activity participation was important, as did 78% of those isolated on one characteristic, and 75% of those isolated on multiple characteristics. Among residents with staff-observed group activity participation, 64% of those not contextually isolated reported were observed participating in group activities, as were 59% of those isolated on one characteristic, and 52% of those isolated on multiple characteristics. Conclusion: Residents with ADRD facing contextual isolation placed less importance on group activity than residents who were not contextually isolated.
Hypertonic saline nasal irrigation and gargling (HSNIG) has the potential to reduce COVID 19 transmission. We present a pilot cluster randomised controlled trial to assess the feasibility and acceptability of a future trial to test the effectiveness of HSNIG in care homes (CHs). Staff in the intervention CHs were invited to perform HSNIG whereas control CHs carried on with their routine protection procedures. The acceptability of HSNIG was explored via interviews and online surveys. Seven (21%) of contacted CHs participated but following randomisation three (43%) dropped out leaving two intervention CHs and two control CHs. Facilitators to uptake of HSNIG included motivated ‘champions’ and integration into routines. Barriers included a lack of ownership and perceptions of reduced risk from COVID-19. Recruiting and retaining CHs in this study was challenging. Although HSNIG was reported to be safe and acceptable by staff, further work is required to quantify and optimise its acceptability.
Objectives: As COVID-19 spread across the United States, and most rapidly in skilled nursing homes, public health departments developed policies to mitigate the spread. Concerns grew over whether this spread linked to nursing home quality. Design: We collected data on nursing home quality, staffing, and COVID-19 cases from the Centers of Medicare and Medicaid Services. Demographic data was sourced from Long Term Care Focus. Settings and Participants: The analysis used cross-sectional data from 1,025 California skilled nursing homes including quality ratings and confirmed COVID-19 cases between May 17, 2020 and August 23, 2020. Methods: The dependent variable was confirmed COVID-19 cases among residents. The primary independent variables were Overall Rating and Health Inspection Rating, while also including nursing home beds, patient race composition, ownership and geographic classification. Results: 5-Star Overall Rating, 5-Star Health Inspection Rating, and a lower count of health inspection deficiencies each predicted a lower likelihood of having a confirmed COVID resident case (p<.05). Conclusions and Implications: Skilled nursing homes with higher quality ratings and fewer health inspection deficiencies were less likely to have a confirmed case of COVID-19 among residents.
Background: The COVID-19 pandemic disproportionately affected the older adult population, especially those in nursing homes (NHs). However, there is also evidence that some NHs fared better than others. Objectives: This study examines a set of nursing home related factors to understand whether these factors are associated with the number of COVID-19 cases. Design: We combined three datasets from the Centers for Medicare & Medicaid Services (CMS) – the Star Rating Dataset, the Provider Information Dataset, and the COVID-19 Nursing Home Dataset. Setting and Participants: 4390 NHs that responded to the CMS survey. Methods: Data used is from the period of Jan 1–Dec 27, 2020 for all 12 Midwestern states. The measures used were self-reported information on ratings, staff shortages, PPE shortage, number of beds, Registered Nurse (RN), Licensed Practical Nurses (LPN), Certified Nursing Assistants (CNA) hours per resident, star rating and ownership. Results: Of the 4390 NHs in 12 Midwestern states, high performing NHs were less likely to have more than 30 COVID-19 cases versus low-performing facilities for two of the CMS domains (health inspections, 520 NHs [27.6%] vs 1363 NHs [72.4%]; and staffing 773 NHs [41.1%] vs 1110 NHs [58.9%]). There was also a statistically significant association COVID-19 cases and star rating, NH ownership, NH size, RN, LPN, and CNA staffing in NHs (all p ≤ 0.01). NH ownership status persisted as a predictor of COVID 19 cases when controlled for NH size. Conclusions: Our study highlights two interesting findings. A) a statistically significant association between NH ownership structure and COVID-19 cases among residents - for-profit NHs had higher number of COVID-19 cases B) a statistically significant negative association between RN and CNA staffing and COVID-19 cases (i.e., more staffing hours of RNs and CNA correlated with a smaller number of COVID-19 cases) and a statistically significant positive association between LPN staffing and COVID-19 cases. We discuss ensuing policy implications for NHs.
Background: The literature indicates that palliative care for people with dementia needs to be enhanced. Objectives: To assess barriers to providing high-quality palliative dementia care and potential solutions to overcome these barriers, as perceived by physicians responsible for end-of-life care with dementia. Design: Cross-sectional study. Setting: The Netherlands. Participants: A representative sample of 311 elderly care physicians of whom 67% (n=207) responded. Measurements: A postal survey in 2013 containing open-ended items probing for barriers in the elderly care physicians’ practices and possible solutions. Answers were coded and grouped using qualitative content analysis and presented to expert physicians in 2021. Results: Barriers to palliative care in dementia were (1) beliefs held by family, healthcare professionals or the public that are not in line with a palliative care approach, (2) obstacles in recognizing and addressing care needs, (3) poor interdisciplinary team approach and consensus, (4) limited use or availability of resources, and (5) poor family support and involvement. Suggested solutions were improving communication and information transfer, and educating healthcare staff, families and the public about palliative care in dementia. Timely and frequent communication with the family, including advance care planning, and more highly skilled nursing staff were also proposed as solutions. Conclusions: The results suggest a strong need for ongoing education for healthcare professionals about palliative dementia care. Strengthening interprofessional collaboration and shared responsibility for advance care planning is also key. Increasing public awareness of the dementia trajectory and the need for a proactive approach call for a broader societal agenda setting.
