Objectives Keeping staff in post-acute and long-term care (PALTC) settings up to date on adult vaccinations is important to protect them and reduce the spread of vaccine-preventable illness to residents. This quality improvement (QI) project aimed to increase vaccination coverage among PALTC staff while exploring improvement strategies tailored to this setting. Design QI project conducted in 2, 12-month cohorts between 2022 and 2024. Setting and Participants QI teams from 15 skilled nursing facilities and 6 assisted living facilities across 9 states participated in the QI project. QI teams included staff and administrators working at the facility and corporate level in roles such as medical directors, directors/assistant directors of nursing, and infection preventionists. Methods QI teams implemented vaccination strategies, reported monthly staff vaccination coverage for 3 vaccines (COVID-19, influenza, and hepatitis B), received monthly technical assistance, and met quarterly with other facilities to share lessons learned. We report staff vaccination coverage at baseline and end point by vaccine, highlight common challenges across participating facilities, and provide examples of facilities' QI strategies. Results Most facilities did not improve staff vaccination coverage. Only 1 of 16 facilities with complete COVID-19 coverage data (6%) showed a modest improvement over time, 7 of 15 facilities with complete influenza coverage data (47%) maintained or improved coverage, and 4 of 6 facilities with complete hepatitis B coverage data (67%) showed improvement. Facilities focused their QI efforts on making vaccination convenient, respecting staff autonomy, and engaging staff in dialog but were challenged by staffing shortages, limited data infrastructure, and vaccine hesitancy. Facilities found it especially difficult to gather and report immunization data for staff; in some cases, low coverage reflected missing data. Conclusions and Implications Improving PALTC staff vaccination coverage nationally will require addressing data gaps, making vaccination convenient and affordable for staff, and addressing vaccine hesitancy through respectful dialog.
Objectives To examine prescribing trends in prevalence and initiation of individual antipsychotics among a predominantly US-based cohort of adults with dementia from 2016 to 2025, with demographic stratification and formal trend analysis. Design Retrospective cohort study. Setting and Participants This study used TriNetX Research Network data from 111 health care organizations. Adults aged ≥65 years with dementia between January 1, 2016 and December 31, 2025 were included; individuals with prior psychotic disorders were excluded. Methods Eighteen Food and Drug Administration–approved antipsychotics, including 14 second-generation and 4 first-generation agents, were identified from electronic health record prescription data. Annual prevalence and initiation (proportion and rates) were calculated overall and by age, sex, and race. Joinpoint regression was used to estimate annual percent change (APC) and average APC in initiation. Results Among 950,573 patients with dementia (mean age, 82 years; 56.4% female), the prevalence of antipsychotic use increased from 2016 to 2025. Quetiapine and haloperidol were the most frequently used agents, increasing from 3605 to 18,432 and from 4745 to 15,829 per 100,000, respectively. Olanzapine prevalence increased from 1205 to 9264 per 100,000 patients. Initiation rates rose substantially, driven by select antipsychotics; quetiapine initiations increased nearly 5-fold, whereas olanzapine showed a steep increase (average APC, 30.51%; P < .001). Use was highest among individuals aged 75 to 84 years and varied by sex and race. Joinpoint analyses demonstrated late-period acceleration for several agents, including quetiapine, olanzapine, risperidone, and brexpiprazole. Conclusions and Implications Antipsychotic use in dementia increased substantially over the past decade, driven primarily by rising initiation of selected agents. These findings highlight marked agent-specific and demographic heterogeneity in prescribing patterns and underscore the need for continued monitoring of antipsychotic use in this high-risk population.
OBJECTIVES Timely recognition of the terminal phase among nursing-home residents is essential to align care goals. However, how dynamic changes during this period relate to mortality beyond baseline factors remains unclear. We aimed to examine baseline values and temporal changes in clinical and daily life conditions during the last 3 months of life. DESIGN Retrospective cohort study using explainable machine learning with repeated stratified crossvalidation. SETTING AND PARTICIPANTS Five nursing homes in the Kanto region of Japan. Included were 87 residents who died between August 2022 and June 2024 (cases) and 278 surviving controls (total n = 365). METHODS We analyzed longitudinal data on clinical status, vital signs, physical, cognitive, and oral function, nutritional status, and bowel movements from routine electronic care records of 365 matched decedents and surviving controls. Extreme gradient boosting and SHapley Additive exPlanations (SHAP) values were used to describe how baseline indicators and temporal changes were associated with all-cause mortality. RESULTS Models incorporating monthly change indicators from the last 3 months and weekly indicators from the last 4 weeks showed substantially better discrimination than the baseline-only model. With dynamic indicators included, short-term changes in vital signs, oral intake, and bowel movements had the largest SHAP contributions, whereas activities of daily living, body mass index, and background clinical characteristics contributed mainly through baseline levels measured 3 months before death. Time-specific SHAP analyses indicated a 2-phase structure: bowel-movement changes 2 to 3 months prior were more strongly related to mortality, whereas rapid deterioration in oral intake and vital signs became dominant from the final month to week. CONCLUSIONS AND IMPLICATIONS Mortality was associated with long-term frailty and short-term physiological decline. Characterizing these monthly and weekly patterns using routine assessment systems may support earlier recognition of end-of-life transition and inform care planning without increasing staff burden.
Objectives/Design This narrative synthesis of reviews consolidates readmission risk factors for patients with dementia to establish the most significant risks and explore interventions to reduce readmissions. Methods A narrative synthesis of reviews was conducted. Six electronic databases were searched in April 2025. Of the 304 articles initially identified, a total of 14 articles met the full inclusion criteria and were included. Results Thirty-day readmission rates across the reviews ranged from 16% to 30% in people with dementia and 10% to 17% for those without. Risk factors for 30-day readmission were comorbidities, living alone, ethnic minorities, and behavioral and psychological symptoms of dementia. Definitions and comparators varied across reviews. Organizational risks were ineffective discharge planning and poor communication across services. Readmission reduction focused on case management, improved communication, and interdisciplinary care. Conclusions and Implications Rates of readmission for people with dementia appeared higher. Personal characteristics, comorbidities, and organizational influences are associated with readmission. Some interventions were found to reduce readmissions, such as case management, but the heterogeneity in the studies makes it difficult to assess where to focus services. Developing a deeper understanding of persons most at risk of readmission will facilitate interventions for those most at risk.
