OBJECTIVES:To describe trends and identify factors associated with place of death among individuals with Huntington's disease (HD). DESIGN:Retrospective cohort of deceased individuals with HD from the Centers for Disease Control and Prevention's National Center for Health Statistics. SETTING AND PARTICIPANTS:A total of 13,350 individuals with HD who died in the United States between 2009 and 2019. METHODS:We analyzed place of death, categorized as long-term care (LTC) facility, home, hospital, hospice facility, and other locations. Trends in the places of death from 2009 to 2019 were assessed using linear regression models. Multivariate logistic regression models were used to identify sociodemographic factors associated with place of death. RESULTS:From 2009 to 2019, the greatest proportion of deaths occurred in LTC facilities (48.4%). There was a significantly decreasing trend in the proportion of deaths occurring in LTC facilities (53.5%-43.9%, P < .001). A greater proportion of deaths in rural areas occurred in LTC facilities compared with all other locations (P < .001 for all comparisons). In the multivariate model, aged younger than 44 years, Black race, Hispanic ethnicity, some college education or greater, and being married were associated with significantly lower odds of dying in a LTC facility compared with home. CONCLUSIONS AND IMPLICATIONS:Despite a decreasing trend, LTC facilities remain a cornerstone of support for individuals with HD, particularly in rural areas. These results suggest multiple avenues for research to improve accessibility and quality of care for individuals with late stages of HD. Future studies are needed to further understand the impact of rurality and lack of support in the home on the accessibility and quality of LTC and hospice care for individuals with HD. These results may also help inform interventions focused on training and staff education within LTC and hospice facilities to better manage HD progression and symptoms.

Outcomes1. Enhance the learner's knowledge of palliative care referral criteria for nursing home residents.2. Describe priority criteria for palliative care specialist consultation for nursing home residents.Key MessageNH residents experience a multitude of unmet palliative care needs. This qualitative descriptive study records the perspective of key individuals involved in the care of nursing home residents. Participants describe important screening and referral criteria along with perspectives on prioritization criteria for palliative care resources in nursing homes.ImportanceNursing home residents do not receive palliative care services in relation to their high prevalence of serious illness. One critical barrier to high quality palliative care in the nursing home setting is the lack of consistent and standardized screening and referral criteria.Objective(s)To explore, identify, and describe potential nursing home resident palliative care referral criteria from the perspective of nursing home staff, nursing home providers, and palliative care specialists.Scientific Methods UtilizedWe applied a rapid qualitative approach to analyze semi-structured interviews using directed content analysis. Participants were eligible if they worked in the nursing home setting or provided palliative care to nursing home residents.ResultsSeventeen participants representing various roles (e.g., nurses, physician, nurse practitioners) participated. Our analysis identified five domains related to potential nursing home resident palliative care referral criteria: 1) uncontrolled symptoms, 2) serious illness, 3) global indicators of decline 4) support needs, and 5) transition to hospice. Overall, there was consensus among our participants regarding the importance of these domains and the prioritization of patients with uncontrolled symptoms, specifically those experiencing pain, dyspnea, and behavioral manifestations of dementia. Additionally, the number of factors identified within these five domains was extensive and diverse.Conclusion(s)The complex array of criteria uncovered in this study highlights the intricate decision-making process surrounding palliative care referrals in nursing homes. It emphasizes the pressing need for enhanced clarity and standardized guidelines.ImpactBy understanding the diverse domains and factors influencing palliative care referrals, we can work towards establishing evidence-based criteria. Further research is imperative to discern the optimal method for integrating these domains into a standardized process for identifying nursing home residents who would benefit from palliative care, ultimately improving the overall care provided to nursing home residents with serious illness.

Outcomes1. Enhance the learner's knowledge of palliative care benefits for nursing home residents.2. Enhance the learner's knowledge of barriers to palliative care for nursing home residents.Key MessageThis qualitative descriptive study records the perspective of clinicians involved in the care of nursing home residents. Participants describe the benefits and barriers of palliative care at the resident and facility level. The results provide targets for future interventions aimed at improving access to palliative care for nursing home residents.IntroductionPalliative care can improve comfort, quality of life, and patient/family care experiences while decreasing cost. Despite these positive outcomes, nursing home residents do not receive palliative care services relative to the high prevalence of perceived need.ObjectiveTo identify and describe the benefits and barriers of palliative care in nursing homes from the perspective of nursing home staff, primary care practitioners, and specialty palliative care providers.MethodsWe applied a rapid qualitative approach to analyze semi-structured interviews using directed content analysis. Participants were eligible if they worked in the nursing home setting or provided palliative care to nursing home residents.ResultsParticipants (N=17) included nursing home key informants representing a variety of roles (e.g., nurses, physician, nurse practitioners). Participant perceptions of benefits and barriers are organized at the resident and facility level.Benefits. Resident-level: 1) improved symptom management; and 2) extra support and services [subthemes: spiritual care, bereavement, transparent discussions and anticipatory guidance]. Facility-level: 3) legal and regulatory compliance [subthemes of opioid prescribing, behavior management, and nursing home regulations]; and 4) extra medical support [subtheme of preventing hospitalization].Barriers. Resident-level: 1) misperceptions of palliative care [subtheme of stigma]; 2) transportation difficulties; 3) conflicted goals of care [subthemes of rehabilitation, complex family dynamics, and lack of anticipatory guidance]; and 4) financial disincentives. Facility-level: 5) financial disincentives; 6) workforce limitations; and 7) lack of referral standards.ConclusionsOur findings describe perceived benefits and barriers of palliative care in nursing homes from the perspective of key informants. For nursing home administrators and policymakers, the identified barriers can inform the development of targeted training programs and resources for staff to address these challenges effectively. Moreover, recognizing the benefits can emphasize the value of investing in palliative care services and encourage the integration of such programs into the standard care provided.KeywordsScientific Research / Models of Palliative Care Delivery

Objectives Despite common use of palliative care screening tools in other settings, the performance of these tools in the nursing home has not been well established; therefore, the purpose of this review is to (1) identify palliative care screening tools validated for nursing home residents and (2) critically appraise, compare, and summarize the quality of measurement properties. Design Systematic review of measurement properties consistent with Consensus-based Standards for the selection of health Measurement Instruments (COSMIN) guidelines. Settings and participants Embase (Ovid), MEDLINE (PubMed), CINAHL (EBSCO), and PsycINFO (Ovid) were searched from inception to May 2022. Studies that (1) reported the development or evaluation of a palliative care screening tool and (2) sampled older adults living in a nursing home were included. Methods Two reviewers independently screened, selected, extracted data, and assessed risk of bias. Results We identified only 1 palliative care screening tool meeting COSMIN criteria, the NECesidades Paliativas (NEC-PAL, equivalent to palliative needs in English), but evidence for use with nursing home residents was of low quality. The NEC-PAL lacked robust testing of measurement properties such as reliability, sensitivity, and specificity in the nursing home setting. Construct validity through hypothesis testing was adequate but only reported in 1 study. Consequently, there is insufficient evidence to guide practice. Broadening the criteria further, this review reports on 3 additional palliative care screening tools identified during the search and screening process but which were excluded during full-text review for various reasons. Conclusion and Implications Given the unique care environment of nursing homes, we recommend future studies to validate available tools and develop new instruments specifically designed for nursing home use. In the meantime, we recommend that clinicians consider the evidence presented here and choose a screening instrument that best meets their needs.

Upon hospital discharge, medically complex patients are frequently referred for skilled nursing facility (SNF) care or skilled home health care (HHC). Both settings provide restorative and supportive services; however, the intensity of services, such as around the clock nursing support, are greater in SNF care. Both settings have high rates of rehospitalizations. However, individuals often desire to avoid care in an institutional setting, eager to return home and remain there. Supporting patients in the home allows for more targeted use of SNF by individuals that may lack housing and caregiver resources.

BACKGROUND:National POLST guidance indicates POLST is intended for individuals at risk of life-threatening clinical events due to serious illness. Even though this patient population includes many, but not all, nursing facility residents, there is evidence that POLST is used broadly in this setting. This study aimed to identify clinician perspectives regarding factors that influence their decision-making about whether to use POLST with nursing facility residents and to distinguish between inappropriate and appropriate use. METHODS:We conducted a descriptive qualitative study to explore the experience of nursing facility clinicians using POLST with residents and deciding who is appropriate and inappropriate for POLST. Participants were purposively sampled from multiple states using POLST. Interviews were audio-recorded and professionally transcribed. We used rapid qualitative analysis to code data and identify themes. RESULTS:We interviewed 28 clinicians from 14 states about how they decided whether to use POLST with nursing facility residents and to distinguish between inappropriate and appropriate use. Four themes emerged as factors driving clinician-decision-making POLST use: (1) belief that "everyone is appropriate"; (2) resident and family preferences; (3) resident health status; and (4) policies requiring POLST [Correction added after first online publication on 07 Feb 2024. The word "For" has been changed to "Four" in the previous sentence.]. In most cases, participants cited resident and family preferences for treatment limitations as well as prognosis and clinical assessments in determining when POLST use was appropriate. Factors influencing potentially inappropriate POLST use included nursing facility policies requiring POLST completion that preempted clinical judgments of appropriateness. CONCLUSIONS:Findings highlight the disconnect between National POLST guidance and current use of POLST in nursing facilities. Policies requiring POLST use in nursing facilities and the belief that "everyone is appropriate" may impede clinician autonomy and lead to potentially inappropriate POLST use. Given varying approaches to POLST use in nursing facilities, there is a need to refocus attention on the intended population for POLST.

Background Home health care (HHC) is a leading source of care support for older adults with serious illness, particularly patients living with dementia (PLWD). Demand for HHC is expected to continue to grow, driven by an aging population and preference for non-institutional care. HHC agencies are frequently under pressure to find effective approaches for improving care delivery and quality. One strategy that has the potential to improve the quality of life and patient satisfaction in HHC for PLWD is the integration of palliative care. Therefore, we sought to understand the experiences and needs of PLWD and their family caregivers specifically focusing on ways that HHC and palliative care may be integrated as part of the care transition from hospital to home, to better support PLWD and their families.Methods We conducted a descriptive qualitative study focusing on the perspectives of patients, caregivers, and healthcare team members about palliative care delivery for patients receiving HHC. Interviews were audio-recorded and professionally transcribed. In this analysis, we specifically report on dementia-related content using an iterative, team-based thematic analysis approach.Results We identified three themes: 1) 'Living in the Whirlwind' which describes the many competing demands on caregivers time and the associated feeling of loss of control, 2) 'Thinking Ahead' which describes the importance of thinking beyond the day-to-day tasks to begin planning for the future, and 3) 'Pathways Forward' which describes the integration of palliative care into HHC to provide enhanced support for PLWD and their caregivers.Conclusion In this qualitative study, our formative work identified the importance of providing anticipatory guidance (e.g., safety, advance care planning) coupled with emotional and pragmatic care supports (e.g., finding resources, navigating insurance) to sustain caregivers who are struggling with the whirlwind.

Background: Understanding factors associated with risk of pain allows residents and clinicians to plan care and set priorities, however, factors associated with pain in nursing home residents has not been conclusively studied.Aim: To evaluate the association between pain and nursing home (NH) resident demographic and clinical characteristics.Design: Retrospective analysis of Minimum Data Set 3.0 records of nursing home residents residing in 44 Indiana NHs between September 27, 2011 and December 27, 2019 (N = 9,060).Results: Pain prevalence in this sample of NH residents was 23.7%. Of those with pain, 28.0% experienced moderate to severe/frequent pain and 54.6% experienced persistent pain. Risk factors for moderate to se-vere/frequent pain include female sex; living in a rural setting; intact, mildly, or moderately impaired cognition; arthritis; contracture; anxiety; and depression. In contrast, stroke and Alzheimer's disease and Alzheimer's-disease related dementias (AD/ADRD) were associated with decreased risk of reporting mod-erate to severe/frequent pain, likely representing both the under-assessment and under-reporting of pain among cognitively impaired NH residents. Risk factors for persistent pain included age < 70, Black race, living in a rural location, intact cognition, contracture, and depression.Conclusions: Pain remains a pressing problem for NH residents. In this study, we identified demographic and clinical factors associated with moderate to severe frequent pain and persistent pain. Residents with a diagnosis of AD/ADRD were less likely to report pain, likely representing the difficulty of evaluating pain in these residents. It is important to note that those with cognitive impairment may not experience any less pain, but assessment and reporting difficulties may make them appear to have less pain. Knowledge of factors associated with pain for NH residents has the potential for improving the ability to predict, prevent, and provide better pain care in NH residents.& COPY; 2023 American Society for Pain Management Nursing. Published by Elsevier Inc. All rights reserved.

Advance care planning (ACP) is an important component of person-centered care for older adults in nursing facilities. Although nursing facilities have a statutory obligation to offer ACP to residents, there are no minimum training requirements for staff. Lack of consistent ACP training contributes to significant variability in ACP conversation quality, inaccurate or incomplete documentation of preferences, and infrequent re-evaluation of prior decisions. Indiana added ACP training for nursing facility staff to the Value-Based Purchasing formula for 2019. Facilities received 5 points (of a 100-point total formula) if at least one staff member completed the designated ACP training during the year. ACP Foundations Training was developed by faculty at Indiana University and made available to all Indiana nursing facilities. A total of 1,087 participants, representing 94.2% (501 of 532) Indiana nursing facilities, completed the training. Approximately every participant (99.4%) agreed that the training had practical value. This academic-government partnership was successful in providing basic information about ACP to staff at most nursing facilities across Indiana and offers a model for states to provide critical educational content to nursing facility staff by incentivizing training. [Journal of Gerontological Nursing, 48(2), 31-35.]

OBJECTIVES:To describe the pain prevalence in nursing home (NH) residents and the factors associated with the experience of pain.DESIGN:Systematic review of descriptive studies.SETTING AND PARTICIPANTS:Three electronic databases were searched from 2010 to September 2020 in English. Descriptive studies that examined pain in NH residents, reported pain prevalence, and/or associated factors were included. Studies that focused exclusively on a specific disease or type of care such as cancer or hospice were excluded.METHODS:Two reviewers independently screened, selected, extracted data, and assessed risk of bias from included studies; narrative synthesis was performed. The review was guided by the Biopsychosocial Model of Chronic Pain for Older Adults.RESULTS:Twenty-six studies met our inclusion criteria. Overall, the prevalence of current pain ranged from 22.2% to 85.0%, the prevalence of persistent pain ranged from 19.5% to 58.5%, and the prevalence of chronic pain ranged from 55.9% to 58.1%. A variety of pain scales were used reporting higher pain prevalence for those using self-report measures (31.8% to 78.8%) or proxy measures (29.5% to 85.0%) compared with using chart review (22.2% to 29.3%) as the source of pain information. The studies reviewed provide support that certain diseases and clinical conditions are associated with pain. Impairment in activities of daily living (ADL) (12 studies), cognition (9 studies), depression (9 studies), and arthritis (9 studies) are the most widely studied factors, whereas depression, ADL impairment, arthritis, dementia, and cognitive impairment present the strongest association with pain.CONCLUSION AND IMPLICATIONS:This review highlights the complexities of pain in NH residents and has implications for both clinical practice and future research. Understanding the factors that underlie the experience of pain, such as depression, is useful for clinicians evaluating pain and tailoring management therapies. In addition, the gaps in knowledge uncovered in this review are important areas for future research.

Abstract Up to 80% of older adults living in a nursing home (NH) experience pain and up to 32% have substantial pain. Pain in NH residents is associated with poor quality of life, higher likelihood of depression, and decreased life satisfaction. Pain in NH residents has often been studied using a cross-sectional approach, which fails to consider the temporal nature of pain. Therefore, the purpose of this analysis was to identify and characterize clinically meaningful, dynamic pain trajectories in NH residents using data from the Minimum Data Set. A retrospective longitudinal analysis was conducted using group-based trajectory modeling with pain scores from admission to discharge or a maximum of 28 assessments. We identified four distinct trajectories: 1) consistent pain absence (48.9%), 2) decreasing-increasing pain presence (21.8%), 3) increasing-decreasing pain presence (15.3%), and 4) persistent pain presence (14.0%). Relative to residents’ in the consistent pain absence trajectory, the likelihood of being in the persistent pain presence trajectory was more than twice as high for those living in a rural versus (AOR 2.7, CI 2.2-3.4, p<.001), over 4 times higher for those with hip fracture (AOR 4.3 CI 2.6-7.0, p<.001), nearly 3 times higher for those with a fracture other than hip (AOR 2.9, CI 2.0-4.1, p<.001), and almost twice as high for those with contracture (AOR 1.7, CI 1.4-2.1, p<.001). Using residents’ characteristics associated with persistent pain such as hip fracture or contracture may improve care planning based on early identification or risk stratification and can improve mitigation of persistent pain.

Direct oral anticoagulants (DOACs) have expanded options for treating patients with atrial fibrillation (AF). However, DOACs are not warfarin substitutes, and NPs need to be aware of the difference. DOACs are first-line agents when treating AF, yet warfarin has not been replaced. Individualized patient characteristics drive current guidelines.

Risk factors for developing Alzheimer disease include hypercholesterolemia, hypertension, obesity, and diabetes. Due to lack of effective treatments for Alzheimer disease, nutrition and primary prevention becomes important.