Survival prediction in nursing home residents using the Minimum Data Set subscales: ADL Self-Performance Hierarchy, Cognitive Performance and the Changes in Health, End-stage disease and Symptoms and Signs scales

Association Between Falls, Head Impacts, and Mortality Among Older Adults in Long-Term Care

OBJECTIVES

Residents in long-term care (LTC) are at high risk for falls, and falls in LTC often result in impact to the head, with clinical consequences that may be challenging to detect. We examined whether the survival of LTC residents associates with falls and fall-related head impacts.

DESIGN

Prospective cohort study.

SETTING AND PARTICIPANTS

This study was conducted in 2 Vancouver-area LTC homes where falls were captured on video from surveillance cameras. A total of 232 participants (133 females, 99 males) experienced at least 1 fall captured on video, among whom 84% (n = 194) died between January 2011 and January 2020. The mean age at death was 86.5 (SD = 8.5) years, and the mean survival time after enrollment to this study was 3.8 (SD = 2.1) years.

METHODS

Univariable and multivariable models were used to determine how survival time depended on the rate of falls (falls per 365 days), the percentage of falls on video involving head impact, sex, age at death, and baseline physical and cognitive status.

RESULTS

On average, participants experienced 6.2 (SD = 7.0) falls per 365 days, and 36.9% (SD = 36.3) of video-captured falls resulted in head impact. In multivariable analyses, an increase of 1 fall per 365 days resulted in a 4.2% higher risk of death [hazard ratio (HR) = 1.042, 95% CI 1.023-1.062, P < .001]. A 1% increase in falls involving head impact resulted in an 0.5% higher risk of death (HR 1.005, 95% CI 1.001-1.010, P = .015). Participants who experienced head impact in all video-captured falls had a 50% higher risk for death than those who always avoided head impact.

CONCLUSIONS AND IMPLICATIONS

Survival in LTC is associated with the rate of falls and percentage of falls involving head impact. Improved efforts are required to prevent falls in LTC, and reduce the frequency and consequences of head impacts during falls (eg, through compliant flooring).

Institutional and individual factors associated with functional outcomes in nursing home residents under long-term care insurance in Korea: A multilevel analysis

OBJECTIVE

The purpose of this study was to analyze the relationship between institutional and individual characteristics that influence changes in the functional outcomes of nursing home residents.

METHODS

Long-term Care Insurance claims data with basic information of nursing home(n = 3,263) and long-term care needs assessment data of nursing home residents(n = 34,717) was used. The independent variable was classified into individual (level 1) and nursing home characteristics (level 2). Changes in physical function, cognitive function, and behavioral symptoms were used as dependent variables.

RESULTS

The institutional factors of nursing homes contributed relatively little to substantial changes in function of nursing home residents. Ownership, size, and nursing home staff including care worker and physical/occupational therapist were important determinants of functional changes in nursing home residents.

CONCLUSION

To improve the quality of nursing homes in Korea, regulations on staffing should be modified, and an disincentive policy should be introduced for low-quality institutions.

The interRAI CHESS scale is comparable to the palliative performance scale in predicting 90-day mortality in a palliative home care population

Background

Prognostic accuracy is important throughout all stages of the illness trajectory as it has implications for the timing of important conversations and decisions around care. Physicians often tend to over-estimate prognosis and may under-recognize palliative care (PC) needs. It is therefore essential that all relevant stakeholders have as much information available to them as possible when estimating prognosis.

Aims

The current study examined whether the interRAI Changes in Health, End-Stage Disease, Signs and Symptoms (CHESS) Scale is a good predictor of mortality in a known PC population and to see how it compares to the Palliative Performance Scale (PPS) in predicting 90-day mortality.

Methods

This retrospective cohort study used data from 2011 to 2018 on 80,261 unique individuals receiving palliative home care and assessed with both the interRAI Palliative Care instrument and the PPS. Logistic regression models were used to evaluate the relationship between the main outcome, 90-day mortality and were then replicated for a secondary outcome examining the number of nursing visits. Comparison of survival time was examined using Kaplan-Meier survival curves.

Results

The CHESS Scale was an acceptable predictor of 90-day mortality (c-statistic = 0.68; p < 0.0001) and was associated with the number of nursing days (c = 0.61; p < 0.0001) and had comparable performance to the PPS (c = 0.69; p < 0.0001). The CHESS Scale performed slightly better than the PPS in predicting 90-day mortality when combined with other interRAI PC items (c = 0.72; p < 0.0001).

Conclusion

The interRAI CHESS Scale is an additional decision-support tool available to clinicians that can be used alongside the PPS when estimating prognosis. This additional information can assist with the development of care plans, discussions, and referrals to specialist PC teams.

Physical performance as a predictor of mortality in nursing home residents: A five-year survival analysis

This study developed a five-year survival analysis to verify the relationship between the Short Physical Performance Battery (SPPB) and death in older adults residing in nursing homes (NHs). A total of 114 residents of NHs in Northeast Brazil participated in the follow-up. In addition to the SPPB, the older adults answered questions about sociodemographic and health condition information. The relationship between physical performance and mortality was evaluated using the Kaplan Meier survival curves and Cox proportional regression. As a result, 61.40% of the participants presented low performance and 41.22% died. Low physical performance increased the chance of death by 2.77 times in five years (adjusted Hazard Ratio 2.77; 95% CI 1.40-5.50; p < 0.01). Low SPPB Gait Speed Test also represented a 2.58-fold increased risk of dying (adjusted HR 2.58; 95% CI 1.38-4.83; p < 0.01). The results of this study showed that low physical performance can predict the mortality of older adults residing in NHs over five years.

Classifying home care clients' risk of unplanned hospitalization with the resident assessment instrument

Aim

The aim was to identify tools for classifying the risk of unplanned hospitalization among home care clients utilizing the Resident Assessment Instrument-Home Care (RAI-HC).

Findings

The Detection of Indicators and Vulnerabilities for Emergency Room Trips (DIVERT) Scale predicts unplanned hospitalizations in home care clients. In the oldest age groups, however, it works poorly.

Message

DIVERT Scale can be used for identifying high-risk home care clients needing urgent care planning to prevent unplanned hospital admissions and their potential adverse consequences. Clients scoring high in the scale and experiencing the outcome earlier than others, should be the primary group for more detailed assessment.

Supplementary Information

The online version contains supplementary material available at 10.1007/s41999-022-00665-x.

Purpose

To identify predictive case finding tools for classifying the risk of unplanned hospitalization among home care clients utilizing the Resident Assessment Instrument-Home Care (RAI-HC), with special interest in the Detection of Indicators and Vulnerabilities for Emergency Room Trips (DIVERT) Scale.

Methods

A register-based, retrospective study based on the RAI-HC assessments of 3,091 home care clients (mean age 80.9 years) in the City of Tampere, Finland, linked with hospital discharge records. The outcome was an unplanned hospitalization within 180 days after RAI-HC assessment. The Area Under the Curve (AUC) and the sensitivity and specificity were determined for the RAI-HC scales: DIVERT, Activities of Daily Living Hierarchy (ADLh), Cognitive Performance Scale (CPS), Changes in Health, End-Stage Diseases, Signs, and Symptoms Scale (CHESS), and Method for Assigning Priority Levels (MAPLe).

Results

Altogether 3091 home care clients had a total of 7744 RAI-HC assessments, of which 1658 (21.4%) were followed by an unplanned hospitalization. The DIVERT Scale had an AUC of 0.62 (95% confidence interval 0.61–0.64) when all assessments were taken into account, but its value was poorer in the older age groups (< 70 years: 0.71 (0.65–0.77), 70–79 years: 0.66 (0.62–0.69), 80–89 years: 0.60 (0.58–0.62), ≥ 90 years: 0.59 (0.56–0.63)). AUCs for the other scales were poorer than those of DIVERT, with CHESS nearest to DIVERT. Time to hospitalization after assessment was shorter in higher DIVERT classes.

Conclusion

The DIVERT Scale offers an approach to predicting unplanned hospitalization, especially among younger home care clients. Clients scoring high in the DIVERT algorithm were at the greatest risk of unplanned hospitalization and more likely to experience the outcome earlier than others.

Supplementary Information

The online version contains supplementary material available at 10.1007/s41999-022-00665-x.

Mortality in nursing home residents stratified according to subtype of dementia: a longitudinal study over three years

Background

There are several subtypes of dementia caused by different pathophysiology and with different clinical characteristics. Irrespective subtype, the disease is progressive, eventually leading to the need for care and supervision on a 24/7 basis, often provided in nursing homes (NH). The progression rate and course of the disease might vary according to subtype. The aim of this study was to explore whether the mortality rate for NH residents varied according to the subtype of dementia.

Methods

NH residents were followed from admission to NH over a period of 36 months or until death with annual follow-up examinations. Demographic and clinical data were collected. The diagnosis of dementia and its subtype at baseline (BL) were set according to international accepted criteria. Kaplan-Meier analysis was performed to estimate median survival time. A Cox regression model was estimated to assess the impact of dementia diagnosis and demographic and clinical variables on mortality.

Results

A total of 1349 participants were included. When compared to persons with Alzheimer’s disease (AD), persons with frontotemporal dementia (FTD) and dementia with Lewy bodies or Parkinson’s disease dementia (DLB/PDD) were younger and had more neuropsychiatric symptoms. Median survival for the total sample was 2.3 years (95% confidence interval: 2.2–2.5). When compared to persons with AD, having no dementia or unspecified dementia was associated with higher mortality, while we found similar mortality in other subtypes of dementia. Higher age, male gender, poorer general health, higher dependency in activities of daily living, and more affective symptoms were associated with higher mortality.

Conclusion

Mortality did not differ across the subtypes of dementia, except in persons with unspecified dementia or without dementia, where we found a higher mortality. With a median survival of 2.3 years, NH residents are in the last stage of their lives and care and medical follow-up should focus on a palliative approach. However, identifying the subtype of dementia might help carers to better understand and address neuropsychiatric symptoms and to customize medical treatment.

COVID-19 excess mortality among long-term care residents in Ontario, Canada

The coronavirus disease 2019 (COVID-19) has had devastating consequences worldwide, including a spike in global mortality. Residents of long-term care homes have been disproportionately affected. We conducted a retrospective cohort study to determine the scale of pandemic-related deaths of long-term care residents in the province of Ontario, Canada, and to estimate excess mortality due to a positive COVID-19 test adjusted for demographics and regional variations. Crude mortality rates for 2019 and 2020 were compared, as were predictors of mortality among residents with positive and negative tests from March 2020 to December 2020. We found the crude mortality rates were higher from April 2020 to June 2020 and from November 2020 to December 2020, corresponding to Wave 1 and Wave 2 of the pandemic in Ontario. There were also substantial increases in mortality among residents with a positive COVID-19 test. The significant differences in excess mortality observed in relation to long-term care home ownership category and geographic region may indicate gaps in the healthcare system that warrant attention from policymakers. Further investigation is needed to identify the most relevant factors in explaining these differences.

Discontinuation of beta-blockers among nursing home residents at end of life

BACKGROUND

Given limited life expectancy of nursing home (NH) residents, harms of continuing beta-blockers (BBs) may outweigh clinical benefits. Our objective was to describe beta-blocker discontinuation for NH residents during the last year of life, and identify characteristics associated with earlier discontinuation.

METHODS

This was a retrospective cohort study that included all long-stay residents in fee-for-service Medicare who died in 2016 and were prescribed oral BBs 1 year before death. Beta-blocker discontinuation was defined as a gap in medication on hand for ≥45 days per Medicare Part D claims, measured from the last date drug was on hand. Comorbidities were obtained from Chronic Condition Warehouse, and other characteristics from the Minimum Data Set. Kaplan-Meier curves were used to describe time to first discontinuation. Findings were stratified by cardiac diagnoses, perceived life expectancy of <6 months, or elevated mortality index.

RESULTS

Eighty-eight thousand two hundred and eighty-four residents were prescribed ≥1 daily BB 12 months before death. Mean age was 84.1 years and 69.2% were female. Of these, 60,573 residents (68.6%) remained on a BB in the last 45 days of life, and 57,880 residents (65.6%) had ≥1 cardiac diagnosis. Only 5239 residents (5.9%) had elevated mortality index, whereas 16,798 residents (19.0%) had perceived poor prognosis. In the last year of life, there was no difference in beta-blocker discontinuation pattern between residents with and without cardiac diagnoses. Residents with perceived poor prognosis and elevated mortality index discontinued BBs earlier. For example, mean time until discontinuation among residents with poor perceived prognosis was 245 versus 279 days in residents without such prognosis (p < 0.0001).

CONCLUSIONS

BBs are commonly prescribed to NH residents in the final year of life. Overall, discontinuation occurs earlier in residents for whom clinicians perceive limited life expectancy, suggesting that improved prognostication may offer an important opportunity to reduce polypharmacy toward end of life.

Probable Delirium and Associated Patient Characteristics in Long-Term Care and Complex Continuing Care: A Population-Based Observational Study

OBJECTIVES

To estimate the prevalence of probable delirium in long-term care (LTC) and complex continuing care (CCC) settings and to describe the resident characteristics associated with probable delirium.

DESIGN

Population-based cross-sectional study using routinely collected administrative health data.

SETTING AND PARTICIPANTS

All LTC and CCC residents in Ontario, Canada, assessed with the Resident Assessment Instrument-Minimum Dataset (RAI-MDS) assessment between July 1, 2016, and December 31, 2016 (LTC n=86,454, CCC n=10,217).

METHODS

Probable delirium was identified via the delirium Clinical Assessment Protocol on the RAI-MDS assessment, which is triggered when individuals display at least 1 of 6 delirium symptoms that are of recent onset and different from their usual functioning. RAI-MDS assessments were linked to demographic and health services utilization databases to ascertain resident demographics and health status. Multivariable logistic regression was used to identify characteristics associated with probable delirium, with adjusted odds ratios (ORs) and 95% confidence intervals (CIs) reported.

RESULTS

Delirium was probable in 3.6% of LTC residents and 16.5% of CCC patients. LTC patients displayed fewer delirium symptoms than CCC patients. The most common delirium symptom in LTC was periods of lethargy (44.6% of delirium cases); in CCC, it was mental function varying over the course of the day (63.5% of delirium cases). The odds of probable delirium varied across individual demographics and health characteristics, with increased health instability having the strongest association with the outcome in both care settings (LTC: OR 30.4, 95% CI 26.2-35.3; CCC: OR 21.0, 95% CI 16.7-26.5 for high vs low instability).

CONCLUSIONS AND IMPLICATIONS

There were differences in the presentation and burden of delirium symptoms between LTC and CCC, potentially reflecting differences in delirium severity or symptom identification. Several risk factors for probable delirium in LTC and CCC were identified that may be amenable to interventions to prevent this highly distressing condition.

Impact of the Physician Orders for Life-Sustaining Treatment (POLST) Program Maturity Status on the Nursing Home Resident's Place of Death

The Physician Orders for Life-Sustaining Treatment (POLST) program was developed to enhance quality of care delivered at End-of-Life (EoL). Although positive impacts of the POLST program have been identified, the association between a program maturity status and nursing home resident's likelihood of dying in their current care settings remain unanswered. This study aims to evaluate the impact of the POLST program maturity status on nursing home residents' place of death. Using multiple national-level datasets, we examined total 595,152 residents and their place of death. The result showed that the long-stay residents living in states where the program was mature status had 12% increased odds of dying in nursing homes compared that of non-conforming status. Individuals residing in states with developing program status showed 11% increase in odds of dying in nursing homes. The findings demonstrate that a well-structured and well-disseminated POLST program, combined with a continued effort to meet high standards of quality EoL care, can bring out positive health outcomes for elderly patients residing in care settings.

Frailty and risk of re-hospitalisation and mortality for aged care residents following a fall injury hospitalisation

OBJECTIVES

To examine the role of frailty in risk of re-hospitalisation and mortality for aged care residents following a fall injury hospitalisation.

METHODS

Retrospective analysis of linked hospitalisation and aged care data of adults aged ≥65 years residing in aged care. A semi-competing risk analysis examined risk of hospital readmission.

RESULTS

Residents who had intermediate or high frailty, who were aged 70-79 or 80-89 years, who had 1-2 or ≥3 comorbidities, sustained a hip fracture, and who had either low, moderate or high complex health-care requirements had a higher risk of being readmitted to hospital. Frailty was not associated with mortality for those with no hospital readmission or mortality after readmission.

CONCLUSION

Frailty is an important prognostic factor associated with readmission for residents of aged care hospitalised for a fall injury. Frailty screening could assist to identify people at a high risk of re-hospitalisation following a fall injury.

Predicting care intensity in geriatric home care patients: a comparison of different measures

BACKGROUND

Dependency in older ages is increasing. Many older persons receive care while living in the community. We aimed to identify the predictive value of four clinical measurements to predict home care intensity in older patients following discharge from hospital to home care over 90 days.

METHODS

We included 425 inpatients from the "Frailty Department-Local Palliative Care Network" of the local social health authority (ASST) Lecco, Italy (mean age 75.4 years, SD 14.5; female 75.5%). Changes in Health, End-stage disease, and Signs and Symptoms, light version (CHESS-Lite), activities of daily living (ADL), frailty, and the Service Urgency Algorithm. Receiver operative curves were used to calculate the area under the curve (AUC) for predicting Home Care Intensity coefficient (ratio of the number of days when any home care was provided 90 days post-discharge). The interRAI Contact Assessment Instrument was used to calculate these measures.

RESULTS

Analysis was stratified using six different home care intensity score cut-offs. CHESS-Lite had a higher AUC for predicting home care intensity at all cut-off levels but was best for predicting the highest level of home care intensity (≥ 0.8) where the AUC was 0.71 (0.64-0.79). The frailty index also had an acceptable AUC. ADL had the lowest AUC.

CONCLUSIONS

Health instability measured with CHESS-Lite has a high predictive value for identifying home care intensity in geriatric patients after discharge from hospital to home, especially in persons with higher home care intensity scores. Geriatric patients with high health instability should be focused on at discharge to prioritize assessment and initiate timely services for home care support.

Overall mortality and causes of death in newly admitted nursing home residents

BACKGROUND

In spite of a rapidly ageing population, there is a lack of population-based data on mortality among nursing home residents in Southern Europe.

AIMS

To assess mortality rates, their determinants, and causes of death in newly admitted nursing home residents in the Veneto region (northeastern Italy).

METHODS

19,392 subjects aged ≥ 65 years admitted to regional nursing homes during 2015-2017 were recruited in a cohort mortality study based on linked health records. Risk factors for mortality were investigated by Cox regression. The distribution of causes of death was retrieved from death certificates.

RESULTS

Mortality peaked in the first 4 months after admission; thereafter the monthly mortality rate fluctuated around 3% in males and 2% in females. Overall mortality was 23% at 6 months and 34% at 1 year. In addition to age, gender, and dependency, main risk factors for mortality were recent hospitalization (first 4 months after entry into the facility), and the burden of comorbidities (subsequent follow-up period). The most represented causes of mortality were similar in the first and in the subsequent period after admission: cardio-cerebrovascular diseases, neurodegenerative diseases, respiratory diseases, and infections.

DISCUSSION

The first months after admission represent a period at high risk of mortality, especially for patients with a recent hospitalization. Causes reported in death certificates suggest mainly an acute deterioration of pre-existing chronic conditions.

CONCLUSION

Health care plans should be personalized for newly admitted vulnerable patients. Palliative care needs should be recognized and addressed for high-risk non-cancer patients.

Resident-Level Factors Associated with Hospitalization Rates for Newly Admitted Long-Term Care Residents in Canada: A Retrospective Cohort Study

Chez les résidents en soins de longue durée (SLD), l’hospitalisation peut amener des complications telles que le déclin fonctionnel. L’objectif de notre étude était d’examiner l’association entre les données démographiques et de santé et le taux d’hospitalisation des résidents nouvellement admis en SLD. Nous avons mené une étude de cohorte rétrospective incluant tous les centres de SLD de six provinces et d’un territoire du Canada, à l’aide des données de la RAI-MDS 2.0 et de la Discharge Abstract Database. Nous avons inclus les résidents nouvellement admis ayant eu une évaluation entre le 1er janvier et le 31 décembre 2013 (n = 37 998). Les résidents de sexe masculin avec une santé plus instable et une déficience fonctionnelle de modérée à grave présentaient des taux d’hospitalisation plus élevés, tandis que les résidents avec une déficience cognitive de modérée à grave avaient des taux moindres. Les résultats de notre étude pourraient contribuer à l’identification des résidents nouvellement admis qui seraient plus à risque d’hospitalisation et à l’élaboration de stratégies préventives plus ciblées, incluant la réadaptation, la planification préalable de soins, les soins palliatifs et les services gériatriques spécialisés.

Development and Validation of a Prognostic Tool for Identifying Residents at Increased Risk of Death in Long-Term Care Facilities

BACKGROUND

To promote better care at the end stage of life in long-term care facilities, a culturally appropriate tool for identifying residents at the end of life is crucial.

OBJECTIVE

This study aimed to develop and validate a prognostic tool, the increased risk of death (IRD) scale, based on the minimum data set (MDS).

DESIGN

A retrospective study using data between 2005 and 2013 from six nursing homes in Hong Kong.

SETTING/SUBJECTS

A total of 2380 individuals were randomly divided into two equal-sized subsamples: Sample 1 was used for the development of the IRD scale and Sample 2 for validation.

MEASUREMENTS

The measures were MDS 2.0 items and mortality data from the discharge tracking forms. The nine items in the IRD scale (decline in cognitive status, decline in activities of daily living, cancer, renal failure, congestive heart failure, emphysema/chronic obstructive pulmonary disease, edema, shortness of breath, and loss of weight), were selected based on bivariate Cox proportional hazards regression.

RESULTS

The IRD scale was a strong predictor of mortality in both Sample 1 (HR_sample1 = 1.50, 95% confidence interval [CI]: 1.37-1.65) and Sample 2 (HR_sample2 = 1.31, 1.19-1.43), after adjusting for covariates. Hazard ratios (HRs) for residents who had an IRD score of 3 or above for Sample 1 and Sample 2 were 3.32 (2.12-5.21) and 2.00 (1.30-3.09), respectively.

CONCLUSIONS

The IRD scale is a promising tool for identifying nursing home residents at increased risk of death. We recommend the tool to be incorporated into the care protocol of long-term care facilities in Hong Kong.

Impact of long term care and mortality risk in community care and nursing homes populations

OBJECTIVES

To identify the survival time, the mortality risk factors and the individuals' characteristics associated with cognitive and physical status at discharge, among the Portuguese long-term care (LTC) populations.

SETTINGS

Home-and-Community-Based Services (HCBS) and three types of Nursing Homes (NH).

PARTICIPANTS

20,984 individuals admitted and discharged in 2015.

MEASUREMENTS

The Kaplan-Meier survival analysis and the Cox Proportional Hazards Models were used to study the mortality risk; the Wilcoxon signed-rank test to identify the number of individuals with cognitive and physical changes between admission and discharge; two cumulative odds ordinal logistic regressions to predict the cognitive and physical dependence levels at discharge RESULTS: The mortality rate at HCBS was 30%, and 17% at the NH, with a median survival time of 173 and 200 days, respectively. The main factors associated with higher mortality were older age, male gender, family/neighbour support, neoplasms and cognitive/physical dependence at admission. In NH/HCBS, 26%/18% of individuals improve their cognitive status, while in physical status the proportion was 38%/27%, respectively. Finally, older age, being illiterate and being classified at the lowest cognitive and physical status at admission decrease the likelihood of achieving a higher level of cognitive and physical independence at discharge.

CONCLUSIONS

The adoption of a robust and complete assessment tool, the definition of guidelines to enable a periodical assessment of individuals' autonomy and the adoption of benchmark metrics allowing the comparison of results between similar units are some of the main goals to be taken into account for future developments of this care in Portugal.

Minimum Data Set Changes in Health, End-Stage Disease and Symptoms and Signs Scale: A Revised Measure to Predict Mortality in Nursing Home Residents

OBJECTIVES

To revise the Minimum Data Set (MDS) Changes in Health, End-stage disease and Symptoms and Signs (CHESS) scale, an MDS 2.0-based measure widely used to predict mortality in institutional settings, in response to the release of MDS 3.0.

DESIGN

Development of a predictive scale using observational data from the MDS and Medicare Master Beneficiary Summary File.

SETTING

All Centers for Medicare and Medicaid Services (CMS)-certified nursing homes in the United States.

PARTICIPANTS

Development cohort of 1.3 million Medicare beneficiaries newly admitted to a CMS-certified nursing home during 2012. Primary validation cohort of 1.2 million Medicare recipients who were newly admitted to a CMS-certified nursing home during 2013.

MEASUREMENTS

Items from the MDS 3.0 assessments identified as likely to predict mortality. Death information was obtained from the Medicare Master Beneficiary Summary File.

RESULTS

MDS-CHESS 3.0 scores ranges from 0 (most stable) to 5 (least stable). Ninety-two percent of the primary validation sample with a CHESS scale score of 5 and 15% with a CHESS scale of 0 died within 1 year. The risk of dying was 1.63 times as great (95% CI=1.628-1.638) for each unit increase in CHESS scale score. The MDS-CHESS 3.0 is also strongly related to hospitalization within 30 days and successful discharge to the community. The scale predicted death in long-stay residents at 30 days (C=0.759, 95% confidence interval (CI)=0.756-0.761), 60 days (C=0.716, 95% CI=0.714-0.718) and 1 year (C=0.655, 95% CI=0.654-0.657).

CONCLUSION

The MDS-CHESS 3.0 predicts mortality in newly admitted and long-stay nursing home populations. The additional relationship to hospitalizations and successful discharges to community increases the utility of this scale as a potential risk adjustment tool.

Besides Depression, Number of Physiological Diseases is More Important than Physical Function on Mental Health of Elderly Adults in Taiwan

This study contrasted the relative importance between the number of physiological diseases and activities of daily living (ADLs) to the mental health of elderly adults after controlling for mini-mental state exam (MMSE) scores and depression. Participants were 1342 elderly people with a mean age of 73.22 years and living in three communities in southern Taiwan. Age, gender, years of education duration, marital status, and MMSE and hamilton depression rating scale (HAMD) scores were control variables. The ability of the ADLs scale scores and number of physiological diseases to predict mental health, as measured by the 12-item Chinese health questionnaire, was compared using hierarchical regression analyses. The final hierarchical model indicated that only HAMD and the number of physiological diseases scores were significant and that the former was much more predictive than the latter. The results imply that the number of physiological diseases is more predictive of mental health than ADLs scores and that depression is a dangerous risk factor for elderly people.

Survival prediction among nursing home residents: A longitudinal study

AIM

To determine the survival time and predictors of survival of residents in a nursing home.

METHODS

Nursing home residents admitted from June 2008 (when the nursing home started operating) to December 2012 (n = 230) to a new nursing home in Hong Kong were prospectively followed. The predictors of survival in the residents were assessed annually, with the exception of those who did not want to continue with the study, or were hospitalized, discharged from the nursing home or died, to compare changes occurring from 2008 to 2012. Cox's regression analysis was used to examine the predictors of survival.

RESULTS

A total of 66 of the nursing home residents (28.7%) died during the study period. The median length of survival was 20.46 months. Sex, the number of diseases, depressive symptoms, cognitive status and nutritional status were found to be significant predictors of survival.

CONCLUSIONS

It is crucial for healthcare providers to offer quality care to residents in long-term care to enhance their well-being in the final sojourn of their lives. Although there are no consistent reports of predictors in the international literature, it is important to address the modifiable predictors, as this might lead to improvements in the quality of life of the residents. Geriatr Gerontol Int 2018; 18: 428-433.

Subjective measures of health and all-cause mortality - the Rotterdam Study

BACKGROUND

Subjectively assessed health is related to mortality. Various subjective indicators of health have been studied, but it is unclear whether perceived physical functioning or mental health best accounts for the relation with mortality.

METHOD

We studied the relation of subjective measures of health with all-cause mortality in 5538 participants of age 55 to 96 years at baseline from the Rotterdam Study. Various instruments of subjectively assessed health were used, that included basic activities of daily living (BADL), instrumental activities of daily living (IADL), quality of life (QoL), positive affect, somatic symptoms and negative affect. All participants completed questionnaires for each subjective measure of health and were followed for mortality for a mean of 12.2 (s.e. = 0.09) years. Cox regression analysis was conducted in the total sample.

RESULTS

In this cohort, 2021 persons died during 48 534 person-years of follow-up. All measures of subjective health were related to mortality after adjusting for age, gender, education, cognition, prevalent chronic diseases and cardiovascular risk [BADL hazard ratio (HR, calculated per Z-score) = 1.35, 95% confidence interval (CI) 1.29-1.41; IADL HR = 1.27, 95% CI 1.22-1.32; QoL HR = 0.85, 95% CI 0.81-0.89; positive affect HR = 0.92, 95% CI 0.88-0.96; somatic symptoms HR = 1.11, 95% CI 1.06-1.16; and negative affect HR = 1.05, 95% CI 1.01-1.10]. In the mutually adjusted model, only BADL (HR = 1.24, 95% CI 1.16-1.32) and IADL (HR = 1.10, 95% CI 1.04-1.17) remained independently associated with mortality.

CONCLUSIONS

Measures of subjectively assessed health are important indicators of mortality. Our study shows that of the different measures of subjective health, perceived physical health predicts mortality over and above mental health. Conversely, the association between mental health and mortality may partly be explained by poor perceived physical health.

The Need for Accurate Risk Prediction Models for Road Mapping, Shared Decision Making and Care Planning for the Elderly with Advanced Chronic Kidney Disease

As people age, chronic kidney disease becomes more common, but it rarely leads to end-stage kidney disease. When it does, the choice between dialysis and conservative care can be daunting, as much depends on life expectancy and personal expectations of medical care. Shared decision making implies adequately informing patients about their options, and facilitating deliberation of the available information, such that decisions are tailored to the individual's values and preferences. Accurate estimations of one's risk of progression to end-stage kidney disease and death with or without dialysis are essential for shared decision making to be effective. Formal risk prediction models can help, provided they are externally validated, well-calibrated and discriminative; include unambiguous and measureable variables; and come with readily applicable equations or scores. Reliable, externally validated risk prediction models for progression of chronic kidney disease to end-stage kidney disease or mortality in frail elderly with or without chronic kidney disease are scant. Within this paper, we discuss a number of promising models, highlighting both the strengths and limitations physicians should understand for using them judiciously, and emphasize the need for external validation over new development for further advancing the field.

Updating the Cognitive Performance Scale

This study presents the first update of the Cognitive Performance Scale (CPS) in 20 years. Its goals are 3-fold: extend category options; characterize how the new scale variant tracks with the Mini-Mental State Examination; and present a series of associative findings. Secondary analysis of data from 3733 older adults from 8 countries was completed. Examination of scale dimensions using older and new items was completed using a forward-entry stepwise regression. The revised scale was validated by examining the scale's distribution with a self-reported dementia diagnosis, functional problems, living status, and distress measures. Cognitive Performance Scale 2 extends the measurement metric from a range of 0 to 6 for the original CPS, to 0 to 8. Relating CPS2 to other measures of function, living status, and distress showed that changes in these external measures correspond with increased challenges in cognitive performance. Cognitive Performance Scale 2 enables repeated assessments, sensitive to detect changes particularly in early levels of cognitive decline.

Predictors of Functional Changes in Italian Nursing Home Residents: The U.L.I.S.S.E. Study

OBJECTIVES

To identify independent predictors of the risk of functional decline in older nursing home (NH) residents.

DESIGN

A longitudinal observational study.

SETTING

Thirty-one NHs participating in the U.L.I.S.S.E. project, distributed throughout Italy.

PARTICIPANTS

All older (≥65 years) long-term NH residents without complete disability and with at least one follow-up evaluation during the 12-month study period (n = 1263).

MEASUREMENTS

All participants underwent a standardized comprehensive evaluation using the Italian version of the Minimum Data Set for NHs. The activities of daily living (ADLs) Long-Form scale was used to evaluate functional status. Facility characteristics were collected using an ad hoc designed questionnaire.

RESULTS

Of the NH residents, 40.4% experienced a decline in the ADL during the follow-up. The mixed effect logistic regression model showed that depression (odds ratio [OR] 1.45, confidence interval [CI] 1.16-1.81, P = .005) and the use of antipsychotics (OR 1.30, CI 1.06-1.60, P = .016) were associated with a higher probability of ADL decline, whereas the presence of a geriatrician (OR 0.60, CI 0.41-0.88, P = .015) and a higher than median hour per resident per week of nursing care (OR 0.55, CI 0.37-0.80, P = .006) were associated with a lower risk.

CONCLUSIONS

Our findings suggest that preventing functional decline in NH residents might be possible by optimizing the management of depression and by reducing the current high prescription rate of antipsychotics. Moreover, the presence of a geriatrician, associated with an adequate amount of nursing care, seem to be important facilities characteristics to achieve this goal. These findings should be tested in large-scale pragmatic clinical trials.

Which factors are associated with mortality in institutionalized older adults with dementia?

Residential facilities are increasingly used as a resource for dependent older adults and a high percentage of patients with dementia die there. Information about the leading medical causes and exposures to risk factors of mortality in institutionalized older patients with dementia could guide the development of clinical management interventions. The data of 387 institutionalized adults aged over 60, diagnosed with dementia, was analyzed retrospectively. Information about sociodemographic, comorbidities, quality of life and leisure and free time variables was collected in a survey answered by caregivers; after 19 months, information was collected on the result variable (living vs. deceased). A multivariate logistic regression model was created to determine the factors associated with mortality, which were: age (odds ratio (OR)=1.986; 95% confidence interval (CI): 1.229-3.209); diabetes (OR=2.322; 1.350-3.996); hypertension (OR=1.695; 1.044-2.752); diseases of the genitourinary system (OR=2.455;1.419-4.248), worsening of health over last twelve months (OR=1.653; 1.018-2.685) and not performing passive (OR=1.616; 0.968-2.700) or social (OR=2.242; 1.170-4.299) leisure activities. Besides age, the number of comorbid illnesses and the inability to perform leisure activities predicted mortality in institutionalized adults with dementia. These predictors might be useful clinical markers for identifying patients at increased risk for mortality.

Use of the interRAI CHESS scale to predict mortality among persons with neurological conditions in three care settings

Background

Persons with certain neurological conditions have higher mortality rates than the population without neurological conditions, but the risk factors for increased mortality within diagnostic groups are less well understood. The interRAI CHESS scale has been shown to be a strong predictor of mortality in the overall population of persons receiving health care in community and institutional settings. This study examines the performance of CHESS as a predictor of mortality among persons with 11 different neurological conditions.

Methods

Survival analyses were done with interRAI assessments linked to mortality data among persons in home care (n = 359,940), complex continuing care hospitals/units (n = 88,721), and nursing homes (n = 185,309) in seven Canadian provinces/territories.

Results

CHESS was a significant predictor of mortality in all 3 care settings for the 11 neurological diagnostic groups considered after adjusting for age and sex. The distribution of CHESS scores varied between diagnostic groups and within diagnostic groups in different care settings.

Conclusions

CHESS is a valid predictor of mortality in neurological populations in community and institutional care. It may prove useful for several clinical, administrative, policy-development, evaluation and research purposes. Because it is routinely gathered as part of normal clinical practice in jurisdictions (like Canada) that have implemented interRAI assessment instruments, CHESS can be derived without additional need for data collection.

High-level activities of daily living and disease-specific mortality during a 12-year follow-up of an octogenarian population

BACKGROUND

Little is known about the relationship between disease-specific mortality and high-level activities of daily living in the elderly. We examined whether mortality is associated with high-level activities of daily living in an octogenarian population.

METHODS

We conducted a population-based cross-sectional and prospective cohort study in 693 older persons aged 80 years and living in Japan's Fukuoka Prefecture. We then evaluated the association between 12-year disease-specific mortality and high-level functional capacity as measured by the Tokyo Metropolitan Institute of Gerontology Index of Competence, which is a standardized multidimensional 13-item instrument; items 1 through 5 are classified as instrumental self-maintenance activity, items 6 through 9 as intellectual activity, items 10 through 13 as social roles activity, and all 13 items together yield total functional capacity.

RESULTS

By the 12-year follow-up of the 693 participants, 413 had died, 242 survived, and 38 were unable to be located. Of the 413 who died, 105 died of cardiovascular disease, 73 of respiratory tract disease, 71 of cancer, and 39 of senility. Of the other 125 deaths, 59 were due to other diseases, and the cause of death for 66 participants is not known. The hazard ratio (HR) for all-cause mortality, adjusted for confounding factors with multivariate Cox analyses, fell by 6% (HR 0.937, 95% confidence interval [CI] 0.899-0.978, P = 0.003) with each one-point increase in participants' scores on the Tokyo Metropolitan Institute of Gerontology Index of total functional capacity. With one-point increases in instrumental self-maintenance activity and in intellectual activity, the HRs for all-cause mortality decreased by 14% (HR 0.856, 95% CI 0.787-0.930, P = 0.000) and 12% (HR 0.884, 95% CI 0.794-0.983, P = 0.023), respectively. Respiratory mortality with HR adjustment fell by 11% (HR 0.887, 95% CI 0.804-0.978, P = 0.016) and 24% (HR 0.760, 95% CI 0.627-0.922, P = 0.005) with one-point increases in the scores of total functional capacity and instrumental self-maintenance activity, respectively. Similarly, mortality due to senility fell by 16% (HR 0.838, 95% CI 0.743-0.946, P = 0.004), 29% (HR 0.707, 95% CI 0.564-0.886, P = 0.003), and 29% (HR 0.710, 95% CI 0.522-0.966, P = 0.029) with one-point increases in the scores of total functional capacity, instrumental self-maintenance activity, and intellectual activity, respectively.

CONCLUSION

These findings suggest that high-level activities of daily living may be an independent predictor of mortality due to all causes, respiratory disease and senility in older persons.

Activities of daily living dependency and disease-specific mortality during 12-year follow-up in an 80-year-old population

BACKGROUND AND AIMS

Although total mortality is likely to be higher in elderly individuals with frailty or impaired activities of daily living (ADL), little is known about the relationships between disease-specific mortality and ADL dependency in the elderly. Therefore, we examined whether 12-year disease-specific mortality may be associated with ADL dependency in an 80-year-old population.

METHODS

In 1998, of 1,282 community-dwelling residents of Japan's Fukuoka Prefecture, 824 (64.3 %) (309 males and 515 females) participated, the remaining 458 subjects did not participate, and their deaths and causes of death were followed up for 12 years after the baseline examination. ADL dependency was determined according to the guidelines for disabled elderly from the Health, Labor, and Welfare Ministry of Japan, and ADL dependency was measured only at baseline.

RESULTS

During the 12-year follow-up, 506 died, 276 did not die, and 42 were lost. Of the 506 who died, 128 died due to cardiovascular disease, 96 to respiratory tract disease, 87 to cancer, and 51 to senility. The subjects were classified into three groups as follows: ADL-1 (independent group, n = 600), ADL-2 (almost-independent group, n = 113), and ADL-3 (dependent group, n = 93).Total-cause mortality was 2.8 times higher in ADL-3 subjects, respiratory disease mortality was 4.1 times higher in ADL-3 subjects, and senility mortality was 5.7 times higher in ADL-3 subjects than in ADL-1 subjects, after adjusting for various confounding factors. There was no association between mortality due to cancer or cardiovascular disease and ADL dependency.

CONCLUSIONS

We found an independent association between ADL dependency and mortality due to all causes, respiratory disease or senility, but no association with mortality due to cancer or cardiovascular disease. These findings suggest that improving ADL dependency may reduce all mortality and mortality due to respiratory disease or senility.

Mortality in older care home residents in England and Wales

BACKGROUND

mortality in UK care homes is not well described.

OBJECTIVE

to describe 1-year mortality and predictors in older care home residents compared with community residents.

METHOD

cohort study using the THIN primary care database with 9,772 care home and 354,306 community residents aged 65-104 years in 293 English and Welsh general practices in 2009.

RESULTS

a total of 2,558 (26.2%) care home and 11,602 (3.3%) community residents died within 1 year. The age and sex standardised mortality ratio for nursing homes was 419 (95% CI: 396-442) and for residential homes was 284 (266-302). Age-related increases in mortality were less marked in care homes than community. Comorbidities and identification as inappropriate for chronic disease management targets predicted mortality in both settings, but associations were weaker in care homes. The number of drug classes prescribed and primary care contact were the strongest clinical predictors of mortality in care homes.

CONCLUSIONS

older care home residents experience high mortality. Age and diagnostic characteristics are weaker predictors of risk of death within care homes than the community. Measures of primary care utilisation may be useful proxies for frailty and improve difficult end of life care decisions in care homes.

A mix of bulk and ready-to-use modified-texture food: impact on older adults requiring dysphagic food

Ready-to-use modified-texture food (rMTF) products are commercially available and may have greater appeal than conventional in-house or commercial bulk modified-texture food (cMTF) products. A nine-month pilot study using a prospective interrupted time-series design where participants (n = 42) served as their own controls investigated the impact of cMTF + rMTF on weight goals, weight, food intake, and co-morbidity. Seventy-four per cent of participants achieved their weight goals at the end of six months on rMTF and, although insignificant, participants did have a trend towards weight gain while on rMTF (OR 3.5 p = .16). Main-plate food intake (grams) was not significantly different over time, but a downwards trajectory suggests decreased consumption that was compensated for by a significantly higher fat intake during the intervention period (p = .01). Increased co-morbidity and a decreasing volume of food consumed are common in older adults with dysphagia, and enhanced food products are needed to meet nutrient needs. Methodological issues encountered in this study can provide guidance for future work.

Prevention of mortality and pneumonia among nursing home older adults by dual pneumococcal and seasonal influenza vaccination during a pandemic caused by novel pandemic influenza A (H1N1)

OBJECTIVE

To evaluate the efficacy of dual vaccination of seasonal influenza and pneumococcus in nursing home older adults during a novel pandemic of influenza A (H1N1).

SETTING

Nine nursing homes in Hong Kong.

PARTICIPANTS

A total of 532 nursing home older adults were included in the study.

MEASUREMENTS

Efficacy of dual vaccination of seasonal influenza and pneumococcus in nursing home older adults during a novel pandemic influenza A (H1N1).

DESIGN

A prospective 12-month cohort study was conducted on older residents from December 2009 to November 2010. Participants were divided into 3 groups according to their choice of vaccination: received both seasonal influenza and 23-valent pneumococcal polysaccharide vaccine (PPV-TIV group), received seasonal influenza vaccine alone (TIV group), and those who refused both vaccinations (unvaccinated group). Those who had received vaccination for influenza A (H1N1) were excluded. Outcome measures included mortality from all causes, pneumonia, and vascular causes.

RESULTS

There were 246 in the PPV-TIV group, 211 in the TIV group, and 75 in the unvaccinated group. Baseline characteristics were similar among the groups. The 12-month mortality rates of the PPV-TIV, TIV alone group, and unvaccinated group were 17.1%, 27.0%, and 37.3% respectively (P < .001). Multivariate analysis demonstrated that, compared with vaccination of seasonal influenza alone, dual vaccination significantly reduced all-cause mortality (hazard ratio [HR] 0.54; 95% confidence interval [CI]: 0.35-0.84; P < .01), mortality from pneumonia (HR 0.60; 95% CI: 0.35-0.99; P < .05), and mortality from vascular causes (HR 0.24; 95% CI: 0.09-0.64; P < .01).

CONCLUSIONS

During an influenza pandemic or when the circulating influenza strain was not matched by the trivalent seasonal influenza vaccine, dual vaccination of influenza and pneumococcus provided additional protection to nursing home older adults in reducing mortality.

The frailty syndrome: a comprehensive review

The frailty syndrome is defined as unintentional weight and muscle loss, exhaustion, and declines in grip strength, gait speed, and activity. Evidence with respect to the clinical definition, epidemiology, mechanisms, interactions, assessment, prevention, and treatment of frailty in the older adult is reviewed.

Assessment of nursing home residents in Europe: the Services and Health for Elderly in Long TERm care (SHELTER) study

BACKGROUND

Aims of the present study are the following: 1. to describe the rationale and methodology of the Services and Health for Elderly in Long TERm care (SHELTER) study, a project funded by the European Union, aimed at implementing the interRAI instrument for Long Term Care Facilities (interRAI LTCF) as a tool to assess and gather uniform information about nursing home (NH) residents across different health systems in European countries; 2. to present the results about the test-retest and inter-rater reliability of the interRAI LTCF instrument translated into the languages of participating countries; 3 to illustrate the characteristics of NH residents at study entry.

METHODS

A 12 months prospective cohort study was conducted in 57 NH in 7 EU countries (Czech Republic, England, Finland, France, Germany, Italy, The Netherlands) and 1 non EU country (Israel). Weighted kappa coefficients were used to evaluate the reliability of interRAI LTCF items.

RESULTS

Mean age of 4156 residents entering the study was 83.4 ± 9.4 years, 73% were female. ADL disability and cognitive impairment was observed in 81.3% and 68.0% of residents, respectively. Clinical complexity of residents was confirmed by a high prevalence of behavioral symptoms (27.5% of residents), falls (18.6%), pressure ulcers (10.4%), pain (36.0%) and urinary incontinence (73.5%). Overall, 197 of the 198 the items tested met or exceeded standard cut-offs for acceptable test-retest and inter-rater reliability after translation into the target languages.

CONCLUSION

The interRAI LTCF appears to be a reliable instrument. It enables the creation of databases that can be used to govern the provision of long-term care across different health systems in Europe, to answer relevant research and policy questions and to compare characteristics of NH residents across countries, languages and cultures.

End-of-life issues in caring for patients with dementia: the case for palliative care in management of terminal dementia

The number of people suffering with dementia is increasing in the general population and the trend is projected to continue as people live longer, especially in countries with developed economies. The most common cause of dementia (among the many other causes) is Alzheimer's dementia, which is considered a terminal illness. The disease could eventually lead to death, or death could occur as a consequence of co-morbid physical complications. The problem of end of life (EOL) care for patients suffering from dementia though spoken of and written about, does not get the attention and system support as for example patients suffering from cancer receive. Many reasons have been advanced for the current state of affairs where EOL issues for patients suffering from dementia are concerned. This article attempts to revisit the issues, and the reasons, that may contribute to this. Some guidelines on palliative management in cases of patients suffering from severe dementia exist; the evidence base for these guidelines though is relatively weak. The ethical and legal issues that may influence or impact on the decision to initiate the palliative care pathway in the management of EOL issues for dementia patients in the terminal or end stage of the illness is highlighted. Initiatives by the department of health in England and Wales, and other bodies with interest in dementia issues and palliative care in the United Kingdom to ensure good and acceptable EOL pathways for patients with dementia are mentioned.

Predicting mortality of residents at admission to nursing home: a longitudinal cohort study

Background

An increasing numbers of deaths occur in nursing homes. Knowledge of the course of development over the years in death rates and predictors of mortality is important for officials responsible for organizing care to be able to ensure that staff is knowledgeable in the areas of care needed. The aim of this study was to investigate the time from residents' admission to Icelandic nursing homes to death and the predictive power of demographic variables, health status (health stability, pain, depression and cognitive performance) and functional profile (ADL and social engagement) for 3-year mortality in yearly cohorts from 1996-2006.

Methods

The samples consisted of residents (N = 2206) admitted to nursing homes in Iceland in 1996-2006, who were assessed once at baseline with a Minimum Data Set (MDS) within 90 days of their admittance to the nursing home. The follow-up time for survival of each cohort was 36 months from admission. Based on Kaplan-Meier analysis (log rank test) and non-parametric correlation analyses (Spearman's rho), variables associated with survival time with a p-value < 0.05 were entered into a multivariate Cox regression model.

Results

The median survival time was 31 months, and no significant difference was detected in the mortality rate between cohorts. Age, gender (HR 1.52), place admitted from (HR 1.27), ADL functioning (HR 1.33-1.80), health stability (HR 1.61-16.12) and ability to engage in social activities (HR 1.51-1.65) were significant predictors of mortality. A total of 28.8% of residents died within a year, 43.4% within two years and 53.1% of the residents died within 3 years.

Conclusion

It is noteworthy that despite financial constraints, the mortality rate did not change over the study period. Health stability was a strong predictor of mortality, in addition to ADL performance. Considering these variables is thus valuable when deciding on the type of service an elderly person needs. The mortality rate showed that more than 50% died within 3 years, and almost a third of the residents may have needed palliative care within a year of admission. Considering the short survival time from admission, it seems relevant that staff is trained in providing palliative care as much as restorative care.