Resourse Use and Disease Couse in dementia - Nursing Home (REDIC-NH), a longitudinal cohort study; design and patient characteristics at admission to Norwegian nursing homes

Using a Robot to Address the Well-Being, Social Isolation, and Loneliness of Care Home Residents via Video Calls: Qualitative Feasibility Study

Background

About 40,000 people are living in Norwegian care homes, where a majority are living with a dementia diagnosis. Social isolation and loneliness are common issues affecting care home residents' quality of life. Due to visitation restrictions during the pandemic, residents and family members started using digital solutions to keep in contact. There is no framework or guidelines to inform the uptake and use of technologies in the care home context, and this often results in non-adoption and a lack of use after the introduction phase. Hence, there is a great need for research on the feasibility of a robot that can facilitate video communication between residents and family members.

Objective

This study aimed to (1) introduce video communication through a robot to address social isolation and loneliness in a care home during a period of 6 weeks and (2) identify elements central to the feasibility concerning testing and evaluating the use of the robot.

Methods

Three focus group interviews were undertaken: 1 with family members (n=4) and 2 with care staff (n=2 each). The informants were purposely selected to ensure that they had the proper amount of experience with the robot to have the ability to inform this study's objectives. The focus group interviews were tape-recorded and transcribed verbatim, then subsequently analyzed using systematic text condensation.

Results

The data analysis of focus group interviews and individual interviews resulted in three categories: (1) organizing the facilitation of video calls, (2) using a robot in dementia care, and (3) user experience with the robot.

Conclusions

Video communication in care homes is a feasible alternative to face-to-face interactions, but it depends on organizational factors such as information flow, resources, and scheduling. In dementia care, the user-friendly robot supports person-centered care through tailored social interaction. Both family members and staff express enthusiasm for video calls as an option and see its potential for future use.

Classification of the trajectory of changes in food intake in special nursing home for oldest-old in the 6 months before death: A secondary analysis

BACKGROUND

For the oldest-old residents around their 90s living in facilities, quality end-of-life care is crucial. While an association between reduced food intake and death is known, specific patterns of intake changes before death are not well-documented.

AIMS

This study aims to classify food intake changes among residents in Japan's special nursing homes during the 6 months before death, enabling precision care for each group using routinely recorded data.

METHODS

Sixty-nine deceased older adults from five special nursing homes were studied over 3.5 years (January 2016 to June 2020). Criteria included: at least six months' residency before death, ability to eat orally during the study period, and death within the facility. We created a time-series dataset for 69 participants, documenting their average weekly food intake (on a scale of 0-10). Subsequently, we used cluster analysis to identify clusters of change in the average weekly food intake from the 6 months before death.

RESULTS

Eligible residents' mean age was 89.7 ±  6.7 years, and 79.7% were female. Cluster analysis classified 4 clusters of decline in food intake changes during the last 6 months before death: immediate decrease (n = 14); decrease from 1 month before death (n = 24); decrease from 3 months before death (n = 7); and gradual decrease for 6 months before death (n = 24).

CONCLUSION

This study identified four groups of food intake prior to death. Recognizing food intake clusters in practical settings can help manage and provide appropriate end-of-life care in facilities with few medical providers but many care providers.

Characteristics and Effectiveness of Physical Therapist-Supervised Exercise Interventions for Nursing Home Residents With Dementia: A Systematic Review

Background and Objectives

Although physical therapy, in particular exercise therapy, is widely used in nursing home residents with dementia, the literature on this topic is relatively scarce. This systematic review aimed to summarize the literature on the characteristics and effectiveness of exercise interventions supervised by physical therapists in nursing home residents with dementia.

Research Design and Methods

Six electronic databases were systematically searched for relevant studies up to August 17, 2022. Randomized controlled trials (RCTs) comparing exercise interventions supervised by a physical therapist to any other form of intervention or usual care in nursing home residents with dementia were selected. Data were narratively analyzed and forest plots visualizing exercise effects were created.

Results

From the 1 377 records retrieved and screened, 6 RCTs, reported in 11 papers, met the selection criteria. Included studies used multimodal or aerobic exercise interventions, with the frequency, duration and intensity varying across studies. Three of the 6 studies were at high risk of bias. Due to inconsistency in the findings and variety in outcome measures, results on the effectiveness of the interventions are inconclusive.

Discussion and Implications

Our review emphasizes the need for more robust studies to offer understanding of the efficacy of exercise interventions supervised by physical therapists for nursing home residents with dementia.

Cause and place of death in Norwegian nursing home residents

BACKGROUND

Nursing home (NH) residents are in their last phase of life, and two aims of the NH's medical care in Norway is to prevent unnecessary hospital admissions that would not benefit the resident and to facilitate a peaceful death in familiar surroundings when the time comes. However, little is known about the share of residents dying in NHs and the causes of death. We therefore evaluated the cause and place of death in a cohort of NH residents followed from the time of NH admission until death.

METHODS

NH residents were followed from admission to the NH and over the entire course of their NH stay. Demographic and clinical data were collected. Cause and place of death were retrieved from the Norwegian Cause of Death Registry.

RESULTS

Of 1283 residents, 6.2% died in hospital and 91.2% in a NH. Those who died in hospitals were more often male, died sooner after NH admission, had a less severe degree of dementia and had poorer general health. Dementia was the most common underlying cause of death, followed by cardiovascular disease.

CONCLUSIONS

Dementia is one of the main causes of death in NH residents. In addition, our findings indicate a low number of inappropriate referrals to hospital during the last stage of life. However, further research should explore whether the terminal phase of NH residents is formed in accordance with their preferences and whether appropriate palliative care is offered.

Does cognitive impairment moderate the relationship between social isolation and anxiety? A 5-year longitudinal study of a nationally representative sample of community residing older adults

BACKGROUND

Anxiety is common in older adults and social isolation is one of the leading factors associated with their anxiety. However, what is unknown is how the relationship between social isolation and anxiety differs by cognitive status. Therefore, this study was conducted to (1) compare the level of social isolation and anxiety in older adults who developed probable dementia and mild cognitive impairment (MCI) to those who maintained normal cognitive function over 5 years; and (2) determine if cognitive impairment moderates the relationship between changes in social isolation and changes in anxiety over 5 years.

METHODS

A secondary data analysis was conducted using the National Social Life, Health, and Aging Project (NSHAP): Wave 2 (2010-2011) and Wave 3 (2015-2016). The participants were categorized into three groups: Participants who developed probable dementia over 5 years (4.3%), developed probable MCI (19.1%), or maintained normal cognitive function (76.6%). Weighted linear regression analyses with a group interaction were used to examine the moderating effect of cognitive impairment on the relationship between changes in social isolation and anxiety.

RESULTS

At the 5-year follow up, there were statistically significant differences in social isolation between the three groups (p = 0.043). Regression analyses showed that increased social isolation over time was related to increased anxiety over 5 years regardless of cognitive status after controlling for covariates (p = 0.017).

CONCLUSIONS

The relationship between social isolation and anxiety was a universal phenomenon regardless of cognitive status. Tailored interventions targeting both people with or without cognitive impairment are needed to lessen social isolation and anxiety.

Pain and quality of life in nursing home residents with dementia after admission - a longitudinal study

BACKGROUND

Pain in nursing home (NH) residents with dementia is commonly reported and may affect Quality of Life (QoL) negatively. Few longitudinal studies have explored how pain and QoL develop in NH residents with dementia starting from their admission to the NH.

AIM

The aim was to explore pain, QoL, and the association between pain and QoL over time in persons with dementia admitted to a NH.

METHODS

A convenience sample, drawn from 68 non-profit NHs, included a total of 996 Norwegian NH residents with dementia (mean age 84.5 years, SD 7.6, 36.1% men) at NH admission (A1), with annual follow-ups for two years (A2 and A3). Pain and QoL were assessed using the Mobilization-Observation-Behavior-Intensity-Dementia-2 (MOBID-2) Pain Scale and the Quality of Life in Late-Stage Dementia (QUALID) scale, respectively, at all assessments. Severity of dementia, personal level of activities of daily living, general medical health, neuropsychiatric symptoms, and the prescription of psychotropic drugs and analgesics (opioids and/or paracetamol) were also assessed at all assessments.

RESULTS

Mean (SD) MOBID-2 pain intensity scores were 2.1 (2.1), 2.2 (2.2), and 2.4 (2.1) at A1, A2, and A3, respectively. Participants who were prescribed analgesics had higher pain intensity scores at all assessments than participants not prescribed analgesics. The mean (SD) QUALID scores at each assessment were 19.8 (7.1), 20.8 (7.2), and 22.1 (7.5) at A1, A2, and A3, respectively. In the adjusted linear mixed model, higher pain intensity score, prescription of opioids, and prescription of paracetamol were associated with poorer QoL (higher QUALID total score and higher scores in the QoL dimensions of sadness and tension) when assessed simultaneously. No time trend in QoL was found in these adjusted analyses.

CONCLUSION

NH residents with dementia who have higher pain intensity scores or are prescribed analgesics are more likely to have poorer QoL. Clinicians, NH administrators, and national healthcare authorities need to look into strategies and actions for pharmacological and non-pharmacological pain treatment to reduce pain intensity while simultaneously avoiding negative side effects of pain treatment that hamper QoL.

A Multifaceted Intervention and Its Effects on Antibiotic Usage in Norwegian Nursing Homes

We explored the impact of an antibiotic quality improvement intervention across 33 nursing homes (NHs) in one Norwegian county, compared against four control counties. This 12-month multifaceted intervention consisted of three physical conferences, including educational sessions, workshops, antibiotic feedback reports, and academic detailing sessions. We provided clinical guiding checklists to participating NHs. Pharmacy sales data served as a measure of systemic antibiotic use. The primary outcome was a change in antibiotic use in DDD/100 BD from the baseline through the intervention, assessed using linear mixed models to identify changes in antibiotic use. Total antibiotic use decreased by 15.8%, from 8.68 to 7.31 DDD/100BD (model-based estimated change (MBEC): -1.37, 95% CI: -2.35 to -0.41) in the intervention group, albeit not a significantly greater reduction than in the control counties (model-based estimated difference in change (MBEDC): -0.75, 95% CI: -1.91 to 0.41). Oral antibiotic usage for urinary tract infections (UTI-AB) decreased 32.8%, from 4.08 to 2.74 DDD/100BD (MBEC: -1.34, 95% CI: -1.85 to -0.84), a significantly greater reduction than in the control counties (MBEDC: -0.9, 95% CI: -1.28 to -0.31). The multifaceted intervention may reduce UTI-AB use in NHs, whereas adjustments in the implementation strategy may be needed to reduce total antibiotic use.

Prevalence and persistent prescription of analgesic drugs in persons admitted with dementia to a nursing home - A longitudinal study

The overall aim was to explore the prevalence and persistent regular prescription of opioids and paracetamol among nursing home (NH) residents with dementia at admission and over time. A total of 996 residents with dementia, mean (SD) age 84.5 (7.6) years and (36.1% men), were included at admission (A1). Yearly assessments were performed for two years (A2 and A3) or until death. Pain was assessed using the Mobilization-Observation-Behavior-Intensity-Dementia-2 (MOBID-2) Pain Scale. Information regarding prescription of analgesics, general physical health, personal activities of daily living, severity of dementia, neuropsychiatric symptoms, and prescription of psychotropic drugs was collected. A generalized linear mixed model was used to explore whether pain severity was associated with persistent and persistent prescription of opioids and/or paracetamol across timepoints. At A1, 495 of 996 (49.7%) NH residents were prescribed analgesics and prevalence increased at the follow-ups (A2: n = 630, 65.1%; A3: n = 382, 71.2%). Paracetamol was the most frequently prescribed analgesic at all assessments (A1: 45.5%; A2: 59.5%; A3: 67.1%). Opioid prescriptions were quite prevalent (A1: 18.1%; A2: 25.1%; A3: 28.3%), with odds approximately 13 times (OR = 13.3, 95% CI 6.8-26.0) and 9 times (OR = 8.6, 95% CI 3.7-20.3) higher for prescription at follow-up A2 and A3, respectively, relative to prescription at A1. In adjusted analyses, higher pain intensity and poor physical health were associated with prescription and persistent prescription of opioids and paracetamol. In conclusion, prevalence and persistent prescription of analgesics were high in NH residents with dementia. The odds for the prescription of opioids at follow-up were high if prescribed at baseline. Interdisciplinary collaboration, routine assessment of pain at admission and regularly thereafter, and systematic drug reviews are essential to adequately assess and treat pain in NH residents with dementia.

Factors associated with formal and informal resource utilization in nursing home patients with and without dementia: cross-sectional analyses from the COSMOS trial

OBJECTIVES

To investigate the association between clinical, demographic, and organizational factors and formal (health professionals) and informal (relatives) resource utilization in nursing home patients with and without dementia.

METHODS

Baseline data from the multicomponent cluster randomized control COSMOS trial including 33 Norwegian nursing homes and 723 residents with and without dementia. Nursing home staff (n = 117) participated as proxy raters to approximate formal and informal resource use in daily care.

MEASUREMENTS

The primary outcome was the Resource Utilization in Dementia - Formal Care scale to assess formal and informal care time in hours/month regarding basic activities of daily living (ADL), instrumental ADL, and supervision. Secondary outcomes were hours/week spent on formal and informal leisure activities. Behavioral and psychological symptoms in dementia (BPSD) were assessed by the Neuropsychiatric Inventory-Nursing Home version, physical function by the Physical Self-Maintenance Scale, and psychotropic drug use by the Anatomical Therapeutic Chemical classification system. Organizational factors were ward size and staff ratio.

RESULTS

Generalized linear mixed-effect models and two-part modelling revealed an association between increased formal care time and poorer physical function, higher agitation and psychotropic drug use and lower cognitive function (all p < .05). Enhanced formal leisure time was related to better ADL function (p < .05) and smaller wards (p < .05). The family related leisure time was associated with agitation, decline in ADL function, smaller wards, and better staffing ratio (all p < .05). Married patients received more informal direct care (p < .05) and leisure time (p < .05) compared to unmarried/widowed.

CONCLUSION

For nursing home staff, higher agitation and psychotropic drug use, and lower cognitive function, is associated with more direct care time, whereas leisure time activities are less prioritized in people with lower physical function. Informal caregivers' engagement is encouraged by smaller nursing homes and better staff ratio. Therefore, we recommend stakeholders and healthcare professionals to consider these clinical and organizational factors to optimize treatment and leisure time activities in nursing home patients with various needs.

TRIAL REGISTRATION

ClinicalTrials.gov ; NCT02238652.

The Course of Depressive Symptoms Over 36 Months in 696 Newly Admitted Nursing Home Residents

OBJECTIVES

To investigate the course of depressive symptoms in newly admitted nursing home (NH) residents and how resident characteristics were associated with the symptoms. To identify groups of residents following the same symptom trajectory.

DESIGN

An observational, multicenter, longitudinal study over 36 months with 7 biannual assessments.

SETTING AND PARTICIPANTS

Representing 47 Norwegian NHs, 696 residents were included at admission to a NH.

METHODS

Depressive symptoms were assessed with the Cornell Scale for Depression in Dementia (CSDD). We selected severity of dementia, functional impairment, physical health, pain, use of antidepressants, age, and sex as covariates. Time trend in CSDD score was assessed by a linear mixed model adjusting for covariates. Next, a growth mixture model was estimated to investigate whether there were groups of residents following distinct trajectories in CSDD scores. We estimated a nominal regression model to assess whether the covariates at admission were associated to group membership.

RESULTS

There was a nonlinear trend in CSDD score. More severe dementia, a lower level of functioning, poorer physical health, more pain, use of antidepressants, and younger age at admission were associated with higher CSDD scores. Growth mixture model identified 4 groups: (1) persistent mild symptoms (32.6%), (2) persistent moderate symptoms (50.8%), (3) increasing symptoms (5.1%), and (4) severe but decreasing symptoms (11.6%). A lower level of functioning, poorer physical health, more pain, use of antidepressants, and younger age at admission were associated with higher odds for belonging to the severe but decreasing symptoms group compared with the persistent mild symptoms group.

CONCLUSIONS AND IMPLICATIONS

Most NH residents were in trajectory groups with persistent mild or moderate depressive symptoms. Residents with more severe dementia, lower levels of functioning, poor physical health, severe pain, younger age at admittance, and who are using antidepressants should be monitored closely and systematically with respect to depression. Taking actions toward a more personalized treatment for depression in NHs is a priority and should be investigated in future studies.

Pain in nursing home residents with dementia and its association to quality of life

OBJECTIVES

We aimed to describe pain, use of analgesics and quality of life (QoL) in people with dementia admitted to a Norwegian nursing home (NH), and to explore if and how pain was associated with their QoL when adjusting for sociodemographic characteristics, other health conditions and use of analgesics.

METHOD

A total of 953 Norwegian NH residents with dementia (mean age 84.0, SD 7.5 years, 35.8% men) were included at admission to the NH. Pain and QoL were assessed using the Mobilization-Observation-Behavior-Intensity-Dementia-2 (MOBID-2) Pain Scale and the Quality of Life in Late-Stage Dementia (QUALID) scale, respectively. Severity of dementia, personal level of activities of daily living, general medical health, neuropsychiatric symptoms, and the use of psychotropic drugs and analgesics were assessed.

RESULTS

In total, 36% of the participants had clinically relevant pain intensity (MOBID-2 ≥ 3) and 52% received analgesics. Paracetamol was most frequently prescribed (45%). In an adjusted linear mixed model, more severe pain was associated with higher QUALID total scores, indicating poorer QoL (regression coefficient 0.52, 95% CI 0.36-0.69).

CONCLUSION

Pain prevalence at NH admission was high in residents with dementia; half used analgesics, particularly paracetamol. More severe pain was associated with poorer QoL when adjusting for sociodemographic characteristics, other health conditions, and use of analgesics. The routine assessment of pain at NH admission can uncover undiagnosed and untreated pain and allow for adequate non-pharmacological and pharmacological pain management and likely increased QoL.

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.

Health professionals' experience of nursing home residents' consumption of alcohol and use of psychotropic drugs

Background:

Nursing home (NH) residents are in most cases in older ages and use prescription drugs. As alcohol interacts with many commonly prescribed drugs, NH residents may be more vulnerable to the effects of alcohol.

Aim:

To investigate the experiences of health professionals in Norwegian NHs when it comes to residents' alcohol consumption and use of psychotropic drugs, and the facilitation of such use in the NH.

Method:

Focus-groups and individual interviews with NH health professionals were performed in 2017 and 2018. The data were analysed using content analysis.

Findings:

Two main themes emerged: (1) the balancing of alcohol consumption, and (2) the use of psychotropic drugs. Each of these themes involved reasoning, which revealed that the informants in general had little attention regarding alcohol consumption among residents, and few institutions had policies regarding serving and consumption of alcohol. The informants reported an increased attention regarding use of psychotropic drugs and a tendency towards less use of psychotropic drugs among the residents than before, but few informants reported use of standardised observations tools of symptoms related to prescribing and discontinuation of drugs.

Conclusion:

Alcohol policies or procedures related to alcohol consumption were uncommon at the NH that the interviewees of this study represented, and the professionals regarded infrequent serving and consumption of alcohol among the residents as a part of everyday life. In cases when residents frequently consumed alcohol, the professionals used dialogue to underpin the adherent risks and they also tried to control the consumption of the resident in different ways. The interviewees were aware of various side-effects of psychotropic drugs; they were also aware of their effects in combination with alcohol.

The Humanistic and Economic Burden of Alzheimer's Disease

Alzheimer's disease (AD) is the leading cause of cognitive impairment and dementia in older individuals (aged ≥ 65 years) throughout the world. As a result of these progressive deficits in cognitive, emotional, and physical function, AD dementia can cause functional disability and loss of independence. To gain a deeper understanding of the recent literature on the burden of AD, including that of mild cognitive impairment (MCI) due to AD, we conducted a comprehensive targeted review of the PubMed-indexed literature (2014 to 2021) to examine the humanistic and economic burden of AD (including MCI) in North America, Europe, and Asia. Our literature review identified a range of factors associated with quality of life (QoL): some factors were positively associated with QoL, including caregiver relationship, religiosity, social engagement, and ability to engage in activities of daily living (ADL), whereas other factors such as neuropsychiatric symptoms were associated with poorer QoL. While patient- and proxy-rated QoL are highly correlated in patients with early AD dementia, proxy-rated QoL declines more substantially as severity worsens. The maintenance of self-reported QoL in patients with more severe AD dementia may be due to lack of awareness or to adaptation to circumstances. Compared to persons with normal cognition, MCI is associated with a greater cost burden, and individuals with MCI exhibit worse QoL. Key drivers of the societal economic burden of AD include disease severity, dependence level, institutionalization, and comorbidity burden. Evaluation of the impact of a hypothetical disease-modifying treatment delaying the progression from MCI to AD has suggested that such a treatment may result in cost savings.

The Effect of the NorGeP–NH on Quality of Life and Drug Prescriptions in Norwegian Nursing Homes: A Randomized Controlled Trial

Background: The effect of the Norwegian General Practice–Nursing Home (NorGeP–NH) criteria has never been tested on clinical outcomes in nursing home (NH) residents. We performed a cluster-randomized trial in Norwegian NHs and tested the effect of NorGeP–NH on QoL (primary outcome), medication prescriptions, and physical and mental health (secondary outcomes) for the enrolled residents; Methods: Fourteen NHs were randomized into intervention NHs (iNHs) and control NHs (cNHs). After baseline data collection, physicians performed NorGeP–NH on the enrolled residents. We assessed the difference between cNHs and iNHs in the change in primary outcome from baseline to 12 weeks and secondary outcomes from baseline to eight and 12 weeks by linear mixed models; Results: One hundred and eight residents (13 lost to follow-up) and 109 residents (nine lost to follow-up) were randomized to iNHs and cNHs, respectively. Difference in change in QoL at 12 weeks between cNHs and iNHs was not statistically significant (mean (95% CI)): −1.51 (−3.30; 0.28), p = 0.101). We found no significant change in drug prescriptions over time. Difference in depression scores between cNHs and iNHs was statistically significant after 12 weeks. Conclusions: Our intervention did not affect QoL or drug prescriptions, but reduced depression scores in the iNHs. NorGeP–NH may be a useful tool, but its effect on clinical outcomes may be scarce in NH residents. Further studies about the effectiveness of NorGeP–NH in other healthcare contexts and settings are recommended.

The perceptions, needs and preferences of informal caregivers of nursing home residents with dementia regarding physical therapy: A qualitative study

INTRODUCTION

Informal caregivers often support nursing home residents with dementia in making therapeutic decisions. We explored the perceptions, needs and preferences of informal caregivers of nursing home residents with dementia regarding physical therapy.

METHOD

We conducted eleven semi-structured interviews. Thematic analysis was used.

RESULTS

Five themes emerged: 1) visibility and familiarity; 2) communication; 3) aim and content; 4) dosage and location; 5) level of expertise and the role of the physical therapist within the interdisciplinary team. Informal caregivers' perceptions of physical therapy included a lack of visibility and familiarity. They needed more communication, and empathic communication skills of the physical therapists. Preferences included physical therapy to be enjoyable, accessible and tailored to the needs of the resident.

CONCLUSION

Physical therapists need to involve informal caregivers in physical therapy care. Implementing shared decision-making will help to get informal caregivers more involved, but has yet to be studied in this setting.

Use of psychiatric medication in three Arctic nursing homes: association with dementia and psychiatric symptoms

As more people reaches advanced age, more people experience cognitive impairment and dementia. Dementia is a degenerative disease in which behavioural and psychological symptoms frequently occur, resulting in admissions to nursing homes (NHs), where the most common treatment has been medical treatment. The aim was to compare three rural Arctic NHs in Iceland in their use of psychiatric medication, type of dementia among residents, level of cognitive impairment and selected quality indicators, as well as considering national data, for the period 2016-2018. Data from the interRAI-MDS 2.0 evaluation were used. Residents with severe cognitive impairment used more antipsychotic medications, and residents with mild and severe cognitive impairment used more antidepressants than residents with no cognitive impairment did. Diagnoses of Alzheimer's Disease and Related Dementias (ADRD) are more common in the capital area and the national average than they are in the rural NHs. This indicates need for diagnostic assessments of ADRD to be conducted in rural areas. Benchmarking is beneficial for local and national regulatory bodies to find areas for improvement. The NHs did not have a lower quality of care compared with the whole country, but areas for improvement were identified. One of the NHs has already started this process.

Genome-wide association identifies the first risk loci for psychosis in Alzheimer disease

Psychotic symptoms, defined as the occurrence of delusions or hallucinations, are frequent in Alzheimer disease (AD with psychosis, AD + P). AD + P affects ~50% of individuals with AD, identifies a subgroup with poor outcomes, and is associated with a greater degree of cognitive impairment and depressive symptoms, compared to subjects without psychosis (AD - P). Although the estimated heritability of AD + P is 61%, genetic sources of risk are unknown. We report a genome-wide meta-analysis of 12,317 AD subjects, 5445 AD + P. Results showed common genetic variation accounted for a significant portion of heritability. Two loci, one in ENPP6 (rs9994623, O.R. (95%CI) 1.16 (1.10, 1.22), p = 1.26 × 10-8) and one spanning the 3'-UTR of an alternatively spliced transcript of SUMF1 (rs201109606, O.R. 0.65 (0.56-0.76), p = 3.24 × 10-8), had genome-wide significant associations with AD + P. Gene-based analysis identified a significant association with APOE, due to the APOE risk haplotype ε4. AD + P demonstrated negative genetic correlations with cognitive and educational attainment and positive genetic correlation with depressive symptoms. We previously observed a negative genetic correlation with schizophrenia; instead, we now found a stronger negative correlation with the related phenotype of bipolar disorder. Analysis of polygenic risk scores supported this genetic correlation and documented a positive genetic correlation with risk variation for AD, beyond the effect of ε4. We also document a small set of SNPs likely to affect risk for AD + P and AD or schizophrenia. These findings provide the first unbiased identification of the association of psychosis in AD with common genetic variation and provide insights into its genetic architecture.

Do prescription rates of psychotropic drugs change over three years from nursing home admission?

BACKGROUND

In this longitudinal study, we describe how psychotropic drugs (PTDs) are prescribed in nursing home (NH) patients from admission and over a 3-year period, to understand which clinical and environmental factors are associated with PTD prescription.

METHODS

We used data from the Resource Use and Disease Course in Dementia - Nursing Home (REDIC-NH) study, examining physical and mental health, dementia, and PTD prescription during a 3-year period from admission to a NH. Data were collected every six months. At baseline, we included 696 participants from 47 Norwegian NHs. We presented prevalence, incidence, and deprescribing rates of PTD prescriptions for each assessment point. We calculated the odds of receiving PTDs and used a generalized linear mixed model to analyze the variables associated with a change in odds throughout the 3-year period.

RESULTS

PTD prescriptions were frequent throughout the 3-year period. Antidepressants had the highest prescription rates (28.4%-42.2%). Every PTD category had the highest incidence rate between admission and six months, and antipsychotics had the highest values (49.4%). Deprescribing rates were comparable between assessment points. The odds of antipsychotic prescriptions were lower for older people (OR = 0.96, 95%CI:0.92-0.99, p = 0.023). People with more severe dementia had lower odds of being prescribed sedatives/hypnotics (OR = 0.89, 95%CI:0.85-0.94, p < 0.001).

CONCLUSIONS

PTDs, particularly antidepressants, are widely prescribed over time to NH patients. Older patients are less likely to receive antipsychotics. A higher severity of dementia decreases the odds of being prescribed sedatives/hypnotics. Close attention should be paid to PTD prescriptions during long-term NH stay to avoid prolonged and excessive treatment with these types of drugs.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT01920100 .

Residents' and Relatives' Experiences of Acute Situations: A Qualitative Study to Inform a Care Model

Background and Objectives

As new models of care aiming to reduce hospitalizations from nursing homes emerge, their implementers must consider residents’ and relatives’ needs and experiences with acute changes in the residents’ health situations. As part of the larger INTERCARE implementation study, we explored these persons’ experiences of acute situations in Swiss nursing homes.

Research Design and Methods

3 focus groups were conducted with residents and their relatives and analyzed via reflexive thematic analysis.

Results

The first theme, the orchestra plays its standards, describes experiences of structured everyday care in nursing homes, which functions well despite limited professional and competency resources. The second theme, the orchestra reaches its limits, illustrates accounts of acute situations in which resources were insufficient to meet residents’ needs. Interestingly, participants’ perceptions of acute situations went well beyond our own professional view, that is, changes in health situations, and included situations best summarized as “changes that might have negative consequences for residents if not handled adequately by care workers.” Within the third theme, the audience compensates for the orchestra’s limitations, participants’ strategies to cope with resource limitations in acute situations are summarized.

Discussion and Implications

Our findings suggest differences between care providers’ and participants’ perspectives regarding acute situations and care priority setting. Alongside efforts to promote staff awareness of and responsiveness to acute situations, care staff must commit to learning and meeting individual residents’ and relatives’ needs. Implications for the development and implementation of a new nurse-led model of care are discussed.

Associations between caregiver mastery and anxiety in persons living with dementia: A study of dyads living in community

Anxiety is common in persons living with dementia (PLWD), and particularly burdensome for caregivers. Little is known about how caregiver factors such as caregiver mastery can influence anxiety in PLWD. This study was conducted to examine the relationship between caregiver mastery and anxiety in PLWD. Secondary data analysis was conducted using baseline data from a randomized controlled trial of 170 dyads of community residing PLWD and their caregivers. Logistic regression analyses were used for data analyses. After controlling for covariates (e.g., age, cognitive impairment, sleep impairment, and depression), a higher level of caregiver mastery was related to lower odds of anxiety presentation in PLWD (OR=0.870, 95% CI=0.759-0.998, p=0.046). As caregiver mastery is related to anxiety in PLWD, a comprehensive education program for caregivers that can improve their caregiving skills and mastery is suggested to improve anxiety in PLWD.

Exploring life-space in the nursing home. An observational longitudinal study

BACKGROUND

Traditional performance-based measurements of mobility fail to recognize the interaction between the individual and their environment. Life-space (LS) forms a central element in the broader context of mobility and has received growing attention in gerontology. Still, knowledge on LS in the nursing home (NH) remains sparse. The aim of this study was to identify LS trajectories in people with dementia from time of NH admission, and explore characteristics associated with LS over time.

METHODS

In total, 583 people with dementia were included at NH admission and assessed biannually for 3 years. LS was assessed using the Nursing Home Life-Space Diameter. Association with individual (age, sex, general medical health, number of medications, pain, physical performance, dementia severity, and neuropsychiatric symptoms) and environmental (staff-to-resident ratio, unit size, and quality of the physical environment) characterises was assessed. We used a growth mixture model to identify LS trajectories and linear mixed model was used to explore characteristics associated with LS over time.

RESULTS

We identified four groups of residents with distinct LS trajectories, labelled Group 1 (n = 19, 3.5%), Group 2 (n = 390, 72.1%), Group 3 (n = 56, 10.4%), Group 4 (n = 76, 14.0%). Being younger, having good compared to poor general medical health, less severe dementia, more agitation, less apathy, better physical performance and living in a smaller unit were associated with a wider LS throughout the study period.

CONCLUSION

From NH admission most NH residents' LS trajectory remained stable (Group 2), and their daily lives unfolded within their unit. Better physical performance and less apathy emerged as potentially modifiable characteristics associated with wider LS over time. Future studies are encouraged to determine whether LS trajectories in NH residents are modifiable, and we suggest that future research further explore the impact of environmental characteristics.

Managing Pain and Psychosis Symptoms in Nursing Home Patients: Results from a Cluster-Randomized Controlled Trial (COSMOS)

OBJECTIVES

In nursing homes (NHs), 30% to 60% of patients experience daily pain and >80% have dementia. This can lead to neuropsychiatric symptoms, including psychosis symptoms such as delusion. We investigated if there was a relationship between pain and psychosis symptoms over time. We also aimed to investigate the effect of a multicomponent intervention (COSMOS) on pain, psychosis symptoms, and analgesic prescription.

DESIGN

COSMOS is a cluster-randomized, single blinded, controlled trial. Each NH unit was defined as a cluster and randomized to either the COSMOS intervention or care as usual. The COSMOS intervention is a multicomponent intervention, consisting of staff training in communication, pain treatment, medication review, organization of activities, and safety. The intervention lasted for 4 months with a follow-up at month 9.

SETTING AND PARTICIPANTS

Sixty-seven units from 33 Norwegian NHs in 8 municipalities. The study included 723 patients aged ≥65 years, residing at the NH ≥2 weeks before inclusion. Patients with a life expectancy <6 months were excluded.

MEASURES

Pain was measured using the Mobilization-Observation-Behavior-Intensity-Dementia Pain Scale. Psychosis symptoms were measured using the Neuropsychiatric Inventory-NH version. Measurements were performed at baseline, and months 4 and 9.

RESULTS

Multilevel Mixed-Effect statistical analysis found that psychosis symptoms as a group (odds ratio [OR] 2.03, P = .009), and delusion (OR 2.12, P = .007) were associated with pain over time. No significant intervention effect on psychosis symptoms was observed. Compared with the control group, people with dementia in the intervention group experienced less musculoskeletal pain (β: -0.47, P = .047). Analgesic prescription was not affected by the intervention.

CONCLUSION AND IMPLICATIONS

Pain is associated with psychosis symptoms, and pain assessment should be done when making treatment decisions on psychosis symptoms in NH patients. The COSMOS intervention improved musculoskeletal pain in people with dementia, but not psychosis symptoms, and there is need for further studies on treatment of psychosis symptoms in NH patients.

'We must have a new VIPS meeting soon!' Barriers and facilitators for implementing the VIPS practice model in primary health care

Introduction

Person-centred care is a philosophy of care rather than a method ready for implementation and utilisation in daily work. Internationally, few methods for the implementation of person-centred care have been widely adopted in clinical and care practice. In Norway, the VIPS practice model is a commonly used model for person-centred care implementation.

Method

Qualitative manifest content analysis was used. Managers and leaders in the municipalities, care institutions and domestic nursing care services were eligible for inclusion if their workplace had implemented the VIPS practice model and conducted the consensus meeting regularly for a minimum of 12 months. Seventeen respondents were included. Individual interviews were conducted either via FaceTime, Skype or telephone.

Results

Three global categories emerged describing the implementation process: (1) factors that impact the decision made at municipal level to implement person-centred care; (2) requirements for a good start at unit level and (3) factors that help to support the new routines in the unit. The categories were entwined; the results of one affected the results of the others. The informants from both domestic nursing care and institutions described the same factors as important for the implementation of the VIPS practice model.

Conclusion

To implement person-centred care by use of the VIPS practice model, the frontline staff need sufficient information about the rationale for implementing the model. The management’s vision and ethos of person-centred care must be followed by time set aside for staff training and regularly scheduled VIPS practice model consensus meetings. Head nurses are key to getting the new routines established and maintained and should be supported by the management.

Non-benzodiazepine hypnotic use for sleep disturbance in people aged over 55 years living with dementia: a series of cohort studies

BACKGROUND

Sleep disturbance affects around 60% of people living with dementia and can negatively affect their quality of life and that of their carers. Hypnotic Z-drugs (zolpidem, zopiclone and zaleplon) are commonly used to treat insomnia, but their safety and efficacy have not been evaluated for people living with dementia.

OBJECTIVES

To estimate the benefits and harms of Z-drugs in people living with dementia with sleep disturbance.

DESIGN

A series of observational cohort studies using existing data from (1) primary care linked to hospital admission data and (2) clinical cohort studies of people living with dementia.

DATA SOURCES

Primary care study - Clinical Practice Research Datalink linked to Hospital Episode Statistics and Office for National Statistics mortality data. Clinical cohort studies - the Resource Use and Disease Course in Dementia - Nursing Homes (REDIC) study, National Alzheimer's Coordinating Centre (NACC) clinical data set and the Improving Well-being and Health for People with Dementia (WHELD) in nursing homes randomised controlled trial.

SETTING

Primary care study - 371 primary care practices in England. Clinical cohort studies - 47 nursing homes in Norway, 34 Alzheimer's disease centres in the USA and 69 care homes in England.

PARTICIPANTS

Primary care study - NHS England primary care patients diagnosed with dementia and aged > 55 years, with sleep disturbance or prescribed Z-drugs or low-dose tricyclic antidepressants, followed over 2 years. Clinical cohort studies - people living with dementia consenting to participate, followed over 3 years, 12 years and 9 months, for REDIC, NACC and WHELD, respectively.

INTERVENTIONS

The primary exposure was prescription or use of Z-drugs. Secondary exposures included prescription or use of benzodiazepines, low-dose tricyclic antidepressants and antipsychotics.

MAIN OUTCOME MEASURES

Falls, fractures, infection, stroke, venous thromboembolism, mortality, cognitive function and quality of life. There were insufficient data to investigate sleep disturbance.

RESULTS

The primary care study and combined clinical cohort studies included 6809 and 18,659 people living with dementia, with 3089 and 914 taking Z-drugs, respectively. New Z-drug use was associated with a greater risk of fractures (hazard ratio 1.40, 95% confidence interval 1.01 to 1.94), with risk increasing with greater cumulative dose (p = 0.002). The hazard ratio for Z-drug use and hip fracture was 1.59 (95% confidence interval 1.00 to 2.53) and for mortality was 1.34 (95% confidence interval 1.10 to 1.64). No excess risks of falls, infections, stroke or venous thromboembolism were detected. Z-drug use also did not have an impact on cognition, neuropsychiatric symptoms, disability or quality of life.

LIMITATIONS

Primary care study - possible residual confounding because of difficulties in identifying patients with sleep disturbance and by dementia severity. Clinical cohort studies - the small numbers of people living with dementia taking Z-drugs and outcomes not necessarily being measured before Z-drug initiation restricted analyses.

CONCLUSIONS

We observed a dose-dependent increase in fracture risk, but no other harms, with Z-drug use in dementia. However, multiple outcomes were examined, increasing the risk of false-positive findings. The mortality association was unlikely to be causal. Further research is needed to confirm the increased fracture risk. Decisions to prescribe Z-drugs may need to consider the risk of fractures, balanced against the impact of improved sleep for people living with dementia and that of their carers. Our findings suggest that when Z-drugs are prescribed, falls prevention strategies may be needed, and that the prescription should be regularly reviewed.

FUTURE WORK

More research is needed on safe and effective management strategies for sleep disturbance in people living with dementia.

STUDY REGISTRATION

This study is registered as European Union electronic Register of Post-Authorisation Studies (EU PAS) 18006.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 25, No. 1. See the NIHR Journals Library website for further project information.

Trajectories of physical performance in nursing home residents with dementia

Background

In nursing homes (NH) the prevalence of dementia ranges from 50 to 84% and most residents have extensive physical-performance impairments. However, from time of admission, development of physical performance in NH residents with dementia remains unexplored.

Aims

To explore the overall trend in physical performance, associated characteristics, and groups following distinct trajectories from time of admission, in NH residents with dementia.

Methods

We followed newly admitted NH residents diagnosed with dementia (N = 583) from 47 NHs across Norway for 3 years. Individual assessments were conducted biannually, and main outcome measure was the Short Physical Performance Battery (SPPB). Facility-level characteristics included unit size, staff-to-resident ratio, and quality of the physical environment (Special Care Unit Environmental Quality Scale, SCUEQS).

Results

From time of admission, NH residents with dementia showed a significant overall decline in physical performance. Further, we identified three distinct trajectory groups with significantly different baseline physical-performance status (“good,” “moderate,” and “poor”), differences between groups maintained and all declined across time. Younger age, good general medical health, less-severe dementia, and less musculoskeletal pain were associated with both an average higher overall trend and better baseline group-belonging. Additionally, less apathy and more psychosis were associated with a higher overall trend, and agitation was associated with poorer baseline group-belonging.

Conclusions

To prevent excessive decline in physical performance in this population, NH clinicians should focus efforts specifically on assessment of physical performance at admission and on identification and management of musculoskeletal pain and neuropsychiatric symptoms.

Electronic supplementary material

The online version of this article (10.1007/s40520-020-01499-y) contains supplementary material, which is available to authorized users.

Nursing home residents with cognitive impairment can participate in advance care planning: A qualitative study

AIMS

To describe advance care planning in nursing homes when residents with cognitive impairment and/or their next of kin participated and identify associated challenges.

DESIGN

A qualitative study of nine advance care planning conversations in four Norwegian nursing home wards. During the implementation of advance care planning, we purposively sampled residents with cognitive impairment, their next of kin and healthcare personnel. The implementation followed a "whole-ward" approach aimed at involving the whole ward in fostering an inclusive, holistic advance care planning discussion. Involving as many residents as possible, preferably together with their next of kin, were central.

METHODS

From observed and audio-recorded advance care planning conversations that took place from November 2015 to June 2016, we conducted a thematic analysis of the transcripts and field notes. Reporting adhered to the COREQ guidelines.

RESULTS

Residents actively relayed their preferences regarding healthcare and end-of-life issues, despite the cognitive impairment. Next of kin provided constructive support and conversations were largely resident-focused. However, involving residents was also challenging, findings included: residents' preferences were often vague, relevant medical information from healthcare personnel lacked and the next of kin were sometimes unaware of the resident's previously held preferences. Moreover, residents tended to focus more on the past and present than the future end-of-life care.

CONCLUSIONS

Residents with cognitive impairment can participate actively and meaningfully in advance care planning, if the healthcare personnel actively listens. However, several challenges can arise. Supported decision-making can improve communication and resident involvement, reinforcing a relational understanding of autonomy.

IMPACT

Persons with cognitive impairment should be invited to participate in advance care planning. Their participation may make its benefits and more person-centred care attainable to persons that are often not involved. Successful involvement of persons with cognitive impairment in advance care planning may rely on robust implementation.

Course of activities of daily living in nursing home residents with dementia from admission to 36-month follow-up

Background

Dementia is affecting both the person with the disease and the family members. It is associated with nursing home admission, and a reduced ability to perform personal activities of daily living (P-ADL). The aim of this study was to examine the association between the severity of dementia and P-ADL function, and to study if additional factors such as neuropsychiatric symptoms, type of nursing home unit, and use of medication were associated with P-ADL function.

Methods

A total of 582 nursing home residents with dementia, included at admission to the nursing home, were followed with biannual assessments for 36 months. P-ADL was assessed using the Physical Self-Maintenance scale, and severity of dementia was measured with the Clinical Dementia Rating scale. In addition, neuropsychiatric symptoms, general physical health, and use of medications were assessed at the same time points. Demographic information was collected at baseline. Linear mixed models were estimated.

Results

There was a significant (p < 0.05) non-linear decline in P-ADL function over time in analysis not adjusting for any characteristics. More severe dementia at baseline and at the follow-up assessments was associated with lower P-ADL function (p < 0.001), with the association being stable over time. A higher level of neuropsychiatric symptoms, not using anti-dementia medication, being in a regular care unit as compared to a special care unit and having poor/fair general physical health as compared to good/excellent, were associated with a lower P-ADL function.

Conclusion

The association between more severe dementia and lower P-ADL function was stable over a 36-month follow-up period of nursing home residents with dementia. Health care planners and clinicians should be aware of this when planning for and treating nursing home residents.

Does Psychotropic Drug Prescription Change in Nursing Home Patients the First 6 Months After Admission?

OBJECTIVES

To explore the course of psychotropic drug (PTD) prescription from admission (BL) to 6-month follow-up (6m) in Norwegian nursing homes (NHs). To examine how clinical variables, such as neuropsychiatric symptoms (NPS), cognition, physical health, and NH characteristics at BL are associated with prescription rates at 6 months.

DESIGN

An observational longitudinal cohort study (data from the Resource Use and Disease Course in Dementia-Nursing Home study) designed to examine the course of dementia, psychiatric and somatic diseases, and drug prescriptions in NH patients during the first 6 months after admission.

SETTING AND PARTICIPANTS

We included 696 patients at admission to 47 representative Norwegian NHs.

METHODS

Demographic and clinical characteristics at BL and 6m are presented. Dementia severity was assessed by the Clinical Dementia Rating scale and the Functional Assessment Staging of Alzheimer's Disease scale. Final diagnosis was made by 2 of the authors (G.S. and S.B.) according to ICD-10 criteria. Prevalence, incidence, and persistence rates of PTD prescriptions for people with dementia are presented. Generalized mixed models were used to identify possible predictors for the course of PTD prescription from BL to 6m.

RESULTS

Prescription rates of antidepressants, antipsychotics, anxiolytics, sedatives, and hypnotics increased in people with dementia from BL (67.5% received at least 1 PTD) to 6m (74.0% received at least 1 PTD). Younger age and higher Neuropsychiatric Inventory-affective subsyndrome score at BL were associated with higher odds of antidepressant prescription, whereas patients with higher comorbidity at BL had lower odds of receiving antidepressants, both at BL and 6m. Higher Neuropsychiatric Inventory-affective subsyndrome scores at BL were associated with higher odds of sedative and hypnotic prescription at both assessment points.

CONCLUSIONS AND IMPLICATIONS

PTD prescription rates increase from BL to 6m. Medication appropriateness should be frequently evaluated after admission to optimize PTD prescriptions.

The Prevalence of Cognitive Impairment on Admission to Nursing Home among Residents with and without Stroke: A Cross-Sectional Survey of Nursing Homes in Ireland

Post-stroke cognitive impairment (PSCI) is a common consequence of stroke. Epidemiological evidence indicates that, with an ageing population, stroke and PSCI are likely to increase in the coming decades. This may have considerable implications for the demand for nursing home placement. As prevalence estimates of both cognitive impairment and dementia on admission to nursing home among residents with and without stroke have not yet been compared, they were estimated and compared in this study. We performed a cross-sectional survey to establish the admission characteristics of 643 residents in 13 randomly selected nursing homes in Ireland. The survey collected data on resident's stroke and cognitive status at the time of nursing home admission. The survey found, among nursing home residents that experienced stroke prior to admission, prevalence estimates for cognitive impairment (83.8%; 95% CI = 76.9-90.6%) and dementia (66.7%; 95% CI = 57.9-75.4%) were significantly higher compared to residents that had not experienced stroke prior to admission (cognitive impairment: 56.6%; 95% CI = 52.4-60.8%; X2 (1) = 28.64; p < 0.001; dementia: 49.8%; 95% CI = 45.6-54.1%; X2 (1) = 10.47; p < 0.01). Since the prevalence of PSCI is likely to increase in the coming decades, the findings highlight an urgent need for health service planning for this increased demand for nursing home care to meet the care needs of these stroke survivors.

Top Ten Tips Palliative Care Clinicians Should Know About Cognitive Impairment and Institutional Care

Most long-term care (LTC) residents are of age >65 years and have multiple chronic health conditions affecting their cognitive and physical functioning. Although some individuals in nursing homes return home after receiving therapy services, most will remain in a LTC facility until their deaths. This article seeks to provide guidance on how to assess and effectively select treatment for delirium, behavioral and psychological symptoms for patients with dementia, and address other common challenges such as advanced care planning, decision-making capacity, and artificial hydration at the end of life. To do so, we draw upon a team of physicians with training in various backgrounds such as geriatrics, palliative medicine, neurology, and psychiatry to shed light on those important topics in the following "Top 10" tips.

Informal and formal care among persons with dementia immediately before nursing home admission

Background

Dementia is a care intensive disease, especially in the later stages, implying in many cases a substantial carer burden. This study assesses the use of formal and informal care resources among persons with dementia during the last month before nursing home admission. It also describes main providers of informal care and assesses the extent of informal care rendered by the extended social network.

Methods

In this cross-sectional study, we collected data about persons with dementia that were newly admitted to a nursing home in Norway. Information about the amount of formal and informal care during the last 4 weeks preceding nursing home admission was collected from the primary caregivers. Clinical data were collected by examining the patients, while sociodemographic data was collected from the patients’ files.

Results

A total of 395 persons with dementia were included. The amount of informal care provided by the family caregiver was 141.9 h per month SD = 227.4. Co-resident patients received five times more informal care than non-co-residents. Informal care from the extended social network was provided to 212 patients (53.7%) with a mean of 5.6 (SD = 11.2) hours per month and represented 3.8% of the total informal care rendered to the patients. Formal care was provided to 52.7% of the patients with a mean of 18.0 (SD = 50.1) hours per month. Co-residency was significantly associated with more informal care, and the associations varied with respect to age, relation to the caregiver, and the caregiver’s working situation. Good/excellent general health was associated with less formal care.

Conclusion

Persons with dementia on the verge of admission to a nursing home are mainly supported by the family caregiver, and the use of informal care is particularly high among co-residents. In order to delay nursing home admission, future research should explore the unrealized care potential in extended social networks, as well as the potential for increasing the number of recipients of formal care services.

Modifiable factors associated with anxiety in persons with dementia: An integrative review

OBJECTIVES

The purpose of this integrative review was to examine factors related to the presence of anxiety in person with dementia (PWD) and to identify potentially modifiable factors among them.

METHODS

An integrative review was conducted using PsycINFO, CINAHL, AgeLine, PubMed, Embase, Web of Science, and Scopus. Among 1856 studies identified, 27 studies were included.

RESULTS

A number of modifiable factors associated with anxiety were identified. Individual level factors included pain, physical health, physical functioning, fatigue, sleep disturbance, disclosure of diagnosis, embarrassment about memory problems, separation from caregivers, views about oneself and others, social rejection, social isolation, and interactions with others. Caregiver factors associated with anxiety in PWD included caregiver stress, caregiver's negative reactions towards the behavioral problems of PWD, and competence about caregiving.

CONCLUSION

The results of this review can be used to identify potential targets for interventions to reduce for anxiety in persons with dementia.

Assessing the Prevalence of Undetected Possible Dementia in Faroese Nursing Homes

INTRODUCTION

To assess the prevalence of possible dementia among nursing home residents in the Faroe Islands.

METHOD

This cross-sectional study, undertaken in 2017, included all nursing homes in the Faroe Islands (n = 30), housing 591 residents. All residents were invited to participate, except those with an existing clinical diagnosis of dementia or living in dementia units (n = 207). A total of 232 residents participated, while 39 declined and 113 were unable to give consent, had died, or were not permanent residents at the time of examination. Cognitive screening was carried out using the Mini-Mental State Examination (MMSE) and the Informant Questionnaire on Cognitive Decline (IQCODE).

RESULTS

Possible dementia was found in 49% to 78% of the participants depending on the method used. According to both MMSE and IQCODE (AND rule), possible dementia was present in 105 participants (49%). According only to IQCODE, 119 participants (55%) scored above the cut-off (≥3.6), according to MMSE alone, 162 participants (72%) scored below the cut-off (≤24 on MMSE), while 175 participants (78%) screened positive according to either MMSE or IQCODE (OR rule). A rough estimate of the prevalence of possible dementia in the entire nursing home population (n = 591) including residents with known dementia and those with possible dementia from this study was between 61% and 73%.

CONCLUSION

A high percentage (49-78%) of the participating nursing home residents without a pre-dementia diagnosis were assessed to have possible dementia based on screening with standardized tools, indicating a high degree of dementia underdiagnoses in Faroese nursing homes. This high prevalence of dementia is of significance for the clinical practice, running, and planning of nursing homes and pinpoints a need to act upon this, not only in the Faroes but also worldwide.

The Neuropsychiatric Inventory: Development and Applications

REASONS FOR THE STUDY

The Neuropsychiatric Inventory (NPI) has been used for studies of neuropsychiatric symptoms in neurodegenerative disorders for the past 25 years. This article reviews the history of the development and application of the NPI.

MAIN FINDINGS

The NPI consists of 10 (or 12) items that are assayed with questions, subquestions, and ratings of frequency and severity. The NPI has been shown to be valid and reliable. The NPI has been translated into approximately 40 languages; it has 4 of versions designed for different clinical applications. The NPI studies show contrasting profiles of behavioral symptoms in different neurologic disorders. The NPI has been used in approximately 350 clinical trials. In economic studies, the NPI captures the cost of behavioral symptoms in dementias.

PRINCIPLE CONCLUSIONS

The NPI is a useful instrument for capturing behavioral changes in Alzheimer disease and other neurodegenerative disorders.

Diagnostic Failure of Cognitive Impairment in Nursing Home Residents May Lead to Impaired Medical Care

BACKGROUND/OBJECTIVES

Dementia and cognitive impairment are common in nursing homes. Few studies have studied the impact of unnoted cognitive impairment on medical care. This study aimed to estimate the prevalence of diagnostic failure of cognitive impairment in a sample of Swedish nursing home residents and to analyze whether diagnostic failure was associated with impaired medical care.

METHOD

A total of 428 nursing home residents were investigated during 2008-2011. Subjects without dementia diagnosis were grouped by result of the Mini Mental State Examination (MMSE), where subjects with <24 points formed a possible dementia group and the remaining subjects a control group. A third group consisted of subjects with diagnosed dementia. These three groups were compared according to baseline data, laboratory findings, drug use, and mortality.

RESULTS

Dementia was previously diagnosed in 181 subjects (42%). Among subjects without a dementia diagnosis, 72% were cognitively impaired with possible dementia (MMSE <24). These subjects were significantly older, did not get anti-dementia treatment, and had higher levels of brain natriuretic peptide compared to the diagnosed dementia group, but the risks of malnutrition and pressure ulcers were similar to the dementia group.

CONCLUSIONS

Unnoted cognitive impairment is common in nursing home residents and may conceal other potentially treatable conditions such as heart failure. The results highlight a need to pay increased attention to cognitive impairment among nursing home residents.

Improved patient participation through advance care planning in nursing homes-A cluster randomized clinical trial

OBJECTIVE

To improve patient participation in advance care planning in nursing homes where most patients have some degree of cognitive impairment.

METHODS

This was a pair-matched cluster randomized clinical trial with eight wards in eight Norwegian nursing homes. We randomized one ward from each of the matched pairs to the intervention group. We included all patients above 70. The primary outcome was prevalence of documented patient participation in end-of-life treatment conversations. The intervention included implementation support using a whole-ward approach where regular staff perform advance care planning and invite all patients and next of kin to participate.

RESULTS

In intervention group wards the patients participated more often in end-of-life treatment conversations (p < 0.001). Moreover, the patient's preferences, hopes AND worries (p = 0,006) were more often documented, and concordance between provided TREATMENT and patient preferences (p = 0,037) and next of kin participation in advance care planning with the patient (p = 0,056) increased.

CONCLUSION

Improved patient participation - also when cognitively impaired - is achievable through advance care planning in nursing homes using a whole-ward approach.

PRACTICE IMPLICATIONS

Patients with cognitive impairment should be included in advance care planning supported by next of kin. A whole-ward approach may be used to implement advance care planning.

TRIAL REGISTRATION

ISRCTN registry (ID ISRCTN69571462) - retrospectively registered.

Examining the association between genetic liability for schizophrenia and psychotic symptoms in Alzheimer's disease

Psychosis (delusions or hallucinations) in Alzheimer's disease (AD + P) occurs in up to 50% of individuals and is associated with significantly worse clinical outcomes. Atypical antipsychotics, first developed for schizophrenia, are commonly used in AD + P, suggesting shared mechanisms. Despite this implication, little empirical research has been conducted to examine whether there are mechanistic similarities between AD + P and schizophrenia. In this study, we tested whether polygenic risk score (PRS) for schizophrenia was associated with AD + P. Schizophrenia PRS was calculated using Psychiatric Genomics Consortium data at ten GWAS p value thresholds (PT) in 3111 AD cases from 11 cohort studies characterized for psychosis using validated, standardized tools. Association between PRS and AD + P status was tested by logistic regression in each cohort individually and the results meta-analyzed. The schizophrenia PRS was associated with AD + P at an optimum PT of 0.01. The strongest association was for delusions where a one standard deviation increase in PRS was associated with a 1.18-fold increased risk (95% CI: 1.06-1.3; p = 0.001). These new findings point towards psychosis in AD-and particularly delusions-sharing some genetic liability with schizophrenia and support a transdiagnostic view of psychotic symptoms across the lifespan.

Understanding Frontotemporal Disease Progression and Management Strategies

Dementia is defined as loss of intellectual functions, including thinking, remembering, and reasoning. Cognitive deficits are severe enough to interfere with an individual's daily functioning. Frontotemporal dementia (FTD) is a result of degeneration of the frontal and/or temporal lobes of the brain. FTD is a leading cause of early-onset dementia in approximately 10% of dementia cases. FTD presents in the fourth and fifth decades as progressive changes in personality, affect, and behavior. The etiology of FTD is unknown; treatment focuses on behavioral and symptom management. Early recognition of FTD and knowledge of interventional strategies are needed to support families and caregivers.

Inter-organisational collaboration in palliative care trajectories for nursing home residents: A nation-wide mixed methods study among key persons

Introduction

Multiple care organisations, such as home care services, nursing homes and hospitals, are responsible for providing an appropriate response to the palliative care needs of older people admitted into long-term care facilities. Integrated palliative care aims to provide seamless and continuous care. A possible organisational strategy to help realise integrated palliative care for this population is to create a network in which these organisations collaborate. The aim is to analyse the collaboration processes of the various organisations involved in providing palliative care to nursing home residents.

Method

A sequential mixed-methods study, including a survey sent to 502 participants to evaluate the collaboration between home and residential care, and between hospital and residential care, and additionally three focus group interviews involving a purposive selection among the survey participants. Participants are key persons from the nursing homes, hospitals and home care organisations that are part of the 15 Flemish palliative care networks dispersed throughout the region of Flanders, Belgium.

Results

Survey data were gathered from 308 key persons (response rate: 61%), and 16 people participated in three focus group interviews. Interpersonal dimensions of collaboration are rated higher than structural dimensions. This effect is statistically significant. Qualitative analyses identified guidelines, education, and information-transfer as structural challenges. Additionally, for further development, members should become acquainted and the network should prioritise the establishment of a communication infrastructure, shared leadership support and formalisation.

Discussion

The insights of key persons suggest the need for further structuration and can serve as a guideline for interventions directed at improving inter-organisational collaboration in palliative care trajectories for nursing home residents.

Psychosis symptoms in nursing home residents with and without dementia-Cross-sectional analyses from the COSMOS study

OBJECTIVE

To investigate the characteristics of nursing home residents with psychosis and the association with potential underlying factors, such as pain, sleep disturbances, and antipsychotic medication.

METHOD

Five hundred forty-five residents with and without dementia from 67 Norwegian nursing home units were included in the cross-sectional analyses. Psychosis was the main outcome measure in our study; other outcome measures include quality of life (QoL), activities of daily living (ADL) function, cognitive function, pain, and antipsychotic medication.

RESULTS

One hundred twelve residents had one or more symptoms of psychosis, and compared with residents without psychosis, they had lower QoL (p < 0.001), ADL function (p = 0.003), and cognitive functioning (p = 0.001). Adjusted logistic regression analyses showed that psychosis was associated with the prevalence of pain (OR: 3.19; 95% CI, 1.94-5.24), sleep disturbances (OR: 4.51; 95% CI, 2.91-6.99), and total number of medication (OR: 1.10; 95% CI, 1.03-1.17). Residents with psychosis but without antipsychotic medication had better QoL (p = 0.005) compared with residents receiving any antipsychotics.

CONCLUSION

Psychosis in NH residents is associated with pain, sleep disturbances, and number of medications. Residents with psychosis have poor QoL, although better QoL was observed among those who did not use antipsychotic medication.

My husband is not ill; he has memory loss - caregivers´ perspectives on health care services for persons with dementia

BACKGROUND

To explore informal caregivers' perspectives and perceived needs related to health care services/activities for older adults with dementia, in order to understand barriers and facilitators to participation. The study represents a first step, and explores challenges to overcome, in order to design new activities and services adapted to older adults with dementia.

METHODS

We used a qualitative approach where eight caregivers of people with a dementia diagnosis were included. We recruited participants from a counselling service centre, for home dwelling people with dementia and their families, in a Norwegian municipality. We transcribed data from two focus group interviews and completed analyses by use of Systematic Text Condensation method.

RESULTS

The findings indicate that current health care services for people with dementia do not meet the needs of either the people with dementia or their caregivers. The few activities/services offered are characterised by passivity and lack of individual and personalised care. Existing health care services and new activities should consider each individual's resources, interests, and physical function to ensure that both people with dementia and their caregivers want to accept support.

CONCLUSIONS

To develop health care services and activities for people with dementia, participation and involvement from both people with dementia and their caregivers is necessary. People with dementia are more than their diagnosis. Future health care providers have to widen their focus and consider the individual person with dementia.

Assessing Potentially Inappropriate Medications in Nursing Home Residents by NORGEP-NH Criteria

Background: Nursing home residents often have several conditions that necessitate the use of multiple medicines. This study investigates the prevalence of potentially inappropriate medications (PIMs) and its associations with sex, age, number of medicines, and study location (rural/urban). Methods: A cross-sectional study of long-term care residents from six nursing homes. Data was collected from medical records. We identified PIMs by applying the NORGEP-NH criteria. We conducted a Poisson regression analysis to investigate the association between the number of PIMs and sex, age, number of medicines, and study location. Results: We included 103 (18.4%) of 559 residents (68.0% women; mean age 83.2 years, mean number of daily used medicines 7.2 (SD = 3.6)). We identified PIMs in 56% of the residents (mean number = 1.10, SD = 1.26). In adjusted analyses, residents ≥80 years had 0.43 fewer PIMs compared to residents <80 years (p < 0.05). Residents using 4–6, 7–9, and 10+ medicines had on average 0.73, 1.06, and 2.11 more PIMs compared to residents using 0–3 medicines (p < 0.001), respectively. Conclusion: PIM use is prevalent among nursing home residents and is significantly associated with age and number of medicines. Our findings suggest a modest decrease in residents using PIMs compared to previous studies. Nevertheless, prescribing quality in nursing home residents in both urban and rural areas is still of great concern.

The use of direct care in nursing home residents: A longitudinal cohort study over 3 years

OBJECTIVES

To evaluate the trend in the use of direct care in a cohort of nursing home (NH) residents and explore its association with resident characteristics and organizational factors.

METHODS/DESIGN

A total of 696 NH residents from 47 Norwegian NHs were included at admissions at NH. In 537 residents, the use of direct care was assessed every 6 months over a course of 3 years. A multiple model was estimated to identify demographic, clinical, and organizational characteristics associated with the use of direct care time.

RESULTS

Six months after admission, on average, 76.2 hours of direct care were rendered to each resident per month, while this number was reduced to 50.3 hours per month at the end of the study period. Most residents (92%) showed a stable use of direct care time, while a small group of residents displayed a much higher and varying use of direct care time. Increasing dementia, neuropsychiatric symptoms, and decreasing function in activities of daily living were associated with higher use of direct care time. Direct care time constituted about 50% of the staff's working time.

CONCLUSION

In Norwegian NHs, high use of direct care time was associated with younger age, more severe dementia, and severe neuropsychiatric symptoms. By identifying factors that impact on direct care time, preventive measures might be put in place to the benefit of the residents and possibly to improve resource use. Further research should explore the association between direct care time, quality of care, and the residents' quality of life.

Prevalence of Depression, Anxiety and PTSD in People with Dementia: a Systematic Review and Meta-Analysis

There appears to be a link between depression/anxiety/PTSD and dementia, although the evidence is incomplete and the reason is unclear. Mental illness may cause dementia or may be prodromal or comorbid with dementia, or dementia may trigger a relapse of symptoms in individuals with a history of mental illness. This study examined the link between depression/anxiety/PTSD and dementia by evaluating the prevalence of these disorders in people with dementia, relative to their healthy peers. Existing meta-analyses have examined the prevalence of clinically-significant depression and anxiety in Alzheimer's disease (AD), and depression in frontotemporal dementia (FTD), but have not considered vascular dementia (VaD), dementia with Lewy bodies (DLB), PTSD, or anxiety in FTD. The current meta-analysis compared the prevalence of clinically-significant depression, anxiety and PTSD in the four most common types of dementia (AD, VaD, DLB, FTD) and in unspecified dementia to that of healthy controls (PROSPERO number: CRD42017082086). PubMed, EMBASE, PsycINFO and CINAHL database searches identified 120 eligible studies. Prevalence rates were calculated for depression and anxiety in AD, VaD, DLB, FTD, unspecified dementia, and controls. PTSD data were only available for unspecified dementia. Subgroup analyses indicated that depression, but not anxiety, was more prevalent in people with dementia compared to controls; however, the anxiety analyses were probably under-powered. The results support a link between depression and dementia; however, the link between anxiety or PTSD and dementia remains unclear due to insufficient data. Longitudinal data is now needed to clarify whether depression/anxiety/PTSD may be risk factors for dementia.

The course of neuropsychiatric symptoms in nursing home residents from admission to 30-month follow-up

Aim

The aim of this study was to describe the prevalence and persistence of clinically significant neuropsychiatric symptoms (NPS) in nursing home residents with dementia, and to study the association between severity of dementia and specific neuropsychiatric sub-syndromes over time.

Methods

In total, 583 residents with dementia were included at admission to a nursing home and followed with biannual assessments until death, or to 30-month follow-up. At the end of the 30-month follow-up, 305 participants had died and 57 had left the study for other reasons, leaving 221 residents in the study. We collected data on demographics, cognition, severity of dementia, NPS, personal activities of daily living (P-ADL), physical health, medication and type of nursing home unit. NPS was assessed using the Neuropsychiatric Inventory (NPI), the Nursing Home version.

Results

The prevalence and persistence at two consecutive time-points of clinically significant NPS was high during the study period. The mean NPI agitation sub-syndrome score increased during the study period, while the NPI affective and psychosis sub-syndrome scores remained unchanged. More severe dementia was associated with higher NPI agitation, psychosis and affective sub-syndrome scores. The association remained unchanged over time for agitation and psychosis. For the NPI affective sub-syndrome, the association was stronger at the beginning, and declined towards the end of the study period.

Conclusion

The findings of high prevalence and persistence at two consecutive time points of clinically significant NPS over time, and the associations between severity of dementia and NPI sub-syndromes shed light on the burden and care needs of nursing home residents with dementia after admission to nursing home care. This information is of interest to health care planners and providers to enable them to increase the quality of care for nursing home residents.

Mortality in nursing home residents: A longitudinal study over three years

OBJECTIVE

Nursing home (NH) stay is the highest level of formal care. With the expected demographic changes ahead, the need for NH placement will put an increasing socioeconomic strain on the society. Survival in NHs and factors predicting survival are important knowledge in order to evaluate NH admission policies and plan future NH capacity.

METHODS

We followed 690 NH residents included at admission to NH over a period of three years. Participants were examined at baseline (BL) and every six months. Demographic and clinical data were collected, including comorbidity, severity of cognitive impairment, dependency in activities of daily living (ADL) and neuropsychiatric symptoms. Median survival was calculated by the Kaplan-Meier analysis, and factors associated with mortality were identified by Cox models with baseline and time-dependent covariates.

RESULTS

Median survival in NH was 2.2 years (95% confidence interval [CI]: 1.9-2.4). Yearly mortality rate throughout the three-year observation period was 31.8%. Mortality was associated with higher age and comorbidity at BL, and more severe dementia, higher ADL-dependency, less severe psychotic symptoms, and a lower BMI throughout the study period. Of the organizational variables, living on a ward with more residents resulted in a higher risk of mortality.

CONCLUSION

In conclusion, the NH mortality rate remained stable throughout the three-year study period with about one third of the residents deceasing each year. Individual resident characteristics appeared to be more important than organizational variables for predicting mortality risk. The finding of an association between ward size and mortality risk deserves further investigation in future studies.

Cross-sectional study of prevalence of dementia, behavioural symptoms, mobility, pain and other health parameters in nursing homes in Austria and the Czech Republic: results from the DEMDATA project

Background

This paper provides a first comparative exploratory analysis of our findings from DEMDATA, a collaborative project between Austria and the Czech Republic. Analysed here are data from the residents and the environment assessment protocol.

Methods

In a cross sectional study design, residents from randomly drawn and stratified nursing homes were investigated using a common study protocol.

Results

From a total resident pool of 1666 persons, 1085 (571 in Austria, 514 in the Czech Republic) persons signed a consent form and participated in the data collection.

More than 70% of residents assessed were female and the population was on average 85 years old. A discrepancy between the presence of a medical diagnosis in the charts of the residents and the results of cognitive testing was found. In Austria, 85.2%, in the Czech Republic 53.0% of residents had cognitive impairment. In Austria 80.0%, and in the Czech Republic 56.7% had behavioural problems. With respect to pain, 44.8% in Austria, and 51.5% in the Czech Republic had mild to severe pain. 78.4% of Austrian and 74.5% of the residents had problems with mobility and both populations were in danger of malnutrition.

Conclusions

Most of the prevalence rates are comparable with previous studies also using direct resident assessment. Variations in prevalence rates seem to result mainly from the assessment technique (direct cognitive testing vs. medical chart review). The high prevalence rates for dementia, behavioural symptoms, pain and malnutrition indicate an immediate call for attention to further research and practice development.