Behavioral and Cognitive Problems as Determinants of Malnutrition in Long-Term Care Facilities, a Cross-Sectional and Prospective Study

OBJECTIVES

To investigate the cross-sectional and prospective associations between behavior and cognitive problems and malnutrition in long-term care facilities (LTCF).

DESIGN

Cross-sectional and prospective routine care cohort study.

SETTING

6874 Residents in Dutch LTCFs (period 2005-2020).

PARTICIPANTS

Data were obtained from the InterRAI-LTCF instrument. Cross-sectional analyses on prevalence of malnutrition at admission included 3722 residents. Prospective analyses studied incident malnutrition during stay (total follow-up time 7104 years) and included data of 1826 residents with first measurement on admission ('newly-admitted') and n=3152 with first measurement on average ~1 year after admission ('existing').

MEASUREMENTS

InterRAI scales for communication problems (CS), aggressive behavior (ABS), social engagement (RISE), depressive symptoms (DRS), cognitive performance (CPS) and the total number of behavior and cognitive problems were investigated as independent variables and malnutrition (ESPEN 2015 definition) as dependent variable in regression analyses. Results were stratified for gender and group 'newly-admitted' vs. 'existing'.

RESULTS

On admission, 9.5% of residents was malnourished. In men, low social engagement was associated with prevalence of malnutrition. In women, all behavior and cognitive problems except depression were associated with malnutrition in the unadjusted analyses, but this attenuated in the full model taking all problems into account. The incidence of malnutrition during stay amounted to 8.9%. No significant associations of behavior and cognitive problems with malnutrition incidence were seen in 'newly-admitted' male residents while in 'existing' male residents all determinants were significantly associated. In 'newly-admitted' female residents CS, ABS and CPS, and in 'existing' female residents CS, RISE, ABS and CPS were significantly associated with incident malnutrition. All associations slightly attenuated after adjustment. Malnutrition incidence increased with increasing number of combined behavior and cognitive problems.

CONCLUSION

Residents with behavior and cognitive problems are at an increased risk of being malnourished at admission, or becoming malnourished during stay in a LTCF, especially residents with multiple behavior and cognitive problems.

Resilience in older persons: A systematic review of the conceptual literature

Although ageing research increasingly incorporates resilience, a common notion on what resilience means is lacking. We aimed to give a comprehensive overview of the conceptual literature on resilience in older persons, identifying areas of consensus and variation/debate. A systematic search of eight databases from different disciplines led to the inclusion of 36 texts. Across the conceptual literature of resilience in older persons, three common features of descriptions of resilience were identified: a stressor, a response and a mechanism. Based on differences in their interpretation of how resilience is expressed we distinguished two perspectives. The first, classical and most widely applied perspective, describes the expression of resilience as a positive response to a high intensity stressor. The second, newer perspective, describes resilience in the context of responses relative to equilibrium, following low intensity stressors. Almost all descriptions across the two perspectives describe the resilience mechanism to be dynamic and emphasize the importance of the context in achieving resilience. This review provides clarity on the current conceptual status of resilience in older persons, an important step towards a higher level of consistency in the future use of resilience in ageing.

Consensus on treatment for residents in long-term care facilities: perspectives from relatives and care staff in the PACE cross-sectional study in 6 European countries

Background

In long-term care facilities often many care providers are involved, which could make it difficult to reach consensus in care. This may harm the relation between care providers and can complicate care. This study aimed to describe and compare in six European countries the degree of consensus among everyone involved in care decisions, from the perspective of relatives and care staff. Another aim was to assess which factors are associated with reporting that full consensus was reached, from the perspective of care staff and relatives.

Methods

In Belgium, England, Finland, Italy, the Netherlands and Poland a random sample of representative long-term care facilities reported all deaths of residents in the previous three months (n = 1707). This study included residents about whom care staff (n = 1284) and relatives (n = 790) indicated in questionnaires the degree of consensus among all involved in the decision or care process. To account for clustering on facility level, Generalized Estimating Equations were conducted to analyse the degree of consensus across countries and factors associated with full consensus.

Results

Relatives indicated full consensus in more than half of the residents in all countries (NL 57.9% - EN 68%), except in Finland (40.7%). Care staff reported full consensus in 59.5% of residents in Finland to 86.1% of residents in England. Relatives more likely reported full consensus when: the resident was more comfortable or talked about treatment preferences, a care provider explained what palliative care is, family-physician communication was well perceived, their relation to the resident was other than child (compared to spouse/partner) or if they lived in Poland or Belgium (compared to Finland). Care staff more often indicated full consensus when they rated a higher comfort level of the resident, or if they lived in Italy, the Netherland, Poland or England (compared to Finland).

Conclusions

In most countries the frequency of full consensus among all involved in care decisions was relatively high. Across countries care staff indicated full consensus more often and no consensus less often than relatives. Advance care planning, comfort and good communication between relatives and care professionals could play a role in achieving full consensus.

Electronic supplementary material

The online version of this article (10.1186/s12904-019-0459-9) contains supplementary material, which is available to authorized users.

[Comparing case management care models for people with dementia and their caregivers: the design of the COMPAS study]

BACKGROUND

Dementia care in The Netherlands is shifting from fragmented, ad hoc care to more coordinated and personalized care. Case management contributes to this shift. The linkage model and a combination of intensive case management and joint agency care models were selected based on their emerging prominence in The Netherlands. It is unclear if these different forms of case management are more effective than usual care in improving or preserving the functioning and well-being at the patient and caregiver level and at the societal cost.

OBJECTIVE

The objective of this article is to describe the design of a study comparing these two case management care models against usual care. Clinical and cost outcomes are investigated while care processes and the facilitators and barriers for implementation of these models are considered.

DESIGN

Mixed methods include a prospective, observational, controlled, cohort study among persons with dementia and their primary informal caregiver in regions of The Netherlands with and without case management including a qualitative process evaluation. Community-dwelling individuals with a dementia diagnosis with an informal caregiver are included. The primary outcome measure is the Neuropsychiatric Inventory for the people with dementia and the General Health Questionnaire for their caregivers. Costs are measured from a societal perspective. Semi-structured interviews with stakeholders based on the theoretical model of adaptive implementation are planned.

RESULTS

521 pairs of persons with dementia and their primary informal caregiver were included and are followed over two years. In the linked model substantially more impeding factors for implementation were identified compared with the model.

DISCUSSION

This article describes the design of an evaluation study of two case management models along with clinical and economic data from persons with dementia and caregivers. The impeding and facilitating factors differed substantially between the two models. Further results on cost-effectiveness are expected by the beginning of 2015. This is a Dutch adaptation of MacNeil Vroomen et al., Comparing Dutch case management care models for people with dementia and their caregivers: The design of the COMPAS study.

Dementia: predictors of diagnostic accuracy and the contribution of diagnostic recommendations

OBJECTIVES

To explore and quantify the relative contribution of guideline recommendations and other determinants in the family physicianamprsquos diagnostic work-up of patients suspected of dementia.

STUDY DESIGN

We prospectively studied 64 family physicians in an Eastern district in the Netherlands who diagnosed dementia according to the national Dutch guidelines in primary care. Their diagnoses were compared with the reference standard embodied by the memory clinic team of the University Medical Center Nijmegen.

POPULATION

The physicians evaluated 107 patients older than 55 years suspected of having dementia.

OUTCOMES MEASURED

Predictive values of various clinical and demographic parameters were measured in both univariate and multivariate logistic regression analyses.

RESULTS

Activities of daily living (ADL) dependency (odds ratio [OR] = 5.3, P =.03), years since symptoms first started (OR = 1.84, P =.03), and the presence of somatic comorbidity (OR = 0.48, P =.02) independently contributed to the prediction of the presence or absence of dementia. The area under the receiver-operating characteristic (ROC) curve for these 3 variables together was 0.79. The ROC area of the family physiciansamprsquo diagnosis to determine the final diagnosis was 0.74. The number of recommendations applied did not additionally contribute to the assessment of the final diagnosis.

CONCLUSIONS

The diagnostic accuracy of the family physician was reasonable. For family physicians, ADL dependency is a better predictor of dementia than cognitive impairment. Family physicians should be aware of diagnostic difficulties in patients with somatic comorbidity. We were unable to confirm the diagnostic value of many of the recommendations of dementia guidelines.

[Methods to improve patient compliance in the use of antidepressants]

Compliance during treatment with antidepressants is important, yet about half of the patients stop using antidepressive medication within 3 months. A structured treatment programme, in which the patient actively participates, with extensive education, surveillance of side effects and compliance, simple regimes, improving problem-solving behaviour and eventually engaging and educating family members and friends can improve compliance. This has been demonstrated in published studies. Research has shown that interventions that enhance compliance can lead to a better outcome of the depression.