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IMPORTANCE: High-quality evidence on how to improve palliative care in nursing homes is lacking. OBJECTIVE: To investigate the effect of the Palliative Care for Older People (PACE) Steps to Success Program on resident and staff outcomes. DESIGN, SETTING, AND PARTICIPANTS: A cluster-randomized clinical trial (2015-2017) in 78 nursing homes in 7 countries comparing PACE Steps to Success Program (intervention) with usual care (control). Randomization was stratified by country and median number of beds in each country in a 1:1 ratio. INTERVENTIONS: The PACE Steps to Success Program is a multicomponent intervention to integrate basic nonspecialist palliative care in nursing homes. Using a train-the-trainer approach, an external trainer supports staff in nursing homes to introduce a palliative care approach over the course of 1 year following a 6-steps program. The steps are (1) advance care planning with residents and family, (2) assessment, care planning, and review of needs and problems, (3) coordination of care via monthly multidisciplinary review meetings, (4) delivery of high-quality care focusing on pain and depression, (5) care in the last days of life, and (6) care after death. MAIN OUTCOMES AND MEASURES: The primary resident outcome was comfort in the last week of life measured after death by staff using the End-of-Life in Dementia Scale Comfort Assessment While Dying (EOLD-CAD; range, 14-42). The primary staff outcome was knowledge of palliative care reported by staff using the Palliative Care Survey (PCS; range, 0-1). RESULTS: Concerning deceased residents, we collected 551 of 610 questionnaires from staff at baseline and 984 of 1178 postintervention in 37 intervention and 36 control homes. Mean (SD) age at time of death ranged between 85.22 (9.13) and 85.91 (8.57) years, and between 60.6% (160/264) and 70.6% (190/269) of residents were women across the different groups. Residents’ comfort in the last week of life did not differ between intervention and control groups (baseline-adjusted mean difference, −0.55; 95% CI, −1.71 to 0.61; P = .35). Concerning staff, we collected 2680 of 3638 questionnaires at baseline and 2437 of 3510 postintervention in 37 intervention and 38 control homes. Mean (SD) age of staff ranged between 42.3 (12.1) and 44.1 (11.7) years, and between 87.2% (1092/1253) and 89% (1224/1375) of staff were women across the different groups. Staff in the intervention group had statistically significantly better knowledge of palliative care than staff in the control group, but the clinical difference was minimal (baseline-adjusted mean difference, 0.04; 95% CI, 0.02-0.05; P < .001). Data analyses began on April 20, 2018. CONCLUSIONS AND RELEVANCE: Residents’ comfort in the last week of life did not improve after introducing the PACE Steps to Success Program. Improvements in staff knowledge of palliative care were clinically not important. TRIAL REGISTRATION: ISRCTN Identifier: ISRCTN14741671

Drugs may interact with geriatric syndromes by playing a role in the continuation, recurrence or worsening of these conditions. Aim of this study is to assess the prevalence of interactions between drugs and three common geriatric syndromes (delirium, falls and urinary incontinence) among older adults in nursing home and home care in Europe. We performed a cross-sectional multicenter study among 4023 nursing home residents participating in the Services and Health for Elderly in Long-TERm care (Shelter) project and 1469 home care patients participating in the Identifying best practices for care-dependent elderly by Benchmarking Costs and outcomes of community care (IBenC) project. Exposure to interactions between drugs and geriatric syndromes was assessed by 2015 Beers criteria. 790/4023 (19.6%) residents in the Shelter Project and 179/1469 (12.2%) home care patients in the IBenC Project presented with one or more drug interactions with geriatric syndromes. In the Shelter project, 288/373 (77.2%) residents experiencing a fall, 429/659 (65.1%) presenting with delirium and 180/2765 (6.5%) with urinary incontinence were on one or more interacting drugs. In the IBenC project, 78/172 (45.3%) participants experiencing a fall, 80/182 (44.0%) presenting with delirium and 36/504 (7.1%) with urinary incontinence were on one or more interacting drugs. Drug–geriatric syndromes interactions are common in long-term care patients. Future studies and interventions aimed at improving pharmacological prescription in the long-term care setting should assess not only drug–drug and drug–disease interactions, but also interactions involving geriatric syndromes.

Dementia poses a substantial economic burden on society. Knowing which factors predict high costs in dementia may help to better target interventions and optimize resource allocation. This study aimed to identify predictors of the total societal costs in dementia patients and their informal caregivers.

Caregivers of persons with dementia play an important and economically valuable role within society, but many may do so at a considerable cost to themselves. Knowing which caregivers have the highest risk of developing a mental disorder may contribute to better support of ultra-high-risk groups with preventive interventions. This study aims to describe the incidence of depression and anxiety disorders in caregivers and to identify its significant predictors.

BACKGROUND: Sophisticated approaches are needed to improve the quality of care for elderly people living in residential care facilities. We determined the effects of multidisciplinary integrated care on the quality of care and quality of life for elderly people in residential care facilities. METHODS: We performed a cluster randomized controlled trial involving 10 residential care facilities in the Netherlands that included 340 participating residents with physical or cognitive disabilities. Five of the facilities applied multidisciplinary integrated care, and five provided usual care. The intervention, inspired by the disease management model, consisted of a geriatric assessment of functional health every three months. The assessment included use of the Long-term Care Facility version of the Resident Assessment Instrument by trained nurse-assistants to guide the design of an individualized care plan; discussion of outcomes and care priorities with the family physician, the resident and his or her family; and monthly multidisciplinary meetings with the nurse-assistant, family physician, psychologist and geriatrician to discuss residents with complex needs. The primary outcome was the sum score of 32 risk-adjusted quality-of-care indicators. RESULTS: Compared with the facilities that provided usual care, the intervention facilities had a significantly higher sum score of the 32 quality-of-care indicators (mean difference – 6.7, p = 0.009; a medium effect size of 0.72). They also had significantly higher scores for 11 of the 32 indicators of good care in the areas of communication, delirium, behaviour, continence, pain and use of antipsychotic agents. INTERPRETATION: Multidisciplinary integrated care resulted in improved quality of care for elderly people in residential care facilities compared with usual care. TRIAL REGISTRATION: www.controlled-trials.com trial register no. ISRCTN11076857.

Samenvatting: Achtergrond: Dit artikel beschrijft de studieopzet van een studie naar de klinische en economische effecten van een multidisciplinair integraal zorgmodel op functionele gezondheid, kwaliteit van zorg en kwaliteit van leven van ouderen in verzorgingshuizen. Methode: De studie is opgezet als een cluster gerandomiseerd gecontroleerd klinisch onderzoek in vijf interventiehuizen en vijf huizen met gebruikelijke zorg in het noordwesten van Nederland bij in totaal meer dan 500 bewoners. Alle bewoners die niet terminaal ziek zijn en die in staat zijn om een ‘informed consent’ te tekenen en die geïnterviewd kunnen worden, worden geïncludeerd. Voor de bewoners die cognitieve problemen hebben, zullen de partners en/of naaste familieleden benaderd worden voor het beantwoorden van de vragenlijst. Het multidisciplinaire integrale zorgmodel bestaat uit verschillende elementen: (1) Een multidimensionale geriatrische beoordeling van de functionele gezondheid en zorgbehoefte van de bewoners uitgevoerd door getrainde verzorgenden met de internetapplicatie van de Long Term Care Facility versie van het Resident Assessment Instrument (RAIview). RAIview levert directe identificatie van probleemgebieden die de basis vormen voor een individueel zorgplan. (2) De uitkomsten van RAIview worden besproken in een multidisciplinair overleg met de betrokken verzorgende, de huisarts, specialist ouderengeneeskunde en psycholoog en zo nodig andere betrokken disciplines. Op dit overleg worden de zorgplanacties vastgesteld die tot verbetering van de functionele gezondheid en vermindering van risicofactoren kunnen leiden. Het zorgplan wordt met de bewoner en/of familie besproken en aan de wensen van de bewoner aangepast. (3) De huisarts kan bij complexe problematiek de specialist ouderengeneeskunde en/of de psycholoog consulteren. Uitkomstmaten zijn: 32 risico-indicatoren voor kwaliteit van zorg (gebaseerd op RAIview), kwaliteit van leven (SF12), functionele gezondheid (COOP-WONCA), zelfredzaamheid (GARS), mening van de bewoner over de kwaliteit van zorg (QUOTE), ziekenhuis- en verpleeghuisopname, sterfte, gezondheidszorggebruik en kosten. Discussie: Dit onderzoek is naar wij weten uniek omdat er nog geen studies gedaan zijn naar de effecten en kosten van een multidisciplinair integraal zorgmodel op de functionele gezondheid en kwaliteit van zorg voor kwetsbare ouderen in verzorgingshuizen. Trial registratienummer: ISRCTNI1076857