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The article discusses U.S. nursing home (NH) reform based on the National Academies of Sciences, Engineering, and Medicine (NASEM) report in 2023. Topics covered include integration of resident and family experience into measures of NH quality, design of private bedrooms and smaller units, and Medicaid payment accuracy. Also noted are such report limitations as the absence of a vision for NHs in the future, and of inputs on post acute care, and on the status of the certified nursing assistant.

Background: Assisted living (AL) is the largest residential long‐term care provider in the United States, including for persons with Alzheimer's disease and related dementias. Despite recognizing the challenge of infection control for persons with dementia, this study of 119 AL communities is the first to describe dementia‐relevant COVID‐19 infection control across different types of AL communities, and to discuss implications for the future. Methods: From a parent study sampling frame of 244 AL communities across seven states, 119 administrators provided data about COVID‐19 infection control practices and resident behaviors. Data were collected from July 2020 through September 2021. Communities were differentiated based on the presence of beds/units dedicated for persons living with dementia, as being either dementia‐specific, mixed, or integrated. Data obtained from administrators related to feasibility of implementing seven infection control practices, and the extent to which residents themselves practiced infection prevention. Analyses compared practices across the three community types. Results: Less than half of administrators found it feasible to close indoor common areas, all community types reported a challenge organizing group activities for safe distancing, and more than half of residents with dementia did not wear a face covering or maintain physical distance from other residents when indicated. Dementia‐specific AL communities were generally the most challenged with infection control during COVID‐19. Conclusion: All AL community types experienced infection control challenges, more so in dementia‐specific communities (which generally provide care to persons with more advanced dementia and have fewer private beds). Results indicate a need to bolster infection prevention capacity when caring for this especially vulnerable population, and have implications for care in nursing homes as well. [ABSTRACT FROM AUTHOR]

Purpose: To inform overprescribing and antibiotic stewardship in nursing homes (NHs), we examined the concordance between clinicians' (NH primary care providers and registered nurses) diagnosis of suspected UTI with a clinical guideline treated as the gold standard, and whether clinician characteristics were associated with diagnostic classification. Methods: We conducted a cross‐sectional web‐based survey of a U.S. national convenience sample of NH clinicians. The survey included a discrete choice experiment with 19 randomly selected clinical scenarios of NH residents with possible UTIs. For each scenario, participants were asked if they thought a UTI was likely. Responses were compared to the guideline to determine the sensitivity and specificity of clinician judgment and performance indicators. Multivariable logistic mixed effects regression analysis of demographic, work, personality, and UTI knowledge/attitudes characteristics was conducted. Results: One thousand seven hundred forty‐eight NH clinicians responded to 33,212 discrete choice scenarios; 867 (50%) were NH primary care providers and 881 (50%) were NH registered nurses, 39% were male, and the mean age was 45 years. Participants were uncertain about diagnosis in 30% of scenarios. Correct classification occurred for 66% of all scenarios (providers: 70%; nurses: 62%). Respondent judgment had a sensitivity of 78% (providers: 81%; nurses: 74%) and specificity of 54% (providers: 59%; nurses: 49%) compared to the clinical guideline. Adjusting for covariates in multivariable models, being a nurse and having higher closemindedness were associated higher odds of false positive UTI (odds ratio [OR] 1.61, p < 0.001; and OR 1.09, p = 0.039, respectively), although higher UTI knowledge and conscientiousness were associated with lower odds of false positive UTI ratings (OR 0.80, p < 0.001; OR 0.90, p = 0.005, respectively). Conclusions: Clinicians tend to over‐diagnose urinary tract infections, necessitating systems‐based interventions to augment clinical decision‐making. Clinician type, UTI knowledge, and personality traits may also influence behavior and deserve further study. [ABSTRACT FROM AUTHOR]

Randomized controlled trials are considered the most rigorous research design in efficacy and effectiveness research; however, such trials present numerous challenges that limit their applicability in real‐world settings. As a consequence, pragmatic trials are increasingly viewed as a research design that overcomes some of these barriers with the potential to produce findings that are more reproducible. Although pragmatic methodology in long‐term care is receiving increasing attention as an approach to improve successful dissemination and implementation, pragmatic trials present complexities of their own. To address these complexities and related issues, experts with experience conducting pragmatic trials, developing nursing home policy, participating in advocacy efforts, and providing clinical care in long‐term care settings participated in a virtual consensus conference funded by the National Institute on Aging in Spring 2021. Participants identified 4 cross‐cutting principles key to dissemination and implementation of pragmatic trial interventions: (1) stakeholder engagement, (2) diversity and inclusion, (3) organizational strain and readiness, and (4) learn from adaptations. Participants emphasized that implementation processes must be grounded in the perspectives of the people who will ultimately be responsible for implementing the intervention once it is proven to be effective. In addition, messaging must speak to long‐term care staff and all others who have a stake in its outcomes. Although our understanding of dissemination and implementation strategies remains underdeveloped, this article is designed to guide long‐term care researchers and community providers who are increasingly aware of the need for pragmatism in disseminating and implementing evidence‐based care interventions. See related editorial by Zimmerman et al. and Special Articles by Gurwitz et al. and Resnick et al. in this issue. [ABSTRACT FROM AUTHOR]

As a method of research, pragmatic trials are recommended so as to generate results that are applicable to real‐world care. This intent is especially important for the millions of older adults who receive long‐term care in thousands of nursing homes and assisted living communities across the country—and many millions more around the globe. This article presents key points raised by experts participating in a conference funded by the National Institute of Aging held at the 2021 conference of the Society for Post‐Acute and Long‐term Care Medicine. The purpose of the conference was to convene leading clinicians, researchers, and industry partners to address special considerations of pragmatic trials in long‐term care. Cross‐cutting and unique challenges and solutions to conducting pragmatic trials were discussed focusing on 3 areas of clinical relevance to long‐term care: (1) functional care and outcomes, (2) psychosocial care and quality of life, and (3) medical care and outcomes, with a special focus on persons with dementia. Challenges and innovative solutions were organized across the 9 domains of the revised Pragmatic‐Explanatory Continuum Indicator Summary (PRECIS) Tool, and future research recommendations for pragmatic trials in long‐term care were identified. See related editorial by Zimmerman et al. and Special Articles by Gurwitz et al. and Levy et al. in this issue. [ABSTRACT FROM AUTHOR]

See related Special Articles by Gurwitz el al. and Levy et al. and Resnick et al. in this issue. [ABSTRACT FROM AUTHOR]

Background/Objectives: Certified nursing assistants (CNAs) who work in nursing homes (NHs) face significant work and personal stress. Self‐compassion training has been shown to decrease stress postintervention in previous studies among healthcare providers and those in helping professions. This study examines the feasibility, acceptability, and preliminary outcomes of self‐compassion training to address CNA stress and well‐being. Design: Pre–post intervention. Setting: Three mid‐size, nonprofit NHs in North Carolina. Participants: Thirty CNAs, with a mean age of 49, 96% of whom were female, and 83% black/African American. Intervention: In one NH, participants received an 8‐week, 2.5‐h/session (20 h total) group intervention. At the time of recruitment for NHs 2 and 3, a briefer format (6‐week, 1‐h/session; 6 h total) became available and was preferred by CNAs, thus both NHs 2 and 3 participants received a 6‐h group intervention. All interventions occurred in meeting rooms within participating NHs during shift changes. Measurements: Intervention attendance, retention, and acceptability; self‐compassion, stress, burnout, depression, and attitudes toward residents with dementia, and job satisfaction pre‐, post‐, 3‐month post‐, and 6‐month postintervention were assessed. Results: Attendance and program satisfaction were high, and attrition was low for both training formats. Self‐compassion was significantly improved at all time periods (p < 0.001), and stress and depression improved significantly through 3 months (p < 0.05), but not 6 months. No statistically significant change in job satisfaction was noted. Conclusion: Self‐compassion interventions are feasible and acceptable for CNAs working in NHs and show promise for managing stress and improving well‐being and compassion toward residents. The briefer 6‐h format may maximize participation, while still providing benefits. [ABSTRACT FROM AUTHOR]

Introduction: The goal of this study was to update understanding of the current roles and responsibilities of certified nurse‐midwives (CNMs) in the education of resident physicians. Three subaims were to (1) examine the involvement of CNMs in the education of residents in obstetrics and gynecology and family medicine, (2) examine the typology of CNMs' collaboration with residents, and (3) describe CNMs' opinions regarding their educational roles and responsibilities. Methods: This descriptive study used an electronic survey sent to CNMs involved in the education of medical residents. Survey participants were identified using an online directory of CNMs involved in academic midwifery practices in the United States. Survey items included both closed‐ended and open‐ended questions to generate quantitative and qualitative data, respectively. Results: Of the 146 CNMs invited to participate, surveys were received from 85, a response rate of 58%. Seventy of the respondents fit inclusion criteria of working with family medicine and obstetrics and gynecology resident physician programs. Most of the midwives' educational roles included informal mentorship of residents, supervision and consultation of intrapartum care, and caring for either their own or residents' patients. All respondents agreed that incorporating CNMs into clinical teams and faculty roles improves resident education. The majority of respondents desired a greater degree of involvement in resident education, with 57% preferring a blended interaction model. Discussion: The majority of CNM respondents reported a preference to have greater involvement in the education of residents. Although CNMs desire a blended interaction or fully integrated model of collaboration with resident physicians, the current state of CNM involvement does not fulfill this degree of collaboration. Opportunities exist for further research, including surveys of resident physicians who work with CNMs, leaders in midwifery, residency program directors, and policy makers. [ABSTRACT FROM AUTHOR]

OBJECTIVES: To determine if antibiotic prescribing in community nursing homes (NHs) can be reduced by a multicomponent antibiotic stewardship intervention implemented by medical providers and nursing staff and whether implementation is more effective if performed by a NH chain or a medical provider group. DESIGN: Two‐year quality improvement pragmatic implementation trial with two arms (NH chain and medical provider group). SETTING: A total of 27 community NHs in North Carolina that are typical of NHs statewide, conducted before announcement of the US Centers for Medicare and Medicaid Services antibiotic stewardship mandate. PARTICIPANTS: Nursing staff and medical care providers in the participating NHs. INTERVENTION: Standardized antibiotic stewardship quality improvement program, including training modules for nurses and medical providers, posters, algorithms, communication guidelines, quarterly information briefs, an annual quality improvement report, an informational brochure for residents and families, and free continuing education credit. MEASUREMENTS: Antibiotic prescribing rates per 1000 resident days overall and by infection type; rate of urine test ordering; and incidence of Clostridium difficile and methicillin‐resistant Staphylococcus aureus (MRSA) infections. RESULTS: Systemic antibiotic prescription rates decreased from baseline by 18% at 12 months (incident rate ratio [IRR] = 0.82; 95% confidence interval [CI] = 0.69‐0.98) and 23% at 24 months (IRR = 0.77; 95% CI = 0.65‐0.90). A 10% increase in the proportion of residents with the medical director as primary physician was associated with a 4% reduction in prescribing (IRR = 0.96; 95% CI = 0.92‐0.99). Incidence of C. difficile and MRSA infections, hospitalizations, and hospital readmissions did not change significantly. No adverse events from antibiotic nonprescription were reported. Estimated 2‐year implementation costs per NH, exclusive of medical provider time, ranged from $354 to $3653. CONCLUSIONS: Antibiotic stewardship programs can be successfully disseminated in community NHs through either NH administration or medical provider groups and can achieve significant reductions in antibiotic use for at least 2 years. Medical director involvement is an important element of program success. J Am Geriatr Soc 68:46–54, 2019 See related editorial by Furuno et al. in this issue. [ABSTRACT FROM AUTHOR]

OBJECTIVES: To characterize assessments of a patient's ability to report elder abuse within the context of an emergency department (ED)–based screen for elder abuse. DESIGN: Cross‐sectional study in which participants were screened for elder abuse and neglect. SETTING: Academic ED in the United States. PARTICIPANTS: Patients, aged 65 years and older, presenting to an ED for acute care were assessed by trained research assistants or nurses. MEASUREMENTS: All patients completed the four‐item Abbreviated Mental Test 4 (AMT4), then completed a safety interview (using the Emergency Department Senior Abuse Identification tool) designed to detect multiple domains of elder abuse and received a physical examination. Based on the cognitive assessment and safety interview, assessors ranked their confidence in the patient's ability to report abuse as absolutely confident, confident, somewhat confident, or not confident. To assess interrater reliability, two assessors independently rated confidence for a subset of patients. RESULTS: Assessors suspected elder abuse in 18 of 276 patients (6.5%). Assessors were absolutely confident in the patient's ability to report abuse for 95.7% of patients, confident for 2.5%, somewhat confident for 1.5%, and not confident for 0.3%. Among patients with an AMT4 of 4 (n = 249), assessors were confident or absolutely confident in 100% of patients. Among patients with an AMT4 of less than 4 (n = 27), they were confident or absolutely confident in the patient's ability to report abuse for 81% of patients, including 11 of 12 patients with mild cognitive impairment and 7 of 11 patients with severe cognitive impairment. For patients receiving paired evaluations (n = 131), agreement between assessors regarding patient ability to report abuse was 97% (κ = 0.5). CONCLUSIONS: In this sample of older adults receiving care in an ED, research assistants and nurses felt that the vast majority were able to report elder abuse, including many patients with cognitive impairment. J Am Geriatr Soc 68:170–175, 2019 [ABSTRACT FROM AUTHOR]

Background/Objectives The poor oral hygiene of nursing home ( NH) residents is a matter of increasing concern, especially because of its relationship with pneumonia and other health events. Because details and related risk factors in this area are scant and providers need to be able to easily identify those residents at most risk, this study comprehensively examined the plaque, gingival, and denture status of NH residents, as well as readily available correlates of those indicators of oral hygiene, including items from the Minimum Data Set ( MDS). Design Oral hygiene assessment and chart abstract conducted on a cross-section of NH residents. Setting NHs in North Carolina (N = 14). Participants NH residents (N = 506). Measurements Descriptive data from the MDS and assessments using three standardized measures: the Plaque Index for Long-Term Care ( PI- LTC), the Gingival Index for Long-Term Care ( GI- LTC), and the Denture Plaque Index ( DPI). Results Oral hygiene scores averaged 1.7 (of 3) for the PI- LTC, 1.5 (of 4) for the GI- LTC, and 2.2 (of 4) for the DPI. Factors most strongly associated with poor oral hygiene scores included having dementia, being on hospice care, and longer stay. MDS ratings of gingivitis differed significantly from oral hygiene assessments. Conclusions The findings identify resident subgroups at especially high risk of poor oral health who can be targeted in quality improvement efforts related to oral hygiene; they also indicate need to improve the accuracy of how MDS items are completed. [ABSTRACT FROM AUTHOR]

Objectives Due to the high rates of inappropriate antibiotic prescribing for presumed urinary tract infections ( UTIs) in nursing home ( NH) residents, we sought to examine the antibiotic prescribing pathway and the extent to which it agrees with the Loeb criteria; findings can suggest strategies for antibiotic stewardship. Methods Chart review of 260 randomly-selected cases from 247 NH residents treated with an antibiotic for a presumed UTI in 31 NHs in North Carolina. We examined the prescribing pathway from presenting illness, to the prescribing event, illness work-up and subsequent clinical events including emergency department use, hospitalization, and death. Analyses described the decision-making processes and outcomes and compared decisions made with Loeb criteria for initiation of antibiotics. Results Of 260 cases, 60% had documented signs/symptoms of the presenting illness and 15% met the Loeb criteria. Acute mental status change was the most commonly documented sign/symptom (24%). NH providers (81%) were the most common prescribers and ciprofloxacin (32%) was the most commonly prescribed antibiotic. Fourteen percent of presumed UTI cases included a white blood cell count, 71% included a urinalysis, and 72% had a urine culture. Seventy-five percent of cultures grew at least one organism with ≥100,000 colony-forming units/milliliter and 12% grew multi-drug resistant organisms; 28% of antibiotics were prescribed for more than 7 days, and 7% of cases had a subsequent death, emergency department visit, or hospitalization within 7 days. Discussion Non-specific signs/symptoms appeared to influence prescribing more often than urinary tract-specific signs/symptoms. Prescribers rarely stopped antibiotics, and a minority prescribed for overly long periods. Providers may need additional support to guide the decision-making process to reduce antibiotic overuse and antibiotic resistance. [ABSTRACT FROM AUTHOR]

Objectives To understand the range of symptoms that present to family caregivers of community-dwelling persons with Alzheimer's disease and related dementias ( ADRD). Design Six-month longitudinal prospective study to identify the incidence of new or worsening symptoms and their association with acute care medical service use. Setting Community-based sample of volunteers from multiple states. Participants A total of 136 patient-caregiver dyads with a range of dementia severity. Measurements Forty four symptoms and signs common in older persons and/or persons with dementia; frequency of emergency department visits, hospitalizations, and death; and associations between reported symptoms and acute medical care. Results During a mean of 5.7 months' follow-up, new or worsening organ-specific (90% of participants), nonspecific (89%), and behavioral (88%) symptoms were common, with the average caregiver reporting seven new or worsening symptoms. Most common were worsening confusion (74%), decreased activity (64%), agitation (57%), hallucinations/delusions (45%), voice and speaking problems (45%), not eating or drinking (44%), and stress/anxiety (41%). Hospitalization and emergency department use occurred respectively in 19% and 20% of participants, and were associated with organ-specific symptoms ( OR 3.15, P = .02), less so with nonspecific symptoms ( OR 2.27, P = .07), and very little with behavioral symptoms ( OR 1.44, P = .38). Within each symptom category, certain symptoms were significantly associated with acute medical service use. Conclusion Family caregivers of persons with ADRD must respond to a variety of medical, nonspecific, and behavioral symptoms. The high incidence of new or worsening symptoms and of acute medical care use suggests a need to better target symptom evaluation and management in caregiver education. [ABSTRACT FROM AUTHOR]

Objectives To develop and validate the Dental Activities Test (DAT), a clinical tool for measuring dentally related function in cognitively impaired older adults. Design Cross-sectional study design. Setting Three assisted living residences in North Carolina. Participants Assisted living residents with normal to impaired cognition aged 50 and older; not blind, deaf, or severely physically disabled; and English speaking (N = 90). Measurements Items for the DAT were developed based on focus group discussions, literature review, and clinical relevance. Cronbach alpha, interrater reliability, and test-retest reliability were examined, and construct validity was assessed in relation to correlations with cognitive and functional assessments. Correlations between the DAT and oral health measures were also analyzed to evaluate the concurrent validity of the DAT. Results The DAT has excellent internal consistency reliability (Cronbach alpha 0.90), test-retest reliability (correlation coefficient (r) = 0.84), and interrater reliability (r = 0.90). In terms of construct validity, higher DAT scores were significantly associated with better cognitive function, as well as better activity of daily living and instrumental activity of daily living function. Finally, the DAT was significantly associated with oral hygiene and gingival health. Conclusion The DAT is a reliable and valid instrument to measure dentally-related function in older adults with cognitive impairment. [ABSTRACT FROM AUTHOR]

Objectives To examine perspectives on antibiotic use and antibiotic stewardship of nurses and medical providers in nursing homes ( NHs). Design Cross-sectional survey. Setting NHs in North Carolina (N = 31). Participants Nursing staff (n = 182) and medical providers (n = 50). Measurements Respondents completed a self-administered questionnaire about their perspectives on antibiotic use in their NH, the influence of residents and families on antibiotic prescribing decisions, and readiness to improve antibiotic stewardship. Open-ended questions on barriers to antibiotic stewardship were also asked. Linear mixed modeling was used to analyze differences between respondent groups and to test for associations with individual and organizational characteristics. Results All respondents supported reducing antibiotic use, although medical providers' support was significantly stronger ( P = .005). When asked about their perception of residents' and family members' preference for antibiotic use in the case of suspected infection and the influence of that preference on antibiotic-prescribing decisions, respondents indicated that residents and families favor antibiotic use and influence prescribing decisions. Nurses reported a stronger perception than medical providers that families prefer antibiotics ( P = .04) and influence prescribing decisions ( P = .02). All respondents reported commitment and efficacy to change practices (mean 4.0-4.1 for nurses and 3.6-3.9 for medical providers on a 5-point scale). Four significant associations related to organizational and individual characteristics were found: directors of nursing and specialist nurses reported greater self-efficacy for changing practice than other nurses ( P = .003), medical providers with a subspecialty (e.g., geriatrics) reported greater self-efficacy ( P = .007) and commitment to change ( P = .001) than those without a subspecialty, and medical providers specializing in hospice and palliative care rated family influence ( P = .006) higher than those with other subspecialties. Conclusion Nursing staff and medical providers share a commitment to reducing unnecessary antibiotic use. Antibiotic stewardship interventions should foster cooperation and build competency to implement alternative management approaches and to educate residents and families. Nurse leaders and medical providers with long-term care training may be especially effective champions for antibiotic stewardship. [ABSTRACT FROM AUTHOR]

Objectives To determine whether antibiotic prescribing can be reduced in nursing homes using a quality improvement ( QI) program that involves providers, staff, residents, and families. Design A 9-month quasi-experimental trial of a QI program in 12 nursing homes (6 comparison, 6 intervention) conducted from March to November 2011. Setting Nursing homes in two regions of North Carolina, roughly half of whose residents received care from a single practice of long-term care providers. Participants All residents, including 1,497 who were prescribed antibiotics. Intervention In the intervention sites, providers in the single practice and nursing home nurses received training related to prescribing guidelines, including situations for which antibiotics are generally not indicated, and nursing home residents and their families were sensitized to matters related to antibiotic prescribing. Feedback on prescribing was shared with providers and nursing home staff monthly. Measurements Rates of antibiotic prescribing for presumed urinary tract, skin and soft tissue, and respiratory infections. Results The QI program reduced the number of prescriptions ordered between baseline and follow-up more in intervention than in comparison nursing homes (adjusted incidence rate ratio = 0.86, 95% confidence interval = 0.79-0.95). Based on baseline prescribing rates of 12.95 prescriptions per 1,000 resident-days, this estimated adjusted incidence rate ratio implies 1.8 prescriptions avoided per 1,000 resident-days. Conclusion This magnitude of effect is unusual in efforts to reduce antibiotic use in nursing homes. Outcomes could be attributed to the commitment of the providers; outreach to providers and staff; and a focus on common clinical situations in which antibiotics are generally not indicated; and suggest that similar results can be achieved on a wider scale if similar commitment is obtained and education provided. [ABSTRACT FROM AUTHOR]

Objectives To evaluate the effectiveness of the Bathing Without a Battle intervention in reducing physical and verbal aggressive behaviors for nursing home residents with dementia. Design A randomized crossover diffusion study, with one group receiving the intervention after one round of baseline observations and a delayed intervention group receiving the intervention after two rounds of baseline observations. Setting Six nursing home facilities in the state of New York. Participants Nursing home residents with dementia (N = 240). Intervention The Bathing Without a Battle educational program, designed for direct-care staff members responsible for bathing residents diagnosed with dementia and implemented through a train-the-trainer model. Measurements Rates of verbal and physical aggressive and agitated behaviors were measured using the Care Recipient Behavior Assessment; secondary measures of effect included bath duration, bath modality, and antipsychotic medication use. Results In spite of implementation obstacles (consent delays and change in leadership at one facility), a significant change was observed in how residents were bathed that translated into a significant reduction in the rate of aggressive and agitated behaviors, particularly verbal, during residents' baths. The use of in-bed baths increased 17%, and average bath duration decreased significantly (average 1.5 minutes less) in the postintervention period, particularly for in-bed baths. Verbal behaviors declined 17.8% ( P = .008), combined verbal and physical behaviors declined 18.6% ( P = .004), and antipsychotic use declined 30% ( P = .002) after the intervention. Conclusion The Bathing Without a Battle educational program, delivered through a train-the-trainer format, is an effective means of improving the bathing experience of residents with dementia in nursing homes. This research supports broadly adopting this intervention, especially for nursing homes serving many residents with dementia. [ABSTRACT FROM AUTHOR]

Objectives To create data-driven typologies of licensed nurse staffing and health services in residential care and assisted living ( RC/ AL). Design Cluster analysis was used to describe the patterns of licensed nurse staffing and 47 services and the extent to which these clusters were related. Setting RC/ AL communities in the United States. Participants A convenience sample of administrators and healthcare supervisors from 89 RC/AL communities in 22 states. Measurement RC/ AL characteristics, licensed nurse staffing (total number of hours that registered nurses ( RNs) and licensed practical nurses ( LPNs) worked), number of hours that contract nurses worked, and availability of 47 services. Results Analysis revealed four licensed nurse staffing clusters defined according to total number of hours and the type of nurse providing the hours ( RN, LPN, or a mix of both). They ranged from no or minimal RN and LPN hours to high nursing hours with a mix of RNs and LPNs. The 47 services clustered into five clusters: basic services; technically complex services; assessments, wound care, and therapies; testing and specialty services; and gastrostomy and intravenous medications. The availability of services was related to the presence of nurses ( RNs and LPNs) except for the gastrostomy and intravenous medication services, which were not readily available. Conclusion The amount and skill mix of licensed nurse staffing varies in RC/ AL and is related to the types of services available. These findings may have implications for resident care and outcomes. Future work in this area, including extension to include nonnurse direct care workers, is needed. [ABSTRACT FROM AUTHOR]

Objectives To provide empirically based recommendations for incorporating body temperature into clinical decision-making regarding diagnosing infection in nursing home ( NH) residents. Design Retrospective. Setting Twelve North Carolina NHs. Participants NH residents (N = 1,007) with 1,858 randomly selected antibiotic prescribing episodes. Measurements Maximum prescription-day temperature plus the three most recent nonillness temperatures were recorded for each prescribing episode. Two empirically based definitions of fever were developed: population-based (population mean nonillness temperature plus 2 population standard deviations ( SDs)) and individualized (individual mean nonillness temperature plus 2 population SDs). These definitions were used along with previously published fever criteria and Infectious Diseases Society of America ( IDSA) criteria to determine how often each prescribing episode was associated with a 'fever' according to each definition. Results Mean population nonillness temperature was 97.7 ± 0.5ºF. If 'normal' were defined as less than 2 SDs above the mean, fever would be defined as any temperature above 98.7ºF, and the previously published fever cut-points and the IDSA criteria are 4.8 SDs above this mean. Between 30% and 32% of the 1,858 prescribing episodes examined were associated with temperatures more than 2 SDs above the population mean nonillness temperature, whereas only 10% to 11% of episodes met the previously published and IDSA fever definitions. Conclusion Clinicians should apply empirically based definitions to assess fever in NH residents. Furthermore, low fever prevalence in residents treated with antibiotics according to all definitions suggests that some prescribing may not be associated with acute bacterial infection. [ABSTRACT FROM AUTHOR]

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Objectives In response to the need for an evidence-based review of factors within long-term care settings that affect the quality of care, this review compared characteristics of nursing homes and other residential long-term care settings for people with dementia and their informal family caregivers with respect to health and psychosocial outcomes. Design Databases were searched for literature published between 1990 and March 2012 that met review criteria, including that at least 80% of the subject population had dementia. Results Fourteen articles meeting review criteria that were of at least fair quality were found: four prospective cohort studies, nine randomized controlled trials ( RCTs), and one nonrandomized controlled trial. Overall, low or insufficient strength of evidence was found regarding the effect of most organizational characteristics, structures, and processes of care on health and psychosocial outcomes for people with dementia and no evidence for informal caregivers. Findings of moderate strength of evidence indicate that pleasant sensory stimulation reduces agitation for people with dementia. Also, although the strength of evidence is low, protocols for individualized care and to improve function result in better outcomes for these individuals. Finally, outcomes do not differ between nursing homes and residential care or assisted living settings for people with dementia except when medical care is indicated. Conclusion Given the paucity of high-quality studies in this area, additional research is needed to develop a sufficient evidence base to support consumer selection, practice, and policy regarding the best settings and characteristics of settings for residential long-term care of people with dementia. [ABSTRACT FROM AUTHOR]

Objectives To develop and test a person-centered, evidence-based mouth care program in nursing homes. Design Pre-post assessment, with an 8-week intervention period and a pilot 6-month extension at one site. Setting Three North Carolina nursing homes. Participants Ninety-seven residents and six certified nursing assistants ( CNAs). Intervention CNAs already working in the facilities were trained as dedicated mouth care aides. A psychologist and dental hygienist provided didactic and hands-on training in evidence-based mouth care products and techniques and in person-centered behavioral care. Measurements Primary outcome measures for natural teeth were the Plaque Index for Long-Term Care ( PI- LTC) and Gingival Index for Long-Term Care( GI- LTC) and for dentures the Denture Plaque Index ( DPI); a dentist unmasked to study design obtained measures. Secondary outcomes included quantity and quality of care provided. Results Outcome scores significantly improved ( P < .001 for PI- LTC and GI- LTC; P = .04 for DPI). Coding of videotaped care episodes indicated that care was more thorough ( P < .001- P = .03) but took more time ( P < .001) after training. Consistency of care appeared to be more important for natural teeth than dentures. Conclusion As little as 8 weeks of mouth care can significantly improve oral hygiene outcomes. Given the consequences of poor oral hygiene, greater attention to mouth care education and provision are merited. The dedicated worker model is controversial, and future work should assess whether other models of care are equally beneficial. [ABSTRACT FROM AUTHOR]

Objectives To better understand the antibiotic prescribing process in assisted living ( AL) communities given the growing rate of antibiotic resistance. Design Cross-sectional survey. Setting Four AL communities in North Carolina. Participants Assisted living residents who received antibiotics (n = 30) from October 20, 2010, to March 31, 2011, a primary family member, staff, and the prescribing medical provider. Measurements Semistructured interviews that were conducted regarding prescribing included the information available at the time of prescribing and the perceptions of the quality of communication between providers, staff, residents and family members about the resident. Providers were asked an open-ended question regarding how to improve the communication process related to antibiotic prescribing for AL residents. Results For the 30 residents who received antibiotic prescriptions, providers often had limited information about the case and lacked familiarity with the residents, the residents' families, and staff. They also felt that cases were less severe and less likely to require an antibiotic than did residents, families, and staff. Providers identified several ways to improve the communication process, including better written documentation and staff and family presence. Conclusion In a small sample of AL communities, providers faced an array of challenges in making antibiotic prescribing decisions. This work confirms the complex nature of antibiotic prescribing in AL communities and indicates that further work is needed to determine how to improve the appropriateness of antibiotic prescribing. [ABSTRACT FROM AUTHOR]

ACADEMIC EMERGENCY MEDICINE 2012; 19:821-827 © 2012 by the Society for Academic Emergency Medicine Abstract Objectives: Motor vehicle collisions (MVCs) are the second most common cause of nonfatal injury among U.S. adults age 65 years and older. However, the frequency of emergency department (ED) visits, disposition, pain locations, and pain severity for older adults experiencing MVCs have not previously been described. The authors sought to determine these characteristics using information from two nationally representative data sets. Methods: Data from the 2008 Healthcare Cost and Utilization Project Nationwide Emergency Department Sample (NEDS) and the National Hospital Ambulatory Medical Care Survey (NHAMCS) were used to estimate MVC-related ED visits and ED disposition for patients 65 years and older. NHAMCS data from 2004 through 2008 were used to further characterize MVC-related ED visits. Results: In 2008, the NEDS contained 28,445,564 patient visits, of which 760,356 (2.7%) were due to MVCs. The NHAMCS contained 34,134 patient visits, of which 1,038 (3.0%) were due to MVCs. National estimates of MVC-related ED visits by patients 65 years and older in 2008 are 226,000 (95% confidence interval [CI] = 210,000 to 240,000) for NEDS and 270,000 (95% CI = 185,000 to 355,000) for NHAMCS. Most older adults with MVC-related ED visits were sent home from the ED (proportion discharged NEDS 78%, 95% CI = 78% to 79%; NHAMCS 77%, 95% CI = 66% to 86%). During the years 2004 through 2008, of MVC-related ED visits by older adults not resulting in hospital admission, moderate or severe pain was reported in 61% (95% CI = 52% to 70%) of those with recorded pain scores. Older patients sent home after MVC-related ED visits were less likely than younger patients to receive analgesics (35%, 95% CI = 26% to 43% vs. 47%, 95% CI = 44% to 50%) during their ED evaluations or as discharge prescriptions (52%, 95% CI = 41% to 62% vs. 65%, 95% CI = 61% to 68%). Conclusions: In 2008, adults age 65 years or older made more than 200,000 MVC-related ED visits. Approximately 80% of these visits were discharged home from the ED, but the majority of discharged patients reported moderate or severe pain. Further studies of pain and functional outcomes in this population are needed. [ABSTRACT FROM AUTHOR]

Objectives To examine cross-national care and outcomes related to end-of-life experiences. Design Postdeath interviews and self-administered questionnaires completed with family caregivers of residents with dementia who died in long-term care settings or shortly after transfer. Setting One hundred eighty-three nursing home and residential care/assisted living settings in the United States and the Netherlands. Participants Family caregivers of 196 residents with dementia who had died (126 in the United States and 70 in the Netherlands). Measurements Nine standardized measures of care and outcomes and single-item measures of overall quality of care and life. Results In adjusted and unadjusted analyses, U.S. family caregivers reported better care and outcomes on most of the standardized measures and better quality of care (single item) in the last 3 days of life; caregivers in the Netherlands reported better quality of life (single item) in the last month and 3 days of life. Exploratory analyses related to hospice use found differences in bivariate but not adjusted comparisons. Conclusion Because previous research favored care in the Netherlands to that in the United States, findings suggest improvement in end-of-life care and outcomes in the United States and stability in the Netherlands. Greater hospice use does not explain improvements in the United States directly and may relate, at least in part, to care provided by long-term care staff themselves. Better understanding of the nature and process of these improvements may suggest areas for additional improvement. [ABSTRACT FROM AUTHOR]

Objectives To describe the provision of medical care in assisted living ( AL) as provided by physicians who are especially active in providing care to older adults and AL residents; to identify characteristics associated with physician confidence in AL staff; and to ask physicians a variety of questions about their experience providing care to AL residents and how it compares with providing care in the nursing home and home care settings. Design Cross-sectional descriptive study. Setting AL communities in 27 states. Participants One hundred sixty-five physicians and administrators of 125 AL settings in which they had patients. Measurements Interviews and questionnaires containing open- and close-ended questions regarding demographics, care arrangements, attitudes, and behaviors in managing medical problems. Results Most respondents were certified in internal medicine (46%) or family medicine (47%); 32% were certified in geriatrics and 30% in medical directorship. In this select sample, 48% visited the AL setting once a year or less, and 19% visited once a week or more. Mean physician confidence in AL staff was 3.3 (somewhat confident), with greater confidence associated with smaller AL community size, nursing presence, and the physician being the medical director. Qualitative analyses identified differences between settings including lack of vital sign assessment in the home setting, concern about the ability of AL staff to assess and monitor problems, and greater administrative and regulatory requirements in AL than in the other settings. Conclusion Providing medical care for AL residents presents unique challenges and opportunities for physicians. Nursing presence and physician oversight and familiarity and communicating with AL staff who are highly familiar with a given resident and can monitor care may facilitate care. [ABSTRACT FROM AUTHOR]

To compare rates of medication errors committed by assisted living staff with different training and to examine characteristics of errors. Observation of medication preparation and passes, chart review, interviews, and questionnaires. Stratified random sample of 11 assisted living communities in South Carolina (which permits nonnurses to administer medications) and Tennessee (which does not). All staff who prepared or passed medications: nurses (one registered nurse and six licensed practical nurses (LPNs)); medication aides (n=10); and others (n=19), including those with more and less training. Rates of errors related to medication, dose and form, preparation, route, and timing. Medication preparation and administration were observed for 4,957 administrations during 83 passes for 301 residents. The error rate was 42% (20% when omitting timing errors). Of all administrations, 7% were errors with moderate or high potential for harm. The odds of such an error by a medication aide were no more likely than by a LPN, but the odds of one by staff with less training was more than two times as great (odds ratio=2.10, 95% confidence interval=1.27-3.49). A review of state regulations found that 20 states restrict nonnurses to assisting with self-administration of medications. Medication aides do not commit more errors than LPNs, but other nonnurses who administered a significant number of medications and assisted with self-administration committed more errors. Consequently, all staff who handle medications should be trained to the level of a medication aide. [ABSTRACT FROM AUTHOR]

Objective To evaluate the effect of ambient bright light therapy (BLT) on agitation among institutionalized persons with dementia. Methods High intensity, low glare ambient lighting was installed in activity and dining areas of a state psychiatric hospital unit in North Carolina and a dementia-specific residential care facility in Oregon. The study employed a cluster-unit crossover design involving four ambient lighting conditions: AM bright light, PM bright light, All Day bright light, and Standard light. Sixty-six older persons with dementia participated. Outcome measures included direct observation by research personnel and completion by staff caregivers of the 14-item, short form of the Cohen-Mansfield Agitation Inventory (CMAI). Results Analyses of observational data revealed that for participants with mild/moderate dementia, agitation was higher under AM light (p = 0.003), PM light (p < 0.001), and All Day light (p = 0.001) than Standard light. There was also a trend toward severely demented participants being more agitated during AM light than Standard light (p = 0.053). Analysis of CMAI data identified differing responses by site: the North Carolina site significantly increased agitation under AM light (p = 0.002) and PM light (p = 0.013) compared with All Day light while in Oregon, agitation was higher for All Day light compared to AM light (p = 0.030). In no comparison was agitation significantly lower under any therapeutic condition, in comparison to Standard lighting. Conclusions Ambient bright light is not effective in reducing agitation in dementia and may exacerbate this behavioral symptom. Copyright © 2010 John Wiley & Sons, Ltd. [ABSTRACT FROM AUTHOR]

OBJECTIVES: To better understand the characteristics and perceptions of immigrants working as nursing assistants in U.S. nursing homes and to determine whether immigrant status is linked to job turnover. DESIGN: Analysis of interview data from a nationally representative sample of nursing assistants working in U.S. nursing homes. SETTING: Five hundred eighty-two nursing homes included in the 2004 National Nursing Assistant Survey. PARTICIPANTS: Two thousand eight hundred eighty-one nursing assistants. MEASUREMENTS: Proportion of respondents who were non-U.S. born or naturalized citizens and relationship between these characteristics and measures of job satisfaction and intention to leave within the subsequent year. RESULTS: Fourteen percent (13.9%) of nursing assistants employed in U.S. nursing homes were immigrants. Immigrants tended to be better educated; more often male, nonwhite, and Hispanic; and concentrated in large, urban facilities than nonimmigrants. They reported feeling less respected by residents and families but not less respected by supervisors, and they were more likely to report intention to leave the job within 1 year. In multivariate analyses, demographic factors, length of time on the job, and noncitizen status were independently associated with plans to leave within a year. CONCLUSION: Attention to the unique factors associated with immigrant status, such as the need to improve communication and garner respect from patients and families, can assist policy-makers, facility administrators, and medical directors in more effectively attracting, training, and supporting this growing segment of the nursing assistant labor pool. [ABSTRACT FROM AUTHOR]

The article examines the associations of self-reported arthritis in 25 urban and rural family practice clinics with education and community poverty in North Carolina. Both disadvantaged white and African American participants in the family practice setting showed increased odds of self-reported arthritis, with stronger associations in African Americans.

Using a survey of a cohort of primary care patients, the authors determined the proportion currently using home blood pressure monitoring (HBPM) and calculated odds ratios (ORs) of factors associated with such use. Overall, 530 questionnaires were received (80% response rate); 35.2% of respondents reported that their doctor had recommended HBPM (95% confidence interval [CI], 31.1–39.3), and 43.1% reported currently using HBPM (95% CI, 38.8–47.3). Compared with patients younger than 45 years, hypertensive patients older than 65 years were more likely to be using HBPM (OR, 2.53; 95% CI, 1.20–5.33). Those with a history of stroke/transient ischemic attack were also more likely to use HBPM (OR, 2.06; 95% CI, 1.00–4.24). Compared with patients with a level of hypertension knowledge <10th percentile, those with a knowledge level >90th percentile were more likely to use HBPM (OR, 1.96; 95% CI, 1.08–3.56). The factor most strongly associated with use of HBPM was recalling a doctor's recommendation to do so (OR, 7.93; 95% CI, 4.96–12.7). [ABSTRACT FROM AUTHOR]

OBJECTIVES: To evaluate the relationship between pain, dyspnea, and family perceptions of the quality of dying in long-term care. DESIGN: After-death interviews. SETTING: Stratified random sample of 111 nursing homes and residential care and assisted living facilities in four states. PARTICIPANTS: Paired interviews from facility staff and family caregivers for 325 deceased residents. MEASUREMENTS: The outcome variable was the Quality of Dying in Long-Term Care (QOD-LTC), a psychometrically sound, retrospective scale representing psychosocial aspects of the quality of dying, obtained from interviews with family caregivers. Facility staff reported the presence, frequency, and severity of pain and dyspnea. RESULTS: During the last month of life, nearly half of residents experienced pain or dyspnea. QOD-LTC scores did not differ for residents with and without pain (4.15 vs 4.02, P=.16). Overall, residents with dyspnea had better QOD-LTC scores than those without dyspnea (4.20 vs 3.99, P=.006). The association between dyspnea and a better QOD-LTC score was strongest in cognitively impaired residents and for those dying in residential care and assisted living facilities. CONCLUSION: For residents dying in long-term care, pain and dyspnea were not associated with a poorer quality of dying as perceived by families of deceased residents. Instead, dyspnea may alert staff to the need for care. Initiatives to improve the quality of dying in long-term care should focus not only on physical symptoms, but also on the alleviation of nonphysical sources of suffering at the end of life. [ABSTRACT FROM AUTHOR]

OBJECTIVES: To describe the end-of-life symptoms of nursing home (NH) and residential care/assisted living (RC/AL) residents, compare staff and family symptom ratings, and compare how staff assess pain and dyspnea for cognitively impaired and cognitively intact residents. DESIGN: After-death interviews. SETTING: Stratified random sample of 230 long-term care facilities in four states. PARTICIPANTS: Staff (n=674) and family (n=446) caregivers for dying residents. MEASUREMENTS: Interview items measured frequency and severity of physical symptoms, effectiveness of treatment, recommendations to improve care, and staff report of assessment. RESULTS: Decedents' median age was 85, 89% were white, and 77% were cognitively impaired. In their last month of life, 47% had pain, 48% dyspnea, 90% problems with cleanliness, and 72% symptoms affecting intake. Problems with cleanliness, intake, and overall symptom burden were worse for decedents in NHs than for those in RC/AL. Treatment for pain and dyspnea was rated very effective for only half of decedents. For a subset of residents with both staff and family interviews (n=331), overall ratings of care were similar, although agreement in paired analyses was modest (kappa=−0.043–0.425). Staff relied on nonverbal expressions to assess dyspnea but not pain. Both groups of caregivers recommended improved application of treatment and increased staffing to improve care. CONCLUSION: In NHs and RC/AL, dying residents have high rates of physical symptoms and need for more-effective palliation of symptoms near the end of life. [ABSTRACT FROM AUTHOR]

OBJECTIVES: To assess the effect of ambient bright light therapy on depressive symptoms in persons with dementia. DESIGN: A cluster-unit crossover intervention trial involving four lighting conditions: morning bright light, evening bright light, all-day bright light, and standard light. SETTING: The common areas of two geriatric units in a state-operated psychiatric hospital in North Carolina and in a dementia-specific residential care facility in Oregon. PARTICIPANTS: Sixty-six older adults with dementia. INTERVENTION: Ambient bright light therapy was delivered through a high-intensity, low-glare lighting system installed in the public areas of study units at both sites. Each lighting condition was provided for multiple 3-week periods in a predetermined sequence. MEASUREMENTS: Staff caregivers completed the Cornell Scale for Depression in Dementia (CSDD) in the last week of each 3-week period to provide information about participants' moods. RESULTS: Analysis indicated a sex-by-treatment interaction ( P=.008). Significant sex differences were found in CSDD scores in response to evening light ( P=.003), all-day light ( P=.001), and standard light ( P≤.001). Depressive symptoms were lowest for women and highest for men during morning light. CONCLUSION: Findings do not support the use of ambient bright light therapy as a treatment for depressive symptoms in persons with dementia, although a subpopulation of persons with dementia may benefit from this intervention. It is likely that individual rather than unit-level interventions are a more effective strategy for delivering bright light therapy for this population. [ABSTRACT FROM AUTHOR]

OBJECTIVES: To determine whether high-intensity ambient light in public areas of long-term care facilities will improve sleeping patterns and circadian rhythms of persons with dementia. DESIGN: A cluster-unit crossover intervention trial involving four conditions: morning bright light, evening bright light, all-day bright light, and minimum standard light. SETTING: The common areas of two geriatric units in a psychiatric hospital and a dementia-specific residential care facility. PARTICIPANTS: Sixty-six older adults with dementia. INTERVENTION: Ambient bright light of approximately 2,500 lux, delivered through a low-glare lighting system installed in the dining and activity areas. Participant exposure averaged 2.5 to 3.0 hours for the morning and evening interventions and 8.4 hours for the all-day intervention. MEASUREMENTS: Nighttime sleep using wrist actigraphy and daytime activity using nonobtrusive daytime observations. RESULTS: Night-time sleep increased significantly in participants exposed to morning and all-day light, with the increase most prominent in participants with severe or very severe dementia (mean increase 16 minutes ( P=.008) for morning, and 14 minutes ( P=.01) for all-day). Morning light produced a mean phase advance of 29 minutes ( P=.02) and evening light a mean phase delay of 15 minutes ( P=.06). Effects on daytime sleepiness were inconsistent, and the number of sleep bouts, mesor, amplitude, intradaily variability, and interdaily stability were not significantly different, indicating that the overall strength of day and night activity rhythms did not change significantly under any treatment condition. CONCLUSION: Bright light appears to have a modest but measurable effect on sleep in this population, and ambient light may be preferable to stationary devices such as light boxes. [ABSTRACT FROM AUTHOR]

OBJECTIVES: To estimate the sensitivity, specificity, and reliability of the Minimum Data Set Cognition Scale (MDS-COGS) in screening for undetected dementia when completed by direct care staff in residential care/assisted living (RC/AL) facilities and secondarily to determine the prevalence of dementia in the sample. DESIGN: A cross-sectional study in which staff were trained to complete the MDS-COGS. Research interviewers and a neuropsychologist obtained information on each participant. Two neurologists reviewed the data and examined the participant, rendering a probable diagnosis of dementia/non-dementia diagnosis. MDS-COGS results were compared with the neurologists' determination. SETTING: Fourteen RC/AL facilities in North Carolina. PARTICIPANTS: Data were collected from 50 staff on 166 residents without a diagnosis of dementia. MEASUREMENTS: In addition to the MDS-COGS, measures included a comprehensive neuropsychological battery. Depression and other neuropsychiatric symptoms were also assessed. RESULTS: Neurologists determined that 38% of participants had probable dementia. An MDS-COGS cutpoint of 2 was highly specific (0.97) but not very sensitive (0.49) for dementia. Test–retest and interrater agreement for a negative screen were high (88% and 93%, respectively). CONCLUSION: The MDS-COGS is a simple, brief screen that RC/AL staff can complete. It will identify with high specificity a subset of residents with undetected dementia, allowing rapid identification of those likely to need dementia care. Caution needs to be exercised in light of its low sensitivity, because some with milder dementia will not be detected. Further work is needed to determine whether staff can and will use the MDS-COGS as a trigger for more-thorough assessment and to guide care and improve outcomes. [ABSTRACT FROM AUTHOR]

OBJECTIVES: To describe two versions of a new measure, The Quality of Dying in Long-Term Care, for postdeath administration to surrogate respondents (staff and family caregivers) of all decedents (QOD-LTC) and of cognitively intact decedents (QOD-LTC-C) who die in nursing homes (NHs) and residential care or assisted living (RC/AL) facilities. DESIGN: Using two levels of exploratory factor analysis, 15 candidate items for the QOD-LTC and 36 candidate items for the QOD-LTC-C were tested using multiple criteria to determine factor structure and interpretability of the quality of dying in long-term care (LTC). SETTING: One hundred seventeen RC/AL facilities and 31 NHs in FL, MD, NC, and NJ. PARTICIPANTS: Family (n=439) and staff (n=332) caregivers of 633 decedents from a stratified random sample from RC/AL facilities and NHs in four states. MEASUREMENTS: Trained interviewers asked respondents to rate statements describing potentially important aspects of the quality of dying using a 5-point Likert scale. The scale items were analyzed using exploratory factor analysis with communalities set to unity using a Promax rotation. RESULTS: The 11-item QOD-LTC (α=0.66), appropriate for surrogate respondents for all decedents, consists of three domains (personhood, closure, preparatory tasks). The 23-item instrument for surrogate respondents of cognitively intact decedents, the QOD-LTC-C (α=0.85), consists of five domains (sense of purpose, closure, control, social connection, preparatory tasks). CONCLUSION: The QOD-LTC and QOD-LTC-C are psychometrically acceptable measures of the quality of the dying experience, developed for and tested in LTC settings. Use of these measures can increase understanding of the dying experience in LTC. [ABSTRACT FROM AUTHOR]

Introduction Dementia Care Mapping (DCM) was originally developed as a clinical tool but has attracted interest as a potential observational measure of quality of life (QOL) and well-being of long-term care residents with dementia. DCM coding involves continuous observation over a 6-h period, with observers recording a Behavior Category Code (BCC, a recording of activity/interaction) and a Well/Ill Being (WIB) score at 5 min intervals. Method Descriptive data from several different research teams on the distribution and psychometric properties of DCM data were compiled and summarized. Results Issues and problems identified include: complex scoring algorithms, inter-rater reliability of the BCCs, limited variability of WIB values, associations between resident characteristics and DCM assessments, rater time burden, and comparability of results across study settings. Conclusions Despite the identified limitations, DCM has promise as a research measure, as it may come closer to rating QOL from the perspective of persons with dementia than other available measures. Its utility will depend on the manner in which it is applied and an appreciation of the measure's strength and limitations. Possible changes that might improve the reliability, validity, and practicality of DCM as a research tool include coding the predominant event (rather than the ‘best’ event), shortening the observation period, and adding ‘0’ as a neutral WIB coding option. Copyright © 2006 John Wiley & Sons, Ltd. [ABSTRACT FROM AUTHOR]

OBJECTIVES: To assess family perceptions of communication between physicians and family caregivers of individuals who spent their last month of life in long-term care (LTC) and to identify associations between characteristics of the family caregiver, LTC resident, facility, and physician care with these perceptions. DESIGN: Retrospective study of family caregivers of persons who died in LTC. SETTING: Thirty-one nursing homes (NHs) and 94 residential care/assisted living (RC/AL) facilities. PARTICIPANTS: One family caregiver for each of 440 LTC residents who died (response rate 66.0%) was interviewed 6 weeks to 6 months after the death. MEASUREMENTS: Demographic and facility characteristics and seven items rating the perception of family caregivers regarding physician–family caregiver communication at the end of life, aggregated into a summary scale, Family Perception of Physician-Family caregiver Communication (FPPFC) (Cronbach alpha=0.96). RESULTS: Almost half of respondents disagreed that they were kept informed (39.9%), received information about what to expect (49.8%), or understood the doctor (43.1%); the mean FPPFC score (1.73 on a scale from 0 to 3) was slightly above neutral. Linear mixed models showed that family caregivers reporting better FPPFC scores were more likely to have met the physician face to face and to have understood that death was imminent. Daughters and daughters-in-law tended to report poorer communication than other relatives, as did family caregivers of persons who died in NHs than of those who died in RC/AL facilities. CONCLUSION: Efforts to improve physician communication with families of LTC residents may be promoted using face-to-face meetings between the physician and family caregivers, explanation of the patient's prognosis, and timely conveyance of information about health status changes, especially when a patient is actively dying. [ABSTRACT FROM AUTHOR]

An editorial written by a consortium of geriatric and gerontology scholarly journal editors argues that humanitarian care is necessary in the treatment of older people with COVID-19, in addition to the need to raise awareness about ageism as it relates to older COVID-19 patients. The editorial also discusses medical protocols for elderly people, allocation of medical resources, and decision making in medical care of COVID-19 patients.

OBJECTIVES: To examine whether hospice enrollment for nursing home (NH) and residential care/assisted living (RC/AL) residents near the end of life is associated with symptoms and symptom management, personal care, spiritual support, and family satisfaction. DESIGN: Structured, retrospective telephone interviews with family and staff who attended to NH and RC/AL residents in the last month of life. SETTING: A stratified sample of 26 NH and 55 RC/AL facilities in four states. Participants: Family members (n=97) and long-term care (LTC) staff (n=104) identified as most involved in care of 124 residents who died over a 15-month period. MEASUREMENTS: A variety of reported measures of care and symptoms before death, including the Discomfort Scale for Dementia of the Alzheimer's Type. RESULTS: Of 124 decedents, 27 (22%) received hospice services. Dementia was less common in hospice enrollees than in decedents who did not receive hospice care. Hospice enrollees more often had moderate/severe pain and dyspnea and received pain treatment and were more likely to receive assistance with mouth care and eating and drinking. There were no differences related to unmet need, and observed differences were largely eliminated when comparisons were limited to residents whose deaths were expected. CONCLUSION: Rates of hospice use observed in this study (22%) were considerably higher than previously reported, although persons with dementia may continue to be underreferred. Hospice use is targeted to dying residents with higher levels of reported pain and dyspnea. Because difference in care largely disappears in cases when death was expected, LTC staff seem to be well positioned to provide end-of-life care for their residents and are advised to remain sensitive to instances in which death may be expected. [ABSTRACT FROM AUTHOR]

(See editorial comments by Dr. Lois Evans on pp 1957–1958)To evaluate the efficacy of two nonpharmacological techniques in reducing agitation, aggression, and discomfort in nursing home residents with dementia. The techniques evaluated were person-centered showering and the towel bath (a person-centered, in-bed bag-bath with no-rinse soap).A randomized, controlled trial, with a usual-care control group and two experimental groups, with crossover.Nine skilled nursing facilities in Oregon and six in North Carolina.Seventy-three residents with agitation during bathing (69 completed the trial) and 37 nursing assistants who bathed them.Agitation and aggression were measured using the Care Recipient Behavior Assessment; discomfort was measured using a modification of the Discomfort Scale for Dementia of the Alzheimer Type. Raters who were blinded to subject status coded both from videotaped baths. Secondary measures of effect included bath duration, bath completeness, skin condition, and skin microbial flora.All measures of agitation and aggression declined significantly in both treatment groups but not in the control group, with aggressive incidents declining 53% in the person-centered shower group (P<.001) and 60% in the towel-bath group (P<.001). Discomfort scores also declined significantly in both intervention groups (P<.001) but not in the control group. The two interventions did not differ in agitation/aggression reduction, but discomfort was less with the towel bath (P=.003). Average bath duration increased significantly (by a mean of 3.3 minutes) with person-centered showering but not with the towel bath. Neither intervention resulted in fewer body parts being bathed; both improved skin condition; and neither increased colonization with potentially pathogenic bacteria, corynebacteria, orCandida albicans.Person-centered showering and the towel bath constitute safe, effective methods of reducing agitation, aggression, and discomfort during bathing of persons with dementia. [ABSTRACT FROM AUTHOR]

(Editorial comments by Drs. Kathy Ruckdeschel and Ira Katz on pp 1774–1775).To examine the prevalence, correlates, and medication management of behavioral symptoms in elderly people living in residential care/assisted living (RC/AL) facilities.Cross-sectional study.A stratified random sample of 193 RC/AL facilities in four states (Florida, Maryland, New Jersey, North Carolina).A total of 2,078 RC/AL residents aged 65 and older.Behavioral symptoms were classified using a modified version of the Cohen-Mansfield Agitation Inventory. Additional items on resistance to care were also examined.Approximately one-third (34%) of RC/AL residents exhibited one or more behavioral symptoms at least once a week. Thirteen percent exhibited aggressive behavioral symptoms, 20% demonstrated physically nonaggressive behavioral symptoms, 22% expressed verbal behavioral symptoms, and 13% resisted taking medications or activities of daily living care. Behavioral symptoms were associated with the presence of depression, psychosis, dementia, cognitive impairment, and functional dependency, and these relationships persisted across subtypes of behavioral symptoms. Overall, behavioral symptoms were more prevalent in smaller facilities. More than 50% of RC/AL residents were taking a psychotropic medication, and two-thirds had some mental health problem indicator (dementia, depression, psychosis, or other psychiatric illness).Integrating mental health services within the process of care in RC/AL is needed to manage and accommodate the high prevalence of behavioral symptoms in this evolving long-term setting. [ABSTRACT FROM AUTHOR]

To define the current state of end-of-life care in residential care/assisted living (RC/AL) facilities and nursing homes (NHs) and to compare these two types of care settings. Interviews of staff and family informants about deaths that occurred during a longitudinal study. Fifty-five RC/AL facilities and 26 NHs in Florida, Maryland, New Jersey, and North Carolina. Two hundred twenty-four staff and family informants that best knew the 73 RC/AL residents and 72 NH residents who died in or within 3 days after discharge from a study facility. Telephone interviews conducted with the facility staff member who knew the decedent best and the family member who was most involved in care during the last month of life of the decedent. Data were collected on circumstances of death, perceptions of dying process, cause of death, care during the last month of life, mood, discomfort, and family satisfaction. Most decedents died in the facility where they had resided, and more than half of the subjects were alone when they died. Greater proportions of staff and family in the NHs knew that the resident's death was only days or weeks away. Both RC/AL and NH residents experienced few highly negative moods, and even on their most uncom-fortable day, the overall discomfort was low for residents in both facility types. Summary ratings of family satisfaction were significantly higher for the RC/AL (32.1) than the NH (41.2) group ( P=.016). These data suggest that end-of-life care in RC/AL settings appears similar in process and outcomes to that provided in NHs. Thus, aging and dying-in-place can effectively occur in RC/AL. [ABSTRACT FROM AUTHOR]

OBJECTIVES: Determine the relationship between a broad array of structure and process elements of nursing home care and (a) resident infection and (b) hospitalization for infection. DESIGN: Baseline data were collected from September 1992 through March 1995, and residents were followed for 2 years; facility data were collected at the midpoint of follow-up. SETTING: A stratified random sample of 59 nursing homes across Maryland. PARTICIPANTS: Two thousand fifteen new admissions aged 65 and older. MEASUREMENTS: Facility-level data were collected from interviews with facility administrators, directors of nursing, and activity directors; record abstraction; and direct observation. Main outcome measures included infection (written diagnosis, a course of antibiotic therapy, or radiographic confirmation of pneumonia) and hospitalization for infection (indicated on medical records). RESULTS: The 2-year rate of infection was 1.20 episodes per 100 resident days, and the hospitalization rate for infection was 0.17 admissions per 100 resident days. Except for registered nurse (RN) turnover, which related to both infection and hospitalization, different variables related to each outcome. High rates of incident infection were associated with more Medicare recipients, high levels of physical/occupational therapist staffing, high licensed practical nurse staffing, low nurses' aide staffing, high intensity of medical and therapeutic services, dementia training, staff privacy, and low levels of psychotropic medication use. High rates of hospitalization for infection were associated with for-profit ownership, chain affiliation, poor environmental quality, lack of resident privacy, lack of administrative emphasis on staff satisfaction, and low family/friend visitation rates. Adjustment for resident sex, age, race, education, marital status, number of morbid diagnoses, functional status, and Resource Utilization Group, Version III score did not alter the relationship between the... [ABSTRACT FROM AUTHOR]

OBJECTIVES: TTo investigate cross-validated methods of identifying patients at increased risk of fracture in nursing homes using readily available data. DESIGN: Prospective cohort study with 18 months of follow-up. SETTING: Forty-seven randomly selected nursing homes in Maryland. PARTICIPANTS: One thousand four hundred twenty-seven white female nursing home residents aged 65 and older were followed for fracture for 18 months after baseline assessment. MEASUREMENTS: Fracture ascertained by physician note or x-ray from chart abstraction; demographic and baseline data extracted from the Minimum Data Set (MDS). RESULTS: Exploratory analyses on a random subset (67%) of the data (development sample) identified variables that might be important in predicting subsequent fracture and included variables for how the resident moved between locations in her room or adjacent corridor (mobility), age, weight, height, independence in eating and dressing, urinary incontinence, resistance to care, falls in the previous 6 months, a dementia score, and other activities of daily living. A simple scoring algorithm derived from a subset of these MDS variables showed good sensitivity (.70) but low specificity (.39) in the random validation sample. CONCLUSION: A scoring algorithm developed in more than 1,400 white females from 47 nursing homes in the state of Maryland shows high sensitivity for identifying women at increased risk for fracture and may be useful in targeting fracture prevention programs. [ABSTRACT FROM AUTHOR]

OBJECTIVES: To identify the extent to which inappropriately prescribed medications (IPMs) are administered to older patients in residential care/assisted living (RC/AL) facilities and to describe facility and resident factors associated with receipt of one or more IPMs. DESIGN: Cross-sectional study of a stratified, representative sample of 193 facilities in four states. SETTING: We identified representative geographic regions within Florida, New Jersey, North Carolina, and Maryland and drew from within them a stratified random sample of 193 RC/AL facilities. Three subtypes of facilities were included in the sample: small homes (<16 beds), larger “new-model” homes, and larger “traditional” homes. PARTICIPANTS: Within each larger home, a random sample of residents aged 65 and older was approached for consent; in smaller homes all residents were approached. The overall enrollment rate was 92%; 2,078 residents were enrolled. MEASUREMENTS: Questionnaires and on-site observations were used to gather data on facility administration and staffing and resident characteristics. All prescription and nonprescription medications taken at least 4 of the 7 days before data collection were taken from medication administration records and coded for analysis. IPM designation was based on modification of a list developed by Beers et al. and currently used by nursing home surveyors. RESULTS: The majority of RC/AL patients were taking five or more medications; 16.0% of these patients were receiving IPMs. The most common IPMs were oxybutynin, propoxyphene, diphenhydramine, ticlopidine, doxepin, and dipyridamole. In multivariate analyses, using generalized estimating equations, IPM use was associated with the number of medications received, smaller facility bed size, moderate licensed practical nurse turnover, absence of dementia, low monthly fees, and absence of weekly physician visits. CONCLUSIONS: IPMs remain a problem in long-term care, but rates in... [ABSTRACT FROM AUTHOR]

A letter to the editor is presented in response to a study examining the inappropriate and excessive use of antipsychotic medications to manage the behavioral and psychological symptoms of dementia.

The article discusses research which was conducted to investigate the challenges of providing cost-effective care to older adults with multiple chronic conditions through the Program of All-Inclusive Care for the Elderly (PACE) and to identify solutions to the challenges which have been developed by PACE providers. Researchers conducted interviews with medical directors from 16 PACE programs. They found that unintended adverse outcomes and cost without benefit were the two main challenges.