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Objective: The care processes directed towards institutionalized older people needs to be tailored on goals and priorities that are relevant for this specific population. The aim of the present study was (a) to describe the distribution of selected health determinants in a sample of institutionalized older adults, and (b) to investigate the impact on survival of such measures., Design: Multicentre longitudinal cohort-study., Setting: 57 nursing homes (NH) in 7EU countries (Czech Republic, England, Finland, France, Germany, Italy, The Netherlands) and 1 non-EU country (Israel)., Participants: 3036 NH residents participating in the Services and Health for Elderly in Long TERm care (SHELTER) study., Measurements: We described the distribution of 8 health determinants (smoking habit, alcohol use, body mass index [BMI], physical activity, social participation, family visits, vaccination, and preventive visits) and their impact on 1-year mortality., Results: During the one-year follow up, 611 (20%) participants died. Overweight (HR 0.79; 95% C.I. 0.64-0.97) and obesity (HR 0.64; 95% C.I. 0.48-0.87) resulted associated with lower mortality then normal weight. Similarly, physical activity (HR 0.67; 95% C.I. 0.54-0.83), social activities (HR 0.63; 95% C.I. 0.51-0.78), influenza vaccination (HR 0.66; 95% C.I. 0.55-0.80) and pneumococcal vaccination (HR 0.76 95% C.I. 0.63-0.93) were associated with lower mortality. Conversely, underweight (HR 1.28; 95% C.I. 1.03-1.60) and frequent family visits (HR 1.75; 95% C.I. 1.27-2.42) were associated with higher mortality., Conclusions: Health determinants in older NH residents depart from those usually accounted for in younger and fitter populations. Ad hoc studies are warranted in order to describe other relevant aspects of health in frail older adults, with special attention on those institutionalized, with the ultimate goal of improving the quality of care and life., (Copyright © 2017 Elsevier B.V. All rights reserved.)

Background: Influenza and pneumococcal vaccines have been proved to be effective and safe in preventing and controlling infection among elderly, reducing morbidity and mortality. However, some evidences raised health concerns related to these vaccinations. This study aims to identify prevalence and outcomes related to influenza and pneumococcal vaccinations in a large European population of frail old people living in nursing homes (NHs)., Methods: We conducted a survival analysis of NH residents participating to the Services and Health for Elderly in Long-TERm project, a prospective cohort study collecting information on residents admitted to 57 NH in eight countries (Czech Republic, England, Finland, France, Germany, Italy, The Netherlands and Israel). Clinical and demographical data were collected using the international resident assessement instrument for long-term care facilities. Incident mortality was recorded during 1-year follow-up. A shared-frailty Cox regression model was used to assess the impact of vaccination status on mortality., Results: Mean age of 3510 participants was 84.6 years (SD = 7.7). In total, 81.7 and 27.0% received influenza and pneumococcal vaccination, respectively. Overall, 727 (20.7%) residents died during the follow-up period. After adjusting for potential confounders, which included age, sex, number of diseases, depression, cognitive and functional status, influenza (HR = 0.80; 95% CI 0.66-0.97) and the combination of influenza and pneumococcal vaccination (HR = 0.72; 95% CI 0.57-0.91), but not pneumococcal vaccination alone (HR = 0.52; 95% CI 0.25-1.06), were associated with a statistically significant reduction in mortality in respect of no vaccinations., Conclusion: In a population of older adult living in NH influenza and the combination of influenza and pneumococcal vaccination were associated with a reduction in all-cause mortality respect to no vaccination., (© The Author 2017. Published by Oxford University Press on behalf of the European Public Health Association. All rights reserved.)

Objective: Among elderly individuals with dementia, the use of antipsychotics has been associated with serious adverse events including ischemic stroke and death. Multiple medications can interact with antipsychotics and increase the risk of such adverse events. The purpose of this retrospective, longitudinal cohort study was to estimate the prevalence of potential antipsychotic drug interactions and their effect on increasing the risk of death among cognitively impaired elderly individuals treated with antipsychotics., Methods: We conducted a retrospective longitudinal cohort study in 59 nursing homes of 7 European Union countries and Israel. The study was conducted during the years 2009 to 2011. Participants were cognitively impaired individuals aged 65 years or older residing in the participating nursing homes and being treated with antipsychotics (N = 604). Risk of death associated with potential antipsychotic drug interactions was the main outcome. The inter-Resident Assessment Instrument for Long Term Care Facilities (interRAI LTCF) was used to assess participants. Follow-up time was 12 months., Results: The prevalence of potential antipsychotic drug interactions was 46.0%. Antipsychotic drug interactions were associated with higher mortality (incidence rate of 0.26 per person-year in the antipsychotic drug-interaction group versus 0.17 per person year in the no antipsychotic drug-interaction group). After adjusting for potential confounders, risk of death was higher in the group of residents with potential antipsychotic drug interactions relative to those unexposed to such interactions (hazard ratio = 1.71; 95% CI, 1.15-2.54)., Conclusions: Part of the observed excess risk of death associated with the use of antipsychotic medications in elderly individuals with cognitive impairment may be attributable to antipsychotic drug interactions. Antipsychotics should be used with extreme caution especially among those individuals receiving concomitant cardiovascular or psychotropic medications., (© Copyright 2017 Physicians Postgraduate Press, Inc.)

Background: Concurrent vision and hearing impairment, known as dual sensory impairment (DSI), is associated with increased mortality. We aimed to examine individual and joint associations of DSI and involvement in activities with mortality in a large European nursing home study., Methods: In total, 2,851 nursing home residents in 59 facilities in eight countries were followed for 1 year in the Services and Health for Elderly in Long TERm Care study. Vision and hearing impairment and average time of involvement in activities were assessed by trained research staff using the interRAI Long Term Care Facilities. Association between DSI and 1-year all-cause mortality was examined using Cox proportional hazards models adjusted for age, sex, facility, diagnoses of coronary heart disease and diabetes mellitus, self-rated health, end-stage disease, and functional and cognitive status. The modifying effect of involvement in activities on the association was investigated by the additive hazard model., Results: DSI, defined as moderate to severe impairment in both senses, was independently associated with a 35% increased risk of 1-year mortality compared with non-DSI. Residents with DSI who were involved in activities did not have higher mortality, while residents with DSI who were not involved in activities had 51% higher mortality than non-DSI residents who were involved in activities, equivalent to approximately 209 additional deaths per 1,000 person-years (p = .012) due to the interaction between DSI and no involvement in activities., Conclusions: DSI is associated with increased mortality at nursing homes when combined with no involvement in activities., (© The Author 2015. Published by Oxford University Press on behalf of The Gerontological Society of America. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Objectives: To investigate if dual sensory impairment (DSI) in the form of a combined visual and hearing impairment is associated with the onset of behavioral symptoms in nursing homes., Methods: A total of 1524 nursing home residents without behavioral symptoms at baseline followed for 12 months in 59 nursing homes from the Czech Republic, England, Finland, France, Germany, Israel, Italy, and The Netherlands. The interRAI instrument for long-term care facilities was assessed by trained staff at baseline and 12 months later., Results: Altogether, 11% of residents had a new onset of behavioral symptoms (wandering, verbal abuse, physical abuse, socially inappropriate behavior, public disrobing, and resisting care) at 12-month follow-up. In multivariate analyses adjusted for potential confounders, DSI residents had significantly higher incidence of new behavioral symptoms at 12-month follow-up, irrespective of the severity of vision and hearing impairments [odds ratio (OR) = 2.1, 95% confidence interval (CI) = 1.3:3.4 for mild DSI, OR = 2.5, 95% CI = 1.6:4.0 for moderate DSI, and OR = 2.1, 95% CI = 1.2:3.7 for severe DSI] compared with residents without sensory impairment. Among the different types of symptoms, only abusive behaviors were less likely to be associated with DSI., Conclusions: This study provides evidence that DSI could play a significant role in the development of behavioral symptoms in nursing home residents. More attention should be paid to DSI even when each of vision and hearing function is only minimally impaired., (Copyright © 2015 AMDA – The Society for Post-Acute and Long-Term Care Medicine. Published by Elsevier Inc. All rights reserved.)

Objectives: To assess insomnia and its correlates as part of the Services and Health for Elderly in Long TERm care (SHELTER) study, funded by the 7th Framework Programme of the European Union., Design: Cross-cultural investigation., Setting: Long-term care facilities (LTCFs) in eight European countries (Czech Republic, France, Finland, Germany, England, the Netherlands, Italy) and one non-European country (Israel)., Participants: Elderly residents (N = 4,156) of 57 LTCFs., Measurements: Information on insomnia, age, sex, activities of daily living (ADLs), cognitive status, depression, major stressful life events, physical activity, fatigue, pain, and sleep medication use was extracted from the International Resident Assessment Instrument (interRAI)LTCF instrument. Rates of insomnia and its correlates were analyzed. Multivariate logistic regression was used to assess factors associated with insomnia, controlling for demographic variables., Results: The prevalence of insomnia was 24% (range 13-30%), with significant differences between countries (P < .001). More insomnia complaints were reported in older than younger residents (P < .001). Higher rates of insomnia were associated with hypnosedatives and depression in all countries (P < .001) and with stressful life events, fatigue, and pain in most countries (P < .001). No associations were found between insomnia and ADLs, physical activity, or cognitive status. Age, depression, stressful life events, fatigue, pain and hypnosedatives were independent significant predictors of insomnia, controlling for all other variables and for country., Conclusion: Hypnosedatives and depression were strong predictors of insomnia beyond cultural differences. Overall, psychosocial variables were more strongly related to insomnia than functional and mental capacities., (© 2014, Copyright the Authors Journal compilation © 2014, The American Geriatrics Society.)

Background: Visual and hearing impairments are known to be related to functional disability, cognitive impairment, and depression in community-dwelling older people. The aim of this study was to examine the prevalence of sensory impairment in nursing home residents, and whether sensory impairment is related to other common clinical problems in nursing homes, mediated by functional disability, cognitive impairment, and depressive symptoms., Methods: Cross-sectional data of 4007 nursing home residents in 59 facilities in 8 countries from the SHELTER study were analyzed. Visual and hearing impairments were assessed by trained staff using the interRAI instrument for Long-Term Care Facilities. Generalized linear mixed models adjusted for functional disability, cognitive impairment, and depressive symptoms were used to analyze associations of sensory impairments with prevalence of clinical problems, including behavioral symptoms, incontinence, fatigue, falls, problems with balance, sleep, nutrition, and communication., Results: Of the participants, 32% had vision or hearing impairment (single impairment) and another 32% had both vision and hearing impairments (dual impairment). Residents with single impairment had significantly higher rates of communication problems, fatigue, balance problems, and sleep problems, as compared with residents without any sensory impairment. Those with dual impairment had significantly higher rates of all clinical problems assessed in this study as compared with those without sensory impairment. For each clinical problem, the magnitude of the odds ratio for specific clinical problems was higher for dual impairment than for single impairment., Conclusion: Visual and hearing impairments are associated with higher rates of common clinical problems among nursing home residents, independent of functional disability, cognitive impairment, and depressive symptoms., (Copyright © 2014 AMDA – The Society for Post-Acute and Long-Term Care Medicine. Published by Elsevier Inc. All rights reserved.)

Objective: To identify pharmacological and nonpharmacological pain management approaches and associated factors in nursing home residents across Europe., Setting, Participants, and Measurements: Cross-sectional study with 4156 residents who were assessed using the interRAI instrument for Long Term Care Facilities (interRAI LTCF), including pharmacological and nonpharmacological pain management modalities. Those reporting pain were included in the analyses (n = 1900). A deeper analysis was performed for the subsample of residents who reported "current pain," defined as pain at least 1 day within the past 3 days (n = 838), and those who reported "current pain of moderate to severe intensity" (n = 590)., Results: Up to 24% of residents who reported pain did not receive any pain medication and up to 11% received it only PRN (as-needed basis), independent of current pain-intensity levels; 61% did not receive any nonpharmacological treatment and 21% received neither pharmacological nor nonpharmacological pain modalities. Considerable differences could be demonstrated across European countries. Factors positively associated with pharmacological pain management were being of female gender, reporting cancer, and having moderate or severe pain. High turnover rates of regular staff and low-to-moderate physicians' availability were negatively associated. Factors positively associated with nonpharmacological treatment were fractures and need of assistance in activities of daily living. Dementia, large nursing home facilities, above-average and high turnover rates of nursing staff, a low physicians' availability, and severe pain intensity were negatively associated., Conclusion: Despite some advances in recent years, pain treatment in European nursing home residents remains to be suboptimal and requires further improvement., (Copyright © 2013 American Medical Directors Association, Inc. Published by Elsevier Inc. All rights reserved.)

Objective: Pharmacological treatment of older adults with cognitive impairment represents a challenge for prescribing physicians, and polypharmacy is common in these complex patients. The aim of the current study is to assess prevalence and factors related to polypharmacy in a sample of nursing home (nursing home) residents with advanced cognitive impairment., Methods: We conducted a cross-sectional analysis of 1449 nursing home residents with advanced cognitive impairment participating to the Services and Health for Elderly in Long Term Care (SHELTER) project, a study collecting information on residents admitted to 57 nursing home in eight countries. Data were collected using the International Resident Assessment Instrument (InterRAI) for long-term care facilities. Polypharmacy status was categorized into three groups: nonpolypharmacy (zero to four drugs), polypharmacy (five to nine drugs), and excessive polypharmacy (≥10 drugs)., Results: Polypharmacy was observed in 735 residents (50.7%) and excessive polypharmacy was seen in 245 (16.9%). Compared with nonpolypharmacy, excessive polypharmacy was associated directly with ischemic heart disease (odds ratio [OR], 3.68; 95% confidence interval [CI], 2.01-6.74), diabetes mellitus (OR, 2.66; 95% CI; 1.46-4.84), Parkinson's disease (OR, 2.84; 95% CI, 1.36-5.85), gastrointestinal symptoms (OR, 1.20; 95% CI, 1.43-3.39), pain (OR, 3.12; 95% CI, 1.99-4.89), dyspnea (OR, 2.57; 95% CI, 1.31-5.07), and recent hospitalization (OR, 2.56; 95% CI, 1.36-5.85). An inverse relation with excessive polypharmacy was shown for age (OR, 0.74; 95% CI, 0.59-0.93), activities of daily living disability (OR, 0.79; 95% CI, 0.63-0.99) and presence of a geriatrician on the nursing home staff (OR, 0.36; 95% CI, 0.20-0.64)., Conclusion: Polypharmacy and excessive polypharmacy are common among nursing home residents with advanced cognitive impairment. Determinants of polypharmacy status includes not only comorbidities, but also specific symptoms, age, and functional status. A geriatrician in the facility is associated with lower prevalence of excessive polypharmacy., (Copyright © 2013 The Alzheimer's Association. Published by Elsevier Inc. All rights reserved.)

Objective and Design: Few studies have compared cross-national characteristics of residents with pain in European long term care facilities. The SHELTER project, a cross-national European study on nursing home residents, provides the opportunity to examine this issue. The present study aimed to evaluate key figures about pain and compare them with seven European countries and Israel., Setting, Participants, and Measurements: A total of 3926 nursing home residents were assessed by the interRAI instrument for Long Term Care Facilities (interRAI LTCF). Prevalence of pain, frequency, intensity, consistency, and control were estimated and compared cross-nationally. Correlates between patient-related characteristics and inadequate pain management were tested using bivariate and multivariate logistic regression models., Results: Overall, 1900 (48.4%) residents suffered from pain. Pain prevalence varied significantly among countries, ranging from 19.8% in Israel to 73.0% in Finland. Pain was positively associated with female gender, fractures, falls, pressure ulcers, sleeping disorders, unstable health conditions, cancer, depression, and number of drugs. It was negatively associated with dementia. In a multivariate logistic regression model, all associations remained except for sleeping disorders. Clinical correlations varied considerably among countries. Although in 88.1% of cases, pain was self-rated by the residents as sufficiently controlled, in only 56.8% of cases was pain intensity self-rated as absent or mild. Pain control and intensity improved within 1 year., Conclusion: Pain prevalence is high and varies considerably across Europe. Although most residents considered pain as adequately controlled, a closer look confirmed that many still suffer from high pain intensities. Analyzing the reasons behind these differences may help to improve pain management., (Copyright © 2013 American Medical Directors Association, Inc. Published by Elsevier Inc. All rights reserved.)

Introduction: Older adults with advanced cognitive impairment have a limited life expectancy and the use of multiple drugs is of questionable benefit in this population. The aim of the present study was to assess if, in a sample of nursing home (NH) residents with advanced cognitive impairment, the effect of polypharmacy on mortality differs depending on estimated life expectancy., Methods: Data were from the Services and Health for Elderly in Long TERm care (SHELTER) project, a study collecting information on residents admitted to 57 NHs in 8 European countries. Polypharmacy was defined as the concomitant use of 10 or more drugs. Limited life expectancy was estimated based on an Advanced Dementia Prognostic Tool (ADEPT) score of 13.5 or more. A Cognitive Performance Scale score of 5 or more was used to define advanced cognitive impairment. Participants were followed for 1 year., Results: Mean age of 822 residents with advanced cognitive impairment entering the study was 84.6 (SD 8.0) years, and 630 (86.6%) were women. Overall, 123 participants (15.0%) had an ADEPT score of 13.5 or more (indicating limited life expectancy) and 114 (13.9%) were on polypharmacy. Relative to residents with ADEPT score less than 13.5, those with ADEPT score of 13.5 or higher had a lower use of benzodiazepines, antidementia drugs, and statins but a higher use of beta-blockers, digoxin, and antibiotics. Polypharmacy was associated with increased mortality among residents with ADEPT score of 13.5 or more (adjusted hazard ratio [HR] 2.19, 95% confidence interval [CI]: 1.15-4.17), but not among those with ADEPT score less than 13.5 (adjusted HR 1.10, 95% CI: 0.71-1.71)., Discussion: Polypharmacy is associated with increased mortality in NH residents with advanced cognitive impairment at the end of life., Conclusion: These findings underline the need to assess life expectancy in older adults to improve the prescribing process and to simplify drug regimens., (Copyright © 2013 American Medical Directors Association, Inc. Published by Elsevier Inc. All rights reserved.)

Background: This study assesses prevalence and patients characteristics related to polypharmacy in a sample of nursing home residents., Methods: We conducted a cross-sectional analysis on 4,023 nursing home residents participating to the Services and Health for Elderly in Long TERm care (SHELTER) project, a study collecting information on residents admitted to 57 nursing home in 8 countries. Data were collected using the interRAI instrument for long-term care facilities. Polypharmacy status was categorized in 3 groups: non-polypharmacy (0-4 drugs), polypharmacy (5-9 drugs) and excessive polypharmacy (≥ 10 drugs)., Results: Polypharmacy was observed in 2,000 (49.7%) residents and excessive polypharmacy in 979 (24.3%) residents. As compared with non-polypharmacy, excessive polypharmacy was directly associated not only with presence of chronic diseases but also with depression (odds ratio [OR] 1.81; 95% confidence interval [CI] 1.38-2.37), pain (OR 2.31; 95% CI 1.80-2.97), dyspnoea (OR 2.29; 95% CI 1.61-3.27), and gastrointestinal symptoms (OR 1.73; 95% CI 1.35-2.21). An inverse association with excessive polypharmacy was shown for age (OR for 10 years increment 0.85; 95% CI 0.74-0.96), activities of daily living disability (OR for assistance required vs independent 0.90; 95% CI 0.64-1.26; OR for dependent vs independent 0.59; 95% CI 0.40-0.86), and cognitive impairment (OR for mild or moderate vs intact 0.64; 95% CI 0.47-0.88; OR for severe vs intact 0.39; 95% CI 0.26-0.57)., Conclusions: Polypharmacy and excessive polypharmacy are common among nursing home residents in Europe. Determinants of polypharmacy status include not only comorbidity but also specific symptoms, age, functional, and cognitive status.

Background: Aims of the present study are the following: 1. to describe the rationale and methodology of the Services and Health for Elderly in Long TERm care (SHELTER) study, a project funded by the European Union, aimed at implementing the interRAI instrument for Long Term Care Facilities (interRAI LTCF) as a tool to assess and gather uniform information about nursing home (NH) residents across different health systems in European countries; 2. to present the results about the test-retest and inter-rater reliability of the interRAI LTCF instrument translated into the languages of participating countries; 3 to illustrate the characteristics of NH residents at study entry., Methods: A 12 months prospective cohort study was conducted in 57 NH in 7 EU countries (Czech Republic, England, Finland, France, Germany, Italy, The Netherlands) and 1 non EU country (Israel). Weighted kappa coefficients were used to evaluate the reliability of interRAI LTCF items., Results: Mean age of 4156 residents entering the study was 83.4 ± 9.4 years, 73% were female. ADL disability and cognitive impairment was observed in 81.3% and 68.0% of residents, respectively. Clinical complexity of residents was confirmed by a high prevalence of behavioral symptoms (27.5% of residents), falls (18.6%), pressure ulcers (10.4%), pain (36.0%) and urinary incontinence (73.5%). Overall, 197 of the 198 the items tested met or exceeded standard cut-offs for acceptable test-retest and inter-rater reliability after translation into the target languages., Conclusion: The interRAI LTCF appears to be a reliable instrument. It enables the creation of databases that can be used to govern the provision of long-term care across different health systems in Europe, to answer relevant research and policy questions and to compare characteristics of NH residents across countries, languages and cultures., (© 2012 Onder et al; licensee BioMed Central Ltd.)