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National (and global) vaccination provides an opportunity to control the COVID-19 pandemic, which disease suppression by societal lockdown and individual behavioural changes will not. We modelled how vaccination through the UK's vaccine priority groups impacts deaths, hospital and ICU admissions from COVID-19. We used the UK COVID-19 vaccines delivery plan and publicly available data to estimate UK population by age group and vaccination priority group, including frontline health and social care workers and individuals deemed 'extreme clinical vulnerable' or 'high risk'. Using published data on numbers and distributions of COVID-19-related hospital and ICU admissions and deaths, we modelled the impact of vaccination by age group. We then modified the model to account for hospital and ICU admission, and death among health and social care workers and the population with extreme clinical vulnerability and high risk. Our model closely matches the government's estimates for mortality after vaccination of priority groups 1-4 and groups 1-9. The model shows vaccination will have a much slower impact on hospital and ICU admissions than on deaths. The early prioritisation of healthcare staff and clinically vulnerable patients increases the impact of vaccination on admissions and also protects the healthcare service. An inflection point, when 50% of the adult population has been vaccinated - with deaths reduced by 95% and hospital admissions by 80% - may be a useful point for re-evaluating vaccine prioritisation. Our model suggests substantial reductions in hospital and ICU admissions will not occur until late March and into April 2021., (© 2021 Association of Anaesthetists.)

In this cohort study, we aim to compare outcomes from coronavirus disease 2019 (COVID-19) in people with severe epilepsy and other co-morbidities living in long-term care facilities which all implemented early preventative measures, but different levels of surveillance. During 25-week observation period (16 March-6 September 2020), we included 404 residents (118 children), and 1643 caregivers. We compare strategies for infection prevention, control, and containment, and related outcomes, across four UK long-term care facilities. Strategies included early on-site enhancement of preventative and infection control measures, early identification and isolation of symptomatic cases, contact tracing, mass surveillance of asymptomatic cases and contacts. We measured infection rate among vulnerable people living in the facilities and their caregivers, with asymptomatic and symptomatic cases, including fatality rate. We report 38 individuals (17 residents) who tested severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)-positive, with outbreaks amongst residents in two facilities. At Chalfont Centre for Epilepsy (CCE), 10/98 residents tested positive: two symptomatic (one died), eight asymptomatic on weekly enhanced surveillance; 2/275 caregivers tested positive: one symptomatic, one asymptomatic. At St Elizabeth's (STE), 7/146 residents tested positive: four symptomatic (one died), one positive during hospital admission for symptoms unrelated to COVID-19, two asymptomatic on one-off testing of all 146 residents; 106/601 symptomatic caregivers were tested, 13 positive. In addition, during two cycles of systematically testing all asymptomatic carers, four tested positive. At The Meath (TM), 8/80 residents were symptomatic but none tested; 26/250 caregivers were tested, two positive. At Young Epilepsy (YE), 8/80 children were tested, all negative; 22/517 caregivers were tested, one positive. Infection outbreaks in long-term care facilities for vulnerable people with epilepsy can be quickly contained, but only if asymptomatic individuals are identified through enhanced surveillance at resident and caregiver level. We observed a low rate of morbidity and mortality, which confirmed that preventative measures with isolation of suspected and confirmed COVID-19 residents can reduce resident-to-resident and resident-to-caregiver transmission. Children and young adults appear to have lower infection rates. Even in people with epilepsy and multiple co-morbidities, we observed a high percentage of asymptomatic people suggesting that epilepsy-related factors (anti-seizure medications and seizures) do not necessarily lead to poor outcomes., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Background: Enduring family engagement and informal support is crucial to the health and well-being of adults with developmental disabilities (DD) residing in supported accommodation. The COVID-19 pandemic and restrictive measures enforced in residential settings have resulted in changes in daily routine and modified the ways families can interact with and provide support to residents. Yet, the impact of these changes has not been empirically explored., Aim: Explore how family caregivers have interacted with and supported their relatives with DD residing in supported accommodation during the pandemic., Methods: Changes in frequencies of communication modes and types of informal support were measured through a cross-sectional and anonymous online survey which completed by 108 family caregivers of adults with DD., Results: Most family caregivers adopted remote communication technologies; however, these were not perceived to be effective in filling the gap created by reduced face-to-face contact. While families were able to provide emotional support and advocacy using digital technologies, they were limited in their ability to provide significant social support., Conclusions: Findings may help key stakeholders develop and implement novel strategies and policies to accommodate the changing circumstances and to ensure continuity of family engagement and informal support in the context of COVID-19., (Copyright © 2020 Elsevier Ltd. All rights reserved.)

Background Atrial fibrillation (AF) is a risk factor for stroke in older people. Oral anticoagulants can reduce stroke risk but they are commonly under prescribed in the elderly, often due to concerns regarding the risk of bleeding. Prescribing in aged care residents may also be further complicated by associated geriatric conditions such as dementia and risk of falls. Systematic assessment of stroke and bleed risk can help identify people with AF expected to benefit from anticoagulant therapy and optimise prescribing. Objective The aim of this study was to assess the prescribing of anticoagulants in elderly aged care residents in accordance with Australian guideline recommendations. Setting Nineteen aged care facilities across southeast Queensland. Method A clinical audit of anticoagulant therapy in aged care residents was conducted. Main outcome measure Information was collected from the records of residents with non-valvular AF to assess the risk of stroke and bleeding and compare this prescribing to current evidence-based guidelines for anticoagulation in AF. Results A total of 1754 residents were screened with 359 (20.4%) identified to have a diagnosis of non-valvular AF. There were 356 (99.2%) residents with non-valvular AF and a sufficiently high risk of stroke to warrant the use of an anticoagulant. Of these, 172 (48.3%) were prescribed an oral anticoagulant and 40 (11.2%) residents had a documented decision not to prescribe oral anticoagulants in their records. The majority of residents prescribed anticoagulation were receiving non-vitamin K antagonists (76.8%). The prescribed dose was consistent with recommendations for 44.8% of residents prescribed oral anticoagulant therapy. Conclusion Many residents with non-valvular AF and significant risk of stroke were not receiving oral anticoagulation despite a lack of documented reason for non-prescribing. Non-vitamin K antagonists were widely prescribed but dosing of these agents could still be improved. There remains a need to improve anticoagulant prescribing for aged care residents and optimise stroke prevention in this population.

Background Australian government funding for Residential Medication Management Reviews and Home Medicines Reviews commenced in 1997 and 2001 respectively. Limited data are available on their provision in Australia. Objective To investigate the extent and characteristics of Home Medicines Review and Residential Medication Management Review services provided by accredited pharmacists practising in Western Australia. Setting Pharmacists in Western Australia accredited by the Australian Association of Consultant Pharmacy or Society of Hospital Pharmacists of Australia. Method A paper questionnaire was developed and sent to 198 accredited pharmacists in Western Australia in June 2017. Simple descriptive statistics summarised demographic information and other responses. Logistic regression evaluated factors associated with the frequency of provision of Home Medicines Reviews. Main outcome measure Frequency and factors influencing services provided. Results Of 102 (51.5%) questionnaires returned, 67 (65.7%) respondents were female. Many were aged between 31 and 40 years (53; 52.0%). Most were accredited by the Australian Association of Consultant Pharmacy (101; 99.0%) and mainly offered Home Medicines Reviews (70; 68.6%). Home Medicines Reviews provided over the previous 12 months were limited in frequency with one quarter providing either 1-10 (27; 26.5%) or 21-50 (28; 27.5%) reviews. The median "average" preparation, interview and report writing times, plus communication with other health professionals aggregated to 175.0 min (interquartile range: 140.0-235.0 min) for Home Medicine Reviews and 110.0 min (90.0-140.0) for Residential Medication Management Reviews. Pharmacists born overseas and those who were accredited for a longer time were associated with performing 51 or more Home Medicines Reviews annually. Only one-third (36/101; 35.6%) agreed the current payment was appropriate. Most agreed their Home Medicines Reviews (92/96; 95.8%) and Residential Medication Management Reviews (26/28; 92.9%) provided improved patient outcomes. Over 97% of accredited pharmacists intended to continue to remain accredited. Conclusions Wide variations were evident in the times taken for tasks associated with performing reviews. Most respondents considered their medication reviews contributed to improved patient outcomes. The wide variation in times taken for the reviews suggests a tiered structure for service provision, with appropriate payment within each tier, since most consider current remuneration inadequate.

Background: The exponential rise in people living longer but requiring residential care is adding pressure to already overstretched aged care nurses. Consequently, a person-centred care culture in residential care remains aspirational, rather than a reality. For nursing students in Australia and elsewhere, clinical placements in aged care facilities are under-utilised due to negative perceptions about the likelihood for learning. Creative strategies to engage students to safely challenge ageist thinking and to inspire enthusiasm for learning in this context are needed., Objectives: The purpose of this thematic review of the literature is to better understand challenges related to learning in aged care settings and identify innovative strategies to enhance nursing student learning experiences in residential aged care placements., Review Methods: A literature review was undertaken in 2019 using CINAHL, PUBMED, Elsevier, Medline, ProQuest and Google Scholar. The search was limited to papers that were peer reviewed, in English, and published between 2001 and the date of review (mid-2019) in order to situate the review in the new millennium., Results: 47 articles and books were included in the review that introduce solutions and innovative strategies that could be used to improve students' attitudes to learning in aged care and from older people. The literature review was categorized into three main themes, including: barriers to working with older people; the need for pedagogical change to foster empathy; and innovative strategies to address barriers., Conclusion: These themes are useful to consider in designing engaging learning and teaching for nursing students to be effective in working in aged care., Competing Interests: Declaration of competing interest No conflict of interest has been declared by the authors., (Copyright © 2020. Published by Elsevier Ltd.)

Background: Simulation is used widely in health education to develop healthcare providers' knowledge and skills. The use of simulation however, as an educational strategy among aged care worker is not well understood., Objectives: This review sought to describe studies where simulation is used to educate healthcare providers working within aged care settings; describe the method and structure used in simulations in residential aged care; the key learning outcomes for the participants in this setting; and identify any gaps in the current literature to illuminate future research opportunities., Design: The review follows the Joanna Briggs Institute Scoping Review methodology and utilises the PRISMA-ScR Checklist. Searches of CINAHL Complete, PubMed and Scopus databases were completed using the search terms "Simulation" AND "training" AND "Aged Care" OR "Elderly" OR "Older People". Inclusion criteria were peer-reviewed, English, full-text articles published from database inception to July 2018., Results: Twenty studies were included in this review. Studies differed in their methodology, sample size and participants and their findings varied significantly. Fourteen studies originated from the United States of America, five from Canada, and one from Taiwan. Studies were published between 1977 and July 2018. Clinical topics used in simulation were aggression and violence; dementia; aging; death and dying; range of motion exercises; person-centred care; sepsis; and dressing residents. Simulation types were role play, simulated patients, and mannequins. Debrief was described in less than a third of studies. Just over half of the studies evaluated participant outcomes., Discussion/conclusion: This study demonstrated a large paucity of evidence utilising simulation for training within aged care settings. It highlights the need for future research in this area where simulation could be utilised to meet the unique learning needs of nurses working in aged care., (Copyright © 2019. Published by Elsevier Ltd.)

Objective: Dependency on others can compromise self-determination for older persons in the palliative phase in residential care. Family members can support the residents' self-determination but may also jeopardize it. Quality of care (QoC) is linked to respecting the autonomy of the residents and providing opportunities to participate in decision-making. The aim of the study was to provide knowledge about residents' and family members' perceptions of QoC and self-determination and to detect possible differences between their experiences., Method: This cross-sectional study used an abbreviated version of the questionnaire, Quality from the Patients' Perspective, with additional items about decision-making. Wilcoxon's signed rank test was used to analyze the perception of QoC and to detect differences between residents' and family members' perceptions., Result: QoC was perceived as lower than preferred in the majority of items and there was a high level of agreement between residents and family members. Lowest mean values in QoC were found in: support when feeling lonely; support when feeling worry, anxiety or fear; and staff's time to talk to the residents. Decision-making in everyday life and in life-changing situations showed that neither residents nor family members trusted staff to know about the residents' preferences., Significance of Results: Broad improvements are needed, especially in psychosocial care. Several of the negative outcomes on QoC and self-determination seem to derive from a focus on practical tasks and the lack of trustful relationships between residents and staff. An early implementation of palliative care, with a focus on what brings quality to each resident's life, could facilitate QoC and self-determination, in both everyday life and at the end of life.

Background: Few studies have examined patient characteristics and treatment patterns among patients with dementia and agitation in the United States (US)., Objective: To examine real-world treatment patterns and characteristics of patients with agitation related to dementia who were treated with antipsychotics in US residential care and community-based settings., Methods: This retrospective chart review collected US physician-level data from patients 55 to 90 years old initiated on an antipsychotic medication for the treatment of agitation related to dementia from January 2018 to May 2018. Clinical characteristics and treatment patterns were assessed overall and stratified by residential care and community-based settings., Results: A total of 313 participating physicians, 59.5% of whom were primary care physicians, abstracted 801 patient charts (residential care: n = 312; community-based: n = 489). Of patients with agitation who were initiated on an antipsychotic, most patients (74.5%) were initiated within 3 months of the onset of their studied agitation episode, and 62.8% experienced multiple agitation episodes before initiation. While non-pharmacological therapies are recommended first-line approach for agitation in dementia, use of non-pharmacological therapy before initiation of antipsychotics was reported for only 37.8% of patients in residential care and 21.3% in community-based settings., Conclusion: Most patients were initiated on an antipsychotic treatment after multiple episodes of agitation and largely without initial non-pharmacological therapy, suggesting that current treatment guideline recommendations for first-line non-pharmacological intervention may not be adequately followed in clinical practice. Understanding the clinical burden and treatment patterns among dementia patients with agitation is imperative for effective disease management.

Aged residential care (ARC) admission needs are increasing beyond the available capacity in many countries, including New Zealand. Therefore, identifying modifiable factors which may prevent or delay ARC admissions is of international importance. Hearing impairment is common among older adults and thought to be an important predictor, although the current evidence-base is equivocal. Using the largest national database to date, competing-risk regression analysis was undertaken on 34,277 older adults having standardised home care assessments between 1 July 2012 and 31 May 2014, aged ≥65 years, and still living in the community 30 days after that assessment. Minimal hearing difficulty was reported by 10,125 (29.5%) participants, moderate difficulty by 5,046 (14.7%), severe difficulty/no hearing by 1,334 (3.9%), while 17,769 (51.8%) participants reported adequate hearing. By 30 June 2014, the study end-point, 6,389 (18.6%) participants had an ARC admission while 6,082 (17.7%) had died. In unadjusted competing-risk regression analyses, treating death as a competing event, hearing ability was significantly associated with ARC admission (p < 0.001). However, in adjusted analyses, this relationship was completely confounded by other variables (p = 0.67). This finding implies that screening for hearing loss among community-living older adults is unlikely to impact on ARC admission rates.

Background: Residential Aged Care Facilities (RACFs) are moving towards a Consumer Directed Care (CDC) model of care. There are limited examples of CDC in ageing research, and no evaluation of a comprehensive CDC intervention in residential care was located. This study will implement and evaluate a staff training program, Resident at the Center of Care (RCC), designed to facilitate and drive CDC in residential care., Methods: The study will adopt a cluster randomized controlled design with 39 facilities randomly allocated to one of three conditions: delivery of the RCC program plus additional organizational support, delivery of the program without additional support, and care as usual. A total of 834 staff (22 in each facility, half senior, half general staff) as well as 744 residents (20 in each facility) will be recruited to participate in the study. The RCC program comprises five sessions spread over nine weeks: Session 1 clarifies CDC principles; Sessions 2 to 5 focus on skills to build and maintain working relationships with residents, as well as identifying organizational barriers and facilitators regarding the implementation of CDC. The primary outcome measure is resident quality of life. Secondary outcome measures are resident measures of choice and control, the working relationship between resident and staff; staff reports of transformational leadership, job satisfaction, intention to quit, experience of CDC, work role stress, organizational climate, and organizational readiness for change. All measures will be completed at four time points: pre-intervention, 3-months, 6-months, and 12-month follow-up. Primary analyses will be conducted on an intention to treat basis. Outcomes for the three conditions will be compared with multilevel linear regression modelling., Discussion: The RCC program is designed to improve the knowledge and skills of staff and encourage transformational leadership and organizational change that supports implementation of CDC. The overarching goal is to improve the quality of life and care of older people living in residential care., Trial Registration: ACTRN12618000779279; Registered 9 May 2018 with the Australian and New Zealand Clinical Trials Registry (ANZCTR; http://www.anzctr.org.au/ ).

Background: Medication management of type 2 diabetes mellitus (T2DM) in residential aged care facilities (RACFs) requires consideration of the residents’ goals of care and susceptibility to adverse drug events (ADEs)., Objective: The aim of this article is to review best practice medication management for residents diagnosed with T2DM., Discussion: Management of T2DM in RACFs is often focused on maintaining residents’ quality of life rather than intensive glycaemic management to reduce chronic complications, because the risks of intensive glycaemic management typically outweigh the potential benefits. Australian RACF guidelines recommend individualised glycated haemoglobin targets of 7–8.5% (53–69 mmol/mol). Strategies to reduce the risk of preventable ADEs may include education for residents, carers and staff; assessment of hypoglycaemic risk and renal function; medication review and regimen simplification; de-intensification of glucose-lowering medications; and appropriate end-of-life medication management. Use of a resident-centred multidisciplinary approach and resources tailored to the RACF setting will support residents to achieve best possible health outcomes and quality of life.

Sleep disturbance is a common symptom in institutionalized older adults that reduces their quality of life and may contribute to progression of cognitive impairment. While we found that a 7-week combination of resistance training, walking and social activity significantly improved sleep in institutionalized older adults compared with a usual care control group, no one to our knowledge has determined the acute effects of resistance training on same-day sleep in this population. Given the effort required to promote exercise adherence in institutionalized older adults and to obtain a positive training effect, understanding of the acute effects of resistance training on same-day sleep architecture should be elucidated, especially with respect to unintended consequences. This secondary data analysis assessed if resistance training altered the same-day sleep architecture in institutionalized older adults. Forty-three participants (age 81.5 ± 8.1 years, male = 17, female = 26) had two attended overnight polysomnography tests in their rooms for sleep architecture analysis; one polysomnography with same-day resistance training, one without any resistance training. Resistance training consisted of chest and leg press exercises (three sets, eight repetitions, 80% predicted one-repetition maximum). There were no significant changes in sleep architecture between either polysomnography nights; sleep efficiency (P = 0.71), time in non-rapid eye movement stages (P = 0.50), time in rapid eye movement stages (P = 0.14), time awake (P = 0.56), time until sleep onset (P = 0.47), total sleep stage shifts (P = 0.65) or rapid eye movement sleep stage latency (P = 0.57). Our results show no acute same-day effects of resistance training on sleep architecture in institutionalized older adults. Clinical Trial Registration ClinicalTrials.gov Identifier: NCT00888706., (© 2017 European Sleep Research Society.)

Background There are limited options for the treatment of behavioral and psychological symptoms of dementia (BPSD). Objective Evaluate the efficacy and safety of using atypical antipsychotics for BPSD among patients residing in long-term care. Setting Long term care community facility in the United States. Methods Retrospective observational study of patients residing in a long-term care facility with a diagnosis of dementia not trauma-induced with documented BPSD treated with an atypical antipsychotic for at least 2 weeks. Paper medical records were reviewed from January 1, 1990 until March 23, 2010. Main outcome measure Behavioral/psychological efficacy outcomes were documented beginning 2 weeks after atypical antipsychotic therapy was initiated and safety outcomes were documented from the time of atypical antipsychotic initiation, until the last documentation available. Efficacy and safety outcomes were documented as part of routine clinical practice based on the responsible clinician. Results A total of 85 distinct atypical antipsychotic treatment periods for 73 unique patients were included. Nearly 50% of patients continued atypical antipsychotic treatment for at least 1 year and 5.6% of treatments were discontinued due to an adverse event. Patients' behavioral/psychological outcomes improved for 52 (61%) treatments, remained stable for 17 (20%) treatments, and worsened for 16 (19%) treatments. Adverse events were reported by 57% of patients, with the most common adverse events being metabolic, fall related, and extrapyramidal symptoms. The odds ratio for an adverse event was 1.08 (p = 0.03) for every 90 day increase in duration of treatment. Conclusion In patients who reside in a long-term care setting, atypical antipsychotic treatment improved BPSD, but also increased the potential risk of adverse events.

Background: Identifying how persons with dementia experience lived space is important for enabling supportive living environments and creating communities that compensate for the fading capabilities of these persons. Several single studies have explored this topic; however, few studies have attempted to explicitly review and synthesize this research literature. The aim of this systematic meta-synthesis was therefore to interpret and synthesize knowledge regarding persons with dementia's experience of space., Methods: A systematic, computerized search of AgeLine, CINAHL Complete, Embase, Medline and PsycINFO was conducted using a search strategy that combined MeSH terms and text words for different types of dementia with different descriptions of experience. Studies with 1) a sample of persons with dementia, 2) qualitative interviews as a research method and 3) a description of experiences of lived space were included. The search resulted in 1386 articles, of which 136 were identified as eligible and were read and assessed using the CASP criteria. The analysis was inspired by qualitative content analyses., Results: This interpretative qualitative meta-synthesis included 45 articles encompassing interviews with 672 persons with dementia. The analysis showed that living in one's own home and living in long-term care established different settings and posed diverse challenges for the experience of lived space in persons with dementia. The material revealed four main categories that described the experience of lived space: (1) belonging; (2) meaningfulness; (3) safety and security; and (4) autonomy. It showed how persons with dementia experienced a reduction in their lived space due to the progression of dementia. A comprehensive understanding of the categories led to the latent theme: "Living with dementia is like living in a space where the walls keep closing in"., Conclusion: This meta-synthesis reveals a process whereby lived space gradually becomes smaller for persons with dementia. This underscores the importance of being aware of the experiences of persons with dementia and the spatial dimensions of their life-world. To sustain person-centred care and support the preservation of continuity and identity, one must acknowledge not only the physical and social environment but also space as an existential experience for persons with dementia.

Background: The potential harms of some medications may outweigh their potential benefits (inappropriate medication use). Despite recommendations to avoid the use of potentially inappropriate medications (PIMs) in older adults, the prevalence of PIM use is high in different settings including residential aged care. However, it remains unclear what the costs of these medications are in this setting. The main objective of this study was to determine the costs of PIMs in older adults living in residential care. A secondary objective was to examine if there was a difference in costs of PIMs in a home-like model of residential care compared to an Australian standard model of care., Methods: Participants included 541 participants from the Investigation Services Provided in the Residential Environment for Dementia (INSPIRED) Study. The INSPIRED study is a cross-sectional study of 17 residential aged care facilities in Australia. 12 month medication costs were determined for the participants and PIMs were identified using the 2015 updated Beers Criteria for older adults., Results: Of all of the medications dispensed in 1 year, 15.9% were PIMs and 81.4% of the participants had been exposed to a PIM. Log-linear models showed exposure to a PIM was associated with higher total medication costs (Adjusted β = 0.307, 95% CI 0.235 to 0.379, p < 0.001). The mean proportion (±SD) of medication costs that were spent on PIMs in 1 year was 17.5% (±17.8) (AUD$410.89 ± 479.45 per participant exposed to a PIM). The largest PIM costs arose from proton-pump inhibitors (34.4%), antipsychotics (21.0%) and benzodiazepines (18.7%). The odds of incurring costs from PIMs were 52% lower for those residing in a home-like model of care compared to a standard model of care., Conclusions: The use of PIMs for older adults in residential care facilities is high and these medications represent a substantial cost which has the potential to be lowered. Further research should investigate whether medication reviews in this population could lead to potential cost savings and improvement in clinical outcomes. Adopting a home-like model of residential care may be associated with reduced prevalence and costs of PIMs.

Seniors Housing, Skilled Nursing, And The Economy.

Background: A need exists to better understand the impact of depression on functional outcomes following TBI., Objectives: To evaluate the prevalence and severity of depression among a large group of chronic TBI adults; to determine the impact of depression on outcomes of post-hospital residential rehabilitation programs; and to assess effectiveness of post-hospital residential rehabilitation programs in treating depression., Methods: 820 adults with moderate to severe traumatic brain injury (TBI) were assigned to one of four groups based on MPAI- 4 depression ratings: (1) Not Depressed, (2) Mildly Depressed, (3) Moderately Depressed, and (4) Severely Depressed. Functional status was assessed at admission and discharge with the MPAI-4 Participation Index. Differences among groups were evaluated using conventional parametric tests. Rasch analysis established reliability and validity of MPAI-4 data., Results: Rasch analysis demonstrated satisfactory construct validity and internal consistency (Person reliability = 0.89-0.92, Item reliability = 0.99). Of the 820 subjects, 39% presented with moderate to severe depressive symptoms at admission, These subjects demonstrated significantly higher MPAI-4 Participation scores than the mild and not depressed groups. Depressed groups realized significant improvement in symptoms, but, those remaining depressed at discharge had significantly greater disability than those who improved., Conclusions: Depressive symptoms had a deleterious impact on outcome. Remediation of symptoms during rehabilitation significantly improved outcomes.

The US National Survey of Residential Care Facilities was used to conduct cross-sectional analyses of residential care facilities (n = 2302). Most residential care facilities lacked computerized capabilities for one or more of these capabilities in 2010. Lacking computerized systems supporting electronic health information exchange with pharmacies was associated with non-chain affiliation (p < .05). Lacking electronic health information exchange with physicians was associated with being a small-sized facility (vs large) (p < .05). Lacking computerized capabilities for discharge/transfer summaries was associated with for-profit status (p < .05) and small-sized facilities (p < .05). Lacking computerized capabilities for medical provider information was associated with non-chain affiliation (p < .05), small- or medium-sized facilities (p < .05), and for-profit status (p < .05). Lack of electronic health record was associated with non-chain affiliation (p < .05), small- or medium-sized facilities (p < .05), for-profit status (p < .05), and location in urban areas (p < .05). eHealth disparities exist across residential care facilities. As the older adult population continues to grow, resources must be in place to provide an integrated system of care across multiple settings., (© The Author(s) 2015.)

Understanding conservation and livelihood threats in park landscapes is important to informing conservation policy. To identify threats, we examined perceived risks of residents living near three national parks in Uganda. We used cross-sectional household data to document, rank, and measure severity of perceived risks. Three risk categories, grouped into protected area, climate, and health, were cited by 80 % of respondents and received the highest severity scores. Elevation, proximity to the park, local forest loss, recent population change, and measures of poverty were the most important variables in predicting whether or not an individual identified these risks as the most or second most severe risk. Health issues were cited throughout the landscape, while problems attributed to climate (mainly insufficient rainfall) were reported to be most severe farther from the park. Increased population density was associated with increased perceived risk of health challenges, but decreased perceived risks attributed to the park and climate. Participatory risk mapping provides the opportunity to make standardized comparisons across sites, to help identify commonalities and differences, as a first step to examining the degree to which conservation management might address some of these local challenges and where mitigation techniques might be transferable between different sites or conflict scenarios.

Background: Surveys suggest most people would prefer to die in their own home., Aim: To examine predictors of place of death over an 11-year period between 2000 and 2010 in Dumfries and Galloway, south west Scotland., Design: Retrospective cohort study., Setting/participants: 19,697 Dumfries and Galloway residents who died in the region or elsewhere in Scotland. We explored the relation between age, gender, cause of death (cancer, respiratory, ischaemic heart disease, stroke and dementia) and place of death (acute hospital, cottage hospital, residential care and home) using regression models to show differences and trends. The main acute hospital in the region had a specialist palliative care unit., Results: Fewer people died in their own homes (23.2% vs 29.6%) in 2010 than in 2000. Between 2007 and 2010, men were more likely to die at home than women (p < 0.001), while both sexes were less likely to die at home as they became older (p < 0.001) and in successive calendar years (p < 0.003). Older people with dementia as the cause of death were particularly unlikely to die in an acute hospital and very likely to die in a residential home (p < 0.001). Between 2007 and 2010, an increasing proportion of acute hospital deaths occurred in the specialist palliative care unit (6% vs 11% of all deaths in the study)., Conclusion: The proportion of people dying at home fell during our survey. Place of death was strongly associated with age, calendar year and cause of death. A mismatch remains between stated preference for place of death and where death occurs., Competing Interests: The author(s) declared no potential conflicts of interest with respect to the research, authorship and/or publication of this article., (© The Author(s) 2016.)

Objectives: It has been suggested that since 1990, de-institutionalisation of mental healthcare in Western Europe has been reversed into re-institutionalisation with more forensic beds, places in protected housing services and people with mental disorders in prisons. This study aimed to identify changes in the numbers of places in built institutions providing mental healthcare in Western Europe from 1990 to 2012, and to explore the association between changes in psychiatric bed numbers and changes in other institutions., Settings and Data: Data were identified from 11 countries on psychiatric hospital beds, forensic beds, protected housing places and prison populations. Fixed effects regression models tested the associations between psychiatric hospital beds with other institutions., Results: The number of psychiatric hospital beds decreased, while forensic beds, places in protected housing and prison populations increased. Overall, the number of reduced beds exceeded additional places in other institutions. There was no evidence for an association of changes in bed numbers with changes in forensic beds and protected housing places. Panel data regression analysis showed that changes in psychiatric bed numbers were negatively associated with rising prison populations, but the significant association disappeared once adjusted for gross domestic product as a potential covariate., Conclusions: Institutional mental healthcare has substantially changed across Western Europe since 1990. There are ongoing overall trends of a decrease in the number of psychiatric hospital beds and an increase in the number of places in other institutions, including prisons. The exact association between these trends and their drivers remains unclear. More reliable data, information on the characteristics of patients in different institutions, long-term pathway analyses and effectiveness studies are required to arrive at evidence-based policies for the provision of institutional mental healthcare., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/)

Adults with intellectual and developmental disabilities (IDD) frequently become frail earlier than the general population, resulting in higher care needs. This population is at risk for institutionalization, or re-institutionalization, into long-term care (LTC). Using a retrospective cohort design to follow 3,034 individuals (18-99 years) living in Ontario, Canada, and assessed with the Resident Assessment Instrument-Home Care, individuals were characterized with a frailty index (FI) for persons with IDD. Survival analyses determined differences in rates of admission to LTC and survival in the community. Frail individuals had greater rates of admission than non-frail individuals, adjusted HR = 2.19, 95% CI [1.81, 2.64]. The FI predicts institutionalization.

Persons living with dementia have many health concerns, including poor nutritional states. This narrative review provides an overview of the literature on nutritional status in persons diagnosed with a dementing illness or condition. Poor food intake is a primary mechanism for malnutrition, and there are many reasons why poor food intake occurs, especially in the middle and later stages of the dementing illness. Research suggests a variety of interventions to improve food intake, and thus nutritional status and quality of life, in persons with dementia. For family care partners, education programs have been the focus, while a range of intervention activities have been the focus in residential care, from tableware changes to retraining of self-feeding. It is likely that complex interventions are required to more fully address the issue of poor food intake, and future research needs to focus on diverse components. Specifically, modifying the psychosocial aspects of mealtimes is proposed as a means of improving food intake and quality of life and, to date, is a neglected area of intervention development and research., (© 2016 New York Academy of Sciences.)

Most adolescents are placed in residential youth care (RYC) because of severe psychosocial strains and child maltreatment, which represent risk factors for developing mental disorders. To plan RYC units and ensure that residents receive evidence-based psychiatric interventions, it is necessary to obtain reliable and valid prevalence estimates of mental disorders in this population. However, there is a lacuna of research on diagnoses derived from standardized clinical interviews. The aim of this study was to assess the prevalence and comorbidity of mental disorders applying diagnostic interviews in an entire population of adolescents living in RYC in Norway. All young people in RYC were invited to participate in the study. Eighty-six RYC institutions with 601 eligible adolescents were included and 400 adolescents, 12-20 years old, participated in the study, yielding a response rate of 67 %. Anonymous Child Behaviour Checklist scores for 141 (70 %) of the declining residents were also available, allowing diagnoses according to the Diagnostic and Statistical Manual of Mental Disorders Fourth Edition (DSM-IV) for 541 youths to be estimated. Diagnoses were assessed by trained interviewers with the Child and Adolescent Psychiatric Assessment interview (CAPA). Seventy-six point two per cent (71.5-80.8 CI 95 %) of adolescents received at least one 3-month DSM-IV diagnosis. Prevalence rates for internalizing psychiatric disorders were higher than for behavioural disorders. Comorbidity was high between these two groups. Mental disorders were prevalent among children and youth in RYC. Our results create major concerns and challenge the existing organization of the RYC system.

Objective: To examine the relationship between self-reported pain and psychological well-being of people with dementia (PWD) living in residential long-term care as indicated by displays of observed emotional expression over the daytime period., Design: Secondary analysis using repeated measures of self-report and observational data., Setting and Subjects: A total of 177 PWD were included from 17 nursing homes and six assisted living facilities in Michigan and Pennsylvania., Methods: Negative emotional expression was used as an indicator of reduced psychological well-being. Pain was assessed through PWD's response to a question about presence of pain obtained at each observation. Cognitive impairment was assessed using the Mini-Mental Status Examination. Linear mixed models were used that accounted for correlation of negative emotional expression measurements over time for each participant and between participants within the same facility., Results: Among 171 participants who were able to express their pain, 44% of PWD reported pain once or more during the daytime period. Severity of cognitive impairment was related to expression of negative emotion. PWD with pain displayed more negative emotional expression than PWD without pain., Conclusions: Routine pain assessment is feasible among PWD with moderate to severe dementia and positive report of pain is associated with greater observed negative emotional expression, an indicator of reduced psychological well-being. Improving pain management holds potential for enhancing psychological well-being among PWD living in residential long-term care., (Wiley Periodicals, Inc.)

Background: Surveillance technology such as tag and tracking systems and video surveillance could increase the freedom of movement and consequently autonomy of clients in long-term residential care settings, but is also perceived as an intrusion on autonomy including privacy., Objective: To explore how clients in residential care experience surveillance technology in order to assess how surveillance technology might influence autonomy., Setting: Two long-term residential care facilities: a nursing home for people with dementia and a care facility for people with intellectual disabilities., Methods: Ethnographic field study., Ethical Considerations: The boards representing clients and relatives/proxies of the clients were informed of the study and gave their written consent. The clients' assent was sought through a special information leaflet. At any time clients and/or proxy were given the option to withdraw from the study. The research protocol was also reviewed by a medical ethics committee., Findings: Our findings show a pattern of two themes: (1) coping with new spaces which entailed clients: wandering around, getting lost, being triggered, and retreating to new spaces and (2) resisting the surveillance technology measure because clients feel stigmatized, missed the company, and do not like being "watched.", Conclusion: Client experiences of surveillance technology appear to entail a certain ambivalence. This is in part due to the variety in surveillance technology devices, with each device bringing its own connotations and experiences. But it also lies in the devices' presupposition of an ideal user, which is at odds with the actual user who is inherently vulnerable. Surveillance technology can contribute to the autonomy of clients in long-term care, but only if it is set in a truly person-centered approach., (© The Author(s) 2014.)

The vast majority of children and youth with chronic and complex health conditions who also have intellectual and developmental disabilities are cared for in their homes. Social, legal, policy, and medical changes through the years have allowed for an increase in needed support within the community. However, there continues to be a relatively small group of children who live in various types of congregate care settings. This clinical report describes these settings and the care and services that are provided in them. The report also discusses reasons families choose out-of-home placement for their children, barriers to placement, and potential effects of this decision on family members. We examine the pediatrician's role in caring for children with severe intellectual and developmental disabilities and complex medical problems in the context of responding to parental inquiries about out-of-home placement and understanding factors affecting these types of decisions. Common medical problems and care issues for children residing outside the family home are reviewed. Variations in state and federal regulations, challenges in understanding local systems, and access to services are also discussed., (Copyright © 2014 by the American Academy of Pediatrics.)

Background: Although dementia at the end of life is increasingly being studied, we lack prospective observational data on dying patients. In this study symptoms were observed in patients with dementia in the last days of life., Methods: When the elderly care physicians in two Dutch nursing homes expected death within one week, symptoms of (dis)comfort, pain and suffering were observed twice daily. For this the Pain Assessment in Advanced Dementia (PAINAD; range 0-10), Discomfort Scale-Dementia of Alzheimer Type (DS-DAT; range 0-27), End-Of-Life in Dementia-Comfort Assessment in Dying (EOLD-CAD; range 14-42) and an adapted version of the Mini-Suffering State Examination (MSSE; range 0-9), were used. Information on care, medical treatment and treatment decisions were also collected., Results: Twenty-four participants (median age 91 years; 23 females), were observed several times (mean of 4.3 observations (SD 2.6)), until they died. Most participants (n = 15) died from dehydration/cachexia and passed away quietly (n = 22). The mean PAINAD score was 1.0 (SD 1.7), DS-DAT 7.0 (SD 2.1), EOLD-CAD 35.1 (SD 1.7), and MSSE 2.0 (SD 1.7). All participants received morphine, six received antibiotics, and rehydration was prescribed once., Conclusion: In these patients with dementia and expected death, a low symptom burden was observed with validated instruments, also in dehydrated patients without aggressive treatment. A good death is possible, but might be enhanced if the symptom burden is regularly assessed with validated instruments. The use of observation tools may have influenced the physicians to make treatment decisions.

With an increasing ageing population, there is a growing concern about how the elderly would be looked after. The primary purpose of this paper is to develop scenario analysis using simulated data where various criteria are incorporated into modeling policy targets, and apply an intertemporal productivity analysis to observe inefficiencies as reform unfolds. The study demonstrates how dynamic network data envelopment analysis (DN-DEA) can be used to evaluate the changing productivity of residential aged care (RAC) networks over time. Results indicate that it takes 9 years for 90 % of the RAC networks to have 85 % or more of the total beds in high-level care, and an optimal bed capacity is reached by the end of year 7. Number of beds and registered nurses employed are the main sources of inefficiency. The common core inefficient cohort identified with the paper's method represents a sub-group of RAC networks more deserving of closer managerial attention because of their constantly inefficient operations over time.

Background: The increase of the elderly population and the high prevalence of chronic diseases have contributed to the increasing importance of functional ability as a global public health problem. This study aimed to assess functional capacity in institutionalized elders, as well as undertake an exploratory analysis of its associated factors., Methods: This is a cross-sectional study with institutionalized Brazilian elders. Functional capacity was assessed using the Katz Index for Activities of Daily Living (ADL) and the Lawton Scale for Instrumental Activities of Daily Living (IADL). The characteristics of dependent individuals were described and logistic regression models were developed for both scales. Multiple models that included all selected variables were developed using a hierarchical approach. We considered the results from the Wald test (p <0.05) as a rule for progressing to the next level., Results: A population of 760 elders was considered. The prevalence of dependence was 50.3% for ADL and 81.2% for IADL. We observed associations between ADL dependence and the following factors: self-report of stroke, difficulty of walking 400 meters, lower total scores in questions related to the temporal orientation section of the cognition test, and self-reports of frequently feeling upset. IADL dependence was associated with educational level, self-report of cancer, difficulty of walking 400 meters, use of glasses, and self-reported memory problems., Conclusions: Sociodemographic and health conditions were associated with functional incapacity in institutionalized elders. Based on these findings, we emphasize the importance of both prevention and treatment of chronic conditions as well as social support in the maintenance of individuals' autonomy.

In 2010, 17% of residential care communities had dementia special care units. Beds in dementia special care units accounted for 13% of all residential care beds. Residential care communities with dementia special care units were more likely than those without to have more beds, be chain-affiliated, and be purposely built as a residential care community, and less likely to be certified or registered to participate in Medicaid. Residential care communities with dementia special care units were more likely than those without to be located in the Northeast and in a metropolitan statistical area, and less likely to be in the West. Assisted living and similar residential care communities provide an alternative to nursing homes for individuals with dementia who can no longer live independently. In 2010, about 42% of individuals living in residential care communities had Alzheimer's disease or other dementia. Individuals with dementia can live in residential care communities that have dementia special care units, or in a more traditional setting where these residents are integrated with residents without dementia. Many states require residential care communities with dementia special care units to have certain physical features (e.g., locked door) and specially trained staff to care for residents with dementia. This report compares residential care communities with and without dementia special care units., (All material appearing in this report is in the public domain and may be reproduced or copied without permission; citation as to source, however, is appreciated.)

The number of people living longer is increasing, and those with physical or cognitive impairments may need admission into long-term care settings. In long-term care there is a need to increase nursing staff's capacity to meet the care needs of residents, develop a team approach to providing care and provide opportunities for staff to improve their knowledge and skills. One approach to meet these needs has been to employ a nurse practitioner (NP). The purpose of this paper is to examine nursing staff's perceptions of how working with an NP affected their ability to provide care, function as a team and increase their knowledge and skill. Data used in this paper were obtained from nursing staff and managers who participated in focus groups that were part of case studies conducted in the second phase of a larger sequential, two-phase mixed-methods study. NPs used multiple approaches to increase staff knowledge and skills and improve quality of care. These findings describe the benefits of employing NPs in long-term care settings., (Copyright © 2013 Longwoods Publishing.)

Key Findings: In 2010, only 17% of residential care communities in the United States used electronic health records. Residential care communities that used electronic health records were more likely to be larger, not-for-profit, chain-affiliated, colocated with another care setting, and in a nonmetropolitan statistical area. The types of information most commonly tracked electronically by residential care communities that used electronic health records were medical provider information, resident demographics, individual service plans, and lists of residents' medications and active medication allergies. Four in 10 residential care communities that used electronic health records also had support for electronic exchange of health information with service providers; nearly 25% could exchange with pharmacies, and 17% could exchange with physicians., (All material appearing in this report is in the public domain and may be reproduced or copied without permission; citation as to source, however, is appreciated.)

Objective: Population ageing is driving many countries to review health and social care policies. For many, an important component is residential long-term care (LTC). This study uses New Zealand to ascertain the extent different reports provide consistent and accurate estimates of LTC use., Methods: We searched for available cross-sectional information about use of LTC by people aged 65 years or over in NZ's population since 1988. In addition, for one geographic region, Auckland, we compared research survey data at three time-points with the nearest census estimates., Results: Fifty-eight national-level estimates (census, subsidy payments and population surveys) were found. Since 2000, estimates of the proportion of older people reportedly living in long-term care ranged from 3.4% to 9.2%. Comparisons with Auckland studies demonstrated improved reporting in the 2006 census., Conclusion: Estimates of the proportion of people living in residential LTC varied widely. OECD reports, often used for cross-national comparisons, were particularly inconsistent., Implications: While estimates of the proportion of people living in residential LTC in NZ are inconsistent, improvements are evident in census and subsidy data. Reconciling new data with previous reports prior to publication may reduce variations in reporting. Improved reliability will assist understanding of within-country trends and international comparisons, and better inform decisions shaping health services for older people., (© 2013 The Authors. ANZJPH © 2013 Public Health Association of Australia.)

Accelerating the design of technologies to support health in the home requires 1) better understanding of how the household context shapes consumer health behaviors and (2) the opportunity to afford engineers, designers, and health professionals the chance to systematically study the home environment. We developed the Living Environments Laboratory (LEL) with a fully immersive, six-sided virtual reality CAVE to enable recreation of a broad range of household environments. We have successfully developed a virtual apartment, including a kitchen, living space, and bathroom. Over 2000 people have visited the LEL CAVE. Participants use an electronic wand to activate common household affordances such as opening a refrigerator door or lifting a cup. Challenges currently being explored include creating natural gesture to interface with virtual objects, developing robust, simple procedures to capture actual living environments and rendering them in a 3D visualization, and devising systematic stable terminologies to characterize home environments.

Background: The effects of a regular and graduated walking program as a stand-alone intervention for individuals in long-term care are unclear. Exercise and fall prevention programs typically studied in long-term care settings tend to involve more than one exercise mode, such as a combination of balance, aerobic, strengthening, and flexibility exercises; and, measures do not always include mental health symptoms and behaviors, although these may be of even greater significance than physical outcomes., Methods/design: We are randomly assigning residents of long-term care facilities into one of three intervention groups: (1) Usual Care Group--individuals receive care as usual within their long-term care unit; (2) Interpersonal Interaction Group--individuals receive a comparable amount of one-on-one stationary interpersonal interaction time with study personnel administering the walking program; and, (3) Walking Program Group--individuals participate in a supervised, progressive walking program five days per week, for up to half an hour per day. Assessments completed at baseline, 2 and 4 months during intervention, and 2 and 4 months post-intervention include: gait parameters using the GAITRite® computerized system, grip strength, the Berg Balance Scale, the Senior Fitness Test, the Older Adult Resource Services Physical Activities of Daily Living, the Geriatric Depression Scale Short Form, the Cornell Scale for Depression in Dementia, the Revised Memory and Behavior Problems Checklist, the Short Portable Mental Status Questionnaire, the Coloured Analogue Scale, pain assessment scales, and the number and nature of falls. Sophisticated data analytic procedures taking into account both the longitudinal nature of the data and the potential for missing data points due to attrition, will be employed., Discussion: Residents in long-term care have a very high number of comorbidities including physical, mental health, and cognitive. The presence of dementia in particular makes standardized research protocols difficult to follow, and staff shortages, along with inconsistencies related to shift changes may impact on the accuracy of caregiver-rated assessment scales. Practical challenges to data collection validity and maintenance of inter-rater reliability due to the large number of research staff required to implement the interventions at multiple sites are also posed., Trial Registration: ClinicalTrials.gov NCT01277809.

Background: For residents of long term care, hospitalisations can cause distress and disruption, and often result in further medical complications. Multi-disciplinary team interventions have been shown to improve the health of Residential Aged Care (RAC) residents, decreasing the need for acute hospitalisation, yet there are few randomised controlled trials of these complex interventions. This paper describes a randomised controlled trial of a structured multi-disciplinary team and gerontology nurse specialist (GNS) intervention aiming to reduce residents' avoidable hospitalisations., Methods/design: This Aged Residential Care Healthcare Utilisation Study (ARCHUS) is a cluster- randomised controlled trial (n = 1700 residents) of a complex multi-disciplinary team intervention in long-term care facilities. Eligible facilities certified for residential care were selected from those identified as at moderate or higher risk of resident potentially avoidable hospitalisations by statistical modelling. The facilities were all located in the Auckland region, New Zealand and were stratified by District Health Board (DHB)., Intervention: The intervention provided a structured GNS intervention including a baseline facility needs assessment, quality indicator benchmarking, a staff education programme and care coordination. Alongside this, three multi-disciplinary team (MDT) meetings were held involving a geriatrician, facility GP, pharmacist, GNS and senior nursing staff., Outcomes: Hospitalisations are recorded from routinely-collected acute admissions during the 9-month intervention period followed by a 5-month follow-up period. ICD diagnosis codes are used in a pre-specified definition of potentially reducible admissions., Discussion: This randomised-controlled trial will evaluate a complex intervention to increase early identification and intervention to improve the health of residents of long term care. The results of this trial are expected in early 2013., Trial Registration: Australian New Zealand Clinical Trials Registry: ACTRN 12611000187943.

Background: A thorough understanding of the literature generated from research in care homes is required to support evidence-based commissioning and delivery of healthcare. So far this research has not been compiled or described. We set out to describe the extent of the evidence base derived from randomized controlled trials conducted in care homes., Methods: A systematic mapping review was conducted of the randomized controlled trials (RCTs) conducted in care homes. Medline was searched for "Nursing Home", "Residential Facilities" and "Homes for the Aged"; CINAHL for "nursing homes", "residential facilities" and "skilled nursing facilities"; AMED for "Nursing homes", "Long term care", "Residential facilities" and "Randomized controlled trial"; and BNI for "Nursing Homes", "Residential Care" and "Long-term care". Articles were classified against a keywording strategy describing: year and country of publication; randomization, stratification and blinding methodology; target of intervention; intervention and control treatments; number of subjects and/or clusters; outcome measures; and results., Results: 3226 abstracts were identified and 291 articles reviewed in full. Most were recent (median age 6 years) and from the United States. A wide range of targets and interventions were identified. Studies were mostly functional (44 behaviour, 20 prescribing and 20 malnutrition studies) rather than disease-based. Over a quarter focussed on mental health., Conclusions: This study is the first to collate data from all RCTs conducted in care homes and represents an important resource for those providing and commissioning healthcare for this sector. The evidence-base is rapidly developing. Several areas - influenza, falls, mobility, fractures, osteoporosis - are appropriate for systematic review. For other topics, researchers need to focus on outcome measures that can be compared and collated.

Background: Nutrition is an important issue for elderly residents of long-term care facilities (LTCFs). About 20% of elderly LTCF residents in Taiwan are malnourished., Purpose: This study investigated correlations between nutritional status and physical function, admission frequency, hospitalstay duration, and mortality in elderly LTCF residents., Methods: Researchers used a retrospective study design and convenient sampling to enroll 174 subjects aged 67 to 105 years (average, 82.5 years) who were living in legally registered LTCFs in Beitou District, Taipei City, Taiwan. A review of LTCF resident files provided data on subjects' demographics, physical examination laboratory results for the most recent 1-year period, anthropometry, physical function, admission frequency, hospital stay duration, and causes of admissions. Subjects had lived in their LTCF for more than 1 year before their enrollment date. Subjects who died during and after the study period were also included in analysis., Results: Results showed significant changes over the study year in subjects' nutritional status, physical function, and calf circumference. Physical function was found significantly correlated with calf circumference, hospitalization status was found correlated with nasal-gastric tube feeding status, and eating pattern was found correlated with calf circumference and levels of both serum albumin and cholesterol. Nutritional status, calf circumference, albumin level, and cholesterol level also correlated significantly with hospitalization status. In this study, the likelihood of hospitalization increased with age and nasal-gastric tube feeding use. Hospital stay duration for subjects receiving nasal-gastric tube feeding was longer than that for those receiving oral feeding. Also, weak nutritional status scores for calf circumference and hemoglobin levels were factors associated with increased mortality risk., Conclusions/implications for Practice: Findings recommend that greater attention should be paid to the nutritional status of elderly persons living in LTCFs to reduce hospitalization and death risks, cut medical expenses, and improve quality of care.

This paper uses observations from two British Columbia studies to illustrate the shortcomings of widely used ratio-based approaches for residential long-term care capacity planning. It shows that capacity plans based on a fixed ratio of beds per population over age 75 may result in either excess capacity or long wait times for admission. It then investigates the use of linear regression models to obtain a "best" ratio by relating optimal plans derived by rigorous analytical methods to population characteristics and shows that no single ratio applies broadly. While the use of regression is promising, finding these "best" ratios is too analytically complex for general practice. The paper concludes by providing and evaluating an easy-to-use planning method, which we call the average flow model (AFM). The AFM combines demand forecasts with length-of-stay estimates to produce enhanced capacity plans. The AFM is transparent, easily implemented in a spreadsheet and well suited for "what if?" analyses.

Background: In the 1980s, special care units devoted to persons with dementia (SCU) were established, and in the 1990s, a new system of sheltered housing for persons with dementia (SH) was inaugurated., Aim: The aim of this study was to examine the establishment of SCUs and SH units and to explore the effects of varying patient-staff ratios and unit sizes., Method: On five occasions (1996/1997, 2000/2001, 2004/2005, 2008, 2010/2011), a detailed questionnaire was sent by post to all Norwegian municipalities. It contained questions about the provision of services for persons with dementia., Results: In 1996/1997, 70% of the municipalities had SCUs and 13.3% of the beds in Norwegian nursing homes were in SCUs. In 2010/11, 87% of the municipalities had such services, which filled 23.8% of the beds in nursing homes. The number of beds in SH units increased from 856 beds in 1996/1997 to 2181 beds in 2010/11. SCUs have on average three patients per carer on an ordinary weekday day-time shift. These numbers have been quite stable throughout the study period. The ratio is about 3.5 patients per carer in the SH units and is also stable., Conclusions: The rate of increase in the provision of institutional beds facilitated for persons with dementia has been slow in Norway over the last 14 years. Both SCUs and SH units seem to have stable staffing ratios and the number of beds in each unit is also stable.

This commentary explores transitions in care for people who have severe and persistent mental illnesses and reside in long-term care communities. Challenges and historical approaches as well as barriers to successful transitions are examined. Recent policy changes in North Carolina are discussed and contextualized in emerging evidence-based practices that emphasize intentional collaborative efforts.

Parenting a child with severely challenging behaviours is very stressful and threatens family well-being. Short break (respite) services are commonly provided as a support to families but surprisingly little attention has been paid to adapting these services when children and families have complex needs. This article describes the model of service that has evolved in three separate locations which successfully provides overnight short breaks and/or community-based support to families. The model was documented and validated through individual and group interviews with a range of stakeholders--around 30 in all. The services are embedded within multi-agency partnerships and four particular features are highlighted: the values and ethos underpinning the service; the service procedures; the organization of short breaks; and the role of an intensive support/outreach service. The rationale for complex service models is discussed and the key lessons for replicating this model are reviewed.