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Directions & Connections
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Author Guidelines
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General Information
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Table of Contents
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Editorial Board
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Increasing Awareness of the Factors Producing Falls: The Mini Falls Assessment
Falls represent one of the most common harmful occurrences in nursing homes, and injurious falls account for approximately 60% of all liability cases filed against nursing homes. Persons in nursing homes fall three times more frequently than persons living in the community. There are approximately 1.7 (0.6–3.6) falls per nursing home bed per year. Falls are the major cause of hip fractures, head trauma, lacerations, other fractures, and soft tissue injuries. As we age, falls are inevitable; therefore, our goals are to decrease the number of falls and prevent injuries where possible. Among nursing home residents, rates of hip fracture can be as high as 6.2% in women and 4.9% in men. The cost of falls in the United States is estimated to be $40 billion by 2020. Although single intervention programs have minor effects on falls, the Cochrane review has found that multifactorial interventions successfully reduce falls. Despite this, certified nursing aides believe that falls are not preventable.
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Can Background Checks of Long Term Care Residents Improve Safety?
The recent article in the Journal of the American Medical Association, “State policies for the residency of offenders in long term care facilities: Balancing right to care with safety,” outlines an important area of concern for practitioners. Until recently, the complexities of criminal offenders requiring long term care have been largely unexplored. The thought of a vulnerable loved one living in close proximity to a criminal offender is a frightening idea for families, and the public will increasingly look to the long term care medicine community to ensure the protection of residents. To further facilitate the establishment of best practices surrounding this issue, the American Medical Directors Association recently passed a resolution to explore how nursing homes can best address the anticipated future increase in residents with criminal/correctional histories.
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Muslim Nursing Homes in the United States: Barriers and Prospects
Abstract: Historically, many nursing homes in the United States have been established by religious groups. This was done to provide care for the elderly when care could not be furnished in other venues.Despite several attempts reported in the literature, there are currently no Muslim nursing homes in the United States. In the Arab and Muslim world, the acceptance and success of such an institution has been somewhat variable. As the Arab Muslim population in the United States ages and becomes more frail, the Muslim community will have to evaluate the need to establish nursing homes to provide care for elderly.
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To Evacuate or Shelter in Place: Implications of Universal Hurricane Evacuation Policies on Nursing Home Residents
Abstract: Objective: To examine the differential morbidity/mortality associated with evacuation versus sheltering in place for nursing home (NH) residents exposed to the 4 most recent Gulf hurricanes.Methods: Observational study using Medicare claims and NH data sources. We compared the differential mortality/morbidity for long-stay residents exposed to 4 recent hurricanes (Katrina, Rita, Gustav, and Ike) relative to those residing at the same NHs over the same time periods during the prior 2 nonhurricane years as a control. Using an instrumental variable analysis, we then evaluated the independent effect of evacuation on outcomes at 90 days.Results: Among 36,389 NH residents exposed to a storm, the 30- and 90-day mortality/hospitalization rates increased compared with nonhurricane control years. There were a cumulative total of 277 extra deaths and 872 extra hospitalizations at 30 days. At 90 days, 579 extra deaths and 544 extra hospitalizations were observed. Using the instrumental variable analysis, evacuation increased the probability of death at 90 days from 2.7% to 5.3% and hospitalization by 1.8% to 8.3%, independent of other factors.Conclusion: Among residents exposed to hurricanes, evacuation significantly exacerbated subsequent morbidity/mortality.
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The Specificity of Geriatric Rehabilitation: Myth or Reality? A Debate from an Italian Perspective
Despite increasing evidence about its effectiveness, the specificity of geriatric rehabilitation too often remains an elusive question. In fact, the term “geriatric rehabilitation” is used to target a specific population (ie, older patients) rather than a specific approach. Recently in our country, a government guideline failed to indicate specific directions in this field, with negative consequences on the practice of old citizens’ rehabilitation. In this historical period in Italy, the rehabilitation of old persons lacks a scientific background to be followed by different services. In these conditions, because of the limited availability of economic resources and high demand for services with a proven cost-effectiveness, geriatric rehabilitation is at high risk of being overshadowed unless its proper value can be demonstrated.
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Psychosocial Assessment of Nursing Home Residents via MDS 3.0: Recommendations for Social Service Training, Staffing, and Roles in Interdisciplinary Care
Abstract: The Minimum Data Set 3.0 has introduced a higher set of expectations for assessment of residents’ psychosocial needs, including new interviewing requirements, new measures of depression and resident choice, and new discharge screening procedures. Social service staff are primary providers of psychosocial assessment and care in nursing homes; yet, research demonstrates that many do not possess the minimum qualifications, as specified in federal regulations, to effectively provide these services given the clinical complexity of this client population. Likewise, social service caseloads generally exceed manageable levels. This article addresses the need for enhanced training and support of social service and interdisciplinary staff in long term care facilities in light of the new Minimum Data Set 3.0 assessment procedures as well as new survey and certification guidelines emphasizing quality of life. A set of recommendations will be made with regard to training, appropriate role functions within the context of interdisciplinary care, and needs for more realistic staffing ratios.
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Sarcopenia and Mortality among Older Nursing Home Residents
Abstract: Background and Aims: Sarcopenia has been indicated as a reliable marker of frailty and poor prognosis among the oldest individuals. At present, no data are available on sarcopenia in the nursing home population. The aim of the current study was to explore the relationship between sarcopenia and all-cause mortality in a population of elderly persons aged 70 years and older living in a nursing home in Italy.Methods: This study was conducted among all subjects (n = 122) aged 70 years and older who lived in the teaching nursing home of Catholic University of Rome between August 1, 2010, and September 30, 2010. According to the European Working Group on Sarcopenia in Older People (EWGSOP), sarcopenia was diagnosed in presence of low muscle mass plus either low muscle strength or low physical performance. The primary outcome measure was survival after 6 months.Results: Forty residents (32.8%) were indentified as affected by sarcopenia. This condition was more common in men (68%) than in women (21%). During the follow-up period, 26 (21.3%) patients died. After adjusting for age, gender, cerebrovascular diseases, osteoarthritis, chronic obstructive pulmonary disease, activity of daily living impairment, and body mass index, residents with sarcopenia were more likely to die compared with those without sarcopenia (adjusted hazard ratio 2.34; 95% confidence interval 1.04–5.24).Conclusions: The present study suggests that among subjects living in a nursing home, sarcopenia is highly prevalent and is associated with a significantly increased risk of all-cause death. The current findings support the possibility that sarcopenia has an independent effect on survival among nursing home residents.
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Epidemiology of Falls in Residential Aged Care: Analysis of More Than 70,000 Falls From Residents of Bavarian Nursing Homes
Abstract: Objective: Falls and fall-related injuries are leading problems in residential aged care facilities. The objective of this study was to provide descriptive data about falls in nursing homes.Design/Setting/Participants: Prospective recording of all falls over 1 year covering all residents from 528 nursing homes in Bavaria, Germany.Measurements: Falls were reported on a standardized form that included a facility identification code, date, time of the day, sex, age, degree of care need, location of the fall, and activity leading to the fall. Data detailing homes' bed capacities and occupancy levels were used to estimate total person-years under exposure and to calculate fall rates. All analyses were stratified by residents' degree of care need.Results: More than 70,000 falls were recorded during 42,843 person-years. The fall rate was higher in men than in women (2.18 and 1.49 falls per person-year, respectively). Fall risk differed by degree of care need with lower fall risks both in the least and highest care categories. About 75% of all falls occurred in the residents' rooms or in the bathrooms and only 22% were reported within the common areas. Transfers and walking were responsible for 41% and 36% of all falls respectively. Fall risk varied during the day. Most falls were observed between 10 am and midday and between 2 pm and 8 pm.Conclusion: The differing fall risk patterns in specific subgroups may help to target preventive measures.
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The Influence of Hospice Use on Nursing Home and Hospital Use in Assisted Living Among Dual-Eligible Enrollees
Abstract: Objective: This study examined the impact of hospice enrollment on the probabilities of hospital and nursing home admissions among a sample of frail dual-eligible assisted living (AL) residents.Design: The study used a retrospective cohort design. We estimated bivariate probit models with 2 binary outcome variables: any hospital admissions and any nursing home admissions after assisted living enrollment.Setting: A total of 328 licensed AL communities accepting Medicaid waivers in Florida.Participants: We identified all newly admitted dual-eligible AL residents in Florida between January and June of 2003 who had complete state assessment data (n = 658) and followed them for 6 to 12 months.Measurements: Using the Andersen behavioral model, predisposing (age, gender, race), enabling (marital status, available caregiver, hospice use), and need (ADL/IADL, comorbidity conditions, and incontinence) characteristics were included as predictors of 2 binary outcomes (hospital and nursing home admission). Demographics, functional status, and caregiver availability were obtained from the state client assessment database. Data on diagnosis and hospital, nursing home, and hospice use were obtained from Medicare and Medicaid claims. Death dates were obtained from the state vital statistics death certificate data.Results: The mean age of the study sample was 81.5 years. Three-fourths were female and 63% were White. The average resident had a combined ADL/IADL dependency score of 11.49. Fifty-eight percent of the sample had dementia. During the average 8.9-month follow-up period, 6.8% were enrolled in hospice and 10.2% died. Approximately 33% of the sample had been admitted into a hospital and 20% had been admitted into a nursing home. Bivariate probit models simultaneously predicting the likelihood of hospital and nursing home admissions showed that hospice enrollment was associated with lower likelihood of hospital (OR = 0.24, P < .01) and nursing home admissions (OR = 0.56, P < .05). Significant predictors of hospital admissions included higher Charlson Comorbidity Index score and incontinence. Predictors of nursing home admissions included higher Charlson Comorbidity Index score, the absence of available informal caregiver, and incontinence.Conclusions: Hospice enrollment was associated with a lower likelihood of hospital and nursing home admissions, and, thus, may have allowed AL residents in need of palliative care to remain in the AL community. AL providers should support and facilitate hospice care among older frail dual-eligible AL residents. More research is needed to examine the impact of hospice care on resident quality of life and total health care expenditures among AL residents.
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Raloxifene and Tibolone in Elderly Women: A Randomized, Double-Blind, Double-Dummy, Placebo-Controlled Trial
Abstract: Objectives: The authors’ first aim was to study the effects of raloxifene and tibolone on body mass density, handgrip strength, and other secondary frailty components. The secondary aim was to compare the effects of raloxifene and tibolone and their safety in older women.Design/Setting/Participants: A randomized, double-blind, double- dummy, placebo-controlled trial conducted in an academic hospital in the Netherlands among 318 community living women aged >70 were randomized; 290 received the allocated intervention: 97 placebo, 101 raloxifene, and 92 tibolone.Interventions: Randomization was made to raloxifene 60 mg, tibolone 1.25 mg, or placebo. Assessments were performed at baseline and after 3, 6, 12, and 24 months. The study was conducted from July 2003 to January 2008. The tibolone group stopped earlier in February 2006, because of results of the Long-Term Intervention on Fractures with Tibolone study, suggesting an increased risk of cerebrovascular accident.Measurements: Primary endpoints were body mass density and handgrip strength. Secondary endpoints were muscle power and strength, mobility measures, body composition, verbal memory, mental processing speed, anxiety, mood, and quality of life.Results: Tibolone and raloxifene had similar body mass density-effect sizes (d = .24–.47), and had no effect on handgrip muscle strength. For the 15 words test the effect on direct recall of concrete and abstract words (d = .40 and d =.27, respectively) and on delayed recall of concrete words (d = .77) were significantly higher in the raloxifene group compared to placebo and to tibolone. In the raloxifene group the health status (EuroQol VAS (0–100) was improved 2.4 points [95% CI 0.5–4.2; P = .012] over 24 months.Conclusion: In women >70 years old, raloxifene and tibolone significantly and similarly increased body mass density but not muscle strength. Raloxifene had also positive effects on verbal memory and health status. New research with selective estrogen receptor modulators like raloxifene might be promising on frailty endpoints in elderly women.Trial registration number: Nederlands Trial Register: 1232
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Light Therapy for Seniors in Long Term Care
Abstract: Objectives: To investigate the effects of light therapy on cognition, depression, sleep, and circadian rhythms in a general, nonselected population of seniors living in a long term care facility.Design: A double-blind, placebo-controlled trial.Setting: The experiment took place at a long term care facility in Pennsylvania.Participants: Study participants (15 treatment, 13 placebo) were residents receiving either personal care or skilled nursing care.Intervention: Treatment consisted of approximately 400 lux of blue light administered for 30 minutes per day, Monday through Friday, for 4 weeks. The placebo was approximately 75 lux of red light generated from the same device.Measurements: Behavioral assessments were made using the MicroCog Assessment of Cognitive Functioning, Geriatric Depression Scale, and Profile of Mood States. Daytime sleepiness was evaluated using the Epworth Sleepiness Scale.Results: Three of the 4 composite scores from the MicroCog as well as the mean Tension/Anxiety score from the Profile of Mood States showed a significant treatment versus placebo effect.Conclusion: Blue light treatment led to significant cognitive improvements compared with placebo red light and may be a promising environmental intervention to reduce cognitive symptoms in elderly, long-term care residents.
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Minimal Trauma Fractures: Lifting the Specter of Misconduct by Identifying Risk Factors and Planning for Prevention
Abstract: Minimal trauma fractures are an unfortunate, yet not uncommon, event for frail elderly individuals in long term care facilities. These fractures result in significant morbidity including pain and loss of function along with significantly increased mortality. Further concern exists for the medico-legal issues raised after a minimal trauma fracture is discovered. The controversy at hand is whether such fractures are primarily the result of inadequate, careless, or abusive care practices. We build a case to the contrary. Although the data regarding this condition are limited, there exists a reasonable evidence base to identify an at-risk patient population. We present a representative case and subsequent literature review of minimal trauma fractures to illustrate the condition, including risk factors, mode of presentation, and patient outcomes. No direct research has been conducted on the pathophysiology of these fractures. Extrapolating from other similar conditions and likely associated comorbid illnesses, we explore possible physiologic explanations for their occurrence. Again, no direct investigation into prevention or treatment of minimal trauma fractures has been published. Instead, we consider a variety of pharmacologic and nonpharmacologic interventions that may modify the risk for minimal trauma fractures considering the previously identified risk factors and probable pathophysiologic changes leading to fracture development. We propose that reducing minimal trauma fractures in the frail elderly nursing home population will require careful staff education, close attention to identify at-risk patients, and implementation of select interventions aimed at preventing such fractures.
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Scope and Severity Index: A Metric for Quantifying Nursing Home Survey Deficiency Number, Scope, and Severity Adjusted for the State-Related Measurement Bias
Abstract: Objectives: To develop a metric (scope and severity index [SSI]) to measure nursing home deficiency number, scope, and severity adjusted for the state-related bias and to test its convergent and predictive validity.Design: We assigned scope and severity weights to each level of scope and severity (A-L). SSI was calculated as a sum of all weights per survey which was further corrected for the state-level bias by dividing by the state average number of health deficiencies and multiplying by the national average number of health deficiencies. Data source - National Online Survey, Certification, and Reporting system.Setting: All Medicare/Medicaid-certified skilled nursing facilities.Measurements: We correlated SSI with nursing home staffing levels (convergent validity) and denial of payment for new admissions (predictive validity).Results: The expert panel reached agreement on the scope and severity weights: Level A = 5, B = 10, C = 15, D = 20, E = 30, F = 40, G = 35, H = 50, I = 65, J = 55, K = 75, and L = 100 points. Scope and severity per deficiency was positively correlated with the number of deficiencies in that survey. SSI contained almost no state-related bias, but yet related state-level variability. It demonstrated strong face, convergent, and predictive validity.Conclusions: SSI rendered a valuable metric to conduct quantitative analyses of nursing home deficiency number, scope, and severity across states. Future research should investigate the positive relationship between scope and severity of deficiencies and their number. Better understanding and correction of other factors introducing systematic bias to the survey results (e.g. regional impact) can further improve the accuracy of survey result evaluation.
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Effectiveness of Intervention Programs In Preventing Falls: A Systematic Review of Recent 10 Years and Meta-Analysis
Abstract: Objective: To examine the reported effectiveness of fall-prevention programs for older adults by reviewing randomized controlled trials from 2000 to 2009.Design: Systematic review and meta-analysis of randomized controlled trials.Data Sources: A systematic literature search of articles was conducted using 5 electronic databases (Medline, PubMed, PsycINFO, CINAHL, and RefWorks), including articles describing interventions designed to prevent falls, in English with full text availability, from 2000 through 2009.Review Methods: Of a potential 227 studies, we identified 17 randomized controlled trials with a duration of intervention of at least 5 months of follow-up. Inclusion and exclusion criteria were used to assess the methodological qualities of the studies. We excluded unidentified study design, quasi-experimental studies, and/or studies that were nonspecific regarding inclusion criteria.Data Extraction: Primary outcome measures were number of falls and fall rate. Methodological quality assessment included internal and external validity, reporting, and power. Data were extracted independently by 2 investigators and analyzed using a random-effects model. We analyzed the effectiveness of these fall intervention programs using their risk ratios (RR) in 2 single-intervention versus 15 multifactorial intervention trials, 3 nursing homes versus 14 community randomized controlled trials, and 8 Model 1 (initial intervention with subsequent follow up) versus 9 Model II (ongoing intervention throughout the follow-up) studies.Results: The combined RR for the number of falls among 17 studies was 0.855 (z = –2.168; p = .030; 95% CI = 0.742–0.985; Q = 196.204, df = 16, P = .000, I2 = 91.845), demonstrating that fall-prevention programs across the studies were effective by reducing fall rates by 14%, but with substantial heterogeneity. Subgroup analysis indicated that there was a significant fall reduction of 14% in multifactorial intervention (RR = 0.856, z = –2.039, P = .041) with no variation between multifactorial and single-intervention groups (Q = 0.002, P = .961), 55% in the nursing home setting (RR = 0.453, z = –9.366, P = .000) with significant variation between nursing home and community groups (Q = 62.788, P = .000), and no significant effect was gained by dividing studies into either in Model I or II. Sensitivity analysis found homogeneity (Q = 18.582, df = 12, P = .099, I2 = 35.423) across studies with a 9% overall fall reduction (RR = 0.906, 95% CI = 0.853–0.963, z = –3.179, P = .001), including a fall-reduction rate of 10% in multifactorial intervention (RR = 0.904, z = –3.036, P = .002), 9% in community (RR = 0.909, z = –3.179, P = .001), and 12% in Model I (RR = 0.876, z = –3.534, P = .000) with no variations among all the groups. Meta regression suggested that the model fit explained 68.6% of the relevant variance.Conclusions: The meta-sensitivity analysis indicates that randomized controlled trials of fall-prevention programs conducted within the past 10 years (2000–2009) are effective in overall reduction of fall rates of 9% with a reduction of fall rates of 10% in multifactorial interventions, 9% in community settings, and 12% in Model I interventions (initial intervention efforts and then subsequent follow-up).
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Associations Between Published Quality Ratings of Skilled Nursing Facilities and Outcomes of Medicare Beneficiaries with Heart Failure
Abstract: Introduction: Nursing Home Compare quality ratings are designed to allow patients, families, and clinicians to compare facilities based on quality, but associations of the current measures with important clinical outcomes are not known. Our study examined associations between ratings and readmission and mortality among Medicare beneficiaries admitted to a skilled nursing facility with a primary diagnosis of heart failure.Methods: We conducted a retrospective cohort study of 164,672 Medicare beneficiaries discharged to skilled nursing facilities after hospitalization for heart failure in 2006–2007. The main outcome measures were readmission and mortality within 90 days.Results: One-fifth of the 13,619 skilled nursing facilities received a 1-star rating and 11% received a 5-star rating. Nearly half of the patients discharged to a skilled nursing facility were readmitted to a hospital within 90 days after discharge, and 30% died within 90 days. Compared with patients in 5-star skilled nursing facilities, patients in 1-star facilities had higher risks of 90-day readmission (hazard ratio, 1.08) and mortality (1.15). After adjustment for facility size and ownership type, the associations between the quality rating and readmission were not statistically significant, but the associations with mortality were significant.Conclusion: Publicly reported Nursing Home Compare quality ratings of Medicare-certified skilled nursing facilities were modestly associated with 90-day readmission and mortality among Medicare beneficiaries discharged to these facilities after hospitalization for heart failure.
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