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  • Improving Evidence-Based Oral Health of Nursing Home Residents Through Coaching by Dental Hygienists
    J. Am. Med. Dir. Assoc. (IF 4.899) Pub Date : 2019-11-25
    Lisa Volk; Melony Spock; Philip D. Sloane; Sheryl Zimmerman

    Good oral hygiene has an impact on the overall health of residents in long-term care; however, significant improvement is needed in nursing homes. A “boots on the ground” project was developed that incorporates Mouth Care without a Battle, an evidence-based approach to person-centered daily mouth care, into 22 New York State nursing homes using a coaching model with part-time dental hygienists. This report discusses implementation of the quality improvement project, which improved the quality of daily mouth care provided to nursing home residents, as well as changed the knowledge and attitudes of the staff providing their care, all supported by regional dental hygienist coaches.

    更新日期:2020-01-17
  • Effectiveness of a Diet and Resistance Exercise Intervention on Muscle Health in Older Adults: ProMuscle in Practice
    J. Am. Med. Dir. Assoc. (IF 4.899) Pub Date : 2020-01-14
    Ellen J.I. van Dongen; Annemien Haveman-Nies; Esmée L. Doets; Berber G. Dorhout; Lisette C.P.G.M. de Groot

    Objectives Clinical studies show that resistance exercise and a protein-rich diet can counteract the age-related decline of muscle mass, strength, and physical performance. The aim of the ProMuscle in Practice study was to test effectiveness of a resistance exercise and dietary protein intervention for older adults implemented in a real-life setting. Design A randomized controlled multicenter intervention study. Setting and Participants One hundred sixty-eight community-dwelling older adults were included (age 75 ± 6 years). A 12-week intensive support intervention including progressive resistance exercise supervised by a physiotherapist and dietitian guidance on increasing protein intake was followed by a voluntary 12-week moderate support intervention to continue the adapted lifestyle pattern. The control group received no intervention. Methods Compliance was measured through attendance lists and 3-day food records. Physical functioning, leg strength (3-repetition maximum, knee extension strength), lean body mass [(LBM) dual-energy X-ray absorptiometry], and quality of life (5-level EQ-5D) were measured at baseline, and after 12 and 24 weeks. Differences in change between groups were assessed with linear mixed model analysis. Results The intervention group increased protein intake and attended 83.6% of the training sessions. Short Physical Performance Battery score slightly increased in intervention participants [from 10.1 (95% confidence interval 9.7–10.5) to 10.4 (10.0–10.8) at week 12 and 10.6 (10.2–10.9) at week 24], where control participants decreased (time × treatment interactions, P < .05). Improvements in intervention group compared with controls were also observed for Timed Up-and-Go, strength and LBM at both time points (time × treatment interactions, P < .05). No difference between groups was found for the 6-Minute Walking Test, activities of daily living, and quality of life. Conclusions and Implications ProMuscle in Practice was effective on improving muscle strength and LBM, with small changes in the composite function score in community-dwelling older adults in a real-life setting. Further research should explore feasibility of real-life implementation, as well as improving long-term compliance.

    更新日期:2020-01-14
  • Morbidity Measures Predicting Mortality in Inpatients: A Systematic Review
    J. Am. Med. Dir. Assoc. (IF 4.899) Pub Date : 2020-01-14
    Cheng Hwee Soh; Syed Wajih Ul Hassan; Julian Sacre; Andrea B. Maier

    Objectives Morbidity is an important risk factor for mortality and a variety of morbidity measures have been developed to predict patients' health outcomes. The objective of this systematic review was to compare the capacity of morbidity measures in predicting mortality among inpatients admitted to internal medicine, geriatric, or all hospital wards. Design A systematic literature search was conducted from inception to March 6, 2019 using 4 databases: Medline, Embase, Cochrane, and CINAHL. Articles were included if morbidity measures were used to predict mortality (registration CRD42019126674). Setting and Participants Inpatients with a mean or median age ≥65 years. Measurements Morbidity measures predicting mortality. Results Of the 12,800 articles retrieved from the databases, a total of 34 articles were included reporting on inpatients admitted to internal medicine, geriatric, or all hospital wards. The Charlson Comorbidity Index (CCI) was reported most frequently and a higher CCI score was associated with greater mortality risk, primarily at longer follow-up periods. Articles comparing morbidity measures revealed that the Geriatric Index of Comorbidity was better predicting mortality risk than the CCI, Cumulative Illness Rating Scale, Index of Coexistent Disease, and disease count. Conclusions and Implications Higher morbidity measure scores are better in predicting mortality at longer follow-up period. The Geriatric Index of Comorbidity was best in predicting mortality and should be used more often in clinical practice to assist clinical decision making.

    更新日期:2020-01-14
  • Association Between Bisphosphonates and Hospitalized Clostridioides difficile Infection Among Frail Older Adults
    J. Am. Med. Dir. Assoc. (IF 4.899) Pub Date : 2020-01-10
    Kevin W. McConeghy; Andrew R. Zullo; Christine W. Lary; Tingting Zhang; Yoojin Lee; Lori. Daiello; Douglas P. Kiel; Sarah Berry

    Objectives Clostridioides difficile infection is a major source of morbidity and mortality among frail older adults, especially those in nursing homes (NHs). Safety reports have signaled that bisphosphonate use may be a contributing cause. We therefore evaluated the risk of C difficile hospitalization associated with oral bisphosphonate use in the NH. Design Observational, retrospective new-user cohort study. Setting The cohort included US NH residents aged ≥65 years who became a long-stay resident (>100 days in the NH) between January 1, 2008 and December 31, 2009. Methods We conducted a study of NH residents using linked Medicare claims and Minimum Data Set records. Residents were new users of an oral bisphosphonate 1:1 matched to new calcitonin users (“active” comparator) on propensity scores controlling for more than 100 covariates. The outcome was risk of hospitalization for C difficile infection in a Cox proportional hazards model adjusted for previous antibiotic and proton pump inhibitor use. Results Our final analytical cohort included 17,753 bisphosphonate and 5348 calcitonin users. In the matched cohort, 84/5209 (1.6%) vs 71/5209 (1.4%) C difficile–related hospitalizations occurred in bisphosphonate and calcitonin users, respectively. We observed no significant difference in the risk of hospitalization among bisphosphonate users (hazard ratio: 1.11, 95% confidence interval: 0.80-1.51). Antibiotic and proton pump inhibitor exposure before and after osteoporosis treatment was also similar between bisphosphonate and calcitonin users. Conclusions and Implications C difficile infection should not be a consideration when prescribing bisphosphonates to frail older adults given the lack of a significant association.

    更新日期:2020-01-11
  • Associations Between Somatic Multimorbidity Patterns and Depression in a Longitudinal Cohort of Middle-Aged and Older Chinese
    J. Am. Med. Dir. Assoc. (IF 4.899) Pub Date : 2020-01-09
    Shan-Shan Yao; Gui-Ying Cao; Ling Han; Zi-Ting Huang; Zi-Shuo Chen; He-Xuan Su; Yonghua Hu; Beibei Xu

    Objectives Depressive symptoms are commonly seen among patients with multiple chronic somatic conditions, or somatic multimorbidity (SMM); however, little is known about the relationships between depressive symptoms and different SMM combinations. Our study aimed to delineate the patterns of SMM and their longitudinal associations with depressive symptoms among a nationally representative sample of middle-aged and older Chinese adults. Design We employed a longitudinal design. Setting and Participants Older adults (N = 10,084) aged ≥45 years from the China Health and Retirement Longitudinal Study 2011-2015 participated (mean age = 57.7 years at baseline; 53.3% men). Methods Sixteen chronic somatic conditions were ascertained at baseline via questionnaires. Depression was assessed with the Center for Epidemiological Studies Depression Scale at baseline and during follow-up. Patterns of SMM were identified via exploratory factor analyses. Generalized estimating equations were used to evaluate the longitudinal associations between patterns of SMM and the presence of depressive symptoms at follow-up. Results Compared with participants with no somatic condition, those with 1, 2, and 3 or more somatic conditions had a 21%, 66%, and 111% greater risk, respectively, for the presence of depressive symptoms. Increased factor scores for 4 patterns identified, cardio-metabolic pattern [adjusted odds ratio (AOR) 1.12, 95% confidence interval (CI) 1.06, 1.20], respiratory pattern (AOR 1.25, 95% CI 1.17, 1.33), arthritic-digestive-visual pattern (AOR 1.29, 95% CI 1.22, 1.37), and hepatic-renal-skeletal pattern (AOR 1.09, 95% CI 1.02, 1.16), were all associated with a higher risk of having depressive symptoms. Conclusions and Implications All SMM patterns were independently associated with depression among middle-aged and older Chinese adults, with greater odds for people with comorbid arthritic-digestive-visual conditions and respiratory conditions. Clinical practitioners should treat the middle-aged and older population under a multiple-condition framework combining SMM and mental disorders.

    更新日期:2020-01-09
  • Impact of Overweight and Obesity on Functional and Clinical Outcomes of Early Parkinson's Disease
    J. Am. Med. Dir. Assoc. (IF 4.899) Pub Date : 2020-01-09
    Ryul Kim; Jin-Sun Jun

    Objective To determine whether being overweight or obese contributes to disease progression and functional status in Parkinson's disease (PD). Design Cohort study using data from the Parkinson Progression Markers Initiative (PPMI). Setting and Participants A total of 399 drug-naive patients with early PD were classified into normal weight (body mass index of 18.5–24.9, n = 139), overweight (25.0–29.9, n = 167), and obese (30.0 or more, n = 93) groups. Methods The primary outcome was the development of functional dependency. Functional dependency was defined as a Schwab and England score of less than 80% at any time point that remained throughout follow-up. The secondary outcomes were the changes in the Movement Disorders Society Unified Parkinson Disease Rating Scale motor score measured in the off-medication state and the Montreal Cognitive Assessment score across visits. Results Over a 5-year follow-up period, the incidence of functional dependency was higher in the obese group than in the normal weight group (P = .001). No difference was observed between the overweight and normal weight groups (P = .429). The multivariable Cox model confirmed that obesity, but not overweight, increased the risk of dependency (hazard ratio 2.63, 95% confidence interval 1.32–5.23, P = .006). The increase in the Movement Disorders Society Unified Parkinson Disease Rating Scale motor score was greater in the obesity (P < .001) and overweight (P = .004) groups than in the normal weight group. Changes in the Montreal Cognitive Assessment score did not differ among the groups (P = .978). Conclusions and Implications We found that obesity is related to an increased risk of functional dependency and rapid motor progression in patients with early PD. Although being overweight did not increase the risk of dependency, this condition was associated with rapid motor progression.

    更新日期:2020-01-09
  • Adverse Outcomes of Polypharmacy in Older People: Systematic Review of Reviews
    J. Am. Med. Dir. Assoc. (IF 4.899) Pub Date : 2020-01-08
    Laurie E. Davies; Gemma Spiers; Andrew Kingston; Adam Todd; Joy Adamson; Barbara Hanratty

    Objective Polypharmacy is widespread among older people, but the adverse outcomes associated with it are unclear. We aim to synthesize current evidence on the adverse health, social, medicines management, and health care utilization outcomes of polypharmacy in older people. Design A systematic review, of systematic reviews and meta-analyses of observational studies, was conducted. Eleven bibliographic databases were searched from 1990 to February 2018. Quality was assessed using AMSTAR (A Measurement Tool to Assess Systematic Reviews). Setting and participants Older people in any health care setting, residential setting, or country. Results Twenty-six reviews reporting on 230 unique studies were included. Almost all reviews operationalized polypharmacy as medication count, and few examined medication classes or disease states within this. Evidence for an association between polypharmacy and many adverse outcomes, including adverse drug events and disability, was conflicting. The most consistent evidence was found for hospitalization and inappropriate prescribing. No research had explored polypharmacy in the very old (aged ≥85 years), or examined the potential social consequences associated with medication use, such as loneliness and isolation. Conclusions and implications The literature examining the adverse outcomes of polypharmacy in older people is complex, extensive, and conflicting. Until polypharmacy is operationalized in a more clinically relevant manner, the adverse outcomes associated with it will not be fully understood. Future studies should work toward this approach in the face of rising multimorbidity and population aging.

    更新日期:2020-01-09
  • Peak Expiratory Flow and the Risk of Injurious Falls in Older Adults: The Role of Physical and Cognitive Deficits
    J. Am. Med. Dir. Assoc. (IF 4.899) Pub Date : 2020-01-08
    Caterina Trevisan; Debora Rizzuto; Stina Ek; Stefania Maggi; Giuseppe Sergi; Laura Fratiglioni; Anna-Karin Welmer

    Objectives Previous studies showed that peak expiratory flow (PEF) is associated with health-related outcomes in advanced age, but the extent to which it may be related to falls risk remains unclear. We aimed to detect the association between PEF and injurious falls in older adults and to explore the role of cognitive and physical deficits in this association. Design Prospective study with a 6-year follow-up. Setting and Participants The study involves 2234 community-dwelling older adults with no history of pulmonary disease. Methods For each study participant, we assessed the PEF at baseline, expressed as standardized residual (SR) percentile and derived from the normalization of residuals between the measured and predicted PEF values (based on individual age, sex, and body height); incident injurious falls over 6 years, from Hospital Discharge Diagnosis; and physical and cognitive functioning at the baseline and at 3- and 6-year follow-ups by evaluating walking speed, balance, chair stand, and Mini-Mental State Examination, respectively. Results Over the follow-up, 232 individuals experienced injurious falls. Cox models indicated 7% higher risk of falls per each 10th reduction in PEF SR-percentile. The risk of injurious falls increased by more than twice for those who had PEF SR-percentile <10th as for values of 80th-100th (hazard ratio = 2.31, 95% confidence interval: 1.41-3.76). Physical deficits mediated 63% of the total effect of PEF on falls risk. Conclusions and Implications Our findings suggest that low PEF is associated with higher risk of injurious falls in older adults, and most of this association is explained by balance or muscular strength deficits.

    更新日期:2020-01-09
  • Association Between Acetylcholinesterase Inhibitors and Osteoporotic Fractures in Older Persons With Alzheimer's Disease
    J. Am. Med. Dir. Assoc. (IF 4.899) Pub Date : 2020-01-08
    Dae Yeon Won; Seong Jun Byun; Jin Sook Jeong; Ju-Young Shin

    Objective To identify the association between the use of acetylcholinesterase inhibitors (AChEIs) and risk of osteoporotic fractures in older persons with Alzheimer's disease (AD). Design, Setting, and Participants A nested case-control study was conducted using the Korean National Health Insurance Service-National Elderly Cohort database. Patients with AD who were newly diagnosed with osteoporotic fractures were identified as cases. Up to 3 controls were matched with cases according to age, sex, and duration of follow-up. Methods Participants were considered as exposed to AChEIs if they had been prescribed at least 1 AChEI during a period of 2 years before the index date. A conditional logistic regression was performed to estimate the adjusted odds ratios with 95% confidence intervals for the association between the use of AChEIs and osteoporotic fractures in patients with AD. We also examined the impact of dose, duration of treatment, and timing of exposure on the estimates of the association between the use of AChEIs and risk of osteoporotic fractures. Results The study cohort comprised 45,006 patients diagnosed with AD, of which 9470 patients, including 2385 cases and 7085 controls, were available for the study. The mean ages (standard deviations) were 78.6 (6.9) years in the cases and 80.0 (6.9) years in the controls. Adjusted odds ratios for the association between the use of AChEIs and osteoporotic fractures in patients with AD was 1.18 (95% confidence interval 1.07–1.31). Conclusions and Implications Our data indicated that the use of AChEIs was not associated with a reduced risk of osteoporotic fractures in patients with AD; in contrast, their use was associated with a mild increased risk of osteoporotic fractures. Thus, clinicians should consider the possibility of AChEIs-associated fractures among older persons with AD. Findings of this study will support shared decision making among prescribers, patients, and caregivers.

    更新日期:2020-01-09
  • A Systematic Review of Nursing Home Palliative Care Interventions: Characteristics and Outcomes
    J. Am. Med. Dir. Assoc. (IF 4.899) Pub Date : 2020-01-08
    Joan G. Carpenter; Karissa Lam; Ashley Z. Ritter; Mary Ersek

    Background Despite recommendations to integrate palliative care into nursing home care, little is known about the most effective ways to meet this goal. Objective To examine the characteristics and effectiveness of nursing home interventions that incorporated multiple palliative care domains (eg, physical aspects of care—symptom management, and ethical aspects—advance care planning). Design Systematic review. Methods We searched MEDLINE via PubMed, Embase, CINAHL, and Cochrane Library's CENTRAL from inception through January 2019. We included all randomized and nonrandomized trials that compared palliative care to usual care and an active comparator. We assessed the type of intervention, outcomes, and the risk of bias. Results We screened 1167 records for eligibility and included 13 articles. Most interventions focused on staff education and training strategies and on implementing a palliative care team. Many interventions integrated advance care planning initiatives into the intervention. We found that palliative care interventions in nursing homes may enhance palliative care practices, including processes to assess and manage pain and symptoms. However, inconsistent outcomes and high or unclear risk of bias among most studies requires results to be interpreted with caution. Conclusions and Implications Heterogeneity in methodology, findings, and study bias within the existing literature revealed limited evidence for nursing home palliative care interventions. Findings from a small group of diverse clinical trials suggest that interventions enhanced nursing home palliative care and improved symptom assessment and management processes.

    更新日期:2020-01-08
  • Safety and Effectiveness of Direct Oral Anticoagulants vs Warfarin in People With Atrial Fibrillation and Dementia
    J. Am. Med. Dir. Assoc. (IF 4.899) Pub Date : 2020-01-06
    Laura Fanning; Wallis C.Y. Lau; Pajaree Mongkhon; Kenneth K.C. Man; J. Simon Bell; Jenni Ilomäki; Pēteris Dārziņš; Kui Kai Lau; Li Wei; Ian C.K. Wong

    Objective To determine risks of embolic events, bleeding, and mortality with direct oral anticoagulants (DOACs) vs warfarin in people with atrial fibrillation (AF) and dementia. Design New-user retrospective cohort study using The Health Improvement Network database. Setting and Participants A population-based sample comprising people with AF and dementia prescribed DOACs or warfarin from August 2011 to September 2017. Methods Risk of ischemic stroke (IS), ischemic stroke/transient ischemic attack/systemic embolism (IS/TIA/SE), all-cause mortality, intracranial bleeding (ICB), gastrointestinal bleeding (GIB), and other bleeding were compared for DOACs vs warfarin using propensity score–adjusted Poisson regression. Incidence rate ratios (IRRs) and absolute risk differences (ARDs) were calculated. Results Overall, 2399 people with AF and dementia initiated DOACs (42%) or warfarin (58%). Before propensity score adjustment, patients who initiated DOACs were older and had more comorbidities. After adjustment, DOAC initiators demonstrated similar risks of IS, TIA, or SE; IS alone; and other bleeding but reduced ICB risk (IRR 0.27, 95% CI 0.08, 0.86; ARD −5.2, 95% CI –6.5, −1.0, per 1000 person-years) compared with warfarin. Increased risk of GIB (IRR 2.11, 95% CI 1.30, 3.42; ARD 14.8, 95% CI 4.0, 32.4, per 1000 person-years) and all-cause mortality (IRR 2.06, 95% CI 1.60, 2.65; ARD 53.0, 95% CI 30.2, 82.8, per 1000 person-years) were observed in DOAC initiators compared with warfarin. Conclusions and Implications Among people with AF and dementia, initiating treatment with DOACs compared with warfarin was associated with similar risks of IS, TIA, or SE and IS alone. DOAC-treated patients demonstrated reduced ICB risk but increased GIB and all-cause mortality risks. We cannot exclude the possible impact of residual confounding from channeling of DOACs toward older and sicker people, particularly for the outcome of all-cause mortality. Further safety data are urgently needed to confirm findings.

    更新日期:2020-01-06
  • Community-Dwelling Older Women: The Association Between Living Alone and Use of a Home Nursing Service
    J. Am. Med. Dir. Assoc. (IF 4.899) Pub Date : 2019-12-27
    Angela Joe; Marissa Dickins; Joanne Enticott; Rajna Ogrin; Judy Lowthian

    Objective To investigate the use of home nursing by community-dwelling older women to determine the nature of services required by those living alone. Design A retrospective cohort study using routinely collected data. Setting and Participants Women aged 55 years and older living in metropolitan Melbourne who received an episode of nursing care from a large community home-based nursing service provider between January 1, 2006 and December 31, 2015. Methods Descriptive and inferential statistical analyses were used to examine the relationship between client- and service-related factors and use of community nursing services. The primary outcome of interest was the hours of service received in a care episode. Results A total of 134,396 episodes of care were analyzed, in which 51,606 (38.4%) episodes involved a woman who lived alone. The median hours of care per episode to women who lived alone was almost 70% more than that for women who lived with others. Multivariable regression identified factors influencing the amount of service use: living alone status, cognitive health status, and number of required home nursing activities. After adjusting for confounding and interactions, living alone was associated with at least 13% more hours of care than is provided to those not living alone. Compared with women who lived with others, women living alone required almost double the amount of assistance with medication management and were 30% more likely to experience a deterioration in their condition or be discharged from home nursing care into an acute hospital. From 2006 to 2015, for all women there was a trend toward fewer hours of nursing service provided per episode. Conclusions and Implications Community-dwelling older women who live alone have greater service needs and higher rates of discharge to hospital. This knowledge will help guide provision of services and strategies to prevent clinical deterioration for this population.

    更新日期:2019-12-29
  • Diagnosis, Treatment, and Prevention of Urinary Tract Infections in Post-Acute and Long-Term Care Settings: A Consensus Statement From AMDA's Infection Advisory Subcommittee
    J. Am. Med. Dir. Assoc. (IF 4.899) Pub Date : 2019-12-27
    Muhammad S. Ashraf; Swati Gaur; Oluma Y. Bushen; Teena Chopra; Philip Chung; Kalin Clifford; Elizabeth Hames; Cees M.P.M. Hertogh; Amar Krishna; Dheeraj Mahajan; David R. Mehr; Vycki Nalls; Theresa Ann Rowe; Steven J. Schweon; Philip D. Sloane; Kavita K. Trivedi; Laura W. van Buul; Robin L.P. Jump

    The diagnosis and management of urinary tract infections (UTIs) among residents of post-acute and long-term care (PALTC) settings remains challenging. Nonspecific symptoms, complex medical conditions, insufficient awareness of diagnostic criteria, and unnecessary urine studies all contribute to the inappropriate diagnosis and treatment of UTIs in PALTC residents. In 2017, the Infection Advisory Subcommittee at AMDA—The Society for Post-Acute and Long-Term Care Medicine convened a workgroup comprised of experts in geriatrics and infectious diseases to review recent literature regarding UTIs in the PALTC population. The workgroup used evidence as well as their collective clinical expertise to develop this consensus statement with the goal of providing comprehensive guidance on the diagnosis, treatment, and prevention of UTIs in PALTC residents. The recommendations acknowledge limitations inherent to providing medical care for frail older adults, practicing within a resource limited setting, and prevention strategies tailored to PALTC populations. In addition, the consensus statement encourages integrating antibiotic stewardship principles into the policies and procedures used by PALTC nursing staff and by prescribing clinicians as they care for residents with a suspected UTI.

    更新日期:2019-12-27
  • Recommendations for Mandatory Influenza Vaccinations for Health Care Personnel From AMDA's Infection Advisory Subcommittee
    J. Am. Med. Dir. Assoc. (IF 4.899) Pub Date : 2019-12-27
    Elizabeth Frentzel; Robin L.P. Jump; Laurie Archbald-Pannone; David A. Nace; Steven J. Schweon; Swati Gaur; Fatima Naqvi; Naushira Pandya; William Mercer

    Preventing influenza infections is a national health priority, particularly among geriatric and adults with frailty who reside in post-acute and long-term care (PALTC) settings. Older adults account for more than 70% of deaths from influenza, a reflection of decreased vaccine effectiveness in that age group. Annually vaccinating health care personnel (HCP) working with these patients against influenza is critical to reducing influenza morbidity and mortality among patients. PALTC HCP have the lowest influenza vaccination rate when compared to HCP in other settings. The Advisory Committee on Immunization Practices recommends that all HCP receive an annual influenza vaccination, including those who do not have direct patient care responsibilities. Here, we discuss the importance of influenza vaccination for HCP, detail recommendations for influenza vaccination practice and procedures for PALTC settings, and offer support to PALTC settings and their staff on influenza vaccinations.

    更新日期:2019-12-27
  • A Review of Nonantibiotic Agents to Prevent Urinary Tract Infections in Older Women
    J. Am. Med. Dir. Assoc. (IF 4.899) Pub Date : 2019-06-18
    Christian M. Gill; Maria-Stephanie A. Hughes; Kerry L. LaPlante

    Objective This article provides a comprehensive literature review on nonantibiotic agents used for the prevention of urinary tract infections (UTIs) in women ≥45 years of age. Design A structured review was performed by conducting a literature search to identify relevant studies pertaining to the use of nonantibiotic agents to prevent UTIs in women who were perimenopausal through postmenopausal. Recommendations were made for or against the use of each nonantibiotic agent, unless data were unavailable. Levels of evidence were assigned to each recommendation made. Setting and participants Studies on the prevention of UTIs with women subjects ≥45 years of age in the community, inpatient, and long-term care settings were considered for inclusion. Measure The efficacy and safety of using ascorbic acid, cranberry products, d-mannose, estrogens, lactobacilli, and methenamine hippurate for prevention of UTIs was assessed. Results There is evidence to support use of estrogens (A-I) in postmenopausal women, and cranberry capsules (C-I) in women ≥45 years of age for the prevention of UTIs. There was a lack of evidence to make recommendations for or against the use of ascorbic acid, cranberry juice, cranberry capsules with high proanthocyanidin (PAC) content, d-mannose, lactobacillus, and methenamine hippurate in this population. Conclusions/Implications Current studies support that estrogens and cranberry capsules may have a role in preventing UTIs in women ≥45 years of age. Further research is needed to elucidate the role of these nonantibiotic agents and how they may be used to decrease antibiotic use.

    更新日期:2019-12-27
  • Reducing Fluoroquinolone Use and Clostridioides difficile Infections in Community Nursing Homes Through Hospital–Nursing Home Collaboration
    J. Am. Med. Dir. Assoc. (IF 4.899) Pub Date : 2019-12-27
    Christina B. Felsen; Elizabeth S. Dodds Ashley; Grant R. Barney; Dallas L. Nelson; Joseph A. Nicholas; Hongmei Yang; Marie E. Aydelotte; Alexander Karlic; Nirmala C. Nicholas; Kim K. Petrone; Rena D. Pine; Scott L. Schabel; Annette Medina-Walpole; Ghinwa K. Dumyati

    Objective Nursing homes (NHs) are an important target for antibiotic stewardship (AS). We describe a collaborative model to reduce Clostridioides difficile infections (CDIs) in NHs through optimization of antibiotic use including a reduction in high-risk antibiotics such as fluoroquinolones. Design Quasi-experimental, pre- and post-intervention study. Setting and participants Six NHs in Monroe County, NY. Methods A hospital-based AS expert team assisted NHs in identifying targets for improving antibiotic use. Interventions included (1) collaboration with a medical director advisory group to develop NH consensus guidelines for testing and treatment of 2 syndromes (urinary tract infections and pneumonia) for which fluoroquinolone use is common, (2) provision of multifaceted NH staff education on these guidelines and education of residents and family members on the judicious use of antibiotics, and (3) sharing facility-specific and comparative antibiotic and CDI data. We used Poisson regression to estimate antibiotic use per 1000 resident days (RD) and CDIs per 10,000 RD, pre- and post-intervention. Segmented regression analysis was used to estimate changes in fluoroquinolone and total antibiotic rates over time. Results Postintervention, the monthly rate of fluoroquinolone days of therapy (DOT) per 1000 RD significantly decreased by 39% [rate ratio (RR) 0.61, 95% confidence interval (CI) 0.59-0.62, P < .001] across all NHs and the total antibiotic DOT decreased by 9% (RR 0.91, 95% CI 0.90-0.92, P < .001). Interrupted time series analysis of fluoroquinolone and total DOT rates confirmed these changes. The quarterly CDI rate decreased by 18% (RR 0.82, 95% CI 0.68-0.99, P = .042). Conclusions and implications A hospital-NH partnership with a medical director advisory group achieved a significant reduction in total antibiotic and fluoroquinolone use and contributed to a reduction in CDI incidence. This approach offers one way for NHs to gain access to AS expertise and resources and to standardize practices within the local community.

    更新日期:2019-12-27
  • Copper for the Prevention of Outbreaks of Health Care–Associated Infections in a Long-term Care Facility for Older Adults
    J. Am. Med. Dir. Assoc. (IF 4.899) Pub Date : 2019-04-04
    Sarah Zerbib; Lydie Vallet; Anaëlle Muggeo; Christophe de Champs; Annick Lefebvre; Damien Jolly; Lukshe Kanagaratnam

    Objective We aimed to study the efficacy of copper as an antimicrobial agent by comparing incidence rates during outbreaks in areas equipped vs not equipped with copper surfaces in a long-term facility for dependent older adults (nursing home). Design Prospective observational pilot study in a nursing home. Setting and participant All persons resident in the nursing home belonging to Reims University Hospital, from February 1, 2015 to June 30, 2016, were included. Methods Incidence rates for health care–related infections during outbreaks occurring during the study period were compared between the wing that was equipped and the wing that was not equipped with copper surfaces. Results are expressed as relative risks (RRs) and 95% confidence intervals (95% CIs). Results During the study period, 556 residents were included; average age was 85.4 ± 9.2 years, and 76% were women. Four outbreaks occurred during the study period: 1 influenza, 1 keratoconjunctivitis, and 2 gastroenteritis outbreaks. The risk of hand-transmitted health care–associated infection was significantly lower in the area equipped with copper surfaces (RR 0.3, 95% CI 0.1-0.5). Conclusions and implications In our study, copper was shown to reduce the incidence of hand-transmitted health care–associated infections and could represent a relatively simple measure to help prevent HAIs in nursing homes.

    更新日期:2019-12-27
  • Changes in US Nursing Home Infection Prevention and Control Programs From 2014 to 2018
    J. Am. Med. Dir. Assoc. (IF 4.899) Pub Date : 2019-12-27
    Mansi Agarwal; Andrew W. Dick; Mark Sorbero; Lona Mody; Patricia W. Stone

    Objective Burgeoning rates of antibiotic resistance have resulted in a shift in national focus to improve infection prevention and control programs in US nursing homes (NHs). We sought to evaluate the changes in nursing home infection prevention and control programs over time. Design Retrospective comparative analysis of national nursing home survey data from 2014 and 2018. Setting and participants We used survey data from 2 nationally representative samples of US nursing homes (945 NHs in 2014 and 888 in 2018). Methods Three indices measuring antibiotic stewardship, outbreak control, and urinary tract infection prevention (ranging from 0 to 100) were developed to measure the change in infection prevention and control programs. Multivariable linear regression models were used to identify facility and infection preventionist characteristics associated with each index. Decomposition models were used to identify contributions of factors on the differences in each index over time. Results From 2014 to 2018, we saw strengthening of antibiotic stewardship practices by 33 percentage points, outbreak control practices by 13 percentage points, and urinary tract infection prevention practices by 6 percentage points. Although we found several predictors of these improvements, much of the improvement was due to the difference in time. Conclusions and Implications Policy mandates and greater national attention are likely important factors in improving nursing home infection prevention and control practices. Further work is needed to evaluate the effect of these programs on resident outcomes.

    更新日期:2019-12-27
  • Decrease in Antibacterial Use and Facility-Level Variability After the Introduction of Guidelines and Implementation of Physician-Pharmacist-Nurse Quality Circles in Swiss Long-term Care Facilities
    J. Am. Med. Dir. Assoc. (IF 4.899) Pub Date : 2019-07-18
    Catherine Plüss-Suard; Anne Niquille; Delphine Héquet; Séverine Krähenbühl; Renaud Pichon; Giorgio Zanetti; Olivier Bugnon; Christiane Petignat

    Objectives The objective of this study is to describe antibacterial use in long-term care facilities and to investigate the determinants of use. Design This study is a quality improvement study conducted from January 2011 to December 2016. Setting Long-term care facilities in the canton of Vaud, Western Switzerland, were investigated. Participants Twenty-three long-term care facilities were included in this study. Intervention The intervention included the publication of local guidelines on empirical antibacterial therapy and the implementation of physician-pharmacist-nurse quality circles. Measures The main outcome was antibacterial use, expressed as defined daily doses (DDD) per 1000 beds per day. Statistical analyses were performed through a 1-level mixed model for repeated measurements. Results Antibacterial use decreased from 45.6 to 35.5 DDD per 1000 beds per day (−22%, P < .01) over the 6-year study period, which was mostly explained by reduced fluoroquinolone use (−59%, P < .001). A decrease in range of use among LTCFs was observed during the study period, and 27% of antibacterial use was related to the WATCH group (antibiotics with higher toxicity concerns and/or resistance potential) according to the AWaRe categorization of the WHO, decreasing from 17.3 DDD per 1000 beds per day to 9.5 (−45%) over the study period. The use of antibacterials from the RESERVE group (“last-resort” treatment options) was very low. Conclusion and implications A reduction in facility-level antibacterial use and in variability across LTCFs was observed over the study period. The dissemination of empirical antibacterial prescription guidelines and the implementation of physician-pharmacist-nurse quality circles in all LTCFs of the canton of Vaud likely contributed to this reduction. Antibacterials from the WATCH group still represented 27% of the total use, providing targets for future antibiotic stewardship activities.

    更新日期:2019-12-27
  • Outbreak of Human Metapneumovirus in a Nursing Home: A Clinical Perspective
    J. Am. Med. Dir. Assoc. (IF 4.899) Pub Date : 2019-05-14
    Damien Seynaeve; Brigitte Augusseau-Rivière; Pascal Couturier; Christine Morel-Baccard; Caroline Landelle; Jean-Luc Bosson; Gaëtan Gavazzi; Marie-Reine Mallaret

    Objectives To describe a human metapneumovirus (hMPV) outbreak occurring in a nursing home for older adults and to identify the risk factors associated with the clinical infection. Design A retrospective, case-controlled study. Setting and participants A French nursing home for older adults between December 27, 2014 and January 20, 2015. Probable cases were residents presenting at least 1 respiratory symptom or 1 constitutional symptom. Confirmed cases identified in the same way as probable cases but with a positive RT-PCR test for hMPV. Controls were residents with no symptoms of respiratory infection. Measures Identification of hMPV was realized on nasal swab samples by RT-PCR. Results Seventy-eight older people were resident at the time of the outbreak. Three of the 4 tested were positive for hMPV by RT-PCR and negative for 13 other viruses or bacteria. All probable infected residents presented cough; other symptoms were scarcer. An inflammatory response was present, with median C-reactive protein at 50 mg/L. The median duration of the illness was 7 days. The rate of infection among residents was high (51%), with 5 hospitalizations (12.5%) and 1 death (2.5%). In multivariate analysis, vaccination against influenza virus appeared to emerge as associated with a probable hMPV infection, but this might be an artifact, as the proportion of unvaccinated residents was low (15%). A clear infected population profile was hard to define, although limited autonomy and low ADL score may play a role. Basic hygiene precautions were reinforced, but droplet precautions seemed difficult to apply rigorously to this population. Conclusions/Implications Clinical and biological presentations were nonspecific. The rate of infection was high, highlighting the need for the rapid introduction of strict precautions to contain the infection.

    更新日期:2019-12-27
  • Impact of Stiffer Arteries on the Response to Antihypertensive Treatment: A Longitudinal Study of the SardiNIA Cohort
    J. Am. Med. Dir. Assoc. (IF 4.899) Pub Date : 2019-12-26
    Edward G. Lakatta; Danilo AlunniFegatelli; Christopher H. Morrell; Edoardo Fiorillo; Marco Orru; Alessandro Delitala; Michele Marongiu; David Schlessinger; Francesco Cucca; Angelo Scuteri

    Objectives Carotid-femoral pulse wave velocity (PWV), an index of arterial stiffness and a proxy of arterial aging, has been reported to be an independent determinant of cardiovascular health. Whether the effects of antihypertensive treatment vary in the presence of accelerated arterial aging (stiffer artery, ie, PWV >10 m/s) has not been established. We tested this hypothesis in a longitudinal study in a large community-dwelling population. Design Longitudinal population study with repeated measures. Setting and Participants Study population consisted of a cohort of 6011 volunteers (2546 men and 3465 women, age range 14-101 years; 15,011 observations over a median follow-up of 6.8 years) participating in the SardiNIA Study. Measures Repeated measures of PWV, blood pressure (BP), and metabolic risk factors and the antihypertensive medication trajectories of BP and PWV over time were assessed via mixed effects models. Results Antihypertensive treatment significantly affected the trajectory of BP in both participants with (−0.47 ± 0.20 mmHg/y, P = .02) and participants without stiffer arteries (−0.47 ± 0.07 mmHg/y, P = .001). They also affected the trajectory of PWV in participants with stiffer artery, independent of the BP values. Conclusions and Implications Antihypertensive treatment is effective in reducing both BP and PWV in older individuals with stiffer arteries.

    更新日期:2019-12-27
  • Tibetan Medicated Bathing Therapy for Patients With Post-stroke Limb Spasticity: A Randomized Controlled Clinical Trial
    J. Am. Med. Dir. Assoc. (IF 4.899) Pub Date : 2019-12-25
    Meng Wang; Shouguo Liu; Zhihang Peng; Yi Zhu; Xiaodong Feng; Yihuang Gu; Jianhua Sun; Qiang Tang; Hongxia Chen; Xiaolin Huang; Jun Hu; Wei Chen; Jie Xiang; ChunXiao Wan; Gangqi Fan; Jianhu Lu; Wenguang Xia; Lihua Wang; Jianan Li

    Objective To determine the short- (4 weeks) and long-term (6 month) effectiveness of Tibetan medicated bathing therapy in patients with post-stroke limb spasticity. Design Prospective, blinded, randomized controlled trial. Subjects Post-stroke patients with limb spasticity were recruited between December 2013 and February 2017 and randomly assigned 1:1 to a control group that received conventional rehabilitation (n = 222) or an experimental group that received Tibetan medicated bathing therapy in combination with conventional rehabilitation (n = 222). Methods All patients received conventional rehabilitation. In addition, the experimental group received Tibetan medicated bathing therapy. The interventions were conducted 5 times per week for 4 weeks. The primary endpoint was changes from baseline after 4 weeks of therapy in muscle tone in the spastic muscles (elbow flexors, wrist flexors, finger flexors, knee extensors, ankle plantar flexors), as measured by the Modified Ashworth Scale (MAS). Results The mean change from baseline after 4 weeks of therapy in the MAS score for the elbow flexors (P = .017), wrist flexors (P < .001), and ankle plantar flexors (P < .001) was significantly greater in patients in the experimental group compared to the control group. The benefit was maintained for 3 muscle groups (elbow flexors P < .001, wrist flexors P = .001, and ankle plantar flexors P < .001) and 6 months (elbow flexors P < .001, wrist flexors P = .002, and ankle plantar flexors P < .001) after therapy. All adverse events were mild, and no serious adverse reactions to Tibetan medicated bathing therapy were recorded. Conclusions and Implications Tibetan medicated bathing therapy, in combination with conventional rehabilitation, has potential as a safe, effective treatment for the alleviation of post-stroke upper limb spasticity. Tibetan medicated bathing therapy was most advantageous for patients who had a baseline muscle tone score of 1+ to 2 on the MAS in the affected limb and recent onset of stroke (duration of the disease of 1-3 months).

    更新日期:2019-12-25
  • Association Between Home Health Services and Facility Admission in Older Adults With and Without Alzheimer's Disease
    J. Am. Med. Dir. Assoc. (IF 4.899) Pub Date : 2019-12-24
    Jinjiao Wang; Thomas V. Caprio; Adam Simning; Jingjing Shang; Yeates Conwell; Fang Yu; Yue Li

    Objectives To evaluate the association between home health (HH) services, including skilled nursing (SN), physical therapy (PT), occupational therapy, social work (SW), and homemaking aide assistance with the hazard of unplanned facility admissions among Medicare patients with and without Alzheimer's disease and related dementias (ADRD). Design Analysis of the Outcome and Assessment Information Set and billing records. Setting A not-for-profit HH agency serving multiple counties in New York State. Participants Adults ≥65 years old who received HH from January 1, 2017 to December 31, 2017. Measures Outcome was time from HH start of care to an unplanned facility admission of any type, including the hospital, nursing home, and rehabilitation facility. Independent variables included weekly intensity (visits/week, hours/week) of SN, PT, occupational therapy, SW, and, homemaking aide assistance separately. ADRD was identified by diagnosis (International Classification of Diseases, Tenth Revision codes in billing records) and cognitive impairment assessment (Outcome and Assessment Information Set). Results Of the sample (N = 6153), 14.9% had an unplanned facility admission. In multivariable Cox proportional hazard models that adjusted for time-varying effects of HH intensity and covariates, receiving the highest intensity of SN (3.3 visits of 2.78 hours per week) and PT (2.5 visits of 2 hours per week) was related to up to a 54% and 86% decrease, respectively, in the hazard of unplanned facility admission among patients with ADRD (n = 1525), and decreases of 56% and 90%, respectively, among patients without ADRD (n = 4628). Receiving any SW was related to 40% decreased in the hazard of facility admission in patients without ADRD only. Other HH services were not consistently related to the risk of facility admission. Conclusions and Implications Receiving a higher intensity of SN and PT was associated with reduced hazards of unplanned facility admission among HH patients with and without ADRD. Policies should ensure that patients with ADRD receive a sufficient amount and appropriate mix of HH services.

    更新日期:2019-12-25
  • Residential Greenness and Frailty Among Older Adults: A Longitudinal Cohort in China
    J. Am. Med. Dir. Assoc. (IF 4.899) Pub Date : 2019-12-20
    Anna Zhu; Lijing Yan; Chenkai Wu; John S. Ji

    Objectives Frailty is an accumulation of deficits characterized by reduced resilience to stressors and increased vulnerability to adverse outcomes. There is evolving evidence on the health benefits of residential greenness, but little is known about its impact on frailty. Design A longitudinal cohort study. Setting and participants We included older adults aged ≥65 years from the Chinese Longitudinal Healthy Longevity Survey (CLHLS) with a 12-year follow-up. Methods We assessed residential greenness by calculating the Normalized Difference Vegetation Index (NDVI) in the 500 m radius around participants' residence. We used 39 self-reported health items to construct a frailty index (FI) as a proportion of accumulated deficits. We defined an FI of ≤0.21 as nonfrail and prefrail, and an FI of >0.21 as frail. We used the mixed effects logistic regression models to examine the association between residential greenness and frailty, adjusted for a number of covariates. Results We had 16,238 participants, with a mean age of 83.0 years (standard deviation: 11.5). The mean baseline NDVI and FI were 0.40, and 0.12, respectively. Compared to the participants living in the lowest quartile of residential greenness, those in the highest quartile had a 14% [odds ratio (OR): 0.86, 95% confidence interval (CI): 0.77, 0.97] lower odds of frailty. The association was stronger among urban vs rural residents. Additionally, each 0.1-unit increase in annual average NDVI was related to a 2% higher odds of improvement in the frailty status (OR: 1.02, 95% CI: 1.00, 1.04). Conclusions and Implications Our study suggests that higher levels of residential greenness are related to a lower likelihood of frailty, specifically in urban areas.

    更新日期:2019-12-21
  • Effectiveness of Powerful Tools for Caregivers on Caregiver Burden and on Care Recipient Behavioral and Psychological Symptoms of Dementia: A Randomized Controlled Trial
    J. Am. Med. Dir. Assoc. (IF 4.899) Pub Date : 2019-12-19
    Antonio Terracciano; Ashley Artese; Jenie Yeh; LaVon Edgerton; Lisa Granville; Damaris Aschwanden; Martina Luchetti; Robert L. Glueckauf; Yannick Stephan; Angelina R. Sutin; Paul Katz

    Objective The aim of this study was to evaluate the effectiveness of a psychoeducational intervention, Powerful Tools for Caregivers (PTC), for family caregivers of individuals with dementia. Design A pragmatic, 2-arm randomized controlled trial compared the PTC intervention, as delivered in practice, to usual care. Participants randomized to usual care functioned as a control group and then received the PTC intervention. Intervention PTC is a 6-week manualized program that includes weekly 2-hour classes in a group setting facilitated by 2 trained and certified leaders. The educational program helps caregivers to enhance self-care practices and manage emotional distress. Setting and participants Two stakeholder organizations delivered the intervention in community settings. Participants were family caregivers of individuals with dementia recruited from the community in Florida. Methods Primary outcomes were caregiver burden and behavioral and psychological symptoms of dementia of the care recipient. Secondary outcomes included caregiver depressive symptoms, self-efficacy, self-rated health, and life satisfaction. Measures were collected at baseline (n = 60 participants), postintervention (n = 55), and at 6-week follow-up (n = 44). Results Intent-to-treat analyses found PTC reduced caregiver burden (d = −0.48) and depressive symptoms (d = −0.53), and increased self-confidence (d = 0.68), but found no significant benefit for behavioral and psychological symptoms of dementia in care recipients. PTC was rated highly by participants and program attrition was low, with 94% of caregivers completing at least 4 of the 6 classes. Conclusions and implications Although no significant effects were found for behavioral and psychological symptoms of dementia, this trial supports the effectiveness of PTC to improve caregiver outcomes as delivered in the community.

    更新日期:2019-12-20
  • Development and Validation of the Norfolk Quality of Life Fatigue Tool (QOL-F): A New Measure of Perception of Fatigue
    J. Am. Med. Dir. Assoc. (IF 4.899) Pub Date : 2019-12-16
    Etta J. Vinik; Aaron I. Vinik; Serina A. Neumann; Rajan Lamichhane; Steven Morrison; Sheri R. Colberg; Ying-Chuen Lai; James Paulson; Richard Handel; Carolina Casellini; Kim Hodges; Joshua Edwards; Henri K. Parson

    Objectives To design a questionnaire to evaluate and distinguish between cognitive and physical aspects of fatigue in different age groups of “nondiseased” people and guide appropriate prevention and interventions for the impact of frailty occurring in normative aging. Study design and participants The Norfolk QOL-Fatigue (QOL-F) with items of cognitive and physical fatigue, anxiety, and depression from validated questionnaires including items from the Patient-Reported Outcomes Measure Information System (PROMIS) databank was developed. The preliminary QOL-F was administered to 409 healthy multiethnic local participants (30-80 years old) in 5 age groups. Methods The authors distilled the item pool using exploratory (EFA) and confirmatory factor analysis (CFA). EFA identified 5 latent groups as possible factors related to problems due to fatigue, subjective fatigue, reduced activities, impaired activities of daily living (ADL), and depression. Results CFA demonstrated good overall fit [χ2(172) = 1094.23, P < .001; Tucker-Lewis index = 0.978; root mean square error of approximation = 0.049] with factor loadings >0.617 and strong interfactor correlations (0.69-0.83), suggesting that fatigue in each domain is closely related to other domains and to the overall scale except for ADL. The 5-factor solution displayed good internal consistency (Cronbach α = 0.78-0.94). Total and domain scores were fairly equivalent in all age groups except for the 40 to 49-year-old group with better overall scores. In addition, 70 to 79-year-olds had better ADL scores. In item response analysis, factor scores in different age groups were similar, so age may not be a significant driver of fatigue scores. Fatigue scores were significantly higher in females than in males (P < .05). Conclusions and clinical implications The developed Norfolk QOL-F tool demonstrated fatigue as a perceived cognitive phenomenon rather than an objective physical measure, suggesting mandatory inclusion of cognitive as well as physical measures in the evaluation of people as they age. QOL-F is able to distinguish QOL-F domain scores unique to different age groups, proposing clinical benefits from physical, balance, and cognitive interventions tailored to impact frailty occurring in normative aging.

    更新日期:2019-12-17
  • Sepsis Survivors Transitioned to Home Health Care: Characteristics and Early Readmission Risk Factors
    J. Am. Med. Dir. Assoc. (IF 4.899) Pub Date : 2019-12-16
    Kathryn H. Bowles; Christopher M. Murtaugh; Lizeyka Jordan; Yolanda Barrón; Mark E. Mikkelsen; Christina R. Whitehouse; Jo-Ana D. Chase; Miriam Ryvicker; Penny Hollander Feldman

    Objective To profile the characteristics of growing numbers of sepsis survivors receiving home healthcare (HHC) by type of sepsis before, during, and after a sepsis hospitalization and identify characteristics significantly associated with 7-day readmission. Design Cross-sectional descriptive study. Data sources included the Outcome and Assessment Information Set (OASIS) and Medicare administrative and claims data. Setting and Participants National sample of Medicare beneficiaries hospitalized for sepsis who were discharged to HHC between July 1, 2013 and June 30, 2014 (N = 165,228). Methods We used an indicator distinguishing among 3 types of sepsis: explicitly coded sepsis diagnosis without organ dysfunction; severe sepsis with organ dysfunction; and septic shock. We compared these subgroups' demographic, clinical and functional characteristics, comorbidities, risk factors for rehospitalization, characteristics of the index hospital stay, and predicted 7-day hospital readmission. Results The majority (80.7%) had severe sepsis, 5.7% had septic shock, and 13.6% had sepsis without acute organ system dysfunction. The medical diagnoses recorded at HHC admission identified sepsis or blood infection only 7% of the time, potentially creating difficulty identifying the sepsis survivor in HHC. Among sepsis types, septic shock survivors had the greatest illness burden profile. This study describes 12 key variables, each of which individually raises the relative 7-day readmission risk by as much as 60%. Increased risk of 7-day rehospitalization was found among those with septic shock, 3 or more previous inpatient stays, index hospital length of stay of >8 days, dyspnea, >6 functional dependencies, and other risk factors. Conclusions and Implications Implications for practice include using our findings to identify sepsis survivors who are at risk for early readmission. Assessment for these factors may profile the at-risk patient, thereby triggering the call for additional acute care intervention such as delayed discharge, or post-acute intervention such as early home visit and outpatient follow-up.

    更新日期:2019-12-17
  • The Association of Oral Bisphosphonate Use With Mortality Risk Following a Major Osteoporotic Fracture in the United Kingdom: Population-Based Cohort Study
    J. Am. Med. Dir. Assoc. (IF 4.899) Pub Date : 2019-12-12
    Shahab Abtahi; Andrea M. Burden; Piet Geusens; Joop P. van den Bergh; Tjeerd van Staa; Frank de Vries

    Objectives Bisphosphonates (BPs) might have extra benefits in reducing mortality because of their anti-atherosclerotic effects, but studies reported conflicting results. We investigated the association between oral BP use and mortality risk following a major osteoporotic fracture (MOF) in the United Kingdom. Design This was a population-based cohort study. Setting and Participants In total, 163,273 adults aged 50 years and older with an MOF between 2000 and 2018 from the Clinical Practice Research Datalink in the United Kingdom. Methods Cox proportional hazards models were used to estimate the risk of all-cause mortality in current (0‒6 months), recent (7‒12 months), and past (>1 year) exposures to oral BPs after nonhip MOF and hip fracture. In addition, stratification by sex, BP type, and duration of follow-up was performed. Results Compared with never users of oral BPs, current BP use was associated with a 7% higher all-cause mortality risk after nonhip MOF, whereas a 28% lower all-cause mortality risk was observed after hip fracture. Past BP exposure was associated with a 14% and 42% lower risk after nonhip MOF and hip fracture, respectively. When considering only the first 5 years of follow-up, mortality risk associated with current BP use was significantly lower for both fracture groups, and the greatest reduction in mortality risk was observed within the first year. Women had slightly lower risk compared with men. Conclusions and Implications We found a slight increased risk of all-cause mortality with current BP exposure after a nonhip MOF; however, a protective effect was observed following a hip fracture. Both the timing and the effect size of an association based on the anti-atherosclerotic hypothesis of BPs are not supported by our results. The decreasing trend of the mortality risk with shorter durations of follow-up suggests that the observed association is likely due to unknown distortion or unknown pleiotropic properties of BPs.

    更新日期:2019-12-13
  • Measurement of Dynamical Resilience Indicators Improves the Prediction of Recovery Following Hospitalization in Older Adults
    J. Am. Med. Dir. Assoc. (IF 4.899) Pub Date : 2019-12-11
    Sanne M.W. Gijzel, Jerrald Rector, Fokke B. van Meulen, Rolinka Schim van der Loeff, Ingrid A. van de Leemput, Marten Scheffer, Marcel G.M. Olde Rikkert, René J.F. Melis

    Objectives Acute illnesses and subsequent hospital admissions present large health stressors to older adults, after which their recovery is variable. The concept of physical resilience offers opportunities to develop dynamical tools to predict an individual's recovery potential. This study aimed to investigate if dynamical resilience indicators based on repeated physical and mental measurements in acutely hospitalized geriatric patients have added value over single baseline measurements in predicting favorable recovery. Design Intensive longitudinal study. Setting and Participants 121 patients (aged 84.3 ± 6.2 years, 60% female) admitted to the geriatric ward for acute illness. Measurements In addition to preadmission characteristics (frailty, multimorbidity), in-hospital heart rate and physical activity were continuously monitored with a wearable sensor. Momentary well-being (life satisfaction, anxiety, discomfort) was measured by experience sampling 4 times per day. The added value of dynamical indicators of resilience was investigated for predicting recovery at hospital discharge and 3 months later. Results 31% of participants satisfied the criteria of good recovery at hospital discharge and 50% after 3 months. A combination of a frailty index, multimorbidity, Clinical Frailty Scale, and or gait speed predicted good recovery reasonably well on the short term [area under the receiver operating characteristic curve (AUC) = 0.79], but only moderately after 3 months (AUC = 0.70). On addition of dynamical resilience indicators, the AUC for predicting good 3-month recovery increased to 0.79 (P = .03). Variability in life satisfaction and anxiety during the hospital stay were independent predictors of good 3-month recovery [odds ratio (OR) = 0.24, P = .01, and OR = 0.54, P = .04, respectively]. Conclusions and Implications These results highlight that measurements capturing the dynamic functioning of multiple physiological systems have added value in assessing physical resilience in clinical practice, especially those monitoring mental responses. Improved monitoring and prediction of physical resilience could help target intensive treatment options and subsequent geriatric rehabilitation to patients who will most likely benefit from them.

    更新日期:2019-12-11
  • Epidemiology of Antibiotic Use for Urinary Tract Infection in Nursing Home Residents
    J. Am. Med. Dir. Assoc. (IF 4.899) Pub Date : 2019-12-09
    Nicola D. Thompson, Austin Penna, Taniece R. Eure, Wendy M. Bamberg, Grant Barney, Devra Barter, Paula Clogher, Malini B. DeSilva, Ghinwa Dumyati, Erin Epson, Linda Frank, Deborah Godine, Lourdes Irizarry, Marion A. Kainer, Linda Li, Ruth Lynfield, J.P. Mahoehney, Joelle Nadle, Shelley S. Magill

    Objectives Describe antibiotic use for urinary tract infection (UTI) among a large cohort of US nursing home residents. Design Analysis of data from a multistate, 1-day point prevalence survey of antimicrobial use performed between April and October 2017. Setting and participants Residents of 161 nursing homes in 10 US states of the Emerging Infections Program (EIP). Methods EIP staff reviewed nursing home medical records to collect data on systemic antimicrobial drugs received by residents, including therapeutic site, rationale for use, and planned duration. For drugs with the therapeutic site documented as urinary tract, pooled mean and nursing home–specific prevalence rates were calculated per 100 nursing home residents, and proportion of drugs by selected characteristics were reported. Data were analyzed in SAS, version 9.4. Results Among 15,276 residents, 407 received 424 antibiotics for UTI. The pooled mean prevalence rate of antibiotic use for UTI was 2.66 per 100 residents; nursing home–specific rates ranged from 0 to 13.6. One-quarter of antibiotics were prescribed for UTI prophylaxis, with a median planned duration of 111 days compared with 7 days when prescribed for UTI treatment (P < .001). Fluoroquinolones were the most common (18%) drug class used. Conclusions and Implications One in 38 residents was receiving an antibiotic for UTI on a given day, and nursing home–specific prevalence rates varied by more than 10-fold. UTI prophylaxis was common with a long planned duration, despite limited evidence to support this practice among older persons in nursing homes. The planned duration was ≥7 days for half of antibiotics prescribed for treatment of a UTI. Fluoroquinolones were the most commonly used antibiotics, despite their association with significant adverse events, particularly in a frail and older adult population. These findings help to identify priority practices for nursing home antibiotic stewardship.

    更新日期:2019-12-09
  • Reducing Hospital Readmissions Through a Skilled Nursing Facility Discharge Intervention: A Pragmatic Trial
    J. Am. Med. Dir. Assoc. (IF 4.899) Pub Date : 2019-12-05
    Rebekah L. Gardner, Kimberly Pelland, Rouba Youssef, Blake Morphis, Kathleen Calandra, Lara Hollands, Stefan Gravenstein

    Objective To determine if implementation of Project Re-Engineered Discharge (RED), designed for hospitals but adapted for skilled nursing facilities (SNFs), reduces hospital readmissions after SNF discharge to the community in residents admitted to the SNF following an index hospitalization. Design A pragmatic trial. Setting and participants SNFs in southeastern Massachusetts, and residents discharged to the community. Methods We compared SNFs that deployed an adapted RED intervention to a matched control group from the same region. The primary outcome was hospital readmission within 30 days after SNF discharge, among residents who had been admitted to the SNF following an index hospitalization and then discharged home. January 2016 through March 2017 was the baseline period; April 2017 through June 2018 was the follow-up period (after implementation of the intervention). We used a difference-in-differences analysis to compare the intervention SNFs to the control group, using generalized estimating equation regression and controlling for facility characteristics. Results After implementation of RED, readmission rates were lower across all 4 measures in the intervention group; control facilities’ readmission rates remained stable or increased. The relative decrease was 0.9% for the primary outcome of hospital readmission within 30 days after SNF discharge and 1.7% for readmission within 30 days of the index hospitalization discharge date (P ≤ .001 for both comparisons). Conclusions and Implications We found that a systematic discharge process developed for the hospital can be adapted to the SNF environment and can reduce readmissions back to the hospital, perhaps through improved self-management skills and better engagement with community services. This work is particularly timely because of Medicare's new Value-Based Purchasing Program, in which nursing homes can receive incentive payments if their hospital readmission rates are low relative to their peers. To verify its scalability and broad potential, RED should be validated across a broader diversity of SNFs nationally.

    更新日期:2019-12-05
  • Combining Procalcitonin and Rapid Multiplex Respiratory Virus Testing for Antibiotic Stewardship in Older Adult Patients With Severe Acute Respiratory Infection
    J. Am. Med. Dir. Assoc. (IF 4.899) Pub Date : 2019-11-30
    Chien-Chang Lee, Julia Chia-Yu Chang, Xiao-Wei Mao, Wan-Ting Hsu, Shey-Ying Chen, Yee-Chun Chen, Chorng-Kuang How

    Objectives Virus infection is underevaluated in older adults with severe acute respiratory infections (SARIs). We aimed to evaluate the clinical impact of combining point-of-care molecular viral test and serum procalcitonin (PCT) level for antibiotic stewardship in the emergency department (ED). Design A prospective twin-center cohort study was conducted between January 2017 and March 2018. Setting and Participants Older adult patients who presented to the ED with SARIs received a rapid molecular test for 17 respiratory viruses and a PCT test. Measures To evaluate the clinical impact, we compared the outcomes of SARI patients between the experimental cohort and a propensity score–matched historical cohort. The primary outcome was the proportion of antibiotics discontinuation or de-escalation in the ED. The secondary outcomes included duration of intravenous antibiotics, length of hospital stay, and mortality. Results A total of 676 patients were included, of which 169 patients were in the experimental group and 507 patients were in the control group. More than one-fourth (27.9%) of the patients in the experimental group tested positive for virus. Compared with controls, the experimental group had a significantly higher proportion of antibiotics discontinuation or de-escalation in the ED (26.0% vs 16.1%, P = .007), neuraminidase inhibitor uses (8.9% vs 0.6%, P < .001), and shorter duration of intravenous antibiotics (10.0 vs 14.5 days, P < .001). Conclusions and Implications Combining rapid viral surveillance and PCT test is a useful strategy for early detection of potential viral epidemics and antibiotic stewardship. Clustered viral respiratory infections in a nursing home is common. Patients transferred from nursing homes to ED may benefit from this approach.

    更新日期:2019-11-30
  • Respiratory Practices in the Long-term Care Setting: A Human Factors–Based Risk Analysis
    J. Am. Med. Dir. Assoc. (IF 4.899) Pub Date : 2019-11-30
    Morgan J. Katz, Patience M. Osei, Arjun Vignesh, Andrea Montalvo, Ifeoluwa Oresanwo, Ayse P. Gurses

    Objective To systematically assess safety risks pertaining to tracheostomy care in the long-term care (LTC) setting using a human factors engineering approach. Design We utilized a 5-part approach to complete our proactive risk assessment: (1) performed a hierarchical task analysis of the processes of tracheostomy stoma and suctioning; (2) identified failure modes where a subtask may be completed inappropriately; (3) prioritized each failure mode based on a risk priority scale; (4) identified contributing factors to and consequences for each of the prioritized failure modes; and (5) identified potential solutions to eliminate or mitigate risks. Setting Three high-acuity LTC facilities with ventilator units across Maryland. Methods The hierarchical task analysis was conducted jointly by 2 human-factors experts and an infectious disease physician based on respiratory care policies from the Centers for Disease Control and Prevention and existing policies at each LTC facility. The findings were used to guide direct observations with contextual inquiry and focus group sessions to assess safety risks for residents receiving tracheostomy care. Results Direct observations of tracheostomy care and suctioning in the LTC setting revealed significant variations in practice. Respiratory therapists working in LTC reported lack of training and ambiguity concerning recommended procedures to reduce infection transmission in daily care. Highest risk steps identified in tracheostomy care and suctioning included hand hygiene, donning gloves, and providing intermittent suctioning as the suction catheter was withdrawn. Participants identified risk mitigation strategies targeting these high-risk failure modes that addressed contributing factors related to 5 work system components: person (knowledge and competency), task (eg, urgency or time constraints), tools and technology (eg, availability of hand sanitizer), environment (eg, communal rooms), and organization (eg, patient safety culture). Conclusions and implications Human factors analysis of the highest-risk steps in respiratory care activities in the LTC setting suggest several potential mitigation strategies to decrease the risk of infection transmission. Clear procedure guidelines with training are needed to reduce ambiguity and improve care in this setting. Involving frontline staff in patient safety issues using human factors principles and risk analysis may encourage participation and improve the infection prevention culture in LTC.

    更新日期:2019-11-30
  • Antibiotic Stewardship in European Nursing Homes: Experiences From the Netherlands, Norway, Poland, and Sweden
    J. Am. Med. Dir. Assoc. (IF 4.899) Pub Date : 2019-11-30
    Laura W. Van Buul, Annelie A. Monnier, Pär-Daniel Sundvall, Peter Ulleryd, Maciek Godycki-Cwirko, Anna Kowalczyk, Morten Lindbaek, Cees M.P.M. Hertogh

    Antibiotics are among the most widely prescribed drugs in long-term care facilities, which highlights the importance of antibiotic stewardship (ABS) in this setting. In this article, we describe the experiences with ABS in nursing homes (NHs) from the perspective of 4 European countries: the Netherlands, Norway, Poland, and Sweden. In these countries, a large variety of initiatives to develop and implement ABS in NHs have been introduced in recent years. Among these initiatives are national antibiotic prescribing surveillance systems, NH-specific prescribing guidelines, and national networks of healthcare institutions that exchange information and develop ABS policy. Several initiatives evolved as a result of political prioritization of antibiotic resistance, translated into national action plans. Experiences of the 4 countries with the presented initiatives may inspire other countries that aim to develop or improve ABS in the long-term care setting.

    更新日期:2019-11-30
  • Effectiveness of Intervention Based on End-effector Gait Trainer in Older Patients With Stroke: A Systematic Review
    J. Am. Med. Dir. Assoc. (IF 4.899) Pub Date : 2019-11-29
    Elvira Maranesi, Giovanni Renato Riccardi, Valentina Di Donna, Mirko Di Rosa, Paolo Fabbietti, Riccardo Luzi, Luigi Pranno, Fabrizia Lattanzio, Roberta Bevilacqua

    Objective The objective of the article is to analyze the effects of the end-effector technology for gait rehabilitation on acute, subacute, and chronic stroke in order to verify the efficacy of the treatment in older people, based on evidence from randomized controlled trials, and thus increase the clinical knowledge for future applications in the hospital setting. Design A systematic review of the literature was conducted in October 2018. The data were collected from Cochrane, Embase, Scopus, and PubMed databases, analyzing manuscripts and articles of the last 10 years. Setting We included only randomized controlled trials written in English and aimed to study the effects of end-effector devices in improving walking in stroke patients. We selected 20 studies, and the results were divided into subacute stroke patients and chronic stroke patients. Measures Quality evaluation was performed using the PEDro scale. Of the 10 studies considered, 9 were randomized controlled trials. The PEDro scale score ranged from 7 to 10. Results Robotic-assisted gait trainer is more effective for subacute stroke patients with a lower function ambulation assessment, showing significant changes in independent walking ability. One possible explanation of the improvement of the gait speed and functional ambulation is the opportunity of receiving a more intensive and repetitive task-oriented training through end-effector robotic-based intervention. Conclusions and Implications The use of robotic-assisted gait trainer, together with a conventional treatment, seems to improve the walking capability of patients. Future research trials should take into account the impact of the robotic end-effector gait training on the oldest population, as this target was only partially included in the studies examined. Availability of new evidence will support the design of innovative assistive models for the clinical rehabilitation setting, which will take into account the need of personalizing the intervention to support the growing oldest old population.

    更新日期:2019-11-29
  • Weakness May Have a Causal Association With Early Mortality in Older Americans: A Matched Cohort Analysis
    J. Am. Med. Dir. Assoc. (IF 4.899) Pub Date : 2019-11-27
    Ryan McGrath, Brenda M. Vincent, Mark D. Peterson, Donald A. Jurivich, Lindsey J. Dahl, Kyle J. Hackney, Brian C. Clark

    Objectives Quantifying the association between muscle weakness and mortality with carefully matched cohorts will help to better establish the impact of weakness on premature death. We used a matched cohort analysis in a national sample of older Americans to determine if those who were weak had a higher risk for mortality compared with control groups with incrementally higher strength capacities. Design Longitudinal panel. Setting Detailed interviews that included physical measures were conducted in person, whereas core interviews were often performed over the telephone. Participants Data from 19,729 Americans aged at least 50 years from the 2006-2014 waves of the Health and Retirement Study were analyzed. Measures A handgrip dynamometer was used to assess handgrip strength (HGS) in each participant. Men with HGS <26 kg were considered weak, ≥26 kg were considered not weak, and ≥32 kg were considered strong. Women with HGS <16 kg were classified as weak, ≥16 kg were classified as not-weak, and ≥20 kg were classified as strong. The National Death Index and postmortem interviews determined the date of death. The greedy matching algorithm was used to match cohorts. Results Of the 1077 weak and not-weak matched pairs, 401 weak (37.2%) and 296 not-weak (27.4%) older Americans died over an average 4.4 ± 2.5-year follow-up. There were 392 weak (37.0%) and 243 strong (22.9%) persons who died over a mean 4.5 ± 2.5-year follow-up from the 1057 weak and strong matched pairs. Those in the weak cohort had a 1.40 [95% confidence interval (CI) 1.19, 1.64] and 1.54 (CI 1.30, 1.83) higher hazard for mortality relative to persons in the not-weak and strong control cohorts, respectively. Conclusions and Implications Our findings may indicate a causal association between muscle weakness and mortality in older Americans. Health care providers should include measures of HGS as part of routine health assessments and discuss the health risks of muscle weakness with their patients.

    更新日期:2019-11-28
  • Optimizing Quality of Life With Cognitive Impairment: A Study of End-of-Life Care in Assisted Living
    J. Am. Med. Dir. Assoc. (IF 4.899) Pub Date : 2019-11-26
    Laura Arneson, Alexis A. Bender, Maggi N. Robert, Molly M. Perkins

    Objectives Assisted living (AL) is an expanding site of end-of-life (EOL) care in the United States. Understanding determinants of quality of life (QoL) for AL residents near EOL is vital to optimize care for this growing population, most of whom have some degree of cognitive impairment (CI). This analysis aimed to identify factors associated with QoL in a diverse sample of AL residents with CI approaching EOL. Design Observational cross-section design. Setting and participants Data are from a 5-year study funded by the National Institute on Aging examining EOL care of residents in 7 diverse AL communities in metropolitan Atlanta (n = 67). Methods CI was assessed with the Montreal Cognitive Assessment (scores ≤ 26) and QoL was determined with the self-reported QoL in Alzheimer's disease survey adapted for use in AL. Psychological distress was assessed using the Patient Health Questionnaire–4 and fatigue was assessed using the 13-item Functional Assessment of Chronic Illness Therapy Fatigue Scale. Initial descriptive analyses were followed by backward stepwise regression analyses to select a best-fitting model of QoL. Results The final model predicted 27% of the variance in QoL. CI was not significantly correlated with QoL and was not retained in the final model. Pain and functional limitation also did not meet inclusion criteria (P ≤ .10) and were sequentially removed, producing a final model of QoL in terms of psychological distress (β = −0.28, P = .032), fatigue (β = −0.26, P = .048), and race (β = 0.21, P = .063). Conclusions and Implications The lack of a significant correlation between degree of CI and self-reported QoL suggests that AL residents have the potential to experience high QoL, despite CI. Interventions to reduce psychological distress and manage fatigue could be implemented during EOL care to attempt to improve QoL for AL residents with CI. The correlation between race and QoL warrants investigation into possible racial disparities in AL and EOL care.

    更新日期:2019-11-27
  • FRAIL Scale also Predicts Long-Term Outcomes in Older Patients With Acute Coronary Syndromes
    J. Am. Med. Dir. Assoc. (IF 4.899) Pub Date : 2019-11-26
    Oriol Rodríguez-Queraltó, Francesc Formiga, Ramón López-Palop, Francisco Marín, María T. Vidán, Manuel Martínez-Sellés, Pablo Díez-Villanueva, Juan Sanchís, Miguel Corbí, Jaime Aboal, Eva Bernal, Oriol Alegre, Lourdes Vicent, Albert Ariza-Solé

    Objectives No previous studies have assessed the role of the FRAIL scale in predicting long-term outcomes in older patients with acute coronary syndromes (ACS). Design, Setting and Participants The multicenter observational LONGEVO-SCA registry included unselected patients ≥80 years of age with ACS from 44 centers. A comprehensive geriatric assessment was performed during hospitalization. Measures Frailty was measured by the FRAIL scale. For the purpose of this study, main outcome measured was mortality or readmission at 24 months. Results A total of 498 patients were included. Mean age was 84.3 years. A total of 198 patients (33.1%) were prefrail and 135 (27.1%) frail. Patients who were prefrail and frail had a higher degree of comorbidities, and higher prevalence of disability, cognitive impairment, and nutritional risk. A total of 165 out of 498 patients (33.1%) died, and 331 patients (66.7%) died or were readmitted at 24 months. Both prefrailty and frailty were associated with a higher mortality compared with robust patients (P < .001). The incidence of mortality or readmission was also higher in patients who were prefrail or frail (P < .001). After adjusting for potential confounders, the association between frailty and mortality or readmission remained significant (hazard ratio 1.28 for prefrailty and hazard ratio 1.96 for frailty, P < .001). The FRAIL scale showed an optimal ability for predicting mortality or readmission (area under the receiver operating characteristics curve 0.86, 95% confidence interval 0.83‒0.89). The area under the receiver operating characteristics curve from the Global Registry of Acute Coronary Events risk score was 0.89. No significant differences were observed between both AUC values (P = .163). Conclusions and Implications The FRAIL scale independently predicted long-term outcomes in older patients with ACS. The predictive ability of this scale was comparable to the strongly recommended Global Registry of Acute Coronary Events risk score. Frailty assessment is mandatory for improving risk prediction in these complex patients.

    更新日期:2019-11-27
  • Importance of Frailty for Association of Antipsychotic Drug Use With Risk of Fracture: Cohort Study Using Electronic Health Records
    J. Am. Med. Dir. Assoc. (IF 4.899) Pub Date : 2019-07-01
    Rafael Gafoor, Judith Charlton, Rathi Ravindrarajah, Martin C. Gulliford

    Objective To evaluate association of first- or second-generation antipsychotic (AP) drugs with fracture risk at different levels of frailty over the age of 80 years. Design Population-based cohort study. Setting and Participants United Kingdom Clinical Practice Research Datalink including 153,304 patients aged 80 years and older between 2006 and 2015. Methods Rates of fracture and adjusted rate ratios (RR) were estimated by AP drug exposure category, adjusting for age, sex, frailty, number of deficits, and dementia diagnosis. Results Data were analyzed for 165,726 treatment episodes (153,304 patients; 61.3% women; mean age 83 years; 21,365 fractures; 681,221.1 person-years of follow-up). AP exposure was associated with increasing age, frailty, and dementia diagnosis. After adjusting for frailty and covariates, first-generation AP exposure was associated with risk of any fracture, RR 1.24 (95% confidence interval 1.07–1.43, P = .003). Second-generation AP exposure was associated with femur fracture (RR 1.41, 1.22–1.64, P < .001) but less strongly with any fracture (RR 1.12, 1.01–1.24, P = .033). Fracture incidence increased with frailty level. The number of person-years of first-generation AP treatment associated with 1 additional fracture at any site was 75 (42–257) for severely frail patients but 187 (95% confidence interval 104–640) for ‘fit’ patients. For second-generation AP, 1 additional femur fracture might result from 173 (111–323) person-years treatment in severe frailty but 365 (234–681) person-years treatment for ‘fit’ patients. Conclusions and Implications Frail patients are more likely to receive AP drug treatment, but their absolute risk of AP-associated fracture is substantially greater than for nonfrail patients.

    更新日期:2019-11-26
  • Dementia Cafés as a Community Resource for Persons With Early-Stage Cognitive Disorders: A Nationwide Survey in Japan
    J. Am. Med. Dir. Assoc. (IF 4.899) Pub Date : 2019-05-31
    Hajime Takechi, Tomoyuki Yabuki, Masahiko Takahashi, Hisao Osada, Shinji Kato

    Objectives Dementia cafés are expected to serve as a new community resource based on the national dementia strategy in Japan. The objective of the present study was to examine effective ways to manage dementia cafés through an overview of dementia cafés in Japan and an analysis of the factors related to their effectiveness on attendees. Design Cross-sectional analysis. Setting and participants Representatives of 1477 dementia cafés in Japan. Measures Questionnaires regarding the dementia cafés' characteristics, management members, staff, their guests and effectiveness on people with dementia, their families, and community members were sent to the cafés, with instructions to have them completed by the café representatives. Logistic regression analysis was performed with the effect on each guest attribute as a dependent variable, and factors related to the effectiveness of dementia cafés were analyzed. Results Questionnaires were sent to a total of 2728 dementia cafés in Japan, and responses were received from 1477 (54.1%). The most common meeting frequency and meeting hours were once a month (64.8%) and 2 hours (53.8%), respectively. Analysis of the effectiveness of dementia cafés on 3 groups of guests indicated the following preferences for café program: people with dementia preferred frequent meetings and activities, families of people with dementia preferred having a place for private consultation and advice and peer meetings, and community members preferred frequent meetings and both mini-lectures and private consultation and advice. Logistic regression analysis further revealed that all types of guests preferred the presence of the same types of guests. Conclusions/Implications This study revealed the multicomponent nature of dementia cafés. The results suggest that a good balance of programs and guests would enhance the cafés' effectiveness among the multiple stakeholders in regard to dementia, especially in the early stage of the disease.

    更新日期:2019-11-26
  • Lap Time Variability From a 400-m Walk Is Associated With Future Mild Cognitive Impairment and Alzheimer's Disease
    J. Am. Med. Dir. Assoc. (IF 4.899) Pub Date : 2019-06-18
    Qu Tian, Susan M. Resnick, Stephanie A. Studenski, Luigi Ferrucci

    Objectives To determine whether the trajectory of preclinical lap time variability from a 400-m walk differentiates participants with future mild cognitive impairment (MCI)/Alzheimer's disease (AD) from matched controls. Design A case-control retrospective study embedded in a large longitudinal cohort study, the Baltimore Longitudinal Study of Aging (BLSA). Setting In the BLSA, participants were scheduled for clinical visits, including mobility and cognitive assessments. Data reported here were collected between April 2007 and September 2017 (average follow-up 5.2 ± 2.4 years). Participants 67 participants developed MCI/AD and 134 age- and sex-matched controls remained cognitively normal. Measurements Diagnoses of MCI and AD were adjudicated at a consensus conference. The rate of change in lap time variability between MCI/AD cases prior to symptom onset and controls were compared using mixed effects linear regression, and adjusted for baseline executive function, memory, gait speed, and changes in gait speed. Results Compared to controls, eventual MCI/AD cases had a greater rate of increase in lap time variability prior to symptom onset (β = 0.59, P = .009). This association was independent of baseline cognition, gait speeds at baseline or change over time from a 6-m or 400-m walk. Conclusion/Implications Independent of other early indicators and gait slowing, a greater rate of increase in lap time variability from a 400-m walk differentiates individuals who eventually develop MCI/AD from controls, suggesting that early pathology affects the automaticity of walking. Lap time variability can be assessed during routine clinical practice over time and might help identify individuals at risk for future MCI/AD.

    更新日期:2019-11-26
  • Managing Paratonia in Persons With Dementia: Short-term Effects of Supporting Cushions and Harmonic Techniques
    J. Am. Med. Dir. Assoc. (IF 4.899) Pub Date : 2019-06-18
    Bieke Van Deun, Nele Van Den Noortgate, Anke Van Bladel, Koen De Weerdt, Dirk Cambier

    Objectives Paratonia, a form of hypertonia typically seen in dementia, is often associated with difficulties in positioning and daily care. No evidence-based therapy or clinical guideline for management is available. In this study, the short-term effect of harmonic techniques (HT) and supporting cushions (SC) on paratonia was explored. Design This was a multicenter interventional clinical trial with AB/BA crossover design. Each intervention (SC or HT) was subsequently implemented over 1 week in each of the participants. Setting and participants The study included 22 participants with moderate to severe paratonia from 9 different nursing homes in Flanders, Belgium. Methods Measurements of biceps brachii and rectus femoris muscle tone (MyotonPRO), maximal elbow and knee extension (goniometer), and pain (Pain Assessment Checklist for Seniors With Limited Ability to Communicate) were performed on 3 different days within 1 week. The effect of HT on nursing care was evaluated with the Pain Assessment Checklist for Seniors With Limited Ability to Communicate and visual analog scale ratings of discomfort items. Results After 30 minutes of positioning with SC, participants had lower biceps brachii muscle tone (P = .041) and higher maximal elbow extension (P = .006) than without SC. After a 30-minute session of HT, a significant increase in biceps brachii muscle tone (P = .032) and maximal extension of elbow (P < .001) and knee (P = .028) was found. Pain (P = .003) and discomfort (P = .001 to P = .019) during morning care were significantly lower when care was preceded by 30 minutes of HT. Conclusions/Implications This explorative study revealed beneficial short-term effects on range of motion for both SC and HT and a positive effect of SC on upper limb muscle tone. Beneficial effects of HT were found on resident's pain and caregiver's discomfort during care. The results of the present study are encouraging and can contribute to the development of evidence-based interventions for paratonia.

    更新日期:2019-11-26
  • Severe Fear of Falling Is Associated With Cognitive Decline in Older Adults: A 3-Year Prospective Study
    J. Am. Med. Dir. Assoc. (IF 4.899) Pub Date : 2019-07-24
    Hye-Mi Noh, Yong Kyun Roh, Hong Ji Song, Yong Soon Park

    Objectives Fear of falling (FOF) is common in older adults. We investigated whether FOF affects development of cognitive decline over a 3-year period in community-dwelling older adults with intact cognition. Design Retrospective, cohort, observational. Setting and participants Data for 4280 older adults with normal cognition at baseline from the Survey of Living Conditions and Welfare Needs of Korean Older Persons (2008 and 2011). Methods History of falls and severity of FOF (no fear, somewhat fearful, or very fearful) were assessed at baseline (2008). We evaluated cognitive function using the Korean version of the Mini-Mental State Examination in 2008 and 2011, and defined cognitive decline as a decrease of ≥3 points over the 3-year study period. Multivariable logistic regression analysis was performed to examine the association between FOF and cognitive decline. Results The prevalence of being somewhat fearful of falling was 54.6% and that of being very fearful was 9.7%. The participants who were somewhat fearful of falling had a 1.2-fold higher risk of cognitive decline; this finding lost significance in adjusted models. The participants who were very fearful of falling had a 1.45-fold higher risk of cognitive decline than those with no FOF after adjusting for confounders [odds ratio (OR) 1.45, 95% confidence interval (CI) 1.08–1.95]. When we divided the participants according to age, sex, and baseline cognitive function, the association was significant in men (OR 2.29, 95% CI 1.24–4.25), participants age >70 years (OR 1.57, 95% CI 1.06–2.33), and those with a Mini-Mental State Examination score <30 (OR 1.45, 95% CI 1.07–1.98). Conclusions and implications Being very fearful of falling increased the risk of cognitive decline in older Korean adults. Physicians should be aware of the risk of development of cognitive impairment in older individuals with FOF.

    更新日期:2019-11-26
  • A Group-based Trajectory Analysis of Longitudinal Psychotropic Agent Use and Adverse Outcomes Among Older People
    J. Am. Med. Dir. Assoc. (IF 4.899) Pub Date : 2019-07-18
    Shih-Tsung Huang, Yu-Wen Wen, Susan Shur-Fen Gau, Liang-Kung Chen, Fei-Yuan Hsiao

    Objective Existing evidence on long-term psychotropic polypharmacy in older people is scarce despite serious safety concerns regarding this issue. This study aims to identify distinct trajectories of longitudinal psychotropic agent use and to examine the association with the risk of mortality and unplanned hospitalization according to distinct trajectories. Design A retrospective longitudinal cohort study based on data from Taiwan's National Health Insurance Research Database (NHIRD). Setting and participants A population-based study including 39,803 eligible participants aged 65 years or older who were newly prescribed oral psychotropic agents in 2004. Measures We assessed 5 years of monthly consumption of psychotropic agents among eligible participants and used group-based trajectory modeling to identify distinct groups of longitudinal psychotropic use. Cox proportional hazards models were used to examine the association between distinct trajectories of longitudinal psychotropic agent use and subsequent 1- and 3-year unplanned hospitalization and all-cause mortality. Results Among 39,803 eligible participants, we identified 5 trajectories of longitudinal psychotropic agent use over a 5-year follow-up period: sustained intense (7.1%), moderate increasing (12.1%), decreasing (13.4%), slowly increasing (15.7%), and infrequent users (51.6%). Moderate increasing and sustained intense use were associated with significantly higher risks of unplanned hospitalization [moderate increasing use: hazard ratio [HR] 1.30, 95% confidence interval (CI) 1.18-1.44; sustained intense use: HR 1.40, 95% CI 1.24-1.58] and all-cause mortality (moderate increasing use: HR 1.25, 95% CI 1.09-1.44; sustained intense use: HR 1.32, 95% CI 1.12-1.56) than infrequent use. Similar results were observed at 3 years of follow-up. Conclusions/Implications Older people with moderately increasing and sustained intense use of psychotropic agents over time had higher risks of unplanned hospitalization and mortality. Tracking older people's use of psychotropic agents over time may help to identify individuals at greatest risk of unplanned hospitalization and mortality.

    更新日期:2019-11-26
  • Relationship Between Nutritional Status and Insomnia Severity in Older Adults
    J. Am. Med. Dir. Assoc. (IF 4.899) Pub Date : 2019-05-17
    Pinar Soysal, Lee Smith, Ozge Dokuzlar, Ahmet Turan Isik

    Objectives Both insomnia and malnutrition are quite common and can cause similar negative consequences, such as falls, depression, and cognitive impairment in older adults, but there is no study investigating the relationship between the 2. The aims were to investigate relationships between insomnia/insomnia severity and Mini Nutritional Assessment (MNA) score and serum nutrient levels. Setting and participants Aged 65 years or older, 575 outpatients were included. Methods MNA scores >23.5, 17-23.5, and <17 were categorized as normal nutritional status, malnutrition risk, and malnutrition, respectively. Serum vitamin B12, vitamin D, and folate deficiencies were also evaluated. Insomnia Severity Index (ISI) with scores of 8 and higher indicated insomnia, which was further stratified as mild (8-14), moderate (15-21), or severe (22-28). Results The mean age was 73.1 ± 7.7 years, with 73.2% being female. The prevalence of patients with no insomnia, mild insomnia, moderate insomnia, and severe insomnia were 34.4%, 20.9%, 30.1%, and 14.6%, respectively. After adjusting for gender, education, number of drugs, Charlson Comorbidity Index, presence of depression, and Mini-Mental State Examination scores, patients with insomnia had lower MNA scores than those without insomnia (OR = 0.84, 95% CI: 0.7-0.9, P < .001). There were significant relationships between moderate/severe insomnia and the presence of malnutrition and risk of malnutrition (OR = 1.6, 95% CI: 1.0-2.5, P = .046; OR = 1.6, 95% CI: 1.0-2.7, P = .042) and MNA scores (OR = 0.83, 95% CI: 0.7-0.9, P < .001)/OR = 0.82, 95% CI: 0.7-0.9, P < .001). There was no significant difference between insomnia severity status and serum vitamin D, vitamin B12, folate levels, or classification of these nutrients (P > .05). Conclusions/Implications There is a close relationship between MNA scores and insomnia or insomnia severity in older adults. Therefore, when evaluating an older patient with insomnia, malnutrition should be evaluated, or insomnia should also be questioned in an older patient with malnutrition. Thus, more effective management of the 2 can be possible.

    更新日期:2019-11-26
  • Dietary Protein Intake and Falls in Older People: Longitudinal Analyses From the Osteoarthritis Initiative
    J. Am. Med. Dir. Assoc. (IF 4.899) Pub Date : 2019-05-08
    Nicola Veronese, Pinar Soysal, Brendon Stubbs, Stefania Maggi, Sarah E. Jackson, Jacopo Demurtas, Stefano Celotto, Ai Koyanagi, Francesco Bolzetta, Lee Smith

    Objectives Literature regarding dietary protein intake and risk of falls is limited to a few studies with relatively small sample sizes and short follow-ups, which have reported contrasting findings. Thus, we investigated whether dietary protein intake is associated with risk of falls in a large cohort of North American adults. Design Data were drawn from the Osteoarthritis Initiative, a cohort study, with 8 years of follow-up. Setting and participants Community-dwelling adults with knee osteoarthritis or at high risk for this condition. Methods Dietary protein intake was recorded using the Block Brief 2000 food frequency questionnaire and categorized using gender-specific quartiles (Q). Falls were self-reported in response to the question “Did you fall during the past year?” categorized as yes vs no and made during the 6 visits over 8 years of follow-up. Results are reported as relative risks (RRs), with their 95% confidence intervals (CIs), using a multivariable Poisson regression. Results The final sample consisted of 4450 adults (mean age 61.2 years, females = 59.6%). Higher dietary protein intake was significantly associated with higher frequency of falls during the year before baseline. After adjusting for 17 potential confounders, people with the greatest amount of protein intake (Q4) had a significantly higher risk of falling over the 8-year follow-up period (RR 1.112, 95% CI 1.027-1.211, P = .009) than those with the lowest protein intake (Q1). Conclusions/Implications In this cohort of people affected by knee osteoarthritis or at high risk for this condition, high dietary protein intake may increase the risk of falls in older people, but further research is needed to confirm or refute these findings.

    更新日期:2019-11-26
  • Sociodemographic Factors and Characteristics of Caregivers as Determinants of Skilled Nursing Facility Admissions When Modeled Jointly With Functional Limitations
    J. Am. Med. Dir. Assoc. (IF 4.899) Pub Date : 2019-03-20
    Terese Sara Høj Jørgensen, Heather Allore, Janet L. MacNeil Vroomen, Brent Vander Wyk, George O. Agogo

    Objectives We examined whether previously identified relationships between sociodemographic factors and caregivers for skilled nursing facility (SNF) admissions are replicated when jointly accounting for longitudinal change in functional limitations. We further explored the impact of caregivers by investigating the relationship between caregiver's characteristics and SNF admissions. Design Longitudinal follow-up study. Setting The United States of America. Participants In total, 3875 older Americans from the 2011-2015 rounds of the National Health and Aging Trends Study linked with Centers for Medicare and Medicaid Services. Measures Sociodemographic factors and caregiver's characteristics were used to predict change in functional limitations from baseline and time to first SNF admission using a joint modeling approach. Results In total, 11.3% of the study population had a SNF admission during follow-up. For sociodemographic factors, non-Hispanic white, <9th grade education, and having at least 1 caregiver were associated with higher hazards of SNF admission than other race/ethnicity, college or higher education, and no caregiver, respectively. In contrast, living with a partner or living with others was associated with lower hazard of SNF admissions. For characteristics of caregivers, medical-supportive caregiver was associated with increased hazard of SNF admissions, whereas partner caregiver was protective of SNF admissions. Jointly modeling SNF admissions and change in functional limitations resulted in greater precision of effect estimates than modeling these outcomes separately. Conclusions and implications The study provides insight that can help identify high-risk populations for future interventions to prevent or delay SNF admissions. The relation between caregivers and SNF admissions depended on caregiver's characteristics. Future work should focus on providing help to those without a partner caregiver or needing help managing their health to ensure independent living and improve the well-being of older adults. Precision increased when jointly modeling the SNF admission with change in functional limitations.

    更新日期:2019-11-26
  • Effect of Vitamin D Supplementation on Depressive Symptoms in Patients With Knee Osteoarthritis
    J. Am. Med. Dir. Assoc. (IF 4.899) Pub Date : 2018-11-03
    Shuang Zheng, Liudan Tu, Flavia Cicuttini, Weiyu Han, Zhaohua Zhu, Benny Antony, Anita Wluka, Tania Winzenberg, Tao Meng, Dawn Aitken, Leigh Blizzard, Graeme Jones, Changhai Ding

    Objectives To determine the effect of vitamin D supplementation and maintaining sufficient serum vitamin D on depressive symptoms in patients with knee osteoarthritis (OA) and vitamin D deficiency. Design A prespecified secondary analysis of a multicentre, randomized, double-blind, placebo-controlled trial. Participants were randomly assigned to receive oral vitamin D3 (50,000 IU, n = 209) or placebo (n = 204) monthly for 24 months. In addition, participants who completed the trial were classified into 2 groups according to their serum 25(OH)D levels at month 3 and 24 as follows: not consistently sufficient (serum 25(OH)D ≤ 50 nmol/L at month 3 and/or 24), and consistently sufficient (serum 25(OH)D > 50 nmol/L at both month 3 and 24). Multilevel mixed-effect models were used to compare differences of change in PHQ-9 scores between groups. Setting and Participants This clinical trial was conducted in participants with symptomatic knee OA and vitamin D deficiency from June 2010 to December 2013 in Tasmania and Victoria, Australia. Measures The primary outcome was the depressive symptoms change over 24 months, which was measured using the Patient Health Questionnaire (PHQ-9, 0-27). Results Of 599 participants who were screened for eligibility, 413 participants were enrolled (mean age: 63.2 years; 50.3% female) and 340 participants (intervention n = 181, placebo n = 159, 82.3% retention rate) completed the study. The baseline prevalence of depression (PHQ-9 score ≥5) was 25.4%. Depressive symptoms improved more in the vitamin D supplementation group compared to the placebo group [β: −0.66, 95% confidence interval (CI): −1.22 to −0.11, P for difference = .02] and in the participants who maintained vitamin D sufficiency compared to those who did not (β: −0.73, 95% CI: −1.41 to −0.05, P for difference = .04) over 24 months. Conclusions/Implications These findings suggest that vitamin D supplementation and maintaining adequate vitamin D levels over 24 months may be beneficial for depressive symptoms in patients with knee OA.

    更新日期:2019-11-26
  • Depression is Associated With Sarcopenia Due to Low Muscle Strength: Results From the ELSA-Brasil Study
    J. Am. Med. Dir. Assoc. (IF 4.899) Pub Date : 2018-11-05
    Claudia Szlejf, Claudia K. Suemoto, Andre R. Brunoni, Maria Carmen Viana, Arlinda B. Moreno, Sheila M.A. Matos, Paulo A. Lotufo, Isabela M. Benseñor

    Objectives To investigate the association of sarcopenia and its defining components with depression in Brazilian middle-aged and older adults. Design Cross-sectional study. Setting and Participants This analysis included 5927 participants from the ELSA-Brasil Study second data collection, aged 55 years and older, with complete data for exposure, outcome, and covariates. Measures Muscle mass was evaluated by bioelectrical impedance analysis and muscle strength by hand-grip strength. Sarcopenia was defined according to the Foundation for the National Institutes of Health (FNIH) criteria. Depression was assessed using the Clinical Interview Scheduled Revised (CIS-R). Information on sociodemographic characteristics, lifestyle, and clinical comorbidities were also obtained. Results The frequencies of sarcopenia, presarcopenia, low muscle mass, low muscle strength, and low muscle strength without loss of muscle mass was 1.9%, 18.8%, 20.7%, 4.8%, and 2.9%, respectively. After adjustment for sociodemographic characteristics, clinical conditions, and lifestyle factors, depression was associated with sarcopenia (odds ratio [OR] = 2.23, 95% confidence interval [CI] = 1.11-4.48, P = .024) and low muscle strength (OR = 1.94, 95% CI = 1.20-3.15, P = .007), but it was not associated with presarcopenia, low muscle mass, and low muscle strength without loss of muscle mass. Conclusions Depression is associated with sarcopenia defined by the FNIH criteria mainly because of its association with weakness. Future studies are needed to clarify the temporal relationship between both conditions.

    更新日期:2019-11-26
  • Two-Year Weight Loss but Not Body Mass Index Predicts Mortality and Disability in an Older Japanese Community-Dwelling Population
    J. Am. Med. Dir. Assoc. (IF 4.899) Pub Date : 2019-06-18
    Marcio M. Nishida, Mika Okura, Mihoko Ogita, Tomoki Aoyama, Tadao Tsuboyama, Hidenori Arai

    Objective Previous studies in older populations have shown a cardioprotective effect for obesity, an observation known as the obesity paradox. However, whether a decrease or increase in body weight over a certain period affects disability and mortality in older adults remains unknown. Hence, we examined whether the percent body weight change can predict the risk of mortality and disability in older Japanese adults. Design We performed a longitudinal prospective cohort study. Setting and participants We investigated 1229 community-dwelling older adults (aged ≥65 years) living in Japan. Methods Participants were divided into 3 groups (weight loss, stable weight, and weight gain) based on percentage body weight change (using 1 standard deviation from the mean as cutoff points) between 2011 and 2013. Death and disability incidences were monitored between April 2013 and March 2016. Disability was defined as the need for new long-term care insurance (LTCI). Results The rates of death and new LTCI requests over the 3-year follow-up were 2.4% and 4.7%, respectively. The weight loss group (reduction >4.8%) had a 5.0% death rate and an 11.1% new LTCI rate, which were significantly higher than those in the stable weight (1.6% and 3.8%, respectively) and weight gain (ie, gain >3.1%) groups (3.9% and 4.7%, respectively). Cox regression analysis confirmed a higher risk for death [hazard ratio (HR) = 3.10, 95% confidence interval (CI) = 1.31-7.31] and new LTCI requests (HR = 3.03, 95% CI = 1.69-5.43) only in the weight loss group. The body mass index did not significantly influence the risk of death or disability. Conclusions/Implications Weight loss over 2 years but not body mass index was associated with a higher death and disability risk during the subsequent 3-year follow-up period among older participants. Weight change surveillance can improve the quality of health care by early identifying frailty and death risk population.

    更新日期:2019-11-26
  • The Multidimensional Prognostic Index Predicts Falls in Older People: An 8-Year Longitudinal Cohort Study of the Osteoarthritis Initiative
    J. Am. Med. Dir. Assoc. (IF 4.899) Pub Date : 2019-11-25
    Nicola Veronese, Giacomo Siri, Alberto Cella, Stefania Maggi, Ekaterini Zigoura, Matteo Puntoni, Lee Smith, Clarissa Musacchio, Antonella Barone, Carlo Sabbà, Francesco Vallone, Alberto Pilotto

    Objectives Falls are associated with several negative outcomes. Early identification of those who are at risk of falling is of importance in geriatrics, and comprehensive geriatric assessment (CGA) seems to be promising in this regard. Therefore, the present study investigated whether the multidimensional prognostic index (MPI), based on a standard CGA, is associated with falls in the Osteoarthritis Initiative (OAI). Design Longitudinal, 8 years of follow-up. Setting and participants Community-dwelling older people (≥65 years of age) with knee osteoarthritis or at high risk for this condition. Methods A standardized CGA including information on functional, nutritional, mood, comorbidities, medications, quality of life, and cohabitation status was used to calculate a modified version of the MPI, categorized as MPI-1 (low), MPI-2 (moderate), and MPI-3 (high risk). Falls were self-reported and recurrent fallers were defined as ≥2 in the previous year. Logistic regression was carried out and results are reported as odds ratio (ORs) with their 95% confidence intervals (CIs). Results The final sample consisted of 885 older adults (mean age 71.3 years, female = 54.6%). Recurrent fallers showed a significant higher MPI than their counterparts (0.46 ± 0.17 vs 0.38 ± 0.16; P < .001). Compared with those in MPI-1 category, participants in MPI-2 (OR 2.13; 95% CI 1.53‒2.94; P < .001) and in MPI-3 (OR 5.98; 95% CI 3.29-10.86; P < .001) reported a significant higher risk of recurrent falls over the 8-years of follow-up. Similar results were evident when using an increase in 0.1 points in the MPI or risk of falls after 1 year. Conclusions and implications Higher MPI values at baseline were associated with an increased risk of recurrent falls, suggesting the importance of CGA in predicting falls in older people.

    更新日期:2019-11-26
  • Educating Dutch General Practitioners in Dementia Advance Care Planning: A Cluster Randomized Controlled Trial
    J. Am. Med. Dir. Assoc. (IF 4.899) Pub Date : 2019-11-20
    Bram Tilburgs, Raymond Koopmans, Myrra Vernooij-Dassen, Eddy Adang, Henk Schers, Steven Teerenstra, Marjolein van de Pol, Carolien Smits, Yvonne Engels, Marieke Perry

    Objectives Advance care planning (ACP) is seldom initiated with people with dementia (PWD) and mainly focuses on medical end-of-life decisions. We studied the effects of an educational intervention for general practitioners (GPs) aimed at initiating and optimizing ACP, with a focus on discussing medical and nonmedical preferences of future care. Design A single-blinded cluster randomized controlled trial. Setting and participants In 2016, 38 Dutch GPs (all from different practices) completed the study. They recruited 140 PWD, aged ≥65 years at any stage and with any type of dementia, from their practice. Methods Intervention group GPs were trained in ACP, including shared decision-making and role-playing exercises. Control group GPs provided usual care. The primary outcome was ACP initiation: the proportion of PWD that had at least 1 ACP conversation documented in their medical file. Key secondary outcomes were the number of medical (ie, resuscitation, hospital admission) and nonmedical (ie, activities, social contacts) preferences discussed. At the 6-month follow-up, subjects' medical records were analyzed using random effect logistics and linear models with correction for GP clustering. Results 38 GP clusters (19 intervention; 19 control) included 140 PWD (intervention 73; control 67). Four PWD (2.9%) dropped out on the primary and key secondary outcomes. After 6 months, intervention group GPs initiated ACP with 35 PWD (49.3%), and control group GPs initiated ACP with 9 PWD (13.9%) [odds ratio (OR) 1.99; P = .002]. Intervention group GPs discussed 0.8 more medical [95% confidence interval (CI) 0.3, 1.3; P = .003] and 1.5 more nonmedical (95% CI 0.8, 2.3; P < .001) preferences per person with dementia than control group GPs. Conclusions and Implications Our educational intervention increased ACP initiation, and the number of nonmedical and medical preferences discussed. This intervention has the potential to better align future care of PWD with their preferences but because of the short follow-up, the GPs' long-term adoption remains unknown.

    更新日期:2019-11-21
  • Predictors of Rehospitalization in Post-Acute Rehabilitation among Different Ethnic Groups
    J. Am. Med. Dir. Assoc. (IF 4.899) Pub Date : 2019-11-20
    Verena R. Cimarolli, Francesca Falzarano, Stephanie Hicks

    Objectives Previous research has shown that ethnicity may play a role in increased risk for hospital readmission during a post-acute rehabilitation care (PARC) stay. However, little is known about risk factors influencing discharge status from PARC settings among different ethnic groups. Hence, the aim of our study was to investigate the relationship of individual characteristics (eg, sex, neighborhood quality) and health behavior (use of rehabilitation services) with rehospitalization across ethnic groups of older adult patients who received post-acute rehabilitation for a cardiovascular disease at a skilled nursing facility (SNF). Design Retrospective study with data extraction from electronic medical records (EMRs) at admission and discharge. Setting SNF. Participants The sample consisted of 520 post-acute rehabilitation patients (96 Hispanics, 172 African Americans, and 252 Whites) 60 years or older with an admitting condition of a circulatory-related disease. Measurements Sociodemographic and health-related variables, and discharge status (rehospitalized or home). Results For the Hispanic sample, lower community quality was associated with a greater likelihood of being rehospitalized. For African Americans, having no social support, higher levels of admission functional dependency, and shorter length of stay were significantly associated with a higher likelihood of being rehospitalized. For the group of White participants, the following variables emerged as risk factors for rehospitalization: being male, lower admission cognitive functioning, higher levels of admission depressive symptomatology, and shorter length of stay. Conclusions/Implications Individual characteristics and health behaviors that are risk factors for rehospitalization during a post-acute stay vary across ethnic groups. Hence, the study provides insights for PARC clinicians into specific patient characteristics to be aware of as risk factors for less optimal patient outcomes.

    更新日期:2019-11-21
  • Vitamin D Supplementation for Extraskeletal Indications in Older Persons
    J. Am. Med. Dir. Assoc. (IF 4.899) Pub Date : 2019-11-19
    Lauren E. Bode, Mallory McClester Brown, Emily M. Hawes

    Low levels of vitamin D have been implicated in a wide variety of conditions highly prevalent in the geriatric population, including fractures, functional limitations, cancer, cardiovascular disease, and depression. Vitamin D supplementation is often considered integral to the prevention of falls and fractures in the setting of osteoporosis. For other conditions, however, consensus is lacking, and the clinician may struggle to balance competing recommendations around screening, supplementation, and monitoring. This review seeks to provide an overview of the available evidence on the use of vitamin D supplementation to ameliorate sarcopenia, enhance cognition, treat depression, prevent cancer, and reduce mortality—outcomes that are common concerns in the geriatric population for which the merits of treatment are not always certain. Evidence suggests vitamin D supplementation may decrease mortality. Therefore, it may be reasonable to prescribe routine supplementation with oral cholecalciferol 800 to 1000 IU daily to all patients aged ≥65 years who do not have a contraindication. No screening or monitoring would be recommended for this population. We additionally recommend the use of oral cholecalciferol over ergocalciferol for any routine supplementation as this benefit was only observed with cholecalciferol. For patients with depression or cognitive disorders, we recommend screening for vitamin D deficiency, treating with oral cholecalciferol if present, and monitoring periodically to target a level of >30 ng/mL as an adjunct to usual care. The level of evidence certainly would not justify the use of vitamin D in place of more evidence-based therapies, but given the burden of these conditions in the geriatric population, we believe the potential benefit justifies the minimal risk.

    更新日期:2019-11-19
  • Vitamin K Antagonists and Direct Oral Anticoagulants in Nonagenarian Patients With Atrial Fibrillation
    J. Am. Med. Dir. Assoc. (IF 4.899) Pub Date : 2019-11-19
    Sergio Raposeiras-Roubín, David Alonso Rodríguez, Santiago Jesús Camacho Freire, Emad Abu-Assi, Rafael Cobas-Paz, Carlos Rodríguez Pascual, Julio García Comesaña, Alberto González-Carrero López, Naiara Cubelos Fernández, Álvaro López-Masjuán Ríos, María Cespón-Fernández, Isabel Muñoz-Pousa, Berenice Caneiro-Queija, Adrián Rodríguez Albarrán, Sara Álvarez Castañera, Julia Verísimo Guillén, Alberto Carpintero Vara, Cristina Barreiro Pardal, Andrés Iñíguez-Romo

    Objectives Nonagenarian patients are underrepresented in clinical trials that have evaluated oral anticoagulation in patients with atrial fibrillation (AF). The aim of this study was to assess the pronostic impact of oral anticoagulation in patients with AF age ≥90 years. Design Retrospective multicenter study of nonagenarian patients with AF. Setting and participants A total of 1750 nonagenarian inpatients and outpatients with nonvalvular AF between January 2013 and December 2018 in 3 Spanish health areas were studied. Methods Patients were divided into 3 groups based on antithrombotic therapy: nonoral anticoagulants (30.5%), vitamin-K antagonists (VKAs; 28.6%), and direct oral anticoagulants (DOACs; 40.9%). During a mean follow-up of 23.6 ± 6.6 months, efficacy outcomes (death and embolic events) were evaluated using a Cox regression analysis and safety outcomes (bleeding requiring hospitalization) by competing-risk regression. Results were complemented with a propensity score matching analysis. Results During follow-up, 988 patients died (56.5%), 180 had embolic events (10.3%), and 186 had major bleeding (10.6%). After multivariable adjustment, DOACs were associated with a lower risk of death and embolic events than nonanticoagulation [hazard ratio (HR) 0.75, 95% confidence interval (CI)] 0.61‒0.92), but VKAs were not (HR 0.87, 95% CI 0.72‒1.05). These results were confirmed after propensity score matching analysis. For bleeding, both DOACs and VKAs proved to be associated with a higher risk (HR for DOAC 1.43; 95% CI 0.97‒2.13; HR for VKA 1.94; 95% CI 1.31‒2.88), although findings for DOACs were not statistically significant (P = .074). For intracranial hemorrhage (ICH), only VKAs—not DOACs—presented a higher risk of ICH (HR 4.43; 95% CI 1.48‒13.31). Conclusions and implications In nonagenarian patients with AF, DOACs led to a reduction in mortality and embolic events in comparison with nonanticoagulation. This reduction was not observed with VKAs. Although both DOACs and VKAs increased the risk of bleeding, only VKAs were associated with higher ICH rates.

    更新日期:2019-11-19
  • Advance Directive Preferences Among Terminally Ill Older Patients and Its Facilitators and Barriers in China: A Scoping Review
    J. Am. Med. Dir. Assoc. (IF 4.899) Pub Date : 2019-07-04
    Jing Liao, Bei Wu, Ping Ni, Jing Mao

    Objectives To explore advance directive (AD) preferences and the facilitators and barriers of promoting ADs among terminally ill older patients in China. Design A scoping review was used to identify key themes in ADs. Setting and participants Studies from 2007 to 2017 were identified from the MEDLINE and Cochrane libraries. Articles concerning important components of ADs in terminally ill older patients were selected. Measures Eligible articles concerning important components of ADs in terminally ill older patients were thematically synthesized. Later, implementation evidence was identified from core components. Results We used 13 articles and identified key components in ADs: (1) Chinese cultural characteristics; (2) policy support; (3) advance care planning (ACP); (4) hospice-palliative care (HPC); (5) prognosis disclosure and life-sustaining treatment preference; (6) knowledge about ADs for patients and their families; (7) the prevalence of ADs; (8) implementation of ADs; (9) staff experience and training; and (10) effective communication between patients, their families, and health care professionals. Facilitators in implementing ADs included previous comfort-oriented end-of-life care experience of patients or their families, and the enactment of relevant policy. Barriers included traditional Chinese cultural beliefs; lack of policy; lack of knowledge of ADs, ACP, and HPC; and poor communication between physicians, patients, and family members. Conclusions/Implications Chinese patients still showed positive preferences toward ADs. The implementation of ADs could be promoted through public education about ADs, the learning of ACP and HPC, and relevant policy development in China.

    更新日期:2019-11-18
  • Adherence to “No Transfer to Hospital” Advance Directives Among Nursing Home Residents
    J. Am. Med. Dir. Assoc. (IF 4.899) Pub Date : 2019-05-27
    Leah Nemiroff, Emily Gard Marshall, Jan L. Jensen, Barry Clarke, Melissa K. Andrew

    Objectives Many older adults in long-term care (LTC) experience acute health crises but are at high risk of transfer distress and in-hospital morbidity and mortality. Residents often complete advance directives (ADs) regarding future care wishes, including directives for hospital transfers. This study aims to estimate the prevalence of, and adherence to, “no transfer to hospital” ADs in LTC, and to explore the circumstances leading to transfers against previously expressed directives. Design We conducted a mixed methods study in 10 nursing homes in Nova Scotia, Canada. A total of 748 resident charts and Emergency Health Services (EHS) database notes were reviewed from 3 time periods spanning implementation of a new primary care model, Care by Design (CBD). Measures ADs were divided into those requesting transfer to hospital vs on-site management only, which were then analyzed in relation to actual hospital transfers. Reasons for EHS calls, management, and qualitative data were derived from the EHS database. Resident variables were obtained from LTC charts. Measures were compared between time periods. Results ADs were complete in 92.4% of charts. Paramedics were called for 80.5% of residents, and 73.6% were transferred to hospital, 51.3% of whom had explicit ADs to the contrary. The majority of those were transferred for fall-related injuries, followed by medical illness. Unclear care plans, symptom control, and perceived need for investigations and procedures all influenced transfer decisions. Conclusions/Implications The use of “no transfer to hospital” directives did not appear to impact the number of residents being transferred to acute care. Half of those transferred to hospital had explicit ADs to the contrary, largely driven by fall-related injury. The high incidence of injury-related transfers highlights an important gap in advance care planning. Clarifying transfer preferences for injury management in advance directives may lead to better end-of-life experiences for residents and improve effective resource utilization.

    更新日期:2019-11-18
  • Experienced Quality of Post-Acute and Long-Term Care From the Care Recipient's Perspective–A Conceptual Framework
    J. Am. Med. Dir. Assoc. (IF 4.899) Pub Date : 2019-05-10
    Katya Y.J. Sion, Roy Haex, Hilde Verbeek, Sandra M.G. Zwakhalen, Gaby Odekerken-Schröder, Jos M.G.A. Schols, Jan P.H. Hamers

    This article aims to conceptualize experienced quality of post-acute and long-term care for older people as perceived by care recipients. An iterative literature review and consultations with stakeholders led to the development of the INDividually Experienced QUAlity of Long-term care (INDEXQUAL) framework. INDEXQUAL presents the process of an individual care experience consisting of a pre (expectations), during (experiences), and post (assessment) phase. Expectations are formed prior to an experience by personal needs, past experiences, and word-of-mouth. An experience follows, which consists of interactions between the players in the caring relationships. Lastly, this experience is assessed by addressing what happened and how it happened (perceived care services), how this influenced the care recipient's health status (perceived care outcomes), and how this made the care recipient feel (satisfaction). INDEXQUAL can serve as a framework to select or develop methods to assess experienced quality of long-term care. It can provide a framework for quality monitoring, improvement, and transparency.

    更新日期:2019-11-18
  • Ultra-brief Screeners for Detecting Delirium Superimposed on Dementia
    J. Am. Med. Dir. Assoc. (IF 4.899) Pub Date : 2019-07-03
    Erika Steensma, Wenxiao Zhou, Long Ngo, Jacqueline Gallagher, Sharon Inouye, Douglas Leslie, Marie Boltz, Ann Kolanowski, Lorraine Mion, Edward R. Marcantonio, Donna Fick

    Objective Delirium superimposed on dementia (DSD) is common, morbid, and costly, yet frequently undiagnosed. Our study aimed to develop a brief screening test to improve health care worker recognition of DSD. Design/Setting/Participants Older hospitalized adults with dementia were prospectively enrolled from medical and surgical inpatient units of 3 hospitals (2 in Pennsylvania, 1 in Tennessee). Measures The reference standard delirium assessment used Confusion Assessment Method (CAM) criteria and was based on a structured interview including the Mini-Mental State Examination, interviewer observations, and medical record review. To develop the screening test, 1-, 2-, and 3-item combinations from the reference standard assessment were analyzed to determine their sensitivity and specificity in diagnosing delirium presence in a dementia population compared to the reference standard. For multiple-item screeners, error on 1 or more items was considered a positive screen. Results Overall, 391 older adults with dementia were enrolled (mean age: 83.9 years, 71.1% female), and 95 (24.4%) developed DSD during their hospitalization, based on the reference standard. The best single-item screen for DSD was “What day of the week is it?” with 84% sensitivity [95% confidence interval (CI): 0.75, 0.91] and 41% specificity (CI: 0.35, 0.47). The best 2-item screen was “list the days of the week backwards” and “What day of the week is it?” with 93% sensitivity (CI: 0.85, 0.97) and 30% specificity (CI: 0.25, 0.36). The best 3-item screen was “list the days of the week backwards,” “What type of place is this? [hospital]” and “Does the patient appear sleepy?” with 94% sensitivity (CI: 0.87, 0.98) and 42% specificity (CI: 0.36, 0.48). Conclusions/Implications We identified a 3-item DSD screener with excellent sensitivity but limited specificity. This screener can be used to quickly rule out DSD in populations with a high prevalence of dementia and is a promising step toward developing efficient tools for DSD recognition among care providers.

    更新日期:2019-11-18
  • Development and Validation of the Nursing Home Care-related Quality of Life Scale
    J. Am. Med. Dir. Assoc. (IF 4.899) Pub Date : 2019-06-21
    Eunhee Cho, Kyongeun Lee, Deulle Min, Soo Jung Chang, Jeongah Kim, Hyejin Kim

    Objectives We developed an instrument to assess nursing home residents' quality of life (QOL), with a focus on QOL-related factors modifiable through nursing home care, within the South Korean context; then, we tested its validity and reliability. Design The scale was constructed through a literature review, qualitative interviews, expert panel review, and a focus group interview; then, it was validated through survey research. Setting and participants Residents (N = 667) from 42 nursing homes in South Korea participated in scale validation. Methods Ninety-nine items across 5 dimensions were initially drafted through a literature review and qualitative interview data. The expert panel review and a focus group interview yielded a scale with 31 items across 3 dimensions. Next, using survey data from nursing home residents, we examined the construct and concurrent validity and reliability (using Kuder-Richardson 20) of the 31-item QOL scale. Results Through a series of factor analyses, the 31 items were reduced to 17 items across 2 dimensions: Environment and Services (13 items) and Social Interaction (4 items). This 17-item scale was further examined for model fitness and reliability. The scale had acceptable to good fit (root mean square error of approximation = 0.07 and 0.07; comparative fit index = 0.83 and 0.98 for Environment and Services and Social Interaction, respectively), and good concurrent validity and internal consistency (Kuder-Richardson 20 = 0.72). Conclusions and implications This 17-item scale is a valid and reliable tool to assess nursing home residents' QOL in South Korea, with a focus on factors modifiable through nursing home care. Through more research to test its usefulness, validity, and reliability, the scale can be used as an index of nursing home care quality and contribute to the development of strategies to improve nursing home residents' QOL.

    更新日期:2019-11-18
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