August 11, 2020

The COVID-19 pandemic has affected older people disproportionately, especially those living in long-term care facilities. In many countries, evidence shows that more than 40% of COVID-19 related deaths have been linked to long-term care facilities, with figures being as high as 80% in some high-income countries. Concerted action is needed to mitigate the impact across all aspects of long-term care, including home- and community-based care, given that most users and providers of care are those who are vulnerable to severe COVID-19.

This policy brief provides 11 policy objectives and key action points to prevent and manage COVID-19 across long-term care. Its intended audience is policy makers and authorities (national, subnational and local) involved in the COVID-19 pandemic. The brief builds on currently available evidence on the measures taken to prevent, prepare for and respond to the COVID‑19 pandemic across long-term care services including care providers

The number of older people, including those living with dementia, is rising, as younger age mortality declines. However, the age-specific incidence of dementia has fallen in many countries, probably because of improvements in education, nutrition, health care, and lifestyle changes. Overall, a growing body of evidence supports the nine potentially modifiable risk factors for dementia modelled by the 2017 Lancet Commission on dementia prevention, intervention, and care: less education, hypertension, hearing impairment, smoking, obesity, depression, physical inactivity, diabetes, and low social contact. We now add three more risk factors for dementia with newer, convincing evidence. These factors are excessive alcohol consumption, traumatic brain injury, and air pollution. We have completed new reviews and meta-analyses and incorporated these into an updated 12 risk factor life-course model of dementia prevention. Together the 12 modifiable risk factors account for around 40% of worldwide dementias, which consequently could theoretically be prevented or delayed. The potential for prevention is high and might be higher in low-income and middle-income countries (LMIC) where more dementias occur.

The World Health Organization (WHO) advised in April 2020 that over 95% of COVID-19 fatalities worldwide were among adults over the age of 60 years. As the disproportionate impact of COVID-19 on older people continues to evolve, there is an undeniable urgency for Member States to focus pandemic response policies and protocols on protecting and respecting the lives of older people during this unprecedented time.

The WHO Country and Technical Guidance website contains tools and resources intended to equip Member States to appropriately prepare for and respond to the COVID-19 pandemic. Whereas an analysis of the publications available in late April 2020 revealed only 27 of 76 resources focused specifically on the needs of older people, more than half of new and updated guidance since published have responded to the global call to focus on this disproportionately impacted group.

Although codes of conduct, guidelines and standards call for healthcare practitioners to protect patients’ dignity, there are widespread concerns about a lack of attention to the dignity of older people who need assistance with toileting, incontinence or bladder or bowel care in health or social care settings that provide long-term care. Incontinence and care dependence threatens patient dignity. The aim of this research was to explore, describe and explain the concept of dignity as it relates to continence care for older people requiring long-term care. METHODS: The first four steps of Rodgers evolutionary method of concept analysis were followed. First, a comprehensive and systematic search of databases and key guidelines about continence care was undertaken to identify empirical research about dignity and continence care in older people in facilities that provide permanent residential or inpatient care of older people for day-to-day living. Data were extracted on the authors, date, sample, country of origin, and key definitions, attributes, contexts and consequences from each included record. Findings were inductively analysed and grouped according to whether they were the key attributes and antecedents of dignity in relation to continence care or the consequences of undignified continence care. RESULTS: Of 625 articles identified, 18 were included in the final analysis. Fifty individual attributes were identified that were categorised in 6 domains (respect, empathy, trust, privacy, autonomy and communication). A further 15 were identified that related to the environment (6 physical and 9 social). Key consequences of undignified continence care were also identified and categorised into 3 levels of impact (resident/family member, staff or organisation). CONCLUSIONS: This research resulted in a conceptual understanding of dignity that can be used as a value or guiding principle in an ethic of care for older people who need assistance with toileting, incontinence or bladder or bowel care in long-term care settings.

Despite extensive literature describing the use of social media in health research, a gap exists around best practices in establishing, implementing, and evaluating an effective social media knowledge translation (KT) and exchange strategies. OBJECTIVE: This study aims to examine successes, challenges, and lessons learned from using social media within health research and to create practical considerations to guide other researchers. METHODS: The Knowledge Translation Platform of the Alberta Strategy for Patient-Oriented Research SUPPORT Unit formed a national working group involving platform staff, academics, and a parent representative with experience using social media for health research. We collected and analyzed 4 case studies that used a variety of social media platforms and evaluation methods. The case studies covered a spectrum of initiatives from participant recruitment and data collection to dissemination, engagement, and evaluation. Methods and findings from each case study as well as barriers and facilitators encountered were summarized. Through iterative discussions, we converged on recommendations and considerations for health researchers planning to use social media for KT. RESULTS: We provide recommendations for elements to consider when developing a social media KT strategy: (1) set a clear goal and identify a theory, framework, or model that aligns with the project goals and objectives; (2) understand the intended audience (use social network mapping to learn what platforms and social influences are available); (3) choose a platform or platforms that meet the needs of the intended audience and align well with the research team’s capabilities (can you tap into an existing network, and what mode of communication does it support?); (4) tailor messages to meet user needs and platform requirements (eg, plain language and word restrictions); (5) consider timing, frequency, and duration of messaging as well as the nature of interactions (ie, social filtering and negotiated awareness); (6) ensure adequate resources and personnel are available (eg, content creators, project coordinators, communications experts, and audience stakeholder or patient advocate); (7) develop an evaluation plan a priori driven by goals and types of data available (ie, quantitative and qualitative); and (8) consider ethical approvals needed (driven by evaluation and type of data collection). CONCLUSIONS: In the absence of a comprehensive framework to guide health researchers using social media for KT, we provide several key considerations. Future research will help validate the proposed components and create a body of evidence around best practices for using and evaluating social media as part of a KT strategy.

We are seeking presentations, posters, workshops, and other activities that facilitate active participation, networking, reflection and learning, and that can be delivered in an online format.

We are driven by allowing you to design your own conference experience that reflects your interests, experience, priorities, and learning styles. Drawing in leaders in knowledge mobilization from all across Canada and beyond, it is our hope you will come away from CKF20 enriched, energized, and engaged in this field like never before.

Our objective is to build on the past successes of CKF to make this a preeminent event to learn and engage about knowledge mobilization in Canada. We aim to:

Build capacity for knowledge mobilization through tools and workshops
Engage professionals across sectors to enable partnerships and collaboration
Facilitate networking to create opportunities to mentor and coach
Share and access the latest tools, techniques, and opportunities in knowledge mobilization

Grants will be awarded for scholarly activities that centre around intersectional gender approaches including, but not limited to, feminist, anti-racist and/or anti-colonial/decolonial, queer, and critical disability methodologies, such as talks, workshops, networking, outreach, research meetings, and organizing conferences relevant to the mandate of Intersections of Gender

Intersections of Gender (IG) is offering a grant program to encourage the development of collaborative projects led by University of Alberta faculty in Tri-Council research fields interested in developing intersectional research design and constructing a diverse, interdisciplinary research team. This includes, but is not limited to, using feminist, anti-racist and/or anti-colonial/decolonial, queer, and critical disability methodologies.

The IG Thesis Grant (IG-TG) is open to graduate students (masters and doctoral level) at the University of Alberta for research in any field. The grant supports research and research creation activities that are part of a thesis or equivalent. The IG-TG supports scholarly, clinical, and/or creative arts activities. Applications will be accepted from students in any program in which the institution offers a master’s, doctoral, or equivalent degree. There are no restrictions on citizenship and all disciplines are eligible for funding. Awarded to a student registered full-time or part-time in a graduate degree program. A student may only receive the award once during their tenure at UAlberta.

The SPOR Evidence Alliance Seed Grant aims to encourage a culture of learning, innovation, and advancement of science in the areas of knowledge synthesis, guideline development, knowledge translation, and patient-oriented research by funding methods projects at the conceptual stage.

Only projects studying methodological advancements of guideline development in a patient-oriented research setting will be considered; guideline projects themselves are not eligible for inclusion. Successful projects must have a strong focus on patient-oriented research and include stakeholder engagement in the conduct of the work.

The COVID-19 pandemic is posing an unprecedented challenge to healthcare systems worldwide. Older adults, which frequently present multiple chronic comorbidities, are more susceptible to COVID-19 and experience more likely negative outcomes, in terms of disease severity and mortality. However, chronological age per se may not entirely explain the dramatic scenario described among the frailest and oldest persons. Comorbidities and functional status may indeed play a relevant role. Patients at high risk of adverse clinical outcomes in COVID-19 infection are the same at risk of malnutrition, namely older adults and multimorbid individuals. In fact, COVID-19 can negatively impact on nutritional status, both in patients admitted to the hospital with the most severe manifestations of the infection, as well as in those who experience milder/asymptomatic forms of the disease. Despite being quite difficult in these emergency circumstances, nutritional status needs to be assessed in all COVID-19 patients upon admission and during hospital stay. Early nutritional support should be guaranteed in order to improve several malnutrition-related adverse outcomes. The evaluation of the nutritional status is today even more crucial than in normal times given the delicate status of older patients with COVID-19.

To assess the American Testing Guidance for Nursing Homes (NHs)-updated May 19, 2020-with a new COVID-19 case. DESIGN: Case investigation. SETTING AND SUBJECTS: All 79 residents and 34 health care personnel (HCP) of an NH. METHODS: Seven days after identification of a COVID-19 resident, all residents and HCP underwent real-time reverse-transcriptase polymerase chain reaction (rRT-PCR) testing for SARS-CoV-2 with nasopharyngeal swabs. This was repeated weekly in all previously negative subjects until the testing identified no new cases, and in all positive subjects until the testing was negative. COVID-19 infection prevention and control (IPC) measures were implemented in all residents and HCP with positive testing or with COVID-19 symptoms. Standard IPC was also implemented in all HCP. Six weeks after initial testing, all residents underwent testing for enzyme-linked immunosorbent assay-based IgG antibodies directed against the SARS-CoV-2. Symptoms were serially recorded in residents and HCP. RESULTS: A total of 36 residents had a positive rRT-PCR at baseline and 2 at day 7. Six HCP had a positive rRT-PCR at baseline and 2 at day 7. No new COVID-19 cases were diagnosed later. Among the SARS-CoV-2-positive cases, 6 residents (16%) and 3 HCP (37%) were asymptomatic during the 14 days before testing. Twenty-five residents (92.3%) and all 8 HCP (100%) with a positive rRT-PCR developed IgG antibodies against SARS-CoV-2. Among the residents and HCP always having tested negative, 2 (5%) and 5 (11.5%), respectively, developed IgG antibodies against SARS-CoV-2. These 2 residents had typical COVID-19 symptoms before and after testing and 2/5 HCP were asymptomatic before and after testing. CONCLUSIONS AND IMPLICATIONS: This study shows the validity of the updated American Testing Guidance for Nursing Homes (NHs). It suggests implementing COVID-19 IPC in both residents and HCP with positive testing or COVID-19 symptoms and warns that asymptomatic HCP with repeated negative rRT-PCR testing can develop antibodies against SARS-CoV-2.

Data from the Norwegian Intensive Care Registry show a median ventilation time of 8.2 days for SARS CoV-2 infected patients admitted to intensive care in Norway. At the time of writing (18th April 2020, regular hospital stays are lasting between three to four weeks. Currently, 155 infected patients are undergoing treatment in hospitals; 61 are admitted to intensive care, and 47 people are ventilated. So far in Norway, 6992 people have tested positive and 162 people died; 3 died at home, 64 in hospitals, and 95 died in 22 nursing homes. The average age of the deceased is 84 years; 55% have been men. The average daily costs for a bed in intensive care units, regular hospital wards and in nursing homes are $4,000 USD, $900 USD, and $180 USD, respectively. The Norwegian Directorate of Health recommends that nursing home patients should not be transferred to intensive care in hospitals including respiratory treatment because of high mortality rates.

The physical, cognitive and neuropsychiatric challenges associated with Dementia with Lewy bodies make people particularly vulnerable to COVID-19. Adverse effects may also occur from social isolation, the under-treatment of existing DLB related symptoms/problems and the negative impact on caregivers. A vigilant multi-disciplinary approach is needed to meet the health and psychosocial needs of people with DLB and support family caregivers.

On April 14, the Society of Swallowing and Dysphagia of Japan (SSDJ) proposed its position statement on dysphagia treatment considering the ongoing spread of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). The main routes of transmission of SARS-CoV-2 are physical contact with infected persons and exposure to respiratory droplets. In cases of infection, the nasal cavity and nasopharynx have the highest viral load in the body. Swallowing occurs in the oral cavity and pharynx, which correspond to the sites of viral proliferation. In addition, the possibility of infection by aerosol transmission is also concerning. Dysphagia treatment includes a broad range of clinical assessments and examinations, dysphagia rehabilitation, oral care, nursing care, and surgical treatments. Any of these can lead to the production of droplets and aerosols, as well as contact with viral particles. In terms of proper infection control measures, all healthcare professionals involved in dysphagia treatment must be fully briefed and must appropriately implement all measures. In addition, most patients with dysphagia should be considered to be at a higher risk for severe illness from COVID-19 because they are elderly and have complications including heart diseases, diabetes, respiratory diseases, and cerebrovascular diseases. This statement establishes three regional categories according to the status of SARS-CoV-2 infection. Accordingly, the SSDJ proposes specific infection countermeasures that should be implemented considering 1) the current status of SARS-CoV-2 infection in the region, 2) the patient status of SARS-CoV-2 infection, and 3) whether the examinations or procedures conducted correspond to aerosol-generating procedures, depending on the status of dysphagia treatment. This statement is arranged into separate sections providing information and advice in consideration of the COVID-19 outbreak, including “terminology”, “clinical swallowing assessment and examination”, “swallowing therapy”, “oral care”, “surgical procedure for dysphagia”, “tracheotomy care”, and “nursing care”. In areas where SARS-CoV-2 infection is widespread, sufficient personal protective equipment should be used when performing aerosol generation procedures. The current set of statements on dysphagia management in the COVID-19 outbreak is not an evidence-based clinical practice guideline, but a guide for all healthcare workers involved in the treatment of dysphagia during the COVID-19 epidemic to prevent SARS-CoV-2 infection.

The coronavirus (COVID-19) pandemic is disproportionately affecting older people and those with underlying comorbidities. Guidelines are needed to help clinicians make decisions regarding appropriate use of limited NHS critical care resources. In response to the pandemic, the National Institute for Health and Care Excellence published guidance that employs the Clinical Frailty Scale (CFS) in a decision-making flowchart to assist clinicians in assessing older individuals’ suitability for critical care. This commentary raises some important limitations to this use of the CFS and cautions against the potential for unintended impacts. The COVID-19 pandemic has allowed the widespread implementation of the CFS with limited training or expert oversight. The CFS is primarily being used to assess older individuals’ risk of adverse outcome in critical care, and to ration access to care on this basis. While some form of resource allocation strategy is necessary for emergencies, the implementation of this guideline in the absence of significant pressure on resources may reduce the likelihood of older people with frailty, who wish to be considered for critical care, being appropriately considered, and has the potential to reinforce the socio-economic gradient in health. Our incomplete understanding of this novel disease means that there is a need for research investigating the short-term predictive abilities of the CFS on critical care outcomes in COVID-19. Additionally, a review of the impact of stratifying older people by CFS score, as a rationing strategy is necessary in order to assess its acceptability to older people as well its potential for disparate impacts.

Preparation for an impending death through EOL (end-of-life) discussions and human presence when a person is dying is important for both patients and families. OBJECTIVE: The aim was to study whether EOL discussions were offered and to what degree patients were alone at time of death when dying from Covid-19, comparing deaths in nursing homes and hospitals. DESIGN: The national Swedish Register of Palliative Care (SRPC) was used. All expected deaths from Covid-19 in nursing homes and hospitals were compared with, and contrasted to, deaths in a reference population (deaths in 2019). SETTING AND SUBJECTS: A total of 1346 expected Covid-19 deaths in nursing homes (n=908) and hospitals (n=438) were analyzed. RESULTS: Those who died were of a more advanced age in nursing homes (mean 86.4 years) and of a lower age in hospitals (mean 80.7 years) (p<0.0001). Fewer EOL discussions with patients were held compared with deaths in 2019 (74% vs. 79%, p<0.001) and dying with someone present was much more uncommon (59% vs. 83%, p<0.0001). In comparisons between nursing homes and hospital deaths, more patients dying in nursing homes were women (56% vs. 37%, p<0.0001) and significantly fewer had a retained ability to express their will during the last week of life (54% vs. 89%, p<0.0001). Relatives were present at time of death in only 13% and 24% of the cases in nursing homes and hospitals, respectively (p<0.001). The corresponding figures for staff were 52% and 38% (p<0.0001). CONCLUSION: Dying from Covid-19 negatively affects the possibility of holding an EOL discussion and the chances of dying with someone present. This has considerable social and existential consequences for both patients and families.[/bg_collapse]

During the first few months of the COVID-19 pandemic, Canadian nursing homes implemented strict no-visitor policies to reduce the risk of introducing COVID-19 in these settings. There are now growing concerns that the risks associated with restricted access to family caregivers and visitors have started to outweigh the potential benefits associated with preventing COVID-19 infections. Many residents have sustained severe and potentially irreversible physical, functional, cognitive, and mental health declines. As Canada emerges from its first wave of the pandemic, nursing homes across the country have cautiously started to reopen these settings, yet there is broad criticism that emerging visitor policies are overly restrictive, inequitable and potentially harmful. We reviewed the nursing home visitor policies for Canada?s ten provinces and three territories as well as international policies and reports on the topic to develop evidence-informed, data-driven and expert-reviewed guidance for the re-opening of Canadian nursing homes to family caregivers and visitors.; During the first few months of the COVID-19 pandemic, Canadian nursing homes implemented strict no-visitor policies to reduce the risk of introducing COVID-19 in these settings. There are now growing concerns that the risks associated with restricted access to family caregivers and visitors have started to outweigh the potential benefits associated with preventing COVID-19 infections. Many residents have sustained severe and potentially irreversible physical, functional, cognitive, and mental health declines. As Canada emerges from its first wave of the pandemic, nursing homes across the country have cautiously started to reopen these settings, yet there is broad criticism that emerging visitor policies are overly restrictive, inequitable and potentially harmful. We reviewed the nursing home visitor policies for Canada?s ten provinces and three territories as well as international policies and reports on the topic to develop evidence-informed, data-driven and expert-reviewed guidance for the re-opening of Canadian nursing homes to family caregivers and visitors.

Increasing numbers of people dying from COVID-19 are reported, but data are lacking on the way they die. Objective: To study symptoms and symptom relief during the last week of life, comparing nursing homes with hospitals. Design: The Swedish Register of Palliative Care with national coverage was used. Breakthrough symptoms were registered as Yes/No. Symptom relief was recorded on a 3-grade scale as complete-partial-no relief. All deaths in COVID-19 were contrasted to deaths in a reference population (deaths 2019). Deaths at nursing homes were compared with deaths in hospitals. Setting and Subjects: All deaths in hospitals or nursing homes (n = 490) were analyzed. Deaths in other settings (specialized palliative care wards [n = 11], in palliative home care [n = 2], or in their own homes [n = 8]) were excluded (n = 21). Only patients with expected deaths (n = 390) were entered in the final analysis. Results: Breathlessness as a breakthrough symptom was more common in COVID-19 patients than in the 2019 reference population (p < 0.001) and relief of breathlessness, as well as anxiety, delirium, and death rattles was less successful in COVID-19 patients (p < 0.05 to p < 0.01 in different comparisons). Patients were older in nursing homes than in hospitals (86.6 years vs. 80.9 years, p < 0.001) and more often female (48% vs. 34%, p < 0.001). Breakthrough of breathlessness was much more frequently reported in hospital settings than in nursing homes, 73% versus 35% (p < 0.0001), and complete relief was more rarely possible in hospitals, 20% versus 42% (p < 0.01). The proportion of partial relief+complete relief was comparable, 92% versus 95% (ns). Also, anxiety and pain were more often completely relieved in nursing homes (p < 0.01 in both comparisons). Conclusion: The lower symptom prevalence in nursing homes may be explained by elderly frail residents dying already in the first phase of the COVID-19 disease, before acute respiratory distress syndrome develops.[/bg_collapse]

Nursing homes are highly vulnerable to the occurrence of COVID-19 outbreaks, which result in high lethality rates. Most of them are not prepared to SARS-CoV-2 pandemic. METHODS: A coordinated on-site medicalization program (MP) in response to a sizeable COVID-19 outbreak in four nursing homes was organized, with the objectives of improving survival, offering humanistic palliative care to residents in their natural environment, and reducing hospital referrals. Ten key processes and interventions were established (provision of informatics infrastructure, medical equipment, and human resources, universal testing, separation of ‘clean’ and ‘contaminated’ areas, epidemiological surveys, and unified protocols stratifying for active or palliative care approach, among others). Main outcomes were a composite endpoint of survival or optimal palliative care (SOPC), survival, and referral to hospital. RESULTS: 272 out of 457 (59.5%) residents and 85 out of 320 (26.5%) staff members were affected. The SOPC, survival, and referrals to hospital, occurred in 77%, 72.5%, and 29% of patients diagnosed before MP start, with respect to 97%, 83.7% and 17% of those diagnosed during the program, respectively. The SOPC was independently associated to MP (OR=15 [3-81]); and survival in patients stratified to active approach, to the use of any antiviral treatment (OR=28 [5-160]). All outbreaks were controlled in 39 [37-42] days. CONCLUSIONS: A coordinated on-site medicalization program of nursing homes with COVID-19 outbreaks achieved a higher survival or optimal palliative care rate, and a reduction in referrals to hospital, thus ensuring rigorous but also humanistic and gentle care to residents.

As infectious disease doctors and healthcare epidemiologists, our collective practice has been dedicated to preventing the spread of resistant bacteria in NHs, with a focus on implementing and assessing the use of personal protective equipment (PPE).Thus, we were well-positioned to provide guidance for preventing the introduction of COVID-19 into the local NHs, and subsequently preventing its spread within these facilities when we had cases. Here are some lessons learned.

This study sheds light on the agenda setting role of the media during the COVID-19 crisis by examining trends in nursing home (NH) coverage in four leading national newspapers-The New York Times, Washington Post, USA Today, and Los Angeles Times. METHODS: Keyword searches of the Nexis Uni database identified 2,039 NH-related articles published from September 2018 to June 2020. Trends in the frequency of NH coverage and its tone (negative) and prominence (average words, daily article count, opinion piece) were examined. RESULTS: Findings indicate a dramatic rise in the number of NH articles published in the months following the first COVID-19 case, far exceeding previous levels. NH coverage became considerably more prominent, as the average number of words and daily articles on NHs increased. The proportion of negative articles largely remained consistent, though volume rose dramatically. Weekly analysis revealed acceleration in observed trends within the post-COVID-19 period itself. These trends, visible in all papers, were especially dramatic in The New York Times. DISCUSSION: Overall, findings reveal marked growth in the frequency and number of prominent and negative NH articles during the COVID-19 crisis. The increased volume of coverage has implications for the relative saliency of NHs to other issues during the pandemic. The increased prominence of coverage has implications for the perceived importance of addressing pre-existing deficits and the devastating consequences of the pandemic for NHs.

The pandemic of viral infection with the Severe Acute Respiratory Syndrome Virus-2 (SARS-CoV-2) that causes COVID-19 disease has put the nursing home industry in crisis. The combination of a vulnerable population that manifests nonspecific and atypical presentations of COVID-19, staffing shortages due to viral infection, inadequate resources for and availability of rapid, accurate testing and personal protective equipment, and lack of effective treatments for COVID-19 among nursing home residents have created a “perfect storm” in our country’s nursing homes. This perfect storm will continue as society begins to reopen, resulting in more infections among nursing home staff and clinicians who acquire the virus outside of work, remain asymptomatic, and unknowingly perpetuate the spread of the virus in their workplaces. Because of the elements of the perfect storm, nursing homes are like a tinderbox, and it only takes one person to start a fire that could cause many deaths in a single facility. Several public health interventions and health policy strategies, adequate resources, and focused clinical quality improvement initiatives can help calm the storm. The saddest part of this perfect storm is that many years of inaction on the part of policymakers contributed to its impact. We now have an opportunity to improve nursing homes to protect residents and their caregivers ahead of the next storm. It is time to reimagine how we pay for and regulate nursing home care in order to achieve this goal. This article is protected by copyright. All rights reserved.

The following article serves as a means tohighlightthe need for increased scrutiny of the value and potentially adverse effect the 24-hour news cycle has on individuals, particularly residents in a long-term care setting amidst the COVID-19 pandemic or other large-scale catastrophic events. The work will emphasize what is currently known regarding the impact media plays on an individual, including mood, opinion, worldview, and overall mental health and wellness. The conclusion will focus on discussing current means of assessment with future recommendations for heightened evaluation in this already vulnerable population.

As the COVID-19 epidemic progressed, the French government issued a number of ministerial directives to mobilize support around older adults by creating dedicated local platforms. In relation with these national recommendations, the French regions rapidly deployed an organizational strategy for helping nursing homes to manage the COVID-19 epidemic. The present report describes the platform’s resources and actions for helping nursing homes to care for older patients with COVID-19 in the Indre-et-Loire county of France.

The first known cases of COVID-19 in Italy were observed on January 31 in two Chinese tourists holidaying in Rome. On April 9, 2020, the total number of cases reported by the authorities reached 143.6 thousand. The mortality rate of coronavirus arrived at 12.2%, higher than that registered in other countries. This fact may be partially explained by the country’s relatively high proportion of older people. Mortality rate appeared to be higher for the elderly patient: for people between 80 and 89 years of age, the fatality rate was 31%.

As of May 16, 2020, the World Health Organization (WHO) reported a total of 4,434,653 confirmed cases of coronavirus disease 2019 (COVID-19) worldwide, including 302,169 COVID-19-related deaths.) Since the first case of COVID-19 was reported on January 20, 2020, Korea has extensively tested all contacts, with an emphasis on identifying individuals with respiratory illness, tracing, and testing for severe respiratory syndrome coronavirus 2 (SARS-CoV-2) that causes COVID-19.)

Older people are particularly affected by the COVID-19 outbreak because of their vulnerability as well as the complexity of health organisations, particularly in the often-compartmentalised interactions between community, hospital and nursing home actors. In this endemic situation, with massive flows of patients requiring holistic management including specific and intensive care, the appropriate assessment of each patient’s level of care and the organisation of specific networks is essential. To that end, we propose here a territorial organisation of health care, favouring communication between all actors. This organisation of care is based on three key points: To use the basis of territorial organisation of health by facilitating the link between hospital settings and geriatric sectors at the regional level.To connect private, medico-social and hospital actors through a dedicated centralised unit for evaluation, geriatric coordination of care and decision support. A geriatrician coordinates this multidisciplinary unit. It includes an emergency room doctor, a supervisor from the medical regulation centre (Centre 15), an infectious disease physician, a medical hygienist and a palliative care specialist.To organise an ad hoc follow-up channel, including the necessary resources for the different levels of care required, according to the resources of the territorial network, and the creation of a specific COVID geriatric palliative care service. This organisation meets the urgent health needs of all stakeholders, facilitating its deployment and allows the sustainable implementation of a coordinated geriatric management dynamic between the stakeholders on the territory.

In related research, Stall and colleagues examined the relation between ownership of a long-term care (LTC) facility and the occurrence, extent and mortality associated with outbreaks of coronavirus disease 2019 (COVID-19) in Ontario’s 623 LTC facilities. In their analysis, adjusted at the facility level, the authors found no association between ownership and the odds of an outbreak occurrence. They did find, however, that facilities run on a for-profit basis had more extensive outbreaks and more deaths than facilities run on a nonprofit basis, with an even more marked effect when for-profit facilities were compared with facilities that were entirely municipally run. However, when multi-bed room design was added to the model, for-profit ownership status lost its significance for these outcomes, leading the authors to conclude that building upgrades should be an important part of addressing the problems in the LTC sector in Ontario

Nursing homes provide long-term care and have residential-oriented hospitalizations characterized by medical, nursing, and social-care treatments for a typically geriatric population. In the current emergency phase, the problem of infections in residential structures for the elderly is taking on considerable importance in relation to the significant prevalence rates of COVID-19. SAFETY IMPROVEMENT STRATEGIES: Prevention and control measures for SARS-CoV-2 infection in nursing homes should be planned before a possible outbreak of COVID-19 occurs and should be intensified during any exacerbation of the same. Each facility should identify a properly trained contact person-also external-for the prevention and control of infections, who can refer to a multidisciplinary support committee and who is in close contact with the local health authorities. The contact person should collaborate with professionals in order to prepare a prevention and intervention plan that considers national provisions and scientific evidence, the requirements for reporting patients with symptoms compatible with COVID-19, the indications for the management of suspected, probable or confirmed cases of COVID-19. DISCUSSION: Adequate risk management in residential structures implies the establishment of a coordination committee with dedicated staff, the implementation of a surveillance program for the rapid recognition of the outbreaks, the identification of suitable premises and equipment, the application of universal precautions, the adaptation of care plans to reduce the possibility of contagion among residents, the protection of operators and staff training initiatives.

Coronavirus disease 2019 (COVID-19) has taken an enormous toll on US nursing homes, claiming the lives of at least 7000 residents and staff across 4100 facilities and accounting for nearly 20% of COVID-19 deaths in the United States. On April 19, 2020, the Centers for Medicare & Medicaid Services began requiring nursing homes to report COVID-19 cases in their facilities. Our objective was to describe the characteristics and quality of nursing homes with COVID-19 cases in states where public health departments have begun to publicly report their statuses.

The inability of LTC to cope with the devastating impact of COVID-19 within its institutions comes as no surprise. It is a result of the deep-rooted devaluation of care work that happens at the intersection of ageism, ableism, sexism, and racism and is further aggravated by a rude marketization of this healthcare sector.

En un brote de COVID-19, las residencias geriátricas asistidas son entornos donde existe un riesgo elevado de tener resultados graves. Ello se debe tanto a la edad avanzada de los residentes y a la frecuencia con que presentan problemas de salud crónicos como al movimiento del personal sanitario entre instalaciones de la zona.
Métodos
Tras la identificación, el 28 de febrero de 2020, de un caso confirmado de COVID-19 en una residencia asistida en el condado de King, Washington, Salud Pública-Seattle y el condado de King, con la ayuda de los Centros para el Control y la Prevención de Enfermedades, pusieron en marcha una investigación del caso, la localización de contactos, la cuarentena de las personas expuestas, el aislamiento de los casos confirmados y sospechosos y la mejora in situ de la prevención y el control de la infección.
Resultados
El 18 de marzo se determinó que un total de 167 casos confirmados de COVID-19, que afectaban a 101 residentes, 50 trabajadores sanitarios y 16 visitantes, estaban vinculados epidemiológicamente a la residencia. La mayoría de los residentes afectados presentaban enfermedades respiratorias compatibles con la COVID-19; sin embargo, en 7 residentes no se documentaron síntomas. Las tasas de hospitalización de los residentes, de los visitantes y del personal fueron del 54,5%, 50,0% y 6,0%, respectivamente. La tasa de letalidad de los residentes fue del 33,7% (34 de 101). En esa misma fecha se había identificado al menos un caso confirmado de COVID-19 en un total de 30 centros asistidos en el condado de King.
Conclusiones
En el contexto del rápido aumento de los brotes de COVID-19, se necesitan medidas proactivas por parte de las residencias geriátricas para identificar y excluir al personal y a los visitantes potencialmente infectados, vigilar activamente a los pacientes potencialmente infectados y aplicar medidas apropiadas de prevención y control de la infección para evitar la introducción del COVID-19.

The UK hosts some of the world’s longest-running longitudinal cohort studies, who make repeated observations of their participants and use these data to explore health outcomes. An alternative method for data collection is record linkage; the linking together of electronic health and administrative records. Applied nationally, this could provide unrivalled opportunities to follow a large number of people in perpetuity. However, public attitudes to the use of data in research are currently unclear. Here we report on an event where we collected attitudes towards recent opportunities and controversies within health data science. Methods: The event was attended by ~250 individuals (cohort members and their guests), who had been invited through the offices of their participating cohort studies. There were a series of presentations describing key research results and the audience participated in 15 multiple-choice questions using interactive voting pads. Results: Our participants showed a high level of trust in researchers (87% scoring them 4/5 or 5/5) and doctors (81%); but less trust in commercial companies (35%). They supported the idea of researchers using information from both neonatal blood spots (Guthrie spots) (97% yes) and from electronic health records (95% yes). Our respondents were willing to wear devices like a ‘Fit-bit’ (78% agreed) or take a brain scan that might predict later mental illness (73%). However, they were less willing to take a new drug for research purposes (45%). They were keen to encourage others to take part in research; whether that be offering the opportunity to pregnant mothers (97% agreed) or extending invitations to their own children and grandchildren (98%). Conclusions: Our participants were broadly supportive of research access to data, albeit less supportive when commercial interests were involved. Public engagement events that facilitate two-way interactions can influence and support future research and public engagement efforts.

Practice facilitation is a promising strategy to enhance care processes and outcomes in primary care settings. It requires that practices and their facilitators engage as teams to drive improvement. In this analysis, we explored the practice and facilitator factors associated with greater team engagement at the mid-point of a 12-month practice facilitation intervention focused on implementing cardiovascular prevention activities in practice. Understanding factors associated with greater engagement with facilitators in practice-based quality improvement can assist practice facilitation programs with planning and resource allocation. METHODS: One hundred thirty-six ambulatory care small to medium sized primary care practices that participated in the EvidenceNow initiative’s NC Cooperative, named Heart Health Now (HHN), fit the eligibility criteria for this analysis. We explored the practice and facilitator factors associated with greater team engagement at the mid-point of a 12-month intervention using a retrospective cohort design that included baseline survey data, monthly practice activity implementation data and information about facilitator’s experience. Generalized linear mixed-effects models (GLMMs) identified variables associated with greater odds of team engagement using an ordinal scale for level of team engagement. RESULTS: Among our practice cohort, over half were clinician-owned and 27% were Federally Qualified Health Centers. The mean number of clinicians was 4.9 (SD 4.2) and approximately 40% of practices were in Medically Underserved Areas (MUA). GLMMs identified a best fit model. The Model presented as odd ratios and 95% confidence intervals suggests greater odds ratios of higher team engagement with greater practice QI leadership 17.31 (5.24-57.19), [0.00], and practice location in a MUA 7.25 (1.8-29.20), [0.005]. No facilitator characteristics were independently associated with greater engagement. CONCLUSIONS: Our analysis provides information for practice facilitation stakeholders to consider when considering which practices may be more amendable to embracing facilitation services.

The paper opens with a brief history of two of the major intellectual components of the recent utilitarian turn in clinical research, namely ‘pragmatic trials’ and ‘implementation science’. The two schools of thought developed independently and the paper scrutinises their mutual compatibilities and incompatibilities, asking: i) what do the leading advocates of pragmatic trials assume about the transfer of research findings to real-world practice and ii) what role pragmatic trials can and should play in the evaluation of implementation science strategies. METHODS: The paper utilises ‘explication de texte’: i) providing a close reading of the inferential logics contained in major published expositions of the two paradigms, and ii) interrogating the conclusions of a pragmatic trial of an intervention providing guidelines on retinal screening aimed at family practitioners. RESULTS: The paper is in two parts. Part 1 unearths some significant incommensurability – the pragmatic trial literature retains an antiquated view of knowledge transfer and is overly optimistic about the wide applicability the findings of pragmatic trials to ‘real world’ conditions. Part 2 of the paper outlines an empirical strategy to better penetrate the mechanisms of knowledge transfer and to tackle the issue of the generalisabilty of research findings in implementation science. CONCLUSIONS: Pragmatism, classically, is about problem solving and the melding of perspectives. The core research requirement in implementation science is a fundamental shift from the narrow shoulders of pragmatic trials to a model of explanation building based upon a multi-case, multi-method body of evidence.

There is a growing recognition of the importance of evidence to support allocative policy decisions in health care. This study is based on interviews with politicians in four regional health authorities in Sweden. Drawing on theories of strategic use of knowledge, the article analyses how politicians perceive and make use of expert knowledge represented by the National Guidelines, embracing both a scientific and a political rationale. As health care is an organisation with a dual basis for legitimacy – at the same time a political and an action organisation – it affects knowledge use. We investigate how the context of health care priority setting influences the conditions for knowledge use among regional politicians. Our findings illustrate the dilemma of political decision-makers and how they prefer to use expert knowledge. The politicians use this policy instrument in a legitimising fashion, as it will fit into the current political debate on more equal care. As an instrument for resource allocation the politicians noted that ‘facts’ per se could not provide them with a sufficient basis for legitimising their governing of health care. The dualistic organisational context makes knowledge important as a political weapon in negotiations with the medical profession.

Evidence-based care plans can fail when they do not consider relevant patient life circumstances, termed contextual factors, such as a loss of social support or financial hardship. Preventing these contextual errors can reduce obstacles to effective care. OBJECTIVE: To evaluate the effectiveness of a quality improvement program in which clinicians receive ongoing feedback on their attention to patient contextual factors. DESIGN, SETTING, AND PARTICIPANTS: In this quality improvement study, patients at 6 Department of Veterans Affairs outpatient facilities audio recorded their primary care visits from May 2017 to May 2019. Encounters were analyzed using the Content Coding for Contextualization of Care (4C) method. A feedback intervention based on the 4C coded analysis was introduced using a stepped wedge design. In the 4C coding schema, clues that patients are struggling with contextual factors are termed contextual red flags (eg, sudden loss of control of a chronic condition), and a positive outcome is prospectively defined for each encounter as a quantifiable improvement of the contextual red flag. Data analysis was performed from May to October 2019. INTERVENTIONS: Clinicians received feedback at 2 intensity levels on their attention to patient contextual factors and on predefined patient outcomes at 4 to 6 months. MAIN OUTCOMES AND MEASURES: Contextual error rates, patient outcomes, and hospitalization rates and costs were measured. RESULTS: The patients (mean age, 62.0 years; 92% male) recorded 4496 encounters with 666 clinicians. At baseline, clinicians addressed 413 of 618 contextual factors in their care plans (67%). After either standard or enhanced feedback, they addressed 1707 of 2367 contextual factors (72%), a significant difference (odds ratio, 1.3; 95% CI, 1.1-1.6; P = .01). In a mixed-effects logistic regression model, contextualized care planning was associated with a greater likelihood of improved outcomes (adjusted odds ratio, 2.5; 95% CI, 1.5-4.1; P < .001). In a budget analysis, estimated savings from avoided hospitalizations were $25.2 million (95% CI, $23.9-$26.6 million), at a cost of $337 242 for the intervention. CONCLUSIONS AND RELEVANCE: These findings suggest that patient-collected audio recordings of the medical encounter with feedback may enhance clinician attention to contextual factors, improve outcomes, and reduce hospitalizations. In addition, the intervention is associated with substantial cost savings.[/bg_collapse]

To conduct a systematic review of literature examining the establishment and operation of clinical ethical committees (CECs) in long-term care (LTC). DESIGN: Systematic review. SETTING AND PARTICIPANTS: LTC recipients/family or staff. METHODS: Five databases (Ovid Medline, Ovid Cochrane Library, Ovid PsycINFO, Ovid EMBASE, and CINAHL via EbscoHost) were systematically searched from their inception to May 8, 2020. The initial search was conducted on August 22, 2017, and updated on May 8, 2020, to identify peer-reviewed studies, commentaries, or editorials. The quality of studies was assessed using the Mixed Methods Appraisal Tool. RESULTS: Thirty-three articles were identified for inclusion, of which 13 were primary studies. Most articles were set in the United States. The purpose of establishing a CEC in LTC was typically to assist in dealing with ethical issues and improve the quality of care. The articles described the roles of CECs to include prospective case consultation, case review, policy development, and ethics education. Articles rarely reported whether the CEC was required by or enshrined in law. Membership of CECs was between 4 and 20 members and most commonly included nursing staff, physicians, and directors/administrators. The rationale behind the membership was rarely described. For case consultation, articles described that CECs were typically convened upon referral. The resident issues which a CEC could address included end-of-life care decisions, autonomy/self-determination, and medical treatment decisions. The staff issues addressed by CECs included medical treatment decisions, end-of-life care decisions, and decision-making issues. The decision-making process followed by CECs varied. The outcome of a CEC meeting was typically a recommendation, whereas the implementation of CEC recommendations and decisions were rarely reported. CONCLUSIONS AND IMPLICATIONS: This systematic review identifies how CECs operate in the LTC setting. CECs have the potential to provide valuable support in addressing complex ethical issues in LTC; however, empirical research is required to determine their efficacy in the LTC setting.

Certified nursing assistant (CNA) turnover and retention are critical aspects of facilities’ ability to provide cost-effective, high quality person-centered care. Previous studies and industry practice often treat turnover and retention as similar concepts, assuming that low turnover and high retention are synonymous. The study addressed the question of whether turnover and retention rates differ and if so, what do those differences mean for nursing home practice, policy, and research. RESEARCH DESIGN AND METHODS: This study examines facility-level factors associated with CNA retention and turnover rates using 2015 data from the Ohio Biennial Survey of Long-Term Care Facilities, Ohio Medicaid Cost Reports, Certification and Survey Provider Enhanced Report, and the Area Health Resource File. Using bivariate tests and regression analysis, we compare rates and the factors associated with retention and turnover. RESULTS: The mean facility annual retention rate was 64% and the mean annual turnover rate was 55%. As expected, there was a statistically significant and negative correlation between the rates (r = -0.26). However, some facilities had both high retention and high turnover and some had low rates for both measures. Not all the variables that are associated with turnover are also associated with retention. DISCUSSION AND IMPLICATIONS: CNA retention is not simply the absence of CNA turnover. Given the differences, nursing homes may need to use strategies and policies designed to target a particular stability measure.

Mealtime engagement is defined as verbal and nonverbal assistance provided by caregivers to guide and motivate care-recipients in eating. Quality mealtime engagement is critical to improve mealtime difficulties and intake among older adults with dementia requiring eating assistance. Few tools are feasible and valid to measure mealtime engagement. This study developed and tested the Mealtime Engagement Scale (MES). RESEARCH DESIGN AND METHODS: Items were developed based on literature review and expert review and finalized based on content validity and corrected item-total correlation. A secondary analysis of 87 videotaped observations capturing 18 nursing home staff providing mealtime care to residents with dementia was conducted. Internal consistency, inter-rater reliability, and intra-rater reliability were assessed. Concurrent and convergent validity were examined through correlation (rs) with the Relational Behavior Scale (RBS) and the Mealtime Relational-Care Checklist (M-RCC), respectively. RESULTS: The 18-item MES was developed with adequate content validity (Scale-CVI=1.00; Scale-CVI/Average=0.962-0.987). Each item is scored from 0 (never) to 3 (always). The total scale score ranges from 0 to 54. Higher scores indicate greater mealtime engagement. The MES had very good internal consistency (Cronbach’s alpha=0.837), outstanding inter-rater reliability (Interclass Correlation=0.920), outstanding intra-rater reliability (Interclass Correlation =0.956), adequate concurrent validity based on strong correlation with the RBS (rs=0.821, p&.001), and fair convergent validity based on weak correlation with the M-RCC (rs=0.219, p=.042). DISCUSSION AND IMPLICATIONS: Findings provide preliminary psychometric evidence of MES to measure mealtime engagement. Future testing is needed among more and diverse samples in different care settings to accumulate psychometric evidence.

As part of a nursing home intervention study, the aim of this paper was 1) to evaluate the effects of a staff education programme about person-centred care and promotion of thriving on relatives’ satisfaction with quality of care and their perceptions of the person-centredness of the environment, and 2) to outline factors of importance to explain the variance in relatives’ satisfaction with quality of care. Relatives are often referred to as vital for the operationalisation of person-centredness in nursing homes, representing an important source of information for care planning and quality of care assessments. However, the evidence for effects of person-centredness in nursing homes on relatives’ experiences is sparse and little is known on what could explain their satisfaction with the quality of care. METHODS: A multi-centre, non-equivalent controlled group before-after design with study sites in Australia, Norway and Sweden. Staff in the intervention group participated in a 14-month education on person-centredness, person-centred care, thriving and caring environment. Staff in the control group received a one-hour lecture before the intervention period. Data were collected at baseline, after the intervention and six months after the end of the intervention, and analysed using descriptive statistics, a generalised linear model and hierarchical multiple regression. RESULTS: In general, relatives from both the intervention and control nursing homes were satisfied with the quality of care, and no statistically significant overall between-group-effects of the intervention were revealed on satisfaction with quality of care or perceptions of the person-centredness of environment. A person-centred environment in terms of safety and hospitality were identified as factors of prominent importance for the relatives’ satisfaction with the quality of care. CONCLUSION: The findings of this paper provide a foundation for future research in terms of intervention design in nursing home contexts. Staff availability, approachability, competence and communication with relatives may be important factors to consider to improve quality of care from the perspective of relatives, but more research both with and for relatives to people living in nursing homes is necessary to identify the keys to success. TRIAL REGISTRATION: ClinicalTrials.gov- NCT02714452 . Registered on March 19, 2016.

To evaluate outcomes associated with pharmacist-led medication reviews in residential aged care facility (RACF) residents with dementia. METHODS: Six scientific databases were searched. All study designs investigating pharmacist-led medication reviews in RACF residents with dementia were considered. The protocol was registered with PROSPERO (CRD42019121681). RESULTS: One randomised controlled trial (RCT) and five observational studies were identified. Two studies reported reductions in medication usage per resident, and one study reported improved appropriateness of psychotropic use following reviews as part of multi-faceted, collaborative interventions. In three studies, reviews undertaken as an isolated intervention or by a visiting pharmacist with minimal collaboration with physicians were associated with low implementation rates of recommendations to alter therapy. CONCLUSION: Pharmacist-led medication reviews, when conducted collaboratively, may improve the use of medicines in RACF residents with dementia. However, robust conclusions cannot be drawn, largely due to the low quality of evidence available, including only one RCT.

Nursing homes (NHs) are critical end-of-life (EOL) care settings for 70% of Americans dying with Alzheimer’s disease/related dementias (ADRD). Whether EOL care/outcomes vary by NH/market characteristics for this population is unknown but essential information for improving NH EOL care/outcomes. Our objectives were to examine variations in EOL care/outcomes among decedents with ADRD and identify associations with NH/market characteristics. DESIGN: Cross-sectional. OUTCOMES: Place-of-death (hospital/NH), presence of pressure ulcers, potentially avoidable hospitalizations (PAHs), and hospice use at EOL. Key covariates were ownership, staffing, presence of Alzheimer’s units, and market competition. SETTING AND PARTICIPANTS: Long-stay NH residents with ADRD, age 65 + years of age, who died in 2017 (N = 191,435; 14,618 NHs) in NHs or hospitals shortly after NH discharge. METHODS: National Medicare claims, Minimum Data Set, public datasets. Descriptive analyses and multivariable logistic regressions. RESULTS: As ADRD severity increased, adjusted rates of in-hospital deaths and PAHs decreased (17.0% to 6.3%; 11.2% to 7.0%); adjusted rates of dying with pressure ulcers and hospice use increased (8.2% to 13.5%; 24.5% to 40.7%). Decedents with moderate and severe ADRD had 16% and 13% higher likelihoods of in-hospital deaths in for-profit NHs. In NHs with Alzheimer’s units, likelihoods of in-hospital deaths, dying with pressure ulcers, and PAHs were significantly lower. As ADRD severity increased, higher licensed nurse staffing was associated with 14%‒27% lower likelihoods of PAHs. Increased NH market competition was associated with higher likelihood of hospice use, and lower likelihood of in-hospital deaths among decedents with moderate ADRD. CONCLUSIONS AND IMPLICATIONS: Decedents with ADRD in NHs that were nonprofit, had Alzheimer’s units, higher licensed nurse staffing, and in more competitive markets, had better EOL care/outcomes. Modifications to state Medicaid NH payments may promote better EOL care/outcomes for this population. Future research to understand NH care practices associated with presence of Alzheimer’s units is warranted to identify mechanisms possibly promoting higher-quality EOL care.

Many people living in long-term care homes (LTCH) experience changes in behaviour termed the behavioural and psychological symptoms of dementia (BPSD). The valid and reliable assessment of BPSD is essential to guide treatment and monitor the effect of interventions. The aim of this study was to identify behavioural assessment tools implemented in LTCH and factors that impact on their use in clinical care. METHODS: We completed an online mixed-design survey of 300 randomly selected Canadian LTCH between September and November 2018. Respondents were asked to report tools used, reasons for use, methods of administration, training/supports available, confidence in use and challenges faced. Survey results were summarized descriptively and the correlation between implementation supports and confidence examined. Free-text responses were analysed qualitatively. RESULTS: Of 300 LTCH invited to participate, 103 completed the survey. Homes reported using a mean 2.2 ± 1.1 (range 0-7) different tools. The two most commonly used tools were the Dementia Observation System (DOS) and Cohen-Mansfield Agitation Inventory (CMAI). Overall confidence in most aspects of tool use was reported to be high, with workload identified as the greatest challenge. Training and supports correlated with confidence in tool use. Qualitative findings indicate tools provide valuable data to understand behaviours, facilitate team communication, target interventions and track outcomes. CONCLUSIONS: Behavioural assessment tools, in particular a direct observation tool, are widely used in clinical care in Canadian LTCH. Education, enhanced resources, leadership support and applications of technology represent opportunities to improve their use.

In their important article, Haward et al. (2020) discuss whether guidelines for treating extremely premature babies should be altered to free up ventilators during crises such as COVID-19 pandemic. 1 The authors’ claim is that premature babies do not deserve special consideration for ventilator treatment but merely equal consideration. In this brief commentary, I continue their discussion by considering additional factors that may help us determine whom we should save in a crisis: babies or the elderly.

Most older people, and especially those in need of long-term care, suffer from one or more chronic diseases. Consequently, older people have an increased need of medical care, including specialist care. There is little evidence as yet whether older people with greater medical care needs obtain adequate medical care because existing studies do not sufficiently control for differences in morbidity. In this study we investigate whether differences in medical specialist utilization exist between older people with and without assessed long-term care need in line with Book XI of the German Social Code, while at the same time controlling for individual differences in morbidity. METHODS: We used data from the 11 German AOK Statutory Health and Long-term Care Insurance funds of 100,000 members aged 60 years or over. Zero-inflated Poisson regression analyses were applied to investigate whether the need for long-term care and the long-term care setting are associated with the probability and number of specialist visits. We controlled for age, gender, morbidity and mortality, residential density, and general practitioner (GP) utilization. RESULTS: Older people in need of long-term care are more likely to have no specialist visit than people without the need for long-term care. This applies to nearly all medical specialties and for both care settings. Yet, despite these differences in utilization probability the number of specialist medical care visits between older people with and without the need for long-term care is similar. CONCLUSION: Older people in need of long-term care might face access barriers to specialist care. Once a contact is established, however, utilization does not differ considerably between those who need long-term care and those who don’t; this indicates the importance of securing an initial contact.

Internationally, most studies have focused on quality and safety in long-term care. However, studies focusing on the economic evaluation of quality and security in long-term care are sparse. Moreover, the economic evaluation of nurse practitioner care in long-term care is lacking, particularly in Québec Canada where roles are new. PURPOSE: To evaluate the effectiveness of introducing nurse practitioners in six long-term care facilities in Québec using a cost-savings analysis in terms of reduction of nurse practitioner sensitive events (NPSEs). METHODS: A cost savings analysis was completed using a prospective observational study. All residents (n = 538) under the care of teams that included nurse practitioners who experienced at least one of the following NPSEs: falls, pressure ulcers, short-term transfers, and a change in the time needed to administer the medications consumed were included. Data were collected from September 1st 2015 to August 31st 2016. Descriptive statistics identified numbers of cases for falls, pressure ulcers, short-term transfers, and the number of medications consumed. A literature analysis was used to estimate excess median long-term care facility related costs of these NPSEs. Costs were calculated in 2016 Canadian dollars. The cost savings with the reductions that occurred for falls, pressure ulcers, short term transfers, and the time needed to administer medications after the implementation of a primary healthcare nurse practitioner role in the six long term care facilities were also estimated. FINDINGS: The median cost of 341 cases of falls, 32 cases of pressure ulcers and 53 cases of short-term transfers in the six long-term facilities would range between CAD 4,516,337.8 and CAD 5,281,824.4. Moreover, the total costs savings from the reduction of adverse events including the reduction of nursing administration time for medications would be between CAD 1,942,533.6 and CAD 3,254,403.4. DISCUSSION: This is the first study to present the financial consequence of adverse events sensitive to nurse practitioner care in long-term care. Important cost savings were generated from the reduction of adverse events after the implementation of nurse practitioner roles in long-term care. Government should consider these results for prevention and improvements in quality and safety in long-term care.

The Hospital Elder Life Program (HELP) has been shown to prevent delirium in hospitalized older adults. The objective of this study was to test the efficacy of HELP adapted to long-term care (HELP-LTC). DESIGN: Cluster randomized controlled trial. SETTING: A 514-bed academic urban nursing home. PARTICIPANTS: A total of 219 long-term nursing home residents who developed an acute illness or change in condition were randomly assigned to HELP-LTC (n = 105) or usual care (n = 114) by unit. INTERVENTION: HELP-LTC is a multicomponent intervention targeting delirium risk factors of cognitive impairment, immobility, dehydration, and malnutrition. Two certified nursing assistants (CNAs) delivered HELP-LTC components twice daily 7 days per week. In addition, recommendations were given to primary providers to reduce medications associated with delirium. MEASUREMENTS: Delirium (primary outcome) and delirium severity were ascertained each weekday by a research assistant blinded to group assignment, using the Confusion Assessment Method (CAM) and CAM severity score (CAM-S), respectively. Cognitive function was determined using the Cognitive Performance Scale (CPS). Hospitalization was ascertained by chart review. RESULTS: Participants were 81.7 years of age on average and 65.3% female. At baseline, usual care group participants had better cognitive function than intervention group participants (CPS = 1.33 vs 2.25; P = .004). Delirium symptoms declined over the course of the episode (mean CAM-S = 3.63 at start vs 3.27 at end). Overall, 33.8% of the total sample experienced incident delirium. After adjusting for baseline cognitive function, no significant differences were found in delirium or delirium severity between intervention and usual care groups. Hospitalization was not significantly different between groups. CONCLUSION: An intervention targeting delirium risk in long-term nursing home residents did not prevent delirium or reduce delirium symptoms. Baseline differences in cognitive function between groups, greater than expected improvements in both groups, quality-enhancing practices such as consistent assignments delivered to both groups, and adaptations of the intervention may have biased results toward null.

The development and testing of a nursing facility resident satisfaction survey (i.e., CoreQ) that could be used for public reporting purposes is presented here. This is important as very little satisfaction with care information is publicly available for nursing facility consumers. Validity testing is reported detailing the development of the CoreQ: Short Stay Discharge questionnaire and a measure that was calculated from the items in the questionnaire. This questionnaire resulted in four items whose combined score gives a measure representing participants’ overall satisfaction with the nursing facility. The measure parsimoniously reports this satisfaction as a score (ranging from 0 to 100) and was recently endorsed by the National Quality Forum (NQF). The measure may have significance for report cards and payment metrics, as it incorporates the consumers’ opinion.

Faced with increased expectations regarding the quality and safety of health care delivery systems, a number of stakeholders are increasingly looking for more efficient ways to deliver care. This study was conducted to provide a critical appraisal and synthesize the best available evidence on the impact of implementing clinical microsystems (CMS) on the quality of care and safety of the health care delivery. DATA SOURCES: A comprehensive and systematic search of 6 electronic databases, from 1998 to 2018, was conducted to identify empirical literature published in both English and French, evaluating the impact of implementing CMS in health care settings. STUDY SELECTION: We included all study designs that evaluate the impact of implementing CMS in health care settings. DATA EXTRACTION: Independent reviewers screened abstracts, read full texts, extracted data from the included studies, and appraised the methodological quality. RESULTS: Of the 1907 records retrieved, 35 studies met the inclusion criteria. The settings included general practice clinics (n = 18), specialized care units (n = 14), and emergency and ambulatory units (n = 3). The implementation of CMS helped to develop the patient-centered approach, promote interdisciplinarity and quality improvement skills, increase the fluidity of the clinical acts performed, and increase patient safety. It contributed to increasing patients’ and clinicians’ satisfaction, as well as reducing hospital length of stay and reducing hospital-acquired infections. The implementation of CMS also contributed to the development and refinement of diagnostic tools and measurement instruments. CONCLUSION: The CMS approach is unique because of the primacy given to the quality of care offered and the safety of patients over any other consideration, and its ability to redesign health care delivery systems. Efforts still need to be made to legitimize the approach in various health care settings worldwide.

In April, 2019, the Alzheimer’s Association Dementia Care Provider Roundtable convened to discuss common challenges faced when implementing person-centered, non-pharmacological practices in long-term care and other settings that provide care and programs for persons living with dementia, and to develop relevant, specific guidance from the perspective of administrative leaders from 23 long-term and community-based care provider organizations (representing home, community-based, and residential care). Guidance related to 5 practice areas emerged from the facilitated discussion: having a foundational person-centered culture, conceptualizing behaviors as expressions and focusing on behavioral support, identifying antecedents and placing person-centeredness before protocols, modifying training to promote person-centered culture, and valuing implementation flexibility. In developing the practice guidance, a related list of priority areas for research and policy were also identified.

In Canada, there were over 60,000 long-term care facility patient transfers to emergency departments (EDs) in 2014, with up to a quarter of them being potentially preventable. Each preventable transfer exposes the patient to transport- and hospital-related complications, contributes to ED crowding, and adds significant costs to the health care system. There have been many proposed and studied interventions aimed at alleviating the issue, but few attempts to assess and evaluate different interventions across institutions. METHODS: A systematic search of MEDLINE, CINAHL, and EMBASE for studies describing the impact of interventions aimed at reducing preventable transfers from long-term care facilities to EDs on ED transfer rate. Two independent reviewers screened the studies for inclusion and completed a quality assessment. A tabular and narrative synthesis was then completed. This study adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis Extension for Scoping Reviews (PRISMA-ScR) guidelines. RESULTS: A total of 26 studies were included (Cohen’s k = 0.68). One was of low quality (Cohen’s k = 0.58). Studies were summarized into five themes based on intervention type: Telemedicine, Outreach Teams, Interdisciplinary Care, Integrated Approaches, and Other. Effective interventions reported reductions in ED transfer rates post intervention ranging from 10 to 70%. Interdisciplinary health care teams staffed within long-term care facilities were the most effective interventions. CONCLUSION: There are several promising interventions that have successfully reduced the number of preventable transfers from long-term care facilities to EDs in a variety of health care settings. Widespread implementation of these interventions has the potential to reduce ED crowding in Canada.

Pain among long-term care residents is often underdiagnosed and inadequately treated. We examined the effect of a multimodal intervention on certified nursing assistants’ pain recognition knowledge and verbal reporting behavior. Secondarily, we examined pain documentation in a newly established pain log compared with pain verbally reported to nurses and documented in the electronic health record (EHR). DESIGN: Quality improvement project using a pretest-posttest design. SETTING: A skilled nursing and rehabilitation facility in Southwestern Pennsylvania including two long-term care units and one transitional rehabilitation unit. PARTICIPANTS/SUBJECTS: Fifty-six nursing assistants. METHODS: The intervention was a face-to-face educational session with a training video and introduction of a new pain log used to document residents’ pain. Pain knowledge was measured before and after the educational intervention. Multiple measures were used to examine nursing assistants’ pain reporting. RESULTS: Nursing assistants’ pain knowledge improved (p < .001). There was no change in verbal pain reporting behaviors. The percent of pain episodes documented in the electronic health record that were reported to nurses varied by unit type (45% on the long-term care units vs. 100% on the rehabilitation unit) but remained unchanged postintervention. Pain logs were used more often on the rehabilitation than the long-term care units; use was low overall. Nursing assistant reports that nurses provided feedback on their reports of resident pain increased from 45% in week 1 to 75% in week 4. CONCLUSIONS: Although the multimodal intervention improved nursing assistants&apos; pain knowledge and their perceptions of the feedback they received from nurses when they reported pain, it had no effect on certified nursing assistants reporting of pain to nurses (per nurse report).[/bg_collapse]

Consumers play a key role in the U.S. nursing home (NH) oversight through a federally established complaint process. However, past variation by state in complaint numbers and rates raised questions about the uniformity of the process. We examined state variation in numbers of complaints at intake and substantiated complaints, percentages of NHs with at least one complaint and one substantiated complaint, number of allegations per complaint, and complaint substantiation rates. We found state variation most prominently at the intake level, ranging from 0.4 to 30.4 complaints per NH. The investigation process appears to reduce this variation: however, variation remains among states in frequency and prevalence of substantiated complaints. Further work is needed to ensure federal standards concerning the handling of consumer complaints are applied equally across the states. This includes policies affecting how complaints are initially filed, in addition to how complaints are investigated.

This article aimed to advance the understanding of ‘what works’ in visual art interventions from the perspective of key stakeholders, including people with dementia, their family members and visual art professionals. METHOD: Semi-structured interviews were conducted with 22 participants, exploring their perceptions on barriers, facilitators, perceived benefits, experiences of delivering/attending a visual art intervention and any recommendations for implementation. RESULTS: Five factors were identified within the interviews that indicated important considerations for intervention structure and implementation, including benefits of group work, a skilled facilitator, participant choice, artistic ability and activity content. While art therapists expressed a clear protection of professional boundaries, the success of all of the visual art interventions was largely attributed to the supportive facilitator who possessed certain core values such as empathy and compassion and had knowledge in both artistic practice and the impact of living with dementia. It was clear the group dynamic was valued, and it was important to provide enjoyable, failure-free activity content with a strong focus on the creative process. CONCLUSION: These findings offer a direction for evidence-based practice when implementing visual art interventions.

To assess whether organisational culture influences the fidelity of implementation of the Integrated Chronic Disease Management (ICDM) model at primary healthcare (PHC) clinics. DESIGN: A cross-sectional study. SETTING: The ICDM model was introduced in South African clinics to strengthen delivery of care and improve clinical outcomes for patients with chronic conditions, but the determinants of its implementation have not been assessed. PARTICIPANTS: The abbreviated Denison organisational culture (DOC) survey tool was administered to 90 staff members to assess three cultural traits: involvement, consistency and adaptability of six PHC clinics in Dr. Kenneth Kaunda and West Rand (WR) health districts. PRIMARY AND SECONDARY OUTCOME MEASURES: Each cultural trait has three indices with five items, giving a total of 45 items. The items were scored on a Likert scale ranging from one (strongly disagree) to five (strongly agree), and mean scores were calculated for each item, cultural traits and indices. Descriptive statistics were used to describe participants and clinics, and Pearson correlation coefficient to asses association between fidelity and culture. RESULTS: Participants’ mean age was 38.8 (SD=10.35) years, and 54.4% (49/90) were nurses. The overall mean score for the DOC was 3.63 (SD=0.58). The involvement (team orientation, empowerment and capability development) cultural trait had the highest (3.71; SD=0.72) mean score, followed by adaptability (external focus) (3.62; SD=0.56) and consistency (3.56; SD=0.63). There were no statistically significant differences in cultural scores between PHC clinics. However, culture scores for all three traits were significantly higher in WR (involvement 3.39 vs 3.84, p=0.011; adaptability 3.40 vs 3.73, p=0.007; consistency 3.34 vs 3.68, p=0.034). CONCLUSION: Leadership intervention is required to purposefully enhance adaptability and consistency cultural traits of clinics to enhance the ICDM model’s principles of coordinated, integrated, patient-centred care.

To test the effects of deploying a humanoid companion robot (Kabochan) in comparison with usual care for long-term care facilities’ residents with dementia. DESIGN: A 2-arm, randomized controlled trial with ABAB withdrawal design, lasting 32 weeks. After an 8-week baseline period, Kabochan was introduced in a nonfacilitated, individual approach with experimental-group participants (n = 52) for 8 weeks, then removed for 8 weeks, and then reintroduced for another 8 weeks. The control group (n = 51) received the usual standardized care. SETTING AND PARTICIPANTS: Seven long-term care facilities in Hong Kong. 103 residents (76% women, 87.2 ± 7.4 years) with a clinical diagnosis of dementia. MEASURES: Outcome assessments occurred at 5 time points: baseline (week 1) and the end of each phase (weeks 8, 16, 24, and 32). Primary outcomes were assessed with the Neuropsychiatric Inventory Questionnaire (symptom severity and caregiver distress subscales) and the Geriatric Depression Scale; secondary outcomes were measured by the Hong Kong Montreal Cognitive Assessment 5-minute Protocol, the Modified Barthel Index for Activities of Daily Living, and the Quality of Life-Alzheimer’s disease scale. RESULTS: A multivariate analysis of variance indicated a statistically significant group × time interaction for neuropsychiatric-related caregiver distress at week 16 (F = 6.72, P = .011), with a moderate effect size (η(p)(2) = 0.06). When Kabochan was removed in the withdrawal phase (weeks 17-24), the neuropsychiatric symptoms became more severe at week 24 for the intervention group (F = 4.68, P = .003), although the effect size was small to moderate (η(p)(2) = 0.04). No statistical between-group differences were found in other health outcomes. CONCLUSIONS AND IMPLICATIONS: The Kabochan was potentially effective at reducing short-term neuropsychiatric symptoms and relevant caregiver distress for residents with dementia. An individualized care plan with continuous monitoring is required to integrate the humanoid robot into routine dementia care.

The contemporary long-term care provider and interdisciplinary team are well aware of the recent focus on antibiotic use in their settings. Regulatory changes implemented by Centers for Medicare and Medicaid Services beginning in 2016 have required long-term care settings to look at antibiotic use in a more comprehensive way and to align their programs with the Centers for Disease Control and Prevention’s Core Elements for Antibiotic Stewardship for Nursing Homes. As long-term care settings have worked to develop antibiotic stewardship programs over the past several years, there have been many discoveries about the processes involved in gathering data about antibiotic use and associated attributes, including dose, duration of therapy, and indication for use. Attempts to align these attributes with appropriateness may require integration of data elements from pharmacy records and the individual resident’s electronic medical record. In this article, we systematically discuss relevant antibiotic use metrics, sources of antibiotic use data, collecting and reporting antibiotic use data, concluding with implications for policy, practice, and research. Only by measuring antibiotic use can we start to assess the effectiveness of antibiotic stewardship program to induce meaningful change in the care of residents in long-term care.

The Preferences Assessment Tool (PAT) in the Minimum Data Set (MDS) 3.0 assesses 16 resident preferences for daily routines and activities. Although integrating important preferences into care planning is essential to provide person-centered care in nursing homes (NHs), preferences rated as important but unmet or unimportant may not receive much attention. This study aims to (1) identify the prevalence of unmet preferences and unimportant preferences, and (2) examine their associations with resident and facility-level characteristics. DESIGN: This is a longitudinal study of residents in NHs. SETTINGS AND PARTICIPANTS: We used data from 2012-2017 MDS assessments of long-stay residents aged 65 or older in 295 Minnesota NHs. In total, 51,859 assessments from 25,668 residents were included. METHODS: Generalized linear mixed models were used to analyze resident and facility-level characteristics associated with having any unmet preferences, and with the number of unimportant preferences. RESULTS: Across all years for both daily routine preferences and activity preferences, 3.3% to 5.1% of residents reported that at least 1 or more preference was important but unmet, and 10.0% to 16.6% reported that 4 or more out of the 8 preferences were unimportant. Residents with higher depressive symptoms, and poorer physical and sensory function were more likely to report unmet preferences. Residents with poorer physical and sensory function, and living in rural facilities and facilities having fewer activity staff hours per resident day were more likely to report unimportant preferences. CONCLUSIONS AND IMPLICATIONS: Residents with functional and sensory limitations and living in underresourced NHs are more likely to report that preferences are unimportant, or that they are important but unmet. It is important for staff to elicit preferences that truly matter for residents, and to enable residents to meet their preferences.

Music programs have the potential to provide an effective non-pharmacological tool for caregivers to reduce depression and agitation and increase quality of life in people with dementia. However, where such programs are not facilitated by a trained music therapist, caregivers need greater access to information about how to use music most effectively in response to key challenges to care, and how to pre-empt and manage adverse responses. OBJECTIVE: This study reports on the trial of a Guide for use of music with 45 people with dementia and their caregivers in residential care facilities and home-based care. METHODS: The study used a pre-post experimental design in which participants were randomly allocated to a treatment group or a waitlist control group. RESULTS: Improvements to quality of life were found in the experimental group over the 6-week period. Significant increases in Interest, Responsiveness, Initiation, Involvement, and Enjoyment were reported for individual listening sessions. CONCLUSION: The Guide can provide an effective protocol for caregivers to follow in selecting music to manage particular challenges to care, confirming the need for caregivers to be prepared to monitor and manage potential negative responses.

To determine clinical characteristics and treatment complications of patients with late-stage Parkinsonism living in nursing homes compared with those living at home. DESIGN: Cross-sectional analysis. SETTING AND PARTICIPANTS: This study is an analysis of 692 patients with late stage Parkinsonism recruited to an in-depth international study, Care of Late-Stage Parkinsonism (CLaSP). MEASURES: Sociodemographic characteristics were compared between patients who were living in a nursing home (n = 194) and those living at home (n = 498). Clinical assessments included the Unified Parkinson’s Disease Rating Scale (UPDRS), the nonmotor symptom scale, the neuropsychiatric inventory, and a structured interview of patients and carers. Predictors of nursing home status were determined in a multivariate analysis. RESULTS: Nursing home placement was strongly associated with more severe cognitive impairment, worse UPDRS motor scores and disability, and with being unmarried and older. Although nursing home residents had significantly higher axial scores, falls were less common. Despite similar levodopa equivalence doses, they had less dyskinesia. Nonmotor symptom burden, particularly delusion, hallucination, and depression scores were higher in nursing home residents, and they were more frequently on psychotropic medication. They had lower rates of dopamine agonist use and lower rates of impulse control disorders. In multivariate analysis, being unmarried, presence of cognitive impairment, worse disease severity as assessed on the UPDRS parts II and III, severity of delusions, and lower rate of dyskinesia were associated with nursing home placement. CONCLUSIONS AND IMPLICATIONS: These clinical characteristics suggest that in patients with Parkinsonsim who are nursing home residents, presence of cognitive impairment and delusions particularly add to the higher overall symptom burden, and more often require specific treatments, including clozapine. Despite similar levodopa equivalent daily dose, motor severity is higher, and dyskinesias, indicative of a response to levodopa, are less common. Falls, however, also occur less commonly, and dopamine agonists are less frequently used, with lower rates of impulse control disorder.

A common problem in nursing home residents, urinary incontinence (UI) can lead to hygiene and skin problems, sleep disturbance, and decreased quality of life. This study evaluated the level of knowledge regarding UI among nursing home residents in Muğla, Turkey. METHODS: This study included 64 (19 females, 45 males) nursing home resident volunteers. Their physical and sociodemographic characteristics; daily living activities (Barthel Index); and the presence, frequency, severity, and type of UI as well as its impact on daily living were evaluated (International Consultation on Incontinence Questionnaire-Short Form) and history of treatment was queried. An Incontinence Quiz was used to assess the residents’ knowledge of incontinence. RESULTS: The participants were living in nursing homes for 34.48±33.16 months. Their educational level was low and most were single. The mean Barthel Index score was 89.75±13.00. Twenty-five participants had UI (18.8% urge, 4.7% stress, 15.6% mixed/other type), and the mean International Consultation on Incontinence Questionnaire-Short Form score was 8.08±4.24. Forty-four percent of the participants had no treatment and none had physiotherapy for incontinence. The mean Incontinence Quiz score was 4.88±1.96, indicating a low level of knowledge. The items with the highest ratio of incorrect responses (second and 14th) were related to the causes of incontinence and care seeking. CONCLUSION: These findings underscore the necessity of increasing knowledge among nursing home residents about the reasons and health care options for UI. Further studies on appropriate strategies to improve UI knowledge in this population will be of great value.

The management of diabetes in long-term care (LTC) facilities requires facility staff to perform most self-care activities on the behalf of the residents. A practical model of care to improve diabetes management was developed and implemented at 6 LTC facilities in the Northeast United States between 2009 and 2012. The components of the program included (1) developing an individualized education curriculum and educating LTC interdisciplinary staff; (2) educating patients and caregivers; and (3) developing a clinical care algorithm. Over 500 staff members were educated and achieved competence. There were 1031 residents screened for risk of hypo- or hyperglycemia on admission, and 245 residents (24%) experienced hypoglycemia and 240 residents (23%) experienced hyperglycemia. Hypoglycemia episodes resolved without recurrence in 73%-90% cases because of interventions initiated by LTC staff. The implementation of a practical model of diabetes management in LTC facilities can improve staff education and lead to improved diabetes management.

To describe the oral health status and dental service use of older adults with complex needs living within the community and aged residential care (ARC) facility settings, and to determine associations between dental service utilization and sociodemographic variables. DESIGN: Secondary analysis of 2 continuously recruited national cohorts. SETTING AND PARTICIPANTS: Adults aged ≥65 years having standardized assessments between July 1, 2012, and May 31, 2018, within New Zealand and who provided consent. METHODS: All community-living older people with complex needs undergo a standardized assessment, using the Home Care International Residential Assessment Instrument (interRAI-HC), whereas all ARC facility residents undergo Long Term Care Facilities assessments (interRAI-LTCF). Anonymized data from consenting participants were extracted. Cross-sectional analyses of oral health status and dental service use variables employed logistic regression models, whereas longitudinal analysis of factors influencing dental service utilization employed binary generalized estimating equation models. RESULTS: Overall, 144,380 interRAI-HC assessments from 97,229 participants, and 195,549 interRAI-LTCF assessments from 62,798 participants were eligible. At first assessment, their average age was 81.9 years (range: 65-109 years) and 84.4 years (range: 65-110 years), respectively. Approximately 65% of the participants wore dentures; 9% had broken, fragmented, loose, or otherwise nonintact natural teeth; and 10% reported difficulties chewing. Overall, only 25.3% of community-dwelling older adults and 17.5% of ARC residents had a dental examination within the previous year. Stark inequalities were observed with, for example, Māori participants having adjusted odds 3.14 [95% confidence interval (CI): 2.88, 3.42] and 2.08 (95% CI: 1.81, 2.39) of not having a dental examination in community and ARC facility settings compared with their New Zealand European counterparts. CONCLUSIONS AND IMPLICATIONS: Heavy and unequal oral health burdens were observed among older adults with complex needs, together with low dental service uptake. New Zealand needs an oral health policy for older adults.

We examine the relationship between dementia and psychiatric disorder diagnoses among long-term care residents in nursing homes across the state of Rhode Island (RI), USA.Observational clinical study.Two hundred fifty-five residents with and without the diagnosis of dementia were included in this study.Prevalence analysis was used to elucidate information on psychiatric disorders in the overall cohort, and among residents with dementia. Questions from the quality of life questionnaire (EQ-5D-3L) that provides information on self-care, anxiety/depression, and resident’s view of how healthy they are, were used to evaluate their association with dementia and psychiatric disorders. A logistic regression analysis was conducted to understand the relationship between dementia and mental illness diagnoses in long-term care facilities. Finally, a subgroup logistic regression analysis was performed for residents with Alzheimer disease.65.1% of all residents suffered from at least 1 psychiatric disorder. Anxiety was the most common diagnosis (36.5%), followed by depression (28.6%), and insomnia (14.9%). There was a positive and statistically significant association between any mental illness diagnosis and dementia (adjusted OR: 3.73; 95% CI: 1.34-10.41). Bipolar disorder and insomnia were negatively and statistically significantly associated with dementia (adjusted OR: 0.17; 95% CI: 0.03-0.89 AND adjusted OR: 0.39; 95% CI: 0.16-0.96 respectively). Age and COPD were also statistically associated with dementia (adjusted OR: 1.07; 95% CI: 1.03-1.11 AND adjusted OR: 0.28, 95% CI: 0.12-0.66). Alzheimer disease was positively and significantly associated with the diagnosis of any mental illness (adjusted OR: 3.77; 95% CI: 1.17-12.20).We studied the relationship between dementia and diagnoses of psychiatric disorders present in long-term care residents. We found that residents with a diagnosis of dementia were more likely to suffer from at least 1 psychiatric disorder. Further work is needed to establish the neuropathophysiological relationship between psychiatric disorders and dementia.

The objective of this study was to explore and synthesize evidence on the effectiveness and implementation of recreational therapy programs to enhance mobility outcomes (e.g., balance, functional performance, fall incidence) for older adults in long-term care. The authors conducted a scoping review of 66 studies following the PRISMA guidelines. Two independent reviewers evaluated each article, and a third reviewer resolved discrepancies. Randomized controlled studies provided strong to moderate evidence that tai chi programs, walking, dancing, and ball games improve flexibility, functional mobility, and balance. Studies assessing program implementation highlighted that program delivery was facilitated by clear instruction, encouragement, attendance documentation, and minimal equipment. This review elucidated the benefit of recreational therapy programs on mobility. It also identified the need for customized programs based on individuals’ interests and their physical and mental abilities. These findings and recommendations will assist practitioners in designing effective and feasible recreational therapy programs for long-term care.

The story of antipsychotics overuse in nursing homes is similar to infection control lapses. It is one of patient harm, inadequate oversight, and insufficient staffing. And it is one of often avoidable heartbreak. Addressing the issues in nursing homes begins with considering the immense vulnerability of our nursing home population and committing to tackling the multitude of interrelated challenges that persist. The scourge of COVID-19 in nursing facilities demonstrates the tragic consequences of turning a blind eye to our nation’s seniors and individuals with disabilities, and it underscores the need for robust emergency preparedness and oversight of the nursing home industry.

Structured Abstract Objective. To understand the evidence base for care interventions for people living with dementia (PLWD) and their caregivers, and to assess the potential for broad dissemination and implementation of that evidence.

Data sources. We searched Ovid Medline, Ovid Embase, Ovid PsycINFO, CINAHL, and the Cochrane Central Register of Controlled Trials (CENTRAL) to identify randomized controlled trials, nonrandomized controlled trials, and quasi-experimental designs published and indexed in bibliographic databases through March, 2020.

Review methods. We searched for nondrug interventions targeting PLWD, their informal or formal caregivers, or health systems. Two investigators screened abstracts and full-text articles of identified references for eligibility. Eligible studies included randomized controlled trials and quasi-experimental observational studies enrolling people with Alzheimer’s disease or related dementias or their informal or formal caregivers. We extracted basic study information from all eligible studies. We assessed risk of bias, and summarized results for studies not judged to be NIH Stage Model 0 to 2 (pilot or small sample size studies) or to have high risk of bias. We grouped interventions into categories based on intervention target.

Results. We identified 9217 unique references, of which 627 unique studies with an additional 267 companion articles were eligible. We classified interventions into 37 major categories. With few exceptions, we did not combine data quantitatively due to variability of interventions, comparison groups, outcomes measured, and study timing. Low-strength evidence shows that an intensive multicomponent intervention for informal caregiver support, with education, group discussion, in-home and phone support, and caregiver feedback (i.e. discrete adaptations of REACH II), may improve informal caregiver depression at 6 months. Low-strength evidence also shows that collaborative care models (i.e. Care Ecosystems or discrete adaptations of the ACCESS models) may improve quality of life for PLWD and health system-level markers, including improvements in guideline-based quality indicators and reducing emergency room visits. The literature does not allow for further determination of whether the very small to small average effects in quality of life applied to all enrolled PLWD or if larger effects were concentrated in an unidentified subgroup. For all other interventions and outcomes, we found the evidence insufficient to draw conclusions. Insufficient evidence does not mean that the intervention is determined to be of no value to PLWD or their caregivers. Rather, it means that due to the uncertainty of the evidence, we could not draw meaningful conclusions at this time.

Conclusions. Despite hundreds of studies, very little evidence supports widespread dissemination of any general care approaches for PLWD or caregivers. This review demonstrates the need for larger, longer-term, and more rigorous studies of interventions.

The Leadership in Patient-Oriented Research: Pragmatic Clinical Trials Certificate is a unique training opportunity developed to increase the knowledge, capacity, and practical skills of clinical trial professionals across Alberta. The vision of this program is to create a highly trained workforce to raise the standard for clinical trial conduct in Alberta.

The purpose of the certificate is to integrate currently available training, such as the ACRC recommended training courses, while providing additional content, patient-oriented research concepts, and practical application exercises using real-world and Alberta-specific examples. Upon completion of the certificate, learners will be able to:

Employ a common understanding of information required to work on clinical trials in Alberta
Develop and apply knowledge of specific regulations, good clinical practice, research ethics standards, and trial management
Apply knowledge of resources and structure of clinical trials processes in Alberta
Identify and integrate patient-oriented research principles into practice

Implementing evidence-based practices is a complex process. There are dozens of implementation theories, models and frameworks in the literature, but knowing which one to use and when is often a barrier to implementation on the ground. The Planning for Implementation Practice (PIP™) workshop provides a practical approach for teams developing an implementation plan for a new intervention or innovation. PIP™ covers the core elements of implementation science with a focus on learning and planning. Participants will gain a foundational understanding of implementation science and learn how to use an evidence-based implementation planning framework.

The workshop is intended for implementers, researchers, practitioners, community partners and policy/decision-makers. PIP™ is appropriate for implementation teams from any field or sector who are a) new to implementation science and b) currently working to implement a practice, intervention or innovation in their setting.

Identifying, developing and executing strategies that foster knowledge translation across research, policy and science communication communities. Developing project schedules including milestones, critical path, timelines, deliverables and reporting. Analyzing scientific, public health and policy trends to determine effectiveness of programs and initiatives. Researching and recommending new opportunities for external collaborations and partnerships. Coordinating the schedule for program and event calendars. Writing grant applications. Writing solicitation documentation in support of philanthropic funding opportunities. Promoting research initiatives to increase program visibility and reputation. Providing consultation and advice on the application of the research network’s policies and procedures. Promoting the research network’s capabilities to industrial, governmental and philanthropic sectors to enhance research and innovation funding opportunities. Fostering and maintaining networks to build capacity and collaboration. Monitoring program accounts. With support from a Finance & Accounting administrator, preparing project expense/revenue modeling, forecasting cost-to-completion and financial tracking. Verifying the accuracy and completeness of financial elements in grant submissions. Directing the activities of multiple ongoing staff-appointed employees. Overseeing the activities of research interns.