Collection of articles on Aging is available here.
Who to Talk to About my Pain? A Brief Qualitative Study on Perception of Pain and its Management in Swiss Nursing Home Residents
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T. Brunkert, M. Simon, J. Haslbeck and F. Zúñiga.
Pain Manag Nurs 2020 Apr;21(2):151-156
BACKGROUND: The prevalence of pain in nursing home (NH) residents is high. Insufficiently treated pain reduces quality of life and often leads to negative health consequences. Pain experience in older people can be influenced by physical, psychosocial, emotional, and spiritual factors. AIMS: To inform development of NH pain management interventions, we studied residents’ pain related perceptions and needs. DESIGN: This was a qualitative descriptive substudy (embedded in ProQuaS, a larger pain project). SETTINGS: Three Swiss NHs. PARTICIPANTS/SUBJECTS: A purposeful sample of eight NH residents with severe pain and no severe cognitive impairment, based on information from the Minimum Data Set. METHODS: Eight semistructured interviews were conducted between October and December 2016. The audio-recorded interviews were transcribed verbatim and analyzed inductively using thematic analysis. RESULTS: Three central themes were identified from the interview data: dealing with major life changes, managing pain, and using formal care. The interviews highlighted the multidimensionality of pain experience in NH residents. In complex pain situations, participants perceived that care workers did not respond adequately to their needs. They had learned to cope with their pain using self-developed strategies and direct consultations with their physicians. CONCLUSIONS: The perceived lack of responsiveness may prompt NH residents to bypass care workers with their pain management concerns. This study’s findings will inform the development of an educational intervention for NH care workers.

Potentially inappropriate prescribing in dementia: a state-of-the-art review since 2007
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J. Delgado, K. Bowman and L. Clare.
BMJ Open 2020 Jan 2;10(1):e029172-2019-029172
OBJECTIVES: Dementia frequently occurs alongside comorbidities. Coexisting conditions are often managed with multiple medications, leading to increased risk of potentially inappropriate medication and adverse drug reactions. We aimed to estimate prevalence of, and identify factors reported to be associated with, potentially inappropriate prescribing (PIP) for older individuals diagnosed with dementia. DESIGN: We used a state-of-the-art review approach, selecting papers written in English and published from 2007 to January 2018. Publications were retrieved from Scopus and Web of Science databases. Inclusion criteria included a formal diagnosis of dementia, a formal classification of PIP and reported prevalence of PIP as an outcome. Random effects models were used to provide a pooled estimate of prevalence of PIP. The Appraisal tool for Cross-Sectional Studies (AXIS tool) was used to assess bias in the included studies. RESULTS: The bibliographic search yielded 221 citations, with 12 studies meeting the inclusion criteria. The estimates of PIP prevalence for people living with dementia ranged from 14% to 64%. Prevalence was 31% (95% CI 9 to 52) in the community, and 42% (95% CI 30 to 55) in nursing/care homes. PIP included prescribing likely related to dementia (eg, hypnotics and sedative and cholinesterase inhibitors) and prescribing related to treatment of comorbidities (eg, cardiovascular drugs and non-steroidal anti-inflammatory medication). Higher levels of comorbidity were associated with increased risk of PIP; however, only one study investigated associations with specific comorbidities of dementia. CONCLUSION: PIP remains a significant issue in healthcare management for people living with dementia. Higher levels of comorbidity are associated with increased prevalence of PIP, but the specific conditions driving this increase remain unknown. Further work is necessary to investigate PIP related to the presence of common comorbidities in patients living with dementia.

Support of nursing homes in infection management varies by US State Departments of Health
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R. Dorritie, D. D. Quigley, M. Agarwal, A. Tark, A. Dick and P. W. Stone.
J Hosp Infect 2020 Jun;105(2):258-264
BACKGROUND: In many countries, healthcare-associated infections (HAIs) are problematic in long-term aged care living facilities. In the United States (US), HAIs occur frequently in nursing homes (NHs). Identifying effective practices for state Departments of Health (DOHs) to help NHs improve infection prevention and control and reduce HAIs is necessary. AIM: As a first step, the objective was to systematically examine and catalogue the variations in state intentions and activities related to HAI prevention in NHs. METHODS: An environmental scan of state DOH websites, HAI plans, and HAI state infographics was conducted. Data were collected on 16 items across three domains: (1) intentions to reduce HAIs in NHs, (2) actions to reduce HAIs in NHs, and (3) website usability. FINDINGS: State infection control support for NHs varied widely. Most states (92%) mentioned NHs in their HAI plans and 76% included NHs in their infographic. Half has an HAI prevention advisory council, while one-third had a state HAI prevention collaborative. Only 57% of HAI plans that mentioned NHs included training materials on HAI reduction. The most common training available was on antibiotic stewardship. CONCLUSION: Many US states have room for improvement in the support they provide NHs regarding infection prevention and control. Specific areas of improvement include: (1) increased provision of training materials on HAI reduction, (2) focusing training materials on common HAIs, and (3) NH engagement in collaboratives aimed at HAI reduction. More research is needed linking DOH activities to resident outcomes.

Predictors of Functional Decline in Nursing Home Residents: The Shelter Project
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M. Fedecostante, G. Onder, P. Eusebi, et al.
J Gerontol A Biol Sci Med Sci 2020 Jul 13;75(8):1600-1605
BACKGROUND: The aim of our study was to identify independent predictors of functional decline in older nursing home (NH) residents, taking into account both resident and facility characteristics. METHODS: Longitudinal observational study involving 1,760 older (≥65 y) residents of NH participating in the SHELTER* study (57 NH in eight countries). All residents underwent a comprehensive geriatric assessment using the interRAI LTCF. Functional decline was defined as an increase of at least one point in the MDS Long Form ADL scale during a 1 year follow-up. Facility and country effects were taken into account. RESULTS: During the study period 891 (50.6%), NH residents experienced ADL decline. Residents experiencing ADL decline were older, had lower disability at baseline, were more frequently affected by severe dementia and by urinary incontinence, and used more antipsychotics. In the mixed-effect logistic regression model, factors independently associated with a higher risk of functional decline were dementia and urinary incontinence, whereas the presence of a geriatrician was a protective factor. CONCLUSIONS: Both resident and facility characteristics are associated with the risk of functional decline in NH residents. Increasing the quality of healthcare by involving a geriatrician in residents’ care might be an important strategy to improve the outcome of this vulnerable population.

Attitudes towards deprescribing: The perspectives of geriatric patients and nursing home residents
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C. Lundby, P. Glans, T. Simonsen, et al.
J Am Geriatr Soc 2021 Feb 17
BACKGROUND/OBJECTIVES: Successful deprescribing requires insight into patients’ thoughts about deprescribing. We described attitudes towards deprescribing in a large sample of geriatric patients and nursing home residents. DESIGN: Interview-based questionnaire study. SETTING: Denmark. PARTICIPANTS: Geriatric inpatients (n = 44), geriatric outpatients (n = 94), and nursing home residents (n = 162) with an Orientation-Memory-Concentration score of ≥8. MEASUREMENTS: Participants completed the validated Danish version of the revised Patients’ Attitudes Towards Deprescribing (rPATD) questionnaire by interview. Attitudes were reported descriptively, and rPATD factor scores were compared between participant groups and across participant characteristics. RESULTS: Participants had a median age of 82 years (interquartile range [IQR] 76-89) and used a median of 8 medications (IQR 5-10). Thirty-three percent of participants would like to try stopping one of their medications on their own, while 87% were willing to stop one on their physician’s advice. Geriatric inpatients reported slightly greater perceived burden of taking medication compared to geriatric outpatients and nursing home residents (median “burden” score 50 vs 42, p = 0.11), while geriatric outpatients reported slightly more involvement in their medication use compared to nursing home residents (median “involvement” score 80 vs 75, p < 0.05) and geriatric inpatients (median “involvement” score 80 vs 70, p < 0.01). An increasing number of medications was associated with an increased “burden” score (p(trend) = 0.001): Those using 1-4 medications daily had a median score of 25 (IQR 17-33) compared to 58 (IQR 42-75) among those using ≥10 medications daily. Similarly, an increasing number of medications was associated with a higher “concerns about stopping” score (p(trend) = 0.001) and a lower “appropriateness” score (p(trend)  < 0.001), respectively. CONCLUSION: Geriatric patients and nursing home residents are generally open towards deprescribing, particularly if proposed by their physician. Some differences exist between populations and across individual patient characteristics. Clinicians should increase awareness of deprescribing as a possibility in these populations and tailor their deprescribing approach to the individual patient.

Effect of Instrumental Activities of Daily Living habituation due to routinising therapy in patients with frontotemporal dementia
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K. Nakanishi and T. Yamaga.
BMJ Case Rep 2021 Feb 4;14(2):e240167. doi: 10.1136/bcr-2020-240167
We examined whether Instrumental Activities of Daily Living (IADL) improves with routinising therapy for a patient with frontotemporal dementia (FTD) living in a group home. The patient exhibited symptoms of agitation, apathy, disinhibition, irritability and stereotyped behaviour. The care staff experienced long-term care burden and the patient was spending time idly. An occupational therapist, in collaboration with care staff, evaluated the patient and routinised the household chores included in IADL. Consequently, a routine of household chores was established, reducing behavioural and psychological symptoms of dementia and long-term care burden, and the quality of life (QOL) of the patient improved. The results suggested that routinising IADL of the patient with FTD reduced long-term care burden and improved QOL of the patient.

Hypoglycemia in Older People With Type 2 Diabetes: Prevention and Treatment Strategies for Outpatient and Long-Term Care Facility Settings
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J. V. Nguyen, S. Roseberry, J. A. Rivas and K. A. B. Cauthon.
Sr Care Pharm 2021 Feb 1;36(2):112-121
Hypoglycemia in the older population is a significant problem accounting for increased hospitalizations, emergency room visits, health care costs, and decreased quality of life. Older patients are more susceptible to hypoglycemia because of the increased prevalence of comorbidities requiring multiple medications, age-related physiologic changes, and a progressive decline in health. Older patients are less likely to present with symptoms of hypoglycemia and symptoms may frequently appear at a lower threshold of blood glucose than in younger patients. Consequently, preventing and treating hyperglycemia in older patients can be challenging. If mismanaged, the impact of hypoglycemia in these patients can lead to acute and chronic negative outcomes. Insulin and sulfonylureas should be closely monitored, and deprescribing should be routinely considered in older patients at high risk for hypoglycemia.

International comparison of pressure ulcer measures in long-term care facilities: Assessing the methodological robustness of 4 approaches to point prevalence measurement
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M. Poldrugovac, M. Padget, L. Schoonhoven, N. D. Thompson, N. S. Klazinga and D. S. Kringos.
J Tissue Viability 2021 Jan 24
INTRODUCTION: Pressure ulcer indicators are among the most frequently used performance measures in long-term care settings. However, measurement systems vary and there is limited knowledge about the international comparability of different measurement systems. The aim of this analysis was to identify possible avenues for international comparisons of data on pressure ulcer prevalence among residents of long-term care facilities. MATERIAL AND METHODS: A descriptive analysis of the four point prevalence measurement systems programs used in 28 countries on three continents was performed. The criteria for the description and analysis were based on the scientific literature on criteria for indicator selection, on issues in international comparisons of data and on specific challenges of pressure ulcer measurements. RESULTS: The four measurement systems use a prevalence measure based on very similar numerator and denominator definitions. All four measurement systems also collect data on patient mobility. They differ in the pressure ulcer classifications used and the requirements for a head-to-toe resident examination. The regional or country representativeness of long-term care facilities also varies among the four measurement systems. CONCLUSIONS: Methodological differences among the point prevalence measurement systems are an important barrier to reliable comparisons of pressure ulcer prevalence data. The alignment of the methodologies may be improved by implementing changes to the study protocols, such as aligning the classification of pressure ulcers and requirements for a head-to-toe resident skin assessment. The effort required for each change varies. All these elements need to be considered by any initiative to facilitate international comparison and learning.