Collection of articles on Aging is available here.

Evaluation of the Psychometric Properties of PainChek® in UK Aged Care Residents with advanced dementia
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Babicova I, Cross A, Forman D, Hughes J, Hoti K.
BMC Geriatr 2021 May 28;21(1):337-021-02280-0.
BACKGROUND: The aim of this study was to further validate PainChek®, an electronic pain assessment instrument, with a population living with dementia in a UK care home. METHOD: This study utilised a correlational design to evaluate the psychometric properties of PainChek® when compared to the Abbey Pain Scale (APS). Blinded paired pain assessments were completed at rest and immediately post-movement by a researcher and a nurse. A total of 22 participants with a diagnosis of moderate-to-severe dementia and a painful condition were recruited using opportunity sampling. RESULTS: Overall, 302 paired assessments were collected for 22 participants. Out of these 179 were conducted during rest and 123 were immediately post-movement. The results demonstrated a positive significant correlation between overall PainChek® pain scores and overall APS pain scores (r = 0.818, N = 302, p < .001, one-tailed), satisfactory internal consistency (α = 0.810), moderate single measure intraclass correlation (ICC = 0.680) and substantial inter-rater agreement (κ = 0.719). CONCLUSIONS: PainChek® has demonstrated to be a valid and reliable instrument to assess the presence and severity of pain in people with moderate-to-severe dementia living in aged care.


Estimated Cardiorespiratory Hospitalizations Attributable to Influenza and Respiratory Syncytial Virus Among Long-term Care Facility Residents
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Bosco E, van Aalst R, McConeghy KW, Silva J, Moyo P, Eliot MN, et al.
JAMA Netw Open 2021 Jun 1;4(6):e2111806.
IMPORTANCE: Older adults residing in long-term care facilities (LTCFs) are at a high risk of being infected with respiratory viruses, such as influenza and respiratory syncytial virus (RSV). Although these infections commonly have many cardiorespiratory sequelae, the national burden of influenza- and RSV-attributable cardiorespiratory events remains unknown for the multimorbid and vulnerable LTCF population. OBJECTIVE: To estimate the incidence of cardiorespiratory hospitalizations that were attributable to influenza and RSV among LTCF residents and to quantify the economic burden of these hospitalizations on the US health care system by estimating their associated cost and length of stay. DESIGN, SETTING, AND PARTICIPANTS: This retrospective cohort study used national Medicare Provider Analysis and Review inpatient claims and Minimum Data Set clinical assessments for 6 respiratory seasons (2011-2017). Long-stay residents of LTCFs were identified as those living in the facility for at least 100 days (index date), aged 65 years or older, and with 6 months of continuous enrollment in Medicare Part A were included. Follow-up occurred from the resident’s index date until the first hospitalization, discharge from the LTCF, disenrollment from Medicare, death, or the end of the study. Residents could re-enter the sample; thus, long-stay episodes of care were identified. Data analysis was performed between January 1 and September 30, 2020. EXPOSURES: Seasonal circulating pandemic 2009 influenza A(H1N1), human influenza A(H3N2), influenza B, and RSV. MAIN OUTCOMES AND MEASURES: Cardiorespiratory hospitalizations (eg, asthma exacerbation, heart failure) were identified using primary diagnosis codes. Influenza- and RSV-attributable cardiorespiratory events were estimated using a negative binomial regression model adjusted for weekly circulating influenza and RSV testing data. Length of stay and costs of influenza- and RSV-attributable events were then estimated. RESULTS: The study population comprised 2 909 106 LTCF residents with 3 138 962 long-stay episodes and 5 079 872 person-years of follow-up. Overall, 10 939 (95% CI, 9413-12 464) influenza- and RSV-attributable cardiorespiratory events occurred, with an incidence of 215 (95% CI, 185-245) events per 100 000 person-years. The cost of influenza- and RSV-attributable cardiorespiratory events was $91 055 393 (95% CI, $77 885 316-$104 225 470), and the length of stay was 56 858 (95% CI, 48 757-64 968) days. CONCLUSIONS AND RELEVANCE: This study found that many cardiorespiratory hospitalizations among LTCF residents in the US were attributable to seasonal influenza and RSV. To minimize the burden these events place on the health care system and residents of LTCFs and to prevent virus transmission, additional preventive measures should be implemented.

Hearing and vision health for people with dementia in residential long term care: Knowledge, attitudes and practice in England, South Korea, India, Greece, Indonesia and Australia
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Dawes P, Leroi I, Chauhan N, Han W, Harbishettar V, Jayakody DMP, et al.
Int J Geriatr Psychiatry 2021 Apr 30.
OBJECTIVES: Up to 90% of people with dementia in long term care (LTC) have hearing and/or vision impairment. Hearing/vision difficulties are frequently under-recognised or incompletely managed. The impacts of hearing/vision impairment include more rapid cognitive decline, behavioural disturbances, reduced quality of life, and greater care burden. This research investigated LTC staff knowledge, attitudes and practice regarding hearing/vision care needs for residents with dementia. METHODS: A survey of staff in LTC facilities in England, South Korea, India, Greece, Indonesia and Australia. Respondents used a five-point scale to indicate agreement or YES/NO response to questions regarding sensory-cognitive care knowledge (what is known); attitudes (what is thought); practice (what is done). RESULTS: Respondents reported high awareness of hearing/vision care needs, although awareness of how to identify hearing/vison difficulties or refer for assessment was low. Most felt that residents were not able to use hearing/vision devices effectively due to poor fit, being poorly tolerated or lost or broken devices. A substantial minority of respondents reported low confidence in supporting use of assistive hearing/vision devices, with lack of training the main reason. Most staff did not undertake routine checking of hearing/vision devices, and it was rare for facilities to have designated staff responsible for sensory needs. Variation among countries was not significant after accounting for staff experience and having received dementia training. CONCLUSIONS: There is a need to improve sensory support for people with dementia in LTC facilities internationally. Practice guidelines and training to enhance sensory-cognitive knowledge, attitudes and practice in professional care teams is called for.

Dementia Enlightened?! A Systematic Literature Review of the Influence of Indoor Environmental Light on the Health of Older Persons with Dementia in Long-Term Care Facilities
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Goudriaan I, van Boekel LC, Verbiest MEA, van Hoof J, Luijkx KG.
Clin Interv Aging 2021 May 24;16:909-937.
Light therapy for older persons with dementia is often administered with light boxes, even though indoor ambient light may more comfortably support the diverse lighting needs of this population. Our objective is to investigate the influence of indoor daylight and lighting on the health of older adults with dementia living in long-term care facilities. A systematic literature search was performed within PubMed, CINAHL, PsycINFO, Web of Science and Scopus databases. The included articles (n=37) were published from 1991 to 2020. These articles researched the influence of existing and changed indoor light conditions on health and resulted in seven categories of health outcomes. Although no conclusive evidence was found to support the ability of indoor light to decrease challenging behaviors or improve circadian rhythms, findings of two studies indicate that exposure to (very) cool light of moderate intensity diminished agitation. Promising effects of indoor light were to reduce depressive symptoms and facilitate spatial orientation. Furthermore, there were indications that indoor light improved one’s quality of life. Despite interventions with dynamic lighting having yielded little evidence of its efficacy, its potential has been insufficiently researched among this study population. This review provides a clear and comprehensive description of the impact of diverse indoor light conditions on the health of older adults with dementia living in long-term care facilities. Variation was seen in terms of research methods, (the description of) light conditions, and participants’ characteristics (types and severity of dementia), thus confounding the reliability of the findings. The authors recommend further research to corroborate the beneficial effects of indoor light on depression and to clarify its role in supporting everyday activities of this population. An implication for practice in long-term care facilities is raising the awareness of the increased lighting needs of aged residents.

Specialist residential dementia care for people with severe and persistent behaviours: A ten-year retrospective review
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Gresham M, Morris T, Min Chao S, Lorang C, Cunningham C.
Australas J Ageing 2021 May 27.
Very severe behavioural and psychological symptoms of dementia (BPSD) have low prevalence but disproportionately poor outcomes for persons with dementia, others and systems of care, including inappropriate use of medication, tenuous accommodation, poor quality of life and increased costs. The Australian Government has established new Special Dementia Care Programmes (SDCPs) to provide interim care for up to 12 months for those with severe and persistent BPSD unsuitable for mainstream aged care. This 10-year retrospective review describes environmental design, governance, clinical processes, characteristics and outcomes for 80 residents of a similar-aged care mental health partnership SDCP. A key finding was that average length of stay was slightly over 12 months. All surviving residents except one were able to be transferred to mainstream aged care services. Doses of regular and PRN antipsychotic and anxiolytic medications were significantly reduced. SDCPs may have the potential to improve care and outcomes for this group of vulnerable older people.

Managing Pain and Psychosis Symptoms in Nursing Home Patients: Results From a Cluster-Randomized Controlled Trial (COSMOS)
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Habiger TF, Achterberg WP, Flo-Groeneboom E, Mannseth J, Husebo BS.
J Am Med Dir Assoc 2021 Jun 1.
OBJECTIVES: In nursing homes (NHs), 30% to 60% of patients experience daily pain and >80% have dementia. This can lead to neuropsychiatric symptoms, including psychosis symptoms such as delusion. We investigated if there was a relationship between pain and psychosis symptoms over time. We also aimed to investigate the effect of a multicomponent intervention (COSMOS) on pain, psychosis symptoms, and analgesic prescription. DESIGN: COSMOS is a cluster-randomized, single blinded, controlled trial. Each NH unit was defined as a cluster and randomized to either the COSMOS intervention or care as usual. The COSMOS intervention is a multicomponent intervention, consisting of staff training in communication, pain treatment, medication review, organization of activities, and safety. The intervention lasted for 4 months with a follow-up at month 9. SETTING AND PARTICIPANTS: Sixty-seven units from 33 Norwegian NHs in 8 municipalities. The study included 723 patients aged ≥65 years, residing at the NH ≥2 weeks before inclusion. Patients with a life expectancy <6 months were excluded. MEASURES: Pain was measured using the Mobilization-Observation-Behavior-Intensity-Dementia Pain Scale. Psychosis symptoms were measured using the Neuropsychiatric Inventory-NH version. Measurements were performed at baseline, and months 4 and 9. RESULTS: Multilevel Mixed-Effect statistical analysis found that psychosis symptoms as a group (odds ratio [OR] 2.03, P = .009), and delusion (OR 2.12, P = .007) were associated with pain over time. No significant intervention effect on psychosis symptoms was observed. Compared with the control group, people with dementia in the intervention group experienced less musculoskeletal pain (β: -0.47, P = .047). Analgesic prescription was not affected by the intervention. CONCLUSION AND IMPLICATIONS: Pain is associated with psychosis symptoms, and pain assessment should be done when making treatment decisions on psychosis symptoms in NH patients. The COSMOS intervention improved musculoskeletal pain in people with dementia, but not psychosis symptoms, and there is need for further studies on treatment of psychosis symptoms in NH patients.

Urinary Incontinence Is Associated With Increased All-Cause Mortality in Older Nursing Home Residents: A Meta-Analysis
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Huang P, Luo K, Wang C, Guo D, Wang S, Jiang Y, et al.
J Nurs Scholarsh 2021 May 22.
PURPOSE: Urinary incontinence is a syndrome common in older adults, but it is not clear whether urinary incontinence is associated with the risk for mortality in elderly nursing home residents. METHODS: We conducted a systematic review and meta-analysis in PubMed, Cochrane, Embase, the Cumulative Index to Nursing and Allied Health Literature (CINAHL), and Web of Science databases. The Newcastle-Ottawa Scale (NOS) was used to assess the quality of the included studies. The meta-analysis was summarized using a random-effects or fixed-effects model, and the heterogeneity among studies was examined using the I2 statistic. FINDINGS: Six cohort studies with 1,656 participants were included in the final analysis. The NOS score for each study was greater than 6. Urinary incontinence was significantly associated with a higher risk for mortality in nursing homes, with a hazard ratio (HR) of 1.20 (95% confidence interval [CI] 1.12-1.28, I(2) = 41.6%). The significant association of urinary incontinence with increased mortality risk was observed in subgroup analysis according to region, status of dementia, and follow-up period, with a pooled HR of 2.02 (95% CI 1.32-3.11, I(2) = 0%) for Asian countries, 1.18 (95% CI 1.11-1.26, I(2) = 41.6%) for Western countries, 1.17 (95% CI 1.09-1.26, I(2) = 0%) for patients with dementia, 1.35 (95% CI 1.13-1.60, I(2) = 58.9%) for patients without dementia, 1.16 (95% CI 1.07-1.25, I(2) = 43.2%) for studies with a follow-up period of 1 year, and 1.30 (95% CI 1.15-1.48, I(2) = 24.5%) for studies with a follow-up period of more than 1 year. CONCLUSIONS: Urinary incontinence is associated with an increased risk for death among residents of care facilities. Therefore, it was necessary to screen the elderly dwelling in nursing homes who were experiencing or at risk for urinary incontinence with useful tools (e.g., overactive bladder symptom score, bladder control self-assessment questionnaire, three incontinence questions). In addition, early interventions strategies, such as weight loss, stopping smoking, pelvic floor muscle training, and medical and surgical treatments would contribute to decreasing the risk for urinary incontinence and preventing adverse outcomes in nursing home residents. CLINICAL RELEVANCE: In our study, we found that the elderly with urinary incontinence who resided in nursing homes had a higher risk for mortality than those without urinary incontinence. Therefore, urinary incontinence in the elderly residing in nursing homes is of particular concern. Early detection and intervention are important for the elderly with urinary incontinence, and caregivers should be made aware of this importance.

Uncontrolled Pain and Risk for Depression and Behavioral Symptoms in Residents With Dementia
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Jenny Wei Y, Chen C, Fillingim RB, DeKosky ST, Schmidt S, Pahor M, et al.
Journal of the American Medical Directors Association 2021/06.
ObjectivesLimited cohort studies have assessed the association between uncontrolled pain and risk for behavioral and psychological symptoms of dementia (BPSDs). We conducted a longitudinal cohort study to examine whether associations exist between uncontrolled pain and risk for 2 common BPSDs?depression and behavioral symptoms?among long-term care (LTC) residents with Alzheimer disease and related dementia (ADRD).; ObjectivesLimited cohort studies have assessed the association between uncontrolled pain and risk for behavioral and psychological symptoms of dementia (BPSDs). We conducted a longitudinal cohort study to examine whether associations exist between uncontrolled pain and risk for 2 common BPSDs?depression and behavioral symptoms?among long-term care (LTC) residents with Alzheimer disease and related dementia (ADRD).

Effect of progressive muscle relaxation on adaptation to old age and quality of life among older people in a nursing home: a randomized controlled trial
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Kütmeç Yilmaz C.
Psychogeriatrics 2021 May 6.
BACKGROUND: Changes occurring in the aging process, the presence of decline in physical and cognitive functions, and the limitations of participation in activities affect adaptation to old age and the quality of life. This study aimed to examine the effect of progressive muscle relaxation (PMR) exercises on adaptation to old age and the quality of life of older people. METHODS: A randomized controlled trial design was used. The sample consisted of 45 older residents (21 intervention subjects, 24 controls) from a nursing home in a city of Turkey. The intervention group received progressive muscle-relaxation sessions twice weekly for 8 weeks, while the control group received routine care. All PMR exercises were led by the researcher. All participants were evaluated at baseline and after 8 weeks using the Assessment Scale of Adaptation Difficulty for the Elderly and the Nottingham Health Profile. RESULTS: As a result of PMR exercises performed for 8 weeks, the Assessment Scale of Adaptation Difficulty for the Elderly and Nottingham Health Profile total mean scores of the intervention group improved significantly (P  0.05). CONCLUSION: The results of this study indicate that progressive muscle relaxation can increase adaptation to old age and the quality of life and of older people in a nursing home.

Impacts of multi-morbidity, hemoglobin levels, and frailty on functional disability of older adult residents of long-term care facilities: A structural equation analysis
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Liu LH, Kao CC, Wang RH, Liu YH.
Geriatr Gerontol Int 2021 Jun;21(6):532-537.
AIM: Previous studies have focused on the relationship between multi-morbidity, frailty, and anemia or functional disability alone rather than in combination. This study aimed to explore the impacts of multi-morbidity, hemoglobin levels, and frailty on functional disability simultaneously in older adult residents of long-term care facilities. METHODS: This was a cross-sectional study. Data were retrieved from the electronic health records of eight long-term care facilities. Data from a total of 352 subjects aged at least 60 years and residing in these facilities for at least 6 months were analysed. Analytic datasets included the Barthel Index of Activities of Daily Living, the Frailty Phenotype Criteria, the number of chronic diseases, hemoglobin levels, age, and gender. RESULTS: The final model demonstrated acceptable goodness-of-fit indices, namely goodness-of-fit index, comparative fit index, and incremental fit index ≧0.90, root mean square error of approximation  0.05). Frailty, multi-morbidity, and hemoglobin levels all had direct associations with functional disability (all P < 0.001). Hemoglobin levels had a direct association with frailty (ß = -0.11). Multi-morbidity had an indirect association (ß = 0.04) with functional disability through hemoglobin levels. Hemoglobin levels had an indirect association (ß = 0.05) with functional disability through frailty. CONCLUSIONS: The impacts of multi-morbidity, hemoglobin levels, and frailty on functional disability were explored. A high-quality disease management program, interventions for the prevention of frailty, and the provision of continued education for staff about reducing progressive frailty and functional disability for older adult residents are recommended. Geriatr Gerontol Int 2021; 21: 532-537.

Effectiveness of intergenerational participation on residents with dementia: A systematic review and meta-analysis
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Lu LC, Lan SH, Hsieh YP, Lan SJ.
Nurs Open 2021 May 22.
AIM: This meta-analysis evaluated the effectiveness of intergenerational program participation for long-term care institution residents with dementia. DESIGN: A systematic review and meta-analysis. METHODS: Ten electronic databases were systematically searched until August 2020: CINAHL, the Cochrane Library, EBSCO, EMBASE, Ovid Medline, ProQuest, Psychology and Behavioral Sciences Collection, PubMed, Scopus, and Web of Science. The Joanna Briggs Institute tool (JBI tool) was used for the quality appraisal of the included publications, and Review Manager 5.3 was used for the meta-analysis. RESULTS: Thirteen articles were identified (1993-2015). Intergenerational program participation could improve the pleasure level and significantly reduce disengagement behaviours of residents with dementia. The intergenerational program intervention caused no apparent improvement in their quality of life, depression levels, and engagement levels.

Interventions for Nursing Home Residents with Dysphagia-A Scoping Review
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Melgaard D, Westergren A, Skrubbeltrang C, Smithard D.
Geriatrics (Basel) 2021 May 21;6(2):55. doi: 10.3390/geriatrics6020055.
Oropharyngeal dysphagia is common in nursing home residents. The objective of this scoping review was to summarize and disseminate the findings from the literature on interventions for dysphagia in nursing home residents. Searches were conducted in four databases. The criteria for including the studies were nursing home residents, dysphagia, interventions, original research, published in English, Danish, Norwegian, or Swedish with no restriction placed regarding publication date. Excluded were literature reviews, editorial comments, conference abstracts, protocols, papers not available in full text, and studies with a mixed population, for example, geriatric patients and nursing home residents and where the results were not separated between the groups. A total of 14 papers were included and analyzed. The included papers represented interventions focusing on feeding intervention, oral hygiene, caregiver algorithm, stimulation (taste and smell), teaching the residents what to eat, mobilization of the spine, exercises/training, and positioning. This scoping review identifies sparse knowledge about interventions affecting nursing home residents’ dysphagia. But the results indicate that multi-component interventions, including staff training, training of residents, and/or next of kin, might be successful. This scoping review clarifies that there is a need for well-designed studies that uncover which specific interventions have an effect in relation to nursing home residents with dysphagia and can serve as a guide for designing multi-component person-centered intervention studies. Future studies should implement high evidence study designs, define the measures of dysphagia, and quantify the severity of dysphagia, its underlying diseases, and comorbidities.

Sex Differences in Behavioral and Psychological Signs and Symptoms of Dementia Presentation Regarding Nursing Home Residents with Cognitive Impairment Suffering from Pain – Results of the Services and Health for Elderly in Long-Term Care Study
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Mühler C, Mayer B, Bernabei R, Onder G, Lukas A, Services and Health for Elderly in Long-Term Care (SHELTER) Study Investigators.
J Am Med Dir Assoc 2021 May 3.
OBJECTIVE: Behavioral and psychological symptoms of dementia (BPSD) place a heavy burden on patients as well as caregivers. Recently, pain was identified as an important determinant of BPSD. However, it is not yet known what influence sex has on BPSD and pain. Thus, the present study aimed to identify possible associations between BPSD, pain, and sex. DESIGN: A retrospective evaluation of cross-sectional data derived from the Services and Health for Elderly in Long-Term Care (SHELTER) Study database, a cross-national European study on nursing home residents. SETTING AND PARTICIPANTS: The study involved 4156 residents who were assessed using the interRAI instrument for Long-Term Care Facilities. Included in the analysis were only patients with cognitive impairment (n = 2822) (67.9%) of which 712 (25.2%) were male and 2110 (74.8%) were female. METHODS: Differences in prevalence were tested using the χ(2) test while bivariate logistic regression models were used to evaluate factors associated with sex. RESULTS: Men showed behavioral symptoms such as wandering, verbal and physical abuse as well as sexual uninhibited behavior significantly more often than women. Regarding psychiatric symptoms, only depression was significantly more frequent in women. Surprisingly, in the presence of pain these differences in BPSD incidence between men and women were no longer detectable. Logistic regression analysis showed that in women with dementia/communication problems, the presence of pain could be indicated by resistance to care, sleeping disorders, and possibly by the presence of delusions and anxiety whereas in men it was related to abnormal thought processes, and in both sexes to depression CONCLUSIONS AND IMPLICATIONS: From a clinical point of view, resistance to care and sleeping disorders in women and abnormal thought processes in men as well as depression in both sexes should be seen as indicators of possible underlying pain in noncommunicative people. Thus, knowledge of sex-specific BPSD presentations can improve pain management in this particularly patient group.

The guidelines and policies that influence the conduct of Animal-Assisted Activities in Residential Aged-Care Facilities: A systematic integrative review
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Newton W, Signal T, Judd J.
Complement Ther Clin Pract 2021 May 3;44:101395.
INTRODUCTION: For some time, Residential Aged Care Facilities (RACF) have incorporated animals into their environment to relieve loneliness and isolation for aged-care residents. However, research examining this practice is not as developed. This paper aims to identify the policies and practices influencing the conduct of Animal-Assisted Activities (AAA) in RACF focusing on the Australian context. METHODS: Peer-reviewed and gray literature were searched using an array of databases including CINAHL; Embase; Medline; Pubmed; Scopus and Web of Science; Google Scholar; PROSPERO, Proquest Dissertations; Theses Global; Animal Studies Repository; Medicine and Health Science Commons; Open Gray and a targeted Google search for relevant Australian Guidelines. Database searches had no time limits. Nine documents published between 1990 and 2018 were identified, appraised and subsequently included in the analysis. RESULTS: Facilities have not developed or implemented core policies; instead, there appears to be a reliance on AAA providers ensuring resident safety. Animal welfare is also identified as an emerging area, warranting further action and policy development. CONCLUSION: The requirement for effective AAA policies for RACF staff continues to be an area of need. Over the last 30 years, the development of policies guiding the provision of animal activities within RACFs has been inconsistent in both content and application, including the implementation of basic hygiene policies. If the international situation is indicative, further work is needed in Australia to develop and enforce infection control, risk management and animal welfare policies in RACF and AAA organizations. SYSTEMATIC REVIEW REGISTRATION: PROSPERO registration # CRD42020150440.

Potential Overtreatment and Undertreatment of Type 2 Diabetes Mellitus in Long-Term Care Facilities: A Systematic Review
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Stasinopoulos J, Wood SJ, Bell JS, Manski-Nankervis JA, Hogan M, Sluggett JK.
J Am Med Dir Assoc 2021 May 15.
OBJECTIVE: To investigate the prevalence, outcomes, and factors associated with potential glycemic overtreatment and undertreatment of type 2 diabetes mellitus (T2DM) in long-term care facilities (LTCFs). DESIGN: Systematic review. SETTING AND PARTICIPANTS: Residents with T2DM and aged ≥60 years living in LTCFs. MEASURES: Articles published between January 2000 and September 2020 were retrieved following a systematic search of MEDLINE, EMBASE, Cochrane Library, CINAHL plus, and gray literature. Inclusion criteria were the reporting of (1) potential overtreatment and undertreatment quantitatively defined (implicitly or explicitly) based on hemoglobin A1c (HbA1c) and/or blood glucose; (2) prevalence, outcomes, and associated factors of potential glycemic overtreatment and undertreatment; and (3) the study involved residents of LTCFs. RESULTS: Fifteen studies were included. Prevalence of potential overtreatment (5%-86%, n = 15 studies) and undertreatment (1.4%-35%, n = 8 studies) varied widely among facilities and geographical locations, and according to definitions used. Prevalence of potential overtreatment was 16%-74% when defined as treatment with a glucose-lowering medication in a resident with ≥1 hypoglycemia risk factor or serious comorbidity, together with a HbA1c 8.5% and the prevalence 1.4%-14.8% (n = 6 studies). No studies prospectively measured resident health outcomes from overtreatment and undertreatment. Potential overtreatment was positively associated with use of oral glucose-lowering medications, dementia diagnosis or dementia severity, and/or need for assistance with activities of daily living (n = 2 studies). Negative association was found between potential overtreatment and use of insulin/combined insulin and oral glucose-lowering medication. No studies reported factors associated with potential undertreatment. CONCLUSIONS AND IMPLICATIONS: The prevalence of potential glycemic overtreatment and undertreatment varied widely among residents with T2DM depending on the definition(s) used in each study. Longitudinal studies examining associations between glycemic management and health outcomes, and the use of consensus definitions of overtreatment and undertreatment are required to establish findings about actual glycemic overtreatment and undertreatment in LTCFs.

Higher Resource Utilization and Costs in Long-Term Nursing Home Residents With Overactive Bladder: A Retrospective Study of Medicare Beneficiaries
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Sura S, Shiozawa A, Ng D, Aparasu RR.
J Am Med Dir Assoc 2021 Jun;22(6):1300-1306.
OBJECTIVES: To determine the all-cause health care resource utilization and costs among long-term nursing home (LTNH) residents with and without overactive bladder (OAB). DESIGN: Retrospective cohort study. SETTING AND PARTICIPANTS: Minimum Data Set (MDS)-linked Medicare Part A, B, and D claims data from 2013 to 2015 were analyzed. LTNH residents aged 65 years or older with a diagnosis of OAB (n = 216,731) were propensity score matched with LTNH residents without OAB (n = 300,327) (non-OAB cohort). METHODS: We measured health care resource utilization and costs associated with OAB by setting (inpatient, outpatient, emergency department, or prescription) during the 6 months following nursing home admission. Descriptive and multivariate (negative binomial for health care resource utilization and 2-part model for costs) analyses were performed to examine the health care resource utilization and costs among LTNH residents with and without OAB. The annual cost attributed to OAB was calculated as the difference between total annual OAB costs and total annual non-OAB costs. RESULTS: A total of 214,505 patients were included in each matched cohort. Across all health care resource categories, LTNH residents with OAB had higher health care resource utilization and costs compared to the non-OAB cohort (all P < .001). The mean annual direct total cost was $57,984 in the OAB cohort compared with $54,285 in the non-OAB cohort. The annual cost of OAB in nursing homes was estimated at $793 million. Adjusted analyses revealed that the OAB cohort was 9% more likely to have hospitalization and emergency department visits, 15% more likely to have outpatient visits, 27% more likely to have physician visits, and 12% more likely to have prescription counts compared with the non-OAB cohort. CONCLUSIONS AND IMPLICATIONS: The study findings suggest that LTNH residents with OAB have significantly more health care resource utilization compared with patients without OAB. These results provide health care decision makers with recent estimates of the burden of OAB in LTNH to assist them with resource planning.

The dignity of older individuals with Alzheimer’s disease and related dementias: A scoping review
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Torossian MR.
Dementia (London) 2021 May 27:14713012211021722.
BACKGROUND: Supporting human dignity is the essence of delivery of care. Dignity is one’s sense of self-value that is influenced by the perceived value attributed to the individual from others. Individuals with Alzheimer’s disease and related dementias (ADRD) are at risk of violations of their dignity, due to their diminished autonomy, the alteration in their sense of self, the loss of meaningful social roles, and their limited interactions with peers and confirmation of identity. OBJECTIVES: A scoping review was conducted to explore the state of art regarding the dignity of individuals with ADRD. Methods: A search was conducted using CINAHL, PubMed, Web of Science, and PsycINFO. Relevant articles were analyzed and organized based on the themes they addressed, and a narrative description of findings was presented. RESULTS: Twenty-six articles were included in the review. Findings highlighted characteristics of care that affected the dignity of these individuals. Researchers found that care was task-centered, depersonalized, and lacked a genuine connection. Individuals with ADRD experienced embarrassment, lack of freedom, and powerlessness, which contributed to feelings of being devalued, and threatened their dignity. Studies testing interventions to enhance dignity were either inconclusive, lacked rigor, or had no lasting effect. Conclusion: The dignity of individuals with ADRD may be violated during healthcare interactions. More research is needed to objectively measure the dignity of these individuals and examine the effectiveness of interventions aimed at promoting dignity.

An examination of three prescribing cascades in a cohort of older adults with dementia
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Trenaman SC, Bowles SK, Kirkland S, Andrew MK.
BMC Geriatr 2021 May 8;21(1):297-021-02246-2.
BACKGROUND: Prescribing cascades are a source of inappropriate prescribing for older adults with dementia. We aimed to study three prescribing cascades in older Nova Scotians with dementia using administrative databases. METHODS: Cohort entry for Nova Scotia Seniors’ Pharmacare Program beneficiaries was the date of dementia diagnosis. Prescription drug dispensing data was extracted for inciting medication and second treatment (cholinesterase inhibitor and bladder anticholinergic, metoclopramide and Parkinson’s disease medication, or calcium channel blocker (CCB) and diuretic) over the six-year period April 1, 2009 to March 31, 2015. In three separate analyses, dispensing an inciting medication signaled a look back of 365 days from the date of first dispensing to confirm that the second treatment was started after the inciting medication. The prescribing cascade was considered when the second treatment was started within 180 days of the inciting treatment. Sex differences in the prescribing cascade were tested using t-tests or chi square tests as appropriate. Both univariate (unadjusted) and multivariate (adjusted) logistic regression (adjusted for age, rurality, and sex) and Cox proportional hazards regression was used to identify risk factors for the prescribing cascade. RESULTS: From March 1, 2005 to March 31, 2015, 28,953 Nova Scotia Seniors’ Pharmacare beneficiaries with dementia (NSSPBD) were identified. There were 60 cases of bladder anticholinergics following cholinesterase inhibitors, 11 cases of Parkinson’s disease medication following metoclopramide, and 289 cases of a diuretic following CCB in the cohort. Regression analysis demonstrated that risk of bladder anticholinergics following cholinesterase inhibitors and diuretics following CCBs were associated with female sex. Cox regression suggested that bladder anticholinergics were less often used by those on cholinesterase inhibitors and did not identify CCB use as leading more frequently to diuretic use. CONCLUSIONS: The combination of diuretics following CCB was the most common prescribing cascade and bladder anticholinergics following cholinesterase inhibitors the second most common. However, exposure to the inciting medications did not increase risk of exposure to the second treatments. Combinations of bladder anticholinergics following cholinesterase inhibitors and diuretics following CCBs were more common for women raising concern that women may be at increased risk of these prescribing cascades.

How PARO can help older people in elderly care facilities: A systematic review of RCT
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Wang X, Shen J, Chen Q.
Int J Nurs Knowl 2021 May 7.
PURPOSE: This review aims to systematically evaluate the effects of Paro on older adults and provide a stronger basis for the rational application of Paro in aged care facilities. METHODS: Articles published between January 2003 and January 2020 via five databases (PubMed, Web of Science, EMBASE, Cochrane Library, Cumulative Index to Nursing and Allied Health Literature (CINAHL), and Chinese database SinoMed) were searched. The Cochrane collaboration tool for randomized controlled trials was used to assess the quality of all included studies. RESULTS: Nine articles were included in this systematic review. All articles were summarized according to three themes: quality of life, and biopsychological conditions, and drug usage. CONCLUSIONS: The review demonstrated that interaction with Paro can be beneficial for improving quality of life (QOL), biopsychological conditions, and reducing psychotropic and pain medical usage. Since the differences of the study design and low to moderate quality of these studies, however, we should be cautious to make positive comments on the role of Paro. IMPLICATIONS OF NURSING PRACTICE: The implications of Paro in aged care facilities have positive effects on nursing outcomes. This review helps caregivers understand the advantages and disadvantages of care robots, and promotes the integration of intelligent technology and manual services in nursing practice.

Next of kin participation in the care of older persons in nursing homes: A pre-post non-randomised educational evaluation, using within-group and individual person-level comparisons
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Westergren A, Ahlström G, Persson M, Behm L.
PLoS One 2021 Jan 25;16(1):e0244600.
BACKGROUND: Next of kin participation in care is a cornerstone of palliative care and is thus important in nursing homes, and outcomes following interventions need to be evaluated using robust methods. OBJECTIVE: To use within-group and within-individual analytical approaches to evaluate the participation of next of kin in care following an intervention and to compare the outcome between the intervention and control groups. METHODS: A pre-post intervention/control group study design was used. The educational intervention, directed towards staff members, focused on palliative care. The Next of Kin Participation in Care scale comprises the Communication and Trust subscale and the Collaboration in Care subscale, with nine items each. In total, 203 persons (intervention group: n = 95; control group: n = 108) were included. Three different analytical approaches were used: 1) traditional within-group comparison of raw ordinal scores and linearly transformed interval scores; 2) modern within-individual (person-level) interval score comparisons; 3) comparisons between the intervention group and control group based on individual person-level outcomes. RESULTS: Within-group comparisons of change revealed no change in any of the groups, whether based on raw or transformed scores. Despite this, significant improvements at the individual level were found in 32.9% of the intervention group and 11.6% of the control group for the total scale (p = 0.0024), in 25% of the intervention group and 10.5% of the control group for the Communication and Trust subscale (p = 0.0018), and in 31.2% of the intervention group and 10.5% of the control group for the Collaboration in Care subscale (p = 0.0016). However, a significant worsening at the individual level in Collaboration in Care was found in 35.1% of the intervention group but only among 8.4% of the control group (p < 0.0005). CONCLUSION: The intervention seems to have a positive impact on next of kin participation in care in nursing homes, especially for communication and trust. However, some next of kin reported decreased participation in care after the intervention. Modern individual person-level approaches for the analysis of intervention outcomes revealed individual significant changes beyond traditional group-level comparisons that would otherwise be hidden. The findings are relevant for future outcome studies and may also necessitate a re-evaluation of previous studies that have not used individual person-level comparisons. TRIAL REGISTRATION: This study is part of the intervention project registered under Clinical Trials Registration NCT02708498.

How Do Changes in Oral Health and Chewing Efficiency Affect the Changes of Oral-Health-Related Quality of Life of Nursing-Home Residents in the Short Term?
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Zenthöfer A, Ehret J, Zajac M, Kilian S, Kostunov J, Rammelsberg P, et al.
Clin Interv Aging 2021 May 11;16:789-798.
OBJECTIVE: To evaluate how changes in oral health and chewing efficiency affect the changes in oral-health-related quality of life (OHRQoL) of nursing-home residents over six months. METHODS: The study was conducted in nine nursing homes. Sociodemographic and general data were collected for all eligible individuals (n = 150). Of these, 114 participants (mean age 82.0 [± 9.5] years, 77.2% women) were available for the following tests at baseline and six months later: a comprehensive examination of dental and general health, a two-colour mixing-ability test (to assess chewing efficiency), the Geriatric Oral Health Assessment Index (GOHAI; to evaluate the OHRQoL), and the Mini Mental State Examination (MMSE; to diagnose the presence and severity of dementia). Univariate and multivariate linear regression models were compiled to analyse possible factors affecting OHRQoL. RESULTS: For the final analysis, 108 participants were available. For the study cohort as a whole, a decrease in the number of functional occluding pairs (C: 0.195; p = 0.034) and an increase in dental-treatment needs (C: -1.968; p = 0.056) had the greatest negative effects on OHRQoL as expressed by the GOHAI score. For denture wearers, a deterioration of denture condition (C: -2.946; p = 0.003) was the most important predictor for a decline in OHRQoL. CONCLUSION: A short-term decline in oral health and function affects the OHRQoL of nursing-home residents. The most important dental variables in this regard are the number of functional occluding pairs and dental and denture-related treatment needs.