Aging

Collection of articles on Aging is available here.

Identifying and Managing Hearing and Vision Loss in Older People in Care Homes: A Scoping Review of the Evidence.
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W. Andrusjak, A. Barbosa and G. Mountain.
Gerontologist 2020 Apr 2;60(3):e155-e168
Poor identification of sensory impairments in care homes can be due to multiple factors. This scoping review identifies and synthesizes the literature into the detection of hearing and vision loss in the care home environment, and the management of these sensory losses once identified. RESEARCH DESIGN AND METHODS: A scoping review methodology was used to identify primary research of any design published from 1985 to September 2018. Six electronic databases were searched, and articles were also sourced from reference lists, relevant charity organizations and published experts. RESULTS: Six electronic databases and multiple gray literature sources identified 51 articles for inclusion. The evidence confirmed that lack of knowledge in care home staff, poor management of assistive aids, unsuitable environment, lack of connections with optometrists and audiologists, underuse of effective screening tools, and the added complexity of assisting those with dementia are all barriers to effective practice. Conversely, flexible training programs, availability of a variety of assistive aids, simple screening tools, and adaptions to the environment are effective facilitators. DISCUSSION AND IMPLICATION: This review acknowledges that the barriers to identification and management of hearing and vision loss in care homes are multifaceted and that collaboration of multiple stakeholders is required to implement change and improve the residents’ ear and eye care. Recommendations are offered to support more effective service provision tailored to meet the needs of people with sensory impairments living in care homes, and this could subsequently improve best practice.

Instrumental Swallowing Assessment in Adults in Residential Aged Care Homes: A Scoping Review.
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Olga Birchall, Michelle Bennett, Nadine Lawson, Susan M. Cotton and Adam P. Vogel.
Journal of the American Medical Directors Association 2020/10
To systematically describe evidence on the use of instrumental swallowing assessment for residents of aged care homes.; ObjectivesTo systematically describe evidence on the use of instrumental swallowing assessment for residents of aged care homes.

Innovative practice: Can music reminiscence approaches be used in moderate-severe dementia? A pilot of music mirrors.
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M. F. Camerlynck, O. Sedgwick and H. Lister.
Dementia (London) 2020 Sep 30:1471301220960847
Music-based therapies have been widely evaluated for individuals with dementia. Music Mirrors (MM) is a new music-based reminiscence tool that looks to improve person-centred care, encourage conversation and stimulate reminiscence. Since MM is designed for persons with mild dementia, this project looked to determine the feasibility, acceptability and efficacy of the tool with three individuals with moderate to severe dementia. Over 6 weeks, 12 sessions were conducted, assessing for mood and behavioural changes during and after each session. Despite limitations to the project, overall results suggest that MM can be beneficial to people with moderate to severe dementia.

A survey of the experience of living with dementia in a dementia-friendly community.
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N. Darlington, E. Mathie, A. Mayrhofer, et al.
Dementia (London) 2020 Oct 8:1471301220965552
Dementia-friendly communities (DFCs) are one way in which people living with dementia can be supported to be active, engaged and valued citizens. Quantitative evaluations of the experiences of those with dementia living within these communities are scarce. This article reports findings from a survey of people living with dementia on their experience of living in a DFC. Two-hundred and forty people living with dementia completed a cross-sectional survey in six DFCs across England. Around half of respondents reported they were aware they were living in a DFC. Being aware of living in a DFC was associated with taking part in leisure activities (p = 0.042), community centre attendance (p = 0.009), being involved in organised activities or groups (p < 0.001), feeling understood (p = 0.008), and feeling valued for their own contributions to the community (p = 0.002). This study illustrates the contribution that surveys can make in facilitating the expression of views and experiences of people living with dementia. Awareness of living within a DFC is associated with greater involvement in, and belonging to, the wider community.

The stability of care preferences following acute illness: a mixed methods prospective cohort study of frail older people.
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S. N. Etkind, N. Lovell, A. E. Bone, et al.
BMC Geriatr 2020 Sep 29;20(1):370-020-01725-2
Patient preferences are integral to person-centred care, but preference stability is poorly understood in older people, who may experience fluctuant illness trajectories with episodes of acute illness. We aimed to describe, and explore influences on the stability of care preferences in frail older people following recent acute illness. METHODS: Mixed-methods prospective cohort study with dominant qualitative component, parallel data collection and six-month follow up. STUDY POPULATION: age ≥ 65, Rockwood Clinical Frailty score ≥ 5, recent acute illness requiring acute assessment/hospitalisation. Participants rated the importance of six preferences (to extend life, improve quality of life, remain independent, be comfortable, support ‘those close to me’, and stay out of hospital) at baseline, 12 and 24 weeks using a 0-4 scale, and ranked the most important. A maximum-variation sub-sample additionally contributed serial in-depth qualitative interviews. We described preference stability using frequencies and proportions, and undertook thematic analysis to explore influences on preference stability. RESULTS: 90/192 (45%) of potential participants consented. 82/90 (91%) answered the baseline questionnaire; median age 84, 63% female. Seventeen undertook qualitative interviews. Most participants consistently rated five of the six preferences as important (range 68-89%). ‘Extend life’ was rated important by fewer participants (32-43%). Importance ratings were stable in 61-86% of cases. The preference ranked most important was unstable in 82% of participants. Preference stability was supported by five influences: the presence of family support; both positive or negative care experiences; preferences being concordant with underlying values; where there was slowness of recovery from illness; and when preferences linked to long term goals. Preference change was related to changes in health awareness, or life events; if preferences were specific to a particular context, or multiple concurrent preferences existed, these were also more liable to change. CONCLUSIONS: Preferences were largely stable following acute illness. Stability was reinforced by care experiences and the presence of family support. Where preferences were unstable, this usually related to changing health awareness. Consideration of these influences during preference elicitation or advance care planning will support delivery of responsive care to meet preferences. Obtaining longer-term data across diverse ethnic groups is needed in future research.

Nursing Home Residents’ Functional Trajectories and Mortality After a Transfer to the Emergency Department.
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V. Guion, P. De Souto Barreto and Y. Rolland.
J Am Med Dir Assoc 2020 Jul 10
To describe nursing home residents’ (NHRs) functional trajectories and mortality after a transfer to the emergency department (ED). DESIGN: Case-control observational multicenter study. SETTING AND PARTICIPANTS: In total, 1037 NHRs presenting to 17 EDs in France over 4 nonconsecutive weeks in 2016. METHODS: Finite mixture models were fitted to longitudinal data on activities of daily living (ADL) scores before transfer (time 1), during hospitalization (time 2), and within 1 week after discharge (time 3) to identify groups of NHRs following similar functional evolution. Factors associated with mortality were investigated by Cox regressions. RESULTS: Trajectory modeling identified 4 distinct trajectories of ADL. The first showed a high and stable (across time 1, time 2, and time 3) functional capacity around 5.2/6 ADL points, with breathlessness as the main condition leading to transfer. The second displayed an initial 37.8% decrease in baseline ADL performance (between time 1 and time 2), followed by a 12.5% recovery of baseline ADL performance (time 2‒time 3), with fractures as the main condition. The third displayed a similar initial decrease, followed by a 6.7% recovery. The fourth displayed an initial 70.1% decrease, followed by an 8.5% recover, with more complex geriatric polypathology situations. Functional decline was more likely after being transferred for a cerebrovascular condition or for a fracture, after being discharged from ED to a surgery department, and with a heavier burden of distressing symptoms during transfer. Mortality after ED transfer was more likely in older NHRs, those in a more severe condition, those who were hospitalized more frequently in the past month, and those transferred for cerebrovascular conditions or breathlessness. CONCLUSIONS AND IMPLICATIONS: Identified trajectories and factors associated with functional decline and mortality should help clinicians decide whether to transfer NHRs to ED. NHRs with high functional ability seem to benefit from ED transfers whereas on-site alternatives should be sought for those with poor functional ability.

Dental and Oral Health Care in Nursing Homes: Results from Two Multi-Stakeholder Surveys.
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C. Lewis, S. R. Zwetchkenbaum, R. R. Baier, D. Harris and R. L. Gardner.
R I Med J (2013) 2020 Oct 1;103(8):62-68
To characterize oral health practices using data from statewide, multi-stakeholder surveys. STUDY DESIGN AND METHODS: We analyzed data from two Rhode Island surveys. Together, the surveys targeted all nursing homes, residents, and resident representatives in Rhode Island, and asked about staff training on mouth care, frequency of dental provider visits, enrollment in nursing home dental programs, and barriers to oral health. Primary Results: Responding nursing home administrators reported high levels of commitment to oral health. Among residents enrolled in a nursing home dental care program, 76.1% had a preventive visit in the prior six months, compared to 31.0% of residents not enrolled. The majority of facilities (71.8%) reported that staff received training on routine mouth care at the time of hire. CONCLUSIONS: Our findings highlight opportunities to better support nursing homes in providing residents with high-quality oral health, including acquiring staff skills to manage care-resistant behaviors, and routinely assessing residents’ ability to provide their own mouth care.

Measuring the prevalence of 60 health conditions in older Australians in residential aged care with electronic health records: a retrospective dynamic cohort study.
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K. E. Lind, M. Z. Raban, L. Brett, M. L. Jorgensen, A. Georgiou and J. I. Westbrook.
Popul Health Metr 2020 Oct 8;18(1):25-020-00234-z
The number of older Australians using aged care services is increasing, yet there is an absence of reliable data on their health. Multimorbidity in this population has not been well described. A clear picture of the health status of people using aged care is essential for informing health practice and policy to support evidence-based, equitable, high-quality care. Our objective was to describe the health status of older Australians living in residential aged care facilities (RACFs) and develop a model for monitoring health conditions using data from electronic health record systems. METHODS: Using a dynamic retrospective cohort of 9436 RACF residents living in 68 RACFs in New South Wales and the Australian Capital Territory from 2014 to 2017, we developed an algorithm to identify residents’ conditions using aged care funding assessments, medications administered, and clinical notes from their facility electronic health record (EHR). We generated age- and sex-specific prevalence estimates for 60 health conditions. Agreement between conditions recorded in aged care funding assessments and those documented in residents’ EHRs was evaluated using Cohen’s kappa. Cluster analysis was used to describe combinations of health conditions (multimorbidity) occurring among residents. RESULTS: Using all data sources, 93% of residents had some form of circulatory disease, with hypertension the most common (62%). Most residents (93%) had a mental or behavioural disorder, including dementia (58%) or depression (54%). For most conditions, EHR data identified approximately twice the number of people with the condition compared to aged care funding assessments. Agreement between data sources was highest for multiple sclerosis, Huntington’s disease, and dementia. The cluster analysis identified seven groups with distinct combinations of health conditions and demographic characteristics and found that the most complex cluster represented a group of residents that had on average the longest lengths of stay in residential care. CONCLUSIONS: The prevalence of many health conditions among RACF residents in Australia is underestimated in previous reports. Aged care EHR data have the potential to be used to better understand the complex health needs of this vulnerable population and can help fill the information gaps needed for population health surveillance and quality monitoring.

Prevalence of Vision Loss and Associations With Age-Related Eye Diseases Among Nursing Home Residents Aged ≥65 Years.
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W. A. Monaco, J. E. Crews, A. T. H. Nguyen and A. Arif.
J Am Med Dir Assoc 2020 Oct 8
To examine data from Delaware nursing homes to determine prevalence of age-related eye diseases (AREDs), vision impairment, and blindness and to compare the findings with the results of 11 US investigations of vision and eye health in nursing homes. DESIGN: This is a cross-sectional, retrospective study of nursing home patients. SETTING AND PARTICIPANTS: Twenty nursing homes in Delaware participated in the study, yielding comprehensive eye examination records for 2019 study participants. METHODS: Summary statistics and regression analyses. RESULTS: The overall prevalence of vision impairment or blindness was 63.8% and was above 60% for each age, sex, and race category. Prevalence of vision impairment or blindness was 68.4% among patients with cataracts, 69.4% among patients with macular degeneration, 70.5% among patients with glaucoma, and 68.4% among patients with diabetic retinopathy. Prevalence of blindness was 14.1%. Among patients with AREDs, prevalence of blindness ranged from 15.0% for patients with cataracts to 22.6% for patients with diabetic retinopathy. When compared with other investigations, we found wide variation in vision and eye factors reported and wide variation in the prevalence of those factors. Only 4 studies diagnosed both AREDs and visual function. Seven studies reported AREDs, and 7 reported vision impairment and/or blindness. Vision impairment or blindness ranged from 29% to 67%; cataract ranged from 32% to 83%; macular degeneration ranged from 4.6% to 70.7%. Glaucoma ranged from 5.3% to 41.4%; diabetic retinopathy ranged from 1.7% to 3.1%. CONCLUSIONS AND IMPLICATIONS: Comprehensive eye examinations showed that vision impairment and blindness affected 63.8% of nursing home residents. Compared with other studies, there was a wide range of vision factors reported and wide variation in the prevalence of vision impairment or blindness and AREDs. This investigation suggests the importance of eye care in nursing homes and the importance of reporting standard vision and eye health factors to inform policy and practice.

Associations between Nutritional Status, Frailty and Health-Related Quality of Life among Older Long-Term Care Residents in Helsinki.
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K. S. Salminen, M. H. Suominen, H. Kautiainen and K. H. Pitkälä.
J Nutr Health Aging 2020;24(3):319-324
The aim of this study was to examine how nutritional status modifies the association between frailty and health-related quality of life (HRQoL) among older nursing home residents. We also investigated how residents’ energy intake is linked to frailty score. DESIGN AND PARTICIPANTS: A total of 486 older (> 65 years of age) nursing home residents living in Helsinki, Finland were included to this cross-sectional study. METHODS: We collected data on the residents’ background information, HRQoL by 15D, nutritional status by Mini Nutritional Assessment (MNA), frailty status (Fried’s phenotype criteria; pre-frail: 1-2 criteria and frail: 3-5) and energy intake (one- or two-day food records). RESULTS: The frail residents were more often malnourished and had lower HRQoL than those in the prefrail group. Energy and protein intakes were significantly lower among frail women than prefrail women. Energy intake was linearly associated with frailty points. When residents in the frail and prefrail groups were divided according to their nutritional status, both nutritional status and frailty were associated with HRQoL, but there was no interaction. CONCLUSIONS: Both nutritional status and frailty were associated with HRQoL, and lower energy intake indicated a higher frailty score. An adequate energy intake may promote residents’ HRQoL and prevent frailty in long-term care.

Sedatives and Sedation at the End of Life in Nursing Homes: A Retrospective Multicenter Cohort Study.
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E. Schildmann, S. Meesters, B. Grüne, et al.
J Am Med Dir Assoc 2020 Oct 8
There is scarce information about sedation in nursing homes at the end of life. We aimed to assess (1) the use of sedatives generally and “sedatives with continuous effect,” based on objective operational criteria, within the last week of life in nursing homes and (2) factors associated with this treatment. DESIGN: Retrospective cohort study, using the nursing homes’ medical records. SETTING AND PARTICIPANTS: Residents who died in 4 German nursing homes from January 2015 to December 2017 and whose medical records were available (n = 512). METHODS: Sedatives analyzed were those recommended by guidelines for “palliative sedation”: benzodiazepines, levomepromazine, haloperidol (≥5 mg/d), and propofol. The definition of “sedatives with continuous effect” and doses judged as at least moderately sedating were consented by palliative care clinicians and pharmacists, based on the literature. Descriptive statistics and multivariate logistic regression analysis were performed (R version 3.6.1). RESULTS: Overall, 110/512 (21%) deceased residents received a sedative at least once during the last week of life, 46/512 (9%) “sedatives with continuous effect.” Oral lorazepam was used most frequently. Eleven of 512 (2%) residents received doses judged as at least moderately sedating. The term sedation was not used. Most frequent indications were agitation (58/110; 53%) and anxiety (35/110; 32%); no indication was noted for 36/110 (33%) residents. The resident’s involvement in the decision for sedatives was documented in 3/110 (3%). Multivariate logistic regression analysis showed significant associations between use of sedatives and age (OR = 0.94, P < .001) as well as institution (P < .001). CONCLUSIONS AND IMPLICATIONS: Our data indicate a lower prevalence of sedation compared to international data and considerable differences regarding prevalence between institutions. These differences, potential setting-specific challenges, and need for support measures for consistent best practice of sedation in nursing homes should be further explored.

Physical and psychological states interfere with health-related quality of life of institutionalized elderly: a cross-sectional study.
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I. P. Silva E Farias, L. A. S. Montenegro, R. L. Wanderley, et al.
BMC Geriatr 2020 Oct 6;20(1):386-020-01791-6
Nursing home elders experience many problems that may influence their quality of life, in example of cognitive, mental, nutritional and physical disabilities. Concerning about elders’ wellbeing may help them living with dignity. This study aimed to investigate factors associated with Health-Related Quality of Life (HRQoL) of institutionalized elders in a capital city of Brazilian Northeast. METHODS: A cross-sectional study was conducted with 125 institutionalized elders living in the metropolitan region of João Pessoa (Brazil). The following variables were tested regarding their association with the elders’ HRQoL: Socio-demographic characteristics; Performance of daily-living activities, Frailty status, Cognitive status, Nutritional status, Self-perception of oral health and Depression status. Hierarchical multiple Poisson loglinear and binary logistic regressions analyses were performed in order to assess the impact of each independent variable on HRQoL, considering a significance level of 5%. RESULTS: The median of HRQoL of institutionalized elders was 64. Multivariate regression models showed that retirement, frailty and depression were statistically associated with poor HRQoL (p < 0.05). Not-frail elderly and less depressed were more likely to present higher HRQoL scores. CONCLUSIONS: Lower HRQoL of institutionalized elderly is associated with decline of physical and psychological states. Institutions should be advised to plan and implement actions that would improve the HRQoL of institutionalized elderly.

Care Transitions to the Community from Veterans Affairs Nursing Homes: Experiences of Social Connection and Disconnection.
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K. V. Simons, E. S. Bower, S. M. Gillespie and W. L. Mills.
J Am Med Dir Assoc 2020 Sep 14
This study aimed to further knowledge of older Veterans’ experiences with transitioning to the community from Veterans Affairs nursing homes (Community Living Centers or CLCs) with emphasis on social functioning. DESIGN: A qualitative study design was used in addition to administration of standardized depression and mental status screens. SETTING AND PARTICIPANTS: Veterans (n = 18) and caregivers (n = 14) were purposively sampled and recruited from 2 rural CLCs in Upstate New York. METHODS: Semistructured interviews were completed with Veterans in the CLC prior to discharge (to explore experiences during the CLC stay and expectations regarding discharge and returning home) and in the home 2-4 weeks postdischarge (to explore daily routines and perceptions of overall health, mental health, and social functioning). Caregivers participated in 1 interview, completed postdischarge. The 9-item Patient Health Questionnaire and the Brief Interview for Mental Status were administered postdischarge. RESULTS: Thematic analysis of verbatim transcriptions revealed 3 inter-related themes: (1) Veterans may experience improved social connectedness in CLCs by nature of the unique care environment (predominantly male, shared military experience); (2) Experiences of social engagement and connectedness varied after discharge and could be discordant with Veterans’ expectations for recovery prior to discharge; and (3) Veterans may or may not describe themselves as “lonely” after discharge, when physically isolated. Veterans lacked moderate to severe cognitive impairment (Brief Interview for Mental Status: range = 14-15); however, they reported a wide range in depressive symptom severity postdischarge (9-item Patient Health Questionnaire: mean = 4.9, SD = 6.1, median/mode = 3, range = 0-23). CONCLUSIONS AND IMPLICATIONS: This study identified a potential for increased social isolation and disengagement after discharge from Veterans Affairs nursing homes. Nursing homes should integrate social functioning assessment for their residents, while extending care planning and transitional care to address patient-centered social functioning goals.

Antibiotic Use Among Residents Receiving Skilled Nursing Care in 29 U.S. Nursing Homes.
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S. Song, B. M. Wilson, T. Bej, et al.
J Am Geriatr Soc 2020 Oct 9
Data describing antibiotic use in U.S. nursing homes remain limited. We report antibiotic use among skilled nursing facility residents from 29 U.S. nursing homes and assessed correlations between antibiotics prescribed to residents in skilled care and nursing home characteristics. DESIGN: Retrospective cohort study. SETTING: Twenty-nine U.S. nursing homes in the same healthcare corporation. PARTICIPANTS: Residents receiving skilled care in 2016. MEASUREMENTS: We used pharmacy invoice and nursing home census data to calculate the days of antibiotic therapy per 1,000 days of skilled care (1,000 DOSC), the rate of antibiotic starts per 1,000 DOSC, the length of antibiotic therapy, and the average antibiotic spectrum index. We also assessed correlations between antibiotic use and nursing home characteristics. RESULTS: Antibiotics accounted for an average of 9.6% (±0.6%) of systemic medications prescribed among residents receiving skilled care. On average, 26.8% (±2.9%) of antibiotics were intravenous. Fluoroquinolones were prescribed at the highest rates (19% across all facilities), followed by beta-lactam/beta-lactamase inhibitors (11%), first- and second-generation cephalosporins, sulfonamides, and oral tetracyclines (each at 9%). Both the proportion of residents using enrolled in Medicare and number of unique prescribers responsible for systemic prescriptions positively correlated with the rate of antibiotic starts. CONCLUSIONS: Our study demonstrates that pharmacy invoices represent a useful and preexisting source of data for assessing antibiotic prescriptions among individuals receiving skilled nursing care. The correlation between the number of unique prescribers and antibiotic starts suggests that prescribers are central to efforts to improve antibiotic use in nursing homes.

“I Didn’t Even Make My Bed”: Hospital Relocations and Resident Adjustment in Long-Term Care Over Time.
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T. Sussman and B. Orav-Lakaski.
Gerontologist 2020 Jan 24;60(1):32-40
This prospective longitudinal qualitative study sought to identify the conditions that help or hinder older adults’ capacities to adjust to long-term care (LTC) when relocating from hospital. DESIGN AND METHODS: Informed by the principles of constructivist grounded theory, this study employed semi-structured interviews with LTC home residents. Participants were interviewed 4 weeks after their initial relocation, and again every 6 months until they had either resided in their final LTC home for at least 3 months or been enrolled in the study for 2 years. Transcribed interviews were analyzed using the constant comparative method that employs the principle of comparison to guide the analytic process. FINDINGS: A total of nine residents participated in 24 interviews and most had undergone two or more moves. Analysis of the data revealed that multiple forced moves challenged residents’ capacities to find home in LTC by contributing to anxiety and uncertainty, hindering resident-staff relations, and interfering with residents’ desires to connect with one another. Analysis of the data further revealed that relocation frameworks may require adaptations to more accurately reflect older adults’ experiences with relocation from hospital to LTC. IMPLICATIONS: Hospital relocations pose many challenges to residents’ capacities to find home in LTC, in part, because they initiate a process of multiple moves. Until the moving process from hospital truly acknowledges and explores residents’ preferences, offers choices, and supports joint decision making, it will remain challenging for the LTC home sector to help residents find meaning, purpose, and home in LTC.

Bayesian analysis of the association between effective strategies of multimodal nonpharmacological intervention and characteristics of cognitive function in nursing home residents with cognitive impairment: A cross-sectional study.
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K. Yorozuya, S. Yamane, M. Nobuhisa, et al.
Medicine (Baltimore) 2020 Sep 11;99(37):e22154
The cognitive function of nursing home (NH) residents with cognitive impairment (CI) tends to decline over time. An effective multimodal non-pharmacological intervention (MNPI) strategy is needed to improve the cognitive function of NH residents with CI.The aim of this study was to clarify the cognitive function characteristics of NH residents with CI in whom a non-pharmacological intervention (NPI) can be implemented, consisting of MNPI using a Bayesian analysis, and to incorporate suggestions to make the MNPI strategy as effective as possible.This study had a cross-sectional design. The 61 subjects were selected from the residents of 5 NHs, of whom 90.16% were female, and the mean (standard deviation) age was 87.20 ± 6.90. Analyses were performed using a hierarchical Bayesian model, and the global and specific cognitive functions as assessed by the Japanese version of the Neurobehavioral Cognitive Status Examination were the response variables. Three types of NPI (cognitive enhancement NPI, physical NPI, psychological and psychosocial NPI), and activities of daily living (ADL), as assessed by the Barthel index, were the explanatory variables.Cognitive enhancement NPI was revealed to have no association with any cognitive function. Physical NPI was negatively associated with orientation [OR 0.31 (95% credible interval (95% CI) -2.33, -0.10)], comprehension [OR 0.16 (95% CI -2.78, -0.95)] and naming [OR 0.49 (95% CI -1.47, -0.02)]. Psychological and psychosocial NPI was positively associated with comprehension [OR 3.67 (95% CI 0.52, 2.13)]. Barthel index was positively associated with total Japanese version of the Neurobehavioral Cognitive Status Examination [OR 1.74 (95% CI 0.08, 2.12)], comprehension [OR 3.49 (95% CI 0.45, 4.67)], repetition [OR 10.07 (95% CI 0.53, 9.01)], naming [OR 2.24 (95% CI 0.07, 3.20)], and calculations [OR 18.82 (95% CI 2.71, 9.40)].The implementation of MNPI should be preceded by cognitive enhancement NPI and physical NPI. Providing ADL enhancing NPI in response to cognitive improvement may be an effective strategy. Providing cognitive enhancement NPI, physical NPI, psychological, and psychosocial NPI, as well as ADL-enhancing NPI at the same time, is also an effective strategy for subjects with mild dementia who are considered to have relatively high cognitive functions.