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OBJECTIVE: To investigate whether an electronic health record (EHR)-integrated decision tool, combined with supportive interventions, results in more appropriate antibiotic prescribing in nursing home (NH) residents with suspected urinary tract infection (UTI), without negative consequences for residents.DESIGN: Cluster randomized controlled trial with NHs as the randomization unit; intervention group NHs received the EHR-integrated decision tool and supportive interventions, and control group NHs provided care as usual.SETTING AND PARTICIPANTS: 212 residents with suspected UTI, from 16 NHs in the Netherlands.METHODS: Physicians collected data at index consultation (ie, UTI suspicion) and during a 21-day follow-up period (March 2019-March 2020). Overall antibiotic prescribing data at NH level, 12 months prior to and during the study, was derived from the electronic prescribing system. The primary study outcome was the percentage of antibiotic prescriptions for suspected UTI that was appropriate, at index consultation. Secondary study outcomes included changes in treatment decision, complications, UTI-related hospitalization, and mortality during follow-up; and pre-post study changes in antibiotic prescribing at the NH level.RESULTS: 295 suspected UTIs were included (intervention group: 189; control group: 106). The between-group difference in appropriate antibiotic prescribing was 13% [intervention group: 62%, control group: 49%; adjusted odds ratio (OR) 1.43, 95% CI 0.57-3.62]. In both groups, complications (2% vs 3%), UTI-related hospitalization (2% vs 1%), and possible UTI-related mortality (2% vs 2%) were rare. The pre-post study difference in antibiotic prescriptions per 1000 resident-care days was -0.95 in the intervention group NHs and -0.05 in the control group NHs (P = .02).CONCLUSION AND IMPLICATIONS: Although appropriate antibiotic prescribing improved in the intervention group, this does not provide sufficient evidence for our multidisciplinary intervention. Despite this inconclusive result, our intervention could potentially still be effective, because we established a large reduction in the number of antibiotic prescriptions in the intervention group.

Objectives: The researchers aimed to (1) explore the occurrence of psychological resilience in the face of a major life stressor and conflict in older residents of long-term care facilities (LTCFs), and (2) identify factors associated with resilience in this population. Design: Longitudinal cohort study using the Dutch InterRAI-LTCF cohort. Setting and participants: Older residents (≥60 years old) of 21 LTCFs in the Netherlands. Methods: The researchers selected 2 samples of residents who had at least 2 assessments surrounding (1) an incident major life stressor, or (2) incident conflict with other resident or staff. A resilient outcome was operationalized as not having clinically meaningful mood symptoms at the post-stressor assessment and equal or fewer mood symptoms at the post-stressor relative to the pre-stressor assessment. The researchers used 2 resilience outcomes per stressor: 1 based on observer-reported mood symptoms and 1 based on self-reported mood symptoms. The most important factors from among 21 potential resilience factors for each of the 4 operationalizations of resilience were identified using a backward selection procedure with 2-level generalized estimating equations analyses. Results: Forty-eight percent and 50% of residents were resilient in the face of a major life stressor, based on observer-reported (n = 248) and self-reported (n = 211) mood, respectively. In the face of conflict, 26% and 51% of the residents demonstrated resilience, based on the observer-reported (n = 246) and self-reported (n = 183) mood, respectively. Better cognitive functioning, a strong and supportive relationship with family, participation in social activities, and better self-reported health were most strongly associated with resilience in the face of a major life stressor. Better communicative functioning, absence of psychiatric diagnoses, a strong and supportive relationship with family, not being lonely, social engagement, and not reminiscing about life were most strongly associated with resilience in the face of conflict. Conclusions and Implications: Factors with a social aspect appear to be particularly important to psychological resilience in older LTCF residents, and provide a potential target for intervention in the LTCF setting.

Objective: Fall prevention is important in many hospitals. Current fall-risk-screening tools have limited predictive accuracy specifically for older inpatients. Their administration can be time-consuming. A reliable and easy-to-administer tool is desirable to identify older inpatients at higher fall risk. We aimed to develop and internally validate a prognostic prediction model for inpatient falls for older patients. Design: Retrospective analysis of a large cohort drawn from hospital electronic health record data. Setting and Participants: Older patients (≥70 years) admitted to a university medical center (2016 until 2021). Methods: The outcome was an inpatient fall (≥24 hours of admission). Two prediction models were developed using regularized logistic regression in 5 imputed data sets: one model without predictors indicating missing values (Model-without) and one model with these additional predictors indicating missing values (Model-with). We internally validated our whole model development strategy using 10-fold stratified cross-validation. The models were evaluated using discrimination (area under the receiver operating characteristic curve) and calibration (plot assessment). We determined whether the areas under the receiver operating characteristic curves (AUCs) of the models were significantly different using DeLong test. Results: Our data set included 21,286 admissions. In total, 470 (2.2%) had a fall after 24 hours of admission. The Model-without had 12 predictors and Model-with 13, of which 4 were indicators of missing values. The AUCs of the Model-without and Model-with were 0.676 (95% CI 0.646-0.707) and 0.695 (95% CI 0.667-0.724). The AUCs between both models were significantly different (P = .013). Calibration was good for both models. Conclusions and Implications: Both the Model-with and Model-without indicators of missing values showed good calibration and fair discrimination, where the Model-with performed better. Our models showed competitive performance to well-established fall-risk-screening tools, and they have the advantage of being based on routinely collected data. This may substantially reduce the burden on nurses, compared with nonautomatic fall-risk-screening tools.

Objective: To explore the course of quality of life (QoL) and possible resident-related predictors associated with this course in institutionalized people with young-onset dementia (YOD). Design: An observational longitudinal study. Setting and Participants: A total of 278 residents with YOD were recruited from 13 YOD special care units in the Netherlands. Methods: Secondary analyses were conducted with longitudinal data from the Behavior and Evolution in Young-ONset Dementia (BEYOND)-II study. QoL was assessed with proxy ratings, using the Quality of Life in Dementia (QUALIDEM) questionnaire at 4 assessment points over 18 months. Predictors included age, gender, dementia subtype, length of stay, dementia severity, neuropsychiatric symptoms, and psycho tropic drug use at baseline. Multilevel modeling was used to adjust for the correlation of measurements within residents and clustering of residents within nursing homes. Results: The total QUALIDEM score (range: 0-111) decreased over 18 months with a small change of 0.65 (95% confidence interval-1.27,-0.04) points per 6 months. An increase in several domains of QoL regarding care relationship, positive self-image, and feeling at home was seen over time, whereas a decline was observed in the subscales positive affect, social relations, and having something to do. Residents with higher levels of QoL and more advanced dementia at baseline showed a more progressive decline in QoL over time. Sensitivity analyses indicated a more progressive decline in QoL for residents who died during the follow-up. Conclusion and Implications: This study shows that although overall QoL in nursing home residents with YOD was relatively stable over 18 months, there were multidirectional changes in the QoL subscales that could be clinically relevant. Higher levels of QoL and more advanced stages of dementia at baseline predicted a more progressive decline in QoL over time. More longitudinal studies are needed to verify factors influencing QoL in YOD. (c) 2020 The Authors. Published by Elsevier Inc. on behalf of AMDA -The Society for Post-Acute and Long-Term Care Medicine. This is an open access article under the CC BY-NC-ND license (http:// creativecommons.org/licenses/by-nc-nd/4.0/).

Geriatria; Atenció aguda; Model d’atenció Geriatría; Cuidados agudos; Modelo de cuidado Geriatrics; Acute care; Model of care Objective Throughout Europe, the number of older adults requiring acute hospitalization is increasing. Admission to an acute geriatric unit outside of a general hospital could be an alternative. In this model of acute medical care, comprehensive geriatric assessment and rehabilitation are provided to selected older patients. This study aims to compare patients' diagnoses, characteristics, and outcomes of 2 European sites where this care occurs. Design Exploratory cohort study. Setting and participants Subacute Care Unit (SCU), introduced in 2012 in Barcelona, Spain, and the Acute Geriatric Community Hospital (AGCH), introduced in 2018 in Amsterdam, the Netherlands. The main admission criteria for older patients were acute events or exacerbations of chronic conditions, hemodynamic stability on admission, and no requirement for complex diagnostics. Measures We compared setting, characteristics, and outcomes between patients admitted to the 2 units. Results Data from 909 patients admitted to SCU and 174 to AGCH were available. Patients were admitted from the emergency department or from home. The mean age was 85.8 years [standard deviation (SD) = 6.7] at SCU and 81.9 years (SD = 8.5) ( P < .001) at AGCH. At SCU, patients were more often delirious (38.7% vs 22.4%, P < .001) on admission. At both units, infection was the main admission diagnosis. Other diagnoses included heart failure or chronic obstructive pulmonary disease. Five percent or less of patients were readmitted to general hospitals. Average length of stay was 8.8 (SD = 4.4) days (SCU) and 9.9 (SD = 7.5) days (AGCH). Conclusions and Implications These acute geriatric units are quite similar and both provide an alternative to admission to a general hospital. We encourage the comparison of these units to other examples in Europe and suggest multicentric studies comparing their performance to usual hospital care. The research conducted at the Subacute Care Unit (Parc Sanitari Pere Virgili) did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. The Acute Geriatric Community Hospital (AGCH, Amsterdam University Medical Centers) research receives funding though ZonMw, the Netherlands Organization for Health Research and Development, project number 808393598041. Moreover, the care provided at the AGCH is provided in a partnership between Cordaan, a community and home care organization and the Amsterdam University Medical Center, location Academic Medical Center. The AGCH is financially supported by Zilveren Kruis, a health insurance company.

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ObjectivesTo determine the number of steps taken by older patients in hospital and 1 week after discharge; to identify factors associated with step numbers after discharge; and to examine the association between functional decline and step numbers after discharge.DesignProspective observational cohort study conducted in 2015–2017.Setting and ParticipantsOlder adults (≥70 years of age) acutely hospitalized for at least 48 hours at internal, cardiology, or geriatric wards in 6 Dutch hospitals.MethodsSteps were counted using the Fitbit Flex accelerometer during hospitalization and 1 week after discharge. Demographic, somatic, physical, and psychosocial factors were assessed during hospitalization. Functional decline was determined 1 month after discharge using the Katz activities of daily living index.ResultsThe analytic sample included 188 participants [mean age (standard deviation) 79.1 (6.7)]. One month postdischarge, 33 out of 174 participants (19%) experienced functional decline. The median number of steps was 656 [interquartile range (IQR), 250–1146] at the last day of hospitalization. This increased to 1750 (IQR 675–4114) steps 1 day postdischarge, and to 1997 (IQR 938–4098) steps 7 days postdischarge. Age [β = −57.93; 95% confidence interval (CI) −111.15 to −4.71], physical performance (β = 224.95; 95% CI 117.79–332.11), and steps in hospital (β = 0.76; 95% CI 0.46–1.06) were associated with steps postdischarge. There was a significant association between step numbers after discharge and functional decline 1 month after discharge (β = −1400; 95% CI –2380 to −420; P = .005).Conclusions and ImplicationsAmong acutely hospitalized older adults, step numbers double 1 day postdischarge, indicating that their capacity is underutilized during hospitalization. Physical performance and physical activity during hospitalization are key to increasing the number of steps postdischarge. The number of steps 1 week after discharge is a promising indicator of functional decline 1 month after discharge.

Objective: Early identification of older people at risk of falling is the cornerstone of fall prevention. Many fall prediction tools exist but their external validity is lacking. External validation is a prerequisite before application in clinical practice. Models developed with electronic health record (EHR) data are especially challenging because of the uncontrolled nature of routinely collected data. We aimed to externally validate our previously developed and published prediction model for falls, using a large cohort of community-dwelling older people derived from primary care EHR data. Design: Retrospective analysis of a prospective cohort drawn from EHR data. Setting and Participants: Pseudonymized EHR data were collected from individuals aged ≥65 years, who were enlisted in any of the participating 59 general practices between 2015 and 2020 in the Netherlands. Methods: Ten predictors were defined and obtained using the same methods as in the development study. The outcome was 1-year fall and was obtained from free text. Both reproducibility and transportability were evaluated. Model performance was assessed in terms of discrimination using the area under the receiver operating characteristic curve (ROC-AUC), and in terms of calibration, using calibration-in-the-large, calibration slope and calibration plots. Results: Among 39,342 older people, 5124 (13.4%) fell in the 1-year follow-up. The characteristics of the validation and the development cohorts were similar. ROC-AUCs of the validation and development cohort were 0.690 and 0.705, respectively. Calibration-in-the-large and calibration slope were 0.012 and 0.878, respectively. Calibration plots revealed overprediction for high-risk groups in a small number of individuals. Conclusions and Implications: Our previously developed prediction model for falls demonstrated good external validity by reproducing its predictive performance in the validation cohort. The implementation of this model in the primary care setting could be considered after impact assessment.

Objectives: The aim was to characterize multimorbidity patterns in a large sample of older individuals living in nursing homes (NHs) and to investigate their association with mortality, also considering the effect of functional status. Design: Observational and retrospective study. Setting and Participants: We analyzed data on 4131 NH residents in Italy, aged 60 years and older, assessed through the interRAI long-term care facility instrument. Entry date was between 2014 and 2018, and participants were followed until 2019. Methods: Multimorbidity patterns were identified through principal component analysis; for the identified components, subjects were stratified in quintiles (Q) with respect to their loading values, with the higher quantiles indicating greater expression of the component's pattern. Their association [hazard ratio (HR) and 95% CI] with mortality was tested in Cox regression models. Analyses were stratified by disability status. Results: Four patterns of multimorbidity were identified: (1) heart diseases; (2) dementia and sensory impairments; (3) heart, respiratory, and psychiatric diseases; and (4) diabetes, musculoskeletal, and vascular diseases. For the heart diseases pattern [HR Q5 vs Q1 = 1.83 (1.53–2.20)] and the dementia and sensory impairments pattern [HR Q5 vs Q1 = 1.23 (1.06–1.42)], as the specific multimorbidity expression increases, the risk of mortality increases. On stratifying by disability status, the association between the multimorbidity patterns and mortality was not always present. Conclusions and Implications: Different multimorbidity patterns are differentially associated with mortality in older residents of NHs, confirming that multimorbidity's prognosis is strictly dependent on the underlying disease combinations. This knowledge may be useful to implement personalized preventive and therapeutic care pathways for institutionalized older adults, which respond to individuals’ health needs.

OBJECTIVES: This study evaluated logistics, process data, and barriers/facilitators for the implementation and use of C-reactive protein point-of-care testing (CRP POCT) for suspected lower respiratory tract infections (LRTIs) in nursing home (NH) residents.DESIGN: This process evaluation was performed alongside a cluster randomized, controlled trial (UPCARE study) to evaluate the effect of CRP POCT on antibiotic prescribing for suspected LRTIs in NH residents.SETTING AND PARTICIPANTS: Eleven NHs in the Netherlands.METHODS: Data sources for process data regarding intervention quality included a questionnaire among NH staff, logs, reports, and CRP POCT-analyzer records. Barriers and facilitators for implementation were assessed in focus group interviews with physicians and nurses from 3 NHs.RESULTS: Correct patient selection for CRP POCT and generally continued CRP POCT use indicated good fidelity. The initial training and training of new employees seemed to fit the need, but some POCT-user group sizes had increased over time, which could have impeded frequent use. Users were generally satisfied with CRP POCT and perceived its use feasible and relevant. Facilitators for implementation were initial commitment and active initiation, followed by continued attention and enthusiasm for building routine practice and trust. Short lines of communication between staff, short distance to the POCT-analyzer, 24/7 coverage of staff, and a clear task division facilitated continued attention and routine practice.CONCLUSIONS AND IMPLICATIONS: This process evaluation showed sufficient quality of providing CRP POCT in Dutch NHs. We processed findings of intervention quality and implementation knowledge into key recommendations for CRP POCT implementation in this setting. Future research could focus on CRP POCT use in countries with different organization of care in NHs.

© 2022 The AuthorsObjectives: Geriatric inpatient rehabilitation aims to restore function, marked by physical performance, to enable patients to return and remain home after hospitalization. However, after discharge some patients are soon readmitted, institutionalized, or may die. Whether changes in physical performance during geriatric rehabilitation are associated with these short-term adverse outcomes is unknown. This study aimed to determine the association of changes in physical performance during geriatric inpatient rehabilitation with short-term adverse outcomes. Design: Observational longitudinal study. Setting and Participants: Geriatric rehabilitation inpatients of the REStORing health of acutely unwell adulTs (RESORT) cohort study of the Royal Melbourne Hospital (Melbourne, Australia) were included. Methods: The change from admission to discharge in the Short Physical Performance Battery (SPPB) score, balance, gait speed (GS), chair stand test (CST), and hand grip strength (HGS) were calculated and analyzed using logistic regression analysis with readmission, incidence of institutionalization, and mortality, and ≥1 adverse outcome within 3 months postdischarge. Results: Of 693 inpatients, 11 died during hospitalization and 572 patients (mean age 82.6 ± 7.6 years, 57.9% female) had available physical performance data. Within 3 months postdischarge, 47.3% of patients had ≥1 adverse outcome: readmission was 20.8%, institutionalization was 26.6%, and mortality was 7.9%. Improved SPPB score, balance, GS, CST, and HGS were associated with lower odds of institutionalization and mortality. Improved GS was additionally associated with lower odds of readmission [odds ratio (OR) 0.35, 95% CI 0.16-0.79]. CST score had the largest effect, with a 1-point increase associating with 40% lower odds of being institutionalized (OR 0.60, 95% CI 0.42-0.86), 52% lower odds of mortality (OR 0.48, 95% CI 0.29-0.81), and a 24% lower odds of ≥1 adverse outcome (OR 0.76, 95% CI 0.59-0.97). Conclusions and Implications: Improvement in physical performance was associated with lower odds of short-term institutionalization and mortality indicating the prognostic value of physical performance improvement during geriatric inpatient rehabilitation.

Objectives: In the first months of 2021, the Dutch COVID-19 vaccination campaign was disturbed by reports of death in Norwegian nursing homes (NHs) after vaccination. Reports predominantly concerned persons >65 years of age with 1 or more comorbidities. Also, in the Netherlands adverse events were reported after COVID-19 vaccination in this vulnerable group. Yet, it was unclear whether a causal link between vaccination and death existed. Therefore, we investigated the risk of death after COVID-19 vaccination in Dutch NH residents compared with the risk of death in NH residents prior to the COVID-19 pandemic. Design: Population-based longitudinal cohort study with electronic health record data. Setting and Participants: We studied Dutch NH residents from 73 NHs who received 1 or 2 COVID-19 vaccination(s) between January 13 and April 16, 2021 (n = 21,762). As a historical comparison group, we included Dutch NH residents who were registered in the same period in 2019 (n = 27,591). Methods: Data on vaccination status, age, gender, type of care, comorbidities, and date of NH entry and (if applicable) discharge or date of death were extracted from electronic health records. Risk of death after 30 days was evaluated and compared between vaccinated residents and historical comparison residents with Kaplan-Meier and Cox regression analyses. Regression analyses were adjusted for age, gender, comorbidities, and length of stay. Results: Risk of death in NH residents after one COVID-19 vaccination (regardless of whether a second vaccination was given) was decreased compared with historical comparison residents from 2019 (adjusted HR 0.77, 95% CI 0.69-0.86). The risk of death further decreased after 2 vaccinations compared with the historical comparison group (adjusted HR 0.57, 95% CI 0.50-0.64). Conclusions and Implications: We found no indication that risk of death in NH residents is increased after COVID-19 vaccination. These results indicate that COVID-19 vaccination in NH residents is safe and could reduce fear and resistance toward vaccination.

Objectives: We aimed to explore the effects of the Dutch COVID-19 lockdown (March 20–May 25, 2020) on mood, behavior, and social and cognitive functioning of older residents of long-term care facilities (LTCFs) prospectively. Design: Mixed methods: historically controlled longitudinal cohort study and focus groups. Setting and Participants: Residents of Dutch LTCFs. Methods: Residents who were assessed during and prior to the lockdown were compared to residents of the same wards with 2 assessments prior to the lockdown. We used mixed models and generalized estimating equation analyses to explore differences in changes in mood, withdrawal and aggressive behavior, loneliness and conflict, and cognition and delirium. We also explored whether the effect of the lockdown differed for different subgroups. In 2 online focus groups, LTCF care professionals, ranging from care staff to physicians, reflected on their experiences of the effect of the lockdown and the cohort study results. Results: The lockdown group of 298 residents was compared to the control group of 625 residents. Self-reported mood symptoms showed a slightly greater increase during the lockdown. During the first half of the lockdown, the level of conflict with other residents decreased whereas it increased in the control group. The subgroup with moderate-severe cognitive impairment showed a decrease in withdrawal during the lockdown, whereas the group with no-mild cognitive impairment showed a statistically nonsignificant relative increase. Professionals described great individual variation in the effects of the lockdown on residents. Facilities attempted to preserve the experienced positive effects, for example, by promoting tranquility in shared rooms and continuing to organize individualized ward-based activities. Conclusions and Implications: We did not find clinically relevant negative effects of the lockdown on mood, behavior, and social and cognitive functioning in older residents of LTCFs at the group level. Possibly, staff mitigated the negative effects at the group level. Meanwhile, they learned lessons that they continue to apply to enhance resident well-being.

Diet is a promising intervention target to prevent or slow Alzheimer's disease (AD). Early (predementia) stages of AD offer a unique opportunity for dietary interventions. Nutritional assessment methods to estimate nutrient intake have, however, not been validated in clinical populations. Hence, we assessed the association between nutrient intake assessed by food frequency questionnaire (FFQ) and nutrient status measured by nutritional biomarkers in blood in a clinical sample of controls, mild cognitive impairment (MCI), and patients with AD.

OBJECTIVES:After hospitalization, many older adults need post-acute care, including rehabilitation or home care. However, post-acute care expenses can be as high as the costs for the initial hospitalization. Detailed information on monthly post-acute health care expenditures and the characteristics of patients that make up for a large share of these expenditures is scarce. We aimed to calculate costs in acutely hospitalized older patients and identify patient characteristics that are associated with high post-acute care costs.DESIGN:Prospective multicenter cohort study (between October 2015 and June 2017).SETTING AND PARTICIPANTS:401 acutely hospitalized older persons from internal medicine, cardiology, and geriatric wards.MEASUREMENTS:Our primary outcome was mean post-acute care costs within 90 days postdischarge. Post-acute care costs included costs for unplanned readmissions, home care, nursing home care, general practice, and rehabilitation care. Three costs categories were defined: low [0-50th percentile (p0-50)], moderate (p50-75), and high (p75-100). Multinomial logistic regression analyses were conducted to assess the associations between costs and frailty, functional impairment, health-related quality of life, cognitive impairment, and depressive symptoms.RESULTS:Costs were distributed unevenly in the population, with the top 10.0% (n = 40) accounting for 52.1% of total post-acute care costs. Mean post-acute care costs were €4035 [standard deviation (SD) 4346] or $4560 (SD 4911). Frailty [odds ratio (OR) 3.44, 95% confidence interval (CI) 1.78-6.63], functional impairment (OR 1.80, 95% CI 1.03-3.16), and poor health-related quality of life (OR 1.89, 95% CI 1.09-3.28) at admission were associated with classification in the high-cost group, compared with the low-cost group.CONCLUSIONS/IMPLICATIONS:Post-acute care costs are substantial in a small portion of hospitalized older adults. Frailty, functional impairment, and poor health-related quality of life are associated with higher post-acute care costs and may be used as an indicator of such costs in practice.

Objectives To evaluate whether discontinuation of antihypertensive medication in community-dwelling older people is associated with a reduction in memory complaints and/or incident dementia. Design Prospective observational cohort study within the Prevention of Dementia by Intensive Vascular Care (preDIVA) trial. Setting and Participants Community-dwelling participants (aged 70-78 years at baseline) who underwent 2-yearly assessments during 6-8 years of follow-up. Measures Cox regression analyses of the relation between discontinuation of antihypertensive medication during the study and change in subjective memory complaints, incident dementia, and mortality. Results Dementia occurred more often in participants discontinuing antihypertensive treatment (13.4% vs 6.2%, P = .02); mortality was similar (16.5% vs 13.9%, P = .52). Discontinuation of antihypertensive medication was associated with a double dementia hazard [hazard ratio (HR) (95% confidence interval) = 2.15 (1.15-4.03)], which somewhat attenuated after adjustment for sex, blood pressure, number of antihypertensives and other medications [HR = 1.92 (1.01-3.65)], and additionally for stroke, cardiovascular disease, diabetes, smoking, memory complaints, and MMSE score [HR = 1.79 (0.93-3.44)]. Antihypertensive discontinuation was associated with an approximately 50% higher hazard of dementia and/or mortality combined [HR = 1.58 (1.04-2.40); model 2: HR = 1.64 (1.07-2.51); model 3: HR = 1.49 (0.96-2.30)]. Antihypertensive discontinuation was not associated with change in memory complaints [odds ratio (95% confidence interval) = 0.96 (0.55-1.67)]. Subgroup and sensitivity analyses addressing possible sources of bias and confounding gave similar results. Conclusions/Implications Our results suggest that antihypertensive withdrawal in community-dwelling older people does not preserve cognition and may in fact increase dementia risk. This is not due to reduced mortality as competing risk. Additional analyses suggest results are unlikely to be explainable by confounding, reverse causality, or observational biases. Studies with person-specific reasons for antihypertensive discontinuation may be able to exclude reverse causality completely. Given the beneficial effects of antihypertensive medication on cardiovascular risk, observational data may be the best currently obtainable on the pressing issue of when withdrawal of antihypertensives in older people is acceptable and what consequences need to be weighed.

ObjectivesTo establish the prevalence and course of geriatric syndromes from hospital admission up to 3 months postdischarge and to determine the probability to retain geriatric syndromes over the period from discharge until 3 months postdischarge, once they are present at admission.DesignProspective multicenter cohort study conducted between October 2015 and June 2017.Setting and participantsAcutely hospitalized patients aged 70 years and older recruited from internal, cardiology, and geriatric wards of 6 Dutch hospitals.MeasuresCognitive impairment, depressive symptoms, apathy, pain, malnutrition, incontinence, dizziness, fatigue, mobility impairment, functional impairment, fall risk, and fear of falling were assessed at admission, discharge, and 1, 2, and 3 months postdischarge. Generalized estimating equations analysis were performed to analyze the course of syndromes and to determine the probability to retain syndromes.ResultsA total of 401 participants [mean age (standard deviation) 79.7 (6.7)] were included. At admission, a median of 5 geriatric syndromes were present. Most prevalent were fatigue (77.2%), functional impairment (62.3%), apathy (57.5%), mobility impairment (54.6%), and fear of falling (40.6%). At 3 months postdischarge, an average of 3 syndromes were present, of which mobility impairment (52.7%), fatigue (48.1%), and functional impairment (42.5%) were most prevalent. Tracking analysis showed that geriatric syndromes that were present at admission were likely to be retained. The following 6 geriatric syndromes were most likely to stay present postdischarge: mobility impairment, incontinence, cognitive impairment, depressive symptoms, functional impairment, and fear of falling.ImplicationsAcutely hospitalized older adults exhibit a broad spectrum of highly prevalent geriatric syndromes. Moreover, patients are likely to retain symptoms that are present at admission postdischarge. Our study underscores the need to address a wide range of syndromes at admission, the importance of communication on syndromes to the next care provider, and the need for adequate follow-up care and syndrome management postdischarge.

esidents of long-term care (LTC) homes have suffered disproportionately during the COVID-19 pandemic, from the virus itself and often from the imposition of lockdown measures. Provincial Geriatrics Leadership Ontario, in collaboration with interRAI and the International Federation on Aging, hosted a virtual Town Hall on September 25, 2020. The purpose of this event was to bring together international perspectives from researchers, clinicians, and policy experts to address important themes potentially amenable to timely policy interventions. This article summarizes these themes and the ensuing discussions among 130 attendees from 5 continents. The disproportionate impact of the COVID-19 pandemic on frail residents of LTC homes reflects a systematic lack of equitable prioritization by health system decision makers around the world. The primary risk factors for an outbreak in an LTC home were outbreaks in the surrounding community, high staff and visitor traffic in large facilities, and crowding of residents in ageing buildings. Infection control measures must be prioritized in LTC homes, though care must be taken to protect frail and vulnerable residents from their overly blunt application that deprives residents from appropriate physical and psychosocial support. Staffing, in terms of overall numbers, training, and leadership skills, was inadequate. The built environment of LTC homes can be configured for both optimal resident well-being and infection control. Infection control and resident wellness need not be mutually exclusive. Improving outcomes for LTC residents requires more staffing with proper training and interprofessional leadership. All these initiatives must be underpinned by an effective quality assurance system based on standardized, comprehensive, accessible, and clinically relevant data, and which can support broad communities of practice capable of effecting real and meaningful change for frail older persons, wherever they chose to reside. ispartof: Journal Of The American Medical Directors Association vol:22 issue:6 pages:1-5 ispartof: location:United States status: published

© 2021 The AuthorsObjectives: This study aimed to describe objectively measured physical activity and sedentary behavior in geriatric rehabilitation patients receiving care in the home-based compared to the hospital-based setting. Design: Observational matched cohort study. Setting and Participants: Home-based (patient's home) or hospital-based (ward) geriatric rehabilitation was delivered to inpatients within the REStORing health of acutely unwell adulTs (RESORT) observational, longitudinal cohort of the Royal Melbourne Hospital (Melbourne, Victoria, Australia). Methods: Patients were asked to wear ActivPAL4 accelerometers for 1 week and were assessed by a comprehensive geriatric assessment at admission, discharge, and followed up after 3 months. Hospital-based patients were matched to home-based patients for sex and baseline physical function [Short Physical Performance Battery (SPPB), activities (instrumental) of daily living, and Clinical Frailty Scale]. Differences in patient characteristics and physical activity (total, standing and walking durations, number of steps and sit-to stand transitions) and sedentary behavior (total, sitting and lying durations) were assessed. Results: A total of 159 patients were included: 18 home-based [mean age: 81.9 ± 8.6 years, 38.9% female, median (interquartile range [IQR]) SPPB: 7.0 (5.0-9.0)] and 141 hospital-based [mean age: 82.9 ± 7.8 years, 57.4% female, median (IQR) SPPB: 1.0 (0.0-4.0)] patients, of whom 18 were matched [mean age: 80.1 ± 7.4 years, 38.9% female, median (IQR) SPPB: 6.5 (4.8-10.0)]. Median physical activity measures were consistently higher in home-based patients compared to the total group of hospital-based patients. After matching, physical activity measures remained >2.4 times higher and were significantly different for all measures (total physical activity, standing and walking durations, and steps) except for sit-to-stand transitions. Sedentary behaviors were similar with home-based patients spending non-significantly more time sitting but significantly less time lying than hospital-based patients (matched and total). Conclusions and Implications: Home-based inpatients are more physically active than hospital-based inpatients independent of matching for sex and baseline physical function, which supports home-based geriatric rehabilitation.

OBJECTIVES: To mitigate the spread of COVID-19, a nationwide restriction for all visitors of residents of long-term care facilities including nursing homes (NHs) was established in the Netherlands. The aim of this study was an exploration of dilemmas experienced by elderly care physicians (ECPs) as a result of the COVID-19 driven restrictive visiting policy. SETTING AND PARTICIPANTS: ECPs working in Dutch NHs. METHODS: A qualitative exploratory study was performed using an open-ended questionnaire. A thematic analysis was applied. Data were collected between April 17 and May 10, 2020. RESULTS: Seventy-six ECPs answered the questionnaire describing a total of 114 cases in which they experienced a dilemma. Thematic analysis revealed 4 major themes: (1) The need for balancing safety for all through infection prevention measures versus quality of life of the individual residents and their loved ones; (2) The challenge of assessing the dying phase and how the allowed exception to the strict visitor restriction in the dying phase could be implemented; (3) The profound emotional impact on ECPs; (4) Many alternatives for visits highlight the wish to compensate for the absence of face-to-face contact opportunities. Many alternatives for visits highlight the wish to compensate for the absence of face-to-face opportunities but given the diversity of NH residents, alternatives were often only suitable for some of them. CONCLUSIONS AND IMPLICATIONS: ECPs reported that the restrictive visitor policy deeply impacts NHs residents, their loved ones, and care professionals. The dilemmas encountered as a result of the policy highlight the wish by ECPs to offer solutions tailored to the individual residents. We identified an overview of aspects to consider when drafting future visiting policies for NHs during the COVID-19 pandemic.

Contains fulltext : 232401.pdf (Publisher’s version ) (Open Access) OBJECTIVES: Extreme neuropsychiatric symptoms can be a heavy burden for nursing home (NH) residents, relatives, and caregivers. Sometimes, when extreme neuropsychiatric symptoms are considered refractory, continuous palliative sedation is administered. The aim of this study was to explore the trajectory leading to continuous palliative sedation and its administration in NH residents with dementia and refractory neuropsychiatric symptoms. DESIGN: A qualitative interview and explorative study was performed. SETTING AND PARTICIPANTS: Relatives, elderly care physicians, and other staff members involved with 3 NH residents with dementia and extreme refractory neuropsychiatric symptoms who received continuous palliative sedation were interviewed. These NH residents lived on dementia special care units of 3 NHs in the Netherlands. METHODS: Consecutive sampling was used to select participants. Medical files were studied. Semistructured interviews were conducted. Transcriptions were analyzed with thematic analysis, including directed content analysis. RESULTS: Nine in-depth interviews with 13 participants were held. Analysis resulted in 6 main themes, with several subthemes reflecting phases of the continuous palliative sedation trajectory: (1) run-up, describing an unbearable struggle of the resident; (2) turning point, at which hope was lost; (3) considering continuous palliative sedation and administration of intermittent sedation; (4) decision to start continuous palliative sedation based on 1 decisive trigger; (5) administration of continuous palliative sedation with stakeholders experiencing relief; and (6) evaluation. CONCLUSIONS AND IMPLICATIONS: The trajectory leading up to continuous palliative sedation in NH residents with dementia and extreme refractory neuropsychiatric symptoms was complex and burdensome, but the initiation led to relief and contentment for all those involved. This study highlights that continuous palliative sedation can be a valuable treatment option among these residents. A recommendation is to include external consultation in the decision process and to administer intermittent sedation as a preceding step when continuous palliative sedation is considered.

Objective: The aims of this study were (1) to investigate the relationship between different neuropsychiatric symptoms (NPS) and the level of distress experienced by nurses caring for residents with young-onset dementia (YOD) and (2) to compare these findings with those for nurses caring for residents with late-onset dementia (LOD). Design/Setting: This is a retrospective study conducted in Dutch long-term care facilities. Data were used from the Behavior and Evolution of Young-ONset Dementia studies (BEYOND) Parts I and II and the WAAL Behavior in Dementia-II (Waalbed-II) study. Participants: A total of 382 nursing home residents with YOD and 261 nursing home residents with LOD were included. Measurements: The Neuropsychiatric Inventory, nursing home version, was used to assess nursing staff distress and the frequency (F) and severity (S) of NPS. Multilevel logistic regression analysis was used to investigate the relationships between nursing staff distress related to NPS and YOD and LOD care units, the F x S score per symptom, gender, dementia subtype, and dementia severity. Results: Nurses working in YOD care units rated sleep and nighttime behavior disorders, delusions, and agitation/aggression most often as highly distressing and euphoria most often as not distressing. Multivariate analyses indicated that the frequency and severity of NPS were significantly associated with staff distress in all symptoms, except for apathy. Comparison of the 2 groups of nurses demonstrated that the odds for distress related to sleep and nighttime behavior disorders were higher for nurses in YOD care units than for nurses in LOD units. For both the YOD and LOD nurses, irritability in male residents had higher impact than similar behavior in female residents. Conclusion: This study provides important insight into distress related to individual NPS and the interaction with residents' characteristics. All NPS result in distress. The frequency and severity of the behavior is an important predictor. Sleep and nighttime behavior disorders are more likely to result in distress in YOD nurses than in LOD nurses. The amount of distress related to NPS emphasizes the urgent need for adequate management of NPS and the support of professional caregivers. (C) 2017 AMDA - The Society for Post-Acute and Long-Term Care Medicine.

Objectives Caring for people with Korsakoff syndrome (KS) residing in specialized long-term care facilities (LTCFs) can be distressing because of challenging neuropsychiatric symptoms (NPS). However, good-quality studies on NPS in this under-researched population are lacking. This study examined the prevalence and severity of NPS in people with KS living in specialized LTCFs and the associated caregiver distress. Design Cross-sectional, observational study. Data were obtained using structured interviews with care staff, elderly care physicians, and residents. Setting Nine specialized LTCFs in the Netherlands. Participants KS residents admitted for at least 3 months. Measurements The prevalence and severity of NPS were measured with the Neuropsychiatric Inventory–Questionnaire (NPI-Q). The associated caregiver distress was assessed with the NPI Distress Scale (NPI-D) according to the nurse or nurse assistant. Results Almost all of the 281 residents (96.4%) showed at least 1 NPS and 45.8% showed 5 or more symptoms. Irritability/lability (68.3%), agitation/aggression (58.7%), and disinhibition (52.7%) were most prevalent. Although the mean level of severity for all NPS was relatively low, half of the residents (49.1%) had at least 1 severe NPS. Care staff experienced low levels of distress associated with NPS. Conclusion NPS are highly prevalent in KS residents. Unexpectedly, these did not have any severe impact on residents and care staff. Acquiring more insight into the persistence and course of NPS, and its associations, among KS residents is important to better understand and reduce these symptoms and, ultimately, improve the quality of care for these residents.

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Introduction: In nursing home (NH) residents with a very short life expectancy, the benefits of preventive cardiovascular medication maintenance are questionable. Objective: To assess the prevalence of 4 classes of preventive cardiovascular medication (PCM) in NH residents, and to explore differences of prevalence across length of stay, mortality risk, cognitive impairment, functional disability, and across countries. Methods: A 12-month prospective cohort study was conducted in 57 NHs in 8 countries (Czech Republic, England, Finland, France, Germany, Italy, The Netherlands, and Israel). We assessed the prevalence at first measurement of 4 classes of PCM: oral anticoagulants (OAC), platelet aggregation inhibitor (PAI), antihypertensive (AHT), and lipid-modifying agent (LMA), in older (60+ years) residents with valid medication assessments. The PCM prevalence was compared across the length of stay (short 12 months), health instability as defined by Changes in Health, End-Stage Disease, Signs, and Symptoms Scale (CHESS) > 3, cognitive impairment by Cognitive Performance Scale (CPS) > 2, and functional disability was measured using the Activities of Daily Living Hierarchy Scale (ADLH) ≥5. Results: Of the 3759 eligible residents, 2175 (57.9%) used at least 1 PCM. The prevalence of the 4 groups of PCM: OAC, PAI, AHT and LMA were 5.6%, 34.9%, 35.7%, and 10.4%, respectively. PCM use was lower in long-stay residents versus mid-stay: 56.0% vs. 62.7%, in cognitively impaired residents (47.1% vs. 67%), in residents with a high mortality risk (47.4% vs. 58.6%), and in residents with a high ADLH score (48.6% vs 64.0%). Conclusion: Although the prevalence of PCM use was lower in long-stay, cognitively impaired residents, persons with a high mortality risk, and residents with more functional disabilities, there seems to be room for deprescribing.

Objective: To determine whether the implementation of a national program to improve quality of care in geriatric rehabilitation (GR) in the Netherlands improves successful GR in terms of independence in activities of daily living (ADL), discharge destination, and length of stay.Design: Prospective longitudinal study, comparing 2 consecutive cohorts: at the start of implementation (n = 386) and at 1 year after implementation (n = 357) of this program.Setting/Participants: Included were 16 skilled nursing facilities, 743 patients (median age 80 years, interquartile range 72-85; 64.5% females) indicated for GR and their health care professionals (elderly care physicians, physiotherapists, and nursing staff).Intervention: National program to stimulate self-organizing capacity to develop integrated care to improve GR service delivery in 4 domains: alignment with patients' (care) needs, care coordination, team cooperation, and quality of care.Measurements: Data on patients' characteristics, functional outcomes at admission and discharge, length of stay, and discharge destination were collected via an online questionnaire sent to health care professionals. The primary outcome measure was successful rehabilitation defined as independence in ADL (Barthel Index >= 15), discharge home, and a short length of stay (lowest 25% per diagnostic group). Generalized estimating equation analysis was used to adjust for age, gender, and clustering effects in the total population and for the 2 largest diagnostic subgroups, traumatic injuries and stroke. Results: In the total population, at 1 year postimplementation there was 12% more ADL independence [ odds ratio (OR) 1.59, 95% confidence interval (CI) 1.00-2.54]. Although successful rehabilitation (independence in ADL, discharge home, short length of stay) was similar in the 2 cohorts, patients with traumatic injuries were more successful 1 year postimplementation (OR 1.61, 95% CI 1.01-2.54). In stroke patients, successful rehabilitation was similar between the cohorts, but with more independence in ADL in the follow-up cohort (OR 1.99, 95% CI 1.09-3.63).Conclusions: This study shows that 1-year after the implementation of the Dutch national program to improve quality of care there was more independence in ADL at discharge, but the combined outcome of successful GR (independence in ADL, discharge home, short length of stay) was only significantly improved in patients with traumatic injuries. (C) 2016 AMDA - The Society for Post-Acute and Long-Term Care Medicine.

Objective To investigate whether the CYP2C9*2 and *3 variants modify benzodiazepine-related fall risk. Design Three prospective studies; the Rotterdam Study, B-PROOF, and LASA. Setting Community-dwelling individuals living in or near five Dutch cities. Participants There were 11,485 participants aged ≥55 years. Measurements Fall incidents were recorded prospectively. Benzodiazepine use was determined using pharmacy dispensing records or interviews. Cox proportional hazard models adjusted for age and sex were applied to determine the association between benzodiazepine use and fall risk stratified for CYP2C9 genotype and comparing benzodiazepine users to nonusers. The results of the three studies were combined applying meta-analysis. Within benzodiazepine users, the association between genotypes and fall risk was also assessed. Results Three thousand seven hundred five participants (32%) encountered a fall during 91,996 follow-up years, and 4% to 15% (depending on the study population) used benzodiazepines. CYP2C9 variants had frequencies of 13% for the *2 allele and 6% for the *3 allele. Compared to nonusers, current benzodiazepine use was associated with an 18% to 36% increased fall risk across studies with a combined hazard ratio (HR) = 1.26 (95% confidence interval [CI], 1.13; 1.40). CYP2C9*2 or *3 allele variants modified benzodiazepine-related fall risk. Compared to nonusers, those carrying a CYP2C9*2 or *3 allele and using benzodiazepines had a 45% increased fall risk (HR, 1.45 95% CI, 1.21; 1.73), whereas CYP2C9*1 homozygotes using benzodiazepines had no increased fall risk (HR, 1.14; 95% CI, 0.90; 1.45). Within benzodiazepine users, having a CYP2C9*2 or *3 allele was associated with an increased fall risk (HR, 1.35; 95% CI, 1.06; 1.72). Additionally, we observed an allele dose effect; heterozygous allele carriers had a fall risk of (HR = 1.30; 95% CI, 1.05; 1.61), and homozygous allele carriers of (HR = 1.91 95% CI, 1.23; 2.96). Conclusions CYP2C9*2 and *3 allele variants modify benzodiazepine-related fall risk. Those using benzodiazepines and having reduced CYP2C9 enzyme activity based on their genotype are at increased fall risk. In clinical practice, genotyping might be considered for elderly patients with an indication for benzodiazepine use. However, because the exact role of CYP2C9 in benzodiazepine metabolism is still unclear, additional research is warranted.

The rapid ageing of populations around the world and the associated shift in the burden of disease from infectious to chronic conditions are creating complex challenges for national governments. Addressing the needs of these older populations in a sustainable and equitable way, will be a fundamental pillar of socioeconomic development in the 21st Century. The World Health Organization (WHO) Global strategy and action plan on ageing and health, which was adopted by all the Organization's 194 Member states in 2016, provides a clear framework for global action. One critical priority is to establish sustainable and equitable long-term care systems in every country. WHO defines long-term care as "the activities undertaken by others to ensure that people with, or at risk of, a significant ongoing loss of intrinsic capacity can maintain a level of functional ability consistent with their basic rights, fundamental freedoms and human dignity". These activities include both social care and health care, as well as contributions from other sectors, such as education or transport. And these activities need to be effectively coordinated if they are to efficiently, equitably and sustainably meet the needs of older people. This requires the stewardship of governments to ensure that: care is accessible and affordable; the rights of older people to lives of meaning and dignity are upheld regardless of their physical or mental capacity; services are oriented around the individual's specific needs; caregivers are supported; the workforce (both paid and unpaid) are treated fairly; and older people's intrinsic capacity is maintained for as long as possible. WHO has proposed three inter-related strategies to establish and sustain long-term care systems. System infrastructure needs to be developed and continually improved. The capacity of the workforce needs to be strengthened and families and communities must be supported. And the care and support provided needs to be more person-centred and integrated, underpinned by minimum standards and accreditation for care providers. This paper outlines some of the critical issues confronting governments in countries at all levels of development if this ambitious vision is to be achieved.

Physician burnout is a critical factor influencing the quality of care delivered in various healthcare settings. Although the prevalence and consequences of burnout have been well documented for physicians in various jurisdictions, no studies to date have reported on burnout in the postacute and long-term care setting. In this exploratory study, we sought to quantify the prevalence of burnout among 3 cohorts of physicians, each practicing in nursing homes in the United States (US), Canada, or The Netherlands. International comparisons were solicited to highlight cultural and health system factors potentially impacting burnout levels. Using standard survey techniques, a total of 721 physicians were solicited to participate (Canada 393; US 110; The Netherlands 218). Physicians agreeing to participate were asked to complete the “Maslach Burnout Inventory” using the Survey Monkey platform. A total of 118 surveys were completed from The Netherlands, 59 from Canada, and 65 from the US for response rates of 54%, 15%, and 59%, respectively. While US physicians demonstrated more negative scores in the emotional exhaustion subscale compared with their counterparts in Canada and The Netherlands, there were no meaningful differences on the depersonalization and personal accomplishments subscales. Factors explaining these differences are explored as well as approaches to future research on physician burnout in postacute and long-term care.

Objectives The aim of the current study was to investigate whether a new functional classification, based on basic (BADL) and instrumental (IADL) activities of daily living and frailty, is associated with mortality in older adults during 10 years of follow-up. Design Cohort study, with a follow-up of 10 years. Setting and participants A total of 924 participants aged 70 and older from the Frailty and Dependence in Albacete (FRADEA) study, a population-based sample of Spanish older adults. Measures At baseline, a new functional classification of 8 categories was constructed with limitations in BADL using the Barthel Index, limitations in IADL using the Lawton IADL Index, and the criteria of the frailty phenotype. Associations with 10-year mortality were assessed using Kaplan-Meier curves and Cox proportional hazard models. Results The risk of mortality gradually increased toward the less functionally independent end of the classification. The presence of mild, moderate, or severe BADL impairment was associated with mortality, in models adjusted for age, sex, comorbidity and institutionalization. The analyses also revealed that those who were BADL independent, IADL dependent and prefrail [hazard ratio (HR) = 2.27, 95% confidence interval (CI) = 1.22-4.20], and those who were BADL independent and frail (HR = 3.74, 95% CI = 1.88-7.42) had an increased risk of mortality. Conclusions/implications A new functional classification composed of BADL, IADL, and frailty representing the functional continuum is effective in stratifying the risk for mortality in older adults. Frailty is a high-mortality-risk state close to subjects with mild disability in BADL, needing an intensive specialized approach. Prefrailty with any impairment in IADL has an intermediate mortality risk and should be offered primary care interventions.

Objectives COVID-19 has caused many nursing homes to prohibit resident visits to prevent viral spread. Although visiting restrictions are instituted to prolong the life of nursing home residents, they may detrimentally affect their quality of life. The aim of this study is to capture perspectives from the relatives of nursing home residents on nursing home visiting restrictions. Design A cross-sectional online survey was conducted. Setting and participants: A convenience sample of Dutch relatives of nursing home residents (n = 1997) filled in an online survey on their perspectives regarding nursing home visiting restrictions. Methods The survey included Likert-item, multi-select, and open answer questions targeting four key areas: (1) communication access to residents, (2) adverse effects of visiting restrictions on residents and relatives, (3) potential protective effect of visiting restrictions, (4) important aspects for relatives during and after visiting restrictions. Results Satisfaction of communication access to nursing home residents was highest when respondents had the possibility to communicate with nursing home residents by nurses informing them via telephone, contact behind glass, and contact outside maintaining physical distance. Satisfaction rates increased when respondents had multiple opportunities to stay in contact with residents. Respondents were concerned that residents had increased loneliness (76%), sadness (66%), and decreased quality of life (62%) while study respondents reported personal sadness (73%) and fear (26%). There was no consensus amongst respondents if adverse effects of the visiting restrictions outweighed the protective effect for nursing home residents. Respondents expressed the need for increased information, communication options, and better safety protocols. Conclusion and Implications Providing multiple opportunities to stay in touch with nursing home residents can increase satisfaction of communication between residents and relatives. Increased context specific information, communication options and safety protocols should be addressed in national health policy., Nursing home residents and their relatives are affected by visiting restrictions. Experienced needs for more context specific information, communication options and safety protocols should be addressed in national health policy.

OBJECTIVES: The prevalence of different geriatric syndromes in older home care (HC) recipients is yet to be determined. Dizziness is often regarded as a geriatric syndrome. The natural course of dizziness in older people is still unknown, because of a lack of longitudinal studies. The objective of this study was to investigate the prevalence and persistence of dizziness in HC recipients. DESIGN: Prospective cohort study. SETTING: Home care organizations in 6 European countries participating in the EU-funded Identifying best practices for care-dependent elderly by Benchmarking Costs and outcomes of community care (IBenC) project. PARTICIPANTS: 2616 community-dwelling long-term HC recipients aged 65 years or older. METHODS: Data were collected at baseline and 6 and 12 months by using the interRAI Home Care instrument (interRAI-HC). Dizziness status was assessed by the number of days people experienced dizziness in the last 3 days (0-3) and later dichotomized for analyses (present or not in the last 3 days). Dizziness persistence was defined as the odds for dizzy people at baseline to also report dizziness at subsequent follow-up moments, compared with people who were not dizzy at baseline. The pattern of dizziness was descriptively analyzed in recipients who completed all measurements. Generalized estimating equations analysis was used to determine the persistence of dizziness symptoms. RESULTS: The prevalence of dizziness of 2616 eligible HC recipients at baseline was 25.1%, ranging from 16.2% (Belgium) to 39.7% (Italy). The majority of dizzy recipients at baseline also experienced dizziness after 6 and 12 months (79.1%). Dizziness persistence was high at 6 months [odds ratio (OR) 57.8, 95% confidence interval (CI) 43.1-77.5] and at 12 months (OR 30.2, 95% CI 22.3-41.1). CONCLUSIONS AND IMPLICATIONS: Dizziness in older HC recipients in Europe is common, and dizziness persistence is high. This warrants a more active approach in treating dizziness in older HC recipients. ispartof: Journal Of The American Medical Directors Association vol:21 issue:3 pages:338-343 ispartof: location:United States status: published

Objectives To examine the association of benzodiazepines and anticholinergic drug usage with the risk of dementia. Design Prospective cohort study. Setting Community-dwelling participants, recruited in family practices in the Netherlands. Participants In total, 3526 individuals aged 70 to 78 years without dementia within 116 participating family practices. Methods Information about drug use was reported at baseline and at 2-year follow-up and was cross-checked with the participants’ electronic health records. Anticholinergic drug exposure was defined by the anticholinergic cognitive burden score. Participants were evaluated for dementia during follow-up assessments every 2 years, supplemented by information from electronic health records and the National Death Registry. Results During a median follow-up of 6.7 years, dementia developed in 233 participants (7%). In participants using benzodiazepines, 6% developed dementia vs 7% in nonusers [hazard ratio (HR) 0.71, 95% confidence interval (CI) 0.58–1.07]. Persistent usage of benzodiazepines at baseline and after 2-year follow-up did not substantially alter the point-estimate (HR 0.60, 95% CI 0.34–1.10). Use of any anticholinergic drugs was not associated with incident dementia (HR 1.01, 95% CI 0.50–1.10). Dementia risk was significantly increased for participants with persistent drug use with a high anticholinergic cognitive burden score (HR 1.95, 95% CI 1.13–3.38) though this effect was absent when excluding participants taking antidepressants or antipsychotics (HR 0.42, 95% CI 0.06–3.01). Conclusions and Implications In our study population, benzodiazepine usage was not associated with an increased risk of dementia. Persistent high anticholinergic exposure was associated with an increased risk of dementia over 6 years of follow-up, and this association was driven by antidepressant or antipsychotic drug use, suggesting confounding by indication bias contributing to this. Although this observation could ameliorate prescription hesitance, healthcare providers are still advised to carefully weigh the potential benefits of benzodiazepines and anticholinergic drugs against the associated adverse health outcomes.

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

The initiative described here aims to identify quality indicators (QIs) germane to the international practice of primary care providers (PCP) in post-acute and long-term care in order to demonstrate the added value of medical providers in nursing homes (NHs). A 7-member international team identified and adapted existing QIs to the AMDA competencies for medical providers. QI sources included the ACOVE 3 Quality Indicators (2007), NH Quality Indicators (2004), NH Residential Care Quality Indicators (2002), and AGS Choosing Wisely (2014). We recruited a technical expert panel (TEP) consisting of 11 panelists from the US, Canada, and the European Union, selected for their knowledge and leadership in post-acute and long-term care. The TEP, using a RAND Modified Delphi approach, provided pre-meeting ratings, discussed items in-person for clarification, and re-rated items following discussion. When panelists rated more than 1 option for a particular QI as valid and feasible, the most stringent option was selected for inclusion in the final candidate set of QIs. Panelists confidentially rated an initial 103 items on validity and feasibility of implementation. During the meeting, panelists added 18 QIs and modified 18. In post-meeting analysis, we eliminated 7 QIs rated not valid and 9 QIs for which a more stringent QI was rated valid and feasible. This resulted in a final set of 97 QIs rated valid and feasible and 8 rated valid but not feasible. This set of QIs for PCPs in the NH identified practices in which provider engagement adds value through expertise in geriatric syndromes, employing evidence-based practice, advocating for residents, delivering person-centered care, facilitating advance care planning, and communicating effectively to coordinate care. Next steps include pilot testing and evaluating the association between adherence to QIs, PCP staffing models, and better outcomes.

Background and objective The use of psychotropic medication and cardiovascular medication has been associated with an increased risk of falling. However, other frequently prescribed medication classes are still under debate as potential risk factors for falls in the older population. The aim of this systematic review and meta-analysis is to evaluate the associations between fall risk and nonpsychotropic and noncardiovascular medications. Methods and design A systematic review and meta-analysis. A search was conducted in Medline, PsycINFO, and Embase. Key search concepts were “falls,” “aged,” “medication,” and “causality.” Studies were included that investigated nonpsychotropic and noncardiovascular medications as risk factors for falls in participants ≥60 years or participants with a mean age ≥70 years. A meta-analysis was performed using the generic inverse variance method, pooling unadjusted and adjusted odds ratio (OR) estimates separately. Results In a qualitative synthesis, 281 studies were included. The results of meta-analysis using adjusted data were as follows (a pooled OR [95% confidence interval]): analgesics, 1.42 (0.91-2.23); nonsteroidal anti-inflammatory drugs (NSAIDs), 1.09 (0.96-1.23); opioids, 1.60 (1.35-1.91); anti-Parkinson drugs, 1.54 (0.99-2.39); antiepileptics, 1.55 (1.25-1.92); and polypharmacy, 1.75 (1.27-2.41). Most of the meta-analyses resulted in substantial heterogeneity that did not disappear after stratification for population and setting in most cases. In a descriptive synthesis, consistent associations with falls were observed for long-term proton pump inhibitor use and opioid initiation. Laxatives showed inconsistent associations with falls (7/20 studies showing a positive association). Conclusion Opioid and antiepileptic use and polypharmacy were significantly associated with increased risk of falling in the meta-analyses. Long-term use of proton pump inhibitors and opioid initiation might increase the fall risk. Future research is necessary because the causal role of some medication classes as fall-risk-increasing drugs remains unclear, and the existing literature contains significant limitations.

BACKGROUND: Malnutrition and frailty are two geriatric syndromes that significantly affect independent living and health in community-dwelling older adults. Although the pathophysiology of malnutrition and physical frailty share common pathways, it is unknown to what extent these syndromes overlap and how they relate to each other.METHODS: A systematic review was performed resulting in a selection of 28 studies that assessed both malnutrition and frailty in community-dwelling older adults. Furthermore, a meta-analysis was performed on 10 studies that used Mini- Nutritional Assessment and the Fried frailty phenotype to estimate the prevalence of malnutrition within physical frailty and vice versa.RESULTS: In the systematic review, 25 of the 28 studies used the Mini-Nutritional Assessment (long or short form) for malnutrition screening. For frailty assessment, 23 of the 28 studies focused on the physical frailty phenotype, of which 19 followed the original Fried phenotype. Fifteen studies analyzed the association between malnutrition and frailty, which was significant in 12 of these. The meta-analysis included 10 studies with a total of 5447 older adults. In this pooled population of community-dwelling older adults [mean (standard deviation) age: 77.2 (6.7) years], 2.3% was characterized as malnourished and 19.1% as physically frail. The prevalence of malnutrition was significantly associated with the prevalence of physical frailty (P < .0001). However, the syndromes were not interchangeable: 68% of the malnourished older adults was physically frail, whereas only 8.4% of the physical frail population was malnourished.CONCLUSIONS: The systematic review and meta-analysis revealed that malnutrition and physical frailty in community-dwelling older adults are related, but not interchangeable geriatric syndromes. Two out of 3 malnourished older adults were physically frail, whereas close to 10% of the physically frail older adults was identified as malnourished.

Aim Little is known about the impact of activity-based funding (ABF) to increase treatment intensity and decrease length of stay (LOS) of inpatient geriatric patients. In January 2014, ABF was implemented in The Netherlands with the aim to increase treatment intensity and shorten LOS in geriatric rehabilitation (GR). Objectives To describe the influence of ABF on treatment intensity and LOS of inpatient GR patients before and after ABF was implemented. Design Population-based, retrospective cohort study. Setting Thirty nursing homes providing inpatient GR across The Netherlands. Data Collection Digital medical records of patients who had received inpatient GR in Dutch nursing homes across The Netherlands were studied between January 1, 2013 and March 14, 2016. We calculated the mean treatment intensity in hours per week and median LOS in days in 3 cohorts according to the year of admittance. In addition, a historical representative cohort of GR patients who were admitted in 2007 was studied that represented the situation before the ABF reform was announced (eg, funding with a fixed price per day). In 2013, the funding with a fixed price per day was still in use but with compulsory ABF registration. In 2014 and 2015, the ABF was fully implemented. Statistical differences in treatment intensity and LOS were calculated between patients admitted in 2007 and 2013, 2013 and 2014, and 2013 and 2015. Statistical significance was set at a P value of

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Background and objective Use of certain medications is recognized as a major and modifiable risk factor for falls. Although the literature on psychotropic drugs is compelling, the literature on cardiovascular drugs as potential fall-risk-increasing drugs is conflicting. The aim of this systematic review and meta-analysis is to provide a comprehensive overview of the associations between cardiovascular medications and fall risk in older adults. Methods Design: A systematic review and meta-analysis. Data sources: Medline, Embase, and PsycINFO. Key search concepts were “fall,” “aged,” “causality,” and “medication.” Studies that investigated cardiovascular medications as risk factors for falls in participants ≥60 years old or participants with a mean age of 70 or older were included. A meta-analysis was performed using the generic inverse variance method, pooling unadjusted and adjusted odds ratios (ORs) separately. Results In total, 131 studies were included in the qualitative synthesis. Meta-analysis using adjusted ORs showed significant results (pooled OR [95% confidence interval]) for loop diuretics, OR 1.36 (1.17, 1.57), and beta-blocking agents, OR 0.88 (0.80, 0.97). Meta-analysis using unadjusted ORs showed significant results for digitalis, OR 1.60 (1.08, 2.36); digoxin, OR 2.06 (1.56, 2.74); and statins, OR 0.80 (0.65, 0.98). Most of the meta-analyses resulted in substantial heterogeneity that mostly did not disappear after stratification for population and setting. In a descriptive synthesis, consistent associations were not observed. Conclusion Loop diuretics were significantly associated with increased fall risk, whereas beta-blockers were significantly associated with decreased fall risk. Digitalis and digoxin may increase the risk of falling, and statins may reduce it. For the majority of cardiovascular medication groups, outcomes were inconsistent. Furthermore, recent studies indicate that specific drug properties, such as selectivity of beta-blockers, may affect fall risk, and drug-disease interaction also may play a role. Thus, studies addressing these issues are warranted to obtain a better understanding of drug-related falls.

Background and objective Falls are a major public health problem in older adults. Earlier studies showed that psychotropic medication use increases the risk of falls. The aim of this study is to update the current knowledge by providing a comprehensive systematic review and meta-analysis on psychotropic medication use and falls in older adults. Methods and design This study is a systematic review and meta-analysis. A search was conducted in Medline, PsycINFO, and Embase. Key search concepts were “falls,” “aged,” “medication,” and “causality.” Studies were included that investigated psychotropics (antipsychotics, antidepressants, anxiolytics, sedatives, and hypnotics) as risk factors for falls in participants ≥60 years of age or participants with a mean age of ≥70 years. Meta-analyses were performed using generic inverse variance method pooling unadjusted and adjusted odds ratio (OR) estimates separately. Results In total, 248 studies met the inclusion criteria for qualitative synthesis. Meta-analyses using adjusted data showed the following pooled ORs: antipsychotics 1.54 [95% confidence interval (CI) 1.28–1.85], antidepressants 1.57 (95% Cl 1.43–1.74), tricyclic antidepressants 1.41 (95% CI 1.07–1.86), selective serotonin reuptake inhibitors 2.02 (95% CI 1.85–2.20), benzodiazepines 1.42 (95%, CI 1.22–1.65), long-acting benzodiazepines 1.81 (95%, CI 1.05–3.16), and short-acting benzodiazepines 1.27 (95%, CI 1.04–1.56) Most of the meta-analyses resulted in substantial heterogeneity that did not disappear after stratification for population and healthcare setting. Conclusions Antipsychotics, antidepressants, and benzodiazepines are consistently associated with a higher risk of falls. It is unclear whether specific subgroups such as short-acting benzodiazepines and selective serotonin reuptake inhibitors are safer in terms of fall risk. Prescription bias could not be accounted for. Future studies need to address pharmacologic subgroups as fall risk may differ depending on specific medication properties. Precise and uniform classification of target medication (Anatomical Therapeutic Chemical Classification) is essential for valid comparisons between studies.

Background: The provision of institutional long term care for older people varies across Europe reflecting different models of health care delivery. Care for dying residents requires integration of palliative care into current care work, but little is known internationally of the different ways in which palliative care is being implemented in the care home setting. \ud \ud Objectives: To identify and classify, using a new typology, the variety of different strategic, operational and organisational activities related to palliative care implementation in care homes across Europe. \ud \ud Design and methods: We undertook a mapping exercise in 29 European countries, using two methods of data collection: (1) a survey of country informants and (2) a review of data from publically available secondary data sources and published research. Through a descriptive and thematic analysis of the survey data we identified factors that contribute to the development and implementation of palliative care into care homes at different structural levels. From this data a typology of palliative care implementation for the care home sector was developed and applied to the countries surveyed. \ud \ud Results: We identified three levels of palliative care implementation in care homes: macro (national/regional policy, legislation, financial and regulatory drivers), meso (implementation activities such as education, tools/frameworks, service models and research) and micro (palliative care service delivery). This typology was applied to data collected from 29 European countries and demonstrates the diversity of palliative care implementation activity across Europe with respect to the scope, type of development and means of provision. We found that macro and meso factors at two levels shape palliative care implementation and provision in care homes at the micro organisational level. \ud \ud Conclusions: Implementation at the meso and micro level is supported by macro level engagement, but can happen with limited macro strategic drivers. Ensuring the delivery of consistent and high quality palliative care in care homes is supported by implementation activity at these three levels. Understanding where each country is in terms of activity at these three levels (macro, meso and micro) will allow strategic focus on future implementation work in each country.

Objectives Pneumonia is a frequent condition in older people. Our aim was to examine the total healthcare cost related to pneumonia in nursing home (NH) residents over a 1-year follow-up period. Design This was a prospective, longitudinal, observational, and multicenter study that was a part of the Incidence of Pneumonia and related Consequences in Nursing Home Resident study. Setting Thirteen NHs located in Languedoc Roussillon and Midi-Pyrenees regions in France were included. Participants Resident in NH, older than 60 years and had a group iso-resource score ranging from 2 to 5. Measurements Pneumonia events were characterized according to the Observatoire du Risque Infectieux en Geriatrie criteria. Direct medical and nonmedical costs were assessed from the French health insurance perspective. Healthcare resources was retrospectively gathered from the French Social Health Insurance database and valued using the tariffs reimbursed by the French health insurance. Sociodemographic variables, clinical factors, vaccinations, cognition, depression, functional status, frailty index, as well as group iso-resource score were also recorded. Results Among the 800 patients initially included in the Incidence of Pneumonia and Related Consequences in Nursing Home Resident study, 345 which were listed in the database of the French Social Health Insurance were included in this economic study. Among them, 64 (18%) experienced at least 1 episode of pneumonia during the 1-year follow-up period. Mean annual total additional cost for a patient who experienced at least 1 episode of pneumonia during the 1 year follow-up period is 2813€. On average, total annual costs increased by 60% to 93% when a patient experienced at least 1 episode of pneumonia. Conclusions NH-acquired pneumonia has a great impact on total cost of care for NH residents. Our results suggest the potential economic savings that could be achieved if pneumonia could be prevented in NHs.