Epidemiology of Homicide in Community-Dwelling Older Adults: A Systematic Review and Meta-Analysis.

BACKGROUND: Empirical research investigating older adult homicide is sparse and rarely accumulated for greater insights. This systematic review and meta-analysis quantifies the prevalence and characteristics of homicide victimization among older adults (65 years and older) compared with younger adults (18-64 years). METHOD: We searched Cumulative Index to Nursing and Allied Health Literature, Cochrane, Criminal Justice Abstracts, EMBASE, MEDLINE, ProQuest, PsycINFO, Scopus, and Web of Science for studies published before December 31, 2018 (International Prospective Register of Systematic Reviews registration: CRD42017054536). Included were English-language, original, peer-reviewed studies describing the homicide of older adults. Excluded were studies not meeting age criteria, residence as an institution, or with insufficient outcome variables. The review included 39 studies; 17 were included in the meta-analysis. Data were extracted via open access or from study authors. Heterogeneity was assessed through study-level random effects estimates. RESULTS: Pooled homicide rates per 100,000 population were 2.02 (95% CI [1.23, 3.33]) for older adults (n = 35,325) and 3.98 (95% CI [2.42, 6.53]) for younger adults (n = 607,224; rate ratio = .51, 95% CI [0.37, 0.70], p < .001). Proportion estimates for older adults: victim female 46.3%, location home 71.4%, offender familiar 25.2%, compared to stranger, 24.2%, motive argument 36.1%, compared to felony 30.8%, and weapon firearm 24.5%. Older adults were significantly different to younger adult victims (p = <.001) for female (OR = 2.5, 95% CI [2.02, 3.10]), home (3.87, 95% CI [3.45, 4.35]), stranger (1.81, 95% CI [1.66, 1.98]), argument (0.33, 95% CI [0.28, 0.39]), felony (2.78, 95% CI [2.58, 2.99]), and firearm (0.38, 95% CI [0.36, 0.40]). CONCLUSIONS: Homicide against older adults differs from younger adults and warrants specific research and tailored prevention strategies.

Search and rescue incidents among persons 65 years and older in the USA: Examination of factors associated with death.

OBJECTIVES: Older people are vulnerable to becoming lost from home, especially if alone and in unfamiliar environments. Incidents of older persons becoming lost are frequently reported and often requiring a search and rescue (SAR) response. Becoming lost is distressing to the person concerned, their carer, and family and may result in physical injury and/or death. This study examined what factors are associated with death among older persons reported lost from home. METHODS/DESIGN: A retrospective cross-sectional study. Data were obtained from the International Search and Rescue Incident Database from 1985 to 2013. Participants comprised persons aged 65 years and older living in the United States. Individual, SAR incident, and environmental factors were analysed. The primary outcome of this study was lost person found alive or found dead on arrival. Relationships between categorical variables and outcome were summarised with contingency tables, chi-squared test p-values (or Fisher's-exact-test), and odds ratios (OR) with 95% confidence intervals (CI). Association between continuous variables and outcome were examined using multiple logistic regression. p-value of <0.05 was considered significant. RESULTS: Among the 5242 SAR incidents, 1703 met the inclusion criteria, of which 87.8% (n = 1495) were found alive and 12.2% (n = 208) were found dead. Factors associated with death included: male gender (OR 1.46; CI 1.01-2.13; p = 0.048), cognitively intact (OR 0.32; CI 0.22-0.47; p < 0.001), prolonged SAR duration (OR: 1.028; CI: 1.021-1.035; p < 0.001), found in water/wetlands (OR 7.40; CI 3.37-16.24; p < 0.001), and extreme weather (OR: 2.06; 95% CI: 1.10-3.86; p = 0.024). CONCLUSIONS: Older people have a fundamental human right to protection from preventable deaths. Findings indicate these rights are not being protected with deaths occurring frequently among older people who have become lost from home. To minimise fatalities, knowledge of factors associated with death could inform the development suitable assessment and intervention strategies for SAR teams and caregivers.

Integrity in Guardianship Decision Making: Applying the Will and Preferences Paradigm.

Guardianship laws have changed significantly over the 20th and 21st centuries to shift from the "best interests" model to the "supported decision-making" model. Such changes reflect the importance of supporting the dignity of risk of persons who lack decision-making capacity for some decisions. Recent changes to the Victorian Guardianship and Administration Act 2019 (Vic) in Australia require guardians to give effect to the "will and preferences" of the represented person, as far as practicable. The changes reveal a compromise between the competing rights to autonomy and to safety. Here, we explore the meaning of "will and preferences" before considering the personal factors that may contribute to the understanding of an individual's will and preferences. The practical challenge of ascertaining, interpreting, and giving effect to a person's will and preferences are also discussed. Finally, we consider the practical challenge of identifying when a person needs decision-making support.

Evaluation of an online course for prevention of unwanted sexual behaviour in residential aged care services-A pilot study.

BACKGROUND: Residential aged care services (RACS) staff have substantial gaps in knowledge to prevent and manage unwanted sexual behaviour (USB) in RACS. OBJECTIVES: This study aimed to explore the feasibility of a pilot online course (intervention) addressing USB in RACS. METHOD: Development of a self-guided e-learning educational course was based on existing research, national and international approaches to human rights approaches to sexual assault and underwent internal and external peer review. An anonymous, online, cross-sectional survey was conducted post-intervention completion. RAC-Communiqué subscribers were recruited via an e-invitation. English speaking enrolled or registered nurses, employed in an Australian RACS, were eligible. From the 167 participants who expressed interest to enrol, 129 were eligible and 45 returned completed consent forms. Fifteen survey items regarding perceived competence and intervention satisfaction were analysed. RESULTS: The intervention addressed content pertaining to staffs' legal and regulatory requirements, managing incidents and awareness of key services. Thirty-eight of 45 eligible participants responded (84.4%). Participants reported they would recommend the intervention to a colleague (n = 36, 97.3%). Participants self-reported (i) advanced learning post-completion; (ii) raised awareness (n = 29, 78.4%) (iii) prompted current practice reflection (n = 35, 94.6%) and (iv) prompted improving USB workplace management (n = 34, 91.9%). Results are subjected to social desirability bias. CONCLUSIONS: The intervention was relevant, engaging and practical. The findings contribute to a more comprehensive understanding of the specific training topics relevant and useful to RACS staff. IMPLICATION FOR PRACTICE: E-learning tools could be an effective teaching method for USB in RACS. The intervention may be a useful tool to encourage staff to reflect and change current practice.

Aged care nurses' perception of unwanted sexual behaviour in Australian residential aged care services.

OBJECTIVES: To explore aged care nurses' awareness and experience of unwanted sexual behaviour (USB) in residential aged care services (RACS). METHODS: An anonymous online questionnaire was administered to an opportunistic sample of RACS nurses enrolled to complete an e-learning course in Australia. From the 167 participants who expressed interest to enrol, 129 were eligible and 53 returned completed consent forms. RESULTS: 46/53 responded of which most were females (41/45, 91.1%). Few respondents reported resident-resident USB (<35%) or staff-resident USB (<22%) happened once a year. Most respondents had not been informed by a resident of USB (>75%) or had personally reported USB within their internal reporting system (>77%). Respondents were also unaware if their facility had lodged an incident report to the regulator or law enforcement authorities within the past 12 months (34/46, 73.9%). Finally, most considered there to be no barriers to reporting USB (35/46, 77.8%). CONCLUSIONS: Respondents' awareness and estimates of USB directed at residents were much lower than known national prevalence rates. This lack of awareness could be a substantive barrier to recognition and optimal management of this form of abuse.

Places of living and places of dying: the case for preventing suicide in residential long-term care.

This commentary addresses the increasing public health problem of suicide in later life and presents the case for preventing suicide in residential long-term care settings. We do so by examining this issue from the perspective of three levels of stakeholders - societal, organisational and individual - considering the relevant context, barriers and implications of each. We begin by discussing contemporary societal perspectives of ageing; the potential impact of ageism on prevention of late-life suicide; and the roles of gender and masculinity. This is followed by a historical analysis of the origin of residential long-term care; current organisational challenges; and person-centred care as a suicide prevention strategy. Finally, we consider suicide in long-term care from the perspective of individuals, including the experience of older adults living in residential care settings; the impact of suicide on residential care health professionals and other staff; and the impact of suicide bereavement on family, friends and other residents. We conclude with recommendations for policy reform and future research. This commentary aims to confront the often unspoken bias associated with preventing suicide among older adults, particularly those living with complex medical conditions, and invoke an open dialogue about suicide prevention in this population and setting.

A Proactive Nursing Home Risk Stratification Model for Disaster Response: Lessons Learned from COVID-19 to Optimize Resource Allocation.

A coordinated emergency management response to disaster management in nursing homes is desperately needed globally. During the most recent COVID-19 pandemic, aside from a few exemplary countries, most countries have struggled to protect their nursing home populations. Timely and appropriate allocation of resources to nursing homes during disaster response is a challenging yet crucial task to prevent morbidity and mortality of residents. The responsibility for the management of nursing homes during the pandemic was multifaceted, and responsibilities lay at the national, jurisdictional, and regional levels. Success in managing COVID-19 in nursing homes required all these levels to be aligned and supportive, ideally through management by an emergency response leadership team. However, globally there is a paucity of effective management strategies. This article uses the example of the COVID-19 pandemic to propose a risk stratification system to ensure timely and appropriate allocation of resources to nursing homes during disaster preparation and management. Nursing homes should be risk-stratified according to 4 domains: risk of intrusion, capability for outbreak containment, failure in organizational capability, and failure in the availability of community and health care supports. Risk stratification should also consider factors such as current levels of community transmission, if applicable, and geographic location of nursing homes and services. Early identification of nursing homes at risk for infectious disease, or disasters, and targeted allocation of resources might help reduce the number of outbreaks, lower the mortality, and preserve community supports such as acute hospital services. The next step is to debate this concept to validate the selected variables and then develop and pilot test a risk stratification tool for use.

An Ageing Population Creates New Challenges Around Consent to Medical Treatment.

Obtaining consent for medical treatment in older adults raises a number of complex challenges. Despite being required by ethics and the law, consent for medical treatment is not always validly sought in this population. The dynamic nature of capacity, particularly in individuals who have dementia or other cognitive impairments, adds complexity to obtaining consent. Further challenges arise in ensuring that older people comprehend the medical treatment information provided and that consent is not vitiated by coercion or undue influence. Existing mechanisms to address issues surrounding consent for older adults only address incapacity and raise further challenges. As the ageing population increases, these issues are likely to become more profound, thus action is required to address these challenges. Raising awareness, more education, engaging with people with dementia, and conducting further research would assist in beginning to overcome these challenges.

Characteristics of nursing homes associated with COVID-19 outbreaks and mortality among residents in Victoria, Australia.

OBJECTIVE: To determine nursing home characteristics associated with COVID-19 outbreak, outbreak size and mortality, during the second wave in Victoria, Australia. METHOD: Population-based cross-sectional study of all nursing homes in Victoria between 7 July and 13 November 2020. RESULTS: There were one or more resident cases of COVID-19 in 9.7% of nursing homes (74/766). COVID-19 intrusion was more likely in larger metropolitan facilities, privately owned by large chains, with a past history of regulatory non-compliance, located close to high-risk industry. Larger outbreaks were associated with homes in metropolitan areas, accommodating 91 or more residents, with shared rooms, owned by private providers operating many (11 or more) facilities. The highest case-fatality rates were observed in homes owned by not-for-profit providers operating many facilities, located close to high-risk industry. CONCLUSION: Stratifying nursing homes according to characteristics associated with morbidity and mortality can inform risk management, prioritising emergency responses and optimising future nursing home operations.

Risk Stratification of Nursing Homes to Plan COVID-19 Responses: A Case Study of Victoria, Australia.

OBJECTIVE: Emergency management responses to coronavirus disease 2019 (COVID-19) in nursing homes lacked preparation and nuance; moving forward, responses must recognize nursing homes are not generic organizations or services, and individually appreciate each's unique nature, strengths, and limitations. The objective of this study was to describe an approach to stratifying nursing homes according to risk for COVID-19 outbreak. METHODS: Population-based cross-sectional study of all accredited nursing homes in Victoria (n = 766), accommodating 48,824 permanent residents. We examined each home's facility structure, governance history, socio-economic status, proximity to high-risk industry, and proximity and size of local acute public hospital, stratified by location, size, and organizational structure. RESULTS: Privately owned nursing homes tend to be larger and metropolitan-based, and publicly owned homes regionally based and smaller in size. The details reveal additional nuance, eg, privately owned metropolitan-based medium- to large-sized facilities tended to have more regulatory noncompliance, no board of governance, and fewer Chief Executive Officers with clinical background. In contrast, the smaller, publicly owned, remote facilities perform better on those same metrics. CONCLUSIONS: Nursing homes should not be regarded as generic entities, and there is significant underlying heterogeneity. Stratification of nursing homes according to risk level is a viable approach to informing more nuanced policy direction and resource allocation for emergency management responses.

Attitudes towards dignity of risk in older people: A survey following a short narrative film.

OBJECTIVE: To evaluate aged care staff's 'willingness to help an older person with risk-taking activities' that improve quality of life ('dignity of risk'). METHODS: Opportunity-based cross-sectional anonymous electronic survey in four Australian jurisdictions, conducted immediately after screening a short animated narrative film describing 'dignity of risk'. Survey comprised nine questions including respondent demographics, professional role, risk-taking and outcome. RESULTS: From 24 separate screenings, there were 929 respondents. Agreement to 'help an older person with risk-taking activities' was associated with respondent prediction of the least severe harm occurring (OR = 2.22 [1.20, 4.12], P = .001). Conversely, respondents in non-executive, non-managerial roles-that is, nurses and care workers-were unlikely to agree to help with risk-taking activities (OR 0.36-0.49, P ≤ .03). There was not an association with respondent's age grouping (P = .6). CONCLUSION: Staff self-reported attitudes towards dignity of risk are important to understand to enhance in an older person's quality of life.

Deaths of young people living in residential aged care: a national population-based descriptive epidemiological analysis of cases notified to Australian coroners.

AIM: This study provides a descriptive epidemiological analysis stratified by age of deaths reported to Australian Coroners of residential aged care facility residents aged under 65 years. METHOD: A national population-based retrospective analysis was conducted of deaths of Australian residential aged care facility residents reported to Australian Coroners between 2000 and 2013. Descriptive statistics compared adult residents categorised using age by factors relating to the individual, incident and death investigation. RESULTS: Of the 21,736 deaths of residential aged care facilities residents aged over 20 years reported to Australian Coroners, 782 (3.6%) were of residents aged 20-64 years. Natural cause deaths occurred at similar rates irrespective of age. Intentional external cause deaths were higher in residents aged 20-64 years (5.3% vs. 16.0%; OR 3.43, 95% CI 2.0-5.9; p < 0.001), with suicide rates three times that of the over 65 years group (13.2% vs. 4.1%; OR 0.28, 95% CI 0.16-0.51; p < 0.001). External cause deaths from choking and falls were most common in the younger and older groups respectively. CONCLUSIONS: More is required to prevent external cause deaths in young residential care facility residents.IMPLICATIONS FOR REHABILITATIONOne in seven (14.1%) deaths of people aged 20-64 years in residential aged care facilities are premature and potentially avoidable. The more common external causes of death include suicide, choking and falls.The prevalence and causes of preventable deaths in this study provide a basis for prompting and developing more specific prevention policies and practices to reduce harm for young people in residential aged care. Specifically, addressing loneliness would improve social inclusion, mental health and suicide risk. Better management of progressive neurological conditions with multidisciplinary team and re-ablement programs would reduce risk of choking and falls.Improving outcomes for young people in residential aged care requires a co-ordinated, multisector approach comprising relevant government departments, aged care providers, researchers and clinicians.Effective planning requires more information about the cause and nature of deaths, and due to the small event counts, this would ideally involve an international collaboration.

Injury prevention among young people in nursing homes: Recommendations following expert consultation forums.

BACKGROUND: Approximately 6,000 people under the age of 65 years reside in nursing homes each year in Australia. These young people in nursing homes are at risk of premature death and preventable morbidity from injuries. Choking and falls are the leading causes of premature deaths in this cohort with reported rates of 44% and 33%, respectively. OBJECTIVES: To develop injury prevention recommendations for young people in Australian nursing homes. METHODS: This mixed-methods study comprised two expert consultation panels and a follow-up survey. Two expert and stakeholder consultation panels used a modified nominal group technique to formulate recommendations. A short survey was subsequently given to participants to validate responses from the panels and to provide an opportunity to evaluate and rank recommendations. RESULTS: Ten recommendations were formulated for consideration that focused on system-wide reforms. Four were ranked as most important for implementation: education and training for nursing home staff; implementation of National Disability Insurance Scheme; support for coordinated care; and increasing residential housing stock that is appropriately designed. CONCLUSION: Extensive changes are needed to prevent injury for young people in nursing homes. Implementation should reduce the risk of injury and lead to an improved quality of life for this cohort. IMPLICATIONS FOR PRACTICE: This study provides an evidence base for aged care practitioners to improve practice within nursing homes to reduce fatal and non-fatal injuries for young people in nursing homes.

Systematic Review of Randomized Controlled Trials in Australian Nursing Homes from 2000 to 2018.

BACKGROUND/OBJECTIVES: High-quality research provides an evidence base for optimal practice care in clinical settings, yet, little is known about the nature and extent of randomized control trials (RCTs) conducted in Australian nursing homes (NHs). Research from other settings and other countries is not necessarily transferable to the Australian NH sector. We sought to identify and describe RCTs conducted in Australia which investigated interventions targeted at improving care for NH residents. DESIGN: The design of this study comprised a systematic literature search with a narrative review. Studies were included if they were RCTs published after 2000, conducted in an Australian NH, and evaluated a health intervention which may have directly or indirectly benefitted the NH resident. SETTING: Australian NHs. PARTICIPANTS: Nursing home residents. MEASUREMENTS: Jurisdiction (state or territory where the study was conducted), number of NHs recruited in each trial, number of residents included in each trial, intervention characteristics, comparator characteristics, and characteristics of outcome. RESULTS: Only 43 articles reporting on 39 RCTs were identified. In contrast, 30 Australian musculoskeletal RCTs were published in just 2 years (2011-2012). Most of the RCTs identified were conducted in New South Wales (n = 14), Queensland (n = 10), and Victoria (n = 9). The mean number of NHs included in each trial was 22.4 (standard deviation (SD) = 27.0), with a median of 14.5 (interquartile range (IQR) = 27.8), while the mean number of residents included was 412.4 (SD = 921) with a median of 187 (IQR = 341.0). The most common interventions targeted: managing dementia (n = 20), prevention of falls (n = 7), and addressing mental health issues (n = 6). CONCLUSION: This review provides evidence of the paucity of high-quality research in the form of RCTs, in the Australian NH setting and demonstrates the need for Australia to improve its research capability in the NH sector.

Use of Alcohol in Long Term Care Settings: A Comparative Analysis of Personal Choice, Public Health Advice and the Law.

Alcohol is one of the most widely available psychoactive substances globally. Many accept the risks associated with alcohol consumption for reasons such as social engagement and feelings of pleasure. Alcohol consumption in a nursing home (NH) setting highlights the moral and logistical challenges of balancing the need for a safe living and working environment with the dignity of risk (DoR) and personal autonomy of residents. This analysis explores public health, human rights, and legal frameworks in their approach to a NH resident's choice to drink alcohol. Key issues under the public health framework include the medical risks associated with alcohol consumption, whether residents with impaired cognitive functioning have the capacity to make a decision about alcohol consumption, and the practical and ethical implications of supplying alcohol to residents. Under a legal framework, NHs must consider the legal imperative to respect residents' rights, the possibility of liability in negligence, duties owed to employees, the existence of substitute decision-makers, and liquor licensing laws. Fundamental considerations under the human rights framework include the damaging psychological effects of risk-avoidance and the importance of inclusive risk assessment processes. Alcohol policies should incorporate elements from all 3 frameworks. There is limited data publicly available about alcohol policies in NHs. Further research is needed to establish current practice and to evaluate the merits and disadvantages of different policies. Establishing inclusive and thorough decision-making processes is key to achieving better consumer-directed care.

Developing a clinical screening tool for identifying COVID-19 infection in older people dwelling in residential aged care services.

OBJECTIVE: To develop and conduct preliminary feasibility testing of a clinical screening instrument for early identification of COVID-19 infection in older people residing in residential aged care services (RACS). METHODS: A qualitative study was conducted using a multi-modal approach involving examination of existing literature and national guidelines for COVID-19 clinical screening, formulation of a discussion document with peer review and feasibility testing of a prototype screening tool. RESULTS: Existing COVID-19 clinical screening tools do not consider age-related impacts on clinical presentation. The qualitative analysis identified the important clinical elements to include were a lower threshold for temperature, occurrence of a recent fall and change in functional status. The new elements also had to be simple and feasible to implement. Overall feedback was positive with all participants recommending the use of the new tool. CONCLUSION: A new screening tool for RACS residents was developed addressing the pathophysiological changes with ageing and atypical features of COVID-19 infection.