Medication Appropriateness for Older Nursing Home Patients With a Limited Life Expectancy: From STOPP/START Version 2 to the ReNeWAL Criteria.

OBJECTIVES: To adapt the 2015 Screening Tool of Older Persons' Prescriptions (STOPP)/Screening Tool to Alert to Right Treatment (START) criteria to older nursing home patients with a limited life expectancy of 1.5 to 2 years. DESIGN: A modified Delphi consensus study. SETTING AND PARTICIPANTS: The study was established in The Netherlands and conducted online. The international panel consisted of 23 experts with experience in medicine for older people. METHODS: The expert panel was presented with the 2015 STOPP/START criteria using an online survey program (Survey Monkey). The panelists were asked for their opinion on the appropriateness of the STOPP and START criteria, and adaptations to these criteria for older nursing home patients with a limited life expectancy on 4-point Likert scales. Consensus was defined as ≥70% of the panelists answering (very) inappropriate or (very) appropriate, and (completely) disagree or (completely) agree. RESULTS: Twenty-one panelists completed all 3 Delphi rounds. The final list of "Represcribing for Nursing home residents With A Limited life expectancy (ReNeWAL)" criteria comprises 132 criteria: 98 criteria to stop (70 original STOPP criteria and 28 adapted) and 34 criteria to start (16 original START criteria and 18 adapted) for older nursing home patients with a limited life expectancy. Considerations that panelists mentioned for adapting criteria were mainly prevention and treatment of discomfort. CONCLUSION AND IMPLICATIONS: It is clear that represcribing for older nursing home patients is highly complex and requires the consideration of various elements. The ReNeWAL criteria may be useful in enhancing represcribing for older nursing home patients with a limited life expectancy.

Variation in Excess Mortality Across Nursing Homes in the Netherlands During the COVID-19 Pandemic.

OBJECTIVES: Nursing home residents constituted a vulnerable population during the COVID-19 pandemic, and half of all cause-attributed COVID-19 deaths occurred within nursing homes. Yet, given the low life expectancy of nursing home residents, it is unclear to what extent COVID-19 mortality increased overall mortality within this population. Moreover, there might have been differences between nursing homes in their ability to protect residents against excess mortality. This article estimates the number of excess deaths among Dutch nursing home residents during the pandemic, the variation in excess deaths across nursing homes, and its relationship with nursing home characteristics. DESIGN: Retrospective, use of administrative register data. SETTING AND PARTICIPANTS: All residents (N = 194,432) of Dutch nursing homes (n = 1463) in 2016-2021. METHODS: We estimated the difference between actual and predicted mortality, pooled at the nursing home level, which provided an estimate of nursing home-specific excess mortality corrected for resident case-mix differences. We show the variation in excess mortality across nursing homes and relate this to nursing home characteristics. RESULTS: In 2020 and 2021, the mortality probability among nursing home residents was 4.0 and 1.6 per 100 residents higher than expected. There was considerable variation in excess deaths across nursing homes, even after correcting for differences in resident case mix and regional factors. This variation was substantially larger than prepandemic mortality and was in 2020 related to prepandemic spending on external personnel and satisfaction with the building, and in 2021 to prepandemic staff absenteeism. CONCLUSIONS AND IMPLICATIONS: The variation in excess mortality across nursing homes was considerable during the COVID-19 pandemic, and larger compared with prepandemic years. The association of excess mortality with the quality of the building and spending on external personnel indicates the importance of considering differences across nursing home providers when designing policies and guidelines related to pandemic preparedness.

Compiling a Set of Actionable Quality Indicators for Medical Practitioners in Dutch Nursing Homes: A Delphi Study.

Most quality indicators (QIs) currently used in nursing homes reflect the care delivered by the entire multidisciplinary team and are not specific for medical practitioners. International experts have proposed a set of QIs that specifically reflect the quality of medical care in nursing homes. The objective of the Delphi study described here was to compile a set of actionable QIs tailored for medical practitioners working within Dutch nursing homes. This was achieved through the evaluation of 15 existing national QIs and 35 international QIs by a panel of medical practitioners, comprising medical specialists, nurse practitioners, and physician assistants, who are working in Dutch nursing homes. Panelists rated each QI on (1) level of direct control by medical practitioners and (2) its relevance to the quality of medical care. QIs progressing to subsequent rounds required panel agreement on both direct control (≥70% ≥3 points on a 4-point scale) and relevance (≥70% ≥8 on a 10-point scale). In the last round, each panelist selected the 5 most relevant QIs and arranged them in order of importance. These top 5 rankings were converted into points for an overall final ranking. There was consensus on 42 QIs being under the control of medical practitioners, and 21 of these QIs were considered relevant for quality of care. Most of the 21 QIs originated from the international QI set. This finding supports the transferability of the internationally developed QIs to the Dutch nursing home context and provides opportunities to compare the quality of medical care in nursing homes across countries. In the final ranking, the QI related to new medication prescriptions received the highest rating, followed by 3 QIs related to advance care planning. Future research should focus on evaluating the feasibility of measuring the selected QIs and assessing their measurement properties before implementing them in professional learning and quality improvement initiatives for medical practitioners in nursing homes.

Urinary Tract Infection Guideline Adherence in a Dutch Sentinel Nursing Home Surveillance Network.

OBJECTIVES: To investigate guideline adherence 3 years after the introduction of a national guideline on urinary tract infections (UTIs) in frail older adults. Appropriate use of urine dipstick tests, treatment decisions, and antibiotic drug choices in residents with (suspected) UTIs without a catheter were examined. DESIGN: Observational prospective study. SETTING AND PARTICIPANTS: Nineteen nursing homes participating in a Dutch Sentinel Nursing Home Surveillance Network. METHODS: As of September 2021, for a 3-month period, medical practitioners recorded additional clinical information in the electronic health record in case of a (suspected) UTI. Based on this information, adherence to guideline recommendations was assessed. Nonadherence was classified into 2 categories: (1) "intentional nonadherence" as reported by practitioners and (2) "nonadherence otherwise" applied to all other cases where the recorded information was discordant with the guideline recommendations. RESULTS: A total of 532 cases of (suspected) UTIs from 469 residents were analyzed. In 455 cases (86%), dipsticks were used. For the 231 cases where clinical signs and symptoms already indicated no UTI treatment according to the guideline, a dipstick was still inappropriately ordered in 196 cases (85%). The decision to prescribe or withhold antibiotics was in 69% of the cases adherent, in 6% intentionally nonadherent, and in 25% nonadherent otherwise. The type of prescribed antibiotic was adherent to the recommended antibiotics for cystitis in 88% and for UTIs with signs of tissue invasion in 48%. Overall, for 40% of suspected UTIs, adherence to all relevant recommendations could be established, and in 9% practitioners reported intentional nonadherence to the guideline. CONCLUSIONS AND IMPLICATIONS: There is considerable room for improvement in all clinical stages of managing a suspected UTI in Dutch nursing homes, particularly with regard to the importance of patient's clinical signs and symptoms for appropriate dipstick use and antibiotic UTI treatments.

Barriers and facilitators for physical fitness training in orthopedic geriatric rehabilitation. A qualitative study.

PURPOSE: The aim of this explorative, qualitative study is to identify factors that potentially influence the execution of physical fitness training in inpatient orthopedic geriatric rehabilitation (GR), from the perspectives of patients, their relatives and professionals. MATERIALS AND METHODS: In GR wards of skilled nursing facilities in the Netherlands, semi-structured interviews were held with triads of patients, their relatives and responsible nurses, and focus groups with members of the multidisciplinary teams. Verbatim reports were analyzed according to the framework method. RESULTS: We found twelve categories of barriers and facilitators related to characteristics of the patients, their family, staff, training program and organization. CONCLUSIONS: The barriers and facilitators found largely correspond with those found for participation in exercise in related settings, but also show important differences. This overview of barriers and facilitators enables multidisciplinary teams to design improvements at the level of the organization and interventions, as well as at the level of the individual training program, tailoring it to the patient's circumstances and needs. Further research should focus on weighing these barriers and facilitators to develop a feasible guidance for daily practice, as well as testing their effect on the adherence to existing physical fitness training guidelines.

Physical fitness training is important in reaching functional goals in orthopedic geriatric rehabilitation.Practicing outside of therapy can be stimulated by clarity about expectations, proper training equipment and tailored stimulation/assistance.Training volume and intensity should meet the guidelines, but be tailored to the patient.Characteristics of the program, staff and organization need to be considered as they impact the physical fitness training.

A Process Evaluation of an Antibiotic Stewardship Intervention for Urinary Tract Infections in Nursing Homes.

OBJECTIVES: To assess the internal and external validity of a cluster randomized controlled trial (cRCT) evaluating a decision tool with supportive interventions for the empirical treatment of urinary tract infections (UTIs) in nursing homes (NHs), and to identify facilitators and barriers in implementing this antibiotic stewardship intervention. DESIGN: Mixed-methods process evaluation study. SETTING AND PARTICIPANTS: Physicians, nursing staff, client council members, and residents of Dutch NHs. METHODS: We used cRCT data of the ANNA study (Antibiotic Prescribing and Non-prescribing in Nursing Home Residents With Signs and Symptoms Ascribed to Urinary Tract Infection). In addition, we sent out an online evaluation questionnaire, conducted semistructured interviews with physicians and nursing staff, and consulted client council members. RESULTS: Internal validity was lowered: control group physicians participated in several non-study-related activities regarding UTI. External validity was good: almost all intervention components had a high fidelity (52%-74%) and were perceived as relevant (physicians: 7.2-8.6 of 10, nursing staff: 6.5-8.5 of 10) and feasible (physicians: 7.5 of 10, nursing staff 6.4 of 10), with feasibility for residents with dementia and urine incontinence needing attention. The most common reason for deviating from the advice generated by the decision tool was an unclear illness presentation. Identified facilitators to implementation were confidence in the intervention, repeated intervention encounter, and having "champions" in the NH. Barriers were limited involvement of nursing staff, unstable nursing teams, residents' and representatives' belief that antibiotics should be prescribed, and a low antibiotic prescribing threshold within the NH culture. CONCLUSIONS AND IMPLICATIONS: Lowered internal validity may have reduced the study effect. Attention should be paid to the feasibility of the intervention in residents with dementia and urinary incontinence. Improvement opportunities for implementation were higher nursing staff involvement and repeated intervention offering.

The Role of Nursing Staff Regarding Goal Setting and Achieving in Geriatric Rehabilitation: A Focus Group Study.

PURPOSE: The aim of this study was to explore and clarify the role of nursing staff in geriatric rehabilitation on supporting patients in goal setting and achieving, through reflecting on rehabilitation interventions. DESIGN: A descriptive qualitative study was conducted. METHODS: We conducted four online focus group interviews with 23 members of the nursing staff working in geriatric rehabilitation. They reflected on six interventions, preclassified into three types: setting goals in the admission phase, increasing patient participation in order to personalize the rehabilitation trajectory, and supporting patients in working on short-term goals. Data were analyzed using thematic content analysis. RESULTS: Setting goals in the admission phase is primarily the task of the multidisciplinary team rather than the nursing staff. Interventions to increase patient participation align with the coordinating role of nursing staff in the rehabilitation team. Working on short-term goals is of great value to patients. CLINICAL RELEVANCE TO THE PRACTICE OF REHABILITATION NURSING: The connection between the patient's personal goals and professional treatment aimed at functional recovery can be enhanced by strengthening the position of nursing staff working in geriatric rehabilitation. CONCLUSION: Members of nursing staff in geriatric rehabilitation see themselves playing a coordinating role in the multidisciplinary team, supporting the patient in goal work. Interventions aimed at advancing patient participation and providing support for short-term goals reinforce this role.

Association of Vulnerability Screening on Hospital Admission with Discharge to Rehabilitation-Oriented Care after Acute Hospital Stay.

BACKGROUND: We assessed the vulnerability of patients aged ≥70 years during hospital admission based on the Short Dutch Safety Management Screening (DSMS). Screening of four geriatric domains aims to prevent adverse outcomes and may support targeted discharge planning for post-acute care. We explored whether the DSMS criteria for acutely admitted patients were associated with rehabilitation-oriented care needs. METHODS: This retrospective cohort study included community-dwelling patients aged ≥70 years acutely admitted to a tertiary hospital. We recorded patient demographics, morbidity, functional status, malnutrition, fall risk, and delirium and used descriptive analysis to calculate the risks by comparing the discharge destination groups. RESULTS: Among 491 hospital discharges, 349 patients (71.1%) returned home, 60 (12.2%) were referred for geriatric rehabilitation, and 82 (16.7%) to other inpatient post-acute care. Non-home referrals increased with age from 21% (70-80 years) to 61% (>90 years). A surgical diagnosis (odds ratio [OR]=4.92; 95% confidence interval [CI], 2.03-11.95), functional decline represented by Katz-activities of daily living positive screening (OR=3.79; 95% CI, 1.76-8.14), and positive fall risk (OR=2.87; 95% CI, 1.31-6.30) were associated with non-home discharge. The Charlson Comorbidity Index did not differ significantly between the groups. CONCLUSION: Admission diagnosis and vulnerability screening outcomes were associated with discharge to rehabilitation-oriented care in patients >70 years of age. The usual care data from DSMS vulnerability screening can raise awareness of discharge complexity and provide opportunities to support timely and personalized transitional care.

Observation of urinary tract infection signs and symptoms in nursing home residents with impaired awareness or ability to communicate signs and symptoms: The development of supportive tools.

BACKGROUND: Antibiotics are often inappropriately prescribed for urinary tract infections (UTIs) in nursing home (NH) residents. Research emphasises the importance of prescribing antibiotics only if there are UTI-related signs and symptoms (S&S). However, for many NH residents it is challenging to find out whether such S&S are present, for example due to cognitive disorders. OBJECTIVES: To provide insight into the assessment of UTI-related S&S in NH residents with impaired awareness or ability to communicate S&S, and to develop supportive tools for the observation of UTI-related S&S in this subgroup of NH residents, by nursing staff. METHODS: We performed a practice-based study using mixed methods. Data of 295 cases of suspected UTI were analysed to determine how often UTI-related S&S were 'not assessed/non-assessable' in residents with and without dementia. Barriers and facilitators in observing UTI-related S&S in NH residents with impaired awareness or ability to communicate S&S were derived from interviews and focus groups with nursing staff. Literature review, focus group data, additional telephone interviews and questionnaires with nursing staff were used in a step-by-step process, including pilot testing, to develop supportive tools for the observation of UTI-related S&S. RESULTS: UTI-related S&S were assessable in the majority of NH residents with dementia. The proportion 'not assessed/non-assessable' S&S in residents with dementia increased with increasing severity of dementia. In residents with very severe dementia, up to 58% of the S&S were 'not assessed/non-assessable'. Knowing the resident, working methodologically, and being sufficiently skilled to interpret observations in residents facilitate the assessment of UTI-related S&S. Insights acquired during the different study elements resulted in the development of an observation checklist and a 24-h observation tool. CONCLUSIONS: The more NH residents have impaired awareness of ability to communicate S&S, the more difficult it seems to be to assess UTI-related S&S. The observation checklist and 24-h observation tool developed in the current study may support nursing staff in their observation of UTI-related S&S in this group of NH residents.

Advance Care Planning in Huntington Disease: The Elderly Care Physician's Perspective.

OBJECTIVE: Huntington disease (HD) has a poor prognosis. Decision-making capacity and communication ability may become impaired as the disease progresses. Therefore, HD patients are encouraged to engage in advance care planning (ACP). Elderly care physicians (ECPs) can play an important role in ACP in HD patients. However, little is known about their experiences in this role. The aim of this study is to gain insight into how ECPs practice ACP with HD patients. DESIGN: A qualitative interview study. SETTING AND PARTICIPANTS: Nine ECPs working in HD-specialized nursing homes in the Netherlands. METHODS: We conducted semistructured interviews with ECPs between June 2018 and July 2020. RESULTS: Two phases could be identified in the process of ACP. In the first phase, when the feared future seems to be far away, the ECP asks about the patient's wishes for the future in an accommodating manner. In the second phase, when the feared future is closer, future medical treatment and care becomes less hypothetical. Agreement has to be reached on upcoming treatment decisions. In this phase, the ECP takes a more guiding role, and consequently encounters more difficulties, such as maintaining a positive patient/family-physician relationship while dealing with disagreements with patient or family. Most participants shared their experiences with euthanasia when asked about ACP. When making a comparison of ACP between HD patients and patients with other neurodegenerative disorders in nursing homes, the ECPs emphasized the similarities. CONCLUSIONS AND IMPLICATIONS: ACP in HD can be classified into 2 phases, which differ in ECPs' approach and the complexity experienced by the ECP. Awareness of this finding may help to further develop training and education in ACP, including dealing with euthanasia, to make ECPs feel better equipped in practicing ACP in HD.

Exercise testing and training in frail older adults with an orthopedic impairment participating in a geriatric rehabilitation program: an international Delphi study.

BACKGROUND: Little is known about exercise testing and training in orthopedic geriatric rehabilitation. This study aims to obtain expert-consensus-based recommendations on this matter. METHODS: Using an online Delphi study we aimed to reach international expert consensus on statements related to testing and training of endurance capacity and muscle strength. Participants needed to have relevant research or clinical expertise. Statements were evaluated and explanatory comments could be provided. After each round anonymous results were presented to participants. Statements could be adjusted or new ones could be formulated if necessary. Consensus was defined as > 75% of participants agreeing. RESULTS: Thirty experts completed the first round. Twenty-eight (93%) the second and 25 (83%) completed the third round. The majority of experts were physical therapists. Consensus was reached on a total of 34 statements. The statements and comments reflected the need for a pragmatic and tailored approach in this population both for testing and training. For example, for testing endurance capacity, a 6 Minute walk test was promoted and for testing muscle strength, performance in a functional activity was suggested. Ratings of perceived exertion were promoted for monitoring intensity of endurance and muscle strength training in patients without cognitive impairment. CONCLUSION: In orthopedic GR, endurance and muscle strength testing should be pragmatic and is preferably performed in functional activities. For endurance training existing guidelines of the American College of Sports Medicine can be strived for but adapted as needed and for muscle strength training only lower intensities are agreed upon.

Nursing home residents with Huntington's disease: Heterogeneity in characteristics and functioning.

BACKGROUND: In Huntington's disease (HD), admission to a nursing home (NH) is required in advanced disease stages. To gain insight in care needs, more knowledge is needed on the functioning of this group. OBJECTIVE: Describing patient and disease characteristics, their functioning, and gender differences. METHODS: A cross-sectional descriptive design was used to collect data of 173 patients living in eight Dutch HD-specialized NHs. Data were collected on characteristics and functioning. We tested for gender differences. RESULTS: Mean age was 58.3 years and 49.7% were men. Activities of daily living and cognition varied from 46 to 49% mildly impaired to 22-23% severely impaired. Communication was severely impaired in 24%. Social functioning was low in 31% and high in 34%. A majority of patients used psychotropic medications (80.3%) and showed neuropsychiatric signs (74%). Women were on average more dependent in ADL (severely impaired 33.3% vs 12.8%), more often depressed (26.4% vs 11.6%), and prescribed antidepressant medications more often (64.4% vs 48.8%) than men. CONCLUSIONS: The population of HD patients in NHs is heterogeneous in terms of patient and disease characteristics, and functioning. As a consequence, care needs are complex leading to implications for the required expertise of staff to provide adequate care and treatment.

Prevalences and Indications of Psychotropic Drug Prescriptions in Nursing Home Residents with Korsakoff Syndrome.

Psychotropic drugs (PD) are often prescribed to nursing home residents with Korsakoff syndrome (KS). It is unknown whether these drugs are prescribed correctly or whether they are prescribed off-label, for example, to treat behavioral symptoms. To get more insight into PD prescriptions, a descriptive study was performed. The type, category and indications of PD prescriptions of 285 participants were analyzed using medication charts and questionnaires. Behavioral symptoms were investigated with the Neuropsychiatric Inventory-Questionnaire. The results showed that atypical antipsychotics (57.1%) were prescribed more frequently than typical antipsychotics (49.3%). Of the antidepressants, selective serotonin/norepinephrine reuptake inhibitors (63.1%) were most frequently prescribed, followed by tricyclic antidepressants (23.4%). Of the benzodiazepines, anxiolytics (85.7%) were more prescribed than hypnotics (24.5%). Besides psychiatric disorders, PD were also prescribed to treat behavioral symptoms varying from 29.9% (antipsycho-tics) to 26.3% (benzodiazepines) and 9.3% (antidepressants). Furthermore, prescriptions were high if behavioral symptoms were present. To conclude, PD are often prescribed to residents with KS for an unapproved indication, namely behavioral symptoms. Additional research is needed to obtain further insight into the current prescribing culture and the effectiveness of PD. The insights thus obtained may, ultimately, contribute to the appropriate prescription of PD for people with KS.

Impaired Awareness in People with Severe Alcohol-Related Cognitive Deficits Including Korskoff's Syndrome: A Network Analysis.

BACKGROUND: Impaired awareness of one's own functioning is highly common in people with Korsakoff's syndrome (KS). However, it is currently unclear how awareness relates to impairments in daily functioning and quality of life (QoL). METHODS: We assessed how impaired awareness relates to cognitive, behavioral, physical, and social functioning and QoL by applying a network analysis. We used cross-sectional data from 215 patients with KS or other severe alcohol-related cognitive deficits living in Dutch long-term care facilities (LTCFs). RESULTS: Apathy has the most central position in the network. Higher apathy scores relate positively to reduced cognition and to a greater decline in activities of daily living and negatively to social participation and the use of antipsychotic drugs. Impaired awareness is also a central node. It is positively related to a higher perceived QoL, reduced cognition and apathy, and negatively to social participation and length of stay in the LTCF. Mediated through apathy and social participation, impaired awareness is indirectly related to other neuropsychiatric symptoms. CONCLUSIONS: Impaired awareness is closely related to other domains of daily functioning and QoL of people with KS or other severe alcohol-related cognitive deficits living in LTCFs. Apathy plays a central role. Network analysis offers interesting insights to evaluate the interconnection of different symptoms and impairments in brain disorders such as KS.

Supporting older patients in working on rehabilitation goals: A scoping review of nursing interventions.

BACKGROUND: Nurses are consistently present throughout the rehabilitation of older patients but are apprehensive about performing goal-centred care in the multidisciplinary team. OBJECTIVES: The aim of this review was to explore working interventions on setting goals and working with goals designed for nurses in geriatric rehabilitation, and to describe their distinctive features. METHODS: We performed a scoping review. We searched MEDLINE and CINAHL through August 4, 2021. Search terms related to the following themes: nurses, rehabilitation, geriatric, goal and method. We used snowballing to find additional. From the selected studies, we systematically extracted data on means, materials and the nursing role and summarized them in a narrative synthesis, using intervention component analysis. RESULTS: The study includes 13 articles, describing 11 interventions which were developed for six different aims: improving multidisciplinary team care; increasing patient centredness; improving disease management by patients; improving the psychological, and emotional rehabilitation; increasing the nursing involvement in rehabilitation; or helping patients to achieve goals. The interventions appeal to four aspects of the nursing profession: assessing self-care skills incorporating patient's preferences; setting goals with patients, taking into account personal needs and what is medically advisable; linking the needs of the patient with multidisciplinary professional treatment and vice versa; and thus, playing an intermediate role and supporting goal achievement. CONCLUSIONS: The interventions show that in goal-centred care, the nurse might play an important unifying role between patients and the multidisciplinary team. With the support of nurses, the patient may become more aware of the rehabilitation process and transfer of ownership of treatment goals from the multidisciplinary team to the patient might be achieved. Not many interventions were found meant to support the nursing role. This may indicate a blind spot in the rehabilitation community to the additional value of its contribution.

The quality of geriatric rehabilitation from the patients' perspective: a scoping review.

BACKGROUND: the efficacy and outcomes of geriatric rehabilitation (GR) have previously been investigated. However, a systematic synthesis of the aspects that are important to patients regarding the quality of GR does not exist. OBJECTIVE: the aim of this scoping review was to systematically synthesise the patients' perspective on the quality of GR. METHODS: we followed the Scoping Review framework and gathered literature including a qualitative study design from multiple databases. The inclusion criteria were: a qualitative study design; a geriatric population; that patients had participated in a geriatric rehabilitation programme and that geriatric rehabilitation was assessed by the patient. The results sections of the included studies were analysed using a thematic analysis approach. RESULTS: twenty articles were included in this review. The main themes identified were: (i) the need for information about the rehabilitation process, (ii) the need for telling one's story, (iii) the need for support (physical, psychological, social and how to cope with limitations), (iv) the need for shared decision-making and autonomy, (v) the need for a stimulating rehabilitation environment and (vi) the need for rehabilitation at home. CONCLUSION: in this study, we identified the aspects that determine the quality of rehabilitation from the patient's perspective, which may lead to a more holistic perspective on the quality of GR.

Effect of a multifaceted antibiotic stewardship intervention to improve antibiotic prescribing for suspected urinary tract infections in frail older adults (ImpresU): pragmatic cluster randomised controlled trial in four European countries.

OBJECTIVE: To evaluate whether antibiotic prescribing for suspected urinary tract infections in frail older adults can be reduced through a multifaceted antibiotic stewardship intervention. DESIGN: Pragmatic, parallel, cluster randomised controlled trial, with a five month baseline period and a seven month follow-up period. SETTING: 38 clusters consisting of one or more general practices (n=43) and older adult care organisations (n=43) in Poland, the Netherlands, Norway, and Sweden, from September 2019 to June 2021. PARTICIPANTS: 1041 frail older adults aged 70 or older (Poland 325, the Netherlands 233, Norway 276, Sweden 207), contributing 411 person years to the follow-up period. INTERVENTION: Healthcare professionals received a multifaceted antibiotic stewardship intervention consisting of a decision tool for appropriate antibiotic use, supported by a toolbox with educational materials. A participatory-action-research approach was used for implementation, with sessions for education, evaluation, and local tailoring of the intervention. The control group provided care as usual. MAIN OUTCOME MEASURES: The primary outcome was the number of antibiotic prescriptions for suspected urinary tract infections per person year. Secondary outcomes included the incidence of complications, all cause hospital referrals, all cause hospital admissions, all cause mortality within 21 days after suspected urinary tract infections, and all cause mortality. RESULTS: The numbers of antibiotic prescriptions for suspected urinary tract infections in the follow-up period were 54 prescriptions in 202 person years (0.27 per person year) in the intervention group and 121 prescriptions in 209 person years (0.58 per person year) in the usual care group. Participants in the intervention group had a lower rate of receiving an antibiotic prescription for a suspected urinary tract infection compared with participants in the usual care group, with a rate ratio of 0.42 (95% confidence interval 0.26 to 0.68). No differences between intervention and control group were observed in the incidence of complications (<0.01 v 0.05 per person year), hospital referrals (<0.01 v 0.05), admissions to hospital (0.01 v 0.05), and mortality (0 v 0.01) within 21 days after suspected urinary tract infections, nor in all cause mortality (0.26 v 0.26). CONCLUSIONS: Implementation of a multifaceted antibiotic stewardship intervention safely reduced antibiotic prescribing for suspected urinary tract infections in frail older adults. TRIAL REGISTRATION: ClinicalTrials.gov NCT03970356.

Dealing with requests for euthanasia in incompetent patients with dementia. Qualitative research revealing underexposed aspects of the societal debate.

OBJECTIVES: In the Netherlands, a case of euthanasia of an incompetent patient with dementia and an advance euthanasia directive (AED) caused great societal unrest and led to a petition signed by more than 450 physicians. In this paper, we investigate these physicians' reasons and underlying motives for supporting the 'no sneaky euthanasia' petition, with the aim of gaining insight into the dilemmas experienced and to map out topics in need of further guidance. METHODS: Twelve in-depth interviews were conducted with physicians recruited via the webpage 'no sneaky euthanasia'. General topics discussed were: reasons for signing the petition, the possibilities of euthanasia in incompetent patients and views on good end-of-life care. Data were interpreted using thematic content analysis and the framework method. RESULTS: Reasons for supporting the petition are dilemmas concerning 'sneaky euthanasia', the over-simplified societal debate, physicians' personal moral boundaries and the growing pressure on physicians. Analysis revealed three underlying motives: aspects of handling a euthanasia request based on an AED, good end-of-life care and the doctor as a human being. CONCLUSIONS: Although one of the main reasons for participants to support the petition was the opposition to 'sneaky euthanasia', our results show a broader scope of reasons. This includes their experience of growing pressure to comply with AEDs, forcing them to cross personal boundaries. The underlying motives are related to moral dilemmas around patient autonomy emerging in cases of decision-making disabilities in advanced dementia. To avoid uncertainty regarding patients' wishes, physicians express their need for reciprocal communication.

Psychological Resilience in Older Residents of Long-Term Care Facilities: Occurrence and Associated Factors.

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.

The Disability Paradox? Trajectories of Well-Being in Older Adults With Functional Decline.

Objectives: The 'disability paradox' (DP) suggests that most older adults maintain subjective well-being (SWB) despite functional decline. However, this may depend the SWB component: positive affect (PA), negative/depressed affect (NA/DA) or life satisfaction (LS). We assessed trajectories of these components in older adults with substantial functional decline. Methods: Data originated from the Longitudinal Aging Study Amsterdam (N = 2545) observed during 1992-2008. Using latent class growth analysis, we distinguished a group with substantial functional decline and examined their SWB trajectories and individual characteristics. Results: The DP occurred more frequently for DA (Men:73%, Women:77%) and LS (Men:14%, Women:83%) than for PA (Men:26%, Women:17%). Higher perceived control (mastery) emerged as the most consistent factor associated with higher odds of the DP. Discussion: We provide a nuanced view of the DP, shifting the question from whether it exists to for which dimension of SWB and for whom it is more or less apparent.