Clinical Comorbidities and Transitions Between Care Settings Among Residents of Assisted Living Facilities: A Repeated Cross-Sectional Study.

OBJECTIVE: We investigate the changes in the sociodemographic characteristics, clinical comorbidities, and transitions between care settings among residents of assisted living facilities. DESIGN: Repeated cross-sectional study. SETTING AND PARTICIPANTS: Linked, individual-level health system administrative data on residents of assisted living facilities in Ontario, Canada, from January 1, 2013, to December 31, 2019. METHODS: Counts and proportions were calculated to describe the sociodemographic characteristics and clinical comorbidities. Relative changes and trend tests were calculated to quantify the longitudinal changes in the characteristics of residents of assisted living facilities between 2013 and 2019. A Sankey plot was graphed to display transitions between different care settings (ie, hospital admission, nursing home admission, died, or remained in the assisted living facility) each year from 2013 to 2019. RESULTS: There was a 34% relative increase in the resident population size of assisted living facilities (56,9752019 vs 42,6002013). These older adults had a mean age of 87 years, and women accounted for nearly two-thirds of the population across all years. The 5 clinical comorbidities that had the highest relative increases were renal disease (24.3%), other mental health conditions (16.8%), cardiac arrhythmias (9.6%), diabetes (8.5%), and cancer (6.9%). Nearly 20% of the original cohort from 2013 remained in an assisted living facility at the end of 2019, and approximately 10% of that cohort transitioned to a nursing home in any year from 2013 to 2019. CONCLUSIONS AND IMPLICATIONS: Residents of assisted living facilities are an important older adult population that has progressively increased in clinical complexity within less than a decade. Clinicians and policy makers should advocate for the implementation of on-site medical care that is aligned with the needs of these older adults.

Development of an Advance Care Planning Policy within an Evidenced-Based Evaluation Framework.

Background: As the population is aging and medical advancements enable people to live longer, advance care planning (ACP) becomes increasingly important in guiding future care decisions; however, they are often incomplete or absent from the patient chart. This study describes the development and implementation of an ACP policy in a post-acute care and long-term care setting using a systematic implementation framework. Methods: A process evaluation that parallels the Replicating Effective Programs (REP) framework was used to understand stakeholder experiences with ACP and identify gaps in practice. Physicians, multidisciplinary staff, patients, and substitute decision makers engaged in focus groups and interviews, and completed surveys. A retrospective chart review determined Plan for Life Sustaining Treatment (PLST) form completion rates. Results: Stakeholder feedback identified barriers and facilitators to ACP including a need for staff training, user-friendly resources, and standardization of ACP practice. The PLST form was developed and embedded in the electronic medical record, and had a 92% and an 87% PLST completion rate on 2 pilot units. Conclusion: The study showed the usefulness of the REP model in guiding the evaluation as an effective tool to enhance implementation practices and inform ACP policy development that can be replicated in other organizations.

Predictors of intracranial hemorrhage in patients treated with catheter-directed thrombolysis for deep vein thrombosis.

BACKGROUND: Although acute intracranial hemorrhage (ICH) is a rare complication of catheter-directed thrombolysis (CDT), it remains a major concern associated with the use of CDT. The incidence and clinical predictors of developing ICH in the setting of CDT are not known. METHODS: The National Inpatient Sample database was used to identify all patients with proximal lower extremity or caval deep vein thrombosis (DVT) from January 2005 to December 2013 in the United States. Multivariate logistic regression was performed to identify the clinical predictors of ICH between patients with DVT who had received anticoagulation therapy alone and those who had been treated with CDT plus anticoagulation therapy. RESULTS: Of 138,049 patients with proximal lower extremity or caval DVT, 7119 (5.2%) had received anticoagulation therapy and CDT. Of the patients treated with anticoagulation alone, ICH had occurred in 0.2% compared with 0.7% for those treated with CDT (P < .01). The independent predictors of ICH in the CDT cohort were a history of stroke (odds ratio [OR], 19.4; 95% confidence interval [CI], 8.8-42.8; P < .01), chronic kidney disease (OR, 2.2; 95% CI, 1.1-4.7; P = .03), age >74 years (OR, 2.2; 95% CI, 1.2-4.3; P = .02), male sex (OR, 1.8; 95% CI, 1.01-3.3; P = .048). Of those patients treated with anticoagulation alone, the risk factors for the development of ICH were a history of stroke, hospital teaching status, and age >74 years. CONCLUSIONS: The results from the present nationwide observational study showed that of patients with DVT treated with CDT, the independent predictors for developing ICH were a history of stroke, chronic kidney disease, male sex, and age >74 years.

Quality Indicators of Primary Care Provider Engagement in Nursing Home Care.

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.

International survey of nursing home research priorities.

This article reports the findings of a policy survey designed to establish research priorities to inform future research strategy and advance nursing home practice. The survey was administered in 2 rounds during 2013, and involved a combination of open questions and ranking exercises to move toward consensus on the research priorities. A key finding was the prioritization of research to underpin the care of people with cognitive impairment/dementia and of the management of the behavioral and psychological symptoms of dementia within the nursing home. Other important areas were end-of-life care, nutrition, polypharmacy, and developing new approaches to putting evidence-based practices into routine practice in nursing homes. It explores possible innovative educational approaches, reasons why best practices are difficult to implement, and challenges faced in developing high-quality nursing home research.

Spinal Manipulative Therapy for Chronic Lower Back Pain in Older Veterans: A Prospective, Randomized, Placebo-Controlled Trial.

INTRODUCTION: Chronic lower back pain (CLBP) is problematic in older veterans. Spinal manipulative therapy (SMT) is commonly utilized for CLBP in older adults, yet there are few randomized placebo-controlled trials evaluating SMT. METHODS: The purpose of the study was to compare the effectiveness of SMT to a sham intervention on pain (Visual Analogue Scale, SF-36 pain subscale), disability (Oswestry Disability Index), and physical function (SF-36 subscale, Timed Up and Go) by performing a randomized placebo-controlled trial at 2 Veteran Affairs Clinics. RESULTS: Older veterans (≥ 65 years of age) who were naive to chiropractic were recruited. A total of 136 were included in the study with 69 being randomly assigned to SMT and 67 to sham intervention. Patients were treated 2 times per week for 4 weeks assessing outcomes at baseline, 5, and 12 weeks postbaseline. Both groups demonstrated significant decrease in pain and disability at 5 and 12 weeks. At 12 weeks, there was no significant difference in pain and a statistically significant decline in disability scores in the SMT group when compared to the sham intervention group. There were no significant differences in adverse events between the groups. CONCLUSIONS: The SMT did not result in greater improvement in pain when compared to our sham intervention; however, SMT did demonstrate a slightly greater improvement in disability at 12 weeks. The fact that patients in both groups showed improvements suggests the presence of a nonspecific therapeutic effect.

Frailty consensus: a call to action.

Frailty is a clinical state in which there is an increase in an individual's vulnerability for developing increased dependency and/or mortality when exposed to a stressor. Frailty can occur as the result of a range of diseases and medical conditions. A consensus group consisting of delegates from 6 major international, European, and US societies created 4 major consensus points on a specific form of frailty: physical frailty. 1. Physical frailty is an important medical syndrome. The group defined physical frailty as "a medical syndrome with multiple causes and contributors that is characterized by diminished strength, endurance, and reduced physiologic function that increases an individual's vulnerability for developing increased dependency and/or death." 2. Physical frailty can potentially be prevented or treated with specific modalities, such as exercise, protein-calorie supplementation, vitamin D, and reduction of polypharmacy. 3. Simple, rapid screening tests have been developed and validated, such as the simple FRAIL scale, to allow physicians to objectively recognize frail persons. 4. For the purposes of optimally managing individuals with physical frailty, all persons older than 70 years and all individuals with significant weight loss (>5%) due to chronic disease should be screened for frailty.

Reliability and validity of prehospital case finding for depression and cognitive impairment.

OBJECTIVES: To evaluate the test-retest reliability, the concurrent criterion validity, and the construct validity of prehospital, emergency medical service (EMS) case finding for depression and cognitive impairment in older adults. DESIGN: Cross-sectional study. SETTING: Prehospital EMS system and hospital emergency department. PARTICIPANTS: EMS providers and community-dwelling older adult (aged > or =60) patients. INTERVENTIONS: Case finding instruments for depression (Patient Health Questionnaire-2; PHQ-2) and cognitive impairment (Six-Item Screener). MEASUREMENTS: The reliability and validity of these instruments. RESULTS: Moderate test-retest reliability was found for prehospital application of the PHQ-2 (kappa=0.50) and Six-Item Screener (kappa=0.52), fair concurrent criterion validity for depression (kappa=0.36), and slight to fair concurrent criterion validity for cognitive impairment (kappa=0.11-0.23). Construct validity was demonstrated using the Multitrait-Multimethod Matrix. CONCLUSION: Moderate test-retest reliability and construct validity were demonstrated for prehospital case finding by EMS providers for cognitive impairment and depression using these instruments. Slight to fair concurrent criterion validity was found, a result that methodological limitations could explain. These findings provide additional support for the concept of using EMS providers to detect older adults at risk for these conditions. Further work is needed to confirm the validity and effectiveness of prehospital screening before such programs are implemented.

N-acetyl cysteine as a glutathione precursor for schizophrenia--a double-blind, randomized, placebo-controlled trial.

BACKGROUND: Brain glutathione levels are decreased in schizophrenia, a disorder that often is chronic and refractory to treatment. N-acetyl cysteine (NAC) increases brain glutathione in rodents. This study was conducted to evaluate the safety and effectiveness of oral NAC (1 g orally twice daily [b.i.d.]) as an add-on to maintenance medication for the treatment of chronic schizophrenia over a 24-week period. METHODS: A randomized, multicenter, double-blind, placebo-controlled study. The primary readout was change from baseline on the Positive and Negative Symptoms Scale (PANSS) and its components. Secondary readouts included the Clinical Global Impression (CGI) Severity and Improvement scales, as well as general functioning and extrapyramidal rating scales. Changes following a 4-week treatment discontinuation were evaluated. One hundred forty people with chronic schizophrenia on maintenance antipsychotic medication were randomized; 84 completed treatment. RESULTS: Intent-to-treat analysis revealed that subjects treated with NAC improved more than placebo-treated subjects over the study period in PANSS total [-5.97 (-10.44, -1.51), p = .009], PANSS negative [mean difference -1.83 (95% confidence interval: -3.33, -.32), p = .018], and PANSS general [-2.79 (-5.38, -.20), p = .035], CGI-Severity (CGI-S) [-.26 (-.44, -.08), p = .004], and CGI-Improvement (CGI-I) [-.22 (-.41, -.03), p = .025] scores. No significant change on the PANSS positive subscale was seen. N-acetyl cysteine treatment also was associated with an improvement in akathisia (p = .022). Effect sizes at end point were consistent with moderate benefits. CONCLUSIONS: These data suggest that adjunctive NAC has potential as a safe and moderately effective augmentation strategy for chronic schizophrenia.

Altering cAMP levels within a central pattern generator modifies or disrupts rhythmic motor output.

Cyclic AMP is a second messenger that has been implicated in the neuromodulation of rhythmically active motor patterns. Here, we tested whether manipulating cAMP affects swim motor pattern generation in the mollusc, Tritonia diomedea. Inhibiting adenylyl cyclase (AC) with 9-cyclopentyladenine (9-CPA) slowed or stopped the swim motor pattern. Inhibiting phosphodiesterase with 3-isobutyl-1-methylxanthine (IBMX) or applying dibutyryl-cAMP (dB-cAMP) disrupted the swim motor pattern, as did iontophoresing cAMP into the central pattern generator neuron C2. Additionally, during wash-in, IBMX sometimes temporarily produced extended or spontaneous swim motor patterns. Photolysis of caged cAMP in C2 after initiation of the swim motor pattern inhibited subsequent bursting. These results suggest that cAMP levels can dynamically modulate swim motor pattern generation, possibly shaping the output of the central pattern generator on a cycle-by-cycle basis.

Application of assessing care of vulnerable elders-3 quality indicators to patients with advanced dementia and poor prognosis.

OBJECTIVES: To use a formal decision-making strategy to reach clinically appropriate, internally consistent decisions on the application of quality indicators (QIs) to vulnerable elders (VEs) with advanced dementia (AD) or poor prognosis (PP). DESIGN: Using a conceptual model that classifies QIs principally by aim and burden of the care process, 12 clinical experts rated whether each Assessing Care of Vulnerable Elders-3 (ACOVE-3) QI should be applied in evaluating quality of care for older persons with AD or PP. QI exclusions were assessed for each of the 26 conditions and by whether these conditions were mainly medical (e.g., diabetes mellitus), geriatric (e.g., falls), or crosscutting processes of care (e.g., pain management). QI exclusions were also identified for older persons who decided against hospitalization or surgery. RESULTS: Of 392 ACOVE-3 QIs, 140 (36%) were excluded for patients with AD and 135 (34%) for patients with PP; 57% of QIs focusing on medical conditions were excluded from patients with AD and 53% from patients with PP, whereas only 20% of QIs for geriatric conditions were excluded from AD and 15% from PP. All QIs with care processes judged to carry a heavy burden were excluded; 86% of moderate-burden QIs were excluded from AD and 92% from PP. All QIs aimed at long-term goals were excluded; 83% of intermediate-term goal QIs were excluded from AD and 98% from PP. Individuals holding a preference to forgo hospitalization or surgery would be excluded from 7% of potentially applicable QIs. CONCLUSION: Measurement of quality of care for VEs with AD, PP, and less-aggressive care preferences should include only a subset of the ACOVE-3 QIs, largely those whose burden is light and whose goal is continuity or short-term improvement or prevention.

Approaches to appropriate drug prescribing for the older adult.

When prescribing for the older adult, the office-based physician walks the fine line between introducing the drugs that are considered best practices for each disease that the person has and acknowledging that as the number of drugs increases, the risks of adverse drug reactions, drug-drug interactions, or drug-disease interactions increase considerably. Establishing the clinician-patient partnership to develop goals of care is the first step in the process. Avoiding drugs that are likely to be associated with adverse outcomes (the Beers Criteria list) is an important next step, as is awareness of the prescribing cascade. It is also important, however, to not be overly pessimistic. Quality of care and quality of life may be greatly enhanced by careful use of prescription and over-the-counter medications in the older adult.

Appropriateness of quality indicators for older patients with advanced dementia and poor prognosis.

OBJECTIVES: To evaluate the applicability of process-of-care quality indicators (QIs) to vulnerable elders and to measure the effect of excluding indicators based on patients' preferences and for advanced dementia and poor prognosis. DESIGN: The Assessing Care of Vulnerable Elders (ACOVE) project employed 203 QIs for care of 22 conditions (including six geriatric syndromes and 11 age-associated diseases) for community-based persons aged 65 and older at increased risk of functional decline or death. Relevant QIs were excluded for persons deciding against hospitalization or surgery. A 12-member clinical committee (CC) of geriatric experts rated whether each QI should be applied in scoring quality of care for persons with advanced dementia (AdvDem) or poor prognosis (PoorProg). Using content analysis, CC ratings were formulated into a model of QI exclusion. Quality scores with and without excluded QIs were compared. SETTING: Enrollees in two senior managed care plans, one in the northeast United States and the other in the southwest. PARTICIPANTS: CC members evaluated applicability of QIs. QIs were applied to 372 vulnerable elders in two senior managed care plans. MEASUREMENTS: Frequency and type of QIs excluded and the effect of excluding QIs on quality of care scores. RESULTS: Of the 203 QIs, a patient's preference against hospitalization or surgery excluded 10 and eight QIs, respectively. The CC voted to exclude 81.5 QIs (40%) for patients with AdvDem and 70 QIs (34%) for patients with PoorProg. Content analysis of the CC votes revealed that QIs aimed at care coordination, safety or prevention of decline, or short-term clinical improvement or prevention with nonburdensome interventions were usually voted for inclusion (90% and 98% included for AdvDem and PoorProg, respectively), but QIs directed at long-term benefit or requiring interventions of moderate to heavy burden were usually excluded (16% and 19% included, respectively). About half of QIs aimed at age-associated diseases were voted for exclusion, whereas fewer than one-quarter of QIs for geriatric syndromes were excluded. Thirty-nine patients (10%) in our field trial held preferences or had clinical conditions that would have excluded 68 QIs. This accounted for 5% of all QIs triggered by these 39 patients and 0.6% of QIs overall. The quality score without exclusion was 0.57 and with exclusion was 0.58 (P =.89). CONCLUSION: Caution is required in applying QIs to vulnerable elders. QIs for geriatric syndromes are more likely to be applicable to these individuals than are QIs for age-associated diseases. The objectives of care, intervention burdens, and interval before anticipated benefit affect QI applicability. At least for patients with AdvDem and PoorProg, identification of applicable or inapplicable QIs is feasible. In a community-based sample of vulnerable elders, few QIs are excluded.