Time to and predictors of dual incontinence in older nursing home admissions.

AIMS: There are few studies of nursing home residents that have investigated the development of dual incontinence, perhaps the most severe type of incontinence as both urinary and fecal incontinence occur. To determine the time to and predictors of dual incontinence in older nursing home residents. METHODS: Using a cohort design, records of older nursing home admissions who were continent or had only urinary or only fecal incontinence (n = 39,181) were followed forward for report of dual incontinence. Four national US datasets containing potential predictors at multiple levels describing characteristics of nursing home residents, nursing homes (n = 445), and socioeconomic and sociodemographic status of the community surrounding nursing homes were analyzed. A Cox proportional hazard regression with nursing home-specific random effect was used. RESULTS: At 6 months after admission, 28% of nursing home residents developed dual incontinence, at 1 year 42% did so, and at 2 years, 61% had dual incontinence. Significant predictors for time to developing dual incontinence were having urinary incontinence, greater functional or cognitive deficits, more comorbidities, older age, and lesser quality of nursing home care. CONCLUSIONS: The development of dual incontinence is a major problem among nursing home residents. Predictors in this study offer guidance in developing interventions to prevent and reduce the time to developing this problem which may improve the quality of life of nursing residents.

Racial disparities in primary prevention of incontinence among older adults at nursing home admission.

AIMS: Maintaining continence of nursing home (NH) residents promotes dignity and well-being and may reduce morbidity and healthcare treatment costs. To determine the prevalence of older continent adults who received primary prevention of incontinence at NH admission, assess whether there were racial or ethnic disparities in incontinence prevention, and describe factors associated with any disparities. METHODS: The design was an observational cross-sectional study of a nation-wide cohort of older adults free of incontinence at NH admission (n = 42,693). Four US datasets describing NH and NH resident characteristics, practitioner orders for NH treatment/care, and socioeconomic and sociodemographic status of the community surrounding the NHs were analyzed. Disparities were analyzed for four minority groups identified on the minimum data set using the Peters-Belson method and covariates at multiple levels. RESULTS: Twelve percent of NH admissions received incontinence prevention. There was a significant disparity (2%) in incontinence prevention for Blacks (P < 0.05): Fewer Black admissions (8.6%) were observed to receive incontinence prevention than was expected had they been part of the White group (10.6%). The percentage of White admissions receiving incontinence prevention was 10.6%. Significant factors associated with disparity in receiving incontinence prevention were having greater deficits in ADL function and cognition and more comorbidities. No disparity disadvantaging the other minority groups was found. CONCLUSIONS: Greater efforts for instituting incontinence prevention at the time of NH admission are needed. Eliminating racial disparities in incontinence prevention seems an attainable goal. Appropriate staff training, organizational commitment, and monitoring progress toward equitable outcomes can help achieve this goal. Neurourol. Urodynam. 36:1124-1130, 2017. © 2016 Wiley Periodicals, Inc.

Analysis of Racial and Ethnic Disparities as Possible Risk Factors for Development of Incontinence by Nursing Home Residents.

Incontinence is a common health problem among nursing home (NH) residents. Differences between black and white NH residents in incontinence prevalence have been reported. Although reducing health disparities is a principal objective of the national health care agenda, little is known about disparities in incidence of new incontinence in NHs. The purpose of this study was to assess whether there were racial/ethnic disparities in the time to development of incontinence in adults over age 65 who had been continent on NH admission. If no racial or ethnic disparities in time to incontinence were found, other predictors of time to incontinence would be explored. Three national databases were sources of data on 42,693 adults over 65 admitted to 446 for-profit NHs in a national chain. Multi-level predictors of time to any type of incontinence were analyzed, using Cox proportional hazards regression for white Non-Hispanic NH admissions and the Peters-Belson method for minority NH admissions: American Indians/Alaskan Natives, Asians/Pacific Islanders, Black non-Hispanics, and Hispanics. No racial/ethnic disparities in time to incontinence were found. Approximately 30% of all racial/ethnic groups had developed incontinence by 6 months. Those who developed incontinence sooner were older and had greater deficits in activities of daily living (ADL) and cognition. Results were consistent with past evidence and suggest that interventions to maintain continence from the time of admission should be applied across racial/ethnic groups.

Prevalence of pressure ulcers by race and ethnicity for older adults admitted to nursing homes.

Little is known about the prevalence of pressure ulcers (PUs) among racial and ethnic groups of older individuals admitted to nursing homes (NHs). NHs admitting higher percentages of minority individuals may face resource challenges for groups with more PUs or ones of greater severity. This study examined the prevalence of PUs (Stages 2 to 4) among older adults admitted to NHs by race and ethnicity at the individual, NH, and regional levels. Results show that the prevalence of PUs in Black older adults admitted to NHs was greater than that in Hispanic older adults, which were both greater than in White older adults. The PU rate among admissions of Black individuals was 1.7 times higher than White individuals. A higher prevalence of PUs was observed among NHs with a lower percentage of admissions of White individuals. [Journal of Gerontological Nursing, 40(3), 20-26.].

Social Engagement After Nursing Home Admission: Racial and Ethnic Disparities and Risk Factors.

Older adults admitted to nursing homes (NHs) are at risk for low social engagement, which has associations with medical, psychological, and social well-being. Minorities may be at a disadvantage for social engagement because of their racial or ethnic group identity. This study assessed whether there were racial/ethnic disparities in social engagement among older adults ( N = 15,927) at 1 year after their NH admission using multi-level predictors. No racial or ethnic-based disparities in social engagement were found; hence, an analysis of risk factors at NH admission that predicted low social engagement at 1 year for all residents was conducted. Significant risk factors for low social engagement were low social engagement at admission, deficits in activities in daily living and cognition, problems with vision and communication, and residing in an NH in an urban community. Results highlight the importance of initiating interventions to increase social engagement at the time of NH admission.

Racial and ethnic disparities in the healing of pressure ulcers present at nursing home admission.

BACKGROUND: Pressure ulcers increase the risk of costly hospitalization and mortality of nursing home residents, so timely healing is important. Disparities in healthcare have been identified in the nursing home population but little is known about disparities in the healing of pressure ulcers. PURPOSE: To assess racial and ethnic disparities in the healing of pressure ulcers present at nursing home admission. Multi-levels predictors, at the individual resident, nursing home, and community/Census tract level, were examined in three large data sets. METHODS: Minimum Data Set records of older individuals admitted to one of 439 nursing homes of a national, for-profit chain over three years with a stages 2-4 pressure ulcer (n=10,861) were searched to the 90-day assessment for the first record showing pressure ulcer healing. Predictors of pressure ulcer healing were analyzed for White admissions first using logistic regression. The Peters-Belson method was used to assess racial or ethnic disparities among minority group admissions. RESULTS: A significantly smaller proportion of Black nursing home admissions had their pressure ulcer heal than expected had they been part of the White group. There were no disparities in pressure ulcer healing disadvantaging other minority groups. Significant predictors of a nonhealing of pressure ulcer were greater deficits in activities of daily living and pressure ulcer severity. CONCLUSIONS: Reducing disparities in pressure ulcer healing is needed for Blacks admitted to nursing homes. Knowledge of disparities in pressure ulcer healing can direct interventions aiming to achieve equity in healthcare for a growing number of minority nursing home admissions.

Prevention of Incontinence-Associated Skin Damage in Nursing Homes.

Racial/ethnic disparities in preventing health problems have been reported in nursing homes. Incontinence is common among nursing home residents and can result in inflammatory-type skin damage, referred to as incontinence-associated skin damage (IASD). Little is known about the prevention of IASD and whether there are racial/ethnic disparities in its prevention. This study assessed the proportion of older nursing home residents receiving IASD prevention after developing incontinence after admission ( n = 10,713) and whether there were racial/ethnic disparities in IASD prevention. Predictors of preventing IASD were also examined. Four national data sets provided potential predictors at multiple levels. Disparities were analyzed using the Peters-Belson method; predictors of preventing IASD were assessed using hierarchical logistic regression. Prevention of IASD was received by 0.12 of residents and no racial/ethnic disparities were found. Predictors of preventing IASD were primarily resident-level factors including limitations in activities of daily living, poor nutrition, and more oxygenation problems.

Prevalence of appropriate and problematic antiepileptic combination therapy in older people in the nursing home.

OBJECTIVES: To determine the prevalence of mono- and poly-antiepileptic drug (AED) therapy in a cohort of nursing home (NH) residents and to describe specific AED combinations used, as well as demographic, clinical, and functional factors associated with poly-AED therapy and the most common AED combination. DESIGN: Retrospective, point prevalence study. SETTING: All NHs owned/managed by Beverly Enterprises. PARTICIPANTS: All residents aged 65 and older residing in one of the study NHs on July 1, 1999, and receiving an AED (N=3,881). MEASUREMENTS: Data were gathered using two secondary source data sets: physicians' orders (AED use) and the Minimum Data Set (health status indicators). RESULTS: Of residents taking AEDs, 370 (9.5%) were taking two or more; 268 of those (72%) were taking problematic AED combinations (those with the potential of undesirable pharmacokinetic or pharmacodynamic interactions). Phenytoin (PHT) with phenobarbital (PB) was the most common combination (27.0%). Logistic regression indicated that poly-AED subjects were more likely to have a diagnosis of epilepsy/seizure (epi/sz) and less likely to have a diagnosis of cerebrovascular accident (CVA). Residents taking the PHT/PB combination were more likely to have an epi/sz diagnosis and longer NH stay. The association between CVA and PHT/PB polytherapy differed by presence or absence of aphasia. CONCLUSION: The overall prevalence of poly-AED therapy is less than 10% in NH residents, but 72% of those residents were receiving problematic polytherapy combinations, thereby exposing them to potential risk of adverse reactions and toxicity.

Variations in product choices of frequently purchased herbs: caveat emptor.

BACKGROUND: Patients who report use of herbs to their physicians may not be able to accurately describe the ingredients or recommended dosage because the products for the same herb may differ. The purpose of this study was to describe variations in label information of products for each of the 10 most commonly purchased herbs. METHODS: Products for each of 10 herbs were surveyed in a convenience sample of 20 retail stores in a large metropolitan area. Herbs were those with the greatest sales dollars in 1998: echinacea, St John's wort, Ginkgo biloba, garlic, saw palmetto, ginseng, goldenseal, aloe, Siberian ginseng, and valerian. RESULTS: Each herb had a large range in label ingredients and recommended daily dose (RDD) across available products. Strengths were not directly comparable because of ingredient variability. Among 880 products, 43% were consistent with a benchmark in ingredients and RDD, 20% in ingredients only, and 37% were either not consistent or label information was insufficient. Price per RDD was a significant predictor of consistency with the benchmark, but store type was not. CONCLUSIONS: Persons self-medicating with an herb may be ingesting ingredients substantially different from that recommended by a benchmark, both in quantity and content. Higher price per label RDD was the best predictor of consistency with a benchmark. This study demonstrates that health providers and consumers need to closely examine label ingredients of presumably the same or similar herbal products.

Are there racial-ethnic disparities in time to pressure ulcer development and pressure ulcer treatment in older adults after nursing home admission?

OBJECTIVE: The objective of this study was to assess whether there are racial and ethnic disparities in the time to development of a pressure ulcer and number of pressure ulcer treatments in individuals aged 65 and older after nursing home admission. METHOD: Multi-level predictors of time to a pressure ulcer from three national surveys were analyzed using Cox proportional hazards regression for White Non-Hispanic residents. Using the Peters-Belson method to assess for disparities, estimates from the regression models were applied to American Indians/Alaskan Natives, Asians/Pacific Islanders, Blacks, and Hispanics separately resulting in estimates of expected outcomes as if they were White Non-Hispanic, and were then compared with their observed outcomes. RESULTS: More Blacks developed pressure ulcers sooner than expected. No disparities in time to a pressure ulcer disadvantaging other racial/ethnic groups were found. There were no disparities in pressure ulcer treatment for any group. DISCUSSION: Reducing disparities in pressure ulcer development offers a strategy to improve the quality of nursing home care.

Racial and Ethnic Disparities in Time to Cure of Incontinence Present at Nursing Home Admission.

As many as half of older people that are admitted to nursing homes (NHs) are incontinent of urine and/or feces. Not much is known about the rate of cure of incontinence present at NH admission, but available reports suggest the rate is low. There have been racial and ethnic disparities in incontinence treatment, but the role of disparities in the cure of incontinence is understudied. Using the Peters-Belson method and multilevel predictors, our findings showed that there were disparities in the time to cure of incontinence for Hispanic NH admissions. A significantly smaller proportion of older Hispanic admissions were observed to have their incontinence cured and cured later than expected had they been White. Reducing disparities in incontinence cure will improve health outcomes of Hispanic NH admissions. Significant predictors in our model suggest strategies to reduce the disparity including attention to managing fecal incontinence and incontinence in those with cognitive impairment, improving residents' functional status, and increasing resources to NHs admitting older Hispanics with incontinence to develop innovative and cost effective ways to provide equitable quality care.

Prevalence of incontinence by race and ethnicity of older people admitted to nursing homes.

OBJECTIVE: While admissions of minorities to nursing homes (NHs) are increasing and prevalence of incontinence in NHs remains high, little is known about incontinence among racial-ethnic groups of NH admissions other than blacks. The purpose of this study was to describe the prevalence of incontinence among older adults admitted to NHs by race/ethnicity at three levels of measurement: individual resident, NH, and Census division. DESIGN: Cross-sectional and descriptive. PARTICIPANTS AND SETTING: Admissions of persons age 65 or older to 1 of 457 NHs of a national, for-profit chain over 3 years 2000-2002 (n = 111,640 residents). METHODS: Data sources were the Minimum Data Set v. 2.0 and 2000 US Census. Prevalence of the following definitions of incontinence was analyzed: Only Urinary Incontinence (UI), Only Fecal Incontinence (FI), Dual Incontinence (DI; UI and FI), Any UI (UI with or without FI), Any FI (FI with or without UI), and Any Incontinence (UI and/or FI and/or DI). RESULTS: Asian patients, black patients, and Hispanic patients had a higher prevalence of Any Incontinence (67%, 66%, and 58%, respectively) compared to white patients (48%) and American Indian patients (46%). At the NH level, all prevalence measures of incontinence (except Only UI) appear to trend in the opposite direction from the percentage of NH admissions who were white. Among Asian and white patients, there was a higher prevalence of all types of incontinence in men compared with women except for Only UI. Among Census divisions, the prevalence of all types of incontinence, except Only UI, was lowest in the 2 divisions with the highest percentage of white admissions to their NHs. CONCLUSIONS: NHs admitting more racial/ethnic minorities may be faced with managing more incontinence and needing additional staffing resources. The association of the prevalence of most types of incontinence with the race/ethnicity of NH admissions at all levels of measurement lend support to the growing evidence that contextual factors beyond individual resident characteristics may contribute to NH differences.

Use of antiepileptic medications in nursing homes.

The University of Minnesota Epilepsy Research and Education Program published two studies evaluating the use of antiepileptic drugs (AEDs) among nursing home (NH) elderly. The studies used a large, nongovernmental data set for studying this population. This chapter is a summary of those two studies. In the first study, a 1-day point prevalence study, 10.5% of the NH residents had one or more AED orders, a prevalence 10 times greater than that found in the community. In a multivariate analysis of factors associated with AED treatment, seizure indication was the most important factor, and age was inversely related to AED use. Phenytoin was the most commonly used AED, followed by carbamazepine, phenobarbital, and valproic acid. The most frequently used combination was phenytoin and phenobarbital. In the second study, evaluating NH admission data, 8% of newly admitted residents were already receiving one or more AEDs when they entered the NH. Factors associated with AED use in this group included epilepsy/seizure disorder, age, cognitive performance, and manic depression (bipolar disease). Among residents recently admitted who were not using an AED at entry, 3% were initiated on an AED within 3 months of admission. Among the factors associated with the initiation of AEDs during this period, the strongest association was with epilepsy/seizure disorder. Manic depression (bipolar disease) was also significantly associated with initiation of an AED after admission. In this group, there was an inverse relationship between age and initiation of an AED.

Prevalence and correlates of perineal dermatitis in nursing home residents.

BACKGROUND: Perineal dermatitis is an adverse outcome of incontinence, which is common in older nursing home residents; yet knowledge about perineal dermatitis in this population is sorely lacking. OBJECTIVES: To determine the prevalence and significant correlates of perineal dermatitis in older nursing home residents. METHODS: Assessment data from 59,558 records in the Minimum Data Set (MDS) were linked with 2,883,049 orders in the medical record which enabled definition of variables related to perineal dermatitis, identification of cases, and determination of the prevalence of perineal dermatitis. Data from two subsamples, each with the records of 10,215 older nursing home residents, were analyzed using logistic regression to identify the significant correlates of perineal dermatitis. RESULTS: Perineal dermatitis was found in 5.7% (n = 3,405) of residents and 73% of these were incontinent. Having perineal dermatitis was significantly associated with (a) impairments in tissue tolerance (i.e., more health problems, presence of a fever, requiring nutrition support, and having more problems of diminished perfusion or oxygenation); (b)problems of the perineal environment (i.e., having fecal incontinence only, double incontinence, and more items associated with mechanical chafing); and (c) altered toileting ability from daily use of restraints. DISCUSSION: Several correlates of perineal dermatitis (mechanical chafing, fecal and double incontinence, and use of restraints) appear modifiable through nursing intervention. Clinical interventions should consider the complex health status of this population.

Ginkgo biloba use in nursing home elderly with epilepsy or seizure disorder.

PURPOSE: Ginkgo biloba, among the most widely used herbs, possesses the capacity both to induce and to inhibit seizures. The purpose of this study was to describe the prevalence of ginkgo and other common herb prescribing in a sample of nursing home (NH) elderly diagnosed with epilepsy/seizure (Epi/Sz) disorder and to determine demographic, clinical, and functional factors associated with ginkgo use. METHODS: This was a 1-year prevalence study of 68,403 NH residents living in 557 nursing facilities throughout the United States. RESULTS: Overall, herb use in the NHs was very low (0.41%). Ginkgo was prescribed 162 times, more than any other herb. St. John's wort was prescribed 40 times; garlic, 29 times; and all others, <20 times, for a total of 307 herb orders. Among all residents with an herb order, ginkgo was prescribed for 61.9% of residents with an Epi/Sz diagnosis and 58.0% (p = 0.820) of residents without an Epi/Sz diagnosis. Dementia, educational level, and the interaction of age group with cognitive impairment were all significantly associated with herb use among Epi/Sz residents. Cognitive impairment and the interaction of Epi/Sz disorder with dementia were associated specifically with ginkgo use. CONCLUSIONS: Ginkgo is the most frequently prescribed herb in this population in which >50% of all herb orders were written for ginkgo. The concern with ginkgo use among elderly with Epi/Sz is the lack of standardization that characterizes ginkgo products. In the absence of standardization, the likelihood is increased that ginkgo products may be adulterated with the Ginkgo biloba plant parts most commonly associated with seizure provocation.

Preparing a large data set for analysis: using the minimum data set to study perineal dermatitis.

AIM: The aim of this paper is to present a practical example of preparing a large set of Minimum Data Set records for analysis, operationalizing Minimum Data Set items that defined risk factors for perineal dermatitis, our outcome variable. BACKGROUND: Research with nursing home elders remains a vital need as 'baby boomers' age. Conducting research in nursing homes is a daunting task. The Minimum Data Set is a standardized instrument used to assess many aspects of a nursing home resident's functional capability. United States Federal Regulations require a Minimum Data Set assessment of all nursing home residents. These large data would be a useful resource for research studies, but need to be extensively refined for use in most statistical analyses. Although fairly comprehensive, the Minimum Data Set does not provide direct measures of all clinical outcomes and variables of interest. METHOD: Perineal dermatitis is not directly measured in the Minimum Data Set. Additional information from prescribers' (physician and nurse) orders was used to identify cases of perineal dermatitis. The following steps were followed to produce Minimum Data Set records appropriate for analysis: (1) identification of a subset of Minimum Data Set records specific to the research, (2) identification of perineal dermatitis cases from the prescribers' orders, (3) merging of the perineal dermatitis cases with the Minimum Data Set data set, (4) identification of Minimum Data Set items used to operationalize the variables in our model of perineal dermatitis, (5) determination of the appropriate way to aggregate individual Minimum Data Set items into composite measures of the variables, (6) refinement of these composites using item analysis and (7) assessment of the distribution of the composite variables and need for transformations to use in statistical analysis. RESULTS: Cases of perineal dermatitis were successfully identified and composites were created that operationalized a model of perineal dermatitis. CONCLUSION: Following these steps resulted in a data set where data analysis could be pursued with confidence. Incorporating other sources of data, such as prescribers' orders, extends the usefulness of the Minimum Data Set for research use.

Antiepileptic drug use in nursing home admissions.

Although 1 of 10 nursing home residents is taking an antiepileptic drug (AED), no study to our knowledge has determined whether most residents are already receiving AED treatment when they are admitted or are given these drugs afterward. That differentiation was the focus of this study. The study group consisted of 10,318 residents, 65 years and older, admitted to 510 nursing homes located throughout the United States during the first quarter of 1999. AED prevalence at admission was 7.7%; three fifths had an epilepsy/seizure indication. In a multivariate analysis, factors associated with AED use at admission included epilepsy/seizure, bipolar depression, age group, and cognitive performance. In the follow-up cohort (N = 9,516), postadmission initiation of AEDs was 2.7%; one fifth had an epilepsy/seizure indication. In the multivariate analysis, factors associated with postadmission AED initiation included epilepsy/seizure indication, bipolar depression, age group, peripheral vascular disease, and cognitive performance. This rate of AED postadmission initiation within the first 3 months of admission was much higher than expected, suggesting that new symptoms may develop after admission. Results also show that the rate of AED use in nursing homes is not static.