Factors associated with institutionalization among the oldest old: Results based on the nationally representative study 'old age in Germany (D80+)'.

OBJECTIVES: To examine the factors associated with institutionalization among individuals aged 80 years and over in Germany (total sample and stratified by sex). METHODS/DESIGN: We used data from the nationally representative 'Old Age in Germany (D80+)' (analytic sample: n = 9572 individuals), including individuals aged 80 years and over in Germany. Institutionalization (private living vs. institutionalization) served as an outcome measure. For the written interview, data collection took place from November 2020 to April 2021. Multiple logistic regressions of the overall sample (also stratified by sex) were applied. RESULTS: In the analytic sample, 10.2% (95% CI: 9.2%-11.3%) of the participants were institutionalized. The odds of being institutionalized were positively associated with being female (OR: 2.02, 95% CI: 1.08 to 3.80), being 90 years and over (compared to 80-84 years, OR: 1.67, 95% CI: 1.17 to 2.40), not being married (e.g., being single compared to being married: OR: 14.06, 95% CI: 6.73 to 29.37), higher education (e.g., high education compared to low education: OR: 1.88, 95% CI: 1.25 to 2.84), more favorable self-rated health (OR: 1.32, 95% CI: 1.07 to 1.62) and greater functional impairment (OR: 15.34, 95% CI: 11.91 to 19.74). Sex-stratified regressions were also conducted, mostly yielding similar results. CONCLUSION: Our study highlighted the role of several sociodemographic factors (particularly marital status, e.g., being single) and functional impairment for the risk of institutionalization among the oldest old in Germany. This study confirms findings in studies in younger samples that functional decline is the main factor associated with institutionalization. As functional decline may be modifiable, efforts to maintain functional abilities may be important. This knowledge is important for relevant groups (such as clinicians and policy-makers) because it may guide early intervention and prevention efforts, can help allocate healthcare resources effectively and shape policies to support independent living. Further insights using longitudinal data is recommended.

Costs of care trajectories of people with dementia compared with matched controls. Longitudinal analysis of linked health and administrative data.

OBJECTIVES: To provide insight into the health and social care costs during the disease trajectory in persons with dementia and the impact of institutionalization and death on healthcare costs compared with matched persons without dementia. METHODS: Electronic health record data from family physicians were linked with national administrative databases to estimate costs of primary care, medication, secondary care, mental care, home care and institutional care for people with dementia and matched persons from the year before the recorded dementia diagnosis until death or a maximum of 4 years after the diagnosis. RESULTS: Total mean health and social care costs among persons with dementia increased substantially during the disease trajectory, mainly due to institutional care costs. For people who remained living in the community, mean health and social care costs are higher for people with dementia than for those without dementia, while for those who are admitted to a long-term care facility, mean health and social care costs are higher for people without dementia than for those with dementia. CONCLUSIONS: The steep rise in health and social care costs across the dementia care trajectory is mainly due to increasing costs for institutional care. For those remaining in the community, home care costs and hospital care costs were the main cost drivers. Future research should adopt a societal perspective to investigate the influence of including social costs.

Institutionalization for good governance to reach sustainable health development: a framework analysis.

BACKGROUND: This article explores the concept of institutionalization, which is the process of transforming ideas into programs and automating actions, in the context of health system governance and sustainable development. Institutionalization is a key mechanism for creating accountable and transparent institutions, which are essential for achieving health system resilience and sustainability. This study identifies the components and dimensions of institutionalization in the health system and its relationship with good governance and sustainable health development. MAIN TEXT: We applied a scoping review method in five steps. First, we formulated a question for our research. Then, we concluded a comprehensive literature search in five electronic databases for identifying relevant studies. This review has two phases: identifying the concept of institutional approach and its components in health system, and its relationship with good governance to reach Sustainable Health Development (SHD). The third step was study selection, and the 1st author performed data abstraction. The key issues which are identified in our review, related to the concepts of SDH, its goals, pillars and principles; positive peace; good governance; components of institutional approach components, and their relations. Finally, we summarized and organized our findings in a format of a proposed conceptual framework, to underpin the role of institutionalization in the health system to achieve sustainable development. CONCLUSION: Institutionalization is a key concept for achieving positive peace and good governance, which requires meaningful involvement of leaders, politicians, civil society, and public participation. It also depends on the conditions of justice, human rights, transparency, accountability and rule of law. In the wake of COVID-19, institutionalization is more crucial than ever for advancing sustainable development, especially in the context of low and middle-income countries (LMICs).

Malnutrition Prevalence and Nutrient Intakes of Indonesian Older Adults in Institutionalized Care Setting: A Systematic Review of Observational Studies.

INTRODUCTION: Data on the prevalence of malnutrition and nutrient intakes among Indonesian older adults in institutionalized care setting are scattered and scarce. Thus, we conducted a systematic review of published and gray literature to estimate (1) the prevalence of malnutrition, (2) the level and distribution of habitual energy and nutrient intakes, and (3) the prevalence of inadequacy of energy and nutrient intakes among hospitalized and institutionalized older adults in Indonesia. METHODS: This systematic review was written following the PRISMA 2020 checklist. The population of this review was Indonesian older adults in institutionalized care settings, including hospital wards, orphanages, nursing homes, residential facilities, and rehabilitation centers. Malnutrition was assessed using body mass index, the Mini Nutritional Assessment (MNA) score, or the subjective global assessment (SGA) score. The dietary intakes (from food recalls, food records, or food frequency questionnaire) were compared with the Indonesian Recommended Dietary Allowances for people aged 65-80. The prevalence of inadequacy was calculated using two-thirds of the Recommended Dietary Allowance as a proxy for the estimated average requirement. RESULTS: The search yielded 330 studies from electronic databases, resulting in fifteen eligible studies. One report was obtained from an unpublished study. Based on the JBI criteria, most studies had low risk of bias and represented the target population. The prevalence of malnutrition in hospital, nursing home, and other institutionalized care ranged from 6.5% to 48.3% in hospitals and 3.2% to 61.0% in other institutionalized care units. In the hospital setting, there was a high prevalence of inadequacies for all nutrients, particularly protein (20%), calcium (more than 90%), and vitamin D intakes (more than 50%). In nursing homes, these proportions were exceptionally high for protein (66%) and calcium and vitamin D intakes (almost 100%). CONCLUSION: The high risk of malnutrition in Indonesian older adults in institutionalized care setting is pronounced, along with poor intakes of macronutrients and micronutrients in both settings.

Predicting informal dementia caregivers' desire to institutionalize through mining data from an eHealth platform.

BACKGROUND: Dementia is a leading factor in the institutionalization of older adults. Informal caregivers' desire to institutionalize (DI) their care recipient with dementia (PwD) is a primary predictor of institutionalization. This study aims to develop a prediction model for caregivers' DI by mining data from an eHealth platform in a high-prevalence dementia country. METHODS: Cross-sectional data were collected from caregivers registering on isupport-portugal.pt. One hundred and four caregivers completed the Desire to Institutionalize Scale (DIS) and were grouped into DI (DIS score ≥ 1) and no DI (DIS score = 0). Participants completed a comprehensive set of sociodemographic, clinical, and psychosocial measures, pertaining to the caregiver and the PwD, which were accounted as model predictors. The selected model was a classification tree, enabling the visualization of rules for predictions. RESULTS: Caregivers, mostly female (82.5%), offspring of the PwD (70.2), employed (65.4%), and highly educated (M 15 years of schooling), provided intensive care (Mdn 24 h. week) over a median course of 2.8 years. Two-thirds (66.3%) endorsed at least one item on the DIS (DI group). The model, with caregivers' perceived stress as the root of the classification tree (split at 28.5 points on the Zarit Burden Interview) and including the ages of caregivers and PwD (split at 46 and 88 years, respectively), as well as cohabitation, employed five rules to predict DI. Caregivers scoring 28.5 and above on burden and caring for PwD under 88 are more prone to DI than those caring for older PwD (rules 1-2), suggesting the influence of expectations on caregiving duration. The model demonstrated high accuracy (0.83, 95%CI 0.75, 0.89), sensitivity (0.88, 95%CI 0.81, 0.95), and good specificity (0.71, 95%CI 0.56, 0.86). CONCLUSIONS: This study distilled a comprehensive range of modifiable and non-modifiable variables into a simplified, interpretable, and accurate model, particularly useful at identifying caregivers with actual DI. Considering the nature of variables within the prediction rules, this model holds promise for application to other existing datasets and as a proxy for actual institutionalization. Predicting the institutional placement of PwD is crucial for intervening on modifiable factors as caregiver burden, and for care planning and financing.

Impact of an oral nutritional supplement on the body composition of older adults with or at risk of malnutrition in an institutionalised setting: A randomised controlled trial.

BACKGROUND: Malnutrition often manifests as a body weight (BW) reduction and unhealthy alteration in body composition. The present study aimed to assess the efficacy of an oral nutritional supplement (ONS) in improving BW and body composition among older adults with malnutrition. METHODS: An open-label randomised controlled, parallel-group study was conducted among older adults (age ≥ 60 years) with/at risk of malnutrition (mini nutrition assessment-short form score ≤ 11). In total, 50 participants were randomly assigned to the intervention (IG) and control (CG) groups (1:1 ratio). The IG received the ONS (57 g/day; 247 kcal/serving, 12 g protein) before bedtime for 12 weeks. CG received 200 mL of water. Anthropometric measurements, body composition analysis, and dietary and physical activity assessments were performed at the beginning and end of the study. RESULTS: Forty-two participants (IG: 20, CG: 22) completed the study. The mean ± SD ages of the IG and CG were 75.4 ± 6.1 and 74.8 ± 5.2 years, respectively (p = 0.73). The IG had a significant increase in BW (+1.68 ± 1.16 vs. -0.46 ± 0.95 kg; p < 0.001), lean mass (+1.23 ± 0.93 vs. -0.45 ± 0.90 kg; p < 0.001) and fat mass (+0.54 ± 0.82 vs. -0.06 ± 0.82 kg; p = 0.02) compared to the CG. One-quarter of the IG (n = 5) achieved a weight gain > 5% of BW, whereas none in the CG did (p = 0.01). No significant changes were observed in bone mineral content in either group. CONCLUSIONS: For malnourished older adults, supplementing with an ONS, along with regular food intake, significantly increased BW, lean mass and fat mass compared to control following the regular diet without supplementation.

Predicting sojourn times across dementia disease stages, institutionalization, and mortality.

INTRODUCTION: Inferring the timeline from mild cognitive impairment (MCI) to severe dementia is pivotal for patients, clinicians, and researchers. Literature is sparse and often contains few patients. We aim to determine the time spent in MCI, mild-, moderate-, severe dementia, and institutionalization until death. METHODS: Multistate modeling with Cox regression was used to obtain the sojourn time. Covariates were age at baseline, sex, amyloid status, and Alzheimer's disease (AD) or other dementia diagnosis. The sample included a register (SveDem) and memory clinics (Amsterdam Dementia Cohort and Memento). RESULTS: Using 80,543 patients, the sojourn time from clinically identified MCI to death across all patient groups ranged from 6.20 (95% confidence interval [CI]: 5.57-6.98) to 10.08 (8.94-12.18) years. DISCUSSION: Generally, sojourn time was inversely associated with older age at baseline, males, and AD diagnosis. The results provide key estimates for researchers and clinicians to estimate prognosis.

[Manfred Pflanz (1923-1980) - A key Protagonist for the Institutionalization of Social Medicine and Medical Sociology in Germany]. / Manfred Pflanz (1923­1980) ­ zentraler Akteur bei der Institutionalisierung von Sozialmedizin und Medizinsoziologie.

Manfred Pflanz, an internist with his focus on social medicine, medical sociology and epidemiology, (1923-1980) played a key role in the institutional integration of social science expertise into medicine in the Federal Republic of Germany during the 1960s and 70 s. The present study, a biographic sketch of Pflanz, describes his work, his programmatic ideas on social medicine and medical sociology, and his activities as an expert consultant in public health for various political entities. This should enable getting an insight into the origins and ramifications, as well as the contemporary programs and international embeddedness of the overlapping fields of social medicine and medical sociology in Germany.

Negative effects of institutionalization on the sense of self in Alzheimer's Disease.

In this longitudinal study, we investigated the effects of institutionalization on the sense-of-self in individuals with Alzheimer's Disease (AD). We recruited two groups of participants: one living in care facilities (i.e., institutionalized-group) and another group living in their own home (i.e., non-institutionalized-group). In the two groups, we assessed the "Who-am-I" task on which participants were invited to provide statements beginning with the phrase "I am" that they felt were essential in defining who they are. We assessed this task, in the two groups, at a baseline (approximately one-month before-institutionalization) and at a follow-up (approximately six months after institutionalization). We analyzed whether responses on the "Who-am-I" task reflected physical-, social-, or psychological-self. Unlike at the baseline, fewer statements describing physical-, social-, and psychological-self were observed in the institutionalization than in the non-institutionalized group at the follow up. These findings demonstrate negative effects of institutionalization on the sense of self in AD.

[Nutritional Status of Institutionalized Elderly and Its Relationship with Functional Status During 2019]. / Estado nutricional de personas mayores institucionalizadas y su relación con el estado funcional durante el año 2019.

Aging is associated with physiological, economic, and psychological changes that can compromise nutritional and functional status. AIM: To determine the nutritional status of institutionalized older people living in a long-term nursing home "Fundación las Rosas" (FLR), the largest long-stay establishment in Chile, in 2019, and its relationship with functionality. METHODS: Descriptive study of analysis of secondary data in 1646 older adults institutionalized in FLR (60% women). The information collected was weight, height, Body mass index (BMI), Barthel Index, Mini-Mental State Examination, area, macrozone, sex, age, and date of admission to FLR. Logistic regression models of functionality and nutritional status, unadjusted and adjusted, were performed. RESULTS: The percentage of normal-weight people was 40.3%; 38.1% presented some degree of malnutrition due to deficit, and 9.5% presented severe malnutrition (BMI≤18.5 kg/m2). 70% of people present total dependency. The low educational level reached 73%. Logistic regressions determined that people who were overweight, 70 years of age or older, had a low level of education, and cognitive impairment were positively associated with dependency, excluding bedridden people, with the strongest associations being not having any level of schooling and having cognitive impairment. The persons of low weight, with cognitive impairment, and with a low educational level were positively associated with institutionalized bedridden elderly, the strongest associations being not having any level of schooling and having cognitive impairment. CONCLUSIONS: In this study, malnutrition due to deficit and excess are positively associated with decreased functionality, and a low educational level is associated with dependency and being bedridden.

[Pharmacological intervention in the medication review of institutionalised elderly patients under polypharmacy]. / Intervención farmacéutica en la revisión del tratamiento en pacientes mayores polimedicados institucionalizados.

OBJECTIVE: To describe the Drug-Related Problems (DRP) and their resolution after pharmacological review in institutionalised elderly patients under polypharmacy. DESIGN: Descriptive, retrospective cohort study from January to October of 2022. LOCATION: Twelve nursing homes at the Community of Madrid. PARTICIPANTS: 295 patients aged 65 or older taking at least 5 chronic medications prescribed prior to the treatment review. INTERVENTIONS: Medication reviews carried out by the pharmacist and agreed upon in face-to-face meetings between the primary care doctor, the nursing home doctor and the pharmacist. MAIN MEASUREMENTS: Detected DRP, types and resolution. A age, sex, and number of medications before and after the intervention. Pharmacological subgroups according to anatomical therapeutic chemical classification system (ATC) and active pharmaceutical ingredients involved in the detected DRPs. RESULTS: 1425 DRP were detected, with a mean of 4.85 (SD 3.33) DRPs/patient. The most frequent DRP was reconciliation error (32.52%), followed by pharmaceutical regimen and dosaje. Among the 1425 improvement proposals, 86.73% of them were accepted.Significant statistically differences were observed between the number of medications per patient prior to the pharmacotherapy review (12.29) and after it (10.20), obtaining an average difference of 2.09 (95%CI: 1.98-2.21; P<.001). CONCLUSIONS: It is found that the intervention of multidisciplinary team in which the pharmacist performs a revision of the medication decreased the number of prescribed medications. Therefore, it reduces polymedication and its associated risks.

[Factors contributing to frailty in institutionalized older adults: a multi-institutional cross-sectional study].

AIM: To reveal the characteristics and the oral function of institutionalized frail older adults and the factors contributing to frailty. METHODS: This multicenter, cross-sectional study included 214 patients. A questionnaire was administered to registered dietitians from these institutions. Sex, age, height, weight, grip strength, calf circumference, level of care need, FRAIL-NH, MNA® -SF, dysphagia, food form and water thickening, number of medications, major diseases, comorbidities, independence in daily living of older people with dementia, use of medication with dry mouth, nutritional care issues (malnutrition-related problems) by multiple occupations in Nutrition and Eating Swallowing Screening, Assessment and Monitoring, and nine oral-related items were evaluated. RESULTS: One hundred six patients (49.5%) were classified as frail, 75% of the patients were women, and the mean BMI was 19.7 kg/m2. Older adults with frailty were characterized by high care needs, malnutrition, multiple comorbidities, multiple medications, eating and swallowing disorders, the requirement of feeding assistance, and the need to adjust the shape of meals and fluids. The multivariable OR (95%CI) for "choking and residue problems" was 1.81 (1.20-2.73), while that for "dietary concentration problems" was 4.28 (2.10-8.74). CONCLUSION: Caregivers must maintain posture and provide meal assistance. Professionals in various occupations must adjust the proper food form and medication content. Meal times must be examined in consideration of the times at which drugs will be most effective. Oral care must be provided, and an environment must be created to help the subject concentrate. Focusing on problems of choking, residue, and concentration on meals is expected to improve frailty, aspiration pneumonia, and the prognosis of institutionalized older adults.

[On clinical elites and their role in institutionalization of new national clinical disciplines (the second half of XX century)].

The development of national clinical medicine in Russia in XX century is related not only to evolution of scientific schools, but also to such historical phenomenon as clinical elites. In the article definition of therapeutic elites is proposed. The destiny of therapeutic elites and their role in institutionalization of national clinical disciplines is discussed.

Is anticholinergic and sedative drug burden associated with postdischarge institutionalization in community-dwelling older patients acutely admitted to hospital? A Norwegian registry-based study.

PURPOSE: Investigate the association between anticholinergic (AC) and sedative (SED) drug burden before hospitalization and postdischarge institutionalization (PDI) in community-dwelling older patients acutely admitted to hospital. METHODS: A cross-sectional study using data from the Norwegian Patient Registry and the Norwegian Prescription Database. We studied acutely hospitalized community-dwelling patients ≥70 years during 2013 (N = 86 509). Patients acutely admitted to geriatric wards underwent subgroup analyses (n = 1715). We calculated drug burden by the Drug Burden Index (DBI), use of AC/SED drugs, and the number of AC/SED drugs. Piecewise linearity of DBI versus PDI and a knot point (DBI = 2.45) was identified. Statistical analyses included an adjusted multivariable logistic regression model. RESULTS: In the total population, 45.4% were exposed to at least one AC/SED drug, compared to 52.5% in the geriatric subgroup. AC/SED drugs were significantly associated with PDI. The DBI with odds ratios (ORs) of 1.11 (95% CI 1.07-1.15) for DBI < 2.45 and 1.08 (95% CI 1.04-1.13) for DBI ≥ 2.45. The number of AC/SED drugs with OR of 1.07 (95% CI 1.05-1.09). The AC component of DBI with OR 1.23 and the number of AC drugs with OR 1.13. In the subgroup, ORs were closer to 1 for AC drugs. CONCLUSIONS: The use of AC/SED drugs was highly prevalent in older patients before acute hospital admissions, and significantly associated with PDI. The number, or just using AC/SED drugs, gave similar associations with PDI compared to applying the DBI. Using AC drugs showed higher sensitivity, indicating that to reduce the risk of PDI, a clinical approach could be to reduce the number of AC drugs.

New horizons in schizophrenia in older people.

People aged 65 years and older will soon constitute more than a quarter of the total population with schizophrenia, challenging the existing systems of care. For a long time, research into schizophrenia in later life was very limited. However, recent years have seen an encouraging surge in novel and high-quality studies related to this stage of life. Older people with schizophrenia consist of those who had an early onset and aged with the disorder, and of a smaller but sizeable group with a late onset or a very late onset. With ageing, physical needs gain importance relative to psychiatric needs. Medical comorbidity contributes to a markedly higher mortality compared to the general population. In many persons, symptoms and functioning fluctuate with time, leading to deterioration in some but improvement in others. Of note, a substantial number of older people may experience subjective well-being in spite of ongoing symptoms and social impairments. The majority of individuals with schizophrenia reside in the community, but when institutionalization is required many are placed in residential or nursing homes where staff is often ill-equipped to address their complex needs. There is a clear need for implementation of new models of care in which mental health and general health systems cooperate. This review provides a state-of-the-art overview of current knowledge in late life schizophrenia and related disorders, with a focus on themes with clinical relevance.

Exploring the Pathophysiology of Delirium: An Overview of Biomarker Studies, Animal Models, and Tissue-Engineered Models.

Delirium is an acute brain disorder associated with disorganized thinking, difficulty focusing, and confusion that commonly follows major surgery, severe infection, and illness. Older patients are at high risk for developing delirium during hospitalization, which may contribute to increased morbidity, longer hospitalization, and increased risk of institutionalization following discharge. The pathophysiology underlying delirium remains poorly studied. This review delves into the findings from biomarker studies and animal models, and highlights the potential for tissue-engineered models of the brain in studying this condition. The aim is to bring together the existing knowledge in the field and provide insight into the future direction of delirium research.

A novel easy-to-use index to predict institutionalization and death in older population - a 10-year population-based follow-up study.

BACKGROUND: Various indexes have been developed to estimate the risk for mortality, institutionalization, and other adverse outcomes for older people. Most indexes are based on a large number of clinical or laboratory parameters. An index based on only a few parameters would be more practical to use in every-day clinical practice. Our aim was to create an index to predict the risk for mortality and institutionalization with as few parameters as possible without compromising their predictive ability. METHODS: A prospective study with a 10-year follow-up period. Thirty-six clinical and fourteen laboratory parameters were combined to form an index. Cox regression model was used to analyze the association of the index with institutionalization and mortality. A backward statistical method was used to reduce the number of parameters to form an easy-to-use index for predicting institutionalization and mortality. RESULTS: The mean age of the participants (n = 1172) was 73.1 (SD 6.6, range 64‒97) years. Altogether, 149 (14%) subjects were institutionalized, and 413 (35%) subjects deceased during the follow-up. Institutionalization and mortality rates increased as index scores increased both for the large 50-parameter combined index and for the reduced indexes. After a backward variable selection in the Cox regression model, three clinical parameters remained in the index to predict institutionalization and six clinical and three laboratory parameters in the index to predict mortality. The reduced indexes showed a slightly better predictive value for both institutionalization and mortality compared to the full index. CONCLUSIONS: A large index with fifty parameters included many unimportant parameters that did not increase its predictive value, and therefore could be replaced with a reduced index with only a few carefully chosen parameters, that were individually associated with institutionalization or death.

Diagnosis of behavioral symptoms as a predictor of institutionalization among Medicaid patients with dementia.

OBJECTIVES: Behavioral symptoms are commonly observed in the course of dementia. This study aimed to assess the association of the diagnosis of a cluster of behavioral symptoms (e.g., agitation, aggression, psychotic symptoms, and delirium/wandering) with the likelihood of subsequent institutionalization. METHODS: A retrospective cohort study of adults aged 65 and above diagnosed with dementia identified in the IBM® MarketScan® Multistate Medicaid database between October 01, 2015, and September 30, 2019, was conducted. The index date was defined as the first diagnosis date of dementia. The presence or absence of behavioral symptoms was identified in the 6 months prior to the index date (baseline). Institutionalization was evaluated 12 months (follow-up) post the index date. The association between diagnosed behavioral symptoms during the baseline period and institutionalization in the follow-up period was assessed using a multivariable logistic regression, adjusting for baseline sociodemographic and clinical characteristics. RESULTS: The study cohort included 40,714 patients with dementia. A diagnosis of behavioral symptoms was found among 2,067 (5.1%) patients during the baseline period. An increased likelihood of institutionalization was found during the follow-up among patients with agitation and aggression in baseline (OR = 1.51 (95% CI: 1.18-1.92)) compared to patients without these symptoms at baseline. Patients with psychotic symptoms in baseline had significantly higher odds of getting institutionalized during the follow-up compared to patients without psychotic symptoms in baseline (OR = 1.36 (95% CI: 1.20-1.54)). Similarly, patients with symptoms of delirium and wandering in baseline had a higher likelihood of institutionalization than patients without these symptoms at baseline (OR = 1.61 (95% CI: 1.30-1.99)). CONCLUSION: Several diagnosed behavioral symptoms were associated with a higher risk of institutionalization among older adults with dementia and should be considered when planning treatment strategies for the effective management of the condition.

Trauma of separation: the social and emotional impact of institutionalization on children in a post-soviet country.

BACKGROUND: In the former Soviet Union (fSU) region, which has the highest rate of institutional care worldwide, 'social orphans' -indigent children who have one or both parents living-are placed in publicly run residential institutions to receive education, food, and shelter. Few studies have focused on understanding the emotional effects of separation and life in an institutional environment on children who grow up with their families. METHODS: Semi-structured qualitative interviews (N = 47) were conducted with 8- to 16-year-old children with a history of institutional care placement and their parents in Azerbaijan. Semi-structured qualitative interviews were conducted with 8- to 16-year-old children (n = 21) involved in the institutional care system in Azerbaijan and their caregivers (n = 26). Trained interviewers collected narratives about children's experiences prior to being separated from their families while living in an institution, as well as the impact of institutional placement on their emotional well-being. We applied thematic analysis with inductive coding. RESULTS: Most of the children entered institutions around the school entry age. Prior to entering institutions, children had already experienced disruptions within their family environments and multiple traumatic events, including witnessing domestic violence, parental divorce, and parental substance abuse. Once institutionalized, these children may have had their mental health further impaired by a sense of abandonment, a strictly regimented life, and insufficiencies of freedom, privacy, developmentally stimulating experiences, and, at times, safety. CONCLUSION: This study illustrates the emotional and behavioral consequences of institutional placement and the need to address accumulated chronic and complex traumatic experiences that occurred before and during institutional placement, which may affect emotion regulation and the familial and social relationships of children who lived in institutions in a post-Soviet country. The study identified mental health issues that could be addressed during the deinstitutionalization and family reintegration process to improve emotional well-being and restore family relationships.

Effectiveness of community hospital post-acute care on mortality, re-admission, institutionalization, and activation of a home care programme in Emilia-Romagna region, Italy.

BACKGROUND: In Italy, there is scant evidence on the impact of Community Hospitals (CHs) on clinical outcomes. AIMS: To assess the effectiveness of CHs versus long-term care hospital or inpatient rehabilitation facilities on mortality, re-admission, institutionalization, and activation of a home care programme in the Emilia-Romagna Region (ERR-Italy) after acute hospitalisation. METHODS: We implemented a cohort study drawing upon the ERR Administrative Healthcare Database System and including hospital episodes of ERR residents subject ≥ 65 years, discharged from a public or private hospital with a medical diagnosis to a CH or to usual care between 2017 and 2019. To control for confounding, we applied a propensity score matching. RESULTS: Patients transferred to CHs had a significantly lower risk of dying but an increased risk of being readmitted to community or acute hospital within 30/90 days from discharge. The hazard of institutionalisation within 30/90 days was significantly lower in the whole population of the CH exposed group but not among patients with cardiac or respiratory chronic diseases or diabetes. The activation of a home care program within 90 days was slightly higher for those who were transferred to a CH. DISCUSSION: The findings of our study show mixed effects on outcomes of patients transferred to CHs compared to those who followed the post-acute usual care and should be taken with cautious as could be affected by the so-called 'confounding by indication'. CONCLUSIONS: The study contributes to the intermediate care available evidence from a region with a well-established care provision through CHs.