One Way Out? A Multistate Transition Model of Outcomes After Nursing Home Admission.

OBJECTIVES: To understand how the odds of both adverse and positive transitions vary over the course of episodes of care in nursing homes. DESIGN: Retrospective cohort study of individuals admitted to nursing homes using clinical and administrative Canadian Resident Assessment Instrument version 2 data linked to emergency department and hospital records. SETTING AND PARTICIPANTS: Adults aged 65 years and older, admitted to nursing homes in Ontario, Alberta, British Columbia, and Yukon Territories in Canada, from 2010 to 2015. The sample involved 163,176 individuals with 1,088,336 RAI 2.0 assessments. MEASURES: Data on mortality and hospitalization were obtained from nursing home and hospital records. Multistate Markov models were employed to estimate odds ratios characterizing covariate effects on transitions to different states of health, hospitalization, and death, stratified by day of stay beginning with the initial 90-day period after admission to a nursing home. RESULTS: The first 90 days of stay after admission were characterized by higher odds of both adverse and positive outcomes after adjusting for numerous covariates. Newly admitted residents had greater odds of becoming worse in health instability, being hospitalized, or dying. However, they also had greater odds of being discharged home or improving in health compared with later stages of the episode of care. These associations varied by the resident's Changes in Health, End-Stage Disease, Signs, and Symptoms (CHESS) scores at the start of each 90-day follow-up period, and CHESS was associated with differential rates of death, hospitalization, and discharge home. CONCLUSIONS/IMPLICATIONS: The initial 90-day period after nursing home placement is one in which the likelihood of both adverse and positive changes is elevated for nursing home residents. Special efforts must be taken after admission to identify and respond to risk factors that may increase the resident's odds of negative outcomes. At the same time, there may be a window of opportunity for the person's transition back to the community after a brief nursing home stay.

Clinical Complexity and Use of Antipsychotics and Restraints in Long-Term Care Residents with Parkinson's Disease.

BACKGROUND: Patients with Parkinson's disease (PD) and/or Parkinsonism are affected by a complex burden of comorbidity. Many ultimately require institutional care, where they may be subject to the application of physical restraints or the prescription of antipsychotic medications, making them more vulnerable to adverse outcomes. OBJECTIVES: The objectives of this paper are to: 1) describe the clinical complexity of older institutionalized persons with PD; and 2) examine patterns and predictors of restraint use and prescription of antipsychotics in this population. METHODS: Population-based cross-sectional cohort study. Residents with PD and/or Parkinsonism living in long-term care (LTC) facilities in 6 Canadian provinces and 1 Northern Territory and Complex Continuing Care (CCC) facilities in Manitoba and Ontario, Canada. The RAI MDS 2.0 instrument was used to assess all LTC residents and CCC residents. Clinical characteristics and the prevalence of major comorbidities were examined. Multivariate modeling was used to identify the characteristics of PD residents most associated with the prescription of antipsychotics and the use of restraints in LTC and CCC facilities. RESULTS: Residents with PD in LTC and CCC exhibit a high prevalence of dementia, major psychiatric disorders, stroke, heart failure, chronic obstructive pulmonary disease and diabetes mellitus. More than 90% of LTC and CCC residents with PD had cognitive impairment; with more than half having moderate to severe impairment. Residents with PD were more likely to receive antipsychotics than those without PD. Antipsychotic use was associated with psychosis and aggressive behaviours, but also with unsteady gait and higher comorbidity and medication count. Similarly, although more common in CCC than LTC facilities, both psychosis and aggressive behaviours were associated with restraint use, as was greater cognitive and functional impairment, and urinary incontinence. Younger age, male gender, and lower physician access were all associated with greater antipsychotic and restraint use. CONCLUSIONS: LTC and CCC residents with PD are very complex medically. Use of antipsychotics and restraints is common, and their use is often associated with factors other than psychosis or aggression.