Comparing the Experiences of Participants With Mild Cognitive Impairment and Mild Dementia During an Oral Health Intervention.

Background and Objectives: Cognitive impairment is associated with poor oral health outcomes. Oral hygiene tasks are an essential target of interventions aiming to improve oral health for older adults with cognitive impairment. We aimed to examine whether experiences in an oral health intervention based on the Adaptive Leadership Framework for Chronic Illness differed between individuals with mild cognitive impairment (MCI) or mild dementia (MD) and their respective care partners. Research Design and Methods: This was a secondary analysis using directed content analysis and then an interpretive-description approach to analyze the data from a theory-driven intervention study. We included 10 people with MCI and their care partners (n = 20) and 8 people with MD and their care partners (n = 16) in the treatment arm of the intervention. For each participant, we analyzed audio recordings of 4 intervention coaching sessions, each ranging between 30 and 45 min. We managed the data and coding using ATLAS.TI software. Results: Participants in both the MCI and MD groups experienced similar challenges in adapting to changes in oral hygiene techniques, and both groups worked on learning new oral hygiene techniques taught by the dental hygienist and meeting individualized goals developed with their care partner, interventionist, and hygienist. On the other hand, there were subtle differences in technical challenges between participants in MCI and MD groups; participants in the MCI group reacted more actively to dental hygienist suggestions than the MD group. Discussion and Implications: Study findings provide information about how researchers and clinicians might tailor interventions to meet the learning needs of individuals and care partners in each group.

A Cross-Sectional, Correlational Study Comparing Individual Characteristics of Younger and Older Nursing Home Residents using Western Canadian Resident Assessment Instrument-Minimum Data Set (RAI-MDS) 2.0.

OBJECTIVE: To compare characteristics of nursing home (NH) residents by age categories in Western Canada. DESIGN: A cross-sectional, correlational analysis of secondary data. SETTING AND PARTICIPANTS: 89,231 residents living in Western Canada NHs in the provinces of Alberta, Manitoba, and British Columbia in 2016 and 2017. METHODS: Resident characteristics (age, sex, marital status, body mass index, medical diagnoses, cognitive function, physical function, depressive symptoms) came from the Resident Assessment Instrument-Minimum Data Set 2.0 and were analyzed using chi-square, analysis of variance, and post hoc pairwise tests. Human developmental stage age categories were used to create 5 age groups: 18-34, 35-50, 51-64, 65-80, and 81 years and older. RESULTS: The demographics, medical diagnoses, cognitive function, and physical function characteristics of NH residents among 5 age groups differed considerably (all P < .001). Residents aged 18-34 years were predominately male, never married, with a higher incidence of paralysis and traumatic brain injury. Residents aged 35-50 years had a higher incidence of stroke and multiple sclerosis, and residents aged 51-64 years mainly were morbidly obese and more prone to depression. Residents aged 65-80 years were predominately married and more prone to diabetes, and residents aged 81 years and older were predominately widowed, with a higher incidence of dementia compared with others. CONCLUSIONS AND IMPLICATIONS: Findings describe the uniqueness of younger NH age groups and indicate that the youngest NH residents often have the severe disability and a modest support system (as defined by partnered status) compared to older residents in NHs. Future studies must analyze longitudinal data that track the growth of, and changes in, residents' health and functional status.

Developing a toolkit to improve resident and family engagement in the safety of assisted living: Engage-A stakeholder-engaged research protocol.

Assisted living (AL) communities are experiencing rising levels of resident acuity, challenging efforts to balance person-centered care-which prioritizes personhood, autonomy, and relationship-based care practices-with efforts to keep residents safe. Safety is a broad-scale problem in AL that encompasses care concerns (e.g., abuse/neglect, medication errors, inadequate staffing, and infection management) as well as resident issues (e.g., falls, elopement, and medical emergencies). Person and family engagement (PFE) is one approach to achieving a balance between person-centered care and safety. In other settings, PFE interventions have improved patient care processes, outcomes, and experiences. In this paper, we describe the protocol for a multiple methods AHRQ-funded study (Engage) to develop a toolkit for increasing resident and family engagement in AL safety. The study aims are to engage AL residents and family caregivers, AL staff, and other AL stakeholders to (1) identify common AL safety problems; (2) prioritize safety problems and identify and evaluate existing PFE interventions with the potential to address safety problems in the AL setting; and (3) develop a testable toolkit to improve PFE in AL safety. We discuss our methods, including qualitative interviews, a scoping review of existing PFE interventions, and stakeholder panel meetings that involved a Delphi priority-setting exercise. In addition to describing the protocol, we detail how we modified the protocol to address the unique challenges of the COVID-19 pandemic. Study findings will result in a toolkit to improve resident and family engagement in the safety of AL that will be tested in future research.

Overdiagnosis of urinary tract infections by nursing home clinicians versus a clinical guideline.

PURPOSE: To inform overprescribing and antibiotic stewardship in nursing homes (NHs), we examined the concordance between clinicians' (NH primary care providers and registered nurses) diagnosis of suspected UTI with a clinical guideline treated as the gold standard, and whether clinician characteristics were associated with diagnostic classification. METHODS: We conducted a cross-sectional web-based survey of a U.S. national convenience sample of NH clinicians. The survey included a discrete choice experiment with 19 randomly selected clinical scenarios of NH residents with possible UTIs. For each scenario, participants were asked if they thought a UTI was likely. Responses were compared to the guideline to determine the sensitivity and specificity of clinician judgment and performance indicators. Multivariable logistic mixed effects regression analysis of demographic, work, personality, and UTI knowledge/attitudes characteristics was conducted. RESULTS: One thousand seven hundred forty-eight NH clinicians responded to 33,212 discrete choice scenarios; 867 (50%) were NH primary care providers and 881 (50%) were NH registered nurses, 39% were male, and the mean age was 45 years. Participants were uncertain about diagnosis in 30% of scenarios. Correct classification occurred for 66% of all scenarios (providers: 70%; nurses: 62%). Respondent judgment had a sensitivity of 78% (providers: 81%; nurses: 74%) and specificity of 54% (providers: 59%; nurses: 49%) compared to the clinical guideline. Adjusting for covariates in multivariable models, being a nurse and having higher closemindedness were associated higher odds of false positive UTI (odds ratio [OR] 1.61, p < 0.001; and OR 1.09, p = 0.039, respectively), although higher UTI knowledge and conscientiousness were associated with lower odds of false positive UTI ratings (OR 0.80, p < 0.001; OR 0.90, p = 0.005, respectively). CONCLUSIONS: Clinicians tend to over-diagnose urinary tract infections, necessitating systems-based interventions to augment clinical decision-making. Clinician type, UTI knowledge, and personality traits may also influence behavior and deserve further study.

Staff Reports of Behavioral Expressions of Persons With Dementia in 250 Assisted Living Communities.

BACKGROUND AND OBJECTIVES: Assisted living (AL) residents with dementia commonly exhibit behavioral expressions (BEs), yet no study has examined how AL staff perceive and respond to BEs in terms of the "ABC" model of antecedents, behaviors, and consequences, or how perceptions relate to organizational characteristics. Understanding staff perceptions may inform interventions. RESEARCH DESIGN AND METHODS: A convergent, mixed methods design was used in a study of health care supervisors from 250 AL communities in 7 states who reported 366 cases of resident BEs (one successful and one unsuccessful case). Qualitative analysis identified antecedents, BEs, staff responses, resident outcomes, and disposition (aging in place or discharge). Content analysis identified themes and compared case types. Descriptive statistics examined organizational characteristics associated with identifying antecedents. RESULTS: One quarter of cases recognized antecedents; slightly more were identified in successful (28%) compared to unsuccessful cases (20%); staff in dementia-only and smaller communities identified antecedents more often. Combativeness and anxiety were the most frequently reported BEs. The majority of both types of cases reported staff responses. Medication management was enacted as a response in 40% of cases compared to psychiatric assessment in 33% of cases. DISCUSSION AND IMPLICATIONS: Staff training is indicated to increase AL staff recognition of antecedents; doing so might reduce the use of antipsychotic medications. Psychiatric assessment plays an important role in dementia care in AL and warrants further examination. Results could be helpful for applied behavioral researchers interested in developing ways to improve the identification of antecedents of BEs of persons with dementia.

Feasibility of Routine Quality of Life Measurement for People Living With Dementia in Long-Term Care.

OBJECTIVES: Maximizing quality of life (QoL) is the ultimate goal of long-term dementia care. However, routine QoL measurement is rare in nursing home (NH) and assisted living (AL) facilities. Routine QoL measurement might lead to improvements in resident QoL. Our objective was to assess the feasibility of using DEMQOL-CH, completed by long-term care staff in video calls with researchers, to assess health-related quality of life (HrQoL) of NH and AL residents with dementia or other cognitive impairment. DESIGN: Cross-sectional study. SETTING AND PARTICIPANTS: We included a convenience sample of 5 NHs and 5 AL facilities in the Canadian province of Alberta. Forty-two care staff who had worked in the facility for ≥3 months completed DEMQOL-CH assessments of 183 residents who had lived in the facility for 3 months or more and were aged ≥65 years. Sixteen residents were assessed independently by 2 care staff to assess inter-rater reliability. METHODS: We assessed HrQoL in people with dementia or other cognitive impairment using DEMQOL-CH, and assessed time to complete, inter-rater reliability, internal consistency reliability, and care staff ratings of feasibility of completing the DEMQOL-CH. RESULTS: Average time to complete DEMQOL-CH was <5 minutes. Staff characteristics were not associated with time to complete or DEMQOL-CH scores. Inter-rater reliability [0.735, 95% confidence interval (CI): 0.712-0.780] and internal consistency reliability (0.834, 95% CI: 0.779-0.864) were high. The DEMQOL-CH score varied across residents (mean = 84.8, standard deviation = 11.20, 95% CI: 83.2-86.4). Care aides and managers rated use of the DEMQOL-CH as highly feasible, acceptable, and valuable. CONCLUSIONS AND IMPLICATIONS: This study provides a proof of concept that DEMQOL-CH can be used to assess HrQoL in NH and AL residents and provides initial indications of feasibility and resources required. DEMQOL-CH may be used to support actions to improve the QoL of residents.

Younger Nursing Home Residents: A Scoping Review of Their Lived Experiences, Needs, and Quality of Life.

OBJECTIVES: The percentage of younger nursing home (NH) residents (ages 18-64 years) in some countries such as the United States and Canada has been increasing over the years. In fact, it is generally held that younger NH residents are considerably different from the older residents (age ≥65 years). There is a need to understand who they are, why they resided in NHs, and their quality of life (QoL). The aims of the study were to describe the experiences, needs, and QoL among younger residents living in NHs. DESIGN: Scoping review. SETTINGS AND PARTICIPANTS: (Younger) Residents of NHs. METHODS: Five databases (PubMed, CINAHL, PsycINFO, Web of Science, and Scopus) and Google Scholar were used to search for relevant studies. PRISMA diagram was used to guide this scoping review. RESULTS: The key findings of the study cover 5 themes: (1) Confinement, (2) Lack of socialization, (3) Lack of privacy, (4) Lack of appropriate settings, and (5) Loss of identity, as well as results of QoL were generated. CONCLUSIONS AND IMPLICATIONS: This scoping review provides a deeper understanding of the lived experiences, needs, and QoL among younger NH residents. The results provide suggestions for future studies regarding new interventions to optimize the QoL of NH residents.

Evaluation of a Training Toolkit to Improve Clinicians' Skills for Dementia Advance Care Planning.

Background: Primary care clinicians care for most persons with Alzheimer's disease and related dementias (ADRDs), yet lack dementia-specific skills in advance care planning (ACP). Objectives: To develop and evaluate a training toolkit for primary care clinicians to improve ACP communication for people with ADRD and their families. Design: Clinical practice outcomes assessment and pre-post-training evaluation. Intervention training toolkit addressed ACP skills by dementia stage: (1) advance directives in early dementia, (2) decision-making capacity in moderate dementia, (3) Physician Orders for Life-Sustaining Treatment (POLST) in late-stage dementia, and (4) hospice and hospitalization in advanced dementia. Setting/Subjects: Nonhospitalized clinical care sites, 51 clinicians in North Carolina, USA. Measurements: Data collection utilized structured chart abstractions and pre- and post-training surveys. Results: Of 51 participants trained, 33 had encounters with patients with ADRD in study period. Most participants were women (n = 42), white (n = 37), and physicians (n = 31). Participants increased documentation of surrogates (22.7% vs. 35.5%, p = 0.03), decision-making capacity (13.5% vs.23.2%, p = 0.04), and POLST completion (9.2% vs. 18.8%, p = 0.03). Training increased ACP documentation (6.4% vs. 14.5%, p = 0.031) and goals of care (GOC) decision-making discussions (17.0% vs. 31.9%, p = 0.005). In pre-post-comparisons, participant confidence increased in determining capacity, exploring dementia prognosis, GOC, eliciting surrogates, and leading family meetings (all p < 0.001). Most participants strongly agreed that the training addressed skills used in practice (n = 34), contained clear language (n = 40), took an appropriate amount of time (n = 32), and was designed effectively (n = 35). Conclusion: This video-based training resource increased the use of dementia-specific ACP communication skills and clinician confidence.

To What Extent Do Local Nursing Home Prescribing Patterns Relate to Psychotropic Prescribing in Assisted Living?

OBJECTIVE: In nursing homes (NHs), psychoactive medication use has received notable attention, but less is known about prescribing in assisted living (AL). This study examined how antipsychotic and antianxiety medication prescribing in AL compares with NHs. DESIGN: Observational, cross-sectional AL data linked to publicly reported NH measures. SETTING AND PARTICIPANTS: Random sample of 250 AL communities and the full sample of 3371 NHs in 7 states. METHODS: We calculated the percentage of residents receiving antipsychotics and antianxiety medications. For each AL community, we calculated the distance to NHs in the state. Linear models estimated the relationship between AL prescribing and that of the closest and farthest 5 NHs, adjusting for AL characteristics and state fixed effects. RESULTS: The prescribing rate of potentially inappropriate antipsychotics (i.e., excluding for persons with recorded schizophrenia and Tourette syndrome) and of antianxiety medications (excluding for those on hospice) in AL was 15% and 21%, respectively. Unadjusted mean antipsychotic prescribing rates were nominally higher in AL than NHs (14.8% vs 14.6%; P = .056), whereas mean antianxiety prescribing was nominally lower in AL (21.2% vs 22.6%; P = .032). In adjusted analyses, AL rates of antipsychotic use were not associated with NH rates. However, being affiliated with an NH was associated with a lower rate of antipsychotic use [b = -0.03; 95% confidence interval (CI) -0.50 to -0.001; P = .043], whereas antianxiety rates were associated with neighboring NHs' prescribing rates (b = 0.43; 95% CI 0.16-0.70; P = .002). CONCLUSIONS AND IMPLICATIONS: This study suggests reducing antipsychotic medication use in NHs may influence AL practices in a way not accounted for by local NH patterns. And, because antianxiety medications have not been the focus of national campaigns, they may be more subject to local prescribing behaviors. It seems advantageous to consider prescribing in AL when efforts are implemented to change NH prescribing, as there seems to be related influence whether by affiliation or region.

Nursing Home Clinicians' Decision to Prescribe Antibiotics for a Suspected Urinary Tract Infection: Findings From a Discrete Choice Experiment.

OBJECTIVE: To determine which nursing home (NH) resident characteristics were most important to clinicians' decision to prescribe antibiotics for a suspected urinary tract infection (UTI), including both evidence-based and non-evidence-based characteristics. DESIGN: Web-based discrete choice experiment with 19 clinical scenarios. For each scenario, clinicians were asked whether they would prescribe an antibiotic for a suspected UTI. SETTING: Online survey. PARTICIPANTS: Convenience sample of 876 NH physicians and advanced practice providers who practiced primary care for NH residents in the United States. METHODS: Each scenario varied information about 10 resident characteristics regarding urinalysis results, resident temperature, lower urinary tract symptoms, physical examination, antibiotic request, mental status, UTI risk, functional status, goals of care, and resident type. We derived importance scores for the characteristics and odds ratios (ORs) for specific information related to each characteristic from a multinomial logistic regression. RESULTS: Approximately half of the participants were male (56%) with a mean age of 49 years. Resident characteristics differed in their importance (ie, part-worth utility) when deciding whether to prescribe for a suspected UTI: urinalysis results (32%), body temperature (17%), lower urinary tract symptoms (17%), physical examination (15%), antibiotic request (7%), mental status (4%), UTI risk (4%), functional status (3%), goals of care (2%), and resident type (1%). Information about "positive leukocyte esterase, positive nitrates" was associated with highest odds of prescribing [OR 19.6, 95% confidence interval (CI) 16.9, 22.7], followed by "positive leukocyte esterase, negative nitrates" (OR 6.7, 95% CI 5.8, 7.6), and "painful or difficult urination" (OR 4.8, 95% CI 4.2, 5.5). CONCLUSIONS AND IMPLICATIONS: Although guidelines focus on lower urinary tract symptoms, body temperature, and physical examination for diagnosing a UTI requiring antibiotics, these characteristics were considered less important than urinalysis results, which have inconsistent clinical utility in NH residents. Point-of-care clinical decision support offers an evidence-based prescribing process.

An untapped resource in the nursing workforce: Licensed practical nurses who transition to become registered nurses.

BACKGROUND: A more diverse registered nurse (RN) workforce is needed to provide health care in North Carolina (NC) and nationally. Studies describing licensed practical nurse (LPN) career transitions to RNs are lacking. PURPOSE: To characterize the occurrence of LPN-to-RN professional transitions; compare key characteristics of LPNs who do and do not make such a transition; and compare key characteristics of LPNs who do transition in the years prior to and following their transition. METHODS: A retrospective design was conducted using licensure data on LPNs from 2001 to 2013. Cohorts were constructed based on year of graduation. FINDINGS: Of 39,398 LPNs in NC between 2001 and 2013, there were 3,161 LPNs (8.0%) who had a LPN-to-RN career transition between 2001 and 2013. LPNs were more likely to transition to RN if they were male; from Asian, American Indian, or other racial groups; held an associate or baccalaureate degree in their last year as an LPN (or their last year in the study if they did not transition); worked in a hospital inpatient setting; worked in the medical-surgical nursing specialty; and were from a rural area. DISCUSSION: Our findings indicate that the odds of an LPN-to-RN transition were greater if LPNs were: male; from all other racial groups except white; of a younger age at their first LPN licensure; working in a hospital setting; working in the specialty of medical-surgical nursing; employed part-time; or working in a rural setting during the last year as an LPN. CONCLUSION: This study fills an important gap in our knowledge of LPN-to-RN transitions. Policy efforts are needed to incentivize: LPNs to make a LPN-to-RN transition; educational entities to create and communicate curricular pathways; and employers to support LPNs in making the transition.

New or Worsening Symptoms and Signs in Community-Dwelling Persons with Dementia: Incidence and Relation to Use of Acute Medical Services.

OBJECTIVES: To understand the range of symptoms that present to family caregivers of community-dwelling persons with Alzheimer's disease and related dementias (ADRD). DESIGN: Six-month longitudinal prospective study to identify the incidence of new or worsening symptoms and their association with acute care medical service use. SETTING: Community-based sample of volunteers from multiple states. PARTICIPANTS: A total of 136 patient-caregiver dyads with a range of dementia severity. MEASUREMENTS: Forty four symptoms and signs common in older persons and/or persons with dementia; frequency of emergency department visits, hospitalizations, and death; and associations between reported symptoms and acute medical care. RESULTS: During a mean of 5.7 months' follow-up, new or worsening organ-specific (90% of participants), nonspecific (89%), and behavioral (88%) symptoms were common, with the average caregiver reporting seven new or worsening symptoms. Most common were worsening confusion (74%), decreased activity (64%), agitation (57%), hallucinations/delusions (45%), voice and speaking problems (45%), not eating or drinking (44%), and stress/anxiety (41%). Hospitalization and emergency department use occurred respectively in 19% and 20% of participants, and were associated with organ-specific symptoms (OR 3.15, P = .02), less so with nonspecific symptoms (OR 2.27, P = .07), and very little with behavioral symptoms (OR 1.44, P = .38). Within each symptom category, certain symptoms were significantly associated with acute medical service use. CONCLUSION: Family caregivers of persons with ADRD must respond to a variety of medical, nonspecific, and behavioral symptoms. The high incidence of new or worsening symptoms and of acute medical care use suggests a need to better target symptom evaluation and management in caregiver education.

Role of body temperature in diagnosing bacterial infection in nursing home residents.

OBJECTIVES: To provide empirically based recommendations for incorporating body temperature into clinical decision-making regarding diagnosing infection in nursing home (NH) residents. DESIGN: Retrospective. SETTING: Twelve North Carolina NHs. PARTICIPANTS: NH residents (N = 1,007) with 1,858 randomly selected antibiotic prescribing episodes. MEASUREMENTS: Maximum prescription-day temperature plus the three most recent nonillness temperatures were recorded for each prescribing episode. Two empirically based definitions of fever were developed: population-based (population mean nonillness temperature plus 2 population standard deviations (SDs)) and individualized (individual mean nonillness temperature plus 2 population SDs). These definitions were used along with previously published fever criteria and Infectious Diseases Society of America (IDSA) criteria to determine how often each prescribing episode was associated with a "fever" according to each definition. RESULTS: Mean population nonillness temperature was 97.7 ± 0.5 ºF. If "normal" were defined as less than 2 SDs above the mean, fever would be defined as any temperature above 98.7 ºF, and the previously published fever cutpoints and the IDSA criteria are 4.8 SDs above this mean. Between 30% and 32% of the 1,858 prescribing episodes examined were associated with temperatures more than 2 SDs above the population mean nonillness temperature, whereas only 10% to 11% of episodes met the previously published and IDSA fever definitions. CONCLUSION: Clinicians should apply empirically based definitions to assess fever in NH residents. Furthermore, low fever prevalence in residents treated with antibiotics according to all definitions suggests that some prescribing may not be associated with acute bacterial infection.

Licensed nurse staffing and health service availability in residential care and assisted living.

OBJECTIVES: To create data-driven typologies of licensed nurse staffing and health services in residential care and assisted living (RC/AL). DESIGN: Cluster analysis was used to describe the patterns of licensed nurse staffing and 47 services and the extent to which these clusters were related. SETTING: RC/AL communities in the United States. PARTICIPANTS: A convenience sample of administrators and healthcare supervisors from 89 RC/AL communities in 22 states. MEASUREMENT: RC/AL characteristics, licensed nurse staffing (total number of hours that registered nurses (RNs) and licensed practical nurses (LPNs) worked), number of hours that contract nurses worked, and availability of 47 services. RESULTS: Analysis revealed four licensed nurse staffing clusters defined according to total number of hours and the type of nurse providing the hours (RN, LPN, or a mix of both). They ranged from no or minimal RN and LPN hours to high nursing hours with a mix of RNs and LPNs. The 47 services clustered into five clusters: basic services; technically complex services; assessments, wound care, and therapies; testing and specialty services; and gastrostomy and intravenous medications. The availability of services was related to the presence of nurses (RNs and LPNs) except for the gastrostomy and intravenous medication services, which were not readily available. CONCLUSION: The amount and skill mix of licensed nurse staffing varies in RC/AL and is related to the types of services available. These findings may have implications for resident care and outcomes. Future work in this area, including extension to include nonnurse direct care workers, is needed.

Dementia in relation to family caregiver involvement and burden in long-term care.

To better understand the process and outcomes of family involvement for long-term care residents with varying stages of dementia, we analyzed family and staff data for 467 residents of 24 residential care/assisted living and nursing-home settings. Adjusted analyses found that although the amount of family visitation did not significantly vary by resident cognitive status (15 versus 20 visits/month to persons with and without dementia, respectively), the nature of the visit did. Families of cognitively intact residents spent more time in activities related to social and community engagement, such as taking residents on trips and calling and writing letters (p<.001), while families of more impaired residents spent more time on care-related activities, including tasks related to nutrition (p<.027), mobility (p=.001), and discussing care with staff (p=.007), the latter of which was associated with greater burden (p<.001). Staff identified similar patterns but perceived less family involvement.

Differences in assisted living staff perceptions, experiences, and attitudes.

Research within residential care/assisted living (RC/AL) settings has shown that the attitudes of personal care (PC) staff toward their organization and its residents and families can affect the quality of resident care. This article describes the perceptions, experiences, and attitudes of PC staff and their supervisors, and considers these data in the context of non-hierarchical staffing patterns-a philosophically expected, yet unproven tenet of RC/AL. Using data collected from 18 RC/AL communities, these analyses compared the characteristics, perceptions, experiences, and attitudes of PC staff (N = 250) and supervisors (N = 30). Compared to supervisors, PC staff reported greater burden, frustration, depersonalization, hassles, and feeling significantly more controlling of, and less in partnership with, families (p < 0.05). Because the PC staff experience is crucial for resident outcomes, more work is needed to create an environment where PC staff are less burdened and have better attitudes toward work and families.

Comparing families and staff in nursing homes and assisted living: implications for social work practice.

Nursing homes and residential care/assisted living settings provide care to 2.4 million individuals. Few studies compare the experience of, and relationships between, family and staff in these settings, despite ongoing family involvement and evidence that relationships are problematic. Data from 488 families and 397 staff members in 24 settings examined family involvement and family and staff burden, depressive symptoms, and perceptions; and staff absenteeism and turnover. There were few differences across setting types. Although conflict rarely occurred, there was room for improvement in family-staff relations; this area, and preparing family for their caregiving roles, are appropriate targets for social work intervention.

Systematic review: Effective characteristics of nursing homes and other residential long-term care settings for people with dementia.

OBJECTIVES: In response to the need for an evidence-based review of factors within long-term care settings that affect the quality of care, this review compared characteristics of nursing homes and other residential long-term care settings for people with dementia and their informal family caregivers with respect to health and psychosocial outcomes. DESIGN: Databases were searched for literature published between 1990 and March 2012 that met review criteria, including that at least 80% of the subject population had dementia. RESULTS: Fourteen articles meeting review criteria that were of at least fair quality were found: four prospective cohort studies, nine randomized controlled trials (RCTs), and one nonrandomized controlled trial. Overall, low or insufficient strength of evidence was found regarding the effect of most organizational characteristics, structures, and processes of care on health and psychosocial outcomes for people with dementia and no evidence for informal caregivers. Findings of moderate strength of evidence indicate that pleasant sensory stimulation reduces agitation for people with dementia. Also, although the strength of evidence is low, protocols for individualized care and to improve function result in better outcomes for these individuals. Finally, outcomes do not differ between nursing homes and residential care or assisted living settings for people with dementia except when medical care is indicated. CONCLUSION: Given the paucity of high-quality studies in this area, additional research is needed to develop a sufficient evidence base to support consumer selection, practice, and policy regarding the best settings and characteristics of settings for residential long-term care of people with dementia.

Challenges of antibiotic prescribing for assisted living residents: perspectives of providers, staff, residents, and family members.

OBJECTIVES: To better understand the antibiotic prescribing process in assisted living (AL) communities given the growing rate of antibiotic resistance. DESIGN: Cross-sectional survey. SETTING: Four AL communities in North Carolina. PARTICIPANTS: Assisted living residents who received antibiotics (n = 30) from October 20, 2010, to March 31, 2011, a primary family member, staff, and the prescribing medical provider. MEASUREMENTS: Semistructured interviews that were conducted regarding prescribing included the information available at the time of prescribing and the perceptions of the quality of communication between providers, staff, residents and family members about the resident. Providers were asked an open-ended question regarding how to improve the communication process related to antibiotic prescribing for AL residents. RESULTS: For the 30 residents who received antibiotic prescriptions, providers often had limited information about the case and lacked familiarity with the residents, the residents' families, and staff. They also felt that cases were less severe and less likely to require an antibiotic than did residents, families, and staff. Providers identified several ways to improve the communication process, including better written documentation and staff and family presence. CONCLUSION: In a small sample of AL communities, providers faced an array of challenges in making antibiotic prescribing decisions. This work confirms the complex nature of antibiotic prescribing in AL communities and indicates that further work is needed to determine how to improve the appropriateness of antibiotic prescribing.

Community-based service use by elders with dementia and their caregivers: a latent class analysis.

BACKGROUND: With the increase in the number of older adults with dementia, research efforts have focused on increasing community-based support service (CBSS) use to improve older adult and caregiver outcomes. However, the research on factors that may explain CBSS use has been focused on individual characteristics, and how the care recipient and caregiver as a pair influence CBSS use has not been accounted for. OBJECTIVE: To classify care recipients with dementia and their caregivers who shared similar patterns of CBSS use and to identify predictors of class membership. METHODS: Participants were 1,813 elders with dementia and their caregivers from the National Longitudinal Caregiver Study, a cross-sectional dataset from 1998. A latent class analysis was used to identify classes of CBSS users by examining use of caregiver support group, home aide, home health, adult day care, and respite care. Multinomial logistic regression analysis was used to examine relationships between predisposing, enabling, and need variables and class membership. RESULTS: Three classes, that is, Low Users, Adult Day Users, and Home-Based Users, comprised 80%, 10%, and 10% of the sample, respectively. Adult Day Users reported significantly more enabling resources and greater service need. Predictors of home-based use included care recipient age, activities of daily living limitations, number of skilled nursing facilities in the local county, and the extent of caregiver physical limitations from comorbid conditions. DISCUSSION: Using latent class analysis allows identification of specific subtypes of CBSS users, prevalence of user subtype, and risk factors for underutilization. Determining the long-term outcomes of class membership may identify specific groups at risk, which could inform the design of interventions to improve assessment for and delivery of CBSS.