The course of behavioral problems in elderly nursing home patients with dementia when treated with antipsychotics.

BACKGROUND: Although antipsychotic treatment of behavioral problems in dementia is common, studies investigating the course of these symptoms in nursing homes are scarce. Our primary objective is therefore to describe the course of behavioral problems during antipsychotic treatment in a large sample of elderly nursing home patients with dementia. METHODS: The course of behavioral problems during antipsychotic treatment was studied by comparing the characteristics of patients before, during and after antipsychotic treatment. The study was conducted using the VURAIDB, a database with over 40,000 assessments of over 10,000 nursing home residents in the Netherlands. We used the Challenging Behavior Profile (CBP) to measure an overall behavior score. RESULTS: In total, 556 patients starting with antipsychotics were studied. Of these, 101 (18.2%) improved and 260 (46.8%) deteriorated at three months on the behavior score, compared with their scores before therapy (z = -7.955; P<0.0001). Patients with severe challenging behavior showed improvement more often than patients with mild disturbances. The course of behavioral symptoms after withdrawal was evaluated in 520 patients. Of these patients, 352 (68%) remained stable or improved at 3 months compared with their scores before withdrawal (z = -0.697; p = 0.486), this figure was 58% at 6 months after withdrawal (z = -2.77; p = 0.006). CONCLUSIONS: During treatment of nursing home residents with dementia with antipsychotics the severity of most behavioral problems continues to increase in most patients, with only one out of six patients showing improvement. After withdrawal of antipsychotics, behavioral problems remained stable or improved in 58% of patients.

[Stroke patients in need of long-term nursing home care. Who are they? What are their problems? Which care do they receive?]. / CVA-patiënten die aangewezen zijn op langdurige verpleeghuiszorg. Wie zijn ze? Met welke problemen kampen zij? Welke zorg ontvangen ze?

BACKGROUND AND OBJECTIVE: Many patients who suffer from an acute stroke, will need long-term nursing home care. We are poorly informed about the demographic and clinical characteristics and about the care problems and received care of these patients. This study aims to provide a first description of these characteristics in this group of patients. METHODS: Data on demographic and health-related characteristics, social participation and received care were collected with the Minimum Data Set of the Resident Assessment Instrument, from january 2004-march 2007, in patients who needed long-term nursing home care. Data were collected in eight nursing homes at admission and six months after admission. RESULTS: Many patients were functionally impaired, suffered from depressive symptoms and pain, and were cognitively impaired. In addition, decisional capacity was frequently diminished. The majority of patients were residing at somatic wards, even when severe cognitive impairment was present, such as dementia. Several forms of restraints were frequently used, also at somatic wards. About 40% of the patients, mostly residing at somatic wards, received paramedical treatment. Social engagement was low and was correlated with functional impairment. CONCLUSIONS: Stroke patients who need long-term nursing home care suffer from problems in several domains. The high prevalence of cognitive impairment in stroke patients residing at somatic wards, combined with the ample use of restraints on these wards, raises questions about the appropriateness of the currently delivered care to these patients, considering the problems they have.

[Prevalence of ulcers in Dutch nursing homes]. / Het vóórkomen van ulcera in verpleeghuizen.

INTRODUCTION: Earlier cross-sectional research in the Netherlands has found that one out of three nursing home patients has a pressure ulcer. The prevalence of other ulcers is unknown. METHODS: In eight nursing homes 2295 patients were assessed with the Minimum Data Set (MDS). The mean age of the patients was 82.9 years (SD 7.4) and 70% was female. One third had severe cognitive impairment and only 17% had no or little ADL impairment. RESULTS: Prevalence of pressure ulcers was: stage 1: 3,6%; stage 2: 2,5%; stage 3: 1,2%; stage 4: 0,8%. Having a pressure ulcer was strongly correlated with ADL dependency: Odds Ratio (OR) 8,4 for moderate ADL-dependency, and OR 35,4 for severe ADL-dependency. Patients with pressure ulcers had more often pain (OR 2,7) and depressive symptoms (OR 2,1). Bowel incontinence was significantly correlated (OR 2,6) with pressure ulcers, just as the presence of an indwelling catheter (OR 3,2) and the use of diapers (OR 2,2), but urinary incontinence was not correlated with pressure ulcers. The prevalence of a venous ulcers was 2,6% and 1,7% had a venous ulcer higher than stage 1. The combination of foot ulcers and diabetes occurred in 1,2%, the combination of a peripheral vascular disease and ulcers in only 0,7%. The use of pressure reducing interventions increased with ADL dependency, nevertheless only 44% of the very dependent patients used these interventions.

[The calculation of quality indicators for Home Care agencies in 11 European countries]. / Berekenen van kwaliteitsindicatoren voor de thuiszorg: voorbeeld uit het ADHOC project, een vergelijking tussen thuiszorgorganisaties uit 11 Europese landen.

OBJECTIVES: To describe and calculate Home Care Quality Indicators from data of the European Aged in Home Care (ADHOC) project. With due regard for risk factors, home care agencies at country level have been compared with each other on quality of care. METHODS: The indicators of Home Care quality of care (HCQIs) are calculated based on methods that have been developed in the US and Canada. The values of these QIs are risk adjusted on the basis of odds ratios of covariates resulting from logistic regression analysis on the ADHOC sample. To enhance the comparison of QIs between countries we have used the method of percentile thresholds and QI aggregate sum measure related to those. RESULTS: Risk adjusted values of 22 Home Care Quality Indicators differed considerably between home care agencies in the eleven European countries that participated in ADHOC. The QI aggregate showed which countries probably had the best home care and which had the worst. CONCLUSIONS: There are quality indicators available, derived from data of the Resident Assessment Instrument for Home Care, with which quality of care between home care agencies in and across nations can be adequately compared. Examples of this type of indicator are: social isolation, inadequate pain control, failure to improve in impaired locomotion in the home.

The MDS Challenging Behavior Profile for long-term care.

The objective was to construct a reliable and valid challenging behavior scale with items from the Minimum Data Set (MDS). Exploratory factor analyses of a sample of 656 nursing home residents yielded a 16-item Behavior Profile containing four internally consistent and valid subscales measuring conflict behavior, withdrawn behavior, agitation and attention seeking behavior (alpha range: 0.69-0.80). On a second dataset of 227 nursing home residents, internal consistency, inter-rater reliability and validity against the Behavior Rating Scale for Psychogeriatric Inpatients (GIP) were established. Internal consistency of the subscales ranged between 0.54 and 0.78. The overall inter-rater reliability of the items was 0.53 (kappa); of the scale it was 0.75 (ICC). The MDS Challenging Behavior Profile could potentially be an important contribution to existing clinical MDS-scales but additional studies on reliability, validity and usefulness are needed.

[The ZZP Questionnaire. Reliability of a new resource utilization measure]. / Betrouwbaarheid van de Zorgzwaartepakket (ZZP) scorelijst.

Data to determine the resource utilization of care recipients need to be reliable and the items that are measured need to be useful. In 2006, the Dutch Ministry of Health and Welfare has mandated all nursing homes and homes for the elderly to measure the Resource Utilization of all residents with the ZZP Questionnaire. Are the data resulting from this measurement reliable and is each of the 54 items of the ZZP Questionnaire useful? To answer this we tested the reliability of the data in a nursing home and a home for the elderly in two wards each. For 122 residents questionnaires were completed such that the inter- and intra-rater reliability of the answers could be assessed. Ten of the 54 items in the questionnaire showed insufficient inter rater reliability (<0.40) on the weighted Cohen kappa and another sixteen moderate (0.40 - 0.60). On the intra rater reliability test seven items had an insufficient kappa and another fifteen moderate. Besides, ten clusters of items could be formed with in-cluster Spearman correlation rates of .75 or higher. From the results of the reliability tests and the item intercorrelation rates we concluded that a substantial number of items needs to be improved and that in the ZZP Questionnaire 15 of the 54 items appear to be redundant on statistical grounds.

[Combined vision and hearing impairment: in an estimated 30,000-35,000 people aged 55 years or over in The Netherlands]. / Gecombineerde visus- en gehoorbeperking: naar schatting bij 30,000-35,000 55-plussers in Nederland.

OBJECTIVE: To determine the number of older people with acquired dual sensory impairment (DSI) in The Netherlands. DESIGN: Combination of studies in the general population and in relevant subpopulations. METHOD: Eight databases derived from recent studies on older persons with vision and hearing data on Dutch subjects aged 55 years or over were selected for further analysis. The measurement methods included self-reports, clinical measurements and observations. The prevalences of DSI were calculated for the general population, the non-institutionalised population, and subgroups such as older people in nursing homes and homes for the elderly. The calculated prevalences were extrapolated to the overall Dutch population. RESULTS: For the non-institutionalised population of 55 years and older, the prevalences of acquired DSI in two different data sets were 0.4% (95% CI: 0.2-0.6) and 0.6% (95% CI: 0.3-0.8), respectively. Among the inhabitants of homes for the elderly these percentages were 5.4% (95% CI: 0.9-9.9) and 5.5% (95% CI: 3.8-7.2), and in nursing homes they were 12.7% (95% CI: 9.7-15.7) and 16.7% (95% CI: 14.6-18.8). Acquired DSI was most common in persons 85 years of age and older. It was estimated that the number of people aged 55 years and over with acquired DSI in The Netherlands is 30,000 to 35,000. CONCLUSION: DSI is particularly a problem of the oldest old. An integrated approach to the visual and hearing problems of these subjects is essential.

The RAI-PC: an assessment instrument for palliative care in all settings.

Large numbers of persons in most types of healthcare settings have palliative care needs that have considerable impact on their quality of life. Therefore, InterRAI, a multinational consortium of researchers, clinicians, and regulators that uses assessment systems to improve the care of elderly and disabled persons, designed a standardized assessment tool, the Resident Assessment Instrument for Palliative Care (RAI-PC). The RAI-PC can be used for both the design of individual care plans and for case mix and outcomes research. Some elements of this instrument are taken from the resident assessment instrument (RAI) mandated for use in all nursing homes in the United States and widely used throughout the world. The RAI-PC can be used alone or in counjunction with the other assessment tools designed by the InterRAI collaboration: the RAI for homecare (RAI-HC), for acute care (RAI-AC), and for mental health care (RAI-MH). The objective of this study was to field test and carry out reliability studies on the RAI-PC. After appropriate approvals were obtained, the RAI-PC instrument was field tested on 151 persons in three countries in more than five types of settings. Data obtained from 144 of these individuals were analyzed for reliability. The reliability of the instrument was very good, with about 50 percent of the questions having kappa values of 0.8 or higher, and the average kappa value for each of the eight domains ranging from 0.76 to 0.95. The 54 men and 95 women had a mean age of 79 years. Thirty-four percent of individuals suffered pain daily. Eighty percent tired easily; 52 percent were breathless on exertion; and 19 to 53 percent had one or more other symptoms, including change in sleep pattern, dry mouth, nausea and vomiting, anorexia, breathlessness at rest, constipation, and diarrhea. The number of symptoms an individual reported increased as the estimated time until death declined. The "clinician friendly" RAI-PC can be used in multiple sites of care to facilitate both care planning and case mix and outcomes research.

[Integrated health information system based on Resident Assessment Instruments]. / Geïntegreerd gezondheidsinformatiesysteem op basis van Resident Assessment Instrumenten.

The paper explores the meaning of Resident Assessment Instruments. It gives a summary of existing RAI instruments and derived applications. It argues how all of these form the basis for an integrated health information system for "chain care" (home care, home for the elderly care, nursing home care, mental health care and acute care). The primary application of RAI systems is the assessment of client care needs, followed by an analysis of the required and administered care with the objective to make an optimal individual care plan. On the basis of RAI, however, applications have been derived for reimbursement systems, quality improvement programs, accreditation, benchmarking, best practice comparison and care eligibility systems. These applications have become possible by the development on the basis of the Minimum Data Set of RAI of outcome measures (item scores, scales and indices), case-mix classifications and quality indicators. To illustrate the possibilities of outcome measures of RAI we present a table and a figure with data of six Dutch nursing homes which shows how social engagement is related to ADL and cognition. We argue that RAI/MDS assessment instruments comprise an integrated health information system because they have consistent terminology, common core items, and a common conceptual basis in a clinical approach that emphasizes the identification of functional problems.

Integrated health information systems based on the RAI/MDS series of instruments.

There is a growing need for an integrated health information system to be used in community, institutional and hospital based settings. For example, changes in the structure, process and venues of service delivery mean that individuals with similar needs may be cared for in a variety of different settings. Moreover, as people make transitions from one sector of the healthcare system to another, there is a need for comparable information to ensure continuity of care and reduced assessment burden. The RAI/MDS series of assessment instruments comprise an integrated health information system because they have consistent terminology, common core items, and a common conceptual basis in a clinical approach that emphasizes the identification of functional problems.

[Nursing home day-care: a growing function for a rather stable patient group]. / Verpleeghuisdagbehandeling: een groeiende functie voor een tamelijk vast omschreven doelgroep.

This article is a descriptive study of the characteristics of nursing home day-care patients in the Netherlands in 1995 at first admission and at discharge. Data were derived from the National Nursing Home Registration System (SIVIS), in which in 1995 over 85% of Dutch nursing homes participated. Newly admitted day-care patients are characterized by high age (89% older than 65 years), a distribution with (only!) 9% more women than men and a morbidity pattern of chronic somatic (cerebrovascular disease 45%) and psychogeriatric (dementia 80%) disorders. This morbidity pattern was associated with a considerable degree of disability, in particular regarding the activities of daily living and mobility. Most patients (78%) come from their own homes. The average length of stay from admittance to discharge, for both somatic and psychogeriatic day-care patients was nine months. For about 10% of the somatic patients and 40% of the psychogeriatic ones ambulatory day-care resulted in (subsequent) admission to the nursing home itself. In the last decade nursing home day-care capacity has increased rapidly and parallel to this also the number of day-care patients. Remarkably the average level of disability and the average period of treatment of nursing home day-care patients has remained approximately the same in this period.

Variation in training programmes for Resident Assessment Instrument implementation.

BACKGROUND: this paper provides an overview of the Minimum Data Set/Resident Assessment Instrument (MDS/RAI) training programmes in eight countries where the system has been introduced into nursing homes. Formal education and training in the skills of assessment and care planning of nursing home personnel is reputed to be poor. In response to this problem several researchers and clinicians view MDS/RAI implementation as an opportunity to upgrade staff knowledge in care of elderly people. RESULTS: the courses in the eight countries varied in content and length according to the different goals each interRAI researcher planned when the MDS/RAI was implemented. As expected the greatest differences in training approach were between the USA and other countries. In the USA, where the MDS/RAI was mandated for use in all nursing homes, tens of thousands of professionals had to be oriented to use the system in a relatively short period of time in order to comply with the law. The training programmes therefore tended to be very short compared with those that emerged in countries where the MDS/RAI was freely chosen and implemented.

Transitions across various continuing care settings.

PURPOSE: to compare cross-nationally the sources and rates of admission and discharge in nursing homes. METHODS: data on admission were used from the Minimum Data Set of the Resident Assessment Instrument as collected in a multi-nation database at the University of Michigan. Additional data containing longitudinal episodes were used from databases in the Netherlands, Switzerland and the USA. RESULTS: the sources and rates of admission and discharge in nursing homes vary widely between countries. In Japan 47.5% of the sample was admitted from another long-term care setting, in Italy and the USA 36% and 42% respectively were admitted directly from hospital, while in Denmark and Iceland more than 60% came from home. The longitudinal data show that in the Netherlands, residents' return to home was much more likely than in Geneva or the USA (27% vs 5% vs 10%) and that in the USA a relatively large number of nursing home residents (>45%) was discharged (intermittently) to a hospital within 180 days after first admission as compared to the Netherlands (10%). CONCLUSIONS: there are large differences between countries in admission and discharge to and from nursing homes. Various policies, payment schemes, care patterns and routine referrals influence this and can be studied with cross-national data now available.

[Characteristics of patients during their stay in a nursing home and at discharge]. / Kenmerken van patiënten tijdens verblijf in het verpleeghuis en bij ontslag.

OBJECTIVE: To determine the characteristics of patients during stay in nursing homes, and at the moment of discharge or death. DESIGN: Cross-sectional study. METHOD: Data were collected concerning September 30th 1991 using the National Nursing Home Registration System SIVIS, in which over 80% of the nursing homes participate. There were 45,471 patients (23,395 somatic and 22,076 psychogeriatric patients). RESULTS: Frequent morbidity consisted of stroke, neurological disorders, locomotor disorders and dementia. There was a high degree of disability regarding the activities of daily life and mobility. The average length of stay for somatic patients was just over one year, that for psychogeriatric patients almost two and a half years. After rehabilitation, one-third of the patients could be discharged to their homes or to a home for the aged. (Most of the remaining patients eventually died in the nursing home.) CONCLUSION: Residing nursing home patients are mainly characterised by chronic disorders. Consequently, disabilities and handicaps occur in many areas, such as self-care, mobility and psychological functioning. For a number of patients the distinction between somatic or psychogeriatric nursing becomes irrelevant. For all categories of patients the utilisation of care resources is increasing.

[Characteristics of nursing home patients at initial admission: age, sex and morbidity]. / Kenmerken van verpleeghuispatiënten bij eerste opname: leeftijd, geslacht en morbiditeit.

INTRODUCTION: Some 35,000 new patients are admitted yearly to 'verpleeghuizen' or Dutch nursing homes. This paper describes some characteristics of these patients. METHOD: Data were collected using the national Nursing Home Registration System SIVIS of the Dutch centre for health care information. The response rate to the registration by the nursing homes is over 80%. RESULTS: Newly admitted nursing home patients are characterised by a (very) high age (over 50% of the patients are 80 years and over), a distribution of twice as many women as men and a morbidity pattern of chronic somatic and psychogeriatric, as well as orthopaedic disorders. CONCLUSION: Among elderly patients the nursing home patients constitute of a heterogeneous purpose of admission and morbidity pattern. Nursing home care focuses on rehabilitation, long-term care and terminal care.

[Nursing care needs of nursing home patients in large cities do not explain the greater work stress on the staff]. / Verpleegbehoefte van verpleeghuispatiënten in grote steden geen verklaring voor hogere werkdruk personeel.

A comparative study has been carried out to determine the influence of the care needs of patients on work pressure of nursing staff in the nursing homes of Amsterdam, Rotterdam and The Hague. Data of nursing home patients, resident at specific dates in nursing homes in the three largest cities have been compared with data from the rest of the Netherlands, altogether more than 40,000 patients at the time. The data came from the Dutch Nursing Home Information System (SIVIS). The differences have been determined in care needs and the changes in care needs in recent years. Nursing home patients in the three largest cities appear to have lower care needs than patients in the rest of the country. The care needs of the patients in the large cities hardly changed from 1986 to 1989. In the rest of the Netherlands a clear increase has occurred in the care needs of somatic and of psychogeriatric patients in the same period. The care needs of the patients in the three largest cities therefore cannot explain a higher work pressure of nursing staff as compared to the situation in nursing homes elsewhere in the Netherlands.

[Recalculation of bed occupancy ratio of short- and long-stay nursing home patients]. / Het beddenaandeel van kort- en langverblijvende verpleeghuispatiënten herberekend.

The authors present a revised equation by which the ratio of beds occupied by short- and long-term patients can be calculated. In 1984, 8.2% of the beds were occupied by short-stay somatic patients, compared to 2.17% occupied by short-stay psychogeriatric patients, the dividing line between short-stay and long-stay patients being 6 months. These data are also compared with those in 1985. In the latter year a distinction is made between somatic short-stay patients who died, and other somatic short-stay patients.

[Length of stay in nursing homes. Arrangements in short- and long-term stays]. / Verblijfsduur in verpleeghuizen. Een ordening in kort en lang verblijf.

For general and specific planning purposes in nursing homes it is necessary to know the number of beds available for the different groups of patients. The length of stay of patients, however, varies substantially. This makes it difficult to calculate the numbers and types of beds which will be available at any given moment. By drawing the dividing line between a short and a long stay at six months we are able to discuss factors concerning length of stay more lucidly. According to this criterion, 64.9% of the somatic patients discharged in 1984 were short-stay patients, compared with 31.3% short-stay psychogeriatric patients. The total number of beds needed for short-stay patients in 1984 amounted to 34.4% of the total number of beds available for somatic patients and 12.5% of the beds available for psychogeriatric patients. The precise figures vary considerably between nursing homes. This variation is greater for somatic than for psychogeriatric patients.