Advance care plans in UK care home residents: a service evaluation using a stepped wedge design.

INTRODUCTION: advance care planning (ACP) in care homes has high acceptance, increases the proportion of residents dying in place and reduces hospital admissions in research. We investigated whether ACP had similar outcomes when introduced during real-world service implementation. METHODS: a service undertaking ACP in Lincoln, UK care homes was evaluated using routine data. Outcomes were proportion of care homes and residents participating in ACP; characteristics of residents choosing/declining ACP and place of death for those with/without ACP. Hospital admissions were analysed using mixed-effects Poisson regression for number of admissions, and a mixed-effects negative binomial model for number of occupied hospital bed days. RESULTS: About 15/24 (63%) eligible homes supported the service, in which 404/508 (79.5%) participants chose ACP. Residents choosing ACP were older, frailer, more cognitively impaired and malnourished; 384/404 (95%) residents choosing ACP recorded their care home as their preferred place of death: 380/404 (94%) declined cardiopulmonary resuscitation. Among deceased residents, 219/248 (88%) and 33/49 (67%) with and without advance care plan respectively died in their care home (relative risk 1.35, 95% confidence interval [CI] 1.1-1.6, P < 0.001). Hospital admission rates and bed occupancy did not differ after implementation. DISCUSSION: About 79.5% participants chose ACP. Those doing so were more likely to die at home. Many homes were unwilling or unable to support the service. Hospital admissions were not reduced. Further research should consider how to enlist the support of all homes and to explore why hospital admissions were not reduced.

Investigating the prevalence of malnutrition, frailty and physical disability and the association between them amongst older care home residents.

BACKGROUND: Malnutrition, frailty and physical disability are inter-related, more prevalent in the older population and increase the risk of adverse health outcomes. Thus, screening is essential, especially in the understudied care home setting where the population is vulnerable and at higher risk of malnutrition. Furthermore, prevalence may vary depending upon screening tools used. The aims of this study were to: 1) investigate the prevalence of 1) malnutrition risk using Mini Nutritional Assessment - Short Form (MNA-SF) and Malnutrition Universal Screening Tool (MUST), 2) frailty using the Edmonton Frailty Scale (EFS), 3) physical disability using the Barthel Index (BI) and (4) examine the association between variables and coexistence of states. METHODS: Screening for malnutrition (MNA-SF and MUST) and frailty (EFS) was performed as part of a comprehensive geriatric assessment (CGA) in 527 residents from 17 care homes in Lincoln, UK. Mean age of the group was 85.6 ± 7.6 years and body mass index, BMI 23.0 ± 5.1 kg/m2. RESULTS: A high prevalence of malnutrition risk was detected: 41.4% by MNA-SF and 25.5% by MUST (high risk/malnourished). Furthermore, there was a clear discordance between MNA-SF and MUST scoring of malnutrition; for example, the percentage of those identified as being at low risk was 18.8% using the MNA-SF and 57.0% using the MUST. In addition, there was a high prevalence of severe frailty by EFS (69.6%) and functional impairment by BI (62.0%). There was good association between some variables (P < 0.001) and 33.4% of residents had coexistence of all three states of malnutrition, frailty and physical disability. CONCLUSIONS: Malnutrition risk, frailty and physical disability are highly prevalent in care home residents and interrelated. However, prevalence varies depending on the screening tool used. More research should be conducted in the care home setting to improve daily clinical practice as screening may impact upon subsequent treatment and care modalities and clinical outcomes.

The Bromhead Care Home Service: the impact of a service for care home residents with dementia on hospital admission and dying in preferred place of care.

People with dementia have worse outcomes associated with hospital admission, are more likely to have interventions and are less likely to be offered palliative care than people without dementia. Advance care planning for care home residents has been shown to reduce hospital admissions without increasing mortality. Studies have shown that staff confidence in managing delirium, a common reason for admission, improves with training. A service combining education for care home staff and advance care planning for care home residents with dementia was introduced to care homes in Boston, UK. There were improvements in staff confidence in recognition, prevention, management and knowledge of factors associated with delirium and dysphagia. 92% of carers rated the service >9/10. Admissions fell by 37% from baseline in the first year and 55% in the second and third years. All but one resident died in the preferred place of care.