Search and rescue incidents among persons 65 years and older in the USA: Examination of factors associated with death.

OBJECTIVES: Older people are vulnerable to becoming lost from home, especially if alone and in unfamiliar environments. Incidents of older persons becoming lost are frequently reported and often requiring a search and rescue (SAR) response. Becoming lost is distressing to the person concerned, their carer, and family and may result in physical injury and/or death. This study examined what factors are associated with death among older persons reported lost from home. METHODS/DESIGN: A retrospective cross-sectional study. Data were obtained from the International Search and Rescue Incident Database from 1985 to 2013. Participants comprised persons aged 65 years and older living in the United States. Individual, SAR incident, and environmental factors were analysed. The primary outcome of this study was lost person found alive or found dead on arrival. Relationships between categorical variables and outcome were summarised with contingency tables, chi-squared test p-values (or Fisher's-exact-test), and odds ratios (OR) with 95% confidence intervals (CI). Association between continuous variables and outcome were examined using multiple logistic regression. p-value of <0.05 was considered significant. RESULTS: Among the 5242 SAR incidents, 1703 met the inclusion criteria, of which 87.8% (n = 1495) were found alive and 12.2% (n = 208) were found dead. Factors associated with death included: male gender (OR 1.46; CI 1.01-2.13; p = 0.048), cognitively intact (OR 0.32; CI 0.22-0.47; p < 0.001), prolonged SAR duration (OR: 1.028; CI: 1.021-1.035; p < 0.001), found in water/wetlands (OR 7.40; CI 3.37-16.24; p < 0.001), and extreme weather (OR: 2.06; 95% CI: 1.10-3.86; p = 0.024). CONCLUSIONS: Older people have a fundamental human right to protection from preventable deaths. Findings indicate these rights are not being protected with deaths occurring frequently among older people who have become lost from home. To minimise fatalities, knowledge of factors associated with death could inform the development suitable assessment and intervention strategies for SAR teams and caregivers.

Thermal Injury Deaths of Community-dwelling Older People With Dementia.

Although people with dementia are prone to the risk of fire and burn injuries, the relationship between fatal thermal injuries and dementia has not been investigated. We examined coronial files in the state of Victoria, Australia between July 1, 2000 and December 31, 2014, for unintentional thermal injury causing deaths of community dwelling people, aged 65 years and older to identify those with dementia. Mortality for Victorian populations with and without dementia was calculated using direct age standardization. In total, 105 deaths were identified of which 18 (17%) had dementia. Mortality was more than 3-fold greater for people with dementia (3.0 vs. 0.8 per 100,000 person-years) and they more often lived with others when the injury occurred (56%, n=10 vs. 29% n=25, P=0.028). Our results suggest that older people with dementia are at greater risk of death through thermal injury. Further research should consider investigating a larger population through combining databases across multiple jurisdictions.

Applying dignity of risk principles to improve quality of life for vulnerable persons.

OBJECTIVES: Freedom of choice impacts quality of life. Expressed through dignity of risk (DoR), nursing home (NH) residents should be afforded the dignity to take risks to enhance well-being. How DoR is understood and implemented in the context of aged care remains largely unknown. This study explored the meaning and the barriers and facilitators to applying DoR to NH residents. METHODS: Qualitative study, comprising semistructured interviews. Senior policy makers and advocate guardians working in the aged care or disability sector were invited to participate. Recruitment continued until data saturation was reached. Two researchers coded interviews, applying inductive and thematic analysis. RESULTS: Fourteen participants took part during 2016-2017. Analysis demonstrated uniformity in participants' description of DoR, comprising four elements: (a) individuals are at the centre of decision making; (b) life involves risk; (c) individuals must have choice; and (d) DoR is a continuum of experiences. Three main barriers for implementing DoR into practice were identified: (a) balancing autonomy with risks; (b) situational nature of DoR; and (c) taking responsibility for risk. CONCLUSION: The novel findings provide an explicit understanding of DoR and the facilitators and barriers to applying the principle in the NH setting. These findings inform those who engage in making and implementing choices in the presence of risk for vulnerable clients. To translate the multifaceted elements of DoR into practice requires the development of unambiguous policies/guidelines about who will be responsibility for potential risks that may arise from residents' choices. Further, education programmes supporting care staff/management to enact resident choices in the presence of real or perceived risk are required.

Suicide among Nursing Home Residents: Development of Recommendations for Prevention Using a Nominal Group Technique.

This research aimed to develop and prioritize recommendations for prevention of suicide among nursing home residents. The study employed a nominal group technique, comprising three rounds, including two forums and a follow-up survey to prioritize recommendations for prevention. Participants included experts and stakeholders in aged care, geriatric psychiatry, suicide prevention, and public policy. The study was conducted and described in accordance with the consolidated criteria for reporting qualitative studies (COREQ). Nine participants (n = 6 males, 66%) developed eleven recommendations for prevention. The top three prioritized recommendations included expanding state and national suicide prevention frameworks, aligning nursing home life with community living, and improving residents' access to mental health services. The recommendations provide a foundation for suicide prevention strategies in Australian nursing homes and contribute to the limited international knowledge base on prevention of suicide among nursing home residents.

Self-management of heart failure in dementia and cognitive impairment: a systematic review.

BACKGROUND: The cornerstone of effective management in heart failure (HF) is the ability to self-care. Aims include i) To determine factors influencing self-care in HF patients with cognitive impairment (CI) and ii) to determine the influence of cognitive domains on self-care in patients with HF and CI. METHODS: MEDLINE, CINAHL, EMBASE, EBSCOHost, PsychINFO, ProQuest Research Library, Health Technology Assessment Database, The Cochrane Library, Web of Science and Scopus databases were systematically searched. Original research describing the relationship between cognition and HF self-care in community-dwelling older persons with dementia/CI in English, published in a peer-reviewed journal from 1stJanuary(2000)-22ndMarch(2016) was identified. Study and population characteristics, data sources, self-care processes, methods of cognitive assessment, cognitive domains affected, study outcomes, impact of impairment, and other risk factors of self-care impairment were abstracted by two reviewers. RESULTS: Of 10,688 studies identified, 14 met the inclusion criteria. Patients with HF and CI ranged from 14 to 73%. Where reported, self-care maintenance adequacy ranged from 50 to 61%; self-care management adequacy ranged from 14 to 36% and self-care confidence adequacy ranged from 0 to 44% on the Self-care of Heart Failure Index (SCHFI). All but one study predicted poor self-care ability according to poor outcome on cognitive testing. Additionally, specific cognitive domain deficits impaired self-care. Subjects with lower cognitive scores were less likely to seek assistance while subjects with depression had poor self-care abilities. CONCLUSIONS: Clinicians must consider the type and severity of impairments in cognitive domains to tailor management. Awareness of depression, self-confidence and support access may modulate self-care ability.

The impact of cognitive impairment in dementia on self-care domains in diabetes: A systematic search and narrative review.

Self-management is integral to effective chronic disease management. Cognitive impairments (CogImp) associated with dementia have not previously been reviewed in diabetes mellitus (DM) self-care. The aims of this study are to know (1) whether CogImp associated with dementia impact self-care and (2) whether specific CogImp affects key DM self-care processes. A systematic literature search with a narrative review was conducted according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. This review examined studies published from January, 2000 to February, 2016 describing the relationship between cognition and DM self-care domains in community dwelling older adults with dementia/CogImp. Eight studies met inclusion criteria. Decrements in all self-care domains were associated with CogImp. Problem solving was related to reduced disease knowledge (OR 0.87, 95% CI = 0.49-1.55), resulting in poorer glycemic control. Decision-making impairments manifested as difficulties in adjusting insulin doses, leading to more hospital admissions. People without CogImp were better able to find/utilize resources by adhering to recommended management (OR 1.03, 95% CI = 1.02-1.05). A lack of interaction with health care providers was demonstrated through reduced receipt of important routine investigation including eye examinations (ARR = 0.85, 95% CI = 0.85-0.86), HbA1c testing (ARR = 0.96, 95% CI = 0.96-0.97), and LDL-C testing (ARR = 0.91, 95% CI = 0.901-0.914). People without CogImp had better clinic attendance (OR 2.17, 95% CI = 1.30-3.70). Action taking deficits were apparent through less self-testing of blood sugar levels (20.2% vs 24.4%, P = 0.1) resulting in poorer glycemic control, self-care, and more frequent micro/macrovascular complications. Persons with diabetes and CogImp, particularly in domains of learning, memory and executive function, were significantly impaired in all self-care tasks.

Unexplained absence resulting in deaths of nursing home residents in Australia-A 13-year retrospective study.

OBJECTIVES: To examine deaths of Australian nursing home (NH) residents following an unexplained absence. METHODS: Population based cross-sectional study was conducted using coronial data from the National Coronial Information System. Participants are residents of accredited NHs if death followed an unexplained absence and was reported to the Coroner between July 1, 2000 and June 30, 2013. Individual, organisational, environmental, and unexplained absence event factors were extracted from coronial records. Data were analysed using descriptive statistics. RESULTS: Of 21 672 NH deaths, 24 (0.1%) followed an unexplained absence. This comprised 17 unintentional external (injury-related) causes and 7 natural cause deaths. Drowning was the most frequent external cause of death (59%, n = 10). Deaths occurred more frequently in males (83.3%, n = 20), and in the age group 85-94 years (37.5%, n = 9). The majority of NH residents, for whom data were available (n = 15), had a diagnosis of dementia (86.7%, n = 13). Most residents were found in waterways (41.7%, n = 10). Median distance travelled was 0.5 km (IQR: 0.25-2.4 km), with almost 70% of residents found within 1.0 km of their NH. Most residents left the NH by foot (88.2%, n = 15). Half of the residents were found within 6 hours of time last seen (median: 6 hours, 40 minutes; IQR: 6.0-11.45 hours). CONCLUSION: Unexplained absences in elderly NH residents are a relatively common event. This study provides valuable information for aged care providers, governments, and search and rescue teams, and should contribute to debates about balancing issues of safety with independence.

Suicide among nursing home residents in Australia: A national population-based retrospective analysis of medico-legal death investigation information.

OBJECTIVES: Suicide among nursing home residents is a growing public health concern, currently lacking in empirical research. This study aims to describe the frequency and nature of suicide among nursing home residents in Australia. METHODS: This research comprised a national population-based retrospective analysis of suicide deaths among nursing home residents in Australia reported to the Coroner between July 2000 and December 2013. Cases were identified using the National Coronial Information System, and data collected from paper-based coroners' records on individual, incident, and organizational factors, as well as details of the medico-legal death investigation. Data analysis comprised univariate and bivariate descriptive statistical techniques; ecological analysis of incidence rates using population denominators; and comparison of age and sex of suicide cases to deaths from other causes using logistic regression. RESULTS: The study identified 141 suicides among nursing home residents, occurring at a rate of 0.02 deaths per 100 000 resident bed days. The ratio of deaths from suicide to deaths from any other cause was higher in males than females (OR = 3.56, 95%CI = 2.48-5.12, P = <0.001). Over half of the residents who died from suicide had a diagnosis of depression (n = 93, 66.0%) and had resided in the nursing home for less than 12 months (n = 71, 50.3%). Common major life stressors identified in suicide cases included the following: health deterioration (n = 112, 79.4%); isolation and loneliness (n = 60, 42.6%); and maladjustment to nursing home life (n = 42, 29.8%). CONCLUSIONS: This research provides a foundational understanding of suicide among nursing home residents in Australia and contributes important new information to the international knowledge base.

Frequency and nature of coroners' recommendations from injury-related deaths among nursing home residents: a retrospective national cross-sectional study.

BACKGROUND: Coroners are tasked with the investigation of unnatural and unexpected deaths. In Australia, the coroner's role also includes making recommendations for promoting interventions to improve public safety. However, the coroners' role in public health and safety in the aged care setting is an underexplored area of research. OBJECTIVES: To describe the frequency and nature of coroners' recommendations for prevention of harm from injury-related deaths among nursing home residents in Australia. SETTING: Accredited nursing homes in Australia. SUBJECTS: Nursing home residents whose deaths resulted from external causes occurring between 1 July 2000 and 31 December 2013 and notified to a coroner. MEASUREMENTS: Coroners' recommendations were identified and extracted from the National Coronial Information System. Descriptive statistical techniques were used to calculate the frequency and proportion of recommendations made. The nature of recommendations was quantified using a method comprising seven elements derived from internationally accepted and applied public health conceptual models of mortality causation and prevention. RESULTS: Coroners made recommendations about the prevention of harm in 53 of the 3289 (1.6%) external cause deaths of nursing home residents. Recommendations were most frequently made for deaths resulting from falls; however, the rate of recommendations per 1000 deaths was highest for thermal mechanisms and complications of clinical care. Most recommendations described the 'countermeasure' element, but rarely specified a timeframe for implementation. CONCLUSION: Coroners' recommendations need to be further enhanced in the age care setting. The development of national and international guidelines on best practice in the formulation of effective recommendations should be undertaken.

The Use of Deceased Controls in Epidemiologic Research: A Systematic Review.

Scholarly debate on the use of deceased controls in epidemiologic research continues. This systematic review examined published epidemiologic research using deceased persons as a control group. A systematic search of 5 major biomedical literature databases (MEDLINE, CINAHL, PsycINFO, Scopus, and EMBASE) was conducted, using variations of the search terms "deceased" and "controls" to identify relevant peer-reviewed journal articles. Information was sought on study design, rationale for using deceased controls, application of theoretical principles of control selection, and discussion of the use of deceased controls. The review identified 134 studies using deceased controls published in English between 1978 and 2015. Common health outcomes under investigation included cancer (n = 31; 23.1%), nervous system diseases (n = 26; 19.4%), and injury and other external causes (n = 22; 16.4%). The majority of studies used deceased controls for comparison with deceased cases (n = 95; 70.9%). Investigators rarely presented their rationale for control selection (n = 25/134; 18.7%); however, common reasons included comparability of information on exposures, lack of appropriate controls from other sources, and counteracting bias associated with living controls. Comparable accuracy was the most frequently observed principle of control selection (n = 92; 68.7%). This review highlights the breadth of research using deceased controls and indicates their appropriateness in studies using deceased cases.

Premature deaths of nursing home residents: an epidemiological analysis.

OBJECTIVES: To conduct a descriptive epidemiological analysis of external cause deaths (premature, usually injury-related, and potentially preventable) of nursing home residents in Australia. DESIGN: Retrospective study of a cohort of nursing home residents, using coronial data routinely recorded by the National Coronial Information System. SETTING AND PARTICIPANTS: Residents of accredited Australian nursing homes, whose deaths were reported to coroners between 1 July 2000 and 30 June 2013, and determined to have resulted from external causes. MAIN OUTCOME MEASURES: Causes of death, analysed by sex and age group, and by location of incidents leading to death and location of death. Rates of death were estimated on the basis of Australian Bureau of Statistics population and Australian Institute of Health and Welfare nursing home data. RESULTS: Of 21672 deaths of nursing home residents, 3289 (15.2%) resulted from external causes. The most frequent mechanisms of death were falls (2679 cases, 81.5%), choking (261 cases, 7.9%) and suicide (146 cases, 4.4%). The incidents leading to death usually occurred in the nursing home (95.8%), but the deaths more frequently occurred outside the nursing home (67.1%). The annual number of external cause deaths in nursing homes increased during the study period (from 1.2 per 1000 admissions in 2001-02 to 5.3 per 1000 admissions in 2011-12). CONCLUSION: The incidence of premature and potentially preventable deaths of nursing home residents has increased over the past decade. A national policy framework is needed to reduce the incidence of premature deaths among Australians living in nursing homes.

Completion of Limitation of Medical Treatment forms by junior doctors for patients with dementia: clinical, medicolegal and education perspectives.

Objective Limitation of Medical Treatment (LMT) forms are an essential element of end-of-life care. Decision making around LMT is complex and often involves patients with dementia. Despite the complexity, junior doctors frequently play a central role in completing LMT forms. The present study sought perspectives from a range of stakeholders (hospital clinicians, medical education personnel, legal and advocacy staff) about junior doctors' roles in completing LMT forms in general and for patients with dementia. Methods Qualitative data were gathered in semi-structured interviews (SSI) and theoretical concepts were explored in roundtable discussion (RD). Participants were recruited through purposive and convenience sampling drawing on healthcare and legal personnel employed in the public hospital and aged care systems, selected from major metropolitan hospitals, healthcare and legal professional bodies and advocacy organisations in Victoria, Australia. The contents of the SSIs and RD were subject to thematic analysis using a framework approach. Data were indexed according to the topics established in the study aim; categories were systematically scrutinised, from which key themes were distilled. Results Stakeholders reported that completing LMT forms was difficult for junior doctors because of a lack of medical and legal knowledge, as well as clinical inexperience and inadequate training. Healthcare organisations (HCOs) either lacked policies about the role of junior doctors or had practices that were discordant with policy. In this process, there were substantial gaps pertaining to patients with dementia. Recommendations made by the study participants included the provision of supervised clinical exposure and additional training for junior doctors, strengthening HCO policies and explicit consideration of the needs of patients with dementia. Conclusions LMT forms should be designed for clarity and consistency across HCOs. Enhancing patient care requires appropriate and sensitive completion of LMT. Relevant HCO policy and clinical practice changes are discussed herein, and recommendations are made for junior doctors in this arena, specifically in the context of patients with dementia. What is known about the topic? Junior doctors continue to play a central role in LMT orders, a highly complex decision-making task that they are poorly prepared to complete. LMT decision making in Australia's aging population and for people with dementia is especially challenging. What does this paper add? A broad range of stakeholders, including hospital clinicians, medical education personnel and legal and advocacy staff, identified ongoing substantial gaps in education and training of junior doctors (despite what is already known in the literature). Furthermore, LMT decision making for patients with dementia is not explicitly considered in policy of practice. What are the implications for practitioners? Current policy and practice are not at the desired level to deliver appropriate end-of-life care with regard to LMT orders, especially for patients with dementia. Greater involvement of executives and senior clinicians is required to improve both practice at the bed side and the training and support of junior doctors, as well as creating more robust policy.

The utility of medico-legal databases for public health research: a systematic review of peer-reviewed publications using the National Coronial Information System.

BACKGROUND: Medico-legal death investigations are a recognised data source for public health endeavours and its accessibility has increased following the development of electronic data systems. Despite time and cost savings, the strengths and limitations of this method and impact on research findings remain untested. This study examines this issue using the National Coronial Information System (NCIS). METHODS: PubMed, ProQuest and Informit were searched to identify publications where the NCIS was used as a data source for research published during the period 2000-2014. A descriptive analysis was performed to describe the frequency and characteristics of the publications identified. A content analysis was performed to identify the nature and impact of strengths and limitations of the NCIS as reported by researchers. RESULTS: Of the 106 publications included, 30 reported strengths and limitations, 37 reported limitations only, seven reported strengths only and 32 reported neither. The impact of the reported strengths of the NCIS was described in 14 publications, whilst 46 publications discussed the impacts of limitations. The NCIS was reported to be a reliable source of quality, detailed information with comprehensive coverage of deaths of interest, making it a powerful injury surveillance tool. Despite these strengths, researchers reported that open cases and missing information created the potential for selection and reporting biases and may preclude the identification and control of confounders. CONCLUSIONS: To ensure research results are valid and inform health policy, it is essential to consider and seek to overcome the limitations of data sources that may have an impact on results.

Senior staff perspectives of a quality indicator program in public sector residential aged care services: a qualitative cross-sectional study in Victoria, Australia.

OBJECTIVE: The aims of the present study were to describe the views of senior clinical and executive staff employed in public sector residential aged care services (RACS) about the benefits and limitations of using quality indicators (QIs) for improving care, and to identify any barriers or enablers to implementing the QI program. METHODS: A cross-sectional qualitative study using semistructured interviews and direct observation of key informants involved in the QI program was performed across 20 public sector RACS in Victoria, Australia. Participants included senior clinical, executive and front-line staff at the RACS. The main outcome measures were perceived benefits and the enablers or barriers to the implementation of a QI program. RESULTS: Most senior clinical and executive staff respondents reported substantive benefits to using the QIs and the QI program. A limited number of staff believed that the QI program failed to improve the quality of care and that the resource requirements outweighed the benefits of the program, resulting in disaffected staff. CONCLUSIONS: The QIs and QI program acted as a foundation for improving standards of care when used at the front line or point of care. Senior executive engagement in the QI program was vital to successful implementation.

The Overuse, Underuse, and Misuse of Dialysis in ESKD Patients with Dementia.

The profile of patients on chronic dialysis has shifted. There is a growing group of older patients with comorbid dementia and ESKD, who are at risk of overuse, underuse, and misuse of dialysis. Policy is lacking to help guide treatment decisions in this group. This paper explores clinical considerations specific to patients with comorbid ESKD and dementia. These include: the impact of comorbid dementia on dialysis effectiveness and feasibility; burden of care issues that are specific to patients with dementia; and capacity, autonomy, and consent. A better understanding of these issues may help guide discussions and decision making about treatment. For some older patients with multiple comorbidities including dementia, dialysis does not provide survival or quality of life benefit compared to medical management. These patients also experience additional treatment burden due to a 'dementia unfriendly' environment. However, exceptions may include patients who are younger, more independent, and have fewer comorbidities. Patients with dementia are often inappropriately assumed to lack capacity to participate in treatment decision making, and are at risk of having their preferences overlooked. Many patients with mild-to-moderate dementia remain capable of reporting their preferences and quality of life, and should always be involved in treatment discussions where possible.

Completed suicide among nursing home residents: a systematic review.

OBJECTIVE: The aim of this study is to systematically review published research describing the frequency, nature, and contributing factors of completed suicides among nursing home residents. METHODS: In accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Statement, this review examined all original, peer-reviewed literature published in English between 1 January 1949 and 31 December 2013 describing completed suicides among nursing home residents. Information extracted for analysis included: study and population characteristics, method of suicide, potential risk factors, and interventions. RESULTS: Eight studies were identified; the majority (n = 5) conducted in the United States of America. There were 113 suicides in nursing homes reported in the literature, 101 with detailed information available for aggregate analysis. The majority were male (n = 62, 61.4%), aged between 61 and 93 years. Suicide was most commonly by hanging (n = 27, 38.0%) or falling from a height (n = 27, 38.0%). Risk factors were considered in a proportion of studies. Depression was examined in 27 cases and present in 18 (67%). Duration of residence was examined in 25 cases, 13 (52%) of which had resided in the nursing home less than 12 months. Physical health was examined in 22 cases, 11 (50%) of whom were experiencing physical decline. Prior suicidal behaviour, cognitive function, and personal loss were also examined. Organizational risk factors and intervention strategies were rarely considered. CONCLUSIONS: There is a paucity of research describing completed suicide among nursing home residents. More large-scale research is required using standardized methods for reporting information to better understand and prevent completed suicides in this setting.

Resident-to-resident physical aggression leading to injury in nursing homes: a systematic review.

BACKGROUND: resident-to-resident aggression (RRA) is an understudied form of elder abuse in nursing homes. OBJECTIVE: the purpose of this systematic review was to examine the published research on the frequency, nature, contributing factors and outcomes of RRA in nursing homes. METHODS: in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Statement, this review examined all original, peer-reviewed research published in English, French, German, Italian or Spanish between 1st January 1949 and 31st December 2013 describing incidents of RRA in nursing homes. The following information was extracted for analysis: study and population characteristics; main findings (including prevalence, predisposing factors, triggers, nature of incidents, outcomes and interventions). RESULTS: eighteen studies were identified, 12 quantitative and 6 qualitative. The frequency of RRA ranged from 1 to 122 incidents, with insufficient information across the studies to calculate prevalence. RRA commonly occurred between exhibitors with higher levels of cognitive awareness and physical functionality and a history of aggressive behaviours, and female targets who were cognitively impaired with a history of behavioural issues including wandering. RRA most commonly took place in the afternoon in communal settings, was often triggered by communication issues and invasion of space, or was unprovoked. Limited information exists on organisational factors contributing to RRA and the outcomes for targets of aggression. CONCLUSIONS: we must continue to grow our knowledge base on the nature and circumstances of RRA to prevent harm to an increasing vulnerable population of nursing home residents and ensure a safe working environment for staff.