Dying With Dementia in Long-Term Care

To better understand the experiences and potential unmet need of persons with dementia who die in long-term care

Improving dementia diagnosis and management in primary care: a cohort study of the impact of a training and support program on physician competency, practice patterns, and community linkages

Abstract Background Primary care physicians routinely provide dementia care, but may lack the clinical skills and awareness of available resources to provide optimal care. We conducted a community-based pilot dementia training intervention designed to both improve clinical competency and increase utilization of local dementia care services. Methods Physicians (N = 29) and affiliated staff (N = 24) participated in a one-day training program on dementia screening, diagnosis and management that included direct engagement with local support service providers. Questionnaires about their dementia care competency and referral patterns were completed before and 6 months after the training intervention. Results Physicians reported significantly higher overall confidence in their dementia care competency 6 months post-training compared to pre-training. The largest reported improvements were in their ability to educate patients and caregivers about dementia and making appropriate referrals to community care services. Participants also reported markedly increased use of cognitive screening tools in providing care. Community service providers recorded approximately 160 physician-initiated referrals over a 2 year-period post-training, compared to few beforehand. Conclusions Combining a targeted physician practice-based educational intervention with community service engagement improves dementia care competency in clinicians and promotes linkages between clinical and community dementia care providers

Optimizing Antibiotic Stewardship in Nursing Homes: A Narrative Review and Recommendations for Improvement

The emerging crisis in antibiotic resistance and concern that we now sit on the precipice of a post-antibiotic era have given rise to advocacy at the highest levels for widespread adoption of programmes that promote judicious use of antibiotics. These antibiotic stewardship programmes, which seek to optimize antibiotic choice when clinically indicated and discourage antibiotic use when clinically unnecessary, are being implemented in an increasing number of acute care facilities, but their adoption has been slower in nursing homes. The antibiotic prescribing process in nursing homes is fundamentally different from that observed in hospital and clinic settings, with formidable challenges to implementation of effective antibiotic stewardship. Nevertheless, an emerging body of research points towards ways to improve antibiotic prescribing practices in nursing homes. This review summarizes the findings of this research and presents ways in which antibiotic stewardship can be implemented and optimized in the nursing home setting

Effect of the Bathing Without a Battle Training Intervention on Bathing-Associated Physical and Verbal Outcomes in Nursing Home Residents with Dementia: A Randomized Crossover Diffusion Study

To evaluate the effectiveness of the Bathing Without a Battle intervention in reducing physical and verbal aggressive behaviors for nursing home residents with dementia

Preferences Versus Practice: Life-Sustaining Treatments in Last Months of Life in Long-Term Care

To determine the prevalence and correlates of decisions made about life-sustaining treatments among residents in long-term care settings, including how often decisions were honored and characteristics associated with decisions not being followed

<span class="italic">n</span>–3 Fatty acids, hypertension and risk of cognitive decline among older adults in the Atherosclerosis Risk in Communities (ARIC) study

OBJECTIVE: Recent research indicates that n-3 fatty acids can inhibit cognitive decline, perhaps differentially by hypertensive status. DESIGN: We tested these hypotheses in a prospective cohort study (the Atherosclerosis Risk in Communities). Dietary assessment using a food-frequency questionnaire and plasma fatty acid exposure by gas chromatography were completed in 1987-1989 (visit 1), while cognitive assessment with three screening tools--the Delayed Word Recall Test, the Digit Symbol Substitution Test of the Wechsler Adult Intelligence Scale-Revised and the Word Fluency Test (WFT)--was completed in 1990-1992 (visit 2) and 1996-1998 (visit 4). Regression calibration and simulation extrapolation were used to control for measurement error in dietary exposures. SETTING: Four US communities--Forsyth County (North Carolina), Jackson (Mississippi), suburbs of Minneapolis (Minnesota) and Washington County (Maryland). SUBJECTS: Men and women aged 50-65 years at visit 1 with complete dietary data (n = 7814); white men and women in same age group in the Minnesota field centre with complete plasma fatty acid data (n = 2251). RESULTS: Findings indicated that an increase of one standard deviation in dietary long-chain n-3 fatty acids (% of energy intake) and balancing long-chain n-3/n-6 decreased the risk of 6-year cognitive decline in verbal fluency with an odds ratio (95% confidence interval) of 0.79 (0.66-0.95) and 0.81 (0.68-0.96), respectively, among hypertensives. An interaction with hypertensive status was found for dietary long-chain n-3 fatty acids (g day-1) and WFT decline (likelihood ratio test, P = 0.06). This exposure in plasma cholesteryl esters was also protective against WFT decline, particularly among hypertensives (OR = 0.51, P < 0.05). CONCLUSION: One implication from our study is that diets rich in fatty acids of marine origin should be considered for middle-aged hypertensive subjects. To this end, randomised clinical trials are needed

A National Typology of Health Service Regulation in Assisted Living

Background and Objectives State regulating agencies use 350 different licenses and certifications to govern assisted living (AL), resulting in significant variation in regulations governing health services, the scope of practice, and capacity. This lack of standardization makes it difficult to compare and contrast AL operations and residents’ outcomes across similarly regulated communities. Research Design and Methods We used qualitative and quantitative methods to empirically develop and describe a typology of state AL regulations that captures inter and intra-state variation. Based on the rules governing health services, we created regulatory specificity scores for five thematic dimensions: medication administration, third-party care, skilled nursing, medication review, and licensed nurse staffing. With these scores, we conducted a K-means cluster analysis to identify groups of AL license types. To differentiate the regulatory types, we calculated standardized mean differences across structure, process, outcome, and resident characteristics of the AL communities licensed under each type. Results We identified six types of AL differentiated by the regulatory provisions governing health services: Housing, Holistic, Hybrid, Hospitality, Healthcare, and Health Support. The types align with previous work and reflect tangible differences in resident characteristics, health service structures, processes, and outcomes. Discussion and Implications This typology effectively captures differences across regulated dimensions and can inform and support quality of care. Researchers, policymakers, and consumers may benefit from using this typology and acknowledging these differences in AL licensure when designing research studies, developing policies, and selecting an AL community

Recommendations for Medical and Mental Health Care in Assisted Living Based on an Expert Delphi Consensus Panel A Consensus Statement

Importance Assisted living (AL) is the largest provider of residential long-term care in the US, and the morbidity of AL residents has been rising. However, AL is not a health care setting, and concern has been growing about residents’ medical and mental health needs. No guidance exists to inform this care. Objective To identify consensus recommendations for medical and mental health care in AL and determine whether they are pragmatic. Evidence Review A Delphi consensus statement study was conducted in 2021; as a separate effort, the extent to which the recommendations are reflected in practice was examined in data obtained from 2016 to 2021 (prepandemic). In the separate effort, data were from a 7-state study (Arkansas, Louisiana, New Jersey, New York, Oklahoma, Pennsylvania, Texas). The 19 Delphi panelists constituted nationally recognized experts in medical, nursing, and mental health needs of and care for older adults; dementia care; and AL and long-term care management, advocacy, regulation, and education. One invitee was unavailable and nominated an alternate. The primary outcome was identification of recommended practices based on consensus ratings of importance. Panelists rated 183 items regarding importance to care quality and feasibility. Findings Consensus identified 43 recommendations in the areas of staff and staff training, nursing and related services, resident assessment and care planning, policies and practices, and medical and mental health clinicians and care. To determine the pragmatism of the recommendations, their prevalence was examined in the 7-state study and found that most were in practice. The items reflected the tenets of AL, the role of AL in providing dementia care, the need for pragmatism due to the diversity of AL, and workforce needs

Assessment of Dentally Related Function in Individuals with Cognitive Impairment: The Dental Activities Test

To develop and validate the Dental Activities Test (DAT), a clinical tool for measuring dentally-related function in cognitively-impaired older adults

Advance Care Planning in Nursing Homes and Assisted Living Communities

To determine the prevalence and characteristics of advance care planning (ACP) among persons dying in long-term care (LTC) facilities, and to examine the relationship between respondent, facility, decedent, and family characteristics and ACP