Relationship Between Home Caregivers and Caregivers Employed at Selected Institutions Providing Assistance to Seniors with Their Care Recipients Suffering from Dementia

Introduction: There are many difficulties connected with caring for an elderly person sufferring dementia. Symptoms such as aggression or apathy, as well as the progressive nature of the disorder, affect the attitude of both home and institutional caregivers towards the people for whom they care. An important element related to the provision of care is the relationship between a senior with dementia and those who provide the care (home and institutional caregivers). The aim of the article is to characterise and compare these relations. Material and methods: The study comprised 124 participants, 57 professional caregivers and 67 home carers. Two standardised questionnaires were used: the Neuropsychiatric Inventory Questionnaire (NPI-Q) and the Quality of Carer-Patient Relationship - QCPR Questionnaire. Additionally, the respondents provided socio-demographic data. The study was conducted via electronic media in the first quarter of 2021. Results: It was found that there is a significant difference in the relationship between home and institutional caregivers, with their charges in the dimension of "warmth and attachment" (measured by QCPR). People providing professional care have significantly higher scores in this area. There was also a significant difference between scores in the 'no conflict and criticism' dimension (measured by QCPR) for home and professional caregivers. Institutional caregivers, in relation to their care recipients, have a higher level of this indicator than home caregivers. Conclusions: Relationships between seniors with dementia and institutional or home carers differ with regard to some issues. The differences in relationships with seniors suffering dementia may be due to the time spent caring for this person and the caregiver's response to symptoms of dementia.

Hybrid simulation modelling of networks of heterogeneous care homes and the inter-facility spread of Covid-19 by sharing staff

Although system dynamics [SD] and agent-based modelling [ABM] have individually served as effective tools to understand the Covid-19 dynamics, combining these methods in a hybrid simulation model can help address Covid-19 questions and study systems and settings that are difficult to study with a single approach. To examine the spread and outbreak of Covid-19 across multiple care homes via bank/agency staff and evaluate the effectiveness of interventions targeting this group, we develop an integrated hybrid simulation model combining the advantages of SD and ABM. We also demonstrate how we use several approaches adapted from both SD and ABM practices to build confidence in this model in response to the lack of systematic approaches to validate hybrid models. Our modelling results show that the risk of infection for residents in care homes using bank/agency staff was significantly higher than those not using bank/agency staff (Relative risk [RR] 2.65, 95% CI 2.57–2.72). Bank/agency staff working across several care homes had a higher risk of infection compared with permanent staff working in a single care home (RR 1.55, 95%CI 1.52–1.58). The RR of infection for residents is negatively correlated to bank/agency staff’s adherence to weekly PCR testing. Within a network of heterogeneous care homes, using bank/agency staff had the most impact on care homes with lower intra-facility transmission risks, higher staff-to-resident ratio, and smaller size. Forming bubbles of care homes had no or limited impact on the spread of Covid-19. This modelling study has implications for policy makers considering developing effective interventions targeting staff working across care homes during the ongoing and future pandemics.

Long-term exposure to air pollution and COVID-19 incidence: a prospective study of residents in the city of Varese, Northern Italy

ObjectivesTo investigate the association between long-term exposure to airborne pollutants and the incidence of SARS-CoV-2 up to March 2021 in a prospective study of residents in Varese city.MethodsCitizens of Varese aged ≥18 years as of 31 December 2019 were linked by residential address to 2018 average annual exposure to outdoor concentrations of PM2.5, PM10, NO2, NO and ozone modelled using the Flexible Air quality Regional Model (FARM) chemical transport model. Citizens were further linked to regional datasets for COVID-19 case ascertainment (positive nasopharyngeal swab specimens) and to define age, sex, living in a residential care home, population density and comorbidities. We estimated rate ratios and additional numbers of cases per 1 µg/m3 increase in air pollutants from single- and bi-pollutant Poisson regression models.ResultsThe 62 848 residents generated 4408 cases. Yearly average PM2.5 exposure was 12.5 µg/m3. Age, living in a residential care home, history of stroke and medications for diabetes, hypertension and obstructive airway diseases were independently associated with COVID-19. In single-pollutant multivariate models, PM2.5 was associated with a 5.1% increase in the rate of COVID-19 (95% CI 2.7% to 7.5%), corresponding to 294 additional cases per 100 000 person-years. The association was confirmed in bi-pollutant models; excluding subjects in residential care homes; and further adjusting for area-based indicators of socioeconomic level and use of public transportation. Similar findings were observed for PM10, NO2 and NO. Ozone was associated with a 2% decrease in disease rate, the association being reversed in bi-pollutant models.ConclusionsLong-term exposure to low levels of air pollutants, especially PM2.5, increased the incidence of COVID-19. The causality warrants confirmation in future studies; meanwhile, government efforts to further reduce air pollution should continue.

Key Components for the Delivery of Palliative and End-of-Life Care in Care Homes in Hong Kong: A Modified Delphi Study

Integrating the palliative care approach into care home service to address the complex care needs of older adults with frailty or advanced diseases has been increasingly recognized. However, such a service is underdeveloped in Hong Kong owing to socio-cultural and legal concerns. We adopted a modified Delphi study design to identify the key components for the delivery of palliative and end-of-life care in care home settings for the local context. It was an iterative staged method to assimilate views of experts in aged care, palliative care, and care home management. A multidisciplinary expert panel of 18 members consented to participate in the study. They rated their level of agreement with 61 candidate statements identified through a scoping review in two rounds of anonymous surveys. The steering group revised the statements in light of the survey findings. Eventually, the finalized list included 28 key statements concerning structure and process of care in seven domains, namely policy and infrastructure, education, assessment, symptom management, communication, care for dying patients, and family support. The findings of this study underscored concerns regarding the feasibility of statements devised at different levels of palliative care development. This list would be instrumental for regions where the development of palliative and end-of-life care services in care home setting is at an initial stage.

The uptake and use of a minimum data set (MDS) for older people living and dying in care homes: a realist review

Background Care homes provide long term care for older people. Countries with standardised approaches to residents’ assessment, care planning and review (known as minimum data sets (MDS)) use the aggregate data to guide resource allocation, monitor quality, and for research. Less is known about how an MDS affects how staff assess, provide and review residents’ everyday care. The review aimed to develop a theory-driven understanding of how care home staff can effectively implement and use MDS to plan and deliver care for residents. Methods The realist review was organised according to RAMESES (Realist And Meta-narrative Evidence Synthesis: and Evolving Standards) guidelines. There were three overlapping stages: 1) defining the scope of the review and theory development on the use of minimum data set 2) testing and refining candidate programme theories through iterative literature searches and stakeholders’ consultations as well as discussion among the research team; and 3) data synthesis from stages 1 and 2. The following databases were used MEDLINE via OVID, Embase, CINAHL (Cumulative Index to Nursing and Allied Health Literature), ASSIA [Applied Social Sciences Citation Index and Abstracts]) and sources of grey literature. Results Fifty-one papers informed the development of three key interlinked theoretical propositions: motivation (mandates and incentives for Minimum Data Set completion); frontline staff monitoring (when Minimum Data Set completion is built into the working practices of the care home); and embedded recording systems (Minimum Data Set recording system is integral to collecting residents’ data). By valuing the contributions of staff and building on existing ways of working, the uptake and use of an MDS could enable all staff to learn with and from each other about what is important for residents’ care Conclusions Minimum Data Sets provides commissioners service providers and researchers with standardised information useful for commissioning planning and analysis. For it to be equally useful for care home staff it requires key activities that address the staff experiences of care, their work with others and the use of digital technology. Registration PROSPERO registration number CRD42020171323.

The SAFEST review: a mixed methods systematic review of shock-absorbing flooring for fall-related injury prevention

Background Shock-absorbing flooring may minimise impact forces incurred from falls to reduce fall-related injuries; however, synthesized evidence is required to inform decision-making in hospitals and care homes. Methods This is a Health Technology Assessment mixed methods systematic review of flooring interventions targeting older adults and staff in care settings. Our search incorporated the findings from a previous scoping review, MEDLINE, AgeLine, and Scopus (to September 2019) and other sources. Two independent reviewers selected, assessed, and extracted data from studies. We assessed risk of bias using Cochrane and Joanna Briggs Institute tools, undertook meta-analyses, and meta-aggregation. Results 20 of 22 included studies assessed our outcomes (3 Randomised Controlled Trials (RCTs); 7 observational; 5 qualitative; 5 economic), on novel floors (N = 12), sports floors (N = 5), carpet (N = 5), and wooden sub-floors (N = 1). Quantitative data related to 11,857 patient falls (9 studies), and 163 staff injuries (1 study). One care home-based RCT found a novel underlay produced similar injurious falls rates (high-quality evidence) and falls rates (moderate-quality evidence) to a plywood underlay with vinyl overlay and concrete sub-floors. Very low-quality evidence suggested that shock-absorbing flooring may reduce injuries in hospitals (Rate Ratio 0.55, 95% CI 0.36 to 0.84, 2 studies; 27.1% vs. 42.4%; Risk Ratio (RR) = 0.64, 95% CI 0.44 to 0.93, 2 studies) and care homes (26.4% vs. 33.0%; RR 0.80, 95% CI 0.70 to 0.91, 3 studies), without increasing falls. Economic evidence indicated that if injuries are fewer and falls not increased, then shock-absorbing flooring would be a dominant strategy. Fracture outcomes were imprecise; however, hip fractures reduced from 30 in 1000 falls on concrete to 18 in 1000 falls on wooden sub-floors (OR 0.59, 95% CI 0.45 to 0.78; one study; very low-quality evidence). Staff found moving wheeled equipment harder on shock-absorbing floors leading to workplace adaptations. Very low-quality evidence suggests staff injuries were no less frequent on rigid floors. Conclusion Evidence favouring shock-absorbing flooring is uncertain and of very low quality. Robust research following a core outcome set is required, with attention to wider staff workplace implications. Trial registration PROSPERO CRD42019118834.

The predictive utility of functional status at discharge: a population-level cohort analysis

Background Functional status is a patient-important, patient-centered measurement. The utility of functional status measures to inform post-discharge patient needs is unknown. We sought to examine the utility of routinely collected functional status measures gathered from older hospitalized patients to predict a panel of post-discharge outcomes. Methods In this population-based retrospective cohort study, Adults 65+ discharged from an acute hospitalization between 4 November 2008 and 18 March 2016 in Ontario, Canada and received an assessment of functional status at discharge using the Health Outcomes for Better Information and Care tool were included. Multivariable regression analysis was used to determine the relationship between functional status and emergency department (ED) re-presentation, hospital readmission, long term care facility (LTCF) admission or wait listing (‘LTCF readiness’), and death at 180 days from discharge. Results A total of 80 020 discharges were included. 38 928 (48.6%) re-presented to the ED, 24 222 (30.3%) were re-admitted, 5 037 (6.3%) were LTCF ready, and 9 047 (11.3%) died at 180 days. Beyond age, diminished functional status at discharge was the factor most associated with LTCF readiness (adjusted Odds Ratio [OR] 4.11 for those who are completely dependent for activities of daily living compared to those who are independent; 95% Confidence Interval [CI]: 3.70-4.57) and death (OR 3.99; 95% CI: 3.67-4.35). Functional status also had a graded relationship with each outcome and improved the discriminability of the models predicting death and LTCF readiness (p<0.01) but not ED re-presentation or hospital re-admission. Conclusion Routinely collected functional status at discharge meaningfully improves the prediction of long term care home readiness and death. The routine assessment of functional status can inform post-discharge care and planning for older adults.

Outcomes of advance care directives after admission to a long-term care home: DNR the DNH?

Background Residents of long-term care homes (LTCH) often experience unnecessary and non-beneficial hospitalizations and interventions near the end-of-life. Advance care directives aim to ensure that end-of-life care respects resident needs and wishes. Methods In this retrospective cohort study, we used multistate models to examine the health trajectories associated with Do-Not-Resuscitate (DNR) and Do-Not-Hospitalize (DNH) directives of residents admitted to LTCH in Ontario, Alberta, and British Columbia, Canada. We adjusted for baseline frailty-related health instability. We considered three possible end states: change in health, hospitalization, or death. For measurements, we used standardized RAI-MDS 2.0 LTCH assessments linked to hospital records from 2010 to 2015. Results We report on 123,003 LTCH residents. The prevalence of DNR and DNH directives was 71 and 26% respectively. Both directives were associated with increased odds of transitioning to a state of greater health instability and death, and decreased odds of hospitalization. The odds of hospitalization in the presence of a DNH directive were lowered, but not eliminated, with odds of 0.67 (95% confidence interval 0.65–0.69), 0.63 (0.61–0.65), and 0.47 (0.43–0.52) for residents with low, moderate and high health instability, respectively. Conclusion Even though both DNR and DNH orders are associated with serious health outcomes, DNH directives were not frequently used and often overturned. We suggest that policies recommending DNH directives be re-evaluated, with greater emphasis on advance care planning that better reflects resident values and wishes.