Predictors of Nursing Home Admission in the Older Population in Belgium

BackgroundThis study examines the risk factors associated with nursing home admission (NHA) in Belgium to contribute to a better planning of the future demand for nursing home (NH) services and health care resources.MethodsIndividual level linkage of the 2013 Belgian health interview survey data and health insurance data (2012 to 2018) was done. Only non-institutionalized participants, aged ≥65 years at the time of the survey were included in this study (n=1930). Participants were followed until NHA, death or end of study period, i.e., December 31, 2018. The risk of NHA was calculated using a competing risk analysis.ResultsOver the follow-up period (median 5.29 years), 226 individuals were admitted to a NH and 268 died without admission to a NH. The overall cumulative risk of NHA was 1.4%, 5.7% and 13.1% at, respectively 1 year, 3 years and the end of follow-up. After multivariable adjustment, higher age, low educational attainment, belonging to low income household, living alone, use of home care services and a number of need factor (e.g., history of falls, suffering from urinary incontinence, depression or Alzheimer disease, etc.) were significantly associated with a higher risk of NHA, while female, individuals with multimorbidity and increased contacts with health care providers were significantly associated with a decreased risk of NHA. Subjective health and limitations are both significant determinants of NHA, but subjective health is an effect modifier on the effect of limitations and vice versa.ConclusionsOur findings pinpoint important predictors of NHA in older adults, and offer possibilities of prevention to avoid or delay NHA for this population. The strong impact of need factors on the risk of NHA may indicate equitable access to NHA (i.e., those in need for support have access to NH). Practical implications include prevention of falls and appropriate and timely management of physical chronic conditions and neurodegenerative disorders. Focus should also be on people living alone to provide the appropriate social support and/or home care services. Further investigation of predictors of NHA should include contextual factors such as the availability of nursing-home beds, hospital beds, physicians and waiting lists for NHA.

Social and Regional Factors Predict the Likelihood of Admission to a Nursing Home After Acute Hospital Stay in Elderly People with Chronic Health Conditions: A Multilevel Analysis Using Routinely Collected Hospital and Census Data in Switzerland.

Background: If hospitalisation becomes inevitable in the course of a chronic disease, discharge from acute hospital care in elderly individuals is often associated with temporary or persistent frailty, functional limitations and the need for help with daily activities. Thus, acute hospitalisation represents a particularly vulnerable phase of transient dependency on social support and health care. This study examines how social and regional inequality affect the decision for an institutionalisation after acute hospital discharge in Switzerland. Methods: The current analysis uses routinely collected inpatient data from all Swiss acute hospitals that was linked on the individual level with Swiss census data. The study sample included N=60,209 patients 75 years old and older living still at a private home and being hospitalised due to a chronic health condition in N=199 hospitals between 2010 and 2016. Random intercept multilevel logistic regression was used to assess the impact of social and regional factors on the odds of a nursing home admission after hospital discharge. Results: Results show that 7.8% of all patients were admitted directly to a nursing home after hospital discharge. We found significant effects of education level, insurance class, living alone and language regions on the odds of nursing home admission in a model adjusted for age, gender, nationality, health status, year of hospitalisation and hospital-level variance. The language regions moderated the effect of education and insurance class but not of living alone.Conclusion: Acute hospital discharge in elderly is a critical moment of transient dependency. Social and health care should work closely and coordinated together for a well-supported hospital discharge to avoid unnecessary institutionalisations of socially disadvantaged patients.

Cognitive Impairment Trends Among Older Adults in a Medicaid Home and Community-Based Service Program

Cognitive impairment (CI) is an important risk factor for nursing home admission, but little is known about CI among older adults in Medicaid HCBS programs. Racial and ethnic group CI disparities are found among community-dwelling older adults, but these CI trends have not been explored in Medicaid HCBS populations. In this study, we determined how CI is associated with older adults’ racial and ethnic group identification and educational attainment in Connecticut’s Medicaid HCBS program. The study cohort includes program enrollees age >65 during January-March 2019 (N=3,520). CI measures include: Cognitive Performance Scale (CPS), ranging from 0-8 (cognitively intact to very severe impairment); and a dichotomous measure incorporating Alzheimer’s disease or other dementia diagnosis (ADRD) and CPS score signifying moderate or severe CI. Study cohort characteristics: 75.7% female; age, mean(sd)=79.1(8.2); Non-Hispanic White=47.8%; Non-Hispanic Black=15.9%; Non-Hispanic Other=2.7%; Hispanic=33.6%; HS education=21.7%; mean(sd) CPS score=2.7(1.9); 36.1% with ADRD/high CPS2 score. In multivariate regression models adjusting for age and sex, CPS scores were not independently associated with race and ethnicity, and the likelihood of having ADRD/high CPS scores did not differ by race and ethnicity (all p-values >0.05). In these same models, persons with more than high school education had significantly lower CPS scores (b=-.12; p<.001), and significantly lower likelihood of having ADRD/high CPS scores (AOR=0.61; p<.001), than persons with less than high school education. We conclude that educational level is independently associated with CI, but race and ethnicity are not in this cohort. Policy and practice implications will be discussed.

What Keeps Older People out of Nursing Homes? A Meta-Analysis

Perhaps one of the most examined, and costly, health transitions older people experience is nursing home admission. In addition to the financial costs nursing home admission poses to older people, their families, and other payers (e.g., the public), institutionalization is linked with a range of negative outcomes and represents a loss of independence and quality of life to many older persons. The current meta-analysis attempted to synthesize all available randomized controlled trials available to ascertain which intervention approaches appeared to prevent nursing home entry for older adults. The MEDLINE, PsycInfo, CINAHL, Cochrane, and EMBASE databases were searched to August, 2020. Abstracts were screened (N = 28,120) to identify randomized controlled trials of interventions to prevent or delay nursing home admission as well as systematic reviews. Identified studies were cross-referenced until the point of saturation, resulting in 1,786 studies for additional inclusion/exclusion screening. Following a consensus-based review among the authors that included risk of bias, 323 randomized controlled trials were included in the meta analysis. Although several intervention modalities appeared protective against nursing home admission and approached statistical significance, preliminary results suggest that comprehensive geriatrics assessment (pooled OR = .69, 95% CI: .50, .95) and specialized, inpatient geriatrics care (pooled OR: .77, 95% CI: .59, .99) were most consistent in helping to prevent institutionalization among older persons. The findings emphasize the importance of geriatrics when delivering optimal care to older persons. Integrating such approaches more effectively into a largely fee-for-service healthcare paradigm remain a critical challenge.

Residence in HUD Housing Associated With Greater Benefit From HCBS Services for Medicaid Enrollees in Pennsylvania

State Medicaid programs seek to shift the delivery of long-term care services away from institutional settings and toward community-based settings by expanding access to home-and-community-based services (HCBS). HCBS are hypothesized to prevent or delay the need for protracted nursing home stays. This study explores the question of which types of community residence maximize this protective effect of HCBS. We used a probabilistic matching technique to identify whether waiver-eligible Medicaid enrollees were likely to reside in project-based HUD housing in 2013. We applied multinomial logistic regression to observe the risk of long-stay nursing home admission (>100 days) relative to persistent community residence in the subsequent four years. Our model controlled for age, race, gender, urban status, and receipt of home-and-community based services. Our predictor of interest was the interaction between receipt of home and community based services (HCBS) and residence in HUD housing. The eligible baseline population included 152,632 community-residing Pennsylvania Medicaid enrollees in 2013. The analytic sample excluded individuals who died during 2013 or who were no longer waiver-eligible after 2013. Residence in HUD project-based housing while receiving HCBS is independently associated with a 27% percent reduction in risk of long-stay nursing home admission (p = .01) when controlling for individual-level demographics. No significant association was observed between the predictor of interest and risk of death during the follow-up period, suggesting that this finding is not likely confounded by individual health status. Further research should test whether this association is causal and specify possible mechanisms.

Aging in Place for Older Subsidized Housing Residents: The Influence of Social Connection and Social Environment

Older adults living in subsidized housing experience health disparities including disproportionate rates of social isolation and nursing home admission. Little is known about how social relationships and social environment influence aging in place for this population. We interviewed 58 residents aged 62 or older. Qualitative thematic analyses revealed that social relationships both inside and outside the building contributed to residents’ experience of aging in place. Relationships with other residents and staff members provided social support, while connections to family and friends outside the building “opened up” the residents’ world and provided a sense of connection to the larger community. Social and physical environment also contributed, with residents’ ability to move between private and public spaces leading to feelings of freedom and independence. Discussion focuses on expanding definitions of aging in place to encompass residents’ experiences and implications for improving aging in place for this population.

Impact of Physical and Social Frailty on the Utilization of Nursing Care Services in Very Old Adults

Frailty, characterized by increased vulnerability to external stressors, has been found to increase the risk of healthcare utilization and nursing home admission. As the age group of 80 years or older remains frequently underrepresented in previous research, this study examined the impact of physical and social frailty on the utilization of nursing care services in very old population of North Rhine-Westphalia. Using data from a representative cross-sectional study, 1,577 community-dwelling and institutionalized individuals aged ≥80 years were included. Physical frailty was defined according to Fried’s criteria (exhaustion, weight loss, low handgrip strength, low physical activity). Social frailty was measured with self-reported loneliness, social isolation, and time spent with others. The use of outpatient care services, day care, informal and inpatient care were considered. Multinomial regression was applied to investigate the impact of physical and social frailty on the use of outpatient and inpatient care services, controlling for relevant sociodemographic and health related characteristics. Compared to very old adults who did not use any care services, no association was found between frailty and the use of outpatient or informal care. Comparing nonusers of care services with institutionalized individuals, nursing home residents were less likely to experience physical frailty and pre-frailty, but were more likely to be socially isolated and to feel lonely. These findings suggest that physical frailty might have been successfully prevented in the context of institutional inpatient care. However, early identification and intervention focused on social inclusion of the institutionalized very old individuals are needed to reverse social frailty.

To Clarify The Duration and Characteristics of the Continuation of Home Care for Older People With Dementia

As populations age worldwide, older people with dementia are increasing. Caregivers are also aging, necessitating arrangements like social services. How to prolong the home care desired by older people remains unclear. Using data from the Osaka National Health Insurance Database from 2012 to 2017 on insured persons’ registers, medical notes, and care benefits, this study included 9591 people aged ≤74 years with first dementia drug prescription between April 2013 and December 2017. Using the prescription as baseline and hospitalization or nursing home admission as outcomes, home care duration and characteristics of medical and nursing care services during the year before baseline were evaluated. Survival was compared by Kaplan–Meier curves and the log-rank test. Multivariate analysis was performed using the Cox proportional hazards model. During follow-up, the outcomes were observed in 1473 patients : 317 admission , 1145 hospitalized and 11 both. Mean duration of home care in patients with the outcomes was 11.5 months, which differed significantly from patients without these outcomes. When patients were grouped by hospitalization in year before first prescription, the survival curves differed significantly. In multivariate analysis, sex, renin-angiotensin system agonists, hyperlipidemia drugs, hospitalization history in past year, care level, and diabetes drugs were significantly associated with the outcomes. Taken together, hospitalization history, female sex, and diabetes were associated with home care disruption. Those undergoing cardiovascular disease treatment continued to live at home. For people with dementia, it is important to intervene by focusing on past medical and nursing care to continue life at home.

Duration of resuscitation efforts and long-term prognosis following in-hospital cardiac arrest (IHCA)

Background The decision to terminate resuscitation efforts can be challenging. Notably, the association between duration of resuscitation and long-term survival and functional outcomes after in-hospital cardiac arrest (IHCA) is unknown. Purpose To examine 30-day and 1-year survival stratified by duration of resuscitation efforts. Further, to report long term outcome (1-year survival) without anoxic brain damage or nursing home admission among 30-day IHCA survivors. Methods We included all patients with IHCA from 13 Danish hospitals between January 1st, 2013 to December 31st, 2015. Patients were only included if there was clinical indication for a resuscitation attempt. Data on IHCA was obtained from the DANARREST database, which was linked to national registries to retrieve information on patient characteristics, survival, anoxic brain damage and nursing home admission. Patients were stratified into four groups (A-D) according to quartiles of duration of resuscitation efforts: Group A (<5 minutes), group B (5–11 minutes), group C (12–20 minutes) and group D (≥21 minutes). Using multivariable regression analysis, outcomes were standardized for patient age, sex, Charlson Comorbidity Index, witnessed arrest, monitored arrest, cardiopulmonary resuscitation (CPR) prior to arrival of the in-hospital cardiac arrest team and defibrillation. Results The study population comprised of 1868 patients, median age was 74 (1st-3rd quartile [Q1-Q3] 65–81 years) and 65.0% were men. In total, 52.1% (n=973) of the patients achieved return of spontaneous circulation (ROSC). The overall median duration of resuscitation was 12 min (Q1-Q3 5–21 min). The standardized absolute chance of 30-day survival was 63.6% (95% CI 58.0%-69.0%) for group A, 34.0% (95% CI 29.7%-38.2%) for group B, 14.1% (95% CI 10.7%-17.5%) for group C and 9.0% (95% CI 6.8%-11.8%) for group D. Similarly, the chance of 1-year survival was highest for group A (51.5%; 95% CI 46.3%-56.7%) gradually decreasing to 7.0% (95% CI 4.5%-9.5%) in group D (Fig. 1). Among 30-day survivors of an IHCA, the standardized absolute chance of survival without anoxic brain damage or nursing home admission within one-year post-arrest was highest for patients resuscitated in group A (83.2%; 95% CI 78.4%-88.1%), decreasing to 72.3% (95% CI 64.5%-80.0%) in group B, 68.3% (95% CI 55.3%-81.2%) in group C and 71.1% (95% CI 54.2%-88.0%) in group D (Fig. 2). Conclusion Short time to ROSC after in-hospital cardiac arrest is associated with better long-term prognosis. However, the majority of 30-day survivors are alive 1-year post-arrest without anoxic brain damage and without need for nursing home admission despite prolonged resuscitation. FUNDunding Acknowledgement Type of funding sources: None. Figure 1 Figure 2

Do prescription rates of psychotropic drugs change over three years from nursing home admission?

Background In this longitudinal study, we describe how psychotropic drugs (PTDs) are prescribed in nursing home (NH) patients from admission and over a 3-year period, to understand which clinical and environmental factors are associated with PTD prescription. Methods We used data from the Resource Use and Disease Course in Dementia – Nursing Home (REDIC-NH) study, examining physical and mental health, dementia, and PTD prescription during a 3-year period from admission to a NH. Data were collected every six months. At baseline, we included 696 participants from 47 Norwegian NHs. We presented prevalence, incidence, and deprescribing rates of PTD prescriptions for each assessment point. We calculated the odds of receiving PTDs and used a generalized linear mixed model to analyze the variables associated with a change in odds throughout the 3-year period. Results PTD prescriptions were frequent throughout the 3-year period. Antidepressants had the highest prescription rates (28.4%–42.2%). Every PTD category had the highest incidence rate between admission and six months, and antipsychotics had the highest values (49.4%). Deprescribing rates were comparable between assessment points. The odds of antipsychotic prescriptions were lower for older people (OR = 0.96, 95%CI:0.92–0.99, p = 0.023). People with more severe dementia had lower odds of being prescribed sedatives/hypnotics (OR = 0.89, 95%CI:0.85–0.94, p < 0.001). Conclusions PTDs, particularly antidepressants, are widely prescribed over time to NH patients. Older patients are less likely to receive antipsychotics. A higher severity of dementia decreases the odds of being prescribed sedatives/hypnotics. Close attention should be paid to PTD prescriptions during long-term NH stay to avoid prolonged and excessive treatment with these types of drugs. Trial registration ClinicalTrials.gov Identifier: NCT01920100.