Long-term care for the elderly. The future of nursing homes.

Continuing growth in the number of impaired elderly persons necessitates a continued reliance on nursing homes to care for at least those who are most impaired or most lacking in other supports, despite dissatisfaction over the quality of nursing home services and anxiety about the costs. Nursing home care now costs more than $30 billion annually, half of which comes from governmental sources. The Medicaid program, in particular, is central to all aspects of the nursing home industry. Private long-term care insurance is unlikely to solve the problem of nursing home financing. Rationalizing public expenditures will hinge critically on greater clarity as to just what roles nursing homes are expected to fulfill in the system of care, especially how they are supposed to relate to other services provided to Medicare beneficiaries.     

Anxiety disorders in nursing homes: a literature review of prevalence, course and risk indicators

Psychiatric disorders such as dementia and depression are highly prevalent in nursing homes. The prevalence of anxiety disorders is less clear. Prevalence, course and risk-indicators of anxiety disorders among nursing home residents were examined, based on a review of the literature. Medline and PsychINFO searches were conducted for 1966-2002. Twelve studies were considered relevant. These differed substantially with respect to study-population, diagnostic instruments and diagnostic criteria that were used and the specific anxiety disorders investigated. The prevalence of anxiety disorders ranged from 0-20%. Only in one study the course of anxiety disorders was investigated. About 60% of the nursing home residents recovered in one year. The most important risk-indicators for anxiety disorders identified were: female sex, depression, lack of social support, poor physical health and functional and cognitive impairments. Generalization of these results to the Dutch nursing home population is restricted by the substantial heterogeneity of the studies. Further studies are required to provide reliable estimates of prevalence, course and risk-indicators of anxiety disorders among nursing home residents using appropriate diagnostic instruments and adjusted diagnostic criteria. This will enhance detection and improve treatment of anxiety disorders among nursing home residents.     

Cognition problems during rehabilitation of stroke patients in a nursing home

In many regions in the Netherlands the care for stroke patients is organised in a coordinated stroke service. Within these stroke services, each year more patients are referred to nursing homes for a period of rehabilitation. A stroke leads to lasting cognitive and emotional consequences in more than half of the stroke patients. These consequences interfere with the daily life of the patients and their caregivers. Due to the nature and severity of these problems specific care is needed in the nursing home. In the present article a procedure for cognitive screening in a nursing home is described and data of a large group of patients are presented. These data clearly show the magnitude of the cognitive problems: high percentages of impairments are found in many cognitive domains. In the discussion therefore arguments are given for specialised care - assessment as well as treatment - in the nursing home for stroke patients with cognitive deficits.     

Modeling the spread of methicillin-resistant Staphylococcus aureus in nursing homes for elderly

Methicillin-resistant Staphylococcus aureus (MRSA) is endemic in many hospital settings, including nursing homes. It is an important nosocomial pathogen that causes mortality and an economic burden to patients, hospitals, and the community. The epidemiology of the bacteria in nursing homes is both hospital- and community-like. Transmission occurs via hands of health care workers (HCWs) and direct contacts among residents during social activities. In this work, mathematical modeling in both deterministic and stochastic frameworks is used to study dissemination of MRSA among residents and HCWs, persistence and prevalence of MRSA in a population, and possible means of controlling the spread of this pathogen in nursing homes. The model predicts that: (i) without strict screening and decolonization of colonized individuals at admission, MRSA may persist; (ii) decolonization of colonized residents, improving hand hygiene in both residents and HCWs, reducing the duration of contamination of HCWs, and decreasing the resident∶staff ratio are possible control strategies; (iii) the mean time that a resident remains susceptible since admission may be prolonged by screening and decolonization treatment in colonized individuals; (iv) in the stochastic framework, the total number of colonized residents varies and may increase when the admission of colonized residents, the duration of colonization, the average number of contacts among residents, or the average number of contacts that each resident requires from HCWs increases; (v) an introduction of a colonized individual into an MRSA-free nursing home has a much higher probability of leading to a major outbreak taking off than an introduction of a contaminated HCW.     

Edentulism and dental caries in Victorian nursing homes

doi: 10.1111/j.1741‐2358.2011.00510.x Edentulism and dental caries in Victorian nursing homes Objectives: The aim of this project was to investigate edentulism and dental caries in nursing home residents in Victoria, Australia. Background: The Australian population is ageing with a growing number of people living in nursing homes. These residents are at increased risk for dental caries, have more teeth present now than at any time in the past 50 years and often have difficulty maintaining adequate oral hygiene. Materials and methods: Clinical dental examinations were conducted at 31 nursing homes in Melbourne and regional Victoria between May 2005 and June 2006. A total of 510 residents were examined out of 1345 eligible participants. Socio‐demographic and medical history was collected via questionnaire. Results: Just over half of the residents were dentate (53.9%), and dentate residents had a mean of 14.4 teeth present and 2.66 untreated decayed teeth. Residents who required total assistance with oral hygiene had more decayed teeth and fewer filled teeth than residents who did not require assistance. Conclusions: Nursing home residents in Victoria are retaining an increasing number of natural teeth and have more tooth surfaces at risk for dental caries. Untreated dental caries was a significant problem for residents, particularly for those who are dependent on others for their daily oral hygiene care.     

High prevalence of Clostridium difficile colonization among nursing home residents in Hesse, Germany

Clostridium difficile is the most common cause of antibiotic-associated diarrhoea in hospitals and other healthcare facilities. The elderly are particularly susceptible and at increased risk for adverse outcome as a result of C. difficile infection. The aim of this study was to determine the prevalence of C. difficile colonization among residents of nursing homes in Hesse and to compare it with the prevalence in the general population living outside long-term care facilities (LTCF). We assessed possible risk factors for C. difficile colonization and determined the genotype of circulating strains. C. difficile was isolated from 11/240 (4.6%) nursing home residents and 2/249 (0.8%) individuals living outside LTCF (p = 0.02). Ten of 11 (90.9%) isolates from nursing homes and one of two isolates from the population outside LTCF were toxigenic. The prevalence of C. difficile colonization varied from 0% to 10% between different nursing homes. Facilities with known actual or recent CDI cases were more likely to have colonized residents than facilities without known CDI cases. C. difficile PCR-ribotypes 014 and 001 were the most prevalent genotypes and accounted for 30% and 20% of toxigenic isolates in nursing homes, respectively. Interestingly, no individuals carried the epidemic strain PCR-ribotype 027. Our results suggest that residents of nursing homes in Germany are at high risk for colonization by virulent C. difficile strains. The high prevalence of C. difficile colonization in nursing homes underscores the importance of good adherence to standard infection control precautions even in the absence of a diagnosed infection. They also emphasize the need for specific programs to increase the awareness of healthcare professionals in LTCF for CDI.     

Patient satisfaction and quality in home health care of elderly islanders

Patient satisfaction has been a widely investigated subject in health care research. Quality of care from the patient perspective, especially in home health care, however has been investigated only very recently. Home health care is a system of care provided by skilled practitioners to patients in their homes under the direction of a physician. Multidisciplinary nature of home health care services present challenges to quality measurement that differ from those found in a more traditional hospital settings. The aim of the study was to investigate the satisfaction of elderly patients living on islands with home health care. Participants receiving skilled nursing care in their homes, for any diagnosis, who met selection criteria, were surveyed about their perception of the quality of health care. The research was conducted during the year 2010 among the residents of Kvarnerian islands (Krk, Cres and Mali Losinj) under the authority of Croatian Institute for Health Insurance that approved the protocols employed in the investigation. Most older patients (96.2%) reported high levels of satisfaction with health services delivery. Common leading diagnosis among home health care patient include diseases of circulatory system (28.9% of patients), nutritional and metabolic disease (14.5%), malignant diseases (13.2%), musculoskeletal and connective tissue disease (11.8%), diseases of the nervous system (9.2%), followed by injury and poisoning (7.9%). Provision of home health care was well received by elderly patients. Home health care providers seek to provide high quality, safe care in ways that honour patient autonomy and accommodate the individual characteristics of each patients home and family. The demographics of an aging society will sustain the trend towards home-based care. Therefore, research on effective practices, conducted in home health care settings, is necessary to support excellent and evidence-based care.     

A multilevel latent Markov model for the evaluation of nursing homes' performance

The periodic evaluation of health care services is a primary concern for many institutions. We consider services provided by nursing homes with the aim of ranking a set of these structures with respect to their effect on resident health status. Since the overall health status is not directly observable, and given the longitudinal and multilevel structure of the available data, we rely on latent variable models and, in particular, on a multilevel latent Markov model where residents and nursing homes are the first and the second level units, respectively. The model includes individual covariates to account for resident characteristics. The impact of nursing home membership is modelled through a pair of random effects affecting the initial distribution and the transition probabilities between different levels of health status. Through the prediction of these random effects we obtain a ranking of the nursing homes. Furthermore, the proposed model accounts for nonignorable dropout due to resident death, which typically occurs in these contexts. The motivating dataset is gathered from the Long Term Care Facilities programme, a health care protocol implemented in Umbria (Italy). Our results show that differences in performance between nursing homes are statistically significant.     

Samenwerking tussen woonzorgcentra en voorzieningen voor personen met verstandelijke beperkingen

Considering the increasing life expectancy of people with intellectual disabilities (ID), the importance of cooperation between services for people with ID and elderly care services has been stressed in Flanders and the Netherlands, as well as internationally. However, the prevalence, intensity and content of such a cooperation are yet unknown. In order to gain information to address this issue, an online-survey was delivered to directors of all nursing homes in Flanders (n = 781). 229 surveys were completed.In more than 75% of the nursing homes, people with ID were among the residents over the past decade. However, at the same time a lack of expertise has been identified as a barrier to provide them optimal care and support. Hence, the respondents point out that a cooperation with ID care services could be beneficial. Nevertheless, those partnerships only arose in a quarter of the nursing homes so far, primarily for the purpose of exchange of expertise. Intersectoral multidisciplinary consultations and intersectoral care team consultations have been taking place as well, be it mainly in the context of a persons’ transition from an ID care service to a nursing home. Until now, radical cooperations which involve an exchange of staff, seem to be rather rare.     

Attitudes to and knowledge about oral health care among nursing home personnel--an area in need of improvement

doi: 10.1111/j.1741‐2358.2011.00562.x
Attitudes to and knowledge about oral health care among nursing home personnel – an area in need of improvement Background: In 1999, a dental reform became law in Sweden that regulated both dental care to dependent individuals and training in oral health care for nursing home personnel. Substantial resources have been channelled into these efforts, but the outcome of these efforts has not been evaluated. The aim of this study was to explore attitudes to and knowledge about oral health care among nursing home personnel more than 5 years after the law was adopted, that being 2005. Methods: A total of 454 individuals employed at nursing homes answered a questionnaire of 16 multiple‐choice items concerning attitudes to and knowledge about oral health care. Results: Eighty‐nine per cent considered oral health care to be an important part of good nursing. The answers indicated problems, however, when it came to its implementation and knowledge, and 35% stated that they had had no formal education in oral health care. Conclusions: Despite generally positive oral health care attitudes, it is important that oral health care education is available to and made of interest for all nursing home personnel, especially in light of the increase in number of natural teeth and frequency of crowns and bridges among dependent elderly.     

The law and the local fairness of care practice. Reflections on the ethnographic field investigation concerning the failure of the Bopz Act in psychogeriatric nursing home care

Ten years after its introduction the Special Admissions to Psychiatric Hospitals Act (Bopz) still awaits full implementation in the field of psychogeriatric nursing home care. Ethnographic research into moral problems related to care giving in dementia patients in Dutch nursing homes yielded several reasons for this discrepancy between law and care practice. Firstly, practical effectuation of this law rests predominantly on the shoulders of nurses and nurse assistants who are mainly inspired by moral motives such as carefulness and providing safety and who are ill informed about the law and its prerequisites. Secondly, there is the problem of the loss of a common shared world of meaning, which in relational terms is typical for the process of dementia. As a result of this, crucial concepts of the Bopz loose their applicability as the disease progresses. Finally, there is an immanent tension between the anthropology of care and care giving and the anthropological presuppositions of the law, health law included, which on a fundamental level contributes to the resistance of the care practice to the legal procedures of the Bopz. These factors must be accounted for in new legislation or revision of the current law. In the mean time we urge the necessity to develop a moral code concerning how to deal with resistive behaviour and opposition to care of demented nursing home patients.     

The dental awareness of nursing home staff in Singapore - a pilot study

Objective: The aim of this pilot study was to assess the oral health knowledge among staff working in a local nursing home managed by a voluntary welfare organisation. Method: A self‐administered questionnaire was completed by 53 nursing staff working in a home with 270 residents. The questionnaire was structured to assess the staff's knowledge of dental caries, periodontal disease and the care and use of dentures. Results: 99.6% of the respondents felt that oral health care of the elderly was very important. However, only 45.3% of them attributed the cause of dental caries to the frequent intake of sugar. Bacteria in dental plaque was identified by 88.7% of them as the main cause of periodontal disease while 96.2% of them indicated that dentures should be cleaned at least once a day and rinsed after every meal. Conclusion: The staff of this nursing home demonstrated positive knowledge of periodontal disease and denture care. However, their knowledge of dental caries revealed substantial room for improvement. This could signal an area for future staff training and development. Such efforts would help establish a team of caregivers who can improve the oral health and quality of life for residents in the nursing home.     

Caries experience in existing and new nursing home residents in Adelaide,Australia

Objectives: The Adelaide Dental Study of Nursing Homes was instigated to provide comprehensive information concerning oral disease experience, incidence and increments in a random sample of those older South Australians residing in Adelaide nursing homes. Methods: This paper presents caries experience results for existing and new nursing home residents, and caries incidence and increments for existing residents, from dental inspections conducted at the baseline and one‐year data collections. Results: The residents in this study were very functionally dependent, medically compromised, cognitively impaired and behaviourally difficult older adults, the great majority of whom had moderate to severe cognitive impairment. Residents gave their carers many complex and challenging behavioural problems during oral hygiene care provision. Existing and new residents had similar dental history, oral hygiene, and socio‐detnographic characteristics, and similar cognitive, medical, functional, and nutritional status. Oral disease experience was high in both existing and new residents. There were no significant differences between existing and new residents for their dentate status, tooth status, coronal caries experience, or root caries experience, with the exceptions that new residents had significantly greater mean number of teeth, more filled coronal and root surfaces, and also new residents had significantly fewer decayed retained roots. Large numbers of tooth surfaces were covered in plaque and debris that negated more precise assessment of caries. The existing residents had caries increments on both coronal (2.5 surfaces) and root surfaces (1.0 surfaces) over the one‐year period. Coronal caries incidence was 64% and root caries incidence was 49% of existing residents. Conclusions: Oral disease experience was high in both existing and new residents. There were few significant differences between existing and new residents’ oral health status. New residents were being admitted to nursing homes with a compromised oral health status. Coronal and root caries increments and incidence were high for existing residents over the one‐year period.     

Paediatric home nursing scheme in Gateshead.

A scheme to provide specialised nursing care for sick children in their own homes was begun in Gateshead in 1974. Selected district nurses were retrained in the paediatric unit on which the scheme was based and nursed at home 22 children referred to them by general practitioners as the alternative to hospital admission and 39 discharged to their care by the hospital. Most of the children were aged 3 years or less and came from working-class homes. Most of the mothers who were asked were in favour of the scheme.     

Private rest homes in the care of the elderly.

Sixteen private rest homes were visited to assess their facilities and the types of disability of the residents. Apart from one home, which was a hotel for the elderly, all the homes provided care for physically and mentally frail elderly people over the long term. Although care was good the trends in the use of the homes are worrying, and stricter regulations are required to ensure appropriate levels of care. Greater support is also required from district nursing services.     

The elderly mentally ill--whose responsibility?

The elderly mentally ill make considerable demands on health and social services. To evaluate the need for these services a one-day census of all people aged 65 and over was carried out in an area containing 220 000 people (40 000 over 65). Data were obtained on the nursing needs and psychiatric state of the 2162 elderly people in hospital or local authority residential homes for the elderly, or living at home receiving care from the community nursing service. One-third were classified as having psychiatric problems, more than half of them being outside hospital. Residential homes and community nurses play a significant part in caring for the elderly mentally ill, and an integrated but flexible manpower policy is important.