Assisted Living

Nursing homes using antipsychotic drugs for dementia care can and should take most residents off these medications, according to the international healthcare research organization the Cochrane Collaboration.

Members of the Cochrane Dementia and Cognitive Improvement Group looked at nine trials with 606 participants, most of them nursing home residents. The trials all tracked what happened when people with dementia were taken off antipsychotic medications. Seven trials were conducted in nursing homes, one trial in an outpatient setting and one in both settings. In these trials, different types of antipsychotics prescribed at different doses were withdrawn. Both abrupt and gradual withdrawal schedules were used.

After reviewing the studies, the researchers determined that it's generally safe and advisable to stop giving antipsychotics to those with behavioral symptoms of dementia, including agitation, aggression, depression, wandering and delusions. "Our findings suggest that many older people with Alzheimer's dementia and NPS can be withdrawn from chronic antipsychotic medication without detrimental effects on their behaviour. It remains uncertain whether withdrawal is beneficial for cognition or psychomotor status, but the results of this review suggest that discontinuation programmes could be incorporated into routine practice." One exception may be older people who had more severe NPS prior to going on antipsychotics. The study results suggest discontinuing antipsychotics has few or no negative effects, and may improve verbal fluency.

"We recommend that programs that aim to withdraw older nursing home residents from long-term antipsychotics should be incorporated into routine clinical practice, especially if the NPS are not severe," the study authors wrote.

The Centers for Medicare & Medicaid Services set a goal of reducing use of these drugs by 15% by the end of 2012.

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Photo © Dwight Eschliman, Getty Images

From Mcknights - The Centers for Medicare & Medicaid Services has made more information about nursing home deficiencies available online. CMS began posting deficiency report information on the Nursing Home Compare and Five-Star Nursing Home Quality Rating System websites last July. The online materials, based on data from Form CMS-2567, Statement of Deficiencies and Plan of Correction, currently include the most recent standard health survey report and complaint surveys going back 15 months.

CMS has made older information available and is providing more detail about the deficiencies identified in these reports, according to a March 22 memo from Thomas E. Hamilton, director, Survey and Certification Group.

"We plan to expand the time period for which CMS-2567 reports are published (from the current single survey cycle to a period encompassing the preceding three standard health surveys and three years of complaint surveys)," Hamilton wrote. "Further, to improve the public's ability to interpret CMS-2567 findings, we also plan to add indicators for the scope and severity of each deficiency cited on the forms."

CMS does not post plans of correction (PoCs) online, and demand for these will likely increase as more deficiency information is made public, according to the memo. People can request the PoCs from CMS State Survey Agencies or directly from facilities, and federal law mandates the plans must be provided upon request. However, states already are supposed to post facility PoCs online, and CMS does link to state websites through Nursing Home Compare.

Obviously these reports should be on concern because consumers will use them in evaluating and choosing care so in many respects they become a marketing tool. The experience of care after all is the marketing.

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A study by Jacques Donzé, M.D., M.Sc., of Brigham and Women's Hospital, Boston, and colleagues suggests that a prediction model can identify before discharge the risk of potentially avoidable 30-day rreadmission in hospitalized patients.

The study at an academic medical center analyzed all patient discharges from any medical services between July 2009 and June 2010.

Potentially avoidable 30-day readmissions to three hospitals were identified using a computerized algorithm based on administrative data. Among 10,731 eligible discharges, 2,398 discharges (22.3 percent) were followed by a 30-day readmission, of which 879 (8.5 percent of all discharges) were identified as potentially avoidable, according to the study results.

The prediction score identified seven independent factors, referred to as the HOSPITAL score: hemoglobin at discharge, discharge from an oncology service, sodium level at discharge, procedure during the index admission, index type of admission, number of admissions during the last 12 months and length of stay.

"This score has potential to easily identify patients who may need more intensive transitional care interventions," the study concludes.

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Long-term care financing system for consumers must be revamped within five years to meet the needs of aging baby boomers, according to The SCAN Foundation. In eight reports the organization laid out policy recommendations for taking pressure off government programs while increasing the availability and affordability of long-term care financing for consumers.

The SCAN Foundation's policy brief series entitled, Shaping Affordable Pathways for Aging with Dignity, provides an updated body of intellectual capital on LTC financing options and approaches to facilitate a national policy dialogue. These papers build on various policy concepts developed over the last two decades, and account for recent health policy changes that are reshaping the current LTC financing discussion. Authored by an independent set of well-known experts, the papers accomplish four critical tasks:

• outline the state of LTC financing choices Americans have available today
• define opportunities to improve uptake of LTC financing mechanisms
• clarify the role of Medicaid spend-down and its effect on Medicaid financing
• propose a range of policy pathways that could increase the availability and uptake of LTC financing risk protection for middle-income Americans.

The overview brief linked to highlights the current state of LTC, describes the need for a set of affordable and accessible LTC financing solutions, links LTC financing to the ensuing entitlement reform debate, and provides a summary of each paper in the series.

"The current private long-term care insurance market is effectively broken, as it has never held more than 10% of the potential market and many insurers have stopped offering these policies altogether," stated Gretchen E. Alkema, Ph.D., vice president of policy and communications at The SCAN Foundation. "Reasons for lack of uptake are many: lack of public understanding and interest, high monthly premiums, and underwriting standards that make it difficult for individuals to qualify for coverage."

Almost one-third of all Medicaid spending in 2011 went to long-term care, according to National Health Policy Forum numbers cited by SCAN. Instituting a mandatory long-term care insurance program for workers is one option for bringing down this government spending without limiting access to care. A mandatory program of this type would bring Medicaid spending down $49 billion over 15 years, while a voluntary program would reduce spending by only $5.6 billion, according to an Avalere Health report funded by SCAN.

However, "recent debates over the design of the ACA highlight that there is little taste for new mandated benefits," wrote researchers from Harvard University and LifePlans Inc., in another of the SCAN reports. These researchers put forward a number of policy changes they believe are more realistic.

Simplifying long-term care insurance products and mandating that employers and other institutional purchasers offer this insurance along with standard healthcare packages will increase consumer understanding and demand they say. Private insurers should explore options for bringing down premiums, such as offering one or two-year deductible periods in addition to the standard 90-day period.

A robust consumer education program to raise public awareness of this issue is also a must, according to SCAN President and CEO Bruce Chernof, M.D. Along with devising "a new set of tools" for financing long-term care, addressing this "knowledge deficit" should be the top priority of the Congressional Commission on Long-Term Care, Chernof told McKnight's.

Perhaps the good people from SCAN have not looked at the economy recently. Mandated insurance should have been rolled out with the Affordable Care Act. Sailing that ship twice will be difficult. However I do agree that a great deal of education needs to take place. The public is fairly clueless about aging issues and more in denial of them than anything else. We all have a part in changing that.

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Assisted living regulations, statutes, and policies in 18 states were changed, according to the 2013 edition of "Assisted Living State Regulatory Review" published by the National Center for Assisted Living (NCAL).

"Nine states made major changes to their assisted living regulations last year. Colorado, Michigan, and New Jersey made innovative changes to their survey processes," said Karl Polzer, NCAL's senior policy director and the report's author. "Continuing a multi-year trend, more than one-third of states refined or developed assisted living regulations."

The annual report summarizes state assisted living regulations across 21 categories including life safety, physical plant requirements, medication management, and move-in/move-out criteria. The NCAL report is the only source that summarizes the assisted living regulations in 50 states and the District of Columbia that is published to inform the public.

An analysis accompanying the report identified several trends such as expanding disclosure and reporting requirements in five states--California, Florida, Ohio, Oregon, and Washington. The life safety or physical plant standards were changed in Missouri, North Dakota, Oregon, and West Virginia.

"State regulators work closely with NCAL and eagerly await this report to identify trends and find out what other states are doing," says David Kyllo, NCAL's executive director. "NCAL is proud to provide this complimentary and unique resource to consumers, regulators, legislators, assisted living professionals, aging organizations, media, and researchers."

The report also provides contact information for state agencies that oversee assisted living; and includes each agency's website address. The report along with an analysis of trends and state-by-state highlights is available online at NCAL.org.

From McKnights - Long-term care facilities will have to notify the federal government, state survey agencies, state long-term care ombudsmen, residents and residents' legal representatives at least 60 days in advance of any closure, under a final rule issued by the Centers for Medicare & Medicaid Services. The facilities will also have to provide a relocation plan for residents.

The final rule took effect April 20. Administrators who do not comply with the rule will face fines of up to $100,000. Under a new provision in the final rule, administrators may appeal penalties before an administrative law judge, with further appeals to the Department of Health and Human Services and judicial review available.

The full rule is available here.

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Skilled nursing facilities that have fewer rehospitalizations are likely to retain their licensed nurses at a higher rate than other SNFs, according to a study in Gerontology.

The purpose of the study was to determine the relationships among licensed nurse retention, turnover, and a 30-day rehospitalization rate in nursing homes (NHs). Researchers combined two data sources: NH facility-level data (including characteristics of the facility, the market, and residents) and the Florida Nursing Home Staffing Reports (which provide staffing information for each NH) for 681 Florida NHs from 2002 to 2009.

Results indicated that an NH's licensed nurse retention rate is significantly associated with the 30-day rehospitalization rate, controlling for demographic characteristics of the patient population, residents' preferences for hospitalization, and the ownership characteristics of the NH. The NHs experiencing a 10% increase in their licensed nurse retention had a 0.2% lower rehospitalization rate, which equates to 2 fewer hospitalizations per NH annually. Licensed nurse turnover is not significantly related to the 30-day rehospitalization rate. Turnover of licensed nurses was not found to be significantly related to rehospitalization rates.

"These findings highlight the need for ... administrators and policy makers to focus on licensed nurse retention, and future research should focus on the measures of staff retention for understanding the staffing/quality relationship," the researchers stated.

The Medicare Payment Advisory Commission recently issued its first Congressional report that included data on 30-day rehospitalizations for skilled nursing facilities. The overall rate was 10%, but significant variation among facilities suggests they should face penalties for excessive rehospitalizations to bring down Medicare costs, the report said.

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Older adults can improve their decision making and working memory simply by improving their mood.

Researchers found that easy mood-boosters -- like giving people a small bag of candy -- helped seniors do significantly better on tests of decision-making and working memory. "There has been lots of research showing that younger adults are more creative and cognitively flexible when they are in a good mood. But because of the cognitive declines that come with aging, we weren't sure that a good mood would be able to help older adults," said Ellen Peters, co-author of the study and professor of psychology at Ohio State University./p>

The study was done with Stephanie Carpenter of the University of Michigan; David Västfjäll of Linköping University in Sweden; and the late Alice Isen, of Cornell University. It appears in the current issue of the journal Cognition and Emotion.

The study involved 46 adults aged 63 to 85. Half of them were put into a good mood by receiving a thank-you card and two small bags of candy, tied with a red ribbon, when they arrived at the lab for the experiment. The other "neutral mood" participants did not receive a card or candy.

The participants completed the study on a computer. Those who were induced into the positive mood had a background screen that was designed to help keep them feeling positive -- it featured smiling suns on a sky-blue background. The neutral-mood participants had a similar background, but with neutral round images with no face.

In the decision-making task, the findings were clear: older adults who were put into a good mood chose significantly better than those who were in the neutral mood.

Later in the experiment, the researchers tested working memory -- how much information people can hold in their mind at any one time. Researchers read aloud a group of intermixed letters and numbers and participants were to repeat the group back in numeric and then alphabetic order. Results showed that the older adults who were induced into a good mood scored better on this test of working memory.

I think the operative word here is "induced." We can't always induce people into a good mood. So how do you go about helping people to improve their mood overall? Well maybe you start by showing them studies like this one!

That said, I believe that if you have a person-centered culture in your organization it may naturally lead to both happier staff members and residents/patients. And when you aide that with a good activities program, you take steps in helping people have a more positive attitude and the benefits that come from that.

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A study published in Personnel Psychology examined some of the most common negative stereotypes of older workers that impact workplace interactions, promotions, and other factors that can affect an employee's quality of life.

The study examines six of the most common and damaging stereotypes: Compared with younger workers, older employees are (1) less motivated, (2) less willing to engage in training and career development programs, (3) more resistant to change, (4) not as trusting, (5) more likely to experience health problems that affect their work, and (6) more vulnerable to work-family conflicts.

The authors reviewed 380 empirical articles. About 5 percent had been published in the 1970s and 1980s, 16 percent in the 1990s, 37 percent between 2000 and 2005, and the remaining 42 percent since 2005. The authors found empirical support for only one of those stereotypes. Older workers are less likely to engage in career development. The five other stereotypes were off the mark.

In 2010, according to the U.S. Bureau of Labor Statistics, 55 percent of U.S. employees were older than 40. By 2018, the 55- to 75-year-old segment of the workforce will increase by 11 million, accounting for almost a quarter of the working population.

In a corresponding article in Strategy + Business, these strategies were suggested to combat ageism.

• Blinding: withholding workers' ages from decision makers with responsibility for hiring, firing, performance evaluations, and promotions.
• Managers can turn to affirmative action, treating older workers in a preferential way to counteract the damaging effects of the stereotypes.
• Raising consciousness about age stereotypes. Managers should carefully track personnel decisions to look for patterns of age discrimination. Increasing opportunities for employees of all ages to work side by side could help reduce negative stereotyping. And managers could directly confront the issue, evoking positive stereotypes about older employees by highlighting their experience and judgment. Holding frank discussions about how age stereotypes play out in the workplace can reduce negative perceptions and also increase the well-being of older employees.

Where do you see your organization in this study? Can a different attitude in this area impact your recruitment and retention efforts?

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A team of researchers from the Ontario Brain Institute reviewed 871 research articles on exercise and Alzheimer's conducted over the last 50 years. They then closely examined the 45 most comprehensive studies, pooling the data for their analysis.

They found that more than one out of every seven cases of Alzheimer's disease could be prevented by increasing the amount of physical activity an individual performs. The research finds that as little as 30 minutes of light exercise can lower the risk of an individual developing Alzheimer's.

In 2011, approximately 15% of older adults (65 y+) in Ontario were living with some form of cognitive impairment or dementia, an estimated 60%-70% of whom had Alzheimer's disease.

Within older adults with Alzheimer's disease, regular physical activity improved quality of life (QOL), activities of daily living (ADL), and decreased the occurrence of depression. In older adults without Alzheimer's disease, those who were very physically active were almost 40% less likely to develop Alzheimer's disease as those who were inactive.

At the population level, it was observed that more than 1 in 7 cases of Alzheimer's disease could be prevented if everyone who is currently inactive were to become physically active at a level consistent with current activity recommendations.

Easy lesson here for aging services providers. Start incorporating more exercise activities into your activities programs.

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