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Objective

To evaluate the impact on place of death of a hospital at home service for palliative care.

Design

Pragmatic randomised controlled trial.

Setting

Former Cambridge health district.

Participants

229 patients referred to the hospital at home service; 43 randomised to control group (standard care), 186 randomised to hospital at home.

Intervention

Hospital at home versus standard care.

Main outcome measures

Place of death.

Results

Twenty five (58%) control patients died at home compared with 124 (67%) patients allocated to hospital at home. This difference was not significant; intention to treat analysis did not show that hospital at home increased the number of deaths at home. Seventy three patients randomised to hospital at home were not admitted to the service. Patients admitted to hospital at home were significantly more likely to die at home (88/113; 78%) than control patients. It is not possible to determine whether this was due to hospital at home itself or other characteristics of the patients admitted to the service. The study attained less statistical power than initially planned.

Conclusion

In a locality with good provision of standard community care we could not show that hospital at home allowed more patients to die at home, although neither does the study refute this. Problems relating to recruitment, attrition, and the vulnerability of the patient group make randomised controlled trials in palliative care difficult. While these difficulties have to be recognised they are not insurmountable with the appropriate resourcing and setting.

Key messagesTerminally ill patients allocated to hospital at home were no more likely to die at home than patients receiving standard careAlthough the subsample of patients actually admitted to hospital at home did show a significant increase in likelihood of dying at home, whether this was due to the service itself or the characteristics of patients admitted to hospital at home could not be determinedThe need to balance ideal research design against the realities of evaluation of palliative care had the effect that the trial achieved less statistical power than originally plannedParticular problems were that many patients failed to receive the allocated intervention because of the unpredictable nature of terminal illness, inclusion of other service input alongside hospital at home, and the wide range of standard care availableThe trial illustrated problems associated with randomised controlled trials in palliative care, none of which are insurmountable but which require careful consideration and resourcing before future trials are planned

Background

Nutritional status often deteriorates in Alzheimer’s disease (AD). Less is known about whether nutritional care reverses malnutrition and its harmful consequences in AD. The aim of this study is to examine whether individualized nutritional care has an effect on weight, nutrition, health, physical functioning, and quality of life in older individuals with AD and their spouses living at home.

Methods

AD patients and their spouses (aged >65 years) living at home (n = 202, 102 AD patients) were recruited using central AD registers in Finland. The couples were randomized into intervention and control groups. A trained nutritionist visited intervention couples 4–8 times at their homes and the couples received tailored nutritional care. When necessary, the couples were given protein and nutrient-enriched complementary drinks. All intervention couples were advised to take vitamin D 20 μg/day. The intervention lasted for one year. The couples of the control group received a written guide on nutrition of older people. Participants in the intervention group were assessed every three months. The primary outcome measure is weight change. Secondary measures are the intake of energy, protein, and other nutrients, nutritional status, cognition, caregiver’s burden, depression, health related quality of life and grip strength.

Discussion

This study provides data on whether tailored nutritional care is beneficial to home-dwelling AD patients and their spouses.

Trial registration

ACTRN 12611000018910

Objective

To compare effectiveness of patient care in hospital at home scheme with hospital care.

Design

Pragmatic randomised controlled trial.

Setting

Leicester hospital at home scheme and the city's three acute hospitals.

Participants

199 consecutive patients referred to hospital at home by their general practitioner and assessed as being suitable for admission. Six of 102 patients randomised to hospital at home refused admission, as did 23 of 97 allocated to hospital.

Intervention

Hospital at home or hospital inpatient care.

Main outcome measures

Mortality and change in health status (Barthel index, sickness impact profile 68, EuroQol, Philadelphia geriatric morale scale) assessed at 2 weeks and 3 months after randomisation. The main process measures were service inputs, discharge destination, readmission rates, length of initial stay, and total days of care.

Results

Hospital at home group and hospital group showed no significant differences in health status (median scores on sickness impact profile 68 were 29 and 30 respectively at 2 weeks, and 24 and 26 at 3 months) or in dependency (Barthel scores 15 and 14 at 2 weeks and 16 for both groups at 3 months). At 3 months' follow up, 26 (25%) of hospital at home group had died compared with 30 (31%) of hospital group (relative risk 0.82 (95% confidence interval 0.52 to 1.28)). Hospital at home group required fewer days of treatment than hospital group, both in terms of initial stay (median 8 days v 14.5 days, P=0.026) and total days of care at 3 months (median 9 days v 16 days, P=0.031).

Conclusions

Hospital at home scheme delivered care as effectively as hospital, with no clinically important differences in health status. Hospital at home resulted in significantly shorter lengths of stay, which did not lead to a higher rate of subsequent admission.

Key messagesThe effectiveness of hospital at home schemes for avoiding hospital admission has not been tested in a trialIn this study patients suitable for hospital at home care were randomised to hospital at home or hospital care and followed up for three monthsThere were no clinically or statistically significant differences in outcome as measured by the sickness impact profile 68, Barthel index, Philadelphia geriatric morale scale, and EuroQolLength of stay in care and total days of care were about 45% less for patients randomised to hospital at homeFor patients who meet the admission criteria, hospital at home schemes can provide an effective and acceptable alternative to hospital admission

Dining-out behavior is associated not only with socio-demographic characteristics such as gender, education, occupation, residence, and marital status, but also with individual preferences, such as eating-out activities, interests, and opinions. We investigated dining-out behaviors and their associated factors. Announcements by health practioners and the Chief of Dong Office were used to recruit 739 residents (217 males and 522 females) in Chuncheon, Korea. Information on the frequency and reasons for eating out, the standards for meal selection, and the overall satisfaction with restaurants, based on taste, nutrition, amount, price, service, sanitation, and subsidiary facilities of restaurants, was obtained through personal interviews with a structured questionnaire. Among all respondents, 46.3% of subjects ate outside of the home once or twice a month, and 33.8% reported that they ate out only a few times a year, or never. This was much higher than the national average of 52.0% as reported by the Korean National Health and Nutrition Survey (KNHNS) in 2001. The frequency of eating out differed significantly according to age (p=0.001), family income (p<0.001), residential area (p<0.001), and educational level (p<0.001). The most common reasons for dining out were meetings (46.7%), followed by special celebrations (15.4%), and enjoyment (11.2%). Korean food (55.3%) was the most frequently selected type of meal when eating out, and food was most often selected based on personal preferences (41.4%) and taste (29.8%); only 5.5% and 7.7% of subjects considered nutrition or other factors (e.g., sanitation), respectively. The results showed that the frequency of eating out for Chuncheon residents was much lower than the national average; in addition, eating-out behaviors depended on the residents' socio-demographic and personal characteristics.

Objective To determine whether vaccination of care home staff against influenza indirectly protects residents.

Design Pair matched cluster randomised controlled trial.

Setting Large private chain of UK care homes during the winters of 2003-4 and 2004-5.

Participants Nursing home staff (n=1703) and residents (n=2604) in 44 care homes (22 intervention homes and 22 matched control homes).

Interventions Vaccination offered to staff in intervention homes but not in control homes.

Main outcome measures The primary outcome was all cause mortality of residents. Secondary outcomes were influenza-like illness and health service use in residents.

Results In 2003-4 vaccine coverage in full time staff was 48.2% (407/884) in intervention homes and 5.9% (51/859) in control homes. In 2004-5 uptake rates were 43.2% (365/844) and 3.5% (28/800). National influenza rates were substantially below average in 2004-5. In the 2003-4 period of influenza activity significant decreases were found in mortality of residents in intervention homes compared with control homes (rate difference −5.0 per 100 residents, 95% confidence interval −7.0 to −2.0) and in influenza-like illness (P=0.004), consultations with general practitioners for influenza-like illness (P=0.008), and admissions to hospital with influenza-like illness (P=0.009). No significant differences were found in 2004-5 or during periods of no influenza activity in 2003-4.

Conclusions Vaccinating care home staff against influenza can prevent deaths, health service use, and influenza-like illness in residents during periods of moderate influenza activity.

Trial registration National Research Register N0530147256.

Objective

To evaluate the effectiveness of home visiting programmes that offer health promotion and preventive care to older people.

Design

Systematic review and meta-analysis of 15 studies of home visiting.

Participants

Older people living at home, including frail older people at risk of adverse outcomes.

Outcome measures

Mortality, admission to hospital, admission to institutional care, functional status, health status.

Results

Home visiting was associated with a significant reduction in mortality. The pooled odds ratio for eight studies that assessed mortality in members of the general elderly population was 0.76 (95% confidence interval 0.64 to 0.89). Five studies of home visiting to frail older people who were at risk of adverse outcomes also showed a significant reduction in mortality (0.72; 0.54 to 0.97). Home visiting was associated with a significant reduction in admissions to long term care in members of the general elderly population (0.65; 0.46 to 0.91). For three studies of home visiting to frail, “at risk” older people, the pooled odds ratio was 0.55 (0.35 to 0.88). Meta-analysis of six studies of home visiting to members of the general elderly population showed no significant reduction in admissions to hospital (odds ratio 0.95; 0.80 to 1.09). Three studies showed no significant effect on health (standardised effect size 0.06; –0.07 to 0.18). Four studies showed no effect on activities of daily living (0.05; –0.07 to 0.17).

Conclusion

Home visits to older people can reduce mortality and admission to long term institutional care.

What is already known on this topicThe benefits of regular, preventive home visits to older people are the subject of controversyA recent systematic review found no clear evidence that preventive home visits were effectiveWhat this study addsThis meta-analysis of 15 trials shows that home visiting can reduce mortality and admission to institutional care among older people

Objective

To assess the effects of an intervention programme designed to increase use of hip protectors in elderly people in nursing homes.

Design

Cluster randomised controlled trial with 18 months of follow up.

Setting

Nursing homes in Hamburg (25 clusters in intervention group; 24 in control group).

Participants

Residents with a high risk of falling (459 in intervention group; 483 in control group).

Intervention

Single education session for nursing staff, who then educated residents; provision of three hip protectors per resident in intervention group. Usual care optimised by brief information to nursing staff about hip protectors and provision of two hip protectors per cluster for demonstration purposes.

Main outcome measure

Incidence of hip fractures.

Results

Mean follow up was 15 months for the intervention group and 14 months for the control group. In total 167 residents in the intervention group and 207 in the control group died or moved away. There were 21 hip fractures in 21 (4.6%) residents in the intervention group and 42 hip fractures in 39 (8.1%) residents in the control group (relative risk 0.57, absolute risk difference −3.5%, 95% confidence interval −7.3% to 0.3%, P=0.072). After adjustment for the cluster randomisation the proportions of fallers who used a hip protector were 68% and 15% respectively (mean difference 53%, 38% to 67%, P=0.0001). There were 39 other fractures in the intervention group and 38 in the control group.

Conclusion

The introduction of a structured education programme and the provision of free hip protectors in nursing homes increases the use of protectors and may reduce the number of hip fractures.

What is already known on this topicNursing home residents are at particularly high risk of fracturing a hipHip protectors can effectively prevent hip fracturesAdherence to the use of hip protectors is poorWhat this study addsThe use of hip protectors in nursing homes can be substantially increased by a single session education targeted at nursing staff and residents and provision of free hip protectorsIncreasing the use of hip protectors resulted in a relative reduction of hip fractures of about 40%

Background

There is limited information available on how characteristics of the organization of nursing home care and especially group living home care and staff ratio contribute to care staff well being, quality of care and residents' quality of life. Furthermore, it is unknown what the consequences of the increasingly small scale organization of care are for the amount of care staff required in 2030 when there will be much more older people with dementia.

Methods/Design

This manuscript describes the design of the 'Living Arrangements for people with Dementia study' (LAD-study). The aim of this study is to include living arrangements from every part of this spectrum, ranging from large scale nursing homes to small group living homes. The LAD-study exists of quantitative and qualitative research. Primary outcomes of the quantitative study are wellbeing of care staff, quality of care and quality of life of residents. Furthermore, data concerning staff ratio and characteristics of the living arrangements such as group living home care characteristics are assessed. To get more in-depth insight into the barriers and facilitators in living arrangements for people with dementia to provide good care, focus groups and Dementia Care Mapping are carried out.

Discussion

Results of this study are important for policymakers, directors and staff of living arrangements providing nursing home care to people with dementia and essential for the development of methods to improve quality of care, residents' and staff well-being. Data collection will be repeated every two years, to generate knowledge on the results of changing policies in this field.

Most public funding methods for long-term care do not adequately match payment rates with patient need for services. Case-mix payment systems are designed to encourage a more efficient and equitable allocation of limited health care resources. Even nursing home case-mix payment systems, however, do not currently provide the proper incentives to match rehabilitation therapy resources to a patient's needs. We were able to determine by a review of over 8,500 patients in 65 nursing homes that certain diagnoses, partial dependence in activities of daily living (ADLs), clear mental status, and improving medical status are associated with the provision of rehabilitation services to nursing home residents. These patient characteristics are clinically reasonable predictors of the need for therapy and should be considered for use in nursing home case-mix reimbursement systems. Primary payment source also was associated with the provision of rehabilitation services even after taking into account significant patient characteristics. It is unclear how much of the variation in service use across payers is due to differences in patient need as opposed to differences in the financial incentives associated with current payment methods.

Objective To compare the clinical effectiveness of a programme of physiotherapy and occupational therapy with standard care in care home residents who have mobility limitations and are dependent in performing activities of daily living.

Design Cluster randomised controlled trial, with random allocation at the level of care home.

Setting Care homes within the NHS South Birmingham primary care trust and the NHS Birmingham East and North primary care trust that had more than five beds and provided for people in the care categories “physical disability” and “older people.”

Participants Care home residents with mobility limitations, limitations in activities of daily living (as screened by the Barthel index), and not receiving end of life care were eligible to take part in the study.

Intervention A targeted three month occupational therapy and physiotherapy programme.

Main outcome measures Scores on the Barthel index and the Rivermead mobility index.

Results 24 of 77 nursing and residential homes that catered for residents with mobility limitations and dependency for activities of daily living were selected for study: 12 were randomly allocated to the intervention arm (128 residents, mean age 86 years) and 12 to the control arm (121 residents, mean age 84 years). Participants were evaluated by independent assessors blind to study arm allocation before randomisation (0 months), three months after randomisation (at the end of the treatment period for patients who received the intervention), and again at six months after randomisation. After adjusting for home effect and baseline characteristics, no significant differences were found in mean Barthel index scores at six months post-randomisation between treatment arms (mean effect 0.08, 95% confidence interval −1.14 to 1.30; P=0.90), across assessments (−0.01, −0.63 to 0.60; P=0.96), or in the interaction between assessment and intervention (0.42, −0.48 to 1.32; P=0.36). Similarly, no significant differences were found in the mean Rivermead mobility index scores between treatment arms (0.62, −0.51 to 1.76; P=0.28), across assessments (−0.15, −0.65 to 0.35; P=0.55), or interaction (0.71, −0.02 to 1.44; P=0.06).

Conclusions The three month occupational therapy and physiotherapy programme had no significant effect on mobility and independence. On the other hand, the variation in residents’ functional ability, the prevalence of cognitive impairment, and the prevalence of depression were considerably higher in this sample than expected on the basis of previous work. Further research to clarify the efficacy of occupational therapy and physiotherapy is required if access to therapy services is to be recommended in this population.

Trial registration ISRCTN79859980

Background

With increasing age and longevity, the rising number of frail elders with complex and numerous health-related needs demands a coordinated health care delivery system integrating cure, care and welfare. Studies on the effectiveness of such comprehensive chronic care models targeting frail elders show inconclusive results. The CareWell-primary care program is a complex intervention targeting community-dwelling frail elderly people, that aims to prevent functional decline, improve quality of life, and reduce or postpone hospital and nursing home admissions of community dwelling frail elderly.

Methods/design

The CareWell-primary care study includes a (cost-) effectiveness study and a comprehensive process evaluation. In a one-year pragmatic, cluster controlled trial, six general practices are non-randomly recruited to adopt the CareWell-primary care program and six control practices will deliver ‘care as usual’. Each practice includes a random sample of fifty frail elders aged 70 years or above in the cost-effectiveness study. A sample of patients and informal caregivers and all health care professionals participating in the CareWell-primary care program are included in the process evaluation. In the cost-effectiveness study, the primary outcome is the level of functional abilities as measured with the Katz-15 index. Hierarchical mixed-effects regression models / multilevel modeling approach will be used, since the study participants are nested within the general practices. Furthermore, incremental cost-effectiveness ratios will be calculated as costs per QALY gained and as costs weighed against functional abilities. In the process evaluation, mixed methods will be used to provide insight in the implementation degree of the program, patients’ and professionals’ approval of the program, and the barriers and facilitators to implementation.

Discussion

The CareWell-primary care study will provide new insights into the (cost-) effectiveness, feasibility, and barriers and facilitators for implementation of this complex intervention in primary care.

Trial registration

The CareWell-primary care study is registered in the ClinicalTrials.gov Protocol Registration System: NCT01499797

The use of community-based social services additionally to regular home help services to support older persons at risk of institutionalization was studied. Structured interviews were held with 292 persons, who specifically pointed out that they prefer to remain independently at home. Bivariate and multivariate logistic regression models were developed to study the association between social service use and personal, health-related and wellbeing characteristics. 195 respondents indicated that they made use of at least one social service (68%). Only three services (individual care, social-cultural activities and restaurant facilities), out of nine, were used regularly. Those who lived in a sheltered environment or were supported by informal caregivers or who visited day care had a significantly higher probability of using these services. More attention should be given to the nature and accessibility of community-based social services in order to have distinctive added value in enabling older persons to age in place.

BACKGROUND/OBJECTIVES

The Emergency Department (ED) is an important source of health care for nursing home residents. The objective of this study was to characterize ED use by nursing home residents in the United States (US).

DESIGN

Analysis of the National Hospital Ambulatory Medical Care Survey

SETTING

US Emergency Departments, 2005-2008

PARTICIPANTS

Individuals visiting US EDs, stratified by nursing home and non-nursing home residents.

INTERVENTIONS

None

MEASUREMENTS

We identified all ED visits by nursing home residents. We contrasted the demographic and clinical characteristics between nursing home residents and non-nursing home residents. We also compared ED resource utilization, length of stay and outcomes.

RESULTS

During 2005-2008, nursing home residents accounted for 9,104,735 of 475,077,828 US ED visits (1.9%; 95% CI: 1.8-2.1%). The annualized number of ED visits by nursing home residents was 2,276,184. Most nursing home residents were elderly (mean 76.7 years, 95% CI: 75.8-77.5), female (63.3%), and non-Hispanic White (74.8%). Compared with non-nursing home residents, nursing home residents were more likely have been discharged from the hospital in the prior seven days (adjusted OR 1.4, 95% CI: 1.1-1.9). Nursing home residents were more likely to present with fever (adjusted OR 1.9; 95% CI: 1.5-2.4) or hypotension (systolic blood pressure ≤90 mm Hg, OR 1.8; 95% CI: 1.5-2.2). Nursing home patients were more likely to receive diagnostic test, imaging and procedures in the ED. Almost half of nursing home residents visiting the ED were admitted to the hospital. Compared with non-nursing home residents, nursing home residents were more likely to be admitted to the hospital (adjusted OR 1.8; 95% CI 1.6-2.1) and to die (adjusted OR 2.3; 95% CI 1.6-3.3).

CONCLUSIONS

Nursing home residents account for over 2.2 million ED visits annually in the US. Compared with other ED patients, nursing home residents have higher medical acuity and complexity. These observations highlight the national challenges of organizing and delivering ED care to nursing home residents in the US.

Background

Home care plays a vital role in many health care systems, but there is evidence that appropriate targeting strategies must be used to allocate limited home care resources effectively. The aim of the present study was to develop and validate a methodology for prioritizing access to community and facility-based services for home care clients.

Methods

Canadian and international data based on the Resident Assessment Instrument – Home Care (RAI-HC) were analyzed to identify predictors for nursing home placement, caregiver distress and for being rated as requiring alternative placement to improve outlook.

Results

The Method for Assigning Priority Levels (MAPLe) algorithm was a strong predictor of all three outcomes in the derivation sample. The algorithm was validated with additional data from five other countries, three other provinces, and an Ontario sample obtained after the use of the RAI-HC was mandated.

Conclusion

The MAPLe algorithm provides a psychometrically sound decision-support tool that may be used to inform choices related to allocation of home care resources and prioritization of clients needing community or facility-based services.

Background

Changes in health status, triggered by events such as infections, falls, and geriatric syndromes, are common among nursing home (NH) residents and necessitate transitions between NHs and Emergency Departments (EDs). During transitions, residents frequently experience care that is delayed, unnecessary, not evidence-based, potentially unsafe, and fragmented. Furthermore, a high proportion of residents and their family caregivers report substantial unmet needs during transitions. This study is part of a program of research whose overall aim is to improve quality of care for frail older adults who reside in NHs. The purpose of this study is to identify successful transitions from multiple perspectives and to identify organizational and individual factors related to transition success, in order to inform improvements in care for frail elderly NH residents during transitions to and from acute care. Specific objectives are to:

1. define successful and unsuccessful elements of transitions from multiple perspectives;

2. develop and test a practical tool to assess transition success;

3. assess transition processes in a discrete set of transfers in two study sites over a one year period;

4. assess the influence of organizational factors in key practice locations, e.g., NHs, emergency medical services (EMS), and EDs, on transition success; and

5. identify opportunities for evidence-informed management and quality improvement decisions related to the management of NH – ED transitions.

Methods/Design

This is a mixed-methods observational study incorporating an integrated knowledge translation (IKT) approach. It uses data from multiple levels (facility, care unit, individual) and sources (healthcare providers, residents, health records, and administrative databases).

Discussion

Key to study success is operationalizing the IKT approach by using a partnership model in which the OPTIC governance structure provides for team decision-makers and researchers to participate equally in developing study goals, design, data collection, analysis and implications of findings. As preliminary and ongoing study findings are developed, their implications for practice and policy in study settings will be discussed by the research team and shared with study site administrators and staff. The study is designed to investigate the complexities of transitions and to enhance the potential for successful and sustained improvement of these transitions.

Background

Evidence demonstrates that measures are needed to optimise therapy and improve administration of medicines in care homes for older people. The aim of this study is to determine the clinical and cost effectiveness of a novel model of multi-professional medication review.

Methods

A cluster randomised controlled trial design, involving thirty care homes. In line with current practice in medication reviews, recruitment and consent will be sought from general practitioners and care homes, rather than individual residents. Care homes will be segmented according to size and resident mix and allocated to the intervention arm (15 homes) or control arm (15 homes) sequentially using minimisation. Intervention homes will receive a multi-professional medication review at baseline and at 6 months, with follow-up at 12 months. Control homes will receive usual care (support they currently receive from the National Health Service), with data collection at baseline and 12 months. The novelty of the intervention is a review of medications by a multi-disciplinary team. Primary outcome measures are number of falls and potentially inappropriate prescribing. Secondary outcome measures include medication costs, health care resource use, hospitalisations and mortality.

The null hypothesis proposes no difference in primary outcomes between intervention and control patients. The primary outcome variable (number of falls) will be analysed using a linear mixed model, with the intervention specified as a fixed effect and care homes included as a random effect. Analyses will be at the level of the care home. The economic evaluation will estimate the cost-effectiveness of the intervention compared to usual care from a National Health Service and personal social services perspective.

The study is not measuring the impact of the intervention on professional working relationships, the medicines culture in care homes or the generic health-related quality of life of residents.

Discussion

This study will establish the effectiveness of a new model of multi-professional clinical medication reviews in care homes, using novel approaches to recruitment and consent. It is the first study to undertake an examination of direct patient outcomes, together with an economic analysis.

Trial Registration

ISRCTN: ISRCTN90761620

There were 59,500 Children in out-of-home care in England in 2008. Research into this population points to poor health and quality of life outcomes over the transition to adult independence. This undesirable outcome applies to mental health, education and employment. This lack of wellbeing for the individual is a burden for health and social care services, suggesting limitations in the current policy approaches regarding the transitional pathway from care to adult independence. Although the precise reasons for these poor outcomes are unclear long term outcomes from national birth cohorts suggest that mental health could be a key predictor for subsequent psychosocial adjustment.

Researching the wellbeing of children in out-of-home care has proven difficult due to the range and complexity of the factors leading to being placed in care and the different methods used internationally for recording information. This paper delineates the estimated prevalence of mental health problems for adolescents in the care system, organisational factors, influencing service provision, and pathways through the transition from adolescence to independent young adult life. The extent to which being taken into care as a child moderates adult wellbeing outcomes remains unknown. Whether the care system enhances, reduces or has a null effect on wellbeing and specifically mental health cannot be determined from the current literature. Nonetheless a substantial proportion of young people display resilience and experience successful quality of life outcomes including mental capital. A current and retrospective study of young people transitioning to adult life is proposed to identify factors that have promoted successful outcomes and which would be used to inform policy developments and future longitudinal studies.

Background

Being at risk of undernutrition is a global problem among older people. Undernutrition can be considered inadequate nutritional status, characterized by insufficient food intake and weight loss. There is a lack of Norwegian studies focusing on being at risk of undernutrition and self-care ability, sense of coherence, and health-related issues among older home-dwelling people.

Aim

To describe the prevalence of being at risk of undernutrition among a group of older home-dwelling individuals in Norway, and to relate the results to reported self-care ability, sense of coherence, perceived health and other health-related issues.

Methods

A cross-sectional design was applied. A questionnaire with instruments for nutritional screening, self-care ability, and sense of coherence, and health-related questions was sent to a randomized sample of 450 persons (aged 65+ years) in southern Norway. The study group included 158 (35.1%) participants. Data were analysed using statistical methods.

Results

The results showed that 19% of the participants were at medium risk of undernutrition and 1.3% at high risk. Due to the low response rate it can be expected that the nonparticipants can be at risk of undernutrition. The nutritional at-risk group had lower self-care ability and weaker sense of coherence. Living alone, receiving help regularly to manage daily life, not being active and perceived helplessness emerged as predictors for being at risk of undernutrition. The results indicate difficulties in identifying people at nutritional risk and supporting self-care activities to maintain a good nutritional status.

Conclusion

Health care professionals have to be able to identify older home-dwelling people at risk of undernutrition, support self-care activities to enable people at risk to maintain a sufficient nutritional status, and be aware that older people living alone, who receive help, feel helpless, and are inactive are especially vulnerable.

Although approximately 50% of nursing home residents fall annually, the surrounding circumstances remain inadequately understood. This study explored nursing staff perspectives of person, environment, and interactive circumstances surrounding nursing home falls. Focus groups were conducted at two nursing homes in the mid-Atlantic region with the highest and lowest fall rates among corporate facilities. Two focus groups were conducted per facility: one with licensed nurses and one with geriatric nursing assistants. Thematic and content analysis revealed three themes and 11 categories. Three categories under the Person theme were Change in Residents’ Health Status, Decline in Residents’ Abilities, and Residents’ Behaviors and Personality Characteristics. There were five Nursing Home Environment categories: Design Safety, Limited Space, Obstacles, Equipment Misuse and Malfunction, and Staff and Organization of Care. Three Interactions Leading to Falls categories were identified: Reasons for Falls, Time of Falls, and High-Risk Activities. Findings highlight interactions between person and environment factors as significant contributors to resident falls.

Objective To determine the effectiveness of the provision of whole food to enhance completion of treatment for tuberculosis.

Design Parallel group randomised controlled trial.

Setting Three primary care clinics in Dili, Timor-Leste.

Participants 270 adults aged ≥18 with previously untreated newly diagnosed pulmonary tuberculosis.

Main outcome measures Completion of treatment (including cure). Secondary outcomes included adherence to treatment, weight gain, and clearance of sputum smears. Outcomes were assessed remotely, blinded to allocation status.

Interventions Participants started standard tuberculosis treatment and were randomly assigned to intervention (nutritious, culturally appropriate daily meal (weeks 1-8) and food package (weeks 9-32) (n=137) or control (nutritional advice, n=133) groups. Randomisation sequence was computer generated with allocation concealment by sequentially numbered, opaque, sealed envelopes.

Results Most patients with tuberculosis were poor, malnourished men living close to the clinics; 265/270 (98%) contributed to the analysis. The intervention had no significant beneficial or harmful impact on the outcome of treatment (76% v 78% completion, P=0.7) or adherence (93% for both groups, P=0.7) but did lead to improved weight gain at the end of treatment (10.1% v 7.5% improvement, P=0.04). Itch was more common in the intervention group (21% v 9%, P<0.01). In a subgroup analysis of patients with positive results on sputum smears, there were clinically important improvements in one month sputum clearance (85% v 67%, P=0.13) and completion of treatment (78% v 68%, P=0.3).

Conclusion Provision of food did not improve outcomes with tuberculosis treatment in these patients in Timor-Leste. Further studies in different settings and measuring different outcomes are required.

Trial registration Clinical Trials NCT0019256.

Objectives

To determine the effectiveness of early assisted discharge for chronic obstructive pulmonary disease (COPD) exacerbations, with home care provided by generic community nurses, compared with usual hospital care.

Design

Prospective, randomised controlled and multicentre trial with 3-month follow-up.

Setting

Five hospitals and three home care organisations in the Netherlands.

Participants

Patients admitted to the hospital with an exacerbation of COPD. Patients with no or limited improvement of respiratory symptoms and patients with severe unstable comorbidities, social problems or those unable to visit the toilet independently were excluded.

Intervention

Early discharge from hospital after 3 days inpatient treatment. Home visits by generic community nurses. Primary outcome measure was change in health status measured by the Clinical COPD Questionnaire (CCQ). Treatment failures, readmissions, mortality and change in generic health-related quality of life (HRQL) were secondary outcome measures.

Results

139 patients were randomised. No difference between groups was found in change in CCQ score at day 7 (difference in mean change 0.29 (95% CI −0.03 to 0.61)) or at 3 months (difference in mean change 0.04 (95% CI –0.40 to 0.49)). No difference was found in secondary outcomes. At day 7 there was a significant difference in change in generic HRQL, favouring usual hospital care.

Conclusions

While patients’ disease-specific health status after 7-day treatment tended to be somewhat better in the usual hospital care group, the difference was small and not clinically relevant or statistically significant. After 3 months, the difference had disappeared. A significant difference in generic HRQL at the end of the treatment had disappeared after 3 months and there was no difference in treatment failures, readmissions or mortality. Early assisted discharge with community nursing is feasible and an alternative to usual hospital care for selected patients with an acute COPD exacerbation.

Trial registration: NetherlandsTrialRegister NTR 1129.

Objectives

To compare the costs of admission to a hospital at home scheme with those of acute hospital admission.

Design

Cost minimisation analysis within a pragmatic randomised controlled trial.

Setting

Hospital at home scheme in Leicester and the city's three acute hospitals.

Participants

199 consecutive patients assessed as being suitable for admission to hospital at home for acute care during the 18 month trial period (median age 84 years).

Intervention

Hospital at home or hospital inpatient care.

Main outcome measures

Costs to NHS, social services, patients, and families during the initial episode of treatment and the three months after admission.

Results

Mean (median) costs per episode (including any transfer from hospital at home to hospital) were similar when analysed by intention to treat—hospital at home £2569 (£1655), hospital ward £2881 (£2031), bootstrap mean difference −305 (95% confidence interval −1112 to 448). When analysis was restricted to those who accepted their allocated place of care, hospital at home was significantly cheaper—hospital at home £2557 (£1710), hospital ward £3660 (£2903), bootstrap mean difference −1071 (−1843 to −246). At three months the cost differences were sustained. Costs with all cases included were hospital at home £3671 (£2491), hospital ward £3877 (£3405), bootstrap mean difference −210 (−1025 to 635). When only those accepting allocated care were included the costs were hospital at home £3698 (£2493), hospital ward £4761 (£3940), bootstrap mean difference −1063 (−2044 to −163); P=0.009. About 25% of the costs for episodes of hospital at home were incurred through transfer to hospital. Costs per day of care were higher in the hospital at home arm (mean £207 v £134 in the hospital arm, excluding refusers, P<0.001).

Conclusions

Hospital at home can deliver care at similar or lower cost than an equivalent admission to an acute hospital.

Objectives

To determine the prevalence and health outcomes of meticillin-resistant Staphylococcus aureus (MRSA) colonisation in elderly care home residents. To measure the effectiveness of improving infection prevention knowledge and practice on MRSA prevalence.

Setting

Care homes for elderly residents in Leeds, UK.

Participants

Residents able to give informed consent.

Design

A controlled intervention study, using a stepped wedge design, comprising 65 homes divided into three groups. Baseline MRSA prevalence was determined by screening the nares of residents (n=2492). An intervention based upon staff education and training on hand hygiene was delivered at three different times according to group number. Scores for three assessment methods, an audit of hand hygiene facilities, staff hand hygiene observations and an educational questionnaire, were collected before and after the intervention. After each group of homes received the intervention, all participants were screened for MRSA nasal colonisation. In total, four surveys took place between November 2006 and February 2009.

Results

MRSA prevalence was 20%, 19%, 22% and 21% in each survey, respectively. There was a significant improvement in scores for all three assessment methods post-intervention (p≤0.001). The intervention was associated with a small but significant increase in MRSA prevalence (p=0.023). MRSA colonisation was associated with previous and subsequent MRSA infection but was not significantly associated with subsequent hospitalisation or mortality.

Conclusions

The intervention did not result in a decrease in the prevalence of MRSA colonisation in care home residents. Additional measures will be required to reduce endemic MRSA colonisation in care homes.

Article summary

Article focus

To assess the effectiveness of an educational intervention on the prevalence of MRSA in care homes for the older people.

Key messages

There was a high rate of MRSA colonisation in elderly residents of care homes during the study period.

The intervention improved the infection prevention knowledge and practice of staff working in care homes but did not reduce the prevalence of MRSA colonisation of residents.

MRSA colonisation was associated with previous and subsequent MRSA infection but was not significantly associated with subsequent hospitalisation or mortality.

Additional measures are required to reduce endemic MRSA colonisation in care homes.

Strengths and limitations of this study

This is a large prospective study, including 65 homes and 2492 residents. MRSA prevalence was monitored over a 28-month period.

The intervention was plausible, unlikely to be harmful, and the assessments of the intervention were reasonable.

A significant improvement was seen in scores for all three intervention assessment methods; however, the intervention was associated with a small but significant increase in MRSA prevalence.

It was not possible to identify or control for the factors responsible for the increase in MRSA prevalence following the intervention.

Background

The effect of food supplementation provided by the World Food Programme to patients and their families enrolled in a predominantly HIV/AIDS home based care programme in Bangwe Malawi is assessed.

Methods

The survival and nutritional status of patients and the nutritional status of their families recruited up to six months before a food supplementation programme started are compared to subsequent patients and their families over a further 12 months.

Results

360 patients, of whom 199 died, were studied. Food supplementation did not improve survival but had an effect (not statistically significant) on nutritional status. Additional oil was given to some families; it may have improved survival but not nutritional status.

Conclusion

Food supplementation to HIV/AIDS home based care patients and their families does not work well. This may be because the intervention is too late to affect the course of disease or insufficiently targeted perhaps due to problems of distribution in an urban setting. The World Food Programme's emphasis on supplementary feeding for these families needs to be reviewed.

Background

The effectiveness and efficiency of nursing-home dementia care are suboptimal: there are high rates of neuropsychiatric symptoms among the residents and work-related stress among the staff. Dementia-care mapping is a person-centred care method that may alleviate both the resident and the staff problems. The main objective of this study is to evaluate the effectiveness and cost-effectiveness of dementia-care mapping in nursing-home dementia care.

Methods/Design

The study is a cluster-randomised controlled trial, with nursing homes grouped in clusters. Studywise minimisation is the allocation method. Nursing homes in the intervention group will receive a dementia-care-mapping intervention, while the control group will receive usual care. The primary outcome measure is resident agitation, to be assessed with the Cohen-Mansfield Agitation Inventory. The secondary outcomes are resident neuropsychiatric symptoms, assessed with the Neuropsychiatric Inventory - Nursing Homes and quality of life, assessed with Qualidem and the EQ-5D. The staff outcomes are stress reactions, job satisfaction and job-stress-related absenteeism, and staff turnover rate, assessed with the Questionnaire about Experience and Assessment of Work, the General Health Questionnaire-12, and the Maastricht Job Satisfaction Scale for Health Care, respectively. We will collect the data from the questionnaires and electronic registration systems. We will employ linear mixed-effect models and cost-effectiveness analyses to evaluate the outcomes. We will use structural equation modelling in the secondary analysis to evaluate the plausibility of a theoretical model regarding the effectiveness of the dementia-care mapping intervention. We will set up process analyses, including focus groups with staff, to determine the relevant facilitators of and barriers to implementing dementia-care mapping broadly.

Discussion

A novelty of dementia-care mapping is that it offers an integral person-centred approach to dementia care in nursing homes. The major strengths of the study design are the large sample size, the cluster-randomisation, and the one-year follow-up. The generalisability of the implementation strategies may be questionable because the motivation for person-centred care in both the intervention and control nursing homes is above average. The results of this study may be useful in improving the quality of care and are relevant for policymakers.

Trial registration

The trial is registered in the Netherlands National Trial Register: NTR2314.