Journal of the American Medical Directors Association最新文献

Objectives: Individuals with motoric cognitive risk (MCR) syndrome have a high dementia risk. However, a knowledge gap exists in the measurement procedure for slow gait speed, which is a crucial component of MCR diagnosis. The study aimed to systematically review slow gait speed measurement practices in MCR diagnosis to identify critical constructs in gait speed measurement procedure.

Design: Systematic review.

Setting and participants: Included studies were conducted in clinical and community settings, involving participants with MCR receiving gait speed measurement.

Methods: A systematic search across PubMed, Medline, Embase, CINHAL (EBSCO), Web of Science, Cochrane Library, and ProQuest Dissertation from inception until January 2024 for articles with detailed MCR diagnosis. Study quality was evaluated with the Joanna Briggs Institute (JBI) Critical Appraisal Checklists and slow gait speed measurement methods were summarized through narrative synthesis.

Results: From 27,600 unique entries, 50 relevant studies with 55 cohorts were identified and included in the review. Slow gait speed measurement methods in existing MCR studies showed heterogeneity in measurement tools, start/end protocols and buffer distance, walking test distance, number of tests, calculation methods, and cutoff values. Commonly, manual stopwatches and 4-meter walking test distance with a 2-meter buffer at each end at a usual pace were used, averaging 2 tests for gait speed analysis, with the need for cohort-specific slow gait cutoff values.

Conclusions and implications: The measurement practices of slow gait speed in MCR diagnosis were heterogeneous. A relatively comprehensive gait speed measurement procedure with 7 constructs was initially delineated in this study based on synthesis analysis, with the potential to improve diagnostic accuracy and consistency of MCR, although further validation is still needed.

Objectives: To analyze patient and facility characteristics associated with smaller versus larger nursing home (NH) chains.

Design: This study used a cross-sectional study design.

Setting and participants: NHs affiliated with multi-facility chains in the United States.

Methods: Using nationally representative data from LTCFocus 2021 Facility-Level File and the June 2023 Centers for Medicare and Medicaid Services (CMS) Affiliated Entity Performance Measures, we assessed differences in facility and patient characteristics among categories of NH chains size based on the number of certified beds (smallest to largest quintile of NH chain size) using one-way analysis of variance testing. We conducted linear regression analyses to examine the association between the quintile of chain size and staffing outcomes.

Results: Among the 9348 NHs associated with 610 chains in our sample, the smallest quintiles of NH chains had the lowest percentage of for-profit facilities, a higher percentage of patients with Alzheimer's and dementia-related diseases, and higher percentages of long-stay residents needing assistance with activities of daily living (ADLs). The largest chain quintile was associated with fewer staffing hours per resident day (HPRD) for all total nurse staff -0.69 (95% CI, -0.86 to -0.52; P < .001), registered nurses (-0.25 HPRD; 95% CI, -0.32 to -0.17; P < .001), certified nursing assistants (CNAs) (-0.37 HPRD; 95% CI, -0.48 to -0.26; P < .001), and weekend total nurse staff (-0.57 HPRD; 95% CI, -0.71 to -0.42; P < .001]). The CMS staffing rating was also lower in larger NH chains (-0.73 for quintile 5; 95% CI, -0.98 to -0.48; P < .001).

Conclusions and implications: Larger NH chains tended to treat less clinically complex patients and were associated with lower staffing ratios. Given increased attention and stricter rules regarding staffing by government agencies, increased monitoring of staffing in NHs affiliated with large chains by policymakers, antitrust agencies, and regulators is warranted.

Objectives: Survey nursing home (NH) clinicians about the indications for NH gabapentinoid use, the factors driving increased prescribing, and their experiences with gabapentinoid deprescribing.

Design: Online clinician survey.

Setting and participants: NH clinicians prescribing gabapentinoids in US NHs.

Methods: An anonymous survey of NH prescribers was conducted using SurveyMonkey from March 15 to July 1, 2024. Recruitment employed crowdsourcing, targeting the membership of NH clinician organizations. A multidisciplinary team developed the instrument. Content focused on the magnitude of gabapentinoid prescribing for different, previously identified, indications, as well as clinician deprescribing experiences and perspectives.

Results: Sixty-two self-identified NH prescribers participated: 76% White, 55% female, 77% physicians. One-third had geriatric training certifications. Most NH gabapentinoids were started in other care settings by non-NH clinicians. Gabapentinoid prescribing initiated in NHs was principally off-label for pain syndromes. Although prescribing solely for psycho-behavioral symptoms was rare, most clinicians reported that gabapentinoids have some utility in treating these symptoms and consequently may be preferred over alternative analgesics when psycho-behavioral symptoms coexist with pain. Gabapentinoid deprescribing occurs infrequently and is deprioritized relative to opioid reduction efforts. Most clinicians acknowledged potential gabapentinoid side effects; however, severe harms were rarely observed, and half agreed that gabapentinoids are generally safe and well-tolerated. Seventy-nine percent perceive gabapentinoids as safer and better tolerated than opioids, 57% than benzodiazepines, and 40% than antipsychotics.

Conclusions and implications: An opportunity exists to increase NH safety by prioritizing gabapentinoid gradual dose reduction requirements. Because so many prescriptions originate outside NHs, any reduction effort should emphasize deprescribing across all care settings. Clinicians' perceptions of gabapentinoids as reasonable but unmonitored alternatives to opioids and psychotropics contribute to their increased use. Safety and efficacy data supporting such prescribing for nonapproved indications in NHs is lacking. Existing NH psychotropic reporting and reduction mandates should include gabapentinoids regardless of indication.

Objectives: Frailty is a heterogeneous syndrome with distinct patterns. This study aimed to identify frailty risk patterns and their predictive value for mortality in older adults.

Design: Prospective longitudinal study.

Setting and participants: Data were obtained from a 2017 survey of 609 independently mobile adults aged 65 years and older in suburban Japan, focusing on those at risk for at least 1 frailty dimension.

Methods: Frailty assessments were extracted from the Kihon checklist, and subgroups were identified using latent class analysis. Associations between frailty patterns and 3-year mortality were assessed using Kaplan-Meier survival analysis and Cox proportional hazards modeling.

Results: Three frailty patterns were identified: "high risk of cognitive impairment" (76.0%), "moderate risk of cognitive, physical, and oral dysfunction" (14.3%), and "high risk of cognitive, physical, and functional decline" (9.7%). We recorded 52 deaths during a mean follow-up time of 25.7 months (standard deviation: 12.6) and a median follow-up time of 26.5 months. Kaplan-Meier analysis showed significant survival differences among the groups (log-rank: P < .001). Compared with the high risk of cognitive impairment group, the moderate risk of cognitive, physical, and oral dysfunction group had a 145% higher mortality risk (adjusted hazard ratio, 2.45; 95% confidence interval, 1.22-4.90), while the high risk of cognitive, physical, and functional decline group exhibited a 220% higher risk of mortality (adjusted hazard ratio, 3.20; 95% confidence interval, 1.53-6.70).

Conclusions and implications: The findings reveal the heterogeneity of frailty among community-dwelling Japanese older adults, with a high prevalence of cognitive impairment risk. The subgroup with risk of cognitive, physical, and functional decline had the highest mortality risk, highlighting the need for multidimensional assessment and intervention.

Objectives: Long-term care (LTC) staff may develop dissociation due to high-stress work environments and trauma exposures. This study aimed to (1) assess the prevalence of pathological dissociation in LTC home staff during the COVID-19 pandemic; (2) examine the associations of pathological dissociation with demographic characteristics, mental health, insomnia, and professional quality of life; and (3) examine whether pathological dissociation was sensitive to change following a coherent breathing intervention.

Design: We analyzed data from a pre-post breathing intervention study conducted between January and September 2022.

Settings and participants: Participants were 254 staff (care aides, nurses, and managers) from 31 LTC homes in Alberta, Canada.

Methods: We measured pathological dissociation using the Dissociative Experiences Scale-Taxon (DES-T). We conducted χ² test and t tests to examine the association of pathological dissociation with other variables pre-intervention. We used a 2-level random intercept logistic regression analysis to examine the change in pathological dissociation from pre- to post-intervention.

Results: About 12% and 8% of the sample experienced pathological dissociation pre- and post-intervention, respectively. Pathological dissociation was significantly associated with stress, psychological distress, anxiety, depression, posttraumatic stress disorder, and insomnia (P < .05); it was also significantly associated with language, race, and professional role (P < .05). Participants had lower odds of experiencing pathological dissociation post-intervention compared with pre-intervention (odds ratio, 0.41; P = .045).

Conclusions and implications: LTC home staff exhibited a high prevalence of pathological dissociation during COVID-19, significantly linked to other mental health measures. A coherent breathing intervention showed potential in reducing reports of dissociation. Further research is needed to understand dissociation in LTC staff and its interplay with mental health outcomes, sleep quality, and personal/work-related factors. Understanding the work environment's role and assessing interventions targeting working conditions could mitigate dissociation and promote a trauma-informed workplace. Rigorous study designs are needed to generate stronger evidence for nonpharmacological interventions like coherent breathing.

Objectives: Nursing home (NH) administrator perceptions regarding the utility of Alzheimer's disease (AD) disease-modifying medications in NHs are important because many short and long-stay residents have mild AD. This study examined the interest of directors of nursing (DoNs) in using new AD disease-modifying treatments, changes in attitudes based on differences in costs to the NH, and characteristics (DoN and NH) associated with such changes.

Design: This is a cross-sectional study.

Setting and participants: This study is based on a 2022 nationally representative survey of 340 NH DoNs, which was drawn from a stratified random sample of US NHs with ≥30 beds and with a 26.6% response rate.

Methods: We conducted a descriptive analysis to assess the awareness of new AD disease-modifying treatments and the support for their use. We applied logistic regression models to explore the associations between the interest of the DoN in using these new AD treatments and various characteristics.

Results: Most (86%) DoNs stated that they would at least sometimes support the usage of a new disease-modifying medication if there were no NH costs. This percentage was lower if the NH costs per resident were $2000 per year (51.3%) and $20,000 per year (14%). NHs with moderate shares of dual-eligible residents were more sensitive to cost.

Conclusions and implications: Our findings indicated that the interest of DoNs in using disease-modifying treatments for dementia varies widely according to the cost to the NHs. The uptake of new AD medications in the NH setting should be monitored, and targeted efforts may be needed to mitigate inequities in access for less-resourced NHs.

Objectives: To examine the optimal range of steps for an individual based on the dose-response relationship of the number of steps taken with disability incidence and all-cause mortality stratified by age and physical frailty.

Design: Prospective cohort study.

Setting and participants: 8664 community-dwelling older adults.

Methods: The daily number of steps was measured using an accelerometer. Disability incidence and mortality were prospectively determined over 60 months. Participants were stratified using a nonlinear restricted cubic spline based on age >75 or <75 years and physical frailty, per the revised Japanese version of the Cardiovascular Health Study criteria.

Results: The study cohort's median age was 74 years [interquartile range (IQR) range 71-78), and 54.0% were female. Incidental disability and death were observed in 1373 (15.8%) and 529 (6.1%) participants, respectively. The median steps per day were 5514 (IQR 3878-7616). Daily steps were nonlinearly associated with disability incidence and mortality. The optimal cutoff points for frail and nonfrail participants were, respectvely, 2168 [hazard ratio (HR) 0.74, 95% CI 0.56-0.98] and 7459 (HR 0.86, 95% CI 0.74-0.99) steps for disability incidence and 2593 (HR 0.63, 95% CI 0.40-0.98) and 3282 (HR 0.77, 95% CI 0.61-0.98) steps for all-cause mortality. The optimal cutoff points for participants >75 and <75 years were, respectively, 6066 (HR 0.83, 95% CI 0.72-0.99) and 8573 (HR 0.77, 95% CI 0.59-0.99) steps for disability incidence and 1824 (HR 0.67, 95% CI 0.46-0.98) and 4128 (HR 0.72, 95% CI 0.52-0.99) steps for all-cause mortality.

Conclusions and implications: Participants >75 years and frail participants required lower daily steps for preventing disability incidence and all-cause mortality than those <75 years and nonfrail participants, indicating that lower targets may still provide health-promoting benefits. Thus, the optimal step number should be considered based on individual characteristics, including age and frailty.