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long-term care

Methicillin-resistant Staphylococcus aureus and Vancomycin-resistant Enterococci Among Older Adults

Methicillin-resistant Staphylococcus aureus and Vancomycin-resistant Enterococci Among Older Adults

Teaser: 


Focus on Long-term Care Facilities

Shelly A. McNeil, MD, FRCPC, Division of Infectious Diseases, Queen Elizabeth II Health Sciences Centre and Dalhousie University, Halifax, NS.
Lona Mody, MD, Divisions of Geriatric Medicine, Veterans Affairs Medical Center and The University of Michigan Medical School, Ann Arbor, MI, USA.
Suzanne Bradley, MD, Divisions of Geriatric Medicine and Infectious Diseases, Veterans Affairs Medical Center and The University of Michigan Medical School, Ann Arbor, MI, USA.

Methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant enterococci (VRE) are important causes of morbidity and mortality in hospitals, and rates of MRSA and VRE in long-term care facilities (LTCF) have increased. However, the majority of residents in LTCF are asymptomatically colonized and the risk of infection with MRSA or VRE in this setting is low. Extension of stringent infection control practices required to control the spread of MRSA and VRE in acute care hospitals is not warranted in the LTCF setting. Patients known to be colonized with MRSA or VRE should not be refused admission to a LTCF and, in the absence of symptomatic infection, measures beyond routine standard precautions are not necessary.

Capacity Assessment for Admission to Long-term Care: A Double-edged Sword

Capacity Assessment for Admission to Long-term Care: A Double-edged Sword

Teaser: 

Helen Gia Levin, BA(Psychology), BSW, MSW, RSW, Member of Ontario Association of Professional Social Workers, Regional Geriatric Program Central Service, Toronto, ON.
Zoë Anne Levitt, BSW, MSW, RSW, Social Worker, Regional Geriatric Program Central Service, Toronto, ON.

Performing the assessment for capacity to make admission decisions to long-term care can either be simple or fraught with problems. A discussion of two clinical case examples will illustrate how this process, which appears to be straightforward, can become quite complex. The authors assume that the readers have a working knowledge of the process for assessing elders' capacity to make admission decisions to long-term care.
Key words: admission decisions, long-term care, capacity assessment, Consent and Capacity Board.

Dementia and Wandering Behaviour in Long-term Care Facilities

Dementia and Wandering Behaviour in Long-term Care Facilities

Teaser: 

Nina M. Silverstein, PhD, Associate Professor, Gerontology, University of Massachusetts Boston, College of Public & Community Service, Boston, MA.
Gerald Flaherty, Director of Special Projects & Safe Return Alzheimer's Association, Massachusetts Chapter, Boston, MA.

Nearly half of all residents in long-term care settings suffer from some type of dementing illness, with Alzheimer disease by far the most common type. People with dementia should be presumed at high risk for wandering due to their cognitive deficits and unpredictable behaviour. Recommendations are shared to minimize attempts to wander and actual wandering episodes by promoting a more therapeutic environment both through the physical structure and through staff training. In addition, effective strategies to follow in situations when a resident is, in fact, missing are presented.
Key words: dementia, wandering, long-term care, environment.

Natural History of Long-Term Care Clients

Natural History of Long-Term Care Clients

Teaser: 

Madhuri Reddy, MD, Associate Editor, Geriatrics & Aging.

In order to effectively plan future long-term care (LTC) environments, it is important to ascertain the natural history of clients once placed in these environments. What, for instance, are the predictors of client mortality and the probability of a change in function, either to improve or deteriorate, once placed in a certain level of care? Environments need to be flexible and, most of all, promote independence and an enhanced quality of life.

Changes in Care Requirements Over Time
It is well established that the functional status of many nursing home (NH) clients improves after NH placement or after transitions between different levels of care. Some aspects of functional status (hygiene, dressing, grooming and transferring), as well as depressed mood, are likely to improve shortly after NH admission.1 One study of over 9,500 elderly clients admitted to a NH for at least 100 days found that 51.5% experienced a change in function during the first 90 days. This change usually represented an improvement rather than a decline. In fact, thirty-seven percent of this long-stay client sample was able to return home.2

Predictors of Mortality
Several studies have indicated that predictors of mortality in the elderly are increased age, male sex, poor physical status, poor social supports and poor cognitive functioning.3,4,5 Few studies, however, have investigated the predictors of mortality specific to the NH population.

Controversies and Difficulties in Making Long-Term Care Predictions of Client Needs

Controversies and Difficulties in Making Long-Term Care Predictions of Client Needs

Teaser: 

Madhuri Reddy , MD, FRCPC,
Associate Editor, Geriatrics & Aging.

As the Canadian population ages, policy makers must begin to make predictions regarding the needs of long-term care (LTC) clients. This is confounded by a number of variables that make long-term predictions difficult. In the following article, different schools of thought and theories on the variables that will influence the needs of the LTC sector in the next several decades are reviewed.

Numbers of Clients that Require LTC
The Expansion of Morbidity Hypothesis

The expansion of morbidity hypothesis suggests that the numbers of clients requiring institutional LTC will increase, leading to an increased burden of disability and dependency.1,2 With advances in medical, social and economic conditions, active-life expectancy has increased3 and the age of onset of terminal dependency has been postponed; however, some believe that the duration of terminal dependency will eventually increase.1 There has been an increase in both the hospital length-of-stay of elderly clients and the proportion of the lifespan spent in long-term hospital care. The number of very old people, including centenarians, has also steadily risen. There is evidence that both disability and dependency have also increased. In Canada, up to 80% of the gain in life expectancy consists of increased years of disability.

Why are Clients Inappropriately Placed in High Levels of Care?

Why are Clients Inappropriately Placed in High Levels of Care?

Teaser: 

 

Madhuri Reddy, MD, FRCPC
Associate Editor,
Geriatrics & Aging,
Toronto, ON.

 

Introduction
It is well documented that, throughout North America, a large percentage of elderly clients (10-52%) do not have the medical need or are not sufficiently disabled to justify placement in high level of care settings such as a nursing home (NH).1,2,3,4

The placement of low-care clients in NH is often assumed to indicate inappropriate and inefficient use of NH resources.5 In addition, it is well established that disabled clients prefer home or community-based care rather than receiving care in NHs.6 So why do clients continue to be placed in high levels of care that they do not need?

Subjective Placement Criteria
The process of client placement does not always explore the possibility that the client may best be cared for outside of a long-term care (LTC) institution. In addition, even when clients truly do need NH care, the definitions of the various levels of care are often vague; thus, adherence by placement committees is often inconsistent. This lack of objective criteria regarding the level of care required by a particular patient leads to subjective decision-making by a placement panel; this can result in patients who require the same level of care being placed in different levels depending on who makes the decision.

Living Wills and the Long-Term Care Patient

Living Wills and the Long-Term Care Patient

Teaser: 

Michael Gordon, MD, MSc, FRCPC
Vice President of Medical Services,
Baycrest Centre for Geriatric Care,
Professor of Medicine,
University of Toronto, Toronto, ON.

 

The nurse and physician were very upset. They felt that Mrs. B.'s daughter was not respecting her mother's wishes to forgo CPR should she experience a cardiac arrest. A year earlier, when Mrs. B. entered the nursing home with late-stage Parkinson's disease, she had filled out an advance directive, naming her daughter, rather than her ailing husband, as her surrogate and indicating that, in the event of a cardiac arrest, she did not want to be resuscitated. Over the course of the year, as her disease progressed and she underwent repeated aspirations, it became evident that the end was in sight. Mrs. B.'s daughter told the staff that she would not accept the DNR order and, as the "lawful" surrogate, was requesting that "everything" be done should her mother have a cardiac arrest.

Dr. M. was distraught. Six months earlier, he and his younger brother and sister had, with some reluctance, agreed to the insertion of a PEG tube for their mother who suffered from late-stage Alzheimer disease and had stopped eating after a bout of pneumonia. They felt that by feeding her, she might have a chance at recovery and had not really thought through the long-term consequences of their decision.

The Structure of Long-Term Care in Canada

The Structure of Long-Term Care in Canada

Teaser: 

Madhuri Reddy, MD, FRCP(C)
Associate Editor,
Geriatrics & Aging.

Background
Institutional long-term care (LTC) is expensive for both the individual and society.1 As Canada's population ages, there will be growing pressure for institutional beds and greater interest in reducing or delaying admission to an institution.2

The structure and financing of LTC varies widely not only among, but also within countries.3 The Canadian health care system is federally-based, and although both federal and provincial levels of government contribute financially to the LTC system, individual provinces are ultimately responsible for the delivery of health care services.4

In anticipation of the growing population of frail elderly, several countries are in the process of reforming their LTC systems. There is a trend to change the purpose of nursing homes (NHs) to provide mostly for clients with complicated care needs.3 Researchers worldwide are investigating how to correctly determine clients' needs and how to create instruments that can appropriately assess these needs.5 LTC placement criteria are being optimized, alternatives to LTC are being explored, and many countries are expanding their community and home care services.3

Single-Entry System in Canada
In order to make the process of LTC placement more efficient and streamlined, a 'single-entry' system has been introduced in several Canadian provinces.

Long-Term Care: It is Worth the Investment

Long-Term Care: It is Worth the Investment

Teaser: 

In most jurisdictions, the number of people residing in long-term care (LTC) facilities at a single point in time is usually greater than the number of people who are in acute care hospitals. Yet far greater resources, both human and financial, are invested in acute care hospitals. Most of this disparity is, of course, quite appropriate. Acute care hospitals, with their short length of stay, actually treat many more patients than do LTC facilities. LTC facilities are primarily places of residence, with medical care added on where appropriate, and the expensive high tech approach of hospitals is neither wanted nor needed.

Despite this, it is difficult to believe that current resources in nursing homes are even remotely adequate. These resources are not just financial, although finances are certainly an issue. In the last few years in Ontario, the routine reimbursement for nursing home physicians has decreased by 25%. As well, in order for a physician to bill, the new rules require that he or she have face-to-face contact with the patient. No remuneration is provided for conferences with the rest of the health care team. This is making it increasingly difficult to convince physicians that being an attending physician in a LTC facility is worthwhile. Remuneration to the homes has not kept up with 'medical inflation,' and each year it seems that fewer personnel with professional qualifications are actually working in our LTC facilities. Even the physical environment of many LTC facilities leaves much to be desired. Lack of governmental funding for construction means that in many provinces private companies are the predominant providers of LTC.

However, there is also an information gap in our LTC facilities. Part of this is because of a general lack of knowledge of medical issues in the nursing home setting. Only in the last two decades has any significant effort been invested in advancing medical care within the nursing home by conducting research on these residents. Numerous articles have attested to the fact that improved care can benefit a number of objective outcomes, such as incontinence, falls and fractures.

In this edition of G&A we have a superb series of articles on Heart Disease in the Nursing Home, edited by one of North America's leading geriatric cardiologists, Wilbert Aronow. There are articles on stable coronary artery disease, congestive heart failure and endocarditis prophylaxis. Two other articles in this series, acute coronary syndromes and pacemakers, will appear in a later issue. Our own Associate Editor, Madhuri Reddy, reviews the structure of LTC across the country, and Gina Bravo discusses the details of LTC in Quebec.

There is also an interesting article on quality indicators in LTC by Jean Chouinard. I believe that the fundamental reason for the lack of resources invested in LTC is the societal belief that it is not worth the investment. Obviously, as a geriatrician, I believe that LTC is absolutely worth the investment and establishing guidelines for quality LTC is of crucial importance. Unfortunately, it is often more difficult to measure quality in LTC, as the simple measures (mortality, return to work etc.) that are relevant in acute care are not necessarily so in LTC facilities. When colleagues of mine, who previously were unconcerned about quality in LTC, have parents or grandparents admitted to LTC facilities, it is amazing to watch them transform into believers! If we believe that the frail elderly in nursing homes (and not just our own family members) deserve quality care, we must work towards it. The first step in that effort is defining and measuring quality indicators.

Let us not forget that many of us will end up in LTC facilities, when quality of care will suddenly become of paramount importance. Enjoy this issue.

Long-Term Care in Quebec: Its Structure and Impact on Older Adults

Long-Term Care in Quebec: Its Structure and Impact on Older Adults

Teaser: 

Gina Bravo, PhD
Head, Department of Community
Health Sciences,
University of Sherbrooke
Researcher, Research Centre,
Sherbrooke University
Geriatric Institute,
Sherbrooke, QC.

Introduction
Over the past 30 years, as in all provinces across Canada, the population has aged rapidly in Quebec. From 1901 to 1971, a span of 70 years, the proportion of people aged 65 and over increased by only 2.1%: from 4.8%-6.9%. By comparison, it will rise by 21% in the next 70 years. In fact, according to recent projections, 28% of the people living in Quebec will be over 65 by the year 2041.1

While a majority of older adults consider themselves to be in good health, a significant proportion suffers from impairments that require long-term care. The Canadian Health and Activity Limitations Survey established the prevalence of physical impairments among people aged 65-74 years old at 31%; it is 55% in those over 75. While most elderly individuals live with family members, partially compensating for their impairment, many live alone or with a spouse who also suffers from impairment.2

A Historical Perspective

Introduction of new services
In response to the increasing health care requirements of an aging society, provincial health authorities developed a broad range of services adapted to the needs of the aged.