Journal of the American Medical Directors Association

BackgroundNursing homes have become the epicentre of the coronavirus disease 2019 (COVID-19) pandemic in Canada. Previous research demonstrates that for-profit nursing homes deliver inferior care across a variety of outcome and process measures, raising the question of whether for-profit homes have had worse COVID-19 outcomes than non-profit homes. MethodsWe conducted a retrospective cohort study of all nursing homes in Ontario, Canada from March 29-May 20, 2020 using a COVID-19 outbreak database maintained by the Ontario Ministry of Long-Term Care. We used hierarchical logistic and count-based methods to model the associations between nursing home profit status (for-profit, non-profit or municipal) and nursing home COVID-19 outbreaks, COVID-19 outbreak sizes, and COVID-19 resident deaths. ResultsThe analysis included all 623 Ontario nursing homes, of which 360 (57.7%) were for-profit, 162 (26.0%) were non-profit, and 101 (16.2%) were municipal homes. There were 190 (30.5%) COVID-19 nursing home outbreaks involving 5218 residents (mean of 27.5 {+/-} 41.3 residents per home), resulting in 1452 deaths (mean of 7.6 {+/-} 12.7 residents per home) with an overall case fatality rate of 27.8%. The odds of a COVID-19 outbreak was associated with the incidence of COVID-19 in the health region surrounding a nursing home (adjusted odds ratio [aOR], 1.94; 95% confidence interval [CI] 1.23-3.09) and number of beds (aOR, 1.40; 95% CI 1.20-1.63), but not profit status. For-profit status was associated with both the size of a nursing home outbreak (adjusted risk ratio [aRR], 1.96; 95% CI 1.26-3.05) and the number of resident deaths (aRR, 1.78; 95% CI 1.03-3.07), compared to non-profit homes. These associations were mediated by a higher prevalence of older nursing home design standards in for-profit homes. Interpretation: For-profit status is associated with the size of a COVID-19 nursing home outbreak and the number of resident deaths, but not the likelihood of outbreaks. Differences between for profit and non-profit homes are largely explained by older design standards, which should be a focus of infection control efforts and future policy.

ObjectiveTo evaluate whether home-based extended rehabilitation for older people with frailty after hospitalisation with an acute illness or injury can improve physical health-related quality of life and is cost-effective. Trial designPragmatic, multi-centre, individually randomised controlled parallel group superiority trial with economic evaluation and embedded process evaluation. SettingRecruitment from 15 NHS Trusts in England, with home-based intervention delivery. ParticipantsEligible participants were 65 years or older with mild/moderate/severe frailty (score of 5-7 on Clinical Frailty Scale) admitted to hospital with acute illness/injury, then discharged home directly, or from intermediate care (post-acute care) rehabilitation services. Recruitment took place December 2017 to August 2021, with follow-up to August 2022. InterventionsParticipants were randomly assigned (1.28:1) to the Home-based Older Peoples Exercise (HOPE) programme - a 24-week home-based manualised, progressive exercise intervention as extended rehabilitation, or usual care (control). Participants were not masked to allocation. Main outcome measuresPrimary outcome was physical health-related quality of life, measured using the physical component summary (PCS) of the modified Short Form 36-item health questionnaire (SF36) at 12 months. Secondary outcomes at six and 12 months included physical and mental health-related quality of life, functional independence, death, hospitalisations and care home admissions. Researchers involved in data collection were masked to allocation. ResultsWe randomised 740 participants (410 HOPE, 330 control) across 15 sites. 479 (64.7%) participants completed 12-month follow-up. 188 HOPE participants (45.9%) completed 24 weeks of intervention delivery. Over half of participants completed more than 75% of prescribed exercises. Intention-to-treat analyses showed no evidence that HOPE was superior to control for 12-month PCS score (adjusted mean difference -0.22, 95% CI -1.47 to 1.03; p = 0.73). There was some evidence of a higher rate of all-cause hospitalisations in the control arm (incidence rate ratio 1.12, 95% CI 1.00 to 1.25; p = 0.05), but no differences in other outcomes. The process evaluation found the intervention was largely delivered as intended and proved acceptable to most participants. The economic analysis showed HOPE plus usual care costs of GB{pound}1,401 with 0.024 QALY improvement compared to the control. Incremental cost-effectiveness ratio GB{pound}58,375. LimitationsThe HERO trial was delivered during especially challenging circumstances that included the COVID-19 pandemic. We examined outcomes taking account of this but detected no difference in primary or secondary outcomes, providing reassurance that COVID-19 was unlikely to have influenced trial results. ConclusionsBased on our findings, we do not recommend routine commissioning of extended rehabilitation for older people with frailty after discharge home from hospital or intermediate care, following an acute admission with a medical illness or injury. Trial registrationISRCTN-13927531 (19/04/2017).

BackgroundCOVID-19 pandemic has had a major impact on society, including on residents of nursing homes (NH), who have a higher risk of complications and mortality due their physical and intellectual disabilities. AimTo identify which risk factors associated with developing COVID-19 infection with symptoms in institutionalized older people. MethodsA 1-year longitudinal multicenter study was conducted in 5 NH during the period December 2019 to March 2021. The inclusion criteria used were residents aged 65 years or over, living in the NH permanently, with a diagnostic test for COVID-19 confirmed by reverse transcription polymerase chain reaction and/or serological test. The main variable was symptomatic COVID-19, with at least one of the following symptoms (fever, respiratory difficulties, cough, diarrhea, sudden urinary incontinence and disorientation or delirium). Three assessments were performed: baseline, six and twelve months follow-up. Descriptive and bivariate analysis (calculating relative risk-RR) were performed, considering a 95% confidence level and a statistically significant p <0.05. ResultsOf the total sample of 78 individuals who tested positive for COVID-19, mean age 84.6 years (SD={+/-}7.8), 62 (79.5%) were female; 40 (51.3%) participants presented with COVID-19 symptoms. Living in a private NH (RR=3.6, 95% CI [1.2-11.0], p=0.023) and having suffered a stroke (RR=4.1, 95% CI [1.1-14.7], p=0.033) were positively associated with developing COVID-19 infection with symptoms. ConclusionsHaving suffered a stroke and living permanently in a private health care facility were positively associated with symptomatic COVID-19 in this sample of institutionalized older people.

ObjectiveSystematically review and critically appraise evidence for the association between delirium and falls in community-dwelling adults aged 60 years and above MethodsWe searched EMBASE, MEDLINE, PsycINFO, Cochrane Database of Systematic Reviews, CINAHL and Evidence-Based Medicine Reviews (EBMR) databases in April 2023. Standard methods were used to screen, extract data, assess risk of bias (using Newcastle Ottawa scale), provide a narrative synthesis and where appropriate conduct meta-analysis. ResultsWe included eight studies, with at least 3505 unique participants. Five found limited evidence for an association between delirium and subsequent falls: one adjusted study showed an increase in falls (RR 6.66;95% CI 2.16-20.53) but the evidence was low certainty. Four non-adjusted studies found no clear effect. Three studies (one with two subgroups treated separately) found some evidence for an association between falls and subsequent delirium: meta-analysis of three adjusted studies showed an increase in delirium (pooled OR 2.01; 95%CI 1.52-2.66), one subgroup of non-adjusted data found no clear effect. Number of falls and fallers were reported in the studies. Four studies and one subgroup were at high risk of bias and one study had some concerns. ConclusionsWe found limited evidence for the association between delirium and falls. More methodologically rigorous research is needed to understand the complex relationship, establish how and why this operates bi-directionally and identify potential modifying factors involved. We recommend the use of standardised assessment measures for delirium and falls. Clinicians should be aware of the potential relationship between these common presentations. Key pointsO_LIThis is the first systematic review of the association between delirium and falls in the wider community population. C_LIO_LIThere is relatively limited but consistent evidence on the direction of effect for both delirium preceding falls and falls preceding delirium. C_LIO_LIMore high-quality longitudinal work is needed to explore the nature of this potentially complex and bidirectional relationship. C_LIO_LIHistory of falls and delirium should be considered when assessing patients with incidence/suspected incidence of falls or delirium. C_LI

BackgroundFalls are a major cause of morbidity in older adults. Low-cost wearable devices track potential falls risk factors, but adoption in older adults remains uncertain. MethodsWe conducted a 6-month prospective observational study in community-dwelling adults who self-reported a recent fall or were deemed at increased risk. Participants were given a wrist-worn wearable device (Fitbit, Garmin or Polar), synced with a smartphone application (Smplicare app) to collect additional information by questionnaires, including self-reported falls. We analysed adherence wearing the devices, and studied step count and sleep data in relation to falls. ResultsOf 284 people (74.2{+/-}9.0 years, 68% women) in the study, 266 (94%) provided at least 7 days of data, with 196 (76%) engaged on at least half of study days. Engagement did not differ by self-reported technology confidence. There were 81 (30%) people who reported a fall during follow-up, but only 5 (6%) resulted in hospital attendance. Each additional hour of average sleep was associated with a 24% reduction in falls risk (HR 0.76, 95% CI 0.63 to 0.92), but in multivariable models only carer support (aHR 3.47, 95% CI 1.46 to 8.26) and incontinence (aHR 2.26, 95% CI 1.34 to 3.82) remained independently associated with falls. No changes in step or sleep patterns were noted after falls, but there was high individual heterogeneity. ConclusionWearable adoption, risk factor identification and digital self-reporting of falls is feasible in older adults using low-cost commercial technology. The importance of simple wearable measures like sleep for fall risk were outweighed by markers of frailty. Future research should understand how these granular wearable data could add to proactive falls risk assessment.

BackgroundPharmacogenomic assisted prescribing of medications utilizes individual genetic information to identify drug-gene interactions. We aimed to assess potential pharmacogenomic drug-gene interactions in geriatric emergency department (ED) patients that have sustained a fall. MethodsThis was a prospective study involving 25 older adult ED patients with fall related injury. Data collected included current medications, demographics and mechanism of injury. All patients provided a DNA sample for pharmacogenomic testing, MatchMyMeds (DNA Labs, Boca Raton, FL) which assessed genetic data for 23 enzyme systems and reports on potential drug-gene interactions for 134 medications. Each patients medications were reviewed against their pharmacogenomic report and categorized as Green (go), Yellow (caution) or Red (stop) based on their genetic information and published interactions by the Clinical Pharmacogenetics Implementation Consortium (CPIC), Dutch Pharmacogenetics Working Group (DPWG) and Food and Drug Administration-approved drug label information. The main study outcome was pharmacogenomic drug-gene interactions. ResultsOf the 25 patients enrolled (median age, 81 years, IQR: 76-85), 68% were female. Patients were taking a median of 8 medications (IQR: 5-11). The most common types were antihypertensives, statins, anticoagulants, and anti-platelet medications. Significant drug-gene interactions (Yellow or Red) were identified in 14/25 (56%) patients. Further, 6/25 (24%) had one or more potentially serious (Red) interactions identified. ConclusionsIn geriatric ED patients with a fall-related injury, a majority have a significant pharmacogenomic drug-gene interactions. DNA testing identifies these interactions and can assist with pharmacogenomic-guided medication prescribing which may decrease ADEs and improve clinical outcomes. Key PointsO_LIPolypharmacy is associated with adverse drug events and fall-related injuries. C_LIO_LIPharmacogenomic can identify drug-gene interactions in older ED adults that sustain a fall. C_LIO_LISignificant drug-gene interactions are common in older ED adults that sustain a fall. C_LIO_LIPharmacogenomic-guided medication prescribing which may decrease ADEs and improve clinical outcomes C_LI

In line with population ageing, the number of global deaths is predicted to increase. There have been projections that, within the next 20 years, in England and Wales, care homes may become the most common place of death. In order to respect the autonomy of their residents, it is therefore, vital that care home staff are able to have Advance Care Planning conversations. However, care home staff may lack the knowledge or confidence to have such discussions. Further, a systematic review found a paucity of evidence about whether Advance Care Planning training interventions for care home staff are effective. New, higher quality studies are now available, justifying this review update. We sought to address two questions: 1) What Advance Care Planning education interventions exist for care home staff? and 2) how effective are these interventions? All measurable outcomes of effectiveness (e.g. health system/resource-related, patient/relative-related, staff-related) including both qualitative and quantitative measures of effectiveness were considered. DesignThe review adheres to the Preferred Reporting Items for Systematic Reviews and Meta- Analyses (PRISMA) and is registered on PROSPERO (ID: CRD42022337865). Original research evaluating Advance Care Planning education for care home staff and reporting any measurable outcome of effectiveness was included. We searched Ovid Medline All, Ovid Embase, Cochrane Central Register of Controlled Trials, EBSCO CINAHL, EBSCO ERIC, and Ovid PsycINFO from March 2018 (3 months prior to original review search cut-off) to June 2022, with supplemental journal and website searches. The results were synthesised by narrative synthesis. FindingsThe current review update almost doubled the number of included studies in a relatively short period. This review includes 10 studies (n = 310 care homes), from the UK, Belgium, Norway and Canada. UK studies were mainly related to the Gold Standard Framework for Care Homes. Two studies adopted multi-component education interventions. Outcome measures included resident/family, staff and health service-related concepts. Even after identifying a further 5 papers, there remains insufficient evidence to determine the effectiveness of Advance Care Planning education interventions for care home staff. ConclusionsAdvance Care Planning education interventions are heterogeneous and often complex in their design, flexibility, target populations, and outcomes. There remains insufficient data to determine the effectiveness of Advance Care Planning education interventions for care home staff, with a particularly urgent need to agree on outcome measures of the effectiveness. Future research could consider updating the existing Delphi consensus on outcome measures for evaluating Advance Care Planning, in light of this systematically collected evidence, with a view to agreeing outcomes that are specific to Advance Care Planning education interventions for care home staff.

Importance and ObjectiveCOVID-19 has a high mortality rate amongst nursing home populations (26.4% nationally and 28.3% in New Jersey). Identification of factors influencing mortality in COVID-19 positive nursing home populations may help direct physicians towards appropriate glycemic, blood pressure, weight, kidney function, lipid, thyroid, and hematologic management to reduce COVID-19 mortality. Design, Setting, and ParticipantsRetrospective cross-sectional study of patients in two nursing home facilities (one urban, one suburban) from 3/16/2020 to 7/13/2020 with positive COVID-19 PCR assays. Age, race, sex, lipids, hematologic parameters, body mass index, blood pressure, thyroid function, albumin, blood urea nitrogen, creatinine, and hemoglobin A1c were correlated with COVID-19 mortality by chi-squared analysis. Main Outcome and Results56 patients met the inclusion criteria for the study. Mortality was 14.3% while the New Jersey nursing home average mortality rate was 28.3% as of August 2020. Our patient cohort had a 49.5% reduction in mortality compared to the state average. In our overall cohort, none of the clinical parameters correlated with COVID-19 mortality using chi-squared analysis. In the 56 patient cohort, average clinical and laboratory findings were 74.0 years, 62.5% female, 28.5% uncontrolled hypertension, BMI 25.6, hemoglobin A1c 6.4, TSH 2.4, vitamin B12 568.3, folate 12.4, iron 47.8, total iron binding capacity 271.8, hemoglobin 11.6, albumin 3.5, triglycerides 100.3, total cholesterol 133.5, HDL 40.9, and BUN to Creatinine ratio 22.2:1. Logistic multivariate regression analyses failed to demonstrate clinically significant correlation with COVID-19 mortality. In the urban nursing home, BUN to creatinine ratio exceeding 20:1 was the only factor that showed statistical significance to COVID-19 mortality (p = 0.03). In the suburban nursing home, age over 80 was the only clinical factor demonstrating statistical significance to COVID-19 mortality (p = 0.003). Conclusions and RelevanceIn our COVID-19 positive nursing home patients, no one parameter was clinically significant in the overall 56-patient cohort; however, mortality in our population was 14.3% compared to New Jerseys 28.3%, a 49.5% reduction in mortality. Rigorous control of the aforementioned clinical parameters may have contributed to this reduction in mortality. Further research requires analysis of more nursing home patients to determine whether rigorous control of clinical parameters decreases mortality from COVID-19. Key PointsO_ST_ABSQuestionC_ST_ABSWhat clinical parameters lead to a lower mortality rate in nursing home patients with COVID-19? FindingsIn this cross-sectional analysis of 56 SARS-CoV-2 positive New Jersey nursing home residents from March to July 2020, controlling hemoglobin A1c, blood pressure, hematologic and lipid panels to recommended levels yielded a mortality rate of 14.3%, a 49.5% reduction from the 28.3% mortality rate of COVID-19 in New Jersey nursing homes. MeaningMaintaining rigorous control of clinical parameters in nursing home populations may account for a decreased mortality rate of COVID-19.

Background.COVID-19 infection has limited preventive or therapeutic drug options at this stage. Some of common existing drugs like angiotensin-converting enzyme inhibitors (ACEi), angiotensin II receptor blockers (ARB) and the HMG-CoA reductase inhibitors ( statins) have been hypothesised to impact on disease severity. However, up till now, no studies investigating this association were conducted in the most vulnerable and affected population groups, i.e. older people residing in nursing homes. The purpose of this study has been to explore the association of ACEi/ARB and/or statins with clinical manifestations in COVID-19 infected older people residing in nursing homes. Methods and Findings.We undertook a retrospective multi-centre cohort study in two Belgian nursing homes that experienced similar COVID-19 outbreaks. COVID-19 diagnoses were based on clinical suspicion and/or viral presence using PCR of nasopharyngeal samples. A total of 154 COVID-19 positive subjects was identified. The outcomes were 1) serious COVID-19 defined as a long-stay hospital admission (length of stay [&ge;] 7 days) or death (at hospital or nursing home) within 14 days of disease onset, and 2) asymptomatic, i.e. no disease symptoms in the whole study-period while still being PCR diagnosed. Disease symptoms were defined as any COVID-19-related clinical symptom (e.g. coughing, dyspnoea, sore throat) or sign (low oxygen saturation and fever) for [&ge;] 2 days out of 3 consecutive days. Logistic regression models with Firth corrections were applied on these 154 subjects to analyse the association between ACEi/ARB and/or statin use with the outcomes. Age, sex, functional status, diabetes and hypertension were used as covariates. Sensitivity analyses were conducted to evaluate the robustness of our statistical significant findings. We found a statistically significant association between statin intake and the absence of symptoms during COVID-19 infection (unadjusted OR 2.91; CI 1.27-6.71; p=0.011), which remained statistically significant after adjusting for age, sex, functional status, diabetes mellitus and hypertension. The strength of this association was considerable and clinically important. Although the effects of statin intake on serious clinical outcome (long-stay hospitalisation or death) were in the same beneficial direction, these were not statistically significant (OR 0.75; CI 0.25-1.85; p=0.556). There was also no statistically significant association between ACEi/ARB and asymptomatic status (OR 1.52; CI 0.62-3.50; p=0.339) or serious clinical outcome (OR 0.79; CI 0.26-1.95; p=0.629). Conclusions.Our data indicate that statin intake in old, frail people could be associated with a considerable beneficial effect on COVID-19 related clinical symptoms. The role of statins and any interaction with renin-angiotensin system drugs need to be further explored in larger observational studies as well as randomised clinical trials.

BackgroundAs certain medications increase risk of falls, it is important to review and optimise prescribing in those who have fallen to reduce risk of recurrent falls. ObjectivesTo systematically review evidence on the prevalence and types of potentially inappropriate prescribing (PIP), including falls-risk increasing drug (FRID) use, in fallers. MethodsA systematic search was conducted in July 2024 in MEDLINE, EMBASE, CINAHL, and Google Scholar using keywords for fall events, inappropriate prescribing, and FRIDs. Observational studies (cohort, case-control, cross-sectional, before-after) and randomised trials were included. Studies were eligible where participants had experienced a fall and PIP (including FRID use) was reported. Random-effects meta-analyses were conducted to pool prevalence of inappropriate prescribing and mean number of inappropriate prescriptions across studies, with stratified analysis to assess heterogeneity. ResultsFifty papers reporting 46 studies met the inclusion criteria. All studies assessed FRIDs, and twenty-nine assessed other PIP. The prevalence of PIP at the time of the fall was reported in 43 studies, and the pooled estimate was 68.6% (95%CI 66.1-71.2%). Among 23 studies reporting it, the mean number of inappropriate prescriptions per participant was 2.21 (95%CI 1.98-2.45). The most common FRIDs prescribed were sedatives/hypnotics, opioids, diuretics, and antidepressants. Twenty-one studies assessed changes in PIP prevalence post-fall; nine reported decreasing prevalence, with others noting increases/no change/mixed results. ConclusionInappropriate prescribing is highly prevalent among fallers, with cardiovascular and psychotropic drugs being the most common. This suggests significant scope to optimise medicines use in these patients to potentially reduce falls risk and improve outcomes.

BackgroundMore than one in four older adults experience a fall each year. While exercise programs are effective in reducing fall-related injuries (FRI), participation remains low due to access barriers. The primary aim of this study was to evaluate whether older adults who registered for Nymbl, a self-guided, asynchronous, balance application, experienced fewer FRIs as compared to age-similar individuals who did not register. MethodsThis retrospective cohort study used data from Kaiser Permanente Colorado, linked to Nymbl registration and usage records based on patient name and demographic information between February 2018 and September 2024. The cohort included individuals aged 60 and older with continuous health plan enrollment for 12 months before and after Nymbl registration (or a randomly assigned index date). Logistic regression models estimated the association between Nymbl registration and FRIs during the 12-month follow-up, stratified by history of FRIs. Marginal effects reported the absolute risk difference associated with Nymbl registration. Secondary analyses examined dose-response effects of Nymbl usage and whether the effect of Nymbl was additive to participation in other exercise programs. ResultsWe identified 3,735 individuals who registered for Nymbl and 114,219 age-eligible non-registrants. Among individuals with a prior FRI, Nymbl registration was associated with a 4.24 percentage point reduction in acute FRIs, however no significant effect was estimated for individuals without a baseline FRI. Secondary analysis indicated that at least five sessions were required to achieve a meaningful reduction in FRIs, and effects were limited to those not already participating in other exercise programs. ConclusionFindings from this study suggest that asynchronous, self-guided balance applications may reduce FRIs among older adults with a history of falls who are not otherwise engaged in structured exercise programs. Remotely delivered fall prevention programs may help overcome access barriers and can be used to supplement in-person and guided exercise programs.

BackgroundFear of falling (FoF) is common amongst community-dwelling older adults and is associated with higher falls risk. FoF is common amongst those with gait and balance abnormalities (GABAb), yet the ability of FoF measures to predict GABAb has not been assessed. MethodsData were reviewed from attendees of the North Tyneside Community Falls Prevention Service. The Falls Efficacy Scale International (FES-I) was used to measure falls efficacy, with a score larger than 23.5 indicating a concern for falling. Gait and balance measures were assessed, with cut-offs used to indicate poor and non-poor results for timed up and go (TUG) (>14s), five times sit to stand (FTSS) (>15s) and gait speed (GS) (<1 m/s). Receiver operating characteristic curves were generated for sensitivity and specificity analysis. ResultsFES-I score had good to excellent sensitivity when predicting TUG (87.1%), FTSS (82.9%) and GS results (73.0%) indicative of significant GABAb. Moderate specificity was also observed when predicting GS (62%) and FTSS (62.3%); a low to moderate specificity was observed when predicting TUG (50.0%). ConclusionA FES-I score of 23.5 or more showed high specificity in identifying those with prolonged TUG and FTSS and slower GS, with moderate specificity.

BackgroundCare home residents have complex care and support needs, as demonstrated by their vulnerability during the COVID-19 pandemic. There is a perception that the needs of residents have increased, but evidence is limited. We investigated changes in health and functioning of care home residents over two decades in England and Wales. MethodsWe conducted a repeated cross-sectional analysis over a 24-year period (1992-2016), using data from three longitudinal studies, the Cognitive Function and Ageing Studies (CFAS) I and II and English Longitudinal Study of Ageing (ELSA). To adjust for ageing of respondents over time results are presented for the 75-84 age group. ResultsAnalysis of 2,280 observations from 1,745 care home residents demonstrated increases in severe disability (difficulty in at least two from washing, dressing and toileting). The prevalence of severe disability increased from 63% in 1992 to 87% in 2014 (subsequent fall in 2016 although wide confidence intervals). The prevalence of complex multimorbidity (problems in at least three out of six body systems) increased within studies over time, from 33% to 54% in CFAS I/II between 1992 and 2012, and 26% to 54% in ELSA between 2006 and 2016. ConclusionOver two decades, there has been an increase in disability and the complexity of health problems amongst care home residents in England and Wales. A rise in support needs for residents places increasing demands on care home staff and health professionals. This is an important concern for policymakers when considering the impact of COVID-19 infection in care homes. Key pointsO_LICare home residents have complex care and support needs, which has contributed to their vulnerability during the COVID-19 pandemic. C_LIO_LIDespite a perception that the needs of care home residents have increased over time, the epidemiological evidence is limited. C_LIO_LIThis study demonstrates an increase in the level of disability and the complexity of health problems amongst care home residents in England and Wales over two decades. C_LIO_LIThe rise in support needs for care home residents places increasing demands on care home staff and health professionals, and should be an important consideration for policymakers and service commissioners when considering the impact of current and future waves of COVID-19 infection in this setting. C_LI

Advance care planning is essential for aligning future care with the values and preferences of people living with dementia and their families. Challenges from people with dementias fluctuating mental capacity, gradual decline and healthcare professionals limited advance care planning knowledge and skills remain to enable people with dementia to fully engage with the process; tailored interventions are needed. This rapid review synthesised evidence on advance care planning interventions, communication strategies and health-related outcomes in dementia care. Following Cochranes guidance for rapid reviews, we searched CINAHL, Cochrane Central, PubMed, and Web of Science through May 2025. After duplicate removal, title-abstract and full-text screening were conducted in Covidence with dual independent reviewers. Data extraction and quality assessment, using Joanna Briggs Institute tools, employed a single-reviewer approach with verification by second reviewer. Twenty-five studies from 2015-2025 across 12 countries met inclusion criteria. Included articles were of quantitative designs (n=15), qualitative (n=5) and mixed methods (n=4). Interventions fell into three categories: video as decision aids; web-based tools; and multicomponent programmes combining education, structured discussions, and documentation support for people with dementia, families and healthcare professionals. Primary outcomes consistently showed increased advance care planning uptake. Certain secondary outcomes--carer burden, cost of care, carers sense of competence, hospitalisation rates, quality-adjusted life year, quality of life of people with dementia, rate of burdensome treatments--demonstrated mixed results. Communication strategies identified included embedding relevant theories such as relational autonomy and shared decision-making frameworks for advance care planning process. Study quality ranged from poor (n=8) to high (n=6). Common limitations include small sample sizes, unclear randomisation and allocation processes and limited reflexivity in qualitative research. These findings suggest that contextually tailored advance care planning interventions improve uptake but require standardised outcomes and broader cultural adaptation to comprehensively assess impacts on health outcomes.

BackgroundDementia is associated with frailty leading to increased risks of falls and hospitalisations. Interventions are required to maintain functional ability, strength and balance. DesignMulti-centre parallel group randomised controlled trial, with embedded process evaluation. Procedures were adapted during the COVID-19 pandemic. ParticipantsPeople with mild dementia or mild cognitive impairment (MCI), living at home, and a family member or carer. ObjectivesTo determine the effectiveness of an exercise and functional activity therapy intervention compared to usual care. InterventionA specially-designed dementia-specific rehabilitation programme focussing on strength, balance, physical activity and performance of ADL, which was tailored, progressive, addressed risk and the psychological and learning needs of people with dementia, providing up to 50 therapy sessions over 12 months. The control group received usual care plus a falls risk assessment. Main outcome measureThe primary outcome was the informant-reported Disability Assessment for Dementia (DAD) 12 months after randomisation. Secondary outcomes were: self-reported ADL, cognition, physical activity, quality of life, frailty, balance, functional mobility, fear of falling, mood, carer strain and service use (at 12 months) and falls (between months 4 and 15). Results365 people were randomised, 183 to intervention and 182 to control. Median age of participants was 80 years (range 65-95), median Montreal Cognitive Assessment score 20/30 (range 13-26), 58% were men. Participants received a median of 31 (IQR = 22-40) therapy sessions out of a possible maximum of 50. Participants reported completing a mean 121 minutes/week of PrAISED activity outside of supervised sessions. Primary outcome data were available for 149 (intervention) and 141 (control) participants. There was no difference in DAD scores between groups: adjusted mean difference -1.3/100, 95% Confidence Interval (-5.2 to +2.6); Cohens d effect size -0.06 (-0.26 to +0.15); p=0.5. Upper 95% confidence intervals excluded small to moderate effects on any of the range of secondary outcome measures. Between months 4 and 15 there were 79 falls in the intervention group and 200 falls in the control group, adjusted incidence rate ratio 0.78 (0.5 to 1.3); p= 0.3. ConclusionThe intensive PrAISED programme of exercise and functional activity training did not improve ADLs, physical activity, quality of life, reduce falls or improve any other secondary health status outcomes even though uptake was good. Future research should consider alternative approaches to risk reduction and ability maintenance. Trial registrationISRCTN15320670. FundingNational Institute for Health and Care Research What is already knownO_LIDementia is associated with progressive loss of functional ability, including activities of daily living and mobility, and a high risk of falls C_LIO_LIExercise programmes and rehabilitation therapies may improve ability, or slow the rate of decline, but evidence from trials and systematic reviews is equivocal C_LI What this study tells usO_LIWe developed an intensive dementia-specific exercise and functional activity rehabilitation programme, lasting 12 months, taking account of motivation, learning needs and context, in particular the need to engage carers, and evaluated it in a randomised controlled trial C_LIO_LIThe programme was very well received by participants and therapists, but had no effect on activities of daily living, physical activity, quality of life, falls, cognition or any other health status outcome C_LIO_LIWe are unlikely to be able to change rate of loss of ability in dementia through exercise or functionally orientated rehabilitation therapy. C_LIO_LIWe need different ways of defining wellbeing after a dementia diagnosis. C_LI

BackgroundFalls among older adults are a leading cause of fractures, loss of independence, and need for long-term care. Community salons in Japan promote social participation and health activities among older adults. Hydrogen-rich water is widely used as a health product, but evidence in community settings remains limited. MethodsWe conducted a prospective observational study among 48 community-dwelling older adults attending community salons in Hiroshima City, Japan. Hydrogen-rich water was offered by the salon operators as part of routine activities; the research team did not assign participants to consume it. Participants were categorized at baseline according to their usual hydrogen-rich water consumption at the salons (consumers vs non-consumers) and followed for six months. The primary outcome was the 30-second chair stand test (CS-30). Secondary outcomes included the Timed Up and Go test (TUG), usual gait speed, one-leg stance time, and grip strength. Within-group changes and between-group differences in change scores were compared. ResultsAll 48 participants completed follow-up, and no serious adverse events were reported during the study period. The consumers group showed a greater improvement in CS-30 over six months (baseline 12.96 (SD 3.21) to follow-up 14.52 (SD 3.59); change 1.57 (SD 2.41)) compared with the non-consumers group (12.52 (SD 3.00) to 12.22 (SD 3.54); change -0.30 (SD 1.55)), with a significant between-group difference in change scores (p=0.003). The consumers group also showed a greater increase in usual gait speed (0.91 (SD 0.24) to 0.98 (SD 0.26); change 0.07 (SD 0.08)) than the non-consumers group (0.94 (SD 0.24) to 0.97 (SD 0.22); change 0.03 (SD 0.05); p=0.008). No significant between-group differences were observed for TUG (p=0.57), one-leg stance time (p=0.13), or grip strength (p=0.10). ConclusionIn community-dwelling older adults participating in community salons, routine hydrogen-rich water consumption was associated with improved lower extremity function as measured by CS-30 and gait speed. Because exposure was not randomized, residual confounding cannot be excluded, and causal inference is limited. Larger studies with stronger designs are warranted.

BackgroundMobility loss is common in hospitalized older adults, and resources to prevent mobility loss are finite. Our goal was to develop a rapid, universal screening tool that identifies individuals at risk of losing the ability to walk during hospitalization on the first hospital day. Second, we determined if the model could inform the use of mobility-preserving interventions. MethodsWe included patients admitted to a general medical service, aged [&ge;]65 years, who could walk on admission (Braden Scale Activity subset >=3). Patients were considered to have a new mobility impairment if the activity score was <3 on discharge. We used predictors available on the first hospital day to develop (2017-18) and validate (2019) a prediction model. We determined the association between predicted risk and therapy use in the validation cohort to highlight the models clinical utility. Results5542 patients were included (median age 76yrs, 48% women); 7.6% were discharged unable to walk. The model included six predictors: age, marital status, medication administrations, Glasgow Coma Scale verbal score, serum albumin, and urinary catheter presence. In the validation cohort, the model discriminated well (c-statistic 0.75) and was strongly associated with hospital-acquired mobility loss (lowest decile 1%, highest decile 24%). In the validation cohort, therapy consultation ordering increased linearly with predicted risk; however, observed mobility loss increased exponentially. ConclusionThe Day-1 Mobility Loss model predicts the risk of mobility loss in hospitalized older adults on the first hospital day. Further, it identifies at-risk older adults who may benefit from mobility interventions.

PurposeAdults living in residential-aged-care-homes (RACHs) with oropharyngeal dysphagia may not have timely access to instrumental swallowing assessment due to barriers, including the need to travel off-site for assessment. This study describes the feasibility, utility, and acceptability of mobile Flexible-Endoscopic-Swallowing-Assessment (mFEES) in Australian residential-aged-care-homes (RACHs). MethodResidents with dysphagia living in RACHs were assessed using onsite mFEES. Feasibility, utility, and acceptability were measured at institutional, resident, and implementation levels. ResultHealthcare professionals and medical decision makers reported that mFEES facilitated a better understanding of residents swallowing function/dysphagia management and was beneficial over off-site services. Self-rated discomfort during mFEES was low and most residents presented with no or minimal anxiety about the procedure. Costs of mobile assessments are documented. ConclusionmFEES was a safe, well tolerated, and practical service that offered opportunity to enhance person-centered clinical care in older adults living with dysphagia in RACHs.

Background Older adults' walking has so far been evaluated using standardised assessments of walking capacity within a clinical setting. By taking the evaluation out of the laboratory into the real world, this study provides first evidence of the ability of Digital Mobility Outcomes (DMOs) to detect changes over time and the Minimal Important Difference (MID) in patients after proximal femoral fracture (PFF). This will guide the implementation of DMOs in research and clinical care. Methods For this multicenter prospective cohort study, 381 community-dwelling older adults were included within one year after sustaining a PFF and assessed at two time points, separated by six months. Walking activity and gait DMOs were measured using a single wearable device worn on the lower back for up to seven days. A global impression of change question and three mobility-related outcome measures (Late-Life Function and Disability Instrument; Short Physical Performance Battery; 4m gait speed) were used as anchor variables. To assess each DMOs ability to detect changes, we calculated the standardized mean change as effect size. For estimating MIDs, both distribution-based and anchor-based methods were applied, followed by triangulation by experts if at least three anchor-based estimates were available per DMO, resulting in single-point estimates. Results All three anchor variables demonstrated substantial changes. Overall, 10 out of 24 available DMOs showed large and 7 DMOs moderate positive effects in the expected direction of the respective anchors. Seven DMOs showed no or only small effects. For 12 DMOs, at least three anchor-based estimates were available, enabling MID triangulation. MIDs for walking activity DMOs per day were: a walking duration of 10 minutes, a step count of 1,000 steps, 50 walking bouts (WB), and 15 WBs in WBs over 10 seconds. For gait DMOs, depending on the walking bout length, MIDs for walking speed were between 0.04 m/s and 0.08 m/s, and MIDs for cadence between 4 and 6 steps/minute. Almost all DMOs showed a strong ability to detect improvement in mobility, but rarely in detecting decline. Conclusions For the first time, MIDs are presented for real-world DMOs in PFF patients. These MIDs inform sample size requirements and interpretation of intervention effects for clinical trials, thereby providing guidance and reassurance for clinicians and regulatory bodies.

ObjectivesDetermine individual level risk factors for care home residents testing positive for SARS-CoV-2. Study DesignLongitudinal observational cohort study using individual-level linked data. SettingCare home residents in Wales (United Kingdom) between 1st September 2020 and 1st May 2021. Participants14,786 older care home residents (aged 65+). Our dataset consisted of 2,613,341 individual-level daily observations within 697 care homes. MethodsWe estimated odds ratios (ORs [95% confidence interval]) using multilevel logistic regression models. Our outcome of interest was a positive SARS-CoV-2 polymerase chain reaction (PCR) test. We included time dependent covariates for the estimated community positive test rate of COVID-19, hospital admissions, and vaccination status. Additional covariates were included for age, positive PCR tests prior to the study, sex, frailty (using the hospital frailty risk score), and specialist care home services. ResultsThe multivariable logistic regression model indicated an increase in age (OR 1.01 [1.00,1.01] per year of age), community positive test rate (OR 1.13 [1.12,1.13] per percent increase in positive test rate), hospital inpatients (OR 7.40 [6.54,8.36]), and residents in care homes with non-specialist dementia care (OR 1.42 [1.01,1.99]) had an increased odds of a positive test. Having a positive test prior to the observation period (OR 0.58 [0.49,0.68]) and either one or two doses of a vaccine (0.21 [0.17,0.25] and 0.05 [0.02,0.09] respectively) were associated with a decreased odds of a positive test. ConclusionsOur findings suggest care providers need to stay vigilant despite the vaccination rollout, and extra precautions should be taken when caring for the most vulnerable. Furthermore, minimising potential COVID-19 infection for care home residents admitted to hospital should be prioritised. SUMMARY BOXESO_ST_ABSSection 1: What is already known on this topicC_ST_ABSO_LICare home residents are at a high risk of COVID-19 infection, but existing literature has mainly focussed on excess mortality rather than infection risk. C_LIO_LIIn our study we were able to investigate associations between COVID-19 infections and the community positive test rate of COVID-19, the vaccination status of care home residents, hospital admissions, and frailty. C_LI Section 2: What this study addsO_LIOur study suggests an increased community positive test rate and hospital inpatients had an increased likelihood of a positive SARS-CoV-2 polymerase chain reaction test, whilst one or two doses of vaccination indicated a decreased chance of a positive test. C_LIO_LIOur findings suggest care providers need to stay vigilant despite the vaccination rollout, and extra precautions should be taken when caring for the most vulnerable, especially in a hospital setting. C_LI