Journal of the American Medical Directors Association

BackgroundUnderstanding the lived experiences of people dying with frailty is essential to develop models of care that are appropriate to meet the needs of this growing population. AimSynthesise qualitative evidence on the experiences of people dying with frailty. DesignSystematic review of qualitative literature and thematic synthesis. PROSPERO registration CRD42019141907. Data sourcesFourteen electronic databases (CINAHL, Cochrane, Embase, EThOS, Google, Medline, NDLTD, NHS Evidence, NICE, Open grey, Psychinfo, SCIE, SCOPUS and Web of Science) searched from inception to May 2024. Studies were included if they reported on the lived experiences of people dying with frailty, and used an explicit measure of frailty for their sample. Quality was appraised using the Saini and Schlonsky checklist. ResultsOf 6,340 unique articles, 19 met inclusion criteria, describing the views of 138 people dying with frailty, 186 relatives /informal carers, and 240 professional caregivers. We identified three themes: Identifying with frailty and dying, Emotional needs, and Support with daily living. There was wide variation in peoples understanding of frailty, and of their proximity to death. Emotional responses to physical symptoms often had a greater impact on lived experiences than the symptoms themselves. People frequently reported a desire to live in the present, with priorities focused more on living than dying. ConclusionApproaches to palliative care for people dying with frailty should address emotional, as well as physical needs, and facilitate maintenance of existing daily routines. Ensuring that care planning accounts for individual understandings of frailty, and prognostic uncertainty may be particularly helpful. What is already known about the topic?O_LIHealth and social care professionals and policy makers recognise the need to improve equity in palliative care provision for people dying with frailty C_LIO_LIA previous systematic review of quantitative literature highlighted the diverse range of physical, psychological and social needs of people dying with frailty C_LI What this paper adds?O_LIThe narratives of people dying with frailty often focus on the emotional impact of physical symptoms, and fears around uncertainty C_LIO_LIPeople do not always recognise or identify with the concept of frailty, and unless actively dying, often express the desire to be supported to live independently for as long as possible C_LIO_LICare providers express the need for holistic care, and voice frustration at service failures, including lack of time and personnel C_LI Implications for practice, theory or policyO_LIServices for people dying with frailty should be configured to be collaborative, flexible, holistic and responsive to changing needs C_LIO_LIClinical training should emphasise the importance of monitoring patient needs, and both understanding and communicating uncertainty and unclear prognoses C_LIO_LIFuture work and funding must now concentrate on developing and evaluating appropriate models of care C_LI

Introduction - Worldwide, nursing home residents have experienced disproportionately high COVID-19 mortality due to the intersection of congregate living, multimorbidity, and advanced age. Among 12 OECD countries, Canada has had the highest proportion of COVID-19 deaths in nursing home residents (78%), raising concerns about a skewed pandemic response that averted much transmission and mortality in community-dwelling residents, but did not adequately protect those in nursing homes. To investigate this, we measured temporal variations in hospitalizations among community and nursing home-dwelling decedents with COVID-19 during the first and second waves of the pandemic. Methods - We conducted a population-based cohort study of residents of Ontario, Canada with COVID-19 who died between March 11, 2020 (first COVID-19 death in Ontario) and October 28, 2020. We examined hospitalization prior to death as a function of 4 factors: community (defined as all non-nursing home residents) vs. nursing home residence, age in years (<70, 70-79, 80-89, [&ge;]90), gender, and month of death (1st wave: March-April [peak], May, June-July 2020 [nadir], 2nd wave: August-October 2020). Results - A total of 3,114 people with confirmed COVID-19 died in Ontario from March to October, 2020 (Table 1), of whom 1,354 (43.5%) were hospitalized prior to death (median: 9 days before death, interquartile range: 4-19). Among nursing home decedents (N=2000), 22.4% were admitted to hospital prior to death, but this varied substantially from a low of 15.5% in March-April (peak of wave 1) to a high of 41.2% in June-July (nadir of wave 1). Among community-dwelling decedents (N=1,114), admission to acute care was higher (81.4%) and remained relatively stable throughout the first and second waves. Similar temporal trends for nursing home versus community decedents were apparent in age-stratified analyses (Figure 1). Women who died were less likely to have been hospitalized compared to men in both community (80% women vs 84% men) and nursing home (21% women vs 24% men) settings. Discussion - Only a minority of Ontario nursing home residents who died of COVID-19 were hospitalized prior to death, and that there were substantial temporal variations, with hospitalizations reaching their lowest point when overall COVID-19 incidence peaked in mid-April, 2020. While many nursing home residents had pre-pandemic advance directives precluding hospitalization, the low admission rate observed in March-April 2020 (15.5%) was inconsistent with both higher admission rates in subsequent months (>30%), and comparatively stable rates among community-dwelling adults. Our findings substantiate reports suggesting that hospitalizations for nursing home residents with COVID-19 were low during the peak of the pandemics first wave in Canada, which may have contributed to the particularly high concentration of COVID-19 mortality in Ontarios nursing homes.

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.

Introduction: End of life decision making poses unique challenges for individuals with dementia and their family caregivers as cognitive decline shifts decision making responsibility to surrogates. Methods: Using 2010 to 2022 Health and Retirement Study (HRS) exit interview data, we compared advance directive completion, decision making needs near death, involvement of others in decision making, and concordance between expressed preferences and care received among decedents with and without dementia. Analyses incorporated HRS exit interview sampling weights, primary sampling units, and strata to account for the complex multistage probability design of HRS and produce nationally representative estimates of U.S. older adult decedents (50 years or older). Weighted descriptive statistics and design adjusted Wald tests were used to compare groups. Results: Among 5,389 decedents, 1,010 (weighted 17.7%) had dementia prior to death. Decedents with dementia were more likely to have completed advance directives than those without dementia (81.3% vs. 69.1%, p<.001). However, they also had significantly higher decision making needs in the final days of life (54.3% vs. 47.2%, p<.001). Children or grandchildren were more frequently involved in care decisions for decedents with dementia (63.9% vs. 45.6%, p<.001). Despite differences in decision making processes, most decedents in both groups expressed preferences for comfort focused care, and preference care concordance exceeded 90% in both groups. Conclusions: Findings suggested that dementia reshaped the structure and intensity of the shared decision making process by increasing surrogate engagement and decisional demands, underscoring the importance of early advance care planning and structured support for family caregivers to sustain goal concordant care.

BackgroundNursing Home (NH) residents are at high risk of serious illness and death from coronavirus disease 2019 (Covid-19), especially with the SARS-CoV-2 variants of concerns (VOC). It is unknown as to whether a history of Covid-19 prior to the vaccine and post-vaccine RBD-IgG levels are predictors of BNT162b2 vaccine effectiveness against VOC-{delta} in nursing home residents. MethodsWe analyzed the data from two NHs that faced a VOC-{delta} outbreak in July-August 2021. These NHs had suffered prior Covid-19 outbreaks in 2020 and 2021. In many of the residents, RBD-IgG levels were measured 6 weeks after the second vaccine dose, i.e. 3 to 5 months before the VOC-{delta} outbreak onset, and again during the outbreak (SARS-CoV-2 IgG II Quant assay, Abbott Diagnostics). We compared residents with vs without prior Covid-19 for (i) VOC-{delta} incidence, (ii) the correlation between post-vaccine RBD-IgG levels and VOC-{delta} incidence, and (iii) the time-related change in RBD-IgG levels. ResultsAmong the 140 analyzed residents (58 to 101 years; 94 females, 46 men, mean age: 84.6 yr {+/-} 9.5 yr), one resident among the 44 with prior Covid-19 before vaccination developed a VOC-{delta} infection during the outbreak (1.3%) vs 55 of the 96 without Covid-19 prior to vaccination (57.3 %)(p<0.0001). The median value for RBD-IgG 6 weeks after the vaccine and during the outbreak was higher in residents with prior Covid-19 (31,553 AU/mL and 22,880 AU/mL) than in those without (1,050 AU/mL and 260 AU/mL)(p<0.0001). In residents without Covid-19 prior to vaccination, post-vaccination RDB-IgG levels did not predict protection against VOC-{delta} infection. ConclusionsIn contrary to residents with prior SARS-CoV-2 infection, those without a history of Covid-19 before two BNT162b2 doses are not protected against VOC-{delta} infection and their RBD-Ig-G levels are low 3 to 5 months after vaccination. This suggests that a booster vaccine dose should be considered in this group of residents for a better protection against VOC-{delta} infection.

AimsThis study aimed to quantify the prevalence of frailty, and investigate the impact of frailty on adverse outcomes, in older patients with cancer in Vietnam. MethodsA prospective, observational study was conducted in adults aged 65 or above with cancer who attended the outpatient clinics of two urban hospitals in Vietnam from September 2023 to May 2024. Frailty was defined by the Carolina Frailty Index (CFI) and participants with a CFI >0.35 were identified as frail. All participants were followed up for 3 months after discharge, recording falls, all-cause hospitalization, and all-cause mortality. ResultsThere were 379 participants (mean age 72.3 years, 48.5% female). The prevalence of frailty was 26.6% (95%CI 22.2% - 31.0%), highest in participants with stomach cancer (35.7%) and lung cancer (33.9%). Participants with advanced stages of cancer had a significantly higher prevalence of frailty: 39.3% in stage 4, 21.7% in stage 3, compared to 18.1% in stage 2 and 13.0% in stage 1. During the follow up, 19.0% of the participants had a fall (44.4% in the frail vs. 9.7% in the non-frail, p<0.001), 33.4% were admitted to hospitals (42.2% in the frail vs. 30.1% in the non-frail, p=0.026). The mortality rate was 1.9% (5.1% in the frail vs. 0.7% in the non-frail, p=0.017). Odds ratios were 7.48 (95%CI 4.24 - 13.40, p<0.001) for falls, 1.71 (95%CI 1.06 - 2.75, p=0.027) for all-cause hospitalization, and 7.10 (95%CI 1.36 - 37.22, p=0.020) for all-cause mortality. ConclusionFrailty was observed in over a quarter of the participants, with the highest prevalence among those with stomach and lung cancer. Frailty significantly increased the odds of falls, hospitalization, and mortality in three months post-discharge. Further research is needed to gain a better understanding of the impact of frailty on adverse outcomes, and the quality of life for older adults with cancer in Vietnam.

Background Falls are a major safety concern in healthcare. In palliative care, patients are particularly vulnerable due to complex symptom burdens and rapid physical decline. However, standard falls risk assessment tools, primarily designed for acute clinical environments, rely on static risk scores and lack efficacy in hospice settings. The Falls Early Warning Score (FEWS) is a observational tool developed to address the specific contributing factors and complex needs of palliative patients. Aims To explore and understand staff views regarding the implementation, utility, and benefits of the FEWS tool to identify people at risk of falling in a specialist palliative care inpatient unit. Methods A mixed-methods study was conducted at a UK hospice. Healthcare professionals with clinical experience using the FEWS chart completed an electronic questionnaire assessing their confidence, practice, and perceived barriers. Questionnaire outcomes informed subsequent face-to-face, semi-structured interviews. Qualitative data were evaluated using reflexive thematic analysis. Results Eleven staff completed the questionnaire, and five participated in interviews. Three major themes were identified: (1) Education, highlighting staff preferences for 1:1 training and the necessity of dedicated user guides; (2) Location and format of the FEWS tool, contrasting the data collection benefits of electronic formats against the bedside accessibility of paper charts; and (3) Recognised benefits of the FEWS tool, including its ability to prompt safe staffing levels, highlight variable patient presentation, and mitigate the emotional and physical impact of falls. Conclusions It is feasible and highly acceptable to integrate bespoke falls risk assessment tools into palliative care. By addressing the unique complexities of hospice patients, customised tools like FEWS can empower staff and support dynamic clinical decision-making. Further research is required to evaluate their clinical efficacy in reducing falls.

ObjectivesDelirium in hospitalised older adults is associated with negative health outcomes. Admission to an alternative care setting may lower the incidence of delirium. The Acute Geriatric Community Hospital (AGCH) was recently opened in the Netherlands and uses a multi-component non-pharmacological intervention strategy to prevent delirium. The objective of this study was to describe the incidence of delirium at the AGCH and compare this incidence to existing rates from literature. If a possible effect on delirium is seen in this comparison this would support conducting a larger prospectively controlled study on delirium in this new care setting. DesignProspective cohort feasibility study; exploratory meta-analysis of proportions. Setting and ParticipantsThe AGCH is an acute geriatric unit in a skilled nursing facility for patients aged >65 years with acute medical conditions. MethodsDelirium assessment using the Confusion Assessment Method (CAM) upon admission and on day one, two and three or until delirium had resolved. Patients charts were reviewed if CAM was missing. In an linear mixed-effects model, the delirium incidence rate in AGCH was compared to pooled delirium incidence rates from six studies found in a high-quality review. Results214 patients from the AGCH (mean age 81.9 years, 47% male, 12% with a history of dementia) were included in the analysis. Delirium developed in 8% (18/214) (95% confidence interval [CI] 5-13%) of patients during AGCH admission compared to 16% (95% CI 12-21%) in hospitals. Admission to the AGCH was associated with a decreased delirium incidence rate compared to the hospital control group (OR[odds ratio]= 0.49, 95% CI 0.24-0.98, p-value=0.044). Conclusions and implicationsThe delirium incidence in the AGCH was low compared to those incidences found in general hospitals in literature. Based on these findings a controlled observational or randomized study measuring delirium in this care setting is recommended.

ImportancePrevious reports have suggested reductions in mortality risk from COVID-19 throughout the first wave of the COVID-19 pandemic. Mortality changes later in the pandemic and pandemic effects on other types of geriatric hospitalizations are less studied. ObjectivesTo describe the changes in hospitalizations and 30-day mortality in Stockholm for patients 70+ receiving inpatient geriatric care for COVID-19 and other causes. DesignObservational study. For patients 70 or older, we present the incidence of 30-day mortality from COVID-19 in the Stockholm region, in relationship to geriatric hospitalizations and 30-day mortality after admission for COVID-19 and other causes. SettingHospitalizations for patients 70+ from geriatric clinics in Stockholm, Sweden hospitalized for COVID-19 or other causes between March 2020 and July 31, 2021, were included. ParticipantsThe total number of geriatric hospitalizations for patients 70+ was 5,320 for COVID-19 and 32,243 for non-COVID-19 causes, corresponding to 4,565 individual COVID-19 patients and 19,308 non-COVID-19 patients. Exposure(s)The date of hospital admission to a geriatric clinic. Main Outcome(s) and Measure(s): 30-day mortality after admission. ResultsIn patients with COVID-19, the 30-day mortality rate was highest at the beginning of the first wave (29% in March-April 2020), decreased as the first wave subsided (7% July-August), increased again in the second wave (17% November-December), but failed to increase as much in the third wave (11-13% March-July 2021). In non-COVID-19 geriatric patients during the same period, the 30-day mortality presented a similar trend, but with a smaller magnitude of variation (5 to 10%). The number of persons 70 or older testing positive for COVID-19 in Stockholm reached two peaks in 2020 (April and December), fell in January 2021 and then increased again in March-April 2021. Conclusions and RelevanceDuring the first and second waves, hospital admissions and 30-day mortality after geriatric hospitalization for COVID-19 increased in periods of high community transmission, although the mortality peak was lower in wave 2 than in wave 1. The mortality for non-COVID geriatric cases was lower and more stable but also showed an increase with the pandemic peaks. KEY POINTSO_ST_ABSQuestionC_ST_ABSMultiple previous reports in different countries and settings have shown higher case fatality ratio or hospitalized case fatality ratio for COVID-19 in the first wave compared to the second wave of the pandemic. However, less is known about how the COVID-19 waves specifically affected the care of geriatric patients, including those with conditions other than COVID. FindingsThe total number of hospitalizations was 5,320 for COVID-19 and 32,243 for non-COVID-cases. In COVID-patients, the 30-day mortality rate was highest at the beginning of the first wave (29% in March-April 2020), reached 17% at the second wave peak (November-December) followed by 11-13% in the third wave (March-July 2021). The mortality in non-COVID geriatric patients showed a similar trend, but of lower magnitude (5-10%). During the incidence peaks, COVID-19 hospitalizations displaced non-COVID geriatric patients. MeaningHospital admissions and 30-day mortality after hospitalizations for COVID-19 increased in periods of high community transmission, albeit with decreasing mortality rates from wave 1 to 3, with a possible vaccination effect in wave 3. Thus, the healthcare system could not compensate for the high community spread of COVID-19 during the pandemic peaks, which also led to displacing care for non-COVID geriatric patients. These results are important for planning healthcare resources in future health emergencies.

ObjectivesIdentify facility factors associated with a larger COVID-19 outbreak among residents in Maryland nursing homes (NHs). DesignObservational Setting and ParticipantsAll Maryland NHs. MethodsResident COVID-19 cases were collected for each Maryland NH from January 1, 2020 through July 1, 2020. Cumulative COVID-19 incidence through July 1, 2020 was collected for each county and Baltimore City. Facility characteristics for each Maryland NH were collected from time periods prior to January 1, 2020. NH outbreaks were defined as larger when total resident COVID-19 cases exceeded 10% of licensed beds. Descriptive and multivariable analyses were conducted to assess the strongest predictors for the primary outcome of larger COVID-19 outbreak. ResultsNHs located in counties with high cumulative incidence of COVID-19 were more likely to have larger outbreaks (OR 4.5, 95% CI 2.3-8.7, p<0.01). NHs with at least 100 beds were more likely to have larger outbreaks, especially among facilities with >140 licensed beds (100-140 beds vs <100 beds: OR 1.9, 95% CI 0.9-4.1, p=0.09; >140 beds vs <100 beds: OR 2.9, 95% CI 1.3-6.1, p<0.01). NHs with more short-stay residents (OR 2.2, 95% CI 1.1-4.8, p=0.04) or fewer Certified Nursing Assistant hours daily (OR 2.6, 95% CI 1.3-5.3, p<0.01) also were more likely to have larger outbreaks. Resident race and gender were not significant predictors of larger outbreaks after adjustment for other factors. ConclusionsLarge NHs with lower staffing levels and many short-stay residents in counties with high COVID-19 incidence were at increased risk for COVID-19 outbreaks. Understanding the characteristics of nursing homes associated with larger outbreaks can help us prepare for the next pandemic. Brief summaryMaryland nursing homes in counties with a high COVID-19 incidence, more licensed beds, a higher proportion of short-stay residents, or lower CNA staffing hours were more likely to have a larger outbreak early in the pandemic.

BackgroundTreatment intensity of end-of-life care is the degree of aggressiveness of medical care aimed at providing life-prolonging medical care to patients with serious life-limiting illnesses. This study aims to assess the demographic and health characteristics associated with older adults with serious life-limiting illnesses who received highly intense end-of-life care. MethodsFor this cross-sectional analysis, we pooled the 2015 to 2019 Medicare claims data of adults 65 years and older who visited at least one of the 29 emergency departments (EDs) enrolled in the Primary Palliative Care for Emergency Medicine. We identified those with serious life-limiting illnesses using a Gagne score of seven or higher. Our outcome measure was treatment intensity, defined using acute care and intensive care unit (ICU) admissions. Acute care admission was measured as a binary variable and ICU admission was measured as a three-point nominal variable. The predictor variables were age, sex, race/ethnicity, and illness severity (Gagne score). To assess the odds of acute care and ICU admissions, we used a generalized estimating equation model and a multinomial regression model, respectively. We performed the same analyses among the population without serious life-limiting illnesses to observe differences in effect sizes of intense treatment. ResultsOf the 301,083 older adults that visited one of the 29 EDs, 13% had serious life-limiting illnesses. Age was associated with 9% and 7% increased odds of acute care (95% CI: 1.04 - 1.14) and ICU (95% CI: 1.02 - 1.12) admissions. We reported significant associations by sex, race/ethnicity, and illness severity (Gagne score). The effect sizes of the observed association between measures of treatment intensity and the demographic and health characteristics were smaller among those with serious life-limiting illnesses compared to those without serious life-limiting illnesses. ConclusionOlder adults with serious life-limiting illnesses who present to the ED experience intense treatment. Identifying demographic and health characteristics associated with treatment intensity may inform the need for serious illness conversations in the ED.

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.

ContextIn the UK, and in other countries, people living with a terminal illness are eligible for financial support to help with the costs of serious illness and to support their dignity and independence. This study investigates the take-up of benefits in the last year of life and identifies sociodemographic, clinical, and geographical factors associated with underclaiming. MethodsRetrospective cohort study using linked mortality, Census and benefits data for all people who died aged 16+ from chronic illnesses in England and Wales between 1 May 2018 and 30 April 2021. Outcome was receipt of non-means tested disability benefits in the last 12 months of life. We describe geographical variation in take up, and association with sociodemographic, clinical and geographical exposures using Poisson models. FindingsOur population included 1,049,493 eligible decedents, with an overall take-up rate of 65.9%. After adjusting for sociodemographic factors, variation in take-up by cause of death was wide: liver disease 44% (95% CI 43-45%), heart failure 52% (51-52%), cancer 62% (61-62%), dementia 75% (74-75%), and neurodegenerative diseases 90% (88-91%). Across Local Authorities, the age-and-sex-standardised take-up varied from 53% to 78%; rates were generally higher in more deprived areas, but not uniformly. ConclusionsIn England and Wales, 1 in 3 people who die from expected causes (120,000 each year) do not receive the benefits for which they are eligible. Our analysis uses novel data linkages and highlights clinical and sociodemographic groups and geographical areas that could be targeted with proactive take-up initiatives.

BackgroundDemand for community-based end-of-life care is rising globally, driven by ageing populations with increasingly complex needs. Community nurses have a central role in providing end-of-life care, yet the proportion of their time spent in supporting people in their final year of life remains unclear. AimsTo investigate how much of community nurses daily work involves caring for people in their last year of life, and the extent to which end-of-life care visits are cancelled, deferred or undertaken to unsatisfactory standards. DesignAnonymous online survey and multimethod analysis. Setting/participantsUnited Kingdom survey of community nurses, circulated via professional networks, social media and snowball sampling, between 28 April and 27 June 2025. ResultsA total of 1,471 nurses responded. Most worked in community and district nursing services (78.6%, 1156/1471) or specialist palliative care services (11.8%, 174/1471). Community and district nurses spent 23.5% (median) of their last shift providing end-of-life care. Over one in ten respondents (11.6% (171/1471) reported deferring at least one end-of-life visit during their last shift. Specialist palliative nurses were twice as likely to defer visits compared to community and district nurses (OR=2.48, 95% CI: 1.63-3.72, p<0.001). Staff shortages, demand exceeding capacity, and other systematic barriers contributed to deferring visits. ConclusionsCommunity nurses play a vital role in end-of-life care, yet some of this important patient care is left undone or deferred. Investment in core and specialist nursing services, with efforts to enable and sustain this workforce, is urgently needed to meet globally growing demand for community-based end-of-life care. What is already known about the topic?O_LIDemand for community end-of-life care is growing in many countries. C_LIO_LICommunity nurses play a key role in end-of-life care, yet the volume and complexity of their daily work supporting people in the last year of life remains poorly understood. C_LI What this paper addsO_LINurses working in community and district nursing services spent a median of 23.5% of their last clinical shift providing end-of-life care. C_LIO_LIHalf (52%) of respondents who provided end-of-life care during their last shift reported delivering one or more aspects of this care below their professional satisfaction, due to workload and capacity issues. C_LIO_LIOver one in ten (11.6%) of nurses reported having deferred or cancelled end-of-life care visits on their last shift, significantly more specialist palliative care nurses (24%) than community and district nurses (10.4%). C_LI Implications for practice, theory or policyO_LIOur findings reveal a notable proportion of deferred and cancelled end-of-life care visits and care not undertaken to nurses professional satisfaction. C_LIO_LISustained, intentional investment in core and specialist nursing services, together with improved system-wide integration, is needed to support this vital workforce. C_LIO_LIFurther research is necessary to understand how community and district nurses and specialist palliative care nurses can most effectively prioritise end-of-life care within finite resources and competing demands. C_LI

Nursing homes (NH) continue to struggle with COVID-19 morbidity and mortality with older adult residents at greater risk of infection due to proximity to other residents, advanced aging-related chronic illnesses, and contact with staff. While many states have prioritized COVID-19 vaccinations among older adults, vaccinations among NH staff vary. The purpose of this study was to quantify the relationship between nursing home staff vaccination uptake and COVID-19 infections among residents. A zero-inflated Poisson regression model was constructed to predict the weekly number of COVID-19 cases among Missouri nursing home residents using data from the Centers for Medicaid and Medicare Services. A total of 1,124 COVID-19 infections were reported among 504 NH residents between January 1, 2021 and August 22, 2021. After adjusting for number of total residents, resident vaccine rate, staff quality rating, and respective county COVID-19 rate, for every percent increase in nursing home staff vaccine rate the risk of COVID-19 infections significantly decreased by 13% (IRR 0.87, 95% CI 0.81, 0.93). This study identified that NH staff, likely due to greater mobility, are important to prioritize in vaccination efforts to protect themselves and residents of their facilities from COVID-19 infections. Further, the CMS staff ratings were significant predictors of infection as well, which highlight the structural challenges that exist within and outside the context of a highly infectious and deadly pandemic. These results also provide insights to optimizing vaccination roll-out to best protect our communities most vulnerable residents.

Dementia is a progressive degenerative disease, typically affecting older adults for which there is currently no cure. Dementia is characterised by progressive impairment to several cognitive functions including memory and orientation, practical abilities and mood changes, all of which can impact personality and social relationships. The theory of social death has been explored for people living with dementia as the ability to maintain social interactions are threatened leading to a loss of social identity and exclusion and withdrawal from the wider community. A relationship-centred care approach has been recommended to improve care for older people in long-term care, aiming to create environments conducive to relationships, considering the needs of the person living with dementia and also the staff and family members involved in their care. The Senses Framework by Nolan was designed to promote relationships, acknowledging the experiences of all parties across six senses: security, continuity, belonging, purpose, fulfilment and significance. Utilising the Senses Framework has the potential to sustain meaningful relationships by fostering a sense of value and empowerment. This Rapid Evidence Summary aims to explore the evidence assessing the benefits of a relationship triad approach (Senses Framework and other relationship-centred care approaches) in long term care settings (including care homes) for people living with dementia. Nine primary studies and one systematic review were identified. The benefits of using a relationship-centred approach were mapped under each of the senses described within the Senses Framework, detailed separately for people living with dementia, relatives and care home staff. For people living with dementia, interventions using touch and music increased the sense of security and belonging reducing neuropsychiatric conditions such as agitation and aggression. Memory boxes were used to support a sense of significance and continuity and significant moments from the past brought pleasure and enabled meaningful conversations. For relatives and staff, improved communication and relationships increased confidence and trust and by working together they found that they could exert more influence and could develop into a powerful force for change.

ImportanceResident crowding in nursing homes is associated with larger SARS-CoV-2 outbreaks. However, this association has not been previously documented for non-SARS-CoV-2 respiratory infections. ObjectiveWe sought to measure the association between nursing home crowding and respiratory infections in Ontario nursing homes prior to the COVID-19 pandemic. Design, Setting, and ParticipantsWe conducted a retrospective cohort study of nursing home residents in Ontario, Canada over a five-year period prior to the COVID-19 pandemic, between September 2014 and August 2019. ExposureUsing administrative data, we estimated the crowding index equal to the mean number of residents per bedroom and bathroom (residents / [0.5*bedrooms+0.5*bathrooms]). OutcomesThe incidence of outbreak-associated infections and mortality per 100 nursing home residents per year. We also examined infection and mortality outcomes for outbreaks due to 7 specific pathogens: coronaviruses (OC43, 229E, NL63, HKU1), influenza A, influenza B, human metapneumovirus, parainfluenza virus, respiratory syncytial virus, rhinovirus/enterovirus. ResultsThere was one or more respiratory outbreak in 93.9% (588/626) nursing homes in Ontario. There were 4,921 outbreaks involving 64,829 cases of respiratory infection, and 1,969 deaths. Outbreaks attributable to a single identified pathogen were principally caused by influenza A (29%), rhinovirus (11.7%), influenza B (8.1%), and respiratory syncytial virus (6.1%). Among homes, 42.7% (251/588) homes had a high crowding index ([&ge;] 2.0). After adjustment, more crowded homes had higher outbreak-associated respiratory infection incidence (aRR 1.89; 95% 1.64-2.18) and mortality incidence (aRR 2.28; 95% 1.84-2.84). More crowded homes had higher adjusted estimates of the incidence of infection and mortality for each of the 7 respiratory pathogens examined. Conclusions and RelevanceResidents of crowded nursing homes experienced more respiratory-outbreak infections and mortality due to influenza and other non-SARS-CoV-2 respiratory pathogens. Decreasing crowding in nursing homes is an important patient safety target beyond the COVID-19 pandemic.

ObjectivesThis study tested the use of the Palliative Prognostic Index (PPI), an established cancer prognostic tool, in a general medicine group within an acute setting for non-selective adult palliative care. The PPI score ranges from 0 to 15, with scores <6 indicating a prognosis of over 6 weeks and scores >6 indicating under 3 weeks. MethodsData from 256 patients seen over three months by the Ashford and St Peters NHS Foundation Trust Palliative Care team were analysed. PPI scores were calculated and correlated with patients date of death (DoD) to evaluate predictive value. ASPH is a medium sized hospital in England with 500 adult beds. ResultsAmong 256 patients, 145 had cancer and 111 had non-malignant disease. Higher PPI scores correlated with more accurate prognostic predictions, with an overall prediction accuracy of 70%. ConclusionsThe study demonstrates the PPI tools value for mixed groups of non-malignant and malignant diseases. The ASPH population is representative of most UK areas, suggesting that the PPI tool can guide timely care decisions in general medical settings.

BackgroundA majority of community-dwelling older people will in the near future be in need of increased health care. By investigating the relationship between gut health, well-being and nutrient intake we aim to recognize areas through which health might be promoted. MethodsA cross-sectional observational study was performed enrolling 229 older adults ([&ge;]65 years). Validated questionnaires were used to assess gut health, nutrient intake and well-being. Results65% of the participant experienced gastrointestinal symptoms. Gastrointestinal symptoms significantly correlated to anxiety, stress and decreased quality of life. Dyspepsia correlated to a lower energy percentage of protein. An intake below the nutritional recommendations was found for protein, fibre, fat (monounsaturated/polyunsaturated), while an intake above the recommendations was found for saturated fats and alcohol DiscussionA majority of the community-dwelling older adults experienced gastrointestinal symptoms and had an imbalanced macronutrient intake. Gut health, diet and well-being all represents important areas for future intervention studies.

BackgroundPre-injury frailty among older trauma patients is a predictor of increased morbidity and mortality. We sought to determine the relationship between frailty status and the care trajectories of older adult patients who underwent frailty screening in the emergency department (ED). MethodsUsing a retrospective cohort design of a single institutional trauma database, we pooled data on trauma patients, 65 years and older, who had frailty screening at ED presentation (N=987). The predictor variable was frailty status, measured as either robust, pre-frail, or frail. The outcome variables were measures of clinical care trajectory: inpatient admission, length of hospital stay, home discharge, and discharge to rehabilitation. We controlled for age, sex, race/ethnicity, body mass index, Charlson Comorbidity Index, injury type and severity, and Glasgow Coma Scale score. We performed multivariable logistic and quantile regressions to measure the influence of frailty on post-trauma care trajectories. ResultsThe mean (SD) age of the study population was 81 (9.0) years and the population was predominantly female (66%) and non-Hispanic White (64%). Compared to older adult trauma patients classified as robust, those categorized as frail had 2.8 (95% CI: 1.75 - 4.40), 0.4 (95% CI: 0.27 - 0.63), and 2.1 (95% CI: 1.38 - 3.27) times the adjusted odds of hospital admission, home discharge, and discharge to rehabilitation, respectively. Those classified as pre-frail (Adjusted MD: 1.0; 95% CI: 0.46 - 1.54) and frail (Adjusted MD: 2.0; 95% CI: 1.35 - 2.65) had longer lengths of hospital stay compared to those classified as robust. ConclusionPre-injury frailty is a predictor of care trajectories for older-adult trauma patients.