Summary of Articles From the Journal of the American Geriatrics Society: December 2010, Volume 58

Reviewed, prepared, and submitted by Joseph G. Ouslander, MD, Executive Editor, Journal of the American Geriatrics Society Title: Hospice Use and Outcomes in Nursing Home Residents With Advanced Dementia Authors: Kiely DK, Givens JL, Shaffer ML, et al Summary: This prospective cohort study of 323 nursing home (NH) residents with advanced dementia and their healthcare proxies (HCPs) in 22 Boston area NHs sought to identify characteristics associated with hospice referral, and to examine the association between hospice use and the treatment of pain and dyspnea and unmet needs during the last 7 days of life. Data were collected at baseline and quarterly for up to 18 months. HCPs reported unmet needs during the last 7 days of the residents’ lives for communication, information, emotional support, and help with personal care. Twenty-two percent of residents were referred to hospice. After multivariable adjustment, factors associated with hospice referral were nonwhite race, eating problems, HCP's perception that the resident's had less than 6 months to live, and better HCP mental health. Residents in hospice were more likely to receive scheduled opioids for pain and oxygen, morphine, scopolamine, or hyoscyamine for dyspnea. HCPs of residents in hospice reported fewer unmet needs in all domains during the last 7 days of the residents’ life. In the 22 NHs in this study, a minority of NH residents with advanced dementia received hospice care. Hospice recipients were more likely to received scheduled opioids for pain and symptomatic treatment for dyspnea and had fewer unmet needs at the end of life reported by their HCPs. Comment: These data suggest that hospice, or palliative care is underutilized in NH residents with advanced dementia. However, there is an increasing use of hospice in NHs, and there is concern that some of this increase may be inappropriate. Moreover, Medicare payment rules for hospice care for NH residents are complicated, and may result in substantial out-of-pocket costs to the resident and/or family. Thus, the decision about enrolling a NH resident in a hospice program must be individualized, with prognosis, preferences, and financial implications all considered. The opinions expressed are solely those of the reviewer and do not necessarily reflect those of the American Geriatrics Society or the Journal of the American Geriatrics Society. ______________________________________________________________________ Title: A Randomized Controlled Trial of a Multifactorial Falls Prevention Intervention for Older Fallers Presenting to Emergency Departments Authors: Russell MA, Hill KD, Day LM, et al Summary: This randomized controlled trial carried out in 7 emergency departments (ED) in Melbourne, Australia, examined the effect of a referral-based, targeted, multifactorial falls prevention intervention on the occurrence of recurrent falls and injuries in older people after a fall and discharge directly home from the ED. Community-dwelling people aged 60 and older were eligible unless they were unable to follow simple instructions or walk independently. The intervention included targeted referrals to existing community services and health promotion recommendations, based on the falls risk factors found in a baseline assessment. Three hundred sixty-one participants were randomized to the standard care group and 351 to the intervention group. No significant difference was found between the two groups over the 12-month follow-up period in number of fallers (relative risk [RR] =1.11, 95% confidence interval [CI] = 0.95–1.31) or number of participants sustaining an injury from a fall (RR=1.06, 95% CI=0.86–1.29). Comment: While this type of intervention program makes a lot of sense, this well designed study does not support the use of a referral-based targeted multifactorial intervention program to reduce subsequent falls or fall injuries in older people who present to an ED after a fall. It is likely that a more intensive intervention with more rigorous follow-up of adherence to referrals and other recommendations will be needed to reduce falls and related injuries in fallers who present to an ED. The opinions expressed are solely those of the reviewer and do not necessarily reflect those of the American Geriatrics Society or the Journal of the American Geriatrics Society. ______________________________________________________________________ Title: A Randomized Clinical Trial on Preventing Pressure Ulcers With Wheelchair Seat Cushions Authors: Brienza D, Kelsey S, Karg P, et al Summary: This randomized clinical trial sought to determine the efficacy of skin protection wheelchair seat cushions in preventing pressure ulcers in the elderly nursing home (NH) population. Participants were randomly assigned to a skin protection or segmented foam cushion. Residents aged 65 and older of 12 NHs who were using wheelchairs for 6 or more hours per day and had a Braden score of 18 or less and a combined Braden activity and mobility score of 5 or less were eligible to participate. Two hundred thirty-two participants were recruited between June 2004 and May 2008 and followed for 6 months or until pressure ulcer incidence. All participants were provided with a fitted wheelchair and randomized into skin protection (SPC, n = 113) or segmented foam (SFC, n = 119) cushion groups. The SPC group received an air, viscous fluid and foam, or gel and foam cushion. The SFC group received a 7.6-cm crosscut foam cushion. The main outcome was pressure ulcer incidence over 6 months for wounds near the ischial tuberosities (IT ulcers). Secondary analysis was performed on combined IT ulcers and ulcers over the sacrum and coccyx (sacral ulcers). One hundred eighty participants reached a study end point, and 42 were lost to follow-up. Ten did not receive the intervention. There were eight (6.7%) IT ulcers in the SFC group and one (0.9%) in the SPC group (P=.04). There were 21 (17.6%) combined IT and sacral ulcers in the SFC group and 12 (10.6%) in the SPC group (P=.14). Comment: This well-designed trial in a challenging population demonstrates that skin protection cushions used with fitted wheelchairs, when compared to segmented foam cushions, lower pressure ulcer incidence for elderly NH residents. This intervention should be strongly considered to help prevent pressure ulcers among NH residents who spend much of the day in a wheelchair and who are at high risk for the development of this complication. The opinions expressed are solely those of the reviewer and do not necessarily reflect those of the American Geriatrics Society or the Journal of the American Geriatrics Society.