Anja Noro

Pain in European long-term care facilities: Cross-national study in Finland, Italy and the Netherlands

&NA; There have been very few and limited cross‐national comparisons concerning pain among residents of long‐term care facilities in Europe. The aim of the present cross‐sectional study has been to document the prevalence of pain, its frequency and severity as well as its correlates in three European countries: Finland (north), Italy (south) and the Netherlands (western central). Patients (aged 65 years or above) were assessed with the Minimum Data Set 2.0 (MDS).The final sample comprised 5761 patients from 64 facilities in Finland, 2295 patients from 8 facilities in the Netherlands and 1959 patients from 31 facilities in Italy. The prevalence of pain – defined as any type of pain – varied between 32% in Italy, 43% in the Netherlands and 57% in Finland. In nearly 50% of cases, pain was present daily; there were no significant differences in pain prevalence between patients with cancer diagnosis and those with non‐cancer diagnosis. Regardless of the different prevalence estimates, pain was moderate‐to‐severe in over 50% of cases in all the countries. In multivariate logistic regression models, clinical correlates of pain were substantially similar across countries: pain was positively correlated with more severe physical disability (ADL impairment), clinical depression and a diagnosis of osteoporosis. Pain was negatively correlated with a diagnosis of dementia and more severe degrees of cognitive deterioration. We conclude that pain is frequently encountered in long‐term care facilities in Europe and that, despite cultural and case‐mix differences, pain speaks one language.

Gender, Living Arrangements, and Social Circumstances as Determinants of Entry Into and Exit From Long-Term Institutional Care at Older Ages: A 6-Year Follow-Up Study of Older Finns

PURPOSE Due to population aging, the need for long-term institutional care is increasing. We study the potentially modifiable sociodemographic factors that affect the rate of entry into and exit from long-term care. DESIGN AND METHODS A 40% sample from the population registration data of Finns aged 65 and older living in private households at the end of 1997 (n = 280,722) was followed for first entry into (n = 35,926) and subsequent exit -- due to death or return to the community -- from long-term institutional care until the end of 2003. RESULTS Being female, old, living alone, and of low socioeconomic status increased the risk for entering long-term care. Exit was affected by the same factors, but the associations were weaker and, with the exception of age, in the opposite direction. Womens higher risk for entry was due to older age and greater likelihood of living alone. The effects of living arrangements and socioeconomic factors on entry were stronger among men and were attenuated after adjustment for each other and for health status. The mean duration of care was 1,064 days among women and 686 among men. IMPLICATIONS Gender, age, living arrangements, and socioeconomic status are major determinants of institutional residence. Women and certain other population groups, e.g., those living alone, are likely to spend a longer time in institutional care because of higher rates of entry and lower rates of exit. These results have implications for the financing of long-term care and for targeting of interventions aimed at delaying it.

Nursing working conditions in relation to restraint practices in long-term care units

Objectives:This study examined the effects of nursing working conditions on the use of physical restraints and antipsychotics as restraints in long-term care units for elderly residents. Design:Cross-sectional data were obtained in Finland in 2002 from long-term care units that used the Resident Assessment Instrument (RAI) system and participated in a survey on working conditions. Setting:A sample of 91 inpatient units in 31 facilities (23 residential homes and 8 health centers). Participants:Data included 2430 resident assessments and 977 nursing staff survey responses. Measurements:We measured unit-level mean scores of physical restraint and antipsychotics use as restraints and resident characteristics (activities of daily living, cognitive impairment, and daily behavioral problems) based on the RAI system as measured by the Minimum Data Set 2.0. Head nurses reported the structural factors (nurse staffing levels and unit size). Nursing working conditions were measured by the Job–Demands and Job–Control Scales in the staff survey questionnaire. Results:Controlling for resident characteristics, nurses’ job demands and control had a combined effect on restraint practices. Job demands strongly increased the risk of physical restraint use in units where nurses reported low job control (odds ratio [OR] = 13.31, 95% confidence interval [CI] 1.55–114.30, P = 0.019), but not among high-control units (OR = 0.23, 95% CI 0.04–1.29, P = 0.090). Although the use of antipsychotics was not related to job demands in units with low control (OR = 1.11, 95% CI 0.26–4.99, P = 0.891), the antipsychotics use in particular decreased when high job demands were coupled with high job control (OR = 0.17, 95% CI 0.03–0.91, P = 0.038). Conclusion:The results suggest that restraint use can be reduced by enhancing working conditions so that the nursing staff has possibilities for skill usage and decision-making.

Vision and hearing impairments and their associations with falling and loss of instrumental activities in daily living in acute hospitalized older persons in five Nordic hospitals

BACKGROUND Many older people believe sensory problems are inevitably, a part of growing old, and avoid assessment and help. Such problems are often also overlooked by health professionals. The aim of this study was to find the prevalence of hearing and vision impairment and their associations with loss of instrumental activities in daily living (IADL) and risk of falling in patients aged 75 years or older, admitted to a medical ward in an acute hospital in each of the five Nordic countries. METHOD The Minimum Data Set for Acute Care was used for data collection in 770 patients. Premorbid data, admission data and history of falls over 3 months were obtained on admission by interview and observation. Hearing impairment was present if the patient required a quiet setting to be able to hear normal speech. Vision impairment was defined as unable to read regular print in a newspaper. RESULTS Bivariate and logistic regression analyses were performed. Forty-eight per cent of the patients had a hearing impairment, 32.3% had vision impairment and 20.1% had both. Hearing impairment was associated with falling but not in the logistic regression model. Hearing and vision impairment were associated with loss of IADL but only combined impairment was independently. CONCLUSION Hearing and vision impairments were frequent among older patients in the medical wards. Falling was associated with hearing loss and IADL loss with hearing, vision and combined impairments. Sensory loss was also associated with fear of falling. It is recommended routinely to screen sensory functions in older patients in a medical setting. Intervention studies are needed to determine whether improvements in hearing and vision can prevent falls and further loss of function in this patient population.

The effects of ownership, staffing level and organisational justice on nurse commitment, involvement, and satisfaction: A questionnaire study

BACKGROUND Elderly care systems have undergone a lot of changes in many European countries, including Finland. Most notably, the number of private for-profit firms has increased. Previous studies suggest that employee well-being and the quality of care might differ according to the ownership type. OBJECTIVE The present study examined whether the ownership type and the staffing level were associated with organisational commitment, job involvement, and job satisfaction. In addition, we examined the potential moderating effect of organisational justice on these associations. DESIGN Cross-sectional questionnaire study. PARTICIPANTS AND SETTING 1047 Finnish female staff members aged 18-69 years working in sheltered housing or nursing homes (units n=179). METHODS The relationships were studied with analyses of covariance (ANCOVA), adjusting for the effects of age and case-mix. RESULTS Organisational commitment and job satisfaction levels were low in for-profit sheltered homes when justice levels were low, but when justice levels were high, for-profit sheltered homes did not differ from other ownership types. Similarly, organisational justice acted as a buffer against low commitment resulting from low staffing levels. Staffing levels were lowest in public sheltered homes and highest in not-for-profit sheltered homes. CONCLUSION The results show that organisational justice can act as a buffer against low organisational commitment that results from low staffing levels and working in for-profit sheltered homes. Increasing justice in regard to the management, outcomes, and procedures in the organisation would thus be important.

Job demands and job strain as risk factors for employee wellbeing in elderly care: an instrumental-variables analysis

BACKGROUND The association between psychosocial work environment and employee wellbeing has repeatedly been shown. However, as environmental evaluations have typically been self-reported, the observed associations may be attributable to reporting bias. METHODS Applying instrumental-variable regression, we used staffing level (the ratio of staff to residents) as an unconfounded instrument for self-reported job demands and job strain to predict various indicators of wellbeing (perceived stress, psychological distress and sleeping problems) among 1525 registered nurses, practical nurses and nursing assistants working in elderly care wards. RESULTS In ordinary regression, higher self-reported job demands and job strain were associated with increased risk of perceived stress, psychological distress and sleeping problems. The effect estimates for the associations of these psychosocial factors with perceived stress and psychological distress were greater, but less precisely estimated, in an instrumental-variables analysis which took into account only the variation in self-reported job demands and job strain that was explained by staffing level. No association between psychosocial factors and sleeping problems was observed with the instrumental-variable analysis. CONCLUSIONS These results support a causal interpretation of high self-reported job demands and job strain being risk factors for employee wellbeing.

Admission profile is predictive of outcome in acute hospital care

Background and aims: The purpose of this study is to describe predictors for discharge and one-year outcomes of acute-care hospital patients, 75 years of age or over, based on admission status information. We carried out a prospective study of a randomly selected patient population, from one urban acute-care hospital in each of the Nordic countries. 763 persons aged 75+ were randomly selected from acute admissions to the participating hospitals. 749 observations at discharge and 655 observations at one year were used in analyses. Methods: Data were collected with the MDS-AC 1.1 instrument within 24 hours of admission, and at day 7 or discharge, whichever came first. Outcome information was collected either by interviewing the patient or from patient records or registers. Discharge and one-year outcome (home, institution, death) were modeled by multinomial logistic regression, with admission status variables as predictors. Results: At discharge, 84% of subjects returned home, 11% went to an institution and 5.6% had died. At one year, 64% were still living at home, 24% had died, and 12% had moved to an institution. For discharge outcome, those having hospital admission due to a new problem or exacerbation of an old one had a higher risk of dying (OR 3.3) than returning home. Moderate to severe cognitive problems predicted death (OR 2.2) and institutionalization (OR 8.6) compared with discharge home. Problems in instrumental activities of daily living predicted death (OR 3.1) and institutionalization (OR 6.0). At one year, those with exacerbationof an old problem (OR 2.1) or with a new or exacerbated existing problem (OR 2.3) had a higher risk of dying than of institutionalization or discharge home. Having some cognitive problems (OR 2.8) or moderate to severe cognitive problems (OR 6.6) predicted institutionalization, but not dying or discharge home. Those with some problems in activities of daily living had a higher risk of both dying (OR 1.7) and of institutional care (OR 2.7). Those with moderate to severe problems in activities of daily living had also a higher risk of institutional care (OR 4.7) compared with those living at home. Conclusions: Evidence predictive of discharge and one-year outcomes in older acute hospital medical care patients seems to be visible from the beginning of the hospital stay. In order to increase the efficient use of health care services and quality of care, systematic standardized and streamlined assessment should be performed during the admission process.

Assessing prevalence of antimicrobial use and infections using the minimal data set in Finnish long-term care facilities

Of all residents (n = 12,784) for whom a minimum data set 2.0 form was completed in long-term care facilities (n = 253) using a Resident Assessment Instrument in April and September 2011 in Finland, 16% received antimicrobials, most commonly methenamine (42%) and trimethoprim (24%). The prevalence of urinary tract infections was 8%, wound infection 2%, and pneumonia 2%. Minimum data set form provides a feasible tool for collecting data on antibiotic use and infections in long-term care facilities.

Recent Visual Decline—A Health Hazard with Consequences for Social Life: A Study of Home Care Clients in 12 Countries

Information about recent visual decline (RVD) and its consequences is limited. The aim was to investigate this in an observational, prospective study. Participants were recipients of community home services, ≥65 years, from Ontario (Canada, n = 101618), Finland (the-RAI-database, STAKES, n = 1103), and 10 other European countries (the-Aged-in-HOmeCarestudy (AdHOC), n = 3793). The instrument RAI-HC version 2.0 was used in all sites. RVD was assessed by the item “Worsening of vision compared to status 90 days ago” and was present in 6–49% in various sites, more common among persons living alone, and in females. In the AdHOC sample, RVD was independently associated with declining social activity and limited outdoors activities due to fear of falling. The combination of stable vision impairment (SVI) and RVD was independently associated with IADL loss. RVD is common and has greater impact than SVI on social life and function. Caregivers should be particularly aware of RVD, its consequences, and help patients to seek assessments, treatment, and rehabilitation.

Use of Antipsychotics in Older Home Care Patients in Finland

ObjectiveTo investigate the use of antipsychotic medications, and factors associated with such use, in elderly patients in home care in Finland.MethodA retrospective study was designed using cross-sectional data gathered between 1 July and 31 December 2004 in Finland. Data were extracted from the Resident Assessment Instrument (RAI) database, based on Minimum Data Set for Home Care (MDS-HC) assessments. Patients aged ≥65 years from five home care units in different parts of Finland (urban and rural) were included, yielding a total of 1106 patient assessments.ResultsThe prevalence of antipsychotic use was 11% among home care patients. Factors independently associated with use of antipsychotics in the logistic regression model were: any psychiatric diagnosis (odds ratio [OR] 6.62, 95% CI 4.19, 10.45), delusions (OR 4.19, 95% CI 2.22, 7.90), parkinsonism (OR 3.08, 95% CI 1.07, 8.87), not at ease interacting with others (OR 1.88, 95% CI 1.06, 3.36) and moderate-to-severe cognitive impairment (OR 1.47, 95% CI 1.06, 2.04). By contrast, patients aged ≥85 years (OR 0.59, 95% CI 0.43, 0.81) were significantly less likely to be taking antipsychotics. Use of atypical antipsychotic medication was associated in the logistic regression model with delusions (OR 4.05, 95% CI 2.01, 8.17), parkinsonism (OR 3.66, 95% CI 1.10, 12.19), any psychiatric diagnosis (OR 3.06, 95% CI 1.66, 5.63), moderate-to-severe cognitive impairment (OR 2.0, 95% CI 1.32, 3.03) and age ≥85 years (OR 0.66, 95% CI 0.44, 0.99). However, use of conventional antipsychotics was associated only with any psychiatric diagnosis (OR 8.88, 95% CI 5.05, 15.61) and age ≥85 years (OR 0.65, 95% CI 0.44, 0.98).ConclusionThe prevalence of antipsychotic medication use in elderly home care patients was higher than that previously reported among elderly people living in the community in Finland and Sweden (3–9%). Several predictive factors such as psychiatric diagnosis, delusions and cognitive impairment were associated with use of antipsychotics whereas there was a negative association between age ≥85 years and use of antipsychotics.