Background: Given the potential adverse effects of antipsychotics, high use in nursing homes creates concern. Our study goal was to explore the use of antipsychotics in relation to resident characteristics, and to assess the appropriateness of antipsychotic prescribing in Belgian nursing homes.

Methods: Data were used from a cross-sectional study (Prescribing in Homes for the Elderly; PHEBE) conducted in 76 nursing homes in Belgium. Antipsychotics were classified into typical and atypical, using the anatomical therapeutic and chemical classification. Ten inappropriate antipsychotic prescribing indicators were selected from the updated Beers criteria (2003), Bergen District Nursing Home Study (BEDNURS) indicators, and Screening Tool of Older People's Prescriptions criteria (STOPP).

Results: The residents' mean age was 84.8 years, 78.1% of whom were female. The prevalence of antipsychotic utilization was 32.9%. Antipsychotics were mainly indicated for dementia-related agitation, and psychosis with/without dementia. Higher use of antipsychotics was found for dementia (OR: 3.27; 95% CI: 2.61–4.09), insomnia (OR: 1.38; 95% CI: 1.10–1.73), depression (OR: 1.30; 95% CI: 1.03–1.65), and age <80 years (OR: 1.79; 95% CI: 1.38–2.33). Inappropriate antipsychotic prescribing indicators scoring the highest among users were: long-term use (92.6%), use despite risk of falling (45.6%), combined use with other psychotropics (31.8%), and duplicate use (15.1%). Inappropriate prescribing was associated with depression (OR: 3.41) and insomnia (OR: 2.17).

Conclusion: The indicator-driven analysis of antipsychotic prescribing quality revealed a need for improvement, with the main prescribing problems relating to duration and combination of therapies. Risks/benefits of off-label use need to be evaluated more consciously at the start of therapy, and at periodic re-evaluations.

A self-administered mailed questionnaire was sent to a stratified random sample of medical administrators in Ontario homes for the aged (HFAs) and nursing homes (NHs) in 1991 in order to explore the types and extent of medical-administrative activities undertaken by these physicians, and their perceptions of skills, attitudes and knowledge that were important in carrying out their roles. Three key findings emerged from the survey. First, considerable variation exists in the extent of medical administrative activities undertaken within each of the two facility types and, in some cases, across the two facility types. Second, there were few activities which ≥75 per cent of medical administrators reported undertaking on all occasions and many activities which ≥25 per cent of physicians reported not undertaking on any occasion. Third, in general, medical administrators did not express values congruent with adoption of a broader management role in facility administration, financing, and planning activities. Research and policy implications for the evolving role of medical administrators in NHs and HFAs are discussed.

This review provides an update on current evidence surrounding the epidemiology, treatment and prevention of non-respiratory infections in care homes. It covers urinary tract infection (UTI), methicillin-resistant Staphylococcus aureus (MRSA), decubitus ulcers, scabies, tinea infections and viral and bacterial gastroenteritis. The care home sector provides a unique ecological niche for infections, housing frail older people with multiple co-morbidities and frequent contact with healthcare services in a semi-closed environment. This leads to differences in the diagnosis and management of infections – particularly of outbreaks – when compared with community-dwelling counterparts. It is essential that care home staff play a role in the early recognition, isolation and treatment of infections, but they are often not trained as healthcare professionals – this presents a challenge to systematized response. Effective interface between care homes, public health and infection control services are essential to the delivery of care, yet it is not clear how to structure such links most effectively.

Sleep problems in older adults are common and disturbance in sleep is associated with increased mortality. These problems are more pronounced in the care home population because of institutional factors and a high prevalence of frailty and co-morbidity. This article reviews the randomized controlled trials undertaken to address sleep problems in care homes. These suggest that stand-alone therapies – oral melatonin and light therapy – have no effect on sleep but that combination treatments – physical exercise plus sleep hygiene, physical exercise plus sleep hygiene plus light and melatonin plus light – may have positive effects. These effects are more marked for daytime arousal than nocturnal sleep. Practical considerations for care homes are how to maximize light exposure, incorporate exercise into daily routines and minimize night-time disruption for residents. Trials undertaken so far are compromised by small sample size and inappropriate randomization strategies and further research is therefore required.

Background: Currently there is no standardized procedure for recording direct care time of dementia patients in a nursing home. Recording the direct care time, however, provides an important component of both cost estimates for time-dependent reimbursement of nursing activities and for recording the degree of dependency as an outcome measure for the efficiency of new treatment methods for dementia patients. The purpose of this study is thus to develop and validate the “RUD-FOCA” (Resource Utilization in Dementia – Formal Care), based on the RUD lite, as a standardized tool to measure the direct care time actually required in the nursing home.

Methods: Based on four hypotheses, construct validity was tested within a randomized controlled trial in a sample of 148 residents in six German nursing homes. The RUD-FOCA records the care time in three areas: activities of daily living (ADL), instrumental activities of daily living (IADL) and supervision. For validation, the residents’ capabilities were examined using the Barthel Index, the Nurses’ Observation Scale on Geriatric Patients (NOSGER), the Alzheimer Disease Assessment Scale (ADAS), the Erlangen Test on Activities of Daily Living (E-ADL) and the Mini-mental State Examination (MMSE). The hypotheses assume relationships between the time required for care in the three areas and the limitations involved in these areas. The retest reliability was also determined.

Results: ADL care accounts for two-thirds of total care time in the homes. The hypotheses which refer to total time, ADL and supervision are supported by differentiated correlation profiles. The IADL hypothesis is not supported owing to even, low correlations. The retest reliability was r = 0.76 for the entire care time.

Conclusions: Overall time and the times for ADL care and supervision can be considered valid estimates. The validity is lowest for recording IADL times. Thus, the RUD-FOCA is suitable as an instrument to determine the direct care time in the nursing home. Recording IADL times should be improved by detailed operationalization.

Background: Most studies examining psychotropic medication use on cognition in older persons with dementia include measures of global cognitive function. The present study examined the relationship between different types of psychotropic medication and specific cognitive functions in older people with dementia.

Methods: Two hundred and six institutionalized older adults with dementia (180 women, mean age 85 years) were administered neuropsychological tests. Psychotropic medication use was extracted from their medical status and categorized as: sedatives, antidepressants and antipsychotics.

Results: Analysis of covariance revealed that psychotropic consumers, and particularly those who used antipsychotics, performed worse on neuropsychological tests of executive/attentional functioning than non-consumers. There were no differences between consumers of other classes of psychotropic drugs and non-consumers. The number of psychotropic drugs used was inversely related to executive/attentional functioning.

Conclusions: These findings show that in institutionalized older adults with dementia, specific impairment of cognitive function, i.e. executive/attentional impairments, are associated with antipsychotic medication use. Future longitudinal studies are recommended.

Background: Aggressive behavior (AB) is common in institutional settings. It is an important issue because of its consequences on both the person manifesting such behaviors and their caregivers. Although there are numerous studies assessing non-pharmacologic strategies to manage AB in older adults, no extensive review of the literature is available. This review synthesizes the current knowledge on the effectiveness of non-pharmacological interventions in institutional settings.

Method: Papers describing the assessment of a non-pharmacological intervention to manage AB in which participants were at least 60 years old and living in a long-term care facility were selected mainly by searching various databases.

Results: A total of 41 studies were identified and included in the review. These studies mainly use quasi-experimental designs and include less than 30 participants. Sixty-six percent (27/41) of the studies report either a statistically or behaviorally significant reduction of AB as a result of a non-pharmacological intervention. Staff training programs and environmental modifications appear to be the most effective strategies.

Conclusion: Non-pharmacological interventions seem effective for managing AB. Future studies on the effectiveness of these interventions need to be more rigorous. Development in this field needs to be based on knowledge regarding the determinants of AB in older adults.

Objective: To describe a population-based, multifaceted shared-care intervention for late-life depression in residential care as a new model of geriatric practice, to outline its development and implementation, and to describe the lessons learned during the implementation process. Setting: A large continuing-care retirement community in Sydney, Australia, providing three levels of care (independent living units, assisted-living complexes, and nursing homes). Participants:) The intervention was implemented for the entire non-nursing home population (residents in independent and assisted living: N = 1,466) of the facility and their health care providers. Of the 1,036 residents who were eligible and agreed to be interviewed, 281 (27.1%) were classified as depressed according to the Geriatric Depression Scale. Intervention Description: The intervention included: (a) multidisciplinary collaboration between primary care physicians, facility health care providers, and the local psychogeriatric service; (b) trainning for primary care physicians and other facility health care providers about detecting and managing depression; and (c) depression-related health education/promotion programs for residents. Conclusions: The intervention was widely accepted by residents and their health care providers, and was sustained and enhanced by the facility after the completion of the study. It is possible to implement and sustain a multifaceted shared-care intervention for late-life depression in a residential care facility where local psychogeriatric services are scarce, staff-to-resident ratios are low, and the needs of depressed to residents are substantial.