Annals of Long Term Care

CLINICAL INVESTIGATIONS
Risk Factors Associated with the Occurrence of Fractures in U.S. Nursing Homes: Resident and Facility Characteristics and Prescription Medications
William Spector, PhD, Thomas Shaffer, MHS, D. E. B. Potter, MS, Rosaly Correa-de-Araujo, MD, M. Rhona Limcangco, PhD

OBJECTIVES: To determine whether resident and facility characteristics and prescription medications influence the occurrence of fractures in nursing homes (NHs).

DESIGN: Panel study with 1-year follow-up.

SETTING: A nationally representative sample of NHs from the Medical Expenditure Panel Survey (MEPS).

PARTICIPANTS: Residents aged 65 and older who were in sample NHs on January 1, 1996.

MEASUREMENTS: Health status measures were collected from facility records and abstracted using a computer-assisted personal interview instrument. Fracture and drug data were updated every 4 months to provide a full year of information. Drug data were obtained from monthly medication administration records. The occurrences of fractures were obtained from medical records. Administered medications were classified using the Department of Veterans Affairs medication classification system. Facility characteristics were based on MEPS survey data collected from NH sources.

RESULTS: In 1996, 6% of residents in a NH at the beginning of the year experienced a fracture during their NH stay(s). Resident risk factors included aged 85 and older, admitted from the community, exhibited agitated behaviors, and used both wheelchair and cane or walker. Use of anticonvulsants, antidepressants, opioid analgesics, iron supplements, bisphosphonates, thiazides, and laxatives were associated with fractures. A high certified nurse aide ratio was negatively associated with fractures.

CONCLUSION: The findings indicate that fractures are associated with resident and facility characteristics and prescribing practices. It reaffirms the importance of medication review with special attention on opioid analgesics, antidepressants, and anticonvulsants to reduce the risk of fractures. J Am Geriatr Soc 2007;55(3):327-333.

Decisions to Forgo Hospitalization in Advanced Dementia: A Nationwide Study
Susan L. Mitchell, MD, MPH, Joan M. Teno, MD, MS, Orna Intrator, PhD, Zhanlian Feng, PhD, and Vincent Mor, PhD

OBJECTIVES: To examine the prevalence and factors associated with decisions to forgo hospitalization in nursing home (NH) residents with advanced dementia.

DESIGN: Cross-sectional study.

SETTING: All Medicare- and Medicaid-certified NHs within the 48 contiguous U.S. states.

PARTICIPANTS: NH residents with advanced dementia were identified using Minimum Data Set (MDS) assessments completed close to April 1, 2000 (N=91,521).

MEASUREMENTS: Multilevel, multivariate logistic regression identified factors independently associated with having a do-not-hospitalize (DNH) directive. Independent variables included subject characteristics (MDS), facility factors (On-line Survey of Certification of Automated Records), and hospital referral region (HRR) features (Dartmouth Atlas).

RESULTS: Nationwide, 7.1% (n=6,518) residents with advanced dementia had DNH orders (range 0.7% in Oklahoma to 25.9% in Rhode Island). Resident characteristics associated with having a DNH order were older age, white, living will, durable power of attorney for health care, and total functional dependence. Controlling for these factors, DNH orders were more likely in residents of facilities with the following features: not part of a chain, urban location, special care dementia unit, fewer black residents, nurse practitioner or physician assistant on staff, higher staffing ratios, and location in HRRs with fewer intensive care unit admissions during terminal hospitalizations.

CONCLUSION: Directives to forgo hospitalization for U.S.