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M.D. Simon1, S.D. Meshkat1, N. Raja1,2


1. Office of Population Health and Accountable Care, UCLA Health System, Los Angeles, California. USA; 2. Division of Medicine, UCLA Health System, Los Angeles, California, USA. Corresponding author: Megan D. Simon, 10960 Wilshire Blvd. Suite 1410, Los Angeles, CA 90024, mdsimon@mednet.ucla.edu

Jour Nursing Home Res 2021;7:17-22
Published online April 30, 2021, http://dx.doi.org/10.14283/jnhrs.2021.4



Objectives: As COVID-19 spread across the United States, and most rapidly in skilled nursing homes, public health departments developed policies to mitigate the spread. Concerns grew over whether this spread linked to nursing home quality. Design: We collected data on nursing home quality, staffing, and COVID-19 cases from the Centers of Medicare and Medicaid Services. Demographic data was sourced from Long Term Care Focus. Settings and Participants: The analysis used cross-sectional data from 1,025 California skilled nursing homes including quality ratings and confirmed COVID-19 cases between May 17, 2020 and August 23, 2020. Methods: The dependent variable was confirmed COVID-19 cases among residents. The primary independent variables were Overall Rating and Health Inspection Rating, while also including nursing home beds, patient race composition, ownership and geographic classification. Results: 5-Star Overall Rating, 5-Star Health Inspection Rating, and a lower count of health inspection deficiencies each predicted a lower likelihood of having a confirmed COVID resident case (p<.05). Conclusions and Implications: Skilled nursing homes with higher quality ratings and fewer health inspection deficiencies were less likely to have a confirmed case of COVID-19 among residents.

Key words: COVID-19, nursing home, healthcare quality.



A Center for Disease Control investigation in early March revealed how quickly SARs-CoV-2 spread in one Washington nursing home in King’s County. After just a few weeks, the nursing home’s index case infected an additional 167 employees, residents and visitors (1). Tracers found that this outbreak spread to eight more facilities and continued spreading across the county and beyond. This King’s County nursing home had the highest possible CMS Star Rating for its region, and its outcome posed the question of how to prepare skilled nursing homes(NH) for the spread of a new, unknown virus.

Links Between CMS Scores and Quality Outcomes

Center for Medicare and Medicaid Services (CMS) Star Ratings come from a step-wise mix of scores on health inspections, quality, and staffing, before weighing the final score relative to performance in the state (2). The overall score is limited first by the health inspection rating, with the scores from the other components added thereafter. NHs with the top 10% of overall scores in each state receive a 5-star rating. High CMS Star Ratings significantly associate with improved quality outcomes including lower rates of emergency department visits, 30-day and 90-day readmissions, and mortality (3-5).
The components of the CMS Star Rating also demonstrate significant effects. Higher health inspection scores associate with a lower risk of 30-day readmissions and mortality (3, 6). Higher quality star ratings associate with a 20% reduction in ED visits (5). A meta-analysis of 150 studies determined that a higher ratio of nursing staff to patients is also linked to fewer health inspection deficiencies, lower readmissions and improved CMS clinical quality metrics (7).

Previous Factors Attributed to the Spread of COVID-19 in Skilled Nursing Homes

Key factors determined to influence the spread of COVID-19 include a difficulty identifying individuals infected with COVID-19 based on signs and symptoms alone, industry trends in nursing home staff working at more than one facility, and location of a facility in a region with high community prevalence of the virus (8, 9).
Metropolitan regions have found that individuals of Black and Latinx race or ethnicity disproportionally make up more confirmed COVID-19 cases and deaths. A project within the San Francisco Mission District discovered that when testing was offered to all residents in the community, individuals identifying as Latinx represented 40% of those tested but 95% of confirmed cases (10). Risk factors listed include inability to shelter in place and maintain income, frontline service work, unemployment, and household income <$50,000 a year. In May, a multi-state analysis revealed that NHs with a lower percentage of white residents, and a greater percentage of Black residents, are significantly more likely to have COVID-19 outbreaks (9).
While some studies found an inconsistent association between Overall CMS Star Rating and COVID-19 cases (8, 9), others found a significant link, including a study in California that analyzed cases reported between May 17th through June 2nd (11, 12). Since then, California Department of Public Health announced a new mandate for proactive facility-wide testing which had the effect of accelerating the identification of one or more cases. By looking at a longer time period, this study seeks to further understand the relationship between COVID-19 resident cases and quality ratings in California NHs. It also aims to determine whether health inspection findings associate with confirmed cases, while adjusting for NH size, ownership status and a higher percentage of white residents compared to California average.



Cross-sectional data was collected for 1,101 skilled nursing homes in California through CMS publicly-reported data and the Shaping Long Term Care in America Project. NHs were then selected for analysis based on availability of data for each of the variables.

Data Collection

COVID-19 case volume was reported by NHs from May 17 to August 23, 2020 to the CDC National Healthcare Safety Network and shared via the CMS Nursing Home COVID-19 Public File (13). Reporting of cases prior to May 17th, 2020 was deemed optional. NHs were categorized by those with one or more reported resident cases or no reported resident cases.
Patient demographic data was collected from the Shaping Long Term Care in America Project, supported by the National Institute on Aging and Brown University (14). Though the dataset’s creation was several years ago, recent studies have used it to demonstrate significant association between skilled nursing home composition of race/ethnicity and presence of confirmed COVID-19 cases (9, 11, 12). NHs were categorized into either above the California average percentage of white residents (59.5%), or not above average.
NH metrics were extracted from the Centers of Disease Control to measure urban-rural classification, and from CMS Nursing Home Compare to measure bed count and ownership status (15). While previous studies found significance with occupancy rate (12), CMS data on NH occupancy showed declines each week reported, potentially confounding more SNFs reporting suspected or confirmed cases. To avoid selecting a confounding variable, we used CMS bed count.
CMS Nursing Home Compare also provided measures of quality, including Overall Star Rating, Staffing Star Rating, and Health Inspection Star Rating. To understand these measures more deeply, we also looked at count of health deficiencies by CMS-defined category, as well as average licensed practice nursing (LPN) hours per resident per day, which uses mandated payroll reporting and total residents at the NH to estimate the average. Since NHs are required to have a minimum of one registered nurse staffed at all hours, LPN staffing is more likely to vary independent of bed count (2). We used the Health Inspection rating as the primary independent variable as it has the greatest potential to impact a NH’s overall rating (2).

Statistical Analyses

We measured significant relationships between the independent variables and confirmed COVID-19 cases using univariate logistic regressions. We then used multivariate logistic regressions to estimate the impact of the independent variables on cases while adjusting for size, ownership, above average white resident percentage and rural classification. Analyses were performed using R v 3.6.3. (R Core Team, 2020)
After analyzing the effect of Overall Star Rating, we looked at the rating components including Health Inspection Star Rating, and Staffing Star Rating. In order to understand the effect of specific deficiencies on cases, we used the three most common categories of Health Inspection deficiencies as defined by CMS: Quality of Life, Resident Rights and Resident Assessment and Care Planning deficiencies.



We analyzed the results of 1,025 skilled nursing homes in California. Table I shows characteristics of NH by COVID-19 confirmed resident case volume and the resulting significance of independent logistic analyses. Each CMS quality or demographic variable showed a significant relationship to COVID-19 cases reported, with the exception of staffed LPN hours per patient per day.

Table 1
Characteristics of Skilled Nursing Homes with COVID-19 Cases (n=1025)

Count(percentage) are presented for overall and health inspection ratings, white resident percentage, ownership, and geographic classification. Mean(standard deviation) are presented for health inspection deficiency categories, beds and LPN staffing hours. P Value measures the significance of independent logistic regressions with the variable and presence of a confirmed COVID-19 case; Sources: CMS Nursing Home COVID-19 Public File, CMS Minimum Data Set, LTC Focus, CDC


To understand the relationship between Health Inspection Ratings and COVID-19 cases, we used a multivariate logistic regression. Table II summarizes the results of the first model which used Health Inspection Rating as the key independent variable. Health Inspection Rating showed a significant association to cases, while adjusting for beds, white resident percentage, ownership, and rural classification. The Odds Ratio of a 5-Star Rated NH having a case reported compared to a 1-Star NH was 0.45, suggesting these nursing homes are 45% less likely to have a confirmed case (95% CI 0.25 – 0.80). For each additional bed, the odds of a confirmed case increased by 1.5% (OR 1.015, 95% CI 1.01 – 1.02). NHs with above average percentage of white residents had a 57% lower likelihood of a confirmed case (OR 0.565, 95% CI 0.42 – 0.75). For-profit ownership associated with a 70% greater likelihood (OR 1.704, 95% CI 1.13 – 2.58). Lastly, nursing homes in rural areas had a 16% lower likelihood of a confirmed case (OR 0.162, 95% CI 0.06 – 0.46). Using these variables, Figure I plots the model’s predicted probability of each indexed nursing home to have a confirmed case. If the facility did have a case during the time period, they are marked in red while those without are marked in green.

Table 2
Regression Results of Health Inspection Rating and COVID-19 Cases among California Skilled Nursing Homes

*p<.001, †p<.01, ‡p<.05; 1025 cases


Individual deficiencies also have a significant relationship with COVID-19 cases. Table III summarizes the results in this second model. Each quality deficiency associated with a 6.7% greater likelihood of a confirmed case (OR 1.067, 95% CI 1.04 – 1.10) and each resident rights deficiency associated with an 8.1% greater likelihood (OR 1.081, 95% CI 1.04 – 1.12). Among the categories, care plan deficiencies had the largest effect size where each additional deficiency increased the likelihood of a confirmed case by 11.3% (OR 1.113, 95% CI 1.07 – 1.16).

Figure 1
Graph of 1,025 Skilled Nursing Homes’ Predicted Probability of a Confirmed Case of COVID-19 Among Residents

This graph plots each of the 1,025 nursing facilities against the model’s prediction of a confirmed case. Facilities are marked with a red “X” if the facility had 0 resident cases during the time period and a green “X” if the facility and 1 or more resident cases.

Table 3
Regression Results of Health Inspection Deficiency Category and COVID-19 Cases among California Skilled Nursing Homes

*p<.001, †p<.01, ‡p<.05; 1025 cases



This study shows a significant association between a number of important skilled nursing home quality metrics and the likelihood of a confirmed COVID-19 case. The association remained after adjusting for influential NH demographics, including bed count, white resident percentage, ownership and rural classification. Figure I plots the model’s success in predicting if a facility has a confirmed case. The model is relatively more accurate when a facility has a very low or very high probability predicted based on these variables.
Fewer quality, residents’ rights or care plan deficiencies each associate with a lower likelihood of COVID-19 cases. These findings may answer current questions about the importance of CMS Health Inspections and also impact future policies and practices to support quality of care. Experts recommend increased oversight and regulation of nursing homes which contrasts with the CMS announcement in June 2020 to reduce frequency of inspections (16, 17). Further research and transparency is needed to understand the effect of these changes on patient care as well as how CMS identifies and categorizes health inspection deficiencies. In September 2020, CMS launched a new website, CareCompare, with less information about nursing home quality (17). Experts called for increased transparency on this website of quality ratings and enforcement of accurate ownership and financial information, which have proven ties to repeat quality issues (17). Our research shows that quality ratings and inspection findings have a meaningful association to the likelihood of an outbreak and are important data to share.
Because CMS Health Inspection Ratings may be weighted by the amount of time to respond to deficiencies and the relative performance of a nursing home compared to others in its state, a direct count of deficiency types may be more indicative of infection risk than ratings themselves (2). This study found significance with the three most common deficiency types. Future analyses should seek to understand the effect of other deficiency types on infection control.
While Staffing Rating demonstrated a significant association with the likelihood of a confirmed case (p<.001), other factors may limit this significance. These include recent changes in minimum staffing waivers and the relative movement of asymptomatic carriers (8). The intersection of quantity of staffing, quality of training and percentage of shared part-time staff with other NHs is of considerable interest for future studies.
Other factors beyond the scope of this study may contribute to the size of the outbreak, including amount of traffic in and out of NHs, air exchange rate and amount of physical space per resident (1, 8, 10).
Additionally, education and supplies for infection prevention continue to be of importance in preventing the spread (1, 9, 15). Patient-level factors, such as socioeconomic status, comorbidities or age, may also impact prevalence and presentation of the virus in NHs. More research is needed to capture and understand the relative effect of these factors in addition to quality ratings.
This study design is limited to NHs in only one state, California. This state was selected in part because of its mandate for weekly facility testing and relative accuracy of mandated reporting. Still, the study is limited by the ability and willingness of NHs to test residents, and the true frequency of such tests. Due to this, the effect size may be underrepresented in this analysis.
This analysis does not suggest a causal link between health deficiencies and COVID-19 outbreak size. It looks to define the significance of quality ratings in relation to COVID-19 cases, which can highlight areas of opportunity for future outbreak management.
Skilled nursing homes with higher quality ratings and fewer health inspection deficiencies were less likely to have a confirmed case of COVID-19 among residents. By working to excel in these measures, while also following current COVID-19 public health guidelines, skilled nursing homes may impact their performance on outbreak management of COVID-19 or other viruses.
Public policies to support ample staffing and adherence to infection prevention may also provide significant benefit. Some experts call for the reinstatement and expansion of a previous requirement for nursing homes to employ a part-time infection preventionist. CMS reduced this requirement in 2019 from infection preventionists employed “part-time” to “sufficient time” (19). Beginning January 1, 2021, California requires a full-time infection preventionist at all skilled nursing homes (20). Further research should evaluate the effect of this intervention and others on type and frequency of health inspection findings, quality of patient care, and overall prevention of the spread of infectious diseases.


Acknowledgements: We would like to thank the public health workers at the California Department of Public Health, Centers for Medicare and Medicaid Services, and LTCFocus for collecting this information and making it available to patients, family members and researchers.

Funding: The authors have declared no funding related to this article.

Conflict of Interest: The authors have declared no conflicts of interest.

Ethical standards: This study used data freely available in the public domain. Therefore, the authors did not seek approval from an ethics body.



1. McMichael TM, Currie DW, Clark S, et al. Epidemiology of Covid-19 in a long-term care facility in King County, Washington. New England Journal of Medicine 2020;382(21):2005-2011.doi:10.1056/NEJMoa2005412 Published Online First: 21 May 2020.
2. Design for Nursing Home Compare Five-Star Quality Rating System: Technical User’s Guide. The Centers of Medicare and Medicaid Services. 2020 Oct. https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/CertificationandComplianc/Downloads/usersguide.pdf(accessed 1 Feb 2021).
3. Pandolfi MM, Wang Y, Spenard A, et al. Associations between nursing home performance and hospital 30-day readmissions for acute myocardial infarction, heart failure and pneumonia at the healthcare community level in the United States. Int J Older People Nurs 2017;12(4), e12154. doi:10.1111/opn.12154
4. Unroe KT, Greiner MA, Colón-Emeric C, et al. Associations between published quality ratings of skilled nursing facilities and outcomes of medicare beneficiaries with heart failure. J Am Med Dir Assoc. 2012;13(2):188.e1-188.e1886. doi:10.1016/j.jamda.2011.04.020 Published Online First: 31 May 2011.
5. Bartley MB, Rahman PA, Storlie CB, et al. Associations of SNF Quality Ratings With 30-Day Rehospitalizations and ED Visits. Ann Longterm Care. 2020;28(1):e11-e17. doi:10.25270/altc.2019.12.00091 Published Online First: 6 Dec 2019.
6. Neuman MD, Wirtalla C, Werner RM. Association Between Skilled Nursing Facility Quality Indicators and Hospital Readmissions. JAMA. 2014;312(15):1542–1551. doi:10.1001/jama.2014.13513. Published Online First 15 Oct 2014.
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9. Testimony of R. Tamara Konetzka, PhD: Caring for Seniors amid the COVID-19 Crisis. Special Committee on Aging, U.S. Senate. 116th Congress, 2nd Session 21st May (2020). https://www.aging.senate.gov/imo/media/doc/SCA_Konetzka_05_21_20.pdf (accessed 1 Feb 2021).
10. Chamie G, Marquez C, Crawford E, et al. SARS-CoV-2 Community Transmission During Shelter-in-Place in San Francisco. medRxiv Published Online First: 17 Jun 2020. doi:10.1101/2020.06.15.20132233v1
11. Li Y, Temkin-Greener H, Shan G, Cai X. COVID-19 Infections and Deaths among Connecticut Nursing Home Residents: Facility Correlates. J Am Geriatr Soc. 2020;10.1111/jgs.16689. Published Online First 18 Jun 2020.
12. He M, Li Y, Fang F. Is There a Link between Nursing Home Reported Quality and COVID-19 Cases? Evidence from California Skilled Nursing Facilities. JAMDA Published Online First: 15 Jun 2020. doi:10.1016/j.jamda.2020.06.016.
13. CMS Nursing Home COVID-19 Public File. Centers for Medicare and Medicaid Services. https://data.cms.gov/provider-data/ (accessed 1 Feb 2021).
14. Brown University School of Public Health. LTCfocus: Long-term Care: Facts on Care in the US. 2018; http://ltcfocus.org/. (accessed 1 Feb 2021).
15. National Center for Health Statistics 2013Urban-Rural Classification Scheme for Counties. Centers for Disease Control and Prevention. 1 June 2017. https://www.cdc.gov/nchs/data_access/urban_rural.htm#Data_Files_and_Documentation (accessed 5 April 2021).
16. Wang X, Ferro E, Zhou G, Hashimoto D, Bhatt D. Association Between Universal Masking in a Health Care System and SARS-CoV-2 Positivity Among Health Care Workers. JAMA Published Online First: 14 Jul 2020. doi:10.1001/jama.2020.12897.
17. Harrington C, Montgomery A, King T, et al. These Administrative Actions Would Improve Nursing Home Ownership and Financial Transparency in the Post COVID-19 Period. Health Affairs. Published Online First: 11 Feb 2021. doi:10.1377/hblog20210208.597573; (accessed 19 Feb 2021) https://www.healthaffairs.org/do/10.1377/hblog20210208.597573/full/
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R.M. Buchanan1,2, K. Ibrahim1,2, H.C. Roberts1,2, B. Stuart3, F. Webley3, Z. Eminton3, D. Ball3, F. Chinnery3, J. Parkes1,2, J. Wyatt1, T. Daniels4


1. Faculty of Medicine, University of Southampton, Southampton, Hampshire, United Kingdom; 2. NIHR Applied Research Collaboration Wessex, University of Southampton, Hampshire, United Kingdom; 3. Southampton Clinical Trials Unit, University of Southampton, Southampton, Hampshire, United Kingdom; 4. Respiratory Department, University Hospital Southampton, Southampton, Hampshire, United Kingdom & University of Southampton Respiratory Biomedical Research Centre, United Kingdom. Corresponding author: Ryan M Buchanan, University of Southampton, Room AC22, C level, South Academic Block, University Hospital Southampton, Tremona Road, Southampton, Hampshire SO16 6YD, ryan.buchanan@soton.ac.uk

Jour Nursing Home Res 2021;7:13-16
Published online April 30, 2021, http://dx.doi.org/10.14283/jnhrs.2021.3



Hypertonic saline nasal irrigation and gargling (HSNIG) has the potential to reduce COVID 19 transmission. We present a pilot cluster randomised controlled trial to assess the feasibility and acceptability of a future trial to test the effectiveness of HSNIG in care homes (CHs). Staff in the intervention CHs were invited to perform HSNIG whereas control CHs carried on with their routine protection procedures. The acceptability of HSNIG was explored via interviews and online surveys. Seven (21%) of contacted CHs participated but following randomisation three (43%) dropped out leaving two intervention CHs and two control CHs. Facilitators to uptake of HSNIG included motivated ‘champions’ and integration into routines. Barriers included a lack of ownership and perceptions of reduced risk from COVID-19. Recruiting and retaining CHs in this study was challenging. Although HSNIG was reported to be safe and acceptable by staff, further work is required to quantify and optimise its acceptability.

Key words: COVID-19, nasal irrigation, gargling, hypertonic saline, care home, Sars-CoV-2; HSNIG.



COVID-19 has a high mortality rate in older people (1). There have been many devastating outbreaks in care homes (CHs) (2). In England there were over 12000 deaths in CHs in the 1st wave of the pandemic and CH associated fatalities accounted for over a third of total deaths in the USA in the same time-frame (3, 4).
It is recognised that COVID-19 is carried in the nasal passages of asymptomatic individuals (5–8). Nasal irrigation with salty water is already used as a simple and cheap treatment for sinusitis and hypertonic saline and has been shown to have anti-microbial (8) and anti-viral properties (9). A trial of regular hypertonic saline nasal irrigation rinse and mouth gargle (HSNIG) for viral upper respiratory tract infections has shown a reduction in transmission of symptoms to close contacts (8). Importantly, this study also recorded a decline in the viral load of corona viruses indicating the potential utility of HSNIG in reducing COVID-19 transmission (10).
The effectiveness of HSNIG by CH staff at preventing COVID-19 in residents has not been investigated. However, before designing an effectiveness trial of HSNIG by CH staff to prevent COVID-19 in residents it is necessary to pilot the study design and the HSNIG intervention. Therefore the aim of this study was to assess the feasibility of recruiting and randomising CHs and the acceptability of HSING by CH staff.



Study design and setting

The study was a pilot cluster-RCT of daily HSNIG for CH staff. Whole CHs were randomised 1:1 to either HSNIG by staff, or usual infection control/hygiene practice. To meet our study objectives we aimed to recruit eight CHs.
All CHs in Hampshire (United Kingdom) were potentially eligible to participate in the study. Exclusion criteria included CHs where HSNIG was already part of hygiene policy or those with ≥50% of agency staff. CH managers were contacted by phone; those who expressed interest were emailed an information sheet and contacted to ask if they wanted to participate. The Southampton Clinical Trials Unit (CTU) randomised CHs to intervention or control immediately after recruitment. The study had ethical approval from a UK National Research Ethics Committee (20/WA/0162). The study protocol was registered online: http://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=379905&isReview=true.


Staff were asked to perform HSNIG at the beginning of each shift and up to twice more mid-shift for 12 weeks. The CH manager was asked to nominate an enthusiastic champion to lead training and implementation. A video produced by the research team was sent to the managers and the nominated champions (see link-https://www.youtube.com/watch?v=__-QSLlGWps) that demonstrated how to perform HSNIG. The HSNIG equipment was a plastic 60ml galley pot, 1.5g of sea salt in two sachets and a plastic stirrer (cost 0.16 GBP). Staff members had to make up the solution themselves and could opt out of performing HSNIG at any time.

Control care homes

All CHs were asked to continue with existing infection control precautions including hand washing and protection equipment as per CH policy. Control CHs were not asked to perform HSNIG or given the training videos.

Data collection and analysis

HSNIG champions were asked about engagement with HSNIG training and the number of staff rinsing during shifts via weekly online surveys. A purposive sample of staff, managers and champions in the intervention CHs (including those which withdrew and continued) were also invited for a telephone interview to explore their views and experiences with the study. Interviews transcripts were anonymised and analysed using thematic analysis with constant comparison (11).



Recruitment and randomisation

Thirty-three CHs were approached and seven agreed to participate (Figure 1). Twenty-six CHs declined to participate in the study: six (23%) declined by ‘head office’ without further explanation, three (12%) declined because of an active outbreak of COVID-19, three (12%) declined because they were ‘too busy’ and one (4%) declined to participate because the idea of HSNIG was unacceptable to staff members.

Seven CHs were randomised. One dropped out immediately after allocation to ‘control’ because the manager found this unacceptable and wanted to use HSNIG. Two of the four CHs in the intervention arm never implemented HSNIG because one was overwhelmed and the other felt the pandemic had passed (Figure 1). Therefore, four CHs completed the study (dropout rate= 43%): two in the control arm and two in the intervention arm.

Acceptabilty of the HSNIG

The online ‘champions’ weekly survey from the two intervention CHs that implemented HSNIG were received for four weeks (weeks 1 to 4) of the intended 12-week study period. The champions reported that the proportion of staff administering HSNIG 2-3 times per shift varied from 40% to 100% during these weeks. We received no survey returns after week 4. However, the qualitative interviews indicated that staff carried on performing the procedure until the end of 12 weeks.
Six telephone interviews were conducted with two managers, two champions and two staff members from three out of the four CHs that were randomised to the intervention. These included two CHs that implemented HSNIG and one that withdrew. Interviews took place 6-12 weeks following randomisation and were on average 20minutes long.

Figure 1
CONSORT diagram showing care home recruitment and retention in the study


Barriers and facilitators for HSNIG implementation in CHs are summarised with direct quotes from participants in Table 1. A number of facilitators to uptake of the HSNIG were reported including enthusiastic champions and motivated staff. Strong leadership and a shared commitment from managers and champions as well as the integration of HSNIG into daily routines also facilitated implementation. Easily accessible information and training materials as well as the simplicity of the intervention were additional facilitators. All interviewees were satisfied with the training materials and found them understandable. Participants reported that group training with champions was preferable as it promoted a shared commitment by staff and that having someone to watch them was reassuring. No staff members reported adverse events from HSNIG and most participants found the intervention easy, quick and non-invasive. Some described finding it easier the more they did it.

Table 1
Quotes from qualitative interviews highlighting important barriers and facilitators for the uptake of hypertonic saline nasal irrigation and gargling by care home staff


A number of barriers were reported including a lack of staff motivation. This was due to staff already feeling that COVID-19 was less a threat, or due to negative test results and feeling they were doing enough to prevent the virus from coming to their home. Perceived lack of proven benefits from the HSNIG and the view that nothing can stop COVID-19 from spreading contributed to staff lack of motivation. Lack of ownership by managers and champions was also a reported barrier that influenced staff motivation to implement HSNIG. Interviewees also mentioned how time constraints and workload during the pandemic and the fact that they had to implement other infection control procedures hindered them from trying the intervention. Some interviewees also reported that HSNIG was an unpleasant experience that made some feel sick and unwilling to carry on with it.



We have shown two important positive findings. Firstly, it is feasible to recruit CHs for a cluster RCT of HSNIG by CH staff and secondly, whilst some staff members can willingly and safely perform HSNIG, its widespread implementation is challenging. Specifically, randomisation to standard care was unacceptable for one CH and retention of CHs in the intervention group proved challenging. Furthermore, we highlight significant difficulties with remote data collection to ascertain the acceptability of HSNIG in CHs during a pandemic.
Other teams have described some of the challenges we have encountered in CH research. Gaining necessary regulatory approvals takes time – particularly for clinical trials (13), recruitment can be problematic (14), and taking consent from participants is challenging (15). Based on our experience in this study we would argue that research in the ‘COVID-era’ with limited access to the CHs by any visitors, including researchers, is a new obstacle.
Limitations of this study affect the reliability of our findings. Our sample of interview participants was small and the majority were from CHs that had successfully implemented HSNIG for a period. This may have led to an overly positive assessment of the HSNIG procedure. Even within these CHs we were reliant on participants contacting us for an interview and it is likely these willing individuals were more engaged with the study.
Despite these limitations, our findings are worthy of consideration when designing a future effectiveness trial. An alternative design such as a stepped-wedge (12) trial should be considered, and whilst managerial support and the use of champions are likely to help, it is likely that researchers need to be physically present in the CH setting to support implementation of HSNIG and collect clinical outcome data collection.
HSNIG has the potential to reduce transmission of COVID-19 to CH residents and other respiratory viruses. However, the acceptability of HSNIG by CH staff needs further investigation and acceptable, reliable and safe approaches to collect quantitative data from CHs during the COVID pandemic need to be considered.


Acknowledgements: The research team are very grateful to the care homes and staff members who participated in the study. We are also grateful to our patient and public involvement representatives who gave up their time to support the design and implementation of the study. The study was sponsored by the University of Southampton. The opinions expressed in this document are those of the authors. The sponsor had no role in the design, methods, data collection, analysis and preparation of this paper.

Funding Source: This research is funded as part of a block grant by the National Institute for Health Research (NIHR) Applied Research Collaboration Wessex. The views expressed are those of the authors and not necessarily those of the NHS, the NIHR, or the Department of Health. RB is supported by the NIHR Academic Clinical Lecturer scheme. KI, HCR and JP receive support from the NIHR Applied Research Collaboration (ARC) Wessex. HCR receives support from the NIHR Southampton Biomedical Research Centre.

Conflict of Interest: All authors declare no conflicts of interest.

Ethical standards: All aspects of the study was approved by the National Health Service for England Research Ethics Committee (Reference number 20/WA/0162) and the University of Southampton ethics committee. Care home workers were invited to conduct the hypertonic saline nasal irrigation and gargling (HSNIG) procedure by care home managers and champions. They were free to opt out at any time. Care home staff who participated in the telephone interviews gave verbal consent. Written consent was not taken to minimise physical contact between researchers and the care home environment – care homes were in ‘lock down’ during the study. A record of the verbal consent procedure was recorded on the trust file on the secure University of Southampton server.



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M. Nagae1, T. Mitsutake2, M. Sakamoto3


1. Department of Agro-Environmental Sciences, Faculty of Agriculture, Graduate School of Kyushu University, Laboratory of Systematic Forest and Forest Products Sciences, Fukuoka, Japan; 2. Department of Physical Therapy, Fukuoka International University of Health and Welfare, Fukuoka, Japan; 3. Division of Medical Education Development, Research & Education Center for Community Medicine, Faculty of Medicine, Saga University, Saga, Japan. Corresponding author: Masumi Nagae,: Department of Agro-Environmental Sciences, Faculty of Agriculture, Graduate School of Kyushu University 744, Motooka, Nishi-ku, Fukuoka 819-0395, Japan, Phone/Fax: +81-92-802-4673, nagae.masumi.258@kyushu-u.ac.jp

Jour Nursing Home Res 2021;7:9-12
Published online February 24, 2021, http://dx.doi.org/10.14283/jnhrs.2021.2



This study aimed to clarify the practices of skincare such as bathing, face-washing, and using of skincare products, among older adults living in nursing homes in Japan. From July to August 2017, questionnaire surveys were mailed to 343 long-term care facilities in one prefecture in Japan, and 105 facilities returned the survey. Management policies on the use of facial skincare products was significantly associated with the number of resident/caregiver ratio. Meanwhile, residents in nursing homes with higher numbers of caregivers washed their faces and bathed at lower rates. There were no correlations between the number of resident/caregiver ratio, face-washing, and bathing times. When older residents could not independently perform their skin cleansing and care, that care is likely to happen less often. Sufficient manpower for the support of older residents’ skincare will improve the quality of life in long-term nursing facilities.

Key words: Activities of daily living (ADL), nursing home, skin cleansing, skincare, quality of life.



Japan is a country with one of the fastest aging populations. In 2017, the older population (65 years old or older) was 3.52 million (1).
Quality of life (QOL) among older populations has become an important outcome measure because it can give a more comprehensive “view of health care in the country and the specific growing population” (2).
Skincare in late adulthood has come to be recognized as one of the cornerstone nursing practices (3). However, given the limited number of studies, it is unclear how skincare has been practiced in public health worldwide. Moreover, it is also unclear how the basic ADLs with regard to skincare for older residents in nursing homes are currently being provided. This study aimed to collect practical data in Japanese nursing homes on the basic ADLs regarding skincare such as bathing, face-washing and the use of skincare products, and deduced the surroundings of those practices.



Study setting and participants

A questionnaire survey was conducted at 343 long-term care facilities that were registered in a prefecture in Japan, from July to August 2017. Once facilities agreed to voluntarily participate in this study and provided their consent, respective administrators answered the questionnaires. We referred to the research protocol from a previous study which had carried out in Germany (4). Meanwhile, we referred to the response rates from another previous study regarding Japanese nursing homes, which reported that those rates of domestic surveys were usually around 30% (5). The study protocol was in keeping with the ethical standards laid down in the Declaration of Helsinki and was approved by the Faculty of Medicine, Saga University Sciences Committee on Ethics (29-26, 2017). All participants provided informed consent before participating in the study.


To gain an overview of the facilities, data regarding the type of facility and the number of employees working in each job type at the facilities were also collected.
The variables of residents’ skin cleansing and care were assessed from questions which were re-formulated based on a previous study (6). We inquired about how often the residents washed their face per day and bathed per week, with or without help. We also asked about the facilities’ policies regarding their use of skin cleansing and application products on residents’ faces and bodies (See appendix for more information).

Statistical analyses

First, types and numbers of facilities in this sample were compared descriptively with those from the prefecture and Japan (7-9). Second, the basic information on nursing homes that were surveyed in this study descriptively. In the present study, 94-96% of facilities provided older residents with cleansing-products of hair and skin on their own responsibility. On the other hand, skincare products were provided according to each facility’s management policy. Therefore, we categorized the facilities based on the use of face-application products. Facilities where residents individually provided their own face-application products or they did not use any product were defined as Individual management; facilities where a face-application product was provided for the residents were defined as Nursing home management. Third, the Mann-Whitney U-test was performed to compare basic characteristics of nursing homes and characteristics of nursing homes’ skincare, by two categories based on the use of face-application products. Finally, Spearman’s rank correlation analysis was performed between number of caregivers, number of resident/caregiver ratio, and each item of characteristics of nursing homes’ skincare to analyse each association. A p-value of less than 0.05 was considered as a statistically significant difference. The analyses were performed using SPSS 25.0 J for Windows (SPSS, Chicago).




Of the 343 long-term care facilities contacted, 105 facilities (31%) agreed to participate in this study and provided informed consent. Table1 shows the number of nursing homes in a prefecture in Japan, and those which took part in the present study, and basic information and characteristics of nursing homes’ skincare in this sample and by two categories based on types of management of face-application products usage.
The proportions of different types of facilities, such as nursing home, special nursing home, long-term care health facility, and medical long-term care facility were as follows: the sample survey 2017 (53.4%, 26.2 %, 13.6%, 6.8 %, respectively), Statistics A Prefecture 2017 (65.3 %, 16.6 %, 12.0%, 6.1%, respectively) (Table 1), and Japanese national statistics from 2017 (50.2%, 29.3%, 16.1%, 4.4%, respectively).

Table 1
Nursing home characteristics

All nursing homes registered on Welfare and Medical Service Agency of a prefecture in Japan, during the research (in 2017); † Each p value is the level of significance of comparison between Individual skincare management versus Nursing home skincare management; ‡ Each value is expressed as n (%) or median (0.25–0.75). P values were determined by Mann–Whitney U test. § Two of 105 facilities did not fit any of these four care home types, and four of 105 facilities did not show either one of two management types.


Analyses between individual-management-type and nursing-home-management-type facilities regarding the use of face-application products and manpower

There was no significant difference between characteristics of nursing homes’ skincare by two categories based on the use of face-application products (Table 1). However, there was a significantly higher older residents/caregiver ratio in individual-management facilities [2.2 (1.8-3.1)] compared to nursing-home-management facilities [1.8 (1.4-2.2)] (p = 0.031).

Relationship between face-washing and bathing frequency and manpower environment in facilities

Table 2 shows the result of correlations between number of caregivers, number of older residents/caregiver ratio, and each item of the characteristics of nursing homes’ skincare. There was a significant negative correlation between number of caregivers and the number of older residents/caregiver ratio (correlation coefficient [R] = -0.319, p = 0.002). Number of caregivers had a significant negative correlation with both residents with need for help (R = -0.283, p =0.005) and without need for help (R = -0.230, p = 0.042) to perform daily face-washing. Similarly, number of caregivers had a significant negative correlation with both residents with need for help (R = -0.461, p < 0.001) and without need for help (R = -0.485, p<0.001) to take their weekly bath.
Contrastingly, there was no significant correlation between number of resident/caregiver ratio and daily face-washing frequency for both residents with need for help (R = 0.003, p = 0.980) and without need for help (R = 0.124, p = 0.294). Similarly, there was no significant correlation between number of resident/caregiver ratio and weekly bath frequency for both residents who needed for help (-0.043, p = 0.685) or those who did not need for help (R = 0.031, p=0.790).

Table 2
Spearman’s rank correlation coefficients between manpower at facilities and face-washing and bathing frequencies

* statistically significant (p<0.05) correlation coefficients.



Residents in facilities bathed and washed their faces fewer times than other people performed those activities at their homes (10). Japan is aging ever faster, and understaffing of welfare work has been a serious problem (11). However, no significant correlation was found between the resident/caregiver ratio and the frequency of face-washing or bathing. Thus, lack of manpower may not be a direct factor related to the limited number of opportunities for face-washing or bathing. In contrast, there was a significant difference of the number of taking care of older residents between two categories based on types of management of face-application products usage.
Since the late 1990s, nursing care in Japan has been developed in terms of individual and unit care, which has created a homelike environment (12). However, the government recommendation for bathing merely states, “at least twice a week using an appropriate method”, and there are no guidelines for the quality of bathing.
Even if facilities observe minimum standard rules, the quality of bathing practices differs from that in regular homes. Most facilities tend to have less frequency of daily face-washing and weekly bath. Their face-washing or bathing policies might have been developed to observe the guidelines on the minimum number of bathing times (13), even if there are enough staff members to support older residents. In contrast, management policy on the use of facial skincare products was significantly associated with the number of the resident/caregiver ratio. Individual-management-type facilities showed a 2.2 resident/caregiver ratio, on the other hand, Nursing-home-management-type facilities showed 1.8 resident/caregiver ratio. This small difference affected residents’ opportunities to use skincare products. Enhancing QOL is an important part of older adults’ healthcare (3), and it has gained more attention in recent years (8). Moreover, policies around older residents’ care have been designed to support personal dignity (14). Additionally, it has reported that maintaining healthy skin was associated with better mental and emotional wellbeing (15). However, if facilities always leave older adults to their own skincare without looking at the personal environment, the policy is not consistent with supporting personal dignity and wellbeing.


This study has a few limitations. First, the present study was conducted at long-term care facilities in only one prefecture in Japan, and the facilities participated voluntarily. We cannot completely remove the possibility of selection bias. Secondly, this study was a cross-sectional survey that focused on the lifestyles of nursing home residents, so these results should be cautiously applied to clinical practice.



Regardless of these limitations, to the best of our knowledge, this was the first study to collect practical data on skin cleansing and care in Japanese nursing homes. As for the support for activities of daily living in long term care, facilities do not only obey guidelines, but also should examine how best to support residents from the viewpoint of personal dignity and the individual care.


Study design: MN, TM, MS; data collection and analysis: MN and manuscript preparation: MN, MS.

Conflict of Interest: The authors have no potential conflicts of interest to disclose.
Funding: This work was supported by JSPS KAKENHI under Grant number JP17K09218.

Ethical standards: The study protocol was approved by the Faculty of Medecine, Saga University Sciences Committee on Ethics (29-26, 2017).



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5. Sawamura K., Nakashima T., Nakanishi M. Provision of individualized care and built environment of nursing homes in Japan. Archives of Gerontology and Geriatrics. 2013; 56 (3)3: 416-424. doi.org/10.1016/j.archger.2012.11.0096. Kottner, J., Lichterfeld, A., & Blume-Peytavi, U. Maintaining skin integrity in the aged: a systematic review. British Journal of Dermatology 2013; 169 (3): 528–542. doi: 10.1111/bjd.12469
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14. Coventry, M. L. Care with dignity: A concept analysis journal of gerontological nursing. Thorofare 2006; 32 (5): 42–48. https://doi.org/10.3928/00989134-20060501-08
15. Blume-Peytavi, U., Kottner, J., Sterry, W. et al. Age-associated skin conditions and diseases: current perspectives and future options. Gerontologist 2016; 56 (2): 230–242. doi: 10.1093/geront/gnw003



C.W. Tew1,2, S.P. Ong2,*, P.L.K. Yap1,2, A.Y.C. Lim2, N. Luo3, G.C.H. Koh3, T.P. Ng2,4, S.L. Wee2,5,6


1. Department of Geriatric Medicine. Khoo Teck Puat Hospital, Singapore; 2. Geriatric Education and Research Institute, Singapore; 3. Saw Swee Hock School of Public Health, National University of Singapore. Singapore; 4. Gerontological Research Programme, Department of Psychological Medicine, Yong Loo Lin School of Medicine, National University of Singapore. Singapore; 5. Health and Social Sciences Cluster, Singapore Institute of Technology, Singapore; 6. Program of Health Services and System Research, Duke-National University of Singapore Graduate Medical School;Singapore. * Joint first authors. Corresponding author: Shiou Liang Wee, PhD, Geriatric Education and Research Institute, 2 Yishun Central 2, Singapore 768024, Tel: 65-68078011. Email: weeshiouliang@gmail.com; Philip Lin Kiat Yap, Department of Geriatric Medicine, Khoo Teck Puat Hospital, 90 Yishun Central, Singapore 768828, Tel: 65-66022154. Email: yap.philip.lk@ktph.com.sg

Jour Nursing Home Res 2021;7:1-8
Published online February 4, 2021, http://dx.doi.org/10.14283/jnhrs.2021.1


Background: Literature emphasises the benefits of person-centred approaches in nursing homes. Objectives: To describe the quality of life, well/ill being and person-centred care of residents, and explore relationship between person-centred care and well/ill being in 7 nursing homes. Design: A cross-sectional study. Setting: Seven nursing homes of different built period and design typologies in Singapore. Participants: 696 nursing home residents. Measurements: Measures used were EQ-5D for quality of life, Dementia Care Mapping for well/ill being, Resident Satisfaction Score and Person-Directed Dementia Care Assessment Tool as measure of person-centred care. Results: Mean EQ-5D-5L index was 0.096 (SD=0.45). Most residents had at least moderate problems in mobility (66.5%), self-care (63.6%) and usual activities (63.0%). Mean well/ill being score was 1.69 (SD=0.98). A state of neutrality (WIB=+1) (48%) was most observed, followed by well-being (WIB>+1) (29%) and ill-being (WIB<+1) (6%). High positive potential behaviors were recorded 37% of the time, while low/no positive potential behaviors amount to 39%. The overall resident satisfaction score was 3.43/5 with borderline satisfaction with environment, food and activities, and low satisfaction with lifestyle and quality of interaction. The overall level of person-centred care was modest 2.3/4. Activities scored highest while the weakest domain was Environment. The overall level of person-centred care was positively correlated with resident well/ill being score (F=4.43, p<0.001). Conclusions: A higher level of person-centred care is associated with better resident well-being. Beyond their physical and custodial needs, the residents’ psychosocial needs can be better fulfilled. The areas of person-centred care amenable to improvement relate to environment, staff knowledge and training. These findings can inform resident care planning, policy development, and future research to support nursing homes in their endeavour to move towards more holistic and person-centric care.

Key words: Quality of life, person-centred care, lived experiences, nursing home, person-directed care.

Abbreviations: NH: nursing home; ADA: Alzheimer’s Disease Association; QoL: quality of life; BCC: behavioural category codes; PCC: person-centred care; WIB: well/ill being; RSS: resident satisfaction survey; ME: mood and engagement; RAF: resident assessment form; PE: personal enhancers; ADL: activities of daily living; PD: personal detractors; DCM: dementia care mapping; PDDCAT: person-directed dementia care assessment tool.



Asia-Pacific population is ageing rapidly. Its population proportion aged 60 years and above is projected to rise from 15% currently to more than 25% (1.3 billion) in 2050 (1). Among the countries, Singapore is one of the most rapidly aging nation, having transitioned from an aging to an aged society in 19 years. By 2050, it is projected that more than 20% of its population will be aged 65 years and above, making it a ‘super-aged’ society (2).
When older people develop functional dependence, family members usually become care providers as the preference is for Asian elders to remain at home (3). However, declining birth rates and employment-related migration meant that this reliance on family members is becoming less viable. Thus, the shift towards formal residential long-term care as a more pragmatic solution. This growing demand was recognised in the well-regarded Singapore Healthcare Master Plan 2020 (4, 5). As a part of its comprehensive plan for its aging population, Singapore aimed to increase the number of nursing homes (NH) in Singapore by two to three annually to provide additional 1000 beds each year, thereby increasing the bed number from 8,800 in 2011 to 17,000 in 2020 (6).
WHO defined healthy aging as a “process of maintaining the functional ability that enables well-being in older age” (7). NHs must provide a supportive care environment to maximise their residents’ well-being even with their physical limitations. This called for a paradigm shift of NH care from the medical and institution-based approach to a person-centric one (8). One which goes beyond assisting the residents with their disabilities to providing continued opportunities for autonomy, connectedness, meaning and joy. This more humanistic approach can close the gap between lower life quality reported in NH residents compared to their home-dwelling counterparts (9).
The quality of life (QoL) among NH residents in Asia has been reported. A study of six NHs in Singapore reported that the residents rated their QoL only modestly and more than 30% voiced dissatisfaction over not having their preference in routines and food respected (10). Qualitative studies of NHs in neighbouring Asian countries echo the residents’ dissatisfaction with the highly institution-centred life, restricted activities, distancing relationships, inability to maintain previous lifestyles and lack individualized care (11, 12).
In keeping with the older people’s wish to receive care in a humanistic and nurturing environment (13), more NHs are striving to better support the personhood of their residents (14). Person-centred care (PCC) can improve the care quality and well-being of NH residents (15). Current literature on the application of PCC in NHs and its association with residents’ well-being in Asia is limited. Funded by grants to design and build sustainable person-centric NHs in Singapore, this study examined resident well-being, satisfaction, and the level of PCC in Singapore NHs. We adopted PCC assessments that can be used objectively by NH staff so that the NHs involved can continue to use these assessments as baseline for care improvement. We also examined the relationship of PCC with resident well-being.



This is a cross-sectional study of residents from seven Singapore NHs. Data was collected between December 2016 and February 2019 from residents and care staff. There were 69 NHs in Singapore in 2016. The seven institutions in this study (Supplementary Table 1) were selected in consultation with the national NH planning agency to be representative of local NHs in terms of resident composition, design typology and year built. These homes offered residential care for individuals requiring assistance in most of their activities of daily living (ADL) or daily nursing procedures.
The residents were selected with proportional stratified random sampling according to their functional status and dementia diagnosis. Following institutional research guidelines, informed consent was obtained from residents with mental capacity to consent to be involved in the study, and from a family member for residents with insufficient capacity. From the sample, an average of 30 residents per NH was randomly selected for Dementia Care Mapping (DCM). Thirty residents with communication ability per NH completed the Resident Satisfaction Survey (RSS). The ability to communicate is defined by being able to give comprehensible responses to the questionnaire. Ethics approval was obtained from National University of Singapore.

Subjects’ characteristics

Subjects’ demographics, dementia diagnosis, and functional status were obtained from medical records. Functional status was assessed by the Resident Assessment Form (RAF) used for all NHs (16). It uses nine indicators, including physical, cognitive, and psychological domains to categorize residents: 1:being ambulant and independent in ADLs; 2:semi-ambulant and semi-independent in ADLs, 3:non-ambulant, wheelchair bound and requiring assistance in ADLs, and 4:bedbound, fully dependent in ADLs or requiring daily nursing care. Categories 3 or 4 is a NH admission criterion. Selected category 2 residents were admitted as their care needs were not met in the community.

Quality of Life

EQ-5D measures health-related QOL (17), with norm values for Singapore (18). The proxy EQ-5D-5L version used had been validated (19). Direct care staff received training by the research team on EQ-5D, knew the residents well and had been in contact with the residents in the seven days prior to rating. Residents’ QOL were rated on a 5-level scale on mobility, self-care, usual activities, pain/discomfort and anxiety/depression. The health states were converted to individual index QOL scores and utility score calculated from Singapore value set (18, 20).

Well/Ill-being (WIB)

DCM is grounded in PCC (21). Developed as a tool for care staff, DCM has been adopted (22) as an objective measure of, and tool to improve well-being and care quality (23). Two certified DCM mappers from the local Alzheimer’s Disease Association tracked five residents per mapper each time. The residents’ actions (Behavioural Category Codes (BCCs)), and Well/Ill Being (WIB) values were recorded at 5-minute intervals. WIB scores were recorded on an 6-point ordinal scale (+5:extremely high level of well-being; +3:moderate level of well-being; +1: no well-being or ill-being observable; -1:modest level of ill-being; -3:moderate level of ill-being; -5:extreme distress). Each resident was observed over two two-hour sessions (am and pm during meal/activity times in communal spaces). BCCs were aggregated into those with high and low potentials for well-being. Based on the BCC, length of time in each BCC and Mood and Engagement (ME) values recorded, the overall WIB score was calculated, denoting the affective state of each subject. The effects of care actions on residents were noted as actions that improve well-being [Personal Enhancers (PEs)] or reduce well-being [Personal Detractors (PDs)]; and were classified into 5 Fundamental Needs (Comfort, Attachment, Occupation, Identity, and Inclusion). Rate of PE/PD is the number of PEs/PDs per person-hour mapped (22).

Resident Satisfaction

Residents graded their satisfaction on 5 domains of care: environment, interaction with people, activities, food, and impact on lifestyle and overall. Each domain is graded based on a set of questions pertaining to care. The levels of satisfaction were reported on a scale of 1-5 (1:strong dissatisfaction; 3:neutral; 5:high satisfaction).

Person-Centred Care

The Person-Directed Dementia Care Assessment Tool (PDDCAT) was developed as a guide for promoting PCC for people with dementia in long-term care settings (24). We adopted PDDCAT as measure and improvement tool for PCC because care staff identifies key strengths and areas for improvement. With re-assessments over time, it facilitates the practice improvement process. Six (staff knowledge and training, problem solving, knowledge and training, environment, care plans and activities) of nine PDDCAT domains with relevance to direct care and can be assessed by NH staff were adopted (186 indicators assessed, Table 4). Each indicator was scored 1-4 (1:item not present; 2:item present but could be improved; 3:item present in a satisfactory way and considered a strength; 4:item is significant strength that can be used to help implement other practices). Each of six domains were independently assessed by two care staff (trained by research team) in each NH. Any disagreement was resolved during review by a research trainer to achieve a consensus rating. The two research trainers were the Alzheimer’s Disease Association DCM mappers who were experienced in using PDDCAT for care improvement.

Statistical analysis

Statistical analysis was performed using Stata, version 14.0 (StataCorp, College Station, TX). Descriptive statistics were computed for sociodemographic and clinical variables. Results were presented as proportion for categorical variables and mean (SD) for continuous variables. Analysis of covariance was used to compare the mean well-being of the residents (WIB) between the 7 NH with respective to PDDCAT score, with adjustment for age, gender, dementia diagnosis, communication ability and RAF category.



Study sample comprised 696 residents from 7 NH (Table 1), and resembled Singapore population of Chinese majority. Most (94.0%) subjects were at least wheelchair-bound and required assistance in most ADLs. Most (91.5%) could communicate and 32.5% had dementia diagnosis.

Table 1
Demographics of residents


Quality of Life (QoL)

Mean EQ-5D-5L index was 0.096 (SD=0.45). Based on the Singapore value set, the EQ-5D-5L utility score can range from −0.77 to 1.0 (1=perfect health, 0=death, and less than 0=health state worse than death). About two-thirds had at least moderate problems in mobility (66.5%), self-care (63.6%) and usual activities (63.0%) (Table 2). Less than one-third had at least moderate problems in the psychological dimensions of pain/discomfort (25.0%) and anxiety/depression (30.1%).

Well/Ill Being (WIB)

207 residents were mapped over 718.25 hours (8619×5-minutes). Their socio-demographics, functional status and dementia diagnoses were comparable to the main group (Table 2).

Table 2
Numbers and proportions reporting levels within EQ-5D dimensions

Table 3 shows the DCM profile. Mean WIB score of the whole group was 1.69/5 (SD=0.98), just above the +1 level (no signs of well- or ill-being), with score +1 in 48% of the observations. This implied that the residents were in a state of neutrality (no overt well- or ill-being) most of the time. A score more than +1 (well-being) was recorded 29%, while a score less than -1 (ill-being) was recorded 6% of the time.

Table 3
Profile of Dementia Care Mapping (DCM)

Top 3 behavioral codes were sleeping (18%), passively engaged (17%) and leisure activities (13%) (Table 3). Other than leisure activities, relatively little time were spent in other activities high potential to improve well-being, e.g. articulation (8%), exercise (2%), vocational activities (1%), and religion (0%). Overall, behaviors with a high potential for well-being were observed 37%, while those with little/no potential for well-being 39% of the time.
Supplementary Table 2 shows the PEs and PDs identified in DCM. The rates of PEs and PDs were 0.0021 and 0.0014, respectively. While care enhancers (warmth, acknowledgement, facilitation) were observed, overall PEs rate was only modestly higher than PDs. The top five detractors (objectification, ignoring, imposition, withholding and infantilization) compromised 4 of the 5 Fundamental Needs. Occupation was most undermined (86 incidences), mostly by objectification (treated with debasing attitude) and imposition of care without consent. Inclusion was next most compromised (46 incidences), mostly by staff ignoring residents (39 incidences).

Resident Satisfaction

Approximately two-thirds of residents reported being satisfied with care while 60% agreed with statement “I feel happy” (Supplementary Figure 1). The mean overall satisfaction was 3.43/5 (SD=0.83). Residents reported moderate satisfaction in environment (3.25, SD=0.54), food (3.23, SD=0.68) and activities (3.17, SD=0.11). They reported least satisfaction with impact on lifestyle (2.65, SD=0.73) and quality of interaction (2.97, SD=0.63). The 6 questions with the lowest scores (more than 50% reported dissatisfaction) were: 1) time in outdoor spaces, 2) interaction with community, 3) ability to maintain same home routine, 4) awareness of happenings outside NH, 5) staff informing residents about what is happening and 6) staff asking residents for their preferences (Supplementary Figure 1).

Figure 1
Box plot of WIB with PDDCAT for each nursing home

ANOVA, F = 4.43, p<0.001.


PCC measured by PDDCAT

The mean score of the six PCC domains was 2.31/4 (SD=0.36). Table 4 shows domain scores and component indicators. Environment had the lowest score (2.10/4, SD=0.38). Lack of visual cues and personalisation of space were especially deficient. Next lowest was Staff Knowledge and Training (2.24/4, SD=0.45).This was followed by Care Plans (2.33/4, SD=0.51), Language and Communications (2.36/4, SD=0.45), and Problem-Solving Processes for Behavioural Communications (2.47/4, SD=0.31). Even the best performing domain, Activities (2.71/4 SD=0.23) fell short of the score of 3 (signifies strength). Only Activity Engagement Process (a sub-domain of Activities), scored 3.15/4, SD=0.51, meaning while all the key components of PCC were present, only Activity Engagement Process could be considered a strength.

Table 4
Domains and indicators of Person-Directed Dementia Care Assessment Tool (PDDCAT)


WIB scores were significantly different between 7 NH (Figure 1) and were correlated with the level of PCC. NH with higher level of PCC (by overall mean PDDCAT scores) had higher well-being (WIB) (Spearman coefficient correlation r=0.955, p<0.001). After controlling for age, gender, dementia diagnosis, communication ability and RAF category, the differences between NH remained significant (F=4.43, p<0.001).



We examined QoL, well-being, satisfaction, and person-centred care in NH residents. We used both residents’ self-reporting and objective observer ratings. Significant findings emerged which may form a baseline for continuous practice improvement and policy initiatives to improve NH residents’ well-being in Singapore.
Residents’ custodial needs were met in the NHs. Mean DCM WIB score (1.69/5) suggested most residents were relatively comfortable albeit uninvolved. Majority (77%) of WIB Mood and Engagement states recorded were of neutrality / relative well-being, with a state of mild ill-being observed in only 6% of overall mapping. From RSS, two-thirds residents were satisfied with overall care and in environment and food. However, their EQ-5D index value of 0.096 is comparable to that of persons with dementia during hospitalization (25). The low QoL by EQ-5D was mainly due to problems with mobility, self-care, and usual activities as most residents (93.9%) had moderate to severe disabilities based on RAF. In contrast, the domains pain/discomfort and anxiety/depression showed most residents had little problems. However, the extent of psychological distress might have been under-appreciated in the assessment by proxies. Other factors such as dignity, autonomy, and security also contribute to the residents’ QoL of NH (25).
Our findings suggest inadequacies in meeting the psychosocial-emotional needs of NH residents. As DCM was performed during activity periods in communal spaces, residents should be most engaged. However, less than 30% of time was spent being engaged and in a state of well-being. Residents were often in borderline and detached conditions with neither sign of pleasure nor distress (48% of the time). Conceivably, disengagement magnifies apathy, boredom and loneliness which speeds physical, cognitive, and functional deterioration (26). A key component of QoL comprises participation in activities meaningful to the person (27). Hence, the amount of time spent in activities with high potential for well-being is a measure of the care environment’s capacity for meaningful engagement. Although 37% of the residents’ time was spent in behaviours with the potential to improve well-being, an equal proportion (39%) was on activities with low or no potential. Positive caregiving (PEs), focusing on individuality and potential, can improve psychological care in persons with dementia. The theoretical basis of PCC considers sense of personal worth, agency, social confidence and hope as global states of well-being for human (21). In PCC, the rate of PEs should far exceed that of PDs. In this study, the rate of PEs (0.0021) was comparable to the rate of PDs (0.0014). In addition, a wide range of negative of care practices (PDs) were identified, suggesting room for improvement in PCC.
The shortcomings in addressing residents’ psycho-emotional were reiterated by RSS findings, more than half were dissatisfied in areas of psycho-emotional needs and autonomy (interaction with community, maintain home routine, awareness of happenings outside NH, staff informing residents about what is happening and considering their preferences). Yet, despite the relatively low level of satisfaction in these areas, most residents reported being contented with overall care. This suggests accommodation of standards and lowering of expectations for personal fulfilment, connectedness, and autonomy in NH life. These findings are consistent with previous research reporting seniors learnt to cope by lowering life expectations (28,29). This study also demonstrated a clear association between level of PCC and residents’ well-being. Instead of consigning to lowering expectations, the residents should be empowered as stakeholders in care planning to achieve person-centred care and higher well-being.
PDDCAT suggested suboptimal level of PCC, pointing to staff training and physical environment as areas for improvement. NHs can consider using DCM as a practice improvement tool in staff training (30). Care can be improved by reviewing the various BCCs and associated ME values; considering the impact of care detractors and enhancers to determine how activities and interactions can be modified to enhance well-being. In addition, NH must promote staff attitude towards making personhood central to care provision. Care process enhancement needs to be complemented with an enabling environment. Both physical and social environment influence the well-being of NH residents. In terms of physical environment, there was lack of visual cues to prompt independence (e.g. items for self-initiated activities or labelling to allow identification of areas) or promote self-esteem (e.g. display of individual creations). Opportunities for personalisation of space was limited due to shared rooms, the use of standard furniture and limited personal space. NHs physical environment should provide adequate personal space, outdoor space, facilitate orientation, offer different activity areas and enough mobility space to promote independence and freedom.
As a first step in research translation, findings were discussed with individual NHs. Two NHs had incorporated their results and implemented DCM for care development. As NH staff adopt DCM, significant challenges remain in PCC implementation (31). Nevertheless, even as the importance of involving residents in decision-making is increasingly recognized, balancing the provision of PCC with pragmatic constraints of shared living environment remain a challenging yet worthwhile pursuit.
Another constraint in our context pertains to direct NH care provided by foreign workforce. The resulting communication challenges has been identified as a factor for poor QOL (25). Care staff must overcome language and sociocultural differences to better understand and meet residents’ needs. Fundamentally, closing the gap between care philosophies and their translation into an actual care environment that is truly resident-directed (32) is a clear priority. This study was conducted before the COVID-19 pandemic and its implications on infection control have become more urgent (33).

Strengths and limitations of study

Previous studies on residents’ QOL in Asian NH (11, 12) mainly provided qualitative insights with few quantitative documentations of PCC (34), none that used DCM and other PCC measures. Using data sources that offered perspectives of the residents, direct care staff as well as third-party observers to provide a holistic view on PCC and well-being, ours is the most comprehensive Asian study on the lived experience of NH residents.
The PDDCAT had been developed as a person centric care assessment and improvement tool. It was selected as it involved comprehensive and objective assessment by NH staff as PCC measurement and improvement tool. However, as with many PCC measures, it needs further validation (35).
The selection of varied types of NHs was meant to provide a large and representative sample of the local NH population. However, the potential for selection bias cannot be excluded and limits generalisability. The DCM and PDDCAT are developed for persons with dementia but only a third of our subjects (likely underestimate) had formal dementia diagnosis. Nevertheless, these measures have been demonstrated to be useful in persons with or without dementia (32, 36). The effectiveness of DCM and PDDCAT for quality improvement need further study.


Conclusion and implications

Higher level of PCC is associated with better resident well-being. Beyond their physical and custodial needs, the residents’ psychosocial needs can be better fulfilled. The areas of PCC identified for improvement were related to environment and staff knowledge and training. These findings inform resident care planning, policy development, and future research to support NHs in their endeavour to move towards more holistic and PCC.


Funding: This research is supported by the National Research Foundation and Ministry of National Development, Singapore under the L2 NIC Award No. L2NICTDF1-2017-5. Any opinions, findings and conclusions or recommendations expressed in this material are those of the author(s) and do not reflect the views of National Research Foundation, Singapore and Ministry of National Development, Singapore. It also received funding from a private donation to Saw Swee Hock School of Public Health, National University of Singapore. The sponsors had no role in the design and conduct of the study; in the collection, analysis, and interpretation of the data; in the preparation of the manuscript; or in the review or approval of the manuscript.

Acknowledgements: We acknowledge the contribution of the School of Design and Environment, National University of Singapore. We are also grateful for the cooperation of the staff, families and residents of the participating nursing homes, Carol Fusech and Koh Hwan Jing from ADA for conducting DCM and PDDCAT training, and Ms Chua Xin Ying who helped to coordinate the study set up.

Conflict of interest: Chee Wee Tew declares no conflict of interest. Siew Pei Ong declares no conflict of interest. Philip Lin Kiat Yap declares no conflict of interest. Amber Yew Chen Lim declares no conflict of interest. Nan Luo declares no conflict of interest. Gerald Choon Huat Koh declares no conflict of interest. Tze Pin Ng declares no conflict of interest. Shiou Liang Wee declares no conflict of interest.

Ethical standards: Ethics approval was obtained from the National University of Singapore (S-18-078). Informed consent to participate in the study were obtained from residents who were able to make decisions, and from a family member for residents with insufficient capacity.





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J. Wearing1,2,*, M. Stokes3,4, R.A. de Bie1, E.D. de Bruin5,6

1. Department of Epidemiology, Faculty of Health, Medicine and Life Sciences, School for Public Health and Primary Care, Maastricht University, Maastricht, The Netherlands; 2. Adullam Spital und Pflegezentren, Basel, Switzerland; 3. School of Health Sciences, University of Southampton, Southampton, United Kingdom; 4. Centre for Sport, Exercise and Osteoarthritis Research Versus Arthritis, Nottingham, United Kingdom; 5. Institute of Human Movement Sciences and Sport (IBWS) ETH, Department of Health Sciences and Technology, ETH Zurich, Zürich, Switzerland; 6. Division of Physiotherapy, Department of Neurobiology, Care Sciences and Society, Karolinska Institute, Stockholm, Sweden. Corresponding author: Julia Wearing, Adullam Spital und Pflegezentren, Basel, Switzerland, E-mail: j.wearing@bluewin.ch, Phone: +41 61 2669799

Jour Nursing Home Res 2020;6:120-126
Published online December 16, 2020, http://dx.doi.org/10.14283/jnhrs.2020.30



Background: Age-related neurological and muscular changes lead to low strength and function in older people. The proportional contribution of these changes to strength decline alters with increasing age. However, it is not clear how the muscle changes in older people which have excessive loss of strength due to multimorbidity and inactivity. Unlike community-living older adults, intramuscular alterations are rarely evaluated in nursing-home residents despite their potential importance for specific sarcopenia assessment and guiding interventions to improve strength. Objectives: To explore potential relationships between muscle strength, muscle quantity, contractile quality and physical activity in older nursing-home residents. Design: A cross-sectional proof-of-concept study. Setting: A nursing-home in Switzerland. Participants: 24 nursing-home residents, median age (range) 86.5 (68-103) years. Measurements: Sonographic measures of muscle thickness and echotexture were used as surrogate measures of muscle quantity and contractile quality of the quadriceps muscle. The relationship between sonographic measures and isometric strength of the knee extensors, gait speed and physical activity was evaluated using Pearson’s and Spearman’s correlation coefficients. A subgroup analysis of low (n=12) and normal (n=12) physical activity, based on energy expenditure cut off values of 383 kcal/week for men and 270 for women, was also undertaken. Results: In nursing home residents with normal physical activity, muscle quality positively correlated with knee extensor strength (r=0.727, p=.007) and gait speed (r=0.588, p=.044) while muscle thickness was not (p=0.966 and p=.564 respectively). There was no correlation among variables for n=24 or the subgroup with low physical activity. Conclusions: The results provide proof of concept that poor muscle quality is associated with low strength in older nursing-home residents that are physically active. Ultrasound derived muscle quality assessment has potential to detect activity-related muscle differences in old age, associated with sarcopenia, and may be more appropriate than muscle thickness measures.

Key words: Knee extensor strength, muscle quality, heterogeneity, nursing-home residents, physical activity.



Age-related neurological and muscular changes lead to low strength in older people with an increased risk of functional decline (1). Residents of nursing homes, in particular, often have excessive muscle weakness (2) due to multiple chronic diseases, inactivity and malnutrition (1). To prevent adverse health outcomes, assessment of muscle disorders, and preservation or improvement in muscle strength are essential (3).
For several decades, the age-related muscle disorder sarcopenia has been mainly attributed to a reduction in muscle mass (1). Recently, however, it has been shown that the relationship between strength and muscle mass is inconsistent in older people and that strength decreases to a higher extent than mass with aging (4). Explanatory models have now highlighted the potential role of muscle quality and neural function, in addition to muscle mass, as key determinants of muscle strength (4). Muscle quality has been shown to decrease with age but is suspected to change more due to muscle disuse, which often accompanies aging (5). In the clinical context of strength, muscle quality refers to contractile characteristics of muscle fibres (5) and can be determined e.g. by the ratio of muscle strength per body mass or muscle imaging techniques (6). The quality of muscular contraction is thought to be diminished by multiple factors (5), including the accumulation of intramuscular connective and adipose (non-contractile) tissue (7), muscle fibre necrosis and inflammation that change the density and heterogeneity of the muscle structure (8).
Evaluation of intramuscular non-contractile tissue has been recently applied in research that focuses on age-related changes in muscle as well as in patients with muscle impairments such as muscular dystrophy (5, 9). While Magnetic Resonance Imaging has been widely used to quantify morphologic abnormalities in muscles, B-mode ultrasound imaging has been shown to be a reliable alternative in clinical settings, complementing functional measures of muscles and demonstrating disease progression by changes in thickness and echo intensity (9). Clinical trials evaluating healthy older, community-living people have shown that strength consistently declines along with altered muscle quality, however its relation to muscle quantity is controversial (10-12). Moreover, muscle quality has been shown to be positively related to gait performance (12, 13). Despite the high informative value of ultrasound measures in detecting muscle changes in healthy elderly, there is a lack of studies using ultrasound in older (≥ 65 years), particularly in oldest-old (≥ 85 years), comorbid people (14).
Only a few studies to date have evaluated muscle characteristics in nursing-home residents. As muscle strength decreases with age, particularly rapidly after the age of 80 years (15), the proportional contribution of muscular and neurological changes leading to strength decline also changes (4, 15). Particularly in people with a very low muscle condition such as in nursing-home residents (1, 2, 16), the muscle might show a specific pattern of biological changes. Moreover, as the evaluation of muscle function by assessments typically used in older adults is limited in people with very low muscle condition due to physical restrictions (17), evaluation of ultrasound-derived muscle changes might be a valuable alternative for this cohort. Therefore, morphologic changes in muscle, and relationships between strength, function and physical activity in this population merit separate attention to improve clinical assessment of sarcopenia in this population. So far, it has been shown in computer-tomographical scans that cross-sectional area of the quadriceps femoris was related to knee extensor strength and gait speed in frail, older nursing-home residents (18). However, whether there is a relationship between ultrasound measures of muscle morphology and strength of the lower extremities in nursing-home residents has not been explored to date (7).
The objectives of this study were 1. To explore potential relationships between sonographic measures of muscle quantity, quality and strength of the knee extensors in older nursing-home residents, specifically including oldest-old people, and 2. To examine the relationships of knee extensor characteristics and gait speed within subgroups based on physical activity level.



Study design

An observational, cross-sectional proof-of-concept (19) study design was used to explore the potential relationships between muscle strength, sonographically measured thickness, indices of quality, and physical function in a convenience sample of older, comorbid residents of a nursing-home in Switzerland, including oldest-old people (≥ 85 years).

Participants recruitment

Residents were included if they were able to walk, with or without the aid of a walking device, and cognitively able to understand study content. Exclusion criteria were a) severe impairment in decision making (Cognitive performance scale > 4 points) (20), b) acute illness, c) a history of acute lower limb pathology within the last 6 months (fracture and/or surgery) and d) skin disorders involving the anterior thigh.
All participants provided informed consent following a verbal and written explanation of the study procedures, which complied with the principles of the Declaration of Helsinki for ethical research in humans. The study received approval from the local ethics committee (Ethikkommission Nordwest- und Zentralschweiz (EKNZ), project-ID 2017-00839).

Data collection

Participants demographics

Age, height and body mass of the participants and number of chronic diseases that may affect muscle characteristics (metabolic, musculoskeletal, neurological, psychiatric, respiratory disease, renal insufficiency and cancer) were extracted from nursing assessments and medical history.
Muscle strength, muscle morphology, physical function and physical activity were examined by a physiotherapist trained and experienced in musculoskeletal assessments.

Muscle strength

Maximal isometric strength of the knee extensor was measured with a hand-held dynamometer (Microfet®, CompuFET, Hoggan Health Industries, Biometrics Europe). For measurements, participants were seated on a plinth, with their back and thighs fully supported, knee positioned at 90° and lower leg hanging freely. The curved transducer pad of the dynamometer was positioned at 80% of the length of the tibia. Participants were requested to push against the dynamometer as hard as possible for 3 seconds.
The peak force measured during two trials was recorded in kg. Relative strength was calculated by normalizing peak force to body mass. Isometric muscle strength determined by hand-held dynamometry in older adults has been shown to be comparable to strength values measured with the gold standard method of isokinetic strength testing (21) with a high test-retest reliability (ICC 0.90-0.98) (22).

Muscle morphology

Real-time, B-mode ultrasonography (Nemio MX Type SSA-590A, Toshiba, Japan) with a 12-MHz linear transducer array (45 mm footprint) was used to obtain two transverse scans of the rectus femoris and vastus intermedius muscles at a site two-thirds of the distance between the antero-superior iliac spine and the superior pole of the patella. Standardized sonographic settings were used for all participants and images were acquired using a uniform protocol developed for older adults (23). Ultrasound images were post-processed using a MATLAB code (MathWorks®, Massachusetts, USA). Muscle thickness was calculated as the distance between the fascial layers that distinguish muscles from the subcutaneous fat layer, and muscles from bone. Thickness values were expressed as a percentage of total thigh thickness to account for individual body composition (23). Sonographic measures of quadriceps thickness have been previously shown to be highly correlated (r = 0.98) with gold standard measures obtained from Magnetic Resonance Imaging (14), and have a reported intra-rater reliability of ICC 0.88-.099 in older people (8, 23).
Muscle echotexture was characterized by echo intensity and heterogeneity, determined over a rectangular region of interest. Echo intensity was estimated by calculating the mean grayscale value in unspecified units (UU), ranging between 0–255. High values reflected hyperechoic tissue which reportedly reflects the accumulation of non-contractile tissue (9), muscle fibre necrosis and inflammation (8). Tissue heterogeneity was estimated by calculating the standard deviation (SD) of grayscale value (24). Low SD reflected low heterogeneity which indicates homogenous tissue structure and evenly distributed non-contractile tissue within muscle (24). Homogeneous muscle tissue patterns have been shown to be positively associated with muscle disorders (24), and age-related strength differences (25). Quantification of tissue heterogeneity has been demonstrated to be sensitive in detecting neuromuscular disorders including myopathy and muscle dystrophy (26).

Physical function

Preferred gait speed was evaluated over a 4m distance. This method is commonly used for evaluation of functional performance in older adults and shows excellent test-retest reliability in older people with comorbidities (17).

Physical activity

Physical activity was evaluated using the German Physical Activity 50+ questionnaire (27), which measures the duration of various household and leisure time activities and allows for estimation of energy expenditure based on the Compendium for Physical Activities (28). Its performance characteristics have been reported elsewhere (27). Energy expenditure was reported in kcal/week and dichotomized into low- and normal physical activity based on cut off values of 383 and 270 kcal/week for men and women, respectively (29). For evaluation of physical activity, participants as well as nurses responsible for their care, who closely observe the nursing-home residents 24h/7d were interviewed, to increase precision of the responses.

Statistical analysis

Normal distribution of the data was evaluated using the Shapiro-Wilk test. Normally distributed data have been reported as mean (SD), not normally distributed data as median (range). For normally distributed data, Pearson’s correlation coefficient was used to evaluate correlations between measures of muscle strength, muscle morphology, physical performance and physical activity, and to analyze relationships between knee extensor characteristics within the physical activity subgroups. For not normally distributed data, Spearman’s correlation coefficient was used accordingly.



Descriptive Analysis

The study sample included n=24 participants (18 women), median age (range) 86.5 (68-103) years, with n=12 participants in each physical activity-subgroup (Table 1).

Table 1
Descriptive characteristics of the participants

†data not normally distributed

Correlation analysis (n=24)

Knee extensor strength normalized to body mass was not significantly correlated to sex or measures of muscle morphology, physical function or physical activity (Table 2).

Table 2
Correlations among demographic parameters, quadriceps muscle strength and morphology, physical function
and physical activity (n= 24)

CD = number of chronic diseases, KES = knee extensor strength normalized to body mass, QT = quadriceps thickness in relation to total thickness, RG = Rectus grayscale, RGSD = rectus grayscale standard deviation, GS = gait speed, PA = physical activity, Significance p<.05; †correlations determined by Spearman’s Correlation Coefficient; Body mass was excluded from the correlation analysis as muscle strength has been normalized to mass.


Correlations within physical activity subgroups (n=12 each)

To determine if a higher activity level, mainly achieved by walks in the garden and outside the nursing-home, is important to determine relationships of morphological measures and strength of the quadriceps, the sample was divided into two subgroups categorized by the physical activity cut-off value of 270kcal for women and 383kcal for men. The cut off value determines whether a person is at risk for frailty (29). Both subgroups included n=12 participants with an energy expenditure of mean (SD) 68 kcal/week (100) in the slow group and 1297 kcal/week (1445) in the group with normal physical activity.
Within the subgroup with normal physical activity, knee extensor strength was positively correlated with tissue heterogeneity (r = 0.727, p = .007) but not with muscle thickness (r = 0.014, p = .966). Similarly, muscle tissue heterogeneity was positively correlated with gait speed (r = 0.588, p = .044). However, within the subgroup of people with low physical activity, there were no significant correlations among knee extensor strength normalized to body mass, comorbidities, muscle thickness and muscle echo intensity and heterogeneity, or gait speed (Table 3).

Table 3
Correlation analysis between muscle characteristics of the knee extensor and gait speed within subgroups of physical activity

CD = number of chronic diseases, KES = knee extensor strength normalized to body mass, QT = quadriceps thickness in relation to total thickness, RG = Rectus grayscale, RGSD = rectus grayscale standard deviation, GS = gait speed, PA = physical activity; †correlations determined by the Spearman’s correlation coefficient; *significance, p<.05


Correlations of rectus femoris tissue heterogeneity with knee extensor strength, in those with normal and low physical activity are shown in Figure 1. Figure 2 presents two ultrasound images with different muscle tissue heterogeneity.

Figure 1
Correlations between rectus femoris tissue heterogeneity and knee extensor strength

Scatterplot of rectus femoris tissue heterogeneity and knee extensor strength normalized to body mass in those with normal physical activity (A) and low physical activity (B).

Figure 2
Correlations between rectus femoris tissue heterogeneity and knee extensor strength

Two ultrasound images with similar grayscale value of muscle tissue (region indicated by yellow line) but different in grayscale standard deviation (SD): (A) higher grayscale SD (heterogeneous tissue) of a participant with normal physical activity level, (B) lower grayscale SD (homogenous tissue) of a participant with low physical activity level; the length of the yellow arrow defines the muscle thickness between subcutaneous tissue above it and bone below.



This study explored potential relationships among ultrasound derived indices of muscle quality characteristics, muscle function (gait speed) and physical activity in older, multimorbid nursing-home residents. This proof-of-concept study targeting muscle aging mechanisms showed that ultrasound assessments explored the relationship between muscle quality, strength of the knee extensors and gait speed in older (68-103 years) nursing-home residents with normal physical activity. Ultrasound imaging seems to be a useful measure for detecting physical activity-related muscle differences in this cohort, contributing to comprehensive sarcopenia assessment. It can be useful to detect differences in muscle quality associated with limitations in muscle function in people not capable of performing functional measures of strength.
While knee extensor strength values in the current study are comparable to strength values reported for nursing-home residents of other European countries (18), strength and muscle morphology were not related to age. Although muscle characteristics change over the lifespan, differences within a group of older, comorbid people might be more related to disuse than to age per se (1). The relationship between knee extensor strength, muscle thickness and muscle morphology differed depending on the physical activity level in this sample of participants. The cut-off value for low- and normal-physical activity (279/383 kcal per week) in the current study is equivalent to the energy expended by a 50-kg body mass woman whose only activity is to walk at a comfortable speed for 20 minutes a day, 5 times a week. Physical activity at this level reflects very little activity even for nursing home residents and is considered to be indicative of high disability (16).
In elderly residents with normal physical activity, tissue heterogeneity, a measure of muscle quality (6, 25), correlated with knee extensor strength but not thickness. This finding is consistent with previous literature in community-living elderly (10-13). Muscle quality might, therefore, be a more appropriate indicator of age-related changes in muscle strength than muscle thickness. In the present study, muscle heterogeneity was not only related to strength in the subgroup with normal physical activity but also to gait speed, an important measure of functional status (1). Even if a causal relationship cannot be established by these data, they indicate mutual impact between these factors. It is possible that minimizing the accumulation of non-contractile tissue in muscle through physical activity interventions (5) could also effectively improve non-contractile tissue dispersion and positively affect gait. Further research evaluating the impact of physical activity on muscle heterogeneity could verify this suggestion.
Within the low physical activity subgroup, no significant relationships were observed between knee extensor strength and common sonographic measures of muscle morphology (muscle thickness and echo intensity). This finding cannot be compared to the literature as, to our knowledge, this is the first study to evaluate those relationships in nursing-home residents concerning physical activity. One potential reason for the present results might be that once muscle strength drops below a certain threshold, morphological interactions are less apparent. Alternatively, it is possible that the sonographic approach in the present study is not sufficiently sensitive to detect physical activity-related differences in muscle of highly reduced condition. The detection of catabolic biomarkers in blood samples could potentially give more detailed information about muscular changes (5). Another reason might be that neurological components of strength were not considered in this study as an explanatory factor for low strength. However, echotexture analysis of ultrasound images provides important information in the context of age-related muscle disorder even in older, comorbid nursing-home residents.
The present findings are indicative of the following hypotheses: 1. Muscle quality contributes to age-related decrease in strength in nursing-home residents. Further research is needed to verify this hypothesis and should also focus on the neurological determinant of muscle strength. 2. Grayscale SD evaluated by echo intensity of ultrasound images could be used to detect differences in age-related muscle quality. The accordance of different methods detecting heterogeneity in muscle structure would have to be evaluated.


One potential limitation of this study is that tissue heterogeneity is likely to vary within a given muscle and may be dependent on subcutaneous tissue thickness (25). While this study adopted a standardized region of interest for estimating tissue heterogeneity, it should be recognized that calculation of parameters at the midpoint of the muscle, without taking subcutaneous tissue into consideration, may not be reflective of the whole muscle unit. The findings are, however, consistent with other studies in which tissue heterogeneity has been shown to be altered in neuromuscular disease and age-related muscle wasting (24, 25). Secondly, we cannot be certain that the isometric strength measurements involved maximal effort of the participants. Discrepancies between voluntary muscle contraction und maximal possible contraction could have been detected by electrical muscle stimulation using the interpolated twitch technique (30) but this is not feasible outside of laboratory settings. Therefore, the assessment of maximal isometric voluntary contraction is an appropriate alternative as it has been shown to be reliable in strength detection of older adults in clinical settings (22). Although further studies are needed to verify the results, the findings of the present study provide new insights into muscle characteristics in older, including oldest-old, institutionalized people.



The present results provide proof-of-concept that muscle tissue heterogeneity, a sonographically measured index of muscle quality, is positively related to knee extensor strength and gait speed, in older nursing-home residents with normal physical activity level. The findings indicate that the assessment of muscle quality from ultrasound images might be a more appropriate method to detect age-related differences in muscle than the evaluation of muscle thickness, at least in older people with normal physical activity. Given the sample size of the current study (n = 24), assessment of ultrasound-derived muscle morphology in a larger population sample is warranted. Inclusion of these assessments may be recommended as part of a comprehensive assessment of sarcopenia and for monitoring the outcome of preventative interventions designed to improve muscle strength and function in older individuals.


Funding: The authors received no specific funding for this work.

Acknowledgments: We would like to thank the nursing-home residents for their participation, Dr. Hans-Jörg Ledermann for his valuable suggestions during the planning of this research work, and the nursing staff for their help in recruitment and data collection. We acknowledge Adullam Spital und Pflegezentrum Basel for providing equipment.

Conflict of interest: Julia Wearing declares that she has no competing interests. Maria Stokes declares that she has no competing interests. Rob A. de Bie declares that he has no competing interests. Eling D. de Bruin declares that he has no competing interests.



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J. Chrusciel1, S. Zid1, V. Suissa2, A. Letty3, P.-E. Hay3, D. Armaingaud3, M. Dramé4, L. Godaert5, S. Sanchez1

1. Centre Hospitalier de Troyes, Public Health Department, Troyes, France; 2. Université Paris 8, Laboratoire de Psychopathologie et Neuropsychologie, Paris, France; 3. Fondation Korian pour le Bien Vieillir, Paris, France; 4. CHU de Martinique, CIC 1424 Antilles Guyane, Fort-de-France, France; 5. CHU de Martinique, Pôle de Gériatrie Gérontologie, Fort-de-France, France. Corresponding author: Jan Chrusciel, MD, MSc, Centre Hospitalier de Troyes, Public Health Department, Troyes, France, Phone : +33 3 25 49 71 19 / Fax + 33 3 25 49 49 50. E-mail: jan.chrusciel@ch-troyes.fr

Jour Nursing Home Res 2020;6:114-119
Published online December 4, 2020, http://dx.doi.org/10.14283/jnhrs.2020.29



Background: Entering a NH can represent considerable mental trauma in addition to an increased financial strain. An improved understanding of the psychological issues at play could help professionals to adopt a more empathic attitude. Objectives: the main objective of our study was to identify distinctive profiles of adults aged over 65 in four European countries in order to understand the difficulties associated with the transition to a nursing home. Design: Cross-sectional study and Hierarchical Cluster Analysis. Participants: Retired people from Germany, Belgium, France, and Italy aged 65 or older selected by quota sampling and contacted via an online survey, the Ipsos Poll Institute Access Panel. Methods: Cross-sectional survey. A Principal Components Analysis was performed on the answers to the questionnaire, and clusters were identified by Hierarchical Cluster Analysis using Ward’s method. Measurements: The data was collected using an Internet questionnaire. Results: A total of 4160 subjects aged 65 years or older were selected. Principal component analysis identified six well-defined groups: wealthy homeowners, flexible single people, wealthy Germans, low-income introverts, socially isolated women, Italian homebirds. Conclusions: Understanding the profiles of older Europeans could help healthcare professionals decide how to orient them towards acceptance of their new life in the nursing home.

Key words: Nursing home, successful aging, cross-sectional study, principal components analysis, hierarchical cluster analysis.


An estimated 728,000 persons live in the various residential care structures available for older people in France (418,000 in the United Kingdom and 1.5 million in the United States). The risk of entry into a nursing home (NH) has been shown to vary according to geographical and clinical factors (1). Entry into a NH is associated with a state of frailty, and a decrease in the social environment’s ability to provide direct support (2–5), meaning life at home is no longer possible. The problem of caregiver burden is likely to increase in the years to come. The growing number of divorces, a decrease in natality (6) and a higher life expectancy are leading to a reduction in household size, which in turn reduces the potential number of caregivers (7, 8). These changes call for a re-evaluation of the current health policy regarding older people (9). The concept of home covers physical and cognitive entities and is specific to each individual (10). The place where life is lived, one’s home can extend beyond the walls of the house and include relations with loved ones and daily interactions (11). Often, the decision to enter a NH is a default choice, because the person is no longer capable of living independently despite assistance. NH entry is sometimes (12) not anticipated by the person, and often decided by their children and/or spouse. As cognitive impairment predicts entry in the NH (13–15), cognitively impaired patients sometimes do not expect such a transition and can easily be disoriented in the process (16).
Thus, entering a NH can represent considerable mental trauma in addition to an increased financial strain (17, 18). Moreover, this can happen in a context when the patient is experiencing depressive symptoms (19). The older person transitions from a situation where they were in control, to a situation where everything is decided for them by others (20). Therefore, knowledge of the profile of the future resident is important to prevent problems and misconceptions when the transition to a nursing home is nearing.
An improved understanding of the psychological issues at play could help professionals to adopt a more empathic attitude at the early stages of envisioning the transition to a nursing home (21).
Therefore, the main objective of our study was to use an on-line survey to identify clusters of people aged 65 years or older of four European countries based on their characteristics and including their attitudes regarding accommodation.


Materials and Methods

Ethical approval

Patients gave informed consent to take the survey. The survey was exempt from Institutional Review Board approval under the French Public Health law n° 2004-806 (9 August 2004).

Study population

The survey was carried out in February 2016 by a poll institute in a sample of individuals from the population of retired persons in four European countries, selected using quota sampling. A total of 4160 subjects aged 65 years or older were selected. This cross-sectional study was carried out using an internet questionnaire (Appendix 1) sent to the selected individuals in France (n=1000), Belgium (n=1076), Italy (n=1081) and Germany (n=1003). Participants took the online survey from their place of residence, using their personal computer. The reference population selected was diverse in terms of age, including both recently retired persons as well as oldest-old individuals. The characteristics used for the quota sampling method were sex, age, socio-professional category, region, city size, number of persons in the household, autonomy (dependent/independent), marital status, place of residence, income and highest educational qualification. The aims of the survey were also to obtain useful information about the different subgroups of the population (according to age, sex, income etc.).

The Ipsos© Access Panel

The questionnaires were administered via the Access Panel online service belonging to Ipsos Interactive Services©. The Access Panel is a pool of households and individuals spread homogeneously across the whole country and who regularly accept to participate in market research studies. The panel comprises over 600,000 individuals on whom detailed information has been collected in addition to the data used to establish the quotas (e.g. the size of the household, income, level of education, number of children etc.). This methodology aims to achieve adequate representativeness for the different quota. Numerous quality controls were carried out at all stages of the survey.

Quality control procedures

Quality control procedures were implemented at each stage of data collection and all the online sessions were performed using the CONFIRMIT software. This system enables automatic management of how the questionnaire scrolls (guides, filters), eliminates coding errors, displays questions or sub-questions in random order to avoid bias linked to the order of appearance of the items on the questionnaire, and ensures automated control of quotas in real time. This software meets ISO 9001 certification standards (2008 version).

Development of the questionnaire

The questionnaire was developed jointly by the Korian Foundation for Successful Ageing and IPSOS© with the assistance of a sociologist. The questionnaires contained 25 question units. The topics addressed include concepts related to attachment to the home environment. A number of sociodemographic characteristics were also recorded (age, sex, household, income, marital status, level of education). The questionnaire was professionally translated and the accuracy of the translation was confirmed by the investigators in each country.

Statistical analysis

For descriptive analysis, qualitative variables were presented as absolute frequencies with percentages. Questionnaire results were analysed using a Principal Components Analysis (PCA), which was performed based on questions 1,7, 8, 10, 14, 19, 34, 36 as active variables, while socio-demographic variables and questions 1, 3, 7, 8, 10, 11, 14, 19, 21, 24, 25, 33,34, 35, 36, 37,38 were used as illustrative variables. Clusters of residents were identified with Hierarchical Cluster Analysis using Ward’s distance. The analysis was realised using SPAD software.



The study population comprised 4160 individuals from Germany, Belgium, France, and Italy. The characteristics of the study population are described in Table 1. Overall, 2389 (57%) were women; 1414 (34%) were aged 65 to 69, and 2709 (65%) were living maritally. A majority (2938, 70%) were homeowners, while 1253 (30%) showed signs of social precariousness including low income, and 1159 (27%) had a low level of education.

Table 1
Characteristics of the study population according to their cluster


The Principal Components Analysis identified six groups whose main characteristics are described below and in Table 2:
Group 1 (N=994, 23%): well-off males with a high level of education. They were fond of their lodgings, furniture and personal belongings. They enjoyed life and felt confident about the future. This first group mainly preferred to stay at home, adapting their residence to meet their evolving needs rather than sharing accommodation with others.
Group 2 (N=786, 19%): single, flexible and young, with a high proportion of people from Germany and Belgium. Their satisfaction with, and fondness for their residence were of lesser magnitude than in Group 1. They were willing to move to accommodation that was more suitable for their physical capacity. This group was also characterised by loneliness, and less contact with those around them. They were less confident about the future due to a more pronounced anticipation of future dependency.
Group 3 (N=1014, 24%): middle-class people with a well-developed social network, living maritally and able to count on their children. They were happy and satisfied, both physically and mentally. They felt younger than their age. They were independent and lived with a sense of pleasure. As in Group 1, they were fond of their home, their furniture and their habits. This could explain their preference to adapt their current accommodation to their changing needs rather than moving.
Group 4 (N=187, 5%): People of lower income, young, and fragile with less developed networks, these people were less likely to be able to count on their spouse. They were not fulfilled, either mentally or physically. Life was a source of pleasure for only 65% in this group, compared to an average of 78%. In this group, income was lower than average. They often lived in rented accommodation, and were less attached to their residence and their habits. Consequently, they were willing to change accommodation if it meant better living conditions, and 50% would envision living in a NH.

Table 2
Characteristics of the different profiles identified by principal component analysis


NH: Nursing Home

Group 5 (N=470, 25%): socially isolated women. They had limited financial resources and a low level of education. They suffered from social precariousness, with few friends on whom they could count, and had physical problems that made them dependent (48%). The majority of people in this group did not consider life to be a source of pleasure, and they had less confidence in the future. They would be willing to move houses and region for an accommodation that was more suited to their needs, because they felt little attachment to their furniture, personal belongings and daily habits.
Group 6 (N=709, 17%): fond of their residence, predominantly women (72%) of Italian nationality (45%). This group presented some similarities with Group 5, in that its members were dependent and isolated. People in this group did not feel physically and mentally fulfilled. They could not save money due to their relatively low income. Only 38% of them feel confident about the future. Contrarily to Group 5, they were very attached to their habits, their furniture and their home, and consequently, were not willing to move.



We show that there are different typologies regarding participants’ characteristics linked to accommodation and the attitude towards a change of place of living. Young, recently-retired people, living maritally, independent and fond of their routine, were more frequent among Belgian and German respondents. These groups preferred to adapt their accommodation to their changing needs rather than live in a NH. German respondents who had a more precarious social situation than their wealthier counterparts had fewer social links, and their attachment to material belongings and their accommodation was low. They showed a readiness to move or live in a NH if the living conditions were better. German nursing homes are highly regulated and have seen an improvement in quality in the last years (22, 23). Moving into a NH can be a strategy to combat loneliness, although loneliness is also prevalent in nursing homes (24).
People from Italy were well-represented in two profiles: the first comprised mainly socially-oriented individuals who were very fond of their home. Despite difficult living conditions, they preferred to remain at home rather than to live in a NH. This is consistent with cultural expectations in Southern Countries, where social support from the family is the norm (25, 26). The second profile comprised essentially isolated individuals with few social contacts. For these individuals entry into a NH could represent a solution to achieve a better quality of life.
The frequency of females in this cluster is not surprising as European statistics show that older women often live alone (27).
Our results are coherent with previous data published in the literature (28). Social isolation and loneliness can lead physically able-bodied older persons to seek out collective living arrangements, such as assisted living. Our study also reveals geographical specificities, which may be at least partially explained by different policies regarding care of older adults in society between countries in the North versus the South of Europe. In southern European countries such as Italy, the fate of incapacitated older persons depends on the family rather than on institutional solidarity (25), in contrast with northern countries like Germany or Belgium. These findings can be interpreted as evidence that culture and socio-economic factors can influence older adults’ attitude towards their place of residence (29, 30). Other factors also play an important role in a person’s ability to construct a new “home” for themselves in a NH (31). More research is needed to ascertain if the identified profiles can predict adverse outcomes surrounding the transfer to a NH (32).
Our findings also show that living maritally, which was more frequent among Belgian and German people, contributed to a happier and more fulfilling life both mentally (33) and physically. These results are coherent with previous reports that couples are better equipped to deal with household chores than a single person. Furthermore, in case of dependency, the spouse is usually the primary caregiver, thus delaying the need for entry into long-term care (34).

Strengths and Limitations of the study

Our study population comprised a sample of individuals recruited by a poll institute in four European countries. The study sample was relatively large, although it could not be fully representative of the European population of persons aged over 65 years. Respondents needed to have access to the internet, which potentially excludes some of the oldest old and participants with lower levels of education from participating. The cross-sectional nature of the study implies that we could not follow the evolution and outcomes of the identified profiles. We hypothesise that patients who declare being most attached to their residence and their habits will be most impacted when a change is needed. However, the extent to which the profiles identified in this article predict adverse outcomes, mood changes or behavioural problems surrounding entry in the nursing home has not been studied here. People from groups 4 to 6 seem particularly at risk in the period surrounding entry in the nursing home. The available data suggests that suicides often occur in the first year after entry in the nursing home, although it is unclear if anticipation is a substantial risk factor (35). As in the general population, suicide occurs predominantly in males (36).


Conclusions and Implications

Entry into a NH is often experienced as a profound rupture, and this transition should be guided and anticipated. Understanding how the characteristics of older Europeans are linked to their attitude regarding their accomodation is a first step towards helping newly arriving residents to better accept their new life in the NH. The understanding of the psychological factors at stake can create a more empathic attitude by professionals and help to improve integration.

Funding: There is no funding to disclose in connection with this study.

Acknowledgements: N/A

Ethical standards: Patients gave informed consent to take the survey. The survey was exempt from Institutional Review Board approval under the French Public Health law n° 2004-806 (9 August 2004).

Open Access: This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits use, duplication, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license and indicate if changes were made.



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26. Walker A. A European perspective on quality of life in old age. Eur J Ageing 2005;2:2–12. https://doi.org/10.1007/s10433-005-0500-0.
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28. Rijnaard MD, van Hoof J, Janssen BM, Verbeek H, Pocornie W, Eijkelenboom A, et al. The Factors Influencing the Sense of Home in Nursing Homes: A Systematic Review from the Perspective of Residents. J Aging Res 2016;2016:1–16. https://doi.org/10.1155/2016/6143645.
29. Brownie S, Horstmanshof L, Garbutt R. Factors that impact residents’ transition and psychological adjustment to long-term aged care: a systematic literature review. Int J Nurs Stud 2014;51:1654–66. https://doi.org/10.1016/j.ijnurstu.2014.04.011.
30. Riedl M, Mantovan F, Them C. Being a Nursing Home Resident: A Challenge to One’s Identity. Nurs Res Pract 2013;2013:1–9. https://doi.org/10.1155/2013/932381.
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32. Snowdon J, Day S, Baker W. Why and how antipsychotic drugs are used in 40 Sydney nursing homes. Int J Geriatr Psychiatry 2005;20:1146–52. https://doi.org/10.1002/gps.1407.
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A.F. Jacinto1, W. Achterberg2, P.A. Wachholz3, T. Dening4, K. Harrison Dening5, R. Devi6, D. Oliveira7, I. Everink8, P.S. Azevedo3, P.J.F .Villas Boas3, K. Hinsliff-Smith9, M. Hoedl10, J.M.G.A. Schols8, V. Shepherd11, A.C.M. Gratao12, R.C. de Melo13, H.A.W. Watanabe14, M.S. Zazzetta15, C. Goodman16,17, K. Spilsbury6, A.L. Gordon18,19


1. Disciplina de Geriatria e Gerontologia, Departamento de Medicina, Escola Paulista de Medicina – Universidade Federal de São Paulo (UNIFESP), Brazil; 2. Department of Public Health and Primary care, Leiden University Medical Center, Leiden, The Netherlands; 3. Disciplina de Clínica Médica, Departamento de Clínica Médica, Faculdade de Medicina de Botucatu – Universidade Estadual Paulista Júlio de Mesquita Filho (UNESP), Brazil; 4. Division of Psychiatry & Applied Psychology, University of Nottingham, UK; 5. Dementia UK, London, UK; School of Health Sciences, University of Nottingham, UK; 6. School of Healthcare, University of Leeds, Leeds, UK; 7. Departamento de Psiquiatria, Escola Paulista de Medicina, Universidade Federal de São Paulo (UNIFESP), Brazil; 8. Maastricht University, Care and Public Health Research Institute, Department of Health Services Research, Maastricht, The Netherlands; 9. De Montfort University, Health and Life Sciences Faculty. Edith Murphy Building, Room 3.09, Leicester LE1 9BH, UK; 10. Institute of Nursing Science, Medical University of Graz, Graz, Austria; 11. Centre for Trials Research, Cardiff University, 4th floor Neuadd Meirionnydd, Heath Park, Cardiff CF14 4YS UK; 12. Department of Gerontology, Federal University of São Carlos (UFScar), Brazil; 13. Escola de Artes, Ciências e Humanidades – Universidade de São Paulo (USP), Brazil; 14. School of Public Health, University of São Paulo (USP), Brazil; 15. Departamento de Gerontologia, Universidade Federal de São Carlos (UFScar), Brazil; 16. Centre for Research in Public Health and Community Care, University of Hertfordshire, UK; 17. NIHR Applied Research Collaboration – East of England (ARC-EoE), Cambridge, UK; 18. Division of Medical Sciences and Graduate Entry Medicine, University of Nottingham, UK; 19. NIHR Applied Research Collaboration – East Midlands (ARC-EM), Nottingham, UK. Corresponding author: Alessandro Ferrari Jacinto, Rua Castanheiro, 16 – Vila Mariana, São Paulo – SP – 04023-040 – Brazil, E-mail: alessandrojacinto@uol.com.br, Phone:+55 (11)55752692,  https://orcid.org/0000-0002-1977-5880, Twitter: @JacintoFerrari

Jour Nursing Home Res 2020;6:109-113
Published online November 27, 2020, http://dx.doi.org/10.14283/jnhrs.2020.28



The Brazilian care home sector is underdeveloped, and the limited available evidence suggests that care quality falls below international standards. Development of the Brazilian care home sector could be associated with better outcomes for those receiving care, and more efficient use of resources across health and social care. Research has an important role to play. This article summarises research priorities for Brazilian long-term care homes developed as part of an international workshop held in Brazil and the UK, and attended by 71 clinicians and researchers from 6 Brazilian Universities, supported by an international faculty of 8 Brazilian, 8 British, 2 Dutch and 1 Austrian academics. The research priorities identified were: understanding and supporting multidisciplinary working in care homes, with emphasis on describing availability of multidisciplinary teams and how they operate; dignity and sensitivity to cultural needs, with emphasis on collating accounts from Brazilian stakeholders about dignity in care and how it can be delivered; enriching the care home environment with art, music and gardens, with a focus on developing arts in the care home space in a way that is sensitive to Brazilian cultural identity; and benchmarking quality of care, with emphasis on exploring how international quality benchmarking tools can be adapted for use in Brazilian care homes, taking account of new initiatives to include person-centred outcomes as part of benchmarking. Instrumental to research in these priority areas will be establishing care home research capacity in Brazil.

Key words: Long-term care, aged, Brazil, research.



In common with other BRICS (Brazil, Russia, India, China and South Africa) countries, Brazil is affected by rapid population ageing. In 2014, 14.6% of Brazilians were aged over 60 years, a proportion projected to grow to 33.5% by 2060 (1). Increases in average life expectancy have been accompanied by higher prevalence of multimorbidity and functional dependency, and unmet need for health and social care amongst older people.
All Brazilian citizens can access free healthcare at the point of delivery through a national health care system, the ‘Sistema Único de Saúde’ (SUS, or Unified Health System). This system, however, does not cover long-term care in care homes.
Care homes are facilities which provide 24 hour care, with or without specialist nursing input (2). They are a feature of most developed, and many developing, health and social care economies. They provide capacity to look after people with 24-hour care needs through support from dedicated staff, something which even the most generously funded healthcare systems struggle to reimburse in people’s own homes.
In Brazil, a small number of care homes (7%) are state-funded (3). A small and developing private sector provides care in facilities, akin to residential or nursing homes seen in high income countries, but these remain beyond the means of many (4) The bulk of current provision comes from small, localised organisations which are funded precariously through a combination of older people’s retirement benefits, community charities, and funding from municipalities.
The current estimated capacity of 100,000 beds across 3,549 institutions represents 0.03 beds per head of population over 80 years of age in Brazil (5). This differs considerably from England and the Netherlands, which have 0.12 and 0.23 beds per head of population over the age of 80 years respectively (6).
All Brazilian care homes are led by Technical Directors, many of whom do not have a healthcare degree. There is no requirement for health professionals (doctors, nurses and allied health professionals) to be employed by care homes, and the structure of healthcare input to care homes is highly variable. Healthcare in Brazilian care homes is mostly provided by doctors without any formal postgraduate training in primary care, geriatric medicine, gerontology or old age psychiatry. A cross-sectional study using objective quality indicators adapted from the United States found that quality of care in Brazilian care homes was variable and fell some way short of international standards (7).
Research in Brazilian care homes is underdeveloped, has not been a particular focus of the academic community and has not been supported or funded in a strategic way. Against this background, the Improving care in LOng-Term Care InstitUtionS in Brazil and Europe through Collaboration and Research (LOTUS) consortium was formed to develop research in Brazilian care homes through international learning and collaboration. It comprised two workshops, the first held at UNESP Medical School, Botucatu, Brazil, in April 2019, and the second held at University of Nottingham, United Kingdom (UK), in August 2019.
The workshops comprised visits to Brazilian and UK care homes and round-table sessions to identify priorities for future research in Brazilian care homes, harnessing links with international institutions to accelerate progress. We present here a summary of the identified priorities, in part as a manifesto to drive our research programme forward, and in part to inform similar collaborations around long-term care between high-, low- and middle-income countries elsewhere.


Choosing the priority areas

Workshop attendance was free-of-charge. Delegates were invited using e-mail lists for Brazilian national gerontology and geriatric medicine organisations. Registration was via a public webpage in English and Portuguese, which was publicised using Twitter. Brazilian organisers, comprising eight academics from a range of disciplines, consulted widely to ensure the programme represented a broad constituency with an interest in care homes. Using this approach we recruited 71 clinicians and academics from six Brazilian universities, including healthcare professionals, social scientists, demographers, gerontologists, designers and architects. Eleven academics from six UK, two Dutch and one Austrian universities were invited based upon expertise which matched the programme prepared by the Brazilian committee. The first two days comprised small group workshops and plenary sessions which enabled delegates to share experiences, with a focus on opportunities and challenges that could be addressed by research. At the end of day 2, delegates were presented with a list of nine possible research domains drawn from discussions, which they were asked to rank in terms of priority. The topics chosen were discussed and developed more fully over the remaining one day of Brazilian and two days of UK-based workshops.


Priority area 1 – Understanding and Supporting Multidisciplinary Working in Care Homes

Caring for older people with complex needs requires a multi-domain approach recognising the contributions of mental and physical wellbeing, functional capabilities, social networks and environment to overall health and wellbeing. From a nursing and social care perspective this is reflected in the evidence-base for person- and relationship-centred care (8) From a medical perspective, it is expressed through the evidence for comprehensive geriatric assessment (CGA) (9). Whilst person-centred care and CGA have exponents in Brazil, they are not yet widely accepted. The extent to which care homes are set-up to deliver them is not clear.
Comprehensive care approaches draw upon expertise of multiple professionals working as a team. In high income countries, multidisciplinary teams can be based in and employed by care homes – as in the Netherlands – or can be composed of numerous visiting professionals – as in the UK and Austria. The latter scenario can present challenges around co-ordinating assessments by different professionals and managing their inputs to ongoing care, with the need to take account of remote working and asynchronicity of inputs (10).
Surveys of care homes in Brazil have focussed mainly on the structure of institutions and the profile of the residents who receive care, particularly focussing on health status, falls and frailty (11–13). Data have not been collected hitherto on how such institutions are staffed, in terms of the disciplinary background of staff involved in care, or how such staff integrate into a multidisciplinary team.
Following the LOTUS workshops, we have commenced a survey to establish how multidisciplinary teams operate across ten care homes, five not-for-profit/philanthropic and five for-profit, spread across five Brazilian cities in São Paulo State (Botucatu, São Paulo City, Ourinhos, São Carlos and Campinas). Following this we propose more detailed qualitative research to understand in greater detail how professionals from multiple backgrounds connect and interact in care homes. Given the variation in geography, climate, culture and economic resource between Brazilian states, an explanatory approach will be required to accommodate and understand variability.


Priority area 2 – Dignity and Sensitivity to Cultural Needs

Dignity is defined in the Oxford English Dictionary as ‘the quality of being worthy or honourable; worthiness, worth, nobleness, and excellence’. The challenge lies in translating fine sentiments about maintaining dignity into care practice. Dignity can be complicated. For example, is it something that can be observed and measured objectively by meeting certain standards, or is it subjective and perceived at an individual or interpersonal level? Two people may observe the same interaction, such as a visit to the toilet, and come to different conclusions about how dignified it was.
Three main interactional qualities have been described (14) that help to preserve care home residents’ sense of dignity: experiencing love and confirmation; experiencing social inclusion and fellowship; and experiencing humane warmth and understanding within a caring culture, while being met as an equal human being.
There are several important cultural aspects of dignity (15). Staff and residents of care homes are often of differing backgrounds. This may include different socio-economic status, ethnic origins, speaking different languages, having differing sexualities or gender identities, or being of different faith. The linguistic issue, present in many countries due to dependence on migrant workers in long term care, can be particularly challenging in Brazil because, although Portuguese is the predominant language, the country is multi-lingual and not all older people speak Portuguese. Even where this is not the case, a care home of reasonable size will contain a diverse group of residents, with different educational and occupational experiences. They are likely to have different care preferences and needs. Some may observe a religion, others not. These aspects of individuality need to be understood and respected to support dignity in care.
Dignity is an important part of the realpolitik of care homes in developed countries. In the UK, for example, charitably funded national initiatives led by academics in partnership with care homes focus on dignity, whilst legislative and regulatory frameworks explicitly emphasise residents’ right to dignified care. The concept of dignity is less established in Brazilian care homes. There is a high level of stigma attached to care homes and their residents. Stigma leads to ageism, exertion of power, isolation, seclusion, poor quality care, and high professional turnover, all of which may impact upon provision of dignified care and impair the ability of staff to see individuals behind negative labels and stereotypes. Dignity is not used as a measure of care quality in Brazil.
We need to understand the levers required in Brazil to promote culture change from the current preoccupation with meeting physical care needs to a more person- and relationship-centred approach. It is likely that the answer will lie in staff feeling empowered and valued, so that they can prioritise dignity in care (16). There will be organisational and cultural issues specific to Brazil that influence how to empower and support staff and residents. Research needs to examine the perceptions of different stakeholders about what constitutes dignity and what different priorities for change may be. We propose that the first step should be a scoping review of the Brazilian literature of long-term care and dignity, followed by qualitative interview studies.


Priority area 3 – Enriching the Care Home Environment with Art, Music and Gardens

The proportion of care home residents with dementia, internationally, ranges from 30-60% (17). Activities such as art interventions are helpful in supporting people with dementia (18) and are one of the few effective non-pharmacological strategies in dementia care. Music, for example, is associated with improvement in cognitive performance and mood of care home residents (19).
There is evidence that residents from Brazilian care homes are less able to access stimulating recreational activities than in higher income countries (20). This could relate, again, to the emphasis placed on physical needs within Brazilian care homes. Initiatives that have developed around recreational activities have been led by research teams. One such project involved working with participants from two care homes and two day centres using museum objects as a focus (21). Sensory strategies like smell, tactile and sound experiences were explored in addition to reminiscence. Eight to 15 people participated every week, with additional trips to museums every two months. This museum project also incorporated a music experience, using exhibits and photos in the museum. Although similar to initiatives conducted in other countries, a key learning point was how evocative and stimulating the smells, flavours and sounds of Brazil were for residents living with dementia. The smell of coffee, and the sound of “serestas” were associated with a particularly strong affective response.
Further work is required to work out how to enrich care home environments in ways which are sensitive to Brazilian culture and hence work. It is also clear that research is central to establishing such approaches in the mainstream of Brazilian care homes.


Priority area 4 – Benchmarking quality of care

Care provider organisations have a duty of care to protect the safety of clients and to ensure that care meets, and exceeds, minimum acceptable standards. Approaches to quality control and governance in care homes internationally vary and include: professionalism-based regulatory systems, where groups of professionals or provider organisations take responsibility for quality control; inspection-based regulatory systems, where statutory providers send independent staff inspect care homes; and data measurement and reporting based regulatory systems, where audit of minimum dataset submissions are used (5).
Regardless of the approach adopted, there is increasing emphasis across high-income countries on reliable metrics about quality of care, which can enable providers to understand areas which require improvement and to act upon them. A highly established approach uses the international Resident Assessment Instrument (interRAI), an interlinked suite of resources, whereby resident-level assessment conducted by care home staff can inform care protocols and also generate institution level case-mix analyses and quality markers. There are, though, challenges associated with implementing such a detailed and comprehensive approach (22). A contrasting approach – adopted in the Netherlands, Austria, Switzerland, Turkey and one region of the UK – is the International Prevalence Measurement of Care Quality (in Dutch: Landelijke Prevalentiemeting Zorgkwaliteit, LPZ) – which takes a more straightforward, once-yearly audit-based approach to benchmarking and then uses the findings from these observations as the basis of quality improvement (23). These approaches are now being modified to take account of person- and relationship centred care, with inclusion of quality of care from the resident’s perspective included in the Individually Experienced Quality of Long-Term Care (INDEXQUAL) framework, and its adaptations to take account of professional caregivers’ and families’ perspectives (24).
Very little benchmarking data are available in the Brazilian care home sector. Benchmarking using a sub-component of the interRAI has been conducted on a small scale basis as part of a study in 35 homes conducted in Rio Grande do Norte State of Brazil (7). It is therefore feasible within the context of a cross-sectional research cohort study. Further work is required to consider the wider role of benchmarking, its feasibility, its implementation in routine practice, and how it can be used to drive quality improvement. As with other domains described above, the shift to resident- and relationship-centred benchmarking will need specific adaptation to the Brazilian cultural context.



Each of the above priority areas is challenged by the relative under-development of the Brazilian care home sector. It is well established that effective research in care homes requires collaboration, and co-design, between residents and relatives, staff from the care home sector, and academics. There are specific challenges to recruitment and retention of care home staff and residents in research, and to data collection and analysis in care home cohorts, that require sector-specific expertise which takes time to develop.
There is good evidence that an established care home research network can help cultivate the necessary competencies in academic and care home staff, and that the resulting research can drive up standards of care, and generate the case for capacity in the care home sector (25). A highly structured model, such as the South Holland Nursing Home Research Network (26), may be challenged by the limited capacity and relative under-development of Brazilian long-term care as it stands. Other examples, though, are available, such as the UK National Institute of Health Research Enabling Research in Care Homes (EnRICH) model (27), where care homes are recruited as research opportunities become available, with a network slowly developing over time. This might better suit the Brazilian situation.
Most of the work required to address the above priority areas will comprise mixed-methods research. Whilst both positivist biomedical research and inductive qualitative approaches are established in Brazil, researchers from these different backgrounds have not frequently come together. Relationship and team building will be required. In addition, new approaches that can make sense of complex interactive systems, need to be imported. Realist enquiry, with its ability to describe how context affects the mechanisms at play within complex systems, to deliver outcomes that matter, could be useful (28). Implementation science, with its insights into how to implement and sustain evidence-based approaches to care, will be able to provide approaches which can make sense of the wide variation in approaches to care home services across Brazil (29).
As we write this paper, the world in general, and Brazil in particular, is still in the grip of the COVID-19 pandemic. This pandemic has been associated with significant mortality in the care home sector. We do not yet fully understand the extent to which it has impacted upon the Brazilian care homes (3) Internationally COVID-19 has challenged models of healthcare delivery to care homes, remuneration and funding models, how data are collected and collated on care home residents, how staff are trained, and how buildings are designed to maximise quality of life and wellbeing for residents (30). Most of these areas of uncertainty are highlighted by the research priorities which we had already identified in our workshop before the arrival of COVID-19. That they have been reinforced by the pandemic highlights how research to understand each of these domains is central to the development and delivery of good care. The pandemic has laid bare how devastating it can be for care home residents, and society more generally, if we do not prioritise and focus upon these research areas.


Implications for practice and research

This document is presented to provoke discussion and thought. It makes no claims to be representative of all Brazilian academics with an interest in care home research. The strengths of our approach included the use of two face-to-face workshops, one held in Brazil, free-to-attend and publicised through national academic and clinical practice networks. Advanced planning and an open discursive approach at the meeting was designed to give full voice to Brazilian academics from diverse backgrounds, and to enable them to set the agenda and priorities going forward. Limitations are that Brazil is a large country and running our workshop in one city in São Paulo State may have limited the ability of colleagues from more remote parts of the country to attend. Not all Brazilian representatives were able to attend the second workshop in the UK. Brazilian colleagues are not all fluent in English and the workshop may have given prominence to the ideas of those who were most conversant in this language. Laying out in this paper the ideas developed through the workshop programme, represents a further opportunity to discuss important topics and to generate dialogue. We hope that colleagues that we have not hitherto engaged with, will feel empowered to join the debate.
We have highlighted in this paper the need for rapid development in the Brazilian long-term care sector. Close collaboration between care providers and researchers has the potential to accelerate the development of the sector, drive up standards and improve efficiency and effectiveness of care. International collaboration can help accelerate the development of a Brazilian care home research community to support this process.


Funding: The workshops were funded by the UK The Academy of Medical Sciences, Global Challenges Research Fund, reference number AAM 128769. The participation of Paula S Azevedo was financed in part by the Coordenação de Aperfeiçoamento de Pessoal de Nível Superior – Brasil (CAPES) – Finance Code 001. Adam Gordon and Claire Goodman are supported by the NIHR Applied Research Collaborations for East Midlands and East of England respectively. Professor Goodman also receives NIHR support as a NIHR Senior Investigator. The views expressed are those of the authors and not necessarily those of the NHS, the NIHR or the Department of Health and Social Care.

Conflict of interest: The authors have no conflict of interest to declare.

Ethical standards: This international collaborative workshop was exempt from the need for ethical approval under the guidelines of the host countries (Brazil and UK)

Open Access: This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits use, duplication, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license and indicate if changes were made.



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V.L. Keevil1,2,3, A. Liou4, L. Van Der Poel1, S. Wallis1, R. Romero-Ortuno1,5, R. Biram1


1. Department of Medicine for the Elderly, Cambridge University Hospitals NHS Foundation Trust. United Kingdom; 2. Department of Medicine, University of Cambridge. United Kingdom; 3. Cambridge Institute of Public Health, University of Cambridge, United Kingdom; 4. Baylor, Scott and White Medical Center, Temple, Texas, United States of America;
5. Discipline of Medical Gerontology, Trinity College Dublin, Mercer’s Institute for Successful Ageing, St James’s Hospital, Dublin, Ireland. Corresponding author: Dr Victoria L Keevil, Box 135, Department of Medicine for the Elderly, Addenbrooke’s Hospital, Hills Road, Cambridge. CB2 0QQ, Email: vlk20@cam.ac.uk. Tel: 01223 217785;

Jour Nursing Home Res 2020;6:104-108
Published online November 18, 2020, http://dx.doi.org/10.14283/jnhrs.2020.27



We describe the frequency, characteristics and outcomes of emergency admissions to one large university hospital in England from residential and nursing homes. Any older adult (>75 years) admitted as an emergency over two years was included. Patient variables were retrieved from an electronic patient record and living status was established using an official register of care homes and manual inspection of medical records. The rate of emergency admission per bed-year was highest from residential homes (mean 0.68, SD 0.24), with lower rates from nursing (mean 0.49, SD 0.20) and dual-registered facilities (mean 0.49, SD 0.23). Older adults admitted from nursing beds had the highest frailty, illness acuity and inpatient mortality but those from residential beds had the highest odds of 30-day readmission, compared to older adults from their own homes (odds ratio 1.63, 95% confidence interval 1.30, 2.04). Residential home residents are frequent users of emergency inpatient services and may benefit most from enhanced community healthcare.

Key words: Care home, hospital outcomes, frailty.



Care home residents are frequent users of emergency hospital services and admission episodes are often complicated by factors such as delirium and deconditioning (1). However, the rates of emergency hospital admission from care homes vary considerably, suggesting that high rates are not inevitable. Some admissions may be avoidable, in that care could have been delivered equally well in the community, or inappropriate, in that the risks of hospital admission outweigh any potential benefits. Lowering the number of avoidable or inappropriate hospital admissions is not only better for patients but could also help reduce pressure on inpatient hospital services (2).
Several vanguard projects across England have sought to optimize the health of care home residents and reduce avoidable or inappropriate hospital admissions. These projects bring together medical, social and voluntary services in new models of care and this ‘Enhanced Health in Care Homes’ (EHCH) framework is due to be applied more widely (3). However, to date these projects have reported mixed success, with results suggesting care home type is an important consideration and interventions appear more successful in residential than nursing homes (4).
It would be helpful to understand more about the care home residents who access emergency hospital services, in order to better inform interventions aimed at reducing unnecessary hospitalization. The characteristics and outcomes of care home residents admitted to a large university hospital in England were previously described (5). However, older adults admitted from residential versus nursing facilities were not differentiated and this is emerging as an important factor. Therefore, we now present updated results examining whether care home residents are homogenous in terms of their rates of admission, characteristics and hospital outcomes or whether nursing and residential home residents differ in these respects.



All emergency inpatient admissions of adults aged >75 years presenting to one hospital were included in this retrospective, observational study approved by the hospital’s Safety and Quality Support Department (Project register number 7368). Presentations to the Emergency Department (ED) without subsequent admission were not included. Data was collected prospectively over two years via an electronic patient record. Additional information on the methodology is available (Appendix 1).
In brief, age, sex, permanent address, admission weight, ED blood tests, discharge specialty, illness acuity (ED Modified Early Warning Score, ED-MEWS), Clinical Frailty Scale score (CFS) (6) and history of ‘dementia or cognitive concern’ were retrieved . A Charlson Co-morbidity Index (CCI) was retrospectively calculated from discharge diagnoses.
Admission post-code was cross-matched with addresses for care homes registered with the United Kingdom regulator, the Care Quality Commission (CQC), within five local counties. Patient records identified as a ‘match’ were further screened using the first line of the address and records were manually checked if this was discordant. The number of registered beds at each care home and care home type (residential, nursing or dual-registered) were ascertained from the CQC website. Patients from dual-registered homes were further investigated to establish whether a nursing or residential bed was occupied at the time of admission.
The following hospital outcomes were available: 30-day inpatient mortality; prolonged length of stay (≥10 days), delayed discharge (stay >1 day beyond the ‘clinically fit date’) and 30-day readmission.

Data analysis

Rates of admission to our hospital from each care home were calculated by: total number of admission episodes from the care home/ (study time [years] x number of beds in the care home); and described by care home type (nursing / residential / dual-registered).
The sample size was then restricted to the first admission episode for each patient and patient characteristics were described as count with percentage (%), mean with standard deviation (SD) or median with inter-quartile range (IQR). Relationships between living status and hospital outcomes were evaluated using logistic regression (prolonged LOS, delayed discharge and 30-day readmission) and Cox proportional hazards regression (inpatient mortality). Living status was categorized as admission from ‘own home’ versus ‘residential bed’ versus ‘nursing bed’ rather than care home type, since the proportional hazards assumption was violated by those living in dual-registered care homes.



Out of 26,700 admission episodes, 2599 were older adults admitted from a care home (residential: 1365, nursing: 518, dual: 716). The majority were from one county (1933). On average the rate of admission from care homes to our centre was 0.59 admission episodes/bed-year (SD 0.25; median 0.59, IQR 0.42-0.77). Residential homes had the highest rate of admission (mean 0.68, SD 0.24; median 0.73, IQR 0.54-0.83), with lower rates from homes offering nursing care (Dual-registered homes: mean 0.49, SD 0.23; median 0.45, IQR 0.31-0.59; Nursing homes: mean 0.49, SD 0.20; median 0.51, IQR 0.41-0.65).
There were 14,766 first admission episodes with complete data for age, sex and living status (32 episodes deleted). Care home residents were more likely to be older, female, have cognitive impairment, higher frailty and present with higher illness acuity compared to older adults admitted from their own homes, with those occupying nursing beds exhibiting the highest frailty and illness acuity (Table 1).

Table 1
Patient Characteristics by Living Status (Own home vs residential bed vs nursing bed)

#characteristics described as mean (standard deviation) unless otherwise indicated; ## median (interquartile range); ###percentages may not add up to 100% due to missing data. *figures exclude those who died during the inpatient admission episode (n=1014). Kg: kilograms. CFS: Clinical Frailty Score. ED-MEWS: Emergency Department Modified Early Warning Score. CRP: C-reactive protein; CCI: Charlson Co-morbidity Index;’ after the sentence ending kilograms. and before CFS.


Hospital outcomes varied by living status (Table 1) and these trends were further explored using multiple regression. Inpatient mortality was higher in those admitted from a nursing bed, then residential bed, then own home (Appendix 2, Figure 1) and associations persisted after adjustment for demographics, co-morbidity and illness acuity (Table 2). Adjustment for frailty completely attenuated associations between admission from a residential bed and inpatient mortality but admission from a nursing bed remained an independent predictor of inpatient mortality.

Table 2
Associations between living status and hospital outcomes (N= 10 145)

Model 1: age and sex adjusted; Model 2: model 1 + CCI, ED-MEWS category (0–3 ‘low acuity’ and ≥4 ‘high acuity’), discharge specialty (medical versus non-medical), and history of dementia or cognitive concern; Model 3: model 2 + clinical frailty scale category (0–4 ‘up to vulnerable’; 5 ‘mild frailty’; 6 ‘moderate frailty’; 7–8 ‘severe–very severe frailty’; and 9 ‘terminally ill’). Prolonged LOS: N=10,145; Delayed discharge: N=8,482; 30-day re-admission: N=9,527. CCI: Charlson Co-morbidity Index; ED MEWS: Emergency Department Modified Early Warning Score. Those who died during the admission episode were excluded from analyses of delayed discharge and 30 day readmission.


All care home residents had lower odds of prolonged length of stay and delayed discharge compared to older adults admitted from their own home, with the strongest associations in those admitted from nursing beds. However, there was no association between admission from a nursing bed and higher odds of 30-day readmission to hospital whereas admission from a residential bed was a strong predictor of this outcome (OR 1.63, 95% CI 1.30-2.04; Table 2).



We report findings consistent with other studies suggesting that residential home residents have higher rates of emergency hospital admission compared to nursing home residents (4). We also found that admission from a nursing bed is an independent risk factor for inpatient mortality and admission from a residential bed is an independent predictor of 30-day readmission.
Our data is not able to untangle why emergency hospital admission rates are highest from residential homes. It is possible that existing community healthcare resources, which are under considerable strain (7), are less able to support older adults in residential compared to nursing care. This is consistent with interim results from several EHCH vanguard projects, which suggest that strategies such as alignment of care homes with a named primary care practice and improved access to a range of community healthcare professionals are only effective in residential homes (8-11). Care homes that have a nursing component are likely to already have links with such community resources, limiting the benefit of additional resource allocation.
Older adults admitted from residential beds also had higher odds of 30-day hospital readmission, consistent with the higher admission rates from residential homes overall. Each admission is an opportunity to provide older adults access to multidisciplinary comprehensive geriatric assessment (12). For those admitted from residential care, our results suggest this should include a focus on factors influencing readmission. It is likely that residents may need extra support immediately after an acute illness episode, beyond the level normally provided by a residential home, mirroring the experience of older adults discharged back to their own homes (13). We have also observed anecdotally that residential homes sometimes continue to look after residents who develop nursing needs, e.g., during terminal decline. We were unable to find any literature describing the extent of this practice and very little evaluating available support, apart from some evidence of confusion around the roles and responsibilities of healthcare professionals providing end of life care in this setting (14). This is a significant knowledge gap.
Admission from a nursing bed was an independent predictor of inpatient mortality and both residential and nursing home residents presented with higher illness acuity and had higher inpatient mortality compared to older adults admitted from their own homes. This reinforces the need for early advanced care planning and development of personalized treatment plans in both residential and nursing home patients admitted to hospital (12). Our findings also support the development of specialized frailty measures to describe the heterogeneity of the nursing home population since it is likely that our measure of frailty, the CFS, exhibited a ceiling effect (15).
Our study has several limitations. We utilized routinely collected data from one hospital limiting the generalizability of results and our ability to capture all admissions from care homes in our area, although it is unlikely that care homes would routinely transfer residents to multiple different hospitals for urgent care. We also had more missing data than a traditional research study and we did not have data on all desired variables, e.g., admission diagnoses (5). Misclassification of living status may also have occurred, although this error will be less than in other studies where manual inspection of individual patient records was not possible (4).
In summary, older adults living in residential homes have high rates of hospital admission and high odds of 30-day readmission. Residential home residents may benefit most from strategies to strengthen community healthcare resources.


Acknowledgements: We would like to thank the Clinical Informatics team at our centre for their help with data retrieval from the electronic patient record system. There are no conflicts of interest to declare.

Funding: No funding was received to conduct this study. VLK is currently funded by a MRC/ NIHR Clinical Academic Research Partnership grant (MR/T023902/1). RRO is funded by Science Foundation Ireland (https://www.sfi.ie) under the 2018 President of Ireland Future Research Leaders Programme, grant number 18/FRL/6188.

Declaration of Conflicts of Interest: The authors declare no conflicts of interest.





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H.H. Keller1, C.M. Steele2, C. Lengyel3, N. Carrier4, S.E. Slaughter5, J.M. Morrison6, L.M. Duizer7


1. Schlegel-University of Waterloo Research Institute for Aging, Waterloo, Canada; 2. Toronto Rehabilitation Institute, University Health Network, Toronto, Canada; 3. Faculty of Agricultural and Food Sciences, University of Manitoba, Winnipeg, Canada; 4. École des sciences des aliments, de nutrition et d’études familiales, Faculté des sciences de la santé et des services communautaires, Université de Moncton, Moncton, Canada; 5. Faculty of Nursing, University of Alberta, Edmonton, Canada; 6. Department of Kinesiology, University of Waterloo, Waterloo, Canada; 7. Department of Food Science, University of Guelph, Guelph, Canada. Corresponding author: Lisa M Duizer, Department of Food Science, University of Guelph, Guelph, ON Canada, N1G 2W1, Phone: 519-824-4120 ext 53410 Email: lduizer@uoguelph.ca



Abstract: The aim of this research was to examine the prevalence of olfactory impairment in a sample of individuals living in long term care (LTC) homes and to examine associations between olfactory scores and food and fluid intake. Data were collected as part of a cross-sectional study conducted in 32 LTC homes across 4 provinces in Canada. Olfactory capabilities of 300 individuals were estimated using Burghart Sniffin’ Sticks. Food and fluid intake and self-reported olfactory capabilities were also collected. Based on Sniffin’ Stick scores, participants were classified into groups (anosmic vs not anosmic) with the majority (n=273) classified as anosmic. Differences in dietary and body weight data between the two groups were examined using pooled t-tests. No differences existed between olfactory group and body weight, caloric intake, nutrient intake or overall diet quality. Results indicate that older adults in LTC homes have significant olfactory impairments that do not show an association with food and fluid intake.

Key words: Olfactory capabilities, dietary intake, Making the Most of Mealtimes.



Olfactory impairment can have a significant impact on many aspects of an individual’s life, particularly as it relates to nutrition. Individuals with olfactory impairment show an increased risk of poor diet quality (1). Community dwelling women aged 65 who have olfactory losses consume more sweet foods and have a lower preference for fruits and vegetables (2). Recent research however, shows no association between olfactory function and nutritional status when examined using the short and long forms of the Mini Nutritional Assessment (MNA) (3, 4). The MNA tool detects risk of malnutrition through a collation of anthropometric measurements, mobility, food intake and body mass index (5). This tool, however, does not specifically measure food and fluid intake. In one of the few studies where actual nutrient intakes were assessed, no effect of olfactory impairment on macronutrient intake of older Korean adults was found (6). Olfactory impairments, however, were self-reported and not measured using a validated tool. The aim of the current research is to examine the prevalence of olfactory impairment in a sample of older adults living in Canadian long term care (LTC) homes and the associations between olfactory scores when measured using a validated olfaction tool and nutrient and energy intake collected using measures of actual food intake.



Study Design

Data analysed in this paper were resident level factors that were collected as part of the Making the Most of Mealtimes (M3) study, a cross-sectional research project conducted in 32 LTC homes in 4 Canadian provinces (7). The overall aim of the larger study was to identify and measure multi-level determinants (resident-, dining room- and home-level) of food and fluid intake in residents. The complete protocol of the data collection at all levels of the study has been outlined elsewhere (7). The study was approved by research ethics boards from the participating Universities within the four provinces (University of Waterloo, University of Alberta, University of Manitoba, Université de Moncton, University Hospital Network at the University of Toronto and University of Guelph) and from LTC home sites as required.


In each of the 32 homes, residents were randomly selected to take part in the study based on the following inclusion criteria: over the age of 65, informed consent provided by the resident or substitute decision maker, no hospital admission in the previous month, residing in the home for at least one month, consumption of an oral diet, and meals consumed in the dining room. Recruitment of residents occurred until a quota of 20 residents per home was met. In total, 639 participated in the study and of these 300 individuals took part in the olfactory tests. These individuals had the cognitive capabilities (CPS score <3) and consented to be involved in olfactory testing.

Resident Level Measures

To measure olfactory capability, participants (n=300) were presented with the “Sniffin’ Stick” – Screening 12 Test (Burghart Messtechnik GmbH). This measure has high test-retest reliability and has previously been used to characterize individuals based on olfactory capabilities (8). In brief, the “Sniffin’ Stick” test involves presenting participants with a “pen” infused with an odour. To ensure consistency with testing, a trained research assistant removed the lid from the pen and held it approximately 2 cm from each nostril of the participant. After sniffing the pen with each nostril, the participant was asked to identify the odour by pointing to a labelled picture from a choice of four placed in front of them. The research assistant recorded the response prior to moving on to the next pen. In total, 12 pens were presented to participants for sniffing. All participants were allowed to take breaks as necessary. Residents (n=295) also self-reported their olfactory capability by rating their ability to smell food as poor, fair, good or excellent.
Weighed food intake of each participant was collected over three non-consecutive days (2 weekdays and one weekend day) by trained research assistants. Main plate food items were individually weighed before and after each of nine meals and the amount consumed was determined through subtraction. Consumption of beverages, side dishes and snacks was estimated using the production menu and by measuring serving ware. Consumption of food between meals was estimated by observing participants and/or asking residents, family and staff. Food Processor Nutrition Analysis Software version 10.14.1 (Esha Research, Salem, OR, USA) was used for nutrient analysis and estimates of energy (kcal and kcal/body weight), protein (g and g/kg body weight), carbohydrate (g/d) and nutrient intake (Vitamins A, B1, B2, B3, B6 and B12, C, D, E, folate, calcium, copper, iron, magnesium, phosphorus, selenium and zinc). Micronutrient intakes were used to determine nutrient adequacy ratio (NAR) as outlined by Kant (9). For each vitamin, this ratio was calculated as the adjusted intake from food or fluid (no multi-nutrient pills) divided by the recommended dietary allowance (RDA) for the nutrient (by gender and age); a maximum value of 1.0 was used (e.g., intake = RDA). The mean adequacy ratio (MAR) was calculated by averaging the 17 NAR’s. A higher MAR score indicated better diet quality, where a value equal to 1.0 was interpreted as all micronutrients being consumed above the RDA for the resident. Demographic information including age (years), sex (male/female), body weight (kg) and body mass index (BMI), estimated using ulna length, were also collected and used in this analysis.

Statistical Analysis

Number of correct responses obtained for the olfactory test were used to categorize individuals based on their olfactory capabilities: anosmic – 6 or less odours; potentially anosmic – scores of 7 to 10; and normosmic – scores of 11 or 12 (8). Frequency of individuals falling within each category was calculated. The self-reported smell capabilities were then analysed using a one-way analysis of variance (ANOVA) to examine the association between actual smell ability and self-reported olfactory capability.
Given the low number of individuals in the normosmic group (1% of the population), olfactory capabilities were re-categorized into anosmic (those who scored ≤ 8 on the olfactory test) and not anosmic (those who scored greater than 8) as per Hummel (8). Differences in resident characteristics and dietary intakes were examined between these two groups using pooled t-tests for equal variance.


Results & Discussion

Olfactory categorizations shown in Table 1 indicate that the majority of the LTC home residents (over 70%) completing the olfactory test were classified as anosmic. Counts of responses ranged from 11 individuals not able to correctly identify any smells (score of 0) to one person correctly identifying all samples (score of 12). The median score was 5. Others have found similar prevalence rates; prevalence of olfactory impairment has been shown to increase with age where 62.5% between the ages of 80 and 97 have impaired olfaction (10).

Table 1
Categorization of individuals based on actual and self-reported olfactory capabilities

a. Based on categorization by Hummel et al. (8); b. n=300; c. n=295 due to unanswered data


When asked about their olfactory capability, almost 50% of the sample felt that their smell capabilities were “good” (Table 1). Those who self-reported their capabilities to be poor had significantly lower “Sniffin’ Sticks” scores (M = 3.33, SD = 2.42) than those who indicated their smell capability as fair (M = 4.74, SD = 2.39), good (M = 5.58, SD = 2.38) or excellent (M = 5.11, SD = 2.48; F3,291 = 8.88, p < 0.0001) indicating that individuals are aware that they have olfactory losses.
When individuals were reclassified into two groups (anosmic and not anosmic) and groups compared, no differences were found between olfactory ability and body weight, BMI, or any of the dietary intake measures (Table 2). This result confirms previous evidence on lack of an association between olfactory ability when other olfactory measures are used and dietary intake (6, 11).
Given that the smell of a food typically contributes to a desire to consume a food, the results observed in this study may appear counterintuitive. There are, however, a number of reasons why a reduction in olfactory ability does not affect food intake. First, it is well documented that changes to olfactory capabilities are gradual and not easily noticed by individuals (12). This may be one reason why others have not found a relation between olfactory dysfunction and preference for flavor enhanced foods (13, 14). Second, there are other factors, aside from the odours and flavours associated with food that contribute to the desire to eat. The first activity that individuals undergo when food is put in front of them is to look at the food. It is at this point that a judgement is made as to whether or not the food will be consumed. While there is evidence that individuals who consume modified textured diets use the appearance of the food as one indicator to decide if the food is safe for them to eat (15), whether this holds true for individuals consuming a regular textured diet has not been clearly elucidated. Future research should assess the impact of appearance on the acceptability of foods served to individuals in LTC. It may be that by making a food look more appealing, individuals may be more likely to eat it regardless of their olfactory capabilities. Last, for individuals in LTC, mealtime is an important part of the day. While food is essential to mealtimes, the larger context of the dining experience, including interactions with others is also important. Recent research by Trinca et al (16) showed that energy and protein intakes were greater when family/volunteers were present at the meal. It may be that social factors such as this compensate for any olfactory impairments present in the population and may be more relevant to support intake.

Table 2
Resident characteristics (demographics and dietary intakes) based on likelihood of olfactory impairment

a. Differences not examined; b. Mean adequacy ratio calculated by averaging nutrient adequacy ratios for 17 vitamins


Although it is often suggested that individuals with olfactory impairments should be provided with foods with enhanced tastes and smells to improve intake, our results suggest that this strategy may not be useful and that factors other than olfactory impairment are contributing to the high levels of inadequate intake within this population.


Funding: Funding for the Making the Most of Mealtimes project was provided by the Canadian Institutes of Health Research (grant numbers 201403MOP-326892-NUT-CENA-25463)

Conflict of interest: Dr. Keller reports grants from Canadian Institutes for Health Research, during the conduct of the study; Dr. Steele reports grants from National Institutes of Health, other from International Dysphagia Diet Standardisation Initiative, outside the submitted work. No other conflicts have been reported.

Ethical standard: Ethics approval has been received from the University of Waterloo, University of Alberta, University of Manitoba, Université de Moncton, University Hospital Network at the University of Toronto and University of Guelph and from LTC home sites as required.



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J. Wearing1,2, M. Stokes3,4, R.A. de Bie1, E.D. de Bruin5,6


1. Department of Epidemiology, Faculty of Health, Medicine and Life Sciences, School for Public Health and Primary Care, Maastricht University, Maastricht, The Netherlands; 2. Adullam Spital und Pflegezentren, Basel, Switzerland ; 3. School of Health Sciences, University of Southampton, Southampton, United Kingdom; 4. Centre for Sport, Exercise and Osteoarthritis Research Versus Arthritis, Nottingham, United Kingdom; 5. Institute of Human Movement Sciences and Sport (IBWS) ETH, Department of Health Sciences and Technology, ETH Zurich, Zürich, Switzerland; 6. Division of Physiotherapy, Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, Stockholm, Sweden. Corresponding author: Julia Wearing, Department of Epidemiology, Faculty of Health, Medicine and Life Sciences, School for Public Health and Primary Care, Maastricht University, Maastricht, The Netherlands; E-mail: j.wearing@bluewin.ch, Phone: +41 61 2669799

Jour Nursing Home Res 2020;6:93-99
Published online October 22, 2020, http://dx.doi.org/10.14283/jnhrs.2020.25



Background: Handgrip strength and a chair-stand-test are often used to evaluate strength and function, and to detect probable sarcopenia in community-living, older adults. In institutionalized, frail older people, evaluation of muscle performance is of particular importance but it has received little attention. Objectives: To evaluate the feasibility of handgrip strength and the chair stand test in nursing-home residents, and their relation to overall strength, daily functioning and frailty. Design: A cross-sectional study. Setting: A nursing-home in Switzerland. Participants: 30 nursing-home residents, 23 women, age median (range) 86.5 (68-103) years. Measurements: Handgrip strength, the chair stand test, knee extensor and elbow flexor strength, gait speed, activities of daily living and frailty were assessed. The Mann-Whitney-U Test was used to compare sub-groups of sarcopenia (probable sarcopenia versus no probable sarcopenia) while Cohen’s Kappa and Area under the Receiver Operating Characteristic curve examined relationships between tests. Results: All participants were able to perform the handgrip strength test, while only 14 could complete the chair rise test. Probable sarcopenia was detected by handgrip strength in 22 and chair stand test in 24 (8 slow; 16 unable to complete) participants, with an overlap of 19. Probable sarcopenia, detected by each of the tests, was significantly associated with low gait speed and severe frailty status, while low handgrip strength also indicated low elbow flexor and knee extensor strength, and high dependence in activities of daily living. Conclusions: Handgrip strength test is superior to the chair stand test as a strength test to detect probable sarcopenia in nursing-home residents, as it could be completed by more frail people. Sarcopenia-specific cut off values in handgrip strength indicated overall strength, leg function, performance of daily activities and frailty, hence, the test could be used as a screening test for physical condition. Although further research is needed, given the importance of detecting muscle performance, handgrip strength testing is recommended in nursing-home residents.

Key words: Probable sarcopenia, nursing-home residents, handgrip strength, chair stand test, frailty.




Muscle strength is a very important prerequisite for healthy aging (1). It is a predictor of adverse health outcomes, such as dependence in activities of daily living (ADL) and mortality (2) in community-living older adults. Older people whose strength drops significantly due to chronic diseases or inactivity, and who lose independence in daily activities, receive support from home care or become institutionalised in long-term care (3). At admission to the institution, people are assessed for their need of care. However, standardized assessment of muscle status is typically not undertaken (4) even though nursing-home residents are at risk for further strength and functional decline (3, 5). Rather, residents are specifically evaluated for physical capacity only when negative consequences of functional decline, such as falls, occur. Since low muscle strength and function can be improved even in frail older people (6), strength testing is considered important in order to prescribe tailored interventions in a timely manner.
The two strength tests, handgrip strength (HGS) and chair stand test (CST), are quick and easy to perform and reportedly meaningful for health-related outcomes in community-dwelling older people (7). The European Working Group for Sarcopenia in Older People (EWGSOP2) advocates these two tests with distinct cut-off values to detect those likely to have sarcopenia (probable sarcopenia): the HGS of <16 kg for women and < 27 kg for men, and a CST of > 15 seconds (8). In case of probable sarcopenia detection, recommended interventions are initiated to improve strength even if the diagnosis of sarcopenia is not/not yet confirmed (8), as prevention of decline is vital. However, strength testing in long-term care has been little explored (5), despite the urgent need for specific information about muscle performance in this population. Feasibility of strength tests in older nursing-home residents to detect probable sarcopenia is questionable (7, 9). Moreover, the indicative value of probable sarcopenia detected by the EWGSOP2 guidelines for health-related outcomes, such as frailty and ADL dependence, in older nursing-home residents has not been explored to date. The objectives of this study, therefore, were to:
1. Evaluate the feasibility of HGS and CST in nursing-home residents
2. Evaluate the prevalence of probable sarcopenia detected by each test, according to cut off values defined by the EWGSOP2
3. Explore the differences between the sub-groups with/without probable sarcopenia in regard to strength, function, ADL dependence, comorbidities and frailty



Study design

An observational, cross-sectional study to assess muscle strength, physical function and frailty was undertaken in Swiss nursing-home residents between August and December 2017.


Older adults, aged 65 years and over, were screened for exclusion criteria by a certified nurse based on the RAI (Resident Assessment Instrument) which is routinely performed in nursing-home residents. Exclusion criteria were: a) severely impaired decision making (Cognitive performance scale > 4 points); b) a history of acute lower limb pathology (fracture and/or surgery within the last 6 months); c) limb paralysis; and d) confinement to bed. Volunteers who were able to understand study content and signed informed consent, were included in the study. All study procedures complied with the principles of the Declaration of Helsinki for ethical research in humans and the study received approval from the local ethics committee (project-ID 2017-00839).

Sample size

Sample size (n=30) was estimated a priori based on previously published data on prevalence of sarcopenia in nursing-home residents (10). The calculated number would be sufficient to detect a prevalence of 50% at a 90% confidence level and with 85% precision (d = 0.15).

Data collection

Strength measures, the CST, gait speed and the frailty assessment were examined by a physiotherapist trained and experienced in musculoskeletal assessments.
HGS was measured with a hydraulic hand dynamometer (Jamar®, Lafayette, USA) according to the standardized protocol of the American Society of Hand Therapists (11). The maximal value of two trials was used to identify residents with and without probable sarcopenia according to a cut-off value of 16 kg for women and 27 kg for men, as defined by the EWGSOP2 (8).
CST was performed according to a standardized protocol, published by Guralnik (12). The test involves the completion of five chair rises from a full-seated position to upright stance in as short time as possible with the arms crossed over the chest. The time for completion of five chair stands was measured with a stop watch. Classification of “probable sarcopenia” or “no probable sarcopenia” was based on a cut off value of 15 seconds (8).
Participant demographics, medical history, cognitive performance and self-performance in ADL were obtained using the RAI (Minimum Data Set Version 2.0). For evaluation of cognition and ADL, participants’ performance was closely observed by trained nurses and then encoded with the standardized RAI-item coding system.
a) Age was reported in years, height in meters and weight in kg.
b) Medical history included chronic diseases of the metabolic, musculoskeletal, neurological, and respiratory system, psychiatric conditions, renal insufficiency, vertigo and cancer. Number and type of diseases were recorded.
c) Cognitive performance was classified on the Minimum Data Set Cognitive Performance Scale ranging from 0 (= intact cognition) to 6 (= severely limited cognition) points (13).
d) Basic ADL included 10 usual daily activities of nursing-home residents: bed mobility, transfer, dressing, eating/drinking, toilet use, personal hygiene, walking in a room and in a corridor, locomotion on and outside the ward. Each of the 10 activities was rated on a scale from 0 (independent) to 4 (fully dependent), with a full range of 0–40, based on the performance of the last 7 days. Participants were categorized as a) independent in ADL when total score was 0, and as dependent in ADL when total score was ≥ 1, which reflected assistance or staff oversight in at least one activity.

Maximum voluntary isometric contraction strength of the knee extensor and elbow flexor muscles was measured using a hand-held dynamometer (Microfet2®, CompuFET, Hoggan Health Industries, Biometrics Europe). For measurement, the participant was seated with their back resting against a firm support, thighs fully supported. Knee and elbow were flexed at 90° respectively while the participants were asked to push against the dynamometer as hard as possible. The highest value of two trials was recorded. Intraclass Correlation Coefficient (ICC) reported for repeated measures of hand-held dynamometry range between 0.90 and 0.98 in older adults (14).
Habitual gait speed (m/s) was evaluated over a 4-meter, level walkway at participant’s preferred speed. Time was recorded to the nearest hundredth of a second with a stopwatch. Participants were permitted the use of a walking aid. Test-retest reliability of gait speed assessments recorded over comparable distances have been shown to be adequate (ICC of 0.715) and related to measures of physical function (r = 0.554) in older individuals (15).
Physical frailty was evaluated according to Fried’s frailty criteria (16), namely unintentional weight loss < 5kg in the past year, weakness (low HGS), exhaustion (self-report), slowness (slow walking speed) and low physical activity. Participants were classified as “pre-frail” in case of 1-2 positive criteria and as “frail” in case of 3-5 positive criteria.

Statistical Analysis

IBM SPSS Statistics, Version 23 was used for statistical analysis. The Mann-Whitney-U Test was used to compare the sub-groups, probable sarcopenia versus no probable sarcopenia, with respect to strength, physical function, ADL performance and frailty. Feasibility was based on the number of people that were able to complete the EWGSOP2 advocated screening tests for detection of probable sarcopenia. Cohen’s Kappa and the area under the Receiver Operating Characteristic (ROC) curves (AUC) were applied for relationships between the two detection tests and accuracy of the tests to detect frailty status and gait speed.


Descriptive characteristics Of a total of 30 nursing-home residents with median (range) age 86.5 (68-103) years, height 1.62 (1.49-1.72) m and weight 66.5 (35-95) kg, 23 were female. Prefrailty was detected in 13, frailty in 17 participants, and 29 had more than two chronic diseases. The cognitive performance, with 0 being cognitively intact, was median (range) 1 (0-3).
Feasibility of test performance All participants could perform the HGS test, however only 14 participants (47%) could successfully get up from a chair at all. Subsequently, participants who could not complete the CST (n=16) and those who performed slower than the cut off value (n=8) were combined as the slow/no CST group.
Prevalence of probable sarcopenia Low HGS was prevalent in 78% (n=22) while the prevalence of probable sarcopenia detected by slow/no CST was 80% (n=24). Cohen’s Kappa showed an overlap of n=19 between the people assessed by low HGS and those assessed by slow/no CST. The Kappa value of 0.259 (95%CI 0.293-0.311) demonstrates a fair relationship between the two tests (17) (Table 1).

Table 1
Crosstabulation for prevalence and overlap of people with probable sarcopenia detected by low HGS and slow/no CST


Differences between the sub-groups with/without probable sarcopenia Participants with probable sarcopenia detected by low HGS also had lower elbow flexor and knee extensor strength, slower gait speed, were more often dependent in ADL and had more symptoms of frailty than people without (p < .05). However, there was no significant difference in age, height, weight, comorbidities or the ability to perform the CST between sub-groups (Table 2).

Table 2
Differences (median (min-max)) between participants with and without probable sarcopenia detected by low HGS
and low/no CS

Continuous variables are documented as median (range); *p-values with exact significance, 2-tailed; †categorical variables are presented as percentages


Participants with probable sarcopenia detected by slow CST, had significantly slower gait speed and more frailty symptoms than those without. Age, height, weight, strength, ADL performance and comorbidities did not differ between sub-groups (Table 2).
The AUC showed that probable sarcopenia detected by HGS distinguished between frailty statuses to 72% and gait speed to 77%. The CST distinguished between frailty statuses to 85% and gait speed to 79% (Fig. 1 and 2).

Figure 1
ROC curve and AUC: handgrip strength (1a) and chair stand test (1b) accuracy in discriminating frailty status

Figure 2
ROC curve and AUC: handgrip strength (Fig.2a) and chair stand test (Fig.2b) accuracy in determining gait speed



This group of 30 nursing-home residents was heterogeneous in their health and frailty status. However, the participants are representative of institutionalized, older people in regard to muscle strength and physical function (18).
The feasibility of performing the two EWGSOP2 advocated tests differed significantly in this group of nursing-home residents. While all participants could perform the HGS test, more than half of the residents could not stand up from a seated position without the use of their upper limbs. Oldest-old nursing-home residents often experience an excessive loss in muscle strength which might drop below the necessary threshold needed for standing up (19). Hence, the floor effect of the CST observed in this study might limit its usefulness in this population even if participants who have not been able to perform the test were also classified as having probable sarcopenia, as were participants who had results below the threshold. Modifications of the proposed CST performance (8) that are recommended to avoid floor effects in older people suggest to use the 30s CST (7) or the fastest of two chair stands at comfortable speed (20). However, even if the original test was modified to just one repetition, this floor effect would remain as none of the participants in this study who were unable to perform the CST including five repetitions, were able to complete even a single chair stand. The test might be sufficiently meaningful if test results are dichotomized in the subgroups slow/no CST and normal CST.
Moreover, the two tests detected different sub-groups as having probable sarcopenia. The EWGSOP2 advocates that both tests can be used interchangeably as estimates of strength (8). However, they may identify different determinants of muscle strength. HGS may be reflective of overall isometric strength (21) while the CST does not only measure pure muscle strength but also reflects other neuro-muscular properties such as power and balance [25, 26]. Arguably, power and balance are not normally required in nursing-home residents as the chair stand is typically performed slowly with use of arms/hands as additional support (27).
The prevalence of probable sarcopenia was almost threefold higher in this group of nursing-home residents than in community-living older people of similar age (22), and 20% higher than in nursing-home residents who were 10 years younger (23). Nursing-home residents are at particular risk of strength decline (3) due to physical inactivity and malnutrition (1). Given the negative associations of muscle weakness, such as mobility limitations and high risk of falls (1), the high prevalence of probable sarcopenia highlights the need for feasible strength assessment in these individuals to initiate adequate interventions and to avoid further decline.
Overall, both detection tests had an indicative value for gait speed and frailty, while HGS was also suggestive of overall strength and ADL performance in this study of elderly nursing-home residents.
The participants with probable sarcopenia had lower isometric elbow flexor and knee extensor strength than those without, but only when detected by low HGS. This may reflect that HGS is an indicator of general neuromuscular capacity (2, 21) whereas CST covers task-specific capabilities such as leg power (see previous section) (24, 25). Further research is needed to evaluate the relationship between HGS, the CST and different aspects of strength as well as feasible modifications of the CST for the very old population.
The sub-groups differed in gait speed, independent of test for detection by 0.2 m/s. Both tests were almost equally accurate in distinguishing gait speed. An increase of 0.1m/s has been reported to be a substantial change (26) that significantly improves survival after one year (27). Previous literature evaluating physical function in nursing-home residents reported a significant correlation between HGS and gait speed (r = 0.24, p<.001) (23). The present results, applying sarcopenia-specific cut off values for HGS (8), contribute the knowledge that people with low HGS and CST are likely to have gait speed indicating particular risk for falls and hospitalization (28). Hence, detection of probable sarcopenia as an indicator of walking speed, can be used to initiate individual gait assessment.
Regarding ADL, only low HGS could detect differences, not the CST. More people with probable sarcopenia were dependent in ADL than those without, which is consistent with findings reported in community-living older adults (22), and in people across different health care settings (5). Independence in ADL is of particular importance in older people due to its relation to quality of life and health care costs (29). Therefore, HGS had an additional value over CST in this population as it could potentially be used for frequent screening of ADL performance.
Number of comorbidities were not different between sub-groups, independent of the detection test. These findings correspond with previous literature that evaluated the relationship between HGS and the occurrence of comorbidity (≥ 3 chronic diseases) in community-living older adults (30). Hence, low HGS and CST have indicative value for physical function in older nursing-home residents independent of chronic diseases.
Both detection tests of probable sarcopenia might also be useful as screening tests for frailty status with the CST being superior to HGS, since it was more accurate in distinguishing between prefrail and frail nursing-home residents. Even though frailty symptoms occurred in all 30 participants, reflecting a very vulnerable population, the status of frailty is meaningful for adverse outcomes and mortality (16).

Limitations of the study

A limitation of this study is the small number of participants which led to small sub-groups. The findings could therefore be under/overestimated. However, since information about muscle status in nursing-home residents is rare, the findings may still provide indicative evidence for future research. Secondly, participants were only recruited from one nursing-home in Switzerland. However, important health parameters are similar across residents of nursing-homes in Europe, such as functional decline and severity of disability (3). Therefore, the results could be considered generizable to nursing-homes in this continent.



Muscle strength testing is crucial in older people who are at risk for strength decline, as well as for those already experiencing consequences of muscle weakness, such as functional limitations and ADL dependence. The present results provide novel, clinically relevant data about the feasibility of strength tests for nursing-home residents that can be used for detection of probable sarcopenia but also as screening tests for health outcomes. Low HGS as well as slow/no CST demonstrate high prevalence of probable sarcopenia in nursing-home residents, indicating low level of physical function and frailty. However, the CST may not be an implementable measure of strength in clinical practice of nursing-homes, hence, HGS is recommended as a routine test for detection of probable sarcopenia.


Funding: The authors received no specific funding for this work.

Acknowledgments: We would like to thank the nursing-home residents for their participation. We acknowledge Adullam Spital und Pflegezentrum Basel for providing equipment and wish to thank Dr. Hans-Jörg Ledermann for his valuable suggestions during the planning of this research work, and the nursing staff for their help in recruitment and data collection.

Conflict of interest: Julia Wearing declares that she has no competing interests. Maria Stokes declares that she has no competing interests. Rob de Bie declares that he has no competing interests. Eling de Bruin declares that he has no competing interests.

Ethical standards: Volunteers who were able to understand study content and signed informed consent, were included in the study. All study procedures complied with the principles of the Declaration of Helsinki for ethical research in humans and the study received approval from the local ethics committee (project-ID 2017-00839).



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