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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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O.O. Omotowa1, L.C. Hussey2


1. Idaho State University School of Nursing, Idaho Fall, USA; 2. Walden University School of Nursing, Columbia, Maryland, USA. Corresponding author: Omotayo O. Omotowa, Idaho State University School of Nursing, Idaho Falls ID 83402, USA, omotomot@isu.edu, Telephone: 2082821117, Fax: 2082827966

Jour Nursing Home Res 2020;6:90-92
Published online October 9, 2020, http://dx.doi.org/10.14283/jnhrs.2020.24



Adequate nurse staffing levels are critical to nursing homes’ residents’ quality of care outcomes. The number of nurse staffing hours per resident day directly affects being with, and supervising residents’ activities in ways to prevent falls. Studies have shown some negative direct relationships between nurse staffing levels and occurrences of falls in nursing homes. The objective of this report is to examine the relationship between nurse staffing and occurrence of falls in nursing homes. Articles were search from nursing and health care databases such as CINAHL Plus, Academic Search Complete, Medline Complete, and ProQuest Nursing using different levels of nurse staffing, nursing homes, and long-term care. Information was also retrieved from the Center for Diseases Prevention and Control and the Centers for Medicare and Medicaid Services websites. Results showed that increased number of total nurses, increased licensed nurses, and increase ratio of registered nurses to certified nurse aids skill-mix were related to fewer numbers of falls. Falls are detrimental to nursing homes’ older adults’ quality of life. Adequate nurse staffing levels is imperative to maintain the dignity, wellbeing, and quality of life for vulnerable nursing homes’ residents.

Key words: Nursing homes, nurse staffing, falls.



Falls, an adverse event affecting quality of life and wellbeing experiences among nursing homes’ older adults, are an unfortunate common occurrence happening to a large number of this population every year in the United States. The occurrence of falls is reported to be happening to 50%-75% of the 1.4 million older adult nursing homes’ residents every year in the United States (1). Frailty and reduced physiological functionality predispose this population to increased danger of falling. In some cases, the older adult residents sustain injuries such open wounds, fractures, and traumatic brain injury that lead to functional disability, morbidity, poor quality of life, and/or eventual deaths (1-5).
Older adults residing in nursing homes experience worse outcomes and complication rates after falls and upon admission to the hospital when compared to their community counterparts (5-6). Impact of falls on the residents and their families continue to be a source of concern for all nursing homes health care stakeholders. In general, studies showed that causes of falls among the older adults population were mostly due to the presence of multiple diseases, cognitive impairment, increased mobility and physical activities, poly-pharmacy, urinary incontinence, unsafe gait/balance difficulty, weak body parts, malnutrition, limb impairment, decreased peak muscle power, and inadequate safety equipment (2, 4, 7, 8). In nursing homes, successful prevention of falls measures would involve assessment and identification of risk factors, especially the modifiable factors, and effective focused intervention activities (2, 9) by adequate number of higher skilled nurse staffing.
Some studies have revealed that nursing homes residents experience falls in different locations such as hallways, dining rooms, lounges, and the greater occurrences associated with fractures happen in the residents’ bedrooms and bathrooms (5, 10). Majority of the falls among residents happened during unknown activities (this implies that the staff was unaware of what and how happened when the falls occurred), followed by when walking and transferring; and, infrequently during reaching, sitting, and standing (5, 10). Residents were also found to fall during all hours of the day, with the most incidences happening in the early morning hours from 5 a. m to 8 a. m (5). This time window is when care delivery process is heightened and the need for nursing care and assistance by the older adults from nurses is usually higher.


The Relationship between Nurse Staffing Levels and Falls

Adequate nurse staffing levels are critical to nursing homes’ residents’ quality of care outcomes. Different levels of nurse staffing, skills-mix, and total nurses’ hours were studied as predictors of falls, with or without serious injuries, among the nursing homes’ residents (11-14). Researchers examined the impact of nurse staffing on falls incidences using total nurse (TN) hours per resident day (HPRD) and registered nurse skill-mix (11); registered nurse, registered nurse skill-mix, and certified nurse aide HPRD (14); and certified nurse aide and licensed nurse HPRD (13). These studies showed that insufficient number of nurse staffing HPRD, staffing to resident ratio, and inadequate registered nurse skill-mix affect the process and quality of care provided to the residents, including assessment, being with, caring for, and supervising their cares and activities for fall prevention. An overview of the studies reviewed is shown in Table 1.

Table 1
An overview of studies reviewed

Figure 1
Illustration of the relationship of nurse staffing levels/hours and occurrence of falls


Researchers found out that higher number of TN (certified nurse aide and registered nurse) staffing per 100 residents (12), increase registered nurse HPRD, increase staffing to resident ratio, and increase registered nurse to certified nurse aide skills-mix (14, 16) contributed to reduced fall rate. Findings also showed that consistent staffing and higher certified nurse aide, registered nurse, and licensed practical nurse HPRD (13, 16) were related to fewer number of fall incidences in nursing homes and facilities providing long term care services for the older adults. In determining the registered nurses and licensed practical nurses’ knowledge on eight causes of falls, Gray-Miceli, de Cordova, Crane, Quigley, & Ratcliffe (17) found that registered nurses had higher average knowledge scores than the licensed practical nurses, even though neither correctly identified all the causes of falls among the older adults. The authors considered registered nurses’ scores an indication of better performance in falls prevention (17); making increased registered nurse staffing level a positive factor in reduction of falls.
A few of the studies showed mixed outcomes of the relationships of nurse staffing and falls among the older adults in nursing homes or long term care facilities (13-15). A lack of statistically significant relationships were reported between occurrence of falls and nurse staffing levels or skills-mix; and all direct care nurse staffing HPRD including certified nurse aide, nurse aide, licensed vocational nurse, baccalaureate prepared registered nurse, trained feeding assistants, untrained staff, and trainees (11, 14-15). A mixed methods study on newly admitted short-stay nursing homes residents concluded that licensed nurses (registered and licensed practical/vocational nurses) were not significantly associated with falls (13). A study by Backhaus et al. (18) showed an increase in probability of falls among the older adults in somatic facilities (wards that provide care for residents with physical disabilities) that employed baccalaureate prepared registered nurses.
It is evident that inadequate nurse staffing hours and unlicensed nurse skills are detrimental to nursing homes older adults’ safe and quality of care processes and outcomes. Falls are increasingly prevalent among the older adult nursing homes’ residents due to their frailty, aging process, medical conditions, and vulnerability. Adequate and appropriate nurse staffing levels are necessary for avoidance of falls and maintenance of wellbeing, dignity (19), and quality of end of life for the nursing homes older adults.


Conflict of interest: The authors did not get financial support nor had an affiliation with any organization with any financial or non-financial interest in the subject matter discussed in this article.

Ethical Standards: This article does not violate any ethical standards. It does not involve one-on-one interaction with human or animal participants.



1. Center for Disease Control and Prevention. Home and recreational Safety: Important facts about falls, 2017. Retrieved from https://www.cdc.gov/homeandrecreationalsafety/falls/adultfalls.html
2. Álvarez Barbosa F, Pozo-Cruz B, Pozo-Cruz J, et al. Factors associated with the risk of falls of nursing home residents aged 80 or older. Rehabilitation Nursing 2016; 41(1): 16.
3. Cantalice Alves AH, Freire de Araújo Patrício AC, Fernan des de Albuquerque K, et al. Occurrence of falls among elderly institutionalized: prevalence, causes and consequences. Revista De Pesquisa: Cuidado E Fundamental 2016; 8(2): 4376-4386.
4. Damián J, Pastor-Barriuso R, Valderrama-Gama E, de Pedro-Cuesta J. Factors associated with falls among older adults living in institutions. BMC Geriatrics 2013; 13(6): 1-9.
5. McArthur C, Gonzalez DA, Roy E, Giangregorio L. What are the circumstances of falls and fractures in long-term care? Canadian Journal on Aging / La Revue canadienne du vieillissement 2016; 35(4): 491-498.
6. Botwinick I, Johnson JH, Safadjou S, et al. Geriatric nursing home falls: A single institution cross-sectional study. Archives of Gerontology and Geriatrics 2016; 63: 43-48.
7. Clancy A, Balteskard B, Perander B, Mahler M. Older persons’ narrations on falls and falling–Stories of courage and endurance. International Journal of Qualitative Studies on Health & Well-Being 2015; 10: 1-10.
8. Lannering C, Ernsth Bravell M, Midlöv P, Östgren C, Mölstad S. Factors related to falls, weight-loss and pressure ulcers – more insight in risk assessment among nursing home residents. Journal of Clinical Nursing 2016; 25(7/8): 940-950.
9. Kadono NA, Pavol MJ. Effects of aging-related losses in strength on the ability to recover from a backward balance loss. Journal of Biomechanics 2013; 46(1): 13–18.
10. Robinovitch S, Feldman F, Yang Y, et al. Video capture of the circumstances of falls in elderly people residing in long-term care: an observational study. Lancet n.d; 381(9860): 47-54.
11. Backhaus R, van Rossum E, Verbeek H, et al. Quantity of staff and quality of care in Dutch nursing homes: A cross-sectional study. Journal of Nursing Home Research 2016; 2: 90-93.
12. Sandoval Garrido FA, Tamiya N, Kashiwagi M, et al. Relationship between structural characteristics and outcome quality indicators at health care facilities for the elderly requiring long-term care in Japan from a nationwide survey. Japan Geriatric Society 2014; 14(2): 301-308.
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16. Horn SD, Hudak SL, Barrett RS, Cohen LW, Reed DA, Zimmerman S. Interpersonal care processes, falls, and hospitalizations in green house and other nursing homes. Seniors Housing & Care Journal 2016; 24(1): 31-46. Retrieved from http://www.nic.org/analytics/publications/seniors-housing-care-journal/
17. Gray-Miceli D, de Cordova PR, Crane GL, Quigley P, Ratcliffe SJ. Nursing home registered nurses’ and licensed practical nurses’ knowledge of causes of falls. Journal of Nursing Care Quality 2016; 31(2): 153-60.
18. Backhaus R, van Rossum E, Verbeek H, et al. Relationship between the presence of baccalaureate-educated RNs and quality of care: a cross-sectional study in Dutch long-term care facilities. BMC Health Services Research 2017; 17(53): 171-179.
19. Centers for Medicare & Medicaid Services. (2015). Nursing home data compendium 2015 edition. Retrieved from https://www.cms.gov




E.P. Arble1, S. Shankar1, S.W. Steinert1, A.M. Daugherty2


1. Department of Psychology, Eastern Michigan University, Ypsilanti, MI, USA; 2. Department of Psychology, Department of Psychiatry and Behavioral Neurosciences, Institute of Gerontology, Wayne State University, Detroit, MI, USA. Corresponding author: Eamonn P. Arble, Department of Psychology, Eastern Michigan University, Ypsilanti, 341 Science Complex, Ypsilanti, MI 48197. Email: earble2@emich.edu

Jour Nursing Home Res 2020;6:89
Published online October 7, 2020, http://dx.doi.org/10.14283/jnhrs.2020.23


Dear Editor,

The COVID-19 pandemic has created a crisis in nursing home facilities across the United States (1). Workers in these facilities are carrying a tremendous burden, facing the anxiety of possible infection, grief from the loss of those in their care, and increased workloads (2). As a result, nursing home workers are experiencing a variety of emotional consequences, including symptoms of mood disorders and posttraumatic stress disorder (PTSD) (3). Given these challenges, the role of psychosocial support among nursing home workers should be carefully considered, as it may predict overall emotional functioning.
We examined this among nursing home employees (N = 103, age 24-79 years; 90% female; 72.8% Caucasian) in the Metro Detroit region who were surveyed anonymously, online April 29 to May 14, 2020. A wide range of PTSD (range = 0-62; M = 20.56, SD = 16.76), depression (range = 0-20; M = 4.27, SD = 4.79), anxiety (range = 0-18; M = 3.29, SD = 3.84), and stress symptoms (range = 0-18; M = 6.14, SD = 5.02) were reported, with some workers demonstrating clinical elevations. Across all measures, poorer relationship quality was associated with greater symptom severity (all p < 0.001) of PTSD (ρ = 0.62), depression (ρ = 0.58), anxiety (ρ = 0.50) and perceived stress (ρ = 0.63).
In our sample, those reporting poorer relationship quality also reported greater symptoms of affective disturbance. This is a clear indication that nursing home workers experiencing relational deficits may be at increased risk for emotional disruption. This finding aligns with previous research (4). Greater emotional strain calls for increased social support, but the ability to receive such support can be diminished in the face of quarantines and fears of infection. Unfortunately, workers in nursing homes may find themselves becoming increasingly isolated at precisely the time when they could most benefit from their interpersonal connections. Nursing home workers, administrators, and researchers should thus investigate mechanisms to obtain psychosocial support in the midst of quarantine, particularly when workplace strain has increased. Developing a workplace culture within nursing homes that facilitates and encourages workers to identify and connect with sources of emotional support may be critical as we continue to navigate the COVID-19 pandemic.


Acknowledgments: This work was not externally funded. All authors declare to have no conflict of interests in regard to this work.

Conflicts of interest: The authors have no conflicts of interest to disclose.

Ethical standard: The study was approved by the institutional review boards at Eastern Michigan University and Wayne State University.



1. Davidson PM, Szanton SL. Nursing homes and COVID-19: We can and should do better. Journal of Clinical Nursing 2020; 29: 2758–2759.
2. Dorritie R, Quigley DD, Agarwal M, Tark A, Dick A, Stone PW. Support of nursing homes in infection management varies by US State Departments of Health. Journal of Hospital Infection 2020; 105: 258–264.
3. Rossi R, Socci V, Pacitti F et al. Mental Health Outcomes Among Frontline and Second-Line Health Care Workers During the Coronavirus Disease 2019 (COVID-19) Pandemic in Italy. JAMA Network Open 2020; 3: e2010185.
4. Williams KL, Galliher RV. Predicting depression and self-esteem from social connectedness, support, and competence. Journal of Social and Clinical Psychology 2006; 25: 855–874.


J. De Kerimel1, N. Tavassoli1, C. Mathieu1, P. De Souto Barreto1,2, C. Berbon1, H. Blain3, B. Vellas1,2, Y. Rolland1,2

1. Gérontopôle de Toulouse; 31059 Toulouse, France; 2. INSERM 1027; 31059 Toulouse, France; 3. Pole Gérontologie. Montpellier University Hospital, Montpellier University, MUSE, Montpellier, France. Corresponding author: Professor Yves Rolland, Gerontopôle de Toulouse, 20 rue du Pont Saint Pierre, 31 059 Toulouse, France; Tel: 05 61 77 64 45, E-Mail : rolland.y@chu-toulouse.fr

Jour Nursing Home Res 2020;6:82-88
Published online September 30, 2020, http://dx.doi.org/10.14283/jnhrs.2020.22


Background: Few researches describe old people living in residential homes despite this population being reported to consume much of medical care. Our hypothesis is that many older people living in these structures are frail and that residential home may be targeted places for the implementation of strategy to prevent functional decline. Objective: Our goal is to describe the geriatric characteristics of older people living in residential homes. Methods: This study was a cross-sectional, observational survey carried out in residential homes in Toulouse (France). A questionnaire covering general informations about the residential homes and services offered to residents and a self-assessment questionnaire for all residents (including, FinD questionnaire for frailty, SARC-F for sarcopenia, loneliness, and depressive symptoms, fear of falling) were completed. Results: 1,274 older adults living in 29 residential homes received the questionnaire and 807 (63.3%) people participated (mean age; standard deviation, SD = 83.0; 9.5, female 74.5%). A large majority are not disabled (mean ADL score; SD = 5.4; 0.9), lived alone (83.9%) and suffer from loneliness (29.8%). More than half were positively screened for frailty (53.7%) and 37.2% for sarcopenia; 53.5% had depressive symptoms, and 59.1% reported a fear of falling. Conclusion: Our study suggests that prevalence of frailty in older people living in residential homes is high. This result supports that older people living in residential homes could be a target population to implement strategy to prevent functional decline.

Key words: Frailty, residential home, ICOPE, prevention.



In France, residential homes are institutions for older people that can be described as intermediaries: they host older adults between the community-dwelling people who are mainly autonomous subjects and the Long-Term Care (LTC) residents where dependent older people live. Residential homes offer residents common and personalized equipment or services, which vary from one institution to another and whose use is optional. Older people who live there are considered institutionalized. Residential homes are frequently the first step before living in LTC Facilities (LTCFs), when higher level of care is needed. Resident in residential homes may own or rent their homes. Both family doctors and healthcare professionals (eg, nurses, physiotherapist) respond to their patients in the same way as in the community without a structured organization of care in these facilities as it exists in LTC Facilities (LTCFs). A French national survey reports that residential homes have 101,880 beds among the 727,930 places in all aged care facilities (1) (13.99% of all the places of institution for older adults). This survey reports that 77.3% of residents living in residential home are barely or not dependent on basic activities of daily living. Residents enter about 5 years younger than in the LTCFs (80 years and 8 months versus 85 years and 3 months). Clinical profile and health events of these residents are almost unknown in France and abroad. A recent study in the UK shows that the rate of transfer to the emergency room per year and by bed of older people living in residential homes is significantly higher than that observed in LTCFs (around 68% versus 49% respectively) (2). Other studies in Asia point out that the usual practice in residential homes is to hospitalize residents when an acute problem occurs (3).
This high rate of use of care services in a still autonomous population suggests that this population is frail and could therefore be a suitable population for the implementation of interventions to prevent functional decline. Research in Australia confirms that many subjects living in residential homes are frail (up to 60% using THE FRAIL-NH score) (4) and that their use of hospitalizations is high (5). The current organization of care in these facilities does not seem to be currently focused on strategies for detecting frailty or towards actions to prevent functional decline. However, observational data suggests that in residential homes, an environment conducive to the maintenance of functional capacities is associated with a lower prevalence of frailty (6), suggesting that lifestyle may influence the functional decline of these residents.
Our aim is to describe the geriatric characteristics of older people living in residential homes. Our hypothesis is that many older people living in these structures are frail and that residential homes may be targeted places for the implementation of strategy such as ICOPE (Integrated Care for Older People) to prevent their functional decline (7).




This study is a cross-sectional, observational and descriptive survey of older people living in residential homes. LTCFs or nursing home settings were not involved in this work. Residential homes in the center and suburbs of Toulouse (South-West, France) were contacted by email and phone call and invited to participate in the study. The administrative directors of these facilities were met during a physical interview to explain the purpose of the investigation.


Before data collection, an information meeting was held in each residence to inform residents and their families of the investigation. A poster for the residents, their families and the health care professionals involved was also placed at the reception of each facility. The data collection was carried out over a four-month period (from April 2nd to July 2nd, 2017) for all residential homes and for the resident. Residents could get help from a third party such as a family caregiver in the event of difficulties. A member of the research team (Gérontopôle of the University Hospital of Toulouse) was able, in a place that respected confidentiality, to help people if they had any trouble filling in the forms.

Variables of interest

Two questionnaires were filled out: the first questionnaire provided by the Administrative Director of the residential homes, covered general information about the facility and services offered to residents. This questionnaire provided information on the administrative characteristics of the residential home, the waiting time for the residents before entering the facility, the number of residents in the facility and the number of residents participating in prevention activities. Type of prevention activities (physical activity, nutritional activity, memory workshop, others) organized in the facility was collected.
The second questionnaire was composed of self-reported questions and scales, explained and provided by the administrative directors of the institutions to all their residents. This self-reported questionnaire was accompanied by an information leaflet. The self-reported questionnaire asked for: marital/living status (alone, spouse, other), age, sex, frailty screening (using the FiND (Frail Non-Disabled) instrument) (8), functional status (Katz ADL score for the 6 items of the basic activities of daily life (9) and the 8 items of the Lawton IADL for the instrumental activities of daily life) (10), fear of falling («Are you afraid of falling?» yes/no) and its impact (Does this fear lead you to reduce your activity? yes/no), memory complaint («Do you complain about memory? yes/no), depressive symptoms (Mini-GDS Scale) (11), sleep disturbances (Do you have sleep difficulties? yes/no), feeling of loneliness (Do you suffer from loneliness? yes/no), nutritional status (Body Mass Index (BMI) defined by weight divided by squared height; BMI of less than 21 was considered underweight), screening for sarcopenia (SARC-F Questionnaire) (12), hearing (Are you embarrassed to hear ? Due to hearing disturbances, are you embarrassed for the acts of everyday life) and visual disturbances (due to visual disturbances, are you embarrassed to distinguish faces? are you embarrassed to move? are you embarrassed for other activities?).
The questionnaire FiND (8) is a self-questionnaire with a very good ability to correctly identify frail elderly people living in homes. This questionnaire consists of 5 questions: A. Do you have difficulty walking 400 meters? B. Do you have difficulty climbing stairs? C. In the past year, have you unintentionally lost more than 4.5 kg? D. How many times in the last week have you felt that everything you did was an effort or that you couldn’t go? E. What is your level of physical activity?
If A+B≥1, the individual is considered dependent. If A+B = 0 and C+D+E≥1, the individual is considered frail. If A+B+C+D+E = 0, the individual is considered robust. This questionnaire identifies seniors living at home with an increased risk of functional decline. FiND is a tracking tool to identify at risk subjects, with a pertinence close to the reference assessment tools such as the criteria of Fried’s phenotype criteria.
The SARC-F (12) is a simple five-items questionnaire based on the cardinal characteristics or consequences of sarcopenia: Strength, Aids for walking, ability to Rise from a chair, and Climb stairs, and risk of Falls. The score ranges from 0 to 10. Subjects are considered sarcopenic if the score is ≥4 and the subject is considered non-sarcopenic if the score is 0 to 3 (12).
The Mini-GDS consists of 4 questions and has demonstrated excellent reliability for detecting depressive symptoms in older adults compared to the well validated 30 items GDS scale (11).
All information was provided anonymously and on a voluntary basis. This investigation has been validated by the Toulouse University-Hospital according to the French ethic and regulatory law (Registration number: RC31/17/0068).



A total of 29 residential homes in Toulouse and the suburbs of Toulouse volunteered, 18 residential homes (with 3 establishments run by private commercial or associative groups), and 11 intergenerational facilities (i.e. apartments suitable for seniors). The admission period was more than 1 year for 83.6% of residents and more than 5 years for 31.01%. 44.1% of residents participate in prevention activities proposed by the facilities. These residents participate in balance and physical activity workshops (28.8%), memory workshops (29.5%), nutrition workshops (4.9%) and other workshops (2.8%).

Table 1
Characteristics of the Population living in Residential facilities (n=807)

Notes. FiND, Frail Non-Disabled» [FiND] instrument; ADL, Activity of Daily Living; IADL Instrumental Activity of Daily Living; SARC-F Questionnaire that assessed Strength, Assistance walking, Rise from a chair, Climb stairs and Falls; GDS, Geriatric Depression Scale; BMI, Body Mass Index=Weight/Height².


A total of 1,274 older people received the questionnaire. It was completed by 807 people (63.3%). The response rate per residence varies from 29% to 100%. Resident characteristics are reported in Table 1. In our survey, the typical profile of an older adult living in a residential home is a 83.0-year-old woman, living alone, autonomous for the basic activities of daily life but having difficulties in 2 to 3 instrumental activities of daily life. More than once in two resident is frail. They are rarely robust. In this population, about 4 out of 10 people were positively screened for sarcopenia, 15% are malnourished (BMI<21) and 19% are obese (BMI≥30). Six out of 10 residents are afraid of falling and this fear reduces their involvement in activities in a quarter of cases. A memory complaint is reported by 41.6% of respondents, 24.7% have sleep problems. About one in two people have depressive symptoms and one-third of people complain of loneliness. 6.3 to 31.3% residents have sensory disorders (sight, hearing) that affect their daily life.



In residential home, 53.7% of older adults are frail according to the FiND questionnaire. Prevalence of frailty has been reported to be between 3 to 20% in middle-aged and older community-dwelling Europeans (13). Frail older adults are exposed to various adverse events such as falls, hospitalizations (14) and to a rapid functional decline especially when the uncoordinated and fragmented care are provided (15). This makes the frail older population a target group for the organization of integrated care (16). Our survey shows that seniors living in residential homes are a target group for the organization of preventive measures. The various geriatric areas explored in our survey allow us to consider strategies for preventing functional decline. The lack of coordination of care by a team of caregivers, as it exists in LTCFs, should lead to consider relevant innovative models for primary care.
A care model that could be tested in such a frail, non-disabled population is the WHO Integrated Care for Older People (ICOPE) program for primary care and social services. This community approach initiates a personalized and integrated approach to maintaining the intrinsic abilities of older adults to prevent disability (17). ICOPE offers pre-established models for assessing, responding to and monitoring intrinsic capacities (mobility, vision, hearing, cognition, mood, nutrition) that complement traditional care for chronic diseases, with the aim of preventing dependency (Table 2). The screening test can be carried out by a health professional but also by self-assessment of the patient (or aid of a family caregiver) using a mobile application (App) or BOTFRAIL (conversational robot on the Internet) (18,19). We believe this approach would be particularly relevant in the context of residential facilities. Only 30% of residents participated in physical activity and balance or nutrition programs.
Our study presents the methodological limitations of a self-reported cross-sectional survey. The lack of data on comorbidities and the use of care services (such as hospitalizations or emergency room transfers) and the number of non-responder residents (36.7%) are limits of this research. However, there is currently little information to describe the population living in residential homes in France and our results support the data of the international literature (2, 3).

Table 2
Screening Tool for the “Integrated Care for Older Persons” (ICOPE)


In conclusion, the elderly living in residential homes are mostly frail patients. Our work opens up opportunities for preventive strategies against functional decline on this population. In light of these results, future research should evaluate the implementation of the ICOPE program in residential homes.

Conflict of interest: All the authors declare no conflict of interest.


1. DRESS Survey 2015 https://drees.solidarites-sante.gouv.fr/IMG/pdf/14-10.pdf
2. Keevil VL, et al. Emergency hospital admissions in older adults from residential and nursing homes: frequency, characteristics and outcomes. JNHR 2020
3. J Kh Luk. End-of-life services for older people in residential care homes in Hong Kong. Hong Kong Med J 2018 Feb;24 (1):63-67.
4. Theou O, Tan EC, Bell JS, Emery T, Robson L, Morley JE, Rockwood K, Visvanathan R. Frailty Levels in Aged Care Facilities Measured Using the Frailty Index and FRAIL-NH Scale. J Am Geriatr Soc. 2016 Nov;64(11):e207-e212.
5. Theou O, Sluggett JK, Bell JS, Lalic S, Cooper T, Robson L, Morley JE, Rockwood K, Visvanathan R. Frailty, Hospitalization, and Mortality in Residential Aged Care. J Gerontol A Biol Sci Med Sci. 2018 Jul 9;73(8):1090-1096.
6. Zhu A, Yan L, Wu C, Ji JS. Residential Greenness and Frailty Among Older Adults: A Longitudinal Cohort in China. J Am Med Dir Assoc. 2020 Jun;21 (6):759-765.e2.) suggesting that lifestyle may influence the functional decline of these residents.
7. Sanchez-Rodriguez D, Annweiler C, Gillain S, Vellas B. Implementation of the Integrated Care of Older People (ICOPE) App in Primary Care: New Technologies in Geriatric Care During Quarantine of COVId. The Journal of Frailty and Aging. 2020:1.
8. Cesari M, Demougeot L, Boccalon H, Guyonnet S, Abellan Van Kan G, Vellas B, Andrieu S. A self-reported screening tool for detecting community-dwelling older persons with frailty syndrome in the absence of mobility disability: the FiND questionnaire. PLoS One. 2014 Jul 7;9(7):e101745.
9. Hartigan I. A comparative review of the Katz ADL and the Barthel Index in assessing the activities of daily living of older people. Int J Older People Nurs. 2007 Sep;2 (3):204-12.
10. Graf C. The Lawton instrumental activities of daily living scale. Am J Nurs. 2008 Apr;108(4):52-62.
11. Clement JP, Nassif RF, Léger JM, Marchan F. Development and contribution to the validation of a brief French version of the Yesavage Geriatric Depression Scale. Encephale. 1997 Mar-Apr;23(2):91-9.
12. Malmstrom TK, Miller DK, Simonsick EM, Ferrucci L, Morley JE. SARC-F: a symptom score to predict persons with sarcopenia at risk for poor functional outcomes. J Cachexia Sarcopenia Muscle. 2016 Mar;7(1):28-36.
13. Santos-Eggimann B, Cuénoud Patrick, Spagnoli Jacques, Junod Julien. Prevalence of frailty in middle-aged and older community-dwelling europeans living in 10 countries. J Gerontol A Biol Sci Med Sci 2009;64:675-81
14. Hoogendijk EO, Afilalo J, Ensrud KE, Kowal P, Onder G, Fried LP. Frailty: implications for clinical practice and public health. Lancet. 2019 Oct 12;394 (10206):1365-1375.
15. Clegg A, Young J, Iliffe S, Rikkert MO, Rockwood K. Frailty in elderly people. Lancet. 2013 Mar 2;381 (9868):752-62.
16. Sadler E, Potterton V, Anderson R, Khadjesari Z, Sheehan K, Butt F, Sevdalis N, Sandall J. Service user, carer and provider perspectives on integrated care for older people with frailty, and factors perceived to facilitate and hinder implementation: A systematic review and narrative synthesis. PLoS One. 2019 May 13;14(5):e0216488.
17. Cesari M, Araujo de Carvalho I, Amuthavalli Thiyagarajan J, Cooper C, Martin FC, Reginster JY, et al. Evidence for the Domains Supporting the Construct of Intrinsic Capacity. J Gerontol A Biol Sci Med Sci. 2018;73(12):1653-60.
18. Sanchez-Rodriguez D, Annweiler C, Gillain S, Vellas B. Implementation of the Integrated Care of Older People (ICOPE) App in Primary Care: New Technologies in Geriatric Care During Quarantine of COVId. The Journal of Frailty and Aging. 2020:1.
19. Takeda C, Guyonnet S, Sumi Y, Vellas B, Araujo de Carvalho I. Integrated Care for Older People and the Implementation in the INSPIRE Care Cohort. J Prev Alzheimers Dis. 2020;7(2):70-4.



M.H. Huang1, A. Burnham3, L. Doyle4, D. Fry2, L. Wiske4, M. Kolanda4, E. Khitrik4, J. Goode4, H. Smith4, K. Shea4, N. Houston4


1. Physical Therapy Department, College of Health Sciences, University of Michigan-Flint. Flint, MI, USA; 2. College of Health Sciences, University of Michigan-Flint. Flint, MI, USA; 3. The Boston Home. Boston, MA, USA; 4. Doctor of Physical Therapy Program, Franklin Pierce University. Manchester, NH, USA. Corresponding author: Min H. Huang, PT, PhD, 2157 William S. White Building, 303 E. Kearsley Street, Flint, MI 48502-1950, USA, Email: mhhuang@umich.edu, Phone: 810-762-3373, Fax: 810-766-6668


Jour Nursing Home Res 2020;6:78-81
Published online September 17, 2020, http://dx.doi.org/10.14283/jnhrs.2020.21



This study examined the outcomes of 10-week daily resistive inspiratory exercise in 34 adults with advanced multiple sclerosis (MS) in a long-term care facility. Respiratory muscle strength (maximum inspiratory [MIP] and expiratory pressure [MEP]) and fatigue (Modified Fatigue Impact Scale-5) were measured at pre-test, post-test, and 8-week retention. Activity participation (days/week attending group social activities) and respiratory infections were analysed during the baseline, exercise, and retention. Participants were aged 60.0±8.5 years and non-ambulatory (Expanded Disability Status Scale = 8.5±0.4). MIP (p=0.02) and activity participation (p=0.019) differed significantly by time. Bonferroni post-hoc analysis revealed that MIP was greater at post-test (41.6%±23.9%) than pre-test (35.6%±22.0%) (p=0.004), and participants attended more social activities during exercise phase (5.0±3.4 days/week) than baseline (4.0±2.1 days/week) (p=0.043). Fatigue did not change by time. Among the participants, 18%, 6%, and 9% had respiratory infections during baseline, exercise, and retention, respectively. Resistive inspiratory exercise improved activity participation without worsening fatigue during the course of exercise in persons with advanced MS.

Key words: Respiratory, resistive inspiratory exercise, rehabilitation, activity participation, multiple sclerosis.



In persons with multiple sclerosis (MS), respiratory muscle weakness is associated with disability (1), respiratory dysfunction, and mortality (2). Among various respiratory training methods for persons with MS, resistive inspiratory exercises have consistently increased inspiratory muscle strength (3). A daily 10-week exercise program using a threshold inspiratory trainer (IMT) has demonstrated efficacy on improving inspiratory muscle strength in persons with advanced MS (4). By improving ventilation, oxygen uptake, and exercise endurance (5), resistive inspiratory exercises may positively impact a broader range of health outcomes beyond respiratory muscle strength in persons with advanced MS.
Restrictions in activities, fatigue, and respiratory infections are major concerns in persons with MS. Over 70% of non-ambulatory persons with severe MS have reduced participation in social/lifestyle activities, such as social occasions, pursuing hobby, or outdoor activities (6). Fatigue is a leading complaint affecting 80% of persons with MS (7). MS increases the risk of serious respiratory infections (hazard ratio = 1.31) (8). The investigation of effects of IMT exercises on activity participation, fatigue, and respiratory infections may provide new insight into rehabilitation interventions for persons with advanced MS. The primary purpose of this study was to examine the participation of social activities before and after 10 weeks of resistive inspiratory exercises using IMT in persons with advanced MS at a long-term care facility. The secondary purpose was to examine if the exercises influenced self-reported fatigue and respiratory infections.




This study is a repeated measures within-subject design.


We recruited participants from The Boston Home, a facility specialised in the long-term care of people with advanced MS. Inclusion criteria were age>18 years, MS diagnosis, non-ambulatory with Expanded Disability Status Scale (EDSS) >=6.5, ability to follow instructions and communicate in English, and providing consent. The EDSS ranges from 0=no neurologic involvement to 10=death due to MS. Exclusion criteria were recent hospitalisation as a result of MS exacerbation within 2 months prior to or during enrolment in the study, acute illness or unstable medical conditions, and current smoker. The University of Michigan-Flint and Franklin Pierce University Institutional Review Boards approved the study. All participants provided their consent.

Sample Size

G*Power [9] was used to estimate the sample size required to achieve a significant difference in activity participation across 3 time periods. At least 27 participants would be required based on alpha level = 0.05, power = 0.80, and a medium partial η2 effect size = 0.06.

Resistive Inspiratory Exercises

Participants performed resistive inspiratory exercises for 10 weeks using the IMT device, which costs about $30 per unit (Philips, Andover, MA) (daily dosage = 3 sets of 15 repetitions) (4). Each participant completed 3 sets of 15 repetitions daily using his/her own IMT device. Most sessions lasted approximately 15 minutes including rest breaks to avoid fatigue and other discomfort. The participants performed the exercises sitting in a chair or bed while keeping their upper body as upright as possible. First a nose clip was applied to ensure that the participants breathed in through the mouth. The participants sealed lips around the mouthpiece and inhaled deeply through the IMT. As the air flowed in, a valve opened, and the device provided resistance to inhalation. The participants continued inhaling and exhaling without removing the IMT from the mouth unless they needed to take a break between exercise repetitions. Each participant was given an exercise log to record the repetitions completed per day. Before starting the exercise program, the research team instructed the participants on using the IMT and observing the precautions during exercises, such as pain, light headedness, dizziness, shortness of breath, perceived exhaustion as measured by a score on the Borg Rate of Perceived Exertion >=15, or other symptoms. The staff at the facility (nursing assistant, rehabilitation aide, or trained student volunteers) received training on using the IMT, documenting the exercise log, and reporting any symptoms experienced by the participants. The participants performed the exercises on their own with the supervision or assistance from the staff whenever necessary. The initial IMT resistance was 30% of baseline maximum inspiratory pressure (MIP), or the lowest IMT resistance of 9 cmH2O when 30% of baseline MIP was less than 9 cmH2O. At the end of each week, the research team progressed the IMT resistance based on symptoms, Borg Rate of Perceived Exertion, and baseline MIP (see Table 1 in (4) for protocol).


Participant Characteristics

Demographics, body-mass-index (BMI), years of MS diagnosis, Expanded Disability Status Scale (EDSS), number of comorbidities measured by Functional Comorbidity Index [10], and cognition measured by oral version of Symbol Digit Modality Test (SDMT) (11) were obtained by interviews and reviews of medical records at the time of enrolment.

Respiratory Muscle Strength

MIP and maximum expiratory pressure (MEP) were obtained as global measurements of inspiratory and expiratory muscle strength, respectively using MicroRPM Pressure Meter (Micro Direct, Inc. Lewiston, ME) (12). During each assessment, the best values from three trials of MIP and MEP were retained for analysis. MIP and MEP values were expressed as percentages of age- and gender-adjusted predicted values (12). Participants were measured before (pre-test) and after (post-test) 10-week exercises, and 8 weeks after exercises (retention).

Participation in Group Social Activities

The number of days each participant attending at least one structured group social activity per week represents participation in social activities. The staff, residents, and family members jointly developed these programs to promote an engaging social life. Every day, each resident chose the activities to attend, such as coffee, movies, watercolors, Tai-Chi, bingo, parties, and community outings (See updated activity calendar https://www.thebostonhome.org/programs-and-services/activities.html). The activity team led activities and took the attendance of all residents using a daily calendar. To minimise bias, the activity team and participants were not informed of the study purpose. At the end of study, the author (AB) extracted the participants’ attendance records. The number of unique calendar days per week on which the participants attended at least one structured group social activity was counted. For example, if a participant attended at least one activity on four out of seven days in a week, activity participation was recorded as “4” for that week. The weekly participation was calculated during baseline (10 weeks before exercises), training (10-weeks exercises), and retention (8 weeks post exercises).

Modified Fatigue Impact Scale-5 Item

Modified Fatigue Impact Scale-5 item (MFIS-5) is a self-report measurement and an abbreviated version of Modified Fatigue Impact Scale recommended for use in the MS population (13). MFIS-5 evaluates how fatigue may have affected a person’s cognitive, physical and psychosocial function during the past 4 weeks. Each item is scored from 0 to 4 (‘never, ‘rarely’, ‘sometimes’, ‘often’, and ‘almost always’) with higher scores indicating more severe impact of fatigue. The sum of raw scores from 5 items is the MFIS-5 total score (from 0 to 20). MFIS-5 has good test-retest reliability (ICC=0.76) (14). MFIS-5 was measured at pre-test (before exercises), post-test (after exercises), and retention (8 weeks post-exercises).

Respiratory Infections

Infectious diseases of the upper or lower respiratory tract, such as common colds, flu, or pneumonia, were documented routinely at the facility. To minimise bias, the staff recording the infections were not informed of the study purpose. At the end of study, the author (AB) extracted the participants’ data using a pre-structured form. The episodes of respiratory infections, number of hospital admissions, and length of stay were counted during baseline (10 weeks before exercises), training (10-weeks exercises), and retention (10 weeks post-exercises).

Statistical Analysis

Data were analysed using IBM® SPSS Version 24 (Armonk, New York). Descriptive statistics were calculated for all variables. Repeated measures ANOVA in General Linear Model was used to compare MIP and MEP values and MFIS-5 between pre-test, post-test, and retention, and activity participation between baseline, training, and retention. Effect size of partial η2 was calculated (small = 0.01, medium = 0.06, and large = 0.14) (15). Because of the low incidence, descriptive statistics were reported for respiratory infections. Two-tailed significance level was p < 0.05.



Participant Characteristics

Among 38 participants who consented, one dropped out due to illness and three were absent at assessments. Table 1 presents the participants’ characteristics.

Table 1
Participant characteristics



MIP were 35.6%±22.0% at pre-test, 41.6%±23.9% at post-test, and 39.4%±25.6% at retention. MEP were 26.4%±14.3% at pre-test, 28.1%±13.9% at post-test, and 27.2%±14.3% at retention. MIP differed significantly by time (p=0.023, ηp2=0.07 for medium effect size). Bonferroni post-hoc test showed that MIP significantly increased from pre-test to post-test (p=0.04). MEP did not differ by time. No adverse events were reported in the study.

Activity Participation

The participants spent 4.0±2.1 days/week during baseline, 5.0±3.4 days/week during training, and 4.8±3.5 days/week during retention attending at least one structured group social activity. Activity participation differed significantly by time (p=0.01, ηp2=0.13 for medium effect size). Bonferroni post-hoc test revealed that activity participation was significantly greater during training than baseline (p=0.043).


The MFIS-5 was 6.4±4.7 at pre-test, 5.1±4.9 at post-test, and 5.5±5.5 at retention and did not differ by time.

Respiratory Infections

Table 2 presents the data on respiratory infections. Only one participant had recurrent infections (two episodes) in the study.

Table 2
The total and average numbers of respiratory infections and resulting hospital admissions, and the length of stay during the baseline no training, IMT training and post-training retention phases

Values are expressed as n or mean (%). N=34; IMT: Inspiratory muscle trainer.



This study is the first to demonstrate that in non-ambulatory persons with severe physical limitations from advanced MS, resistive inspiratory exercises significantly increased not only inspiratory muscle strength, but also participation in group social activities. Fatigue did not change and respiratory infections remained low in the study. Benefits of resistive inspiratory exercises extend beyond improving respiratory muscle strength and likely have positive impact on societal participation in persons with advanced MS living in a long-term care facility.
MIP but not MEP increased after the IMT exercises, demonstrating a task-specific response to the type of activities being imposed. Improved social engagement is particularly meaningful for individuals with severe physical limitations. Our results indicate that resistive inspiratory exercises are a safe and effective intervention to promote participation without adverse events and increased fatigue. This study has limitations. The small sample size was relevant small but had sufficient power based on a priori estimate. Data were extracted retrospectively but blinding had been applied during measurements to minimise bias. In conclusion, 10-week daily resistive inspiratory exercises improved inspiratory muscle strength and activity participation among non-ambulatory persons with advanced MS living in a long-term care facility.


Funding: National Multiple Sclerosis Society funded this study (Grant number: PP-1703-27264).

Declaration of Interest: The authors report no conflict of interest.

Clinical Trials Registry: NCT03345199.

Ethical standards: The participants provided their written informed consent before enrolling in this study. The University of Michigan-Flint and Franklin Pierce University Institutional Review Boards approved the study.



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R. Meehan


Corresponding author: Rebecca Meehan, Ph.D. Associate Professor, School of Information, Kent State University, 1125 Risman Rd., Kent, OH, USA 44242, RMeehan3@kent.edu, 330-672-9715

Jour Nursing Home Res 2020;6:73-77
Published online September 11, 2020, http://dx.doi.org/10.14283/jnhrs.2020.20



Background: As health information technology (IT) sophistication evolves in long term care (LTC) facilities, it is critical to understand the user experience of health IT among all LTC caregivers to support their roles in providing quality care. Objectives: To examine the end user’s (nursing assistants) experience of a newly implemented wall-mounted, touch screen point-of-care (POC) system in a LTC facility in the mid-western United States. Design: This study used a descriptive qualitative method to conduct a user experience study. Setting: The study site was a chain-affiliated, non-profit continuing care retirement community in the Midwest United States, with 79 skilled nursing facility beds licensed for LTC and 29 beds licensed for rehabilitation. Participants: This purposive sample included state tested nursing assistants (NA) (n=25), representing all three work shifts (day, afternoon, and night). Measurements: Measures included a semi-structured one-on-one interview and a short questionnaire using both closed ended and open ended questions to examine the user experience of the new health IT in terms of 1) usability, (2) overall evaluation (what is working, what is not, what can be improved), and (3) whether the POC has helped staff members to provide better care. Results: Nursing assistants reported satisfaction with the system, ease of use, and a more effective data capture experience than compared to using a paper chart. Most respondents agreed that the POC helped staff to provide better care. Respondents voiced concerns in areas of how best to configure the POC system and best practices on how to use the system more effectively going forward. Conclusions: Optimizing the user experience of health IT among NA staff can affect clinical outcomes for LTC residents. Recommendations for improvements include improved usability to ensure data is captured efficiently, enhanced and more frequent training for accuracy, ergonomic adjustments for reaching the screen and entering data without injury, and modifications to protect resident health information privacy.

Key words: Health Information Technology, nursing assistant, long term care.



As long term health care (LTC) settings continue to expand their use of health information technology (IT), it is important to examine the user experience of all health IT end users in order to understand what is working and what needs to be improved in the evolving health IT ecosystem. Health IT solutions can play a part in making the documentation process more efficient, effective and better overall for residents and staff but this has been a gradual process for LTC settings (1, 2) with roughly 67% of LTC facilities having adopted electronic health records (EHRs) as of 2017 (3, 4). EHRs and other health IT systems provide opportunities to improve quality of care for older adult residents, through improved and more efficient communication both within LTC facilities and between the LTC and referring hospitals (2, 5, 6). Alexander and colleagues (2017) explored health IT sophistication in LTC and found IT capability was greater than IT extent of use in all health domains, the highest being in residential care. Other studies of health IT use in LTC settings have shown that having the health IT system or capability does not mean that it is being used consistently, and to its intended benefit (5). To better develop the extent of use, it is important to examine how end users are interacting with health IT. While studies have examined the use of health IT in long term care (2, 5-11); few studies have focused on the user experience of nursing assistants in health IT.
Nursing assistants (NA) are the front-line health care workers who are attending to daily care needs of the older adult residents of long-term care who have physical and/or cognitive challenges making it difficult to take care of themselves. NAs use health records, health IT and communication with nursing staff to be informed about each resident, and to communicate updates on residents’ health status to the extended care team. LTC settings introducing new health IT systems for NAs need to ensure that the systems are easy to use and helpful in NA daily responsibilities while promoting better care for their residents.
This study focuses on the user experience of NAs working in a LTC short term rehabilitation and LTC units, both of which had installed a new wall mounted, touch screen point of care (POC) system on which NAs recorded data from daily care they provided to each resident, replacing a long-used paper flow sheet system.



This study uses a descriptive qualitative method, incorporating both a semi-structured one-on-one interview and a short questionnaire to examine the end users’ (NAs) experience of a newly implemented (in the past 8 months) POC in a LTC facility. NAs are required to enter vitals and other patient care information from daily care rounds for residents into the POC system, which is automatically uploaded to the EHR for review and care coordination with other care team members. The POC system replaced the former hand-written paper flow sheets previously used by NAs. A descriptive qualitative method can be used to describe an event in the everyday terms of the event (12). The descriptive qualitative method is useful in the healthcare research as it allows a focus on the experience of health care stakeholders and their description of a phenomenon in the health care setting (13). The questionnaire used both closed ended and open-ended questions, which has been shown to be an effective strategy when assessing user experience of new technology or software (14).
Closed ended questions asked in the questionnaire help to provide background on how much experience participants had with technology, how long they had worked in their current job, in LTC in general, as well their assessment of the user experience of the POC system. Usability of the POC system was measured using items adapted from the task, user, representation and function (TURF) framework (15) by asking respondents (using the 5-point Likert-type scale) to what extent the system was easy to use and satisfactory. Open-ended questions in the interview asked respondents to describe their experiences of the wall mounted POC screen in three areas: (1) usability, (2) overall evaluation (what is working, what is not, what can be improved), and (3) whether the POC has helped staff members to provide better care.


This purposive sample included NAs (n=25), on all three shifts, working at a dual-licensed skilled nursing and rehabilitation unit, housed within a chain-affiliated, non-profit continuing care retirement community in the Midwest United States. The study site has 79 skilled nursing facility beds licensed for LTC and 29 beds licensed for rehabilitation. Inclusion criteria for participation in the study were employees at the study site who are state tested nursing assistants (NA) who work directly caring for patients and who enter data in the POC wall mounted system. The author recruited participants by displaying a poster describing the study in the staff break room, along with flyers in NA mailboxes. The response rate for the study was 83%, with 30 nursing assistants meeting inclusion criteria, and 25 agreeing to participate. Informed consents were obtained from participants, with participants receiving a $10 gift card to a local grocery store. Interviews, conducted during a meal or break time, averaged 17 minutes, ranging from 10 –28 minutes. Interviews were audio recorded with the participants’ permission. Interviews were then transcribed and analyzed for themes and patterns.


Content analysis was used to evaluate data from respondents, aligned with the qualitative descriptive method (16). The investigator and two research assistants, all of whom are trained in qualitative data analysis techniques, followed a process of (a) coding data from notes and interviews; (b) recording insights and reflections from the study; (c) identifying patterns, phrases, and important features; (d) reconciling elements consistent across data; and (e) assessing these patterns in the context of the related literature. Intercoder reliability was achieved through “negotiated agreement” (17) by using a process in which the research team members coded a transcript, compared codes, and then discussed any differences to reconcile them for a final coding solution.



Sample Characteristics

As a group, respondents had a wide range of experience working in long-term care settings, averaging 5 and ½ years working onsite. The turnover of NAs at the study site was lower than national averages, with respondents having an average of 4 years of employment at the study site and ranging from 6 months to 16 years. All respondents are women. Respondents were well acquainted with basic touch screen technology, with most all respondents (n=22) having experience on personal computers and smart phones, with some of the newer hires to the facility having more daily experience using smart phones for communications and transactions than those who had been at the facility for a while. Most respondents (N=21) reported they spend about 20% of their shift using the POC system.


Respondents were asked how easy the system was to use (1 = very difficult to 5 =very easy). Most respondents rated the system as “easy or very easy” to use (n=22). One respondent said “I mean it’s pretty self-explanatory…it has answers right there. You just have to click it.” Respondents were asked how satisfied they were with the POC system (1 = very dissatisfied to 5 =very satisfied). Most (n=23) were either very satisfied or satisfied. Several users (n=7) commented on ways to improve the usability and saying that the POC system currently needs “too many clicks’” to get to a certain page of a resident’s information.

What is Working Well and What Needs Improvement

Respondents were asked an open-ended question about what was working well and what was not or could be improved in the POC system. Themes of the responses included a) ergonomic issues, b) privacy, c) efficiency, and d) training.
a) Ergonomic issues were mentioned as an area for POC improvement by several respondents. Many respondents (n=5) mentioned the need to have the touchscreen monitor mounted lower on the wall, because it became more of an effort to reach for some people. One respondent said: “…I have problems touching the screen with my hand; after a while it begins to hurt.” Some respondents (n=3) offered an alternative to the wall mounted unit, suggesting a monitor on a desk or cart instead of on the wall for both ergonomic and privacy concerns. Some respondents (n=4) mentioned that the wall placement was helpful to have one less thing to carry, bridging both ergonomic and efficiency benefits.
b) Some (n=5) were worried about maintaining residents’ privacy, because POC data is entered on the large wall mounted screen in a common hallway. While there were visual protections to prevent people from viewing the information from the sides, it was still visible if someone was standing behind the NA. One respondent shared: “…it’s a privacy thing because you put in the information you have, and people [are] walking past, seeing what you are putting in [the POC] .” Another respondent mentioned that she ”…found it awkward to have to tell someone in the hallway to look away from the screen,” to protect the resident’s privacy, so, often, she would just continue to add the information, trying to block information by moving, but not saying anything to passersby.
c) A few respondents (n=4) mentioned that when they enter in information on vitals or other health information, the screen information often lags, taking more time than expected to show that the data was saved. This time lag led to confusion as to whether the data was captured, and overall frustration with the process. One respondent said “…when it goes slow, it doesn’t work well for anybody because we’re all standing there charting on one person. We have a big facility and if it’s just two people on a floor and we’re charting on one person and it takes ten minutes, you have two lights going off and then by the end of the day, you only charted on like six people. That was in an hour and we still have six more people to chart on. Those are the days that we wish we would have had the [paper] book instead.” Beyond being slow occasionally, the POC system sometimes ‘froze’ resulting in potential data inaccuracies because of the lag time between care given and documentation of that care. Some conveyed that if a system froze, they would go to another unit on another hallway to add data, but this caused a delay for the other nursing assistants assigned to that hallway.
d) The facility offered a 30-minute initial training on the wall mounted POC software, with refresher courses offered every 2 to 3 months. Although all respondents indicated that the training was adequate, they commented that they would welcome additional training sessions. One respondent suggested that it could have been explained better if the training session was broken up in different groups, with one group of experienced computer users, and another group with limited experience on computers. Beyond technical training, respondents voiced concern over the need for NAs to get periodic training on how to accurately document care. Several respondents conveyed a frustration over being able to correctly document care issues for the resident by both themselves and their co-workers. One respondent said: “Right now [for food eaten] the values go from zero. I think it says none and then it’s zero to 25, 26 to 49, 50 to 70 and then 75 to – it’s a big difference for someone with diabetes to show if they eat nothing to a little bit.” In terms of transfer assistance, charting the wrong classification for the resident’s care can create a situation where the next care team member is physically unprepared to transfer the resident and may need more help. One respondent described her co-worker’s confusion over how to characterize the dependence level of a resident when it comes to transferring the resident between a chair and bed. She said: “…when someone [needs] a Hoyer we used to put [document] that as an ‘extended assist’ function but in reality because it’s a Hoyer lift…we have to list that person as ‘total dependence’… I think that was a big question about the terminology.” Some respondents conveyed that they need other more specific levels of classification. Another respondent, who had worked at the facility for many years, added “I’m not going to lie, sometimes I still get confused with limited and extensive [assist].”

Does the POC Help Staff to Provide Better Care

Most (n=17) of the respondents agreed with the statement that the POC helps them provide better care to their patients, explaining that it is because they have better access to patient information. One respondent said “… it’s very useful, because it gives me the [resident] profile… I know how they transfer…there’s nothing going to slip by me on this person.” Some (n=3) mentioned the advantage in no longer having to rely on asking nurses for patient related information since they have the information in the POC system. One respondent works on all different units shared “…[be]cause I’m a ‘float’, meaning like I get thrown on every hallway possible; I’m downstairs, I’m upstairs, I’m everywhere. So if I was given a report by an aide that didn’t really tell me much about the person I could just go in the computer [POC] and look at the patient records and figure out how they transferred, if they got dementia…It helps me walk into the room and [prepare] myself better to them because I understand them now.”

Table 1
Sample Characteristics



When LTC facilities install new health IT for NAs, there is necessary preparation, integration and on-going monitoring and maintenance to do in order to derive the proposed value of such a system. The POC system helped NAs to gain insight into the changing needs of their residents and communicate updates to other care team members in an efficient and effective manner. Consistent with research on use of health IT in LTC settings, effective use of the POC system for NAs demonstrates an organizational culture that is receptive to innovation and one that is open to leveraging health IT across care team (6). Findings of this study showed a setting with higher health IT sophistication (8) because the POC system operated by the NAs was used extensively and was integrated into the daily care routine. Aligned with other studies (9, 10) many respondents in the study indicated that the POC system allowed them to get relevant information about the residents, without having to communicate directly with nurses, making the process more efficient.
Specific recommendations for implementing a touchscreen, wall mounted POC system include concerns for ergonomic design, usability, privacy, training on system use and ongoing training on care documentation as these all influence quality of patient care and user/employee satisfaction. Findings from the study suggest further consideration of ergonomic and privacy issues of the POC. The height of any wall mounted data entry screen needs to be adjustable to accommodate the differing physical heights of the NA staff members, ensuring that all staff can reach and use the screen comfortably. In terms of usability, the POC system should be updated to provide feedback to the user on the status of the system (18), allowing the user to know if the system has frozen, and they need to restart the data entry or if the POC is registering the data and just taking a longer time. Regarding privacy, the POC system did not prevent viewing from people who could observe an NA in the hallway entering data, putting NAs in a difficult position, as respondents voiced concerns around how to keep information private. Their distress over privacy also shows that NAs have limitations on what they can do if someone is standing over their shoulder as they enter data. Policies or procedures need to be reconsidered around how best to protect resident’s personal health information when NAs are entering data on screens in the hallway with other passersby present. Training needs to include interpretation of coding and documenting health status, rather than only the technical aspects of how to use the POC system. When respondents discussed their experiences in documenting care, many were confused about how to document the amount of food residents consumed, and the extent of assistance needed by residents when transferring from their bed or chair. In a like manner, many discussed not being clear on how to document a resident’s need for assistance when transferring from a bed or chair. Issues with documentation cascade and affect care and preparedness to lift residents, contributing to the threat to LTC worker safety (19). NAs, physical therapists and other staff members who need to lift, transfer and move residents safely rely on the accuracy of this information to help keep themselves and the residents safe.
This study is one of few examinations of health IT use among NAs in LTC settings. Future research should examine POC and related health IT use among NAs at other LTC sites, as well as user research among other interdisciplinary care team members. Moreover, future research should evaluate time savings in care tasks using new health IT. As health IT sophistication increases among LTC sites, the evolution of their organizational culture will depend not only on evaluations of how all stakeholders are interacting and using health IT systems, but also how well adjustments and corrections can be implemented to optimize use of the systems and to improve care.


Funding: Funding for this project was provided by the author’s university.

Conflict of interest: No conflict of interest.

Ethical standards: Institutional Review Board (IRB) of Kent State University approved this research protocol.



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R.J. Fischer

Corresponding author: Robert J. Fischer, MD, Mann-Grandstaff Veterans Affairs Medical Center, 4815 N. Assembly Street, Spokane, WA 99205, USA, Email: robert.fischer@va.gov, Phone: 509-434-7200

Jour Nursing Home Res 2020;6:69-72
Published online September 10, 2020, http://dx.doi.org/10.14283/jnhrs.2020.19



We report a case series of 38 patients infected with coronavirus disease 2019 (COVID-19) evacuated to Mann-Grandstaff Veterans Affairs Medical Center (MGVAMC) in Spokane, Washington following disease outbreak in a skilled nursing home (SNH). Range of symptoms were none to mild on transfer. Patients were admitted to stem the outbreak, provide enhanced medical care and improve clinical outcome. The nursing home outbreak was arrested within two weeks of the initial patient transfer and mortality in this cohort was 13.2%.

Key words: COVID-19, skilled nursing home, outbreak, evacuation, mortality.



As of July 7, the United States has suffered the largest number of COVID-19 confirmed cases (2,980,906) and deaths (131,248) worldwide, representing roughly a quarter of all cases and deaths globally (1). According to the American Geriatrics Society, nursing home residents are among the most vulnerable to complications and death from COVID-19 and represent a particular challenge in diagnosis and infection control owing to the frequent absence of typical symptoms along with the highly contagious nature of the disease (2), even among asymptomatic patients (3).
As of June 28, there have been 126,402 COVID-19 confirmed cases in nursing homes and 33,517 deaths with a fatality rate of 28% (4). Nursing home cases represent 4% of all COVID-19 cases in the US but 26% of deaths (33,509 of 131,248). Of the 1.3 million residents in 15,600 nursing homes, 9.7% have contracted COVID-19 by recent reporting. Two or more cases were experienced in 30.1% of the 14,577 reporting nursing homes, however, 129 facilities suffered 100 or more cases as of June 28. Overall, 5,522 (37.9%) had at least one infected resident (5).
Here we report on a COVID-19 outbreak in a SNH and the results of our efforts to stem infection and improve resident outcome.



This observational case series describes a cohort of 38 COVID-19 patients evacuated from a 100-bed local SNH to a designated acute care unit in the MGVAMC in Spokane, Washington between April 24 and June 2, 2020 after testing positive for infection. Patients were asymptomatic or only mildly symptomatic at time of transfer and would normally not meet hospital admission criteria. The goals of hospitalization were to stem the outbreak by removing infected patients from the SNH and provide enhanced medical care to prevent disease progression. At a minimum, daily physician rounding was conducted and a high nurse-to-patient ratio maintained (1:3 to 1:4). Consultation with physical and respiratory therapy, nutritional services, pharmacy, physiatry, rehabilitation services, audiology, social work, chaplaincy and other services were readily provided as necessary. Oral and fluid intake were monitored closely, and electrolyte imbalance corrected when identified.
Real-time reverse-transcriptase polymerase chain reaction (RT-PCR) sample collection was performed at MGVAMC by swabbing the nasopharynx. Testing was accomplished using the Cepheid GeneXpert™ rapid testing platform. All sample collection and processing followed CDC guidelines. Demographic and clinical data and information related to comorbidities were abstracted from electronic medical records (Department of Veteran Affairs Computerized Patient Records System, CPRS). A case was determined to be symptomatic if there was presence of fever, cough, shortness of breath or if the attending physician diagnosed symptomatic COVID-19 at any point during the hospitalization. The duration of viral shedding is defined as the number of days between the first positive COVID-19 test and the last positive test prior to two serial negative tests at least 24 hours apart. The COVID-19 case duration is the number of days between an initial positive test and the second negative test 24 hours after the initial negative test (test of cure). For those who succumbed, the date of decease was used as an end date for both measures. Data to calculate the Modified National Early Warning System (NEWS) (6) score was obtained from review of admission notes in the electronic health record.
Patients were returned to the SNH following hospitalization at MGVAMC only after strict discharge criteria were met: two negative RT-PCR tests at least 24 hours apart, or a period of 30 days had elapsed since the first positive test if negative testing could not be achieved; and no new resident or staff cases identified in the SNH for two consecutive weeks. For those residents still shedding virus after 30 days and returned to the SNH, isolation was required until two serial negative tests were obtained. At the time of the outbreak, there were 86 residents present in the SNH with a first resident case identified on April 6. By the time of evacuation (April 24), 35 residents and 12 staff had already tested positive for COVID-19.



Table 1 is a summary of the demographic and clinical findings of the cohort of 38 patients on admission to MGVAMC. The median age was 83 with a male to female ratio of 3 to 1. The most prevalent underlying conditions associated with severe COVID-19 disease were hypertension (68.4%) and cardiac disease (57.9%). The median number of these comorbidities was 2.0 (IQR, 1.3-3.0) with a maximum of 5 conditions. Additionally, 57.9% of patients suffered from dementia. The median number of medical problems listed in the electronic health record was 22. Moreover, 76.3% of patients requested to continue or initiate “do not attempt resuscitation” status after goals of care discussions with the attending physician. Many in the cohort suffered from a wide array of serious conditions such as Huntington’s disease, Parkinson’s disease, liver disease, post-traumatic stress disorder and history of stroke.

Table 1
Demographics and Findings

*Underlying conditions (comorbidities) known to be a risk for Severe COVID-19 (as of April 24, 2020); †Electronic Health Record; ‡A count of problems excluding COVID-19; §Modified National Early Warning Score of 5-6 represents medium risk progression to severe disease; ||Viral shedding is duration between initial RT-PCR positive test and last positive test; {Among those who died – duration is between initial test and date of decease; #Case duration is days between a first positive test and second negative testing for COVID-19; **A second negative RT-PCR test for COVID-19 repeated 24 hours after previous negative test. Results of RT-PCR testing obtained from Apr 24 to June 24.

Notably, 44.7% of the cohort remained asymptomatic throughout hospitalization with 13.2% unable to respond verbally to questions owing to underlying conditions. The median Modified National Early Warning Score (an indicator of risk of clinical deterioration) was 5.0 (IQR, 3.0-6.0). A score of 5-6 indicates a medium risk for progression to severe COVID-19. Twenty patients (52.6%) had a score equal to or greater than 5 while 7 (18.4%) a score compatible with high risk. The mortality rate for the cohort was 13.2% (5 patients). One of 38 evacuated patients received RemdesivirTM (Gilead Sciences) antiviral therapy by protocol and did well. No patients received hydroxychloroquine, but several patients did receive antibiotic therapy for community-acquired pneumonia. One patient in the cohort was transiently admitted to the ICU for cardiac-related issues unrelated to COVID-19.
Viral shedding showed a median duration of 29.0 days (IQR, 20.3-36.8) with a maximum of 71. Case duration, a median of 49.0 days (IQR, 24.0-56.8) and a maximum of 77. The cohort underwent serial RT-PCR testing at intervals between one and two weeks to minimize patient discomfort and test kit consumption.
Prior to SNH resident evacuation to MGVAMC, 35 residents and 12 staff were infected between March 23 and April 24 (32 days). Following evacuation, the last case occurred on May 11 (staff member), 17 days later. As of this publication, no additional resident cases have been detected (Figure 1). Overall, 46 of 83 residents contracted COVID-19 (55.4%) and 10 patients died (21.7%) during the period of this study. Of the 38 patients evacuated to MGVAMC, the case fatality rate was 13.2%.

Figure 1
Skilled Nursing Home Outbreak and Testing



With respect to infection transmission in nursing homes, it is important to recognize that there is frequent, prolonged and close contact between frail patients and staff during activities of daily living (ADLs). Assistance is required for ambulating, feeding, dressing, personal hygiene, continence and toileting (7). Lai et al. (2020) point out that nursing home “residents share the same sources of air, food, water, caregivers, and medical care” and are exposed to visitors who come and go at will (8). These factors contribute to the high degree of COVID-19 penetration in skilled nursing homes in the US (5) and may explain the difficulty with outbreak control experienced by the SNH we observed before evacuation of infected residents to MGVAMC.
Our findings serve to highlight the extent of underlying health and cognitive conditions and disabilities among SNH residents. There is also growing evidence nursing home resident comorbidities including Alzheimer’s disease and related dementias (ADRD) contribute strongly to coronavirus mortality in skilled nursing homes (9). For example, it is difficult to elicit a reliable history from cognitively impaired patients and they often present with atypical symptoms (10); as a consequence, they are at risk for delay in diagnosis of symptomatic and serious infection. Fully 60% of our cohort were cognitively impaired. Comorbidities, cognitive disability, persistent absence of symptoms of infection and the impact of immunosenescence (11) combined to mask typical signs and symptoms of disease and made detection of progressive COVID-19 a challenge for the MGVAMC caregivers. This difficulty with accurate assessment, triage and treatment would be an even greater challenge in the SNH setting.
The duration of viral shedding may provide important insight into the severity of COVID-19 in our cohort. These patients experienced a median duration of viral shedding of 29 days. This is comparable to findings from Wuhan, China showing a median of 31 days in patients with severe COVID-19 (12). The duration of viral shedding in asymptomatic and mildly symptomatic younger patients has been reported to show a median of only 19 days (13). Furthermore, advanced age and comorbidities do not appear to play a role in the duration of viral shedding (12, 14). A possible explanation for prolonged viral shedding in our cohort, therefore, may be more advanced COVID-19 than is apparent on daily clinical assessment in the SNH. This is borne out by our findings that over half of the cohort had a Modified NEWS score of 5 or more on evacuation and admission to MGVAMC.
Our cohort is likely representative of nursing home residents everywhere insofar as they are elderly, poor historians, suffer from numerous serious health conditions, and may often present atypically (2) and with blunted fever response to infection (15). The ability to distinguish symptoms of COVID-19 from those associated with underlying health conditions along with an attenuated physiologic response to infection combine to place nursing home residents at serious risk for delay in appropriate comprehensive supportive care with subsequent rapid progression of infection and suboptimal outcome.
Our decision to evacuate the SNH residents to our hospital appeared to have a salutary effect on outbreak control. Seventeen days after implementing evacuation procedures, no further cases of COVID-19 had been identified among residents or staff.
There are significant limitations to this case series. The number of patients is small (38), observations are retrospective, and the study does not have a matched control group for comparison purposes.
Our findings do suggest that early evacuation of COVID-19 residents from the SNH stemmed the outbreak and improved patient outcomes by timely hospitalization and robust multidisciplinary medical care following positive testing. In order to avoid prolonged isolation, however, additional research is needed to resolve the question of infectivity in residents who continue to test positive for COVID-19 over very long periods of time.

Acknowledgments: This material is the result of work supported with resources and the use of facilities at the Mann-Grandstaff Veterans Affairs Medical Center, Spokane, Washington, USA. The views expressed in this article are those of the author and do not necessarily reflect the position or policy of the Department of Veterans Affairs or the United States government. I would like to acknowledge the men and women of Mann-Grandstaff VA Medical Center for their dedication and skill in the care of community patients during the COVID-19 pandemic and in fulfilling Veterans Affairs’ fourth mission. I also would like to recognize Stephen D. Fischer for his invaluable assistance in proofreading this submission.

Funding: This observational study did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. The author declares that he has no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

Conflict of interest: None.

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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