Articles Posted in Quality of Care

As our population ages, there has been an increase in the number of elderly patients that undergo neurosurgical interventions. This increase is accompanied by aging risk factors, such as frailty, that increase the risk of complications post-surgery. A recent study undertook the task of surveying how recent falls affected patients who underwent a neurosurgical operation, focusing on a patient’s outcome relative to their fall history in the six months prior to their surgery.

The study’s overall findings were that patients with at least one fall six months prior to a neurosurgical procedure, had an increased risk of complications following their discharge. It specifically focused on the number of those discharged to a facility post-surgery, re-admittance rate, and the rate of complications. 18 % of those studied were discharged to a long term care facility after the operation, 17% were readmitted within thirty days, and 28% also had a complication arise within thirty days of their discharge date.

The results of this study give reasons to include fall history in preoperative risk assessments prior to any neurosurgery. While the frailty of an elderly patient is already considered in these assessments, it is important to include patients fall history since there reason to believe that these falls affect patients’ recovery. Neurosurgical procedures  As shown in the study there is a higher risk of complications that arise when a patient has suffered a fall.

The regular use of physical restraints on patients in nursing home facilities without an appropriate medical reason or regard for their dignity and wellbeing is not only a strong indicator of poor quality of care, but also a sign of elder abuse and neglect.  Older adults with dementia in particular are affected by this organizational conduct and are vulnerable to debilitating physical and psychological side effects.  Moreover, it is a violation of their human rights. In the United States, a staggering 38% of senior patients in these types of facilities experience being physically restrained at least once every day.  Although a variety of organizations that strive to reduce or eliminate the use of physical restraints exists, most of their initiatives have not been successful.  However, a longitudinal, multidirectional psychosocial and educational program that was developed to promote patient-centered care for older adults with dementia and reduce the use of physical restraints was implemented in 41 nursing homes with positive results.

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Malnutrition is one of the primary dangers for older adult residents living in long-term care settings.  Defined as the state of not having adequate food and micronutrient intake, malnutrition is common among elderly patients and can damage physical and cognitive functioning.  Nursing home and assisted living facility staff must protect their patients from inadequate micronutrient intake in order to help maintain their quality of life and avoid increasing their risk of morbidity and mortality. Multiple factors at the patient (e.g., dementia), staff (e.g., training, staffing levels during meals), and home (e.g. quality of meals) levels interact and contribute to the increase in risk of poor food intake.  Substantial research has shown that inadequate nutrient density of food is one of the top 10 deficiencies in nursing homes.  These facilities must improve their quality of meals in order to promote food intake and enhance nutritional status and quality of life of their patients. Studies that have focused on micronutrient needs for improving the health and quality of life of residents in long-term care have found that even at the meal planning level, much improvement is needed in regards to nutrient density.

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Innovative care environments are created for older adults with dementia to enhance patient-centered care.  Studies have shown that green care farms, which provide 24-hour nursing care, are an excellent alternative to traditional nursing homes.  These farms allow patients to engage in more physical activities and social interactions than residents in traditional nursing home settings, allowing them to have better quality of life and improved health outcomes.

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After the Wells Fargo scandal earlier this year in which the company admitted that its bankers created millions of fraudulent accounts, Wells Fargo is once again in the public eye for its attempt to stay out of courts by forcing the customers of these fraudulent accounts into closed door arbitration agreements. When existing customers were set up with fake accounts, they were entered into a new contract that required any disputes to be handled through arbitration and out of the court room. This new contract left existing customers dealing with an agreement that they never signed. The unfairness of this situation has left many customers without the legal rights to address the issue of fraudulent accounts in the court room or through a class action. Several Democrats have expressed their concern at the unfairness of these arbitration agreements and have advocated for legislation that provides remedies to those who were forced into these binding contracts without their consent. For example, California state Senator Bill Dodd introduced a bill to “override forced-arbitration clauses in contracts created through fraud”. This type of legislation would allow law suits to be brought against companies committing fraud despite the arbitration agreements in the customer’s contracts.

An editorial by the LA Times also disagrees with Wells Fargo’s ability to force their customers into arbitration for accounts their customers did not create, especially when these arbitration agreements are usually meant to favor the business rather than the consumer. Leaders such as Representative Brad Sherman and Senator Sherrod Brown have proposed similar bills to that of Senator Dodd’s, hoping to bar banks from requiring arbitration agreements in the future. Since these arbitration agreements are an attempt by Wells Fargo to stay out of the court room and settle disputes privately, the Consumer Financial Protection Bureau has proposed to prohibit banks from blocking future class action lawsuits brought on by customers. This will allow class actions to serve as a check on bank’s actions.

Similar to Wells Fargo’s practice of forcing their customers into arbitration agreements before doing business with them, some nursing homes and skilled living facilities also have their incoming patients sign into similar arbitration agreements before being admitted. These types of agreements are unfair to residents of these facilities since they are denied full legal remedies in the event that they are wrongfully treated. If their needs are not taken care of properly or they experience abuse and/or neglect residents with an arbitration agreement often find it difficult to pursue legal measures against the facilities that wronged them. These arbitration agreements create a legal barrier around these facilities, aiding them in avoiding law suits if they commit elder abuse or neglect towards their residents.

With more than 47 million people worldwide suffering from Alzheimer’s disease and other forms of dementia there is a growing need to identify the cause of these diseases as well as treatments for them. Millions of dollars have gone into the improvement of technologies and the research of brain mapping. At the USC Stevens Neuroimaging and Informatics Institute, Arthur Toga and Paul Thompson have been leading projects that are changing the world of neuroimaging. Toga and his team of researchers are on a quest to use digital imaging to map the brain. They believe that this type of detailed brain mapping will lead to solutions for neurodegenerative diseases such as Alzheimer’s and Dementia. Recent developments have led these scientists closer to the goal of better understanding these diseases and providing a breakthrough in how to prevent them.
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Animal assisted interventions (AAI) have become a growing topic of interest in research in recent years.  The possibility of AAI was first realized when a psychiatrist named Boris Levinson recognized the benefits that AAI produced as his dog accompanied him when he would visit a behaviorally disturbed child under his care.  In later years, interest in the therapeutic use of animals in long-term care grew.  The Alzheimer’s Association encourages the use of AAI with patients suffering with Alzheimer’s disease as a management strategy. According to the Association, “Meaningful activities, such as those that involve music, art and pet visits, can help enrich the lives of people with Alzheimer’s disease.  Pets, for instance, have been shown to reduce depression and boost self-esteem.”  A study conducted in 2003 found that animal-assisted therapy significantly decreased agitated behaviors in elderly patients with severe dementia and increased meaningful social interactions during the intervention.  However, both of these positive effects stopped once the intervention was removed.  Studies found that, in general, therapy using pets appeared to lower levels of aggression, promote prosocial behavior, and enhance health outcomes in patients with dementia.

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Loneliness isn’t just a feeling, it’s a powerful syndrome that affects many older adults worldwide.  According to a recent article published in the Journal of the American Medical Directors Association (JAMDA), loneliness can promote the deterioration of health and cognitive function, lower quality of life, and increase the rate of mortality.  The term constitutes a subjective feeling, a state in which an individual’s social network in reality does not meet their own expectations.   Thus, a person can suffer from loneliness even while surrounded by others.  Older adults commonly experience feelings of loneliness.  According to recent statistics, 4% to 9% of older adults living in the community experience continual loneliness, and an additional one-third could suffer from some degree of loneliness.  However, not much research has been done to understand the prevalence of loneliness in older adults living in nursing home facilities, even though it is known that residents in these long-term care settings are suggested to be at high risk for loneliness.  One Norwegian study found that more than half of nursing home residents who were cognitively intact suffered from loneliness.  It is important to note though, that cognitively intact residents make up a small fraction of the nursing home population.

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Ensuring that dependent older adults with complex health problems receive high quality long-term care has been a long-standing challenge for the health care systems around the world.  Currently, the need is greater than ever, considering that older adults battling with a multiple of chronic diseases and functional and/or cognitive disabilities are becoming more prevalent as the elderly population worldwide continues to expand.  Nursing home facilities provide 24-hour intensive care for individuals who are commonly physically or cognitively disabled, or both.  The delivery of quality of care and maintenance of quality of life in nursing homes are often unsuccessful, however, and has long been a great concern to consumers, providers of care, and policy makers.  The evidence that nursing home residents frequently suffer from preventable adverse outcomes (such as negative drug events, bed sores, falls resulting in serious injury, physical and pharmaceutical restraint use, delirium, and elder abuse) continues to grow and increase the risk of morbidity and mortality.

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Dementia is a serious group of cognitive conditions that promotes progressive deterioration in cognition, increased apathy, and reduced level of physical functioning.  Many older adults, especially those living in long-term care settings such as those in nursing homes or assisted living facilities, suffer from dementia. According to recent reports, more than half of the elderly nursing home population suffer from symptoms of agitation and almost 40% suffer from depressed mood.  These findings are highly similar to those of international studies that have explored the prevalence of neuropsychiatric symptoms expressed in nursing home patients with dementia.  Specifically, they found that the prevalence of neuropsychiatric symptoms significantly increases with severe dementia.  Therefore, it is no surprise that substantial evidence has proven that there is a strong association between dementia’s symptoms of depression and behavioral disorders and decreased quality of life.

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