Background: Mounting evidence of loneliness and negative health impacts has placed loneliness among the "geriatric giants" in need of intervention by the healthcare system. Objective: To evaluate the literature regarding the health impact of loneliness among older adults living in congregate living settings (i.e., assisted living, nursing homes). Materials and methods: Five databases were searched for quantitative and qualitative studies from January 1990 through August 2021. Methodological quality was assessed using modified criteria specific to quantitative and qualitative studies. Dual review assured the quality of the systematic review conduct. Results: Five qualitative, 3 mixed method, 19 cross-sectional, and 4 cohort articles were eligible. Despite different tools used to measure loneliness, loneliness appeared common among older residents in congregate living situations. In most studies, loneliness was associated with depression (regardless of scale used), albeit all but one came from cross-sectional studies. Few studies noted the association between loneliness and suicidal ideation and frailty. The three cohort studies that evaluated loneliness and mortality had mixed results. Resilience and activities appeared to mediate the association between loneliness and negative health outcomes and social support appeared to moderate associations. Conclusions: For older adults living in congregate long term care settings, loneliness is a common phenomenon, with cross-sectional studies suggesting links to depression, suicidal ideation, and frailty. Additional longitudinal studies to understand the impact of loneliness on health outcomes in older adults living in congregate settings are needed, as are rigorous evidence-based interventions to address loneliness and mitigate its harmful effects during life's final chapter.

Background: U.S. nursing homes provide long-term care to over 1.2 million older adults, 60% of whom were physically frail and 68% had moderate or severe cognitive impairment. Limited research has examined the longitudinal experience of these two conditions in older nursing home residents. Methods: This national longitudinal study included newly-admitted non-skilled nursing care older residents who had Minimum Data Set (MDS) 3.0 (2014-16) assessments at admission, 3 months, and 6 months (n = 266,001). Physical frailty was measured by FRAIL-NH and cognitive impairment by the Brief Interview for Mental Status. Separate sets of group-based trajectory models were fitted to identify the trajectories of physical frailty and trajectories of cognitive impairment, and to estimate the association between older residents' characteristics at admission with each set of trajectories. A dual trajectory model was used to quantify the association between the physical frailty trajectories and cognitive impairment trajectories. Results: Over the course of the first six months post-admission, five physical frailty trajectories ["Consistently Frail" (prevalence: 53.0%), "Consistently Pre-frail" (29.0%), "Worsening Frailty" (7.6%), "Improving Frailty" (5.5%), and "Consistently Robust" (4.8%)] and three cognitive impairment trajectories ["Consistently Severe Cognitive Impairment" (35.5%), "Consistently Moderate Cognitive Impairment" (31.8%), "Consistently Intact/Mild Cognitive Impairment" (32.7%)] were identified. One in five older residents simultaneously followed the trajectories of "Consistently Frail" and "Consistently Severe Cognitive Impairment". Characteristics associated with higher odds of the "Improving Frailty", "Worsening Frailty", "Consistently Pre-frail" and "Consistently Frail" trajectories included greater at-admission cognitive impairment, age ≥ 85 years, admitted from acute hospitals, cardiovascular/metabolic diagnoses, neurological diagnoses, hip or other fractures, and presence of pain. Characteristics associated with higher odds of the "Consistently Moderate Cognitive Impairment" and "Consistently Severe Cognitive Impairment" included worse at-admission physical frailty, neurological diagnoses, hip fracture, and receipt of antipsychotics. Conclusions: Findings provided information regarding the trajectories of physical frailty, the trajectories of cognitive impairment, the association between the two sets of trajectories, and their association with residents' characteristics in older adults' first six months post-admission to U.S. nursing homes. Understanding the trajectory that the residents would most likely follow may provide information to develop a comprehensive care approach tailored to their specific healthcare goals.

Background For the 1.2 million older adults residing in U.S. nursing homes, little is known about their experience with physical frailty and cognitive impairment, two critical interrelated aging conditions. Methods Minimum Data Set 3.0 was used. Physical frailty was measured by FRAIL-NH and cognitive impairment by Brief Interview for Mental Status and Cognitive Performance Scale. Demographic and clinical characteristics were adjusted accordingly. Aim 1 described the prevalence of physical frailty and cognitive impairment and longitudinally examined the association between two conditions with the non-proportional odds model. Aim 2 used latent class analysis to identify physical frailty subgroups and estimated their association with cognitive impairment using multinomial logistic regression. Aim 3 fitted group-based trajectory models to identify physical frailty trajectories and cognitive impairment trajectories and quantified the association between the two sets of trajectories. Main Results Around 60% of older residents were physically frail and 68% had moderate/severe cognitive impairment, with improvement and worsening observed in both conditions, particularly in the first three months. Older residents with moderate/severe cognitive impairment were consistently and increasingly more likely to be frail. Three physical frailty subgroups were identified at admission. Greater cognitive impairment was associated with higher odds to belong to “severe physical frailty”. Five physical frailty trajectories and three cognitive impairment trajectories were identified over the first six months. One in five older residents were “Consistently Frail” and “Consistently Severe Cognitive Impairment”. Conclusion Findings emphasized the need for care management tailored to the heterogeneous presentations and progression trajectories of physical frailty and cognitive impairment.

OBJECTIVES: Persons aged < 65 years account for a considerable proportion of US nursing home residents with schizophrenia. Because they are often excluded from psychiatric and long-term care studies, a contemporary understanding of the characteristics and management of working-age adults (22-64 years old) with schizophrenia living in nursing homes is lacking. This study describes characteristics of working-age adults with schizophrenia admitted to US nursing homes in 2015 and examines variations in these characteristics by age and admission location. Factors associated with length of stay and discharge destination were also explored. DESIGN: This is a cross-sectional study using the Minimum Data Set 3.0 merged to Nursing Home Compare. SETTING AND PARTICIPANTS: This study examines working-age (22-64 years) adults with schizophrenia at admission to a nursing home. METHODS: Descriptive statistics of resident characteristics (sociodemographic, clinical comorbidities, functional status, and treatments) and facility characteristics (ownership, geography, size, and star ratings) were examined overall, stratified by age and by admission location. Generalized estimating equation models were used to explore the associations of age, discharge to the community, and length of stay with relevant resident and facility characteristics. Coefficient estimates, adjusted odds ratios, and 95% CIs are presented. RESULTS: Overall, many of the 28,330 working-age adults with schizophrenia had hypertension, diabetes, and obesity. Those in older age subcategories tended to have physical functional dependencies, cognitive impairments, and clinical comorbidities. Those in younger age subcategories tended to exhibit higher risk of psychiatric symptoms. CONCLUSIONS AND IMPLICATIONS: Nursing home admission is likely inappropriate for many nursing home residents with schizophrenia aged < 65 years, especially those in younger age categories. Future psychiatric and long-term care research should include these residents to better understand the role of nursing homes in their care and should explore facility-level characteristics that may impact quality of care.

INTRODUCTION: Suicide is a leading cause of mortality in the United States and recent initiatives have sought to increase monitoring of suicide risk within healthcare systems. Working-age adults (22-64 years) admitted to nursing homes may be at risk for suicidal ideation, yet little is known about this population. METHODS: The national nursing home database, Minimum Dataset 3.0, was used to identify 323,436 working-age adults newly admitted to a nursing home in 2015. This cross-sectional study sought to describe sociodemographic and clinical characteristics, examine behavioral health treatment received, and determine resident characteristics associated with suicidal ideation at nursing home admission using logistic regression and reports adjusted odds ratios (aOR). RESULTS: Suicidal ideation was present among 1.27% of newly admitted working-age residents. Almost 25% of those with suicidal ideation had no psychiatric diagnosis. Factors associated with increased odds of suicidal ideation included younger age (aOR 1.90), admission from the community (aOR 1.92) or a psychiatric hospital (aOR 2.38), cognitive impairments (aOR 1.46), pain (aOR 1.40), rejection of care (aOR 1.91), and psychiatric comorbidity (aOR depression: 1.91, anxiety disorder: 1.11, bipolar disorder: 1.62, schizophrenia: 1.32, post-traumatic stress disorder: 1.17). LIMITATIONS: Due to the cross-sectional nature of this study, no causal inferences about suicidal ideation and the explored covariates can be made. The Minimum Dataset 3.0 has only one measure of suicidal ideation the Patient Health Questionnaire. CONCLUSION: Factors other than psychiatric diagnosis may be important in identifying newly admitted working-age nursing home residents who require on-going suicide screening and specialized psychiatric care.

OBJECTIVES: To longitudinally examine the latent statuses of depressive symptoms and their association with cognitive impairment in older U.S. nursing home (NH) residents. METHOD: Using Minimum Data Set 3.0, newly-admitted, long-stay, older NH residents with depression in 2014 were identified (n = 88,532). Depressive symptoms (Patient Health Questionnaire-9) and cognitive impairment (Brief Interview of Mental Status) were measured at admission and 90 days. Latent transition analysis was used to examine the prevalence of and the transition between latent statuses of depressive symptoms from admission to 90 days, and the association of cognitive impairment with the statuses at admission. RESULTS: Four latent statuses of depressive symptoms were identified: 'Multiple Symptoms' (prevalence at admission: 17.3%; 90 days: 13.6%), 'Depressed mood' (20.0%; 19.5%), 'Fatigue' (27.4%; 25.7%), and 'Minimal Symptoms' (35.3%; 41.2%). Most residents remained in the same status from admission to 90 days. Compared to residents who were cognitively intact, those with moderate impairment were more likely to be in 'Multiple Symptoms' and 'Fatigue' statuses; those with severe impairment had lower odds of belonging to 'Multiple Symptoms', 'Depressed Mood', and 'Fatigue' statuses. CONCLUSION: By addressing the longitudinal changes in the heterogeneous depressive symptoms and the role of cognitive impairment, findings have implications for depression management in older NH residents.

BACKGROUND: Little is known about the heterogeneous clinical profile of physical frailty and its association with cognitive impairment in older U.S. nursing home (NH) residents. METHODS: Minimum Data Set 3.0 at admission was used to identify older adults newly-admitted to nursing homes with life expectancy > /=6 months and length of stay > /=100 days (n = 871,801). Latent class analysis was used to identify physical frailty subgroups, using FRAIL-NH items as indicators. The association between the identified physical frailty subgroups and cognitive impairment (measured by Brief Interview for Mental Status/Cognitive Performance Scale: none/mild; moderate; severe), adjusting for demographic and clinical characteristics, was estimated by multinomial logistic regression and presented in adjusted odds ratios (aOR) and 95% confidence intervals (CIs). RESULTS: In older nursing home residents at admission, three physical frailty subgroups were identified: "mild physical frailty" (prevalence: 7.6%), "moderate physical frailty" (44.5%) and "severe physical frailty" (47.9%). Those in "moderate physical frailty" or "severe physical frailty" had high probabilities of needing assistance in transferring between locations and inability to walk in a room. Residents in "severe physical frailty" also had greater probability of bowel incontinence. Compared to those with none/mild cognitive impairment, older residents with moderate or severe impairment had slightly higher odds of belonging to "moderate physical frailty" [aOR (95%CI)moderate cognitive impairment: 1.01 (0.99-1.03); aOR (95%CI)severe cognitive impairment: 1.03 (1.01-1.05)] and much higher odds to the "severe physical frailty" subgroup [aOR (95%CI)moderate cognitive impairment: 2.41 (2.35-2.47); aOR (95%CI)severe cognitive impairment: 5.74 (5.58-5.90)]. CONCLUSIONS: Findings indicate the heterogeneous presentations of physical frailty in older nursing home residents and additional evidence on the interrelationship between physical frailty and cognitive impairment.

Purpose of Review: To describe approaches to measuring deprescribing and associated outcomes in studies of patients approaching end of life (EOL). Recent Findings: We reviewed studies published through 2020 that evaluated deprescribing in patients with limited life expectancy and approaching EOL. Deprescribing includes reducing the number of medications, decreasing medication dose(s), and eliminating potentially inappropriate medications. Tools such as STOPPFrail, OncPal, and the Unnecessary Drug Use Measure can facilitate deprescribing. Outcome measures vary and selection of measures should align with the operationalized deprescribing definition used by study investigators. Summary: EOL deprescribing considerations include medication appropriateness in the context of patient goals for care, expected benefit from medication given life expectancy, and heightened potential for medication-related harm as death nears. Additional data are needed on how EOL deprescribing impacts patient quality of life, caregiver burden, and out-of-pocket medication-related costs to patients and caregivers. Investigators should design deprescribing studies with this information in mind.

INTRODUCTION: In older US nursing home (NH) residents, there is limited research on the prevalence of physical frailty, its potential dynamic changes, and its association with cognitive impairment in older adults' first 6 months of NH stay. METHODS: Minimum Data Set (MDS) 3.0 is the national database on residents in US Medicare-/Medicaid-certified NHs. MDS 3.0 was used to identify older adults aged > /=65 years, newly admitted to NHs during January 1, 2014, and June 30, 2016, with life expectancy > /=6 months at admission and NH length of stay > /=6 months (N = 571,139). MDS 3.0 assessments at admission, 3 months, and 6 months were used. In each assessment, physical frailty was measured by FRAIL-NH (robust, prefrail, and frail) and cognitive impairment by Brief Interview for Mental Status and Cognitive Performance Scale (none/mild, moderate, and severe). Demographic characteristics and diagnosed conditions were measured at admission, while presence of pain and receipt of psychotropic medications were at each assessment. Distribution of physical frailty and its change over time by cognitive impairment were described. A nonproportional odds model was fitted with a generalized estimation equation to longitudinally examine the association between physical frailty and cognitive impairment, adjusting for demographic and clinical characteristics. RESULTS: Around 60% of older residents were physically frail in the first 6 months. Improvement and worsening across physical frailty levels were observed. Particularly, in those who were prefrail at admission, 23% improved to robust by 3 months. At admission, 3 months, and 6 months, over 37% of older residents had severe cognitive impairment and about 70% of those with cognitive impairment were physically frail. At admission, older residents with moderate cognitive impairment were 35% more likely (adjusted odds ratio [aOR]: 1.35, 95% confidence interval [CI]: 1.33-1.37) and those with severe impairment were 74% more likely (aOR: 1.74, 95% CI: 1.72-1.77) to be frail than prefrail/robust, compared to those with none/mild impairment. The association between the 2 conditions remained positive and consistently increased over time. DISCUSSION/CONCLUSION: Physical frailty was prevalent in NHs with potential to improve and was strongly associated with cognitive impairment. Physical frailty could be a modifiable target, and interventions may include efforts to address cognitive impairment.

OBJECTIVES: To identify subgroups of nursing home (NH) residents in the USA experiencing homogenous depression symptoms and evaluate if subgroups vary by cognitive impairment. METHODS: We identified 104 465 newly admitted, long-stay residents with depression diagnosis at NH admission in 2014 using the Minimum Data Set 3.0. The Patient Health Questionnaire-9 was used to measure depression symptoms and the Brief Interview of Mental Status for cognitive impairment (intact; moderately impaired; severely impaired). Latent class analysis (LCA) with logistic regression was used to: (a) construct the depression subgroups and (b) estimate adjusted odds ratios (aOR) and 95% confidence intervals (CI) of the associations between the subgroups and cognitive impairment level, adjusting for demographic and clinical characteristics. RESULTS: The best-fitted LCA model suggested four subgroups of depression: minimal symptoms (latent class prevalence: 42.4%), fatigue (32.0%), depressed mood (14.5%), and multiple symptoms (11.2%). Odds of subgroup membership varied by cognitive impairment. Compared to residents with intact cognition, those with moderate or severe cognitive impairment were less likely to belong to the fatigue subgroup [aOR(95% CI): moderate: 0.75 (0.71-0.80); severe: 0.26 (0.23-0.29)] and more likely to belong to the depressed mood subgroup [aOR (95% CI): moderate: 4.54 (3.55-5.81); severe: 6.41 (4.86-8.44)]. Residents with moderate cognitive impairment had increased odds [aOR (95% CI): 1.19 (1.12-1.27)] while those with severe impairment had reduced odds of being in the multiple symptoms subgroup [aOR (95% CI): 0.63 (0.58-0.68)]. CONCLUSIONS: Findings provide a basis for improving depression management with consideration of both subgroups of depression symptoms and levels of cognitive function.