Smarter Decisions,
Better Care

UpToDate synthesizes the most recent medical information into evidence-based practical recommendations clinicians trust to make the right point-of-care decisions.

  • Rigorous editorial process: Evidence-based treatment recommendations
  • World-Renowned physician authors: over 5,100 physician authors and editors around the globe
  • Innovative technology: integrates into the workflow; access from EMRs

Choose from the list below to learn more about subscriptions for a:


Subscribers log in here


Related articles

Medical care of the nursing home patient in the United States

INTRODUCTION

Nursing home care in the United States includes both long-term residential care and short-term postacute or rehabilitative care. While the number of Americans living in nursing homes for extended periods has fallen steadily over the past decade as an increasing proportion of older individuals remain in their homes or in assisted living facilities, the number receiving short term nursing home care has risen dramatically. In 2008, approximately 1.4 million people lived in a nursing home at any given time. However, over the course of the year, over 3.25 million people spent time in a skilled nursing facility [1].

Nursing home residents, whether short- or long-stay, tend to be old, female, and have multiple impairments in their activities of daily living (ADLs). Of those in nursing homes in 2008, 16.2 percent were between the ages of 65 and 74, 33.0 percent were between 75 and 84, 32.0 percent were between 85 and 94, and 5.2 percent were 95 years of age or older [1]. In the same population, 8.5 percent had impairments in 3 ADLs, 30.8 percent had impairments in 4 ADLs, and 18.4 percent had impairments in 5 ADLs. Cognitive impairment is also widespread in this population, with 10.4 percent exhibiting severe or very severe impairment, 30.7 percent having moderate or moderately severe impairment, and only 32.0 percent showing no impairment.

Nursing home care represents a substantial segment of health care costs for older individuals: in the US in 2006, $124.9 billion was spent on nursing home care, of which 17 percent was paid by Medicare, 43 percent by Medicaid, 7 percent by private insurance, and 26 percent out of pocket [2]. Long-term patients live at the facility and are often described as receiving custodial care. Room and board costs for this group are generally paid for by Medicaid, long term care insurance, or out-of-pocket by patients or their families. For most short-stay nursing home patients discharged from a hospital setting, the goal is to return to the community. A subset of these patients may be at the nursing home for short-term end of life care and some will require long-term nursing home care. Room and board costs for this group are generally paid by their skilled nursing facility (SNF) benefit, which, in the case of Medicare, covers up to 100 days per benefit period if care needs meet specific clinical criteria.

Physicians providing medical care in the nursing home must be knowledgeable about regulatory, ethical, and epidemiological as well as geriatric issues [3]. For certain conditions, such as heart failure, diabetes mellitus, and chronic obstructive pulmonary disease, medical management is similar to outpatient management. This topic will focus on those conditions in nursing home patients that warrant a particular approach or heightened awareness. Many are geriatric syndromes that comprise constellations of symptoms that may have any of several etiologies.

COMPREHENSIVE GERIATRIC ASSESSMENT

Comprehensive geriatric assessment includes an evaluation of the patient's functional, physical, cognitive, emotional, and psychosocial status. It is a cost-effective intervention that improves quality of life in a variety of settings [4] and is recommended for use in frail elders by the American Geriatrics Society [5]. The nursing home is an ideal environment in which to carry out comprehensive geriatric assessment since its population is at high risk and its residential character facilitates implementation of recommendations. (See "Comprehensive geriatric assessment".)

                                       

Subscribers log in here

To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information or to purchase a personal subscription, click below on the option that best describes you:
Literature review current through: Aug 2014. | This topic last updated: Aug 13, 2014.
The content on the UpToDate website is not intended nor recommended as a substitute for medical advice, diagnosis, or treatment. Always seek the advice of your own physician or other qualified health care professional regarding any medical questions or conditions. The use of this website is governed by the UpToDate Terms of Use ©2014 UpToDate, Inc.
References
Top
  1. Centers for Medicare and Medicaid Services. Nursing Home Data Compendium 2009 Edition. Available at: https://www.cms.gov/CertificationandComplianc/Downloads/nursinghomedatacompendium_508.pdf (Accessed on October 18, 2011).
  2. Henry J Kaiser Family Foundation. Medicaid and long-term care services and supplies, October 2010.
  3. Zweig SC, Popejoy LL, Parker-Oliver D, Meadows SE. The physician's role in patients' nursing home care: "She's a very courageous and lovely woman. I enjoy caring for her". JAMA 2011; 306:1468.
  4. Keeler EB, Robalino DA, Frank JC, et al. Cost-effectiveness of outpatient geriatric assessment with an intervention to increase adherence. Med Care 1999; 37:1199.
  5. American Geriatrics Society. Comprehensive geriatric assessment position statement 2005. Available at: www.americangeriatrics.org/products/positionpapers/cga.shtml (Accessed on April 30, 2007).
  6. https://www.cms.gov/NursingHomeQualityInits/25_NHQIMDS30.asp.
  7. http://www.medicare.gov/NHCompare (Accessed on January 05, 2011).
  8. Owsley C, McGwin G Jr, Scilley K, et al. Effect of refractive error correction on health-related quality of life and depression in older nursing home residents. Arch Ophthalmol 2007; 125:1471.
  9. Owsley C, McGwin G Jr, Scilley K, et al. Impact of cataract surgery on health-related quality of life in nursing home residents. Br J Ophthalmol 2007; 91:1359.
  10. Friedman DS, Muñoz B, Roche KB, et al. Poor uptake of cataract surgery in nursing home residents: the Salisbury Eye Evaluation in Nursing Home Groups study. Arch Ophthalmol 2005; 123:1581.
  11. Cohen-Mansfield J, Taylor JW. Hearing aid use in nursing homes. Part 1: Prevalence rates of hearing impairment and hearing aid use. J Am Med Dir Assoc 2004; 5:283.
  12. Cohen-Mansfield J, Infeld DL. Hearing aids for nursing home residents: current policy and future needs. Health Policy 2006; 79:49.
  13. Borson S, Scanlan JM, Chen P, Ganguli M. The Mini-Cog as a screen for dementia: validation in a population-based sample. J Am Geriatr Soc 2003; 51:1451.
  14. Chodosh J, Edelen MO, Buchanan JL, et al. Nursing home assessment of cognitive impairment: development and testing of a brief instrument of mental status. J Am Geriatr Soc 2008; 56:2069.
  15. Raina P, Santaguida P, Ismaila A, et al. Effectiveness of cholinesterase inhibitors and memantine for treating dementia: evidence review for a clinical practice guideline. Ann Intern Med 2008; 148:379.
  16. Qaseem A, Snow V, Cross JT Jr, et al. Current pharmacologic treatment of dementia: a clinical practice guideline from the American College of Physicians and the American Academy of Family Physicians. Ann Intern Med 2008; 148:370.
  17. Mitchell SL, Teno JM, Kiely DK, et al. The clinical course of advanced dementia. N Engl J Med 2009; 361:1529.
  18. Mitchell SL, Miller SC, Teno JM, et al. Prediction of 6-month survival of nursing home residents with advanced dementia using ADEPT vs hospice eligibility guidelines. JAMA 2010; 304:1929.
  19. Jones RN, Kiely DK, Marcantonio ER. Prevalence of delirium on admission to postacute care is associated with a higher number of nursing home deficiencies. J Am Med Dir Assoc 2010; 11:253.
  20. Kiely DK, Bergmann MA, Murphy KM, et al. Delirium among newly admitted postacute facility patients: prevalence, symptoms, and severity. J Gerontol A Biol Sci Med Sci 2003; 58:M441.
  21. Marcantonio ER, Kiely DK, Simon SE, et al. Outcomes of older people admitted to postacute facilities with delirium. J Am Geriatr Soc 2005; 53:963.
  22. Inouye SK, van Dyck CH, Alessi CA, et al. Clarifying confusion: the confusion assessment method. A new method for detection of delirium. Ann Intern Med 1990; 113:941.
  23. Wong CL, Holroyd-Leduc J, Simel DL, Straus SE. Does this patient have delirium?: value of bedside instruments. JAMA 2010; 304:779.
  24. Lyons WL. Delirium in postacute and long-term care. J Am Med Dir Assoc 2006; 7:254.
  25. Inouye SK, Bogardus ST Jr, Charpentier PA, et al. A multicomponent intervention to prevent delirium in hospitalized older patients. N Engl J Med 1999; 340:669.
  26. McCusker J, Cole M, Abrahamowicz M, et al. Environmental risk factors for delirium in hospitalized older people. J Am Geriatr Soc 2001; 49:1327.
  27. Marcantonio ER, Simon SE, Bergmann MA, et al. Delirium symptoms in post-acute care: prevalent, persistent, and associated with poor functional recovery. J Am Geriatr Soc 2003; 51:4.
  28. Hoover DR, Siegel M, Lucas J, et al. Depression in the first year of stay for elderly long-term nursing home residents in the USA. Int Psychogeriatr 2010; 22:1161.
  29. Levin CA, Wei W, Akincigil A, et al. Prevalence and treatment of diagnosed depression among elderly nursing home residents in Ohio. J Am Med Dir Assoc 2007; 8:585.
  30. Leontjevas R, Gerritsen DL, Smalbrugge M, et al. A structural multidisciplinary approach to depression management in nursing-home residents: a multicentre, stepped-wedge cluster-randomised trial. Lancet 2013; 381:2255.
  31. McGivney SA, Mulvihill M, Taylor B. Validating the GDS depression screen in the nursing home. J Am Geriatr Soc 1994; 42:490.
  32. Alexopoulos GS, Abrams RC, Young RC, Shamoian CA. Cornell Scale for Depression in Dementia. Biol Psychiatry 1988; 23:271.
  33. Reynolds CF 3rd, Dew MA, Pollock BG, et al. Maintenance treatment of major depression in old age. N Engl J Med 2006; 354:1130.
  34. Chen Y, Briesacher BA, Field TS, et al. Unexplained variation across US nursing homes in antipsychotic prescribing rates. Arch Intern Med 2010; 170:89.
  35. Cummings JL. Alzheimer's disease. N Engl J Med 2004; 351:56.
  36. Husebo BS, Ballard C, Sandvik R, et al. Efficacy of treating pain to reduce behavioural disturbances in residents of nursing homes with dementia: cluster randomised clinical trial. BMJ 2011; 343:d4065.
  37. www.fda.gov/medwatch/safety/2008/safety08.htm#Antipsychotics (Accessed on September 15, 2011).
  38. Huybrechts KF, Gerhard T, Crystal S, et al. Differential risk of death in older residents in nursing homes prescribed specific antipsychotic drugs: population based cohort study. BMJ 2012; 344:e977.
  39. Street JS, Clark WS, Gannon KS, et al. Olanzapine treatment of psychotic and behavioral symptoms in patients with Alzheimer disease in nursing care facilities: a double-blind, randomized, placebo-controlled trial. The HGEU Study Group. Arch Gen Psychiatry 2000; 57:968.
  40. Schneider LS, Tariot PN, Dagerman KS, et al. Effectiveness of atypical antipsychotic drugs in patients with Alzheimer's disease. N Engl J Med 2006; 355:1525.
  41. Folstein M, Bylsma F. Noncognitive symptoms of Alzheimer disease. In: Alzheimer Disease, Terry R, Katzman R, Bick K. (Eds), Raven Press, New York 1994. p.27.
  42. Meeks TW, Jeste DV. Beyond the Black Box: What is The Role for Antipsychotics in Dementia? Curr Psychiatr 2008; 7:50.
  43. Rubenstein LZ, Josephson KR, Robbins AS. Falls in the nursing home. Ann Intern Med 1994; 121:442.
  44. Ray WA, Taylor JA, Meador KG, et al. A randomized trial of a consultation service to reduce falls in nursing homes. JAMA 1997; 278:557.
  45. Thapa PB, Gideon P, Cost TW, et al. Antidepressants and the risk of falls among nursing home residents. N Engl J Med 1998; 339:875.
  46. Ray WA, Thapa PB, Gideon P. Benzodiazepines and the risk of falls in nursing home residents. J Am Geriatr Soc 2000; 48:682.
  47. Kiel DP, Magaziner J, Zimmerman S, et al. Efficacy of a hip protector to prevent hip fracture in nursing home residents: the HIP PRO randomized controlled trial. JAMA 2007; 298:413.
  48. Fulop T, Pawelec G, Castle S, Loeb M. Immunosenescence and vaccination in nursing home residents. Clin Infect Dis 2009; 48:443.
  49. Fabiszewski KJ, Volicer B, Volicer L. Effect of antibiotic treatment on outcome of fevers in institutionalized Alzheimer patients. JAMA 1990; 263:3168.
  50. van der Steen JT, Ooms ME, van der Wal G, Ribbe MW. Pneumonia: the demented patient's best friend? Discomfort after starting or withholding antibiotic treatment. J Am Geriatr Soc 2002; 50:1681.
  51. High KP, Bradley SF, Gravenstein S, et al. Clinical practice guideline for the evaluation of fever and infection in older adult residents of long-term care facilities: 2008 update by the Infectious Diseases Society of America. Clin Infect Dis 2009; 48:149.
  52. D'Agata E, Mitchell SL. Patterns of antimicrobial use among nursing home residents with advanced dementia. Arch Intern Med 2008; 168:357.
  53. Barker WH, Borisute H, Cox C. A study of the impact of influenza on the functional status of frail older people. Arch Intern Med 1998; 158:645.
  54. Hayward AC, Harling R, Wetten S, et al. Effectiveness of an influenza vaccine programme for care home staff to prevent death, morbidity, and health service use among residents: cluster randomised controlled trial. BMJ 2006; 333:1241.
  55. Hayden FG, Osterhaus AD, Treanor JJ, et al. Efficacy and safety of the neuraminidase inhibitor zanamivir in the treatment of influenzavirus infections. GG167 Influenza Study Group. N Engl J Med 1997; 337:874.
  56. Hayden FG, Atmar RL, Schilling M, et al. Use of the selective oral neuraminidase inhibitor oseltamivir to prevent influenza. N Engl J Med 1999; 341:1336.
  57. Hayden FG, Treanor JJ, Fritz RS, et al. Use of the oral neuraminidase inhibitor oseltamivir in experimental human influenza: randomized controlled trials for prevention and treatment. JAMA 1999; 282:1240.
  58. www.cdc.gov/flu/han011406.htm (Accessed on September 15, 2011).
  59. Peters PH Jr, Gravenstein S, Norwood P, et al. Long-term use of oseltamivir for the prophylaxis of influenza in a vaccinated frail older population. J Am Geriatr Soc 2001; 49:1025.
  60. Patriarca PA, Arden NH, Koplan JP, Goodman RA. Prevention and control of type A influenza infections in nursing homes. Benefits and costs of four approaches using vaccination and amantadine. Ann Intern Med 1987; 107:732.
  61. Simor AE. Diagnosis, management, and prevention of Clostridium difficile infection in long-term care facilities: a review. J Am Geriatr Soc 2010; 58:1556.
  62. Cohen SH, Gerding DN, Johnson S, et al. Clinical practice guidelines for Clostridium difficile infection in adults: 2010 update by the society for healthcare epidemiology of America (SHEA) and the infectious diseases society of America (IDSA). Infect Control Hosp Epidemiol 2010; 31:431.
  63. Nicolle LE, Bentley D, Garibaldi R, et al. Antimicrobial use in long-term-care facilities. Infect Control Hosp Epidemiol 1996; 17:119.
  64. Kelly CP, Pothoulakis C, LaMont JT. Clostridium difficile colitis. N Engl J Med 1994; 330:257.
  65. Johnson S, Homann SR, Bettin KM, et al. Treatment of asymptomatic Clostridium difficile carriers (fecal excretors) with vancomycin or metronidazole. A randomized, placebo-controlled trial. Ann Intern Med 1992; 117:297.
  66. Nicolle LE, Henderson E, Bjornson J, et al. The association of bacteriuria with resident characteristics and survival in elderly institutionalized men. Ann Intern Med 1987; 106:682.
  67. Colgan R, Nicolle LE, McGlone A, Hooton TM. Asymptomatic bacteriuria in adults. Am Fam Physician 2006; 74:985.
  68. U.S. Preventive Services Task Force. Screening for asymptomatic bacteriuria in adults: U.S. Preventive Services Task Force reaffirmation recommendation statement. Ann Intern Med 2008; 149:43.
  69. Nicolle LE, Bradley S, Colgan R, et al. Infectious Diseases Society of America guidelines for the diagnosis and treatment of asymptomatic bacteriuria in adults. Clin Infect Dis 2005; 40:643.
  70. Quagliarello V, Ginter S, Han L, et al. Modifiable risk factors for nursing home-acquired pneumonia. Clin Infect Dis 2005; 40:1.
  71. Yoneyama T, Yoshida M, Ohrui T, et al. Oral care reduces pneumonia in older patients in nursing homes. J Am Geriatr Soc 2002; 50:430.
  72. Terpenning MS, Taylor GW, Lopatin DE, et al. Aspiration pneumonia: dental and oral risk factors in an older veteran population. J Am Geriatr Soc 2001; 49:557.
  73. Terpenning M. Geriatric oral health and pneumonia risk. Clin Infect Dis 2005; 40:1807.
  74. Naughton BJ, Mylotte JM. Treatment guideline for nursing home-acquired pneumonia based on community practice. J Am Geriatr Soc 2000; 48:82.
  75. Loeb M, Carusone SC, Goeree R, et al. Effect of a clinical pathway to reduce hospitalizations in nursing home residents with pneumonia: a randomized controlled trial. JAMA 2006; 295:2503.
  76. Hutt E, Kramer AM. Evidence-based guidelines for management of nursing home-acquired pneumonia. J Fam Pract 2002; 51:709.
  77. Mills K, Graham AC, Winslow BT, Springer KL. Treatment of nursing home-acquired pneumonia. Am Fam Physician 2009; 79:976.
  78. Morrison RS, Siu AL. Survival in end-stage dementia following acute illness. JAMA 2000; 284:47.
  79. Givens JL, Jones RN, Shaffer ML, et al. Survival and comfort after treatment of pneumonia in advanced dementia. Arch Intern Med 2010; 170:1102.
  80. Finucane TE, Christmas C, Travis K. Tube feeding in patients with advanced dementia: a review of the evidence. JAMA 1999; 282:1365.
  81. Schultz M, Hernández JM, Hernández NE, Sanchez RO. Onset of tuberculosis disease: new converters in long-term care settings. Am J Alzheimers Dis Other Demen 2001; 16:313.
  82. Jensen PA, Lambert LA, Iademarco MF, et al. Guidelines for preventing the transmission of Mycobacterium tuberculosis in health-care settings, 2005. MMWR Recomm Rep 2005; 54:1.
  83. Finucane TE. The American Geriatrics Society statement on two-step PPD testing for nursing home patients on admission. J Am Geriatr Soc 1988; 36:77.
  84. Won A, Lapane K, Gambassi G, et al. Correlates and management of nonmalignant pain in the nursing home. SAGE Study Group. Systematic Assessment of Geriatric drug use via Epidemiology. J Am Geriatr Soc 1999; 47:936.
  85. Jensen PA, Lambert LA, Iademarco MF, et al. Guidelines for preventing the transmission of Mycobacterium tuberculosis in health-care settings, 2005. MMWR Recomm Rep 2005; 54:1.
  86. Hollenack KA, Cranmer KW, Zarowitz BJ, O'Shea T. The application of evidence-based principles of care in older persons (issue 4): pain management. J Am Med Dir Assoc 2007; 8:e77.
  87. www.chcr.brown.edu/commstate/PDF/FASTFACTS3.pdf.
  88. Sloane PD, Ivey J, Helton M, et al. Nutritional issues in long-term care. J Am Med Dir Assoc 2008; 9:476.
  89. Sullivan DH, Johnson LE, Bopp MM, Roberson PK. Prognostic significance of monthly weight fluctuations among older nursing home residents. J Gerontol A Biol Sci Med Sci 2004; 59:M633.
  90. Vellas B, Guigoz Y, Garry PJ, et al. The Mini Nutritional Assessment (MNA) and its use in grading the nutritional state of elderly patients. Nutrition 1999; 15:116.
  91. Sampson EL, Candy B, Jones L. Enteral tube feeding for older people with advanced dementia. Cochrane Database Syst Rev 2009; :CD007209.
  92. American Geriatrics Society Ethics Committee and Clinical Practice and Models of Care Committee. American geriatrics society feeding tubes in advanced dementia position statement. J Am Geriatr Soc 2014; 62:1590.
  93. Robertson RG, Montagnini M. Geriatric failure to thrive. Am Fam Physician 2004; 70:343.
  94. Rigler SK, Webb MJ, Redford L, et al. Weight outcomes among antidepressant users in nursing facilities. J Am Geriatr Soc 2001; 49:49.
  95. Koretz RL, Avenell A, Lipman TO, et al. Does enteral nutrition affect clinical outcome? A systematic review of the randomized trials. Am J Gastroenterol 2007; 102:412.
  96. Simmons SF, Keeler E, Zhuo X, et al. Prevention of unintentional weight loss in nursing home residents: a controlled trial of feeding assistance. J Am Geriatr Soc 2008; 56:1466.
  97. Yeh S, Wu SY, Levine DM, et al. Quality of life and stimulation of weight gain after treatment with megestrol acetate: correlation between cytokine levels and nutritional status, appetite in geriatric patients with wasting syndrome. J Nutr Health Aging 2000; 4:246.
  98. Simmons SF, Alessi C, Schnelle JF. An intervention to increase fluid intake in nursing home residents: prompting and preference compliance. J Am Geriatr Soc 2001; 49:926.
  99. Feinsod FM, Levenson SA, Rapp K, et al. Dehydration in frail, older residents in long-term care facilities. J Am Med Dir Assoc 2004; 5:S35.
  100. Dasgupta M, Binns MA, Rochon PA. Subcutaneous fluid infusion in a long-term care setting. J Am Geriatr Soc 2000; 48:795.
  101. Thomas DR. Prevention and treatment of pressure ulcers. J Am Med Dir Assoc 2006; 7:46.
  102. www.npuap.org/PDF/push3.pdf.
  103. Pham B, Stern A, Chen W, et al. Preventing pressure ulcers in long-term care: a cost-effectiveness analysis. Arch Intern Med 2011; 171:1839.
  104. Frías Soriano L, Lage Vázquez MA, Maristany CP, et al. The effectiveness of oral nutritional supplementation in the healing of pressure ulcers. J Wound Care 2004; 13:319.
  105. Desneves KJ, Todorovic BE, Cassar A, Crowe TC. Treatment with supplementary arginine, vitamin C and zinc in patients with pressure ulcers: a randomised controlled trial. Clin Nutr 2005; 24:979.
  106. Hilmer SN, McLachlan AJ, Le Couteur DG. Clinical pharmacology in the geriatric patient. Fundam Clin Pharmacol 2007; 21:217.
  107. Messinger-Rapport BJ, Thomas DR, Gammack JK, Morley JE. Clinical update on nursing home medicine: 2009. J Am Med Dir Assoc 2009; 10:530.
  108. Witherington EM, Pirzada OM, Avery AJ. Communication gaps and readmissions to hospital for patients aged 75 years and older: observational study. Qual Saf Health Care 2008; 17:71.
  109. Field TS, Gurwitz JH, Avorn J, et al. Risk factors for adverse drug events among nursing home residents. Arch Intern Med 2001; 161:1629.
  110. Linsky A, Hermos JA, Lawler EV, Rudolph JL. Proton pump inhibitor discontinuation in long-term care. J Am Geriatr Soc 2011; 59:1658.
  111. Boockvar KS, Carlson LaCorte H, Giambanco V, et al. Medication reconciliation for reducing drug-discrepancy adverse events. Am J Geriatr Pharmacother 2006; 4:236.
  112. Lapane KL, Hughes CM, Daiello LA, et al. Effect of a pharmacist-led multicomponent intervention focusing on the medication monitoring phase to prevent potential adverse drug events in nursing homes. J Am Geriatr Soc 2011; 59:1238.
  113. Tjia J, Rothman MR, Kiely DK, et al. Daily medication use in nursing home residents with advanced dementia. J Am Geriatr Soc 2010; 58:880.
  114. Tinetti ME, Bogardus ST Jr, Agostini JV. Potential pitfalls of disease-specific guidelines for patients with multiple conditions. N Engl J Med 2004; 351:2870.
  115. Gabrel CS. Characteristics of elderly nursing home current residents and discharges: data from the 1997 National Nursing Home Survey. Adv Data 2000; :1.
  116. Dubeau CE, Simon SE, Morris JN. The effect of urinary incontinence on quality of life in older nursing home residents. J Am Geriatr Soc 2006; 54:1325.
  117. Fantl JA, Newman DK, Colling J, et al. Urinary incontinence in adults: acute and chronic management. Clinical Practice Guideline No. 2. 1996 Update. Agency for Health Care Policy and Research; Rockville, MD 1996.
  118. www.amda.com/tools/cpg/incontinence.cfm (Accessed on April 30, 2007).
  119. Zarowitz BJ, Ouslander JG. The application of evidence-based principles of care in older persons (issue 6): urinary incontinence. J Am Med Dir Assoc 2007; 8:35.
  120. Eustice S, Roe B, Paterson J. Prompted voiding for the management of urinary incontinence in adults. Cochrane Database Syst Rev 2000; :CD002113.
  121. Fink HA, Taylor BC, Tacklind JW, et al. Treatment interventions in nursing home residents with urinary incontinence: a systematic review of randomized trials. Mayo Clin Proc 2008; 83:1332.
  122. Hu TW, Igou JF, Kaltreider DL, et al. A clinical trial of a behavioral therapy to reduce urinary incontinence in nursing homes. Outcome and implications. JAMA 1989; 261:2656.
  123. Phillips C, Polakoff D, Maue SK, Mauch R. Assessment of constipation management in long-term care patients. J Am Med Dir Assoc 2001; 2:149.
  124. Volicer L, Lane P, Panke J, Lyman P. Management of constipation in residents with dementia: sorbitol effectiveness and cost. J Am Med Dir Assoc 2004; 5:239.
  125. Bradley EH, Wetle T, Horwitz SM. The patient self-determination act and advance directive completion in nursing homes. Arch Fam Med 1998; 7:417.
  126. Gillick MR. Adapting advance medical planning for the nursing home. J Palliat Med 2004; 7:357.
  127. Molloy DW, Guyatt GH, Russo R, et al. Systematic implementation of an advance directive program in nursing homes: a randomized controlled trial. JAMA 2000; 283:1437.
  128. Kane RS, Burns EA. Cardiopulmonary resuscitation policies in long-term care facilities. J Am Geriatr Soc 1997; 45:154.
  129. Gordon M, Cheung M. Poor outcome of on-site CPR in a multi-level geriatric facility: three and a half years experience at the Baycrest Centre for Geriatric Care. J Am Geriatr Soc 1993; 41:163.
  130. Shah MN, Fairbanks RJ, Lerner EB. Cardiac arrests in skilled nursing facilities: continuing room for improvement? J Am Med Dir Assoc 2006; 7:350.
  131. Murphy DJ, Murray AM, Robinson BE, Campion EW. Outcomes of cardiopulmonary resuscitation in the elderly. Ann Intern Med 1989; 111:199.
  132. FitzGerald JD, Wenger NS, Califf RM, et al. Functional status among survivors of in-hospital cardiopulmonary resuscitation. SUPPORT Investigators Study to Understand Progress and Preferences for Outcomes and Risks of Treatment. Arch Intern Med 1997; 157:72.
  133. Lahn M, Friedman B, Bijur P, et al. Advance directives in skilled nursing facility residents transferred to emergency departments. Acad Emerg Med 2001; 8:1158.
  134. Tolle SW, Tilden VP, Nelson CA, Dunn PM. A prospective study of the efficacy of the physician order form for life-sustaining treatment. J Am Geriatr Soc 1998; 46:1097.
  135. Hickman SE, Nelson CA, Perrin NA, et al. A comparison of methods to communicate treatment preferences in nursing facilities: traditional practices versus the physician orders for life-sustaining treatment program. J Am Geriatr Soc 2010; 58:1241.
  136. Volicer L, Rheaume Y, Brown J, et al. Hospice approach to the treatment of patients with advanced dementia of the Alzheimer type. JAMA 1986; 256:2210.
  137. Molloy DW, Guyatt GH. A comprehensive health care directive in a home for the aged. CMAJ 1991; 145:307.
  138. Phelan EA, Borson S, Grothaus L, et al. Association of incident dementia with hospitalizations. JAMA 2012; 307:165.
  139. Mitchell SL, Teno JM, Intrator O, et al. Decisions to forgo hospitalization in advanced dementia: a nationwide study. J Am Geriatr Soc 2007; 55:432.
  140. Hanson LC, Ersek M. Meeting palliative care needs in post-acute care settings: "to help them live until they die". JAMA 2006; 295:681.
  141. Teno JM, Clarridge BR, Casey V, et al. Family perspectives on end-of-life care at the last place of care. JAMA 2004; 291:88.
  142. Baer WM, Hanson LC. Families' perception of the added value of hospice in the nursing home. J Am Geriatr Soc 2000; 48:879.
  143. Miller SC, Lima J, Gozalo PL, Mor V. The growth of hospice care in U.S. nursing homes. J Am Geriatr Soc 2010; 58:1481.
  144. Ouslander JG, Lamb G, Tappen R, et al. Interventions to reduce hospitalizations from nursing homes: evaluation of the INTERACT II collaborative quality improvement project. J Am Geriatr Soc 2011; 59:745.
  145. Finlayson E, Wang L, Landefeld CS, Dudley RA. Major abdominal surgery in nursing home residents: a national study. Ann Surg 2011; 254:921.
  146. Casarett D, Karlawish J, Morales K, et al. Improving the use of hospice services in nursing homes: a randomized controlled trial. JAMA 2005; 294:211.
  147. Jencks SF, Williams MV, Coleman EA. Rehospitalizations among patients in the Medicare fee-for-service program. N Engl J Med 2009; 360:1418.
  148. Medicare Payment Advisory Commission. Report to the Congress: Promoting greater efficiency in Medicare. June 2007.
  149. Saliba D, Kington R, Buchanan J, et al. Appropriateness of the decision to transfer nursing facility residents to the hospital. J Am Geriatr Soc 2000; 48:154.
  150. Gozalo P, Teno JM, Mitchell SL, et al. End-of-life transitions among nursing home residents with cognitive issues. N Engl J Med 2011; 365:1212.