JAMDA 14 (2013) 233e235

JAMDA

journal homepage: www.jamda.com

Editorial

Research Can Improve Care in the Nursing Home

Yves Rolland MD, PhD a,b,*, Philipe de Souto Barreto PhD a

aGérontopôle de Toulouse, Institut du Vieillissement, CHU Toulouse, Toulouse, Franceb Inserm U1027, University of Toulouse III, Toulouse, France

A growing number of older adults are living in institutionalsettings. In developed nations, 2% to 5% of elderly people are living innursing homes (NHs)1; this prevalence rises to up to 25% in the 85and older age group. Despite the increase of both the aging popula-tion and the number of institutionalized older people, clinicalresearch in NHs is still scarce. As an illustration, a rapid Medlinesearch using the key words “nursing home” and “elderly” showedthat only 2.5% of studies in the elderly have been carried out in thissetting. Research is, however, essential to improve the quality of carein NHs.

The Journal previously reported, on behalf of the InternationalAssociation of Gerontology and Geriatrics and the World HealthOrganization, the need to increase high-quality research activityin NHs.2 Figure 1 illustrates the small number of research studiesperformed in NHs, particularly the paucity of randomizedcontrolled trials (RCTs). Most current articles report the results ofcase-controlled, cross-sectional studies, short-duration interventions,or pilot studies on nursing strategies to overcome potential obstaclesfor improving the quality of care in small samples of NH residents.Robust evidence on how to provide optimal care for this institu-tionalized population is still lacking. Unfortunately, there has been noclear trend of improvement for this problem during the past 20 years(Figure 1).

Therapeutic strategies and protocols of care currently applied inNHs rely on little scientific foundation. We must admit that most ofour clinical practices in NHs are empirical. Our knowledge to providethe best health care in this specific population is still largely lackingbecause research has been mainly developed in community-dwellingelderly or among hospitalized older adults. Evidence from other po-pulations may not be relevant for the NH population. NH residentsdiffer from community-dwelling individuals in many aspects.Compared with community-dwelling elderly people, NH residents areolder, frailer, or frequently disabled. They have more comorbidities,take more medications, and are, then, more predisposed to developadverse health events.3 Acute diseases and falls result in a high rate ofhospitalization in this population.4 Moreover, residents’ health statusalso relies on the NH leadership and organization of the NH staff.2 TheNH population has a short life expectancy, and the main challenge

The authors report no conflict of interest in relation to the current manuscript.* Address correspondence to Yves Rolland, MD, PhD, Gérontopôle de Toulouse,

Pavillon Junot, 170 avenue de Casselardit, Hôpital La Grave-Casselardit, 31300Toulouse, France.

E-mail address: rolland.y@chu-toulouse.fr (Y. Rolland).

1525-8610/$ - see front matter Copyright � 2013 - American Medical Directors Associahttp://dx.doi.org/10.1016/j.jamda.2013.01.019

should be to preserve their quality of life5; therefore, the outcomesfor this population may differ from those of older adults living in thecommunity.

The poor representativeness of NH residents in clinical researchcan be explained by the fact that the most frequent criteria ofexclusion in clinical or pharmacological research include highlyprevalent conditions in NHs (dementia, behavioral disturbances, co-morbidity, polymedication, disability, legal protection, palliativecare). Institutionalization is often by itself a criterion of exclusion inpharmacological studies, and entry to an NH means withdrawal fromthe study in major clinical trials. As a result, most of the drugsfrequently prescribed for NH residents have never been tested in RCTsin this population.2,6 By contrast, this population, characterized byhigh rates of medication use and high risks of drug-drug interactionsand adverse drug reactions, had a low representativeness in phar-macological trials. The national drug approval agencies shouldencourage trials that include NH residents and require data from thisvulnerable population before drug approval.2

The specificity of research in the NH should also be emphasized.Behavioral disturbances, falls, physical and chemical restraints, tran-sitional care, geriatric syndromes such as anorexia,7 vitamin Ddeficiency, health care costs, medications, and nutrition are examplesof topics of interest treated in the top 10 most cited manuscripts in thefield of NHs during the past 10 years (Table 1). Depression, painmanagement, pressure ulcers, sarcopenia,18 and incontinence aresome other frequent conditions in NHs that need to be betterinvestigated; research on these domains should also involve the fieldsof geronto-technology and social, architectural, ethical, and economicsciences.

Research and quality of NH care go hand in hand. NH research canimprove the ongoing training of NH staff, encourage new strategies ofcare, including medications19 and nonpharmacological interventions,enhance daily practice, help to change negative cultural and societalrepresentations of NHs and NH residents, change the negative imageof health professionals about working in NHs, and improve theworking condition. Research can set up dynamic partnerships withthe family of NH residents, associations for the elderly, other NHs, andthe geriatric hospital department. For all these reasons, research inthe institutional setting would contribute to improving the quality ofcare in the NH.

However, there are various challenges to overcome to developresearch in NHs. One of the most important is certainly the lack ofenthusiasm among NH staff, because research is invariably consid-ered as additional work, which tends to impose supplemental

tion, Inc.

Fig. 1. Number* of manuscripts in “nursing home,” “elderly,” and “randomized controlled trial.” *Using the advanced research in PubMed Medline between January 1, 1992, andDecember 31, 2011: Key words “elderly” or “nursing home,” filter title, and “randomized controlled trial.”

Editorial / JAMDA 14 (2013) 233e235234

pressure on already overstretched NH activities. Identifying barriersto research development can maximize research involvement.20 Timeis needed to motivate, explain, and answer questions of the NH staff,but also to encourage the residents and families to participate inscientific studies.

Research in NHs must overcome many other difficulties. Forinstance, nonpharmacological interventions are more complicated toconduct in NHs than pharmacological studies. To avoid contaminationof the intervention between research arms, nonpharmacologicalstudies would require randomization in cluster with a large numberof participants. At the same time, the high dropout rate due to resi-dents’ worsening health and death needs to be accounted for insample size calculations during the design of the research protocol.Despite these constraints, nonpharmacological studies are one of themost important areas of research that must be implemented in NHs.Nonpharmacological programs support the idea that a specific(sometimes multifaceted) intervention adapted to the specific need ofa specific resident can be tested.21 This kind of research does notmatch with the usual design of the double-blind placebo-controlledtrials. The methodological issues related to nonpharmacologicalinterventions reduce the access to high-impact journals and then theattractiveness for researchers to perform these studies. Moreover,nonpharmacological studies are not supported by the pharmacolog-ical industry and must overcome the lack of funding. In NHs,researchers must deal with a large number of confounding factorsrelated to the subjects themselves (eg, number and severity of co-morbidities, medications taken) but also related to NH structure and

Table 1Top 10 Most Cited Manuscripts* in the Topic of Nursing Home (During the Past 10 Years)

Ranking[Reference]

Authors Year Title of the Manuscript

1 [8] Brodaty et al 2003 Meta-analysis of psychosocial interven2 [9] Rubenstein 2006 Falls in older people: Epidemiology, ris3 [10] Naylor et al 2004 Transitional care of older adults hospit4 [11] Inouye et al 2007 Geriatric syndromes: Clinical, research5 [12] Braithwaite et al 2003 Estimating hip fracture morbidity, mor6 [13] Leibson et al 2002 Mortality, disability, and nursing home

A population-based study7 [14] Broe et al 2007 A higher dose of vitamin D reduces the

multiple-dose study8 [15] Ensrud et al 2002 Central nervous systemeactive medica9 [16] Moreland et al 2004 Muscle weakness and falls in older adu10 [17] Guigoz 2006 The Mini Nutritional Assessment (MNA

*Web of Knowledge Web site using topic “nursing home” and date range “October 1Geriatrics Society or Journal of Gerontology Medical Sciences or Journal of Nutrition Health

internal organization (eg, presence of special care units, systematicassessment of drug prescriptions, number of care professionals). Mostresidents have poor mobility, and any additional investigations, suchas studies based on imagery, are complicated to perform.

With regard to research ethics, cognitive impairment (which ishighly prevalent in NH populations) constitutes a problem becausesigned informed consents are impossible to obtain from some resi-dents (especially those with dementia). A large number of residentsare demented, have behavioral disturbances, and take drugs with sideeffects, such as antipsychotics. Most ethic committees demand toexclude severely demented residents because of their failure tounderstand the constraints, risks, and outcomes of the research.However, severely demented residents need and have the right tobenefit from research advances like any other patient does. Excludingdemented people from research is an unfair and unjustified proce-dure. If we want to improve the care of NH residents, the ethical issueof the informed consent should be simplified with respect to humanrights.

We need also to highlight that there are advantages to developingresearch in NHs. Because of the ease of accessibility and monitoring,some interventions (such as physical activity, nutritional supple-mentation) are much easier and less expensive to organize in NHsthan in the community. Given that the eventual interventions aredeveloped in the participants’ life space, a high adherence to thetreatment will probably be obtained. Moreover, NH residents areoverall more vulnerable and have a higher rate of adverse events (eg,falls, fracture, infection, hospitalization) than older people living in

(n ¼ 1930)

No. Citations(Web of Knowledge)

tions for caregivers of people with dementia 240k factors and strategies for prevention 208alized with heart failure: A randomized, controlled trial 200, and policy implications of a core geriatric concept 187tality and costs 187use for persons with and without hip fracture: 146

risk of falls in nursing home residents: A randomized, 144

tions and risk for falls in older women 141lts: A systematic review and meta-analysis 137) review of the literature: What does it tell us? 122

st 2002 to October 1st 2012” published by Age and Ageing or Journal of the Americanand Aging or the Journal of the American Medical Directors Association.

Editorial / JAMDA 14 (2013) 233e235 235

the community. Higher treatment adherence and the initial worsehealth status of NH residents could explain the higher efficacy re-ported by studies in NHs than in the community setting (as forvitamin D trials22). Developing research in the NH also has a strongeducational component, as it is an opportunity to promote practicalknowledge to the staff (physicians, nurses, nurses’ aides, and otherprofessionals). Furthermore, because resources are limited in NHs,research in physical activity, nutrition, behavioral disturbances, or anyintervention can also give extra hands (eg, occupational therapist,dietician, psychologist) to the nursing staff.

Physicians working in NHs have a genuine desire to participatein clinical studies if the purposes of the research target the specificproblems and needs of the residents and propose meaningfulinterventions to improve the quality of care in NHs.3 To fill in thegap between knowledge and practice, it is our duty to developnetworks of researchers and NHs to perform high-quality trans-lational studies.23,24 These groups must focus their works on clini-cally relevant research priorities identified in NHs.3,25 Theimprovement of the quality of care in NHs will rely on futureevidence from research performed in this setting, their feasibility inthe real-life condition, and the successful dissemination of newclinical evidence.

References

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2. Tolson D, Rolland Y, Andrieu S, et al. International Association of Gerontologyand Geriatrics: A global agenda for clinical research and quality of care innursing homes. J Am Med Dir Assoc 2011;12:184e189.

3. Rolland Y, Abellan van Kan G, Hermabessiere S, et al. Descriptive study ofnursing home residents from the REHPA network. J Nutr Health Aging 2009;13:679e683.

4. Rolland Y, Andrieu S, Crochard A, et al. Psychotropic drug consumption atadmission and discharge of nursing home residents. J Am Med Dir Assoc 2012;13:407.e7e407.e12.

5. Iris M, DeBacker NA, Benner R, et al. Creating a quality of life assessmentmeasure for residents in long term care. J AmMed Dir Assoc 2012;13:438e447.

6. Salzman C, Jeste DV, Meyer RE, et al. Elderly patients with dementia-relatedsymptoms of severe agitation and aggression: Consensus statement on treat-ment options, clinical trials methodology, and policy. J Clin Psychiatry 2008;69(6):889e898.

7. Donini LM, Dominguez LJ, Barbagallo M, et al. Senile anorexia in differentgeriatric settings in Italy. J Nutr Health Aging 2011;15:775e781.

8. Brodaty H, Green A, Koschera A. Meta-analysis of psychosocial interventionsfor caregivers of people with dementia. J Am Geriatr Soc 2003;51:657e664.

9. Rubenstein LZ. Falls in older people: Epidemiology, risk factors and strategiesfor prevention. Age Ageing 2006;35:ii37eii41.

10. Naylor MD, Brooten DA, Campbell RL, et al. Transitional care of older adultshospitalized with heart failure: A randomized, controlled trial. J Am Geriatr Soc2004;52:675e684.

11. Inouye SK, Studenski S, Tinetti ME, Kuchel GA. Geriatric syndromes: Clinical,research, and policy implications of a core geriatric concept. J Am Geriatr Soc2007;55:780e791.

12. Braithwaite RS, Col NF, Wong JB. Estimating hip fracture morbidity, mortalityand costs. J Am Geriatr Soc 2003;51:364e370.

13. Leibson CL, Tosteson AN, Gabriel SE, et al. Mortality, disability, and nursinghome use for persons with and without hip fracture: A population-based study.J Am Geriatr Soc 2002;50:1644e1650.

14. Broe KE, Chen TC, Weinberg J, et al. A higher dose of vitamin D reduces the riskof falls in nursing home residents: A randomized, multiple-dose study. J AmGeriatr Soc 2007;55:234e239.

15. Ensrud KE, Blackwell TL, Mangione CM, et al. Central nervous system-activemedications and risk for falls in older women. J Am Geriatr Soc 2002;50:1629e1637.

16. Moreland JD, Richardson JA, Goldsmith CH, Clase CM. Muscle weakness andfalls in older adults: A systematic review and meta-analysis. J Am Geriatr Soc2004;52:1121e1129.

17. Guigoz Y. The Mini Nutritional Assessment (MNA) review of the literature:What does it tell us? J Nutr Health Aging 2006;10:466e485.

18. Kimyagarov S, Klid R, Fleissig Y, et al. Skeletal muscle mass abnormalities areassociated with survival rates of institutionalized elderly nursing home resi-dents. J Nutr Health Aging 2012;16:432e436.

19. Garcia-Gollarte F, Baleriola-Julvez J, Ferrero-Lopez I, Cruz-Jentoft AJ. Inappro-priate drug prescription at nursing home admission. J Am Med Dir Assoc 2012;13:83.e9e83.e15.

20. Cohen-Mansfield J, Thein K, Marx MS, Dakheel-Ali M. What are the barriers toperforming nonpharmacological interventions for behavioral symptoms in thenursing home? J Am Med Dir Assoc 2012;13:400e405.

21. Lorefalt B, Wilhelmsson S. A multifaceted intervention model can give a lastingimprovement of older peoples’ nutritional status. J Nutr Health Aging 2012;16:378e382.

22. Avenell A, Gillespie WJ, Gillespie LD, O’Connell D. Vitamin D and vitamin Danalogues for preventing fractures associated with involutional and post-menopausal osteoporosis. Cochrane Database Syst Rev 2009;(2):CD000227.

23. Rantz MJ, Zwygart-Stauffacher M, Hicks L, et al. Randomized multilevelintervention to improve outcomes of residents in nursing homes in need ofimprovement. J Am Med Dir Assoc 2012;13:60e68.

24. Vellas B, Stephan E. A research agenda for nursing homes. J Am Med Dir Assoc2011;12:393e394.

25. Brazil K, Maitland J, Ploeg J, Denton M. Identifying research priorities in longterm care homes. J Am Med Dir Assoc 2012;13:84.e1e84.e4.