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Four factors trigger nursing home residents to reject care.

LONG BEACH, CALIF. -- Rejection of care by nursing home residents was associated with four potentially modifiable factors in an analysis of data on 3,230 residents.

Clinicians should screen for the conditions--delusion, delirium, minor or major depression, and severe or worse pain--when residents reject care such as blood work, taking medications, and assistance with activities of daily living, Dr. Shinya Ishii and associates reported in a prize-winning poster presentation at the annual meeting of the American Medical Directors Association.

If the associations seen in the study are causal, appropriate interventions may improve residents' willingness to accept care, the researchers suggested.

The team analyzed data on residents scheduled for Minimum Data Set assessments in 71 nursing homes in eight states. Nurses identified residents who were rejecting care.

The likelihood of doing so increased fourfold in the presence of delusion and doubled with delirium, depression, or severe to "horrible" pain, reported Dr. Ishii of the Department of Veterans Affairs' Geriatric Research Education and Clinical Center, Los Angeles.

Among the 312 residents who exhibited rejection-of-care behaviors, 18% had delusions, 35% had delirium, 32% had minor depression, 15% had major depression, and 30% had severe-to-horrible pain. Some symptoms overlapped.

An attributable-risk analysis suggested that 19% of care-rejecting behavior could be eliminated if delusions were stopped and that 5% of care rejection might end if delirium were reversed. Treating minor depression might eliminate 7% of care-rejecting behavior, reversing major depression might eliminate 10% of care-rejecting behavior, and ending severe or worse pain might eliminate 5% of care-rejecting behavior, Dr. Ishii reported.

Several covariates also were associated with rejection of care, including being male and having moderate or severe cognitive impairment.

Factors that were not associated with rejection of care included hallucination, mild to moderate pain, hearing and vision impairment, and infections (including urinary tract infection, pneumonia, wound infection, HIV, tuberculosis, and viral hepatitis).

The large, geographically diverse sample of residents strengthened the findings of the study, but its cross-sectional design did not allow examination of temporal sequences, the investigators noted. Also, the lack of any significant association between care rejection and infection might be attributable to different time frames for reporting infection, compared with those governing the other variables.

Disclosures: The investigators reported having no disclosures.

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Title Annotation:GERIATRICS
Publication:Internal Medicine News
Article Type:Report
Geographic Code:1USA
Date:May 1, 2010
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