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Author Guidelines
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Table of Contents
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Editorial Board
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Directions & Connections
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General Information
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Pain—“God’s Megaphone”
“I’m just pain covered in skin.”—Mrs WilsonThe Grapes of WrathJohn Steinbeck Pain is considered to be the fifth vital sign. Pain is complex. Although pain is derived from a noxious sensory stimulus, how it is perceived is highly subjective. A person’s emotional state, past experiences, and expectations all can modify the intensity of the perceived pain. C.S. Lewis called pain “God’s megaphone,” but this does not provide an excuse for health care professionals not to treat pain.
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Physical Restraints: Abusive and Harmful
Contemporary health care policy around the world promotes the use of evidence-based medicine and, as such, it is reasonable to assume that this would lead to similarities in health care practices in comparable economies. Interestingly, this does not seem to be the case with the use of restraining technologies and restraint policies implemented within hospitals and nursing homes. Definitional ambiguity surrounding what is an abusive act may in part account for these practice variations, given that interpretations of an abusive act are contingent on particular circumstances. For example, if a practitioner restrains a patient who is behaving aggressively, it might be interpreted as a justifiable act, or an act of abuse that may be criminal, depending on the situation.
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On Assisted Living, Are We Hitting the Mark or Missing the Boat?
This issue of the Journal of the American Medical Directors Association includes a study by Becker et al, looking at predictors of avoidable hospitalizations among Medicaid-enrolled assisted living residents with so-called “ambulatory-care sensitive” (ACS) conditions during 2003 to 2008. The study concludes that increased age, being of certain race or ethnicity, and having comorbid physical health conditions were associated with a higher risk of ACS hospitalization. In contrast, the risk of ACS hospitalization was reduced for older residents, those with a dementia diagnosis, and those of African American ethnicity. The study also identified that the risk of hospitalization was lower in African Americans with dementia and younger individuals with a major psychotic disorder. The authors conclude that there is a need to investigate further whether the health needs of people with certain psychosocial characteristics are being met adequately, and that various ethnic and racial characteristics may result in inadequate care that results in avoidable hospitalization.
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Psychotropic Drug Consumption at Admission and Discharge of Nursing Home Residents
Abstract: Objectives: To quantify transitions of residents into or out of nursing homes (NHs) and to describe psychotropic drug prescription at admission and discharge and with regard to dementia diagnosis.Design: A descriptive, cross-sectional, noninterventional study.Setting: The setting included 300 NH in France.Participants: Participants included 2231 NH residents.Measurements: Participants reported the number, origin, and destination of residents transiting into or out of the NH in the previous 3 months and provided information on NH characteristics. For eight residents admitted or discharged by the NH, information was collected on medical characteristics, including psychotropic and antidementia drug prescription, and dementia status.Results: The mean number of beds in participating NHs was 85.9 ± 33.2 (mean occupation rate = 96.6%). The mean number of admissions and discharges in the previous 3 months was 13.7 ± 8.5 and 11.2 ± 4.3, respectively. Most admissions (direct admission 3.2 ± 3.3 or readmission 6.4 ± 6.0) and discharges (4.4 ± 6.7) were from and to the hospital. Of the 2231 residents included, 1005 (45.0%) were diagnosed with dementia. At least one psychotropic drug (antidepressant, hypnotic, antipsychotic, or anxiolytic) was prescribed to 70.7% of residents and in particular an antipsychotic to 19.1% of residents. Psychotropic drugs, and in particular antipsychotic drugs, were significantly more prescribed to demented residents than to nondemented residents (76.2% vs 64.3% and 28.0% vs 11.8%, respectively). The extent of prescription (at least one psychotropic drug) was similar in residents admitted to (70.2%) and discharged from (67.5%) the NHs. Antidementia drugs (acetylcholinesterase inhibitors or NMDA receptor antagonists) were prescribed to 53.7% of demented residents.Conclusion: Movement of residents into and out of NHs and especially from and to the hospital is extensive and the prescription rate for psychotropic drugs is very high in this population, especially in residents with dementia. Multiple groups of health care providers should be targeted by educational measures to improve the quality of care for NH residents.
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Prognosis of an Abnormal One-Leg Balance in Community-Dwelling Patients With Alzheimer’s Disease: A 2-Year Prospective Study in 686 Patients of the REAL.FR Study
Abstract: Objectives: The aim of this study was to explore the predictive value of an abnormal one-leg balance (OLB) test for functional decline, nursing home admission, and mortality in community-dwelling patients affected with Alzheimer’s disease (AD).Design: A 2-year prospective, observational cohort study.Setting: Nineteen memory centers across France.Participants: A total of 686 community-dwelling patients with AD.Measurements: Mini-mental state examination, Activity of Daily Living scale, and balance (ability to stand unassisted for 5 seconds on 1 leg) were reported every 6 months. Functional decline was defined as a loss of 0.5 or more points at a 5-point Activity of Daily Living score (bathing, dressing, toileting, continence, and feeding). Nursing home admission and mortality were recorded. Neuropsychiatric symptoms, medication, and caregiver’s burden were assessed every 6 months. Time-to-event analyses were used.Results: At baseline, 632 patients with AD had a balance measurement (mean age = 77.8 years, SD = 6.9; 72.2% were women) and 15.2% had an abnormal OLB test: these patients were older, had lower mini-mental state examination and Activity of Daily Living scores, and more neuropsychiatric symptoms, osteoarthritis, comorbidities and medications (all P < .05). After adjustment for age and sex, the risk of functional decline (hazard ratio [HR]: 1.69; 95% confidence interval [CI], 1.26–2.26), nursing home admission (HR: 2.51; 95% CI, 1.69–3.73), and death (HR: 2.42; 95% CI, 1.43–4.11) was higher in patients with an abnormal OLB. After adjustment for other potential confounders, the presence of an abnormal OLB was significantly associated only with nursing home admission (HR: 1.73, 95% CI, 1.09–2.75).Conclusion: In the present study, an abnormal OLB predicts nursing home admission in patients with AD. Although statistically significant when solely adjusted for age and sex, an abnormal OLB test failed to predict functional decline and mortality when adjusted for multiple confounders.
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Antidepressant Prescribing Patterns in the Nursing Home: Second-Generation Issues Revisited
Abstract: Introduction: The object of this study was to provide an updated evaluation of the quality of antidepressant management and prescribing patterns in nursing homes in the context of organizational and resident factors.Design: Pearson correlation and chi-square analyses were conducted using information gathered from random nursing home charts.Setting: Nursing home facilities in and around the Louisville, KY, metropolitan area (n = 10).Participants: Chart reviews were randomly chosen for 20% of long term care resident records in participating homes (n = 209).Measurements: Demographic information, documentation of depression diagnoses, and antidepressant prescribing patterns were evaluated using the Quality of Depression Management and Antidepressant Prescribing rating scale and information found in the Minimum Data Set 2.0.Results: Of the sample, 59.8% was prescribed antidepressants at the time of the chart review; 205 chart reviews indicated the absence or presence of a depression diagnosis. For those with documented depression diagnoses (n = 126), nearly one-quarter were not prescribed antidepressants. Of 79 chart reviews indicating no depression diagnosis, nearly a third were receiving an antidepressant. Documentation related to changes in dosing, the presence or absence of side effects, or reasons for continuation were suboptimal.Conclusion: Discrepancy between antidepressant prescribing and the presence/absence of depression diagnoses continue to exist for nursing home residents. The quality of antidepressant documentation in nursing home charts continues to be inadequate. Future research should aim to explore possible solutions to these discrepancies and deficiencies in documentation.
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A Review of the Effectiveness of Antidepressant Medications for Depressed Nursing Home Residents
Abstract: Background: Antidepressant medications are the most common psychopharmacologic therapy used to treat depressed nursing home (NH) residents. Despite a significant increase in the rate of antidepressant prescribing over the past several decades, little is known about the effectiveness of these agents in the NH population.Objective: To conduct a systematic review of the literature to examine and compare the effectiveness of antidepressant medications for treating major depressive symptoms in elderly NH residents.Methods: The following databases were searched with searches completed prior to January 2011 and no language restriction: MEDLINE, Embase, PsycINFO, CINHAL, CENTRAL, LILACS, ClinicalTrials.gov, International Standard Randomized Controlled Trial Number Register, and the WHO International Clinical Trial Registry Platform. Additional studies were identified from citations in evidence-based guidelines and reviews as well as book chapters on geriatric depression and pharmacotherapy from several clinical references. Studies were included if they described a clinical trial that assessed the effectiveness of any currently-marketed antidepressant for adults aged 65 years or older, who resided in the NH, and were diagnosed by DSM criteria and/or standardized validated screening instruments with Major Depressive Disorder, minor depression, dysthymic disorder, or Depression in Alzheimer's disease.Results: A total of eleven studies, including four randomized and seven non-randomized open-label trials, met all inclusion and exclusion criteria. It was not feasible to conduct a meta-analysis because the studies were heterogeneous in terms of study design, operational definitions of depression, participant characteristics, pharmacologic interventions, and outcome measures. Of the four randomized trials, two had a control group and did not demonstrate a statistically-significant benefit for antidepressant pharmacotherapy over placebo. While six of the seven non-randomized studies identified a response to an antidepressant, their results must be interpreted with caution as they lacked a comparison group.Conclusions: The limited amount of evidence from randomized and non-randomized open-label trials suggests that depressed NH residents have a modest response to antidepressant medications. Further research using rigorous study designs are needed to examine the effectiveness and safety of antidepressants in depressed NH residents, and to determine the various facility, provider, and patient factors associated with response to treatment.
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Current Dilemmas of Nursing Homes in Chengdu: A Cross-Sectional Survey
Abstract: Objectives: Chengdu, China, is facing challenges from the growth of the elderly population. There are nursing homes in Chengdu, but there is no study on the current status of these nursing homes and their residents. The present study was conducted to investigate the current situation of nursing homes in Chengdu.Design, Setting, and Participants: This cross-sectional study randomly selected 10 nursing agencies from the 110 agencies in Chengdu (5 main zones and districts) using a cluster random sampling method. Descriptive statistics were used to analyze the data.Results: Ten agencies (10%) were surveyed: 5 government-run social welfare, 2 collective run, and 3 private institutions. The basic service in the nursing home includes personal care, basic medical care, room cleaning, meals, and laundry. Standard setting, assessment, rehabilitation therapy, and some equipment and volunteer service monitoring are inadequate. Most care staff receive little training in elder care. Some have no qualified certification and they have low income, heavy work, and insufficient knowledge. The whole team has a high mobility.Conclusions: Nursing homes in Chengdu are at a lower level than those in developed countries.
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What Are the Barriers to Performing Nonpharmacological Interventions for Behavioral Symptoms in the Nursing Home?
Abstract: Objective: Behavioral symptoms are common in persons with dementia, and nonpharmacological interventions are recommended as the first line of therapy. We describe barriers to conducting nonpharmacological interventions for behavioral symptoms.Design: A descriptive study of barriers to intervention delivery in a controlled trial.Settings: The study was conducted in six nursing homes in Maryland.Participants: Participants were 89 agitated nursing home residents with dementia.Intervention: Personalized interventions were developed using the Treatment Routes for Exploring Agitation decision tree protocol. Trained research assistants prepared and delivered the interventions. Feasibility of the interventions was determined.Measurements: Barriers to Intervention Delivery Assessment, activities of daily living, cognitive functioning, depressed affect, pain, observed agitation, and observed affect.Results: Barriers were observed for the categories of resident barriers (specifically, unwillingness to participate; resident attributes, such as unresponsive), barriers related to resident unavailability (resident asleep or eating), and external barriers (staff-related barriers, family-related barriers, environmental barriers, and system process variables). Interventions pertaining to food/drink and to 1-on-1 socializing were found to have the fewest barriers, whereas higher numbers of barriers occurred with puzzles/board games and arts and crafts activities. Moreover, when successful interventions were presented to participants after the feasibility period, we noted fewer barriers, presumably because barrier identification had been used to better tailor interventions to each participant and to the environment.Conclusion: Knowledge of barriers provides a tool by which to tailor interventions so as to anticipate or circumvent barriers, thereby maximizing intervention delivery.
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Which Score Most Likely Represents Pain on the Observational PAINAD Pain Scale for Patients with Dementia?
Abstract: Objectives: We sought to determine a cutoff score for the observational Pain Assessment in Advanced Dementia (PAINAD), to adequately assess pain in clinical nursing home practice and research.Design and Setting: We used data from multiple sources. We performed a literature review on PAINAD, performed secondary data analysis of a study examining psychometric properties of PAINAD in nursing home patients with dementia, and performed another study in nursing home patients with dementia specifically aimed at determining a cutoff score for PAINAD.Participants: Patients with dementia in long term care facilities.Measurements: We related PAINAD scores (range 0 to 10) to (1) self-reported and proxy-reported pain by global clinical judgment and (2) scores on another pain assessment instrument (DOLOPLUS-2), and (3) we compared scores between painful and supposedly less painful conditions.Results: Findings from this study showed that a cutoff value of 2 should serve as a trigger for a trial with pain treatment. Although the majority of patients scoring 1 or 0 were not in pain, pain could be ruled out.Conclusion: Based on the findings of multiple available data sources, we recommend that a PAINAD score of 2 or more can be used as an indicator of probable pain. A score of 1 is a sign to be attentive to possible pain. Future work may focus on cutoff scores for the presence of pain and severe pain in other frequently used pain tools, and on further development of methodology to assess cutoff scores.
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Family Caregiving in Advanced Chronic Organ Failure
Abstract: Objectives: To assess caregiver burden as well as positive aspects of family caregiving in advanced chronic obstructive pulmonary disease (COPD), chronic heart failure (CHF), and chronic renal failure (CRF).Design: Cross-sectional observational study.Setting: Patients recruited at the outpatient clinics of academic and general hospitals in the Netherlands.Participants: Patients with advanced COPD (n = 73), CHF (n = 45), and CRF (n = 41) and their family caregivers.Measurements: Caregiver burden and positive aspects of caregiving were assessed using the Family Appraisal of Caregiving Questionnaire for Palliative Care and were compared among family caregivers of patients with COPD, CHF, or CRF using linear regression analysis while controlling for characteristics of patients and family caregivers.Results: Most family caregivers were female partners of participating patients. Caregiver distress and caregiver strain scores were relatively low, whereas scores for positive caregiving appraisals and family well-being were relatively positive. Caregiver strain, positive caregiving appraisals, and family well-being were comparable for family caregivers of patients with COPD, CHF, or CRF. Caregiver distress was higher for family caregivers of patients with COPD than CHF. The experience of caregiving was influenced by being the patient's spouse, patient's psychological symptoms, and the presence of comorbidities.Conclusions: Family caregiving for patients with COPD, CHF, or CRF should not only be seen as a burden, but also as a positive experience. To support family caregivers, attention should be paid to caregiver burden and the positive aspects of family caregiving.
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The Role of Cognitive Impairment in the Use of the Diskus Inhaler
Abstract: Background and Purpose: Drugs delivered by metered-dose inhalers and dry powder inhalers (DPIs) are a mainstay in the treatment of chronic lung disease; however, previous studies suggest cognitive impairment hinders proper use of inhalers. The purpose of this study was to determine the relationship between the score on the Mini-Mental State Exam (MMSE) and the ability of nursing facility residents to complete the steps required for proper use of a multiunit-dose DPI (Diskus).Methods: Nursing facility residents who had never used a multiunit-dose DPI (Diskus), who scored between 10 and 24 inclusive on the MMSE, and who were able to hold a breath for 10 seconds were recruited for an observational study to test their ability to use a placebo-loaded Diskus when supervised and assisted by personnel trained in the proper use the Diskus. Ability to use the DPI was assessed by the Diskus Evaluation Rating Scale (DERS), an instrument developed specifically for this study. Possible scores on the DERS ranged from 0 to 19, with a score of 0 indicating no limitations in any of the steps involved in using the Diskus and 19 indicating inability to do any of the steps after 3 supervised attempts.Results: Forty Diskus-naïve nursing facility residents (86 ± 9 years of age; 32 women) with MMSE scores between 10 and 24 inclusive and the ability to hold a breath for 10 seconds were enrolled in the study. Mean MMSE scores were 17.4 ± 4.2, whereas the mean score on the DERS was 5.1 ± 3.2 (range 1–16). After controlling for age, gender, and education, a significant inverse relationship was noted between scores on the MMSE and the DERS such that for every 1-point increase on the MMSE, the subject's DERS score decreased by 0.345 points (P = .003). Overall, 38 of the 40 subjects with MMSE scores between 10 and 24 inclusive were able to use the Diskus successfully.Conclusion: For MMSE scores, the better the performance on the MMSE, the better the performance on the DERS. More important, 95% of the subjects in this study could use the Diskus successfully when properly supervised. In contrast to earlier studies, these findings suggest that a multiunit-dose DPI can be prescribed as one component of the regimen for chronic lung disease in patients with substantial cognitive impairment.
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Interdisciplinary Geriatric and Psychiatric Care Reduces Potentially Inappropriate Prescribing in the Hospital: Interventional Study in 150 Acutely Ill Elderly Patients with Mental and Somatic Comorbid Conditions
Abstract: Background: Potentially inappropriate medications and prescription omissions (PO) are highly prevalent in older patients with mental comorbidities.Objective: To evaluate the effect of interdisciplinary geriatric and psychiatric care on the appropriateness of prescribing.Design: Prospective and interventional study.Setting: Medical-psychiatric unit in an academic geriatric department.Participants: Participants were 150 consecutive acutely ill patients aged on average 80.0 ± 8.1 years suffering from mental comorbidities and hospitalized for any acute somatic condition.Intervention: From admission to discharge, daily collaboration provided by senior geriatrician and psychiatrist working in a usual geriatric interdisciplinary care team.Measurements: Potentially inappropriate medications and PO were detected and recorded by a trained independent investigator using STOPP/START criteria at admission and discharge.Results: Compared with admission, the intervention reduced the total number of medications prescribed at discharge from 1347 to 790 (P < .0001) and incidence rates for potentially inappropriate medications and PO reduced from 77% to 19% (P < .0001) and from 65% to 11% (P < .0001), respectively. Independent predictive factors for PIP at discharge were being a faller (odds ratio [OR] 1.85; 95% confidence interval [CI] 1.43–2.09) and for PO, the increased number of medications (OR 1.54; 95% CI 1.13–1.89) and a Charlson comorbidity index greater than 2 (OR 1.85; 95% CI 1.38 – 2.13). Dementia and/or presence of psychiatric comorbidities were predictive factors for both potentially inappropriate medications and PO at discharge.Conclusion: These findings hold substantial promise for the prevention of IP and OP in such a comorbid and polymedicated population. Further evaluations are, however, still needed to determine if such an intervention reduces potentially inappropriate prescribing medication-related outcomes, such as incidence of adverse drug events, rehospitalization, or mortality.
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Mortality Following Nursing Home–Acquired Lower Respiratory Infection: LRI Severity, Antibiotic Treatment, and Water Intake
Abstract: Objective: In some nursing home populations, antibiotic treatment may not reduce mortality following lower respiratory infection (LRI). To better inform treatment decisions, we determined influences on mortality following LRI among antibiotic-treated and non–antibiotic-treated residents in 2 populations.Design: Observational, prospective, cohort studies.Setting: Ninety-seven nursing homes (36 US, 61 Netherlands).Participants: Residents (1044 US, 513 Netherlands) who met a standardized study definition for LRI.Measurements: Demographics, symptoms and physical findings of LRI, functional status, major illness diagnoses, dementia status, treatments, and date of death within 6 months after diagnosis.Methods: We estimated a 2-period (0–14/15–90 days) weighted proportional hazards model of mortality for antibiotic-treated (n = 1280) and non–antibiotic-treated (n = 277) residents; both weights and regressors provide “doubly robust” risk adjustment—for LRI (illness) severity using a prognostic score and for nonrandom receipt of antibiotic treatment using a propensity score.Results: In both the United States and the Netherlands, 14-day mortality was associated with three factors—LRI severity, water intake at diagnosis, and antibiotic use (not directly by severe dementia)—that accounted for 82% or, sequentially, 39%, 42%, and 1% of the cross-national mortality difference. The LRI Severity Score (based only on at-diagnosis eating dependency, pulse rate, decreased alertness, and breathing difficulty, with adequate discrimination [c ≥ 0.74] and calibration, and cross-indexed to commonly used LRI mortality measures) was related to mortality through 90 days, regardless of treatment. With sufficient water intake at diagnosis, 14-day mortality was unrelated to not receiving antibiotic treatment (adjusted hazard ratio [AHR], 1.20; 95% confidence interval, 0.70–2.04); insufficient water intake was related to increased 14-day mortality with antibiotics (AHR, 1.90; 1.38–2.60) or without (AHR, 7.12; 4.83–10.5). After 14 days, relative mortality worsened for antibiotic-treated residents with insufficient water intake. Inadequate water intake was related to increased eating dependence at onset of the LRI (OR, 4.2; 3.0–5.8).Conclusion: LRI severity, water intake, and antibiotic use explain mortality in both studies and reconcile cross-study Dutch/US 14-day mortality differences. LRI severity, derived at 14 days, is related to mortality through 90 days, regardless of treatment, and is key to risk adjustment. With adequate hydration, the survival benefit from antibiotic use is nonsignificant. Conversely, hydration, even without antibiotic treatment, appears central to curative treatment. In LRI guidelines, treatment, and research, the relative benefits of antibiotics and hydration for curative treatment should be addressed.
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“The Way We Do Things Around Here”: An International Comparison of Treatment Culture in Nursing Homes
Abstract: Objectives: In this study, we sought to measure treatment culture (beliefs, values, and normative practices associated with medication prescribing and administration) in two samples of nursing homes (in Northern Ireland and New Zealand) and to document the range of scoring achieved by staff in both countries. Responses between nurse managers and registered nurses were also compared.Design: A cross-sectional study using an adapted treatment culture questionnaire was distributed by mail (in June and September 2008) to 159 nursing homes in Northern Ireland and completed by the nurse manager and registered nurses. In New Zealand, staff in 14 facilities participated and questionnaires were distributed by a research assistant who visited the homes (March to November 2008).Measurements: Completed questionnaires were scored using a prespecified scoring system, with a higher score indicating a more resident-centered treatment culture and a lower score indicating a more traditional approach to care. The maximum score possible was 75. Scores were compared between countries and between different categories of staff. Views were also sought and knowledge tested (from structured questions) on the use of psychotropic prescribing in the nursing home environment.Results: The response rates for nurse managers and nurses in Northern Ireland were 35.5% and 10.1%, respectively; in New Zealand, the response rate was 90.9% for managers and 71% for nurses. The mean score for the Northern Ireland and New Zealand homes was 39.5 and 39.1, respectively (P > .05). There were also no differences between scores achieved by nurse managers and registered nurses between and across both countries. There were some cross-country differences on the approach to challenging behavior in residents and nurses (in both countries) were more likely than nurse managers to report (incorrectly) that haloperidol is indicated for short-term insomnia.Conclusion: This quantitative assessment has raised interesting issues in relation to the measurement of treatment culture in the nursing home setting in two countries. Further insights into the importance of treatment culture will be pursued in qualitative studies.
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