Predictors of mortality in nursing home residents: a 2-year prospective longitudinal study.

doi:10.21203/rs.3.rs-2452648/v1

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Predictors of mortality in nursing home residents: a 2-year prospective longitudinal study.

https://doi.org/10.21203/rs.3.rs-2452648/v1

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Background

The age, multimorbidity, immunodeficiency and frailty of older people living in nursing homes make them vulnerable to COVID-19 and to mortality in general. For this reason, our objective is to verify the incidence of general and COVID-19 mortality and to analyse its predictive factors in older people living in nursing homes over a 2-year period.

Methods

A two-year prospective longitudinal multicenter study was carried out in 5 nursing homes in Central Catalonia (Spain) between 2020 and 2022. Date and causes of deaths were recorded. In addition, sociodemographic and health data were collected. For the effect of mortality, survival curves were performed using the Kaplan-Meier method and multivariate analysis using Cox regression.

Results

The total sample of 125 subjects had a mean age of 85.10 years (standard deviation = 7.3). A total of 59 (47.2%) deaths were recorded at 24 months (95% confidence interval [CI], 38.6–55.9) and 25 (20.0%) were due to COVID-19 most in first 3 months. In the multivariate analysis, functional impairment (hazard ratio [HR]: 2.40, 95% CI: 1.33–4.32, p = 0.003) was a significant risk factor for mortality independently of age (HR: 1.17, 95% CI: 0.69-2.00, p = 0.549) and risk of sarcopenia (HR: 1.40, 95% CI, 0.63–3.12, p = 0.403).

Conclusions

Nearly half of this sample of nursing home residents died within the 2-year period, and 20% were attributed to COVID-19. Functional impairment was a risk factor for overall mortality and COVID-19 mortality, independent of age and risk of sarcopenia.

Mortality

COVID-19

nursing homes

older adults

functional impairment.

Aging brings with it multiple problems and limitations in the functionality, independence and autonomy of older people (1). Globally, older people have an average life expectancy of up to 80 years (2). However, in Spain, the characteristics of the population residing in Nursing Homes (NHs) have a mean age over 80 years, high comorbidity, high functional impairment, and severe cognitive impairment (2).

According to the World Health Organization (WHO), aging can be characterized by the appearance of different complex health stages that occur in the last stages of a person's life (3). Factors such as frailty, urinary and fecal incontinence, sarcopenia, falls, pressure ulcers, functional and cognitive impairment, among others, are common as we age (4). These health problems, geriatric syndromes, associated with aging, are those that are going to determine mortality risk more reliably than the diseases themselves (2). Functional impairment, gender, frailty, malnutrition, continence impairment (5) and NH type (6) can be considered indicators of survival, markers of mortality.

At the socioeconomic level, detecting the factors that can trigger a pathology and the application of appropriate preventive treatment to reduce the risk of this pathology can have great repercussions in the geriatric setting (7).

In December 2019, the COVID-19 (Coronavirus disease) pandemic started to have a major impact on society (8). NHs became the so-called "Pandemic hot spots" due to high mortality rates (9).

It is estimated that approximately 300,000 older adults in Spain live in NHs (10). From the beginning of the first wave of the COVID-19 pandemic until April 2022, 13% of NH residents died in Spain (7). Although we have vaccinations, older people are still at high risk of serious ill health and death and so understanding the predictors of mortality during the pandemic are important to understand (2). Mortality risk factors should be easily and commonly assessed by NH staff to ensure the future needs of this population (2).

Literature indicates that aging and the presence of comorbidities such as functional dependence are associated with an increased risk of mortality in the COVID-19 pandemic (11). The analysis of risk factors for COVID-19 mortality in NH have already been detailed in some studies (12). However, they are mainly focused on the direct impact of COVID-19 in the first wave and with a maximum duration of one year. For this reason, a longer observational study evaluating the direct and indirect impact of a wide range of health and sociodemographic outcomes on mortality of geriatric residents is required.

The main objective of this study was to determine the incidence of overall and COVID-19 mortality and to analyze its predictive factors in older people living in nursing homes over a 2-year period.

Study design and population

This is a 2-year multicenter observational cohort study. It was designed following the Strengthening the Reporting of Observational studies in Epidemiology (STROBE) standards for cohort studies (13). It is a substudy of the OsoNaH project (14) registered in Clinical Trials with ID NCT04297904. The study was conducted in five NHs in Osona (a county in Central Catalonia, Spain). Those residents aged 65 years or older who lived in the NH permanently were included. Those in coma or in palliative care (short-term prognosis), those who refused (or their legal guardian) to participate in the study, and those who left the NH in the 2-year cohort period, were excluded.

Sample size

Considering the findings of Burgaña Agoües et al (2021) (12), i.e. difference in proportions between individuals with severe functional impairment (23.0%) and deceased persons (11.1%), and with a confidence level of 95% and a power of 80%, a sample size of 122 participants was estimated.

Study procedures

The primary outcomes were overall mortality and COVID-19 in the 2-year follow-up period. Registration of mortality included cause and date of death, deaths in total, deaths due to COVID-19 including confirmed cases and deaths due to suspected symptomatic COVID-19 (15). Additional COVID-19 data collected included the presence of the disease, whether they had symptoms (16), the performance of COVID-19 detection tests such as C-Reactive Protein (CRP), serological tests and/or Rapid Antigen Pots (RAP) (17).

Sociodemographic and health information, such as age, sex, NH type, smoking and drinking habits, chronic conditions and hospitalizations, were obtained from NH records and checked with NH professionals. All sociodemographic variables and those described below were collected at baseline, at the start of the study January 2020 just prior to the onset of the COVID-19 pandemic. Falls (number) during the last year were obtained from NH records. Nutritional status was assessed using the Mini Nutritional Assessment (MNA) (18). To identify individuals at risk of developing sarcopenia we used the SARC-F (19). Functional capacity, excluding continence items, was measured using the modified Barthel Index (20). Continence status was reported using section H of the Minimum Data Set (MDS) version 3.024 (21). Cognitive status was assessed using the Pfeiffer scale (22) and frailty using the Clinical Frailty Scale (CFS) (23). Sedentary behavior (SB) and waking time movement behaviours (WTMB) were assessed by the ActivPAL ^3TM activity monitor (PAL Technologies Ltd., Glasgow, UK), considered the gold standard for assessing SB and highly accurate in identifying postural changes in older adults (24).

Ethical permission was obtained. Signed informed consent was obtained from the resident or his/her legal guardian.

Statistical analysis

Nominal and ordinal quantitative variables in this part of the longitudinal study were initially examined by descriptive statistics and expressed according to frequency in percentages and quantitative variables with mean and standard deviation (SD). To assess the effect of independent health and sociodemographic variables on mortality, survival curves were formed using the Kaplan Meier method. Individuals who died during the 2-year follow-up were censored at the time of death, and those who did not die were censored at the end of the study. The log-rank test was used to assess differences between survival curves. For bivariate analysis, the log-rank test was used. Variables with p-values equal to or less than 0.25 and the variables age and sex were considered amenable to testing in the multiple model. Multivariate analysis was performed by Cox regression, using the hazard ratio (HR) as a measure of effect. Inferential statistical analysis was performed with a confidence level of 95%. Statistical Package for the Social Sciences (SPSS) 27 (SPSS Inc., Chicago IL) was used for the analysis.

We recruited 125 individuals, representing 67.6% of the total number of NH residents in the study. The reasons for not being included in the study were the refusal of guardians and individuals to participate and the fact that some did not meet the criteria for age or residence in the institution. Finally, 7 (3.8%) participants who left the NHs to reside elsewhere, were also excluded.

The mean age of participants was 85.1 years (SD = 7.3) and 104 (83.2%) were women. The mean number of months living in NH was 27.5 (SD = 112.14); 40 (32.0%) lived in state subsidized places and 85 (68.0%) in private NHs. Only 4.8% of the residents were smokers and 7.2% were alcohol drinkers. The mean number of chronic conditions were 5.0 (SD = 2.5) of which arterial hypertension (AHT) and dementia were the most common. UI was identified in 87 (69.6%) residents and fecal incontinence in 36 (28.8%). Fifty-eight (46.4%) residents fell one or more times in the previous year. Regarding nutritional variables, 13.5% had lost weight in the previous year and 62.4% were obese (median BMI = 27.0, SD = 5.1), 44.8% were at risk of malnutrition or malnourished. Risk of sarcopenia was identified in 94 (75.2%) individuals. Some individuals (41.6%) had severe or total functional dependence. Mostly (76.0%) were cognitively impaired. In terms of frailty, 105 individuals (84%) had some degree of frailty. Residents had a mean waking time of 11.0 (SD = 1.5) hours. During waking hours, residents spent a mean of 1.6 (SD = 1.7) hours in an upright position. In the total sample, 26 (SD = 0.43) hospitalizations occurred over the 24 months (see Table 1).

Table 1: (here)

Table 1

Descriptive analysis of the sample of institutionalized older adults living in nursing homes of Central Catalonia, Spain (n = 125). **Variables Frequency (%) Mean (SD)**
NH TYPE
State subsidized places	40 (32.0)
Private	85 (68.0)
SMOKING	6 (4.8)
DRINKERS	9 (12.7)
CHRONIC CONDITIONS		5.0 (2.46)
Hypertension	80 (64.0)
Dementia	68 (54.4)
Cardiac Pathology	51 (40.8)
Depression	36 (28.8)
Diabetes Mellitus II	36 (28.8)
Renal Pathology	32 (25.6)
CVA	25 (20.0)
Cancer	23 (18.4)
Pulmonary pathology	22 (17.6)
URINARY INCONTINENCE
Yes	87 (69.6)
No	35 (28.0)
Unclassifiable	3 (2.4)
FECAL INCONTINENCE
Yes	36 (28.8)
No	87 (69.6)
Unclassifiable	2 (1.6)
FALL/S IN PREVIOUS YEAR	58 (46.4)
NUTRITIONAL STATUS
Unvoluntary weight loss	25 (13.5)
Risk of malnutrition or malnourished	56 (44.8)
Obesity	78 (62.4)
RISK OF SARCOPENIA	94 (75.2)
FUNCTIONAL IMPAIRMENT
Independent	7 (5.6)
Slightly dependent	47 (37.6)
Moderately dependent	19 (15.2)
Severely or totally dependent	52 (41.6)
COGNITION
No cognitive deficit	10 (8.0)
Mild cognitive deficit	20 (16.0)
Moderate cognitive deficit	24 (19.2)
Severe cognitive deficit	58 (46.4)
Unknown	13 (10.4)
SB AND WTMB
Waking hours		11.0 (1.5)
% of waking time in SB		82.6% (17.5)
Hours in upright position (standing and walking)		1.6 (1.7)
Steps per day		1.345 (2417.4)
Sit to stand transitions per day		18.2 (18.3)
HOSPITALIZATIONS		26 (0.43)

SD: Standard Deviation. NH: Nursing Homes. CVA: Cerebral vascular accident. SB: Sedentary Behavior.

WTMB: Waking time movement behaviour.

In the 2-year period from baseline to the end of the study, 59 participants (47.2%) died (95% confidence interval [CI], 38.6–55.9), of whom 25 (20.0%) died from COVID-19 and 34 (27.2%) from other causes. Deaths from COVID-19 all occurred in the first year of the study.

With respect to cumulative survival and days elapsed since baseline to the date of the last data collection, we observed that in the first year, 44 (74.5%) of the 59 individuals had already died and the majority in the first 90 days (at the peak of COVID-19).

Survival and associated factors according to the variable mortality.

In the bivariate analysis, mortality was associated with functional impairment, UI, risk of sarcopenia, % of waking time in SB and fecal continence with a p value of less than 0.050. The remaining health and sociodemographic variables were not significant (Table 2).

Table 2: (here)

Table 2

Analysis of the association of survival with the mortality variable (yes/no) in relation to health, functional and sociodemographic variables¹ among older people living in NHs (n = 125).
Variables	n (%)	Number of deaths	Number of survivors	Probability of death (%)	p (Log Rank)
FUNCTIONAL IMPAIRMENT (n = 125)
No/ Mild or Moderate	73 (58.4)	24	49	65.3	0.001*
Total impairment	52 (41.6)	35	17	31.6
URINARY INCONTINENCE (n = 122)
No	35 (28.0)	10	25	66.8	0.008*
Yes	87 (69.6)	49	38	43.2
RISK OF SARCOPENIA (n = 125)
No	31 (24.8)	9	22	71.0	0.018*
Yes	94 (75.2)	50	44	45.0
% WAKING TIME IN SB (n = 84)
≤ 85%	41 (48.8)	11	30	73.2	0.028*
> 85%	43 (51.2)	22	21	48.4
FECAL INCONTINENCE (n = 123)
No	87 (70.7)	35	52	57.9	0.029*
Yes	36 (29.3)	22	14	38.4
NH TYPE (n = 125)
State subsidized places	40 (32.0)	14	26	64.8	0.076
Private	85 (68.0)	45	40	46.1
NUTRITIONAL STATUS (n = 79)
Normal	23 (29.2)	7	16	69.6	0.082
At risk or malnourished	56 (70.8)	31	25	43.6
DRINKERS (n = 71)
No	62 (87.3)	34	32	45.5	0.249
Yes	9 (12.7)	1	4	80.0

1: With a p value lower than 0.250.

* Statistically significant (< 0.05).

SB: Sedentary behavior.

NH: Nursing Homes.

The variables were tested for collinearity and none of them showed collinearity with each other. In the multivariate analysis, the model with best adjustment values was the one including severe functional impairment, age and risk of sarcopenia. The result showed that functional impairment (HR: 2.40, 95% confidence interval [CI], 1.33–4.32, p = 0.003) predicts mortality independently of age (HR: 1.17, 95% CI, 0.69-2.00, p = 0.549) and risk of sarcopenia (HR: 1.40, 95% CI, 0.63–3.12 p = 0.403) (Table 3).

Table 3: (here)

Table 3

Survival univariate and multivariate Cox analysis ¹ in older people living in NHs (n = 125).
Variables	HR (Exp^B)	CI (95%)	p (Cox)	HR (Exp^B)	CI (95%)	p (Cox)
	Univariate analysis			Multivariate analysis
FUNCTIONAL IMPAIRMENT (n = 125)
No/ Mild or Mod.	Ref.		0.001*	Ref.		0.003*
Total impairment.	2.77	(1.64–4.67)	0.001*	2.40	(1.33–4.32)	0.003*
URINARY INCONTINENCE (n = 122)
Yes	Ref.		0.010*
No	2.43	(1.23–4.81)	0.010*
RISK OF SARCOPENIA (n = 125)
Yes	Ref.		0.022*	Ref.		0.403
No	2.29	(1.12–4.66)	0.022*	1.40	(0.63–3.12)	0.403
FECAL INCONTINENCE (n = 123)
No	Ref.		0.031*
Yes	1.80	(1.05–3.07)	0.031*
% WAKING TIME IN SB (n = 84)
-/= 85%	Ref.		0.033*
+ 85%	2.20	(1.07–4.55)	0.033*
NH TYPE (n = 125)
Private	Ref.		0.080
State subsidized places	0.85	(0.32–1.06)	0.080
NUTRITIONAL STATUS (n = 79)
Normal	Ref.		0.089
Risk or malnourished	2.04	(0.89–4.64)	0.089
AGE (n = 125) ≤ 85 > 86	Ref. 1.33	(0.78–2.26)	0.284	Ref. 1.17	(0.69–2.00)	0.549

1: Variables with a p value lower than 0.250 in univariate analysis are shown.

* Statistically significant (p < 0.05).

HR: Hazard Ratio.

CI: confidence interval.

SB: Sedentary behavior. NH: Nursing Homes.

Survival and associated factors according to the variable COVID − 19 or other-cause mortality.

The number of individuals in this variable is 59. In the univariate analysis, functional impairment, living in a private NH and being older than 86 years, malnutrition and being a woman were risk factors for COVID-19 mortality. Functional impairment was associated with mortality from other health causes with a p value below 0.050. Mortality from other health causes was also associated with % of waking time in SB (Tables 4 and 5).

Table 4: (here)

Table 4

Analysis of the association of survival with mortality (covid-19 or other causes) in relation to health and sociodemographic variables¹ of older people living in NHs (n = 59).
Variables	n (%)	Deaths for covid-19 (number of events)	Deaths due to other causes (number of events)	Probability of death (%)	p (Log Rank)
NUTRITIONAL STATUS (n = 38)
Normal	7 (18.4)	5	5	28.6	0.022*
Risk or malnourished	31 (81.6)	10	21	61.8
SEX (n = 59)
Male	9 (15.2)	6	3	14.6	0.041*
Female	50 (84.7)	19	31	49.9
FUNCTIONAL IMPAIRMENT (n = 59)
No/ Mild or Moderate	24 (40.6)	15	9	26.1	0.045*
Total impairment	35 (59.3)	10	25	63.5
% WAKING TIME IN SB (n = 33)
≤85%	11 (33.3)	7	4	36.4	0.082
> 85%	22 (66.6)	6	16	68.7
FECAL INCONTINENCE (n = 57)
No	35 (61.4)	18	17	37.6	0.132
Yes	22 (38.6)	6	16	68.2
HOSPITALIZATIONS (n = 46)
No	34 (73.9)	17	17	32.0	0.194
Yes	12 (26.1)	4	8	58.2

1: With a p value lower than 0.250.

* Statistically significant (< 0.05).

SB: Sedentary Behavior.

NH: Nursing Homes.

Collinearity between variables was tested and none of the variables were collinear with each other. The number of individuals in this variable is 59. Different combinations of significant variables such as functionality, age and risk of sarcopenia, among others, were tested by multivariate analysis but no significant results were found (see Table 5).

Table 5: (here)

Table 5

Univariate Cox analysis of mortality by covid-19 versus other causes in relation to covariables¹ in older people living in NHs (n = 59).
Variables	HR (Exp^B)	CI (95%)	p value
	(Univariate analysis)
FUNCTIONAL IMPAIRMENT (n = 59)
No/ Mild or Moderate impairment	Ref.		0.001*
Total impairment	2.04	(1.40–2.97)	0.001*
NH TYPE (n = 59)
State Subsidized places Private	Ref. 1.73	(1.13–2.66)	0.012*
AGE (n = 59)
≤ 85	Ref.		0.035*
≥ 86	1.47	(1.03–2.11)	0.035*
FECAL INCONTINENCE (n = 57)
No	Ref.	(0.99–2.18)	0.055
Yes	1.47		0.055
RISK OF SARCOPENIA (n = 59)
Yes	Ref.	(0.95–2.16)	0.082
No	1.43		0.082
URINARY INCONTINENCE (n = 59)
Yes	Ref.	(0.95–2.08)	0.090
No % WAKING TIME IN SB (n = 33)	1.41		0.090
≤85%	Ref.		0.161
> 85%	1.36	(0.88–2.09)	0.161

1: Variables with a p value lower than 0.250 are shown.

* Statistically significant (< 0.05). HR: Hazard Ratio. CI: Confidence interval. NH: Nursing Homes. SB: Sedentary Behavior.

The main objective of this study was to examine the incidence of overall and COVID-19 mortality and analyze their predictive factors in older people living in NHs over a two-year period from the start of the pandemic. The results showed that functional impairment resulted in a risk of overall mortality and COVID-19 mortality, independently of age and risk of sarcopenia.

Research on risk of mortality in institutionalized older people comprises longitudinal, observational studies with an average duration of one year (25). In our study, we extended the cohort to two years to better assess mortality risks during the COVID-19 pandemic, particularly as there is still the potential of mortality due to COVID-19 even 2 years on. Studies on mortality risk identify that mortality risk increases significantly as dependence increases. Severe functional and cognitive impairments are of great importance and are directly associated to increased mortality in older persons living in NHs (2). The characteristics of these older institutionalized in Spanish nursing homes (NH) may influence the incidence of mortality (2).

The results indicate that most of the older people died in the first three months of the longitudinal study as this coincided with the outbreak of the COVID-19 pandemic. 74.5% of the deaths in this longitudinal study occurred in the first year of the pandemic. In the second year of this study, the survival curve recovered horizontality, following the implementation of measures for the prevention of spread of COVID-19 infection. Individuals identified as "at risk of sarcopenia" were those who, with the highest incidence, died earlier in the 24-month period of the study. Likewise, those with more frailty also died earlier. The cause of these deaths was 25 individuals (20.0%) died from COVID-19 and 34 (27.2%) from other causes.

This study has a higher incidence of mortality in a one-year period than other studies conducted in older people. A study conducted in Barcelona in the first year of the pandemic reports a 15.9% mortality rate due to COVID-19 in institutionalized older people (26). Regarding deaths from other causes, a study conducted in the same period reports excess mortality among institutionalized older people (34.8%). It attributes the excess mortality from other causes in the first year of the pandemic to the fact that the cause of death of the resident was sometimes unknown due to limited access to COVID-19 diagnostic tests (26). This fact could also have been the case in the present study.

We also report the association of health, social and demographic variables with mortality. In the bivariate analysis with Cox Regression, functional impairment, UI, sarcopenia risk and % of waking time in SB were found to be factors associated with mortality in the residents of NHs in Osona. Functional impairment, type of NH and age were associated with COVID-19 mortality.

We also found that UI was associated with mortality. In a recent meta-analysis, UI was highly predictive of mortality (27). The same was seen in a mortality study in Japan (28). Those who spend more time in sedentary behavior had a higher mortality risk in this study and this has also been seen in other studies within NHs, even with different methods of measurement of SB (29).

The current study also showed increased mortality with type (private) of NH. The type of NH and the size of NH (resident beds) have been shown to influence mortality over the COVID-19 pandemic in several studies (26). Braun et al. attributed these results to the lack of organization and shortage of personal protective equipment (PPE) in private NHs as possibly in the present study (30).

This study has some limitations. The main limitation is the relatively small sample included in the study due to the onset of the COVID-19 pandemic that prevented the collection of more data at baseline. The proportion of men was probably lower due to their lower survival rate compared to women. It is noteworthy that older women survive more than men in the face of severe disability and there is a higher percentage of the female sex in NH (21). Nevertheless, these results give us an idea for further research along these lines.

This study has some limitations. The main limitation is the relatively small sample included in the study due to the onset of the COVID-19 pandemic that prevented further data collection at baseline. The proportion of men was probably lower due to their lower survival rate compared to women. The high degree of dependency of the study population, it is also worth noting that women survive longer than men in the face of severe disability that women survive longer than men in the face of severe disability.

It is possible that some of the deaths recorded from other health causes in the pandemic were COVID-19 deaths and could not be confirmed due to lack of access to diagnostic tests mainly in the first six months of the study.

The strength of the study lies in the on-site data collection (telematically with NH health professionals) in the first two years of the full COVID-19 pandemic. This has made it possible to extract all the real information, in six-month waves, on the health of residents in the midst of the pandemic: What has been the evolution of the pandemic, what has been the mortality and COVID-19 mortality, how have evolved the typology of COVID-19 diagnostic tests and residents' symptomatology, what change in residents' health has been brought about by vaccination, how the pandemic has directly modified aspects of health of older people living in NH such as falls, hospitalizations, functional decline and sphincter continence. With the data collected prior to the pandemic and during the following two years, it has allowed a portrait of the residents to be drawn to see how they were previously and how they have been affected by a pandemic that has impacted worldwide; what were the initial health conditions that have acted as risk factors or protective factors for decline or mortality in the COVID-19 pandemic.

The incidence of mortality in the 2 years since the onset of the COVID-19 pandemic in NH was high: of the 59 deaths, 25 (18.9%) died from COVID-19, all in the first year of the study (84% in the first 6 months). The results indicate that the first three months (90 days from the start of the longitudinal study), coinciding with the peak of the COVID-19 pandemic, accounted for the majority of COVID-19 deaths (20%).

Functional impairment was a risk factor for overall mortality and COVID-19 mortality, independent of age and risk of sarcopenia.

Implications for Practice

This study has revealed that the type of nursing homes and primarily its management can influence the health status of its residents. This suggests that investments should be made in the proper management of nursing homes, especially the larger and privately managed ones.
A comprehensive geriatric assessment and analysis of mortality risk factors in a nursing home can allow us to establish intervention protocols to prevent the deterioration of health and the lack of quality of life of older people living in nursing homes. Only in this way can we improve the quality of care.
Knowing the risk factors for mortality among institutionalized older persons in NH allows us to apply person-centered preventive measures.

NH: Nursing Homes, WHO: World Health Organization, COVID-19 (Coronavirus disease), STROBE: Strengthening the Reporting of Observational Studies in Epidemiology, PCR: C-Reactive Protein, TAR: Rapid Antigen Pots, MDS: Minimum Data Set, BMI: Body Mass Index, MNA: Mini Nutritional Assessment, SARC-F: Questionnaire Assistance in Walking, Rising from Chair, Climbing Stairs and Falling, CFS: Clinical Frailty Scale, SB: Sedentary behavior, WTMB: Waking Time Movement Behaviors, ICC: Interclass Correlation Coefficient, SPSS: Statistical Package for the Social Sciences, SD: Standard Deviation, HR: Hazard Ratio, AHT: Arterial Hypertension, IU: Urinary Incontinence, CVA: Cerebral Vascular Accident, CI: Confidence Interval, PPE: Personal Protective Equipment.

Ethics approval and consent to participate

Ethical permission was obtained by the Ethics and Research Committee of the University of Vic - Central University of Catalonia (registration number 92/2019 and 109/2020). Signed informed consent was gained from the resident or his/her legal guardian. The project meets the criteria required in the Helsinki Declaration, as well as the Organic Law 3/2018 (December 5) on the Protection of Personal Data and Guarantee of Digital Rights.

Consent for publication

Not applicable

Availability of data and material

The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.

Competing interests

The authors declare that they have no competing interests.

Funding

This work was supported by the Hestia Chair from Universitat Internacional de Catalunya (grant number BI-CHAISS-2019/003) and the research grant from the Catalan Board of Physiotherapists Code R03/19.

Authors' contributions

Anna Escriba-Salvans: Conceptualization, Methodology, Formal analysis, Investigation, Writing - Original Draft, Writing - Review & Editing. Eduard Minobes-Molina: Conceptualization, Methodology, Writing - Review & Editing, Funding acquisition. Pau Farrés-Godayol: Formal analysis, Writing - Review & Editing. Dyego Leandro Bezerra de Souza: Writing - Review & Editing. Dawn A Skelton: Supervision, Writing - Review & Editing. Javier Jerez-Roig: Conceptualization, Methodology, Supervision, Funding acquisition.

Acknowledgements

We thank all the members of the study NH for their contribution to this work and the older adults who participated in the study.

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Predictors of mortality in nursing home residents: a 2-year prospective longitudinal study.

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