Randomised controlled trial of health assessments for older Australian veterans and war widows

OBJECTIVE: To assess the effect of home-based health assessments for older Australians on health-related quality of life, hospital and nursing home admissions, and death. DESIGN: Randomised controlled trial of the effect of health assessments over 3 years. PARTICIPANTS AND SETTING: 1569 community-living veterans and war widows receiving full benefits from the Department of Veterans' Affairs and aged 70 years or over were randomly selected in 1997 from 10 regions of New South Wales and Queensland and randomly allocated to receive either usual care (n = 627) or health assessments (n = 942). INTERVENTION: Annual or 6-monthly home-based health assessments by health professionals, with telephone follow-up, and written report to a nominated general practitioner. MAIN OUTCOME MEASURES: Differences in health-related quality of life, admission to hospital and nursing home, and death over 3 years of follow-up. RESULTS: 3-year follow-up interviews were conducted for 1031 participants. Intervention-group participants who remained in the study reported higher quality of life than control-group participants (difference in Physical Component Summary score, 0.90; 95% CI, 0.05-1.76; difference in Mental Component Summary score, 1.36; 95% CI, 0.40-2.32). There was no significant difference in the probability of hospital admission or death between intervention and control groups over the study period. Significantly more participants in the intervention group were admitted to nursing homes compared with the control group (30 v 7; P < 0.01). CONCLUSIONS: Health assessments for older people may have small positive effects on quality of life for those who remain resident in the community, but do not prevent deaths. Assessments may increase the probability of nursing-home placement.     

Low bone mineral density and risk of fracture in white female nursing home residents

CONTEXT: Low bone mineral density (BMD) is a strong risk factor for fracture in community-dwelling white women, but the relationship in white female nursing home residents, for whom fracture rates are highest, is less clear. OBJECTIVE: To assess the relative contribution of low BMD to fracture risk in nursing home residents. DESIGN: Prospective cohort study with baseline data collected April 1995 to June 1997, with 18 months of follow-up. SETTING: Forty-seven randomly selected nursing homes in Maryland. PATIENTS: A total of 1427 white female nursing home residents aged 65 years or older. MAIN OUTCOME MEASURE: Documented osteoporotic fracture occurring during follow-up as a function of baseline BMD measurements higher vs lower than the median, and after controlling for demographic, functional, cognitive, psychosocial, and medical factors. RESULTS: A total of 223 osteoporotic fractures occurred among 180 women. Low BMD and transfer independence were significant independent risk factors for fracture in this nursing home sample (P<.001) and the 2 factors acted synergistically (P =.06) to further increase fracture risk. Compared with women whose BMD was higher than the median (0. 296 g/cm(2)), those whose BMD was lower than the median had an unadjusted hazard ratio for risk of fracture of 2.1 (95% confidence interval [CI], 1.5-2.8); women who were independent in transfer had a hazard ratio of 1.6 (95% CI, 1.2-2.2) compared with women dependent in transfer. Among residents independent in transfer, those with BMD below the median had a more than 3-fold increase in fracture risk compared with those with higher BMD (unadjusted hazard ratio, 3.1; 95% CI, 2.2-4.4). Among residents dependent in transfer, those with BMD below the median had a 60% increase in fracture risk (unadjusted hazard ratio, 1.6; 95% CI, 1.1-2.3). Adjustment for covariates did not alter the BMD-fracture relationship. CONCLUSIONS: Our data indicate that low BMD and independence in transfer are significant predictors of osteoporotic fracture in white female nursing home residents. JAMA. 2000;284:972-977     

Comparison of nursing home residents admitted from home or hospital.

A growing elderly population coupled with a reduction in hospital long term care has led to an increase in the independent nursing home sector. This is an expensive resource. Proper placement is therefore essential to ensure its efficient use. Prior to the introduction of care management there was no standard assessment procedure for admission to nursing home care from different sources. A nursing home population (n = 624) in North and West Belfast was studied and mental scores, levels of disability, and the source of admission to the nursing home recorded. Residents admitted from geriatric medical units (n = 132) were compared with those from general medical and surgical wards (n = 168) and those from home (n = 243). Residents who were admitted from a geriatric unit were the most disabled, those admitted from home were the least and those from general wards had intermediate levels of disability (p < 0.005). This is likely to be the result of different assessment procedures for prospective nursing home residents. With the introduction of care management, it is hoped that standardised assessment will follow. The roles of different medical specialists in this process is not yet clear. Further study is needed to assess the appropriateness of placement in nursing homes under care management.     

Efficacy of influenza vaccine in nursing homes. Reduction in illness and complications during an influenza A (H3N2) epidemic

From December 10, 1982, to March 4, 1983, when influenza A (H3N2) viruses circulated in Michigan, outbreaks of influenza-like illness were identified in seven nursing homes in Genesee County; 272 (27%) of 1,018 residents were affected. Unvaccinated residents were more likely than vaccinated residents to become ill (risk ratio [RR], 2.6; 95% confidence interval [Cl], 1.8-3.6) and were subsequently more likely to be hospitalized (RR, 2.4; 95% Cl, 1.2-4.8), develop roentgenographically proven pneumonia (RR, 2.9; 95% Cl, 1.6-5.3), or die (RR, 5.6; 95% Cl, 1.2-9.1). Similar observations were made during investigations in six of the eight remaining nursing homes in Genesee County, in which 57 (12%) of 458 residents became ill sporadically. These findings suggest that influenza vaccine can reduce the incidence and severity of influenza virus infections among the elderly and chronically ill and underscore the importance of vaccination programs for those in nursing homes and in the general community.     

The epidemiology and natural history of pressure ulcers in elderly nursing home residents

We analyzed prospective data from 19,889 elderly residents of 51 nursing homes from 1984 to 1985 to determine the prevalence, incidence, and natural history of pressure ulcers. Among all residents admitted to nursing homes, 11.3% possessed a stage II through stage IV pressure ulcer. For those residents admitted to the nursing home without pressure ulcers during the study period, the 1-year incidence was 13.2%. This increased to 21.6% by 2 years of nursing home stay. People already residing in a nursing home at the start of the study had a 1-year incidence of 9.5%, which increased to 20.4% by 2 years. Pressure ulcers were associated with an increased rate of mortality, but not hospitalization. Longitudinal follow-up of residents with pressure ulcers demonstrated that a majority of their lesions were healed by 1 year. Most of the improvement occurred early in a person's nursing home stay. Although nursing home residents with pressure ulcers have a higher mortality, with good medical care pressure ulcers can be expected to heal.     

Development and validation of fall risk screening tools for use in residential aged care facilities

OBJECTIVE: To develop screening tools for predicting falls in nursing home and intermediate-care hostel residents who can and cannot stand unaided. DESIGN AND SETTING: Prospective cohort study in residential aged care facilities in northern Sydney, New South Wales, June 1999 - June 2003. PARTICIPANTS: 2005 people aged 65-104 years (mean +/- SD, 85.7 +/- 7.1 years). MAIN OUTCOME MEASURES: Demographic, health, and physical function assessment measures; number of falls over a 6-month period; validity of the screening models. RESULTS: Ability to stand unaided was identified as a significant event modifier for falls. In people who could stand unaided, having either poor balance or two of three other risk factors (previous falls, nursing home residence, and urinary incontinence) increased the risk of falling in the next 6 months threefold (sensitivity, 73%; specificity, 55%). In people who could not stand unaided, having any one of three risk factors (previous falls, hostel residence, and using nine or more medications) increased the risk of falling twofold (sensitivity, 87%; specificity, 29%). CONCLUSIONS: These two screening models are useful for identifying older people living in residential aged care facilities who are at increased risk of falls. The screens are easy to administer and contain items that are routinely collected in residential aged care facilities in Australia.     

Multiple antibiotic-resistant Klebsiella and Escherichia coli in nursing homes

CONTEXT: Infections caused by ceftazidime sodium-resistant gram-negative bacteria that harbor extended-spectrum beta-lactamases (ESBLs) are increasing in frequency in hospitals in the United States. OBJECTIVES: To report a citywide nursing home-centered outbreak of infections caused by ESBL-producing gram-negative bacilli and to describe the clinical and molecular epidemiology of the outbreak. DESIGN: Hospital-based case-control study and a nursing home point-prevalence survey. Molecular epidemiological techniques were applied to resistant strains. SETTINGS: A 400-bed tertiary care hospital and a community nursing home. PATIENTS: Patients who were infected and/or colonized with ceftazidime-resistant Escherichia coli, Klebsiella pneumoniae, or both and controls who were admitted from nursing homes between November 1990 and July 1992. MAIN OUTCOME MEASURES: Clinical and epidemiological factors associated with colonization or infection by ceftazidime-resistant E coli or K pneumoniae; molecular genetic characteristics of plasmid-mediated ceftazidime resistance. RESULTS: Between November 1990 and October 1992, 55 hospital patients infected or colonized with ceftazidime-resistant E coli, K pneumoniae, or both were identified. Of the 35 admitted from 8 nursing homes, 31 harbored the resistant strain on admission. All strains were resistant to ceftazidime, gentamicin, and tobramycin; 96% were resistant to trimethoprim-sulfamethoxazole and 41% to ciprofloxacin hydrochloride. In a case-control study, 24 nursing home patients colonized with resistant strains on hospital admission were compared with 16 nursing home patients who were not colonized on hospital admission; independent risk factors for colonization included poor functional level, presence of a gastrostomy tube or decubitus ulcers, and prior receipt of ciprofloxacin and/or trimethoprim-sulfamethoxazole. In a nursing home point-prevalence survey, 18 of 39 patients were colonized with ceftazidime-resistant E coli; prior receipt of ciprofloxacin or trimethoprim-sulfamethoxazole and presence of a gastrostomy tube were independent predictors of resistance. Plasmid studies on isolates from 20 hospital and nursing home patients revealed that 17 had a common 54-kilobase plasmid, which conferred ceftazidime resistance via the ESBL TEM-10, and mediated resistance to trimethoprim-sulfamethoxazole, gentamicin, and tobramycin; all 20 isolates harbored this ESBL. Molecular fingerprinting showed 7 different strain types of resistant K pneumoniae and E coli distributed among the nursing homes. CONCLUSIONS: Nursing home patients may be an important reservoir of ESBL-containing multiple antibiotic-resistant E coli and K pneumoniae. Widespread dissemination of a predominant antibiotic resistance plasmid has occurred. Use of broad-spectrum oral antibiotics and probably poor infection control practices may facilitate spread of this plasmid-mediated resistance. Nursing homes should monitor and control antibiotic use and regularly survey antibiotic resistance patterns among pathogens.     

Cognitive and behavioural impairment among elderly people in institutions providing different levels of care.

OBJECTIVE: To compare the prevalence and degree of cognitive and behavioural impairment in elderly patients in institutions providing different levels of care. DESIGN: Prevalence study. SETTING: A nursing home, a home for the aged and psychogeriatric wards in a provincial psychiatric hospital. PATIENTS: Only subjects 65 years of age or older were eligible for inclusion. A random sample was selected comprising 25% of the residents in the nursing home and the home for the aged; of the 119 asked to participate 95 agreed (44 in the nursing home and 51 in the home for the aged). All 50 on the psychogeriatric wards agreed to participate. MAIN OUTCOME MEASURES: The Mini-Mental State Examination (MMSE) and the Kingston Dementia Rating Scale (KDRS). RESULTS: An MMSE score of less than 24 (cognitive impairment) was given to 37 (84%) of the residents in the nursing home, 43 (84%) of those in the home for the aged and 48 (96%) of the patients in the psychiatric hospital; the corresponding numbers for a KDRS score of more than 0 (cognitive impairment) were 41 (93%), 48 (94%) and 50 (100%). The seven patients receiving the highest level of care at the home for the aged (special care) had more behavioural problems than those in the psychiatric hospital did (p less than 0.001). CONCLUSIONS: Cognitive and behavioural impairment was widespread in the three institutions regardless of the level of care. When planning services and allocating resources government funding agencies should consider the degree and prevalence of such impairment among elderly people in institutions.     

Access to palliative care and hospice in nursing homes

Nursing homes are the site of death for many elderly patients with incurable chronic illness, yet dying nursing home residents have limited access to palliative care and hospice. The probability that a nursing home will be the site of death increased from 18.7% in 1986 to 20.0% by 1993. Dying residents experience high rates of untreated pain and other symptoms. They and their family members are isolated from social and spiritual support. Hospice improves end-of-life care for dying nursing home residents by improving pain control, reducing hospitalization, and reducing use of tube feeding, but it is rarely used. For example, in 1997 only 13% of hospice enrollees were in nursing homes while 87% were in private homes, and 70% of nursing homes had no hospice patients. Hospice use varies by region, and rates of use are associated with nursing home administrators' attitudes toward hospice and contractual obligations. Current health policy discourages use of palliative care and hospice for dying nursing home residents. Quality standards and reimbursement rules provide incentives for restorative care and technologically intensive treatments rather than labor-intensive palliative care. Reimbursement incentives, contractual requirements, and concerns about health care fraud also limit its use. Changes in health policy, quality standards, and reimbursement incentives are essential to improve access to palliative care and hospice for dying nursing home residents. JAMA. 2000;284:2489-2494.     

Admission of nursing home patients to geriatric medical wards.

Comparison was made between patients admitted from a nursing home and all other patients admitted to a geriatric medical unit in 1990 and 1993. The number of nursing home patient admissions rose from 26 in 1990 to 106 in 1993. Nursing home patients were frailer both physically and mentally with a dementia rate of 78% (in those who survived, 1993) and a mortality rate of 19.8% (1993), compared with a dementia rate of 19% and a mortality rate of 11.3% in all other admissions in 1993. Male patients admitted from a nursing home were more likely to die than females (33% versus 14.5%, 1993). Lengths of stay of nursing home patients were shorter, largely due to the availability of a 'safe environment' when discharged, but also related to shorter survival times. 61% of patient admissions from nursing homes in 1993 were considered 'unnecessary' and could have been avoided if specialist advice had been available before admission.     

入住疗养院者骨质疏松患病及防治状况研究

【目的】探讨美国圣路易斯州入住疗养院者骨质疏松的患病及防治状况。【方法】用定量超声骨密度测定仪测量2 17例入住疗养院者 (年龄 42～ 10 2岁 ,平均 83 3岁 )右侧跟骨的骨密度 ,结合病史及病历记录情况 ,对入住疗养院者骨质疏松防治状况进行分析。【结果】入住疗养院者的骨密度低于同年龄段的社区居民 ,骨质疏松的患病率较高 (5 8 5 %) ,只有18 4 %的疗养院入住者跟骨骨密度在青年成人骨密度均值 1个标准差内。未诊断的骨质疏松占 83 5 %,未治疗骨质疏松占6 3 0 %,只有 37 0 %的骨质疏松患者服用钙剂及 /或维生素D治疗 ,用雌激素替代或用阿伦二膦酸盐积极治疗的仅有 3 1%。【结论】疗养院入住者骨密度低、骨质疏松患病率高 ,但防治状况差。     

The physician's role in patients' nursing home care: "She's a very courageous and lovely woman. I enjoy caring for her"

More than 1.5 million adults live in US nursing homes, and approximately 30% of individuals in the United States will die with a nursing home as their last place of residence. Physicians play a pivotal role in the rehabilitation, complex medical care, and end-of-life care of this frail and vulnerable population. The reasons for admission are multifactorial and a comprehensive care plan based on the Minimum Data Set guides the multidisciplinary nursing home team in the care of the patient and provides assessments of the quality of care provided. Using the cases of 2 patients with different experiences, we describe the physician's role in planning for admission, participating as a team member in the ongoing assessment and care in the nursing home, and guiding care at the end of life. The increasing population of older adults has also promoted community-based and residential alternatives to traditional nursing homes. The future of long-term care will include additional challenges and rich innovations in services and options for older adults.     

Ten-year incidence of diabetes in older Australians: the Blue Mountains Eye Study

OBJECTIVE: To estimate the incidence of diabetes and impaired fasting glucose (IFG), and increased risk associated with the metabolic syndrome, in a representative population-based sample of older Australians. DESIGN, SETTING AND PARTICIPANTS: The Blue Mountains Eye Study examined 3654 residents aged 49 + years (82.4% response rate) during 1992-1994, and re-examined 2335 (75.1% of survivors) during 1997-1999 and 1952 (75.6% of survivors) during 2002-2004; 2123 participants with normal blood glucose levels at baseline were considered at risk of developing incident diabetes. Main outcome measures: Incident diabetes (or IFG) was defined in participants at risk who were newly diagnosed by a physician during the follow-up or found to have a fasting blood glucose level >or= 7.0 mmol/L (or 5.6-6.9 mmol/L). Kaplan-Meier cumulative 10-year incidence was calculated. RESULTS: The overall 10-year incidence of diabetes and IFG was 9.3% and 15.8%, respectively. Participants with metabolic syndrome at baseline had a higher risk of incident diabetes than those without metabolic syndrome (29.2% v 8.6%). Baseline factors associated with incident diabetes were elevated fasting glucose level (adjusted odds ratio [OR], 4.5; 95% CI, 3.4-6.1 per mmol/L), obesity (OR, 2.0; 95% CI, 1.3-2.8), diabetes family history (OR, 1.7; 95% CI, 1.2-2.5), current smoking (OR, 1.6; 95% CI, 1.0-2.7) and high density lipoprotein cholesterol level < 1.0 mmol/L (OR, 2.4; 95% CI, 1.5-3.8). Similar baseline factors were associated with incident IFG. CONCLUSION: This population-based study provides data on the incidence of diabetes and IFG in an older, predominantly white population, and confirms that metabolic and lifestyle factors are major risk factors for diabetes.     

Care of the elderly in north and west Belfast.

A survey of all elderly people aged 65 years and over from North and West Belfast receiving long-term care in residential and nursing homes, and in psycho-geriatric and geriatric care was undertaken. A total of 967 subjects was studied and physical dependency and mental impairment documented. The high dependency of residents in geriatric and psycho-geriatric care was highlighted, with greater levels of dependency than among those receiving nursing home care. Professional assessment prior to admission should be common to all long-term care facilities and is essential if services for the projected demographic increase in numbers of very elderly people are to be provided, and inappropriate admission and expenditure avoided.     

Quality of the last year of life of older adults: 1986 vs 1993

CONTEXT: The population is aging and life expectancy is increasing, but whether morbidity and disability late in life also increase is unknown. OBJECTIVE: To examine whether the use of health care services, disability and cognitive function, and overall quality of life in the year before death among older adults has changed over time. DESIGN AND SETTING: The 1986 and 1993 National Mortality Followback Surveys, which were probability samples of all deaths in the United States with response rates of next of kin of 90% and 88% for those aged 65 years and older. PARTICIPANTS: Next of kin were asked to report the health status of a total of 9179 decedents who were 65 years and older in 1986 and 6735 in 1993, representing 1.5 and 1.6 million decedents aged 65 years and older. MAIN OUTCOME MEASURES: Days of hospital or nursing home stays, number and length of disability in 5 activities of daily living, duration of impairment in 3 measures of cognitive function, and an overall sickness score among individuals aged 65 through 84 years and those aged 85 years and older. RESULTS: Women used significantly fewer hospital and nursing home services in the last year of life in 1993 vs 1986 (mean reduction, 3.3 nights for both age groups for hospital services; mean reduction 18.4 nights for nursing home for women aged 65-84 years and 42.3 nights for women > or =85 years). Men had no changes except those aged 85 years and older had a decline in nursing home nights of 32.6. The proportion of women aged 85 years and older with restriction of at least 2 activities of daily living decreased from 62.5% in 1986 to 52.1% in 1993 (P<.01), and those with normal cognitive function increased from 50.3% to 56.2% (P<.05). Their mean overall sickness score decreased and quality-of-life improved. Among women aged 65 through 84 years, the number with normal cognitive function increased and the mean sickness score decreased, but those with at least 2 activities of daily living impairments increased and the overall quality of life declined. A similar pattern of change was found in the oldest-old men except that cognitive function worsened. Most parameters for men aged 65 through 84 years did not change significantly. CONCLUSIONS: Men and women at least 85 years old in the US experienced a better overall quality of life in the last year of life in 1993 than those in 1986. Most measures for men and women aged 65 through 84 years improved or did not change.     

Estimating prognosis for nursing home residents with advanced dementia

Context  Survival varies for patients with advanced dementia, and accurate prognostic tools have not been developed. A small proportion of patients admitted to hospice have dementia, in part because of the difficulty in predicting survival. Objectives  To identify factors associated with 6-month mortality in newly admitted nursing home residents with advanced dementia and to create a practical risk score to predict 6-month mortality in this population. Design, Setting, and Participants  This was a retrospective cohort study of data from the Minimum Data Set (MDS). All Medicare or Medicaid licensed nursing homes in New York and Michigan were included. Participants had advanced dementia and were admitted to New York nursing homes between June 1, 1994, and December 30, 1998 (derivation cohort, n = 6799), and to Michigan nursing homes from October 1, 1998, through July 30, 2000 (validation cohort, n = 4631). Main Outcome Measures  MDS factors associated with 6-month mortality were determined in the derivation group, and the resulting mortality risk score was evaluated in the validation cohort. Risk score performance was compared with the cut point of 7c on the Functional Assessment Staging (FAST) scale. Results  Among residents with advanced dementia, 28.3% (n = 1922) died within 6 months of nursing home admission in the derivation cohort; 35.1% (n = 1626) died in the validation cohort. The 6-month mortality rate increased across risk scores (possible range, 0-19): 0 points, 8.9% mortality; 1 to 2, 10.8%; 3 to 5, 23.2%; 6 to 8, 40.4%; 9 to 11, 57.0%; and at least 12, 70.0% in the validation cohort. The area under the receiver operating characteristic (AUROC) curve for predicting 6-month mortality was 0.74 and 0.70 in the derivation and validation cohorts, respectively. Our risk score demonstrated better discrimination to predict 6-month mortality (AUROC, 0.64 for a cutoff of =" BORDER="0">6 points vs 0.51 for FAST stage 7c). Conclusion  A risk score based on 12 variables from the MDS estimates 6-month mortality for nursing home residents with advanced dementia with greater accuracy than existing prognostic guidelines.      

Predicting mortality in nursing home residents with lower respiratory tract infection: The Missouri LRI Study.

CONTEXT: Lower respiratory tract infection (LRI) is a leading cause of mortality and hospitalization in nursing home residents. Treatment decisions may be aided by a clinical prediction rule that identifies residents at low and high risk of mortality. OBJECTIVE: To identify patient characteristics predictive of 30-day mortality in nursing home residents with an LRI. DESIGN, SETTING, AND PATIENTS: Prospective cohort study of 1406 episodes of LRI in 1044 residents of 36 nursing homes in central Missouri and the St Louis, Mo, area between August 15, 1995, and September 30, 1998. MAIN OUTCOME MEASURE: Thirty-day all-cause mortality. RESULTS: Thirty-day mortality was 14.7% (n = 207). In a logistic analysis, using generalized estimating equations to adjust for clustering, we developed an 8-variable model to predict 30-day mortality, including serum urea nitrogen, white blood cell count, body mass index, pulse rate, activities of daily living status, absolute lymphocyte count of less than 800/microL (0.8 x 10(9)/L), male sex, and deterioration in mood over 90 days. In validation testing, the model exhibited reasonable discrimination (c =.76) and calibration (nonsignificant Hosmer-Lemeshow goodness-of-fit statistic, P =.54). A point score based on this model's variables fit to the entire data set closely matched observed mortality. Fifty-two percent of residents had low (score of 0-4) or relatively low (score of 5-6) predicted 30-day mortality, with 2.2% and 6.2% actual mortality, respectively. CONCLUSIONS: Our model distinguishes nursing home residents at relatively low risk for mortality due to LRI. If independently validated, our findings could help physicians identify nursing home residents in need of different therapeutic approaches for LRI.     

标准化沟通模式在养老机构老年人迁移应激中的应用

目的　探讨SBAR标准化沟通模式在养老机构老年人中迁移应激的应用效果。方法　选取2016年4—9月南昌市某养老机构新入住的57例老年人为对照组,2017年3—8月该养老机构新入住的61例老年人为观察组,对照组采用传统交接方式入住,观察组根据SBAR标准化沟通模式的结构框架,设计SBAR老年人入住交接表。比较两组老年人入住初期问题发生率,采用简版老年抑郁量表（GDS-15）和应激反应问卷（SRQ）评价老年人入住期间抑郁情况和迁移应激反应。结果　观察组入住初期问题发生率低于对照组（P<0.05）。观察组入住1周、入住1个月、入住2个月GDS-15评分均低于对照组（P<0.05）。入住2个月后,观察组SRQ总分、情绪反应、躯体反应、行为反应得分均低于对照组（P<0.01）。结论　SBAR标准化沟通模式规范了老年人入住交接流程,有效改善了老年人迁移应激反应,提高了养老护理工作效率,可在机构养老中进行推广。     

Acute medical bed usage by nursing home residents.

An increasing number of elderly patients in nursing home care appears to be presenting to hospital for acute medical admission. A survey of acute hospital care was undertaken to establish accurately the number and character of such admissions. A total of 1300 acute medical beds was surveyed in Northern Ireland in June 1996 and January 1997 on a single day using a standardised proforma. Demographic details, diagnosis and length of admission were recorded. A total of 84 patients over the age of 65 (mean 79.5 years) admitted from nursing home care was identified in June 1996 and a total of 125 (mean 83.3 years) in January 1997. A total of 88 (70%) of admissions in 1997 were accompanied by a general practitioner's letter. The assessing doctor judged that 12 (9.6%) of admissions in 1997 could have had investigations and or treatment reasonably instituted in a nursing home. The proportion of acute medical beds occupied by nursing home residents was 6% in June 1996 rising to 10% in January 1997. The study accurately identifies the significant contribution of nursing home patients to acute medical admissions and the low proportion in whom admission was unnecessary. Closure of long stay hospital facilities should be accompanied by investment in community medical services and also reinvestment in acute hospital care for elderly people.