Home from home: residents' opinions of nursing homes and long-stay wards

OBJECTIVE: To compare the levels of satisfaction expressed by residents of nursing homes with those of patients in geriatric long-stay wards. DESIGN: A structured satisfaction questionnaire containing 37 closed and two open questions was used to elicit responses from residents of nursing homes in the former South West Thames Regional Health Authority area. This was compared with a similar survey using the same questionnaire among patients in geriatric long-stay wards surveyed in 1989. SETTING: respondents came from a sample of nursing homes chosen to be representative of both size and geographical location. Nursing homes were stratified by number of beds (1-19, 20-29, 30+) and clustered by location (to reflect the urban, semi-rural and coastal nature of the region). SUBJECTS: A random sample was drawn from each grouping (size and location) to yield a resident sample of 850 in 36 nursing homes. This figure was similar to the number of patients (808) in geriatric long-staywards surveyed in 1989. All eligible nursing home patients were assessed for physical dependency. Mental confusion was ascertained by the Abbreviated Mental Test Score (AMTS). Patients who scored three or less on the AMTS (indicative of severe confusion) or had dysphasia, profound deafness or concurrent serious illness were excluded from further study. RESULTS: 377 nursing home residents were able to complete the questionnaire and their answers were compared with those of 291 long-stay geriatric patients. The responses to the five themes--relations with staff, autonomy, amenities, privacy and social environment-show some minor differences between the two groups but what is more noticeable is the similarity of their views. This is important as much social policy assumes that the more 'homely' atmosphere of the nursing home should elicit higher levels of satisfaction than the 'institutional' setting of the hospital ward. CONCLUSION: We conclude that the difference between nursing homes and hospital wards in terms of their institutionalizing capacities is not as profound as policy-makers believe.     

Profiling disability within nursing homes: a census-based approach

BACKGROUND: a significant minority of older people live in residential care. While disability is often a major contributory factor, it may not be measured or managed adequately by health and social services. At present there is little information comparing levels of disability within nursing homes and the community, and no mechanisms for monitoring changes in this disability ratio longitudinally. OBJECTIVE: to examine the prevalence of disability among older nursing home residents compared to its prevalence among older people in the community using a census-based approach. DESIGN: nationwide census over one night in 2002. SETTING: all homes and dwellings in the Republic of Ireland. Method: disability was measured using a six-item questionnaire embedded in a census form. Prevalence of disability was quantified among the general population and nursing homes residents aged 65 and over. Comparisons were made of sex, and number and type of disabilities between nursing home residents and their age-matched peers living within the community. RESULTS: the results showed a high level of disability within nursing homes with almost 90% of residents having a recorded disability compared with less than 30% of those aged 65 and over, living in the community. Nursing home residents had on average 4.5 disabilities ranging from hearing and visual problems to difficulties remembering and concentrating. CONCLUSION: there is a very high level of physical, sensory and cognitive disability among nursing home residents. Strategic health and functional questions in national censuses may be helpful in planning appropriate services for older people in residential care, as well as tracking trends in disability.     

The prevalence of eye disease in nursing home and non-nursing home geriatric populations

The objective of this study was to determine whether rates of eye disease among the elderly are higher for residents of nursing homes than for persons who reside elsewhere. Articles reporting the prevalence of eye disease in geriatric populations (classified as nursing home or non-nursing home) were identified through a Medline search and a search of articles' bibliographies. Identified articles were reviewed, and the relevant data compared with prevalence rates obtained from 738 residents of two nursing homes in New York City. Each of the nursing home residents received an ocular examination upon admission that determined the presence or absence of four varieties of eye disease-i.e. cataracts, age-related macular degeneration, glaucoma, and diabetic retinopathy. Demographic data were obtained through chart review. Results indicate that prevalence rates of eye disease found in geriatric nursing home populations are generally higher than those found in other geriatric populations. With the exception of the rates for diabetic retinopathy, the rates found in the combined nursing home population sampled in this study were much higher than those reported in any previous study. It is concluded that eye disease is a more serious problem for elderly residents of nursing homes than for the elderly who reside in the community. Possible reasons for this are discussed.     

Extended care in nursing homes: a program for a county teaching medical center

A continuity care program for patients in nursing homes using internal medicine residents in training has been developed in a county teaching hospital. Resident physicians on a paid basis assume primary care responsibility for 1000 patients in 29 private community nursing homes. A faculty internist coordinates the activities of the residents and monitors patient care through an extended care office in the county hospital. The program has produced a significant upgrading of the continuity and quality of care of patients in these nursing homes as well as providing medical residents with geriatric and nursing home experience. The increased sensitivity and concern for the needs of nursing home patients developed by the medical residents seems to continue after they complete their training.     

Clinical characteristics and six-month outcomes of nursing home residents with low activities of daily living dependency

BACKGROUND: Up to 30% of nursing home residents have very little dependency in activities of daily living (ADLs). We compared the characteristics and six-month outcomes of a sample of low-ADL--dependent nursing home residents (LDR) with other residents. METHODS: This is a cross-sectional, six-month follow-up study using secondary data analysis. We combined the separate 1990 and 1993 cohorts in the Resident Assessment Instrument evaluation study. In each case these data were collected in the same 254 nursing homes in 10 states. We studied residents with a length of stay greater than 60 days and age 65 years and older (N = 3955). We compared the baseline characteristics of LDR (n = 985) with all other residents. We then compared six-month outcomes of LDR with other residents and characteristics of LDR with poor outcomes (death or worsened ADL disability) with LDR who remained stable. RESULTS: The LDR had a significantly decreased frequency of geriatric syndromes (i.e., cognitive impairment, urinary incontinence, under-nutrition, vision problems, poor balance, and pressure ulcers) and neurological disease but had the same frequency of non-neurological chronic diseases and were on more medications. Thirty-one percent had poor six-month outcomes associated with baseline poor cognition, incontinence, poor appetite, and presence of vascular disease, daily pain, shortness of breath, and multiple medications. CONCLUSION: Our research identified 29% of nursing home residents with higher physical function (LDR) who had fewer geriatric syndromes and neurological disease diagnoses; 69% of these remained stable at 6 months. Those LDR with a higher risk of poor outcomes could be prospectively identified. LDR who remained stable for 6 months may represent a group who could potentially be maintained in the community.     

Life satisfaction of elderly individuals in regular community housing, in low-cost community housing, and high and low self-determination nursing homes

Numerous studies have found that giving nursing home residents more control or self-determination in their daily lives increases their life satisfaction. However, it is not known if elderly people living in high self-determination nursing homes are as satisfied with life as elderly people living in the community. In this study, it was found that elderly persons living in regular community housing, in low-cost community housing, and in high self-determination nursing homes reported similar levels of life satisfaction, and more life satisfaction than elderly people living in low self-determination nursing homes. Health and sociodemographic variables could not account for these findings. The common assumption that nursing homes have detrimental effects on life satisfaction appears unwarranted in the case of those that provide opportunities for self-determination.     

VISITORS TO NURSING HOMES: FEW OR MANY?

The presence of family and friends in nursing homes ensures that residents continue to have meaningful and personal relationships with others. With the aim of filling a gap in the Australian gerontological literature on the institutionalised aged, this study reports on the contacts that the elderly in nursing homes have with family and friends. A questionnaire was administered to assess whether residents at eight nursing homes had contact with people living in the community during the week prior to the interview, and examine whether there are differences between residents in who contacts them. The results reveal that like their American and English counterparts, the Australian aged living in nursing homes are not generally forgotten by their family or friends; the childless residents are not without visitors; and who comes to visit varies with the marital status of the resident.     

Mental illness and psychotropic medication use in the nursing home

The authors examined mental illness and psychotropic medications use among nursing home residents. Data were drawn from the Texas Long-Term Care Reimbursement Project, a 1986 study of nearly 2,000 residents in 49 nursing homes. The study measured the use of antipsychotics and other psychotropic medications, physical health conditions, mental illness diagnoses, behavior, and nursing and other direct-care time for sampled residents. The findings indicated that 45% of the sample was receiving an antipsychotic or other psychotropic medication. Although psychotropics were prescribed more extensively for those with a psychiatric diagnosis, nearly one half of persons without a psychiatric diagnosis were receiving psychotropic medications at the time of the survey. Moreover, psychotropics were quite prevalent among those with unstable medical conditions and/or severe activities of daily living impairment. Neither a mental illness diagnosis, evidence of a behavioral problem, nor use of psychotropics was significantly correlated with the amount of nursing or other direct-care time received by residents. The findings raise concerns about the widespread prescribing of these medications, especially among residents who have no supporting psychiatric diagnosis and/or who have physical health conditions making them vulnerable to adverse drug effects.     

Study of constipation in a geriatric hospital, day hospital, old people's home and at home

A study of constipation and related factors was carried out in 439 geriatric hospital patients, 183 people living in two old people's homes, and 78 patients visiting a geriatric day hospital. In addition, a cross-sectional survey of constipation and related factors was undertaken in 138 people older than 74 years and 74 people aged 41 to 50 years living at home. Constipation and the use of laxatives were most frequent in the geriatric hospital (79% and 76% respectively), followed by the old people's homes (59% and 60%), the day hospital (29% and 31%), elderly living at home (38% and 20%) and middle-aged living at home (12% and 5%). The results suggest an increased risk of constipation for the persons walking less than 0.5 km daily [relative risk (RR) = 1.7], walking with help (RR = 3.4), chairbound (RR = 6.9) and bedbound (RR = 15.9). The relative risk of constipation increased for the persons living in the old people's homes (RR = 1.7) and the geriatric hospital (RR = 2.2), and also with advancing age (between 75 and 84 years, RR = 2.9; over 84 years, RR = 4.9). The prevalence of constipation was directly correlated to fecal and urinary incontinence.     

Presentation and Management Outcomes of Corneal and Scleral Perforations in Geriatric Nursing Home Residents

We compared the clinical presentation and treatment outcomes of corneal and scleral perforations in geriatric nursing home residents, geriatric community residents, and non-geriatric population. The medical records of patients who were treated for corneal and scleral perforations at the Prince of Wales Hospital, Hong Kong between January 1, 2004 and May 1, 2013, were reviewed retrospectively. Of 144 cases, 53 (37%) occurred in the geriatric population, of which 16 (11%) lived in nursing homes, and 37 (26%) were community residents. There were 91 (63%) patients in the non-geriatric group. The mean age of the patients in nursing home geriatric group was 86.5 years (87.5% females). The most common etiology of perforation was trauma. Rupture due to fall was more common in geriatric patients (P < 0.001) whereas laceration due to penetrating eye injury was more common in non-geriatric patients (P < 0.001). There were more cases of infection leading to spontaneous perforation in geriatric nursing home group compared to the other groups (P = 0.001). In the geriatric nursing home group, visual acuity at presentation (P < 0.001) and postoperative visual acuity (P = 0.012) was worse compared to the other groups. Our study showed that corneal and scleral perforations in the geriatric nursing home residents carry a poor visual prognosis. The causes and anatomical outcomes of such events in geriatric age group differ from those in the general population. In our study, geriatric patients residing in nursing homes had worse baseline as well as posttreatment visual acuity, compared to community residents.     

Problems identified by geriatric evaluation at a nursing home]

A geriatric evaluation was carried out in a group of 37 elderly nursing home residents. A complete history and physical examination was performed in all the patients. We identified 185 new medical problems in the patients, 40.7 per cent of whom were rehabilitation candidates. A functional status evaluation on daily activities showed dependency in 56.8 per cent of the patients while in daily instrumental activities 51.3 to 81 per cent of the patients required assistance. A mental status evaluation showed abnormalities in 46.8 per cent of the patients. This analysis shows the need of implementing this particular form of evaluation of elderly patient in our community and nursing homes.     

Old people in homes

With regard to gerontological problems (multiple morbidity, insufficient epidemiological knowledge, under-assessment of mental illness, displacement) the results of a total survey of residents over 65 of age in all the geriatric nursing homes and homes for the elderly in the Berlin (W) district of Charlottenburg are presented. Our main interest was in the following items: diagnosis, psychopathology, clinical and personal data, medical and social care, extent of personal contacts with non-residents, and the institutional environment. Results are discussed and inferences for better care, particularly of the mentally ill residents, are indicated.     

Quality of life in nursing homes following the group-living principle

Background

The purpose of this study was to analyze the subjective quality of life in elderly people in nursing homes following the group-living principle.

Methods

The Nottingham Health Profile (NHP) was employed. A comparison with the German representative subsample of elderly living independently age-group over 75 was conducted. Psychometric properties and appropriateness were analyzed.

Results

The mean NHP scale scores suggest an acceptable perception of residents’ quality of life (n?=?145). Our findings indicate that with exception of the NHP scale physical mobility, the perceived quality of life of group-living nursing home residents and independently living elderly over 75 years (German reference values) are nearly on the same level. With the exception of the subscale social isolation, the results of the current study show that the NHP is suitable for assessing the subjective quality of life in nursing home environments.

Conclusion

The results of the first pilot study in the research field of subjective quality of life in group-living nursing homes are presented. The study focused on very old people with age-specific reduced physical and mental abilities. The NHP should also be considered as a reliable, valid and useful alternative to resident satisfaction surveys.     

The demand for homes in old age

A study is reported of the utilization of non-clinical institutional care (geriatric and old people's homes) by the elderly inhabitants of Mannheim (pop. 306,000). The aim of the research was to establish the probability of admission to institutional care of an elderly person from this population, and to examine the influence of socio-demographic features. Under the West German health insurance system, most of the long-stay care of the elderly is provided not in hospitals but in nursing and geriatric homes. Data were collected on age at admission, place of residence before admission, duration of stay, age at death and place of death, as well as on the financial basis of care. The data were gathered retrospectively, the sample consisting of all inhabitants of Mannheim over 65 years old who died in the year 1982 (N = 2,585). At any given time only about four per cent of the elderly population will be in institutional care. In this respect, Mannheim is typical for the Federal Republic of Germany. However, the research findings demonstrate that approximately one elderly person in five will spend the last period of his life in this type of care. Seen in this light, the geriatric and old people's homes acquire a much greater social significance than is revealed by the number of institutional places alone.     

Does hospice have a role in nursing home care at the end of life?

OBJECTIVES: To assess the possible benefits and challenges of hospice involvement in nursing home care by comparing the survival and needs for palliative care of hospice patients in long-term care facilities with those living in the community. DESIGN: Retrospective review of computerized clinical care records. SETTING: A metropolitan nonprofit hospice. PARTICIPANTS: The records of 1,692 patients were searched, and 1,142 patients age 65 and older were identified. Of these, 167 lived in nursing homes and 975 lived in the community. MEASUREMENTS: Patient characteristics, needs for palliative care, and survival. RESULTS: At the time of enrollment, nursing home residents were more likely to have a Do Not Resuscitate order (90% vs 73%; P < .001) and a durable power of attorney for health care (22% vs 10%; P < .001) than were those living in the community. Nursing home residents also had different admitting diagnoses, most notably a lower prevalence of cancer (44% vs 74%; P < .032). Several needs for palliative care were less common among nursing home residents, including constipation (1% vs 5%; P = .02), pain (25% vs 41%; P < .001), and anticipatory grief (1% vs 9%; P < .001). Overall, nursing home residents had fewer needs for care (median 0, range 0-3 vs median 1, range 0-5; rank sum test P < .001). Nursing home residents had a significantly shorter survival (median 11 vs 19 days; log rank test of survivor functions P < .001) and were less likely to withdraw from hospice voluntarily (8% vs 14%; P = .03). However, there was no difference in the likelihood of becoming ineligible during hospice enrollment (6% for both groups). CONCLUSIONS: These results suggest that hospices identify needs for palliative care in a substantial proportion of nursing home residents who are referred to hospice, although nursing home residents may have fewer identifiable needs for care than do community-dwelling older people. However, the finding that nursing home residents' survival is shorter may be of concern to hospices that are considering partnerships with nursing homes. An increased emphasis on hospice care in nursing homes should be accompanied by targeted educational efforts to encourage early referral.     

Die gerontopsychiatrische Versorgungsrealität in einer westdeutschen Großstadt

A comprehensive survey of psychogeriatric services was carried out as a part of public health planning in Solingen, a city of 165,000 inhabitants. The investigations consisted of extensive questionnaires and numerous interviews. Mental disorders are suspected in 15-20% of general practitioner's patients, in 62% of community health care center clients and in 65.5% of the residents of geriatric nursing homes and old people's homes. Hardly half of the latter and less than 20% of the clients of community health care center are under psychiatric treatment. Psychiatrists reach only about half as many elderly persons as must be expected from epidemiological data; the rate of clinical psychogeriatric treatment is lower than in some other German regions. The extend of psychotherapy in old age is very low. Collaboration between general practitioners and psychiatrists should be improved; in institutions training and supervision are deficient.     

Limitations of the SF-36 in a sample of nursing home residents

OBJECTIVE: to assess test characteristics of the Medical Outcomes Study SF-36 (Short-Form 36) with residents of nursing homes. RESEARCH DESIGN: nursing home residents with 17 or more points on the Mini-Mental State Examination (MMSE) and > or = 3 months residence (128 of 552 screened) were selected randomly. Interviewers administered the SF-36 (repeated after 1 week), Geriatric Depression Scale and MMSE. We recorded activities of daily living and medication data from medical records. Data analysis included test-retest intraclass correlations, item completion, score distributions and SF-36 correlations with measures of physical and mental functioning. RESULTS: 97 nursing home residents (75.8%) consented. Test-retest intraclass correlation coefficients were good to excellent (range = 0.55 to 0.82). Convergent validity between SF-36 physical health scales and the activities of daily living index was modest (r range = -0.37 to -0.43). About 25% of residents scored zero (lowest score) on at least one SF-36 physical function measure. SF-36 mental health scales correlated strongly with the Geriatric Depression Scale (r range = -0.63 to -0.71) and modestly with bodily pain (r = -0.35). No SF-36 scales correlated strongly with the MMSE. CONCLUSION: only one in five nursing home residents met minimal participation criteria, suggesting limited utility of the SF-36 in nursing homes. Reliability and validity characteristics were fairly good. Skewed scores were noted for some SF-36 scales. The utility of the SF-36 may be limited to assessments of subjects with higher cognitive and physical functioning than typical nursing home residents. The SF-36 might benefit from modification for this setting, or by tests of proxy ratings.     

Autonomy despite multimorbidity in old age--the Berlin-based AMA research consortium

The proportion of the population with multiple illnesses increases with age and growing numbers of people are now living to a very old age. Despite medical progress and improved living conditions, many old people have to deal with physical, psychological, and social impairments. It is a crucial challenge for health and social policy to support the elderly with health-related impairments in their desire to lead as independent a life as possible. Against this background the research consortium Autonomy Despite Multimorbidity in Old Age (AMA I) examined the extent to which the self-determined life style of multimorbid old and very old persons can be supported and maintained. In order to reflect the diversity of life worlds of the elderly, the study sample included participants who were not notably impaired in their everyday functioning, participants in need of nursing care and participants with cognitive impairments. Moreover, the sample comprised both older persons who were still living in their own homes and nursing home residents. The studies conducted within the AMA framework focused on the resources available to old persons living in different situations and on how these resources can be strengthened. This article presents findings from the first phase of funding of the AMA research consortium. In a second phase of funding (2011-2013, AMA II), sustainable practice-based interventions are being developed to mobilize resources which can help multimorbid older persons to maintain their autonomy and the practical viability of these interventions will be tested.     

Nutritional status of the very old: anthropometric and biochemical findings in apparently healthy women in old people's homes.

To obtain reference values for comparison with malnourished geriatric patients, the nutritional status of 50 apparently healthy women aged 75 or older living independently in two old people's homes in Heidelberg was examined. All women were able to walk, and were free from overt disease and signs of mental deterioration. Anthropometric measurements (body height and weight, triceps skinfold thickness, midarm circumference) and biochemical determinations of protein and vitamin status were performed. Anthropometric parameters were similar to those obtained in "younger" samples of healthy elderly, lower than those reported in younger adults, and markedly greater than those reported in geriatric patients. The majority of biochemical findings were within normal reference ranges established for healthy young adults. Only plasma retinol concentrations were below the reference limit in 8 women (16%). These findings show clearly that even in the very old, major alterations in biochemical indicators of nutritional status are rare. Neither advanced age nor institutionalization are associated with malnutrition. This obviously suggests that malnutrition in old age is mainly related to physical and mental disabilities.