First nursing home admissions: time spent at home and in institutions after discharge.

We tracked 96 percent of a sample of 1,942 nursing home patients admitted to a nursing home for the first time in 1982-83. Patients discharged alive from the nursing home were followed for two years or until death. The relative time spent at home, in hospitals, and in skilled nursing facilities is reported. Of the 705 patients discharged from their initial nursing home admission to homes in the community, about 50 percent made only one transfer and only 15 percent made four or more transfers. Of the 509 discharged to a hospital, 26 percent died there and 37 percent of the 374 survivors made four or more moves in the next two years. In all, 1,332 patients were discharged alive and they spent almost two-thirds of the subsequent two years, or their remaining lifetimes, in the community. Of those who transferred only once, over two-thirds of their follow-up time was spent in their own homes. Policies concerned with long-term care should use some type of actuarial data base to successfully plan and implement long-term care insurance.     

Locked confinement: First and second impressions

This article evaluates the practical and therapeutic merits of using locked confinement from a first-hand perspective. The author describes her experiences working as a child care worker in settings with and without locked confinement rooms. The point is made that the profession of child care defines itself at least in part by the methods it chooses to employ. Since workers have reactions, sometimes strong ones, to the very procedures they currently use, it is important as a research exercise to attempt analysis of how those reactions arise and how they change over time. Her conclusion is that there are effective alternatives to locked confinement.     

Functional assessment of nursing home patients. Reliability and relevance.

Functional assessment of patients for resource allocation or staffing requires a higher level of interrater reliability than functional assessment in normal clinical settings. Although many functional assessment instruments are available, interrater reliability of these items has frequently not been reported. An assessment instrument based on the Long Term Care Minimum Data Set format was used for 290 patients in six wards in two Veterans Administration nursing homes. Each patient was assessed independently by two nurse caregivers to obtain reliability information. Different reliability measures yielded differing evaluations of the reliability of the instrument. Absolute agreement rates combined with Kendall's tau-b were most useful in deciding on the reliability of items in the instrument.     

Weight loss in nursing home patients: prognostic implications

Weight loss is commonly used as a screening tool to assess quality of care and nutritional status in the nursing home setting. To evaluate the prognostic value of weight loss, the charts of 199 nursing home patients (414 nursing home patient years; mean age 87 years) were reviewed over a 3-year period. Weights recorded at nursing home admission and during the study period were compared with weights at the time of acute care hospitalization, transfer between levels of nursing home care, change in level of functional status, and death. There were no significant changes in weight before acute care hospitalizations, although patients who died lost an average of 10% of their body weight from the time of nursing home admission (P less than .001). In addition, weight loss was associated with decreased functional ability and transfer to a higher level of nursing home care. Despite the association of weight loss with subsequent morbidity and mortality, moderate weight loss of up to 20% was a poor predictor of mortality. Although weight loss is routinely used as a screening tool in the nursing home setting, it is not a sensitive marker for underlying disease. The efficacy of active intervention in nursing home patients who lose weight requires further study.     

Malnutrition in tubefed nursing home patients with pressure sores.

This study compares the nutritional status and dietary intake of 14 tubefed nursing home patients with pressure sores (age: 70 +/- 5 years, mean +/- SEM) to 12 tubefed patient-controls without sores (age: 60 +/- 7 years). Patients tended to have higher calorie intake (32 +/- 3 kcal/kg) than patient-controls (26 +/- 2 kcal/kg, p = 0.11). Protein intake was significantly higher in patients (1.4 +/- 0.2 g/kg) than patient-controls (0.9 +/- 0.1 g of protein per kg, p less than 0.05). Despite increased calorie and protein intake, biochemical measures of nutritional status were worse in the patients. Serum albumin was lower in patients (33 +/- 1 g/L) than in patient-controls (37 +/- 1 g/L, p less than 0.05) as was level of hemoglobin (patients: 117 +/- 5; patient-controls: 132 +/- 5 g/L, p less than 0.05). Patients with stage IV (severe) sores had lower serum cholesterol levels (3.46 +/- 0.31 mmol/L, n = 5) than patients with stage II/III (milder) sores (4.58 +/- 0.23 mmol/L, n = 9, p less than 0.05). Plasma zinc was low in both patients (11.2 +/- 0.6 mumol/L) and patient-controls (11.5 +/- 0.7 mumol/L, p = NS). Pressure sore surface area was positively correlated with calorie intake per kilogram of body weight (r = +0.59, p less than 0.04) and negatively correlated with body mass index (r = -0.70, p less than 0.03), hemoglobin (r = -0.55, p less than 0.07) and serum cholesterol (r = -0.57, p less than 0.05).(ABSTRACT TRUNCATED AT 250 WORDS)     

Nutritional status of nursing home patients

Nutritional surveys were conducted on all 115 patients of a Medicare-approved nursing home. The techniques of nutritional assessment used included anthropometric measurements (weight/height, triceps skinfold, arm-muscle and arm circumference), biochemical and hematologic tests (serum albumin, serum transferrin, total lymphocyte count, hemoglobin, and hematocrit), and an intradermal skin test for cell mediated immunity. The prevalence of protein-calorie malnutrition (PCM) of moderate to severe degree was very high by currently used standards (weight/height, 43%; triceps skinfold, 37%; arm-muscle circumference, 85%; serum albumin, 32%; serum transferrin, 38%; and total lymphocyte counts, 22%). Anemia was found in 52% of the men and 14% of the women by normal adult standards; in addition, 19% of the patients had negative cell-mediated immunity (CMI) tests. The mortality rate during the 6 months after surveying was 13% for the immunocompetent (CMI-positive) patients and 48% for the anergic (CMI-negative). These findings confirm that PCM is prevalent in 85% of nursing home patients according to currently accepted nutritional assessment standards. In this nursing home population, 485 had marasmus, 35% had marasmus-kwashiorkor mixed syndrome, and 2% had kwashiorkor. Perhaps new standards need to be derived for such specific age groups as the elderly.     

Serum magnesium levels in nursing home patients

The elderly nursing home patient is at risk for hypomagnesemia due to poor nutritional intake, multiple chronic disease states, and polypharmacy. In order to assess the need to screen for magnesium deficiency in a long-term care setting, serum magnesium levels were determined in 75 nursing home patients. Mild hypomagnesemia was observed in 3 of the patients, all with poor eating habits. Diuretic use, although common, was not associated with magnesium deficiency. Routine screening for hypomagnesemia in nursing home patients with adequate nutritional intake does not appear warranted.