Nursing Home Residents

Nearly 1.6 million Americans live in nursing homes. They are usually:

• Old (average age 80 years or older; almost 90 percent are older than
  65)
• Female
• Physically and mentally impaired

These statistics can mask the similarity of the nursing home patient.

• Nearly half (45%) of people discharged from nursing homes stayed
  less than 90 days
• Among this group, most were admitted for short-term rehabilitation,
  acute illness, or terminal care
• Those who stay for long-term care typically have serious mental and/or
  physical problems

Improving Quality of Care

Improving the quality of care for individuals who will live in a nursing
home for many years is a difficult task. For these individuals the nursing
home serves as a health care facility and a home. The 1985 Institute
of Medicine report and the resulting regulations that were part of the
1987 Omnibus Reconciliation Act (OBRA) tried to address this dual role
of the nursing home and encouraged a de-emphasis on the medical model of
long-term care. However, much remains to be accomplished to improve the
quality of nursing home care.

One strategy to improve the care of nursing home residents is a
systematic approach to screening, health maintenance, and preventive
practices. This is a controversial concept. Although there is
enthusiasm for targeting preventive measures in older, community living
individuals, there is little agreement (and even less data) on what
specific measures should be recommended. The approach to take with the
frail elderly in the nursing home is even less clear.

Goals of Prevention in Late Life

The goals of prevention change in late life. In younger persons, goals
target disease-specific morbidity and mortality, but in older
individuals with many chronic conditions this focus loses its value. More
relevant goals include:

• Prevention of iatrogenic illness (illness or problems acquired as a
  result of treatment, like drug-to-drug interactions)
• Prolonging the period of effective activity and function
• Ensuring an adequate social support system
• Combining an approach tailored to the individual along with
  institution-wide efforts

For example, evaluating the risk of falling can be expanded into a
comprehensive, institution-wide program to reduce accidental injury and
encourage mobility. A recent study evaluated the benefits of a fall
prevention assessment in high-risk nursing home patients. The assessment
was completed by a nurse practitioner. Several correctable problems were
identified, including muscle weakness, postural hypotension, gait and
balance disorders, adverse drug effects, occult infection, dehydration,
and metabolic disorders. Hospitalizations for patients in the group
receiving this evaluation and intervention were reduced as compared to a
similar group of high-risk patients.

Similarly, evaluating the nursing home patient’s nutritional status
can be expanded into an active program that identifies weight loss and
adult failure-to-thrive syndrome. Clinically, failure-to-thrive is
defined by unintentional weight loss, which may be reversible or
irreversible. In the nursing home, in addition to weight loss,
conditions associated with undernutrition include anemia, hip fractures,
pressure ulcers, depression, and dementia. Careful evaluation of
high-risk individuals and implementation of support involving family,
nursing staff, the dietician, and other staff may improve nutritional
status and prevent disability. Similar preventive programs could address
other common clinical problems such as pressure ulcers and recurrent
urinary tract infections.

Prevention of Iatrogenic Problems

The prevention of iatrogenic problems is an area of great potential in
the nursing home. Careful evaluation of medication use and reducing the
risks of hospitalization are two areas with particular promise. The
average nursing home resident takes more than eight medications and
in this population the use of high-risk medications, for example
digoxin, diuretics, and psychoactive drugs, is particularly common.
The risks for drug-to-drug interactions and drug-to-disease interactions
are especially high. In one study, older patients using six to ten drugs
during a year had a 13 percent rate of adverse reactions. The
physician should be decisive about discontinuing unnecessary medications.

Nursing home patients are frequently transferred to the emergency room
for evaluation or the hospital for treatment. The risk for iatrogenic
problems (those resulting from the care provided) in these situations is
high.

• Communication between hospital and nursing home may be poor. A
  different physician may be directing the patient’s care after transfer
  to the hospital. Important information on symptoms, baseline
  functioning, ongoing or new treatments, and advanced directives do not
  always come with the patient, and hospital staff infrequently try to
  gather the missing data.
• Many of these patients have delirium, which may be aggravated
  by the transfer, which complicates assessment and treatment in the
  hospital.
• Over-treatment, under-treatment, and misdiagnosis are not uncommon.
  An important preventive strategy in the nursing home is to consider
  carefully the need to transfer a patient to a hospital. If at all
  possible acute evaluations should be initiated without a transfer.
• If hospitalization is required, continuity of care must be ensured.
  Nursing home clinical records should be provided to the hospital, and
  the nursing home attending physician should supervise the hospital
  care, or communicate regularly with the hospital attending.

These are a few examples of strategies that could make a significant
difference in the quality of life for long-stay nursing home residents.
Maintaining function, avoiding iatrogenic illness, and targeting
interventions to individuals are essential components of high-quality
care in the nursing home.

Adapted from Geriatric Medicine – Gerontology Report, Winter/Spring;
1998, V.8 No.1

For more information:

Go to the Senior Health health topic.