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Thursday, November 20, 2014
Nearly 1.6 million Americans live in nursing homes. They are usually:
These statistics can mask the similarity of the nursing home patient.
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.
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:
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.
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.
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
Last Reviewed: Apr 10, 2006
Gregg Warshaw, MD
Director, Office of Geriatric Medicine
College of Medicine
University of Cincinnati