Nursing dependency in registered nursing homes and long term care geriatric wards in Edinburgh.

There has been growing interest and public investment in registered nursing homes, apparently based on the assumption that these homes are the private equivalent of hospital long term care. We have tested this hypothesis in a survey comparing 400 patients in 18 registered nursing homes with 217 patients in 11 geriatric long term care wards in Edinburgh. The nursing home patients formed a distinct and separate group: 362 (92%) were women, 392 (98%) were single or widowed, and 358 (90%) were self financing, whereas in the geriatric long term care group 148 (68%) were women and 35 (16%) were still married. Patients in nursing homes were also far less dependent than those in geriatric long term care wards (p less than 0.005). This study suggests that there may be large differences between the patients in these two types of institution, particularly with regard to nursing dependency. This finding has important implications in the future planning of long term places for the dependent elderly.     

Residential care for elderly people: a decade of change.

OBJECTIVE--To determine the changes between 1979 and 1990 in demography and dependency levels in elderly people in residential care. DESIGN--Censuses of those aged 65 years and over in any type of residential care at midnight on 11 December 1979 and 27 November 1990. SETTING--Leicestershire District Health Authority (population 865,133, 1991 census), coterminous with county and social services boundaries. MAIN OUTCOME MEASURES--Age, sex, length of stay, and dependency levels (measured by activities of daily living). RESULTS--In 1990 (1979), 6079 (4678) elderly people were enumerated in 241 (133) establishments, a 30% increase in the numbers of elderly people in residential care and an 82% increase in the number of establishments between 1979 and 1990. Dependency levels rose between 1979 and 1990 in all but the geriatric sector, the greatest increases being found in private residential homes where the largest percentage increase in the number of residents had occurred. CONCLUSIONS--Dependency levels in residential care have risen substantially, particularly in the private sector, even beyond levels expected from the greater numbers of elderly people. With the impending move to community care, dependency levels are likely to rise further, and more appropriate staff training and medical input to homes will become necessary.     

Private rest homes in the care of the elderly.

Sixteen private rest homes were visited to assess their facilities and the types of disability of the residents. Apart from one home, which was a hotel for the elderly, all the homes provided care for physically and mentally frail elderly people over the long term. Although care was good the trends in the use of the homes are worrying, and stricter regulations are required to ensure appropriate levels of care. Greater support is also required from district nursing services.     

De nieuwe redactieadviesraad van het Tijdschrift voor Gerontologie en Geriatrie

It is unknown how often choking occurs in geriatric wards and in nursing homes and what the treatment and outcomes are in regular practice. A questionnaire was sent to Dutch geriatricians (N = 130), nursing home physicians (N = 130), and trainees for these disciplines (N = 215), in order to gain information about the experience, practice and competence of physicians in choking in geriatric and nursing home patients. We also analysed to what extent geriatric and nursing home wards were prepared for accurate handling of choking. The response rate was 30%. More than half of the responders had experienced an episode of food choking at least once in the past five years. The mortality rate in the reported cases was high (30%). The majority of the patients who died of choking had not received the Heimlich-manoeuvre. Physicians who had attended resuscitation training long ago felt as competent to manage a choking episode as physicians that had recently attended resuscitation training. Of all geriatric wards and nursing homes, the majority lacked a guideline on how to handle in acute food choking. Geriatric wards and nursing homes do not seem to be well prepared for acute food choking in several aspects. Despite methodological shortcomings of this study, the results underline the necessity of clarification of the terms used, and development and implementation of guidelines for this important problem.     

Seroprevalence of Helicobacter pylori and Length of Stay in a Nursing Home

Background. Helicobacter pylori infection appears to be contracted mainly in childhood, and it is associated with disadvantaged socioeconomic conditions, overcrowding, and living in institutions. In this study we determined the seroprevalence of H. pylori among elderly patients (age ≥ 70 years) admitted to a major medical center in Israel, and studied the relationship between seroprevalence of H. pylori and the duration of stay in a nursing home prior to the admission.
Patients and Methods. Whole blood from 182 consecutive patients hospitalized at the Rabin Medical Center was tested for the presence of anti- H. pylori IgG using Helisal Rapid Blood Test kit (Cortecs Diagnostics). Multivariate logistic regression analysis was used to study the relation between H. pylori seropositivity and possible predictive factors such as age, gender and duration of stay in a nursing home.
Results. Of the 182 patients included in the study, 80 (44%) were living in nursing homes (NH) and 102 (56%) were living in their own homes (H) prior to admission. Subjects that stayed in nursing homes for more than 15 months were significantly more likely to be seropositive than subjects with a shorter duration of stay (84% and 63% respectively, p = 0.03). Using a multivariate logistic regression analysis on both the NH group and the whole group, seropositivity was found to be significantly associated with duration of stay in a nursing home (  p = 0.03 and p = 0.01 respectively). Seropositivity was not associated with age in either group.
Conclusions. Living in a nursing home is associated with increased risk for H. pylori infection in the elderly. There is a strong correlation between the duration of stay in a nursing home and the prevalence of H. pylori infection.     

Boom in private rest homes in Southampton: impact on the elderly in residential care

A survey in 1986 of 450 elderly people in 51 private rest homes and 206 residents of seven local authority (part III) homes in the Southampton area showed no significant difference in overall dependency between the two populations. Although age and sex distributions of the residents of part III homes had remained the same between 1982 and 1986, the average level of dependency had fallen significantly. Since the provision of places increased because of expansion in the private sector residential care institutions are generally catering for a more independent population.     

Continuing dental care for Highlands elderly: current practice and attitudes of dental practitioners and home supervisors

Objective : To investigate current practice and attitudes of Highland dentists and home supervisors to continued dental care of elderly residents. Methods : A cross‐sectional questionnaire was designed to survey the current practice and attitudes of Highland dentists and residential care supervisors in their provision of dental care for the elderly at home and in long stay accommodation. Results : The response rate was 94% of dentists and 79% of homes. Despite 86% of dentists providing domiciliary care and 93% of homes transport to a surgery, no more than a quarter of residents had had contact with a dentist in the previous year. The distribution of residents varied with dependant individuals living in nursing units and the least dependant in residential homes. Only 1% of all residents were totally bed bound. Domiciliary patients were less likely to receive continuing care compared with those seen in a surgery and 75% of homes had to initiate dental care. In terms of patient referral, the majority of GDPs would refer uncooperative patients, salaried dentists would refer those with complex medical histories and community dentists would refer those requiring complex treatments. A dental assessment was undertaken in 46% of homes and 81% of these kept a record of dental care. Conclusion : This study highlights the need for a co‐ordinated, seamless continuing dental care service, tailored to the actual needs of the elderly individuals it is designed to serve, particularly in a remote and rural area.     

Community care: the independent sector.

The independent sector, which consists of the voluntary and private sectors, is a vital element in supporting older people in the community. The voluntary sector, coordinated by the Council for Voluntary Service and the National Council for Voluntary Organisations, provides a variety of services, including practical help, reassurance and companionship, and advice, information, campaigning, and advocacy. The private sector owns all of the nursing homes and most of the residential homes and is gradually becoming more involved with the provision of services to help support older people in their own homes. With this increase in size and importance of the independent sector over recent years, there is now a real need for greater communication between the private, voluntary, and statutory agencies in any one region. In some areas, forums made up of representatives of these various sectors meet to discuss relevant issues and construct local policies, thus allowing a more coordinated approach to the delivery of services.     

The ZZP Questionnaire. Reliability of a new resource utilization measure

Data to determine the resource utilization of care recipients need to be reliable and the items that are measured need to be useful. In 2006, the Dutch Ministry of Health and Welfare has mandated all nursing homes and homes for the elderly to measure the Resource Utilization of all residents with the ZZP Questionnaire. Are the data resulting from this measurement reliable and is each of the 54 items of the ZZP Questionnaire useful? To answer this we tested the reliability of the data in a nursing home and a home for the elderly in two wards each. For 122 residents questionnaires were completed such that the inter- and intra-rater reliability of the answers could be assessed. Ten of the 54 items in the questionnaire showed insufficient inter rater reliability (<0.40) on the weighted Cohen kappa and another sixteen moderate (0.40 - 0.60). On the intra rater reliability test seven items had an insufficient kappa and another fifteen moderate. Besides, ten clusters of items could be formed with in-cluster Spearman correlation rates of .75 or higher. From the results of the reliability tests and the item intercorrelation rates we concluded that a substantial number of items needs to be improved and that in the ZZP Questionnaire 15 of the 54 items appear to be redundant on statistical grounds.     

Abortion and the NHS: the first decade.

Analysis of statistics published since the Abortion Act showed that from 1972 about half the abortions carried out on residents of England and Wales had been performed within the National Health Service. Regional variations in the proportions of abortions performed within the NHS had persisted. In some health regions fewer abortions were being carried out than before. In 1975 about 40% of abortions on single women and women with no existing children were performed within the NHS. Trends in the concurrent sterilisation rate, gestational age at operation, duration of stay in hospital, and mortality and complication rates suggested a steady improvement in the effectiveness and efficiency of abortion services. Nevertheless, the NHS still compares poorly with the private sector and some other countries.     

Differences in durations of stay for surgery in the NHS and private sector in England and Wales.

Median durations of stay in England and Wales for eight "marker" operations were consistently shorter for patients in pay beds in the National Health Service than for patients in independent acute hospitals or public sector beds. This pattern was seen for both preoperative and postoperative stay and among specific age groups. Differential use of other hospitals for part of the period of care was not a factor, except for patients having hip replacement operations treated in NHS pay beds, one in seven of whom appeared to transfer to public sector care postoperatively. These findings suggest that there is scope for a possible further reduction in durations of stay in public sector beds and, within the private sector, for an assessment of whether spells in independent hospitals need be longer than in NHS pay beds.     

'Fiber 7' supplement as an alternative to laxatives in a nursing home

Background: Chronic constipation is a common and bothersome problem in elderly nursing home patients. Although fibre has a known role in the treatment of constipation, laxatives are still widely used in nursing home patients. Objective: To determine whether the addition of a fibre supplement to oral diet can reduce the use of laxatives in a long‐term care facility. Participants and methods: Oral diet of 92 nursing home residents (all older than 65) on chronic laxatives (docusate, milk of magnesia with Cascara, psyllium) was supplemented with ‘Fiber 7’, a natural powder fibre (7 g per meal twice a day). During the next 2.5 years discontinuation of laxatives was attempted. Results: Laxatives were successfully discontinued in 63 of the 92 patients (68.5%, 95% confidence interval 59–78%). The fibre supplement was well tolerated. The cost of care was decreased by $3.5 per patient every month or by $220/month for the 63 patients. Conclusions: Use of ‘Fiber 7’ allowed discontinuation of laxatives in 63 of 92 nursing home residents. The fibre supplement was a safe and convenient alternative to laxatives and decreased the cost of medical care.     

The TAPS project. 17: Readmission to hospital for long term psychiatric patients after discharge to the community.

OBJECTIVE--To identify risk factors which increase the likelihood of readmission for long stay psychiatric patients after discharge from hospital. DESIGN--Follow up for five years of all long stay patients discharged from two large psychiatric hospitals to compare patients readmitted and not readmitted. SETTING--Friern and Claybury Hospitals in north London and their surrounding catchment areas. Most patients were discharged to staffed or unstaffed group homes. SUBJECTS--357 psychiatric patients who had been in hospital for over one year, of whom 118 were "new" long stay and 239 "old" long stay patients. MAIN OUTCOME MEASURES--Readmission to hospital and length of subsequent stay. RESULTS--Of all discharged patients 97 (27%) were readmitted at some time during the follow up period, 57 (16%) in the first year after discharge, and 31 (9%) then remained in hospital for over a year. The best explanatory factors for readmission were: male sex, younger age group, high number of previous admissions, higher levels of symptomatic and social behavioural disturbance, a diagnosis of manic-depressive psychosis, and living in a non-staffed group home. CONCLUSIONS--During the closure of psychiatric hospitals, facilities need to be preserved for acute relapses among long term, and especially younger, discharged patients. Staffed group homes may help prevent relapse and reduce the number of admission beds required.     

Evolución clínica y funcional de los pacientes que ingresan en residencias tras una fractura de cadera. Implementación de un programa de intervención multinivel

Background and objectiveThe aim of this study was to determine the clinical and functional outcomes of patients discharged to nursing homes after a hip fracture.MethodsThe study included all patients admitted to a group of nursing homes after a hip fracture in 2016. A geriatric assessment protocol was applied, and patients were treated with a specific protocol for 90 days. They were assessed for nutritional status (Mini-Nutritional Assessment and Body Mass Index), pain (Visual Analogue Scale, and the PAINAD Scale), the presence of pressure ulcers, blood test (D vitamin, haemoglobin, proteins), and functional status (Barthel index and Functional Assessment Categories).ResultsOut of a total of 175 patients, 116 (75%) met the inclusion criteria. The mean age was 84.9 years old (±6.7 SD), and 91 (78.4%) were women. At admission, 73.8% of 65 residents had anaemia, 76.7% hypovitaminosis D, 88% malnutrition or «at risk of malnutrition», and 15.3% had pressure ulcers. After 90 days, the moderate-severe functional status (Barthel index < 60) was reduced from 90.4 to 39.6%, dependence due to gait from 97.3 to 36.1%, and moderate-severe pain from 88.9 to 14.4%. Most of the pressure ulcers healed (94.4%).ConclusionsPatients admitted to nursing homes after a hip fracture had poor clinical and functional status. This study shows that after 90 days from admission these patients had positive outcomes in terms of functionality, gait, pain control, and pressure ulcers healing.     

"Homeward bound": a minimal care rehabilitation unit.

A 20 bed minimal care rehabilitation unit was set up by Newham District Health Authority in a small hospital originally scheduled for closure when a new district general hospital was opened. During the first year 114 patients were admitted (throughput 5.7), with a median length of stay of 30 days; in the second year 173 patients were admitted (throughput 8.65) with a median length of stay of 28.5 days. The cost per inpatient day was less than that of an inpatient day at the district''s long stay geriatric unit. Before the unit opened 24% of the acute beds had been occupied for more than six weeks, whereas two years later only 6% of the acute beds were occupied for such a period.     

NHS waiting list have been a boon for private medicine in the UK.

Health care: public, private or both? In Great Britain, about 13% of the population is covered by private health insurance, and everyone else is served by the public health care system known as the National Health Service, or NHS. Caroline Richmond, who examined the impact of private medical practice in Britain, says people become private patients for one compelling reason: to avoid the NHS''s notoriously long waiting lists for surgery. According to Professor Alan Maynard, a health care researcher, the mainstays of the private sector are the "three h''s" --hips, hernias and hemorrhoids-- along with some elective surgery, particularly in gynecology and opthalmology. Another small sector focuses on fertility regulation and cosmetic surgery. Although the levels are not monitored closely, physician consultants are not permitted to earn more than 10% of their income from private practice.     

Betrouwbaarheid van de Zorgzwaartepakket (ZZP) scorelijst

The ZZP Questionnaire. Reliability of a new resource utilization measure. Data to determine the resource utilization of care recipients need to be reliable and the items that are measured need to be useful. In 2006, the Dutch Ministry of Health and Welfare has mandated all nursing homes and homes for the elderly to measure the Resource Utilization of all residents with the ZZP Questionnaire. Are the data resulting from this measurement reliable and is each of the 54 items of the ZZP Questionnaire useful? To answer this we tested the reliability of the data in a nursing home and a home for the elderly in two wards each. For 122 residents questionnaires were completed such that the inter- and intra-rater reliability of the answers could be assessed. Ten of the 54 items in the questionnaire showed insufficient inter rater reliability (<0.40) on the weighted Cohen kappa and another sixteen moderate (0.40 – 0.60). On the intra rater reliability test seven items had an insufficient kappa and another fifteen moderate. Besides, ten clusters of items could be formed with in-cluster Spearman correlation rates of .75 or higher. From the results of the reliability tests and the item intercorrelation rates we concluded that a substantial number of items needs to be improved and that in the ZZP Questionnaire 15 of the 54 items appear to be redundant on statistical grounds.Tijdschr Gerontol Geriatr 2007; 38: 166-173     

Oral hygiene of elderly people in long-term care institutions--a cross-sectional study

Objective: The aim of this cross‐sectional study was to assess the level of oral hygiene in elderly people living in long‐term care institutions and to investigate the relationship between institutional and individual characteristics, and the observed oral cleanliness. Materials and methods: Clinical outcome variables, denture plaque and dental plaque were gathered from 359 older people (14%) living in 19 nursing homes. Additional data were collected by a questionnaire filled out by all health care workers employed in the nursing homes. Results: Only 128 (36%) residents had teeth present in one or both dental arches. About half of the residents (47%) wore complete dentures. The mean dental plaque score was 2.17 (maximum possible score = 3) and the mean denture plaque score was 2.13 (maximum possible score = 4). Significantly more plaque was observed on the mucosal surface of the denture with a mean plaque score of 2.33 vs. 1.93 on the buccal surface (p < 0.001). In the multiple analyses only the degree of dependency on an individual level was found to be significantly correlated with the outcome dental plaque (odds ratio: 3.09) and only the management of the institution with denture plaque (odds ratio: 0.43). Conclusion: Oral hygiene was poor, both for dentures and remaining teeth in residents in long‐term care institutions and only the degree of dependency of the residents and the management of the institutions was associated with the presence of dental plaque and denture plaque respectively.     

An Approach to Patient Care Classification

Employing the principles of progressive patient care and using data obtained from charts, nurses and resident physicians, 265 patients on the wards of a teaching hospital were classified into one of six optimal levels of care by the resident physicians and also by an outside observer. It was assumed that facilities for the three alternatives to general hospital care, i.e. long-term hospital care, nursing care and sheltered care, were available in the community. It was also assumed that socio-economic factors presented no barrier to hospital discharge.The outside observer allocated 96 patients, approximately one-third, to the alternative facilities outside the general hospital. Those factors found to have statistically significant effects on assigned levels of care were the diagnoses, length of stay, region of residence, bed status, extent of nursing care, hospital service and discharge status. The residents allocated 60 patients, approximately one-fifth, to alternative facilities.The extent of agreement between the residents and the outside observer reached 81% for those to alternate versus general hospital care.This method could be used by nurses and residents to screen out those most suitable for care in alternate facilities.     

Availability,affordability and stock-outs of commodities for the treatment of snakebite in Kenya

BackgroundAnnually, about 2.7 million snakebite envenomings occur globally. Alongside antivenom, patients usually require additional care to treat envenoming symptoms and antivenom side effects. Efforts are underway to improve snakebite care, but evidence from the ground to inform this is scarce. This study, therefore, investigated the availability, affordability, and stock-outs of antivenom and commodities for supportive snakebite care in health facilities across Kenya.Methodology/principal findingsThis study used an adaptation of the standardised World Health Organization (WHO)/Health Action International methodology. Data on commodity availability, prices and stock-outs were collected in July-August 2020 from public (n = 85), private (n = 36), and private not-for-profit (n = 12) facilities in Kenya. Stock-outs were measured retrospectively for a twelve-month period, enabling a comparison of a pre-COVID-19 period to stock-outs during COVID-19. Affordability was calculated using the wage of a lowest-paid government worker (LPGW) and the impoverishment approach. Accessibility was assessed combining the WHO availability target (≥80%) and LPGW affordability (<1 day’s wage) measures. Overall availability of snakebite commodities was low (43.0%). Antivenom was available at 44.7% of public- and 19.4% of private facilities. Stock-outs of any snakebite commodity were common in the public- (18.6%) and private (11.7%) sectors, and had worsened during COVID-19 (10.6% versus 17.0% public sector, 8.4% versus 11.7% private sector). Affordability was not an issue in the public sector, while in the private sector the median cost of one vial of antivenom was 14.4 days’ wage for an LPGW. Five commodities in the public sector and two in the private sector were deemed accessible.ConclusionsAccess to snakebite care is problematic in Kenya and seemed to have worsened during COVID-19. To improve access, efforts should focus on ensuring availability at both lower- and higher-level facilities, and improving the supply chain to reduce stock-outs. Including antivenom into Universal Health Coverage benefits packages would further facilitate accessibility.