Journal of Gerontological Nursing

Functional and Mental Status Outcomes: of Clients Discharged from Acute Gerontological Versus Medical/Surgical Units

Margie Huber, RNC, MSN; Anita Kennard, RNCS, MSN

Abstract

The challenge to conduct research that could enhance the nursing care provided to older adults in the acute care setting is especially crucial. In 1981, 48.9 million people reached the age of 55 years or older. This constituted more than one fifth of the American population. The United States Bureau of Census expects the 55 and over age group to increase at a rate of 1 13% between 1982 and 2050.1 In addition, the mean number of chronic illnesses for those 65 to 69 years old was four, and it is projected to increase to five for those 75 and older.2

These statistics certainly have a direct impact on health-care delivery. Not only is the demographic make-up of society changing, but the effects of age and disease also have a significant impact on the functional reserve of all organ systems.3 Chronological age is not a reliable predictor of performance in individual adults.4 The use of additional functional assessment tools is critical to the care of the elderly in an acute care setting because individual functional status can be broad in this sector of the population. To maintain or increase the client's functional outcome, identification of abilities and limitations must be performed early and appropriate interventions initiated. This in turn can affect the financial constraints of the health-care delivery system, which has been forced to assess the efficiency as well as the effectiveness of its services. By providing early and appropriate interventions directed at maintaining or increasing the clients' functional and mental status, the clients' length of stay can be minimized and costs contained.

Brody et al reported how attempts were made to increase the functional level and to prevent institutionalization of the elderly on a geriatric unit.5 Applegate et al described the functional status on admission, discharge, and 6 months after discharge of 100 elderly persons treated at a community hospital assessment and rehabilitation unit.6 The findings suggest that care through the geriatric unit resulted in improved function and decreased nursing home placement. The authors recommend future studies with comparison groups.

Very few studies report the use of control groups. Boyer et al included a control group in an acute care geriatric unit in their study.7 The findings reflected a significant improvement in the acute care geriatric unit clients' functional scores at the .05 level. However changes in psychobehavior and sensory scores were not significant at the .05 level.

The purpose of this study was to determine if the Acute Gerontology Unit (AGUX with a specialized approach to care, affected the functional and mental status outcomes as compared with a general medical/surgical (M/S) unit where the approach to care is not specialized. Specifically, the following research questions were addressed: What is the functional status of clients discharged from AGU in comparison with an M/S unit? What is the mental status of the clients discharged from AGU in comparison with an M/S unit?

BACKGROUND

The Deaconess Hospital, Cincinnati, is a 250-bed, nonprofit, general medical/surgical hospital with a strong elderly patient base. In November 1988, the year-to-date percentage of admissions reimbursed by Medicare was 60%, compared with 40% for other area community hospitals.

To prepare for the unique needs of the elderly hospitalized client, a 23-bed AGU was opened in September 1984. In January 1988, the capacity was adjusted to 3 1 beds. The focus of the unit is not to only meet acute care needs, but also to evaluate and care for chronic illnesses and losses that occur as a result of aging. The goal is to have each client achieve an optimal level of functioning. A multidisciplinary approach addresses the…

The challenge to conduct research that could enhance the nursing care provided to older adults in the acute care setting is especially crucial. In 1981, 48.9 million people reached the age of 55 years or older. This constituted more than one fifth of the American population. The United States Bureau of Census expects the 55 and over age group to increase at a rate of 1 13% between 1982 and 2050.1 In addition, the mean number of chronic illnesses for those 65 to 69 years old was four, and it is projected to increase to five for those 75 and older.2

These statistics certainly have a direct impact on health-care delivery. Not only is the demographic make-up of society changing, but the effects of age and disease also have a significant impact on the functional reserve of all organ systems.3 Chronological age is not a reliable predictor of performance in individual adults.4 The use of additional functional assessment tools is critical to the care of the elderly in an acute care setting because individual functional status can be broad in this sector of the population. To maintain or increase the client's functional outcome, identification of abilities and limitations must be performed early and appropriate interventions initiated. This in turn can affect the financial constraints of the health-care delivery system, which has been forced to assess the efficiency as well as the effectiveness of its services. By providing early and appropriate interventions directed at maintaining or increasing the clients' functional and mental status, the clients' length of stay can be minimized and costs contained.

Brody et al reported how attempts were made to increase the functional level and to prevent institutionalization of the elderly on a geriatric unit.5 Applegate et al described the functional status on admission, discharge, and 6 months after discharge of 100 elderly persons treated at a community hospital assessment and rehabilitation unit.6 The findings suggest that care through the geriatric unit resulted in improved function and decreased nursing home placement. The authors recommend future studies with comparison groups.

Very few studies report the use of control groups. Boyer et al included a control group in an acute care geriatric unit in their study.7 The findings reflected a significant improvement in the acute care geriatric unit clients' functional scores at the .05 level. However changes in psychobehavior and sensory scores were not significant at the .05 level.

The purpose of this study was to determine if the Acute Gerontology Unit (AGUX with a specialized approach to care, affected the functional and mental status outcomes as compared with a general medical/surgical (M/S) unit where the approach to care is not specialized. Specifically, the following research questions were addressed: What is the functional status of clients discharged from AGU in comparison with an M/S unit? What is the mental status of the clients discharged from AGU in comparison with an M/S unit?

BACKGROUND

The Deaconess Hospital, Cincinnati, is a 250-bed, nonprofit, general medical/surgical hospital with a strong elderly patient base. In November 1988, the year-to-date percentage of admissions reimbursed by Medicare was 60%, compared with 40% for other area community hospitals.

To prepare for the unique needs of the elderly hospitalized client, a 23-bed AGU was opened in September 1984. In January 1988, the capacity was adjusted to 3 1 beds. The focus of the unit is not to only meet acute care needs, but also to evaluate and care for chronic illnesses and losses that occur as a result of aging. The goal is to have each client achieve an optimal level of functioning. A multidisciplinary approach addresses the physical and psychosocial needs of the elderly client. Multidisciplinary conferences are held weekly to discuss the client's progress and to plan for discharge. Early initiation of available resources is the rule. The family or significant others are recognized as important participants and are included in the client's care plan. Environmental elements are in place to prevent sensory deprivation; ie, calendars and clocks are located in each room. Handrails have been installed in the corridors as safety measures. Norman Rockwell prints line the hallways to create a home-like atmosphere and remind clients of pleasant memories. Charting racks are placed outside each room to promote nurse/ client interaction.

Nurses are interviewed and specially selected to staff the AGU. Demonstration of a genuine concern for older adults' well-being is expected. The nurses attend monthly gerontological inservice programs provided by the gerontology nurse specialist. As demonstrated in a previous study, the AGU nurses' gerontological knowledge base is higher than nurse scores from general M/S units on a gerontological knowledge test. AGU staffing patterns are based on acuity and desired intervention with clients, and are slightly higher than those on a general M/S unit. A modified form of primary nursing is practiced.

The AGU admission criteria is as follows:

* Clients with a deficit of one of the five basic senses.

* Clients with functional deficits that are reversible.

* Clients who are prone toward complications of immobility with rehabilitative potential.

Table

TABLE 1SAMPLE COMPARISONS FORAGE AND ACUITY

TABLE 1

SAMPLE COMPARISONS FORAGE AND ACUITY

* Clients with physical or mental deficits who would benefit from preferential admission and scheduling.

* Clients who would benefit from a multidisciplinary approach to care.

* Clients with dysfunctions in the areas of mobility, activities of daily living, and bowel/bladder function that are reversible.

A client who does not meet the above criteria may be considered for admission if the family is providing the care in the home and could benefit from multidisciplinary education.

METHOD

Sample

The control unit selected for the study was a M/S unit that admits clients with similar diagnoses as the experimental unit (AGU). The client's admission diagnosis had to meet the criteria for both units. During data collection, supervision of both units was under the same person, the director of medical/surgical units. The same social service RN/discharge planner served both units. Staffing patterns were similar but slightly higher on AGU.

The subjects from the control and experimental units consisted of a convenience sample of clients 55 years of age or older with similar admission diagnoses. The sample size was 79 clients, composed of 48 subjects from the experimental unit and 3 1 subjects frcm the control unit. Table 1 reflects the mean age and acuity of the subjects.

Procedure

Functional and mental status assessments were completed by the gerontology clinical nurse specialist within 24 hours of admission and again at the time of discharge. Prior to the assessments, an informed consent was obtained from the attending physician and client or family member. Subjects were advised that they could discontinue participation in the study at any time. All data were obtained through direct observation, interview, or review of record by the same gerontology clinical nurse specialist. Subjects with functional status scores of 15 (reflecting total dependency) and those with mental status scores of 21 or less were deleted.

Assessment Tools

There are many functional assessment tools available. The CADET functional assessment tool was selected for its ability to provide quantifiable and descriptive data. The tool could also be administered easily and in relatively short time. A long-range goal on the unit was to eventually include a functional assessment tool as part of the admission packet. The CADET was chosen to satisfy these needs and to provide a means of identifying abilities, capabilities, and changes in functional status.

CADET was developed as an unpublished functional ability instrument for physical and occupational therapists. Rameizl significantly modified the tool and incorporated it in the geriatric assessment process.8 CADET, an acronym, identifies five functions: communication, ambulation, daily living activities, elimination, and transfer. Each function is subscored: 1 = independent in self-care with or without assistive devices; 2 = needs some hands-on help, physical assistance, or verbal cuing; 3 = dependent, needs total assistance. Total score range for the CADET is 5 to 15. The total quantitative scores can be qualified as follows: 5-6 = no essential dependence; 7-8 = mild dependence; 9-10 = moderate dependency; 11 and over = severe dependency.

Table

TABLE 2PERCENT OF SAMPLE BY FUNCTIONAL STATUS SCORES AT DISCHARGE

TABLE 2

PERCENT OF SAMPLE BY FUNCTIONAL STATUS SCORES AT DISCHARGE

The CADET was used in a larger geriatric institution to measure selfcare function. The tool has been demonstrated to have a high internal consistency, inter-rater reliability, and construct validity.

The internal consistency and interrater reliability co-efficient of CADET are exceptionally high: 0.984 and 0.936, respectfully. All items contribute strongly to total instrument and in the following rank order: transfer, daily activities, elimination, communication, and ambulation.9

Mental status is an important aspect of assessing functional capacity. The Folstein Mini Mental Status Examination (MMSE) was selected to assess the clients1 cognitive level. Kane and Kane described how the examination addresses orientation memory, attention, and ability to name and to follow verbal and written commands.10 An administration time of 5 to 10 minutes met the requirement for a comprehensive mental status exam, yet was not time consuming. The score maximum is 30 points: scores of 2 1 or less are usually obtained in clients with dementia, schizophrenia, delirium, or affective disorders. Test/ retest reliability is better than 0.8 in 24-hour intervals with different examiners; test/retest in 28 days for clinically stable clients was 0.98.

The CADET was pilot tested with 25 clients and found acceptable. No alterations were made to the tool. Data from the pilot study were not included in the findings. The Folstein MMSE was not tested because it was already being used for cognitive screening at the Deaconess Hospital.

RESULTS

Sample comparisons for age and acuity are shown in Table 1. The mean age for the clients from the experimental unit was 74.31 and 74.00 for the control unit The mean acuity for the experimental unit was 7.12 and 6.03 for the control unit. These data reflected a significant difference in the acuity level (P = .001). The overall mean length of stay for clients on the AGU was 10.9 days, compared with 12.2 days for clients on the control unit. Although not statistically significant, overall hospitalization was decreased by 1.3 days. The overall mean costs for clients on the AGU were less than for clients on die control unit. The difference, however, in overall mean costs was not found to be statistically significant.

The research question posed in this study was whether clients in the experimental group would show significantly more improvement in their CADET and Folstein scores than those in the control group. Because data for both of these measures were collected at admission and discharge, repeat measures of analysis of variance were used to examine differences between the experimental and control groups. These analyses determined that the effect of participation in the experimental group versus the control group was not statistically significant for either the CADET or Folstein scores.

In addition to examining whether the change in these CADET and Folstein scores varied for the two units, patients were categorized into those whose scores improved, declined, or remained the same on these measures. Subjects were divided into high and low acuity groups, and percentages applied to those whose functions improved, declined, or remained the same. The range for the low and high acuity groups for the experimental unit was 4.30 to 6.61 and 6.78 to 11.59, respectively. The control unit's ranges were 3.69 to 6.66 and 6.71 to 9.30, respectively. The results of these analyses for the CADET scores are reflected in Table 2; Folstein scores are provided in Table 3.

The figures in Table 2 indicate that for those with lower acuity, the difference in outcomes of client functions was not statistically significant. For higher acuity patients, however, the difference between the AGU and the control unit was statistically significant, with a higher percentage of those in the control group experiencing a decline. Despite a small number of cases, these results indicate that a significantly higher percentage of patients on the AGU either remained the same or realized improvement in functioning as measured by CADET scores. This suggests that the level of treatment provided on this unit may be particularly useful for higher acuity patients. The figures in Table 3 reveal no significant difference in improved mental functioning for either high or low acuity patients.

DISCUSSION

The data indicate that the average age of the clients on each unit was virtually identical. However, as noted earlier, acuity or degree of illness is more essential than chronological age within the elderly population. The experimental subjects* mean acuity of 7.12 displays a significant difference (P = .001) in comparison with the control unit's mean of 6.03. Basic care hours were the same for both units. However, time frames were added for items unique to the care on the AGU. This may account for some of the differences exhibited in acuity level. Despite the higher acuity, the average length of stay on the AGU was 1.3 days less than on the control unit. In a similar vein, the overall mean costs for the AGU were found to be less than for the control unit, although not at a statistically significant level. The significance of this information is that a specialized service was provided at no greater cost.

The CADET proved to be useful in measuring functional change. The fact that a significantly greater percentage of AGU higher acuity clients increased in functional level or remained the same is relevant and encouraging, as documentation of outcome is imperative in today's health-care system. Our findings are consistent with others that gerontological units do support increased functional levels.6·7·11 This suggests that the multidisciplinary approach, along with specialized care of the elderly, enhances functional outcome, which may be particularly true for clients with higher acuity levels.

Results also suggest that a specialized unit in an acute care setting can aid in preventing a decline in functional status. According to Warshaw et al, of all settings in which elderly Americans receive health care, the acute care hospital has had the least focus on functional status.12 It is in this setting, however, that the elderly may be at highest risk. The capacity to automatically bounce back to a premorbid level of functioning decreases as one ages, as does the margin for maintaining that balance of optional functions. It is not enough to just assume that functioning will automatically return. The nurse working with the elderly client must assess those functioning strengths and incorporate them into the clients' plan of care. Early attention to what a client can do can serve as a solid base upon which to build. Setting reachable goals of a progressively difficult nature with the client can aid in promoting that sense of accomplishment and positive self-esteem, as well as the will to go on. Maintaining an atmosphere where clients are encouraged and praised for attempts as well as successes promotes a sense of "I can" and "I will."

Table

TABLE 3PERCENT OF SAMPLE BY MENTAL STATUS SCORES AT DISCHARGE

TABLE 3

PERCENT OF SAMPLE BY MENTAL STATUS SCORES AT DISCHARGE

A comprehensive and accurate picture of the client's ability to live and function should include a mental status assessment. Foreman studied reliability and validity of three cognitive screening tools.13 Of the three, the FoIstein Mini Mental Status Examination was found to be appropriate for this study. Although no significant difference in the MMSE scores of the two units was detected, it is important to note that a greater percentage of decline in MMSE scores was evidenced on the control unit versus the experimental unit. The AGU results suggest that perhaps the interventions initiated to promote sensory awareness may aid in preventing a decline in mental status. A result similar to that of Boyer et al also found that the psychobehavior and sensory scores were not significantly different at the .05 level between the control and geriatric units.7 A decline in mental status was not reported in their findings.

CONCLUSION

Functional and mental status assessments play a unique role in monitoring the client's status. These tools are an essential addition to any data system that deals with outcome evaluation. Brown cautions that tools are just that - tools - to aid and facilitate, not substitute for clinical judgment.14 Of course, no scoring method alone can replace clinical judgment, but standardized tools do provide common language for all disciplines and provide a framework on which to not only monitor outcome, but also promote quality of care.

The older adult population is heterogeneous and must not be stereotyped. As a direct result of this study, the CADET has now been included not only on the admission form, but also on the discharge form from the AGU.

This study supports the need for specific units within the acute care setting to meet the needs of the elderly. In a time where nurses are being forced to look at the appropriateness, quality, and cost effectiveness of the care that they are providing, this study supports that nurses should be specially educated to work with the elderly to assess, plan, intervene, and evaluate their needs. They can then make a positive impact on the outcome of an elderly client in an acute hospital setting.

Furthermore, nurses - regardless of setting - are challenged to look at the implications of this study for working with the elderly. Preventing complications is a key, mainly by means of early proactive intervention. This includes keeping the client oriented by calendars and pictures, as well as by engaging the client in reality-based conversation. Encourage clients to be active participants in their own care by doing "with" the client as opposed to doing "for" the client. Starting postoperative measures aimed at maintaining or increasing functional capacity, ie, ambulating, cough, and deep breathing, as soon as possible. Also important is the nurses' responsibility as members of a multidisciplinary team to regularly communicate significant findings to other team members. Early intensive attention to functional and mental status can set the pace for the client's recovery.

This study also supports the value of additional research. Can a specific variable between the AGU and M/S units be identified and measured? Can variables specific to the AGU be enhanced to further affect the functional and mental status of the client? A key concern in today's health-care system is cost; therefore, other areas of inquiry may include, What is the length of stay on an AGU compared with the that for a client with the same Diagnosis Related Group (DRG) on an M/S unit? What is the variance between total costs and DRG reimbursement between the two units? Can costs and length of stay be further contained on specialty units with the elderly? These questions are pertinent and relevant to nursing and health care in general. Future research studies can aid in clarifying these issues.

REFERENCES

  • 1. United States Senate Special Committee on Aging and American Association of Retired Persons. Aging American Trends and Projections. Washington, DC: Special Committee on Aging, United State Senate; 1984.
  • 2. Collins JG. Prevalence of Selected Chronic Conditions. Washington, DC: National Center for Health Statistics; 1986. Series 10, No. 155.
  • 3. Guyton AC. Textbook of Medical Physiology. Philadelphia: WB SaundersCo; 1981.
  • 4. National Institute of Health. Normal Human Aging: The Baltimore Longitudinal Study of Aging. Washington, DC: US Government Printing Office; 1984. National Institute of Health Publication No. NIH 84-2430.
  • 5. Brody S, Balabar DJ, Pickar G, et al. A diagnostic and treatment center for aging. Gerontologist. 1976; 16:47.
  • 6. ApplegateWB, AdkinsD, VandezwaagR, et al. A geriatric rehabilitation and assessment unit in a community hospital. J Am Geriatr Soc. 1983; 31:206-210.
  • 7. Boyer N, Chuang JC, Gipner D. An acute care geriatric unit. Nursing Management. 1986; 17(5):22-25.
  • 8. Rameizl P. A self-care assessment tool. Geriatr Nurs. 1983; 6:377-378.
  • 9. Rameizl PP, Pastorello T. Functional assessment in long-term care: Reliability and validity tests of CADET and FROMAJE. Presented at the 37th Annual Scientific Meeting of the Gerontological Society of America; 1984; San Antonio, Tx.
  • 10. Kane RA, Kane RL. Assessing the Elderly. A Practical Guide to Measurement. Lexington, Ma: Lexington Books; 1985.
  • 11. Rubenstein LZ, Abrass LA, Kane RL. Improved care for patients on a new geriatric evaluation unit. / Am Geriatr Soc. 1981; 29:53!-536.
  • 12. Warshaw GA, Morse JT, Friedman SW, et al. Functional disability in the hospitalized elderly. JAMA. 1982; 248:847.
  • 13. Foreman MD. Reliability and validity of mental status questionnaire in elderly hospitalized patients. Nurs Res. 1987:36:216-220.
  • 14. Brown MD. Functional assessment of the elderly. Journal of Gerontological Nursing. 1988;14(5):13-17.

TABLE 1

SAMPLE COMPARISONS FORAGE AND ACUITY

TABLE 2

PERCENT OF SAMPLE BY FUNCTIONAL STATUS SCORES AT DISCHARGE

TABLE 3

PERCENT OF SAMPLE BY MENTAL STATUS SCORES AT DISCHARGE

10.3928/0098-9134-19910701-07

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