The United States Department of Health and Human Services (1990), reported that by the year 2000 the number of elderly people over the age of 65 will constitute 13% of the general population, with the most rapid population increase being that of the "old old" or those over the age of 85. Baum (1991) stated that within the elderly population 5% are institutionalized, of these, 2.1% are under 75 years of age, 7.1% are between the ages of 75 and 84, and 19.3% are 85 and over. Based upon these reported demographics, it can be predicted that the number of those requiring institutionalization will continue to grow, and that the health care needs of this segment of the population will be of major concern in the near future.
Dementia is the leading cause of admission to nursing homes. Gray, Parish, and Dorevitch (1992) reported that 64% of nursing home applicants in their study were being admitted due to dementia. Zarian, Peter, Lee and Kleinfeld (1989) found that the most frequent reason for hospital admissions among nursing home residents with dementia was due to infection (62.5%), with pneumonia accounting for 60% of the diagnoses. To complicate the problem, the clinical presentation of infection is often atypical in the elderly population whether or not dementia is present. Oftentimes older individuals will present with behavioral changes such as confusion, rather than displaying the typical signs and symptoms of infection, cough and fever (Fox, 1988). In addition, eiders requiring long-term care placement are more likely to have some form of dementia and are at increased risk for developing infection. In the absence of a complete baseline assessment upon admission, with special attention given to cognitive status, the clinical picture of occult infection becomes blurred and a treatable condition may then progress to the point of requiring acute intervention.
Goldman and Lazarus (1988) stated that about 85% of patients exhibiting confused behavior have irreversible dementia, while the remaining 15% will have an underlying treatable condition. One of the most common underlying causes for symptoms of confusion is infection. Infection is a frequent complication found in nursing home residents, but the incidence of infection is greater for demented residents (Darnowski, Gordon, & Simor, 1991). In general, infectious processes can be more injurious to older adults and lead to more serious outcomes or even death. According to the U.S. DHHS (1990), the fifth leading cause for death in the elderly population (those over age 65) is infectious diseases, specifically pneumonia and influenza. One possible explanation for this is the decline in activity in the immune system as one ages. Lehtonen, Eskola, Vainio, and Lehtonen (1990) compared immune system activity between young adults and older adults. The results showed that the total number of Tlymphocytes was 20% lower in the elders as compared with the younger controls. Additionally, the decrease in numbers of B-cell was statistically significant with the elders possessing approximately one-half the number found in the young adults.
The purpose of this study was to compare the health outcomes of persons residing in a retirement home in which baseline health histories, physical examinations, and basic mental status tests were not performed within the first 3 months of admission (Group A), with those who received a complete assessment within the first 3 months (Group B).
Research questions addressed in this study reflected the information found in the literature and the clinical experience of the investigator. They focused on comparisons between Group A and Group B, specifically whether or not screening upon admission: 1) makes a difference in being able to reduce the incidence of recurrent acute outpatient visits, or 2) if it contributes to earlier assessment and management of problems once they present; therefore, preventing negative sequelae. Comparisons were made between the two groups based on the following: the number of baseline diagnoses for every resident; number of times residents were seen and treated as outpatients (within 6 months after admission to the retirement home); number of outpatient visits to the health care center that were preventive versus acute; level of acuity of each outpatient visit; number of acute infirmary admissions (within 6 months after admission to the retirement home); the precipitating reasons and /or diagnoses for acute infirmary admissions; number of times an infectious process was cited as the reason or part of the reason for an infirmary admission of a resident; and number of infirmary admissions that were due to confusion or dementia-related behaviors.
The design of this study was a retrospective, longitudinal chart survey of the intake procedures for admissions to a retirement home done before and after January 1992.
The setting for the study was a private retirement home in a large metropolitan city in the state of Washington. The retirement home consisted of 90 independent living apartments and an infirmary which was designed to treat outpatients. A 90-bed inpatient skilled nursing facility was attached to the infirmary for treating patients who required hospitalization. Admission procedures at the facility differed before and after January 1992. Prior to January 1992 the intake procedure was inconsistent, while all of the new admissions received complete histories and physicals within 3 months, only some of the patients were assessed for cognitive status using standardized mental exam screening tools. Of those who were tested on mental status functioning, only one was screened within the same year of admission to the retirement center. In addition, in many cases the full battery of mental tests was not utilized with only some of the available tools being included in the intake screening. After January 1992 all admissions to the retirement center were standardized, using the following protocol: Within three months of admission a complete history and physical was performed and the following mental status screening tools were utilized:
Trail Making Test: an array of numbered circles, which requires that a line be drawn from one circle to the next in a sequential fashion. This test is highly sensitive for diagnosing brain damage, particularly areas of the brain which allows one to interpret visual data, such as what is required when driving, especially in unfamiliar territory and heavy traffic (Jarvis & Barth, 1984).
Clock-Drawing Test requires that one simply draw the face of a clock, a task which tests temporoparietal function - a reflection of spatial orientation. Spatial orientation appears to be affected in Alzheimer's disease (WolfKlein, Silverstone, Levy, & Brod, 1989).
Fromaje Test: an acronym which stands for and also tests for function, reasoning, orientation, memory, arithmetic, judgment, and emotional status (Eisdorfer & Friedel, 1977).
Set Test: one must verbally list 5 to 10 cities, animals, fruits, and colors up to ten in each category, with a point awarded for each item. This easily used test identifies the presence and level of senile dementia (Kane & Kane, 1985).
Mini-Mental State Exam: a questionnaire containing eleven questions which in part one grossly assesses orientation, attention, and memory. The second part tests one's ability to name objects, follow written and verbal commands, and lastly the ability to write legibly (Holstein, Folstein, & McHugh, 1975).
The intake protocol was modified to include an admission to the health care center or infirmary for a period of observation for at least 24 to 48 hours, the focus being on the mental, emotional, and physical status of the individual contingent upon the admission baseline data.
Degree of Urgency of Visits to ffce Health Care Center
The environmental setting chosen for this study was a limiting factor. This was a retirement home with elders residing independently as opposed to a long-term care facility. It can then be assumed that those elders included in this study were healthier than typical nursing home patients, thus influencing the data so that it would not mirror previous research conducted in nursing homes.
Two lists of charts were compiled by the nurse practitioner who worked at the retirement home. One list contained the names of all 68 patients admitted to the retirement home prior to January 1992 (Group A), and the other list contained the names of all 21 patients admitted after January 1992 (Group B). The names of potential participants were randomly selected by counting every fifth chart in group A (n=15) and by counting every other chart in group B (n=15).
It was not necessary to obtain special permission for this study as the residents had previously signed a form, upon admission, stating that a chart review may be necessary for studies conducted in the future. All of the residents had signed forms on the front of the charts. This project was conducted as part of quality assurance and was eventually utilized to change the current admission procedure protocol.
DATA COLLECTION METHOD
A screening questionnaire was designed and implemented during the chart review to record whether or not a resident was given a complete history and physical exam within the policy guidelines established by the institution. How the resident was screened was also noted. For instance, whether or not a complete intake analysis was performed or if only parts of the available screening tools were utilized, was noted. The data collection instrument included information on the presence of confusion or infection as precipitating reasons for acute infirmary admissions.
Data analysis consisted of frequencies, percentages, and a t-test for independent samples. Findings are presented for each of the categories previously mentioned.
Baseline Diagnoses of Residents
The baseline diagnoses were numerous and varied per resident. The total number of diagnoses for residents not screened (group A) was 103 or an average of 6.87 diagnoses per resident. For those residents who were screened upon admission to the retirement home (group B) there were 92 baseline diagnoses, an average of 6.13 diagnoses per resident.
Number of Outpatient Health Care Center Visits Within 6 Months After Admission to the Retirement Home
In group A there were 264 outpatient visits to the health care center In group B there were 274 such visits.
Number of Outpatient Visits Which Were Preventive Health Care Versus Acute Intervention
In group A there were 44 outpatient preventive visits and 220 acute visits. In group B there were 137 preventive visits and 137 acute visits. The difference in preventive visits between the groups using a t-test for independent samples was significant (p<01).
Level of Acuity of Each Acute Outpatient Visit to the Health Care Center
Each visit to the health care center was scrutinized for degree of urgency. Visits were categorized as mild, urgent, or serious. Mild visits were those in which the presenting complaint would not have required immediate attention and could have waited beyond 24 hours before treatment. Urgent visits were those in which the presenting complaint required treatment within 24 hours or if left untreated would have more than likely progressed to an acute condition. Serious visits were conditions which required immediate attention on the part of the nurse practitioner in order to prevent serious complications (Table).
Number of Acute Infirmary Admissions Between the Two Groups Within 6 Months of Admission to the Retirement Home
There were 18 infirmary admission or 64% of the total admission in group A. In group B there were 10 admissions or 36% of the total.
Reasons for Admissions to the Infirmary
The most frequent admission diagnosis for those residents not screened (group A) was infection (23%) followed by cognitive changes (17%). Residents who were screened within 3 months following admission to the retirement home (group B) presented most often with infection (25%) as well, but the next most frequent diagnoses were pain (17%), gastrointestinal difficulties (17%), dizziness (17%), and fatigue (17%). (Cognitive changes only accounted for 8% of the infirmary admissions.)
Infirmary Admissions Due to Infectious Processes
In group A infectious processes were cited 7 times or 23% of the 30 total diagnoses or symptoms precipitating admissions. In group B infectious processes accounted for 3 or 25% of the total 12 admitting diagnoses.
Cognitive Changes Admissions to the Infirmary
In group A there were 4 admissions due to confusion or dementiarelated behaviors. An additional admission was due to a reported loss of consciousness, so it was categorized as a cognitive change. Therefore, there were a total of 5 (17% of the 30 total diagnoses) symptoms diagnosed as cognitive changes which required infirmary admissions. In group B one resident (8% of the 12 total diagnoses) was admitted due to slurred speech and mentation changes.
Despite the increasing emphasis on preventive health care in general, extensive intake screening histories and physicals are not routinely performed in all long-term care institutions. The rationale for practicing preventive nursing care is that it may reduce the number of acute problems. Comprehensive baseline assessments assist in identifying problems most frequently seen in long-term care and appropriate measures can be taken before serious problems arise. However, when baseline histories and physicals are not routinely performed upon nursing home placement, the clinical picture becomes blurred and distinguishing between baseline functioning from underlying pathology becomes difficult, if not impossible.
The non-screened group, or group A, had 93(24%) fewer preventive visits, 83(62%) more acute outpatient visits, and 8(64%) more infirmary admissions than group B. In addition, group A had 55% more mild visits, 70% more urgent visits, and 90% more serious visits out of the total acute outpatient visits to the health care center. Based on these data it can be concluded that regardless of baseline diagnoses, performing a thorough intake history and physical exam and conducting regular prevention visits may lead to fewer acute visits, less complicated or serious acute visits, and fewer infirmary admissions.
In group A, infectious processes was the most frequently cited reason for infirmary admissions (23%). The second highest reason for infirmary admissions was cognitive changes (17%). Likewise in group B infectious processes comprised the majority of the admission diagnoses (25%). However, in this group cognitive changes accounted for only 8% of the admissions - the lowest cited causal factor. For both groups as a whole, infectious processes were the most frequent diagnoses precipitating infirmary admissions (24%). Cognitive changes (14%), along with pain (14%) and gastrointestinal disturbances (14%), were cited as the second most frequent admission diagnoses. Aside from the gastrointestinal disturbances and pain, the above mentioned percentages parallel those findings in the literature. That is, infectious processes and cognitive changes are common problems found in institutionalized elders.
In group A, the residents who were admitted for cognitive changes were also responsible for 57% of the infectious processes admissions. In group B, the resident who was admitted for cognitive changes was also responsible for 1 out of the 3 infectious processes admissions or 33% of the total. These data support the literature in that the residents who were cognitively deficient were also admitted for a substantial amount of infections, thus accounting for the majority of such admissions in group A and one-third of the admissions in group B. Furthermore, in group A the number of confused residents requiring infirmary admission was one-half the total number of residents being admitted, yet these 3 residents were responsible for close to 60% of the infectious processes admissions. Similarly, there was only one confused resident requiring infirmary admission from group B and this lone resident was responsible for 33% of the infectious processes admissions. Thus, there appears to be a link between confusion and likelihood for developing an infectious process.
The significance of this study for nursing practice in long-term care, including retirement homes, is that it emphasizes the importance of intake health histories and physical exams and of conducting preventive health care visits. This practice may diminish the number of acute outpatient visits, ameliorate the acuity of each of these visits, and prevent hospital admissions. Recognizing that infectious diseases and cognitive changes are prevalent in these facilities alerts the practitioner to the increased likelihood that residents will be presenting with such problems. Furthermore, with solid baseline information available the practitioner will be better equipped to recognize subtle clinical changes which would then signal possible underlying acute processes.
- Baum, C.M. (1991). Addressing the needs of the cognitively impaired elderly from a family policy perspective. The American journal of Occupational Therapy, 45(7), 594-606.
- Darnowski, S.B., Gordon, M., & Simor, A. (1991). Two years of infection surveillance in a geriatric long-term care facility. American Journal of Infection Control, 19(4), 185-190.
- Eisdorfer, C., & Friede!, R.O. (eds.). (1977). Cognitive and emotional distttrbance in the elderly, pp. 78-79.
- Folstein, M.F., Folstein, S.E., & McHugh, RR. (1975). Mini-Mental State. A practical method for grading the cognitive state of patients for the clinician, iournal of Psychiatric Research, 12, 189-198.
- Fox, R.A. (1988). Atypical presentation of geriatric infections. Geriatrics, 43(5), 58-68.
- Goldman, L.S., & Lazarus, L.W. (1988). Assessment and management of dementia in the nursing home. Clinics in Geriatric Medicine, 4(3), 589-601.
- Gray, L.C., Parish, S.J., & Dorevitch, M. (1992). A population-based study of assessed applicants to long-term nursing home care. Journal of the American Geriatrics Society, 40(6), 596-600.
- Jarvis, P.E., & Earth, J.T. (1984). HalsteadReitan Test Battery: An interpretive guide.
- Lehtonen, L-, Eskola, J-, Vaiino, O., & Lehtonen, A. (1990). Changes in lymphocyte subsets and immune competence in very advanced age. Journal of Gerontology, 45(3), 108-112.
- United States Department of Health and Human Services. (1990). Healthy People 2000: National health promotion and disease objectives. Washington D.C.: U.S. Government Printing Office.
- Wolf-Klein, G.P., Silverstone, F.A., Levy, A.P., & Brod, M.S. (1989). 'Screening for Alzheimer's disease by clock drawing. Journal of the American Geriatrics Society, 37, 730-734.
- Zarian, D.A., Peter, S.A., Lee, S., & Kleinfeld, M. (1989). The causes and frequency of acute hospitalization of patients with dementia in a long-term care facility. Journal of the National Medical Association, Sï(4), 373-377.
Degree of Urgency of Visits to ffce Health Care Center