According to the latest census in 2011, 11.9% of the Irish population was 65 or older (Central Statistics Office, 2015). This figure is projected to increase to 22% by 2040, with the number of 85-year-old adults doubling in the next decade (Central Statistics Office, 2015). Approximately 5% of individuals 65 or older reside permanently in long-term care facilities (LTCFs). With the population rising, nursing home care may become increasingly prevalent. In recent years, 1,200 public nursing home beds have been closed for various reasons, ranging from staffing reductions and building relocation to the inability of some homes to comply with Health Information and Quality Authority (HIQA) guidelines. These closures have resulted in many residents being transferred between facilities.
Frail older adults in nursing home care are particularly vulnerable to fluctuations in surroundings or daily routine. Transfer trauma, or relocation stress, has been previously described in multiple studies but few have examined intra-institutional transfer of frail, cognitively impaired residents between LTCFs (Lander, Brazil, & Ladrigan, 1997; McKinney & Melby, 2002; Robertson, Warrington, & Eagles, 1993). In 1992, the North American Nursing Diagnostic Association approved relocation stress as a new nursing diagnosis that encompasses the physical and psychological symptoms experienced by patients during times of relocation. Symptoms include depression, anxiety, agitation, and fluctuations in sleeping and eating habits (Carpenito, 2000).
The current study aim was to describe the cohort of highly dependent LTC residents who relocated between LTCFs in a region of Ireland. The authors sought to determine whether an effect on mortality was associated with relocation in this group and examine whether stress-related morbidity occurred surrounding the time of relocation.
A retrospective analytical study was performed of residents of all publicly funded LTC wards or facilities that closed in the region in 2011. The two LTCFs studied cared for the most highly dependent residents in the region. One LTCF closed completely due to the facility moving to a new building. These residents moved to a new LTCF, but retained the same staff (Group 3). The second LTCF did not close entirely, but experienced closure of some wards due to non-compliance with HIQA guidelines. Among these residents, some changed wards within the same facility (Group 1) and some moved to new facilities (Group 2). All residents residing on wards that were to be closed were required to move. The final location of the move, whether within the same facility or to a new one, was ultimately the choice of residents and their families. Residents of the LTCF that partially closed who did not transfer were used as controls (Group 4).
The case notes of all residents involved were reviewed in detail, and nursing staff caring for residents were interviewed. Data were collected on patient demographics, major illnesses, and length of time in LTC. Patients who had been in LTC for less than 3 months at the time of the relocation were excluded from the study.
The high level of frailty of the study population was defined using pre-existing validated assessment tools of overall disease burden, cognitive impairment, and physical function. The degree of chronic comorbid disease burden was recorded using the Cumulative Illness Rating Scale for Geriatrics (CIRS-G). The tool uses a Likert scale, assigning a 1 to 5 severity rating to disease burden in each organ system, with higher numbers indicating more severe disease. The CIRS-G can be used to gather data retrospectively, has good interrater reliability, and has been shown to predict health status and 18-month mortality in geriatric populations (Salvi et al., 2008). The Clinical Dementia Rating (CDR; O'Bryant et al., 2010) scale was used to quantify residents' degree of cognitive impairment. Semi-structured interviews with nursing staff were conducted to determine residents' level of impairment across six cognitive domains, ranging from memory and judgement to the ability to tend to personal care. The CDR scale has been shown to successfully classify severity of dementia (O'Bryant et al., 2010). The current study results are shown as the sum of all CDR domains. Functional level and mobility were recorded using the modified Barthel Index (Collin, Wade, Davies, & Horne, 1998).
Mortality at 30 and 90 days after relocation was recorded. As a measure of morbidity, including illness and psychological distress, antibiotic medication use in the 30 days before and after transfer and new antidepressant and anxiolytic medication prescriptions after relocation were evaluated. Psychological stress has frequently been associated with immune suppression and susceptibility to illness, particularly in older, physically frail individuals (Segerstrom & Miller, 2004). Therefore, new physical and psychological illness around the time of transfer was believed to be indicative of a stress response in relocated residents.
A total of 76 residents who transferred (mean age = 82.4, SD = 12.4 years, range = 28 to 102 years; 38.2% males) and 62 control residents (mean age = 80.4, SD = 14.1 years, range = 61 to 102 years; 33.9% males) were included. Both groups were highly dependent (i.e., modified Barthel Index score [range = 0 to 20, with a score of 0 indicating full nursing care and dependence in completing all activities of daily living]: control group = 1.7 versus transfer group = 2.6). Average score of the CIRS-G was 25, and the CDR scale ranged from 10 to 13, indicating high overall frailty and significant cognitive impairment in all groups (Table). The most common primary diagnoses in both groups were dementia (31.6%), stroke (19.7%), and decreased mobility (14.5%).
Patient Characteristics (N = 138)
Due to the small number of residents in Groups 1, 2, and 3, the results were analyzed by dividing residents into two groups: those who transferred (i.e., movers) and those who did not transfer (i.e., non-movers). No significant difference was noted in overall mortality rates between groups (18.4% movers versus 17.7% non-movers) (Figure 1). However, a trend toward increased mortality in the first 30 days following relocation was noted, with 10.5% of residents dying within this time period. There was a significantly higher prescription rate of antibiotic medications among the relocated population in the 90 days prior to the move (59.2% versus 27.4%, p = 0.017). Movers also had a greater number of new antidepressant or anxiolytic medication prescriptions than non-movers (19.7% versus 8.1%, p = 0.05) (Figure 2).
Mortality at 30 and 90 days.
Note. LTCF = long-term care facility.
Percentages of antibiotic (AB) and antidepressant (AD) medication prescriptions.
Note. LTCF = long-term care facility.
Although the current study did not demonstrate increased mortality among transferred residents, a significant increase was noted in morbidity before and after transfer. Residents who transferred had increased rates of illness as illustrated by greater antibiotic and antidepressant medication prescription rates in the months before and after transfer, which may be indicative of stress-related illness. These increased rates of illness are in agreement with a prospective study by Hodgson, Freedman, Granger, and Erno (2004) who demonstrated increased stress among residents prior to relocation by measuring morning salivary cortisol levels. Mortality and morbidity may actually increase in the period prior to relocation, especially if residents have been well prepared and are anticipating the move (Thorson & Davis, 2000). However, the topic of relocation stress remains controversial, with some arguing that moving to an improved physical environment may have positive long-term effects on residents' well-being (Mirotznik & Kamp, 2000).
The cohort of residents in the current study represent a frail and vulnerable group. As indicated by their modified Barthel Index and CDR scores, many were highly dependent and cognitively impaired. The study population also had high scores on the CIRS-G, indicating that they experienced multiple comorbidities across many organ systems. There were no significant differences in overall health status between movers and non-movers that might account for differing outcomes. The high 90-day mortality across all groups is a reflection of their frailty and is in agreement with what would be expected in LTC residents in Ireland (McCann, O'Reilly, & Cardwell, 2009).
The numbers of residents were too small to analyze each of the four groups separately, but each subgroup of residents who transferred had unique transfer circumstances and facility effects that may have contributed to their outcomes. Group 1 moved wards within the same facility, but acquired new staff. They resided in 6-bed wards along hospital-like corridors as they had previously, and their environment and daily routine were unaltered. Group 2 moved from an older building with 6-bed wards to various newer LTCFs with single-bed rooms, different daily routines, and unfamiliar staff. This group experienced the most disruption. Group 3 moved from an older building with multi-bed wards to a new LTCF with single rooms. All residents in this group moved together and they retained the same staff, providing ongoing familiarity and continuity of care. Theoretically, maintaining some aspect of continuity throughout the move should reduce the amount of stress residents experience.
Interestingly, the highest rate of antidepressant medication prescriptions was noted in the group of residents who changed facilities but retained the same nursing staff. However, it seems unlikely that this group would have experienced the highest levels of relocation stress. These residents maintained the most continuity of care by retaining the same staff, moving together as a group, and relocating to an improved ward environment. Perhaps the increase in antidepressant medication prescriptions is because staff were more familiar with residents and better able to detect fluctuations in their mood that would be indicative of relocation stress. Maintaining continuity of care, especially in these times of transition, may improve patient outcomes and boost their morale.
Overall, the results indicate that LTC residents experience increased levels of stress resulting in significant morbidity before and after relocation. Changes in environment and familiar routine can adversely affect this frail population. It is important that nursing staff and relatives of LTC residents implement proper planning and vigilance to minimize any distress caused to patients during times of relocation. Nurses should receive training on specific care needs that may arise in times of relocation, such as reorientation protocols, maintaining a familiar schedule, and increased caution with mobility to prevent falls. Quality of care can be improved by avoiding unnecessary transfers, preparing residents for the move, and minimizing stressors and disruption of routine during relocation.
- Carpenito, L.J. (2000). Nursing diagnosis: Application to clinical practice (8th ed.). Philadelphia, PA: Lippincott.
- Central Statistics Office. (2015). Census. Retrieved from http://www.cso.ie/en/census
- Collin, C., Wade, D.T., Davies, S. & Horne, V. (1998). The Barthel ADL index: Reliability study. International Disability Studies, 10, 61–63. doi:10.3109/09638288809164103 [CrossRef]
- Hodgson, N., Freedman, V.A., Granger, D.A. & Erno, A. (2004). Biobehavioral correlates of relocation in the frail elderly: Salivary cortisol, affect, and cognitive function. Journal of the American Geriatrics Society, 52, 1856–1862. doi:10.1111/j.1532-5415.2004.52505.x [CrossRef]
- Lander, S.M., Brazil, A.L. & Ladrigan, P.M. (1997). Intrainstitutional relocation. Effects on residents' behavior and psychosocial functioning. Journal of Gerontological Nursing, 23(4), 35–41. doi:10.3928/0098-9134-19970401-13 [CrossRef]
- McCann, M., O'Reilly, D. & Cardwell, C. (2009). A census-based longitudinal study of variations in survival amongst residents of nursing homes and residential homes in Northern Ireland. Age and Ageing, 38, 711–717. doi:10.1093/ageing/afp173 [CrossRef]
- McKinney, A.A. & Melby, V. (2002). Relocation stress in critical care: A review of the literature. Journal of Clinical Nursing, 11, 149–157. doi:10.1046/j.1365-2702.2002.00577.x [CrossRef]
- Mirotznik, J. & Kamp, L.L. (2000). Cognitive status and relocation stress: A test of the vulnerability hypothesis. The Gerontologist, 40, 531–539. doi:10.1093/geront/40.5.531 [CrossRef]
- O'Bryant, S.E., Lacritz, L.H., Hall, J., Waring, S.C., Chan, W., Khodr, Z.G. & Cullum, C.M. (2010). Validation of the new interpretive guidelines for the clinical dementia rating scale sum of boxes score in the national Alzheimer's coordinating center database. Archives of Neurology, 67, 746–749. doi:10.1001/archneurol.2010.115 [CrossRef]
- Robertson, C., Warrington, J. & Eagles, J.M. (1993). Relocation mortality in dementia: The effects of a new hospital. International Journal of Geriatric Psychiatry, 8, 521–525. doi:10.1002/gps.930080611 [CrossRef]
- Salvi, F., Miller, M.D., Grilli, A., Giorgi, R., Towers, A.L., Morichi, V. & Dessi-Fulgheri, P. (2008). A manual of guidelines to score the modified cumulative illness rating scale and its validation in acute hospitalized elderly patients. Journal of the American Geriatrics Society, 56, 1926–1931. doi:10.1111/j.1532-5415.2008.01935.x [CrossRef]
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- Thorson, J.A. & Davis, R.E. (2000). Relocation of the institutionalized aged. Journal of Clinical Psychology, 56, 131–138. doi:10.1002/(SICI)1097-4679(200001)56:1<131::AID-JCLP12>3.0.CO;2-S [CrossRef]
Patient Characteristics (N = 138)
|Variable||Mean (SD, Range)|
|Group 1 (n = 34)||Group 2 (n = 14)||Group 3 (n = 28)||Group 4 (n = 62)|
|Age (years)||80.5 (14.3) (28 to 98)||82.2 (10.6) (61 to 97)||82.8 (10.7) (53 to 102)||82.4 (10.6) (61 to 103)|
|Time in LTC (months)||86.2 (88.4) (8 to 384)||60.9 (61.8) (10 to 120)||62.3 (62.5) (7 to 324)||63 (65) (8 to 240)|
|CIRS-G score||25.9 (3.7) (21 to 36)||25.5 (3.4) (22 to 33)||25.6 (3.5) (18 to 33)||25.4 (3.3) (18 to 32)|
|Modified Barthel Index score||1.7 (2.6) (0 to 11)||4.4 (4.1) (0 to 11)||2.8 (3.8) (0 to 14)||3.2 (4) (0 to 20)|
|CDR score||13.1 (6.3) (0 to 18)||9.9 (6.4) (0 to 18)||10.1 (6.7) (0 to 18)||11.9 (6.2) (0 to 18)|