Relocation experiences with unplanned admission to a nursing home: a qualitative study

Commentary to Skudlik et al. (2023): why a scoping review and why only Germany?

This letter to the editor is a commentary on the scoping review by Skudlik et al. (2023) on the relocation of older people to nursing homes in Germany. In this commentary, we question certain methodological decisions that, in our view, particularly affect transferability of the results and give a partial picture of the phenomena studied by limiting the inclusion to German studies. We also have questions about the choice of knowledge synthesis method and why the concept of "nursing home" was not defined. We hope that this letter will open a constructive scientific discussion on an important topic that is understudied as the world's population ages.

The perspectives of older people living with dementia regarding a possible move to a nursing home

BACKGROUND/OBJECTIVES

Moving into a nursing home is often an unavoidable life event for older people living with dementia. It is associated with negative emotions and outcomes. Research capturing their perspectives is scarce. This study aims to identify how older people living with dementia perceive a potential life in a nursing home and to understand their (future) care wishes.

MATERIALS AND METHODS

This study is part of the European TRANS-SENIOR research network. The study followed a qualitative phenomenological methodology. Semi-structured interviews with 18 community-dwelling older people living with dementia were conducted between August 2018 and October 2019 (METCZ20180085). A stepwise interpretive phenomenological analysis was performed.

RESULTS

The majority of community-dwelling older people feared the idea of potentially moving to a nursing home. The participants associated a possible move with negative perceptions and emotions. Additionally, this study emphasized the importance of knowledge of current and past experiences with care when identifying the participant's wishes. They wanted to remain (a) individuals, who are (b) autonomous and have (c) social contacts if they would move to a nursing home.

DISCUSSION/IMPLICATIONS

This study showed how past and current care experiences can educate/inform healthcare professionals on the future care wishes of older people living with dementia. The results indicated that listening to the wishes, and life stories of people living with dementia could be a way of identifying 'a suitable time' to suggest a move to a nursing home. This could improve the transitional care process and adjustment to living in a nursing home.

Discharge Disposition and Loss of Independence Among Survivors of COVID-19 Admitted to Intensive Care: Results From the SCCM Discovery Viral Infection and Respiratory Illness Universal Study (VIRUS)

OBJECTIVES

To describe incidence and risk factors of loss of previous independent living through nonhome discharge or discharge home with health assistance in survivors of intensive care unit (ICU) admission for coronavirus disease 2019 (COVID-19).

DESIGN

Multicenter observational study including patients admitted to the ICU from January 2020 till June 30, 2021.

HYPOTHESIS

We hypothesized that there is a high risk of nonhome discharge in patients surviving ICU admission due to COVID-19.

SETTING

Data were included from 306 hospitals in 28 countries participating in the SCCM Discovery Viral Infection and Respiratory Illness Universal Study COVID-19 registry.

PATIENTS

Previously independently living adult ICU survivors of COVID-19.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

The primary outcome was nonhome discharge. Secondary outcome was the requirement of health assistance among patients who were discharged home. Out of 10 820 patients, 7101 (66%) were discharged alive; 3791 (53%) of these survivors lost their previous independent living status, out of those 2071 (29%) through nonhome discharge, and 1720 (24%) through discharge home requiring health assistance. In adjusted analyses, loss of independence on discharge among survivors was predicted by patient age ≥ 65 years (adjusted odds ratio [aOR] 2.78, 95% confidence interval [CI] 2.47-3.14, P < .0001), former and current smoking status (aOR 1.25, 95% CI 1.08-1.46, P  =  .003 and 1.60 (95% CI 1.18-2.16), P  =  .003, respectively), substance use disorder (aOR 1.52, 95% CI 1.12-2.06, P  =  .007), requirement for mechanical ventilation (aOR 4.17, 95% CI 3.69-4.71, P < .0001), prone positioning (aOR 1.19, 95% CI 1.03-1.38, P  =  .02), and requirement for extracorporeal membrane oxygenation (aOR 2.28, 95% CI 1.55-3.34, P < .0001).

CONCLUSIONS

More than half of ICU survivors hospitalized for COVID-19 are unable to return to independent living status, thereby imposing a significant secondary strain on health care systems worldwide.

Factors associated with adaptation level in the older adult residential care facilities: a path analysis

Background

It has become very common for older adults to relocate to residential care facilities. Yet whether older adults adapt to life in a long-term care residential facility through perception, reflection, and conscious behavioral choices is a challenging social issue. Previous research has shown that adaptation is influenced by physical, mental, psychological, social systems, and other debris factors. However, existing knowledge is often based on unidirectional relationships between these factors and adaptation. Few studies have formally examined bivariate relationships between these factors, and the influence of adaptation between these factors internally remains unclear. Therefore, there is a need to examine the structural causality of adaptation in residential care facilities influenced by a combination of physical, emotional, social and psychological factors, life satisfaction, and social support.

Methods

The present cross-sectional study recruited older adults from three residential care facilities in Henan province, China, through convenience sampling. The Chinese Nursing Home Adjustment Scale (NHAS), Geriatric Depression Scale-15 (GDS-15) and Social Support Scale (SSRS), Satisfaction with Life Scale (SWLS), and Barthel Index were employed to measure the older adult' adjustment level, depression level, social support, satisfaction with life, and self-care ability of the BMC, respectively. The relationships between depression, social support, self-care, satisfaction with life, and adaptation were analyzed and a structural equation model was developed.

Results

A total of 210 participants completed the questionnaire. The model demonstrated an acceptable fit of the data. The results showed that the difference between life satisfaction and depression on the level of adaptation was 60 and 23%, respectively. Social support and life satisfaction had a positive direct effect on the level of adaptation, both showing a positive correlation with the level of adaptation. Depression, on the other hand, have a direct effect on the level of adaptation and showed a negative correlation with the level of adaptation. Self-care ability indirectly influenced adaptation mediated by social support.

Conclusion

Social support has a positive impact on both life satisfaction and depression, which in turn promotes adaptation. As a major source of social support, family members and nursing home staff in residential care facilities can enhance social support for older people through improved interaction, which can have a meaningful and positive impact on levels of adjustment. The model demonstrates the strengthening and weakening of social support, self-care, life satisfaction, and depression levels, which can help inform the development of relevant care health strategies for older people to promote levels of adjustment and improve quality of life.

The effect of horticultural therapy on older adults in pension institutions: a systematic review

AIMS

To systematically evaluate the effect of horticultural therapy (HT) on older adults in pension institutions.

DESIGN

Systematic review was conducted based on the checklist for PRISMA.

METHODS

The searches were conducted in the Cochrane library, Embase, Web of Science, PubMed, Chinese Biomedical Database (CBM), and the China Network Knowledge Infrastructure (CNKI), from their inception until May 2022. In addition, manual screening of references of relevant studies was performed to identify potential studies. We conducted a review of quantitative studies published in Chinese or English. Experimental studies were evaluated using the Physiotherapy Evidence Database (PEDro) Scale.

RESULTS

A total of 21 studies involving 1214 participants were included in this review, and the quality of the literature was good. Sixteen studies were Structured HT. The effects of HT were significant in terms of physical, physiological, and psychological aspects. In addition, HT improved satisfaction, quality of life, cognition, and social relationships, and no negative events were found.

CONCLUSION

As an affordable non-pharmacological intervention with a wide range of effects, horticultural therapy is suitable for older adults in pension institutions and is worth promoting in pension institutions, communities, homes, hospitals, and other institutions that require long-term care.

The association of intraoperative low driving pressure ventilation and nonhome discharge: a historical cohort study

PURPOSE

To evaluate whether intraoperative ventilation using lower driving pressure decreases the risk of nonhome discharge.

METHODS

We conducted a historical cohort study of patients aged ≥ 60 yr who were living at home before undergoing elective, noncardiothoracic surgery at two tertiary healthcare networks in Massachusetts between 2007 and 2018. We assessed the association of the median driving pressure during intraoperative mechanical ventilation with nonhome discharge using multivariable logistic regression analysis, adjusted for patient and procedural factors. Contingent on the primary association, we assessed effect modification by patients' baseline risk and mediation by postoperative respiratory failure.

RESULTS

Of 87,407 included patients, 12,584 (14.4%) experienced nonhome discharge. In adjusted analyses, a lower driving pressure was associated with a lower risk of nonhome discharge (adjusted odds ratio [aOR], 0.88; 95% confidence interval [CI], 0.83 to 0.93, per 10 cm H2O decrease; P < 0.001). This association was magnified in patients with a high baseline risk (aOR, 0.77; 95% CI, 0.73 to 0.81, per 10 cm H2O decrease, P-for-interaction < 0.001). The findings were confirmed in 19,518 patients matched for their baseline respiratory system compliance (aOR, 0.90; 95% CI, 0.81 to 1.00; P = 0.04 for low [< 15 cm H2O] vs high [≥ 15 cm H2O] driving pressures). A lower risk of respiratory failure mediated the association of a low driving pressure with nonhome discharge (20.8%; 95% CI, 15.0 to 56.8; P < 0.001).

CONCLUSIONS

Intraoperative ventilation maintaining lower driving pressure was associated with a lower risk of nonhome discharge, which can be partially explained by lowered rates of postoperative respiratory failure. Future randomized controlled trials should target driving pressure as a potential intervention to decrease nonhome discharge.

[If dependency makes vulnerable: Nursing home residents' claims for dignity-conserving nursing care - A narrative literature review]

If dependency makes vulnerable: Nursing home residents' claims for dignity-conserving nursing care - A narrative literature review Abstract. Introduction: Due to an increase in the very old population, it is important to know what is needed in order to support older people's needs regarding dignity-conserving nursing care when living in a nursing home. Aim: The aim of this article is to gather information on how nursing home residents feel respected and protected in regards of their dignity. Methods: A narrative literature review was conducted in the databases CINAHL Complete and PubMed. Six qualitative studies met the inclusion criteria and were compared regarding similarities. Results: The protection of dignity is jeopardized not only by the residents' dependency, but also by nurses, social environment, and society. To protect their own dignity, residents wanted to be perceived as individuals and be treated with respect. Additionally, they wanted to be as independent as possible and take part in meaningful activities. Discussion: Facilitation of staff members as well as flat, peripheral leadership structures are important in order to protect the residents' dignity. The residents' needs regarding social and societal participation has been additionally challenged due to the Covid-19 pandemic. At the same time, the pandemic enforced innovations that may help protect nursing home residents' dignity. Conclusions: These findings can help nurses to protect the dignity of nursing home residents in their daily lives and in the implementation of care measures.

Trajectory and Predictors of Mental Health Symptoms and Wellbeing in Newly Admitted Nursing Home Residents

OBJECTIVES

This study determined changes in multiple aspects of mental health and wellbeing in newly admitted nursing home residents, and identified risk and protective factors.

METHODS

Participants were 204 residents recently admitted to one of 42 nursing homes in Melbourne, Australia. A subgroup of 82 participants were followed up eight months post-admission. Depression, anxiety, stress, adjustment, and quality of life were assessed at baseline and follow-up. Predictive factors (demographics, health, transition factors, nursing home characteristics) were examined in multiple regression analyses.

RESULTS

Rates of depression and anxiety were high at both baseline and follow-up. Low self-rated health and medical comorbidity predicted poor wellbeing at baseline. Higher perceived control in the relocation to the nursing home and engagement in meaningful activities were associated with better post-admission outcomes. Baseline psychotropic medication use predicted lower anxiety at follow-up but did not impact depressive symptoms.

CONCLUSIONS

There were no significant changes in mental health and wellbeing from one to eight months post-admission. The negative effect of residing in a for-profit nursing home requires further investigation.

CLINICAL IMPLICATIONS

Individual activity scheduling and an opportunity to participate in relocation decision-making and planning may support resident wellbeing post-admission.

Program to Enhance Adjustment to Residential Living (PEARL): Effect on Adjustment, Anxiety, Quality of Life, and Stress

OBJECTIVES

The Program to Enhance Adjustment to Residential Living (PEARL) is a five session intervention primarily designed to address high rates of depression in newly admitted residents. This study reports the efficacy of PEARL on secondary outcomes of resident adjustment, symptoms of anxiety, quality of life, and stress.

METHODS

A cluster randomized controlled trial was conducted with 219 newly admitted nursing home residents (M age = 85.5 years) from 42 nursing homes. Outcomes were assessed at baseline, post-intervention, and at two and six month post-intervention follow-up, compared to a standard care condition.

RESULTS

There was a significant overall condition by time interaction for adjustment (p = .027) and quality of life (p = .015), but not for stress (p = .309). While the overall condition by time interaction was not significant for anxiety (p = .221), there was a significant interaction contrast six-month post-intervention, indicating a greater decrease in anxiety scores in the intervention group relative to control (p = .039).

CONCLUSIONS

This study demonstrates the broad effects of PEARL on the wellbeing of newly admitted residents.

CLINICAL IMPLICATIONS

PEARL is a brief intervention that may be feasible for routine use in nursing homes to facilitate adjustment and improve residents' quality of life.

Municipal healthcare professionals' interprofessional collaboration during older patients' transitions in the municipal health and care services: a qualitative study

Background

Interprofessional collaboration is vital to assist patients towards a healthy transition in the municipal health and care services. However, no study has so far investigated municipal health care providers’ inter-professional collaboration during older patients’ transition in the municipal health and care services. The aim of this study is therefore to describe and explore what influence health care providers’ inter-professional collaboration within and across municipal facilities during older patients’ transitions in the municipal health and care services.

Method

The study has a descriptive, interpretive design. Focus group interviews and individual interviews with municipal health care providers different professions were performed.

Results

Municipal health care providers’ inter-professional collaboration during older patients transitions in the municipal health and care services was challenging. Two main themes were identified: The patient situation itself and Professional. Personal, and Practical circumstances. The results show that the municipal priority of patients staying at home as long as possible facilitated inter-professional collaboration across the short-term care facility and the home care services. Inter-professional collaboration across facilities with the long-term care facility was downgraded and health care providers in this facility had to cope as best they could.

Conclusion

Prioritising and facilitating inter-professional collaboration between the short-term care facility and the home care services, contributed to health care providers experiencing doing a proper and safe patient assistance. Yet, this priority was at a cost: Health care providers in the long-term care facility, and in particular registered nurses felt squeezed and of less worth in the municipal health and care services. It was a strain on them to experiencing unplanned and often rushed patient transition into long-term care facility. To focus on municipal inter-professional and inter-facility collaboration during patients in transition to long-term care placement is vital to maintain the patients, and the health care providers working in these facilities.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-022-08226-5.

Family care prior to the admission of the elderly in a nursing home and continuity in family care: A comparative study of Colombia and Spain

This study examined the background before admission to a nursing home and the conditions for the continuity of care, of the relatives of older adults of Colombia and Spain. The study sample comprised 546 participants: 278 and 268 from Colombia and Spain, respectively. Structured interviews were conducted with the older adults’ relatives. Sociodemographic similarities predominated, although in the Colombian sample there were significantly more unrelated people. Similarities in previous and current care conditions also predominated too. Cluster 1 included all the cases of Colombian low-resource nursing homes, and Cluster 2 included all the relatives of Colombian high-resource nursing homes and all the Spanish centers. The type of nursing home was the variable more important to identify the abovementioned clusters. Conclusions: Family members from Colombia and Spain continue to care for the elderly admitted to geriatric homes. The type of geriatric center is what establishes the differences in the users.

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Spanish and Colombian family caregivers continue to provide care to the elderly after their admission to the residence.

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There are more similarities than differences between Spanish and Colombian family caregivers.

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Reconciling work-family implies a difficult balance, especially among women, who are more overloaded.

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The deterioration of the health of the elderly was the most frequent reason for admission.

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There are differences between relationships and provision of care in the elderly living in low-income residences in Colombia with respect to the rest of the Colombian and Spanish sample.

Effects of an emotional support programme on older adults living in nursing homes: A quasi-experimental study

This study aimed to examine the feasibility and validity of an emotional support programme developed for older adults living in nursing homes, using a quasi-experimental design. Older adults in the intervention group attended a 12-week emotional support programme while those in the control group received usual care. Outcome variables, assessed at baseline and at 1-month and 3-month follow ups, included nursing home adjustment, perceived social support, and quality of life. Group-by-time interaction effects were found concerning nursing home adjustment and perceived social support. Significant improvements in the two variables were observed in the intervention group, but no significant difference was found in quality of life. The emotional support programme based on social learning theory resulted in significant improvements in nursing home adjustment and perceived social support. To respond to the demands of an ageing society, further studies are needed on this topic.

Improving In-Hospital Care For Older Adults: A Mixed Methods Study Protocol to Evaluate a System-Wide Sub-Acute Care Intervention in Canada

Introduction:

Acute care hospitals often inadequately prepare older adults to transition back to the community. Interventions that seek to improve this transition process are usually evaluated using healthcare use outcomes (e.g., hospital re-visit rates) only, and do not gather provider and patient perspectives about strategies to better integrate care. This protocol describes how we will use complementary research approaches to evaluate an in-hospital sub-acute care (SAC) intervention, designed to better prepare and transition older adults home.

Methods:

In three sequential research phases, we will assess (1) SAC transition pathways and effectiveness using administrative data, (2) provider fidelity to SAC core practices using chart audits, and (3) SAC implementation outcomes (e.g., facilitators and barriers to success, strategies to better integrate care) using provider and patient interviews.

Results:

Findings from each phase will be combined to determine SAC effectiveness and efficiency; to assess intervention components and implementation processes that ‘work’ or require modification; and to identify provider and patient suggestions for improving care integration, both while patients are hospitalized and to some extent after they transition back home.

Discussion:

This protocol helps to establish a blueprint for comprehensively evaluating interventions conducted in complex care settings using complementary research approaches and data sources.

Unplanned nursing home admission among discharged polymedicated older inpatients: a single-centre, registry-based study in Switzerland

OBJECTIVE

To investigate patient characteristics and the available health and drug data associated with unplanned nursing home admission following an acute hospital admission or readmission.

DESIGN

A population-based hospital registry study.

SETTING

A public hospital in southern Switzerland (Valais Hospital).

PARTICIPANTS

We explored a population-based longitudinal dataset of 14 705 hospital admissions from 2015 to 2018.

OUTCOME MEASURES

Sociodemographic, health and drug data, and their interactions predicting the risk of unplanned nursing home admission.

RESULTS

The mean prevalence of unplanned nursing home admission after hospital discharge was 6.1% (n=903/N=14 705). Our predictive analysis revealed that the oldest adults (OR=1.07 for each additional year of age; 95% CI 1.05 to 1.08) presenting with impaired functional mobility (OR=3.22; 95% CI 2.67 to 3.87), dependency in the activities of daily living (OR=4.62; 95% CI 3.76 to 5.67), cognitive impairment (OR=3.75; 95% CI 3.06 to 4.59) and traumatic injuries (OR=1.58; 95% CI 1.25 to 2.01) had a higher probability of unplanned nursing home admission. The number of International Classification of Diseases, 10th version diagnoses had no significant impact on nursing home admissions, contrarily to the number of prescribed drugs (OR=1.17; 95% CI 1.15 to 1.19). Antiemetics/antinauseants (OR=2.53; 95% CI 1.21 to 5.30), digestives (OR=1.78; 95% CI 1.09 to 2.90), psycholeptics (OR=1.76; 95% CI 1.60 to 1.93), antiepileptics (OR=1.49; 95% CI 1.25 to 1.79) and anti-Parkinson's drugs (OR=1.40; 95% CI 1.12 to 1.75) were strongly linked to unplanned nursing home admission.

CONCLUSIONS

Numerous risk factors for unplanned nursing home admission were identified. To prevent the adverse health outcomes that precipitate acute hospitalisations and unplanned nursing home admissions, ambulatory care providers should consider these risk factors in their care planning for older adults before they reach a state requiring hospitalisation.

'The Primacy of 'Home': An exploration of how older adults' transition to life in a care home towards the end of the first year

This grounded theory study sought to explore how older adults' experience the transition from living at home to a care home with a specific focus on the latter part of the first year of the move. The study was carried out within a large Health Trust in the UK between August 2017 and May 2019. Purposive sampling was used in the initial stages of data collection. Thereafter and consistent with grounded theory methodology, theoretical sampling was employed to undertake semi-structured interviews with 17 individuals from eight care homes between 5 and 12 months after the move. This paper reports five key categories which were: (a) The lasting effect of first Impressions 'They helped me make my mind up' (b) On a Journey 'I just take it one day at a time', (c) Staying connected and feeling 'at home' 'You get something good out of it you know…you get hope'. (d) Managing loss and grief 'It was important for me to say cheerio to the house' and (e) Caring relationships 'I didn't realise that I was lonely until I had company'. Together these five categories formed the basis of the core category 'The Primacy of 'Home' which participants identified as a place they would like to feel valued, nurtured and have a sense of belonging. This study identifies that it is important for individual preferences and expectations to be managed from the outset of the move. Individuals and families need to be supported to have honest and caring conversations to promote acceptance and adaptation to living in a care home while continuing to embrace the heart of 'home'. Key recommendations from this study include the need to raise awareness of the significance of the ongoing psychological and emotional well-being needs of older people which should be considered in policy directives and clinical practice.

Analysis of Transition of Patients with Parkinson's Disease into Institutional Care: A Retrospective Pilot Study

Parkinson's disease (PD) is a neurodegenerative disease which gives a person a high risk of becoming care-dependent. During disease progression, the amount of care concerning activities of daily living can increase, possibly resulting in transition of the people with Parkinson's disease (PwP) to a care facility. However, there is a lack of knowledge concerning the factors leading to institutionalization of PwP and the consequences for them and their informal caregivers. The aim of this cross-sectional retrospective study was to investigate reasons leading to the transition into an institutional care facility, the process of decision-making and its effects on PwP symptoms and caregiver burden. Participating PwP had to be institutionalized for at most one year after transition at study inclusion. Participants completed a range of semiquantitative questionnaires as well as the caregiving tasks questionnaire. Fourteen patient-caregiver pairs were included. PwP suffered from late-stage PD symptoms with high dependence on help, experiencing several hospitalizations before transition. Analyses revealed a significant decrease in caregiver burden and depressive symptoms of the caregivers after PwP institutionalization. Factors influencing the transition were, e.g., fear of PwP health issues and concerns about caregivers' health. This study presents new insights into the process of institutionalization and its influence on caregiver burden, including aspects for discussions of physicians with PwP and their caregivers for counselling the decision to move to institutional care.

Assessing Residents' Perceptions of Their Relocation to Long-Term Care: Psychometric Validation of the View of Relocation Scale

OBJECTIVES

Relocation to long-term care is a major challenge for older people. The View of Relocation Scale (VRS) was developed to address the need for a brief instrument to assess residents' perceptions of the relocation.

DESIGN

Secondary analysis of data collected in a cluster randomized trial. The psychometric properties of the VRS examined in this study included factorial structure (using exploratory factor analysis), unidimensionality (Rasch modeling), internal consistency reliability (Kuder-Richardson Formula 20, squared multiple correlations, and item-total correlations), and known groups validity (analysis of variance). The results were used to identify the psychometrically most robust items for inclusion into the final version of the instrument.

SETTING AND PARTICIPANTS

Participants were 202 long-term care residents in Melbourne, Australia (mean age = 85.52 years, standard deviation = 7.33), who had relocated to the facility a mean of 4.4 weeks previously. Residents with moderately severe and severe dementia were excluded.

MEASURES

The VRS was developed following a review of the literature describing residents' views of relocation and was designed for administration shortly after their relocation.

RESULTS

There was support for a 2-factor, 10-item solution, with separate subscales assessing Perceived Control (degree of control in the decision making and planning for the relocation) and Perceived Need (perceived need for the relocation to long-term care). Participants who were admitted directly from hospital reported higher perceived need but lower perceived control than those admitted to the facility from home.

CONCLUSION AND IMPLICATIONS

The VRS can be used to understand the impact of older people's perceptions of relocation to long-term care on their subsequent adjustment and well-being, and to identify those who may benefit from tailored support.

‘Knowing me, knowing you’: an exploration of the views and experiences of nursing home residents and staff on their nursing home as ‘home’

The overall aim of this grounded theory study was to explore the context of a nursing home as ‘home’ from the perspective of residents and staff. Sixteen focus group interviews were used to collect qualitative data from nursing home residents (N = 48) and staff (N = 44). Five distinct categories captured the views and experiences of participating residents and staff. These were: (a) Starting off on the right foot, ‘First impressions can be the lasting ones; (b) Making new and maintaining existing connections, ‘There is great unity between staff and residents’; (c) The nursing home as home, ‘It's a bit like home from home for me’; (d) Intuitive knowing, ‘I don't even have to speak, she just knows’; and (e) Feeling at home in a regulated environment, ‘It takes the home away from nursing home’. Together these five categories formed the basis of the core category ‘Knowing me, knowing you’, which captures the experiences of participants who repeatedly highlighted the importance of relationships and feelings of mutuality and respect between and among staff and residents as central to feeling at home in a nursing home. The reciprocity and mutuality associated with the core category, ‘Knowing me, knowing you’, was at times challenged by staff shortages, time constraints, and conflicting priorities associated with the co-existence of a regulated and homely environment.

What Factors Predict Adverse Discharge Disposition in Patients Older Than 60 Years Undergoing Lower-extremity Surgery? The Adverse Discharge in Older Patients after Lower-extremity Surgery (ADELES) Risk Score

BACKGROUND

Adverse discharge disposition, which is discharge to a long-term nursing home or skilled nursing facility is frequent and devastating in older patients after lower-extremity orthopaedic surgery. Predicting individual patient risk allows for preventive interventions to address modifiable risk factors and helps managing expectations. Despite a variety of risk prediction tools for perioperative morbidity in older patients, there is no tool available to predict successful recovery of a patient's ability to live independently in this highly vulnerable population.

QUESTIONS/PURPOSES

In this study, we asked: (1) What factors predict adverse discharge disposition in patients older than 60 years after lower-extremity surgery? (2) Can a prediction instrument incorporating these factors be applied to another patient population with reasonable accuracy? (3) How does the instrument compare with other predictions scores that account for frailty, comorbidities, or procedural risk alone?

METHODS

In this retrospective study at two competing New England university hospitals and Level 1 trauma centers with 673 and 1017 beds, respectively; 83% (19,961 of 24,095) of patients 60 years or older undergoing lower-extremity orthopaedic surgery were included. In all, 5% (1316 of 24,095) patients not living at home and 12% (2797 of 24,095) patients with missing data were excluded. All patients were living at home before surgery. The mean age was 72 ± 9 years, 60% (11,981 of 19,961) patients were female, 21% (4155 of 19,961) underwent fracture care, and 34% (6882 of 19,961) underwent elective joint replacements. Candidate predictors were tested in a multivariable logistic regression model for adverse discharge disposition in a development cohort of all 14,123 patients from the first hospital, and then included in a prediction instrument that was validated in all 5838 patients from the second hospital by calculating the area under the receiver operating characteristics curve (ROC-AUC).Thirty-eight percent (5360 of 14,262) of patients in the development cohort and 37% (2184 of 5910) of patients in the validation cohort had adverse discharge disposition. Score performance in predicting adverse discharge disposition was then compared with prediction scores considering frailty (modified Frailty Index-5 or mFI-5), comorbidities (Charlson Comorbidity Index or CCI), and procedural risks (Procedural Severity Scores for Morbidity and Mortality or PSS).

RESULTS

After controlling for potential confounders like BMI, cardiac, renal and pulmonary disease, we found that the most prominent factors were age older than 90 years (10 points), hip or knee surgery (7 or 8 points), fracture management (6 points), dementia (5 points), unmarried status (3 points), federally provided insurance (2 points), and low estimated household income based on ZIP code (1 point). Higher score values indicate a higher risk of adverse discharge disposition. The score comprised 19 variables, including socioeconomic characteristics, surgical management, and comorbidities with a cutoff value of ≥ 23 points. Score performance yielded an ROC-AUC of 0.85 (95% confidence interval 0.84 to 0.85) in the development and 0.72 (95% CI 0.71 to 0.73) in the independent validation cohort, indicating excellent and good discriminative ability. Performance of the instrument in predicting adverse discharge in the validation cohort was superior to the mFI-5, CCI, and PSS (ROC-AUC 0.72 versus 0.58, 0.57, and 0.57, respectively).

CONCLUSION

The Adverse Discharge in Older Patients after Lower Extremity Surgery (ADELES) score predicts adverse discharge disposition after lower-extremity surgery, reflecting loss of the ability to live independently. Its discriminative ability is better than instruments that consider frailty, comorbidities, or procedural risk alone. The ADELES score identifies modifiable risk factors, including general anesthesia and prolonged preoperative hospitalization, and should be used to streamline patient and family expectation management and improve shared decision making. Future studies need to evaluate the score in community hospitals and in institutions with different rates of adverse discharge disposition and lower income. A non-commercial calculator can be accessed at www.adeles-score.org.

LEVEL OF EVIDENCE

Level III, diagnostic study.

The adaptation of older adults' transition to residential care facilities and cultural factors: a meta-synthesis

Background

The transition to residential care facilities can be stressful for older people, entailing numerous challenges. Many qualitative studies focused on the adjustment and the experiences associated with older adults’ admission to residential care facilities. However, there have been few studies to synthesize qualitative studies and pay attention to the cultural factors influencing adaptation. The aim is to appraise the adaptation of older people’ s transition to the residential care facilities.

Methods

We followed the method of Preferred Reporting Items of Systematic Review and Meta-Analysis (PRISMA). Six databases (CINHAL, Cochrane, Embase, Pubmed, PsycInfo, and Web of Science) were searched systematically from their inception until April 2020 using Medical Subject Headings (MSH) or Subject Headings plus free-text words. The CASP evaluation for qualitative studies was used for quality appraisal and meta-aggregation was used in the data analysis.

Results

Ten studies (from 7 countries on 3 continents) were included in this review. We synthesized two main findings: the impacts of culture on adaptation and the transition process.

Conclusions

Understanding the cultural factors helps nursing staff to gain new insight into older adults’ transition to residential care facilities. The consideration of cultural factors might be incorporated into tailored interventions for residents during transition. Nursing staff is advised to pay attention to the decision-making process before residents’ admission to the residential care facilities, and care plans are best made by residents, family members, and staff members together at the beginning of the decision-making process.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12877-020-01987-w.

The factors of adaptation to nursing homes in mainland China: a cross-sectional study

BACKGROUND

China is one of the most rapidly ageing countries and has the largest ageing population in the world. The demand for long-term care is increasing. Nursing home placement is one of the most stressful events in a person's life. Although research on relocation adjustment has been conducted in many countries, few studies have been related to the predictors of nursing home adjustment in mainland China. This study aimed to identify the predictors of nursing home adjustment in the context of filial piety in mainland China.

METHODS

This was a descriptive study that employed a cross-sectional survey. A total of 303 residents from 22 nursing homes in Nanjing, China, were recruited. A structured questionnaire about residents' characteristics, activities of daily living, social support, resilience, and nursing home adjustment was administered. Multiple linear regression was used to identify the predictors of adaptation to nursing homes.

RESULTS

The predictors of nursing home adjustment were the satisfaction with services(β = .158, P < .01), number of diseases(β = -.091, P < .05), length of stay(β = .088, P < .05), knowledge of the purpose of admission (β = .092, P < .05), resilience(β = .483, P < .001) and social support(β = .186, P < .001). The total explained variance for this model was 61.6%.

CONCLUSION

Nursing staff members should assess the characteristics of residents to promote their better adjustment. Resilience had the most significant influence on the level of adaptation, which has been the primary focus of interventions to improve adjustment. The management of disease comorbidities in nursing homes should be standardized and supervised by the government. More volunteers from universities and communities should be encouraged to provide social support to residents. Moreover, a caring culture needs to be emphasized, and the value of filial piety should be advocated in nursing homes of East Asian countries.

Development and Exploration of Psychometric Properties of the Family Adjustment Questionnaire for Admitting an Older Adult to a Nursing Home (CAFIAR)

Background: Admitting an older adult to a nursing home involves significant adjustment efforts by the family. Our goal was to prepare an assessment instrument for this, given that there was none to date. Method: Participants-134 relatives from different nursing homes in the region of Murcia. Instruments-structured interview for socio-demographic information, satisfaction with the nursing home, well-being and health self-assessment, Radloff's Depression Questionnaire (CES-D), and the first version of CAFIAR. Results: A 15-item instrument with three factors was obtained: Factor 1 (Unease due to admitting an older adult to a nursing home), Factor 2 (Relief), and Factor 3 (Nostalgia and concern for the older adult), in addition to a general adjustment index, with a Cronbach's alpha of 0.74. The general adjustment index and the subscales that demonstrate poor adjustment were significantly correlated with depression and a worse health self-assessment, while the Relief subscale, which indicates better adjustment, was significantly correlated with well-being and a positive health self-assessment. Conclusions: The family adjustment in admitting an older adult to a nursing home questionnaire (CAFIAR) has adequate psychometric properties to assess family adaptation in admitting an older adult to an institution.

Effects of Yangsaeng (Health Management) Therapy for Korean Older Adults in Nursing Home

The number of older adults admitted to nursing homes is steadily increasing, and the health management for them is a very important issue in Korean society. This study aimed to examine the effects of Yangsaeng (health management) therapy on physical health status, depression, life satisfaction, and Yangsaeng (health management) of Korean older adults in nursing homes. A quasi-experimental study design using a pretest-posttest control group was employed. Study participants were a total of 80 older adults (intervention: n = 40, control: n = 40) in a nursing home in Seoul, South Korea. Yangsaeng therapy as an intervention consisted of the Meridian therapy and Qi-gong therapy. Yangsaeng therapy was conducted for 50 min per one time, twice a week, and for 10 weeks. Measures were general characteristics of study participants, Cornell Medical Index, Geriatric Depression Scale, life satisfaction scale, and Yangsaeng scale. Data were collected from April 2018 to March 2019. There were statistically significant differences on physical health status, depression, life satisfaction, and Yangsaeng between the two groups. Yangsaeng therapy was an effective intervention for improving physical health status, life satisfaction, and Yangsaeng, and for decreasing depression of older adults in nursing homes. Health care providers need to pay attention to Yangsaeng therapy as a Korean traditional intervention method for the health management of the older adults residing in nursing homes.

Relocation experiences of the elderly to a long-term care facility in Taiwan: a qualitative study

BACKGROUND

Relocation to a long-term care (LTC) facility is a major life change for most elderly people. Following relocation, many elderly experience difficulties in adapting to changes in the living environment. Taiwan is increasingly becoming an "aging society" and the numbers of those who relocate from family residences to long-term residential care facilities have increased over years. However, in-depth evidence on the experiences of the elderly of their stay in LTC facilities in Taiwan is relatively sparse. This study aimed to explore the relocation experiences of the elderly to a LTC facility to inform policy and practice to address their needs effectively.

METHODS

A qualitative study, using semi-structured in-depth interviews, was conducted to explore the experiences of 16 elderly people who have relocated to and lived in a LTC facility in Taiwan for up to a period of 12 months. All interviews were recorded, transcribed, and analyzed using grounded theory approach.

RESULTS

Participants' accounts reflected four interrelated key themes: wish to minimize the burden, but stay connected with the family; perceived barriers to adaptation; valuing tailored care; and acceptance and engagement. Each theme included interrelated subthemes that influenced one another and represented the different stages in the relocation journey. Most participants viewed relocation as a way of minimizing the burden of their care from family members, but desired to keep a close connection with family and friends. Participants recounted experiences of psychological resistance while making the decision to relocate. Fear of losing autonomy and the ability to perform self-care was a major reason for resistance to adapt. Provision of tailored care was accorded much value by the participants. The decision to accept the relocation and to adapt themselves to the new environment due to their needs for constant care was explicit in some accounts.

CONCLUSIONS

Relocation to LTC facility is a dynamic process in the first year of moving into the facility, and involves a range of emotions, feelings and experiences. Adaptation of the elderly into the LTC facility can be maximized if the relocation is well planned with provisions for individually tailored care and family involvement.

"You're at their mercy": Older peoples' experiences of moving from home to a care home: A grounded theory study

BACKGROUND

Internationally, it is recognised that the transition to a care home environment can be an emotional and stressful occasion for older people and their families. There is a paucity of research that takes into consideration the initial phase of the relocation process, incorporating individuals' experiences of the move.

AIM

To explore individuals' experiences of moving into a care home. This paper has a specific focus on the preplacement (7 days) and immediate postplacement (within 3 days) period of the move to the care home.

DESIGN

A grounded theory method was used to conduct semi-structured interviews with 23 participants.

RESULTS

Data analysis revealed five distinct categories that captured the experience of the preplacement and immediate postplacement period. These were as follows: (a) inevitability of the move: "I had to come here," (b) making the move: "Abrupt Departures," (c) decision-making and exercising choice: "What can I do, I have no choice," (d) maintaining identity: "Holding on to self" and (e) maintaining connections: "I like my family to be near." Together, these five categories formed the basis of the concept "You're at their Mercy" which encapsulates the perceived transition experience of the older people within the study. Participants felt that the move was out of their control and that they were "at the mercy" of others who made decisions about their long-term care.

CONCLUSIONS

Moving to a care home represents a uniquely significant relocation experience for the individual. Key factors influencing the move were the individuals' perceived lack of autonomy in the pre- and postrelocating period of moving to a care home. Nurses have a key role to play in working with older people to influence policy and practice around decision-making, planning and moving to a care home with greater emphasis on autonomy and choice so that older people do not feel "at the mercy" of others as they navigate such a major transition.

IMPLICATIONS FOR PRACTICE

There is a need to standardise approaches and develop person-centred interventions to support older people considering relocation to a care home and nurses have a key role to play in making this happen.

"I Didn't Even Make My Bed": Hospital Relocations and Resident Adjustment in Long-Term Care Over Time

PURPOSE OF THE STUDY

This prospective longitudinal qualitative study sought to identify the conditions that help or hinder older adults' capacities to adjust to long-term care (LTC) when relocating from hospital.

DESIGN AND METHODS

Informed by the principles of constructivist grounded theory, this study employed semi-structured interviews with LTC home residents. Participants were interviewed 4 weeks after their initial relocation, and again every 6 months until they had either resided in their final LTC home for at least 3 months or been enrolled in the study for 2 years. Transcribed interviews were analyzed using the constant comparative method that employs the principle of comparison to guide the analytic process.

FINDINGS

A total of nine residents participated in 24 interviews and most had undergone two or more moves. Analysis of the data revealed that multiple forced moves challenged residents' capacities to find home in LTC by contributing to anxiety and uncertainty, hindering resident-staff relations, and interfering with residents' desires to connect with one another. Analysis of the data further revealed that relocation frameworks may require adaptations to more accurately reflect older adults' experiences with relocation from hospital to LTC.

IMPLICATIONS

Hospital relocations pose many challenges to residents' capacities to find home in LTC, in part, because they initiate a process of multiple moves. Until the moving process from hospital truly acknowledges and explores residents' preferences, offers choices, and supports joint decision making, it will remain challenging for the LTC home sector to help residents find meaning, purpose, and home in LTC.

Facilitators and inhibitors of transition for older people who have relocated to a long-term care facility: A systematic review

Moving into a long-term care facility to live permanently is a significant life event for older people. Care facilities need to support older people to make a healthy transition following relocation. To help achieve this, we need to understand what facilitates and inhibits the transition process from the perspective of older people, their families, and care facility staff. Our review generated new knowledge to inform this understanding. We addressed the question: what factors facilitate and inhibit transition for older people who have relocated to a long-term care facility? Five electronic databases, PsychINFO, British Nursing Index, CINAHL, MEDLINE and Web of Science were searched for the period January 1990 to October 2017. Grey literature searches were conducted using Google Scholar, and Social Science Research Network. Data were extracted for individual studies and a narrative synthesis was conducted informed by Meleis's Theory of Transition. Thirty-four studies (25 qualitative, 7 quantitative and 2 mixed methods) met the inclusion criteria. Data synthesis identified that transition following relocation was examined using a variety of terms, timelines and study designs. Potential personal and community focused facilitators and inhibitors mapped to four themes: resilience of the older person, interpersonal connections and relationships, this is my new home, and the care facility as an organisation. These findings can inform the development of interventions for these target areas. They highlight also that further research is warranted to understand the organisational culture of long-term care facilities, how this influences transition, and how it might be shaped to create and sustain a caring culture for older people.

Aggressive behaviour risk assessment tool for long-term care (ABRAT-L): Validation study

This prospective cohort study was conducted to validate the usefulness of the Aggressive Behaviour Risk Assessment Tool for Long-Term Care (ABRAT-L) in predicting aggressive events. A total of 615 newly admitted residents at 22 long-term care homes in Canada were included. The risk of aggression was assessed using the six-item ABRAT-L within 24 hours of admission, and incident reports of aggressive events occurring within 30 days of admission were collected. Forty-seven residents out of 615 had one or more aggressive events (7.6%). The receiver operating characteristics analysis of ABRAT-L showed a good discriminant ability at the previously recommended cut-off score of 4, with satisfactory sensitivity and specificity. The usefulness of ABRAT-L in identifying potentially aggressive residents at the time of admission was confirmed. This validation study supports the adoption of a proactive risk assessment tool, ABRAT-L, as a part of routine admission assessments at long-term care homes.

Comparisons of Health Promoting Behavior, Depression, and Life Satisfaction Between Older Adults in Rural Areas in South Korea Living in Group Homes and at Home

Background:

In South Korea, population aging is advancing at a more rapid rate in rural areas than urban areas, leading to a particularly high percentage of rural-dwelling older adults.

Purpose:

The aim of this study was to examine and compare health promoting behaviors, depression, and life satisfaction between rural-dwelling older adults who live, respectively, in group homes and at home.

Methods:

A cross-sectional descriptive study design was employed. Study participants included 160 older adults aged 65 years and older who were living in group homes (n = 80) and at home (n = 80) in Gyeonggi province, South Korea. The Health Promotion Lifestyle Profile-II was used to examine health promoting behaviors, the Korean Geriatric Depression Screening Scale was used to examine depression, and the Life Satisfaction Index was used to examine life satisfaction. Data were analyzed using SPSS Version 21.0.

Results:

The data showed significant differences between the two groups in terms of health promoting behaviors (t = −9.035, p < .001), depression (t = 20.861, p < .001), and life satisfaction (t = −12.153, p < .001).

Conclusions/Implications for Practice:

The mean scores for health promotion behaviors and life satisfaction were higher, and the mean score for depression was lower in the group-home group than the at-home group. The findings from this study may be employed as basic data for establishing residence-appropriate nursing intervention protocols for older adults living in rural areas.