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Predictors of nursing home placement and mortality of residents in intermediate care

Age and Ageing, Nov, 1994 by Stephen R. Lord

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Assessments of sensorimotor function, cognitive status and health measures were made in 95 intermediate-care (hostel) residents (mean age 82.7 years). The residents were then followed up for 3 years to determine which measures were associated with nursing-home placement and/or death. Information on the outcome of 92 participants was available at the end of the 3-year period. At this time, 53 residents (58%) were still residing at the hostel, seven (8%) had been transferred to nursing homes and 32 residents (35%) had died. Sixteen of the 3 subjects who had died had been transferred to nursing homes. Discriminant function analysis identified tactile sensitivity, ankle dorsiflexion strength, reaction time, sway with eyes open on a compliant (foam rubber) surface and cognitive impairment as the variables that significantly discriminated between subjects who were still in intermediate care and subjects who had been transferred to nursing homes. This procedure correctly classified 88% of subjects into intermediate care or nursing home groups. These variables, with the exception of ankle dorsiflexion strength, were also included in the final discriminant model when predicting mortality, correctly classifying 71% of the subjects. The findings indicate that cognitive impairment and reduced functioning in a number of sensorimotor factors are strongly related to poor outcomes for residents in hostel care.

Introduction

Whilst many persons in industrialized societies maintain good health and independence into their eighties and beyond, a significant number exhibit functional deterioration and as a result require increased community support services or institutional placement. It has been suggested that if this high-risk group could be identified in advance, specific interventions could be implemented so as to assist in the long-term management of problems and prevent or delay unfavourable outcomes [1, 2].

It has been found that cognitive status, self-report measures of activity, and the time required to perform tasks that simulate activities of daily living are useful markers of functional dependency and good predictors of institutionalization and death in older persons [1-8]. Reuben et al. have also found significant associations between functional status measures such as the Physical Performance Test and the Tinetti gait score and subsequent institutionalization and death [9]. They suggested that performance-based measures extend the skills required beyond the capacity to undertake basic activities of daily living and also provide useful measures for evaluating response to therapeutic programmes.

In previous studies, we have found that poor performances in tests of sensorimotor function and stability are associated with falling in both intermediate-care and community-dwelling populations [10, 11]. Our approach to this problem has been based on the assessment of functional performance, rather than the identification of diseases or disorders, and has placed major emphasis on the quantitative measurement of visual processes, vestibular function, peripheral sensation, muscle strength, reaction time and body sway - factors outlined in our conceptual model [12] as the major body systems that contribute to balance control, and which all show age-associated decline in function. Within this conceptual framework, any debilitating medical condition (whether diagnosed or not) would be manifest by reduced functioning in one or more sensorimotor system.

In this paper, this approach is utilized to examine whether these physiological factors are also associated with increased risk of nursing-home placement and death in persons living in a hostel for aged persons (an intermediate-care institution). The predictive validity of a number of health and life-style measures is also assessed.

Methods

The sample: Ninety-five residents of a hostel for aged persons took part in the study. The sample comprised 16 men and 79 women of mean age 82.7, SD = 6.6 years (range 59-97 years). The hostel provided intermediate care (provision of meals, room cleaning and maintenance), with subjects residing in their own rooms. To qualify for this level of care, residents must be able to walk, bathe, feed and toilet themselves without nursing assistance.

Many subjects reported medical conditions: 18 subjects (19%) reported a history of heart attack, 13 (14%) reported stroke, 39 (41%) reported high blood pressure, ten (11%) reported cancer and 58 (61%) reported osteoarthritis. The presence of these conditions was not significantly associated with either outcome measure.

Physiological measures: The test battery included nine tests of individual sensory and motor systems and four 'composite' tests of reaction time and stability. Visual acuity was measured using a standard Snellen Chart and contrast sensitivity was assessed using the Melbourne Edge Test - a non-grating test specifically designed for screening purposes [13]. Three measures of peripheral sensation were made: tactile sensitivity at the ankle (assessed using a Semmes - Weinstein Pressure Aesthesiometer) [14], vibration sense at the knee (assessed using an electronic device which drove a 20O Hz vibration of varying intensity), and proprioception, which was tested using an apparatus which measured any error in matching the position of the lower limbs (measured in degrees) [12]. Vestibular sense was assessed using two tests: the Vestibular Stepping Test [15] and a test of vestibuloocular stability [12].

Health Care Industry

Predictors of nursing home placement and mortality of residents in intermediate care

Age and Ageing, Nov, 1994 by Stephen R. Lord

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