Problems of Institutionalization and Elderly
By Robert Thomas, PT
By the year 2040, it is expected that the nursing home population will expand 350 percent to 5.2 million inhabitants. This exponential increase, in some part, is due to the rapidly expanding aging population, particularly the oldest sector of this group (age 85 and older). Further, the proliferation of managed care organizations has led to the use of the nursing home as a less costly alternative for skilled and long-term care for enrollees.
Associated with institutionalization of the elderly, however, are some costly problems that may further lead to decline in health. This article will summarize some of the predictors of institutionalization as well as problems that are faced by the institutionalized older person.
Less than 5 percent of the over-65 population reside in nursing homes. The demographic composite of this group is listed in Table 1. This institutionalized population is normally divided into two groups: short term and long term. The short-term group consists of people residing in the nursing home for less than six months (usually discharged to home and the community after rehabilitation, back to the hospital or discharged secondary to death).
The long-term group consists of the older, more frail resident who is confused and often incontinent.
There are a number of factors that are predictive of institutionalization. Five major factors are:
1. Loss of physical function. Dependence on others for activities of daily living is a primary predictor of institutionalization. The Figure charts loss of basic activities of daily living (ADL) and instrumental activities of daily living (IADL) function in the older population in general. Sixty percent of people over age 65 who are dependent in five to seven ADLs live in a nursing home.
As the elderly get older, there is an increased loss of ADL and IADL function. With higher level IADL function, the percentage of people admitting difficulty with tasks in fact need help with those tasks.
With more basic ADLs, the older population still can perform a greater number of tasks despite admitting difficulty with performance.
2. Restricted mobility. Re-stricted mobility (i.e., gait, getting in and out of bed, transfers, etc.) has also been identified as a major predictor of institutionalization.
Independent mobility outside of the home can be associated with lower risk of institutionalization in the over-80 population.
3. Social resources/support. Stress on a family caregiver is an independent predictor of admission to an institution. Sixty-three percent of the institutionalized elderly have living children who are unable to provide caregiving support outside of the nursing home.
A study by House found an increased risk of death and institutionalization among people with a low quantity of social relationships.1 Women were not as negatively affected as men by this low quantity because the quality of relationships was stronger.1
4. Health perception. A person's positive health perception can be an asset even when ADLs are impaired. Health perception is typically determined by one's perceived level of independence and the amount of social support available.
A poor health perception is a higher predictor of institutionalization.
5. Socioeconomic status. Poverty is an independent predictor of dependence and admission into an institution.
Adverse Consequences of Institutionalization
Once a person does enter a nursing home setting, there are a number of potential adverse consequences of institutionalization faced by the resident.
1. Sense of control. One change faced by many long-term care residents is loss of control over health and other personal affairs.
Health care professionals generally agree that interventions that enhance control by nursing home patients promote health.
Rodin found in research related to sense of control that increasing age leads to variability in preferred amounts of control.2 In some cases, greater control over health, activities, etc. increase patient stress, worry and self-blame in the nursing home patient. One could conclude that it is essential that we determine which of our residents can handle higher levels of control and which cannot.
2. Iatrogenic illness. An iatrogenic illness is an unintended, harmful condition resulting from a diagnostic or therapeutic intervention or an accidental injury occurring in an institutional setting. Adverse drug reactions are the most common iatrogenic illness occurring in 20 percent to 25 percent of institutionalized residents. Other examples of iatrogenic illnesses include nosocomial infections (occurring within 72 hours of admission e.g., UTI, pneumonia), fluid and electrolyte imbalance, and trauma (e.g., falls).
Lefevre et al found in their research a 6.5 times greater chance of acquiring iatrogenic complication in residents who had lower Glasgow coma scale scores and an inability to walk without assistance. 3 Decreased function and cognition are possible predictors of iatrogenic illness.
3. Immobility sequelae. There are a number of adverse consequences due to bed rest and immobility. Pressure sores, bone loss, hypoxemia, constipation and weakness are some of the manifestations of this sequelae.
In the long-term care setting, we often enforce bed rest and immobility. Raised beds, shiny floors, cluttered hallways, sterile walls and corridors and physical and chemical restraints are environmental barriers that may force residents to remain in bed and ultimately lead to decline in function.
4. Undernutrition. "Failure to thrive" is a phrase used to denote malnutrition in patients usually with a history of functional decline. The four components of "failure to thrive" include 1) malnutrition (weight loss), 2) impaired physical functioning, 3) depression, and 4) cognitive impairment.
All components need to be manifested for proper diagnosis of "failure to thrive."
In the long-term care setting, it is crucial that all members of the transdisciplinary team strive to prevent some of the adverse consequences associated with institutionalization.
The following are some preventive solutions recommended to decrease the acquisition of these problems in this elderly population.
1. Modify the facility environment. The team members in the facility should seek ways to modify the sometimes hostile environment of the institution. Carpeting in hallways, large numbered clocks and calendars, handrails and other identifying pictures are ways to decrease the sterile nature of the institution.
Continually searching for ways to decrease the use of physical and chemical restraints is essential to improve the environment.
2. Prevent iatrogenic illness. One of the major iatrogenic complications that occurs is adverse drug reaction. Avoiding polypharmacy and reviewing medications of the long-term care resident is an important way of preventing iatrogenic illness.
3. Detect and treat functional impairments. Comprehensive nursing assessments are a necessary part of the identification and treatment of functional impairment. Referral to physical, occupational and speech therapy is an essential adjunct to maintaining function in this population.
4. Promote mobility. Finding ways to maintain mobility is vital. Through PT, OT and restorative nursing, decreasing the consequences of immobility should be a primary goal of the transdisciplinary team.
Bedside exercises for temporarily immobile residents to promote flexibility and strength are important in preparation for later mobility.
5. Assess and treat nutritional needs/psychosocial needs. With the intervention of social services and dietary services, undernutrition and failure to thrive can be prevented.
Physical Therapy's Role
For physical therapists, there are a number of assessment tools that can be used in the long-term care setting to establish functional baseline and identify those residents who have a higher likelihood of acquiring the adverse complications of institutionalization (Table 2). By understanding the potential adverse consequences of institutionalization and armed with these tools, the physical therapist can make a profound difference in the assessment and treatment of the elderly resident in the long-term care setting.
1. House, J.S., Landis, K.R., & Umberson, D. (1988). Social relationships and health. Science, July 29, vol. 241, 540-545.
2. Rodin, J. (1986). Aging and health: Effects of the sense of control. Science, Sept. 19, vol. 233, 1271-1275.
3. Lefevre, F., Potts, S., Soglin, L., Yarnold, P., Martin, G., & Webster, J. (1992, October). Iatrogenic complications in high-risk, elderly patients. Archives of Internal Medicine, 152, 2074-2080.
4. Mahoney, F.I., & Barthel, D.W. (1965). Functional evaluation: The Barthel index. Maryland State Medical Journal, 14(2): 61-65.
5. Katz, S. et al. (1963). Studies of illness in the aged. The index of ADL: A standardized measure of biological and psychosocial function. JAMA, 185: 914-919.
6. Gloth, F.M., Walston, J., Meyer, J., & Pearson, J. (1995). Reliability and validity of the Frail Elderly Functional Assessment Questionnaire. American Journal of Physical Medicine and Rehabilitation, 74(1): 45-53.
7. Schnelle, J.F., MacRae, P.G., & Simmons, S. et al. (1994). Safety assessment for the frail elderly: A comparison of restrained and unrestrained nursing home residents. Journal of American Geriatric Society, 42: 586-592.
Guccione, A.A. (1993). Geriatric physical therapy. St. Louis: Mosby-Year Book Inc.
Ouslander, J.G., Osterweil, D., & Morley, J. (1991). Medical care in the nursing home. New York: McGraw-Hill Inc.
Reichman, W.E., & Katz, P.R. (1996). Psychiatric care in the nursing home. New York: Oxford University Press.
Robert Thomas is a geriatric physical therapist and serves as PT clinical director for Sundance Rehabilitation Corp. in the Portland, OR, region. He also lectures nationally for GREAT seminars on rehabilitation solutions for the institutionalized elderly.