686575 research-article2017
JAHXXX10.1177/0898264316686575Journal of Aging and HealthFerrah et al.
Article
Death Following Recent Admission Into Nursing Home From Community Living: A Systematic Review Into the Transition Process
Journal of Aging and Health 1–21 © The Author(s) 2017 Reprints and permissions: sagepub.com/journalsPermissions.nav https://doi.org/10.1177/0898264316686575 DOI: 10.1177/0898264316686575 journals.sagepub.com/home/jah
Noha Ferrah, MD1, Joseph Elias Ibrahim, FAFPHM1, Chebiwot Kipsaina, MD1, and Lyndal Bugeja, PhD1,2
Abstract Objective: This study examines the impact of the transition process on the mortality of elderly individuals following their first admission to nursing home from the community at 1, 3, and 6 months postadmission, and causes and risk factors for death. Method: A systematic review of relevant studies published between 2000 and 2015 was conducted using key search terms: first admission, death, and nursing homes. Results: Eleven cohort studies met the inclusion criteria. Mortality within the first 6 month postadmission varied from 0% to 34% (median = 20.2). Causes of deaths were not reported. Heightened mortality was not wholly explained by intrinsic resident factors. Only two studies investigated the influence of facility factors, and found an increased risk in facilities with high antipsychotics use. Discussion: Mortality in the immediate period following admission may not simply be due to an individual’s health status. Transition processes and facility characteristics are potentially independent and modifiable risk factors. 1Monash
University, Victoria, Australia Court of Victoria, Australia
2Coroners
Corresponding Author: Joseph E. Ibrahim, Department of Forensic Medicine, Monash University, 65 Kavanagh Street, Southbank, Victoria 3006, Australia. Email: [email protected]
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Keywords transition, admission, long-term care, death, mortality
Introduction The decision to admit an older person into a nursing home is commonly motivated by the belief that they are no longer safe at home (McLennon, Habermann, & Davis, 2010; Ryan & Scullion, 2000). Although there is some evidence that nursing homes may be safer alternative to home care in certain circumstances (Wysocki et al., 2014), it has long been shown that newly admitted older people are at a 2½ times greater risk of dying than those who remain in the community (Aneshensel, Pearlin, Levy-Storms, & Schuler, 2000; McClendon, Smyth, & Neundorfer, 2006). Moreover, a recent study reported a significant increase in the number of residents who died within 6 months of being admitted into nursing homes between 2006 and 2012 (Schon, Lagergren, & Kareholt, 2016). Possible explanations are either frailer individuals likely to experience greater mortality rates selfselect into nursing homes or the transition process and institutional or facility characteristics contribute to premature death (Aneshensel et al., 2000; Shamliyan, Talley, Ramakrishnan, & Kane, 2013). The fact that we still ignore which factors lead to heightened mortality is startling, as this would thoroughly change the approach and management of the 1.4 million people admitted to a nursing home each year in the United States alone (HarrisKojetin, Sengupta, Park-Lee, & Valverde, 2013). Transitions from one place of residence to another are recognized as highrisk periods for patient and resident safety, often characterized by fragmentation in care delivery and insufficient communication between health providers, often due to inadequate definition of the various clinicians’ responsibilities (Boling, 2009; Naylor, 2002). Although nursing home care may be considered a safer alternative to community care for dependent older persons (McLennon et al., 2010), the transition can result in new adverse health events or an acute deterioration of preexisting conditions. These include delirium, worsening disability, malnutrition, falls, injury, and medication-related events (LaMantia, Scheunemann, Viera, Busby-Whitehead, & Hanson, 2010). Stressors identified during a transition period include increased risk of acute injury, disorganized transfers, unfamiliar hazardous environment, and altered patient, resident, staff routines (Greenwald, Denham, & Jack, 2007). Institutionalization also disrupts an individual’s everyday life, leading to readjustment of behavior and sometimes lifelong routines. This set of challenges is particularly problematic for
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vulnerable residents with prevalent cognitive and functional impairment, complex medical conditions, and limited functional reserve (Oakes et al., 2011; Rothman & Brown, 2007). On the contrary, there is evidence that individuals may achieve good quality of life in the community if adequately supported (Huss, Stuck, Rubenstein, Egger, & Clough-Gorr, 2008). The decision to transition to nursing home care therefore requires an informed discussion about the benefits and risks between the individual and their family, clinicians, and nursing home providers. Recent evidence suggests a dichotomy between two groups of residents: one who moves into an institution to live on several years, and another who dies shortly following admission, and increasingly earlier following institutionalization (Schon et al., 2016). While long-term mortality in the former group has been considered (Carlson et al., 2001; Cereda et al., 2011; Dale, Burns, Panter, & Morris, 2001), little is known about why early mortality in the latter occurs increasingly sooner following admission and in a growing number of residents. Studies into nursing home mortality following first admission have focused on resident risk factors (Dale et al., 2001); hence, little is known about the factors surrounding the process of transition, the posttransition period, or nursing home characteristics. As the impact of the transition process diminishes with time (Aneshensel et al., 2000), a more informative metric to examine is mortality within the first 6 months posttransition, as well as the type and levels of preparation prior to transitioning, as this is an important moderator of mortality (Holder & Jolley, 2012). Although a somewhat arbitrary cutoff, there appears to a difference in rates of mortality before and after a period of 6 months postadmission, which therefore appears to be used as a benchmark of early mortality following admission (Aneshensel et al., 2000; Schon et al., 2016). Therefore, this systematic review aimed to determine the impact of the transition process on nursing home residents following first admission by determining (a) the mortality rates within the first 6 months postadmission, (b) the risk factors associated with mortality, and (c) the causes of death.
Method This review was conducted in accordance with PRISMA guidance (Moher et al., 2015). A “transition point” is defined as “some form of destabilisation in the life of a person resulting in change in the level of care and/or support they require” (Hollander, 2001). In this review, “transition” is the process relating to the events and activities before, during, and after a move from community dwelling to nursing home care.
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First admission was defined as the admission of residents from the community to a nursing home (also referred to as long-term care, social care, care homes, or residential aged care services).
Search Strategy Inclusion criteria comprised the following: i. Original research published in a peer-reviewed journal between January 2000 and August 2015; ii. Studies available in English, French, German, or Spanish, as identified during title and abstract review; iii. Study population was nursing home residents; iv. Examined mortality within 6 months of a first admission. Studies were excluded if they 1. examined transfer into, but not out of, acute health care services (emergency departments, hospital inpatient); 2. examined outcomes of older individuals living in the community, as the focus of the present study is the impact of transitioning from the community to a nursing home; 3. investigated transfer to respite care; 4. reported nursing home admission as a study end point; 5. were bibliography, case report, comment, conference abstract, dissertation, thesis, editorial, guidelines, tutorial, or review. Key terms describing first admission, death, and nursing homes (Appendix Table A1) were used. The search included Medline, EMBASE, and Cochrane database of systematic reviews; PsycINFO; CINAHL; Ageline; Web of Science; and Scopus databases. Two authors independently searched the reference list of identified studies. The title and abstracts were screened for eligibility, and then the full text article was reviewed for inclusion by consensus. Predefined data items were extracted or calculated by one of the authors (Tables 1 and 2). Reported scales and scores for functional impairment and comorbidity were converted into a single three-tier scale to compare resident characteristics across studies (Appendix Tables A2 and A3). Two independent reviewers assessed study quality using the National Institutes of Health (NIH; 2015) quality assessment tool for observational studies.
5
Aim 72
24
3
22
6
12
P, Co
P, Co
R, Co
P, Co
R, Co
P, Co
140
10,900
380
60,105
1,195
272
—
—
5,891
—
—
283
95
—
152
508
59
—
S, L
—
S, L
S, L
—
Follow-up Exposed Nonexposed Facility Country Design (months) residents (n) residents (n) NHs (n) size
Social selection vs. social USA causation to explain excess deaths in first admitted residents with dementia Bercovitz, Gruber- Health care utilization USA Baldini, Burton, between NH and Hebel decedents and (2005) survivors, and variation with length of stay Bronskill et al. Association between CAN (2009) antipsychotics and short-term mortality in NH residents Connolly, Broad, Short-term mortality NZL Boyd, Kerse, in NH residents in and Gott (2014) Auckland region Huybrechts, Association between CAN Rothman, psychotropic Silliman, medications and death Brookhart, and upon NH admission Schneeweiss (2011) Liu & Wen (2010) Health outcomes in NH TWN vs. residential home residents following admission
Aneshensel, Pearlin, LevyStorms, & Schuler (2000)
Author, year
Methodology
Table 1. Summary Characteristics and Methods of Studies Included.
—
84
86
84 (77-91)
82 (74-90)
—
M age (range)
52
40
30
32
32
41
—
37
—
44
50
100
—
Mild
—
Mild
Mod
—
Sev
—
—
—
Mild
—
(continued)
8
8
7
9
9
8
Male Dementia/cognitive Severity of Functional Quality (%) impairment (%) comorbidity impairment rating
Setting and population
6
Aim
Methodology
6
60
12
3
R, Co
R, Co
P, Co
P, Co
120
258
841
11,430
1,064
—
—
—
—
—
1
30
—
1,074
59
L
S
—
S, L
75
83 (75-91)
79
—
81
M age (range)
38
30
41
33
30
—
21
—
100
50
—
—
—
—
Mod
—
Mod
—
Sev
Mild
9
8
8
8
9
Male Dementia/cognitive Severity of Functional Quality (%) impairment (%) comorbidity impairment rating
Setting and population
Note. Aim: NH = nursing home. Countries: USA = The United States of America; CAN = Canada; NZL = New Zealand; TWN = Taiwan; GBR = The United Kingdom; NLD = The Netherlands. Study design: P = prospective; R = retrospective; Co = cohort. Facility size: S = small (150 beds). Severity of comorbidity/functional impairment: Mod = moderate; Sev = severe. Quality ratings score: poor = 0-4; fair = 5-9; good = 10-14.
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P, Co
Follow-up Exposed Nonexposed Facility Country Design (months) residents (n) residents (n) NHs (n) size
Association between USA dementia, mortality, adverse health events, and discharge in first admitted residents Mitchell et al. Mortality risk factors in USA (2004) first admitted residents with advanced dementia and 6-month mortality prediction score Raines & Wight Mortality of individuals GBR (2002) admitted to NH from hospital vs. community Sutcliffe et al. Psychiatric morbidity, GBR (2007) cognitive impairment, and survival in first admitted residents Wijnia, Ooms, and Falls risk assessment tool NLD van Balen (2006) for first admitted NH residents
Magaziner et al. (2005)
Author, year
Table 1. (continued)
7
Social selection vs. social causation to explain excess deaths in first admitted residents with dementia
Aneshensel et al. (2000)
Health care Bercovitz, utilization Gruberbetween nursing Baldini, home decedents Burton, and and survivors, Hebel (2005) and variation with length of stay Bronskill et al. Association between (2009) antipsychotics and short-term mortality in NH residents Short-term Connolly, mortality in Broad, Boyd, NH residents in Kerse, and Auckland region Gott (2014)
Aim
Author, year
3 months −
−
8,655 (14.4)a
−
1 month −
123 (10.3)
2,705 (4.5)
26 (6.8)
76 (20)
−
−
40 (14.7)
6 months
Mortality postadmission n (%)
Table 2. Key Findings of Studies Included.
+
NA
NA
+
Mortality admitted vs. nonadmitted
Advancing age
Recently hospital discharge
Hospitalization in previous year Decreasing subjective physical health Severity cognitive impairment Advancing age Men White Greater ADL impairments Greater comorbidities Dementia protective Men
Intrinsic
(continued)
Admit from public hospital Admit to private hospital
Facilities with higher antipsychotic therapy rates
−
−
Extrinsic
Mortality risk factors
8 3 months −
−
0.12b
−
1 month −
−
−
−
Aim
Association between psychotropic medications and death upon NH admission
Huybrechts, Rothman, Silliman, Brookhart, and Schneeweiss (2011) Liu & Wen (2010)
Health outcomes in NH vs. residential home residents following admission Magaziner et al. Association between (2005) dementia, mortality, adverse health events, and discharge in first admitted residents Mitchell et al. Mortality risk (2004) factors in first admitted residents with advanced dementia and 6-month mortality prediction score 3,548 (31)
0.14b
0
1,031 (9.5)
6 months
Mortality postadmission n (%)
Author, year
Table 2. (continued)
NA
NA
NA
NA
Mortality admitted vs. nonadmitted
Male Age >83 years Comorbidities Functional impairment
−
−
−
Intrinsic
(continued)
−
−
−
Conventional antipsychotics, antidepressants, benzodiazepines
Extrinsic
Mortality risk factors
9
Aim
3 months −
−
−
1 month −
−
24 (20)
−
53 (19.8)
184 (34)
6 months
Mortality postadmission n (%)
NA
NA
NA
Mortality admitted vs. nonadmitted
−
Functional dependence Depression
Intrinsic
−
−
−
Extrinsic
Mortality risk factors
Note. Mortality in admitted versus not admitted: + = significant difference in mortality prevalence; − = no significant difference in mortality prevalence; NA = no comparison group (not admitted) included; NR = statistical analysis not performed and/or results not reported; ADL = activities of daily living. aMortality at 4 months postadmission. bRate of death per 100 patient/days in dementia patients admitted under a Medicare qualified stay.
Mortality of individuals admitted to NH from hospital vs. community Sutcliffe et al. Psychiatric (2007) morbidity, cognitive impairment, and survival in first admitted residents Wijnia, Ooms, Falls risk assessment and van Balen tool for first admitted NH (2006) residents
Raines et al. (2002)
Author, year
Table 2. (continued)
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Figure 1. PRISMA guidance flow diagram of identification, screening, and inclusion of eligible studies.
Results Study and Population Characteristics The review process is summarized in Figure 1. The search yielded 2,547 records of which 11 met the inclusion criteria (Table 1). Six studies were from North America (Aneshensel et al., 2000; Bercovitz, Gruber-Baldini,
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Burton, & Hebel, 2005; Bronskill et al., 2009; Huybrechts, Rothman, Silliman, Brookhart, & Schneeweiss, 2011; Magaziner et al., 2005; Mitchell et al., 2004), three from Europe (Raines & Wight, 2002; Sutcliffe et al., 2007; Wijnia, Ooms, & van Balen, 2006), and two from Australasia (Connolly, Broad, Boyd, Kerse, & Gott, 2014; Liu & Wen, 2010). All were cohort studies, judged according to NIH assessment criteria to be of overall fair quality: seven were prospective (Aneshensel et al., 2000; Bercovitz et al., 2005; Connolly et al., 2014; Liu & Wen, 2010; Magaziner et al., 2005; Sutcliffe et al., 2007; Wijnia et al., 2006) and the remaining four had a retrospective design (Bronskill et al., 2009; Huybrechts et al., 2011; Mitchell et al., 2004; Raines & Wight, 2002). Only two studies compared outcomes following transition to groups consisting of the same residents preceding transition and/or of nonadmitted residents (Aneshensel et al., 2000; Connolly et al., 2014). Studies were heterogeneous in number of participating facilities (1-1,074) and residents (120-60,105). Nonetheless, demographic characteristics were homogeneous across studies, with most residents being female, above 80 years of age, and with multiple comorbidities, cognitive impairment or dementia, and some degree of functional impairment (Table 1).
Mortality Measures Mortality within the first 6 months of admission was measured at different time intervals across studies and varied ranging from 0% to 34% of the total study population (median = 20.2; Table 1). In one study, 0.14 deaths per 100 patient/ days 3-month postcare admission were reported (Magaziner et al., 2005). One study observed a rapid decline in resident’s survival rate (26%) in the first 6 months postadmission followed by a return to higher levels of 47%, 54%, and 66% at 1, 2, and 3 years postadmission, respectively (Aneshensel et al., 2000). Comparing mortality postadmission to nursing home with community dwellers, the same study reported an increased risk of death (risk ratio = 1.80; for persons admitted for reasons other than poor health) independent of physical health and socioeconomic status (Aneshensel et al., 2000). This study should be interpreted with caution as health status prior to admission to the care home was established using a questionnaire with family carers rather than a formal medical assessment. Causes of deaths were not reported in any of the studies.
Pretransition Phase Risk Factors Within studies, reported predisposing factors were limited, mostly nonmodifiable, and included age >80 years old, being male, with greater functional
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impairment, and number of comorbidities. Other factors were discordant in impact, including dementia predisposing to death in one study (Aneshensel et al., 2000) yet protective in another (Bercovitz et al., 2005). Recent hospital admission was associated with an increase in mortality risk (Aneshensel et al., 2000; Bronskill et al., 2009) but not in another (Raines & Wight, 2002; Table 2). While the proportion of residents with dementia or cognitive impairment ranged from 21% to 100%, there was no apparent correlation with levels of mortality when comparing between studies. Heterogeneity also applied to functional impairment; however, where known, severity of comorbidities ranged from mild to moderate.
Transition Phase Risk Factors Most studies included nursing homes of various sizes from the small of 50 residents or less to large accommodating 200 or more residents. Many did not specify the number of residents accommodated. Therefore, there was insufficient information to ascertain the size of the nursing home on mortality. Studies also did not include a description of the facility, or programs implemented to facilitate the transition to nursing home, or explicitly recommended any measures to prevent mortality. Nonetheless, indicators reflecting transitional stress (such as difficulty or problems arranging placement, family or caregiver distress, or disagreement on placements) were not found to be associated with mortality in the first 6 months in one study (Aneshensel et al., 2000).
Posttransition Phase Risk Factors Results on the contribution of the transition experience were difficult to ascertain. Characteristics of the destination facilities, such as staff number, qualifications, and orientation programs upon admission, were seldom described. One study (Bronskill et al., 2009) found at 30 and 120 days an increased risk of death (adjusted hazard ratio = 1.28, confidence interval [CI] = [1.06, 1.56], and adjusted hazard ratio = 1.25, CI = [1.13, 1.39], respectively) with admission to a facility with higher intensity of antipsychotic drug use. The second study (Huybrechts et al., 2011) found that among older residents admitted to nursing homes, users of conventional antipsychotics, antidepressants, and benzodiazepines had a higher risk of death (rate ratio [RR] = 1.47, CI = [1.14, 1.91]; RR = 1.20, CI = [0.96, 1.50]; RR = 1.28, CI = [1.04, 1.58], respectively) compared with users of atypical antipsychotics.
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Discussion Notwithstanding the lack of comparison groups in all but two studies and heterogeneity of population sizes, this review confirms that mortality in the first 6 months following admission to nursing homes is high. As expected, intrinsic resident factors are significantly associated with a heightened risk of death postadmission (older, frail, dependent, males with multiple comorbidities). However, the fact that newly admitted residents experienced higher mortality rates even when physical health and sociodemographic characteristics are statistically controlled (Aneshensel et al., 2000) raises the possibility of modifiable risk factors (transition process, facility characteristics) as independent contributors. The published data from observational studies do not provide definitive evidence to determine whether transitioning into nursing home contributes to death in the period immediately following admission. This review highlights a substantive gap in our knowledge that we are compelled to address. Potentially, we may be admitting people who are no longer deemed safe in the community into an environment that is even more hazardous (disorientation, spread of communicable diseases, increased antipsychotic use). Addressing this issue requires a systematic approach to improve safety during the transition process and in admitting facilities. The other major concern is that some individuals are being admitted who, although not thought of as archetype palliative patients, do require end-of-life care, which is not commonly accessible in nursing homes (Schon et al., 2016). In both of these situations, the individual and family, if fully informed and aware of the risks, prognosis, and potential outcomes, may choose to remain at home. The transition as well as the pre- and postadmission events and processes were seldom described, precluding us from determining whether mortality may be due to the transfer or changing conditions regardless of the quality of the new environment. Adverse events (e.g., falls requiring hospitalization, skin ulcers, hip and nonhip fractures, and respiratory infections) are likely to occur during and immediately after admission (Baumgarten et al., 2003; Capezuti, Boltz, Renz, Hoffman, & Norman, 2006; Doupe et al., 2011). In older and frailer individuals, such events may set them on a trajectory to premature death (e.g., hip fractures as a result of falls, or delirium or disorientation associated with unfamiliar or change of environment). These may be prevented through interventions such as sufficient lead-in time, information of the actual transfer and destination facility, and participation in decision making (e.g., choosing the room or bed; Holder & Jolley, 2012).
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There was a paucity of information about institutional factors such as the characteristics of the facilities posttransition, which is surprising as environmental factors such as unfamiliar and hazardous space causing injuries with altered routines are known to affect residents’ health (Dale et al., 2001; Greenwald et al., 2007; Wolinsky, Callahan, Fitzgerald, & Johnson, 1992). Interpretation of institutional factors is challenging. For instance, one of the two studies investigating atypical antipsychotics examined prescribing at an institutional level (Huybrechts et al., 2011) while the other (Magaziner et al., 2005) was an individual-resident level. The drivers of institutional highprescription of atypical antipsychotics are likely to be different from drivers of resident-by-resident decisions to prescribe antipsychotics. To fulfill their obligations in the provision of safer care, nursing home staff and operators require this type of information to reduce potential hazards. An equally important finding was the lack of cause-specific mortality. An understanding of whether deaths are thus due to natural (exacerbation of a chronic disease) or injury-related (falls, choking on food) causes that could have been prevented through tailored effective preventive measures is not possible. Strengths of the review are the contemporary search period, use of multiple databases, and languages. In light of the dearth of evidence on mortality postadmission into nursing homes, this review demonstrates a substantive gap in knowledge on an issue bearing a major and significant impact on individuals and aged care sector as a whole. This constitutes a necessary precursor that informs subsequent programs of empirical research in this field. Limitations of the review are a number of studies did not include a control group of nontransitioned residents, or solely compared mortality preand posttransition. Some studies had very small sample sizes, and important organizational factors that may significantly influence mortality rates such as the quality of care provided and the transfer process were not reported. Studies took place in a variety of nursing home settings, which may have an impact on mortality levels, reflecting the global diversity in aged care facilities. Generalizing insights from these studies is challenging as practices such as rates of antipsychotic prescribing, size, and governance of nursing homes vary enormously within and between countries (Gallagher, Barry, & O’Mahony, 2007). The extrapolation of these findings to other settings must be done cautiously as some studies included residents with mild cognitive and functional impairment. It is likely that the contextual and mechanistic factors underpinning transition of a resident with mild dependency into a
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large nursing home that operates large services over 200 beds will be different to those of a resident with high dependency into a small nursing home that operates 50 beds or less. Better empirical evidence is required, to determine how and to what extent the process of transition into long-term care influences subsequent mortality. Specifically, future primary studies should include a comparison group of nonadmitted residents followed in the period preceding and following transition. In addition, better descriptions of the facility environment and process of care and their influence on mortality should be included. Anecdotal evidence from aged care and clinical practitioners suggests that residents comprise subgroups of older people, some of whom deteriorate relatively rapidly after admission while others live much longer. New evidence emerges that may validate this (Schon et al., 2016). Identifying residents with higher mortality rates could enable appropriate discussions around palliative care at this point of transition. Some residents may gain more benefits by not making the transition but, rather, receive palliative care at home. Additional research should be conducted to further elucidate the risk factors predisposing to death in the first 6 months postadmission, with a view to design a predictive tool for prospective nursing home residents. This could provide better prognostic information, thereby contributing to decision making about if and when to transition. Deciding whether to stay in a community residence, relocate into nursing home, or initiating community or institution-based palliative care is a complex undertaking. This could be a first step toward improving the quality of life, including end-of-life, of older frail people at risk.
Conclusion Transition of care to the nursing home environment from the community is hazardous. A safer transfer is a duty care nursing home executives, managers, the government, and health and aged care professionals owe to residents. Answers are needed to the questions of whether, and to what extent, excess mortality is linked to the transfer process itself, to the environment and practices at destination, or to the fact that it is a significant stressful life event. This knowledge will contribute to providing optimal care for older people. Initiatives to make transitions safer are now possible by acting on the knowledge that there are modifiable risk factors.
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Appendix Table A1. Medline search terms and definitions of transition MEDLINE list of search terms (subject headings in italic). Transition of care (n=18) Patient transfer Patient admission Health Facility Moving Health Facility Closure Relocat* Posttransfer* Postadmission* Posttransition* Postplacement* post after following new* adj3 Transfer*Admission*Transition* Placement* Admit*
Mortality (n=19) Mortality “cause of death” Fatal outcome Mortality, premature Survival rate Death Asphyxia Brain death Death, sudden Death, sudden, cardiac Drowning Iatrogenic Disease mo.fs. Death* Mortalit* Surviv* Fatal* Iatrogen* Die*
Nursing home (n=14) Residential facilities Nursing homes Long term care Homes for the aged Housing for the elderly Skilled nursing facilities Long*term care Longterm care Home*for the aged Old Age Home* Nursing home* Residential aged care Residential facilit* Skilled nursing facilit*
Ovid Medline search strategy Patient Transfer/ Patient Admission/ health facility closure/ or health facility moving/ Institutionalization/ (Relocat* or Posttransfer* or Postadmission* or Posttransition* or Postplacement*).tw. ((post or after or following or new*) adj3 (Transfer* or Admission* or Transition* or Placement* or Admit*)).tw. mortality/ or “cause of death”/ or fatal outcome/ or mortality, premature/ or survival rate/ death/ or asphyxia/ or brain death/ or death, sudden/ or death, sudden, cardiac/ or drowning/ Iatrogenic Disease/ mo.fs. (Death* or Mortalit* or Surviv* or Fatal* or Iatrogen* or Die*).tw. residential facilities/ or homes for the aged/ or nursing homes/ or skilled nursing facilities/ Long-Term Care/ Housing for the Elderly/ (Long*term care or Longterm care or Home* for the aged or Old Age Home* or Nursing home* or Residential aged care or Residential facilit* or Skilled nursing facilit*).tw. 1 or 2 or 3 or 4 or 5 or 6 7 or 8 or 9 or 10 or 11 12 or 13 or 14 or 15 16 and 17 and 18 limit 19 to yr= “2000 - 2015”
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Ferrah et al. Table A2. Conversion of Scales Reporting Functional Impairment of Nursing Home Residents (Hirdes, 2003; Mahoney & Barthel, 1965; Patricia, 2003). Converted scale for functional impairment Mild
Moderate
Severe
Corresponding reported scales and scores for functional impairment Katz ADL scale: 6-4/6 ADL scale: 1-12/28 Barthel scale: 90-100/100 Barthel ADL score: 13-20/20 Katz ADL scale: 2-3/6 ADL scale: 13-20/28 Barthel scale: 60-89/100 Barthel ADL score: 5-12/20 Katz ADL scale: 0-1/6 ADL scale: 21-28/28 Barthel scale: 0-59/100 Barthel ADL score: 0-4/20
Note. ADL = activities of daily living.
Table A3. Conversion of Scales Reporting Severity of Comorbid Conditions of Nursing Home Residents (Haas et al., 2013; Hirdes, 2003; Quan et al., 2011). Converted scale for severity of comorbidities Mild Moderate Severe
Corresponding reported scales and scores for severity of comorbidities Charlson comorbidity index: 1-2 Chess score: 0-1 Chronic comorbidity count: 0-1 Charlson comorbidity index: 3-4 Chess score: 2-3 Chronic comorbidity count: 2-3 Charlson comorbidity index: ≥5 Chess score: 4-5 Chronic comorbidity count: ≥4
Acknowledgments The authors thank Dr. Megan Bohensky for her assistance with the analysis of mortality measures.
Declaration of Conflicting Interests The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
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Journal of Aging and Health
Funding The authors received no financial support for the research, authorship, and/or publication of this article.
References Aneshensel, C. S., Pearlin, L. I., Levy-Storms, L., & Schuler, R. H. (2000). The transition from home to nursing home mortality among people with dementia. The Journals of Gerontology, Series B: Psychological Sciences & Social Sciences, 55, S152-S162. Baumgarten, M., Margolis, D., Gruber-Baldini, A. L., Zimmerman, S., German, P., Hebel, J. R., & Magaziner, J. (2003). Pressure ulcers and the transition to longterm care. Advances in Skin & Wound Care, 16, 299-304. Bercovitz, A., Gruber-Baldini, A. L., Burton, L. C., & Hebel, J. R. (2005). Healthcare utilization of nursing home residents: Comparison between decedents and survivors. Journal of the American Geriatrics Society, 53, 2069-2075. Boling, P. A. (2009). Care transitions and home health care. Clinics in Geriatric Medicine, 25, 135-148. Bronskill, S. E., Rochon, P. A., Gill, S. S., Herrmann, N., Hillmer, M. P., Bell, C. M., . . . Stukel, T. A. (2009). The relationship between variations in antipsychotic prescribing across nursing homes and short-term mortality: Quality of care implications. Medical Care, 47, 1000-1008. Capezuti, E., Boltz, M., Renz, S., Hoffman, D., & Norman, R. G. (2006). Nursing home involuntary relocation: Clinical outcomes and perceptions of residents and families. Journal of the American Medical Directors Association, 7, 486-492. Carlson, M. C., Brandt, J., Steele, C., Baker, A., Stern, Y., & Lyketsos, C. G. (2001). Predictor index of mortality in dementia patients upon entry into long-term care. The Journals of Gerontology, Series A: Biological Sciences & Medical Sciences, 56, M567-M570. doi:10.1093/gerona/56.9.M567 Cereda, E., Pedrolli, C., Zagami, A., Vanotti, A., Piffer, S., Opizzi, A., . . . Caccialanza, R. (2011). Nutritional screening and mortality in newly institutionalised elderly: A comparison between the geriatric nutritional risk index and the mini nutritional assessment. Clinical Nutrition, 30, 793-798. Connolly, M. J., Broad, J. B., Boyd, M., Kerse, N., & Gott, M. (2014). Residential aged care: The de facto hospice for New Zealand’s older people. Australasian Journal on Ageing, 33, 114-120. Dale, M. C., Burns, A., Panter, L., & Morris, J. (2001). Factors affecting survival of elderly nursing home residents. International Journal of Geriatric Psychiatry, 16, 70-76. Doupe, M., Brownell, M., St. John, P., Strang, D. G., Chateau, D., & Dik, N. (2011). Nursing home adverse events: Further insight into highest risk periods. Journal of the American Medical Directors Association, 12, 467-474. doi:10.1016/j. jamda.2011.02.002
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Gallagher, P., Barry, P., & O’Mahony, D. (2007). Inappropriate prescribing in the elderly. Journal of Clinical Pharmacy and Therapeutics, 32, 113-121. doi:10.1111/j.1365-2710.2007.00793.x Greenwald, J. L., Denham, C. R., & Jack, B. W. (2007). The hospital discharge: A review of a high risk care transition with highlights of a reengineered discharge process. Journal of Patient Safety, 3, 97-106. Haas, L. R., Takahashi, P. Y., Shah, N. D., Stroebel, R. J., Bernard, M. E., Finnie, D. M., . . . Naessens, J. M. (2013). Risk-stratification methods for identifying patients for care coordination. The American Journal of Managed Care, 19, 725-732. Harris-Kojetin, L., Sengupta, M., Park-Lee, E., & Valverde, R. (2013). Long-term care services in the United States: 2013 overview (Vital & health statistics. Series 3, No. 37, Analytical and epidemiological studies). Atlanta, Georgia: U.S. Department of Health and Human Services, Public Health Service, National Center for Health Statistics. Hirdes, J. (2003). The MDS-CHESS Scale: A new measure to predict mortality in institutionalized older people. Journal of the American Geriatrics Society, 51, 96-100. doi:10.1034/j.1601-5215.2002.51017.x Holder, J. M., & Jolley, D. (2012). Forced relocation between nursing homes: Residents’ health outcomes and potential moderators. Reviews in Clinical Gerontology, 22, 301-319. Hollander, M. J. (2001). Final report of the study on the comparative cost analysis of home care and residential care services. Ottawa, Ontario: Health Transition Fund, Health Canada. Huss, A., Stuck, A. E., Rubenstein, L. Z., Egger, M., & Clough-Gorr, K. M. (2008). Multidimensional preventive home visit programs for community-dwelling older adults: A systematic review and meta-analysis of randomized controlled trials. Journals of Gerontology, Series A: Biological Sciences & Medical Sciences, 63A, 298-307. Huybrechts, K. F., Rothman, K. J., Silliman, R. A., Brookhart, M. A., & Schneeweiss, S. (2011). Risk of death and hospital admission for major medical events after initiation of psychotropic medications in older adults admitted to nursing homes. Canadian Medical Association Journal, 183, E411-E419. LaMantia, M. A., Scheunemann, L. P., Viera, A. J., Busby-Whitehead, J., & Hanson, L. C. (2010). Interventions to improve transitional care between nursing homes and hospitals: A systematic review. Journal of the American Geriatrics Society, 58, 777-782. Liu, L.-F., & Wen, M.-J. (2010). A longitudinal evaluation of residents’ health outcomes in nursing homes and residential care homes in Taiwan. Quality of Life Research, 19, 1007-1018. Magaziner, J., Zimmerman, S., Gruber-Baldini, A. L., Van Doorn, C., Hebel, J. R., German, P., . . . Baumgarten, M. (2005). Mortality and adverse health events in newly admitted nursing home residents with and without dementia. Journal of the American Geriatrics Society, 53, 1858-1866.
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Mahoney, F. I., & Barthel, D. W. (1965). Functional evaluation: The Barthel Index. Maryland State Medical Journal, 14, 61-65. McClendon, M. J., Smyth, K. A., & Neundorfer, M. M. (2006). Long-term-care placement and survival of persons with Alzheimer’s disease. Journals of Gerontology, Series B: Psychological Sciences & Social Sciences, 61, P220-P227. McLennon, S. M., Habermann, B., & Davis, L. L. (2010). Deciding to institutionalize: Why do family members cease caregiving at home? Journal of Neuroscience Nursing, 42, 95-103. doi:10.1097/JNN.0b013e3181ce5c45 Mitchell, S. L., Kiely, D. K., Hamel, M. B., Park, P. S., Morris, J. N., & Fries, B. E. (2004). Estimating prognosis for nursing home residents with advanced dementia. Journal of the American Medical Association, 291, 2734-2740. Moher, D., Shamseer, L., Clarke, M., Ghersi, D., Liberati, A., Petticrew, M., . . . Stewart, L. A. (2015). Preferred reporting items for systematic review and metaanalysis protocols (PRISMA-P) 2015 statement. Systematic Reviews, 4, Article 1. doi:10.1186/2046-4053-4-1 National Institutes of Health. (2015). Quality assessment tool for observational cohort and cross-sectional studies. Retrieved from http://www.nhlbi.nih.gov/health-pro/ guidelines/in-develop/cardiovascular-risk-reduction/tools/cohort Naylor, M. D. (2002). Transitional care of older adults. Annual Review of Nursing Research, 20, 127-147. Oakes, S. L., Gillespie, S. M., Ye, Y., Finley, M., Russell, M., Patel, N. K., & Espino, D. (2011). Transitional care of the long-term care patient. Clinics in Geriatric Medicine, 27, 259-271. Patricia, P. K. (2003). Measures of adult general functional status: The Barthel Index, Katz Index of Activities of Daily Living, Health Assessment Questionnaire (HAQ), MACTAR Patient Preference Disability Questionnaire, and Modified Health Assessment Questionnaire (MHAQ). Arthritis Care & Research, 49(Suppl. 5), S15-S27. Quan, H., Li, B., Couris, C. M., Fushimi, K., Graham, P., Hider, P., . . . Sundararajan, V. (2011). Updating and validating the Charlson comorbidity index and score for risk adjustment in hospital discharge abstracts using data from 6 countries. American Journal of Epidemiology, 173, 676-682. Raines, J. E., & Wight, J. (2002). The mortality experience of people admitted to nursing homes. Journal of Public Health, 24, 184-189. Rothman, M., & Brown, L. (2007). The vulnerable geriatric casualty: Medical needs of frail older adults during disasters. Generations, 31(4), 16-20. Ryan, A. A., & Scullion, H. F. (2000). Nursing home placement: An exploration of the experiences of family carers. Journal of Advanced Nursing, 32, 1187-1195. Schon, P., Lagergren, M., & Kareholt, I. (2016). Rapid decrease in length of stay in institutional care for older people in Sweden between 2006 and 2012: Results from a population-based study. Health and Social Care in the Community, 24, 631-638. doi:10.1111/hsc.12237 Shamliyan, T., Talley, K. M. C., Ramakrishnan, R., & Kane, R. L. (2013). Association of frailty with survival: A systematic literature review. Ageing Research Reviews, 12, 719-736. doi:10.1016/j.arr.2012.03.001
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Sutcliffe, C., Burns, A., Challis, D., Mozley, C. G., Cordingley, L., Bagley, H., & Huxley, P. (2007). Depressed mood, cognitive impairment, and survival in older people admitted to care homes in England. The American Journal of Geriatric Psychiatry, 15, 708-715. Wijnia, J. W., Ooms, M. E., & van Balen, R. (2006). Validity of the STRATIFY risk score of falls in nursing homes. Preventive medicine, 42, 154-157. Wolinsky, F. D., Callahan, C. M., Fitzgerald, J. F., & Johnson, R. J. (1992). The risk of nursing home placement and subsequent death among older adults. Journal of Gerontology, 47, S173-S182. Wysocki, A., Kane, R. L., Dowd, B., Golberstein, E., Lum, T., & Shippee, T. (2014). Hospitalization of elderly medicaid long-term care users who transition from nursing homes. Journal of the American Geriatrics Society, 62, 71-78. doi:10.1111/jgs.12614
JAHXXX10.1177/0898264316686575Journal of Aging and HealthFerrah et al.
Article
Death Following Recent Admission Into Nursing Home From Community Living: A Systematic Review Into the Transition Process
Journal of Aging and Health 1–21 © The Author(s) 2017 Reprints and permissions: sagepub.com/journalsPermissions.nav https://doi.org/10.1177/0898264316686575 DOI: 10.1177/0898264316686575 journals.sagepub.com/home/jah
Noha Ferrah, MD1, Joseph Elias Ibrahim, FAFPHM1, Chebiwot Kipsaina, MD1, and Lyndal Bugeja, PhD1,2
Abstract Objective: This study examines the impact of the transition process on the mortality of elderly individuals following their first admission to nursing home from the community at 1, 3, and 6 months postadmission, and causes and risk factors for death. Method: A systematic review of relevant studies published between 2000 and 2015 was conducted using key search terms: first admission, death, and nursing homes. Results: Eleven cohort studies met the inclusion criteria. Mortality within the first 6 month postadmission varied from 0% to 34% (median = 20.2). Causes of deaths were not reported. Heightened mortality was not wholly explained by intrinsic resident factors. Only two studies investigated the influence of facility factors, and found an increased risk in facilities with high antipsychotics use. Discussion: Mortality in the immediate period following admission may not simply be due to an individual’s health status. Transition processes and facility characteristics are potentially independent and modifiable risk factors. 1Monash
University, Victoria, Australia Court of Victoria, Australia
2Coroners
Corresponding Author: Joseph E. Ibrahim, Department of Forensic Medicine, Monash University, 65 Kavanagh Street, Southbank, Victoria 3006, Australia. Email: [email protected]
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Keywords transition, admission, long-term care, death, mortality
Introduction The decision to admit an older person into a nursing home is commonly motivated by the belief that they are no longer safe at home (McLennon, Habermann, & Davis, 2010; Ryan & Scullion, 2000). Although there is some evidence that nursing homes may be safer alternative to home care in certain circumstances (Wysocki et al., 2014), it has long been shown that newly admitted older people are at a 2½ times greater risk of dying than those who remain in the community (Aneshensel, Pearlin, Levy-Storms, & Schuler, 2000; McClendon, Smyth, & Neundorfer, 2006). Moreover, a recent study reported a significant increase in the number of residents who died within 6 months of being admitted into nursing homes between 2006 and 2012 (Schon, Lagergren, & Kareholt, 2016). Possible explanations are either frailer individuals likely to experience greater mortality rates selfselect into nursing homes or the transition process and institutional or facility characteristics contribute to premature death (Aneshensel et al., 2000; Shamliyan, Talley, Ramakrishnan, & Kane, 2013). The fact that we still ignore which factors lead to heightened mortality is startling, as this would thoroughly change the approach and management of the 1.4 million people admitted to a nursing home each year in the United States alone (HarrisKojetin, Sengupta, Park-Lee, & Valverde, 2013). Transitions from one place of residence to another are recognized as highrisk periods for patient and resident safety, often characterized by fragmentation in care delivery and insufficient communication between health providers, often due to inadequate definition of the various clinicians’ responsibilities (Boling, 2009; Naylor, 2002). Although nursing home care may be considered a safer alternative to community care for dependent older persons (McLennon et al., 2010), the transition can result in new adverse health events or an acute deterioration of preexisting conditions. These include delirium, worsening disability, malnutrition, falls, injury, and medication-related events (LaMantia, Scheunemann, Viera, Busby-Whitehead, & Hanson, 2010). Stressors identified during a transition period include increased risk of acute injury, disorganized transfers, unfamiliar hazardous environment, and altered patient, resident, staff routines (Greenwald, Denham, & Jack, 2007). Institutionalization also disrupts an individual’s everyday life, leading to readjustment of behavior and sometimes lifelong routines. This set of challenges is particularly problematic for
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vulnerable residents with prevalent cognitive and functional impairment, complex medical conditions, and limited functional reserve (Oakes et al., 2011; Rothman & Brown, 2007). On the contrary, there is evidence that individuals may achieve good quality of life in the community if adequately supported (Huss, Stuck, Rubenstein, Egger, & Clough-Gorr, 2008). The decision to transition to nursing home care therefore requires an informed discussion about the benefits and risks between the individual and their family, clinicians, and nursing home providers. Recent evidence suggests a dichotomy between two groups of residents: one who moves into an institution to live on several years, and another who dies shortly following admission, and increasingly earlier following institutionalization (Schon et al., 2016). While long-term mortality in the former group has been considered (Carlson et al., 2001; Cereda et al., 2011; Dale, Burns, Panter, & Morris, 2001), little is known about why early mortality in the latter occurs increasingly sooner following admission and in a growing number of residents. Studies into nursing home mortality following first admission have focused on resident risk factors (Dale et al., 2001); hence, little is known about the factors surrounding the process of transition, the posttransition period, or nursing home characteristics. As the impact of the transition process diminishes with time (Aneshensel et al., 2000), a more informative metric to examine is mortality within the first 6 months posttransition, as well as the type and levels of preparation prior to transitioning, as this is an important moderator of mortality (Holder & Jolley, 2012). Although a somewhat arbitrary cutoff, there appears to a difference in rates of mortality before and after a period of 6 months postadmission, which therefore appears to be used as a benchmark of early mortality following admission (Aneshensel et al., 2000; Schon et al., 2016). Therefore, this systematic review aimed to determine the impact of the transition process on nursing home residents following first admission by determining (a) the mortality rates within the first 6 months postadmission, (b) the risk factors associated with mortality, and (c) the causes of death.
Method This review was conducted in accordance with PRISMA guidance (Moher et al., 2015). A “transition point” is defined as “some form of destabilisation in the life of a person resulting in change in the level of care and/or support they require” (Hollander, 2001). In this review, “transition” is the process relating to the events and activities before, during, and after a move from community dwelling to nursing home care.
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First admission was defined as the admission of residents from the community to a nursing home (also referred to as long-term care, social care, care homes, or residential aged care services).
Search Strategy Inclusion criteria comprised the following: i. Original research published in a peer-reviewed journal between January 2000 and August 2015; ii. Studies available in English, French, German, or Spanish, as identified during title and abstract review; iii. Study population was nursing home residents; iv. Examined mortality within 6 months of a first admission. Studies were excluded if they 1. examined transfer into, but not out of, acute health care services (emergency departments, hospital inpatient); 2. examined outcomes of older individuals living in the community, as the focus of the present study is the impact of transitioning from the community to a nursing home; 3. investigated transfer to respite care; 4. reported nursing home admission as a study end point; 5. were bibliography, case report, comment, conference abstract, dissertation, thesis, editorial, guidelines, tutorial, or review. Key terms describing first admission, death, and nursing homes (Appendix Table A1) were used. The search included Medline, EMBASE, and Cochrane database of systematic reviews; PsycINFO; CINAHL; Ageline; Web of Science; and Scopus databases. Two authors independently searched the reference list of identified studies. The title and abstracts were screened for eligibility, and then the full text article was reviewed for inclusion by consensus. Predefined data items were extracted or calculated by one of the authors (Tables 1 and 2). Reported scales and scores for functional impairment and comorbidity were converted into a single three-tier scale to compare resident characteristics across studies (Appendix Tables A2 and A3). Two independent reviewers assessed study quality using the National Institutes of Health (NIH; 2015) quality assessment tool for observational studies.
5
Aim 72
24
3
22
6
12
P, Co
P, Co
R, Co
P, Co
R, Co
P, Co
140
10,900
380
60,105
1,195
272
—
—
5,891
—
—
283
95
—
152
508
59
—
S, L
—
S, L
S, L
—
Follow-up Exposed Nonexposed Facility Country Design (months) residents (n) residents (n) NHs (n) size
Social selection vs. social USA causation to explain excess deaths in first admitted residents with dementia Bercovitz, Gruber- Health care utilization USA Baldini, Burton, between NH and Hebel decedents and (2005) survivors, and variation with length of stay Bronskill et al. Association between CAN (2009) antipsychotics and short-term mortality in NH residents Connolly, Broad, Short-term mortality NZL Boyd, Kerse, in NH residents in and Gott (2014) Auckland region Huybrechts, Association between CAN Rothman, psychotropic Silliman, medications and death Brookhart, and upon NH admission Schneeweiss (2011) Liu & Wen (2010) Health outcomes in NH TWN vs. residential home residents following admission
Aneshensel, Pearlin, LevyStorms, & Schuler (2000)
Author, year
Methodology
Table 1. Summary Characteristics and Methods of Studies Included.
—
84
86
84 (77-91)
82 (74-90)
—
M age (range)
52
40
30
32
32
41
—
37
—
44
50
100
—
Mild
—
Mild
Mod
—
Sev
—
—
—
Mild
—
(continued)
8
8
7
9
9
8
Male Dementia/cognitive Severity of Functional Quality (%) impairment (%) comorbidity impairment rating
Setting and population
6
Aim
Methodology
6
60
12
3
R, Co
R, Co
P, Co
P, Co
120
258
841
11,430
1,064
—
—
—
—
—
1
30
—
1,074
59
L
S
—
S, L
75
83 (75-91)
79
—
81
M age (range)
38
30
41
33
30
—
21
—
100
50
—
—
—
—
Mod
—
Mod
—
Sev
Mild
9
8
8
8
9
Male Dementia/cognitive Severity of Functional Quality (%) impairment (%) comorbidity impairment rating
Setting and population
Note. Aim: NH = nursing home. Countries: USA = The United States of America; CAN = Canada; NZL = New Zealand; TWN = Taiwan; GBR = The United Kingdom; NLD = The Netherlands. Study design: P = prospective; R = retrospective; Co = cohort. Facility size: S = small (150 beds). Severity of comorbidity/functional impairment: Mod = moderate; Sev = severe. Quality ratings score: poor = 0-4; fair = 5-9; good = 10-14.
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P, Co
Follow-up Exposed Nonexposed Facility Country Design (months) residents (n) residents (n) NHs (n) size
Association between USA dementia, mortality, adverse health events, and discharge in first admitted residents Mitchell et al. Mortality risk factors in USA (2004) first admitted residents with advanced dementia and 6-month mortality prediction score Raines & Wight Mortality of individuals GBR (2002) admitted to NH from hospital vs. community Sutcliffe et al. Psychiatric morbidity, GBR (2007) cognitive impairment, and survival in first admitted residents Wijnia, Ooms, and Falls risk assessment tool NLD van Balen (2006) for first admitted NH residents
Magaziner et al. (2005)
Author, year
Table 1. (continued)
7
Social selection vs. social causation to explain excess deaths in first admitted residents with dementia
Aneshensel et al. (2000)
Health care Bercovitz, utilization Gruberbetween nursing Baldini, home decedents Burton, and and survivors, Hebel (2005) and variation with length of stay Bronskill et al. Association between (2009) antipsychotics and short-term mortality in NH residents Short-term Connolly, mortality in Broad, Boyd, NH residents in Kerse, and Auckland region Gott (2014)
Aim
Author, year
3 months −
−
8,655 (14.4)a
−
1 month −
123 (10.3)
2,705 (4.5)
26 (6.8)
76 (20)
−
−
40 (14.7)
6 months
Mortality postadmission n (%)
Table 2. Key Findings of Studies Included.
+
NA
NA
+
Mortality admitted vs. nonadmitted
Advancing age
Recently hospital discharge
Hospitalization in previous year Decreasing subjective physical health Severity cognitive impairment Advancing age Men White Greater ADL impairments Greater comorbidities Dementia protective Men
Intrinsic
(continued)
Admit from public hospital Admit to private hospital
Facilities with higher antipsychotic therapy rates
−
−
Extrinsic
Mortality risk factors
8 3 months −
−
0.12b
−
1 month −
−
−
−
Aim
Association between psychotropic medications and death upon NH admission
Huybrechts, Rothman, Silliman, Brookhart, and Schneeweiss (2011) Liu & Wen (2010)
Health outcomes in NH vs. residential home residents following admission Magaziner et al. Association between (2005) dementia, mortality, adverse health events, and discharge in first admitted residents Mitchell et al. Mortality risk (2004) factors in first admitted residents with advanced dementia and 6-month mortality prediction score 3,548 (31)
0.14b
0
1,031 (9.5)
6 months
Mortality postadmission n (%)
Author, year
Table 2. (continued)
NA
NA
NA
NA
Mortality admitted vs. nonadmitted
Male Age >83 years Comorbidities Functional impairment
−
−
−
Intrinsic
(continued)
−
−
−
Conventional antipsychotics, antidepressants, benzodiazepines
Extrinsic
Mortality risk factors
9
Aim
3 months −
−
−
1 month −
−
24 (20)
−
53 (19.8)
184 (34)
6 months
Mortality postadmission n (%)
NA
NA
NA
Mortality admitted vs. nonadmitted
−
Functional dependence Depression
Intrinsic
−
−
−
Extrinsic
Mortality risk factors
Note. Mortality in admitted versus not admitted: + = significant difference in mortality prevalence; − = no significant difference in mortality prevalence; NA = no comparison group (not admitted) included; NR = statistical analysis not performed and/or results not reported; ADL = activities of daily living. aMortality at 4 months postadmission. bRate of death per 100 patient/days in dementia patients admitted under a Medicare qualified stay.
Mortality of individuals admitted to NH from hospital vs. community Sutcliffe et al. Psychiatric (2007) morbidity, cognitive impairment, and survival in first admitted residents Wijnia, Ooms, Falls risk assessment and van Balen tool for first admitted NH (2006) residents
Raines et al. (2002)
Author, year
Table 2. (continued)
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Figure 1. PRISMA guidance flow diagram of identification, screening, and inclusion of eligible studies.
Results Study and Population Characteristics The review process is summarized in Figure 1. The search yielded 2,547 records of which 11 met the inclusion criteria (Table 1). Six studies were from North America (Aneshensel et al., 2000; Bercovitz, Gruber-Baldini,
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Burton, & Hebel, 2005; Bronskill et al., 2009; Huybrechts, Rothman, Silliman, Brookhart, & Schneeweiss, 2011; Magaziner et al., 2005; Mitchell et al., 2004), three from Europe (Raines & Wight, 2002; Sutcliffe et al., 2007; Wijnia, Ooms, & van Balen, 2006), and two from Australasia (Connolly, Broad, Boyd, Kerse, & Gott, 2014; Liu & Wen, 2010). All were cohort studies, judged according to NIH assessment criteria to be of overall fair quality: seven were prospective (Aneshensel et al., 2000; Bercovitz et al., 2005; Connolly et al., 2014; Liu & Wen, 2010; Magaziner et al., 2005; Sutcliffe et al., 2007; Wijnia et al., 2006) and the remaining four had a retrospective design (Bronskill et al., 2009; Huybrechts et al., 2011; Mitchell et al., 2004; Raines & Wight, 2002). Only two studies compared outcomes following transition to groups consisting of the same residents preceding transition and/or of nonadmitted residents (Aneshensel et al., 2000; Connolly et al., 2014). Studies were heterogeneous in number of participating facilities (1-1,074) and residents (120-60,105). Nonetheless, demographic characteristics were homogeneous across studies, with most residents being female, above 80 years of age, and with multiple comorbidities, cognitive impairment or dementia, and some degree of functional impairment (Table 1).
Mortality Measures Mortality within the first 6 months of admission was measured at different time intervals across studies and varied ranging from 0% to 34% of the total study population (median = 20.2; Table 1). In one study, 0.14 deaths per 100 patient/ days 3-month postcare admission were reported (Magaziner et al., 2005). One study observed a rapid decline in resident’s survival rate (26%) in the first 6 months postadmission followed by a return to higher levels of 47%, 54%, and 66% at 1, 2, and 3 years postadmission, respectively (Aneshensel et al., 2000). Comparing mortality postadmission to nursing home with community dwellers, the same study reported an increased risk of death (risk ratio = 1.80; for persons admitted for reasons other than poor health) independent of physical health and socioeconomic status (Aneshensel et al., 2000). This study should be interpreted with caution as health status prior to admission to the care home was established using a questionnaire with family carers rather than a formal medical assessment. Causes of deaths were not reported in any of the studies.
Pretransition Phase Risk Factors Within studies, reported predisposing factors were limited, mostly nonmodifiable, and included age >80 years old, being male, with greater functional
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impairment, and number of comorbidities. Other factors were discordant in impact, including dementia predisposing to death in one study (Aneshensel et al., 2000) yet protective in another (Bercovitz et al., 2005). Recent hospital admission was associated with an increase in mortality risk (Aneshensel et al., 2000; Bronskill et al., 2009) but not in another (Raines & Wight, 2002; Table 2). While the proportion of residents with dementia or cognitive impairment ranged from 21% to 100%, there was no apparent correlation with levels of mortality when comparing between studies. Heterogeneity also applied to functional impairment; however, where known, severity of comorbidities ranged from mild to moderate.
Transition Phase Risk Factors Most studies included nursing homes of various sizes from the small of 50 residents or less to large accommodating 200 or more residents. Many did not specify the number of residents accommodated. Therefore, there was insufficient information to ascertain the size of the nursing home on mortality. Studies also did not include a description of the facility, or programs implemented to facilitate the transition to nursing home, or explicitly recommended any measures to prevent mortality. Nonetheless, indicators reflecting transitional stress (such as difficulty or problems arranging placement, family or caregiver distress, or disagreement on placements) were not found to be associated with mortality in the first 6 months in one study (Aneshensel et al., 2000).
Posttransition Phase Risk Factors Results on the contribution of the transition experience were difficult to ascertain. Characteristics of the destination facilities, such as staff number, qualifications, and orientation programs upon admission, were seldom described. One study (Bronskill et al., 2009) found at 30 and 120 days an increased risk of death (adjusted hazard ratio = 1.28, confidence interval [CI] = [1.06, 1.56], and adjusted hazard ratio = 1.25, CI = [1.13, 1.39], respectively) with admission to a facility with higher intensity of antipsychotic drug use. The second study (Huybrechts et al., 2011) found that among older residents admitted to nursing homes, users of conventional antipsychotics, antidepressants, and benzodiazepines had a higher risk of death (rate ratio [RR] = 1.47, CI = [1.14, 1.91]; RR = 1.20, CI = [0.96, 1.50]; RR = 1.28, CI = [1.04, 1.58], respectively) compared with users of atypical antipsychotics.
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Discussion Notwithstanding the lack of comparison groups in all but two studies and heterogeneity of population sizes, this review confirms that mortality in the first 6 months following admission to nursing homes is high. As expected, intrinsic resident factors are significantly associated with a heightened risk of death postadmission (older, frail, dependent, males with multiple comorbidities). However, the fact that newly admitted residents experienced higher mortality rates even when physical health and sociodemographic characteristics are statistically controlled (Aneshensel et al., 2000) raises the possibility of modifiable risk factors (transition process, facility characteristics) as independent contributors. The published data from observational studies do not provide definitive evidence to determine whether transitioning into nursing home contributes to death in the period immediately following admission. This review highlights a substantive gap in our knowledge that we are compelled to address. Potentially, we may be admitting people who are no longer deemed safe in the community into an environment that is even more hazardous (disorientation, spread of communicable diseases, increased antipsychotic use). Addressing this issue requires a systematic approach to improve safety during the transition process and in admitting facilities. The other major concern is that some individuals are being admitted who, although not thought of as archetype palliative patients, do require end-of-life care, which is not commonly accessible in nursing homes (Schon et al., 2016). In both of these situations, the individual and family, if fully informed and aware of the risks, prognosis, and potential outcomes, may choose to remain at home. The transition as well as the pre- and postadmission events and processes were seldom described, precluding us from determining whether mortality may be due to the transfer or changing conditions regardless of the quality of the new environment. Adverse events (e.g., falls requiring hospitalization, skin ulcers, hip and nonhip fractures, and respiratory infections) are likely to occur during and immediately after admission (Baumgarten et al., 2003; Capezuti, Boltz, Renz, Hoffman, & Norman, 2006; Doupe et al., 2011). In older and frailer individuals, such events may set them on a trajectory to premature death (e.g., hip fractures as a result of falls, or delirium or disorientation associated with unfamiliar or change of environment). These may be prevented through interventions such as sufficient lead-in time, information of the actual transfer and destination facility, and participation in decision making (e.g., choosing the room or bed; Holder & Jolley, 2012).
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There was a paucity of information about institutional factors such as the characteristics of the facilities posttransition, which is surprising as environmental factors such as unfamiliar and hazardous space causing injuries with altered routines are known to affect residents’ health (Dale et al., 2001; Greenwald et al., 2007; Wolinsky, Callahan, Fitzgerald, & Johnson, 1992). Interpretation of institutional factors is challenging. For instance, one of the two studies investigating atypical antipsychotics examined prescribing at an institutional level (Huybrechts et al., 2011) while the other (Magaziner et al., 2005) was an individual-resident level. The drivers of institutional highprescription of atypical antipsychotics are likely to be different from drivers of resident-by-resident decisions to prescribe antipsychotics. To fulfill their obligations in the provision of safer care, nursing home staff and operators require this type of information to reduce potential hazards. An equally important finding was the lack of cause-specific mortality. An understanding of whether deaths are thus due to natural (exacerbation of a chronic disease) or injury-related (falls, choking on food) causes that could have been prevented through tailored effective preventive measures is not possible. Strengths of the review are the contemporary search period, use of multiple databases, and languages. In light of the dearth of evidence on mortality postadmission into nursing homes, this review demonstrates a substantive gap in knowledge on an issue bearing a major and significant impact on individuals and aged care sector as a whole. This constitutes a necessary precursor that informs subsequent programs of empirical research in this field. Limitations of the review are a number of studies did not include a control group of nontransitioned residents, or solely compared mortality preand posttransition. Some studies had very small sample sizes, and important organizational factors that may significantly influence mortality rates such as the quality of care provided and the transfer process were not reported. Studies took place in a variety of nursing home settings, which may have an impact on mortality levels, reflecting the global diversity in aged care facilities. Generalizing insights from these studies is challenging as practices such as rates of antipsychotic prescribing, size, and governance of nursing homes vary enormously within and between countries (Gallagher, Barry, & O’Mahony, 2007). The extrapolation of these findings to other settings must be done cautiously as some studies included residents with mild cognitive and functional impairment. It is likely that the contextual and mechanistic factors underpinning transition of a resident with mild dependency into a
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large nursing home that operates large services over 200 beds will be different to those of a resident with high dependency into a small nursing home that operates 50 beds or less. Better empirical evidence is required, to determine how and to what extent the process of transition into long-term care influences subsequent mortality. Specifically, future primary studies should include a comparison group of nonadmitted residents followed in the period preceding and following transition. In addition, better descriptions of the facility environment and process of care and their influence on mortality should be included. Anecdotal evidence from aged care and clinical practitioners suggests that residents comprise subgroups of older people, some of whom deteriorate relatively rapidly after admission while others live much longer. New evidence emerges that may validate this (Schon et al., 2016). Identifying residents with higher mortality rates could enable appropriate discussions around palliative care at this point of transition. Some residents may gain more benefits by not making the transition but, rather, receive palliative care at home. Additional research should be conducted to further elucidate the risk factors predisposing to death in the first 6 months postadmission, with a view to design a predictive tool for prospective nursing home residents. This could provide better prognostic information, thereby contributing to decision making about if and when to transition. Deciding whether to stay in a community residence, relocate into nursing home, or initiating community or institution-based palliative care is a complex undertaking. This could be a first step toward improving the quality of life, including end-of-life, of older frail people at risk.
Conclusion Transition of care to the nursing home environment from the community is hazardous. A safer transfer is a duty care nursing home executives, managers, the government, and health and aged care professionals owe to residents. Answers are needed to the questions of whether, and to what extent, excess mortality is linked to the transfer process itself, to the environment and practices at destination, or to the fact that it is a significant stressful life event. This knowledge will contribute to providing optimal care for older people. Initiatives to make transitions safer are now possible by acting on the knowledge that there are modifiable risk factors.
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Appendix Table A1. Medline search terms and definitions of transition MEDLINE list of search terms (subject headings in italic). Transition of care (n=18) Patient transfer Patient admission Health Facility Moving Health Facility Closure Relocat* Posttransfer* Postadmission* Posttransition* Postplacement* post after following new* adj3 Transfer*Admission*Transition* Placement* Admit*
Mortality (n=19) Mortality “cause of death” Fatal outcome Mortality, premature Survival rate Death Asphyxia Brain death Death, sudden Death, sudden, cardiac Drowning Iatrogenic Disease mo.fs. Death* Mortalit* Surviv* Fatal* Iatrogen* Die*
Nursing home (n=14) Residential facilities Nursing homes Long term care Homes for the aged Housing for the elderly Skilled nursing facilities Long*term care Longterm care Home*for the aged Old Age Home* Nursing home* Residential aged care Residential facilit* Skilled nursing facilit*
Ovid Medline search strategy Patient Transfer/ Patient Admission/ health facility closure/ or health facility moving/ Institutionalization/ (Relocat* or Posttransfer* or Postadmission* or Posttransition* or Postplacement*).tw. ((post or after or following or new*) adj3 (Transfer* or Admission* or Transition* or Placement* or Admit*)).tw. mortality/ or “cause of death”/ or fatal outcome/ or mortality, premature/ or survival rate/ death/ or asphyxia/ or brain death/ or death, sudden/ or death, sudden, cardiac/ or drowning/ Iatrogenic Disease/ mo.fs. (Death* or Mortalit* or Surviv* or Fatal* or Iatrogen* or Die*).tw. residential facilities/ or homes for the aged/ or nursing homes/ or skilled nursing facilities/ Long-Term Care/ Housing for the Elderly/ (Long*term care or Longterm care or Home* for the aged or Old Age Home* or Nursing home* or Residential aged care or Residential facilit* or Skilled nursing facilit*).tw. 1 or 2 or 3 or 4 or 5 or 6 7 or 8 or 9 or 10 or 11 12 or 13 or 14 or 15 16 and 17 and 18 limit 19 to yr= “2000 - 2015”
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Ferrah et al. Table A2. Conversion of Scales Reporting Functional Impairment of Nursing Home Residents (Hirdes, 2003; Mahoney & Barthel, 1965; Patricia, 2003). Converted scale for functional impairment Mild
Moderate
Severe
Corresponding reported scales and scores for functional impairment Katz ADL scale: 6-4/6 ADL scale: 1-12/28 Barthel scale: 90-100/100 Barthel ADL score: 13-20/20 Katz ADL scale: 2-3/6 ADL scale: 13-20/28 Barthel scale: 60-89/100 Barthel ADL score: 5-12/20 Katz ADL scale: 0-1/6 ADL scale: 21-28/28 Barthel scale: 0-59/100 Barthel ADL score: 0-4/20
Note. ADL = activities of daily living.
Table A3. Conversion of Scales Reporting Severity of Comorbid Conditions of Nursing Home Residents (Haas et al., 2013; Hirdes, 2003; Quan et al., 2011). Converted scale for severity of comorbidities Mild Moderate Severe
Corresponding reported scales and scores for severity of comorbidities Charlson comorbidity index: 1-2 Chess score: 0-1 Chronic comorbidity count: 0-1 Charlson comorbidity index: 3-4 Chess score: 2-3 Chronic comorbidity count: 2-3 Charlson comorbidity index: ≥5 Chess score: 4-5 Chronic comorbidity count: ≥4
Acknowledgments The authors thank Dr. Megan Bohensky for her assistance with the analysis of mortality measures.
Declaration of Conflicting Interests The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
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Funding The authors received no financial support for the research, authorship, and/or publication of this article.
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