Nursing Homes Can Be A Health Hazard

By George Leposky

Two recent studies of nursing homes document what many people already believe that nursing homes can be hazardous to their patients’ health:

A study supported by The Commonwealth Fund found widespread malnutrition and dehydration among nursing-home patients.

A Massachusetts study disclosed that close to one in four nursing-home patients may experience an "adverse drug event" in the course of a year, and that more than half of such occurrences are preventable.

A link between the two studies’ findings is cognitive impairment, which includes depression and dementia. Sixty to 70 percent of nursing-home residents are cognitively impaired, and many of them require assistance to eat. In many nursing homes, such assistance is provided inadequately or not at all.

Cause and effect may vary from patient to patient. Improper nutrition can make patients depressed. Depression can prevent patients from eating properly, causing malnutrition. Furthermore, certain medications - including psychoactive drugs prescribed for cognitively impaired patients - can decrease the appetite or irritate the stomach.

The Massachusetts study found that psychoactive drugs - antipsychotics, antidepressants, sedatives, and hypnotics - were among the most common medications associated with preventable adverse drug events, including oversedation, confusion, hallucinations, delirium falls, and bleeding. More than 36 percent of the nursing-home residents used antidepressants, 24 percent used sedatives or hypnotics, and 17 percent used antipsychotic medications.

Like A Developing Country

The malnutrition researchers are Sarah Greene Burger and Julie Prince Bell of the National Citizens’ Coalition for Nursing Home Reform; and Jeanie Kayser-Jones, a nursing professor at the University of California, San Francisco. They reviewed studies showing malnutrition among 35 to 85 percent of U.S. nursing home residents, and substandard body weight among 30 to 50 percent.

Lead investigator for the adverse drug events study is Jerry H. Gurwitz, M.D., from the Meyers Primary Care Institute, a joint initiative of the University of Massachusetts Medical School and the Fallon Healthcare System in Worcester, Massachusetts. An article about this study appeared in the August 1, 2000, issue of the American Journal of Medicine, which is published by the National Institute on Aging (one of the National Institutes of Health).

Burger, Bell, and Kayser-Jones note that the National Nursing Home Reform Act of 1987 mandates that nursing homes prevent malnutrition and dehydration. "Yet," they wrote, "the level of malnutrition and dehydration in some American nursing homes is similar to that found in many poverty-stricken developing countries where inadequate food intake is compounded by repeated infections."

Based on his study’s findings, Gurwitz predicts that at least 350,000 adverse drug events occur each year in U.S. nursing homes.

Both Studies Point To Human Factors

The malnutrition and adverse drugs events studies both point to staffing problems in the nation’s 17,000 nursing homes, which care for about 1.5 million Americans over age 65 at any given time. An estimated 53 percent of all Americans who turned 65 in 1990 will experience a nursing home stay during their lifetime. Yet, staffing levels and expertise in many of these facilities leave much to be desired.

According to Burger, Bell, and Kayser-Jones, a certified nursing assistant (CNA) should be available to help every two to three residents who require assistance to eat and drink, but CNAs typically help seven to nine residents in the daytime and as many as 12 to 15 in the evening.

"Compounding the inadequate numbers of CNAs is a 93 percent per year staff turnover rate," they say. "A newly hired CNA may not know how to care for a resident already at risk for malnutrition and dehydration."

In addition to improving direct-care staffing levels at mealtimes, they call for cross-training administrators and other nursing-home personnel to help feed the patients, and for "further exploring the development of another category of worker at mealtime." They also urge better record-keeping, more sophisticated standards for determining when a patient is becoming malnourished, and government action to improve compliance by deficient nursing homes.

Ordering Errors and Monitoring Lapses

Gurwitz says 47 percent of the preventable adverse drug events were ordering errors by healthcare providers giving the wrong dose, the wrong drug, or drugs with harmful interactions and 49 percent were due to failure by caregivers to monitor residents adequately. The monitoring lapses include inattention to the results of laboratory tests that could disclose a problem, and "failure or delay in responding to symptoms or signs of drug toxicity."

His report recommends:

Educating doctors and other healthcare professionals about giving medications to frail elderly patients.

Better surveillance and reporting systems for adverse drug events.

"Systems-based prevention strategies to prevent ordering and monitoring errors in drug therapy." This refers to computer-based ordering systems, which can alert a prescribing physician to potential problems such as a patient’s poor kidney function, allergies, or a dangerous interaction with another drug the patient is taking.

Such systems have helped to prevent serious medication errors in hospitals. Now Gurwitz and colleagues are testing them in two large nursing homes. He describes his group’s efforts as "an incredible opportunity to improve meaningfully on the health of a very vulnerable patient population."

George Leposky is editor of Ampersand Communications, a news-features syndicate based in Miami, Florida.

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