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a Division of Geriatric Medicine, Saint Louis University, and GRECC, VA Medical Center, St. Louis, Missouri
John E. Morley, Division of Geriatric Medicine, St. Louis University School of Medicine, 1402 S. Grand Blvd., M238, St. Louis, MO 63104 E-mail: morley{at}slu.edu.
DURING the past decade, there has been an attempt to medicalize the nursing home industry. This has led to an attempt to replace nursing home with "long-term care." While the introduction of a medical director into nursing homes and intense medical research into care in nursing homes has resulted in improved medical care, it has also been associated with increased bureaucratic regulations that have decreased the ability of residents to live in a home-like atmosphere for their final years.
In this issue of the Journal, two articles explore the effects of introduction of versions of the Eden Alternative into nursing homes. The Eden Alternative utilized pets, plants, and children together with involvement of all the staff in creating a home-like atmosphere in the nursing home (1). Despite great enthusiasm for the Eden Alternative, there are minimum scientific data for its ability to enhance outcomes in nursing homes. Coleman and colleagues (2), in this issue of the Journal, studied the effect of the Eden Alternative in one nursing home compared with another that provided traditional care. Although there were some suggestions of increased enthusiasm among residents and staff, no evidence of medical improvement could be discerned using qualitative tools. Overall, this is not particularly surprising, as the Eden Alternative is more likely to affect emotional status than physical health. The rates of depression in both facilities were not reported. A previous study has suggested that the Eden Alternative may decrease depression (3). Also, the validity of the Minimum Data Set to compare two facilities has not been established. Overall, this study suggests that physician and other health professional care is more likely to improve physical health than environmental alterations in the home.
In contrast, Banks and Banks (4) demonstrated that pet therapy can improve the emotional health of nursing home residents. An important component of their study was to target residents who liked animals. Past experience suggests that some residents dislike or are fearful of animals, and, if included in studies of pet therapy, they skew the results in a negative direction, resulting in an overall failure to demonstrate a positive effect. However, Guay (5) has suggested that pet therapy can result in atypical infections (i.e., zoonosis). Examples could include psittacosis, toxocariasis, pasturellosis, Q fever, leptospirosis, and bartonellosis. A recent outbreak of atypical scabies in a nursing home with an active Eden Alternative may have been an example of this (6).
An important role of health professionals in nursing homes is to go beyond typical medical diagnoses that affect quantity of life and to look for new ways to evaluate and treat illnesses or syndromes that affect quality of life of nursing home residents. One example is the recognition and appropriate treatment of pain. Pain is considered the fifth vital sign (7). A recent study has shown that nurses' aides and licensed practical nurses consistently underestimate pain in nursing home residents (8). Kamel and colleagues (9) showed that utilizing pain assessment scales, including "pain faces," increased the frequency of diagnosing pain among nursing home residents. This was particularly true in the old-old and cognitively impaired residents.
Exercise therapy is an important component of nursing homes. Exercise has been shown to improve outcomes in some but not all older persons (10)(11). Resistance exercise may be particularly useful and can result not only in improved strength (12) but also decreased depression (13). Both weight training and a nursing rehabilitative care program have been shown to result in a significant reduction in the rates of loss of activities of daily living in nursing home residents (14). The Functional Fitness for Long-Term Care Program was designed to maintain range of motion and to improve strength, balance, flexibility, mobility, and function (15). Attendance averaged 86%. This program showed significant improvements in balance, flexibility, mobility, and knee and hip strength compared with a control group receiving range-of-motion exercises only.
Depression is a major problem for residents of nursing homes (16). Depression is a major cause of severe weight loss in nursing homes (17). Besides the introduction of programs such as the Eden Alternative and pet therapy, bright light therapy (10,000 lux) has been shown to be effective as a nonpharmacological therapy to prevent depression in nursing home residents (18).
Two recent studies have identified undernutrition as a major factor for progression of deteriorating functional status in the nursing home population (19)(20). Pressure ulcer development is commonly associated with undernutrition (21). Studies from Holland have shown that weight gain can be produced in the nursing home with either environmental enhancement (22) or putting taste enhancers in the food (23). This is in keeping with a study of persons living at home who decreased their nutritional risk when they received a socialization at mealtimes intervention (24). Multiple medical causes of anorexia in the nursing home, ranging from depression and medications, to withdrawal of psychotropic medicines, have been identified (25)(26). Cytokines are not only potent inhibitors of appetite (27) but also cause muscle mass loss (28) and lower albumin levels (29). Recently, Yeh and colleagues (30) demonstrated that, in nursing home residents, megestrol acetate was most effective in increasing weight gain in persons with elevated cytokine levels. The Council for Nutritional Clinical Strategies in Long Term Care has developed a clinical guide for the management of unintended weight loss that focuses both on environmental as well as medical issues (31).
Hip fractures are associated with devastating outcomes in older persons (32)(33)(34). Hip fractures occur because of a combination of falls and osteoporosis. Falls need to be carefully worked up in nursing homes and appropriate prevention methods put in place (35). Postprandial hypotension occurs in 25% of older persons with falls (36). It is particularly common in persons with Parkinson's disease (37). Older persons with falls need to be carefully assessed for both orthostasis and postprandial hypotension (38).
It is clear that a balance between maintaining a home-like environment and appropriate medical care is the approach most likely to optimize quality of life for nursing home residents. Maintaining a Continuous Quality Improvement program with a focus on the issues important in a nursing home rather than a medical focus is liable to produce optimal outcomes (39). This requires the ability to recognize mistakes and develop procedures to prevent their recurrence. Unfortunately, our bureaucratic oversight of nursing homes and the legal system focus on a single mistake as a cause célèbre.
There is a need to move from a system that punishes the single mistake to an arbitration system that looks at system-wide errors and looks for appropriate corrective, not punitive, action. The modern system predominantly benefits lawyers who do nothing directly to improve the care for nursing home residents. The money made by lawyers could go a long way to improving nursing home care. A step toward this would be for each state to develop an arbitration panel consisting of health professionals, administrators, and the public. This should be interposed between the justice system and nursing homes. This would allow the focus to be where it should be—on improving the quality of life of those living in nursing homes. The only losers we can see in this system would be lawyers—and we do not believe this would create many tears among those of us who care.
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This article has been cited by other articles:
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  A. N. Rahman and J. F. Schnelle The Nursing Home Culture-Change Movement: Recent Past, Present, and Future Directions for Research Gerontologist, April 1, 2008; 48(2): 142 - 148. [Abstract] [Full Text] [PDF]
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 I. Gasquet, S. Dehe, P. Gaudebout, and B. Falissard Regular Visitors Are Not Good Substitutes for Assessment of Elderly Patient Satisfaction With Nursing Home Care and Services J. Gerontol. A Biol. Sci. Med. Sci., November 1, 2003; 58(11): M1036 - 1041. [Abstract] [Full Text] [PDF]
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J. E. Morley, J. H. Flaherty, and D. R. Thomas Editorial: Geriatricians, Continuous Quality Improvement, and Improved Care for Older Persons J. Gerontol. A Biol. Sci. Med. Sci., September 1, 2003; 58(9): M809 - 812. [Full Text] [PDF]
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 M B Kapp "At least Mom will be safe there": the role of resident safety in nursing home quality Qual. Saf. Health Care, June 1, 2003; 12(3): 201 - 204. [Abstract] [Full Text] [PDF]
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W. A. Banks and J. E. Morley Memories Are Made of This: Recent Advances in Understanding Cognitive Impairments and Dementia J. Gerontol. A Biol. Sci. Med. Sci., April 1, 2003; 58(4): M314 - 321. [Full Text] [PDF]
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G. T. Grossberg and A. K. Desai Management of Alzheimer's Disease J. Gerontol. A Biol. Sci. Med. Sci., April 1, 2003; 58(4): M331 - 353. [Full Text] [PDF]
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J. E. Morley, H. M. Perry III, and D. K. Miller Editorial: Something About Frailty J. Gerontol. A Biol. Sci. Med. Sci., November 1, 2002; 57(11): M698 - 704. [Full Text] [PDF]
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