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AUTHOR'S REPLY |
University of Minnesota School of Public Health Minneapolis, Minnesota
Address correspondence to Robert L. Kane, MD, University of Minnesota School of Public Health, D351 Mayo (MMC 197), 420 Delaware St. SE, Minneapolis, MN 55455. E-mail: kanex001{at}umn.edu
To the Editor:
The letter from Drs. Coll-Planas and Nikolaus and Ms. Loayza raises an important issue. Studies to predict nursing home admission should distinguish between proximal and distal predictors. Studies such as AHEAD (Assets and Health Dynamics Among the Oldest Old) are looking for distal predictors that antedate nursing home admission by several years. By contrast, the precipitating factors, one of which may be worsening on incontinence or crossing a threshold of severity or frequency, may be separate. The longer-term predictors may be useful in targeting individuals to whom attention may be directed in the hope of staving off a future nursing home admission. The proximal predictors would require an immediate care plan to develop a strategy for meeting the exigency in order to divert the patient from a nursing home admission. In the former case, the warning sign may not be the problem that needs treatment—it may only be an indicator of the need to do a more thorough assessment. In the latter case, it may well be the critical problem.
The dependency in bathing observed in the Gill study (1) seems to be more an indicator than a target for intervention. Another interpretation of this indicator was suggested by my wife, who proposed that some people who could probably use help in bathing may insist on bathing themselves to act independently. This demonstration of determination for autonomy may itself be a sign of someone who will resist a nursing home admission.
Reference
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