Evidence-Based Project. Janquilyn D. Merida. Nursing 6023 Philosophy of Science. Dr. Mancuso

Transcription

1 1 Evidence-Based Project Janquilyn D. Merida Nursing 6023 Philosophy of Science Summer 2008 Dr. Mancuso

2 2 Table of Contents Section Page I. Title Page..1 II. III. IV. Table of Contents 2 Introduction...3 Purpose.3 V. Justification.4 VI. VII. VIII. IX. Definition of Terms...5 Methodology..5 Review of Literature.6 Conclusions.11 X. Evaluation 12 XI. XII. Implications and Further Research.12 References...13

3 3 Introduction Medical research and innovation has positively contributed to the aging of society. Due to increased life expectancy over the past century, acutely or chronically ill older persons experience numerous transitions across various health care settings (Magilvy & Congdon, 2000). As chronic illness increases with age, it threatens older adults ability to live independently (Davis & Magilvy, 2000). Elderly patients with multiple chronic conditions precipitate an annual nursing home admission of one million. According to Freedman, Berkman, Rapp, and Ostfield (1994), the strongest and most consistent predictors of nursing home entry are functional status, mental status, and age (p. 843). This paper will explore the clinical indicators that are indicative of a cognizant elder s decision to choose longitudinal care utilizing assessment and diagnosis. By determining the current best evidence regarding assessment of self-care, the remainder of the oriented senior s life will be enhanced. Purpose The goal of the literature review was revelation of clinical indicators that would propel the geriatric client to institutionalized care. The clinical problem that will guide this review is derived from the four-part PICO format. The patient or problem of interest is elders that sign themselves into a nursing home or assisted living facility. The intervention is the addition of frequent hospitalizations or doctor visits to usual care. The control or alternate treatment is comparison of Adult Protective Services (APS), family, or physician placement. The outcome of interest is the percentage of short-stays for therapy or skilled

4 4 nursing that progress to longitudinal care. The final question is as follows: Does the addition of frequent hospitalizations to usual care in elders that sign-in to long term care (LTC) increase the percentage of short-stays for therapy or skilled nursing that progress to LTC, when compared to family placement, APS, or physician placement? Justification Currently 12.4% of the population is 65 years of age and older (U.S. Census Bureau, 2006). Despite aging trends, independence, as it relates to self-care, has been a global theme. According to findings from the Davis & Magilvy study (2000), participants said taking care of self meant staying close to God and family as they defined and experienced certain values-working hard and keeping busy, handling one s own problems, and not being overly dependent on others, especially for medical care (p.212). The findings from Quine & Morrell s Australian study revealed older adults fear of loss of independence and nursing home admission. Quine & Morrell (2007) stated that living alone was significantly associated with fear of loss of independence in females, only and with a fear of admission to a nursing home in both males and females (p. 212). The Chinese have historically lived long lives in extended families. The recent family-structure change to the small nuclear family necessitates an increased demand for old age homes to care for the functionally impaired older person (Tse, 2006). The aforementioned loss of function is demonstrated by the latter Belgium study. After a proximal femur neck fracture, the rate of nursing home admission was higher, both for men and women at any age compared with age-

5 5 and gender-matched population (p. 508), according to Reginster, Gillet, Sedrine, Brands, Ethgen, Froidmont, & Gosset (1995). Definition of Terms For the purpose of this project, the following conceptual terms are defined: 1.) self-care needs are universal, developmental, and health deviation requirements and 2.) universal self-care needs include sufficient air, food, water, elimination, balanced activity and rest, solitude and interaction, protection from hazards, and promotion of function (Clark, 2000, p. 352). A cognizant elder s factual statement or acquiescence that institutionalization is required for assistance of activities of daily living (ADLs) is the operational definition of acceptance of inability for self-care. Methodology The review of literature was conducted utilizing the 4S approach. Systems evidence was gleaned from BMJ Clinical Evidence Handbook by indexing hip fracture. Synopses were obtained utilizing Ovid by searching inability of elder self-care and nursing home or assisted living admission. Syntheses data was extracted from the Cochrane Library by searching elderly nursing home admission. Studies were extracted from MEDLINE with Full Text searching elderly nursing home admission. Studies were extracted from PubMed utilizing elderly self-care and nursing home.

6 6 Review of Literature Systems An estimated 1.26 million hip fractures occurred in adults in 1990; although, they are more common in people > 65 years (BMJ, 2006). Fracture risks increases proportionately to age. After a hip fracture, a 15-25% decline in the ability to perform daily activities is to be expected, and about 10-20% of the survivors will require a change to a more dependent residential status (p.413), according to BMJ Clinical Evidence (2006). The aforementioned systems data is good information; although, the format required for this project is holistic. Synopses McCauley and Travis examined the stress involved with nursing home decision-making utilizing a conceptual framework. They examined data from 142 telephone interviews with responsible parties of first-time, nursing home residents that were recently admitted. Higher levels of reported stress were directly associated with more factors triggering the decision to admit, higher levels of competing demands, and limited time (p. 269), according to McCauley and Travis (2000). This case represents an example of the control of alternate treatment of acceptance of inability for self-care. The study would have been better if the mental status of the resident was stated. It can only be inferred that the patient was either functionally or cognitively limited. The predictors and prognosis associated with inability to ambulate after a fall was addressed in a cohort study. There were 1103 subjects aged 72 years and older. Tinetti, Liu, & Claus (1993) stated, inability to get up without help was

7 7 reported after 220 of 596 noninjurious falls (p. 65). One hundred forty-eight residents reported inability to get up after at least one fall of the 313 noninjured fallers. The risk factors independently associated with inability to get up compared with nonfallers include the following: at least 80 years of age or older, depression, and poor balance and gait. Sedative use and previous stroke did not achieve significance. Fallers who were unable to get up were more likely to suffer lasting decline in ADLs compared with nonfallers who were able to get up (26 vs. 35%). The following trends were not statistically significant: fallers who were unable to get up were more likely to die, to be hospitalized, and to suffer a decline in ADLs for at least 3 days, and were less likely to be placed in a nursing home than were fallers who were able to get up. Tinetti et al (1993) states, the frequency of inability to get up and the short- and long-term morbidity associated with this inability suggest the need for preventive and treatment efforts (p. 65). This study is a great example of a proposed intervention to the problem statement, since a fall or frequent falls is a clinical indicator of self-care inability. Syntheses Montgomery, Mayo-Wilson, and Dennis reviewed non-demented older adults with physical impairments and both physical and intellectual impairments. The amount of formal and informal care required will likely increase in amount and value as western populations continue to age (Montgomery et al, 2008, p. 2). The objectives of the review is to assess the effectiveness of personal assistance programs for older adults with impairments, and the impacts of personal

8 8 assistance on partners, families and caregivers, compared to other interventions. Randomized clinical trials, quasi-randomized controlled trials and nonrandomized controlled studies of personal assistance compared to other forms of support or to no intervention in which participants (65+) were prospectively assigned to study groups and in which control group outcomes were measured concurrently with intervention group outcomes. Only one of the four included studies is consistent with this project analysis. Braun 1987 matched clients in three long-term care settings in Honolulu: nursing home and two community settings (p. 11), according to Montgomery et al. (2008). There were 100 eligible participants receiving personal assistance and 101 in nursing homes. The participants were on average 78 and 80 years old. The community participants lived with a caregiver and received personal assistance for up to 24 hours per day supervised by a social worker. In Braun 1987, personal assistance recipients were less likely than people in nursing homes to report that they would live elsewhere or that they worried about their care in the future. Braun 1987 reports that participants in intervention group improved in spending time outside the placement setting where participants in nursing homes did not (p. 13), according to Montgomery et al (2008). Twenty seven participants (31%) died across three groups in Braun 1987 which was a secondary outcome. Braun 1987 reports that there were no significant differences in morbidity for 49 participants in: infections, injuries, and rashes. Braun 1987 reports that personal assistance participants made significant improvement over time in more ADL items than did patients in the nursing

9 9 home setting (Montgomery et al, 2007, p. 15). Most participants in Braun 1987 reported sleeping well and a good appetite with no significant difference between groups. The aforementioned review of the four studies found some evidence that personal assistance substitutes for informal care and it did not find evidence that personal assistance reduces long-term institutional care. The meta-analysis was a good example of the patient or problem of interest for acceptance of self-care inability. McClure, Turner, Peel, Spinks, Eakin, and Hughes reviewed population-based interventions for the prevention of fall-related injuries in older people. Their objective was the assessment of population-based interventions for reducing fall-related injuries among older people. The included studies were those that reported changes in medically treated fall-related injuries among older people following the implementation of a controlled population-based intervention (McClure et al, 2008, p. 1). Six of the 25 identified studies met the inclusion criteria. Significant decreases in fall-related injuries were reported in each of the included studies with the relative reduction in fall-related injuries ranging from 6 to 33%. Despite methodological limitations of the evaluation studies reviewed, the consistency of reported reductions in fall-related injuries across all programs support the preliminary claim that the population-based approach to the population of fall-related injury is effective and can form the basis of public health practice (p. 12), according to McClure et al (2008). Data extraction by two review authors provided adequate review literature. The aforementioned is an example of prevention of intervention necessitating longitudinal care entry.

10 10 Studies Data from a cohort of 2812 noninstitutionalized elderly persons (65+) living in New Haven in 1982 were used to predict nursing home admission through 1985 (Freedman et al, 1994). Respondents were interviewed yearly from 1982 through 1991 with fewer than 1% being lost to follow-up. Three years of followup data was utilized from 1982 to 1985, during which 354 participants experienced at least one nursing home episode. The absence of regular contact with a spouse was highly associated with nursing home entry for men. The size, not the composition, of the network was predictive of female nursing home admission. The analysis supported the hypothesis that for older persons, the presence of a family network is associated with reduced risk of nursing home entry. This study is at best indicative of the patient or problem of interest. Today many residents are utilizing longitudinal care despite a family network including a spouse. Koening, George, Titus, and Meador performed a cross-sectional analysis of 811 patients (50+) admitted to Duke University Medical Center to determine the impact of religion and spirituality on acute care hospitalization (ACH) and LTC. Organized religious activity (ORA) was the only religious variable related to fewer ACH days and fewer hospitalizations, an effect that is explained fully by physical health status and that disappeared when examined prospectively. The number of LTC days was inversely related to nonorganizational religious activity (NORA), religiosity through religious radio and/or television (RTV), and daily spiritual experiences (DSE) which were partially explained by social support but

11 11 not by medical illness severity. Interactions with race and sex reached statistical significance in African Americans and women. African Americans who were more involved in private religious activities or who reported more spiritual experiences used fewer LTC services. Women that experienced DSE had fewer LTC days than men. This unique qualitative study measured the outcome of interest. It did not measure longitudinal care; however, it eluded that African Americans and women that are spiritually-grounded require less LTC days for episodic LTC. Conclusion In summary, people are living longer. Increasing age is associated with chronic illness and fracture risk. Fall prevention; however, has been identified as a public health initiative with age > 80, depression, and poor balance as fall risks or cues. Those elders that fall and cannot get up justifiably have a fear of loss of independence. Independence of self-care needs may be maintained initially by utilizing care assistance. A family network also may delay institutional care of the geriatric patient; however, increased caregiver stress promotes family placement. Sustaining a hip fracture, almost always leads to rehabilitation or LTC stay; although, increased spirituality in blacks and females is associated with a reduction of LTC needs. It is noteworthy; however, that the aforementioned hip fracture patient readily accepts their inability of self-care at least temporarily.

12 12 Evaluation The literature quality was good; however, it was indirectly relevant to the project. The literature review contained a good foundation for clinical decisions, particularly the system data and meta-analyses. The study designs were both quantitative and qualitative without uniform findings, which is most attributable to lack of information on the operational definition. The conclusions of the literature review were consistent with the hypotheses of the selected evidence. Implications and Further Research Internal Medicine practices are plagued with geriatric clients with complex chronic illnesses. Family practices are involved with geriatric care to a lesser extent and usually the practitioners choose a less-complex patient. Loss of function or self-care deficits, unfortunately are inherent perils to those clients 65 years of age or older. Many times the provider or family has to intervene when the elder needs home health or institutionalized care. There are also worse circumstances when Adult Protective Services are contacted to act on the seniorcitizen s behalf. Where is the documented literature on an elder choosing long-term care or assisted living? The information lives in the patient care records of all of the institutionalized elderly that do not have dementia diagnoses, that do not take psychotropics, and those that do not have orthopedic aftercare diagnoses. This invaluable information may also be disclosed from the elder as you make rounds, as I do weekly.

13 13 References BMJ Clinical Evidence Concise. (2006). Banta Harrisonburg, VA: Banta Book Group. Clark, C.C. (1998). Wellness self-care by healthy older adults. The Journal of Nursing Scholarship, 30(4), Davis, R & Magilvy, J.K. (2000). Quiet pride: The experience of chronic illness by rural older adults. The Journal of Nursing Scholarship, 32(4), Freedman, V.A., Berkman, L.F., Rapp, S.R., & Ostfeld, A.M. (1994). Family networks: Predictors of nursing home entry. American Journal of Public health, 84, Koenig, H.G., George, L.K., Titus, P., & Meador, K.G. (2004). Religion, spirituality, and acute care hospitalization and long-term care use by older adults. Archives of Internal Medicine, 164(14), Magilvy, J.K. & Congdon, J.G. (2000). The crisis nature of health care transitions for rural older adults. Public Health Nursing, 17(5), McCauley, W.J. & Travis, S. (2000). Factors influencing level of stress during the nursing home decision process. Journal of Clinical Geropsychology, 6(4), McClure, R., Turner, C., Peel, N., Spinks, A., Eakin, E., & Hughes, K. (2008). Population-based interventions for the prevention of fall-related injuries in older people. Cochrane Database of Systematic Reviews 2005, Issue 1, Art. No.: CD

14 14 Montgomery, P., Mayo-Wilson E., & Dennis, J. (2008). Personal assistance for older adults (65+) without dementia. Cochrane Database of Systematic Reviews, Issue 1, Art. No.: CD Publication Manual of the American Psychological Association (5 th ed.). (2001). Washington, DC: American Psychological Association. Quine, S. & Morrell, S. (2007). Fear of loss of independence and nursing home admission in older Australians. Health Social Care Community, 15(3), Reginster, J-Y., Gillet, P., Sedrine, B.W., Brands, G., Ethgen, O., Froidmont, C., & Gosset, C. (1999). Direct costs of hip fractures in patients over 60 years of age in Belgium. Pharmacoeconomics, 15(5), Tinetti, M.E., Liu, W.-L., & Claus, E.B. (1993). Predictors and prognosis associated with inability to get up after falls among elderly persons. JAMA, 269(1), Tse, M.M.Y. (2006). Nursing home placement: perspectives of communitydwelling older persons. Journal of Clinical Nursing, 16,

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