Which finding for an 85-year-old client would be of most concern to the nurse

Nursing homes have changed dramatically over the past several decades. These changes have been driven by government regulations and consumer pressures. When compared to nursing homes of past decades, today’s nursing homes are highly regulated and high-quality, sophisticated institutions for the care and treatment of older adults who have severe physical health concerns and/or mental disabilities. Assisted-living facilities do not have the same regulations that guide care in nursing homes.

Who Lives in Nursing Homes?

Almost half of all people who live in nursing homes are 85 years or older. Relatively few residents are younger than 65 years of age. Most are women (72%), many of whom do not have a spouse (almost 70% are widowed, divorced, or were never married). Many also have only a small group of family members and friends for support.

The Most Common Reason for Living in a Nursing Home

Some type of disability when it comes to performing the activities of daily living (ADLs) is the most common reason that older people live in nursing homes. Not surprisingly, people living in nursing homes generally have more disability than people living at home. Over 80% of nursing home residents need help with 3 or more ADLs (such as dressing and bathing). About 90% of residents who are able to walk need assistance or supervision.  More than half of residents have incontinence (the inability to control bowels or the bladder), and more than a third have difficulty with hearing or seeing.

In addition to physical problems, mental conditions are common in nursing home residents. In fact, dementia remains the most common problem, and affects an estimated 50-70% of residents. More than three fourths of nursing-home residents have problems making daily decisions, and two-thirds have problems with memory or knowing where they are from time to time.  

At least one-third of nursing home residents have problematic behaviors. These behaviors may include being verbally/physically abusive, acting inappropriately in public, resisting necessary care, and wandering. Communication problems are also common—almost half of nursing home residents have difficulty both being understood and understanding others. Depression is another condition that affects nursing home residents. Research has shown it may occur more in nursing home residents than in individuals living in the community.  

Length of Stay

Length of stay varies greatly in nursing homes. About 25% of people admitted to these facilities stay only a short time (3 months or less). Many people who stay for a short time are initially admitted to the nursing home for rehabilitation or for terminal (end-of-life) care. About half of residents spend at least one year in the nursing home, and 21% live there for almost 5 years. Interestingly, function often initially improves in many residents who stay for a longer time.  

Risk Factors for Admission

There are several risk factors for admission to a nursing home:

• Age. The chance of being admitted to a nursing home increases with age. For example, about 15% of people 85 years and older live in nursing homes, compared with just 1.1% of people 65-74 years of age.
• Low income.
• Poor family support, especially in cases where the older adult lacks a spouse or children.
• Low social activity.
• Functional or mental difficulties. 
• Race/ethnicity. People who are Caucasian are more likely than others to be admitted to a nursing home.
• Geriatric syndromes (such as frailty, frequent falls, pressure sores, dementia, etc.) also increase the risk for nursing home admission.

Characteristics of Nursing Homes

Nursing homes increasingly offer medical services similar to those offered in hospitals after surgery, illness, or other sudden medical problems. Older adults need a higher level of care, and hospital stays are shorter than they used to be. Medical services vary a lot among nursing homes, but usually include:

• skilled nursing care
• orthopedic care (care for muscle, joint, and bone problems)
• breathing treatments
• support after surgery
• physical, occupational, and speech therapy
• intravenous therapy and antibiotics
• wound care 

Nursing homes provide nutritional counseling, social work services, and recreational activities, as well as respite care, hospice care, and end-of-life care. However, it is important to know goals of care in a nursing home and what to expect during a stay at a nursing home. Nursing homes are not hospitals, and you may not get the same intensity of care in terms of testing, evaluations by physicians, nurse practitioners or other team members. Also, nursing homes do not have in-house pharmacies as well as diagnostics such as laboratory services, radiology services in their facility. They mostly contract with programs in the community for these services. Care is tailored to what is needed based on state of health and skilled care needs.

Choosing a Nursing Home

Your healthcare provider or other healthcare professional (such as a home health nurse or social worker) can provide recommendations for nursing homes. In addition, the Centers for Medicare and Medicaid Services provides detailed information that can help you compare different nursing homes.

Older adults and/or family members can check the CMS website (https://www.medicare.gov/care-compare/) to find out how a given facility is doing in terms of quality of care. Family members can also try to visit as many homes as possible to get a sense of the overall feeling and quality of care. Using a checklist can help you evaluate quality, the range of services, convenience, and costs. Your visit may last an hour or two so that you can meet and talk with the admissions officers, nursing home administrators, directors of nursing, and social workers. Remember that no nursing home is perfect, and all will likely be very different from a person's current living situation.

Suggested Questions to Ask When Visiting a Nursing Home

• Is the nursing home clean? 

• Is the facility well maintained?

• Do the residents look well cared for?

• Are the rooms adequate in size? If the rooms are semi-private, is there adequate separation between beds to create a personal space for belongings?

• What recreational and private spaces are available?

• Are there safety features, such as railings and grab bars?

• Is the home licensed by the state and certified by Medicare and/or Medicaid?
• How many nurses and nursing assistants are there compared to residents? Ask about staffing ratios and how they compare to state and national averages.

• Do the administrators and medical professionals have special training in geriatrics or long-term care?

• Does the medical director have specialized training to be an active engaged medical director? Do they have a Certified Medical Director (CMD) designation?
• Are key professionals (administration, rehabilitation, nursing, activities, etc.) full-time or part-time?

• How long have the managers and nursing staff worked at the nursing home?

• Is vaccination against influenza required for all staff members? If the vaccination is not required, what percent of staff members get the influenza vaccine?

• Who will be the physician or nurse practitioner following the resident, and how accessible are they?

• How close is the nursing home to family members? How close is it to the nearest hospital?

• What is the food like? Look at a sample menu and ask to see a planned weekly menu to observe variations throughout the week.

• How much do basic services cost? What services are covered?

• What additional services are available? How much do they cost?

• What happens if a person runs out of money and needs medical aid?

• Has the hospital or primary care clinic provided enough information regarding treatment, medications, and other care needed during the nursing home stay?

The Centers for Medicare and Medicaid Services (CMS) uses several quality measures to rate nursing homes. For example, CMS reports the percent of residents who:

• receive seasonal flu vaccines and the pneumococcal (pneumonia) vaccine
• were physically restrained
• had one or more falls with major injury
• have pressure ulcers
• lose too much weight

Nursing homes may often seem scary and depressing and moving into one can fill people with a sense of betrayal and failure. Family involvement is important in helping the older person make the transition to a new living arrangement.

Contrary to the stereotype, families do not abandon their loved ones by placing them in a nursing home. In fact, only a few nursing home residents are truly without any family. Family members are encouraged to visit residents regularly and to be involved in the total care of their older relative. Family members can offer company and help with the basic activities of daily living, and they may be better able to communicate the needs of the resident. Lastly, family members and friends known to the older adult may be able to assist in redirecting behavioral issues or provide reassurance to the older person who has experienced a major life event in transitioning to a nursing home.

Last Updated October 2020