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PRIVATE NURSING HOME RESIDENTS IN HONG KONG HOW

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					                                                                                JYY Leung et al • Profile on POAH Residents




PRIVATE NURSING HOME RESIDENTS IN HONG
KONG - HOW FRAIL ARE THEY AND THEIR NEED
FOR HOSPITAL SERVICES
JYY Leung. FHKAM (Med)
Senior Medical Officer
TKK Yu. FHKAM (Med)
Senior Medical Officer
YL Cheung, B Sc
Nursing Officer
LC Ma, B Sc
Registered Nurse
SP Cheung
Community Nurse
CP Wong, FRCP (Edin, Glasg), FHKAM (Med)
Department of Geriatrics, Ruttonjee Hospital,             J HK Geriatr Soc 2000;10:65-69
Queen’s Road East, Wanchai, Hong Kong                     Correspondence to: Dr. Jenny YY Leung


Summary                                                   time for Care and Attention home (C&A home) is
    We studied the profile and hospital utiliszation      about 36 months whereas for infirmary is about
rate of 933 residents from a random sample of             26 months. Currently, there are about 572 private
private nursing homes in the Hong Kong East region.       nursing homes (PNH) in Hong Kong with 28,000
Most PNH residents were sufferers of chronic medical      residents. It is usually felt that those living in PNH
illness. 30 % is either bed or chairbound while 50-       are frailer and that they attend Accident and
70% is dependent in various modalities of basic           Emergency department (A&E) often and
activities of daily living. 40% is incontinent, either    hospitalized frequently. However, no study has been
bowel or bladder. Use of restrainer is about 13%          done previously to document the profile of the PNH
whereas use of Ryles’ tube is about 3.5%. Presence        residents in terms of medical, functional, nursing
of bedsore is about 7.1%. Hospitalization rate is         care dependency and their rate of utilization of
about 50 % over six months’ period and attendance         hospital and out patient services.
at Specialist Out-patient Clinic is about 60%. Old age,       Community Geriatrics Assessment Teams
increase in number of medical diagnosis and               (CGAT) were formed under the Hospital Authority
medications, dependency in toileting, presence of         since 1994 to support elderly residing in Care
Ryles’ tube or bedsores and need for SOPD follow          and Attention Homes (C&A Homes). Residents of
up in past six months are associated with increased       C&A Home require supervisory level of care. CGATs
rate of hospitalizations. We propose that there is a      were formed to provide medical and rehabilitative
need of community geriatics support to these frail        support to C&A Homes. In 1997, CGAT team
elderly.                                                  began to introduce pilot service to PNH. However,
Keywords: elderly, nursing homes, community               profiles of PNH residents is lacking which are of
geriatrics services                                       importance in planning and organizing of service
                                                          structure.
Introduction:                                                 The primary objective of this study is to assess
   The population of Hong Kong has reached 6.3            the medical, functional, nursing care dependency
million by year 1996. Elderly above 65 years old          and pattern of utilization of hospital services of PNH
account for 10% of population. The percentage of          residents in Hong Kong East Region. The secondary
elderly above 65 years old is expected to rise to         objective is to analyze the factors associated with
11.7% by 20011. While Social Welfare Department /         frequent utilization of hospital admissions.
non-government organizations (NGOs) provide
18,587 places of institutionalized care for elderly       Methods
by 1998-1999 (including 1,800 in private nursing          Study population
homes under bought place placement scheme) 2,                 Between July - December 1997, out of 55 (total
there is a great demand for more placement. Waiting       of 2058 residents) PNHs in Hong Kong East region,


                                                                                                                      65
Journal of the Hong Kong Geriatrics Society • Vol. 10 No.2 July 2000



we randomly recruited 16 private nursing homes                         were analyzed. Linear logistic regression model with
of various sizes (10- 173 places/home) from                            presence of hospital admission in past six months
representative geographical regions of Hong Kong                       as dependent variable and sex, age, number of
East region (Wanchai, Causeway Bay, North Point,                       diagnosis, no of medications, presence of bedsores,
Shaukeiwan and Chaiwan respectively) for our                           use of Ryles’ tube, number of SOPD follow up,
study. All residents from these randomly selected                      mobility and seven aspects of activities of daily living
homes (933 in total) were recruited. The residents                     as independent variables were used to assess the
recruited constitute about 45 % of all PNH residents                   prediction of these factors on hospital admissions.
in Hong Kong East region.                                              All statistical analysis were done using SPSS software.

Assessment of residents                                                Results
    Three nurses of community geriatric assessment                     1) Demographic characteristics
team (CGAT) of the Department of Geriatrics,                               Among 933 PNH residents, 662 (71%) are female
Ruttonjee Hospital performed assessment of 933                         while 271 (29%) are male. 884 (94.8%) are above
residents in person at PNH. Areas assessed                             65 years old. Mean age is 80.4 (± 9) years.
included medical, functional and nursing care
dependency.                                                            2) Medical profile
    Medical history and diagnosis were obtained by                         Chronic medical illnesses comprise the vast
going through medical records and interview with                       majority of medical problems. The ten most common
residents. Records of hospital admissions and                          medical diagnoses in order of descending frequency
attendance at specialist out patient department                        are cerebrovascular accident (28.8%), hypertension
(SOPD) in past six months were obtained                                (28%), ischaemic heart disease or congestive heart
retrospectively by asking residents, going through                     failure (19.6%), dementia (17.3%), diabetes mellitus
records / appointment sheet and discharge summary                      (17%), fractures of all sorts (15.4%), chronic
written by doctors kept at PNH. Medications taken                      obstructive airway disease (9.9%), parkinsonism
by residents were inspected, counted and names                         (7.6%), peptic ulcer (5.3%) and malignancy of all
recorded.                                                              sorts (5.3%). (Figure 1). Average number of
    For functional status, performance of residents                    diagnosis is 2.2/ residents.
on the day of interview was taken as the recorded
                                                                                                 400
status. Mobility status were classified in 4 grades
                                                                                                 350
as independent, require aids, chair-bound or bed-
                                                                           Number of residents




                                                                                                 300
bound. Activities of daily living (ADL) were classified
                                                                                                 250
in 4 grades as independent, require mild assistance,
                                                                                                 200
require moderate assistance or totally dependent.
                                                                                                 150
Altogether 7 modalities of ADL were included,
                                                                                                 100
namely feeding, transfer, toileting, grooming,
                                                                                                 50
dressing, stairs and bathing.                                                                     0
    Nursing care dependency was specifically
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assessed in certain areas. Orientation to time, place,
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person were assessed in person on day of interview.
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Those that were oriented in three aspects were
                                                                       Figure 1: Medical diagnosis of 933 private nursing home
regarded as normal. Bowel and bladder continence
                                                                       residents in HK East Region
status was recorded. Incontinence was considered
if resident has uncontrolled leakage of urine or                           As for the use of medications, mean number of
faeces, regardless of amount, for more than two                        medications per resident is 4.7. About 20% of
times per week. Use of Ryles’ tube, foley, restrainer,                 residents have polypharmamacy with medications
presence of bedsores or contractures were all noted                    ≥ 5 in number. Only 23 % of residents do not take
during interview and assessment. Physical restraint                    any medications (Figure 2). As a comparison,
was defined as use of ankle or wrist cuffs, belts                      nursing home residents in US receives 7.2
and vests noted on the day of interview.                               medications / resident3.

Statistical analysis                                                   3) Functional profile
    Descriptive data on 933 PNH residents were                             Only 31% of residents are fully independent.
given. Patterns of utilization of hospital services                    38% require walking aids, 24% are chair-bound


 66
                                                                                                                                                         JYY Leung et al • Profile on POAH Residents




                                  250                                                                                       80
                                                                                                                                                                                     71
                                                                                                                                                                                                             nil
                                                                                                                            70                                                                               once
     Number of residents




                                  200
                                                                                                                                                                                                             twice
                                                                                                                            60
                                                                                                                                                                                                             thrice




                                                                                                           % of residents
                                  150                                                                                             51
                                                                                                                            50                                                                               >thrice
                                                                                                                                                                43

                                  100                                                                                       40
                                                                                                                                       31
                                                                                                                            30
                                  50                                                                                                                                            19
                                                                                                                            20
                                                                                                                                            12                       13 12 12
                                                                                                                                                                                          10            11
                                     0                                                                                      10
                                         nil   one    two   three     four   five   six   >six                                                   3   3                                         3    2

                                                     Number of medications                                                  0
                                                                                                                                   Emergency
                                                                                                                                                                     SOPD                      GP
                                                                                                                                 admissions/A&E
Figure 2: Number of medications taken by private nursing home                                                                      attendance

residents                                                                                               Figure 4: Frequency of utilizing and out patient services in
while 7% are completely bed-bound. Concerning 7                                                         past 6 months
domains (bathing, stairs, dressing, toileting,                                                          6) Factors associated with increased hospitalizations
grooming, transfer and feeding) of activities of daily                                                  and specialty out patient service (Table 1)
living (ADL), 21.1 - 57.3% of residents are totally
dependent, with dependency greatest for bathing,                                                            Using stepwise linear regression, seven factors
followed by stairs, transfer, toileting , grooming,                                                     are associated with hospitalizations as listed below.
dressing and feeding (Figure 3).                                                                        Apart from toileting, all other aspects of ADL are
                                                                                                        not associated with hospitalizations. And neither
                                                                                                        do mobility status had effect on hospitalizations.
                                                                                                        Table 1: Factors influencing hospitalizations of PNH residents
                                                                                                                                                                        OR (95% CI)                          P value
  700                                                                                                   Old age (> 70 years )                                           1.72 (1.11-2.66)                     0.0005
  600
  500                                                                                                   Number of medical diagnosis
  400
                                                                                              Bathing
                                                                                                        (> 3 medical diagnosis)                                         2.23 (1.53-3.25)                     0.003
  300                                                                                   Stairs
  200                                                                              Dressing             Number of medications
                                                                              Grooming
  100                                                                    Toileting                      (≥ 5 medications)                                               1.74 (1.25-2.48)                     0.0001
                                                                    Transfer
    0                      Inde       Mil   He     Tot         Feeding                                  Presence of Ryles’ tube                                          3.08 (1.4-6.6)                      0.0003
                               pen        d    av      a
                                   den assisa y ass lly dep                                             Presence of bedsores                                             5.67 (2.93-11)                      0.0002
                                      t      nt    isa      end
                                                       nt       ent
                                                                                                        SOPD follow up
Figure 3: Degree of dependency of 7 modalities of activities of
                                                                                                        (Yes vs No in past 6 months)                                    2.71 (1.90-3.87)                     0.0001
daily living of private nursing home residents
                                                                                                        Toileting dependency                                            2.03 (1.56-2.64)                     0.0012
4) Nursing care dependency
    One third of residents are found to have                                                            Discussion
impairment of orientation. Bowel and urinary                                                                At present, C&A Home, nursing homes (run by
incontinence is common, comprising 41.5% and                                                            NGOs) and infirmaries (run by HA) are under great
41.7% of residents respectively. Use of Ryles’ tube                                                     demand with waiting time in terms of years of
and foley catheter is 3.5% and 1.7% respectively.                                                       duration. Private nursing homes has become an
Use of restrainer is about 13.3%. Presence of                                                           important placement when elderly are faced with
bedsores is 7.1%                                                                                        medical illness that result in acute deterioration
                                                                                                        of health and disabilities. This account for large
5) Pattern of utilizing hospital services in past six                                                   proportion of residents suffering from cere-
months (Figure 4)                                                                                       brovascular accident and fractures (notably hip
    50% of residents have attended at least once or                                                     fractures) residing in PNH. Chronic medical illness
more to Accident or Emergency Department /                                                              like congestive heart failure, chronic obstructive
emergency hospitalizations in past six months. 57%                                                      airways disease, dementia and parkinsonism make
and 23% have attended Specialist Out Patient                                                            up a significant proportion of diagnosis. Only 5.3%
Department and Government Out Patient                                                                   of residents suffer from cancer of all sorts suggest
Department (GOPD) respectively at least once in                                                         that PNH as a terminal care placement is not
past six months.                                                                                        common.


                                                                                                                                                                                                                   67
Journal of the Hong Kong Geriatrics Society • Vol. 10 No.2 July 2000



    This echoes with the most common medical                               United States intermediate care nursing home
diagnosis resulting in disability (either catastrophic                 or skilled nursing home residents show a
or progressive disability) in a cohort of 6070 elderly                 cumulative hospitalization rate of 57% at 6 months
over 70 years old in 3 communities in USA4 which                       from a cohort follow up prospectively13. Our local
included cerebrovascular accident, hip fracture,                       figure is 50%, which is similar though it is a
congestive heart failure, pneumonia, ischaemic                         retrospective figure. This shows that PNH residents
heart disease, cancer, diabetes mellitus and                           do need hospital support. One study14 cited three
dehydration. Cross sectional data in Hong Kong of                      reasons for hospitalizations. 70 % are due to lack
2032 elderly also reveal that stroke, dementia and                     of intravenous therapy, 15% due to poor doctor
fractures are the main chronic diseases associated                     nurse communication and lack of diagnostic
with severe functional limitation in elderly5.                         services while 15% are due to pressure from family
    Table 2 shows the comparison of demographic                        or nursing home staff. Infection of the skin and
characteristics between residents of PNH of Hong                       lung, symptomatic urinary tract infections and
Kong and that of other countries. There is similarity                  fevers of uncertain source occur most frequently15.
between Japan and Hong Kong though the data                                Our profile showed that about 40-50% of PNH
from Japan included all residents (n=1255) from                        residents could be classified as frail elderly. The
15 Hokkaido facilities, representing the three types                   type of medical illnesses, number of medications
of nursing homes and long-term hospitals in Japan                      per resident, demographic characteristics, rate of
in 1993.                                                               hospitalizations, presence of pressure ulcers and
                                                                       incontinence of our PNH residents are comparable
Table 2: Age and sex distribution (%) of nursing homes residents
in other countries6                                                    with other developed countries. However, as PNH
                                                                       in Hong Kong lack well -qualified staff, more support
Country     Denmark         France USA Japan Hong Kong                 should be given to these PNH. This can be in form
Age (years)                     Distribution (%)                       of community outreach team providing service at
<65            4.2           10.2      6.5     4.6  5.2                PNH. Study has been done over six years showing
65-74         10.9           15.0     12.4     14.0 15.9               that introduction of regular visits to nursing home
75-84         34.8           30.5     33.9     46.3 45.2               by a physician can reduce hospitalizations and
85+           50.1           44.3     47.2     35.2 33.7               medical costs of these frail older patient 16 .
Female Gender 76.2           69.9     73.2     71.7 71.0               Targeting on frail residents with risk factors as
                                                                       identified in the study may lead to a reduction in
    The health profile of PNH residents showed that                    hospitalizations.
they require much care. 31% are bed-bound, 50%                             Our study has several limitations. First, the
are dependent in ADL in some ways, 41% have                            studied population of PNH is confined to randomly
problems of incontinence, 73 % need administration                     selected homes in Hong Kong East Region, as it is
of regular medications and 3.5% of them require                        part of the project of the community geriatric team
Ryles’ tube. The private nursing homes scenario in                     o f t h e h o s p i t a l . S e c o n d l y , r e t r o s p e c t iv e
Hong Kong is the same as other countries where                         documentation of hospitalization and out patient
residents are increasingly older, more ill and more                    attendance may result in some degree of errors.
functionally dependent 7,8. Urinary incontinence                       Counterchecking with hospital computer record is
prevalence is quoted as 43-65 % in PNH in seven                        difficult, as names of PNH are usually not written
foreign countries 9. Restrainer use of 13.3% in our                    down and some patients use their home address
setting is lower than that of nursing homes in                         instead of PNH address.
United States, which is about 25-85% before the
implementation of OBRA ‘1987 regulations 10.                           Conclusions
However, the figures in United States include                              PNH residents belong to a very frail elderly
restraint by means of chairs with locking lap and                      group. Most are sufferers of chronic medical illness
full side-rails which is not included in our study.                    and 50-70% is dependent in some ways in mobility
The frequency of using restrainer is the same as                       and basic activities of daily living. Hospitalization
countries like France, Italy, Sweden and Australia                     rate is about 50 % over six months’ period and
which give restrainer use of about 13-17%11. Lowest                    attendance at Specialist Out-patient Clinic is about
rate of restrainer use is in Denmark and Japan with                    60%. Old age, increase in number of medical
reported rate of < 9%. The prevalence of pressure                      diagnosis and medications, dependency in toileting,
ulcers is 7% in local setting and is lower than that                   presence of Ryles’ tube or bedsores are associated
of Ohio nursing homes with pressure sores of 12%12.                    with increased rate of hospitalizations. Profile of


 68
                                                                                                      JYY Leung et al • Profile on POAH Residents



PNH residents is comparable with that of other                                   in nursing homes and patients receiving home health care. N Engl J
developed countries. Poor medical, functional and                                Med 1990;322:21-27.
high dependency nursing care profile of PNH                                  8. Stern MC, Jagger C, Clarke M. Residential care for elderly people:
residents justified CGAT support. The extent of                                  a decade of change. Br Med J 1993;306:827-830.
                                                                             9. Antonio S, Eva , Jan B et al . Urinary incontinence in nursing home
which CGAT support can result in reducing
                                                                                 residents: a cross national comparison. Age and Aging 1997;26-S2:
hospitalizations, re ducing de ve lopment of
                                                                                 49-54.
complications like bedsores, reducing use of                                 10. Hawes C, Mor V, Philips C et al. The OBRA - 87 Nursing home
restrainer and improving functional status of                                    regulations and implementation of the resident assessment
residents need confirmation by future studies.                                   instrument: effects on process quality. J Am Geriatr Soc 1997;45:
                                                                                 977-985.
References                                                                   11. Ljunggren G, Philips C, Sgadari A et al. Comparisons of restraint
 1. Census and Statistics Department, Hong Kong Population                       use in nursing homes in eight countries. Age and Aging 1997;26-
    Projections 1992-2011.                                                       S2:43-47.
 2. Apple Daily News, 3rd April, 1998.                                       12. Sputor WD, Fortimky RH. Pressure ulcer prevalence in Ohio nursing
 3. Beers MH, Ouslander JG, Fingold SF et al. Inappropriate medication           homes: clinical and facility correlates. Jour of Aging Health. 1998;
    prescribing in skilled- nursing facilities. Ann Med Intern 1992;117:         10/1:62-80.
    684-689.                                                                 13. Barker WH, Zimmer JG, Hall WJ et al. Rates, patterns, causes and
 4. Ferrucci L, Gurainik J, Panor M et al. Hospital diagnoses, medicare          costs of hospitalization of nursing home residents: a population
    charges and nursing home admissions in the year when older persons           based study. Am J of Public Health 1994;84:1615-1620.
    become severely disabled. J Am Med Asso 1997;277:728-734.                14. Bergman H. Appropriateness of patient transfer from a nursing home
 5. Fries BE, Schroll M, Hawes C et al. Approaching cross- national              to a acute care hospital. J Am Geriatr Soc 1991;81:1207-1209.
    comparisons of nursing home residents. Age and Aging 1997;26-            15. Magaziner J, Tenney JH, DeForge B et al. Prevalence and
    S2: 13-18.                                                                   characteristics of nursing home acquired infections in the aged.
 6. Woo J, Ho SC et al, Impact of chronic disease on functional                  J Am Geriatr Soc 1991;39:1071-1078.
    limitation in elderly Chinese aged 70 years and over- cross- sectional   16. Ackermann RJ, Kemle KA. The effect of a physician assistant on
    and longitudinal survey. J Geront- Ser -A- Biol- Sci- Med- Sci 1998;         the hospitalization of nursing home residents. J Am Geriatr Soc
    53:102-106.                                                                  1998;46:610-614.
 7. Shaughnessy PW, Krammer AM. The increased needs of patients




   LEARNING POINTS
   1. Private nursing homes residents are frail. 31% are bed bound, 50% dependent in ADL, 41%
      have incontinence and 3.5% required Rye’s tube feeding.
   2. Before the introduction of CGAT to PNH, the cumulative hospitalisation rate over six
      months was 50%. This was comparable with the hospitalisation rate of 57% at intermediate
      care / skilled nursing homes in the States.
   3. There is a need to support PNH through CGAT services and the outcomes need to be
      evaluated.




                                                                                                                                                69

				
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