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Residential homes for the elderly — Which are the safest?
Publ. ttlth. Lond. (1980) 94,223-228
Residential Homes for the Elderly Which are the Safest? J. M. Morfitt IBISc., M.B.,, Ch.f3.,D./C.H., M.F.C.M. (I), D.P.H., D. R.C.O.G.
(Social Services), Specialist in Community Medicine Wolverhampton Area Health Authority, George House, St. John's Square, Wotverhampton W V2 4DF, West Midlands An account of a one-year study o f the incidence o f home accident injuries needing referral to Accident and Emergency Department in the residents of Wolverhampton Metropolitan Borough Council's homes for the elderly. The epidemiology of these accidents was analysed, and it was found that a large percentage o f them occurred in bedrooms. The incidence of accidents, including those causing fractures was highest in the modern, purpose-built homes o f unitary design. These homes had a relatively high percentage of high-dependency residents, and it was thought that selection of residents played the main part in their adverse accident experience. In contrast, relatively few accidents occurred in the non-purpose built homes, which were converted from large dwellings. The prospects for prevention are discussed. Introduction A number of studies have shown that residents of homes for the elderly have an increased risk o f home accident injuries, particularly fractures. ~ ,2,3 The problem is, we do not know why. There have been speculations that a high accident rate might reflect the policy o f the staff of the residential home in encouraging high mobility, while conceivably the converse could be true, whereby immobility increases osteoporosis and frailty to such a degree that the individual is at • an increased risk following trivial mishaps. 4 This simple observational study o f accidents in Wolverhampton residential homes for the elderly was undertaken in the hope of casting some light on this problem. Methods This was an incidence study o f accidents treated at an Accident and Emergency Department for a population of 575 residents within Wolverhampton Metropolitan Borough Council's homes for the elderly, all aged 65 years or over, in 1978. All 15 o f these homes were situated within the boundaries o f a compact borough, which was served b y a single Accident and Emergency Department at the Royal Hospital. The survey was retrospective and cases were found by looking through all the entries in the Accident and Emergency Department record books from I st January 1978 to 31st December 1978, where the patient's age was 65 years or over, and their address was given as one o f the 15 residential homes. The hospital casualty record card and where appropriate the in-patient records were consulted. Armed with information concerning the date and time of attendance at the Accident and Emergency Department, each home was visited to obtain additional information from the home's day book, and on occasion word-of-mouth recollections from the officer-in-charge. 0038-35o6]80[040223+06 $01.00/0
~)1980 The Society of Community Medicine
Z M. Mo~tt
224
The Homes Three different categories of residential home were identified. The four most recently built homes (Bradley, Sheldon, Woden and Broadway) were purpose-built of unit design. In these homes each unit provides bedrooms and day-rooms catering for the limited mobility of a small group of residents. A quite different group of homes can be described as converted large dwellings (Bromley, Claremont, Park, Rosedale and View/ands). Some of these homes had chair-lifts but the residents had to be able to walk from their bedrooms to the dining room and lounge. In the third group, the residential homes were purpose-built but not on a unitary design plan. In these homes (Dale, Homer, Muchall, Rookery, Underhfll and Warstones) there were large communal lounges and dining rooms.
Results During 1978, 83 residents (out of a total of 575) attended the Accident and Emergency Department at the Royal Hospital following a home accident L,ljury. Several were accident "repeaters", one attending on four occasiom, two on three occasions, and nine on two occasions. The remaining 71 attended once only. There was a total of 99 attendanees, and unless otherwise indicated, the analyses that follow are analyses of attendanees rather than of persons.
Type o2"acadent A t'all was the cause of the accident in 96 6.ases. There were two cases of laceration by sharp objects, and one case of dog bite injury. There were no cases of poisoning, suffocation, or bums and scalds. "TABLE1.Typeof injury
Fracture Laceration "Non-bony injury" Abrasion Others
28 31 31 7 2 99
The percentage of fractures was lower than that found in the National Home Accident Surveillance System3 data, where 38.6% of homes residents seen at Accident and Emergency Departments in 1977 had a fracture. This suggests that there may have been a lower threshold for casualty referral in Wolverhampton.
Disposal at accident and emergency department Twenty-one were admitted to hospital, incurring a total of 968 in-patient days, 14 were referred to fracture clinic or out-patients, 64 were sent home with no further appointment.
Residential Itomes
225
The overall percentage admitted was lower than that found in the National Home Aecidem Surveillance System data ~ where 29-2% o f homes residems, seen at Accident and Emergency Departments in 1977 were admitted. This is further evidence that a lower threshold for casualty referral might be operating in Wolverhampton. Ottlcotrle An arbitrary end.point for assessing outcome was set as 26th March 1979. By that date, the outcome for the 83 residenLs who had attended Accident and Emergency Department was as follows: 1 still detained in hospital, 70 were back in their residential homes, 12 had died. In 10 cases, the patient either died as a result o f the fracture ~eceived, or that fracture was an associated cause of death. TABLE 2. The location of the accidents
Location in Ihe home Bedroom Lounge/sitting room Corridodhnding Stairs Toilet/bathro0m Lift Dining room Gardcra Other outdoor loealion Otherlocations Unknown
Number of accidents % (urtknowns excluded) 32 9 9 2 5 3 2 2 6 3 26 99
,43.9 12.4 12"4 2"7 6-8 4. I 2.7 2"7 8.2 4, ! t 00
These ffmdings are very similar to those of the National Home Accident Surveillance System,3 in that stairs account for relatively few accidents, while ~he room where most accidents occur is the bedroom. The thning o f the accidents Over a quarter of the accidents occurred after 11 p.m. and before 8 a,m. This is in line with lhe relatively high proportion o f accidents that occurred in bedrooms (Table 2). Age and sex distribution of the accidents Sixty female residents, of mean age 82-7 years, made 70 casualty attendances. Twenly-three male residents, o f mean age 81-4 years made 29 casualty attendances. As might have been expected the incidence of home accident injuries, including fractures, rose progressively from the age of 75 years onwards. The relatively high incidence o f accidents experienced by tire residents aged under 75 years was in line with the findings of a similar survey carried out in Toronto (Table 3). ~:
J. M. Morfitt
226
It is likely lhat the current residents under 75 years of age constitute a particularly infirm group, who were selected for admission because they were unable to c~tre for themselves
TABLE 3. Age dis~xibul~onof the aeeiden'ts .
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
q]l]lllll
[
Age Group
II
[[
]
[
Population in the homes
Attendanees
Attendanees per 1000 residents per year
30 77 129 151 107 81 575
6 13 tl 26 21 22 99
200 169 85 172 196 272
65-69 70-74 75-79 80-84 85-89 90 + Total
TABLE 4. Analysis of incidence by type of residential home ii
Type of home
Unit-type Other purpose-bufft Converted large dwelling
Population
Number of attendances (all injuries)
Rate/1000 Year
Number of attendances (fractures)
Rate/1000 Year
184 266
41 48
223
12 13
65 49
! 25 575
10 99
80
3 28
24
181
i
X lO.89 2 allinjuries. = P<
0.01
Both fractures and other home accident injuries showed a regular trend in incidence, being highest in the modern unit-type homes, and lowest in the converted large dwellings. The different incidence in the different types o f homes could not be explained by differences in agestructures, which were very similar in the three types of home. Various measures of dependency (number o f residents in wheel chairs, number needing help with walking, incontinence and a sh-nple measure of mental status)i were compared in the different types of home. The only measure to show a significant difference between the three types of home was the proportion of residents in wheel chaks. While the unit-type homes had a higher percentage of wheel chair home residnets, the 50 residents in wheel chairs made 9 casualty attendances compared to 90 attendances made by the 525,residents not in wheel chairs; a similar accident incidence in the two groups.
Residential Homes
227
Discussion Great care is taken by the Social Services Department to select suitable residents for the different categories of residential homes provided. Thus the frailer old people with strictly limited mobility are not admitted to the "converted large dwelling" type ofhome~ but tend to be cared for in the modern unit-type homes. The adverse accident experience in these homes, which are well-designed and staffed, may well be due to the effects of selection, leading to a highly dependent and infirm population being concentraled in the unit.type homes. Clark s in his Stoke-on.Trent stuciy of women who had fractured a femur found that about a quarter could be considered as preventable (i.e. and environmental cause, leading to a fall in a patient ha good health), another half gave some Jimited scope for p~evention, while in a quarter of the accidents factors in the patients such as osteoporosis, poor vision, and cerebro-vascular disease were such that there were little or no prospects for prevention. Certainly, the frail aged people in residential homes present a daunting prospect for accident prevention. High quality medical care and monitoring of what must be considered an important "at-risk" group may have something to offer, if only the avoidance of inappropriate medication. The fact that so many of the accidents are occurring in bedrooms and at night suggests that prescribed hypnotics may play a part although there is controversy as to the importance o f fl~ese drugs as possible causes of accidents in this age group. 6 ,7,8 Recently Brocklehurst et al 9 suggested that tl~e time of translocation of an old person from independent to institutional living is a time when medical screening is particularly important. However, attempts to change the residents, to make them safer, offer relatively little scope. We are therefore ,left with attempts at changing the environnaent to make it safer. I suggest that the location to examine is the bedroom, where so many o f the accidents occur. It might not be possible to prevent aged residents from falling, but it might be possible to prevent or reduce the injury, by moderating the energy transfer? ° Whether a fall on to the floor results in a fracture or not may well depend on the type o f floor covering. In residential homes, bedroom floor coverings may have to withstand the el tects ol incontinence, and a report t ~ has commended the use of carpet tiles laid loos¢ on PVC tiles. Small areas of damage could be dealt with by lifting individual tiles and cleaning or replacing them. The matter is one of considerable importance. If Wolverhampton's experience in 197g was typical, one might expect that in a single year, out of the 100,000 residents of local authority homes for the elderly in England and Wales, there would be 17,200 Accident and Emergency attendances, 4870 o f them for fractures and 3650 would be admitted to hospital. The cost to the N.H.S. xvould be a staggering £6,087,000 if local costings were extrapolated.
1. 2. 3. 4. 5 6. 7.
References Bennett, A. E., Dearie, M., Elliott, A. & Holland, W. W. (1968). Care of old people in residentiai homes. British Journal o f Preventive and Social Medicine 22, 193-8. Grimley Evans, J., Prudham, D. & Wandless, I. (1979). A prospective study of fractured proximal femur: Incidence a~adoutcome. Public Health London 93, 235-4t. Morfitt, J. M. (1979). Accidents to oicl people m residential homes. Public Health London 93, 177-84. Bennett, A. E. (I 979). Personal communication. Clark, A. N. G. (1968). Factors in fracture of the female femur. Gerontologia Clinica I, 292-300. Macdonald, J. B. & Macdonald, E. T. (1977). Nocturnal femoral fracture and continuing widespread use of barbiturate hypnotics. British Medical Journal ii, 483-5. Brocklehurst, J. C., Exton-Smith, A. N., Lampert Barber, S. M. & Palmer M. K. (1977). British Medical Journal ii, 699.
228
J. M. Morfitt
8. Dunn, T. B. (1977). British Medical Journal ii, 699--1088. 9. Brocklehurst, J. C., Carty, M. H., Leeming, J. T. & Robinson, J. M. (1978). Medical screening of old people accepted for residential care. Tire Lancet ii, 1 4 1 - 3 . 10. Wailer, J. A. (1974). Injury in aged-clinical and epidemiological implications. N e w York State Journal o f Medicine 74, 2200-7. ! i. A report on the provision o f residential accommodation for the elderly mentally infirm. Wyvern Partnership and Social Services Unit, University of Birmingham (I 977) 52. 12. Gryfe, C. 1., Amies, A. & Ashley, M. J. (1977). A longitudinal study o f falls in an elderly population. Age and Ageing 6, 20 I-10.
Residential Homes for the Elderly Which are the Safest? J. M. Morfitt IBISc., M.B.,, Ch.f3.,D./C.H., M.F.C.M. (I), D.P.H., D. R.C.O.G.
(Social Services), Specialist in Community Medicine Wolverhampton Area Health Authority, George House, St. John's Square, Wotverhampton W V2 4DF, West Midlands An account of a one-year study o f the incidence o f home accident injuries needing referral to Accident and Emergency Department in the residents of Wolverhampton Metropolitan Borough Council's homes for the elderly. The epidemiology of these accidents was analysed, and it was found that a large percentage o f them occurred in bedrooms. The incidence of accidents, including those causing fractures was highest in the modern, purpose-built homes o f unitary design. These homes had a relatively high percentage of high-dependency residents, and it was thought that selection of residents played the main part in their adverse accident experience. In contrast, relatively few accidents occurred in the non-purpose built homes, which were converted from large dwellings. The prospects for prevention are discussed. Introduction A number of studies have shown that residents of homes for the elderly have an increased risk o f home accident injuries, particularly fractures. ~ ,2,3 The problem is, we do not know why. There have been speculations that a high accident rate might reflect the policy o f the staff of the residential home in encouraging high mobility, while conceivably the converse could be true, whereby immobility increases osteoporosis and frailty to such a degree that the individual is at • an increased risk following trivial mishaps. 4 This simple observational study o f accidents in Wolverhampton residential homes for the elderly was undertaken in the hope of casting some light on this problem. Methods This was an incidence study o f accidents treated at an Accident and Emergency Department for a population of 575 residents within Wolverhampton Metropolitan Borough Council's homes for the elderly, all aged 65 years or over, in 1978. All 15 o f these homes were situated within the boundaries o f a compact borough, which was served b y a single Accident and Emergency Department at the Royal Hospital. The survey was retrospective and cases were found by looking through all the entries in the Accident and Emergency Department record books from I st January 1978 to 31st December 1978, where the patient's age was 65 years or over, and their address was given as one o f the 15 residential homes. The hospital casualty record card and where appropriate the in-patient records were consulted. Armed with information concerning the date and time of attendance at the Accident and Emergency Department, each home was visited to obtain additional information from the home's day book, and on occasion word-of-mouth recollections from the officer-in-charge. 0038-35o6]80[040223+06 $01.00/0
~)1980 The Society of Community Medicine
Z M. Mo~tt
224
The Homes Three different categories of residential home were identified. The four most recently built homes (Bradley, Sheldon, Woden and Broadway) were purpose-built of unit design. In these homes each unit provides bedrooms and day-rooms catering for the limited mobility of a small group of residents. A quite different group of homes can be described as converted large dwellings (Bromley, Claremont, Park, Rosedale and View/ands). Some of these homes had chair-lifts but the residents had to be able to walk from their bedrooms to the dining room and lounge. In the third group, the residential homes were purpose-built but not on a unitary design plan. In these homes (Dale, Homer, Muchall, Rookery, Underhfll and Warstones) there were large communal lounges and dining rooms.
Results During 1978, 83 residents (out of a total of 575) attended the Accident and Emergency Department at the Royal Hospital following a home accident L,ljury. Several were accident "repeaters", one attending on four occasiom, two on three occasions, and nine on two occasions. The remaining 71 attended once only. There was a total of 99 attendanees, and unless otherwise indicated, the analyses that follow are analyses of attendanees rather than of persons.
Type o2"acadent A t'all was the cause of the accident in 96 6.ases. There were two cases of laceration by sharp objects, and one case of dog bite injury. There were no cases of poisoning, suffocation, or bums and scalds. "TABLE1.Typeof injury
Fracture Laceration "Non-bony injury" Abrasion Others
28 31 31 7 2 99
The percentage of fractures was lower than that found in the National Home Accident Surveillance System3 data, where 38.6% of homes residents seen at Accident and Emergency Departments in 1977 had a fracture. This suggests that there may have been a lower threshold for casualty referral in Wolverhampton.
Disposal at accident and emergency department Twenty-one were admitted to hospital, incurring a total of 968 in-patient days, 14 were referred to fracture clinic or out-patients, 64 were sent home with no further appointment.
Residential Itomes
225
The overall percentage admitted was lower than that found in the National Home Aecidem Surveillance System data ~ where 29-2% o f homes residems, seen at Accident and Emergency Departments in 1977 were admitted. This is further evidence that a lower threshold for casualty referral might be operating in Wolverhampton. Ottlcotrle An arbitrary end.point for assessing outcome was set as 26th March 1979. By that date, the outcome for the 83 residenLs who had attended Accident and Emergency Department was as follows: 1 still detained in hospital, 70 were back in their residential homes, 12 had died. In 10 cases, the patient either died as a result o f the fracture ~eceived, or that fracture was an associated cause of death. TABLE 2. The location of the accidents
Location in Ihe home Bedroom Lounge/sitting room Corridodhnding Stairs Toilet/bathro0m Lift Dining room Gardcra Other outdoor loealion Otherlocations Unknown
Number of accidents % (urtknowns excluded) 32 9 9 2 5 3 2 2 6 3 26 99
,43.9 12.4 12"4 2"7 6-8 4. I 2.7 2"7 8.2 4, ! t 00
These ffmdings are very similar to those of the National Home Accident Surveillance System,3 in that stairs account for relatively few accidents, while ~he room where most accidents occur is the bedroom. The thning o f the accidents Over a quarter of the accidents occurred after 11 p.m. and before 8 a,m. This is in line with lhe relatively high proportion o f accidents that occurred in bedrooms (Table 2). Age and sex distribution of the accidents Sixty female residents, of mean age 82-7 years, made 70 casualty attendances. Twenly-three male residents, o f mean age 81-4 years made 29 casualty attendances. As might have been expected the incidence of home accident injuries, including fractures, rose progressively from the age of 75 years onwards. The relatively high incidence o f accidents experienced by tire residents aged under 75 years was in line with the findings of a similar survey carried out in Toronto (Table 3). ~:
J. M. Morfitt
226
It is likely lhat the current residents under 75 years of age constitute a particularly infirm group, who were selected for admission because they were unable to c~tre for themselves
TABLE 3. Age dis~xibul~onof the aeeiden'ts .
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
q]l]lllll
[
Age Group
II
[[
]
[
Population in the homes
Attendanees
Attendanees per 1000 residents per year
30 77 129 151 107 81 575
6 13 tl 26 21 22 99
200 169 85 172 196 272
65-69 70-74 75-79 80-84 85-89 90 + Total
TABLE 4. Analysis of incidence by type of residential home ii
Type of home
Unit-type Other purpose-bufft Converted large dwelling
Population
Number of attendances (all injuries)
Rate/1000 Year
Number of attendances (fractures)
Rate/1000 Year
184 266
41 48
223
12 13
65 49
! 25 575
10 99
80
3 28
24
181
i
X lO.89 2 allinjuries. = P<
0.01
Both fractures and other home accident injuries showed a regular trend in incidence, being highest in the modern unit-type homes, and lowest in the converted large dwellings. The different incidence in the different types o f homes could not be explained by differences in agestructures, which were very similar in the three types of home. Various measures of dependency (number o f residents in wheel chairs, number needing help with walking, incontinence and a sh-nple measure of mental status)i were compared in the different types of home. The only measure to show a significant difference between the three types of home was the proportion of residents in wheel chaks. While the unit-type homes had a higher percentage of wheel chair home residnets, the 50 residents in wheel chairs made 9 casualty attendances compared to 90 attendances made by the 525,residents not in wheel chairs; a similar accident incidence in the two groups.
Residential Homes
227
Discussion Great care is taken by the Social Services Department to select suitable residents for the different categories of residential homes provided. Thus the frailer old people with strictly limited mobility are not admitted to the "converted large dwelling" type ofhome~ but tend to be cared for in the modern unit-type homes. The adverse accident experience in these homes, which are well-designed and staffed, may well be due to the effects of selection, leading to a highly dependent and infirm population being concentraled in the unit.type homes. Clark s in his Stoke-on.Trent stuciy of women who had fractured a femur found that about a quarter could be considered as preventable (i.e. and environmental cause, leading to a fall in a patient ha good health), another half gave some Jimited scope for p~evention, while in a quarter of the accidents factors in the patients such as osteoporosis, poor vision, and cerebro-vascular disease were such that there were little or no prospects for prevention. Certainly, the frail aged people in residential homes present a daunting prospect for accident prevention. High quality medical care and monitoring of what must be considered an important "at-risk" group may have something to offer, if only the avoidance of inappropriate medication. The fact that so many of the accidents are occurring in bedrooms and at night suggests that prescribed hypnotics may play a part although there is controversy as to the importance o f fl~ese drugs as possible causes of accidents in this age group. 6 ,7,8 Recently Brocklehurst et al 9 suggested that tl~e time of translocation of an old person from independent to institutional living is a time when medical screening is particularly important. However, attempts to change the residents, to make them safer, offer relatively little scope. We are therefore ,left with attempts at changing the environnaent to make it safer. I suggest that the location to examine is the bedroom, where so many o f the accidents occur. It might not be possible to prevent aged residents from falling, but it might be possible to prevent or reduce the injury, by moderating the energy transfer? ° Whether a fall on to the floor results in a fracture or not may well depend on the type o f floor covering. In residential homes, bedroom floor coverings may have to withstand the el tects ol incontinence, and a report t ~ has commended the use of carpet tiles laid loos¢ on PVC tiles. Small areas of damage could be dealt with by lifting individual tiles and cleaning or replacing them. The matter is one of considerable importance. If Wolverhampton's experience in 197g was typical, one might expect that in a single year, out of the 100,000 residents of local authority homes for the elderly in England and Wales, there would be 17,200 Accident and Emergency attendances, 4870 o f them for fractures and 3650 would be admitted to hospital. The cost to the N.H.S. xvould be a staggering £6,087,000 if local costings were extrapolated.
1. 2. 3. 4. 5 6. 7.
References Bennett, A. E., Dearie, M., Elliott, A. & Holland, W. W. (1968). Care of old people in residentiai homes. British Journal o f Preventive and Social Medicine 22, 193-8. Grimley Evans, J., Prudham, D. & Wandless, I. (1979). A prospective study of fractured proximal femur: Incidence a~adoutcome. Public Health London 93, 235-4t. Morfitt, J. M. (1979). Accidents to oicl people m residential homes. Public Health London 93, 177-84. Bennett, A. E. (I 979). Personal communication. Clark, A. N. G. (1968). Factors in fracture of the female femur. Gerontologia Clinica I, 292-300. Macdonald, J. B. & Macdonald, E. T. (1977). Nocturnal femoral fracture and continuing widespread use of barbiturate hypnotics. British Medical Journal ii, 483-5. Brocklehurst, J. C., Exton-Smith, A. N., Lampert Barber, S. M. & Palmer M. K. (1977). British Medical Journal ii, 699.
228
J. M. Morfitt
8. Dunn, T. B. (1977). British Medical Journal ii, 699--1088. 9. Brocklehurst, J. C., Carty, M. H., Leeming, J. T. & Robinson, J. M. (1978). Medical screening of old people accepted for residential care. Tire Lancet ii, 1 4 1 - 3 . 10. Wailer, J. A. (1974). Injury in aged-clinical and epidemiological implications. N e w York State Journal o f Medicine 74, 2200-7. ! i. A report on the provision o f residential accommodation for the elderly mentally infirm. Wyvern Partnership and Social Services Unit, University of Birmingham (I 977) 52. 12. Gryfe, C. 1., Amies, A. & Ashley, M. J. (1977). A longitudinal study o f falls in an elderly population. Age and Ageing 6, 20 I-10.