Q & A With the Expert on: Successful Admission to a Long-Term Care Facility

Facilitating Transfers from Independent Living to Assisted Living

Q: Mrs. D, an 88-year-old white female, lived in her own apartment with some help from a housekeeper for a few hours daily (meal preparation and light cleaning). She had a history of hypertension, transient ischemic attacks, multi-infarct dementia (Mini-Mental State Examination, 24/30), hyponatremia, and a history of a gastrointestinal bleed within the past year with a subsequent anemia, as well as a 60-year history of smoking (one-half pack per day) and regular alcohol use (four glasses daily). She had a history of frequent falls (2-3 times per week), and although she had not sustained a fracture, she had multiple skin tears and lacerations. Her medications included clopidogrel 75 mg qd, ferrous sulfate 325 mg bid; amlodipine 10 mg qd; and demeclocycline 300 mg bid. Mrs. D often did not change out of her night clothes, and she generally spent most of her day in bed. She would eat her meals alone at her kitchen table, and sit up when her family came to visit. Her son and daughter-in-law visited in the late afternoon or evening a few times per week, and would sometimes bring her to their home for a visit. Her son, driven by her persistent requests, supplied her with wine on a weekly basis. The family could no longer handle the frequent calls from Mrs. D and the all-too-common emergency room visits, and they suggested that she move to an assisted living facility. She was resistant to the move, but no alternative option was provided. She was told that she would be unable to stay alone in her apartment any longer. What interventions can be implemented to facilitate a successful move to an assisted living setting with regard to Mrs. D’s health status and overall quality of life?

A: As required by the state, a comprehensive evaluation for assisted living was conducted by the nurse manager of the facility. If fully utilized, the comprehensive assessment tool is an important resource to develop care plans that guide providers on how to optimize underlying function and capability of a resident. It was noted that Mrs. D needed verbal cues and supervision with bathing and dressing, and medication management. She was not safe to smoke alone, and drinking alcohol was increasing her risk of falls as well as impacting her medical condition (associated gastritis and hyponatremia). This information was incorporated into her nursing plan of care.

The nursing assistant assigned to her was involved in this plan, and it was decided that she would be encouraged to get up daily, bathe and dress, and be provided with verbal encouragement and cues to complete her personal care activities. Negotiation occurred between the nursing assistant and Mrs. D, and they established a plan where she would go to the dining room for dinner but receive all other meals in her room. Mrs. D’s excessive alcohol intake also needed to be addressed in light of her safety. According to the 2000 National Household Survey on Drug Abuse, more than 2 million people 65 years of age or older have some sort of alcohol problem. Older adults who do engage in treatment to abstain from alcohol have been noted to have substantially better outcomes and are more likely to complete treatment when compared to younger adults. Specifically, structured interventions that remove access to alcohol and provide alternative activities can be very effective in preventing ongoing high-risk alcohol intake in these individuals.

Successful treatment plans require a strong interdisciplinary team approach, and they must include support from family and friends. At the time of transfer, all alcohol was removed from Mrs. D’s new apartment, and her son was instructed to refrain from supplying her with wine. He was assured that the nursing staff would reinforce that they were withholding the alcohol for medical reasons: high blood pressure and low sodium levels. Mrs. D was started on low-dose lorazepam to prevent withdrawal. The nursing assistant assigned to her provided scheduled visits for bathing, dressing, and medications, and to help her get to the dining room for at least one meal daily. Smoking persisted, initially with supervision. Mrs. D accepted the daily structure and visits as being the reason for withholding the alcohol. She enjoyed the meal with her peers and walked each evening to the dining room. She still spent most of her day in bed and did not participate in other facility activities. She has had no falls in the past year since transfer, has abstained from all alcohol use, and is satisfied in her new apartment in assisted living.

Her family is ecstatic with regard to her current status, both from a social perspective as well as her improved medical status: she has had no recent falls, has improved blood pressure, and the staff was able to discontinue the demeclocycline, as her sodium levels returned to normal without excessive alcohol intake. Transfers to assisted living and nursing home settings are often dreaded by older individuals and their families. There are many instances, however, in which such transfers optimize quality of life by virtue of the team approach to care and the structured activities provided in these sites.

Suggested Reading

Blow FC, Barry KL. Older patients with at-risk and problem drinking patterns: New developments in brief interventions. J Geriatr Psychiatry Neurol 2003;13(3):115-123.

Davies S, Nolan M. “Making it better:” Self-perceived roles of family caregivers of older people living in care homes. A qualitative study. Int J Nurs Stud 2005. [Epub ahead of print.]

Fleming MF, Manwell LB, Barry KL, et al. Brief physician advice for alcohol problems in older adults: A randomized community-based trial. J Fam Pract 1999;48(5):378-384.

National Center for Assisted Living. Assisted Living State Regulatory Review. 2004. Accessed October 7, 2005.

National Institute on Alcohol Abuse and Alcohol. The Physicians’ Guide to Helping Patients with Alcohol Problems. 2004; NIH Publication No. 95-3769.

Ockene JK, Adams A, Hurley TG, et al. Brief physician- and nurse practitioner-delivered counseling for high-risk drinkers: Does it work? Arch Intern Med 1999;11;159(18):2198-2205.

Oslin DW. Late-life alcoholism: Issues relevant to the geriatric psychiatrist. Am J Geriatr Psychiatr 2004;12(6):571-583.

Resnick B. Alcohol use in a continuing care retirement community. J Gerontol Nurs 2003;29(10):22-29.

U.S. Department of Health and Human Services and the Substance Abuse and Mental Health Services Administration. Summary of the Findings from the 2000 National Household Survey on Drug Abuse. Accessed October 7, 2005.