Rachael Wonderlin

Loneliness, isolation, and the usage of physical and chemical restraints are common and ignored battles that rage within nursing homes. The simple freedoms many individuals take for granted: the ability to travel as one pleases, control one’s medication intake, and the right to get immediate responses from medical personnel, are simple pleasures that many elderly nursing home residents do not have. Recent studies have shed more light on the inside occurrences of these senior care facilities. Although conditions in these facilities have improved over the past few decades, there is a long way to go before these places can truly be considered homes in which to live. At the present time, nursing homes often resemble simple holding pens in which to keep individuals who have dropped out of society’s consciousness.

A nursing home is usually defined as a facility that provides long-term care for chronically debilitated older adults. The term “nursing home” can also refer to physical rehabilitation homes and long-term mental hospital facilities. In this paper, however, I will focus on only elderly care facilities. As cited in class on January 13th, 2009, only four to five percent of the aging population actually lives in long-term care facilities. Most common in nursing homes are those considered the “oldest old”, or individuals 85 and older. Not surprisingly, the lack of an able caregiver for an elderly individual greatly increases the chances that she or he will end up in a senior home. Most residents have lost family members over the years and are often widowed, so it makes sense that the death of a close relative is the most common cause preceding admittance to a nursing home (Harper, Lebowitz, 1986).

There are 15,562 nursing homes in the United States, but only 27 of them have been ranked as “five-star” locations. This 1 to 5 star ranking is given to each individual home based on three factors: health inspections, nurse staffing, and individual quality measures. The rankings are listed on Nursing Home Compare, a federal website created by the Centers for Medicare and Medicaid Services, better known as CMS. “Health inspections” are defined broadly, with 180 different measures to evaluate. “Nursing” is scored by a report that comes from each individual home. The report must list the average number of registered nurses, licensed practical nurses, licensed vocational nurses, and certified nurse aides who were on the payroll during the two weeks prior to the most recent regular inspection. “Individual quality measures” are based mainly on the residents’ complaints of pain and immobility within the home. Despite the broad categories, less than 0.2% of the senior homes in this country have achieved five stars (Comarow, 2009).

A report issued by the U.S. Department of Health and Human Services in July 2000 found that most nursing homes are dangerously understaffed, especially profit-making nursing homes. Among the consequences of understaffing, according to the report, are increases in preventable problems like severe bedsores, malnutrition, dehydration, congestive heart failure, and infections (Ehrenreich, 2001). To add to the problem, “nurses” in senior homes are not the RNs (Registered Nurses) that get their Bachelors of Science at accredited universities. Instead, they are CNAs (Certified Nursing Assistants) that can get by with just a certification in health. According to PayScale.com, a CNA with less than a year’s experience will receive a starting salary of around $9.73 per hour. An RN, on the other hand, will be paid around $21.83 for the same amount of experience (Hourly Rate Survey Report, Payscale). Still, it is the CNAs that care for our aging population. Barbara Ehrenreich, author of Nickel and Dimed, spent a year of her life pretending to be an uneducated, unskilled American eking out an existence any way she could. This quest, ironically, led Ehrenreich to a senior home. The PhD journalist managed to spend a few months in the home in order to evaluate what goes on behind closed doors. Walking in and applying for a job, she found, was almost effortless. She writes,

What is this business of letting someone in off the street to run a nursing home, or at least a vital chunk of a nursing home, for a day…it would have been easy for an aide to make a life-threatening mistake, such as serving sugar-containing foods to a diabetic. I consider myself- and my patients – extremely fortunate that I did not inadvertently harm someone on this day when I fed the Alzheimer’s ward by myself (Ehrenreich, 2003, p. 105).

Why is it that people working in other types of businesses have to have stacked resumes, great references, and a great education when people working in senior homes barely need to finish high school?

The decades between 1910 and 1950 saw a huge growth in the amount of geriatric patients in hospitals. By the 1950s, patients aged 65 and up were being admitted to state hospitals four times faster than the younger generations. During the 1970s, however, nursing homes became the alternative to state hospitals (Fogel et al., 1993). According to the U.S. Department of Health and Human Service’s 1986 report, Mental Illness in Nursing Homes: Agenda for Research, elderly people are increasingly being shifted out of mental hospitals and into senior homes that are not readily equipped to deal with the patients’ issues. Prior to the 1987 Omnibus Budget Reconciliation Act (OBRA), the homes lacked a universal mental health program policy. In fact, less than 1 in 10 individuals needing mental health services actually received any help (Harper, Lebowitz, 1986).

Instead of dealing with the mental issues at hand, most senior homes have fallen into the habit of overmedicating their patients. In fact, the term ‘chemical restrains’ refers to the usage of psychoactive drugs that are prescribed in order to restrain residents, even in daily life. By subduing resident activity, nurses and other facilitators have less complaints and problems to deal with (Gruneir, Lapane, Miller, & Mor, 2008). In one Swedish study, 7,904 residents were examined in order to evaluate the quality of drug therapy in nursing homes. According to the study, about 65% of the residents were prescribed 10 or more drugs and 86% of this population had at least one psychoactive medication. 74% of the residents had at least one problematic prescription. This means that the prescription was causing the resident to have a large amount of side effects. The over usage of drugs was partially attributable to the fact that the average number of physicians prescribing drugs per resident was 3.9. This high number of physicians resulted in polypharmacy and, therefore, a lower quality of drug therapy. With almost four doctors for each patient, an overdose or drug-on-drug interaction is unavoidable (Bergman, Olsson, Carlsten, Waern & Fastbom, 2007).

Not only are drugs often misused in amount, patients are often given drugs for disorders that they do not have. Antipsychotic drugs, prescribed often for individuals with schizophrenia, are used widely in nursing homes. In one Australian study, the report shows that antipsychotic drugs were prescribed for 577 of the 2,302 residents studied. Of these residents, only 114 actually had schizophrenia. According to the study, “In Sydney in 2003, most (80%) of the nursing home residents for whom antipsychotics were prescribed did not have a diagnosis of schizophrenia” (Snowdon, Day & Baker 2005). Interestingly, most of the antipsychotics were used for residents with dementia and cerebral disease instead of those with actual schizophrenia. To add to the problem, antipsychotic medications were unsubsidized for patients without schizophrenia, meaning that the patients had to pay in full the prices charged by the supplying pharmacists. Pharmaceutical medications are expensive and considering the amount of medications being prescribed, handling medicals bills cannot be painless, especially for patients lacking familial financial support (Snowdon et al., 2005).

To add to the problems within nursing home facilities, it is difficult to obtain straightforward and consistent information when it comes to studies. For example, the Department of Health and Human Services issued a report in 2001 under the Office of Inspector General, Janet Rehnquist. Among many other things, it states,

While drug usage rates for anti-psychotic and anti-anxiety medications have been rising, most psychotropic drug use in nursing homes is medically appropriate. Where it is inappropriate, the problems do not appear to be related to inappropriate chemical restraints [as defined as illegal by OBRA 1987] but rather to inappropriate dosage, chronic use, a lack of documented benefit to the resident, and inappropriate duplicate drug therapy. We do note, however, that lack of adequate documentation for residents’ psychotropic drug use is of some concern (Psychotropic Drug Use in Nursing Homes, 2009) [emphasis added].

This study proposes that drug usage in nursing homes is under control, although this data does not seem to match other, previous conclusive studies. The study does admit to a “lack of adequate documentation,” and cites that inappropriate usages of the drugs were found. Is this, however, not the definition of ‘chemical restraints’? Interestingly, Janet Rehnquist, appointed by George W. Bush in 2001, recently stepped down from her position as Health Department Inspector General under much controversy. Accused of purposefully delaying a Medicare inspection report, and, among other things, keeping an unloaded firearm illegally stowed in her office, Rehnquist stepped down in June 2003 (Pear, 2003). This is not to suggest that the report issued by the Department of Health and Human Services is completely false. Rather, the government, unlike third party researchers, is financially involved in the issues concerning Medicare. It becomes questionable whether these studies are as conclusive and unbiased as the ones conducted by other parties uninvolved in the issue.

Although physical restraint use has declined in the last decade, its prevalence still remains a problem in U.S. nursing homes. While chemical restraints involved the usage of drugs to keep the elderly population subdued, physical restraints are defined as any device that prevents a resident’s free movement. The consequences of restraint use include injury, ulcers, decline in cognitive ability, and even mortality (Gruneir et al., 2008). Although side rails on beds in nursing home facilities are used to prevent residents from falling out of bed, this practice does not always accomplish its goal. Interestingly, there is actually more evidence to the contrary: most nursing home residents who use the side rails lack the cognitive ability to use the call bell and perceive the side rail as a barrier. Climbing over the side rail can increase the rate of injury since the rails add up to 2 feet in fall height. Although the FDA has issued guidelines in order to protect against hospital bed entrapment, many nursing homes purchase refurbished beds from hospitals. Some of these beds are actually greater than five years old (Capezuti, Wagner, Brush, Boltz, Renz & Talerico, 2007).

Physical restraints can also describe the wide usage of walkers and wheelchairs within the home. Although the devices seem to be sold with the best intentions, these mobility pieces can also hinder their owners. According to a 2003 study, wheelchairs may be the last real form of freedom and independence that residents have. The home analyzed in this study, The Boston Home, worked to create a protocol in order to allow residents to use wheelchairs safely and efficiently. Previous studies showed that the loss of the ability to use a wheelchair or other assistance technology greatly decreased the patient’s quality of life. Although the new protocols implemented were done to ensure patient safety, there have been issues that are associated with limiting the use of a patient’s power wheelchair. These include: increased levels of clinical depression, changes or declines in cognition, and patient reports of having some difficulty getting to activities and locations (Mendoza, Pittenger, Saftler-Savage & Weinstein, 2003).

It is easy to take life for granted, especially when it comes to the ability to control and dictate daily decisions. For many nursing home residents, this lack of choice is a sad reality. Independence becomes a thing of the past for many of our elderly. Often restrained by physical, mental, and emotional constraints, nursing home residents are subdued in daily life. The residents are usually not in control of the small things in their lives: when they eat, what they eat, what time is bedtime, what kinds of drugs they are required to take. I propose that it is our responsibility as a nation to make senior homes a better place to live, rather than a place to die.

References
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