1. The Changing Face of the Care Home? Dr. David M Marwick, Rubislaw Place Medical Practice 2014 Introduction Since nursing home and general practice alignment in Aberdeen in 2007, I have been the responsible GP for my practice’s care home. The facility has twenty-six beds. At the time of alignment, the residents or their proxies were encouraged to register with the practice. This has continued and as time has passed and new clients have entered the home, most residents of our aligned home are now registered with the practice. The majority of the residents have dementia, they frequently have often multiple co- morbidities and together they represent some of the most vulnerable patients in the practice’s population. In 2011 monthly multidisciplinary meetings were initiated to ensure that their complex needs were being addressed. These are regularly attended by myself, a nurse, the practice’s aligned geriatrician, a psycho geriatrician, community psychiatric nurse, the practice pharmacist and a palliative care specialist. Three or four of the residents are discussed each month. In addition, at each meeting, we now have a review of any deaths. Over the last year or so, our impression has been that there has been a change in the journey experienced by residents in the care home. New clients seemed often to be older and frailer, seemed more likely to be in a more advanced state of dementia than their predecessors and, especially during a spate of deaths over this past winter, it felt as if the duration of their stay in the care home was significantly more time-limited. Aims For my project for the Dementia Scholarship I sought to examine if there has been a demonstrable change in the demographic of patients entering the care home and if there has indeed been a change in life expectancy. Methods The medical records and archived care home records for all residents of the care home who were registered with the practice since alignment in 2007 were investigated. Information was gathered on age when admitted, whether admission was from home or via hospital, whether or not the resident had a diagnosis of dementia at the time of admission, duration of stay, age at death and whether death occurred at the home or in hospital. Results 60 residents were identified who were registered with the practice since nursing home alignment in 2007. Of these, 5 residents had moved at different times to different care homes. The medical or care home records of 50 of the remaining 55 residents were available for investigation. 30 residents were dead and 20 are current residents. Females and males account for 42 and 8 residents respectively. Though alignment occurred in 2007, a number of residents who came to register with the practice had been resident in the care home for some years before. The available data therefore covers a period of 10 years from 2004 to the present day. Comparison was made between the first and second groups of 25 residents ( from date of admittance to the care home rather than when they registered with the practice). The first group of 25 residents were admitted to the home from July 2004 to February 2011 and the second group from March 2011 to May 2014. Age on admission The average age on admission of the earlier group was 85 years and that of the later group, 82 years. Route of admission 21 residents were admitted to the home via hospital and 4 from home for both the earlier and later groups. Diagnosis of dementia 16 of the first group of 25 residents had a diagnosis of dementia at the time of their admission compared with 14 of the second group. Duration of stay Of the first group of 25 residents admitted to the home from July 2004 to February 2011, 19 were dead and 6 remain alive in the home Of the second group admitted from March 2011 to May 2014, 11 were dead and 14 continue to live at the home Comparison was made between the two groups of duration of stay in the home from time of admission to time of death of the deceased residents. The average length of stay of the first group was 27 months and of the second group, 11 months. Place of death 26 of the 30 deceased residents died in the home, 17 from the former group and 9 from the latter. The other 4 residents died in hospital. Age at death The average age at death of the 19 residents from the first group and the 11 residents from the second group was 87 and 84 years respectively. Discussion Contrary to prior perception, the results indicate that rather than being older, the more recent residents of the care home were a little younger. Similarly, rather than more frequently having a diagnosis of dementia, the second group of residents were a little less commonly affected at the time of entering the home. No difference between the two groups was seen for route of admission to the care home. The most apparent difference between the two groups was the duration of stay. Of the first 25 residents, the average length of stay of those who died was 27 months as opposed to 11 months for the second cohort. In the first group, only one of the 19 residents who died while registered with the practice did so within one month of entering the home. Three of the 11 deceased residents from the second cohort died within a month of going into care. Of those who are deceased, the longest duration of stay in the home was a resident from the first group who passed away after 82 months. However, 2 residents, both also from the first group and both still alive, continue to live in the home after 104 and 119 months. On closer examination of the available data, dementia did not seem to be a predictor of early death. The average length of stay of a resident who had a diagnosis of dementia on entering care was 24 months compared to 18 months of a resident who did not have dementia on admission. The home was the final place of care for the majority of all the residents. Conclusion The small differences between the average age of the first and second groups of 25 residents and whether or not there was a diagnosis of dementia are unlikely to be significant. However, the results do show that life expectancy of residents entering the home over the later three years of the study period would appear to have reduced. Though no older or no more likely to be suffering from dementia, this observation suggests that, compared to earlier years, care home residents on admission are in a significantly more frail and vulnerable state. Application to Practice The results of this study have significant implications for myself, the practice and the home. New residents to the home are likely to have complex medical problems and sometimes poor life expectancy. When these patients register with the practice it has already become a priority to request, summarise and code their notes to aid the delivery of optimum care. Discussions with residents and their families about anticipatory care commence early and they are subject to multidisciplinary review at the earliest opportunity. What cannot be underestimated is the effect of increasingly frequent death on the morale of the care home staff. It appears that the days of the majority of residents living for a number of additional years in a care home are gone. What now exists is more akin to hospice care for the very frail elderly often suffering from dementia. Care home staff need to be trained accordingly and provided with the requisite support. Personal Learning from the GP Dementia Scholarship I applied to do the Dementia Scholarship to “expand my knowledge of the investigation, diagnosis and management of dementia”. I have met these goals. Influential to my application was looking after the care home residents and wanting to reinforce my knowledge base in order to deliver better care to this very vulnerable group. I hope I can succeed in that. Acknowledgements I would like to thank Mrs Elaine Booth, manager of the care home and Mrs Judith Saville, administration assistant at the practice, who assisted me in the compilation of this report.