These different clinical findings suggest that the disease in the symptomatic, younger patients was more advanced, though with respect to risk factors, indications for anticoagulant therapy, electrocardiographic abnormalities during therapy and duration of therapy they were comparable to the other patients. In this series of patients neither abrupt nor gradual cessation of anticoagulant therapy was associated with an exceptionally high incidence of myocardial infarction or death over a 6month follow-up period.

We thank Miss Francine Bergeron, RN, of the anticoagulant clinic, Mrs. Diane Roy and Miss Claudette Sheehy for their secretarial assistance, and Mr. P. De LaDurantaye for his statistical help.

References I. GIFFORD RH, FEINSTEIN AR: A critique of methodologies in studies of anticoagulant therapy for myocardial infarction. N Engi I

Med 280: 351, 1969

2. KINODON HS: Anticoagulants: a guide for practitioners. Postgrad Med 54: 61, 1973 3. FEINSTEIN AR: More blood for the anticoagulant battle. N Engi .! Med 292: 1400, 1975 4. GUREWIcH V: Guidelines for the management

of anticoagulant therapy. Hemostasis 2: 176, 1976

Semin

Thromb

5. KEYES JN, DRAKE EH, SMITH FJ: Survival rates after acute myocardial infarction with long-term anticoagulant therapy. Circulation

14: 254, 1966 6. NIcHoL ES, KEYES JN, BORG JF, Ct al: Long-term anticoagulant therapy in coronary atherosclerosis. Am Heart 1 55: 142, 1958 7. KAMATH VR, THORNE MG: Ischaemic heartdisease and withdrawal of anticoagulant therapy. Lancet 1: 1025, 1969 8. MICHAELS L: Recurrence of thromboembolic disease after discontinuing anticoagulant therapy. A study of factors affecting incidence.

Br Heart / 32: 359, 1970 9. VANCLEVE RB: The rebound phenomenon. Fact or fancy? Experience with discontinuation of long-term anticoagulant therapy after myocardial infarction. Circulatton 32: 878,

1965 10. Idem: Letting go of the bear's tail. Experience with discontinuation of long-term anti-coagulant therapy. JAMA 196: 140, 1966

Square pegs in round holes: a study of residents in Iong*term institutions in London, Ont. R.I..T. CAPE, B SC, MD, FRCP (EDIN), FRCP[C], FACP; C. SHORROCK;* R. TREE;* R. PABLO, MA; A.J. CAMPBELL, MB, CH B, MRACP; D.G. SEYMOUR, MB, CH B, B SC, MRCP

A large random sample of people In the long-term institutions (homes for the aged, nursing homes and continuing care hospitals) of London, Ont. was studied to assess the suitability of these people, according to physical and mental status, for the institution in which each resided. The results indicated a relative need for beds in homes for the aged and nursing homes. A high proportion (290/o to 540/o) of people in the three types of institutions were unsuitably placed. Greater flexibility is needed in institutional arrangements, and institutions should be examined for their potential to provide support in maintaining the elderly at home. The findings of this study add some weight to the arguments of those calling for more and better home care programs for the disabled. Un large echantillonnage randomise de gens places dans des institutions de soins a long terme (foyers pour vieillards, maisons de repos et h6pitaux de soins continus) de London, Ont. a ete 6tudi6 dans le but d'6valuer l'aptitude de ces personnes a resider dans leurs institutions respectives, selon leurs statuts physique et mental. Les resultats indiquent un manque relatif de lits dans les foyers pour vieillards et les maisons de repos. Un fort pourcentage (290/o a 540/o) des From the University of Western Ontario, London, Ont. *Summer student Reprint requests to: Dr. R.D.T. Cape, Department of geriatric medicine, Parkwood Hospital, 81 Grand Ave., London, Ont. N6A 5C1

gens dans les trois types d'lnstitutions etaient inadequatement places. Une plus grande flexibilite est necessaire dans les amenagements des institutions, et on devrait examiner leur capacite d'assurer le support requis pour l'entretien des vielliards a domicile. Les resultats de cette etude ajoutent aux arguments de ceux qui demandent un plus grand nombre et de meilleurs programmes de soins pour les invalides. In 1973, according to Statistics Canada, there were more than 1.8 million people aged 65 years or more in this country, of whom 38% were aged 75 or more. Estimates quoted by Schwenger1 suggest that these figures will increase in the next 60 years to 4.4 million for the population aged 65 or more and 1.5 million for the subgroup aged 75 or more. Schwenger has drawn attention to the increase in the proportion of elderly individuals living in institutions between 1962 (8.5% of those aged 65 or more) and 1972 (over 9%) in the province of Ontario, which has one of the highest rates of long-term institutional care for old people in the world. The object of the study reported below was to determine the proportion of this population in London, Ont. living in the type of institution most suited to their needs. Types of long-term institutional care There are 2350 beds for care of the elderly and chronically ill in the London area available to an elderly population (aged 65 years or more) of ap-

1284 CMA JOURNAL/DECEMBER 3, 1977/VOL. 117

proximately 28 000. These beds are of three types, classified according to the working party on patient care classification of the Ontario Ministry of Health2 in 1975: 1. Residential care: "that required by a person who is ambulant, with decreased physical and/or mental faculties, and who requires supervision or assistance with activities of daily living and provision for meeting psycho-social needs through social and recreational services." This type of care is provided by homes for the aged. 2. Extended health care: "that required by a person with a relatively stabilized (physical or mental) chronic disease or functional disability, who, having reached the apparent limit of his recovery, is not likely to change in the near future, he or she requiring availability of personal care on a continuing 24 hour basis, with medical and professional nursing supervision and provision for meeting psycho-social needs." This type of care is usually found in nursing homes. 3. Long-term care: "that required by a person who has a functional disability (physical or mental) but no acute illness, stable or unstable vital processes and limited potential for rehabilitation. Such individuals require medical management and skilled nursing care." This type of care is available in continuing care hospitals. Methods Study design The study was designed to discover

if the available beds in the different institutions were occupied by the type of person for whom they were intended. To discover this we conducted a survey of a random sample of occupants of institutional beds in the summer of 1976. The main objectives of the survey were to answer two questions: 1. Is the proportion of beds of each type appropriate to the needs of the community? 2. Is each individual in the institution that is most suitable for his or her needs?

Procedure With the full cooperation of all the long-term institutions in the area a random sample of 731 persons was obtained from a total population of 2242 people (108 were not studied because of lack of time) by the selection of every third individual on the alphabetical list of residents and patients in each of the institutions. A Lorm covering personal demographic characteristics, assessment of mental status, capability in activities of daily living and related clinical information on diagnosis and medications was devised. It was kept as simple as possible to ensure accurate recording of the relevant information. The names of the person, his or her doctor and the institution were not included to provide absolute confidentiality. Although not necessary for assessing placement, sex, date of birth, date of admission, number of previous hospitalizations, diagnoses and medications were included. Further details of the assessment of particular aspects are provided below: 1. Mental status: The assessment consisted of seven questions or instructions briefly testing orientation to time and place. The individual was asked the date, the day of the week, the name of the institution and his or her age and date of birth, and was asked to subtract 3 from 20, then to continue subtracting down to 0. Except for the current date, for which a deviation of 1 day was allowed, a precisely correct response was required. The patient was classified as normal if there were six or seven correct responses, occasionally confused if there were three, four or five correct responses, or demented if there were only one or two correct responses. 2. Hearing: Hearing was regarded as normal if a conversational voice was heard, impaired if the voice had to be raised, or deaf if it was difficult to communicate with the person even by shouting. 3. Sight: Sight was assessed by means of a chart for determination of visual acuity. It was held 30 cm from the

person's eyes and he or she was asked to read the letters and words on it. If the person was able to read 6-mmhigh print, eyesight was assessed as normal; if he or she could read only 13-mm-high print, eyesight was assessed as impaired. If the individual could not name objects or count fingers held out at the same distance, he or she was assessed as blind. 4. Ambulation: This was assessed by direct observation whenever possible, and otherwise (for 30% of persons) the head nurse was asked to provide the information. 5. Falls: The number of falls was recorded and, as corroboration, both the elderly person and the head nurse were asked about them. 6. Activities of daily living: This was the most important factor in assessing the type of facility in which the person should be placed. The person's competence in such activities was checked with the head nurse. For each of six functions - bathing, dressing, toileting, transfer, continence and feeding - a score of 3 was given if the person was independent, 2 if partial assistance was required and 1 if total assistance was required. A total score between 6 (the minimum possible) and 18 (the maximum possible) was recorded for each patient. Validation Interviewing and completion of the forms were carried out by two of the authors (CS. and R.T.). Initially they worked together but later they completed most of the forms alone. Hence a concern in the use of the forms was the consistency between the raters and from one occasion to the next for

the same rater. As a test of validation 30 patients at one institution were studied by each rater. One week later 15 of the subjects assessed by C.S. were reassessed by R.T. and vice versa. Interrater and test-retest reliability coefficients for 23 variables ranged from 0.819 to 1.000. The highly satisfactory coefficients indicated that the raters had a high degree of consistency in making their assessments and, therefore, any variations attributable to differences between the raters or the ratings were not large enough to prohibit the drawing of reliable conclusions. Results The age and sex distribution of the sample is shown in Fig. 1. Of the 731 persons 34.9% were aged 85 years or more and 87.1 % were beyond retirement age. The proportion of men in the quinquennial groups diminished steadily from 65 years onwards, to a low of 12.3 % in the nonagenarian group. The mean age of residents in homes for the aged and continuing care hospitals was 81 years, while in nursing homes it was 79. Certain general characteristics of the sample were noted. Almost one half had some difficulty in walking, more than one quarter had significant loss of mentation and more than one third had periods of incontinence. Almost 80% had good hearing but more than 30% had impaired vision. Perhaps the most striking feature was that almost 20% consumed six or more drugs each day (Fig. 2). In all three types of institution the average number of medications taken daily per person was between 3.7 and 3.9. 20.4%

d

150l7.5. 16.5% 128 110 (I)

I-

z W 100-

83.2%

I-

4

10.7%

0. is-

0

uJ I

50-

7.7%

7.0% 51

44'E 37.7%

3.4w 2.6% 25

64 65-69 70-74 75-79 80-84 85-89 90+ OVER

20

9.5%

CE,

z w I-

a. I3.O.

IA. 0 IAJ U

10.7%

Z 0I0 La. 0

6.4%

I 6ORMORE NUMBER OF MEDICATIONS

FIG. 2-Number of medications taken daily by the 731 persons.

is the proportion of beds of each type appropriate to the needs of the community? To answer this question we needed a method of assessing each individual in a manner that would allow his or her needs to be matched with the criteria laid down at the beginning of this paper. The most reliable guide was the person's ability in activities of daily living and the first step was to allocate subjects to one of three groups. If the person's score was 16 to 18 he or she

was judged to be suitable for a home for the aged, if 10 to 15 for a nursing home and if 6 to 9 for a continuing care hospital. Two other criteria were used to refine this method of selection. Incontinence and inability to get to the washroom automatically made the person suitable for a continuing care hospital. Of the 731 persons 132 (18%) were in "special-care" beds and were excluded from this part of the study; a separate report on them will appear later. Of the 599 persons 237 were judged suitable for a home for the aged, 212 for a nursing home and 150 for a continuing care hospital. At the time of the study the actual numbers in these groups were 224, 190 and 185, respectively. The detailed results are shown in Fig. 3. By multiplying these numbers by three we can assess the London situation (Fig. 4). In round figures the need is for 40 more beds in homes for the aged, 70 more in nursing homes and 100 fewer in continuing care hospitals. The survey cannot, of course, give any information on the total need for institutional beds in the city for the care of the elderly and disabled. The answer to the question posed at the head of this section is that, according to our assessment, there was an excess of 113 beds in continuing care hospitals, which represented 19% of those available; these 113 should have been distributed in a ratio of 7:4 in nursing homes and homes for the aged, respectively.

ACTUAL PLACEMENT

'If

4,

HFA

NH

CCH

159 -* (67%)

59 -> (25%)

19 -*

(71%)

4, (31%)

is each individual in the institution that is most suitable for his or her needs? The answer to this question also lies in Fig. 3, with the same criteria applied as described in the previous paragraph. Reading down column 1 it can be seen that 71% of residents of homes for the aged were appropriately placed, but 23 % required nursing home care and 6% the care of a continuing care hospital; only 46% of nursing home residents were in the right type of institution (column 2), as were 51 % of those in continuing care hospitals (column 3). If all subjects had been placed correctly the percentages enclosed in boxes with solid lines would all be 100. The answer to the question posed is, therefore, No in 29% to 54% of cases. One other piece of evidence from the survey results is important: 62 individuals (8% of the 731 studied) scored a maximum of 18 in competence in activities of daily living, had a normal mental status and had no clinical problems. There was no apparent reason why these people should have been in any institution. Discussion It would be foolish to overemphasize the findings of one study, but a similar investigation in Kingston produced the same type of results.3 What does this mean? There seems to be good evidence that a considerable number of people, 90% of whom are elderly, are not in the type of institution that best suits their needs. Why? Assuming that the original assessment on each application to the institutions was accurate there are four possible reasons for the great extent of inappropriate placement:

TOTAL 800.

.-.'

HFA

(8%) .-. 237

.1.

LU

0

(10%)

32.4% 761 50.6% 719

EZZIZIPREDICTED 29.0% 682

Co

., 600

26.0% 614

0

LiZj ACTUAL 253% 595

z 0

88 -. (42%)

'4,(23%)

APPROPRIATE PLACEMENT

20.5% 482

Co 0

LU 400 U

49

0

(46%)

(39%)

0

z 0

F-----

U 200-3

-.

CCH

13 -.*

43 -* (28%)

94 -* (63%) -. 150

(6%)

(23%)

(51%)

'4,

I

4,

0 0.

4' HFA

4, FIG.

3-Actual

and

appropriate

placement

4 190 of

P

599

of

the

'I,

185 .99 -. persons. HFA = home hospital.

NH

CCH

TYPE OF INSTITUTION

FIG. 4-Projected numbers of beds needed and actually available in the three types of institution. ADL = activities of daily living.

1. There is a delay between the assessment and the actual move into an institution. The whole system is bedevilled by form-filling. The interval from the day of decision or agreement that an institution is an individual's answer to future care to the day of entry into that institution is usually 1 to 6 months. At the end of this time the institution may no longer be appropriate for that individual. 2. Few patients remain in the same clinical state over a long period. Having been admitted to a nursing home either the patient may improve to the point where return home or admission to a home for the aged may be possible, or his or her condition may deteriorate, necessitating care in a hospital. 3. It is well known that the moving of elderly patients from one institution to another can be upsetting to them. For this reason most institutions will try to keep individuals in the environment they have grown to enjoy and rely on, even if deterioration in their condition has resulted in their no longer being in the most suitable institution. 4. Many applications for placement

arise from crisis admissions to "acutecare" hospitals. In Hamilton and district more than 1000 of the 2000 persons placed in a long-term institution in 1975 were transferred from an acutecare hospital.4 A further 300 were in an inappropriate institution and only 600 in their own homes. The waiting time in this efficient organization appeared to be between 2 and 3 months. Pressure from an acute-care hospital may lead to hasty decision-making and the seizing of the first available bed whether it is the most appropriate or not. Once a system that relies heavily on institutions for care of the elderly has been adopted it is very important that it work. The results of our straightforward attempt to assess the appropriateness of placements in a sizeable urban community suggest that there may be major flaws in present arrangements. They support the growing emphasis on the need for more and improved support for old people in their own homes and suggest that less rigidity and more pleomorphism in institutions would be a major step forward. It is

possible that these two concepts may be blended and that institutions should be examining what part they might play in sustaining elderly people at home by providing day-hospital facilities, schemes of intermittent admission and "meals-on-wheels" services. Without such developments there seems little hope of altering the sad state of affairs uncovered by our study. This study was carried out under the summer student program, University of Western Ontario, and was supported by funds from Parkwood Hospital and the Women's Christian Association. Computer time was made available by the health care research unit, University of Western Ontario. References 1. SCHWENGER CW: The geriatric crisis in Canada: real or imagined? I Long Term Care Admin 3 (3): 22, 1975 2. Patient Care Classification by Types of Care, booklet no 75-2222 8/75, Toronto, Ontario Ministry of Health, 1975 3. KsAus AS, SPASOFF RA, BEATTIB El, et al: Elderly Applicants to Long-Term Care Institutions. II. The Application Process; Placement and Care Needs, Queen's University, department of community health and epidemiology, Kingston, Ont 4. Hamilton and District Health Council: Fourth Annual Report of the Assessment and Placement Service, Hamilton, Ont, 1975

MEDICLINICS POSTGRADUATE MEDICAL REFRESHER COURSE

FORT LAUDERDALE, FLORIDA MARCH 6- 17, 1978 PRE*REGISTRATION - $300.00 M EDICLI N lOS 832 Central Medical Building Saint Paul. Minnesota 55104

EXCELLENT FACULTY, FINEST HOTEL, PEAK OF WINTER SEASON CMA JOURNAL/DECEMBER 3, 1977/VOL. 117 1287