Modelos de cielo

The last few decades have witnessed an increase of the ageing population and their care has presented looming challenges in many countries. As elderly populations continue to grow, the number of older people with functional disabilities is also on the increase. Impairments in physical and mental functioning in elderly adults reduce healthy life expectancy (World Health Organization (WHO), 2014), healthcare costs and makes the need for long-term care inevitable in many cases (Lubitz et al., 2003). Consequently, in many countries, there is an increasing demand for nursing home care options. Care home residents are a distinct group with chronic medical problems which have assumed increased relevance because of the high healthcare burden.

A care home is defined as an institution which provides accommodation and care for people with complex needs who are unable to look after themselves (National Institute for Health Research (NIHR), 2016). The term care home inludess both nursing homes and residential homes. Nursing homes provide accommodation and assistance with personal care as well as 24-hour nursing care. Residential homes provide accommodation without nursing care, some homes provide both levels of care. Many care homes offer rehabilitation facilities (physiotherapy, occupational therapy and speech & language therapy) and recreational activities also. The level of care for the residents can change, more often from residential to nursing because of an increase in care needs.

49 Most care home residents are women who are over 85 years old. There is considerable overlap in health status and need and support amongst residents in all care homes. The median period from admission to care home to death is about 15 months, the average life expectancy is less than 2.5 years, but about 27% live for more than 3 years (National Institute for Health Research (NIHR), 2016). Given these, end-of-life care is a core component of care in many care home settings which can have impact on research, regardless of the research question.

The National Centre for Health Statistics of the Centers for Disease Control and Prevention in the USA (CDC) estimated 1.5 million adults over the age of 65 years are currently living in nursing homes; a number expected to triple by 2030 (Centers for Disease Control and Prevention, 2012). There are an estimated 450,000 people (0.64% of the population) living in care homes in the UK, this is 4% of the population aged 65 years and over; 9.7% of who are 75 years and over and 23.7% are 85 years and over (Office for National Statistics, 2011). A similar proportion (0.68%) has been reported in the Netherlands, where approximately 117,000 older people out of a national population of 17.08 million live in care homes (Verbeck – Qudijk 2012).

The proportion of care home residents is lower in developing countries: social, economic and cultural practices are responsible for this. In these countries, older people with care needs can rely on kinship networks to provide support, but with the established trend of population ageing and the rapid increases in the oldest age groups, the situation is changing. Studies from a wide range of developing communities indicate important shifts in inter-generational relations, whereby older generations are becoming less confident about receiving care and

50 support from younger family members (Aboderin, 2004, Bhat, Dhruvarajan, 2001) and there is evidence that care institutions are becoming an increasingly acceptable alternative to the traditional family care (Redondo, Lloyd-Sherlock, 2009).

A survey in India in 1984 showed that 91% of people said it was their duty to care for older parents; 10 years later, this had reduced to 77% (Jamuna, 2003). The survey also found no children supported the idea of sending older people to care homes in 1984, but 10 years later, 23% did. This changing social trend has contributed to the growing demand for care homes in the city of Buenos Aires, Argentina. According to the 2001 Census, 2% of Argentines aged 65 years and over, and 5% of people aged 80 years and over were living in care homes, almost all of which operated on a private for-profit basis (INDEC, 2001).

In the UK, 75% of care home residents are moderately disabled, with female residents having the higher proportion of disability. Shah and colleagues found that the mean age for nursing and residential homes was 84.9 and 86.1 years respectively compared to 74.7 for controls (Shah et al 2010). A health survey of 410,000 older people found 57% of women and 48% of men needed help with one or more `self-care` tasks and the following reasons were given for admission to care homes (Bebbington, Darton & Netten, 2001);

Physical health problems 69% Mental health problems 43% Functional disablement 42%

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Lack of motivation 22%

Present home physically unsuitable 15% Family break-down (incl. loss of carer) 8% Need for rehabilitation 6% Fear of being the victim of crime 4%

Abuse 2%

Loneliness or isolation 2% Homelessness 1% More than one reason may be given.

Oliver found that the common precipitants of care home admission were dementia, falls and fractures, and declining mobility and incontinence (Oliver 2014).

A survey found that local authority funded and self-funded residents differed in their levels of dependency and age when entering care; self-funded residents tended to be older and less dependent than publicly funded residents (Netten, Darton & Curtis, 2002).

The sources of admissions of the older person to care homes vary (Bebbington, Darton & Netten, 2001):

Admission from hospital 52% Admission from a private household 29%

Admission from one form of care home to another (residential or nursing home) 13% Admission from sheltered accommodation 6%.

52 Care home residents have high prevalence of cognitive impairment such as dementia (Alzheimer`s Society, 2013), depression (Godfrey, Denby, 2004) musculoskeletal problems (Arthritis Research UK, 2015), stroke (Martin, Meltzer & Elliot, 1998), Parkinson`s disease (Parkinson`s UK, 2015) and people at the end of life pathway. In a cross-sectional analyisis of 326 English and Welsh general practices, Shah and colleagues (2010) found that the prevalence ratios for dementia were 14.8 (95% CI 13.4 – 16.4) for nursing and 13.5 (95% CI 12.4 – 14.8) for residential homes compared to controls. Stroke and severe mental illness were commoner in nursing and residential homes but hypertension, respiratory and cancer diagnoses were slightly less common. Recorded disease prevalences in nursing and residential homes were similar (Shah et al 2010).

About 97,000 (17.8% of all those who die in England each year) are from care homes (Office for National Statistics (ONS), 2014) and 3,000 care homes in England are now registered for end-of-life care; 462 have received the Gold Standards Framework (GSF) accreditation, a Quality Hallmark that ensures the integrity and sustainability of the process (Care Quality Commission (CQC), 2015). The GSF is a systematic evidenced based approach to optimising the care for patients nearing the end of life and is widely used in the community and care home setting. The acute hospital training programme focuses on improving care provided by frontline generalist ward staff for all patients thought to be in the final months , weeks or days of life by introducing earlier identification and anticipation of needs and planning care in alignment with patient`s needs and preferences.

53 Hansen LC and colleagues found that care home environment allows staff to form closer relationships with residents and their families than is possible in a busy hospital environment thereby providing an appropriate environment for end-of-life care (Hanson, Gilliam & Lee, 2010). Care homes are often characterised by rigid schedules, high workloads, high staff turnover and large numbers of unregulated care providers with limited education and training (Mentes, Tripp-Reimer, 2002). Medical care is often provided by several General Practitioners (GP) whose offices are located off site, pharmacist visits are intermittent and only few care homes have advanced medical facilities on site.

There are an estimated 440,000 people living in 18,000 care homes in England (Commission for Social Care Inspection (CSCI), 2006). In Lincolnshire, there are 295 care homes representing 1.6% of care homes in England. London metropolis has the highest number. The UK Government specifies the minimum standard of care desired through the Care Standards Act and monitors implementation using the Care Quality Commission (CQC) in England, the Care Inspectorate in Scotland and the Care and Social Services Inspectorate in Wales.