INTERNATIONAL JOURNAL OF GERIATRIC PSYCHIATRY, VOL. 8: 521-525 (1993)

RELOCATION MORTALITY IN DEMENTIA: THE EFFECTS OF A NEW HOSPITAL

CAROL ROBERTSON* JILL WARRINGTON* AND JOHN M . EAGLES? *Registrar in Psychiatry, $Consultant Psychiatrist, Royal Cornhill Hospital, Aberdeen, Scotland

SUMMARY

Relocation mortality has been cited as an important factor when considering the placement of elderly patients. This study describes the fate of dementia patients relocated to facilitate the move to a new hospital. Some wards were moved as intact units-that is, the patients were kept together and there was little change in the nursing or medical staff. Two other wards were closed, and these patients were dispersed to several existing and new wards and experienced changes of nursing and medical staff. All patients underwent prerelocation and postrelocation orientation programmes. The mortality figures for the total patient group before and after the relocation do not show any statistically significant increase in mortality postrelocation. However, for wards that were closed and where the patients suffered maximum disruption to patient group and nursing staff, there was a significant increase in mortality rates.

KEY WORDS-Dementia, relocation, mortality.

Relocation is a life event which represents a major change in the lives of most individuals. Relocating the institutionalized elderly to a new residence has been cited as a potentially traumatic event, with reports from earlier studies of up to 35% increase in the mortality of relocated geriatric patients (Aldrich and Mendkoff, 1963; Jasnau, 1967).

In reviewing some 28 studies of interinstitution relocation published over 20 years, Borup (1983) reported that the findings of four support an increase in mortality whereas 21 support no such increase, the three remaining studies being incon- clusive. Some studies, for example Schulz and Bren- ner (1977), have examined the effectiveness of preparatory programmes and reported a decrease in postrelocation mortality for certain groups of patients participating in preparatory programmes. Jasnau (1967) noted that for patients given the option to move, those prepared to advance and those moved on an individual rather than en masse basis had a better outcome postrelocation. These findings were supported by Schulz and Brenner (1977).

Studies by Davies et a/. (1990) and by Aldrich

and Mendkoff (1963) found the highest mortality rate in relocation nursing home residents to be in the anticipatory period in the year prior to the move. Csank and Zweig (1980), however, did not find any increase in prerelocation mortality when they reviewed their earlier work and examined only the patients with chronic brain syndrome who were subsequently relocated. They suggested that most care was needed with this group after relocation. Csank and Zweig (1980) felt that patients with chronic brain syndrome should have particular attention paid to minimizing change in their per- sonal living space and belongings. Where possible, they also recommended that there be continuity of treatment regimes and personal relationships, a view upheld by Anthony et al. (1987).

It was against this background of rather conflict- ing research findings that extensive relocations were required among psychogeriatric patients in Grampian.

This article compares relocation mortality in demented elderly patients among groups which underwent different patterns of relocation.

* Address for correspondence: Carol Robertson, DRCOG, MRCGP, MRCPsych, Royal Cornhill Hospital, 26 Cornhill Road, Aberdeen, AB9 2ZH, Scotland. Tel: 0224 681818. Fax: 0224 840784.

PATIENTS AND METHODS

For many years, the majority of hospital care for the demented elderly in Aberdeen has been pro-

08854230/93/060521-05$07.50 0 1993 by John Wiley & Sons, Ltd.

Received 2 September 1992 Accepted 11 January 1993

522 C. ROBERTSON, J . WARRINGTON AND J . M. EAGLES

vided on two sites. The main psychiatric teaching hospital, Royal Cornhill, is a large city centre estab- lishment. Kingseat Hospital is a villa-style hospital, situated rurally, 11 miles to the northeast of the city. In August 1991 new purpose-built accommo- dation on the Royal Cornhill site became ready for occupation.

On the Royal Cornhill site three female psycho- geriatric wards (to be called RC) with a total popu- lation of 73 patients were to be relocated to the new facility. These wards were relocated as com- plete units to wards in the new building and there were no significant changes in nursing or medical staff. There was no preselection of the patients to be moved.

At Kingseat, one villa was earmarked for closure and consisted of one female ward of 23 patients and one male ward of 24 patients (to be called KS). The suitability of patients to be transferred to the new hospital was largely based on the wishes of the relatives, the frequency and ease of visiting and the likely benefits to the patients of relocation. Patients were not specifically selected on the grounds of their physical health. Patients from the closed villa were relocated either to the new hospi- tal or to one of the four existing psychogeriatric wards on the Kingseat site. These patients suffered a considerable change to their patient group and nursing staff.

On both sites every effort was made to communi- cate the plans to the patients, but this was obviously limited by their level of cognitive functioning. On the Cornhill site, where possible, the patients were taken to visit the new wards prior to relocation and the postrelocation orientation of the patients was given considerable attention by the nursing staff.

Prior to the relocation the two groups of patients-RC and KS-were compared in terms of their age, length of stay in hospital and physical health. The average age of the RC group was 82.12 years and that of the KS group 81.73 years. The average length of stay in hospital was 80.19 months for the RC patients and 44.51 months for the KS group. This large difference in length of stay between the two groups can be accounted for by six patients in the RC group each of whom had been in hospital for more than 400 months. There were no such patients in the KS group. If these six patients are omitted from the calculation of average length of stay the two groups are very simi- lar (RC 37.75 months, KS 44.51 months). With regard to physical health, each patient was rated

by the first or second author on a four-point scale ranging from ‘fit and well’ to ‘terminally ill’. This rating was achieved by examination of medical records and discussion with nursing and medical staff. The average of these scores was very similar for the two groups. The comparability of the two groups with regard to these three parameters is not surprising given that each group was derived from similar ‘GP catchment populations’ and admitted to similar psychogeriatric beds.

Through the Aberdeen Psychiatric Case Regis- ter, mortality figures for a period of 2 years were collected for each ward. The bed occupancy figures for all the wards were also obtained. Thus the mor- tality figures as a percentage of total patient popu- lation could be examined. The 47 patients who had originally been in the Kingseat villa were ‘followed’ to their new wards and their mortality noted. All patients in the study were considered to suffer from senile or presenile dementia and the average Mini Mental State Score (Folstein et al., 1975) for the patients was 5 out of a possible score of 30.

For the statistical analysis, the data were assumed to follow a bimodal distribution, ie there were only two possible outcomes for the patients following relocation for the purposes of this study, mortality or survival. Using classical statistical the- ory of maximum likelihood estimates (Kleinbaum et al., 1988), the appropriate parameters for the distribution were established and from this the appropriate test statistic applied. The test statistic followed a chi-squared distribution (with a 1 degree of freedom). This allowed significance levels to be calculated for the difference in mortality between the prerelocation and postrelocation periods.

RESULTS

The total mortality figures for the wards were exa- mined monthly from February 1990 (18 months prior to the relocation) to February 1992 (6 months after the relocation). These figures were examined in conjunction with the average bed occupancy for those wards in the same time period.

In view of the small number of deaths and the need to compared seasonally similar periods, the results were examined in 6-month blocks.

For the RC wards, the total number of deaths in the 6 months period was divided by the average bed occupancy thus giving a percentage of deaths per 6 months. For the KS villa that was closed, the postrelocation mortality was calculated on the

RELOCATION MORTALITY IN DEMENTIA 523

Table 1. Relocation mortality by type of relocation over time

Pre-relocation Post-relocation Feb. 90-July 90 Aug. 90-Jan. 91 Feb. 91-July 91 Aug. 91-Jan. 92

AN Patients Average ward occupancy 129 121.6 122.9 No. of deaths 9 20 16 %mortality 6.91 15.60 13

RC patients Average ward occupancy 82.8 No. ofdeaths 2 'YO mortality 2.40

81.5 13 15.95

76.3 12 15.70

133.3 22 16.50

81.1 10 1 I .48

KS patients Average ward occupancy 46.2 46.1 46.6 46.0 No. of deaths I I 4 12 %mortality 15.10 15.2 8.58 26

Fig. 1. Percentage pre- and postrelocation mortality of All patients, RC patients and KS patients

total number of deaths divided by the number of patients at the point of closure.

Table 1 shows the actual number of deaths and average ward occupancy for the four time periods. From these the percentage mortality pre- and pos- trelocation has been calculated for all patients together, the RC patients and the KS patients.

The histogram (Fig. 1) shows the mortality figures for the three 6-month periods prior to the

relocation and for the one 6-month period follow- ing the relocation for the groups individually and as a single group.

Statistical analysis showed that for all the patients considered together there was no signifi- cant change in the mortality rates postrelocation. The data for the three Royal Cornhill wards (RC) which were relocated on the same site, with intact groups of patients and with similar nursing and

524 C. ROBERTSON, J . WARRINGTON AND J . M . EAGLES

medical staff, again show no statistically significant change in the mortality rates following the reloca- tion.

However, the data for the two Kingseat wards (KS) which were closed and where most disruption was experienced by the patients are in contrast to the results for the All patients and RC groups. For the KS patients, comparing the total prerelocation period to the postrelocation period showed a statis- tically significant increase in mortality rates x2 = 6.535, 1 degree of freedom, p = 0.01 1. Similar results were obtained by comparing the seasonally similar prerelocation period to the postrelocation period.

DISCUSSION

This study provides an opportunity for a naturalis- tic study of the effects on mortality of different patterns of relocation. The number of deaths occur- ring during this study was thankfully small and interpretation of the results must be viewed in the light of this. Although the total numbers involved are also relatively small, it seems likely that with progress towards community care it will become increasingly difficult to study larger groups of relo- cating patients. By the nature of the reorganization of the psychogeriatric service in Aberdeen, no suit- able control group could be identified. However, the patient groups from the original wards acted as their own controls by comparing their mortality rates before and after the relocation. An analysis of mean survival times postrelocation will be infor- mative in due course, but as yet sufficient time has not elapsed since the relocation for these data to be meaningful.

The results of this study indicate that for the total group of patients and for the RC patients considered separately, there was no significant increase in mortality postrelocation. This is also the case when comparing seasonally similar time periods. However, when the KS patients were con- sidered separately, there was a statistically signifi- cant increase in mortality postrelocation. These patients were exposed to a much altered patient and nursing group and can be presumed to have suffered a more stressful experience than the patients who had only their physical surroundings changed. This finding is in keeping with the findings of Csank and Zweig (1980) and Anthony et al. (1987), who noted that continuity of relationships was important for demented patients and where

possible patients should be relocated with other familiar patients and staff.

Clover et al. (1989) have shown that a stressful living situation can increase susceptibility to infec- tion with influenza, presumably due to alteration in immune responses. The more disrupted patients in the present study would have been exposed not only to additional stress, but also to novel infec- tious agents through their contact with new groups of nurses and patients.

Anthony et al. (1987) found that the relocated demented elderly suffer an increase in depressive behaviour following relocation, and since it has been established by Murphy et al. (1988), Rovner et al. (1991) and Ashby et al. (1991) that depressed elderly patients have an increased mortality, it may be that depression is an intervening variable increasing the mortality of relocated patients.

Whatever the cause, the conclusion remains unaltered that it appears preferable to relocate patients as complete ward groups.

Despite the increased mortality in the KS group, the overall mortality rates were not significantly increased. This can possibly be attributed to the prerelocation preparation which the patients underwent, since such preparation can have a pro- tective effect (Schulz and Brenner 1977). Csank and Zweig (1 980) found that organically brain damaged patients did not have an increased mortality risk in the anticipatory period and this is in keeping with our findings.

Most previous studies on this subject have been of non-demented elderly patients and have not pro- vided the opportunity to study the effects on morta- lity of different patterns of relocation. As indicated, this study was able to compare two groups of demented patients experiencing quite different levels of disruption through relocation. At a local level the study was welcome as it had been antici- pated, in the light of previous experience, that a significant number of patients would have died as a result of the relocation. The results justify the efforts made to prepare patients for the move, and the subsequent orientation work following reloca- tion. The increased mortality of the KS patients should be noted and perhaps any future relocation of demented patients should aim, as far as possible, to maintain patient and staff groups intact.

ACKNOWLEDGEMENTS

We would like to thank the following people: Drs Olley and Alexander, consultant psychogeriatri-

RELOCATION MORTALITY IN DEMENTIA 525

cians, for allowing us to research their patients;

ward staff and patients of all the psychogeriatric

and Ramsey, C. N. (1989) Family functioning and

Pract. 28* 735-39.

of chronically ill geriatric patients with organic brain

Mrs Julie Bett for secretarial and clerical help; the stress as predictors of influenza B infection. J. Fum.

wards studied for their cooperation. We are grate- ful to senior nursing staff for providing

Csank, J. z. and Zweig, J. p. ( 1980) mortality

damage before and after relocation. J. Am. Geriatr. background information, to Dr Chris Perera for soci, 7683, assistance with assessing the MMSE Of patients and to Mrs Marion Campbell for statistical

Davies, R. E., Thorson, J. A. and Copenhaven, J. H. (1990) Effects of a forced institutional relocation on

assistance.

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