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Relocation puts elderly nursing home residents at risk of stress, although the stress is short lived: Commentary

Relocation puts elderly nursing home residents at risk of stress,
although the stress is short lived
Hodgson N, Freedman VA, Granger DA, et al. Biobehavioral correlates of relocation in the frail elderly: salivary cortisol, affect, and
cognitive function. J Am Geriatr Soc 2004;52:1856–62.
QWhat are the effects of moving elderly people to a new nursing home?
Design: Randomised controlled trial.
Setting: Long term nursing homes in greater Philadelphia and
Horsham, Pennsylvania between June 2001 and spring 2002.
Population: 77 nursing home residents aged 65 and over.
Assessment: Participants were divided into two groups: residents
moving to a new nursing home, and residents remaining in the
Philadelphia nursing home. Baseline measurements were
recorded in July and August 2001. Residents were moved during
fall 2001, measurements were taken 1 week before moving, and
1 week and 4 weeks after moving.
Outcomes: Mini-Mental State Examination scores, Observed
Affect Rating Scale scores, salivary cortisol, blood pressure, and
Follow up period: Outcomes were assessed 1 week before the
move, and 1 week and 4 weeks after the move.
1 week before moving: residents moving had a significantly greater
increase from baseline in late afternoon cortisol compared with
residents remaining (p = 0.015) 1 week after moving: residents
moving had a significantly greater increase from baseline in early
morning cortisol and mild pleasure, although they had a greater
reduction in pulse, anxiety, and sadness compared with residents
remaining (early morning cortisol: p = 0.005; mild pleasure:
p = 0.042; pulse: p = 0.002; anxiety: p = 0.027; sadness: p = 0.003).
4 weeks after moving: residents moving had a significantly greater
reduction from baseline in late afternoon cortisol, pulse, anxiety, and
sadness compared with residents remaining (late afternoon cortisol:
p = 0.030; pulse: p = 0.002; anxiety: p = 0.002; sadness: p = 0.005).
Elderly nursing home residents may experience stress before
relocation, although the stress is short lived. Quality of care can be
improved by preparing residents for relocation, by identifying and
alleviating stressors associated with relocation.
Results should be treated with caution. The study conducted multiple
analyses for different outcomes, which increases the likelihood that
significant results would have arisen by chance.
For correspondence: Dr Nancy Hodgson, Senior Research Scientist, Polisher
Research Institute, Madlyn and Leonard Abramson Center for Jewish Life,
1425 Horsham Road, North Wales, PA 19454, USA; nhodgson@abram-
Sources of funding: National Institute on Aging Grant R03 AG19896-01, the
Pennsylvania State University College of Health and Human Development
and Population Research Institute, and the Polisher Research Institute.
Hodgson et al examined the effects of moving nursing home
residents from one environment to another. Staff in skilled nursing
and other long term care facilities, as well as family members,
commonly believe that frail older adults experience adverse physical,
psychological, and cognitive effects from the stress of relocation.
Whereas several early studies found adverse effects post-transfer,
more recent investigations examining a range of health outcomes have
concluded that relocation produces no ill effects. Indeed, some argue that
a move to an improved physical environment has positive effects on
residents’ wellbeing.
Hodgson et al make an important contribution to the literature on the
controversy regarding the direction, nature, and extent of relocation
effects in nursing home residents. The first randomised controlled trial to
examine this issue, the study involved a naturally occurring experiment
where residents were relocated to a new facility over a 7 month period. A
move preparation programme provided information and support to those
who agreed to the relocation. The principal outcome measure was
salivary cortisol, a sensitive, non-invasive assessment of a physiological
marker of the stress response.
Repeated measures were also made of
cognitive status, observed affect, blood pressure, and pulse rate.
Compared with the group who had not yet moved, relocated residents
exhibited higher cortisol levels 1 week after the move followed by a
significant decline at 4 weeks post-transfer. At this later point, those who
had relocated also had lower pulse rates and significantly fewer
symptoms of depression and anxiety than the controls. No cognitive
response to the move was found.
Because the sample was homogeneous with respect to race and
culture, the study’s generalisability is limited. The signed consent rate was
only slightly more than 50%, and the study authors do not report
comparisons of the clinical characteristics of the refusals and the
participants. In addition, xerostomia (dry mouth), common in nursing
home residents, prevented one-third of those enrolled in the trial from
providing analysable saliva samples. Nonetheless, the findings suggest
that with preparation beforehand and assistance in the early weeks post-
transfer, stress can be minimised; if the move is to a more pleasant,
supportive environment, residents’ experience may be positive.
Additional research is needed with other populations and to further
explore the relationship between changes in affect and the stress
response as measured by sensitive biomarkers.
Allyson M Washburn, PhD
Saybrook Graduate School and Research Center, San Francisco CA,
1 Markus E, Blenker M, Bloom M, et al. The impact of relocation upon
mortality rates of institutionalized aged person. J Gerontol 1971;26:537–
2 Coffman TL. Relocation and survival of institutionalized aged: a re-
examination of the evidence. Gerontologist 1981;21:483–500.
3 Mirotznik J, Kamp LL. Cognitive status and relocation stress: a test of the
vulnerability hypothesis. Gerontologist 2000;40:531–9.
4 Kirschbaum C, Hellmammer DH. Salivary cortisol. Encycl Stress
AETIOLOGY 49 on October 13, 2016 - Published by from
at risk of stress, although the stress is short
Relocation puts elderly nursing home residents
doi: 10.1136/ebmh.8.2.49
2005 8: 49 Evid Based Mental Health
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Two decades of research have produced equivocal evidence and opinion as to whether relocation is likely to affect the survival of elderly persons, or under what conditions. Published and unpublished data for 26 relocated groups are analyzed by procedures giving comparable (z-score) estimates of mortality outcomes across the entire set of investigations. The results show no general relocation effect and no systematic effect of age, sex, mental or physical status, choice, preparation, environmental change, or mass versus individualized transfer on post-move mortality. Differences in outcome are interpreted in terms of the balance of integrative versus disintegrative processes in the support systems of those who are (to be) relocated.
This study investigated whether cognitively impaired nursing home residents are at particular risk of experiencing harmful effects during a mass, intra-institutional, interbuilding relocation. A pretest-post-test experimental-comparison group design was used. Data on cognitive status, functional capacity, psychosocial health status, physical health status, and mortality were abstracted from the Minimum Data Set Plus and were analyzed using continuous and discrete survival analyses, controlling for covariates as well as baseline status of outcome variables. None of the Relocation x Cognitive Status interaction effects were significant. Relocation main effects indicated that movers in general were more likely than nonmovers to decline in physical health status. Evidence also emerged for a positive long-term effect of moving on psychosocial health status. These findings suggest cognitively impaired residents are not at unusual risk of harmful effects as a consequence of mass, interbuilding transfer. Given the significant relocation main effects, though, caution must be taken in moving cognitively impaired residents, as it should be in moving any residents.