We’re all different and we’re the same: the story of the European nursing home resident

Length of stay and mortality in nursing homes across Europe have many similarities. There is an opportunity for long-term care systems within Europe to learn from each other, to improve the quality and effectiveness. The median length of stay continues to be influenced predominantly by mortality. In this issue of Age and Ageing, Reilev et al. report a prospective cohort study of more than 5,000 newly admitted nursing home residents in Denmark [1]. This study covered the entire Danish nursing home population and reports on morbidity, mortality and length of stay in the nursing home and hospitalizations. Although European countries are at first sight very heterogenous in their long-term care systems, the picture of this study draws is comparable with that seen in many European countries. Residents who are admitted into nursing homes in Denmark are generally very old (median 84 years), mostly female (63%) and have multimorbidity, with dementia being the most common diagnosis. The indication for nursing home admission is moderate to severe functional impairment resulting in a need for intensive carer support. The median length of stay in a Danish nursing home is 2.2 years, with 70% surviving the first year. These data are comparable with Norway, with a 2.2-year median length of stay and an annual mortality of 32% [2], Germany with a 2.1 year [3] and Northern Ireland with a 2.3-year median length of stay [4]. Upon admission, men tend to be a little younger than women, have a shorter length of stay and die earlier in all of these studies. Residents with dementia live longer than those admitted for other reasons [5]. In Denmark, in common with most countries studied, admissions to care homes are frequently preceded by crises of health and wellbeing, often marked by hospital admission [1, 6]. Changes to policy do not seem to have affected the patterns of morbidity and mortality in nursing homes as much as might have been expected. As an “ageing in place” policy has dominated strategies in many European countries over the past decade [7], one might expect that this would make consecutive admission cohorts older, more dependent and sicker, and thus a decrease in length of stay. However, there is little evidence to support this. It could be the case that now there are more residents with a very short length of stay (death within 6 weeks), because many studies exclude these residents as in the study by Reilev et al. [1]. However, again, we have no data to confirm such a hypothesis. The median length of stay continues to be influenced predominantly by mortality. Furthermore, physical conditions such as organ failure (COPD, heart failure) are much stronger predictors of mortality than dementia in nursing home cohorts. In many countries, the majority of residents have dementia, and so this diagnosis tends to act as an admission criterion to nursing homes rather than a marker of mortality risk. In the United Kingdom, for example, 62% of care home residents have dementia [8]. The above suggests that the population receiving care in nursing homes across Europe is comparable, despite significant differences in how care is structured and funded. One area where policy has, perhaps, affected case mix more, is in end-of-life care. A recent study found that residents in Poland are 6 years younger than in Belgium or the UK, and there was variation in length of stay of deceased residents across six European countries [9]. These cross-national differences are very pronounced in people with dementia [10, 11]. A recent German study found that 51% of nursing home residents with dementia were hospitalised in the last month of life, compared with 8% in the Netherlands [12], and 20% Belgium, respectively [3]. The differences in these data seem to be linked to advance care policies, establishing palliative care goals and avoiding burdensome procedures and transitions at the end of life. Good care in nursing homes mirrors the principles of good end-of-life care. It is clear that there are some opportunities for cross-cultural comparisons and learning here. So, the population across nursing homes in Europe is very similar but there is evidence that its’ composition, and how residents use healthcare services, can be influenced by policy. There is an opportunity for long-term care systems within Europe to learn from each other, to improve the quality and effectiveness of care. A challenge, in this context, is that there is a lack of shared data systems or agreed minimum datasets across and between countries. Developing shared approaches is important if we are to do the best for residents of long-term care [13]. None. None.