Recognition and management of acute functional decline in older people living in care homes: a qualitative interview study with UK care home staff

Problem

Older people living in care homes sometimes experience episodes of acute functional decline. These represent a diagnostic challenge to GPs and can result in antibiotic prescriptions or hospital admissions, though these may not always be the most appropriate management strategies. In this study we aimed to understand how episodes of acute functional decline are recognised, managed and escalated by care home staff.

Approach

This was a qualitative interview study with UK care home staff, including managers, nurses and carers. Staff were recruited through advertisements circulated via email mailing lists, social media and word of mouth. Interviews were conducted over the phone between January 2021 and February 2022. They were semi-structured and based on a flexible topic guide. Thematic analysis was facilitated by NVivo software.

Findings

Care home staff generally felt confident in recognising when residents were less well than usual, especially if they knew them well. However, they sometimes felt it was difficult to differentiate between an ‘off day’ and something more significant. Care home staff usually associated an acute functional decline with an underlying infection, particularly in the urine. Other causes they considered included medication side effects, constipation, dehydration and stroke. Initial management steps in the care home included a general assessment to check for possible causes and measuring clinical observations. Many staff mentioned doing a urine dipstick as part of their initial assessment, although some talked about how this was no longer recommended. Some care home staff felt comfortable monitoring residents for a few days themselves. Some would try an intervention like analgesia or encouraging oral fluids in this period. Others preferred escalating directly to a GP or other healthcare professional. Some care home staff reflected that they had increased confidence in their own assessments since the beginning of the pandemic as they had had fewer GP visits and had become more independent.

Consequences

This study has helped us to understand how staff recognise acute functional decline and explore the processes occurring in the care home before external help is sought. Care home staff have described a range of different practices and levels of confidence. We have identified potential areas for additional support and training, including the use of urine dipsticks.