INTERNATIONAL JOURNAL OF GERIATRIC PSYCHIATRY

Int J Geriatr Psychiatry 2006; 21: 281–287.

Published online 13 February 2006 in Wiley InterScience (www.interscience.wiley.com). DOI: 10.1002/gps.1453

Nursing home institutionalization: a source

of eustress or distress for the elderly?
Paolo Scocco1*, Monica Rapattoni2 and Giovanna Fantoni3
1
Department of Mental Health, Padua, Italy
2
Regional Centre for the Study of Brain Aging (CRIC), Arcugnano (VI), Italy
3
L’Alveare, Cooperativa Sociale, Verona, Italy

SUMMARY
Objective To investigate why elderly persons moved to a nursing home and detect any change in their psychopathological
and cognitive profile, dependency and perceived QOL.
Method We considered 100 elderly consecutively admitted to a nursing home, within 1 week of admission and 6 months
later. Data were collected from medical and nursing records (medical and psychiatric history, ADL), interviews (MMSE,
reasons for admission) and self-report instruments (GDS, BSI, WHOQOL-brief).
Results At admission, 68 subjects were able to participate in the survey and agreed to take part. Only 5.9% (n ¼ 4) had
moved to the nursing home by their own choice, 26.5% (n ¼ 18) because they were lonely and 36.7% (n ¼ 25) because they
had no caregiver available. The reasons for admission reported by the interviewed residents only partly corresponded with
the ones noted in their records. Twenty-six subjects had an MMSE score
18 and agreed to undertake complete assessment.
The scores of 20 of the 26 subjects exceeded the cut-off on the GDS and five of the nine BSI subscales. During the follow-up
period, 19 of the 68 originally assessed residents died (33 of the entire sample of 100) and one refused to continue to take
part in the survey. The mean MMSE and ADL scores of the 48 survivors decreased from 16.87 (SD  7.32) to 14.27
(SD  7.24; t ¼ 4.89, p < 0.000) and from 8.22 (SD  3.55) to 6.39 (SD  3.56; t ¼ 5.34, p < 0.000), respectively. The scores
achieved on GDI and BSI subscales worsened in 20 survivors with MMSE
18. The score achieved on the QOL physical
health domain also worsened. Comparison of the subjects who died and survived during the follow-up period showed a
significant difference in terms of ADL (6.60 SD  4.221 vs 3.64 SD  3.773 F ¼ 11.639; p < 0.001).
Conclusion The 68 original participants expressed feelings of loneliness and marginalization, but these experiences were
not noted in their personal records. Most subjects presented psychiatric symptoms and cognitive decline. After 6 months, the
clinical condition of the sample, particularly the females, had worsened, with a 33% mortality rate. This suggests that mov-
ing to a nursing home did not bring about improvement or stabilization; rather, psychiatric symptoms worsened and quality
of life was perceived more poorly. Copyright # 2006 John Wiley & Sons, Ltd.

key words — nursing home; quality of life; follow up; elderly; reasons for admission

INTRODUCTION the onset of a psychiatric disorder. The ideal reaction

Elderly people moving to a nursing home (NH)
experience a rapid change in their psycho-physical
balance. Such change may be eustressful (or uplift-
ing) or distressful. Subjective reaction to a stressful
event may alter homeostasis, implying unstructured
psychological suffering or a disruption preceding
*Correspondence to: Dr P. Scocco, Community Mental Health
Centre, Via Buzzaccarini 1, 35124 Padova, Italy. Tel:
þ39049692416. Fax: þ390498807050.
E-mail: scocco.paolo@virgilio.it
Copyright # 2006 John Wiley & Sons, Ltd.
is one that promotes somatic and psychological
homeostasis; it is regulated by learning, influenced
by positive interpersonal relations and gratifies emo-
tional ties (Longo Fiammingo, 1983). Hence, sub-
jects’ psychic and somatic conditions may be
worsened or enhanced by the transfer to a nursing
home.
The prevalence of psychiatric and dementia-related
symptoms among nursing home residents is high
(Magaziner et al., 2000; Teresi et al., 2001). Such dis-
orders and events may also be the reason behind the
Received 03 February 2005
Accepted 17 August 2005
282
transfer to an NH (Black et al., 1999). In addition,
residents’ quality of life (QOL) is lower than that
of elderly individuals living in the community
(Nagamoto et al., 1995). In most cases, older people
move to a nursing home when their health declines or
they loose lose their independence; this may be
accompanied by feelings of demise and uselessness,
influencing perception of quality of life (Su-Zu Tseng
and Ruey-Hsia, 2001).
The aim of our study was to assess why older sub-
jects moved to an NH and to evaluate any changes in
their psychopathological and cognitive profile, degree
of dependency and perceived QOL, after six months
spent in an NH.
METHOD
Between June 2002 and April 2003 we enrolled to the
study 100 subjects aged 65 and over, consecutively
admitted to a large NH (383 beds) in Mestre-Venezia
(Italy).
Figure 1 illustrates the recruitment procedure and
assessments made in the individual groups of subjects.
Informed consent to take part in the study was
sought from those subjects able to participate. If the
subject agreed, a willing family member could be
involved in obtaining consent. Those agreeing to take
Time 1
(within 7 days of admission)
100 newly admitted =>65 y
Data obtained: Demographic and health status data, ADL
32 too ill to be approached 68 approached for consent
MMSE, reason for admission
27 scored => 18 at MMSE
1 drop out
Time 2
Follow-up
(6 months later)
14 out of 32 died
49 approached for consent
1 refused
Figure 1. Patients flow and assessment procedure
Copyright # 2006 John Wiley & Sons, Ltd.
p. scocco et al.
part were assessed by the MMSE and asked why they
had been admitted to an NH.
The complete test package was administered to
willing subjects achieving an MMSE score of 18/30
and over. The entire procedure was performed within
7 days of admission to the NH and then 6 months
later, for follow-up purposes.
The interviews were carried out by two psycholo-
gists from the project team, who had been trained
on how to approach the elderly and administer tests.
Study group meetings were organized at regular inter-
vals to discuss any details and problems.
The NH staff agreed to cooperate with the research-
ers with a view to improving their clinical and perso-
nal knowledge of newly admitted residents.
INSTRUMENTS
From the documentation on admission to the facility,
we obtained demographic, family and health status
data, reasons for admission to the NH and level of
Activities of Daily Living (ADL: Katz et al., 1970).
The following were administered to those residents
able to participate and who gave their consent:
* The Mini-Mental State Examination (MMSE;
Folstein et al., 1975): a widely used measure of
cognitive status;
* An open question about reasons for admission.
Subjects with an MMSE of 18/30 or over who were
willing to take part:
(no refusals);
* The Geriatric Depression Scale (GDS; Yesavage
Assessment:
et al., 1983), which is a check-list of 30 yes/no
items. A score of 11 marks the cut-off for
depression;
* The Brief Symptoms Inventory (BSI; Derogatis
26 assessed:
GDS, BSI, WHOQOL
and Melisaratos, 1983; De Leo et al., 1993). This
consists of 49 items in nine subscales (Somatiza-
tion, Anxiety, Phobic Anxiety, Obsession/Compul-
sion, Hostility, Interpersonal Sensitivity, Paranoid
Ideation, Depression, Psychoticism) and a Global
19 out of 68 died Distress Index (GDI);
* The brief version of the World Health Organization
Quality of Life questionnaire (WHOQOL-brief;
Orley et al., 1998), which is a patient-centered
48 consented;
assessment:
self-report instrument based on 25 facets covering
ADL, MMSE 4 main areas (physical domain, psychological
domain, social relationships and environment).
20 scored =>18 at MMSE
Assessment:
GDS, BSI, WHOQOL
The GDS, BSI and WHOQOL-brief are generally
self-administered, although administration may be
assisted.
Int J Geriatr Psychiatry 2006; 21: 281–287.
 nursing home institutionalization
ANALYSES
Statistical analysis was performed using SPSS, ver-
sion 11.5. ANOVA, the t-test or the Kruskal–Wallis
test, as appropriate, to investigate cognitive, psycho-
pathological and quality of life profile. Bonferroni
corrections for multiple comparisons were used for
the Test Post Hoc.
RESULTS
Sample at admission
Description of all 100 newly admitted residents. The
mean age of the total sample was 83.85 (SD  8.33);
70% were females, who were significantly older than
the males (t ¼ 2.80 p < 0.05). Over 80% of the sam-
ple had a low educational level (41% had no academic
qualifications), but the males had a higher mean num-
ber of schooling years than the females (5.93—SD
3.26 vs 4.16—SD 3.06; t ¼ 2.610 p < 0.01). The
widowed accounted for 62% of the sample; on aver-
age, the males had been widowed for 136.20 months
(SD  105.03) and the females for 223.91 months
(SD  163.49).
The psychiatric disorders gleaned from medical
records were as follows: 59% suffered from dementia,
19% from other psychiatric disorders (e.g. depressive
disorders, alcohol addiction and/or abuse etc); 10% of
the sample presented comorbid psychiatric disorders.
Twenty-two residents in the sample had received no
diagnosis of psychiatric disease.
Thirteen percent of relatives of the test subjects suf-
fered from dementia and 10% from depression and
alcohol addiction.
Eighty-seven of the residents were not self-
sufficient on admission to the NH, while the remain-
ing 13% were autonomous.
Thirty-two subjects were too unwell to consent to
continue assessment.
Subjects able to participate. The mean MMSE score
of these 68 subjects, adjusted for age and education,
Table 1. Characteristics of all 100 subjects at admission
Non assessable
Subjects (no.) 32
Gender M/F 10/22
Mean Age (SD) 83.03 (  10.31)
Mean ADL (SD) 1.41 (  1.76)
Mean MMSE (SD) NA
Bold entries indicate the significant differences.
Copyright # 2006 John Wiley & Sons, Ltd.
283
was 16.46 (SD  7.23; min 0.4 max 29.7) with mean
ADL scores of 7.60 (SD  3.65) (see Table 1).
The reasons for admission to NH reported by the
residents were: 18 (26.5%) because they ‘felt lonely’;
25 (36.8%) because ‘no caregiver was available’ for
them; ten (14.7%) because of ‘disease, disability
and impossibility of being cared for at home’; five
(7.4%) due to ‘disputes with relatives’; four (5.9%)
based on ‘free choice’; one resident said he had no
house to live in, while another had been transferred
from another institution (four residents replied: ‘I
don’t know’).
The reasons for admission reported in the residents’
records were: ‘caregivers not available’ (n ¼ 49;
72%), ‘resident is sick, an invalid or unable to be
cared for at home’ (n ¼ 17; 25%); coming from ‘other
facilities’ (n ¼ 2; 3%).
Twenty-seven of the 68 residents (11 males and 16
females) had an MMSE score of 18/30 or higher (15
subjects achieved 24/30 or higher). One subject sub-
sequently dropped out; hence, we ultimately assessed
26 residents with the whole test package within 7 days
of admission (see Fig. 1).
Comparison between admission and follow-up
Within 6 months of admission to the nursing home, 33
of the 100 residents died (see Fig. 1). Of the 68 sub-
jects who had participated at the time of admission,
19 had died, one subject declined to take part in the
follow-up; thus, the follow-up evaluation was admi-
nistered to 48 elderly people. Nevertheless, the mean
MMSE score fell from 16.87 (SD 7.32) to 14.27
(SD  7.24; t ¼ 4.89, p < 0.000), while the ADL
scores decreased from 8.22 (SD 3.55) to 6.39
(SD  3.56; t ¼ 5.34, p < 0.000).
Twenty (seven males and 13 females) scored ¼ >
18 on the MMSE.
The mean GDS score rose from 15.05 (SD  5.14;
min 7, max 26) to 16.9 (SD  5.5; t ¼ 1.92, p < 0.05).
At follow-up, all but one subject exceeded the cut-off
Subjects
MMSE < 18 MMSE> 18 F–p
41 27
11/30 11/16
83.73 (  7.18) 85.00 (  7.47) 0.411–< 0.664
6.68 (  3.61) 9.00 (  3.32) 49.59–< 0.000
11.55 (  4.33) 23.90 (  3.23) 160.3–< 0.000
Int J Geriatr Psychiatry 2006; 21: 281–287.
284 p. scocco et al.

value, while four subjects had a score below the cut-
off at the first assessment.
Compared to the initial assessment, at follow-up
the survivors showed a poorer mean score on all
BSI subscales and on the GDI, which exceeded the
cut off value (indicating distress in this area).
At follow-up, the females had a significantly higher
BSI score than the males on the following scales:
somatization (males 0.69 SD  0.24 vs females 1.76
SD  0.57; F ¼ 21.489; sig. ¼ 0.000), interpersonal
sensitivity (males 0.75 SD  0.52 vs females 1.29
SD  0.54; F ¼ 4.651; sig. ¼ 0.045) and GDI (males
0.73 SD  0.19 vs females 1.29 SD  0.40; F ¼
11.970; sig. ¼ 0.003).
During the follow-up period, respondents’ score for
perceived quality of life was significantly lower (indi-
cating a worse QOL) in the physical area, where the
average score dropped from 53.92 (SD 13.71) at base-
line to 46.07 (SD 17.76) at follow up (t ¼ 2.159
p < 0.03).
Comparison of the scores achieved on the tests
administered at the time of admission to the NH by
those who had deceased and those who had survived
at follow-up, did not show any significant difference.
Only the ADL score (6.60 SD  4.221 vs 3.64
SD  3.773 F ¼ 11.639; p < 0.001) was significantly
lower in the deceased than in the survivors.
DISCUSSION
In order to track the evolution of the cognitive, psy-
chological and QOL profile of recently institutiona-
lized elderly, we used self-report, dimensional
evaluation and a conservative approach (including
subjects with an MMSE of at least 18, who are gener-
ally not assessed with self-report instruments). Older
adults living in an NH frequently suffer from comor-
bid disorders with complex symptoms (e.g. depres-
sion and dementia; Lyketsos et al., 1997), take a
wide range of drugs and present varying degrees of
disability. This is why category-based diagnostic pro-
cedures are difficult and sometimes useless. More-
over, the diagnoses from medical records at the
nursing home were not so complete and accurate. A
dimensional approach permits evolution to be viewed
over time even when the sample shows modest
changes, irrespective of the disorders or concomitant
conditions underlying symptoms.
We also included a population with an MMSE
score of at least 18, because we believe it is important
to give voice to the demented elderly (Schnelle,
2003); we agree with Godlove Mozley et al. (1999)
who claimed that ‘not knowing where I am doesn’t
mean I don’t know what I like’. In that study, the
authors found that over 77% of subjects who scored
10 or over on the MMSE were ‘interviewable’. Like-
wise, other authors have claimed that QOL can actu-
ally be measured by self-report instruments in a large
proportion of the nursing home population, including
cognitively impaired residents (Kane et al., 2003).
Nevertheless, the decision to include a population
with MMSE ¼ > 18 may, in the psychometric assess-
ment, be seen as being rather an arbitrary one.
However, as already noted by Andresen et al.
(1999), an MMSE cut-off of 18 or lower, including
only those able to make a self-report, amounts to eval-
uating just one in four nursing home residents.
This study has a number of limitations. We consid-
ered a sample of 100 residents consecutively admitted
to just one large, urban NH. To date, studies on NHs
have proven quite difficult: therefore, it is not possible
to generalize our results because of broad variability
in this setting in terms of size (e.g. number of
beds), location (e.g. rural, suburban and urban) and

Table 2. Brief Symptoms Inventory scores at admission and follow-up

Admission Follow-up

Cut-off Mean  SD No. subjects > Cut-off Mean  SD No. subjs. > Cut-off t–p

Somatization 0.69 0.88  0.37 15 1.38  0.70 17 3.678–< 0.001

Obsessive/Compulsive 0.91 0.83  0.54 9 1.07  0.62 10 1.931–< 0.03
Interpersonal Sensitivity 0.80 0.81  0.62 10 1.10  0.58 12 1.891–< 0.04
Depression 0.74 1.42  0.54 17 1.92  0.95 18 2.719–< 0.01
Anxiety 0.80 1.00  0.59 10 1.08  0.74 12 0.342–0.37
Hostility 0.77 0.66  0.59 7 0.73  0.68 11 0.475–0.32
Phobic Anxiety 0.53 0.53  0.58 8 0.57  0.74 7 0.30–0.39
Paranoid Ideation 0.79 0.70  0.61 9 0.90  0.71 10 1.842–< 0.05
Psychoticism 0.46 0.60  0.47 11 0.87  0.54 17 1.624–0.06
GDI 0.61 0.85  0.34 14 1.10  0.44 19 2.326–< 0.02

In bold: scores exceeding the cut-off.

Copyright # 2006 John Wiley & Sons, Ltd. Int J Geriatr Psychiatry 2006; 21: 281–287.
 nursing home institutionalization
organization (e.g. availability of professionals, finan-
cial arrangements). Overall organization of services
provided to the elderly has also witnessed many
changes in recent years (Reichman et al., 1998;
Purandare et al., 2004).
Data gleaned from medical records (e.g. psychiatric
diagnoses of patients and their relatives) were prob-
ably unreliable and it was not always possible to trace
back to the method used to recoup available data.
Despite these limitations, longitudinal self-evaluation
provided significant data and information.
The Brief Symptom Inventory showed that the
symptom areas at the time of admission to an NH
were Somatization, Anxiety, Depression, Psychoti-
cism (and ‘General Distress’). At follow-up, resi-
dents’ condition had worsened, with a higher
score exceeding the threshold value in all BSI areas,
except Hostility. As to gender, females performed
worse than males in the following areas: somatiza-
tion, interpersonal sensitivity and overall evalua-
tion (GDI).
The depressive symptoms measured by the BSI-
depression subscale and GDS showed comparable
levels of severity. Previous studies have indicated a
lower prevalence. However, the studies in question
adopted different rating scales. Using the Hamilton
Rating Scales for Depression (HDRS), Bekaroglu
et al. (1991) observed depressive symptoms in 41%
of NH residents vs 29% of residents in the local com-
munity. Horigichi and Inamy (1991) interviewed 920
elderly residents admitted to 32 NHs and 1153 com-
munity residents. They used the Zung Self-Rating
Depression Scale (ZSRS) and observed that 61% of
the former and 36% of the latter showed depressive
symptoms. These differences in frequency in our data
at the time of admission may be explained by the dif-
ferent evaluation method (self-rating scales, in parti-
cular the GDS, overestimate depression compared to
scales administered by others, such as the HDRS) or
by the different time frame.
The presence of persistent depressive symptoms
after spending a period of time in an NH was also
highlighted by Katz et al. (1989), although other
authors observed a reduction of symptoms (Payne
et al., 2002).
We found a high rate of psychotic symptoms.
In fact, psychoticism and paranoid ideation were
observed in 50% of 26 residents evaluated at admis-
sion. Morriss et al. (1990) found that 21% of 125
patients newly admitted to NH had delusions.
Wancata et al. (2003) observed stabilization over
6 months of any non-cognitive symptoms among
NH residents suffering from dementia. Such symp-
Copyright # 2006 John Wiley & Sons, Ltd.
285
toms affected 38% of demented patients within just
2 weeks of admission and 36.1% after 6 months.
The most frequent symptoms were flattened or incon-
gruous affect, suspiciousness or aggressiveness and
anxiety.
Psychic status was found to worsen more in female
than in male residents.
Moving to an institution is not always a deliberate
choice made by the elderly. In fact, it turned out that
less than 6% of respondents claimed to have person-
ally decided to live in an NH. These data are con-
firmed by a study by Mattimore et al. (1997). These
authors measured willingness to live permanently
in a nursing home on a five-point scale ranging
from ‘very willing’ to ‘would rather die’. Of 9105
approached patients from five university medical cen-
ters, 3262 (36%) agreed to take part in the survey. Of
these, 26% said they were ‘very unwilling’, 30%
would ‘rather die’; however, 7% were ‘very willing’
to live permanently in a nursing home.
It also emerged that the reasons for admission
reported by the interviewed residents only partly cor-
responded to those noted in the records. Clearly, being
transferred to an NH because of ‘feeling lonely’ or
because of ‘disputes with relatives’ does not exactly
correspond in semantic nor conceptual terms to ‘care-
giver not available’. Interestingly, the records did not
indicate any instances of ‘free choice’.
Thus, although admission to these facilities in Italy
does not happen in a vacuum but is shaped by the
decisions of a multiprofessional team (although this
rarely includes healthcare providers such as psychia-
trists or psychologists), which evaluates each sub-
ject’s needs and resources, this assessment does not
seem to fully consider the elderly person’s subjective
experience.
While Gonzalez-Salvador et al. (2000) claimed that
their sample of residents in a long-term care facility
exhibited a better QOL than expected, our data
showed that 6 months after entry, the elderly per-
ceived a worse quality of life in terms of physical
health. This was also confirmed by a worsening in
the level of activities of daily life, assessed by ADL.
The subjects who died prior to follow-up were also
significantly characterized by lower autonomy. The
prognostic value of reduced autonomy on mortality
at the time of admission to an NH has been reported
several times in the literature (Fillenbaum, 1985;
Lichtenstein et al., 1985).
We observed a high mortality rate at 6 months. Yet,
there exists wide variation in the mortality rate among
NHs; this was accounted for by residents’ character-
istics (Dale et al., 2001).
Int J Geriatr Psychiatry 2006; 21: 281–287.
286 p. scocco et al.
KEY POINTS
* This longitudinal study has shown that elderly
people entering a nursing home in poor physical
and mental health and with a low quality of life,
further declined after 6 months’ follow-up.
* The elderly able to participate in our study
complained about feeling lonely and margin-
alized.
* The reasons for admission to the nursing home
reported by the interviewed residents only
partly corresponded to those noted in the
records. Only 6% actually chose to be admitted,
but records indicated solely the lack of
caregivers or that medical condition prevented
care at home; they did not report any instances
of ‘free choice’.
* The evaluation of each subject’s needs and
resources, prior to admission to a nursing home
does not seem to take full account of the elderly
person’s subjective experience.
CONCLUSION
This is a longitudinal study on the evolution of cogni-
tive performance, psychopathological manifestations
and QOL in a sample of residents recently admitted
to an NH and evaluated through self-report instru-
ments. This cohort of elderly was seriously ill. Sub-
jects able to participate complained about feeling
lonely and marginalized, but these experiences were
not noted in their personal records. Most assessed
residents presented psychiatric symptoms and cogni-
tive decline.
After 6 months, the sample’s clinical condition was
observed to have worsened, with a 33% mortality rate.
Thus, moving to a nursing home appears to have
emphasized rather than stabilized their psychiatric
symptoms, with a worsening in perceived quality of life.
A more comprehensive study might confirm these
observations and help establish whether and how
institutionalization can have an impact on the life
course of frail elderly patients.
ACKNOWLEDGEMENTS
We thank Sabrina Canton for her help in collecting
the data.
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