Relocation Stress Syndrome

It is my belief, supported by research, that transfer trauma can happen in an emergency room, in acute-care hospital admission, a move to an assisted living facility, a move into a caregiver’s home, and a relocation from one’s home community to be nearer to a family caregiver. Frail elders with dementia are the population most susceptible however all elders may succumb to transfer trauma. Also, transfer trauma can “occur in the family members or adult children who are watching or overseeing the transition of an older adult from one location to another, and their reactions need to be addressed as well” (Jackson, 2015, p. 10). “The condition termed relocation stress or transfer trauma refers to a set of symptoms and outcomes that result from a transfer from one environment to another. The research evidence from studies since the 1960s with adequate statistical power and methodological control shows adverse effects associated with all types of transfer. The breadth and quality of this evidence were sufficient to convince the North American Nursing Diagnostic Association to approve a diagnosis called relocation stress syndrome in 1992 and for the United States Administration on Aging (AOA) to include transfer trauma in its Emergency Preparedness Manual for the Aging Network in 1995. This manual complements the U.S. Nursing Home Reform Act of 1987 that guarantees stability of residence for reasons other than insufficient medical provision, danger to health and safety, or nursing home closure. The severity and scope of transfer trauma effects vary with the symptoms and outcomes observed, the type of transfer, the mental and physical frailty of the elderly movers, and their readiness for relocation” (Lakehead University, n.d., p.1). Most recently, Centers for Medicare and Medicaid Services (CMS) released enhanced regulations which make intra-facility transfers even more difficult for nursing home providers. Lakehead University (n.d.) indicates that “the most severe outcome is death. Based on large-scale controlled studies, authors reported that transferred residents have mortality rates 2-4 times higher than in otherwise comparable residents without transfer. Further findings from these studies showed that death was frequent within hours or days of transfer and that the mortality risk was higher following inter-facility rather than intra-facility transfer. Other studies of fatal transfer trauma found disproportionately higher mortality in residents with cognitive impairment. These studies were of geriatric residents with dementing disorder and geriatric residents following deinstitutionalization from psychiatric facilities” (p.2). “There are few studies on involuntary home to institution relocation, but those which do exist show an increased mortality rate over voluntary moves and indicate that the similarity of the new environment to the old is also an important factor. Studies on moves from one institution to another show a lower mortality rate where the move is accompanied by extensive preparation. There are conflicting results in studies on the involuntary institution to institution transfers, but the majority show an increased mortality rate and indicate that persons in ill health (as in transfers to nursing homes) have more trouble adapting than do healthy individuals” (Fleming, 1985, p. 52).

“The medical evidence on transfer trauma is somewhat contradictory. Some studies have found negative consequences from relocation; others have not. Dr. L. Pastalan [a gerontologist] reviewed the literature [in 1985] on relocation to resolve the contradictions. He found that the apparent contradictions arose largely due to qualifying factors underlying the conclusions. He listed five major factors: 1) The degree of choice in making a move; 2) the degree of environmental change; 3) the degree of health; 4) the degree of preparation; and 5) the methodology used in the study” (Fleming, 1985, p. 51).

“Dr. Pastalan also pointed out a carefully designed relocation preparation program can reduce the danger. He lists many important considerations in designing such a program, including personal counseling, involving the relocatee and family in the decision making as much as possible and visiting the new location as much as possible before moving” (Fleming, 1985, p. 52). Dr. Pastalan also reports “that the first three months immediately following the move are the most dangerous” (Fleming, 1985, p. 52).

More recent research expands on the scope of transfer trauma beyond institutional care. This example relates to emergency room care of elders: “[ED] nurses recognized that the ED environment could be “delirium-inducing,” exemplified by the following statement: “In the ED we often have to work quickly with the [older] patients, and that can lead to their not being fully aware of what we are doing, leading to increased confusion” (Boltz, Parke, Shuluk, Capezuti, & Galvin, 2013, p. 448). “The major characteristics of relocation stress include loneliness, depression, anger, apprehension, and anxiety. The minor characteristics are listed as changes in former eating and sleeping habits, dependency, insecurity, lack of trust and a need for excessive reassurance. [These same characteristics may also be seen in the caregivers of patients experiencing transfer trauma.] Relocation stress may be defined as a state in which individual experiences physiological and psychosocial disturbance as a result of transfer from one environment to another” (Robinson, 2002, p. 7). Jackson (2015) states “symptoms of transfer trauma may occur before, during, and for several months after a move and may be mild or severe depending on the individual and the circumstances” (p. 10). Eldercare providers should be anticipating some emotional response to a transfer, planned or unplanned, by older patients. “Transitions are often unplanned, occur on nights and weekends, involve clinicians who may not have an ongoing relationship with the older patient, and happen so quickly that formal and informal support systems cannot adequately respond” (Hooyman & Kiyak, 2011, p. 759).

Mood disorders are not uncommon in the elderly, and most often the problem is depression. Untreated major depression is one of the most significant contributors to excess morbidity and mortality in geriatrics. For this purpose, an instrument such as the Short Geriatric Depression Scale is a good screening tool for use by health practitioners (Hooyman & Kiyak, 2011, p. 230). This assessment should be compared to a baseline mood assessment best obtained from a caregiver or other family member to determine if depression is of a new onset since the transfer.

“Anxiety more often precedes depression than vice versa. Primary care providers must probe further when patients complain of diffuse pain, fast or irregular heart rate, fatigue, sleep disturbance, and restlessness” (Hooyman & Kiyak, 2011, p. 240). Another mood symptom seen in transfer trauma is delirium which is often confused with dementia. “Delirium is usually caused by some external variables. It presents as an abrupt change in behavior, hallucinations, and problems with memory” (Hooyman & Kiyak, 2011, p. 244).

“Common behavior-related symptoms [in patients suffering from transfer trauma] include combativeness, screaming, and complaining. They might wander, shut down, withdraw, refuse care, isolate themselves, and refuse to take medication” (Jackson, 2015, p. 10). Many of these same behaviors may be exhibited by caregivers experiencing transfer stress or trauma. Also, transfer trauma may exhibit in physiological symptoms including “confusion, pain, falling, a rapid heartbeat from anxiety, sleeplessness, poor appetite, and weight gain or loss” (Jackson, 2015, p. 10). Jackson (2015) summarizes by reporting that “if unaddressed, the consequences of transfer trauma can be severe, potentially resulting in an erosion of cognitive and physical functioning” (p. 10).

“When a move is necessary, the experience may be bewildering at best, and traumatic at worst. But trauma isn’t inevitable. When individuals transfer to good facilities and transition expertise has guided the move, distress will be minimized and will ease with time” (Jackson, 2015, p. 10). There are some “specific services and settings that promote the effective movement of patients between levels of care and across care settings” (Hooyman & Kiyak, 2011, p. 759). “Transitional care is the relatively brief time interval that begins with preparing a patient to leave one setting and concludes when the patient is received in the next. Barriers to effective transitions include poor communication, cultural differences, health literacy issues, inadequate education of elders and their family caregivers, and the lack of a single point person to ensure continuity of care (Hooyman & Kiyak, 2015, pp. 759-760). “Effort should be made to ensure that individuals are not transferred needlessly, or too swiftly. Social workers need to advocate for the right placement in the right level of care, involve the patients to the highest degree possible, and devote themselves to whatever they can do to help the client adjust, encouraging the highest possible level of communication among all parties” (Jackson, 2015, p. 10). “Annually, there is nearly one ED visit for every two older Americans. Older adults also are at increased risk for serious complications in the ED compared to younger people. Additionally, ED environments, which are often characterized by bright lights, the fast pace of activity, and loud noises, can be disorienting to older adults and potentially interfere with the effectiveness of care” (AGS, 2018). A joint initiative among ED and geriatric advisors in 2014 developed the Geriatric Emergency Department Guidelines, a standardized set of recommendations (AGS, 2018). The following examples of EDs designed to address the specific needs of elders are exciting and innovative. Most certainly, less trauma would be evidenced in these ED models.

At Holy Cross Memorial Hospital in Silver Spring, MD “the [Seniors Emergency] Center’s team—a patient-centered practice—includes physicians, a geriatric nurse practitioner, registered nurses and a social worker, all specially trained in geriatric emergency medicine. The team delivers compassionate, personalized elder health care—with quick and accurate diagnosis and treatment plans developed with each patient’s special needs in mind. Details that create a calm, gentle and nurturing environment [include]: • Treatment bays separated by walls, not curtains, for added privacy and quiet,

• Thicker mattresses and heated blanket for patients,

• Safety features like handrails, softer lighting, and non-slip floors,

• Special speakers that make it easier to listen to music or watch TV,

• Telephones and remote controls with larger buttons,

• Space set aside for private family consultations,

• A centrally located nursing station so staff can keep a close eye on every patient (Holy Cross Health, 2018).

In Manhattan at Mount Sinai Hospital the geriatric emergency department or “Geri-ed” opened in 2012 with the following enhancements: • No beeping machines or blinking lights or scurrying medical residents. • A simulated skylight with a photographic rendering of a robin’s-egg-blue sky, puffy clouds, and leafy trees, which turns dark at night, intended to combat “sundowning” — agitation and confusion at the end of the day. • A volunteer is circulating among the patients like a flight attendant, making soothing conversation and offering reading glasses, Sudoku puzzles and hearing aids. • Resembling a clinic more than it does an emergency room: there are nonskid floors, rails along the walls, reclining chairs for patients and thicker mattresses to reduce bedsores. • To keep the noise down, the curtain rings and rods around the beds are made of plastic instead of metal. • A bedside GeriPad, an iPad that lets patients have a two-way video conversation with a nurse or touch the screen to ask for lunch, pain medication or music (Hartocollis, A., 2012).

In a nutshell, geriatric EDs provide a special knowledge, special products, and special staff. Before being seen by the ED physician, but post-triage, a geriatric care manager makes an assessment, and a care plan is developed by social and medical history, patient wishes, and advance directives. For nursing home elders who stay in a hospital receiving services that their home is certified to deliver, they are better treated in their home (nursing facility) where they have familiar staff, routines, and environment. An unnecessary and undesired inpatient hospital stay done solely to qualify an institutionalized elder for an SNF stay and subsequent rehabilitation and skilled nursing care covered by Medicare Part A can cause undue stress on elders especially those who have dementia. “The long-standing policy [three-day hospital stay] implemented to discourage premature discharges from hospitals, might now be inappropriately lengthening hospital stays for patients who could be transferred sooner” (Grebla, Keohane, Lee, Lipsitz…Trivedi, 2015, p. 1324). “In 1965, three days was the amount of time generally needed to admit, evaluate, and establish a plan of care for a patient” (L & M Policy Research, 2016, p. 34). Hospitals are now able to do the same in less than 24 hours and sometimes shorter during an emergency room visit.

With an emphasis today being placed on patient-centered care, one would hope that lawmakers, CMS, and HCFA could focus more on the individual care needs, the physician’s recommendations, the patient’s wishes, and the quality and availability of services offered outside an acute setting. Frankly, having the hospital as the gatekeeper of whether someone is eligible for SNF care is rudimentary and doesn’t acknowledge the value that skilled nursing facilities have added in the 21st century to the rehabilitation, skilled nursing care, and chronic disease management of elders unable to remain in their home or in a lesser level of care. In my opinion, no high-tech setting or product replaces the value of specialized knowledge and special staff in dealing with elders. It is not a job for the faint at heart and requires a unique set of skills and the ability to connect with people. It requires an open mind and open heart. For those that choose to work with the geriatric population, it can be rewarding, fulfilling, soulful, challenging, humorous, sad, and engaging.

“Geriatricians, nurses, and nurse practitioners, pharmacists, social workers, dentists, physical therapists, and occupational therapists who can work with elders will be in even greater demand as baby boomers reach their 80s. The shortage of geriatric specialists in these health professions, estimated to be only 25 percent the number needed in 2030, will place significant demands on available providers. This projected shortage of geriatric specialists, especially those with LTC experience, may also put frail elders at greatest risk if their chronic conditions are not effectively managed in the community and hospitalization is required” (Hooyman & Kiyak, 2011, p. 765). Hooyman & Kiyak (2011) report “in the 2009 congressional session, there was widespread support for a federal bill known as the Retooling the Healthcare Workforce for an Aging America Act which would fund geriatric training, education, and loan forgiveness” (p. 765). Unfortunately, this bill was passed to the Subcommittee on Health and lies dormant on the Hill awaiting cost estimates from the Congressional Budget Office (CBO). Thus far evidence has been presented which supports that transfer trauma is real and is happening in a variety of settings where frail elders experience changes and unfamiliar environments and faces. Transfer trauma is stressful for the patient and the caregiver, but it also affects the healthcare worker, too. Just like the caregivers, health care workers are watching or overseeing the transition of an older adult from one location to another, and they also can experience feelings of helplessness, anxiety, frustration, irritability, and sadness. The health system is failing to provide the necessary and innovative support services to reduce transfer trauma from happening in patients, caregivers, and healthcare workers. Individual nursing homes, hospital EDs, public care managers, private care managers, adult day health care centers, support groups, and advocacy groups are all trying to put a band-aid on a systemic problem. Our health system can do better.

There are many transition models out there but all focus on clear communication among patients, caregivers, and healthcare providers. Recognizing the signs of transfer trauma, preventing trauma by preempting the triggers, reducing the distress brought upon by change, providing skilled and compassionate staff, and an openness to innovative ideas and programs will move the charge forward. When elders move between care settings in a system that transition standards of care are the norm, trauma will be minimized, and our efforts will be rewarded.

References American Geriatric Society (AGS). (2018). Geriatric emergency department collaborative. Retrieved from https://www.americangeriatrics.org/programs/geriatrics-emergency-department-collaborative Aneshensel, C.S., Pearlin, L. I., Levy-Storms, L., & Schuler, R. H. (2000, May 1). The transition from home to nursing home mortality among people with dementia. The Journals of Gerontology: Series B, 55:3, pp. S152- S162. https://doi.org/10.1093/geronb/55.3.S152 Boltz, M., Parke, B., Shuluk, J., Capezuti, E., & Galvin, J. E. (2013). Care of the older adult in the emergency department: Nurses views of the pressing issues. The Gerontologist, 53(3), pp. 441–453. http://doi.org/10.1093/geront/gnt004 Fleming, J. (1985). Hospital transfers into nursing homes: A potential charter remedy for unwilling transferees. Journal of Law and Social Policy, pp. 50-76. Retrieved from http://digitalcommons.osgoode.yorku.ca/jlsp/vol1/iss1/5 Grebla, R. C., Keohane, L., Lee, Y., Lipsitz, L. A., Rahman, M., & Trivedl, A. N. (2015). Waiving the three-day rule: Admissions and length-of-stay at hospitals and skilled nursing facilities did not increase. Health Affairs (Project Hope), 34(8), pp.1324–1330. http://doi.org/10.1377/hlthaff.2015.0054 Hartocollis, A. (2012, April 9). For the elderly, emergency rooms of their own. https://www.nytimes.com/2012/04/10/nyregion/geriatric-emergency-units-opening-at-us-hospitals.html Holy Cross Health. (2018). Holy cross hospital seniors emergency center: National model of geriatric emergency medical services. Retrieved from http://www.holycrosshealth.org/seniors-emergency-center Hooyman, N. R. & Kiyak, H. A. (2011). Social gerontology: A multidisciplinary perspective, ninth edition. Boston, MA: Pearson Education dba Allyn & Bacon. Jackson, K. (2015). Prevent elder transfer trauma: Tips to ease relocation stress. Social Work Today, 15:1, p. 10. Retrieved from http://www.socialworktoday.com/archive/011915p10.shtml Johnson, S. (1998). Who moved my cheese? New York, NY: G. P. Putnam’s Sons. Lakehead University (n.d.). Transfer Trauma. Retrieved from http://flash.lakeheadu.ca/~mstones/transfertrauma.htm L & M Policy Research. (2016, December 5). Evaluation of skilled nursing facility 3-day Pioneer ACO waiver – Final report. Retrieved from https://innovation.cms.gov/Files/reports/pioneeraco-snf-evalrpt.pdf Robinson, V. (2002, September 23). A brief literature review of the effects of relocation on the elderly. Retrieved from https://www.heu.org/sites/default/files/uploads/research_reports/HEU_Literature_Review _Sept23_2002.pdf