-Cyril H. Wecht, M.D., J.D.
While the overall autopsy rate in the general population has been steadily decreasing, autopsies performed in patients over 65 years of age are being performed even less frequently. Nearly 20% of such deaths occur in nursing homes; however, less than 1% of all nursing home deaths have autopsies performed. Nursing home deaths are 3 - 10 times less likely to be autopsied than deaths in the same age population occurring in other settings.
Nearly 13% of the population (1.5 million people) in the United States is age 65 years and older. Approximately 18,000 nursing homes are in operation in the United States, housing nearly 1,628,300 residents. Autopsies are performed on approximately 8% of patients over 65 years of age in the general population; however, only approximately 5% of those over 65 years and approximately 20% of those over 85 years reside in nursing homes. There have been only a few studies that have examined the forensic pathologic and epidemiologic aspects of nursing home deaths that fall under the jurisdiction of coroners and medical examiners.
Several reasons have been proposed for the paucity of autopsies in the nursing home population. Death of an elderly person, especially one residing in a nursing home, is less likely to be viewed as premature than the death of a young person. While death in the elderly nursing home population may be more likely, death may still occur prematurely. Relatives of elderly persons may be more difficult to locate in order to obtain autopsy consent since two thirds of those residing in nursing homes have no living relatives.
An additional challenge to gaining consent to perform an autopsy is the lack of reimbursement from insurance companies and Medicare. However, it has been noted that the number of geriatric autopsies, even among coroner and medical examiner offices, is low. Another proposed reason for the low number of autopsies is that postmortem examinations are often viewed in non-academic institutions as a time-consuming exercise with little benefit, given the advances in ante-mortem diagnostic procedures.
Perhaps the most prevalent reason for dwindling autopsy numbers is the fear of litigation due to missed ante-mortem findings revealed upon postmortem examination. However, missed disease processes and the opportunity to prevent them in the future are the most important reasons why autopsies should be performed.
Autopsies in this age group may elucidate unexpected causes of death and contributing factors and serve to improve the quality of care, prevent premature death, and improve life expectancy in the elder population. One published study revealed that in 32.3% of all deaths, the cause of death was misdiagnosed clinically and was of such a significance that, had the proper diagnosis been made, the patient would have most likely lived.
In the United States, the nursing home population continues to increase each year; yet some trends remain consistent. The majority of nursing home residents are female (70%).
Bronchopneumonia, the most common cause of death among the nursing home population, was correctly diagnosed premortem 73% of the time. Cerebral vascular accident was the most accurately diagnosed premortem condition (92%). However, PE was diagnosed correctly only 39% of the time.
The suicide rate among the elderly is higher than that of any other age group, with one fifth of all suicides being committed by older adults. Men over 85 years of age have the highest suicide rate. The rate of suicide among those in a nursing home is lower than those residing in the community; however, the rapidly increasing population of those over the age of 65 years will lead to an increase in the number of nursing home residents and may lead to an increase in the numbers of suicides in this population as well. Studies have shown that 2% of all suicides and 1% - 11% of elderly suicides take place in the nursing home setting. The most prevalent finding among suicide victims in the nursing home is a diagnosable mental disorder, most commonly depression. Additionally, suicides commonly occur soon after admission to the nursing home or after a personal loss.
Examination of the causes of death in this population reveals accidental death from blunt force trauma as a significant cause of death of nursing home residents. Increased monitoring of patients may decrease the number of accidental deaths in this population, and in light of these findings, it is important to implement policies and procedures to evaluate the causes of blunt force trauma in these institutions and develop preventive measures that nursing homes can take to ensure the safety of their residents.
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