Many nursing home residents spend a potentially unhealthful amount of time in bed, between 15 and 18 hours a day, sometimes more. Why? A low staffing level is the strongest predictor of excessive in-bed times, followed by impairments in residents’ functional ability, according to a new study by the Borun Center for Gerontological Research, a joint venture between the David Geffen School of Medicine at UCLA and the Jewish Home for the Aging of Greater Los Angeles.

The study also found that the more time residents spent in bed during the day, the more they slept during the day, the more socially isolated they were and the less they ate. These findings, noted the authors, are in keeping with other studies showing that excessive time in bed is associated with detrimental outcomes, including under-nutrition, pressure ulcer development, pneumonia and urinary incontinence.

“Though they didn’t surprise us, the findings are important,� said lead author Dr. Barbara M. Bates-Jensen, adjunct assistant professor at the medical school. “They sharpen the focus on a widespread problem that has been inadequately addressed despite its serious health implications and negative impact on quality of life. The irony is, this highly regulated industry offers no regulatory advice for getting residents up and out of bed.�

The study compared nursing homes with low staffing levels — less than 3.4 staff hours per resident per day — to facilities with some of the industry’s highest staffing levels — more than 3.7 staff hours per resident per day. Residents in lower-staffed homes were observed in bed an estimated average of five hours a day, between 7 a.m. and 7 p.m., versus an estimated average of three daytime hours for residents in the high-staffed homes. Given that many residents are put to bed by 7 p.m. — a finding from previous Borun Center research — residents in low-staffed homes could be spending as much as an average of 17 hours a day in bed, Bates-Jensen said.

The article, “Factors Related to Excessive In-bed Times Among Nursing Home Residents,� appears in the June issue of the Journal of the American Geriatrics Society. A total of 882 long-stay residents in 34 nursing homes throughout Southern California participated. The authors interviewed residents, observed them at hourly intervals on one day to estimate in-bed time and measure social engagement, monitored mealtimes, and conducted physical performance evaluations to assess residents’ ability to stand and bear weight.

Of the study’s findings, Dr. John F. Schnelle, director of the Borun Center, said, “It’s time-consuming to help residents out of bed each day, all the more so when those residents are frail or disabled. Short-staffed facilities, arguably the majority of nursing homes, must struggle to meet this challenge. But neither predictor — not low staffing levels or high disability levels — justify the excessive in-bed times observed in this study.�

The authors pointed out that letting residents with physical impairments linger in bed could accelerate their decline. And the fact that residents with similar physical disabilities were observed out of bed more frequently in the high-staffed homes suggests in-bed times can be improved.

The authors call for more research to inform the development of practice guidelines pertaining to the amount of time that residents should spend in bed. “Complex questions arise,� Bates-Jensen said. “Should a depressed resident be allowed to stay in bed all day if that’s his preference? Most of us would probably agree he shouldn’t. But what about a resident who is not depressed but wants to spend most of the day in bed? Balancing resident autonomy against provider beneficence is an ongoing challenge in nursing homes. We need more information to adequately address these complex questions.�

The Borun Center for Gerontological Research, established in 1989 and housed at the Jewish Home for the Aging in Reseda, Calif., is an interdisciplinary center for applied research that focuses on creating, testing and promoting the adoption of behavioral interventions to improve daily care and quality of life in nursing homes. It currently is developing Web-based training modules that will help nursing homes prevent mobility decline among residents and improve other, related daily care processes.