Adaptive strategies after health decline in later life: increasing the person-environment fit by adjusting the social and physical environment

Following the press-competence model (PCM) of Lawton and associates, we tested two expectations as to the adaptations older adults make to their socio-physical environment following health decline: (1) depending on the change in their functional limitations, older adults use adaptive strategies ranging from mobilizing informal care to moving into a residential setting; (2) the more people succeed in realizing suitable adaptations, the higher their wellbeing, measured as depressive symptoms, after a health decline. Data come from two waves of a longitudinal study among Dutch people aged 60–85 and living independently at baseline (Longitudinal Aging Study Amsterdam, LASA). The 819 respondents with a decline in self-reported functional disability within 3 years time were selected for analysis. Results of multivariate logistic and regression analyses show that (1) all adaptive strategies under study occur in response to health decline; (2) mobilization of informal care and moving to a care setting alleviates the negative effect of health decline on depressive symptoms. Furthermore, mobilization of professional home care was associated with more depressive symptoms independent of health decline, whereas adjustment of the home had no effect on depressive symptoms. We argue that some support was found for Lawton’s PCM, but that evidence can be improved by studying more closely which adaptive strategies alleviate the environmental stress induced by specific physical disabilities.     

Religious involvement and 6-year course of depressive symptoms in older Dutch citizens: results from the Longitudinal Aging Study Amsterdam

OBJECTIVES: Expanding on cross-sectional studies, associations are examined between religious involvement and the 6-year course of depressive symptoms in older adults. METHODS: Subjects are 1,840 community-dwelling older adults (aged 55 to 85) participating in three measurement cycles of the Longitudinal Aging Study, Amsterdam. Assessments include aspects of religious involvement, depressive symptoms, physical health, self-perceptions, social integration, urbanization, and alcohol use. RESULTS: Church attendance is negatively associated with the course of depressive symptoms, also after adjustment for explanatory variables. Among respondents with functional limitations, lower depression scores are found for those who attend church on a regular basis. For respondents who are bereaved or nonmarried, however, slightly higher depression scores are found for those with high levels of orthodox beliefs. DISCUSSION: There is a consistent negative association over time between church attendance and depressive symptoms in older Dutch citizens. Both stress-buffering as well as depression-evoking effects of religious involvement are found.     

Longitudinal associations of depressive symptoms,subjective memory decline,and cognitive functioning among Chinese older adults: Between-person and within-person perspective

ObjectivesWe examined between- and within-person associations between depressive symptoms and cognitive functioning among Chinese older adults (aged 60+) over time. Furthermore, we also investigated whether subjective memory decline (SMD) is uniquely associated with cognitive functioning above and beyond depressive symptoms for both between-person and within-person associations.MethodsAbout 7385 older adults from the China Health and Retirement Longitudinal Study reported their demographic and health status, and completed self-report measures of depressive symptoms and SMD, as well as a battery of cognitive tests, every two years at three times between 2011 and 2015.ResultsThere were significant between-person and within-person associations between depressive symptoms and cognitive functioning. Furthermore, SMD was uniquely associated with cognitive functioning for both within-person and between-person associations after controlling for depressive symptoms.ConclusionsThe results highlight the importance of careful screening and monitoring of depressive symptoms and SMD for the benefits of cognitive functioning among Chinese older adults. More importantly, SMD has practical implications for the care of Chinese older adults given significant cultural stigma attached to mental illness within Chinese culture.     

Concurrent and long-term predictors of older adults' use of community-based long-term care services: the Caregiver Health Effects Study

Objective: This study examined concurrent and long-term associations between caregiver-related characteristics and the use of community long-term care services in a sample of 186 older adults caring for a disabled spouse. Method: We used two waves of data from the Caregiver Health Effects Study, an ancillary study of the Cardiovascular Health Study. Caregiver-related need variables as predictors of service use were of primary interest and included caregiving demands, caregiver mental and physical health, and mastery. Their contribution to service use was examined after controlling for known predictors of service use. Results: At Time 1, more caregiver depressive symptoms predicted greater service use; at Time 2, more caregiver activity restriction and depressive symptoms predicted greater formal service use; increases in caregiver activity restriction and depressive symptomatology over time predicted increases in service use. Discussion: Caregiver-related need variables play a significant role in defining utilization patterns of community-based long-term care services among older adults.     

Functional disability and health care expenditures for older persons.

BACKGROUND: The rapidly expanding proportion of the US population 65 years and older is anticipated to have a profound effect on health care expenditures. Whether the changing health status of older Americans will modulate this effect is not well understood. This study sought to determine the relationship between functional status and government-reimbursed health care services in older persons. METHODS: Longitudinal cohort study of a representative sample of community-dwelling persons 72 years or older. Clinical data were linked with data on 2-year expenditures for Medicare-reimbursed hospital, outpatient, and home care services and Medicare- and Medicaid-reimbursed nursing home services. Per capita expenditures associated with different functional status transitions were calculated, as were excess expenditures associated with functional disability adjusted for demographic, health, and psychosocial variables. RESULTS: The 19.6% of older persons who had stable functional dependence or who declined to dependence accounted for almost half (46.3%) of total expenditures. Persons in these groups had an excess of approximately $10 000 in expenditures in 2 years compared with those who remained independent. The 9.6% of patients who were dependent at baseline accounted for more than 40.0% of home health and nursing home expenditures; the 10.0% who declined accounted for more than 20.0% of hospital, outpatient, and nursing home expenditures. CONCLUSIONS: Functional dependence places a large burden on government-funded health care services. Whereas functional decline places this burden on short- and long-term care services, stable functional dependence places the burden predominantly on long-term care services. Declining rates of functional disability and interventions to prevent disability hold promise for ameliorating this burden.     

Changes predicting long-term care use among the oldest-old

PURPOSE: The aim of this study was to identify health-related changes occurring between 1983 and 1990 that characterize and differentiate 1996 long-term care outcomes (no services, home care, nursing home) among people aged 85 years and older. DESIGN AND METHODS: Variables capturing health-related changes between 1983 and 1990 in a cohort (N = 616) of Aging in Manitoba Longitudinal Study participants aged 85 years and older were used in a series of logistic regression models to identify factors that best predicted the use of long-term care services in 1996, controlling for age and sex. RESULTS: Factors predicting home care use relative to no services included changes in self-rated health, income adequacy, and railings outside of the house. Factors predicting nursing home use relative to home care included age and changes in general life satisfaction. Factors predicting nursing home use relative to no services included age; previous service use; length of time in the community; and changes in income adequacy, type of housing, and state of mind. IMPLICATIONS: These findings challenge assumptions about the linearity of the continuum of long-term care services, because different factors were shown to predict home care use than were shown to predict nursing home use.     

Impact of informal care levels on discontinuation of living at home in community-dwelling dependent elderly using various community-based services

The aim of the study was to examine the effect of informal care levels on overall discontinuation of living at home, all-cause death, hospital admission, and long-term care placement for community-dwelling older people using various community-based services during a 3-year period. Prospective cohort study of 1582 community-dwelling disabled elderly and paired informal caregivers was conducted. Baseline data included the recipients and caregivers’ demographic characteristics, comorbidities, informal care levels (sufficient, moderate, and insufficient care), which were evaluated by trained visiting nurses, and the level of formal community-based service use. Among 1582 participants, 97 died at home, 692 were admitted to hospitals, 318 died during their hospital stay, and 117 were institutionalized in long-term care facilities during 3 years of follow-up. A multivariate Cox hazard model demonstrated that when compared with a sufficient informal care level, an insufficient informal care level was associated with overall discontinuation of living at home, all-cause mortality, hospitalization, and institutionalization during 3 years of follow-up (hazard ratio: 1.65, 95% confidence interval: 1.15-2.36; 1.98, 1.17-3.34; 1.56, 1.04-2.35; 2.93, 1.25-6.86, respectively). The results suggested that informal caregiving is an important factor in the prevention of overall discontinuation of living at home in a population of disabled older people.     

Older adults' preferences for informal,formal, and mixed support for future care needs: a comparison of Germany and the United States

Based on the complementary model of support use, we investigated older adults' preferences for short-term and long-term future care needs in a U.S. and a German sample (65+ years). A greater preference for the exclusive use of informal support and for mixed support (a combination of informal and formal support) was found with regard to short-term care needs whereas a greater preference for the exclusive use of formal support was reported for long-term care needs. German seniors were more likely than U.S. seniors to report a preference for informal support. U.S. seniors, however, were more likely than German seniors to prefer mixed support. Being male, and having more contact with relatives predicted stronger preferences for informal and mixed support. In addition, age, the number of adult children, previous receipt of support, education, and income were associated with preferences for future support.     

Clinical characteristics and longitudinal changes of informal cost of Alzheimer's disease in the community

Most estimates of the cost of informal caregiving in patients with Alzheimer's disease (AD) remain cross-sectional. Longitudinal estimates of informal caregiving hours and costs are less frequent and are from assessments covering only short periods of time. The objectives of this study were to estimate long-term trajectories of the use and cost of informal caregiving for patients with AD and the effects of patient characteristics on the use and cost of informal caregiving. The sample is drawn from the Predictors Study, a large, multicenter cohort of patients with probable AD, prospectively followed annually for up to 7 years in three university-based AD centers in the United States (n=170). Generalized linear mixed models were used to estimate the effects of patient characteristics on use and cost of informal caregiving. Patients' clinical characteristics included cognitive status (Mini-Mental State Examination), functional capacity (Blessed Dementia Rating Scale (BDRS)), comorbidities, psychotic symptoms, behavioral problems, depressive symptoms, and extrapyramidal signs. Results show that rates of informal care use and caregiving hours (and costs) increased substantially over time but were related differently to patients' characteristics. Use of informal care was significantly associated with worse cognition, worse function, and higher comorbidities. Conditional on receiving informal care, informal caregiving hours (and costs) were mainly associated with worse function. Each additional point on the BDRS increased informal caregiving costs 5.4%. Average annual informal cost was estimated at $25,381 per patient, increasing from $20,589 at baseline to $43,030 in Year 4.     

The Influence of Long-Term Care Insurance on the Likelihood of Nursing Home Admission

OBJECTIVES: To determine the effect of long-term care (LTC) insurance on nursing home use.
DESIGN: Longitudinal analysis, 1998 to 2006 waves of the Health Retirement Study.
SETTING: Community-dwelling nationally representative sample.
PARTICIPANTS: Nineteen thousand one hundred seventy adults aged 50 and older, 1998 wave.
METHODS: Two groups of respondents were created at baseline: those with and without an LTC insurance policy. Respondents admitted to the nursing home from 1998 to 2006 were identified. Propensity scores were used to control for known predictors of LTC insurance possession. A Cox proportional hazards model was used to compare the probability of nursing home admission over 8 years of follow-up for respondents possessing LTC insurance and those without a policy.
RESULTS: Of the 19,170 respondents aged 50 and older in 1998, 1,767 (9.2%) possessed LTC insurance. A total of 1,778 (8.5%) were admitted to a nursing home during the 8-year period: 149 (8.7%) of those with LTC insurance and 1,629 (8.4%) of those without LTC insurance. The hazard ratio, adjusted for propensity score, for those with LTC insurance entering a nursing home compared with those without was 1.07 (95% confidence interval=0.83–1.38). Likelihood of nursing home admission was relatively low because the low-risk population included in the study, limiting the power to detect small differences in risk of nursing home utilization between groups.
CONCLUSION: There was no difference in nursing home utilization between low-risk older adults who did and did not possess an LTC insurance policy.     

Are public care and services for older people targeted according to need? Applying the Behavioural Model on longitudinal data of a Swedish urban older population

The objectives were to identify factors that predict the use of home help services and transition into institutional care and to study to what extent care services were targeted according to the individuals’ needs. A further objective was to study whether people who had moved into institutional care facilities had received home help prior to institutionalisation. A community-dwelling sample (n=502) aged 81–100 was twice interviewed and assessed with medical examinations. Their use of public elderly care between 1994/1996 and 2000 was studied using survival analyses. Need factors, according to the Andersen Behavioural Model, were the most important predictors for the use of elderly care. Among people living alone, dementia, functional limitations, and depressive symptoms predicted the use of home help services and institutionalisation. Among non-demented cohabiting people, depressive symptoms and dependence in ADLs increased the likelihood of both home help and institutionalisation. Among cohabiting people with dementia, the effect of dementia was difficult to separate from the effects of ADL limitations and depression. Enabling factors were of importance among cohabiting people. A high level of education increased the likelihood of moving into institutional care, and informal extra-residential care increased the likelihood of both outcomes indicating that elderly care resources had not been targeted solely according to need. Predisposing factors such as age and gender were of importance only among people living alone. Basically the same factors predicted both the receipt of home help and institutionalisation. Only 4% of people living alone and 5% of those cohabiting moved to institutions without previously receiving home help.     

Older adults' reports of formal care hours and administrative records

PURPOSE: Personal assistance care is a Medicaid benefit in New York, but few data are available on its prevalence and contribution to home care. We examined these issues in a New York City sample by assessing older adults' reports of weekly home care hours and Medicaid billing records. DESIGN AND METHODS: With help from New York City's Human Resources Administration, we identified all respondents in an ongoing population-based survey of Medicare enrollees who were receiving Medicaid-reimbursed personal assistance care in 1996. RESULTS: Of respondents in the sample, 10.3% (185 of 1,902 alive through 1996) had Medicaid claims for personal assistance care. The mean was 46.1 hr/week for reported hours and 40.1 hr/week for administrative claims. Accuracy of reported hours was evident in a high correlation (r =.91; p <.001) between respondent reports and authorized claims, and a consistently high and mostly constant ratio of billed to reported hours across all categories of activities of daily living disability. IMPLICATIONS: In this urban, low income, and mostly minority sample, older adults' reports of weekly formal care hours were valid when matched against administrative records. Respondent reports of formal care hours were valid even in complex care situations.     

An estimate of long-term care needs and identification of risk factors for institutionalization among Hong Kong Chinese aged 70 years and over

BACKGROUND: The goal of this study is to estimate the long-term care needs of the Hong Kong Chinese population age 70 years and older, and to identify risk factors for institutionalization. METHODS: A three-year prospective follow-up study was carried out in Hong Kong Special Administrative Region, China. 2,032 subjects aged 70 years and older were recruited territory-wide by stratified random sampling of the Old Age and Disability Allowance register, covering over 90% of the elderly population. A questionnaire was administered at baseline to obtain information on social, functional, physical, and mental health status, and place of residence. A repeat interview was carried out at 36 months. The number of subjects moving from home to institution or vice versa, and the number who had died, were noted. Univariate analysis was performed to determine risk factors for institutionalization, and backward stepwise multiple logistic regression was used to identify independent factors predisposing to institutionalization. RESULTS: The institutionalization rate per year is estimated to be 0.7% for the 70-79 age group, and 1.5% for the 80+ age group. Using population figures projected by the Hong Kong Census, the corresponding number of places required will be 24,150 and 42,000, respectively, for the two age groups by 2005, whereas the number of government subvented places projected to be available is unlikely to be more than 40,000 for the whole population. Age, being a woman, being single, not having a formal education, cognitive impairment, physical dependency, and the presence of depressive symptoms were factors predisposing to institutionalization. In multivariate analysis, age, marital status, and dependency were identified as independent factors. CONCLUSION: The requirement for institutional places is unlikely to be met by government, the shortfall likely to be met by the private sector. Maintenance of functional independence, good social support network, engagement in social activities, and good informal carer support may reduce demand for institutional care.     

Identifying trajectories of depressive symptoms for women caring for their husbands with dementia

OBJECTIVES: To use an innovative statistical method, Latent Class Trajectory Analysis (LCTA), to identify and describe subgroups (called trajectories) of caregiver depressive symptoms in a national sample of wives providing informal care for their husbands with dementia.
DESIGN: Longitudinal.
SETTING: Community.
PARTICIPANTS: Respondents to the National Longitudinal Caregiver Survey were wife caregivers of veterans with dementia who were identified through Veterans Affairs hospitals nationally.
MEASUREMENTS: Mean number of depressive symptoms as measured using the Center for Epidemiologic Studies Depression scale (CES-D, 20-item scale).
RESULTS: Overall mean depressive symptoms of wife caregivers were 6.2 of 20, below the cutpoint (8 or 9/20) associated with clinical depression. Four distinct trajectories of caregiver depressive symptoms were identified. The trajectory with the highest number of symptoms (11.9 of 20), contained one-third of the sample. Another third had mean depressive symptoms virtually identical to the overall sample mean. The final third were divided between two trajectories, low depressive symptoms (mean CES-D, 3.0/20, 22% of sample) and very low (mean CES-D, 0.8/20, 14% of sample). Approximately two-thirds of the sample members were in a depressive symptom trajectory, with substantially higher or lower numbers of symptoms than the overall mean. Two subjective measures asked of wife caregivers (desire for more help, life satisfaction) were significantly associated with membership in the highest depressive symptom trajectory.
CONCLUSION: LCTA identified important depressive symptom subgroups of wife caregivers. A population-averaging method identified a mean effect that was similar to the effect in one-third of the cases but substantially different from that in two-thirds of the cases.     

Longitudinal changes in the amount of informal care among publicly paid home care recipients

PURPOSE: This study examined how the amount of informal care received by disabled elders changes when they are receiving publicly paid home care, and whether formal service use, disability, caregiving arrangements, and demographic characteristics of older adults predict changes in the amount of informal care. DESIGN AND METHODS: Hierarchical linear models were estimated, using 3-year data (12 repeated observations) collected from elderly participants (N = 888) in Michigan's Home- and Community-Based Medicaid Waiver Program. RESULTS: The amount of informal care declined in the beginning period when publicly paid home care was received, and then it stabilized. Changes in activities and instrumental activities of daily living and caregiver residence predicted changes in the amount. The living arrangement and age of elders predicted different patterns of change over time. Neither formal service amount nor its change significantly predicted the amount of informal care. IMPLICATIONS: Informal caregivers do not relinquish caregiving when publicly paid home care is available. Expanding community-based long-term care is a means of fostering partnerships between formal and informal caregivers.     

Comparative costs of home care and residential care

PURPOSE: This paper reports on Canadian research that examined the cost effectiveness of home care for seniors as a substitute for long-term institutional services. DESIGN AND METHODS: Two Canadian cities were included in the research: Victoria, British Columbia, and Winnipeg, Manitoba. The research computes the costs of formal care and informal care in both settings and ensures comparable groups of clients in both settings by comparing individuals at the same level of care. RESULTS: The results reveal that costs were significantly lower for community clients than for facility clients, regardless of whether costs only to the government were taken into account or whether both formal and informal costs were taken into account. When informal caregiver time is valued at either minimum wage or replacement wage, there was a substantial jump in the average annual costs for both community and facility clients relative to when informal caregiver time was valued at zero. IMPLICATIONS: Nevertheless, the results reveal that home care is significantly less costly than residential care even when informal caregiver time is valued at replacement wage.     

Factors that Affect Older Japanese People’s Reluctance to Use Home Help Care and Adult Day Care Services

The purpose of this study was to examine the factors related to the reluctance of older Japanese people to utilize home help services and day services. Home help services consist of three different types of services (i.e., assisting in bathing and toileting, doing household choirs, such as cooking and laundry, and counseling) and are provided by visiting home helpers at the homes of older people. Day services are services (e.g., providing bathing and meals, monitoring the health status of older people, and counseling) that are provided at day service centers in the community to improve the physical and psychological functioning of older people and to help the burden of caregiving of family members. The data used in the study came from the first wave of the Nihon University Japanese Longitudinal Study of Aging, conducted in November 1999 (and again in March 2000 for those people who had been unable to respond to the initial survey). Face-to-face interviews were conducted with a national probability sample of 6,700 people aged 65 and older. Logistic regression analyses were used to analyze factors that were thought to be related to older people’s reluctance to use services. Approximately, one half of the respondents indicated reluctance to use home help services, and one quarter of the respondents showed reluctance to use day services. Respondents who were female and who lived in urban areas showed a higher probability of feeling reluctant about using both home-help and day services. Also, respondents who had had caregiving experience using these two types of services showed a lower probability of feeling reluctant about using the services. Furthermore, respondents who were older and had income showed a higher probability of feeling reluctant about using day services, whereas those who had had caregiving experience and who participated in social activities showed a lower probability of feeling reluctant about using day services. According to the 1999 survey, there were still many older Japanese people who felt reluctant about using either type of care service. But it is expected that the quality of services under Kaigo Hoken (the mandatory public long-term care social insurance system) will improve further and that older people’s attitudes toward service utilization will change for the better. In the meantime, professional service providers will have to be sensitive to older people’s perceptions about service utilization if they would like to continue to contribute to the improvement process of Kaigo Hoken as a positive force. This study used data from the Nihon University Japanese Longitudinal Study of Aging (NUJLSOA). This survey was conducted by the Nihon University Center for Information Networking as one of their research projects.     

Chronic disease and lifestyle transitions: results from the Longitudinal Aging Study Amsterdam

OBJECTIVE: This article addresses the association between course of chronic disease and lifestyle. METHOD: We examined differences in unhealthy lifestyles--smoking, excessive alcohol use, being sedentary--and transitions herein after 6 years in prevalent and incident chronic disease categories--lung and cardiovascular disease, diabetes, and osteoarthritis and/or rheumatic arthritis--among 2,184 respondents aged 55 years and older from the Netherlands. We also examined if transitions in lifestyle co-occurred with changes in disease-related symptomatology. RESULTS: Proportions of respondents who smoked decreased over time, whereas proportions of respondents who were sedentary increased. Respondents with incident cardiovascular disease demonstrated more lifestyle transitions than respondents from other disease categories. Respondents demonstrating healthy lifestyle transitions did not differ from those persisting in unhealthy lifestyles in change in disease-related symptoms. DISCUSSION: Health promotion may benefit from these findings in a way that patient groups at risk for not initiating healthy lifestyles might be identified sooner.     

Consequences of falling in older men and women and risk factors for health service use and functional decline

OBJECTIVES: (1) to examine consequences of falls in older men and women and (2) to examine risk factors for health service use and functional decline among older fallers. METHODS: the study was performed within the Longitudinal Aging Study Amsterdam. In 1998/1999, potential risk factors were assessed during the third data collection. In 1999/2000, 204 community-dwelling persons (> or =65 years) who reported at least one fall in the year before the interview, were asked about consequences of their last fall, including physical injury, health service use, treatment and functional decline (i.e. decline in functional status, social and physical activities). RESULTS: as a consequence of falling, respondents reported physical injury (68.1%), major injury (5.9%), health service use (23.5%), treatment (17.2%), and decline in functional status (35.3%), and social (16.7%) and physical activities (15.2%). Using multivariate logistic regression, specific risk factors for health service use after falling could not be identified. Female gender (OR = 2.8, 95% CI = 1.5-5.1), higher medication use (OR = 1.5, 95% CI = 1.0-2.2) and depressive symptoms (OR = 1.9, 95% CI = 1.3-2.8) were independently associated with functional decline after falling. Depressive symptoms (OR = 2.0, 95% CI = 1.2-3.3) and falls inside (OR = 2.6, 95% CI = 1.1-6.5) were risk factors for decline in social activities, while female gender (OR = 2.7, 95% CI = 1.1-7.0) and depressive symptoms (OR = 1.9, 95% CI = 1.2-3.0) were risk factors for decline in physical activities after falling. CONCLUSIONS: almost 70% of the respondents suffered physical injury, almost one-quarter used health services and more than one-third suffered functional decline after falling. No risk factors were found for health service use needed after falling. Female gender, higher medication use, depressive symptoms and falls inside were risk factors for functional decline after falling.