Bathing disability and the risk of long-term admission to a nursing home

BACKGROUND: The prevalence of disability in bathing and the likelihood of a long-term nursing home admission increase substantially with age. We performed a prospective study to determine whether the occurrence of persistent disability in bathing is associated with the risk of a long-term nursing home admission, independent of potential confounders, including persistent disability in other essential activities of daily living. METHODS: We studied 754 community-living persons, 70 years old or older, who were nondisabled in four essential activities of daily living. Participants were followed with monthly telephone interviews for a median of 75 months to determine the occurrence of persistent (i.e., present for at least 2 consecutive months) disability in bathing and the time to the first long-term nursing home admission, defined as longer than 3 months. RESULTS: One hundred thirteen (15.0%) participants had a long-term nursing home admission. At least one episode of persistent bathing disability occurred among 59 (52.2%) participants with a long-term nursing home admission and 210 (32.8%) without a long-term admission (p <.001). In a proportional hazards model that was fully adjusted for potential confounders, the occurrence of persistent bathing disability increased the risk of a long-term nursing home admission by 77% (hazard ratio 1.77, 95% confidence interval 1.05 to 2.98), but had no effect on the risk of a short-term nursing home admission (hazard ratio 0.87, 95% confidence interval 0.51 to 1.49). CONCLUSIONS: Among community-living older persons, the occurrence of persistent disability in bathing is independently associated with the risk of a long-term nursing home admission, but has no effect on short-term admissions. Interventions directed at the prevention and remediation of bathing disability have the potential to reduce the burden and expense of long-term care services.     

The prevalence and impact of arthritis in older persons

Objective. To review what is known about the prevalence and impact of arthritis on disability and health care expenditures incurred by older persons. Methods. The current prevalence estimates of osteoarthritis and osteoporosis in the US are examined, and what is known about the relationship of arthritis, broadly defined to disability, and the impact of arthritis-specific disability on home care and nursing home use by older persons are reviewed. Results. Arthritis is a major contributor to disability among older people and is especially disabling for older women, who have higher prevalence rates and greater disability than their male counterparts. Studies of the relationship of arthritis to long-term care use indicate that arthritis can be a risk factor insofar as it can cause disability that results in homeboundedness, which, in turn is a risk factor for nursing home use. It is possible that previous analyses that included arthritis and disability as competing risk factors for nursing home use underestimate the contribution of arthritis because arthritis is a risk factor for disability; thus, the two variables may be strongly correlated. Conclusions. More study is needed to understand the contribution of sex to prevalence of arthritis and severity of arthritis-specific disability. The route through which arthritis affects long-term care use also needs careful longitudinal study. If arthritis is confirmed to be a major risk factor for disability that leads to long-term care use, the development and testing of interventions to prevent/minimize arthritis-specific disability should be a major research priority.     

Functional Trajectories in Older Persons Admitted to a Nursing Home with Disability After an Acute Hospitalization

OBJECTIVES: To characterize the functional trajectories of older persons admitted to a nursing home with disability after an acute hospitalization.
DESIGN: Prospective cohort study of 754 community-living persons aged 70 and older who were initially nondisabled in four essential activities of daily living (ADLs).
SETTING: Greater New Haven, Connecticut.
PARTICIPANTS: The analytical sample included 296 participants who were newly admitted to a nursing home with disability after an acute hospitalization.
MEASUREMENTS: Information on nursing home admissions, hospitalizations, and disability in essential ADLs was ascertained during monthly telephone interviews for up to 9 years. Disability was defined as the need for personal assistance in bathing, dressing, walking inside one's home, or transferring from a chair.
RESULTS: The median time to the first nursing home admission with disability after an acute hospitalization was 46 months (interquartile range 27.5–75.5), and the mean number±standard deviation of ADLs that participants were disabled in upon admission was 3.0±1.2. In the month preceding hospitalization, 189 (63.9%) participants had no disability. The most common functional trajectory was discharged home with disability (46.3%), followed by continuous disability in the nursing home (27.4%), discharged home without disability (21.6%), and noncontinuous disability in the nursing home (4.4%). Only 96 (32.4%) participants returned home at (or above) their premorbid level of function.
CONCLUSION: The functional trajectories of older persons admitted to a nursing home with disability after an acute hospitalization are generally poor. Additional research is needed to identify the factors responsible for these poor outcomes.     

Assessing life expectancies of institutionalized older persons in Hong Kong

BACKGROUND: In Hong Kong, it has been projected that, by the year 2010, there will be 0.86 million persons aged 65 or older. The demand for residential care places continues to rise. Information on the survival of older persons will allow better management of care in institutional settings. OBJECTIVE: The Weibull model was developed to predict the 18-month survival of a group of Chinese nursing home residents. METHODS: In this prospective cohort study, 590 older residents from four nursing homes with different levels of care were enrolled. The main outcome measure was survival at 18 months. Information on subject demographics, clinical data and disability levels as measured by the Patient Assessment Instrument (PAI) was collected at baseline. Life expectancies were derived from accelerated failure time models. RESULTS: Independent predictors of decreased survival derived from the Weibull model included increased age, male gender, diagnosis of cancer, presence of malnutrition and functional dependence. Significant interaction was observed between male gender and PAI score. The goodness of fit of the model was satisfactory. CONCLUSIONS: From this study, the model for predicting life expectancy in nursing home residents can assist policy makers in planning long-term care. It can also guide clinicians to make more appropriate management decisions for their older patients.     

Profiling disability within nursing homes: a census-based approach

BACKGROUND: a significant minority of older people live in residential care. While disability is often a major contributory factor, it may not be measured or managed adequately by health and social services. At present there is little information comparing levels of disability within nursing homes and the community, and no mechanisms for monitoring changes in this disability ratio longitudinally. OBJECTIVE: to examine the prevalence of disability among older nursing home residents compared to its prevalence among older people in the community using a census-based approach. DESIGN: nationwide census over one night in 2002. SETTING: all homes and dwellings in the Republic of Ireland. Method: disability was measured using a six-item questionnaire embedded in a census form. Prevalence of disability was quantified among the general population and nursing homes residents aged 65 and over. Comparisons were made of sex, and number and type of disabilities between nursing home residents and their age-matched peers living within the community. RESULTS: the results showed a high level of disability within nursing homes with almost 90% of residents having a recorded disability compared with less than 30% of those aged 65 and over, living in the community. Nursing home residents had on average 4.5 disabilities ranging from hearing and visual problems to difficulties remembering and concentrating. CONCLUSION: there is a very high level of physical, sensory and cognitive disability among nursing home residents. Strategic health and functional questions in national censuses may be helpful in planning appropriate services for older people in residential care, as well as tracking trends in disability.     

Functional disability of older persons in long-term care facilities in Korea

The aim of this study was to examine functional disability of older persons in long-term care facilities and to identify factors associated with their levels of functioning. The first national survey of older residents in nursing and residential care homes in Korea was conducted in 1999. Of the 1105 respondents who completed the interview 73% in residential care homes and 88% in nursing homes reported limitations in functioning. The percentage of persons with three or more limitations in activities of daily living (ADL) was 63% among nursing home residents and 36% among those at residential care homes. Overall, persons of older age, female, widowed, with less family support, and bearing out-of-pocket costs of medical care tended to show higher levels of disability. Presence of arthritis, hypertension, and stroke was found to be significantly associated with increased likelihood of disability. Multivariate analysis revealed variability in the associations by type of facility. Characteristics such as older age, women, and stroke were significantly associated with a higher likelihood of disability for those in both residential and nursing homes. Arthritis, fracture, exercise, and contact with family members, however, were found to be independently associated with disability among those in residential care homes only. Recent government proposals to improve care delivered to long-term care residents need to take into account their differing levels of functional disability and its associated care needs.     

Health and long-term care use trajectories of older disabled women

PURPOSE: I examined health and long-term care use trajectories of a sample of chronically disabled older women eligible for both Medicare and Medicaid by exploring their use data in order to understand and anticipate the increasing demand on the health and long-term care delivery systems as aging female baby boomers reach age 65 and older. DESIGN AND METHODS: A sample of older disabled women in Ohio who completed preadmission review was divided into three groups on the basis of the setting in which they received their initial long-term care services. RESULTS: I was able to establish a long-term care career for the sample members beginning with receiving long-term care in the community, followed by a transition stage in which care was received in the community and in a nursing home, and finally by a stage at which they entered and remained in a nursing home. As the sample members proceeded along their long-term care career and their health and disability status worsened, I found a clear shift in the kind of care needed from hospital and home care to nursing home care. There was also a shift in the major payer, from Medicare to Medicaid. IMPLICATIONS: As the baby boomers age, a much larger number of women will be disabled and need health and long-term care services. For a considerable number of these women, Medicaid gradually becomes the major payer for care, an issue that needs close observation.     

A randomized clinical trial of outpatient geriatric evaluation and management

OBJECTIVES: To measure the effects of outpatient geriatric evaluation and management (GEM) on high-risk older persons' functional ability and use of health services. DESIGN: Randomized clinical trial. SETTING: Ambulatory clinic in a community hospital. PARTICIPANTS: A population-based sample of community-dwelling Medicare beneficiaries age 70 and older who were at high risk for hospital admission in the future (N = 568). INTERVENTION: Comprehensive assessment followed by interdisciplinary primary care. MEASUREMENTS: Functional ability, restricted activity days, bed disability days, depressive symptoms, mortality, Medicare payments, and use of health services. Interviewers were blinded to participants' group status. RESULTS: Intention-to-treat analysis showed that the experimental participants were significantly less likely than the controls to lose functional ability (adjusted odds ratio (aOR) = 0.67, 95% confidence interval (CI) = 0.47-0.99), to experience increased health-related restrictions in their daily activities (aOR = 0.60, 95% CI = 0.37-0.96), to have possible depression (aOR = 0.44, 95% CI = 0.20-0.94), or to use home healthcare services (aOR = 0.60, 95% CI = 0.37-0.92) during the 12 to 18 months after randomization. Mortality, use of most health services, and total Medicare payments did not differ significantly between the two groups. The intervention cost $1,350 per person. CONCLUSION: Targeted outpatient GEM slows functional decline.     

Multidimensional preventive home visit programs for community-dwelling older adults: a systematic review and meta-analysis of randomized controlled trials

BACKGROUND: Multidimensional preventive home visit programs aim at maintaining health and autonomy of older adults and preventing disability and subsequent nursing home admission, but results of randomized controlled trials (RCTs) have been inconsistent. Our objective was to systematically review RCTs examining the effect of home visit programs on mortality, nursing home admissions, and functional status decline. METHODS: Data sources were MEDLINE, EMBASE, Cochrane CENTRAL database, and references. Studies were reviewed to identify RCTs that compared outcome data of older participants in preventive home visit programs with control group outcome data. Publications reporting 21 trials were included. Data on study population, intervention characteristics, outcomes, and trial quality were double-extracted. We conducted random effects meta-analyses. RESULTS: Pooled effects estimates revealed statistically nonsignificant favorable, and heterogeneous effects on mortality (odds ratio [OR] 0.92, 95% confidence interval [CI], 0.80-1.05), functional status decline (OR 0.89, 95% CI, 0.77-1.03), and nursing home admission (OR 0.86, 95% CI, 0.68-1.10). A beneficial effect on mortality was seen in younger study populations (OR 0.74, 95% CI, 0.58-0.94) but not in older populations (OR 1.14, 95% CI, 0.90-1.43). Functional decline was reduced in programs including a clinical examination in the initial assessment (OR 0.64, 95% CI, 0.48-0.87) but not in other trials (OR 1.00, 95% CI, 0.88-1.14). There was no single factor explaining the heterogenous effects of trials on nursing home admissions. CONCLUSION: Multidimensional preventive home visits have the potential to reduce disability burden among older adults when based on multidimensional assessment with clinical examination. Effects on nursing home admissions are heterogeneous and likely depend on multiple factors including population factors, program characteristics, and health care setting.     

Effectiveness of a group outpatient visit model for chronically ill older health maintenance organization members: a 2-year randomized trial of the cooperative health care clinic

OBJECTIVES: To compare the effectiveness of Cooperative Health Care Clinic ((CHCC) group outpatient model for chronically ill, older health maintenance organization (HMO) patients) with usual care. DESIGN: Two-year, randomized, controlled trial conducted with recruitment from February 1995 through July of 1996. SETTING: Nonprofit group model HMO. PARTICIPANTS: Two hundred ninety-four adults (145 intervention and 149 usual care), aged 60 and older (mean age 74.1) with 11 or more outpatient visits in the prior 18 months, one or more self-reported chronic conditions, and expressed interest in participating in a group clinic. INTERVENTION: Monthly group meetings held by patients' primary care physicians. MEASUREMENT: Differences in clinic visits, inpatient admissions, emergency room visits, hospital outpatient services, professional services, home health, and skilled nursing facility admissions; measures of patient satisfaction, quality of life, self-efficacy, and activities of daily living (ADLs). RESULTS: Outpatient, pharmacy services, home health, and skilled nursing facility use did not differ between groups, but CHCC patients had fewer hospital admissions (P=.012), emergency visits (P=.008), and professional services (P=.005). CHCC patients' costs were $41.80 per member per month less than those of control patients. CHCC patients reported higher satisfaction with their primary care physician (P=.022), better quality of life (P=.002), and greater self-efficacy (P=.03). Health status and ADLs did not differ between groups. CONCLUSION: The CHCC model resulted in fewer hospitalizations and emergency visits, increased patient satisfaction, and self-efficacy, but no effect on outpatient use, health, or functional status.     

Outcomes of managed care of dually eligible older persons

PURPOSE: To assess changes in various functional and satisfaction measures between older persons enrolled in Minnesota Senior Health Options (MSHO), a managed care program for older persons eligible for both Medicare and Medicaid. DESIGN AND METHODS: We used two sets of matched controls for MSHO enrollees and their families and matched controls living in the community and in nursing homes: Persons in the same county who were eligible to enroll but did not enroll in MSHO and persons in other metropolitan areas where MSHO is not available. For the community sample, we used questionnaires to measure functional status (activities of daily living), pain, unmet care needs, satisfaction, and caregiver burden. Approximately 2 years after the first survey, we resurveyed respondents who lived in the community at the time of the first survey. For the nursing home residents, we used annual assessments to calculate case mix to compare changes in functional levels over time. RESULTS: There were few significant differences in change over time between the MSHO sample and the two control groups. Out-of-area controls showed greater increases in pain but in-area controls showed less interference from pain. Compared with out-of-area controls, MSHO clients showed greater increase in homemaker use, meals on wheels, and outpatient rehabilitation. Compared with in-area controls, they showed more use of meals on wheels and less help from family with household tasks. There were few differences in satisfaction, but the MSHO families showed significantly lower burden than controls on five items. IMPLICATIONS: The analyses show only modest evidence of benefit from MSHO compared with the two control groups. The model represented by MSHO does not appear to generate substantial differences in outcomes across function, satisfaction, and caregiver burden.     

Effects on health care use and associated cost of a home visiting program for older people with poor health status: a randomized clinical trial in the Netherlands

BACKGROUND: Home visiting programs have been developed to improve the functional abilities of older people and subsequently to reduce the use of institutional care services. The results of trials have been inconsistent and their cost-effectiveness uncertain. Home visits for a high-risk population rather than the general population seems a promising approach. We therefore studied the effects of a home visiting program for older people with poor health. This article describes the effects on health care use and associated cost. METHODS: We conducted a randomized clinical trial among 330 community-dwelling citizens, aged 70-84 years, in the Netherlands. Participants in the intervention group (n = 160) received eight home visits by a trained home nurse over an 18-month period; a multidimensional geriatric assessment of problems was included. The main outcomes are: admissions to hospital, nursing home, and home for older persons; contacts with medical specialists, general practitioners, and paramedics; and hours of home care help. The data on health care use were mostly obtained from computerized databases of various medical administration offices; the follow-up period was 24 months. RESULTS: Inpatient and outpatient health care use was similar for both groups, with the exception of a higher distribution of aids and in-home modifications in favor of the intervention group. No differences were found between the intervention and control group in health care cost. CONCLUSION: The home visiting program did not appear to have any effect on the health care use of older people with poor health and had a low chance of being cost-effective. We conclude that these visits are probably not beneficial for such persons within the health care setting in the Netherlands or comparable settings in other Western countries.     

Factors Related to Primary Health Care Provision: A Cross-Sectional Study in an Elderly Rural Population

We examined the relationship between social support, lifestyle habits, and disease-related factors in two primary health care settings: the health care center and the elders’ homes. Logistic regression analysis was performed to determine the effect of independent variables on the provision of health care services. Those who received home visits were significantly older, had lower family income, and had poorer social support systems. Furthermore, elderly people with nutritional risk status, heart failure, functional dependence, or cognitive impairment were among those most likely to request in-home care visits. Our study suggests that age, nutritional risk, and functional dependence are the most important factors to predict the use of home health care services compared with general practitioner visits.     

Projected use of long-term-care services by enrolled Veterans

PURPOSE: The purpose of this article is to describe the projected use for long-term-care services through 2012. DESIGN AND METHODS: We constructed a static-component projection model using age, function, and other covariates. We obtained enrollee projections from the Veterans Health Administration (VHA) and combined these with nursing home and community long-term-care service use rates from the 1999 National Long-Term Care Survey and the 2000 National Health Interview Survey. RESULTS: Over the next decade, the number of oldest veterans (aged 85+) will double, and VHA-enrolled veterans aged 85 and older will increase sevenfold. This will result in a 20-25% increase in use for both nursing home and home- and community-based services. VHA currently concentrates 90% of its long-term-care resources on nursing home care. However, among those who receive long-term care from all formal sources, 56% receive care in the community. Age and marital status are significant predictors of use of either type of formal long-term-care service for any given level of disability. VHA's experience with the mandatory nursing home benefit suggests that even when the cost to the veteran is near zero, only 60-65% of eligibles will choose VHA-provided care. Assisted living represents nearly 15% of care provided during the past decade to individuals in nursing homes, and approximately 19% of veterans using nursing homes have disability levels comparable to those of men supported in assisted living. IMPLICATIONS: As most of the increased projected use for long-term care will be for home- and community-based services, VHA will need to expand those resources. Use of VHA resources to leverage community services may offer new opportunities to enhance community-based long-term care.     

Medicare and Medicaid home health and Medicaid waiver services for dually eligible older adults: risk factors for use and correlates of expenditures

PURPOSE: The purpose of this work was to, among frail dually eligible older adults, determine risk factors for the likelihood of using Medicare home health and Medicaid home health services and to, among service users, determine correlates of Medicare home health, Medicaid home health, and Medicaid waiver service expenditures. DESIGN AND METHODS: Dually eligible individuals enrolled in Connecticut's Medicaid home- and community-based services (HCBS) waiver program for the aged (N = 5,232) were identified from a statewide database containing person-level linked data from Medicare claims, Medicaid claims, and uniform clinical assessment forms. Expenditures, based on claims data, were observed from the month following clinical assessment over the period August 1995 to December 1997. RESULTS: In multivariate models controlling for medical conditions and sociodemographic variables, similar functional disability measures were strongly associated with the probability of the use of, and expenditures for, Medicare home health and Medicaid home health services; severe cognitive impairment was strongly associated with greater Medicaid waiver service expenditures. IMPLICATIONS: Given the similarity of factors associated with Medicare and Medicaid home health service use and expenditures, greater integration of Medicare and Medicaid financing, reimbursement, and delivery strategies for home health services may be feasible and warranted for dually eligible older adults enrolled in state Medicaid HCBS waiver programs.     

The yield,reliability, and validity of a postal survey for screening community-dwelling older people

OBJECTIVES: To assess the yield, reliability, and validity of a postal survey developed to identify older persons in need of outpatient geriatric assessment and follow-up services. DESIGN: A longitudinal cohort study. SETTING: Outpatient primary care clinic at a Department of Veterans Affairs teaching ambulatory care center. PARTICIPANTS: Patients (N = 2,382) aged 65 and older who returned a Geriatric Postal Screening Survey (GPSS) that screened for common geriatric conditions (depression, cognitive impairment, urinary incontinence, falls, and functional status impairment). Validity and reliability testing was performed with subsamples of patients classified as high or lower risk based on responses to the GPSS. MEASUREMENTS: Test-retest reliability was measured by percentage agreement and kappa statistic. The diagnostic validity of the 10-item GPSS was tested by comparing single GPSS items to standardized geriatric assessment instruments for depression, mental status and functional status, as well as direct questions regarding falls, urinary incontinence, and use of medications. Validity was also tested against clinician evaluation of the specific geriatric conditions. Predictive validity was tested by comparing GPSS score with 1-year follow-up data on functional status, survival, and healthcare use. RESULTS: Respondents identified as high risk by the GPSS had scores that indicated significantly greater impairment on structured assessment instruments than those identified as lower risk by GPSS. The overall mean percentage agreement between the test and retest surveys was 88.3%, with a mean weighted kappa of 0.70. In comparison with a structured telephone interview and with a clinical assessment, individual items of the GPSS showed good accuracy (range 0.71-0.78) for identifying symptoms of depression, falls, and urinary incontinence. Over a 1-year follow-up period, the GPSS-identified high-risk group had significantly (P <.05) more hospital admissions, hospital days and nursing home admissions than the lower-risk group. CONCLUSION: A brief postal screening survey can successfully target patients for geriatric assessment services. In screening for symptoms of common geriatric conditions, the GPSS identified a subgroup of older outpatients with multiple geriatric syndromes who were at increased risk for hospital use and nursing home admission and who could potentially benefit from geriatric intervention.     

Healthcare utilization of elderly persons hospitalized after a noninjurious fall in a Swiss academic medical center

OBJECTIVES: To determine the risk of hospital readmission, nursing home admission, and death, as well as health services utilization over a 6-month follow-up, in community-dwelling elderly persons hospitalized after a noninjurious fall. DESIGN: Prospective cohort study with 6-month follow-up. SETTING: Swiss academic medical center. PARTICIPANTS: Six hundred ninety persons aged 75 and older hospitalized through the emergency department. MEASUREMENTS: Data on demographics and medical, physical, social, and mental status were collected upon admission. Follow-up data were collected from the state centralized billing system (hospital and nursing home admission) and proxies (death). RESULTS: Seventy patients (10%) were hospitalized after a noninjurious fall. Fallers had shorter hospital stays (median 4 vs 8 days, P<.001) and were more frequently discharged to rehabilitation or respite care than nonfallers. During follow-up, fallers were more likely to be institutionalized (adjusted hazard ratio=1.82, 95% confidence interval=1.03-3.19, P=.04) independent of comorbidity and functional and mental status. Overall institutional costs (averaged per day of follow-up) were similar for both groups ($138.5 vs $148.7, P=.66), but fallers had lower hospital costs and significantly higher rehabilitation and long-term care costs ($55.5 vs $24.1, P<.001), even after adjustment for comorbidity, living situation, and functional and cognitive status. CONCLUSION: Elderly patients hospitalized after a noninjurious fall were twice as likely to be institutionalized as those admitted for other medical conditions and had higher intermediate and long-term care services utilization during follow-up, independent of functional and health status. These results provide direction for interventions needed to delay or prevent institutionalization and reduce subsequent costs.     

Gender and ethnic/racial disparities in health care utilization among older adults

OBJECTIVE: We examine the role of economic access in gender and ethnic/racial disparities in the use of health services among older adults. METHODS: Data from the 1993-1995 study on the Asset of Health Dynamics Among the Oldest Old (AHEAD) were used to investigate differences in the 2-year use of health services by gender and among non-Hispanic White versus minority (Hispanic and African American) ethnic/racial groups. Analyses account for predisposing factors, health needs, and economic access. RESULTS: African American men had fewer physician contacts; minority and non-Hispanic White women used fewer hospital or outpatient surgery services; minority men used less outpatient surgery; and Hispanic women were less likely to use nursing home care, compared with non-Hispanic White men, controlling for predisposing factors and measures of need. Although economic access was related to some medical utilization, it had little effect on gender/ethnic disparities for services covered by Medicare. However, economic access accounted for minority disparities in dental care, which is not covered by Medicare. DISCUSSION: Medicare plays a significant role in providing older women and minorities access to medical services. Significant gender and ethnic/racial disparities in use of medical services covered by Medicare were not accounted for by economic access among older adults with similar levels of health needs. Other cultural and attitudinal factors merit investigation to explain these gender/ethnic disparities.