The Use and Cost of Community Care Services by Elders with Unimpaired Cognitive Function, with Cognitive Impairment/No Dementia and with Dementia

Performance measures rather than self-report measures of functional status predict home care use in community-dwelling older adults

BACKGROUND

Occupational therapists frequently assess functional status (FS) to determine the home care (HC) service requirements of older adults. However, it is unclear which type of FS measure is most effective for this purpose.

PURPOSE

This study investigated the predictive ability of three measures of FS (a self-report measure of usual behaviour, a self-report measure of capacity, and an observational performance measure-the Performance Assessment of Self-Care Skills [PASS]) on formal HC utilization.

METHOD

A secondary analysis of 2001 Aging in Manitoba Longitudinal Study (AIM) data was conducted.

FINDINGS

The odds of receiving HC within the 30-month follow-up period were 1.32 times (or 30%) higher for each increase in the number of dependent tasks based upon a standardized performance measure. The self-report measures did not predict HC utilization.

IMPLICATIONS

This study suggests that standardized performance measures-in particular, the PASS-are more predictive of formal HC use in community-dwelling older adults than self-report measures.

Use of Community Services by Seniors Before and After an Emergency Visit

À l'aide de données provenant d'une cohorte de 1 352 personnes àgées demeurant dans la communauté et ayant visité l'urgence d'un centre hospitalier, nous avons étudié la prévalence (avant la visite à l'urgence) et l'incidence (pendant une période de suivi de six mois) de l'utilisation des services communautaires de santé ainsi que les facteurs reliés à l'utilisation de ces services. Les données ont été recueillies lors d'entrevues à l'urgence et au téléphone lors du suivi. Avant la visite à l'urgence, 59,8 pour cent des patients avaient au moins une incapacité en regard aux activités de la vie quotidienne (AVQ); 16,8 pour cent des patients ayant une incapacité recevaient des services communautaires. Parmi les patients qui ne recevaient pas ces services auparavant, 45,4 pour cent ont développé une nouvelle incapacité pour les AVQ pendant les trois mois suivant la visite à l'urgence; et 23,5 pour cent des patients avec une nouvelle incapacité ont commencé à recevoir des services communautaires. En contrôlant pour l'ampleur des besoms, les patients admis à l'hôpital se sont avérés être plus susceptibles de recevoir des services pendant la période de suivi que ceux ayant reçu leur congé de l'urgence. Il existe probablement de nombreux besoins non comblés pour les services communautaires dans cette population.

Indicators of Home Care Use in Urban and Rural Settings

This study employs a longitudinal design to examine rural–urban differences in home care service use over time, drawing on data from the Manitoba Study of Health and Aging (MSHA). Characteristics of community-dwelling, cognitively intact adults aged 65 years or older not receiving home care services in the province of Manitoba (n = 855) were collected in 1991/1992. Place of residence was categorized as urban/small-town zone or predominantly rural area. A 5-year follow-up determined subsequent home care use. Urban residents were more likely to receive home care than those in small-town zones or predominantly rural areas. Characteristics associated with use differed according to place of residence, with the exception of baseline physical functioning and changes in physical functioning that consistently emerged as significant. Directions for future research are discussed.

Inhome Service Use by Caregivers and Their Elders: Does Cognitive Status Make a Difference?

The intent of this study was to examine the effect of cognitive status on the use of inhome services by caregivers and their elders. Data from the screening, clinical and community-caregiver phases of the Manitoba Study on Health and Aging (MSHA-1) were analysed utilizing a modified Andersen-Newman model. The findings indicated that those with dementia were more likely to use personal care services and use two or more inhome services than caregivers and their elders with no cognitive impairment and those with cognitive impairment but no dementia. Functional status of the elder and living arrangement of the caregiver and elder were strongly associated with the use of specific inhome services and with overall use. Policy and research implications of the findings including other significant factors such as caregiver employment, are presented.

Prevalence of mental illness and its impact on the use of home care and nursing homes: a population-based study of older adults in Manitoba

OBJECTIVES

To determine the prevalence of mental illness in older adults and its effect on home care and personal care home (PCH) use.

METHODS

Using nonidentifying administrative records (fiscal years 1997-1998 to 2001-2002) from the Population Health Research Data Repository housed at the Manitoba Centre for Health Policy, we determined the 5-year period prevalence for individuals aged 55 years and over (119 539 men and 145 752 women) for 3 mental illness categories: cumulative mental disorders (those having a diagnosis of depression, anxiety disorder, personality disorder, schizophrenia, and [or] substance abuse), any mental illness, and dementia. We calculated age-specific and age-adjusted rates of home care and PCH use and the prevalence of mental illness in PCH residents.

RESULTS

From the group aged 55 to 59 years to the group aged 90 years or older, the prevalence of mental illness increased with the population's age. The prevalence of any mental illness rose from 32.4% to 45.0% in men and from 42.6% to 51.9% in women, and dementia prevalence rose from 2.0% to 33.6% in men and from 1.3% to 40.3% in women. The age-adjusted annual rates of open home care cases per 1000 population aged 55 and older varied by mental illness grouping (no mental disorder, 57 for men and 91 for women; cumulative mental disorders, 162 for men and 191 for women; dementia, 300 for men and 338 for women). The age-adjusted rates of PCH use per 1000 population aged 75 years and older also varied by mental illness grouping (no mental disorder, 53 for men and 78 for women; cumulative mental disorders, 305 for men and 373 for women; dementia, 542 for men and 669 for women). Among patients admitted to (or resident in) a PCH in 2002-2003, 74.6% (87.1%) had a mental illness, and 46.0% (69.0%) had dementia.

CONCLUSIONS

Mental illness affects the use of home care and nursing homes profoundly. Individuals with dementia used home care at 3 times the rate of those having no mental illness diagnosis, and they used PCHs at 8 times the rate.

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.

Neuropsychological detection of cognitive impairment: inter-rater agreement and factors affecting clinical decision-making

The agreement between neuropsychologists identifying cognitive impairment (CI) in older adults was examined, as were factors influencing the classification process. Twenty four neuropsychologists in 18 study centers classified cases with or without CI after reviewing neuropsychological findings and other relevant information. All cases were participants in the third wave of the Canadian Study of Health and Aging, a study of CI in later life. For 117 randomly selected cases, a second neuropsychologist reviewed the same material and reclassified the cases. Cases given the same (concordant) or different (discordant) classifications were compared with respect to patient and rater characteristics. The inter-rater agreement was moderate (77.7% agreement, kappa = .49). On all measures of cognitive functioning, the concordant group without impairment obtained a higher mean score than the discordant group, and the discordant group obtained a higher mean score than the concordant group with impairment. For 5 out of 8 cognitive measures, the concordant group with impairment differed from the concordant group without impairment and the discordant group, but the latter two groups did not differ significantly. The findings are comparable to others in the field and highlight the need for neuropsychologists to further clarify procedures for identifying subtle, or mild, forms of cognitive impairment.

Activities of daily living (ADL) and instrumental activities of daily living (IADL) items were stable over time in a longitudinal study on aging

OBJECTIVE

The purpose of this analysis was to examine the stability over time of the activities of daily living (ADL) and instrumental activities of daily living (IADL) items in the Aging in Manitoba (AIM) Longitudinal Study and to evaluate the existence of differential item functioning across settings (home, nursing home).

STUDY DESIGN AND SETTING

The study used data from 607 participants of the AIM Longitudinal Study who were more than 85 years of age in 1996 and who had complete data from 1983, 1990, and 1996 for all ADL and IADL items. Rasch analysis was used to examine how the rating scale of the ADL and IADL items was used by participants, and to determine if the ordering of items remained stable across three time periods (1983, 1990, 1996) and the two different settings (home, nursing home).

RESULTS

The rating scale worked best when dichotomized into "received no assistance" and "receives assistance." Except for four items (making tea, making meals, doing nursing care, and going outside in any weather), the items were stable across administration periods, and across settings.

CONCLUSION

The AIM can be used to evaluate changes in disability over time and may have the potential to identify those at risk for transitions in care.

Mild cognitive impairment and everyday functioning in older adults

The relations between mild cognitive impairment without dementia (MCI/CIND) and everyday functional abilities were examined using data from the Canadian Study of Health and Aging (CSHA). Individuals were identified with MCI/CIND if both caregiver report and clinician judgment agreed on the presence of cognitive impairment in the absence of dementia. Cross-sectional and longitudinal comparisons indicated that individuals with MCI/CIND demonstrated a broad range of impairment in instrumental activites of daily living (IADL) compared to individuals with no cognitive impairment (NCI). In cross-sectional analyses, neuropsychological measures of memory and psychomotor speed were significantly related to impairment in eight areas of functioning. In addition, poorer memory performance was significantly predictive of future impairment in money management.

Dementia and depressive symptoms as predictors of home help utilization among the oldest old: population-based study in an urban area of Sweden

OBJECTIVE

The objective of this article is to investigate predictors of public home help utilization, particularly mental health problems such as dementia and depressive symptoms.

METHODS

A population-based sample of community-dwelling people aged 81-100 was interviewed and assessed with medical examinations (N = 502).

RESULTS

Dementia increased the odds of receiving public home help among people residing alone. Among coresiding people, it increased the odds of receiving home help, but only among those who had extra residential care. Depressive symptoms decreased the odds of receiving home help among people with lower levels of education who lived alone. Depressive symptoms among highly educated people who lived alone and among coresiding people of any educational level were not related to receipt of home help.

DISCUSSION

Improvement of screening activities for public home help needs of community-dwelling elders might allow better targeting of limited social resources to the most needy.

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.

Explaining the use and non-use of community-based long-term care services by caregivers of persons with dementia

The purpose of this paper is to synthesize and critically evaluate the current literature that explains the use and non-use of formal community-based long-term care services by caregivers of persons with dementia. There are four issues related to formal community service use by caregivers: reluctance to initiate formal services; under-utilization of available services; delayed utilization of services; and inappropriate utilization of services. Despite substantial research efforts to understand these issues, the reasons for low rates of community service use by this population remains unclear. Common methodological problems and limitations in the underlying theoretical assumptions in the literature, as they relate to caregivers of persons with dementia, have limited the usefulness of the current research for informing practice and policy. A conflict-theory model of decision-making is proposed as an alternative theoretical framework for understanding the particularity and complexity of the decision-making process leading up to the initiation of formal service use. Utilization of formal services is a result of a complex and subjective decision-making process that is unrelated to objective circumstances. The proposed conflict theory model of decision-making can inform policy and practice regarding the development of appropriate, timely and individualized interventions to facilitate the use of formal services by caregivers of persons with dementia.

Cognitive impairment, no dementia: concepts and issues

This article reviews the concept of mild cognitive impairment in groups of people whose cognitive impairment does not warrant a diagnosis of dementia (cognitive impairment, no dementia; CIND). Problems with the application of existing sets of criteria to the Canadian Study of Health and Aging (CSHA) data sets are addressed and a procedure for identifying a subgroup presumed "at risk" for developing dementia is presented. Application of an informant's report of changes in cognitive functioning and neuropsychologists' ratings of mild to severe deficits in any of eight cognitive domains results in approximately half of the CIND cases being identified as "at risk." The rationale for the collection of specific information related to CIND in CSHA-2 is provided. A minority of people identified with CIND at CSHA-2 showed only memory impairment, and most demonstrated cognitive loss over the preceding five-year interval. This article provides a conceptual basis for procedures to identify people with cognitive impairment most likely to decline to dementia.

Applying activity-based costing in long-term care

As greater numbers of the elderly use health services, and as health care costs climb, effective financial tracking is essential. Cost management in health care can benefit if costs are linked to the care activities where they are incurred. Activity-based costing (ABC) provides a useful approach. The framework aligns costs (inputs), through activities (process), to outputs and outcomes. It allocates costs based on client care needs rather than management structure. The ABC framework was tested in a residential care facility and in supportive housing apartments. The results demonstrate the feasibility and advantages of ABC for long term care agencies, including community-based care.