Home and Community Care Digest

Home and Community Care Digest 5(3) September 2006 : 0-0

Unmet care needs indicative of nursing home placement and death

Abstract

Elderly individuals with dementia who have difficulties performing activities of daily living are at increased risk of experiencing negative health outcomes such as pressure ulcers, dehydration, or falls. No research study has examined how unmet care needs in elderly people with dementia affect the risk of death and nursing home placement. This study found that elderly individuals in the community with dementia and unmet care needs for several important activities of daily living are more likely to require nursing home placement and have a higher risk of mortality. The results of the study suggest that unmet care needs may be useful in identifying individuals at risk for institutional placement and death.
Background: Elderly individuals need to carry out many different activities of daily living (ADLs) and instrumental activities of daily living (IADLs), by themselves or with assistance, in order to live successfully in the community. ADLs are activities such as eating, dressing, and walking around while IADLs comprise actions such as banking, grocery shopping, and using a telephone. Dementia can make these tasks challenging due to decreased cognitive ability. Past research has shown that people with dementia who cannot complete these tasks are more likely to fall, develop a pressure ulcer, go hungry, become dehydrated, and injure themselves. So far, no study has examined the relationship between elderly people with dementia living in the community who cannot complete important daily tasks and their risk of nursing home admission or death.

Methods: Dementia patients and their caregivers (n=5,831) were recruited from 8 different US states. Were these formal and family/friend caregivers? Caregivers were defined as the person who provided the most assistance to the patient. The study participants were interviewed every 6 months over an 18 month period. Caregivers reported care demands for ADLs and IADLs and whether the patient had unmet needs with any of these tasks. A screening tool for behavioural problems and cognitive impairment was used to assess the patients. Caregiver stress and depression levels were measured. The researchers also noted which community-based care services the caregivers and patients had used during the previous 6 months. Research personnel tracked patient outcomes during the course of the study (i.e. death or nursing home placement). The study authors analyzed the impact of unmet care needs on the risk of nursing home placement and death, after taking into account the patients' overall health status.

Findings: There were 5,381 patients and caregivers. Nearly 60% of the patients and over 70% of the caregivers were female. On average, the patients were 88 years of age and their caregivers were 49 years. Approximately, 90% of the patients were Caucasian and one-third of the caregivers were employed. Caregivers indicated diverse levels of burden and reported positive well-being with regards to depression. A variety of community-based services were used by the study participants in the previous six months. Over a 6-month period, individuals used chore services, on average, were used 21 times, adult day services were used 7 times, and personal care service 45 times. Caregivers had, on average, 14 hours of secondary help in a typical week. The attrition rate was high (due to death, nursing home placement or lost to follow-up): 2,996 patients and caregivers remained at the end of the study. A key finding of this study is that unmet ADLs are important predictors of nursing home placement and death. While patients with 1 unmet ADL need were no more likely to die or enter a nursing home than patients with no unmet care needs, patients with 2 or more unmet ADL needs were 77% more likely to enter a nursing home and 37% more likely to die compared to patients with no unmet ADL needs. The statistical analyses demonstrated that unmet need was associated with increased risk of nursing home placement and death.

Conclusions: As the number of unmet care needs for ADLs increased, so did the risk of nursing home placement and death in a sample of elderly patients with dementia. This study suggests that assessing unmet ADL needs might be a good predictor of future institutional placement or death. The results also suggest that it might be possible to delay institutionalization and death by identifying patients with unmet care needs and increasing caregiver and community resources in order to ensure that the patient is able to successfully complete the important tasks of daily living.

Reference: Gaugler, J.E., Kane, R.L., Kane, R.A., Newcomer, R.. "Unmet Care Needs and Key Outcomes in Dementia". Journal of the American Geriatric Society. 2005; 53: 2098-2105.

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