Age and Ageing Advance Access published online on February 12, 2007
Age and Ageing, doi:10.1093/ageing/afl185
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Profiling disability within nursing homes: a census-based approach
Department of Medical Gerontology, Trinity Centre for Health Sciences, Adelaide and Meath Hospital, Dublin 24, Ireland
Tel (+353) 1 414 3215; Fax (+353) 1 414 3244. Email: arhc{at}amnch.ie
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Abstract |
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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.
Keywords: nursing homes, disabled persons, prevalence, aged, elderly
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Introduction |
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Ageing at all stages of development is accompanied by both growth and loss. The losses of old age, in particular those brought about by age-related disease, give rise to increasing levels of disability in later life. Beyond a certain level of disability, the ability for an individual to live independently in his or her own home becomes compromised. This trend appears to have been attenuated in recent decades, with a reduction in the amount of disability within the older population in some countries in the developed world [1]. Manton et al. showed an acceleration of decline in chronic disability prevalence from 1994 to 1999 in the United States compared with the period from 1989 to 1994. In addition they found a large relative and absolute drop in institutional use between 1982 and 1999, despite more than 30% increase in the over 65 population in the United States [2].
Despite these encouraging developments, age-related disability continues to be one of the commonest factors precipitating admission into nursing homes. Those needing long-term care tend to be a very frail and vulnerable group: in one Irish study almost a quarter of those requiring long-term care died in hospital while awaiting placement [3]. Studies in the United Kingdom have shown that about 75% of residents in nursing homes are moderately to severely disabled [4, 5]. At present limited data exists comparing physical and mental disabilities of nursing home residents compared to older people living in the community, and there is little by way of longitudinal data to monitor the trend in disability so that planning for appropriate services can take place. The Irish census directly assessed disability for the first time in 2002. We used data obtained from the 2002 Census [6] to quantify disability in nursing homes and relate it to the levels of disability among community-dwelling older people.
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Methods |
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Information was obtained using data from the 2002 Irish National Census [6]. The census took place on the night of Sunday 28 April 2002. On this night everybody who was in the state was included in a census form, including people who were staying temporarily in a household, persons in communal establishments and persons on board vessels. The rubric ‘nursing home’ was broad in intent, and included public, voluntary and private nursing homes, as well as welfare homes (which accounted for 1,056 beds in the Republic of Ireland in 1999) and residential homes.
The Census form included two questions on disability of which there were six parts. This was the same format used in the 2000 US census, which underwent extensive consultation and testing with people with disability [7]. A designated person in each household or institution was given the responsibility for filling out the census forms. Data on disability was derived from answers to question 14 and 15 of the census questionnaire.
Question 14 was a two-part question, which asked of persons of all ages of the existence of the following long lasting conditions.
- Blindness, deafness or a severe visual or hearing deficit.
- A condition that substantially limits one or more basic physical activities such as walking, climbing stairs, reaching, lifting or carrying.
Question 15 was a four-part question that asked whether an individual had a physical, mental or emotional condition, lasting 6 months or more that made it difficult to perform certain activities. The four activity categories were:
- learning, remembering and concentrating;
- dressing, bathing or getting around inside the house;
- going outside the home alone to shop or visit the doctor;
- working at a job or business.
Individuals were classified as having a disability if they ticked ‘yes’ in response to any of the categories in question 14 and 15.
From this data, disability prevalence within the general population aged 65 and over was calculated, and the prevalence of disability among nursing home residents aged 65 and over was quantified. Comparisons were then made by way of number and type of disabilities between nursing home residents and those living in the community.
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Results |
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There were 436,001 people aged 65 and over living in the Republic of Ireland on the night of the Census: 189,155 (43%) men and 246,846 women (57%). Of these, 14,764 (3.4% of the general population) were resident in nursing homes: 3,887 (26.3%) men and 10,877 (73.6%) women.
Table 1 shows the age breakdown of those living in nursing homes and in the community, almost 80% of those living in the community over the age of 65 are between 65 and 80 years old while 70% of those living in nursing homes were aged over 80.
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While the prevalence of any disability among community-dwelling older people was 29%, this prevalence was 85% (Chi-square = 2064.3, P<0.001) in those living in nursing homes. Residents of nursing homes with a recorded disability had on average 4.5 disabilities (SD = 4.3) ranging from hearing and visual problems to difficulties remembering and concentrating (Table 2).
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Almost three-quarters of nursing home patients are unable to go outside alone compared to 15% of those in the community (Chi-square = 3038.2, P<0.001). Over two-thirds of nursing home residents have a condition that limits one or more basic physical activity, 64% have difficulties dressing, bathing and mobilising, while 58% have difficulties learning, remembering and concentrating, suggestive of a very high prevalence of dementia. This compares to almost 20% (Chi – square = 2062.5, P<0.001), 11% (Chi – square = 2735.0, P<0.001) and 8% (Chi – square = 3815.3, P<0.001) respectively of older people living in the community.
Of those with a recorded disability (Table 3), 79% of those in nursing homes with disability were limited in at least one physical activity, 83% were unable to go outside alone and 75% had difficulties dressing, bathing or getting around inside the house. This compares to 66% (Chi – square = 894.4, P<0.001), 51% (Chi – square = 4513.3, P<0.001) and 36% (Chi – square = 6630.5, P<0.001) respectively for those older people with disabilities living in the community. Of those nursing home residents with a recorded disability, 67% had difficulties learning, remembering and concentrating compared to just over a quarter of those living in the community with a disability (Chi – square = 8, 774.3, P<0.001) again suggesting high rates of cognitive impairment (and to a lesser extent, dementia) within nursing homes.
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Discussion |
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As far as the authors are aware, this is the first paper in biomedical literature that has used a national census to attempt to quantify the prevalence and nature of disabilities within nursing homes in comparison with disability levels of older people living in the community.
These results confirm the presence of very high levels of disability among nursing home residents in the Republic of Ireland, with over 85% of those residents having at least one recorded disability. While our data suggests that people with physical disability make up the majority of nursing homes residents with disabilities (almost three times the level occurring in the community), there is also a high prevalence of memory problems that would be suggestive of a high prevalence of dementia. In our data, nursing home residents are almost 8 times more likely to suffer memory problems than older people in the community, possibly one of the factors that contribute to nursing home admission.
There is a difference in the age profile between those living in the community and those in nursing homes. Those living in nursing homes are older with the majority aged over 80 while those living in the community are mostly under 80. It would be expected that this older population would incur higher disability prevalence: however, our point is to quantify the extent to which nursing homes are repositories of significant and complex disability. It is also not possible from the available data to compare the distribution of disabilities between males and females living in the community and nursing homes.
The institutional prevalence of disability found in this study is similar to that found in surveys in the United Kingdom, which also indicates a high level of dependency as well as high rates of dementia, physical disability and chronic disease [4, 5]. Medical morbidity and associated disability rather than non-specific frailty and social needs were the main factors implicated for admission in over 90% of older people to nursing homes in the United Kingdom. More than 50% of these residents had dementia, stroke or another neurodegenerative disease. In a survey of dependency and clinical diagnoses of residents in 244 care homes across the United Kingdom, Bowman [7] found a very high level of disability: nearly half the residents were immobile, and a further 32% could only walk with assistance. Nearly two thirds were classified as being confused or forgetful, which is likely to indicate the presence of dementia. Over a quarter had three disabilities simultaneously, suffering from confusion, immobility and incontinence.
The data that was retrieved from the Irish Census is probably conservative, as there is evidence that health and functional status tend to be under-documented by care staff in other studies [5], and in many cases the data sheet may have been filled in by staff without specific training in the assessment and care of older people. However, while there is some evidence that the rating of disability using this US Census data is dependent on the nature of the relationship between the person filling in the questionnaire and the older person [8], the levels of disability recorded in the community is similar to that found in a 2004 community survey of disability among older Irish people living in the community [9].
Fewer than 15% of those aged 65 and over in a nursing home had no recorded disability, leading to questions over the reason for admission, although some of these may have been residents in welfare homes. A similar figure to this has been found in studies in the United Kingdom, and may arise in part from a lack of standardized criteria for admission into nursing homes. Evidence exists of a tendency of private nursing homes in the Republic of Ireland to refuse those with significant dependency [10] when other data suggests that new admissions into long-term care facilities with low dependency needs were more likely to be self-funding [11]. Resources need to be targeted towards the most dependent individuals with an emphasis towards home-based care for those with lower dependency. Unfortunately it was beyond the scope of the information obtained here to compare any differences in disabilities between patients in private and public nursing homes.
Our data reaffirms that nursing homes are populated by the most frail group of older people, and highlight the need for appropriate health and care resources for older people in nursing homes. Most of these residents may benefit from activity and therapy services, but there is inadequate provision of these services when compared to their age and disease matched community peers [12]. It has been shown in the United Kingdom that chronic disease management for care home residents is inferior to that of age-matched community peers [13] and there are considerable variations in the utilisation of acute medical services [14]. Challis et al. noted that 35% of recently admitted care-home residents suffered from rheumatological disorders and/or stroke [5], conditions which have potential for active rehabilitation. They found that therapy or activity staff were rare in any nursing home. Eighty per cent of homes had less than 6 min of ‘activity staff’ time per occupied bed per day, 47% of homes surveyed had none. It has also been shown that those with dementia, living within residential care environments, have disability needs as well as mental health and social needs that are not addressed. These unmet needs were associated with psychological problems, such as anxiety and depression [15]. Given the lack of official standards of care in the Irish long-term care system, it is likely that the situation gives rise to similar concerns [16].
This study supports the use of census-based data to track disability trends in residential care. While further in-depth research is required to define more precisely the nature of the disabilities that are present, Calsyn et al. found that all three disability measures used in the census questions exhibited moderate to good test-retest reliability [17]. These results suggest that the census disability questions may be sufficiently valid for planning purposes and that the disability data may be of considerable assistance in planning and development of resources for both nursing home residents and those living in the community, as well as tracking changes not only of the numbers in residential care but also the levels and complexity of their disability. Longitudinal study of this data, given the large numbers and the universal coverage of a census, will contribute to our understanding of whether or not compression of morbidity is occurring. International comparison of such trends would be facilitated if countries other than the Republic of Ireland and the United States adopted similar questionnaires in national censuses.
Conflicts of interest
No conflicts of interests exist.
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Acknowledgements |
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We would like to acknowledge the support and statistical advice of the Irish Central Statistics Office, and in particular the helpful advice from Francis McCann, BSc.
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References |
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