Coping with activities of daily living in different care settings

Transcription

1 Age and Ageing 2001; 30: 489±494 # 2001, British Geriatrics Society Coping with activities of daily living in different care settings PIA LAUKKANEN, PERTTI KARPPI 1,EINO HEIKKINEN 2,MARKKU KAUPPINEN 2 Health Centre of the City of JyvaÈskylaÈ, PO Box 52, FIN JyvaÈskylaÈ, Finland 1 Geriatric Unit, Central Finland Health Care District, JyvaÈskylaÈ, Finland 2 The Finnish Centre for Interdisciplinary Gerontology, JyvaÈskylaÈ, Finland Address correspondence to: P. Laukkanen. Fax: q358) pia.laukkanen@jkl.fi Abstract Objective: to measure the functional capacity of elderly people cared for in different health and welfare care settings, with functional capacity de ned in terms of activities of daily living. Subjects and methods: we assessed all people aged 065 in health-centre hospitals or nursing homes or receiving home nursing and home help services in Central Finland n=5652) using the Evergreen activities of daily living index, which comprises nine physical and nine instrumental activities of daily living. Results: assessments of functional capacity were obtained for nearly all subjects: only 33 forms 0.6%) were returned with incomplete data. The mean activities of daily living sum score range 0±54) was lowest for women receiving home nursing 17.3), and highest for women in long-term care at health-centre hospitals 48.4). Low scores described good and high scores poor functional capacity. Age showed no association with the mean activities of daily living sum score in any of the care settings. Conclusion: the Evergreen activities of daily living index was easy to use and successfully distinguishes between people in different care settings. Policies of assigning older people to different settings appear to be sound and sensible as the main de ning criterion is level of functional capacity rather than age. Keywords: activities of daily living, elderly people, home care, home help, home nursing, hospital care, long-term care, nursing home, short-term care Introduction In Finland, men spend on average 6 months of their lifetime in institutional care; women an average of 18 months [1]. Only 10% of the population aged 75 have no chronic illness [2], yet half of those in this age group describe their health as good or very good [3]. Health status cannot be adequately measured on the basis of diagnoses alone: we also need reliable methods for assessing functional capacity [4, 5]. Studies of functional capacity are no substitute for clinical examination [6]. In the late nineteenth and early twentieth centuries, functional capacity was measured by number of days lost through illness, or the number of people per 1000 population who were ill or un t for work [7, 8]. The concept of incapacity and its duration was introduced later; this provided such new measures as the number of days lost through illness during the previous year and the duration of illness [9]. More systematic measurements of functional capacity were used after the Second World War in the United States, where various indices were developed to assess the ability of war veterans to cope independently in the community. These were the rst standardized tests [10, 11]. The earliest instruments were designed to measure how chronically ill or institutionalized patients could cope with physical activities of daily living ADLs) [12]. Later, researchers also began to take an interest in how people coped outside institutions and to measure instrumental ADLs [13], which comprised aspects of psychological and social capacity. The many published ADL indices have been extensively reviewed and compared [14±17]. They differ in classi cation, methods of measurement and the number and scope of questions. Coping with ADL can be assessed with a self-administered questionnaire, by interviewing the elderly person or a proxy family member or healthcare professional) or by observation. The patients in the study of Rubenstein and colleagues [18] rated their functional capacity better than their nurses did. Family members gave poorer ratings than the patients themselves. 489

2 P. Laukkanen et al. Coping with a speci c activity may be assessed on the basis of need for assistance from another person or a technical aid, slowness, fatigue or experienced dif culties. As a rule, the need to rely on help from another person or to use a technical aid may be considered an indication of severe functional decline. On the other hand, it also indicates there is a determination to compensate for the loss of functional capacity [19]. The purpose of this study was, rst, to nd out whether healthcare for older people relates to their current level of functional capacity; secondly, to nd out how well a combined physical and instrumental ADL measure can distinguish between people in community and institutional care; and, thirdly, to establish whether age is a factor in the choice of type of care. Subjects and methods We carried out the study in the Central Finland healthcare district, which has a population of around , about of whom were aged 065. The sample comprised people who, on the survey date, were in health-centre hospitals or nursing homes, or who received home nursing or home help services Table 1). We obtained the data from 12 health-centre hospitals; only one hospital with 40 beds) failed to provide the data requested. We collected data on all patients in the district's 28 nursing homes. All 30 municipalities in the district provided complete data for home nursing and home help. In the whole data set, there were only 33 forms with incomplete data 0.6%). The total number of subjects was % of the population aged 65 or over). Patients in long- and short-term care in hospitals and nursing homes are mentioned separately because the two groups differ in the reasons for treatment. The mean age ranged from 79.5 years short-term hospital care and home nursing) to 82.9 years long-term nursing-home care). About 11% of the patients were older than 90. Seven were older than 100, the oldest being a woman of 104 who lived in a nursing home. The Evergreen ADL index was used on 22 April 1999 to measure the functional capacity of subjects in all of the care settings. Patients receiving both home nursing and home help were analysed as one group. The term `home care' is used in this study to refer to home help, home nursing and a combination of both services. Detailed instructions were given to home helps only helping in the home) and nurses in other settings) to assess the subject's ability to cope with activities according to their observations. Permission to conduct the study was obtained from the ethics committee of the Central Finland Health Care District. Results We assessed 5652 people: 17.7% were in hospital, 18.4% were in nursing homes, 28.9% were receiving both home nursing and home help, 20.9% were receiving home nursing and 14.0% were receiving home help only. The ADL sum score ranged from 0 to 54. Low scores described good and high scores poor functional capacity Table 2). Women receiving home nursing had the lowest mean ADL score 17.3), women in hospital long-term care the highest 48.4). A statistically signi cant sex difference was observed in long-term nursing-home care, where ADL sum scores were 42.6 for men and 44.1 for women student's t-test, P=0.014), and in home nursing, where the score was higher for men 21.0) than women 17.3; P-0.001). Differences between the sum scores for different care settings were evident Figure 1). Those in shortterm care had better functional capacity than those in long-term careðindeed, for the most part they were as independent as community-dwelling people. The results indicate that older people had been assigned to different care settings not on the basis of their age, but on their level of functional capacity. The mean Evergreen ADL sum score for long-term patients of health-centre hospitals and nursing homes was Table 1. Characteristics of clients in different care settings in Central Finland Mean age, % of clients, by age group, years Setting n % % female years and SD) 65±69 70±74 75±79 80±84 85±89 90±95 95q Long-term care ) Hospital ) Nursing home ) Short-term care ) Hospital ) Nursing home ) Home nursing/home help ) Home nursing ) Home help ) Total )

3 Coping with activities of daily living in different care settings Table 2. Mean Evergreen activities of daily living ADL) sum scores in different care settings and statistical signi cance of gender differences tested with Student's t-test) Mean ADL sum score and SD) Setting Men Women P value Long-term care ) ) Hospital ) ) Nursing home ) ) Short-term care ) ) Hospital ) ) Nursing home ) ) Home nursing/home help ) ) Home nursing ) ) Home help ) ) Total ) ) LSD test) except between long-term hospital care and long-term nursing-home care in the 65±69 age group and those over 90. The percentage distribution of ADL sum scores of patients in different care settings Table 3) shows that most individuals were allocated according to their ADL scores. However, some people in long-term care had very low scores and some people who were receiving home care had coping with ADLs. The physical ADL activity that caused least was eating: among home-care patients 85.9% had no problems Table 4). Nearly half of patients receiving long-term care were unable to move indoorsðeven with personal assistance. Among those receiving home care, 28.5% needed personal assistance to move outdoors. The instrumental ADL activity that caused least was using the telephone, with which 69.8% of those receiving home care had no problems Table 5). Large numbers of home-care clients needed assistance to use public transport and to do their shopping: 38.3% were unable to use public transport and 30.7% were unable to do their shopping even with assistance). Less than one-third of home-care subjects could take their medication without. Figure 1. Mean Evergreen activities of daily living sum scores for elderly people aged 065 in various care settings. ***P difference between care settings: one-way analysis of variance followed by LSD test). Figure 2. Mean Evergreen activities of daily living sum scores by age for those receiving long-term care in health-centre hospitals j) and nursing homes m) and those receiving home care m). virtually the same for all age groups Figure 2). By contrast, in home care, the mean sum scores increased with increasing age. The differences were also statistically signi cant one-way analysis of variance followed by Discussion The results of this cross-sectional study of functional capacity ability to cope with activities of daily living) in 5652 people provide a reliable description of people aged 065 years receiving care in different settings. Almost all those in institutional or home care had dif culties with daily activities. However, 1 in 10 of those who were in short-term hospital care were able to cope with all activities without help. Presumably, these patients had been admitted to hospital for simple tests or short-term treatments that had no impact on functional capacity. The subjects had been assigned to their care settings based on their functional capacity rather than age, suggesting a sensible policy of service allocation. Population studies, on the other hand, indicate that dif culties in ADLs tend to increase with advancing age [20, 21]. Not only does the number of ADL activities causing dif culties increase with age, but so does the degree of they cause [22]. Research evidence suggests that about 1 in 6 men and women aged 065 need assistance with physical or instrumental ADLs, while 1 in 3±4 of those aged 075 and 1 in 2 of those aged 085 need help [20, 22, 23]. Disability gures are markedly higher when we look at the numbers with dif culties in performing activities [24]. Raw sum scores of ADL indices are used to describe the level of functional capacity. However, this method may conceal relevant information. For instance, if an individual moves from the category `some ' to `needs assistance', it will have no major impact on 491

4 P. Laukkanen et al. Table 3. Percentage distribution of activities of daily living ADL) sum scores of patients in different care settings Activities of daily living sum score, % Setting n 1±10 11±20 21±30 31±40 41± Long-term care Hospital Nursing home Short-term care Hospital Nursing home Home nursing/home help Home nursing Home help Total Table 4. Independence levels in physical activities of daily living in long-term hospital and nursing home), short-term hospital and nursing home) and home home nursing and/or home help) care % of people, by level of independence Activity/care setting Without Some Needs assistance Unable even with help Eating Long-term Short-term Home Getting up from bed Long-term Short-term Home Toileting Long-term Short-term Home Dressing Long-term Short-term Home Moving indoors Long-term Short-term Home Bathing Long-term Short-term Home Climbing stairs Long-term Short-term Home Moving outdoors Long-term Short-term Home Cutting toenails Long-term Short-term Home Table 5. Independence levels in instrumental activities of daily living in long-term hospital and nursing home), short-term hospital and nursing home) and home home nursing and/or home help) care % of people, by level of independence Activity/care setting Without Some Needs assistance Unable even with help Using telephone Long-term Short-term Home Handling nances Long-term Short-term Home Food preparation Long-term Short-term Home Doing light housework Long-term Short-term Home Taking of own medication Long-term Short-term Home Laundry Long-term Short-term Home Shopping Long-term Short-term Home Using public transport Long-term Short-term Home Doing heavy housework Long-term Short-term Home

5 Coping with activities of daily living in different care settings the sum scoreðbut it may be an absolutely decisive change with respect to that individual's coping at home. Although the use of sum scores may lead to misjudgements in the case of individual patients, they do provide useful epidemiological evidence on the level of functional capacity at group level [25]. The data obtained in this study may be used for assessing the need for assistance among patients in different care settings. At the individual level, interpretations must also take account of the results obtained for individual itemsðjust as clinical examination takes into account all the data collected [26]. The use of dichotomous categories is probably the main weakness of ADL indices: the crude classi cation of individuals into those who need or do not need assistance obscures much limited functional capacity and reduced quality of life. If the dichotomous categories are formed on the basis of whether people can cope with or without, a group will contain people who cannot perform an activity without assistance from two others and people who have some minor in performing that activity. Not all activities are equally important or equally valuable, and attempts have therefore been made to develop weighted scales e.g. the Barthel index) [27]. The problem here especially with instrumental ADLs) is that different individuals vary in their assessments of what is most important. It is dif cult to say whether a major need for assistance in one activity is more essential than a minor need for help in many activities. Instrumental ADL problems have been reported most often in heavy housework, such as cleaning [24, 28, 29]. The same result was found in the present study. We found that women in long-term nursing-home care have less functional capacity than men, whereas men receiving home nursing have poorer functional capacity than women. One explanation is that men can rely on the help of a wife, which means they can continue to live at home even when they are in a poor condition. Earlier studies have also found sex differences. Men cope with most instrumental ADLs better than women, but women have fewer dif culties with preparing meals [24, 30]. In physical ADL scales, both men and women report most dif culties in mobility [24, 30]. Eating and toileting usually cause fewest problems [22, 30]. A major for studies of institutional care is that there are many different kinds of intermediate care: it is dif cult to say what constitutes institutional care and what should be de ned as `care in the community'. The decision to move into institutional care is in uenced not only by individual factors, but also by the living environment, the availability of institutional beds and admission criteria. The ready availability of nursinghome beds in itself tends to increase the numbers going into long-term care [31]. Earlier research suggests that the main distinguishing features between elderly people living in institutions and those living at home are reduced memory and dif culties with ADLs [32]. Dif culties with ADLs, advanced age, female sex, frailty, use of technical aids, confusion, poor self-rated health, living alone and lack of social networks may predict institutionalization [20, 33, 34]. The most crucial factor with regard to autonomy is to retain one's functional capacity and to cope with everyday routines for as long as possible, in spite of illness. Even comparatively minor functional disabilities tend to predict more severe problems. The dif culties usually start with instrumental ADLs and only later expand to physical ADLs [35]. For this reason, measurements of functional capacity and coping with daily activities, especially among people who live at home, should include not only physical but also instrumental ADLs. The Evergreen ADL index was useful in distinguishing institutionalized elderly people from those in community care in terms of their functional capacity. The subjects had been appropriately assigned to their respective care settings. Those with the lowest functional capacity were in long-term institutional care. Age was not a factor in determining the type of care setting. Key points. The Evergreen activities of daily living index, which clearly distinguishes older people in different care settings, combines physical activities of daily living and instrumental activities of daily living measures.. 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