Prospective Outcomes of Informal and Formal Home Care: Mortality and Institutionalization. 4.1 Mortality

12/19/1990

The fact that help is associated with death would make great sense in the absence of adjustors for severity of illness. However, we have controlled for a wide range of health status indicators and still obtain this result; i.e., disabled persons receiving help with daily living activities, irrespective of severity of illness, are nearly two and one-half times as likely to die as those persons who received no help.

At least two explanations for this seemingly anomalous result are possible. one is that despite our efforts, some key dimension of condition severity is left uncontrolled in our multivariate analysis. Considerable discussion has emerged in the recent literature of the appropriate way to measure functional deficits (e.g., Weiner et al., 1990). However, no consensus has yet emerged and there exists no compelling empirical findings to suggest that our additive scale of ADLs is not the best way of capturing functional decrements. Stone and Murtaugh (1990), Kasper (1990), and Coughlin et al. (1989) have argued the need to include measures of cognitive status and behavior. Jackson and Burwell (1990), on the other hand, argue that most persons with cognitive impairments will be counted by measuring ADL and IADL deficits. We measured both ADL and IADL and we included indices of Alzheimer and confusion. The LSOA contains no clear indices of behavior, per se.

We cannot rule out the possibility, as well, that some help may be deleterious, leading to accelerated decline in functioning and even physiological integrity. This may happen because too much help induces dependency, loss of automony and "the will to live."

Receipt of help, as it turns out, is predictive of death only for those living with spouse. Perhaps those living with spouse (or their proxies) reported help only when it came from someone other than the spouse; that is, they assumed the interviewer perceived help from the spouse as a given and was inquiring only about other help. Individuals receiving this "external" help, undoubtedly, would tend to be very ill with medical conditions which acted to impair their functioning.

We controlled for a number of major medical conditions; and, in fact, both cancer and stroke prove to be strong predictors of mortality. However, our controls for terminal illnesses are undoubtedly incomplete so that the variable indexing receipt of help, in fact, may reflect care needs related to other terminal medical conditions. With one exception, none of the other caregiving arrangements appears to have any effect on the risk of dying. Although not quite significant (at the .05 level), persons receiving all unpaid help were only 73 percent as likely to die over the two-year period as those receiving both unpaid and paid help. This runs counter to the direction hypothesized and could reflect unmeasured illness severity or, perhaps, deterioration owing to induced dependency or loss of emotional support from friends.

A number of effects of confounding variables are quite interesting. Not surprisingly, the likelihood of death increases with age and is lower for females. Social contacts reduce the risk of death, a consistent finding in a number of rigorous studies dating back to Berkman and Syme (1979). Health status as reported by respondents proves to be the most powerful predictor of death. Persons appear to have a rather accurate sense of their total physiological well-being. Three other health status indices also are significant predictors of death. Number of ADL deficits, cancer, and stroke all have been found in previous studies to be rather powerful predictors of mortality. Number of hospital inpatients stays, categorized in much research as a measure of health status, also positively predicts death.

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