Prospective Outcomes of Informal and Formal Home Care: Mortality and Institutionalization. 4.2 Institutionalization


Reported difficulty with or inability to do an ADL or IADL, even after controlling for a continuous scale of ADL and IADL deficits, positively predicted admission to a nursing home among the LSOA population. Those (or their proxies) reporting such an impairment were one and one-half times as likely to be institutionalized over a two-year period. This finding is consistent with past research.

We found little support in our data for the remainder of our hypotheses. Except for our measure of the impact of close family caregiving as opposed to unpaid caregiving from more distant unpaid sources, the particular care arrangement seems to make little difference. For the close versus distant unpaid care arrangements, the impact appears to be opposite from that hypothesized, although it is not statistically significant. Persons receiving unpaid help all from close family were almost two times (1.8) more likely to have been institutionalized as those receiving all of their unpaid help from more distant relatives. Perhaps disabled persons receiving help all from close family are more impaired than their counterparts and the services they receive are more intensive than those services received from more distant relatives. This would suggest the need to measure the specific kind and intensity of help received.

Another explanation may be that close relatives provide inappropriate or too much care, contributing to the impaired relative's deterioration. In the latter case, deterioration may result in increased dependency and loss of control. We controlled for perceived control over health, but this may be too narrow a measure, or the sense of total control felt may not get articulated by the respondent. In the former case, care simply may not meet the need; for example, care may be of the unskilled variety when skilled care is needed.

Finally, Litwak (1985) has argued that joint caregiving by paid and unpaid sources is optimal in meeting the needs of impaired elders. We did not find any such effect in our test.

However, it is not clear that we measured the tandem care arrangement that Litwak has in mind. According to his formulation, the situation is ideal when the formal and the informal caregivers function in complementary fashion, i.e., when the unpaid caregiver performs the nonuniform tasks and the paid sources provide the routinized or skilled tasks. It may be that our joint caregivers in many instances were competing to carry out the same tasks or to meet the same needs. When the potential for this situation exists, Litwak argues, the formal and primary groups must adapt by developing buffering arrangements. There is no guarantee, of course, that this happened nor any information in our data which would allow us to assess this precisely. As is, however, our findings show no benefit of the joint arrangement in terms of reducing risk of institutionalization.

As with the mortality outcome, a number of interesting independent effects of the confounding variables on risk of institutionalization are worth noting. Age, as has been found in numerous previous studies, including our own, is positively related. Each year above 65 increases the risk by 11%. Interestingly, the effect of education proves to be curvilinear, with those with a high school education the most likely to enter a nursing home. College education seems to have no added salutary impact in terms of likelihood of nursing home admission beyond what a grade school education provides.

As has been uncovered in previous research, persons living alone are at a significantly elevated risk of entering a nursing home relative to those who live with a spouse or other persons. As with mortality, social contacts reduce the risk of nursing home admission substantially. Each additional contact reduces a disabled person's risk of institutionalization by 25 percent.

A person's sense of control over his or her health, independently of ADL status, is negatively related to risk of nursing home admission. Relative to persons reporting a great deal of control, persons perceiving themselves as possessing only some control were 50 percent more likely to enter a nursing home over a two-year period. Those reporting little or no control are approximately twice as likely to be institutionalized. Likewise, those reporting fair or poor health status are two times more likely to enter a nursing home over a two-year period than are those reporting excellent health.

As with mortality, several specific medical conditions predicted admission to a nursing home, although these conditions are different than the ones that predict death. Persons with Alzheimers and persons with a history of falling at least twice or falling as a result of dizziness are roughly two times more likely to be admitted to a nursing home than those not experiencing these conditions.

Instead of number of prior hospital stays, which was a very powerful predictor of death, having experienced any nursing home stay prior to the respondent interview turned out to be a very powerful predictor of nursing home admission over the subsequent two-year period. Persons with such a history were over four times more likely to be institutionalized again.

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