Prospective Outcomes of Informal and Formal Home Care: Mortality and Institutionalization. 4.3 Conclusions


Overall, differences in caregiving arrangements do not seem to affect the likelihood of death or institutionalization over a two-year period for disabled elderly who receive help from others in carrying out their daily activities. Being disabled itself distinguishes those with a significantly higher risk of entering a nursing home, and receipt of help among those who are disabled further distinguishes those with a greater risk of dying over a subsequent two-year period.

Perhaps if we had been able to separate short-term or transitory nursing home admissions from long-term or permanent nursing home stays, differences in caregiving arrangements might have shown more impact. Because the dates surrounding nursing home stays were missing from the data base, we were unable to ascertain the length of these stays. Being able to distinguish more finely among close family (i.e., spouse vs. adult child) or possibly among gradations of more distant relatives might have made a difference as well. However, small cell sizes did not permit such fine distinctions.

Still another factor may have seriously limited our ability to discern effects of even the broader care arrangements we tested with the data at hand. Health among persons 70 and over all too frequently can decline precipitously and without much warning. This sudden failure of major physiological systems and the abrupt onslaught of care needs which accompany it may overwhelm the capacity of any caregiving arrangements outside of an inpatient setting to adjust to these needs. Litwak, as well as others (Doty, 1986; Harkins, 1985) have made just such a point. Perhaps, treating caregiving arrangements as condition-specific would help in this regard. Conditions, for example, which call for the application of substantial skilled or medical care may well be more difficult to cope with or arrange for than conditions calling only for significantly increased personal care.

Comparisons of condition-focused care arrangements notwithstanding, it is becoming increasingly clear that a steady decline in functioning as people age is not the norm. This is the pattern that most of us have assumed, however. we have been lured into committing the "ecological fallacy" by looking too many times at tables and graphs of the functional status of the elderly in the aggregate. From such aggregate data, as we noted in our introductory section, we observe a monotonic pattern of functional diminution when we look at 70 year old versus 80 year old versus 90 year old populations. Aggregate patterns so often observed do not represent a simple agglomeration of individuals' health experiences, however. They reflect a "smoothing" of the data, a statistical phenomenon. At the individual level, declines in health status are often abrupt and they are not infrequently reversible (Whitehall, 1990). Our faulty assumption has gotten in the way of designing data collection which captures these abrupt discontinuities. A discontinuity or catastrophic perspective would lead us, at the least, to try harder to measure health status over more frequent intervals, certainly shorter than 24 months.

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