Cognitive impairment: a challenge for community care. A comparison of the domiciliary service receipt of cognitively impaired and equally dependent physically impaired elderly women

Age and Ageing,  July, 1997  by Margaret Ely,  Carol Brayne,  Felicia A. Huppert,  Daniel W. O'Connor,  Penny A. Pollitt

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Abstract

Objectives: to compare the domiciliary service receipt of cognitively impaired and equally dependent physically impaired elderly women prior to the passing of the UK Community Care Act. Methods: secondary analysis of a population survey conducted in 1986 in the city of Cambridge. The analysis used data on 1585 women aged 75 and over living in the community. The effect of type of impairment on the receipt of domiciliary services (meals-on-wheels, home help and community nursing) is measured using a multivariate model which allows for adjustment for dependency level and other potential confounding factors. Results: the odds of an elderly woman getting help from any of the domiciliary services whilst not being significantly affected by cognitive impairment (odds ratio 0.7, 95% CI 0.5-1.2) are increased by physical impairment (odds ratio 1.8, 95% CI 1.2-2.5). Similar results were found for the home help service. The differences were exaggerated in the case of the community nursing service, whilst receipt of meals-on-wheels was similar for women of with all types of impairment. Conclusions: in the late 1980s, cognitively impaired elderly women received less help from the domiciliary services than equally dependent physically frail women who lived in similar household circumstances. The development of specialist services appropriate to the needs of cognitively impaired elderly people presents a challenge to community care policy, especially since this group are at high risk of institutionalization.

Introduction

The central aim of the policy embodied in the UK National Health Service (NHS) and Community Care Act of 1990 is to develop community services to enable elderly people to five independently in the community for as long as possible[1]. The policy has particular implications for the care of the cognitively frail elderly since a high proportion of 'such people were in institutional care in the late 1980s, prior to the implementation of this policy. Recent analysis of the Office of Population Censuses and Surveys disability survey shows that one-third of those with severe cognitive disability, compatible. with moderate or severe dementia, aged 65 and over were in institutions in 1986. Whilst only 5.5% of the total population of the UK had this level of cognitive disability, almost half of all elderly people in institutional care were in this category[2]. If the policy of enabling elderly people to live in the community is to be effective, developments in community services must address the needs of cognitively frail people in particular.

There has been much speculation about the impact of the policy changes implemented in 1993 which are currently being investigated by the Evaluating Community Care for Elderly People project at the Personal Social Services Research Unit. The national provision of the community services home helps, meals-on-wheels, district nursing and day centre places is reported as having decreased in relation to the numbers of elderly people (aged 75+) in the population between 1985 and 1993[1, 3], although the first objective of the Community Care Act is to "encourage the targeting of home-based services on those people whose need for them is greatest"[4]. To examine the effect of such targeting on the cognitively frail in particular we await the results of recent population-based epidemiological studies, in particular the Medical Research Council Longitudinal Study of Cognitive Function and Ageing. The impact of the policy changes can then be assessed by comparison with studies conducted prior to this period of change.

In the search for such a baseline measure of service receipt by cognitively frail elderly people, we examined the evidence provided by epidemiological studies conducted during the latter half of the 1980s[5-7]. Published studies, for example the Hughes Half Project for Later Life, conducted in Cambridge in 1986, reported that demented elderly people received more service help than those who were cognitively normal [8], but a large proportion of the latter group were independent and therefore had no need for service help, whilst many of the demented group would also be physically impaired. The present study of the service receipt aims to overcome these problems by including physical as well as cognitive impairment factors, and a common measure of need for help -- the dependency on others for help with basic activities of daily living (ADLs). In order to make adjustment for dependency level and other potential confounding factors affecting service receipt, multivariate logistic regression was used.

Methods

Design

The study made use of the secondary analysis of a population survey conducted for the Hughes Hall Project for Later Life during 1986-87. A screening interview was given to 2609 residents of the city of Cambridge aged 75 and over, about one-third of the total population of the city[5]. The sample used for this analysis consisted of the 1585 women aged 75 and over living in the community. Men were excluded from this study because of the difficulty of ascertaining a level of disability for the majority whose domestic needs had always been attended to by women -- their dependency was not a satisfactory measure of their disability.