An international study of social engagement among nursing home residents - Continuing and Rehabilitative Care for Elderly People: A Comparison of Countries and Settings

Age and Ageing, Nov, 1997 by Marianne Schroll, Palmi V. Jonsson, Vincent Mor, Katherine Berg, Sylvia Sherwood

Introduction

The decision to move into a nursing home is precipitated by deterioration in health which causes impairment-related functional limitations that lead to dependency. Admission into a long-term care institution solves several problems for the elderly person, relatives and community service agency staff. But what is the quality of a person's life after taking up residence in a facility since the direct cause of their admission is unlikely to be reversed?

Institutions are often associated with a hospital-like routine which requires that residents comply with the schedules established by professionals and other caretakers. Residents often are obliged to accept the `sick role' in return for their being relieved of their usual social obligations. More recently, however, the role of the nursing facility as a home has been emphasized along with a call for residents to remain involved in social life.

In constructing the Minimum Data Set (MDS) as the core of the Resident Assessment Instrument (RAI) particular attention was paid to developing measures that would evaluate positive aspects of residents' social functioning as well as their physical and mental functional abilities. The MDS items `measuring psychosocial well-being move beyond a simple counting of social interactions and activity participation and instead focus on residents' engagement in the social world around them. Using these items, a new measure of social engagement for a nursing home population that is structurally distinct from measures of depression and anxiety, conflict in relationships or problematic behaviours has been introduced and tested for reliability and validity in a random sample of US nursing homes [1].

In order to determine the applicability of this measure to nursing home residents from different cultures and countries, we extend the work of the original developers by comparing residents in five countries stratified by physical and cognitive functioning.

Methods

This study was conducted as part of the interRAI cross-national comparison of continuing care facility residents assessed by the RAI translated into the languages of participating countries. Five countries were selected on the basis of recent testing of the MDS in populations of nursing homes in defined areas [2]. The countries selected were Denmark (1992), Iceland (1994), Italy (1993), Japan (1993) and the USA (1993). The sample of 396 277 represents all residents in the homes surveyed in the selected countries. Registered nurses with experience in long-term care collected all resident data in each home, based on residents' records, conversations with staff and interactions with and observations of the residents. In all countries but the USA, the data were collected as part of special research and demonstration projects. In the USA the data are required by regulations implemented in 1991.

Social engagement

Assessments of social engagement over the last 7 days are made, based upon behaviour (verbal, body language or actions). The index of social engagement was developed from dichotomous items in the MDS that indicated the presence or absence of the behaviour in question. All items reflecting social engagement were included. The average inter-rater reliabilities of these items (K values) for the six questions were satisfactory for the five countries: Denmark (0.56), Italy (0.68), Iceland (0.70), Japan (0.53) and the USA (0.58).

Activities of daily living (ADL)

The residents' ADL classification is based on six items on activities of daily self-performance from the MDS: transfer, locomotion, dressing, eating, toilet use, bathing and one bladder continence item. For each of the six ADL items residents were rated on a five-point scale regarding dependency. A six-category ADL self-performance index was created [1]. Dichotomizing the ADL index, those with ADL scores of 4 or greater (highly dependent or dependent) were classified as low in ADL functioning (totally dependent on two or more ADL items or totally dependent in one ADL items and also incontinent); those with scores lower than 4 were classified as having high ADL functioning.

Cognition

Residents' cognition was classified on five items from the MDS which have established validity in relation to the Mini-Mental State Exam and the Test for Severe Impairment [3]. The five items utilized in the index are: cognitive skills for daily decision making, residents' ability to make themselves understood, short-term memory, whether the resident is in coma and ADL performance in eating. A seven-category cognitive impairment index was constructed. We dichotomized the index by combining the three `severe' groups into a `low cognitive functioning group', including those who were moderately severely impaired, moderately impaired in their decision-making and understood only sometimes or never. All other residents were classified as having `good' cognitive functioning.

Results

Sample description

The characteristics of the five countries are also described by Fries et al. [2]. In Denmark, all nursing home residents in Copenhagen were invited to participate in a survey in 1993; 3451 (78%) participated with a mean age of 83.6. Of these, 76% were women, belonging mainly to the RUG-III [3] case-mix groups with reduced physical functions, impaired cognition or clinically complex. Only 2% of residents were in the groups characterized by rehabilitation, extensive care and special care; 49% were dependent or highly dependent in ADL and 31% had severe cognitive impairment.