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OBJECTIVE: To describe functional deficits among older adults living alone and receiving home nursing following medical hospitalization, and the association of living alone with lack of functional improvement and nursing home utilization 1 month after hospitalization.
DESIGN: Secondary analysis of a prospective cohort study.
PARTICIPANTS: Consecutive sample of patients age 65 and over receiving home nursing following medical hospitalization. Patients were excluded for new diagnosis of myocardial infarction or stroke in the previous 2 months, diagnosis of dementia if living alone, or nonambulatory status. Of 613 patients invited to participate, 312 agreed.
MEASUREMENTS: One week after hospitalization, patients were assessed in the home for demographic information, medications, cognition, and self-report of prehospital and current mobility and function in activities of daily living (ADLs) and independent activities of daily living (IADLs). One month later, patients were asked about current function and nursing home utilization. The outcomes were lack of improvement in ADL function and nursing home utilization 1 month after hospitalization.
RESULTS: One hundred forty-one (45%) patients lived alone. After hospital discharge, 40% of those living alone and 62% of those living with others had at least 1 ADL dependency (P= .0001). Patients who were ADL–dependent and lived alone were 3.3 (95% confidence interval [95% CI], 1.4 to 7.6) times less likely to improve in ADLs and 3.5 (95% CI, 1.0 to 11.9) times more likely to be admitted to a nursing home in the month after hospitalization.
CONCLUSION: Patients who live alone and receive home nursing after hospitalization are less likely to improve in function and more likely to be admitted to a nursing home, compared with those who live with others. More intensive resources may be required to continue community living and maximize independence.
Older adults may undergo substantial changes in function and living status when hospitalized for acute medical illness. Decline in function in activities of daily living (ADLs) occurs in one third of hospitalized older adults, 1–3 and frequently heralds an end to community living. While a number of studies have focused on risk factors for functional decline and nursing home placement at the end of hospitalization, 3–10 less is known about outcomes once patients are discharged home. Yet, for many patients, the posthospitalization period is one of dynamic flux. Changes in functional status (both improvement and worsening) commonly occur even after hospitalization, and the risk of nursing home placement may persist. 3,10 To best allocate posthospital health care services, it is important to determine who is at risk for lack of improvement in function and for nursing home placement.
One of the primary tasks of the posthospital period is to improve function, with the goal of recovering function that was lost because of acute illness and iatrogenic complications of hospitalization. Improvement is not universal. In a previous study of patients who lost ADL function associated with hospitalization, 41% had not recovered to their prehospital baseline by 3 months after discharge. 3
We hypothesized that older adults who lived alone in the community following hospitalization would be less likely to improve in function after discharge, compared with those who lived with others. Lacking encouragement from an in-home caregiver, patients living alone may be reluctant to assume independence in basic tasks, continuing instead to rely on support from outside the home. Such patients may also be more vulnerable to the effects of insufficient rehabilitation and new or continued medical illness. Thus, they may be at high risk for nursing home placement as well.
While little is known about the outcomes of frail older adults who live alone in the community after hospitalization, data suggest that adequate social support is essential for functional recovery and maintenance of community living. 11–13 However, these studies did not specifically examine posthospital living arrangements. In a population of older adults receiving home nursing services following hospitalization for medical illness, we have described the deficits in function and mobility among patients who are discharged to home alone, in comparison with those who are discharged to home with others, and the temporal changes in ADL and instrumental ADL (IADL) function over 1 month, comparing those living alone and those living with others. Finally, we have analyzed, controlling for other factors, the association of living alone with 2 adverse outcomes 1 month after hospitalization. For the subset of patients dependent in ADL function at hospital discharge, we have evaluated the association of living alone with lack of improvement in ADL function and, for the full cohort, the association of living alone with nursing home admission. We also determined whether frequency of informal support would affect outcomes for those who lived alone. We hypothesized that increased frequency of informal supports would be associated with greater likelihood of functional improvement and decreased risk of nursing home admission.
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In our study, almost half of patients who received home nursing services following medical hospitalization lived alone. Patients living alone had a substantial burden of dependency in very basic tasks. Half needed help preparing meals, and almost half were dependent in 1 or more ADLs. Inability to perform these tasks or to obtain help in performing them poses a significant threat to independent living.
Our data suggest that those who live alone, although at a higher functional level both prehospital and at discharge, are less likely to improve in ADL function in the month after discharge, even after controlling for age, cognitive ability, prehospital assistive device use, and discharge function. The poorer improvement among the living alone group is not just due to their higher discharge functional level. Our results are consistent across different ADL levels, suggesting that the effect of living alone is independent of discharge function. Patients discharged from the hospital to home alone are also more likely to be admitted to a nursing home in the month following discharge.
While previous studies have evaluated the effects of task support or marital status on ADL outcomes posthospitalization, 11–13 there is little research specifically examining the effects of living alone. Wilcox et al. found that lack of adequate task support 6 weeks posthospitalization for stroke, myocardial infarction, or hip fracture predicted increased disability 6 months later. 13 Oxnam et al. found that adequacy of social support predicted subsequent functional level for patients following open heart surgery. 11 Finally, Verbrugge et al. demonstrated lower self-rated health and activity levels for unmarried older adults posthospitalization. 12 Our data complement these studies by extending findings of increased risk to the general medical population and by demonstrating that functional recovery is jeopardized for those living alone.
In addition, our study clarifies the relationship between type of ADL dependency and likelihood of improvement. There was no difference in likelihood of improvement in dressing; however, patients who lived alone were significantly less likely to improve in bathing. Bathing is a complex physical activity that poses significant challenges to postural control. Indeed, older adults are more fearful of falling while bathing than with any other ADL or IADL. 28–30 Patients who live alone may be more afraid of falling because of their higher risk for a long lie and thus are more reluctant to attempt independent bathing.
The trajectory of improvement in IADL function was similar for both groups; however, this does not contradict the findings related to ADLs. For patients who have caregivers at home, IADLs may be slower to improve than ADLs. Independent activities of daily living, such as shopping and meal preparation, are tasks that can be performed by another person. Activities of daily living, such as bathing and toileting, are basic self-care tasks. Patients may have a greater impetus to become independent in basic self-care tasks because of their personal nature.
For patients who lived alone, provision of adequate informal supports from outside the home aided functional recovery. We found that patients who lived alone and had greater frequency of visits from a primary outside support were more likely to improve in function. One reason could be that frequent informal support from an outside source may encourage rehabilitation, improve compliance with medical and physical therapy, and decrease patients' fear of falling. An alternative explanation suggested by Welch et al. is that patients who lack informal supports may remain dependent in ADLs in order to continue to use formal supports, such as home nursing services, to meet their practical needs. 31
Admission to a nursing home, whether for a short stay or on a more permanent basis, is one consequence of not being able to obtain help with daily tasks. Previous literature has shown that people living alone are at increased risk for institutionalization, 20,21 especially at hospital discharge. 8–10 Our study extends previous findings to show that risk of nursing home admission does not end after hospital discharge. Patients who are discharged to home alone with home nursing services remain at increased risk for nursing home admission throughout the subsequent month.
Interestingly, we found that those who lived alone and had a greater frequency of outside informal support from another person were at higher risk for being admitted to a nursing home than those who lived alone with less outside support. One explanation for this could be that closely involved family, friends, or neighbors have a greater sense of responsibility for the person's well-being and are more apt to seek out living arrangements that provide more supervision. An alternative explanation could be that those utilizing more informal supports are more frail. Although we adjusted for multiple measures of frailty, including discharge ADL function, cognition, and prehospital assistive device use, there may have been additional components that we were unable to measure.
Adequate planning during the discharge planning phase from the hospital is necessary to ensure that individuals who live alone will receive sufficient help with ADLs and IADLs. For patients who live alone, discharge planning should take into account the capacities of the patient and the availability of social resources in the home. In particular, patients who live alone after hospital discharge may require more intensive resources to maintain community living and improve in function. In our study, all patients received home nursing services, often including physical therapy and occupational therapy. This suggests that home nursing and rehabilitative services may not be sufficient in intensity, frequency, or duration to provide adequate support to improve ADL function. Informal supports are another important consideration for care provision. Our study suggests such supports may increase functional independence, but may not be sufficient to prevent nursing home admissions. Discharge planning should consider the availability of informal supports for patients who live alone, but should note that they may be of limited benefit in preventing nursing home placement.
There are a number of limitations to this analysis. First, determination of functional status was subjective. In hospitals, subjective report may overestimate ADL function compared with objective performance 32 or reports of family and nurses. 33 However, our study relied on subjective determination of ADL function within the first week after hospital discharge, and patients may have more accurate knowledge of abilities at this time. Indeed, studies of outpatients have shown a high correlation between objective and subjective functional measures. 34,35 To maximize accuracy, we used proxies when necessary, and to prevent measurement error over time, we used the same interviewers and proxies 1 month later. Second, measurement error may result in regression toward the mean over time. However, because ADL function assesses categorical abilities rather than continuous numerical data, measurement error is less likely to occur. A third concern is the potential for reporting bias by those living alone (i.e., bias toward overestimating function at discharge compared with those living with others). However, in a separate study (the St. Mary's site of the Hospital Outcomes Project for the Elderly) that examined objective and subjective ADLs at hospital discharge, patients who lived alone were no more likely to overestimate function than patients who lived with others (M. Jalaluddin, personal communication, September 1998). Fourth, small sample size may have decreased our ability to control for multiple additional risk factors and to evaluate the effect of living alone independent of gender. However, other potential risk factors from the literature were examined and included if significant, or borderline significant, in univariate analysis. Fifth, our sample consisted of predominantly white and fairly well-educated patients. Significant racial differences in posthospitalization formal and informal care patterns exist, 36 and our findings may not be generalizable to nonwhite populations. In addition, this study excluded patients who had a recent stroke or myocardial infarction, were nonambulatory, or had a diagnosis of dementia, and lived alone. Thus, our data apply primarily to those ambulatory at home after a general medical hospitalization. However, similar findings have been found for poststroke and post-myocardial infarction populations. 13 Finally, our findings apply only to the first month after discharge. However, 1-month outcomes are of particular relevance, given the fact that home health expenditures are greatest in the immediate posthospital period.
From 33% to 44% of hospitalized older adults receive home health services following discharge; 37,38 thus, this study potentially represents a large segment of the post-hospitalization population. Our study shows that older adults who live alone after hospital discharge and receive home nursing services frequently have a significant burden of dependency in ADLs and IADLs that jeopardizes their ability to live independently. Patients who live alone after hospitalization are less likely to improve in ADL function and are more likely to be admitted to a nursing home in the subsequent month. Such patients may benefit from increased social and medical supports to maintain independent living and improve function.