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This article integrates the results of a series of prospective studies that used data from the 1982-1984 National Long Term Care Survey to (a) provide a comprehensive view of the effects of caregiver burden over a two-year period, (b) suggest ways in which caregiver burden intersects with the continuum of care, and (c) explore the implications for long-term care research and policy. Each dimension of caregiver burden had different consequences for each long-term care outcome. Neither personal nor interpersonal burden had an independent effect on changes in the informal task support network. Personal burden, but not interpersonal burden, influenced changes in the use of formal services. Interpersonal burden, but not personal burden, influenced nursing home admissions.

The European Communities provide a contemporary naturally occurring laboratory for the comparative study of social policy formation and implementation. This is particularly the case regarding social policies for ageing populations. The substantive focus of this paper is long-term care policy and, more particularly, policy choices regarding relative emphasis on medical in contrast to social care of dependent older adults. The strategy of the paper is to discuss, first, the limits of comparative theories of social policy formation in predicting policies in a highly value-laden topic like long-term care. The paper then summarises factors which may explain the extraordinary but inconclusive attention given to long-term care policy in the United States. Finally, the paper outlines some questions about LTC policy in the EC which would benefit from comparative policy analysis. Particular attention will be directed to the balance of medical and social care for dependent elderly people, the role of housing policy in the context of general care policy, and the generic issue of public and private sector interaction in welfare states. Systematic exchange of LTC information among EC countries and between these countries and the US is encouraged.

Objectives. Proposals for publicly financed home care for the elderly now tend to include cognitive impairment criteria as wells as activities of daily living (ADL) criteria. The numbers of elderly deemed eligible for services will depend on the definitions of ADL and cognitive impairment used. Methods. Data from the 1984 National Long-Term Care Survey were used to generate a series of estimates of the community-dwelling elderly with ADL disabilities and cognitive impairment. Results. When only ADL criteria are used, estimates of diaability range from 472 000 to over 3 million (1.6% to 12.5% of the community-dwelling elderly). These estimates increase to approximately 1 million to 4.2 million (3.5% to 14.0% of the community-dwelling elderly) when cognitive impairment criteria are added. Conclusions. The use of more stringent or more liberal eligibity criteria will have dramatic effects on the number of elders who qualify for services. The nature of the eligibity criteria employed in any expansion of federally financed home care benefits will be major factor in determining the costs of such a program. (Am J Public Health. 1992;82:853-856)

One major purpose of this study was to identify environmental factors related to suicide in long-term care facilities. Questionnaires were mailed to a random sample of administrators at 1,080 facilities. Information was collected on facility characteristics, overt suicide, and intentional life-threatening behavior. Chi-square analyses revealed 4 environmental characteristics related to suicidal behavior and deaths from suicide: staff turnover, size, auspices, and per diem cost. More suicides occurred in larger facilities and facilities with higher staff turnover. Religious or 'other' facilities experienced more suicidal deaths than public or private facilities; facilities charging less experienced more deaths.

This study examined the dental state of institutionalized elderly and their need for care. An oral examination was carried out on 479 elderly persons living in long-term care facilities with a m age of 74.9 years. Results showed an overall DMF score of 27.0 and the average number of teeth in de subjects was 7.5. A large proportion of teeth (76.6%) was lost through dental caries and the loss in significantly with age. Consequently, 56.1% of subjects were edentulous, of whom 78.8% were without dentures. Among the conditions that required urgent dental care, majority of subjects needed extract of residual roots and loose teeth. A lesser proportion required treatment for gross caries (4.8%), periodontal disease (5.0%), suspected tumor (0.2%), as well as alleviation of pain and infection ari from mucosal lesions (4.8%), abscesses (3.3%) and TMJ problems (2.8%). The treatment needs for dentures and episodic care are high among institutionalized elderly and need to be addressed.

In this paper we examine the influence of cultural preferences on living arrangements for a sample of older unmarried Hispanic and non-Hispanic white females. We develop a conceptual framework composed of three sets of factors: availability of kin, economic and health feasibility, and cultural desirability. Our analyses show that household living arrangements among Hispanic and non-Hispanic females are more similar when we control for these three sets of factors, and that cultural desirability factor are particularly important. The likelihood that elderly Hispanic females will reside in an institution is actually decreased, however, when we control for these factors; this finding suggests a strong reluctance among Hispanics to use formal long-term care facilities.

The rapid growth of the elderly population has resulted in an increase in the number of elderly people in need of long-term care for chronic disabilities. As an alternative to costly institutional placement for the frail elderly, it has been recommended that home and community-based long-term care programs be developed for cost containment and better quality of life for the patient. The present paper reports the results of a comparison of the characteristics of elderly patients admitted to two types of care settings - nursing home and community-based care - and their six-month outcome in those settings. Data were collected from 352 patients certified to be in need of an intermediate care facility. They received the required services either in the community or in a nursing home. Patients were observed and interviewed, charts were reviewed, and patient functioning was discussed with formal and informal caregivers. Significantly more Caucasian patients and those with dementia, cancer, poor scores on measurements of functioning, and patients taking more medications were admitted to nursing homes as opposed to community-based programs. A greater proportion of nursing home patients died within six months of placement than did community-based patients. Being male was a predictor of death for nursing home patients, but not for community-based patients. In general, the best predictor of six-month outcome was level of functioning before admission. Patient characteristics affected outcome differently in the two settings. Controlling for initial patient differences, however, similar patient outcomes could be expected in the two types of settings. (Consumer Summary produced by Reliance Medical Information, Inc.)

Those caught in the 'Medicaid gap' are elderly people with too much income to qualify for Medicaid, but too little income to afford long-term care as paying patients. They often receive inadequate care, and their caregivers become financially and emotionally burdened. The present paper describes the income, health, and functional capacity of those falling into the Medicaid gap in Florida. It also reports on the strategies caregivers use to cope with their dilemma. Interviews were conducted with 68 patients (or their caregivers), who had applied for Medicaid and had been rejected. Nearly half were married and a third were widowed. More than 70 percent were over the age of 70 years. Sixty-six percent of the subjects were male. More than half of the subjects in this sample had applied for Medicaid because they were in need of institutional care as a result of illness. About one-third did so because of financial problems. Ten percent of the sample applied for Medicaid because as paying patients in nursing homes, they were in jeopardy of being discharged. Caregivers reported that they spent a significant amount of their incomes on the care of their elders/spouses; more than 25 percent reported that they had great difficulty in meeting their own expenses because of these financial obligations. When asked what they would do if their elder or spouse became more needy in the future, 61 percent said that there was nothing that they could do. Those most likely to fall into the Medicaid gap are those who receive a pension. They are functionally impaired, in poor health, and require long-term assistance. It is recommended that a national program be instituted to address this growing problem. (Consumer Summary produced by Reliance Medical Information, Inc.)

Progressive dementias, such as Alzheimer's disease, account for approximately 50 percent of nursing home admissions in the US. As the national population ages, the number is increasing. Special care units (SCU) have evolved as one way to meet the needs of these patients. They are specially designed for the cognitively impaired, staff is specially trained, and activities are individualized. The present study was designed to identify factors contributing to the quality of care of demented patients in nursing homes. Sixty-three nursing home units, including both SCUs and non-SCUs, were observed and data was collected on the type and quality of care given, staff and administrative attitudes, overall environment, and the patient population. Ratings were then made and the authors classified the units into one of eight types: ideal, uncultivated, heart of gold, rotten at the core, institutional, limited, conventional, and execrable. The 'ideal' setting had a therapeutic rather than maintenance philosophy of care, an administration knowledgeable in dementia, a staff highly experienced in caring for memory-impaired patients, and an overall concern for staff and patients. Physical maintenance of the unit was important, as was its layout; patients had privacy and rooms were personalized. The first three types of units comprised 22 percent of the 63 units surveyed; 21 percent fell into the execrable, rotten at the core, or conventional categories. No SCUs fell into the two worst categories, and no non-SCUs fell into the two best. It is not clear why this is true, but it is possible that SCUs receive better funding and can therefore provide better overall care, or that differences in admission policies of the two types of units have an effect. The results show that SCUs can provide high-quality care for demented patients and that all SCUs are not equally able to do this. Consumers may use the types of units presented in this article as a general guideline in choosing nursing home care for a demented adult. (Consumer Summary produced by Reliance Medical Information, Inc.)

Hospital patients who are ready to be discharged into long-term facilities, such as nursing homes, often remain in acute care hospital beds because long-term care beds are unavailable. Known as 'alternate care patients', they cannot be discharged to home, and create what is known as 'the blocked bed.' There are financial implications of alternate care patients for hospitals; the introduction of prospective payment systems from Medicare and some insurance companies provide for a certain amount of money per admission regardless of length of stay. The reduced access to acute care beds is also a problem. The present study looked at data on the alternate care population in four general hospitals over a three-year period. The hospitals began a collaborative effort to collect data on alternate care in response to the growing problem. Data included length of alternate care stay, patient age, payor status, level of disability, and patient disposition when released from alternate care. Using this data, the growth of the alternate care phenomenon was analyzed, and a comparison was made between hospital patients aged 65 and over who were not placed in alternate care and patients who were placed in alternate care before discharge. Patients placed in alternate care were generally older than those discharged directly from acute care, and with increasing age the use of alternate care increased. The alternate care patient was also more likely to have Medicaid or to be self-paying than the discharged patient. More alternate care patients were discharged to nursing homes (46.1 to 54.1 percent) than to other destinations following alternate care, and 11.2 percent to 14.6 percent were eventually discharged to home from the hospital. Approximately 14 percent of the beds in the four hospitals were considered alternate care beds during the three-year period studied. One solution to the problem of blocked acute care beds would be to increase the number of nursing home beds in the community. Other changes are possible as well. Overall, there is a need for programs designed to meet the needs of this elderly, alternate care population, so that valuable acute care beds are available to the patients who need them. Hopefully, data such as provided in this study will stimulate thought as to how to accomplish this. (Consumer Summary produced by Reliance Medical Information, Inc.)

An accurate perspective of the variation in current mixes of familial/public sector support for older individuals with health-related needs requires a careful assessment of the huge diversity in the sociodemographic composition of the older population as well as in the availability and type of family caregiving resources. This analysis of a sample of individuals 60 years of age and older from the National Survey of Families and Households attempts to provide an in-depth assessment of the sociodemographic composition of the older population and variation in primary kin support for this population by determining (a) the proportions of various age/race/gender population segments of the elderly that have one or more potential primary kin caregivers; (b) the number and proportions of these population segments who are in need of family support due to health status; and (c) who within these population segments receives familial assistance and who does not, given a consideration of both the potential family support network and health status. The analysis also includes an illustrative exercise exploring the potential future impact on the level of unmet need from changes in female labor force participation rates and norms regarding both work and parent care.

It is estimated that 25 to 50 percent of all elderly people will at some point enter a nursing home. The elderly tend to be very concerned about one day having to seek nursing home care. A study was performed to better understand this concern as a response to beliefs that the elderly have regarding nursing homes. The survey included questions on believes regarding the quality of care in nursing homes, quality of life, costs, and family's role. Data were collected from 250 non-institutionalized individuals over the age of 60. Subjects were also evaluated for their risk of being placed in a home, based upon factors of age and health. Concerns related to care more frequently determined their reactions than their own degree of personal risk for entering a nursing home. Two individual concerns that were consistently related to fear were the expectation that seeking help from family members instead of being placed would be difficult, and the perception of a poor quality of life for nursing home residents. (Consumer Summary produced by Reliance Medical Information, Inc.)

Home care may be a lower-cost alternative to long-term care services. However, research has raised the questions of whether home care is an effective substitute for nursing home care and if it is cost-effective. Quality of life is known to improve for those cared for at home, but the strain of caring for these individuals is difficult for some families to manage. There is considerable debate over how to determine criteria for community-based care. Using data from a national long-term care survey, levels of cognitive impairment, disruptive behaviors, and functional disabilities in an elderly population were noted. It was found that more than 25 percent of the elderly living in the community had some cognitive impairment. Of those with functional disabilities, only 8 percent were caused by cognitive impairments. If cognitive impairment were to be added to the criteria for determining nursing home eligibility, there would be a significant increase in the number of people eligible. When looking at data for disruptive behaviors, interpretation is difficult. There is no doubt that eligibility requirements for long-term care must take into account who is most in need. However, it is sometimes difficult to determine this, and the research remains incomplete. The cognitively-impaired seem to cause the most strain when community-based care is provided. However, providing long-term care based on cognitive impairment is likely to strain the long-term care system. The policy debate continues, with current focus on such factors as availability of resources, finances, and personal preference. (Consumer Summary produced by Reliance Medical Information, Inc.)