Australasian Journal on Ageing Vol 24 No 3 September 2005 Research 169 ndash173 169

Blackwell Publishing LtdResearchPrediction of nursing home placement

Patterns and predictors of nursing home placement over 14 years Dubbo study of elderly Australians

John McCallumVictoria University Melbourne Victoria Australia

Leon A Simons and Judith SimonsUniversity of NSW Lipid Research Department St Vincentrsquos Hospital Sydney New South Wales Australia

Yechiel FriedlanderDepartment of Social Medicine Hebrew University-Hadassah Hospital Israel

Objective To describe patterns and predictors of nursing home placementMethods This is a longitudinal study of an elderly cohort living in Dubbo New South Wales Australia A total of 1233 men and 1572 women aged 60 years and older living in the community were examined in 1988 and followed for 14 years The incidence of nursing home placement and underlying clinical diagnoses were assessed Results were modelled for baseline predictors of placement using Cox proportional hazards regressionResults From 2805 subjects in the study there were 244 (87) nursing home placements 95 in men (77) and 149 in women (95) A total of 44 placements were primarily due to dementia but dementia was a secondary diagnosis in another 20 of cases The other principal diagnoses were stroke (16) and coronary heart disease (14) Median time to death in a nursing home was 105 months in men and 90 months in women In a Cox proportional hazards model using baseline characteristics the hazard of nursing home placement increased significantly with age (hazard ratio = 113) urinary incontinence (166) impaired peak expiratory flow (319) physical disability (159) and depression (185) The hazard of placement was significantly reduced by alcohol intake (055) and female gender (055) Socioeconomic factors were not significantConclusions Dementia and disability-related care burdens rather than other health conditions are the dominant causes of nursing home placement in an unselected elderly community Risk factors such as incontinence impaired respiratory function and depression have been identified and these are potentially amenable to intervention

Key words cohort study dementia elderly nursing home placement

IntroductionIn the year 2000 121 of the Australian population wereaged 65+ similar to 125 in the USA and 128 in Canadabut lower than Japan (17) Germany (164) and the UK(16) [1] As populations age a growing need for assistanceincreases the demand for nursing home placement in particularas the population aged 80+ becomes older still Access toAustralian nursing homes is gained via a national networkof Aged Care Assessment Teams Until 1997 the ResidentialClassification Instrument was used to assess the need for nursinghome placement based on a level of need for assistance Thisinstrument covers items such as mobility continence bathingdressing cognitive ability behaviour nursing treatmentsand procedures A new Resident Classification System imple-mented from October 1997 incorporated previous levels of theearlier instrument and hence maintained relatively good con-sistency between the two systems over time

Evaluation of the Australian nursing home admission processhas been limited and more generally the factors predictingnursing home placement are poorly studied Factors such as agegender marital status home ownership dementia physicaldisability and comorbid illness have been shown to be of impor-tance in nursing home placement [23] It may be possible toidentify predictors of nursing home placement in addition toclassical risk factors many years before patients developirreversible functional decline hence offering the prospect ofsome prevention

The Dubbo study of the elderly is an ongoing longitudinalstudy of a cohort of Australians aged 60 years and older whohave been closely followed since 1988 [4] They were initiallyfree of significant cognitive impairment and were living inthe community This report describes patterns of nursing homeplacement over a 14-year period including rates of placementmajor underlying illnesses at the time of placement as wellas predictors of placement related to the 1988 baselineassessment

MethodThe study population comprised all non-institutionalisedresidents of the Dubbo local government area in New SouthWales who were born before 1930 (ie those 60+ years) Theparticipation rate was 73 of those eligible based on a recon-ciliation of family doctor and electoral records A group of2805 citizens 1233 men and 1572 women were first inter-viewed in 1988 and have been followed to the present withcontinuous recording of death hospitalisation and residentialcare data Methods and measures have been described in detail

Correspondence to Professor Leon A Simons Lipid Research Department St Vincentrsquos Hospital Email lsimonsnotesmedunsweduau

M c C a l l u m J S i m o n s L A S i m o n s J e t a l

170 Australasian Journal on Ageing Vol 24 No 3 September 2005 Research 169 ndash173

elsewhere [4ndash6] Briefly the baseline examinations compriseddemographic psychosocial and medical assessments includingexamination of fasting blood samples The medical examinationincluded anthropometry blood pressure resting ECG peakexpiratory flow and blood testing for lipids and glucose Trainedinterviewers administered a questionnaire which explored socialsupport self-rating of health functional health (as activities ofdaily livinginstrumental activities of daily living) depressionstatus (Center for Epidemiological Studies Depression Scale)and cognitive function (Short Portable Mental Status Question-naire) Other items covered in the questionnaire were demo-graphics education alcohol and tobacco use medicationsand past medical history The study population was broadlyrepresentative of the Australian population born before 1930by gender age employment socioeconomic status housingtenure tobacco usage blood pressure and other variables [56]

Dubbo is a major semiurban centre with a population of 34 000about 400 km from Sydney and health and aged care servicesare well developed Nursing home admissions in Dubbowere routinely collected while placement outside Dubbo wastracked by 2-yearly questionnaires Placements were followedfor 14 years from late 1988 Medical records were codedaccording to the International Classification of Diseases9th edition (Clinical Modification) and 10th edition (AustralianModification) The coding was accepted at face value withoutverification of records

Age- and sex-specific nursing home placement rates were calcu-lated and other descriptive data were derived as indicated inthe Results section Ages referred to are those at study entryThe contribution of baseline predictors to placement wasexamined using Cox proportional hazards regression modelsThose dying prior to nursing home placement were censoredA large number of biomedical and behavioural variables wereentered in a single block and a final model then recalculatedas the most parsimonious version retaining only variablesof statistical significance as well as potential confounders (egmarital status home ownership self-rated health educationlevel diabetes or prior cardiovascular disease) Point estimatesand 95 confidence intervals were calculated from the regres-sion coefficients Statistical analysis was performed using SPSSversion 11 The study has received ongoing approval frominstitutional ethics committees at St Vincentrsquos Hospital SydneyUniversity of New South Wales and University of WesternSydney All participants gave informed written consent

ResultsFrom the 2805 participants in the study there were 1207deaths (43 of cohort) comprising 637 men (52) and 570women (36) A total of 2616 subjects (93) were hospital-ised at least once and 244 (87) required nursing home place-ment over the 14 years of follow-up Of those surviving at least12 months from baseline assessment there were 1148 deaths59 dying in hospital 11 in a nursing home and 30 in thecommunity Nursing home placement showed a rise in the last2ndash3 months of life (Fig 1)

The 244 nursing home placements were comprised of 95 men(77) and 149 women (95) Age- and sex-specific place-ment rates are shown in Table 1 This indicates a flattening inplacement rates above 75 years in men while rates in womenrose continuously into old age exceeding men in those75 years and older

The principal diagnosis leading to nursing home placement isshown for men and women in Figure 2 At the baseline assess-ment all participants had satisfactory scores on the Short Port-able Mental Status Questionnaire indicating that they werenot cognitively impaired Over 14 years approximately 44of placements were primarily due to dementia (major types notseparated in this analysis) Inspection of medical records

Figure 1 Admission to a nursing home in a given month during the last year of life

Figure 2 Nursing home admissions by diagnostic group ()

Table 1 Nursing home placements over 14 years (rate100)

Age group (years) Malesfemales Males Females

60ndash64 415483 24 1465ndash69 321366 40 4170ndash74 252320 119 9775ndash79 158229 177 21080+ 87174 161 276

P r e d i c t i o n o f n u r s i n g h o m e p l a c e m e n t

Australasian Journal on Ageing Vol 24 No 3 September 2005 Research 169 ndash173 171

revealed that dementia was present in a further 20 ofplacements although not listed as the principal problemThe other principal diagnoses were stroke or coronary heartdisease

The age-adjusted death rate of men placed in a nursing homewas 67100 versus 49100 in men not placed The correspond-ing rates in women were 80100 and 34100 The median timeto death in a nursing home was 105 months in men and90 months in women The corresponding times in thoseplaced with dementia were longer men 180 months andwomen 145 months

The final proportional hazards model showing independentpredictors of nursing home placement is summarised in Table 2This model uses the baseline measures rather than factorsimmediately prior to placement The hazard of nursing homeplacement was significantly increased by the following at base-line age urinary incontinence impaired peak expiratory flowphysical disability and depression The hazard of placementwas significantly reduced by the presence at baseline of a mod-erate alcohol intake and female sex The initial regressionmodel included a large number of biological and psychosocialvariables which did not approach significance Non-significantbaseline variables in the final model were prior heart diseaseor stroke diabetes cigarette smoking marital status homeownership education level living alone self-rated health andthe presence of private health insurance Blood pressure was ofborderline significance

DiscussionThe strength of the Dubbo study lies in its longitudinal designwhich allows identification of risk factors for placement over

the period of the study These factors are then able to beaddressed in prevention programs However this method alsohas a weakness namely that baseline parameters at time zeromay have quite different impacts on nursing home placementat say 5 10 or 15 years follow-up Hence any direct compar-isons with other studies over different timeframes must beapproached with caution As well the risk factors in questionwere those included at study baseline and reflected the state ofknowledge and study focus in 1988 Only 73 of eligible cit-izens were recruited into the study in 1988 and it is possiblethat the remaining 27 had higher placement rates All thoseentering had satisfactory cognitive function scores on the ShortPortable Mental Status Questionnaire Thus this key measurewas not available as a predictor The diagnosis of dementia wasmade between the time of baseline examination and the pointof nursing home placement

Our results give an estimate of nursing home placement ratesas well as the proximate medical causes of placement Webelieve the estimates are reasonably reliable because this was awell-defined cohort where very few members were untraceablein our routine postal and telephone follow-up procedures [4]In regression analyses care burdens predominantly thoseassociated with dementia were the dominant factors whichlead to nursing home placement Those with dementia whoenter a nursing home then stay longer than those who enter forother reasons There is a higher rate of admission to nursinghomes just prior to death which indicates a major role of theseinstitutions in palliative care as well as a dominant role indementia care

The only comparable data on nursing home placement rates inAustralia comes from the Blue Mountains Eye Study whichreported incidence over 6 years [3] We have recalculated age-and sex-specific placement rates over the initial 6 years in theDubbo study yielding 61 placements Rates in the two studiesare compared in Table 3 Placement rates in the Blue Moun-tains Study were generally higher than in the Dubbo cohort Itis known that the Blue Mountains district in NSW does attracta high proportion of retirees who are not long-term residentsThis is not the case in Dubbo As the comparison in Table 3 isbased on age-specific rates the data are most likely indicativeof a genuinely higher demand for nursing home placement inthe Blue Mountains Why retirees who are not long-term resi-dents need increased placement is a key question

Table 2 Baseline predictors of nursing home placement over 14 years in Cox proportional hazards regression

Variable Probability Hazard ratio 95 confidence interval

Age 0001 113 110ndash116Female 0002 055 038ndash081Incontinence 0010 166 113ndash244Peak expiratory flow 0001

Tertile 1 319 201ndash506Tertile 2 237 149ndash378

Blood pressure 0272= 160ndash19995ndash99 140 097ndash202ge 200100 145 087ndash243

Activities of daily livingSeverely impaired 0020 159 107ndash235

Alcohol 0003Any 055 041ndash0741ndash7 drinksweek 052 037ndash0728ndash14 drinksweek 062 040ndash09715ndash28 drinksweek 066 035ndash123

Depression score 0012Tertile 2 171 114ndash258Tertile 3 185 122ndash282

For categorical variables the opposite category served as the reference group Other reference groups were as follows peak expiratory flow tertile 3 blood pressure lt 14090 activities of daily living no impairment alcohol zero intake depression score tertile 1 Hazard ratio for continuous variables refers to each standard deviation of change There were separate models for any alcohol versus zero and quantity of alcohol versus zero

Table 3 Nursing home placements over 6 years in two Australian studies (rate100)

Age group (years) Males Females

Dubbo BM Dubbo BM

60ndash64 0 08 02 1365ndash69 19 18 19 3070ndash74 24 40 13 3975ndash79 63 95 66 8680ndash84 47 149 73 210

BM Blue Mountains Eye Study [3]

M c C a l l u m J S i m o n s L A S i m o n s J e t a l

172 Australasian Journal on Ageing Vol 24 No 3 September 2005 Research 169 ndash173

As consistently reported in the literature [37ndash9] we havefound that advancing age is a predictor of placement a 13increasestandard deviation of 7 years and independent ofmeasured health and care needs Being female in Dubboreduces placement risk by 45 However the international lit-erature is equivocal on the effects of gender American womenhave a reduced risk of nursing home admission after control-ling for the effects of age poverty functional status and socialsupport [9] Women in Hong Kong had an increased riskof nursing home admission [10] but in other studies femalegender was not significant when other factors were controlled[23811]

Impaired physical activity (ie severely impaired activities ofdaily living) conveyed a 59 higher risk of placement a qual-itatively similar finding to that in the Blue Mountains study Inearlier work [12] we identified factors which delay the onset ofdisability which is a factor heavily weighted in the Australianassessment for placement in a nursing home Looking at dis-ability onset over 8 years we found that people with three ormore hospital admissions (the average level of use) manifesteddisability 5 years earlier than those with fewer admissionsOther factors which predicted onset of disability includedolder age baseline disability high body mass index poor peakexpiratory flow blood pressure medication depression andstroke Disability is now noted to be a factor in residential careadmission It is important that the disabling consequences ofillness and inactivity are taken seriously in health consultationsand health promotion campaigns as this may potentially delayor prevent the need for nursing home placement

The benefit of alcohol consumption a 45 reduction in place-ment risk at any intake is consistent with previous findings [3]and highlights the relationship with cardiovascular and allcause mortality [13] This further suggests a relationshipbetween nursing home admission and vascular health There isalso support for an argument that it is moderate alcohol intakewhich protects against dementia and therefore nursing homeplacement [1415] Urinary incontinence at baseline conveys a66 higher risk of nursing home placement and much can bedone to prevent this problem [16] provided we overcome theprejudice and fear associated with reporting and treatingthe condition Impaired respiratory function independent ofdiagnosed respiratory disease conveyed a greater than 200higher risk of placement and other major events in the study[17] This is a known biomarker of functional age [18]

Our findings over 14 years reveal no major issues of equity ofaccess for older people to nursing homes as indicated by edu-cational differences Instead access to nursing homes is drivenby care needs such as incontinence disability impaired respi-ratory function and depression It is known that inequalities inlife chances are determined much earlier in life Given theseexist the aged care system responds according to the needspresenting to the aged care gatekeepers Because in Australiathe availability of publicly funded services by older people isextensive and independently needs and means tested there is

less opportunity and need for lsquosocialrsquo rather than needs-basedadmissions

The growing numbers of older people with dementia andsevere disabilities will require increased service system capacityto meet their needs The policy critical questions centre aroundhow much and what type of care There are as well new policyissues for development of prevention programs related to therisk factors identified here Depression and incontinence areprime targets for prevention while disability levels and peakexpiratory flow performance are of further interest The resultsreported here contribute to the emerging epidemiologicalinvestigation of late life frailty and service use The prioritybeing given nationally to ageing issues should promote furtherrisk factor analyses and the development of effective interven-tions to reduce the need for institutional care

AcknowledgementsWe acknowledge the work of our Dubbo nurse manager MrsLyn Dallinger and her predecessors in collecting the data usedin the present study Dr Robyn Maddern assisted withpreparation of the manuscript Funding for this study camefrom an Australian Research Council grant in collaborationwith lsquoindustryrsquo partners Australian Department of Familyand Community Services Department of Health and Ageingand Southern Cross Homes The funding bodies made noinput to the design conduct or reporting of the findings

Key Pointsbull An Australian longitudinal community study over

14 years shows that dementia and disability-relatedfactors rather than other health conditions predictnursing home placement

bull Incontinence impaired respiratory function anddepression are risk factors for placement that maybe amenable to intervention

bull Socioeconomic differences in access were notevident in the Australian system

References1 Australian Institute of Health and Welfare Australiarsquos Health 2004 Can-

berra Australian Institute of Health and Welfare 20042 Wolinsky F Johnson R The use of health services by older adults Journal

of Gerontology Social Sciences 1991 46 S345ndashS3573 Wang JJ Mitchell P Smith W Cumming RG Leeder SR Incidence of

nursing home placement in a defined community Medical Journal ofAustralia 2001 174 271ndash275

4 Simons L The Dubbo Study of the Elderly Available from URL httpwwwdubbostudyorg (accessed 14 July 2005)

5 Simons LA McCallum J Simons J et al The Dubbo study An Australianprospective community study of the health of the elderly Australian andNew Zealand Journal of Medicine 1990 20 783ndash789

6 Simons LA McCallum J Friedlander Y Simons J Powell I Heller RDubbo study of the elderly Sociological and cardiovascular risk factorsat entry Australian and New Zealand Journal of Medicine 1991 21701ndash709

M c C a l l u m J S i m o n s L A S i m o n s J e t a l

170 Australasian Journal on Ageing Vol 24 No 3 September 2005 Research 169 ndash173

elsewhere [4ndash6] Briefly the baseline examinations compriseddemographic psychosocial and medical assessments includingexamination of fasting blood samples The medical examinationincluded anthropometry blood pressure resting ECG peakexpiratory flow and blood testing for lipids and glucose Trainedinterviewers administered a questionnaire which explored socialsupport self-rating of health functional health (as activities ofdaily livinginstrumental activities of daily living) depressionstatus (Center for Epidemiological Studies Depression Scale)and cognitive function (Short Portable Mental Status Question-naire) Other items covered in the questionnaire were demo-graphics education alcohol and tobacco use medicationsand past medical history The study population was broadlyrepresentative of the Australian population born before 1930by gender age employment socioeconomic status housingtenure tobacco usage blood pressure and other variables [56]

Dubbo is a major semiurban centre with a population of 34 000about 400 km from Sydney and health and aged care servicesare well developed Nursing home admissions in Dubbowere routinely collected while placement outside Dubbo wastracked by 2-yearly questionnaires Placements were followedfor 14 years from late 1988 Medical records were codedaccording to the International Classification of Diseases9th edition (Clinical Modification) and 10th edition (AustralianModification) The coding was accepted at face value withoutverification of records

Age- and sex-specific nursing home placement rates were calcu-lated and other descriptive data were derived as indicated inthe Results section Ages referred to are those at study entryThe contribution of baseline predictors to placement wasexamined using Cox proportional hazards regression modelsThose dying prior to nursing home placement were censoredA large number of biomedical and behavioural variables wereentered in a single block and a final model then recalculatedas the most parsimonious version retaining only variablesof statistical significance as well as potential confounders (egmarital status home ownership self-rated health educationlevel diabetes or prior cardiovascular disease) Point estimatesand 95 confidence intervals were calculated from the regres-sion coefficients Statistical analysis was performed using SPSSversion 11 The study has received ongoing approval frominstitutional ethics committees at St Vincentrsquos Hospital SydneyUniversity of New South Wales and University of WesternSydney All participants gave informed written consent

ResultsFrom the 2805 participants in the study there were 1207deaths (43 of cohort) comprising 637 men (52) and 570women (36) A total of 2616 subjects (93) were hospital-ised at least once and 244 (87) required nursing home place-ment over the 14 years of follow-up Of those surviving at least12 months from baseline assessment there were 1148 deaths59 dying in hospital 11 in a nursing home and 30 in thecommunity Nursing home placement showed a rise in the last2ndash3 months of life (Fig 1)

The 244 nursing home placements were comprised of 95 men(77) and 149 women (95) Age- and sex-specific place-ment rates are shown in Table 1 This indicates a flattening inplacement rates above 75 years in men while rates in womenrose continuously into old age exceeding men in those75 years and older

The principal diagnosis leading to nursing home placement isshown for men and women in Figure 2 At the baseline assess-ment all participants had satisfactory scores on the Short Port-able Mental Status Questionnaire indicating that they werenot cognitively impaired Over 14 years approximately 44of placements were primarily due to dementia (major types notseparated in this analysis) Inspection of medical records

Figure 1 Admission to a nursing home in a given month during the last year of life

Figure 2 Nursing home admissions by diagnostic group ()

Table 1 Nursing home placements over 14 years (rate100)

Age group (years) Malesfemales Males Females

60ndash64 415483 24 1465ndash69 321366 40 4170ndash74 252320 119 9775ndash79 158229 177 21080+ 87174 161 276

P r e d i c t i o n o f n u r s i n g h o m e p l a c e m e n t

Australasian Journal on Ageing Vol 24 No 3 September 2005 Research 169 ndash173 171

revealed that dementia was present in a further 20 ofplacements although not listed as the principal problemThe other principal diagnoses were stroke or coronary heartdisease

The age-adjusted death rate of men placed in a nursing homewas 67100 versus 49100 in men not placed The correspond-ing rates in women were 80100 and 34100 The median timeto death in a nursing home was 105 months in men and90 months in women The corresponding times in thoseplaced with dementia were longer men 180 months andwomen 145 months

The final proportional hazards model showing independentpredictors of nursing home placement is summarised in Table 2This model uses the baseline measures rather than factorsimmediately prior to placement The hazard of nursing homeplacement was significantly increased by the following at base-line age urinary incontinence impaired peak expiratory flowphysical disability and depression The hazard of placementwas significantly reduced by the presence at baseline of a mod-erate alcohol intake and female sex The initial regressionmodel included a large number of biological and psychosocialvariables which did not approach significance Non-significantbaseline variables in the final model were prior heart diseaseor stroke diabetes cigarette smoking marital status homeownership education level living alone self-rated health andthe presence of private health insurance Blood pressure was ofborderline significance

DiscussionThe strength of the Dubbo study lies in its longitudinal designwhich allows identification of risk factors for placement over

the period of the study These factors are then able to beaddressed in prevention programs However this method alsohas a weakness namely that baseline parameters at time zeromay have quite different impacts on nursing home placementat say 5 10 or 15 years follow-up Hence any direct compar-isons with other studies over different timeframes must beapproached with caution As well the risk factors in questionwere those included at study baseline and reflected the state ofknowledge and study focus in 1988 Only 73 of eligible cit-izens were recruited into the study in 1988 and it is possiblethat the remaining 27 had higher placement rates All thoseentering had satisfactory cognitive function scores on the ShortPortable Mental Status Questionnaire Thus this key measurewas not available as a predictor The diagnosis of dementia wasmade between the time of baseline examination and the pointof nursing home placement

Our results give an estimate of nursing home placement ratesas well as the proximate medical causes of placement Webelieve the estimates are reasonably reliable because this was awell-defined cohort where very few members were untraceablein our routine postal and telephone follow-up procedures [4]In regression analyses care burdens predominantly thoseassociated with dementia were the dominant factors whichlead to nursing home placement Those with dementia whoenter a nursing home then stay longer than those who enter forother reasons There is a higher rate of admission to nursinghomes just prior to death which indicates a major role of theseinstitutions in palliative care as well as a dominant role indementia care

The only comparable data on nursing home placement rates inAustralia comes from the Blue Mountains Eye Study whichreported incidence over 6 years [3] We have recalculated age-and sex-specific placement rates over the initial 6 years in theDubbo study yielding 61 placements Rates in the two studiesare compared in Table 3 Placement rates in the Blue Moun-tains Study were generally higher than in the Dubbo cohort Itis known that the Blue Mountains district in NSW does attracta high proportion of retirees who are not long-term residentsThis is not the case in Dubbo As the comparison in Table 3 isbased on age-specific rates the data are most likely indicativeof a genuinely higher demand for nursing home placement inthe Blue Mountains Why retirees who are not long-term resi-dents need increased placement is a key question

Table 2 Baseline predictors of nursing home placement over 14 years in Cox proportional hazards regression

Variable Probability Hazard ratio 95 confidence interval

Age 0001 113 110ndash116Female 0002 055 038ndash081Incontinence 0010 166 113ndash244Peak expiratory flow 0001

Tertile 1 319 201ndash506Tertile 2 237 149ndash378

Blood pressure 0272= 160ndash19995ndash99 140 097ndash202ge 200100 145 087ndash243

Activities of daily livingSeverely impaired 0020 159 107ndash235

Alcohol 0003Any 055 041ndash0741ndash7 drinksweek 052 037ndash0728ndash14 drinksweek 062 040ndash09715ndash28 drinksweek 066 035ndash123

Depression score 0012Tertile 2 171 114ndash258Tertile 3 185 122ndash282

For categorical variables the opposite category served as the reference group Other reference groups were as follows peak expiratory flow tertile 3 blood pressure lt 14090 activities of daily living no impairment alcohol zero intake depression score tertile 1 Hazard ratio for continuous variables refers to each standard deviation of change There were separate models for any alcohol versus zero and quantity of alcohol versus zero

Table 3 Nursing home placements over 6 years in two Australian studies (rate100)

Age group (years) Males Females

Dubbo BM Dubbo BM

60ndash64 0 08 02 1365ndash69 19 18 19 3070ndash74 24 40 13 3975ndash79 63 95 66 8680ndash84 47 149 73 210

BM Blue Mountains Eye Study [3]

M c C a l l u m J S i m o n s L A S i m o n s J e t a l

172 Australasian Journal on Ageing Vol 24 No 3 September 2005 Research 169 ndash173

As consistently reported in the literature [37ndash9] we havefound that advancing age is a predictor of placement a 13increasestandard deviation of 7 years and independent ofmeasured health and care needs Being female in Dubboreduces placement risk by 45 However the international lit-erature is equivocal on the effects of gender American womenhave a reduced risk of nursing home admission after control-ling for the effects of age poverty functional status and socialsupport [9] Women in Hong Kong had an increased riskof nursing home admission [10] but in other studies femalegender was not significant when other factors were controlled[23811]

Impaired physical activity (ie severely impaired activities ofdaily living) conveyed a 59 higher risk of placement a qual-itatively similar finding to that in the Blue Mountains study Inearlier work [12] we identified factors which delay the onset ofdisability which is a factor heavily weighted in the Australianassessment for placement in a nursing home Looking at dis-ability onset over 8 years we found that people with three ormore hospital admissions (the average level of use) manifesteddisability 5 years earlier than those with fewer admissionsOther factors which predicted onset of disability includedolder age baseline disability high body mass index poor peakexpiratory flow blood pressure medication depression andstroke Disability is now noted to be a factor in residential careadmission It is important that the disabling consequences ofillness and inactivity are taken seriously in health consultationsand health promotion campaigns as this may potentially delayor prevent the need for nursing home placement

The benefit of alcohol consumption a 45 reduction in place-ment risk at any intake is consistent with previous findings [3]and highlights the relationship with cardiovascular and allcause mortality [13] This further suggests a relationshipbetween nursing home admission and vascular health There isalso support for an argument that it is moderate alcohol intakewhich protects against dementia and therefore nursing homeplacement [1415] Urinary incontinence at baseline conveys a66 higher risk of nursing home placement and much can bedone to prevent this problem [16] provided we overcome theprejudice and fear associated with reporting and treatingthe condition Impaired respiratory function independent ofdiagnosed respiratory disease conveyed a greater than 200higher risk of placement and other major events in the study[17] This is a known biomarker of functional age [18]

Our findings over 14 years reveal no major issues of equity ofaccess for older people to nursing homes as indicated by edu-cational differences Instead access to nursing homes is drivenby care needs such as incontinence disability impaired respi-ratory function and depression It is known that inequalities inlife chances are determined much earlier in life Given theseexist the aged care system responds according to the needspresenting to the aged care gatekeepers Because in Australiathe availability of publicly funded services by older people isextensive and independently needs and means tested there is

less opportunity and need for lsquosocialrsquo rather than needs-basedadmissions

The growing numbers of older people with dementia andsevere disabilities will require increased service system capacityto meet their needs The policy critical questions centre aroundhow much and what type of care There are as well new policyissues for development of prevention programs related to therisk factors identified here Depression and incontinence areprime targets for prevention while disability levels and peakexpiratory flow performance are of further interest The resultsreported here contribute to the emerging epidemiologicalinvestigation of late life frailty and service use The prioritybeing given nationally to ageing issues should promote furtherrisk factor analyses and the development of effective interven-tions to reduce the need for institutional care

AcknowledgementsWe acknowledge the work of our Dubbo nurse manager MrsLyn Dallinger and her predecessors in collecting the data usedin the present study Dr Robyn Maddern assisted withpreparation of the manuscript Funding for this study camefrom an Australian Research Council grant in collaborationwith lsquoindustryrsquo partners Australian Department of Familyand Community Services Department of Health and Ageingand Southern Cross Homes The funding bodies made noinput to the design conduct or reporting of the findings

Key Pointsbull An Australian longitudinal community study over

14 years shows that dementia and disability-relatedfactors rather than other health conditions predictnursing home placement

bull Incontinence impaired respiratory function anddepression are risk factors for placement that maybe amenable to intervention

bull Socioeconomic differences in access were notevident in the Australian system

References1 Australian Institute of Health and Welfare Australiarsquos Health 2004 Can-

berra Australian Institute of Health and Welfare 20042 Wolinsky F Johnson R The use of health services by older adults Journal

of Gerontology Social Sciences 1991 46 S345ndashS3573 Wang JJ Mitchell P Smith W Cumming RG Leeder SR Incidence of

nursing home placement in a defined community Medical Journal ofAustralia 2001 174 271ndash275

4 Simons L The Dubbo Study of the Elderly Available from URL httpwwwdubbostudyorg (accessed 14 July 2005)

5 Simons LA McCallum J Simons J et al The Dubbo study An Australianprospective community study of the health of the elderly Australian andNew Zealand Journal of Medicine 1990 20 783ndash789

6 Simons LA McCallum J Friedlander Y Simons J Powell I Heller RDubbo study of the elderly Sociological and cardiovascular risk factorsat entry Australian and New Zealand Journal of Medicine 1991 21701ndash709

P r e d i c t i o n o f n u r s i n g h o m e p l a c e m e n t

Australasian Journal on Ageing Vol 24 No 3 September 2005 Research 169 ndash173 171

revealed that dementia was present in a further 20 ofplacements although not listed as the principal problemThe other principal diagnoses were stroke or coronary heartdisease

The age-adjusted death rate of men placed in a nursing homewas 67100 versus 49100 in men not placed The correspond-ing rates in women were 80100 and 34100 The median timeto death in a nursing home was 105 months in men and90 months in women The corresponding times in thoseplaced with dementia were longer men 180 months andwomen 145 months

The final proportional hazards model showing independentpredictors of nursing home placement is summarised in Table 2This model uses the baseline measures rather than factorsimmediately prior to placement The hazard of nursing homeplacement was significantly increased by the following at base-line age urinary incontinence impaired peak expiratory flowphysical disability and depression The hazard of placementwas significantly reduced by the presence at baseline of a mod-erate alcohol intake and female sex The initial regressionmodel included a large number of biological and psychosocialvariables which did not approach significance Non-significantbaseline variables in the final model were prior heart diseaseor stroke diabetes cigarette smoking marital status homeownership education level living alone self-rated health andthe presence of private health insurance Blood pressure was ofborderline significance

DiscussionThe strength of the Dubbo study lies in its longitudinal designwhich allows identification of risk factors for placement over

the period of the study These factors are then able to beaddressed in prevention programs However this method alsohas a weakness namely that baseline parameters at time zeromay have quite different impacts on nursing home placementat say 5 10 or 15 years follow-up Hence any direct compar-isons with other studies over different timeframes must beapproached with caution As well the risk factors in questionwere those included at study baseline and reflected the state ofknowledge and study focus in 1988 Only 73 of eligible cit-izens were recruited into the study in 1988 and it is possiblethat the remaining 27 had higher placement rates All thoseentering had satisfactory cognitive function scores on the ShortPortable Mental Status Questionnaire Thus this key measurewas not available as a predictor The diagnosis of dementia wasmade between the time of baseline examination and the pointof nursing home placement

Our results give an estimate of nursing home placement ratesas well as the proximate medical causes of placement Webelieve the estimates are reasonably reliable because this was awell-defined cohort where very few members were untraceablein our routine postal and telephone follow-up procedures [4]In regression analyses care burdens predominantly thoseassociated with dementia were the dominant factors whichlead to nursing home placement Those with dementia whoenter a nursing home then stay longer than those who enter forother reasons There is a higher rate of admission to nursinghomes just prior to death which indicates a major role of theseinstitutions in palliative care as well as a dominant role indementia care

The only comparable data on nursing home placement rates inAustralia comes from the Blue Mountains Eye Study whichreported incidence over 6 years [3] We have recalculated age-and sex-specific placement rates over the initial 6 years in theDubbo study yielding 61 placements Rates in the two studiesare compared in Table 3 Placement rates in the Blue Moun-tains Study were generally higher than in the Dubbo cohort Itis known that the Blue Mountains district in NSW does attracta high proportion of retirees who are not long-term residentsThis is not the case in Dubbo As the comparison in Table 3 isbased on age-specific rates the data are most likely indicativeof a genuinely higher demand for nursing home placement inthe Blue Mountains Why retirees who are not long-term resi-dents need increased placement is a key question

Table 2 Baseline predictors of nursing home placement over 14 years in Cox proportional hazards regression

Variable Probability Hazard ratio 95 confidence interval

Age 0001 113 110ndash116Female 0002 055 038ndash081Incontinence 0010 166 113ndash244Peak expiratory flow 0001

Tertile 1 319 201ndash506Tertile 2 237 149ndash378

Blood pressure 0272= 160ndash19995ndash99 140 097ndash202ge 200100 145 087ndash243

Activities of daily livingSeverely impaired 0020 159 107ndash235

Alcohol 0003Any 055 041ndash0741ndash7 drinksweek 052 037ndash0728ndash14 drinksweek 062 040ndash09715ndash28 drinksweek 066 035ndash123

Depression score 0012Tertile 2 171 114ndash258Tertile 3 185 122ndash282

For categorical variables the opposite category served as the reference group Other reference groups were as follows peak expiratory flow tertile 3 blood pressure lt 14090 activities of daily living no impairment alcohol zero intake depression score tertile 1 Hazard ratio for continuous variables refers to each standard deviation of change There were separate models for any alcohol versus zero and quantity of alcohol versus zero

Table 3 Nursing home placements over 6 years in two Australian studies (rate100)

Age group (years) Males Females

Dubbo BM Dubbo BM

60ndash64 0 08 02 1365ndash69 19 18 19 3070ndash74 24 40 13 3975ndash79 63 95 66 8680ndash84 47 149 73 210

BM Blue Mountains Eye Study [3]

M c C a l l u m J S i m o n s L A S i m o n s J e t a l

172 Australasian Journal on Ageing Vol 24 No 3 September 2005 Research 169 ndash173

As consistently reported in the literature [37ndash9] we havefound that advancing age is a predictor of placement a 13increasestandard deviation of 7 years and independent ofmeasured health and care needs Being female in Dubboreduces placement risk by 45 However the international lit-erature is equivocal on the effects of gender American womenhave a reduced risk of nursing home admission after control-ling for the effects of age poverty functional status and socialsupport [9] Women in Hong Kong had an increased riskof nursing home admission [10] but in other studies femalegender was not significant when other factors were controlled[23811]

Impaired physical activity (ie severely impaired activities ofdaily living) conveyed a 59 higher risk of placement a qual-itatively similar finding to that in the Blue Mountains study Inearlier work [12] we identified factors which delay the onset ofdisability which is a factor heavily weighted in the Australianassessment for placement in a nursing home Looking at dis-ability onset over 8 years we found that people with three ormore hospital admissions (the average level of use) manifesteddisability 5 years earlier than those with fewer admissionsOther factors which predicted onset of disability includedolder age baseline disability high body mass index poor peakexpiratory flow blood pressure medication depression andstroke Disability is now noted to be a factor in residential careadmission It is important that the disabling consequences ofillness and inactivity are taken seriously in health consultationsand health promotion campaigns as this may potentially delayor prevent the need for nursing home placement

The benefit of alcohol consumption a 45 reduction in place-ment risk at any intake is consistent with previous findings [3]and highlights the relationship with cardiovascular and allcause mortality [13] This further suggests a relationshipbetween nursing home admission and vascular health There isalso support for an argument that it is moderate alcohol intakewhich protects against dementia and therefore nursing homeplacement [1415] Urinary incontinence at baseline conveys a66 higher risk of nursing home placement and much can bedone to prevent this problem [16] provided we overcome theprejudice and fear associated with reporting and treatingthe condition Impaired respiratory function independent ofdiagnosed respiratory disease conveyed a greater than 200higher risk of placement and other major events in the study[17] This is a known biomarker of functional age [18]

Our findings over 14 years reveal no major issues of equity ofaccess for older people to nursing homes as indicated by edu-cational differences Instead access to nursing homes is drivenby care needs such as incontinence disability impaired respi-ratory function and depression It is known that inequalities inlife chances are determined much earlier in life Given theseexist the aged care system responds according to the needspresenting to the aged care gatekeepers Because in Australiathe availability of publicly funded services by older people isextensive and independently needs and means tested there is

less opportunity and need for lsquosocialrsquo rather than needs-basedadmissions

The growing numbers of older people with dementia andsevere disabilities will require increased service system capacityto meet their needs The policy critical questions centre aroundhow much and what type of care There are as well new policyissues for development of prevention programs related to therisk factors identified here Depression and incontinence areprime targets for prevention while disability levels and peakexpiratory flow performance are of further interest The resultsreported here contribute to the emerging epidemiologicalinvestigation of late life frailty and service use The prioritybeing given nationally to ageing issues should promote furtherrisk factor analyses and the development of effective interven-tions to reduce the need for institutional care

AcknowledgementsWe acknowledge the work of our Dubbo nurse manager MrsLyn Dallinger and her predecessors in collecting the data usedin the present study Dr Robyn Maddern assisted withpreparation of the manuscript Funding for this study camefrom an Australian Research Council grant in collaborationwith lsquoindustryrsquo partners Australian Department of Familyand Community Services Department of Health and Ageingand Southern Cross Homes The funding bodies made noinput to the design conduct or reporting of the findings

Key Pointsbull An Australian longitudinal community study over

14 years shows that dementia and disability-relatedfactors rather than other health conditions predictnursing home placement

bull Incontinence impaired respiratory function anddepression are risk factors for placement that maybe amenable to intervention

bull Socioeconomic differences in access were notevident in the Australian system

References1 Australian Institute of Health and Welfare Australiarsquos Health 2004 Can-

berra Australian Institute of Health and Welfare 20042 Wolinsky F Johnson R The use of health services by older adults Journal

of Gerontology Social Sciences 1991 46 S345ndashS3573 Wang JJ Mitchell P Smith W Cumming RG Leeder SR Incidence of

nursing home placement in a defined community Medical Journal ofAustralia 2001 174 271ndash275

4 Simons L The Dubbo Study of the Elderly Available from URL httpwwwdubbostudyorg (accessed 14 July 2005)

5 Simons LA McCallum J Simons J et al The Dubbo study An Australianprospective community study of the health of the elderly Australian andNew Zealand Journal of Medicine 1990 20 783ndash789

6 Simons LA McCallum J Friedlander Y Simons J Powell I Heller RDubbo study of the elderly Sociological and cardiovascular risk factorsat entry Australian and New Zealand Journal of Medicine 1991 21701ndash709

M c C a l l u m J S i m o n s L A S i m o n s J e t a l

172 Australasian Journal on Ageing Vol 24 No 3 September 2005 Research 169 ndash173

As consistently reported in the literature [37ndash9] we havefound that advancing age is a predictor of placement a 13increasestandard deviation of 7 years and independent ofmeasured health and care needs Being female in Dubboreduces placement risk by 45 However the international lit-erature is equivocal on the effects of gender American womenhave a reduced risk of nursing home admission after control-ling for the effects of age poverty functional status and socialsupport [9] Women in Hong Kong had an increased riskof nursing home admission [10] but in other studies femalegender was not significant when other factors were controlled[23811]

Impaired physical activity (ie severely impaired activities ofdaily living) conveyed a 59 higher risk of placement a qual-itatively similar finding to that in the Blue Mountains study Inearlier work [12] we identified factors which delay the onset ofdisability which is a factor heavily weighted in the Australianassessment for placement in a nursing home Looking at dis-ability onset over 8 years we found that people with three ormore hospital admissions (the average level of use) manifesteddisability 5 years earlier than those with fewer admissionsOther factors which predicted onset of disability includedolder age baseline disability high body mass index poor peakexpiratory flow blood pressure medication depression andstroke Disability is now noted to be a factor in residential careadmission It is important that the disabling consequences ofillness and inactivity are taken seriously in health consultationsand health promotion campaigns as this may potentially delayor prevent the need for nursing home placement

The benefit of alcohol consumption a 45 reduction in place-ment risk at any intake is consistent with previous findings [3]and highlights the relationship with cardiovascular and allcause mortality [13] This further suggests a relationshipbetween nursing home admission and vascular health There isalso support for an argument that it is moderate alcohol intakewhich protects against dementia and therefore nursing homeplacement [1415] Urinary incontinence at baseline conveys a66 higher risk of nursing home placement and much can bedone to prevent this problem [16] provided we overcome theprejudice and fear associated with reporting and treatingthe condition Impaired respiratory function independent ofdiagnosed respiratory disease conveyed a greater than 200higher risk of placement and other major events in the study[17] This is a known biomarker of functional age [18]

Our findings over 14 years reveal no major issues of equity ofaccess for older people to nursing homes as indicated by edu-cational differences Instead access to nursing homes is drivenby care needs such as incontinence disability impaired respi-ratory function and depression It is known that inequalities inlife chances are determined much earlier in life Given theseexist the aged care system responds according to the needspresenting to the aged care gatekeepers Because in Australiathe availability of publicly funded services by older people isextensive and independently needs and means tested there is

less opportunity and need for lsquosocialrsquo rather than needs-basedadmissions

The growing numbers of older people with dementia andsevere disabilities will require increased service system capacityto meet their needs The policy critical questions centre aroundhow much and what type of care There are as well new policyissues for development of prevention programs related to therisk factors identified here Depression and incontinence areprime targets for prevention while disability levels and peakexpiratory flow performance are of further interest The resultsreported here contribute to the emerging epidemiologicalinvestigation of late life frailty and service use The prioritybeing given nationally to ageing issues should promote furtherrisk factor analyses and the development of effective interven-tions to reduce the need for institutional care

AcknowledgementsWe acknowledge the work of our Dubbo nurse manager MrsLyn Dallinger and her predecessors in collecting the data usedin the present study Dr Robyn Maddern assisted withpreparation of the manuscript Funding for this study camefrom an Australian Research Council grant in collaborationwith lsquoindustryrsquo partners Australian Department of Familyand Community Services Department of Health and Ageingand Southern Cross Homes The funding bodies made noinput to the design conduct or reporting of the findings

Key Pointsbull An Australian longitudinal community study over

14 years shows that dementia and disability-relatedfactors rather than other health conditions predictnursing home placement

bull Incontinence impaired respiratory function anddepression are risk factors for placement that maybe amenable to intervention

bull Socioeconomic differences in access were notevident in the Australian system

References1 Australian Institute of Health and Welfare Australiarsquos Health 2004 Can-

berra Australian Institute of Health and Welfare 20042 Wolinsky F Johnson R The use of health services by older adults Journal

of Gerontology Social Sciences 1991 46 S345ndashS3573 Wang JJ Mitchell P Smith W Cumming RG Leeder SR Incidence of

nursing home placement in a defined community Medical Journal ofAustralia 2001 174 271ndash275

4 Simons L The Dubbo Study of the Elderly Available from URL httpwwwdubbostudyorg (accessed 14 July 2005)

5 Simons LA McCallum J Simons J et al The Dubbo study An Australianprospective community study of the health of the elderly Australian andNew Zealand Journal of Medicine 1990 20 783ndash789

6 Simons LA McCallum J Friedlander Y Simons J Powell I Heller RDubbo study of the elderly Sociological and cardiovascular risk factorsat entry Australian and New Zealand Journal of Medicine 1991 21701ndash709

P r e d i c t i o n o f n u r s i n g h o m e p l a c e m e n t

Australasian Journal on Ageing Vol 24 No 3 September 2005 Research 169 ndash173 173

7 Kaplan RM Wingard DL McPhillips JB Williams-Jones D Barrett-Connor E Cigarette smoking mortality institutional and community-based care utilization in an adult community Journal of CommunityHealth 1992 17 53ndash60

8 Hanley RJ Alecwith L Wiener J Kennell DL Predicting elderly nursinghome admissions Results from the 1982ndash1984 National Long-TermCare Survey Research on Aging 1990 12 1999ndash2028

9 Kersting R Impact of social support diversity and poverty on nursinghome utilization in a nationally representative sample of older AmericansSocial Work in Health Care 2001 33 67ndash87

10 Woo J Ho SC Yu AL Lau J An estimate of long-term care needs andidentification of risk factors for institutionalisation among Hong KongChinese aged 70 years and over Journal of Gerontology A BiologicalSciences and Medical Sciences 2000 55 M64ndashM69

11 Hancock R Arthur A Jagger C Matthews R The effect of older peoplersquoseconomic resources on care home entry under the United Kingdomrsquoslong-term care financing system Journal of Gerontology B PsychologicalScience and Social Sciences 2002 5 S285ndashS293

12 Simons LA McCallum J Friedlander Y Simons J Healthy ageing is asso-

ciated with reduced and delayed disability Age and Ageing 2000 29143ndash148

13 Simons LA McCallum J Friedlander Y Ortiz M Simons J Moderatealcohol intake is associated with survival in the elderly The Dubbo StudyMedical Journal of Australia 2000 173 121ndash124

14 Ruitenberg A van Sweiten JC Witterman JCM et al Alcohol consumptionand risk of dementia the Rotterdam study Lancet 2002 359 281ndash286

15 Mukamal KJ Kuller LH Fitzpatrick AL Longstreth WT Mittleman MASiscovick DS Prospective study of alcohol consumption and risk ofdementia in older adults JAMA 2003 289 1405ndash1413

16 McCallum J Improving continence services and outcomes through eval-uation Paper presented at Health Outcomes Conference CanberraAugust 2002

17 Simons LA McCallum J Simons J Friedlander Y Relationship of peakexpiratory flow with mortality and ischaemic heart disease in elderly Aus-tralians Medical Journal of Australia 1997 166 526ndash529

18 Anstey KJ Lord SR Smith GA Measuring Human Functional Age areview of empirical findings Experimental Aging Research 1996 22245ndash266