Cross-sectional data (n = 6,487) from four Nordic countries, Denmark, Finland, Iceland and Sweden, were utilized to determine the prevalence of daily pain and its association with disability in institutional long-term care. Every resident in each of the participating institutions was assessed with Minimum Data Set version 1.0. The sample was representative of institutional long-term care in Copenhagen and Reykjavik. In addition, the data collected from Stockholm and Helsinki provided substantial information on the residents in these capitals. The results showed that 22–24 per cent of the residents experienced daily observable pain and this was most evident in the most disabled subjects. In addition to disability and female gender, diseases or conditions independently associated with pain were terminal prognosis, osteoporosis, pneumonia, arthritis, depression, anaemia, peripheral vascular disease, cancer and cardiac heart failure. The association between pain and severe cognitive impairment was negative. The results strongly indicate that daily pain in long-term care has a complex association with disability, the latter acting together with underlying diseases as a source and/or result of pain. Thus, a vicious circle between pain and disability can be anticipated.

The demographic shift towards an older population in Canada has led to concerns about the increased share of society's resources required to provide health care, social assistance, public pensions, housing, etc. for this group. Preoccupation with this problem, however, has obscured the fact that seniors actively contribute tosociety in many ways, not the least of which is the provision of substantial amounts of unpaid time contributions of various sorts. Using data from the 1992 General Social Survey on Time Use (cycle 7), this paper estimates the amount and market value (at replacement cost) of unpaid help -both informal help to others and formal help to organizations — of individuals age 55 and over. Travel time in connection with unpaid help is also analysed. We find that participation rates and average hours are higher in the informal help sector relative to the formal sector both by age and by gender. The estimates also show that the market value of these contributions is substantial, and that seniors contribute a disproportionate share of the value of unpaid help contributed by all individuals over the age of 25.

The objective of this research is to determine the prevalence and risk factors for primary hypothyroidism in a sample of Canadian seniors. The Canadian Study of Health and Aging (CSHA) was a prevalence survey of seniors living at home and in long-term care facilities (n = 10,263). Detailed clinical examinations were conducted on 2,914 seniors, of which 1,415 had serum TSH levels measured.The ten Canadian Provinces were grouped into five geographic regions (Atlantic, Quebec, Ontario, Prairies and British Columbia). Only seniors who underwent detailed clinical examinations (n = 2,914) are included. Hypothyroidism was defined as seniors taking thyroid hormone replacement or seniors having a serum TSH level greater than 10 mU/L. An estimated 9.6 per cent of seniors had hypothyroidism, 5.1 per cent were inadequately treated and 2.1 per cent were untreated. Age, gender, cultural background, geographic region and place of residence were potential risk factors for hypothyroidism. Hypothyroidism was found to be a prevalent problem in this population.

We establish the potential for outcomes evaluation of a long-term care population-based dataset. Data come from the Health Care Financing Administration's case-mix and quality demonstration project including all Medicare/ Medicaid certified homes of five U.S. states during 1992–1994. Using the Minimum Data Set, we identified nearly 70,000 residents over 65 years of age with congestive heart failure. We provide a preliminary analysis of pharmacotherapy of congestive heart failure and its effects on decline in physical functioning. Functional outcome, expressed as the rate of ADL decline, was improved for patients on combination therapy relative to those on digoxin or ACE-inhibitors alone. The availability of a population-based data set provides a means of evaluating current policies and practices.

A survey of service providers was undertaken to identify issues regarding the provision of service to aging adults with developmental disabilities (DD). Seventy-five questionnaires were sent to 38 agencies involved in the support of older adults with and without disabilities. Forty-four or 59 per cent of surveys were returned. Results suggested that service providers did not feel adequately trained to address many of the needs of aging adults with DD. Respondents requested additional training in dealing with such issues as the health and medical concerns of older adults with DD, and recreational and retirement planning for aging clients with DD. Service providers also required assistance from professionals such as psychologists and medical personnel who were knowledgeable about aging and/or DD. Results were consistent with previous surveys in finding that training for service providers and medical/health care support were key issues. The information reported here updates and extends our knowledge of the needs of those involved in the support of aging adults with DD in the Canadian service sector and details the specific types of information and support required. Preliminary recommendations for modifications to service delivery, policy, and educational programs, are offered.

The aim of this study was to investigate the age differences in the rates and costs of broad categories of medical procedures (diagnostic, therapeutic and surgical) during the last year of life as well as hospitalization among the adult population of Quebec. The study is population-based and took into account 90 per cent of deaths occurring among the Quebec population (15 years and older) in 1991. The data were collected from the physician claim files of the Health Insurance Board. Costs were defined as physician payments for the procedures performed. The results showed that the rates of these procedures increase with age to reach a maximum in middle life and then decrease among the elderly. A similar trend was observed in the average cost of surgery and diagnostic procedures but the average cost of therapeutic procedures followed a constant decline with age. These data suggest that the oldest old do not seem to get more aggressive care at the end of life than younger decedents.

Increasing expenditures for prescription drugs have placed seniors in the spotlight of health reforms because they are the main users of prescription drugs. Substantial improvements could be made in the utilization of prescription drugs that would enhance the benefits of therapy, and minimize adverse effects, particularly for seniors. A variety of problems have been documented, including the over- and under-use of drug therapy, prescribing errors, treatment compliance, and cost-ineffective prescribing. Health care system policies, selected physician and hospital-based pharmacist interventions, and decision-aids and compliance aids have been shown to be effective for components of the problem. Integration of key policies and interventions into a comprehensive solution for optimal drug use is needed. This will include: (1) revision of policies guiding the relationship between the drug industry and health sector, (2) regulations requiring adequate drug testing in seniors for drug approval, (3) a Consumer Health Institute to provide a central objective resource for patient information and decision support systems, (4) integrated clinical information systems to support prescribing, dispensing and drug and disease management systems for pharmacists and primary care physicians, and (5) reforms in medical training and licensure.

The goal of this literature review is to identify key issues in the patterns of medical care utilization of services for seniors as a contribution to the National Consensus process on designing and delivering health care reforms which foster seniors' independence (Shapiro & Havens, 2000). A search strategy used to identify the relevant literature since 1985 focussing mainly on peer-reviewed journal articles is described and the results of the search strategy are summarized. Key articles are identified, analysed and synthesized based on Canadian and American evidence covering patterns of institutional care, physician use, ambulatory care and the determinants of utilization of these services.

Prior to the past decade, much research examining outcomes of home care programs, including efforts at delaying institutional placement, maintaining function, and supporting independence, was atheoretical in character. Outcomes hoped for were often unobserved. New policy developments require comprehensive assessment of need and aggregation of this assessment information. As more and more patients leave hospitals with complex clinical problems and extensive rehabilitative goals there has been a corresponding explosion of home care services. Social care models, while they still exist, are becoming a smaller component of the overall home care market. In this changing environment, questions are now being asked concerning the appropriateness of the care programs in home care and other post-acute care settings. There are also concerns that need to be addressed about movement of clients between post-acute settings. In this paper, we describe a set of proposed functional, behavioural, and social outcome measures that are germane to evaluating the efficacy of programmatic efforts within the post-acute continuum. Data were collected with a standardized data collection instrument, the Resident Assessment Instrument for Home Care (RAI-HC). We provide data summarizing these proposed outcomes and evidence of known groups validity in a cross-national sample of home care clients. Data highlight the differing characteristics of clients across these agencies and provide evidence that this standardized data collection instrument can capture data that is reliable and valid for describing populations and evaluating program effectiveness.

Determining the appropriate intensity of investigation and treatment for individual elderly patients in long-term care settings can present a significant challenge to physicians, especially when patients are incompetent to decide for themselves. However, respecting established intervention levels may represent an even greater challenge, given the realities of coverage by on-call physicians. This paper describes a new Intervention Level Scale for competent as well as incompetent long-term care elderly, and its validation as a communication tool between attending and on-call physicians. Specifically studied were (a) concordance of interventions, (b) whether prior knowledge of an intervention level by an on-call physician was considered useful, (c) applicability of the scale in different institutions and (d) necessity of physician training for optimal use. The scale's uniqueness resides in the fact that it is based on personal values of life, rather than institutional resources, and it incorporates directives on family contact.

Research indicates that self-rated health is related to a variety of health-related outcomes, such as mortality and functional disability, even when controlling for more “objective” health measures. The present study extends previous research by prospectively examining the relation between self-rated health and health care use among a representative sample of elderly Canadians (N = 1,181) interviewed in 1991/92. Survey data were linked to administrative records of health care use. Self-rated health was positively related to the number of physician visits during the 12 months following the survey, as well as to the number of tests incurred (e.g., laboratory tests, X-rays), even when controlling for demographic variables, functional disability, morbidity, and prior health care use. Older adults who rated their health as “bad/poor” or “fair” were also more likely to be hospitalized than those who rated their health as “excellent”. These results highlight the importance of considering global measures of health when examining health care use.

Ensuring the delivery of comprehensive, high quality programs and services to seniors in Canada over the coming decades presents a significant challenge to policy makers and health care professionals. The goal of this study was to provide decision-makers with data on recent trends in the utilization of health services by seniors in Alberta. We compared recent trends in the utilization of acute hospital services (1992/93–1997/98), home care services (1994/95–1997/98), claims for physician consultations and procedures (1995/96–1997/98) and long-term facility care (1990–1996) for Albertans less than and over 65 years of age. We also assessed trends in the use of prescription drugs (1992/93–1997–98) by Albertans 65 years and older. Data for these analyses were obtained from Alberta Health and Wellness administrative databases and reports. Overall, the trends indicate fewer, though sicker, patients being cared for in institutions and more patients being cared for in the community. The receipt of prescription drugs obtained outside of facilities has also increased among seniors in recent years. The extent and appropriateness of substitution of community care for institutional care, the quality of that care, and whether health outcomes are better, worse, or unchanged, are important subjects for further study.

This study explored the determinants of self-rated health and happiness for elderly, institutionalized Canadians in the 1994/95 National Population Health Survey: Health Institutions. Separate ordinal logistic regression models were developed for self-rated health and happiness in a subsample of 780 elderly residents. The results indicate that older Canadians in institutions vary in their ratings of their health and happiness, and that demographic characteristics, illness-related factors, disability and social integration predict these variations. Both self-rated good health and happiness were consistently associated with being older, having fewer chronic diseases, fewer perceived memory difficulties and less pain. Whereas good health was associated with higher education and independence in ambulation, happiness was associated with greater grasping ability, more frequent attendance at group activities in the institution and the community and having a flexible schedule. These findings have important implications since many of the factors identified are potentially modifiable through rehabilitative and nursing interventions.

Using census data, this study investigates change in the residential segregation of persons age 65 years and over from younger persons in Canadian census metropolitan areas (CMAs) between 1981 and 1991. In each CMA, age-segregation is first evaluated in terms of inner city-suburban population distributions, and then according to the degree of segregation across census tracts expressed by the Index of Dissimilarity. Although the CMAs typically had moderate segregation levels in both 1981 and 1991, there were consistent trends toward (i) increasing proportions of the elderly living in suburban areas, and (ii) declining degrees of age-segregation across census tracts. It is proposed that these trends are partly attributable to the aging in place of suburban residents. Correlation and regression analyses indicate that in 1991 lower degrees of segregation were associated with CMAs which had relatively high percentages of both older dwellings and elderly population. The policy implications of the results are discussed.

Although the experiences of formal and informal caregiving have been discussed and debated in the literature, more is assumed than is actually known (McDaniel & Gee, 1993). This qualitative study explored both informal and formal caregivers' perceptions of their own caregiving and the views of each other's caregiving. Information was collected through the use of in-depth interviews with 23 family caregivers and 15 nurses providing home care to older persons. Analysis of interview transcripts and field notes reveals that both informal and formal caregivers engage in all facets of caring work – physical, intellectual and emotional care – but that they carry out this work in varying degrees, and for different reasons. The reasons given for these differences, namely the nurses' professional knowledge and higher status designation, are key elements that define the boundaries between professional and family caregiving. However, it is apparent that, over time, this demarcation diminishes as family caregivers' knowledge and skill match those of health professionals. Study findings point to implications for future theory development and research.