Limitations of the study
Due to the extensive social screening, only four nursing homes were included in our study, which might not be representative for the elderly population at large. Yet, our research supports the general observation that maintaining the house often constitutes the biggest stumbling block. Our sample size is limited: 125 of which 74 for the logistic regression.
The statistical analyses focussed on the 74 cases at the extremes of the scale, namely the earliest versus the latest applicants. Due to worries about the vagueness and ambiguity of the data in the midrange, the in-between category (3-12 months) was excluded from the analysis. This was the best strategy in light of the data to investigate the current question.
The time spans between onset of a need for care and a request in our sample showed a skewed distribution. Most people put in a request within the first six months. In addition to that, estimates of the onset of a need in the midrange of that time scale were less certain than at either end of the scale. Elderly people or their families are unable to give the precise week/month when the need for care actually began and in general, their situation deteriorates slowly. However people that cannot cope put in a request within the first 3 months and people that can cope manage for at least a year and beyond. The strategy therefore employed here was to use the cut-off point of 3 months (used by the professionals) and 12 months and focus the statistical analyses on these extreme points.
The selection of the independent variables was perhaps not the most appropriate for the logistic regression, but it concerns standard parameters. The interaction between some variables is inherent to this kind of research. Married people have more chance of I-ADL help since they have someone to do the chores for them.
The study focussed on observed data as the needs are assessed by professionals according to standardised scales, rather than on subjective data. Over the past few years, practical experience has shown that in addition to these objective needs, subjective (social-emotional) needs play an increasingly important role. For instance, dependency in terms of outside mobility cannot be entirely resolved by means of a shopping service. Once people are no longer able to get about on their own, a great many social activities are no longer possible which can lead to extreme isolation.
Minor local variations in the scope of home care support can sometimes determine whether an elderly person can stay at home or not. Mostly this involves organised voluntary work, e.g. 'granny sitting' (day and night).
I-ADL is the most prominent factor for the urgency of a request for admission
An urgent request seems to be mainly determined by deficits in household activities. It signifies that the score on the Katz scale is not the most important reason for admission to institutional care although physical or mental shortcomings are the key criteria in legal terms. This is the explanation of the paradox in Table which showed that the elderly without or with limited P-ADL limitations (category O/A) were also among those making the earliest requests. Crucial are deficiencies in performing Instrumental Activities of Daily Living.
It is likely that there is confusion between I-ADL and living conditions but they are not entirely similar. The one is on the demand side, the other on the supply side. I-ADL is the objective need assessment for specific household activities. The broader living conditions point to the presence or absence of a positive microclimate (including housing, protected living which gives some feeling of security, supervision and concrete forms of P-ADL or I-ADL help).
Also living conditions and marital status are not covering the same. This is shown in Table : only 17% of the women was married whereas the living conditions of 45% of them were qualified as positive. Some authors indicate that improved P-ADL (self-care) does not guarantee a diminishing need for I-ADL support. 'The need for help with the Instrumental Activities of Daily Living did not change, even with better physical conditions' [21
]. A population-based survey among the elderly in Belgium has shown that the number of people aged over 65 with severe P-ADL problems fell from 25% in 1966 to 16% in 2001. Problems with I-ADL declined too, from 28% in 1966 to 14% in 2001 but there was no parallel decline in the 'demand' for professional I-ADL supports [22
Professional and informal home care do not currently adequately meet the I-ADL needs
Although community care was promoted during the last 20 years, there was a further increase in institutional care. This might be the result of a caring gap in the provision of I-ADL support, both informal and professional care. As our study shows, the greater the I-ADL need, the sooner people move into an institution, we can suggest that the level of home help coverage is not related to home help needs.
Waiting list times for professional home help can be as high as half a year. Not the payment for domestic tasks is a problem, rather a probable shortage of personnel. "The strain will be less on the financial side than on the shortage of services and people willing to render the care required" [23
Belgian research revealed that 17% of the current O- and A- residents in nursing homes could have stayed at home, with support of the community [24
]. "A sizeable proportion of those admitted to nursing homes could be kept out if suitable services were available" [19
The relevance of supporting informal care
Several authors underscore the critical role of the spouse in influencing the living conditions. The presence and the motivation of the co-resident are by far the most essential to enable the provision of home care [9
Support for living conditions, for housing and for the main carer can postpone institutionalisation [17
]. The support for informal care is as important as that for direct personal help for the elderly [16
]. For people with Alzheimer's disease, informal care is five times as important as professional care and the people that have to take up this burden are to a large extent the older partners/spouses [27
The strength or resilience of the informal care is related to intrinsic characteristics. Closeness and a good current relationship between the caregiver and the patient reduce the risk of nursing home placement [28
Supporting the I-ADL needs is the greatest guarantee to delay or prevent institutionalisation
Trends in nursing home usage suggest that people enter nursing homes at a later age. This may be due to healthy ageing. Older people are living longer and with fewer disabilities [21
]. However, it may also be due to growth in options [31
A survey of the services for the elderly in Europe illustrates this ever expanding range of types of community care [1
]. All sorts of services are becoming increasingly available, enabling older people to live longer independently at home. But feeling in control of the help desired is important for the elderly (self-regulated dependency) [33
Over the last few years we have seen a noticeable trend towards private entrepreneurs who have discovered the specialised niche market of senior citizens. They are increasingly meeting the wishes of the 'great grey group' in terms of both buildings and the services provided.
Recently, (mostly commercial) 'care hotels' have begun to offer an excellent combination of residence, care and wellbeing. These pure wellness arrangements mainly benefit the wealthiest segment of the ageing population.
As institutional care is not a primary option for most elderly, home care needs to be stimulated. Supporting the existing main carer for men can lengthen community care. For women, to a large extent widows, a main carer is mostly not available. Sheltered housing and adequate home help can provide the desired increase in care.
In Belgium additional sheltered housing is needed. Almost twenty years after the launch of these 'service houses' only half of the planned capacity has been achieved. The objective was to provide sheltered housing for 2% of people above 60 years. However, this criterion was established at a time when the obvious need for this type of services was less clear than it is today. Indeed, today waiting lists for service houses are much longer than those for nursing homes - five or six years are not unusual. Waiting times for nursing home admission are between 3 and 9 months.
The other type of service that needs enhancing is home help in ordinary housing, which is to a large extent replacing or relieving the main carer. Despite an increase in the last two decades, the capacity of the services nevertheless remains below the required level.
Here again, private providers are increasingly offsetting the shortfall. Besides traditional home help services such as 'meals-on-wheels' and 'cleaning services' offered by the municipalities, the commercial sector is providing more and more supplemental forms of care to complement the services of the municipalities and other non-profit organisations that help with domestic duties and personal care. We are thinking of safety alarms, laundry/ironing services, transport services, home automation and gardening.
In Sweden, private providers delivered about 9% of public care for the elderly in 1999 [32