Comparison Study: The Impact of On-site Comprehensive Service Access on Self-Reported Health and Functional Status of Older Adults
Article Outline
Objective
To evaluate the impact of on-site comprehensive service access by comparing functional outcomes and self-rated health between 2 older adult samples.
Methods
Data came from 131 randomly selected residents living independently in 2 retirement communities that provided on-site comprehensive service access and 1723 community-dwelling older adults from the second Longitudinal Study on Aging, Wave 3 (LSOA II), who did not have compatible services access. All subjects were age 70+, white, with intact cognitive function, and had 12 or more years of education. We applied regressed measures of functional status and self-rated health on on-site comprehensive service access (yes versus no) in multivariate models that adjusted for covariates.
Results
After adjusting for covariates, results indicated that residents with access to on-site comprehensive service settings is significantly associated with less risk for activities of daily living (ADL) limitations (β = –0.40, P < .001) and Nagi impairments (β = –0.62, P ≤ .001), and better self-rated health (OR = 4.3; 95% CI 2.03–9.15) than the comparison group.
Conclusion
On-site comprehensive service access appears to have positive association on functional outcomes and self-rated health. Future studies should explore specific components of on-site comprehensive service access (eg, home health, social activities) that may account for these desirable outcomes.
Keywords: Aged, comprehensive service access, coordinated care, effectiveness, retirement community, licensed adult homes
The number of older adults (age 65 and older) in the United States is expected to double over the next 25 years, from 13% (35 million) to 25% (70 million), and the oldest-old subgroup (age 85+) is currently the fastest growing segment of the population.1 As a result, the prevalence of functional limitations or disabilities in the population is likely to increase in the coming years, making society's ability to provide needed care for these older adults a crucial health care challenge. One promising way of addressing this challenge may be by optimizing the functional independence and autonomy of elderly individuals through the provision of on-site comprehensive service access within the context of residential retirement communities.
In the past few decades, an increasing number of residential retirement communities that provide comprehensive services, such as continuing care retirement communities (CCRCs) and independent living communities with licensed adult homes (ILC&LAHs) have become available to accommodate older adults in need of health care or support services.2, 3, 4 CCRCs generally offer multiple levels of care, including independent living, assisted living, and skilled nursing care, housed in different areas of the same community or campus,4 while ILC&LAHs typically offer independent living apartments and/or licensed adult homes. Both types of communities provide comprehensive service access that includes residential services (eg, housing, meals, and housekeeping), social and recreational services, transportation, and various levels of health care services. These services are available to the residents of CCRC and ILC&LAH; its associated fees are imbedded in the entrance and monthly fee schedules. The assurance of access to quality of health care and social services was part of the contractual agreements presented to the potential candidates upon admission to the residential community.
Research has shown that many older adults prefer to remain in their own homes and within their own communities for as long as possible.4, 5, 6, 7, 8 People over the age of 70 who do move out of their homes typically do so primarily in response to declining health and increasing functional disabilities or the loss of a spouse.7, 8, 9 For those who had functional limitations and in need of assistance with household tasks or personal basic needs (eg, activities of daily living [ADLs]), moving into a residential community seems logical. One direct benefit of residing in a comprehensive service access setting is the better access to daily activities assistance and health care and social services that are all situated in one location. The availability of a wide spectrum of services is likely to bring improvements in physical health and thus slow down or delay the onset of dependency.10 Several studies have shown a link between health benefits and social support and levels of social activity,11 and stronger social support is consistently associated with better functional performance.12, 13 Residents are more satisfied with their daily lives, spend more time with other people, spend significantly less time watching television, and self-report better health.14 Still other studies have shown psychological factors such as emotional vitality, adaptation, and resilience to be related to emotional well-being, better function, and adaptation in later life.15, 16
Despite the growing number of CCRCs and ILCs&LAHs, the effect of on-site comprehensive service access on self-reported health and functional outcomes within a residential setting is currently lacking. The purpose of this study is to assess the potential health benefits—measured by physical function and self-reported health—of residing in retirement communities where on-site comprehensive service access is provided. We hypothesize that older adults who reside in settings with “on-site comprehensive service access” (Ithaca group) will have better functional status (ie, ADL, instrumental ADL [IADL], and Nagi's disability score) and better self-reported health status than older adults who reside in the community without comparable access to on-site comprehensive services (Longitudinal Study on Aging [LSOA] group).
Methods
Data for this study come from 2 sources: The Ithaca study (n = 131) and the second Longitudinal Study on Aging, Wave 3 (n = 1723). More detailed information about the 2 data sources and study settings are elaborated as follows.
Ithaca Study
The Ithaca group consists of 131 randomly selected individuals, age 70 or older with intact cognition (Mini-Mental State Exam [MMSE] >23) residing in independent apartments in either a continuing care retirement community (Kendal at Ithaca, n = 101), or an independent living community with licensed adult home (Longview, n = 31), both located in Ithaca, New York.
Kendal at Ithaca (Kendal) is a not-for-profit continuing care retirement community designed for active adults over the age of 65 who are in good physical and mental health. Open since 1995, this CCRC offers 213 independent living cottages/apartments, 36 adult home single units, and a 35-bed skilled nursing facility on a 105-acre campus. There is a one-time entrance fee and an ongoing monthly maintenance fee that covers the cost of a variety of services including 1 meal per day, housekeeping, linen service, grounds maintenance, library, pool, exercise facilities, adult care, on-site medical services, rehabilitation facilities, social services and pharmacy services, a skilled nursing facility as part of its life-care contract, and an office with a full-time employee who coordinates residents' health care and support services.
Longview offers 101 independent living apartments and a 60-room licensed Adult Home facility situated on a 34-acre picturesque campus near the Finger Lakes region, New York. Longview is designed for older adults who are in good physical and mental health upon entering the community. The independent living apartments include a mix of studios and 1- and 2-bedroom units. No entrance fee is required; however, a monthly rental fee covers the cost of housing, 1 meal per day, housekeeping services, grounds maintenance, emergency response and assistance, exercise facilities, a pool, greenhouse, activities room, and nature trail. Amenities and services provided to Adult Home residents include a furnished living area, a personal care aide available 24 hours a day to supervise medications, assistance with weekly showers and laundry, and 3 meals per day. Longview also has a comprehensive intergenerational partnership with a nearby 4-year comprehensive college that generates some 50 educational, social, health, and cultural opportunities for residents each semester.
The Ithaca study was conducted in August of 2005. Data were obtained through a structured questionnaire administered in person in either the residents' apartments or cottages or in a meeting room within the Kendal or Longview. The length of the interviews was approximately 45 minutes. Information obtained from participants included demographic characteristics, health status, health care utilization, and perceived quality of life. The questionnaires used in this study were identical to that of LSOA II. This was part of the study design to use the LSOA as the reference group. The LSOA study instrument is widely used and validated.17, 18, 19, 20, 21, 22 Study subject confidentiality and informed consent processes were in compliance with research protocols of the University at Albany, State University of New York (SUNY), the Kendal, and the Longview. The results of bivariate analyses indicated that there were no significant differences in gender, race, marital status, number of chronic conditions, or social support between the Kendal and Longview study samples, thus the Kendal and Longview study subjects were combined and used as the comparison group (Ithaca group).
Longitudinal Study on Aging II
Data for the reference group came from the Second Longitudinal Study of Aging, Wave 3, conducted in 2000 (LSOA II). The LSOA II study design and sample selection procedures are well documented and have been published elsewhere.17, 18, 19, 23, 24 Briefly, the LSOA II is a collaboration effort of the National Center for Health Statistics (NCHS) and the National Institute on Aging (NIA). The goals of the LSOA II study are to better understand disability pathways and interrelationships between determinants and functional outcomes among older adults.25 The LSOA II is a longitudinal study with a national representative sample consisting of 9447 civilian, noninstutionalized persons 70 years of age at the time of the LSOA II baseline interview.25 For the second follow-up interview (Wave 2), 8905 subjects were traced and located and 7998 interviews were obtained; and the third follow-up interviews (Wave 3), 7936 were successfully traced and located and 6465 were interviewed.25 To make the 2 samples compatible, the following persons in the LSOA II sample were excluded from the analysis: persons suffering from Alzheimer's disease, persons who were institutionalized or hospitalized at the time of the interview, persons who needed assistance completing the interview due to language barriers, and persons with impaired cognition measured by the Telephone Interview for Cognitive Status (TICS score <14).26 The TICS questionnaires and scores calculation have gone through several iterations of changes26; the TICS-M modified version has a total scores range from 0 to 22, with higher scores indicating better cognitive function. We used the MMSE total score (24/30) to find the equivalent of TICS total score. Persons with TICS scores less than 14 were considered cognition impaired and were excluded from the study. In addition, because the Ithaca sample was highly educated and all white, only individuals from the LSOA II Wave 3 sample who were white with 12 or more years of education were included in the final analysis. For the purpose of comparison, we applied these exclusion criteria to the LSOA II sample to match the Ithaca sample; as a result, the LSOA II sample is no longer a national representative; instead, it represents a subset of a sample that meets our Ithaca study criteria. For that, we did not apply weights adjustment to make the LSOA II a national representative sample. The final sample size used for the study was 1854 (LSOA II = 1723, Ithaca = 131).
Measures
Outcome VariablesThere were 2 major outcomes of interest in this study: functional status and self-rated health. Functional status was assessed with survey items pertaining to ADLs,27 IADLs,28, 29 and Nagi activities.30 An ADL summary score was calculated based on responses to 6 questions asking about the difficulty of bathing, dressing, eating, transferring, walking, and toileting. An IADL summary score was calculated based on responses to 6 questions asking about the difficulty in preparing meals, shopping for groceries, managing money, using the telephone, doing light housework, and doing heavy housework. For each item, a score of 0 was assigned for no difficulty with the task and a score of 1 was assigned for difficulty with the task. The scores for the ADL and IADL 6-item scale summary measure ranged from 0 to 6, with 0 indicating no difficulty with any tasks and 6 indicating difficulty with all 6 tasks. Similarly, a Nagi summary score was calculated based on responses to 7 questions asking about the difficulty in walking up 10 steps without resting, stooping, crouching, or kneeling; reaching overhead, walking a quarter mile, reaching out as if to shake hands, grasping, and lifting or carrying 10 pounds. The scores for the Nagi 7-item scale summary measure ranged from 0 to 7, with 0 indicating no difficulty with any tasks and 7 indicating difficulty with all 7 tasks.
Self-rated health, a variable that has consistently been shown to be a strong and independent predictor of future morbidity and mortality,31, 32 was measured based on the single item “How would you rate your health?” Answers were dichotomized as excellent/very good/good versus fair/poor.
Control VariablesTwo categories of control variables were included in this study: demographic characteristics and chronic conditions. Demographic characteristics included age (in years), gender (0 = female, 1 = male), educational attainment (in years), and living arrangements (0 = lives alone; 1 = lives with others). Race was not included, as all subjects were Caucasian. Chronic conditions were measured using a self-reported count of 7 of the most common conditions among older adults, including heart conditions (any heart disease, angina, arrhythmias, congestive heart failure, coronary heart disease, heart attack, hardening of arteries, or peripheral arterial disease), arthritis (any arthritis, arthritis of hip, knees, or hands), osteoporosis, diabetes, hypertension, cancer, and respiratory conditions (any asthma, emphysema, chronic bronchitis, or pneumonia). Summary scores ranged from 0 to 7, with 0 indicating no chronic conditions and 7 indicating the presence of all chronic conditions.
Independent Variable (On-site Comprehensive Service Access)Comprehensive service access is a proxy variable attempting to capture the potential health benefits derived from being exposed to the on-site comprehensive service environment in the Ithaca study group. Comprehensive service access refers to access to a comprehensive list of services and amenities specific to the Ithaca group, including housing, meals, transportation, medical services, wellness programs, and social activities. The LSOA group residents are more likely not to have compatible services. A dummy variable was created using the Ithaca group as the comparison group (on-site comprehensive service access = yes) and the LSOA II sample as the reference group (on-site comprehensive service access = no).
Data Analysis
The data analyses began with a comparison of the comprehensive service access and community-dwelling residents on selected covariates. Covariates associated with the variable of interest (comprehensive service access), significant at the P < .10 level, were retained for subsequent analyses. Next, bivariate associations between comprehensive service access (yes versus no) and the outcomes of interest were estimated, using linear regression for continuous outcome variables and logistic regression for dichotomous outcome variables. Finally, these associations were examined in a multivariate context, controlling for the effects of age, gender, education, living arrangement, and comorbidity.
Results
Table 1 shows the comparisons of selected characteristics between the Ithaca sample and the LSOA II sample. The mean age of the Ithaca sample was 82.8 years (SD = 5.6) with a range from 72 to 98; a majority (64.1%) of these residents were female; 48.9% lived alone; the mean number of years of education was 17.6 years (SD = 2.7); and, the mean number of reported chronic conditions was 2.67 (SD = 1.5). In comparison to the LSOA II group, the Ithaca group residents were significantly older (P < .0001), had more education (P < .0001), and were more likely to live alone (P < .0001) than the LSOA II sample. The Ithaca group also reported a significantly higher number of chronic conditions (P < .0001) than the LSOA II sample. There was no significant difference in gender between these 2 groups.
Table 1. Demographic Characteristics of Study Participants (n = 1854)
| Characteristics | Ithaca (n = 131) No. (%) | LSOA II (n = 1,723) No. (%) | P Value |
|---|---|---|---|
| Age | |||
 65–74 | 10(7.6) | 1035(60.1) | |
| 75–84 | 67(51.2) | 649(37.7) | |
| 85+ | 54(41.2) | 39(2.3) | |
| Mean (SD) | 82.8(5.6) | 74.4(4.0) | <.0001 |
| Female | 84(64.1) | 1084(62.9) | .78 |
| White | 131(100.0) | 1723(100.0) | n/a |
| Education, y, mean (SD) | 17.6(2.7) | 13.7(2.1) | <.0001 |
| Living alone | 64(48.9) | 545(31.6) | <.0001 |
| Chronic conditions, mean (SD) | 2.7(1.5) | 1.7(1.2) | <.0001 |
Table 2, sections a and b, show comparisons of ADLs and IADLs between the Ithaca group and the LSOA II group. These bivariate analyses indicate that there was no significant difference in the overall mean number of ADLs between the 2 groups. For ability to live independently in the community, the results indicate that the LSOA II group had higher IADL impairment than the Ithaca group (0.85 versus 0.49), and the difference was statistically significant (P = .004). Of the individual IADL items, the Ithaca group had a significantly higher proportion of residents reporting difficulty in shopping for groceries than the LSOA II sample. For Nagi disability (Table 2, section c), the Ithaca group reported more difficulty in doing Nagi's activities than the reference group. Of these 7 Nagi's items, self-reported grasping (P < .0001), walking up 10 steps without resting (P = .01), and reaching overhead difficulty (P = .05) were significantly higher in the Ithaca group. However, in the bivariate analysis, there was no statistically significant difference between the overall mean of the 2 groups.
Table 2. Self-reported Difficulties with Activities of Daily Living (ADLs), Instrumental Activities of Daily Living (IADLs), and Nagi's Disability (n = 1854)
| a. ADLs | b. IADLs | c. Nagi's | |||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|
| Activities | Ithaca | LSOA II | P Value | Activities | Ithaca | LSOA II | P Value | Activities | Ithaca | LSOA II | P Value |
| No. (%) | No. (%) | No. (%) | No. (%) | No. (%) | No. (%) | ||||||
| Bathing/Showering | 11(8.4) | 156(9.1) | .80 | Preparing meals | 8(6.1) | 70(4.1) | .26 | Walking up 10 steps without resting | 38(29.0) | 336(19.7) | .01 |
| Walking across room | 45(34.4) | 426(24.8) | .02 | Grocery Shopping | 29(22.1) | 144(8.4) | <.0001 | Stooping, crouching, kneeling | 63(48.1) | 730(42.4) | .21 |
| Dressing | 8(6.1) | 112(6.5) | .86 | Managing money | 12(9.2) | 41(2.4) | <.0001 | Reaching overhead | 11(8.4) | 254(14.7) | .05 |
| Eating | 3(2.3) | 54(3.1) | .59 | Using the telephone | 12(9.2) | 54(3.1) | .0003 | Walking 0.25 mile | 33(25.2) | 502(29.3) | .32 |
| Transferring | 19(14.5) | 235(13.7) | .78 | Doing light housework | 13(9.9) | 71(4.1) | .002 | Reaching out as if to shake hands | 2(1.5) | 23(1.3) | .85 |
| Toileting | 2(1.5) | 72(4.2) | .13 | Doing heavy housework | 37(28.2) | 464(27.0) | .75 | Grasping | 35(26.7) | 205(11.9) | <.0001 |
| Lifting/carrying 10 pounds | 24(18.3) | 339(19.7) | .70 | ||||||||
| Mean (SD) | 0.67(1.0) | 0.61(1.2) | .56 | Mean (SD) | 0.49(0.9) | 0.85(1.0) | .004 | Mean (SD) | 1.57(1.6) | 1.39(1.7) | .23 |
Table 3 shows the self-reported chronic conditions between the 2 groups. The Ithaca group had a significantly higher proportion of residents reporting that they had osteoporosis (P = .004), heart conditions (P = .07), cancer (P < .001), and respiratory conditions (P < .0001). The overall mean number of chronic conditions indicated that the Ithaca group had a significantly higher number of chronic conditions than the LSOA II (2.7 versus 1.7; P < .0001) group.
Table 3. Self-reported Chronic Conditions (n = 1854)
| Ithaca | LSOA II | ||
|---|---|---|---|
| Condition | No. (%) | No. (%) | P Value |
| Osteoporosis | 42(32.3) | 362(21.5) | .004 |
| Diabetes | 10(7.6) | 159(9.3) | .54 |
| Arthritis | 67(51.1) | 1005(58.3) | .11 |
| Hypertension | 59(45.0) | 791(46.2) | .80 |
| Heart condition | 19(14.6) | 363(21.3) | .07 |
| Cancer | 33(25.2) | 114(6.6) | <.0001 |
| Respiratory conditions | 45(35.4) | 136(7.9) | <.0001 |
| Mean (SD) | 2.7(1.5) | 1.7(1.2) | <.0001 |
Table 4 shows the results of multivariate linear regression while adjusting for age, gender, education, living arrangement, and chronic conditions. The results in Table 4a show that Ithaca group residents who had comprehensive service access had significantly fewer ADL functional limitations (P = .0009) and Nagi's disabilities (P = .0003) than the LSOA II sample without compatible comprehensive service access. In addition, the CCRC/ILC residents had fewer IADL limitations than the LSOA II sample, although this difference was not statistically significant. For self-rated health, the results (Table 4b) show that residents in the Ithaca group were 4.3 times more likely to have “Good” or better self-rated health (odds ratio [OR] 4.31, confidence interval [CI] 2.03–9.15) than the LSOA II sample.
Table 4. Adjusted Beta Estimates (on-site comprehensive service access/no on-site comprehensive service access)⁎ of Multivariate Linear and Logistic Regressions (n = 1854)
| Outcome Measures | Estimated β† | Centers SE | P Value |
|---|---|---|---|
| ADL‡ | −0.398 | 0.120 | .0009 |
| IADL§ | −0.029 | 0.102 | .774 |
| Nagi∥ | −0.615 | 0.169 | .0003 |
| Outcome Measures | Odds Ratio† | 95% CI |
|---|---|---|
| Self-rated health | 4.31 | (2.03–9.15) |
⁎Reference group (Longitudinal Study on Aging II = no coordinated care). |
†Adjusted for age, gender, education, living arrangement, and chronic conditions. |
‡ADL score range from 0–6 with higher scores indicating worse function. |
§IADL score range from 0–6 with higher scores indicating worse function. |
∥Nagi scores range from 0–7 with higher scores indicating worse function. |
Discussion
The results support our hypothesis that residing in a comprehensive service access setting is associated with better functional outcomes and better self-rated health compared to the sample residing in the community without compatible comprehensive service access. Because the Ithaca sample was significantly older (83 versus 74) and had a higher number of chronic conditions (2.7 versus 1.8) than the LSOA II sample, one might have expected to observe worse physical functioning among the Ithaca group compared to their community-dwelling counterparts; instead, no significant functional difference in ADLs and Nagi's were revealed in bivariate analyses. Furthermore, multivariate analyses showed that after adjusting for age, gender, education, living arrangement, and chronic conditions, the Ithaca group actually had fewer ADL and Nagi's disabilities than the community-dwelling sample. It is reasonable to believe that these significant differences in functional outcomes may be associated with the benefits of on-site comprehensive service access that was readily available to the Ithaca group.
The potential benefits of having access to comprehensive service on functional outcomes and self-reported health status evidenced in this study may be discussed from medical, social, psychological, and environmental perspectives.
From the medical perspective, the result of a disease or physiological condition that is intrinsic to the individual may reduce the individual's ability to perform daily tasks for self-care and independent living. With on-site comprehensive service access, available health and social services, medical attention, treatments, or rehabilitation before onset of impairment may be provided to the Ithaca group in a timely manner, this may prevent further disease progression, functional deterioration and thus lessen functional disability. Our results support previous findings that the availability of a wide spectrum of services is likely to bring improvements in physical health and thus slow down or delay the onset of dependency.10 On-site comprehensive service access is not necessarily readily available to community-dwelling LSOA II older adults. If a community-dwelling older adult needs various health care services after an acute hospitalization for example, the needed post-acute care would have to be coordinated by the individual, family members, or caregivers. Navigating through our fragmented and complicated medical system often results in delays, as well as sometimes inadequate medical services. Without comprehensive service access readily available, the progression of disease may be accelerated and thus hasten functional disability.
From a social perspective, increased opportunities for social interaction in the Ithaca group may be associated with the favorable outcomes observed in the current study. Participants of the Ithaca group have many social programs and activities readily available on campus, and the natural campus living environment facilitates social gathering and socialization; these social integration mechanisms promote social support and prevent isolation, which in turn may lead to positive health outcomes observed in this study. Conversely, the LSOA II community-dwelling older adults may have less opportunity to access various health screening, prevention, or social programs/activities held in senior centers. Among other access issues, geographical location and means of transportation could be difficult issues. For example, many older adults have vision impairments and are unable to drive; gaining access to health and social programs in the senior center often becomes cumbersome in coordinating transportation due to different working schedules of family members or friends. Many community-dwelling older adults may forgo these social activities and become more isolated. This may have adverse effects on health and functional outcomes.12, 13
Psychological well-being involved both in thought processes and behavior can be dictated by health status, education, and life experiences, but it also can be affected by active participation in social activities and social involvement. Participants of the Ithaca group have access to many social programs and activities on campus, which may result in better psychological well-being, and hence better physical function and this finding is consistent with previous studies.15, 16 Although psychological well-being cannot cure disease, relieve pain, or improve functional disabilities, it can cushion tragic events (eg, death of spouse or loved ones) that may lead to depression and aggravation of chronic conditions. Better psychological well-being may indirectly contribute to better physical functioning in the Ithaca group.
“How well we age depends more on how we live than on our genes” and “our relationship to our environment heavily determines our mental attitude and behavior”33 From an environmental perspective, the physical environments of comprehensive service access settings may contribute to the functional and health benefits observed. In the Ithaca group, the housing and living environments are designed to accommodate the special needs of older adults with various levels of functional limitations or disabilities, and hence are conducive and encouraging to functional independence and autonomy. For example, handrails and grab bars in the bathroom, raised toilet seats, and wider access doors are designed to compensate for functional limitation and are, therefore, conducive to independent living. Having compensatory assistive devices in place can effectively remove or negate some functional disabilities. As another example, even-surfaced and well-lighted outside walkways on campus are designed to encourage and promote exercise and physical activities; safety concerns and practicality for residents with walkers or wheelchairs are taken into consideration.
Finally, an interesting finding of this study regarding self-reported health is that the Ithaca group was 4 times more likely to report that they had excellent/very good/good health than the LSOA II group. Self-reported health is an indicator of health status. Studies have shown that self-reported health is significantly associated with chronic conditions and functional disability. Our finding regarding self-reported health is different from these previous studies.34, 35, 36 The Ithaca group was older, had a higher number of chronic conditions, and a higher proportion lived alone. In many regards, one would expect the Ithaca group to have worse self-rated health than the LSOA II group. However, after adjusting for the baseline differences, the significant association of on-site comprehensive service access on self-rated health was persistently better in the Ithaca group. Thus, it appears that the positive association of on-site comprehensive service access is multidimensional, enhancing not only functional outcomes but also overall self-rated health.
Several caveats concerning these findings are in order. First, the study sites are located in Ithaca, NY, a college town where residents of the 2 communities are predominately white and highly educated compared with the general population. The findings of this study may be generalizable only to similar populations of residents in CCRC or ILC&LAH settings, like the setting at Kendal and Longview under study. Second, impairments and functional limitations affect so many aspects of our individual, family, or social life, but, because of the epidemiological nature of the study, not all potential confounding variables were measurable. For example, depression may have profound influence on performance of ADL tasks, but LSOA II does not have the data available for comparisons. And, finally, these analyses were based on one wave of data, which did not allow us to observe how health changes were affected by on-site comprehensive service access over time.
Despite these possible limitations, the positive association between comprehensive service access and functional outcomes and self-rated health are evidenced in our findings. Availability of on-site comprehensive service access such as health and social services seems to be beneficial in fostering functional independence and autonomy among older adults.
Acknowledgments
We are grateful to the participants at Longview and Kendal at Ithaca who completed the surveys. Without their cooperation and support, this study would not have been possible. Our thanks also goes to Mr. Daniel Governanti, the executive Director of Kendal at Ithaca, who provided our team with consistent guidance and support.
References
- . A Profile of Older Americans, 2007. http://agingcarefl.org/aging/AOA–2007profile.pdfAccessed September 11, 2008.
- . Assisted living literature through May 2004: Taking stock. Gerontologist. 2007;47:125–140
- . The search and selection of assisted living facilties by elders and family. Med Care. 2007;45:729–738
- . Patterns of service use in a continuing care retirement community. Gerontologist. 2000;40:698–705
- . http://www.aspe.hhs.govAccessed June 3, 2008
- In: Krout JA, Wethington E editor. Residential Choices and Experiences of Older Adults: Pathways to Life Quality. New York: Springer Publishing; 2003;
- . Why healthy elders move to a continuing care retirement community. N C Med J. 1996;57:378–380
- . Regional retirement migration: the case of Cape Cod. J Gerontol. 1991;46:S33–S42
- . Older persons who move: Reasons and health consequences. J Appl Gerontol. 1996;15:325–344
- . Assessing the health impact of age-specific housing. Health Soc Care Community. 2001;9:228–234
- . Psychological stress as a predictor of psychological adjustment and health status in patients with rheumatoid arthritis. Patient Educ Couns. 2005;59:192–198
- Determinants of disability after lower extremity fracture. J Trauma. 2000;49:1002–1011
- . Social relationships, social support, and patterns of cognitive aging in healthy, high-functioning older adults: MacArthur studies of successful aging. Health Psychol. 2001;20:243–255
- . The Benefits of Independent Living: A Comparative Analysis of Residents and Non-Residents 2003. www.seniorshousing.orgAccessed August 15, 2008
- . Stamina in later life. Soc Sci Med. 1985;21:997–1006
- Emotional vitality among disabled older women: The Women's Health and Aging Study. J Am Geriatr Soc. 1998;46:807–815
- . Targeting elders for geriatric evaluation and management: Reliability, validity, and practicality of a questionnaire. Aging (Milano). 1995;7:159–164
- Physical activity, functional limitations, and disability in older adults. J Am Geriatr Soc. 2000;48:1264–1272
- . High body mass index does not predict mortality in older people: Analysis of the Longitudinal Study of Aging. J Am Geriatr Soc. 2001;49:968–979
- . The impact of cognitive functioning on mortality and the development of functional disability in older adults with diabetes: The second longitudinal study on aging. BMC Geriatr. 2006;6:8
- . Physical activity, disability, and the risk of hospitalization for breast cancer among older women. J Gerontol A Biol Sci Med Sci. 2000;55:M418–M421
- . The predictive value of self assessed general, physical, and mental health on functional decline and mortality in older adults. J Epidemiol Community Health. 2000;54:123–129
- . Longitudinal Studies on Aging. http://www.cdc.gov/nchs/LSOA.htmAccessed June 3, 2008
- . Measures of cognitive functioning in the 1994–2000 second longitudinal study of aging. National Health Stat Report. 2008;1–15July 7
- . Longitudinal Studies on Aging: LSOA II. http://www.cdc.gov/nchs/about/otheract/aging/lsoa2.htm#surveyAccessed June 3, 2008
- . Telephone Interview for Cognitive Status (TICS): A Professional Manual. Odessa, FL: Psychological Assessment Resources, Inc; 2003;
- Studies of illness in the aged: The index of ADL: A standardized measure of biological and psychosocial function. JAMA. 1963;185:914–919
- . Assessment of older people: Self-maintaining and instrumental activities of daily living. Gerontologist. 1969;9:179–186
- . The Supplement on Aging to the 1984 National Health Interview Survey (Forum/USDHHS 1987 (2004). Older Americans 2004: Key Indicators of Well-Being). Washinton, DC: US Government Printing Office, Federal Interagency Forum on Aging-Related Statistitics; 2004;
- . An epidemiology of disability among adults in the United States. Milbank Mem Fund Q Health Soc. 1976;54:439–467
- . Self-rated health (Comparisons between three different measures. Results from a population study). Int J Epidemiol. 2001;30:326–333
- . Self-rated health and mortality: a review of twenty-seven community studies. J Health Soc Behav. 1997;38:21–37
- . ElderHouse: Planning Your Best Home Ever. White River Junction, Vermont: Chelsea Green Publishing Company; 2002;14
- . Factors associated with change in physical functioning in the elderly: A six-year prospective study. J Aging Health. 1993;5:140–153
- . Treatment of major depression in later life: A life cycle perspective. Psychiatr Q. 1997;68:221–246
- . Health status indicators among community-dwelling elders with arthritis: The Bambui health and aging study. J Rheumatol. 2006;33:342–347
This study was supported by a research grant from the SUNY at Albany Faculty Research Awards Program (FRAP-A).
PII: S1525-8610(08)00322-8
doi:10.1016/j.jamda.2008.09.003
© 2009 American Medical Directors Association. Published by Elsevier Inc. All rights reserved.
