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Blackwell Science, LtdOxford, UKGGIGeriatrics and Gerontology International1444-15862005 Blackwell Science Asia Pty LtdMarch 2005515358Original ArticleComparison between

different types of careK Akamatsu


et al.

Geriatrics and Gerontology International 2005; 5: 53–58

ORIGINAL ARTICLE

Analysis of comprehensive
geriatric assessment of elderly
residents in a social welfare home
for the aged compared with those
in a residential care home in an
urban area in Japan
Katsuhiro Akamatsu,1 Aya Saito,1 Taizo Wada,2 Masayuki Ishine,2
Matheus Roriz-Cruz,2 Kiyohito Okumiya3 and Kozo Matsubayashi4
1
Department of Social Ecology, Kyoto University Graduate School of Public Health, 2Department of Field
Medicine, Kyoto University Graduate School of Medicine, 3Research Institute for Humanity and Nature and
4
Center for South-east Asian Studies, Kyoto University, Kyoto, Japan

Background: The purpose of the present study was to clarify the influence of the socio-
economic factors during the middle age on the results of comprehensive geriatric assess-
ments in later stage of life.
Methods: A cross-sectional, questionnaire-based study was conducted of elderly resi-
dents in a welfare home for the aged in Osaka and those in a residential care home in
Kyoto. Results of questionnaires pertaining to activities of daily living (ADL), quality of life
(QOL) and a 15-item Geriatric Depression Scale as well as medical and social histories of
the two groups were compared by unpaired T-test and c2 test.
Results: Elderly residents in the welfare home were significantly younger and more were
both male and unmarried or divorced than among those in the residential care home.
Scores in ADLs and QOLs were significantly lower and the prevalence of depression was
significantly higher in residents in the welfare home than in the residential care home.
Conclusion: The ADLs, mental mood and subjective QOLs of residents in the welfare
home were significantly lower than those of residents in the residential care home. The
reason for these differences is suggested to be due to both the differences in the lifestyles
of the residents in their middle age and the difference in the quality and quantity of care
the residents are receiving. Local social welfare government should pay more attention to
lower ADLs and QOLs of residents in welfare homes and increase efforts to improve the
quality and quantity of care for them.

Keywords: activities of daily living, comprehensive geriatric assessment, quality of life, res-
idential care home, social support, social welfare homes for the aged.

Introduction
With a rapid increase in the aged population, the life
Accepted for publication 9 August 2004. styles of elderly people in Japan are diversifying. The
elderly may be living with extended family, in an elderly
Correspondence: Dr Katsuhiro Akamatsu, Department of Field
Medicine, Kyoto University School of Public Health, Yoshida-
household, alone, in an admission-paid residential care
Konoe-cho, Sakyo-ku, Kyoto 606-8501, Japan. Email: home or be institutionalized. Logically, living with
akamatsu@pine.mbox.media.kyoto-u.ac.jp extended family may reduce the cost of health care for

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K Akamatsu et al.

the frail elderly.1 However, the number of extended fam- clinic, a dining room, several halls and a small store. The
ilies in Japan has actually decreased with the growth of number of staff was 97. Another difference between the
the aged population. On the other hand, it has become two homes was the fee. The welfare home was free of
too difficult to bear the burden of taking care of the frail charge, while the residents in residential care home paid
elderly in the nuclear families. Facing to this rapid monthly fees for common facilities and staff in addition
change of the aged community, a long-term care insur- to the large initial payment.
ance system was introduced in 2000 in Japan. Against Providing written informed consent before enroll-
an expected outcome of this long-term care insurance ment, all residential subjects in both homes completed
system, many elderly people have been institutionalized the 65-item questionnaire with or without the assis-
in Japan. In particular, needy elderly people without tance of the staff. The comprehensive geriatric assess-
caregivers have been institutionalized in welfare homes ment included ADLs, screening for depression and
for the aged (‘Yôgo Rôjin Home’, social welfare insti- quantitative assessment of QOL and medical condi-
tutes in Japan) by the approval of the local government. tions. For basic-ADL assessment, each subject rated
On the other hand, some wealthy elderly people with his/her independence in seven items (walking, ascend-
few caregivers have chosen to live in admission-paid ing and descending stairs, feeding, dressing, making
residential care homes. Welfare homes for the aged are his/her toilet, bathing, grooming) in terms of how
under control of the law of welfare, and admission to the much help he/she needed and scored from 3 to 0.
homes is decided by the local government with admis- (3 = completely independent, 2 = need some help,
sion criteria of (i) need; (ii) inferior living condition or 1 = need much help, 0 = completely dependent). The
domestic problem; (iii) independence of ADL; and (iv) items were added to give scores ranging from 0 to 21,
no acute disease. with low scores indicating disability.2–5 Information-
Although comprehensive geriatric assessments related function was defined as the summed score of
(CGA) have been introduced into clinical settings, com- five functions (visual acuity, hearing acuity, conversa-
munity-based settings and some institutions, few geri- tion, memory in one day and use of the telephone)
atric assessments have been introduced to residents in using a rating scale from 0 (impossible) to 3 (completely
welfare homes for the aged or in admission-paid resi- independent), which gives a score ranging from 0 to 15.
dential care homes. We have introduced CGA in a res- For higher-level functional capacity, each subject rated
idential care home in Kyoto and reported that quality of his/her independence in the Tokyo Metropolitan Insti-
life (QOL) of wealthy elderly residents in the home was tute of Gerontology (TMIG) index of competence.6,7
equal to or higher than that of community-dwelling eld- This assessment consists of a 13-item index including
erly people.2,3 The ultimate aim of care for the elderly three sublevels of competence: (i) instrumental ADLs
both in welfare homes for the aged and in residential (five items rated on a yes/no basis: the ability to use
care homes is to sustain activities of daily living (ADL) public transportation, buy daily necessities, prepare
and to improve QOL of their elderly residents. meals, pay bills, handle banking matters); (ii) intellec-
In this paper, to clarify the long-standing socio- tual ADLs (four items rated on a yes/no basis: the abil-
economic influence on ADLs and QOLs of the elderly, ity to fill forms, read newspapers, read books or
we compared findings of CGA such as ADLs, preva- magazines, having interest in television programs or
lence of depression and QOLs between needy residents news articles on health); and (iii) social ADLs (four
in a welfare home for the aged and wealthy residents in items rated on a yes/no basis: the ability to visit friends,
a residential care home in an urban area in Japan. give advice to relatives and friends, visit someone at the
hospital, initiate conversation with younger people).
Methods We screened for depressive symptoms using the Jap-
anese version of the 15-item Geriatric Depression Scale
Study population consisted of 283 residents in a welfare (GDS-15).8,9 We defined depression as a GDS-15 score
home for the aged in Osaka (male : female = 152 : 131, of six or more, with a score of six to nine indicating
mean age: 77.8 ± 7.3 years) and 203 residents in a resi- ‘mild depression’, and a score of 10 or more indicating
dential care home in Kyoto (male : female = 58 : 145, ‘severe depression’. QOL was assessed using a 100 mm
mean age: 80.3 ± 6.6 years). Physical independence at visual analog scale (worst QOL on the left end of the
the time of admission was one of the common admis- scale, best on the right) in the following five items; sub-
sion criteria of the two homes. The residents in the wel- jective sense of health, relationship with family, rela-
fare home in Osaka also had economical difficulties or tionship with friends, financial status and subjective
domestic problems. The home consisted of 300 beds, a happiness.10,11 Lifestyle (current exercise habits, drink-
medical clinic, a dining room, a hall, and a small store. ing alcohol, smoking and so on), and medical histories
The number of the staff was 46. The residential care (histories of stroke, heart diseases and osteoarthropa-
home in Kyoto we evaluated was a condominium-type thies, as well as taking antihypertensive drugs) were also
one with 300 residents, 226 private rooms, a medical assessed.

54
Comparison between different types of care

Statistical analysis was performed using StatView tionship, friendship, financial satisfaction and subjective
ver.5 for Macintosh (SAS institute, Inc., Cary, NC). The happiness) were significantly lower in the residents of
Student’s t-test was used for continuous variables and the welfare home than those in the residents of the res-
c2 test was used for categorical variables. A P-value less idential care home.
than 0.05 was used to indicate statistical significance.
Discussion
Results
Rowe postulated the concept of ‘successful aging’ as the
Two hundred and eighty-three residents in the welfare ultimate aim of geriatric medicine or the care for the
home and 203 residents in the residential care home elderly.12 Successful aging or QOL includes better con-
participated and completed the questionnaire. Residents ditions in physical,13 mental, socio-economical and
with cognitive impairment who could not answer the spiritual dimensions.14,15 CGA has been revealed to be as
questionnaire were excluded. These were 94.3% and useful as medical diagnosis in evaluating ADLs, mental
74.1% of all the eligible residents aged 65 years or older state, social and economic conditions and subjective
in the welfare home and in the residential care home, QOLs in the elderly.16,17
respectively. Reasons for non-participation of eligible In this study, we introduced CGA to residents in a
residents in both homes included hospitalization (60%), welfare home for the aged and a residential care home in
difficulty in communication (30%) and unwillingness to an urban area in Japan. The welfare home for the aged
give informed consent (10%). accepts needy elderly people who have economic diffi-
Table 1 shows the comparison of baseline character- culties and domestic problems according to decisions of
istics between the residents in the two homes. The mean the local government, while the residential care home is
age, rate of residents aged 75 years or older and rate of being chosen by fairly wealthy elderly people who have
female residents were significantly higher in the residen- few caregivers to spend the last stage of their life. Until
tial care home than in the welfare home. Rates of now, few findings of CGA for either residents living in
unmarried, divorced and current smokers were signifi- welfare homes for the aged or those in residential care
cantly higher in the welfare home than in the residential homes have been reported,2,5 probably because the two
care home. Mean monthly income of residents in the types of home for the aged were regarded as being quite
residential care home was 11 times higher than that of different institutions.
residents in the welfare home. As for medical status, This cross-sectional comparative study of CGA for
rates of hypertension and stroke were higher in the wel- elderly residents in the two homes for the elderly clearly
fare home whereas the rate of hyperlipidemia was revealed differences between the two groups. There
higher in the residential care home. were differences in marital status, life style, medical
Table 2 shows the comparison of ADLs between the
residents in the two homes. There were no differences
in the mean score of basic ADL or in the independence
rate of basic ADL between the two groups. However,
information-related functions and advanced ADLs
such as instrumental, intellectual and social ones were
significantly higher in the residents in the residential
care home than those in the welfare home, though the
mean age of residents in the residential care home was
significantly higher than that of residents in the welfare
home.
Table 3 shows the comparison of scores of GDS-15
between the residents in the two homes. Mean score
of GDS-15 and the rate of residents with screening-
based depression defined as GDS-15 score ≥ 6 were
significantly higher in the welfare home (score =
6.1, rate = 53.4%) than in the residential care home
(score = 4.8, rate = 37.5%). The rate of screening-based
severe depression defined as GDS-15 score ≥ 10 was
also significantly higher in the welfare home (20.8%)
than in the residential care home (10.0%).
Figure 1 shows the comparison of scores in quanti-
tative 5-item QOLs using the visual analog scale. All Figure 1 Comparison of scores on quality of life (QOL) scale
QOLs except the sense of subjective health (family rela- (0–100) between elderly residents in the two homes.

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K Akamatsu et al.

Table 1 Comparison of baseline characteristics between residents in the two homes

Welfare home for Residential care P


the aged (n = 283) home (n = 203)
Mean age ± SD. 77.8 ± 7.3 80.3 ± 6.6 < 0.0001
Residents aged ≥ 75 years old (%) 62.9 81.3 < 0.0001
Male/female 152/131 58/145 < 0.0001
Marital state < 0.0001
Widowed (%) 39.1 40.9
Unmarried (%) 30.9 14.3
Divorced (%) 24.8 5.4
Lifestyle
Drinking alcohol (%) 28.4 22.3 0.1313
Smoking (%) 42.9 11.8 < 0.0001
Work or exercise every day (%) 77.3 81.9 0.2328
Mean monthly income ± SD (¥ 10.000 yen) 2.9 ± 3.9 30.7 ± 24.4 < 0.0001
Medical
Medication (%) 88.3 80.4 0.0176
History of hypertension (%) 44.5 33.0 0.0105
History of heart disease (%) 20.1 17.3 0.4209
History of stroke (%) 24.4 5.9 < 0.0001
History of diabetes (%) 10.6 5.9 0.0696
History of hyperlipidemia (%) 14.8 29.1 < 0.0001
History of osteoarthropathy (%) 63.3 64.0 0.4821
History of falls (%) 20.4 22.0 0.6779

Table 2 Comparison of activities of daily living (ADL) scales between elderly residents in two homes

Welfare home Residential P


for the aged care home
Mean scores of basic ADL (0–21) 19.3 ± 2.9 19.5 ± 3.4
Independence on basic ADL (%) 60.1 67.5 0.0946
Information-related functions (0–15) 12.7 ± 2.6 14.3 ± 1.5
Independence on information-related functions (%) 35.7 65.5 < 0.0001
Mean scores of instrumental ADL (0–5) 3.1 ± 1.8 4.3 ± 1.4
Independence on instrumental ADL (%) 33.9 72.4 < 0.0001
Mean scores of intellectual ADL (0–4) 2.1 ± 1.4 3.6 ± 0.9
Independence of intellectual ADL (%) 21.2 74.9 < 0.0001
Mean scores of social role (0–4) 1.4 ± 1.2 2.9 ± 1.2
Independence on social ADL (%) 6.0 44.8 < 0.0001
Mean scores of TMIG (0–13) 6.6 ± 3.7 10.8 ± 2.9
Independence on TMIG (%) 2.5 39.4 < 0.0001
TMIG, Tokyo Metropolitan Institute of Gerontology.

Table 3 Comparisons of scores on geriatric depression scale (GDS-15) between elderly residents in two homes

Welfare home Residential P


for the aged care home
Mean scores in GDS 6.1 ± 3.7 4.8 ± 3.5 < 0.0001
GDS ≥ 6 (%) 53.4 37.5 0.0006
GDS ≥ 10 (%) 20.8 10.0 0.0015

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Comparison between different types of care

conditions, instrumental, intellectual and social ADLs, respective homes. Local government providing social
prevalence of depression and subjective QOL, as well as welfare programs should pay more attention to lower
socio-economic situations. Although the mean age of ADLs and QOLs of residents in welfare homes for the
the elderly people living in the welfare home was lower aged, and should make more effort to improve the qual-
than that of the residents in the residential care home, ity and quantity of care for the elderly residents.
ADLs and QOLs were lower and the prevalence of
depression was higher. These differences might be due Acknowledgments
to social and economical activities and their achieve-
ments during their middle age before admission to the We would like to thank all the elderly residents who par-
homes. The elderly people living in the welfare home ticipated in this study both in the welfare home for the
have socio-economic problems demonstrated by a high aged and in the residential care home. We also thank all
unmarried rate, high divorce rate and low income. The the staff in two homes, who helped with our question-
high numbers of men in the welfare home may have naire survey.
some influence on these results. On the other hand,
most of the elderly residents in the residential care
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