A. THOSE NOW IN INSTITUTIONS

At the end of 1971, a little over 5 percent of the elderly were in institutions. Some 1,106,103 were in nursing homes and about 100,000 were in mental institutions. (The aged constitute almost 30 percent of mental hospital inpatients.)

1

The 5 percent figure is roughly comparable to the percentage of institutionalized elderly in other industrialized nations.2

And yet the 5 percent figure is deceptive. The number of people actually in institutions is not a definitive measure of the number of people who may have chronic illness and may need treatment. The 5 percent figure represents only the number of elderly in nursing homes and related facilities on any given day. Recent studies indicate an 80 percent or higher turnover rate.

A widely published study by Dr. Robert Kastenbaum of Wayne State University notes: "While one in 20 seniors is in a nursing home or related facility on any given day, one out of five seniors will spend some time in a nursing home during a lifetime.” 4

B. ESTIMATES OF REAL NEED

How many older Americans need nursing home care? As indicated above, the 5 percent figure can be misleading. The most persuasive estimates mirror Dr. Kastenbaum's finding that one senior in five will spend some time in a nursing home prior to his death. A recent working paper by Burton Dunlop of the Urban Institute estimates that 25 percent of the total aged population (or about 5 million people) require some type of care for chronic illness. Two million receive care in nursing homes or elsewhere. Among the remaining 3 million requiring care according to Dunlop, the breakdown would be as follows: nursing homes, 600,000; home health care, 1.3 million; congregate living facilities or help in preparing their meals, another 1.1 million.5

It appears evident that if the 2.4 million elderly in the community do not have their needs for home health, supportive service and meal services met, they will deteriorate to the point where institutionalization will be necessary, or they will die.

C. WHO CAN AFFORD LONG-TERM CARE?

It is a simple fact that most older Americans cannot afford the long-term care they require.

The financial chasm between need and ability to pay can be readily summed up:

Average nursing home charges in the United States are about $600 a month, and average Social Security benefits for a retired couple amount to $310 a month.

1 See reference No. 1, p. 397, reference No. 12, p. 3, and results of Subcommittee Questionnaire to State Departments of Mental Health in Supporting Paper Number 7. (See p. 27 for references mentioned in footnotes.)

2 Shanas, Ethel, "Measuring the Home Health Needs of the Aged in Five Countries," Journal of Gerontology, Vol. 26, No. 1 (1971), pp. 37–40.

See reference No. 13, p. 16-17. A figure of 86 percent per year is offered by reference No. 12, p. 4.

Kastenbaum, Robert, "The Four Percent Fallacy", presented to the 1972 Annual Meeting of the Gerontological Society, as printed in Aging and Human Development, Vol. 4, No. 1, 1973.

See reference No. 19, pp. 2, 11, 19.

Moreover, Medicare is of little help, paying for the care of only 70,000 persons on any given day out of the 1 million in longterm care facilities. It is only Medicaid-a Federal-State program requiring a means test-which is extensively used.

Many are too proud to seek welfare. Asset limitations constitute another barrier. Some elderly persons, who would otherwise qualify, refuse to participate because of their reluctance to lower their assets by (1) accepting a lien on their homes, or (2) reducing their savings. D. A PORTRAIT OF THE NURSING HOME POPULATION

One million older Americans are in nursing homes. What are they like? The following summary discusses facts which must be considered in any evaluation of long-term care in this Nation:

They are very old.-The average age of patients is 82; 95 percent are over 65 and 70 percent over 70.7

Most of them are female.-Women outnumber men two to one in pre-1970 studies and three to one in more recent tabulations.8

Most of them are widows.-Sixty-three percent are widowed; 22 percent never married; about 5 percent were divorced and only 10 percent are married.9

They are alone. Since most nursing home patients are in their 70's and 80's they may well have outlived their own children. Almost 50 percent have no viable relationship with a close relative, and another 30 percent have only collateral relatives near their own age.10

The great majority are white.-96 percent of nursing home patients are white, with blacks accounting for an additional 2 percent. The remainder includes diverse groups such as Mexican-Americans, elderly Asians or Indians, etc.11

Most of them come to the nursing home from their private homes. More than 55 percent of patients came to the long-term care facility from their own or relatives homes; 32 percent came from hospitals (22 percent from general and 10 percent from State mental hospitals); 13 percent came from other nursing homes or homes for the aged, boarding homes, or other housing. 12

Most of them could expect to be in a nursing home well over a year. But many studies indicate that the length of stay in a nursing home is 2 or more years.1

13

Most patients entering a nursing home will die there.-There is great variation in statistics on this subject. Some studies indicate that

"Trends in Long-Term Care", Part 18, hearing by the Subcommittee on Long-Term Care, Washington, D.C., Öctober 28, 1971, p. 2006.

See reference No. 25: reference No. 15, p. 17: reference No. 23, p. 8; reference No. 8, p. 3. These sources and others indicate an average age from 79 to 83.

8 There is a consensus of opinion concerning this figure. See reference No. 12, p. 3; reference No. 15, p. 17.

See reference No. 25; reference No. 17, p. 13.

10 See reference No. 25: reference No. 17, p. 13; reference No. 22, p. 32.

11 See reference 8, pp. 3-4. See also "Trends in Long-Term Care", Part 20, hearing by the Subcommittee on Long-Term Care, Washington. D.C.. August 10, 1972, p. 2439.

12 See reference No. 17, p. 15. See also "Selected Institutional Characteristics of LongTerm Care Facilities", George Washington University, Department of Health Care Administration, Long-Term Care Monograph Series, No. 4 (1970).

13 Measuring length of stay in long-term care facilities is difficult and subject to considerable error. Complicating this measurement is the fact that patients may move from nursing home to nursing home, or from nursing home to hospital and back again several times in one year. However, four sources indicate a length of stay of over two years. See reference No. 21, p. 25; reference No. 25, p. 4; reference No. 23, p. 11; reference No. 17. p. 17; and reference No. 22, p. 33.

87 percent of patients died in the nursing home; others reveal that only 4 percent of nursing home patients can ever be returned to the community. The more conservative figures indicate that 50 percent of nursing home patients die in nursing homes; 21 percent are returned to hospitals; 19 percent are sent home (or to their relatives homes) and 10 percent are placed in other accommodations.1

Nursing home patients generally have about four chronic or crippling disabilities.—Authoritative studies reveal that nursing home patients have 3.8 disabilities. Cardiovascular disease ranks first, experienced by 65 percent of the patients. What is loosely termed senility is generally found among 20 percent of the patients; fractures are third most prevalent at 11 percent, followed by arthritis at 10 percent.15

A majority of patients are mentally impaired.-Widely supported data establishes that 55 percent or more of long-term care patients are mentally impaired. One study, however, put the figure at 80 percent.16

Less than half of the patients can walk.-About 55 percent require assistance in bathing; 47 percent need help in dressing; 11 percent in eating and 33 percent are incontinent."

They take large quantities of drugs.-The average nursing home patient takes 4.4 different drugs per day, some taken 2 and 3 times; 70 percent take five or more drugs per day. Some recent studies average seven different drugs a day. The average cost of drugs per patient is $300 per year.18

They regard the nursing home with fear and hostility, and there are sharp increases in the death rate associated with transfer to nursing homes. Much evidence clearly indicates that old people look upon a nursing home with fear and hostility. It has been documented that old people believe entry into a home is a prelude to death, and that there is a negative relationship between survival and institutionalization. Substantially higher death rates were recorded among those admitted to nursing homes than among control groups, generally those on a list waiting admission.

This phenomenon has been termed "transplantation shock" by one researcher, who recorded a 42 percent death rate for those admitted to institutional facilities and 28 percent for those waiting admission.

14 See reference No. 17, p. 25; reference No. 22, p. 34: "Trends in Long-Term Care", Part 1, hearing by the Subcommittee on Long-Term Care, Washington, D.C., July 30, 1969, testimony of Joseph Hunt, Commissioner, Rehabilitation Services Administration, Social and Rehabilitation Service, U.S. Department of Health, Education, and Welfare, p. 18; and Reference No. 12, p. 4.

15 See reference No. 23, pp. 12-13; reference No. 22, pp. 37 and 41; reference No. 10, p. 11. 18 Mental Health Care and the Elderly: Shortcomings in Public Policy, report of the Special Committee on Aging, November 1971, p. 8; Fisch, M., Shaninian, S., and Goldfarb, A., "Early brain damage in the aged: a community and clinical study," Office of Consultant on Services for the Aged, State of New York Department of Mental Hygiene, duplicated (1962) Goldfarb, A.. "Prevalence of psychiatric disorder in metropolitan old age and nursing homes." Journal of American Geriatric Society (1962), pp. 77-84; Goldfarb, Alvin I.. "The Senile Older Person in Selected Papers." 5th Annual Conf. of State Executives on Aging, U.S. Department of Health, Education, and Welfare, Washington, D.C. 1965; Lowenthal, M.. "Social isolation and mental illness in old age," Amer. Soc. Rev., 29, 1964. pp. 54-70; National Center for Health Statistics, 1965, "Characteristics of residents in institutions for the aged and chronically ill--United States," April-June 1963, Public Health Service Publication No. 1000 Serial 12- No. 2. Washington: Government Printing Office. 17 See reference No. 17. p. 20; reference No. 21, pp. 23-24; reference No. 26, p. 5. 18 See reference No. 23, p. 16; reference No. 22, p .42; letter of November 19, 1973 from pharmacist John Rawlings (of Nampa, Idaho) to Senator Frank Church citing an average of 5.6 drugs per patient per day; "A Prospective Study of Drug Preparation and Administration in Extended Care Facilities" by Allan Cheung, Pharm. D. M.P.H., Assistant Professor of Clinical Pharmacy, School of Pharmacy, University of Southern California, Los Angeles, California January 31, 1973 unpublished monograph in Committee files. For more details, see Supporting Paper 2.

Some experts charge that the shock of the uprooting is the cause, and others emphasize attitudes associated with the move. 19

Most nursing home patients are placed in fucilities close to their homes. Five out of six nursing home patients are housed in facilities less than 25 miles away from their community home. Proximity is the major consideration to families of nursing home patients.20

Some have visitors, but most do not.-Estimates vary, but there is agreement that most nursing home patients do not have visitors. This is because a third or more have no relatives. A comprehensive New Hampshire study disclosed that 42 percent had visitors weekly."1

There is little evidence to support the theory that families "dump" their aged into nursing homes.--Most studies indicate that institutionalization is the last, not the first resort, of families. Elaine Brody of the Philadelphia Geriatrics Center has written about families facing this question:

In general they have exhausted all other alternatives, endured severe personal, social and economic stress in the process, and made the final decision with utmost reluctance. This has ceased to be an issue in gerontology.22

E. THE SIGNIFICANCE OF THE "FIVE PERCENT" Many studies and news stories make much of the fact that "only 5 percent of the elderly are in nursing homes."

As has been stated, however, the 5 percent total neither reflects total patient population or overall need for care of chronic illnesses.

The significance of this figure goes far beyond the numbers directly affected.--The quality of care in the latter years of life is important for those in the early years of life, because (1) there is a strong likelihood that their own parents or grandparents will need such care, and (2) the odds are good that they will also need a nursing home at some time in their lives.

Emotions now run strong when a decision must be made about nursing home placement. Part of that emotional reaction is one

10 Blenker, Margaret, "Environmental Change and the Aging Individual", The Gerontologist, Vol. 7, No. 2, June 1967, pp. 101-105; Whittier and Williams, "The CoinciderceConstancy of Mortality Figures for Aged Psychotic Patients Admitted to State Hospitals". Journal of Nervous and Mental Diseases Vol. 124: pp. 618-620, 1956; Kay, Norris and Post, "Prognosis in Psychiatric Disorders of the Elderly", Journal of Mental Science, Vol. 102: pp. 129-140, 1956; Carmargo and Preston, "What Happens to Patients Who Have Been Hospitalized for the First Time When Over 65?", American Journal of Psychiatry, Vol. 102: pp. 168-183, 1945; Lieberman, M. A., "Relationship of Mortality Rates to Entrance to a Home for the Aged", Geriatrics Vol. 16: No. 10: pp. 515-519, 1961; Lieberman, M. A.. "Institionalization of the Aged: Effects on Behavior, Journal of Gerontology, July 1969; Ferrari, N., Institutionalization and Attitude Change in an Aged Population, A Field Test of the Dissenance Theory, Doctoral Dissertation, Western Reserve University, June 1960; Aldrich and Mendkoff, "Relocation of the Aged and Disabled: A Mortality Study", Journal of the American Geriatrics Society, Vol. 11: No. 3: pp. 185-194, 1963; Jasnau, K. F.: "Individualized versus mass transfer of nonpsychotic geriatric patients from mental hospitals to nursing homes, with special reference to the death rate," J. Am. Geriatrics Soc. Vol. 15: 280-284, 1967; Novick, L. J.: "Easing the stress of moving day," Hospitals, Chicago, Aug. 16, 1967.

20 See reference No. 8, p. 5; reference No. 21, p. 43.

21 See reference No. 17, p. 20; reference No. 21, p. 45: reference No. 25, p. 4.

22 Brody, Elaine, "Institutional Settings: Nursing Homes and Other Congregate Living Facilities." Lecture, July 16, 1969, University of Southern California; Friedsam. H. J. and H. R. Dick. "Decisions Leading to Institutionalization of the Aged". Final Report, Social Security Administration Cooperative Research and Demonstration Grant Program. Project 037 (CI) 20-031, unpublished 1963: Kent, Donald P.. "Aging-Fact or Fancy." The Gerontologist, Vol. 5, No. 2, June, 1965; Pincus. Allen, "Toward a Developmental Viewing of Aging for Social Work," Social Work, Vol. 12, No. 3, July, 1967: Lowenthal, Marjorie. Lives in Distress, Basic Books, Inc., N.Y. 1964; and Shanas, Ethel, "Family Responsibilty and the Health of Older People, Journal of Gerontology, XV, 1960.

of possible guilt: "Have we done everything we could?" But part of the reaction is because the nursing home industry has taken its present shape in a very few years. The industry is still young and has made mistakes.

It should be an objective of public policy to insist that mistakes be corrected and that positive advances be made in the quality of care, especially since demand is increasing. The growth of the industry, therefore, is a prime element in any consideration of nursing home care in the United States today.