Authors
Guzel Discigil MD¹
Ayfer Gemalmaz MD¹
Nil Tekin MD²
¹Adnan Menderes University Department of Family Medicine Aydin,TURKEY
²Narlidere Geriatric Center, Izmir, TURKEY

Corresponding Authors:
Guzel Discigil, MD
Assistant Professor
Adnan Menderes University Medical Faculty,
Department of Family Medicine
1962 sokak No:30/1
Aydin, 09100
TURKEY
E-mail : guzeld@yahoo.com
Phone : +90 256 213 9373
Fax : +90 256 214 6495

Co-authors:
Ayfer Gemalmaz MD
Adnan Menderes University Medical Faculty,
Department of Family Medicine
1962 sokak No:30/1 Aydin, 09100 TURKEY
e-mail: guzeld@yahoo.com
Phone : +90 256 213 9373
Fax : +90 256 214 6495

Nil Tekin MD
Narlidere Geriatric Center, Izmir, TURKEY
e- mail: ntekin@adu.edu.tr
Phone: +90 232 238 5243
Fax: : +90 256 214 6495

Aging is a process of gradual and spontaneous change in individual cells and organs resulting in changes in function, in appearance, and thus in the experience of aging.⁽¹⁾ It is a known fact that the world's population is getting older. The elderly population is expected to double in the next thirty years in the United States and an increased rate of 62.0% is expected in Europe between 1990-2025^(2,3). The elderly population increases gradually in Turkey and it is expected to reach a rate of 9.0% until 2025, despite having a younger population compared to developed countries^(4,5). Care of elderly patients requires special knowledge of the presentation and management of disease in this age group, including physiologic and social problems and requires attention to the functional consequences of disease and disability⁽⁶⁾.

Comprehensive geriatric assessment provides interdisciplinary assessment, treatment planning, case management, and, often, rehabilitation for frail elderly persons and is especially important for those suspected of needing long-term institutional care⁽⁷⁾. So it is defined as a multidimensional, multidisciplinary diagnostic process, to determine medical, psychosocial, and functional capacities and problems in elderly. In addition, comprehensive geriatric assessment programs linking geriatric evaluation, are effective for improving survival and function in the elderly^(8,9). It is important to understand disease and disability measurement needs, factors for healthy aging cost-effective approach in order to provide proper health care for the elderly⁽¹⁰⁾.

In the present study, we aimed to perform comprehensive geriatric assessment in nursing home residents and community-dwelling elderly and compare functional disabilities and related factors in these two elderly groups living in different surroundings.

Statistical analyses included descriptive statistics, student t-test, and univariate and one hundred and one, of 110 elderly living in Aydin Nursing Home were included in the study. Informed consent was obtained from each participant. Nine bed-ridden elderly were excluded from the study due to inability to obtain informed consent. Katz activities of daily living (ADL), Lawton instrumental activities of daily living (IADL) and a questionnaire regarding demographic and medical data were filled out by face to face interview and from nursing home medical records of elderly. Tinetti balance and gait evaluation (TBG) and mini mental state examination (MMSE) were applied by trained physicians.

One hundred elderly over 65 years old were randomly chosen from registered patients of a Family Medicine out-patient clinic, and were called and invited to the clinic for evaluation. Eleven elderly declined to participate and twelve elderly were excluded due to incomplete participation. A total of 77 community dwelling elderly were included in the study. Comprehensive geriatric assessment including Katz, ADL, Lawton IADL, TBG, and MMSE were applied by the same physicians.

Comprehensive geriatric assessment begins with a review of major categories of functional ability, which are activities of daily living (ADL) and instrumental activities of daily living (IADL). ADL are self care activities that a person must perform every day such as eating, dressing, bathing, transferring between the bed and a chair, using the toilet, controlling bladder and bowel. IADL are activities that enable a person to live independently in his/her house, such as preparing meals, performing housework, taking drugs, running errands, managing finances, using the telephone. Deficits in ADL and IADL indicate the risk of becoming more dependent in performing these activities⁽¹⁾. Mini-Mental State Examination is a validated screening test to assess cognitive function, which can be administrated reliably by trained health providers. It measures attention, orientation, registration and recall memory, language function and praxis⁽¹⁾. A score of 24 and lower on MMSE might be consistent with cognitive impairment and further examination is needed⁽¹¹⁾. Tinetti balance and gait evaluation test is an effective and simple screening test to assess balance and gait status of the elderly. A score of 19 and lower for Tinetti Balance and Gait evaluation might be consistent with fall risk^(12,13).

Statistical analyses included descriptive statistics, and univariate and multivariate analysis. Chi-square or Fisher exact test was used for univariate analysis. Logistic regression analysis was used as multivariate analysis to assess the associations with the two elderly groups and comprehensive geriatric assessment domains, ADL, IADL, TBG, and MMSE. A statistical package for the social sciences (SPSS) version 10.0 was used for statistical analysis.

Mean age of the total group was 73,87 ± 7,63 and age range was between 60-95 years of age. There were ninety one (51.1%) women and 87 (48.95) men. Seventy-seven elderly were living in the community and 101 were nursing home residents. Table1 shows demographic characteristics of the elderly.

Table1: Demographic characteristics of nursing home and community-dwelling elderly.

	Nursing Home elderly (n=101) n (%)	Community - dwelling elderly (n=77) n (%)
Age 74 years old 75-84 years old 85 years old	44 (43,6 %) 40 (39,6 %) 17 (16,8 %)	55 (71,4 %) 18 (23,4 %) 4 (5,2 %)
Gender Men Women	64 (63,4 %) 37 (36,6 %)	23 (29,9 %) 54 (70,1 %)
Marital Status Married Not married Divorced or separated	9 (8,9 %) 14 (13,9 %) 78 (77,2 %)	38 (49,4 %) 0 (0 %) 39 (50,6 %)
Education Illiterate Primary school Middle school High school	33 (32,7 %) 52 (50,5 %) 8 (7,9 %) 8 ( 7,9 %)	45 (58,4 %) 30 (39,0 %) 1 (1,3 %) 1 (1,3 %)
Occupation Housewife Farmer Other	32 (31,7 %) 15 (14,9 %) 54 (53,4 %)	39 (50,6 %) 28 (36,4 %) 10 (13,0 %)
Children None 1-2 3-4 4	26 (25,7 %) 31 (30,7 %) 35 (34,7 %) 9 (8,9 %)	6 (7,8 %) 15 (19,5 %) 35 (45,4 %) 21 (27,3 %)

Elderly living in nursing homes were older (p=0.001), more likely to be single (p=0.001), male (p=0.001), and to have less children (p=0.001) than the elderly living in the community.
Hypertension rate was 48.9%, and it was the most prevalent chronic disease in the whole group. Coronary artery disease (p=0.001), cataract (p=0.000) and hearing deficits (p=0.01) were more common among elderly living in nursing home.

Mean total score of TBG was 19.55 for elderly living in nursing homes, whereas it was 23.51 for elderly living in the community. This result shows us that nursing home residents carry a risk of fall. Likewise mean score of MMSE living in nursing home residents was 19.68 whereas it was 25.00 for community dwelling elderly, which also shows us, nursing home residents need further examination in order to rule out cognitive impairment. Table 2 shows mean scores for Katz ADL, Lawton IADL, Tinetti balance and gait and MMSE and their association with elderly in both groups. Results of multivariate analysis showed that community dwelling elderly had 3 to 8 fold better outcomes on ADL (OR=8.11, 95% CI= 2.35-28.83) IADL (OR=6.57, 95% CI= 3.04-14.19) , balance and gait (OR=3.02, 95% CI= 1.51-6.00)and MMSE (OR=5.98, 95% CI= 2.28-15.68).

Table 2: Mean age and mean scores for Katz ADL, Lawton IADL, Tinetti balance and gait and MMSE in elderly living in community, nursing home and the total group.

* p<0.001                   †p<0.01

In the present study, we aimed to conduct comprehensive geriatric assessment in nursing home residents and community-dwelling elderly and compare functional ability and related factors in these two elderly groups.

Urbanization and industrialization has brought about changes in family structure of immigrants in cities. With ageing of the population and tchanges in social relationships, the number of institutionalizations has risen spectacularly during the last decades⁽¹⁴⁾. Transition to core family of the modern world, from traditional extended family has affected elderly and caused isolation⁽¹⁵⁾. In this perspective, geriatric evaluation of institutionalized elderly and elderly living in their own surrounding is important in understanding needs and determining characteristics of health services to elderly living in different surroundings.

Many studies report that mean age, being single and education level are higher in institutionalized elderly, which is similar to our results^(16,17). There is various data about gender distribution both in community dwelling and institutionalized elderly. Studies from developed countries report that higher number of women residents live in nursing home ^(14,18,19). However studies from Turkey predominantly report higher rate of male residency in nursing homes in various locations^{(16, 17, 20, 21)}. In the present study elderly men were more prevalent in nursing homes, similar to other studies from our country. Nursing home preference of elderly men may be explained by cultural characteristics and social initiative of patriarchal communities.

Dey AN. has reported that a significantly large proportion of nursing home residents needed assistance in their ADL's and IADL's (18). In our study, similar to reported results, nursing home residents were highly dependent on ADL and IADL.

Falls are one of the most common geriatric syndromes threatening the independence of older persons. Between 30 and 40 percent of community-dwelling adults older than 65 years fall each year, and the rates are higher for nursing home residents⁽²²⁾. Fracture risk is greater for those living in institutions compared with those living in private homes⁽²³⁾. Impairment of cognitive function, balance and mobility skills increase fall risk⁽²⁴⁾.

Cognitive and behavioral impairment was found to be widespread in institutions regardless of the level of care⁽²⁵⁾. In the present study, 84% of elderly living in nursing homes had low MMSE score, which shows increased risk of cognitive impairment and suggests further examination is required. In addition, Tinetti balance and gait total score was lower, and fall risk was present for those living in nursing homes.

Increases in expected life span should draw attention of health professionals to understand healthy aging, measuring and coping with functional disabilities. In addition elderly living in different surroundings may have different needs. In the present study, we conclude that nursing home residents show lower performance on all four domains of comprehensive geriatric assessment, which were ADL, IADL, MMSE and TBG, than elderly living in the community. The degree and prevalence of functional impairment among elderly people in different surroundings should be taken into consideration when planning health services and availability of quality home care services that might help to cope with functional disabilities among the elderly.