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GUEST EDITORIAL |
University of Minnesota, School of Public Health, Minneapolis.
Address correspondence to Robert L. Kane, MD, University of Minnesota, School of Public Health, D351 Mayo (MMC 197), 420 Delaware St. SE, Minneapolis, MN 55455. E-mail: kanex001{at}umn.edu
CRITICS of observational studies, even those that employ sophisticated statistical models to address issues around selection bias, are quick to challenge any hard claims to causation. Even more tenuous are the claims from epidemiological studies. These critics like to compare these studies to the astronomical observations of Ptolemy, who could predict the motions of stars with great accuracy but completely misinterpreted their meaning.
The article by Professor Gill and colleagues in this issue of the Journal (1) raises an intriguing observation—namely, that losing the ability to bathe oneself is associated with a higher likelihood of a long-term admission to a nursing home. One might be content to acknowledge this risk factor and move on. After all, any geriatrician knows that bathing is an early-loss Activity of Daily Living (ADL) (2). However, the authors, after warning about confusing association and cause, use these findings to suggest that efforts directed toward interventions intended to prevent and remediate bathing disability have the potential to reduce the burden and expense of long-term care services. Now that sounds pretty causal.
What might be going on here? Bathing as a risk factor seems quite feasible. There are two types of risk factors: those that simply predict (such as age or socioeconomic status) and those that are malleable (cholesterol or high blood pressure). Bathing is more likely in the former category, but in what form? Is the crucial element the lack of a bath or the inability to bathe? Providing services can address the former but will not change the latter. Bathing may be the predictor of greater disability now or in the future. But in Gill's study bathing, persists as a risk factor even when nonbathing disability is accounted for. The risk level drops substantially (from 3.76 to 1.90) but it is still there.
The literature on risk factors for nursing home admission is confusing to say the least. A 7-year follow-up of the AHEAD (Assets and Health Dynamics Among the Oldest Old) cohort showed that disability (ADL and IADL [Instrumental ADL]) and dementia played important roles, along with age, race, gender, socioeconomic status, and available caregivers (3). A biracial study in North Carolina found no effect of ADL or IADL impairment but a strong effect from cognitive impairment (4). Fear of falling has been cited as a major risk factor (5). Risk factors for PACE [Program of All-Inclusive Care for the Elderly] enrollees, who are presumably getting more intensive care and are already nursing home certifiable, include age, IADLs, and bowel incontinence (6). Urinary incontinence was a risk factor for both ADL decline and nursing home admission (7). An earlier 10-year follow-up identified age, ADLs, and restricted outside mobility as risk factors (8).
Do we really think that the inability to bathe is enough to put a person in a nursing home, or conversely, that bathing people better or more frequently will keep them out of nursing homes? Bathing is one of the ADLs performed less frequently. Will getting people help with bathing delay nursing home admissions when a large body of literature dating back to the Channeling Demonstration (9) offers a mixed picture about the effectiveness of even substantial home- and community-based services on preventing nursing home admissions unless there is an active effort to shift the locus of care (10–13)? By contrast, two meta-analyses on the effects of preventive home visits on nursing home placement suggested a benefit, at least for persons with relatively good functional status (14,15).
Addressing just one element in what is often a complex set of demands for informal care seems like a small step. Bathing was not high on the list of reasons caregivers gave for nursing home placements (16).
A more attractive thought is that bathing is related to some other factor, also associated more causally with admission to a nursing home, but what can it be? Gill's analysis controlled for age, sex, race, physical frailty, cognitive impairment, body mass index, chronic conditions, persistent nonbathing disability, and acute hospitalization in the prior month.
References
This article has been cited by other articles:
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  L. Coll-Planas, T. Nikolaus, and E. P. Loayza WHAT CAN IT BE AND WHAT WAS IT REALLY? ABOUT BATHING AND URINARY INCONTINENCE LEADING TO NURSING HOME ADMISSION J. Gerontol. A Biol. Sci. Med. Sci., June 1, 2007; 62(6): 681 - 681. [Full Text] [PDF]
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