Professional Documents
Culture Documents
Adult Day Care
Adult Day Care
Objectives: To assess outcomes and satisfaction among frail elderly day care clients
and their informal caregivers and the impact of adult day care on the cost of health ser-
vices. Methods: One-hundred eight elderly participants were randomly assigned to
the experimental group (immediate admission to an adult day care center) and 104
participants to the control group (3 months on a waiting list). Results: Participants’
and caregivers’ subjective perceptions of the day center’s effects were positive. How-
ever, using standard research instruments, there was no evidence of an effect of day
center attendance on the client’s anxiety, depression, or functional status; on caregiver
burden; or on the cost of health services. Discussion: It is difficult to demonstrate
objectively the benefits of programs and interventions that are perceived by clients,
caregivers, and staff to have positive effects. In future studies, maintenance of high
levels of participation should be incorporated as an explicit program goal.
AUTHORS’ NOTE: This research was funded by the National Health and Research Devel-
opment Program (Health and Welfare Canada Grant No. 6605-3262-57). The authors wish to
thank the day care centers’ coordinators and staff for their unflagging collaboration; research
assistants Manon Laroche and Lynn Villeneuve; and Daniel Thomas, Christina Wolfson, and
JOURNAL OF AGING AND HEALTH, Vol. 14 No. 2, May 2002 237-259
© 2002 Sage Publications
237
238 JOURNAL OF AGING AND HEALTH / May 2002
Manon Desjardins for their helpful comments. Earlier versions of this work were presented at the
Canadian Association on Gerontology annual meetings in Montreal (1993) and in Calgary
(1987). Correspondence should be sent to Mona Baumgarten, Ph.D., Department of Epidemiol-
ogy and Preventive Medicine, University of Maryland, 660 West Redwood Street, Baltimore
MD 21201; email: [email protected].
Baumgarten et al. / DAY CARE FOR THE FRAIL ELDERLY 239
in reducing caregiver burden and stress. The results are less clear
regarding the day center’s effectiveness in maintaining or restoring the
clients’ functional independence and reducing health care costs.
Methodological problems make it difficult to draw definitive conclu-
sions from these studies. Some studies used a pre-post design and did
not include a control group (Capitman, 1982; Jackson, 1983; Strain
et al., 1987). Several studies used quasi-experimental designs with
control groups composed of a relatively small number of clients who
were not attending the day center (Chappell & Blandford, 1987; Rafferty,
1979; Rathbone-McCuan & Levenson, 1975; Weiler et al., 1976). In
addition, these studies did not always clearly define the client popula-
tion, available resources, and activities of the day centers, making it
difficult to know exactly what was evaluated. One of the most rigorous
studies of day care for older persons is the Veterans Adult Day Health
Care Study (Hedrick et al., 1993), a large, congressionally mandated,
randomized, controlled trial. Because this study was done in the con-
text of the veterans health care system, generalization to non-veteran
community-based adult day care is difficult.
In summary, no rigorous experimental study has been conducted to
evaluate multipurpose adult day care centers. The principal objective
of the current study was to determine the effect of multipurpose day
centers (similar to Conrad et al.’s [1993] moderate-intensity clinical/
social or general purpose day centers) on symptoms of depression and
anxiety in the clients, on caregiver burden, and on the client’s func-
tional status. A second objective was to assess the clients’ and care-
givers’ perception of the extent to which the day center had helped the
clients. Third, we aimed to determine how the day center outcomes
differed according to the level of attendance. Finally, we wished to
quantify the impact of adult day care on the cost of health and social
services.
Method
SETTING
Adult day care centers in the Province of Quebec, Canada, offer the
frail older person, on an outpatient basis, a personalized program of
240 JOURNAL OF AGING AND HEALTH / May 2002
CHOICE OF SITES
At the time of the study, there were 30 geriatric day centers in the
metropolitan Montreal area. We used a questionnaire and structured
interview to gather the data necessary for selecting day centers for the
study. To be selected, the staff members of the day center had to
express their willingness to participate in the study, and the waiting
time for admission to the day center had to be at least 3 months. To
ensure continuity, the center had to demonstrate administrative and
programmatic stability. In addition, to ensure homogeneity among
day care programs, the day center had to offer programs aimed at both
the functional and psychosocial rehabilitation of the clients, empha-
size group rather than individual treatment, include clients suffering
from cognitive disorders, offer respite for caregivers, offer assisted
transportation to clients, and anticipate at least four admissions per
month over the data collection period.
STUDY DESIGN
Because access to day centers at the time of the study had been
widely available in Quebec for more than a decade, it would not have
been acceptable ethically to withhold the service from clients random-
ized to the control group. For the same reason, the amount of time the
control group spent on the waiting list could be no longer than the
average waiting time (approximately 3 months) for clients not
involved in the research project. After extensive consultation with
clinical and administrative personnel from the day centers, we decided
that the 3-month study period was long enough for changes in client
and caregiver well-being, if they were going to occur, to have become
apparent.
PARTICIPANTS
All clients referred to any of the participating day centers were eli-
gible for the study, except (a) those who were younger than 60 years
old, (b) those who could speak neither English nor French, (c) those
who were too cognitively impaired to be interviewed and who did not
have an informal caregiver, and (d) those who were referred to the day
center for individual specialized treatments (e.g., rehabilitation treat-
ment for Parkinson’s patients). Study eligibility was determined by
day center staff using standard criteria provided by the research team.
Day center staff members were also responsible for obtaining written
consent for participation in the study. Once eligibility was determined
and consent obtained, randomization was carried out by the study
coordinator and communicated to the day center.
Clients with urgent needs were not included in the study because it
was ethically unacceptable for them to spend 3 months on the waiting
list in the event that they were randomized to the control group. Clients
were considered to have urgent needs if they were receiving 20 hours
or more per week of home care or if their informal caregiver was expe-
riencing an episode of acute ill health at the time of referral.
The caregiver was defined as the person who was most involved in
assisting the client on a daily basis, regardless of whether the caregiver
and client lived together. Paid caregivers were not eligible. Clients
with no eligible caregiver were included in the study but were consid-
ered only in the analyses concerning the impact of day centers on cli-
ents. Because clients with cognitive impairment (defined as a score of
Baumgarten et al. / DAY CARE FOR THE FRAIL ELDERLY 243
MEASURES
Outcome Variables
Covariates
Costs
DATA COLLECTION
ANALYSIS
Because this was a multicenter study, the first step in the analysis
consisted of determining whether there was heterogeneity in the
results from the different sites. For each outcome variable, the Time 2
value was used as the dependent variable in a multiple linear regres-
sion analysis that included group membership (experimental versus
control) and site as independent variables, the Time 1 value of the out-
come variable as a covariate, and the interaction between group and
site. Because none of the analyses yielded significant interaction
246 JOURNAL OF AGING AND HEALTH / May 2002
terms, we did not consider the site variable in any of the subsequent
analyses.
Although randomization, in principle, should have ensured study
groups that were comparable with respect to important prognostic
variables, we included potential confounders in the analysis to adjust
for any residual confounding. For each outcome variable, multiple lin-
ear regression was carried out with the Time 2 value as dependent vari-
able, group membership (0 = control, 1 = experimental) as independ-
ent variable, along with the Time 1 value of the outcome variable and a
series of potential confounders as covariates. For anxiety and depres-
sion among clients, we included the following covariates:
sociodemographic characteristics (age, sex, education, ethnic group,
and whether the client lived alone), social resources, stressful life
events, and ADL score. For functional status among clients, we
included only sociodemographic characteristics. For caregiver bur-
den, the covariates were caregiver’s age, sex, ethnic group, education,
social resources, and stressful life events and whether the caregiver
lived with the client. For health care costs, we included the client’s
age, sex, education, ADL score, and ethnic group and whether the cli-
ent lived alone.
The primary approach was an intention-to-treat analysis in which
participants were categorized according to the group to which they
were randomized, regardless of whether they remained in that group
for the entire 3-month study period. Although no clients in the control
group were admitted to a day center during the study period, a substan-
tial number of experimental clients had little or no attendance at the
day center. Therefore, secondary analyses were carried out to examine
the effect of attendance on the outcome variables. Clients were classi-
fied according to whether they had attended the day center at least 13
times; this corresponds to an average of once a week over the 3-month
study period and was considered by the day center professionals to
constitute a minimal intervention. For each outcome variable, regres-
sion analysis was carried out, using the Time 2 value as dependent
variable, client’s attendance (0 = less than 13 visits, 1 = 13 visits or
more) as independent variable, and the same covariates as for the
major analyses described above.
Baumgarten et al. / DAY CARE FOR THE FRAIL ELDERLY 247
Results
There were eight day centers in the Montreal region that fulfilled
the eligibility criteria and agreed to participate. Two of the original
participating centers withdrew from the study after enrolling only a
few clients; the clients from these two centers were not included in any
of the analyses. Three of the remaining centers took part in the study
for the entire enrollment period (April 1990 to December 1991). The
other three centers participated for periods varying from 6 to 9
months.
A total of 370 clients were referred to the six participating centers
during the enrollment period. Of these, 35 (9.5%) could not be
included because they had urgent needs, and 55 (14.9%) were ineligi-
ble for other reasons. Of the 280 eligible clients, 29 (10.4%) refused to
sign the consent form. The remaining eligible clients (n = 251) were
randomized. At Time 1, 11 participants provided unreliable or incom-
plete data, 2 could not be reached, 1 died before being contacted for
interview, and 1 refused. Of the remaining 236 participants contacted
at Time 2, 2 could not be reached, 8 refused, 7 had died, 4 had been
institutionalized in the intervening period, and 3 were too sick to be
interviewed. The final sample of 212 clients included 108 clients in
the experimental group and 104 in the control group. Eighty-nine cli-
ents (42.0%) suffered from cognitive impairment and did not contrib-
ute data to the analyses concerning depression and anxiety; these anal-
yses were based on 61 clients in the experimental group and 62
controls. Because 30 clients (14.2%) did not have an eligible care-
giver, the final caregiver sample was made up of 89 in the experimen-
tal group and 93 in the control group. The numbers of clients recruited
by the six participating day centers were 76, 20, 56, 23, 26, and 11,
respectively.
The average age in the source sample (that is, the sample made up
of all 280 eligible participants) was 77.8 years, whereas in the final
sample it was 77.2. The proportion who were women was 73.2% in the
source sample and 73.6% in the final sample. Thus, the final sample
was almost identical to the source sample with respect to these basic
demographic characteristics.
248 JOURNAL OF AGING AND HEALTH / May 2002
Table 1
Baseline Client and Caregiver Characteristics, by Group
Clients
Mean age (years) 76.4 (7.6) 78.0 (6.9)
Age 80 years or older (%) 38.9 43.3
Women (%) 74.1 73.1
More than elementary school (%) 65.7 59.6
Lives alone (%) 48.6 51.5
No informal caregiver (%) 10.2 10.6
MMSE score of less than 22 (%) 28.3 25.0
Clients
Mean age (years) 54.2 (16.2) 58.4 (15.3)
Age 65 years or older (%) 33.7 39.8
Women (%) 73.0 71.0
More than high school (%) 32.6 45.2
Lives alone (%) 42.0 48.4
Lives with client (%) 55.1 48.4
Relationship to client (%)
Spouse 25.0 28.9
Child 46.6 44.4
Other 28.4 26.7
Note. MMSE = Mini–Mental State Exam. Lower score indicates greater cognitive impairment.
Numbers in parentheses represent standard deviations.
quite different (see Table 4). High attendees were slightly older than
low attendees and were somewhat more likely to be male. High
attendees were significantly more likely to have a spouse caregiver
(37.1% vs. 14.7%, respectively) and significantly less likely to have
no caregiver (5.7% vs. 13.2%, respectively). High attendees were
somewhat more impaired cognitively and significantly more impaired
functionally than low attendees. High attendees had somewhat higher
depression scores but slightly lower anxiety scores at baseline than
low attendees. Caregivers of high attendees were slightly older and
slightly more likely to be women. The mean burden score was much
higher among caregivers of high attendees than among caregivers of
low attendees (32.1 versus 17.5, p < .05).
250 JOURNAL OF AGING AND HEALTH / May 2002
Table 2
Outcome Variables at Time 1 and Time 2, by Group
Note. CES-D = Center for Epidemiologic Studies Depression Scale; ADL = activities of daily living.
Table 3
Perception of Day Center’s Effect
Percentage
Clients (n = 57)
Attendance at day center helped client feel moderately or a great deal:
Less depressed 56.2
Less anxious 47.3
More independent 29.8
Less lonely 64.9
Caregivers (n = 86)
Client’s attendance at day center helped caregiver feel moderately
or a great deal:
Less depressed 41.8
Less anxious 50.0
That he or she had more time to pursue own activities 39.6
That his or her relationship with client had improved 25.6
Note. Perceptions based on responses of clients and caregivers in the experimental group.
Outcome variables at Time 1 and Time 2 among high and low atten-
dees are shown in Table 5. Among participants, there were only small
differences between low and high attendees with respect to changes in
Baumgarten et al. / DAY CARE FOR THE FRAIL ELDERLY 251
Table 4
a
Client and Caregiver Characteristics, by Client’s Attendance at Day Center
Clients
Mean age (years) 76.3 (8.2) 77.1 (6.1)
Age 80 years or older (%) 38.2 42.9
Women (%) 77.9 68.6
Relationship to caregivera (%)
Spouse 14.7 37.1
Other 72.1 57.1
No caregiver 13.2 5.7
Mean MMSE score 24.2 (6.0) 21.9 (6.4)
Mean ADL scorea 4.0 (1.2) 4.6 (1.3)
Mean CES-D score 15.7 (11.1) 18.5 (11.8)
Mean anxiety score 39.5 (14.5) 37.2 (10.3)
Caregivers
Mean age (years) 53.3 (16.7) 55.3 (14.8)
Age 65 years or older (%) 30.8 34.4
Women (%) 73.1 78.1
Mean caregiver burden scorea 17.5 (13.5) 32.1 (19.4)
Note. MMSE = Mini–Mental State Exam; ADL = activities of daily living; CES-D = Center for
Epidemiologic Studies Depression Scale. CES-D score and anxiety score were based only on the
responses of cognitively intact clients (51 low attendees and 20 high attendees). Numbers in pa-
rentheses represent standard deviations.
a. Based on clients and caregivers randomized to the experimental group.
*p < .05.
mean CES-D score, mean anxiety score, or mean ADL score. Care-
giver burden decreased substantially among caregivers of high atten-
dees, whereas among caregivers of low attendees, the burden score
increased somewhat. Controlling for potential confounding variables
using linear regression had almost no effect on the magnitude of the
changes, and none of the differences was statistically significant.
The mean cost of services per client over the 3-month study period
was $2,935 (SD = $5,536) in the experimental group and $2,138 (SD =
$4,530) in the control group, expressed in 1991 Canadian dollars.
Although the total cost was higher in the experimental group, the dif-
ference was not statistically significant. Controlling for confounding
252 JOURNAL OF AGING AND HEALTH / May 2002
Table 5
Outcome Variables at Time 1 and Time 2, by Client’s Attendance at Day Center Over 3-Month
Perioda
Note. CES-D = Center for Epidemiologic Studies Depression Scale; ADL = activity of daily living.
a. Based on responses of clients randomized to the experimental group.
*p < .05 for the comparison between groups.
variables had little impact on these results; therefore, only the crude
cost estimates are presented. The experimental group had higher mean
costs than the control group for medical and professional care, institu-
tional long-term care, and acute hospital care. However, the mean cost
in the experimental group for home-based long-term care was lower
than in the control group ($342, SD = $502 vs. $473, SD = $739).
None of the differences in cost for the individual service categories
was statistically significant.
Discussion
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