1This research was funded by the Ontario Ministry of Health Policy and. Research Division ... gramme, and the Alzheimer Society of Canada. The authors thank ...
Copyright 1993 by The Cerontological Society of America The Cerontologist Vol.33, No. 6, 714-720
This longitudinal study of 196 caregiver/care receiver dyads was undertaken to determine the variables predictive of caregiver decision to institutionalize a dependent with dementia. Seven variables (use of services, enjoyment of caregiving, caregiver burden and health, caregiver rating and reaction to care receiver behavior and memory problems, and presence of troublesome behaviors) predicted the decision to institutionalize. Six variables (caregiver health and burden, use of services, care receiver cognitive function and troublesome behaviors, and caregiver reaction to behaviors) predicted actual institutionalization at 18 months. Key Words: Caregiving, Dementia, Institutionalization
Factors Determining the Decision To Institutionalize Dementing Individuals: A Prospective Study1
The burden of caring for an individual with dementia at home has been the focus of much research and discussion in recent years. Studies have documented the degree of burden experienced by caregivers and examined those variables (both caregiver and dependent) which best predict such burden (Morris, Morris, & Britton, 1988; Pearlin, Mullan, Semple, & Skaff, 1990). This research has served to highlight the problems experienced by caregivers and has sensitized professionals and policy makers to their distress. Although it is not realistic to expect all dementing individuals to live in the community until they die, remaining at home as long as possible is the preferred option for most. As the dementia progresses, most families struggle with the decision to terminate community care and accept institutionalization as a necessity. With the population aging and more families facing the task of caring for a dependent with dementia, it will become increasingly important to understand more about the process of choosing institutionalization. In particular, it will be helpful to determine which care receiver/caregiver dyads are at
particular risk for cessation of community care. If particularly vulnerable dyads can be identified, it may be possible to offer them appropriate assistance to prolong community care, improve the quality of such care, or offer assistance in placement should it be appropriate. Myriad factors have been examined and the findings are relatively consistent. Caregiver factors, including physical and emotional health, rather than care receiver factors seem to best correlate with the degree of burden (Morris et al., 1988). Other variables such as social support and coping styles are also important. Caregivers who are younger, employed, and caring for more than one dependent tend to be more likely to choose institutionalization (Colerick & George, 1986; Gilhooly, 1986). Caregivers who report higher initial burden and provide more assistance with day-to-day tasks also choose to institutionalize (Brown, Potter, & Foster, 1990; Morycz, 1985; Zarit, Orr, & Zarit, 1985). Caregivers who enjoy their role are less likely to discontinue community care (Pruchno, Michael, & Potashnik, 1990). In addition, the onset of disturbing behavioral problems in the dependent is an important risk factor for placement in long-term care (Chenoweth & Spencer, 1986; Knopman, Kitto, Deinard, & Heiring, 1988; Morycz, 1985; O'Donnell, Drachman, Barnes, Peterson, Swearer, & Lew, 1992; Steele, Rovner, Chase, & Folstein, 1990). There is conflicting information available on the impact of service use on the decision to discontinue home care. Levin, Sinclair, and Gorbach (1986) found that home help decreased institutionalization rates
1 This research was funded by the Ontario Ministry of Health Policy and Research Division, the National Health and Research Development Programme, and the Alzheimer Society of Canada. The authors thank Carla Zucchero for her assistance in the preparation of the manuscript. They also thank the families and patients and the referral agencies who gave of their time and participated in the research. department of Psychiatry, University of Toronto. Sunnybrook Health Science Centre, 2075 Bayview Avenue, Toronto, Ontario, Canada M4N 3M5. Psychology Department, Centre for Research in Human Development, Concordia University, Montreal. "•Department of Social Work, Sunnybrook Health Science Centre, University of Toronto.
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Carole A. Cohen, MD, 2 Dolores P. Gold, PhD,3 Kenneth I. Shulman, MD, 2 Jacinth Tracey Wortley, BSc,2 Glenda McDonald, MSW,4 and Marcia Wargon, MSW4
f I I ; ; : I ;
\ { ;
Method Subjects The initial phase of the study employed a crosssectional design to examine a wide range of dementing individuals and their primary caregivers in order to include those who were being maintained with varying degrees of success in the community. The sample comprised 196 subjects. Included in the sample were individuals who were being successfully maintained by their relatives at home with only routine medical care, who had been referred for longterm supplementary home care, and who were on waiting lists for admission for permanent institutionalization. Subjects were obtained with the cooperation of a wide variety of community and medical agencies. The following criteria were used to select care receivers and their caregivers for the study: (a) a diagnosis of dementia according to DSM III criteria (American Psychiatric Association, 1980) for at least one year; (b) the dependent resided at home with no extended absences for the past year; (c) the availability of at least one caregiver who provided regular and essential care; and (d) the absence of other active disabling medical conditions of a severity threatening physical independence. Over half of the caregivers (59%) were spouses and 27% were children. The mean age of caregivers was 64.41 years, and 76% were women. The mean duration of caregiving was 3.33 years. The average age of the care receivers was 77.46 years with a mean MiniMental State Exam (MMSE) (Folstein, Folstein & McHugh, 1975) score of 15.79. A total of 70% had Vol. 33, No. 6,1993
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received a diagnosis of senile dementia of the Alzheimer type; 15% had a diagnosis of multi-infarct dementia, and the others had received a diagnosis of dementia of unknown etiology, or senility, from their physician. Care Receiver Assessment Data collected for each care receiver included basic demographic data such as age, sex, socioeconomic, ethnic, and marital status, personal and family history, and characteristics of residence. The presence or absence of severe physical illness and/or reversible causes of dementia was assessed. In addition, a research psychiatrist (C.C.) examined every subject to determine DSM III diagnosis (including those other than Dementia), the score on the MiniMental State Exam (MMSE) as an indicator of cognitive functioning, and the presence or absence of troublesome behaviors (paranoia, aggression, wandering, incontinence). Caregiver Assessment A number of measures were selected to assess the salient caregiver variables, based largely upon the recommendations of Zarit et al. (1985) and supplemented by measures suggested by Poulshock and Deimling (1984). The caregivers were queried about caregiving required for Activities of Daily Living (ADL) (Zarit et al., 1985), indicating the type and extent of assistance required with ADL. The interviewer also asked caregivers to list the aspects of caregiving they enjoyed. Answers were categorized into one of six qualitatively different responses. Agreement between two independent raters of enjoyment responses has been found to be 91% (Reis, Gold, Andres, Markiewicz & Gauthier, in press). They were also asked to indicate the number and frequency of community services they used from a comprehensive list of public and private health and social services available in the community. Caregivers were also asked to indicate the number of additional caregivers they had. Caregivers were also asked to indicate their current participation in recreational activities, indicating the kind, frequency, and time spent in recreation. At the beginning of the interview, caregivers were asked if they had decided to continue to maintain their dependent in the community or to seek to institutionalize him or her. The question was repeated at the end of the interview to determine if the procedure of being interviewed influenced the caregiver's decision. Only caregivers who gave consistent responses to the question were retained for the study. Measures taken- to seek institutionalization were documented. Caregivers were asked to assume that appropriate facilities were available, so that the decision reflected primarily the caregivers' assessment of their own situation instead of concern about availability of institutional facilities. The General Health Questionnaire (GHQ) (Goldberg, 1978) was used to assess physical and psychological health as it has been used in the past to
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* \
for male caregivers only. Colerick and George (1986) describe an increased rate of institutionalization when caregivers are more familiar with services. Specific services for caregivers and dependents such as day care, support groups, and day hospital may or may not delay the move to long-term care (Gilleard, Belford, Gilleard, Gledhill, & Whittick, 1984; Lawton, Brody, & Saperstein, 1989; Montgomery & Borgatta, 1989). A well coordinated program of caregiver support may delay institutionalization (Brodaty & Cresham, 1989) and improve quality of life (Mohide, Pringle, Streiner, Gilbert, Muir, & Tew, 1990). Finally, caregiver attitude regarding institutionalization of a dependent is an important determinant of the decision (Deimling & Poulshock, 1985). In order to examine the factors determining the decision regarding institutionalization, we undertook a longitudinal study of a large group of caregivers looking after dementing individuals in the community. We measured not only burden, but also surveyed caregivers regarding their decision to institutionalize their dependent. We measured a wide variety of variables and followed this group longitudinally over time to understand their changing needs. We report here on the findings at the initial interview that predict decision to institutionalize and actual placement at 18 months.
pation; 5 had died; and 1 was otherwise unavailable (see Table 1). When dropouts were compared (using MANOVA) to the continuing subjects on the initial variables, there was no significant difference. At the initial assessment, 150 of the 196 caregivers had indicated that they were planning to continue maintenance of the dependent in the home, and 46 of the caregivers had indicated that they had decided to institutionalize. It had been predicted that specific patterns of troublesome behavior would be especially difficult for caregivers and would be salient in determining caregiver burden and decisions regarding institutionalization. Sizeable numbers of caregivers reported that wandering (47%), paranoia (59%), aggression (39%), or incontinence (38%) occurred on a regular basis. These data were coded for their presence or absence and combined into one variable (troublesome behaviors).
Results
Predictors of Decision To Institutionalize A MANOVA was performed on measures gathered at initial assessment, comparing caregiving dyads where the decision to maintain the dependent at home versus decision to institutitionalize had been made. The variables entered into the analysis were care receiver age, MMSE scores, presence or absence of troublesome behaviors, duration of caregiving and caregiver age, gender, income, total amount of assistance with ADLs provided, number of additional caregivers, total number of aspects of caregiving enjoyed, GHQ scores, burden scores, total frequency of problem behaviors, total negative reactions to problem behaviors, total number of services used, total extent of recreational activities, total extent of social support networks, and total satisfaction with social support received. There was a significant multivariate effect differentiating these two groups [F (18,148) = 2.91, p < .0001]. Univariate analyses indicated that caregivers who had decided to place their dependents used community services more frequently [F (1,165) = 14.35, p < .0001], reported less enjoyment of caregiving [F (1,165) = 11.36, p < .001], higher levels of burden [F (1,165) = 9.16, p < .01], and had worse overall health as measured by the GHQ [F (1,165) =
Follow-up Telephone contact was maintained every 2 months to document changes in the home caregiving situation, and follow-up visits were conducted every 6 months. Once the care receiver had died or had been institutionalized, this portion of the study terminated and the dyad was no longer followed. After 18 months, 37 care receivers were still being maintained at home; 100 were living in institutions, and 19 had died at home. Others were not available for reassessment because 12 caregivers had moved or could not be reached; 22 declined further partici-
Table 1 . Summary of Subjects Lost to Follow-up in the Longitudinal Study
Initial 6 Months 12 Months 18 Months Cumulative Total (18 Months)
Total no. Available
Total no. Unavailable
Care Receiver Deceased
Care Receiver Placed
Declined Participation
196 119 74 37
77 45 37
9 7 3
49 27 24
13 6 3
19
100
22
716
Moved/ Couldn't Reach
Caregiver Deceased
Other
6 2 4
0 3 2
0 0 1
12
5
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examine caregivers' health (Gilleard et al., 1984) and found to correlate with indices of increasing burden. The GHQ has a test-retest reliability coefficient of .75. The Memory and Behavior Problem Checklist (MBPC) (Zarit et al., 1985) was used to evaluate the caregiver's subjective perception of patient memory and behavior problems. Two scores were derived indicating the total frequency of the problem behaviors and the total of the caregiver's negative reactions to them. This scale has been widely used in caregiving research, and scores have been found to correlate with burden (Teri, Larson, & Reifler, 1988). The Burden Interview (Zarit et al., 1985) was used to assess the extent of burden experienced by the caregiver. It was supplemented by items assessing the extent to which the caregiving burden has disrupted the caregiver's relations with other family members and decreased their social activities (Poulshock & Deimling, 1984), thereby assessing the ramifications of burden on other aspects of the caregiver's life. The Past Social Interaction Scale (Gilleard et al., 1984) evaluated the quality of the prior relationship between caregiver and care receiver. Scores on this scale have been found to correlate with the caregiver's degree of distress. The Social Support Questionnaire (Sarason, Levine, Barham, & Sarason, 1983) measured social support received by the caregiver, indicating the number of supporters and the degree of satisfaction with support received. Test-retest reliability coefficients of .90 and .83 have been reported for extent and satisfaction with social support, respectively. Scores correlate negatively with depression and anxiety and positively with happiness.
been placed at 18 months [x2(D = 4.43, p < .05], as were those who were incontinent at initial assessment [x2(D = 3.76, p < .05]. A Discriminant Function Analysis was performed to specify the initial variables that predicted actual care receiver outcome at 18 months. Six variables (caregiver health and burden, use of services, care receiver MMSE scores, presence of troublesome behaviors, caregiver reaction to behavior problems) made significant contributions to the discriminant function [x2(20) = 40.97, p < .01]. The canonical correlation was r = .50. The function correctly classified 75% of all caregivers — 86% for the group placing in institutions, and 55% for the group maintaining at home (including care receivers who died at home).
Predictors of Actual Institutionalization at 18 Months Since decision to institutionalize does not always correspond with actual institutionalization, a further MANOVA was conducted comparing the initial variable responses of 100 caregivers whose dependent had been institutionalized with those who were still maintaining their dependent at home at 18 months. This latter group consisted of 37 caregivers who were actually still maintaining their dependent at home and 19 whose care receiver had died after 18 months but had not been institutionalized before death. Caregivers were compared on the same measures outlined above. The multivariate F was significant [F (18,115) = 2.54, p < .01]. Univariate analyses revealed that caregivers who had actually placed their dependent at 18 months reported worse overall health initially as measured by the GHQ [F (1,132) = 3.77, p < .05] and higher levels of burden [F (1,132) = 4.73, p < .05]. Placers also used community services more frequently at initial assessment [F (1,132) = 4.40, p < .05], were looking after dependents who scored worse on the MMSE [F (1,132) = 5.36, p < .05], exhibited more troublesome behaviors as rated by the research psychiatrist [F (1,132) = 8.56, p < .01], and reacted more negatively to their dependents' behavior problems, [F (1,132) = 3.92, p < .05] (see Table 3).
Table 2. Means and Standard Deviations for Variables Significantly Differentiating Between "Plan to Maintain in Home" vs "Plan to Institutionalize" Groups at Initial Interview Plan to Institutionalize (N = 46)
Plan to Maintain (N == 150) Variable
Mean
SD
Mean
SD
F
Service use Enjoyment of caregiving Burden Health (GHQ)a CR memory and behavior problems CG reaction to memory and behavior problems CR troublesome behaviors
11.06 0.69 37.51 88.93 37.00 18.41 0.80
(6.23) (0.64) (15.69) (11.57) (15.51) (11.77) (0.40)
15.65 0.33 46.03 82.40 43.30 23.58 0.95
(8.00) (0.48) (14.91) (14.74) (16.76) (4.78) (0.22)
14.35t 11.36*** 9.16** 8.44** 4.83* 5.16* 4.92*
Note. CR = care receiver; CG = caregiver. 'Higher scores indicate better health. *p «s .05; **p =s .01; ***p ss .001; t p *s .0001.
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8.44, p < .01]. Caregivers who wanted to institutionalize their dependents also appraised their dependents as having more memory and behavior problems as measured by the MPBC, [F (1,165) = 4.83, p < .05], and reacted more negatively to those problems [F (1,165) = 5.16, p < .05]. Finally, their dependents were rated by the research psychiatrist as having more troublesome behavioral problems [F (1,165) = 4.92, p < .05] (see Table 2). Chi-square analyses were conducted to examine how dichotomous variables were related to decisions regarding institutionalization. The following variables were used in the analyses: caregiver gender, relationship to care receiver (spouse vs nonspouse) and presence vs absence of specific troublesome behaviors. Results indicated that while gender was not related to decision, non-spouses were more likely to have decided to place their dependent [x2(1) = 7.95, p < .01], as were those whose dependent showed aggressive behavior tx2(1) = 14.22, p < .001], or was incontinent [x2(D = 4.18, p < .05]. The data were then analyzed by Discriminant Function Analysis to determine the combination of caregiver and dependent variables that allowed classifications of the dyads into their groups (decided to maintain vs decided to institutionalize). A significant discriminant function was derived [x2(20) = 65.01, p < .0001] with a canonical correlation of r = .55. Seven variables ((1) use of services, (2) enjoyment of caregiving, (3) caregiver burden, (4) health, (5) caregiver rating of, (6) reaction to care receiver behavior and memory problems, and (7) presence of troublesome behaviors) made significant contributions to the function which allowed the correct classification of 83% of all caregivers (93% of the group planning to continue home care and 49% of the group planning to institutionalize). Chi-square analyses were used to examine the relationship between dichotomous variables and actual placement at 18 months. Results indicated that while the relationship to the care receiver was not related to outcome, there was a trend for female caregivers to be more likely to have placed their dependent than male caregivers [x2(1) = 3.49, p < .06]. Care receivers who exhibited aggressive behavior at initial assessment were also more likely to have
Table 3. Means and Standard Deviations for Variables Significantly Differentiating Between "Actually Maintained at Home" vs "Actually Institutionalized" Groups at Initial Interview
Maintained (N = 56)
Institutionalized (N = 100)
Variable
Mean
SD
Mean
SD
F
Health (GHQ)* Burden Service use MMSE CR troublesome behaviors CG reaction to memory and behavior problems
89.67 37.02 10.83 17.04 0.74 17.76
(10.27) (14.23) (6.41) (6.76) (0.44) (11.48)
85.42 42.92 13.42 14.13 0.92 22.38
(12.85) (15.25) (6.99) (7.02) (0.27) (13.44)
3.77* 4.73* 4.40* 5.36* 8.56** 3.92*
Note. CR = care receiver; CG = caregiver. Higher scores indicate better health. *p=£ .05; * * p « .01.
a
Discussion
Studies of predictors of institutionalization have highlighted certain variables as important determinants of nursing home placement. These include availability of long-term care beds, availability of a primary caregiver, financial assets, cognitive functioning, functional capacity, age, and physical health of the dependent (Branch & Jette, 1982). In our study, certain variables were held relatively constant in order to highlight the factors that increase the risk of institutionalization in a particular subgroup of frail dementing elderly. All dependents had memory impairment and had caregivers who accepted primary responsibility for them; however, dependents were excluded if they had major physical problems. Finally, all respondents were aske'd to assume that appropriate facilities were available for institutional care; all resided in the same geographic location, thereby having access to the same pool of long-term care beds. Dropouts were numerous over the course of the study, highlighting the difficult nature of longitudinal studies in this community population. It is quite possible that many of the dropouts related to crisis situations such as illness of the caregiver. In this study we were more successful in predicting which dyads would choose community care (93%) vs placement (49%) at the initial assessment. However, this did not always translate into maintenance in the 718
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home, as 92 of 150 who had originally chosen to maintain had placed at 18 months. A subgroup of these "changers" is particularly worrisome because of their expectations that they can continue community care under any circumstances and hence their reluctance to plan for the future. For these caregivers, placement is more likely to occur in a crisis situation. When actual placement was examined we were able to predict who would be in long-term care at 18 months (86% correct classification). The six variables we have identified should be helpful in targeting vulnerable caregiver/care receiver dyads in the community. Caregiver, care receiver, and situational variables were all found to be important in determining both the decision to institutionalize and actual institutionalization. Not surprisingly, caregiver health and burden both differentiated between caregivers deciding to maintain or institutionalize. Those caregivers in poorer health and experiencing greater burden were more likely to express the desire to place their dependent and had actually placed them at follow-up. The relationship to the dependent was found to be significant in predicting the decision, but not in actual placement. Spouses tended to opt for community care even under difficult conditions but did not always succeed in their endeavour. Spouses may choose community care because of the particular nature of their relationship, but they are more prone to a breakdown in the caregiving situation because of their own age and health. Thus, spouses represent a vulnerable subgroup of caregivers because of their susceptibility to unrealistic expectations and personal frailty. Gender did not predict the decision to institutionalize, but there was a trend for it to predict actual institutionalization. Women were more likely to place their dependents, and once again there seems to be a differential response of men and women to the caregiving experience. This may relate to the fact that women in this study were caring for older, frailer dependents or experienced caregiving as more stressful. Alternately, service use may be more effective in helping male caregivers delay institutionalization (Levin etal.,1986).
Relationship Between Initial Decision and Actual Outcome While 150 of 196 caregivers expressed a desire to maintain their dependent at home at initial assessment, 92 of the 148 who were successfully followed had actually institutionalized them by 18 months. A chi-square analysis was therefore performed to examine the relationship between initial decision and actual status 18 months later. Results indicated that a significantly higher percentage of caregivers who initially decided to place their dependent had actually done so than those whose initial plan was to maintain [x2(D = 29.99, p < .0001]. More than half (51%) of those who initially planned on maintaining had placed their dependent 18 months later.
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higher than previously reported. This may relate to the study design, which was not limited by subjects who were available only at initial and final interviews, as in other studies (Colerick & George, 1986; Pruchnoetal.,1990). Given our findings, it is important to examine available interventions to see whether they will meet the needs of the most vulnerable caregiver/dependent dyads. There is much controversy as to the efficacy of services in preventing or delaying institutionalization (Weissert, 1985). Intervention programs that are tailored to caregiver needs and provide consistent and ongoing follow-up over longer periods of time may offer some relief (Brodaty & Gresham, 1989; Mohide et al., 1990). These programs probably meet the needs of caregivers by providing emotional support, education, and information. The continued involvement of the support personnel enables them to provide additional help in order to avoid crises. Interventions that are more focused (such as respite programs) may not be as effective in delaying institutionalization (Lawton etal.,1989) because they do not meet the specific and changing needs of vulnerable caregivers and dependents. In planning for the future, several issues should be considered. First, it seems appropriate to design services which provide help on an ongoing basis and can target the most vulnerable caregiver dyads. Assessment is important but not sufficient, as dementing individuals and their families need ongoing assistance. They need (a) someone who will be available in crisis situations and (b) a system of care that can respond to them in a flexible manner to stabilize the situation and avoid institutionalization where possible. Secondly, intervention programs aimed at the dependent should be developed specifically to treat behavioral problems in a consistent manner. Little has been done to properly assess behavioral and medication approaches to these problems in a community setting. These problems are significant risk factors for institutionalization and may also be obstacles to the ready access to community services which exclude clients with significant behavioral problems. Finally, the delay of institutionalization may not always be the desired goal in future intervention studies and program development. It may be more desirable to consider improved quality of life — at home or in institutions — as the more realistic and valuable outcome. This formulation accepts the fact that some dementing individuals need to be institutionalized and that others, such as individuals without primary caregivers, will always be at high risk for institutionalization. Particularly vulnerable caregivers such as spouses, who tend to delay institutionalization, may need help in the decision-making process. Other caregivers, who experience a high level of burden and have particularly negative reactions, may benefit from the early placement of their dependent and experience a significant decrease in burden and improvement in health after they are relieved of this role. Early institutionalization should be offered and available for those in need.
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Enjoyment of caregiving was an important factor in determining the decision regarding placement, with those who were able to enjoy more aspects of caregiving being less likely to seek institutionalization. However, the ability to enjoy caregiving did not predict actual placement. This is probably due to the role of unforeseen circumstances and crises which help determine actual outcomes in combination with the caregivers' desires. Other caregiver factors which have previously been reported to be important, such as income and education, were not found to be significant in this study. This may reflect the relative homogeneity of the sample or the greater specification of variables in this study. Behavioral problems proved important in determining the decision to place and actual placement. The caregivers' appraisal of the extent of memory and behavior problems and their reaction of distress to these problems predicted decision and outcome at 18 months. The presence of troublesome behaviors as assessed independently was also significant. In particular, aggressive behavior and incontinence were significant risk factors for termination of community care. These findings replicate those of other studies (Hamel et al., 1990; Steele et al., 1990). The care receiver's MMSE score was not a significant determinant of decision to place but was predictive of actual placement. Caregivers did not base their decision regarding placement on factors related to cognitive impairment of the dependent. However, care receivers with poorer cognitive functioning may have been more vulnerable because of the advanced nature of their disease and therefore more prone to crises necessitating placement in long-term care. Increased use of services predicted the desire to institutionalize and actual institutionalization. Very often, services were used just prior to the placement decision in response to a crisis. In these circumstances a change in the family situation precluded caregiving, and services were used as a stopgap measure until the dependent could be placed. Service involvement may have hastened actual placement when professionals found an unstable situation and recommended institutionalization. In summary, caregiver variables are important in determining actual institutionalization and the decision to institutionalize. Caregivers who enjoy their role and are healthy are less likely to seek institutionalization unless the situation changes dramatically. However, as the care receiver becomes more impaired, with the onset of troubling behaviors such as aggression and incontinence, the caregiving situation is more likely to break down. At these times of change and crisis, a caregiver who has a tendency to react negatively to the dependent is more likely to seek the assistance of services in an attempt to cope. However, it is clear that this service use does not postpone institutionalization. The general thrust of our findings seems to confirm those of other studies. However, our ability to predict the decision regarding institutionalization (particularly the desire to continue community care) was
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