Most Americans are not physically handicapped, but the percentage of adults who experience difficulties in performing daily activities increases with age. These activities of daily living (ADLs), which reflect the person's capacity for self-care, refer to the following sociobiological functions: eating, bathing, dressing, transferring in and out of a bed or chair, walking, getting outside, and using the toilet. More complex behaviors that enable the person to live independently in the community are referred to as instrumental activities of daily living (IADL). I ADLs include doing light housework, managing money, shopping for groceries or clothes, using the telephone, preparing meals, and taking medications.
Impairments in ADLs and IADLs vary not only with age but with sex, ethnicity, and other demographic and personal variables. For example, the percentage of Americans over age 65 who, because of physical disabilities or functional limitations, require assistance with everyday activities is higher for women than for men, higher for blacks and Hispanics than for whites, and higher for people with smaller than those with larger incomes (U.S. Bureau of the Census, 1990b).
Despite some functional impairments, the majority of Americans with physical disabilities do their best to compensate by managing their lives and activities in ways that take their limitations into account. They experience problems but are not, do not need to be, and do not want to reside in a nursing home or other institution. They are usually able to obtain sufficient long-term help from their spouses, other relatives, friends, home health care services, and community service organizations to enable them to remain in the community (see Dey, 1996).
A small minority (approximately 5%) of older adults are in institutions at any one time, and most remain for only a few months. Most are older white female patients in nursing homes, whose numbers have increased since the enactment of Medicare and Medicaid. They usually suffer from several chronic disorders, the primary ones being cardiovascular diseases, cancer, and chronic brain disorders. In all likelihood, attempts were made initially to care for them at home, but, when they became disoriented and confused, wandered away from home, were incontinent, and otherwise revealed a need for more extensive care, they were placed in a nursing home. The transfer was seldom a pleasant one: Moving to new surroundings that lack privacy, have different rules and regulations, patients and staff from other social and cultural backgrounds, and separation from relatives and friends is often traumatic.
Like most institutions, nursing homes vary widely in the quality of care they provide. Skilled nursing facilities are usually best—but also the most expensive, followed by intermediate care facilities and nonskilled institutional or private home facilities. Government-run homes tend to be better than private homes, but this depends to some extent on cost. For people who qualify, a substantial percentage of nursing home care is paid for by Medicaid (see Figure 3-7). The result has been a profit bonanza for some entrepreneurs, and the quality of care has not always kept pace with the profits.
Because of extensive abuses and inadequate care, many nursing homes have not been able to meet federal standards for care. Passage of the Nursing Home Quality Reform Act (198 7) established stricter standards for nursing homes, penalties for violating them, and a patients' "bill of rights" (e.g., right to privacy, right to voice grievances and have them responded to promptly). A combination of poor nursing home care and increased cost has led to a
movement away from hospital-based and nursing home treatment to home health care, day-care centers, and preventive medicine clinics in recent years. However, institution-based treatment is an entrenched part of the medical model of personal health care in the United States; alternative treatment models have been widely discussed but not readily put in place. Additional material on nursing homes is presented in Chapter 9.
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