Functional performance of older adults in a long-term care setting. (includes commentary)

There is increasing awareness of the pivotal role that declining functional performance (bathing, dressing, transferring, continence, ambulation, and stair climbing) plays in maintaining independence and the impact this has on health care resources (Cress et al., 1995; Fried & Guralnik, 1997; Williams, Fries, Foley, Schneider, & Gavazzi, 1994). For older adults who are already institutionalized further loss of function alters the type and amount of nursing required, puts the individual at risk of sequelae from immobility, and influences quality of life (Kaplan, Strawbridge, Camacho, & Cohen, 1993; Mulrow et al., 1994). The majority of older adults living in nursing homes require some assistance with activities of daily living (ADLs) (Aller & Coeling, 1995). About 91 % of nursing home residents require assistance with bathing, 78% with dressing, 63% with toileting, and 40% with eating. Almost two thirds require assistance in transferring from bed to chair, and about the same percentage have walking difficulties. The causes of these functional impairments are multifactorial and include lack of motivation (Mulrow et al., 1996), social issues and cultural expectations (Aller & Coeling, 1995; MacRae et al., 1996), environmental factors (MacRae et al., 1996), coexisting disease states (Ailinger, Dear, & Holley-Wilcox, 1993; Bloom, 1993), fear of falling (Hill, Schwarz, Kalogeropolulos, & Gibson, 1996), and/or nursing care that creates dependency (Waters, 1994). The purpose of this study was to describe the physical status, emotional state (depression and motivation), and functional performance of residents in a long-term care facility and to explore the impact of motivation (intrinsic and extrinsic factors), demographic variables, length of time institutionalized, physical status, depression, and fear of falling on functional performance of older adults in a long-term care setting.

REVIEW OF THE LITERATURE

VARIABLES THAT AFFECT FUNCTIONAL PERFORMANCE

Longitudinal studies of factors that influence functional performance have mainly considered demographic variables and coexisting medical conditions as predictors of function (Cress et al., 1995; Guralnik, Ferrucci, Simonsick, Salive, & Wallace, 1995; LaCroix, Guralnik, Berkman, Wallace, & Satterfield, 1993; Roos & Havens, 1991). These studies generally reported that age, education, and a variety of specific disease states--particularly cardiovascular disease, arthritis, diabetes, cancer, respiratory problems, and neurological problems--were predictive of functional performance.

Attempts to develop more comprehensive models of functional performance included psychosocial variables as predictors of function (Hill et al., 1996; Kaplan et al., 1993). In community-dwelling older adults, in addition to specific medical conditions (e.g., stroke, myocardial infarction), perceived health and exercise activities, age, income, marital status, the psychosocial variables cognitive status, support network, depression, fear of falling, and internal health locus of control were significant predictors of functional performance. Similarly, cognitive status, depression, and social support were predictive of recovery of function in older adults following a disabling event (Harris, O'Hara, & Harper, 1995; Heinemann, Linacre, Wright, Hamilton, & Granger, 1994; Resnick & Daly, 1997).

Fear of falling has been repeatedly identified in both those who have fallen and in those with no history of falls (Chandler, Duncan, Sanders, & Studenski, 1996; Tinetti, Mendes de Leon, Doucette, & Baker, 1994). Although prior studies do not confirm that fear of falling has a causal effect on functional performance, there is a significant correlation between the two factors (Hill et al., 1996).

VARIABLES THAT AFFECT FUNCTIONAL PERFORMANCE IN NURSING HOME RESIDENTS

Fewer researchers have considered the predictors of functional performance in nursing home residents. In one study of 194 nursing home residents (Mulrow et al., 1994), number of chronic illnesses was not predictive of function; however, cognitive impairment, recent infections, stroke, and decubiti did significantly predict function. Moreover, sociodemographic variables, cognitive status, and affective state (depression) significantly added to the explanation of functional performance ([R.sup.2] = .12). In a study (Mulrow et al., 1996) of Mexican American and non-Hispanic White nursing home residents, stroke, dementia, bowel and bladder incontinence, recent infections, and decubiti were significantly related to function. In this latter study, demographic variables did not significantly predict function, and depression was not included as a predictor. None of these studies included motivation or fear of falling as predictors of functional performance in nursing home residents.

MOTIVATION IN THE OLDER ADULT

Motivation has been identified as an important factor in the older adult's recovery from a disabling event (Geelen & Soons, 1996; Glickstein, 1990) and willingness to perform functional activities (Resnick, 1996). Motivation comes from within the individual and moves or prompts the person to action (Kemp, 1988). Motivation refers to the need, drive, or desire to act in a certain way to achieve a certain end (Glickstein, 1990) and is based on two known properties: It is an inferred rather than an observed event, and it energizes as well as directs behavior (Atkinson, 1974). Thus, the critical attributes of motivation include an inner urge or desire followed by action to achieve a goal.

Dishman and Ickes (1981) conceptualized motivation as intrinsic to the individual and defined self-motivation as a general disposition to persevere. Similarly, Marin (1990) described motivation (or the lack of motivation, which he referred to as apathy) as a dimension of the individual's behavior and personality that was continuous and quantifiable. Apathy describes those patients whose lack of motivation is not attributable to a diminished level of consciousness, an intellectual deficit, or emotional distress.

Motivation also has been conceptualized as a component of personality that is influenced by variables extrinsic to the individual (Bandura, 1977, 1986, 1995, 1997; Kemp, 1988; Resnick, 1994, 1996). Bandura (1977, 1986, 1995, 1997) specifically suggested that efficacy expectations were critical to motivation. These efficacy expectations include self-efficacy, which is an individual's judgment of his or her capabilities to organize and execute courses of action to accomplish specific goals, and outcome expectation, which is the belief that performing a specific behavior will result in a certain outcome. Efficacy expectations are appraised and strengthened by four external sources of information: verbal persuasion, vicarious experience, …