Long-Term Care status for the Elderly with Different Levels of Physical Ability: a cross-sectional investigation in first-tier cities of China

doi:10.21203/rs.3.rs-2447369/v1

Background: Long term care (LTC) services providing support to functional impaired senior citizens are considered a viable solution to the aging society. However, what are the clinical characteristics, who is eligible and what should be covered remains unclear in China. Therefore, we aim to investigate the elderly population who require LTC and explore the LTC status of the elderly.

Methods: This is a cross-sectional study conducted in two of four first-tier cities in China. Residents aged 65 and over were recruited from a nursing home and primary hospitals. Participants were divided into three groups (bedridden, domestic and community) then six grades (grade one to six) according to Longshi Scale, and their functional ability was assessed using Modified Barthel Index (MBI). Information such as diseases, complications, daily care needs were collected. Nursing staff were invited to indicate patients’ needs for care.

Results: Participants in the bedridden group accounted for 69.3% of all participants (1157). The most common diagnosis stroke (71.4%), and complication, pulmonary infection (25.2%), suffered by all participants should be focused in LTC. Participants in Longshi Scale grade one to three had higher demand for assistance in daily activities may be the ones eligible for LTC. In the nursing assessment, basic health care, disease care, mobility care, complication prevention care and psychosocial care were summarized as the five main aspects of LTC for the elderly. Feeding, bathing, drinking, bowel management and bladder management were identified as basic care which fulfills participants’ basic physical needs in each Longshi group. Mouth care, artificial airway management, body reposition which can prevent immobility complications were highly demanded by bedridden elderly.

Conclusions: The elderly in grade one to three are the ones in need of LTC most. The content of LTC for elderly should includecare for disease, mobility and psychosocial needs, specially basic care which fulfills their basic physical needs and complicationcare which can prevent immobility complications.

Trial registration: The study design was registered in the Chinese Clinical Trial Registry (ChiCTR-2000034067, Registered 22 Jun 2020, http://www.chictr.org.cn/showproj.aspx?proj=54770)

elderly

disability

long term care

activities of daily living

Longshi Scale

Population aging is one of the most important demographic trends worldwide and there has been a growing trend in China in recent years.[1, 2] It is projected that by 2050, the total number of Chinese senior citizens aged 65 and more will reach approximately 365 million, representing 26.1% of the entire population.[3] A series of health problems can be related to population aging, including age associated chronic diseases, activities of daily living (ADL) impairment and cognitive decline.[4] This posts a great challenge to the current health care system. The National Health Commission reported that, in China, only under 10% of the elderly with different levels of activity dependency and personal care needs have been served in the community or at home, while the majority have yet been cared for.[5] Therefore, providing sufficient and reasonable geriatric care to the elderly in this aging society is an urgent problem that needs to be tackled.[6]

Long term care (LTC) can be an effective measure to cope with the aging society. The World Health Organization proposed that the goal of healthy aging is to promote the development and maintenance of functional capacities throughout life cycle.[7] LTC, aiming to provide assistant to elderly people with disabilities and self-care deficits to perform everyday activities, has been developed quickly all-around the globe. European countries, such as United Kingdom, developed acute and intermediate care system and successfully maintained senior citizen’s physical independence in the community.[8] Asian countries, such as Japan, developed acute care and LTC settings to ensure personal care is provided to the elderly.[9] In Australia, a comprehensive LTC system was established in the community, residential care, hospitals and other types of institutional care to meet varies personal needs of the elderly.[10, 11] In China, LTC has also been promoted by the government to deal with the growing aging population .

China implemented a national long-term care insurance (LTCI) plan in 15 pilot cities in 2016.[12] The LTCI can cover approximately 85–90% of LTC service costs for the elderly who are aged 60 and over, and are covered by the national public health insurance scheme. A study by Fudan University found that the introduction of LTCI in China has reduced the length of hospital stay, inpatient expenditures, and health insurance expenditures in tertiary hospitals by 41.0%, 17.7%, and 11.4% respectively during 2016 and 2017.[13] Therefore, LTC facilities have developed rapidly since 2016. At the same time, there is an increasing trend for elderly people with limited physical capacity to choose LTC institutions as their ideal retirement destination. This can not only help the elder generation reduce financial burden on their family but also the government distribute public medical resources appropriately in the national healthcare system.[14]

However, currently, there is no industrialized standard or interventional protocol available to guide this practice. What are the clinical characteristics, including diagnosis and complication, who is eligible and what should be covered in LTC remains unclear in China. Thus, in this study, we investigate the current application of LTC in hospitals and nursing homes in first-tier cities of China where LTC had successfully integrated into the national healthcare system. The purpose is to understand the main diagnosis and complication of LTC subjects, as well as identify the suitable population eligible for LTC and explore the care needs of elderly with different levels of physical ability. This can provide evidence for the development of specialized LTC standards.

Design

This is a cross-sectional study conducted by the rehabilitation department of Shenzhen Second People’s Hospital, Shenzhen, China. It is a sub-study of a clinical research “The implementation of Longshi Scale” which explored the application value of Longshi Scale national-wide [15]. In our study, Longshi Scale was used to classify the elderly into three groups then six grades by their degree of functional ability to explore their needs in groups. This study conforms to the standards of the Declaration of Helsinki. This study protocol was registered in the Chinese Clinical Trial Registry (No. ChiCTR-2000034067) and was approved by the Ethics Committee of Shenzhen Second People’s Hospital (No. 20180926006).

Study population

Participants were screened and recruited form a nursing home in Shanghai and four primary hospitals in Shenzhen where LTC services had developed comprehensively in the healthcare system and the public welfare system is complete. Shanghai and Shenzhen, two of four first-tier cities (Shanghai, Beijing, Shenzhen and Guangzhou) of China, were pilot cities implemented LTCI plan in China and had this plan launched in 2017 and 2020. Unlike tertiary and secondary hospitals which only provide short-term inpatient services, primary hospitals and nursing homes can provide long-term inpatient care for disabled elderly.

In our study, the nursing home in Shanghai was selected not only because it is one of the largest nursing homes in Shanghai and admits elderly residents with a large variety of functional ability levels but also because it had LTCI implemented. The selection of the primary hospitals in Shenzhen followed the same principle. Among all the primary hospitals in Shenzhen, the ones providing LTC and had LTCI implemented were included in our study.

The inclusion criteria were 1) residents who were aged 65 and over, 2) residents who received long-term care in hospitals or nursing home facilities, 3) participants who signed informed consent forms. The exclusion criteria were 1) residents with mental illnesses, 2) residents who were unwilling to cooperate with the study. In the case where participants were unable to answer questions, their information regarding personal needs and care required were collected by nurses or nursing assistants. Prior to this study, the investigator explained the study procedure and protocol in detail and obtained informed consent from each nursing participant, elderly participant and the guardian of disoriented participants who suffered from dementia or consciousness disorder. The study flowchart was showed in Fig. 1.

Data collection

All the data were collected through questionnaires by allied health practitioners (physiotherapists, occupational therapists and speech pathologists) and nursing staff (registered nurses and nursing assistances) who had training for this study from July 2021 to August 2021. The contents of the questionnaire were as follows: (1) Demographic information, including sex, age, weight and height; (2) Disease information, including primary diagnoses, complications and comorbidities; (3) Functional assessment information, including assessment of Modified Barthel Index (MBI) and Longshi Scale; (4) Care needs information, including nursing assessment and nursing time used.

Considering the labor cost, this study only investigated the care needs during the day, from residents waking up in the morning until settling in bed at night. All data were recorded with an electronic questionnaire system on smart phones and saved on the website (https://www.mikecrm.com). Data deletion, modification or sharing without permission were prohibited. During the data collection process, the database was supervised by a data manager. Once unreasonable data were noticed, the data manager would check with the assessor and correct any errors according to the actual situation.

ADL assessment

Longshi Scale

Longshi Scale is an innovative functional assessment tool developed by Yulong Wang, the head of our rehabilitation institution, and was made the national standard of ADL measurement of China in 2019 (No. GB/T 37103 − 2018). It is a pictorial scale and evaluates ADL base on patient’s daily activity range and level of dependency.[15] In our study, this scale was used to divide participants into three groups then six grades by their level of functional ability to explore their LTC needs in detail. As demonstrated in Fig. 2 (a), participants were first divided into 3 groups according to their daily activity range: bedridden, domestic, and community group. The ones who could not transfer out of the bed independently was in bedridden group. Those who could get out of the bed but could not go outdoors independently with or without assistive devices were in the domestic group. The community group included participants who were able to go outdoors independently with or without assistive devices.

Then, participants were divided into six grades according to their Longshi score and the group they belonged to. As shown in Fig. 2 (b), different sets of three assessing items were evaluated in different groups to achieve the Longshi score. Each item scored from 1 to 3, where score of 1 meant minimal independent, 2 for partially independent, and 3 for maximum to fully independent. Longshi score of participants in each group ranged from 3 to 9 points. Participants in each group were further divided into two grades according to their Longshi scores. For instance, in bedridden group, those with Longshi score of three or four were classified in grade one, whereas those with Longshi score of 5 to 9 were classified in grade two. And so on and so forth for the domestic group and community group. Ultimately, all participants were divided into six grades. The definitions and the Longshi score of each grade are as follows:[16]

1. grade one: complete inability to self-care. Participants in the bedridden group with score 3–4;
2. grade two: basic inability to self-care. Participants in the bedridden group with score 5–9;
3. grade three: partially self-care. Participants in the domestic group with score 3–4;
4. grade four: mostly self-care. Participants in the domestic group with scores 5–9;
5. grade five: basically self-care. Participants in the community group with score 3–4;
6. grade six: complete self-care. Participants in the community group with score 5–9.

We have proven that Longshi Scale was reliable and valid to assess the ADL of functionally

disabled patients.[15] And the Longshi Scale was highly correlated with the MBI in ADL assessment.[17] As it is a newly designed functional assessment scale, all registered healthcare workers have completed the training sessions for Longshi Scale before participants evaluation.

MBI

To investigate the basic physical activities, participants functional ability was evaluated with MBI. MBI was originated from Barthel Index (BI), but the functional division is more subtle than BI.[18] It has been reported that MBI has better test-retest reliability and relatively lower random measurement error than the original BI,[19] thus this scale was used in the LTC facilities where we conducted our study.

The MBI score ranges from 0 (complete dependence of ADL) to 100 points (complete independence of ADL). There are ten assessing items in this scale, including bowel management, bladder management, feeding, bathing, grooming, clothing, toilet use, transfer, walking and climbing stairs.[20] These ten items were used as a guide to identify the area of patient’s needs. Each MBI item has five levels, ranging from level one (complete dependence of activity) to level five (complete independence of activity). Except for participants in level five who were determined as independent ones, all remaining participants required some level of assistance or supervision to perform daily activities were identified as dependent ones. In each MBI assessing item, the ratio of dependent patients was calculated to explore which activity of daily living participants required assistance most. The evaluation process of the MBI was based on previous literature reports.[21]

Nursing assessment

What should be included in LTC for the elderly with functional disability needs to be carefully designed with evidence. In addition to the investigation on participant’s functional disabilities, we also explored participant’s needs from the nursing perspective. In this study, nursing staff were interviewed with face-to-face questionnaires to indicate specific nursing care provided to each participant. Fourteen themes of nursing care required by participants in the day time from waking up in the morning until settling in bed at night were listed. In these fourteen nursing care themes, six items (bathing, feeding, bowel management, bladder management, grooming, transfer) were consistent with the MBI items while remaining eight items (drinking, hypertension management, blood glucose management, assistive motion exercise, mouth care, body reposition, artificial airway management, entertainment) were not included in MBI assessment. All these fourteen items were summarized as five aspects, including basic health care (care for bathing, feeding, drinking, bowel management, bladder management, grooming), disease care (care for hypertension management, blood glucose management), mobility care (care for assistive motion exercise, transfer), complication prevention care (care for mouth care, body reposition, artificial airway management) and psychosocial care (care for entertainment).

Data analysis

All analyses were performed using SPSS 21.0 (IBM, New York, USA). Mean ± standard deviation or median and interquartile was used to describe continuous variables. Individuals with important data missing were excluded from the analysis. One-way ANOVA test was used to explore the differences of age and BMI in three Longshi groups. Kruskal Wallis H test was performed to explore the differences of categorical data in three Longshi groups. Mann-Whitney U test was used to analysis the differences of nursing care needs among different Longshi groups or Longshi grades. Pearson and spearman correlation analysis were used to test the association between MBI and clinical characteristics. A P-value < 0.05 was considered statistically significant.

Clinical characteristics of the elderly residents in three Longshi groups

As the Fig. 1 showed, a total of 1275 participants were screened for eligibility and 1210 of them were confirmed eligible. After excluded individuals with important data missing (n = 53), 1157 elderly residents were recruited in this study. The characteristics of participants are presented in Table 1. They were classified into three groups according to Longshi Scale, the bedridden group, domestic group and community group. The majority of them (69.3%) were in bedridden group, and only 5.4% belonged to community group. The average age of participants in each Longshi group was around 80 years, with no statistic difference (80.37 ± 8.18, 81.14 ± 8.19, 79.94 ± 7.68, p = 0.267). Their duration of disease ranged from 1 month to 3 years. The most common diseases suffered by participants in all three groups were stroke (72.3%, 70.6%, 62.9%, p = 0.272) and hypertension (66.7%, 67.9%, 53.2%, p = 0.076), followed by heart disease (30.3%, 32.1%, 25.8%, p = 0.605), diabetes (32.5%, 35.5%, 27.4%, p = 0.412) and dementia (8.9%, 6.5%, 3.2%, p = 0.162).

Table 1

Clinical characteristics of elderly participants in three Longshi groups
Characteristics	Longshi Scale					MBI
Characteristics	Overall (n = 1157)	Bedridden (n = 802, 69.3%)	Domestic (n = 293, 25.3%)	Community (n = 62, 5.4%)	P₁ value	r	P₂ value
Sex (man, n, %)	567 (49.0)	390 (48.6)	145 (49.5)	32 (51.6)	0.886	0.002	0.941
Age (years, Mean, SD)	80.54 ± 8.16	80.37 ± 8.18	81.14 ± 8.19	79.94 ± 7.68	0.316	0.101	0.001
Duration of disease (months, Median, IQR)	10.63(1.58–36.92)	10.77(1.97–35.07)	11.63(1.07–48.70)	3.47 (0.33–36.53)	0.155	0.041	0.182
BMI (kg/m², M, SD)	21.58 ± 3.50	21.35 ± 3.58	22.08 ± 3.26	22.20 ± 3.23	0.005	0.099	0.001
Living habit
History of smoke (n, %)	49 (4.2)	33 (4.1)	12 (4.1)	4 (6.5)	0.676	0.013	0.659
History of drinking (n, %)	32 (2.8)	18 (2.3)	11 (3.8)	3 (4.8)	0.238	0.044	0.136
Disease
Stroke (n, %)	826 (71.4)	580 (72.3)	207 (70.6)	39 (62.9)	0.272	-0.066	0.025
Hypertension (n, %)	767 (66.3)	535 (66.7)	199 (67.9)	33 (53.2)	0.076	0.022	0.453
Heart disease (n, %)	353 (30.5)	243 (30.3)	94 (32.1)	16 (25.8)	0.605	0.008	0.755
Diabetes (n, %)	382 (33.0)	261 (32.5)	104 (35.5)	17 (27.4)	0.412	0.025	0.397
Dementia (n, %)	92 (8.0)	71 (8.9)	19 (6.5)	2 (3.2)	0.162	-0.046	0.114
Chronic obstructive pulmonary disease (COPD) (n, %)	41 (3.5)	30 (3.7)	9 (3.1)	2 (3.2)	0.861	-0.025	0.405
Cancer (n, %)	18 (1.6)	14 (1.7)	3 (1.0)	1 (1.6)	0.694	-0.009	0.752
Complications
pulmonary infection (n, %)	291 (25.2)	257 (32.0)	33 (11.3)	1 (1.6)	< 0.001	-0.357	< 0.001
urinary tract infection (n, %)	99 (8.6)	79 (9.9)	19 (6.5)	1 (1.6)	0.028	-0.087	0.003
deep vein thrombosis (n, %)	158 (13.7)	128 (16.0)	28 (9.6)	2 (3.2)	0.001	-0.153	< 0.001
pressure ulcers (n, %)	58 (5.0)	47 (5.9)	10 (3.4)	1 (1.6)	0.117	-0.081	0.006

MBI: Modified Barthel Index; BMI: Body Mass Index; SD: Standard deviation; IQR: interquartile range; P₁: p value among bedridden group, domestic group and community group, One-way ANOVA test for age and BMI, Kruskal Wallis H test for other characteristics. P₂: p value of the association between MBI and clinical characteristics, spearman correlation analysis for categorical variables, pearson correlation analysis for continuous variables. r: correlation coefficient.

As showed in our results, complications are common among elderly inpatients. Among four complications, participants in bedridden group had a much higher incidence rate than those in domestic group. Pulmonary infection was the most common complication acquired by participants in bedridden group and domestic group with 32.0% and 11.3% respectively (p < 0.001), followed by deep vein thrombosis (16.0% vs 9.6%, p = 0.007). The incident rates of urinary tract infection (9.9% vs 6.5%, p = 0.084) and pressure ulcers (5.9% vs 3.4%, p = 0.107) within bedridden and domestic group were similar. The chance for participants in the community group to have complication was very low: only 1.7% of them had pulmonary infection and 1.7% had pressure ulcer. Besides, the incidence of pulmonary infection (r=-0.357, p < 0.001), deep vein thrombosis (r=-0.153, p < 0.001), urinary tract infection (r=-0.087, p = 0.003) and pressure ulcers (r=-0.081, p = 0.006) all showed a significant negative association with MBI scores.

Functional disabilities of elderly residents in three Longshi groups

In our study, Longshi Scale was used to classify participants into three groups and six grades to differentiate their level of functional ability in detail. The number of participants in grade five and six were small (only 4 in grade five and 58 in grade six) and both grade five and six belong to the community group, so participants in these two grades were combined as community group for statistics.

Elderly with functional disabilities experience difficulties with their ADL. Thus, their ADL are generally assessed to indicate their needs for assistance.[22] In this study, MBI was used to investigate participants’ ADL abilities. As showed in Table 2, the average MBI score of participants in grade one, two and three was significantly lower than that of the community group (5.79 ± 11.75, 34.83 ± 20.52, 51.97 ± 18.90 vs 68.95 ± 14.14, p < 0.001), whereas the average MBI score of participants in grade four was similar with that of the community group (67.13 ± 15.40 vs 68.95 ± 14.14, p = 0.427). To be more specific, grade one, two and three participants’ average MBI scores in each MBI assessing item were all significantly lower than those in community group (p < 0.001) except grade three participants’ average MBI score in transfer. While the MBI score of participants in grade four showed no significant difference with that of the community group participants in all MBI items except in climbing stairs (P > 0.05).

In the ten MBI assessing items, climbing stairs (99.0%), bathing (97.8%), toilet use (95.1%), grooming (94.7%) and clothing (92.7%) were the top five activities participants required assistance in. Among the ten MBI items, participants in grade one required a majority (more than 90%) assistance in all ten MBI items. While the items that other grade residents required majority assistance in are seven out of ten MBI items in grade two, five out of ten MBI items in grade three, two out of ten MBI items in grade four and only one MBI items (climbing stairs) in community group. The proportions of grade one, two and three participants who require assistance in all MBI activities were significantly higher that those in community group (p < 0.05) while the proportions of grade four participants who require assistance were only higher in clothing and climbing stairs than those in community group (p < 0.05). The percentage of residents who required assistance in each MBI item is presented in Table 2 and different percentage ranges are highlighted in different colors to compare the care needs among residents with various functional ability.

Nursing care required by elderly in three Longshi groups

Fourteen basic nursing care themes selected according to the daily nursing practice in the LTC facilities were used in the nursing assessment, and elderly’s needs for this nursing care is demonstrated in Table 3. Among the nursing care required by participants in three Longshi groups, the common top six needs were bathing (92.6%, 84.1%, 75.0% in male, 91.5%, 85.1%, 83.3% in female), feeding (91.0%, 80.0%, 87.5% in male, 91.0%, 82.4%, 86.7% in female), drinking(87.9%, 79.3%, 78.1% in male, 89.3%, 78.4%, 90.0% in female), bowel management (87.4%, 80.0%, 68.8% in male, 86.2%, 76.4%, 90.0% in female), bladder management (86.9%, 77.2%, 78.8% in male, 85.0%, 77.0%, 90.0% in female) and grooming (79.2%, 78.6%, 68.8% in male, 70.6%, 71.6%, 76.7% in female). Bedridden residents had a much higher needs for assistance in mouth care (68.2% vs 26.9%, 25.0% in male, 64.6% vs 29.1%, 20.0% in female), body reposition (68.5% vs 16.6%, 6.3% in male, 60.0% vs 14.2%, 3.3% in female) and artificial airway management (40.5% vs 2.8%, 0.0% in male, 25.2% vs 1.4%, 0.0% in female) than participants in domestic group and community group. But their demand for assistance in entertainment (36.4% vs 63.4% in male, 30.6% vs 62.2% in female) and transfer (38.2% vs 51.7% in male, 25.5% vs 38.5% in female) were significantly lower than participants in domestic group. In all the nursing care themes except assistive motion exercise and entertainment, the needs required by domestic residents and community residents showed no significant difference (P > 0.05).

Table 3

Care needs of elderly participants in practical nursing programs
Nursing aspects	Nursing items	Male						Female
		Bedridde (n = 390, 68.8%)		Domestic (n = 145, 25.6%)		Community (n = 32, 5.6%)		Bedridde (n = 412, 69.8%)		Domestic (n = 148, 25.1%)		Community (n = 30, 5.1%)
		Care needs (N, %)	Care time (min, Median, quartiles)	Care needs (N, %)	Care time (min, Median, quartiles)	Care needs (N, %)	Care time (min, Median, quartiles)	Care needs (N, %)	Care time (min, Median, quartiles)	Care needs (N, %)	Care time (min, Median, quartiles)	Care needs (N, %)	Care time (min, Median, quartiles)
Basic health care	bathing	361, 92.6%*#	30, 20–40*#	122, 84.1%	30, 20–35	24, 75.0%	30, 20–30	377, 91.5%*	30, 20–40	126, 85.1%	30, 20–36	25, 83.3%	30, 20–30
	feeding	355, 91.0%**	60, 50–90&	116, 80.0%	60, 52–89	28, 87.5%	60, 45–90	375, 91.0%*	60, 45–90	122, 82.4%	60, 45–90	26, 86.7%	60, 50–90
	drinking	343, 87.9%*	25, 15–40	115, 79.3%	23, 15–38	25, 78.1%	20, 12–30	368, 89.3%*	25, 15–40#	116, 78.4%	19, 15–30	27, 90.0%	15, 12–30
	bowel management	341, 87.4%*#	15, 10–20*#&	116, 80.0%	11, 10–15	22, 68.8%&	10, 5–15	355, 86.2%*	10, 9–20	113, 76.4%	10, 8–15	27, 90.0%	10, 10–10
	bladder management	339, 86.9%*#	20, 12–30*	112, 77.2%	15, 10–30	22, 68.8%	17, 12–24	350, 85.0%*	18, 12–30	114, 77.0%	15, 12–30	27, 90.0%	16, 12–25
	grooming	309, 79.2%&	20, 10–30	114, 78.6%	20, 10–30	22, 68.8%	15, 10–30	291, 70.6%	20, 10–30	106, 71.6%	20, 10–30	23, 76.7%	20, 10–20
Disease care	Hypertension management	334, 85.6%**&	5, 3–10*#&	102, 70.3%	5, 3–6	25, 78.1%	3, 2–5	331, 80.3%	5, 3–6*	117, 79.1%	4, 3–5	23, 76.7%	3, 2–5
Disease care	Blood glucose management	156, 40.0%*&	4, 2–9	42, 29.0%	3, 2–8	11, 34.4%	4, 3–6	120, 29.1%	4, 2–8	50, 33.8%	4, 2–6	10,33.3%	4, 2–5
mobility care	assistive motion exercise	272, 69.7%*##&&	30, 30–40	84, 57.9%#	30, 30–52	12, 37.5%	40, 25–60	235, 57.0%	30, 20–45	89, 60.1%	30, 20–50	17, 56.7%	40, 20–90
mobility care	transfer	149, 38.2%*&&	25, 10–40*	75, 51.7%&	30, 20–60	12, 37.5%	28, 20–50	105, 25.5%*	20, 10–40	57, 38.5%	30, 20–60	7, 23.3%	30, 30–60
Complication prevention care	mouth care	266, 68.2%**##	10, 5–15&	39, 26.9%	10, 10–20&	8, 25.0%	10, 6–15	266, 64.6%**##	10, 5–11	43, 29.1%	10, 5–11	6, 20.0%	10, 10–15
	body reposition	267, 68.5%**##&	30, 15–60	24, 16.6%	30, 18–40&	2, 6.3%	20, 10–30	247, 60.0%**##	30, 15–60	21, 14.2%	12, 10–24	1, 3.3%	24, 24–24
	artificial airway management	158, 40.5%**##&&	20, 10–30	4, 2.8%	16, 9–20	0, 0.0%		104, 25.2%**##	17, 10–30	2, 1.4%	20, 15–25	0, 0.0%
Psychosocial care	entertainment	142, 36.4%**	40, 30–60	92, 63.4%#	45, 30–60	14, 43.8%&	60, 30–60	126, 30.6%**##	40, 30–60	92, 62.2%	55, 30–60	22, 73.3%	40, 30–60

*: Compared with domestic group, p < 0.05; **: Compared with domestic group, p < 0.001; #: Compared with community group, p < 0.05; ##: Compared with community group, p < 0.001; &: Compared between male and female, p < 0.05; &&: Compared between male and female, p < 0.001; Mann-Whitney U test.

Among all the nursing care themes, feeding takes the longest nursing time in three Longshi groups (median 60 min both in male and female). In addition, bathing (median 30 min both in male and female in three Longshi groups) and drinking (median 25, 23, 20 min in male, median 25, 19, 15 min in female in three Longshi groups) also requires much nursing time. Entertainment (median 40, 45, 60 min in male, median 40, 55, 60 min in female in three Longshi groups) were relatively less required, but it care takes much time to perform.

When make comparison between male and female, Bedridden male residents had a much higher needs for assistance in grooming (79.2% vs 70.6%), assistive motion exercise (69.7%% vs 57.0%), body reposition (68.5% vs 60.0%), transfer (38.2% vs 25.5%) and artificial airway management (40.5% vs 25.2%) than bedridden female participants. In addition, bedridden male residents need significant more time for assistance in feeding, bowel management and mouth care than the female ones. However, there was almost no significant difference in care needs and care time between male and female in domestic and community residents (p > 0.05).

LTC plays an important role in maintaining the basic living of the elderly with disability in China. Interventions to promote health in older age require a variety of supporting resources and systematic service arrangements from the healthcare system and the government.[23, 24] Before meaningful progress can be made to prepare the country for its rapid entrance into an ageing society, several challenges need to be understood and addressed. First, care needs must be assessed comprehensively; second, service capacity must to be improved; third, nursing resources need to be allocated properly.[1] In order to deal with these challenges, it is necessary to learn about which diagnosis and complications should LTC mainly focus on, identify the population eligible for LTC most, understand what content should LTC contain for the elderly.

In this study, from the questionnaires conducted to elderly participants, health practitioners and nursing staff of the LTC facilities, we revealed the common diseases and complications suffered by the elderly. In addition, we have found that the combined use of MBI and Longshi Scale can accurately identify the elderly population eligible for LTC, which may help decision makers gather information needed for optimal resource allocation. The component of LTC should be designed through the combination of basic physical and essential individual needs to ensure all needs are met.

What are the clinical characteristics of the elderly in LTC?

Chronic diseases are prevalent among the elderly population. It has been reported that chronic diseases accounts for 70% of total disability-adjusted life years lost in China.[4] In this study, we found that the most common chronic diseases suffered by elderly residents were stroke, consistent with the result of a study in German.[25] followed by hypertension, heart disease and diabetes.

Stroke, the most common cerebrovascular diseases, has become the leading disease that cause death and disability in China and all around the world.[26] A study in Netherlands has found cerebrovascular diseases as the strongest disease predictor of nursing home admission [relative risk ratio (RRR) = 11.5].[27] Guccione AA has showed that compared with heart disease and diabetes, stroke was significantly associated with functional limitations.[28] Hypertension and diabetes which are considered as important risk factors of stroke can contribute to the development of cerebrovascular disease.[29, 30].Therefore, our findings suggest that cerebrovascular diseases should be one of the main diseases covered by LTC. Accordingly, LTC facilities need to develop specialized care programs based on the functional characteristics of stroke patients. Health policies should focus on primary care which aims to prevent and manage chronic diseases by early disease detection and patient education, in order to delay disease onset and reduce LTC cost.[31]

Heart disease, Dementia, Cancer and COPD are also the leading causes of disability in China.[1] But in our study, the incidence of the three diseases is relatively low. This is partly because their incidence rate is not as high as that of the stroke.[26] It maybe also due to population selection bias, and needs to be future explored by expanding the sample size in subsequent studies.

Pulmonary infection is the top complication exhibited in all elderly residents especially in bedridden members. We also noticed that the incidence of pulmonary infection in our study was much higher (25.2% vs 3.39%) than that of previous study where its participants were bedridden patients in tertiary and secondary hospitals.[32] One plausible explanation is that prolonged bed rest with little mobilization in LTC facilities can lead to repeated lung infections. It’s has reported that pulmonary infection is the independent risk factors for death in hospitalized bedridden patients.[33] Pneumonia could cause a chronic inflammatory response which could increase cardiovascular mortality risk.[34] In our study, we noticed that to prevent pneumonia, respiratory therapy such as mouth care, artificial airway management and body reposition are important nursing care themes in the nursing assessment and nursing care plan. When repositioning bedridden elderly residents, nursing staff also perform chest physiotherapy to help patients cough out and eliminate mucus and improve breathing.

Besides, consistent with previous study.[26] we found that urinary tract infection, deep vein thrombosis and pressure ulcers are common among bedridden participants. All these conditions can be defined as major immobility complications,[35] and it is reported that they are associated with longer length of stay in hospital and higher mortality.[36, 37] Study shows physical exercise can bring benefits to hospitalized patients including fewer deep venous thromboses and urinary tract infections, and lower the incidence of pneumonia.[38] In our study, we observed that assistive motion exercise and regular reposition were provided by nursing assistants and residents were encouraged to sit out of bed and have a walk whenever they could in the nursing home.

Therefore, we can conclude that preventative care should be included in LTC and should be an essential part. Mouth care and artificial airway management can help prevent pneumonia while body reposition, assistive motion exercise, transfer out of bed and taking a walk can prevent deep vein thrombosis, pressure ulcers and urinary tract infection. It is suggested that these practices should be integrated in nursing care plan to prevent immobility complications for elderly in LTC facilities.

Who is eligible for LTC?

With the rapid growth of the elderly population, China is facing a significant increase of LTC demands but health resources are becoming increasingly constrained.[1] Therefore, it’s essential to make accurate and productive use of available functional assessment tools to identify the characteristics of people in need of LTC. In current practice, MBI or BI is one of the most commonly used ADL assessment tools to evaluate patient’s physical and functional ability in China [39]. A MBI scores less than 40 was defined as severe ADL impairment by the disability assessment standard for LTC (trial) issued by Chinese government in July 2021.[40] However, the optimal cutoff of ADL levels suitable for LTC is still unclear.

In our study, the use of MBI was combined with the use of Longshi Scale to identify the population in need of LTC. Longshi scale was set as the national standard of ADL measurement of China in 2019,[41] and since then it has been widely used among first-tier cities and all over China. We found that the majority of the elderly residents (69.3%) in the included population were classified in the bedridden group while only 5.4% of the elderly belonged to the community group (p < 0.001). Furthermore, the average MBI score of the bedridden residents (also grade one and grade two residents) was significantly lower than that of the community residents (p < 0.001) and the ratios of bedridden residents who require assistance with ten MBI activities were significantly higher than those of the community residents. Therefore, we may suggest that the population group in need of LTC most includes bedridden elderly who rely heavily on others to perform ADL. Senior citizens who are classified in the community group, on the other hand, may not need LTC at all.

Identifying the needs of LTC for the elderly in domestic group can be relatively complicated because participants in this group can partially or mostly self-care but were restricted in daily activity range, thus their needs for LTC should be further distinguished. Using Longshi Scale, we divided participants in domestic group to grade three and grade four. Compared with the community group, The elderly in grade three showed lower in functional ability but higher in independence of ADL, while the ADL functional ability and level of independence of grade four residents were similar with those of the community residents. Moreover, the average MBI scores of grade three residents (51.97) was significantly lower than that of grade four residents (67.13). In previous studies, the MBI or BI scores of residents living in LTC facilities mostly ranges from 10 to 49.[42] Therefore, it can be concluded that the elderly in grade three are more in need of LTC while the elderly in grade four, similar with those in the community group, may not necessarily require LTC.

We suggest that the elderly in Longshi grade one, two and three were the ones eligible for LTC. This finding will help the government or decision makers to make a clearer division of the admission criteria for LTC. Shenzhen, in fact, has adopted Longshi Scale as the criterion for the classification of LTC levels since the beginning of 2022.[43]

How should Elderly LTC be reasonably arranged?

A well-established LTC plan is essential for the elderly with limited physical or functional ability to maintain a basic living. However, the current LTC practice in China is under specialization and lack of standard.[44] Therefore, we tried to explore the indispensable components that should be included in LTC by investigating participants’ functional disability in this study.

As recommended in previous studies,[45] the indicators of quality of care for LCT facilities include hypertension, vision and hearing difficulties, oral health problems, mobility problems, washing, dressing and brushing teeth difficulties, urinary incontinence, feeling of loneliness and lack of autonomy. Accordingly, all these contents can be divided into five aspects, including basic health care (care for vision and hearing difficulties, dressing and brushing teeth difficulties), disease care (care for hypertension and urinary incontinence), mobility care (care for mobility problems), complication prevention care (care for oral health problems) and psychosocial care (care for feeling of loneliness and lack of autonomy), which are pretty consistent with our findings. In our study, nurses and nursing assistants were consulted and provided reference to the investigation from a nursing point of view. According to nursing assessment, all the fourteen nursing items can also be summarized into the above five aspects, which indicated that these five aspects of care should be the main contents of LTC for the elderly.[46] Specially, we found that the common top five nursing care needs for elderly at all functional levels were feeding, bathing, drinking, bowel management and bladder management, which are the most basic human needs for daily living as well as take quite a lot of nursing time, yet at the same time, the most vulnerable to deterioration in the elderly,[47] therefore should given priority to serve for the elderly in LTC facilities.

Results from functional assessment and nursing assessment also showed that participants with different level of disability have different personal care needs. Especially for bedridden participants, the assistance in complication prevention care (mouth care, artificial airway management, body reposition) were needed more by these participants, because these nursing contents can help bedridden patients prevent immobility complications, such as aspiration pneumonia and pressure ulcer. [48] There is evidence that improved oral care can reduce the risk of developing aspiration pneumonia in the elderly.[49] And a review have proved prevention-effectiveness of a pressure ulcer programme in LTC facilities, of which timely body reposition plays the key role.[50] On the contrary, bedridden participants require less assistance for entertainment activities than those in domestic group and community group, which remind that it’s need to pay more attention to the psychosocial needs for the elderly with better functions. These findings suggests that patients with different motor abilities needs to be treated personally, and the content of LTC should be specific to different levels according to patient’s level of independence to meet patient’s personal needs and to avoid resource wasting.

According to our study, we suggest that except disease care and mobility care, basic care, including feeding, bathing, drinking, bladder and bowel management fulfilling the elderly residents’ basic physical needs and complication prevention care, such as mouth care, artificial airway management, body reposition, preventing immobility complications specially for bedridden elderly should be included in LTC. Besides, psychosocial care should not be ignored for the non-bedridden elderly.

limitations

There are some limitations to this study. First, this is an observational study, the elderly participants were recruited from a nursing home and primary hospitals in Shanghai and Shenzhen, which would limit the extensionality of the results of this study. We also only researched LTC in first-tier cities due to the limited Longshi Scale prevalence and LTC had only fully developed in these cities. Therefore, a multi-centered study is needed in further research and further research will be carried out in other cities of China. On top of that, the nursing care themes in the questionnaire were set according to the nursing assessment and nursing care plan in the primary hospitals and nursing home and may do not cover every aspect, so there may be some missing in the nursing details. Third, this study only investigated the care needs during day time, from getting up in the morning to settling in bed at night, so all findings cannot reflect the nursing contents at night. Finally, we did not investigate the elderly population receiving care in community or at home. So, we could not compare the degree of acceptance for the elderly receive different mode of LTC. This needs to be further explored in future studies.

Our study found that cerebrovascular disease and complications due to immobility, especially pulmonary infection, were common among elderly in need of LTC, which should be paid more attention to in daily care. The elderly in Longshi grade one, two and three were the ones in need of LTC most, who were eligible for LTC. LTC should consists of basic health care, disease care, mobility care, complication prevention care and psychosocial care, of which basic care, including feeding, bathing, drinking, bladder and bowel management, which fulfill the elderly’s most basic living needs, and essential care, such as mouth care, artificial airway management, body reposition, which can help prevent major complications for immovable elderly. Our investigation results and findings from allied health practitioners and nursing staff can deepen our understanding of the actual care needs in elderly people, so as to provide a reference for the rational allocation of resources in the health care system of this aging society.

LTC: long time care; LTCI: long-term care insurance; BI: Barthel Index; MBI: modified Barthel Index; ADL: activities of daily living.

Ethics approval and consent to participate

The study design was approved by the Ethics Committee of Shenzhen Second People’s Hospital (No. 20180926006). This study conforms to the standards of the Declaration of Helsinki. Prior to this study, the investigator explained the study procedure and protocol in detail and obtained informed consent from each participant or the guardian of disoriented participants who suffered from dementia or other mental health diseases. Since nursing staff were invited to indicate elderly’ needs for care. All these nursing participants was also explained in detail about the study procedure and protocol, and obtained written informed consent. Participants as well as their relatives or legal guardians can withdraw consent at any time. All participant information and data will be stored securely and identified by a coded ID number only to maintain participants’ confidentiality.

Consent for publication

Not applicable.

Availability of data and materials

The datasets generated and analysed during the current study are included in this published article, as well as available from the corresponding author (Yulong Wang or first athor (Mingchao Zhou) on reasonable request.

Competing interests

The authors declare that they have no competing interests.

Funding

This work was supported by the National Natural Science Foundation of China [grant number 82205065]; Guangdong Basic and Applied Basic Research Foundation [grant number 2020A1515111062] and Shenzhen Second People’s Hospital Clinical Research Foundation [grant numbers 20203357021, 20203357019, 20213357022]. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

Authors’ contributions

ZMC, ZFB and WYL came up with the study design, ZMC, LF, LJH, YQQ, ZZY and WHY conducted the questionnaire survey and collected the data, LXX and ZJ performed the formal analysis and interpretation, WYL provided the funding acquisition and carried out the project management, XF and HDR supervised the research progress and organized the data, ZMC drafted and wrote the manuscript. All authors analyzed and interpreted the data and read and approved the manuscript.

Acknowledgments

The authors thank all the staff members from our institution who actively cooperated in the current research. We are thankful to Mr Aichuan Li, Mis Liying Liu and Mr Guowei Xue (Co. Ltd. Dongfang Huakang medical management. Shanghai, China) for providing us with data collection assistant. We especially give our thanks to Mis Zhihui Hu for helping us in English language editing.

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Table 2 is available in the Supplementary Files section.

No competing interests reported.

Table2.docx

Long-Term Care status for the Elderly with Different Levels of Physical Ability: a cross-sectional investigation in first-tier cities of China

Status:

Journal Publication

Version 1

Abstract

Figures

Introduction

Material And Methods

Design

Study population

Data collection

ADL assessment

Longshi Scale

MBI

Nursing assessment

Data analysis

Results

Clinical characteristics of the elderly residents in three Longshi groups

Functional disabilities of elderly residents in three Longshi groups

Nursing care required by elderly in three Longshi groups

Discussion

What are the clinical characteristics of the elderly in LTC?

Who is eligible for LTC?

How should Elderly LTC be reasonably arranged?

limitations

Conclusions

Abbreviations

Declarations

References

Table 2

Additional Declarations

Supplementary Files

Status:

Journal Publication

Version 1