Objectives: To determine whether cognition moderates the association between facility-level characteristics and individual-level impairments and activity of daily living (ADL) dependency. Design: Longitudinal cohort study. SettingS: Nursing homes (NHs) in Minnesota. Participants: Four thousand nine hundred forty-two NH residents admitted to 377 Minnesota NHs during 2004 were followed for 4 to 8 months. Measurements: According to the Minimum Data Set (MDS) Cognition Scale 3,132 residents had high cognitive function, and 1,810 had low cognitive function. Total ADL score and scores on three ADL tasks at follow-up were used as outcome variables. MDS-derived impairment measures at admission of pain, depression, incontinence, balance dysfunction, and fall history were used to predict ADL changes. Fifteen resident-level and eight facility-level control variables were included in all four ADL models. Results: Effects of NHs and impairments on ADLs tended to be weaker for residents with low cognitive function. Bladder incontinence significantly predicted more dependence in total ADLs, toileting, and personal hygiene in both cognitive groups. Balance dysfunction significantly predicted worse total ADLs, toileting, and personal hygiene in the high-cognition group but only worse toileting function in the low-cognition group. In neither subgroup did any impairment predict worse eating function. Cognition did not modify the relationships between pain, depression, and recent falls and ADLs. Conclusion: Current NH environments and care processes may be inadequate to facilitate ADL changes for residents with severe cognitive impairment. More innovative structural designs, higher staffing levels, and better care processes may be indicated.
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