The Gerontologist
Vol. 46, No. 1, 52–61
Caregivers’ Reasons for Nursing Home
Placement: Clues for Improving Discussions
With Families Prior to the Transition
Gwendolen T. Buhr, MD,1,2 Maragatha Kuchibhatla, PhD,2,3
and Elizabeth C. Clipp, RN, PhD1,2,4,5
Purpose: This study identifies the relative importance
of reasons for institutionalization endorsed by care-
givers of patients with dementia; examines the
relationship between caregivers’ reasons for institu-
tionalization and indicators of caregiver and patient
physical and emotional functioning measured in the
prior year; and compares, on these indicators, care-
givers who institutionalized their care recipients with
caregivers who did not. Design and Methods: Par-
ticipants were 2,200 caregivers from the National
Longitudinal Caregiver Study, including 580 who
institutionalized their care recipient during the 3-year
interval. Caregivers’ reason(s) for institutionalization
were examined and correlated with indicators of
caregiver and patient physical and emotional func-
tioning. These indicators were used in a proportional
hazards model to determine independent predic-
tors. Results: Caregivers’ reasons for placement
included (a) the need for more skilled care (65%);
(b) the caregivers’ health (49%); (c) the patients’
dementia-related behaviors (46%); and (d) the need
for more assistance (23%). Each of these reasons was
significantly associated with indicators in the prior
We gratefully acknowledge the support for this study given through
grants from the Health Service Research & Development Program of the
Department of Veterans Affairs (Grant NRI-95-218; E. Clipp, Principal
Investigator) and the NINR (Grant 1 P20 NR O7795-01, 1P20NR07795-
02; E. Clipp, Principal Investigator). We extend our appreciation to
Martha Doyle, MA, research analyst, for National Longitudinal
Caregiver Study data-management support. A preliminary version of
this article was presented at the annual scientific meeting of the
American Geriatrics Society in May 2003.
Address correspondence to Gwendolen T. Buhr, MD, Department of
Medicine, Division of Geriatrics, Box 3003, Duke University Medical
Center, Durham, NC 27710. E-mail: buhr0001@mc.duke.edu
1
Department of Medicine, Duke University Medical Center,
Durham, NC.
2
Center for the Study of Aging and Human Development, Duke
University Medical Center, Durham, NC.
3
Department of Biostatistics and Bioinformatics, Duke University
Medical Center, Durham, NC.
4
School of Nursing, Duke University Medical Center, Durham, NC.
5
Geriatric Research Education and Clinical Center, Durham Veterans
Affairs Medical Center, Durham, NC.
52
Copyright 2006 by The Gerontological Society of America
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year’s survey. This study uniquely demonstrates that
caregiving task demand and a single-item measure of
caregiver life satisfaction significantly predict place-
ment. Implications: These findings emphasize that
caregivers’ reasons have valid underpinnings and
that institutionalization of dementia patients results
from caregiver and patient factors evident in the year
prior to placement. In routine office visits, caregivers
should be systematically screened; accounts of low
life satisfaction, dementia problem behaviors, or high
task demand should cue clinicians that discussions
of nursing home placement would be timely and
appropriate.
Key Words: Caregiver, Dementia, Task demand,
Institutionalization, Nursing home placement
When family caregivers of individuals with de-
mentia decide that a permanent move to a nursing
home is necessary, their reasons may be multifacto-
rial. Examining these reasons is an important step in
understanding the institutionalization process. Al-
though health care providers are in key positions to
influence caregivers’ decisions, to our knowledge, no
guidelines exist to aid in timing these discussions.
Health care providers who directly raise the issue
for discussion before caregivers reach a ‘‘breaking
point’’ could ease the transition by offering these
caregivers their guidance and support. Although
much has been written about predictors of institu-
tionalization of patients with dementia, little atten-
tion has been given to the caregivers’ subjective
reasons, which is the focus of this study. Because
informal caregivers operate as key decision makers
in this process, their perceptions offer evidence for
the development of guidelines, thus empowering
clinicians to discuss the issue and thus take some of
the guilt and burden from caregivers.
The Gerontologist
 Three categories of patient and caregiver factors
have been found to predict institutionalization in the
context of dementia: patient demographics, caregiver
characteristics, and patient health status. Regarding
patient demographics, in several studies, married
elders were less likely to enter a nursing home,
suggesting the importance of spousal caregivers
(Colerick & George, 1986; Hanley, Alecxih, Wiener,
& Kennell, 1990; Pot, Deeg, & Knipscheer, 2001).
However, in other studies, when the patient–caregiver
relationship and household composition were in-
cluded in multivariate models, only living alone
related to institutionalization (Branch & Jette, 1982;
Gaugler, Kane, Kane, Clay, & Newcomer, 2003;
Greene & Ondrich, 1990; Wolinsky, Callahan,
Fitzgerald, & Johnson, 1992; Yaffe et al., 2002). In
yet another study, though living alone was included,
lower rates of institutionalization were associated
with the caregiver’s being a spouse or child (Hebert,
Dubois, Wolfson, Chambers, & Cohen, 2001). Thus,
there is a complex relationship among living alone,
the relationship of the caregiver to the patient,
and institutionalization. This literature also shows
that Whites compared with Hispanics and African
Americans have had higher rates of institutionaliza-
tion (Gaugler et al., 2003; Greene & Ondrich; Hanley
et al.; McFall & Miller, 1992; Schulz et al., 2004;
Wolinsky et al.; Yaffe et al.). Finally, older age has
been a risk factor for permanent placement in some
studies (Branch & Jette; Gaugler et al., 2000; Hanley
et al.; McFall & Miller; Wolinsky et al.), but not in
others (Colerick & George; Yaffe et al.).
Among caregivers, perceived stress or burden has
been shown to be a key predictor of institutionaliza-
tion (Pot et al., 2001; Gaugler et al., 2003; Hebert
et al., 2001; McFall & Miller, 1992; Schulz et al.,
2004; Yaffe et al., 2002), as have feeling trapped in
the role (Gaugler et al., 2000), health problems
(Hebert et al.), and poor self-rated health (Gaugler
et al., 2000; Gaugler et al., 2003). Studies involving
caregiver age have provided mixed results, with both
younger (Colerick & George, 1986) and older
caregivers (Gaugler et al., 2003; Hebert et al.; Yaffe
et al.) choosing institutionalization.
Studies including dementia characteristics have re-
vealed that higher levels of cognitive and functional
impairment and the presence of difficult behaviors in
care recipients predict institutionalization (Gaugler
et al., 2000; Gaugler et al., 2003; Hebert et al., 2001;
Pot et al., 2001; Yaffe et al., 2002). Greater risk also
has been associated with declining functional status
(Gaugler et al., 2003; Wolinsky, Callahan, Fitzger-
ald, & Johnson, 1993) and a prior nursing home stay
(Hanley et al., 1990; Wolinsky et al., 1992).
In summary, previous research indicates that both
patient and caregiver factors predict nursing home
admission. Caregivers’ stated reasons generally are
not reported as part of this body of literature. The
few studies that report caregivers’ reasons are limited
by small sample sizes and have used data gathered
Vol. 46, No. 1, 2006
from a single interview, either retrospectively (Wing-
ard, Williams-Jones, McPhillips, Kaplan, & Barrett-
Connor, 1990) or around the time of admission
(Arling & McAuley, 1983; Nolan & Dellasega,
2000). To better understand the complex decision-
making process surrounding institutionalization, in
this study we focused exclusively on caregivers’
reasons for institutionalization and related these to
caregiver and patient characteristics gathered in
advance of the decision. The study population was
a large nationally representative group of caregivers
of elderly male veterans with dementia. Our study
aims were as follows: (a) to identify the relative
importance of reasons for institutionalization en-
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dorsed by caregivers of patients with dementia; (b) to
examine the relationship between caregivers’ reasons
for institutionalization and indicators of caregiver
and patient physical and emotional functioning
measured in the prior year; and (c) to use these
indicators to compare caregivers who institutional-
ized their care recipients with caregivers who did
not. To our knowledge, this is the first study to
examine how caregivers’ stated reasons for institu-
tionalization relate to more objective evidence
collected prior to the placement transition.
Design and Methods
Participants
Data derive from the National Longitudinal Care-
giver Study (NLCS), a 4-year longitudinal examina-
tion of informal caregivers of elderly veterans with
dementia living throughout the 48 contiguous states
and Puerto Rico. Participants were available for
inclusion in the NLCS if they had an outpatient visit
to a Veterans Affairs (VA) medical center or VA
community clinic in 1997 as indicated in the 1997 VA
Outpatient Diagnostic File (encounter form data-
base). The NLCS identified patients who met the
following criteria: (a) being 60 years of age or older,
(b) residing in the community, (c) having an avail-
able next of kin or emergency contact, and (d)
having a diagnosis of Alzheimer’s disease or vascular
dementia (Codes 331.0 or 290.4 in the International
Statistical Classification of Diseases, 9th edition).
Of 9,124 eligible households that were sent caregiver
identification letters, 5,773 (63%) responded, and of
those, 3,665 met the inclusion criteria. These care-
givers were sent baseline surveys and 2,279 (62%)
returned their survey, 11 of whom were later found
to be ineligible, leaving a final sample of 2,268. At
both stages of recruitment, the veterans whose
caregivers responded were significantly more likely
to be White, married, cared for by a spouse, and
diagnosed with Alzheimer’s disease as opposed to
vascular dementia.
Caregivers were initially surveyed in 1998, and
follow-ups were sent in 1999, 2000, and 2001. We
excluded caregivers who were unreachable or no
53
 Table 1. Measures Included in the Present Study Arranged as They Relate to the Domain and the
Caregivers’ Reasons for Institutionalization

Domain Variable Related Reason

Caregiver sociodemographic Age, relationship of the caregiver to the All
patient, income, race, years of education
Caregiver health Number of days sick, days in the hospital, ‘‘My health would not permit me to
doctors’ visits, medications, and continue caregiving.’’
comorbidities;a extent to which the
comorbidities interfered with their usual
activities, self-rated health
Patient behavior BRS-D total,a six BRS-D subscales: behavior ‘‘My loved one’s behavior became too
dysregulation, depressive symptoms, difficult to handle.’’
irritability or aggression, inertia,
psychotic symptoms, vegetative symptoms

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Patient physical functioning ADL, IADL, Rosow-Breslau scales ‘‘My loved one needed more advanced or
skilled care than I could provide.’’
Need for skilled care Patient score on modified OARS comorbidity ‘‘My loved one needed more advanced or
scale, patient incontinence (yes or no),a skilled care than I could provide.’’
number of tasks performed for the patient,
time spent supporting patient’s ADLs,
help from home health care (yes or no)
Caregiver social support Instrumental support scale, subjective support ‘‘I needed more assistance from others and
scale, a single item concerning the could not get it.’’
caregivers’ perceived need for more help,a
scale measuring the tasks and time provided
by others, whether others help care for the
patient (yes or no)
Caregiver emotional health Single question measuring life satisfaction, All
multi-item scale measuring stress symptoms,
CES-D
Notes: BRS-D = Behavior Rating Scale–Dementia; ADL = activity of daily living; IADL = instrumental ADL; OARS = Older
Americans Resources and Services; CES-D = Center for Epidemiologic Studies–Depression scale.
a
Variables not included in the multivariate analysis because they were confounded with other variables.

longer providing care by Year 2 from this analysis,
leaving 2,211.
Procedures
The Year 2, 3, and 4 surveys began with questions
concerning changes that may have occurred in the
caregiving situation since the last survey. These in-
cluded an alternate primary caregiver for the pa-
tient, a temporary stay in a care facility by the
patient, a permanent move to a nursing home by the
patient, or the death of the patient. When institu-
tionalization occurred, caregivers were asked to
provide the date of admission, name of the nursing
home, distance from the caregivers’ home, frequency
of visitation, and whether the nursing home was
private pay or a VA facility. The questionnaire then
provided five possible reasons that the move
occurred, and participants were asked to check all
that applied: (a) ‘‘my health would not permit me to
continue caregiving’’; (b) ‘‘my loved one’s behavior
became too difficult to handle’’; (c) ‘‘my loved one
needed more advanced or skilled care than I could
provide’’; (d) ‘‘I needed more assistance from others
and could not get it’’; and (e) ‘‘family or friends
thought it was the best thing to do.’’ Caregivers
could also provide a reason in their own words.
We took several measures to ensure that the move
was permanent. First, there was a separate question
regarding temporary admissions. Furthermore, if
caregivers reported a permanent move, but on the
following year’s survey they were again caring for
their loved one in the community, we did not code
the patient as institutionalized. In addition, we cross-
checked the institutionalization data with the VA
Beneficiary Identification and Records Locator Sub-
system death files and Extended Care databases. We
excluded patients from this sample if they died
within 30 days of entering a nursing home, or were
found through the Extended Care database to have
stayed fewer than 90 days.
Measures
We selected from the survey those indicators of
caregiver and patient physical and emotional func-
tioning that related to the reasons for institutional-
ization (Table 1). Indicator domains included (a)
caregiver sociodemographics, (b) caregiver health,
(c) patient behavior, (d) patient physical functioning,
(e) need for skilled care, (f) caregiver social sup-
port, and (g) caregiver emotional health. Cronbach’s
alphas, calculated for the NLCS baseline data, are
provided in parentheses for the scale measures.

54 The Gerontologist
 Basic caregiver sociodemographics included age
(years), years of education, nature of the caregiver–
patient relationship (spouse or other), annual house-
hold income, and race (White or other).
We estimated caregiver physical health by using
self-rated health on a 4-point scale from poor to ex-
cellent, and three measures covering the previous 6
months: (a) the number of days too sick to perform
caregiving activities, (b) the number of doctors’
visits, and (c) the number of days spent in the hos-
pital. We also included the number of medications
taken by the caregivers, the number of comorbid
illnesses, and the extent to which these illnesses
interfered with caregivers’ usual activities (3-point
scale ranging from 1 = not at all to 3 = a great deal).
We measured patient dementia-related problem
behavior with the Behavior Rating Scale–Dementia
(BRS-D), which assesses behavioral problems and
psychiatric symptoms of individuals with no history
of mental retardation but with some degree of cognitive
impairment (a = 0.70). Six subscales measured
irritability or aggression (a = 0.79), behavior dysregu-
lation (a = 0.66), depressive symptoms (a = 0.74),
inertia (a = 0.57), vegetative symptoms (a = 0.48), and
psychotic symptoms (a = 0.86; see Mack, Patterson, &
Tariot, 1999). For each item, caregivers reported the
frequency of the problem behavior in the previous
month (higher scores indicate greater frequencies).
We estimated patient physical functioning by
using the seven-item instrumental activities of daily
living (IADL) subscale (a = 0.89) and the seven-item
physical activities of daily living (ADL) subscale (a =
0.93) of the OARS Multidimensional Functional
Assessment questionnaire (Fillenbaum, 1988). We
used three of six items originally identified by Rosow
and Breslau (1966) and used by the Established
Populations for Epidemiologic Studies of the Elderly
(known as EPESE) as an estimate of advanced ADLs.
These included performing heavy household work,
walking up and down a flight of stairs, and walking
half a mile (a = 0.75; see Rosow & Breslau; Smith
et al., 1990). Caregivers were asked to rate each item
(ADLs, IADLs, Rosow–Breslau) on a 3-point scale
(1 = needs no help, 2 = needs some help, or 3 =
unable to do).
Indicators that the patient needed skilled care
were the number of illnesses present on a modified
OARS comorbidity scale, whether the caregivers
received help from home health care, the time spent
supporting deficits in patient ADLs, and the number
of tasks (0–22) caregivers performed for the patient
(yes, no, or very rarely; Clipp & Moore, 1995). The
modified OARS comorbidity scale was based on the
original 26 medical conditions to which depression,
need for tube feedings, incontinence of bowel or
bladder, and leg amputations were added, and to
which cerebral palsy, muscular dystrophy, and speech
impediment were removed (Fillenbaum, 1988).
We estimated instrumental social support by using
a multi-item scale from the Duke Social Support
Vol. 46, No. 1, 2006
Index (a = 0.87). Caregivers were asked to report the
frequency with which family and friends provided 13
specific types of assistance (4-point scale from 1 =
never to 4 = regularly). Services included helping
when sick; helping with shopping or running er-
rands; helping with money, meals, household
repairs, and housework; giving financial or personal
advice; providing transportation; giving gifts; listen-
ing to problems; and providing companionship for
the patient (Landerman, George, Campbell, & Blazer,
1989). A measure of tasks and time provided by
others was a multi-item scale of how often secondary
helpers assisted with 18 tasks (4-point scale from 1 =
never to 4 = regularly). The specific tasks included
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bathing, eating, dressing, toileting, grooming, trans-
ferring from one spot to another, walking inside and
outside, cooking, doing housework, doing laundry,
shopping, driving, taking medication, providing com-
panionship, making repairs, doing outside work, and
dealing with social agencies.
We measured subjective social support by using
a 10-item scale from the Duke Social Support Index
(a = 0.64) that requested information on caregivers’
satisfaction with their relationships; whether care-
givers felt lonely, understood, useful, listened to,
included in the lives of family and friends, and as if
they had a definite role in the family and among
friends; and whether the caregivers had someone
they could count on in times of trouble, and someone
with whom they could talk about their deepest
problems. The final item in the subjective-support
scale was a single item concerning caregivers’ desires
for more help from family and friends (3-point
scale from 1 = very much to 3 = not at all; George &
Gwyther, 1986). We summed responses to yield a
total score, with higher scores representing greater
subjective support (Landerman et al., 1989). Also
included was a single item measuring whether there
were other people who helped care for the patient.
We measured caregiver emotional health by using
the Center for Epidemiologic Studies–Depression
scale short form, in which the caregivers rate the
presence or absence of 20 feelings in the previous
week (a = 0.72), a single-item life-satisfaction mea-
sure (3-point scale from not satisfying to very
satisfying; Bradburn, 1969), and a 22-item emotional
symptom scale (a = 0.78). We derived the 22-item
emotional symptom scale, which summed the
presence or absence of stress symptoms, from the
Short Psychiatric Evaluation Schedule (Pfeiffer,
1979) and the Twenty-Two Item Screening Scale
(Langer, 1962).
Statistical Analyses
Initially, we examined bivariate relationships be-
tween caregivers’ reasons for institutionalization and
indicators of caregiver and patient physical and
emotional functioning from the survey completed in
55
the year prior to placement. Using t tests for con- Table 2. Baseline Characteristics of the Sample
tinuous variables and chi-square for categorical
variables, we compared caregivers who chose a Variable M 6 SD
reason with those who did not choose that reason Caregiver sociodemographic factors
across the corresponding indicators. We analyzed Age (years) 67.6 6 10.4
caregiver sociodemographic and emotional health Spouse of the patient (%) 85.9
covariates with each reason, because the caregivers’ Income (annual household in dollars) 25,755 6 15,794
emotional well-being may have influenced the selec- White race (%) 78.7
tion; in addition, spousal caregivers, older care- Education (years) 12.0 6 2.7
givers, and caregivers of different racial backgrounds Caregiver health factors
may have chosen different reasons. The fifth reason, Days sick in the last 6 months 5.6 6 16.9
‘‘family or friends thought it was the best thing to Days in the hospital in the last 6 months 0.69 6 2.9
Doctors’ visits in the last 6 months 4.0 6 5.3
do,’’ did not correspond closely with any survey No. of medications 4.0 6 3.1
indicators and thus was reported only as the number No. of comorbidities from a list of 25

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of caregivers who endorsed this reason. (0–7þ) 3.2 6 2.0
To determine the independent associations be- Extent affected by comorbidities (1 ¼ not
tween caregiver and patient characteristics and insti- at all to 3 ¼ a great deal; 0–15þ) 6.2 6 4.5
tutionalization, we performed a multivariate analysis Self-rated health (1 ¼ poor to
using a proportional hazards model (Cox, 1972). 4 ¼ excellent) 2.6 6 0.77
This powerful method incorporates time to the event BRS-D
(e.g., nursing home placement) rather than simply Total (0–59) 19.2 6 12.0
whether or not the event occurs. The method allows Behavior dysregulation subscale (0–12) 3.7 6 3.5
Depressive symptoms subscale (0–13) 3.3 6 3.4
researchers to look at the relationship between the Irritability or aggression symptoms
time to the event and other variables associated with subscale (0–12) 4.5 6 3.7
it. We incorporated the variables with statistically Inertia subscale (0–2) 1.5 6 0.69
significant bivariate association with institutionali- Psychotic symptoms subscale (0–15) 2.6 6 4.1
zation into a stepwise proportional hazards model, Vegetative symptoms subscale (0–2) 1.4 6 0.73
with institutionalization as the dependent outcome. Patient physical functioning
The model included variables derived from each of ADL (1 ¼ needs no help to 3 ¼ unable
the seven domains (see Table 1). The multivariate to do) 1.5 6 0.58
analysis included the fixed covariates of race and the IADL (1¼ needs no help to 3 ¼ unable
to do) 2.6 6 0.48
caregiver–patient relationship (spouse or other). All Rosow-Breslau (1 ¼ needs no help to
other covariates were time varying. The variable for 3 ¼ unable to do) 2.4 6 0.61
the number of minutes per day that caregivers spent
Indicators that patient needs skilled care
supporting deficits in patients’ ADLs was not Patient comorbidities (0–18) 6.2 6 2.9
normally distributed; therefore, we dichotomized it Patient incontinent, bowel or bladder
at the median (23.0) and entered it into the model as (% yes) 29.9
a categorical variable. We conducted all analyses in No. of tasks performed for patient (0–22) 14.9 6 4.0
SAS 9.1 (SAS Institute, 2004). Minutes per day spent supporting
patient’s ADLs 76.5 6 123.4
Help from home health care (% yes) 13.8
Caregiver social support
Results Instrumental support scale (13–52) 30.8 6 8.1
Subjective support scale (10–30) 22.5 6 3.6
Sample Characteristics How much do you wish others would help
more (1 ¼ very much to 3 ¼ not at all) 2.0 6 0.72
Of the 2,211 caregivers, we excluded 11 from this Others help care for patient (% yes) 48.5
analysis, because they had missing values for all of How often caregiver assistants help (18–72) 27.4 6 12.3
the variables; this resulted in a caregiver sample size Caregiver emotional health factors
of 2,200. Of these, 580 institutionalized their care Life satisfaction (1 ¼ not satisfying
recipients over the 3 years of observation, and 573 to 3 ¼ very satisfying) 2.0 6 0.57
completed the institutionalization module that re- Stress symptoms (0–22) 8.9 6 5.2
quested their reason(s) for seeking permanent nurs- CES-D (0–20) 6.1 6 4.9
ing home care. Of these, we included 572 in the Notes: BRS-D = Behavior Rating Scale–Dementia; ADL =
bivariate analysis of the reasons for institutionaliza- activity of daily living; IADL = instrumental ADL; CES-D =
tion. We excluded 1 respondent from the comparison Center for Epidemiologic Studies–Depression scale. For the
table, N = 2,200.
because the caregiver at the prior year was an
alternate caregiver. Table 2 summarizes the baseline
characteristics of the entire sample. The mean age of were White. Most of the caregivers rated their life
the caregivers was nearly 68 years; 86% of the as fairly satisfying. The mean patient IADL score
caregivers were the spouse of the patient, and 79% was 2.6 (maximum 3), indicating a high degree of

56 The Gerontologist
impairment at baseline. There were 320, 157, and
103 patients institutionalized during the first, second,
and third year, respectively. The mean years of
caregiving for recipients who were not institutional-
ized was 4.6, compared with 4.0 for those who were
institutionalized, which was a statistically significant
difference (p = .0051).
Caregiver Reasons for Institutionalization
Caregivers were asked to choose, among five rea-
sons, all that applied to their situation. We totaled
their responses: 31.1% chose only one reason, 24.3%
two, 18.7% three, 14.0% four, 5.6% five, and 6.5%
none. The most common reason given was ‘‘my loved
one needed more advanced or skilled care than I could
provide,’’ with 373 respondents (65%) choosing this
reason. The second most common reason was ‘‘my
health would not permit me to continue caregiving’’
(278 respondents; 49%), followed closely by ‘‘my loved
one’s behavior became too difficult to handle’’ (261
respondents; 46%). Two-hundred and twelve care-
givers (37%) chose the reason ‘‘others thought it was
the best thing to do,’’ and 133 (23%) chose ‘‘I needed
more assistance from others and could not get it.’’
We performed a bivariate analysis to determine
caregiver and patient indicators that were associated
with the reasons given for institutionalization. For
every reason, there was at least one indicator that
differentiated caregivers who endorsed the reason
from those who did not. Thus, indicators that sup-
ported the ultimate decision were present in the year
before the decision was reached (Table 3). For
example, caregivers who indicated that their health
was the impetus for institutionalization were more
likely to have lower self-rated health, more visits to
the doctor, more sick days, more medications, and
more comorbid illnesses. In addition, caregivers who
cited their health as a reason were more likely to be
a spouse (96.4%; 81.1%; p , .0001), older (71.1 6
7.4; 68.0 6 10.9; p = .0001), have a lower income
(23,419 6 14,027; 27,290 6 16,831; p = .004), lower
life satisfaction, and higher stress symptoms. When
caregivers cited patient behavior as the reason, their
patients were more likely to be their spouses (93.8%;
84.0%; p = .0003) and to have received higher scores
on four of the BRS-D subscales: behavior dysregu-
lation, irritability or aggression symptoms, inertia,
and psychotic symptoms. Caregivers reporting the
need for more assistance from others as their reason
were younger than those who did not choose that
reason (68.0 6 9.7; 70.0 6 9.4; p = .036), and they
also reported lower perceptions of social support and
desire for more help from family or friends in the
year prior to placement. Caregivers reporting the
need for skilled care were caring for patients with
higher scores on the Rosow–Breslau scale, suggesting
deficits in lower body strength.
Vol. 46, No. 1, 2006
Predictors of Institutionalization
We used the same indicators of patient and
caregiver physical and emotional functioning used
in the analysis of the caregivers’ reasons with
multivariable proportional hazards analysis to deter-
mine the predictors of institutionalization (Table 4).
In the final multivariate model, we identified six
significant predictors. For the dichotomous variable,
race, the risk ratio was straightforwardly expressed.
For continuous variables, the risk ratios were
calculated for a 1-unit increase, as well as for the
maximum score for each scale. For example, the
change in probability of admission for a maximal
score of 12 on the behavior dysregulation subscale
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was compared with a score of 1. With respect to
caregiver sociodemographics, White caregivers were
1.7 times more likely than non-Whites to seek
placement. The caregiver emotional health domain
revealed that caregivers whose life was not satisfy-
ing were 2.3 times more likely to institutionalize
compared with those whose life was very satisfying,
and 1.5 times more likely than caregivers whose life
was fairly satisfying. Relating to the need for skilled
care, caregivers with the highest task burden were
5.1 times more likely to seek formal care compared
with those with the lowest burden. In addition, fewer
patient comorbidities was a predictor, with those
with no comorbid condition being 15.1 times more
likely than those with the greatest number of
comorbidities (18) to be institutionalized. Finally,
in the patient behavior domain, patients who scored
the highest on the psychotic symptom and behavior
dysregulation subscales of the BRS-D were re-
spectively 2.4 and 2.3 times more likely to be
institutionalized.
Discussion
Movement to a nursing home is a major life event
for both the patient and caregiver. Despite the
magnitude of the institutionalization decision, there
often is little informed guidance from health care
professionals. Such guidance would increase the
chances for appropriate and timely nursing home
placement, not only benefiting the patient but also
reducing caregiver guilt. Consultation with a health
care provider conveys legitimization to the decision;
in one study, caregivers who did not discuss their
decision with their care provider viewed it the most
negatively (Lundh, Sandberg, & Nolan, 2000).
Unfortunately, clinicians currently are at a disadvan-
tage in initiating these discussions, because they lack
empirical evidence regarding when such discussions
should occur. The unique contributions of this study
were, first, the large number of NLCS caregivers
(n = 580) who institutionalized their care recipients,
and second, the fact that data on caregiver and
patient physical and emotional functioning were
collected during the year before institutionalization,
57
 Table 3. Caregivers’ Reasons for Nursing Home Admission and the Relation to Indicators of
Caregiver and Patient Physical and Emotional Functioning

Reason Yes (M 6 SD) No (M 6 SD) p

‘‘My health would not permit me to continue caregiving.’’
Days sick in the last 6 months 6.9 6 17.8 4.0 6 14.0 .030
Days in the hospital in the last 6 months 0.91 6 3.1 0.87 6 7.3 .924
Doctors’ visits in the last 6 months 5.4 6 5.4 3.5 6 4.0 , .0001
No. of medications 5.0 6 3.0 3.8 6 2.9 , .0001
No. of comorbidities from a list of 25 (0–7þ) 4.2 6 2.1 3.1 6 2.1 , .0001
Extent affected by comorbidities (1 ¼ not at all
to 3 ¼ a great deal; 0–15þ) 8.3 6 4.7 5.7 6 4.5 , .0001
Self-rated health (1 ¼ poor to 4 ¼ excellent) 2.3 6 0.74 2.7 6 0.75 , .0001
Life satisfaction 1.8 6 0.53 1.9 6 0.59 .0092
Stress symptoms 10.5 6 4.8 9.1 6 5.2 .001

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CES-D 7.7 6 5.0 6.9 6 4.9 .064
‘‘My loved one’s behavior became too difficult to handle.’’
Behavior dysregulation subscale (0–12) 6.0 6 3.4 4.4 6 3.7 , .0001
Depressive symptoms subscale (0–13) 3.9 6 3.6 3.4 6 3.5 .115
Irritability or aggression symptoms subscale (0–12) 5.9 6 3.5 4.8 6 3.8 .0007
Inertia subscale (0–2) 1.7 6 0.58 1.6 6 0.67 .017
Psychotic symptoms subscale (0–15) 5.4 6 4.9 3.5 6 4.6 , .0001
Vegetative symptoms subscale (0–2) 1.5 6 0.67 1.4 6 0.73 .254
Life satisfaction 1.8 6 0.56 1.9 6 0.58 .176
Stress symptoms 9.5 6 4.9 10.0 6 5.2 .332
CES-D 7.4 6 4.8 7.1 6 5.1 .400
‘‘My loved one needed more advanced or skilled care than I could provide.’’
Patient comorbidities from a list of 28 (0–18) 6.2 6 2.9 5.9 6 2.6 .189
Patient incontinence (% yes) 41.6 6 0.49 40.4 6 0.49 .787
No. of tasks performed for patient (0–22) 16.1 6 3.70 16.0 6 3.73 .892
Minutes per day spent supporting patient’s ADLs 98.4 6 122.4 82.8 6 130.5 .158
Help from home health care (% yes) 17.1 6 0.38 17.8 6 0.38 .849
ADL (1 ¼ needs no help to 3 ¼ unable to do) 1.6 6 0.52 1.6 6 0.48 .120
IADL (1 ¼ needs no help to 3 ¼ unable to do) 2.8 6 0.30 2.8 6 0.31 .681
Rosow-Breslau (1 ¼ needs no help to
3 ¼ unable to do) 2.5 6 0.50 2.3 6 0.56 .0006
Life satisfaction 1.9 6 0.57 1.9 6 0.57 .864
Stress symptoms 9.8 6 5.1 9.8 6 5.0 .940
CES-D 7.1 6 5.0 7.5 6 5.0 .348
‘‘I needed more assistance from others and could not get it.’’
Instrumental support scale (13–52) 29.0 6 8.5 30.0 6 8.1 .256
Subjective support scale (10–30) 21.4 6 3.3 22.3 6 3.6 .019
How much do you wish others would help
more (1 ¼ very much to 3 ¼ not at all) 1.7 6 0.67 2.0 6 0.69 .0002
Others help care for patient (% yes) 50.0 6 0.50 54.5 6 0.50 .367
How often caregiver assistants help (18–72) 27.4 6 12.2 27.4 6 11.3 .996
Life satisfaction 1.8 6 0.55 1.9 6 0.57 .070
Stress symptoms 10.1 6 4.7 9.7 6 4.2 .448
CES-D 7.6 6 4.7 7.2 6 5.0 .351
Notes: CES-D = Center for Epidemiologic Studies–Depression scale; ADL = activity of daily living; IADL = instrumental
ADL. Table data are taken from the prior year survey data from caregivers who endorsed the reason are compared with data from
caregivers who did not (n = 572).

allowing an analysis of the caregiver and patient data
in the context of their reasons for institutionalization
that were formulated later.
The most commonly cited reasons for institution-
alization included caregivers’ perceptions that skilled
care was needed, that their own health would not
allow them to continue, and that patient dementia-
related problem behaviors were too difficult to
handle. Each of these reasons related significantly to
indicators of caregiver and patient characteristics
from the prior year’s survey, suggesting that care-
givers’ reasons for institutionalizing have valid un-
derpinnings. This effort to substantiate caregivers’
reasons for placement is important, because it informs
clinicians that a majority of caregivers can assess
their situation objectively. In addition, more clearly
understanding the needs and perceptions of caregivers
should enable clinicians to intervene and meet these
needs, perhaps delaying institutionalization.
The most common reason chosen, ‘‘my loved one
needed more advanced or skilled care than I could
provide,’’ related significantly to the care recipients’

58 The Gerontologist
 Table 4. Multivariable Proportional Hazards Model
Examining the Association Between Caregiver and Patient
Characteristics and Patient Nursing Home Entry
Variable Risk Ratio (95% CI)a
Caregiver sociodemographic factors
White race 1.74 (1.32, 2.29)
BRS-D subscales
Behavior dysregulation 1.07 (1.04, 1.11)b
Psychotic symptoms 1.06 (1.04, 1.09)c
Indicators that patient needs skilled care
Fewer patient comorbidities 1.16 (1.12, 1.20)d
No. of tasks performed for patient 1.08 (1.05, 1.11)e
Caregiver emotional health factors
Lower life satisfaction 1.52 (1.27, 1.81)f
Notes: BRS-D = Behavior Rating Scale–Dementia. For
superscripts b through f, the risk ratios were calculated for the
maximum score for each continuous variable.
a
For the continuous variables, the reported risk ratios are
for a 1-unit increase.
b
For an increase of 12 points, the risk ratio is 2.33.
c
For an increase of 15 points, the risk ratio is 2.43.
d
For a decrease of 18 points, the risk ratio is 15.10.
e
For an increase of 22 tasks, the risk ratio is 5.11.
f
For a decrease of 2 points, the risk ratio is 2.30.
scores on the Rosow–Breslau scale. This measure is
similar to the scale used by Wolinsky and colleagues
(1992, 1993) to measure lower body limitations,
which significantly predicted institutionalization.
This result is logical, as the inability of caregivers
to lift nonambulatory patients may be more difficult
to offset than other functional limitations.
Previous studies that examined reasons for
nursing home admission collected data from a single
interview and described more general information
than that revealed in the present study (Arling &
McAuley, 1983; Nolan & Dellasega, 2000;
Smallegan, 1985; Wingard et al., 1990). Although
these studies included patients with various di-
agnoses, the results reflected ours in that the most
common reasons for placement involved the care
recipient’s declining health and function, which
became too much for the caregiver to handle.
Compared with these studies, the current study
offers several advantages: (a) the large national
NLCS sample; (b) the longitudinal nature of the
NLCS, which permitted analysis of patient and
caregiver characteristics prior to institutionalization;
and (c) the restriction of the sample to older
individuals with clinically diagnosed dementia who
predominately were cared for by spouses. Spousal
caregivers of persons with dementia may experience
more trauma and guilt associated with institutional-
ization than those placing a partner because of
a physical disability (Tilse, 1998).
The initial analysis of the caregivers’ reasons was
limited to caregivers who chose institutionalization.
Using a proportional hazards model, we compared
caregivers who institutionalized with those who
continued caregiving in the community as a way to
examine predictors of institutionalization. As in pre-
Vol. 46, No. 1, 2006
vious research, the results showed that race (Gaugler
et al., 2003; Yaffe et al., 2002), patient behavioral
problems (Gaugler et al., 2000, 2003; Yaffe et al.),
and fewer patient comorbidities (Eaker, Vierkant, &
Mickel, 2002) predicted institutionalization. The fact
that increasing comorbidity was not a risk factor
suggests that, rather than number of medical condi-
tions, the timing of placement is determined by
dementia severity and concomitant behavioral and
dependency problems. Relatedly, those patients with
a greater burden of comorbid illness may succumb to
one of those illnesses before the dementia progresses
to the point of requiring formal care.
The study also contributes to the caregiving
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literature by indicating more precisely which prob-
lem behaviors tend to lead to institutionalization. By
entering the BRS-D subscales into the multivariate
model instead of the total score, we demonstrated
that only the behavior dysregulation and psychotic
symptoms subscales reached significance. This sug-
gests that compared to wandering or psychotic be-
haviors in their care recipients, caregivers are more
able to manage depressed, agitated, or apathetic
behaviors or alterations in the sleep or appetite pat-
terns. Greater task burden and lower life satisfaction
in the caregivers also were found to be associated
with a greater risk of institutionalization. Few
studies have included a measure of caregiving hours
or tasks. At least one study (Gaugler, Kane, Kane,
Clay, & Newcomer, 2005) assessed the number of
caregiving hours, but it found no relation to institu-
tionalization. In contrast, this study comprehensively
assessed caregivers’ task demands and found them to
be a significant predictor. To our knowledge, the
life-satisfaction variable used in our study has not
been used in other studies of nursing home place-
ment. However, caregiver life satisfaction likely
relates to caregiver burden (Gaugler et al., 2003;
Yaffe et al., 2002), self-perceived pressure (Pot et al.,
2001), or feeling trapped in their caregiving role
(Gaugler et al., 2000), all of which have been
associated with increased risk of institutionalization.
Clinically, it would be very useful to have a single
question: ‘‘How would you say that you find life
these days?’’ Results of this study suggest that
a caregiver report of low life satisfaction could
signal institutionalization within the next year.
Several limitations of this study should be
considered in future research. First, self-reported
data are considered less reliable than structured
interviews and clinical examinations. In addition,
mailed surveys are associated with relatively low
response rates, potential for poor-quality data if the
questions are easily misunderstood or open ended,
and inability to confirm that the intended respondent
filled out the survey. Furthermore, caregiver assess-
ments of patient functional and behavioral status
may be biased. This limitation may be less important
because caregivers are the key decision makers
regarding institutionalization and their perceptions
59
form the basis of reality in this process. In addition,
the study may not be generalizable to other caregiv-
ing scenarios because it focused on a male veteran
sample predominantly cared for by female spouses
(e.g., dementia-related problems behaviors may not
predict institutionalization among male caregivers
who are physically more able to handle disruptive
behaviors). Finally, although not as homogeneous in
race as some caregiving studies, the majority of
NLCS caregivers were White, and extending con-
clusions to caregivers with diverse ethnic back-
grounds should be done with caution.
Strengths of the study include the numerous valid
and reliable measures available to relate to the major
‘‘caregiver reason’’ domains. Moreover, the NLCS is a
large national level sample, followed longitudinally.
To our knowledge, this is the first study to use such
data to examine informal caregivers’ reasons for
institutionalizing their family members with de-
mentia, and to compare these reported reasons
with indicators of caregiver and patient physical
and emotional functioning prior to institutionaliza-
tion. Findings suggest that clinicians should be able
to identify caregivers who are more likely than
others to institutionalize their care recipients within
a year. Examples of probes and direct questions to
facilitate this process and engage these caregivers
include the following:
Tell me about your [husband’s] behavior at home.
What is [he] doing that troubles you?
Run through a typical day and describe the tasks
you perform for [him].
How is your own health?
Do you have enough support in your role as primary
caregiver?
Do you wish others would help you more?
In general, how satisfied are you with your life?
If a caregiver is considering nursing home place-
ment for one of the issues raised in these questions,
results from this study suggest that the caregiver’s
reasons are reality based, and the caregiver should be
encouraged to examine options for formal long-term
care. The American Medical Association (AMA;
n.d.) has developed a caregiver self-assessment
questionnaire as part of its project to help primary
care physicians identify and help patient caregivers
(American Medical Association Caregiver Self-As-
sessment Questionnaire). This study supports the
psychological emphasis of the AMA’s questionnaire
but also expands the questionnaire to include some
patient characteristics. With the knowledge gained
from this study, clinicians can offer support to
caregivers to help diffuse some of the negative
feelings of guilt, thus facilitating outcomes that are
more positive for both caregiver and patient. Future
studies should investigate the clinical impact of
prompting such discussions with caregivers at
appropriate times in the dementia disease course,
60
with an overall goal of easing the burden associated
with transitioning from home to formal care.
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Received March 31, 2005
Accepted August 22, 2005
Decision Editor: Linda S. Noelker, PhD
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