Predictive factors for entry to long-term residential care in octogenarian Māori and non-Māori in New Zealand, LiLACS NZ cohort

Despite attempts in many countries to reduce use of long-term residential care (LTC), utilisation is common with increasing age [1, 2]. LTC facilities provide accommodation and support for people whose needs for care surpass what is manageable at home with care/support from unpaid/paid carers. Terminology for residential aged care varies by country and level of care. Terms include nursing homes and geriatric hospital care, (for those with high dependency care needs); hostels, residential homes, rest homes, assisted living, (for those who need low dependency care needs,) and dementia care and psychogeriatric care. In this paper LTC refers to low, high, dementia and psychogeriatric care residential facilities, for both short and long-term care. Factors identified as predicting entry to LTC vary according to the availability of services and where and how studies are conducted [2].

Throughout the member countries of the OECD (Organisation for Economic Co-operation and Development), demand for LTC services is expected to increase because the number of people aged 85+ years is rising rapidly. For example, in Aotearoa New Zealand (NZ), official estimates expect numbers aged 85+ will triple, from 75,000 in 2013 to 230,040 by 2040 [3]. In NZ, over two-thirds of people reaching 85 years eventually move into a LTC facility [4]. Understanding service demand is important in countries that have a universal healthcare system such as NZ where all residents have access to healthcare without requiring private health insurance. International comparisons demonstrate more than ten-fold variation in use of LTC [5, 6] Utilisation is related to regional availability of facilities [7], specific disease states such as diabetes [8], differences by country/region and between cultural, religious, ethnic and/or racial groups [2]. In the USA, ethnic minorities and indigenous people enter LTC with poorer health than their European-majority counterparts [9]. Disparities in health outcomes of older indigenous people are often described [10‐12] but seldom become a population-based research focus.

This study is drawn from Life and Living in Advanced Age: A Cohort Study in New Zealand - Te Puawaitanga o Nga Tapuwae Kia Ora Tonu study (LiLACS-NZ) which draws from a population-based sampling frame with indigenous (aged 80–90 years) and non-indigenous (aged 85 years) cohorts of similar size designed to provide similar statistical power. LiLACS-NZ aims to identify predictors of successful advanced ageing for Māori and non-Māori [13, 14] through acknowledging Māori methods and ideologies. Māori culture and Māori kaumātua (elders, both genders) are important components of the cultural fabric of NZ society. Kaumātua hold leadership roles in their whānau (extended family), hapū (sub-tribe), and iwi (tribe). They act as guardians of tikanga (Māori customs and practices) and are generally well respected in their communities [15]. In turn, whānau have cultural obligations to care for and support their kaumātua, sometimes at considerable personal cost [16].

Most commonly reported risk factors for LTC entry are those that constrain independent living: impaired mobility and inability to complete simple tasks such as washing, toileting, shopping, cooking and other ADLs are consistently identified [2]. Other relevant factors include living alone and recurrent falls, both associated with safety [17‐19]. Older age is also a strong predictor of LTC [20], however few studies predicting LTC entry focus on the oldest old (80+) [21]. Importantly, risk factors for entry to LTC may differ for people aged 80+ compared to younger age groups. In a German study, cognitive and functional impairment predicted entry for younger old people (< 80 years) but not for those aged over 82 years [22]. In NZ, research on the topic was limited to small and/or focused studies, [23, 24] but recently a study by Jamieson et al. evaluating social factors influencing LTC entry in those receiving a support needs assessment, found that living alone, negative social interactions, perceived loneliness and carer stress were independently associated with higher likelihood of LTC admission [25]. Further, whether predictive factors for LTC entry apply similarly to all ethnic groups, or why some ethnic groups use LTC less often than others, is largely unaddressed.

Inequities in social determinants of health and healthcare access drive large health and mortality disparities between Māori and non-Māori [26, 27]. Currently, the majority of LTC residents in NZ are European, with few older Māori residents. In 2013, 5.6% of the population aged 65+ were Māori, and 87.8% were European [28]. Of those in LTC, however, just 3.3% were Māori, with 93.4% European [29]. In the LiLACS-NZ study, baseline data showed that, of those with frequent and high levels of need for care, Māori were less likely to be living in LTC [30, 31]. Further, in the study of carers of LiLACS-NZ, Māori received significantly more hours of informal (unpaid) care e.g. from family, than non-Māori, and Māori carers were more likely to live in the same house or on the same property [30]. Living in multi-generational family settings means they are less likely to qualify for formal home support (e.g. help with shopping, travel for medical attention, or household cleaning), thus perversely leading to further disparities in access to formal supports for Māori. Indeed, access to formal home support at baseline in LiLACS-NZ also differed, with Māori receiving formal care being discernably more disabled than those not receiving formal care, a distinction not holding for non-Māori [31]. Whānau has traditionally been an integral part of health for Māori, and indeed the popular Te Whare Tapa Whā [32] model of Māori health notes whānau as one of the four mainstays of health for Māori. One of the recognised roles of whānau is that it “looked after its own aged or disabled members” [33]. How these differences in care patterns and cultural priorities may play out when accessing LTC is the subject of this report.

In line with other countries, NZ urgently needs better understanding of health, demographic and socio-cultural factors that explain ethnic differences in healthcare use, including entry to LTC. The main aims of this prospective study using the LiLACS-NZ cohorts were to assess the proportion who entered LTC over the study period and to identify independent risk factors for LTC entry among NZ Māori and non-Māori octogenarians.

This is the first study to examine prospectively the likelihood of LTC placement for a large group of very old indigenous people. Within the context of advanced ageing in Aotearoa NZ, we show that LTC is used less frequently by indigenous peoples (Māori) and also that the risk factors differ between the indigenous and non-indigenous peoples. These findings add to both the international evidence regarding factors leading to LTC placement [2] and to the dialogue on health services for indigenous peoples [11]. It is evident that non-Māori and Māori in NZ use LTC in different ways, possibly partly because family and whānau support for older family members differs between indigenous and non-indigenous New Zealanders.

Likelihood of entry to LTC for non-Māori is approaching double that for Māori when adjusted for other factors: age, gender, marital status, living situation, self-rated health, depressive symptoms and functional status. Furthermore, in ethnic specific models, Māori and non-Māori had different profiles of factors associated with subsequent LTC entry. For example, living alone at baseline predicted LTC entry for Māori but not for non-Māori, and dependency in ADLs was associated with subsequent LTC entry among non-Māori but not among Māori. This is contrary to most other studies where functional limitation is found to be the primary driver of transition [2]. Other factors, measured and/or unmeasured, may also play a role.

Cultural perspectives are relevant to the search for reasons for the observed differences. That fewer Māori entered LTC over almost 5 years of follow-up may illustrate the impact of Māori cultural practices of whanaungatanga (family connection), manaakitanga (caring for and respecting others) and āwhina (supporting others) whereby whānau have obligations and responsibilities to care for their kaumātua. Those cultural expectations to provide informal support may contribute to fewer Māori receiving formal home-based services (despite worse health), more common use of informal care and less use of LTC, by Māori [31]. Living alone was a stronger factor in LTC placement for Māori than non-Māori, suggesting that the impact of whānau and family care meant for some Māori entry to LTC was delayed or avoided. Anecdotal reports of Māori whānau members moving house (and country) specifically to provide informal care to support kaumātua could not be examined in this analysis, however, these cultural obligations and observed differences in patterns of care, as in baseline data [30, 31, 44], are likely to be relevant to the observed difference in rate of admission to LTC. However, the extent to which Māori whānau will continue to find capacity to provide care into the future is unclear given changing family structures and increased care demands due to rising numbers of kaumātua and their increasing longevity [28]. Older Māori are also less able to access primary care services due to the cost of primary care in NZ [45], thus community support for Māori may need to be strengthened.

We are also unable, in this analysis, to establish whether differential access to home-based supports or culturally driven preferences are the main drivers of LTC entry. While culture-related care patterns may contribute to the lack of association between ADL level and entry to LTC among Māori, other questions are also likely to be relevant. Do Māori who enter LTC find the environment (staff, other residents, systems, food, buildings and gardens) inclusive and accepting of non-European traditions, values and practices? Are LTC institutions able to support and embrace Māori tikanga appropriately? For people in advanced age of any ethnicity, how can family/whānau who provide home-based informal care, often at the loss of careers and income [30, 46] be better supported with health service navigation, skill development (for formal and informal carers) and/or financial assistance [47]. Public discussion is urgently needed regarding access and appropriateness of support services for people of advanced age whether in LTC settings or at home.

There are three additional learnings from this study. Firstly, and consistent with international data, depressive symptoms (as measured by western tools), predicts LTC entry for all participants [48, 49]. Depression has been recognised as sufficient to overwhelm an older person and their support network [50], resulting in escalation in need and entry to LTC [48]. Jamieson et al. confirmed this for NZ in a large study of a higher risk group than the current study, and in which Māori were only half as likely to enter LTC [25]. Risk of entry was 13% higher when the person was depressed, and 28% higher when the carer scored high on a measure of carer stress [25]. Primary care practitioners, practice nurses and community members could be encouraged to recognise and address depressive symptoms in order to avert escalation to LTC, but research is needed to better understand depressive symptoms and coping mechanisms in different cultural settings.

Secondly, supporting a recent systematic review [2] and other NZ research [25], and despite the preponderance of women in care facilities [29], neither gender was at greater likelihood of LTC entry once adjusted for other factors. Greater numbers of women in LTC may be explained instead by women often being married/partnered to older men who die before them, then because they live longer, they stay longer in LTC [29], and also by other factors correlated to gender but where numbers were inadequate to reach significance in the models. Gender was not a significant factor associated with receipt of services in the LiLACS-NZ study after adjustment for living arrangement and marital status [31]. Nevertheless, international studies suggest that some factors are more important for men and women, respectively. For example, being unmarried, living alone and incontinence are associated with greater likelihood of entry to LTC among men, while functional impairment carries a higher likelihood among women [2]. Elsewhere, the association between LTC entry and widowhood is linked to gender and is time-dependent, particularly within the first month of widowhood when older men are at greater likelihood of LTC entry [51, 52].

Thirdly, this study demonstrates that in NZ, no single information source could identify all participants who enter LTC. This is previously reported [53], and continues to have repercussions for monitoring public health and service utilisation. In the current study the most complete source was the subsidy data, finding 199/278 (69%) of those who entered LTC during the study period. However Government subsidies are available only for residents who are deemed eligible for financial assistance after a care needs assessment and an assessment of their assets. Those in lower-level care paying entirely privately are thus not captured from subsidy data and are often omitted from utilisation reports [53]. Some under-reporting is thus possible even using six different data sources. InterRAI data, although introduced after the study start, were next most complete, however the source contributing the most additional information was the death registry data. In all, the three-way combination of subsidy, place of death and hospital discharge data found 247/278 (89%) of those recognised as entering LTC.

Non-Māori people age over 80 years entered LTC at almost twice the rate of Māori during the 6 years of follow-up in this study, after adjustment for important correlates. Factors associated with LTC entry differed between Māori and non-Māori participants, with factors among non-Māori being similar to those identified in overseas studies. For our indigenous peoples, factors other than disability were important and this finding may be related to cultural choices and values. Informed discussion about access to and appropriateness of support services for older people and their carers – in LTC settings and at home – is needed.