Social Participation Among Older Adults Before and After Long-Term Care Facility Entry - PubMed (original) (raw)

Social Participation Among Older Adults Before and After Long-Term Care Facility Entry

Kenneth Lam et al. JAMA Intern Med. 2025.

Abstract

Importance: Social participation is essential throughout life and is associated with decreased mortality and increased quality of life. It is unknown whether long-term care facility (LTCF) entry disrupts or facilitates it.

Objectives: To determine longitudinal trends in social participation before and after entry into nursing homes (NHs) and assisted living facilities (ALs) and to explore factors associated with participation.

Design, setting, and participants: This nationally representative longitudinal cohort study using prospectively collected annual data from the US National Health and Aging Trends Study from 2011 to 2019 included community-dwelling Medicare beneficiaries entering LTCFs. Interviews conducted 4 years before and 2 years after NH or AL entry (index date) were included. Data analysis was performed from September 16, 2022, to May 25, 2025.

Main outcomes and measures: Two categories of social participation comprising 5 activities were assessed: socialization (visiting with friends or family and going out for enjoyment) and community participation (attending religious services, participating in clubs or other organized activities, and volunteering). Participation over time was modeled using linear splines before, upon, and after LTCF entry. Modified Poisson regressions were used to explore associations with maintaining and starting activities, adjusted for age, sex, race and ethnicity, and proxy response were used.

Results: The total sample included 606 LTCF entrants (weighted mean [SD] age 85 [7.4] years, 404 female [66% weighted]), of whom 104 individuals were Black (7%), 23 Hispanic (4%), 464 White (86%); and 15 of any other race and ethnicity (3%). Before entry, social participation decreased in all activities (-4.7 to -2.0% annually). Of the total, 275 (44%) entered a NH and 331 (56%) entered an AL facility. Upon entry, going out for enjoyment decreased (-14.1%), but club participation and religious attendance increased (15.6% and 12.6%, respectively). Before LTCF entry, social participation decreased in all activities (-4.7 to -2.0% annually). After entry, going out for enjoyment decreased (-14.1%), but club participation and religious attendance (12.6%) increased (15.6% and 12.6%, respectively). In exploratory analyses, women were more likely to maintain visits (adjust risk ratio [aRR], 1.3; 95% CI, 1.1-1.5) and start attending religious services (aRR, 1.6; 95% CI, 1.0-2.8). NH residents were less likely to go out for enjoyment (aRR, 0.6; 95% CI, 0.5-0.8 for maintaining; aRR, 0.6; 95% CI, 0.4-1.0 for starting) and keep attending religious services (aRR, 0.7; 95% CI, 0.6-0.9). Black, Hispanic, and residents of other race or ethnicity were much less likely to start going out for enjoyment (aRR, 0.3; 95% CI, 0.1-0.8).

Conclusions and relevance: This cohort study found that LTCF entry generally promoted community participation and reduced socialization. Benefits may be less likely among men, NH entrants, and residents of racial and ethnic minority groups.

PubMed Disclaimer

Conflict of interest statement

Dr. Kotwal reports research consulting fees from Papa Health outside the submitted work. All other authors report no potential conflicts of interest.

Figures

Figure 1.

Figure 1.

Flow diagram for study inclusion. NHATS = National Health and Aging Trends Study, NH = nursing home, AL = assisted living facility, LTCF = long-term care facility.

Figure 2.

Figure 2.

Participation in five social activities before and after long-term care facility entry for (A) socialization activities and (B) community participation activities. Activity participation was modeled with a mixed-effects model, treating individuals as a random effect and spline time as a fixed effect and weighted using NHATS enrollment weights. Figures shows predicted probability and the confidence intervals for the fixed effects portion of the model. The table below provides raw data by 12-month interval from the date of entry, including how many interviews were conducted in each interval and how many participants reported completing each activity. Time was treated as a linear spline with knots at −48 months, 0 months, and 24 months relative to index date and an indicator variable for before versus after entry. Coefficients from this model represent the percent change over time and p-values confirm whether they are non-zero. p-values were adjusted using the Benjamini-Hochberg procedure for multiple comparison (3 trends for 5 activities).

Figure 2.

Figure 2.

Participation in five social activities before and after long-term care facility entry for (A) socialization activities and (B) community participation activities. Activity participation was modeled with a mixed-effects model, treating individuals as a random effect and spline time as a fixed effect and weighted using NHATS enrollment weights. Figures shows predicted probability and the confidence intervals for the fixed effects portion of the model. The table below provides raw data by 12-month interval from the date of entry, including how many interviews were conducted in each interval and how many participants reported completing each activity. Time was treated as a linear spline with knots at −48 months, 0 months, and 24 months relative to index date and an indicator variable for before versus after entry. Coefficients from this model represent the percent change over time and p-values confirm whether they are non-zero. p-values were adjusted using the Benjamini-Hochberg procedure for multiple comparison (3 trends for 5 activities).

Figure 3.

Figure 3.

Characteristics associated with maintaining activities. A forest plot. Adjusted risk ratios (aRR) are from exploratory multivariable modified Poisson regressions of maintained activity with independent variables, adjusted for age, sex, and race. Race/ethnicity was collapsed into White versus non-White due to sample size, with non-White race including Black, any Hispanic, American Indian, Asian, Native Hawaiian, and Other. For each activity, we examined only persons who did the activity in the interview prior to LTCF entry. An aRR > 1 (points to the right of the dotted line; orange is statistically significant with p < 0.05 without correction for multiple comparison) implies the covariate was associated with a higher likelihood of maintaining the activity upon LTCF entry. An aRR < 1 (points to the left of the dotted line; red is statistically significant) implies the covariate was associated with a lower likelihood of maintaining the activity.

Figure 4.

Figure 4.

Characteristics associated with starting activities. A forest plot. Adjusted risk ratios (aRR) are from exploratory multivariable modified Poisson regressions of starting activity with independent variables, adjusted for age, sex, race, and proxy response. Race/ethnicity was collapsed into White versus non-White due to sample size, with non-White race including Black, any Hispanic, American Indian, Asian, Native Hawaiian, and Other. An aRR > 1 (points right of the dotted line; orange is statistically significant with p < 0.05 without correction for multiple comparison) implies the covariate was associated with a higher likelihood of starting the activity upon LTCF entry. An aRR < 1 (points left of the dotted line; red is statistically significant) implies the covariate was associated with a lower likelihood of starting the activity.

Comment in

References

    1. Levasseur M, Richard L, Gauvin L, Raymond É. Inventory and analysis of definitions of social participation found in the aging literature: Proposed taxonomy of social activities. Social Science & Medicine. 2010;71(12):2141–2149. doi: 10.1016/j.socscimed.2010.09.041 -DOI -PMC -PubMed
    1. Rowe JW, Kahn RL. Successful Aging 2.0: Conceptual Expansions for the 21st Century. The Journals of Gerontology Series B: Psychological Sciences and Social Sciences. 2015;70(4):593–596. doi: 10.1093/geronb/gbv025 -DOI -PubMed
    1. Zhang H, Hao X, Qin Y, et al. Social participation classification and activities in association with health outcomes among older adults: Results from a scoping review. Journal of Advanced Nursing. Published online July 27, 2024:jan.16344. doi: 10.1111/jan.16344 -DOI -PubMed
    1. Hanlon P, Wightman H, Politis M, et al. The relationship between frailty and social vulnerability: a systematic review. The Lancet Healthy Longevity. 2024;5(3):e214–e226. doi: 10.1016/S2666-7568(23)00263-5 -DOI -PubMed
    1. Murthy VH. Our Epidemic of Loneliness and Isolation. The U.S. Surgeon General’s Advisory on the Healing Effects of Social Connection and Community; 2023. -PubMed

MeSH terms

Grants and funding

LinkOut - more resources