JOURNAL OF AGING AND HEALTH / May 2002

Baumgarten et al. / DAY CARE FOR THE FRAIL ELDERLY

Adult Day Care for the Frail Elderly:

Outcomes, Satisfaction, and Cost

MONA BAUMGARTEN, PhD

University of Maryland–Baltimore
PAULE LEBEL, MD
University of Montreal
HÉLÈNE LAPRISE, MSc
CLSC de la Région Sherbrookoise
CHANTAL LECLERC, MSc
University of Montreal
CHARLENE QUINN, PhD
University of Maryland–Baltimore

Objectives: To assess outcomes and satisfaction among frail elderly day care clients
and their informal caregivers and the impact of adult day care on the cost of health ser-
vices. Methods: One-hundred eight elderly participants were randomly assigned to
the experimental group (immediate admission to an adult day care center) and 104
participants to the control group (3 months on a waiting list). Results: Participants’
and caregivers’ subjective perceptions of the day center’s effects were positive. How-
ever, using standard research instruments, there was no evidence of an effect of day
center attendance on the client’s anxiety, depression, or functional status; on caregiver
burden; or on the cost of health services. Discussion: It is difficult to demonstrate
objectively the benefits of programs and interventions that are perceived by clients,
caregivers, and staff to have positive effects. In future studies, maintenance of high
levels of participation should be incorporated as an explicit program goal.

The aging of the population has led to the evolution of community-

based long-term care services to meet the health and social service

AUTHORS’ NOTE: This research was funded by the National Health and Research Devel-
opment Program (Health and Welfare Canada Grant No. 6605-3262-57). The authors wish to
thank the day care centers’ coordinators and staff for their unflagging collaboration; research
assistants Manon Laroche and Lynn Villeneuve; and Daniel Thomas, Christina Wolfson, and
JOURNAL OF AGING AND HEALTH, Vol. 14 No. 2, May 2002 237-259
© 2002 Sage Publications

237
238 JOURNAL OF AGING AND HEALTH / May 2002

needs of disabled older persons. In Canada, as in the United States,

adult day care has assumed a major role in the continuum of long-term
care services (Conrad, Hughes, Hanrahan, & Wang, 1993). In addition
to allowing older persons to remain in their homes, adult day care pro-
grams provide support and respite to informal caregivers. Despite the
stated preference of older persons to remain in the community and
despite the investment of national, state, and local governments in
adult day care programs, few research studies have focused on the out-
comes and satisfaction of elderly day care users and their caregivers.
Weissert (1976; Weissert et al., 1989) has described two principal
types of adult day care. One model, day hospital, emphasizes the
assessment and medical treatment of patients, as well as their physical
and functional rehabilitation; this model has been rigorously evalu-
ated by Weissert, Wan, Livieratos, and Katz (1980). The second
model, multipurpose program, constitutes a day care and service facil-
ity whose orientation is essentially social in nature. Conrad et al.
(1993) have empirically derived a typology of six classes of day cen-
ter: Alzheimer’s family care, rehabilitation, high-intensity clinical/
social, moderate-intensity clinical/social, general purpose, and low-
intensity (e.g., senior centers). In addition, Conrad and his coauthors
concluded that although there have been rigorous evaluations of the
most expensive medically oriented day centers, the effects of the more
common types of day care, such as the moderate-intensity clinical/
social center and the general purpose center, have not been adequately
studied.
Studies of multipurpose day centers (Capitman, 1982; Chappell &
Blandford, 1987; Jackson, 1983; Rafferty, 1979; Rathbone-McCuan &
Levenson, 1975; Strain, Chappell, & Blandford, 1987; Weiler, Kim, &
Pickard, 1976) suggest that use of this type of adult day care may
result in improvement in psychosocial measures, such as life satisfac-
tion, quality of interpersonal relationships, and level of social activi-
ties and social integration, among people receiving services from the
day centers. In addition, the day centers seem to be helpful to families

Manon Desjardins for their helpful comments. Earlier versions of this work were presented at the
Canadian Association on Gerontology annual meetings in Montreal (1993) and in Calgary
(1987). Correspondence should be sent to Mona Baumgarten, Ph.D., Department of Epidemiol-
ogy and Preventive Medicine, University of Maryland, 660 West Redwood Street, Baltimore
MD 21201; email: [email protected].
 Baumgarten et al. / DAY CARE FOR THE FRAIL ELDERLY 239

in reducing caregiver burden and stress. The results are less clear
regarding the day center’s effectiveness in maintaining or restoring the
clients’ functional independence and reducing health care costs.
Methodological problems make it difficult to draw definitive conclu-
sions from these studies. Some studies used a pre-post design and did
not include a control group (Capitman, 1982; Jackson, 1983; Strain
et al., 1987). Several studies used quasi-experimental designs with
control groups composed of a relatively small number of clients who
were not attending the day center (Chappell & Blandford, 1987; Rafferty,
1979; Rathbone-McCuan & Levenson, 1975; Weiler et al., 1976). In
addition, these studies did not always clearly define the client popula-
tion, available resources, and activities of the day centers, making it
difficult to know exactly what was evaluated. One of the most rigorous
studies of day care for older persons is the Veterans Adult Day Health
Care Study (Hedrick et al., 1993), a large, congressionally mandated,
randomized, controlled trial. Because this study was done in the con-
text of the veterans health care system, generalization to non-veteran
community-based adult day care is difficult.
In summary, no rigorous experimental study has been conducted to
evaluate multipurpose adult day care centers. The principal objective
of the current study was to determine the effect of multipurpose day
centers (similar to Conrad et al.’s [1993] moderate-intensity clinical/
social or general purpose day centers) on symptoms of depression and
anxiety in the clients, on caregiver burden, and on the client’s func-
tional status. A second objective was to assess the clients’ and care-
givers’ perception of the extent to which the day center had helped the
clients. Third, we aimed to determine how the day center outcomes
differed according to the level of attendance. Finally, we wished to
quantify the impact of adult day care on the cost of health and social
services.

Method

SETTING

Adult day care centers in the Province of Quebec, Canada, offer the
frail older person, on an outpatient basis, a personalized program of
240 JOURNAL OF AGING AND HEALTH / May 2002

therapeutic and preventive activities, developed after an extensive

assessment of needs and abilities. The major goals of day centers are
to reduce psychosocial problems (such as anxiety, insecurity, depres-
sion, and loneliness), to ensure the maintenance or recovery of the cli-
ent’s ability to perform activities of daily living (ADLs), and to ensure
that the client learns and maintains a satisfactory level of
health-related behavior, such as nutrition and exercise. The centers
offer a broad range of activities aimed at the functional, psychological,
and social rehabilitation of the target population and at meeting their
nutritional and health care needs. To enhance socialization, most of
these activities are offered on a group basis rather than individually.
The day centers also offer respite to the families and other caregivers
by allowing them a few hours of free time during the week. Patients
typically suffer from multiple functional and psychosocial problems
and are usually referred to the day center by a community-based home
care team. Once accepted into the program, clients’ recommended
participation is about 6 hours a day, once or twice a week. Assisted
transportation is available to bring the elderly clients to the center.
There is universal access to this program and the service is free,
although the client is required to pay a small daily fee to offset part of
the cost of the midday meal and of transportation. The staff of a typical
center usually includes nurses, recreation technicians, a special care
counselor, a driver, and a receptionist. It may also include a rehabilita-
tion technician, an occupational therapist, and a psychosocial worker.
Individual and group activities that may be offered by the different day
centers include psychosocial support groups, exercise groups, func-
tional and physical rehabilitation, education, information on health
services, and caregiver counseling. Clients participate in the program
for periods ranging from a few weeks to many months. A client is dis-
charged from the day center on achieving individual goals or, more
typically, when the client is admitted to a hospital or nursing home or
the client dies. Moreover, a number of clients drop out of the program
(mainly for health reasons) before achieving their objectives
(Gutman, Milstein, Killam, Lewis, & Hollander, 1993). Quebec’s day
center program corresponds most closely to Weissert’s (1976)
socially oriented multipurpose day care facility and to Conrad and col-
leagues’ (1993) moderate-intensity clinical/social or general purpose
day center.
 Baumgarten et al. / DAY CARE FOR THE FRAIL ELDERLY 241

CHOICE OF SITES

At the time of the study, there were 30 geriatric day centers in the
metropolitan Montreal area. We used a questionnaire and structured
interview to gather the data necessary for selecting day centers for the
study. To be selected, the staff members of the day center had to
express their willingness to participate in the study, and the waiting
time for admission to the day center had to be at least 3 months. To
ensure continuity, the center had to demonstrate administrative and
programmatic stability. In addition, to ensure homogeneity among
day care programs, the day center had to offer programs aimed at both
the functional and psychosocial rehabilitation of the clients, empha-
size group rather than individual treatment, include clients suffering
from cognitive disorders, offer respite for caregivers, offer assisted
transportation to clients, and anticipate at least four admissions per
month over the data collection period.

STUDY DESIGN

Eligible clients were randomly assigned to the experimental or con-

trol group. Stratified randomization was carried out, with each partici-
pating day center representing a stratum. Randomization by permuted
blocks of size six (Friedman, Furberg, & DeMets, 1985; Peto et al.,
1976) was used to ensure that there were approximately equal num-
bers of clients in the experimental and control groups in each center
throughout the study enrollment period.
Clients randomized to the experimental group became eligible for
immediate admission to the day center, whereas clients randomized to
the control group spent 3 months on the waiting list, at which time they
became eligible for admission to the day center. No restrictions were
applied to clients in either group concerning their access to other
health and social services.
In both groups, clients and their informal caregivers were inter-
viewed after randomization but before the admission of the experi-
mental clients to the day center; they were reinterviewed after the end
of the 3-month study period. The median interval between interviews
was 3.5 months (range 2.9 to 5.5 months); for 81 % of clients, the
interval was less than 4 months.
242 JOURNAL OF AGING AND HEALTH / May 2002

Because access to day centers at the time of the study had been
widely available in Quebec for more than a decade, it would not have
been acceptable ethically to withhold the service from clients random-
ized to the control group. For the same reason, the amount of time the
control group spent on the waiting list could be no longer than the
average waiting time (approximately 3 months) for clients not
involved in the research project. After extensive consultation with
clinical and administrative personnel from the day centers, we decided
that the 3-month study period was long enough for changes in client
and caregiver well-being, if they were going to occur, to have become
apparent.

PARTICIPANTS

All clients referred to any of the participating day centers were eli-
gible for the study, except (a) those who were younger than 60 years
old, (b) those who could speak neither English nor French, (c) those
who were too cognitively impaired to be interviewed and who did not
have an informal caregiver, and (d) those who were referred to the day
center for individual specialized treatments (e.g., rehabilitation treat-
ment for Parkinson’s patients). Study eligibility was determined by
day center staff using standard criteria provided by the research team.
Day center staff members were also responsible for obtaining written
consent for participation in the study. Once eligibility was determined
and consent obtained, randomization was carried out by the study
coordinator and communicated to the day center.
Clients with urgent needs were not included in the study because it
was ethically unacceptable for them to spend 3 months on the waiting
list in the event that they were randomized to the control group. Clients
were considered to have urgent needs if they were receiving 20 hours
or more per week of home care or if their informal caregiver was expe-
riencing an episode of acute ill health at the time of referral.
The caregiver was defined as the person who was most involved in
assisting the client on a daily basis, regardless of whether the caregiver
and client lived together. Paid caregivers were not eligible. Clients
with no eligible caregiver were included in the study but were consid-
ered only in the analyses concerning the impact of day centers on cli-
ents. Because clients with cognitive impairment (defined as a score of
 Baumgarten et al. / DAY CARE FOR THE FRAIL ELDERLY 243

less than 22 on the Mini–Mental State Exam [MMSE]) (Folstein,

Anthony, Parhad, Duffy, & Gruenberg, 1985; Folstein, Folstein, &
McHugh, 1975) could not be interviewed, they were not included in
analyses of anxiety and depression among clients.

MEASURES

Outcome Variables

The frequency of depressive symptoms was measured using the

Center for Epidemiologic Studies Depression Scale (CES-D)
(Radloff, 1977; Radloff & Teri, 1986). The CES-D includes 20 items,
graded on a 4-point scale, corresponding to the frequency, in the pre-
ceding week, of each symptom. Possible scores range between 0 and
60, with a higher score indicating more depressive symptoms.
Cronbach’s coefficient of internal consistency (α) was .88 at Time 1
and .89 at Time 2.
Symptoms of anxiety were assessed using Spielberger’s (1983)
State-Trait Anxiety Inventory (STAI). The STAI consists of 40 items,
20 of which pertain to trait anxiety (related to stable aspects of the
individual’s personality) and 20 to state anxiety (related to aspects of
the individual’s current situation). For the purposes of this study, we
used the 20 items included in the state dimension of the STAI. The
score can vary from 20 to 100, and a higher score indicates more anxi-
ety. Cronbach’s α coefficient was .93 at Time 1 and .94 at Time 2.
The client’s functional status was measured using the functional
subscale of the Older Americans Research and Service (OARS) Mul-
tidimensional Functional Assessment Questionnaire (Duke Univer-
sity Center for the Study of Aging and Human Development, 1978;
Fillenbaum & Smyer, 1981; George & Fillenbaum, 1985). The scale
includes seven questions concerning basic ADLs and seven questions
concerning instrumental ADLs. We used summary ratings to classify
clients into one of six categories of functional capacity: 1 = excellent,
2 = good, 3 = mildly impaired, 4 = moderately impaired, 5 = severely
impaired, and 6 = completely impaired. For cognitively impaired cli-
ents, information on functional status was obtained from the
caregiver.
244 JOURNAL OF AGING AND HEALTH / May 2002

To assess caregiver burden, we used Novak and Guest’s (1989)

Caregiver Burden Inventory. The total score on the 24-item scale can
vary between 0 and 96, with a higher score indicating more burden.
Cronbach’s α coefficient was .92 at Time 1 and .93 at Time 2.

Covariates

The client’s cognitive status was measured using the MMSE

(Folstein et al., 1975, 1985). The 11-item MMSE tests orientation,
registration, attention and calculation, recall, language, and praxis.
The score can vary between 0 and 30, with a higher score indicating
less cognitive impairment. The clients’ experience of stressful life
events was determined using the 34 undesirable events from the Lou-
isville Older Person Events Scale (Murrell, Norris, & Hutchins,
1984). The score represents the number of events experienced in the
preceding 6 months. The OARS Social Resources Scale (Duke Uni-
versity Center for the Study of Aging and Human Development, 1978;
George & Fillenbaum, 1985) was used to assess social support. This
eight-item scale incorporates questions on contact with friends, lone-
liness, and satisfaction with social ties. The score can range from 1 to
6, with a higher score indicating less social support.

Costs

Information on the frequency of utilization of health and social ser-

vices was obtained from client and caregiver interviews. This infor-
mation, in conjunction with information on the unit cost of services,
was used to estimate total cost. Seven types of service were consid-
ered: hospital care, physician care, home care services (e.g., home-
maker, visiting nurse, meals on wheels), outpatient professional ser-
vices (e.g., physical therapy, social work), day hospital, long-term
care (respite care, rehabilitation, and nursing home), and transporta-
tion. In addition, for the experimental group, the cost of adult day care
was included in the total cost.
The unit cost for physician care was obtained from Quebec Health
Insurance Board claims data. A unit cost for public services was deter-
mined from published sources, from rate schedules, and by
 Baumgarten et al. / DAY CARE FOR THE FRAIL ELDERLY 245

interviewing key individuals within health care organizations. Infra-

structure and administrative costs were not included when calculating
the cost of home care services. Market prices were used to determine
unit costs for private services. Assumptions about average travel dis-
tance were used to calculate the cost of transportation. Per diem costs,
rather than client-specific costs, were used when calculating the cost
of hospital and other facility care. All costs were calculated in 1991
Canadian dollars.

DATA COLLECTION

Clients and caregivers were interviewed at home by trained inter-

viewers. The specific objectives of the study were not discussed with
the interviewers. Information concerning the client’s attendance at the
day center was recorded by day center staff throughout the study
period.
French versions of the CES-D, STAI, and OARS were obtained
from other researchers or were available from our own previous stud-
ies (Baumgarten et al., 1992, 1994; Fuhrer & Rouillon, 1989;
Spielberger, 1983). A professional translator translated the remaining
instruments from English to French. The resulting questionnaire was
then back-translated into English. The equivalence of the two English
versions was verified by the authors, who are fully bilingual, and
appropriate revisions were made. For 82.5% of participants, the inter-
view was carried out in French.

ANALYSIS

Because this was a multicenter study, the first step in the analysis
consisted of determining whether there was heterogeneity in the
results from the different sites. For each outcome variable, the Time 2
value was used as the dependent variable in a multiple linear regres-
sion analysis that included group membership (experimental versus
control) and site as independent variables, the Time 1 value of the out-
come variable as a covariate, and the interaction between group and
site. Because none of the analyses yielded significant interaction
246 JOURNAL OF AGING AND HEALTH / May 2002

terms, we did not consider the site variable in any of the subsequent
analyses.
Although randomization, in principle, should have ensured study
groups that were comparable with respect to important prognostic
variables, we included potential confounders in the analysis to adjust
for any residual confounding. For each outcome variable, multiple lin-
ear regression was carried out with the Time 2 value as dependent vari-
able, group membership (0 = control, 1 = experimental) as independ-
ent variable, along with the Time 1 value of the outcome variable and a
series of potential confounders as covariates. For anxiety and depres-
sion among clients, we included the following covariates:
sociodemographic characteristics (age, sex, education, ethnic group,
and whether the client lived alone), social resources, stressful life
events, and ADL score. For functional status among clients, we
included only sociodemographic characteristics. For caregiver bur-
den, the covariates were caregiver’s age, sex, ethnic group, education,
social resources, and stressful life events and whether the caregiver
lived with the client. For health care costs, we included the client’s
age, sex, education, ADL score, and ethnic group and whether the cli-
ent lived alone.
The primary approach was an intention-to-treat analysis in which
participants were categorized according to the group to which they
were randomized, regardless of whether they remained in that group
for the entire 3-month study period. Although no clients in the control
group were admitted to a day center during the study period, a substan-
tial number of experimental clients had little or no attendance at the
day center. Therefore, secondary analyses were carried out to examine
the effect of attendance on the outcome variables. Clients were classi-
fied according to whether they had attended the day center at least 13
times; this corresponds to an average of once a week over the 3-month
study period and was considered by the day center professionals to
constitute a minimal intervention. For each outcome variable, regres-
sion analysis was carried out, using the Time 2 value as dependent
variable, client’s attendance (0 = less than 13 visits, 1 = 13 visits or
more) as independent variable, and the same covariates as for the
major analyses described above.
 Baumgarten et al. / DAY CARE FOR THE FRAIL ELDERLY 247

Results

There were eight day centers in the Montreal region that fulfilled
the eligibility criteria and agreed to participate. Two of the original
participating centers withdrew from the study after enrolling only a
few clients; the clients from these two centers were not included in any
of the analyses. Three of the remaining centers took part in the study
for the entire enrollment period (April 1990 to December 1991). The
other three centers participated for periods varying from 6 to 9
months.
A total of 370 clients were referred to the six participating centers
during the enrollment period. Of these, 35 (9.5%) could not be
included because they had urgent needs, and 55 (14.9%) were ineligi-
ble for other reasons. Of the 280 eligible clients, 29 (10.4%) refused to
sign the consent form. The remaining eligible clients (n = 251) were
randomized. At Time 1, 11 participants provided unreliable or incom-
plete data, 2 could not be reached, 1 died before being contacted for
interview, and 1 refused. Of the remaining 236 participants contacted
at Time 2, 2 could not be reached, 8 refused, 7 had died, 4 had been
institutionalized in the intervening period, and 3 were too sick to be
interviewed. The final sample of 212 clients included 108 clients in
the experimental group and 104 in the control group. Eighty-nine cli-
ents (42.0%) suffered from cognitive impairment and did not contrib-
ute data to the analyses concerning depression and anxiety; these anal-
yses were based on 61 clients in the experimental group and 62
controls. Because 30 clients (14.2%) did not have an eligible care-
giver, the final caregiver sample was made up of 89 in the experimen-
tal group and 93 in the control group. The numbers of clients recruited
by the six participating day centers were 76, 20, 56, 23, 26, and 11,
respectively.
The average age in the source sample (that is, the sample made up
of all 280 eligible participants) was 77.8 years, whereas in the final
sample it was 77.2. The proportion who were women was 73.2% in the
source sample and 73.6% in the final sample. Thus, the final sample
was almost identical to the source sample with respect to these basic
demographic characteristics.
248 JOURNAL OF AGING AND HEALTH / May 2002

Table 1 shows baseline client and caregiver characteristics in the

experimental and control groups. About 40% of clients were age 80
years or older, and almost three quarters were women. Controls were
slightly less likely to be cognitively impaired. The mean age of care-
givers was 54.2 years in the experimental group and 58.4 years among
controls. Caregivers in the experimental group had a lower level of
education and they were more likely to live with the client than in the
control group. The distribution by kinship tie to the client was similar
in the two groups: 27.0% of caregivers were the clients’ spouses and
45.5% were the clients’ adult children.
Table 2 shows the unadjusted means for the outcome variables in
the two groups at Time 1 and Time 2. For all variables, the change
between Time 1 and Time 2 was small, and the groups were not signif-
icantly different with respect to the magnitude of the change. Using
linear regression to adjust for covariates had almost no effect on the
magnitude of the differences between the groups with respect to
change between Time 1 and Time 2, so only unadjusted results are
presented.
There were 57 participants in the experimental group for whom
data were available concerning their perception of the day center’s
effect (see Table 3). For depression and anxiety, about half felt that
attendance at the day center had helped them moderately or a great
deal; 64.9% felt that day center attendance had helped them feel less
lonely. Only 29.8% felt that attendance had helped them to be more
independent. Among caregivers, 41.8% said that the client’s atten-
dance at the day center had helped the client’s depression, and 50.0%
said it had helped their anxiety. Almost 40% of caregivers felt that the
client’s attendance had allowed them more time to pursue their own
activities, and 25.6% felt that their relationship with the client had
improved.
There were 103 participants in the experimental group for whom
records of attendance at the day center were available. Of these, 9
(8.7%) never attended the day center. The median number of visits to
the day center during the 13-week study period was 10. Thirty-five cli-
ents (34.0%) attended the day center 13 times or more during the
13-week study period. These clients will be referred to as high atten-
dees, and those who attended fewer than 13 times will be referred to as
low attendees. Baseline characteristics of high and low attendees were
 Baumgarten et al. / DAY CARE FOR THE FRAIL ELDERLY 249

Table 1
Baseline Client and Caregiver Characteristics, by Group

Experimental Group Control Group

(n = 108) (n = 104)

Clients
Mean age (years) 76.4 (7.6) 78.0 (6.9)
Age 80 years or older (%) 38.9 43.3
Women (%) 74.1 73.1
More than elementary school (%) 65.7 59.6
Lives alone (%) 48.6 51.5
No informal caregiver (%) 10.2 10.6
MMSE score of less than 22 (%) 28.3 25.0

Experimental Group Control Group

(n = 89) (n = 93)

Clients
Mean age (years) 54.2 (16.2) 58.4 (15.3)
Age 65 years or older (%) 33.7 39.8
Women (%) 73.0 71.0
More than high school (%) 32.6 45.2
Lives alone (%) 42.0 48.4
Lives with client (%) 55.1 48.4
Relationship to client (%)
Spouse 25.0 28.9
Child 46.6 44.4
Other 28.4 26.7

Note. MMSE = Mini–Mental State Exam. Lower score indicates greater cognitive impairment.
Numbers in parentheses represent standard deviations.

quite different (see Table 4). High attendees were slightly older than
low attendees and were somewhat more likely to be male. High
attendees were significantly more likely to have a spouse caregiver
(37.1% vs. 14.7%, respectively) and significantly less likely to have
no caregiver (5.7% vs. 13.2%, respectively). High attendees were
somewhat more impaired cognitively and significantly more impaired
functionally than low attendees. High attendees had somewhat higher
depression scores but slightly lower anxiety scores at baseline than
low attendees. Caregivers of high attendees were slightly older and
slightly more likely to be women. The mean burden score was much
higher among caregivers of high attendees than among caregivers of
low attendees (32.1 versus 17.5, p < .05).
250 JOURNAL OF AGING AND HEALTH / May 2002

Table 2
Outcome Variables at Time 1 and Time 2, by Group

Experimental Group Control Group

M SD M SD

CES-D score (n = 61) (n = 62)

Time 1 16.9 11.9 15.7 11.6
Time 2 16.5 10.9 14.6 11.9
Anxiety score (n = 59) (n = 60)
Time 1 39.7 13.7 38.1 13.8
Time 2 39.2 14.4 36.4 14.6
ADL score (n = 104) (n = 100)
Time 1 4.2 1.2 4.1 1.2
Time 2 4.3 1.2 4.2 1.3
Caregiver burden score (n = 88) (n = 90)
Time 1 23.2 17.3 23.5 19.7
Time 2 21.0 18.4 19.8 19.3

Note. CES-D = Center for Epidemiologic Studies Depression Scale; ADL = activities of daily living.

Table 3
Perception of Day Center’s Effect

Percentage

Clients (n = 57)
Attendance at day center helped client feel moderately or a great deal:
Less depressed 56.2
Less anxious 47.3
More independent 29.8
Less lonely 64.9
Caregivers (n = 86)
Client’s attendance at day center helped caregiver feel moderately
or a great deal:
Less depressed 41.8
Less anxious 50.0
That he or she had more time to pursue own activities 39.6
That his or her relationship with client had improved 25.6

Note. Perceptions based on responses of clients and caregivers in the experimental group.

Outcome variables at Time 1 and Time 2 among high and low atten-
dees are shown in Table 5. Among participants, there were only small
differences between low and high attendees with respect to changes in
 Baumgarten et al. / DAY CARE FOR THE FRAIL ELDERLY 251

Table 4
a
Client and Caregiver Characteristics, by Client’s Attendance at Day Center

Fewer Than 13 Visits 13 or More Visits

(n = 68) (n = 35)

Clients
Mean age (years) 76.3 (8.2) 77.1 (6.1)
Age 80 years or older (%) 38.2 42.9
Women (%) 77.9 68.6
Relationship to caregivera (%)
Spouse 14.7 37.1
Other 72.1 57.1
No caregiver 13.2 5.7
Mean MMSE score 24.2 (6.0) 21.9 (6.4)
Mean ADL scorea 4.0 (1.2) 4.6 (1.3)
Mean CES-D score 15.7 (11.1) 18.5 (11.8)
Mean anxiety score 39.5 (14.5) 37.2 (10.3)

Fewer Than 13 Visits 13 or More Visits

(n = 52) (n = 32)

Caregivers
Mean age (years) 53.3 (16.7) 55.3 (14.8)
Age 65 years or older (%) 30.8 34.4
Women (%) 73.1 78.1
Mean caregiver burden scorea 17.5 (13.5) 32.1 (19.4)

Note. MMSE = Mini–Mental State Exam; ADL = activities of daily living; CES-D = Center for
Epidemiologic Studies Depression Scale. CES-D score and anxiety score were based only on the
responses of cognitively intact clients (51 low attendees and 20 high attendees). Numbers in pa-
rentheses represent standard deviations.
a. Based on clients and caregivers randomized to the experimental group.
*p < .05.

mean CES-D score, mean anxiety score, or mean ADL score. Care-
giver burden decreased substantially among caregivers of high atten-
dees, whereas among caregivers of low attendees, the burden score
increased somewhat. Controlling for potential confounding variables
using linear regression had almost no effect on the magnitude of the
changes, and none of the differences was statistically significant.
The mean cost of services per client over the 3-month study period
was $2,935 (SD = $5,536) in the experimental group and $2,138 (SD =
$4,530) in the control group, expressed in 1991 Canadian dollars.
Although the total cost was higher in the experimental group, the dif-
ference was not statistically significant. Controlling for confounding
252 JOURNAL OF AGING AND HEALTH / May 2002

Table 5
Outcome Variables at Time 1 and Time 2, by Client’s Attendance at Day Center Over 3-Month
Perioda

Fewer Than 13 Visits 13 or More Visits

M SD M SD

CES-D score (n = 42) (n = 17)

Time 1 16.4 11.5 18.2 12.8
Time 2 16.5 11.8 17.2 9.2
Anxiety score (n = 41) (n = 17)
Time 1 41.0 14.8 37.1 10.6
Time 2 40.6 15.1 36.2 12.8
ADL score (n = 68) (n = 33)
Time 1 4.0 1.2 4.5 1.3
Time 2 4.3 1.2 4.5 1.3
Caregiver burden score (n = 51) (n = 32)
Time 1* 17.8 13.5 32.1 19.4
Time 2 18.4 17.6 26.2 19.6

Note. CES-D = Center for Epidemiologic Studies Depression Scale; ADL = activity of daily living.
a. Based on responses of clients randomized to the experimental group.
*p < .05 for the comparison between groups.

variables had little impact on these results; therefore, only the crude
cost estimates are presented. The experimental group had higher mean
costs than the control group for medical and professional care, institu-
tional long-term care, and acute hospital care. However, the mean cost
in the experimental group for home-based long-term care was lower
than in the control group ($342, SD = $502 vs. $473, SD = $739).
None of the differences in cost for the individual service categories
was statistically significant.

Discussion

In this study, we were not able to demonstrate a positive impact of

adult day care on symptoms of anxiety or depression among elderly
clients over a 3-month study period. In addition, there was no evidence
indicating that participation in the day center program had an effect on
the functional status of the elderly clients or on caregiver burden. This
corroborates the results of earlier studies of adult day care that have
shown no impact on functional outcomes (Burch, Longbottom,
McKay, Borland, & Prevost, 1999; Eagle et al., 1991; Gladman, 1992;
 Baumgarten et al. / DAY CARE FOR THE FRAIL ELDERLY 253

Gladman & Lincoln, 1994; Gladman, Lincoln, & Barer, 1993). An

important finding, however, is that among participants in the experi-
mental group who were sufficiently lucid to be interviewed, almost
two thirds felt that their participation in the activities of the day center
had reduced their symptoms of loneliness, and about one half felt less
anxious and less depressed. Also, perceived burden decreased more
among caregivers of clients who attended the day center frequently
compared to caregivers of clients who did not attend often, although
this difference was not statistically significant.
Various factors need to be considered when interpreting these
results. First, it has been suggested that the heterogeneity of individual
day centers with respect to structure, operations, activities, and client
mix may make it difficult to assess their impact (Brocklehurst, 1995;
Conrad et al., 1993). Therefore, in the present study, special attention
was given to selecting day centers according to explicit criteria and to
ensuring that the centers that were selected were fairly similar in ori-
entation. The fact that the statistical analysis revealed no evidence of
heterogeneity of results across study sites suggests that this strategy
was successful.
The study was designed to have 80% power to detect an effect size
equivalent to 0.5 standard deviations. The power to detect more subtle
differences is lower. The power for the comparison of those with low
and high attendance is even lower due to the smaller number of partici-
pants when restricting analysis to the experimental group. This may
explain why some of the differences we observed, although sugges-
tive, did not achieve statistical significance.
Outcome measures for this study were carefully chosen in collabo-
ration with day center personnel. This was done to ensure that the
measured variables were relevant and corresponded to the reality of
the day centers’ interventions and treatment objectives. Although the
day centers have rather general psychosocial treatment goals (they
seek to enhance the safety, socialization, stimulation, and education of
their elderly clients), we chose more specific indicators of outcome,
among them the effect on depression and anxiety. This allowed us to
measure more precise aspects of the impact of the day centers and to
make use of proven measurement scales. However, it is possible that
the interventions performed in the day centers are not sufficiently
operationalized in terms of specific indicators such as depression and
254 JOURNAL OF AGING AND HEALTH / May 2002

anxiety. As for functional status, it is probably unrealistic to expect

significant gains given the degree of impairment in this population
(almost three quarters of the sample exhibited moderate to severe
functional disability and their average age was 77 years), the irrevers-
ible nature of many of the clients’ chronic conditions, and the role of
adult day care centers, which are typically targeted at maintaining
functional independence or slowing its loss, leaving the task of inten-
sive, one-on-one functional rehabilitation to day hospitals and other
services.
An important consideration in analyzing the results of this study is
the length of the intervention itself (3 months). Ethical considerations
prevented us from extending the intervention for longer than this
period. To do so would have deprived the elderly clients in the control
group of a service that, until then, had been available to them with no
more than a 3-month waiting period. The study period was short when
one considers that it takes some time for older persons to adapt to new
activities and that at the start of the interventions, there may actually
be an increase in anxiety. On the other hand, even studies evaluating
psychosocial interventions taking place over periods ranging up to 3
years (Clarke, Clarke, & Jagger, 1992) have not produced a significant
impact.
The low level of participation in day center activities must be con-
sidered when analyzing the results of this and other studies of the
effectiveness of adult day care (Gutman et al., 1993; Hedrick, Johnson,
Inui, & Diehr, 1991; Montgomery, 1992; Wallace, 1987; Weissert
et al., 1980). Even in cases where one-on-one psychosocial help is
offered, up to 50% of older people may refuse to take part (Clarke
et al., 1992). It has been reported that day center staff tend to attribute
nonattendance to systemic problems, such as long waiting lists,
whereas clients’concerns center on practical issues such as being able
to hear or see well enough to participate and being able to afford the
minimal cost of transportation or meals (Gutman et al., 1993).
In our study, caregivers of high attendees had much higher initial
levels of burden than low attendees (p < .05). Furthermore, the burden
levels of caregivers of high attendees decreased over the study period,
whereas the burden levels of caregivers of low attendees increased
slightly, although the difference was not statistically significant.
Although interesting, such subgroup analyses are limited because
 Baumgarten et al. / DAY CARE FOR THE FRAIL ELDERLY 255

selection factors may explain the different outcomes among those

who choose to attend regularly and those who do not. Still, if these
results are replicated in future studies, they suggest that there is a sub-
group of particularly stressed caregivers who are most likely to benefit
from the day center intervention.
Clients whose participation rates were low were much more likely
not to have a caregiver than those who participated more frequently.
To improve attendance at day centers among people who do not have
informal help, the home care system may have to substitute for these
resources. Future experimental studies of day centers should include
maintenance of high levels of attendance as one of the explicit goals of
the program that is being evaluated.
Studies on respite care (Knight, Lutzky, & Macofsky, 1993; Mont-
gomery, 1992) suggest that to be effective, care must be offered to
families for a significant number of hours per week. Respite care at
home may be more effective than care in an institutional setting
because it frees the caregiver from the burden of preparing the older
person to travel. Furthermore, it has been suggested that the time made
available by the day center’s program is often used by the caregiver to
attend to household tasks rather than to fulfill more basic physiologic,
social, or emotional needs (Berry, Zarit, & Rabatin, 1991). It has also
been found that respite services must consist of several complemen-
tary components (a “service package”) that respond to different needs:
assessment, education, respite, and follow-up. Given the limited
resources available to them, the programs offered by Quebec day cen-
ters correspond to only some of these requirements and are not always
integrated into a comprehensive care plan with other health services.
This may explain why, in this study, there was no significant impact on
caregiver burden.
We found that the mean cost of health and social services over the
3-month study period was somewhat higher in the experimental group
than in the control group, although the difference was not statistically
significant. This finding is consistent with a large number of previous
experimental and quasi-experimental cost effectiveness studies of
adult day care, home care, homemaker services, respite care, and other
types of community-based long-term care (Weissert, 1993; Weissert,
Cready, & Pawelak, 1988) that have found that community-based care
is not less expensive than institutional care. For example, a recent
256 JOURNAL OF AGING AND HEALTH / May 2002

well-designed veterans study found that costs for the intervention

group were 15% higher than for the control group and that the inter-
vention group experienced no clear benefits in terms of health status
(Capitman, 1993; Ehreth, Chapko, Hedrick, & Savarino, 1993). On
the other hand, we noted a decrease in the cost of home-based long-
term care (which includes services such homemaker, visiting nurse,
and meals on wheels) in the experimental group relative to the control
group. This suggests that adult day care may, to some extent, substi-
tute for home-based services.
When considering the cost comparisons, it should be remembered
that the cost of home-based services was underestimated because reli-
able information on administrative and infrastructure costs for those
services was not available at the time of the study. However, the under-
estimation would have affected the experimental and control groups
equally. This, together with the fact that the greatest part of the service
cost is probably attributable to manpower and travel, suggests that any
bias in the comparison between the experimental and control groups is
likely to be small.
Adult day care constitutes an integral part of the spectrum of ser-
vices offered to the community-residing older person. The findings of
our study suggest that clients and caregivers perceive a benefit from
day center attendance, although we were not able to measure that ben-
efit using a rigorous experimental design and standard research instru-
ments. There are several possible explanations for this apparent dis-
crepancy. Perhaps we are measuring the wrong thing: The benefits
that users of the service perceive may not be adequately captured by
conventional research tools. Alternatively, it may be that low levels of
participation in this type of community-based program dilute the
intervention’s effect. Simply offering a service even when, as in the
Canadian context, the service is free and universally available to eligi-
ble individuals does not guarantee that individuals will use the service
and reap its potential benefits. In our view, limiting studies to persons
with high levels of participation (as was done, for example, by Zarit,
Stephens, Townsend, & Greene, 1998) is not the appropriate solution.
Such studies only tell us about the effect of the intervention on a
self-selected subgroup defined by unknown factors (e.g., motivation,
resourcefulness, desperation). From the point of view of policy and
service planning, the important question is the effect of the
 Baumgarten et al. / DAY CARE FOR THE FRAIL ELDERLY 257

intervention on the entire eligible target population. Future studies

should not view low participation simply as a question of noncompli-
ance. Rather, maintenance of high levels of participation should be
incorporated as an explicit program goal.

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