Relationship between Cognitive Function , Self-esteem , Self-care Capabilities , and Activities of Daily Living of Institutionalized Older Adults

Background: With advancing age, there is an increased susceptibility to various functional limitations, cognitive declines, and self-care disabilities, which often results in compromised physical and psychological well-being. Objective: The study was conducted to identify the relationship between cognitive function, self-esteem, self-care capabilities, and activities of daily living of institutionalized older adults. Subjects and Methods: 100 elders of both sexes aged 60 years andabove were included in the study. Mini-Mental State Examination (MMSE), The Katz Activities of Daily Living (ADL) Scale, The Exercise of Self-Care Agency (ESCA) Scale and The Rosenberg SelfEsteem Scale (RSES) were used. Results: Findings revealed the presence of significant relationships between cognitive function and both self-care capabilities and activities of daily living, whereas no significant relationships were found between self-esteem of the studied elders, and their cognitive function, self-care capabilities, and activities of daily living. Conclusion and Recommendations: The findings suggest that, specific emphasis should be placed on the ongoing assessment of cognitive function which is important to predict the self-care of older adults, and to institute the appropriate intervention, and further researches are needed to examine and evaluate the effectiveness of rehabilitation programs to improve elders' cognitive function and self-care capabilities. INTRODUCTION Different physical and psychological factors play a key role in the elder's willingness and ability to participate in selfcare activities. These factors include: physical and cognitive functioning, selfcare capabilities and self-esteem of the older adult. (1) Proper cognitive functioning, self-esteem and self-care capabilities are the important components of independence functioning of the elderly 134 Bull High Inst Public Health Vol.41 No.1 [2011] individual. (2) They are also highly individualized and are based on personal resources, physical and/or psychological health status of older adults. (3) In later life, cognitive function, self-esteem and selfcare capabilities are closely connected to successful performance of activities of daily living. (4) A growing body of research suggests that there is an association between cognitive and physical functioning, and self-esteem among the elderly. (5-7) It was argued that cognitive status is likely to be related to physical functioning, particularly the ability to perform self-care activities and activities of daily living, which may influence both physical and psychological well-being. (8) In this respect, Elovainio et al. (2009) (9) noted that poor cognitive function may play a role in the initiation and the progression of poor physical function and low self-esteem. Another study demonstrated a positive correlation between low cognitive function and later declines in physical functioning. (10) Moreover, it was reported that disability and cognitive impairment show similar patterns of increasing frequency with aging; elders with low cognitive performance are at higher risk of functional impairment. (11) Fairly strong evidence indicated that maintenance of self-care capabilities is the most cost-effective method to ensure enhanced quality of life in old age. It can promote overall health status, encourage independence, maintain physical and psychological well-being, improve cognitive function, and preserve self-esteem in later life. (12,13) However, many factors such as normal physical, cognitive and psychosocial changes which are experienced by the older adults, and chronic illnesses may profoundly influence independent functioning of the elderly, especially in performing activities such as visiting friends or family member, shopping, worshipping outside the home, and vacationing.


INTRODUCTION
individual. (2) They are also highly individualized and are based on personal resources, physical and/or psychological health status of older adults.
(3) In later life, cognitive function, self-esteem and selfcare capabilities are closely connected to successful performance of activities of daily living. (4) A growing body of research suggests that there is an association between cognitive and physical functioning, and self-esteem among the elderly.
(5-7) It was argued that cognitive status is likely to be related to physical functioning, particularly the ability to perform self-care activities and activities of daily living, which may influence both physical and psychological well-being. (8)In this respect, Elovainio et al.
(2009) (9) noted that poor cognitive function may play a role in the initiation and the progression of poor physical function and low self-esteem.
Another study demonstrated a positive correlation between low cognitive function and later declines in physical functioning.(10)   Moreover, it was reported that disability and cognitive impairment show similar patterns of increasing frequency with aging; elders with low cognitive performance are at higher risk of functional impairment.(11)   Fairly strong evidence indicated that maintenance of self-care capabilities is the most cost-effective method to ensure enhanced quality of life in old age.It can promote overall health status, encourage independence, maintain physical and psychological well-being, improve cognitive function, and preserve self-esteem in later life.(12,13)   However, many factors such as normal physical, cognitive and psychosocial changes which are experienced by the older adults, and chronic illnesses may profoundly influence independent functioning of the elderly, especially in performing activities such as visiting friends or family member, shopping, worshipping outside the home, and vacationing.
Fouad & Gawad 135 Performance of these activities requires higher levels of physical and cognitive functioning which consequently affects the self-esteem of elders.(14)   Elders with normal cognitive abilities and high self-esteem are usually motivated to perform self-care.On the other hand, elders with deficits in cognitive functions such as memory, language, abstract thinking and judgment have great difficulty executing activities of daily living, may need to be reminded to perform self-care, may be unaware of the need for self-care and the appropriate methods of achieving it, or may be totally dependent on others in meeting their self-care.Cognitive decline represents a major factor involved in the pathogenesis of age-related frailty and functional decline.In this respect, it was reported that cognitive impairment is the greatest predictor of self-care deficits in the elderly.(15,16)   Performance of self-care activities requires that elders value themselves sufficiently to invest the time and energy in performing activities of daily living.Changes in mood and low self-esteem that may be experienced with aging may directly affect the elder's ability to perform self-care activities. (17,18)Mood changes, feelings of helplessness, hopelessness, incompetence, and perception of self as incapable and frail are possible consequences of self-care limitations and may lead to increased dependency and reduced opportunities for socialization. ( At the same time, problems related to self-care can be devastating to elders because of their effect on self-esteem.(22) The elder with emotional disturbances may direct his/her energy inward or may have no enough energy required to perform the different self-care activities. ( The aim of this research is to identify the relationship between cognitive function, self-esteem, self-care capabilities, and activities of daily living of institutionalized older adults.

Study setting:
The study was carried out in four elderly homes in Alexandria selected randomly by ballot, two governmental homes (Dar El-Hana, and Dar El-Hadaya), and two private homes (Dar Mohamed Ragab, and Dar Ahmos Khalifa).

Study design:
A descriptive correlation design was used to investigate the relationship between the studied variables.

Target population and sampling:
The subjects of the present study comprised 100 elders of both sexes who were residing in the previously mentioned settings, aged 60 years and above, able to communicate effectively, and accepting to participate in the study.
The researcher used to visit the study settings based on a schedule, and started data collection based on the scheduled days from 9 am to 1 pm.All elders who fulfilled the study criteria were included in the study.

Study tools:
The following five tools were used to collect data for this research:

2-Mini-Mental State Examination (MMSE):
The MMSE is a screening instrument developed by Folestein (1975) (25)  The ADL scale is an instrument to assess independent living skills developed by Katz et al (1969). (26) This scale was developed by Kearney and Fleischer (1979) (27) and designed to measure self-care capabilities through the assessment of one's ability to care for self.
(2010) (32) who demonstrated that self-care activities of older adults were associated with their cognitive function.They suggested that the ability of elders to engage in self-care activities is known to rely on their cognitive abilities and not only on their physical abilities.In addition, there is less expectation of achieving optimal levels of cognitive functioning and an outstanding physical functioning in older adults. (13)This can be confirmed by the results of the present study which indicated that about two thirds of the studied elders had low self-care capabilities and all of them were either partially dependent or fully dependent in performing activities of daily living, and at the same time, more than half of them complained of mild to severe cognitive impairment.This association between self-care capabilities, activities of daily living, and cognitive function may be attributed to a common underlying cause which is the age-related physiological changes.
However, El-Husseini (2008) (28)   who reported a positive correlation between self-care capabilities and cognitive status of older adults attributed this finding to the fact that cognitive functioning is considered as a factor which helps elders to adapt the self, the task, and the environment to facilitate functioning.Even the elder who is physically capable to perform self-care activities; he may not be alert enough to know when and how to perform the activities safely.In this regard, it was postulated that the presence of mild cognitive impairment may nevertheless interfere with the elder's ability to manage self-care activities. (8)It is thought that decrements in cognitive functions often jeopardize the elder's ability to manage safely and effectively the self-care activities.
(36)(37) Some researchers rationalized their results by the notion that the physical function and self-care activities can contribute to maintaining high selfesteem among elder people. (36,37)However, elders may have high self-esteem due to different factors rather than the presence of optimal physical functioning and effective performance of self-care activities.Older adults may have high self-esteem when they have accomplished some goals, like having a happy marriage or having done well at a challenging job. (38)This was confirmed by this study's results which revealed that although there was no significant relationship between selfesteem and cognitive function, self-care capabilities, and activities of daily living of the studied elders, more than two thirds of the elders had high self-esteem.In contrast, Železnik (2007) found that the Slovenian elders' self-esteem was not so high.This finding was rationalized by the helplessness which is felt by the studied elders.Those elderly people who are not able to manage their life by themselves may feel abandoned and helpless and lack control over their life which may decrease their self-esteem. (3) However, an explanation of the high self-esteem of the elders of the current study may be that many elders may perceive the decline in their physical health and the physiological changes as normal and expected with aging.Accordingly, they are more accepting of their condition and of their decreased self-care capabilities and are trying to cope with these difficulties.
This explanation is supported by the results of the current research as the majority of the studied elders were satisfied with their health status and about two thirds of them rated their health as good.On the other hand, those who rated their health as good obtained the highest mean score of activities of daily living.This point of result coincided with the findings obtained by Abou El-Seoud (2008) (39) who reported that elders who perceived their health as good perceived their self in a positive manner and had a positive self concept.
Another possible interpretation for the high level of self-esteem among the studied elders is that getting support from relatives and friends, making an effort to connect to others and limiting the time of being alone can enhance self-esteem. (24)In this respect, the majority of elders who participated in the present research visited and were being visited by family members, and about two thirds of them had social relationships with others in the elderly home.In the same direction, Orth et al.
(2010) (40) The present study also showed that there was a significant relationship between leisure time activities and the mean score of self-care capabilities, where the studied elders who practiced hobbies had the highest mean score of self-care capabilities.An explanation of these findings could be that being as active as possible and practicing new hobbies and renewing interests can improve psychological well-being and enhance self-esteem, so motivate the elder to engage in self-care activities.These results are in harmony with those of El-Husseini (2008) (28) who found leisure time activities to be positively correlated with self-care capabilities.She suggested that participation in productive activities promotes cognition, improve physical health status, and increase sense of achievement; all of which improve self-care capabilities.

CONCLUSION AND RECOMMENDATIONS
Based on the results of the current study, it could be concluded that there is significant relationships between cognitive function and both self-care capabilities and activities of daily living, whereas there was no significant relationship between selfesteem of the studied elders, and cognitive Different physical and psychological factors play a key role in the elder's willingness and ability to participate in selfcare activities.These factors include: physical and cognitive functioning, self-care capabilities and self-esteem of the older adult.
-esteem and self-care capabilities are the important components of independence functioning of the elderly Bull High Inst Public Health Vol.41 No.1 [2011] physical activity of older adults can influence the overall quality of life, and may have a large impact on the elders' ability to remain functioning.(3,13) To provide the best quality care, nurses have to be aware of the specific factors that have the greatest impact on the elder's life, and the relationships between such factors.Therefore, this research aimed to identify the relationships between cognitive function, self-esteem, self-care capabilities, and activities of daily living among institutionalized elders.Awareness of these relationships may provide a solid framework to ensure a cost-effective nursing care for older population.The current research revealed that there were significant relationships between both self-care capabilities and activities of daily living, and cognitive function, whereas there was no significant relationship between self-esteem, and cognitive function, self-care capabilities, and activities of daily living of the studied institutionalized elders.This means that self-care capabilities and activities of daily living may be affected by elders' cognitive status and not by their self-esteem.As for the relationship between cognitive function, and self-care capabilities and activities of daily living, the findings of the present research are in agreement with the results of Sánchez-Rodríguez et al. (2009) Winchester et al. (2009)(33) who supported the premise that self-care limitations and cognitive impairment predict activities of daily living.Regarding the relationship between self-esteem, and cognitive function, selfcare capabilities and activities of daily living, the findings of numerous studies are contradicting with the findings of the current study.These previous studies Bull High Inst Public Health Vol.41 No.1 [2011]

( 34 )
This point of view is supported by the results of the present study as the majority of the subjects had no hearing problems, and more than half had no visual problems which may protect their self-esteem and encourage the elder to perform the activities of daily living successfully.This may be true because the studied elders who had no visual problems had the highest mean score of activities of daily living.As regards the self-care capabilities and activities of daily living, the current research pointed out that about two thirds of the studied elders had low self-care capabilities, all of them were partially dependent and fully dependent in performing activities of daily living, and more than half of them move with assistance.These findings may be due to the fact that the elevated life expectancy contributes to an escalating number of people living with low self-care capabilities along with common impairments associated with aging such as cognitive, sensory, and mobility declines.This leads to decreased ability to engage in self-care activities and activities of daily living.In this regard, the present study showed that the activities of daily living of the studied elders had the least mean score.These results are supported by another research which demonstrated that most of older people report self-care difficulties.These disabilities and limitations occur when the elder person has problems with physical function which leads to a restriction in the elder's ability to perform activities of daily living independently.

-demographic and health status structured interview schedule:
1-Socio Health status: satisfaction with health status, and self-rating of health. Physical function: hearing, vision, and mobility status. Social activities: social relationships with others in the elderly home, participation in recreational activities, leisure time activities, and visits to or by family members and friends.

The Rosenberg Self-Esteem Scale (RSES):
institutionalization, the table shows that 45.0% and 36.0% of the studied elders were housewives and employees respectively.The only statistically significant relationship proved was between occupation before institutionalization and cognitive function (F = 13.056,p = 0.000), where the highest mean score of cognitive function was obtained by elders who were employees (26.03  2.61), while the least mean score was obtained by elders who were skilled workers (17.0  2.83).income 400£ and more had the highest mean score of cognitive function (24.16  4.15), whereas those with monthly income less than 100£ had the lowest mean score of cognitive function (16.67  4.51).The table also shows that there were no statistically significant relationships detected between both age and marital status, and the mean scores of cognitive function, selfesteem, self-care capabilities and activities of daily living (p > 0.05).

Table 6 . Distribution of the studied elders according to their self-esteem and self- care capabilities Variables Studied elders (n = 100)
bMeasured by Exercise of Self-Care Agency (ESCA) Scale

Table 7 . Distribution of the studied elders according to their activities of daily living Activities of daily living
a Measured by Katz Activities of Daily Living (ADL) Scale