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Original articles

Nonpharmacological interventions in patients with cognitive impairment: a comparison of residential and nursing homes in Poland

Violetta Kijowska1, Ilona Barańska1, Agata Stodolska1,2, Katarzyna Szczerbińska1
1 Laboratory for Research on Aging Society, Chair of Epidemiology and Preventive Medicine, Department of Sociology of Medicine, Faculty of Medicine, Jagiellonian University Medical College, Kraków, Poland
2 Chair of Internal Medicine and Gerontology, Faculty of Health Sciences, Jagiellonian University Medical College, Kraków, Poland
DOI: 10.20452/pamw.15731
Published online: December 30, 2020.
Key words: cognitive impairment, cognitive therapy, interRAI-LTCF tool, nonpharmacological therapy, nursing home
CCBYNCSACC BY-NC-SA 4.0

In this article
Abstract

Introduction: Availability of nonpharmacological interventions to manage neuropsychiatric symptoms is important to reduce the use of psychotropic drugs in residents with dementia in long‑term care facilities (LTCFs).

Objectives: We aimed to assess prevalence of nonpharmacological interventions in residents with cognitive impairment in LTCFs, and to find factors associated with their participation in cognitive therapy (CT).

Patients and methods: A cross‑sectional analysis of a country‑representative sample of 23 LTCFs in Poland was conducted between 2015 and 2016. We used the InterRAI‑LTCF tool to collect data from 455 residents with cognitive impairment.

Results: Most of the residents were involved in occupational therapy activities (73.4%) and medical rehabilitation (67.2%); however, less than half participated in CT (44.8%) and physical activity group (41.2%), and only 24.2% of individuals received psychological therapy (PT) and only 22.7% of residents were encouraged to enhance their ability with activities of daily living (ADL). We found a positive correlation between participation in enhancing ADL and CT (rho = 0.677; P <⁠0.001), and a considerable variation between the LTCFs in prevalence of PT, CT, and encouraging maintaining ADL. The chance of participating in CT was higher in women (odds ratio [OR], 1.87; 95% CI, 1.15–3.04), residents of nursing homes (OR, 2.79; 95% CI, 1.69–4.60), of larger facilities (OR, 4.09; 95% CI, 2.45–6.81), and among residents having moderate cognitive impairment (OR, 2.27; 95% CI, 1.27–4.08), delusion (OR, 2.31; 95% CI, 1.34–3.98), diagnosis of depression (OR, 5.07; 95% CI, 2.31–11.14), or Alzheimer disease accompanied by behavioral disorders (OR for interaction, 5.25; 95% CI, 1.28–21.58).

Conclusions: We found a relatively high use of medical rehabilitation and occupational therapy and significant diversity between facilities in use of CT, PT, and maintaining / enhancing ADL.

What's new?

In this study, we assessed the use of nonpharmacological interventions in residents with cognitive impairment residing in long‑term care facilities in Poland. We found relatively high accessibility of medical rehabilitation and occupational therapy in most facilities, but much lower cognitive therapy (CT), psychological therapy, and enhancing independence in activities of daily living. Cognitive therapy and psychological therapy were more often available in the facilities where residents participated in enhancing of activities of daily living. Cognitive therapy was more likely provided to residents living in larger facilities or nursing homes and to people with symptoms of depression, delusions, or Alzheimer disease accompanied by behavioral disorders. However, residents with mild or severe cognitive impairment had a lower chance to receive CT compared with persons with moderate cognitive impairment. Hence, the development of nonpharmacological interventions in long‑term care facilities is needed to make them available to all residents with cognitive impairment, and for physicians to refer patients more frequently to CT.

Introduction

As a result of increasingly aging populations amongst many countries of the world, the number of people with cognitive impairment is growing significantly. At the same time, significant changes in the family structure means that family members’ ability to provide continuous care for the chronically ill relatives at home is disrupted. Therefore, many people with cognitive impairment are eventually placed in long‑term care facilities (LTCFs). In Europe, more than 60% of the population in LTCFs are people with cognitive impairment.1,2 A similarly high prevalence of cognitive impairment (65.2%) has also been demonstrated in our study of a nationally represented sample in Poland with 59.2% of residents with cognitive impairment in residential homes (RHs) and 74.5% in nursing homes (NHs).3 This study also revealed a high prevalence of neuropsychiatric symptoms (NPS) among these residents. We found that the prevalence of aggressive behavior (49.5%), agitation (30.3%), and wandering (22.7%) did not differ significantly between the various settings, but NH residents were more likely to show resistance to care (up to 38.7%), hallucinations (up to 25.5%), and delusions (up to 28.9%) when compared with RH residents.4

Such symptoms are common among residents of LTCFs. As a result, residents experience discomfort and a significant burden is put on care staff. Residents therefore require specific pharmacological and nonpharmacological treatment. Psychotropic medications are frequently used to manage NPS despite strong evidence that the risk of adverse effects of these medications outweighs the benefits.5,6 Therefore, they should be used as a second‑line treatment for a limited period of time and withdrawn whenever possible. Because there is some evidence showing efficacy of nonpharmacological therapies with a limited potential for adverse effects, they are recommended as the first‑choice therapy and an alternative option for pharmacological treatment.7,8 A number of studies have highlighted the effectiveness of nonpharmacological therapies such as occupational therapy,9,10 exercise trainings,11-13 music therapy, art therapy, or cognitive and behavioral interventions.

However, it is unknown how often Polish LTCFs residents with cognitive impairment receive nonpharmacological interventions (NPIs), and which particular therapies are available for them. Thus, the aim of this study was to explore the use of different NPIs, namely: medical rehabilitation (MR); restoring everyday life through maintaining / enhancing activities of daily living (enhancing ADL); physical group activity (PA); occupational therapy–type activities (OT); cognitive therapies (CT); and psychological therapy (PT) for residents with cognitive impairment. We also wanted to establish factors associated with the use of CT in a nationally representative sample of such residents in both NHs and RHs in Poland. We assumed the following research hypotheses: 1) The use of NPIs is more frequent among residents with cognitive impairment residing in NHs compared with RHs. 2) The specific facility characteristics such as NH type, larger size, and private ownership status are associated with higher use of certain NPIs. 3) Specific resident characteristics such as level of cognitive impairment, presence of Alzheimer disease (AD) or other dementias are associated with higher chance for participating in CT.

Patients and methods

Recruitment

The study was performed in 23 LTCFs (both NHs and RHs) providing care for older or chronically ill adults from across Poland (see Supplementary material for context of LTCFs). Facilities were randomly selected from all 6 macro regions (according to the Nomenclature of Territorial Units for Statistics codes, NUTS level 1, as binding in 2014) in terms of size, status, geographical region, number of beds, and facility type. The study protocol, including a detailed sample calculation and inclusion criteria to the study3 as well as the comparison of organization of both types of the facilities4 have been described in detail elsewhere.

The sampling procedure met minimum requirements regarding the expected number of both facilities and residents. Out of 49 randomly selected facilities (which expressed initial consent), 26 refused to participate in the study. However, they provided basic organizational data, so we could perform nonresponse analysis which did not show statistically significant differences between LTCFs involved in the study and those which declined to participate.

The study sample involved 1587 residents from 11 NHs and 12 RHs; each resident had their level of cognitive impairment assessed using the Cognitive Performance Scale (CPS). The CPS is a 5‑item observational scale embedded in the InterRAI Long‑Term Care Facilities Assessment System questionnaire (InterRAI‑LTCF). It demonstrates a high level of agreement with the Mini‑Mental State Examination and the Montreal Cognitive Assessment. We excluded 459 residents who did not have cognitive impairment (based on the CPS score with a cut‑off of less than 2 points), and 93 residents who were in coma. We received a sample of 1035 residents with cognitive impairment. Finally, we randomly selected 20 residents from each of the 23 institutions (n = 460). The LTCF staff returned valid questionnaires from 455 residents with cognitive impairment: 214 recruited from NHs and 241 from RHs.

Measurements

Data were collected form 2015 to 2016 using the interRAI‑LTCF questionnaire on the basis of a 3‑day observation of residents by a nurse or psychologist who had undergone a standardized training. The interRAI‑LTCF suit is a standardized tool and consists of over 350 questions comprising a comprehensive geriatric assessment designed to assist clinicians in evaluation the health and functional status of LTCF residents, and their care needs. It includes an inventory of different somatic symptoms and neuropsychiatric signs comprising psychotic symptoms (hallucinations, delusions), behavioral problems (agitation, aggressive behavior, wandering, verbal and physical abuse, resistance to care, socially inappropriate behavior), and depressive signs. The questionnaire also includes a checklist of medical diagnoses of chronic somatic and psychiatric diseases (including depression, AD, and other dementias) retrieved from medical records. Moreover, it contains items regarding pressure ulcers, incontinence, falls, and nutrition.

We also used some scales from the interRAI‑LTCF tool:

  • A 7‑point CPS scale to assess cognitive impairment (mild, 2 points; moderate, 3–4 points, or severe, 5–6 points);

  • The Activities of Daily Living Hierarchy scale (ADLh) measuring functional performance assessing 4 activities: personal hygiene, locomotion, toilet use, eating on a 7‑point scale of dependency (independent, 0–1 points; moderately dependent, 2–3 points; severely dependent, 4–6

    points);

  • The Aggressive Behavior Scale (ABS): a 4‑item scale to measure verbal and physical abuse, socially inappropriate behavior, and resistance to care, ranging from 0 to 12, where a higher score indicates a greater frequency of aggressive

    behavior.

SUPPLEMENTARY MATERIAL
PAIM-20-00353_orig_supp_0.pdf
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ARTICLE INFORMATION
Acknowledgments: The authors would like to thank the managers of long‑term care facilities in Poland who allowed the study to be conducted in their centers, and to the facilities’ nursing staff for participating in collecting the data. Special thanks go to Prof. Jo Hockley, for her assistance in content reviewing of the manuscript. This work was supported by the Jagiellonian University Medical College (no. K/DSC/003080; to VK).
Contribution statement: All authors participated in designing the study. VK formulated the research questions, designed the study, carried it out, collected the data, developed statistical analysis plan, and wrote the article. IB was responsible for data management, the statistical design of the study, and for carrying out the statistical analysis. AS assisted in collecting data, writing the article and provided language proofreading. KS designed the study, supervised the data collection, developed statistical analysis plan, assisted with interpretation of the results, and supervised writing the article. All authors made substantial contribution to interpretation of data and critical revisions of the manuscript.
Conflict of interest: None declared.
References
  1. Mansbach WE, Mace RA, Clark KM, Frith IM. A comparison of cognitive functioning in long‑term care and short‑stay nursing home residents. Ageing Soc. 2017; 37: 1‑13. | Crossref
  2. Onder G, Carpenter I, Finne‑Soveri H, et al. Assessment of nursing home residents in Europe: the Services and Health for Elderly in Long TERm care (SHELTER) study. BMC Health Serv Res. 2012; 12: 5. | Crossref
  3. Kijowska V, Szczerbińska K. Prevalence of cognitive impairment among long‑term care residents: a comparison between nursing homes and residential homes in Poland. Eur Geriatr Med. 2018; 9: 467‑476. | Crossref
  4. Kijowska V, Barańska I, Szczerbińska K. Health, functional, psychological and nutritional status of cognitively impaired long‑term care residents in Poland. Eur Geriatr Med. 2020; 11: 255‑267. | Crossref
  5. Kales HC, Gitlin LN, Lyketsos CG. Management of neuropsychiatric symptoms of dementia in clinical settings: Recommendations from a multidisciplinary expert panel. J Am Geriatr Soc. 2014; 62: 762‑769. | Crossref