Autonomy and social functioning of recently admitted nursing home residents

Key professional stakeholders roles in promoting older people's autonomy in residential care

BACKGROUND

Older people's autonomy is an ethical and legal principle in everyday residential care, but there is a lack of clarity about the roles and responsibilities of the key professional stakeholder groups involved.

RESEARCH OBJECTIVES

This study aimed to identify and define the roles and responsibilities of the key professional stakeholder groups involved in promoting older people's autonomy in residential care settings.

RESEARCH DESIGN

We used a Delphi method with two iterative rounds of online group discussions and collected data from experts in older people's care in Finland in summer 2020. The data were analyzed using deductive-inductive content analysis methods.

ETHICAL CONSIDERATIONS

According to Finnish legislation, this type of research did not need approval from a research ethics committee. Informed consent from the participants was obtained and they were informed about the voluntary nature and confidentiality of the study and their right to withdraw at any time.

RESULTS

Key professional stakeholders had different roles and responsibilities, but their shared, integrated goal was to achieve older people's autonomy in residential care settings. Their combined roles and responsibilities covered all aspects of promoting older people's autonomy, from care and service planning and daily decision-making to service structures that included ethical competencies and monitoring. Multipronged, variable, coordinated strategies were required to identify, assess, and promote autonomy at different levels of care.

CONCLUSION

Key professional stakeholders need to work together to provide an unbroken chain of care that provides older people with autonomy in residential care settings. In future, more knowledge is needed about how to create structures to achieve the shared goal of older people's autonomy in these settings.

Autonomy, independence, and participation of nursing home habitants addressed by assistive technology: a scoping review

CONTEXT

Assistive technologies have been identified by researchers and public policies of the Western world to be promising tools to face the challenge of maintaining quality of life of older people, and especially for nursing home habitants. Independence, autonomy, and participation are major determinants of quality of life of nursing homes habitants. Maintaining quality of life is nowadays a priority for public health policies and institutions of the where the population is growing older every year.

METHOD

This PRISMA-ScR review aims to determine which assistive technologies are used to promote autonomy, independence, and social participation of nursing home habitants. An electronic search was conducted for English, French articles to identify research studies using CINAHL, PubMed, Cochrane Library, PsycINFO, and Googlescholar.

RESULTS

12 papers published between 2009 and 2023 described 6 assistive technologies: technologies integrated into the environment, monitoring technologies, surveillance technologies, information and communication technology, social assistance robots, virtual reality. Six types of AT are currently used worldwide to maintain autonomy, independence and participation of people living in nursing homes. Their use is mainly perceived as positive by habitants, care and non-care staff, next of kin, and experts despite some concerns regarding ethical, financial, consideration.

DISCUSSION

Nevertheless, their impact on habitant's autonomy, independence and participation still needs to be measured using suitable tools to understand their real impact on the quality of life of the elderly.

Medication Decision-Making and the Medicines' Pathway in Nursing Homes: Experiences and Expectations of Involvement of Residents and Informal Caregivers

BACKGROUND

Information on how residents and their informal caregivers are involved in the medicines' pathway in nursing homes is scarce. Likewise, it is not known how they would prefer to be involved therein.

METHODS

A generic qualitative study using semi-structured interviews with 17 residents and 10 informal caregivers from four nursing homes was performed. Interview transcripts were analyzed using an inductive thematic framework.

RESULTS

Four themes were derived to describe resident and informal caregiver involvement in the medicines' pathway. First, residents and informal caregivers show behaviors of involvement across the medicines' pathway. Second, their attitude towards involvement was mainly one of resignation, but variation was noted in their involvement preferences, ranging from minimal information to active participation needs. Third, institutional and personal factors were found to contribute to the resigned attitude. Last, situations were identified that drive residents and informal caregivers to act, regardless of their resigned attitude.

CONCLUSIONS

Resident and informal caregiver involvement in the medicines' pathway is limited. Nevertheless, interviews show that information and participation needs are present and show potential for residents' and informal caregivers' contribution to the medicines' pathway. Future research should explore initiatives to increase the understanding and acknowledgement of opportunities for involvement and to empower residents and informal caregivers to take on their roles.

Comparisons on factors affecting residents fulfilling self-determination in ethno-specific and mainstream nursing homes: a qualitative study

BACKGROUND

Studies revealed that supporting residents fulfilling self-determination is positively associated with their health, wellbeing and quality of life. Cross-cultural care poses significant challenges for nursing home residents to fulfil their self-determination in control of own care and maintaining meaningful connections with others. The aim of the study was to compare factors affecting residents fulfilling self-determination in ethno-specific and mainstream nursing homes.

METHODS

A qualitative descriptive approach was applied to the study. Culturally competent care and person-centred care were employed as guiding frameworks. Individual interviews or a focus group with residents and family members were conducted to collect data.

RESULTS

In total, 29 participants participated in the study. Three main themes were identified: communicating needs and preferences; mastering own care; and maintaining meaningful relationships. Each theme includes sub-themes that detail similarities and differences of factors affecting residents fulfilling self-determination in the two type nursing homes. Findings indicate that residents from both types of nursing homes experienced challenges to communicate their care needs and preferences in daily care activities. Moreover, residents or their representatives from both types of nursing homes demonstrated motivation and competence to master residents' care based on their individual preferences, but also perceived that their motivation was not always supported by staff or the nursing home environment. Residents' competence in mastering their care activities in ethno-specific nursing homes was based on the condition that they were given opportunities to use a language of choice in communication and staff and the nursing home demonstrated culturally competent care for them. In addition, ethno-specific nursing homes showed more recourse to support residents to maintain meaningful relationships with peers and others.

CONCLUSIONS

Culturally competent care created by staff, nursing homes and the aged care system is a basic condition for residents from ethnic minority groups to fulfil self-determination. In addition, person-centred care approach enables residents to optimise self-determination.

Resident and informal caregiver involvement in medication-related decision-making and the medicines' pathway in nursing homes: experiences and perceived opportunities of healthcare professionals

BACKGROUND

Person-centered care has been shown to be beneficial for nursing home residents. The know-how and attitude of healthcare professionals, however, can make its implementation difficult. Also, research on person-centered care with regard to medication decision-making and the medicines' pathway in nursing homes is lacking. This study aimed to provide an understanding of healthcare professionals' attitudes and perspectives on current resident and informal caregiver involvement in medication decision-making and the medicines' pathway in nursing homes.

METHODS

A qualitative, explorative study using semi-structured interviews with a sample of 25 healthcare professionals from four different nursing homes was performed. Interview transcripts were analyzed by means of an inductive thematic framework.

RESULTS

Three overarching domains were identified: 1) features of, 2) drivers and barriers for, and 3) perceived consequences of resident and informal caregiver involvement in medication decision-making and the medicines' pathway. Involvement was mainly initiated by residents and informal caregivers themselves, pointing towards information and participation needs among both groups. Nevertheless, actions of healthcare professionals towards resident and informal caregiver involvement were mainly reactive and fragmentary. Their actions were influenced by the perception of residents and informal caregivers' desire and capabilities to be involved, the perception of their own professional role, but also by organizational factors such as the nursing home's philosophy. Furthermore, organizational concerns tempered the motivation to provide residents and informal caregivers with more medication-related responsibilities.

CONCLUSIONS

Resident and informal caregiver involvement in medication decision-making and the medicines' pathway remains limited in nursing homes. Information and participation needs of residents and informal caregivers were not fully acknowledged by healthcare professionals. As such, we can conclude that there is a need for initiatives, both on an individual and on an organizational level, to create and improve awareness on opportunities to improve resident and informal caregiver involvement in medication decision-making and the medicines' pathway.

Latent profile analysis of self-perceptions of ageing among Chinese community-dwelling older adults

BACKGROUND

Self-perceptions of ageing (SPA) is an important predictor for physical and mental health of older adults in successful ageing. SPA is mainly studied from negative or positive perspectives using variable-centred methodologies. The aim of the current study was to explore distinct profiles of SPA among Chinese community-dwelling older adults using a person-centred method and validate the SPA profiles by examining associations with psychological outcomes.

METHODS

Participants aged 65 and over were randomly divided into test and validation samples (n = 451, respectively). SPA was measured by the Brief Ageing Perceptions Questionnaire using latent profile analysis.

RESULTS

Three SPA profiles were identified. One adaptive subgroup was designated as 'Low ageing awareness and high positive control' (LAPC, 84.7% and 75% in both samples, respectively). Two maladaptive SPA subgroups were designated as 'Low positive consequences and control' (LPCC, 3.9% and 8.2% in both samples, respectively), and 'High ageing awareness and negative control' (HANC, 11.4% and 16.8% in both samples, respectively). Similar to negative/positive SPA, the HANC and LAPC subgroups showed the highest and lowest levels of depressive symptoms and cognitive decline. Low cognitive function was found in the LPCC subgroup.

CONCLUSIONS

These findings highlight the heterogeneity of older adults' SPA. SPA profiles may aid community healthcare providers in China to identify individuals with high risk of maladaptive SPA and to tailor targeted interventions for psychological health in later life. Distinct SPA profiles require different interventions targeting negative or positive control or both aspects. More positive control strategies might be beneficial for cognitive functioning in older adults from the LPCC subgroup.

Analysis of Transition of Patients with Parkinson's Disease into Institutional Care: A Retrospective Pilot Study

Parkinson's disease (PD) is a neurodegenerative disease which gives a person a high risk of becoming care-dependent. During disease progression, the amount of care concerning activities of daily living can increase, possibly resulting in transition of the people with Parkinson's disease (PwP) to a care facility. However, there is a lack of knowledge concerning the factors leading to institutionalization of PwP and the consequences for them and their informal caregivers. The aim of this cross-sectional retrospective study was to investigate reasons leading to the transition into an institutional care facility, the process of decision-making and its effects on PwP symptoms and caregiver burden. Participating PwP had to be institutionalized for at most one year after transition at study inclusion. Participants completed a range of semiquantitative questionnaires as well as the caregiving tasks questionnaire. Fourteen patient-caregiver pairs were included. PwP suffered from late-stage PD symptoms with high dependence on help, experiencing several hospitalizations before transition. Analyses revealed a significant decrease in caregiver burden and depressive symptoms of the caregivers after PwP institutionalization. Factors influencing the transition were, e.g., fear of PwP health issues and concerns about caregivers' health. This study presents new insights into the process of institutionalization and its influence on caregiver burden, including aspects for discussions of physicians with PwP and their caregivers for counselling the decision to move to institutional care.

Older people's perceived autonomy in residential care: An integrative review

Autonomy has been recognised as a key principle in healthcare, but we still need to develop a consistent understanding of older people's perceived autonomy in residential care. This study aimed to identify, describe and synthesise previous studies on the perceived autonomy of older people in residential care. Ethical approval was not required, as this was a review of published literature. We carried out an integrative review to synthesise previous knowledge published in peer-review journals in English up to September 2019. Electronic and manual searches were conducted using the CINAHL, Philosopher's Index, PubMed, SocINDEX, Scopus and Web of Science databases. The data were analysed using the constant comparison method. The review identified 46 studies. Perceived autonomy referred to the opportunities that older people had to make their own choices about their daily life in residential care, and achieving autonomy promoted both health and quality of life. Autonomy was linked to older people's individual capacities, including their level of independence, physical and mental competence, personal characteristics, and whether relatives shared and supported their perceived autonomy. Professionals could facilitate or hinder older peoples' autonomy in a number of ways, including providing opportunities for autonomy, how daily care needs and activities were managed, and controlling older people's choices. Professionals' characteristics, such as education and attitudes, and the older people's living environments were also associated with their perceived autonomy and included organisational characteristics and physical and social care facilitators. Older people's perceived autonomy promoted health and quality of life in residential care. However, their autonomy was associated with a number of protective and restrictive individual and environmental factors, which influenced whether autonomy was achieved.

[Factors associated with personal autonomy among the elderly: a systematic review of the literature]

The scope of this article is to identify factors associated with personal autonomy among the elderly. It is a systematic review of analytical epidemiological studies selected from the PubMed, Web of Science, Scopus and Lilacs databases, without time and language constraints. The search located 3,435 articles and selection was conducted in two phases: reading of abstracts and entire articles, with inclusion and exclusion criteria, by two independent reviewers, resulting in seven selected studies. The risk of bias was assessed using the Newcastle-Ottawa Scale protocol. All studies included were of sectional design and analyzed autonomy from the perspective of the perception of increased autonomy. The instruments used were the Hertz Perceived Entity of Autonomy Scale and the Chinese version of Perceived Enactment of Autonomy Scale. The factors associated with the autonomy of the elderly identified were grouped by functionality, family relations, interpersonal relations, life perception, satisfaction with health services, demographic factors, schooling, general health status and quality of life. The study of personal autonomy among the elderly presented a multifactorial and biopsychosocial character, although it is a recent theme in which further research with more detailed scientific evidence is necessary.

Perspectives on Care for Late-Stage Parkinson's Disease

In the late stage of Parkinson's disease (PD), there is an increasing disease burden not only for the patients but also for their informal caregivers and the health and social services systems. The aim of this study was to explore experiences of late-stage PD patients' and their informal caregivers' satisfaction with care and support, in order to better understand how they perceive the treatment and care they receive. This qualitative substudy was part of the longitudinal European multicentre Care of Late Stage Parkinsonism (CLaSP) project. Individual semistructured interviews were conducted with patients (n = 11) and informal caregivers (n = 9) in Sweden. Data were analysed through the content analysis technique. The final analyses generated one main category: "We are trying to get by both with and without the formal care" and five subcategories: "Availability of health care is important for managing symptoms and everyday life"; "Dependence on others and scheduled days form everyday life"; "There is a wish to get adequate help when it is needed"; "Mixed feelings on future housing and respite care"; and "Family responsibility and loyalty for a functioning everyday life". Having regular contact with PD-specialised health care was perceived as important. Greater access to physiotherapy was wished for. Maintaining autonomy was perceived as important by patients, in both home health care and a future residential care setting. Responsibility and loyalty between spouses and support from children enabled everyday life to carry on at home, indicating a vulnerability for those without an informal caregiver. The results suggest that regular access to PD-specialised health care is important and that a specialised and multidisciplinary approach to the management of PD symptomatology is likely necessary. Non-PD-specialised staff in home health care and residential care facilities should regularly be given opportunities to obtain PD-specific education and information.

The effectiveness of the Program to Enhance Adjustment to Residential Living (PEARL) in reducing depression in newly admitted nursing home residents

BACKGROUND

Depression is common in nursing homes, particularly among newly admitted residents. This cluster randomised controlled trial evaluated the effectiveness of the Program to Enhance Adjustment to Residential Living (PEARL) in reducing depression in this group.

METHODS

Participants were 219 newly-admitted residents (mean of 4.4 weeks since admission) in 42 nursing homes in Melbourne, Australia, with a mean age of 85.5 years (SD = 7.3). Nursing homes were randomly allocated to the intervention or standard care condition. Level of depressive symptoms was evaluated at baseline (T1), one week post- intervention (T2), 2 months post-intervention (T3, primary end point), and 6 months post-intervention (T4). Changes in depressive symptoms in the intervention and control groups over time were compared using a multilevel model, with nursing homes modelled as random intercept.

RESULTS

In intention to treat analyses, depressive symptoms reduced from T1 to T3 to a greater degree in the intervention condition (M_change=2.56, SD_change=5.71) than in the control (M_change=0.63, SD_change=5.25), with a significant, small-medium treatment effect size (p=.035; Cohen's d=0.36). The reduction in depressive symptoms from T1 to T4 was not significant (p=.369; Cohen's d=0.32).

LIMITATIONS

The findings require replication, particularly comparing PEARL with an active control condition.

CONCLUSIONS

PEARL is a simple, brief program that was effective in reducing symptoms of depression in newly admitted nursing home residents.

Reframing Holistic Patient Care in Nursing Homes Through the Lens of Relational Autonomy

In nursing facilities, patient autonomy is more effective when it is reframed under the rubric of relational autonomy. Through this lens, patients, family, and staff, especially nurses, can share conversations that lead to effective decision-making that acknowledges the needs of the whole person within the nexus of the institutional setting.

Activities of daily living, life orientation, and health-related quality of life among older people in nursing homes: a national cross-sectional study in China

PURPOSE

This study aimed to explore the current status of activities of daily living (ADLs), life orientation, and health-related quality of life (HRQoL) among older people in nursing homes and to further examine the mediating role of life orientation in the impact of ADLs on HRQoL.

METHODS

A national cross-sectional study was conducted among older people aged 60 and above in nursing homes by the randomly stratified cluster sampling method. The status of ADLs, life orientation and HRQoL were measured using an ADL scale, a life orientation scale and the SF-12v2 scale, respectively. Multiple linear regression models were used to identify explanatory factors associated with ADLs, life orientation, and HRQoL. The potential mediating role of life orientation in the relationship between ADL and HRQoL was explored by mediation analysis.

RESULTS

The overall prevalence of ADL disability was 52.67%, and 84.37% of older people in nursing homes had a negative life orientation. The mean scores of physical health and mental health among older people in nursing homes were 45.44 ± 6.46 and 42.67 ± 8.48, respectively. Some sociodemographic characteristics were associated with poor physical health and mental health. After adjustments were made for covariates, the life orientation score mediated 13.81% of the total effect of the ADL score on physical component score of HRQoL and mediated 45.33% of the mental component score of HRQoL.

CONCLUSION

A sizeable proportion of older people had ADL disability and negative life orientation, and HRQoL was poor among older Chinese people in nursing homes. Life orientation partially mediates the relationship between ADLs and HRQoL.

Hearing and Cognitive Impairments Increase the Risk of Long-term Care Admissions

Background and Objectives

The objective of the study was to understand how sensory impairments, alone or in combination with cognitive impairment (CI), relate to long-term care (LTC) admissions.

Research Design and Methods

This retrospective cohort study used existing information from two interRAI assessments; the Resident Assessment Instrument for Home Care (RAI-HC) and the Minimum Data Set 2.0 (MDS 2.0), which were linked at the individual level for 371,696 unique individuals aged 65+ years. The exposure variables of interest included hearing impairment (HI), vision impairment (VI) and dual sensory impairment (DSI) ascertained at participants' most recent RAI-HC assessment. The main outcome was admission to LTC. Survival analysis, using Cox proportional hazards regression models and Kaplan-Meier curves, was used to identify risk factors associated with LTC admissions. Observations were censored if they remained in home care, died or were discharged somewhere other than to LTC.

Results

In this sample, 12.7% of clients were admitted to LTC, with a mean time to admission of 49.6 months (SE = 0.20). The main risk factor for LTC admission was a diagnosis of Alzheimer's dementia (HR = 1.87; CI: 1.83, 1.90). A significant interaction between HI and CI was found, whereby individuals with HI but no CI had a slightly faster time to admission (40.5 months; HR = 1.14) versus clients with both HI and CI (44.9 months; HR = 2.11).

Discussion and Implications

Although CI increases the risk of LTC admission, HI is also important, making it is imperative to continue to screen for sensory issues among older home care clients.

Initiation of advance care planning in newly admitted nursing home residents in Flanders, Belgium: A prospective cohort study

AIM

To describe (i) the timing of initiation of advance care planning (ACP) after nursing home admission; (ii) the association of dementia and physical health with ACP initiation; and (iii) if and how analgesic use and use of lipid modifying agents is related to ACP, in a cohort of newly admitted residents.

METHODS

A prospective, observational cohort study of nursing home residents was carried out. Data were collected 3 months, 15 months (year 1) and 27 months (year 2) after admission, using a structured questionnaire and validated measuring tools.

RESULTS

ACP was never initiated during the 2-year stay for 38% of the residents, for 22% ACP was initiated at admission, for 21% during year 1 and for 19% during year 2 (n = 323). ACP initiation was strongly associated with dementia, but not with physical health. Residents without dementia were more likely to have ACP initiation at admission or not at all, whereas ACP initiation was postponed for residents with dementia. Between admission and year 2, analgesic use increased (from 34% to 42%), and the use of lipid-modifying agents decreased (from 28% to 21%). Analgesic use increased more in residents with ACP initiation during year 1 and year 2. The use of lipid-modifying agents was not associated with ACP.

CONCLUSIONS

The timing of ACP initiation differed significantly for residents with and without dementia, which highlights the importance of an early onset of ACP before residents lose their decision-making capacity. ACP conversations might create opportunities to discuss adequate pain and other symptom treatment, and deprescribing at the end of life. Geriatr Gerontol Int 2019; 19: 141-146.

Medication use in a cohort of newly admitted nursing home residents (Ageing@NH) in relation to evolving physical and mental health

BACKGROUND

Medication use is high among nursing home (NH) residents, but there is a lack of longitudinal studies, determining medication use at admission and its evolution over time.

AIM

Describing the evolution of the medication use two years after entering a NH, compared to the baseline observations and exploring the relation to the physical and mental health.

METHODS

Data from the observational prospective Ageing@NH study, based on an inception cohort of newly admitted residents at NHs (65+) was used, selecting those consenting and with medication chart available. Information about socio-demographic, functional and mental characteristics, as well as medication use, was collected at baseline, year 1 and year 2.

RESULTS

Medication chart was available for n = 741 at baseline (mean age 83.8, 66% female), and for n = 342 residents in year 2. The mean number of total medications increased from 8.9 to 10.1 (p-value < 0.001). Polypharmacy was high, with an increase in extreme polypharmacy from 23% to 32%. The biggest increase was noted in the respiratory (from 17% to 27%) and alimentary medications (from 80% to 87%). Cardiovascular medication use in year 2, was lower in those with stable high dependency (77%) and those evolving from low to high dependency (79%), than those with stable low dependency (89%) (p < 0.025). For residents with or evolving to dementia symptoms, decline in most medication groups was observed, especially in pain and sleeping medications, while antipsychotics use increased.

CONCLUSION

Although medication use was high, signs of deprescribing were noted when the physical and mental health of the residents declined.