Trajectories of quality of life and their association with anxiety in people with dementia in nursing homes: A 12-month follow-up study

Understanding the Barriers to and Facilitators of Anxiety Management in Residents of Long-Term Care

Older adults, 65 years of age and older, living in long-term care (LTC) commonly experience anxiety. This study aimed to understand care providers' perspectives on the barriers to and facilitators of managing anxiety in residents of LTC. Ten semi-structured interviews with care providers in LTC were completed. Framework analysis methods were used to code, thematically analyze, designate codes as barriers or facilitators, and map the codes to the Theoretical Domains Framework. Themes were categorized as acting at the resident, provider, or system level, and were labelled as either barriers to or facilitators of anxiety care. Key barriers to anxiety care at each level were resident cognitive impairment or co-morbidities; lack of staff education, staff treatment uptake and implementation; as well as the care delivery environment and access to resources. There is a need to prioritize measurement-based care for anxiety, have increased access to non-pharmacological treatments, and have a care delivery environment that supports anxiety management to improve the care for anxiety that is delivered to residents.

Influence of caregivers' psychological well-being on the anxiety and depression of care recipients with dementia

This study was conducted to examine how caregivers' psychological well-being influences the anxiety or depression of care recipients with dementia. A secondary data analysis was conducted using 666 dyads of older adults with dementia and their caregivers. The odds that care recipients with dementia would experience anxiety increased when caregivers had a negative relationship with care recipients (OR = 1.22, p = 0.042), lower perception of the positive aspects of caregiving (OR = 0.86, p = 0.047), or anxiety (OR = 2.41, p = 0.036). The odds that care recipients with dementia would experience depression increased when caregivers had a greater perception of the negative aspects of caregiving (OR = 1.15, p = 0.023) or anxiety (OR = 2.21, p = 0.045). Since care recipients with dementia and their caregivers spend considerable time together daily, caregivers' psychological well-being can impact care recipients' anxiety and depression.

Pain and quality of life in nursing home residents with dementia after admission - a longitudinal study

BACKGROUND

Pain in nursing home (NH) residents with dementia is commonly reported and may affect Quality of Life (QoL) negatively. Few longitudinal studies have explored how pain and QoL develop in NH residents with dementia starting from their admission to the NH.

AIM

The aim was to explore pain, QoL, and the association between pain and QoL over time in persons with dementia admitted to a NH.

METHODS

A convenience sample, drawn from 68 non-profit NHs, included a total of 996 Norwegian NH residents with dementia (mean age 84.5 years, SD 7.6, 36.1% men) at NH admission (A1), with annual follow-ups for two years (A2 and A3). Pain and QoL were assessed using the Mobilization-Observation-Behavior-Intensity-Dementia-2 (MOBID-2) Pain Scale and the Quality of Life in Late-Stage Dementia (QUALID) scale, respectively, at all assessments. Severity of dementia, personal level of activities of daily living, general medical health, neuropsychiatric symptoms, and the prescription of psychotropic drugs and analgesics (opioids and/or paracetamol) were also assessed at all assessments.

RESULTS

Mean (SD) MOBID-2 pain intensity scores were 2.1 (2.1), 2.2 (2.2), and 2.4 (2.1) at A1, A2, and A3, respectively. Participants who were prescribed analgesics had higher pain intensity scores at all assessments than participants not prescribed analgesics. The mean (SD) QUALID scores at each assessment were 19.8 (7.1), 20.8 (7.2), and 22.1 (7.5) at A1, A2, and A3, respectively. In the adjusted linear mixed model, higher pain intensity score, prescription of opioids, and prescription of paracetamol were associated with poorer QoL (higher QUALID total score and higher scores in the QoL dimensions of sadness and tension) when assessed simultaneously. No time trend in QoL was found in these adjusted analyses.

CONCLUSION

NH residents with dementia who have higher pain intensity scores or are prescribed analgesics are more likely to have poorer QoL. Clinicians, NH administrators, and national healthcare authorities need to look into strategies and actions for pharmacological and non-pharmacological pain treatment to reduce pain intensity while simultaneously avoiding negative side effects of pain treatment that hamper QoL.

Prevalence and persistent prescription of analgesic drugs in persons admitted with dementia to a nursing home - A longitudinal study

The overall aim was to explore the prevalence and persistent regular prescription of opioids and paracetamol among nursing home (NH) residents with dementia at admission and over time. A total of 996 residents with dementia, mean (SD) age 84.5 (7.6) years and (36.1% men), were included at admission (A1). Yearly assessments were performed for two years (A2 and A3) or until death. Pain was assessed using the Mobilization-Observation-Behavior-Intensity-Dementia-2 (MOBID-2) Pain Scale. Information regarding prescription of analgesics, general physical health, personal activities of daily living, severity of dementia, neuropsychiatric symptoms, and prescription of psychotropic drugs was collected. A generalized linear mixed model was used to explore whether pain severity was associated with persistent and persistent prescription of opioids and/or paracetamol across timepoints. At A1, 495 of 996 (49.7%) NH residents were prescribed analgesics and prevalence increased at the follow-ups (A2: n = 630, 65.1%; A3: n = 382, 71.2%). Paracetamol was the most frequently prescribed analgesic at all assessments (A1: 45.5%; A2: 59.5%; A3: 67.1%). Opioid prescriptions were quite prevalent (A1: 18.1%; A2: 25.1%; A3: 28.3%), with odds approximately 13 times (OR = 13.3, 95% CI 6.8-26.0) and 9 times (OR = 8.6, 95% CI 3.7-20.3) higher for prescription at follow-up A2 and A3, respectively, relative to prescription at A1. In adjusted analyses, higher pain intensity and poor physical health were associated with prescription and persistent prescription of opioids and paracetamol. In conclusion, prevalence and persistent prescription of analgesics were high in NH residents with dementia. The odds for the prescription of opioids at follow-up were high if prescribed at baseline. Interdisciplinary collaboration, routine assessment of pain at admission and regularly thereafter, and systematic drug reviews are essential to adequately assess and treat pain in NH residents with dementia.

Pain in nursing home residents with dementia and its association to quality of life

OBJECTIVES

We aimed to describe pain, use of analgesics and quality of life (QoL) in people with dementia admitted to a Norwegian nursing home (NH), and to explore if and how pain was associated with their QoL when adjusting for sociodemographic characteristics, other health conditions and use of analgesics.

METHOD

A total of 953 Norwegian NH residents with dementia (mean age 84.0, SD 7.5 years, 35.8% men) were included at admission to the NH. Pain and QoL were assessed using the Mobilization-Observation-Behavior-Intensity-Dementia-2 (MOBID-2) Pain Scale and the Quality of Life in Late-Stage Dementia (QUALID) scale, respectively. Severity of dementia, personal level of activities of daily living, general medical health, neuropsychiatric symptoms, and the use of psychotropic drugs and analgesics were assessed.

RESULTS

In total, 36% of the participants had clinically relevant pain intensity (MOBID-2 ≥ 3) and 52% received analgesics. Paracetamol was most frequently prescribed (45%). In an adjusted linear mixed model, more severe pain was associated with higher QUALID total scores, indicating poorer QoL (regression coefficient 0.52, 95% CI 0.36-0.69).

CONCLUSION

Pain prevalence at NH admission was high in residents with dementia; half used analgesics, particularly paracetamol. More severe pain was associated with poorer QoL when adjusting for sociodemographic characteristics, other health conditions, and use of analgesics. The routine assessment of pain at NH admission can uncover undiagnosed and untreated pain and allow for adequate non-pharmacological and pharmacological pain management and likely increased QoL.

Evaluation of the Reliability and Validity of the Alzheimer's Disease-Related Quality of Life Instrument among Older Adults with Cognitive Impairment in Mainland China

The purpose of this study is to examine the reliability and validity of the ADRQL instrument among older adults with cognitive impairment in mainland China. Three hundred older adults with cognitive impairment and their primary family caregivers from Wuhan participated in structured interviews. Cronbach's α and Kuder-Richardson Formula 20 were used to examine internal consistency reliability. Confirmatory factor analysis, Heterotrait-Monotrait ratios, and ordinary least square regression were used to assess the factorial validity, discriminant validity, and criterion validity. The ADRQL had acceptable reliability and validity, which can be used to assess overall quality of life for this population.

The relationship between social isolation and anxiety in people with cognitive impairment in the United States

OBJECTIVES

Social isolation among older adults with cognitive impairment is understudied. The purpose of this study is to examine the relationship between social isolation and anxiety in people with cognitive impairment in the United States.

METHODS/DESIGN

Secondary data analyses were conducted using the National Social Life, Health, and Aging Project (NSHAP) Wave 2 (2010-2011) dataset which includes a nationally representative sample of American older adults living at home. A total of 1343 people who had probable cognitive impairment measured by a Montreal Cognitive Assessment (MoCA) score of 22 or less were selected. Anxiety was measured using the anxiety measure of Hospital Anxiety and Depression Scale (HADS-A) and social isolation was measured using Perceived Social Isolation Scale. A weighted multivariable linear regression analysis and weighted F tests were used to examine the relationship between social isolation and anxiety.

RESULTS

We observed that greater social isolation was related to increased anxiety in people with cognitive impairment (coefficients = 0.7242, t = 2.51, p = 0.015), adjusting for severity of cognitive impairment, race, pain, depression, activities of daily living, and instrumental activities of daily living. Weighted F tests showed that persons with clinically significant anxiety (HADS-A ≥ 8) had higher levels of loneliness, including feeling a lack of companionship, feeling left out, and greater social isolation.

CONCLUSIONS

The results of our study suggest that people with cognitive impairment can feel social isolation and it may contribute to their anxiety. Health care professionals, family, and friends of people with cognitive impairment should pay greater attention to social isolation of their loved ones.

Quality of Life Assessment in Older Adults with Dementia: A Systematic Review

INTRODUCTION

In the absence of a cure, dementia is often managed by minimizing risk factors contributing to quality of life (QOL). Attitudes to dementia in older adults may differ from those in relatively younger adults. The aim was to conduct a systematic review of the literature to determine how QOL was assessed in adults, 65 years and older with dementia, and identify factors that influence the reported scores.

METHODS

A systematic review of full-text articles addressing QOL in older adults with dementia, published in English from January 1995 to September 2020, was conducted using PubMed and PsycINFO. We included studies that assessed QOL and involved participants 65 years and older. Studies were evaluated for inclusion by 2 independent pairs of reviewers. We assessed the quality of the studies using the Joanna Briggs Institute's Critical Appraisal Checklist. Study characteristics and findings were summarized. Analysis was by narrative synthesis. We identified social and clinical factors influencing QOL scores.

RESULTS

Of the 1,010 articles identified, 19 met the inclusion criteria. These 19 studies involved 6,279 persons with dementia, with sample sizes from 32 to 1,366. Mean age of participants ranged from 77.1 to 86.6 years. Five measurement tools were identified; Quality of Life in Alzheimer Disease (QOL-AD), Alzheimer Disease-Related Quality of Life (ADRQL), Quality of Life in Late-Stage Dementia (QUALID), QUALIDEM (a dementia-specific QOL tool), and DEMQOL (health-related QOL for people with dementia). Self-ratings of QOL were higher than proxy ratings. Factors commonly influencing self-ratings of QOL included depression, functional impairment, and polypharmacy. Common factors that influenced proxy ratings included functional impairment, presence of neuropsychiatric symptoms, cognitive impairment, and caregiver burden.

CONCLUSION

In evaluating QOL in dementia, self- and proxy reports may complement each other to ensure that all perspectives are addressed.

Care home residents’ quality of life and its association with CQC ratings and workforce issues: the MiCareHQ mixed-methods study

Background

Care home staff have a critical bearing on quality. The staff employed, the training they receive and how well they identify and manage residents’ needs are likely to influence outcomes. The Care Act 2014 (Great Britain. The Care Act 2014. London: The Stationery Office; 2014) requires services to improve ‘well-being’, but many residents cannot self-report and are at risk of exclusion from giving their views. The Adult Social Care Outcomes Toolkit enables social care-related quality of life to be measured using a mixed-methods approach. There is currently no equivalent way of measuring aspects of residents’ health-related quality of life. We developed new tools for measuring pain, anxiety and depression using a mixed-methods approach. We also explored the relationship between care home quality, residents’ outcomes, and the skill mix and employment conditions of the workforce who support them.

Objectives

The objectives were to develop and test measures of pain, anxiety and depression for residents unable to self-report; to assess the extent to which regulator quality ratings reflect residents’ care-related quality of life; and to assess the relationship between aspects of the staffing of care homes and the quality of care homes.

Design

This was a mixed-methods study.

Setting

The setting was care homes for older adults in England.

Participants

Care home residents participated.

Results

Three measures of pain, anxiety and low mood were developed and tested, using a mixed-methods approach, with 182 care home residents in 20 care homes (nursing and residential). Psychometric testing found that the measures had good construct validity. The mixed-methods approach was both feasible and necessary with this population, as the majority of residents could not self-report. Using a combined data set (n = 475 residents in 54 homes) from this study and the Measuring Outcomes in Care Homes study (Towers AM, Palmer S, Smith N, Collins G, Allan S. A cross-sectional study exploring the relationship between regulator quality ratings and care home residents’ quality of life in England. Health Qual Life Outcomes 2019;17:22) we found a significant positive association between residents’ social care-related quality of life and regulator (i.e. Care Quality Commission) quality ratings. Multivariate regression revealed that homes rated ‘good/outstanding’ are associated with a 12% improvement in mean current social care-related quality of life among residents who have higher levels of dependency. Secondary data analysis of a large, national sample of care homes over time assessed the impact of staffing and employment conditions on Care Quality Commission quality ratings. Higher wages and a higher prevalence of training in both dementia and dignity-/person-centred care were positively associated with care quality, whereas high staff turnover and job vacancy rates had a significant negative association. A 10% increase in the average care worker wage increased the likelihood of a ‘good/outstanding’ rating by 7%.

Limitations

No care homes rated as inadequate were recruited to the study.

Conclusions

The most dependent residents gain the most from homes rated ‘good/outstanding’. However, measuring the needs and outcomes of these residents is challenging, as many cannot self-report. A mixed-methods approach can reduce methodological exclusion and an over-reliance on proxies. Improving working conditions and reducing staff turnover may be associated with better outcomes for residents.

Future work

Further work is required to explore the relationship between pain, anxiety and low mood and other indicators of care homes quality and to examine the relationship between wages, training and social care outcomes.

Funding

This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 9, No. 19. See the NIHR Journals Library website for further project information.

Impact of Disturbed Rest-activity Rhythms on Activities of Daily Living in Moderate and Severe Dementia Patients

PURPOSE

People with dementia exhibit disturbed rest-activity rhythms and extended sleep duration issues throughout their disease. Little is known about the effects of these issues on clinical problems for those with moderate and severe dementia. This cross-sectional study aimed to examine the associations of disturbed rest-activity rhythms and extended sleep duration with activities of daily living (ADL).

METHODS

Sleep parameters were measured using an actigraphy device. Cognitive function was assessed using the Mini-Mental State Examination and Cognitive Test for Severe Dementia, the Hyogo Activities of Daily Living Scale was used to assess ADL, and behavioral and psychological symptoms of dementia were assessed using the Neuropsychiatric Inventory-Nursing Home scale. Associations among rest-activity rhythms, sleep duration, and other clinical variables were analyzed with multiple linear regression. Clinical variables were compared between 2 groups categorized by onset timing of rest peak.

PATIENTS

Sixty-four participants with moderate and severe dementia were assessed.

RESULTS

In the correlation analysis, unstable daily rest-activity rhythm was associated with lower ADL. In the multiple linear regression analysis, low intradaily variability, and long daytime sleep duration were associated with low ADL. Aberrant rest peak timing showed lower ADL compared with nonaberrant timing.

CONCLUSIONS

Abnormal rest-activity rhythm and sleep duration in persons with moderate and severe dementia may affect ADL.

The Course of Quality of Life and Its Predictors in Nursing Home Residents With Young-Onset Dementia

OBJECTIVE

To explore the course of quality of life (QoL) and possible resident-related predictors associated with this course in institutionalized people with young-onset dementia (YOD).

DESIGN

An observational longitudinal study.

SETTING AND PARTICIPANTS

A total of 278 residents with YOD were recruited from 13 YOD special care units in the Netherlands.

METHODS

Secondary analyses were conducted with longitudinal data from the Behavior and Evolution in Young-ONset Dementia (BEYOND)-II study. QoL was assessed with proxy ratings, using the Quality of Life in Dementia (QUALIDEM) questionnaire at 4 assessment points over 18 months. Predictors included age, gender, dementia subtype, length of stay, dementia severity, neuropsychiatric symptoms, and psychotropic drug use at baseline. Multilevel modeling was used to adjust for the correlation of measurements within residents and clustering of residents within nursing homes.

RESULTS

The total QUALIDEM score (range: 0-111) decreased over 18 months with a small change of 0.65 (95% confidence interval -1.27, -0.04) points per 6 months. An increase in several domains of QoL regarding care relationship, positive self-image, and feeling at home was seen over time, whereas a decline was observed in the subscales positive affect, social relations, and having something to do. Residents with higher levels of QoL and more advanced dementia at baseline showed a more progressive decline in QoL over time. Sensitivity analyses indicated a more progressive decline in QoL for residents who died during the follow-up.

CONCLUSION AND IMPLICATIONS

This study shows that although overall QoL in nursing home residents with YOD was relatively stable over 18 months, there were multidirectional changes in the QoL subscales that could be clinically relevant. Higher levels of QoL and more advanced stages of dementia at baseline predicted a more progressive decline in QoL over time. More longitudinal studies are needed to verify factors influencing QoL in YOD.

Modifiable factors associated with anxiety in persons with dementia: An integrative review

OBJECTIVES

The purpose of this integrative review was to examine factors related to the presence of anxiety in person with dementia (PWD) and to identify potentially modifiable factors among them.

METHODS

An integrative review was conducted using PsycINFO, CINAHL, AgeLine, PubMed, Embase, Web of Science, and Scopus. Among 1856 studies identified, 27 studies were included.

RESULTS

A number of modifiable factors associated with anxiety were identified. Individual level factors included pain, physical health, physical functioning, fatigue, sleep disturbance, disclosure of diagnosis, embarrassment about memory problems, separation from caregivers, views about oneself and others, social rejection, social isolation, and interactions with others. Caregiver factors associated with anxiety in PWD included caregiver stress, caregiver's negative reactions towards the behavioral problems of PWD, and competence about caregiving.

CONCLUSION

The results of this review can be used to identify potential targets for interventions to reduce for anxiety in persons with dementia.

Clinical factors associated with activities of daily living and their decline in patients with severe dementia

BACKGROUND

To identify the clinical factors affecting activities of daily living (ADL) at baseline and after 6 months.

METHODS

We conducted a single-centre observational study at two time points across 6 months (baseline and after 6 months) from April 2015 to March 2017. in a 270-bed rural recuperation hospital at Hyogo prefecture in Japan. The total number of participants was 131 (male 33, female 98; mean age: 87.0 ± 7.0; mild and moderate dementia, 38; severe dementia, 93). Measurement scales used were Personal Self-Maintenance Scale (PSMS) for assessing ADL, Mini-Mental State Examination and Cognitive Test in Severe Dementia (CTSD) for cognitive function, Neuropsychiatric Inventory-Nursing Home version and Cornell Scale for Depression in Dementia (CSDD) for behavioural/psychological symptoms of dementia, Mini Nutritional Assessment Short form (MNA-SF) for nutritional status, Pain Assessment in Advanced Dementia for pain, and Charlson comorbidity index (CCI) and the number of illness categories based on Cumulative Illness Rating Scale Geriatrics for comorbidities. Multiple regression analyses identified the association between PSMS score as the dependent variable and other variables as independent variables.

RESULTS

In participants with severe dementia, the PSMS scores at baseline were significantly associated with CTSD, CCI, MNA-SF, and CSDD scores. In the longitudinal analysis, only CTSD score was significantly associated with PSMS score after 6 months. It is noteworthy that for participants with severe dementia, the only factor associated with ADL after 6 months was cognitive function, as assessed by CTSD score.

CONCLUSIONS

The most important factor predicting functional decline is cognitive function, even at the severe and profound stage.

Modelling factors of urinary incontinence in institutional older adults with dementia

AIMS AND OBJECTIVES

This study applied structural equation modelling to explore the relationships among agitated behaviours, depression, cognitive function and activities of daily living, as well as associations between these factors and urinary incontinence).

BACKGROUND

A high prevalence of urinary incontinence is found among institutional older adults with dementia. People with urinary incontinence suffer from increased financial burden and social isolation and experience reduced quality of life.

DESIGN

Cross-sectional correlational research. The study complied with the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement.

METHODS

In total, 226 older adults with dementia were recruited through convenience sampling at 15 long-term care facilities in southern Taiwan. The urinary incontinence frequency, agitated behaviours, depression, cognitive function and activities of daily living were evaluated using bladder records, the Cohen-Mansfield Agitation Inventory, the Cornell Scale for Depression in Dementia, the Mini-Mental State Examination and the Barthel Index, respectively.

RESULTS

Activities of daily living performance was found to be significantly associated with urinary incontinence; however, age, cognitive function, depression and agitated behaviours were not significantly related to urinary incontinence. Age did not have effects on any of the variables tested in this model, whereas activities of daily living performance was significantly associated with cognitive function and depression. Results further showed that cognitive function and depression were mediators between activities of daily living and agitated behaviours.

CONCLUSION

Enhanced activities of daily living independency directly reduced urinary incontinence, improved cognitive function, decreased degrees of depression and indirectly reduced agitated behaviours.

RELEVANCE TO CLINICAL PRACTICE

The findings could serve as a valuable reference for long-term care facilities in providing effective urinary incontinence care and prevention to older adults with dementia.

Impacto dos sintomas de ansiedade na qualidade de vida na doença de Parkinson: uma revisão sistemática

RESUMO Objetivo: Revisar estudos relacionados ao impacto da ansiedade na qualidade de vida em pacientes com doença de Parkinson. Métodos: Trata-se de uma revisão sistemática realizada nos bancos de dados PubMed, Scopus, Web of Science e PsycINFO, com os descritores: “anxiety”, “Parkinson's disease” e “quality of life”. Foram selecionados 20 artigos publicados em inglês e sem limite de tempo. Resultado: A maioria dos estudos demonstrou correlação direta entre ansiedade e qualidade de vida em indivíduos com doença de Parkinson. Apenas dois estudos não encontraram essa associação. A presença de sintomas de ansiedade parece estar relacionada com a gravidade dos sintomas motores, sexo feminino e idade mais jovem, levando a um impacto maior na qualidade de vida. Conclusão: Os artigos analisados mostraram que a ansiedade tem impacto negativo sobre a qualidade de vida de indivíduos com doença de Parkinson.