Cognitive Impairment and Quality-of-Life

Cognitive impairment and reduced quality of life among old-age groups in Southern Urban India: home-based community residents, free and paid old-age home residents

AIM

The purpose of the study were (i) to screen for cognitive impairment using Mini-Mental Status Examination among three old-age groups based on dwelling types in Chennai, India i.e. residential paid old-age homes, residential free (charitable) homes and home-based community-dwelling residents; (ii) secondly to investigate factors (demographic, psychological, medical and disability) associated with cognitive impairment in the these old-age; (iii) third, to investigate the independent association between cognitive impairment and health-related quality of life (QOL) among elderly across aged care dwelling types.

METHODS

A total of 499 elderly from three old-age groups were interviewed in this cross-sectional study (173 elderly home-based community-dwellers, 176 paid-home and 150 free-home residents). All the participants were interviewed for their socio-economic condition, medical morbidity, self-reported worry and anxiety, disability and QOL.

RESULTS

42.7% free-home elderly residents were found to have cognitive impairment, whereas 32.4% of paid-home and 21.9% of community-dwelling elderly had cognitive impairment. The residents of free-home were less educated, had lower income and reported higher incidence of worry, anxiety, disability and poor QOL than community-dwelling or paid-home residents. Increasing age, low education, female gender, high blood pressure and disability were associated with cognitive impairment. Cognitive impairment had significant negative effect on their health-related QOL (b = -0.10, P = 0.01), independent of age, gender, education, chronic illness and dwelling type.

CONCLUSION

The burden of cognitive impairment was high in all aged-care dwelling types in urban India; with free charitable home residents being worse affected. Cognitive impairment was associated with disability and poor health-related QOL in these age-care settings.

A life history intervention for individuals with dementia: a randomised controlled trial examining nursing staff empathy, perceived patient personhood and aggressive behaviours

Behaviours of concern (e.g.aggression) are often present in residents of long-term care (LTC) facilities diagnosed with dementia and may impact quality of life. Prior uncontrolled research has shown that an intervention involving sharing resident life histories may be effective in reducing aggressive behaviours and improving quality of life, perhaps by increasing staff empathy. We used a randomised controlled design, involving a considerably larger sample than previous investigations. We also examined staff perceptions of LTC resident personhood in relation to aggressive behaviour. Seventy-three residents were randomised to either a life history intervention (N = 38) or a control condition (N = 35). Ninety-nine nurses and care aides answered questionnaires about their own attitudes and the residents' behaviours and quality of life at baseline, post-intervention and at follow-up. Results of mixed-effects modelling indicated significant differences between groups in personhood perception and resident quality of life. Personhood perception mediated the relationship between the intervention and improved quality of life. We identified significant negative correlations between resident cognitive impairment and staff perceptions of resident personhood. Qualitative findings suggested that staff primarily changed their verbal interactions with residents following the intervention, which may be particularly helpful for residents with the most severe dementia. Our results indicate that LTC residents benefit when life histories are constructed with their families and shared with nursing staff.

Effect of nursing home characteristics on residents' quality of life: a systematic review

The association between nursing home (NH) characteristics and residents' quality of life (QOL) has not been systematically reviewed. This study synthesizes published evidence about the association between NH ownership, affiliation, location, chain membership, percentage of private rooms, facility size, and staffing with residents' QOL. We searched Medline, Web of Science, CINAHL, and Scirus for primary studies published between 1960 and March 31, 2012. We critically appraised risk of bias according to study design, QOL measurements, and adjustment for residents' characteristics. We analyzed the statistical and clinical significance, direction and magnitude of the association. From 1117 citations retrieved, we found one longitudinal quasi-experimental and 10 cross-sectional eligible studies. Variability in the NH characteristics reported and QOL measurements precluded meta-analysis. Studies with low and medium risk of bias (ROB) suggested that nonprofit NHs resulted in better QOL for residents. The low ROB study indicated that in certain QOL domains, rural facilities and facilities with a higher percentage of private rooms were associated with better self-reported resident QOL. All low and medium ROB studies found that RN, LVN/LPN and total nursing staff had no significant relationship with QOL. One longitudinal quasi-experimental study indicated that the Green House with individualized care had better QOL than conventional NHs. The available evidence does not permit strong conclusions about the association between NH characteristics and residents' QOL. The evidence does, however, raise questions about whether NH structure alone can improve residents' QOL and how residents' QOL should be measured and improved.

Certified nursing assistants' perspectives of nursing home residents' pain experience: communication patterns, cultural context, and the role of empathy

This study explored the following issues related to pain management among nursing home (NH) residents: 1) communication patterns between NH residents and certified nursing assistants (CNAs) about pain; 2) how race and ethnicity influence NH residents' pain experiences; and 3) CNAs' personal experiences with pain that may affect their empathy toward the resident's pain experience. The study consisted of a convenience sample of four focus groups (n = 28) from a NH in central Florida. A content analysis approach was used. Data were analyzed with the use of Atlas.ti version 6.2. The content analysis identified four main themes: 1) attitudes as barriers to communication about resident pain care; 2) cultural, religious, and gender influences of resident pain care by CNAs; 3) the role of empathy in CNAs care of residents with pain; and 4) worker strategies to detect pain. Attitudes among CNAs about resident cognitive status and perceived resident burden need to be recognized as barriers to the detection and reporting of pain by CNAs and should be addressed. In addition, NHs should consider a person-centered approach to pain that is culturally competent given the cultural influences of both residents and staff. Finally, educational programs for CNAs that include empathy-inducing scenarios could potentially improve the care provided by CNAs when dealing with residents' pain.

Quality of life at the end of life for nursing home residents: perceptions of hospice and nursing home staff members

This study examined whether the perceptions of nursing staff members about the importance of quality-of-life domains and their perceived ability to influence those domains for residents at the end of life were affected by their institutional affiliation, level of training, or residents' cognitive status. Respondents were 146 Certified Nursing Assistants (CNAs) and Registered Nurses (RNs) from nursing homes and hospices. Magnitude estimation scales were used to rate the importance of and perceived ability to influence 11 quality-of-life domains for both cognitively intact and cognitively impaired residents. Overall, respondents' scores indicated a high level of importance of all quality-of-life domains and similarly positive perceptions that they could influence quality-of-life domains for hypothetical nursing home residents. Analysis of variance revealed that respondents reported lower average importance and ability to influence ratings when considering residents with cognitive impairment. Respondents affiliated with hospice agencies also reported lower average importance and ability to influence ratings on some domains, although the high ratings overall limit the clinical significance of these differences. Importance ratings were not affected by the level of education, but CNAs reported higher perceived ability to influence ratings on four domains than did RNs. Future studies should explore whether the domains measured adequately capture the end-of-life experience in nursing homes.

The effect of cholinesterase inhibitors on risk of nursing home placement among medicaid beneficiaries with dementia

The purpose of this study was to explore the effect of therapy with cholinesterase inhibitors (ChE-Is) on the risk of nursing home (NH) placement in patients with dementia. Participants were enrolled in the Florida Medicaid program during the fiscal year 1998 to 1999 (N=1188). Of these, 378 had Alzheimer disease as their only dementia diagnosis. About 50% of the sample received ChE-Is. The total follow-up period was 36 months. We used Cox proportional hazard regressions to estimate the risk of NH placement. After adjusting for age, sex, race, and cooccurring diagnoses, we found that dementia patients receiving ChE-Is had reduced risk of NH placement by 28% at 12 months [hazard ratio (HR)=0.72, 95% confidence interval (CI) 0.55-0.94] and 21% at 18 months (HR=0.79, 95% CI 0.62-0.99). The reduction in risk was more pronounced in patients with Alzheimer disease only and was still significant at 24 months after baseline (HR=0.66, 95% CI 0.43-0.99). At 36 months, the association between taking ChE-Is and risk of NH placement was not significant and the proportion of participants placed in a nursing was almost identical. Therapy with ChE-Is may temporarily reduce the risk of NH placement in Medicaid beneficiaries with dementia, thereby improving quality of life and preserving personal and societal resources.