Abstract
With over 5 to 7 percent of the world’s population between the age of 60 years old and above being diagnosed with dementia, and over 50.4% of this sector from the United States alone end up in nursing homes and care facilities, the need to conduct a study that will review the quality of life of the residents become necessary. Numerous studies were designed to assess the lives of nursing home residents with the hope of finding ways to improve their physical, and psychological condition. With multiple stories of abuse and depressing state of nursing home residents, it became a fascinating subject in the field of both nursing and psychology to find ways that could help significantly improve the quality of life in nursing homes. One of the interventions that were developed pertains to fostering functional activities, or activities of daily life in the nursing home which is to be adopted by the residents. The goal is to understand whether the proposed intervention can help improve the quality of life in these institutions. Critical appraisal of relevant articles on the topic was conducted in this paper to address this inquiry. Based on the reports that were reviewed, it showed that functional activities and similar activities that foster a certain degree of independence on the part of the residents and extending autonomy to them were favorably accepted. Several of the articles reported positive feedback on patient’s psychosocial well-being, which eventually translated to physical boost. While it was challenging to come to a general conclusion on the quality of life, essential aspects that contributed to the quality of life had been evident.
Keywords: nursing home residents, dementia, quality of life, activities of daily life, functional activities, patient autonomy
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Introduction
According to a report published by the Alzheimer’s Association (2007), there is approximately 50 percent of nursing home and assisted living residents to have dementia and other kinds of cognitive impairment like Alzheimer. The report emphasized the recommendation made by Peter Reed, a Senior Director of Programs for the Alzheimer’s Association, which reiterates the need for a person-centered approach to caring for patients with dementia ("Alzheimer’s Association Releases Dementia Care Practice Recommendations for End-of-Life Care," 2007). Reed further that the kind of care that these patients should receive must be tailored to the changing needs and abilities of each resident. With this statement in mind, nursing care facility managers should initiate activities that will promote the quality of life of patients with dementia in nursing homes and assisted living facilities. Over the course of history, numerous studies had been conducted assessing the role that functional activities have in terms of improving the quality of life and promoting vigor among elderly residents with dementia (De Vriendt, Cornelis, Vanbosseghem, Desmet & Van de Velde, 2018; Henskens, Nauta, Drost & Scherder, 2018; Palm et al., 2018). Many of these studies revealed that patients in nursing homes feel useless, unappreciated, and neglected (De Vriendt, Cornelis, Vanbosseghem, Desmet & Van de Velde, 2018; Henskens, Nauta, Drost & Scherder, 2018; Palm et al., 2018; Kuk et al., 2017). For a number of these patients, especially those who have dementia, they were placed in a facility because they become too much of a burden for their families (Henskens, Nauta, Drost & Scherder, 2018). Old age is the most obvious reason why many of the elderlies are placed in nursing care. However, aside from old age, the risk associated with most elderly-related conditions prompt many family members to put their loved ones in a care facility. This does not always translate well to old people. The elderlies see this as a sign of defeat, frustration, and disappointment. Nursing care facilities have the role of changing this negative perception that nursing home residents have to help them foster optimal quality of life. This paper will conduct a critical appraisal of research evidence associated with facilitating functional activities among nursing home residents with dementia to improve the patient’s quality of life. This paper will conduct a systematic review of the literature to accomplish this objective.
Research Question
The growing number of people with dementia has been increasing at an alarming rate. Based on statistics, approximately 5 to 7 percent of individuals from age 60 and above are manifesting signs of dementia ("Dementia: Incidence and Prevalence," 2016). 50.4% of these population in the US alone are permanently placed under the care of nursing homes ("FastStats: Dementia and Mental Health," 2016). The need to ensure the wellbeing of these group is the top priority for any health facilities in charge of their care is a significant concern. The goal of the study is to warrant the effectiveness of using functional activities in improving the quality of life of nursing home residents diagnosed with dementia. The following questions were raised:
In dementia patients presently residing fulltime in a nursing home, will functional activities help improve the quality of life compare to psychosocial interventions like music therapy?
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PICOT Statement |
Rationale |
| P opulation | Dementia patients who are presently residing fulltime in a nursing home or assisted living facility |
| I ntervention | Foster functional activities as part of their treatment plan to help improve the patient’s quality of life. |
| C omparison | Recreation therapy or psychosocial interventions like music therapy because it fosters relaxation |
| O utcome | Significantly improve the patient’s quality of life as manifested by a positive outlook and foster an active lifestyle, as permitted by the nursing home. |
| T ime | Preferably, improves the quality of life for many nursing home patients within the next five months. |
What makes functional activities more effective in improving the quality of life of dementia patients in a nursing home better that any other psychosocial interventions?
Methodology
To facilitate the course of the study, research was done using different databases. These databases include but were not limited to: PUBMED, Cumulative Index of Nursing and Allied Health Literature (CINAHL), and the Agency for Healthcare Research and Quality (AHRQ). The CINAHL database using the keywords: person-centered care, long-term care, provided two articles. 100 % of the reports submitted were appropriate. PUBMED database using the keywords: person-centered care, dementia, functional activities, quality of life, and nursing home provided 30 articles. 10% of the materials provided were appropriate. Other databases were used but were only minimally helpful or not helpful at all. Overall, three relevant articles will be utilized for this critical appraisal review.
All of the articles found were from nursing research. This is most likely because person-centered care is a philosophy started by nurses that took place in a nursing home. Nurses also monitor the quality of life among patients living in an assisted living environment and nursing care facilities. In the future, as more information is obtained about person-centered care, there will be more nursing research that will be accessible for future studies. Locating information on functional activities in nursing homes was challenging to secure because person-centered care is a newer concept.
Not all research is identical. The chance that multiple studies are at a certain level does not imply that it is appropriate for every research project. Melnyk & Fineout-Overholt (2011), developed a list that identifies the different levels of evidence according to the following criteria.:
Level 1- Systematic review & meta-analysis of randomized controlled trials; clinical guidelines based on systematic reviews or meta-analyses
Level 2 - One or more randomized controlled trials
Level 3 - Controlled trial (no randomization)
Level 4 - Case-control or cohort study
Level 5 - Systematic review of descriptive & qualitative studies
Level 6 - Single descriptive or qualitative study
Level 7 - Expert
Evidence Critique Table
Full APA citation for five sources |
Evidence Strength (I-VII) and Evidence Hierarchy |
| De Vriendt, P., Cornelis, E., Vanbosseghem, R., Desmet, V., & Van de Velde, D. (2018). Enabling meaningful activities and quality of life in long-term care facilities: The stepwise development of a participatory client-centered approach in Flanders. British Journal of Occupational Therapy, 030802261877588. doi: 10.1177/0308022618775880 |
Level 1 - Systematic review & meta-analysis of randomized controlled trials |
| Henskens, M., Nauta, I., Drost, K., & Scherder, E. (2018). The effects of movement stimulation on activities of daily living performance and quality of life in nursing home residents with dementia: a randomized controlled trial. Clinical Interventions in Aging, Volume 13, 805-817. doi: 10.2147/cia.s160031 |
Level 2 - Randomized controlled trial |
| Mondaca, M., Josephsson, S., Katz, A., & Rosenberg, L. (2017). Influencing everyday activities in a nursing home setting: A call for ethical and responsive engagement. Nursing Inquiry, 25(2), e12217. doi: 10.1111/nin.12217 |
Level 4 - Cohort study |
Evidence Summary
The first study focused on developing meaningful activities fostered in nursing homes believing that residents who are suffering from dementia will find these activities as productive and lively. According to the authors, a client-centered, activity-oriented approach will be right for patients who are in nursing homes because the patients will find a more significant use of their time instead of being idly spent watching TV and playing board games (De Vriendt, Cornelis, Vanbosseghem, Desmet & Van de Velde, 2018). During this pilot run, a six-step implementation-evaluation plan was initiated. It was done in a long-term care facility that houses elderly patients diagnosed with different medical and psychological needs. The first part was focused on an in-depth interview of 14 residents, which served as a pre-assessment of how their time was spent in the nursing facility. A survey administered to 171 residents followed this. The survey included questions referring to the type of activities they enjoy, and what gives a sense of personal satisfaction. The third leg of the pilot run was a systematic map and review of the intervention, which included identifying activities that would fit the classification of “meaningful activities.” This was followed by a qualitative evaluation of 24-activities that would help support implementation. A pilot run was conducted to assess the effectiveness of the program. While the study did not show that fostering meaningful activities in nursing home improved the quality of life for many of the residents especially those who have dementia, the results were all optimistic and promoted healthy well-being. The authors failed to offer substantial evidence that would document how meaning activities could help improve the patients’ quality of life. However, this failure was rather on the fact that the authors did not have any quantitative and objective tool that can measure the quality of life. The meaningful activities were inclusive of typical day-to-day activities of a normal person who could be at the prime of their lives. Some of these activities involved gardening, performing daily chores like cooking, dishwashing and laundry, monitoring health conditions, and socializing. A lot of these activities provided positive effects like satisfaction over the activity, enhancement of social networks and it even fosters acceptable medical use. Nevertheless, while in theory, meaningful activities can give patients’ a positive outlook and an optimistic view of their worth, the authors failed to offer substantial evaluating tools that could assess this outcome as far as promoting improving in the patients’ quality of life.
In another study initiated by Marinda Henskens and her colleagues (2018), they tried to assess how movement activities are improving the quality of life and ADL performance of dementia patients in nursing homes. The authors suggested that the quality of life began to deteriorate when people start becoming depending on other people for things affecting their daily lives. Based on the analysis, when older people are at a stage when they are no longer active, they feel useless, become irritable, and frustrated. Some goes to the extreme of becoming depress. Dependence for most people, especially those who were previously engaged in an active lifestyle, is a sign of deterioration. This dependence and deterioration reduce the quality of life for dementia patients in nursing facilities. The study was designed to assess how three movement interventions could help improve the quality of life and the ADL performance of dementia residents. To evaluate this, the authors launched a 6-month double parallel randomized control trial. 87 nursing home residents with dementia from a long-term care facility in Netherland were subjected to the procedure that was aimed at establishing the effects of ADL training. Four groups were formed which were given a specific exercise or social activity. These groups were identified as 1) PADL: physical activity and ADL training, 2) SADL: social activity and ADL training, 3) PCO: physical activity and care-as-usual, and 4) SCO: social activity and care-as-usual (Henskens, Nauta, Drost & Scherder, 2018). The fourth group was the control group. Several standardized tests were also applied. For example, the Global Deterioration Scale was used to determine the severity of dementia. The Qualidem, and the Care Dependency Scale and Erlangen ADL were used to assess the level of dependency of the participants. The participants were tested at three given period—baseline, after three months and after six months. Multilevel analyses were adjusted according to baseline performance, age, and gender. The result came back with positive feedbacks. According to the results, the 6-month ADL training fostered positive results in numerous aspects on the individual’s quality of life like care relationship positive self-image and the homey feeling as compared to the results from the controlled group or the care-as-usual routine.
Lastly, there was another study in 2017 which also showed the everyday activities in a nursing home setting are beneficial for dementia patients. The authors of the study pointed out that the need to adapt activities that would support a sense of stability, predictability and the enjoyment in the local environment is necessary for the elderlies (Mondaca, Josephsson, Katz & Rosenberg, 2017). To assess the merits of their claim, the researchers conducted an epistemological, ethnographic study in a nursing home in Sweden. The facility houses a total of 54 residents with varying needs. Based on the demographic profiling, the residents' age was between 75 to 103 years, and they have been in the facility for two weeks to 5 years. Also, it was found that the residents had multiple chronic conditions which included diabetes, cardiovascular diseases, hearing impairment and limited mobility. There were also patients at a varying level of cognitive decline. The study revealed that many of the patients were still in the denial stage when they are having a hard time harmonizing that their environment no longer supports full independence. The word dependence is a new word for most of them who were previously engaged in an active lifestyle. By fostering functional, daily activities in the nursing home the residents enable the patients to feel still relevant. The study concluded by suggesting that most old people see everyday life activities as something extraordinary. Compared to their younger years, now the simple act of being able to cook their meal, clean their dishes and attending to their hygiene has a deeper meaning. Also, frailty is perceived as a demand to connect, bond, initiate collaborative practice and even social participation. Residents of nursing homes express their desire to engage in activities that will not make their frail and utterly useless. It was recommended that healthcare professions should actively look at the situation and consider measures that would enable the nursing home residents to engage in everyday activities.
Evidence Based Practice Synthesis
Throughout all of the articles reviewed and assessed for this critical appraisal paper, all pointed out to engaging nursing home patients, most especially those with dementia, on functional activities or activities that would necessarily mimic some of the things that young and healthy people used to do. While not all studies showed that such activities contribute to improvement in the quality of life, almost all agreed that the lives of the residents have significantly improved after the interventions were introduced. One important point raised in one of the studies is how nursing home residents perceived their present status. According to the authors, patients observed the nursing home as a final destination for when you are ready to die and is no longer productive in the community (Boogaard et al., 2018; Henskens, Nauta, Drost & Scherder, 2018). In the study initiated by Henskens, et al. (2018), the authors explained how nursing home residents viewed the environment in the nursing home. Many old people think that being in a nursing home means being stripped off of your freedom. Instead, nursing home residents become entirely dependent on other people even on activities of daily life.
Furthermore, dependence has been associated with deterioration and worthlessness. The inability of nursing home residents to make personal decisions, and their inability to perform simple tasks like cooking, washing, and personal hygiene succumb them to depression. Thus, clinicians and other healthcare professionals thought that by engaging older people who are in nursing homes to activities which could make them feel independent and useful would significantly improve their psychological wellbeing, which could also translate to their physical wellness. While it is challenging to report and assess for quality of life due to varying definition of what it entails to have a fully, well-lived life, there were still studies that were able to successfully assess and correlate the quality of live with active participation in interventions that include engaging in functional activities (Henskens, Nauta, Drost & Scherder, 2018). The technique for this success is having the assurance that researchers will have access to tools that would also allow them to measure the quality of life. Most often than not, as manifested in most of the papers on functional activities and quality of life for nursing home residents, these papers had to find the correlation on factors that only contributes to the quality of life but not the entire concept of optimum quality of life (Palm et al., 2018). Several of these researches also revealed that functional activities and activities of daily living all contribute to boosting the morale of nursing home residents. It has also been concluded that by allowing nursing home residents a certain degree of freedom to move and perform tasks or chores that their age and baseline performance will increase their optimism which makes their stay at these facilities tolerable.
Conclusion and Recommendation
Nursing care residents are very fragile. In fact, one study labeled this sector as “frail” (Mondaca, Josephsson, Katz & Rosenberg, 2017). This adjective can be primarily attributed to their age and their physical condition. Many nursing care residents have chronic conditions like diabetes, cardiovascular diseases, and cognitive disorders like dementia. This being the case, a majority of them requires monitoring. Some are even entirely dependent to a care provider. While all of these might be true, nursing home residents still have that ability to feel. Based on numerous surveys initiated throughout the course of history, it has been consistently mentioned that nursing home residents hardly feel comfortable being in a care facility (Brooke, 1989; Horgas & Dunn, 2001; Yaffe, 2002; Heidari, Ghodusi & Shirvani, 2016). Thus, many of these residents suffered from depression and anti-social disorder.
Furthermore, there is also the issue of dependence. There had been mixed emotions on how nursing home residents view dependency. There were some who expressed their frustrations about the kind of care they receive from nursing home facilities. A number of these patients believe that some of their care providers are incompetent in addressing their needs. However, there are those who see dependence as a sign of weakness. When patients experience this, it is important to let know their worth. It is challenging to explain reliance on someone who has been very independent all throughout their life. Some elderlies are not able to handle this emotion well, thus, resulting in frustration, irritability, and aggression (Horgas & Dunn, 2001).
Nevertheless, nursing care facilities should also remember that while the patients under their care may have certain degrees of limitations, the healthcare professionals should still remember that patients’ autonomy should never be compromised. It is challenging to ensure patient safety and wellbeing at this level of care while taking into serious consideration of the patient’s right to autonomy. Review of the ethical standards must be initiated to ensure that these care facilities are not going beyond the boundaries of their roles and obligations. While it is still important that patients are restricted from causing harm to self and others, this should not violate nor limit the patients from making sound and sensible decisions.
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