Transcript predictors of institutionalization among dementia patients in

Azlina Wati Nikmat1,2
Graeme Hawthorne1, Sam Korn1
1Department of Psychiatry, The University of Melbourne
2Department of Psychiatry, University Teknologi MARA
11th
11th Global
Global Conference
Conference on
on Ageing
Ageing "Ageing
"Ageing Connects”
Connects”
 Worldwide:
 Predicted 2 billion people over the age of 60 in 2050 (WHO, 2006)
 Malaysia –
 It is predicted that older adults will increase from :
1,032,300 people (5.9%) in 1991 to
3,439,600 people (9.9%) by the year 2020 (PALA, J. 2005)
11th Global Conference on Ageing "Ageing Connects”
Source: Jorm et al (1987)
11th Global Conference on Ageing "Ageing Connects”
Disabling
condition
Low and middle income
countries
High income countries
World
0-59 Years
60 years and
over
0-59 Years
60 years and
over
All age
Hearing loss
54.3
43.9
7.4
18.5
124.2
Glaucoma
5.7
7.9
0.4
1.5
15.5
Alzheimer and
other dementias
1.3
7.0
0.4
6.2
14.9
Cerebrovascular
Disease
4.0
4.9
1.4
2.2
12.6
Rheumatoid
arthritis
5.9
3.0
1.3
1.7
11.9
* WHO THE GLOBAL BURDEN OF DISEASE – 2004 UPDATE, 2008
 Home care has become the preferred option among the elderly and
their caregivers (Iwarsson et. al, 2007; Suh et. al, 2005)
 Care giving - source of burden and distress for the family caregiver
(Burns & Rabins, 2000; Chene, 2006)
 Nursing home often becomes an option when the caregivers are no
longer able to cope with the disease (Moyle et. al, 2007; Rigaud et. al,
2003)
 Various studies on dementia patients in nursing homes - it is remains
unclear to whether placement of dementia patient in nursing home will
make a difference in their QOL (Moyle et al., 2007).
11th Global Conference on Ageing "Ageing Connects”
Literature review – I: search
 A comprehensive search in the electronic databases of CINAHL, MEDLINE,
Science Direct and PsychINFO from November 2009 to March 2010
 Keywords : “quality of life”, “health related quality of life”, “dementia”,
“nursing homes”, “home nursing”, “residential care” and “home care”
 Other keywords : living arrangement, cognitive impairment, physical
impairment, depression, social isolation and needs.
11th Global Conference on Ageing "Ageing Connects”
Literature review – II: N. papers
Keyword
CINAHL
PsycINFO
Medline
Dementia
7995
64722
21777
Quality of life
8890
13486
4648
Dementia AND Quality of life
111
1210
152
29 related papers; 24 shared papers and 5 unique papers
Dementia AND Quality of life
AND Nursing home/home care
5
343
5
12 related papers; 5 shared papers and 7 unique papers
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Literature review – III: outcomes
 Quality of life of the caregiver
 eg: Alonso et. al, 2004; Bruce, 2005; Kurz, 2003;Thomas et. al, 2006, te Boekhorst
et. al, 2008
 Measuring quality of life
 Context of measures
 eg: Etema et. al, 2005; Inouye et. al, 2009; Smith et. al, 2005; Wolak et. al,
2009
 Reliability of measurement
 eg: Gerritsen et. al, 2007; Kavirajan et. al, 2009; Thorgrimsen et. al, 2003;
Trigg et. al, 2007; Logsdon et. al, 2002; Wolak et. al, 2009
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Literature review – III: outcomes (cont.)
 Proxy versus self report
 eg: Arlt et. al, 2008; Huang et. al, 2009; Moyle et. al, 2007; Ready et. al
2004)
 Factors associated with quality of life
 Living arrangement
 eg: Hoe et. al, 2006; te Boekhorst et. al, 2008
 Cognitive decline
 eg: Missotten et. al, 2008
 Health functions
 eg: Murray & Boyd, 2009
 Pharmacotherapy in dementia
 eg: Ward et. al., 2008; Hughes & Medina-Walpole, 2000; Kirby et. al, 2006
11th Global Conference on Ageing "Ageing Connects”
Literature review – IV: conclusions
 Lack of study comparing the QoL of dementia patients in nursing home and
home care
 Various instruments used in assessing QoL –
 Different construct
 eg: Anderson et. al, 1999; Farquhar, 1995; Grewal et. al, 2006; Brown et.
al. 2004; WHOQoL group, 1998
 Generic vs Specific
 eg: Pettit et. al, 2001; Power et. al, 2005; Selai & Trimble, 1999; Smith et.
al, 2005
 Self report vs proxy report
 eg: Brod et. al, 1999; Thorgrimsen et. al, 2003; Ready et. al, 2002;
Logsdon, 1999; Magaziner, 1997; Rabins et. al, 1999; Selai, 2001)
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The study protocol
 Aims:
Methodology
 To identify and compare the quality of life of dementia patients in nursing
home and those in community (cared by family members)
11th Global Conference on Ageing "Ageing Connects”
 To provide a profile of dementia patients in the nursing home and home
care
 To compare the QoL of dementia patients in the nursing home and home
care
 To identify factors that differentiate the QoL of dementia patients in these
two settings (if any exists)
11th Global Conference on Ageing "Ageing Connects”
 Provide a better life for the demented patients (understanding their needs proper management plan can be addressed to reduce the burden of the
caregivers and provide a better life for the demented patient).
 Provide information about health care in dementia to Government,
clinicians and managers regarding the preferred options for support of older
adults with dementia.
11th Global Conference on Ageing "Ageing Connects”
Mental health/
psychological
QoL
Social
relationship
Environmental
11th Global Conference on Ageing "Ageing Connects”
Physical
functions/
activities
• Research design : Quasi experimental design - cross sectional study
 Sampling population
- Nursing homes (dementia patients residing in government nursing
homes)
- Rumah Ehsan and Rumah Sri Kenangan
- Home care (dementia patients who live with a carer and get services
from the memory clinic in government hospitals)
- Hospital Selayang, Hospital Kuala Lumpur and Hospital Sungai Buloh
11th Global Conference on Ageing "Ageing Connects”
Review medical record for inclusion
and exclusion criteria and exclusion
criteria
Meet criteria
Does not meet criteria
Consent form and provide participant
information sheet
Consent
Administer
SMMSE
Non-consent
Exit
SMMSE score ≥11
SMMSE score <11
Administration of other
assessments
Inclusion criteria
Exclusion criteria
- Consented respondents age 6089 years old
- Sufficient command of the Malay
or English language (able to
complete a questionnaire or
interview)
- Score <11 in the Short Mini
Mental State Examination
(SMMSE)
- No use of antipsychotic
medications
- Respondents aged less than 60 or
more than 90 years old
- Cannot speak or poor
understanding of Malay or English
language
- Score ≥11 in the Short Mini
Mental State Examination
(SMMSE)
- Physically challenged patients (eg;
blind, stroke)
- Psychosis
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Measurements
 Measurements :







Socio-demographic information,
WHO-8,
AQoL-8,
FS,
CSDD,
CANE-S,
Barthel Index
 An average of 60-90 minutes to administer the questionnaires
11th Global Conference on Ageing "Ageing Connects”
• Nursing Homes: Mean = 21.22, SD = 4.64
• Home Care: Mean = 23.29, SD = 4.56
( sd n  sd ne )( Z  Z1  ) 2
2
n
2
e   ne 2
Assumes:
• Test size = 0.05 (α) Zα = 1.96; Power = 0.80 (1-β), Z 1-β = 0.84
• Calculated n = 105 in each study group.
Source of reference:
• DAVIDSON AG, FAYERS PM, NUNN AJ, VENABLES KM & TAYLOR AJ. (1986). Number of patients required in lung function studies.
Thorax. 41 (11): 830-832.
• POWER et al (2005). Development of the WHOQOL-OLD module. Quality of Life Research. 14 (10): 2197-214.
Based on re-analysis of the Melbourne WHOQOL-OLD study data, N = 758 cases.
11th Global Conference on Ageing "Ageing Connects”
Stratified sampling procedure
Location/
Gender
Male
Female
Nursing homes
Home care
Cognitive severity
Cognitive severity
TOTAL
Mild a
Moderate b
Mild a
Moderate b
60-75
14
14
14
14
56
76-89
14
14
14
14
56
60-75
14
14
14
14
56
76-89
14
14
14
14
56
56
56
56
56
TOTAL
112
112
224
Cognitive severity measured by SMMSE
a = SMMSE 6-10
b = SMMSE 0-5
Source of reference: POWER et al (2005). Development of the WHOQOL-OLD module. Quality of Life Research.
14 (10): 2197-214.
Based on re-analysis of the Melbourne WHOQOL-OLD study data, N = 758 cases.
11th Global Conference on Ageing "Ageing Connects”
The preliminary findings
 31 dementia patients from nursing homes and 82 from home care were
invited
 62 agreed to participate
 49 (30: NH, 19: HC) met the study entry criteria and completed the
questionnaire -participation rate of 44%.
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Demographic results
Ethnicity
 Mean age : 70.4 (7.44)
 Female : 55.1 %
 Education : Primary school (46.9 % )
High school (28.6 %)
 Financial status :
Average (36.7 %)
Slightly below average (51 %)
 Relationship satisfaction :
Very satisfied
8.2 %
Satisfied
28.6 %
Neither
10.2 %
Dissatisfied
10.2 %
Very dissatisfied
65.3 %
10%
Malay
27%
Chinese
63%
Indian
Marital status
12%
Single
45%
Married
31%
Separated
Widowed
12%
Health results
 Self reported health : Healthy (65.3%)
 On medication : 83.7%
 Psychiatry meds : 38.8%
 No. of comorbidities
2%
29%
0 to 3
4 to 7
69%
more than 7
Logistic regression
Uni-variate analysis
Table 1: Demographic profiles of dementia patients in home care and nursing homes
Study cohort
Relationship
satisfaction with
children
Financial status
Home care
Nursing home
Satisfied
N (%)
14 (82.40)
N (%)
4 (26.70)
Neither
2 (11.80)
2 (13.30)
Dissatisfied
1 (5.90)
9 (60.0)
Average
15 (78.90)
4 (13.30)
Below average
4 (21.10)
26 (86.70)
11th Global Conference on Ageing "Ageing Connects”
Statistics
Fisher Exact =12.06, p
=0.01
χ2=21.10, df=1, p<0.01
Table 2: Health status of participants by study cohort
Study cohort
Home care
Nursing home
Statistics (a)
Mean (SD)
26.83 (32.0)
33.82 (15.94)
t=0.65, df=21, p=0.52
Not healthy
5 (26.30)
12 (40.00)
Healthy
14 (73.70)
18 (60.00)
χ2=0.96, df=1, p=0.33
Co-morbidities
Mean (SD)
2.95 (1.68)
2.77 (1.99)
t=0.33, df =47, p=0.75
Medication used
No
3 (15.80)
5 (16.70)
Yes
16 (84.20)
25 (83.30)
Fisher Exact, p = 1.00
SMMSE
Mean (SD)
6.63 (3.11)
5.20 (2.28)
t=1.86, df=47, p=0.07
CSDD
Mean (SD)
6.89 (4.27)
7.20 (4.11)
t=0.29, df=47, p=0.80
BI
Mean (SD)
90.26 (13.59)
77.50 (15.63)
t=2.93, df = 47, p<0.01
Months since
diagnosis
Health condition
Discussion
Notes:
SMMSE = Short Mini Mental State Examination; CSDD = Cornell Scale of Depression in Dementia; BI = Barthel
Index; FS = Friendship Scale
a = t = independent t-test
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Table 3: Quality of life, social isolation and needs of dementia patients by study cohort
Study cohort
Scales
Home care
Nursing Home
Statistics (a)
WHO-8
19.63 (3.53)
16.07 (3.71)
t=3.34, df=47, p<0.01
AQOL-8
0.43 (0.18)
0.30 (0.20)
t=2.28, df=47, p=0.03
FS
15.11 (3.63)
10.80 (3.68)
t=4.01, df=47, p<0.01
CANE
8.21 (6.27)
6.19 (1.13)
t=3.14, df=47, p<0.01
Notes:
WHO-8 = EUROHIS-QOL; AQoL-8 = Short Assessment of Quality of Life; FS = Friendship Scale
Means and standard deviations shown.
a = independent t-test
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Multivariate analysis – multiple regression
Table 4: Predictors of QoL in dementia patients
(Constant)
Unstandardized Coefficients
B
Std. Error
28.332
3.125
B
Living arrangement
-1.644
1.574
-.209
Health condition
2.035
1.386
.225
Financial status
-1.975
1.038
-.356
Cornell Scale for Depression
-.301
.133
-.325*
Satisfaction with children
-.035
.549
-.012
*p<0.05
R2
0.48
 The key findings (pilot study) :
1. Dementia patients living at home:
 have more income
 good relationship with children
 more socially connected
 have better physical functions
 Have their needs fulfilled
 have better overall QoL.
2. Suggested predictor for QoL = Depression
 Conclusion: Home care – better overall QOL. Health care plans promoting
community care for dementia patients supported by initiatives to reduce the
burden of the caregivers.
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Acknowledgement
 Research Management Institute of Universiti Teknologi MARA,
Malaysia.
 The University of Melbourne.
Acknowledgeme
nt
 Ministry of Higher Education of Malaysia.
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THANK YOU
THANK YOU
11th Global Conference on Ageing "Ageing Connects”