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Patient with problems in social functioning in long term care facility
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long -term care facility (LTCF) ; behavioral symptoms ; unsettled relationships between residents ; unsettled relationships between resident and staff ; depression
Abstract:
Introduction The main goal of this doctoral dissertation is to analyze the risk factors of behavioral symptoms and unsettled relationships among residents and between residents and staff, as well as risk factors related to the frustration experienced by staff in contact with resident in long-term care facility (LTCF). Moreover this study aims to analyze the line of pharmacological treatment (including antipsychotics, antidepressants, sedatives drugs) and non-pharmacological treatment (categorized as physiotherapy, occupational therapy, psychological care and ADL training) administered to the LTCF residents who manifest behavioral symptoms and unsettled relationships.So far, the behavioral symptoms, as well as unsettled relationships have not been analyzed among polish LTCF residents. Many polish research studies analyze the behavioral disturbances in the context of neuropsychiatric symptoms accompanying dementia. This paper is focused on the analysis of behavioral symptoms and unsettled relationships in the typical LTCF population which consists of residents with variety of chronic somatic and mental diseases, not only limited to patients with dementia. Goals of the study:1) The analysis of risk factors of behavioral symptoms such as verbal and physical aggression, inappropriate social behavior, wandering and resistance to prescribed care and treatment in the LTCF population.2) The analysis of risk factors of unsettled relationships among residents and between residents and staff, as well as determinants related to the frustration experienced by staff in contact with resident.3) The analysis of the treatment approach of LTCF residents with behavioral symptoms and/or unsettled relationships in terms of pharmacological and non-pharmacological interventions. Research hypotheses:1) The behavioral symptoms and unsettled relationships are frequent among LTCF residents.2) Symptoms of depression constitute a significant risk factor of behavioral symptoms, unsettled relationshipsand/or frustration experienced by staff in contact with resident in LTCF.3) Cognitive impairment is an independent risk factor of the occurrence of behavioral symptoms and unsettled relationships among LTCF residents.4) Some somatic diseases in LTCF residents increase the risk of unsettled relationships and/or frustration experienced by staff in contact with resident.5) The LTCF residents manifesting behavioral symptoms and/or unsettled relationships are predominantly treated symptomatically, using antipsychotic and sedative drugs. ; Material and method:This research was performed in LTCF in a big polish city in 2013 (during 8-month period). All patients (354 people) remaining in the long-term care ward of the analyzed LTCF were qualified in the study, excluding the patients in whom it was not possible to complete the questionnaire due to the lack of a discernible consciousness/the presence of coma, or there was lack of data on analyzed variables.The median age of studied group was 79 years. Female gender dominated in the study group (69%).It was a cross-sectional study, using the InterRAI-LTCF questionnaire –an InterRAI Long-Term Care Facilities Assessment System (www.interrai.org).The interRAI LTCF is a comprehensive geriatric assessment tool which was designed to assist clinicians in monitoring the care of LTCF residents and providing a comprehensive view of the resident’s health needs and strengths in long-term care institution. The nurses completed the questionnaire based on 3-day observations of residents while the routine care of resident and information obtained from medical documentation, family members and other staff.In the statistical analyzes the descriptive statistics were applied first, to present the characteristics of the sample in terms of the frequency of occurrence of analyzed features, as well as to assess the significance of differences in characteristics between patients with and without specific symptoms (i.e. the occurrence of particular types of behavioral symptoms, unsettled relationships, and the use of each of pharmacological and non-pharmacological interventions). In the next stage, in order to determine the risk factors of behavioral symptoms, unsettled relationships and type of drug therapy, logistic regression models were developed, taking into account the characterizing variables of the residents, which proved to be important in differentiating them due to the type of behavioral symptoms, unsettled relationships and drug therapy used. In the case of behavioral symptoms, 3 models of logistic regression were developed, testing factors determining the occurrence of verbal aggression, inappropriate social behaviors and resistance to prescribed care and treatment. Similarly, 3 logistic regression models were developed to determine the risk factors for unsettled relationships among residents, between resident and staff, and staff’s frustration in contact with the resident. In order to find potential factors determining the chances of using a specific type of pharmacological treatment, a multivariate logistic regression analysis was carried out. Separate models of logistic regression for therapeutic interventions with the use of antipsychotics, antidepressants and sedatives were estimated. ; Conclusions:1) The results of this study indicatethat behavioral symptoms and unsettled relationships constitute a significant problem in the LTCF population (occurred in 22.9% and 28.8% of patients respectively).The most frequent were the symptoms of verbal aggression (13.4%), followed by inappropriate social behaviors (11%) and resistance to prescribed care or treatment (8.6%). The frequency of the unsettled relationships was comparable in the form of conflicts among patients (20.5%) and between the patient and staff (19.4%). In addition, 17.4% of thenursing staff reported frustration in contact with resident.2) Behavioral symptoms in LTCF residents have a complex etiology. The factors that increase the risk of verbal aggression are symptoms of depression and/or abnormal thinking process. The risk of resistance to prescribed care or treatment is higher when the patient experiences delusions. Inappropriate social behaviors are more likely in patients from 71 to 85 years old, presenting symptoms of depression, cognitive impairment, aphasia or symptoms of abnormal thinking process. Factors that reduce the risk of behavioral symptoms in LTCF residents are a consistent positive outlook (reduces the risk of verbal aggression) and having supportive relationships with family members (minimizes the chances of resistance to prescribed care or treatment).4) The unsettled relationships in LTCF residents have multifactorial etiology. The risk factors are the occurrence of behavioral, depressive and/or psychotic symptoms in LTCF resident. The influence of these factors is independent of the patient's cognitive status. At the same time, moderate cognitive impairments reduce the risk of unsettled relationships between residents, as well as the staff report less likely the frustration in caring for these residents.5) Some somatic and neurological diseases increase the risk of unsettled relationships among LTCF residents. Patients with congestive heart failureand obesity (BMI≥30 kg/m²) significantly more likely initiate the conflicts with staff. At the same time, staff statistically more likely experience the frustration in the care of patients struggling with chronic, progressive neurological diseases such as multiple sclerosis, hemiplegia, paraplegia or quadriplegia.6) Men have a higher risk of presenting behavioral symptoms, unsettled relationships between resident and staff, as well as staff have greater risk to experience the frustration in contact with male patient comparing to women. 7) The occurrence of depressive symptoms is a strong factor increasing the risk of all considered behavioral symptoms as well as unsettled relationships in LTCF residents. ; 8) Behavioral symptoms and unsettled relationships are most often treated with pharmacotherapy in LTCF setting. Non- pharmacological therapies (in the form of occupational therapy, physiotherapy, ADL training) are used much less frequently in this population,but significantly more often in residents cognitively intact, with no physical ADL dependency or communication deficiencies. 9) Residents with behavioral symptoms have a higher risk of prescription of antipsychotics and sedatives compared to antidepressants. The above observation also occurs in patients with behavioral and depressive symptoms.10) Behavioral symptoms and unsettled relationships have multifactorial etiology in LTCF residents. Therefore, the diagnostic process based on the differentiation of the possible causes that underlie these disturbances is crucial for the selection of proper therapy. Thorough observation of patients in terms of the occurrence of depressive symptoms, psychotic symptoms and behavioral symptoms should help to make a correct diagnosis, which will affect the application of an appropriate treatment strategy (taking into account both pharmacotherapy and non-pharmacological interventions) and the effectiveness of treatment.
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Uniwersytet Jagielloński. Collegium Medicum. Wydział Lekarski.
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Biblioteka Medyczna Uniwersytetu Jagiellońskiego- Collegium Medicum