A LongitudinalStudy ofParticipation inNursing HomeActivity Programs

Barty w: Rovner, M.D.

Pearl S. German, Sc.D.

Linda C Burton, Sc.D.

Rebecca D. Clark, B.A.

The authors eualuated participation ill ac­tivityprograms in a prospective study of198neto nursing home admissions. Both on ad­mission and after 1 year, approximately50% ofpatients toere not participating inactivities. Nonparticipatlon was associatedtoith. greater cognitive anti functional il1l-

pairment and the use ofrestraints anti nett­roleptics. Over the year, activity statuschange,'for approximately 50% ofpatientsin relation to these factors. These findingsindicate current limitations in nursinghome activity programs and suggest thatparticipation is a dynamic process influ­enced by identifiable clinical variables. Re­vision of activity programs is necessary tomeet OBRA regulations to improue the qual­ity ofpatients' lives. (American Journal ofGeriatric Psychiatry 1994; 2:169-174)

The mere liberation from restraints is onlya small part of the undertaking... a systemof treatment must be substituted for therestraint system. 1

-John Connolly, M.D., 1856

New federal legislation (Omnibus Bud­get Reconciliation Act [0BRA], 1987) re­quires the diagnosis of psychiatric andbehavioral disorders before neurolepticsand restraints can be used in nursinghomes.' Despite recent decreases in theiruse, the prevalence of inadequately andimproperly treated mental disorders re­mains high.' This problem, along with theprevious excessive use of physical andchemical restraints, has prompted the com­parison of nursing homes to the "mentalinstitutions" of the past."

In the late 18th century, Philippe Pinel,the newly appointed director of the mentalinstitutions of Paris, the Bicetre and theSalpetriere, recognized the overuse of re­straints and prohibited them, I-Ie replacedthem with clinical progranls providing so­cial activity, physical activity, and physicalcomfort. These innovations, designed toachieve the highest level of psychosocialfunctioning for patients, revolutionized thecare of the mentally ill. In nursing homestoday, special care units have evolved thatemploy similar measures." These units fre­quently include activity programs that at­tempt to reinforce patients' remainingcapabilities and minimize the consequencesof their deficits. However, special care unitsare costly to develop and are unavailable tothe majority of nursing home patients withdementia. For all patients, OBRA requiresnursing homes to provide "specialized reha­bilitative services to attain or maintain thehighest practicable physical, mental, andpsychosocial well-being of each resident."The extent to which patients receive theseservices, however, is uncertain.

We have reported previously the highprevalence of dementia and other psychiat­ric disorders in nursing homes and havefound that patients with psychiatric disor-

Received April 9, 1993; revised July 6. 1993; accepted August 24, 1993. From tl~e Dep~rt~ent of I~;ychi~ltty andHuman Behavior, Jefferson Medical College, Thomas Jefferson University and ':Vdl~ Genat~lcPsychiatry I rogram,Philadelphia, PA. Address correspondence to Dr. Rovner, Wills Eye Hospital, Geriatrlc Psychiatry, 900 \Valnut Street,Philadelphia, PA 19107.

Copyright © 1994 The American Association for Geriatric Psychiatry

THE AMERICAN JOURNAL OF GERIATRIC PSYCHIATRY 169

Nursing Home Activities

ders, particularly dementia, are not likely toparticipate in activity programs." In thisstudy, we now describe clinical characteris­tics and treatment factors that relate to activ­ity participation upon admission and over 1year, to refine our understanding of thisaspect of nursing horne life.

METHODS

The subjects (n = 198) were a nursing horneadmission cohort who remained in nursinghaoles longer than 1 year and were part ofa larger longitudinal study. This study ana­lyzed mental morbidity to establish its mag­nitude and type and assessed its influenceon quality of life. The larger study and itsmajor findings have previously been re­ported by German et a1.6 and Rovner et ~11.4

Consecutive new admissions CN= 454) toeight Baltimore-area proprietary nursinghomes from 1987 to 1988 comprised theinitial sample. No subject had resided in anursing h0I11e during the preceding 6months, The demographic and medicalcharacteristics of the sample were cornpara­ble to those reported in the 1985 NationalNursing Horne Survey. The nursing homes'typical sources of payment and staffing pat­terns were comparable to national norms."

Research psychiatrists examined pa­tients to determine the presence and type ofpsychiatric disorders, using a structuredclinical examination.' Cognition was 111ea­sured using the Mini-Mental State Examina­tion (MMSE)? Nursing staff wereinterviewed by research assistants using thePsychogeriatric Dependency Rating Scalesto quantify functional disability (ADLs, ac­tivities of daily living) and behavior disor­clers such as agitation and combativeness."I-Iigher scores indicate greater disability and1110re severe behavior disorders, respec­tively. Data were obtained at 1 1110nth and1 year after admission. Medical diagnoses,hospitalizations during the year, and re­straints and neuroleptic use were obtainedfrom chart reviews. Restraints and neurolep-

170

tic administration were measured as thenumber of days the treatment was used overtotal possible clays. Whether a patient par­ticipated in activity programs at 1 monthand at 1 year was determined by askingnursing staff 1110St familiar with the patient:"To the extent (he/she) is able, does(he/she) generally take part in group ororganized activities that are offered here?"The corporate policy of the nursing homesis to provide one full-time activities therapistfor every 60 residents.

The statistical analyses examined thedemographic, cognitive, functional, behav­ioral, and treatment characteristics of pa­tients in relation to activity participation at 11110nth and at 1 year. At 1 1110nth, chi-squareand z-tests were used. At 1 year, analysis ofvariance (ANOVA) was used to determinewhether statistically significant differencesexisted between patients in four mutuallyexclusive groups: preseoce of activity par­ticipation at 1 month and at 1 year (PIP); noparticipation at either time (NP/NP); partic­ipation at 1 month but not at 1 year (P/NP);or no participation at 1 month but participa­tion at 1 year (NP/P).

RESULTS

Table 1 C0111pareS the clinical and treatmentcharacteristics of the patients participatingand not participating in activities at 1 0100th.

Slightly fewer than half the patients (440/0)were participating; whether they partici­pated or not was unrelated to age, race, orsex. The prevalence of dementia was some­what higher among nonparticipating pa­tients but not significantly so, indicating thatthe diagnosis of dementia per se does notdetermine whether a patient participates.I-Iowever, patients who were more severelydemented and more functionally disabled,and who tended to spend more time inrestraints and to have more severe behaviordisorders were somewhat less likely to par­ticipate. Nonparticipators had fewer medicalconditions than participators, were as able

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to walk independently, and received equiv­alent social support from regular familyvisits.

Table 2 compares the J-year clinicaland treatment characteristics of patientswho participated in activities both at 11110nth and at 1 year (P/P), at neither titne(NP/NP), participated at 1 11100th but not at1 year (P/NP), or did not participate at 11110nth but did participate at 1 year (NP/P).Thirty-four of the 88 patients (38.6°A» whowere participating at 1 month were notparticipating at 1 year, and 52 of the 110patients (47.3%) who were not participatingat 1 month were participating at 1 year. Theoverall proportion of patients participatingdid not change significantly over the year(440/0 at 1 1110nth vs. 53°,,1) at 1 year; X2 = 3.27;df = 1; P> 0.05).

There were no significant differences inage, race, or sex between patients in thesefour groups. There were significant differ­ences in severity of cognitive and functionalimpairment and the use of restraints andpossibly neuroleptics. Inspection of MMSE

Rovner et al.

and ADL scores between groups suggeststhat patients who participated at both 1month and 1 year (PIP) were less cogni­tively and functionally impaired and lesslikely to require restraints and neurolepticsthan patients who participated at neithertime (NP/NP). Patients who were not partic­ipating at 1 1110nth but were participating at1 year (NP/P) resembled patients whoparticipated at both times, and patientswho participated at 1 111011th but not at 1year (P/NP) resembled ITIOre closely thosewho participated at neither time. The in­dicators we used to evaluate severity ofmedical condition (number of medical di­agnoses, hospitalizations during the year,and ability to walk) did not differ betweengroups.

Over the year, there was a slight declinein MMSE scores (average for the four groups= 2.2 ± 1.7) and a slight increase in func­tional dependency scores (average = 1.3 ±1.1), but there were no statistically signifi­cant differences in these changes betweengroups.

TABLE 1. Patients participating and not participating in nursing home activities at 1 month afteradmission

II (%)

Age±SD

Female

\'(Ihite

Dementia

Mini-Mental State Exam''

Activities of Daily Livlng''

Behavior disorder"

Days restrainedd

Neuroleptics

Medical diagnoses"

Able to walk

Social supports

Participating

88 (44)

80.7±9.9

85.20/0

89.50/0

51.30/0

17.6 ±9.2

12.2 ±7.1

2.8±4.327.60/0 ± 0.41

19.5% ± 0.36

3.3± 1.8

55.7%

87.5%>

Not Participating

1]0 (56)

81.5 ± 8.7

83.6%>

96.3°..1068.20/0

13.9± 9.6

15.4±7 .4

4.0±4.8

39,4%±0.45

24.80/0 ±0.41

2.8 ± 1.6

55.50/0

82.70/0

p

NSNSNSNS< 0.01

<0.005

< 0.056

<0.053

NS<0.05

NSNS

Note: Values arc 111eanS ±SD.a 1= - 2.73; df= 190.h 1= 3.11; df = 190.C t = 1.92; df = 193.d t = 1.95; df =193.C t = - 2.08; df;::; 171.

THE AMERICAN JOURNAL OF GERIATIUCPSYCHIATRY 171

Nursing H0111e Activities

DISCUSSION

We studied the clinical and treatment char­acteristics of an admission cohort remainingin nursing homes over 1 year to examinehow these characteristics may relate to par­ticipation in activities. Although the overalllevel of participation did not change overthe year, there was substantial changeamong individual patients over time, Sever­ity of cognitive and functional impairment(and perhaps behavior disorder), in con­junction with potentially modifying treat­ment variables, such as restraints andneuroleptics, may predict types of patientsand aspects of care that relate to activityparticipation initially and over time.

Several methodological considerationsIimir the interpretation of the results. First,the reliability and accuracy of nurses' re­ports of the amount and degree of partici­pation in activities are uncertain. However,nurses 1110St familiar with patients were in­terviewed; activity participation tended tobe an "all or none" phenomenon; and nurs­ing assessments were significantly associ­ated with other independently ascertainedclinical variables. Although these factorssupport the validity of the nurses' assess­ments, objective documentation of actualparticipation rates would have provided

more precise information had this beenavailable.

Second, the varying levels of neurolep­tic and restraint use over the year in relationto activity participation were not distin­guishable. However, residents who re­ceived neuroleptics or were restrained atbaseline were generally seen to be at thesame status at 1 year,"

Third, there were a number of varied,unassessed medical, psychological, and en­vironmental factors that could potentiallyaffect the level of activity participation.These factors might include incidentillnesses, changes in drug therapy, and vari­ation in the availability and training of activ­ities staff. Although some patients may havedeclined to an extent that precluded partic­ipation in activities, the average declines incognition and functioning for patients ineach group were not substantially differentfrom each other, nor so great that suchchanges alone could account for variationin participation levels. In fact, the absenceof any significant differences in indices ofmedical severity, such as the number ofmedical diagnoses, ability to walk, and hos­pitalizations during the year SUpPOltS thisobservation.

Although the data do not permit causalinferences, it is not unreasonable to sup­pose that activity participation is a dynamic

TABLE 2. Characteristics of patients at 1 year after admission by nursing home activity participation{P} or nonparticipation (NP) (at 1 month/l year)

11

Minl-Mental Stale Exam score"Activities of Daily Living indexh

Behavior disorderRestraints"

Nell roleptics''Hospitalized in past yearMedical diagnosesAble to walk

.. J~.= 9.6; df = 3.h F= 6.9; df= 3.c F= 3.7; df= 3.d F= 2.6; df= 3.

172

PIP NP/P P/NP NP/NP P

54 52 34 5816.2 16.4 12.9 7.9 < 0.000112.8 12.6 17.4 18.2 < 0.00013.8 3.3 4.7 5.2 <0.15

29% 310;0 46% 50% <0.0212%) 180/0 27010 290/0 <0.0538.90/0 26.9% 44.1% 31.0% NS3.3 3.0 3.3 2.6 NS

35.2% 46.2% 38.20/0 34.50/0 NS

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process influenced in part by cognition,functional disability, behavior disorder, andthe use of restraints and neuroleptics. Thestudies of Ray et a1.,10 Garrard et al.," andEvans and Strurnpf'" indicate that restraintsand neuroleptics are often inappropriatelyused to "manage" behavior disorders. Wepreviously have demonstrated that de­mented patients, particularly those with de­lusions, hallucinations, or depression, aremost often behaviorally disturbed, mostlikely to be restrained and receive neurolep­tics, and least likely to participate in activityprograms."

These factors, some of which may bemore or less salient and may combine atdifferent times, can either facilitate or pre­vent participation. That some of these fac­tors are consistently associated withparticipation (on admission and over time)suggests that they comprise a relevant unitfor consideration in future studies of activityparticipation in nursing homes. Taken to­gether, these factors describe a tendencytoward homogeneity among patients whoparticipate and among those who do not, ahomogeneity that evolves over time from akind of selection process within the nursinghome. These descriptors also point up thelimited range of existing activity progralTIs.

Although the cognitive capacity of de­rnented patients is itnpaired, their capacityto experience emotion is not. The percep­tion that more cognitively impaired patientsare unable to enjoy or benefit from recrea-

Rovner et al.

tional or rehabilitative activities may ac­count for their nonparticipation in theseprograms and their vulnerability to behaviordisorders. Kurt Goldstein, commenting onthe behavior of brain-damaged persons,noted that activities enable patients...

to keep themselves busy with things thatthey are able to do as a protection againstthings that they cannot cope with. Theactivities which engross them need not beof great value in themselves. Their useful­ness consists apparently in the fact thatthey protect the patient...they allow forsome ordered form of behavior and forthe experience of some kind of self-real­ization.13

If reductions in neuroleptics and re­straints continue under OBRA, there will bean increased need for activity programs toengage patients who otherwise might havebeen physically or chemically restrained.Nursing h0111e activity programs, as theycurrently exist, benefit a subgroup of pa­tients who function more or less highly." Tothe extent that being meaningfully activereflects a higher quality of life, it is discour­aging that so many patients currently fail toparticipate in activities. Creating that oppor­tunity is the next step in the progress ofhumane care in the nursing home.

The authors thank Kate Kellyfor her assis­tance.This tootle was supported bJI National Insti­tute ofMental Health Grant MEl 45293.

References

1. Connolly J: Treatment of the Insane Without He­strainrs. London, UK, Smith, Elder and Company,1856

2. Department of Health and Human Services: Medi­care and Medicaid: requirements for longterrn carefacilities, final rule with requests for comments.Federal Register 1989; 54:5322

3. Rovner B\V, Edelman BA, Cox MilI et al: The impactof antipsychotic drug regulations on psychotropicprescribing practices in nursing homes, Am J PSy­chiatry 1992; 149:1390-1392

4. Rovner 8\'(1, German PS, Broadhead J, et al: Theprevalence and management of dementia and

THE AMERICAN JOURNAL OF GERIATRIC PSYCHIATRY

other psychiatric disorders in nursing homes. IntPsychogerlatr 1990; 2:13-24

5. u.s. Congress, Office of Technology Assessment:Special care units for people with Alzheimer's andother dementias: consumer education, research,regulatory, and reimbursement issues. OTAI-I-543,Washington, DC, U.S. Government Printing Office,1992

6. German PS, Havner B\V, Burton LC~ et al: The roleof mental morbldlty in the nursing home experi­ence. Gerontologist 1992; 32:152-158

7. Folsteln MF, Folsteln SE, McHugh PI{; Mini-MentalState: a practical method for grading the cognitive

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state of patients for the clinician. J Psychiatr Res1975; 12:189-198

8. \Vilkinson Itvl, Graham-White J: PsychogeriatricDependency HatingScales: a method of assessmentfor usc by nurses. BrJ Psychiatry 1980; 137:558-565

9. Burton l.C, German PS, Rovner 13\'(1, ct al: Mentalillness and thc use of restraints in nursing homes,Gerontologist 1992; 32: 164-170

10. Hay \VlA, Federspiel CF, Schaffner \VI: A study ofantipsychotic drug use in nursing h001CS: epidemi­ological evidence suggesting misuse. Am J PublicHealth 1980; 70:485--491

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11. Garrard J, Makriss L, Dunham T, et al: Evaluationof neuroleptic drug use by nursing h0I11C elderlyunder proposed Medicare and Medicaid regula­tions. JArvIA 1991; 265:463-467

12. Evans LKt Strumpf NE: Tying down the elderly: areview of the literature on physical restraint. J AmGeriatr Soc 1989; 37:65-74

13.Goldstein K: The effect of brain damage on thepersonality. Psychiatry 1952; 15:245-260

14. Spector WD, Takada HA: Characteristics of nursinghomes that affect resident outcomes. Journal ofAging and Health 1991; 3:427-454

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