Ling Hui Chang

The Effects of Resident and Nursing Home Characteristics on Activities of Daily Living

BACKGROUNDnExisting studies on the relationships between impairments and activities of daily living (ADLs) in nursing home residents have serious limitations. This study examines the relationships among admission impairments, including pain, depression, incontinence, balance, and falls, and follow-up ADLs, as well as the effect of the nursing home on follow-up ADLs of extended-stay nursing home residents.nnnMETHODSnThis longitudinal cohort study consisted of 4,942 extended-stay residents who were admitted into 377 Minnesota nursing homes during 2004. General linear mixed models were used for all analyses, with 14 resident-level and 8 facility-level control variables.nnnRESULTSnIncontinence and balance function at admission were significantly associated with increases in ADL dependence at follow-up. Individual nursing homes had independent effects on all three ADL models. Similar findings were found after facility-level control variables were added.nnnCONCLUSIONSnIncontinence predicts subsequent ADL functional levels. The relationship between balance dysfunction and subsequent ADL dependence could be causal. Future studies of the causal relationships between impairments and ADL should examine the effectiveness of impairment interventions on ADL as well as these relationships in different subgroups of nursing home residents.

Cognition moderates the relationship between facility characteristics, personal impairments, and nursing home residents' activities of daily living.

OBJECTIVES: To determine whether cognition moderates the association between facility‐level characteristics and individual‐level impairments and activity of daily living (ADL) dependency.

Indicators of perceived useful dementia care assistive technology: Caregivers' perspectives

The study aims to investigate the caregivers context‐specific perceived usefulness of available assistive technology (AT) devices and the professionals perspectives on the usefulness indicators of AT devices for home‐dwelling individuals with mild‐to‐moderate dementia.

A tough-love pedagogy in rehabilitation: integration of rehabilitation ideology with local cultures.

This study problematizes a unique therapeutic relationship in rehabilitation and how the interaction reflects the integration of rehabilitation ideology with local cultures. The data drew from a larger ethnographic study of a rehabilitation unit in Taiwan. Participants included 21 patient–caregiver pairs and their rehabilitation professionals. They participated in in-depth interviews and participant observation. A tough-love pedagogy emerged as a unique therapeutic relationship in the unit. Patients were asked to interpret the stress with therapy as an inevitable, beneficial experience toward recovery. A prevalent supposition that equated poor physical performance with weak morale legitimized the approach. Cultural metaphors used to describe and define rehabilitation transformed the stress that patients experienced with strenuous exercises into a beneficial substance that aids recovery. The transformation of the therapeutic relationship into a pedagogical one helped connect rehabilitation to shared educational experiences. In the unit, the complicit practice of therapists, caregivers, and patients established and perpetuated the practice of a tough-love pedagogy. The congruence between this tough-love approach and traditional Chinese pedagogical principles made the approach legitimate and desired. Die vorliegende Studie problematisiert eine einzigartige therapeutische Beziehung bei der Rehabilitation und wie ihre Interaktion die Integration der Reha-Ideologie bei lokalen Kulturen widerspiegelte. Die Daten bezogen sich auf eine in einer Reha-Abteilung in Taiwan durchgeführte größere ethnographische Studie. Zu den Teilnehmern zählten 21 Patienten/Betreuer-Paare und ihre jeweiligen Reha-Experten. Sie nahmen an ausführlichen Interviews und einer teilnehmenden Beobachtung teil. Eine tough-love-Pädagogik erwies sich als eine einzigartige therapeutische Beziehung in der Abteilung. Die Patienten wurden angehalten, Stress im Rahmen der Therapie als eine unerlässliche, förderliche Erfahrung auf dem Weg der Genesung zu interpretieren. Eine gängige Annahme, die eine schlechte körperliche Leistung mit niedriger Moral gleichsetzte, legitimierte den Ansatz. Die kulturellen Metapher, mit denen eine Rehabilitation beschrieben und definiert wird, wandelten den Stress, den Patienten bei anstrengenden Übungen erfuhren, in eine der Genesung förderlichen Substanz um. Der Wandel von einer therapeutischen in eine pädagogische Beziehung half bei der Verknüpfung von Rehabilitation und gemeinsamen pädagogischen Erfahrungen. In der Abteilung entstand und etablierte sich aus der gemeinsamen Praxis von Therapeuten, Betreuern und Patienten eine Praxis der tough-love-Pädagogik. Die Kongruenz zwischen diesem tough-love-Ansatz und den traditionellen chinesischen pädagogischen Prinzipien machte daraus einen legitimen und wünschenswerten Ansatz. Cette étude présente la problématique dune relation thérapeutique de rééducation et la manière dont cette interaction reflète lintégration de lidéologie de rééducation avec les cultures locales. Les données sont tirées dune étude ethnographique plus large réalisée par un centre de rééducation de Taïwan. Parmi les participants figuraient 21 paires de patients-soignants et leurs professionnels de la rééducation. Ils ont participé à des entretiens approfondis, avec observation des participants. Une pédagogie alliant sympathie et fermeté est apparue comme une relation thérapeutique unique dans le centre. Les patients ont été invités à interpréter le stress associé à la thérapie comme une expérience inévitable mais utile dans la voie vers le rétablissement. Une supposition qui prévaut assimilant mauvaise performance physique et moral bas légitimait cette approche. Les métaphores culturelles utilisées pour décrire et définir la rééducation ont transformé le stress éprouvé par les patients en raison de la difficulté des exercices en un catalyseur bénéfique favorisant le rétablissement. La transformation de la relation thérapeutique en une relation pédagogique a permis dassocier la rééducation à des expériences éducatives partagées. Dans le centre, la complicité établie entre les thérapeutes, les soignants et les patients créé et perpétue la pratique dune pédagogie alliant sympathie et fermeté. La congruence entre cette approche de type «amour vache» ou «qui aime bien châtie bien» et les principes pédagogiques chinois traditionnels a rendu cette démarche légitime et souhaitable. En este estudio se presenta una relación terapéutica única en su tipo en el proceso de rehabilitación y cómo la interacción en esta relación refleja la integración de la percepción psicológica de la rehabilitación y las culturas locales. Los datos se obtuvieron de un estudio etnográfico más amplio realizado en un servicio de rehabilitación de Taiwán. Los participantes fueron 21 pares de pacientes y sus cuidadores y los profesionales de la rehabilitación que los atienden. Todos ellos participaron en entrevistas minuciosas y en procesos de observación de participantes. En este servicio se utiliza solamente un tipo único de relación terapéutica basada en la enseñanza «con mano dura». Se pidió a los pacientes entender la tensión nerviosa experimentada durante la terapia como una experiencia inevitable y beneficiosa en el avance hacia la recuperación. Este método se basa en la hipótesis generalizada de que los malos resultados físicos se asocian a un tratamiento «con mano suave». Las metáforas culturales utilizadas para describir y definir la rehabilitación convirtieron la tensión nerviosa experimentada por los pacientes durante la realización de ejercicios intensos en una experiencia beneficiosa que contribuía a la recuperación. La transformación de la relación terapéutica en una relación pedagógica ayudó a vincular la rehabilitación con experiencias educacionales comunes. En este servicio de rehabilitación, la participación colaboradora de los fisioterapeutas, los cuidadores y los pacientes estableció y perpetuó la práctica de la enseñanza «con mano dura». La congruencia entre este método de enseñanza y los principios pedagógicos tradicionales chinos hacen a este método legítimo y deseable.

Integration of complementary medical treatments with rehabilitation from the perspectives of patients and their caregivers: A qualitative inquiry

Objective: This article uses a qualitative design and examines how patients and their caregivers integrate pluralistic health practices into rehabilitation from their perspectives. Design: Ethnography was used as the framework for research design. Data were collected via participant observation, taped in-depth interviews and regular chart review, and all interviews were transcribed verbatim. Setting: An inpatient rehabilitation unit in Taiwan. Subjects: Twenty-one patients, their caregivers and their rehabilitation professionals. Results: The patients and their caregivers used pluralistic illness explanations and treatments to make sense of their suffering, to control healing and to find the hope that rehabilitation professionals often deliberately avoided giving. Spiritual healing and therapies related to Traditional Chinese Medicine, such as functional food and herbal medicines, were popular alternative therapeutics. Although the patients and their caregivers perceived opposition from the medical staff on the unit, they used a variety of covert strategies to integrate their pluralistic illness explanations and treatments into their daily routines without openly challenging the rehabilitation primacy. Conclusion: Aware of the rehabilitation staffs opposition, the patients and caregivers resorted to a variety of underground strategies to conceal their use of complementary medical treatments.

Determinants of generic and specific health-related quality of life in patients with Parkinson’s disease

Objectives Generic and disease-specific health-related quality of life (HRQoL) instruments may reflect different aspects of lives in patients with Parkinson’s disease (PD) and thus be associated with different determinants. We used the same cluster of predictors for the generic and disease-specific HRQoL instruments to examine and compare the determinants of HRQoL. Method HRQoL was measured in 92 patients with PD by the 36-item Short-Form Health Survey (SF-36) and the 39-item Parkinson’s Disease Questionnaire (PDQ-39). The predictors included demographic and disease characteristics, and motor and non-motor symptoms. Multiple regression analyses were used to identify HRQoL determinants. Results Depressive symptoms and motor difficulties of daily living were the first two significant determinants for both instruments. The other significant determinant for the SF-36 was fatigue and non-motor difficulties of daily living, and for the PDQ-39 was motor signs of PD. Conclusions The results suggest the importance of the evaluation and intervention focused on depressive symptoms and motor difficulties of daily living in patients with PD. In addition, the SF-36 seems more related to non-motor symptoms, while the PDQ-39 appears more associated with motor symptoms. This information is important for understanding results from these two instruments and for choosing which to use.

Institutional contexts contribute to the low priority given to developing self-care independence in a rehabilitation ward: a qualitative study

Objectives: To examine the institutional contexts that contribute to the low priority given to the development of self-care independence in a rehabilitation ward. Design: Research was guided by ethnographic principles of Martyn Hammersley and Paul Atkinson (2007). Individual in-depth interviews were completed. Participant observation was done daily during the rehabilitation stay of the patients. Patients: Six men and three women with neurological impairments and their caregivers. Results: Patients’ daily routines on a rehabilitation ward in Taiwan are described. Four prominent themes emerged from the data: (1) the attitudes of patients, caregivers, and staff facilitated extended rehabilitation stays within the first year after disability, (2) attending therapy sessions was the most important activity, (3) pragmatic considerations, such as ‘faster and easier’, outweighed the value of developing self-care independence, and (4) strategic organization of daily routines to keep therapy the priority was critical for daily activity. Conclusion: Multiple institutional factors jeopardize the development of self-care independence in a rehabilitation ward. The factors include the primacy of biomedical-oriented rehabilitation ideology, insurance reimbursement policies, and cultural values associated with family caregiving. They legitimize the low priority given to developing self-care independence. Therapists need to include a critical review of daily routines (what and how activities are carried out inside and outside of therapy clinics) as part of therapy regime to identify opportunities and institutional constraints to the development of self-care independence.

Developing a referral protocol for community-based occupational therapy services in Taiwan: A logistic regression analysis

Because resources for long-term care services are limited, timely and appropriate referral for rehabilitation services is critical for optimizing clients’ functions and successfully integrating them into the community. We investigated which client characteristics are most relevant in predicting Taiwan’s community-based occupational therapy (OT) service referral based on experts’ beliefs. Data were collected in face-to-face interviews using the Multidimensional Assessment Instrument (MDAI). Community-dwelling participants (n = 221) ≥ 18 years old who reported disabilities in the previous National Survey of Long-term Care Needs in Taiwan were enrolled. The standard for referral was the judgment and agreement of two experienced occupational therapists who reviewed the results of the MDAI. Logistic regressions and Generalized Additive Models were used for analysis. Two predictive models were proposed, one using basic activities of daily living (BADLs) and one using instrumental ADLs (IADLs). Dementia, psychiatric disorders, cognitive impairment, joint range-of-motion limitations, fear of falling, behavioral or emotional problems, expressive deficits (in the BADL-based model), and limitations in IADLs or BADLs were significantly correlated with the need for referral. Both models showed high area under the curve (AUC) values on receiver operating curve testing (AUC = 0.977 and 0.972, respectively). The probability of being referred for community OT services was calculated using the referral algorithm. The referral protocol facilitated communication between healthcare professionals to make appropriate decisions for OT referrals. The methods and findings should be useful for developing referral protocols for other long-term care services.

Diagnostic accuracy of Instrumental Activities of Daily Living for dementia in community-dwelling older adults

BACKGROUNDnmany people living with dementia remain underdiagnosed and unrecognised. Screening strategies are important for early detection.nnnOBJECTIVEnto examine whether the Lawtons Instrumental Activities of Daily Living (IADL) scale, compared with other cognitive screening tools-the Mini-Mental State Examination (MMSE), and the Ascertain Dementia 8-item Informant Questionnaire (AD8)-can identify older (≥ 65 years) adults with dementia.nnnDESIGNnpopulation-based cross-sectional observational study.nnnSETTINGnall 19 counties in Taiwan.nnnPARTICIPANTSncommunity-dwelling older adults (n = 10,340; mean age 74.87 ± 6.03).nnnMETHODSnall participants underwent a structured in-person interview. Dementia was identified using National Institute on Aging-Alzheimers Association core clinical criteria for all-cause dementia. Receiver operator characteristic curves were used to determine the discriminant abilities of the IADL scale, MMSE and AD8 to differentiate participants with and without dementia.nnnRESULTSnwe identified 917 (8.9%) participants with dementia, and 9,423 (91.1%) participants without. The discriminant abilities of the MMSE, AD8 and IADL scale (cutoff score: 6/7; area under curve = 0.925; sensitivity = 89%; specificity = 81%; positive likelihood ratio = 4.75; accuracy = 0.82) were comparable. Combining IADL with AD8 scores significantly improved overall accuracy: specificity = 93%; positive likelihood ratio = 11.74; accuracy = 0.92.nnnCONCLUSIONSnour findings support using IADL scale to screen older community-dwelling residents for dementia: it has discriminant power comparable to that of the AD8 and MMSE. Combining the IADL and the AD8 improves specificity.

Caregiver active participation in psychoeducational intervention improved caregiving skills and competency: Psychoeducation for dementia caregivers

To determine whether giving dementia caregivers active psychoeducational intervention is more efficacious than passive intervention for improving their caregiving skills and reducing their caregiving burden.