Edited by: Rodrigo Orlando Kuljiš, University of Miami School of Medicine, USA
Reviewed by: Ramesh Kandimalla, Emory University, USA; Laura Lorenzo-López, University of A Coruña, Spain
*Correspondence: Lia Fernandes
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Unmet needs are becoming acknowledged as better predictors of the worst prognostic outcomes than common measures of functional or cognitive decline. Their accurate assessment is a pivotal component of effective care delivery, particularly in institutionalized care where little is known about the needs of its residents, many of whom suffer from dementia and show complex needs. The aims of this study were to describe the needs of an institutionalized sample and to analyze its relationship with demographic and clinical characteristics. A cross-sectional study was conducted with a sample from three nursing homes. All residents were assessed with a comprehensive protocol that included Mini-Mental State Examination (MMSE), Geriatric Depression Scale (GDS-15), Neuropsychiatric Inventory (NPI) and Adults and Older Adults Functional Inventory (IAFAI). To identify needs, the Camberwell Assessment of Need for the Elderly (CANE) was used. The final sample included 175 residents with a mean age of 81 standard deviation (SD = 10) years. From these, 58.7% presented cognitive deficit (MMSE) and 45.2% depressive symptoms (GDS). Statistically significant negative correlations were found between MMSE score and met (
With an aged population and the resultant increase of chronic diseases, including dementia, in the near future, the evaluation of the emergent needs of this population has become crucial (Cadieux et al.,
In this context, higher demands are imposed on nursing homes and other long term care facilities (Alzheimer’s Association,
An unmet need is described as a problem for which an individual is not receiving an appropriate assessment or intervention that could potentially meet the need (Iliffe et al.,
In this context, unmet needs can be acknowledged as better predictors of the worst prognostic outcomes than the usual measures of functional or cognitive decline (Gaugler et al.,
Taking this into account, the aims of the present study were to identify and describe the needs presented by an institutionalized sample and to investigate the impact of those needs on health and global functioning by analyzing their relation with other demographic and clinical characteristics.
A cross-sectional multi-center study was conducted in three nursing homes in northern Portugal, between September 2012 and April 2013. A list of residents was obtained for each nursing home that agreed to participate, and all residents were considered eligible. Inclusion criteria were being a permanent resident and being able to give informed consent or assent, depending on the level of cognitive abilities. Terminally ill residents, those with delirium, who were unresponsive or unwilling to complete the assessment were excluded. For each participant a staff member was also interviewed. The participating staff member had to know the resident’s needs in order to be included.
A structured interview to collect general information on socio-demographic status, medical history and pharmacological treatment was carried out. Regarding medication, drugs were coded both as continuous and dichotomous variables (present/absent) for major categories. Anatomical Therapeutic Chemical (ATC) classification (World Health Organization,
Needs were assessed with the Camberwell Assessment of Need for the Elderly (CANE; Reynolds et al.,
Study protocol also included the Mini-Mental State Examination (MMSE; Folstein et al.,
All protocol measures were administered in accordance with written instructions and manuals. The interviews took place in a quiet room, and separate interviews were conducted with staff members to assess the residents’ current met and unmet needs and BPSD.
For analysis proposes the cognitive decline and dementia severity was staged according MMSE ranges as: absent (MMSE of 30), questionable (26–29), mild (21–25), moderate (scores between 11 and 20) and severe dementia (MMSE score ≤10; Perneczky et al.,
The study protocol was approved by the scientific committee of the PhD Program in Clinical and Health Services Research/University of Porto. The project was approved by the three nursing home review boards (Nursing Home of Segurança Social of Porto, Instituição Particular de Solidariedade Social of Porto and Instituição Particular de Solidariedade Social of Matosinhos).
All the participants gave their written informed consent before the beginning of the assessment.
Data analyses were performed using the Statistical Package for Social Sciences (SPSS) version 20.0 for Windows. Descriptive statistics regarding demographics were calculated. Categorical variables were described through absolute frequencies, and continuous variables through mean and standard deviation (SD), median, minimum and maximum (range). Hypotheses on the distribution of continuous variables without normal distribution were tested by the non-parametric tests Mann-Whitney and Kruskal-Wallis, and to assess the strength and direction of associations between continuous variables Spearman’s correlation coefficients were calculated. Where needs were not normally distributed, non-parametric tests were chosen. All significance tests were performed at a two-tailed alpha level of 0.05.
The sample included 248 residents out from the eligible ones. From these, 73 residents (29.4%) were not included due to incapacity related to advanced dementia, acute illness or aphasia (
The mean age of the final sample (
Patients’ characteristics | |
---|---|
Age, years (SD) | 81 (10) |
Gender, n (%) | |
Male | 18 (10) |
Female | 157 (90) |
Marital status, n (%) | |
Single | 55 (31) |
Married | 12 (7) |
Separated/Divorced | 19 (11) |
Widowed | 89 (51) |
Socio-economic classification (Graffar)1, n (%) | |
Very high | 1 (0.6) |
High | 10 (5.9) |
Median | 27 (15.9) |
Low | 68 (40.0) |
Very low | 64 (37.6) |
Education2, years (SD) | 3 (4) |
Duration of institutionalization, years (SD) | 7 (11) |
Number of medications3, mean (SD) | 7 (3) |
Number of comorbidities3, mean (SD) | 9 (4) |
Cognitive impairment (MMSE)3, mean (SD) | 22 (6) |
Depression (GDS)4, mean (SD) | 5 (4) |
Functional status (IAFAI)5, mean (SD) | 43.5 (23.5) |
Behavioral and psychological symptoms (NPI)4, mean (SD) | 6 (12) |
Most residents presented health problems with an average of 9 (SD = 4, range: 2–22) co-morbid medical conditions, and consumed medications for various purposes with a mean of 7 (SD = 3, range: 0–15). Of this sample, 86.0% consumed medication for the cardiovascular system, 79.1% for the nervous system and 68.6% for blood and blood-forming organs (Table
ATC categories ( |
|
---|---|
Alimentary tract and metabolism | 101 (58.7) |
Blood and blood forming organs | 118 (68.6) |
Cardiovascular system | 148 (86.0) |
Dermatologicals | 0 (0) |
Genito urinary system and sex hormones | 14 (8.1) |
Systemic hormonal preparations, excl. sex hormones and insulins | 9 (5.2) |
Antiinfectives for systemic use | 3 (1.7) |
Antineoplastic and immunomodulating agents | 0 (0) |
Musculo-skeletal system | 38 (22.1) |
Nervous system | 136 (79.1) |
Antiparasitic products, insecticides and repellents | 0 (0) |
Respiratory system | 20 (11.6) |
Sensory organs | 10 (5.8) |
Various | 1 (0.6) |
Twelve residents (6.9%) were unable to understand the CANE questions. For them, only the health professional and evaluator perspectives were obtained. Additional comparisons were conducted among those who could and could not complete CANE. Residents who were unable to complete the questionnaire were significantly more cognitively impaired (MMSE mean 22 vs. 18,
Overall 2162 needs were identified, 1523 (70.4%) were met and 639 (29.6%) unmet. The average number of needs identified was 12 (SD = 4, range: 3–18), 9 (SD = 3, range: 1–15) being met and 4 (SD = 2, range: 0–11) unmet. One hundred and seventy (97.1%) out of 175 residents presented one or more unmet needs, and the number of unmet needs did not significantly differ across the three nursing homes (mean 4 vs. 3 vs. 4,
Needs identified |
|||
---|---|---|---|
Need/Domains | No need | Met need | Unmet need |
Accommodation | 175 (100.0) | – | – |
Household skills | 6 (3.4) | 169 (96.6) | – |
Food | 12 (6.9) | 163 (93.1) | – |
Self-care | 48 (27.4) | 127 (72.6) | – |
Caring for other | 175 (100.0) | – | – |
Daytime activities | 20 (11.4) | 27 (15.4) | 128 (73.1) |
Memory | 85 (48.6) | 25 (14.3) | 65 (37.1) |
Eyesight/Hearing | 31 (17.7) | 26 (14.9) | 118 (67.4) |
Mobility | 66 (37.7) | 85 (48.6) | 24 (13.7) |
Continence | 113 (64.6) | 61 (34.9) | 1 (0.6) |
Physical health | – | 163 (93.1) | 12 (6.9) |
Drugs | 34 (19.4) | 136 (77.7) | 5 (2.9) |
Psychotic symptoms | 114 (65.1) | 40 (22.9) | 21 (12.0) |
Psychological distress | 34 (19.4) | 50 (28.6) | 91 (52.0) |
Information | 80 (45.7) | 88 (50.3) | 7 (4.0) |
Safety (deliberate self-harm) | 152 (86.9) | 11 (6.3) | 12 (6.9) |
Safety (accidental self-harm) | 66 (37.7) | 102 (58.3) | 7 (4.0) |
Abuse/neglect | 156 (89.1) | 17 (9.7) | 2 (1.1) |
Behavior | 99 (56.6) | 67 (38.3) | 9 (5.1) |
Alcohol | 168 (96.0) | 4 (2.3) | 3 (1.7) |
Company | 93 (53.1) | 11 (6.3) | 71 (40.6) |
Intimate relationships | 115 (65.7) | 2 (1.1) | 58 (33.1) |
Money | 37 (21.1) | 134 (76.6) | 4 (2.3) |
Benefits | 159 (90.9) | 15 (8.6) | 1 (0.6) |
A total of 172 residents (98.3%) completed the MMSE. The sample scored an average of 22 (SD = 6, range: 5–30) on MMSE, and 101 (58.7%) participants scored for cognitive decline. For those with cognitive decline, the mean number of unmet needs identified was 4 (SD = 2, range: 1–11) compared to a mean of 3 (SD = 2, range: 0–8) for those without (
Needs identified |
|||
---|---|---|---|
Need/Domains | Without ( |
With ( |
|
Accommodation | − | − | − |
Household skills | − | − | − |
Food | − | − | − |
Self-care | − | − | − |
Caring for other | − | − | − |
Daytime activities | 40 (56.3) | 85 (84.2) | <0.001 |
Memory | 5 (7.0) | 57 (56.4) | <0.001 |
Eyesight/Hearing | 48 (67.6) | 67 (66.3) | 0.161 |
Mobility | 6 (8.5) | 17 (16.8) | 0.267 |
Continence | 0 (0) | 1 (1.0) | <0.001 |
Physical health | 4 (5.6) | 7 (6.9) | 0.766 |
Drugs | 2 (2.8) | 3 (3.0) | <0.001 |
Psychotic symptoms | 3 (4.2) | 17 (16.8) | 0.005 |
Psychological distress | 37 (52.1) | 51 (50.5) | 0.061 |
Information | 0 (0) | 4 (4.0) | <0.001 |
Safety (deliberate self-harm) | 6 (8.5) | 5 (5.0) | 0.777 |
Safety (accidental self-harm) | 2 (2.8) | 5 (5.0) | 0.001 |
Abuse/neglect | 1 (1.4) | 1 (1.0) | 0.901 |
Behavior | 1 (1.4) | 6 (5.9) | 0.254 |
Alcohol | 2 (2.8) | 1 (1.0) | 0.596 |
Company | 26 (36.6) | 43 (42.6) | 0.393 |
Intimate relationships | 22 (31.0) | 35 (34.7) | 0.874 |
Money | 0 (0) | 4 (4.0) | <0.001 |
Benefits | 1 (1.4) | 0 (0) | 0.259 |
Needs identified |
|||||
---|---|---|---|---|---|
Need/Domains | No ( |
Questionable ( |
Mild ( |
Moderate ( |
Severe ( |
Accommodation | − | − | − | − | − |
Household skills | − | − | − | − | − |
Food | − | − | − | − | − |
Self-care | − | − | − | − | − |
Caring for other | − | − | − | − | − |
Daytime activities | 3 (50.0) | 31 (56.4) | 33 (73.3) | 53 (86.9) | 5 (100.0) |
Memory | 0 (0) | 1 (1.8) | 17 (37.8) | 39 (63.9) | 5 (100.0) |
Eyesight/Hearing | 1 (16.7) | 39 (70.9) | 32 (71.1) | 39 (63.9) | 4 (80.0) |
Mobility | 1 (16.7) | 3 (5.5) | 5 (11.1) | 11 (18) | 3 (60.0) |
Continence | 0 (0) | 0 (0) | 0 (0) | 1 (1.6) | 0 (0) |
Physical health | 0 (0) | 1 (1.8) | 5 (11.1) | 5 (8.2) | 0 (0) |
Drugs | 0 (0) | 2 (3.6) | 1 (2.2) | 2 (3.3) | 0 (0) |
Psychotic symptoms | 0 (0) | 4 (7.3) | 1 (2.2) | 14 (23) | 1 (20.0) |
Psychological distress | 3 (50) | 27 (49.1) | 25 (55.6) | 31 (50.8) | 2 (40.0) |
Information | 0 (0) | 0 (0) | 0 (0) | 3 (4.9) | 1 (20.0) |
Safety (deliberate self-harm) | 1 (16.7) | 3 (5.5) | 5 (11.1) | 2 (3.3) | 0 (0) |
Safety (accidental self-harm) | 0 (0) | 3 (5.5) | 1 (2.2) | 3 (4.9) | 0 (0) |
Abuse/neglect | 1 (16.7) | 0 (0) | 0 (0) | 1 (1.6) | 0 (0) |
Behavior | 0 (0) | 1 (1.8) | 1 (2.2) | 4 (6.6) | 1 (20.0) |
Alcohol | 0 (0) | 3 (5.5) | 0 (0) | 0 (0) | 0 (0) |
Company | 1 (16.7) | 21 (38.2) | 15 (33.3) | 31 (50.8) | 1 (20.0) |
Intimate relationships | 2 (33.3) | 17 (30.9) | 13 (28.9) | 24 (39.3) | 1 (20.0) |
Money | 0 (0) | 0 (0) | 2 (4.4) | 2 (3.3) | 0 (0) |
Benefits | 0 (0) | 1 (1.8) | 0 (0) | 0 (0) | 0 (0) |
Of the 175 participants, 166 (94.9%) completed the GDS-15, and their average score was 5 (SD = 6, range: 0–14). The study sample was also divided on the basis of GDS score. From the whole sample, 75 residents (45.2%) scored for depression (GDS scores ranged from 5 to 15). Unmet needs were more common in residents who scored for depression. Elderly with depression presented a mean of 5 unmet needs (SD = 2, range: 2–11) compared to those without who had a mean of 3 (SD = 2, range: 0–8;
Needs identified |
||||
---|---|---|---|---|
Need/Domains | No depression ( |
Depression ( |
||
Accommodation | − | − | − | |
Household skills | − | − | − | |
Food | − | − | − | |
Self-care | − | − | − | |
Caring for other | − | − | − | |
Daytime activities | 58 (63.7) | 61 (81.3) | 0.022 | |
Memory | 32 (35.2) | 27 (36.0) | 0.72 | |
Eyesight/Hearing | 55 (60.4) | 55 (73.3) | 0.172 | |
Mobility | 11 (12.1) | 12 (16.0) | 0.078 | |
Continence | 0 (0) | 1 (1.3) | 0.326 | |
Physical health | 3 (3.3) | 7 (9.3) | 0.188 | |
Drugs | 1 (1.1) | 4 (5.3) | 0.166 | |
Psychotic symptoms | 6 (6.6) | 14 (18.7) | 0.013 | |
Psychological distress | 19 (20.9) | 68 (90.7) | <0.001 | |
Information | 2 (2.2) | 2 (2.7) | 0.953 | |
Safety (deliberate self-harm) | 1 (1.1) | 10 (13.3) | 0.002 | |
Safety (accidental self-harm) | 2 (2.2) | 5 (6.7) | 0.322 | |
Abuse/neglect | 1 (1.1) | 1 (1.3) | 0.276 | |
Behavior | 4 (4.4) | 3 (4.0) | >0.999 | |
Alcohol | 2 (2.2) | 1 (1.3) | >0.999 | |
Company | 14 (15.4) | 53 (70.7) | <0.001 | |
Intimate relationships | 17 (18.7) | 39 (52.0) | <0.001 | |
Money | 2 (2.2) | 2 (2.7) | 0.842 | |
Benefits | 0 (0) | 1 (1.3) | 0.211 |
Concerning BPSD, at screening 50.6% of the sample presented at least one symptom, and 56 (33.7%) scored above the NPI cut-off for clinical significance. The average NPI score was 6 (SD = 12, range: 0–76). The most common BPSD across the sample were sleep and nighttime behavior change (54%), delusions (22%), dysphoria/depression (19%), irritability/lability (17%) and agitation/aggression (15%), while the least prevalent were elation/euphoria (3%), aberrant motor behavior (4%) and disinhibition (5%). These results have been described in detail elsewhere (Ferreira et al.,
Needs identified |
||||
---|---|---|---|---|
Need/Domains | Non clinically relev. ( |
Clinically relev. ( |
||
Accommodation | − | − | − | |
Household skills | − | − | − | |
Food | − | − | − | |
Self-care | − | − | − | |
Caring for other | − | − | − | |
Daytime activities | 75 (68.2) | 46 (82.1) | 0.151 | |
Memory | 37 (33.6) | 26 (46.4) | 0.15 | |
Eyesight/Hearing | 74 (67.3) | 38 (67.9) | 0.939 | |
Mobility | 15 (13.6) | 8 (14.3) | 0.006 | |
Continence | 0 (0) | 1 (1.8) | 0.486 | |
Physical health | 10 (9.1) | 2 (3.6) | 0.227 | |
Drugs | 3 (2.7) | 2 (3.6) | 0.654 | |
Psychotic symptoms | 3 (2.7) | 18 (32.1) | <0.001 | |
Psychological distress | 57 (51.8) | 31 (55.4) | 0.105 | |
Information | 4 (3.6) | 3 (5.4) | 0.237 | |
Safety (deliberate self-harm) | 7 (6.4) | 5 (8.9) | 0.596 | |
Safety (accidental self-harm) | 5 (4.5) | 2 (3.6) | 0.601 | |
Abuse/neglect | 2 (1.8) | 0 (0) | 0.583 | |
Behavior | 1 (0.9) | 8 (14.3) | <0.001 | |
Alcohol | 1 (0.9) | 2 (3.6) | 0.197 | |
Company | 43 (39.1) | 25 (44.6) | 0.265 | |
Intimate relationships | 38 (34.5) | 18 (32.1) | 0.566 | |
Money | 1 (0.9) | 3 (5.4) | 0.19 | |
Benefits | 1 (0.9) | 0 (0) | >0.999 |
Of the 175 participants, 151 (86.3%) completed the IAFAI, and their average score was 43.5% (SD = 23.5%, range: 0–93.6%). The functional dependency was correlated with greater unmet needs. Significant correlations between functional dependency and met (
The main aim of the present study was to describe the met and unmet needs of residents in nursing homes. To our knowledge this is the first study systematically conducted with this purpose in the northern Portugal.
Needs assessment has become a central issue following the growing recognition that it could lead to more appropriate and effective provision of care, services and resource usage (Worden et al.,
A negative relationship between lengths of residency and the number of unmet needs was also found, which indicates that the longer the resident had lived in the home, the less their unmet needs were rated. Environmental and physical health needs were generally met, as had already been found by others not only in long-term care (Martin et al.,
The number of unmet needs presented by this sample is greater than those reported by other studies conducted in long term care (Martin et al.,
As noted by Miranda-Castillo et al. (
The study also sought to determine whether the number of needs was related to other important variables. Overall, in this sample more unmet needs were associated with the worst outcomes measured. In line with other studies, the presence of unmet needs was associated with increased cognitive and functional decline (Martin et al.,
It is noteworthy that except for the age of residents, unmet needs were positively correlated with modifiable or treatable characteristics such as the presence of depressive symptoms or behavioral problems. These are areas that have also been found amenable to interventions planned by mental health professionals (Orrell et al.,
The study has some potential limitations and caution should be exercised upon generalization of the present findings. Firstly, its cross-sectional design, with findings that may point toward some important relations but that cannot imply causality. Considering the inclusion and exclusion criteria that were fixed, it is possible that those elderly with more unmet needs were under-recruited due to their incapacity to respond to the evaluation. In this way, the present non-random sample may be less disabled than the actual institutionalized population, which may have led to an underestimation of the real number of needs. Since the residents’ participation was voluntary, it may have induced a positive bias into the findings. Finally, despite the discrepancy of the gender ratio presented in this sample, it is in line with other studies conducted in comparable settings (e.g., Hancock et al.,
Despite the referred limitations, the study also has strengths. Firstly, valid and reliable measures were used. Secondly, the participants were included from various stages of dementia decline. This continuum is thought to represent and capture the range of needs over time in the disease progression. Thirdly, the study included a relatively large sample of residents and a detailed and standardized tool to access needs was applied. Considering the prognostic value of unmet needs, their evaluation should become a standard part of clinical evaluation providing important information to professionals, elderly and caregivers. Finally, as already noted in other studies (Walters et al.,
Most studies have assessed needs using a cross-sectional approach (e.g., Field et al.,
In conclusion, the present study was a contribution to the characterization of needs in nursing homes, which should be promoted in order to improve strategies for future care with different and complementary perspectives integrated into collaborative and tailored elderly care plans.
LF defined and designed the study and supervised the data collection. ARF collected the data. LF and ARF drafted the article. CCD carried out the statistical analyses. All the authors contributed to the interpretation of the data, revision of the article, and approved the final manuscript.
Novartis Farma sponsored the data collection and statistical analysis. The publication was supported by FEDER through Programa Operacional Competitividade e Internacionalização – COMPETE2020 and by National Funds through FCT – Fundação para a Ciência e a Tecnologia within CINTESIS, R&D Unit (reference UID/IC/4255/2013). The sponsors did not play any role in the design, methods, data collection and analyses, or in the preparation of the article.
The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.
The authors wish to thank the participant institutions, clinical staff and residents for their collaboration, and Sónia Martins for the participation of analyses and interpretation of results.