Get 20M+ Full-Text Papers For Less Than $1.50/day. Start a 14-Day Trial for You or Your Team.

Learn More →

The role of physiotherapy in terminal care

The role of physiotherapy in terminal care Introduction: Terminal patients require proper care standards and professional team of doctors, physiotherapists, social workers, educators, psychologists and clergy directly involved in mitigating the suffering of a dying person. A physiotherapist as a member of such a team should be focused on sustaining the patient's quality of life until the end at the level relevant to the patient's health state. This quality of life should be perceived integrally as a combination of procedures reducing pain and physical suffering as well as improving physical fitness and mental well-being. Material and methods:The aim of the research was to define the role of physiotherapy in assessing mental and physical state of terminal patients; to determine the applicability of ADLs, GDS and BDI in diagnosing the validity and usefulness of tiresome physiotherapeutic procedures for terminal patients and to assess the applied tests in predicting terminal patients' . The research was carried out on the turn of 2012 and 2013 in the group of 103 subjects (74 females - 71.8% and 29 males ­ 28.2%) For the research the following methods were used: - Activity of Daily Living scale (ADL)- Beck Depression Inventory (BDI) - Geriatric Depression Scale (GDS) - Questionnaire regarding their willingness to participate in physiotherapeutic procedures. Results: In the research the range of diagnostic possibilities of the applied scales and tests, correlations between theses scales and tests as well as correlations between them and subjects' age and were assessed. Additionally, a questionnaire survey was carried out which assessed the willingness to participate in physiotherapeutic procedures. Strong stress, terminal state of the patient and generalisation of symptoms brought about the fact that only 14.6% of patients declared their willingness to participate in physiotherapeutic procedures. Conclusions: 1. Implementing physiotherapeutic and psychological diagnostic tests in everyday terminal care makes it easier to assess of terminal patients and significantly improves their life and dying with dignity 2. Proper understanding of the symptoms of dying must serve as a basis for organising adequate activities compliant with the progress of a disease of a terminal patient without disturbing the process of dying. 3. Modern physiotherapy in terminal care should limit the range of physiotherapeutic procedures and physical therapy while increasing psychological care in this population. Slowa kluczowe: e-mail: funcional assesment, paliatic care, physioterapy a.ronikier@awf.edu.pl 42 Streszczenie Wstp: Terminalny stan chorego, zblianie si do mierci wymaga wychowania slub spolecznych: lekarzy, fizjoterapeutów, pracowników socjalnych, pedagogów i osoby duchowne do zlagodzenia cierpie starzejcego si bardzo szybko czlowieka. Fizjoterapeuta jako czlonek tego zespolu winien kierowa si w swych dzialaniach trosk o utrzymanie odpowiedniej do wieku jakoci ycia pacjenta, a po jego koniec. T jako ycia naley rozumie integralnie, jako zabiegi redukujce ból i cierpienie fizyczne, poprawiajce sprawno fizyczn i dobrostan psychiczny Material i metody: Celem przeprowadzonych bada bylo okrelenie roli fizjoterapii w ocenie stanu mentalnego i fizycznego pacjentów terminalnych, oraz ocena uytecznoci i wiarygodnoci skal funkcjonalnych ADL, GDS oraz BDI w diagnozowaniu uciliwoci procedur opieki fizjoterapeutycznej nad t grup pacjentów. Oceniano take w oparciu o wyniki przeprowadzonych testów czas przeycia badanych. Badania zostaly przeprowadzone na przelomie roku 2012 i 2013 na grupie 103 pacjentów (74 kobiety ­ co stanowilo 71.8% badanych oraz 29 mczyznach ­ 28.2% badanych). rednia wieku badanych 85.3 + 6.4 lata. W badaniach wykorzystano nastpujce testy funkcjonalne: - Skal Aktywnoci ycia Codziennego ( ADL ) - skal depresji Becka ( BDI ) - Geriatryczn skal depresji (GDS ) oraz przeprowadzono wród badanych ankiet na temat chci ich uczestnictwa w zabiegach fizjoterapeutycznych Wyniki: Analiz statystyczn przeprowadzono trójtorowo, ze wzgldu na zloono problemów badawczych. W badaniach oceniono warto diagnostyczn zastosowanych skal i testów. Nastpnie poddano analizie korelacj pomidzy skalami i testami uytymi w badaniu, poddano take analizie korelacje pomidzy nimi a czasem przeycia pacjentów zbadanych 3 grup. Przeprowadzono równie badania kwestionariuszowe oceniajce ch uczestnictwa pacjentów w procedurach fizjoterapeutycznych. Nasilony stres, poglbiajcy si stan terminalny chorego oraz uogólnienie objawów chorobowych spowodowaly, e jedynie 14,6% pacjentów zadeklarowalo ch uczestnictwa w zabiegach fizjoterapeutycznych. Wnioski: 1. Wprowadzenie do codziennej praktyki w opiece terminalnej, fizjoterapeutycznych i psychologicznych testów diagnostycznych ulatwia ocen przeywalnoci terminalnie chorego pacjenta, w sposób istotny przyczynia si do poprawy jakoci ich ycia i godnego umierania. 2. Poprawne odczytywanie oznak umierania, musi stanowi podstaw do organizacji celowych i adekwatnych dziala zgodnych z postpem choroby terminalnie chorego bez zaburzania procesu jego umierania. 3. Nowoczesna fizjoterapia w opiece terminalnej powinna ograniczy zakres zabiegów fizykalnych i kinezyterapi na rzecz opieki psychologicznej nad ta populacj. Key words: ocena funkcjonalna, opieka paliatywna, fizjoterapia Introduction A physiotherapist must establish such a relation with a patient that it does not increase the suffering but brings relief. Therefore, terminal care requires a special type of empathy, not only as far as intuition and openness are concerned but also taking into account the knowledge of psychiatry and psychology directed at understanding the patient.. A physiotherapist has to do it so that as much information about the patients as possible is collected in order to understand them better. Implementing physiotherapeutic and psychological diagnostic tests in everyday terminal care makes it easier to assess of terminal patients and significantly improves their life and dying with dignity. The aim of the research: ­ to define the role of physiotherapy in assessing mental and physical state of terminal patients; ­ to determine the applicability of ADLs, GDS and BDI in diagnosing the validity and usefulness of tiresome physiotherapeutic procedures for terminal patients; 43 criterion the patients were classified to the following categories: ­ capable individuals collected 5 to 6 points, ­ moderately incapable individuals - 3 to 4 points, ­ deeply incapable individuals - 0 to 2 points. 2. Beck Depression Inventory (BDI) Depression in terminal patients increases with their physical and mental suffering, sadness, feeling of guilt, loneliness, disagreement with the situation and fear from the disease and its results. BDI includes 21 activities. No depression, only low mood was recognised at 0-10 points, mild depression at 11-27 points, while severe depression at more than 28 points. The scale is highly coherent and reliable and is most commonly used in assessing depression in elderly and terminal patients. To compare with the full version of the scale, its shortened version was applied. 3. Geriatric Depression Scale (GDS) GDS assessed the mood of the subjects within the last 2 weeks. A full version of the scale assessing 30 features was applied (a positive reply to the question in the scale - 1 point). Patients without depression (0-10 points); mild depression (11-20 points); severe depression (> 21points). 4. Questionnaire regarding their willingness to participate in physiotherapeutic procedures. During the research the respondents replied to a question regarding their willingness to participate in physiotherapeutic procedures. Results In the research the range of diagnostic possibilities of the applied scales and tests, correlations between theses scales and tests as well as correlations between them and subjects' age and were assessed. Additionally, a questionnaire survey was carried out which assessed the willingness to participate in physiotherapeutic procedures. Strong stress, terminal state of the patient and generalisation of symptoms brought about the fact that only 14.6% of patients declared their willingness to participate in physiotherapeutic procedures. These were the subjects who got 3-4 points according to ADL Scale. The results for quality scales are presented in numerical tables with the structure indices (%). Normal distribution of quantity variables was assessed with Shapiro-Wilk W test. In order to describe the distribution of particular variables a measure of central tendency, measures of dispersion and measures of distribution symmetry were applied. Pearson's linear correlation coefficient with linear regression was used to assess correlations between quantity variables. For intergroup to assess the applied tests in predicting terminal patients' . Material and methods The research was carried out on the turn of 2012 and 2013 in the group of 103 subjects (74 females - 71.8% and 29 males ­ 28.2%) who were residents of Care Home "Kombatant" in Olsztyn, Care Home in Molza and Hospice at the County Hospital in Grudzidz. Average age was 83.5 ± 6.4 years. After 9 months a control study was carried out in order to define the survival period of the examined group. For particular analyses patients were divided into age groups, i.e. the first group ­ patients below 80 years of age (24 subjects ­ 23.3%), the second group ­ below 90 (64 subjects ­ 62.1%) and the third group ­ above 90 (15 subjects ­ 14.6%). For the research the following methods were used: ­ Activity of Daily Living scale (ADL)- [1,2, 4] ­ Beck Depression Inventory (BDI) [3,5] ­ Geriatric Depression Scale (GDS) [4,5,6] ­ Questionnaire regarding their willingness to participate in physiotherapeutic procedures. Statistical analysis was carried out in three stages due to the complexity of research problems. At the first stage the results of scales and tests were compared to the subjects' age, then the correlation between the scales and tests used in the research was analysed while at the last stage the correlation between these tests and scales and survival period of the subjects from the examined group was studied. For the statistical analysis the Statistica 10.0 PL (Statsoft.Inc.2011) software and descriptive statistics of the examined distribution variables were applied. During the research the following research theses were verified: ­ the level of a terminal patient's depression influences the range of physiotherapeutic procedures to be applied; ­ the applied scales and tests correlate with each other and may be helpful in defining the range and character of the physiotherapeutic procedures; ­ the applied scales and tests correlate with the terminal patient's . 1. Activity of Daily Living scale (ADLs) In the research a simplified 6-point ADL scale was applied, which assessed the range of help in particular everyday activities such as: 1 ­ mobility, 2 ­ sphincter muscle control, 3 ­ personal hygiene, 4 ­ getting dressed, 5 ­ eating meals on one's own, 6 ­ communication. Being able to perform the abovementioned activities was marked with 1 point, while not being able to perform them was marked with 0 points. According to this 44 comparisons non-parametric Mann-Whitney U test and Kruskal-Wallis ANOVA test were applied. The level of significance was accepted at p=0.05. 1. ADL variable assessment The range of points of the examined patients in ADL scale. 1 point - 1.94% of patients; 2 points - 65.05%; 3 points 31.07%; 4 points - 1.94%; 5 and 6 points - 0% of patients. The activities which required most help in ADL scale included controlled micturating and defecating ­ 85% and standing up from bed and moving to an armchair ­ 76%. These numbers show that the majority of subjects (65%) are physically disabled individuals for whom every form of physical activity may reduce the effects of functional and systemic changes in a body. However, it does not influence the respondents' willingness to participate in active physiotherapy. 2. BDI variable assessment The range of points in BDI Scale for particular age groups. The level of depression according to BDI: ­ no depression or low mood - 2 subjects (2%), ­ mild depression - 43 subjects ( 41.7%), ­ severe depression - 58 subjects ( 56.3% ) The variable of this scale was also measured in quantity scale. The mean was 28 and the median had one point more with standard deviation at the level of 8. The distribution is bimodal (values 31 and 35 are repeated 7 times in the data set). Minimal value was 7 and maximal value was 44. The distribution is slightly flat and skewed left. The result of Shapiro-Wilk W test contradicts the thesis about normal distribution of the examined variable with the level of significance at p=0.0100. 3. GDS variable assessment The range of the points in GDS for particular age groups was as follows: subjects below 80 years of age - 19 points (SD-4.8); below 90 years of age - 22 points (SD-4.6), above 90 years of age - 23 points (SD-3.2). The level of depression of the subjects according to the scale interpretation proved that all the subjects suffered from depression at different intensity, i.e. 41 patients (38.8%) had mild depression while 62 subjects (68.2%) had severe depression. A growing level of depression which is a symptom of terminal state may lead to more severe disease symptoms and sooner death of a patient. GSD variable is measured in a quantity scale and therefore, a broader spectrum of statistics characterising this variable is presented. A mean level of GSD was 21.1, a median was at the level of 21, while a mode, i.e. the value most frequently repeated in the described set, was at the level of 22 and appeared 13 times. The minimal number of points in the test was 11, while the maximal value was 29 points. The dispersion analysis revealed that standard deviation was at the level of 4.6, and thus, the dispersion was low. The skewness was at the level of -0.3, which means that the distribution is slightly flat, while the negative skewness value at the level of -0.7 indicated that the distribution is skewed left. Shapiro-Wilk W test result at the level of p=0.010 contradicts the thesis about normal distribution of the examined variable. 4. variable assessment The mean in the examined group was 4.29 months with standard deviation at the level of 1.5. The shortest was 1 month since the date of the research, while the longest ­ 8 months. Shapiro-Wilk W test made it possible to disprove the thesis about the normal distribution of the examined variable at the level of p=0.0192. A mean for the examined group (defined by the points in the scales): ADL - 2.3 points, BDI - 28.0 points, GDS- 21.1points. 5. Correlation between particular tests and scales and subjects' age The correlation between the terminal patients' age and particular scales and tests applied in the research was assessed. The correlation between ADL scale and patients' age is presented at the dispersion graph (Figure 1). Every point of the graph has a number of subjects provided. Negative correlation was found at the level of r = -0.1652. Difficulties with everyday activities occur independently from the patients' age and no significant correlation between the patients' age and everyday life activities was observed. Therefore, it may be assumed that after reaching a certain age biological abilities needed for independent existence disappear and functional disability increases. Higher correlation between BDI and the patients' age may suggest its higher ability to diagnose mental state of terminal patients. It confirmed correlations described in numerous studies between age and mental depression as well as between age and the necessity to help this group of people in this matter. The correlation between BDI and age is presented at the dispersion graph 1. Positive correlation was found at the level of r = 0.40506. A high level of terminal patients' depression increases with age and somatic changes connected with the developing disease. The results of the test confirmed, even to a higher degree than BDI test result, that the increase in depression with age makes it necessary to provide psychological care to this group of subjects. These tasks may also be performed by physiotherapists, due to the limited possibilities of clinical psychology in Poland. Tab.1. Descriptive statistics for the BDI, GDS and variables A mean for the examined group (defined by the points in the scales): Frequency ADL - 2.3 points, BDI - 28.0 points, GDS- 21.1points. BDI 28.0 29 21 4 31 and 35 22 3 7 7 GDS-21.1 13 19 11 1 Mean Median Mode of mode Min Max 44 29 8 SD 8.0 4.6 1.5 Skewness -0.5 -0.3 0.2 Kurtosis -0.3 -0.7 -0.6 5. Correlation between particular tests and scales and subjects' age. time research 4.2 The correlation between the terminal patients' age and particular scales and tests applied in Survival was assessed. The correlation between ADL scale and patients' age is presented the at the dispersion graph (Figure 1). Every point of the graph has a number of subjects provided. Negative correlation was found at the level of r = -0.1652. ADL Source: authors' own calculation. Dispersion graph: BDI vs. Age; Age 75.060 + 0.30152 * BDI; Correlation: r = 0.37584 Fig. 1. Graph presenting=dispersion between all scales and subjects' age Dispersion graph: ADL vs. age; Age = 88.019 ­ 1.933 * ADL; Correlation: r = - 0.1652 CI - 0.95 Dispersion graph: ADL vs. age; Age = 88.019 ­ 1.933 * ADL; Correlation: r = - 0.1652 CI - 0.95 Dispersion graph: GSD vs. Age; Age = 71.601 + 0.56470 * GSD; Correlation: r = 0.40506 Dispersion graph: ADL vs. GSD; GSD = 26.117 ­ 2.154 * ADL; Correlation: r = - 0.2566 The correlation between BDI and age is presented at the dispersion graph (Figure 1). Positive correlation was found at the level of r = 0.37584. Dispersion graph: BDI vs. Age; Age = 75.060 + 0.30152 * BDI; Correlation: r = 0.37584 The correlation between BDI and age is presented at the dispersion graph (Figure 1). Positive correlation was found at the Fig. 1. Graph presenting dispersion between all scales and subjects' age level of r = 0.37584. CI - 0.95 Dispersion graph: GSD vs. Age; Age = 71.601 + 0.56470 * GSD; Correlation: r = 0.40506 Dispersion graph: ADL vs.selected tests and scales Correla- -0.2566. The r = - 0.2566 6. Correlations between GSD; GSD = 26.117 ­ 2.154 * ADL; Correlation: more difficulties patients had with everyday activities, the lower the values of ADL and the higher tion between GDS and ADL In order to validate the application of the tests in as- the values of GDS. The correlation between the scales Difficulties with the analysis of the correlation proves their comparability and possibility age and no sessing terminal patients, everyday activities occur independently from the patients' to be used for terminal patients. between particular tests and scales was performed. significant correlation ADL and GDS was assessed age A relatively high correlation was noted between GDS and everyday life activities was observed. The correlation between between the patients' and presented Therefore, itin the dispersion graphthat after reaching a BDI (correlation coefficient r = 0.6631). It suggests may be assumed (Figure 1). Every and certain age biological abilities needed for point of the graph has the number of subjects provided. high comparability of both scales (pictured in Figure 2). Negative correlation was found at the level of r = independent existence disappear and functional disability increases. Higher correlation between BDI and the patients' age may suggest its higher ability to diagnose mental state of terminal patients. It confirmed correlations described in numerous A relatively high correlation was noted between GDS and BDI (correlation coefficient r = 0.6631). It suggests high comparability of both scales (pictured in Figure 2). Wykr. rozrzutu: ADL vs. 5 4 3 2 1 0 0,5 1,0 1,5 2,0 2,5 ADL 3,0 3,5 4,0 4,5 Wykr. rozrzutu: BECK vs. (BD usuwano przypadk.) = 6,4793 - ,0798 * BECK Korelacja: r = -,4129 0,95 Prz.Uf n. Wykr. rozrzutu: BECK vs. (BD usuwano przypadk.) = 6,4793 - ,0798 * BECK Korelacja: r = -,4129 Wykr. rozrzutu: GSD vs. = 6,4305 - ,1037 * GSG Korelacja: r = -,3089 Wykr. rozrzutu: GSD vs. = 6,4305 - ,1037 * GSG Korelacja: r = -,3089 BECK BECK 0,95 Prz.Ufn. 0,95 Prz.Ufn. GSG GSG 0,95 Prz.Ufn. 0,95 Prz.Ufn. Correlation: r = 0.4129 Dispersion BDI BDI vs. ; GDS = 10.397 + + 0.38163 BDI; Correlation: = 0.66317 Dispersion graph: graph:vs. GDSGDS ; GDS = 10.3970.38163 * * BDI;Correlation: rr = 0.66317 Fig. 2. Dispersion survival 6.4793 ­all scales Fig. 2. Dispersion graph: BDI vs.between survivaltime = and all scales Dispersion between time; and 0.0798 * BDI; Dispersion graph: BDI vs. GDS ; GDS = 10.397 + 0.38163 * BDI; Correlation: r = 0.66317 Dispersion graph: BDI vs. ; = 6.4793 ­ 0.0798 * BDI; Correlation: r = 0.4129 Correlation: r = 0.4129own calculation. Additionally, order to assess Source: authors' correlations between particular scales and 1 or 4 points were omitted (4 cases). In CI - 0.950.95 CI Source: authors' own calculation. tests and sometimes of the examined group the differences a non-parametric Mann-Whitney U test were assessed. was applied. Due to the previously presented and described qualitaThe result of Additionally, correlations between particular scales and tests and the test does the thesometimes not contradict of tive character of ADL variable, the correlation between sis about no differences between groups (p=0.2847). Additionally, correlations betweenthe use of Pearson's Although the and sometimes of particular scales and tests group which received 3 points in ADL these variables group assessed with the examined was not were assessed. linear correlation coefficient. However, the examined group were assessed. the test for the scale experienced longer , the differences significance of differences waspresented and described qualitative character of ADL variable, the of Due to the previously applied. Due to the fact are slight and statistically insignificant. The number that the variable measured in ADL scale has only four points in ADL test does not influence of the Due to (1, 2,previously presented andwas 4 oc- assessed with characterof Pearson'slist of means. qualitative the is confirmed by variable, values the 3 and 4 points) and the values and not correlation between these variables 1 described examined patients. It use of ADLthe linear the cur only twice in the set of results, comparative analysis Therefore, better functional activity achieved by e.g. correlation between groups: However, thewas 2not assessed with differencesof Pearson'sDue correlation coefficient. the subjects who test for the significance of the use was applied. survival includes only two these variables had points physiotherapeutic procedures does not affect linear and those who had 3 points in ADL scale. Subjects with time. Fig. 2. Dispersion between and all scales Dispersion graph: BDI vs. ; = 6.4793 ­ 0.0798 * BDI; to the coefficient. However, the test ADL scale has only four values (1, 2, 3 and 4 points) correlation fact that the variable measured in for the significance of differences was applied. Due Tab. that the 1 and 4 measured twice in scale of only four values (1, 2, 3 and 4 points) to theand theMann-Whitney U test results only in ADL the sethas results, comparative analysis includes fact 2. valuesvariable occur Mean range N significant only two and the valuesgroups: the subjects who had in points andp those who had 3 points analysis scale. 1 and 4 occur only twice 2Z the set of results, comparative in ADL includes 47.9 54.5 0.2847 67 32 only two groups: the subjects who had 2 -1.1 points and those who had 3 points in ADL scale. Subjects with 1 or 4 points were omitted (4 cases). In order to assess the differences a nonparametric Mann-Whitney U test was applied. Tab. 3. Mann-Whitney U test particular Source: authors' own calculation ) Tab. 2.Statistical analysis of means inresults ( groups of subjects SD - 2 pts Group with 2 pts Group with 2 pts Subjects with 1 or 4 points were omitted (4 cases). In order to assess the differences a nonparametric Mann-Whitney U test Mean -applied. was group 3 pts Mean - group 2 pts Mean range Group with 2 pts Mean 47.9 range 54.5 Z SD - 3 pts 1.8 4.1 4.5 Tab. 2. Mann-Whitney U test results ( Source: authors' own 1.5 calculation ) N significant Group with 2 pts Group with 2 -1.1 N 67 significant Group with 2 pts 47 The comparison of the patients' state with the use of BDI taking into account their age group. The obtained result is on the verge of statistical significance (p=0.0568). Therefore, the thesis about no differences between the groups concerning depression levels cannot be disproved. However, it is worth noting differences existing between the groups. It is clearly visible that the values obtained in the test increase with the subjects' age, which is confirmed by the list of means. The comparison of the patients' state with the use of GSD taking into account their age group. As far as GDS is concerned, the level of p=0.0239 contradicts the thesis about no differences between age groups. There occurred statistically significant differences concerning the level of depression of the subjects. On the basis of mean ranges, it is clearly visible that the level of the variable increases with age, similarly to BDI, which is confirmed by the list of means. In order to determine statistically significant difference between the groups Multiple Comparison was carried out. This procedure shows that a statistically significant difference occurred only between the groups "above 90 yrs" and "below 80 yrs", i.e. between the youngest and the oldest patients examined. Multiple Comparison Test made it possible to accept the thesis about differences between the youngest group (below 80 yrs) and the middle group (80-90 yrs). For this comparison the significance was at the level of p=0.0117. The result of the comparison of the youngest and the oldest group was on the verge of statistical significance. The result shows that there exists statistically significant negative correlation at the level of r = -0.4129. It means that high values for one variable are accompanied by low values for the other one, i.e. higher values for BDI are accompanied by lower values for . Both scales are of quantitative character and therefore, in order to assess the correlation, Pearson's linear correlation coefficient was used. Tab. 4. Results of correlation test between BDI, GDS and Variable BDI GDS r (x,y) -0.41 -0.31 r2 0.17 0.10 Statistically significant variables (p=0.0015) correlate with each other. Similarly to the abovementioned correlations, the correlation is average and negative (r = -0.3089). The comparison of the patients' state with the use of ADLs taking into account their age group. Due to the fact that there are three age groups, Kruskal-Wallis ANOVA test was applied. It is a non-parametric counterpart of one-factor variance analysis. With the use of this test it was checked whether the number of independent samples come from the same population and whether they differ significantly. The test provided a statistically insignificant result (p=0.5808). Therefore, there are no differences concerning physical fitness between patients from the three compared age groups. The list of means shows that the differences are slight. Tab. 5. Comparison of mean results of tests and according to the subjects sex Variable ADL BDI GDS SURVIVAL Mean ­ female 2.4 28.0 21.6 4.3 Mean ­ male 2.2 28.2 19.9 4.2 SD ­ female 0.6 8.2 4.6 1.6 SD - male 0.5 7.5 4.6 1.5 Tab. 6. Results of Kruskal-Wallis test for ADL,BDI, GDS variables Age group ADL;BDI;GDS below 80 yrs 80-90 yrs above 90 yrs Mean ­ range 53.8; 41.8; 39.1 52.7; 52.8; 54.2 45.9; 65.1; 63.4 N -significant 24; 24; 24 64; 64; 64 15; 15; 15 1.1; 8.5; 7.1 H p ADL- 0.5808 BDI- 0.0568 GDS- 0.0239 Tab. 7. Means and standard deviations for ADL; BDI; GDS variables in age groups Age group below 80 yrs 80-90 yrs above 90 yrs ADL- mean 2.4 2.3 2.2 SD 0.6 0.5 0.4 BDI-mean SD 24.5 28.2 31.7 9.2 7.9 4.4 GDS-mean 11.9 21.5 23.0 SD 4.5 4.7 3.2 Tab. 8. Multiple Comparison results below 80 yrs R:39.083 below 80 yrs 80-90 yrs above 90 yrs --0.10489 0.039845 80 - 90 yrs R:54.164 0.10489 --0.838436 above 90 yrs R:63.433 0.039845 0.838436 - Tab. 9. Multiple Comparison results below 80 yrs R: 68.1 below 80 yrs 80-90 yrs above 90 yrs --0.011 0.066 80-90 yrs R: 47.4 0.011 --1 above 90 yrs R: 45.6 0.066 1 - Discussion The studies on the quality of life of terminal patients take into account various aspects concerning health and disease and are aimed at increasing the participation of patients and their families in assessing their life situation. In their research Guse and Masesare [7] revealed that "patients in long-term care chose the need to help others as the most significant component of their life quality despite their own health limitations In the presented research the level of life activity (ADL) of patients had a crucial meaning for their life and the quality of dying. They revealed a high level of disability (65.5% of all the subjects ­ 1 and 2 points in ADL scale). A deeper disability correlating with deeper changes in their health brings about the need for more intensive care over terminal patients. Problems with functioning in everyday activities unequivocally influence the level of depression, behaviours and feelings of patients.[1,2,8]. Depression scales, i.e. GDS (assessing the patient's state within the last two weeks) and BDI (assessing the patient's state within the last six months), revealed an increase in depressive processes connected with age in the examined group. An average GDS value was 21 points and an average value for BDI was 28 points. Deep depression (21 points and more, according to GDS) was noted in 45% of the respondents, i.e. 46 subjects, while severe depression (28 points and more, according to BDI) was noted in 42% of the respondents (43 subjects). It may indicate the fact that there was no proper diagnosis and therefore, there was no diagnostic treatment. Depressive disorders occur at many stages of patients' life and include numerous factors. The majority of patients experience mainly lower mood, circadian rhythm disturbances, fear and psychomotor retardation. In a clinical image "it may be manifested by poor mimics, sad or strained facial expression, monotonous voice, slowdown or motor anxiety". These symptoms are of a somatic character and may mean mood disorders. Diagnosing depression must be based on patient examination, contact with patients and a detailed assessment of their mental and psychological state. Due to the fact that depression symptoms may be similar to other diseases, they must be analysed taking into account "depressive style of thinking" [8-11] Diagnosing depression in terminal patients is difficult and therefore, "the majority of depression cases in suffering patients are not recognised at all" Depression is frequently a reaction to disease and disability. Limited activity may often serve as a driving force. Terminal diseases increase anxiety about how a patient will manage in this situation. Negative attitude and attention directed "inside" distance patients from the possibility to use clinical support and their passive attitude weakens reactions useful in dealing with difficult situations. Concentrating on a problem brings a risk of destructive symptoms [9,12-14] In many researches, Puyski, Gadecka, Regin [15-17] proves that in 20% of the population of elderly people 49 otherapy in terminal care was accepted only by 14.6% of patients, which indicates that they do not expect such care, but high levels of their depression require detailed diagnosis and broader psychological care which may be provided by physiotherapists. Conclusions: 1. Implementing physiotherapeutic and psychological diagnostic tests in everyday terminal care makes it easier to assess of terminal patients and significantly improves their life and dying with dignity 2. Proper understanding of the symptoms of dying must serve as a basis for organising adequate activities compliant with the progress of a disease of a terminal patient without disturbing the process of dying. 3. Modern physiotherapy in terminal care should limit the range of physiotherapeutic procedures and physical therapy while increasing psychological care in this population. http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Advances in Rehabilitation de Gruyter

The role of physiotherapy in terminal care

Loading next page...
 
/lp/de-gruyter/the-role-of-physiotherapy-in-terminal-care-pa5Q4ijuif
Publisher
de Gruyter
Copyright
Copyright © 2016 by the
ISSN
1734-4948
eISSN
1734-4948
DOI
10.1515/rehab-2015-0038
Publisher site
See Article on Publisher Site

Abstract

Introduction: Terminal patients require proper care standards and professional team of doctors, physiotherapists, social workers, educators, psychologists and clergy directly involved in mitigating the suffering of a dying person. A physiotherapist as a member of such a team should be focused on sustaining the patient's quality of life until the end at the level relevant to the patient's health state. This quality of life should be perceived integrally as a combination of procedures reducing pain and physical suffering as well as improving physical fitness and mental well-being. Material and methods:The aim of the research was to define the role of physiotherapy in assessing mental and physical state of terminal patients; to determine the applicability of ADLs, GDS and BDI in diagnosing the validity and usefulness of tiresome physiotherapeutic procedures for terminal patients and to assess the applied tests in predicting terminal patients' . The research was carried out on the turn of 2012 and 2013 in the group of 103 subjects (74 females - 71.8% and 29 males ­ 28.2%) For the research the following methods were used: - Activity of Daily Living scale (ADL)- Beck Depression Inventory (BDI) - Geriatric Depression Scale (GDS) - Questionnaire regarding their willingness to participate in physiotherapeutic procedures. Results: In the research the range of diagnostic possibilities of the applied scales and tests, correlations between theses scales and tests as well as correlations between them and subjects' age and were assessed. Additionally, a questionnaire survey was carried out which assessed the willingness to participate in physiotherapeutic procedures. Strong stress, terminal state of the patient and generalisation of symptoms brought about the fact that only 14.6% of patients declared their willingness to participate in physiotherapeutic procedures. Conclusions: 1. Implementing physiotherapeutic and psychological diagnostic tests in everyday terminal care makes it easier to assess of terminal patients and significantly improves their life and dying with dignity 2. Proper understanding of the symptoms of dying must serve as a basis for organising adequate activities compliant with the progress of a disease of a terminal patient without disturbing the process of dying. 3. Modern physiotherapy in terminal care should limit the range of physiotherapeutic procedures and physical therapy while increasing psychological care in this population. Slowa kluczowe: e-mail: funcional assesment, paliatic care, physioterapy a.ronikier@awf.edu.pl 42 Streszczenie Wstp: Terminalny stan chorego, zblianie si do mierci wymaga wychowania slub spolecznych: lekarzy, fizjoterapeutów, pracowników socjalnych, pedagogów i osoby duchowne do zlagodzenia cierpie starzejcego si bardzo szybko czlowieka. Fizjoterapeuta jako czlonek tego zespolu winien kierowa si w swych dzialaniach trosk o utrzymanie odpowiedniej do wieku jakoci ycia pacjenta, a po jego koniec. T jako ycia naley rozumie integralnie, jako zabiegi redukujce ból i cierpienie fizyczne, poprawiajce sprawno fizyczn i dobrostan psychiczny Material i metody: Celem przeprowadzonych bada bylo okrelenie roli fizjoterapii w ocenie stanu mentalnego i fizycznego pacjentów terminalnych, oraz ocena uytecznoci i wiarygodnoci skal funkcjonalnych ADL, GDS oraz BDI w diagnozowaniu uciliwoci procedur opieki fizjoterapeutycznej nad t grup pacjentów. Oceniano take w oparciu o wyniki przeprowadzonych testów czas przeycia badanych. Badania zostaly przeprowadzone na przelomie roku 2012 i 2013 na grupie 103 pacjentów (74 kobiety ­ co stanowilo 71.8% badanych oraz 29 mczyznach ­ 28.2% badanych). rednia wieku badanych 85.3 + 6.4 lata. W badaniach wykorzystano nastpujce testy funkcjonalne: - Skal Aktywnoci ycia Codziennego ( ADL ) - skal depresji Becka ( BDI ) - Geriatryczn skal depresji (GDS ) oraz przeprowadzono wród badanych ankiet na temat chci ich uczestnictwa w zabiegach fizjoterapeutycznych Wyniki: Analiz statystyczn przeprowadzono trójtorowo, ze wzgldu na zloono problemów badawczych. W badaniach oceniono warto diagnostyczn zastosowanych skal i testów. Nastpnie poddano analizie korelacj pomidzy skalami i testami uytymi w badaniu, poddano take analizie korelacje pomidzy nimi a czasem przeycia pacjentów zbadanych 3 grup. Przeprowadzono równie badania kwestionariuszowe oceniajce ch uczestnictwa pacjentów w procedurach fizjoterapeutycznych. Nasilony stres, poglbiajcy si stan terminalny chorego oraz uogólnienie objawów chorobowych spowodowaly, e jedynie 14,6% pacjentów zadeklarowalo ch uczestnictwa w zabiegach fizjoterapeutycznych. Wnioski: 1. Wprowadzenie do codziennej praktyki w opiece terminalnej, fizjoterapeutycznych i psychologicznych testów diagnostycznych ulatwia ocen przeywalnoci terminalnie chorego pacjenta, w sposób istotny przyczynia si do poprawy jakoci ich ycia i godnego umierania. 2. Poprawne odczytywanie oznak umierania, musi stanowi podstaw do organizacji celowych i adekwatnych dziala zgodnych z postpem choroby terminalnie chorego bez zaburzania procesu jego umierania. 3. Nowoczesna fizjoterapia w opiece terminalnej powinna ograniczy zakres zabiegów fizykalnych i kinezyterapi na rzecz opieki psychologicznej nad ta populacj. Key words: ocena funkcjonalna, opieka paliatywna, fizjoterapia Introduction A physiotherapist must establish such a relation with a patient that it does not increase the suffering but brings relief. Therefore, terminal care requires a special type of empathy, not only as far as intuition and openness are concerned but also taking into account the knowledge of psychiatry and psychology directed at understanding the patient.. A physiotherapist has to do it so that as much information about the patients as possible is collected in order to understand them better. Implementing physiotherapeutic and psychological diagnostic tests in everyday terminal care makes it easier to assess of terminal patients and significantly improves their life and dying with dignity. The aim of the research: ­ to define the role of physiotherapy in assessing mental and physical state of terminal patients; ­ to determine the applicability of ADLs, GDS and BDI in diagnosing the validity and usefulness of tiresome physiotherapeutic procedures for terminal patients; 43 criterion the patients were classified to the following categories: ­ capable individuals collected 5 to 6 points, ­ moderately incapable individuals - 3 to 4 points, ­ deeply incapable individuals - 0 to 2 points. 2. Beck Depression Inventory (BDI) Depression in terminal patients increases with their physical and mental suffering, sadness, feeling of guilt, loneliness, disagreement with the situation and fear from the disease and its results. BDI includes 21 activities. No depression, only low mood was recognised at 0-10 points, mild depression at 11-27 points, while severe depression at more than 28 points. The scale is highly coherent and reliable and is most commonly used in assessing depression in elderly and terminal patients. To compare with the full version of the scale, its shortened version was applied. 3. Geriatric Depression Scale (GDS) GDS assessed the mood of the subjects within the last 2 weeks. A full version of the scale assessing 30 features was applied (a positive reply to the question in the scale - 1 point). Patients without depression (0-10 points); mild depression (11-20 points); severe depression (> 21points). 4. Questionnaire regarding their willingness to participate in physiotherapeutic procedures. During the research the respondents replied to a question regarding their willingness to participate in physiotherapeutic procedures. Results In the research the range of diagnostic possibilities of the applied scales and tests, correlations between theses scales and tests as well as correlations between them and subjects' age and were assessed. Additionally, a questionnaire survey was carried out which assessed the willingness to participate in physiotherapeutic procedures. Strong stress, terminal state of the patient and generalisation of symptoms brought about the fact that only 14.6% of patients declared their willingness to participate in physiotherapeutic procedures. These were the subjects who got 3-4 points according to ADL Scale. The results for quality scales are presented in numerical tables with the structure indices (%). Normal distribution of quantity variables was assessed with Shapiro-Wilk W test. In order to describe the distribution of particular variables a measure of central tendency, measures of dispersion and measures of distribution symmetry were applied. Pearson's linear correlation coefficient with linear regression was used to assess correlations between quantity variables. For intergroup to assess the applied tests in predicting terminal patients' . Material and methods The research was carried out on the turn of 2012 and 2013 in the group of 103 subjects (74 females - 71.8% and 29 males ­ 28.2%) who were residents of Care Home "Kombatant" in Olsztyn, Care Home in Molza and Hospice at the County Hospital in Grudzidz. Average age was 83.5 ± 6.4 years. After 9 months a control study was carried out in order to define the survival period of the examined group. For particular analyses patients were divided into age groups, i.e. the first group ­ patients below 80 years of age (24 subjects ­ 23.3%), the second group ­ below 90 (64 subjects ­ 62.1%) and the third group ­ above 90 (15 subjects ­ 14.6%). For the research the following methods were used: ­ Activity of Daily Living scale (ADL)- [1,2, 4] ­ Beck Depression Inventory (BDI) [3,5] ­ Geriatric Depression Scale (GDS) [4,5,6] ­ Questionnaire regarding their willingness to participate in physiotherapeutic procedures. Statistical analysis was carried out in three stages due to the complexity of research problems. At the first stage the results of scales and tests were compared to the subjects' age, then the correlation between the scales and tests used in the research was analysed while at the last stage the correlation between these tests and scales and survival period of the subjects from the examined group was studied. For the statistical analysis the Statistica 10.0 PL (Statsoft.Inc.2011) software and descriptive statistics of the examined distribution variables were applied. During the research the following research theses were verified: ­ the level of a terminal patient's depression influences the range of physiotherapeutic procedures to be applied; ­ the applied scales and tests correlate with each other and may be helpful in defining the range and character of the physiotherapeutic procedures; ­ the applied scales and tests correlate with the terminal patient's . 1. Activity of Daily Living scale (ADLs) In the research a simplified 6-point ADL scale was applied, which assessed the range of help in particular everyday activities such as: 1 ­ mobility, 2 ­ sphincter muscle control, 3 ­ personal hygiene, 4 ­ getting dressed, 5 ­ eating meals on one's own, 6 ­ communication. Being able to perform the abovementioned activities was marked with 1 point, while not being able to perform them was marked with 0 points. According to this 44 comparisons non-parametric Mann-Whitney U test and Kruskal-Wallis ANOVA test were applied. The level of significance was accepted at p=0.05. 1. ADL variable assessment The range of points of the examined patients in ADL scale. 1 point - 1.94% of patients; 2 points - 65.05%; 3 points 31.07%; 4 points - 1.94%; 5 and 6 points - 0% of patients. The activities which required most help in ADL scale included controlled micturating and defecating ­ 85% and standing up from bed and moving to an armchair ­ 76%. These numbers show that the majority of subjects (65%) are physically disabled individuals for whom every form of physical activity may reduce the effects of functional and systemic changes in a body. However, it does not influence the respondents' willingness to participate in active physiotherapy. 2. BDI variable assessment The range of points in BDI Scale for particular age groups. The level of depression according to BDI: ­ no depression or low mood - 2 subjects (2%), ­ mild depression - 43 subjects ( 41.7%), ­ severe depression - 58 subjects ( 56.3% ) The variable of this scale was also measured in quantity scale. The mean was 28 and the median had one point more with standard deviation at the level of 8. The distribution is bimodal (values 31 and 35 are repeated 7 times in the data set). Minimal value was 7 and maximal value was 44. The distribution is slightly flat and skewed left. The result of Shapiro-Wilk W test contradicts the thesis about normal distribution of the examined variable with the level of significance at p=0.0100. 3. GDS variable assessment The range of the points in GDS for particular age groups was as follows: subjects below 80 years of age - 19 points (SD-4.8); below 90 years of age - 22 points (SD-4.6), above 90 years of age - 23 points (SD-3.2). The level of depression of the subjects according to the scale interpretation proved that all the subjects suffered from depression at different intensity, i.e. 41 patients (38.8%) had mild depression while 62 subjects (68.2%) had severe depression. A growing level of depression which is a symptom of terminal state may lead to more severe disease symptoms and sooner death of a patient. GSD variable is measured in a quantity scale and therefore, a broader spectrum of statistics characterising this variable is presented. A mean level of GSD was 21.1, a median was at the level of 21, while a mode, i.e. the value most frequently repeated in the described set, was at the level of 22 and appeared 13 times. The minimal number of points in the test was 11, while the maximal value was 29 points. The dispersion analysis revealed that standard deviation was at the level of 4.6, and thus, the dispersion was low. The skewness was at the level of -0.3, which means that the distribution is slightly flat, while the negative skewness value at the level of -0.7 indicated that the distribution is skewed left. Shapiro-Wilk W test result at the level of p=0.010 contradicts the thesis about normal distribution of the examined variable. 4. variable assessment The mean in the examined group was 4.29 months with standard deviation at the level of 1.5. The shortest was 1 month since the date of the research, while the longest ­ 8 months. Shapiro-Wilk W test made it possible to disprove the thesis about the normal distribution of the examined variable at the level of p=0.0192. A mean for the examined group (defined by the points in the scales): ADL - 2.3 points, BDI - 28.0 points, GDS- 21.1points. 5. Correlation between particular tests and scales and subjects' age The correlation between the terminal patients' age and particular scales and tests applied in the research was assessed. The correlation between ADL scale and patients' age is presented at the dispersion graph (Figure 1). Every point of the graph has a number of subjects provided. Negative correlation was found at the level of r = -0.1652. Difficulties with everyday activities occur independently from the patients' age and no significant correlation between the patients' age and everyday life activities was observed. Therefore, it may be assumed that after reaching a certain age biological abilities needed for independent existence disappear and functional disability increases. Higher correlation between BDI and the patients' age may suggest its higher ability to diagnose mental state of terminal patients. It confirmed correlations described in numerous studies between age and mental depression as well as between age and the necessity to help this group of people in this matter. The correlation between BDI and age is presented at the dispersion graph 1. Positive correlation was found at the level of r = 0.40506. A high level of terminal patients' depression increases with age and somatic changes connected with the developing disease. The results of the test confirmed, even to a higher degree than BDI test result, that the increase in depression with age makes it necessary to provide psychological care to this group of subjects. These tasks may also be performed by physiotherapists, due to the limited possibilities of clinical psychology in Poland. Tab.1. Descriptive statistics for the BDI, GDS and variables A mean for the examined group (defined by the points in the scales): Frequency ADL - 2.3 points, BDI - 28.0 points, GDS- 21.1points. BDI 28.0 29 21 4 31 and 35 22 3 7 7 GDS-21.1 13 19 11 1 Mean Median Mode of mode Min Max 44 29 8 SD 8.0 4.6 1.5 Skewness -0.5 -0.3 0.2 Kurtosis -0.3 -0.7 -0.6 5. Correlation between particular tests and scales and subjects' age. time research 4.2 The correlation between the terminal patients' age and particular scales and tests applied in Survival was assessed. The correlation between ADL scale and patients' age is presented the at the dispersion graph (Figure 1). Every point of the graph has a number of subjects provided. Negative correlation was found at the level of r = -0.1652. ADL Source: authors' own calculation. Dispersion graph: BDI vs. Age; Age 75.060 + 0.30152 * BDI; Correlation: r = 0.37584 Fig. 1. Graph presenting=dispersion between all scales and subjects' age Dispersion graph: ADL vs. age; Age = 88.019 ­ 1.933 * ADL; Correlation: r = - 0.1652 CI - 0.95 Dispersion graph: ADL vs. age; Age = 88.019 ­ 1.933 * ADL; Correlation: r = - 0.1652 CI - 0.95 Dispersion graph: GSD vs. Age; Age = 71.601 + 0.56470 * GSD; Correlation: r = 0.40506 Dispersion graph: ADL vs. GSD; GSD = 26.117 ­ 2.154 * ADL; Correlation: r = - 0.2566 The correlation between BDI and age is presented at the dispersion graph (Figure 1). Positive correlation was found at the level of r = 0.37584. Dispersion graph: BDI vs. Age; Age = 75.060 + 0.30152 * BDI; Correlation: r = 0.37584 The correlation between BDI and age is presented at the dispersion graph (Figure 1). Positive correlation was found at the Fig. 1. Graph presenting dispersion between all scales and subjects' age level of r = 0.37584. CI - 0.95 Dispersion graph: GSD vs. Age; Age = 71.601 + 0.56470 * GSD; Correlation: r = 0.40506 Dispersion graph: ADL vs.selected tests and scales Correla- -0.2566. The r = - 0.2566 6. Correlations between GSD; GSD = 26.117 ­ 2.154 * ADL; Correlation: more difficulties patients had with everyday activities, the lower the values of ADL and the higher tion between GDS and ADL In order to validate the application of the tests in as- the values of GDS. The correlation between the scales Difficulties with the analysis of the correlation proves their comparability and possibility age and no sessing terminal patients, everyday activities occur independently from the patients' to be used for terminal patients. between particular tests and scales was performed. significant correlation ADL and GDS was assessed age A relatively high correlation was noted between GDS and everyday life activities was observed. The correlation between between the patients' and presented Therefore, itin the dispersion graphthat after reaching a BDI (correlation coefficient r = 0.6631). It suggests may be assumed (Figure 1). Every and certain age biological abilities needed for point of the graph has the number of subjects provided. high comparability of both scales (pictured in Figure 2). Negative correlation was found at the level of r = independent existence disappear and functional disability increases. Higher correlation between BDI and the patients' age may suggest its higher ability to diagnose mental state of terminal patients. It confirmed correlations described in numerous A relatively high correlation was noted between GDS and BDI (correlation coefficient r = 0.6631). It suggests high comparability of both scales (pictured in Figure 2). Wykr. rozrzutu: ADL vs. 5 4 3 2 1 0 0,5 1,0 1,5 2,0 2,5 ADL 3,0 3,5 4,0 4,5 Wykr. rozrzutu: BECK vs. (BD usuwano przypadk.) = 6,4793 - ,0798 * BECK Korelacja: r = -,4129 0,95 Prz.Uf n. Wykr. rozrzutu: BECK vs. (BD usuwano przypadk.) = 6,4793 - ,0798 * BECK Korelacja: r = -,4129 Wykr. rozrzutu: GSD vs. = 6,4305 - ,1037 * GSG Korelacja: r = -,3089 Wykr. rozrzutu: GSD vs. = 6,4305 - ,1037 * GSG Korelacja: r = -,3089 BECK BECK 0,95 Prz.Ufn. 0,95 Prz.Ufn. GSG GSG 0,95 Prz.Ufn. 0,95 Prz.Ufn. Correlation: r = 0.4129 Dispersion BDI BDI vs. ; GDS = 10.397 + + 0.38163 BDI; Correlation: = 0.66317 Dispersion graph: graph:vs. GDSGDS ; GDS = 10.3970.38163 * * BDI;Correlation: rr = 0.66317 Fig. 2. Dispersion survival 6.4793 ­all scales Fig. 2. Dispersion graph: BDI vs.between survivaltime = and all scales Dispersion between time; and 0.0798 * BDI; Dispersion graph: BDI vs. GDS ; GDS = 10.397 + 0.38163 * BDI; Correlation: r = 0.66317 Dispersion graph: BDI vs. ; = 6.4793 ­ 0.0798 * BDI; Correlation: r = 0.4129 Correlation: r = 0.4129own calculation. Additionally, order to assess Source: authors' correlations between particular scales and 1 or 4 points were omitted (4 cases). In CI - 0.950.95 CI Source: authors' own calculation. tests and sometimes of the examined group the differences a non-parametric Mann-Whitney U test were assessed. was applied. Due to the previously presented and described qualitaThe result of Additionally, correlations between particular scales and tests and the test does the thesometimes not contradict of tive character of ADL variable, the correlation between sis about no differences between groups (p=0.2847). Additionally, correlations betweenthe use of Pearson's Although the and sometimes of particular scales and tests group which received 3 points in ADL these variables group assessed with the examined was not were assessed. linear correlation coefficient. However, the examined group were assessed. the test for the scale experienced longer , the differences significance of differences waspresented and described qualitative character of ADL variable, the of Due to the previously applied. Due to the fact are slight and statistically insignificant. The number that the variable measured in ADL scale has only four points in ADL test does not influence of the Due to (1, 2,previously presented andwas 4 oc- assessed with characterof Pearson'slist of means. qualitative the is confirmed by variable, values the 3 and 4 points) and the values and not correlation between these variables 1 described examined patients. It use of ADLthe linear the cur only twice in the set of results, comparative analysis Therefore, better functional activity achieved by e.g. correlation between groups: However, thewas 2not assessed with differencesof Pearson'sDue correlation coefficient. the subjects who test for the significance of the use was applied. survival includes only two these variables had points physiotherapeutic procedures does not affect linear and those who had 3 points in ADL scale. Subjects with time. Fig. 2. Dispersion between and all scales Dispersion graph: BDI vs. ; = 6.4793 ­ 0.0798 * BDI; to the coefficient. However, the test ADL scale has only four values (1, 2, 3 and 4 points) correlation fact that the variable measured in for the significance of differences was applied. Due Tab. that the 1 and 4 measured twice in scale of only four values (1, 2, 3 and 4 points) to theand theMann-Whitney U test results only in ADL the sethas results, comparative analysis includes fact 2. valuesvariable occur Mean range N significant only two and the valuesgroups: the subjects who had in points andp those who had 3 points analysis scale. 1 and 4 occur only twice 2Z the set of results, comparative in ADL includes 47.9 54.5 0.2847 67 32 only two groups: the subjects who had 2 -1.1 points and those who had 3 points in ADL scale. Subjects with 1 or 4 points were omitted (4 cases). In order to assess the differences a nonparametric Mann-Whitney U test was applied. Tab. 3. Mann-Whitney U test particular Source: authors' own calculation ) Tab. 2.Statistical analysis of means inresults ( groups of subjects SD - 2 pts Group with 2 pts Group with 2 pts Subjects with 1 or 4 points were omitted (4 cases). In order to assess the differences a nonparametric Mann-Whitney U test Mean -applied. was group 3 pts Mean - group 2 pts Mean range Group with 2 pts Mean 47.9 range 54.5 Z SD - 3 pts 1.8 4.1 4.5 Tab. 2. Mann-Whitney U test results ( Source: authors' own 1.5 calculation ) N significant Group with 2 pts Group with 2 -1.1 N 67 significant Group with 2 pts 47 The comparison of the patients' state with the use of BDI taking into account their age group. The obtained result is on the verge of statistical significance (p=0.0568). Therefore, the thesis about no differences between the groups concerning depression levels cannot be disproved. However, it is worth noting differences existing between the groups. It is clearly visible that the values obtained in the test increase with the subjects' age, which is confirmed by the list of means. The comparison of the patients' state with the use of GSD taking into account their age group. As far as GDS is concerned, the level of p=0.0239 contradicts the thesis about no differences between age groups. There occurred statistically significant differences concerning the level of depression of the subjects. On the basis of mean ranges, it is clearly visible that the level of the variable increases with age, similarly to BDI, which is confirmed by the list of means. In order to determine statistically significant difference between the groups Multiple Comparison was carried out. This procedure shows that a statistically significant difference occurred only between the groups "above 90 yrs" and "below 80 yrs", i.e. between the youngest and the oldest patients examined. Multiple Comparison Test made it possible to accept the thesis about differences between the youngest group (below 80 yrs) and the middle group (80-90 yrs). For this comparison the significance was at the level of p=0.0117. The result of the comparison of the youngest and the oldest group was on the verge of statistical significance. The result shows that there exists statistically significant negative correlation at the level of r = -0.4129. It means that high values for one variable are accompanied by low values for the other one, i.e. higher values for BDI are accompanied by lower values for . Both scales are of quantitative character and therefore, in order to assess the correlation, Pearson's linear correlation coefficient was used. Tab. 4. Results of correlation test between BDI, GDS and Variable BDI GDS r (x,y) -0.41 -0.31 r2 0.17 0.10 Statistically significant variables (p=0.0015) correlate with each other. Similarly to the abovementioned correlations, the correlation is average and negative (r = -0.3089). The comparison of the patients' state with the use of ADLs taking into account their age group. Due to the fact that there are three age groups, Kruskal-Wallis ANOVA test was applied. It is a non-parametric counterpart of one-factor variance analysis. With the use of this test it was checked whether the number of independent samples come from the same population and whether they differ significantly. The test provided a statistically insignificant result (p=0.5808). Therefore, there are no differences concerning physical fitness between patients from the three compared age groups. The list of means shows that the differences are slight. Tab. 5. Comparison of mean results of tests and according to the subjects sex Variable ADL BDI GDS SURVIVAL Mean ­ female 2.4 28.0 21.6 4.3 Mean ­ male 2.2 28.2 19.9 4.2 SD ­ female 0.6 8.2 4.6 1.6 SD - male 0.5 7.5 4.6 1.5 Tab. 6. Results of Kruskal-Wallis test for ADL,BDI, GDS variables Age group ADL;BDI;GDS below 80 yrs 80-90 yrs above 90 yrs Mean ­ range 53.8; 41.8; 39.1 52.7; 52.8; 54.2 45.9; 65.1; 63.4 N -significant 24; 24; 24 64; 64; 64 15; 15; 15 1.1; 8.5; 7.1 H p ADL- 0.5808 BDI- 0.0568 GDS- 0.0239 Tab. 7. Means and standard deviations for ADL; BDI; GDS variables in age groups Age group below 80 yrs 80-90 yrs above 90 yrs ADL- mean 2.4 2.3 2.2 SD 0.6 0.5 0.4 BDI-mean SD 24.5 28.2 31.7 9.2 7.9 4.4 GDS-mean 11.9 21.5 23.0 SD 4.5 4.7 3.2 Tab. 8. Multiple Comparison results below 80 yrs R:39.083 below 80 yrs 80-90 yrs above 90 yrs --0.10489 0.039845 80 - 90 yrs R:54.164 0.10489 --0.838436 above 90 yrs R:63.433 0.039845 0.838436 - Tab. 9. Multiple Comparison results below 80 yrs R: 68.1 below 80 yrs 80-90 yrs above 90 yrs --0.011 0.066 80-90 yrs R: 47.4 0.011 --1 above 90 yrs R: 45.6 0.066 1 - Discussion The studies on the quality of life of terminal patients take into account various aspects concerning health and disease and are aimed at increasing the participation of patients and their families in assessing their life situation. In their research Guse and Masesare [7] revealed that "patients in long-term care chose the need to help others as the most significant component of their life quality despite their own health limitations In the presented research the level of life activity (ADL) of patients had a crucial meaning for their life and the quality of dying. They revealed a high level of disability (65.5% of all the subjects ­ 1 and 2 points in ADL scale). A deeper disability correlating with deeper changes in their health brings about the need for more intensive care over terminal patients. Problems with functioning in everyday activities unequivocally influence the level of depression, behaviours and feelings of patients.[1,2,8]. Depression scales, i.e. GDS (assessing the patient's state within the last two weeks) and BDI (assessing the patient's state within the last six months), revealed an increase in depressive processes connected with age in the examined group. An average GDS value was 21 points and an average value for BDI was 28 points. Deep depression (21 points and more, according to GDS) was noted in 45% of the respondents, i.e. 46 subjects, while severe depression (28 points and more, according to BDI) was noted in 42% of the respondents (43 subjects). It may indicate the fact that there was no proper diagnosis and therefore, there was no diagnostic treatment. Depressive disorders occur at many stages of patients' life and include numerous factors. The majority of patients experience mainly lower mood, circadian rhythm disturbances, fear and psychomotor retardation. In a clinical image "it may be manifested by poor mimics, sad or strained facial expression, monotonous voice, slowdown or motor anxiety". These symptoms are of a somatic character and may mean mood disorders. Diagnosing depression must be based on patient examination, contact with patients and a detailed assessment of their mental and psychological state. Due to the fact that depression symptoms may be similar to other diseases, they must be analysed taking into account "depressive style of thinking" [8-11] Diagnosing depression in terminal patients is difficult and therefore, "the majority of depression cases in suffering patients are not recognised at all" Depression is frequently a reaction to disease and disability. Limited activity may often serve as a driving force. Terminal diseases increase anxiety about how a patient will manage in this situation. Negative attitude and attention directed "inside" distance patients from the possibility to use clinical support and their passive attitude weakens reactions useful in dealing with difficult situations. Concentrating on a problem brings a risk of destructive symptoms [9,12-14] In many researches, Puyski, Gadecka, Regin [15-17] proves that in 20% of the population of elderly people 49 otherapy in terminal care was accepted only by 14.6% of patients, which indicates that they do not expect such care, but high levels of their depression require detailed diagnosis and broader psychological care which may be provided by physiotherapists. Conclusions: 1. Implementing physiotherapeutic and psychological diagnostic tests in everyday terminal care makes it easier to assess of terminal patients and significantly improves their life and dying with dignity 2. Proper understanding of the symptoms of dying must serve as a basis for organising adequate activities compliant with the progress of a disease of a terminal patient without disturbing the process of dying. 3. Modern physiotherapy in terminal care should limit the range of physiotherapeutic procedures and physical therapy while increasing psychological care in this population.

Journal

Advances in Rehabilitationde Gruyter

Published: Mar 1, 2016

References