Occupational Therapy Interventions for the Improvement of the Quality of Life of Healthy Older Adults Living in Nursing Homes: A Systematic Review

Abstract

Objective

To evaluate current scientific evidence on the effectiveness of occupational therapy interventions for the improvement of the quality of life of healthy adults over 65 years old living in nursing homes.

Data source

PubMed, Web of Science, Dialnet, Scopus, Cochrane, Cinahl and SciELO databases searched between 2012 and 2022.

Study Inclusion and Exclusion Criteria

a) Studies involving occupational therapy interventions in residential settings (nursing homes or community residential settings), b) Studies conducted on a population of healthy adults over 65 years old, c) Studies with a level of evidence 1a-1b to 3a-3b, d) Studies containing the MeSH descriptors in the keyword list.

Data Extraction

For each study included in the review, key information was collected and entered into a data extraction form based on Cochrane recommendations, using Microsoft Excel v.16.16.21 software.

Data Synthesis

Descriptive summary of study characteristics and summarized methodological quality of the studies.

Results

Six of the articles met the inclusion criteria and were categorised into “promotion of active ageing” and “meaningful activities and quality of life”. Overall, the strength of evidence was moderate, and the risk of bias was low.

Conclusion

Occupational therapy intervention programmes structured around the opportunity to choose meaningful activities can improve the perceived quality of life of healthy older adults living in nursing homes.

Keywords

occupational therapy quality of life homes for the aged older adults nursing homes

Indexing Keywords

aging, interventions, systematic review

Objective

According to the World Health Organization,¹ both the number and proportion of older adults are increasing significantly in populations around the world. At present, Japan is the only country where the percentage of older adults is over 30%. However, by 2050, countries in Europe and North America, Chile, China, the Russian Federation, the Republic of Korea, the Islamic Republic of Iran, Thailand and Vietnam are expected to have a similar proportion.

Today, this global ageing of the population has a direct impact on the health and social care provided to older adults, conditioning geriatric care ranging from the disability prevention and typical age-related disease processes to end-of-life care.¹ This need for care has led to a proliferation of studies and research on improving the well-being and quality of life of this population group, especially in residential settings; understood as institutions intended for temporary or permanent accommodation, with services and intervention programmes appropriate to the needs of the older people being cared for, aimed at achieving a better quality of life and promoting their personal autonomy.²

Quality of life is a multidimensional concept that has evolved throughout history and currently has multiple interpretations. Thus, it is difficult to find a single definition.³

An integrative definition of the concept of quality of life is “quality of life is the result of the complex interaction between objective and subjective factors; the former are shaped by the external conditions, i.e. the economic, socio-political, cultural, personal and environmental factors, that facilitate or hinder the full development of individuals and their personalities; meanwhile, the latter are determined by the subject’s assessment of his or her own life”.⁴

In the case of healthy older adults living in nursing homes, these factors related to their quality of life can be improved by developing interventions from an Occupational Therapy (OT) perspective, as this field is focused on groups or communities and the multiple factors that influence their health and well-being: “OT practitioners develop and implement occupation-based health approaches to enhance occupational performance and participation, quality of life, and occupational justice for populations”.⁵ Likewise, as a social and health care field that addresses the prevention of disability and dependence using occupation based approach, OT becomes a vehicle for the improvement and maintenance of the quality of life and health of older adults.^6,7

However, previous systematic reviews of the literature which synthesise the scientific evidence on the effectiveness of occupation-based interventions among this population and in this area of practice are outdated, with the last one dating back to 2012.⁸

Therefore, the main purpose of this systematic review is to assist practitioners in making evidence-based decisions regarding such interventions. This study aimed to search for, evaluate and synthesise the scientific evidence on OT interventions to improve the quality of life of healthy older adults aged 65 years and over living in nursing homes. The research question guiding the review was: What is the quality of the scientific evidence on the effectiveness of OT interventions in improving the quality of life of healthy older adults aged 65 and over living in nursing homes?

Methods

This systematic review was conducted following the Cochrane Collaboration methodology⁹ and was reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines (PRISMA 2020).¹⁰

Data Sources

The initial search process was conducted by a medical librarian who had experience in conducting systematic reviews in collaboration with the review authors. In each stage of the review, the authors independently assessed the search terms and all studies before comparing the results.

A formal literature search was conducted (19/02/22 and 20/02/22) in the following selected databases: PubMed, Web of Science (WOS), Dialnet, Scopus, Cochrane, Cinahl and SciELO, using MeSH terms and keywords: Occupational Therapy, quality of life, aged and Homes for the Aged. A time limit (2012-2022) was also used as a filter for our search, given that the previous review had been conducted in 2012; no language or country of origin filters were used. In doing so, we tried to gather the latest information as comprehensively as possible. Our aim was to avoid any bias that might affect the information obtained.

The search string used in the databases was:

(1) PubMed: ((occupational therapy [MeSH Terms]) AND (quality of life [MeSH Terms])) AND (aged [MeSH Terms]) AND (Homes for the Aged [MeSH Terms]) Filters: from 2012-2022 → 19 results obtained.

(2) WOS: ((((ALL=(occupational therapy)) AND ALL=(aged)) AND ALL=(Homes for the Aged))) Filters: from 2012- 2022 → 566 results obtained.

(3) Dialnet: (Occupational therapy, quality of life, aged). Filter: 2012-2022 → 6 results obtained.

(4) Scopus: (Occupational therapy AND quality of life AND aged AND Homes for the Aged). Filters: from 2012-2022 → 207 results obtained.

(5) Cochrane: (Occupational therapy AND quality of life AND aged AND Homes for the Aged). Filters: from 2012-2022 → 187 results obtained.

(6) Cinahl: (Occupational therapy AND quality of life AND aged AND Homes for the Aged). Filters: from 2012-2022, aged: 65+ years → 140 results obtained.

(7) SciELO: (Occupational therapy AND quality of life AND aged AND Homes for the Aged). Filters: from 2012-2022 → 2 results obtained.

In addition to the aforementioned databases, a search was also carried out in Google Scholar (https://scholar.google.es/) to identify more studies that could potentially be included, as well as to avoid any bias that could lead to a decrease in the information obtained.

Inclusion and Exclusion Criteria

The following eligibility criteria were established.

→ Inclusion criteria:

(1) Studies involving OT interventions in residential settings (nursing homes or community residential settings).

(2) Studies conducted on a population of healthy adults over 65 years old. Functionally independent adults over 65 years old without any objective illness, physical or cognitive impairment or social problem derived from their health condition.

(3) Studies with a level of evidence 1a-1b to 3a-3b.

(4) Studies containing the MeSH descriptors in the keyword list.

→ Exclusion criteria:

(1) Studies whose primary focus of intervention was not OT related and in a non-residential setting. Older adults living at home or with their relatives, in hospitals and palliative care facilities.

(2) Studies in which the main purpose was related to disabling health conditions (chronic diseases, physical or cognitive impairment or social problems leading to dependency).

(3) Studies that did not contain any of the keywords.

We included studies with an evidence level 1a (systematic review of homogenous randomised controlled trials (RCT) -e.g. similar population or intervention-with or without meta-analysis), 1b (well-designed individual RCT - not a pilot or feasibility study with a small sample size), 2a (systematic review of cohort studies), 2b (individual prospective cohort study, RCT of low quality - e.g. <80% follow-up or a low number of participants, pilot or feasibility study, ecological study, non-randomised two-group study), 3a (systematic review of case-control studies) and 3b (individual retrospective case-control study, non-randomised one-group pretest-posttest study, cohort study). Level 4 (case series - or low-quality cohort or case-control study) and level 5 (expert opinion without explicit critical appraisal: protocols, dissertations and theses, and editorials) studies were excluded.¹¹

We included intervention studies within the scope of OT practice with significant outcomes related to the occupation-based population health approach for the improvement of occupational performance and participation, quality of life and occupational justice. Outcome measures could include life satisfaction (perception of progress toward goal identification), self-concept (beliefs and feelings about self), health and functioning (e.g., health status, self-care capabilities), and socioeconomic factors.⁵

Data Extraction

For each study included in the review, the key information was collected and entered into a data extraction form based on Cochrane recommendations,⁹ using Microsoft Excel v.16.16.21 software. The data extraction process was carried out by the researchers C.U. and P.M. independently. Finally, the whole extraction process was monitored by a third independent reviewer (J.C.A.). Data were extracted from each of the selected studies using the following variables: author/year, level of evidence, study design, risk of bias, participants, inclusion criteria, study setting, intervention and control group, outcome measures and results (see Table S1).

Data Synthesis

We conducted a descriptive summary of study characteristics and evaluated and summarized the methodological quality of the included studies (see Table S1).

The risk of bias in each study (low, moderate or high) was assessed according to the Cochrane risk of bias assessment guidelines.¹² The risk of bias in the systematic review was assessed according to the AMSTAR 2 guidelines.¹³ The results were then compared collaboratively to reach a consensus. Table S2 and Table S3 contain the risk of bias assessment of the included studies.

The strength of evidence was assessed based on guidelines developed by the U.S. Preventive Services Task.¹⁴ The levels are broadly described as follows: high strength of evidence consists of two or more well-designed RCTs whose results are unlikely to be challenged by future studies; moderate strength of evidence is defined as at least one high-quality RCT or multiple studies of moderate quality; low strength of evidence consists of a limited number of incomplete and low-quality studies.

Results

A full-text review was performed on 37 of the 1127 identified studies. Six of those studies met the eligibility criteria and were, therefore, included in the analysis (see Figure 1).

Figure 1.

PRISMA flow diagram of literature search and screen process.

Six studies described OT interventions to improve the quality of life of healthy older adults living in nursing homes: four studies were level 1b,^15-18 one was level 2a⁸ and another one was level 2b.¹⁹ Four studies showed a low risk of bias and two studies met the criteria for a moderate risk of bias (see Table S1, Table S2 and Table S3).

The six studies were divided into two topics, according to the main objective of the intervention programme: a) “promotion of active ageing” and b) “meaningful activities and quality of life”. Each topic was organised according to the primary focus of the intervention: “promotion of active ageing”, with n= 3 (50%): (a1) physical activity,^8,16,19 and (a2) cognitive, leisure and social participation and health promotion activities^8,19; and “meaningful activities and quality of life”, with n= 3 (50%): (b1) communication, volition, habituation and performance capacity activities,¹⁵ and (b2) meaningful occupations.^17,18 Two studies^8,19 were included in the two sub-themes, as they addressed both aspects. The characteristics of each study have been listed in Table S1.

Promoting Active Ageing

Physical activity

In three of the studies, physical activity was the primary intervention.^8,16,19

Cichocki et al¹⁶ (level 1b) conducted a study to assess the effects that an intervention based on multifaceted low-threshold physical activity had on health-related quality of life (HRQOL), physical functioning and activities of daily living (ADLs) of older adults living in nursing homes. The intervention consisted of 20 weekly exercise units (fall risks, walking and mobility aids, dance, bowling and ball games, balance and gait training, postural gymnastics, physical and cardiovascular training through ADL, functional strengthening, perceptual and proprioceptive training, balance, obstacle course, dual-task training, relaxation and breathing exercises, Yoga, Qi Gong and Tai Chi). At the one-year follow-up assessment, subjective health-related quality of life (EuroQol-5D, hereafter EQ-5D) improved significantly in the intervention group.

Johansson and Björklund¹⁹ (level 2b) conducted an active ageing promotion programme that included a physical activity-based intervention (mobility, time and energy). The results showed a positive change in physical functioning, bodily pain and vitality (Short Form Health Survey-36, hereafter SF-36) in the intervention group.

Arbesman and Lieberman⁸ (level 2a) conducted a systematic review to test the impact of active ageing programmes, including physical activity interventions (balance and gait training, lower limb strengthening, Tai Chi and general sitting and standing exercise) on the performance of older adults. Results from multiple longitudinal studies indicated that increased participation in physical activity resulted in reduced mortality, increased functioning and reduced levels of dependency in ADL and instrumental activities of daily living (IADL), which in turn influenced participants' perception of quality of life.

Cognitive, leisure and social participation and health promotion activities

Cognitive, leisure and social participation and health promotion activities were the primary interventions in two studies.^8,19

Johansson and Björklund¹⁹ (level 2b) conducted a study with a quasi-experimental design to test whether a health promotion programme (nutrition, health and ageing, mental well-being, social relationships and technical devices) with a mixed format (individual and group) could maintain/improve the general health and well-being of older adults. At the four-month follow-up, the intervention group showed statistically significant improvements in their general health and psychological well-being (SF-36).

Results from the systematic review by Arbesman and Lieberman⁸ (level 2a) indicated that increasing the participation in cognitive and leisure activities (reading, writing, playing word games or puzzles and attending talks) was associated with a lower risk of developing dementia and increased social participation, as well as the presence of a strong social network, which led to lower levels of physical and cognitive impairment and a better perception of quality of life.

Meaningful Activities and Quality of Life

Communication, volition, habituation and performance capacity activities

Activities related to communication, volition, habituation and performance capacity were the primary intervention in one of the studies.¹⁵

Kawamata et al¹⁵ (level 1b) conducted a study to evaluate the effectiveness of an OT programme based on the Model of Human Occupation (MOHO). The programme is based on talks and seminars that explore the role of personal causality, values, interests, roles, and habits, as well as motor, processing, communication and interaction skills and the environment in the performance of occupations that contribute to the improvement of quality of life and health promotion among healthy older adults. The results showed that said programme met the needs of healthy older adults in coping with the physiological changes of ageing and had a significant effect on physical pain (SF-36) and the environment (World Health Organization Quality of Life-26).

Meaningful occupations

Meaningful occupations were the primary intervention in two studies.^17,18

Nagayama et al¹⁷ (level 1b) evaluated a meaningful activity-based intervention using an iPad app called “Aid for Decision Making in Occupation Choice (ADOC)". The intervention consisted of identifying meaningful occupations from 95 illustrations depicting everyday activities (eg using cutlery for eating, cooking, knitting), setting goals and prioritising occupations. The aim was to test if this approach could improve older adults' quality of life more effectively than an impairment-based approach. After four months of follow-up, the intervention group showed significant improvements in the performance of ADL (Barthel index).

Yoshida et al¹⁸ (level 1b) conducted an OT intervention whose primary focus was the adjustment of the challenge-skill balance of activities. The intervention was based on the individual performance of meaningful activities to determine the factors that hindered occupational performance (challenge components; e.g. environment, time of performance, size of the space for performing the activity) and those that enhanced it (skill components), and then readjust the activities until the challenge and skill components were in balance. The results indicated statistically significant improvements in HRQOL (EQ-5D) in the intervention group.

Limitations

This review is limited by the heterogeneity and the small number of studies that specifically address, both in terms of intervention and outcomes, the improvement of the quality of life of older adults living in nursing homes.

Conclusions

The purpose of this systematic review was to evaluate the scientific evidence on the effectiveness of OT interventions in improving the quality of life of healthy older adults aged 65 years and over living in nursing homes.

This systematic review has identified two main groups of intervention programmes focusing on: a) “promotion of active ageing” and b) “meaningful activities and quality of life”.

First, it is worth noting that those intervention programmes that focus primarily on the meaningfulness of activities, either by adjusting the level of challenge according to the individual’s abilities¹⁸ or by prioritising older people’s decision making,¹⁷ show a high strength of evidence. Similarly, there was an improvement in ADL performance and a decrease in pain in those intervention programmes aimed at increasing personal causality, values, and interests associated with performing meaningful occupations, meeting the coping needs and influencing the environment of older adults living in nursing homes. Overall, this increased their subjective perception of quality of life and HRQOL.¹⁵

These findings are supported by previous research, “The Well Elderly Study”²⁰ and “The USC Well Elderly Study 2”,²¹ which build on the notion that intervention programmes structured around a balanced occupational performance of personally and culturally meaningful activities lead to active ageing and a higher quality of life among older adults, decreasing illness, disability and dependency conditions.

Ultimately, those OT intervention programmes articulated around choosing meaningful activities, adjusting the challenge to the skills of older people, and meeting the needs of coping and influence in the residential setting, seem to show an increase in the perception of quality of life of the older residents.

Second, although the strength of evidence is moderate, results suggest that physical activity interventions can improve subjective health-related quality of life,¹⁶ physical functioning, bodily pain and vitality.¹⁹ They also appear to be associated with reduced mortality, increased functioning and reduced levels of ADL and IADL dependency.⁸

Likewise, the results suggest that, with moderate strength of evidence, those interventions whose primary focus is cognitive activity, developed in a framework that favours social interaction to promote health, can improve general health and psychological well-being,¹⁹ and are linked to lower physical and cognitive impairment and with an improved perception of quality of life in healthy older adults living in nursing homes.⁸

These results are consistent with previous studies conducted in the context of older adults in residential settings, which have shown improvements in the physical functionality and mental state of residents, which are also associated with greater personal autonomy of older adults living in nursing homes.^22,23

In our view, this finding supports the role of OT in promoting and maintaining active ageing in healthy older adults living in nursing homes. Occupational therapists develop programmes and activities with the aim of incorporating physical and health-promoting activities into the daily routine of residents, which is a key aspect of health management, promotion and maintenance.²⁴

This systematic review shows that physical activity, cognitive activities, leisure and social participation can help to support this process. In addition, health promotion activities carried out using a mixed format (individual and group) can lead to a better subjective perception of quality of life among residents.¹⁹

Finally, the strongest evidence indicates that active ageing promotion programmes based on a multidisciplinary approach are effective across a wide range of issues. In multidisciplinary interventions, occupational therapists work together with other fields to provide a wide range of interventions that may include modifications to the residential setting, education and training, preventive health care (e. g risk reduction and health education) and health promotion (e. g exercise and medication review), all of which are key elements of active ageing.⁷

In conclusion, OT intervention programmes structured around the opportunity to choose meaningful activities can improve the perceived quality of life of healthy older adults living in nursing homes. These activities are tailored to the older person’s skills and they seek to meet the needs for coping and influence in residential setting.

So What?

What is already known on this topic?

Factors affecting the quality of life of older adults can be improved through the interventions grounded in an OT perspective.

What does this article add?

This review highlights the need for intervention programmes to improve the quality of life of healthy older adults living in nursing homes, taking a multidisciplinary approach and a client-centred, occupation-based perspective.

What are the implications for health promotion practice or research?

This review finds that interventions focusing on cognitive activity, leisure and social participation and health promotion can potentially lead to less physical and cognitive decline and improved quality of life of healthy older adults living in nursing homes. Health promotion practitioners can incorporate such activities into the daily routine of residents to promote their health, improve their well-being and quality of life.

Supplemental Material

Supplemental Material - Occupational Therapy Interventions for the Improvement of the Quality of Life of Healthy Older Adults Living in Nursing Homes: A Systematic Review

Supplemental Material for Occupational Therapy Interventions for the Improvement of the Quality of Life of Healthy Older Adults Living in Nursing Homes: A Systematic Review by Cristian Uceda Portillo, José Ignacio Calvo Arenillas, and Pedro Moruno Miralles in American Journal of Health Promotion

Footnotes

Authors’ Contribution

Cristian Uceda Portillo: Conceptualized the design of the systematic review, led the analysis and interpretation of the data, drafted the manuscript, and approved the submitted manuscript for review.

José Ignacio Calvo Arenillas: Contributed to the design of the systematic review approach, revised each manuscript draft crucially, and approved the submitted manuscript for review.

Pedro Moruno Miralles: Contributed to the concept of the study, the data extraction process, revised each manuscript draft crucially, and approved the submitted manuscript for review.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

ORCID iD

Cristian Uceda Portillo

Supplemental Material

Supplemental material for this article is available online.

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