The structure and process of physiotherapy services for nursing home residents with dementia in the Netherlands

Abstract

In addition to memory loss, dementia poses significant healthcare challenges, including diminished physical function and increased care dependency.¹ As care dependency grows, the transition from residential to nursing home care may become inevitable.² Physiotherapy services are frequently employed to maintain or improve the physical functioning of nursing home residents with dementia.³

Although physiotherapy is a prevalent therapeutic modality, previous literature indicates significant variation in its employment.⁴ This variation can potentially result in suboptimal treatment. To reduce this variation, calls for guidelines on physiotherapy for nursing home residents with dementia have been made.^{5, 6} Before guidelines can be developed, more knowledge about factors that cause variation is necessary. The aim of this study was therefore to explore the presence of practice variation in physiotherapy services for nursing home residents with dementia in the Netherlands.

We used a cross-sectional study design utilizing an online survey to collect data from physiotherapists working with nursing home residents with dementia. We aimed to include 10% of the approximately 830 Dutch nursing homes which have facilities for people with dementia, with one responding physiotherapist per nursing home. In the Netherlands, nursing home care is integrated into the national insurance scheme. The costs associated with physiotherapy treatment are encompassed within standardized care packages, which are uniform across care providers in the country. Physiotherapists were recruited from November 2022 to March 2023. To prevent repetitive submissions from the same nursing home, the four digits from the postal code were gathered. In case of repetitive submissions, either the survey with the largest number of completed questions, or in case completion was similar, the last received survey was included.

The survey was based on the healthcare framework by Donabedian,⁷ describing the quality of care by its “structure,” “process,” and “outcome”, and was created by two authors (DB, SS) experienced in physiotherapy for nursing home residents with dementia. Survey data output was analyzed in SPSS version 25 (Armonk, NY: IBM Corp.). Descriptive statistics were calculated for all variables. The practice variation thresholds were set in a consensus meeting at >75% and <25% for data presented in percentages. For data expressed as mean and standard deviation the coefficient of variation was calculated, and the thresholds COV >0.8 as variation, COV >0.5 and ≤0.8 as possible variation, and <0.5 as no variation was used.⁸

A total of 109 physiotherapists representing 109 nursing homes participated with a median age of 36 years (range 30–53) and a median working experience 10 years (range 5–19).

In terms of structure (Table 1), nursing homes offered an average of 24 h of physiotherapy per week for an average of 60 residents with dementia. A physician's referral was required to start treatment in 43% of cases. Multidisciplinary team meetings were attended regularly by 93% of participants, with occupational therapists, psychologists, and specialized geriatric physicians being the most frequently involved professionals.

Regarding the process (Table 2), an average of 24% of residents received physiotherapy with a mean frequency of 1.7 times per week. Assessment instruments were used by 70% of respondents, with the POMA Tinetti test being the most prevalent instrument. All respondents reported employing individual exercise therapy sessions. Besides exercise therapy, therapeutic advice to nursing home staff (95% of respondents) and family (57% of respondents) was reported.

Practice variation was detected in 44% of the structure elements and 36% of the process elements of the survey.

The findings highlight both similarities and variations in the delivery of physiotherapy services for nursing home residents with dementia. Variation in the availability of physiotherapy services aligns with the findings of previous studies.⁴ Consensus was present regarding multidisciplinary collaboration, which can be perceived as beneficial, since many geriatric syndromes like sarcopenia, depression, and risk of falls require a multidisciplinary approach.^{9, 10} Besides exercise therapy, physiotherapists have a large advisory role on mobility, risk of falls, walking aids, and occupational health and safety. This is new information, since physiotherapy services in previous reviews were limited to pain management and treating pressure ulcers.⁴ Our study answers previous research questions, namely which factors attribute to practice variation.^{4, 5} Future research could explore which elements are favorable and should be incorporated into daily physiotherapy practice.

Despite the diverse characteristics within the population of nursing home residents with dementia, we emphasize the importance of defining physiotherapy and nursing home standards. Future studies should focus on examining which elements of the structural and procedural framework are favorable and should be integrated into daily practice.

DB, CS, SS, and TVV conceptualized the study. DB and SS developed the survey. DB, CS, SS, and TVV drafted the manuscript. DB and SS performed the data analysis. All authors read, provided feedback, and approved the final manuscript.

The authors have no conflicts.

None.