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DYNAMICS OF LIFE QUALITY PERCEPTION BY PATIENTS UNDER MILD COGNITIVE DECLINE DURING THE SOCIO-MEDICAL REHABILITATION
Kurmyshev M. V.
Efremova D.N.
Savilov V.B.
Psychiatric Hospital № 1 named after N.A. Alekseev, Department of Health, Moscow
ABSTRACT
This article reviews the research results of the subjective perception of life quality by elderly people suffering the beginnings of mild cognitive decline and after the end of a rehabilitation course. The rehabilitation course is aimed at an increase in memory levels and the self-actualization of an elderly person, subject to medical treatment at an outpatient medical rehabilitation department and is beneficial in preserving intellectual potential and development, as well as optimizing the perception of quality of life by increasing communicative relationships and the active everyday life of the elderly.
Keywords: elderly age, cognitive decline, life quality, subjective perception, self-actualization, communication relationships.
The Thematic justification of the research of the quality of life of the elderly is determined by demographic changes associated with an increase in life span.
According to data provided by representatives of the international non-governmental organization named Help Age International affiliated with the United Nations Fund for Population Activities (UNFPA), the problem of an ageing population is of central importance because the elderly (aged over 60) will have exceeded one-fifth of the total world population (22 %) by 2050, provided that their total numbers will amount to 2.03 billion people, whereas currently their total is 809 million (11 %).
As found out by the Pension Fund of the Russian Federation, the number of pensioners in Russia increases by 700 thousand every year and now exceeds 30 million.
An ageing population causes a number of social and economic problems. The process of adapting to old age against a backdrop of rapid socio-political and socio-cultural changes proves to be quite difficult, both for the elderly themselves and for their relatives. Qualitative changes in the structure of personal values and behavior patterns are observed subject to the decreasing ability to retain new and reproduce previously learned information in memory; the rigidity of thinking causes a slowdown in the formation rate of new dynamic stereotypes and a cautious attitude toward the ongoing social changes. [1 and 9]
According to the definition by WHO (World Health Organization), life quality is the perception by individuals of their position in life in the context of the culture and the value system wherein they live, in accordance with their goals, expectations, standards and concerns. Quality of Life is determined by physical, social and emotional life factors that are relevant to the
individual. The Life Quality Index of the elderly is calculated on the basis of statistical data obtained from national institutes and organizations. [7]
According to a social survey conducted by specialists of the Financial University affiliated with the Government of the Russian Federation, quality of life implies: a healthy life span, absence of threats to life and health, a level of consumption of goods and services, a guaranteed access to material values, satisfactory social relations, an access to education and cultural values, and consideration of personal opinion when solving any social problems.
A variety of existing indicators attributed to the field of "quality of life" by experts can be conditionally divided into two categories: objective and subjective. The criteria for the objective assessment of quality of life are the existing standards of people's needs and interests the degree of satisfaction these give (financial situation, housing conditions, consumption of products, goods, services, etc.). The subjective criteria for assessing "quality of life" includes the fact that, during life, every person acquires their own life experience in assessing their state of health, well-being, family relations, as well as one's own satisfaction with life. [7 and 8]
The quality of life of an ageing person depends, first of all, on the degree to which their mental state is preserved, as well as their brain condition and operation. The problem of developing cognitive deficiency when ageing is one of the central problems of modern medical science. Cognitive impairment is diagnosed on approximately 25 % of elderly people, among them 68 % are diagnosed as having dementia and 16-19 % -moderate cognitive defects [2 and 3]. The decline in labor efficiency, easy fatigability, emotional instability and exhaustion of neuropsychic processes, when they are senile asthenia manifestations, do in most cases lead
to a decrease in the ability to adapt to actual life conditions and, accordingly, a decrease in the quality of life. [7]
A rather large number of studies are engaged in exploring relations between cognitive functions and the psychosocial functioning of elderly people [1, 2, 3, 4, 5, 6, 8, and 9]. According to numerous sources, cognitive impairments are determined by the thought disorder structure, affect the state of the personality socio-psychological functions, and are interrelated with dominant emotions; at the same time, the reverse is also true. In addition, experts have established that cognitive functions are directly interrelated with manifestations of the emotional sphere. [8]
According to the opinion of V. N. Shabalin, "studying the role of elderly life quality in the formation of their health is one of the priority areas of fundamental and applied scientific research." [9]
Acuteness of the quality of life subjectively perceived directly affects the level of anxiety and depression of elderly people with mild cognitive decline, and what entails a significant decline in the cognitive component of the individual. When the severity of emotional sufferings (anxiety, depression) reduces, the state of the cognitive sphere and social functioning improves. [4]
The importance of the timely provision of specialty care for preserving the cognitive functions is determined not only by their prevalence, but also by their influence on the activation of social adaptation skills and life quality improvement, as well as the socio-psy-chological functioning of an elderly person.
According to the author of the questionnaire aimed at measuring of life quality, P. W. Jones (St. George's Hospital, SGRQ), life quality is "conformity/non-conformity of desires to opportunities limited by the disease." [13]
The analysis of Russian and foreign theory and practice shows that the existence of a large number of definitions, opinions, and studies emphasizes the urgency of the problem and a lack of a unified approach to its solution, the immaturity of the problem regarding restoration of cognitive functions and the emotionalpersonal component for elderly people with mild cognitive decline.
Until now there has been no unified point of view on the nature, goals and objectives of the process of restoring the cognitive functions and special training sessions accompanying this process, which would contribute to the positive dynamics of subjective perception by patients having mild cognitive decline of their current life quality; methodological foundations remain undeveloped, and this confirms the urgency of the selected research subject.
The objective of this study was to investigate, under conditions of the system of rehabilitation, the clinical peculiarities of the cognitive field and life quality perception typical for elderly people having mild cognitive decline; and to detect any interrelation between cognitive functions of elderly and senile people having mild cognitive decline symptoms with life quality indicators.
The description of groups, materials and methods
The study was conducted among 91 participants of the program for elderly and senile people between 65 to 84 years old, during the period from 03/04/17 to 28/07/17 at N. A. Alekseyev's Design Bureau No. 1 which is a branch of Psychoneurological Dispensary No. 15 of the Medical Rehabilitation Department (Clinic of Memory). The Department offers elderly patients suffering from mild cognitive decline to undergo a course of medical and social rehabilitation.
The selection criteria for patients to be included in the recovery course on cognitive functions was a diagnosed decline in patient's cognitive functions; the selection was based on the complex of clinical and anamnestic criteria (patient's complaints, observations of the attending physician), experimental psychological research (EPR), as well as obtained consent to take part in the study. All patients that underwent the rehabilitation course, had passed a medical examination and received appropriate medical treatment.
The results obtained from the questioning of participants before their inclusion thereof in the rehabilitation program (Snapshot 1) and upon its end (Snapshot 2) were subject to analysis.
The results on the respondents in the age group of 61-75 years (the elderly) are assigned to group 1 (hereafter referred to as Group 1). The results of the respondents in the age group of 76-90 years (old age) were assigned to group 2 (hereafter referred to as Group 2).
To study the peculiarities of the participants' cognitive level, the MMSE test was used (Mini-Mental State Examination, 1975). The testing results (MMSE) within the range of 25 to 27 points are interpreted as proving the symptoms of normal ageing, those within the range of 23-25 points indicate a mild cognitive decline, and the range of 20-23 points is evidence of mild dementia. [11]
So that to conduct a differential analysis of the dynamics of cognitive functions under the conditions of the rehabilitation process, the program participants were examined to detect any possible vascular cognitive disorders (VCD), according to the Modified Ha-chinski Ischemic Scale (MHIS) method (Hachinski et al.). [12]
Using the Ischmic Hachinski Scale (MHIS), we differentiated vascular dementia from Alzheimer's disease. The results on the respondents, according to the scales (MHIS), were measured by different levels. Thus, the level 0-3 corresponds to the presumable presence of atrophic processes (for example, Alzheimer's disease), level 4-6 does not confirm the vascular etiology of dementia, and one can talk about processes of normal ageing. And the level 7-18 presents the possibility of vascular dementia. [12]
In order to study the peculiarities of the quality of life subjective perception by different age groups, the SF-36 "health status survey" questionnaire was applied where 36 items are grouped into eight sections: physical functioning, role activities, bodily pain, general health, vitality, social functioning, emotional state, and mental health.
The results are presented as scores for all 8 scales in points, formed in such a way that a higher score indicates a higher level of the LQ. The author outlines
The scores of each section do range between 0 and 100, where 100 represents absolute health. All sections form two indicators: mental and physical well-being. Further on, the Life Quality Index (LQI) is calculated under special formulas [13, 14, and 15]
In order to determine the strength and direction of the correlation relationship between the characteristics studied, we used Student's rank correlation method (in the SPSS 17.0 software package).
The analysis of psychological diagnosis results (Snapshot 1) showed that patients with cognitive impairment caused by vascular disorders (38 people, 41.9 %) and normal ageing processes (36 people, 39.5 %) prevailed among the participants in the rehabilitation
Table 1 shows that 13 people among the total respondents of Group 1 (46 people) involved in the cognitive function rehabilitation course do correspond to the vascular dementia criteria (level 7-18), judging by the nature of cognitive impairment, and it is possible to suggest that 5 people are affected by atrophic processes (level 0-3). Symptoms of the normal ageing (level 46) are detected on 28 people.
The data presented in Table 1 indicates that in Group 2 (45 people) there are 8 people characterized by normal ageing trends, whereas for 25 people there are trends of vascular dementia development. Symptoms of atrophic processes were observed in 12 people.
four ranges of satisfaction with life quality by a general index (Table 1). [13 and 15]
program (91 people) A decline in cognitive functions, caused by atrophic processes was detected in 17 participants (19.3 %).
Age Group 1 (61-75 years) contains more patients having mild cognitive decline caused by symptoms of the bodies normal ageing and the share of patients having atrophic process symptoms is significantly lower than in Group 2 (76-91).
The data confirming the material extent of cognitive impairments, under the criteria for a brief assessment of cognitive functions (MMSE), and the nature of vascular cognitive disorders (VCD), under the criteria set by the Hachinski test (MHIS), are presented in Table 2 as being divided into participants' age groups.
In general, at the beginning of the rehabilitation program (Snapshot 1), patients with disorders typical for vascular dementia (38 patients, 41.9 %) and for normal ageing (36 patients, 38.7 %) prevailed among the participants of both groups (91 patients); a cognitive function decline caused by atrophic processes was detected in 17 participants (19.3 %).
In order to identify significant components of intellectual and mnestic activity, let us consider the ratio of average scores. The data analysis makes it possible to note that the average level of cognitive function condition, regardless of the nature of the participant's cognitive impairments, has changed at the end of the rehabilitation course (Table 3).
Table 3
The average level of the state of cognitive functions within age groups (n = 91) _ (Mini-Mental State Examination, 1975)_
Group and age Total number of people MMSE snapshot 1, average score MMSE snapshot 2, average score Average
Group 1 (61-75 years old) 46 25.2 27.0 +1.8
Group 2 (76-91 years old) 45 23.8 26.5 +2.7
75 +/- 3 91 24.5 26.25 +1.75
Table 1.
Assessment of the satisfaction level by the general Life Quality Index (LQI)
Life Quality Index (ILQ), points
Very low (Depressive) Low Medium High
4-10 11-20 21-29 30-40
Table 2
Nature of cognitive function impairment (MHIS) (n = 91)
(Modified Hachinski Ischemic Scale, Hachinski et al.)_
Total number of people VCD nature, Hachinski Scale, (MHIS) points
Level 0-3 Level 4-6 Level 7-18
Group 1 (61-75) 46 5 28 13
Group 2 (76-90) 45 12 8 25
Total 91 (19.3 %) (39.5 %) (41.9 %)
Table 3 shows that an increase from 25.2 to 27.0 points (that range of points corresponds to the MMSE criteria) was observed in Group 1 (61-75 years). So, as judged by the MMSE test results, these patients remained within the same range which corresponds to the criterion for mild cognitive decline. [1, 2, and 11]
The average level of cognitive function state for Group 2 (76-91 years) (under the data of the same test) initially matched the criteria for mild severity dementia (23.8).
After the completion of the rehabilitation program, the MMSE level made up 26.5 points and, therefore, met the criteria for mild cognitive decline. That is, a transition to another range occurred in this case. According to the data [1], the cognitive level state has its own dynamics. For some patients under mild cognitive decline, this trend is mainly negative in the majority of cases; but other patients may have a cognitive status that remains stable. [1, 2, 3, 6, and 7].
However, due to the absence of studies (performed under conditions of systematic rehabilitation) on cognitive functions dynamics typical for elderly and senile patients with mild cognitive decline, it can be assumed that the data obtained is indicative of a possible trend to a positive change in the qualitative state of the cognitive sphere within the same range and the need for the further study of the established process conditions.
So that to determine life quality characteristics, the average scores have been calculated as prescribed by the SF-36 "Health Status Survey", at the beginning and at the end of the rehabilitation program; see Snapshot 1 and Snapshot 2 respectively in Table 4.
In addition, we calculated scale No. 9 ("Negative emotions") aimed at measuring the subjective assessment of the way the patient felt and what their mood was when participating in the Cognitive Rehabilitation Program. It was designed to give one answer which matched the patient's feelings as closely as possible. [14 and 15]
Table 4
Average results for all sampled respondents (n = 91)
No. Scales SF-36 Average score Snapshot 1 Average score Snapshot 2
1 Work 23.9 29
2 Personal achievements 25.9 31.5
3 Health 21.8 31.4
4 Communication with relatives and friends 27.3 33.2
5 Internal and external support 25.0 30.0
6 Optimism 24.5 32.0
7 Stress 21.6 30.3
8 Self-control 22.7 30.5
9 Negative emotions 19.8 23.4
10 Life Quality Index (LQI) 23.0 30.1
According to the authors' data, the maximum satisfaction makes up 100 points, and the smaller the score is, the stronger the mental tension is and the lower the satisfaction with life quality in this area is. Comparing the average data obtained for all participants in the rehabilitation program, it can be noted that, at the beginning of the research the average score for the satisfaction with quality of life, the average score (LQI) was 23.0, which, according to the authors, corresponds to the average level of life satisfaction. Experts note that a low and medium level of LQI is often detected in people who are experiencing a burnout and disappointment in future life prospects, as well as those who have no long-term goals and hopes. [13, 14, and 15]
However, after the competition of the rehabilitation course, the same respondents rated their satisfaction level as high; the average value of the Life Quality Index (LQI) reached 30.1 points. A significant fact is that the financial and marital status of the participants remained unchanged during 6 weeks (the rehabilitation course length).
According to the authors, people with a high LQI level, according to the authors, are characterized by personal attributes such as, optimism and an active attitude to life, as well as being able to adapt and ready to cope with difficult situations. [14 and 15]
Let us consider the relationship between changing the cognitive level state and the perception of the quality of life, given that the patients underwent a complete course of the cognitive rehabilitation program over 6 weeks.
The presence of statistically significant differences between the average indicators of life quality, in accordance with the criteria (scales), at the beginning and the end of participation in the rehabilitation program was calculated by the Student's rank correlation method.
1) General Health (GH) = 2.04 - general health status - how patients assess their current state of health and treatment prospects.
2) Physical Functioning (PF) = 2.07 - physical functioning which reflects the extent that a patient's health limits performing any physical exercises (independent living skills, walking, climbing stairs, carrying heavy loads, etc.).
3) Role-Physical (RP) = 2.01 - how the physical state impacts on the role functioning (work, everyday activities).
4) Role-Emotional (RE) = 2.04 - how the emotional state impacts on the role functioning; the parameter shows how much the emotional state interferes
with working or other everyday activities (including increased time, reduced work results, etc.).
5) Social Functioning (SF) = 2.08 - social functioning is determined by the degree that the physical or emotional state interferes with social activity (communication).
6) Bodily Pain (BP) = 2.07 - The intensity of pain and its effect on the ability to engage in everyday activities, including household tasks and employment outside the home.
7) Vitality (VT) = 2.06 - vitality (implies that the patient feels themselves as full of strength and energy, or, on the contrary, exhausted).
8) Mental Health (MH) = 2.09 - self-assessment of mental health; it characterizes one's mood (presence of anxiety-depressive symptoms; a general indicator of positive emotions).
For clarity, we will present the data obtained as a definition range of indicators by the Student's method (Fig. 1)
Fig. 1. Significance area of the distribution of average indicators
In Figure 1, we can see that the statistically correct differences between the average indicators of the Life Quality Index at the beginning of participation in the cognitive functions rehabilitation program and after its completion are distributed within the range from 2.01 to 2.09, what is significantly more than 0.01; accordingly, the indicators are within the significance area.
Thus, considering that all respondents estimated their satisfaction with the quality of their lives as high after they had completed the program for restoring cognitive functions, it can be affirmed that the objectives set during the rehabilitation process were achieved. The presence of a significant relationship between increasing the state level of cognitive functions and the perception of life satisfaction confirms that the participants in the rehabilitation program are satisfied with their activities, and that feature enhances their adaptive potential.
Summary
Summarizing the results of the research conducted, the following conclusions can be drawn.
1. The subjective perception of life satisfaction quality by elderly people affected by mild cognitive decline is a dynamic component and is interrelated with their involvement in the directed rehabilitation of cognitive functions and emotional-personal components.
3. There is a significant relationship between increasing the cognitive function level and the perception of quality of life by elderly and senile patients with mild cognitive decline.
2. An increase in the level of the state of cognitive functions and the life quality satisfaction index is facilitated by the availability of medical and social assistance as an integral complex of medical, psychological, and psychotherapeutic services provided to elderly patients having mild cognitive decline at medical institutions by professional teams consisting of doctors, psychologists, psychotherapists, and social work specialists.
3. The cognitive function restoration program helps to enable many forms of neuropsychic activity; it increases the activity of cortical excitement and inhibi-
tion, what allows elderly people to make decisions confidently and responsibly, process new data, as well as to maintain a longer concentration and attention time.
4. Due to its collective nature, the rehabilitation process restores skills of communication and retention of interest in the interlocutor and decreases the intensity of manifesting any demonstrative traits and egocen-trism.
5. The participation in the rehabilitation program, provided that the patient observes the established regime (of waking up in the morning, working activies, food intake, rest, etc.) over a 5-6 week period, positively affects the patient's overall medical condition.
Thus, the rehabilitation of cognitive functions within a holistic medico-social rehabilitation process reduces the severity of the emotional response to the main disease and socioeconomic situations, increases the assessment of prospects for recovery and the stabilization of well-being, and raises the assessment of the perception of one's general state of health and the future.
Conclusion
The process of social adaptation of elderly people requires society to take action to assist them to adapt to new conditions. Changing the perception of the quality of social life satisfaction requires the elderly person, their relatives and specialists to seek new methods and technologies that increase their vital activity.
The timely implementation of rehabilitation measures for elderly people will make it possible to reduce the risk of cognitive impairment development and avoid any unnecessary long stays in inpatient hospitals.
The cognitive rehabilitation program was made up based on the principle "from simple tasks to complex ones", including a set of tasks for updating one's creative abilities. The program increases opportunities for self-actualization and revives the feeling of satisfaction with one's activities, expands personal adaptive potential and contributes to the positive dynamics of the perception of life satisfaction quality by elderly people with mild cognitive decline.
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ТЕОРЕТИЧН1 КОНЦЕПЦП НЕГАТИВНОГО ПРОФЕС1ОГЕНЕЗУ
ОСОБИСТОСТ1
МЫорадова Н.Е.
к. психол. н, доцент, професор кафедри педагогжи та психологИ Харювський нацюнальний yHiверситет внутрiшнiх справ, м. Хартв, Украша
THEORETICAL CONCEPTS OF A NEGATIVE PROFESSIONAL DEVELOPMENT OF A PERSONALITY
Miloradova N.
Ph.D. in Psychology, Associate Professor, Kharkiv National University
of Domestic Affairs, Kharkiv, Ukraine.
АНОТАЦ1Я
В статп аналiзуються негативш аспекти просування особистосп по професюгенетичних сходинках. Автор розглядае питання особистюного позитивного та негативного професюгенезу, акцентуючи увагу на особливостях саме негативного професюгенезу особистосп, а саме проблемах пов'язаних з подоланням криз професшного становлення, виникненням деформацш та деструкцш, обранням сценарш особистого професшного розвитку.
ABSTRACT
The article describes negative features during moving the career ladder. The author considers the questions of the personal positive and negative professional development of a personality. The author points at such features of the negative professional development of a personality like: problems related to getting over a professional crisis, professional disruptions, picking a scenario of a professional development.
Ключовi слова: професюгенез, позитивний професюгенез, негативний професюгенез, кризи професшного становлення, професшна деформащя, професшна деструкщя, сценарп професшного розвитку.
