Occupational therapy for stroke survivors in UK care homes

Stroke is a major contributor to the global burden of disease. It is the third main cause of death and the largest cause of adult disability in the UK. Stroke is reported to be the second most common cause of disability after dementia in the UK care home population with an estimated 25% of residents living with the consequences of stroke. The aim of this PhD programme of research was to explore the current research evidence for the provision of occupational therapy to stroke survivors living in care homes; investigate current routine occupational therapy practice for this specific stroke population in UK care homes; and to contribute original new knowledge on the health outcomes of sub groups of the care home population with stroke. This study was divided into four distinct projects that were completed alongside a National Institute for Health Research funded phase III multi-centre cluster randomised controlled trial of occupational therapy for care home residents with stroke known as the ‘OTCH study’. The OTCH study evaluated the efficacy of delivering occupational therapy interventions targeted towards increasing and maintaining independent performance of personal self-care activities of daily living and mobility. The PhD student was a member of the OTCH study team with responsibility for delivering the intervention at the Nottingham site. A PhD studentship from the University of Nottingham enabled the development of this complimentary and integrated programme of research. Stage one (reported in chapter two) involved the completion of a Cochrane systematic review and meta-analysis as a means of systematically appraising published randomised controlled trials of occupational therapy interventions for care home residents with stroke to the highest gold standard. Systematic searching identified 1,436 unduplicated records however only 1 study met the inclusion criteria, with another trial ongoing. There was insufficient evidence from the reviewed randomised controlled trial to determine that occupational therapy improves outcomes for care home residents with stroke and therefore further high quality research in this area is needed. Stage two (reported in chapter three) involved a national online survey study to provide contextual demographic data, along with data on the aims, content, funding and provision of occupational therapy services currently being delivered to stroke survivors residing in UK care homes. Out of a total of 138 completed questionnaires, data were analysed from 114 respondents who met the eligibility criteria of providing assessment and treatment to residents in a care home setting. The survey findings confirmed that occupational therapy is being delivered in some care homes; however, interventions for residents with stroke are not routinely delivered by stroke specialist occupational therapists and are not routinely delivered using a systematic, evidence-based approach. Stage three (reported in chapter four) utilised the raw data from the 1,042 participants recruited to the OTCH study to perform subgroup analysis and predictive modelling (including regression modelling and generalised estimating equation (GEE) modelling) with the aim of further investigating the effect of occupational therapy on various subgroups of the participant sample. Subgroup analysis determined that age, time since stroke onset, cognitive status, mood and pain made no difference to the effect of a three month occupational therapy intervention aimed at improving or maintaining independence in basic ADLs (as measured by the Barthel Index (BI)). Predictive modelling found type of care home (residential or nursing) and cognitive status (dementia or normal cognition) to be a far greater predictor of ADL performance and mobility outcome than whether or not the resident had received the occupational therapy intervention. Stage four (reported in chapter five) involved analysis of the content of occupational therapy intervention delivered to the OTCH study participants and their performance in self-care ADLs to account for possible reasons why the trial produced neutral results by (1) exploring the content of the treatment that the intervention arm participants received from the study occupational therapists; and (2) investigating the performance of those participants who had received the allocated occupational therapy intervention, whilst accounting for possible predictor covariates. Binary logistic regression was used to model the relationship between the dependent outcome variable and the explanatory predictor variables. Results of the analyses demonstrated that the therapists did not allocate their time according to those with greater levels of disability and higher levels of need. Residents with dementia received less therapy input than those with mild cognitive impairment or normal cognition. Cognitive status was the strongest predictor of functional outcome. The thesis concludes by highlighting the implications of this new body of research evidence for occupational therapy clinical practice, policy, and future research