Preserving personhood of individuals with advanced dementia: lessons from family caregivers

Acceptability and preliminary effects of the volunteer-supported Meaningful Moments program to engage older adults with advanced dementia on a hospital-based specialized dementia care unit: a mixed methods study

BACKGROUND

Namaste Care offers practical skills for healthcare providers, volunteers, and families to meaningfully engage individuals with dementia in activities (e.g., music, massage, reminiscing, socialization, aromatherapy, snacks). A hospital-based specialized dementia care unit for patients with mid- to late-stage dementia offered an adapted version of the Namaste Care program, which was called Meaningful Moments. The aim of this study was to assess the acceptability and preliminary effects of this novel approach using trained volunteers for older adults with mid- to late-stage dementia.

METHODS

A mixed methods multiphase design was used. Qualitative description was used to explore acceptability of the Meaningful Moments program delivered over 6 months through focus groups (e.g., charge nurses, therapeutic recreationists, nurses, social workers) and individual interviews with one volunteer and two family members. A prospective pre-post-test study design was used to evaluate the preliminary effects of the program for patients with dementia and family members. Outcomes included quality of life, neuropsychiatric symptoms, and pain for patients with dementia and family carer role stress and the quality of visits for families. Data were collected from June 2018 to April 2019. Descriptive analyses of participants' characteristics were expressed as a mean (standard deviation [SD]) for continuous variables and count (percent) for categorical variables. Focus group and individual interview data were analyzed using thematic analysis. The generalized estimating equations (GEE) method was used to assess change in the repeated measures outcome data.

RESULTS

A total of 15 patients received the Meaningful Moments interventions. Families, staff, and volunteers perceived that patients experienced benefits from Meaningful Moments. Staff, volunteers, and families felt fulfilled in their role of engaging patients in the Meaningful Moments program. Individualized activities provided by volunteers were perceived as necessary for the patient population. There were no statistically significant improvements in patient outcomes. There was a statistically significant decline in family carer role stress.

CONCLUSIONS

Using a one-on-one approach by volunteers, patients experienced perceived benefits such as improved mood and opportunities for social interactions. There is a need for tailored activities for older adults with advanced dementia through practical strategies that can offer benefit to patients.

Conceptualising personhood in nursing care for people with altered consciousness, cognition and behaviours: A discussion paper

The aim of this discussion paper is to explore factors and contexts that influence how nurses might conceptualise and assign personhood for people with altered consciousness, cognition and behaviours. While a biomedical framing is founded upon a dichotomy between the body and self, such that the body can be subjected to a medical and objectifying gaze, relational theories of self, multiculturalism and technological advances for life-sustaining interventions present new dilemmas which necessitate discussion about what constitutes personhood. The concept of personhood is dynamic and evolving: where historical constructs of rationality, agency, autonomy and a conscious mind once formed the basis for personhood, these ideas have been challenged to encompass embodied, relational, social and cultural paradigms of selfhood. Themes in this discussion include: the right to personhood, mind-body dualism versus the embodied self; personhood as consciousness, rationality and narratives of self; social relational contexts of personhood and cultural contexts of personhood. Patricia Benner's and Christine Tanner's clinical judgement model is then applied to consider the implications for nursing care that seeks to reflexively incorporate personhood. Nurse clinicians are able to move between conceptions of personhood and act to support the body, as well as presumed autonomy and relational, social and cultural personhood. In doing so, they use analytical, intuitive and narrative reasoning which prioritises autonomous constructions of self. They also incorporate relational and social contexts of the person receiving care within the possibilities of technological advances and constraints of contextual resources.

Dilemmas of intervention: From person-centred to alienation-centred dementia care

Discussions regarding personhood and dementia care are often based on practices of recognition; on notions of being-or not being- 'one of us'. This article provides a short overview of personhood as articulated in dementia care, especially in the assemblage of practices known as 'person-centred care' (PCC), and in post-human approaches that developed following the critique of PCC. This article posits an alternative framework, based on a rereading of the concept of alienation, that we want to call 'alienation-centred care'. It considers the extent to which dynamic prosthetic networks can be adapted to the lives of people with dementia, rather than only examining the individual's reactivity to dementia interventions that define traditional approaches. It further urges us to understand the multiple origins of alienating states. Conclusions explore how this framework might address some of the limitations identified in both humanist and post-human approaches to personhood and dementia.

Filling In: Family Member Support for Nonrelative Residents in Long-Term Care Homes

BACKGROUND AND OBJECTIVES

Past research about family involvement in long-term care (LTC) homes mainly focuses on family members' involvement with their own relative, interactions with staff, and collective activities such as Family Councils. Our research provides novel insights into family member's involvement in the care of residents who are not their relatives, an area that has not previously been explored.

RESEARCH DESIGN AND METHODS

This critical ethnographic study examined ways that family members negotiate and navigate their roles within LTC homes. Data collection and analysis took place at 3 LTC homes in British Columbia, Canada, between 2014 and 2018. Data were collected through participant observation and semistructured interviews. Eleven family member participants shared experiences of caring for residents who were not their relatives.

RESULTS

The umbrella theme was "filling in," which takes place in a care environment that is understaffed and underresourced. The subthemes reflect the various ways that families are "filling in": responding to resident's needs, supporting staff to respond to resident needs, and filling in for residents' families.

DISCUSSION AND IMPLICATIONS

Caring for residents who are not their relatives is facet of family involvement in LTC homes that has not been previously explored. Many family members have expertise in providing person-centered care and they extend this expertise to residents who are not their relatives. Policies and legislation are needed to formalize family involvement in caring for nonrelative residents as it is a component of quality of care for all residents.

The End of Personhood

The concept of personhood has been central to bioethics debates about abortion, the treatment of patients in a vegetative or minimally conscious states, as well as patients with advanced dementia. More recently, the concept has been employed to think about new questions related to human-brain organoids, artificial intelligence, uploaded minds, human-animal chimeras, and human embryos, to name a few. A common move has been to ask what these entities have in common with persons (in the normative sense), and then draw conclusions about what we do (or do not) owe them. This paper argues that at best the concept of "personhood" is unhelpful to much of bioethics today and at worst it is harmful and pernicious. I suggest that we (bioethicists) stop using the concept of personhood and instead ask normative questions more directly (e.g., how ought we to treat this being and why?) and use other philosophical concepts (e.g., interests, sentience, recognition respect) to help us answer them. It is time for bioethics to end talk about personhood.

Healthcare Professionals' Perspectives on Dignity in Dementia: A Qualitative Analysis

In dementia care, the concept of dignity has garnered substantial attention from both researchers and policymakers. However, the concept often remains vague and open to interpretation, potentially leading to misunderstandings and suboptimal care for people with dementia. As healthcare professionals occupy a critical role in upholding dignity, exploring their viewpoints on this complex concept is paramount. In this study, we explore Danish healthcare professionals' views on the dignity of people with dementia and discuss these perspectives against existing theoretical accounts. We employed thematic analysis of data collected during facilitated discussions with a total of 99 healthcare professionals, including nurses and healthcare workers, during which we posed the question, "What is dignity to you?" and documented their perspectives. Through a systematic process of data coding and interpretation, we identified recurring patterns in their responses. This approach allowed us to uncover the depth and complexity of their viewpoints, providing valuable insights into the multifaceted nature of dignity as perceived by healthcare professionals. Our findings revealed that healthcare professionals possessed a nuanced understanding of dignity, recognizing both a subjective element and a universal aspect applicable to all individuals, aligning with theoretical interpretations. However, conceptual ambiguity remained a challenge.

Cancer care for people with dementia: Literature overview and recommendations for practice and research

As many countries experience population aging, patients with cancer are becoming older and have more preexisting comorbidities, which include prevalent, age-related, chronic conditions such as dementia. People living with dementia (PLWD) are vulnerable to health disparities, and dementia has high potential to complicate and adversely affect care and outcomes across the cancer trajectory. This report offers an overview of dementia and its prevalence among patients with cancer and a summary of the research literature examining cancer care for PLWD. The reviewed research indicates that PLWD are more likely to have cancer diagnosed at an advanced stage, receive no or less extensive cancer treatment, and have poorer survival after a cancer diagnosis. These cancer disparities do not necessarily signify inappropriately later diagnosis or lower treatment of people with dementia as a group, and they are arguably less feasible and appropriate targets for care optimization. The reviewed research indicates that PLWD also have an increased risk of cancer-related emergency presentations, lower quality processes of cancer-related decision making, accessibility-related barriers to cancer investigations and treatment, higher experienced treatment burden and higher caregiver burden for families, and undertreated cancer-related pain. The authors propose that optimal cancer care for PLWD should focus on proactively minimizing these risk areas and thus must be highly person-centered, with holistic decision making, individualized reasonable adjustments to practice, and strong inclusion and support of family carers. Comprehensive recommendations are made for clinical practice and future research to help clinicians and providers deliver best and equitable cancer care for PLWD and their families.

Family's role in long-term care-A qualitative study of Finnish family members' experiences on supporting the functional ability of an older relative

Family members are important providers of care for older people. In residential long-term care, however, their role is not always simple and straightforward: responsibility for care provision rests officially with staff members, but in practice family members often contribute to providing care. The main reason for admission to long-term care is functional decline. At the same time, the maintenance of functional ability is a central goal in long-term care. It is therefore reasonable to assume that functional ability is also an important factor in the relationship between family members and long-term care residents. This study aims to explore how family members experience their role in supporting the functional ability of older relatives in residential long-term care. With the approval of the local hospital district's ethics committee, we conducted semi-structured interviews with family members (n = 16) in Finland in 2016. Thematic data analysis showed that family members supported the functional ability of their older parent or spouse by organising and monitoring care and by bringing forth their relative's personal needs and wishes. They often saw their role alongside staff members as ambiguous, and their understanding of the scope of support for functioning extended beyond physical everyday tasks. In their talk, family members broadened the concept of functional ability from daily chores and independence to meaningful social relations and acknowledgement of person's individual background and preferences. Family members' views offer valuable insights into residents' personal needs, values and preferences and in doing so help care workers to support their functional ability with a person-centred care approach.

Examining the Impact of Fictional Life Story of Resident with Dementia on Staff Levels of Empathy, Self-confidence, Workload Burden, and Perception of Resident: A Cross-sectional Survey in Long-term Care Communities

OBJECTIVES

Determine the impact of fictional life story on staff members levels of empathy, self-confidence, workload burden, and perception of resident before the implementation of care for new resident with dementia in long-term care community.

METHODS

An online cross-sectional survey based on two fictive clinical vignettes was used: one vignette described a resident with typical medical information (e.g., level of autonomy, health status, medication …), while the other contained typical medical information and life story information. The two vignettes were visually similar. The order in which vignettes were read was counterbalanced. Staff members (n = 95) were asked to consider the care needed by these residents and to assess, with a visual analogue scale, the amount of useful information provided by vignettes, their self-confidence and level of empathy, their perception of the resident's level of sympathy, his dependence, and the associated workload.

RESULTS

After reading the vignette containing life story information, staff members considered that they had more useful information and empathy for the resident. They also felt more confident about the care. They perceived the resident as more sympathetic and less dependent, and the workload seemed lighter to them compared to the case described in the vignette that did not contain life story information.

CONCLUSIONS

This quantitative study shows, in clinical fictive situations, the positive impact of life story on staff members before care begins.

CLINICAL IMPLICATIONS

Results highlight the importance of considering life story early. Getting to know residents should be the first step of care.

Cross-cultural conceptualization of a good end of life with dementia: a qualitative study

BACKGROUND

Research on the nature of a "good death" has mostly focused on dying with cancer and other life-limiting diseases, but less so on dementia. Conceptualizing common cross-cultural themes regarding a good end of life in dementia will enable developing international care models.

METHODS

We combined published qualitative studies about end of life with dementia, focus group and individual interviews with the researchers, and video-conferencing and continuous email discussions. The interviews were audio-recorded and transcribed verbatim. The data were analyzed thematically, and the researchers developed common themes referring to their original studies.

RESULTS

Fourteen qualitative researchers representing 14 cross-cultural studies covering qualitative data of 121 people with dementia and 292 family caregivers. The researchers and data were from eight countries UK, The Netherlands, Japan, Portugal, Germany, Canada, Brazil, and Ireland. Three focus groups, five individual interviews, and video-conferencing were conducted and feedback on multiple iterations was gained by 190 emails between May 2019 and April 2020 until consensus was achieved. Nine cross-culturally common themes emerged from the discussions and shared interpretation of the data of persons with dementia and family caregivers. Three represent basic needs: "Pain and Symptoms Controlled," "Being Provided Basic Care," and "A Place like Home." Other themes were "Having Preferences Met," "Receiving Respect as a Person," "Care for Caregivers," "Identity Being Preserved," "Being Connected," and "Satisfaction with Life and Spiritual Well-being." "Care for Caregivers" showed the greatest difference in emphasis across cultures. Good relationships were essential in all themes.

CONCLUSIONS

The common cross-cultural themes comprise a framework underpinned by value placed on personhood and dignity, emphasizing that interdependency through relationships is essential to promote a good end of life with dementia. These themes and valuing the importance of relationships as central to connecting the themes could support care planning and further development of a dementia palliative care model.

TRIAL REGISTRATION

The Graduate School and Faculty of Medicine Kyoto University (R1924-1).

Dementia and dignity of identity: A qualitative evidence synthesis

In the late stages of dementia, individuals rely on others for their wellbeing and this creates an ethical imperative for responsive dementia care. Through a qualitative evidence synthesis of literature on what constitutes responsive dementia care, we identified dignity of identity as a central theme. Dignity of identity is the status each of us holds in relation to others and reflects our past experiences and our aspirations for the future. We did a qualitative evidence synthesis of 10 qualitative studies conducted with a total of 149 research participants, 95 of whom had dementia, and 54 of whom were paid and family member caregivers to people with dementia. Using "new materialism disability studies" as our theoretical framework, we illustrate how environments, both material and discursive, shape the abilities of people with dementia in residential care settings (RSCs) to live well and we use our findings to point to ways forward in dignity of identity-enhancing dementia care practice. Echoing the literature, we observe that people with dementia have the virtual capacity to live with dignity of identity and illustrate how material conditions and discourse influence the transition of dignity of identity in people with dementia from a virtual capacity to an actual capacity and how demonstrated capacity in turn influences material conditions and discourse surrounding care for people with dementia in RSCs. We call for a greater acknowledgement within literature on dignity and dementia of structural barriers to dignity of identity-enhancing care. The COVID-19 pandemic has shown us the fatal consequences of insufficient material conditions in RCSs and we hope that on a societal level there is improvement to both the material conditions in RCSs as well as an improvement in discourse about those who live and work in RCSs.

The experiences, priorities, and perceptions of informal caregivers of people with dementia in nursing homes: A scoping review

BACKGROUND

Person-centered care has been shown to increase desired outcomes for people with dementia, yet informal caregivers' dissatisfaction with care is often reported. For those living in a nursing home, informal caregivers are uniquely situated to provide key insights into the individual's care. However, little is known of the informal caregivers' perspective, which hinders efforts to improve their satisfaction with person-centered nursing home care. Thus, we examined the comprehensive experiences, priorities, and perceptions of informal caregivers of nursing home residents with dementia.

METHODS

In collaboration with stakeholders, a scoping review of Medline (Ovid), EMBASE.com, CINAHL (EBSCO), the Cochrane Library (Wiley), and PsycINFO (Ovid) databases from January 2000 to July 2020 was conducted. Data were extracted reflecting the experiences, priorities, and preferences of caregivers of people with dementia residing in nursing homes.

RESULTS

We identified 114 articles that revealed nine themes: (1) communication, (2) transition to nursing home, (3) quality of care, (4) quality of life, (5) informal caregiver role, (6) knowledge of dementia, (7) end-of-life preferences, (8) medication use to manage neuropsychiatric behaviors, and (9) finances.

CONCLUSION

Informal caregivers described aspects of care that led to both positive and negative experiences with and perceptions of nursing home care. The shortcomings in communication were discussed most frequently, indicating a high priority area. While researchers define the identified themes individually, informal caregivers perceive them to be interwoven as they relate to person-centered care delivery. Although we did not assess the quality of included articles, by identifying themes relevant to caregivers' perspectives of nursing home care, our findings may help to inform efforts to optimize caregivers' satisfaction with nursing home care for residents with dementia.

The dignity of older individuals with Alzheimer's disease and related dementias: A scoping review

BACKGROUND

Supporting human dignity is the essence of delivery of care. Dignity is one's sense of self-value that is influenced by the perceived value attributed to the individual from others. Individuals with Alzheimer's disease and related dementias (ADRD) are at risk of violations of their dignity, due to their diminished autonomy, the alteration in their sense of self, the loss of meaningful social roles, and their limited interactions with peers and confirmation of identity.

OBJECTIVES

A scoping review was conducted to explore the state of art regarding the dignity of individuals with ADRD. Methods: A search was conducted using CINAHL, PubMed, Web of Science, and PsycINFO. Relevant articles were analyzed and organized based on the themes they addressed, and a narrative description of findings was presented.

RESULTS

Twenty-six articles were included in the review. Findings highlighted characteristics of care that affected the dignity of these individuals. Researchers found that care was task-centered, depersonalized, and lacked a genuine connection. Individuals with ADRD experienced embarrassment, lack of freedom, and powerlessness, which contributed to feelings of being devalued, and threatened their dignity. Studies testing interventions to enhance dignity were either inconclusive, lacked rigor, or had no lasting effect. Conclusion: The dignity of individuals with ADRD may be violated during healthcare interactions. More research is needed to objectively measure the dignity of these individuals and examine the effectiveness of interventions aimed at promoting dignity.

How Can Autonomy Be Maintained and Informal Care Improved for People With Dementia Living in Residential Care Facilities: A Systematic Literature Review

Background and Objectives

For people with dementia living in residential care facilities, maintaining autonomy and receiving informal care are important. The objective of this review is to understand how caregiving approaches and physical environment, including technologies contribute to the maintenance of autonomy and informal care provision for this population.

Research Design and Methods

A literature review of peer-reviewed articles published between January 1995 and July 2017 was performed. Realist logic of analysis was used, involving context, mechanism and outcome configurations.

Results

Forty-nine articles were included. The improvement of the relationship between residents and formal/informal caregivers is important. This increases the knowledge (sharing) about the resident and contributes to their autonomy. A social, flexible, and welcoming attitude of the formal caregiver improves the provision of informal care. Specially designed spaces, for instance, therapeutic gardens, create activities for residents that remind them of themselves and contribute to their autonomy. Use of technologies reduces caregiver’s time for primary tasks and therefore enables secondary tasks such as interaction with the residents.

Discussion and Implications

The results revealed how residential care facilities could maintain autonomy of their residents and improve informal care delivery using caregiving approaches and the physical environment including technologies. The results are supporting toward each other in maintaining autonomy and also helped in enhancing informal care provision. For residential care facilities that want to maintain the autonomy of their residents and improve informal care delivery, it is important to pay attention to all aspects of living in a residential care facility.

Supporting sustainable occupational lives for partner caregivers of people with dementia

Introduction

This qualitative research explores the experience of partner caregivers and how their partner’s dementia impacts on their daily living and occupational lives, with the aim of informing the sustainability of homecare and decreasing the likelihood of formal care.

Method

Ten participants were recruited through Alzheimer’s Society groups. They were interviewed using the same semi-structured interview process and asked questions about their daily activities and caregiving role. The data was analysed using Braun and Clarke’s thematic analysis process and themes generated using inductive coding and reasoning.

Findings

Three main themes were identified: (1) losing occupational activities and roles; (2) adapting to a new occupational life and (3) adjusting to a new relationship in the trajectory of their partner’s illness.

Conclusion

This study highlights the complex occupational challenges experienced by partner caregivers of people with dementia. It suggests that there is a role for occupational therapists in sustaining homecare by working with partner caregivers as ‘expert service users’. Involvement should be provided at critical points of the caregiving journey and include co-creating technology solutions for social inclusion, sustaining adaptive engagement in personal occupations, creating opportunities for restoration and supporting caregivers to preserve their partner’s personhood.

Family-centeredness in dementia care: what is the evidence?

Over the last decade, person-centered practices in care for adults with Alzheimer's disease and related dementias (AD/RD) has received significant attention from the health care and social service literature, though less attention has been paid to family-centered care (FCC). Initially conceptualized for application in pediatric care, FCC is an approach where clinicians develop partnerships with care recipients' family members and views family members as having expertise to contribute to the clinical team. More recently, FCC has been extended to the literature on AD/RD care, though little is known about the extent to which family-centered interventions have been developed for use in AD/RD clinical practice, or the effectiveness of family-centered care for this population. To contribute to gaps in scholarship, this systematic review identified and evaluated intervention studies examining FCC in AD/RD clinical care. Implications for research and practice are discussed.

Dignifying and undignifying aspects of care for people with dementia: a narrative review

Background

The progressive disease trajectory makes people with dementia increasingly vulnerable and gradually more dependent on others which can lead to admission to a nursing home. Special interest in dignity in people with dementia has led to a growing body of knowledge towards promoting or hindering their dignity.

Aim

The aim of this narrative review was to synthesise dignifying and undignifying aspects of formal and informal care for people with dementia within nursing homes.

Method

The electronic databases CINAHL, SCOPUS, PSycInfo and PubMed were systematically searched with the terms ‘dementia’ and ‘dignity’, complemented with the use of snowballing and reference check. A total of 789 unique items were found. The search and selection process was structured by the PRISMA framework, and both authors formulated the criteria of eligibility. A methodological check was performed using the critical appraisal tool of Hawker. This process led to inclusion of 29 articles which were reviewed with the help of the guidelines for narrative synthesis by Popay et al.

Findings

The emerged dignifying and undignifying aspects of formal and informal care are characterised by either a successful or unsuccessful process of adjustment towards changing abilities, preferences and care needs of people with dementia. Three themes appeared as undignifying aspects of care: ‘Stigmatisation and objectivation’, ‘Scarcity and hastiness’ and ‘Impending estrangement and misunderstanding’. Four themes were identified as dignifying aspect of care: ‘Personalisation’, ‘Respect, attentiveness and encouragement’, ‘Attention for physical care and bodily gestures’, and ‘Foster belonging’. Literature synthesis showed mostly relational aspects of care concerning dignity in people with dementia. Formal and informal caregivers are important in maintaining and promoting their dignity.

Dementia care model: Promoting personhood through co-production

BACKGROUND

Despite robust evidence on its effectiveness, current approaches that aspire to person-centred care (PCC) frequently locate people with dementia as passive recipients rather than as active agents in the care process. We define active involvement in care as 'co-production'. In order to investigate co-production, we set out to review the evidence concerning personhood and dignity in dementia care.

METHOD

We adopted a meta-ethnographic approach to synthesise the predominantly- qualitative literature on personhood and dignity in dementia care using EMBASE, PsycINFO, and ASSIA databases. We also included relevant policy documents. Members of Patient and Public Involvement (PPI) group were consulted throughout.

RESULTS

A total of 14 empirical studies were subjected to content analysis. Three themes were identified: dignity and personhood, coping with dementia, and barriers to dignity in care. The findings suggest that positive strategies and coping mechanisms are associated with superior outcomes in relation to: sense of self, dignity and quality of care. The 22 policy documents yielded six themes pertaining to co-production: the part played by the person with dementia, family, environment, behaviour, governance and law, and health care partnership.

CONCLUSION

Personhood in dementia care is enhanced through co-production, by actively participating in social, civic and political life. This is promoted through behavioural changes at the micro and macro levels of society, including providers of care being trained in co-producing care and policy makers creating opportunities with, rather than for people with dementia.

Entangled in uncertainty: The experience of living with dementia from the perspective of family caregivers

Introduction

Too often dementia care is still fragmented and unresponsive to the needs of people living with dementia and their family caregivers. To develop effective health care services, in-depth insight into the experiences of family caregivers is a prerequisite.

Methods

This Dutch study is a qualitative interview study. The aim was twofold: 1) to develop an in-depth understanding of what it means to live with dementia and 2) to gain insight into what constitutes the art of living with dementia, both from the perspective of family caregivers. Data were gathered through 47 interviews with individuals and 6 focus group interviews. The analysis followed a phenomenologically inspired thematic approach.

Results

The findings show that living with dementia can be understood as becoming entangled in uncertainty and isolation. The following themes illustrate this experience in various phases of the disease: a) Before the diagnosis: a growing uneasy feeling that something is amiss; b) The diagnostic disclosure: an uncertain and upsetting relief; c) Dementia at home: entangled in an isolated and exhausting life; d) Capitulation to relocation: torn between relief and grief. In addition, the study shows that the art of living with dementia is associated with: a) The ability to face tragedy; b) The discovery of meaning and dignity in the context of illness; c) Retaining a sense of connection and bond; d) The primacy of attention and recognition by others.

Discussion and conclusion

Our findings show that dealing with what Boss (2011) called ‘ambiguous loss-experiences’ is one of the most demanding aspects of living with dementia. Based on the findings, we have developed a model that depicts how people handle contingency and seek balance along the continuum of facing and resisting. Our study shows that resilience in the context of living with dementia should not be understood as merely an individual mental ability, nor as a set of behaviours, but rather as a social-ecological enterprise.

The right to mourn in dementia: To tell or not to tell when someone dies in dementia day care

People with dementia (PwD) attending dementia day care often experience the death of others. Little research exists regarding whether PwD should be informed of the death, and if so, how? In this qualitative research, the authors explored, through semistructured interviews, the beliefs and practices of 52 staff members of adult day centers for PwD about these issues. Themes that emerged are that many staff members feel their clients have emotional capacity to mourn, despite their cognitive impairments. There are many different ways to tell PwD about the death of others. Each case should be judged individually. Eighty percent of staff feels sad when a group member dies and 92% desires more training on how to enable their clients to grieve. Research is needed on mourning and PwD, staff training, and ways to help staff with the burden of their own grieving. These methods may improve quality of care and decrease staff burnout.

The meaning of living close to a person with Alzheimer disease

Only a few studies explore the lifeworld of the spouses of persons affected by early-onset Alzheimer disease (AD). The aim of this study is to explore the lifeworld of spouses when their partners are diagnosed with AD, focusing on spouses' lived experience. The study employs an interpretative phenomenological framework. Ten in-depth interviews are performed. The results show that spouses' lifeworld changes with the diagnosis. They experience an imprisoned existence in which added obligations, fear, and worry keep them trapped at home, both physically and mentally. In their longing for freedom, new strategies and attitudes helps the spouses to create an extended "lived space" with their partner. The findings stress the importance of paying attention to the lifeworld of spouses and making clinical recommendations on this basis. Most importantly, the lifeworld perspective has implications for how we understand what care is. We hope to challenge all different healthcare professionals and invite them to discuss the deep meaning of care and the definition of being professional in encounters with vulnerable others from a lifeworld perspective.

[Family dynamics in face of Alzheimer's in one of its member]

OBJECTIVE

To understand the family dynamics when there is a member in the residence with Alzheimer's disease.

METHOD

A study of qualitative approach, using the creative sensitive method (CSM), and with participation of two families who had a member with Alzheimer's disease at home.

RESULTS

Three categories emerged: Effects of Alzheimer's disease and the family dynamics; Development process of Alzheimer's disease and Coping strategies in face of the disease.

CONCLUSION

It was possible to know the manifestations and consequences of Alzheimer's disease in the family, such as mutual help, the mobilization of resources to activate memories of the past, spirituality and faith. There was also understanding of the structure of family dynamics.

Continuity and Change in Life Engagement Among People With Dementia

The purpose of this study was to explore the change and continuity in the engagement in life of people with advanced dementia. The idea of meaningful activities is commonly used in nursing research, but few studies have been performed on what makes activities meaningful. This study aims to shed light on the meaning of activities in a life course context, changes in activity patterns due to dementia disease, and the significance of narratives told by close relatives. The 11 stories of activities were analyzed using thematic narrative analysis with Leontyev's activity theory as a theoretical framework. The findings revealed several types of changes: slow and abrupt changes in everyday and physical activities, changes in the person's level of awareness, and changes in habits in new care settings and environments. The meaningfulness of activities was connected to a person's background, his/her motives, lifestyle and identity, and the contextuality of activities. Through the narratives, nursing care personnel could acquire a nuanced picture of the person and his/her engagement in life. These narratives are vital to helping people who have dementia to keep up with meaningful activities and enhance their quality of life, especially when the person has deficiencies in communication.

Dignity and care for people with dementia living in nursing homes

This article presents and discusses findings from a qualitative study on how the dignity of patients with dementia is preserved or harmed when they live in a nursing home. The results build on participant observation in two nursing home wards, combined with qualitative interviews with seven relatives of patients with dementia. The most important issue for relatives was that their family member with dementia was confirmed as a relational human being. However, relatives experienced lack of resources and task-centred care as threats to confirming, relational care and to patients' dignity. Findings from participant observations confirmed this. In this article, we argue that care which focuses on the residents' personhood, combined with a relational focus, is of great importance in maintaining the dignity of people with dementia living in nursing homes.