Minimizing confusion and disorientation: cognitive support work in informal dementia caregiving

Experiences and perspectives on the optimal timing for initiating advance care planning in patients with mild to moderate dementia: A meta-synthesis

BACKGROUND

Advance care planning is typically initiated during the last six months of a patient's life. However, due to the progressive decline in the decision-making process in individuals with dementia, their involvement in advance care planning is limited to the early stages of the disease. Currently, there is no consensus on the optimal timing for initiating advance care planning for people with dementia, and a comprehensive review of the literature addressing this matter is lacking.

OBJECTIVE

To explore the experiences and perspectives of people with dementia, their family caregivers, and health care professionals with regard to the optimal timing for initiating advance care planning.

DESIGN

A meta-synthesis was conducted.

DATA SOURCE

The following eight electronic databases were searched: PubMed, Embase, Web of Science, Cochrane Library, CINAHL and CNKI, WanFang and Vip.

REVIEW METHODS

This review uses thematic synthesis to systematically synthesize qualitative evidence and report findings according to The Enhancing Transparency in Reporting the Synthesis of Qualitative Research (ENTREQ) and the Joanna Briggs Institute Manual for Evidence Synthesis. Study selection and data extraction were conducted independently by two researchers, and quality was evaluated using the Joanna Briggs Institute's Qualitative Research Standard Assessment tool.

FINDINGS

Twenty-one studies were selected for this review. This review involved an overarching theme: The utilization of pivotal elements to transition from delayed initiation to comprehensive implementation. Three themes emerge, including the prerequisites for initiating advance care planning, not ready to start advance care planning and struggling along narrow roads. For health care professionals, the selection of an opportune moment to initiate advance care planning for people with dementia is not only a challenge but also a crucial prerequisite for the successful implementation of advance care planning. Health care professionals' experience, attitude toward advance care planning, trust relationship with patients, cultural differences among people with dementia and their caregivers, and economic disparities all influence health care professionals' judgment of the timing for initiating advance care planning.

CONCLUSIONS

Determining the optimal timing for initiating advance care planning is a complex process that requires a comprehensive consideration of the realities faced by health care professionals, people with dementia and their caregivers. Therefore, it is imperative to provide relevant training to health care professionals to ensure the successful implementation of advance care planning.

The perspectives of family caregivers of people with Alzheimer´s disease regarding advance care planning in China: a qualitative research

OBJECTIVES

Advance care planning (ACP) enables people to define goals and preferences for future medical treatment and care. Despite universal recognition of the importance of ACP for people with Alzheimer´s disease (AD) internationally, there is little support for its implementation in China. The viewpoint of family caregivers is crucial in making clinical decisions about AD. Therefore, it's critical to understand the family caregivers' perspectives on ACP in order to promote its practice among people with AD in China.

METHODS

Seventeen family caregivers of people with AD were purposively selected in three communities in Guangzhou. Semi-structured interviews were conducted to collect data and the data were analyzed using the thematic analysis.

RESULTS

Three main themes were extracted: ①Attitudes toward ACP including positive and negative attitudes; ②Social pressure influencing ACP decision; ③Behavioral willingness of the implementation of ACP.

CONCLUSIONS

Attitudes, social pressure, and behavioral willingness characterized the behavioral intentions of family caregivers of people with Alzheimer's disease. It is recommended to strengthen efforts to publicity of advance care planning and promote legislation in China.

Decision-Making Support for People With Alzheimer's Disease: A Narrative Review

The proportion of people with dementia has been increasing yearly, and the decision-making capacity of these people has become a major concern in fields such as the financial industry and in medical settings. In this narrative review, we discuss decision-making in people with Alzheimer’s disease (AD), and we propose the support for decision-making in people with AD, especially financial and medical decision-making. We summarize several hypotheses and theories on the decision-making capacity of people with AD. These include the frontal lobe hypothesis, physiological theory, dysfunction of the hypothalamic-pituitary-adrenal (HPA) axis, and the Person-Task-Fit (PTF) framework. Both internal and external factors can affect decision-making by people with AD. Internal factors are affected by changes in the brain and neurotransmitters, as well as alterations in cognitive ability and emotion. External factors include task characters, task contents, and situation influence. Since feedback has a significant effect on decision-making capacity, a series of suggestions may be helpful to improve this capacity, such as explicit advice, simple options, pleasant rewards, the Talking Mats approach, memory and organizational aid, support by caregivers, cognitive training and feedback. Thus, in providing decision-making support for people with AD, it is important to identify the internal and external factors that impair this process and to deal with these factors.

Community-based dementia care re-defined: Lessons from Iceland

Studies of families caring for persons with dementia living at home often reflect feelings of being forgotten and abandoned by the authorities to shoulder the responsibility for care-giving. This has increased interest in how formal services can better support these families. This article analyses how health and social care professionals envision the needs of families of persons with dementia living in the community. It also describes the contributions of the formal care system to these families. The study design was qualitative. It involved interviews with professionals (N = 20), field observations from the settings where they worked, and public documents addressing care-giving for people with dementia. Data were analysed using the framework method. The findings reflected how those providing services to persons experiencing cognitive changes mainly understood the services as specialised. They focused on the diagnosis and treatment of the individual with dementia. They considered other aspects of care, such as attending to practical issues of daily life, to be a private matter, for which the family was responsible. In later stages of dementia, specialised day programs become available, offering rehabilitation to motivate positive daily living-for both the person experiencing dementia and family-centred supporters. Professionals in the field described primary care, community-based healthcare and home care services as poorly equipped to support these families. Participants acknowledged that families were often under a lot of stress and might need more support earlier in the illness. However, they saw themselves as powerless. Towards the end of the data collection, services were being re-designed to emphasise the role of primary care. In light of its holistic and family-centred approach, primary care may be well placed to integrate relational understanding of living with dementia and specialised knowledge of dementia treatment.

Caregiver decisions along the Alzheimer's disease trajectory

Despite the rising prevalence of Alzheimer's disease (AD), there is limited systematic evidence about disease specific decisions. The aim of this qualitative descriptive study was to identify decisions across the AD trajectory using focus groups of past and present caregivers. Qualitative content analysis revealed three main categories with corresponding categories and sub-categories. Main Category One-Decisions pertaining to self-yielded two categories: decision pertaining to the offering of self and care for the caregiver. Main Category Two-Decisions pertaining to the patient-yielded three categories: decisions about care and treatment, living arrangements, and protecting the patient from harm. Main Category Three-Communication and relationships in decisions-yielded two categories: navigation and negotiations. The results of this study will inform healthcare providers and caregivers as they work together to anticipate, prepare, and plan for care management decisions over the AD trajectory.

Living Life and Doing Things Together: Collaborative Research With Couples Where One Partner Has a Diagnosis of Dementia

The aim of this study is to identify relevant content for a self-management guide by using the outcomes of previous research in combination with knowledge and experiences from couples where one partner has a diagnosis of dementia. The study was carried out in three phases: (a) literature search of previous research related to well-being and couplehood in dementia; (b) interviews with couples with dementia based on the findings of the literature search; and (c) further authentication of the findings within expert groups of people with dementia and carers. For analysis of data, we used a hybrid approach of thematic analysis with combined deductive and inductive approaches. The findings of this study indicated that the four main themes "Home and Neighborhood," "Meaningful Activities and Relationships," "Approach and Empowerment," and "Couplehood" with related subthemes could be appropriate targets for a self-management guide for couples where one partner has a diagnosis of dementia.

Self-reported confusion is related to global and regional β-amyloid: data from the Women's healthy ageing project

Disease-modifying treatments for Alzheimer's disease (AD) may require implementation during early stages of β-amyloid accumulation, well before patients have objective cognitive decline. In this study we aimed to assess the clinical value of subjective cognitive impairment (SCI) by examining the cross-sectional relationship between β-amyloid load and SCI. Cerebral β-amyloid and SCI was assessed in a cohort of 112 cognitively normal subjects. Subjective cognition was evaluated using specific questions on memory and cognition and the MAC-Q. Participants had cerebral β-amyloid load measured with ¹⁸F-Florbetaben Positron Emission Tomography (PET). No associations were found between measures of subjective memory impairment and cerebral β-amyloid. However, by self-reported confusion was predictive of a higher global β-amyloid burden (p = 0.002), after controlling for confounders. Regional analysis revealed significant associations of confusion with β-amyloid in the prefrontal region (p = 0.004), posterior cingulate and precuneus cortices (p = 0.004) and the lateral temporal lobes (p = 0.001) after controlling for confounders. An in vivo biomarker for AD pathology was associated with SCI by self-reported confusion on cross-sectional analysis. Whilst there has been a large body of research on SMC, our results indicate more research is needed to explore symptoms of confusion.

Advance care planning and anticipatory decision making in patients with Alzheimer disease

Early advance care planning and anticipatory decision making in the Alzheimer disease (AD) trajectory is a strategy NPs can incorporate to improve managing uncertainty around common decisions. This article explores decisions patients and caregivers face along the AD trajectory and provides resources for patients, caregivers, and NPs.

The potential role of relatives in designing person-centred assistive technologies (innovative practice)

The paper explores the important role of relatives in designing assistive technologies in collaboration with practitioners. A brief case study reports the collaborative design of a 24-hour clock to reduce the impact of visual-spatial impairment on a family member's ability to read time and prevent temporal disorientation.

How family members manage risk around functional decline: the autonomy management process in households facing dementia

Most dementia research investigates the social context of declining ability through studies of decision-making around medical treatment and end-of-life care. This study seeks to fill an important gap in research about how family members manage the risks of functional decline at home. Drawing on three waves of in-depth interviewing in 2012-2014, it investigates how family members in US households manage decline in an affected individual's natural range of daily activities over time. The findings show that early on in the study period affected individuals were perceived to have awareness of their decline and routinely drew on family members for support. Support transformed when family members detected that the individual's deficit awareness had diminished, creating a corresponding increase in risk of self-harm around everyday activities. With a loss of confidence in the individual's ability to regulate his or her own activities to avoid these risks, family members employed unilateral practices to manage the individual's autonomy around his or her activity involvements. These practices typically involved various deceits and ruses to discourage elders from engaging in activities perceived as potentially dangerous. The study concludes by discussing the implications that the social context of interpretive work around awareness and risk plays an important role in how families perceive an elder's functional ability and manage his or her activity involvements.