Unmet needs in community-living persons with dementia are common, often non-medical and related to patient and caregiver characteristics

Healthcare Needs Patterns and Pattern-Predicting Factors in Dementia: Results of the Comprehensive, Computerized Unmet Needs Assessment from the Randomized, Controlled Interventional Trial InDePendent

Background

Determining unmet need patterns and associated factors in primary care can potentially specify assessment batteries and tailor interventions in dementia more efficiently.

Objective

To identify latent unmet healthcare need patterns and associated sociodemographic and clinical factors.

Methods

This Latent Class Analysis (LCA) includes n = 417 community-dwelling people living with dementia. Subjects completed a comprehensive, computer-assisted face-to-face interview to identify unmet needs. One-hundred-fifteen predefined unmet medical, medication, nursing, psychosocial, and social care needs were available. LCA and multivariate logistic regressions were performed to identify unmet needs patterns and patient characteristics belonging to a specific pattern, respectively.

Results

Four profiles were identified: [1] "few needs without any psychosocial need" (n = 44 (11%); mean: 7.4 needs), [2] "some medical and nursing care needs only" (n = 135 (32%); 9.7 needs), [3] "some needs in all areas" (n = 139 (33%); 14.3 needs), and [4] "many medical and nursing needs" (n = 99 (24%); 19.1 needs). Whereas the first class with the lowest number of needs comprised younger, less cognitively impaired patients without depressive symptoms, the fourth class had the highest number of unmet needs, containing patients with lower health status, less social support and higher comorbidity and depressive symptoms. Better access to social care services and higher social support reduced unmet needs, distinguishing the second from the third class (9.7 versus 14.3 needs).

Conclusions

Access to the social care system, social support and depressive symptoms should be assessed, and the patient's health status and comorbidities monitored to more comprehensively identify unmet needs patterns and more efficiently guide tailored interventions.

Examining pain, function, behavioral symptoms and associations with engagement in meaningful activity for residents with dementia in assisted living

OBJECTIVES

The purpose of this study was to examine factors associated with engagement in meaningful activity among residents with dementia in assisted living. We hypothesized that greater functional independence, less pain, and lower behavioral and psychological symptom severity would be associated with higher engagement in meaningful activity after controlling for residents' age, gender, comorbidities, and cognition. Understanding factors associated with engagement in meaningful activity can help to inform strategies for optimizing engagement among residents with dementia in assisted living.

METHOD

This descriptive study used baseline data from a randomized controlled trial, Meaningful Activity for Managing Behavioral Symptoms of Distress (MAC-4-BSD). Linear regression was used to examine factors associated with engagement in meaningful activity.

RESULTS

A total of 71 residents from 5 assisted living settings were included in the sample. Most participants were female (n = 52, 73%), White (n = 62, 87%), and mean age was 85 years old (SD = 8.2). Controlling for age, gender, comorbidities, and cognition, pain was significantly associated with engagement in meaningful activity (b= -2.09, p < 0.05). There were no associations found between function and behavioral symptoms with engagement in meaningful activity.

CONCLUSION

Findings from this study show that pain is a significant factor that is negatively associated with residents' engagement in meaningful activity. Ongoing research is needed to help improve pain management for residents with dementia in assisted living and support their engagement in meaningful activity.

Preferred type, timing and format of dementia information: A cross-sectional survey of carers of people living with dementia

OBJECTIVES

To clarify the unmet information needs of carers of people living with dementia, including the stage of their care journey at which topics become relevant, and the preferred format and mode of delivery of information.

METHODS

A cross-sectional survey of carers of people living with dementia was conducted between April 2022 and October 2022. Carers were recruited through public and private geriatric hospital and community clinics, aged care providers, an online research register and community dementia services. Consenting carers completed a survey assessing sociodemographic characteristics, preferred type and timing of information about dementia, accessing services, changes in behaviour/personality, changes in physical/emotional health, managing own health/well-being and preferred information format and mode of delivery.

RESULTS

A total of 163 carers returned a survey (20% response rate). Most carers (75-98%) reported wanting information across a range of topics. Carers preferred general dementia information at diagnosis, information about accessing services at or within the first year of diagnosis, and information on managing symptoms as they emerged. Carers were most interested in receiving information in-person face-to-face (60% very interested), written information (51% very interested) or via face-to-face group information sessions (42% very interested).

CONCLUSIONS

Carers of people living with dementia expressed a desire for information on a wide range of topics, which changed as the dementia of the person they cared for progressed. Information needs to be made available in a variety of formats to cater for differing ways in which it is consumed.

Variation in Home Healthcare Use by Dementia Status Among a National Cohort of Older Adults

BACKGROUND

Medicare-funded home healthcare (HHC) delivers skilled nursing, therapy, and related services through visits to the patient's home. Nearly one-third (31%) of HHC patients have diagnosed dementia, but little is currently known regarding how HHC utilization and care delivery differ for persons living with dementia (PLwD).

METHODS

We drew on linked 2012-2018 Health and Retirement Study and Medicare claims for a national cohort of 1 940 community-living older adults. We described differences in HHC admission, length of stay, and referral source by patient dementia status and used weighted, multivariable logistic and negative binomial models to estimate the relationship between dementia and HHC visit type and intensity while adjusting for sociodemographic characteristics, health and functional status, and geographic/community factors.

RESULTS

PLwD had twice the odds of using HHC during a 2-year observation period, compared to those without dementia (odds ratio [OR]: 2.03; p < .001). They were more likely to be referred to HHC without a preceding hospitalization (49.4% vs 32.1%; p < .001) and incurred a greater number of HHC episodes (1.4 vs 1.0; p < .001) and a longer median HHC length of stay (55.8 days vs 40.0 days; p < .001). Among post-acute HHC patients, PLwD had twice the odds of receiving social work services (unadjusted odds ratio [aOR]: 2.15; p = .008) and 3 times the odds of receiving speech-language pathology services (aOR: 2.92; p = .002).

CONCLUSIONS

Findings highlight HHC's importance as a care setting for community-living PLwD and indicate the need to identify care delivery patterns associated with positive outcomes for PLwD and design tailored HHC clinical pathways for this patient subpopulation.

Care needs assessment of older adults with dementia in a semi-rural district in Vietnam: A community-based cross-sectional study

BACKGROUND

The increasing needs of people living with dementia (PLWD) in Vietnam present an enormous public health challenge. Vietnam is an understudied country, and little is known regarding the overall unmet needs of caregivers or the demographic risk factors associated with unmet caregiving needs. This study aimed to determine the burden of unmet care needs of community-dwelling PLWD and identify sociodemographic risks associated with unmet care needs.

METHODS

A cross-sectional study in a rural area facing urbanisation in Hanoi, Vietnam recruited PWLD-caregiver dyads with multistage sampling. We utilised the Camberwell Assessment of Need for the Elderly (CANE) instrument to evaluate care needs across four domains. Caregivers rated PLWD needs, with higher scores indicating greater unmet needs. The Mann-Whitney test was employed for comparing two groups, while the Kruskal-Wallis test was used for comparisons involving more than two groups in the analysis, and a P-value of less than 0.05 was considered statistically significant.

RESULTS

Among 90 PLWD participating in the study, the overall mean care needs score was 11.6 ± 4.3, with only 16.2% of PLWD having their care needs met. Environmental and physical needs were more frequently met than psychological or social needs. Only 48.0% and 43.9% of environmental and physical needs were met respectively, and a meagre 20.9% and 23.6% for psychological and social needs. Unmet care needs were more frequent for PWLD who were female, single or divorced, had lower monthly household income, or who were in more advanced stages of dementia, as indicated by Clinical Dementia Rating scores ≥1.

CONCLUSIONS

Unmet needs for PWLD are common. Increased caregiver education, resources, and services in Vietnam are urgently required to improve the quality of life for this population.

Patient portal messages to support an age-friendly health system for persons with dementia

BACKGROUND

Patient portal secure messaging can support age-friendly dementia care, yet little is known about care partner use of the portal and how message concerns relate to age-friendly issues.

METHODS

We conducted a two-part observational study. We first assessed the feasibility of automating care partner identification from patient portal messages by developing and testing a natural language processing (NLP) rule-based classification system from portal messages of 1973 unique patients 65 and older. Second, two independent reviewers manually coded a randomly selected sample of portal messages for 987 persons with dementia to identify the frequency of expressed needs from the 4M domains of an Age-Friendly Health System (medications, mentation, mobility, and what matters).

RESULTS

A total of 267 (13.53%) of 1973 messages sent from older adults' portal accounts were identified through manual coding as sent by a nonpatient author. The NLP model performance to identify nonpatient authors demonstrated an AUC of 0.90. Most messages sent from the accounts of persons with dementia contained content relevant to the 4Ms (60%, 601/987), with the breakdown as follows: medications-36% (357/987), mobility-10% (101/987), mentation-16% (153/987), and what matters (aligning care with specific health goals and care preferences)-21%, 207/987.

CONCLUSIONS

Patient portal messaging offers an avenue to identify care partners and meet the informational needs of persons with dementia and their care partners.

Responses of Persons Living With Dementia to Caregiver Validating Communication: A Secondary Analysis

Background and Purpose: Good communication between persons living with dementia and their caregivers is one important consideration when fostering a positive relationship and improving the effectiveness of care. Care can be a challenge if the person living with dementia does not feel understood or fails to cooperate with care. The individual may feel disrespected and may resist assistance. Validation therapy is a person-centered method for communicating with persons living with dementia that involves validating the experiences, feelings, and reality of an individual to encourage cooperation or provide for safety. The purpose of this study was to identify frequencies of four behavioral responses (cooperation, apathy, resistiveness, and distress) from persons living with dementia when validation communication strategies were used during care activities. Methods: This was a secondary analysis of homecare videos (n = 41) of family caregivers interacting with a person living with dementia during daily care. Behavioral coding was used to examine the relationships between validating communication and the response of a person living with dementia. Caregiver use of specific validation techniques in their communication (affirmation, acknowledging emotions, and verbalizing understanding) was coded along with subsequent responses of the person living with dementia (resistiveness, distress, apathy, or cooperation). Results: Affirmations produced an 11% probability of a cooperative response by the person living with dementia. Caregiver verbalization of understanding resulted in a 6% probability of cooperation, and silence was associated with an 8% probability of cooperation. Nonvalidating communication behaviors were associated with negative reactions. Implications for Practice: Effective person-centered communication between caregivers and persons living with dementia improved cooperation with care and decreased distress. Affirmations and verbalizing understanding were two types of validating communication more likely to elicit a cooperative response and can improve care quality, decrease caregiver burnout, and mitigate challenging behavioral responses in persons living with dementia.

Home and Community-Based Service Use Varies by Health Care Team and Comorbidity Level of Veterans with Dementia

Home and community-based services (HCBSs) such as home care and adult day centers are vital to supporting adults with dementia in community settings. We investigated whether HCBS use (use of both home care and adult day, use of one service, and use of neither service) varied between adults receiving care from three types of health-care teams with case management from social workers and nurses, and by comorbidity level, using 2019 data of 143,281 patients with dementia in the Veterans Health Administration. We compared HCBS use by patients' type of case-managed team (Home-Based Primary Care, geriatrics-based primary care, and dementia-focused specialty care) to patients in none of these teams, stratified by patients' non-dementia comorbidities (<4 or ≥4). Each type of health-care team was associated with both home care and adult day services, at each level of comorbidity. Home-Based Primary Care was most consistently associated with other forms of HCBS use, followed by Dementia Clinics and geriatrics-based primary care, for patients with ≥4 non-dementia comorbidities. Our findings suggest that case management in primary and specialty care settings is a contributor to the use of critical community supports by patients with the most complex needs.

Adaptation of a guided low-intensity behavioral activation intervention for people with dementia in Sweden: a qualitative study exploring the needs and preferences of key stakeholders

BACKGROUND

Despite depression being prevalent in people with dementia, contributing to negative health outcomes and placing increased burden on individuals and family members, access to psychological interventions is limited. A potential solution is guided low-intensity behavioral activation, supported by informal caregivers and guided by healthcare professionals. However, it is necessary to adapt interventions to meet the needs and preferences of key stakeholders to enhance acceptability and relevance. Study objectives were to: (1) explore needs and preferences concerning the content and delivery model of the guided low-intensity behavioral activation intervention; and (2) adapt the intervention to ensure cultural appropriateness, relevancy, and acceptability to people with dementia and their caregivers in Sweden.

METHODS

Semi-structured interviews and focus group discussions were conducted with key stakeholders, including healthcare professionals (n = 18), community stakeholders (n = 7), people with dementia (n = 8), and informal caregivers (n = 19). A draft of the written low-intensity behavioral activation intervention and a description of the proposed intervention delivery model were provided to participants. Open-ended questions explored the perceived relevance of the intervention, alongside needs and preferences concerning content and delivery. A manifest content analysis approach was adopted.

RESULTS

Content analysis resulted in three categories: Content, Delivery procedures, and Illness trajectory. Results highlighted a need to consider the intervention Content via increased cultural adaptation to the Swedish context, and increasing the inclusiveness of intervention content. Delivery procedures were identified as needing to be flexible given the unpredictable nature of caring for people with dementia, with the provision of additional guidance to informal caregivers supporting the intervention. Illness trajectory was viewed as essential to consider, with the intervention regarded as suitable for those early in the dementia trajectory, alongside a need to reduce workbook text to minimize burden given dementia symptomology.

CONCLUSIONS

The intervention and proposed delivery model were generally well received by all stakeholders. We were able to identify key adaptations to enhance cultural appropriateness, relevancy, and acceptability for a currently neglected population. Results will inform a feasibility study to explore the feasibility and acceptability of the intervention and study procedures to inform the design of a future superiority randomized controlled trial.

TRIAL REGISTRATION/PROTOCOL

Not applicable.

Informal Caregivers of People with Dementia in Germany: Psychosocial Characteristics and Unmet Needs

Background

Caregivers of people with dementia living at home (CPwDh) are likely to be affected by a range of health problems. However, CPwDh are often regarded as accompanying persons and receive less attention in research and care. Little is known about this population and their needs in Germany. However, better knowledge of CPwDH is needed to design effective interventions.

Objective

The objective of this report is to describe the situation of CPwDh and highlight differences based on sex and living situation.

Methods

This was a cross-sectional analysis of the psychosocial characteristics of participants in the GAIN trial, a cluster-randomized, controlled intervention trial investigating the effectiveness of a care management program. A total of n = 192 CPwDh were recruited in GP offices, memory clinics or through public campaigns in the German federal state of Mecklenburg-Western Pomerania. The inclusion criteria were an age of 18 years or above, being a CPwDh, written informed consent. In a comprehensive digital assessment, psychosocial variables, burden, and care needs were assessed.

Results

Partners, women, and people living in the same household represented the majority of caregivers, and their mean number of needs was 8.7. Overall, participants indicated a mild to moderate burden. There are differences in burden based on sex and living situation, with caregivers living with people with dementia showing less burden and different psychosocial demographics.

Conclusions

There is a need for interventions to reduce caregivers' unmet needs in the CPwDh. Such interventions should consider differences in sex and living situation to better address individual caregiver needs.

Competency development for a volunteer navigation program to support caregivers of people living with dementia: A modified e-Delphi method

Caregivers of people living with dementia are pillars of the care community. Providing them with adequate support throughout their caregiving journey is essential to their quality of life and may also contribute to improving the care of people living with dementia. Nav-CARE (Navigation - Connecting, Advocating, Resourcing, Engaging) is a volunteer-led navigation program that provides support to older adults with life-limiting illnesses who are living in the community. However, Nav-CARE does not provide support directly to caregivers of people living with dementia. To adapt Nav-CARE to support caregivers, we needed to establish caregivers' needs and the competencies volunteer navigators should be trained in to support caregivers to meet these needs. To do so, a modified e-Delphi method was utilized, which consisted of administering three sequential questionnaires to a panel of 35 individuals with expertise in a variety of dementia related domains. Through this, two final lists of 46 caregivers' needs and 41 volunteer competencies were established to inform the development of volunteer navigator training curriculum. Findings suggest that trained volunteer navigators may be able to support caregivers of people living with dementia throughout the disease trajectory and can be used to inform the development of future dementia navigation programs.

Sociodemographic and Clinical Characteristics of People Living with Dementia and Their Associations with Unmet Healthcare Needs: Insights from the Baseline Assessment of the InDePendent Study

Background

The healthcare needs of People living with Dementia (PlwD) (such as Alzheimer's disease) are often unmet. Information about the needs of community-dwelling PlwD and their association with sociodemographic and clinical characteristics is needed to fill the knowledge gap regarding factors influencing unmet needs among PlwD and to conduct a comprehensive needs assessment to develop tailored interventions.

Objective

To describe sociodemographic and clinical characteristics of the InDePendent study population with particular reference to determinants of unmet needs.

Methods

We analyzed baseline data of the multi-centre cluster-randomized controlled trial (InDePendent) using descriptive statistics to describe patients' sociodemographic and clinical characteristics and Poisson regression models to predict unmet needs, separated by sex. Data were collected personally via face-to-face interviews.

Results

Most of the n = 417 participating PlwD were mild to moderately cognitively impaired, were not depressed, had an average of 10.8 diagnoses, took 6.7 medications, and had, on average, 2.4 unmet needs (62% of PlwD had at least one unmet need) measured by the Camberwell Assessment of Need for the Elderly (CANE). Low social support, a high body-mass-index, a lower education, functional impairment, and worse health status were associated with more unmet needs, regardless of sex. In women, higher unmet needs were associated with more depressive symptoms, a poor financial situation, living alone and not being recently treated by a general practitioner. In males, unmet needs increased with the number of medications taken.

Conclusions

PlwD had a broad array of unmet healthcare needs, indicating primary healthcare provision improvement potentials. The results underscore the significance of early assessment of patient's clinical characteristics and unmet needs as a basis for individualized gender-sensible intervention strategies.∥ClinicalTrials.gov Identifier: NCT04741932, Registered on February 5, 2021.

Effectiveness, acceptability, and completeness and quality of intervention reporting of psychological interventions for people with dementia or mild cognitive impairment: protocol for a mixed-methods systematic review

INTRODUCTION

Mental health difficulties such as anxiety and depression have negative impacts on psychological well-being and are common in people with dementia and mild cognitive impairment. However, access to psychological treatments is limited. This mixed-method systematic review will: (1) examine the effectiveness of psychological interventions to improve mental health and psychological well-being in people with dementia or mild cognitive impairment; (2) examine the effectiveness of these psychological interventions to improve mental health and psychological well-being in informal caregivers; (3) examine potential clinical and methodological moderators associated with effectiveness; (4) explore factors associated with the acceptability of psychological interventions from the perspective of key stakeholders; and (5) examine the completeness and quality of intervention reporting.

METHODS AND ANALYSIS

Electronic databases (ASSIA, CENTRAL, CINAHL, EMBASE, PsycINFO and MEDLINE) will be systematically searched and supplemented with expert contact, reference and citation checking, and grey literature searches. If possible, we will conduct a meta-analysis to examine the overall effectiveness of psychological interventions to improve mental health and psychological well-being in people with dementia or mild cognitive impairment and their informal caregivers; and examine potential clinical and methodological moderators associated with effectiveness. We will conduct a deductive framework synthesis, informed by the theoretical framework of acceptability, to explore factors associated with the acceptability of psychological interventions from the perspective of key stakeholders. In accordance with Joanna Briggs Institute guidance, we will adopt a convergent segregated approach to data synthesis and integration of quantitative and qualitative findings. We will examine the completeness and quality of intervention reporting according to the Template for Intervention Description and Replication checklist and guide.

ETHICS AND DISSEMINATION

No primary data will be collected, and therefore, ethical approval is not required. Results will be disseminated through a peer-reviewed publication, academic conferences, and plain language summaries.

PROSPERO REGISTRATION NUMBER

CRD42023400514.

Healthcare and community stakeholders' perceptions of barriers and facilitators to implementing a behavioral activation intervention for people with dementia and depression: a qualitative study using Normalization Process Theory

BACKGROUND

Depression is commonly experienced by people with dementia, and associated with lower quality of life and functional decline. However, access to evidence-based psychological interventions for people with dementia and depression is limited. One potential solution is guided low-intensity behavioral activation. Following the new Medical Research Council Framework, considering factors such as potential barriers and facilitators to implementation is recommended during the development of new interventions. Aims of this study were to: (1) develop an understanding of existing healthcare and community support in the Swedish context for people with dementia and their informal caregivers; and (2) identify barriers and facilitators to intervention uptake informed by Normalization Process Theory.

METHODS

Semi-structured interviews and focus groups were held with healthcare (n = 18) and community (n = 7) stakeholders working with people with dementia and/or informal caregivers. Interview questions were informed by Normalization Process Theory. Data was analysed utilizing a two-step deductive analysis approach using the Normalization Process Theory coding manual, with inductive categories applied to data related to the main mechanisms of the theory, but not captured by its sub-constructs.

RESULTS

Twelve deductive and three inductive categories related to three Normalization Process Theory primary mechanisms (Coherence, Cognitive Participation, and Collective Action) were identified. Identified barriers to intervention uptake included: (1) additional burden for informal caregivers; (2) lack of appropriate workforce to provide guidance; (3) lack of time and financial resources; (4) people with dementia not recognising their diagnosis of dementia and/or a need for support; and (5) stigma. Identified facilitators to intervention uptake included: (1) intervention has potential to fill a large psychological treatment gap in Sweden; (2) objectives and potential benefits understood and agreed by most stakeholders; and (3) some healthcare professionals recognized their potential role in providing intervention guidance.

CONCLUSIONS

Several barriers and facilitators for future implementation, specific to the intervention, individuals and families, as well as professionals, were identified during intervention development. Barriers were mapped into evidence-based implementation strategies, which will be adopted to overcome identified barriers. A feasibility study further examining implementation potential, acceptability and feasibility, alongside clinical, methodological, and procedural uncertainties associated with the intervention will be conducted.

TRIAL REGISTRATION

Not applicable.

The Relationship Between Adverse Childhood Experiences and Subjective Cognitive Decline Based on Sexual Orientation

OBJECTIVES

Research indicates adverse childhood experiences (ACEs) were associated with subjective cognitive decline (SCD), with higher ACEs reported by sexual minoritized individuals (i.e. lesbian, gay, and bisexual; LGB). This study aimed to explore the relationships between ACEs and SCD based on sexual orientation in middle-aged and older adults.

METHODS

The study included 76,592 participants from the 2019-2020 Behavioral Risk Factor Surveillance Survey (BRFSS). Multivariate logistic regressions analyzed ACEs status, score, and type associations with SCD.

RESULTS

2.18% of the participants identified as sexual minoritized individuals. More sexual minoritized individuals reported SCD compared to heterosexual individuals (10.70% for heterosexuals; 17.27% for sexual minoritized individuals). Positive association between SCD and ACEs status (OR = 2.18, 95%CI: 1.09-4.40) was identified among sexual minoritized individuals.

CONCLUSIONS

The association between ACEs and SCD was strong in both heterosexual and sexual minoritized populations. Given the higher experience of ACEs among sexual minoritized adults, the subsequent frequency of SCD among these adults also may be higher.

CLINICAL IMPLICATIONS

Sexual minoritized older adults may have a history of numerous ACEs, which could contribute to a greater burden of SCD. Clinicians and other stakeholders may wish to consider relationships between ACEs and SCD based on sexual orientation.

Effect of need-based care on behavioural and psychological symptoms in residents with dementia and formal caregivers' distress in nursing homes: a three-arm cluster randomized controlled trial

PURPOSE

To evaluate to what extent the standardized concept of need-based care on Behavioural and Psychological Symptoms of Dementia (BPSD), and formal caregiver distress, is superior when compared to spending more time or standard care with residents with BPSD.

METHODS

A longitudinal cluster randomized controlled study in 23 nursing homes in Belgium with 3 parallel groups was set up. A total of 481 residents with dementia participated. Formal caregivers in the need-based care group treated residents who displayed agitated or aggressive behaviour with a non-pharmacological intervention, tailored to unmet needs, twice a week with re-evaluation every 8 weeks. In the time group, formal caregivers spent 'extra time'. In the standard care group, it was 'care as usual'. Outcomes were measured at four different time points with the Doloplus-2 (to assess pain behaviour), Cohen-Mansfield Agitation Inventory (CMAI) for agitation, the Neuropsychiatric Inventory (NPI-NH) for BPSD and formal caregivers' distress.

RESULTS

Need-based interventions had a significant effect on residents' levels of pain behaviour. In the need-based care group, scores on overall BPSD (agitation and aggression, depression, euphoria, irritability, sleep and night-time behaviour) improved significantly from baseline when compared to other timepoints. No significant different interactions over time were found between all three groups for categorized versions of NPI scores (ever versus never).

CONCLUSION

Need-based care reduced the level of BPSD in residents with dementia as well as formal caregivers' distress. The study supports the importance of tailored non-pharmacological interventions in the residential care for people with dementia.

TRIAL REGISTRY

Trial registration number B300201942084 (18/11/2019).

Needs Assessment and the Identification of Palliative Care Dimensions of the Essential Service Package for the Elderly with Alzheimer's Disease: A Mixed Exploratory Study

AIM

This study was conducted with the aim of assessing the needs and determining the care dimensions of the essential palliative care service package for the elderly with Alzheimer's disease.

METHOD

The mixed exploratory study was conducted in three phases. The first phase of the study was conducted in the form of a qualitative study and a literature review. This qualitative research was done through in-depth and semi-structured interviews with 19 qualified caregivers (11 informal caregivers and 8 formal caregivers) The samples were selected using the purposive sampling method by referring to hospitals, nursing homes, and active branches of the Alzheimer's Association in some provinces. In the second phase, the dimensions of palliative care were codified, and in the third phase, the prioritization and the validation of the dimensions of palliative care were performed in the form of two Delphi rounds.

RESULTS

Based on the results of the first phase of the study, the care dimensions of the service package were placed in eight categories based on National Consensus Project. In the second phase, the needs of Alzheimer's patients were arranged in the form of a questionnaire consisting of 8 parts, with 180 indicators. Then, in the third phase, the dimensions of the palliative care essential package were designed with 74 items in the form of 4 dimensions.

CONCLUSION

The dimensions of the essential service package of palliative care included a series of interventions as well as physical, psychological, cognitive, and spiritual support.

Prevalence and predictors of incident ADRD diagnosis following a Medicare home health episode

INTRODUCTION

Home health (HH) may be an important source of care for those with early-stage/undiagnosed Alzheimer's Disease and Related Dementias (ADRD), but little is known regarding prevalence or predictors of incident ADRD diagnosis following HH.

METHODS

Using 2010-2012 linked Master Beneficiary Summary File (MBSF) and HH assessment data for 40,596 Medicare HH patients, we model incident ADRD diagnosis within 1 year of HH via multivariable logistic regression.

RESULTS

Among HH patients without diagnosed ADRD, 10% received an incident diagnosis within 1 year. In adjusted models, patients were three times more likely to receive an incident ADRD diagnosis if they had HH clinician-reported impaired overall cognition (compared to patients without reported impairment) and twice as likely if they were community-referred (compared to hospital-referred patients).

DISCUSSION

There is a pressing need to develop tailored HH clinical pathways and protect access to community-referred HH to support community-living older adults with early-stage/undiagnosed ADRD.

Trajectories of care of community-dwelling people living with dementia: a multidimensional state sequence analysis

BACKGROUND

The type and level of healthcare services required to address the needs of persons living with dementia fluctuate over disease progression. Thus, their trajectories of care (the sequence of healthcare use over time) may vary significantly. We aimed to (1) propose a typology of trajectories of care among community-dwelling people living with dementia; (2) describe and compare their characteristics according to their respective trajectories; and (3) evaluate the association between trajectories membership, socioeconomic factors, and self-perceived health.

METHODS

This is an observational study using the data of the innovative Care Trajectories -Enriched Data (TorSaDE) cohort, a linkage between five waves of the Canadian Community Health Survey (CCHS), and health administrative data from the Quebec provincial health-insurance board. We analyzed data from 690 community-dwelling persons living with dementia who participated in at least one cycle of the CCHS (the date of the last CCHS completion is the index date). Trajectories of care were defined as sequences of healthcare use in the two years preceding the index date, using the following information: 1) Type of care units consulted (Hospitalization, Emergency department, Outpatient clinic, Primary care clinic); 2) Type of healthcare care professionals consulted (Geriatrician/psychiatrist/neurologist, Other specialists, Family physician).

RESULTS

Three distinct types of trajectories describe healthcare use in persons with dementia: 1) low healthcare use (n = 377; 54.6%); 2) high primary care use (n = 154; 22.3%); 3) high overall healthcare use (n = 159; 23.0%). Group 3 membership was associated with living in urban areas, a poorer perceived health status and higher comorbidity.

CONCLUSION

Further understanding how subgroups of patients use healthcare services over time could help highlight fragility areas in the allocation of care resources and implement best practices, especially in the context of resource shortage.

Dynamics of Interaction among Professionals, Informal Supporters, and Family Caregivers of People with Dementia along the Dementia Care Pathway: A Nationwide Survey in Japan

This study aims to clarify the dynamics of information provision and human interaction to satisfy the needs of family caregivers. A questionnaire survey consisting of items on information received at and after diagnosis, persons and resources consulted, needs, and caregiver-oriented outcomes was conducted. Among the respondents, 2295 individuals who were caring for people with dementia were divided into quartiles by the time after diagnosis, and differences were statistically analyzed. The time after diagnosis in the first to fourth quartiles was 0.73 ± 0.4, 2.52 ± 0.49, 4.89 ± 0.73, and 10.82 ± 3.7 years, respectively. The number of persons consulted by family caregivers increased significantly from the first to the fourth quartiles (p < 0.001). During this time, attributes of professionals and informal supporters changed depending on the quartile. As time progressed, acceptance of the diagnosis increased, but so did its impact on the lives of family caregivers. These findings revealed differences over time in what family caregivers wanted and the dynamics of interactions that filled their needs. Informal supporters accounted for a significant proportion of the total resources. However, many family caregivers thought the information and support were insufficient. Thus, continuous reform of the care pathway is needed.

Paid Care Services and Transitioning out of the Community Among Black and White Older Adults With Dementia

OBJECTIVES

Paid care provided in the home includes important support services for older adults with dementia such as cleaning and personal care assistance. By reducing unmet needs, these services could delay the transition to residential long-term care, but access may differ across racial groups. This study examined the relationship between paid care and transitioning out of the community among Black and White older adults with dementia.

METHODS

Using data from 303 participants (29.4% Black) with probable dementia in the 2011 National Health and Aging Trends Study, competing risk hazards models estimated the association between receiving paid care at baseline and the probability of transitioning out of the community over 8 years (through 2019). Covariate selection was guided by the Andersen model of health care utilization.

RESULTS

Paid care was associated with lower risk of transitioning out of the community (subhazard ratios [SHR] = 0.70, 95% CI [0.50, 0.98]). This effect was similar after controlling for predisposing factors and most prominent after controlling for enabling and need for services factors (SHR = 0.65, 95% CI [0.44, 0.95]). There was no racial difference in the use of paid care despite evidence of greater care needs in Blacks. Furthermore, Black participants were less likely to transition out of the community than Whites.

DISCUSSION

Paid care services may help delay transitions out of the community. Future research should seek to explain racial differences in access to and/or preferences for home-based, community-based, and residential care.

Conceptualizing and Operationalizing Collaboration Among Multiple Caregivers of Older Adults

OBJECTIVES

In many families, multiple caregivers support older adults living with dementia. Studying collaboration among caregivers requires consideration of conceptual and methodological issues that have not been fully explored. This study presents a framework for conceptualizing caregiver collaboration and an index that captures variation in collaboration among multiple caregivers within care networks.

METHODS

We used data from the 2015 waves of the National Health and Aging Trends Study and National Study of Caregiving (NSOC) to operationalize collaboration among multiple caregivers (N = 1,298) of 552 care recipients (Mage = 83.69, SD = 7.73; 71.6% women; 47.9% possible/probable dementia; 38.9% people of color).

RESULTS

The care collaboration index considered individual and overlapping contributions while controlling for the size of the care network (caregivers in network responding to NSOC survey) and total network size (number of caregivers in network) in the statistical model. Larger care networks enabled more collaboration, both in general and across most types of tasks (βs > 0.38). Collaboration was greater among those caring for a Black or Hispanic care recipient, both in general and for household and medical/health tasks specifically (βs > 0.11). Collaboration was also greater among those caring for recipients with probable dementia, both in general and for most tasks (βs > 0.11) but not transportation-related tasks (p = .219).

DISCUSSION

Results are examined in the context of care network dynamics and proposed mechanisms linking care collaboration to outcomes for caregivers and recipients. Strengths and limitations of our conceptualization and operationalization of collaboration are discussed.

Vigilance, risk, and service use among caregivers of people living with dementia

OBJECTIVE

The purpose of this investigation was to understand the dynamics among dementia caregiving, vigilance, and home and community-based service use.

METHODS

This paper is derived from a larger, mixed-methods study on caregiving. We used a descriptive qualitative approach to analyze interview data of 30 family caregivers of relatives with dementia.

RESULTS

We found five domains of vigilance in which caregivers felt "on duty": ensuring attentiveness, ensuring safety, ensuring resources, ensuring healthcare, and ensuring closeness. Formal service use did not necessarily give caregivers relief from vigilance, with the language of risk often employed by caregivers.

CONCLUSION

Because service use could contribute to feelings of vigilance, rather than give caregivers a break from a sense of watchfulness, these findings support calls for dementia-specific training for service providers. In future caregiving research, the relationship between vigilance, caregiver distress, and role captivity should be explored.

Receipt of help by people with cognitive impairment: results from the English Longitudinal Study of Ageing

OBJECTIVES

We investigated whether people with dementia or low memory/orientation reported more help misaligned with needs - more unmet need and/or more unrequired help - than other people with similar levels of functional limitation, and examined associations with quality of life.

METHODS

From pooled English Longitudinal Study of Ageing data from waves 6, 7, and 8, we identified community-dwelling people aged 50+ with: dementia (n= 405); low memory/orientation but no dementia (n= 4520); and intact memory/orientation (n= 10,264). Unmet need (not receiving help for the functional limitation) and unrequired help (receipt of help without the respective functional limitation) were used as outcomes in two-part regressions. Quality of life (CASP-19) was used as a continuous outcome in a linear regression. Functional limitation and its interaction with cognitive status and socio-demographic factors were included in the models.

RESULTS

Those with dementia or low memory/orientation but few functional limitations reported more unmet needs and unrequired help than their counterparts with intact memory/orientation. At high levels of limitations, the needs of those with dementia or lower memory/orientation were met more often and the receipt of unrequired help was similar compared to those with intact memory/orientation. Unmet need and unrequired help were associated with poorer quality of life.

CONCLUSIONS

Unmet need and unrequired help were particular challenges for those with poorer cognition and potentially at early stages of dementia; they were associated with lower quality of life. Our results highlight the importance of good-quality timely diagnosis, identification of needs, and person-centred assessment to help improve quality of life.

The associations between unmet needs with protective factors, risk factors and outcomes among care partners of community-dwelling persons living with dementia

OBJECTIVES

Describe the prevalence and types of unmet needs among community-dwelling dementia care partners (CPs) and determine associations between unmet needs with protective factors, risk factors and outcomes.

METHOD

A cross-sectional analysis of 638 racially and cognitively diverse community-dwelling persons living with dementia (PLWD) and their CPs participating in a comprehensive in-home assessment of dementia-related needs. Unmet CP needs (19 items, 6 domains) were rated by a clinician using the Johns Hopkins Dementia Care Needs Assessment (JHDCNA). Multivariate linear regression models were used to examine associations between total percent unmet CP needs with demographic, protective and risk factors.

RESULTS

Nearly all CPs had at least one unmet need (99.53%), with a mean of 5.7 (±2.6). The most common domains with ≥1 unmet need were memory disorder education, care skills and knowledge of resources (98%), legal issues/concerns (73.8%), CP mental health (44.6%) and access to informal support (42.7%). Adjusted multivariate models suggest the strongest consistent predictive factors relate to informal emotional support, CP physical health, use or difficulty getting formal services/supports (both for CPs and PLWD), and CP time spent with PLWD. Greater levels of unmet needs were associated with worse PLWD outcomes and CP outcomes, after adjusting for demographics.

CONCLUSIONS

CPs have high rates of diverse, but modifiable unmet needs. Data suggest optimal approaches to dementia care should take a family-centered home-based approach that includes routine CP needs assessment, offer targeted interventions that include both traditional medical supports as well as strategies to increase and leverage informal social networks, and ones that can bridge and coordinate medical with non-medical supports. These findings can be used to inform new approaches to support CPs, improve PLWD and CP outcomes, and target groups most at risk for inequities.

Care Need Combinations for Dementia Patients with Multiple Chronic Diseases

Purpose

The purpose of this study was to find care need combinations for dementia patients with multiple chronic diseases and their caregivers.

Patients and Methods

A cross-sectional study was conducted with 83 patients who had multiple chronic diseases. Variables from patients included age, gender, severity of clinical dementia rating, feeding, hypnotics, mobility, getting lost, mood symptoms, and behavioral and psychological symptoms. Moreover, 26 types of care needs were included in this study. The Apriori algorithm was employed to first identify care need combinations and then to find the relationships between care needs and variables from dementia patients with multiple chronic diseases.

Results

Six rules were generated for care need combinations. Four care needs could be formed as a basic care need bundle. Moreover, two additional care needs could be added to provide a wider coverage for patients. In the second stage, 93 rules were found and categorized into three groups, including 2, 6, and 28 general rules with support of 30% but less than 40%, 20% but less than 30%, and 10% but less than 20%, respectively. When the support value is 10% but less than 20%, more variables from patients were found in rules which help the dementia collaborative care team members provide tailor-made care need bundles.

Conclusion

Four basic care needs were social resources referral and legal support (Care (1)), drug knowledge education (Care (3)), memory problem care (Care (5)), and fall prevention (Care (8)). Besides, disease knowledge education (Care (2)) and hypertension care (Care (16)) were frequent unmet needs in this specific population. Moreover, care for the mood of the caregiver (Care (11)) should be considered especially in dementia patients with preserved ambulatory function or with symptoms of hallucination. The collaborative care team should pay more attention to those care needs when assessing this specific population.

Structures for the care of people with dementia: a European comparison

Background

Dementia is a disease that impacts people with dementia, their families, and the healthcare system. In 2018, the number of people with dementia in the EU, the European Free Trade Association (EFTA), and the UK was estimated to be 9.1 million. National dementia strategies and publications by organisations such as Alzheimer Europe outline how dementia-specific care should be designed. This study aims to provide insights into existing formal care structures, models of good practise, and gaps in dementia-specific care for people with dementia in 17 European countries.

Methods

The research is based on guided interviews with country-specific care experts. A mixed-methods approach with a combination of open and closed questions was used. All interviews were recorded and transcribed verbatim based on the transcription rules of Kuckarts (2010). For data evaluation, the qualitative content analysis model of Mayring (2014) was used.

Results

In all 17 countries, efforts for dementia-friendly care and models of good care practise exist. However, there are large differences between European countries regarding the spread of dementia-specific services. In nine countries (Bulgaria, Finland, Italy, Liechtenstein, Luxembourg, the Netherlands, Norway, Sweden, the UK), there are already nationwide structures, while in five countries (Belgium, Greece, Ireland, Portugal, Romania), services are only available in certain regions. In three countries (Austria, Denmark, Germany) dementia-specific outpatient services are widespread nationwide, whereas inpatient services are not. Simultaneously, in all countries, areas with major care gaps exist. Several European states have an urgent need for action concerning the expansion of the provision of dementia-specific services, the reduction of regional differences regarding the provision of care, the elimination of barriers to access to care, the dementia-friendliness of services, and the participation of people with dementia and their relatives in care and research.

Conclusions

To reduce the existing structural inequalities in care between and within European countries, and to establish quality-related minimum standards in the care of people with dementia, transnational concepts are needed. The EU, in cooperation with care planners, research institutions, care providers, and patient organisations, should develop European care guidelines or dementia plans that contain concrete measures, schedules, and budgets.

Evaluating the feasibility, experiences, facilitators of and barriers to carers and volunteers delivering Namaste Care to people with dementia in their own home: a qualitative interview study in the UK and the Netherlands

OBJECTIVES

To evaluate the feasibility, facilitators of and barriers to delivering Namaste Care by volunteers and family carers to community-dwelling people with dementia, and to map family carers and volunteers' experiences with the programme.

DESIGN

Qualitative interview study with two phases: (1) preparation phase; (2) pilot phase.

SETTING

Private residences of community-dwelling people with dementia in the UK and the Netherlands.

PARTICIPANTS

Family carers and volunteers of community-dwelling people with dementia (phase 1: 36 Dutch interviews, phase 2: 9 Dutch and 16 UK interviews).

INTERVENTION

Namaste Care is a multicomponent psychosocial programme, originally developed for people with dementia residing in long-term care facilities. Meaningful activities were offered by carers and volunteers. Each person with dementia was offered 10 one-hour sessions.

RESULTS

Phase 1: Namaste Care was deemed feasible for community-dwelling people with dementia and no major adaptations to the programme were considered necessary. Phase 2: perceived effects of Namaste Care on people with dementia included improved mood and increased interaction. The programme appeared enriching for both family carers and volunteers, providing joy, respite from care and new insights for coping with challenging behaviour. A flexible attitude of the Namaste provider facilitated its delivery. High caregiver burden and a strained relationship between the family carer and person with dementia were considered barriers. Experiences of family carers and volunteers with Namaste Care were very positive (mean satisfaction rating: 8.7 out of 10, SD=0.9, range 7-10).

CONCLUSION

We recommend offering Namaste Care delivered by volunteers, preferably multiple sessions per week of 1.5-2 hours to optimise quality of life of community-dwelling people with dementia. Working with well-matched, flexible Namaste providers is pivotal. Family involvement should be encouraged, although the extent should be adapted depending on preference, caregiver burden and the relationship between the family carer and the person with dementia.

TRIAL REGISTRATION NUMBER

NL5570.

Experiences and expectations of receiving volunteer services among home-based elderly in Chinese urban areas: A qualitative study

BACKGROUND

The various complex needs for assistance among home-based older adults have increased dramatically. Thus, it would be advantageous to recruit volunteers with medical knowledge and a better understanding to support and assist the elderly living in urban communities.

AIM

This study aimed to explore the experiences and expectations of receiving volunteer services among the home-based elderly in Chinese urban areas. DESIGN, SETTING AND PARTICIPANTS: A descriptive qualitative study was conducted following the Consolidated Criteria for Reporting Qualitative Research (COREQ) guidelines. This study was performed in two communities in Wuhan, Hubei Province. A purposive sampling method, which includes criterion and maximum variation sampling, was used to identify and select a diverse range of participants. Semistructured face-to-face interviews with 20 older adults (aged 62-90 years old) were performed. The conventional content analysis method was used for thematic analysis.

RESULTS

Three categories with associated subcategories were identified: experiences of receiving volunteer services including negative and positive experiences; specific needs for volunteer services involving physiological, psychosocial, health-related behaviours and environmental domains; characteristics of expected volunteer services including availability, formats, recipients, providers and service strategies.

CONCLUSIONS

The volunteer services provided to the home-based elderly were found to be unsatisfactory, and lacking relevance and effectiveness. Due to a lack of family support or difficulty in meeting some high-level needs, the home-based elderly expressed a strong demand for volunteer services involving physiological, psychosocial, health-related behaviours and environmental domains. This finding can provide a basis for developing training plans beneficial to volunteers. Furthermore, the present research clarifies the criteria for selecting volunteers and the necessity of supervising and managing volunteers. Improving the effectiveness and accessibility of urban-community volunteer service may reduce the burden on care institutions and home caregivers while enhancing the quality of life and well-being of the elderly.

PATIENT OR PUBLIC CONTRIBUTION

Developing research questions, study design, management and conduct and interpretation of evidence.

“I Didn’t Sign Up for This”: Perspectives from Persons Living with Dementia and Care Partners on Challenges, Supports, and Opportunities to Add Geriatric Neuropalliative Care to Dementia Specialty Care

Background: In the United States, dementia specialty centers affiliated with centers of excellence for research hold promise as locations to develop innovative, holistic care in care systems otherwise siloed by discipline or payer. Objective: We conducted foundational research to inform development of patient-and family-centered palliative care interventions for dementia specialty centers. Methods: We interviewed persons living with dementia (PLWD), current, and former care partners (CP) recruited from a specialty dementia clinic and purposively selected for variation across disease syndrome and stage. A framework method of thematic analysis included coding, analytic matrices, and pattern mapping. Results: 40 participants included 9 PLWD, 16 current CPs, and 15 former CPs of decedents; 48% impacted by Alzheimer’s disease dementia. While help from family, support groups and adult day centers, paid caregiving, and sensitive clinical care were invaluable to PLWD, CPs, or both, these supports were insufficient to navigate the extensive challenges. Disease-oriented sources of distress included symptoms, functional impairment and falls, uncertainty and loss, and inaccessible care. Social and relational challenges included constrained personal and professional opportunities. The obligation and toll of giving or receiving caregiving were challenging. Clinical care challenges for PLWD and/or CPs included care fragmentation, insufficient guidance to inform planning and need for expert interdisciplinary clinical care at home. Conclusion: Findings highlight the breadth and gravity of gaps, which surpass the disciplinary focus of either behavioral neurology or palliative care alone. Results can inform the development of novel interventions to add principles of geriatrics and neuropalliative care to dementia care.

Met and Unmet Needs of Older Adults With Cognitive Impairment, and Burden and Benefits of Their Family Caregivers

OBJECTIVES

This study examined the association between met and unmet needs of older adults with cognitive impairment living in the community and unique types of caregiving experience, each comprising different levels of caregiving burden and benefits.

METHODS

Latent class analysis and multivariable regression were applied to data on 266 caregivers of community-dwelling Singaporean older adults, aged 60 years and above, with cognitive impairment who participated in a community-based dementia care study in 2018.

RESULTS

Three unique types of caregiving experience were identified: satisfied (low burden and high benefits; 54% of caregivers), dissatisfied (low burden and low benefits; 35%), and intensive (high burden and high benefits; 11%). Met needs were positively associated with satisfied caregiving experience (vs. dissatisfied caregiving experience), and both met and unmet needs were positively associated with intensive caregiving experience (vs. dissatisfied caregiving experience). Specifically, caregivers tended to have satisfied caregiving experience if older adults' care needs in daytime activities or mobility were met.

DISCUSSION

Fulfillment of unmet needs of older adults with cognitive impairment is associated with a satisfied caregiver experience characterized by lower caregiver burden and greater caregiver benefits. Identification of and tailored interventions for unmet care needs of older adults will likely promote satisfied caregiving experience.

Identification of Major Cognitive Disorders in Self-Reported versus Administrative Health Data: A Cohort Study in Quebec

BACKGROUND

The first imperative in producing the relevant and needed knowledge about major neurocognitive disorder (MNCD) is to identify people presenting with the condition adequately. To document potential disparities between administrative health databases and population-based surveys could help identify specific challenges in this population and methodological shortfalls.

OBJECTIVE

To describe and compare the characteristics of community-dwelling older adults according to four groups: 1) No MNCD; 2) Self-reported MNCD only; 3) MNCD in administrative health data only; 4) MNCD in both self-reported and administrative health data.

METHODS

This retrospective cohort study used the Care Trajectories-Enriched Data (TorSaDE) cohort, a linkage between five waves of the Canadian Community Health Survey (CCHS) and health administrative health data. We included older adults living in the community who participated in at least one cycle of the CCHS. We reported on positive and negative MNCD in self-reported versus administrative health data. We then compared groups' characteristics using chi-square tests and ANOVA.

RESULTS

The study cohort was composed of 25,125 older adults, of which 784 (3.12%) had MNCD. About 70% of people with an MNCD identified in administrative health data did not report it in the CCHS. The four groups present specific challenges related to the importance of perception, timely diagnosis, and the caregivers' roles in reporting health information.

CONCLUSION

To a certain degree, both data sources fail to consider subgroups experiencing issues related to MNCD; studies like ours provide insight to understand their characteristics and needs better.

Socioeconomic inequality of long-term care for older people with and without dementia in England

Ensuring distributive fairness in the long-term care sector is vitally important in the context of global population ageing and rising care needs. This study, part of the DETERMIND (DETERMinants of quality of life, care and costs, and consequences of INequalities in people with Dementia and their carers) programme, investigates socioeconomic inequality and inequity in the utilisation of long-term care for older people with and without dementia in England. The data come from three waves of the English Longitudinal Study of Ageing (ELSA, Waves 6–8, N = 16,458). We find that older people with dementia have higher levels of care needs and a lower socioeconomic status than those without dementia. The distribution of formal and informal care is strongly pro-poor. When care needs are controlled for, there is no significant inequality of formal or informal care among people with dementia, nor of informal care among people without dementia, but there is a significant pro-rich distribution of formal care among people without dementia. Unmet care needs are significantly concentrated among poorer people, both with and without dementia. We argue that the long-term care system in England plays a constructive role in promoting socioeconomic equality of long-term care for people with dementia, but support for older people with lower financial means and substantial care needs remains insufficient. Increased government support for older people is needed to break the circle between care inequality and health inequality.

Autonomy conquers all: a thematic analysis of nurses’ professional judgement encountering resistance to care from home-dwelling persons with dementia

Background

Adequate care support from home health care nurses is needed to meet the needs of an increasing number of home-dwelling persons with dementia and those who resist care. The decisions nurses make in home health care when encountering resistance from persons with dementia have an extensive impact on the quality of care and access to care. There is little research on what influences nurse’s encounters with resistance to care from home-dwelling persons with dementia.

Research aim

To get insight into how nurses experience resistance to care from home-dwelling persons with dementia.

Methods

A qualitative research design using a thematic analysis was conducted following the six steps by Braun and Clarke. Data was gathered from three focus group and three individual interviews, and a total of 18 nurses from home health care participated. The interviews took place over a period of 5 months, from December 2020 to April 2021.

Ethical considerations

Approved by the Norwegian Centre for Research, reference number 515138 and by the research advisers and home care managers in each section of the municipality.

Results

Two main themes were identified: 1) Challenged by complex and inadequate care structures and 2) Adapting care according to circumstances. There were three subthemes within the first main theme: lack of systematic collaboration and understanding, insufficient flexibility to care, and the challenge of privacy. In the second main theme, there were three subthemes: avoid forced treatment and care to protect autonomy, gray-areas of coercive care and reduced care. The two main themes seemed to be interdependent, as challenges and changes in organizational structures influenced how nurses could conduct their care practices.

Conclusion

Our findings indicate that nurses’ responsibility to decide how to conduct care is downplayed when facing resistance. Further, their professional judgement is influenced by contextual factors and characterized by a strong commitment to avoid forced treatment and care.

A continuous challenge is to safeguard shared decision-making at the same time as it is balanced against risks of severe health damage in home-dwelling persons with dementia. A fundamental question to ask is whether autonomy does conquer all, even when severe health damage is at stake.

Patient cognitive impairment associated with higher home health care delivery costs

OBJECTIVE

To assess whether home health agencies incur significantly higher care delivery costs for patients with cognitive impairment across three timeframes relevant to home health payment policy.

DATA SOURCES

Linked Medicare home health claims and patient assessments, National Health and Aging Trends Study (NHATS), and home health agency cost reports for a nationally representative sample of Medicare beneficiaries receiving home health between 2011 and 2016.

STUDY DESIGN

We modeled care delivery costs incurred by the home health agency as a function of patient cognitive impairment using multivariable, propensity score-adjusted, generalized linear models.

DATA COLLECTION/EXTRACTION METHODS

We identified NHATS participants who experienced an index home health episode between 2011 and 2016 (n = 1214; weighted n = 5,856,333) and linked their NHATS survey data to standardized patient assessment and claims data for the episode, as well as cost report data for the home health agency that provided care.

PRINCIPAL FINDINGS

Across the first 30, 60, and 120 days of caring for a patient with cognitive impairment, we estimate additional costs of care to the home health agency of $186.19 (p = 0.02), $282.46 (p = 0.01), and $740.91 (p = 0.04), respectively.

CONCLUSIONS

Home health agencies incur significantly higher costs when caring for a patient with cognitive impairment. As patient cognitive function is not considered in the most recent Medicare home health reimbursement model, agencies may be disincentivized from providing care to those with cognitive impairment. Policy makers and researchers should carefully monitor home health access among Medicare beneficiaries with cognitive impairment and further investigate the inclusion of patient cognitive function in future risk adjustment models.

Cognitive impairment associated with greater care intensity during home health care

BACKGROUND

In Medicare-funded home health care (HHC), one in three patients has cognitive impairment (CI), but little is known about the care intensity they receive in this setting. Recent HHC reimbursement changes fail to adjust for patient CI, potentially creating a financial disincentive to caring for these individuals.

METHODS

This cohort study included a nationally representative sample of 1214 Medicare HHC patients between 2011 and 2016. Multivariable logistic and negative binomial regressions modelled the relationship between patient CI and care intensity-measured as the number and type of visits received during HHC and likelihood of receiving multiple successive HHC episodes.

RESULTS

Patients with CI had 45% (P < .05) greater odds of receiving multiple successive HHC episodes and received an additional 2.82 total (P < .001), 1.39 nursing (P = .003), 0.72 physical therapy (P = .03), and 0.60 occupational therapy visits (P = .01) during the index HHC episode.

DISCUSSION

Recent HHC reimbursement changes do not reflect the more intensive care needs of patients with CI.

Transcending inequities in dementia care in Black communities: Lessons from the maximizing independence at home care coordination program

Purpose

We examine care partners’ experience of the Maximizing Independence at Home (MIND) intervention, a multicomponent, home-based dementia care coordination program designed to provide high quality, wholistic care coordination for people and families living with dementia. The goal of the study was to understand 1. the unique dementia-related needs of Black care partners and barriers and challenges to caregiving experienced within the Black community, 2. perceived benefits of the MIND program, and 3. ways to improve the program and make it more culturally responsive to the Black community.

Method

We conducted three focus groups totaling 20 care partners of people living with dementia; who participated in the MIND intervention (2014–2019); all Black/African American and English speaking. Verbatim transcriptions were independently analyzed line-by-line by two coders using inductive approaches.

Findings

Participants noted three overarching themes related to dementia care needs and challenges in the Black community: difficulty finding and accessing dementia information and relevant services and supports; familial conflict/lack of sibling and familial support; and lack of effective communication about dementia within Black Communities. Regarding MIND at home program benefits, four themes emerged: 1. perceived to help locate resources (formal and informal); 2. provided care partners an opportunity for socialization and interaction; 3. included comprehensive assessments and helpful linked information; and 4. resulted in a “much needed break for care partners.” Increased diversity of the MIND program personnel, greater clarity and consistency in MIND program promotion, and better communications were themes for how the program could be improved.

Conclusion

Care partners participating in the MIND program perceived common benefits in aspects related to care for the persons living with dementia as well as benefits to themselves, believed the program addressed important challenges and gaps in education, services, and social support, and could be enhanced in its delivery and cultural responsiveness.

6G and Artificial Intelligence Technologies for Dementia Care: Literature Review and Practical Analysis

Background

The dementia epidemic is progressing fast. As the world’s older population keeps skyrocketing, the traditional incompetent, time-consuming, and laborious interventions are becoming increasingly insufficient to address dementia patients’ health care needs. This is particularly true amid COVID-19. Instead, efficient, cost-effective, and technology-based strategies, such as sixth-generation communication solutions (6G) and artificial intelligence (AI)-empowered health solutions, might be the key to successfully managing the dementia epidemic until a cure becomes available. However, while 6G and AI technologies hold great promise, no research has examined how 6G and AI applications can effectively and efficiently address dementia patients’ health care needs and improve their quality of life.

Objective

This study aims to investigate ways in which 6G and AI technologies could elevate dementia care to address this study gap.

Methods

A literature review was conducted in databases such as PubMed, Scopus, and PsycINFO. The search focused on three themes: dementia, 6G, and AI technologies. The initial search was conducted on April 25, 2021, complemented by relevant articles identified via a follow-up search on November 11, 2021, and Google Scholar alerts.

Results

The findings of the study were analyzed in terms of the interplay between people with dementia’s unique health challenges and the promising capabilities of health technologies, with in-depth and comprehensive analyses of advanced technology-based solutions that could address key dementia care needs, ranging from impairments in memory (eg, Egocentric Live 4D Perception), speech (eg, Project Relate), motor (eg, Avatar Robot Café), cognitive (eg, Affectiva), to social interactions (eg, social robots).

Conclusions

To live is to grow old. Yet dementia is neither a proper way to live nor a natural aging process. By identifying advanced health solutions powered by 6G and AI opportunities, our study sheds light on the imperative of leveraging the potential of advanced technologies to elevate dementia patients’ will to live, enrich their daily activities, and help them engage in societies across shapes and forms.

Associations between unmet needs for daytime activities and company and scores on the Neuropsychiatric Inventory-Questionnaire in people with dementia: a longitudinal study

OBJECTIVES

To examine prospectively the association between unmet needs for daytime activities and company and behavioural and psychological symptoms of dementia.

METHODS

We included 451 people with mild or moderate dementia, from eight European countries, who were assessed three times over 12 months. Unmet needs were measured with the Camberwell Assessment of Need for the Elderly. Three sub-syndromes of the Neuropsychiatric Inventory-Questionnaire were regressed, one-by-one, against unmet needs for daytime activities and company, adjusting for demographic and clinical-functional covariates.

RESULTS

Unmet needs for daytime activities were associated with more affective symptoms at baseline, six and twelve months, mean 0.74 (p < 0.001), 0.76 (p < 0.001) and 0.78 (p = 0.001) points higher score respectively, and with more psychotic symptoms at baseline (mean 0.39 points, p = 0.007) and at six months follow-up (mean 0.31 points, p = 0.006). Unmet needs for company were associated with more affective symptoms at baseline, six and twelve months, mean 0.44 (p = 0.033), 0.67 (p < 0.001) and 0.91 (p < 0.001) points higher score respectively, and with more psychotic symptoms at baseline (mean 0.40 points, p = 0.005) and at six months (mean 0.35 points, p = 0.002) follow-up.

CONCLUSION

Interventions to reduce unmet needs for daytime activities and company could reduce affective and psychotic symptoms in people with dementia.

Profiles of Health-Related Patient Activation and Their Determinants: The Results of a Cluster Analysis of Older Adults-Conclusions for Patient Counselling

Health-related proactivity in older adults may significantly increase medication handling, adherence and patient safety. Deficiencies in training in critical characteristics and diversity of older patients may lead to medical errors in diagnosis and drug administration. This study investigated the profiles of health proactivity in older adults and the factors differentiating them, like sociodemographic factors, health status, visit characteristics, and patients’ visit-related expectations, actual experiences, and satisfaction with the visit. Before and after visits, 3391 patients aged 65–95 filled in two sets of questionnaires, that allowed to measure aforementioned factors. Three distinct proactivity profiles emerged from a cluster analysis: high (43%), medium (25%), and low proactivity (32%). Highly proactive patients had the highest expectations, but their visits provided better opportunities to meet them than in other groups. Higher proactivity was related to a longer attendance time, frequent contact with and easier access to the doctor, or a longer time spent with a patient. The findings highlight the need to detect and respond to patients’ expectations regarding psychosocial aspects of care, as well as to improve organizational aspects of care, in order to enhance health proactivity in older adults. The resulting good practice recommendations may significantly improve healthcare workers’ effectiveness in both primary and secondary care.

The Remote Assessment and Dynamic Response Program: Development of an In-Home Dementia-Related Care Needs Assessment to Improve Well-Being

Background and Objectives

The Remote Assessment and Dynamic Response (READyR) Program was developed in order to address the current lack of early-stage dementia care planning programs that assess the care needs of persons with dementia. The goal was to create a program informed by care values and ongoing ecologically valid data. The objectives of this study are to describe the development and design process of the READyR Program, and to evaluate the utility of the READyR Program for identifying dementia-related care needs.

Research Design and Methods

A prototype of the web-based READyR Program tool was first created using digital activity data that were collected by previous studies using a platform of multimodal sensors installed in the homes of older adult couples with and without dementia. Digital activity data were then mapped onto potential care values (e.g., safety & autonomy) to create a values-based needs assessment that is tailored to the individual care dyad. Next, evaluation of the READyR Program by 11 professional dementia care coordinators and case managers (across 3 semistructured focus groups) was used to explore the utility of READyR for assessing dementia-related needs. Qualitative description using conventional content analysis was used to iteratively code focus group data and to describe prevalent themes.

Results

Prevalent focus groups themes included barriers to (e.g., family relationship strain) and facilitators of (e.g., tailored assessments) the optimal process for assessing dementia-related care needs by care coordinators, as well as advantages to (e.g., providing new objective insights into function, and routines) and disadvantages of (e.g., bringing up new questions about care) incorporating the remote monitoring data into a values-based needs assessment.

Discussion and Implications

READyR has the potential to help family members, as well as care coordinators and providers, gain insight into the values-based care needs of persons with early-stage dementia. Clinical Trials Registration Number: NCT04542109.

Sleep Disturbance and Strain Among Caregivers of Persons Living With Dementia

Objective

The study objective was to examine predictors of sleep disturbance and strain among caregivers of persons living with dementia (PLWD).

Methods

This cross-sectional study utilized a sample of community-dwelling older adults and their family caregivers drawn from the 2017 National Health and Aging Trends Study and National Study of Caregiving. Multivariable logistic regression was used to assess the association between caregiver and PLWD characteristics and a composite measure of caregiving strain. High caregiving strain was defined as a total score of ≥ 5 on the 6 caregiving strain items (e.g., emotional difficulty, no time for self). We used multivariable proportional odds models to examine predictors of caregiver sleep-related outcomes (trouble falling back to sleep and interrupted sleep), after adjusting for other caregiver and PLWD factors.

Results

Of the 1,142 family caregivers, 65.2% were female, 15% were Black, and 14% were Hispanic. Average age was 60 years old. Female caregivers were more likely to report high level of strain compared to male caregivers (OR: 2.61, 95% CI = 1.56, 4.39). Compared to non-Hispanic Whites, non-Hispanic Black and Hispanic caregivers had reduced odds of reporting greater trouble falling back asleep [OR = 0.55, CI (0.36, 0.82) and OR = 0.56, CI (0.34, 0.91), respectively]. The odds of reporting greater trouble falling back asleep was significantly greater among caregivers with high blood pressure vs. caregivers without high blood pressure [OR = 1.62, CI (1.12, 2.33)].

Conclusion

In this cross-sectional study, caregivers with greater sleep difficulty (trouble falling back asleep) were more likely to report having high blood pressure. We found no racial/ethnic differences in interrupted sleep among caregivers to PLWD. These results suggest that interventions to improve sleep among caregivers to PLWD may decrease poor cardiovascular outcomes in this group.

Person‐centered assessment of apathy and resistance to care in people living with dementia: Review of existing measures

Introduction

The review described in this paper builds upon the Dementia Care Practice Recommendations (DCPR) published by the Alzheimer's Association in 2018 and addresses behavior change and the need for targeted outcome measures that evolve from person‐centered frameworks and help evaluate interventions. Apathy and resistance to care (RTC) are two specific behavioral expressions of unmet need or distress exhibited by people living with dementia, which are upsetting to formal and family caregivers and compromise quality of life for people living with dementia.

Methods

We conducted literature searches of major databases (PsycInfo, PubMed, EBSCO, CINAHL) for papers examining apathy and RTC constructs in samples of people living with dementia. Reliability and validity coefficients were reviewed and reported, along with examination of whether each measure facilitates contextual understanding of behavior.

Results

Three stand‐alone measures of RTC and ten measures of apathy were identified and reviewed. The RTC measures demonstrated good psychometric properties but do not include the perspective of the person living with dementia or contextual aspects of the behavior. The identified apathy measures demonstrated fair to good psychometric properties, and although there is greater consideration of context, none adequately include the perspective of the person living with dementia.

Discussion

Although reliable and valid measures have been developed to measure apathy and RTC in people living with dementia, there is greater need for conceptually driven measurement of behavior context and for tools that elicit and include the perspective of the person living with dementia.

Home Health Agencies With More Socially Vulnerable Patients Have Poorer Experience of Care Ratings

OBJECTIVES

Examine the relationships between dual eligibility and race/ethnicity characteristics of Medicare-Certified Home Health Agencies (CHHAs) and experience of care ratings.

METHODS

Analysis of 2017 national Consumer Assessment of Healthcare Providers and Systems and matched datasets of 10,906 CHHAs.

RESULTS

CHHAs with higher concentrations of dual-eligible patients were less likely to have high experience of care ratings for all three domains (e.g., for care delivery, quartile 4 vs. 1: odds ratio [OR] = 0.622, p < .001); CHHAs with higher concentrations of racial/ethnic minorities generally were less likely to have high experience of care ratings in care delivery (e.g., Black: quartile 4 vs. 1: OR = 0.418, p<0.001), communication (e.g., Black: quartile 4 vs. 1: OR = 0.316, p<0.001), and specific care issues (e.g., Hispanic: quartile 4 vs. 1: OR = 0.397, p < .001).

DISCUSSION

CHHAs with greater concentrations of dual-eligible patients and racial/ethnic minorities were more likely to have poor experience of care ratings.

Preserved Consciousness in Alzheimer's Disease and Other Dementias: Caregiver Awareness and Communication Strategies

Alzheimer's disease is an insidious onset neurodegenerative syndrome without effective treatment or cure. It is rapidly becoming a global health crisis that is overwhelming healthcare, society, and individuals. The clinical nature of neurocognitive decline creates significant challenges in bidirectional communication between caregivers and persons with Alzheimer's disease (AD) that can negatively impact quality-of-life. This paper sought to understand how and to what extent would awareness training about the levels of consciousness in AD influence the quality-of-life interactions in the caregiver-patient dyad. A literature review of multiple databases was conducted utilizing a transdisciplinary approach. The sum of findings indicates a positive relationship between enhanced caregiver awareness and training, positive interactions, and improved QOL measures among patients and caregivers. A multidirectional relationship was found among healthcare policies, training and education resources, caregivers, and persons with AD. Specifically, the current lack of policy and inadequate training and educational resources has various detrimental effects on patients and caregivers, while improvements in training and education of caregivers yields positive outcomes in communication and QOL. Furthermore, evidence of preserved consciousness in persons with AD was demonstrated from multiple disciplines, including neurobiological, psychological, and biopsychosocial models. The literature further revealed several methods to access the preserved consciousness in persons with AD and related dementias, including sensory, emotional, and cognitive stimulations. The evidence from the literature suggests a reframed approach to our understanding and treatment of persons with AD is not only warranted, but crucial to address the needs of those affected by AD.

You can tell it works - Experiences from using the VIPS practice model in primary healthcare

INTRODUCTION

Person-centred care is a philosophy rather than a method ready for implementation and utilization in daily clinical work. Internationally, few methods for person-centred care have been widely adopted in clinical dementia care practice. In Norway, the VIPS practice model is one that is commonly used for the implementation and use of person-centred care in primary healthcare.

METHOD

Nursing home physicians, managers and leaders in the municipalities, care institutions and domestic nursing care services were eligible for inclusion if their workplace had implemented and used the VIPS practice model for a minimum of 12 months. Individual interviews were conducted via Facetime, Skype or telephone and analysed with qualitative content analysis.

FINDINGS

In all, 20 respondents were included: one manager of health and care services in the municipality, six managers and leaders working in domestic care or daytime activity centres and 10 managers/leaders and three physicians working in nursing homes. Two global categories emerged: category 1: Change in staff's professional reasoning with two sub-categories: (a) an enhanced professional level in discussions and (b) a change in focus from task to person; and category 2: Changes in the clinical work, with three sub-categories: (a) effective interventions, (b) a person-centred work environment and (c) changes in cooperation between stakeholders.

CONCLUSION

Regular use of the VIPS practice model appeared to change the work culture for the benefit of both service users and frontline staff. Increased cooperation between frontline staff, nurses, physicians and next of kin was described. Staff were more focused on the needs of the service users, which resulted in care interventions tailored to the needs of the individual with dementia, loyalty to care plans and fewer complaints from next of kin.

Cognitive impairment among medicare home health patients: comparing available measures

There is growing interest in understanding home health utilization and outcomes for those with cognitive impairment (CI). Yet, approaches to measuring CI during home health vary widely across studies, with little known regarding potential implications for findings. Among a nationally representative sample of community-living Medicare beneficiaries receiving home health (2011-2016), we compare estimated CI prevalence using four different measures and evaluate measure-specific strengths and limitations. CI prevalence estimates ranged from 18.4% of the sample with probable dementia from national survey data; to 27.8% with diagnosed dementia, from Medicare claims; to 26.7% with memory deficit and/or impaired decision-making and 43.9% with reduced cognitive function, from OASIS. Researchers must be deliberate in their choice of CI measure and transparent regarding its benefits and limitations. Regardless of the measure used, a sizable percentage of home health patients have CI, supporting the importance of ongoing research in this area.