Procedural Framework to Facilitate Hospital-Based Informed Consent for Dementia Research

Developing a dementia friendly approach to consent in dementia research

OBJECTIVES

This paper explores the process of gaining consent from the perspectives of people living with dementia, their relatives/carers, and service providers. This is developed based on new primary qualitative research and addresses a gap in critical reflection on the practice and ethical process of research consent.

METHODS

A qualitative approach was used to conduct this research through the implementation of four focus groups run with people living with dementia (n = 12), two focus groups with family members (n = 6), two focus groups with service staff (n = 5).

RESULTS

Data was analysed thematically, to identify two core themes: consent as a journey and the flexible consent approach. These identified concerns with autonomy, decision making and placing people living with dementia at the centre of the consent process. The journey of consent emerged as central to supporting participation and enhancing the consent process.

CONCLUSION

The paper presents new evidence about the lived experience of research consent in the field of dementia, presenting the process of collecting consent in research as a flexible process that is best supported through a growing knowledge of participants and participation sites.

Is shorter always better? The pros and cons of treating Gram-negative bloodstream infections with 7 days of antibiotics

Accumulating evidence from randomized controlled trials (RCTs) supports 7 days treatment for uncomplicated Gram-negative bacteraemia. However, some patient populations were not well represented in these RCTs, including critically ill patients, immunocompromised patients and those with MDR bacteria. In this debate document, we discuss the pros and cons for treating patients with Gram-negative bacteraemia with a 7 day antibiotic course. We surmise that the patients who were not well represented in the RCTs are probably those who have most to lose from the drawbacks of prolonged antibiotic courses, including adverse events, superinfections and resistance development. Treatment durations among these patients can be managed individually, with C-reactive protein or procalcitonin guidance or by clinical measures, and with care to discontinue antibiotics as soon as the patient recovers clinically from the infection.

Effect of horticultural therapy on apathy in nursing home residents with dementia: a pilot randomized controlled trial

Objectives: This study aimed to examine (1) the feasibility of the study procedures (i.e. recruitment, retention, attendance, and assessment completion rates), and (2) the effects of horticultural therapy (HT) on apathy, cognitive ability, quality of life, and functional capacity.Methods: This was a parallel-group, match-paired, randomized controlled trial. Thirty-two participants were allocated to either the experimental or the control group. Data were collected at baseline (T0), immediately postintervention (T1), and 3 months postintervention (T2). The Apathy Evaluation Scale-informant version (AES-I); Mini-Mental State Examination (MMSE); Quality of Life in Alzheimer's disease (QoL-AD) scale; Barthel index (BI) were used to measure apathy, cognitive ability, quality of life, and functional capacity, respectively.Results: The recruitment, retention, attendance and assessment completion rates were 22.7%, 87.5%, 100% and 100%, respectively. The between-group differences in AES-I (p = 0.007) and MMSE (p = 0.034) scores were statistically significant at T1. In the experimental group, the AES-I (p = 0.001), MMSE (p = 0.010), and QoL-AD (p = 0.017) scores were significantly different over time. In the post hoc pair-wise analysis, the AES-I scores of the experimental group observed at T1 were significantly lower than that at T0 (p = 0.032). In the control group, the MMSE scores (p = 0.001) were significantly different over time.Conclusion: HT is feasible for residents with dementia and apathy. The HT program effectively reduced apathy and promoted cognitive function, but its effects on quality of life and functional capacity were not observed.

Dementia Caregivers' Experiences Engaging Supportive Services While Residing in Under-Resourced Areas

BACKGROUND

Family caregivers of people living with dementia benefit from supportive service use to address care needs associated with caregiving. Yet, research consistently demonstrates low rates of service use. Existing research has focused on barriers and facilitators to service use, with few studies examining the influence of caregivers' environmental context which often patterns social advantage and health services accessibility.

OBJECTIVE

To describe the perspectives of caregivers residing in socially disadvantaged areas have in regards to utilizing supportive services.

METHODS

Ten informal caregivers residing in socially disadvantaged areas participated in in-depth interviews that were analyzed using thematic analysis.

RESULTS

Across all interviews, caregivers spontaneously described common precedents of service use (crisis or accumulation of unmet needs) and a distinct sequence of stages (seeking, initiating, and utilizing) surrounding service engagement. Major themes characterizing caregivers' experiences throughout service engagement highlight the varied influence of personal, familial, health, and social system-related factors. Findings demonstrate that caregivers may have different service needs as dementia progresses and that gerontological social work practice can facilitate service use.

CONCLUSION

While preliminary, these findings provide important insights into new domains that can be further examined in future research and intervention efforts to improve supportive service use in socially disadvantaged and underserved communities.

Sleep in Persons Living with Alzheimer's Disease and Related Dementias

Over a typical lifespan, the amount of time people spend each day sleeping decreases. Sleep patterns also change as people age. Sleep disorders are common among persons of all ages, and older adults are particularly vulnerable. Development of age-related neurodegenerative diseases, such as Alzheimer's disease and related dementias, is associated with pronounced sleep disruption. This article provides evidence-based guidelines for diagnosis and clinical management of sleep disorders that occur during the course of treatment of Alzheimer's disease and related dementias. The article presents novel interventions and future directions for clinical practice and sleep research, and addresses diversity and inclusivity.

Recruiting and Retaining Dyads of Hospitalized Persons with Dementia and Family Caregivers

Persons with dementia have high rates of hospitalization, and along with their caregivers commonly experience negative hospital outcomes. The recruitment and retention of acutely ill older adults with dementia and caregivers can pose a challenge to investigators and threaten the validity of findings. The challenges encountered in an ongoing cluster randomized clinical trial in dyads of hospitalized persons with dementia and family care partners are described. The trial tests the efficacy of a nurse-family partnership model that aims to improve the following: (a) the physical and cognitive recovery in hospitalized persons with dementia, and (b) caregiver preparedness and anxiety. Strategies that address challenges include careful preplanning and preparation with the hospital site, strong communication with dyads and between team members, and honoring preferences and needs related to communication.

Tailoring Research Recruitment for Acute Care Settings: Recommendations from People with Dementia and their Caregivers

BACKGROUND

There is a pressing need to increase enrollment and representation in Alzheimer's disease and related dementia (ADRD) research. Current recruitment approaches focus largely on clinic and community settings, with minimal engagement of acute care environments despite their broad use across diverse populations. The objectives of this study were to examine views, preferences, and recommendations regarding acute care-based ADRD research recruitment among persons with dementia and their caregivers.

METHODS

The authors conducted semistructured interviews with recently hospitalized persons with dementia (N=3) and family caregivers (N=28). Interviews were analyzed using thematic analysis.

FINDINGS

All participants endorsed acute care as an appropriate time for recruitment into ADRD research studies and identified important elements of an appropriately tailored recruitment approach and an interpersonally effective research staff. Participants emphasized that this approach should consider the acute care context with respect to participant situation, uncertainty, and timing. Participant suggestions informed the design of a 5-step process to guide ADRD research recruitment in the context of acute care.

DISCUSSION

Findings provide valuable insights from people with dementia and their caregivers regarding opportunities for research engagement surrounding acute care and can inform expanded recruitment in these settings.

Ethical aspects of facilitating the recruitment of people with dementia for clinical trials: A call for further debate

Under-representation of people with dementia in clinical research remains a significant obstacle to develop evidence-based practice guidelines and recommendation for dementia care and slows down the development of disease-modifying pharmacological interventions. This is partly due to the ethical challenges and complexities of recruiting people with dementia for clinical trials. The traditional approach adopted by research ethics committees and regulatory bodies has been to protect people with dementia as a vulnerable population from harms of participating in research. There are concerns that this approach is unduly rigid, precludes the conduct of necessary research, and has exclusionary, paternalistic and discriminatory ramifications. As such, there are increasing calls to shift to a new hybrid facilitative/protective approach. This paper identifies 4 strategies to operationalise the facilitative/protective approach in the context of dementia research. These are: (i) embedding dementia research in clinical care; (ii) increasing the recruitment of people at preclinical stages of dementia; (iii) streamlined proxy consent procedures; and (iv) advance research consent. I note that all 4 strategies hold the promise of facilitating the recruitment of people with dementia in clinical research. Nonetheless, they give rise to a diverse range of new ethical concerns and issues. This necessitates further scholarly work to explore possible ways to address the ethical concerns and issues arisen by the uptake of protective/facilitative approach. In particular, further research is necessary to clarify, to what extent, the said strategies ameliorate or increase the vulnerability of people with dementia.

Ethical and Methodological Considerations for Evaluating Participant Views on Alzheimer's and Dementia Research

The urgent need to expand enrollment in Alzheimer's disease and related dementia (ADRD) research has synergized calls for an empiric science of research recruitment, yet, progress in this area is hindered by challenges to measuring views toward ADRD research. This paper reports ethical and methodological considerations identified through a prospective qualitative study investigating ADRD patient and caregiver views on research recruitment and participation surrounding acute illness. Ethical and methodological considerations were identified through a combination of memoing, collaboration with a Community Advisory Board (CAB), and analysis of interview data from ADRD patients (N = 3) and/or caregivers (N = 28). These included risk for undue influence attributable to role ambiguity/motivational misconceptions, divergent decision-making preferences, bias contributing to low referrals of ADRD participants, and difficulty answering abstract/hypothetical questions. Many considerations were successfully addressed with multifaceted, proactive strategies, and CAB input. Findings have implications for recruitment science research and the validity of inferences regarding research preferences.

Determining medical decision-making capacity in brain tumor patients: why and how?

Background

Brain tumor patients are at high risk of impaired medical decision-making capacity (MDC), which can be ethically challenging because it limits their ability to give informed consent to medical treatments or participation in research. The European Association of Neuro-Oncology Palliative Care Multidisciplinary Task Force performed a systematic review to identify relevant evidence with respect to MDC that could be used to give recommendations on how to cope with reduced MDC in brain tumor patients.

Methods

A literature search in several electronic databases was conducted up to September 2019, including studies with brain tumor and other neurological patients. Information related to the following topics was extracted: tools to measure MDC, consent to treatment or research, predictive patient- and treatment-related factors, surrogate decision making, and interventions to improve MDC.

Results

A total of 138 articles were deemed eligible. Several structured capacity-assessment instruments are available to aid clinical decision making. These instruments revealed a high incidence of impaired MDC both in brain tumors and other neurological diseases for treatment- and research-related decisions. Incapacity appeared to be mostly determined by the level of cognitive impairment. Surrogate decision making should be considered in case a patient lacks capacity, ensuring that the patient's "best interests" and wishes are guaranteed. Several methods are available that may help to enhance patients' consent capacity.

Conclusions

Clinical recommendations on how to detect and manage reduced MDC in brain tumor patients were formulated, reflecting among others the timing of MDC assessments, methods to enhance patients' consent capacity, and alternative procedures, including surrogate consent.

Recruitment and retention of underrepresented populations in Alzheimer's disease research: A systematic review

INTRODUCTION

Alzheimer's disease and related dementias (ADRD) disproportionately impact racial and ethnic minority and socioeconomically disadvantaged adults. Yet, these populations are significantly underrepresented in research.

METHODS

We systematically reviewed the literature for published reports describing recruitment and retention of individuals from underrepresented backgrounds in ADRD research or underrepresented participants' perspectives regarding ADRD research participation. Relevant evidence was synthesized and evaluated for quality.

RESULTS

We identified 22 eligible studies. Seven studies focused on recruitment/retention approaches, all of which included multifaceted efforts and at least one community outreach component. There was considerable heterogeneity in approaches used, specific activities and strategies, outcome measurement, and conclusions regarding effectiveness. Despite limited use of prospective evaluation strategies, most authors reported improvements in diverse representation in ADRD cohorts. Studies evaluating participant views focused largely on predetermined explanations of participation including attitudes, barriers/facilitators, education, trust, and religiosity. Across all studies, the strength of evidence was low.

DISCUSSION

Overall, the quantity and quality of available evidence to inform best practices in recruitment, retention, and inclusion of underrepresented populations in ADRD research are low. Further efforts to systematically evaluate the success of existing and emergent approaches will require improved methodological standards and uniform measures for evaluating recruitment, participation, and inclusivity.