Shared decision-making in persons living with dementia: A scoping review

Public attitudes toward dementia risk prediction: A mixed-methods study

INTRODUCTION

Numerous dementia risk prediction models have been developed, but uptake in clinical practice is poor.

METHODS

We determined public attitude toward dementia risk prediction through the means of a focus group (n = 9) and subsequent online survey (n = 687). Thematic content analysis was used for focus group data and descriptive statistics for survey responses.

RESULTS

Focus group participants expressed reluctance in knowing dementia risk due to fear, emotional burden, and belief that prevention was impossible. Conversely, practical benefits and maximizing present quality of life motivated others to know dementia risk. Of survey respondents, 66.1% would want to know their 10-year risk at present, increasing to 82.3% if preventive medication were available. People perceived their 10-year risk as rather high, yet lower still than their own personal threshold for considering preventive action.

DISCUSSION

Development and implementation of dementia risk prediction tools require attention for personal actionability and emotional impact of risk communication.

HIGHLIGHTS

Among citizens with a particular interest in dementia, a large group is keen to learn their personal dementia risk, particularly when effective preventive measures are available. In focus group participants, hesitancy to learn about dementia risk was common, driven by fear, emotional burden, and doubts about the effectiveness of preventive interventions. The majority of survey participants (72%) believed a healthy lifestyle could reduce dementia risk. People perceived their 10-year risk as rather high, yet lower still than their own personal threshold for considering preventive action.

Medical decision-making experiences of persons with dementia and their carepartners: a qualitative study

BACKGROUND

Persons with dementia (PWD) and their carepartners must often make complex medical decisions, weighing the benefits of medical (surgical and non-surgical) interventions with uncertainty regarding outcomes, both dementia- and non-dementia related, in the short-term and long-term. This study informs gaps in clinical guidance for patient-centered decision-making about medical and surgical interventions for PWD and advancecare planning.

METHODS

We conducted a qualitative study using thematic analysis based on semi-structured interviews with PWD and carepartners.

RESULTS

We interviewed 30 participants (9 PWD, 21 carepartners). Four themes were identified (with related subthemes): 1) PWD and carepartners varied in using decision-making approaches for medical interventions for PWD (a) variations in views about decision-making load; (b) Progressive involvement of carepartners in ACP decision-making as cognition erodes; 2) medical intervention decisions were an inflection point to evaluate values for dyads and involved tradeoffs with implications for end-of-life care and quality of life 3) lack of discussion with clinical team about impact of medical interventions on dementia burdened dyads; 4) decisional quality was facilitated by: (a) a trusting relationship with clinicians; and (b) a multidisciplinary team approach.

CONCLUSION

Most patients with mild-to-moderate dementia and carepartners approach medical intervention decision-making guided by their understanding of the dementia prognosis, but the risks of medical interventions are often unaddressed in discussions with the clinical team, sometimes burdening dyads with undesirable consequences to their quality-of-life. Clinicians should provide dementia-related risks regarding medical intervention outcomes to best facilitate decision-making conversations and advance care planning.

Enhancing healthcare professionals' confidence in ethical decision-making when caring for people with dementia: A qualitative evaluation of the CARE intervention

Aim(s): To evaluate the impact of the CARE intervention on healthcare professionals' perceived confidence levels and understand the factors influencing confidence in ethical decision-making in dementia care. Design: Thematic analysis of post-intervention focus-group interviews. Methods: Twelve focus-group interviews were conducted post-intervention with nurses and other healthcare professionals providing direct caregiving for people with dementia in a Danish municipality. Braun and Clarke's framework guided thematic analysis, which assessed the participants' perceived influence of the CARE intervention on their confidence and gained insights into the factors perceived by participants as impacting confidence in ethical decision-making. Results: Analysis revealed five themes across two overarching domains: the perceived influence of the CARE intervention on healthcare professionals' confidence and factors impacting their confidence. While the intervention reinforced confidence for many, some reported no change due to pre-existing high confidence levels. Factors contributing to confidence included reassurance of ethical practice, peer dialogue, family interaction, and critical reflection, underscoring the importance of peer support and dialogue in bolstering ethical confidence in dementia care. Conclusion: This study presents findings on the CARE intervention's impact on enhancing healthcare professionals' confidence in ethical decision-making in dementia care and offers insights on the potential of peer interaction and support in bolstering ethical confidence.

Cognitive Impairment is Common and Unrecognized in Vascular Surgery Patients

BACKGROUND

Patients' capacities to understand and act upon healthcare information is crucial to decision-making and high-quality care. Cognitive impairment (CI) has been associated with adverse outcomes across a range of diseases and surgeries. Despite the importance of CI, there is little to no information on its prevalence and severity in vascular surgery patients in the United States. We therefore conducted a prospective observational study to better characterize the prevalence and severity of CI in a contemporary vascular surgery practice.

METHODS

We enrolled 111 outpatients attending a vascular surgery clinic using pragmatic consecutive sampling. Patients were excluded if they had a previous diagnosis of blindness, deafness, or dementia. Subjects completed a demographic survey and the Montreal Cognitive Assessment (MoCA), which was administered by a trained proctor. Chart review was used to assess comorbidities. The MoCA is a validated tool consisting of tasks such as clock drawing for assessing CI. It has a lower educational bias and higher sensitivity for detecting mild impairment compared to other examinations. The MoCA is scored from 0-30 based on an objective grading system. Scores between 0-9, 10-17, 18-25, and 26-30 indicate severe, moderate, mild, and no CI, respectively. Statistical analysis, including multivariable modeling, was performed using SAS (SAS Institute, Cary, NC).

RESULTS

Of 163 patients, our analysis included 111 consecutive vascular patients who completed the MoCA. The average age of the entire cohort was 64.1 years, and 58.6% were male. The majority of the patients in the study were White (80.1%). The mean MoCA score of the entire cohort was 22.6 (mild CI). Of all subjects, 77% had CI: 68% with mild and 9% with moderate CI. Hypertension (P = 0.024), congestive heart failure (CHF) (P = 0.028), fewer years of education (P = 0.032), and Medicaid enrollment (P = 0.046) all had significant univariate associations with CI. There was no statistically significant difference between age (P = 0.11) or the primary vascular diagnosis disease for which the patient sought treatment and CI (P = 0.49). Multivariable models demonstrated that only CHF (odds ratio 3.8, P = 0.046) was statistically significantly associated with risk of CI.

CONCLUSIONS

In this first-time prospective study of the entire spectrum of vascular patients in the United States, we found that nearly 4 of every 5 vascular surgery patients have undiagnosed CI. Furthermore, we found that having CHF was associated with a higher likelihood of CI. Given the implications on consent, decision-making, and postoperative care, future work should focus on enrollment of a larger cohort along with an examination of the impact of CI on mortality, length of stay, and other outcomes.

A relational approach to co-create Advance Care Planning with and for people living with dementia: a narrative study

BACKGROUND

Discussing Advance Care Planning (ACP) with people living with dementia (PwD) is challenging due to topic sensitivity, fluctuating mental capacity and symptom of forgetfulness. Given communication difficulties, the preferences and expectations expressed in any ACP may reflect family and healthcare professional perspectives rather than the PwD. Starting discussions early in the disease trajectory may avoid this, but many PwD may not be ready at this point for such discussions. Consequently, the optimal timing to discuss an ACP with and for PwD is undetermined. This study explored the changing needs of PwD and experiences of social contexts that influence ACP initiation and revision and aimed to identify the optimal time to discuss an ACP with PwD.

METHODS

Narrative online and telephone interviews were conducted with 13 PwD and 23 family carers. Participants were recruited via the Join Dementia Research (JDR) Platform. Narrative analysis was used to identify patterns in the data, generating three narratives: Shifting Expectations; Relational Interdependency and Trigger Points.

RESULTS

The Shifting Expectations narrative indicated that PwD's needs shifted to co-constructed needs with their family as PwD's independence declined. This was reflected in the Relational interdependency narrative where PwD almost always co-created and revised their ACPs with trusted key persons who provided relational support. The Trigger points narrative indicated various points in time when PwD can effectively initiate and revise their ACPs, ranging from before the diagnosis to years afterwards, challenging the current suggestion of an early ACP initiation.

CONCLUSIONS

This study highlighted the changing co-constructed needs between PwD and their families that influence how PwD initiate and revise their ACP. The identification of ACP trigger points - the pivotal events throughout the dementia journey - that prompt PwD and family members to discuss their ACPs were suggested, indicating that PwD can initiate and revise their ACPs throughout the disease trajectory provided relational support is available whereby key persons involved in their care are involved and agree with the decisions being made. Therefore, an alternative, relational approach to ACP with and for PwD is recommended.

"It's Akin to Standing Alone on the Platform": A Qualitative Analysis of Family Caregivers' Perceived Benefits of Conversations with Professional Dementia Caregivers

Family caregivers often face challenges in navigating care decisions and maintaining involvement after their relatives transition to long-term care facilities. This study explores family caregivers' perspectives on the benefits of engaging in conversations with professional caregivers in long-term dementia care. Semi-structured interviews were conducted with 17 family caregivers in Denmark. Using thematic and template analysis, five core themes were constructed, highlighting both emotional and practical motivations for communicating with healthcare professionals: (1) feeling disconnected and uninformed about their loved one's care, (2) managing emotional challenges while seeking reassurance, (3) leveraging professional expertise for guidance, (4) fostering collaboration through openness, and (5) achieving mutual understanding and perspective shifts. The findings underscore the critical role of open and ongoing communication among family and professional caregivers in building trust, addressing family caregivers' emotional and informational needs, and supporting them in navigating the shared caregiving roles of long-term dementia care. In addition, the findings point to the potential benefits of structured dialogues to promote family involvement and person-centered care in long-term dementia settings.

Navigating Dilemmas on Advance Euthanasia Directives of Patients with Advanced Dementia

OBJECTIVES

This study revisited the complexities faced by physicians in meeting due care criteria for euthanasia in patients with advanced dementia in The Netherlands. Despite increasing cases and legal provisions for advance euthanasia directives (AEDs), physicians encounter challenges with ethical issues, including patient communication and assessing unbearable suffering in patients who lack decisional capacity. This study examines the perspectives of elderly care physicians (ECPs), support and consultation on euthanasia in The Netherlands (SCEN) physicians, and euthanasia expertise center (EEC) physicians.

DESIGN

A multimethod descriptive study using a questionnaire with both closed and open-ended questions.

SETTING AND PARTICIPANTS

This study explores the complexities faced by physicians in handling AED-based euthanasia requests of patients with advanced dementia.

METHODS

Baseline characteristics of physician subgroups were analyzed descriptively, and subgroup variations were assessed using univariate regression. Qualitative data underwent thematic content analysis.

RESULTS

With a 13.8% response rate, the study included 290 participants: 108 ECPs, 188 SCEN physicians, and 53 EEC physicians. Some had combined roles: ECP and SCEN physicians (n = 29), ECP and EEC physician (n = 1), SCEN physicians and EEC physicians (n = 17), and ECP, SCEN physicians, and EEC physicians (n = 6). ECPs received most AED-based euthanasia requests but only 7 EEC physicians and 1 SCEN physician performed euthanasia. All subgroups stressed the importance of patient communication. ECPs found euthanasia ethically justifiable only when communication was possible, highlighting the need to understand current euthanasia wishes and verify unbearable suffering. Effective communication was deemed crucial for confirming request relevance, identifying obstacles, involving patients, fostering trust, and alleviating fears. Physicians generally agreed that unbearable suffering could be assessed through patient expressions, observations, and family input.

CONCLUSIONS AND IMPLICATIONS

Despite receiving AED-based euthanasia requests, few physicians proceeded. Subgroup analysis showed varying views, with ECPs emphasizing communication and EEC physicians focusing on determining unbearable suffering. All subgroups highlighted the importance of current patient expressions and involvement in the decision-making process.

Nurses' perspectives on shared decision-making in the daily care of hospitalized patients with dementia: An exploratory qualitative study

AIM

Gain insight into the process of shared decision-making (SDM) in daily hospital care for patients with dementia from nurses' perspectives.

DESIGN

Explorative qualitative design.

METHODS

In-depth digital interviews were conducted with 14 registered nurses between June and November 2022. A phenomenological approach was applied using Colaizzi's seven-step method.

RESULTS

Five themes were identified in the data: (1) SDM in daily care: How shared decision-making is applied; (2) Nurses' perceptions and competence: How nurses perceive and manage SDM; (3) Nurses' roles and advocacy: The evolving roles of nurses and their advocacy efforts, (4) Recognition of dementia and its impact: How nurses recognize and manage dementia; and (5) Interventions to support SDM: Strategies and interventions to facilitate SDM.

CONCLUSION

This study highlights the complexity of SDM in patients with dementia. It demonstrates the importance of the involvement of relatives, omission of patient goals in discussions and perceived deficiencies of nurses. The early identification of dementia, evaluation of nuanced capacity and targeted communication are essential. Further research and enhanced training are required to improve care in this context.

IMPACT

Potential areas for further research on SDM in nurses involving patients with dementia include investigating the effects of integrating goal discussions into SDM training for nurses, overcoming barriers to SDM competence, and challenging the idea that SDM is solely the responsibility of physicians. These findings highlight the need for policies that encourage interdisciplinary collaboration, address misconceptions and recommend training programmes that focus on applying SDM to the daily care of patients with dementia, thereby improving the overall quality of patient care.

REPORTING METHOD

The Consolidated Criteria for Reporting Qualitative Research (COREQ) checklist was used for reporting.

PATIENT OR PUBLIC CONTRIBUTION

No patient or public contribution.

Best practice in dementia health care: Key clinical practice pointers from a national conference and innovative opportunities for pharmacy practice

OBJECTIVE

Sub-optimal care of people living with dementia has serious consequences for older populations. The 2021 Australian Royal Commission noted that a large proportion of older adults in aged care live with dementia, yet there are limitations in the knowledge and understanding of staff who care for them. In the pursuit of educating pharmacists, physicians, allied health care professionals, researchers, academics, people living with dementia and their carers, and the public, who are facing the challenges of dementia management, the 'Best Practice in Dementia Health Care' conference was held on November 10, 2022 at Western Health (Sunshine Hospital, Melbourne, Australia).

METHODS

Sixteen experts presented on the current practice and challenges associated with delivering best practice dementia health care to older Australians, often highlighting how medication-related challenges impacted on their area of practice.

RESULTS

Presenters highlighted the importance of individualised medication management plans, considerations of culture and Indigenous communities, the role of technology, and the impact of exercise and the physical environment on care of people living with dementia. Key clinical practice messages from each expert presenter fit into four main topics: 'navigating complexities of medication management'; 'enhancing wellbeing'; 'supportive settings and environments'; and 'programs and services improving care'.

CONCLUSIONS

Pharmacists are crucial members of allied health care teams. They have the necessary medication and comorbidity expertise to review medication regimens, liaise with all health care providers, and provide holistic, pharmacological and non-pharmacological patient education. Towards providing best practice dementia health care, pharmacists can contribute in several ways, such as providing health practitioner education to increase understanding about medications and how they can impact on allied health practice, to ensure that medications are prescribed appropriately and safely. Further, pharmacists can make available resources to ensure people living with dementia receive culturally safe and appropriate care, while advocating for greater understanding of the history and experiences of people living with dementia to ensure care aligns with their day-to-day routines. Finally, pharmacists can provide peer-support to other health care professionals and care staff to ensure optimal management of behavioural and psychological symptoms of dementia. The information and insights shared at the conference can serve as a valuable resource for pharmacists and other health care professionals and researchers working to improve the lives of those living with dementia.

Supporting decision-making for individuals living with dementia and their care partners with knowledge translation: an umbrella review

Living with dementia requires decision-making about numerous topics including daily activities, such as advance care planning (ACP). Both individuals living with dementia and care partners require informed support for decision-making. We conducted an umbrella review to assess knowledge translation (KT) interventions supporting decision-making for individuals living with dementia and their informal care partners. Four databases were searched using 50 different search-terms, identifying 22 reviews presenting 32 KT interventions. The most common KT decision topic was ACP (N=21) which includes advanced care directives, feeding options, and placement in long-term care. The majority of KT interventions targeted care partners only (N=16), or both care partners and individuals living with dementia (N=13), with fewer interventions (N=3) targeting individuals living with dementia. Overall, our umbrella review offers insights into the beneficial impacts of KT interventions, such as increased knowledge and confidence, and decreased decisional conflicts.

Changing the focus: Facilitating engagement in physical activity for people living with mild dementia in a local community-Protocol for a pre-post mixed methods feasibility study

This study aims to address and improve the low physical activity levels among people with mild dementia by implementing a novel shared decision-making and motivational support program, named "Changing the Focus". It will utilise a pre-post mixed methods approach, aiming to recruit 60 community living older people with mild dementia and their care-partners. The shared decision-making process will involve the person living with dementia, their care-partner, and a research therapist, using a purpose-designed discussion tool including factors such as preferred physical activities, health status, local opportunities and program accessibility. This process aims to identify personalised local physical activity opportunities. Participants will be supported with the help of a research therapist to engage in targeted community-based physical activities for 12-months, to progress towards the recommended physical activity guidelines of 150 minutes per week. The intervention provided by the research therapist will include three home visits (baseline, 6- and 12-months) and seven motivational support phone calls (within the first six months). Research therapists may provide additional home visits and support calls as needed. Primary outcomes include program participation (participants living with dementia continuing with the program after 12-months), total physical activity time per week (measured using the Active Australia Survey at baseline, 6- and 12- months) and program acceptability (assessed through semi-structured interviews with participants, care-partners, referrers, and physical activity providers). Secondary outcomes include physical performance, mental health, wellbeing measures, and impact on care-partners (evaluated through physical tests or validated scales at baseline, 6- and 12-months). Other implementation aspects include reach, maintenance, safety (falls, other adverse events) and an economic evaluation. Results will inform feasibility, potential benefits, and challenges associated with this innovative shared decision-making and supported physical activity program for people living with mild dementia. Findings will guide future large-scale studies and contribute to enhancing physical activity opportunities for this population.

Dentists' Approaches to Treatment Decision-Making for People with Dementia: A Qualitative Study

INTRODUCTION

Globally, the number of people living with dementia (PLwD) is projected to increase substantially. Dentists will encounter an increasing number of PLwD retaining natural teeth who need dental care. Dental treatment planning can be complex for PLwD as both oral diseases and dental treatment can be detrimental to patients' oral and social function and comfort. In addition, patients may lack the capacity to make decisions about their treatment, posing further challenges for dentists.

OBJECTIVE

This study aimed to explore dentists' approach to treatment decision-making with or for PLwD.

METHODS

Semistructured one-to-one interviews were completed with 22 dentists between April 2020 and March 2021. Data generation and analysis followed the principles of constructivist grounded theory with data being collected and analyzed simultaneously using a maximum variation sample. Interviews were recorded, transcribed verbatim, and then analyzed, leading to a theoretical understanding of how dentists approach treatment decisions for PLwD.

RESULTS

Four data categories describe dentists' approaches to treatment decision-making for PLwD. Dentists sought to provide individualized care for PLwD. However, they described planning care based on risk-benefit analyses that primarily considered biomedical factors and generic assumptions. There was an underemphasis on the psychological or social implications of dental care or its delivery. Furthermore, while some dentists attempted to involve patients in treatment decisions, they reported fewer attempts to identify the views and preferences of PLwD identified as lacking decisional capacity. In this scenario, dentists reported leading the decision-making process with little regard for patients' known or identified preferences and minimal involvement of PLwD's family.

CONCLUSIONS

Dentists acknowledge the complexity in treatment decision-making for PLwD yet focused heavily on biomedical considerations, with an underemphasis on individuals' preferences and autonomy. Considering psychosocial aspects of care alongside biomedical factors is essential to support holistic person-centered care for this growing patient cohort.

KNOWLEDGE TRANSFER STATEMENT

This study highlighted that dentists may only be considering biomedical aspects of care when considering what treatment is appropriate for people living with dementia. When making or supporting treatment decisions, dentists should explore patients' preferences and actively consider relevant psychosocial factors. These can be actively identified through considered discussions with patients as well as their family members. Gathering this information should support more person-centered and value-concordant decision-making for people living with dementia.

Decision-making involvement and onset of cognitive impairment in community-dwelling older care recipients: a 2-year longitudinal study

BACKGROUND

The decision-making of older adults and people with dementia is attracting more attention among healthcare professionals. While cognitive impairment has been examined as a factor related to decision-making, it can also be assumed that involvement in decision-making leads to the maintenance of cognitive function. This study examined the association of the decision-making process with the onset of cognitive impairment.

METHODS

We analyzed data from a 2-year longitudinal panel survey of community-dwelling care recipients aged ≥65 years in Japan. The sample included 406 participants who responded to both baseline and follow-up surveys, were cognitively intact at baseline, and had no missing cognitive impairment data regarding onset at follow-up. The status of decision-making involvement was assessed using a single item and classified into four categories: 'very involved,' 'less involved,' 'unclear about desired care,' and 'having no one to share the decision.'

RESULTS

Among the participants (women, 65.0%; ≥75 years old: 68.2%), the incidence of cognitive impairment during the follow-up was 26.6%. Multivariable logistic regression showed that, compared with highly involved participants, those who lacked clarity about desired care were more likely to develop an onset of cognitive impairment (odds ratio: 5.49; 95% confidence interval: 1.63-18.54; P = 0.006).

CONCLUSION

Even among cognitively intact care recipients, those who are not able to formulate their desired care may be at risk of cognitive decline. Therefore, support for the decision-making process, not limited to the final decision, is essential to improving the prognosis of community-dwelling care recipients.

Dental decision-making for persons with dementia: A systematic narrative review

Dental decision-making represents the establishment of a common understanding between the dental professional and the recipient of the intervention, which determines oral healthcare and dental treatment policies. Dental decision-making for persons with dementia can be challenging, and there have been no systematic reviews on this topic. Therefore, this systematic narrative review aimed to identify the current state of dental decision-making in persons with dementia. Literature search was performed using PubMed, Web of Science, Cochrane Library, CINAHL, and Google Scholar databases. Through the process of research selection, 7 articles with a high risk of bias were included in this study. This review clarified that there is limited information on the dental decision-making processes for persons with dementia. In conclusion, although this may be difficult due to different medical and socioeconomic conditions, the dilemma between the need to establish evidence for dental decision-making and medical ethics that prioritize a patient-centered position should be discussed globally in the future.