Improving person-centred care in nursing homes through dementia-care mapping: design of a cluster-randomised controlled trial

Economic disadvantage and depressive symptoms among Arab and Jewish women in Israel: the role of social support and formal services

OBJECTIVES

Depression is a major public health concern due to its high prevalence and association with functioning. Ethnic minorities in Western countries are more likely to experience economic disadvantage and exposure to stressors that may put them at higher risk of developing depression. One major protective factor associated with reduced depressive symptoms is an existing support network. This study examined the associations between economic disadvantage, formal and informal social support, and depressive symptoms among two ethnicity groups in Israel: Arab and Jewish mothers of young children, as well as the potential mediating role of formal and informal social support in the associations between economic disadvantage and depressive symptoms.

DESIGN

We recruited a representative sample of 837 Jewish and Arab mothers of children aged 2-6 years. We collected data via structured face-to-face interviews following approval of the university ethic committee. We used the Center for Epidemiologic Studies Depression Scale (CES-D), the Medical Outcomes Study (MOS) scale to measure maternal perceived social support, and a measure designed for this study to quantify formal social support.

RESULTS

Compared to the Jewish mothers, Arab mothers reported more depressive symptoms, greater economic disadvantage, and fewer informal and formal support networks. Economic disadvantage was negatively associated with informal support but positively associated with formal support among both Jewish and Arab mothers. Results further revealed that informal and formal social support mediated the associations between economic disadvantage and symptoms of depression.

CONCLUSIONS

More attention should be paid to the associations between social determinants and mothers' mental health, with a possible shift of focus to macro-level factors, such as economic inequality and minority status.

Effects of a multicomponent physical activity programme, Mobility-Fit, compared with a standard care lower limb strengthening programme, to promote safe mobility among older adults in care facilities: protocol for a cluster randomised controlled trial

INTRODUCTION

Upper limb and core strength training is essential for older adults to safely perform daily activities. However, existing exercise programmes mainly focus on lower limb strength and are not designed or delivered to suit people with different functional capacities. This study describes the design of a two-arm cluster randomised controlled trial to examine the effects of a multicomponent physical activity (PA) programme, Mobility-Fit, on mobility and frailty in older adults living in care facilities.

METHODS AND ANALYSIS

160 older adults from 20 care facilities in Hong Kong will be recruited and randomised by care facilities (1:1) to an intervention or a control group. Participants in the intervention group will attend the Mobility-Fit programme, led by facility-based instructors, three times per week, 45 min per session, for 12 weeks, while the control group will participate in a standard care lower limb strengthening programme offered by the care facility. Participants will then be followed up for 9 months. Mobility-Fit comprises agility, postural coordination, balance and strength training, with suitable dosage based on participant's baseline physical and cognitive function. The primary outcomes encompass upper and lower limb strength, trunk stability, reaction time, mobility function and fall efficacy. Secondary outcomes comprise daily PA level and performance, frailty, cognitive function and quality of life. A repeated measures analysis of variance (ANOVA) and generalised estimating equation (GEE) will be used to examine changes in outcomes over time and between groups. Data will be analysed following the intention-to-treat principles. We will also evaluate programme implementation and health economics throughout the follow-up period.

ETHICS AND DISSEMINATION

Ethical approval was acquired in November 2022 from the Joint CUHK-NTEC Clinical Research Ethics Committee in Hong Kong (CREC-2022-459). Informed consent will be obtained from participants. The results of the study will be disseminated through peer-reviewed articles, conference presentations and social media.

TRIAL REGISTRATION NUMBER

ChiCTR2300072709.

Assessment of the level of social support and associated factors among cancer patients in the comprehensive cancer center at Ethiopia: Ordinal logistic regression analysis level of social support and associated factors among cancer patients

Introduction

Cancer is a serious and common disease, which had a substantial problem in the social status of patients. There was no empirical evidence on the effect of cancer on social support.

Objective

This study aimed to determine the level of social support among cancer patients in a comprehensive cancer center in Ethiopia.

Methods

An institution-based cross-sectional study was done. About 386 study participants who were selected through systematic random sampling involved in the study. Training and close supervision and monitoring were done. The collected data were analyzed using SPSS-25. Descriptive statistics and Chi-square test were done. Ordinal bivariate and multivariate logistic regression were done to show the net effect of independent variables on the dependent variable. Model fitting information, the goodness of test, and the test of parallel line assumption test of the ordinal logistic regression model were carried out.

Results

A total of 386 study subjected were included in the final analysis. The poor, moderate, and strong levels of social support among cancer patients were found to be 45.3%, 34.2%, and 20.5% respectively. The mean score of social support among cancer patients was 10.4 ± 2.6SD. Age, Marital status, residence, educational status, stage III were found to be significant factors for the level of social support.

Conclusion

and recommendation: The level of poor, moderate, and strong social support was found to be 45.3%, 34.2 and 20.5 respectively. Emphasis should be given to those cancer patients who had poor social support, and frequent social status assessment should be done.

Psychological distress and associated factors among cancer patients in public hospitals, Addis Ababa, Ethiopia: a cross-sectional study

BACKGROUND

Cancer has great implications for psychological, social, economic, and emotional dimensions. Psychological distress is overwhelming among cancer patients following a confirmed diagnosis. However, little is known about the prevalence of psychological distress and associated factors among cancer patients in Africa Sub-Saharan. Thus, this study aimed to assess the prevalence of psychological distress and associated factors among cancer patients in public hospitals in Addis Ababa, Ethiopia.

METHODS

An institution-based cross-sectional study was conducted among cancer patients from September 15, 2019, to June 30, 2020. A total of 386 cancer patients selected through a simple random sampling technique participated in the study. Data were collected by an interview-administered questionnaire to evaluate psychological distress with a distress thermometer and social support with the Oslo 3-items Social Support Scale. The collected data were entered into Epi-data version 4.2 and exported into SPSS 25 for analysis, and then binary and multivariate logistic regressions were done to identify the association between dependent and independent variables.

RESULTS

A total of 386 study participants were included in the study with a response rate of 91.4%. The prevalence of psychological distress among cancer patients in public hospitals in Addis Ababa, Ethiopia was 64.5%. Age > 45 years [AOR = 0.41; 95% CI (0.22-0.77)], marital status of being divorced [AOR = 3.3; 95%CI (1.23-8.71)] and married [AOR = 3.2; 95%CI (1.03-10.40)], rural residence [AOR = 1.5; 95%CI (1.15-5.18)], cancer stage II [AOR = 3.9; 95%CI (1.90-15.50)], stage III [AOR = 3.5;95%CI (1.45-8.44)] and stage IV [AOR = 3.4; 95%CI (1.90-10.11)], co-morbidity [AOR = 0.07; 95%CI: (0.03-0.17)], and moderate social support [AOR = 0.36; 95%CI (0.14-0.60)] and strong social support [AOR = 0.06; 95%CI (0.03-0.12)] were found to be significantly associated with psychological distress.

CONCLUSION

The prevalence of psychological distress among cancer patients in public hospitals in Addis Ababa, Ethiopia was high, and age, marital status, place of residence, cancer stage, co-morbidity, and social support were associated with psychological distress. Therefore, interventions focusing on these findings require special emphasis during designing interventions aimed at decreasing psychological distress.

Soundscape Awareness Intervention Reduced Neuropsychiatric Symptoms in Nursing Home Residents With Dementia: A Cluster-Randomized Trial With MoSART

OBJECTIVES

Auditory environments as perceived by an individual, also called soundscapes, are often suboptimal for nursing home residents. Poor soundscapes have been associated with neuropsychiatric symptoms (NPS). We evaluated the effect of the Mobile Soundscape Appraisal and Recording Technology sound awareness intervention (MoSART+) on NPS in nursing home residents with dementia.

DESIGN

A 15-month, stepped-wedge, cluster-randomized trial. Every 3 months, a nursing home switched from care as usual to the use of the intervention.

INTERVENTION

The 3-month MoSART+ intervention involved ambassador training, staff performing sound measurements with the MoSART application, meetings, and implementation of microinterventions. The goal was to raise awareness about soundscapes and their influence on residents.

SETTING AND PARTICIPANTS

We included 110 residents with dementia in 5 Dutch nursing homes. Exclusion criteria were palliative sedation and deafness.

METHODS

The primary outcome was NPS severity measured with the Neuropsychiatric Inventory-Nursing Home version (NPI-NH) by the resident's primary nurse. Secondary outcomes were quality of life (QUALIDEM), psychotropic drug use (ATC), staff workload (workload questionnaire), and staff job satisfaction (Maastricht Questionnaire of Job Satisfaction).

RESULTS

The mean age of the residents (n = 97) at enrollment was 86.5 ± 6.7 years, and 76 were female (76.8%). The mean NPI-NH score was 17.5 ± 17.3. One nursing home did not implement the intervention because of staff shortages. Intention-to-treat analysis showed a clinically relevant reduction in NPS between the study groups (-8.0, 95% CI -11.7, -2.6). There was no clear effect on quality of life [odds ratio (OR) 2.8, 95% CI -0.7, 6.3], psychotropic drug use (1.2, 95% CI 0.9, 1.7), staff workload (-0.3, 95% CI -0.3, 0.8), or staff job satisfaction (-0.2, 95% CI -1.2, 0.7).

CONCLUSIONS AND IMPLICATIONS

MoSART+ empowered staff to adapt the local soundscape, and the intervention effectively reduced staff-reported levels of NPS in nursing home residents with dementia. Nursing homes should consider implementing interventions to improve the soundscape.

Measuring person-centred care in german nursing homes - exploring the construct validity of the Dementia Policy Questionnaire: a cross-sectional study of a secondary data set

BACKGROUND

To ensure the sustainable implementation of dementia-specific person-centred care (PCC) in nursing homes, internal policies are crucial. The preliminary German Dementia Policy Questionnaire, which features 19 dichotomous items, assesses the existence of and evaluates these policies. This article reports the results of an exploration of the construct validity of the preliminary Dementia Policy Questionnaire.

METHODS

This study is a cross-sectional study that references a secondary data set drawn from a national survey study of a randomized, stratified sample of 134 nursing homes in Germany. To explore the construct validity of the preliminary Dementia Policy Questionnaire, we conducted an adjusted multiple correspondence analysis of the pretested 19-item assessment. We included data assessed using the preliminary Dementia Policy Questionnaire from 134 care units associated with 134 nursing homes; these data were collected via telephone interviews with nursing home administrators or their representatives.

RESULTS

Two items assessing visitor regulations and regulations regarding the inclusion of residents in staff selection were less frequent and were therefore excluded from the adjusted multiple correspondence analysis. In total, nine items were assigned to two dimensions. The items assigned to the first dimension assess existing regulations for PCC as well as existing regulations regarding the involvement of the resident, relatives and the multiprofessional team in the collection of information concerning preferences, case conferences or decision making. The items assigned to the second dimension assess existing regulations regarding the systematic assessment of resident preferences and their requirements.

CONCLUSION

The study produces exploratory evidence concerning the preliminary Dementia Policy Questionnaire. Since the dimensions of the items included in this questionnaire cannot be conceptualized clearly, the instrument in its current state requires further development.

Comprehensive geriatric assessment (CGA) in perioperative care: a systematic review of a complex intervention

OBJECTIVES

Comprehensive geriatric assessment (CGA) is a complex intervention applied to older people with evidence of benefit in medical populations. The aim of this systematic review was to describe how CGA is applied to surgical populations in randomised controlled trials. This will provide a basis for design of future studies focused on optimising CGA as a complex intervention.

SETTING

A systematic review of randomised controlled trials.

PARTICIPANTS

A systematic search was performed for studies of CGA in the perioperative period across Ovid MEDLINE, Ovid EMBASE, CINAHL and Cochrane CENTRAL, from inception to March 2021.

INTERVENTIONS

Any randomised controlled trials of perioperative CGA versus 'standard care' were included.

OUTCOME MEASURES

Qualitative description of CGA.

RESULTS

12 121 titles and abstracts were screened, 68 full-text articles were assessed for eligibility and 22 articles included, reporting on 13 trials. 10 trials focused on inpatients with hip fracture, with 7 of these delivering CGA on a geriatric medicine ward, 3 on a surgical ward. The remaining three trials were in elective general surgery all delivering CGA on a surgical ward. CGA components, duration of intervention and personnel delivering the intervention were highly variable across the different studies. Trials favoured postoperative delivery of CGA (11/13). Only four trials reported data on adherence to the CGA intervention.

CONCLUSIONS

CGA as an intervention is variably described and delivered in randomised controlled trials in the perioperative setting. The reporting of both the intervention and standard care is often poor with little focus on adherence. Future research should focus on clearly defining and standardising the intervention as well as measuring adherence within trials.

PROSPERO REGISTRATION NUMBER

CRD42020221797.

Flattening the quality of life curve? A prospective person-centred study from Norway amid COVID-19

Purpose

We examined multidimensional, heterogeneous reactions to the COVID-19 pandemic and associated measures to provide further insights into the developmental processes of risk and adaptation.

Method

We used three-wave questionnaire data from 8156 individuals participating in the Norwegian County Public Health Survey assessed 1–5 months before and three (June 2020) and nine (December 2020) months after the outbreak. Latent profile and latent transition analyses were used to identify latent quality of life (QoL) classes and multiform changes, their probabilities, and predictors.

Results

We identified five distinct QoL classes of varying proportions, namely Flourishing (i.e. 24–40%), Content (31–46%), Content-Symptomatic (8–10%), Languishing (14–20%), and Troubled (2–5%). Despite higher levels of negative affect and lower levels of life satisfaction and positive emotions, most individuals remained in their pre-pandemic QoL profiles. Yet, changes occurred for a meaningful proportion, with transition to a less favourable class more common than to a favourable. Between time 1 and 3, the flourishing and troubled groups decreased by 40% and 60%, while the content and languishing groups increased by 48% and 43%, respectively. Favourable pre-pandemic relational (marital status, support, interpersonal trust, and belonging), health, and economy-related status predicted significantly lower odds of belonging to the high-risk groups both pre-pandemic and during the pandemic.

Conclusions

Overall, this study shows lower levels of QoL amid the COVID-19 pandemic, but substantial stability in the QoL distribution, and an overall levelling of the QoL distribution. Our findings also underscore the importance of financial, health-related, and social capital to QoL.

Supplementary Information

The online version contains supplementary material available at 10.1007/s11136-022-03113-2.

Prevalence of depression and anxiety symptoms and their determinant factors among patients with cancer in southern Ethiopia: a cross-sectional study

OBJECTIVE

The study was aimed to assess the prevalence of depression and anxiety symptoms and their determinant factors among patients with cancer attending follow-up at Hawassa University Comprehensive Specialized Hospital cancer treatment centre, Ethiopia.

DESIGN

Institution-based cross-sectional study design was implemented.

SETTING

Patients with cancer at Hawassa University Comprehensive Specialized Hospital cancer treatment centre from October 2019 to December 2019.

PARTICIPANTS

Randomly selected 415 patients with cancer who had follow-up at cancer treatment centre.

MAIN OUTCOME MEASURES

Anxiety and depression symptoms were assessed using Hospital Anxiety and Depression Scale.

RESULT

The prevalence rates of depression and anxiety symptoms were found to be 244 (58.8%) and 249 (60.0%), respectively. Older age (>50 years) (AOR (adjusted OR)=2.24, 95% CI=1.14 to 4.40), being unemployed (AOR=1.96, 95% CI=1.08 to 3.56), advanced stage of cancer such as stage III (AOR=5.37, 95% CI=1.34 to 21.45) and stage IV (AOR=4.55, 95% CI=1.12 to 18.44), comorbid psychotic symptoms (AOR=1.67, 95% CI=1.07 to 2.61) and eating problem in the past 2 weeks (AOR=6.16, 95% CI=1.98 to 19.11) were independent factors significantly associated with depressive symptoms. In addition, cancer stage such as stage II (AOR=3.92, 95% CI=1.07 to 14.36) and stage IV (AOR=5.04, 95% CI=1.44 to 17.59) and comorbid psychotic symptoms (AOR=1.73, 95% CI=1.12 to 2.66) were significantly associated with anxiety symptoms.

CONCLUSION

Depression and anxiety symptoms among patients with cancer were considerably high. Age, occupation, cancer stage, comorbid psychotic symptoms and eating problem were determinant factors of depressive symptoms among patients with cancer. Moreover, cancer stage and comorbid psychosis were determinants of anxiety symptoms. Healthcare professionals working in the oncology unity need to conduct routine screening and treatment of depression and anxiety symptoms for patients with cancer.

Predictors of unrecognised comorbid depression in patients with schizophrenia at Amanuel mental specialized hospital, Ethiopia: a cross-sectional study

BACKGROUND

The occurrence of depression in patients with schizophrenia (PWS) increases the risk of relapse, frequency and duration of hospitalisation, and decreases social and occupational functioning.

OBJECTIVE

This study aimed to assess prevalence of unrecognised comorbid depression and its determinants in PWS.

METHOD

A cross-sectional study was conducted from 1 to 30 March 2019 at Amanuel mental specialized hospital among 300 PWS. The 9-item Calgary Depression Scale for Schizophrenia was used to assess comorbid depression. Logistic regression was used to determine the association between outcome and explanatory variables. Statistical significance was declared at p value <0.05 with 95% CI.

RESULTS

The prevalence of unrecognised comorbid depression was found to be 30.3%. Living alone (adjusted OR (AOR)=3.49, 95% CI=0.45 to 8.36), having poor (AOR=4.43, 95% CI=1.45 to 13.58) and moderate (AOR=4.45, 95% CI=1.30 to 15.22) social support, non-adherence to medication (AOR=3.82, 95% CI=1.70 to 8.55), presenting with current negative symptoms such as asocialia (AOR=4.33, 95% CI=1.98 to 9.45) and loss of personal motivation (AOR=3.46, 95% CI=1.53 to 7.84), and having suicidal behaviour (AOR=6.83, 95% CI=3.24 to 14.41) were the significant predictors of comorbid depression in PWS.

CONCLUSION

This study revealed considerably a high prevalence of unrecognised comorbid depression among PWS. Therefore, clinicians consider timely screening and treating of comorbid depression in PWS.

Dementia care education interventions on healthcare providers' outcomes in the nursing home setting: A systematic review

Given the increasing prevalence of people with dementia in long-term care, various educational interventions have been developed to enhance the dementia care competence of healthcare providers. The study aim was to appraise the evidence of the effects of dementia care educational programs on improving the preparedness of nursing home staff. Articles on dementia care education interventions for nursing home staff were searched from eight databases. The primary outcomes were staff knowledge, attitude, competence, and sense of competence or self-efficacy related to dementia. The secondary outcomes were psychological outcomes, including burnout, caregiving stress, well-being, and job satisfaction. The quality of evidence was appraised using the Joanna Briggs Institute Critical Appraisal tool. Out of the 3269 articles identified, 19 randomized controlled trials comprising 3947 participants from eight countries were included. The methodological quality of included studies was fair. A significant improvement in staff knowledge regarding dementia was reported. The intervention effects on attitudes and competence were insignificant, and the effects on the sense of competence or self-efficacy related to dementia care were inconsistent. The effects on psychological outcomes seem limited because few significant changes were found. Multiple teaching methods, peer support, qualified trainers, and post-training support were effective components in designing the educational interventions. However, given the variations in content and dose and the methodological limitations of the included studies, the effects of educational programs were inconclusive. The findings highlight the necessity of high-quality studies on dementia-care educational interventions, especially in other cultures than Western countries, such as in Asia.

Living arrangements and life satisfaction: mediation by social support and meaning in life

BACKGROUND

Living arrangements have impact on life satisfaction among older adults. However, the mechanism how it works has received less attention. This study aims to examine the mediating role of meaning in life and social support in the relationship between living arrangements and life satisfaction.

METHODS

A total of 215 older adults from nine nursing homes and three communities were included in this study. The Social Support Rating Scale, Meaning in Life Questionnaire and Life Satisfaction Index A were adopted. Data were analyzed with Hayes' s bias-corrected bootstrapping method.

RESULTS

Both social support and presence of meaning in life had positive correlations with life satisfaction (p<0.001), and they were significant mediators between living arrangements and life satisfaction (p<0.01).

CONCLUSION

To improve the life satisfaction of nursing home residents, more emphasis should be placed on encouraging residents to seek or maintain a meaningful life and creating a more positive climate of social support.

Performance and Receiver Operating Characteristics of the Mini-Mental State Examination Instrument in Detecting Dementia in a Rapidly Aging Developing Country (Jamaica)

OBJECTIVE

To examine the performance of the Mini-Mental State Examination (MMSE) in community-dwelling older persons in a developing country (Jamaica) undergoing rapid population aging.

METHODS

An embedded validity study was conducted utilizing participants from a nationally representative sample of 2782 older persons. Standardized MMSE scores were obtained for study participants. A random selection of 170 persons with MMSE scores greater than 20 and 170 persons with scores 20 or less was done. Field staff were trained to apply the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, criteria for the diagnosis of dementia. In total, 300 participants (167 participants with MMSE score of 20 or less, 133 participants with scores greater than 20) were assessed and categorized according to dementia status. Performance characteristics of the MMSE tool were determined for study participants and appropriate adjustment and analyses subsequently applied to facilitate extrapolation to the nationally representative sample.

RESULTS

The mean MMSE scores for participants with score of 20 and less was 17.1 (standard deviation [SD] = 3.2) and 24.5 (SD = 2.8) for those with scores greater than 20. Dementia was identified in 34 participants. The receiver operating characteristic curve for MMSE scores in relation to dementia diagnosis had an area under the curve value of 0.935 (95% confidence interval, 0.893-0.977). The optimal MMSE cut-point was 18/19 and was consistently so regardless of age category, gender, educational level, and number of chronic illnesses.

CONCLUSION

There is merit in using the MMSE examination as a screening tool for dementia in Jamaica. The findings of this study coupled with widespread use and familiarity among practitioners give credence to the MMSE as a reasonable screening tool for dementia in Jamaica-rapidly aging society.

Interventions for preventing falls in older people in care facilities and hospitals

BACKGROUND

Falls in care facilities and hospitals are common events that cause considerable morbidity and mortality for older people. This is an update of a review first published in 2010 and updated in 2012.

OBJECTIVES

To assess the effects of interventions designed to reduce the incidence of falls in older people in care facilities and hospitals.

SEARCH METHODS

We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register (August 2017); Cochrane Central Register of Controlled Trials (2017, Issue 8); and MEDLINE, Embase, CINAHL and trial registers to August 2017.

SELECTION CRITERIA

Randomised controlled trials of interventions for preventing falls in older people in residential or nursing care facilities, or hospitals.

DATA COLLECTION AND ANALYSIS

One review author screened abstracts; two review authors screened full-text articles for inclusion. Two review authors independently performed study selection, 'Risk of bias' assessment and data extraction. We calculated rate ratios (RaR) with 95% confidence intervals (CIs) for rate of falls and risk ratios (RRs) and 95% CIs for outcomes such as risk of falling (number of people falling). We pooled results where appropriate. We used GRADE to assess the quality of evidence.

MAIN RESULTS

Thirty-five new trials (77,869 participants) were included in this update. Overall, we included 95 trials (138,164 participants), 71 (40,374 participants; mean age 84 years; 75% women) in care facilities and 24 (97,790 participants; mean age 78 years; 52% women) in hospitals. The majority of trials were at high risk of bias in one or more domains, mostly relating to lack of blinding. With few exceptions, the quality of evidence for individual interventions in either setting was generally rated as low or very low. Risk of fracture and adverse events were generally poorly reported and, where reported, the evidence was very low-quality, which means that we are uncertain of the estimates. Only the falls outcomes for the main comparisons are reported here.Care facilitiesSeventeen trials compared exercise with control (typically usual care alone). We are uncertain of the effect of exercise on rate of falls (RaR 0.93, 95% CI 0.72 to 1.20; 2002 participants, 10 studies; I² = 76%; very low-quality evidence). Exercise may make little or no difference to the risk of falling (RR 1.02, 95% CI 0.88 to 1.18; 2090 participants, 10 studies; I² = 23%; low-quality evidence).There is low-quality evidence that general medication review (tested in 12 trials) may make little or no difference to the rate of falls (RaR 0.93, 95% CI 0.64 to 1.35; 2409 participants, 6 studies; I² = 93%) or the risk of falling (RR 0.93, 95% CI 0.80 to 1.09; 5139 participants, 6 studies; I² = 48%).There is moderate-quality evidence that vitamin D supplementation (4512 participants, 4 studies) probably reduces the rate of falls (RaR 0.72, 95% CI 0.55 to 0.95; I² = 62%), but probably makes little or no difference to the risk of falling (RR 0.92, 95% CI 0.76 to 1.12; I² = 42%). The population included in these studies had low vitamin D levels.Multifactorial interventions were tested in 13 trials. We are uncertain of the effect of multifactorial interventions on the rate of falls (RaR 0.88, 95% CI 0.66 to 1.18; 3439 participants, 10 studies; I² = 84%; very low-quality evidence). They may make little or no difference to the risk of falling (RR 0.92, 95% CI 0.81 to 1.05; 3153 participants, 9 studies; I² = 42%; low-quality evidence).HospitalsThree trials tested the effect of additional physiotherapy (supervised exercises) in rehabilitation wards (subacute setting). The very low-quality evidence means we are uncertain of the effect of additional physiotherapy on the rate of falls (RaR 0.59, 95% CI 0.26 to 1.34; 215 participants, 2 studies; I² = 0%), or whether it reduces the risk of falling (RR 0.36, 95% CI 0.14 to 0.93; 83 participants, 2 studies; I² = 0%).We are uncertain of the effects of bed and chair sensor alarms in hospitals, tested in two trials (28,649 participants) on rate of falls (RaR 0.60, 95% CI 0.27 to 1.34; I² = 0%; very low-quality evidence) or risk of falling (RR 0.93, 95% CI 0.38 to 2.24; I² = 0%; very low-quality evidence).Multifactorial interventions in hospitals may reduce rate of falls in hospitals (RaR 0.80, 95% CI 0.64 to 1.01; 44,664 participants, 5 studies; I² = 52%). A subgroup analysis by setting suggests the reduction may be more likely in a subacute setting (RaR 0.67, 95% CI 0.54 to 0.83; 3747 participants, 2 studies; I² = 0%; low-quality evidence). We are uncertain of the effect of multifactorial interventions on the risk of falling (RR 0.82, 95% CI 0.62 to 1.09; 39,889 participants; 3 studies; I² = 0%; very low-quality evidence).

AUTHORS' CONCLUSIONS

In care facilities: we are uncertain of the effect of exercise on rate of falls and it may make little or no difference to the risk of falling. General medication review may make little or no difference to the rate of falls or risk of falling. Vitamin D supplementation probably reduces the rate of falls but not risk of falling. We are uncertain of the effect of multifactorial interventions on the rate of falls; they may make little or no difference to the risk of falling.In hospitals: we are uncertain of the effect of additional physiotherapy on the rate of falls or whether it reduces the risk of falling. We are uncertain of the effect of providing bed sensor alarms on the rate of falls or risk of falling. Multifactorial interventions may reduce rate of falls, although subgroup analysis suggests this may apply mostly to a subacute setting; we are uncertain of the effect of these interventions on risk of falling.

Quality of life in older adults following a hip fracture: an empirical comparison of the ICECAP-O and the EQ-5D-3 L instruments

Background

The purpose of this study was to empirically compare the performance of two generic preference based quality of life instruments, EQ-5D-3 L (with a health and physical function focus) and ICECAP-O (with a wellbeing and capability focus), in a population of older Australians following hip fracture.

Methods

Older adults or their family member proxies (in cases of severe cognitive impairment) following surgery to repair a fractured hip were invited to take part in this cross sectional study. Inclusion criteria included an age of 60 years or older, confirmed falls-related hip fracture and those receiving current palliative care or consented to other research studies were excluded. 87 participants completed the ICECAP-O and EQ-5D-3 L instruments between one and three weeks post-surgery.

Results

For the hip fracture population, the mean ICECAP-O score was 0.639 (SD 0.206, n = 82) and the mean EQ-5D-3 L utility score was 0.545 (SD 0.251, n = 87). There was a statistically significant positive correlation between the ICECAP-O and EQ-5D-3 L scores (r = 0.529, p = < 0.001).

Conclusions

Study findings indicate significant impairments in quality of life post hip fracture. In multiple regression analyses, age and health-related QoL (measured by the EQ-5D) were significant determinants of ICECAP-O scores, while proxy respondent status, age, and capability-related QoL (measured by the ICECAP-O) were significant determinants of EQ-5D scores. Approaches to measuring and valuing quality of life in this sample, should consider the target domains of the intervention in their choice of instrument. Studies aiming to measure the impact of interventions targeting broader domains of wellbeing and QoL should consider including a broader measure of QoL in conjunction with a HRQoL measure.

Effectiveness of psychosocial interventions in reducing grief experienced by family carers of people with dementia: a systematic review protocol

REVIEW OBJECTIVE

The objective is to examine the existing evidence regarding the effectiveness of psychosocial interventions to assist grief pre- and post-bereavement for family carers of people with dementia residing in the community or in a health or social care facility.

REVIEW QUESTION

What psychosocial interventions for family carers of people with dementia are most effective in reducing: (1) anticipatory grief, (2) post-death grief (bereavement), and (3) complicated grief?

Care home services at the vanguard: a qualitative study exploring stakeholder views on the development and evaluation of novel, integrated approaches to enhancing healthcare in care homes

OBJECTIVES

To explore stakeholders' understanding of novel integrated approaches to enhancing care in care homes (a care home 'vanguard') and identify priorities for evaluation.

DESIGN

A qualitative study, using semistructured interviews with commissioners and service providers to/within care homes, and third sector organisations with thematic analysis.

SETTING

A Clinical Commissioning Group (CCG) area in England.

PARTICIPANTS

Thirty interviewees from care homes, the National Health Service (NHS; England) and local authority, third sector (10 care home managers, 5 general practitioners, 4 CCG employees, 4 local authority employees, 1 national (NHS England) vanguard lead, 2 specialist nurses, 2 geriatricians, 1 third sector and 1 health manager).

RESULTS

Four higher level themes emerged from the data: understanding of proposed changes, communication, evaluation of outcome measures of success, and trust and complexity. The vision for the new programme was shared by stakeholders, with importance attached to equitable access to high-quality care. Support for the programme was described as being 'the right thing to do', inferring a moral imperative. However, the practical implications of key aspects, such as integrated working, were not clearly understood and the programme was perceived by some as being imposed, top down, from the health service. Barriers and facilitators to change were identified across themes of communication, outcomes, trust and complexity. Importance was attached to the measurement of intangible aspects of success, such as collaboration. Interviewees understood that outcome-based commissioning was one element of the new programme, but discussion of their aspirations and practices revealed values and beliefs more compatible with a system based on trust.

CONCLUSIONS

Innovation in service delivery requires organisations to adopt common priorities and share responsibility for success. The vanguard programme is working to ensure health and local authorities have this commitment, but engaging care homes that may feel isolated from the welfare system needs sustained dialogue over the longer term. Evaluation of the programme needs to measure what is important to stakeholders, and not focus too closely on resource consumption.

Dementia care mapping in nursing homes: effects on caregiver attitudes, job satisfaction, and burnout. A quasi-experimental trial

BACKGROUND

The Dementia Care Mapping (DCM) method is an internationally recognized complex intervention in dementia research and care for implementing person-centered care. The Leben-QD II trial aimed to evaluate the effectiveness of DCM with regard to caregivers.

METHODS

The nine participating nursing home units were allocated to three groups: (1) DCM method experienced ≥ 1 year, (2) DCM newly introduced during this trial, and (3) regular rating of residents' quality of life (control group). Linear mixed models were fit to cluster-aggregated data after 0, 6, and 18 months, adjusting for repeated measurements and confounders. The primary outcome was the Approaches to Dementia Questionnaire (ADQ) score; the secondary outcomes were the Copenhagen Psychosocial Questionnaire (COPSOQ) and the Copenhagen Burnout Inventory (CBI).

RESULTS

The analysis included 201 caregivers with 290 completed questionnaires (all three data collection time points). The ADQ showed a significant time and time*intervention effect. At baseline, the estimated least-square means for the ADQ were 71.98 (group A), 72.46 (group B), and 71.15 (group C). The non-linear follow-up of group A indicated an estimated-least square means of 69.71 (T 1) and 68.97 (T 2); for group B, 72.80 (T 1) and 72.29 (T 2); and for group C, 66.43 (T 1) and 70.62 (T 2).

CONCLUSIONS

The DCM method showed a tendency toward negatively affecting the primary and secondary outcomes; this finding could be explained by the substantial deviation in adherence to the intervention protocol.

Structural validity and internal consistency of the Qualidem in people with severe dementia

BACKGROUND

Since its development, the Qualidem has had items that were considered unsuited for people with very severe dementia. This study attempted to investigate the applicability of all Qualidem items in people with all stages of dementia severity.

METHODS

Four data sets that contained Qualidem observations on people with dementia were combined. Dementia severity was categorized based on the Global Deterioration Scale (GDS), with a dichotomization of very severe dementia (GDS 7) and others (GDS 1-6). Unidimensional latent-trait models (Mokken scaling) were estimated to fit the Qualidem responses in the overall sample and the dichotomized groups. Scalability was assessed using coefficients of homogeneity (Loevinger's H), while reliability was assessed with Cronbach's α and ρ.

RESULTS

Combining the four databases resulted in 4,354 Qualidem measurements. The scalability of all scales was considered acceptable in the overall sample, as well is in the subgroups (all H > 0.3). Additionally, the reliability was good-excellent in the scales: "positive affect," "positive self-image," "care relationship," and "negative affect." Reliability was questionable-acceptable for "feeling at home," "social relations," "social isolation," and "restless tense behavior." Reliability was poor for "having something to do."

CONCLUSIONS

Statistical considerations allow using all Qualidem items in all dementia stages. Future research should determine balance of statistical- versus conceptual-based reasoning in this academic debate.

The psychosocial problems of families caring for relatives with mental illnesses and their coping strategies: a qualitative urban based study in Dar es Salaam, Tanzania

BACKGROUND

Mental illness may cause a variety of psychosocial problems such as decreased quality of life of the patient's family members as well as increased social distance for the patient and the family caring for the patient. Psychosocial challenges are enhanced by the stigma attached to mental illness, which is a problem affecting not only the patient but also the family as a whole. Coping mechanisms for dealing with mentally ill patients differ from one family to another for a variety of reasons. The aim of the study was to determine the psychosocial problems of mental illness on the family including the coping strategies utilized by family members caring for a person with mental illness.

METHOD

A qualitative study was conducted, involving four focus group discussions and 2 in-depth interviews of family members who were caring for patient with mental illness at Temeke Municipality, Dar es Salaam. Purposive sampling procedure was used to select participants for the study. Audio-recorded interviews in Swahili were conducted with all study participants. The recorded interview was transcribed and qualitative content thematic analysis was used to analyse the data.

RESULTS

Financial constraints, lack of social support, disruption of family functioning, stigma, discrimination, and patients' disruptive behaviour emerged as the main themes in this study. Acceptance and religious practice emerged as the major coping strategies used by family members.

CONCLUSION

Familial care for a person with mental illness has its advantages, yet it has multiple social and psychological challenges. Coping strategies and skills are important for the well-being of the caregiver and the patient. Addressing these psychosocial challenges requires a collaborative approach between the health care providers and government so that the needs of the family caregivers and those of the patients can be addressed accordingly.

A systematic review of instruments for measuring outcomes in economic evaluation within aged care

BACKGROUND

This paper describes the methods and results of a systematic review to identify instruments used to measure quality of life outcomes in older people. The primary focus of the review was to identify instruments suitable for application with older people within economic evaluations conducted in the aged care sector.

METHODS

Online databases searched were PubMed, Medline, Scopus, and Web of Science, PsycInfo, CINAHL, Embase and Informit. Studies that met the following criteria were included: 1) study population exclusively above 65 years of age 2) measured health status, health related quality of life or quality of life outcomes more broadly through use of an instrument developed for this purpose, 3) used a generic preference based instrument or an older person specific preference based or non-preference based instrument or both, and 4) published in journals in the English language after 2000.

RESULTS

The most commonly applied generic preference based instrument in both the community and residential aged care context was the EuroQol - 5 Dimensions (EQ-5D), followed by the Adult Social Care Outcomes Toolkit (ASCOT) and the Health Utilities Index (HUI2/3). The most widely applied older person specific instrument was the ICEpop CAPability measure for Older people (ICECAP-O) in both community and residential aged care.

CONCLUSION

In the absence of an ideal instrument for incorporating into economic evaluations in the aged care sector, this review recommends the use of a generic preference based measure of health related quality of life such as the EQ-5D to obtain quality adjusted life years, in combination with an instrument that has a broader quality of life focus like the ASCOT, which was designed specifically for evaluating interventions in social care or the ICECAP-O, a capability measure for older people.

Diagnostic test accuracy of simple instruments for identifying frailty in community-dwelling older people: a systematic review

BACKGROUND

frailty is a state of vulnerability to adverse outcomes. Routine identification of frailty is recommended in international guidance. This systematic review investigates the diagnostic test accuracy (DTA) of simple instruments for identifying frailty in community-dwelling older people.

METHODS

the review methodology followed Cochrane procedures. Databases were searched from January 1990 to October 2013. Prospective studies assessing the DTA of simple instruments for identifying frailty in community-dwelling older people (aged ≥65 years) as index tests against a reference standard phenotype model, cumulative deficit frailty index or comprehensive geriatric assessment were eligible for inclusion. Sensitivity, specificity, positive predictive value, negative predictive value and likelihood ratios were calculated for index tests. Risk of bias was assessed using the QUADAS-2 checklist.

RESULTS

three studies involving 3,261 participants were included. Median frailty prevalence was 10.5%. Seven index tests were assessed: gait speed, timed-up-and-go test, PRISMA 7 questionnaire, self-reported health, general practitioner clinical assessment, polypharmacy and Groningen Frailty Index. For a gait speed of <0.8 m/s, the sensitivity = 0.99 and specificity = 0.64. For the PRISMA 7, the sensitivity = 0.83 and specificity = 0.83. For the timed get-up-and-go test of 10 s, the sensitivity = 0.93 and specificity = 0.62. DTA was notably lower for all other index tests. All three studies were judged at unclear risk of bias.

DISCUSSION

slow gait speed, PRISMA 7 and the timed get-up-and-go test have high sensitivity for identifying frailty. However, limited specificity implies many false-positive results which means that these instruments cannot be used as accurate single tests to identify frailty.

The economics of dementia-care mapping in nursing homes: a cluster-randomised controlled trial

Background

Dementia-care mapping (DCM) is a cyclic intervention aiming at reducing neuropsychiatric symptoms in people with dementia in nursing homes. Alongside an 18-month cluster-randomized controlled trial in which we studied the effectiveness of DCM on residents and staff outcomes, we investigated differences in costs of care between DCM and usual care in nursing homes.

Methods

Dementia special care units were randomly assigned to DCM or usual care. Nurses from the intervention care homes received DCM training, a DCM organizational briefing day and conducted the 4-months DCM-intervention twice during the study. A single DCM cycle consists of observation, feedback to the staff, and action plans for the residents. We measured costs related to health care consumption, falls and psychotropic drug use at the resident level and absenteeism at the staff level. Data were extracted from resident files and the nursing home records. Prizes were determined using the Dutch manual of health care cost and the cost prices delivered by a pharmacy and a nursing home. Total costs were evaluated by means of linear mixed-effect models for longitudinal data, with the unit as a random effect to correct for dependencies within units.

Results

34 units from 11 nursing homes, including 318 residents and 376 nursing staff members participated in the cost analyses. Analyses showed no difference in total costs. However certain changes within costs could be noticed. The intervention group showed lower costs associated with outpatient hospital appointments over time (p = 0^.05) than the control group. In both groups, the number of falls, costs associated with the elderly-care physician and nurse practitioner increased equally during the study (p<0^.02).

Conclusions

DCM is a cost-neutral intervention. It effectively reduces outpatient hospital appointments compared to usual care. Other considerations than costs, such as nursing homes’ preferences, may determine whether they adopt the DCM method.

Trial Registration

Dutch Trials Registry NTR2314

Effects of dementia-care mapping on residents and staff of care homes: a pragmatic cluster-randomised controlled trial

BACKGROUND

The effectiveness of dementia-care mapping (DCM) for institutionalised people with dementia has been demonstrated in an explanatory cluster-randomised controlled trial (cRCT) with two DCM researchers carrying out the DCM intervention. In order to be able to inform daily practice, we studied DCM effectiveness in a pragmatic cRCT involving a wide range of care homes with trained nursing staff carrying out the intervention.

METHODS

Dementia special care units were randomly assigned to DCM or usual care. Nurses from the intervention care homes received DCM training and conducted the 4-months DCM-intervention twice during the study. The primary outcome was agitation, measured with the Cohen-Mansfield agitation inventory (CMAI). The secondary outcomes included residents' neuropsychiatric symptoms (NPSs) and quality of life, and staff stress and job satisfaction. The nursing staff made all measurements at baseline and two follow-ups at 4-month intervals. We used linear mixed-effect models to test treatment and time effects.

RESULTS

34 units from 11 care homes, including 434 residents and 382 nursing staff members, were randomly assigned. Ten nurses from the intervention units completed the basic and advanced DCM training. Intention-to-treat analysis showed no statistically significant effect on the CMAI (mean difference between groups 2·4, 95% CI -2·7 to 7·6; p = 0·34). More NPSs were reported in the intervention group than in usual care (p = 0·02). Intervention staff reported fewer negative and more positive emotional reactions during work (p = 0·02). There were no other significant effects.

CONCLUSIONS

Our pragmatic findings did not confirm the effect on the primary outcome of agitation in the explanatory study. Perhaps the variability of the extent of implementation of DCM may explain the lack of effect.

TRIAL REGISTRATION

Dutch Trials Registry NTR2314.

The effects of dementia care mapping on nursing home residents' quality of life and staff attitudes: design of the quasi-experimental study Leben-QD II

BACKGROUND

The main objective of care for people with dementia is the maintenance and promotion of quality of life (Qol). Most of the residents in nursing homes have challenging behaviors that strongly affect their Qol. Person-centered care (PCC) is an approach that aims to achieve the best possible Qol and to reduce challenging behaviors. Dementia Care Mapping (DCM) is a method of implementing PCC that has been used in Germany for several years. However, there are no data on the effectiveness of DCM or the challenges of implementation of DCM in German nursing homes.

METHODS/DESIGN

In this quasi-experimental non-randomized cluster-controlled study, the effects of DCM will be compared to 2 comparison groups. 9 nursing homes will take part: 3 will implement DCM, 3 will implement a comparison intervention using an alternative Qol assessment, and 3 have already implemented DCM. The main effect outcomes are Qol, challenging behaviors, staff attitudes toward dementia, job satisfaction and burnout of caregivers. These outcomes will be measured on 3 data points. Different quantitative and qualitative data sources will be collected through the course of the study to investigate the degree of implementation as well as facilitators of and barriers to the implementation process.

DISCUSSION

This study will provide new information about the effectiveness of DCM and the implementation process of DCM in German nursing homes. The study results will provide important information to guide the national discussion about the improvement of dementia-specific Qol, quality of care in nursing homes and allocation of resources. In addition, the study results will provide information for decision-making and implementation of complex psychosocial interventions such as DCM. The findings will also be important for the design of a subsequent randomized controlled trial (e.g. appropriateness of outcomes and measurements, inclusion criteria for participating nursing homes) and the development of a successful implementation strategy.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN43916381.

Inappropriate use of psychotropic drugs in older individuals: implications for practice

Frailty at old age and institutionalization in nursing homes are often associated with multiple chronic diseases (multimorbidity) requiring multiple medications (polypharmacy). Among these chronic conditions, mental health problems (e.g., dementia, depression and insomnia) are common. Psychotropic drugs are frequently used as a treatment approach for these conditions, and the prevalence of their use is high among community-dwelling older adults, but even higher in nursing homes. Furthermore, within the problem of polypharmacy and inappropriate prescribing, psychotropic drugs (defined in this article as antipsychotics, benzodiazepines and antidepressants) constitute a significant proportion. The use of psychotropics in older adults remains controversial given the risk of adverse effects, in contrast to the limited effectiveness. Guidelines advise a thorough risk–benefit analysis before the initiation of psychotropics, in addition to time-limited use and discontinuation. In the future, serious efforts should be undertaken to tackle the burden of inappropriate psychotropic prescribing in older adults by incorporating a multidisciplinary approach and by offering credible alternatives.

Sharing knowledge to advance healthcare policies in Europe for people living with dementia and their carers: the ALCOVE project

BACKGROUND

Alzheimer's disease and other related dementias are public health priorities in the European Union due to their prevalence, cost and profound impact on society. Because of these pressing implications, the European Union decided to create a Joint Action to share knowledge about dementia and health policy in order to preserve the health, quality of life, autonomy and dignity of people living with dementia and their carers in Europe.

METHODS

ALCOVE is a European Community-funded Joint Action coordinated by the HAS (French National Authority for Health) with a 24-month duration. The project's life cycle has been divided into the following four steps: (1) collection of existing information, (2) analysis of existing information and making comparisons across Member States, (3) identifying Evidence, Needs, and Priorities, (4) drafting recommendations and disseminating them.

RESULTS

19 countries are participating in the ALCOVE initiative. The project will publish its final findings in 2013. The project's objectives, participants, method, on-going procedures and work plans are already available on the ALCOVE website: http://www.alcove-project.eu/. Preliminary results show that recommendations will need to focus on clinical and epidemiological data collection, diagnostic system assessment, outstanding approaches for treating behavioural disorders, limiting antipsychotic use, and competence assessment in this vulnerable population.

CONCLUSIONS

The European Member States involved are mobilized to share best health policy practices in order to tackle the challenge of dementia's threat on European health and social systems and to improve the quality of life and care for individuals and their family carers.