Cross-sectional study of prevalence of dementia, behavioural symptoms, mobility, pain and other health parameters in nursing homes in Austria and the Czech Republic: results from the DEMDATA project

Underdiagnosis of dementia in residents of residential aged care services: A scoping review

OBJECTIVE

Dementia is a leading cause of disability, dependence and death worldwide. Timely diagnosis and management of dementia are essential in the community and residential aged care services (RACS) or nursing homes. Underdiagnosis of dementia in RACS may negatively impact the quality of care, resulting in adverse health outcomes. Hence the objective is to review estimates of the prevalence of dementia underdiagnosis, potential associated factors, consequences and evidence of interventions targeting to reduce this underdiagnosis.

METHODS

Guided by Arksey and O'Malley's scoping review framework, this scoping review was conducted as per the PRISMA extension for Scoping Reviews (PRISMA-ScR). Databases were searched to 31 January 2024 for studies published in English since 2010 in Ovid®, including Scopus, MEDLINE, Embase, Emcare and PubMed Central, as well as CINHAL Ultimate, PsycINFO and ProQuest. After removing duplicates, 545 studies proceeded to title, abstract and full-text screening, resulting in four eligible studies. Two additional studies were identified through reference searching.

RESULTS

A total of six studies were included. Most studies were conducted in the last 5 years. The prevalence of dementia underdiagnosis in RACS was 14%-70%. Different scales were applied to identify dementia. Findings from two studies suggested dementia underdiagnosis is more common among those with less severe disease. No studies investigated health outcomes or explored interventions to reduce dementia underdiagnosis.

CONCLUSIONS

Estimates of underdiagnosis in RACS are high and variable. More research is required to clarify factors associated with dementia underdiagnosis in RACS, its consequences and potential interventions to reduce its risk.

What Do We Know About the Validity and Reliability of Mindfulness Self-Report Measures in Persons with Dementia? A Critical Narrative Review

OBJECTIVES

Mindfulness-based interventions (MBIs) for persons with dementia (PwD) have yielded mixed results, possibly attributable to the fact that little is known about the validity and reliability of trait mindfulness self-report measures in PwD. This narrative review sought to identify studies involving self-reported trait mindfulness and other clinical measures that may hold information on the convergent validity and reliability of these measures in PwD.

METHODS

Scientific databases were searched for studies involving PwD and mindfulness assessments.

RESULTS

N = 426 studies from PubMed and N = 156 from PsychInfo databases were reviewed. Four cross-sectional studies were identified that allowed inferences about the validity of mindfulness measures. A qualitative review indicated that convergent validity with other measures varied with sample heterogeneity and cognitive impairment. Merely one MBI included self-reported trait mindfulness, however without reporting sample-specific validity or reliability.

CONCLUSIONS

Despite efforts to implement MBIs in PwD, information on basic methodological psychometric issues is minimal. Future studies ought to address the validity and reliability of self-reported mindfulness in detail across different stages of dementia.

CLINICAL IMPLICATIONS

Results of MBIs need to be considered cautiously. Basic information about psychometric properties of mindfulness self-report measures is required and these measures need to be included systematically in MBIs.

Are quality of care instruments inclusive of older people living with dementia? A scoping review in long-term care settings

More than half of older people in long-term care facilities have dementia. Little is currently known about the methods and instruments which can be used to capture the perspectives of older people, including those with dementia, regarding the quality of care provided in such facilities. The main aims of this scoping review were two-fold. Firstly, to identify quality of care instruments that have been applied in long-term care settings. Secondly, to evaluate how these instruments have been developed and validated, particularly in terms of their applicability among older people with dementia. Seven databases (Medline, Web of Science, Scopus, ProQuest, Ageline, CINHAL and google scholar) were searched for relevant literature without any date limit. We used quality criteria adapted from COSMIN (Consensus-based Standards for the selection of health status Measurement Instruments) guidelines to assess the psychometric properties of the instruments. The search identified 16 quality of care instruments which had been used in long-term care settings. Of which, two (12.5%) were specifically designed for older people with dementia, and three instruments (18.7%) were modified for use with older people with mild to moderate dementia. A variety of methods were used to develop the identified instruments including literature reviews, qualitative interviews, expert panel reviews, pre-testing and piloting with older people. None of the identified instruments had been subjected to comprehensive psychometric assessment. Most instruments for assessing quality of care in long term care settings lack alternative communication techniques tailored to people with dementia. This review highlights the need for more rigorous psychometric testing of existing instruments for assessing quality of care in long-term care settings. Several existing measures show promise and may be taken forward for further testing and development for widespread application with older people, including those living with dementia, in long term care settings.

Addressing healthcare vulnerabilities in nursing homes : Insights from human rights monitoring in two Austrian provinces

BACKGROUND

Current demographic changes bear challenges for national care systems due to higher life expectancy of older citizens. Largely cut off from society, nursing home residents are at risk for violence, neglect, and other potential human rights violations. This study aimed to investigate healthcare vulnerabilities in nursing homes and evaluate the Austrian National Preventive Mechanism (NPM).

METHODS

Between 2017 and 2019, 55 monitoring visits were conducted in 32 nursing homes. Study outcomes from two Austrian provinces included data on infrastructure, occupancy, staffing, resident's demographics and medical conditions, as well as measures related to the functioning of the NPM.

RESULTS

Accessibility with mobility aids was sufficient in 87%, but assistance for persons with visual or hearing impairments solely in 20-40% of the institutions. An understaffing with nursing assistants (-5.2 full-time equivalents in Carinthia) and home helpers (-1.6 in Carinthia and Styria) was present. Less than 20% of the personnel received advanced training related to dementia and neuropsychiatric care. While 50% of the residents were diagnosed with a psychiatric disorder, approximately 36% received support from an appointed legal guardian. Of the monitoring visits 58.1% were conducted due to anonymous complaints and urgent referrals. The median processing times of the NPM and the provincial governments exceeded 250 days.

CONCLUSION

Human rights monitoring reveals critical aspects in nursing home care, including insufficient accessibility, understaffing and inadequate training. Although the authorities' handling times hinder prompt responses, the NPM may foster systemic improvements and accountability within nursing homes.

The prognostic value of the NECPAL instrument, Palliative Prognostic Index, and PROFUND index in elderly residents of nursing homes with advanced chronic condition

BACKGROUND

It is essential to assess the need for palliative care and the life prognosis of elderly nursing home residents with an advanced chronic condition, and the NECPAL ICO-CCOMS©4.0 prognostic instrument may be adequate for both purposes. The objective of this study was to examine the predictive capacity of NECPAL, the Palliative Prognosis Index, and the PROFUND index in elderly residents with advanced chronic condition with and without dementia, comparing their results at different time points.

METHODS

This prospective observational study was undertaken in eight nursing homes, following the survival of 146 residents with advanced chronic condition (46.6% with dementia) at 3, 6, 12, and 24 months. The capacity of the three instruments to predict mortality was evaluated by calculating the area under the receiver operating characteristic curve (AUC), with 95% confidence interval, for the global population and separately for residents with and without dementia.

RESULTS

The mean age of residents was 84.63 years (± 8.989 yrs); 67.8% were female. The highest predictive capacity was found for PROFUND at 3 months (95%CI: 0.526-0.756; p = 0.016), for PROFUND and NECPAL at 12 months (non-significant; AUC > 0.5), and NECPAL at 24 months (close-to-significant (AUC = 0.624; 95% CI: 0.499-0.750; p = 0.053). The highest capacity at 12 months was obtained using PROFUND in residents with dementia (AUC = 0.698; 95%CI: 0.566-0.829; p = 0.003) and NECPAL in residents without dementia (non-significant; AUC = 0.649; 95%CI: 0.432-0.867; p = 0.178). Significant differences in AUC values were observed between PROFUND at 12 (p = 0.017) and 24 (p = 0.028) months.

CONCLUSIONS

PROFUND offers the most accurate prediction of survival in elderly care home residents with advanced chronic condition overall and in those with dementia, especially over the short term, whereas NECPAL ICO-CCOMS©4.0 appears to be the most useful to predict the long-term survival of residents without dementia. These results support early evaluation of the need for palliative care in elderly care home residents with advanced chronic condition.

Opioid deprescribing in long-term care in Ontario: A comparison of resident and facility characteristics

Residents of long-term care (LTC) homes have potentially painful conditions and are prescribed opioids to manage their pain, despite the risks associated with the use of these high-risk medications. Therefore, the overall aim of this study was to describe the associations between resident and facility characteristics of residents prescribed long-term opioid therapy and those who remained on opioids or had opioids deprescribed. We conducted a retrospective cohort study utilizing health administrative databases housed within ICES. Our cohort included 26,592 of 121,564 LTC residents (21.9%) of Ontario LTC homes who were prescribed long-term opioid therapy at cohort inception. Of these residents, 4,299 (16.2%) residents had opioids deprescribed during the follow-up period. Opioid deprescribing was associated with younger age, high comorbidity, and co-prescription with benzodiazepines and gabapentinoids. Our findings suggest that there is variation in the characteristics of residents who continued long-term opioid therapy and those who subsequently had opioids deprescribed, and these characteristics need to be considered as part of individualized pain management plans of care.

A Tablet-Based App to Support Nursing Home Staff in Delivering an Individualized Cognitive and Physical Exercise Program for Individuals With Dementia: Mixed Methods Usability Study

BACKGROUND

The promotion of physical activity in individuals with dementia living in nursing homes is crucial for preserving physical and cognitive functions and the associated quality of life. Nevertheless, the implementation of physical activity programs in this setting is challenging, as the time and expertise of nursing home staff are limited. This situation was further exacerbated by the COVID-19 pandemic. Mobile health apps may be a sustainable approach to overcome these challenges in the long term. Therefore, the Individualized Cognitive and Physical Exercise-App (the InCoPE-App) was developed to support nursing home staff in delivering and implementing tailored cognitive and physical exercise training for individuals with dementia.

OBJECTIVE

This study aims to assess the usability of the InCoPE-App in terms of user performance and user perception in a laboratory setting using a mixed methods approach.

METHODS

Nursing home staff were encouraged to perform 5 basic tasks within the InCoPE-App. Their thoughts while using the app were captured by implementing a think aloud protocol. Then, participants completed the System Usability Scale questionnaire. The think aloud transcripts were qualitatively evaluated to unveil usability issues. All identified issues were rated in terms of their necessity to be fixed. Task completion (ie, success rate and time) and perceived usability were evaluated descriptively.

RESULTS

A total of 14 nursing home employees (mean age 53.7, SD 10.6 years; n=13, 93% women) participated in the study. The perceived usability of the InCoPE-App, as assessed by the System Usability Scale questionnaire, can be rated as "good." The main usability issues concerned navigation logic and comprehensibility of app content.

CONCLUSIONS

The InCoPE-App is a user-friendly app that enables nursing home staff to deliver and implement cognitive and physical exercise training for individuals with dementia in nursing homes. The InCoPE-App can be used with little training, even by people aged ≥50 years, who may have low digital literacy. To achieve sustainable use and high user satisfaction of the InCoPE-App in the long term, it should be implemented and evaluated in a field study.

Is there a casual relation between air pollution and dementia?

Dementia has been cited as a critical public health risk in the contemporary world, while few empirical researchers try to reveal the casual relationship between air pollutant concentrations (APCs) and dementia, especially given the increasing prevalence of air pollution on a global scale. Accordingly, this paper tries to infer the causal relationship between APCs and dementia. The 59,605 valid data was compiled through a combination of the statistic from the China Family Panel Study, China Environmental Statistics Yearbook, World Meteorological Association and China National Bureau of Statistics. The RD design of this study utilizes the discontinuous variation in APCs and dementia as one crosses the Huai River boundary, which is an arbitrary heating policy that causes the significant difference in APCs between the north and south of China. We used stata17.0 to analyze the data. The results of the RD regression indicated that a 100 μ g/m3 rise in APCs led to an increase of 42.4% in the hazard ratio of suffering dementia (Coeff=-0.58, SD= 0.23, P < 0.05). Meanwhile, heterogeneous models revealed that the hazard ratio of suffering dementia by APCs was more significant in the older compared to younger (coeff= 1.35 vs coeff= 1.55, P < 0.05), male compared to female (coeff= 1.62 vs coeff= 0.71, P < 0.05), smoking compared to non-smoke (coeff= 2.12 vs coeff= 0.93, P < 0.05), and thin groups compared to medium and obesity (coeff= 2.05 vs coeff= 1.22, coeff= 1.28, P < 0.05). In addition, the O3 and SO2 were the air pollutants with the highest (coeff= 1.54, P < 0.05) and lowest effects (coeff= 0.81, P < 0.05) on the hazard ratio of suffering dementia among the five APCs, respectively. And the robustness of the results was ensured by changing the RD bandwidth, polynomial order. The results indicated that APCs significantly induced the hazard ratio of suffering dementia of Chinese residents, which provides empirical evidence in supporting the Chinese government to invest more in combating air pollution and ensure the public health of Chinese residents.

Non-pharmacological, psychosocial MAKS-s intervention for people with severe dementia in nursing homes: results of a cluster-randomised trial

BACKGROUND

Severe dementia is one of the most challenging conditions when caring for people in nursing homes. A manualised non-pharmacological, psychosocial group intervention especially adapted to the needs of people with severe dementia (PWSDs) is currently still lacking. To close this gap, we adapted the evidence-based multicomponent non-pharmacological MAKS intervention (Motor stimulation, ADL stimulation, Cognitive [german: Kognitive] stimulation, and Social functioning in a group setting) to the special needs of PWSDs called the MAKS-s intervention, where the s stands for severe dementia.

METHODS

In a prospective, multicentre, cluster-randomised trial with a waitlist control group design, 26 nursing homes comprising 152 PWSDs were randomly assigned to either the MAKS-s intervention group (IG) or control group (CG) - 121 PWSDs were still alive after the 6-month intervention period (t6) and included in the intention-to-treat (ITT) sample. The two primary outcomes, behavioural and psychological symptoms (BPSDs, measured with NPI-NH) and quality of life (QoL, measured with QUALIDEM), and the secondary outcome, activities of daily living (ADLs, measured with ADCS-ADL-sev), were assessed at baseline (t0) and at t6. Mixed ANOVAs were computed to investigate possible effects of the MAKS-s intervention on the outcomes.

RESULTS

In the ITT sample, BPSDs and QoL did not change significantly over time, and group assignment did not affect them, although the IG participants had significantly better overall QoL than the CG participants. ADLs decreased significantly over time, but group assignment did not affect them. Analyses in the per protocol (PP) sample showed comparable results, with the exception that the IG participants showed a significantly greater increase in BPSDs than the CG participants did.

DISCUSSION

Under the situational conditions of the Covid-19 pandemic, no beneficial effects of the MAKS-s intervention on BPSDs, QoL, or ADLs were observed. This finding also means that under 'normal circumstances' (i.e., if there had been no pandemic), we could not make any statements about the effect or non-effect of MAKS-s. In order to be able to address the hypotheses formulated here, the study will have to be repeated incorporating helpful experiences of the present study.

TRIAL REGISTRATION

https://doi.org/10.1186/ISRCTN15722923 (Registered prospectively, 07. August 2019).

Prevalence and Factors Associated with Pain in Nursing Home Residents: A Systematic Review of the Literature

OBJECTIVES

To describe the pain prevalence in nursing home (NH) residents and the factors associated with the experience of pain.

DESIGN

Systematic review of descriptive studies.

SETTING AND PARTICIPANTS

Three electronic databases were searched from 2010 to September 2020 in English. Descriptive studies that examined pain in NH residents, reported pain prevalence, and/or associated factors were included. Studies that focused exclusively on a specific disease or type of care such as cancer or hospice were excluded.

METHODS

Two reviewers independently screened, selected, extracted data, and assessed risk of bias from included studies; narrative synthesis was performed. The review was guided by the Biopsychosocial Model of Chronic Pain for Older Adults.

RESULTS

Twenty-six studies met our inclusion criteria. Overall, the prevalence of current pain ranged from 22.2% to 85.0%, the prevalence of persistent pain ranged from 19.5% to 58.5%, and the prevalence of chronic pain ranged from 55.9% to 58.1%. A variety of pain scales were used reporting higher pain prevalence for those using self-report measures (31.8% to 78.8%) or proxy measures (29.5% to 85.0%) compared with using chart review (22.2% to 29.3%) as the source of pain information. The studies reviewed provide support that certain diseases and clinical conditions are associated with pain. Impairment in activities of daily living (ADL) (12 studies), cognition (9 studies), depression (9 studies), and arthritis (9 studies) are the most widely studied factors, whereas depression, ADL impairment, arthritis, dementia, and cognitive impairment present the strongest association with pain.

CONCLUSION AND IMPLICATIONS

This review highlights the complexities of pain in NH residents and has implications for both clinical practice and future research. Understanding the factors that underlie the experience of pain, such as depression, is useful for clinicians evaluating pain and tailoring management therapies. In addition, the gaps in knowledge uncovered in this review are important areas for future research.

Ethical considerations within pragmatic randomized controlled trials in dementia: Results from a literature survey

Introduction

This review aims to describe the landscape of pragmatic randomized controlled trials (RCTs) in the context of Alzheimer's disease (AD) and related dementias with respect to ethical considerations.

Methods

Searches of MEDLINE were performed from January 2014 until April 2019. Extracted information included: trial setting, interventions, data collection, study population, and ethical protections (including ethics approvals, capacity assessment, and informed consent).

Results

We identified 62 eligible reports. More than two-thirds (69%) included caregivers or health-care professionals as research participants. Fifty-eight (94%) explicitly identified at least one vulnerable group. Two studies did not report ethics approval. Of 57 studies in which patients were participants, 55 (96%) reported that consent was obtained but in 37 studies (67%) no mention was made regarding assessment of the patients' capacity to consent to research participation.

Discussion

Few studies reported protections implemented when vulnerable participants were included. Shortcomings remain when reporting consent approaches and capacity assessment.

Effects of a person-centred and thriving-promoting intervention on nursing home residents' experiences of thriving and person-centredness of the environment

AIM

To evaluate the effects of a person-centred and thriving-promoting intervention on nursing home residents´ experiences of thriving and person-centredness of the environment, and to evaluate if the effects varied between female and male residents.

DESIGN

A multi-centre, non-equivalent controlled group before-after intervention design.

METHODS

Six nursing homes in Australia, Norway and Sweden were allocated to either intervention or control group. The intervention comprised a staff educational programme. A survey using proxy-ratings by staff was administered before (T0), immediately after (T1) and six months after (T2) the intervention. The sample varied between 205 and 292 residents. Linear regression models were used to explore effects.

RESULTS

Statistically significant effects were found on experiences of thriving and person-centredness of the environment. These effects were significant for male residents but not for female residents. The results emphasize the importance of individually tailored social and recreational activities.

Use, usability, and impact of a card-based conversation tool to support communication about end-of-life preferences in residential elder care – a qualitative study of staff experiences

Background

Proactive conversations about individual preferences between residents, relatives, and staff can support person-centred, value-concordant end-of-life (EOL) care. Nevertheless, prevalence of such conversations is still low in residential care homes (RCHs), often relating to staff’s perceived lack of skills and confidence. Using tools may help staff to facilitate EOL conversations. While many EOL-specific tools are script-based and focus on identifying and documenting treatment priorities, the DöBra card tool is developed to stimulate reflection and conversation about EOL care values and preferences. In this study, we explore staff’s experiences of use, usability, and perceived impact of the DöBra cards in supporting discussion about EOL care in RCH settings.

Methods

This qualitative study was based on data from two participatory action research processes in which RCH staff tested and evaluated use of DöBra cards in EOL conversations. Data comprise 6 interviews and 8 group meetings with a total of 13 participants from 7 facilities. Qualitative content analysis was performed to identify key concepts in relation to use, usability, and impact of the DöBra cards in RCH practice.

Results

Based on participants’ experiences of using the DöBra cards as an EOL conversation tool in RCHs, we identified three main categories in relation to its usefulness. Outcomes of using the cards (1) included the outlining of content of conversations and supporting connection and development of rapport. Perceived impact (2) related to enabling openings for future communication and aligning care goals between stakeholders. Use and usability of the cards (3) were influenced by supporting and limiting factors on the personal and contextual level.

Conclusions

This study demonstrates how the DöBra cards was found to be useful by staff for facilitating conversations about EOL values, influencing both the content of discussion and interactions between those present. The tool encouraged reflection and interaction, which staff perceived as potentially helpful in building preparedness for future care-decision making. The combination of providing a shared framework and being adaptable in use appeared to be key features for the DöBra cards usability in the RCH setting.

A Nationwide Survey of Dementia Prevalence in Long-Term Care Facilities in Taiwan

BACKGROUND

As the average life expectancy of global citizens has increased, the prevalence of dementia has increased rapidly. The number of patients with dementia has increased by 6.7 times, reaching 300,000 in the past three decades in Taiwan. To realize the latest actual situation, the need for institutional care for elderly patients with dementia, and also a reference basis for government agencies to formulate dementia-related care policies, we investigated the institutional prevalence of dementia.

METHODS

We randomly sampled 299 out of the 1607 registered long-term care facilities including senior citizens' institutions, nursing homes, and veteran homes in every administrative region of Taiwan. Then, a two-phase survey including MMSE screening, CDR, and clinical confirmation was conducted on each subject from 2019 to 2020.

RESULTS

Among 5753 enrolled subjects, 4765 from 266 facilities completed the examinations with a response rate of 82.8%. A total of 4150 subjects were diagnosed with dementia, 7.4% of whom had very mild dementia. The prevalence of all-cause dementia, including very mild dementia, was 87.1% in all facilities, 87.4% in senior citizens' institutions, 87.1% in nursing homes, and 83.3% in veteran homes. Advanced age, low education, hypertension, Parkinsonism, respiratory disease, stroke, and intractable epilepsy were associated with dementia risk.

CONCLUSIONS

We show that in an aged society, the prevalence of all-cause dementia in long-term care institutions can be as high as 87.1%. This study was completed before the outbreak of COVID-19 and provides a precious hallmark for future epidemiological research. We recommend that the long-term care policy in an aged society needs to take into account the increasing high prevalence of dementia in the institution.

Feasibility and Effectiveness of a Biography-Based Physical Activity Intervention in Institutionalized People With Dementia: Quantitative and Qualitative Results From a Randomized Controlled Trial

The objective of this multicenter randomized controlled trial was to evaluate the feasibility and effectiveness of a physical activity intervention for institutionalized people with dementia, individualized by capacity and biography. The intervention group (n = 34; age: mean = 86.09 years; 79.40% female; mean Mini-Mental State Examination value = 18.59) participated in a multicomponent training program, which included daily activities, dancing, gardening, and sports/games, twice weekly for 3 months. The control group (n = 29; age: mean = 86.34 years; 75.90% female; mean Mini-Mental State Examination value = 19.90) received standard care. Feasibility was evaluated by means of focus groups and feedback questionnaires. Functional performance (Short Physical Performance Battery and Timed Up and Go Test), activities of daily living, and gait were outcomes for effectiveness. A high adherence rate (80.46%) and uniformly positive feedback indicate that the piloted training program is feasible. The results show preliminary effectiveness on functional performance (Short Physical Performance Battery mean t0 = 3.15; mean t1 = 4.50; p = .006) and gait (e.g., velocity mean t0 = 46.97; mean t1 = 58.04; p = .007).

Prevalence of dementia in long-term care institutions: a meta-analysis

ABSTRACT Objective: This study comprises a systematic review and meta-analysis that aimed to estimate the prevalence of dementia in long-term care institutions (LTCIs). Methods: We used the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA). Original transversal and longitudinal articles published until July 2020 were eligible in this review. Databases PubMed/MedLine, Web of Science, Scopus and ScienceDirect were searched. Overall prevalence and confidence intervals were estimated. Heterogeneity was calculated according to the index of heterogeneity (I2). Results: One hundred seventy-five studies were found in all databases and 19 studies were meta-analyses, resulting in an overall prevalence of 53% (CI 46-59%; p < 0.01) of demented older adults living in LTCIs. Conclusion: Prevalence of dementia is higher in older adults living in LTCIs than those living in general communities. This data shows a worrying reality that needs to be changed. There is a need for a better understanding of the elements that cause this increase in dementia in LTCFs to direct actions to improve the quality of life and health of institutionalized elderly.

Use of Patient-Reported Symptoms from an Online Symptom Tracking Tool for Dementia Severity Staging: Development and Validation of a Machine Learning Approach

BACKGROUND

SymptomGuide Dementia (DGI Clinical Inc) is a publicly available online symptom tracking tool to support caregivers of persons living with dementia. The value of such data are enhanced when the specific dementia stage is identified.

OBJECTIVE

We aimed to develop a supervised machine learning algorithm to classify dementia stages based on tracked symptoms.

METHODS

We employed clinical data from 717 people from 3 sources: (1) a memory clinic; (2) long-term care; and (3) an open-label trial of donepezil in vascular and mixed dementia (VASPECT). Symptoms were captured with SymptomGuide Dementia. A clinician classified participants into 4 groups using either the Functional Assessment Staging Test or the Global Deterioration Scale as mild cognitive impairment, mild dementia, moderate dementia, or severe dementia. Individualized symptom profiles from the pooled data were used to train machine learning models to predict dementia severity. Models trained with 6 different machine learning algorithms were compared using nested cross-validation to identify the best performing model. Model performance was assessed using measures of balanced accuracy, precision, recall, Cohen κ, area under the receiver operating characteristic curve (AUROC), and area under the precision-recall curve (AUPRC). The best performing algorithm was used to train a model optimized for balanced accuracy.

RESULTS

The study population was mostly female (424/717, 59.1%), older adults (mean 77.3 years, SD 10.6, range 40-100) with mild to moderate dementia (332/717, 46.3%). Age, duration of symptoms, 37 unique dementia symptoms, and 10 symptom-derived variables were used to distinguish dementia stages. A model trained with a support vector machine learning algorithm using a one-versus-rest approach showed the best performance. The correct dementia stage was identified with 83% balanced accuracy (Cohen κ=0.81, AUPRC 0.91, AUROC 0.96). The best performance was seen when classifying severe dementia (AUROC 0.99).

CONCLUSIONS

A supervised machine learning algorithm exhibited excellent performance in identifying dementia stages based on dementia symptoms reported in an online environment. This novel dementia staging algorithm can be used to describe dementia stage based on user-reported symptoms. This type of symptom recording offers real-world data that reflect important symptoms in people with dementia.

The MAKS-s study: multicomponent non-pharmacological intervention for people with severe dementia in inpatient care - study protocol of a randomised controlled trial

BACKGROUND

Nursing homes accommodate a large number of people with severe dementia. More than 80% of residents with dementia suffer from behavioural and psychological symptoms, that can have consequences on the perceived burden of the formal caregivers. Internationally, the number of studies on non-pharmacological interventions for people with severe dementia is very small. One way to reduce these symptoms is to meet the needs of people with severe dementia. The non-pharmacological group intervention MAKS-s, which we will investigate in this study, is intended to reduce the behavioural and psychological symptoms and to improve the quality of life of such people. Additionally, we will investigate the effects on the burden carried by formal caregivers.

METHODS

With the present study, we will investigate the effectiveness of a multicomponent non-pharmacological intervention for people with severe dementia living in nursing homes (primary target group). A power analysis indicated that 144 dementia participants should initially be included. In addition, a secondary target group (nursing home staff) will be examined with respect to their dementia-related stress experiences. The study will be conducted as a cluster randomised controlled trail in Germany with a 6-month intervention phase. The nursing homes in the waitlist control group will provide "care as usual." The primary endpoints of the study will be the behavioural and psychological symptoms of dementia and the quality of life of people with severe dementia. The total duration of the study will be 18 months. Data will be collected by using observer rating scales.

DISCUSSION

The project has some outstanding quality features. The external validity is high, because it is situated in a naturalistic setting in nursing homes and is being carried out with available nursing employees. Due to this fact, a permanent implementation also seems to be possible. Since the participating nursing homes are disseminated across several German federal states and rural and urban regions, the results should be transferable to the entire population.

TRIAL REGISTRATION

ISRCTN15722923 (Registration date: 07 August 2019).

The Prevalence of Cognitive Impairment on Admission to Nursing Home among Residents with and without Stroke: A Cross-Sectional Survey of Nursing Homes in Ireland

Post-stroke cognitive impairment (PSCI) is a common consequence of stroke. Epidemiological evidence indicates that, with an ageing population, stroke and PSCI are likely to increase in the coming decades. This may have considerable implications for the demand for nursing home placement. As prevalence estimates of both cognitive impairment and dementia on admission to nursing home among residents with and without stroke have not yet been compared, they were estimated and compared in this study. We performed a cross-sectional survey to establish the admission characteristics of 643 residents in 13 randomly selected nursing homes in Ireland. The survey collected data on resident's stroke and cognitive status at the time of nursing home admission. The survey found, among nursing home residents that experienced stroke prior to admission, prevalence estimates for cognitive impairment (83.8%; 95% CI = 76.9-90.6%) and dementia (66.7%; 95% CI = 57.9-75.4%) were significantly higher compared to residents that had not experienced stroke prior to admission (cognitive impairment: 56.6%; 95% CI = 52.4-60.8%; X2 (1) = 28.64; p < 0.001; dementia: 49.8%; 95% CI = 45.6-54.1%; X2 (1) = 10.47; p < 0.01). Since the prevalence of PSCI is likely to increase in the coming decades, the findings highlight an urgent need for health service planning for this increased demand for nursing home care to meet the care needs of these stroke survivors.

How Do German General Practitioners Assess Medical Specialist Care Needs of Nursing Home Residents? Results of a Postal Survey in North-Western Germany

The frequency of contacts of nursing home residents with medical specialists is lower compared to the general population of the same age group in Germany. The aim of this study was to assess general practitioners’ (GPs) views on specialist care needs of nursing home residents, on questions of qualification and care coordination. A cross-sectional study was conducted with a postal questionnaire among a representative sample of 1121 GPs in north-western Germany in 2018. The perceptions of GPs about the relative importance of the type of specialist care that is required in nursing homes was assessed on a five-point Likert scale (0 = very low to 4 = very high). A total of 375 GPs (response 33.5%; mean age 54.4 years; 57.6% male) participated in the survey. GPs assessed care needs as highest for neurologists and psychiatrists (68.7%) and lowest for gynecologists (6.5%). Almost all respondents (96.2%) strongly agreed that medical care for nursing home residents should be coordinated by GPs and that GPs should initiate the referral for further specialist care when required (87.5%). A minority (25.7%) agreed that quality of medical care would improve when care for a nursing home was provided by only one GP practice. GPs perceive the needs of nursing home residents for specialist care as high only in relation to care by neurologists and psychiatrists. GPs consider their own coordination function for medical care in nursing homes as very important.

Dysbiosis, gut barrier dysfunction and inflammation in dementia: a pilot study

BACKGROUND

Dementia is an increasing public health threat worldwide. The pathogenesis of dementia has not been fully elucidated yet. Inflammatory processes are hypothesized to play an important role as a driver for cognitive decline but the origin of inflammation is not clear. We hypothesize that disturbances in gut microbiome composition, gut barrier dysfunction, bacterial translocation and resulting inflammation are associated with cognitive dysfunction in dementia.

METHODS

To test this hypothesis, a cohort of 23 patients with dementia and 18 age and sex matched controls without cognitive impairments were studied. Gut microbiome composition, gut barrier dysfunction, bacterial translocation and inflammation were assessed from stool and serum samples. Malnutrition was assessed by Mini Nutritional Assessment Short Form (MNA-SF), detailed information on drug use was collected. Microbiome composition was assessed by 16S rRNA sequencing, QIIME 2 and Calypso 7.14 tools.

RESULTS

Dementia was associated with dysbiosis characterized by differences in beta diversity and changes in taxonomic composition. Gut permeability was increased as evidenced by increased serum diamine oxidase (DAO) levels and systemic inflammation was confirmed by increased soluble cluster of differentiation 14 levels (sCD14). BMI and statin use had the strongest impact on microbiome composition.

CONCLUSION

Dementia is associated with changes in gut microbiome composition and increased biomarkers of gut permeability and inflammation. Lachnospiraceae NK4A136 group as potential butyrate producer was reduced in dementia. Malnutrition and drug intake were factors, that impact on microbiome composition. Increasing butyrate producing bacteria and targeting malnutrition may be promising therapeutic targets in dementia.

TRIAL REGISTRATION

NCT03167983 .

The relationship between care dependency and pain in nursing home residents

CONTEXT

Pain is a common health problem experienced by up to 57 % of nursing home residents which has many negative side effects, including a reduced quality of life. Several studies have been carried out on the prevalence of pain and pain management. However, these study findings remain controversial.

OBJECTIVES

Therefore, the aim of this study was to compare care dependent and care independent nursing home residents with regard to their (1) pain prevalence and levels and (2) their pain management.

METHODS

This cross-sectional study is conducted annually in Austrian nursing homes. We measured pain prevalence and levels by asking questions about the pain experienced and pain level measured in the seven days prior to the interview, as well as the pain experienced at the time of this interview.

RESULTS

The study sample comprised 81.1 % of the 1528 residents of Austrian nursing homes. Overall, pain prevalence was higher in care dependent residents than in care independent residents. Care dependent residents experienced more often mild/moderate pain than care independent residents. Both, prevalence and levels of pain were not statistically significant different between the levels of care dependency. Care dependent residents who suffered from pain received a statistically significantly higher number of non-pharmacological interventions as compared to care independent residents who suffered from pain.

CONCLUSIONS

We identified a higher prevalence of pain among care dependent residents. Furthermore, the found differences in pain relief seem to be correlated with different degrees of care dependency, an aspect that requires further investigation.

Assessing the Prevalence of Undetected Possible Dementia in Faroese Nursing Homes

INTRODUCTION

To assess the prevalence of possible dementia among nursing home residents in the Faroe Islands.

METHOD

This cross-sectional study, undertaken in 2017, included all nursing homes in the Faroe Islands (n = 30), housing 591 residents. All residents were invited to participate, except those with an existing clinical diagnosis of dementia or living in dementia units (n = 207). A total of 232 residents participated, while 39 declined and 113 were unable to give consent, had died, or were not permanent residents at the time of examination. Cognitive screening was carried out using the Mini-Mental State Examination (MMSE) and the Informant Questionnaire on Cognitive Decline (IQCODE).

RESULTS

Possible dementia was found in 49% to 78% of the participants depending on the method used. According to both MMSE and IQCODE (AND rule), possible dementia was present in 105 participants (49%). According only to IQCODE, 119 participants (55%) scored above the cut-off (≥3.6), according to MMSE alone, 162 participants (72%) scored below the cut-off (≤24 on MMSE), while 175 participants (78%) screened positive according to either MMSE or IQCODE (OR rule). A rough estimate of the prevalence of possible dementia in the entire nursing home population (n = 591) including residents with known dementia and those with possible dementia from this study was between 61% and 73%.

CONCLUSION

A high percentage (49-78%) of the participating nursing home residents without a pre-dementia diagnosis were assessed to have possible dementia based on screening with standardized tools, indicating a high degree of dementia underdiagnoses in Faroese nursing homes. This high prevalence of dementia is of significance for the clinical practice, running, and planning of nursing homes and pinpoints a need to act upon this, not only in the Faroes but also worldwide.

Nursing Education Intervention Effects on Pain Intensity of Nursing Home Residents with Different Levels of Cognitive Impairment: A Cluster-Randomized Controlled Trial

PURPOSE

Pain management in nursing homes is challenging and pain prevalence remains high. The objective of this study was to improve the pain situation of nursing home residents following a nursing-related educational intervention within a cluster-randomized controlled trial (2016-2018).

PARTICIPANTS

Clusters were nursing homes from one nursing home operator in Bavaria, Germany. Nursing home residents who were permanently registered in the facilities, at least 60 years of age, and who themselves or their legal guardians provided informed consent were included.

INTERVENTION

In addition to the implementation of pain nurses and pain care assistants, staff of the intervention group received an educational intervention in pain management, containing classroom (quality circles) and web-based training for nurses.

METHODS

Based on the Mini-Mental State Examination (MMSE), residents were either interviewed (MMSE 10-30) using self-report instruments or observed (MMSE 0-9) by proxy assessment. The primary outcome in residents able to self-report was maximum pain intensity according to Brief Pain Inventory (BPI); in those not able to self-report treatment-relevant pain above cut-off (≥2) on the Pain Assessment in Advanced Dementia (PAINAD).

RESULTS

Out of 20 randomly selected clusters, 9 nursing homes from the control, and 6 nursing homes from the intervention group participated. Multilevel linear (n=347 residents, MMSE 10-30) and logistic regression (n=222 residents, MMSE 0-9) analyses were conducted. Maximum pain intensity was higher after intervention (B=1.32, p<0.01), decreased with a better quality of life (B=-0.07, p<0.001), and was lower when dementia diagnoses were present (B=-1.12, p<0.01). PAINAD scores before and after intervention did not differ significantly (OR=0.89, p=0.724), but chances to exhibit treatment-related pain were higher with decreasing MMSE (OR=0.94, p<0.05).

CONCLUSION

While no significant positive intervention effect was measured, findings suggest nurses' raised awareness towards pain management. Overall results indicate that large-scale educational interventions seem to be less effective in complex nursing home settings without also including specific individual-based intervention measures.

Diagnostic Failure of Cognitive Impairment in Nursing Home Residents May Lead to Impaired Medical Care

BACKGROUND/OBJECTIVES

Dementia and cognitive impairment are common in nursing homes. Few studies have studied the impact of unnoted cognitive impairment on medical care. This study aimed to estimate the prevalence of diagnostic failure of cognitive impairment in a sample of Swedish nursing home residents and to analyze whether diagnostic failure was associated with impaired medical care.

METHOD

A total of 428 nursing home residents were investigated during 2008-2011. Subjects without dementia diagnosis were grouped by result of the Mini Mental State Examination (MMSE), where subjects with <24 points formed a possible dementia group and the remaining subjects a control group. A third group consisted of subjects with diagnosed dementia. These three groups were compared according to baseline data, laboratory findings, drug use, and mortality.

RESULTS

Dementia was previously diagnosed in 181 subjects (42%). Among subjects without a dementia diagnosis, 72% were cognitively impaired with possible dementia (MMSE <24). These subjects were significantly older, did not get anti-dementia treatment, and had higher levels of brain natriuretic peptide compared to the diagnosed dementia group, but the risks of malnutrition and pressure ulcers were similar to the dementia group.

CONCLUSIONS

Unnoted cognitive impairment is common in nursing home residents and may conceal other potentially treatable conditions such as heart failure. The results highlight a need to pay increased attention to cognitive impairment among nursing home residents.

Associations of dry skin, skin care habits, well-being, sleep quality and itch in nursing home residents: Results of a multicentre, observational, cross-sectional study

AIM

Dry skin is one of the most frequent cutaneous problems in aged long-term care residents. Although it is clinically relevant, the impact on quality of life is unclear. The objective was to measure well-being, sleep quality and itch in nursing home residents being 65 years and older and to explore possible associations with demographics, dry skin and skincare habits.

DESIGN

Multicentre, observational, cross-sectional.

METHODS

Sleep quality was assessed with the Richards-Campbell Sleep Quality Questionnaire, well-being with the WHO-Five Well-being Index and itch with the 5-D Itch scale. Skin dryness was measured using the Overall Dry Skin score.

RESULTS

A total of 51 residents were included. The item scores of the sleep quality and itch questionnaires were strongly associated with each other. Demographics, dry skin and skincare habits were not associated with the questionnaires. It is unclear whether basic skincare activities can improve the quality of life in this population.

Use of Central Nervous System (CNS) Medicines in Aged Care Homes: A Systematic Review and Meta-Analysis

BACKGROUND

Both old age and institutionalization in aged care homes come with a significant risk of developing several long-term mental and neurological disorders, but there has been no definitive meta-analysis of data from studies to determine the pooled estimate of central nervous system (CNS) medicines use in aged care homes. We conducted this systematic review to summarize the use of CNS drugs among aged care homes residents.

METHODS

MEDLINE, EMBASE, CINAHL, Scopus, and International Pharmaceutical Abstracts (IPA) databases were searched (between 1 January 2000 and 31 December 2018) to identify population-based studies that reported the use of CNS medicines in aged care homes. Pooled proportions (with 95% confidence interval), according to study location were calculated.

RESULTS

A total of 89 studies reported the use of CNS medicines use in aged care. The pooled estimate of CNS drugs use varied according to country (from 20.3% in Ireland to 49.0% in Belgium) and region (from 31.7% in North America to 42.5% in Scandinavia). The overall pooled estimate of psychotropic medicines use was highest in Europe (72.2%, 95% CI, 67.1-77.1%) and lowest in ANZ region (56.9%, 95% CI, 52.2-61.4%). The pooled estimate of benzodiazepines use varied widely from 18.9% in North America to 44.8% in Europe. The pooled estimate of antidepressants use from 47 studies was 38.3% (95% CI 35.1% to 41.6%) with highest proportion in North America (44.9%, 95% CI, 35.3-54.5%).

CONCLUSION

The overall use of CNS drugs varied among countries, with studies from Australia-New Zealand reported the lowest use of CNS drugs. The criteria for prescribing CNS drugs in clinical practice should be evidence-based. The criteria should be used not to prohibit the use of the listed medications but to support the clinical judgement as well as patient safety.

Data of a sub-analysis of the DEMDATA study: characteristics of Austrian and Czech nursing homes residents

Objectives

The aim of this data paper is to provide the data set of a sub-analysis of the DEMDATA study data. In the DEMDATA study, epidemiological data on the prevalence and severity of dementia, as well as functioning, behavioral problems and other health related factors in residents living in Austrian and Czech nursing homes were collected. The DEMDATA project further provides information on relatives’ perception of the life Quality of residents, care team burden as well as environmental factors. Participating nursing homes were randomly drawn and stratified. Inclusion criteria for participation were that the resident was living permanently in the institution and that he/she and/or a legal representative (where relevant) had signed an informed consent.

Data description

This paper provides data of cognitive, functional and behavioral assessments as well as other health related information of 1085 residents living in Austrian and Czech nursing homes. For each resident, several measurements on his or her cognitive, functional, and behavioral status are available. Also further health-related factors such as quality of life, pain, numbers of falls and hospital stays are provided.