A pragmatic randomised controlled trial (RCT) and realist evaluation of the interdisciplinary home-bAsed Reablement program (I-HARP) for improving functional independence of community dwelling older people with dementia: an effectiveness-implementation hybrid design

Delivery of Neuropsychological Interventions for Adult and Older Adult Clinical Populations: An Australian Expert Working Group Clinical Guidance Paper

Delivery of neuropsychological interventions addressing the cognitive, psychological, and behavioural consequences of brain conditions is increasingly recognised as an important, if not essential, skill set for clinical neuropsychologists. It has the potential to add substantial value and impact to our role across clinical settings. However, there are numerous approaches to neuropsychological intervention, requiring different sets of skills, and with varying levels of supporting evidence across different diagnostic groups. This clinical guidance paper provides an overview of considerations and recommendations to help guide selection, delivery, and implementation of neuropsychological interventions for adults and older adults. We aimed to provide a useful source of information and guidance for clinicians, health service managers, policy-makers, educators, and researchers regarding the value and impact of such interventions. Considerations and recommendations were developed by an expert working group of neuropsychologists in Australia, based on relevant evidence and consensus opinion in consultation with members of a national clinical neuropsychology body. While the considerations and recommendations sit within the Australian context, many have international relevance. We include (i) principles important for neuropsychological intervention delivery (e.g. being based on biopsychosocial case formulation and person-centred goals); (ii) a description of clinical competencies important for effective intervention delivery; (iii) a summary of relevant evidence in three key cohorts: acquired brain injury, psychiatric disorders, and older adults, focusing on interventions with sound evidence for improving activity and participation outcomes; (iv) an overview of considerations for sustainable implementation of neuropsychological interventions as 'core business'; and finally, (v) a call to action.

A Systematic Review of Quality Dementia Clinical Guidelines for the Development of WHO's Package of Interventions for Rehabilitation

BACKGROUND AND OBJECTIVES

As part of the WHO Rehabilitation 2030 call for action, the WHO Rehabilitation Programme is developing its Package of Interventions for Rehabilitation (PIR) to support ministries of health around the globe in integrating rehabilitation services into health systems. As a vital step for this PIR development, we conducted a systematic review of clinical practice guidelines (CPGs) for dementia to identify interventions for rehabilitation and related evidence.

RESEARCH DESIGN AND METHODS

Following WHO Rehabilitation Programme and Cochrane Rehabilitation's methodology, quality CPGs published in English between January 2010 and March 2020 were identified using PubMed, Embase, CINAHL, PEDro, Google Scholar, guideline databases, and professional society websites. Guideline quality was assessed using the Appraisal of Guidelines for Research and Evaluation (II).

RESULTS

Of the 22 CPGs that met the selection criteria, 6 satisfied the quality evaluation. Three hundred and thirty rehabilitation-related recommendations were identified, mostly concentrated in the areas of cognition, emotion, and carer support. There were many strong interventions, with moderate- to high-quality evidence that could be easily introduced in routine practice. However, major limitations were found both in the quality of evidence and scope, especially in areas such as education and vocation, community and social life, and lifestyle modifications.

DISCUSSION AND IMPLICATIONS

Further rigorous research is needed to build quality evidence in dementia rehabilitation in general, and especially in neglected areas for rehabilitation. Future work should also focus on the development of CPGs for dementia rehabilitation. A multipronged approach is needed to achieve Universal Health Coverage for dementia rehabilitation.

Pilot Randomized, Double-Blind, Placebo-Controlled Crossover Trial Evaluating the Feasibility of an Intranasal Oxytocin in Improving Social Cognition in Individuals Living with Alzheimer's Disease

Background

Individuals living with Alzheimer's disease (AD) demonstrate extensive deficits in social cognition. To date, no studies have investigated the feasibility of an intranasal oxytocin (INOT) treatment to improve social cognition in individuals living with AD.

Objective

We conducted a pilot trial to determine recruitment feasibility, enrolment acceptability, and adherence to an INOT treatment to inform on the subsequent design of a future randomized controlled trial (RCT). We also estimated the effect sizes of potential social cognitive function outcome measures related to participants and their caregivers.

Methods

Four individuals with AD were enrolled in a single-center, randomized, double-blind, placebo-controlled crossover trial involving a one-week treatment period with both INOT (72 IU twice daily) and placebo.

Results

All participants reported no treatment-causative or serious adverse events following repeated INOT administration. While enrolment acceptability (100%) and INOT adherence (placebo, 95%; INOT, 98%) were excellent, feasibility of recruitment was not acceptable (i.e., n = 4/58 individuals screened met inclusion criteria). However, positive/large effects were associated with secondary outcomes of self-reported health and wellbeing, caregiver 'burden', intimacy and interpersonal-bonding, following repeated INOT administration. No positive effects were associated with participant outcomes of social cognition.

Conclusion

This pilot RCT provides first evidence that INOT administration in individuals living with AD is safe and well-tolerated. Despite limitations in sample size, moderate-to-large effect size improvements were identified in participant health outcomes as well as core social cognitive functions and 'burden' as reported by a caregiver. This suggests potential broad-ranging beneficial effects of INOT which should be assessed in future RCTs.

Publication Trends in Reablement - A Scoping Review

Background

Reablement is a holistic and multidisciplinary intervention that can facilitate achievement of service users' goals related to their independence in everyday activities. Reablement has been the subject of increasing scientific activity in recent years. Currently, no review has provided a broad overview of the extent and breadth of international publications in reablement.

Objective

The objectives were 1) to map the volume of reablement publications, how the publications had increased over time, and their geographical distribution, 2) to identify the publication types and designs, 3) to identify publication trends, and 4) to identify knowledge gaps in the current peer-reviewed literature.

Methods

The scoping review approach designed by Arksey and O'Malley was used to identify peer-reviewed articles on reablement. Information was obtained on scientific activity on reablement over a period of more than two decades from five electronic databases and without language restrictions. Data was extracted from the eligible articles and both descriptive analysis and thematic analysis of the data was performed.

Results

A total of 198 articles published from 1999 to August 2022 from 14 countries were identified. There is a continuous interest in the field from countries where reablement has been implemented. An international and historical overview among countries with peer-reviewed publications on reablement is presented, which also partly reflects the countries that have implemented reablement. Most of the research derives from Western countries, in particular from Norway. Varied approaches to publications in reablement were noted with the majority being empirical and quantitative in nature.

Conclusion

The scoping review confirms the continued expansion of the breadth of reablement-focused publications in terms of originating countries, target populations, and research designs. In addition, the scoping review contributes to the knowledge base regarding reablement's research front.

Bridging the gap: Study protocol for development of an implementation strategy for evidence-informed reablement and rehabilitation for community-dwelling people with dementia

BACKGROUND

Extensive research supports the use of goal-directed reablement and rehabilitation interventions to address a range of physical, functional, cognitive and behavioural needs of people living with dementia. Despite this, evidence-informed multidisciplinary reablement and rehabilitation interventions are not being offered in usual dementia care across Australia. An examination is needed of how best to implement reablement and rehabilitation interventions within the community-based dementia care sector.

METHODS

Drawing on implementation science, this study uses a four-phase mixed-methods retrospective and prospective approach: (1) clinical audit to evaluate current clinical practice, and through focus groups with practitioners, identify practitioner-led goals and targets for practice change; (2) Delphi survey to converge opinions from the diverse stakeholders involved in reablement in dementia, to reach national consensus around an implementation strategy; (3) hybrid pragmatic effectiveness-implementation pilot will facilitate testing of the implementation strategy in parallel with exploring effectiveness of the reablement intervention specifically within a real-world Australian community aged care context; (4) implementation capacity building.

DISCUSSION

This study will result in a freely available, nationally relevant implementation protocol, designed and tailored via input from key stakeholders over a series of iterative project activities. By testing this protocol via a pilot implementation-effectiveness study, we will generate national information about effectiveness of evidence-informed reablement programs for people living with dementia across various community aged care settings. Outcomes have potential to influence policy and drive widespread practice change, increasing access to evidence-informed reablement and rehabilitation for people living with dementia across Australia.

Factors Impacting User Engagement in Reablement: A Qualitative Study of User, Family Member and Practitioners' Views

Background

The challenges of population aging have fostered the adoption of reablement as a core pillar of older people's care in many developed economies. Aligning with wider literature on the association between "patient" engagement and outcomes, emerging evidence points to the impact user engagement may have on reablement outcomes. To date, existing research on the factors implicated in engagement with reablement is rather limited.

Objective

To identify and describe factors which impact user engagement in reablement from the perspectives of reablement staff, staff in interfacing services, service users and family members.

Sample and Methods

A total of 78 staff were recruited from five sites across England and Wales. Twelve service users and five family members were recruited from three of these sites. Data were collected via focus groups with staff and interviews with service users and families, and subject to thematic analysis.

Results

The data revealed a complex picture of factors potentially impacting user engagement, ranging from user-, family-, and staff-centered factors, the nature of the relationship between staff and users, and aspects of service organization and delivery across referral and intervention pathways. Many are amenable to intervention. As well as offering a more fine-grained understanding of factors reported by previous research, new factors impacting engagement were identified. These included staff morale, equipment provision systems, assessment and reviewing processes, and attention to social reablement needs. Aspects of the wider service context (eg, degree of integration of health and social care) played a role in determining which factors were pertinent.

Conclusion

Findings highlight the complexity of factors influencing engagement with reablement, and the need to ensure features of the wider service context (eg delivery models, referral pathways) do not work against securing and sustaining older people's engagement with reablement.

Impact of relational continuity of primary care in aged care: a systematic review

Background

Greater continuity of care has been associated with lower hospital admissions and patient mortality. This systematic review aims to examine the impact of relational continuity between primary care professionals and older people receiving aged care services, in residential or home care settings, on health care resource use and person-centred outcomes.

Methods

Systematic review of five databases, four trial registries and three grey literature sources to October 2020. Included studies (a) aimed to increase relational continuity with a primary care professional, (b) focused on older people receiving aged care services (c) included a comparator and (d) reported outcomes of health care resource use, quality of life, activities of daily living, mortality, falls or satisfaction. Cochrane Collaboration or Joanna Briggs Institute criteria were used to assess risk of bias and GRADE criteria to rate confidence in evidence and conclusions.

Results

Heterogeneity in study cohorts, settings and outcome measurement in the five included studies (one randomised) precluded meta-analysis. None examined relational continuity exclusively with non-physician providers. Higher relational continuity with a primary care physician probably reduces hospital admissions (moderate certainty evidence; high versus low continuity hazard ratio (HR) 0.94; 95% confidence interval (CI) 0.92–0.96, n = 178,686; incidence rate ratio (IRR) 0.99, 95%CI 0.76–1.27, n = 246) and emergency department (ED) presentations (moderate certainty evidence; high versus low continuity HR 0.90, 95%CI 0.89–0.92, n = 178,686; IRR 0.91, 95%CI 0.72–1.15, n = 246) for older community-dwelling aged care recipients. The benefit of providing on-site primary care for relational continuity in residential settings is uncertain (low certainty evidence, 2 studies, n = 2,468 plus 15 care homes); whilst there are probably lower hospitalisations and may be fewer ED presentations, there may also be an increase in reported mortality and falls. The benefit of general practitioners’ visits during hospital admission is uncertain (very low certainty evidence, 1 study, n = 335).

Conclusion

Greater relational continuity with a primary care physician probably reduces hospitalisations and ED presentations for community-dwelling aged care recipients, thus policy initiatives that increase continuity may have cost offsets. Further studies of approaches to increase relational continuity of primary care within aged care, particularly in residential settings, are needed.

Review registration

CRD42021215698.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12877-022-03131-2.

Evaluation of a wellness and reablement approach in Australia: Learnings from a pilot project

Australian health and aged care reforms mandate a wellness and reablement (W&R) approach with services and the workforce needing to adjust their way of working with older people, to actively promote independence and participation in life's activities. Studies exploring the older person's perspective are sparse. This study aims to understand the older person's experience of a W&R approach, supplemented with experiences of staff trained in the approach. The study evaluates a W&R approach implemented across three community-based sites of a large Australian aged care provider. Staff from participating sites underwent training and were asked to use a W&R approach with at least one older person. Eighteen older people aged 65+ were engaged in the 4-month programme. Semi-structured interviews with older people and staff were conducted on completion of the programme. The W&R approach showed variable benefits and experiences of older people related to goal setting and outcomes. Overall, older people were unfamiliar with goal setting or displayed negative attitudes. Negative emotional responses to health decline and ageing, such as apathy, frustration, embarrassment and sense of helplessness, were identified as barriers to goal pursual. In contrast, enabling factors, such as assistive equipment, staff and social connection, triggered positive emotional responses, which acted as protective factors and enhanced goal pursual. Staff knowledge and understanding of the W&R approach also influenced older people's experience and outcomes. These findings recommend a stronger focus on the social and emotional aspects of W&R and co-developing goals in line with the older person's sense of wellbeing. This approach supports the multiple dimensions of W&R and aligns with principles of positive and healthy ageing. Additional training for staff should be provided, with ongoing mentoring and support from W&R champions. Ensuring that goals are meaningful and valuable to individual older people will enhance successful goal pursual and improve outcomes.

How do participatory methods shape policy? Applying a realist approach to the formulation of a new tuberculosis policy in Georgia

OBJECTIVES

This paper presents the iterative process of participatory multistakeholder engagement that informed the development of a new national tuberculosis (TB) policy in Georgia, and the lessons learnt.

METHODS

Guided by realist evaluation methods, a multistakeholder dialogue was organised to elicit stakeholders' assumptions on challenges and possible solutions for better TB control. Two participatory workshops were conducted with key actors, interspersed by reflection meetings within the research team and discussions with policymakers. Using concept mapping and causal mapping techniques, and drawing causal loop diagrams, we visualised how actors understood TB service provision challenges and the potential means by which a results-based financing (RBF) policy could address these.

SETTING

The study was conducted in Tbilisi, Georgia.

PARTICIPANTS

A total of 64 key actors from the Ministry of Labour, Health and Social Affairs, staff of the Global Fund to Fight AIDS, TB and Malaria Georgia Project, the National Centre for Disease Control and Public Health, the National TB programme, TB service providers and members of the research team were involved in the workshops.

RESULTS

Findings showed that beyond provider incentives, additional policy components were necessary. These included broadening the incentive package to include institutional and organisational incentives, retraining service providers, clear redistribution of roles to support an integrated care model, and refinement of monitoring tools. Health system elements, such as effective referral systems and health information systems were highlighted as necessary for service improvement.

CONCLUSIONS

Developing policies that address complex issues requires methods that facilitate linkages between multiple stakeholders and between theory and practice. Such participatory approaches can be informed by realist evaluation principles and visually facilitated by causal loop diagrams. This approach allowed us leverage stakeholders' knowledge and expertise on TB service delivery and RBF to codesign a new policy.

Feasibility and potential effects of interdisciplinary home-based reablement program (I-HARP) for people with cognitive and functional decline: a pilot trial

Objectives: To test feasibility and potential effects of the interdisciplinary Home-bAsed Reablement Program (I-HARP) that integrates evidence-based strategies and cognitive rehabilitation techniques into a dementia-specific, bio-behavioural-environmental intervention.Methods: A parallel-group randomised controlled pilot trial was conducted in Sydney, Australia, targeting community-dwelling people with amnestic mild cognitive impairment or mild/moderate stages of dementia and their carer (n = 18 dyads). I-HARP comprised: up to 12 home visits by registered nurse, occupational therapist, and psychologist, tailored to the individual client's needs; <A$1000 for home modification/assistive devices; and individual carer support, all provided over four months. Additional allied health services were recommended when necessary. Clients' daily activities, mobility, mood, caregiver burden, and quality of life were assessed at baseline, four months and 12 months. Semi-structured interviews were conducted with I-HARP participants post intervention.Results: Of 51 dyads who expressed interest in participation, 25 were eligible, with 76% consent rate (19/25 eligible dyads consented), and high adherence to the program (all nine intervention group participants completed and complied). Challenges included: need for better carer and allied health support, with more targeted recruitment points to speed up the process. The I-HARP group showed favourable effects across most outcomes at short-term (4 months) and longer-term (12 months) assessments. However, wide Confidence Intervals (CIs) point to the degree of uncertainty around interpretation of these results.Conclusion: The delivery of I-HARP, a dementia-specific reablement program and the trial design concerning randomisation, screening and consent procedures, were deemed feasible, acceptable and appropriate for the target population group. Building on the success and lessons from the pilot, a larger trial is currently underway.

Development of an internationally accepted definition of reablement: a Delphi study

With an ageing society, the demand for health and social care is increasing. Traditionally, staff provide care for their clients rather than with them. In contrast, reablement aims to support people to maximise their competences to manage their everyday life as independently as possible. There is considerable variation between and within countries regarding the conceptual understanding of the approach. This variation affects the ability to evaluate reablement approaches systematically, compare and aggregate findings from different studies, and hinders the development of a robust evidence. Therefore, a Delphi study was conducted in 2018/9 with the aim of reaching agreement on the characteristics, components, aims and target groups of reablement, leading towards an internationally accepted definition of reablement. The study consisted of four Web-based survey rounds. In total, 82 reablement experts from 11 countries participated, reaching agreement on five characteristics (e.g. person-centred), seven components (e.g. goal-oriented treatment plan) and five aims (e.g. increase clients’ independency). Furthermore, most experts agreed that reablement is an inclusive approach irrespective of the person's age, capacity, diagnosis or setting. Based on these features, a definition of reablement was developed, which was accepted by 79 per cent of participating experts. This study is a significant step towards providing conceptual clarity about reablement. Future research should focus on evaluating the implementation of agreed reablement components to inform practice, education and policy.

What works, for whom and under what circumstances? Using realist methodology to evaluate complex interventions in nursing: A scoping review

BACKGROUND

The Medical Research Council's (MRC) framework recommends basing every evaluation of a complex intervention on a theory that explains WHY an intervention works instead of focusing exclusively on the identification IF an intervention works. Theory-based evaluation approaches such as realist evaluations are promising in this respect. The aim of this scoping review is to examine current scientific literature with regard to the use of realist methodology in studies that evaluate complex nursing interventions. We also seek to answer the question whether realist evaluation studies of complex nursing interventions are embedded in the Medical Research Council's framework.

METHODS

A systematic database search in MEDLINE and CINAHL supplemented with snowballing techniques and a hand search in relevant nursing journals were performed between January and February 2018 and updated in July 2019. Both authors independently screened the title / abstract of studies that were initially identified and appraised the full texts if inclusion criteria were fulfilled. Inclusion criteria were the explicit use of realist methodology and a focus on the development or evaluation of complex nursing interventions. Results were summarized narratively.

RESULTS

A total of 28 articles from 22 studies, published between 2010 and 2019, were included. The majority of the studies included originate in the UK. Realist methodology was used by a variety of nursing disciplines, including midwifery, community / public health, critical care, palliative care, gerontological nursing, psychiatric nursing / mental health, and infection control. Study designs included case studies and realist reviews; two studies were conducted alongside a randomized controlled trial. All studies included used more than one method to develop their results; the majority of methods were qualitative by nature. Thirteen of the studies included aimed to develop a theory about what works, for whom and under what circumstances regarding the investigated complex nursing intervention. One study was clearly embedded in the Medical Research Council's framework.

CONCLUSION

Realist evaluation broadens the methodologies that have traditionally been used in nursing. Conceptual clarity on its principal tenets is still needed, as well as the methods used to assess them. Nursing scientists should be more critical when using novel methodology and contribute to academic debates about limitations. Embedding realist evaluations into the Medical Research Council's framework is in its infancy in nursing and needs more contributions in order to develop a common academic position within the profession. Tweetable abstract Realist methodology in nursing - review of the use, methods, limitations and embedding into the Medical Research Council's framework.