Experiences of community-dwelling older people with dementia participating in a person-centred multidimensional interdisciplinary rehabilitation program

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Exploring the Lived Experiences of Physical Activity in Community-Dwelling Adults Living With Dementia and Their Carers

People living with dementia have the same right to well-being as anyone else, including physical activity. Yet, physical activity levels among people with dementia are lower than in the general population, and while the physical activity health benefits are well established, little is known about how people living with dementia experience physical activity. To explore these physical activity experiences, we visited six community settings in one English county and conducted informal interviews with 18 people who were either living with dementia and community dwelling (n = 4), caring for or who had cared for someone with dementia (n = 10), or providing a support service for people living with dementia and their carers (n = 4). Findings highlight both the challenges and facilitators presented by organized groups, service provider skills and qualities, and environmental factors. Additionally, these factors were influential in shaping the physical activity experience of people living with dementia. The findings may be relevant for people providing or planning support services, commissioners, policymakers, and researchers.

Rehabilitation delivery models to foster healthy ageing-a scoping review

Introduction

Rehabilitation is essential to foster healthy ageing. Older adults have unique rehabilitation needs due to a higher prevalence of non-communicable diseases, higher susceptibility to infectious diseases, injuries, and mental health conditions. However, there is limited understanding of how rehabilitation is delivered to older adults. To address this gap, we conducted a scoping review to describe rehabilitation delivery models used to optimise older adults' functioning/functional ability and foster healthy ageing.

Methods

We searched Medline and Embase (January 2015 to May 2022) for primary studies published in English describing approaches to provide rehabilitation to older adults. Three authors screened records for eligibility and extracted data independently and in duplicate. Data synthesis included descriptive quantitative analysis of study and rehabilitation provision characteristics, and qualitative analysis to identify rehabilitation delivery models.

Results

Out of 6,933 identified records, 585 articles were assessed for eligibility, and 283 studies with 69,257 participants were included. We identified six rehabilitation delivery models: outpatient (24%), telerehabilitation (22%), home (18.5%), community (16.3%), inpatient (14.6%), and eldercare (4.7%). These models often involved multidisciplinary teams (31.5%) and follow integrated care principles (30.4%). Most studies used a disease-centred approach (59.0%), while studies addressing multimorbidity (6.0%) and prevalent health problems of older adults, such as pain, low hearing, and vision, or incontinence were scarce. The most frequently provided interventions were therapeutic exercises (54.1%), self-management education (40.1%), and assessment of person-centred goals (40%). Other interventions, such as assistive technology (8.1%) and environmental adaptations (7.4%) were infrequent.

Conclusions

Focusing on primary studies, this scoping review provides an overview of rehabilitation delivery models that are used to foster healthy ageing and highlights research gaps that require further attention, including a lack of systematic assessment of functioning/functional ability, a predominance of disease-centred rehabilitation, and a scarcity of programmes addressing prevalent issues like pain, hearing/vision loss, fall prevention, incontinence, and sexual dysfunctions. Our research can facilitate evidence-based decision-making and inspire further research and innovation in rehabilitation and healthy ageing. Limitations of our study include reliance on published research to infer practice and not assessing model effectiveness. Future research in the field is needed to expand and validate our findings.

A focus groups study of staff team experiences of providing interdisciplinary rehabilitation for people with dementia and their caregivers-a co-creative journey

BACKGROUND

The World Health Organization claims that rehabilitation is important to meet the needs of persons with dementia. Rehabilitation programmes, however, are not routinely available. Person-centred, multidimensional, and interdisciplinary rehabilitation can increase the opportunities for older adults with dementia and their informal primary caregivers to continue to live an active life and participate in society. To our knowledge, staff team experiences of such rehabilitation programmes, involving older adults with dementia and their informal caregivers has not been previously explored.

METHODS

The aim of this qualitative focus group study was to explore the experiences of a comprehensive staff team providing person-centred multidimensional, interdisciplinary rehabilitation to community-dwelling older adults with dementia, including education and support for informal primary caregivers. The 13 staff team members comprised 10 professions who, during a 16-week intervention period, provided individualised interventions while involving the rehabilitation participants. After the rehabilitation period the staff team members were divided in two focus groups who met on three occasions each (in total six focus groups) and discussed their experiences. The Grounded Theory method was used for data collection and analysis.

RESULTS

The analysis resulted in four categories: Achieving involvement in rehabilitation is challenging, Considering various realities by acting as a link, Offering time and continuity create added value, and Creating a holistic view through knowledge exchange, and the core category: Refining a co-creative process towards making a difference. The core category resembles the collaboration that the staff had within their teams, which included participants with dementia and caregivers, and with the goal that the intervention should make a difference for the participants. This was conducted with flexibility in a collaborative and creative process.

CONCLUSIONS

The staff team perceived that by working in comprehensive teams they could provide individualised rehabilitation in creative collaboration with the participants through interaction, knowledge exchange, time and continuity, coordination and flexibility, and a holistic view. Challenges to overcome were the involvement of the person with dementia in goal setting and the mediating role of the staff team members. The staff pointed out that by refinement they could achieve well-functioning, competence-enhancing and timesaving teamwork.

Cognitive rehabilitation for people with mild to moderate dementia

BACKGROUND

Cognitive impairments affect functional ability in people with dementia. Cognitive rehabilitation (CR) is a personalised, solution-focused approach that aims to enable people with mild-to-moderate dementia to manage everyday activities and maintain as much independence as possible.

OBJECTIVES

To evaluate the effects of CR on everyday functioning and other outcomes for people with mild-to-moderate dementia, and on outcomes for care partners. To identify and explore factors that may be associated with the efficacy of CR.

SEARCH METHODS

We searched the Cochrane Dementia and Cognitive Improvement Group Specialised Register, which contains records from MEDLINE, EMBASE, CINAHL, PsycINFO, LILACS, and other clinical trial databases, and grey literature sources. The most recent search was completed on 19 October 2022.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) comparing CR with control conditions and reporting relevant outcomes for the person with dementia and/or the care partner.

DATA COLLECTION AND ANALYSIS

We extracted relevant data from published manuscripts and contacted trial authors if necessary. Within each of the comparisons, we pooled data for each outcome of interest and conducted inverse-variance, random-effects meta-analyses. We evaluated the certainty of the evidence using GRADEpro GDT.

MAIN RESULTS

We identified six eligible RCTs published in English between 2010 and 2022, which together included 1702 participants. The mean age of participants ranged from 76 to 80 and the proportion of male participants was between 29.4% and 79.3%. Most participants, in the studies where the type of dementia was reported, had a diagnosis of Alzheimer's disease (AD; n = 1002, 58.9% of the whole sample, 81.2% of the participants for whom the specific diagnosis was reported). Risk of bias in the individual studies was relatively low. The exception was a high risk of bias in relation to blinding of participants and practitioners, which is not usually feasible with psychosocial interventions.  Our primary outcome of everyday functioning was operationalised in the included studies as goal attainment in relation to activities targeted in the intervention. For our main comparison of CR with usual care, we pooled data for goal attainment evaluated from three perspectives (self-rating of performance, informant rating of performance, and self-rating of satisfaction with performance) at end of treatment and at medium-term follow-up (3 to 12 months). We could also pool data at these time points for 20 and 19 secondary outcomes respectively. The review findings were strongly driven by one large, high-quality RCT.  We found high-certainty evidence of large positive effects of CR on all three primary outcome perspectives at the end of treatment: participant self-ratings of goal attainment (standardised mean difference (SMD) 1.46, 95% confidence interval (CI) 1.26 to 1.66; I2 = 0%; 3 RCTs, 501 participants), informant ratings of goal attainment (SMD 1.61, 95% CI 1.01 to 2.21; I2 = 41%; 3 RCTs, 476 participants), and self-ratings of satisfaction with goal attainment (SMD 1.31, 95% CI 1.09 to 1.54; I2 = 5%; 3 RCTs, 501 participants), relative to an inactive control condition. At medium-term follow-up, we found high-certainty evidence showing a large positive effect of CR on all three primary outcome perspectives: participant self-ratings of goal attainment (SMD 1.46, 95% CI 1.25 to 1.68; I2 = 0%; 2 RCTs, 432 participants), informant ratings of goal attainment (SMD 1.25, 95% CI 0.78 to 1.72; I2 = 29%; 3 RCTs, 446 participants), and self-ratings of satisfaction with goal attainment (SMD 1.19, 95% CI 0.73 to 1.66; I2 = 28%; 2 RCTs, 432 participants), relative to an inactive control condition. For participants at the end of treatment we found high-certainty evidence showing a small positive effect of CR on self-efficacy (2 RCTs, 456 participants) and immediate recall (2 RCTs, 459 participants). For participants at medium-term follow-up we found moderate-certainty evidence showing a small positive effect of CR on auditory selective attention (2 RCTs, 386 participants), and a small negative effect on general functional ability (3 RCTs, 673 participants), and we found low-certainty evidence showing a small positive effect on sustained attention (2 RCTs, 413 participants), and a small negative effect on memory (2 RCTs, 51 participants) and anxiety (3 RCTs, 455 participants).  We found moderate- and low-certainty evidence indicating that at the end of treatment CR had negligible effects on participant anxiety, quality of life, sustained attention, memory, delayed recall, and general functional ability, and at medium-term follow-up on participant self-efficacy, depression, quality of life, immediate recall, and verbal fluency. For care partners at the end of treatment we found low-certainty evidence showing a small positive effect on environmental aspects of quality of life (3 RCTs, 465 care partners), and small negative effects of CR on level of depression (2 RCTs, 32 care partners) and on psychological wellbeing (2 RCTs, 388 care partners).  For care partners at medium-term follow-up we found high-certainty evidence showing a small positive effect of CR on social aspects of quality of life (3 RCTs, 436 care partners) and moderate-certainty evidence showing a small positive effect on psychological aspects of quality of life (3 RCTs, 437 care partners). We found moderate- and low-certainty evidence at the end of treatment that CR had negligible effects on care partners' physical health, psychological and social aspects of quality of life, and stress, and at medium-term follow-up for the physical health aspect of care partners' quality of life and psychological wellbeing.

AUTHORS' CONCLUSIONS

CR is helpful in enabling people with mild or moderate dementia to improve their ability to manage the everyday activities targeted in the intervention. Confidence in these findings could be strengthened if more high-quality studies contributed to the observed effects. The available evidence suggests that CR can form a valuable part of a clinical toolkit to assist people with dementia in overcoming some of the everyday barriers imposed by cognitive and functional difficulties. Future research, including process evaluation studies, could help identify avenues to maximise CR effects and achieve wider impacts on functional ability and wellbeing.

Rehabilitation interventions for persons with hip fracture and cognitive impairment: A scoping review

Background

Hip fractures are common fall-related injuries, with rehabilitation and recovery often complicated by cognitive impairment. Understanding what interventions exist, and in what settings, for people with hip fracture and co-occurring cognitive impairment is important in order to provide more evidence on rehabilitation and related outcomes for this population.

Objective

To examine the extent, nature, and range of literature on rehabilitation interventions for adults with hip fracture and cognitive impairment.

Methods

Articles were required to: include an adult population with hip fracture and cognitive impairment, include a rehabilitation intervention, and be published between January 1, 2000 and November 19, 2021. Articles were excluded if they were opinion pieces, study protocols, conference abstracts, or if they did not describe the rehabilitation intervention. Relevant articles were searched on the following electronic databases: MEDLINE, EMBASE, CINAHL Plus, APA PsycINFO, Cochrane Library, Web of Science, and the Physiotherapy Evidence Database. All articles were double-screened by two reviewers and disagreements were resolved through consensus. Data were extracted and synthesized using descriptive approaches.

Results

Seventeen articles were included in this scoping review. We identified a variety of interventions targeting this population; about half were specific to physical rehabilitation, with the other half incorporating components that addressed multiple aspects of the care journey. Interventions had varying outcomes and no studies qualitatively explored patient or family experiences. All intervations were initiated in hospital, with less than half including cross-sectoral components. About half of the articles described modifying or tailoring the intervention to the participants’ needs, but there was limited information on how to adapt rehabilitation interventions for individuals with cognitive impairment.

Conclusions

More work is need to better understand patient, family, and provider experiences with rehabilitation interventions, how to tailor interventions for those with cognitive impairment, and how to successfully implement sustainable interventions across sectors.

A framework for rehabilitation for older adults living with dementia

Introduction & Background

The aging of the population assures increased prevalence of Individuals Living with Dementia (ILwD) and there will be an increased representation of this cohort requiring physical rehabilitation. If physical therapists (PTs) manage these patients as they do their age-matched, cognitively-intact peers, they will likely be unsuccessful. ILwD have unique needs related to interpersonal and pragmatic components of rehabilitation. Therapeutic nihilism (doubting the benefit of therapy) is well-documented in PTs, either because of existing biases about dementia or previous challenges in working with ILwD. Physical rehabilitation eligibility and placement decisions are often made by PTs without special training in dementia, based upon brief exposure to patients in environments not well-designed for their best functioning. This can lead to underestimation of rehabilitation potential and denial of future PT services. PTs who work with ILwD desire more practical knowledge and targeted skills. Those with more education and training have a more positive attitude and outlook related to ILwD.

Purpose

The purpose of this paper is to introduce a framework for rehabilitation with ILwD equipped with pragmatic ideas to facilitate therapeutic success. The four primary components of the model are: (1) Establish a personal RELATIONSHIP, (2) Use intentional verbal and nonverbal COMMUNICATION, (3) Understand and optimize MOTOR LEARNING capabilities, and (4) Create a safe, purposeful ENVIRONMENT. Specific strategies to help PTs optimize each component are provided with supporting evidence. The model is intended to be dynamic, encouraging PTs to capitalize on the most accessible strategies within their control for a given patient and setting.

Implications

This framework provides a practical resource for working with ILwD with immediate implications for facilitating therapeutic success. The model is displayed in a schematic that reminds the reader of ideas at a glance within the context of each of the components. If an appreciation for this content was among core competencies required among PTs working with ILwD, perhaps there would be significantly fewer patients written off as “uncooperative” or “unable to participate” in PT.

To see, meet and adapt - an interview study about physiotherapists' pedagogical approach to dementia

Background

Physiotherapists need to use pedagogical approaches and strategies in their work. However, there is no previous definition of what a pedagogical approach in physiotherapy means neither in general nor specifically to dementia. The purpose of this study was therefore to gain greater insight into physiotherapists’ pedagogical approach to dementia by investigating physiotherapists’ views and working methods in contact with older people with dementia, relatives, and nursing staff in elderly care.

Methods

This was a qualitative study with an inductive approach. Semi-structured individual interviews were conducted with 15 physiotherapists with experience of working with older people with dementia in elderly care. The interviews were analyzed with qualitative content analysis.

Results

The term “pedagogical approach” could sometimes be experienced as “vague” or “hard to grasp”. Our research nonetheless identified one overarching theme To see, meet and adapt which is based on insights from the interviews grouped in to five categories. This theme can be seen as an expression of the physiotherapists’ pedagogical approach in contact with older people with dementia, relatives, and nursing staff. It captures the participants’ desire to always see the person in front of them, meet them where they are and adapt their own way of working accordingly. Creating a trusting relationship was described as important and made it easier for the participants to adapt their working methods. The participants’ adaptations could apply to the way they communicated with people with dementia, and how they organized tutoring/education of relatives and nursing staff to maximize learning. Learning through experience and reflection was described as a key to advancing the pedagogical approach and the participants experienced their own learning as constantly ongoing.

Conclusions

This study provides increased understanding into physiotherapists’ pedagogical approach in contact with older people with dementia, relatives, and nursing staff in elderly care and shows that learning through experience and reflection can contribute to the development of the pedagogical approach. Thus, opportunity for reflection should be accommodated in the physiotherapists’ work. The importance of more pedagogical education for physiotherapists both in bachelor and master level were also highlighted. Increasing mobility and physical activity in older people with dementia is important since physical inactivity and sedentary behavior is common. Future research may be directed at further exploring physiotherapists’ pedagogical approach in tutoring/education of nursing staff, with the aim of increasing physical activity among older people with dementia.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12877-021-02697-7.