A dyadic advance care planning intervention for people with early-stage dementia and their family caregivers in a community care setting: a feasibility trial

Implementation and effectiveness of advance care planning in hospitalized older adults with chronic heart failure: a mixed-methods systematic review and meta-analysis

Objectives

This study aims to integrate the data on the effects of a pre-established medical care program on hospitalized older adults with chronic heart failure (CHF).

Method

A comprehensive systematic review incorporating mixed research methodologies was undertaken. Quality assessment was conducted using the Critical Appraisal Tool developed by Joanna Briggs Institute, adhering to the PRISMA guidelines for studies. Where appropriate, data were synthesized and aggregated for meta-analysis or meta-aggregation.

Results

A total of 2,825 articles were found, of which 11 met the inclusion criteria. Meta-analysis showed that the implementation of advance care planning (ACP) can significantly increase the willingness and proportion of patients with CHF to choose and receive hospice services during their end-of-life phase. Meta-aggregation showed that the ACP intervention has a positive impact on participants, promotes their knowledge and understanding, and makes them share their decision-making with their families.

Conclusion

ACP is a promising and feasible intervention that can help older adults with CHF accurately understand ACP and express their wishes timely. This study provides insights and empirical evidence to improve ACP, and valuable guidance and reference for future clinical practice.

Systematic review registration

https://www.crd.york.ac.uk/PROSPERO/, PROSPERO, identifier: CRD42024580814.

Effects of a social network enhancement intervention for older adults: a feasibility study

BACKGROUND

Social networks play a critical role in the mental health of older adults. This pilot study investigates the feasibility of a newly developed intervention to enhance older adults' social networks. This intervention was designed on the Theory of Mind's foundation and aimed to enhance older adults' social interaction motivation through theoretical explanations. Furthermore, the courses fostered more social opportunities for the participants through group-based sessions.

METHODS

The feasibility of this intervention was tested using a double-blind, two-arm, non-randomized grouping approach. Older individuals residing in two separate residential buildings (n = 31, mean age = 66.81, 48% women) were divided into an intervention group (n = 15) and a control group (n = 16). They attended daily group sessions at a designated location and completed homework assignments. The primary outcomes of this pilot study were the feasibility of the intervention, and secondary outcomes included Theory of Mind levels and social network indicators. Additional outcomes encompassed levels of global mental health and depression.

RESULTS

All participants completed the pilot intervention and completed assessments. The primary outcomes indicated that the intervention had excellent feasibility, including compliance (attendance and homework completion rates met the standards) and satisfaction (average ratings for all items ranged from 4.47 to 5.00 on a 5-point scale). Interview results revealed that participants in the intervention group found the intervention beneficial for their daily lives and expressed a desire to participate in a formal intervention. Regarding secondary and additional outcomes, compared to the control group, the intervention group exhibited a significant improvement in emotional recognition performance of Theory of Mind. There was a significant increase in the whole network density in the intervention group. There were no significant differences in other social network indicators, global mental health, and depression levels in the intervention group compared to the control group.

CONCLUSIONS

The social network enhancement intervention for older adults is feasible. This pilot study has identified several improvements in the courses and tests. It is necessary to carry out a formal course to examine the effectiveness of the intervention on social networks in older adults.

TRIAL REGISTRATION

Registration number: ChiCTR2100053779; Reg Date: 29/11/2021.

Qualitative evaluation of the SHARING Choices trial of primary care advance care planning for adults with and without dementia

BACKGROUND

Primary care can be an important setting for communication and advance care planning (ACP), including for those with dementia and their families. The study objective was to explore experiences with a pragmatic trial of a communication and ACP intervention, SHARING Choices, in primary care for older adults with and without dementia.

METHODS

We conducted qualitative interviews using tailored semi-structured guides with three groups: ACP facilitators who conducted the intervention; clinicians, managers, and administrators from sites randomized to the intervention; and patients and families who met with ACP facilitators. We used thematic analysis to identify and synthesize emergent themes based on key Consolidated Framework for Implementation Research concepts and Proctor's Implementation Outcomes, triangulating the three groups' perspectives.

RESULTS

We identified five key themes. For acceptability, perceptions of the intervention were mostly positive, although some components were not generally implemented. For adoption, respondents perceived that ACP facilitators mainly focused on conducting ACP, although facilitators often did not implement the ADRD and family engagement aspects with the ACP. For relational connections, ACP facilitator-practice and clinician communication and engagement were key to how the intervention was implemented. For adaptability, ACP facilitators and health systems adapted how the ACP facilitation component was implemented to local preferences and over time, given the pragmatic nature of the trial. And, for sustainability, ACP facilitators and clinicians/managers/facilitators were positive that the intervention should be continued but noted barriers to its sustainability. Patients and families generally did not recall the intervention.

CONCLUSIONS

ACP facilitators and clinicians, managers, and administrators had positive perceptions of the ACP facilitator component of the intervention in this pragmatic trial with adaptation to local preferences. However, engaging those with dementia and families was more challenging in the implementation of this intervention.

Tools for tomorrow: a scoping review of patient-facing tools for advance care planning

Advance care planning (ACP) supports individuals in aligning their medical care with personal values and preferences in the face of serious illness. The variety of ACP tools available reflects diverse strategies intended to facilitate these critical conversations, yet evaluations of their effectiveness often show mixed results. Following the Arskey and O'Malley framework, this scoping review aims to synthesize the range of ACP tools targeted at patients and families, highlighting their characteristics and delivery methods to better understand their impact and development over time. Studies included focused on patient-facing ACP tools across all settings and mediums. Exclusions were applied to studies solely targeting healthcare providers or those only aiming at completion of advance directives without broader ACP discussions. Searches were conducted across PubMed, Embase, CINAHL, The Cochrane Library, and Web of Science. Data were extracted using a predesigned spreadsheet, capturing study population, setting, intervention modality, and intervention theme. Tools were categorized by delivery method and further analyzed through a year-wise distribution to track trends and developments. We identified 99 unique patient-facing tools, with those focusing on counseling (31) and video technologies (21) being the most prevalent while others incorporated online platforms, print materials, games, or some combination of different delivery methods. Over half the tools were designed for specific patient groups, especially for various diseases and racial or ethnic communities. Recent years showed a surge in tool variety and innovation, including integrated patient portals and psychological techniques. The review demonstrates a broad array of innovative ACP tools that facilitate personalized and effective ACP. Our findings contribute to an enhanced understanding of their utilization and potential impacts, offering valuable insights for future tool development and policy making in ACP.

Adaptation of a guided low-intensity behavioral activation intervention for people with dementia in Sweden: a qualitative study exploring the needs and preferences of key stakeholders

BACKGROUND

Despite depression being prevalent in people with dementia, contributing to negative health outcomes and placing increased burden on individuals and family members, access to psychological interventions is limited. A potential solution is guided low-intensity behavioral activation, supported by informal caregivers and guided by healthcare professionals. However, it is necessary to adapt interventions to meet the needs and preferences of key stakeholders to enhance acceptability and relevance. Study objectives were to: (1) explore needs and preferences concerning the content and delivery model of the guided low-intensity behavioral activation intervention; and (2) adapt the intervention to ensure cultural appropriateness, relevancy, and acceptability to people with dementia and their caregivers in Sweden.

METHODS

Semi-structured interviews and focus group discussions were conducted with key stakeholders, including healthcare professionals (n = 18), community stakeholders (n = 7), people with dementia (n = 8), and informal caregivers (n = 19). A draft of the written low-intensity behavioral activation intervention and a description of the proposed intervention delivery model were provided to participants. Open-ended questions explored the perceived relevance of the intervention, alongside needs and preferences concerning content and delivery. A manifest content analysis approach was adopted.

RESULTS

Content analysis resulted in three categories: Content, Delivery procedures, and Illness trajectory. Results highlighted a need to consider the intervention Content via increased cultural adaptation to the Swedish context, and increasing the inclusiveness of intervention content. Delivery procedures were identified as needing to be flexible given the unpredictable nature of caring for people with dementia, with the provision of additional guidance to informal caregivers supporting the intervention. Illness trajectory was viewed as essential to consider, with the intervention regarded as suitable for those early in the dementia trajectory, alongside a need to reduce workbook text to minimize burden given dementia symptomology.

CONCLUSIONS

The intervention and proposed delivery model were generally well received by all stakeholders. We were able to identify key adaptations to enhance cultural appropriateness, relevancy, and acceptability for a currently neglected population. Results will inform a feasibility study to explore the feasibility and acceptability of the intervention and study procedures to inform the design of a future superiority randomized controlled trial.

TRIAL REGISTRATION/PROTOCOL

Not applicable.

Advance Care Planning in Hong Kong

Hong Kong is a well-developed city with outstanding healthcare services, leading to the highest life expectancy in the world. Paradoxically, the quality of end-of-life care in this city lagged behind that of many other high-income regions. Possibly, the advances in medicine contribute to the death denial culture, hindering communication about end-of-life care. This paper discusses challenges arisen due to poor public awareness and professional training and local initiatives to promote advance care planning in the community.

A serious game for engaging older adults in end-of-life care discussion: A mixed method study

OBJECTIVE

To examine the acceptability of a board game newly developed through a co-design process for promoting end-of-life care discussion among Chinese older adults.

METHODS

A multi-centre mixed method study, including a one group pre-test post-test study and focus group interviews, was conducted. Thirty older adults participated in a one-hour game session in a small group format. Acceptability was assessed by attrition rate and satisfaction with the game. Participants' experiences with the game were explored qualitatively. Within-subject changes in self-efficacy and readiness for advance care planning (ACP) behaviours were also examined.

RESULTS

The players generally had positive experiences with the game, giving a low attrition rate. A significantly higher level of self-efficacy in sharing end-of-life care preferences with surrogates was reported after the game session (p = 0.008). There was a slight increase in the proportion of players indicated that they would complete ACP behaviours in the coming months immediately after the intervention.

CONCLUSION

A serious game is acceptable by Chinese older adults to raise discussions regarding end-of-life matters.

PRACTICE IMPLICATIONS

A game can be an ice-breaking tool to increase self-efficacy towards communicating end-of-life care preferences with surrogates, but follow-up support is needed to facilitate the uptake of ACP behaviours.