Reframing person-centered nursing care for persons with dementia

"We are not the person we will be when these things happen:" Reflections on personhood from an ethnography of neuropalliative care

Neuropalliative care developed to address the needs of patients living with life-limiting neurologic disease. One critical consideration is that disease-related changes to cognition, communication, and function challenge illness experiences and care practices. We conducted an ethnography to understand neuropalliative care as a phenomenon; how it was experienced, provided, conceptualized. Personhood served as our conceptual framework; with its long philosophical history and important place in nursing theory, we examined the extent to which it captured neuropalliative experiences and concerns. Personhood contextualized complex losses, aligning the impact of functional and relational changes. Cognition, communication, and functional alterations stretched conceptions of personhood, insinuating it can be relational, fluid, adaptive. Although normative conceptions of personhood guided research and decision-making, ethical considerations suggested personhood could be transformed, remade. We consider the implications of our findings through three themes. First, we examine how literature on illness experience fails to integrate the realities of people living with and dying from neurologic disease; we counter this by interrogating the concept of experience. Second, we turn to Ricoeur's work on recognition to illuminate relational conceptions of personhood to inform care practices. Finally, we reflect on how personhood can bridge the gap left by functional changes, enhance relational engagement, and promote dignity at the end of life.

The Relational Care Framework: Promoting Continuity or Maintenance of Selfhood in Person-Centered Care

We argue that contemporary conceptualizations of "persons" have failed to achieve the moral goals of "person-centred care" (PCC, a model of dementia care developed by Tom Kitwood) and that they are detrimental to those receiving care, their families, and practitioners of care. We draw a distinction between personhood and selfhood, pointing out that continuity or maintenance of the latter is what is really at stake in dementia care. We then demonstrate how our conceptualization, which is one that privileges the lived experiences of people with dementia, and understands selfhood as formed relationally in connection with carers and the care environment, best captures Kitwood's original idea. This conceptualization is also flexible enough to be applicable to the practice of caring for people at different stages of their dementia. Application of this conceptualization into PCC will best promote the well-being of people with dementia, while also encouraging respect and dignity in the care environment.

Competency development for a volunteer navigation program to support caregivers of people living with dementia: A modified e-Delphi method

Caregivers of people living with dementia are pillars of the care community. Providing them with adequate support throughout their caregiving journey is essential to their quality of life and may also contribute to improving the care of people living with dementia. Nav-CARE (Navigation - Connecting, Advocating, Resourcing, Engaging) is a volunteer-led navigation program that provides support to older adults with life-limiting illnesses who are living in the community. However, Nav-CARE does not provide support directly to caregivers of people living with dementia. To adapt Nav-CARE to support caregivers, we needed to establish caregivers' needs and the competencies volunteer navigators should be trained in to support caregivers to meet these needs. To do so, a modified e-Delphi method was utilized, which consisted of administering three sequential questionnaires to a panel of 35 individuals with expertise in a variety of dementia related domains. Through this, two final lists of 46 caregivers' needs and 41 volunteer competencies were established to inform the development of volunteer navigator training curriculum. Findings suggest that trained volunteer navigators may be able to support caregivers of people living with dementia throughout the disease trajectory and can be used to inform the development of future dementia navigation programs.

"I Hope That the People Caring for Me Know About Me": Exploring Person-Centred Care and the Quality of Dementia Care

Background

Person-centred care is at the core of high-quality dementia care but people living with dementia are often excluded from quality improvement efforts. We sought to explore person-centred care and quality of care from the perspectives of persons living with dementia in the community and their care partners.

Methods

We used a qualitative descriptive approach with in-person, semi-structured interviews with 17 participants (9 persons living with dementia and 8 care partners) from Ontario, Canada.

Results

Participants report that person-centred care is essential to the quality of dementia care. Three themes were identified that describe connections between person-centred care and quality of care: 1) "I hope that the people looking after me know about me", 2) "I just like to understand [what's happening] as we go down the road", and 3) "But the doctor doesn't even know all the resources that are available." Participants perceived that quality indicators over-emphasized technical/medical aspects of care and do not entirely capture quality of care.

Conclusions

Persons living with dementia and their care partners provide important insights into person-centredness and quality of care. Their perspectives on "quality" may differ from clinicians and researchers. Research is needed to better integrate their perspectives in quality improvement and person-centred care.

Rethinking the Precedent Autonomy, Current Minimal Autonomy, and Current Well-Being in Medical Decisions for Persons with Dementia

As patient autonomy expands, a highly controversial issue has emerged. Should the advance directives (ADs) of refusing life-saving treatments or requesting euthanasia of persons with dementia (PWDs) who express changed minds or are often in a happy state be fulfilled? There are two autonomy-related positions. The mainstream position in philosophical discussions supports the priority of ADs based on precedent autonomy. Buchanan and Brock, and Dworkin represent this view. The other position supports the priority of PWDs' current wishes based on minimal autonomy represented by Jaworska. By rethinking the theoretical and practical challenges of the two positions and their arguments respectively, the paper concludes that in such a scenario, the priority of ADs is morally indefensible, and it is also challenging to establish minimal autonomy defend the moral priority of PWDs' current wishes. For PWDs whose past values, beliefs, and preferences fade away but who retain apparent intrinsic sentience of well-being, a modified defined quality-of-life (QoL) approach serves as another reasonable basis in their medical decision-making, and the ADs and the QoL should be further merged to reduce the uncertainty of the grey zone.

Singing and music making: physiological responses across early to later stages of dementia

Background: Music based interventions have been found to improve wellbeing for people with dementia. More recently there has been interest in physiological measures to provide additional information about how music and singing impact this population. Methods: This multiple-case study design explored physiological responses (heart rate-HR, electrodermal activity-EDA, movement, and skin temperature-ST) of nine people with mild-to-moderate using simulation modelling analysis.             Results: In study 1,  the singing group showed an increase in EDA (p < 0.01 for 8/9 participants) and HR (p < 0.01 for 5/9 participants) as the session began. HR (p < 0.0001 for 5/9 participants) and ST (p < 0.0001 for 6/9 participants) increased during faster tempos. EDA (p < 0.01 all), movement (p < 0.01 for 8/9 participants) and engagement were higher during singing compared to a baseline control. In study 2 EDA (p < 0.0001 for 14/18 data points [3 music conditions across 6 participants]) and ST (p < 0.001 for 10/18 data points) increased and in contrast to the responses during singing, HR decreased as the sessions began (p < 0.002 for 9/18 data points). EDA was higher during slower music (p < 0.0001 for 13/18 data points), however this was less consistent in more interactive sessions than the control. There were no consistent changes in HR and movement responses during different music genre.   Conclusions: Physiological measures provide valuable information about the experiences of people with dementia participating in musical activities, particularly for those with verbal communication difficulties. Future research should consider using physiological measures. video-analysis and observational measures to explore further how engagement in specific activities, wellbeing and physiology interact.

Singing and music making: physiological responses across early to later stages of dementia

Background: Music based interventions have been found to improve the wellbeing of people living with dementia. More recently there has been interest in physiological measures to provide additional information about how music and singing impact this population. Methods: This multiple-case study design explored physiological responses (heart rate-HR, electrodermal activity-EDA, movement, and skin temperature-ST) of nine people with mild-to-moderate dementia during a singing group, and six people in the later stages of dementia during an interactive music group. The interactive music group was also video recorded to provide information about engagement. Data were analysed using simulation modelling analysis.             Results: The singing group showed an increase in EDA (p < 0.01 for 8/9 participants) and HR (p < 0.01 for 5/9 participants) as the session began. HR (p < 0.0001 for 5/9 participants) and ST (p < 0.0001 for 6/9 participants) increased during faster paced songs. EDA (p < 0.01 all), movement (p < 0.01 for 8/9 participants) and engagement were higher during an interactive music group compared to a control session (music listening). EDA (p < 0.0001 for 14/18 participants) and ST (p < 0.001 for 10/18 participants) increased and in contrast to the responses during singing, HR decreased as the sessions began (p < 0.002 for 9/18 participants). EDA was higher during slower music (p < 0.0001 for 13/18 participants), however this was less consistent in more interactive sessions than the control. There were no consistent changes in HR and movement responses during different styles of music.   Conclusions: Physiological measures may provide valuable information about the experiences of people with dementia participating in arts and other activities, particularly for those with verbal communication difficulties. Future research should consider using physiological measures with video-analysis and observational measures to explore further how engagement in specific activities, wellbeing and physiology interact.

Key Intervention Categories to Provide Person-Centered Dementia Care: A Systematic Review of Person-Centered Interventions

Background:

Person-centered care (PCC) is an important concept in many countries’ national guidelines and dementia plans. Key intervention categories, i.e., a taxonomy of person-centered (PC)-interventions, to provide person-centered dementia care, are difficult to identify from literature.

Objective:

This systematic review aimed to identify and categorize published PC-interventions into key intervention categories to guide the provision of person-centered dementia care.

Methods:

Conduct of this systematic review followed Cochrane guidelines. A search of the dimensions ‘Dementia’, ‘Person-Centered Care’, and ‘Intervention’ combined was performed in PubMed, EMBASE, and Web of Science. Study selection was based on 2-stage screening against eligibility criteria, limited to controlled study designs. Information about interventions and outcomes was extracted into an “Effects Table”. The identified PC-interventions were categorized in intervention categories to provide person-centered dementia care.

Results:

Searches identified 1,806 records. 19 studies were included. These covered a range of psychosocial interventions, oftentimes multi-component interventions, which followed heterogeneous approaches. Studies were conducted in long-term care/hospital settings. Nine key intervention categories were identified: social contact, physical activities, cognitive training, sensory enhancement, daily living assistance, life history oriented emotional support, training and support for professional caregivers, environmental adjustments, and care organization.

Conclusion:

Our findings provide a current overview of published PC-interventions in dementia, which followed heterogeneous approaches under the PCC-concept. The heterogeneity made it challenging to identify a well-defined concept of PCC and common key intervention categories. An effectiveness-evaluation of “PC” - including “relationship-centered”-interventions may be valuable, to assess whether an explicit focus on relationships around PCC-interventions yields an added benefit.

PROSPERO-ID: CRD42021225084.

Active inclusion of people living with dementia in planning for dementia care and services in low- and middle-income countries

Involving people living with dementia in service design and planning has become more common in high-income countries. It remains rare in low- and middle-income countries where two-thirds of the world's people with dementia live. In this commentary article, we explore the barriers to inclusion of people living with dementia in planning in low- and middle-income countries and make a case for the inclusion of people living with dementia in care and service planning. We suggest how this can be done at individual, community or national and state level using the following principles: 1) respecting the rights of people living with dementia to self-determination; 2) valuing people living with dementia's unique understanding of dementia; 3) creating a culture of active inclusion which creates a space for people living with dementia to participate and 4) ensuring appropriate accommodations are in place to maximise participation.

Expanding role of nurses in management of dementia in geriatrics: improving well-being of geriatric patients through quality nursing care

The potential nurses role to include the recognition and management of dementia has been acknowledged. Practice Nurses are well-positioned to provide comprehensive dementia information and support so that people living with dementia are better equipped to self-manage their health and live well with dementia. However, treatment of geriatric dementia has become difficult owing to co-morbidities and cognitive and physical deterioration of these patients. Thus, geriatric dementia patients require special attention during care in homes and clinical settings. In modern medical practice, the role of nurse has become dynamic, ranging from education and personal care. The profession of nursing is considered as critical to meets the needs of the elderly population with dementia and ensure the delivery of high-quality care. Since nurses play such an important role in caring for these individuals, comprehensive reviews lack on their role and experience in geriatric dementia treatment and issues. This review summarizes the expanding role of nurses in the management of geriatric dementia in terms of nurse's knowledge, role, communication, attitude and maintaining patient's quality of life through diverse activities. Furthermore, we also explain the future direction for improving the nursing care to treat dementia in elderly population.

Singing and music making: physiological responses across early to later stages of dementia

Background: Music based interventions have been found to improve the wellbeing of people living with dementia. More recently there has been interest in physiological measures to provide additional information about how music and singing impact this population. Methods: This multiple-case study design explored physiological responses (heart rate-HR, electrodermal activity-EDA, movement, and skin temperature-ST) of nine people with mild-to-moderate dementia during a singing group, and six people in the later stages of dementia during an interactive music group. The interactive music group was also video recorded to provide information about engagement. Data were analysed using simulation modelling analysis.             Results: The singing group showed an increase in EDA (p < 0.01 for 8/9 participants) and HR (p < 0.01 for 5/9 participants) as the session began. HR (p < 0.0001 for 5/9 participants) and ST (p < 0.0001 for 6/9 participants) increased during faster paced songs. EDA (p < 0.01 all), movement (p < 0.01 for 8/9 participants) and engagement were higher during an interactive music group compared to a control session (music listening). EDA (p < 0.0001 for 14/18 participants) and ST (p < 0.001 for 10/18 participants) increased and in contrast to the responses during singing, HR decreased as the sessions began (p < 0.002 for 9/18 participants). EDA was higher during slower music (p < 0.0001 for 13/18 participants), however this was less consistent in more interactive sessions than the control. There were no consistent changes in HR and movement responses during different styles of music.   Conclusions: Physiological measures may provide valuable information about the experiences of people with dementia participating in arts and other activities, particularly for those with verbal communication difficulties. Future research should consider using physiological measures with video-analysis and observational measures to explore further how engagement in specific activities, wellbeing and physiology interact.

Impact of Caring for Terminally Ill Children on Physicians: A Systematic Scoping Review

INTRODUCTION

Caring for terminally ill children influences nurses' and allied health provider's quality of life, ability to provide personalized, dignified and empathetic care and even their concepts of personhood. In the absence of data this review utilizes the Ring Theory of Personhood (RToP) to evaluate how a physician's concept of personhood is affected caring for terminally ill children in order to better support them holistically.

METHODS

Using PRISMA Guidelines, 14 researchers carried out independent searches of PubMed, CINAHL, PsycINFO, Cochrane Library and gray literature databases for articles published between 2000 to 2019. Concurrent and independent employment of content and thematic analysis (Split Approach) was used to enhance the trustworthiness of the analysis.

RESULTS

13,424 titles and abstracts were retrieved, 188 full texts were evaluated, and 39 articles were included and analyzed. Identical categories and themes identified using the Split Approach suggest that caring for dying children in PPC impacts the physician's professional identity, clinical decision making, personal well-being and relationships. The data also suggests that the magnitude of these effects depends on the presence of protective and risk factors.

CONCLUSION

Aside from providing a novel insight into the upon the physician, this review proffers a unique approach to accounting for the presence, magnitude and influence of incoming catalysts, resultant conflicts, and protective and risk factors upon the physician's personhood. Further studies into the changes in personhood are required. Design of a personalized assessment tool based on the RToP will help direct timely, appropriate and personalized support to these physicians.

Stakeholder Engagement in Practice Change: Enabling Person-Centred Mealtime Experiences in Residential Care Homes

Person-centred care is recognized as best practice in dementia care. The purpose of this study was to evaluate the effectiveness of a stakeholder engagement practice change initiative aimed at increasing the provision of person-centred mealtimes in a residential care home (RCH). A single-group, time series design was used to assess the impact of the practice change initiative on mealtime environment across four time periods (pre-intervention, 1-month, 3-month, and 6-month follow-up). Statistically significant improvements were noted in all mealtime environment scales by 6 months, including the physical environment (z = -3.06, p = 0.013), social environment (z = -3.69, p = 0.001), relationship and person-centred scale (z = -3.51, p = 0.003), and overall environment scale (z = -3.60, p = 0.002). This practice change initiative, which focused on enhancing stakeholder engagement, provided a feasible method for increasing the practice of person-centred care during mealtimes in an RCH through the application of supportive leadership, collaborative decision making, and staff engagement.

Namaste care in the home setting: developing initial realist explanatory theories and uncovering unintended outcomes

INTRODUCTION

The End-of-Life Namaste Care Program for People with Dementia, challenges the misconception that people with dementia are a 'shell'; it provides a holistic approach using the five senses, which can provide positive ways of communicating and emotional responses. It is proposed Namaste Care can improve communication and the relationships families and friends have with the person with dementia. Previously used in care homes, this study is the first to explore the pioneering use of Namaste Care in people's own homes.

OBJECTIVE

To develop initial programme theories detailing if, how and under which circumstances Namaste Care works when implemented at home.

DESIGN

A qualitative realist approach following the RAMESES II guidelines was employed to understand not only whether Namaste Care has positive outcomes, but also how these are generated, for whom they happen and in which circumstances.

SETTING

A hospice in the North East of England, operating in the community, through volunteers.

PARTICIPANTS

Programme theories were developed from three focus groups with volunteers implementing Namaste Care (n=8; n=8; n=11) and eight interviews with family carers (n=8).

RESULTS

Four refined explanatory theories are presented: increasing engagement, respite for family carers, importance of matched volunteers and increasing social interaction. It was identified that while Namaste Care achieved some of the same goals in the home setting as it does in the care home setting, it could also function in a different way that promoted socialisation.

CONCLUSIONS

Namaste Care provides holistic and personalised care to people with both moderate and advanced dementia, improving engagement and reducing social isolation. In the present study carers often chose to use Namaste Care sessions as respite. This was often linked to their frustration of the unavoidable dominance of task-focussed care in daily life. Individualised Namaste Care activities thus led to positive outcomes for both those with dementia and their carers.

Person-Centered Dementia Care in China: A Bilingual Literature Review

We conducted a bilingual literature review of the existing studies focusing on person-centered dementia care in China. We synthesized key findings from included articles according to three overarching themes: Chinese cultural relevance of person-centered care (PCC), perceived needs for PCC for older adults in China, implementation and measurement of PCC in China, and person-centered dementia care model. We also drew on frameworks, theories, and other contents from the examined articles to develop a person-centered dementia care model with specific relevance to China. The model is a good starting point to help us operationalize globally relevant core principles of PCC in the specific sociocultural context of China. The framework will be informed by more empirical studies and evolve with the ongoing operationalization of PCC. Although PCC is a new concept and has not been vigorously or systematically studied in China, it is attracting increasing attention from Chinese researchers. More empirical studies are needed to link PCC to measurable outcomes, enrich the framework for applying PCC, and construct assessment and evaluation systems to facilitate the provision of PCC across countries and cultures. Global consortia and collaborations with multidisciplinary expertise to develop a PCC common data infrastructure that is internationally relevant for data sharing and comparison are needed.

The "Violent Resident": A Critical Exploration of the Ethics of Resident-to-Resident Aggression

Resident-to-resident aggression is quite prevalent in long-term care settings. Within popular and empirical accounts, this form of aggression is most commonly attributed to the actions of an aberrant individual living with dementia characterized as the "violent resident." It is often a medical diagnosis of dementia that is highlighted as the ultimate cause of aggression. This neglects the fact that acts of aggression are influenced by broader structural conditions. This has ethical implications in that the emphasis on individual aberration informs public policy strategies for prevention with a focus on restricting the freedom of individuals using behavioural modification, drugs, or other restraints with the intent to protect others from harm. A more ethical approach requires attention to the structural conditions of long-term care that both foster aggression and constrain prevention efforts. To this end, we turn to a model of relational citizenship that offers a theory of embodied selfhood and relationality as essential to human dignity, thus entailing human rights protections. The application of an ethic based on this model offers a more holistic prevention strategy for resident-to-resident aggression by drawing attention to the critical need and obligation to promote human flourishing through system level efforts.

Personhood: An evolutionary concept analysis for nursing ethics, theory, practice, and research

BACKGROUND

The purpose of this concept analysis was to examine how the concept of personhood has been used in the nursing literature. The person is central to nursing, as the object of nursing work, or care, and a key element of theory. Health and illness confront conventional notions of personhood based on the Western philosophy, in delineating boundaries of life and death, and grappling with pathophysiological changes and alterations in capacities that challenge our understandings of what makes a person whole.

METHODS

Rodgers' evolutionary method was selected; it emphasizes the relationship between concepts, language, and communities of users. A literature search between 1950 and 2017 generated 760 articles; 54 were retained for analysis.

RESULTS

Four themes were identified: (1) personhood and nursing ethics, emphasizing scientific advances, and establishing criteria; (2) personhood as a morally significant, relational process realized through nursing care; (3) personhood lost (or neglected); (4) interventions aimed at understanding, recognizing, and enhancing personhood. Related terms, antecedent concepts, and consequences are explored.

CONCLUSIONS

This preliminary view of personhood in the nursing literature demonstrated how the concept has been developed, used, and understood. Areas for future research include nursing ethics, theory, and clinical practice, as well as links with other academic disciplines.

The impact of life story work on person-centred care for people with dementia living in long-stay care settings in Ireland

The potential of life story work to add quality to dementia care is widely acknowledged. Whether this potential is always realised in practice and under what circumstances is less clear. This paper explores whether knowing the person’s life story enhances healthcare professionals’ understanding of the person with dementia and whether this understanding impacts on the person’s care. In-depth interviews were conducted with 11 registered nurses and 12 healthcare assistants who had used life story work with people with dementia living in long-stay care settings. Data were analysed using the constant comparative technique. Engaging in life story work enabled staff to see the person behind the dementia. Understanding (as opposed to knowing) the person with dementia’s life story changed staff’s thinking on what is important when delivering care to people with dementia, with staff giving concrete examples of changes in how they delivered care to the person with dementia and what they considered important when delivering that care. It was concluded that life story work can facilitate a shift to person centred dementia care but how it is implemented matters if this outcome is to be achieved.

Function Focused Care for Assisted Living Residents With Dementia

PURPOSE OF THE STUDY

Assisted living (AL) residents with dementia require assistance with activities of daily living, encounter limited opportunities to engage in physical activity, and often exhibit challenging behavioral symptoms. The Function Focused Care Intervention for the Cognitively Impaired (FFC-CI) teaches and motivates direct care workers (DCWs) to engage residents with dementia in activities that optimize function and activity while minimizing behavioral symptoms. The purpose of this study was to test the impact of FFC-CI on function, physical activity, behavior, and falls.

DESIGN AND METHODS

A cluster-randomized trial included 96 residents with dementia and 76 DCWs from 4 ALs. Generalized estimating equations were used to evaluate outcomes at 3 and 6 months.

RESULTS

There were no treatment by time differences with regard to resident behavior, mood, counts of physical activity based on actigraphy, falls, and function. There were significant increases in physical activity based on kilocalories burned (p = .001), time spent in physical activity based on survey results (p = .001), and time spent in repetitive behaviors, such as wandering (p = .01) among the control group over time. There were no treatment by time differences with regard to DCW beliefs, knowledge, or performance of FFC, except for less decline in job satisfaction among the treatment group (p = .002). Treatment fidelity with regard to delivery and receipt were poor due to high staff attrition in the treatment group (46% vs. 16%) and limited site support.

IMPLICATIONS

The findings from this study can be used to adapt future FFC intervention studies to improve treatment fidelity and optimize intervention efficacy.

What is known about the subjective needs of people with behavioural variant frontotemporal dementia? A scoping review

Behavioural variant frontotemporal dementia (bvFTD) is an early-onset and progressive neurodegenerative disease associated with strong changes in judgement, behaviour, personality and emotions. These changes can cause significant problems in everyday life for people with bvFTD and their families, and have implications for health and society. Currently, there are no suitable evidence-based specific interventions for people with bvFTD. This scoping review aims to identify the self-expressed needs, demands and coping strategies of people with bvFTD. Identifying these issues is the first step towards the development of need-based psycho-social interventions for people with bvFTD. A comprehensive literature research was conducted of German and English scientific articles published between January 2000 and October 2014 using the databases MEDLINE, CINAHL, PsycINFO, PSYNDEX, SocINDEX, GeroLit, the Cochrane Library, ProQuest, the German National Library and additional search strategies in terms of a scoping review. Articles were identified by combining search terms related to 'frontotemporal dementia' with terms related to 'self-expressions', 'needs/demands' and 'coping'. After excluding duplicates, two independent reviewers screened the titles and abstracts of 2317 records for eligibility. Because eligibility could not be assessed from the titles or abstracts of 28 articles, those articles were assessed using the full text. One poster abstract met our research question and a few articles were related, but no article met all of the inclusion criteria. This lack of scientifically based knowledge concerning the perspective of people with bvFTD is discussed with reference to the search strategy and the research questions, disease-related aspects such as changes in behaviour or language and emotions and the difficulties in researching this topic. Recommendations are formulated for future research considering the perspective of people with bvFTD and that will involve the development of appropriate data collection methods. Subsequently, specialised interventions must be developed.

The perseverance time of informal carers for people with dementia: results of a two-year longitudinal follow-up study

Background

Given the projected increase of people with dementia over the next few decades and the related demand for informal care, an important question for health policy makers is to what extent and for how long informal carers can be expected to provide care in a sustainable way. This study aimed to investigate the perseverance time of informal carers for people with dementia.

Methods

A 2-year longitudinal cohort study was conducted. Questionnaires were used to collect data about the care situation, the impact of caregiving on carers and their need for support, and the anticipated and realized perseverance time of informal carers for people with dementia living at home. The data were analysed using bivariate and multivariate analyses.

Results

Two hundred twenty-three carers for people with dementia were included in the study and 25 (11.2 %) dropped out during the follow-up. The results show that after 1 year, 74 (37.4 %) of 198 patients were still living at home, and after 2 years, 44 (22.2 %) patients were still living at home. The variables that were associated with this outcome were identified. When informal carers anticipated that their perseverance time would be less than 1 year, this was indicative of their actual perseverance time.

Conclusions

Anticipated perseverance time provides a fair indication of the actual duration of informal care. It is most accurate when carers anticipate a limited rather than an unlimited perseverance time. Although further research is required to support these findings, the concept of perseverance time may be considered a useful additional instrument in health policy and clinical practice for monitoring carers’ need for support and for planning the transition of care from home to a nursing home.

Music therapy: A nonpharmacological approach to the care of agitation and depressive symptoms for nursing home residents with dementia

Depression, agitation, and wandering are common behaviors associated with dementia and frequently observed among nursing home residents. Even with pharmacological treatment, behaviors often persist, hindering quality of life for elders, their family, and paid caregivers. This study examined the use of music therapy for treatment of these symptoms among 132 people with moderate to severe dementia in nursing homes. Participants were evaluated for depressive symptoms, agitation, and wandering to determine their predominate behavior. There were two assessments, two weeks apart, prior to intervention, followed by a two-week intervention, and two follow-up assessments, also two weeks apart. A repeated measures ANOVA determined that after two weeks of music therapy, symptoms of depression and agitation were significantly reduced; there was no change for wandering. Multivariate analyses confirmed a relationship between music therapy and change in neuropsychiatric symptoms associated with dementia. Results suggest widespread use of music therapy in long-term care settings may be effective in reducing symptoms of depression and agitation.

Evaluation of a pet-assisted living intervention for improving functional status in assisted living residents with mild to moderate cognitive impairment: a pilot study

BACKGROUND

In older adults with cognitive impairment (CI), decreased functional status and increased behavioral symptoms require relocation from assisted living (AL) to nursing homes. Studies support positive effects of pets on health/function.

PURPOSE

Evaluate the effectiveness of the Pet AL (PAL) intervention to support physical, behavioral, and emotional function in AL residents with CI.

METHODS

Cognitively impaired AL residents randomized to 60-90 minute sessions [PAL (n = 22) or reminiscing (n = 18)] twice/week for 12 weeks. PAL interventionist encourages residents to perform skills with the visiting dog; reminiscing interventionist encourages residents to reminisce. Monthly assessment of physical (energy expenditure, activities of daily living), emotional (depression, apathy), and behavioral (agitation) function.

RESULTS

In linear mixed models, physical activity depressive symptoms improved more with PAL.

CONCLUSION

Evidence supports that the PAL program helps preserve/enhance function of AL residents with CI. Additional study is required to evaluate the duration and predictors of effectiveness of the PAL intervention.

Nurses’ Experiences of Providing Care to Dementia Patients Through Home Health Care

Most Western countries aim to enable dementia sufferers to live at home for as long as possible. Person centeredness, continuity of care, and competence level are all important for the quality of home health care (HHC). The aim of this qualitative study is to describe staff’s experiences of providing care to home-dwelling dementia clients through HHC services. The study used a phenomenological-hermeneutic interpretation of focus group interviews. This study supports the value of continuous interpersonal relationships in HHC services. The findings show that specialized teams facilitate continuity and person-centered care, and that after training, staff become more holistically oriented, involve clients in daily care, and experience greater job confidence.

[The participation of patients with dementia in individualised intervention plan meetings: the impact on their well-being and the quality of life]

INTRODUCTION

An individualised intervention plan (IIP) offers a new paradigm in the care of the elderly with dementia, with the aim of increasing their quality of life through personalisation, respect for their freedom, and their participation in the decisions that affect their lives.

OBJECTIVE

To evaluate the impact of the residential home patient with dementia and their quality of care when they take part in the interdisciplinary meeting in which their care plan is decided.

MATERIAL AND METHODS

A total of 52 elderly patients with dementia took part in the study. They were distributed into two groups, one experimental (37 residents) and another control (15 residents). The Dementia Care Mapping (DCM) tool was used to assess the well-being and quality of care of the residents. This tool was used twice, before and after the intervention.

RESULTS

The well-being of the resident, evaluated using the DCM, was similar before and after the intervention in the experimental group. No differences were observed either on comparing the control and experimental groups. However, some indicators of carer behaviour were different before and after the intervention, and when the control and experimental group were compared.

CONCLUSION

The inclusion of elderly persons with dementia in their IIP meeting had a positive effect in the interaction of the staff with the residents, but not on the well-being of the resident.

Maximizing a nurturing care style for persons with dementia: a person-centered analysis

BACKGROUND

Our aim was to structure the configuration of family caregivers' management strategies for the person with dementia (PWD) and to examine factors differentiating caregiving styles.

METHODS

Using a latent class analysis on the data (N = 338) collected from an ambulatory dementia clinic of a tertiary hospital and the local Alzheimer association, we classified overall patterns of caregivers' dementia management strategies into three domains: criticism, encouragement, and active management. As determinants related to caregiving style, caregiver sociodemographics, caregiving experience, and health outcomes were tested while controlling for the PWD's characteristics.

RESULTS

A hierarchical structure of dementia caregiving style was classified into three groups: passive class (33.24%), authoritarian class (29.12%), and nurturing class (37.65%). Caregiver's marital status, employment, reaction to PWD's memory and behavior problems, sense of competence, and perceived gains from caregiving were significantly associated with the caregiving styles derived. In particular, the authoritarian class perceived higher burden whereas the nurturing class was associated with greater gains.

CONCLUSION

A better understanding of caregiver coping and caregiving style is critical to improving care for the PWD. Information on predictive factors related to more constructive coping strategies can be beneficial to design interventions for caregivers. Understanding caregiving styles may thus provide meaningful evidence for more efficient allocation of supportive resources to caregivers caring for the PWD.

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

BACKGROUND

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

METHODS/DESIGN

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

DISCUSSION

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

TRIAL REGISTRATION

Current Controlled Trials ISRCTN43916381.

The full spectrum of ethical issues in dementia care: systematic qualitative review

BACKGROUND

Integrating ethical issues in dementia-specific training material, clinical guidelines and national strategy plans requires an unbiased awareness of all the relevant ethical issues.

AIMS

To determine systematically and transparently the full spectrum of ethical issues in clinical dementia care.

METHOD

We conducted a systematic review in Medline (restricted to English and German literature published between 2000 and 2011) and Google books (with no restrictions). We applied qualitative text analysis and normative analysis to categorise the spectrum of ethical issues in clinical dementia care.

RESULTS

The literature review retrieved 92 references that together mentioned a spectrum of 56 ethical issues in clinical dementia care. The spectrum was structured into seven major categories that consist of first- and second-order categories for ethical issues.

CONCLUSIONS

The systematically derived spectrum of ethical issues in clinical dementia care presented in this paper can be used as training material for healthcare professionals, students and the public for raising awareness and understanding of the complexity of ethical issues in dementia care. It can also be used to identify ethical issues that should be addressed in dementia-specific training programmes, national strategy plans and clinical practice guidelines. Further research should evaluate whether this new genre of systematic reviews can be applied to the identification of ethical issues in other cognitive and somatic diseases. Also, the practical challenges in addressing ethical issues in training material, guidelines and policies need to be evaluated.

Creating relationships with persons with moderate to severe dementia

The study describes how relationships are created with persons with moderate to severe dementia. The material comprises 24 video sequences of Relational Time (RT) sessions, 24 interviews with persons with dementia and eight interviews with professional caregivers. The study method was Constructivist Grounded Theory. The categories of 'Assigning time', 'Establishing security and trust' and 'Communicating equality' were strategies for arriving at the core category, 'Opening up', which was the process that led to creating relationships. Both parties had to contribute to create a relationship; the professional caregiver controlled the process, but the person with dementia permitted the caregiver's overtures and opened up, thus making the relationship possible. Interpersonal relationships are significant to enhancing the well-being of persons with dementia. Small measures like RT that do not require major resources can open paths to creating relationships.

Behavioral cues to expand a pain model of the cognitively impaired elderly in long-term care

BACKGROUND

The purpose of this study was to determine the relationship between hypothesized pain behaviors in the elderly and a measurement model of pain derived from the Minimum Data Set-Resident Assessment Instrument (MDS-RAI) 2.0 items.

METHODS

This work included a longitudinal cohort recruited from Medicare-certified longterm care facilities across the United States. MDS data were collected from 52,996 residents (mean age 83.7 years). Structural equation modeling was used to build a measurement model of pain to test correlations between indicators and the fit of the model by cognitive status. The model evaluates the theoretical constructs of pain to improve how pain is assessed and detected within cognitive levels.

RESULTS

Using pain frequency and intensity as the only indicators of pain, the overall prevalence of pain was 31.2%; however, analysis by cognitive status showed that 47.7% of the intact group was in pain, while only 18.2% of the severely, 29.4% of the moderately, and 39.6% of the mildly cognitively impaired groups were experiencing pain. This finding supports previous research indicating that pain is potentially under-reported in severely cognitively impaired elderly nursing home residents. With adjustments to the measurement model, a revised format containing affective, behavioral, and inferred pain indicates a better fit of the data to include these domains, as a more complete measure of the pain construct.

CONCLUSION

Pain has a significant effect on quality of life and long-term health outcomes in nursing home residents. Patients most at risk are those with mild to severe cognitive decline, or those unable to report pain verbally. Nursing homes are under great scrutiny to maintain standards of care and provide uniform high-quality care outcomes. Existing data from federally required resident surveys can serve as a valuable tool to identify indicators of pain and trends in care. Great responsibility lies in ensuring pain is included and monitored as a quality measure in long-term care, especially for residents unable to communicate their pain verbally.

Relative Preservation of Advanced Activities in Daily Living among Patients with Mild-to-Moderate Dementia in the Community and Overview of Support Provided by Family Caregivers

Little is known about the extent to which advanced activities of daily living among patients with dementia are preserved and how family caregivers of these patients support them in the community. In this cross-sectional assessment of pairs of patients with dementia and their family caregivers, we evaluated basic, instrumental, and advanced activities of daily living by comparing past and present status observed by caregivers with subjective estimations by patients with dementia. We also asked about ways in which support was provided by family caregivers. Thirty-nine pairs of patients with dementia and caregivers who presented to our memory clinic were interviewed. The mean age of patients with dementia was 75.3 ± 7.0 years, and Mini-Mental State Examination scores were 22.3 ± 3.4. We found relative preservation of advanced activities of daily living compared with instrumental activities of daily living. Caregivers provided instrumental, informational, and reminding support to patients with dementia. These findings may reinforce the concept of person-centered support of patients with dementia in the community.

Psychometric Analysis of the Emotional Tone Rating Scale: A Measure of Person-Centered Communication

Psychometric analysis of the Emotional Tone Rating Scale (ETRS) was completed using ratings of naïve listeners who evaluated staff-resident communication in three nursing homes. Interrater consistency was high with ICC (2, 1) for agreement = 0.95 and consistency = 0.95. Factor analysis revealed two factors-person-centered communication and controlling communication-that explained 84.8% of the variance. Person-centered communication included seven descriptors (items) with loadings ranging from 0.84 to 0.98 and a coefficient alpha of 0.98. Controlling communication included five items that loaded from -0.63 to .99 with a coefficient alpha of 0.94. These factors were negatively correlated p = -.64 and demonstrated good ranges, standard deviations, and high item-total correlations. Person-centered communication correlated with higher resident engagement in conversation in contrast to controlling communication. The ETRS provides a measure of person-centered communication that can be used to evaluate interactions between nursing staff and older adults who reside in long term care settings.

‘The problem with Leonard’: A critical constructionist view of need-driven dementia-compromised behaviours

This critical constructionist case study of ‘Leonard,’ a man with frontotemporal dementia living on a special care unit predominantly populated by people with Alzheimer’s disease and related dementias, explores how healthy others’ perceptions of the prevailing physical and psychosocial environment were influenced by Leonard’s behaviour which, in turn, was influenced by people’s perceptions of him as a ‘problem’. Data were obtained through participant observations, individual interviews with staff and residents, and focus groups with family members and nursing staff. Leonard’s ‘needs-driven dementia-compromised’ behaviours are not recognized as such by many of the healthy others with whom he co-creates his psychosocial environment; rather he is constructed as deviant, which undermines his selfhood as well as his quality of life. Education of staff and family members as well as broad organizational change is needed to address the issues underlying the problems for which Leonard is blamed but instead arise largely from the environment within which Leonard is situated.

Sliding interactions: An ethnography about how persons with dementia interact in housing with care for the elderly

This ethnography describes how persons with dementia interact with cognitively intact persons in housing with care for the elderly. The results, drawing upon 31 observation sessions and nine interviews, are described under the following themes, which were interpreted from the standpoint of social interaction theory: interaction with expression of satisfaction, disorientation, and dissociation. Interaction provided satisfaction, but did not always reflect a positive experience. Awareness in persons with dementia seemed to be greater than others perceived and, as a result, interaction was adversely affected by frequent well-intentioned corrections and comments. Participation in interaction can be encouraged and feelings of indignation avoided by assuming that persons with dementia are aware of their situation and how others behave toward them. Sensitivity is required to interpret individuals' expressions of desire not to participate, while simultaneously it is important to try to interpret why they want to refrain.

Measuring the person-centeredness of caregivers working with nursing home residents with dementia

There is increasing interest in promoting person-centered caregiving within gerontology. However, few observational instruments have been developed to measure person-centered caregiving behaviors. In the present study, two innovative coding instruments-the Person-Centered Behavior Inventory (PCBI) and the Global Behavior Scale (GBS)-were used to test the hypothesis that caregivers' person-centeredness would be negatively correlated with residents' resistiveness to care. The study hypothesis was based on the need-driven dementia-compromised theory of behavior. It was expected that person-centered caregiving would better meet residents' needs and be associated with less resistiveness to care. This hypothesis was tested by coding 70 videotaped interactions between 54 caregivers and 20 residents diagnosed with dementia. Resistiveness to care was measured by behaviorally coding residents' resistive behaviors based on the Resistiveness to Care scale. The study hypothesis was supported when the GBS was used to measure person-centeredness, but not when the PCBI was used. The findings provide preliminary support for the predictive and construct validity of the GBS and the PCBI.

Construction and psychometric evaluation of the Swedish language Person-centred Climate Questionnaire - staff version

AIM

The aim of the study was to construct and evaluate psychometric properties of the Swedish language Person-centred Climate Questionnaire - staff version.

BACKGROUND

Person-centred care is often quoted but ill defined, and the literature warrants the development of valid and reliable measurement tools.

METHODS

During 2006, a questionnaire was constructed and distributed to a sample of Swedish hospital staff (n = 600). Questionnaire data was subjected to item analysis and reduction. Psychometrical properties of the questionnaire were evaluated.

RESULTS

The 14-item Person-centred Climate Questionnaire showed satisfactory psychometric properties. Measures of validity were good, internal consistency was high, Cronbach's alpha was satisfactory for the total scale (0.88) and test-retest reliability was adequate.

CONCLUSION

The results indicate that the staff Person-centred Climate Questionnaire is a valid and reliable tool for assessing staff perceptions of the person centredness of hospital environments.

IMPLICATIONS FOR NURSING MANAGEMENT

This instrument makes it possible to study the degree of person-centredness in relation to different organizational systems, environments, staff groups and managerial styles. In addition, staff variables such as turnover rates, health outcomes and efficacy can be related to staff perceived person centredness of the organization.

Views of life and sense of identity in people with Alzheimer's disease

Making it possible for people with Alzheimer's disease to retain a sense of identity during the process of the disease poses a great challenge to care-givers, professionals and family carers. The aim of this study is to elucidate the role of the view of life of people with Alzheimer's in framing their sense of identity. Is their view of life a vital aspect of their sense of identity? ‘View of life’ was interpreted as a vital aspect of sense of identity, understood as the individual's beliefs about their life history and about the attributes that characterised them. Twenty-one people with mild to moderate stages of Alzheimer's disease were interviewed about their life story. The narratives were interpreted using a phenomenological hermeneutic method. By telling their life story, the participants also narrated their view of life, i.e. their conception of reality, their central system of values and their basic emotional attitudes. By their own accounts, the origins of the narrators' central values and basic emotional attitudes were established in early life. They also expressed a sense of meaningfulness and continuity when looking back on their lives. The findings suggest that for a care-giver or confidant, having knowledge of a person with dementia's view of life is valuable when seeking to confirm that person's sense of identity.

Measuring Person-centered Care: A Critical Comparative Review of Published Tools

PURPOSE OF THE STUDY

to present a critical comparative review of published tools measuring the person-centeredness of care for older people and people with dementia.

DESIGN AND METHODS

included tools were identified by searches of PubMed, Cinahl, the Bradford Dementia Group database, and authors' files. The terms "Person-centered," "Patient-centered" and "individualized" (US and UK spelling), were paired with "Alzheimer's disease," "older people," and "dementia" in various combinations. The tools were compared in terms of conceptual influences, perspectives studied and intended use, applicability, psychometric properties, and credibility.

RESULTS

twelve tools eligible for review were identified. Eight tools were developed for evaluating long-term aged care, three for hospital-based care, and one for home care. One tool, Dementia Care Mapping, was dementia specific. A common limitation of the tools reviewed is that they are yet to be used and validated beyond the development period; thus, their validity, reliability, and applicability needs further exploration. Also, the perspective of people with dementia remains absent.

IMPLICATIONS

the review demonstrates the availability of a multitude of tools for measurement of person-centered care in different settings and from different perspectives, even if further testing of the tools is needed. The conceptual underpinnings of the tools are rarely explicit, which makes it difficult to ascertain the conceptual comparability of the tools.

'Knowing what makes them tick': motivating cognitively impaired older adults to participate in restorative care

Nursing home residents with dementia represent a majority of the most functionally impaired individuals residing in nursing homes. Although many perceive this population as having little restorative potential, maintaining resident functional abilities for as long as possible helps to optimize quality of life and decrease caregiver burden. This study used a qualitative design with a focus group methodology to explore facilitators and barriers to engaging cognitively impaired residents in functional activities and exercise. A purposive sample of seven geriatric nursing assistants who were experts in dementia care participated in the study. Twenty-seven codes were reduced to three themes: (i) knowing what makes them tick and move; (ii) teamwork and utilizing resources; and (iii) barriers to restorative care. The study findings were used to revise the Restorative Care for the Cognitively Impaired Intervention and could direct future implementation of programmes in nursing home settings.