Impact of person-centred care training and person-centred activities on quality of life, agitation, and antipsychotic use in people with dementia living in nursing homes: A cluster-randomised controlled trial

Exploring self-experience practices in dementia care: A scoping review

BACKGROUND

Recognised as essential for high-quality dementia service, person-centred care aims to understand and respect the unique needs of each individual. Self-experience practices may offer caregivers an opportunity to acquire knowledge, empathy, and skills related to person-centred care, especially through recreating experiences similar to dementia. Given the need to enhance the understanding of self-experience practices in dementia care, a more comprehensive investigation of these training interventions for (future) caregivers is needed.

METHODS

We conducted a scoping review to map the evidence on the use of self-experience practices in dementia training. We systematically searched Cochrane Library, MEDLINE via PubMed, CINAHL, and Web of Science. We also searched for grey literature, as well as registry entries, and conducted backward citation tracking of included reviews. We analysed data on intervention characteristics, factors influencing the implementation, and learning outcomes based on Kirkpatrick's model.

RESULTS

We included 44 reports across 30 intervention programmes. The majority of reports (91%) were published from 2016 onwards, with 32% originating from the USA and 25% from the UK. We identified passive, interactive, immersive, and multicomponent self-experience interventions in dementia education and training. Learning outcomes based on Kirkpatrick's model were fairly distributed across all identified modalities. Both consumers and providers emphasised aspects related to the development and implementation of practices, particularly organisational-related considerations such as temporal and spatial planning of trainings.

CONCLUSIONS

Our review highlights diverse interventions incorporating self-experience practices, with an increasing role for technological tools. While self-experience interventions engage participants, the impact on individuals with dementia and organisational levels remain largely unreported. Our overview, informed by current literature, underscores unique considerations and challenges associated with dementia-related self-experience practices. Implementing and evaluating complex training interventions using self-experience practices should consider ethical aspects.

TRIAL REGISTRATION

Registry: Registered within the Open Science Framework (available at https://osf.io/fycxa/).

Effects of simulated presence therapy on agitated behavior, cognition, and use of protective constraint among patients with senile dementia

The research was conducted to investigate the improvement of agitated behaviors, cognitive functions, and negative emotions among patients with senile dementia and the burden of caregivers after simulated presence therapy (SPT) intervention. 85 Patients with senile dementia were included as the research subjects and divided into control group (40 cases performed with routine nursing) and observation group (45 cases undergoing routine nursing combined with SPT) via a random number table method. Cohen-Mansfield agitation inventory (CAMI) and protective constraint were used to assess the improvement of agitated behaviors among patients. Besides, apathy evaluation scale-informant (AES-I), functional independence measure (FIM), self-rating depression scale (SDS), self-rating anxiety scale (SAS), clock drawing test, and caregiver burden inventory (CBI) were adopted to evaluate the differences in apathy, daily living and sociability, depression, anxiety, cognitive functions, and caregiver burden between the two groups. It was demonstrated that CAMI score, the duration of protective constraint use, AES-I score, SDS score, SAS score, and CBI score among patients in observation group all apparently decreased compared with those in control group after the intervention. In contrast, FIM and clock drawing test scores both notably increased (p < 0.05). The above findings suggested that SPT could obviously reduce the incidence of agitated behaviors, improve the level of apathy, daily living and sociability, depression, anxiety, and cognitive functions, and relieve caregiver burden among patients with senile dementia during SPT intervention for patients with senile dementia.

The Delivery of Person-Centered Care for People Living With Dementia in Residential Aged Care: A Systematic Review and Meta-Analysis

BACKGROUND AND OBJECTIVES

Person-centered care is the gold standard of care for people living with dementia, yet few systematic reviews have detailed how it is delivered in practice. This mixed-methods review aimed to examine the delivery of person-centered care, and its effectiveness, for people living with dementia in residential aged care.

RESEARCH DESIGN AND METHODS

A systematic review and meta-analysis. Eligible studies were identified across 4 databases. Quantitative and qualitative studies containing data on person-centered care delivered to people with dementia living in residential aged care were included. Meta-analysis using a random-effects model was conducted where more than 3 studies measured the same outcome. A narrative meta-synthesis approach was undertaken to categorize verbatim participant quotes into representative themes. Risk of bias was undertaken using quality appraisal tools from the Joanna Briggs Institute.

RESULTS

41 studies were identified for inclusion. There were 34 person-centered care initiatives delivered, targeting 14 person-centered care outcomes. 3 outcomes could be pooled. Meta-analyses demonstrated no reduction in agitation (standardized mean difference -0.27, 95% confidence interval [CI], -0.58, 0.03), improvement in quality of life (standardized mean difference -0.63, 95% CI: -1.95, 0.70), or reduced neuropsychiatric symptoms (mean difference -1.06, 95% CI: -2.16, 0.05). Narrative meta-synthesis revealed barriers (e.g., time constraints) and enablers (e.g., staff collaboration) to providing person-centered care from a staff perspective.

DISCUSSION AND IMPLICATIONS

The effectiveness of person-centered care initiatives delivered to people with dementia in residential aged care is conflicting. Further high-quality research over an extended time is required to identify how person-centered care can be best implemented to improve resident outcomes.

How can care home activities facilitate social connection in residents? A qualitative study

OBJECTIVES

Good social connection is associated with better physical and mental health but care home residents experience barriers to social connection. Activities present a potential avenue for improving social connection in care homes but residents often experience loneliness despite access to activity programmes. We therefore aimed to identify what aspects of activities facilitate social connection in care home residents.

METHOD

Qualitative study using semi-structured interviews that were analysed using Thematic Analysis. A purposive sample of 35 participants, including 12 residents, 10 family caregivers, nine care home staff and four clinicians, recruited from UK care homes.

RESULTS

We found four main themes describing features of activities important for facilitating social connection: (1) personalisation with respect to residents' interests, social preferences, and cognitive ability; (2) activities which foster a sense of community; (3) finding and emphasising things in common that residents share; and (4) facilitating a sense of involvement with others.

CONCLUSION

We identified the key aspects of activities which facilitate social connection in care homes. These findings can be applied to a range of existing and newly designed activities in care homes and inform the development and testing of psychosocial interventions aiming to improve social connection.

Economics and dementia: Challenges and responses

Economics and dementia are interconnected in many ways. There is, for example, accumulating evidence of the ways in which dementia impacts on the economic status of individuals and families, on health and social care system budgets, and on national economies. An individual's economic status can affect their risk of dementia and their ability to respond to it. Governments and other strategic decision-makers are aware of the (growing, indeed urgent) need to take action - whether that is prevention, treatment or care - but also very aware of the limited resources available to them and to the general population. Research evidence can potentially inform the difficult decisions that government and others need to take. We briefly summarise some economic evaluation studies in the dementia area as a basis for identifying the main challenges of moving from evidence to better policy and practice. We then discuss some possible responses (from a range of stakeholders) to these challenges, and how the STRiDE study has sought to contribute to this fast-moving field.

Feasibility and acceptability of NIDUS-professional, a training and support intervention for homecare workers caring for clients living with dementia: a cluster-randomised feasibility trial

INTRODUCTION

In the first randomised controlled trial of a dementia training and support intervention in UK homecare agencies, we aimed to assess: acceptability of our co-designed, manualised training, delivered by non-clinical facilitators; outcome completion feasibility; and costs for a future trial.

METHODS

This cluster-randomised (2:1) single-blind, feasibility trial involved English homecare agencies. Intervention arm agency staff were offered group videocall sessions: 6 over 3 months, then monthly for 3 months (NIDUS-professional). Family carers (henceforth carers) and clients with dementia (dyads) were offered six to eight complementary, individual intervention sessions (NIDUS-Family). We collected potential trial measures as secondary outcomes remotely at baseline and 6 months: HCW (homecare worker) Work-related Strain Inventory (WRSI), Sense of Competence (SoC); proxy-rated Quality of Life (QOL), Disability Assessment for Dementia scale (DAD), Neuropsychiatric Inventory (NPI) and Homecare Satisfaction (HCS).

RESULTS

From December 2021 to September 2022, we met agency (4 intervention, 2 control) and HCWs (n = 62) recruitment targets and recruited 16 carers and 16/60 planned clients. We met a priori progression criteria for adherence (≥4/6 sessions: 29/44 [65.9%,95% confidence interval (CI): 50.1,79.5]), HCW or carer proxy-outcome completion (15/16 (93.8% [69.8,99.8]) and proceeding with adaptation for HCWs outcome completion (46/63 (73.0% [CI: 60.3,83.4]). Delivery of NIDUS-Professional costs was £6,423 (£137 per eligible client). WRSI scores decreased and SoC increased at follow-up, with no significant between-group differences. For intervention arm proxy-rated outcomes, carer-rated QOL increased, HCW-rated was unchanged; carer and HCW-rated NPI decreased; DAD decreased (greater disability) and HCS was unchanged.

CONCLUSION

A pragmatic trial is warranted; we will consider using aggregated, agency-level client outcomes, including neuropsychiatric symptoms.

Initiatives Targeting Health Care Professionals: A Systematic Review of Knowledge Translation Pain Assessment and Management Studies Focusing on Older Adults

OBJECTIVES

Pain is often undertreated in older adult populations due to factors, such as insufficient continuing education and health care resources. Initiatives to increase knowledge about pain assessment and management are crucial for the incorporation of research evidence into practice. Knowledge translation (KT) studies on pain management for older adults and relevant knowledge users have been conducted; however, the wide variety of KT program formats and outcomes underscores a need to evaluate and systematically report on the relevant literature.

MATERIALS AND METHODS

Using a systematic review methodology, the Cumulative Index to Nursing and Allied Health Literature (CINAHL), MEDLINE, PsycInfo, and Web of Science databases were searched from inception to June 2023. Pain-related KT programs targeted towards older adults, their informal caregivers, and health care professionals were examined. Initiatives focusing on health care professionals are the focus of this review. Initiatives focusing on older adults are reported in a companion article.

RESULTS

From an initial 21,669 search results, 172 studies met our inclusion criteria. These studies varied widely in focus and delivery format but the majority were associated with significant risk of bias. In this report, we are focusing on 124 studies targeting health care professionals; 48 studies involving initiatives targeting older adults are reported in a companion article. Moreover, most programs were classified as knowledge mobilization studies without an implementation component. Across all studies, knowledge user satisfaction with the initiative and the suitability of the material presented were most commonly assessed. Patient outcomes, however, were underemphasized in the literature.

CONCLUSION

Patient and clinical outcomes must be a focus of future research to fully conceptualize the success of KT programs for older adult individuals. Without implementation plans, disseminated knowledge does not tend to translate effectively into practice.

Impact of the iWHELD digital person-centered care program on quality of life, agitation and psychotropic medications in people with dementia living in nursing homes during the COVID-19 pandemic: A randomized controlled trial

INTRODUCTION

iWHELD is a digital person-centered care program for people with dementia in nursing homes adapted for remote delivery during the COVID-19 pandemic.

METHODS

A 16-week two-arm cluster-randomized controlled trial in 149 UK nursing homes compared iWHELD with treatment as usual (TAU). Primary outcome was the overall quality of life with secondary outcomes of agitation and psychotropic use.

RESULTS

iWHELD conferred benefit to quality of life on the primary (F = 4.3, p = 0.04) and secondary measures of quality of life (F = 6.45, p = 0.01) and reduced psychotropic medication use (χ2  = 4.08, p = 0.04) with no worsening of agitation. Benefit was seen in participants who contracted COVID-19, those with agitation at baseline, and those taking psychotropic medications.

DISCUSSION

iWHELD confers benefits to quality of life and key measures of well-being, can be delivered during the challenging conditions of a pandemic, and should be considered for use alongside any emerging pharmacological treatment for neuropsychiatric symptoms.

HIGHLIGHTS

iWHELD is the only remote, digital delivery nursing home training programme for dementia care iWHELD improved quality of life in people with dementia and reduced antipsychotic use without worsening of agitation Residents who contracted Covid-19 during the study also experienced benefits from iWHELD iWHELD offers a valuable, pandemic-safe tool for improving dementia care.

Personhood as projection: the value of multiple conceptions of personhood for understanding the dehumanisation of people living with dementia

We examine the concept of personhood in relation to people living with dementia and implications for the humanity of care, drawing on a body of ethnographic work. Much debate has searched for an adequate account of the person for these purposes. Broad contrasts can be made between accounts focusing on cognition and mental faculties, and accounts focusing on embodied and relational aspects of the person. Some have suggested the concept of the person is critical for good care; others suggest the vexed debates mean that the concept should be abandoned. We argue instead that the competing accounts illuminate the very tensions in personhood which are manifest for all of us, but especially for people living with dementia, and argue that our account has explanatory power in shedding light on how precisely dehumanisation and constraints on agency may arise for people living with dementia, and for staff, within an institutional context.

A psychosocial goal-setting and manualised support intervention for independence in dementia (NIDUS-Family) versus goal setting and routine care: a single-masked, phase 3, superiority, randomised controlled trial

BACKGROUND

Although national guidelines recommend that everyone with dementia receives personalised post-diagnostic support, few do. Unlike previous interventions that improved personalised outcomes in people with dementia, the NIDUS-Family intervention is fully manualised and deliverable by trained and supervised, non-clinical facilitators. We aimed to investigate the effectiveness of home-based goal setting plus NIDUS-Family in supporting the attainment of personalised goals set by people with dementia and their carers.

METHODS

We did a two-arm, single-masked, multi-site, randomised, clinical trial recruiting patient-carer dyads from community settings. We randomly assigned dyads to either home-based goal setting plus NIDUS-Family or goal setting and routine care (control). Randomisation was blocked and stratified by site (2:1; intervention to control), with allocations assigned via a remote web-based system. NIDUS-Family is tailored to goals set by dyads by selecting modules involving behavioural interventions, carer support, psychoeducation, communication and coping skills, enablement, and environmental adaptations. The intervention involved six to eight video-call or telephone sessions (or in person when COVID-19-related restrictions allowed) over 6 months, then telephone follow-ups every 2-3 months for 6 months. The primary outcome was carer-rated goal attainment scaling (GAS) score at 12 months. Analyses were done by intention to treat. This trial is registered with the ISRCTN registry, ISRCTN11425138.

FINDINGS

Between April 30, 2020, and May 9, 2021, we assessed 1083 potential dyads for eligibility, 781 (72·1%) of whom were excluded. Of 302 eligible dyads, we randomly assigned 98 (32·4%) to the control group and 204 (67·5%) to the intervention group. The mean age of participants with dementia was 79·9 years (SD 8·2), 169 (56%) were women, and 133 (44%) were men. 247 (82%) dyads completed the primary outcome, which favoured the intervention (mean GAS score at 12 months 58·7 [SD 13·0; n=163] vs 49·0 [14·1; n=84]; adjusted difference in means 10·23 [95% CI 5·75-14·71]; p<0·001). 31 (15·2%) participants in the intervention group and 14 (14·3%) in the control group experienced serious adverse events.

INTERPRETATION

To our knowledge, NIDUS-Family is the first readily scalable intervention for people with dementia and their family carers that improves attainment of personalised goals. We therefore recommend that it be implemented in health and care services.

FUNDING

UK Alzheimer's Society.

Elements of Long-Term Care That Promote Quality of Life for Indigenous and First Nations Peoples: A Mixed Methods Systematic Review

BACKGROUND AND OBJECTIVES

Little is known about elements of long-term care (LTC) that promote quality of life (QoL) for older Indigenous and First Nations peoples. This systematic review aimed to extend understanding of those deemed most important.

RESEARCH DESIGN AND METHODS

Following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, systematic database and hand-searching were used to find published and unpublished qualitative studies and textual reports. A convergent integrated approach was used to synthesize data, according to the Joanna Briggs Institute methodology for mixed methods systematic reviews.

RESULTS

Included papers (11 qualitative; seven reports) explored views and experiences of Indigenous residents, families, and LTC staff from North America (8), South Africa (1), Norway (1), New Zealand (1), and Australia (7). Elements of care included: (a) codesigning and collaborating with Indigenous and First Nations communities and organizations to promote culturally safe care; (b) embedding trauma-informed care policies and practices, and staff training to deliver culturally safe services; (c) being respectful of individual needs, and upholding cultural, spiritual and religious beliefs, traditional activities and practices; (d) promoting connection to culture and sense of belonging through sustained connection with family, kin, and Indigenous and First Nations communities.

DISCUSSION AND IMPLICATIONS

This review identifies elements or models of care that promote QoL for Indigenous and First Nations peoples in LTC. While included papers were mostly from the United States and Australia, the congruence of elements promoting QoL was evident across all population groups. Findings may be used to inform standards specific to the care of Indigenous and First Nations peoples.

Dementia, nurse staffing, and health outcomes in nursing homes

OBJECTIVE

To estimate and contrast the relationships between nurse staffing and health outcomes in nursing homes with low and high dementia census, to understand the association of staffing hours with dementia care quality.

DATA SOURCES AND STUDY SETTING

A national sample of nursing homes during 2017-2019 (pre-COVID). Data included the Payroll-Based Journal, Medicare Claims, Nursing Home Care Compare, and Long-Term Care Focus.

STUDY DESIGN

Retrospective, regression analyses. We estimated separate linear models predicting six long-term facility-level outcomes. Independent variables included staffing hours per resident-day (HPRD) interacted with the facility percentage of dementia residents, controlling for other resident and facility characteristics.

DATA COLLECTION/EXTRACTION METHODS

Hospital-based nursing homes, those with fewer than 30% dementia residents, and missing data were excluded.

PRINCIPAL FINDINGS

We found that registered nurses and certified nurse assistants HPRDs were likely to exhibit positive returns in terms of outcomes throughout most of the range of HPRD for both high and low-census dementia facilities, although, high- and low-dementia facilities differed in most outcome rates at all staffing levels. Average predicted antipsychotics and activities of daily living as functions of HPRD were worse in higher dementia facilities, independent movement, and hospitalizations did not differ significantly, and Emergency Rooms and pressure sores were worse in lower dementia facilities. Average marginal effects were not statistically different [CI included zero] between the high and low dementia facilities for any outcome.

CONCLUSIONS

These findings suggest that increasing staffing will improve outcomes by similar increments in both low- and high-dementia facilities for all outcomes. However, at any given level of staffing, absolute differences in outcomes between low- and high-dementia facilities remain, suggesting that additional staffing alone will not suffice to close these gaps. Further studies are required to identify opportunities for improvement in performance for both low- and high-dementia census facilities.

Cost-Effectiveness of Non-pharmacological Interventions for Mild Cognitive Impairment and Dementia: A Systematic Review of Economic Evaluations and a Review of Reviews

BACKGROUND

Dementia prevalence is increasing, with no cure at present. Drug therapies have potential side effects and risk of mortality. People with dementia are frequently offered non-pharmacological interventions to improve quality of life and relieve symptoms. Identifying which interventions are cost-effective is important due to finite resources in healthcare services.

AIMS

The aims were to review published economic evaluations of community and nursing home non-pharmacological interventions for people with mild cognitive impairment or dementia and assess the usefulness of these evaluations for decision making in health services, for use by policy and local and national decision makers.

METHODS

We conducted a systematic review (PROSPERO CRD42021252999) of economic evaluations of non-pharmacological interventions for dementia or mild cognitive impairment with a narrative approach to data synthesis.

EXCLUSIONS

interventions for dementia prevention/early detection/end of life care. Databases searched: Academic Search Premier, MEDLINE, Web of Science, EMBASE, Google Scholar, Cumulative Index to Nursing and Allied Health Literature (CINAHL), PsycInfo, Psychology and Behavioural Sciences Collection, PsycArticles, Cochrane Database of Systematic Reviews, Business Source Premier and Regional Business News; timeframe 1 January 2011-11 May 2023. Reporting quality was assessed using the Consolidated Health Economic Evaluation Reporting Standards (CHEERS).

RESULTS

The review included 37 economic evaluations and four reviews worldwide across several distinct forms of care: physical activity, cognition, training, multicomponent, assistive technology and other (specialist dementia care, group living, home care vs care home). The intervention with the strongest evidence of cost-effectiveness was maintenance cognitive stimulation therapy. Case management, occupational therapy and dementia care management also showed good evidence of cost-effectiveness.

CONCLUSION

More economic evidence on the cost-effectiveness of specific dementia care interventions is needed, with consistency of methods and outcome measures. This could improve local and national decision makers' confidence to promote future cost-effective dementia interventions.

Impact of a Multifaceted, Pharmacist-Led Intervention on Psychotropic Medication Use for Residents of Aged Care Facilities: A Parallel Cluster Randomized Controlled Trial

OBJECTIVE

To investigate the effect of a multifaceted intervention on reduction in psychotropic medication use, falls, agitation, emergency department (ED) visits, and hospitalization in residential aged care facilities (RACFs).

DESIGN

Parallel cluster randomized controlled trial. RACFs were randomized to the multifaceted intervention, Medication Management Consultancy (MMC) (n = 5) or control (n = 6) groups. MMC, comprising online education, medication audits, and resources on psychotropic medications and nonpharmacological strategies, educates RACF staff to help reduce the use of antipsychotic medication among RACF residents through a comprehensive understanding of behavioral and psychological symptoms of dementia.

SETTING AND PARTICIPANTS

A total of 439 residents from 11 RACFs in Western Australia.

METHODS

The primary outcome was change in monthly total equivalent doses (mg) of antipsychotic, antidepressant, and benzodiazepine medication use over 12 months compared with a control group. Clinical outcomes included falls, restraints, agitation, ED visits, hospitalization, and knowledge of psychotropic medications among RACF staff at pre- and postintervention were measured. The duration of the intervention was 3 to 6 months. Data were collected at T0 (baseline), T1 (6 months), and T2 (12 months).

RESULTS

The MMC group showed a significant 44% reduction in antipsychotic use compared with the control group at T1 (incidence rate ratios [IRR], 0.56; 95% CI, 0.32-0.99; P = .048) and also significantly reduced the number of ED visits at T1 (IRR, 0.15; 95% CI, 0.06-0.35; P < .0005) and T2 (IRR, 0.04; 95% CI, 0.01-0.13; P < .0005). Staff knowledge about psychotropic medications improved significantly from T0 to T1 and from T0 to T2. Reduction in antidepressant use at either T1 or T2 and benzodiazepine use, compared with control, at T1 and T2 were not significantly different. Other clinical outcomes showed limited impact.

CONCLUSION AND IMPLICATIONS

The MMC intervention reduced the use of antipsychotics and ED visits and improved staff knowledge in RACFs, which impacts the safety and quality of aged care in Australia.

Model Testing of the Factors that are Associated with Care Interactions among Nursing Home Residents with Dementia

OBJECTIVE

The purpose of this study was to test a model of the resident and community factors that are associated with quality of care interactions among nursing home (NH) residents living with dementia and test for invariance between model fit when tested with the Black versus White residents and female versus male residents. It was hypothesized that resident age, gender, race, pain, comorbidities, quality of life, resistiveness to care, function, cognition, community profit status, overall community star rating, community size, and staffing star rating would be directly and/or indirectly associated with quality of care interactions. It was also hypothesized that the model fit would be invariant by resident race and gender.

DESIGN

This was a secondary data analysis using baseline, cross-sectional data from the Evidence Integration Triangle for Behavioral and Psychological Symptoms of Dementia (EIT-4-BPSD) intervention study.

SETTING AND PARTICIPANTS

The study included 528 residents from 55 NH facilities.

METHODS

Descriptive statistics and structural equation modeling was used to test the proposed model.

RESULTS

The results showed that the final model with significant paths only had a poor fit to the data (χ2/df = 10.79, comparative fit index = 0.57, Tucker-Lewis index = 0.15, normed fit index = 0.57, root mean square error of approximation = 0.13). However, the findings indicated that comorbidities, pain, profit status, and overall community star rating were significantly associated with quality of care interactions. There was no difference in model fit between Black residents versus White residents, and between male versus female residents.

CONCLUSIONS AND IMPLICATIONS

This study suggests factors that may influence quality of care interactions. Managing comorbidities, managing pain, and supporting higher quality of care in NH communities will likely help increase the frequency of positive care interactions. These findings can inform future interventions and training curricula for NH care staff to promote positive care interactions.

Cluster randomized trials in nursing homes should better be planned as open-cohort than as closed-cohort

OBJECTIVES

Two designs are frequently used in cluster randomized trials in nursing homes: closed cohort and open cohort. The former design includes residents at the beginning of the trial and then follows them. In the latter design, participants are enrolled at the beginning of the trial or although it is ongoing; at dates of assessment, all residents present in the nursing home are assessed. The open-cohort design is much less used than the closed-cohort design, but it offers several advantages such as less exposure to individual attrition. Objective was to assess whether an open-cohort design could have been feasible in trials with a closed-cohort design.

STUDY DESIGN AND SETTING

Twenty-two closed-cohort trials in nursing homes.

RESULTS

An open-cohort design was considered a relevant alternative for 20 trials. For 16 trials, a resident newly admitted could not opt out of the intervention, and for all trials, the resident could benefit from an intervention effect if it existed. For two trials, newly admitted residents could not benefit from the intervention effect, if it existed.

CONCLUSION

The open-cohort design is well-adapted for most of the interventions assessed in nursing homes by means of a cluster randomized trial and should be considered more often.

Training formal caregivers in the use of live music interventions during personal care with persons living with dementia: a systematic mixed studies review

OBJECTIVES

To examine research on the training of formal caregivers in live music interventions within care situations with persons with dementia.

METHODS

This review was registered with PROSPERO (CRD42020196506). PubMed, PsycINFO (Ovid), MEDLINE, Discovery EBSCO, Embase, CINAHL (Complete), AMED and ProQuest Dissertations and Theses Global were searched in September 2020 and again in October 2022. English, peer-reviewed studies on formal caregivers trained in using live music when caring one-on-one with persons with dementia were included. The Mixed Methods Assessment Tool (MMAT) was employed to assess quality, and narrative synthesis with effect sizes (Hedges-g) and thematic analysis were used for quantitative and qualitative studies respectively.

RESULTS

Nine studies (four qualitative, three quantitative, two mixed methods studies) were included. Quantitative studies demonstrated significant differences for music training on outcomes measuring agitation and emotional expression. Thematic analysis yielded five themes: emotional wellbeing; mutual relationship; shifts in caregivers' experiences; care environment; and insights into person-centered care.

CONCLUSION

Training for staff in live music interventions may benefit the delivery of person-centered care by supporting communication, easing care, and capacitating caregivers to meet the needs of persons with dementia. Findings appeared context specific due to high heterogeneity and small sample sizes. Further research on quality of care and caregiver outcomes, and sustainability of training is recommended.

Psychosocial interventions for reducing antipsychotic medication in care home residents

BACKGROUND

Antipsychotic medications are regularly prescribed in care home residents for the management of behavioural and psychological symptoms of dementia (BPSD) despite questionable efficacy, important adverse effects, and available non-pharmacological interventions. Prescription rates are related to organisational factors, staff training and job satisfaction, patient characteristics, and specific interventions. Psychosocial intervention programmes aimed at reducing the prescription of antipsychotic drugs are available. These programmes may target care home residents (e.g. improving communication and interpersonal relationships) or target staff (e.g. by providing skills for caring for people with BPSD). Therefore, this review aimed to assess the effectiveness of these interventions, updating our earlier review published in 2012.

OBJECTIVES

To evaluate the benefits and harms of psychosocial interventions to reduce antipsychotic medication use in care home residents compared to regular care, optimised regular care, or a different psychosocial intervention.

SEARCH METHODS

We used standard, extensive Cochrane search methods. The latest search date was 14 July 2022.

SELECTION CRITERIA

We included individual or cluster-randomised controlled trials comparing a psychosocial intervention aimed primarily at reducing the use of antipsychotic medication with regular care, optimised regular care, or a different psychosocial intervention. Psychosocial interventions were defined as non-pharmacological intervention with psychosocial components. We excluded medication withdrawal or substitution interventions, interventions without direct interpersonal contact and communication, and interventions solely addressing policy changes or structural interventions.

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methods. Critical appraisal of studies addressed risks of selection, performance, attrition and detection bias, as well as criteria related to cluster randomisation. We retrieved data on the complex interventions on the basis of the TIDieR (Template for Intervention Description and Replication) checklist. Our primary outcomes were 1. use of regularly prescribed antipsychotic medication and 2.

ADVERSE EVENTS

Our secondary outcomes were 3. mortality; 4. BPSD; 5. quality of life; 6. prescribing of regularly psychotropic medication; 7. regimen of regularly prescribed antipsychotic medication; 8. antipsychotic medication administered 'as needed'; 9. physical restraints; 10. cognitive status; 11. depression; 12. activities of daily living; and 13.

COSTS

We used GRADE to assess certainty of evidence.

MAIN RESULTS

We included five cluster-randomised controlled studies (120 clusters, 8342 participants). We found pronounced clinical heterogeneity and therefore decided to present study results narratively. All studies investigated complex interventions comprising, among other components, educational approaches. Because of the heterogeneity of the results, including the direction of effects, we are uncertain about the effects of psychosocial interventions on the prescription of antipsychotic medication. One study investigating an educational intervention for care home staff assessed the use of antipsychotic medication in days of use per 100 resident-days, and found this to be lower in the intervention group (mean difference 6.30 days, 95% confidence interval (CI) 6.05 to 6.66; 1152 participants). The other four studies reported the proportion of participants with a regular antipsychotic prescription. Of two studies implementing an intervention to promote person-centred care, one found a difference in favour of the intervention group (between-group difference 19.1%, 95% CI 0.5% to 37.7%; 338 participants), while the other found a difference in favour of the control group (between-group difference 11.4%, 95% CI 0.9% to 21.9%; 862 participants). One study investigating an educational programme described as "academic detailing" found no difference between groups (odds ratio 1.06, 95% CI 0.93 to 1.20; 5363 participants). The fifth study used a factorial design to compare different combinations of interventions to supplement person-centred care. Results showed a positive effect of medication review, and no clear effect of social interaction or exercise. We considered that, overall, the evidence about this outcome was of low certainty. We found high-certainty evidence that psychosocial interventions intended primarily to reduce antipsychotic use resulted in little to no difference in the number of falls, non-elective hospitalisations, or unplanned emergency department visits. Psychosocial interventions intended primarily to reduce antipsychotic use also resulted in little to no difference in quality of life (moderate-certainty evidence), and BPSD, regular prescribing of psychotropic medication, use of physical restraints, depression, or activities of daily living (all low-certainty evidence). We also found low-certainty evidence that, in the context of these interventions, social interaction and medication review may reduce mortality, but exercise does not.

AUTHORS' CONCLUSIONS

All included interventions were complex and the components of the interventions differed considerably between studies. Interventions and intervention components were mostly not described in sufficient detail. Two studies found evidence that the complex psychosocial interventions may reduce antipsychotic medication use. In addition, one study showed that medication review might have some impact on antipsychotic prescribing rates. There were no important adverse events. Overall, the available evidence does not allow for clear generalisable recommendations.

A rapid literature review on the health-related outcomes of long-term person-centered care models in adults with chronic illness

Introduction

The strong association between age and the increasing prevalence of chronic diseases, makes it imperative to promote self-care throughout life. Systematic knowledge on the health findings of person-centered care models may contribute to designing effective healthcare strategies to promote empowerment for self-care in long-term care.

Objective

To assess the association between the implementation of person-centered care models that promote self-care training in long-term care and health-related outcomes, among adults with chronic illness.

Methods

A rapid review of the literature was performed following the Cochrane rapid review methodology. The electronic databases CINAHL, MedicLatina, MEDLINE, and Psychology and Behavioral Sciences Collection were searched for randomized experimental studies, published between 2017 and 2022, that implemented interventions based on person-centered models to promote self-care in adults aged ≥18 years with chronic diseases and needing long-term health care. Verification of the eligibility of the articles and the extraction of data were performed by two independent investigators. Quantitative data on the health-related variables assessed were collected and, through narrative synthesis, health outcomes were grouped into individual, institutional and societal levels.

Results

Eight studies, mostly conducted in European countries, were included. All satisfied more than 60% of the methodological quality score. A large variability among studies was found regarding the number of participants, the data collection period and duration of the intervention, the samples selected and the care model implemented. A high number of health-related outcomes (n = 17) were analyzed in the studies, using 52 different instruments. The main health-related outcomes were multidimensional, with implications at the individual, institutional and societal levels. The promotion of overall health and wellbeing (n = 4), the implementation of patient-centered care models (n = 1), the positive and more frequent interactions with health professionals (2), the decrease on staff psychosocial distress (n = 1), and the absence of added costs (n = 1), while improving family caregivers' skills (n = 1) were the main health-related outcomes described.

Conclusion

There is a need to develop robust experimental studies focused on the views and experiences of all stakeholders and conducted in different countries and cultures. Short-, medium- and long-term health outcomes should be measured using internationally accepted and validated scales for chronic patients.

Identifying barriers and facilitators to the inclusion of older adults living in UK care homes in research: a scoping review

BACKGROUND

With an ageing population, older adults will have more complex health and social care needs and many of these older adults will be living in care homes. Despite the growth in care home populations, care home residents are often excluded from research that could potentially benefit their care. The purpose of this scoping review is to explore resident-related barriers and facilitators to including older people living in UK care homes in research and to identify potential approaches to modify such barriers.

METHOD

The 6-stage scoping review methodology framework proposed by Arksey and O'Malley guided this review. Five electronic databases (MedLine, PsychINFO, Scopus, Web of Science, CINAHL) and grey literature were searched. Identified articles went through two levels of screening, and those deemed relevant were collated, summarised and reported using a thematic analysis approach.

RESULTS

90 reports were eligible for inclusion and were synthesised into 7 themes and related subthemes: (1) research design; (2) understanding and beliefs about research (resident and care home staff); (3) communication; (4) relationships; (5) eligibility criteria (resident and care home); (6) preference-based decisions; and (7) care home staff and environment. Given the complex interplay of the factors identified, both direct and indirect factors were included.

CONCLUSIONS

A number of recurring barriers and facilitators to the inclusion of care home residents in research are reported. However, isolating resident-related barriers was complex as both direct and indirect factors must be considered as influential. Understanding the barriers and facilitators to inclusion will enable these factors to be addressed and increase the evidence-base for care provided to older people living in care homes.

Differences in Staff-Resident Care Interactions by Nursing Home Racial Composition: a Preliminary Analysis

Limited research has examined racial differences in the quality of staff-resident care interactions in long-term care settings. The quality of care interactions can significantly affect resident quality of life and psychological well-being among nursing home residents living with dementia. Limited research has assessed racial or facility differences in the quality of care interactions. The purpose of the present study was to determine if there were differences in the quality of care interactions among nursing home residents with dementia between Maryland nursing home facilities with and without Black residents. It was hypothesized that after controlling for age, cognition, comorbidities, and function, the quality of care interactions would be better in facilities with Black residents versus those in which there were only White residents. Baseline data from the Evidence Integration Triangle for Behavioral and Psychological Symptoms of Dementia (EIT-4-BPSD) intervention study was used and included 276 residents. The results indicated that facilities in Maryland with Black residents had a 0.27 increase (b = 0.27, p < .05) in the quality of care interaction score compared to facilities without Black residents. The findings from this study will be used to inform future interventions to aid in reducing quality of care disparities in nursing home facilities with and without Black nursing home residents. Future work should continue to examine staff, resident, and facility characteristics associated with the quality of care interactions to improve quality of life among all nursing home residents regardless of race or ethnicity.

Dementia Care Is Widespread In US Nursing Homes; Facilities With The Most Dementia Patients May Offer Better Care

More than three million US nursing home residents were diagnosed with Alzheimer's disease and related dementias (ADRD) between 2017 and 2019. This number is expected to increase as the population ages and ADRD prevalence increases. People with ADRD require specialized care from trained staff. This study addressed two questions: Are residents with ADRD concentrated in nursing homes where they are the majority? If not, what are the implications for their quality of care and life? We answered the first question by determining the ADRD census for each nursing home in the country during the period 2017-19. Using the Minimum Data Set and Medicare claims, we compared characteristics of nursing homes with high and low ADRD census along several dimensions, including staffing, resident outcomes, and resident characteristics. We found that residents with ADRD were dispersed throughout all nursing homes, with fewer than half residing in nursing homes where residents with ADRD accounted for 60-90 percent of the census. Furthermore, only facilities exceeding 90 percent of residents with ADRD seemed to offer better care. These findings raise concerns about the quality of care and life for the majority of residents with ADRD, suggesting that current National Institutes of Health dementia research initiatives and the Biden administration's policies to improve nursing home care should be coordinated.

Why the trial researcher matters: Day-to-day work viewed through the lens of normalization process theory

Researchers working in the field, the places where research-relevant activity happens, are essential to recruitment and data collection in randomised controlled trials (RCTs). This study aimed to understand the nature of this often invisible work. Data were generated through an RCT of a pharmacist-led medication management service for older people in care homes. The study was conducted over three years and employed seven Research Associates (RA) working in Scotland, Northern Ireland, and England. Weekly research team meetings and Programme Management Group meetings naturally generated 129 sets of minutes. This documentary data was supplemented with two end-of-study RA debriefing meetings. Data were coded to sort the work being done in the field, then deductively explored through the lens of Normalization Process Theory to enable a greater understanding of the depth, breadth and complexity of work carried out by these trial delivery RAs. Results indicate RAs helped stakeholders and participants make sense of the research, they built relationships with participants to support retention, operationalised complex data collection procedures and reflected on their own work contexts to reach agreement on changes to trial procedures. The debrief discussions enabled RAs to explore and reflect on experiences from the field which had affected their day-to-day work. The learning from the challenges faced in facilitating care home research may be useful to inform future research team preparation for complex interventions. Scrutinising these data sources through the lens of NPT enabled us to identify RAs as linchpins in the successful conduct of a complex RCT study.

Professional caregivers' participation in the International Caregiver Development Programme: A qualitative study of psychosocial care in nursing homes

AIM

This paper aims to explore professional caregivers' experiences of psychosocial care for older persons living in nursing homes following the professional caregivers' participation in the International Caregiver Development Programme (ICDP).

DESIGN

A qualitative study.

METHODS

About 15 focus group interviews and 25 participatory observations of five ICDP group courses were conducted with 31 employees in nursing homes, including registered nurses, enrolled nurses and nursing aids. The findings emerged through hermeneutic analysis.

RESULTS

Main findings: (i) Adjusting the communication to the residents' psychosocial needs, (ii) Seeing the residents as individuals and (iii) Adjusting to individual interaction with the residents. The professional caregivers experienced that the residents participated more in communication, interaction and activities, in addition to be more satisfied, calm, happy and thankful in interaction with the caregivers. Furthermore, they described that the environment in the units became calmer and that they were considering psychosocial care before medication. Work-related stress seems to impact ICDP participation and may be a barrier to implementation.

Integrating social support into interventions among the elderly in nursing homes: a scoping review

OBJECTIVES

This study aimed to understand the evidence related to integration of social support into interventions, to identify literature gaps related to social support interventions, and to clarify dimensions of supportive functions, outcomes, and providers among the elderly in nursing homes.

DESIGN

This scoping review followed the approach by Arksey and O'Malley. The Mixed Methods Appraisal Tool V.2018 was used for quality assessment of the studies.

DATA SOURCES

Searches were conducted of the PubMed, ScienceDirect, Public Library of Science, SocioHub, Wiley Online Library and PsycINFO databases for publications from 2010 to 2021.

ELIGIBILITY CRITERIA FOR SELECTING STUDIES

We searched for primary studies and heterogeneous study designs published in English. Eligible studies took place in nursing and care homes and had study populations of elderly adults (older adults, geriatrics, ageing, seniors, older people and those aged 60 years and older).

DATA EXTRACTION AND SYNTHESIS

A data extraction form based on Joanna Briggs Institute's recommendations for scoping reviews was used. Two reviewers independently extracted data and performed quality assessment of the studies. Then, extracted data and quality assessment reports were discussed by all authors.

RESULTS

Thirty-one eligible studies were included in this review. 54.8% of the studies provided interventions for cognitively impaired residents. The top-three outcomes were neuropsychiatric symptoms, physical function and quality of life, respectively. The interventions were performed by nursing home staff (83.9%), other persons with specific qualifications (58.1%) and health volunteers (6.5%). Most studies (90.3%) depicted the integration of emotional and instrumental supportive functions into interventions.

CONCLUSION

The appropriate dimensions of supportive function, mainly emotional and instrumental support, are important to integrate into the social care of elderly people living in nursing homes.

A Feasibility Evaluation of the Need-Centered Watch-Assess-Need Intervention-Think Education and Training Program for Behavioral and Psychological Symptoms of Dementia

BACKGROUND

Despite the high prevalence of dementia among residents living in long-term care facilities in Taiwan, most care providers in these facilities have not received adequate training to deal with the behavioral and psychological symptoms of dementia (BPSD). An original care and management model for BPSD has been developed, and model-based recommendations for an education and training program have been made. However, empirical testing has not yet been conducted to determine the efficacy of this program.

PURPOSE

This study was designed to evaluate the feasibility of using the Watch-Assess-Need intervention-Think (WANT) education and training program for BPSD in long-term care settings.

METHODS

A mixed-method design was used. Twenty care providers and 20 corresponding care receivers (residents with dementia) from a nursing home in southern Taiwan were enrolled. Data were collected using a variety of measurement tools, including the Cohen-Mansfield Agitation Inventory, Cornell Scale for Depression in Dementia, Attitude towards Dementia Care Scale, and Dementia Behavior Disturbance Self-efficacy Scale. Qualitative data, including care-provider perspectives on the efficacy of the WANT education and training program, were also collected. Repeated measures were conducted on the results of quantitative data analysis, whereas content analysis was performed on the results of qualitative data analysis.

RESULTS

Findings indicate that the program relieves agitated behavior (p = .01), alleviates depression in those with dementia (p < .001), and enhances care-provider attitudes toward dementia care (p = .01). However, no significant improvement was found in self-efficacy among the care providers (p = .11). In terms of qualitative outcomes, care providers indicated they perceived improved self-efficacy in managing BPSD, improved ability to view problems from a more need-centered perspective, improved attitudes toward dementia and patients' BPSD, and decreased care burden and stress.

CONCLUSIONS/IMPLICATIONS FOR PRACTICE

The study found the WANT education and training program to be feasible in clinical practice. Because of this program's simple and easy-to-remember characteristics, it is recommended that it be vigorously promoted to care providers in both long-term institutional and home care settings to help them effectively address the BPSD.

[Les effets de l'environnement de soins sur les comportements réactifs des personnes ayant des troubles neurocognitifs vivant en centre d'hébergement : Une revue de la portée]

Les personnes âgées atteintes de troubles neurocognitifs (démences) vivant en centre d'hébergement adoptent fréquemment des comportements réactifs qui limitent leur engagement dans des occupations. La présente étude vise à identifier des moyens d'intervention centrés sur l'engagement des personnes âgées ayant un trouble neurocognitif avec l'environnement humain et non humain en centre d'hébergement afin de diminuer leurs comportements réactifs, en particulier les comportements d'errance, d'apathie et d'agitation. Cette revue de la portée est basée sur la méthode proposée par Levac et ses collaborateurs (2010). Parmi les 21 études retenues, la plupart s'intéressent à des interventions ciblant l'environnement non humain (n=9) ou ciblant simultanément l'environnement humain et non humain (n=9). Plusieurs de ces interventions sont efficaces pour diminuer les comportements réactifs et permettent aux personnes âgées de s'engager avec leur environnement. Le support de l'environnement humain semble toutefois nécessaire à l'utilisation optimale de plusieurs interventions.

Italian guidance on Dementia Day Care Centres: A position paper

Dementia Day Care Centres (DDCCs) are defined as services providing care and rehabilitation to people with dementia associated with behavioural and psychological symptoms (BPSD) in a semi-residential setting. According to available evidence, DDCCs may decrease BPSD, depressive symptoms and caregiver burden. The present position paper reports a consensus of Italian experts of different disciplines regarding DDCCs and includes recommendations about architectural features, requirements of personnel, psychosocial interventions, management of psychoactive drug treatment, prevention and care of geriatric syndromes, and support to family caregivers. DDCCs architectural features should follow specific criteria and address specific needs of people with dementia, supporting independence, safety, and comfort. Staffing should be adequate in size and competence and should be able to implement psychosocial interventions, especially focused on BPSD. Individualized care plan should include prevention and treatment of geriatric syndromes, a targeted vaccination plan for infectious diseases including COVID-19, and adjustment of psychotropic drug treatment, all in cooperation with the general practitioner. Informal caregivers should be involved in the focus of intervention, with the aim of reducing assistance burden and promoting the adaptation to the ever-changing relationship with the patient.

Parkinson's Pals: A Student-Led Program to Facilitate Intergenerational Connections and Promote Psychosocial Well-Being Among Persons with Parkinson's Disease

Parkinson's disease (PD) causes unique motor and non-motor symptoms. Despite symptomatic treatment with pharmacotherapies, many persons with PD report feelings of loneliness and demoralization as their disease progresses. These symptoms greatly interfere with quality of life, necessitating novel treatment strategies. In this report, we introduce a new student-led program to improve psychosocial well-being among persons with PD by pairing them with college students. Through weekly one-on-one meetings, students gain a deeper understanding of PD, while patients gain a new social outlet and purpose. Based on the program's initial successes, we advocate for the adoption of similar programs at universities worldwide.

Video Call Usage in Older Adults With or Without Dementia Impacted by the COVID-19 Pandemic

The usage of video calls for social connection generally increased during the COVID-19 pandemic. It remains unclear, how individuals with dementia (IWD), many of who already experienced isolation in their care settings, use and perceive video calls, what barriers and benefits exist, and how the COVID-19 pandemic impacted their use of video calls. An online survey was conducted to healthy older adults (OA) and people surrounding IWD as proxies. Both OA and IWD showed increased use of video calls after COVID-19 and the severity of dementia was not correlated with the video call usage among IWD during this period. Both groups perceived significant benefits in using video calls. However, IWD exhibited more difficulties and barriers to using them compared to OA. Given the perceived benefits of video calls to the quality of life in both populations, education and support by family, caregivers, or healthcare professionals are necessary for them.

Impact of the Covid-19 pandemic on neuropsychiatric symptoms and antipsychotic prescribing for people with dementia in nursing home settings

OBJECTIVES

This study aimed to determine the impact of the Covid-19 pandemic on neuropsychiatric symptoms and antipsychotic use in people with dementia living in nursing homes.

METHODS

This was a comparative analysis of baseline data from two large nursing home studies, one conducted during (COVID-iWHELD study) and one prior (WHELD study) to the pandemic. It involves data from 69 and 149 nursing homes, and 1006 and 666 participants respectively. Participants were people with established dementia (score >1 on Clinical Dementia Rating Scale). Resident data included demographics, antipsychotic prescriptions and neuropsychiatric symptoms using the Neuropsychiatric Inventory Nursing Home version. Nursing home data collected were nursing home size and staffing information.

RESULTS

Overall prevalence of neuropsychiatric symptoms was unchanged from pre-pandemic prevalence. Mean antipsychotic use across the sample was 32.0%, increased from 18% pre-pandemic (Fisher's exact test p < 0.0001). At a nursing home level, the medians for the low, medium and high tertiles for antipsychotic use were 7%, 20% and 59% respectively, showing a disproportionate rise in tertile three. Residents in these homes also showed a small but significant increase in agitation.

CONCLUSION

There has been a significant increase in antipsychotic prescribing in nursing homes since the COVID-19 pandemic, with a disproportionate rise in one third of homes, where median prescription rates for antipsychotics were almost 60%. Strategies are urgently needed to identify these nursing homes and introduce pro-active support to bring antipsychotic prescription rates back to pre-pandemic levels.

The value of supportive care: A systematic review of cost-effectiveness of non-pharmacological interventions for dementia

BACKGROUND

Almost 44 million people are currently living with dementia worldwide. This number is set to increase threefold by 2050, posing a serious threat to the sustainability of healthcare systems. Overuse of antipsychotic drugs for the management of the symptoms of dementia carries negative consequences for patients while also increasing the health expenditures for society. Supportive care (SC) interventions could be considered a safer and potentially cost-saving option. In this paper we provide a systematic review of the existing evidence regarding the cost-effectiveness and cost-utility of SC interventions targeted towards persons living with dementia and their caregivers.

METHODS

A systematic literature review was performed between February 2019 and December 2021 through searches of the databases PubMed (MEDLINE), Cochrane Library, CENTRAL, Embase and PsycINFO. The search strategy was based on PRISMA 2020 recommendations. We considered studies published through December 2021 with no lower date limit. We distinguished between five categories of SC strategies: cognitive therapies, physical activity, indirect strategies (organisational and environmental changes), interventions primarily targeted towards family caregivers, and multicomponent interventions.

RESULTS

Of the 5,479 articles retrieved, 39 met the inclusion criteria. These studies analysed 35 SC programmes located at different stages of the dementia care pathway. Eleven studies provided evidence of high cost-effectiveness for seven interventions: two multicomponent interventions; two indirect interventions; two interventions aimed at caregivers of community-dwelling persons with dementia; one community-based cognitive stimulation and occupational programme.

CONCLUSION

We find that the most promising SC strategies in terms of cost-effectiveness are multicomponent interventions (targeted towards both nursing home residents and day-care service users), indirect strategies (group living and dementia care management at home), some forms of tailored occupational therapy, together with some psychosocial interventions for caregivers of community-dwelling persons with dementia. Our results suggest that the adoption of effective SC interventions may increase the economic sustainability of dementia care.

Person-Centered Climate, Garden Greenery and Well-Being among Nursing Home Residents: A Cross-Sectional Study

Nursing home residents' well-being is often proxy-rated in studies, and few studies have explored the association between resident-rated person-centered climate, garden greenery, and resident-rated well-being. A cross-sectional study was conducted. Questionnaire data from a convenient sample of 470 nursing home residents in a city in Southeast China in 2021 were analyzed using multiple linear regressions, with block-wise models. The instruments used were the Person-centered Climate Questionnaire-Patient version, the Nursing Home Greenery Index, and, for well-being, the EuroQol-Visual Analogue Scale, the Life Satisfaction Questionnaire, and the 9-item Patient Health Questionnaire (depression symptoms). In the unadjusted models, the person-centered climate was positively associated with general health (β 0.29, p < 0.001), person-centered climate and greenery with life satisfaction (β 0.39, and 0.18; both p < 0.001), and negatively with depression (β -0.28, and β -0.23, both p < 0.001). After adjusting for personal and nursing home characteristics, the associations between person-centered climate, greenery, and well-being remained statistically significant. The three models explained 36%, 35%, and 21% of the variance in general health, life satisfaction, and depression, respectively. This study provides knowledge on person-centered climate in long-term care and the access to greenery.

An Explorative Investigation of the Effect of Naturalistic Light on Agitation-Associated Behavior in Nursing Home Residents With Dementia: A Pilot Study

Aim:

To study the effect of naturalistic light, programmed to replicate the spectrum distribution of natural light from dusk to dawn, on agitation measured with a Cohen-Mansfield Agitation Inventory–inspired score of nursing home residents with dementia.

Background:

Though the effects of different types of light on the sleep-wake patterns of senior adults and people with dementia have been examined in several studies, the effects of naturalistic light systems, as a possible nonpharmacological intervention to improve sleep and reduce agitation, have yet to be extensively evaluated due to the relative novelty of the technology.

Methods:

The study was designed as a 6-month pilot study of a prospective interventional longitudinal cohort study, with five participants recruited from a single department of a Danish nursing home. The effect of naturalistic lighting on agitation-associated behaviors was recorded over a 3-day period pre- and postintervention. Results: An overall 71.2% reduction in the frequency of agitation-associated behaviors was recorded, with the frequency of some behaviors even reduced by 100%.

Conclusions:

This pilot study estimates that naturalistic lighting may be a promising nonpharmacological intervention to improve the overall agitation of nursing home residents with dementia, with a possible added benefit of an improved work environment for the staff. This study, therefore, finds indication for the performance of a randomized controlled trial with the same intervention and a larger cohort.

A Systematic Review of the Effectiveness of Educational Interventions in Promoting Person-Centred Care in Dementia Services

OBJECTIVES

To review evidence about the effectiveness of educational programmes in promoting the delivery of person-centered care by staff in dementia services.

METHODS

Several databases were searched, and the methodological quality of identified studies systematically evaluated. A summary mean effect size was calculated for several types of outcome (direct knowledge, applied knowledge, attitudes, self-reported and observed working practices).

RESULTS

Eighteen studies were identified. Results were mixed, with findings of no change, significant improvement, and (in attitude) significant deterioration. Effect size was modest for direct knowledge (standardized mean difference = 0.6), but small or negligible for applied knowledge (0.29) and self-reported (0.06) and observed (0.25) working practices. There was a negative effect for attitudes (-0.17).

CONCLUSIONS

The quality of evidence was poor. Apart from attitudes, the effect sizes are likely to be overestimates. There was little evidence that education programmes can reliably produce substantial improvements in working practices.

CLINICAL IMPLICATIONS

Education alone is unlikely to be sufficient for establishing high standards of person-centered care in services. It needs to be supplemented by steps to ensure that staff develop skills in delivering such care in practice, and by organizational support to ensure staff have sufficient motivation, cues and opportunities for implementation.

Providers' Perspectives on High-Quality Dementia Care in Long-Term Care

OBJECTIVES

To understand dementia care providers' perspectives on high-quality care for persons living with dementia (PLWD) in long-term care (LTC).

DESIGN

A qualitative study using a directed content analysis approach.

SETTING AND PARTICIPANTS

Nine national LTC dementia care providers.

METHODS

We facilitated 5 listening sessions centered around dementia care philosophies, models, and practices. Two researchers first mapped qualitative data to the Holistic Approach to Transformational Change (HATCh) model for dementia care using a directed content analysis approach. They then identified themes and subthemes emerging from the data using a conventional analysis approach. They coded data iteratively and solicited input from 3 additional researchers to reach consensus where needed. Member checks were performed to ensure the trustworthiness of the data during 2 follow-up listening sessions.

RESULTS

The 9 participants described the importance of understanding the experiences of PLWDs in order to provide high-quality dementia care and to deliver such care with the residents and their preferences as the focus. They emphasized experiential education as essential for families and all staff, regardless of role. They noted the need to balance safety with resident choice, as well as the corresponding need for facility leadership and regulators to support such choices. The listening sessions revealed areas to foster person-centered care for PLWD, but also highlighted barriers to implementing this philosophy in LTC settings.

CONCLUSIONS AND IMPLICATIONS

Emergent themes included care practices that center on resident preferences and are supported by staff with the experiential education and communication skills necessary to relate to and support PLWD. These findings provide contextual information for researchers seeking to identify and test interventions that reflect LTC providers' priorities for PLWD and emphasize the need to align research priorities with provider priorities.

Factors associated with formal and informal resource utilization in nursing home patients with and without dementia: cross-sectional analyses from the COSMOS trial

OBJECTIVES

To investigate the association between clinical, demographic, and organizational factors and formal (health professionals) and informal (relatives) resource utilization in nursing home patients with and without dementia.

METHODS

Baseline data from the multicomponent cluster randomized control COSMOS trial including 33 Norwegian nursing homes and 723 residents with and without dementia. Nursing home staff (n = 117) participated as proxy raters to approximate formal and informal resource use in daily care.

MEASUREMENTS

The primary outcome was the Resource Utilization in Dementia - Formal Care scale to assess formal and informal care time in hours/month regarding basic activities of daily living (ADL), instrumental ADL, and supervision. Secondary outcomes were hours/week spent on formal and informal leisure activities. Behavioral and psychological symptoms in dementia (BPSD) were assessed by the Neuropsychiatric Inventory-Nursing Home version, physical function by the Physical Self-Maintenance Scale, and psychotropic drug use by the Anatomical Therapeutic Chemical classification system. Organizational factors were ward size and staff ratio.

RESULTS

Generalized linear mixed-effect models and two-part modelling revealed an association between increased formal care time and poorer physical function, higher agitation and psychotropic drug use and lower cognitive function (all p < .05). Enhanced formal leisure time was related to better ADL function (p < .05) and smaller wards (p < .05). The family related leisure time was associated with agitation, decline in ADL function, smaller wards, and better staffing ratio (all p < .05). Married patients received more informal direct care (p < .05) and leisure time (p < .05) compared to unmarried/widowed.

CONCLUSION

For nursing home staff, higher agitation and psychotropic drug use, and lower cognitive function, is associated with more direct care time, whereas leisure time activities are less prioritized in people with lower physical function. Informal caregivers' engagement is encouraged by smaller nursing homes and better staff ratio. Therefore, we recommend stakeholders and healthcare professionals to consider these clinical and organizational factors to optimize treatment and leisure time activities in nursing home patients with various needs.

TRIAL REGISTRATION

ClinicalTrials.gov ; NCT02238652.

Economic evaluation of CPD activities for healthcare professionals: A scoping review

CONTEXT

Continuing professional development (CPD) activities for healthcare professionals are central to the optimisation of patient safety and person-centred care. Although there is some evidence on the economics of healthcare professionals training, very little is known about the costs and benefits of CPD.

METHODS

This study aimed to review the research evidence on economic evaluations of CPD activities for healthcare professionals. CINAHL, MEDLINE/PubMed, Scopus, Econlit and Web of Science databases were used to identify articles published between 2010 and 2021.

RESULTS

Of the 6791 titles identified, 119 articles met the inclusion criteria and were included in this scoping review. The majority of articles were partial economic evaluations of CPD programmes (n = 70); half were from the USA. Studies that included multiple professions were most prevalent (n = 54), followed by nurses (n = 34) and doctors (n = 23). Patient outcomes were the most commonly reported outcome (n = 51), followed by change in clinical practice (n = 38) and healthcare professionals' knowledge gain (n = 19).

CONCLUSIONS

There is an urgent call for more evidence regarding the economic evaluations of CPD. This is particularly important in view of the rising costs of healthcare globally. The majority of studies included in this review did not provide detailed information on the evaluations and many focused exclusively on the cost of CPD activities rather than outcomes.

Frequency of changed behaviours in residential aged care and common mitigation strategies - A retrospective review of behavioural report logs

BACKGROUND

Changed behaviours in residential aged care facilities (RACF) are frequently reported in the literature. How RACF staff routinely respond to these observed changed behaviours represents a significant gap.

OBJECTIVE

To analyse the frequency of changed behaviour reported within RACF behavioural report logs and to ascertain how staff typically manage these behaviours.

METHODS

Residents (N = 25) with varying levels of cognitive function were recruited from a 160 bed RACF in Queensland, Australia. A retrospective analysis of behavioural report logs was conducted to elucidate prevalence of reported changed behaviours as categorised by RACF staff. Thematic analysis of staff recorded behavioural mitigation strategies was used to categorise staff actions. A case analysis was also conducted to highlight the challenges faced by RACF staff managing persistent acute changed behaviours using identified common mitigation strategies. The STROBE guidelines were followed for reporting.

RESULTS

There were 395 behaviours recorded in a two-month period. Physical agitation, interfering while wandering, trying to get to inappropriate places, verbal refusal of care, physical aggression, and verbal disruption were most frequently reported by staff. Management strategies included redirection, PRN psychotropic medication, reassurance, routine care practices, offering of beverages, repositioning, and rarely analgesia. A 24-h case analysis highlighted how staff utilised redirection and multiple doses of a PRN benzodiazepine with limited effectiveness.

CONCLUSION

This study reveals current mitigation strategies employed by RACF staff in response to acute changed behaviours often associated with dementia. Agitation and wandering are prevalent and are difficult for staff to manage effectively.

RELEVANCE TO CLINICAL PRACTICE

This study highlights that careful consideration should be taken to avoid overuse of PRN benzodiazepines in management of changed behaviours. Short-term mitigation strategies, such as redirection, may not be effective if underlying causes such as pain, physiological, mental, emotional, or social needs are not met.

PATIENT AND PUBLIC CONTRIBUTION

A RACF participated in project design and review.

A Scoping Review of the Measurement of Depression in Older Adults with Cognitive Impairment

OBJECTIVES

Depression and cognitive impairment are disabling conditions that commonly occur together in older adults. The interaction is challenging when choosing appropriate measurement scales. This review aimed to summarize the scales to measure depression symptoms in older people with cognitive impairment, investigating how cognitive impairment is related to the choice of measurement, and how the setting may affect the choice of measurement.

METHODS

A scoping review of literature published between 2015 and 2021.

RESULTS

After screening 1580 articles, 26 were included in the review with 11 different measures of depression symptoms identified. The measures mostly commonly used were the Geriatric Depression Scale (GDS), Cornell Scale for Depression in Dementia (CSDD) and the Neuropsychiatric Inventory (NPI-Q). Most studies did not report on the usability of depression scales used with people with cognitive impairment and only two scales (CSDD and NPI-Q, not GDS) have been validated for use with this population.

CONCLUSIONS

Severe cognitive impairment was under-represented in the identified studies, and no association was detected between study setting, cognitive impairment and type of measure used.

CLINICAL IMPLICATIONS

Clinicians and researchers should consider both the cognitive status of participants and the setting they live in when choosing a measure of depression symptoms.

Digital Technologies to Prevent Social Isolation and Loneliness in Dementia: A Systematic Review

Background: Dementia poses significant and sustained challenges to global society. Diagnosis can lead to increased feelings of loneliness and social isolation. People with dementia living alone are particularly at risk. Considering the growing number of technologies proposed to aid people with dementia address social isolation and loneliness, we reviewed the existing literature. Objective: To collate and summarize current evidence for digital technologies to prevent social isolation and loneliness for people with dementia. Methods: Following the PRISMA guidelines, we systematically searched five databases to identify studies of digital technologies designed to support or prevent social isolation or loneliness for people with dementia. Pre-specified outcomes included social isolation, loneliness, and quality of life. We used deductive thematic analysis to synthesize the major themes emerging from the studies. Results: Ten studies met our inclusion criteria where all studies reported improvements in quality of life and seven reported benefits regarding social inclusion or a reduction in loneliness. Technologies were varied across purpose, delivery format, theoretical models, and levels of personalization. Two studies clearly described the involvement of people with dementia in the study design and five technologies were available outside the research context. Conclusion: There is limited— but increasing— evidence that technologies hold potential to improve quality of life and reduce isolation/loneliness for people with dementia. Results presented are largely based in small-scale research studies. Involvement of people with dementia was limited and few research concepts are reaching implementation. Closer collaboration with people with dementia to provide affordable, inclusive, and person-centered solutions is urgently required.

Application of virtual reality for dementia management

Age is recognized as the major factors of dementia, especially in for Alzheimer’s disease (AD). Given to the aged population, the increased number of demented population has been receiving a great impact in our society. Unfortunately, so far, no cured medicines have been demonstrated to provide effective treatment in AD. The combination of pharmacological and non-pharmacological interventions has been proposed to manage dementia with potential benefits especially in decreasing caregiver’s burden and behavior, as well as psychological problems of demented patients. Recently, giving to the glorious development in digital technologies, the virtual reality, one of the non-pharmacological interventions has been used extensively in dementia managements for its strengths which can be adapted in accordance with the heterogeneous needs from demented patients and their caregivers. However, various study designs and other reasons made these results difficult to be interpreted. In this review our goal is to provide a better understanding for these points.

The Characteristics and Outcomes of People with Dementia in Inpatient Mental Health Care: A Review

OBJECTIVES

Inpatient mental health beds for people with dementia are a limited resource. Practitioners need an understanding of this population to provide high-quality care and design services. This review examines the characteristics, care, and outcomes of people with dementia admitted to inpatient mental health services.

METHODS

Systematic searches of key databases were undertaken up to November 2021. Findings were grouped into categories and then synthesized into a narrative review.

RESULTS

The review identified 36 international papers, the majority of which were retrospective audits. The literature describes significant psychiatric and medical comorbidity and significant risk of change in residence and death associated with admission.

CONCLUSIONS

We found a limited literature describing the characteristics, care, and outcomes of people with dementia in inpatient mental health services. The lack of research is striking given the complexity and vulnerability of this client group. More research is needed to describe the needs of this group, current and best practice to optimize care.

CLINICAL IMPLICATIONS

Professionals working in inpatient mental health services need to be aware of the evidence base available, consider how they evaluate patient outcomes, review their staffing and skills mix, and seek the views of patients and relatives in improving services.

Development of a Quantitative Instrument to Elicit Patient Preferences for Person-Centered Dementia Care Stage 1: A Formative Qualitative Study to Identify Patient Relevant Criteria for Experimental Design of an Analytic Hierarchy Process

Background: Person-centered care (PCC) requires knowledge about patient preferences. This formative qualitative study aimed to identify (sub)criteria of PCC for the design of a quantitative, choice-based instrument to elicit patient preferences for person-centered dementia care. Method: Interviews were conducted with n = 2 dementia care managers, n = 10 People living with Dementia (PlwD), and n = 3 caregivers (CGs), which followed a semi-structured interview guide including a card game with PCC criteria identified from the literature. Criteria cards were shown to explore the PlwD’s conception. PlwD were asked to rank the cards to identify patient-relevant criteria of PCC. Audios were verbatim-transcribed and analyzed with qualitative content analysis. Card game results were coded on a 10-point-scale, and sums and means for criteria were calculated. Results: Six criteria with two sub-criteria emerged from the analysis; social relationships (indirect contact, direct contact), cognitive training (passive, active), organization of care (decentralized structures and no shared decision making, centralized structures and shared decision making), assistance with daily activities (professional, family member), characteristics of care professionals (empathy, education and work experience) and physical activities (alone, group). Dementia-sensitive wording and balance between comprehensibility vs. completeness of the (sub)criteria emerged as additional themes. Conclusions: Our formative study provides initial data about patient-relevant criteria of PCC to design a quantitative patient preference instrument. Future research may want to consider the balance between (sub)criteria comprehensibility vs. completeness.

Actual drug-related harms in residential aged care facilities: a narrative review

INTRODUCTION

Older people in residential aged care facilities (RACFs) have a high risk of safety issues and concerns about the potential quality of care received. This narrative review investigates the types of actual drug-related harms, their prevalence, reporting of any standard definitions for these harms, and their identification methods.

AREAS COVERED

The authors conducted a systematic search on Ovid Embase, Ovid Medline, and PubMed from March 2001 to March 2021. This narrative review included all types of studies targeting aged care residents aged 65 years and above with actual drug-related harms.

EXPERT OPINION

The prevalence of actual drug-related harms in residents ranged from 0.07% to 63.0%. Falls, drug-drug interactions, neuropsychiatric symptoms, anaphylaxis, urinary tract infection, hypoglycemia, hypokalaemia, and acute kidney injury are the most common drug-related harms in older residents. Psychotropic drugs are the most common drug class implicated in these harms. Evidence related to the association between individual psychotropic drugs and injury, or harm is also lacking. Due to the variation in study duration, reported prevalence, identification methods, and absence of a definition for actual drug-related harms in most studies, further research is mandated to understand the prevalence and clinical implications of drug-related harms in older residents.

Exploring changes to resident thriving and associated factors in Swedish nursing homes: A repeated cross-sectional study

OBJECTIVE

This study aimed to explore changes to resident thriving in Swedish nursing homes over a 5-year period and describe changes in associated factors.

METHODS

Cross-sectional data were collected from a randomised sample of Swedish nursing homes in 2013/2014 (baseline) and 2018/2019 (follow-up). Descriptive statistics, independent samples t-tests, and chi squared tests were used to statistically evaluate differences between the samples. Simple and multiple linear regression analyses were used to explore associations between thriving and the study variables.

RESULTS

Resident characteristics were relatively consistent between the full baseline (N = 4831) and follow-up (N = 3894) samples. Within a sub-sample of nursing homes that participated in both data collections mean thriving scores were found to have increased from 152.9 to 155.2 (p ≤ 0.003; d =0.09) and overall neuropsychiatric index scores had decreased from 16.0 to 14.3 (p ≤ 0.004; d =0.09), as had the prevalence of several neuropsychiatric symptoms. Thriving was found to have a positive association with the neuropsychiatric symptom of elation/euphoria, and negative associations with the symptoms of aggression/agitation, depression/dysphoria, apathy, and irritability.

CONCLUSIONS

The results show an increase in overall thriving scores and a decrease in overall neuropsychiatric scores between baseline and follow-up. This study confirmed associations between thriving and certain neuropsychiatric symptoms and established comparative knowledge regarding changes in resident thriving, characteristics, and symptom prevalence. These findings could inform future care and organisational policies to support thriving in nursing homes, particularly among residents at risk of lower thriving due to cognitive impairment or neuropsychiatric symptoms.

Wishes and Needs of Nursing Home Residents: A Scoping Review

Falling birth rates and rising life expectancy are leading to global aging. The proportional increase in older people can be observed in almost all countries and regions worldwide. As a result, more people spend their later years in nursing homes. In homes where person-centered care is implemented, residents report greater satisfaction and quality of life. This approach is based on the wishes and needs of the residents. Therefore, the purpose of this scoping review is to explore the wishes and needs of nursing home residents. A scoping review of the literature was conducted in which 12 databases were systematically searched for relevant articles according to PRISMA-ScR guidelines. Both quantitative and qualitative study designs were considered. A total of 51 articles met the inclusion criteria. Included articles were subjected to thematic analysis and synthesis to categorize findings into themes. The analysis identified 12 themes to which the wishes and needs were assigned: (1) Activities, leisure, and daily routine; (2) Autonomy, independence, choice, and control; (3) Death, dying, and end-of-life; (4) Economics; (5) Environment, structural conditions, meals, and food; (6) Health condition; (7) Medication, care, treatment, and hygiene; (8) Peer relationship, company, and social contact; (9) Privacy; (10) Psychological and emotional aspects, security, and safety; (11) Religion, spirituality; and (12) Sexuality. Nursing home residents are not a homogeneous group. Accordingly, a wide range of needs and wishes are reported in the literature, assigned to various topics. This underscores the need for tailored and person-centered approaches to ensure long-term well-being and quality of life in the nursing home care setting.

Cost-effectiveness of an educational intervention to reduce potentially inappropriate medication

Background

Educational interventions can reduce potentially inappropriate medication (PIM) use in older people. Their effectiveness has been measured mainly as changes in PIM use. In this economic evaluation, we analyse the impact of an educational intervention in terms of costs and quality-adjusted life years (QALYs).

Methods

The educational intervention consisted of activating and interactive training sessions for nursing staff and consulting physicians, and was compared with treatment as usual (TAU). Participants (n = 227) in a cluster randomised trial (cRCT) were residents living permanently in assisted living facilities (n = 20 wards). For economic evaluation, participants’ healthcare service use costs and costs for the intervention were estimated for a 12 month period.

Incremental cost-effectiveness ratios (ICERs) were estimated for QALYs per participant. Cost-effectiveness analysis was conducted from a healthcare perspective. A bootstrapped cost-effectiveness plane and one-way sensitivity analysis were undertaken to analyse the uncertainty surrounding the estimates.

Results

The educational intervention was estimated to be less costly and less effective in terms of QALYs than TAU at the 12 month follow-up [incremental costs –€1,629, confidence interval (CI) –€5,489 to €2,240; incremental effect −0.02, CI –0.06 to 0.02]. The base case ICER was >€80,000/QALY.

Conclusion

The educational intervention was estimated to be less costly and less effective in terms of QALYs compared with TAU, but the results are subject to some uncertainties. Reduction in PIM use or benefits in quality of life did not seem to translate into improvements in QALYs. Our findings emphasise the need for better understanding of the impact of decreasing PIM use on health outcomes.