Differences in emergency department visits and hospitalization between German and Dutch nursing home residents: a cross-national survey

PURPOSE

Assessing and comparing German and Dutch nursing home perspectives on residents' hospital transfers.

METHODS

Cross-sectional study among German and Dutch nursing homes. Two surveys were conducted in May 2022, each among 600 randomly selected nursing homes in Germany and the Netherlands. The questionnaires were identical for both countries. The responses were compared between the German and Dutch participants.

RESULTS

We received 199 German (response: 33.2%) and 102 Dutch questionnaires (response: 17.0%). German nursing homes estimated the proportion of transfers to hospital during 1 year to be higher than in Dutch facilities (emergency department visits: 26.5% vs. 7.9%, p < 0.0001; hospital admissions: 29.5% vs. 10.5%, p < 0.0001). In German nursing homes, the proportion of transfers to hospital where the decision was made by the referring physician was lower than in the Dutch facilities (58.8% vs. 88.8%, p < 0.0001). More German nursing homes agreed that nursing home residents are transferred to the hospital too frequently (24.5% vs. 10.8%, p = 0.0069). German nursing homes were much more likely than Dutch facilities to believe that there was no alternative to transfer to a hospital when a nursing home resident had a fall (66.3% vs. 12.8%, p < 0.0001).

CONCLUSION

German nursing home residents are transferred to hospital more frequently than Dutch residents. This can probably be explained by differences in the care provided in the facilities. Future studies should, therefore, look more closely at these two systems and examine the extent to which more intensive outpatient care can avoid transfers to hospital.

The prognosis of delirium in older outpatients

BACKGROUND

Delirium is a common and serious neuropsychiatric disorder. The prognosis of delirium in older patients living at home has not been studied often before. The aim of this study is to examine the prognosis of delirium in patients attending a memory clinic of a psychiatric hospital.

METHOD

The study population consisted of 85 outpatients diagnosed with delirium between October 2013 and October 2014. Seventeen patients had already been diagnosed as having dementia. Three months after the diagnosis, consenting patients underwent a follow-up visit. We recorded delirium status (remitted or not), new dementia diagnosis, subjective cognitive functioning compared to baseline and to before delirium, level of daily functioning, and place of residence.

RESULTS

After 3 months, 45 (53%) had recovered from delirium, 19 (22,4%) had persistent/recurrent delirium, 12 (14%) patients had died, and another nine (11%) could not be revisited for other reasons than death. None of the 64 re-examined patients reported that their cognitive functioning had recovered to the pre-delirium level, and the mean level of daily functioning did not substantially improve either. The rate of diagnosed dementia increased to 63.8%, and 18 patients (28.1%) had moved to a nursing home.

CONCLUSIONS

Delirium in older outpatients has a poor prognosis. A larger study on the risk factors of the prognosis of delirium in older persons living at home is advised.

Effects of a music therapy and music listening intervention for nursing home residents with dementia: a randomized controlled trial

Introduction

The aim of the present study was to evaluate the effects of an individual music therapy intervention and an individual music listening intervention on neuropsychiatric symptoms and quality of life in people with dementia living in a nursing home and on professional caregiver's burden to be able to make statements about their specific value of application in clinical practice.

Methods

A multicenter single blind randomized controlled trial with three groups was performed: an individual music therapy intervention (IMTI) group (n = 49), an individual music listening intervention (IMLI) group (n = 56) and a control group (n = 53) receiving usual care. The interventions were given during three weeks, three times a week on non-consecutive days during 30-45 minutes for in total nine sessions. The endpoint of the study is the difference from baseline to interim (1,5 week), post-intervention (3 weeks) and follow-up (6 weeks) in reported scores of problem behaviour (NPI-NH) and quality of life (Qualidem) in people with dementia and occupational disruptiveness (NPI-NH) in care professionals.

Results

In total 158 people with dementia were randomized to one of the two intervention groups or the control group. Multilevel analyses demonstrated that hyperactive behaviour assessed by the NPI-NH was significantly more reduced for the IMLI group at follow up and that restless behaviour assessed by the Qualidem was significantly more reduced for the IMTI group at post and follow-up measurement compared to the control group. No significant effects between groups were found in other NPI-NH clusters or Qualidem subscales.

Conclusion

In conclusion, because we found no convincing evidence that the IMTI or IMLI is more effective than the other both interventions should be considered in clinical practice. For the future, we advise further research into the sustainability of the effects with alternative designs, like a single case experimental design.

Comparison of medical care needs and actual care in German and Dutch nursing home residents: A cross-sectional study conducted in neighboring European countries

OBJECTIVE

Assessing and comparing characteristics of German and Dutch nursing homes, their residents as well as residents' medical care needs and the actual provision of care.

METHODS

Two surveys were conducted among 600 randomly selected nursing homes each from Germany and the Netherlands. Questionnaires were mailed in May 2022. Responses were compared between German and Dutch respondents.

RESULTS

We received 199 German (response: 33.2%) and 102 Dutch questionnaires (response: 17.0%). Residents' characteristics were comparable in both countries. While German nursing homes rated residents' general medical care needs higher than Dutch facilities (87.9% vs. 78.4%), the reverse was true for dental care needs (81.4% vs. 71.1%). For all 4 medical specialties surveyed, German nursing homes saw a need for treatment more frequently than Dutch facilities, e.g., 48.3% vs. 11.7% for neurology. In addition, Dutch nursing homes significantly more often considered general practitioners/elder care physicians (GPs/ECPs) to be able to cover these needs. The number of GP/ECP contacts per resident per year was similar in both countries (Germany: 26.5; Netherlands: 28.7). Almost all Dutch facilities had permanently employed allied health professionals (e.g. physiotherapists), whereas this was rarely the case in Germany.

CONCLUSIONS

We observed large differences in nursing home residents' medical care. It appears that GPs/ECPs in the Netherlands cover needs deemed to require specialist consultations in Germany. Some differences between countries can possibly be explained by system-cultural differences. Future studies should therefore look closely at the process of medical care provision and its quality in nursing homes in both countries.

Patterns of psychotropic drug prescriptions and general practice consultations among community-dwelling older people with dementia during the first two years of the COVID-19 pandemic

BACKGROUND

The COVID-19 pandemic and subsequent lockdown measures had serious implications for community-dwelling older people with dementia. While the short-term impacts of the pandemic on this population have been well studied, there is limited research on its long-term impacts. Quantifying the long-term impacts may provide insights into whether healthcare adaptations are needed after the acute phase of the pandemic to balance infection prevention measures with healthcare provision. This study aims to examine patterns of psychotropic drug prescriptions and general practice consultations in community-dwelling older people with dementia during the first two years of the pandemic.

METHODS

We utilised routine electronic health records from three Dutch academic general practice research networks located in the North, East, and South, between 2019 and 2021. We (1) compared the weekly prescription rates of five groups of psychotropic drugs and two groups of tracer drugs, and weekly general practice consultation rates per 1000 participants, between the first two years of the pandemic and the pre-pandemic phase, (2) calculated changes in these rates during three lockdowns and two relaxation phases relative to the corresponding weeks in 2019, and (3) employed interrupted time series analyses for the prescription rates. Analyses were performed for each region separately.

RESULTS

The study population sizes in the North, East, and South between 2019 and 2021 were 1726 to 1916, 93 to 117, and 904 to 960, respectively. Data from the East was excluded from the statistical analyses due to the limited sample size. During the first two years of the pandemic, the prescription rates of psychotropic drugs were either lower or similar to those in the pre-pandemic phase, with differences varying from -2.6‰ to -10.2‰. In contrast, consultation rates during the pandemic were higher than in the pre-pandemic phase, increasing by around 38‰.

CONCLUSIONS

This study demonstrates a decrease in psychotropic drug prescriptions, but an increase in general practice consultations among community-dwelling older people with dementia during the first two years of the pandemic. However, reasons for the decrease in psychotropic drug prescriptions are unclear due to limited information on the presence of neuropsychiatric symptoms and the appropriateness of prescribing.

Well-being, multidisciplinary work and a skillful team: essential elements of successful treatment in severe challenging behavior in dementia

OBJECTIVE

Conceptualize successful treatment of persons with dementia and severe challenging behavior as perceived by professionals.

METHODS

In this concept mapping study 82 experts in dementia care participated. The study followed two phases of data collection: (1) an online brainstorm where participants completed the focus prompt: 'I consider the treatment of people with severe challenging behavior in dementia successful if.'; (2) individual sorting and rating of the collected statements followed by data analysis using multidimensional scaling and hierarchical cluster analysis, resulting in a concept map.

RESULTS

Three clusters were identified, the first addressing treatment outcomes and the latter two addressing treatment processes, each divided into sub-clusters: (1) well-being, comprising well-being of the person with dementia and all people directly involved; (2) multidisciplinary analysis and treatment, comprising multidisciplinary analysis, process conditions, reduction in psychotropic drugs, and person-centered treatment; and (3) attitudes and skills of those involved, comprising consistent approach by the team, understanding behavior, knowing how to respond to behavior, and open attitudes.

CONCLUSIONS

Successful treatment in people with dementia and severe challenging behavior focuses on well-being of all people involved wherein attention to treatment processes including process conditions is essential to achieve this.

Effects of the DICE Method to Improve Timely Recognition and Treatment of Neuropsychiatric Symptoms in Early Alzheimer's Disease at the Memory Clinic: The BEAT-IT Study

BACKGROUND

Neuropsychiatric symptoms (NPS) are highly prevalent in Alzheimer's disease (AD) and are associated with negative outcomes. However, NPS are currently underrecognized at the memory clinic and non-pharmacological interventions are scarcely implemented.

OBJECTIVE

To evaluate the effectiveness of the Describe, Investigate, Create, Evaluate (DICE) method™ to improve the care for NPS in AD at the memory clinic.

METHODS

We enrolled sixty community-dwelling people with mild cognitive impairment or AD dementia and NPS across six Dutch memory clinics with their caregivers. The first wave underwent care as usual (n = 36) and the second wave underwent the DICE method (n = 24). Outcomes were quality of life (QoL), caregiver burden, NPS severity, NPS-related distress, competence managing NPS, and psychotropic drug use. Reliable change index was calculated to identify responders to the intervention. A cost-effectiveness analysis was performed and semi-structured interviews with a subsample of the intervention group (n = 12).

RESULTS

The DICE method did not improve any outcomes over time compared to care as usual. Half of the participants of the intervention group (52%) were identified as responders and showed more NPS and NPS-related distress at baseline compared to non-responders. Interviews revealed substantial heterogeneity among participants regarding NPS-related distress, caregiver burden, and availability of social support. The intervention did not lead to significant gains in quality-adjusted life years and well-being years nor clear savings in health care and societal costs.

CONCLUSION

The DICE method showed no benefits at group-level, but individuals with high levels of NPS and NPS-related distress may benefit from this intervention.

The longitudinal patterns of psychotropic drug prescriptions for subpopulations of community-dwelling older people with dementia: electronic health records based retrospective study

BACKGROUND

Studies focusing on patterns of psychotropic drug prescriptions (PDPs) for subpopulations of community-dwelling older people with dementia are lacking.

OBJECTIVE

The aim of this study was to identify the longitudinal patterns of PDPs in subpopulations.

METHODS

This retrospective study used electronic health records from general practitioners (GPs) in the Netherlands. People (N = 1278) firstly diagnosed with dementia between 2013 and 2015, aged 65 years or older, were selected and categorized into four subpopulations: community-dwelling (CD) group throughout follow-up, ultimately admitted to nursing homes (NH) group, ultimately died (DIE) group, and ultimately deregistered for unclear reasons (DeR) group. Generalised estimating equations were used to estimate the patterns of psychotropic drug prescriptions, after the diagnosis of dementia for a five-year follow-up, and 0-3 months before institutionalisation or death.

RESULTS

Over the five-year follow-up, antipsychotic prescriptions increased steadily in CD (OR = 1.07 [1.04-1.10]), NH (OR = 1.10 [1.04-1.15]), and DIE (OR = 1.05 [1.02-1.08]) groups. Similarly, prescriptions of antidepressants also showed upward trends in CD (OR = 1.04 [1.02-1.06]), NH (OR = 1.10 [1.02-1.18]), and DIE (OR = 1.04 [1.00-1.08]) groups. The other psychotropic drugs did not show clear changes over time in most of the subpopulations. In the three months before institutionalisation, antipsychotic prescriptions increased (OR = 2.12 [1.26-3.57]) in the NH group compared to prior periods. Likewise, before death, prescriptions of antipsychotics (OR = 1.74 [1.28-2.38]) and hypnotics and sedatives (OR = 2.11 [1.54-2.90]) increased in the DIE group, while anti-dementia drug prescriptions decreased (OR = 0.42 [0.26-0.69]).

CONCLUSIONS

After community-dwelling older people are diagnosed with dementia, all subpopulations' prescriptions of antipsychotics and antidepressants increase continuously during the follow-up. While we cannot judge whether these prescriptions are appropriate, GPs might consider a more reluctant use of psychotropic drugs and use alternative psychosocial interventions. Additionally, antipsychotic prescriptions rise considerably shortly before institutionalisation or death, which might reflect that older people experience more neuropsychiatric symptoms during this period.

A Qualitative Evaluation of the Implementation of an Oral Care Program in Home Care Nursing

An Oral Care Program (OCP) was implemented in home care nursing teams in a northern province of the Netherlands to improve the oral health and hygiene of older people who make use of formal home care in 2018-2019. The aim of the current study was to evaluate the experiences of the stakeholders involved (older people, home-care nurses and dental hygienists) and to report the experienced impact of OCP, with a qualitative approach. Three dental hygienists, nine home care nurses, and eight older people were interviewed with semi-structured interviews, which were audio recorded, transcribed and analyzed using thematic analysis. The codes derived were grouped into nine main themes. OCP was experienced as mostly positive by all stakeholders involved. The educational part lead to more awareness towards oral care, but should be repeated regularly. Personalized oral care plans for older people were experienced positively, however, obtaining oral care behavior changes appeared to be difficult. Collaboration between dental hygienists and home care nurses lead to a positive experience from both sides The method and intensity of collaboration varied between the teams. To provide better access to oral health care for older people in the community, a long term collaboration between home care nursing teams and dental care professionals in their working area should be established.

Losing hope or keep searching for a golden solution: an in-depth exploration of experiences with extreme challenging behavior in nursing home residents with dementia

Background

Situations of extreme challenging behavior such as very frequent and/or severe agitation or physical aggression in nursing home residents with dementia can be experienced as an impasse by nursing home staff and relatives. In this distinct part of our WAALBED (WAAL-Behavior-in-Dementia)-III study, we aimed to explore these situations by obtaining the experiences and perspectives of nursing home staff and relatives involved. This can provide a direction in providing tools for handling extreme challenging behavior of nursing home residents with dementia and may improve their quality of life.

Methods

Qualitative multiple case study with individual interviews and focus group discussions. Interviewees were elderly care physicians, psychologists, care staff members, unit managers and relatives (n = 42). They were involved with nursing home residents with dementia and extreme challenging behavior living on dementia special care units in the Netherlands. For these residents, external consultation by the Centre for Consultation and Expertise was requested. Audio-recordings of the interviews were transcribed verbatim and analyzed with thematic analysis, including conventional content analysis.

Results

Seven cases were included. Forty-one individual interviews and seven focus group discussions were held. For six stakeholder groups (resident, relative, care staff, treatment staff, nursing home staff, and the organization), three main factors could be identified that contributed to experiencing a situation of extreme challenging behavior as an impasse: 1) characteristics and attitudes of a stakeholder group, 2) interaction issues within a stakeholder group and 3) interaction issues among (groups of) stakeholders. The experienced difficulties with the resident’s characteristics, as well as suboptimal interdisciplinary collaboration and communication among the nursing home staff are remarkable. Nursing home staff kept searching for a golden solution or lost hope.

Conclusions

This study offers important insights into situations of extreme challenging behavior in nursing home residents with dementia and offers caregivers targets for improving care, treatment and interdisciplinary collaboration, such as working uniformly and methodically.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12877-022-03438-0.

Psychotropic drug treatment for agitated behaviour in dementia: what if the guideline prescribing recommendations are not sufficient? A qualitative study

BACKGROUND

Agitation is a common challenging behaviour in dementia with a negative influence on patient's quality of life and a high caregiver burden. Treatment is often difficult. Current guidelines recommend restrictive use of psychotropic drug treatment, but guideline recommendations do not always suffice.

OBJECTIVE

To explore how physicians decide on psychotropic drug treatment for agitated behaviour in dementia when the guideline prescribing recommendations are not sufficient.

METHODS

We conducted five online focus groups with a total of 22 elderly care physicians, five geriatricians and four old-age psychiatrists, in The Netherlands. The focus groups were thematically analysed.

RESULTS

We identified five main themes. Transcending these themes, in each of the focus groups physicians stated that there is 'not one size that fits all'. The five themes reflect physicians' considerations when deciding on psychotropic drug treatment outside the guideline prescribing recommendations for agitated behaviour in dementia: (1) 'reanalysis of problem and cause', (2) 'hypothesis of underlying cause and treatment goal', (3) 'considerations regarding drug choice', (4) 'trial and error' and (5) 'last resort: sedation'.

CONCLUSION

When guideline prescribing recommendations do not suffice, physicians start with reanalysing potential underlying causes. They try to substantiate and justify medication choices as best as they can with a hypothesis of underlying causes or treatment goal, using other guidelines, and applying personalised psychotropic drug treatment.

Individual differences in the temporal relationship between sleep and agitation: a single-subject study in nursing home residents with dementia experiencing sleep disturbance and agitation

OBJECTIVES

Previous studies on the interrelationship between sleep and agitation relied on group-aggregates and so results may not be applicable to individuals. This proof-of-concept study presents the single-subject study design with time series analysis as a method to evaluate the association between sleep and agitation in individual nursing home residents using actigraphy.

METHOD

To record activity, three women and two men (aged 78-89 years) wore the MotionWatch 8© (MW8) for 9 consecutive weeks. Total sleep time and agitation were derived from the MW8 data. We performed time series analysis for each individual separately. To gain insight into the experiences with the actigraphy measurements, care staff filled out an investigator-developed questionnaire on their and participants' MW8 experiences.

RESULTS

A statistically significant temporal association between sleep and agitation was present in three out of five participants. More agitation was followed by more sleep for participant 1, and by less sleep for participant 4. As for participants 3 and 4, more sleep was followed by more agitation. Two-thirds of the care staff members (16/24) were positive about the use of the MW8. Acceptability of the MW8 was mixed: two residents refused to wear the MW8 thus did not participate, one participant initially experienced the MW8 as somewhat unpleasant, while four participants seemed to experience no substantial problems.

CONCLUSION

A single-subject approach with time series analysis can be a valuable tool to gain insight into the temporal relationship between sleep and agitation in individual nursing home residents with dementia experiencing sleep disturbance and agitation.

Feasibility, usability and clinical value of intensive longitudinal diary assessments in older persons with cognitive impairment and depressive symptoms

OBJECTIVES

To evaluate the feasibility, usability and clinical value of daily diary assessments combined with actigraphy in older persons with cognitive impairment.

METHODS

For 63 days, patients ≥60 years with cognitive impairments filled out a daily diary (including standardized questionnaires and cognitive test battery), and wore an actiwatch (sleep). After the study, participants and clinicians received personal feedback about patterns and daily triggers of depressive symptoms, sleep and cognitive performance. We assessed feasibility (participation rate, compliance and subjective burden), usability (variability and floor- or ceiling effects) and clinical value for patients and their clinicians (questionnaires).

RESULTS

Of 96 eligible patients, 13 agreed to participate (13.5%). One patient dropped out after 2 days, another after 37 days, and another did not complete the cognitive test battery. Compliance rate was high (6.7-10% missing values). Subjective burden was relatively low. Time-series data showed sufficient variability and no floor- or ceiling effects, except for one relevant ceiling effect on the One Back task. The personal feedback report was considered insightful by 4 out of 11 participants and 5 out of 7 clinicians.

CONCLUSION

Daily assessments are suitable for a minority of cognitively impaired older persons, but is helpful to increase insight into their symptoms.

Implementing a Personalized Integrated Stepped-Care Method (STIP-Method) to Prevent and Treat Neuropsychiatric Symptoms in Persons With Dementia in Nursing Homes: Protocol for a Mixed Methods Study

Background

Neuropsychiatric symptoms occur frequently in many nursing home residents with dementia. Despite the availability of multidisciplinary guidelines, neuropsychiatric symptoms are often inadequately managed. Three proven effective methods for managing neuropsychiatric symptoms were integrated into a single intervention method: the STIP-Method, a personalized integrated stepped-care method to prevent and treat neuropsychiatric symptoms. The STIP-Method comprises 5 phases of clinical reasoning to neuropsychiatric symptoms and 4 stepped-care interventions and is supported with a web application.

Objective

This study aims to identify the facilitators and barriers in the implementation of the STIP-Method in nursing homes.

Methods

A mixed methods design within a participatory action research was used to implement the STIP-Method in 4 facilities of 2 Dutch nursing home organizations. In total, we aimed at participation of 160-200 persons with dementia and expected an intervention fidelity of 50% or more, based on earlier studies regarding implementation of effective psychosocial interventions to manage neuropsychiatric symptoms. All involved managers and professionals were trained in the principles of the STIP-Method and in using the web application. An advisory board of professionals, managers, and informal caregivers in each facility supported the implementation during 21 months, including an intermission of 6 months due to the COVID-19 pandemic. In these 6-weekly advisory board meetings, 2 researchers stimulated the members to reflect on progress of the implementation by making use of available data from patient records and the web application. Additionally, the 2 researchers invited the members to suggest how to improve the implementation. Data analysis will involve (1) analysis of facilitators and barriers to the implementation derived from verbatim text reports of advisory board meetings to better understand the implementation process; (2) analysis of patient records in accordance with multidisciplinary guidelines to neuropsychiatric symptoms: personalized, interdisciplinary, and proactive management of neuropsychiatric symptoms; (3) evaluation of the web application in terms of usability scores; (4) pre- and postimplementation analysis of patient records and the web application to evaluate the impact of the STIP-Method, such as changes in neuropsychiatric symptoms and informal caregiver burden.

Results

We enrolled 328 persons with dementia. Data collection started in July 2019 and ended in December 2021. The first version of this manuscript was submitted in October 2021. The first results of data analysis are expected to be published in December 2022 and final results in June 2023.

Conclusions

Our study may increase understanding of facilitators and barriers to the prevention and treatment of neuropsychiatric symptoms in nursing home residents with dementia by implementing the integrated STIP-Method. The need for well-designed implementation studies is of importance to provide nursing homes with optimal tools to prevent and treat neuropsychiatric symptoms.

International Registered Report Identifier (IRRID)

DERR1-10.2196/34550

Evaluation of an Oral Care Program to Improve the Oral Health of Home-Dwelling Older People

The aim of this study was to evaluate the impact of the implementation of an Oral Care Program on home care nurses’ attitudes and knowledge about oral health (care) and the impact on older people’s oral health. A pre–post study, without a control group, was conducted. A preventive Oral Care Program (OCP) was designed, focusing on home care nurses and older people, in collaboration with dental hygienists. Implementation was measured with questionnaires at baseline and after 6 months for home care nurses; for older people, implementation was measured at baseline and after 3 months with the Oral Health Assessment Tool and a questionnaire about oral (self) care between January 2018 and September 2019. Although the study design has limitations, the oral health of older people improved significantly after 3 months and the OCP was most beneficial for people with full dentures. The OCP improved knowledge and attitude of home care nurses. The program fitted well with the daily work routines of home care nurses. Individual-centered care plans for older people, education of home care nurses and the expertise of the dental hygienists have added value in home care nursing. Future implementations should focus on older people with natural teeth.

Distancing Measures and Challenges Discussed by COVID-19 Outbreak Teams of Dutch Nursing Homes: The COVID-19 MINUTES Study

The most severe COVID-19 infections and highest mortality rates are seen among long-term care residents. To reduce the risk of infection, physical distancing is important. This study investigates what physical distancing measures were discussed by COVID-19 outbreak teams of Dutch long-term care organizations and what challenges they encountered. The COVID-19 MINUTES study is a qualitative multi-center study (n = 41) that collected minutes of COVID-19 outbreak teams from March 2020 to October 2021. Textual units about distancing measures were selected and analyzed using manifest content analysis for the first wave: early March-early May 2020; the intermediate period of 2020: mid-May-mid-September 2020; and the second wave: late September 2020-mid-June 2021. During all periods, COVID-19 outbreak teams often discussed distancing visitors from residents. Moreover, during the first wave they often discussed isolation measures, during the intermediate period they often discussed distancing staff and volunteers from residents, and during both the intermediate period and the second wave they often discussed distancing among residents. During all periods, less often admission measures were discussed. Challenges persisted and included unrest among and conflicts between visitors and staff, visitors violating measures, resident non-adherence to measures, and staffing issues. The discussed distancing measures and corresponding challenges may guide local long-term care and (inter)national policymakers during the further course of the COVID-19 pandemic, outbreaks of other infectious diseases, and long-term care innovations.

The Impact of Music on Stress Biomarkers: Protocol of a Substudy of the Cluster-Randomized Controlled Trial Music Interventions for Dementia and Depression in ELderly Care (MIDDEL)

Recently, a large cluster-randomized controlled trial was designed-Music Interventions for Dementia and Depression in ELderly care (MIDDEL)-to assess the effectiveness of music interventions on depression in care home residents with dementia (ClinicalTrials.gov NCT03496675). To understand the pathophysiological mechanisms, we observed the effect of repeated music interventions on stress in this population since chronic stress was associated with depression and an increased risk for dementia. An exploratory study was designed to assess: (1) changes in hair cortisol concentrations as an indicator of longer-term stress; (2) whether baseline stress is a predictor of therapy outcome; (3) pre- and post-treatment effects on salivary α-amylase and cortisol response as an indicator of immediate stress in 180-200 care home residents with dementia and depressive symptoms who partake in the MIDDEL trial. Insights into mediatory effects of stress to explain the effect of music interventions will be gained. Hair cortisol concentrations were assessed at baseline and at 3, 6, and 12 months along with the Perceived Stress Scale. Salivary α-amylase and cortisol concentrations were assessed at 1, 3, and 6 months. Saliva was collected just before a session and 15 and 60 min after a session, along with a stress Visual Analogue Scale.

Job Demands, Work Functioning and Mental Health in Dutch Nursing Home Staff during the COVID-19 Outbreak: A Cross-Sectional Multilevel Study

COVID-19 posed enormous challenges for nursing home staff, which may have caused stress and mental health problems. This study aimed to measure the prevalence of mental health problems among nursing home staff and investigate the differences in job demands, work functioning and mental health between staff with and without COVID contact or COVID infection and across different levels of COVID worries. In this cross-sectional study, 1669 employees from 10 nursing home organizations filled in an online questionnaire between June and September 2020. The questionnaire measured the participants’ characteristics, COVID contact, infection and worries, job demands, work functioning, depressive symptoms and burnout. Differences were investigated with multilevel models to account for clustering at the organization level. Of the participants, 19.1% had high levels of depressive symptoms and 22.2% burnout. Job demands, work functioning, depressive symptoms and burnout differed between participants who never worried and participants who often or always worried about the COVID crisis. Differences were smaller for participants with and without COVID contact or infection. Most models improved when clustering was accounted for. Nursing homes should be aware of the impact of COVID worries on job demands, work functioning and mental health, both at the individual and organizational level.

Use of Benzodiazepines and Z-Drugs in Nursing Home Residents with Dementia: Prevalence and Appropriateness

Background:

Guidelines worldwide recommend restricted prescription of benzodiazepine receptor agonists (BZRAs), i.e., benzodiazepines and Z-drugs, for the treatment of dementia-associated behavioral and psychological symptoms and insomnia.

Objective:

To assess the prevalence and appropriateness of BZRA use among nursing home residents with dementia.

Methods:

This is a post-hoc analysis of BZRA prescriptions from two intervention studies on psychotropic drug use, conducted from 2016 to 2018. It includes 1,111 residents of dementia special care units from 24 Dutch long-term care organizations. We assessed the prevalence of use of continuous and as-needed BZRA prescriptions and their association with registered symptoms. Continuous BZRA prescriptions were evaluated for appropriateness, i.e., whether indication, dosage, duration, and evaluation accorded with guidelines for the treatment of challenging behavior in dementia and sleep disorders.

Results:

The prevalence of BZRA use is 39.2% (95% CI: 36.3%–42.0%): continuous 22.9%; only as-needed 16.3%. Combinations of preferred BZRAs and appropriate indications occur in 19.0% of continuous anxiolytic prescriptions and 44.8% of hypnotic prescriptions. Frequently registered inappropriate indications are aggression/agitation for anxiolytics (continuous: 75.7%; as-needed: 75.2%) and nighttime agitation for hypnotics (continuous: 40.3%; as-needed: 26.7%). None of the continuous prescriptions with appropriate indications were appropriate for all other items. For most of the prescriptions, duration and time to evaluation exceeded 4 weeks.

Conclusion:

BZRA use in nursing home residents with dementia is highly frequent. A large proportion of prescriptions do not follow the guidelines with regard to indication, exceed the recommended duration and are not evaluated in a timely manner. The discrepancy between evidence-based guidelines and daily practice calls for an exploration of factors maintaining inappropriate use.

Cost‐effectiveness of dementia training for caregivers in caregiver‐patient dyads: A randomized controlled study

Introduction

We evaluated the cost‐effectiveness of the “More at Home with Dementia” intervention, a multicomponent training program for co‐residing caregivers of people with dementia (PwDs).

Methods

We performed a two‐armed randomized controlled trial with an intervention and a control group. Participants were community‐dwelling caregivers living with a person with dementia (59 randomized to intervention and 50 to control arm). The training program lasted 5 days and took place in a holiday accommodation. Quality‐adjusted life‐years (QALYs) were calculated using the EuroQol‐5 Dimensions 3 Levels (EQ‐5D‐3L) for caregivers and PwDs. Costs for informal and formal social care, as well as health care, were collected at four times over a 6‐month period from baseline. Information on nursing home admission or death was collected for 2 years after baseline.

Results

QALYs for caregivers and PwDs added together were 0.12 higher in the intervention group compared with the control group (P = .11). After 1 year, there tended to be fewer nursing home admissions in the intervention group, but this difference was lost by 2 years (P = .19). The cost of the intervention was estimated at €1000 (USD 1090) per dyad. Compared with the control group, the intervention group used other health care and formal social care significantly less for a year after baseline (P = .02 and .001, respectively). The estimated decrease in total costs was €10,437 (P = .07), with an estimated 96% probability that the intervention was cost‐effective vs usual care.

Discussion

The multicomponent “More at Home with Dementia” training program is effective and appears to save costs compared with usual care. Savings appear to be achieved by delaying nursing home admissions and by reducing the use of other care resources. Further research is also needed to clarify if this intervention is effective for caregivers who do not live with a PwD, such as adult children, and for the caregivers of patients with other debilitating chronic diseases. At the same time, effort is advised to implement caregiver training in standard care programs.

Antipsychotics for agitation and psychosis in people with Alzheimer's disease and vascular dementia

BACKGROUND

Typical and atypical antipsychotics are widely used to treat agitation and psychosis in dementia. However, whether or not they are beneficial is uncertain. Some trials have yielded negative results and effectiveness may be outweighed by harms.

OBJECTIVES

To assess the efficacy and safety of antipsychotics for the treatment of agitation and psychosis in people with Alzheimer's disease and vascular dementia.

SEARCH METHODS

We searched ALOIS, the Cochrane Dementia and Cognitive Improvement Group's register, MEDLINE (Ovid Sp), Embase (Ovid SP), PsycINFO (Ovid SP), CINAHL (EBSCOhost), Web of Science Core Collection (ISI Web of Science), LILACS (BIREME), ClinicalTrials.gov and the World Health Organization's meta-register, and the International Clinical Trials Registry Portal on 7 January 2021. Two review authors independently screened the title and abstract of the hits, and two review authors assessed the full text of studies that got through this screening.

SELECTION CRITERIA

We included randomised, placebo-controlled, parallel-arm trials comparing the effects of antipsychotics and placebo for the treatment of agitation or psychosis in people with dementia due to Alzheimer's disease or vascular dementia, or both, irrespective of age, severity of cognitive impairment, and setting. (The majority of) participants had to have clinically significant agitation (including aggression) or psychosis or both at baseline. We excluded studies about antipsychotics that are no longer available in the USA or EU, or that are used for emergency short-term sedation. We also excluded head-to-head trials and antipsychotic withdrawal trials.

DATA COLLECTION AND ANALYSIS

The primary outcomes were (1) reduction in agitation or psychosis in participants with agitation or psychosis, respectively at baseline, and (2) the number of participants with adverse events: somnolence, extrapyramidal symptoms, any adverse event, any serious adverse event (SAE), and death. Two review authors independently extracted the necessary data and assessed risk of bias with the Cochrane risk of bias tool. We calculated the pooled effect on agitation and psychosis for typical and atypical antipsychotics separately, and the pooled risk of adverse effects independent of the target symptom (agitation or psychosis). We used RevMan Web for the analyses.

MAIN RESULTS

The search yielded 8233 separate hits. After assessing the full-text of 35 studies, we included 24 trials that met the eligibility criteria. Six trials tested a typical antipsychotic, four for agitation and two for psychosis. Twenty trials tested an atypical antipsychotic, eight for agitation and 12 for psychosis. Two trials tested both drug types. Seventeen of 26 comparisons were performed in patients with Alzheimer's disease specifically. The other nine comparisons also included patients with vascular dementia or mixed dementia. Together, the studies included 6090 participants (12 to 652 per study). The trials were performed in institutionalised, hospitalised and community-dwelling patients, or a combination of those. For typical antipsychotics (e.g. haloperidol, thiothixene), we are uncertain whether these drugs improve agitation compared with placebo (standardised mean difference (SMD) -0.36, 95% confidence interval (CI) -0.57 to -0.15, 4 studies, n = 361); very low-certainty evidence, but typical antipsychotics may improve psychosis slightly (SMD -0.29, 95% CI -0.55 to -0.03, 2studies, n= 240; low-certainty evidence) compared with placebo. These drugs probably increase the risk of somnolence (risk ratio (RR) 2.62, 95% CI 1.51 to 4.56, 3 studies, n = 466; moderate-certainty evidence) and increase extrapyramidal symptoms (RR 2.26, 95% CI 1.58 to 3.23, 3 studies, n = 467; high-certainty) evidence. There was no evidence regarding the risk of any adverse event. The risks of SAEs (RR 1.32, 95% CI 0.65 to 2.66, 1 study, n = 193) and death (RR 1.46, 95% CI 0.54 to 4.00, 6 studies, n = 578) may be increased slightly, but these estimates were very imprecise, and the certainty was low. The effect estimates for haloperidol from five trials were in line with those of the drug class. Atypical antipsychotics (e.g. risperidone, olanzapine, aripiprazole, quetiapine) probably reduce agitation slightly (SMD -0.21, 95% CI -0.30 to -0.12, 7 studies, n = 1971; moderate-certainty evidence), but probably have a negligible effect on psychosis (SMD -0.11, 95% CI -0.18 to -0.03, 12 studies, n = 3364; moderate-certainty evidence). These drugs increase the risk of somnolence (RR 1.93, 95% CI 1.57 to 2.39, 13 studies, n - 3878; high-certainty evidence) and are probably also associated with slightly increased risk of extrapyramidal symptoms (RR 1.39, 95% CI 1.14 to 1.68, 15 studies, n = 4180; moderate-certainty evidence), serious adverse events (RR 1.32, 95% CI 1.09 to 1.61, 15 studies, n= 4316; moderate-certainty evidence) and death (RR 1.36, 95% CI 0.90 to 2.05, 17 studies, n= 5032; moderate-certainty evidence), although the latter estimate was imprecise. The drugs probably have a negligible effect on the risk of any adverse event (RR 1.05, 95% CI 1.02 to 1.09, 11 studies, n = 2785; moderate-certainty evidence). The findings from seven trials for risperidone were in line with those for the drug class.

AUTHORS' CONCLUSIONS

There is some evidence that typical antipsychotics might decrease agitation and psychosis slightly in patients with dementia. Atypical antipsychotics reduce agitation in dementia slightly, but their effect on psychosis in dementia is negligible. The apparent effectiveness of the drugs seen in daily practice may be explained by a favourable natural course of the symptoms, as observed in the placebo groups. Both drug classes increase the risk of somnolence and other adverse events. If antipsychotics are considered for sedation in patients with severe and dangerous symptoms, this should be discussed openly with the patient and legal representative.

COVID-19 management in nursing homes by outbreak teams (MINUTES) - study description and data characteristics: a qualitative study

OBJECTIVES

Nursing homes are hit relatively hard by the COVID-19 pandemic. Dutch long-term care (LTC) organisations installed outbreak teams (OTs) to coordinate COVID-19 infection prevention and control. LTC organisations and relevant national policy organisations expressed the need to share experiences from these OTs that can be applied directly in COVID-19 policy. The aim of the 'COVID-19 management in nursing homes by outbreak teams' (MINUTES) study is to describe the challenges, responses and the impact of the COVID-19 pandemic in Dutch nursing homes. In this first article, we describe the MINUTES Study and present data characteristics.

DESIGN

This large-scale multicentre study has a qualitative design using manifest content analysis. The participating organisations shared their OT minutes and other meeting documents on a weekly basis. Data from week 16 (April) to week 53 (December) 2020 included the first two waves of COVID-19.

SETTING

National study with 41 large Dutch LTC organisations.

PARTICIPANTS

The LTC organisations represented 563 nursing home locations and almost 43 000 residents.

RESULTS

At least 36 of the 41 organisations had one or more SARS-CoV-2 infections among their residents. Most OTs were composed of management, medical staff, support services staff, policy advisors and communication specialists. Topics that emerged from the documents were: crisis management, isolation of residents, personal protective equipment and hygiene, staff, residents' well-being, visitor policies, testing and vaccination.

CONCLUSIONS

OT meeting minutes are a valuable data source to monitor the impact of and responses to COVID-19 in nursing homes. Depending on the course of the COVID-19 pandemic, data collection and analysis will continue until November 2021. The results are used directly in national and organisational COVID-19 policy.

The Online Life Story Book: A randomized controlled trial on the effects of a digital reminiscence intervention for people with (very) mild dementia and their informal caregivers

This paper describes a randomized controlled trial on the Online Life Story Book (OLSB), a digital reminiscence intervention for people with (very) mild dementia living at home. The aim of the study was to investigate the effectiveness of the OLSB on (i) neuropsychiatric symptoms (NPS) in persons with dementia and (ii) the distress and quality of life (QOL) of primary informal caregivers. A randomized controlled trial with individual randomization to one of two conditions was conducted: 1) intervention "Online Life Story Book"; 2) wait list control condition. In the intervention OLSB, a trained volunteer guided the participants through the process of creating an OLSB in approximately 5 meetings within a period of 8-10 weeks. Participants in the control condition received care as usual while they waited for 6 months before starting. Outcomes on NPS and distress and QOL of the informal caregiver were assessed at baseline (baseline, T0), 3 months (T1) and 6 months (T2) post baseline. Of the 42 persons with dementia, 23 were female and 19 were male. They had a mean age of 80 years, ranging from 49 to 95. The total drop-out rate was 14.3 percent. Small but insignificant effects on NPS, caregiver distress and QOL of caregivers were found with the exception of self-rated caregiver distress that reduced significantly during the intervention. One reason to explain the results might be that the included participants were in relatively good health. Practical challenges during the intervention could have affected the results as well. It might also be that the intervention caused effects on other outcomes than NPS and caregiver distress. In future research, it is important to study the effects in persons with more complaints and higher distress and to be careful in the selection of outcome variables in relation to the reminiscence functions served by the intervention.

Very frequent physical aggression and vocalizations in nursing home residents with dementia

OBJECTIVES

We investigated the 2-week prevalence and correlates of very frequent physical aggression (PA) and vocalizations in nursing home (NH)-residents with dementia.

METHOD/DESIGN

This cross-sectional study used combined data of 2074 NH-residents from four studies, collected from 119 dementia special care units in 26 Dutch NH. Very frequent PA was defined as scoring 6 or 7 on the items 'hitting', pushing', 'biting' and 'kicking' of the Cohen Mansfield Agitation Inventory; very frequent vocalizations as scoring 6 or 7 on 'screaming' and 'making strange noises'. We compared NH-residents with very frequent PA or vocalizations with residents with less frequent PA or vocalizations, assessing correlates using univariate and multivariate multilevel logistic regression analyses.

RESULTS

We found a 2-week prevalence of 2.2% (95% confidence interval (CI): 1.63-2.89) of very frequent PA and 11.5% of very frequent vocalizations (95% CI: 10.23-12.98). Very frequent PA was only associated with apathy (odds ratio (OR)=1.93, 95% CI: 1.04-3.61). Correlates of very frequent vocalizations were age (OR = 0.97, 95% CI: 0.951-0.998), dementia severity (overall p-value 0.020), antipsychotic drug use (OR = 1.56, 95% CI: 1.08-2.26), antiepileptic drug use (OR = 2.75, 95% CI: 1.34-5.68) and euphoria (OR = 2.01, 95% CI: 1.22-3.31).

CONCLUSION

Characteristics of NH-residents with very frequent PA or very frequent vocalizations differ from those of NH-residents with less frequent PA or vocalizations. Frontal lobe damage, boredom, pain and/or external factors may explain several of the found associations, but further research is necessary. Our findings may contribute to better care for these residents and thereby to improving their quality of life.

Validation of a modified ambiance scale in nursing homes

OBJECTIVES

We translated and modified an ambiance scale for use by (in)formal caregivers in Dutch nursing homes. We tested validity and reliability of the modified Ambiance Scale.

METHOD

Convenience sampling was used to enrol (in)formal caregivers in three nursing homes in the Netherlands. 104 questionnaires were filled in; 45 by informal caregivers, 46 by formal caregivers. Ten caregivers filled in the questionnaire twice for test-retest purposes. Three original items were used, and seven newly were added to form the modified Ambiance Scale. Each item consisted of an adjective pair assessing an aspect of ambiance on a scale of 1 (homelike) to 5 (institutional). Caregivers filled in the questionnaire on two different days to assess intra rater reliability. Differences in scoring between formal and informal caregivers and between original and new items were analyzed.

RESULTS

The questionnaire was easy to comprehend and fill in. Internal consistency was good (a = 0.93). Validity was found to be good. Factor analysis demonstrated that eight items identified as one factor. No differences in scoring between the first and second assessment were found (p<.001). Formal caregivers scored ambiance more chaotic than informal caregivers did (p<.01). No differences in scoring between original and new items were found (p =.06).

CONCLUSION

This study demonstrated that the modified Ambiance Scale had good internal consistency, moderate replicability and both informal and formal caregivers' overall ratings were comparable. The modified Ambiance Scale is a valid, reliable and easy to use tool to assess ambiance in nursing home settings.

Effects of Caregiver Dementia Training in Caregiver-Patient Dyads on Psychotropic Drug Prescription: A Randomized Controlled Study

Purpose

Does participating in a multicomponent intervention targeting caregivers change the prescription rates of psychotropic drugs of caregivers or the person with dementia (PWD) they live with and care for.

Patients and Methods

Participants were 142 dyads of community-dwelling cohabiting caregivers and PWD randomized to intervention or control (care as usual). Participating caregivers received the intervention in a holiday accommodation over five days in groups of two to six dyads. During this time, caregivers attended 14 psychoeducational group sessions on relevant emotional, relational, practical, financial, and social changes related to living with PWD. These sessions were delivered by a psychologist, a physiotherapist, an occupational therapist, an elderly care physician, a dietician and a social worker and included combating social isolation, planning for the future, re-rolling, medical aspects of dementia, fitness, therapeutic use of facilities, nutrition and using community services. The design was a randomized controlled trial. Outcomes were compared 3 months after baseline. Drug use for both caregivers and PWD were reported as all psychotropic drug use and specified as antipsychotic, antidepressant, and anxiolytic and hypnotic drug use based on Anatomical Therapeutic Chemical (ATC) classifications.

Results

Compared to the control group, no significant difference was observed in psychotropic drug use by 3 months after baseline among caregivers (p 0.22 MD -0.08 95% CI -0.20-0.05) or PWD (p 0.61, MD 0.04 95% -0.12-0.21) in the intervention group.

Conclusion

A multicomponent course for caregivers living with PWD did not affect psychotropic drug use by either person. This may be explained by the low level of baseline drug use and the lack of the prescribing physician involvement in the present study. The low baseline drug use likely reflects selection bias for caregiver participants who were more inclined to use psychosocial interventions in preference to psychotropic medication, making them more likely to participate in caregiver training.

Process evaluation of a tailored intervention to Reduce Inappropriate psychotropic Drug use in nursing home residents with dementia

Background

Research suggests that collaborative and tailored approaches with external expertise are important to process implementations. We therefore performed a process evaluation of an intervention using participatory action research, tailored information provision, and external coaching to reduce inappropriate psychotropic drug use among nursing home residents with dementia. The process evaluation was conducted alongside a randomized controlled trial assessing the utility of this approach.

Methods

We used Leontjevas’ model of process evaluation to guide data collection and analysis, focusing on the relevance and feasibility, extent of performance, and barriers and facilitators to implementation. Data on the relevance and feasibility and on the extent of performance were collected using a questionnaire targeting internal project leaders at nursing homes and our external coaches. Implementation barriers and facilitators were identified by individual semi-structured interviews. The Consolidated Framework for Implementation Research was used to structure and describe the identified barriers and facilitators.

Results

The intervention was viewed positively, but it was also considered time consuming due to the involvement of many people and designing a tailored action and implementation plan was viewed as complex. The extent of performance differed between nursing homes. Delays in implementation and suboptimal execution of actions may have reduced effectiveness of the RID intervention in some nursing homes. Barriers to implementation were reorganizations, staff turnover, communication issues, unclear expectations, and perceived time pressures. Implementation also depended on the involvement and skills of key stakeholders, and organizations’ readiness to change. Although external coaches stimulated implementation, their additional value was rated variably across organizations.

Conclusions

Barriers to implementation occurred on several levels and some barriers appear to be inherent to the nursing home environment and could be points of leverage of future implementation trajectories. This underlines the importance of assessing and supporting organizations in their readiness to change. Sensitivity analyses, taking into account the week in which nursing homes started with implementation and the degree to which actions were implemented as intended, will be appropriate in the effect analyses of the trial.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12877-021-02357-w.

Increasing Older Adult Involvement in Geriatric Assessment: A Mixed-Methods Process Evaluation

Objectives: Goal setting and motivational interviewing (MI) may increase well-being by promoting healthy behavior. Since we failed to show improved well-being in a proactive assessment service for community-dwelling older adults applying these techniques, we studied whether implementation processes could explain this. Methods: Goals set during the comprehensive geriatric assessment were evaluated on their potential for behavior change. MI and goal setting adherence wasassessed by reviewing audiotaped interactions and interviewing care professionals. Results: Among the 280 goals set with 230 frail older adults (mean age 77 ± 6.9 years, 59% women), more than 90% had a low potential for behavior change. Quality thresholds for MI were reached in only one of the 11 interactions. Application was hindered by the context and the limited proficiency of care professionals. Discussion: Implementation was suboptimal for goal setting and MI. This decreased the potential for improved well-being in the participating older adults.

Caregiver dementia training in caregiver-patient dyads: Process evaluation of a randomized controlled study

OBJECTIVES

We performed a randomized controlled study to evaluate the effects of caregiver training on the well-being of both people with dementia and their caregivers. Before the effect analysis, we conducted a process evaluation to estimate internal and external validity. This was anticipated to augment our understanding of the outcomes.

METHODS

We focused on three questions. (a) Was the intervention performed as planned (internal validity)? (b) Can qualitative data be used to inform how the intervention evoked change? (c) Can the study outcomes be extrapolated to all caregivers living with people who have dementia (external validity)?

RESULTS

Responses from participants assigned to the intervention group suggested that the intervention was feasible, could be performed as planned, and that modelling and discussions between participants were important. However, participant recruitment to the entire study was ultimately laborious because participants had issues with the study design (risk of being assigned to the control group) and referrers lacked familiarity with the training (new type of intervention). Participants were also younger and better educated compared with the general population. Some dropouts in the follow-up period occurred due to the number of questionnaires, and this was more pronounced in the control group.

CONCLUSIONS

Although we achieved high internal validity, we lack certainty about the external validity. We not only experienced general difficulty in recruiting participants but also tended to recruit a biased sample that was relatively young and well educated. These factors combine to limit our ability to extrapolate the results to the general population.

Prevalence and risk factors of delirium in psychogeriatric outpatients

BACKGROUND

Delirium is a serious neuropsychiatric syndrome, which requires timely treatment. However, it is easily missed, especially in older patients with premorbid cognitive disorders.

OBJECTIVES

The aim of this study is to investigate the prevalence and risk factors of delirium in older outpatients with and without dementia.

METHOD

We assessed 444 patients referred to the memory clinic of a psychiatric hospital between March 2013 and March 2014. Demographic information, medical history, impairments in daily living activities and referral information were registered. Patients underwent a psychiatric examination using the Delirium Rating Scale-Revised-98 and cognitive tests, a physical examination and laboratory tests. We recorded medication use and changes before and after the onset of symptoms.

RESULTS

Among the 444 outpatients, 85 had probable delirium (prevalence of 19%), and 10 had subsyndromal delirium (2%). The most common triggers were infection (42%), drug-intoxication or withdrawal (22%), and metabolic/endocrine disturbance (12%). Age (OR 1.07, 95% CI 1.02-1.11) and prior delirium (OR 3.34, 95% CI 1.28-8.69) were independent non-modifiable factors associated with an increased risk of delirium. The only independent modifiable risk factor was infection (OR 17.31, 95% CI 8.44-35.49).

CONCLUSIONS

A delirium was detected in one of five patients referred for dementia screening. Most patients could be treated at home. Age and prior delirium were predictive of an increased risk of delirium.

Continuous Palliative Sedation in Nursing Home Residents With Dementia and Refractory Neuropsychiatric Symptoms

OBJECTIVES

Extreme neuropsychiatric symptoms can be a heavy burden for nursing home (NH) residents, relatives, and caregivers. Sometimes, when extreme neuropsychiatric symptoms are considered refractory, continuous palliative sedation is administered. The aim of this study was to explore the trajectory leading to continuous palliative sedation and its administration in NH residents with dementia and refractory neuropsychiatric symptoms.

DESIGN

A qualitative interview and explorative study was performed.

SETTING AND PARTICIPANTS

Relatives, elderly care physicians, and other staff members involved with 3 NH residents with dementia and extreme refractory neuropsychiatric symptoms who received continuous palliative sedation were interviewed. These NH residents lived on dementia special care units of 3 NHs in the Netherlands.

METHODS

Consecutive sampling was used to select participants. Medical files were studied. Semistructured interviews were conducted. Transcriptions were analyzed with thematic analysis, including directed content analysis.

RESULTS

Nine in-depth interviews with 13 participants were held. Analysis resulted in 6 main themes, with several subthemes reflecting phases of the continuous palliative sedation trajectory: (1) run-up, describing an unbearable struggle of the resident; (2) turning point, at which hope was lost; (3) considering continuous palliative sedation and administration of intermittent sedation; (4) decision to start continuous palliative sedation based on 1 decisive trigger; (5) administration of continuous palliative sedation with stakeholders experiencing relief; and (6) evaluation.

CONCLUSIONS AND IMPLICATIONS

The trajectory leading up to continuous palliative sedation in NH residents with dementia and extreme refractory neuropsychiatric symptoms was complex and burdensome, but the initiation led to relief and contentment for all those involved. This study highlights that continuous palliative sedation can be a valuable treatment option among these residents. A recommendation is to include external consultation in the decision process and to administer intermittent sedation as a preceding step when continuous palliative sedation is considered.

The Course of Quality of Life and Its Predictors in Nursing Home Residents With Young-Onset Dementia

OBJECTIVE

To explore the course of quality of life (QoL) and possible resident-related predictors associated with this course in institutionalized people with young-onset dementia (YOD).

DESIGN

An observational longitudinal study.

SETTING AND PARTICIPANTS

A total of 278 residents with YOD were recruited from 13 YOD special care units in the Netherlands.

METHODS

Secondary analyses were conducted with longitudinal data from the Behavior and Evolution in Young-ONset Dementia (BEYOND)-II study. QoL was assessed with proxy ratings, using the Quality of Life in Dementia (QUALIDEM) questionnaire at 4 assessment points over 18 months. Predictors included age, gender, dementia subtype, length of stay, dementia severity, neuropsychiatric symptoms, and psychotropic drug use at baseline. Multilevel modeling was used to adjust for the correlation of measurements within residents and clustering of residents within nursing homes.

RESULTS

The total QUALIDEM score (range: 0-111) decreased over 18 months with a small change of 0.65 (95% confidence interval -1.27, -0.04) points per 6 months. An increase in several domains of QoL regarding care relationship, positive self-image, and feeling at home was seen over time, whereas a decline was observed in the subscales positive affect, social relations, and having something to do. Residents with higher levels of QoL and more advanced dementia at baseline showed a more progressive decline in QoL over time. Sensitivity analyses indicated a more progressive decline in QoL for residents who died during the follow-up.

CONCLUSION AND IMPLICATIONS

This study shows that although overall QoL in nursing home residents with YOD was relatively stable over 18 months, there were multidirectional changes in the QoL subscales that could be clinically relevant. Higher levels of QoL and more advanced stages of dementia at baseline predicted a more progressive decline in QoL over time. More longitudinal studies are needed to verify factors influencing QoL in YOD.

Effects of caregiver dementia training in caregiver-patient dyads: A randomized controlled study

OBJECTIVES

Caregivers for people with dementia (PWD) have reported needing emotional and social support, improved coping strategies, and better information about the illness and available support services. In this study, we aimed to determine the effectiveness of an Australian multicomponent community-based training program that we adapted and implemented in a non-medical Dutch health care setting.

METHODS AND DESIGN

A randomized controlled trial was performed: 142 dyads of cohabiting caregivers and PwD were randomized to control (care as usual) or intervention (training program) groups and outcomes were compared. Programs lasted 1 week, comprised 14 sessions, and were delivered by specialist staff. We included 16 groups of two to six caregivers. The primary outcome was care-related quality of life (CarerQol-7D) at 3 months. The main secondary outcomes for caregivers were self-rated burden, health and mood symptoms, and for PwD were neuropsychiatric symptoms, quality of life, and agitation.

RESULTS

No significant difference was observed for the primary outcome. However, caregivers experienced fewer role limitations due to physical function (adjusted mean difference, 13.04; 95% confidence interval [95%CI], 3.15-22.93), emotional function (13.52; 95%CI, 3.76-23.28), and pain reduction (9.43; 95%CI, 1.00-17.86). Positive outcomes identified by qualitative analysis included better acceptance and coping and improved knowledge of dementia and available community services and facilities.

CONCLUSION

Quantitative analysis showed that the multicomponent course did not affect care-related quality of life but did have a positive effect on experienced role limitations and pain. Qualitative analysis showed that the course met the needs of participating dyads.

A longitudinal study of the impact of social network size and loneliness on cognitive performance in depressed older adults

Objectives: To examine the association of social network size and loneliness with cognitive performance and -decline in depressed older adults.Method: A sample of 378 older adults [70.7 (7.4) years] with a Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition diagnosis of current depressive disorder were recruited from primary care and specialized mental health care. Cognitive performance was assessed at baseline and 2 years follow-up with the Stroop colored-word test, a modified version of the Auditory Verbal Learning Task and the Digit Span subtest from the Wechsler Adult Intelligence Scale, encompassing four cognitive domains; processing speed, interference control, memory, and working memory. Social network size was assessed with the Close Person Inventory and loneliness with the de Jong Gierveld Loneliness Scale at baseline.Results: After adjusting for baseline working memory performance, loneliness was associated with impaired working memory after 2 years [B = -0.08 (-0.17 to 0.00)]. This association was no longer significant after adjusting for age, sex, education level, physical activity, alcohol use and depressive symptom severity [B = -0.07 (-0.16 to 0.03)]. A backward elimination procedure revealed education level to be the only covariable to explain this association. Loneliness was not associated with impairments or decline in other cognitive domains. Social network size was not associated with cognitive impairments or decline.Conclusion: Social network size and loneliness do not predict cognitive decline in depressed older adults.

The construction of a conceptual framework explaining the relation between barriers to change of management of neuropsychiatric symptoms in nursing homes: a qualitative study using focus groups

Background

Several efforts have been made to change management of neuropsychiatric symptoms (NPS) in nursing homes, however only few were successful. Numerous barriers to change in healthcare were identified, yet only one conceptual model is known to study their interrelationships. Unfortunately, this model does not discuss specific barriers encountered in nursing home practice. The aim of this study is to explore perceived barriers to change in the management of NPS in nursing homes and to construct a conceptual framework providing insight into the relative importance and interrelationships of these barriers when improving quality of care.

Methods

Four focus groups were conducted in different dementia special care units of one Dutch nursing home. Participants were either nursing staff, treatment staff or relatives of residents. Qualitative thematic analysis was conducted according to the five phases defined by Braun & Clarke. Finally, a conceptual framework showing the interrelations of barrier-themes was constructed using text fragments of the focus groups.

Results

We constructed a conceptual framework consisting of eight themes of barriers explaining the extent to which change in NPS-management can be achieved: ‘organizational barriers’, ‘personal barriers’, ‘deficiency of staff knowledge’, ‘suboptimal communication’, ‘inadequate (multidisciplinary) collaboration’, ‘disorganization of processes’, ‘reactive coping’ and ‘differences in perception’. Addressing ‘organizational barriers’ and ‘deficiency of staff knowledge’ is a precondition for change. ‘Suboptimal communication’ and ‘inadequate (multidisciplinary) collaboration’ play a key role in the extent of change achieved via the themes ‘differences in perception’ and ‘disorganization of processes’. Furthermore, ‘personal barriers’ influence all themes - except ‘organizational barriers’ - and may cause ‘reactive coping’, which in turn may lead to ‘difficulties to structure processes’.

Conclusions

A conceptual framework was created explaining the relationships between barriers towards achieving change focused on improving management of NPS in nursing homes. After this framework has been confirmed and refined in additional research, it can be used to study the interrelatedness of barriers to change, and to determine the importance of addressing them for achieving change in the provided care.

Large Sample Size Fallacy in Trials About Antipsychotics for Neuropsychiatric Symptoms in Dementia

BACKGROUND

A typical antipsychotics for neuropsychiatric symptoms in dementia have been tested in much larger trials than the older conventional drugs. The advantage of larger sample sizes is that negative findings become less likely and the effect estimates more precise. However, as sample sizes increase, the trials also get more expensive and time consuming while exposing more patients to drugs with unknown safety profiles. Moreover, a large sample size might yield a statistically significant effect that is not necessarily clinically relevant.

OBJECTIVE

To assess (1) the variation in sample size and sample size calculations of antipsychotic trials in dementia, (2) the size of reported treatment effects and related statistical significance, and (3) general study characteristics that might be related to sample size.

STUDY DESIGN AND SETTING

We performed a meta-epidemiological study of randomized trials that tested antipsychotics for neuropsychiatric symptoms in dementia. The trials compared conventional or atypical antipsychotics with placebo or another antipsychotic. Two reviewers independently extracted sample size, sample size calculations, reported treatment effects with p-values, and general study characteristics (drug type, trial duration, type of funding). We calculated a reference sample size of 83 and 433 per study group for the placebo-controlled and head-to-head trials respectively.

RESULTS

We identified 33 placebo-controlled trials, and 18 head-to-head trials. Only 14 (42%) and 2 (11%), respectively, reported a sample size calculation. The average sample size per arm was 34 (range 6-179) in placebo-controlled trials testing conventional drugs, 107 (8-237) in such trials testing atypical drugs, and 104 (95-115) in such trials testing both drug types; it was 31 (10-88) in head-to-head trials. Thirteen out of 18 trials with sample sizes larger than required (72%) reported a statistically significant treatment effect, of which two (15%) were clinically relevant. None of the head-to-head trials reported a statistically significant treatment effect, even though some suggested non-inferiority. In placebo-controlled trials of atypical drugs, longer trial duration (>6 weeks) and commercial funding were associated with higher sample size.

CONCLUSION

Sample size calculations were poorly reported in antipsychotic trials for dementia. Placebo-controlled trials of atypical antipsychotics showed large sample size fallacy while head-to-head trials were massively underpowered.

Cost-consequence analysis of an intervention for the management of neuropsychiatric symptoms in young-onset dementia: Results from the BEYOND-II study

OBJECTIVE

To evaluate the cost-consequences of an intervention for the management of neuropsychiatric symptoms in nursing home residents with young-onset dementia.

METHODS

A stepped wedge design was used. The intervention consisted of an educational program and a multidisciplinary care program and was implemented in 13 nursing homes from September 2015 to March 2017. Costs' outcomes included the time investment of the elderly care physician and health care psychologists regarding the management of neuropsychiatric symptoms, residents' psychotropic drug use, nursing staff absenteeism, and costs of the educational program. Composite cost measure contained the sum of costs of staff absenteeism, costs on psychotropic drugs, and costs of the educational program. Costs of time investment were investigated by comparing means. Costs of psychotropic drug use were analyzed with mixed models at resident level and as part of the composite cost measure on unit level. Staff absenteeism was also analyzed at unit level.

RESULTS

Compared with care as usual, the mean costs of time invested decreased with €36.79 for the elderly care physician but increased with €46.05 for the health care psychologist in the intervention condition. Mixed model analysis showed no effect of the intervention compared with care as usual on the costs of psychotropic drug use, staff absenteeism, and the composite cost measure. The costs of the educational program were on average €174.13 per resident.

CONCLUSION

The intervention did not result in increased costs compared with care as usual. Other aspects, such as the lack of a structured working method, should be taken into account when considering implementation of the intervention.

Run-in periods and clinical outcomes of antipsychotics in dementia: A meta-epidemiological study of placebo-controlled trials

Purpose

Run‐in periods are used to identify placebo‐responders and washout. Our aim was to assess the association of run‐in periods with clinical outcomes of antipsychotics in dementia.

Methods

We searched randomized placebo‐controlled trials of conventional and atypical antipsychotics for neuropsychiatric symptoms (NPS) in dementia in electronic sources and references of selected articles. We extracted (a) the presence of a run‐in period, use of placebo/investigated drug during run‐in (versus washout only), and run‐in duration (1 week or more) and (b) the reduction in NPS, number of participants with somnolence, extrapyramidal symptoms (EPS), and deaths per treatment group. We pooled clinical outcomes comparing antipsychotic and placebo groups in trials with and without run‐in.

Results

We identified 35 trials. Twenty‐nine trials used run‐in. The pooled standardized mean difference in the reduction of NPS was −0.170 (95% CI, −0.227 to −0.112) in trials with run‐in and −0.142 (95% CI, −0.331 to 0.047) in trials without run‐in. The pooled odds ratio for somnolence was 2.8 (95% CI, 2.3‐3.5) in trials with run‐in and 3.5 (95% CI, 1.2‐10.7) in trials without run‐in; for EPS, these ORs were 1.8 (95% CI, 1.4‐2.2) and 2.0 (95% CI, 1.3‐3.1) respectively, and for mortality 1.4 (95% CI, 1.0‐2.0) and 1.6 (95% CI, 0.7‐3.4). The use of placebo/investigated drug during run‐in and run‐in duration did not affect the estimates in a consistent way.

Conclusions

The use of run‐in in trials might have led to overestimated efficacy and especially underestimated risks of side effects of antipsychotics compared with placebo for NPS in dementia.

Effects Of Increasing The Involvement Of Community-Dwelling Frail Older Adults In A Proactive Assessment Service: A Pragmatic Trial

BACKGROUND

Older adults and care professionals advocate a more integrated and proactive care approach. This can be achieved by proactive outpatient assessment services that offer comprehensive geriatric assessments to better understand the needs of older adults and deliver person-centered and preventive care. However, the effects of these services are inconsistent. Increased involvement of the older adult during the assessment service could increase the effects on older adult's well-being.

METHODS

We studied the effect of an assessment service (Sage-atAge) for community-dwelling frail adults aged ≥65 years. After studying the local experiences, this service was adapted with the aim to increase participant involvement through individual goal setting and using motivational interviewing techniques by health-care professionals (Sage-atAge+). Within Sage-atAge+, when finishing the assessment, a "goal card" was written together with the older adult: a summary of the assessment, including goals and recommendations. We measured well-being with a composite endpoint consisting of health, psychological, quality of life, and social components. With regression analysis, we compared the effects of the Sage-atAge and Sage-atAge+ services on the well-being of participants.

RESULTS

In total, 453 older adults were eligible for analysis with a mean age of 77 (± 7.0) years of whom 62% were women. We found no significant difference in the change in well-being scores between the Sage-atAge+ service and the original Sage-atAge service (B, 0.037; 95% CI, -0.188 to 0.263). Also, no change in well-being scores was found even when selecting only those participants for the Sage-atAge+ group who received a goal card.

CONCLUSION

Efforts to increase the involvement of older adults through motivational interviewing and goal setting showed no additional effect on well-being. Further research is needed to explore the relationship between increased participant involvement and well-being to further develop person-centered care for older adults.

Reducing inappropriate psychotropic drug use in nursing home residents with dementia: protocol for participatory action research in a stepped-wedge cluster randomized trial

BACKGROUND

Psychotropic drugs are often prescribed to treat neuropsychiatric symptoms in nursing home residents with dementia, despite having limited efficacy and considerable side effects. To reduce the inappropriate prescribing of these psychotropic drugs, various non-pharmacological, psychosocial, person-centered, or multidisciplinary interventions are advocated. However, existing multidisciplinary interventions have shown variable effects, with limited effectiveness often resulting from suboptimal implementation. We hypothesize that an effective intervention needs to fit the local situation of a nursing home and that support should be offered during implementation.

METHODS

We will embed participatory action research within a stepped-wedge cluster randomized controlled trial to study the effects of a tailored intervention and implementation plan to reduce inappropriate psychotropic drug prescribing. Nursing homes will be provided with tailored information about the perceived problems of managing neuropsychiatric symptoms and we will offer coaching support throughout. Alongside the participatory action research, we will perform a process evaluation to examine the quality of the study, the intervention, and the implementation. Our aim is to recruit 600 residents from 16 nursing homes throughout the Netherlands, with measurements taken at baseline, 8 months, and 16 months. Nursing homes will be randomly allocated to an intervention or a deferred intervention group. During each intervention stage, we will provide information about inappropriate psychotropic drug prescribing, neuropsychiatric symptoms, and difficulties in managing neuropsychiatric symptoms through collaboration with each nursing home. After this, a tailored intervention and implementation plan will be written and implemented, guided by a coach. The primary outcome will be the reduction of inappropriate prescribing, as measured by the Appropriate Psychotropic drug use In Dementia index. Secondary outcomes will be the frequency of psychotropic drug use and neuropsychiatric symptoms, plus quality of life. A mixed methods design will be used for the process evaluation. Effects will be assessed using multilevel analyses. The project leader of the nursing home and the coach will complete questionnaires and in-depth interviews.

DISCUSSION

We anticipate that the proposed tailored intervention with coaching will reduce inappropriate psychotropic drug prescribing for nursing home residents with neuropsychiatric symptoms. This study should also provide insights into the barriers to, and facilitators of, implementation.

TRIAL REGISTRATION

NTR5872 , registered on July 2, 2016.

Goal planning in person-centred care supports older adults receiving case management to attain their health-related goals

PURPOSE

Care for older adults should preferably be provided in a person-centred way that includes goal planning. The aim of the present cohort study is to gain an insight into the results of goal planning, in a person-centred care setting for community-living older adults.

MATERIALS AND METHODS

Within Embrace, a person-centred and integrated care service, older adults set goals with the aim to improve health-related problems. For every goal, they rated severity scores ranging from 0 (no problem) to 10 (extremely severe): a baseline score, a target score and, within one year, an end score to evaluate these goals. The differences between baseline and end scores (goal progress) and target and end scores (goal attainment), and the percentage of goals attained were calculated and compared between health-related domains (i.e., mental health, physical health, mobility, and support).

RESULTS

Among 233 older adults, 836 goal plans were formulated of which 74% (95% Confidence Interval: 71-77) were attained. Goals related to physical health were the most likely to be attained and goals for mobility and pain the least likely.

CONCLUSIONS

Older adults are able to attain health-related goals through collaborative goal planning. We recommend future integrated care programmes for older adults to incorporate goal-planning methods to achieve person-centred care.IMPLICATIONS FOR REHABILITATIONOlder adults experiencing frailty or complex care needs and receiving individual support within an integrated care setting are able to formulate and attain goals using goal planning with severity scores.Goal plans of community-living older adults mostly aim at improving health-related problems concerning physical health, mobility, or support.Goals related to physical health are the most likely to be attained, while goals for mobility and pain are the least likely to be attained.

Barriers and Facilitators of Conducting Medication Reviews in Nursing Home Residents: A Qualitative Study

Objectives: Inappropriate medication prescribing is a recognized clinical problem in nursing home residents of whom many have polypharmacy. However, results about the effectiveness of medication reviews targeted at improving prescribing and deprescribing have been equivocal. We therefore examined barriers and facilitators of conducting medication reviews. Method: We purposively sampled medication reviews to capture salient barriers and facilitators of conducting medication reviews both in nursing home care units for dementia and disabling conditions. We held semi-structured interviews about consecutive steps of medication reviews. Interviews were transcribed verbatim and analyzed with the "method of constant comparison." Results: Six nursing home residents/relatives of nursing home residents, 8 elder care physicians, 5 pharmacists, and 10 nurses took part in the semi-structured interviews. We observed four overarching themes of barriers and facilitators: "realizing fidelity of the patient perspective (theme 1)," "level of comprehensiveness of medication reviews (theme 2)," "inclinations of healthcare providers (theme 3)," and "inter-professional collaboration and alliances (theme 4)." Theme 1 "realizing fidelity of the patient perspective" referred to the observation that assessing the patient perspective was a delicate balance between the value and the impediments of a proper assessment of the patient perspective. Theme 2 "level of comprehensiveness of medication reviews" reflected the struggle of practitioners to find an optimum between medication reviews being both comprehensive and feasible. Theme 3 "inclinations of healthcare providers" concerned setting intervention targets that were complementary to the practices of physicians and keeping the pharmacist blind to the patient perspective as a countermeasure to physicians' inclinations. Finally, theme 4 "inter-professional collaboration and alliances" highlighted mutual support and inter-professional collaboration to strengthen healthcare practitioners' contributions. Discussion: These themes of barriers and facilitators emphasize the need to improve meta-communication during the medication review process. This pertains to the need for healthcare providers to appraise the fidelity of the patient perspective in a dialogue with residents/relatives. Furthermore, discourse between healthcare practitioners is needed beforehand about the level of comprehensiveness intervention targets, and inter-professional collaboration.