Consent and Inclusion of People Living with Dementia (PLWD) in Research: Establishing a Canadian Agenda for Inclusive Rights-Based Practices

BACKGROUND

People living with dementia (PLWD) may want to participate in research, but the guidelines and processes enacted across various contexts may prohibit this from happening.

OBJECTIVE

Understanding the experiences of people with lived experiences of dementia requires meaningful inclusion in research, as is consistent with rights-based perspectives. Currently, the inclusion of PLWD in Canadian research is complex, and guidelines and conceptual frameworks have not been fully developed.

METHODS

This research note outlines a three-year proof-of-concept grant on the inclusion and consent of PLWD in research.

FINDINGS

It presents a brief report on some of the contradictions and challenges that exist in legislation, research guidelines, and research practices and raises a series of questions as part of an agenda on rights and inclusion of PLWD in research.

DISCUSSION

It suggests conceptual, legal, and policy issues that need to be addressed and invites Canadian researchers to re-envision research practices and to advocate for law and policy reform that enables dementia research to align and respect the rights and personhood of PLWD.

Working with a robot in hospital and long-term care homes: staff experience

Although there is a growing literature on the use of telepresence robots in institutional dementia care settings, limited research focused on the perspectives of frontline staff members who deliver dementia care. Our objective was to understand staff perspectives on using telepresence robots to support residents with dementia and their families. Guided by the Consolidated Framework for Implementation Research, we conducted four focus groups and 11 semi-structured interviews across four long-term care (LTC) homes and one hospital in Canada. We included 22 interdisciplinary staff members (e.g., registered nurses, social workers, occupational therapists, recreational therapists) to understand their experiences with telepresence robots. Thematic analysis identified three key themes: 1) Staff Training and Support; 2) Robot Features; 3) Environmental dynamics for Implementation. Our results underscore the imperative of structural support at micro-, meso- and macro-levels for staff in dementia care settings to effectively implement technology. This study contributes to future research and practice by elucidating factors facilitating staff involvement in technology research, integrating staff voices into technology implementation planning, and devising strategies to provide structural support to staff, care teams, and care homes.

The Perspective of Nurses and Healthcare Providers on the use of Television Videos with People with Moderate to Severe Dementia

BACKGROUND

Nurses and healthcare providers need practical tools to deliver person-centred care in hospitals and long-term care homes. Few non-pharmacological interventions are designed to meet the needs of people with moderate to severe dementia. Dementia-friendly television videos (TV videos) offer a familiar stimulation with the potential for meaningful engagement in the relational space of technology. TV videos refer to moving visuals with audio that can be shown on TV and other devices. They can be used for different purposes for people with dementia, such as stimulating memories and facilitating expressions.

PURPOSE

This study aims to understand the perspectives of nurses and healthcare providers on the potential function and practice considerations of using TV videos for people with moderate to severe dementia.

METHODS

We conducted five focus groups with 23 nurses and healthcare providers in a long-term care home and a geriatric hospital unit. Data were analyzed using reflexive thematic analysis and guided by Kitwood's person-centred care model.

RESULTS

Our analysis identified five themes about the use of TV videos: (1) calm the person with dementia who is in emotional distress, (2) form connections with the person with dementia, (3) bring people with dementia together, (4) facilitate the Person's Activities of Daily Living (ADLs), (5) help the person connect with their past.

CONCLUSION

TV videos should be designed to match the person's cognitive abilities, interests, and cultural and linguistic backgrounds. Our findings supplemented Kitwood's model by identifying the person's cultural and language needs.

Dementia care and prevention in community settings: a built environment framework for cognitive health promotion

PURPOSE OF REVIEW

Most people with dementia live in the community. As lifespan increases, one in three persons aged 85+ are expected to live with dementia. We conduct a systematic search to identify frameworks for dementia care and prevention in community settings. This is important to ensure quality of life for people living with cognitive decline (PLCD).

RECENT FINDINGS

61 frameworks are synthesized into the dementia care and prevention in community (DCPC) framework. It highlights three levels of provision: built environment and policy supports, access and innovation, and inclusion across stages of decline. Domains of intervention include: basic needs; built environment health and accessibility; service access and use; community health infrastructure; community engagement; mental health and wellbeing; technology; end-of-life care; cultural considerations; policy, education, and resources. Personhood is not adequately represented in current built environment frameworks. This is supplemented with 14 articles on lived experiences at home and social practices that contribute to PLCD's social identity and psychological safety.

SUMMARY

Policy makers, health and built environment professionals must work together to promote "personhood in community" with PLCD. Clinicians and community staff may focus on inclusion, social identity and a sense of at-homeness as attainable outcomes despite diagnosis.

The perceptions of university students on technological and ethical risks of using robots in long-term care homes

Introduction: The COVID-19 pandemic has disproportionately impacted long-term care (LTC) residents and exacerbated residents' risks of social isolation and loneliness. The unmet emotional needs of residents in LTC have driven researchers and decision-makers to consider novel technologies to improve care and quality of life for residents. Ageist stereotypes have contributed to the underuse of technologies by the older population. Telepresence robots have been found to be easy to use and do not require older adults to learn how to operate the robot but are remotely controlled by family members. The study aimed to understand the perspectives of multidisciplinary university students, including healthcare students, on using telepresence robots in LTC homes. The study would contribute to the future planning, implementation, and design of robotics in LTC. Methods: Between December 2021 and March 2022, our team conducted interviews with 15 multidisciplinary students. We employed a qualitative descriptive (QD) approach with semi-structured interview methods. Our study aimed to understand the perspectives of university students (under the age of 40) on using telepresence robots in LTC homes. Participants were invited to spend 15 min remotely driving a telepresence robot prior to the interview. A diverse team of young researchers and older adults (patient and family partners) conducted reflexive thematic analysis. Results: Six themes were identified: Robots as supplementary interaction; privacy, confidentiality, and physical harm; increased mental well-being and opportunities for interactions; intergenerational perspectives add values; staffing capacity; environmental and cultural factors influence acceptance. Conclusion: We identified a diverse range of perspectives regarding risk and privacy among participants regarding the implementation of telepresence robots in long-term care. Participants shared the importance of the voice of the resident and their own for creating more equitable decision-making and advocating for including this type of technology within LTC. Our study would contribute to the future planning, implementation, and design of robotics in LTC.

Healthy grocery delivery in the usual care for adults recovering from an acute coronary event: protocol for a three-arm randomised controlled trial

INTRODUCTION

Coronary heart disease is a major contributor to the global burden of disease. Appropriate nutrition is a cornerstone of the prevention and treatment of coronary heart disease; however, barriers including cost and access to recommended foods limits long-term adherence for many. We are conducting, in adults with coronary heart disease, a randomised controlled trial comparing usual care with two dietary interventions in which usual care is augmented by 12 weeks free delivered groceries.

METHODS AND ANALYSIS

Three hundred adults recovering from an acute coronary event will be recruited from outpatient cardiovascular services in three regions of Aotearoa New Zealand. Participants will be randomly allocated to three arms: usual care (control group), usual care and the free delivery of foods high in dietary fibre or usual care and the free delivery of foods high in unsaturated fats. Interventions duration is 12 weeks, with a further 12 months follow-up. The primary outcome measures are change in low-density lipoprotein (LDL) cholesterol concentration following the intervention, and a cost-effectiveness analysis of healthcare access and social costs in the year after the intervention. A broad range of secondary outcome measures include other blood lipids, anthropometry, glycaemia, inflammatory markers, gut microbiome, dietary biomarkers, food acceptability, dietary change and the facilitators and barriers to dietary change. The trial will determine whether the free provision of groceries known to reduce cardiovascular risk within usual care will be clinically beneficial and justify the cost of doing so. Results may also provide an indication of the relative benefit of foods rich in dietary fibre or unsaturated fats in coronary heart disease management.

ETHICS AND DISSEMINATION

This trial, The Healthy Heart Study, has Health and Disability Ethics Committee approval (20/NTB/121), underwent Māori consultation, and has locality authority to be conducted in Canterbury, Otago and Southland.

TRIAL REGISTRATION NUMBER

ACTRN12620000689976, U1111-1250-1499.

Staff's Attitudes towards the Use of Mobile Telepresence Robots in Long-Term Care Homes in Canada

This cross-sectional study investigated staff's attitudes towards the use of mobile telepresence robots in long-term care (LTC) homes in western Canada. We drew on a Health Technology Assessment Core Model 3.0 to design a survey examining attitudes towards nine domains of mobile telepresence robots. Staff, including nurses, care staff, and managers, from two LTC homes were invited to participate. Statistical analysis of survey data from 181 participants revealed that overall, participants showed positive attitudes towards features and characteristics, self-efficacy on technology use, organizational aspects, clinical effectiveness, and residents and social aspects; neutral attitudes towards residents' ability to use technology, and costs; and negative attitudes towards safety and privacy. Participants who disclosed their demographic backgrounds tended to exhibit more positive attitudes than participants who did not. Content analysis of textual data identified specific concerns and benefits of using the robots. We discuss options for implementing mobile telepresence robots in LTC.

Call to action-the urgent need for a heart health plan in New Zealand

Cardiovascular diseases are responsible for almost 10,000 deaths annually in Aotearoa New Zealand. Almost a quarter of these are avoidable, increasing to half of all cardiovascular deaths for Māori and Pacific people. Health system reforms are an opportunity to set clear ambitious goals for improved heart health. This has been done for smoking, a cancer plan, mental health and diabetes among other health conditions. Given the scale of avoidable heart disease and avoidable heart health inequity, much of it due to people simply not accessing existing treatment options, there is no excuse not to deliver a national heart health action plan and we urge health policy makers to put it on the agenda.

Co-design of a digital app "WhatMatters" to support person-centred care: A critical reflection

BACKGROUND

People with dementia often do not receive optimal person-centred care (PCC) in care settings. Family members can play a vital role as care partners to support the person with dementia with their psychosocial needs. Participatory research that includes the perspectives of those with lived experience is essential for developing high-quality dementia care and practices.

OBJECTIVE

Throughout 2021-2022, a mobile app, called WhatMatters, was co-developed to provide easy-to-access and personalised support for people with dementia in hospitals and long-term care homes, with input from patients/residents, family partners and healthcare staff. This article discusses and critically reflects on the experiences of patients/residents, family partners, and healthcare staff involved in the co-design process.

METHODS

For the app development, we applied a participatory co-design approach, guided by a User Experience (UX) model. The process involved co-design workshops and user testing sessions with users (patients/residents, family partners, healthcare staff) to co-develop the WhatMatters prototype. We also conducted focus groups and one on one interviews with staff and caregiver participants to explore their experiences. Our research team, which also included patient partners, took part in regular team meetings during the app's development, where we discussed and reflected on the co-design process. Reflexive thematic analysis was performed to identify themes that represent the challenges and rewarding experiences of the users involved in the co-design process, which guided our overall reflective process.

FINDINGS

Our reflective analysis identified five themes (1) clarifying the co-design process, (2) ensuring inclusive collaborations of various users, and (3) supporting expression of emotion in a virtual environment, (4) feeling a sense of achievement and (5) feeling valued.

IMPLICATIONS

WhatMatters offers potential for providing personally relevant and engaging resources in dementia care. Including the voices of relevant users is crucial to ensure meaningful benefits for patients/residents. We offer insights and lessons learned about the co-design process, and explore the challenges of involving people with lived experiences of dementia in co-design work, particularly during the pandemic.

Participatory action research: An exploration from a Freirean perspective of research involving people with dementia

BACKGROUND

Researchers are increasingly being called upon to involve people with dementia in research that pertains to them. Participatory Action Research (PAR) has been one of the approaches that has been utilized to do this. How people understand and apply the ideas behind this approach however has often been atheoretical and diverse. This has implications for how purpose, power, voice and agency are conceived and actualized.

OBJECTIVES

This paper will examine how theoretical construction of PAR can inform the process of meaningfully involving people living with dementia in research. Specifically, drawing on the work of Paulo Freire, this paper will articulate a way of conceptualizing PAR that is explicitly critical and then demonstrate how these ideas informed a PAR study focused on addressing stigma and discrimination with people living with dementia.

CONCLUSION

The purpose of the paper is to engage researchers and people with lived expertise in critical reflection of what it actually means to involve people with dementia in research.

The effects of wholegrain processing on appetite: randomised crossover trial in adults with type 2 diabetes

Aims: Recent observational data indicate higher ultra-processed food intakes are associated with a broad range of adverse health outcomes. Experimental studies on why this might be are lacking. We have considered the effects of wholegrain processing on measures of appetite in free-living adults with type 2 diabetes. Materials and methods: Participants were randomised to two interventions of two-weeks duration, separated by washout. Interventions were nutrient-matched wholegrain foods that differed by the amount of processing. Self-reported hunger and satiety were indicated on visual analogue scales before or after meals for four days at baseline and the end of each intervention. Metabolite markers of appetite were measured pre and post intervention in fasting plasma. Results: 31 adults (63 ± 13 years old, BMI 32.4 ± 7, HbA1c 7.5 ± 3.4% (59 ± 14 mmol mol-1)) commenced the trial, 28 (90%) completed both interventions. Wholegrain consumption, as measured by alkylresorcinols, was balanced between interventions. Self-reported pre-meal hunger was consistently lower at breakfast (MD, mean difference 0.49/10 95% CI 0.03 to 0.94), lunch (MD 0.67/10 95% CI 0.09 to 1.25), and dinner (MD -0.71/10 95% CI 0.19 to 1.23) during the intervention of less processed whole grains when compared with pre-intervention measures, however this did not result in a difference between interventions. Change in metabolite markers of appetite did not differ between interventions. Conclusions: A significant difference in hunger or satiety between less and more processed whole grains over intervention periods of two weeks was not detected within the current trial. Further experimental studies are needed to consider the potential effects of food processing on physiological processes such as appetite to provide mechanistic understanding behind observations of highly processed food intakes and adverse health outcomes.

Beyond Plan-Do-Study-Act cycle - staff perceptions on facilitators and barriers to the implementation of telepresence robots in long-term care

BACKGROUND

Quality improvement (QI) programs with technology implementations have been introduced to long-term care (LTC) to improve residents' quality of life. Plan-Do-Study-Act (PDSA) cycle is commonly adopted in QI projects. There should be an appropriate investment of resources to enhance learning from iterative PDSA cycles. Recently, scholars explored possibilities of implementation science (IS) with QI methods to increase QI projects' generalisability and make them more widely applicable in other healthcare contexts. To date, scant examples demonstrate the complementary use of the two methods in QI projects involving technology implementation. This qualitative study explores staff and leadership teams' perspectives on facilitators and barriers of a QI project to implement telepresence robots in LTC guided by the Consolidated Framework for Implementation Research (CFIR).

METHODS

We employed purposive and snowballing methods to recruit 22 participants from two LTC in British Columbia, Canada: operational and unit leaders and interdisciplinary staff, including nursing staff, care aides, and allied health practitioners. CFIR was used to guide data collection and analysis. Semi-structured interviews and focus groups were conducted through in-person and virtual meetings. Thematic analysis was employed to generate insights into participants' perspectives.

RESULTS

Our analysis identified three themes: (a) The essential needs for family-resident connections, (b) Meaningful engagement builds partnership, and (c) Training and timely support gives confidence. Based on the findings and CFIR guidance, we demonstrate how to plan strategies in upcoming PDSA cycles and offer an easy-to-use tool 'START' to encourage the practical application of evidence-based strategies in technology implementation: Share benefits and failures; Tailor planning with staff partners; Acknowledge staff concerns; Recruit opinion leaders early; and Target residents' needs.

CONCLUSIONS

Our study offers pragmatic insights into the complementary application of CFIR with PDSA methods in QI projects on implementing technologies in LTC. Healthcare leaders should consider evidence-based strategies in implementing innovations beyond PDSA cycles.

Telepresence Robots in Long-Term Care Settings in British Columbia During the COVID-19 Pandemic: Analyzing the Experiences of Residents and Family Members

Telepresence robots are being increasingly used in long-term care (LTC) homes for virtual visits between families and residents. This study investigated the impacts and experiences of residents and their families using a telepresence robot (Double 3) for 4 to 12 months during the COVID-19 pandemic. A total of 51 participants were recruited through purposive sampling, including 9 residents, 15 family members, and 27 staff from 4 LTC homes in British Columbia, Canada. Conversational interviews were conducted with residents and family members. Focus groups and one-to-one interviews were held with frontline staff. Thematic analysis was performed, with five themes identified: (1) Stay connected, (2) Regain autonomy, (3) Relieve caregiver burden, (4) Environmental and technical issues, and (5) Scheduling concerns. In conclusion, telepresence robots helped maintain social connections between residents and families, despite the COVID-19 restrictions.

Periderm Fate during Palatogenesis: TGF-β and Periderm Dedifferentiation

Failure of palatogenesis results in cleft palate, one of the most common congenital disabilities in humans. During the final phases of palatogenesis, the protective function of the peridermal cell layer must be eliminated for the medial edge epithelia to adhere properly, which is a prerequisite for the successful fusion of the secondary palate. However, a deeper understanding of the role and fate of the periderm in palatal adherence and fusion has been hampered due to a lack of appropriate periderm-specific genetic tools to examine this cell type in vivo. Here we used the cytokeratin-6A (Krt-6a) locus to develop both constitutive (Krt6ai-Cre) and inducible (Krt6ai-CreERT2) periderm-specific Cre driver mouse lines. These novel lines allowed us to achieve both the spatial and temporal control needed to dissect the periderm fate on a cellular resolution during palatogenesis. Our studies suggest that, already before the opposing palatal shelves contact each other, at least some palatal periderm cells start to gradually lose their squamous periderm-like phenotype and dedifferentiate into cuboidal cells, reminiscent of the basal epithelial cells seen in the palatal midline seam. Moreover, we show that transforming growth factor-β (TGF-β) signaling plays a critical periderm-specific role in palatogenesis. Thirty-three percent of embryos lacking a gene encoding the TGF-β type I receptor (Tgfbr1) in the periderm display a complete cleft of the secondary palate. Our subsequent experiments demonstrated that Tgfbr1-deficient periderm fails to undergo appropriate dedifferentiation. These studies define the periderm cell fate during palatogenesis and reveal a novel, critical role for TGF-β signaling in periderm dedifferentiation, which is a prerequisite for appropriate palatal epithelial adhesion and fusion.

Using telepresence robots as a tool to engage patient and family partners in dementia research during COVID-19 pandemic: a qualitative participatory study

BACKGROUND

Long-term care (LTC) settings have been disproportionately affected by the COVID-19 pandemic; it is important to address unmet needs and explore practical strategies for supporting LTC residents and staff. The involvement of patient partners and family community members in research planning, implementation and evaluation is the basis of Patient and Public Involvement approach and has been challenging during the COVID-19 pandemic, as visitation restrictions have created barriers to conducting research in healthcare settings. Innovative methods and tools are needed for conducting participatory research. This study investigated the use of telepresence as innovative tools for participatory research based on three projects conducted with patient and family partners during the COVID-19 pandemic.

METHODS

The data source includes (a) team reflective discussions, (b) weekly meeting notes, (c) field notes, and (d) interviews with ten researchers. We applied purposive sampling to select ten researchers who used a telepresence robot to conduct research in British Columbia, Canada. Semi-structured one-to-one interviews were conducted via Zoom virtual meetings. Patient and family partners contributed to team analysis to identify themes.

RESULTS

Analysis of the data produced five themes: (1) Research Enabler, (2) User-Friendly Technology, (3) Increased Engagement, (4) Lack of Infrastructure and Resources, and (5) Training and Technical Obstacles. Based on the results, we propose "ROBOT"-an acronym for five actionable recommendations to support the use of telepresence robots for research. The ROBOT recommendations represent: Realign to adapt, Organize with champions, Blend strategies, Offer timely technical assistance, and Tailor training to individual needs.

CONCLUSIONS

This study offers practical insights into the use of telepresence robots as a safe and innovative tool for conducting remote research with people with dementia, even in times of restricted access, as with COVID-19. Future research should apply more creativity and flexibility in adopting technology to expand possibilities for involving people with dementia in research.

Using the Consolidated Framework for Implementation Research to Foster the Adoption of a New Dementia Education Game During the COVID-19 Pandemic

BACKGROUND AND OBJECTIVES

The pandemic of coronavirus disease 2019 challenged educators to move staff education online and explore innovative ways to motivate learning to support dementia care for patients in geriatric settings. This article presents how the Consolidated Framework for Implementation Research (CFIR) was used to support the adoption of an online dementia education game in Canadian hospitals and long-term care homes (LTC). The dementia education was codeveloped with local staff and patient partners to teach practical person-centered care communication techniques.

RESEARCH DESIGN AND METHODS

CFIR guided our strategy development for overcoming barriers to implementation. Research meetings were conducted with practice leaders, frontline health care workers, and a patient partner. Our analysis examined 4 interactive domains: intervention, inner context, outer settings, and individuals involved and implementation process.

RESULTS

Our analysis identified 5 effective strategies: Easy access, Give extrinsic and intrinsic rewards, Apply implementation science theory, Multiple tools, and Engagement of champion. The CFIR provided a systematic process, a comprehensive understanding of barriers, and possible enabling strategies to implement gamified dementia education. Interdisciplinary staff (n = 3,025) in 10 hospitals and 10 LTC played online games. The evaluation showed positive outcomes in knowledge improvement in person-centered dementia care.

DISCUSSION AND IMPLICATIONS

Gamified education in dementia care offers a social experience and a component of fun to promote adoption. In addition, CFIR is useful for engaging stakeholders to conduct project planning and team reflection for implementation. The real-time discussion and adjustment helped overcome challenges and timely meet the needs of multiple organizations.

Facilitators and Barriers to Using Virtual Reality and its Impact on Social Engagement in Aged Care Settings: A Scoping Review

Aim: This scoping review aims to identify the facilitators and barriers to the implementation of VR technology in the aged-care setting. Background: Virtual reality (VR) offers the potential to reduce social isolation and loneliness through increased social engagement in aged-care settings. Methods and Analysis: This scoping review followed the Joanna Briggs Institute scoping review methodology and took place between March and August 2022. The review included a three-step search strategy: (1) identifying keywords from CINHAL, Embase, Medline, PsycInfo, Scopus, and Web of Science (2) conducting a second search using all identified keywords and index terms across selected databases; and (3) searching the reference lists of all included articles and reports for additional studies. Results: The final review included 22 articles. The analysis identified factors affecting the VR technology implementation in aged care settings to reduce isolation and loneliness: (a) key facilitators are local champions and staff training. (b) barriers include technological adaptability, video quality, and organizational culture. Conclusion: Existing evidence points to VR as a promising intervention to decrease loneliness and feelings of isolation and improve social engagement in older people living in aged-care settings.

THE WHATMATTERS APP: CO-DESIGNING PERSON-CENTERED CARE FOR PEOPLE WITH DEMENTIA IN CARE SETTINGS

The purpose of our study is to provide comfort through digital resources (e.g., music and visual materials) for patients/residents with dementia in hospitals and long-term care. By working with users (patients/residents, families, and staff) and using a co-design approach, we have developed a mobile app prototype called “WhatMatters” to equip staff with a useful digital tool for delivering person-centered care in hospitals and long-term care homes. Using user experience co-design methods, we conducted a series of virtual co-design workshops with acute and long-term care staff (n=10), clinical experts (n=3), residents (n=3), and patient and family partners (n=7) to understand: (a) what “comfort” means, (b) how care needs are communicated and provided for, and (c) how a mobile app may be used to support psychosocial needs of people living with dementia in hospital and long-term care settings. Thematic analysis has identified three themes to inform the development of the mobile app WhatMatters: (a) familiarity brings comfort, (b) sharing of information between staff and families allows for continuity of care and person-centered care, and (c) accessible and curated content can evoke memories and create a comforting space. Our study conclusions are: It is feasible and necessary to work with users (including clinical staff, patient, and family partners) and relevant stakeholders to co-design a mobile app, a useful tool to support the delivery of person-centered care in care settings.

IMPLEMENTING VISUAL VIDEOS AND IMAGES WITH PEOPLE WITH DEMENTIA IN CARE SETTINGS: A SCOPING REVIEW

There is limited literature on using visual videos and images with people with dementia in care settings. We conducted a scoping review on this topic to fill this literature gap. Our scoping review adopted the Joanna Briggs Institute scoping review methodology. We eventually included eleven papers for the review and conducted the content analysis. We found the facilitators for implementing visual videos and images with people with dementia in care settings: 1. Matching people’s interests 2. Being congruent with people’s cognitive abilities 3. Support from families and staff 4. Using in a group setting. We also found the barriers: 1. Staff is unwilling to support 2. Lack of resources 3. Not congruent with the cognitive or other abilities of the people. We found benefits of using visual videos and images with this population: 1. Encourage expression 2. Facilitate discussions with other people 3. Improve well-being. We also found drawbacks: the potential of arousing negative emotions and memories. We suggest future research should include the voices of people with dementia, staff should be trained to support the people in case negative memories and emotions are aroused, and there should be consideration of using visual videos and images to tackle isolation and loneliness in care settings. With these findings, this scoping review should shed light on implementing visual videos and images in care settings.

FLIPPING STIGMA ON ITS EAR: A TOOLKIT FROM PARTICIPATORY ACTION RESEARCH

People living with dementia face persistent stigma, discrimination and social exclusion, with significant emotional, physical and social consequences. Addressing this requires changing attitudes and fostering actions for communities to include people with dementia as citizens with agency and self-determination. This presentation highlights the work of an Action Group (AG) of people living with dementia. As part of a four-year Participatory Action Research study aimed at addressing the stigma, discrimination and social exclusion that is so common to the dementia experience, members of the AG in partnership with the research team developed the Flipping Stigma on its Ear Toolkit. Focus will be on the action-oriented nature of this research project, an overview of the toolkit, and exploration of the communal space that was created by AG members in the process of working together, learning from one another, and making a collective contribution towards addressing stigma, discrimination and social exclusion.

USING VIRTUAL REALITY IN AGED CARE SETTINGS: A SCOPING REVIEW

Recent advancement of virtual reality (VR) technology has led to growing interest in using VR in aged-care settings. VR can help ameliorate experiences of loneliness and social isolation, which is especially important during the COVID-19 pandemic. As a result, increasingly more studies are being published on this topic, and a comprehensive review of studies examining the facilitators and barriers of adopting VR in these settings is needed. This scoping review reports the facilitators and barriers to implementing VR in care settings among older adults, as well as the impact on social engagement and/or loneliness. We followed the Joanna Briggs Institute scoping review methodology, and searched the following databases: CINHAL, Embase, Medline, PsycInfo, Scopus, and Web of Science. Inclusion criteria includes articles published in the last five years that focus on older adults using VR in aged-care settings. 199 articles were retrieved and 21 articles were included in our review. Most of the articles (38%) originated from Australia. Key facilitators for using VR in aged care settings are the technology being user-friendly, comfortable, and easy to clean. Barriers included: technology issues (e.g., internet connectivity), staff attitude/ worries, and impact on residents, and structural considerations (e.g., lack of staff and time to assist with the VR program). VR technology can decrease loneliness and feelings of isolation, and provide opportunities to engage with others. Our review of the current evidence offers insights and recommendations for health care professionals to use VR technology in aged care settings, maximizing benefits and minimizing risks among users.

Gamification of dementia education in hospitals: a knowledge translation project

This knowledge translation study qualitatively explores strategies that facilitated hospital staff engagement in online educational games for dementia education. Interdisciplinary staff (n = 2010) in 10 hospitals played online games to learn about basic communication techniques. We identified five facilitating strategies, E-GAME: Easy access to learning, Give both extrinsic and intrinsic rewards, Apply implementation science theory, Multiple tools, and Evaluation. This article offers useful tips for educators to innovate dementia education for practice improvement.

Update on Nutrition in Diabetes Management

Nutrition is a corner stone of diabetes management, and should be regarded as fundamental to achieving blood glucose control. The current advice for nutrition in diabetes management is discussed, with a focus on body weight, macro and micro nutrients, foods and food groups, dietary patterns, and the lifestyle context. More recent evidence on topics such as body weight and dietary patterns indicate flexibility in what can be recommended, which enables patient preference and may aid adherence. Importantly, a healthy diet for those with diabetes is also appropriate to recommend for their families and the general population.

Facilitators and barriers to using virtual reality and augmented reality and its impact on social engagement in aged care settings: a scoping review protocol

INTRODUCTION

Increasingly more studies are being conducted on the use of virtual reality (VR) and augmented reality (AR) in aged care settings. These technologies can decrease experiences of loneliness which is especially important during the COVID-19 pandemic. With the growing interest in using VR/AR in care settings among older adults, a comprehensive review of studies examining the facilitators and barriers of adopting VR/AR in these settings is needed. This scoping review will focus on facilitators and barriers related to VR/AR in care settings among older adults, as well as the impact on social engagement and/or loneliness.

METHODS AND ANALYSIS

We will follow the Joanna Briggs Institute scoping review methodology. We will search the following databases: CINHAL, Embase, Medline, PsycINFO, Scopus and Web of Science. Additional articles will be handpicked from reference lists of included articles. Inclusion criteria includes articles that focus on older adults using VR or AR in aged care settings. Our team (which includes patient and family partners, an academic nurse researcher, a clinical lead and trainees) will be involved in the search, review and analysis process.

ETHICS AND DISSEMINATION

We will be collecting data from publicly available articles for this scoping review, so ethics approval is not required. By providing a comprehensive overview of the current evidence on the strategies, facilitators, and barriers of using VR/AR in aged care settings, findings will offer insights and recommendations for future research and practice to better implement VR/AR. The results of this scoping review will be shared through conference presentations and an open-access publication in a peer-reviewed journal.

Implementation of the Diabetes Community Exercise and Education Programme (DCEP) for the management of type 2 diabetes: qualitative process evaluation

OBJECTIVES

To examine context-specific delivery factors, facilitators and barriers to implementation of the Diabetes Community Exercise and Education Programme (DCEP) for adults with type 2 diabetes (T2D) using the Reach, Effectiveness, Adoption, Implementation and Maintenance framework.

DESIGN

A qualitative evaluation embedded within the DCEP pragmatic randomised controlled trial. Data collected via focus groups and interviews and analysed thematically.

SETTING

Community-based in two cities (Dunedin and Invercargill) in the lower south island of New Zealand.

PARTICIPANTS

Seventeen adults diagnosed with T2D attending DCEP and 14 healthcare professionals involved in DCEP delivery.

INTERVENTION

DCEP is a twice weekly session of exercise and education over 12 weeks, followed by a twice weekly ongoing exercise class.

RESULTS

While our reach target was met (sample size, ethnic representation), the randomisation process potentially deterred Māori and Pasifika from participating. The reach of DCEP may be extended through the use of several strategies: promotion of self-referral, primary healthcare organisation ownership and community champions. DCEP was considered effective based on perceived benefit. The social and welcoming environment created relationships and connections. People felt comfortable attending DCEP and empowered to learn. Key to implementation and adoption was the building of trusting relationships with local health providers and communities. This takes time and care and cannot be rushed. Training of staff and optimising communication needed further attention. To maintain DCEP, delivery close to where people live and a generic approach catering for people with multiple chronic conditions may be required.

CONCLUSIONS

For success, lifestyle programmes such as DCEP, need time and diligence to build and maintain networks and trust. Beyond frontline delivery staff and target populations, relationships should extend to local healthcare organisations and communities. Access and ongoing attendance are enabled by healthcare professionals practicing in a nuanced person-centred manner; this, plus high staff turnover, necessitates ongoing training.

TRIAL REGISTRATION NUMBER

ACTRN12617001624370.

Dietary fibre in hypertension and cardiovascular disease management: systematic review and meta-analyses

BACKGROUND

Higher dietary fibre intakes are associated with a reduced risk of developing cardiovascular disease (CVD), and increasing intake has been shown to reduce blood pressure and other cardiometabolic risk factors. The extent to which dietary fibre can further reduce risk for those with CVD and treated with cardioprotective drugs has not been clearly established. We have examined the evidence for dietary fibre as adjunct therapy in those with CVD or hypertension.

METHODS

Ovid MEDLINE, Embase, PubMed, and CENTRAL were searched to June 2021. Prospective observational studies reporting on fibre intakes and mortality in those with pre-existing CVD and controlled trials of increasing fibre intakes on cardiometabolic risk factors in those with CVD or hypertension were eligible. Outcomes were mortality (studies) and cardiometabolic risk factors (trials). Data synthesis was with random effects and dose response. Certainty of evidence was assessed using GRADE.

RESULTS

Three prospective studies including 7469 adults with CVD, and 12 trials of 878 adults with CVD or hypertension were identified. Moderate certainty evidence indicates reduced all-cause mortality (relative risk, RR0.75 (95% confidence interval, CI 0.58-0.97)) when comparing higher with lower fibre intakes. Low certainty evidence from trials of adults with cardiovascular disease indicates increasing fibre intakes reduced total (mean difference, MD - 0.42 mmol/L (95%CI - 0.78 to - 0.05) and low-density lipoprotein (LDL) cholesterol (MD - 0.47mmol/L (95%CI - 0.85 to - 0.10)). High certainty evidence from trials of adults with hypertension indicates increasing fibre intakes reduces systolic (MD 4.3 mmHg (95% CI 2.2 to 5.8)) and diastolic blood pressure (MD 3.1 mmHg (95% CI 1.7 to 4.4)). Moderate and low certainty evidence indicated improvements in fasting blood glucose (MD 0.48 mmol/L (- 0.91 to - 0.05)) and LDL cholesterol (MD 0.29 mmol/L (95% CI 0.17 to 0.40)). Benefits were observed irrespective of cardioprotective drug use.

CONCLUSIONS

These findings emphasise the likely benefits of promoting greater dietary fibre intakes for patients with CVD and hypertension. Further trials and cohort analyses in this area would increase confidence in these results.

The diabetes community exercise programme plus usual care versus usual care in patients with type 2 diabetes: A randomised, two-arm, parallel, open-label trial

BACKGROUND

Exercise is important in type 2 diabetes (T2D) management. Focussing on Māori and Pacific people and those from deprived circumstances, the Diabetes Community Exercise Programme (DCEP) was developed to engage people with T2D in exercise. We report the evaluation of whether being offered DCEP (plus usual care) was more effective than usual care in improving glycaemic control at 1-year.

METHODS

A randomised, two-arm, parallel, open-label trial with blinding of outcome assessor and data analyst. Adults (age ≥35 years) with T2D recruited from two New Zealand (NZ) communities were randomised, using opaque sealed envelopes and stratified by centre with random block lengths, to DCEP or usual care. DCEP comprises twice-weekly, two-hour sessions of exercise and education over 12-weeks, followed by a twice-weekly maintenance exercise class. The primary outcome was between-group differences in mean changes of glycated haemoglobin (HbA1c) from baseline to 1-year follow-up with intention-to treat analysis. This trial is registered with the Australian NZ Clinical Trials Registry (ANZCTR): ACTRN12617001624370p and is closed to new participants.

FINDINGS

From 2018 - 2019, of 294 people screened, 165 (mean age 63·8, SD16·2 years, 56% female, 78·5% European, 14% Māori, 6% Pacific, 27% most deprived) were baseline evaluated, randomised, and analysed at study end (DCEP = 83, control = 82). Multimorbidity (≥2) and polypharmacy (>5 medications) were high (82%, 69%). We found no statistically significant between-groups differences in HbA1c (mmol/mol) change at 15 months (mean 3% higher in DCEP, 95% CI 2% lower to 8% higher, p = 0·23). Twelve-week intervention adherence was good (41% attended >80% available sessions). No adverse events were reported.

INTERPRETATION

DCEP was not effective in improving glycaemic control, possibly due to insufficient exercise intensity. Our attendance demonstrated DCEP's cultural accessibility. DCEP might be good to engage in exercise marginalised people with high Hb1Ac levels, multimorbidity, and high polypharmacy.

FUNDING

Health Research Council of New Zealand.

Staff experience of a Canadian long-term care home during a COVID-19 outbreak: a qualitative study

Background

COVID-19 has significant impact on long-term care (LTC) residents and staff. The purpose of this paper is to report the data gathered during a COVID-19 outbreak in a Canadian LTC home regarding staff experiences, challenges, and needs, to offer lessons learned and implications.

Methods

A total of 30 staff from multiple disciplines participated in the study, including nurses, care workers, recreational staff, and a unit clerk. Focus groups (n = 20) and one-on-one interviews (n = 10) were conducted as part of a larger participatory action research (PAR) study in a Canadian LTC home. All data collection was conducted virtually via Zoom, and thematic analysis was performed to identify themes.

Results

Four main themes were identified: We are Proud, We Felt Anxious, We Grew Closer to Residents and Staff Members, and The Vaccines Help.

Conclusions

This research details the resilience that characterizes staff in LTC, while highlighting the emotional toll of the pandemic, particularly during an outbreak. LTC staff in this study found innovative ways to connect and support residents and this resulted in stronger connections and relationships. Leadership and organizational support are pivotal for supporting team resilience to manage crisis and adapt positively in times of COVID-19 pandemic, especially during the period of outbreak.

Facilitators and barriers to using telepresence robots in aged care settings: A scoping review

Social isolation has been a significant issue in aged care settings, particularly during the COVID-19 pandemic, and is associated with adverse outcomes, including loneliness, depression, and cognitive decline. While robotic assistance may help mitigate social isolation, it would be helpful to know how to adopt technology in aged care. This scoping review aims to explore facilitators and barriers to the implementation of telepresence robots in aged care settings. Following the Joanna Briggs Institute scoping review methodology and the PRISMA extension for scoping reviews reporting guidelines, we searched relevant peer-reviewed studies through eight databases: CINAHL, MEDLINE, Cochrane, PsychINFO (EBSCO), Web of Science, ProQuest Dissertations and Theses Global, IEEE Xplore, and ACM Digital Library. Google was used to search gray literature, including descriptive, evaluative, quantitative, and qualitative designs. Eligibility includes: studies with people aged 65 years and older who interacted with a telepresence robot in a care setting, and articles written in English. We conducted a thematic analysis to summarize the evidence based on the constructs in the Consolidated Framework of Implementation Research. Of 1183 articles retrieved, 13 were included in the final review. The analysis yielded three themes: relative advantages, perceived risks and problems, and contextual considerations. The key facilitators to telepresence robot adoption are as follows: a feeling of physical presence, ease of use, mobility, and training. The barriers to implementation are as follows: cost, privacy issues, internet connectivity, and workflow. Future research should investigate the role of leadership support in implementation and practical strategies to overcome barriers to technology adoption in aged care settings.

Correction to: A framework for the identification of long-term social avoidance in longitudinal datasets

[This corrects the article DOI: 10.1098/rsos.170641.][This corrects the article DOI: 10.1098/rsos.170641.].

Technological risks and ethical implications of using robots in long-term care

Introduction

The pandemic provides a unique opportunity to examine new directions in innovative technological approaches in long-term care (LTC) homes. While robotics could enhance staff capacity to provide care, there are potential technology risks and ethical concerns involved in technology use among older people residing in communal aged care homes. This qualitative descriptive study explores the technological risks and ethical issues associated with the adoption of robots in the specific context of LTC homes.

Methods

The research team including patient and family partners employed purposive and snowballing methods to recruit 30 LTC participants: frontline interdisciplinary staff, operational leaders, residents and family members, and ethics experts in dementia care. Semi-structured interviews were conducted. Thematic analysis was performed to identify themes that capture empirical experiences and perspectives of a diverse group of LTC stakeholders about robotic use.

Results

Technological risks include safety, increased workload, privacy, cost and social justice, and human connection. The findings offer practical insights based on the LTC perspective to contribute to the robot ethics literature. We propose a list of pragmatic recommendations, focusing on six principles (ETHICS): Engagement of stakeholders, Technology benefit and risk assessment, Harm mitigation, Individual autonomy, Cultural safety and justice, Support of privacy.

Conclusions

There is both a growing interest as well as fear in using robotics in LTC. Practice leaders need to reflect on ethical considerations and engage relevant stakeholders in making technology decisions for everyday care.

Age effects on clinical and neurocognitive risk factors for suicide attempt in depression - Findings from the AFSP lifespan study

BACKGROUND

Studies of risk factors for suicidal behavior are typically restricted to narrow age ranges, making it difficult to determine if they have the same relevance or potency across the full adult lifespan.

METHODS

This study examined selected clinical and neurocognitive risk factors for suicidal behavior - borderline personality traits, aggression, depressive rumination, memory performance, and language fluency- in a multi-site sample (N = 309, ages 16-80) of depressed patients with a recent (last 5 years) suicide attempt or no history of attempt, and demographically similar non-psychiatric controls. We examined cross-sectional age and attempter/non-attempter differences on these risk factors, and whether certain risk factors were more prominent discriminators of past suicide attempt earlier or later in the lifespan. Correlations with age were computed, and logistic regression was used to classify attempter status based on each risk factor and its interaction with age.

RESULTS

Nearly all risk factors were negatively correlated with age. Borderline traits, aggression, memory, and category fluency each predicted attempter status (p < 0.05), but these effects were not different across ages. In contrast, the association between rumination and suicide attempt status differed across the lifespan, becoming a stronger discriminator of past suicidal behavior at older ages.

LIMITATIONS

The cross-sectional design limits our developmental findings.

CONCLUSIONS

Despite age-related changes in symptom severity or neurocognitive performance, key risk factors for suicidal behavior previously identified in studies with more restricted age-ranges are salient throughout the adult lifespan. In contrast, depressive rumination may be particularly salient in later life.

Evolving partnerships: engagement methods in an established health services research team

BACKGROUND

The Translating Research in Elder Care (TREC) program is a partnered health services research team that aims to improve the quality of care and quality of life for residents and quality of worklife for staff in nursing homes. This team includes academic researchers, trainees, research staff, citizens (persons living with dementia and family/friend caregivers of persons living in nursing homes), and decision-makers (ministries of health, health authorities, operators of nursing homes). The TREC team has experience working with health system partners but wanted to undertake activities to enhance the collaboration between the academic researchers and citizen members. The aim of this paper is to describe the TREC team members' experiences and perceptions of citizen engagement and identify necessary supports to promote meaningful engagement in health research teams.

METHODS

We administered two online surveys (May 2018, July 2019) to all TREC team members (researchers, trainees, staff, decision-makers, citizens). The surveys included closed and open-ended questions guided by regional and international measures of engagement and related to respondents' experience with citizen engagement, their perceptions of the benefits and challenges of citizen engagement, and their needs for training and other tools to support engagement. We analyzed the closed-ended responses using descriptive statistics.

RESULTS

We had a 78% response rate (68/87) to the baseline survey, and 27% response rate (21/77) to the follow-up survey. At baseline, 30 (44%) of respondents reported they were currently engaged in a research project with citizen partners compared to 11(52%) in the follow-up survey. Nearly half (10(48%)) of the respondents in the follow-up reported an increase in citizen engagement over the previous year. Respondents identified many benefits to citizen engagement (unique perspectives, assistance with dissemination) and challenges (the need for specific communication skills, meeting organizing and facilitation, and financial/budget support), with little change between the two time points. Respondents reported that the amount of citizen engagement in their research (or related projects) had increased or stayed the same.

CONCLUSIONS

Despite increasing recognition of the benefits of including persons with lived experience and large-scale promotion efforts, the research team still lack sufficient training and resources to engage non-academic partners. Our research identified specific areas that could be addressed to improve the engagement of citizens in health research.

The voices of lived experience: reflections from citizen team members in a long-term care research program

BACKGROUND

The Translating Research in Elder Care (TREC) program is a partnered health services research team that aims to improve the quality of care and quality of life for residents and quality of worklife for staff in nursing homes. The TREC team undertook several activities to enhance the collaboration between the academic researchers and us, the citizen members. Known as VOICES (Voice Of (potential) Incoming residents, Caregivers Educating uS) we aim to share our experience working with a large research team.

METHODS

We reflect on the findings reported in the paper by Chamberlain et al. (2021). They described the findings from two surveys (May 2018, July 2019) that were completed by TREC team members (researchers, trainees, staff, decision-makers, citizens). The survey questions asked about the respondents' experience with citizen engagement, their perceptions of the benefits and challenges of citizen engagement, and their unmet needs for training.

RESULTS

The paper reported on the survey findings from all the survey respondents (research team, decision-makers, citizens), but much of the results focused on the researcher perspective. They reported that respondents believed that citizen engagement was a benefit to their research but noted many challenges. While we appreciate the researchers' positive perceptions of citizen engagement, much work remains to fully integrate us into all stages of the research. We offer our reflections and suggestions for how to work with citizen members and identify areas for more training and support.

CONCLUSIONS

Despite the increased interest in citizen engagement, we feel there is a lack of understanding and support to truly integrate non-academic team members on research teams. We hope the discussion in this commentary identifies specific areas that need to be addressed to support the continued engagement of citizens and show how the lived experience can bring value to research teams.

Use of participatory action research approach to develop a self-management resource for persons living with dementia

This article describes the use of a participatory action research (PAR) approach to developing a self-management resource for persons living with dementia and care partners. Despite growing evidence that persons with dementia are able to contribute in meaningful ways to decision-making about their care and life preferences, few opportunities exist for them to participate in the design of resources and services meant for them. There is also a need to support the self-management of persons living with dementia with the provision of accurate, high quality, user-friendly information. The Living Well with Dementia resource was developed through a partnership with persons with dementia, family members, Alzheimer Society representatives, primary care providers, and researchers. The methods used in the development of this resource are outlined in six steps employed in this process, from establishment of a PAR team to final resource creation. Informed by a whole systems approach, the resource brings together essential components of self-management into a comprehensive system of care and support for living. It empowers users to be active participants in the application of new knowledge to their lives. Better self-management has important implications for access to health care and quality of life for persons with dementia and care partners.

Home viewing of educational video improves patient understanding of Mohs Surgery

BACKGROUND

Educational videos improve patient knowledge of wound care and skin cancer. However, the effect of viewing an educational video at home prior to Mohs surgery has not been demonstrated.

OBJECTIVE

To evaluate the use of an educational video to improve patient understanding of MMS MATERIALS AND METHODS: Patients scheduled to undergo MMS were randomized to receive standard patient education, or standard patient education with an additional video developed by the authors. The educational material was mailed to patients along with the details of their MMS appointment. Both groups answered questionnaires to assess their knowledge of MMS, as well as their anxiety and satisfaction.

RESULTS

Patients that watched the educational video scored higher on the knowledge questionnaire than patients in the control group (0.8, 95% CI 0.3 to 1.4, p = 0.003), but were not statistically less anxious (-0.7, 95% CI -2.6 to 1.3, p = 0.50). Overall, patients undergoing MMS were satisfied.

CONCLUSION

Home viewing of an educational video prior to MMS can improve patient understanding.

Associations Between Sugars Intakes and Urinary Sugars Excretion and Carbon Stable Isotope Ratios in Red Blood Cells as Biomarkers of Sugars Intake in a Predominantly Māori Population

Determining the extent to which added sugars intake contribute to non-communicable disease in various populations is challenging because it is difficult to accurately measure intakes. Biomarkers may provide a reliable and easily measured method of assessing intakes. In a predominantly Māori population we compared various sugars intake estimates derived from a 36 item sugar-specific food frequency questionnaire (FFQ) with biomarkers of sugars intake; urinary sugars excretion in random spot collections (n = 153) and carbon stable isotope ratios (n = 36) in red blood cells (RBCs, δ¹³C_RBC) and in the alanine fraction of the RBCs (δ¹³C_alanine). Estimated 24 h urinary sucrose+fructose excretion was statistically significantly correlated with intakes of total sugars (r = 0.23), sucrose (r = 0.26) and added sugars from sugar-sweetened beverages (SSBs; r = 0.26). δ¹³C_alanine was correlated with added sugars (r = 0.40). In log linear multiple regression models adjusted with HbA1C and eGFR δ¹³C_alanine predicted added sugars intakes (r ² = 0.29) and estimated 24 h urinary sucrose+fructose excretion predicted intakes of total sugars (r ² = 0.14), sucrose (r ² = 0.17), added sugars (r ² = 0.17) and sugars from SSBs (r ² = 0.14). These biomarkers have potential for improving assessment of sugars intake in New Zealand populations enabling monitoring of the effectiveness of sugar reduction strategies designed to reduce risk of NCDs. However, further validation is required to confirm these preliminary findings.

Cardiovascular risk prediction in type 2 diabetes before and after widespread screening: a derivation and validation study

BACKGROUND

Until recently, most patients with diabetes worldwide have been diagnosed when symptomatic and have high cardiovascular risk, meaning most should be prescribed cardiovascular preventive medications. However, in New Zealand, a world-first national programme led to approximately 90% of eligible adults being screened for diabetes by 2016, up from 50% in 2012, identifying many asymptomatic patients with recent-onset diabetes. We hypothesised that cardiovascular risk prediction equations derived before widespread screening would now significantly overestimate risk in screen-detected patients.

METHODS

New Zealanders aged 30-74 years with type 2 diabetes and without known cardiovascular disease, heart failure, or substantial renal impairment were identified from the 400 000-person PREDICT primary care cohort study between Oct 27, 2004, and Dec 30, 2016, covering the period before and after widespread screening. Sex-specific equations estimating 5-year risk of cardiovascular disease were developed using Cox regression models, with 18 prespecified predictors, including diabetes-related and renal function measures. Equation performance was compared with an equivalent equation derived in the New Zealand Diabetes Cohort Study (NZDCS), which recruited between 2000 and 2006, before widespread screening.

FINDINGS

46 652 participants were included in the PREDICT-1° Diabetes subcohort, of whom 4114 experienced first cardiovascular events during follow-up (median 5·2 years, IQR 3·3-7·4). 14 829 (31·8%) were not taking oral hypoglycaemic medications or insulin at baseline. Median 5-year cardiovascular risk estimated by the new equations was 4·0% (IQR 2·3-6·8) in women and 7·1% (4·5-11·2) in men. The older NZDCS equation overestimated median cardiovascular risk by three times in women (median 14·2% [9·7-20·0]) and two times in men (17·1% [4·5-20·0]). Model and discrimination performance measures for PREDICT-1° Diabetse equations were also significantly better than for the NZDCS equation (eg, for women: R²=32% [95% CI 29-34], Harrell's C=0·73 [0·72-0·74], Royston's D=1·410 [1·330-1·490] vs R²=24% [21-26], C=0·69 [0·67-0·70], and D=1·147 [1·107-1·187]).

INTERPRETATION

International treatment guidelines still consider most people with diabetes to be at high cardiovascular risk; however, we show that recent widespread diabetes screening has radically changed the cardiovascular risk profile of people with diabetes in New Zealand. Many of these patients have normal renal function, are not dispensed glucose-lowering medications, and have low cardiovascular risk. These findings have clear international implications as increased diabetes screening is inevitable due to increasing obesity, simpler screening tests, and the introduction of new-generation glucose-lowering medications that prevent cardiovascular events. Cardiovascular risk prediction equations derived from contemporary diabetes populations, with multiple diabetes-related and renal function predictors, will be required to better differentiate between low-risk and high-risk patients in this increasingly heterogeneous population and to inform appropriate non-pharmacological management and cost-effective targeting of expensive new medications.

FUNDING

Health Research Council of New Zealand, Heart Foundation of New Zealand, and Healthier Lives National Science Challenge.

Gelatinisation and milling whole-wheat increases postprandial blood glucose: randomised crossover study of adults with type 2 diabetes

AIMS/HYPOTHESES

We examined the effects of milling and cooking whole grains in water to achieve starch gelatinisation on postprandial blood glucose using a randomised crossover open-label design. Participants were adults with type 2 diabetes whose body weight or medications had not changed in at least 3 months.

METHODS

Postprandial blood glucose (measured as incremental AUC [iAUC]) was measured following consumption of four nutrient-matched whole-wheat porridge test-meals. Test-meals included gelatinised or native starch and were made with either finely milled or intact whole-wheat.

RESULTS

Eighteen adults (63.1 ± 9.8 years, HbA_1c 57.0 ± 11.5 mmol/mol [7.4 ± 3.2%]) completed the study. iAUC was higher following cooked meals (gelatinised starch) than following uncooked meals (native starch) (mean difference [MD] 268, 95% CI 188, 348 mmol/l × min). Consuming finely milled whole-wheat produced a higher iAUC compared with intact whole-wheat (MD 173, 95% CI 80, 266 mmol/l × min). There was no evidence of an interaction effect (p = 0.841).

CONCLUSIONS

Both the nature of starch and the grain structure of whole-wheat influence the glycaemic response of adults with type 2 diabetes mellitus.

FUNDING

Baking Industry Research Trust of New Zealand and the Riddet Centre of Research Excellence.

TRIAL REGISTRATION

www.anzctr.org.au ACTRN12617000328370.

How do we support walking prescriptions for type 2 diabetes management? Facilitators and barriers following a 3-month prescription

INTRODUCTION Prescribing physical activity is an inexpensive method to promote patients' long-term health, but determinants of adherence with physical activity prescriptions are seldom considered. AIM To identify facilitators and barriers experienced by adults with type 2 diabetes when prescribed regular walking. METHODS Participants were prescribed a regular walking routine that met current physical activity guidelines for type 2 diabetes management for a period of 3 months. Pre- and post-intervention questions considered participants' self-rated health and physical activity amount. Thematic analysis of recorded interviews held after the 3-month prescription identified barriers and facilitators to adherence for participants. RESULTS Twenty-eight adults (aged 60±9 years, body mass index 32.3±4.0kg/m2, HbA1c 59±16mmol/mol) participated in the 3-month intervention, providing 7 years of lived experience. Self-rated health (14%; 95% confidence interval (CI) 7-22%) and time spent walking (+11 min/day; 95% CI 4-18 min/day) increased following the prescription. Major themes motivating participants were: establishing a walking routine; the support of their family members; observing health benefits; and being monitored by a health professional. The greatest barriers were associated with walking in the evening and included feelings of insecurity in the dark or a preference for sedentary behaviour. DISCUSSION A prescription to walk increased time spent in physical activity and self-rated health in adults with type 2 diabetes. Health-care professionals can support walking prescriptions by promoting facilitators and reducing barriers to prescription adherence. Practical solutions to barriers include identifying alternative physical activity opportunities within the house or advice to develop support networks to provide company while walking.

Creating Dementia-Friendly Communities for Social Inclusion: A Scoping Review

Aims: This scoping review explores key strategies of creating inclusive dementia-friendly communities that support people with dementia and their informal caregiver. Background: Social exclusion is commonly reported by people with dementia. Dementia-friendly community has emerged as an idea with potential to contribute to cultivating social inclusion. Methods: This scoping review follows the Joanna Briggs Institute scoping review methodology and took place between April and September 2020. The review included a three-step search strategy: (1) identifying keywords from CINAHL and AgeLine; (2) conducting a second search using all identified keywords and index terms across selected databases (CINAHL, AgeLine, MEDLINE, PsycINFO, Web of Science, ProQuest, and Google); and (3) hand-searching the reference lists of all included articles and reports for additional studies. Results: Twenty-nine papers were included in the review. Content analysis identified strategies for creating dementia-friendly communities: (a) active involvement of people with dementia and caregivers (b) inclusive environmental design; (c) public education to reduce stigma and raise awareness; and (d) customized strategies informed by theory. Conclusion: This scoping review provides an overview of current evidence on strategies supporting dementia-friendly communities for social inclusion. Future efforts should apply implementation science theories to inform strategies for education, practice, policy and future research.

Cost Benefit Analysis of Two Oral health Improvement Programmes

INTRODUCTION

Oral health is frequently given a low priority when healthcare funds are allocated to new initiatives. One method to highlight the health and social benefits of new oral health initiatives is to use cost benefit analysis to show their value.

AIM

To demonstrate how Cost Benefit Analysis (CBA) has been applied to two recent oral health initiatives to evaluate their ability to reduce costs and improve the quality of life.

METHODS

CBA was applied to the Mouth Care Matters project in Kent, Surrey and Sussex, and the Senior Smiles project - improving oral health in residential homes in Australia.

RESULTS

Over a five-year period, the Mouth Care Matters project would generate £2.66 in cost savings, within the healthcare system, for every £1 spent. Over a three year period the Senior Smiles project would generate a cost saving for the healthcare system of $3.14 for every $1 spent. These evaluations were instrumental to enable a national rollout for Mouth Care Matters and a public endorsement of the programme for Senior Smiles.

CONCLUSIONS

Health economics can be a useful tool in aiding care organisations to assess the implications of decisions to spend limited resources in particular areas of healthcare over others.

What is the demand for out-of-hours dermatology? A UK-based region-wide survey of dermatology demand and provision during the evenings and at weekends

BACKGROUND

Little is known about the demand for out-of-hours (OOH) dermatology in the UK, and this can make commissioning of acute services difficult. The East Midlands region has a population of 4.5 million people, with variable access to OOH dermatology services.

AIM

We sought to investigate the provision of, and demand for, OOH dermatology services across the region with a view to informing commissioning decisions for the future.

METHODS

We contacted all dermatology departments in the East Midlands region to establish what level of service was commissioned at evenings and weekends. At the sites providing any form of OOH service, we recorded all requests for advice received after 17.00 h on weekdays, or at any time during weekends and bank holidays over a 3-month period from October to December 2019.

RESULTS

The OOH services provided ranged from 24 h/day cover 7 days/week at one site, to no formal provision across much of the rest of the region. In total, 125 calls were received during the study period, averaging 1 call per day on weekday evenings, and 2 calls per day at weekends and on bank holidays. Of these 125 calls, 11 patients (9%) were prioritized and seen by the on-call dermatologist on the day of referral, and 9 of these had potentially life-threatening skin conditions. A further 39 (31%) were deemed to need review within 24 h and 22 (18%) within 48 h. The remaining 42% were given appointments within 7 days or dealt with by telephone advice.

CONCLUSION

The demand for OOH dermatology across the East Midlands is low, but access to timely dermatology advice is essential in some situations. Commissioning of a regional dermatology OOH service incorporating digital technology may help to improve the equity of access for all patients across the region.

Blood glucose testing in the community: who are the users and do they have elevated blood glucose?

INTRODUCTION On-the-spot blood glucose testing is a health service performed in public spaces to raise diabetes awareness and screen for elevated blood glucose levels. AIM To describe the users of this service and the frequency of detecting elevated blood glucose. METHODS Data collected at point-of-testing on a standardised form over 20 months in two regions of New Zealand were audited. Descriptive and simple inferential statistics report on population demographics and presence of elevated blood glucose (mmol/L). RESULTS Data from 2156 individuals were audited. Most (1680, 78%) were female, the mean age was 52 years (standard deviation 18 years) and all major ethnic groups and socioeconomic quintiles were represented. For 53% of responders, this was their first blood glucose test. In total, 153 (7.1%) cases with elevated blood glucose were identified, including 94 who did not report a previous pre-diabetes or diabetes diagnosis. Blood glucose was not correlated with socioeconomic status (r=0.04; P=0.07), but weakly correlated with age (r=0.19; P<0.001). Blood glucose values did not appear to differ between ethnicities (P=0.052). Men had a higher mean value than women (P=0.003). People with elevated blood glucose access their general practitioner more often than people with normal blood glucose, irrespective of a diabetes diagnosis (P=0.002). DISCUSSION On-the-spot blood glucose testing is a health service accessed by a wide range of people, although more commonly by women than men. Future interventions targeting men may better engage them in health screening. Alongside awareness raising, on-the-spot community testing identified previously unknown elevated blood glucose levels at a rate of 1-in-22, and may lead to the earlier identification and treatment of prediabetes or diabetes.

Canadian Consensus Conference on Psychological and Non-Pharmacological Interventions for Dementia

Psychological and non-pharmacological interventions that could have a positive effect on outcomes important to persons living with dementia are essential to identify given the the limited efficacy of dementia medications and the diverse needs of persons living. In 2019, for the first time the Canadian Consensus Conference on the Diagnosis and Treatment of Dementia (CCCDTD) created a working group to develop recommendations related to a broad range of psychosocial and non-pharmacological interventions exist, typically aimed at improving cognition, symptoms, or well-being, as well as improving caregiver well-being and coping. The recommendations, primarily intended for primary care physicians, may also allow clinicians, organizations, and communities and help to better meet the needs of people living with dementia and their caregivers. A group of 11 experts, including persons living with dementia and informal caregivers, as well as clinicians and researchers from various organizations both nationally and internationally were invited to participate. A rapid review of meta-analyses and literature reviews on psychological and non-pharmacological interventions was conducted. The synthesized results were submitted for a consensus building approach using a Delphi method, involving a panel of more than 50 Canadian participants. Recommendations with a positive vote of 80% or more were considered to have reached consensus. All proposed recommendations reached consensus using the Delphi process. Details of the recommendations are presented. Five recommendations are made: group or individual physical exercise, group cognitive stimulation therapy, psychoeducational interventions for caregivers, dementia friendly organizations/communities, and case management.