Symptom-led staging for semantic and non-fluent/agrammatic variants of primary progressive aphasia

INTRODUCTION

Here we set out to create a symptom-led staging system for the canonical semantic and non-fluent/agrammatic variants of primary progressive aphasia (PPA), which present unique diagnostic and management challenges not well captured by functional scales developed for Alzheimer's disease and other dementias.

METHODS

An international PPA caregiver cohort was surveyed on symptom development under six provisional clinical stages and feedback was analyzed using a mixed-methods sequential explanatory design.

RESULTS

Both PPA syndromes were characterized by initial communication dysfunction and non-verbal behavioral changes, with increasing syndromic convergence and functional dependency at later stages. Milestone symptoms were distilled to create a prototypical progression and severity scale of functional impairment: the PPA Progression Planning Aid ("PPA-Squared").

DISCUSSION

This work introduces a symptom-led staging scheme and functional scale for semantic and non-fluent/agrammatic variants of PPA. Our findings have implications for diagnostic and care pathway guidelines, trial design, and personalized prognosis and treatment for PPA.

HIGHLIGHTS

We introduce new symptom-led perspectives on primary progressive aphasia (PPA). The focus is on non-fluent/agrammatic (nfvPPA) and semantic (svPPA) variants. Foregrounding of early and non-verbal features of PPA and clinical trajectories is featured. We introduce a symptom-led staging scheme for PPA. We propose a prototype for a functional impairment scale, the PPA Progression Planning Aid.

Experiential Avoidance in Advanced Cancer: a Mixed-Methods Systematic Review

BACKGROUND

People with advanced cancer experience psychological distress due to physical symptoms, functional decline, and a limited prognosis. Difficult thoughts, feelings, and emotions may exacerbate distress and lead to avoidance of these experiences which is sometimes referred to as experiential avoidance (EA). Advanced cancer patients may be more likely to engage in EA especially when no obvious solutions to their problems exist. This study aims to examine the terms used to describe EA, the processes that might indicate EA, associations between EA and psychological distress, and to understand why individuals might engage in EA.

METHODS

A mixed-methods review. Literature search of Medline, Embase, Psych INFO, and CINAHL 1980-October 2019.

INCLUSION

adults ≥ 18 years; advanced cancer not amenable to cure.

EXCLUSION

no measures of EA or psychological distress. Risk of bias and study quality assessed. Evidence of statistical techniques collected. Themes coded, grouped, and developed based on meaning.

RESULTS

Nineteen studies identified, 13 quantitative studies and 6 qualitative. The quantitative of which 6 compared early-stage cancers with advanced cancers and examined subscales of EA alongside mood, quality of life, and psychological distress. EA covers a range or terms of which 'avoidant coping' is the commonest. EA is manifest as cognitive, behavioural, and emotional avoidance. A thematic synthesis suggests the function of EA is to protect people from distress, and from confronting or expressing difficult emotions by avoiding communication about cancer, controlling negative information, and maintaining normality and hope and optimism.

CONCLUSIONS

EA may be beneficial in the short term to alleviate distress, but in the longer term, it can impair function and limit engagement in life. Greater clinical awareness of the complexity of EA behaviours is needed. Clinicians and researchers should define EA precisely and be aware of the function it may serve in the short and longer term. Future research studies may consider using specific measures of EA as a primary outcome, to assess the impact of psychological interventions such as ACT.

Grief in family carers of people living with dementia: A systematic review

OBJECTIVES

Grief research in family carers of people with dementia has increased. We aimed to report the prevalence of pre-death and post-death grief and to synthesize associated factors and the relationship between pre-death factors and post-death grief and services used to manage grief.

DESIGN

(Prospero protocol: CRD42020165071) We systematically reviewed literature from PsycINFO, MEDLINE, CINAHL, and ASSIA until April 2020. Effectiveness of intervention data and studies not written in English were excluded; qualitative studies were additionally excluded during study selection. Study quality was assessed using the Mixed Methods Appraisal Tool. Evidence was narratively summarized.

PARTICIPANTS

Family non-paid carers of somebody with any dementia type.

MEASUREMENTS

Validated measures of pre-death and/or post-death grief.

RESULTS

We included quantitative data from 55 studies (44 rated as high quality). Most included solely spouse or adult child carers. Forty-one studies reported pre-death grief, 12 post-death grief, and 6 service use; eight were longitudinal. 17% met the Prolonged Grief Disorder criteria pre-death (n = 1) and 6-26% (n = 4) of participants met the Complicated Grief criteria post-death. Being a spouse, less educated, caring for somebody with advanced dementia, and greater burden and depression were associated with higher pre-death grief. Lower education level and depression were predictive of higher post-death grief. Pre-death factors found to influence post-death grief were grief and depression. Limited service use evidence was reported.

CONCLUSION

Awareness of characteristics which increase the likelihood of higher grief can help identify those in need of support. Future research should focus on what supports or services are beneficial to grief experiences.

Symptom-led staging for primary progressive aphasia

The primary progressive aphasias (PPA) present complex and diverse challenges of diagnosis, management and prognosis. A clinically-informed, syndromic staging system for PPA would take a substantial step toward meeting these challenges. This study addressed this need using detailed, multi-domain mixed-methods symptom surveys of people with lived experience in a large international PPA cohort. We administered structured online surveys to caregivers of patients with a canonical PPA syndromic variant (nonfluent/agrammatic (nvPPA), semantic (svPPA) or logopenic (lvPPA)). In an 'exploratory' survey, a putative list and ordering of verbal communication and nonverbal functioning (nonverbal thinking, conduct and wellbeing, physical) symptoms was administered to 118 caregiver members of the UK national PPA Support Group. Based on feedback, we expanded the symptom list and created six provisional clinical stages for each PPA subtype. In a 'consolidation' survey, these stages were presented to 110 caregiver members of UK and Australian PPA Support Groups, and refined based on quantitative and qualitative feedback. Symptoms were retained if rated as 'present' by a majority (at least 50%) of respondents representing that PPA syndrome, and assigned to a consolidated stage based on majority consensus; the confidence of assignment was estimated for each symptom as the proportion of respondents in agreement with the final staging for that symptom. Qualitative responses were analysed using framework analysis. For each PPA syndrome, six stages ranging from 1 ('Very mild') to 6 ('Profound') were identified; earliest stages were distinguished by syndromic hallmark symptoms of communication dysfunction, with increasing trans-syndromic convergence and dependency for basic activities of daily living at later stages. Spelling errors, hearing changes and nonverbal behavioural features were reported at early stages in all syndromes. As the illness evolved, swallowing and mobility problems were reported earlier in nfvPPA than other syndromes, while difficulty recognising familiar people and household items characterised svPPA and visuospatial symptoms were more prominent in lvPPA. Overall confidence of symptom staging was higher for svPPA than other syndromes. Across syndromes, functional milestones were identified as key deficits that predict the sequence of major daily life impacts and associated management needs. Qualitatively, we identified five major themes encompassing 15 subthemes capturing respondents' experiences of PPA and suggestions for staging implementation. This work introduces a prototypical, symptom-led staging scheme for canonical PPA syndromes: the PPA Progression Planning Aid (PPA 2 ). Our findings have implications for diagnostic and care pathway guidelines, trial design and personalised prognosis and treatment for people living with these diseases.

Connecting in place: older adults' experience of online mindfulness therapy during the COVID-19 pandemic

BACKGROUND

the negative consequences of COVID-19 distancing measures on older adults' mental health and ability to access services have been well documented. Online cognitive behavioural therapy and mindfulness interventions for older adults, carried out during the COVID-19 pandemic, have shown that these interventions are feasible and have potential mental health benefits. However, little research has been carried out on older adults' experiences of engaging with online psychological therapy, and specifically mindfulness therapy.

OBJECTIVES

to understand the experience of older adults engaging with online mindfulness therapy during the COVID-19 pandemic.

STUDY DESIGN

a qualitative analysis of four community-based focus groups.

PARTICIPANTS

thirty-six community dwelling older adults aged between 65 and 85 years were recruited via older adult organisations, charities and the local press. Nineteen percent had long-term physical health conditions, 25% had severe and enduring mental health difficulties and 19% had mild to moderate mental health difficulties.

RESULTS

there was a strong sense of group cohesion and community from the participants.Three main themes were identified: reasons for applying, experience of the mindfulness therapy and connecting at home.

CONCLUSIONS

the majority of participants were positive about attending a mindfulness group online. This extended to the perceived psychological and social benefits as well as practical considerations. While some participants noted technological hurdles at the beginning of the course, the findings challenge previous studies that suggest older adults are reluctant to engage in online psychological therapies and has important implications for the future provision of psychological therapies to this population.

How best to capture the impact of complementary therapies in palliative care: A systematic review to identify and assess the appropriateness and validity of multi-domain tools

BACKGROUND

Complementary therapies are widely used in palliative care settings. Qualitative research found that people with advanced disease report a range of physical and psychological benefits from complementary therapies, however evidence of their effectiveness from clinical trials is inconclusive. This may be because trials are limited by use of inappropriate outcome measures.

AIMS

To identify tools which capture the impact of massage, reflexology and aromatherapy in people with advanced disease. We (1) identified multi-domain tools used to evaluate these therapies in populations with any chronic health condition and (2) assessed whether tools were valid and psychometrically robust in populations with advanced disease.

DESIGN

A two-stage systematic review was conducted using the COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN) guidelines (PROSPERO: CRD42020161199).

DATA SOURCES

Six databases were searched (August 2021). Study methodological quality, tool psychometric properties and evidence quality were assessed. A global comparison score was generated.

RESULTS

Stage 1: 66 trials using 40 different multi-domain tools were identified. Stage 2: Of these tools, we identified papers for seven tools regarding development or validation in advanced disease populations. The majority of psychometric data were inconsistent or inconclusive. Data were mostly of low quality due to methodological issues.

CONCLUSION

Of the tools identified, 'Functional Assessment of Cancer Therapy - General' appears to be the most suitable alternative tool against COMSIN criteria, for trials of massage, reflexology and aromatherapy in palliative care. Further tool validation is required before firm recommendations can be made. Co-development of a core outcome set could ensure relevant domains are assessed.

Rapid development of a COVID-19 care planning decision-aid for family carers of people living with dementia

INTRODUCTION

COVID-19 has disproportionately affected people living with dementia and their carers. Its effects on health and social care systems necessitated a rapid-response approach to care planning and decision-making in this population, with reflexivity and responsiveness to changing individual and system needs at its core. Considering this, a decision-aid to help families of persons with dementia was developed.

OBJECTIVES

To coproduce with people living with dementia, and the people who care for them, a decision-aid for family carers of people living with dementia, to support decisions during the COVID-19 pandemic and beyond.

METHODS

Semi-structured interviews were undertaken in 2020 with: (1) staff from two English national end-of-life and supportive care organizations; and (2) people living with dementia and family carers. Simultaneously, a rapid review of current evidence on making decisions with older people at the end of life was undertaken. Evidence from these inputs was combined to shape the decision-aid through a series of workshops with key stakeholders, including our patient and public involvement group, which consisted of a person living with dementia and family carers; a group of clinical and academic experts and a group of policy and charity leads.

RESULTS

The rapid review of existing evidence highlighted the need to consider both process and outcome elements of decision-making and their effects on people living with dementia and their families. The qualitative interviews discussed a wide range of topics, including trust, agency and confusion in making decisions in the context of COVID-19. The decision-aid primarily focussed on care moves, legal matters, carer wellbeing and help-seeking.

CONCLUSIONS

Combining different sources and forms of evidence was a robust and systematic process that proved efficient and valuable in creating a novel decision-aid for family carers within the context of COVID-19. The output from this process is an evidence-based practical decision-aid coproduced with people living with dementia, family carers, clinical and academic experts and leading national dementia and palliative care organizations.

PATIENT OR PUBLIC CONTRIBUTION

We worked with people living with dementia and family carers and other key stakeholders throughout this study, from study development and design to inclusion in stakeholder workshops and dissemination.

Trust and inclusion during the Covid-19 pandemic: Perspectives from Black and South Asian people living with dementia and their carers in the UK

INTRODUCTION

People from ethnic minority backgrounds living with dementia are more likely to be diagnosed later and have less access to health and social care support than their White counterparts in the United Kingdom (UK). Covid-19 has exacerbated health inequalities and diminished trust from underserved communities in the government and health services. The wider aim of the study was to explore the impact of covid-19 on Black and South-Asian people living with dementia and their carers as well as exploring the experiences of dementia care. The present paper specifically explores their views on trust and mistrust using an ecological model.

METHOD

Semi-structured interviews were conducted with 11 family carers and four people living with dementia from South Asian or Black communities living in the community. Thematic analysis was used to analyse data.

DESIGN

An exploratory qualiative design was used.

RESULTS

Four main themes were developed exploring trust at the structural, organisational, community and individual level. At the structural level, participants discussed the inequity of Covid-19, some lack of trust in the UK Government and confusion in its messaging, and the anxiety sometimes leading to curtailment of media usage. At the organisational level, there was some evidence of a perceived lack of person-centred and culturally sensitive care from healthcare professionals, as well as concerns around care homes as places of safety. At the neighbourhood community level, participants discussed both a distrust as well as a strengthening of relationships and, at the individual level, factors such as knowledge of services, identity, and faith influenced their experience of the pandemic.

CONCLUSIONS

People living with dementia need support at all levels and this study highlights how the pandemic impacted each level. Ways to improve trust in the Government and health professionals alongside culturally adapted health messaging should be explored. Alongside this, an examination of how cultural values and norms may influence help-seeking responses to dementia and increase trust in services may be helpful post-pandemic.

Defining end of life in dementia: A systematic review

BACKGROUND

Dementia is a life-limiting condition that affects 50 million people globally. Existing definitions of end of life do not account for the uncertain trajectory of dementia. People living with dementia may live in the advanced stage for several years, or even die before they reach the advanced stage of dementia.

AIM

To identify how end of life in people with dementia is measured and conceptualised, and to identify the factors that contribute towards identifying end of life in people with dementia.

DESIGN

Systematic review and narrative synthesis.

DATA SOURCES

Electronic databases MEDLINE, EMBASE, PsychInfo and CINAHL, were searched in April 2020. Eligible studies included adults with any dementia diagnosis, family carers and healthcare professionals caring for people with dementia and a definition for end of life in dementia.

RESULTS

Thirty-three studies met the inclusion criteria. Various cut-off scores from validated tools, estimated prognoses and descriptive definitions were used to define end of life. Most studies used single measure tools which focused on cognition or function. There was no pattern across care settings in how end of life was defined. Healthcare professionals and family carers had difficulty recognising when people with dementia were approaching the end of life.

CONCLUSION

End-of-life care and research that focuses only on cognitive and functional decline may fail to recognise the complexities and unmet needs relevant to dementia and end of life. Research and clinical practice should adopt a needs-based approach for people with dementia and not define end of life by stage of disease.

A Multilevel Multidimensional Finite Mixture Item Response Model to Cluster Respondents and Countries

Abstract. The aim of this study was to test the multilevel multidimensional finite mixture item response model of the Forms of Self-Criticising/Attacking and Self-Reassuring Scale (FSCRS) to cluster respondents and countries from 13 samples ( N = 7,714) and from 12 countries. The practical goal was to learn how many discrete classes there are on the level of individuals (i.e., how many cut-offs are to be used) and countries (i.e., the magnitude of similarities and dissimilarities among them). We employed the multilevel multidimensional finite mixture approach which is based on an extended class of multidimensional latent class Item Response Theory (IRT) models. Individuals and countries are partitioned into discrete latent classes with different levels of self-criticism and self-reassurance, taking into account at the same time the multidimensional structure of the construct. This approach was applied to the analysis of the relationships between observed characteristics and latent trait at different levels (individuals and countries), and across different dimensions using the three-dimensional measure of the FSCRS. Results showed that respondents’ scores were dependent on unobserved (latent class) individual and country membership, the multidimensional structure of the instrument, and justified the use of a multilevel multidimensional finite mixture item response model in the comparative psychological assessment of individuals and countries. Latent class analysis of the FSCRS showed that individual participants and countries could be divided into discrete classes. Along with the previous findings that the FSCRS is psychometrically robust we can recommend using the FSCRS for measuring self-criticism.

Challenges faced during the COVID-19 pandemic by family carers of people living with dementia towards the end of life

Background

People living with dementia account for a large proportion of deaths due to COVID-19. Family carers are faced with making significant and emotive decisions during the pandemic, including decisions about end of life. We aimed to explore the challenges faced by family carers of people living with dementia during the first wave of the COVID-19 pandemic in England, as reported by charity telephone support line staff, who were able to objectively discuss a range of different experiences of many different carers who call the helpline. In particular, we focussed on key concerns and areas of decision making at the end of life.

Methods

We conducted a qualitative study using semi-structured interviews with eight telephone support line staff from two UK based charities who support carers of people living with dementia and those at the end of life. Interviews were conducted in the first wave of the pandemic in England in May–June 2020.

Results

An overarching theme of uncertainty and reactivity during a crisis was identified, and within this, five main themes were identified: concerns about care transitions, uncertainty in engaging support and help, pandemic-motivated care planning, maintaining the wellbeing of the person living with dementia, and trust, loss of agency and confusion.

Conclusions

Family carers may be reluctant to seek support because of fear of what may happen to their relative, which may include hospitalisation and becoming ill with COVID-19, care home placement, or not being able to be with a relative at the end of life. In some cases, a lack of trust has developed, and instead carers are seeking support from alternative services they trust such as nationally known charities.This study was used to inform the development of a decision aid to support family carers making decisions about care for their relative with dementia during the pandemic, who the lack the capacity to make their own decisions.

Rapid review of decision-making for place of care and death in older people: Lessons for COVID-19

Introduction

The coronavirus pandemic (COVID-19) has affected the functioning and capacity of healthcare systems worldwide. COVID-19 has also disproportionately affected older adults, including those living with dementia. In the context of COVID-19, decision-making surrounding place of care and place of death in this population involves significant new challenges.

Objectives

To explore key factors that influence place of care and place of death decisions in older adults. A secondary aim was to investigate key factors that influence the process and outcome of these decisions in older adults. To apply findings from current evidence to the context of COVID-19.

Methods

Rapid review of reviews, undertaken using WHO guidance for rapid reviews. Ten papers were included for full data extraction. These papers were published between 2005-2020. Data extracted was synthesised using narrative synthesis, with thematic analysis and tabulation.

Results

Papers included discussed actual place of death, as well as preferred. Results were divided into papers that explored the process of decision-making, and those that explored decision-making outcomes. Factors such as caregiver capacity, the availability of multidisciplinary teams, cultural appropriateness of care packages and advanced care planning were found to be key.

Conclusions

The process and outcomes of decision-making for older people are affected by many factors – all of which have the potential to influence both patients and caregivers experience of illness and dying. Within the context of COVID-19, such decisions may have to be made rapidly and be reflexive to changing needs of systems and of families and patients.

Emotional disclosure in palliative care: A scoping review of intervention characteristics and implementation factors

BACKGROUND

Emotional disclosure is the therapeutic expression of emotion. It holds potential as a means of providing psychological support. However, evidence of its efficacy in palliative settings is mixed. This may be due to variation in intervention characteristics.

AIM

To derive a greater understanding of the characteristics of potentially effective emotional disclosure-based interventions in palliative care by:(1) Developing a taxonomy of emotional disclosure-based interventions tested in people with advanced disease and(2) Mapping and linking objectives, outcomes, underlying mechanisms, and implementation factors.

DESIGN

A scoping review drawing on Intervention Component Analysis to combine evidence from studies' methods, results, and discussion sections.

DATA SOURCES

Six databases were searched to May 2020 including CINAHL, PsycINFO, and MEDLINE. Studies of emotional disclosure in adults with advanced disease were included. Study quality was appraised using an established tool.

RESULTS

Seven thousand seven hundred ninety-two unique records were screened, of which 25 primary studies were included. Intervention characteristics were grouped into classes within three domains: topic of disclosure, format, and dose. Evidence was not available to determine which, if any, of the characteristics is most effective. Thematic synthesis of evidence from methods and discussion sections identified factors to consider in tailoring an emotional disclosure-based intervention to this setting, including: population characteristics (e.g. time since diagnosis), providing a safe environment, and flexibility in format.

CONCLUSIONS

This review approach facilitated a clearer understanding of factors that may be key in developing emotional disclosure-based interventions for palliative populations. Intervention Component Analysis has potential for application elsewhere to help develop evidence-based interventions.

Exploration of the impact of the COVID-19 pandemic on people with dementia and carers from black and minority ethnic groups

INTRODUCTION

Despite community efforts to support and enable older and vulnerable people during the COVID-19 pandemic, many people with dementia and their family carers are still finding it difficult to adjust their daily living in light of the disruption that the pandemic has caused. There may be needs specific to black, Asian and minority ethnic (BAME) populations in these circumstances that remain thus far unexplored.

OBJECTIVE

The aim of the study was to explore the effects of the COVID-19 pandemic on people living with dementia and their family carers of BAME backgrounds, in relation to their experiences of community dementia care and the impact on their daily lives.

DESIGN

15 participants (persons with dementia and carers) were recruited for semistructured qualitative interviews. Respondents were of South Asian and Afro-Caribbean backgrounds. We used thematic analysis to analyse our data from a constructivist perspective, which emphasises the importance of multiple perspectives, contexts and values.

RESULTS

There were a number of ways that the COVID-19 pandemic has impacted BAME persons with dementia and carers with regard to their experiences of dementia community care and the impact on their everyday lives. In particular we identified eight key themes, with subthemes: fear and anxiety, food and eating (encompassing food shopping and eating patterns), isolation and identity, community and social relationships, adapting to COVID-19, social isolation and support structures, and medical interactions. Fear and anxiety formed an overarching theme that encompassed all others.

DISCUSSION

This paper covers unique and underexplored topics in a COVID-19-vulnerable group. There is limited work with these groups in the UK and this is especially true in COVID-19. The results showed that such impacts were far-reaching and affected not only day-to-day concerns, but also care decisions with long-ranging consequences, and existential interests around fear, faith, death and identity.

Let It Out (LIO) study: protocol for a mixed-methods study to optimise the design and assess the feasibility of an online emotional disclosure-based intervention in UK hospices

INTRODUCTION

The current COVID-19 pandemic has forced hospices to look for more ways to support people remotely, including psychological support. Emotional disclosure-based interventions hold potential as a way of providing support remotely. However, evidence of their efficacy in people with terminal illness is mixed. Reviews have highlighted this may be due to interventions not being tailored to the unique needs of this population. In response to this, we are developing Let It Out (LIO), an online, self-guided emotional disclosure-based intervention tailored for people living with terminal illness.

AIMS

The primary objective of the study is to optimise the design of the LIO intervention. Secondary objectives include assessing its acceptability and feasibility; exploring potential impact on well-being; identifying potential adverse effects; and informing choice of outcome measures for potential future evaluation.

METHODS AND ANALYSIS

A single arm, mixed-methods, multisite, longitudinal study. Up to 40 people living with a terminal illness under the care of hospices in England and Scotland will receive the online LIO intervention. LIO consists of 3, self-guided expression sessions over 2 weeks. The primary outcome measures are (1) a structured feedback form completed by participants after the final expression session; and (2) semi-structured interviews and focus groups with ≤15 patient participants, ≤30 hospice staff and ≤15 informal carers. These quantitative and qualitative data will be triangulated via process evaluation to inform optimisation of the intervention design. Secondary outcome measures include validated measures of physical and psychological health collected at baseline and after the final expression session (immediately, 1, 4 and 8 weeks after); and data on recruitment, retention and fidelity.

ETHICS AND DISSEMINATION

The study is approved by the University College London Research Ethics Committee (reference: 15281/002). The findings will be shared through peer-reviewed scientific journals and conferences, and traditional, online and social media platforms.

Rapid development of a decision-aid for people with dementia and their families during COVID-19

Introduction

COVID-19 as a pandemic has disproportionately affected older adults, including those with dementia. The effects on health and social care systems has necessitated a rapid-response approach to care planning and decision-making in this population, with reflexivity and responsiveness to changing individual and system needs at its core. In light of this, a decision-making tool to help families of persons with dementia was developed using a combination of qualitative data and evidence synthesis.

Objectives

To develop a decision-aid using a combination of assessment and evidence-gathering methods for families of persons with dementia.

Methods

Semi-structured interviews with helpline staff from national end-of-life and supportive care organisations formed the basis of the tool design. Co-design with people living with dementia, current and former carers and experts in general practice and social care shaped the next stage. Simultaneously, a rapid review of current evidence on making decisions with older people at the end of life was undertaken.

Results

Output from interviews covered many topics, including trust, agency and confusion in making decisions in the context of COVID-19. The rapid review of existing evidence highlighted the need to consider both process and outcome elements of decision-making.

Conclusions

Combining different sources and forms of evidence was efficient and valuable in creating a novel decision-making tool for persons with dementia and their families within the context of COVID-19. The decision-aid covered care planning, caregiver support systems, access to information and contingency considerations. Upon publication, the tool was adopted by NHS England and other leading healthcare organisations.

Disclosure

No significant relationships.

Rapid review of decision-making for place of care and death in older people: lessons for COVID-19

Introduction

The coronavirus pandemic (COVID-19) has affected the functioning and capacity of healthcare systems worldwide. COVID-19 has also disproportionately affected older adults. In the context of COVID-19, decision-making surrounding place of care (PoC) and place of death (PoD) in older adults involves significant new challenges.

Aims

To explore key factors that influence PoC and PoD decisions in older adults. A secondary aim was to investigate key factors that influence the process and outcome of these decisions in older adults. To apply findings from current evidence to the context of COVID-19.

Methods

Rapid review of reviews, undertaken using WHO guidance for rapid reviews for the production of actionable evidence. Data extracted was synthesised using narrative synthesis, with thematic analysis and tabulation.

Results

10 papers were included for full data extraction. These papers were published between 2005 and 2020. Papers included discussed actual PoD, as well as preferred. Results were divided into papers that explored the process of decision-making, and those that explored decision-making outcomes.

Conclusions

The process and outcomes of decision-making for older people are affected by many factors—all of which have the potential to influence both patients and caregivers experience of illness and dying. Within the context of COVID-19, such decisions may have to be made rapidly and be reflexive to changing needs of systems and of families and patients.

Access to and adequacy of psychological services for adult patients in UK hospices: a national, cross-sectional survey

BACKGROUND

Providing psychological support to people living with terminal illness is a fundamental part of hospice care. Recent research on delivery of psychological services in hospices in the United Kingdom (UK) on a national level, including inequalities or variation in practice, is limited. A nationwide survey will highlight any differences in provision and in doing so help focus future research and inform best practice both within the UK, and internationally. The specific objectives of this survey are to (1) chart the types of psychological support available to adult patients in hospices in the UK in line with the National Institute for Health and Care Excellence model; (2) explore how services are organised; and (3) gather service perspectives on adequacy of care, and facilitators and barriers to appropriate practice.

METHODS

A cross-sectional online survey emailed to adult hospices in the UK in November-December 2019. One staff member involved in the delivery and/or organisation of psychological support was invited to participate per hospice. Of 193 invited hospices, 116 took part.

RESULTS

Sixteen percent rated their hospice psychological service as wholly adequate. The majority reported that services can access specialist professionals, but many relied on external referrals. Barriers to best practice included funding and staff capacity; facilitators included clear referral structures, audit and appropriate needs and outcome assessments.

CONCLUSIONS

Access to psychological professionals has improved since the last survey 15 years ago, but the majority of responders felt their overall service was not wholly adequate. Basic emotional support is largely felt to be sufficient, but our results indicate a need for improvements in access to more specialist care. Partnerships with external mental health services may be key. Our findings highlight core facilitators and barriers to providing good psychological care at the end of life that should be considered by services both within the UK and on an international level.

Complementary therapy in palliative care: A synthesis of qualitative and quantitative systematic reviews

BACKGROUND

Interventions delivered in palliative care are complex and their evaluation through qualitative and quantitative research can lead to contrasting results. In a systematic review of trials, the effectiveness results of complementary therapies in palliative care were inconclusive; however, our qualitative synthesis showed participants perceived them to be beneficial.

AIM

Use a novel methodology to synthesise evidence from qualitative and quantitative systematic reviews on complementary therapy in palliative care to explore the following: (1) If interventions delivered in trials reflect how participants in qualitative studies report they are delivered in real-life settings and (2) whether quality of life measures used in trials capture perceived benefits that are reported in qualitative studies.

METHODS

Two matrix tables were formulated. In one, key components in delivery of the complementary therapy from the qualitative synthesis which are as follows: (1) relationship with therapist, (2) comfortable environment, (3) choices (e.g. area of massage) and (4) frequent sessions, were plotted against intervention description, to explore matches and mismatches. In the other, items included in quality of life scales were compared with perceived benefits of complementary therapy.

RESULTS

None of the trials included all four key delivery components. The five quality of life scales used in the trials failed to capture the range of perceived benefits from the complementary therapies and many included inappropriate or redundant items.

CONCLUSIONS

By integrating qualitative and quantitative review data, we determined the reasons trials may be inconclusive. This methodological exemplar provides a framework for understanding complexity in outcomes across trials and a direction for future research.

Empowering Better End-of-Life Dementia Care (EMBED-Care): A mixed methods protocol to achieve integrated person-centred care across settings

OBJECTIVES

Globally, the number of people with dementia who have palliative care needs will increase fourfold over the next 40 years. The Empowering Better End-of-Life Dementia Care (EMBED-Care) Programme aims to deliver a step change in care through a large sequential study, spanning multiple work streams.

METHODS

We will use mixed methods across settings where people with dementia live and die: their own homes, care homes, and hospitals. Beginning with policy syntheses and reviews of interventions, we will develop a conceptual framework and underpinning theory of change. We will use linked data sets to explore current service use, care transitions, and inequalities and predict future need for end-of-life dementia care. Longitudinal cohort studies of people with dementia (including young onset and prion dementias) and their carers will describe care transitions, quality of life, symptoms, formal and informal care provision, and costs. Data will be synthesised, underpinned by the Knowledge-to-Action Implementation Framework, to design a novel complex intervention to support assessment, decision making, and communication between patients, carers, and inter-professional teams. This will be feasibility and pilot tested in UK settings. Patient and public involvement and engagement, innovative work with artists, policymakers, and third sector organisations are embedded to drive impact. We will build research capacity and develop an international network for excellence in dementia palliative care.

CONCLUSIONS

EMBED-Care will help us understand current and future need, develop novel cost-effective care innovations, build research capacity, and promote international collaborations in research and practice to ensure people live and die well with dementia.

Randomised Controlled Trial of an Online Version of Compassion Mind Training in a Nonclinical Sample

Compassion Mind Training (CMT) is a therapeutic approach to guide highly self-critical individuals to generate compassion. The goal was to probe the efficacy of a short-term, online version of the CMT on self-compassion and self-criticism in a non-clinical population. We conducted a randomized controlled trial with pre-, post-measurements and two-month follow-up. Out of 144 randomly allocated participants 26 and 20 of those allocated to the intervention and control groups, respectively, completed the follow-up measures. The intervention group was instructed through email to practice a different CMT exercise every day for 13 consecutive days. There was a significant effect of the intervention on self-criticism, especially Hated-self and the Self-uncompassionate responding. The CMT group reported a reduction in negative thoughts and feelings with effects present at the two-month follow-up. There was no significant effect of the intervention on self-reassurance and self-compassion. Self-criticism is amenable to change following a short-term online intervention of CMT delivered to a non-clinical population with effects lasting at least two months. These findings are promising and suggest that interventions designed to reduce self-criticism can be provided to broader populations without direct involvement of mental health professionals.

The effectiveness of interventions to improve the care and management of people with dementia in general hospitals: A systematic review

BACKGROUND

People with dementia are at greater risk of being admitted to hospital where care may not be tailored to their needs. Interventions improving care and management are vital.

AIM

Assess the effectiveness of interventions designed to improve the care and management of people with dementia in hospital.

METHOD

Six medical and trial registry, and grey literature databases were searched (1999-1998/2018). Search terms included "Dementia," "Hospital," and "Intervention" and limited to experimental designs. Interventions designed to improve the care and management of people with dementia in the general hospital setting were examined. Outcomes included behavioural and psychological symptoms of dementia (BPSD), psychosocial, clinical, staff knowledge, and length of hospital stay. The CASP tools, Cochrane risk of bias tool, and GRADE system assessed methodological quality and certainty of evidence.

RESULTS

9003 unique citations were identified; 24 studies were included. Studies were limited in study design and their conduct was at a risk of bias. There is very low-quality evidence that multisensory behaviour therapy reduces BPSD. There is low-quality evidence that a multidisciplinary programme reduces postoperative complications and that robot-assisted therapy, music therapy, multimodal-comprehensive care, person-centred care, and family-centred function-focused care interventions improved staff knowledge, competence, efficacy, and communication. No studies reported reduced length of stay.

CONCLUSIONS

Whilst we found that these interventions improved the care and management of people with dementia in hospital, it was low- to very low-quality evidence. New clinical recommendations cannot be made based on current evidence, and robust trial designs are necessary to inform evidence-based care.

The effectiveness of aromatherapy, massage and reflexology in people with palliative care needs: A systematic review

BACKGROUND

Aromatherapy, massage and reflexology are widely used in palliative care. Despite this, there are questions about their suitability for inclusion in clinical guidelines. The need to understand their benefits is a public priority, especially in light of funding pressures.

AIM

To synthesise current evidence on the effectiveness of aromatherapy, massage and reflexology in people with palliative care needs.

DESIGN

A systematic review of randomised controlled trials (PROSPERO CRD42017081409) was undertaken following international standards including Cochrane guidelines. The quality of trials and their pooled evidence were appraised. Primary outcomes on effect were anxiety, pain and quality-of-life.

DATA SOURCES

Eight citation databases and three trial registries were searched to June 2018.

RESULTS

Twenty-two trials, involving 1956 participants were identified. Compared with a control, four evaluated aromatherapy, eight massage and six reflexology. A further four evaluated massage compared with aromatherapy. Trials were at an unclear risk of bias. Many had small samples. Heterogeneity prevented meta-analysis. In comparison with usual care, another therapy or an active control, evidence on the effectiveness of massage and aromatherapy in reducing anxiety, pain and improving quality-of-life was inconclusive. There was some evidence (low quality) that compared to an active control, reflexology reduced pain.

CONCLUSIONS

This review identified a relatively large number of trials, but with poor and heterogeneous evidence. New clinical recommendations cannot be made based on current evidence. To help provide more definitive trial findings, it may be useful first to understand more about the best way to measure the effectiveness of these therapies in palliative care.

Social networks, social capital and end-of-life care for people with dementia: a realist review

OBJECTIVES

(1) To develop an understanding of how social capital may be conceptualised within the context of end-of-life care and how it can influence outcomes for people with dementia and their families with specific reference to the context and mechanisms that explain observed outcomes. (2) To produce guidance for healthcare systems and researchers to better structure and design a public health approach to end-of-life care for people with dementia.

DESIGN

A realist review.

DATA SOURCES

MEDLINE, EMBASE, CINAHL and grey literature.

ANALYSIS

We conceptualised social capital as a complex intervention and, in order to understand how change is generated, used realist evaluation methods to create different configurations of context, mechanism and outcomes. We conducted an iterative search focusing on social capital, social networks and end-of-life care in dementia. All study designs and outcomes were screened and analysed to elicit explanations for a range of outcomes identified. Explanations were consolidated into an overarching programme theory that drew on substantive theory from the social sciences and a public health approach to palliative care.

RESULTS

We identified 118 articles from 16 countries ranging from 1992 to 2018. A total of 40 context-mechanism-outcome configurations help explain how social capital may influence end-of-life care for people with dementia. Such influence was identified within five key areas. These included: (1) socially orientating a person with dementia following diagnosis; (2) transitions in the physical environment of care; (3) how the caregiving experience is viewed by those directly involved with it; (4) transition of a person with dementia into the fourth age; (5) the decision making processes underpinning such processes.

CONCLUSION

This review contributes to the dispassionate understanding of how complex systems such as community and social capital might be viewed as a tool to improve end-of-life care for people with dementia.

PROSPERO REGISTRATION NUMBER

CRD42018084524.

Context, mechanisms and outcomes in end-of-life care for people with advanced dementia: family carers perspective

Background

Keeping people living with advanced dementia in their usual place of residence is becoming a key governmental goal but to achieve this, family carers and health care professionals must negotiate how to provide optimal care. Previously, we reported a realist analysis of the health care professional perspective. Here, we report on family carer perspectives. We aimed to understand the similarities and differences between the two perspectives, gain insights into how the interdependent roles of family carers and HCPs can be optimised, and make recommendations for policy and practice.

Method

Qualitative study using a realist approach in which we used the criteria from guidance on optimal palliative care in advanced dementia to examine key contexts, mechanisms and outcomes highlighted by family carers.

Results

The themes and views of family caregivers resonate with those of health care professionals. Their overlapping anxieties related to business-driven care homes, uncertainty of families when making EOL decisions and the importance of symptom management referring to contexts, mechanisms and outcomes, respectively. Contexts specific to family carers were ad hoc information about services, dementia progression and access to funding. Not all family carers identified dementia as terminal, but many recognised the importance of continuity of care and knowing the wishes of the person with dementia. New mechanisms included specific resources for improving EOL care and barriers to discussing and planning for future care. Family carers identified the importance of comfort, being present, the meeting of basic care needs and feeling the right decisions have been made as good outcomes of care.

Conclusions

Family carers and health care professionals share similar concerns about the challenges to good EOL dementia care. Better understanding of the effects of dementia at the advanced stages would improve confidence in EOL care and reduce uncertainty in decision making for family carers and health care professionals.

Emotional disclosure as a therapeutic intervention in palliative care: a scoping review protocol

INTRODUCTION

Emotional disclosure (ED) is a term used to describe the therapeutic expression of emotion. ED underlies a variety of therapies aimed at improving well-being for various populations, including people with palliative-stage disease and their family carers. Systematic reviews of ED-based psychotherapy have largely focused on expressive writing as a way of generating ED. However, heterogeneity in intervention format and outcome measures has made it difficult to analyse efficacy. There is also debate about the mechanisms proposed to explain the potential effects of ED.We present a scoping review protocol to develop a taxonomy of ED-based interventions to identify and categorise the spectrum of interventions that could be classified under the umbrella term of 'emotional disclosure' in the palliative care setting. By mapping these to associated treatment objectives, outcome measures and explanatory frameworks, the review will inform future efforts to design and evaluate ED-based therapies in this population.

METHODS AND ANALYSIS

The review will be guided by Arksey and O'Malley's five-stage scoping review framework and Levac's extension. The following electronic databases will be searched from database inception: CENTRAL, the Cumulative Index to Nursing and Allied Health Literature (CINAHL), PsycINFO, Scopus, Web of Science and MEDLINE. We will include peer-reviewed studies and reviews. We will also check grey literature, including clinical trial registers, conference proceedings and reference lists, as well as contacting researchers. Articles will be screened by at least two independent reviewers and data charted using an extraction form developed for this review. Results will be analysed thematically to create a taxonomy of interventions, outcome measures and theoretical frameworks.

ETHICS AND DISSEMINATION

This review does not require ethical approval as it is a secondary analysis of pre-existing, published data. The results will inform future research in the development of ED-based interventions and evaluation of their efficacy in the palliative care setting. We will disseminate findings through peer-reviewed journals.

Psychological and physiological effects of emotion focused training for self-compassion and self-protection

Emotion Focused Training for Self-Compassion and Self-Protection (EFT-SCP) is a novel intervention developed on the basis of the latest findings on self-criticism from Emotion-focused therapy and existing programs designed to cultivate compassion. EFTSCP is designed to encourage participants to cultivate self-compassion and protective anger as a way of reducing selfcriticism. Our goal was to investigate the effect of this group-based intervention on self-criticism, self-protection, and self-compassion. A total of 73 students were assigned to the EFT-SCP intervention (n=19), no-treatment control (n=34) or to an active control group (n=20). The intervention group met weekly for 1.5 hours and were instructed to incorporate EFT-SCP tasks into their daily life for 12 weeks. Whilst the no-treatment group did not undergo an intervention, the active control group completed an adapted expressive writing task once a week. In addition to the assessment of heart rate variability during imagery tasks, participants also completed self-reported measures of self-compassion and self-criticism before and after the intervention. Compared with both control groups, the intervention group showed a significant increase in heart rate variability following EFT-SCP (during self-critical imagery, P=.049; probability of superiority was .63, and during self-compassionate imagery P=.007; probability of superiority was .62, both effect sizes were medium) and significant decreases in selfcriticism (Hated Self P=.017; .34 and Inadequate Self P<.001; .33) and self-uncompassionate responding (P<.001; .39). All three effect sizes were small. Participating in EFT-SCP had a positive effect on psychological and physiological outcomes.

Expressive writing as a therapeutic intervention for people with advanced disease: a systematic review

Background

Expressive writing involves writing about stressful or traumatic experiences. Despite trials in people with advanced disease, no systematic review to date has critiqued the evidence on expressive writing in this population. To synthesise the evidence of the effects of expressive writing on pain, sleep, depression and anxiety in people with advanced disease.

Methods

A systematic review according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. CINAHL, CENTRAL, PsycINFO and PubMed were searched from January 1986 to March 2018. Other sources included clinical data registers and conference proceedings. Studies were included if they were randomised controlled trials that assessed the impact of an intervention involving expressive writing for adults with advanced disease and/or studies involving linguistic analysis on the expressive writing output. Methodological quality was assessed using the Cochrane risk of bias tool and the Mixed Methods Appraisal Tool. The Grading of Recommendations Assessment, Development and Evaluation tool was used to assess the level of evidence for the outcomes of interest. The protocol of this systematic review has been registered on PROSPERO (CRD42017058193).

Results

Six eligible studies with a total of 288 participants were identified, including four randomised controlled trials. All of the trials were in cancer and recruited predominantly women. None of the interventions were tailored to the population. Studies had methodological shortcomings and evidence was generally of low quality. Combined analysis of the four trials, involving 214 participants in total, showed no clear difference in the effect of expressive writing on sleep, anxiety or depression compared to an active control. Pain was not evaluated in the trials. In contrast, analysis of the four studies that included linguistic analysis alluded to linguistic mechanisms for potential effects.

Conclusion

Although the trial results suggest there is no benefit in expressive writing for people with advanced disease, the current evidence is limited. There is a need for more rigorous trials. It would be of benefit first to undertake exploratory research in trial design including how best to measure impact and in tailoring of the intervention to address the specific needs of people with advanced disease.

Trial registration

The protocol of this systematic review has been registered on PROSPERO, which can be accessed here (registration number: CRD42017058193).

Electronic supplementary material

The online version of this article (10.1186/s12904-019-0449-y) contains supplementary material, which is available to authorized users.

Aromatherapy, massage and reflexology: A systematic review and thematic synthesis of the perspectives from people with palliative care needs

BACKGROUND

Effectiveness evidence of complementary therapies in people with advanced disease is uncertain, and yet people are still keen to engage in complementary therapy. Insights into people's experiences of complementary therapy in palliative care, the perceived benefits, and how they want it delivered, can inform clinical guidelines and suggest ways to test therapies more appropriately in future evaluations.

AIMS

Explore in people with advanced disease (1) the experiences and perceptions of benefits and harms of aromatherapy, massage, and reflexology and (2) how they would like these therapies delivered.

DESIGN

A systematic review and thematic synthesis of qualitative studies. Database search terms were related to palliative care, aromatherapy, reflexology and massage. Citations and full texts were reviewed independently against predefined inclusion criteria. Studies were appraised for quality. This review is registered at PROSPERO (22/11/2017 CRD42017081409).

DATA SOURCES

MEDLINE, EMBASE, PsycINFO, AMED, CINAHL, KoreaMed and ProQuest with a bibliography search to June 2018.

RESULTS

Five qualitative studies in advanced cancer were identified. Three analytical themes were identified: (1) Experience during the therapy (enhanced well-being and escapism), (2) beyond the complementary therapy session (lasting benefits and overall evaluation), and (3) delivery of complementary therapy in palliative care (value of the therapist and delivery of the complementary therapy).

CONCLUSIONS

People with advanced cancer experience benefits from aromatherapy, reflexology and massage including enhanced well-being, respite, and escapism from their disease. Complementary therapy interventions should be developed in consultation with the target population to ensure they are delivered and evaluated, where feasible, as they wish.

Eating Disorder Examination Questionnaire (EDE-Q): Norms and psychometric properties in U.K. females and males

The Eating Disorder Examination Questionnaire (EDE-Q) is a widely used assessment of eating disorder psychopathology; however, EDE-Q norms are yet to be provided within a nonclinical U.K. adult sample. Second, there is considerable disagreement regarding the psychometric properties of this measure. Several alternative factor structures have been previously proposed, but very few have subsequently validated their new structure in independent samples and many are often confined to specific subpopulations. Therefore, in the current study, we provide norms of the original four-factor EDE-Q structure, and subsequently assess the psychometric properties of the EDE-Q in females and males using a large nonclinical U.K. sample (total N = 2459). EDE-Q norms were consistently higher in females compared with males across all samples. Initial confirmatory factor analyses (CFA) did not support the original 4-factor structure for females or males (Phase 1). However, subsequent exploratory factor analyses (EFA) revealed a 3-factor structure as being the optimal fit for both females and males, using an 18-item and 16-item model, respectively (Phase 2). For females, the newly proposed 18-item structure was validated within an independent student sample and further validated in an additional nonstudent sample. The 16-item 3-factor male structure was also validated within an independent nonstudent sample, but was marginally below accepted fit indices within an independent student sample (Phase 3). Taken together, the above findings suggest that the EDE-Q factor structure may require further reassessment, with greater focus on the qualitative differences in interpretation of EDE-Q items between females and males. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Pain and delirium in people with dementia in the acute general hospital setting

Background

Pain and delirium are common in people with dementia admitted to hospitals. These are often under-diagnosed and under-treated. Pain is implicated as a cause of delirium but this association has not been investigated in this setting.

Objective

To investigate the relationship between pain and delirium in people with dementia, on admission and throughout a hospital admission.

Design

Exploratory secondary analysis of observational prospective longitudinal cohort data.

Setting

Two acute hospitals in the UK.

Methodology

Two-hundred and thirty participants aged ≥70 years were assessed for dementia severity, delirium ((Confusion Assessment Method (CAM), pain (Pain Assessment in Advanced Dementia (PAINAD)) scale and prescription of analgesics. Logistic and linear regressions explored the relationship between pain and delirium using cross-sectional data.

Results

Pain at rest developed in 49%, and pain during activity for 26% of participants during their inpatient stay. Incident delirium developed in 15%, of participants, and 42% remained delirious for at least two assessments. Of the 35% of participants who were delirious and unable to self-report pain, 33% of these participants experienced pain at rest, and 56 experienced pain during activity. The odds of being delirious were 3.26 times higher in participants experiencing pain at rest (95% Confidence Interval 1.03-10.25, P = 0.044).

Conclusion

An association between pain at rest and delirium was found, suggesting pain may be a risk factor for delirium. Since pain and delirium were found to persist and develop during an inpatient stay, regular pain and delirium assessments are required to manage pain and delirium effectively.

47 The impact of supportive-expressive group therapy (SEGT) as an intervention on health-related outcomes and social support for people with advanced disease: a systematic review

Introduction

SEGT has been found to be a valuable manualised model of therapy for reducing emotional distress facilitating the person’s management of the disease-related symptoms and improving quality of life in cancer populations (Butler et al. 2009; Classen et al. 2001; Lemieux et al. 2007). The fundamental domains covered by this model include promoting emotional expression confronting existential issues and optimising social support (Classen et al. 2001; Spiegel Bloom and Yalom 1981). Despite trials there are to our knowledge no systematic reviews that have sought to critic and pool evidence from all Randomised Controlled Trials (RCTs) on SEGT for people with advanced disease.

Aims

To critique and pool the evidence from RCTs on the effectiveness of SEGT as a palliative care intervention for patients with advanced disease.

Methods

Four databases (Pubmed Medline CINAHL PsycINFO) conference proceedings and grey literature were searched for relevant studies in April 2018. A combination of MeSH and free-text terms on SEGT and end-of-life were used. Key review processes will be undertaken in duplicate. If appropriate meta-analysis will be considered.

Results

The search identified unique 2291 citations. Screening these identified 27 potential relevant studies. Following full text review and contact with the authors of not-available full text papers five RCTs on SEGT met our inclusion criteria.

Conclusions

This review is at data extraction phase it will be completed by September. Further understanding of the quality of evidence impact of SEGT on health-related outcomes and social support will allow conclusion to be made for clinical practice.

References

. Butler LD, Koopman C, Neri E, Giese-Davis J, Palesh O, Thorne-Yocam KA, Dimiceli S, Chen X, Fobair P, Kraemer HC, Spiegel D. Effects of supportive-expressive group therapy on pain in women with metastatic breast cancer. Health Psychology2009;28(5):579–587.

. Classen C, Butler LD, Koopman C, Miller E, DiMiceli S, Giese- Davis J, Fobair P, Carlson RW, Kraemer EC, Spiegel D. Supportive-expressive group therapy and distress in patients with metastatic breast cancer: A randomized clinical intervention trial. Archives of General Psychiatry2001;58:494–495.

. Lemieux J, Beaton ED, Hogg-Johnson S, Bordeleau JL, Hunter J, Goodwin PJ. Responsiveness to change to change due to supportive-expressive group therapy improvement in mood and disease progression in women with metastatic breast cancer. Qual Life Res2007;16:1007–1017.

. Spiegel D, Bloom JR, Yalom I. Group support for patients with metastatic cancer. A randomized outcome study. Archives of General Psychiatry1981;38:527–533.

9 Using what people value to develop new interventions in palliative care: a multilevel level review approach

Introduction

Complex interventions are common in palliative care (PC) but are difficult to evaluate. Complementary therapies (CT) are one type of widely-used complex intervention for which there is inconclusive evidence. No systematic review has been conducted in PC of trials or of qualitative studies of patients’ views of CTs. There are novel approaches with established exemplars of using both types of reviews to help develop more clinically appropriate interventions. These approaches are in their infancy in PC research and have much to offer the specialism.

Aims

Using our on-going review on CT we present as an exemplar in PC an approach to draw together the findings of trials and qualitative studies in a data table (matrix) to contrast what patients value and want with how the intervention is tested.

Methods

We sought trials on the effectiveness of CT and qualitative studies on patients’ perspectives about these therapies. Our primary outcomes for trials included anxiety. Eight databases were searched in 2017. Citations and full-text papers were reviewed to identify relevant studies. Meta-analyses pooled trial data where appropriate and a thematic synthesis is being undertaken to understand patient experience. These findings will be combined in a matrix to explore similarities and differences.

Results

19 trials and five qualitative studies were included. Data analysis and development of the matrix which includes intervention content and patients’ needs is currently underway. We will present the final matrix framework.

Conclusions

Our approach demonstrates a potential way in PC to enhance development of practice appropriate complex interventions.

Randomised controlled trial of the new short-term online emotion focused training for self-compassion and self-protection in a nonclinical sample

The Emotion Focused Training for Self-Compassion and Self-Protection (EFT-SCP) is an intervention developed to increase skills of self-compassion and protective anger with the aim to decrease self-criticism. This novel intervention was developed on the basis of the latest findings on self-criticism from Emotion-focused therapy and previous programs cultivating compassion (namely Compassion Mind Training and Mindful Self-Compassion Program). According to existing research, simply cultivating self-compassion is not always sufficient in reducing self-criticism. Therefore, the EFT-SCP was designed to build self-compassion whilst developing protective anger to combat self-criticism. Our goal was to investigate the efficacy of this new, short-term, online EFT-SCP program in a non-clinical population. A randomized control trial was conducted with pre- and post-intervention measurements and two-month follow-up of self-compassion and self-criticism/reassurance. Convenience sampling was used to recruit participants through a snowballing technique on social media. A total of 123 participants were randomly allocated to the EFT-SCP intervention or to a control condition. The intervention group were instructed through emails to complete an EFT-SCP task every day for 14 consecutive days. The control group did not complete any tasks. Out of 123 participants, 31 from intervention group and 20 from control group completed all measurements. There was a significant effect of the EFT-SCP on increasing self-compassion and self-reassurance scores as reported at two-month follow-up. The EFT-SCP was also effective at reducing self-uncompassionate responding and self-criticism (specifically Hated self) with changes evident at two months post-intervention. These findings are encouraging and suggest that interventions designed to enhance self-compassion and decrease self-criticism can be delivered to broader populations without the direct contact with mental health professionals.

The impact of an emotionally expressive writing intervention on eating pathology in female students

Introduction: Previous research demonstrating emotional influences on eating and weight suggest that emotionally expressive writing may have a significant impact on reducing risk of eating pathology. This study examined the effects of writing about Intensely Positive Experiences on weight and disordered eating during a naturalistic stressor.

Method: Seventy-one female students completed an expressive or a control writing task before a period of exams. Both groups were compared on BMI (kg/m²) and the Eating Disorder Examination – Questionnaire (EDE-Q) before the writing task and at 8-week follow-up. A number of secondary analyses were also examined (to identify potential mediators) including measures of attachment, social rank, self-criticism and self-reassurance, stress and mood.

Results: There was a significant effect of intervention on changes in the subscales of the EDE-Q (p = .03). Specifically, expressive writers significantly reduced their dietary restraint while those in the control group did not. There was no significant effect of the intervention on changes in BMI or the other subscales of the EDE-Q (Eating, Weight and Shape Concern). There was also no effect of writing on any of the potential mediators in the secondary analyses.

Discussion: Emotionally expressive writing may reduce the risk of dietary restraint in women but these findings should be accepted with caution. It is a simple and light touch intervention that has the potential to be widely applied. However, it remains for future research to replicate these results and to identify the mechanisms of action.

The Factor Structure of the Forms of Self-Criticising/Attacking & Self-Reassuring Scale in Thirteen Distinct Populations

There is considerable evidence that self-criticism plays a major role in the vulnerability to and recovery from psychopathology. Methods to measure this process, and its change over time, are therefore important for research in psychopathology and well-being. This study examined the factor structure of a widely used measure, the Forms of Self-Criticising/Attacking & Self-Reassuring Scale in thirteen nonclinical samples (N = 7510) from twelve different countries: Australia (N = 319), Canada (N = 383), Switzerland (N = 230), Israel (N = 476), Italy (N = 389), Japan (N = 264), the Netherlands (N = 360), Portugal (N = 764), Slovakia (N = 1326), Taiwan (N = 417), the United Kingdom 1 (N = 1570), the United Kingdom 2 (N = 883), and USA (N = 331). This study used more advanced analyses than prior reports: a bifactor item-response theory model, a two-tier item-response theory model, and a non-parametric item-response theory (Mokken) scale analysis. Although the original three-factor solution for the FSCRS (distinguishing between Inadequate-Self, Hated-Self, and Reassured-Self) had an acceptable fit, two-tier models, with two general factors (Self-criticism and Self-reassurance) demonstrated the best fit across all samples. This study provides preliminary evidence suggesting that this two-factor structure can be used in a range of nonclinical contexts across countries and cultures. Inadequate-Self and Hated-Self might not by distinct factors in nonclinical samples. Future work may benefit from distinguishing between self-correction versus shame-based self-criticism.

Living and dying with advanced dementia: A prospective cohort study of symptoms, service use and care at the end of life

BACKGROUND

Increasing number of people are dying with advanced dementia. Comfort and quality of life are key goals of care.

AIMS

To describe (1) physical and psychological symptoms, (2) health and social care service utilisation and (3) care at end of life in people with advanced dementia.

DESIGN

9-month prospective cohort study.

SETTING AND PARTICIPANTS

Greater London, England, people with advanced dementia (Functional Assessment Staging Scale 6e and above) from 14 nursing homes or their own homes.

MAIN OUTCOME MEASURES

At study entry and monthly: prescriptions, Charlson Comorbidity Index, pressure sore risk/severity (Waterlow Scale/Stirling Scale, respectively), acute medical events, pain (Pain Assessment in Advanced Dementia), neuropsychiatric symptoms (Neuropsychiatric Inventory), quality of life (Quality of Life in Late-Stage Dementia Scale), resource use (Resource Utilization in Dementia Questionnaire and Client Services Receipt Inventory), presence/type of advance care plans, interventions, mortality, place of death and comfort (Symptom Management at End of Life in Dementia Scale).

RESULTS

Of 159 potential participants, 85 were recruited (62% alive at end of follow-up). Pain (11% at rest, 61% on movement) and significant agitation (54%) were common and persistent. Aspiration, dyspnoea, septicaemia and pneumonia were more frequent in those who died. In total, 76% had 'do not resuscitate' statements, less than 40% advance care plans. Most received primary care visits, there was little input from geriatrics or mental health but contact with emergency paramedics was common.

CONCLUSION

People with advanced dementia lived with distressing symptoms. Service provision was not tailored to their needs. Longitudinal multidisciplinary input could optimise symptom control and quality of life.

What are the barriers to care integration for those at the advanced stages of dementia living in care homes in the UK? Health care professional perspective

People with advanced dementia are frequently bed-bound, doubly incontinent and able to speak only a few words. Many reside in care homes and may often have complex needs requiring efficient and timely response by knowledgeable and compassionate staff. The aim of this study is to improve our understanding of health care professionals' attitudes and knowledge of the barriers to integrated care for people with advanced dementia. In-depth, interactive interviews conducted with 14 health care professionals including commissioners, care home managers, nurses and health care assistants in the UK. Barriers to care for people with advanced dementia are influenced by governmental and societal factors which contribute to challenging environments in care homes, poor morale amongst care staff and a fragmentation of health and social care at the end of life. Quality of care for people with dementia as they approach death may be improved by developing collaborative networks to foster improved relationships between health and social care services.

Psychometric evaluation of the Cohen-Mansfield Agitation Inventory in an acute general hospital setting

OBJECTIVES

The Cohen-Mansfield Agitation Inventory (CMAI; (Cohen-Mansfield and Kerin, 1986)) is a well-known tool for assessing agitated behaviours in people with dementia who reside in long-term care. No studies have evaluated the psychometric qualities and factor structure of the CMAI in acute general hospitals, a setting where people with demand may become agitated.

METHOD

Longitudinal study investigating pain, agitation and behavioural problems in 230 people with dementia admitted to acute general hospitals in 2011-2012. Cohen-Mansfield Agitation Inventory was completed as part of a battery of assessments including PAINAD to measure pain.

RESULTS

A nine-item two-factor model of aggressive and nonaggressive behaviours proved to be the best-fitting measurement model in this sample, (χ2  = 96.3, df = 26, p<0.001; BIC [Bayesian Information Criterion] = 4593.06, CFI [Comparative Fit Index] = 0.884, TLI [Tucker Lewis Index] = 0.839, RMSEA [Root Mean Square Error of the Approximation] = 0.108). Although similar to the original factor structure, the new model resulted in the elimination of item 13 (screaming). Validity was confirmed with the shortened CMAI showing similar associations with pain as the original version of the CMAI, in particular the link between aggressive behaviours and pain.

CONCLUSION

The factor structure of the CMAI was broadly consistent with the original solution although a large number of items were removed. Scales reflecting physical and verbal aggression were combined to form an Aggressive factor, and physical and verbal nonaggressive behaviours were combined to form the Nonaggressive factor. A shorter, more concise version of the CMAI was developed for use in acute general hospital settings. Copyright © 2017 John Wiley & Sons, Ltd.

How accurate is the 'Surprise Question' at identifying patients at the end of life? A systematic review and meta-analysis

BACKGROUND

Clinicians are inaccurate at predicting survival. The 'Surprise Question' (SQ) is a screening tool that aims to identify people nearing the end of life. Potentially, its routine use could help identify patients who might benefit from palliative care services. The objective was to assess the accuracy of the SQ by time scale, clinician, and speciality.

METHODS

Searches were completed on Medline, Embase, CINAHL, AMED, Science Citation Index, Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, Open Grey literature (all from inception to November 2016). Studies were included if they reported the SQ and were written in English. Quality was assessed using the Newcastle-Ottawa Scale.

RESULTS

A total of 26 papers were included in the review, of which 22 reported a complete data set. There were 25,718 predictions of survival made in response to the SQ. The c-statistic of the SQ ranged from 0.512 to 0.822. In the meta-analysis, the pooled accuracy level was 74.8% (95% CI 68.6-80.5). There was a negligible difference in timescale of the SQ. Doctors appeared to be more accurate than nurses at recognising people in the last year of life (c-statistic = 0.735 vs. 0.688), and the SQ seemed more accurate in an oncology setting 76.1% (95% CI 69.7-86.3).

CONCLUSIONS

There was a wide degree of accuracy, from poor to reasonable, reported across studies using the SQ. Further work investigating how the SQ could be used alongside other prognostic tools to increase the identification of people who would benefit from palliative care is warranted.

TRIAL REGISTRATION

PROSPERO CRD42016046564 .

Implementing the compassion intervention, a model for integrated care for people with advanced dementia towards the end of life in nursing homes: a naturalistic feasibility study

BACKGROUND

Many people with dementia die in nursing homes, but quality of care may be suboptimal. We developed the theory-driven 'Compassion Intervention' to enhance end-of-life care in advanced dementia.

OBJECTIVES

To (1) understand how the Intervention operated in nursing homes in different health economies; (2) collect preliminary outcome data and costs of an interdisciplinary care leader (ICL) to facilitate the Intervention; (3) check the Intervention caused no harm.

DESIGN

A naturalistic feasibility study of Intervention implementation for 6 months.

SETTINGS

Two nursing homes in northern London, UK.

PARTICIPANTS

Thirty residents with advanced dementia were assessed of whom nine were recruited for data collection; four of these residents' family members were interviewed. Twenty-eight nursing home and external healthcare professionals participated in interviews at 7 (n=19), 11 (n=19) and 15 months (n=10).

INTERVENTION

An ICL led two core Intervention components: (1) integrated, interdisciplinary assessment and care; (2) education and support for paid and family carers.

DATA COLLECTED

Process and outcome data were collected. Symptoms were recorded monthly for recruited residents. Semistructured interviews were conducted at 7, 11 and 15 months with nursing home staff and external healthcare professionals and at 7 months with family carers. ICL hours were costed using Department of Health and Health Education England tariffs.

RESULTS

Contextual differences were identified between sites: nursing home 2 had lower involvement with external healthcare services. Core components were implemented at both sites but multidisciplinary meetings were only established in nursing home 1. The Intervention prompted improvements in advance care planning, pain management and person-centred care; we observed no harm. Six-month ICL costs were £18 255.

CONCLUSIONS

Implementation was feasible to differing degrees across sites, dependent on context. Our data inform future testing to identify the Intervention's effectiveness in improving end-of-life care in advanced dementia.

TRIAL REGISTRATION

ClinicalTrials.gov:NCT02840318: Results.

Experiences of end of life amongst family carers of people with advanced dementia: longitudinal cohort study with mixed methods

Background

Many studies have examined the mental health of carers of people with dementia. Few have examined their experiences in the advanced stages of disease and into bereavement. We aimed to understand the experiences of carers during advanced dementia exploring the links between mental health and experiences of end of life care.

Methods

Mixed methods longitudinal cohort study. Thirty-five family carers of people with advanced dementia (6 at home, 29 in care homes) were recruited and assessed monthly for up to nine months or until the person with dementia died, then at two and seven months into bereavement. Assessments included: Hospital Anxiety and Depression Scale, Short Form 12 health–related quality of life, 22-item Zarit Burden Interview, Brief Coping Orientation to Problems Experienced, Inventory of Complicated Grief and Satisfaction with Care at End of Life in Dementia. Subsequently, 12 carers (34%) were bereaved and 12 undertook a qualitative interview two months after death; these data were analysed thematically. We analysed quantitative and qualitative data independently and then merged findings at the point of interpretation.

Results

At study entry psychological distress was high; 26% reached caseness for depression and 41% for anxiety and median complicated grief scores were 27 [IQR 22–37] indicating that on average 11 of the 16 grief symptoms occurred at least monthly. Physical health reflected population norms (mean = 50) and median burden scores were 17 [IQR 9–30]. Three qualitative themes were identified: the importance of relationships with care services, understanding of the progression of dementia, and emotional responses to advanced dementia. An overarching theme tying these together was the carer’s ability to control and influence end of life care.

Conclusions

While carers report high levels of psychological distress during advanced dementia, the experience of end of life care in dementia may be amenable to change with the provision of sensitive and timely information about the natural progression of dementia. Regular health status updates and end of life discussions can help families understand dementia progression and prepare for end of life. The extent to which our findings reflect practice across the UK or internationally warrants further investigation.

Affect systems, changes in body mass index, disordered eating and stress: an 18-month longitudinal study in women

Background: Evidence suggests that stress plays a role in changes in body weight and disordered eating. The present study examined the effect of mood, affect systems (attachment and social rank) and affect regulatory processes (self-criticism, self-reassurance) on the stress process and how this impacts on changes in weight and disordered eating. Methods: A large sample of women participated in a community-based prospective, longitudinal online study in which measures of body mass index (BMI), disordered eating, perceived stress, attachment, social rank, mood and self-criticism/reassurance were measured at 6-monthly intervals over an 18-month period. Results: Latent Growth Curve Modelling showed that BMI increased over 18 months while stress and disordered eating decreased and that these changes were predicted by high baseline levels of these constructs. Independently of this, however, increases in stress predicted a reduction in BMI which was, itself, predicted by baseline levels of self-hatred and unfavourable social comparison. Conclusions: This study adds support to the evidence that stress is important in weight change. In addition, this is the first study to show in a longitudinal design, that social rank and self-criticism (as opposed to self-reassurance) at times of difficulty predict increases in stress and, thus, suggests a role for these constructs in weight regulation.

An ethnographic study of strategies to support discussions with family members on end-of-life care for people with advanced dementia in nursing homes

BACKGROUND

Most people with advanced dementia die in nursing homes where families may have to make decisions as death approaches. Discussions about end-of-life care between families and nursing home staff are uncommon, despite a range of potential benefits. In this study we aimed to examine practices relating to end-of-life discussions with family members of people with advanced dementia residing in nursing homes and to explore strategies for improving practice.

METHODS

An ethnographic study in two nursing homes where the Compassion Intervention was delivered. The Compassion Intervention provides a model of end-of-life care engaging an Interdisciplinary Care Leader to promote integrated care, educate staff, support holistic assessments and discuss end of life with families. We used a framework approach, undertaking a thematic analysis of fieldwork notes and observations recorded in a reflective diary kept by the Interdisciplinary Care Leader, and data from in-depth interviews with 23 informants: family members, GPs, nursing home staff, and external healthcare professionals.

RESULTS

Four major themes described strategies for improving practice: (i) educating families and staff about dementia progression and end-of-life care; (ii) appreciating the greater value of in-depth end-of-life discussions compared with simple documentation of care preferences; (iii) providing time and space for sensitive discussions; and (iv) having an independent healthcare professional or team with responsibility for end-of-life discussions.

CONCLUSIONS

The Interdisciplinary Care Leader role offers a promising method for supporting and improving end-of-life care discussions between families of people with advanced dementia and nursing home staff. These strategies warrant further evaluation in nursing home settings.