Can Residents With Late-Stage Dementia Still Engage?

Institutionalized persons with dementia often lack access to meaningful activity, which can lead to agitation, loneliness, and depression. Engagement in activity may improve negative symptoms but is difficult in most settings. In this study, we investigated the degree to which the Reading Buddies Program, in which occupational therapy graduate students read books with residents with dementia, engaged residents. We further assessed whether the level of engagement was affected by various parameters, including those related to interaction, environment, attention, attitude, and activity. The primary outcome measure was engagement percentage-duration of time the book was read divided by duration of time the person with dementia engaged with the book. As expected, increased attention, attitude, and activity parameters were associated with increased engagement. None of the environmental parameters significantly affected engagement. Overall, we found that reading with persons with dementia led to a very high level of engagement and appeared to reduce negative symptoms.

An Online Learning Experience Simulating Video Telehealth with Older Adults: Student Perceptions

Older adults are an underserved population with a broad-spectrum of care needs due to multi-morbidity, including increasing rates of mental health conditions. Though a prime target for tele-behavioral health due to access barriers, older adults face a persistent digital divide that necessitates clinician training and education to ensure interprofessional tele-behavioral health is tailored to their needs. This paper presents findings from a simulation learning program designed to teach students about the role of video telehealth with populations with diverse needs. Occupational therapy (OT) students enrolled in a Master's program between 2017 and 2018 conducted a simulated video telehealth session geared for an older adult. Sessions were recorded and annotated by students, who then provided feedback on their experience of the simulation via reflective essays (N = 27). Essays were analyzed using conventional content analysis with themes revealing the benefits of simulation in providing students with an opportunity to experience the often unpredictable nature of video telehealth. Themes also revealed perceived limitations of video and the negative impact of age-related conditions and age itself on older adults' ability to engage in video, reflecting ageist stereotyping and bias as potential barriers to novice practitioners' integration of video telehealth with older adults. Simulation provides students an opportunity to engage in active learning and problem-solving in the moment, fostering students' development of clinical reasoning while promoting reflective practice. Findings reveal the importance of supporting students' recognition of biased attitudes to ensure equitable application of tele-behavioral health care, especially to populations with complex needs.

Understanding Variation in Adoption of Video Telehealth and Implications for Health Care Systems

BACKGROUND

Telehealth has rapidly expanded since COVID-19. Veterans Health Administration (VHA), the largest integrated health care system in the United States, was well-positioned to incorporate telehealth across specialties due to existing policies and infrastructure.

OBJECTIVES

The objective of this study is to investigate predictors of occupational therapy (OT) practitioners' adoption of video telehealth.

METHODS

This study presents data from a convenience sample of VHA occupational therapy (OT) practitioners administered pre-pandemic, in fall 2019. Survey development was guided by the Promoting Action on Research Implementation in Health Services framework, and gathered clinician attitudes, experiences, and perspectives about video telehealth to deliver OT services. Items included telehealth usage, perceived effectiveness of specific OT interventions, and perceptions about evidence. Our outcome variable denoted practitioners' level of adoption of video telehealth: telehealth users (adopters), non-users who want to use telehealth (potential adopters and reference group), and non-users who do not want to use telehealth (non-adopters). In multiple multinomial logistic regressions, we tested whether level of adoption was associated with years of VHA work experience and perceived strength of evidence.

RESULTS

Of approximately 1455 eligible practitioners, 305 VHA occupational therapy practitioners participated in the survey (21% response rate). One hundred and twenty-five (41%) reported using video telehealth, whereas 180 (59%) reported not using video telehealth. Among non-users, 107 (59%) indicated willingness to adopt telehealth whereas 73 (41%) were not willing. More VHA work experience predicted higher odds of being an adopter than a potential adopter; perceptions of stronger evidence regarding video telehealth predicted higher odds of being a potential adopter than a non-adopter.

CONCLUSION

Clinician beliefs and years of experience exerted an influence on clinicians' use or willingness to use video telehealth. Efforts to enhance adoption of video telehealth should address clinicians' beliefs regarding the innovative nature of and organizational resources necessary to foster utilization.

Responding to COVID-19: Resilience in Occupational Therapy

This special issue of the American Journal of Occupational Therapy highlights the contribution of occupational therapy practitioners to the care of clients during the coronavirus disease 2019 (COVID-19) pandemic. The case studies and articles exemplify the resilience of practitioners and the importance of occupational therapy interventions in addressing the physical, cognitive, psychological, and social needs of clients, their families, and care providers. We encourage practitioners to be inventive, to be collaborative, and to contribute to research regarding the benefits of occupational therapy for this population.

Promoting Quality of Life in Advanced Dementia Care: Reading Buddies Program as Service-learning

The Reading Buddies Program was developed as a service-learning component of an Occupational Therapy Practice with Older Adults course as a collaboration between Tufts University and the VA Bedford Health Care System. The purpose of this service-learning program was to challenge graduate students' implicit biases and improve communication skills when working with older adults with significant cognitive impairments. Through this collaboration, occupational therapy students provided individualized, activity-based care to Veterans with advanced dementia. In this qualitative study, a total of 55 guided reflection papers submitted by students were analyzed using NVivo. Four major themes emerged: "I was a fish out of water," "I finally took a risk," "And then I thought, maybe I should give myself a little credit," and, "I am still experimenting with how I feel," illustrating student outcomes and perceived benefits of participation in the Reading Buddies Program. Each theme reflected the development of clinical reasoning which was the targeted impact. Outcomes confirm service-learning as an effective tool and suggest further use for academic programs, emphasizing the potential of creative partnerships to meet educational goals while providing valuable programming to vulnerable populations.

Caregiver Satisfaction with a Video Telehealth Home Safety Evaluation for Dementia

Family caregivers are vital to telehealth-delivered dementia care. The objective of this mixed methods descriptive study conducted in the VA Bedford Healthcare System was to examine caregiver satisfaction with a video telehealth dementia home safety occupational therapy evaluation. Ten caregivers of Veterans with dementia participated. Ratings of caregiver satisfaction, measured by nine Likert scale items including ability to see and hear, were examined in relation to person and visit-related contextual factors extracted from research assistants' field notes, to develop an in-depth understanding of caregiver experience. Person factors included caregiver age and gender and Veteran cognitive status. Visit-related contextual factors included occurrence of technical glitches. Caregiver visit satisfaction was overall positive, with exceptions related to technological glitches and the presence of the person with dementia during the visit. Veteran cognitive status appeared to influence caregiver satisfaction. Implications of the study are that proactively addressing technical glitches and incorporating dementia stage-specific approaches may optimize caregivers' telehealth experience.

Critical Workforce Gaps in Dementia Education and Training

The US Department of Health and Human Services and the Foundation for the National Institutes of Health, through private sector support, sponsored the National Research Summit on Dementia Care: Building Evidence for Services and Supports (Summit) in 2017. Various workgroups were asked to address topics of interest in dementia care and develop recommendations addressing the goals of the Summit. Workforce education and training was identified to be a key issue. As a result, a Workforce Development Workgroup (the Workgroup) was created and addressed two of the Summit's goals. The first goal is to improve the quality of care and support provided to persons living with dementia and those who care for them. The second goal is to accelerate the development, evaluation, translation, implementation, and scaling-up of evidence-based and evidence-informed services for persons living with dementia, their families, and caregivers. In this article, the Workgroup identified gaps in educating and training a dementia-capable workforce. The Workgroup consisted of an interprofessional team with expertise in dementia workforce development from academia, professional organizations, and the federal government. Four recommendations are presented concerning research topics that will advance the education and training of a dementia-capable workforce, which includes health professions students, faculty, practitioners, direct care workers, persons living with dementia, and those who care for them. J Am Geriatr Soc 68:625-629, 2020.

Directed content analysis of Veterans Affairs policy documents: A strategy to guide implementation of a dementia home safety toolkit for Veterans to promote ageing in place

Older adults' preference to age in place, coupled with an increasing prevalence of dementia, creates an imperative to address home safety risks that occur due to cognitive impairment. Providing caregivers with home safety items and education can facilitate ageing in place for older adults living with dementia. In 2015-2017, we examined barriers and facilitators within 17 policy documents and dementia guidelines of the United States (US) Veterans Health Administration pertinent to implementation of a home safety toolkit (HST) for Veterans living with dementia. The documents were issued from 2000 to 2015. Directed qualitative content analysis of these documents guided by themes from stakeholder interviews revealed two key implementation barriers: a focus on physical rather than cognitive risks when determining medical necessity for home equipment, and a focus on rehabilitation and treatment rather than prevention. Mandates for person-centred care planning, including comprehensive assessment, interdisciplinary collaboration, staff education and a focus on population health in primary care facilitate HST implementation. Content analysis can identify policy-level barriers that slow innovation and facilitators that can increase access to care that support ageing in place.

USING ACCESSIBLE TECHNOLOGY TO SUPPORT CAREGIVERS OF PERSONS WITH DEMENTIA

There is widespread enthusiasm about the potential of technology in general to support persons living with dementia and their families and other caregivers. At the same time, recommendations from the 2017 National Research Summit on Care, Services, and Supports for Persons with Dementia and their Caregivers emphasize the need for research to develop, evaluate, and disseminate specific technologies that can achieve meaningful benefits for well-defined subgroups of persons living with dementia and their caregivers, including individuals from diverse populations and individuals who live and receive care in various settings. This symposium focuses on specific home-based technologies to help family caregivers of community-living persons with dementia. Our three speakers will talk about research results for three different technology-related interventions, including: use of home video telehealth visits to help family caregivers provide effective dementia care and provide medical management; use of home video assessments by occupational therapists to help family caregivers increase home safety for community-living persons with dementia; and approaches for making a self-paced Home Safety Toolkit available to family caregivers of community-living veterans with dementia. Each speaker will report both positive outcomes, including family caregiver satisfaction, and barriers encountered in delivering the interventions. Such barriers include difficulties with the technologies as well as caregiver reluctance to change and costs that were not covered by health care insurance or health systems. Our discussant will respond to the presentations and solicit audience questions and discussion.

IMPLEMENTING HOME SAFETY TOOLKIT TO CAREGIVERS OF VETERANS WITH DEMENTIA

The purpose of this project was to study the processes necessary to make a Home Safety Toolkit (HST) for Veterans with dementia accessible to veterans and their caregivers. This Type 3 Implementation–Effectiveness Hybrid Research Design, included diagnostic analyses of the current processes by which Veterans receive home safety items, and identification of modifications necessary in order to provide the HST to Veterans with dementia. Two Veterans Health Administration Networks, one in the Northeast and one in the Mid-Atlantic region, participated. A formative evaluation used semi-structured interviews with key staff informants and caregivers identified facilitators and barriers to successful acquisition and use of home safety items. Qualitative data analysis reveals key barriers of time and cost, selection of best items, and caregiver reluctance to change. There was resounding support from caregivers regarding the potential benefits of self-paced toolkit including education and home safety items to implement for their veteran.

In-Home Video Telehealth for Dementia Management: Implications for Rehabilitation

PURPOSE OF REVIEW

The progressive nature of dementia requires ongoing care delivered by multidisciplinary teams, including rehabilitation professionals, that is individualized to patient and caregiver needs at various points on the disease trajectory. Video telehealth is a rapidly expanding model of care with the potential to expand dementia best practices by increasing the reach of dementia providers to flexible locations, including patients' homes. We review recent evidence for in-home video telehealth for patients with dementia and their caregivers with emphasis on implications for rehabilitation professionals.

RECENT FINDINGS

Eleven studies were identified that involved video visits into the home targeting patients with dementia and/or their family caregivers. The majority describe protocolized interventions targeting caregivers in a group format over a finite, pre-determined period. For most, the discipline of the interventionist was unclear, though two studies included rehabilitation interventions. While descriptions of utilized technology were often lacking, many reported that devices were issued to participants when needed, and that technical support was provided by study teams. Positive caregiver outcomes were noted but evidence for patient-level outcomes and cost data are mostly lacking.

SUMMARY

More research is needed to demonstrate implementation of dementia best care practices through in-home video telehealth. Though interventions delivered using in-home video telehealth appear to be effective at addressing caregivers' psychosocial concerns, the impact on patients and the implications for rehabilitation remain unclear. Larger, more systematic inquiries comparing in-home video telehealth to traditional visit formats are needed to better define best practices.

Feasibility of Telehealth-Delivered Home Safety Evaluations for Caregivers of Clients With Dementia

Video telehealth can increase access to home-based care, thus allowing older adults to maintain functional independence and age-in-place. This is particularly salient for persons with dementia whose cognitive changes increase home safety risk. Little is known about the technological and safety challenges of in-home assessment via video. This feasibility study explored the process and resource requirements of a remotely delivered telehealth occupational therapy home safety evaluation from a Veterans Health Administration (VHA) site. A total of 10 caregivers of veterans with dementia received home safety evaluations using videoconferencing technology using a variety of portable computing devices. Most telehealth evaluations experienced technological difficulties, but formal technical support was only required twice. Videoconferencing is a feasible service delivery option for home safety evaluations; however, infrastructure must support technological needs and client or provider gaps in knowledge. Implications for non-VHA settings and other interventions using videoconferencing are discussed.

Clinical trial of a home safety toolkit for Alzheimer's disease

This randomized clinical trial tested a new self-directed educational intervention to improve caregiver competence to create a safer home environment for persons with dementia living in the community. The sample included 108 patient/caregiver dyads: the intervention group (n = 60) received the Home Safety Toolkit (HST), including a new booklet based on health literacy principles, and sample safety items to enhance self-efficacy to make home safety modifications. The control group (n = 48) received customary care. Participants completed measures at baseline and at twelve-week follow-up. Multivariate Analysis of Covariance (MANCOVA) was used to test for significant group differences. All caregiver outcome variables improved in the intervention group more than in the control. Home safety was significant at P ≤ 0.001, caregiver strain at P ≤ 0.001, and caregiver self-efficacy at P = 0.002. Similarly, the care receiver outcome of risky behaviors and accidents was lower in the intervention group (P ≤ 0.001). The self-directed use of this Home Safety Toolkit activated the primary family caregiver to make the home safer for the person with dementia of Alzheimer's type (DAT) or related disorder. Improving the competence of informal caregivers is especially important for patients with DAT in light of all stakeholders reliance on their unpaid care.

Challenges to Intervention Implementation

BACKGROUND

The pressing need for interventions to improve outcomes for vulnerable caregivers of individuals with Alzheimer's disease (AD) is hindered by inadequate knowledge of variables affecting intervention delivery, receipt, and enactment.

OBJECTIVE

To analyze intervention implementation issues encountered within the Bathing Persons with Alzheimer's Disease at Home (BATH) study.

METHODS

The BATH study, a home-based, randomized, controlled trial of interventions to improve behavioral symptoms and caregiver self-efficacy, consisted of 130 intervention visits to 42 care recipients-caregiver dyads. Data include direct observation, nurse interventionist field notes, case analyses, and caregiver journals, reflecting various perspectives. Content analysis was used to identify key treatment process themes.

RESULTS

Issues that affected the delivery, receipt, and enactment of interventions reflect the intersection of in vivo caregiving and research design.

DISCUSSION

The primary lessons learned were: (a) early identification of caring dyads prior to crisis must be improved; (b) in vivo observation is essential to individualized interventions targeting behavioral etiologies and developing caregiver skills; (c) intervention delivery depends on the nurse interventionist's skills and a flexible, trusting researcher-dyad relationship; (d) complex caregiver situations affect treatment receipt and enactment; and (e) intervention enactment requires coaching, practice, and support over time. These findings help to explain issues impacting intervention implementation to a vulnerable population. Recommendations for intervention research design to maximize internal and external validity in real-life care contexts can inform future outcome studies, aid in the search for improved care, and lead to supportive public policy for families living with AD.

Caregiver competence to prevent home injury to the care recipient with dementia

Home safety is a major concern for persons with a progressive dementia, such as Alzheimer's disease, because much direct care is provided in the home setting. This study used the Home Safety/Injury Model as a frame work to describe the domain of caregiver competence, one of the model's key constructs. Interview data from the perspectives of 17 informants yielded a total of 68 clinical situations that allowed exploration of the scope and dimensions of caregiver competence to prevent accidents in the home. The factors most influential for effective caregiver prevention of home injury were family support, an acceptance and ability to make role changes, teaching and role modeling from professionals, and long-standing values and family traditions. No single factor was sufficient to achieve effective caregiving for making the home safer, but the strength of one or two factors could compensate for the absence of others.