How can we get access to the experiences of people with dementia?

The experiences of people with dementia and their carers participating in individual cognitive stimulation therapy

BACKGROUND

The carer-delivered individual cognitive stimulation therapy (iCST) was developed to improve cognition and quality of life of people with dementia. This study aims to explore people with dementia and family carers' concepts of mental stimulation and experiences of participating in the iCST intervention.

METHODS

A sub-sample of 23 dyads of people with dementia and their family carers who completed the iCST intervention took part in semi-structured in-depth interviews. Data were analysed using framework analysis.

RESULTS

Three main themes emerged, 'Concepts of mental stimulation', 'Experiencing changes in everyday life as a result of participating in iCST' and 'Carer adherence to the intervention' along with 10 sub-themes. The overall experience of participating in iCST was described as having opportunities to engage in enjoyable mentally stimulating activities, motivation to stay active and bringing people with dementia and their carers 'together'. Family carers mentioned that finding time to do the sessions and their relatives being reluctant to engage in the activities could hinder their participation in the intervention.

CONCLUSIONS

People with dementia and their family carers found iCST stimulating and enjoyable, but many had difficulty delivering all the sessions as planned. Family carers suggested that providing extra support by involving other people in delivering the intervention may help to improve adherence to the intervention. iCST may be a useful tool to encourage people with dementia and their carers to communicate. Copyright © 2017 John Wiley & Sons, Ltd.

Involvement of people with dementia in making decisions about their lives: a qualitative study that appraises shared decision-making concerning daycare

OBJECTIVE

To explore how people with dementia, their informal caregivers and their professionals participate in decision making about daycare and to develop a typology of participation trajectories.

DESIGN

A qualitative study with a prospective, multiperspective design, based on 244 semistructured interviews, conducted during three interview rounds over the course of a year. Analysis was by means of content analysis and typology construction.

SETTING

Community settings and nursing homes in the Netherlands.

PARTICIPANTS

19 people with dementia, 36 of their informal caregivers and 38 of their professionals (including nurses, daycare employees and case managers).

RESULTS

The participants' responses related to three critical points in the decision-making trajectory about daycare: (1) the initial positive or negative expectations of daycare; (2) negotiation about trying out daycare by promoting, resisting or attuning to others; and (3) trying daycare, which resulted in positive or negative reactions from people with dementia and led to a decision. The ways in which care networks proceeded through these three critical points resulted in a typology of participation trajectories, including (1) working together positively toward daycare, (2) bringing conflicting perspectives together toward trying daycare and (3) not reaching commitment to try daycare.

CONCLUSION

Shared decision making with people with dementia is possible and requires and adapted process of decision making. Our results show that initial preferences based on information alone may change when people with dementia experience daycare. It is important to have a try-out period so that people with dementia can experience daycare without having to decide whether to continue it. Whereas shared decision making in general aims at moving from initial preferences to informed preferences, professionals should focus more on moving from initial preferences to experienced preferences for people with dementia. Professionals can play a crucial role in facilitating the possibilities for a try-out period.

Emerging age asymmetries in the research relationship: challenges of exploring transition to the fourth age

This article opens the discussion on age asymmetries within the research relationship between researchers who are young and able-bodied and research participants who are much older and have acquired impairments in later life. Based on the knowledge of age relations, we present our conceptualisation of power imbalances based on age. We see these asymmetries as co-existing with other forms of power imbalances between researchers and participants, and argue that these asymmetries are not the results of the limitations of the older adults but rather the consequences of different constellations of possibilities for researchers and participants. Moreover, we assert that taking these asymmetries into account is a necessary step when conducting research with people with acquired impairment in later life. As researchers, reflecting on age asymmetries helped us to avoid othering our research participants and prevented us from marginalising their life experiences. Drawing upon our own research, we reflect upon the network of cognitive, physical and social asymmetries that emerged in our research relationships and identify the main challenges that we faced. In the presence of some of these age asymmetries, we approach the research relationship through the roles which we played vis-à-vis the participants. We consider reflecting and addressing these asymmetries to be a necessary step in creating and maintaining a research relationship based on equality. Only a reflexive and transparent approach to these power imbalances can ensure that data collection and analysis do not contribute to their reproduction. This article presents some general insights on research practices and contributes to the debate on power imbalances in qualitative research. The article also contributes to gerontology and provides new insights about the lives of those individuals with acquired impairment in later life, a topic that has so far received inadequate research attention.

A qualitative study on becoming cared for in Alzheimer's disease: the effects to women's sense of identity

OBJECTIVE

To explore the lived experience of becoming cared for and the impact this has on the identity and sense of self of women with Alzheimer's disease.

METHOD

Eight women with mild-to-moderate Alzheimer's disease were interviewed in Northamptonshire, England, on two separate occasions about their experiences relating to needing assistance with instrumental activities of daily living (IADL) tasks. Interpretative phenomenological analysis was the approach used to underpin this research.

RESULTS

Changes in the women's identity affected by the increased need for assistance with IADL tasks were expressed in terms of: who I am; unhappy being me; fighting to remain me; I'm not the same, but it doesn't worry me; and acceptance and contentment.

CONCLUSION

This study offers an alternative perspective to the view that all women with Alzheimer's disease experience becoming cared for as a negative event in their lives. Some factors universally perceived as being a result of Alzheimer's disease may be a normal part of the life course.

The lived experiences of dementia in married couple relationships

Background and purpose

There are a growing number of couples who become affected by dementia as one partner develops the condition while the other becomes a carer. However, our knowledge about the experiences of couples affected by dementia is limited. Very little knowledge about the impact of dementia on couples has been gained in previous research. The aim of this study was to explore the dyadic perspective of dementia within a couple relationship. Methodology: Six couples were interviewed about their experience of living with dementia. Interview transcripts were subjected to interpretive phenomenological analysis to identify themes across participants’ accounts. Results and conclusion: The analysis revealed three themes: (i) maintaining a bond, (ii) change and adjustment, and (iii) the challenge of coping. The results highlight the importance of studying the dyadic perspective and including people with dementia in research. Couples experienced an enduring commitment to one another as they adjusted to life with dementia.

A Qualitative Study to Explore Ways to Observe Results of Engaging Activities in Clients with Dementia

BACKGROUND

Many occupational therapists face the challenge of helping clients with dementia to select and perform meaningful occupations, which may be difficult due to cognitive impairment. Understanding tacit knowledge of well-experienced occupational therapists could positively affect occupational therapy practice for clients with dementia.

OBJECTIVES OF STUDY

To explore the observations of experienced occupational therapists when evaluating the effects of activities in clients with dementia.

METHODS

Ten occupational therapists with over 10 years of clinical experience participated in this qualitative study. In-depth interviews were conducted to ask the question, "What do you observe in clients with dementia when you assess the effectiveness of activities among these clients?" Findings. From 47 cases, we found five major themes and 18 subthemes. Main themes were "engaging activity," "emotional expression during activity," "verbal expression during activity," "social interaction through activity," and "something obtained as outcome of activity." Relevance to Clinical Practice. The 18 subthemes could be used as viewpoints to observe engagements of activity in clients with dementia.

LIMITATIONS AND RECOMMENDATIONS FOR FURTHER RESEARCH

Future studies could examine which viewpoints were utilized for each type of activity and/or severity of dementia as this was not investigated in the current study.

Being occupied: supporting ‘meaningful activity’ in care homes for older people in England

The benefits of meaningful activity in later life are well documented. Studies show that being occupied contributes to both physical and mental health as well as quality of life. Research also suggests that activity may be beneficial to people residing in care homes, including people living with dementia. This paper presents findings from a study which used the Adult Social Care Outcomes Toolkit (ASCOT) to measure quality of life in six care homes located in the south-east of England. The study found, like previous ones, that care home residents’ days were characterised by a lack of activity. Drawing on observations, interviews and focus groups with residents and staff from these homes, this paper attempts to understand why care home residents do not engage in meaningful activities. We reject the idea that these low levels of activity are a natural part of the ageing process or that they can be explained by notions of resident choice. Instead, the findings point to both insufficient funding and working practices within care homes as more substantive explanations. These explanations inform a discussion of how the low levels of engagement in meaningful activity could be addressed and residents’ quality of life improved.

A scoping review of Finnish doctoral dissertations in older people nursing science

Scientific research is important in guiding the development of evidence-based, cost-effective and comprehensive healthcare. The purpose of this scoping review was to analyse the current stage of research in the field of older people nursing science based on doctoral dissertations completed in Finnish universities. Altogether 418 doctoral dissertations in nursing science were published (1990–2015), and 44 of these (11%) represented older people nursing. The majority of the dissertations focused on patient and family or nursing activities. Usual topics were care procedures and clinical nursing (36%); self-care ability, independence (23%) and existence, being and feeling as an individual person (18%). Only one randomised controlled trial was conducted. The main informants were older people (78%) who were typically interviewed or surveyed. Research in older people nursing science in Finland is focusing on traditional clinical nursing settings. More innovative research is necessary from the perspective of health promotion and technological solutions.

The experience of people with dementia and nurses in hospital: an integrative review

AIMS AND OBJECTIVES

To identify and examine existing research exploring how people with dementia and nurses view acute hospital care.

BACKGROUND

Admission to hospital can be traumatic for a person with dementia due to an inability to cope with unfamiliar environments, faces and routines. Adverse behavioural and health outcomes can result. Dementia adds complexity to patient care. Inability to deliver appropriate care is a source of stress and frustration for nurses.

METHODS

Integrative review of the literature 2005-2015 reporting the experience of people with dementia and nurses caring for them in an acute hospital setting (n = 24).

RESULTS

Hospitals focus on acute medical care; consequently people with dementia are considered low priority and a disruption to normal routine. Risk management often takes priority over patient dignity. People with dementia are stigmatised. Families have significant roles to play in the care of a person with dementia in hospital but are often excluded. Nurses struggle to complete even basic patient care, and focus on tasks often at the expense of specific patient needs. Support for nurses is lacking. The job satisfaction of nurses caring for people with dementia is poor.

CONCLUSIONS

Nurses require improved education and support to care for patients with dementia. Hospitals must focus on genuine caring concurrently with rapid discharge requirements, risk mitigation and fiscal restraint. More research is needed to inform the development of appropriate care for people with dementia in hospitals.

RELEVANCE TO CLINICAL PRACTICE

Nurses must understand the complex needs of people with dementia in hospital. Nurse education about dementia, practical support, strong clinical leadership and role-modelling is needed. Empathy for patients regardless of diagnosis must remain a core attribute of nurses. Current hospital culture requires wider system review to mitigate against stigmatisation of patients with dementia.

Reflections and Recommendations for Conducting In-Depth Interviews With People With Dementia

Despite the importance and advantages of including people with dementia in research, there are various challenges for researchers and participants to their involvement. This article draws on the literature and experiences of a diverse group of authors, including a person with dementia, to provide recommendations about conducting research with people with dementia. Particular attention is given to in-depth interviews as a qualitative technique. More specifically, topics discussed include interview guide preparation, recruitment, obtaining consent/assent, conducting effective interviews, analysis and interpretation of data, effective communication of research findings, and reflections and recommendations for maintaining researcher and participant health. Given the current obstacles to participation in research of people with dementia, this is a timely article providing useful insights to promote improved outcomes using in-depth interviews.

How does a woman with Alzheimer’s disease make sense of becoming cared for?

This case study explores the meaning one woman with Alzheimer’s disease (AD) gives to receiving assistance with instrumental activities of daily living (IADLs) from her spouse. Improving the care of people living with AD is widely accepted as an important outcome in dementia services. Understanding how it feels for the person with AD to receive that care is essential to enhance their quality of life. Experiences identified using interpretative phenomenological analysis focus on a connection to past self and maintaining identity whilst also accepting change. The experience of ‘Sameness and Change’ identifies her feelings of discontinuity whilst ‘Goodness’ depicts her continued emotional expression of care presented in an attempt to remain someone of value within her family. These findings offer new insight and understanding to assist a woman’s transition from carer to becoming cared for.

Decision Trajectories in Dementia Care Networks: Decisions and Related Key Events

This prospective multiperspective study provides insight into the decision trajectories of people with dementia by studying the decisions made and related key events. This study includes three waves of interviews, conducted between July 2010 and July 2012, with 113 purposefully selected respondents (people with beginning to advanced stages of dementia and their informal and professional caregivers) completed in 12 months (285 interviews). Our multilayered qualitative analysis consists of content analysis, timeline methods, and constant comparison. Four decision themes emerged-managing daily life, arranging support, community living, and preparing for the future. Eight key events delineate the decision trajectories of people with dementia. Decisions and key events differ between people with dementia living alone and living with a caregiver. Our study clarifies that decisions relate not only to the disease but to living with the dementia. Individual differences in decision content and sequence may effect shared decision-making and advance care planning.

Exploring the need for a new UK occupational therapy intervention for people with dementia and family carers: Community Occupational Therapy in Dementia (COTiD). A focus group study

OBJECTIVES

In the Netherlands, Graff et al. found Community Occupational Therapy in Dementia (COTiD) demonstrated benefits to people with dementia and family carers. In this study, focus groups took place with people with dementia and family carers to explore how to make COTiD relevant to the UK context.

METHOD

Six focus groups (three with people living with dementia (n = 18) and three with family carers (n = 21)) took place. Participants were asked for their impressions of the intervention, the extent to which it could meet their needs, and what modifications were needed. Audio-recordings of the groups were transcribed and analysed.

RESULTS

Three key themes emerged covering 'loss and living with dementia', 'what helped us', and 'consistency and continuity'. People with dementia and family carers spoke about the impact of their diagnosis on them and their family and what strategies helped. Issues such as timing, follow-up, and the importance of an early intervention in preventing crises were highlighted. There was some concern over the length of the intervention and the disruption it might cause to current schedules.

CONCLUSION

Overall, participants were optimistic about COTiD being used in the United Kingdom if it was to be introduced in a flexible and timely manner, incorporating the needs and existing strategies of the person with dementia. These outcomes have led to changes, such as incorporating more flexibility into COTiD, being made to the intervention prior to its implementation in the United Kingdom.

Individual cognitive stimulation therapy for dementia: a clinical effectiveness and cost-effectiveness pragmatic, multicentre, randomised controlled trial

BACKGROUND

Group cognitive stimulation therapy programmes can benefit cognition and quality of life for people with dementia. Evidence for home-based, carer-led cognitive stimulation interventions is limited.

OBJECTIVES

To evaluate the clinical effectiveness and cost-effectiveness of carer-delivered individual cognitive stimulation therapy (iCST) for people with dementia and their family carers, compared with treatment as usual (TAU).

DESIGN

A multicentre, single-blind, randomised controlled trial assessing clinical effectiveness and cost-effectiveness. Assessments were at baseline, 13 weeks and 26 weeks (primary end point).

SETTING

Participants were recruited through Memory Clinics and Community Mental Health Teams for older people.

PARTICIPANTS

A total of 356 caregiving dyads were recruited and 273 completed the trial.

INTERVENTION

iCST consisted of structured cognitive stimulation sessions for people with dementia, completed up to three times weekly over 25 weeks. Family carers were supported to deliver the sessions at home.

MAIN OUTCOME MEASURES

Primary outcomes for the person with dementia were cognition and quality of life. Secondary outcomes included behavioural and psychological symptoms, activities of daily living, depressive symptoms and relationship quality. The primary outcome for the family carers was mental/physical health (Short Form questionnaire-12 items). Health-related quality of life (European Quality of Life-5 Dimensions), mood symptoms, resilience and relationship quality comprised the secondary outcomes. Costs were estimated from health and social care and societal perspectives.

RESULTS

There were no differences in any of the primary outcomes for people with dementia between intervention and TAU [cognition: mean difference -0.55, 95% confidence interval (CI) -2.00 to 0.90; p-value = 0.45; self-reported quality of life: mean difference -0.02, 95% CI -1.22 to 0.82; p-value = 0.97 at the 6-month follow-up]. iCST did not improve mental/physical health for carers. People with dementia in the iCST group experienced better relationship quality with their carer, but there was no evidence that iCST improved their activities of daily living, depression or behavioural and psychological symptoms. iCST seemed to improve health-related quality of life for carers but did not benefit carers' resilience or their relationship quality with their relative. Carers conducting more sessions had fewer depressive symptoms. Qualitative data suggested that people with dementia and their carers experienced better communication owing to iCST. Adjusted mean costs were not significantly different between the groups. From the societal perspective, both health gains and cost savings were observed.

CONCLUSIONS

iCST did not improve cognition or quality of life for people with dementia, or carers' physical and mental health. Costs of the intervention were offset by some reductions in social care and other services. Although there was some evidence of improvement in terms of the caregiving relationship and carers' health-related quality of life, iCST does not appear to deliver clinical benefits for cognition and quality of life for people with dementia. Most people received fewer than the recommended number of iCST sessions. Further research is needed to ascertain the clinical effectiveness of carer-led cognitive stimulation interventions for people with dementia.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN65945963.

FUNDING

This project was funded by the National Institute of Health Research (NIHR) Health Technology Assessment (HTA) programme and will be published in full in Health Technology Assessment; Vol. 19, No. 64. See the NIHR Journals Library website for further information.

How older adults with mild cognitive impairment relate to technology as part of present and future everyday life: a qualitative study

BACKGROUND

Existing everyday technology as well as potential future technology may offer both challenges and possibilities in the everyday occupations of persons with cognitive decline. To meet their wishes and needs, the perspective of the persons themselves is an important starting point in intervention planning involving technology. The aim of this study was to explore how persons with mild cognitive impairment relate to technology as a part of and as potential support in everyday life - both present and future.

METHODS

Qualitative in-depth interviews with six participants aged 61-86 were conducted and analyzed, using a grounded theory approach.

RESULTS

The findings describe the participants' different ways of relating to existing and potential future technology in everyday occupations as a continuum of downsizing, retaining, and updating. Multiple conditions in different combinations affected both their actions taken and assumptions made towards technology in this continuum. Both when downsizing doing and technology use to achieve simplicity in everyday life and when striving for or struggling with updating, trade-offs between desired and adverse outcomes were made, challenging take-off runs were endured, and negotiations of the price worth paying took place.

CONCLUSIONS

Our findings suggest that persons with mild cognitive impairment may relate to technology in various ways to meet needs of downsized doing, but are reluctant to adopt video-based monitoring technology intended to support valued occupations. Feasibility testing of using already-incorporated everyday technologies such as smartphones and tablets as platforms for future technology support in everyday occupations is suggested.

Risks in situations that are experienced as unfamiliar and confusing - the perspective of persons with dementia

An increasing number of people with dementia are ageing at home in Sweden and in other countries. In order to meet the safety requirements, knowledge about how persons with dementia experience risks is required. The aim of the study was to explore and better understand how persons with dementia, living at home, experience risks in their daily life and how they handle these situations. Twelve persons with dementia were interviewed using open-ended questions, and the data were analyzed using a content analysis approach. Findings showed that participants experienced situations fraught with risks in their daily life as unfamiliar and confusing. Previously familiar places became unfamiliar to them, and details did not come together. They were uncertain about what actually had happened. How the participants handled these situations in order to reduce the risks are described.

Increased self-efficacy: the experience of high-intensity exercise of nursing home residents with dementia - a qualitative study

Background

There has been increasing interest in the use of non-pharmacological interventions, such as physical exercise, to improve the well-being of nursing home residents with dementia. For reasons regarding disease symptoms, persons with dementia might find it difficult to participate in exercise programs. Therefore, it is important to find ways to successfully promote regular exercise for patients in residential care. Several quantitative studies have established the positive effects of exercise on biopsychosocial factors, such as self-efficacy in older people; however, little is known regarding the qualitative aspects of participating in an exercise program among older people with dementia. From the perspective of residents, we explored the experiences of participating in a high-intensity functional exercise program among nursing home residents with dementia.

Methods

The participants were eight elderly people with mild-to-moderate dementia. We conducted semi-structured interviews one week after they had finished a 10-week supervised high-intensity exercise program. We analyzed the data using an inductive content analysis.

Results

Five overreaching and interrelated themes emerged from the interviews: “Pushing the limits,” “Being invested in,” “Relationships facilitate exercise participation,” “Exercise revives the body, increases independence and improves self-esteem” and “Physical activity is a basic human necessity—use it or lose it!” The results were interpreted in light of Bandura’s self-efficacy theory. The exercise program seemed to improve self-efficacy through several mechanisms. By being involved, “being invested in” and having something expected of them, the participants gained a sense of empowerment in their everyday lives. The importance of social influences related to the exercise instructor and the exercise group was accentuated by the participants.

Conclusions

The nursing home residents had, for the most part, positive experiences with regard to participating in the exercise program. The program seemed to increase their self-efficacy through several mechanisms. The instructor competence emerged as an important facilitating factor. The participants emphasized the importance of physical activity in the nursing home.

Disruption, control and coping: responses of and to the person with dementia in hospital

This qualitative study aimed to gain insight into the experience of hospitalisation from the perspectives of the older person with dementia, their family care-giver and other patients sharing the ward (co-patients). Non-participant observation of care on 11 acute hospital wards was supplemented by 39 semi-structured interviews with 35 family care-givers and four co-patients following discharge. Constant comparative analysis produced the core problem facing all those involved: disruption from normal routine meaning that the experience of hospitalisation was disrupted by the presence and behaviour of the person with dementia. Disruption adversely affected the person with dementia, triggering constructive, disengaged, distressed and neutral behaviours. Using Kitwood's model of person-centred care, these behaviours were interpreted as attempts by the person with dementia at gaining a sense of control over the unfamiliar environment and experience. Family care-givers' lives and experiences both inside and outside the hospital were disrupted by the hospitalisation. They too attempted to gain a sense of control over the experience and to give a sense of control to the patient, co-patients and staff. Co-patients experienced disruption from sharing space with the person with dementia and were left feeling vulnerable and sometimes afraid. They too attempted to gain a sense of control over their situation and give some control by helping the person with dementia, the family care-giver and the staff.

The use of assistive technology in the everyday lives of young people living with dementia and their caregivers. Can a simple remote control make a difference?

BACKGROUND

This study was a part of a larger study exploring the impact of assistive technology on the lives of young people living with dementia (YPD). This paper focuses on one of the most useful devices, the simple remote control (SRC). The objective was to explore the reason why the SRC is significant and beneficial in the everyday lives of YPD and their caregivers.

METHODS

This qualitative longitudinal study had a participatory design. Eight participants received an SRC. The range for using it was 0-15 months. In-depth interviews and observations were conducted at baseline and repeated every third month up to 18 months. A situated learning approach was used in the analysis to provide a deeper understanding of the significance and use of SRC.

RESULTS

Young people having dementia spend a substantial amount of time alone. Watching television was reported to be important, but handling remote controls was challenging and created a variety of problems. YPD learned to use SRC, which made important differences in the everyday lives of all family members. Comprehensive support from caregivers and professionals was important for YPD in the learning process.

CONCLUSIONS

The SRC was deemed a success because it solved challenges regarding the use of television in everyday lives of families. The design was recognizable and user-friendly, thus allowing YPD to learn its operation. Access to professional support and advice regarding assistive technology is vital for establishing a system for follow-up and continued collaboration to make future adaptations and adjustments.

The experiences of people with dementia and intellectual disabilities with surveillance technologies in residential care

Background:

Surveillance technology such as tag and tracking systems and video surveillance could increase the freedom of movement and consequently autonomy of clients in long-term residential care settings, but is also perceived as an intrusion on autonomy including privacy.

Objective:

To explore how clients in residential care experience surveillance technology in order to assess how surveillance technology might influence autonomy.

Setting:

Two long-term residential care facilities: a nursing home for people with dementia and a care facility for people with intellectual disabilities.

Methods:

Ethnographic field study.

Ethical considerations:

The boards representing clients and relatives/proxies of the clients were informed of the study and gave their written consent. The clients’ assent was sought through a special information leaflet. At any time clients and/or proxy were given the option to withdraw from the study. The research protocol was also reviewed by a medical ethics committee.

Findings:

Our findings show a pattern of two themes: (1) coping with new spaces which entailed clients: wandering around, getting lost, being triggered, and retreating to new spaces and (2) resisting the surveillance technology measure because clients feel stigmatized, missed the company, and do not like being “watched.”

Conclusion:

Client experiences of surveillance technology appear to entail a certain ambivalence. This is in part due to the variety in surveillance technology devices, with each device bringing its own connotations and experiences. But it also lies in the devices’ presupposition of an ideal user, which is at odds with the actual user who is inherently vulnerable. Surveillance technology can contribute to the autonomy of clients in long-term care, but only if it is set in a truly person-centered approach.

Articulating the strategies for maximising the inclusion of people with dementia in qualitative research studies

It is essential to understand the experience of living with dementia from the perspective of the person with dementia so that services can be appropriately constructed. This review paper, drawing on prior work, identifies key strategies for the meaningful inclusion of persons with dementia within qualitative research studies, it examines the articulation of these strategies and shares how these strategies were operationalised within one national research study in Ireland. Strategies within the literature were categorised and then synthesized into a guide consisting of four main areas; gaining COnsent, maximizing Responses, Telling the story, and Ending on a high (CORTE). The CORTE guideline was used to as a tool for analysing relevant research reports. CORTE is a synthesized account of grouped strategies that could be used to maximize the meaningful involvement of persons with dementia and can also provide a guide for reporting the strategies used so that researchers can learn from each other.

A Survey Method for Identifying Real Support Needs of People with Early-Stage Dementia for Designing Assistive Technology

In this paper, we propose a new interview method of eliciting needs for support completely and accurately from people with early-stage dementia for identifying their real needs, with the eventual objective of designing effective Assistive Technology. The interview procedure consists of the following steps: (1) entirely identifying tasks of a subject’s everyday living, leisure and social activities (referred to, in all, as “social living activities”), (2) evaluating the subject’s confusion levels (SCLs) about identified tasks based on the subject’s self-rating, together with the caregiver’s rating as a reference, and confusion level discrepancies (CLDs) are found, and (3) predicting the subject’s support requirement levels (SRLs) about confusing tasks based on confusion levels followed by the subject’s revision to thereby find SRL discrepancies (SRLDs). Subjects are asked to reconfirm SRL ratings associated with tasks having SRLDs and/or encouraged to raise the ratings of tasks having CLDs to accurately identify the subject’s SRLs. Six subject-caregiver dyads were interviewed and 22 support needs, including 10 needs that were extracted by reconfirmation or encouragement, were elicited from four subjects. These elicited needs covered the entire social living scene from domestic affairs to social activities, showing that the proposed method was effective in systematically eliciting support needs from people with early-stage dementia. No support needs were elicited, however, from subjects with very little awareness of memory impairment, demonstrating one limitation of the proposed method.

Participatory research to design a novel telehealth system to support the night-time needs of people with dementia: NOCTURNAL

Strategies to support people living with dementia are broad in scope, proposing both pharmacological and non-pharmacological interventions as part of the care pathway. Assistive technologies form part of this offering as both stand-alone devices to support particular tasks and the more complex offering of the “smart home” to underpin ambient assisted living. This paper presents a technology-based system, which expands on the smart home architecture, orientated to support people with daily living. The system, NOCTURNAL, was developed by working directly with people who had dementia, and their carers using qualitative research methods. The research focused primarily on the nighttime needs of people living with dementia in real home settings. Eight people with dementia had the final prototype system installed for a three month evaluation at home. Disturbed sleep patterns, night-time wandering were a focus of this research not only in terms of detection by commercially available technology but also exploring if automated music, light and visual personalized photographs would be soothing to participants during the hours of darkness. The NOCTURNAL platform and associated services was informed by strong user engagement of people with dementia and the service providers who care for them. NOCTURNAL emerged as a holistic service offering a personalised therapeutic aspect with interactive capabilities.

Gradually losing one's foothold--a fragmented existence when living alone with dementia

The number of persons with dementia who lives at home for a longer period of time after diagnosis is increasing. Even if the literature in the dementia field is growing, there is a need for more knowledge about everyday life of persons with a dementia disease; particularly the lived perspective of persons who live alone. The aim of this study was to elucidate the phenomenon of living alone with dementia and having a manifest care need. This phenomenological study was carried out from a reflective lifeworld approach. The data material in the study consisted of field notes from 32 visits and transcriptions from 11 tape-recorded conversations with six participants. The results reveal that the person with dementia who lives alone ends up in a vague existence where they cannot survive alone. The person's level of activity comes to a halt and body movement becomes slower. Daily life becomes more difficult to manage and the person's earlier natural way of relating to the world and the people around them is gradually lost. This is followed by a loneliness and forgetfulness that cloud the meaning of life. This study highlights the importance of the patient's perspective needed to better understand the inner life of a person who suffers from dementia. This understanding is important in the organization of help and care as well as for caregivers to better understand these individuals and their needs.

'Like a prison without bars': dementia and experiences of dignity

The aim of this article is to investigate how life in Norwegian nursing homes may affect experiences of dignity among persons with dementia. The study had a qualitative design and used a phenomenological and hermeneutic approach. Participant observation in two nursing home units was combined with qualitative interviews with five residents living in these units. The study took place between March and December 2010. The residents feel that their freedom is restricted, and they describe feelings of homesickness. They also experience that they are not being seen and heard as individual autonomous persons. This lack of freedom, experiences of homesickness and feelings of not being confirmed and respected as individual autonomous persons may be a threat to their personal dignity. In order to protect and enforce the dignity of persons with dementia living in nursing home, we should confirm them as whole and as individual persons, and we should try to make the nursing homes less institutional and more home like.

Experiences of family carers of older people with mental health problems in the acute general hospital: a qualitative study

AIMS

To explore the experiences of family carers of people with cognitive impairment during admission to hospital.

BACKGROUND

Providing appropriate care in acute hospitals for people with co-morbid cognitive impairment, especially dementia or delirium or both, is challenging to healthcare professionals. One key element is close working with family members.

DESIGN

Qualitative interview study.

METHODS

Semi-structured interviews with family carers of 34 older people who had been admitted to a UK general hospital and had co-morbid cognitive impairment. Interviews conducted in 2009 and 2010. Analysis was undertaken using Strauss and Corbin's framework.

FINDINGS

The findings elaborate a core problem, 'disruption from normal routine' and a core process, 'gaining or giving a sense of control to cope with disruption'. Family carers responded to disruption proactively by trying to make sense of the situation and attempting to gain control for themselves or the patient. They tried to stay informed, communicate with staff about the patient and plan for the future. The interaction of the core problem and the core process resulted in outcomes where family members either valued the support of hospital staff and services or were highly critical of the care provided.

CONCLUSION

Family carers are not passive in the face of the disruption of hospitalization and respond both by trying to involve themselves in the care and support of their relative and by trying to work in partnership with members of staff. Nurses need to foster this relationship conscientiously.

Users' and professionals' contributions in the process of designing an easy-to-use videophone for people with dementia

PURPOSE

To develop a design concept for an easy-to-use videophone for people with dementia and to evaluate the design and need of such a product.

METHOD

In this project, we have used an inclusive design approach that includes the target users in the design process. In an earlier study, the need of a videophone was examined and a requirement specification was developed. In this study, a preliminary design concept was developed. Five focus groups of people with dementia, significant others and occupational therapists working with people with dementia were formed to capture their experiences, expectations and thoughts concerning the videophone and the design concept. Data were analysed using a grounded theory approach.

FINDINGS

The participants pointed out that the design of the videophone should be flexible in order to meet the needs of people with dementia, be easy-to-use and not look like assistive technology. In order to facilitate learning, the videophone should be introduced in an early stage of the disease.

CONCLUSIONS

A videophone has potentials to enable videophone calls without assistance, add quality in communication and provide possibilities for monitoring. Further work will focus on developing a prototype to be empirically tested by people with dementia and significant others.

IMPLICATIONS FOR REHABILITATION

An easy-to-use videophone was viewed as an important device that could support people with dementia in making videophone calls without assistance. It was also viewed as a product that significant others could use for monitoring the person with dementia, for example to judge the well-being of the person. But monitoring should be used with caution and not without the consent of the person with dementia. It was viewed as important that the videophone be introduced in an early stage of the disease in order to facilitate learning, so that the person can get used to the new way of making telephone calls and incorporate the new habit in his/her routines. In order to motivate people with dementia to start using a videophone, it was recommended that the videophone should be introduced as a product which is a pleasure to use, and not as a compensation for impairment or to solve a problem.

‘We can't keep going on like this’: identifying family storylines in young onset dementia

In this study, we identify the dominant storylines that were embedded in the narratives of younger people with dementia and their nominated family members. By implementing a longitudinal, narrative design underpinned by biographical methods we generated detailed family biographies with five families during repeated and planned research contacts (N=126) over a 12–15-month period between 2009 and 2010. The application of narrative analysis within and between each family biography resulted in the emergence of five family storyline types that were identified as: agreeing; colluding; conflicting; fabricating; and protecting. Whilst families were likely to use each of these storylines at different points and at different times in their exposure to young onset dementia, it was found that families that adopted a predominantly ‘agreeing’ storyline were more likely to find ways of positively overcoming challenges in their everyday lives. In contrast, families who adopted predominantly ‘conflicting’ and ‘colluding’ storylines were more likely to require help to understand family positions and promote change. The findings suggest that the identification of the most dominant and frequently occurring storylines used by families may help to further understand family experience in young onset dementia and assist in planning supportive services.

Learning and using technology in intertwined processes: A study of people with mild cognitive impairment or Alzheimer’s disease

People with mild cognitive impairment and Alzheimer’s disease are likely to be challenged by the multitude of everyday technology in today’s society. The aim of this study was to explore how they try to prohibit, avoid or solve problems in everyday technology use, maintain skills, and learn to use new technology. To explore how the participants applied and reasoned about using everyday technology in real-life situations interviews were conducted while the participants used their own technology in their homes. Interviews were conducted with 20 participants with mild cognitive impairment ( n = 10) or Alzheimer’s disease ( n = 10). The analyses were inspired from grounded theory and resulted in one core category and three sub-categories that represent sub-processes in the core. The core finding presents a continuous, intertwined process of learning and using everyday technology, highlighting how the context was interwoven in the processes. The participants used a rich variety of management strategies when approaching technology, including communication with the everyday technologies on different levels. The findings underscore that it is important to support continued use of everyday technology as long as it is valued and relevant to the person with mild cognitive impairment or Alzheimer’s disease. The intertwined process of learning and using everyday technology suggests how support could target different sub-processes.

Exploring the affective dimension of the life review process: Facilitators’ interactional strategies for fostering personhood and social value among older adults with early dementia

We employed an auto-ethnography approach to explore the affective dimension of life review sessions with community-dwelling older military veterans with minor cognitive impairment (MCI) and early dementia. Using researchers’ analytic memos, we identified facilitators’ interactional strategies that fostered the participant’s sense of personal identity, dignity and social self-worth. Interaction among participant, caregiver, and facilitators evoked a range of emotional responses, offering a window into the affective world of MCI and early dementia. Positive emotional responses outnumbered negative emotional responses by a ratio of two-to-one in the life review sessions; however, negative emotions were more revelatory of current struggles with declines in health and function. Facilitators utilized two interactional strategies, in particular, to foster personhood and social value of participants: focusing on the participant and creating an empathic connection with the participant. Further work is needed to understand the role of emotions in research interactions and to examine the psychosocial mechanisms through which positive affect functions in promoting identity, personhood and social value among persons with MCI and early dementia.

Managing critical incidents in grocery shopping by community-living people with Alzheimer's disease

AIM

People with Alzheimer's disease (AD) remain in their ordinary housing and continue to use public space despite increasing disabilities. The aim of this study was to discover and describe problematic situations and critical incidents that took place when people with AD performed the ordinary outside-home activity of grocery shopping and how these were met by them.

METHODS

Individual interviews (n = 12) and participant observations (n = 8) with six informants were performed and analysed using a grounded theory approach.

RESULTS

The findings are presented in six categories and each category describes different critical incidents and actions used to meet these. The categories were: (a) Remembering to bring things when leaving home, (b) Finding the way to and from the grocery shop without getting lost, (c) Finding a way through traffic when not feeling safe, (d) Finding objects when organization is disrupted, (e) Choosing when a lot of objects and products are available, and (f) Finding a method to pay when payment opportunities are restricted. The core category, "A challenging and unstable process of meeting critical incidents in grocery shopping", was characterised by reflections and creativity to achieve relative harmony in each critical incident.

CONCLUSIONS

In conclusion, it is important that relatives and professionals take into account relevant actions to help people with AD coordinate with their environment.

Involving people with dementia in the development of supportive IT applications: a systematic review

BACKGROUND

Involving people with dementia in research is not self-evident. Inclusion of people with dementia in the development process of user-friendly, supportive IT applications may be especially useful to improve the quality of these applications and may be beneficial to the person with dementia. The aim of this study was to gain insight into the involvement of people with dementia in developing supportive IT applications. The focus of involvement was on phase, methods, role and impact on the quality of the IT application and on the person with dementia.

METHOD

A systematic search was undertaken using Cochrane Library, PubMED, PsycInfo, EMBASE, and CINAHL. Publications were selected using the following inclusion criteria: publications had to address a development process of an IT application involving people with dementia. The BMJ checklist was used to assess the quality of the included publications.

RESULTS

Twenty-six publications relating to 15 IT programs met the inclusion criteria. People with dementia were mainly involved in the exploratory and technical development phases. The methods most frequently used to involve the participants were interviews, observations and usability try-outs. In most studies, participants were objects of study and informants. People with dementia provided useful feedback and gave valuable recommendations for researchers and designers regarding the development of user-friendly, supportive, IT applications. Involvement in all phases may have empowering effects on people with dementia.

CONCLUSION

To develop valuable, user-friendly, supportive IT applications that increase the quality of life of people with dementia involvement in all phases of the development process is of great importance.

A passive positioning alarm used by persons with dementia and their spouses--a qualitative intervention study

Background

Increasingly, information and communication technology is being used to support persons with dementia living at home and their relatives. The aim of the present intervention study was to describe and explore the use and experiences of using a passive positioning alarm, over time, in daily life among persons with dementia and their spouses.

Methods

Using an ethnographically inspired approach, five couples, each including a person with Alzheimer´ s disease and his/her spouse living in their own home, were repeatedly observed and interviewed regarding their experiences of using a passive positioning alarm. Interview text transcripts and field notes were analyzed using qualitative content analysis.

Results

The main findings show changes over time, where testing and checking the passive positioning alarm successively led to trust in the alarm and in one own´s ability to use it. These components were a prerequisite for the couples to perceive the value of the alarm.

Conclusions

A passive positioning alarm for persons with dementia and their spouses needs to be packaged as a “service” with flexibility for each user and based on user needs, abilities, knowledge and skills. Using a passive positioning alarm can be a valuable support that allows persons with dementia to be alone outdoors and can increase safety and security for them and their spouses. The present study contributes to our understanding of what prerequisites need to be in place and what barriers need to be dealt with before successful implementation can occur.

Modifying the diary interview method to research the lives of people with dementia

Debates about involving people with dementia in qualitative research are extensive, yet the range of methods used is limited. Researchers tend to rely on interview and/or observation methods to collect data, even though these tools might preclude participation. I modified the conventional diary interview method to include photo and audio diaries in an effort to investigate the lives of people with dementia in a participatory way. Sixteen people with dementia kept a diary-written, photo, or audio, whichever suited them best-for 1 month. The purposes of this article are to share the methodological insights gained from this process in the context of emerging literature on sensory ethnography, and to argue for the broader application of the diary interview method in dementia-related research, on the grounds that it mediates an equal relationship and makes visible the "whole person," including the environment in which that person lives.

Detection of activity limitations in older adults with MCI or Alzheimer's disease through evaluation of perceived difficulty in use of everyday technology: a replication study

OBJECTIVES AND METHODS

Earlier research indicates that the ability to use everyday technology (ET) may be sensitive to subtle functional change. People with mild cognitive impairment (MCI) have been identified as significantly more disabled in ET use compared to controls, albeit less disabled than people with dementia. The aim of this study was to investigate the replicability of these findings using an improved version of the Everyday Technology Use Questionnaire (ETUQ) to compare perceptions of relevance and difficulty in ET use in participants with MCI or Alzheimer's disease (AD) and controls. Additional aims were to explore the validity of ETUQ, and the relationships between perceived difficulty in ET use and cognitive status, mood state, and involvement in everyday life activities. In total, 118 participants were included, 37 with AD, 37 with MCI, and 44 controls.

RESULTS

Analyses confirmed that the rating scale of the ETUQ functioned well. The three groups overlapped but differed significantly in their perceptions of ETs relevance (p < 0.05) as well as of difficulties in ET use (p < 0.001). Moderate correlations were also found between ETUQ measures and cognitive status, mood, and involvement in activities, the strongest being that between ETUQ measures and involvement in activities (r = 0.563).

CONCLUSION

Taken together, the findings underscore the plausibility of disability already in people with MCI, as the use of ET strongly correlates to involvement in activities. It is therefore important that professionals who meet older adults with cognitive impairment take this aspect of function into account in assessments and targeted interventions.

Community-dwelling persons with dementia: what do they need? What do they demand? What do they do? A systematic review on the subjective experiences of persons with dementia

OBJECTIVES

Including the perspectives of persons with dementia (PwD) is essential in order to organize care structures for them. With this systematic review, we set out to screen the existing scientific evidence on self-expressions of community-dwelling individuals with dementia in order to provide a research base for developing an intervention for persons in early stages of the disease. The leading research questions for this review are: What needs do PwD living at home express? What are their subjective demands? What do they do to cope with their situation?

METHODS

We performed a systematic literature review of review publications on subjective experiences of PwD. The publications were analysed using MAXQDA 10 to perform a thematic analysis.

RESULTS

We identified 41 relevant reviews, of which 6 met our inclusion criteria. PwD experience the whole range of human emotions. Their needs and demands do not differ significantly from those of other groups of patients with chronic conditions. Coming to terms with the disease and maintaining normality appeared to be major themes. With regard to expectations from the side of professional health care, the need for accompanying, continuous support and counselling appeared to be central. Furthermore, disclosure of diagnosis represents a critical stage for PwD, but our findings indicated that they prefer to be included in this process.

CONCLUSIONS

PwD are well able to express their needs. They should be included in research since they can provide valuable findings. Furthermore, those findings should be implemented in applied dementia care.

The role of leisure within the dementia context

While our understanding of the subjective experience of dementia is growing, leisure's role within that experience is less clear. This study, guided by hermeneutic phenomenology, aimed to understand the meaning and experience of leisure for persons living with early stage memory loss. Four participants with early stage dementia participated in interviews, participant observation, and photovoice, in which participants are given cameras and asked to take photos of their day to day lives (Wang, 1999). Data revealed that participants experienced daily life with dementia, including leisure, within a paradox of challenge and hope. They struggled with the changes they experienced as a result of dementia, such as muddled thinking, fluctuating abilities, draining energy, frightening awareness, and disquieting emotions. However, they found ways to tackle life with dementia, by reconciling life as it is, battling through by being proactive, living through relationships, being optimistic, and prolonging engagement in meaningful activity to live their lives with hope.

The challenge of coming to terms with the use of a new digital assistive device: a case study of two persons with mild dementia

There is an increased interest in supporting persons with dementia with technical services in daily life. The aim of this case study was to explore the complex issues involved in the process from a user driven development to the acceptance and usage of a new digital assistive device for persons with mild dementia. Even though it was developed in a user driven process and personalized to meet their individual needs they rarely used it. To deepening the understanding of this disparity between actual usage and perceived usefulness, the participants were studied whilst performing daily life activities through participant observations and interviews. Their partners were interviewed two years after the first observations to clarify the change in needs over time. The results show that the participant needs encompassed occupation, safety, social interaction, and memory support together with the receipt of general support. The overriding requirement for both participants was a need to maintain their self-image. When the digital assistive device did not correspond with the participants' expectations or view of themselves, their interest in using it faded, since the digital assistive device failed to support their self-image. The acceptance of a digital assistive device by a person with dementia is a process that begins with identifying and personalizing the functions of the device according to individual needs, and then supporting the usage and the gradual integration of the device into daily life. During this process, the person's self-image must be taken into consideration and supported.

Persons with dementia become users of assistive technology: A study of the process

The aim of this study was to explore actions and driving forces of the actors involved in the process of bringing assistive technology (AT) into the life of a person with dementia. Specific focus is placed on the unfolding transactions and what they led to, and how the AT intervention corresponded to the situation of the person with dementia. Three cases, i.e. three persons with dementia and their significant others ( n = 13), were followed using case methodology and grounded theory. The findings show how doing the right thing was the main driving force, although sometimes a source of conflict between actors. The actors’ views differed in many aspects, influencing the choice of problem and selected AT solution as well as the role of the AT and how it was placed and adjusted. A potential risk scenario was also identified, exemplifying how profoundly the view of the one who had decision power influenced the process.

Ethical aspects of researching subjective experiences in early-stage dementia

This article is based on a qualitative longitudinal study that followed the subjective experiences of both people living with dementia and their family members during the early stages of the illness. The purpose of this article is to describe and reflect on the ethical and methodological issues that occurred during data collection. The article focuses on the situation of the person with dementia and the family member and the role of the researcher when conducting the research interviews. Based on the results of this study, conducting research interviews with people with dementia and their family members poses several ethical and methodological challenges that must be addressed. In doing so, ethically sound dementia-specific research methods will be actively developed enhancing our understanding of living with dementia and providing new insights into the care of people with dementia and their family members.

Accessibility in public space as perceived by people with Alzheimer’s disease

Most people with dementia remain living at home as long as possible after being diagnosed, and hence their lives also include activities in the public space. The aim of this study was to illuminate experiences of accessibility in public space in people with Alzheimer’s disease. A qualitative grounded theory approach with repeated in-depth interviews was used. The core category, accessibility as a constantly changing experience, was characterized by changes in the relationship between informants and public space. Changes in the relationship took place in activities and use of place and related to familiarity and comfort, individual motives and interests, and planning and protecting. Other changes occurred in places and problematic situations related to everyday technologies, crowded places with high tempo and noise, and change of landmarks. These changes reduced feelings of accessibility and increased difficulties in carrying out activities in public space. These findings may be helpful when providing support, and supporting community living.