Psychosocial factors that shape patient and carer experiences of dementia diagnosis and treatment: a systematic review of qualitative studies

Perspectives on Components of an Online Training and Support Program for Dementia Family Caregivers in India: A Focus Group Study

OBJECTIVES

There is a considerable need for support interventions for caregivers of people with dementia in developing countries, such as India. The purpose of the study was to identify the components and understand the acceptability of an online training and support program for dementia caregivers in India.

METHODS

Three focus group discussions were carried out with dementia caregivers (2) and health professionals (1) to understand the requirements of an online training and support program from their perspective. The commonly recurring themes were identified and defined using thematic content analysis.

RESULTS

The expectations from an online training and support program were wide-ranging from information about identification and management of dementia to support caregiver well-being. Use of simple language, cultural relevance, and an interactive design were suggestions to facilitate the use of the support program. Lack of time, difficulty in accessing the internet, lack of awareness about the portal, difficulty in reaching the rural population were anticipated as challenges in using the program.

CONCLUSIONS

The study highlights the requisite components of a first of its kind online training and support program in India by integrating the experiences, motivations, challenges, and expectations of caregivers and professionals involved in dementia care.

CLINICAL IMPLICATIONS

The focus group discussions in the current study provide a road map for the development of an online caregiver training and support program underlying the perspectives of the stakeholders for the consolidation of an effective dementia care program for lower resourced settings.

Unburdening dementia - a basic social process grounded theory based on a primary care physician survey from 25 countries

OBJECTIVE

To explore dementia management from a primary care physician perspective.

DESIGN

One-page seven-item multiple choice questionnaire; free text space for every item; final narrative question of a dementia case story. Inductive explorative grounded theory analysis. Derived results in cluster analyses. Appropriateness of dementia drugs assessed by tertiary care specialist.

SETTING

Twenty-five European General Practice Research Network member countries.

SUBJECTS

Four hundred and forty-five key informant primary care physician respondents of which 106 presented 155 case stories.

MAIN OUTCOME MEASURES

Processes and typologies of dementia management. Proportion of case stories with drug treatment and treatment according to guidelines.

RESULTS

Unburdening dementia - a basic social process - explained physicians' dementia management according to a grounded theory analysis using both qualitative and quantitative data. Unburdening starts with Recognizing the dementia burden by Burden Identification and Burden Assessment followed by Burden Relief. Drugs to relieve the dementia burden were reported for 130 of 155 patients; acetylcholinesterase inhibitors or memantine treatment in 89 of 155 patients - 60% appropriate according to guidelines and 40% outside of guidelines. More Central and Northern primary care physicians were allowed to prescribe, and more were engaged in dementia management than Eastern and Mediterranean physicians according to cluster analyses. Physicians typically identified and assessed the dementia burden and then tried to relieve it, commonly by drug prescriptions, but also by community health and home help services, mentioned in more than half of the case stories.

CONCLUSIONS

Primary care physician dementia management was explained by an Unburdening process with the goal to relieve the dementia burden, mainly by drugs often prescribed outside of guideline indications. Implications: Unique data about dementia management by European primary care physicians to inform appropriate stakeholders. Key points Dementia as a syndrome of cognitive and functional decline and behavioural and psychological symptoms causes a tremendous burden on patients, their families, and society. •We found that a basic social process of Unburdening dementia explained dementia management according to case stories and survey comments from primary care physicians in 25 countries. •First, Burden Recognition by Identification and Assessment and then Burden Relief - often by drugs. •Prescribing physicians repeatedly broadened guideline indications for dementia drugs. The more physicians were allowed to prescribe dementia drugs, the more they were responsible for the dementia work-up. Our study provides unique data about dementia management in European primary care for the benefit of national and international stakeholders.

A dyadic perspective on assessment in Alzheimer's dementia: Supporting both care partners across the disease continuum

Written from a dyadic strength-based perspective, this article first provides a brief overview of the Education, Information, and Support section of the 2018 Alzheimer's Disease Dementia Care Practice Recommendations.1 Subsequent sections present a comprehensive overview of available valid and reliable psychosocial measures that assess a selection of important domains for dementia care planning that can be used by families from early stage until end-of-life. Measures selected for the purposes of this article will focus on concepts that are strength-based and most relevant to care dyads as they navigate the difficult disease trajectory: readiness, knowledge, coping, dyadic relationship, care values and preferences. We will also highlight measures that have traditionally targeted the family care partner but can potentially be considered for use with the care partner with dementia, with adjustments, beyond the early stages. Part of this discussion will include various strategies for including persons with dementia in all aspects of their own care using a strength-based perspective, potentially enabling them to answer questions more reliably across disease stages. Last, gaps in existing measures will be identified to provide options to better assess areas of need most meaningful to families, and in ways that positively contribute to the successful aging of those living with dementia and their care partners.

Relational experiences of people seeking help and assessment for subjective cognitive concern and memory loss

Objective: To understand the experience of people who seek help for subjective cognitive concern and memory loss, including people not referred for further assessment. To understand the patients' perspective of the medical process of receiving a cognitive assessment. This work is situated within the context of policy priorities for dementia diagnosis.Methods: Participants with and without dementia were recruited through NHS trusts and community organisations in four regional areas in England. Data were collected using longitudinal qualitative interviews. Transcript data were thematically analysed.Results: Sample of 41 people (mean 75 years, 25 dementia diagnoses). Interpretative thematic analyses focused on the presence or absence of trust in relational experiences. There were three transition points where trust could be specifically developed or undermined: (1) deciding to seek help; (2) healthcare practitioners' response to help-seeking; (3) process and outcome of assessment. Triggers for help-seeking for subjective cognitive concern were being prompted by family and knowing a relative with dementia. When participants perceived healthcare practitioners' behaviour as dismissive, they had less trust in the outcome of the healthcare encounter. Misunderstandings and absence of trust in assessment processes led to participants stating they did not fully agree with the outcomes of the assessment.Conclusions: Healthcare practitioners have an important role in supporting people with subjective cognitive concern ensuring patients have trust in assessment outcomes. Where the validity of the assessment process is seen as ambiguous, people can be left dealing with uncertainty, rather than being clear about ways they can manage their condition, situation or status.

What next? Experiences of social support and signposting after a diagnosis of dementia

The experience of being diagnosed with dementia can be shocking. This may be compounded if individuals feel that there is a lack of signposting onto further avenues of support following diagnosis. This study, then, examines how social support is promoted in the diagnostic process. Using purposive sampling and a grounded theory approach, semi-structured interviews were conducted with 13 members of a dementia empowerment group in Northern Ireland, discussing both their experience of diagnosis and also their subsequent group membership. Respondents reported both positive and negative experiences of diagnosis. Feelings of shock and bewilderment accompanied this process. Only one was able to identify a direct link between a medical professional and referral to the empowerment group, others being referred by other health professionals or dementia navigators. The study indicates that, due to disorienting feelings, one diagnostic consultation is insufficient to explain both the diagnosis and offer follow-up support. Therefore, more explicit links to navigators or other services need to be made at the point of diagnosis to prioritise information regarding opportunities for social engagement for those being diagnosed.

Intention to Be Screened for Alzheimer's Disease in Nondemented Older Adults: Integrated Behavioral Model and Self-Efficacy as Mediation Effect

The study explored factors associated with intention to be screened for Alzheimer's disease (AD). The study also examined whether self-efficacy mediates the relationship between knowledge about screening and the intention to be screened for AD. A population-based, random-digit dialing survey was performed and 1,043 responses were collected from a sample of nondemented persons (50 years or older) living in urban, suburban, and rural areas in a Midwestern state. The findings showed that participants who were younger and who had higher levels of (a) perceived benefits and barriers, (b) social support, and (c) self-efficacy reported higher levels of intention to be screened for AD. Older adults with positive life orientation reported greater intention to be screened for AD, whereas depressed participants were more likely to report a plan to be screened for AD. Self-efficacy mediated the relationship between knowledge about screening and intention to be screened. Older adults were more likely to report intention to be screened when they had positive attitudes about the screen and believed that they could receive the screen. The intention to be screened for AD could serve public awareness by defining effective ways to assist older adults to seek a cognitive screen.

Themes Related to Experienced Quality of Care in Nursing Homes From the Resident's Perspective: A Systematic Literature Review and Thematic Synthesis

Background: The culture change from task-centered care to person- and relationship-centered care has resulted in the resident’s voice gaining importance when assessing experienced quality of care in nursing homes. This review aimed to identify which factors contribute to experienced quality of care in nursing homes worldwide from the resident’s perspective. Method: A systematic literature review and thematic data synthesis were performed. The databases PubMed, Cumulative Index to Nursing and Allied Health Literature (CINAHL), PsycInfo, and Business Source Complete were searched to identify qualitative studies aimed at retrieving factors related to residents’ experienced quality of care in nursing homes. Only studies in which residents themselves were interviewed were included. Results: This literature review included 27 publications covering 14 countries. Thematic analysis revealed three overarching themes related to residents’ care experiences: (a) The nursing home environment consisted of the physical environment and caring environment, (b) individual aspects of living in the nursing home consisted of personhood and coping with change, and (c) social engagement consisted of meaningful relationships and care provision. Discussion: To achieve high experienced quality of care in nursing homes, residents’ care experiences need to be assessed and used in quality management.

Approach to the Older Adult With New Cognitive Symptoms

Dementia affects nearly 50 million people worldwide, translating into one new case every 3 seconds. Dementia syndrome is one of the leading causes of disability among older adults, yet it remains vastly underdiagnosed. A timely diagnosis of dementia is essential to ensuring optimal care and support of individuals and their loved ones. Although there is no single test for dementia, health care providers can use a structured approach to the workup and management of new cognitive symptoms. Comprehensive MEDLINE and PubMed searches were performed to develop an unbiased, practical diagnostic approach to these symptoms. This review guides primary care providers in the workup, diagnosis, delivery, and initial management of patients presenting with new cognitive symptoms.

Next steps after diagnosing dementia: interventions to help patients and families

The way that a diagnosis of dementia is delivered to patients, what information is provided and what practical advice and support is arranged has a lasting impact and deserves at least as much attention as the process of assessment and investigation. Individuals and their families require an honest yet sensitive discussion about the nature and cause of their problems, using non-technical language and tailored to their priorities and needs. This should lead on to the provision of good-quality information in an accessible format. Priorities for intervention include medication review, attention to sensory deficits, appropriate pharmacological and nonpharmacological treatment, best use of memory aids and strategies and discussion of driving eligibility, financial entitlement and legal advice. Referral onwards should be made to an appropriate individual or service to provide ongoing emotional and practical support and signposting.

'I know his needs better than my own' - carers' support needs when caring for a person with dementia

Background

Caring for a person with dementia predisposes informal carers (carers) to mental and physical disability. Carers tend to focus on the needs of the person with dementia and have difficulties expressing their own needs for support. No instrument has yet been developed to directly assess carers’ support needs. The aim of this study is to clarify the main categories of carers’ support needs to inform future development of an instrument to assess carers’ support needs.

Methods

A qualitative approach combining focus group interviews with carers and professionals and individual interviews were used.

Results

Carers’ support needs were categorised into four areas: (i) daily life when caring for a person with dementia, (ii) focus on themselves, (iii) maintain own well‐being, and (iv) communicate and interact with surroundings.

Discussion

Carers have support needs in common regardless of the relation to the person with dementia. Carers tend to focus on the needs of the person with dementia, thus not knowing their own needs. The four main categories clarified in this study may inform the foundation of developing an instrument to facilitate dialogue between carers and professionals with the purpose of assessing carers’ support needs.

Young onset dementia: Public involvement in co-designing community-based support

Whilst the support requirements of people diagnosed with young onset dementia are well-documented, less is known about what needs to be in place to provide age-appropriate care. To understand priorities for service planning and commissioning and to inform the design of a future study of community-based service delivery models, we held two rounds of discussions with four groups of people affected by young onset dementia (n = 31) and interviewed memory services (n = 3) and non-profit service providers (n = 7) in two sites in England. Discussions confirmed published evidence on support requirements, but also reframed priorities for support and suggested new approaches to dementia care at the community level. This paper argues that involving people with young onset dementia in the assessment of research findings in terms of what is important to them, and inviting suggestions for solutions, provides a way for co-designing services that address the challenges of accessing support for people affected by young onset dementia.

Undiagnosed dementia in primary care: a record linkage study

Background

The number of people living with dementia is greater than the number with a diagnosis of dementia recorded in primary care. This suggests that a significant number are living with dementia that is undiagnosed. Little is known about this group and there is little quantitative evidence regarding the consequences of diagnosis for people with dementia.

Objectives

The aims of this study were to (1) describe the population meeting the criteria for dementia but without diagnosis, (2) identify predictors of being diagnosed and (3) estimate the effect of diagnosis on mortality, move to residential care, social participation and well-being.

Design

A record linkage study of a subsample of participants (n = 598) from the Cognitive Function and Ageing Study II (CFAS II) (n = 7796), an existing cohort study of the population of England aged ≥ 65 years, with standardised validated assessment of dementia and consent to access medical records.

Data sources

Data on dementia diagnoses from each participant’s primary care record and covariate and outcome data from CFAS II.

Setting

A population-representative cohort of people aged ≥ 65 years from three regions of England between 2008 and 2011.

Participants

A total of 598 CFAS II participants, which included all those with dementia who consented to medical record linkage (n = 449) and a stratified sample without dementia (n = 149).

Main outcome measures

The main outcome was presence of a diagnosis of dementia in each participant’s primary care record at the time of their CFAS II assessment(s). Other outcomes were date of death, cognitive performance scores, move to residential care, hospital stays and social participation.

Results

Among people with dementia, the proportion with a diagnosis in primary care was 34% in 2008–11 and 44% in 2011–13. In both periods, a further 21% had a record of a concern or a referral but no diagnosis. The likelihood of having a recorded diagnosis increased with severity of impairment in memory and orientation, but not with other cognitive impairment. In multivariable analysis, those aged ≥ 90 years and those aged < 70 years were less likely to be diagnosed than other age groups; those living with a spouse (odds ratio 2.38, 95% confidence interval 1.04 to 5.41) were more likely to be diagnosed than people living alone. The median time to diagnosis from first meeting the criteria for dementia was 3 years. Diagnosis did not affect survival or the probability of a move to residential care.

Limitations

People with moderate to severe dementia at baseline could not consent to record linkage. The small numbers in some groups limited power to detect effects.

Conclusions

The lack of relationship between severity of non-memory impairment and diagnosis may reflect low awareness of other symptoms of dementia. There remains little objective evidence for benefits of diagnosis for people with dementia.

Future work

Potential benefits of diagnosis can be realised only if effective interventions are accessible to patients and carers. Future work should focus on improving support for people living with cognitive impairment.

Study registration

National Institute for Health Research Clinical Research Network Central Portfolio Management System (CPMS 30655).

Funding

This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 8, No. 20. See the NIHR Journals Library website for further project information.

DETERMinants of quality of life, care and costs, and consequences of INequalities in people with Dementia and their carers (DETERMIND): A protocol paper

OBJECTIVES

DETERMIND (DETERMinants of quality of life, care and costs, and consequences of INequalities in people with Dementia and their carers) is designed to address fundamental, and, as yet unanswered questions about inequalities, outcomes and costs following diagnosis with dementia. These answers are needed to improve the quality of care and equity of access to care, and therefore the quality of life, of people with dementia and their carers.

METHOD

DETERMIND is a programme of research consisting of seven complementary workstreams (WS) exploring various components that may result in unequal dementia care: WS1: Recruitment and follow-up of the DETERMIND cohort-900 people with dementia and their carers from three geographically and socially diverse sites within six months following diagnosis, and follow them up for three years. WS2: Investigation of the extent of inequalities in access to dementia care. WS3: Relationship between use and costs of services and outcomes. WS4: Experiences of self-funders of care. WS5: Decision-making processes for people with dementia and carers. WS6: Effect of diagnostic stage and services on outcomes. WS7: Theory of Change informed strategy and actions for applying the research findings.

OUTCOMES

During the life of the programme, analysing baseline results and then follow-up of the DETERMIND cohort over 3 years, we will establish evidence on current services and practice. DETERMIND will deliver novel, detailed data on inequalities in dementia care and what drives positive and negative outcomes and costs for people with dementia and carers, and identify factors that help or hinder living well with dementia.

Screening for Cognitive Impairment in Older Adults: Updated Evidence Report and Systematic Review for the US Preventive Services Task Force

IMPORTANCE

Early identification of cognitive impairment may improve patient and caregiver health outcomes.

OBJECTIVE

To systematically review the test accuracy of cognitive screening instruments and benefits and harms of interventions to treat cognitive impairment in older adults (≥65 years) to inform the US Preventive Services Task Force.

DATA SOURCES

MEDLINE, PubMed, PsycINFO, and Cochrane Central Register of Controlled Trials through January 2019, with literature surveillance through November 22, 2019.

STUDY SELECTION

Fair- to good-quality English-language studies of cognitive impairment screening instruments, and pharmacologic and nonpharmacologic treatments aimed at persons with mild cognitive impairment (MCI), mild to moderate dementia, or their caregivers.

DATA EXTRACTION AND SYNTHESIS

Independent critical appraisal and data abstraction; random-effects meta-analyses and qualitative synthesis.

MAIN OUTCOMES AND MEASURES

Sensitivity, specificity; patient, caregiver, and clinician decision-making; patient function, quality of life, and neuropsychiatric symptoms; caregiver burden and well-being.

RESULTS

The review included 287 studies with more than 280 000 older adults. One randomized clinical trial (RCT) (n = 4005) examined the direct effect of screening for cognitive impairment on patient outcomes, including potential harms, finding no significant differences in health-related quality of life at 12 months (effect size, 0.009 [95% CI, -0.063 to 0.080]). Fifty-nine studies (n = 38 531) addressed the accuracy of 49 screening instruments to detect cognitive impairment. The Mini-Mental State Examination was the most-studied instrument, with a pooled sensitivity of 0.89 (95% CI, 0.85 to 0.92) and specificity of 0.89 (95% CI, 0.85 to 0.93) to detect dementia using a cutoff of 23 or less or 24 or less (15 studies, n = 12 796). Two hundred twenty-four RCTs and 3 observational studies including more than 240 000 patients or caregivers addressed the treatment of MCI or mild to moderate dementia. None of the treatment trials were linked with a screening program; in all cases, participants were persons with known cognitive impairment. Medications approved to treat Alzheimer disease (donepezil, galantamine, rivastigmine, and memantine) improved scores on the ADAS-Cog 11 by 1 to 2.5 points over 3 months to 3 years. Psychoeducation interventions for caregivers resulted in a small benefit for caregiver burden (standardized mean difference, -0.24 [95% CI, -0.36 to -0.13) over 3 to 12 months. Intervention benefits were small and of uncertain clinical importance.

CONCLUSIONS AND RELEVANCE

Screening instruments can adequately detect cognitive impairment. There is no empirical evidence, however, that screening for cognitive impairment improves patient or caregiver outcomes or causes harm. It remains unclear whether interventions for patients or caregivers provide clinically important benefits for older adults with earlier detected cognitive impairment or their caregivers.

Persistent barriers and facilitators to seeking help for a dementia diagnosis: a systematic review of 30 years of the perspectives of carers and people with dementia

OBJECTIVE

To identify barriers and facilitators to help seeking for a dementia diagnosis from the perspective of carers and people with dementia.

DESIGN

A systematic review of the literature was conducted according to the PRISMA guidelines (PROSPERO protocol registration CRD42018092524). Nine electronic databases were searched for qualitative, quantitative, and mixed methods primary research studies. Two independent reviewers screened titles and abstracts, full texts of eligible studies, and conducted quality appraisal of included articles. A convergent qualitative synthesis approach was used.

RESULTS

From 7496 articles, 35 papers representing 32 studies from 1986 to 2017 were included. Studies originated from 13 countries across 4 continents. Barriers and facilitators were reported predominantly by carers. A small number of studies included people with dementia. Barriers included denial, stigma and fear, lack of knowledge, normalization of symptoms, preserving autonomy, lack of perceived need, unaware of changes, lack of informal network support, carer difficulties, and problems accessing help. Facilitators included recognition of symptoms as a problem, prior knowledge and contacts, and support from informal network.

CONCLUSIONS

Studies from a 30-year period demonstrated that barriers to help seeking persist globally, despite increasing numbers of national dementia policies. Barriers and facilitators rarely existed independently demonstrating the complexity of help seeking for a diagnosis of dementia. Multiple barriers compounded the decision-making process and more than one facilitator was often required to overcome them. Multi-faceted interventions to reduce barriers are needed, one approach would be a focus on the development of dementia friendly communities to reduce stigma and empower people with dementia and carers.

Psychosocial Interventions for Family Carers of People With Dementia: A Systematic Review and Meta-Analysis

Objective:This study aimed to review and synthesize findings of the effectiveness of psychosocial interventions aimed at improving outcomes for family carers of people with dementia. Method: A systematic review and meta-analysis were conducted according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. We systematically searched the following databases: Cochrane, PubMed, Cumulative Index to Nursing and Allied Health Literature (CINAHL), PsycInfo, Excerpta Medica Database (EMBASE), and Applied Social Sciences Index and Abstracts (ASSIA). RevMan 5 software was used to conduct meta-analysis and subgroup analysis using a random-effects model. Results: The search yielded 22 high-quality intervention articles that were suitable for further meta-analysis. Meta-analysis revealed that psychosocial interventions have a small to moderate significant effect on carer burden (standardized mean difference [SMD] = −0.34, confidence interval [CI] = [−0.59, −0.09]), depression (SMD = −0.36, CI = [−0.60, −0.13]), and general health (SMD = 0.34, CI = [0.18, 0.51]). Discussion: Psychosocial interventions had a positive impact on carer outcomes; however, these results should be interpreted with caution, given the significant level of heterogeneity in study designs. Future research could examine contextual and implementation mechanisms underlying psychosocial interventions to develop effective support systems for family carers of people with dementia.

Discovering the memory thief: MOOC participants' personal experiences of dementia

Dementia is one of the greatest social issues of our time. There are brief explorations of experiences of dementia in the literature, however this study seeks to further explore the experiences of the general public in relation to dementia. This study aimed to characterise experiences of dementia in the general population. This characterisation was achieved by developing and opening a massive open online course on dementia, which collected information from participants who responded to the question "share your own personal experience of dementia". This data was then analysed by two researchers using Framework Analysis. Four themes (the condition, caring, perception, and control) and indicative quotes are presented and discussed. Experiences of dementia are positive as well as negative. Findings update understanding of these experiences and demonstrate new insights.

Transition Experiences of Caregivers of Older Adults With Dementia and Multiple Chronic Conditions: An Interpretive Description Study

INTRODUCTION

Family caregivers provide most of the care for older persons living with dementia (PLWD) and multiple chronic conditions (MCCs) in the community. Caregivers experience transitions, such as changes to their health, roles, and responsibilities, during the process of caring. Transitions encompass a time when caregivers undergo stressful responses to change. However, we know little about the transition experiences of caregivers of persons living with both dementia and MCCs.

OBJECTIVE

This qualitative study explored the transition experiences of caregivers of PLWD within the context of MCCs, from the perspective of both caregivers and practitioners. The research question was the following: What are the transition experiences of family caregivers in providing care to older PLWD and MCCs living in the community?

METHODS

This study was conducted using an interpretive description approach. Semistructured interviews were conducted with 19 caregivers of older community-dwelling PLWD and MCCs and 7 health-care providers working with caregivers in Ontario, Canada. Concurrent data collection and inductive data analysis were used.

RESULTS

Caregivers of older PLWD and MCCs experienced four key transitions: (a) taking on responsibility for managing multiple complex conditions, (b) my health is getting worse, (c) caregiving now defines my social life, and (d) expecting that things will change. Findings highlight how the coexistence of MCCs with dementia complicates caregiver transitions and the importance of social networks for facilitating transitions.

CONCLUSION

The study provided insight on the transition experiences of caregivers of older PLWD and MCCs. MCCs increased the care load and further complicated caregivers' transition experiences. Health-care providers, such as nurses, can play important roles in supporting caregivers during these transitions and engage them as partners in care.

Community exchange and time currencies: a systematic and in-depth thematic review of impact on public health outcomes

OBJECTIVES

Austerity in government funding, and public service reform, has heightened expectations on UK communities to develop activities and resources supportive of population health and become part of a transformed place-based system of community health and social care. As non-monetary place-based approaches, Community Exchange/Time Currencies could improve social contact and cohesion, and help mobilise families, neighbourhoods, communities and their assets in beneficial ways for health. Despite this interest, the evidence base for health outcomes resulting from such initiatives is underdeveloped.

STUDY DESIGN

A systematic review.

METHODS

A literature review was conducted to identify evidence gaps and advance understanding of the potential of Community Exchange System. Studies were quality assessed, and evidence was synthesised on 'typology', population targeted and health-related and wider community outcomes.

RESULTS

The overall study quality was low, with few using objective measures of impact on health or well-being, and none reporting costs. Many drew on qualitative accounts of impact on health, well-being and broader community outcomes. Although many studies lacked methodological rigour, there was consistent evidence of positive impacts on key indicators of health and social capital, and the data have potential to inform theory.

CONCLUSIONS

Methodologies for capturing impacts are often insufficiently robust to inform policy requirements and economic assessment, and there remains a need for objective, systematic evaluation of Community Exchange and Time Currency systems. There is also a strong argument for deeper investigation of 'programme theories' underpinning these activities, to better understand what needs to be in place to trigger their potential for generating positive health and well-being outcomes.

The key factors for the engagement of primary stakeholders in decision-making for the future care of people with dementia living in the community: a systematic integrative review

BACKGROUND

Engagement of people with dementia who are living in the community, their family or carers, and healthcare professionals in decision-making related to their future care is an area yet to be explored in the literature. In particular, little is known about the factors most likely to underpin their engagement.

OBJECTIVES

To identify key factors for the engagement of the person with dementia living in the community, as well as their family or carer and their healthcare professionals in decision-making processes related to future care.

DESIGN

This is an integrative review guided by the PRISMA guidelines; the Mixed Methods Appraisal Tool was used to assess study quality. MEDLINE, PubMed, CINAHL, PsycINFO and Embase databases were searched for articles published from 2012 to 2018 that focused on people with dementia who live in the community, their family or carers, and community-based healthcare professionals.

RESULTS

Twenty articles were included in the review, and six key factors were identified through thematic analysis: knowledge and understanding of dementia and decision-making for the future, valuing decision-making for the future, healthcare professionals' communication skills, timing of initiating conversations, relationship quality, and orientation to the future.

CONCLUSION

This review identifies the six key factors required for the engagement of the three primary key stakeholders in decision-making about the future care of people with dementia. It also situates the factors within the complex context in which people with dementia, their family or carers, and healthcare professionals typically find themselves.

Social inclusion of people with dementia – an integrative review of theoretical frameworks, methods and findings in empirical studies

The social inclusion of people with dementia (PwD) is recognised as a global goal of legislation, societal initiatives and service provision. Ensuring the social inclusion of PwD in these areas implies that its dimensions and domains are clear and unambiguous. However, the concept of social inclusion as it is currently used by researchers and practitioners is often vague or acts as a container concept for a variety of different approaches. This paper reports on an integrative review that analysed qualitative and quantitative studies on social inclusion and exclusion of PwD. It focused not only on the empirical results of the included studies but also on the theoretical embedding and methodological approaches to the concept of social inclusion and exclusion. We find that empirical studies on the social inclusion of PwD are scarce and largely characterised by a lack of or inconsistent conceptualisation. Against this background, the operationalisation of the concept and the assessment of the individual aspects of social inclusion with standardised instruments seem to be premature. Substantial theoretical and methodological work is needed to guide research on the social inclusion of PwD. The empirical results show that relationships with other people and being integrated into social networks are essential aspects of social inclusion. Likewise, the strategies and attitudes of caring persons can help to create or reinforce exclusion.

Managing behavioural and psychological symptoms in community dwelling older people with dementia: 2. A systematic review of qualitative studies

Background

People living with dementia often develop distressing behavioural and psychological symptoms (BPSD) that can affect their quality of life and the capacity of family carers and staff providing support at home. This systematic review of qualitative studies considers the views and experiences of people living with dementia and care providers about these symptoms and what helps to reduce their impact.

Methods

The two-stage review involved (a) An initial mapping of the literature to understand the range of BPSD, and how it is operationalised by different groups, to develop a search strategy; (b) A search of electronic databases from January 2000 to March 2015, updated in October 2016. Included studies focused on people living in their own homes. Data extraction and thematic analysis were structured to provide a narrative synthesis of the evidence.

Results

We retrieved 17, 871 records and included relevant qualitative papers (n = 58) targeting community-dwelling people with dementia and family carers around the management of BPSD. Five key themes were identified: (1) Helpful interventions/support for BPSD management, (2) Barriers to support services for BPSD management, (3) Challenges around recognition/diagnosis of BPSD, (4) Difficulties in responding to aggression and other BPSD, and (5) Impact of BPSD on family carers and people living with dementia.

Conclusions

Family carers sometimes feel that their experiences of BPSD may not be evident to professionals until a crisis point is reached. Some helpful services exist but access to support, lack of knowledge and skills, and limited information are consistently identified as barriers to their uptake. The lack of common terminology to identify and monitor the range of BPSD that people with dementia living at home may experience means that closer attention should be paid to family carer accounts. Future research should include qualitative studies to evaluate the relevance of interventions.

Joining forces to improve psychosocial care for people with cognitive deficits across diagnoses: social health as a common framework

Cognitive deficits such as memory problems have a major impact on independence in daily life and participation in society in several populations, such as people with dementia, brain injury (i.e. stroke) or a severe mental illness such as schizophrenia. Similarities in the impact on participation and well-being have resulted in the development of comparable psychosocial interventions across populations, aiming to support people to adapt to cognitive deficits or by adapting the environment. These interventions are developed separately, without using the expertise in other fields. We argue that each of the fields and the field of psychosocial care in general would benefit from closer collaboration on development and evaluation of innovative psychosocial interventions. Collaboration has been complicated by the use of different care models and theoretical frameworks, each with their own terminology. The concept of social health - the ability to participate in work or other meaningful activities and to feel healthy despite a condition - translates to the leading care models within the fields of dementia, brain injury and severe mental illness. The concept of social health provides a common language and framework. In this paper, we elaborate on strategies for collaboration using examples of interventions to improve social health.

Qualitative exploration of emotional and social changes from diagnosis to bereavement for spousal caregivers of persons with dementia

OBJECTIVES

To understand how bereaved spousal caregivers of persons with dementia perceive and respond to changes over the course of their spouse's disease, from diagnosis into bereavement.

DESIGN

Qualitative interview study with convenience sampling and thematic analysis approach.

PARTICIPANTS

Participants included eight women and two men (n=10) who had been spousal caregivers for a person with dementia prior to his/her death. Participants were older adults who self-reported good health and were bereaved longer than a year.

SETTING

Data collected in a small Canadian prairie city between fall 2014 and winter 2015.

FINDINGS

Two overarching themes were developed as important components of participants' caregiving journey: emotional reactions to change and variation in social connectedness throughout the caregiving and bereavement journey. Four key sub-themes developed through the analysis of emotional reactions to events: memorable grief overshadows persistent grief, a progressive feeling of hopelessness and overwhelmed, relief is common but hidden and gratitude is a milestone in a constructive bereavement. Three key variations of social connectedness throughout the caregiving and bereavement journey were developed: the importance of social inclusion throughout a caregiving and bereavement journey, the repeated loss of companionship and withdrawing from social interactions is contingent on needs.

CONCLUSIONS

The findings suggest that emotional changes throughout caregiving and bereavement are not linear. The need for support from family, friends and new social supports is influential in enabling the caregiver to move forward during caregiving and bereavement.

Valuing biomarker diagnostics for dementia care: enhancing the reflection of patients, their care-givers and members of the wider public

What is the value of an early (presymptomatic) diagnosis of dementia in the absence of effective treatment? There has been a lively scholarly debate over this question, but until now (future) patients have not played a large role in it. Our study supplements biomedical research into innovative diagnostics with an exlporation of its meanings and values according to (future) patients. Based on seven focusgroups with (future) patients and their care-givers, we conclude that stakeholders evaluate early diagnostics with respect to whether and how they expect it to empower their capacity to (self-) care. They value it, for instance, with respect to whether it (a) explains experienced complaints, (b) allows to start a process of psychological acceptance and social adaptation to the expected degeneration, (c) contributes to dealing with anxieties (with respect to inheritable versions of dementia), (d) informs adequately about when to start preparing for the end of life, (d) informs the planning of a request for euthanasia, or (e) allows society to deal with a growing amount of dementia patients. Our study suggests that information about disease is considered 'harmful' or 'premature' when recipients feel unable to act on that information in their (self-) care. The results of this research offers input to further ethical research. It invites to adopt a care perspective in evaluation and to seek ways to prevent the 'harm' that such diagnostic methods can bring about.

Can Memory Assessment Services (MAS) in England be categorized? A national survey

Background

The effectiveness and efficiency of memory assessment services (MASs) is unknown. Our aim was to determine if a typology can be constructed, based on shared structural and process characteristics, as a basis for a non-randomized evaluation of their effectiveness and cost-effectiveness.

Methods

Survey of random sample of 73 MASs in 2015; comparison of characteristics and investigation of inter-correlation.

Results

It was not possible to group characteristics to form the basis of a typology of MASs. However, there was considerable variation in staff numbers (20-fold), new patients per whole-time equivalent (WTE) staff (20-fold), skill mix and the nurse:doctor ratio (1-10). The operational performance also varied: first appointments (50-120 minutes); time for first follow-up (2-12 weeks); frequency of follow-up in first year (1-5). These differences were not associated with the number of new patients per WTE staff or the accreditation status of the MAS. Post diagnosis, all MASs provided pharmacological treatment but the availability of non-pharmacological support varied, with half providing none or only one intervention while others providing four or more.

Conclusions

In the absence of any clear typology, evaluation of MASs will need to focus on the impact of individual structural and process characteristics on outcomes.

Comparison of the Short Test of Mental Status and the Montreal Cognitive Assessment Across the Cognitive Spectrum

OBJECTIVE

To compare the Short Test of Mental Status (STMS) with the Montreal Cognitive Assessment (MoCA) for predicting and detecting mild cognitive impairment (MCI).

PARTICIPANTS AND METHODS

Participants from the community-based Mayo Clinic Study of Aging (MCSA) (November 24, 2010, through May 19, 2012) and an academic referral Alzheimer's Disease Research Center (ADRC) (March 16, 2015, through September 5, 2018) were analyzed. All participants were evaluated using a standardized neuropsychological battery, and a multidisciplinary consensus diagnosis was assigned. The MCSA and ADRC samples included 313 and 106 stable cognitively normal (CN) participants, 72 and 8 CN participants at baseline who developed incident MCI or dementia, 114 and 96 participants with prevalent MCI, and 25 and 132 participants with dementia, respectively.

RESULTS

There were no statistically significant differences between the 2 tests in 6 of 7 diagnostic comparisons across academic referral and community populations. The STMS had a better area under the curve (0.90; 95% CI, 0.87-0.93) for differentiating prevalent MCI from CN participants in the MCSA cohort compared with the MoCA cohort (0.85; 95% CI, 0.81-0.89; P=.01). In addition, 53% of the stable CN participants (222 of 419) scored less than 26 on the MoCA, with specificity of 47% for diagnosing prevalent MCI.

CONCLUSION

We provide evidence that the STMS performs similarly to the MoCA in a variety of settings and neurodegenerative syndromes. These results suggest that the current recommended MoCA cutoff score may be overly sensitive, consistent with previous studies. We also provide a conversion table for comparing the 2 cognitive tests.

Subjective experiences of cognitive decline and receiving a diagnosis of dementia: qualitative interviews with people recently diagnosed in memory clinics in the UK

OBJECTIVES

To explore people's experiences of cognitive decline and receiving a diagnosis of dementia.

DESIGN

61 semistructured interviews within 2 weeks of diagnosis. Audio recordings were transcribed, line-by-line coded using NVIVO V.11 and analysed using thematic analysis.

SETTING

9 memory clinics (UK).

PARTICIPANTS

People with mild/moderate dementia.

RESULTS

Most participants were diagnosed with Alzheimer's disease (56% female, mean age 81 years). 104 codes were grouped into 22 categories, feeding into 9 subthemes and 4 overarching themes: (1) dissonance, threat to identity and visibility of dementia: dementia was associated with a progressive loss of competence, culminating in being an idiot, crazy and losing the plot. The stigma of dementia led people to hide their diagnosis from others, even close family members. However, decreasing competence in everyday tasks was becoming increasingly visible in family and wider social networks. (2) Vulnerability and being in limbo: people were frustrated by the impact of dementia on their lives and felt vulnerable. Moreover, people were disturbed by not knowing how much and when they would deteriorate further. (3) Loss of control and agency: loneliness, increasing dependence and becoming a burden foreshadowed increasing diminished personal agency. (4) Maintaining agency and self-worth: some people focused on what they could do and the benefits of diagnosis. This involved accepting the diagnosis, adapting to changes by using coping strategies and accepting support from others. This helped people to maintain personal agency and self-worth.

CONCLUSION

While personal acceptance of dementia is challenging, people are additionally troubled about disclosing their diagnosis to others. Limited time in diagnostic appointments and limited postdiagnostic support leave few opportunities to address the emotional impact of a dementia diagnosis. There may be opportunities for healthcare professionals to discuss with patients the benefits of staying positive, implementing coping strategies and accepting support to live well with dementia.

I becomes we, but where is me? The unity-division paradox when caring for a relative with dementia: A qualitative study

BACKGROUND

The number of older people living with dementia is increasing. Admiral Nurses work with these individuals and their families in the UK to manage challenges associated with the condition, providing guidance, advice and reassurance, alongside practical solutions.

AIM

To explore the input of Admiral Nurses as part of people's journey to becoming and being a carer for someone with dementia.

DESIGN

A qualitative study was conducted to describe and understand how Admiral Nurses are experienced and encountered by carers as part of their narrative around supporting a relative with dementia.

METHODS

Semi-structured interviews were conducted with 19 carers between November 2017-April 2018. They lasted between 45 and 90 min. Thematic analysis was used to interpret data.

FINDINGS

An overarching concept of "the unity-division paradox" was derived from the data. This highlights the complex interchange between the carer with (a) the person with dementia, (b) other individuals and (c) external services. Such interactions can make carers feel part of a larger network (unity) but also as if they are on their own, fighting on behalf of the person with dementia (division). This concept was underpinned by the following themes: (a) I becomes we; (b) My private world is encroached by dementia; (c) I'm left navigating an unwieldy system; (d) Are you with or against us?; and (e) Recreating boundaries to rediscover me.

CONCLUSION

The identity and unique characteristics and interests of those caring for a person with dementia may be lost as they encounter tensions associated with the unity-division paradox. Admiral Nurses can help carers feel less alone in managing internal and external struggles by supporting them to do their best for a loved one with dementia.

IMPLICATIONS FOR PRACTICE

Understanding carers' experience and supporting their work may help to increase and sustain their capacity to provide care.

Validity of screening instruments for the detection of dementia and mild cognitive impairment in hospital inpatients: A systematic review of diagnostic accuracy studies

INTRODUCTION

As the population ages, Alzheimer's disease and other subtypes of dementia are becoming increasingly prevalent. However, in recent years, diagnosis has often been delayed or not made at all. Thus, improving the rate of diagnosis has become an integral part of national dementia strategies. Although screening for dementia remains controversial, the case is strong for screening for dementia and other forms of cognitive impairment in hospital inpatients. For this reason, the objective of this systematic review was to provide clinicians, who wish to implement screening, an up-to-date choice of cognitive tests with the most extensive evidence base for the use in elective hospital inpatients.

METHODS

For this systematic review, PubMed, PsycINFO and Cochrane Library were searched by using a multi-concept search strategy. The databases were accessed on April 10, 2019. All cross-sectional studies that utilized brief, multi-domain cognitive tests as index test and a reference standard diagnosis of dementia or mild cognitive impairment as comparator were included. Only studies conducted in the hospital setting, sampling from unselected, elective inpatients older than 64 were considered.

RESULTS

Six studies met the inclusion criteria, with a total of 2112 participants. Diagnostic accuracy data for the Six-Item Cognitive Impairment Test, Cognitive Performance Scale, Clock-Drawing Test, Mini-Mental Status Examination, and Time & Change test were extracted and descriptively analyzed. Clinical and methodological heterogeneity between the studies precluded performing a meta-analysis.

DISCUSSION

This review found only a small number of instruments and was not able to recommend a single best instrument for use in a hospital setting. Although it was not possible to estimate the pooled operating characteristics, the included description of instrument characteristics, the descriptive analysis of performance measures, and the critical evaluation of the reporting studies may contribute to clinician's choice of the screening instrument that fits best their purpose.

Against the stream: early diagnosis of dementia, is it so desirable?

SummaryThe Prime Minister's challenge on dementia called for improved dementia diagnosis rates, based on assumptions of benefit to individuals and those who care for them. Subsequent policies have led to increased target drives for clinical practice to achieve early diagnosis of dementia through intense case identification. However, the current evidence base and treatment options do not support screening for dementia, and there is little empirical evidence that such intensive case identification and early diagnosis for dementia is justified without a better understanding of the benefits, costs and potential harms to individuals and services.Declaration of interestNone.

Psychosocial Interventions for Community-Dwelling People Following Diagnosis of Mild to Moderate Dementia: Findings of a Systematic Scoping Review

National policies and evidence reviews recommend psychosocial interventions (PIs) as an essential support, particularly in the period following dementia diagnosis. However, availability and uptake of these interventions are comparatively low. One of the reasons for this is that clinicians lack information about what might be provided and the potential benefits of different interventions. This article identifies and describes PIs for community-dwelling people following diagnosis of mild to moderate dementia and presents the available evidence to inform practice decisions. A systematic scoping review was employed to map the evidence relating to PIs for this group. This identified 63 relevant studies, testing 69 interventions, which could be grouped into 6 intervention categories: 20 cognition-oriented, 11 behavior-oriented, 11 stimulation-oriented, 13 emotion-oriented, 5 social-oriented, and 9 multimodal. There were three targets for outcome measurement of these PIs: the person with dementia, the family caregiver, and the person-caregiver dyad. Over 154 outcome measures were identified in the studies, with outcomes measured across 11 main domains. The lack of a classification framework for PIs means it is difficult to create a meaningful synthesis of the breadth of relevant evidence to guide clinical practice. Possible dimensions of a classification framework are proposed to begin to address this gap.

Impact of disclosure of a dementia diagnosis on uptake of support services: A pilot study exploring a post-traumatic stress approach

BACKGROUND

At time of diagnosis, people with dementia and their carers can access support services to help them to plan for their future care needs, but often they do not engage with these services. It is not clear why this occurs but a potential explanation explored in this paper is that disclosure of a dementia diagnosis is an overwhelming and highly stressful event that may lead to behavioural avoidance in the manner of post-traumatic stress. In this study we use a post-traumatic stress screening tool to determine whether being diagnosed with dementia shares some qualitative similarities with post-traumatic stress disorder and explore whether this is associated with a reduced likelihood to engage support services following diagnosis.

METHOD

We conducted a small pilot study through the local memory clinic with eight people with dementia and 11 carers returning surveys. Participants completed the Impact of Events Scale-Revised, a validated post-traumatic stress disorder screening tool, and also provided information regarding their experience of the diagnosis and subsequent use of support services.

RESULTS

One person with dementia and two carers had scores on the Impact of Events Scale-Revised indicating a probable diagnosis of post-traumatic stress disorder and two people with dementia and two carers scored within the range of clinical concern. The average Impact of Events Scale-Revised score of those who had taken-up a referral to home support was significantly lower than those who had not.

CONCLUSION

A dementia diagnosis can be associated with symptoms that are consistent with post-traumatic stress, which in turn may affect engagement with support services.

Looking ahead to a future with Alzheimer's disease: coping with the unknown

The conceptualisation of Alzheimer's disease as an illness with ‘no future’ exposes people with the condition to significant fear and stress. Therefore, exploring how people look ahead to the future in the face of Alzheimer's disease is of foremost importance. Semi-structured interviews (N = 14) explored the future outlook of people with early (N = 5) and late-onset (N = 7) Alzheimer's disease and those who support them (N = 14). Thematic analysis identified how participants managed their changing futures through focusing on positive information, and taking ‘one day at a time’. Younger and older people shared similar future outlook and subsequent coping strategies, as predicted by Carstensen's Socioemotional Selectivity Theory. Both people with Alzheimer's disease and those who support them avoided looking far ahead as a way of managing the uncertain future, and had little awareness of future planning in the context of current policies. Such avoidance suggests that policy which encourages future planning should consider its utility and explore ways of helping people to plan, whilst focusing on daily living.

Advance care plans in dementia: user-centred design

OBJECTIVES

Historically, dementia has not been recognised as a life-limiting condition or one that may benefit from a palliative approach to its care. There are many challenges in providing palliative and end-of-life care to this group of people, some of which may be reduced through advance care planning (ACP) to support people with dementia to have a greater influence on their care at end of life. ACP has been defined as a process of discussing and recording of wishes, values and preferences for future care and treatment held between an individual, family members and their care provider(s) that takes effect when the person loses capacity. The objective of this project was to involve people with dementia and their family carers in co-design of ACP guide and template to prepare for further study related to communication processes in ACP.

METHODS

A user-centred design process cycle of development and review was undertaken by Dementia UK which involved people with dementia, family carers, Admiral Nurses and other key stakeholders in developing an ACP guide and template.

RESULTS

Nine cyclical stages were undertaken to achieve the outcome of an ACP guide and template.

CONCLUSION

Co-production using a user-centred design approach offers a structured and inclusive approach to developing ACP materials.Authors.

Living With Dementia: A Meta-synthesis of Qualitative Research on the Lived Experience

Purpose of the Study

To identify and examine the published qualitative research evidence relative to the experience of living with dementia.

Design and Methods

Metasynthesis was used as the methodological framework to guide data collection and analysis.

Results

Three themes were identified. The first theme considered the main condition-related changes experienced by people with dementia (PWD) and showed how these are interlinked and impact upon various areas of people’s lives. The second theme indicated that amidst these changes, PWD strive to maintain continuity in their lives by employing various resources and coping strategies. The third theme underlined the role of contextual factors. The reviewed evidence indicates that, the emerging experience of PWD and their potential to adjust to the continuous changes is influenced by access to and quality of both personal and contextual resources which remain in a constant, transactional relationship to each other.

Implications

The findings were interpreted and discussed in the context of relevant theoretical frameworks and research evidence. It was considered that current evidence and findings presented in this review can be further explored and expanded upon in a more systematic way through research conducted within the theoretical framework of dynamic systems theory. Further research would be also beneficial to explore the subjective experience of dementia from a participatory perspective. Exploring the application of these theoretical standpoints would contribute to the current state of knowledge and offer both PWD and carers fresh perspective on the nature of change and potential for adaptability in dementia.

Measuring the patient experience in community mental health services for older people: A study of the Net Promoter Score using the Friends and Family Test in England

OBJECTIVES

The research aimed to explore the value of the Net Promoter Score as a service improvement tool and an outcome measure. The study objectives were to (1) explore associations between the Net Promoter Score with patient and service-receipt characteristics; (2) evaluate the strength of association between the Net Promoter Score and a satisfaction score; and (3) evaluate its test-retest reliability.

METHODS

A postal survey was sent to service users on caseloads of community mental health teams for older people in four localities of England. The survey collected the Net Promoter Score, a single satisfaction question, and data on socio-demographics, clinical profile, and service receipt. Analysis used non-parametric tests of association and exploratory least squares regression. A second survey was administered for test-retest reliability analysis. Fieldwork concluded in April 2016.

RESULTS

For 352 respondents, the Net Promoter Score was negatively related to age and was lowest for those still within 6 months of their initial referral. Receiving support from a psychiatrist and/or support worker was linked to higher scores. A strong but imperfect correlation coefficient with the satisfaction score indicates they evaluate related but distinct constructs. It had a reasonable test-retest reliability, with a weighted kappa of 0.706.

CONCLUSIONS

Despite doubts over its validity in community mental health services, the Net Promoter Score may produce results of value to researchers, clinicians, service commissioners, and managers, if part of wider data collection. However, multi-item measures would provide greater breadth and improved reliability.

Indirect Music Therapy Practice and Skill-Sharing in Dementia Care

Public interest in the benefits of music for people with dementia has rapidly increased in recent years. In addition to clinical work with clients, music therapists are often required to support and train staff, families, and volunteers and skill-share some music therapeutic skills. Six music therapy researchers from six countries agreed it was timely to organize a roundtable and share their indirect music therapy practice and examples of skill-sharing in dementia care. This article was developed following the roundtable at the World Congress of Music Therapy in 2017 and further discussion among the authors. This process highlighted the diversity and complexity of indirect music therapy practice and skill-sharing, but some common components emerged, including: 1) the importance of making clinical decisions about when direct music therapy is necessary and when indirect music therapy is appropriate, 2) supporting the transition from direct music therapy to indirect music therapy, 3) the value of music therapy skill-sharing in training care home staff, 4) the need for considering potential risks and burdens of indirect music therapy practice, and 5) expanding the role of music therapist and cultivating cross-professional dialogues to support organizational changes. In indirect music therapy practice, a therapist typically works with carers and supporters to strengthen their relationships with people with dementia and help them further develop their self-awareness and sense of competence. However, the ultimate goal of indirect music therapy practice in dementia care remains the wellbeing of people living with dementia.

The start of caring for an elderly dependent family member: a qualitative metasynthesis

BACKGROUND

The family often takes care of an elderly person who suddenly becomes dependent. This greatly affects different aspects of the caregivers' lives. The aim of this study is to explore the initial experiences, during the first year of care, of persons who suddenly become caregivers for elderly dependent relatives.

METHODS

A search in CINAHL, PsycINFO, WOS, Medline, and Scopus and a metasynthesis of qualitative research were conducted including 19 articles.

RESULTS

Three categories were developed to explain the process of becoming a caregiver 'taking on the role' (life changes, uncertainty and confusion, and acceptance or resistance); 'beginning to realise' (new needs, impact, and appraisal); and 'implementing strategies' (seeking help and self-learning, reordering family and social relationships, solving problems, and devising strategies to decrease negative emotions and stress).

CONCLUSIONS

The synthesis provides a comprehensive understanding of the experience of becoming a caregiver in order to help health-care professionals to adapt care plans to this situation.

Prevalence and predictors of psychosocial problems in informal caregivers of older cancer survivors - A systematic review: Still major gaps in current research

Despite the abundance of studies concerning caring for patients with cancer, less is known about caring for an older cancer survivor (≥65 years). We aimed to systematically gather literature about the psychosocial well-being of caregivers of older cancer survivors and to identify possible risk factors for developing psychosocial problems. Fourteen articles met the following inclusion criteria: articles about (a) cancer, (b) informal caregivers, (c) older survivors and a (d) curative setting. After critical appraisal, nearly all were considered to be of moderate-to-strong quality. This results mainly from the specific study population, the valid and reliable measurement instruments and the appropriate statistical methods used in the articles. Main outcomes were burden, depression, anxiety, self-esteem, distress, communication issues, stress and QoL. For all these outcomes, measurement instruments and timing of measurements vary. Also, the results on studied predictors vary widely or not all of them were described in the reviewed articles. There seems to be a higher prevalence of distress, lower QoL and more anxiety in informal caregivers of older cancer survivors compared with the general population, but all were understudied. Based on these results and more focused future research, specific and qualitative support for this group of caregivers can be developed.

Description of general practitioners' practices when suspecting cognitive impairment. Recourse to care in dementia (Recaredem) study

OBJECTIVE

General practitioners (GPs) play a major role in the assessment of dementia but it is still unrecognized in primary care and its management is heterogeneous. Our objective is to describe the usual practices, and their determinants, of French GPs in this field.

METHODS

GPs' characteristics and practices when facing cognitive decline were collected through a telephone interview and a postal questionnaire. A descriptive analysis of all study variables was conducted. The study of quantitative explanatory variables was done by testing the equality of means and the choice of qualitative variables was based on the chi-square independence test or Fischer test.

RESULTS

Hundred two GPs completed the study. GPs were in majority men, working in urban areas. Mean age was 54.4 years old. GPs' feeling of confidence and self-perception of follow-up of national recommendations is linked with their practices. Performing a clinical interview to assess cognitive impairment is linked with good communication skills. GPs feel less confident to give information about resources for dementia. The main reason alleged for underdiagnosis is the limited effectiveness of drug therapy.

CONCLUSIONS

This study underlines the importance of GPs' feeling of confidence when managing cognitively impaired patients with dementia, and the need of increasing training in the field of dementia, which could improve the awareness of GPs about diagnosis and available resources.

Managing diabetes in people with dementia: a realist review

BACKGROUND

Dementia and diabetes mellitus are common long-term conditions that coexist in a large number of older people. People living with dementia and diabetes may be at increased risk of complications such as hypoglycaemic episodes because they are less able to manage their diabetes.

OBJECTIVES

To identify the key features or mechanisms of programmes that aim to improve the management of diabetes in people with dementia and to identify areas needing further research.

DESIGN

Realist review, using an iterative, stakeholder-driven, four-stage approach. This involved scoping the literature and conducting stakeholder interviews to develop initial programme theories, systematic searches of the evidence to test and develop the theories, and the validation of programme theories with a purposive sample of stakeholders.

PARTICIPANTS

Twenty-six stakeholders (user/patient representatives, dementia care providers, clinicians specialising in dementia or diabetes and researchers) took part in interviews and 24 participated in a consensus conference.

DATA SOURCES

The following databases were searched from 1990 to March 2016: MEDLINE (PubMed), Cumulative Index to Nursing and Allied Health Literature, Scopus, The Cochrane Library (including the Cochrane Database of Systematic Reviews), Database of Abstracts of Reviews of Effects, the Health Technology Assessment (HTA) database, NHS Economic Evaluation Database, AgeInfo (Centre for Policy on Ageing - UK), Social Care Online, the National Institute for Health Research (NIHR) portfolio database, NHS Evidence, Google (Google Inc., Mountain View, CA, USA) and Google Scholar (Google Inc., Mountain View, CA, USA).

RESULTS

We included 89 papers. Ten papers focused directly on people living with dementia and diabetes, and the rest related to people with dementia or diabetes or other long-term conditions. We identified six context-mechanism-outcome (CMO) configurations that provide an explanatory account of how interventions might work to improve the management of diabetes in people living with dementia. This includes embedding positive attitudes towards people living with dementia, person-centred approaches to care planning, developing skills to provide tailored and flexible care, regular contact, family engagement and usability of assistive devices. A general metamechanism that emerges concerns the synergy between an intervention strategy, the dementia trajectory and social and environmental factors, especially family involvement. A flexible service model for people with dementia and diabetes would enable this synergy in a way that would lead to the improved management of diabetes in people living with dementia.

LIMITATIONS

There is little evidence relating to the management of diabetes in people living with dementia, although including a wider literature provided opportunities for transferable learning. The outcomes in our CMOs are largely experiential rather than clinical. This reflects the evidence available. Outcomes such as increased engagement in self-management are potential surrogates for better clinical management of diabetes, but this is not proven.

CONCLUSIONS

This review suggests that there is a need to prioritise quality of life, independence and patient and carer priorities over a more biomedical, target-driven approach. Much current research, particularly that specific to people living with dementia and diabetes, identifies deficiencies in, and problems with, current systems. Although we have highlighted the need for personalised care, continuity and family-centred approaches, there is much evidence to suggest that this is not currently happening. Future research on the management of diabetes in older people with complex health needs, including those with dementia, needs to look at how organisational structures and workforce development can be better aligned to the needs of people living with dementia and diabetes.

STUDY REGISTRATION

This study is registered as PROSPERO CRD42015020625.

FUNDING

The NIHR HTA programme.

Managing Faecal INcontinence in people with advanced dementia resident in Care Homes (FINCH) study: a realist synthesis of the evidence

BACKGROUND

Eighty per cent of care home residents in the UK are living with dementia. The prevalence of faecal incontinence (FI) in care homes is estimated to range from 30% to 50%. There is limited evidence of what is effective in the reduction and management of FI in care homes.

OBJECTIVE

To provide a theory-driven explanation of the effectiveness of programmes that aim to improve FI in people with advanced dementia in care homes.

DESIGN

A realist synthesis. This was an iterative approach that involved scoping of the literature and consultation with five stakeholder groups, a systematic search and analysis of published and unpublished evidence, and a validation of programme theories with relevant stakeholders.

DATA SOURCES

The databases searched included PubMed, Cumulative Index to Nursing and Allied Health Literature, The Cochrane Library, Scopus, SocAbs, Applied Social Sciences Index and Abstracts, BiblioMap, Sirius, OpenGrey, Social Care Online and the National Research Register.

RESULTS

The scoping identified six programme theories with related context-mechanism-outcome configurations for testing. These addressed (1) clinician-led support, assessment and review, (2) the contribution of teaching and support for care home staff on how to reduce and manage FI, (3) the causes and prevention of constipation, (4) how the cognitive and physical capacity of the resident affect outcomes, (5) how the potential for recovery, reduction and management of FI is understood by those involved and (6) how the care of people living with dementia and FI is integral to the work patterns of the care home and its staff. Data extraction was completed on 62 core papers with iterative searches of linked literature. Dementia was a known risk factor for FI, but its affect on the uptake of different interventions and the dementia-specific continence and toileting skills staff required was not addressed. Most care home residents with FI will be doubly incontinent and, therefore, there is limited value in focusing solely on FI or on single causes of FI such as constipation. Clinical assessment, knowledge of the causes of FI and strategies that recognise the individuals' preferences are necessary contextual factors. Valuing the intimate and personal care work that care home staff provide to people living with dementia and addressing the dementia-related challenges when providing continence care within the daily work routines are key to helping to reduce and manage FI in this population.

LIMITATIONS

The synthesis was constrained by limited evidence specific to FI and people with dementia in care homes and by the lack of dementia-specific evidence on continence aids.

CONCLUSIONS

This realist synthesis provides a theory-driven understanding of the conditions under which improvement in care for care home residents living with dementia and FI is likely to be successful.

FUTURE WORK

Future multicomponent interventions need to take account of how the presence of dementia affects the behaviours and choices of those delivering and receiving continence care within a care home environment.

STUDY REGISTRATION

This study is registered as PROSPERO CRD42014009902.

FUNDING

The National Institute for Health Research Health Technology Assessment programme.

The informal caregiver's lived experience of being present with a patient who receives a diagnosis of dementia: A phenomenological inquiry

This article describes the lived experience of informal caregivers who accompany loved ones as the loved ones receive a diagnosis of dementia. Each of 12 informal caregivers participated in a face-to-face interview that was audiotaped and transcribed. Analysis of the interview text revealed seven constituents as central to the general structure of this experience: (a) having anticipated the diagnosis; (b) feeling relief; (c) feeling the gravitas of the words; (d) grieving the loss; (e) watching for the patient’s reaction; (f) accepting the diagnosis and taking action; and (g) committing to care. Implications for healthcare providers are discussed, with an emphasis on the need to be sensitive to the experience of both patients and informal caregivers when disclosing a diagnosis of dementia.

Patient and companion concerns when receiving a dementia diagnosis: an observational study of dementia diagnosis feedback meetings

Receiving a diagnosis of dementia is a life-changing event and can cause strong emotional reactions. The aim of this study was to examine patient and companion concerns expressed during dementia diagnosis feedback meetings. Sixty consultations between 19 health-care professionals (HCPs), 60 patients and 59 companions were video-recorded and transcribed. Concerns were identified from the transcripts and were (a) content analysed, (b) coded aselicitedby the HCP orvolunteeredby the patient or companion, and (c) coded according to whether the HCPencouragedordiscouragedelaboration of the concern. A total of 249 concerns were identified (average four concerns per consultation). There were three areas of findings: (a) patients and companions were concerned about the symptoms of dementia and receiving a diagnosis; other concerns related to patients’ mental and physical health, and prognosis, (b) HCPs elicited more patient than companion concerns and mostly elicited concerns aligned with the agenda of diagnosis feedback, and (c) HCPs were more likely to encourage elaboration when they elicited the concern. Nearly 40 per cent of concerns were discouraged by the HPC changing topic, with concerns about prognosis most commonly discouraged. The findings suggest that there were a wide variety of concerns at dementia diagnosis, many extending beyond the experience of dementia symptoms. HCP avoidance of concerns about prognosis demonstrated delicacy in discussing the deteriorating course of dementia.

Coping with Cognitive Impairment in People with Parkinson's Disease and Their Carers: A Qualitative Study

Cognitive impairment is common in Parkinson's disease (PD). However, the psychosocial impact of living and coping with PD and cognitive impairment in people with PD and their carers have not been explored. This paper draws on a qualitative study that explores the subjective impact of cognitive impairment on people with PD and their carers. Thirty-six one-to-one interviews were completed; people with PD were from three groups: normal cognition, mild cognitive impairment, and dementia. Data collection and analysis were iterative, and verbatim transcripts were analysed using thematic analysis. Themes were interpreted in consultation with coping and adaptation theory. The analysis revealed four main themes: threats to identity and role, predeath grief and feelings of loss in carers, success and challenges to coping in people with PD, and problem-focused coping and finding meaning in caring. Our data highlight how cognitive impairment can threaten an individual's self-perception; the ostensible effects of cognitive impairment depended on the impact individual's perceived cognitive impairment had on their daily lives. For carers, cognitive impairment had a greater emotional impact than the physical symptoms of PD. The discussion that developed around protective factors provides possible opportunities for future interventions, such as psychological therapies to improve successful adjustment.

Dementia case-finding in hospitals: a qualitative study exploring the views of healthcare professionals in English primary care and secondary care

OBJECTIVES

In 2012-2013, the English National Health Service mandated hospitals to conduct systematic case-finding of people with dementia among older people with unplanned admissions. The method was not defined. The aim of this study was to understand current approaches to dementia case-finding in acute hospitals in England and explore the views of healthcare professionals on perceived benefits and challenges.

DESIGN

Qualitative study involving interviews, focus groups and thematic content analysis.

SETTING

Primary care and secondary care across six counties in the East of England.

PARTICIPANTS

Hospital staff involved in dementia case-finding and primary care staff in the catchment areas of those hospitals.

RESULTS

We recruited 23 hospital staff and 36 primary care staff, including 30 general practitioners (GPs). Analysis resulted in three themes: (1) lack of consistent approaches in case-finding processes, (2) barriers between primary care and secondary care which impact on case-finding outcomes and (3) perceptions of rationale, aims and impacts of case-finding. The study shows that there were variations in how well hospitals recorded and reported outcomes to GPs. Barriers between primary care and secondary care, including GPs' lack of access to hospital investigations and lack of clarity about roles and responsibilities, impacted case-finding outcomes. Staff in secondary care were more positive about the initiative than primary care staff, and there were conflicting priorities for primary care and secondary care regarding case-finding.

CONCLUSIONS

The study suggests a more evidence-based approach was needed to justify approaches to dementia case-finding. Information communicated to primary care from hospitals needs to be comprehensive, appropriate and consistent before GPs can effectively plan further investigation, treatment or care. Follow-up in primary care further requires access to options for postdiagnostic support. There is a need to evaluate the outcomes for patients and the economic impact on health and care services across settings.

Scaffolding and working together: a qualitative exploration of strategies for everyday life with dementia

Background

living with dementia has been described as a process of continual change and adjustment, with people with dementia and their families adopting informal strategies to help manage everyday life. As dementia progresses, families increasingly rely on help from the wider community and formal support.

Methods

this article reports on a secondary analysis of qualitative data from focus groups and individual interviews with people with dementia and their carers in the North of England. In total, 65 people with dementia and 82 carers took part in the research: 26 in interviews and 121 in focus groups. Focus group and interview audio recordings were transcribed verbatim. A qualitative, inductive, thematic approach was taken for data analysis.

Findings

the article applies the metaphor of scaffolding to deepen understanding of the strategies used by families. Processes of scaffolding were evident across the data where families, communities, professionals and services worked together to support everyday life for people with dementia. Within this broad theme of scaffolding were three sub-themes characterising the experiences of families living with dementia: doing things together; evolving strategies; and fragility and fear of the future.

Conclusions

families with dementia are resourceful but do need increasing support (scaffolding) to continue to live as well as possible as dementia progresses. More integrated, proactive work is required from services that recognises existing scaffolds and provides appropriate support before informal strategies become unsustainable; thus enabling people with dementia to live well for longer.