Identification of community-residing individuals with dementia and their unmet needs for care

Healthcare Needs Patterns and Pattern-Predicting Factors in Dementia: Results of the Comprehensive, Computerized Unmet Needs Assessment from the Randomized, Controlled Interventional Trial InDePendent

Background

Determining unmet need patterns and associated factors in primary care can potentially specify assessment batteries and tailor interventions in dementia more efficiently.

Objective

To identify latent unmet healthcare need patterns and associated sociodemographic and clinical factors.

Methods

This Latent Class Analysis (LCA) includes n = 417 community-dwelling people living with dementia. Subjects completed a comprehensive, computer-assisted face-to-face interview to identify unmet needs. One-hundred-fifteen predefined unmet medical, medication, nursing, psychosocial, and social care needs were available. LCA and multivariate logistic regressions were performed to identify unmet needs patterns and patient characteristics belonging to a specific pattern, respectively.

Results

Four profiles were identified: [1] "few needs without any psychosocial need" (n = 44 (11%); mean: 7.4 needs), [2] "some medical and nursing care needs only" (n = 135 (32%); 9.7 needs), [3] "some needs in all areas" (n = 139 (33%); 14.3 needs), and [4] "many medical and nursing needs" (n = 99 (24%); 19.1 needs). Whereas the first class with the lowest number of needs comprised younger, less cognitively impaired patients without depressive symptoms, the fourth class had the highest number of unmet needs, containing patients with lower health status, less social support and higher comorbidity and depressive symptoms. Better access to social care services and higher social support reduced unmet needs, distinguishing the second from the third class (9.7 versus 14.3 needs).

Conclusions

Access to the social care system, social support and depressive symptoms should be assessed, and the patient's health status and comorbidities monitored to more comprehensively identify unmet needs patterns and more efficiently guide tailored interventions.

Variation in Home Healthcare Use by Dementia Status Among a National Cohort of Older Adults

BACKGROUND

Medicare-funded home healthcare (HHC) delivers skilled nursing, therapy, and related services through visits to the patient's home. Nearly one-third (31%) of HHC patients have diagnosed dementia, but little is currently known regarding how HHC utilization and care delivery differ for persons living with dementia (PLwD).

METHODS

We drew on linked 2012-2018 Health and Retirement Study and Medicare claims for a national cohort of 1 940 community-living older adults. We described differences in HHC admission, length of stay, and referral source by patient dementia status and used weighted, multivariable logistic and negative binomial models to estimate the relationship between dementia and HHC visit type and intensity while adjusting for sociodemographic characteristics, health and functional status, and geographic/community factors.

RESULTS

PLwD had twice the odds of using HHC during a 2-year observation period, compared to those without dementia (odds ratio [OR]: 2.03; p < .001). They were more likely to be referred to HHC without a preceding hospitalization (49.4% vs 32.1%; p < .001) and incurred a greater number of HHC episodes (1.4 vs 1.0; p < .001) and a longer median HHC length of stay (55.8 days vs 40.0 days; p < .001). Among post-acute HHC patients, PLwD had twice the odds of receiving social work services (unadjusted odds ratio [aOR]: 2.15; p = .008) and 3 times the odds of receiving speech-language pathology services (aOR: 2.92; p = .002).

CONCLUSIONS

Findings highlight HHC's importance as a care setting for community-living PLwD and indicate the need to identify care delivery patterns associated with positive outcomes for PLwD and design tailored HHC clinical pathways for this patient subpopulation.

Patient portal messages to support an age-friendly health system for persons with dementia

BACKGROUND

Patient portal secure messaging can support age-friendly dementia care, yet little is known about care partner use of the portal and how message concerns relate to age-friendly issues.

METHODS

We conducted a two-part observational study. We first assessed the feasibility of automating care partner identification from patient portal messages by developing and testing a natural language processing (NLP) rule-based classification system from portal messages of 1973 unique patients 65 and older. Second, two independent reviewers manually coded a randomly selected sample of portal messages for 987 persons with dementia to identify the frequency of expressed needs from the 4M domains of an Age-Friendly Health System (medications, mentation, mobility, and what matters).

RESULTS

A total of 267 (13.53%) of 1973 messages sent from older adults' portal accounts were identified through manual coding as sent by a nonpatient author. The NLP model performance to identify nonpatient authors demonstrated an AUC of 0.90. Most messages sent from the accounts of persons with dementia contained content relevant to the 4Ms (60%, 601/987), with the breakdown as follows: medications-36% (357/987), mobility-10% (101/987), mentation-16% (153/987), and what matters (aligning care with specific health goals and care preferences)-21%, 207/987.

CONCLUSIONS

Patient portal messaging offers an avenue to identify care partners and meet the informational needs of persons with dementia and their care partners.

Informal Caregivers of People with Dementia in Germany: Psychosocial Characteristics and Unmet Needs

Background

Caregivers of people with dementia living at home (CPwDh) are likely to be affected by a range of health problems. However, CPwDh are often regarded as accompanying persons and receive less attention in research and care. Little is known about this population and their needs in Germany. However, better knowledge of CPwDH is needed to design effective interventions.

Objective

The objective of this report is to describe the situation of CPwDh and highlight differences based on sex and living situation.

Methods

This was a cross-sectional analysis of the psychosocial characteristics of participants in the GAIN trial, a cluster-randomized, controlled intervention trial investigating the effectiveness of a care management program. A total of n = 192 CPwDh were recruited in GP offices, memory clinics or through public campaigns in the German federal state of Mecklenburg-Western Pomerania. The inclusion criteria were an age of 18 years or above, being a CPwDh, written informed consent. In a comprehensive digital assessment, psychosocial variables, burden, and care needs were assessed.

Results

Partners, women, and people living in the same household represented the majority of caregivers, and their mean number of needs was 8.7. Overall, participants indicated a mild to moderate burden. There are differences in burden based on sex and living situation, with caregivers living with people with dementia showing less burden and different psychosocial demographics.

Conclusions

There is a need for interventions to reduce caregivers' unmet needs in the CPwDh. Such interventions should consider differences in sex and living situation to better address individual caregiver needs.

Depression and thoughts of self-harm and suicide among people living with dementia: results of a cross-sectional survey

BACKGROUND

Depression is common among people with dementia. Despite most people with dementia living in the community, there have been few investigations of self-reported depressive symptoms and suicidal ideation among community-dwelling people with dementia in Australia. This study aimed to explore the proportion of people with mild, moderate and severe levels of depressive symptoms, and suicidal ideation among a sample of people living with dementia in Australia. Correlates of reporting depressive symptoms were also explored.

METHODS

Adults diagnosed with dementia by a medical professional who were English speaking and community-dwelling were asked to complete a paper and pencil survey. Those who were unable to provide independent consent were excluded. Depression was assessed using the Geriatric Depression Scale -15, and suicidal ideation was assessed using two study-specific items. Multivariable analyses examined quality of life, unmet needs and sociodemographic factors associated with having a score of five or more on the Geriatric Depression Scale-15.

RESULTS

Ninety-four people participated in the study. Thirty-seven percent (n = 35) reported some level of depressive symptoms, with most of these (21%, n = 20) classified as having mild depressive symptoms. Five participants (5%) reported they had had thoughts of being better off dead or hurting themselves, while three (3%) reported having had a plan to end their life. For each additional unmet need, the odds of being depressed increased by 25%(P < 0.001). For each point increase in quality of life, the odds of being depressed decreased by 48% (P < 0.001).

CONCLUSIONS

The high proportion of people with dementia who report depressive symptoms suggests the need to routinely assess depressive symptoms among this group. There may also be benefits in assessing unmet needs and addressing these where possible as part of an approach to reducing depression among people living with dementia in the community.

[Regional Health Care Networks in Germany: Characteristics and Financing Illustrated with Dementia Care Networks]

OBJECTIVES

To describe the characteristics, financing structures and challenges of regional dementia care networks and the use of regional financial network support according to § 45c para. 9 SGB XI.

METHODS

The analysis was based on data from 120 dementia networks that provided information on the network characteristics (location, year of foundation, goals, organizational, personnel and financing structure), the challenges and the use of regional network funding according to § 45c Para. 9 SGB XI. Differences in the organizational, personnel and financing structure depending on the network characteristics were analyzed using t-Tests and ANOVA tests. The use of regional network funding (§ 45c Para. 9) were presented descriptively and discussed against the background of the planned amendment for 2022.

RESULTS

The majority of networks were established between 2011 and 2015. Most networks had educational and care goals and, on average, 28 stakeholders. Medically-associated and longer-established networks and networks with a legal form had significantly more network partners, persons actively involved in the work of the network and funding sources. The linking of stakeholders and the funding were seen as the most significant challenges. Every tenth network received regional network funding (§45c para. 9) but 28% decided not to receive funding. For most networks (50%), the funding was still unknown.

CONCLUSION

Regional dementia networks are very heterogeneously structured. Certain factors can significantly affect the number of partners and funding sources and should, therefore, be considered. Up to now, only one network per region could receive the maximum amount (€20,000) of funding according to §45c para. 9, which limits the usability of this funding, especially in densely populated regions. The amendment now increases the number of networks to be funded within one region and the funding level. It remains to be seen to what extent this amendment will increase the use of the regional network funding.

The associations between unmet needs with protective factors, risk factors and outcomes among care partners of community-dwelling persons living with dementia

OBJECTIVES

Describe the prevalence and types of unmet needs among community-dwelling dementia care partners (CPs) and determine associations between unmet needs with protective factors, risk factors and outcomes.

METHOD

A cross-sectional analysis of 638 racially and cognitively diverse community-dwelling persons living with dementia (PLWD) and their CPs participating in a comprehensive in-home assessment of dementia-related needs. Unmet CP needs (19 items, 6 domains) were rated by a clinician using the Johns Hopkins Dementia Care Needs Assessment (JHDCNA). Multivariate linear regression models were used to examine associations between total percent unmet CP needs with demographic, protective and risk factors.

RESULTS

Nearly all CPs had at least one unmet need (99.53%), with a mean of 5.7 (±2.6). The most common domains with ≥1 unmet need were memory disorder education, care skills and knowledge of resources (98%), legal issues/concerns (73.8%), CP mental health (44.6%) and access to informal support (42.7%). Adjusted multivariate models suggest the strongest consistent predictive factors relate to informal emotional support, CP physical health, use or difficulty getting formal services/supports (both for CPs and PLWD), and CP time spent with PLWD. Greater levels of unmet needs were associated with worse PLWD outcomes and CP outcomes, after adjusting for demographics.

CONCLUSIONS

CPs have high rates of diverse, but modifiable unmet needs. Data suggest optimal approaches to dementia care should take a family-centered home-based approach that includes routine CP needs assessment, offer targeted interventions that include both traditional medical supports as well as strategies to increase and leverage informal social networks, and ones that can bridge and coordinate medical with non-medical supports. These findings can be used to inform new approaches to support CPs, improve PLWD and CP outcomes, and target groups most at risk for inequities.

Care Need Combinations for Dementia Patients with Multiple Chronic Diseases

Purpose

The purpose of this study was to find care need combinations for dementia patients with multiple chronic diseases and their caregivers.

Patients and Methods

A cross-sectional study was conducted with 83 patients who had multiple chronic diseases. Variables from patients included age, gender, severity of clinical dementia rating, feeding, hypnotics, mobility, getting lost, mood symptoms, and behavioral and psychological symptoms. Moreover, 26 types of care needs were included in this study. The Apriori algorithm was employed to first identify care need combinations and then to find the relationships between care needs and variables from dementia patients with multiple chronic diseases.

Results

Six rules were generated for care need combinations. Four care needs could be formed as a basic care need bundle. Moreover, two additional care needs could be added to provide a wider coverage for patients. In the second stage, 93 rules were found and categorized into three groups, including 2, 6, and 28 general rules with support of 30% but less than 40%, 20% but less than 30%, and 10% but less than 20%, respectively. When the support value is 10% but less than 20%, more variables from patients were found in rules which help the dementia collaborative care team members provide tailor-made care need bundles.

Conclusion

Four basic care needs were social resources referral and legal support (Care (1)), drug knowledge education (Care (3)), memory problem care (Care (5)), and fall prevention (Care (8)). Besides, disease knowledge education (Care (2)) and hypertension care (Care (16)) were frequent unmet needs in this specific population. Moreover, care for the mood of the caregiver (Care (11)) should be considered especially in dementia patients with preserved ambulatory function or with symptoms of hallucination. The collaborative care team should pay more attention to those care needs when assessing this specific population.

Community services for older people: a cross-sectional study to explore awareness and the degree of need for long-term care resources

Background: Dementia can lead to family, medical, and social burdens. Long-term care issues of older adults in Taiwan and the burdens of caregivers are beginning to be taken seriously by the government. Relevant resources for older adults have gradually increased; however, older adults and caregivers are often not likely to seek resources and might not know what resources are available.Aims: In this study, we screened for cognitive impairment among community-dwelling older adults, and investigated knowledge of dementia among older adults, awareness of long-term care resources, and the degree of need from caregivers' perspectives.Design: A cross-sectional research design with purposive sampling was used.Methods: This study was carried out in a city in northern Taiwan. In total, 137 older adults completed the surveys with the following inclusion criteria: (1) being 65 years or older and (2) living at home. Additionally, 128 caregivers were also interviewed. Face-to-face interviews were conducted and self-administered questionnaires were delivered to all enrolled participants including: (1) a questionnaire of knowledge of dementia, (2) the Ascertain Dementia (AD)-8 questionnaire; and (3) awareness of community-based long-term care resources and needs questionnaire.Results: Results showed that 16.8% of older adults required a further definite diagnosis of dementia and had relatively low knowledge regarding dementia. Caregivers reported a low level of awareness regarding available long-term care resources despite needing and/or using those resources.Conclusions: Policymakers and practitioners should proactively promote supportive services for older adults and caregivers in the community. Future research should explore strategies for enhancing resource utilization and accessing tailored support to meet the needs of older adults with dementia.

Cognitive impairment associated with greater care intensity during home health care

BACKGROUND

In Medicare-funded home health care (HHC), one in three patients has cognitive impairment (CI), but little is known about the care intensity they receive in this setting. Recent HHC reimbursement changes fail to adjust for patient CI, potentially creating a financial disincentive to caring for these individuals.

METHODS

This cohort study included a nationally representative sample of 1214 Medicare HHC patients between 2011 and 2016. Multivariable logistic and negative binomial regressions modelled the relationship between patient CI and care intensity-measured as the number and type of visits received during HHC and likelihood of receiving multiple successive HHC episodes.

RESULTS

Patients with CI had 45% (P < .05) greater odds of receiving multiple successive HHC episodes and received an additional 2.82 total (P < .001), 1.39 nursing (P = .003), 0.72 physical therapy (P = .03), and 0.60 occupational therapy visits (P = .01) during the index HHC episode.

DISCUSSION

Recent HHC reimbursement changes do not reflect the more intensive care needs of patients with CI.

Prevalence and Type of Unmet Needs Experienced by People Living with Dementia

Background: Accurately identifying the unmet needs of community-dwelling people with dementia allows targeted support to be provided to assist these individuals to stay at home. Objective: We developed a self-report instrument to identify the unmet needs of community-dwelling people with dementia and used this to explore the prevalence and type of unmet needs present in this population. Methods: This was a cross-sectional survey of people with dementia living in the community in Australia. Participants were recruited from geriatric clinics, respite centers, aged care providers, and carers attending support groups. Eligible people with dementia were provided with a study information pack and survey which included the self-report Unmet Needs Instrument for Dementia (UNI-D), sociodemographic characteristics and survey acceptability. Results: The UNI-D contained 26 items across 5 domains and demonstrated acceptable internal consistency, face and construct validity, and acceptability. Ninety-five eligible participants completed the survey (response rate 35%) with 85% identifying at least one unmet need (median = 4; IQR = 1–9). The items most frequently endorsed included needing more help with remembering things (64%), finding possible treatments for dementia (44%), understanding who to contact regarding a problem or concern related to dementia (36%), and to see friends and family more often (33%). Conclusion: The UNI-D is a promising tool to identify the self-reported needs of people with dementia. The development and rigorous testing of interventions targeting unmet needs related to health and wellbeing, dementia support, and meaningful activities appears warranted.

Prevalence and type of unmet needs experienced by carers of people living with dementia

OBJECTIVES

Carers of people with dementia experience significant physical, emotional, and social burdens. Needs assessment can provide important information to assist services in providing support to carers to reduce these burdens. However, few studies have examined the prevalence of unmet needs experienced by carers of people with dementia using a quantitative instrument. This study aimed to examine the prevalence and type of unmet needs experienced by carers of people with dementia in Australia.

METHODS

This was a cross-sectional survey of carers providing support to community-dwelling individuals living with dementia. Carers were recruited through geriatric clinics, aged care providers, support services and community organisations. Consenting carers completed a survey including an 80-item study-specific unmet needs instrument for carers (UNI-C) and sociodemographic characteristics. Descriptive statistics were used to identify the most prevalent unmet needs reported by carers.

RESULTS

A total of 169 carers (response rate 47%) completed the survey. Most (87%) carers reported at least one unmet need. Carers reported a median of 16.0 (IQR = 24.0; max = 58) out of a possible 80 unmet needs. The most frequently endorsed unmet needs spanned a range of areas including emotional wellbeing, accessing health and aged care services, managing apathy, and finding information.

CONCLUSION

This study highlighted that a large proportion of carers experience unmet needs associated with caring for someone with dementia. Developing and rigorously testing interventions to meet carers' commonly reported unmet needs are warranted.

Supplemental data for this article is available online at https://doi.org/10.1080/13607863.2022.2053833 .

Needs Detection for Carers of Family Members with Dementia

Aim: To determine the perceived needs of carers of non-institutionalized family members that suffer from dementia. Methods: Two-steps qualitative study by focus groups of relatives in three centres of different characteristics from the Girona Health Region (step 1) and two in-depth interviews with significant professionals in dementia care (step 2). The analysis was performed based on the interpretation of the transcribed data and the bottom-up coding of categories and themes. The information was triangulated and coding was agreed upon. Results: There were three groups, 26 main carers of community-dwelling relatives with dementia in step 1 and two in-depth interviews with dementia-specialised healthcare and social care professionals in step 2. The demands were categorised according to three main themes: whether they were addressed to the members of care services for more direct and close care, to the agencies for a better joint working and less fragmented system, or to society for better comprehension and social recognition. We emphasize the need for a consultation-liaison reference figure throughout the process both for aspects of greater efficiency in the management of resources and for greater empowerment of carers.

Exploring the contribution of housing adaptations in supporting everyday life for people with dementia: a scoping review

The primary aim of this scoping review was to explore the contribution of housing adaptations to supporting everyday life for people with dementia living at home in the community. The study adopted a scoping review methodology which was guided by the Joanna Briggs Institute Reviewers Manual. Four review questions were developed which subsequently informed the inclusion criteria and search terms. Eight databases were searched resulting in 2,339 records, with 13 papers being included in the review. Evidence from the review found that the most common adaptations were recommended and/or implemented to compensate for a person's physical limitations and for safety reasons, rather than adaptations to support activities of daily living for a person with dementia. Support to implement adaptations was provided by a range of professionals coupled with ‘trial and error’ approaches adopted by the person themselves, and these were seen as key enablers. Barriers to implementing and using adaptations were fourfold: (a) access to information, (b) knowing when to make changes, (c) carer resistance, and (d) the unsuitability of the home. It would appear that housing adaptations have a positive impact on both the person with dementia and the carer (where one is present), with some adaptations having a relatively sustained impact and being particularly effective if implemented early in the lived trajectory of dementia.

Association between apathy and satisfaction with meaningful activities in older adults with mild cognitive impairment: A population-based cross-sectional study

OBJECTIVES

This cross-sectional study aimed to clarify the relationship between apathy, meaningful activities, and satisfaction with such activities of older adults with mild cognitive impairment (MCI).

METHODS

We analyzed 235 older adults with MCI (≥65 years, mean age: 76.9 ± 6.4 years, women: 63.4%) who participated in a community-based health check survey (Tarumizu Study 2018). MCI was defined as at least 1.5 SD below the reference threshold (age- and education-adjusted score) on one or more of the computerized cognitive test including memory, attention, executive functions, and processing speed. Apathy symptoms were assessed using three of the 15 items of Geriatric Depression Scale. Participants selected meaningful activities from the 95 activities of the Aid for Decision-Making in Occupation Choice and evaluated their satisfaction and performance.

RESULTS

Apathy in MCI was prevalent by 23.8%. The categories of meaningful activities revealed no difference, with, or without apathy. Logistic regression analysis showed that activity satisfaction was significantly associated with apathy after adjusting for age, sex, education, instrumental activities of daily living, depressive symptoms, and MCI subtype (OR, 0.62; 95% CI, 0.44-0.88, p = 0.008).

CONCLUSIONS

Satisfaction with the activities that are deemed meaningful is associated with apathy among community-dwelling older adults with MCI.

Beyond the shrinking world: dementia, localisation and neighbourhood

‘Dementia-friendly communities’ herald a shift toward the neighbourhood as a locus for the care and support of people with dementia, sparking growing interest in the geographies of dementia care and raising questions over the shifting spatial and social experience of the condition. Existing research claims that many people with dementia experience a ‘shrinking world’ whereby the boundaries to their social and physical worlds gradually constrict over time, leading to a loss of control and independence. This paper reports a five-year, international study that investigated the neighbourhood experience of people with dementia and those who care for and support them. We interrogate the notion of a shrinking world and in so doing highlight an absence of attention paid to the agency and actions of people with dementia themselves. The paper draws together a socio-relational and embodied-material approach to question the adequacy of the shrinking world concept as an explanatory framework and to challenge reliance within policy and practice upon notions of place as fixed or stable. We argue instead for the importance of foregrounding ‘lived place’ and attending to social practices and the networks in which such practices evolve. Our findings have implications for policy and practice, emphasising the need to bolster the agency of people living with dementia as a route to fostering accessible and inclusive neighbourhoods.

Effects of a Video-based Intervention on Caregiver Confidence for Managing Dementia Care Challenges: Findings from the FamTechCare Clinical Trial

OBJECTIVES

The Supporting Family Caregivers with Technology trial tested the FamTechCare video support intervention against telephone support. Dementia caregivers' video-recorded challenging care encounters and an interdisciplinary team provided tailored feedback. This paper reports on the effects of the intervention on caregiver confidence in managing priority challenges, a secondary outcome of this non-blinded parallel randomized controlled trial.

METHODS

Caregiver/person living with dementia dyads were randomized to the experimental FamTechCare video support (n = 43) or attention control telephone support (n = 41) groups. Caregivers providing in-home care to a person living with mild or more severe dementia were eligible. Caregivers identified three priority challenges using the Caregiver Target Problems Questionnaire and rated the frequency and severity of each challenge and their confidence managing the challenge at baseline and 3-months. Challenges were classified using the FamTechCare Technology-supported Dementia Care Typology. Effects on confidence were compared between groups using the Wilcoxon rank-sum test and within groups using the Wilcoxon signed-rank test.

RESULTS

Caregiver priority challenges included managing dementia behaviors, understanding disease expectations, and performing activity of daily living care. Improvements were observed across the three categories in both groups; however, not all changes were statistically significant. No significant differences were identified between groups.

CONCLUSION

Caregivers in the FamTechCare group reported benefit across all priority challenges including managing dementia behaviors, understanding disease expectations, and performing activity of daily living care.

CLINICAL IMPLICATIONS

Innovative technology provides new opportunities to support family caregivers in dementia home care. Video-recording can be used to enhance support for family caregivers facing care challenges.

Personally tailored activities for improving psychosocial outcomes for people with dementia in community settings

BACKGROUND

People with dementia living in the community, that is in their own homes, are often not engaged in meaningful activities. Activities tailored to their individual interests and preferences might be one approach to improve quality of life and reduce challenging behaviour.

OBJECTIVES

To assess the effects of personally tailored activities on psychosocial outcomes for people with dementia living in the community and their caregivers. To describe the components of the interventions. To describe conditions which enhance the effectiveness of personally tailored activities in this setting.

SEARCH METHODS

We searched ALOIS: the Cochrane Dementia and Cognitive Improvement Group's Specialized Register on 11 September 2019 using the terms: activity OR activities OR occupation* OR "psychosocial intervention" OR "non-pharmacological intervention" OR "personally-tailored" OR "individually-tailored" OR individual OR meaning OR involvement OR engagement OR occupational OR personhood OR "person-centred" OR identity OR Montessori OR community OR ambulatory OR "home care" OR "geriatric day hospital" OR "day care" OR "behavioural and psychological symptoms of dementia" OR "BPSD" OR "neuropsychiatric symptoms" OR "challenging behaviour" OR "quality of life" OR depression. ALOIS contains records of clinical trials identified from monthly searches of a number of major healthcare databases, numerous trial registries and grey literature sources.

SELECTION CRITERIA

We included randomised controlled trials and quasi-experimental trials including a control group offering personally tailored activities. All interventions comprised an assessment of the participant's present or past interests in, or preferences for, particular activities for all participants as a basis for an individual activity plan. We did not include interventions offering a single activity (e.g. music or reminiscence) or activities that were not tailored to the individual's interests or preferences. Control groups received usual care or an active control intervention.

DATA COLLECTION AND ANALYSIS

Two review authors independently checked the articles for inclusion, extracted data, and assessed the methodological quality of all included studies. We assessed the risk of selection bias, performance bias, attrition bias, and detection bias. In case of missing information, we contacted the study authors.

MAIN RESULTS

We included five randomised controlled trials (four parallel-group studies and one cross-over study), in which a total of 262 participants completed the studies. The number of participants ranged from 30 to 160. The mean age of the participants ranged from 71 to 83 years, and mean Mini-Mental State Examination (MMSE) scores ranged from 11 to 24. One study enrolled predominantly male veterans; in the other studies the proportion of female participants ranged from 40% to 60%. Informal caregivers were mainly spouses. In four studies family caregivers were trained to deliver personally tailored activities based on an individual assessment of interests and preferences of the people with dementia, and in one study such activities were offered directly to the participants. The selection of activities was performed with different methods. Two studies compared personally tailored activities with an attention control group, and three studies with usual care. Duration of follow-up ranged from two weeks to four months. We found low-certainty evidence indicating that personally tailored activities may reduce challenging behaviour (standardised mean difference (SMD) -0.44, 95% confidence interval (CI) -0.77 to -0.10; I² = 44%; 4 studies; 305 participants) and may slightly improve quality of life (based on the rating of family caregivers). For the secondary outcomes depression (two studies), affect (one study), passivity (one study), and engagement (two studies), we found low-certainty evidence that personally tailored activities may have little or no effect. We found low-certainty evidence that personally tailored activities may slightly improve caregiver distress (two studies) and may have little or no effect on caregiver burden (MD -0.62, 95% CI -3.08 to 1.83; I² = 0%; 3 studies; 246 participants), caregivers' quality of life, and caregiver depression. None of the studies assessed adverse effects, and no information about adverse effects was reported in any study.

AUTHORS' CONCLUSIONS

Offering personally tailored activities to people with dementia living in the community may be one approach for reducing challenging behaviour and may also slightly improve the quality of life of people with dementia. Given the low certainty of the evidence, these results should be interpreted with caution. For depression and affect of people with dementia, as well as caregivers' quality of life and burden, we found no clear benefits of personally tailored activities.

Care Needs of Community-Residing Male Patients with Vascular Cognitive Impairment

PURPOSE

The aim of this study was to identify the care needs of male patients with vascular cognitive impairment (VCI) and their caregivers.

PATIENTS AND METHODS

This cross-sectional study enrolled 389 male patients with VCI and their caregivers who were cared for by the dementia collaborative care team at Changhua Christian Hospital, Taiwan. Fifteen care needs consisting of most of quality measures for people living with dementia and their caregivers were developed by the care team. Through face-to-face evaluations, individualized care needs were collected. The Apriori algorithm was used to identify care bundles for the patients and their caregivers.

RESULTS

Six basic care needs for patients and their caregivers were identified, including appropriate schedule of activities, regular outpatient follow-up treatment, introduction and referral of social resources, referral to family support groups and care skills training, care for the mood of the caregiver, and health education for dementia and behavioral and psychological symptoms of dementia. Compared to subjects with all dementia subtypes from the previous studies, care for the mood of the caregiver was an important and frequent care need for the male patients with VCI and their caregivers. A comparison among the study and similar studies was made to highlight the strength of this study concentrating on the precise selection of care needs.

CONCLUSION

Collaborative dementia care teams should monitor for caregivers' depression and include this care need into the care bundle when assessing male subjects with VCI.

Unmet needs in community-living persons with dementia are common, often non-medical and related to patient and caregiver characteristics

OBJECTIVE

Understanding which characteristics of persons with dementia (PWD) and their caregivers are associated with unmet needs can inform strategies to address those needs. Our purpose was to determine the percentage of PWD having unmet needs and significant correlates of unmet needs in PWD.

DESIGN

Cross-sectional data were analyzed using bivariate and hierarchical multiple linear regression analyses.

SETTING

Participants lived in the greater Baltimore, Maryland and Washington DC suburban area.

PARTICIPANTS

A sample of 646 community-living PWD and their informal caregivers participated in an in-home assessment of dementia-related needs.

MEASUREMENTS

Unmet needs were identified using the Johns Hopkins Dementia Care Needs Assessment. Correlates of unmet needs were determined using demographic, socioeconomic, clinical, functional and quality of life characteristics of the PWD and their caregivers.

RESULTS

PWD had a mean of 10.6 (±4.8) unmet needs out of 43 items (24.8%). Unmet needs were most common in Home/Personal Safety (97.4%), General Health Care (83.1%), and Daily Activities (73.2%) domains. Higher unmet needs were significantly related to non-white race, lower education, higher cognitive function, more neuropsychiatric symptoms, lower quality of life in PWD, and having caregivers with lower education or who spent fewer hours/week with the PWD.

CONCLUSIONS

Unmet needs are common in community-living PWD, and most are non-medical. Home-based dementia care can identify and address PWD's unmet needs by focusing on care recipients and caregivers to enable PWD to remain safely at home.

Unmet needs of people with Parkinson's disease: A cross-sectional study

AIMS

To identify the type and extent of unmet needs in people with Parkinson's disease and to examine the impact of health locus of control and family support on these needs.

DESIGN

A cross-sectional study.

METHODS

This study was conducted from October 2015 - February 2016 in Korea. Data were collected through questionnaires focusing on unmet needs, health locus of control, family support and clinical features.

RESULTS

Therapeutic needs represented the highest percentage of unmet needs in people with Parkinson's disease (85.05%), followed by social/spiritual/emotional needs (82.72%). Physical needs were the lowest reported score (75.01%). Unmet needs were more frequent in those with more severe non-motor symptoms. Also, higher family support, internal locus of control and doctor locus of control were correlated with more unmet needs.

CONCLUSION

Understanding factors that determine the type and degree of unmet needs in people with PD is important to provide appropriate nursing care. The findings of this study can be used for providing nursing interventions reflecting unmet needs and reducing their unmet needs to improve the overall well-being of people with PD.

IMPACT

This study addressed unmet needs unmet needs specific to Parkinson's disease with respect to their nursing needs. Therapeutic needs were the highest unmet needs in people with PD, followed by social/spiritual/emotional needs, need for certainty and physical needs. The findings may be useful for nurses to identify the unmet needs of people with PD which need to be addressed. By reflecting on unmet needs, nurses can give personally tailored nursing care.

Synthesis of the Literature: Variables Influencing Caregiver Use or Nonuse of Supportive Services

Two out of three caregivers (CGs) of persons with dementia (PWD) living in the community do not use supportive services or resources, and three out of four underutilize available support. These findings are troubling because CGs report many unmet needs in providing support to PWD. What predisposing, enabling, and need variables influence CGs to use or not use support services are poorly understood. This article reviews the literature on CG of PWD to find characteristic variables that are related to CG's decisions to use or not use support services. Instruments used in research studies were named to determine recommendations for future studies. The article organizes the variables following Anderson's model of predisposing, enabling, and need characteristics. It also supports future research to examine CG use or nonuse of resources that could inform practice, funding of programs, and policy.

Factors Influencing Emergency Care by Persons With Dementia: Stakeholder Perceptions and Unmet Needs

BACKGROUND/OBJECTIVES

People with dementia (PwD) frequently use emergency care services. To mitigate the disproportionately high rate of emergency care use by PwD, an understanding of contributing factors driving reliance on emergency care services and identification of feasible alternatives are needed. This study aimed to identify clinician, caregiver, and service providers' views and experiences of unmet needs leading to emergency care use among community-dwelling PwD and alternative ways of addressing these needs.

DESIGN

Qualitative, employing semistructured interviews with clinicians, informal caregivers, and aging service providers.

SETTING

Wisconsin, United States.

PARTICIPANTS

Informal caregivers of PwD (n = 4), emergency medicine physicians (n = 4), primary care physicians (n = 5), geriatric healthcare providers (n = 5), aging service providers (n = 6), and community paramedics (n = 3).

MEASUREMENTS

Demographic characteristics of participants and data from semistructured interviews.

FINDINGS

Four major themes were identified from interviews: (1) system fragmentation influences emergency care use by PwD, (2) informational, decision-making, and social support needs influence emergency care use by PwD, (3) emergency departments (EDs) are not designed to optimally address PwD and caregiver needs, and (4) options to prevent and address emergency care needs of PwD.

CONCLUSION

Participants identified numerous system and individual-level unmet needs and offered many recommendations to prevent or improve ED use by PwD. These novel findings, aggregating the perspectives of multiple dementia-care stakeholder groups, serve as the first step to developing interventions that prevent the need for emergency care or deliver tailored emergency care services to this vulnerable population through new approaches. J Am Geriatr Soc 67:711-718, 2019.

Using The Apriori Algorithm To Classify The Care Needs Of Patients With Different Types Of Dementia

PURPOSE

To elucidate specific combinations of care needs for people living with dementia (PLWD) and their caregivers according to specific subtypes of dementia.

PATIENTS AND METHODS

A cross-sectional study at memory clinics in Changhua Christian Hospital, Taiwan, was conducted. Five hundred and eight people living with dementia and their caregivers joined the dementia collaborative care model. The care team established 15 care needs containing most of quality measures for PLWD and their caregivers. Individualized care plans including different combinations of care needs were addressed through face-to-face assessments. Apriori algorithm was used to find specific combinations of care needs for particular groups of PLWD and their caregivers.

RESULTS

This study identified the basic care needs of PLWD and caregivers including appropriate scheduling of activities, regular outpatient follow-up treatment, introduction and referral of social resources, referral to family support groups and care skills training, and health education for dementia and behavioral and psychological symptoms of dementia. Patients with Alzheimer's dementia required more care to prevent traffic accidents and getting lost, while patients with vascular dementia required more care to prevent falls. The older (≥75 years old) PLWD were associated with more needs of fall prevention and care for the mood of the caregiver, especially in the female patients with mild Alzheimer's dementia (CDR = 1).

CONCLUSION

Bundling the needed care needs might be a more effective means to care for a wide variety of patients with dementia.

Safety Implications for the Homebound Patient With Dementia

Patients with dementia have unique safety needs due to cognitive and behavioral changes associated with dementia. Because the prevalence of dementia is expected to greatly increase with an aging population, and because an estimated 70% of people with dementia live at home, it is essential that healthcare providers receive adequate training on the special needs of this population. This article will discuss home safety interventions with regard to: 1) risk of falling, 2) kitchen use and food safety, 3) medication safety, and 4) wandering and personal safety. A successful health program must include ongoing evaluation of the patient's risk profile with regard to health issues, physical and cognitive deficits, medications, and physical environment. Risks can be accepted, addressed, or actively remediated as appropriate. Good interventions should promote acceptable patient behavior and engage assistive personnel to achieve the desired outcome. To promote safety, the home environment can be modified to encourage positive behaviors and to discourage potentially harmful behaviors. Communication between the patient, trained healthcare providers, and family caregivers is essential.

MIND at Home-Streamlined: Study protocol for a randomized trial of home-based care coordination for persons with dementia and their caregivers

BACKGROUND

Dementia is associated with high health care costs, premature long-term care (LTC) placement, medical complications, reduced quality of life, and caregiver burden. Most health care providers and systems are not yet organized or equipped to provide comprehensive long-term care management for dementia, although a range of effective symptoms and supportive care approaches exist. The Maximizing Independence at Home-Streamlined (MIND-S) is a promising model of home-based dementia care coordination designed to efficiently improve person-centered outcomes, while reducing care costs. This report describes the rationale and design of an NIA-funded randomized controlled trial to test the impact of MIND-S on time to LTC placement, person with dementia outcomes (unmet needs, behavior, quality of life), family caregiver outcomes (unmet needs, burden), and cost offset at 18 (primary end point) and 24 months, compared to an augmented usual care group.

METHODS

This is a 24-month, parallel group, randomized trial evaluating MIND-S in a cohort of 304 community-living persons with dementia and their family caregivers in Maryland. MIND-S dyads receive 18 months of care coordination by an interdisciplinary team comprised of trained non-clinical community workers (e.g. Memory Care Coordinators), a registered nurse, and a geriatric psychiatrist. Intervention components include in-home dementia-related needs assessments; individualized care planning; implementation of standardized evidence-based care strategy protocols; and ongoing monitoring and reassessment. Outcomes are assessed by blinded evaluators at baseline, 4.5, 9, 13.5, 18, and 24 months.

DISCUSSION

Trial results will provide rigorous data to inform innovations in effective system-level approaches to dementia care.

Health conditions and unmet needs for assistance to perform activities of daily living among older adults with dementia in Chile

OBJECTIVE

This study aims to address gaps in health conditions and unmet needs in daily activities between people with dementia (PWD) and without dementia in a developing country and to identify the variables associated with unmet needs among PWD to guide practitioners and policymakers in dealing with an increased burden of dementia.

METHODS

Nationally representative data on 4655 Chileans age 60 and over were used to compare health conditions and unmet needs in daily life activities between individuals with (N = 455, 9.6%) and without dementia. Regression analysis was conducted to identify the variables associated with unmet needs among PWD.

RESULTS

Overall, PWD had worse health and needed greater assistance in performing daily activities than people without dementia. Among PWD, being male was associated with more unmet needs, in both activities of daily living (ADL) and instrumental ADL. Lower educational level and fewer caregivers were associated with more unmet needs for ADL, while inferior functional ability was associated with more unmet needs for instrumental ADL.

CONCLUSIONS

The results from this study call for action by practitioners and policymakers to foster caregiver training, increase supportive services, and advance care planning for PWD.

Comprehensive home-based care coordination for vulnerable elders with dementia: Maximizing Independence at Home-Plus-Study protocol

INTRODUCTION

Despite availability of effective care strategies for dementia, most health care systems are not yet organized or equipped to provide comprehensive family-centered dementia care management. Maximizing Independence at Home-Plus is a promising new model of dementia care coordination being tested in the U.S. through a Health Care Innovation Award funded by the Centers for Medicare and Medicaid Services that may serve as a model to address these delivery gaps, improve outcomes, and lower costs. This report provides an overview of the Health Care Innovation Award aims, study design, and methodology.

METHODS

This is a prospective, quasi-experimental intervention study of 342 community-living Medicare-Medicaid dual eligibles and Medicare-only beneficiaries with dementia in Maryland. Primary analyses will assess the impact of Maximizing Independence at Home-Plus on risk of nursing home long-term care placement, hospitalization, and health care expenditures (Medicare, Medicaid) at 12, 18 (primary end point), and 24 months, compared to a propensity-matched comparison group.

DISCUSSION

The goals of the Maximizing Independence at Home-Plus model are to improve care coordination, ability to remain at home, and life quality for participants and caregivers, while reducing total costs of care for this vulnerable population. This Health Care Innovation Award project will provide timely information on the impact of Maximizing Independence at Home-Plus care coordination model on a variety of outcomes including effects on Medicaid and Medicare expenditures and service utilization. Participant characteristic data, cost savings, and program delivery costs will be analyzed to develop a risk-adjusted payment model to encourage sustainability and facilitate spread.

Unmet need for social care among older people

Understanding the nature and extent of unmet need for social care among older people is a critical policy priority in the United Kingdom and beyond, as national governments juggle the provision of adequate social care for a growing older population with competing funding priorities. Several factors can heighten the experience of unmet need among older people, for instance their family environment, and their health and socio-economic status. This paper contributes empirical evidence on the patterns of unmet need for social care among older people in England today, focusing on the individual characteristics associated with experiencing unmet need in relation to mobility tasks, activities of daily living (ADLs) and instrumental activities of daily living (IADLs). The results show that about 55 per cent of older individuals with an ADL difficulty had unmet need, compared to 24 per cent of those with an IADL difficulty and 80 per cent of those with a mobility difficulty. Characteristics reflecting greater vulnerability were more strongly associated with the risk of experiencing unmet need for ADLs, and such vulnerability was greater for particular ADLs (e.g. bathing), and for a higher number of ADLs. The findings reaffirm the complexity of conceptualising and empirically investigating unmet need in later life, and add to our understanding of the challenges of providing adequate and appropriate social care to older people.

Effectiveness and Safety of Dementia Care Management in Primary Care: A Randomized Clinical Trial

IMPORTANCE

Dementia care management (DCM) can increase the quality of care for people with dementia. Methodologically rigorous clinical trials on DCM are lacking.

OBJECTIVE

To test the effectiveness and safety of DCM in the treatment and care of people with dementia living at home and caregiver burden (when available).

DESIGN, SETTING, AND PARTICIPANTS

This pragmatic, general practitioner-based, cluster-randomized intervention trial compared the intervention with care as usual at baseline and at 12-month follow-up. Simple 1:1 randomization of general practices in Germany was used. Analyses were intent to treat and per protocol. In total, 6838 patients were screened for dementia (eligibility: 70 years and older and living at home) from January 1, 2012, to March 31, 2016. Overall, 1167 (17.1%) were diagnosed as having dementia, and 634 (9.3%) provided written informed consent to participate.

INTERVENTIONS

Dementia care management was provided for 6 months at the homes of patients with dementia. Dementia care management is a model of collaborative care, defined as a complex intervention aiming to provide optimal treatment and care for patients with dementia and support caregivers using a computer-assisted assessment determining a personalized array of intervention modules and subsequent success monitoring. Dementia care management was targeted at the individual patient level and was conducted by 6 study nurses with dementia care-specific qualifications.

MAIN OUTCOMES AND MEASURES

Quality of life, caregiver burden, behavioral and psychological symptoms of dementia, pharmacotherapy with antidementia drugs, and use of potentially inappropriate medication.

RESULTS

The mean age of 634 patients was 80 years. A total of 407 patients received the intended treatment and were available for primary outcome measurement. Of these patients, 248 (60.9%) were women, and 204 (50.1%) lived alone. Dementia care management significantly decreased behavioral and psychological symptoms of dementia (b = -7.45; 95% CI, -11.08 to -3.81; P < .001) and caregiver burden (b = -0.50; 95% CI, -1.09 to 0.08; P = .045) compared with care as usual. Patients with dementia receiving DCM had an increased chance of receiving antidementia drug treatment (DCM, 114 of 291 [39.2%] vs care as usual, 31 of 116 [26.7%]) after 12 months (odds ratio, 1.97; 95% CI, 0.99 to 3.94; P = .03). Dementia care management significantly increased quality of life (b = 0.08; 95% CI, 0 to 0.17; P = .03) for patients not living alone but did not increase quality of life overall. There was no effect on potentially inappropriate medication (odds ratio, 1.86; 95% CI, 0.62 to 3.62; P = .97).

CONCLUSIONS AND RELEVANCE

Dementia care management provided by specifically trained nurses is an effective collaborative care model that improves relevant patient- and caregiver-related outcomes in dementia. Implementing DCM in different health care systems should become an active area of research.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT01401582.

Challenges for Service Robots-Requirements of Elderly Adults with Cognitive Impairments

OBJECTIVE

We focused on identifying the requirements and needs of people suffering from Alzheimer disease and early dementia stages with relation to robotic assistants.

METHODS

Based on focus groups performed in two centers (Poland and Spain), we created surveys for medical staff, patients, and caregivers, including: functional requirements; human-robot interaction, the design of the robotic assistant and user acceptance aspects. Using Likert scale and analysis made on the basis of the frequency of survey responses, we identified users' needs as high, medium, and low priority.

RESULTS

We gathered 264 completed surveys (100 from medical staff, 81 from caregivers, and 83 from potential users). Most of the respondents, almost at the same level in each of the three groups, accept robotic assistants and their support in everyday life. High level priority functional requirements were related to reacting in emergency situations (calling for help, detecting/removing obstacles) and to reminding about medication intake, about boiling water, turning off the gas and lights (almost 60% of answers). With reference to human-robot interaction, high priority was given to voice operated system and the capability of robotic assistants to reply to simple questions.

CONCLUSION

Our results help in achieving better understanding of the needs of patients with cognitive impairments during home tasks in everyday life. This way of conducting the research, with considerations for the interests of three stakeholder groups in two autonomic centers with proven experience regarding the needs of our patient groups, highlights the importance of obtained results.

Measuring the Needs of Family Caregivers of People With Dementia: An Assessment of Current Methodological Strategies and Key Recommendations

While dementia caregivers are regarded as a population with high unmet needs, there is little consensus as to how caregivers’ needs should be conceptualized and measured. This article describes how dementia caregivers’ needs are currently assessed in the scientific literature with the goal of suggesting guidelines for the enhancement of future measurement of caregiver needs. A review of 26 articles identified overarching themes within measurement approaches including variation in methodological rigor, proxy indicators of need, dual needs assessment of caregiver and person with dementia (PWD), and third-party needs assessment. We recommend future research dedicate theoretical attention to the conceptualization and classification of caregivers’ needs to build a stronger foundation for measurement. The measurement development process should capitalize on mixed-methodology and follow instrument development and validation guidelines set forth by measurement theory. Reliable and valid instruments are essential to developing services and policies that address dementia caregivers’ needs.

How to explore the needs of informal caregivers of individuals with cognitive impairment in Alzheimer's disease or related diseases? A systematic review of quantitative and qualitative studies

BACKGROUND

This study aims to review the methodologies used to identify the needs, the existing needs assessment instruments and the main topics of needs explored among caregivers of patients with mild cognitive impairment to dementia.

METHODS

MEDLINE, PsycINFO, The Cochrane Library and Web of science were searched from January 1980 to January 2017. Research studies in English or French were eligible for inclusion if they fulfilled the following criteria: quantitative, qualitative and mixed method studies that used instrument, focus group or semi-structured interviews to assess the informal caregiver's needs in terms of information, coping skills, support and service.

RESULTS

Seventy studies (n = 39 quantitative studies, n = 25 qualitative studies and n = 6 mixed method studies) met the inclusion criteria and were included. Thirty-six quantitative instruments were identified but only one has been validated for the needs assessment of dementia caregivers: the Carer's Needs Assessment for Dementia (CNA-D). The main areas of needs explored in these instruments were: information, psychosocial, social, psychoeducational and other needs.

CONCLUSIONS

No instrument has been developed and validated to assess the needs of informal caregivers of patients with cognitive impairment, whatever the stage and the etiology of the disease. As the perceived needs of caregivers may evolve with the progression of the disease and the dementia transition, their needs should be regularly assessed.

Evaluation of a nurse-led dementia education and knowledge translation programme in primary care: A cluster randomized controlled trial

BACKGROUND

The lack of dementia education programmes for health professionals in primary care is one of the major factors contributing to the unmet demand for dementia care services.

AIMS

To determine the effectiveness of a nurse-led dementia education and knowledge translation programme for health professionals in primary care; participants' satisfaction with the programme; and to understand participants' perceptions of and experiences in the programme.

DESIGN

A cluster randomized controlled trial was used as the main methodology to evaluate health professionals' knowledge, attitudes and care approach. Focus groups were used at the end of the project to understand health professionals' perceptions of and experiences in the programme.

PARTICIPANTS AND SETTINGS

Fourteen community health service centres in a province in China participated in the study. Seven centres were randomly assigned to the intervention or control group respectively and 85 health professionals in each group completed the programme.

METHODS

A train-the-trainer model was used to implement a dementia education and knowledge translation programme. Outcome variables were measured at baseline, on the completion of the programme and at 3-month follow-up. A mixed effect linear regression model was applied to compare the significant differences of outcome measures over time between the two groups. Focus groups were guided by four semi-structured questions and analysed using content analysis.

RESULTS

Findings revealed significant effects of the education and knowledge translation programme on participants' knowledge, attitudes and a person-centred care approach. Focus groups confirmed that the programme had a positive impact on dementia care practice.

CONCLUSIONS

A dementia education and knowledge translation programme for health professionals in primary care has positive effects on their knowledge, attitudes, care approach and care practice.

Social class, dementia and the fourth age

Research addressing social class and dementia has largely focused on measures of socioeconomic status as causal risk factors for dementia and in observed differences in diagnosis, treatment and care. This large body of work has produced important insights but also contains numerous problems and weaknesses. Research needs to take account of the ways in which ageing and social class have been transformed in tandem with the economic, social and cultural coordinates of late modernity. These changes have particular consequences for individual identities and social relations. With this in mind this article adopts a critical gaze on research that considers interactions between dementia and social class in three key areas: (i) epidemiological approaches to inequalities in risk (ii) the role of social class in diagnosis and treatment and (iii) class in the framing of care and access to care. Following this, the article considers studies of dementia and social class that focus on lay understandings and biographical accounts. Sociological insights in this field come from the view that dementia and social class are embedded in social relations. Thus, forms of distinction based on class relations may still play an important role in the lived experience of dementia.

Disability, support and long-term social care of an elderly Spanish population, 2008-2009: an epidemiologic analysis

BACKGROUND

Though poorly known, relationships between disability, need of help (dependency) and use of social services are crucial aspects of public health. The objective of this study was to describe the links between disability, officially assessed dependency, and social service use by an industrial population, and identify areas of inequity.

METHODS

We took advantage of a door-to-door survey conducted in the Cinco Villas district, Spain, in 2008-2009, which provided data on disability, morbidity, and service use among 1216 residents aged ≥50 years, and officially assessed dependency under the 2006 Dependency Act (OAD). Using logistic regression, we combined data collected at homes/residences on 625 disability screened-positive participants, and administrative information on degree of OAD and benefits at date of visit.

RESULTS

Based on 163 disabled persons, the prevalence of residential/community-care users was 13.4% overall, with 6.0% being market-provided, 2.5% supported by the 2006 Act, and 4.9% supported by other public funds. Of 111 OAD applicants, 30 had been assigned an OAD degree; in 29 cases this was the highest OAD degree, with 12 receiving direct support for residential care and 17 receiving home care. Compared to unassessed dependency, the highest OAD degree was linked to residential care (OR and 95% CI) 12.13 (3.86-38.16), declared non-professional care 10.99 (1.28-94.53), and publicly-funded, non-professional care 26.30 (3.36-205.88). In contrast, 43 persons, 58% of the severely/extremely disabled, community-dwelling sample population, 81% of whom were homebound, including 10 persons with OAD but no implemented service plan, made no use of any service, and of these, 40% lacked a non-professional carer.

CONCLUSIONS

Formal service use in the Cinco Villas district attained ratios observed for established welfare systems but the publicly-funded proportion was lower. The 2006 Act had a modest, albeit significant, impact on support for non-professional carers and residential care, coexisting with a high prevalence of non-use of social services by severely disabled persons.

Unmet Needs of Community-Dwelling Primary Care Patients with Dementia in Germany: Prevalence and Correlates

BACKGROUND

To provide an optimal care for persons with dementia (PWD), their individual unmet needs have to be identified and comprehensively addressed.

OBJECTIVES

Present analyses aim to describe the number and types of unmet needs of German primary care patients screened positive for dementia and factors associated with the number of unmet needs.

METHODS

DelpHi-MV (Dementia: life- and person-centered help in Mecklenburg-Western Pomerania) is a general practitioner-based, cluster-randomized controlled intervention trial. Analyses are based on the baseline data of 227 PWD (≥70 years, living at home) of the intervention group who had screened positive for dementia (DemTect<9) and received a standardized computer-assisted needs assessment.

RESULTS

PWD had on average 8.77±5.04 unmet needs (Range = 0-31). More than 90% of the PWD had three or more unmet needs. Unmet needs were identified across all predefined 26 subcategories. The majority of unmet needs occurred in the domains "nursing treatment and care" (38%), "social counseling and legal support" (20%), and "pharmacological treatment and care" (15%). More impairment in the activities of daily living was the only factor that was significantly associated with a higher number of unmet needs, independent of age, gender, living situation, presence of an informal caregiver, cognitive impairment, and depression.

CONCLUSIONS

Present results demonstrate that community-dwelling PWD had a broad range of varying unmet needs. These findings emphasize the importance of a comprehensive needs assessment that allows the identification of individual needs as the basis for a tailored intervention- such as Dementia Care Management- that can address these needs.

The association between cognitive impairment and community service use patterns in older people living in Australia

Family plays a vital role in supporting individuals with dementia to reside in the community, thus delaying institutionalisation. Existing research indicates that the burden of care-giving is particularly high for those caring for a person with dementia. Yet, little is known about the uptake of community services by people with a diagnosis of dementia. Therefore, this study aims to better understand the relationship between cognitive impairment and the receipt of community care services. In order to examine the relationship, secondary data collected across Queensland, Australia, from 59,352 home-care clients aged 65 and over during 2007-2008 are analysed. This cross-sectional study uses regression analyses to estimate the relationship between cognitive impairment and service mix, while controlling for socio-demographic characteristics. The dependent variables include formal services, informal care and total home-care service hours during a 12-month period. The findings of this study demonstrate that cognitive impairment is associated with accessing more hours of respite and day centre care but fewer hours of other formal care services. Additionally, the likelihood of support from an informal caregiver increases when a client becomes cognitively impaired. Therefore, this study demonstrates that there is an increased need for respite programmes to support informal caregivers in the future, as the population of people living with dementia increases. These findings support the need for investigations of new and innovative respite models in the future.

Family Physician-Case Manager Collaboration and Needs of Patients With Dementia and Their Caregivers: A Systematic Mixed Studies Review

PURPOSE

Dementia case management (CM) in primary care is a complex intervention aimed at identifying the various needs of patients with dementia and their caregivers, as well as the organization and coordination of care. A key element of CM is the collaboration of family physicians with case managers. We conducted a systematic mixed-studies review to identify the needs of the patient-caregiver dyad and the effects of CM.

METHODS

We searched MEDLINE, PsycINFO, and EMBASE up to October 2014, regardless of the study design. Our main outcomes were needs of patients and their caregivers and the effects of CM on these needs. We used narrative syntheses to develop a taxonomy of needs and to describe the effects of CM on those needs. We used meta-analysis to calculate the prevalence of needs and the standardized mean differences to evaluate the effects of CM on the needs identified.

RESULTS

Fifty-four studies were included. We identified needs of the patient-caregiver dyad and needs of the patient and caregiver individually. CM addressed the majority of the identified needs. Still, some very common needs (eg, early diagnosis) are overlooked while other needs (eg, education on the disease) are well addressed. Fully establishing the value of CM is difficult given the small number of studies of CM in primary care.

CONCLUSIONS

There is good evidence that case managers, in collaboration with family physicians, have a pivotal role in addressing the needs of the patient-caregiver dyad.

A randomized controlled trial of a community-based dementia care coordination intervention: effects of MIND at Home on caregiver outcomes

OBJECTIVE

To assess whether MIND at Home, a community-based, multicomponent, care coordination intervention, reduces unmet caregiving needs and burden in informal caregivers of persons with memory disorders.

METHODS

An 18-month randomized controlled trial of 289 community-living care recipient (CR)-caregiver (informal caregivers, i.e., unpaid individuals who regularly assisted the CR) dyads from 28 postal code areas of Baltimore, Maryland was conducted. All dyads and the CR's primary care physician received the written needs assessment results and intervention recommendations. Intervention dyads then received an 18-month care coordination intervention delivered by nonclinical community workers to address unmet care needs through individualized care planning, referral and linkage to dementia services, provision of caregiver dementia education and skill-building strategies, and care progress monitoring by an interdisciplinary team. Primary outcome was total percent of unmet caregiver needs at 18 months. Secondary outcomes included objective and subjective caregiver burden measures, quality of life (QOL), and depression.

RESULTS

Total percent of unmet caregiver needs declined in both groups from baseline to 18 months, with no statistically significant between-group difference. No significant group differences occurred in most caregiver burden measures, depression, or QOL. There was a potentially clinically relevant reduction in self-reported number of hours caregivers spent with the CR for MIND participants compared with control subjects.

CONCLUSION

No statistically significant impacts on caregiver outcomes were found after multiple comparison adjustments. However, MIND at Home appeared to have had a modest and clinically meaningful impact on informal caregiver time spent with CRs.

A multidimensional home-based care coordination intervention for elders with memory disorders: the maximizing independence at home (MIND) pilot randomized trial

OBJECTIVES

To assess whether a dementia care coordination intervention delays time to transition from home and reduces unmet needs in elders with memory disorders.

DESIGN

18-month randomized controlled trial of 303 community-living elders.

SETTING

28 postal code areas of Baltimore, MD.

PARTICIPANTS

Age 70+ years, with a cognitive disorder, community-living, English-speaking, and having a study partner available.

INTERVENTION

18-month care coordination intervention to systematically identify and address dementia-related care needs through individualized care planning; referral and linkage to services; provision of dementia education and skill-building strategies; and care monitoring by an interdisciplinary team.

MEASUREMENTS

Primary outcomes were time to transfer from home and total percent of unmet care needs at 18 months.

RESULTS

Intervention participants had a significant delay in time to all-cause transition from home and the adjusted hazard of leaving the home was decreased by 37% (Hazard ratio: 0.63, 95% Confidence Interval: 0.42-0.94) compared with control participants. Although there was no significant group difference in reduction of total percent of unmet needs from baseline to 18 months, the intervention group had significant reductions in the proportion of unmet needs in safety and legal/advance care domains relative to controls. Intervention participants had a significant improvement in self-reported quality of life (QOL) relative to control participants. No group differences were found in proxy-rated QOL, neuropsychiatric symptoms, or depression.

CONCLUSIONS

A home-based dementia care coordination intervention delivered by non-clinical community workers trained and overseen by geriatric clinicians led to delays in transition from home, reduced unmet needs, and improved self-reported QOL.

Unmet needs of community-residing persons with dementia and their informal caregivers: findings from the maximizing independence at home study

OBJECTIVES

To determine the prevalence and correlates of unmet needs in a sample of community-residing persons with dementia (PWD) and their informal caregivers.

DESIGN

Analysis of cross-sectional, baseline participant characteristics before randomization in a care coordination intervention trial.

SETTING

Baltimore, Maryland.

PARTICIPANTS

Community-residing PWD (n=254) and their informal caregivers (n=246).

MEASUREMENTS

In-home assessments of dementia-related needs based on the Johns Hopkins Dementia Care Needs Assessment. Bivariate and multivariate regression analyses were conducted to identify demographic, socioeconomic, clinical, functional, and quality-of-life correlates of unmet needs.

RESULTS

The mean number of unmet needs was 7.7±4.8 in PWD and 4.6±2.3 in caregivers, with almost all PWD (99%) and caregivers (97%) having one or more unmet needs. Unmet needs in PWD were significantly greater in those with higher cognitive function. Ninety percent of PWD had unmet safety needs, more than half had unmet needs for meaningful activities, and almost one-third had not received a prior evaluation or diagnosis. Higher unmet needs in PWD was significantly associated with nonwhite race, lower income, less impairment in activities of daily living, and more symptoms of depression. For caregivers, more than 85% had unmet needs for resource referrals and caregiver education. Higher unmet caregiver needs was significantly associated with nonwhite race, less education, and more symptoms of depression.

CONCLUSION

Many community-residing PWD and their caregivers have unmet dementia-related needs for care, services, and support. Providers should be aware that unmet needs may be higher in minority and low-income community residents, caregivers with lower education, and individuals with early-stage dementia. Identifying and treating symptoms of depression in PWD and caregivers may enable them to address their other unmet needs.

The Attitudes and Perceptions of Older Adults With Mild Cognitive Impairment Toward an Assistive Robot

The purpose of this study was to explore perceived difficulties and needs of older adults with mild cognitive impairment (MCI) and their attitudes toward an assistive robot to develop appropriate robot functionalities. Twenty subjects were recruited to participate in either a focus group or an interview. Findings revealed that although participants reported difficulties in managing some of their daily activities, they did not see themselves as needing assistance. Indeed, they considered that they were capable of coping with difficulties with some compensatory strategies. They therefore declared that they did not need or want a robot for the moment but that they considered it potentially useful either for themselves in the future or for other older adults suffering from frailty, loneliness, and disability. Factors underlying unwillingness to adopt an assistive robot were discussed. These issues should be carefully addressed in the design and diffusion processes of an assistive robot.

Study protocol: translating and implementing psychosocial interventions in aged home care the lifestyle engagement activity program (LEAP) for life

BACKGROUND

Tailored psychosocial activity-based interventions have been shown to improve mood, behaviour and quality of life for nursing home residents. Occupational therapist delivered activity programs have shown benefits when delivered in home care settings for people with dementia. The primary aim of this study is to evaluate the effect of LEAP (Lifestyle Engagement Activity Program) for Life, a training and practice change program on the engagement of home care clients by care workers. Secondary aims are to evaluate the impact of the program on changes in client mood and behaviour.

METHODS/DESIGN

The 12 month LEAP program has three components: 1) engaging site management and care staff in the program; 2) employing a LEAP champion one day a week to support program activities; 3) delivering an evidence-based training program to care staff. Specifically, case managers will be trained and supported to set meaningful social or recreational goals with clients and incorporate these into care plans. Care workers will be trained in and encouraged to practise good communication, promote client independence and choice, and tailor meaningful activities using Montessori principles, reminiscence, music, physical activity and play. LEAP Champions will be given information about theories of organisational change and trained in interpersonal skills required for their role. LEAP will be evaluated in five home care sites including two that service ethnic minority groups. A quasi experimental design will be used with evaluation data collected four times: 6-months prior to program commencement; at the start of the program; and then after 6 and 12 months. Mixed effect models will enable comparison of change in outcomes for the periods before and during the program. The primary outcome measure is client engagement. Secondary outcomes for clients are satisfaction with care, dysphoria/depression, loneliness, apathy and agitation; and work satisfaction for care workers. A process evaluation will also be undertaken.

DISCUSSION

LEAP for Life may prove a cost-effective way to improve client engagement and other outcomes in the community setting.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry ACTRN12612001064897.

A Critical Review of the Use of Telephone Tests to Identify Cognitive Impairment in Epidemiology and Clinical Research

We reviewed the use of telephone tests to identify cognitive impairment. We searched PubMed for epidemiological studies and clinical trials reporting the use of telephone tests to identify cognitive impairment. Validation studies and papers published more than 10 years ago were excluded. A total of 132 abstracts were identified, from which 19 epidemiological studies and four clinical trials were selected. Telephone tests were found to reduce selection bias in epidemiology by including people over large areas and facilitating follow-up in longitudinal studies. The most widely used tests were the Telephone Interview for Cognitive Status (TICS) and its modified version, the TICSm. Interviewing a proxy was included in most of the studies to compensate for the unavailability of some participants because of deafness, disease or death. In the epidemiological studies, results of telephone tests were seldom confirmed by a medical examination. Telephone screening for cognitive impairment to identify individuals eligible for clinical trials is impeded by low efficiency and lack of sensitivity for separating early pathological cognitive impairment from dementia and normal ageing.

The needs of people with dementia living at home from user, caregiver and professional perspectives: a cross-sectional survey

Background

Few reports have been published about differences in perspectives on perceived needs among community-residing people with dementia, their family caregivers, and professionals. The aim of this study was to compare these perspectives.

Method

During 2006 and 2007, one-hundred and fifty two interviews of people with dementia and their caregivers about the needs of the person with dementia were performed by four professionals using The Camberwell Assessment of Need for the Elderly (CANE). Professionals’ views on met and unmet needs of people with dementia were obtained for the total sample, family caregivers’ perspectives were gained for 125 people with dementia, and people with dementia’s views on their own needs were obtained for 125 persons with dementia.

Results

People with dementia reported fewer needs compared with the reports of their caregivers and the professionals. The most frequent unmet needs reported by people with dementia, caregivers and professionals were in the areas of daytime activities, company, and psychological distress; however, people with dementia rated psychological distress as the commonest unmet need.

Conclusions

Since the priorities of people with dementia can be different from those of caregivers and professionals, it is important to consider all perspectives when making care plans. Thus, compliance with treatment of people with dementia and also their quality of life could be potentially improved by a more collaborative partnership with them.

"It's like we're grasping at anything": caregivers' education needs and preferred learning methods

In this qualitative descriptive study, we explored caregivers' educational needs and preferred methods of information delivery. Descriptions are based on five focus groups (N = 29) conducted with ethnically diverse, current and past family caregivers, including those who had previously attended a structured educational program. Themes arose from verbatim data transcriptions and coded themes. Four categories of educational needs were identified: (a) respite, (b) caregiving essentials, (c) self-care, and (d) the emotional aspects of caregiving. Advantages and disadvantages of learning methods are discussed, along with reasons for and outcomes of attending caregiver workshops. An informed caregiver model is proposed. Health care providers must assess educational needs and strive to provide appropriate information as dictated by the care recipient's condition and caregiver's expressed desires. Innovative methods of delivering information that are congruent with different caregiving circumstances and learning preferences must be developed and tested.

The Cornell-Brown scale for quality of life in dementia: Spanish adaptation and validation

The objective of this study was to validate a Spanish version of the Cornell-Brown Scale (CBS) for quality of life (QoL) in dementia. One hundred persons with mild-to-moderate dementia (Diagnostic and Statistical Manual of the American Psychiatric Association, 4th edition) were recruited and interviewed at 5 Spanish centers to obtain sociodemographic information, health perceptions, depressive symptoms (Geriatric Depression Scale 15-item version), functional ability (Barthel Index), dementia severity (Mini-Mental State Examination), specific QoL (CBS), and generic QoL (World Health Organization Quality of Life-BREF version). Analysis was carried out using classical psychometric methods. Internal consistency reliability for the CBS was good (0.87). A priori hypotheses about the relationship between CBS and the World Health Organization Quality of Life-BREF version psychological domain and Geriatric Depression Scale 15-item version were confirmed, indicating good construct validity. Regarding contrasting groups' differences, CBS scores significantly differentiated between healthy and unhealthy and depressed and nondepressed participants but not between those with mild and moderate dementia. The exploratory factor analysis showed a 5-factor solution, which accounted for 63.9% of the total variance of CBS. This study is the first to report the factor structure of the CBS. These results indicate that CBS is a useful tool in assessing persons with dementia. Replication of these results with larger samples is advised. The Spanish version of the CBS is reliable and valid in persons with mild/moderate dementia who are living at home and with a known caregiver.