Guidelines for psychosocial interventions in dementia care: a European survey and comparison

Experiences of cognitive stimulation therapy (CST) in Brazil: a qualitative study of people with dementia and their caregivers

OBJECTIVES

There is a lack of investment in psychosocial treatments for people with dementia in Brazil. Cognitive Stimulation Therapy (CST) is a group-based intervention that has shown to have benefits on activities of daily living and mood for people with dementia in Brazil. This study aims to explore the experiences and perceived changes following CST groups.

METHODS

Individual interviews were conducted with the participants of the group (n = 12) and their caregivers (n = 11). Framework analysis was used to inspect the data.

RESULTS

Two main themes have emerged: 'Personal benefits of being part of the group', containing two subthemes: 'Benefits for caregivers' and 'Benefits for person with dementia' and 'Day-to-day changes', containing seven subthemes; 'Memory', Sociability', 'Language', 'Mood', 'Orientation', 'Everyday activities' and 'Behavioural and psychological symptoms'.

CONCLUSION

Results suggest that CST groups led to perceived personal benefits for the people with dementia and caregivers and that there are perceived changes for the participants of the groups.

Psychosocial interventions for reducing antipsychotic medication in care home residents

BACKGROUND

Antipsychotic medications are regularly prescribed in care home residents for the management of behavioural and psychological symptoms of dementia (BPSD) despite questionable efficacy, important adverse effects, and available non-pharmacological interventions. Prescription rates are related to organisational factors, staff training and job satisfaction, patient characteristics, and specific interventions. Psychosocial intervention programmes aimed at reducing the prescription of antipsychotic drugs are available. These programmes may target care home residents (e.g. improving communication and interpersonal relationships) or target staff (e.g. by providing skills for caring for people with BPSD). Therefore, this review aimed to assess the effectiveness of these interventions, updating our earlier review published in 2012.

OBJECTIVES

To evaluate the benefits and harms of psychosocial interventions to reduce antipsychotic medication use in care home residents compared to regular care, optimised regular care, or a different psychosocial intervention.

SEARCH METHODS

We used standard, extensive Cochrane search methods. The latest search date was 14 July 2022.

SELECTION CRITERIA

We included individual or cluster-randomised controlled trials comparing a psychosocial intervention aimed primarily at reducing the use of antipsychotic medication with regular care, optimised regular care, or a different psychosocial intervention. Psychosocial interventions were defined as non-pharmacological intervention with psychosocial components. We excluded medication withdrawal or substitution interventions, interventions without direct interpersonal contact and communication, and interventions solely addressing policy changes or structural interventions.

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methods. Critical appraisal of studies addressed risks of selection, performance, attrition and detection bias, as well as criteria related to cluster randomisation. We retrieved data on the complex interventions on the basis of the TIDieR (Template for Intervention Description and Replication) checklist. Our primary outcomes were 1. use of regularly prescribed antipsychotic medication and 2.

ADVERSE EVENTS

Our secondary outcomes were 3. mortality; 4. BPSD; 5. quality of life; 6. prescribing of regularly psychotropic medication; 7. regimen of regularly prescribed antipsychotic medication; 8. antipsychotic medication administered 'as needed'; 9. physical restraints; 10. cognitive status; 11. depression; 12. activities of daily living; and 13.

COSTS

We used GRADE to assess certainty of evidence.

MAIN RESULTS

We included five cluster-randomised controlled studies (120 clusters, 8342 participants). We found pronounced clinical heterogeneity and therefore decided to present study results narratively. All studies investigated complex interventions comprising, among other components, educational approaches. Because of the heterogeneity of the results, including the direction of effects, we are uncertain about the effects of psychosocial interventions on the prescription of antipsychotic medication. One study investigating an educational intervention for care home staff assessed the use of antipsychotic medication in days of use per 100 resident-days, and found this to be lower in the intervention group (mean difference 6.30 days, 95% confidence interval (CI) 6.05 to 6.66; 1152 participants). The other four studies reported the proportion of participants with a regular antipsychotic prescription. Of two studies implementing an intervention to promote person-centred care, one found a difference in favour of the intervention group (between-group difference 19.1%, 95% CI 0.5% to 37.7%; 338 participants), while the other found a difference in favour of the control group (between-group difference 11.4%, 95% CI 0.9% to 21.9%; 862 participants). One study investigating an educational programme described as "academic detailing" found no difference between groups (odds ratio 1.06, 95% CI 0.93 to 1.20; 5363 participants). The fifth study used a factorial design to compare different combinations of interventions to supplement person-centred care. Results showed a positive effect of medication review, and no clear effect of social interaction or exercise. We considered that, overall, the evidence about this outcome was of low certainty. We found high-certainty evidence that psychosocial interventions intended primarily to reduce antipsychotic use resulted in little to no difference in the number of falls, non-elective hospitalisations, or unplanned emergency department visits. Psychosocial interventions intended primarily to reduce antipsychotic use also resulted in little to no difference in quality of life (moderate-certainty evidence), and BPSD, regular prescribing of psychotropic medication, use of physical restraints, depression, or activities of daily living (all low-certainty evidence). We also found low-certainty evidence that, in the context of these interventions, social interaction and medication review may reduce mortality, but exercise does not.

AUTHORS' CONCLUSIONS

All included interventions were complex and the components of the interventions differed considerably between studies. Interventions and intervention components were mostly not described in sufficient detail. Two studies found evidence that the complex psychosocial interventions may reduce antipsychotic medication use. In addition, one study showed that medication review might have some impact on antipsychotic prescribing rates. There were no important adverse events. Overall, the available evidence does not allow for clear generalisable recommendations.

Non-pharmacological, psychosocial MAKS-s intervention for people with severe dementia in nursing homes: results of a cluster-randomised trial

BACKGROUND

Severe dementia is one of the most challenging conditions when caring for people in nursing homes. A manualised non-pharmacological, psychosocial group intervention especially adapted to the needs of people with severe dementia (PWSDs) is currently still lacking. To close this gap, we adapted the evidence-based multicomponent non-pharmacological MAKS intervention (Motor stimulation, ADL stimulation, Cognitive [german: Kognitive] stimulation, and Social functioning in a group setting) to the special needs of PWSDs called the MAKS-s intervention, where the s stands for severe dementia.

METHODS

In a prospective, multicentre, cluster-randomised trial with a waitlist control group design, 26 nursing homes comprising 152 PWSDs were randomly assigned to either the MAKS-s intervention group (IG) or control group (CG) - 121 PWSDs were still alive after the 6-month intervention period (t6) and included in the intention-to-treat (ITT) sample. The two primary outcomes, behavioural and psychological symptoms (BPSDs, measured with NPI-NH) and quality of life (QoL, measured with QUALIDEM), and the secondary outcome, activities of daily living (ADLs, measured with ADCS-ADL-sev), were assessed at baseline (t0) and at t6. Mixed ANOVAs were computed to investigate possible effects of the MAKS-s intervention on the outcomes.

RESULTS

In the ITT sample, BPSDs and QoL did not change significantly over time, and group assignment did not affect them, although the IG participants had significantly better overall QoL than the CG participants. ADLs decreased significantly over time, but group assignment did not affect them. Analyses in the per protocol (PP) sample showed comparable results, with the exception that the IG participants showed a significantly greater increase in BPSDs than the CG participants did.

DISCUSSION

Under the situational conditions of the Covid-19 pandemic, no beneficial effects of the MAKS-s intervention on BPSDs, QoL, or ADLs were observed. This finding also means that under 'normal circumstances' (i.e., if there had been no pandemic), we could not make any statements about the effect or non-effect of MAKS-s. In order to be able to address the hypotheses formulated here, the study will have to be repeated incorporating helpful experiences of the present study.

TRIAL REGISTRATION

https://doi.org/10.1186/ISRCTN15722923 (Registered prospectively, 07. August 2019).

Dyadic interventions in older people with chronic diseases: An integrative review

This integrative review aims to explore the current state of dyadic interventions in older people with chronic diseases and to review how these interventions are developed and conducted. 'Older people' and 'dyadic intervention' were searched in six databases to include studies published before August 2021. The constant comparison method was used for data synthesis, combined with the Joanna Briggs Institute (JBI)¹ and mixed methods appraisal tool (MMAT)² to assess the quality of the literature. Nineteen studies were included and could be divided into four types in which caregivers could be seen as subordinators, directors, cooperators and collaborators. Dyadic interaction could be observed in all studies, including dyad coled, patient-led, and caregiver-led interactions. The outcome indicators included patient-, caregiver-, dyad-, and family-related indicators. It is important not only to include the dyad but also to consider the dyadic interactions. In the future, dyadic intervention can be guided by matching dyadic theories. NO PATIENT OR PUBLIC CONTRIBUTION: This study is an integrative review; the study population was not directly contacted. Data from included studies were analysed and interpreted.

Factors Affecting the Use of Speech Testing in Adult Audiology

OBJECTIVE

The aim of this study was to evaluate hearing health care professionals' (HHPs) speech testing practices in routine adult audiology services and better understand the facilitators and barriers to speech testing provision.

DESIGN

A cross-sectional questionnaire study was conducted.

STUDY SAMPLE

A sample (N = 306) of HHPs from the public (64%) and private (36%) sectors in the United Kingdom completed the survey.

RESULTS

In the United Kingdom, speech testing practice varied significantly between health sectors. Speech testing was carried out during the audiology assessment by 73.4% of private sector HHPs and 20.4% of those from the public sector. During the hearing aid intervention stage, speech testing was carried out by 56.5% and 26.5% of HHPs from the private and public sectors, respectively. Recognized benefits of speech testing included (a) providing patients with relatable assessment information, (b) guiding hearing aid fitting, and (c) supporting a diagnostic test battery. A lack of clinical time was a key barrier to uptake.

CONCLUSIONS

Use of speech testing varies in adult audiology. Results from this study found that the percentage of U.K. HHPs making use of speech tests was low compared to that of other countries. HHPs recognized different benefits of speech testing in audiology practice, but the barriers limiting uptake were often driven by factors derived from decision makers rather than clinical rationale. Privately funded HHPs used speech tests more frequently than those working in the public sector where time and resources are under greater pressure and governed by guidance that does not include a recommendation for speech testing. Therefore, the inclusion of speech testing in national clinical guidelines could increase the consistency of use and facilitate the comparison of practice trends across centers.

SUPPLEMENTAL MATERIAL

https://doi.org/10.23641/asha.20044457.

Randomized Controlled Trials of a Psychosocial Intervention for Improving the Cognitive Function among Older Adults: A Scoping Review

Aim: The goal is to explore available evidence and provide greater clarity to what is described as psychosocial intervention to improve cognitive function among older population with MCI as well as identifying areas for future research. Methods: An electronic literature search of PubMed, Cochrane, Ebscohost, Medline, Scopus, and gray resource was conducted to find articles published in English language between 2010 and September 2020. This review focused on research undertaken using randomized clinical trials study design. We extracted information regarding the publication date, geographical location, study setting, intervention mechanism, type of cognitive measurement used, and outcome of the studies. References of this literature were also reviewed to ensure comprehensive search. Result: Out of 240 potential records found, a total of 27 articles were identified following the first round of screening and deletion of duplicates. Full-text article reviews and analysis in the second round of screening narrowed the selection down to four articles. Another three relevant articles obtained from references were also included making a total of seven articles in the final analysis. Findings: Psychosocial intervention strategies for improvement of cognitive function, done in various setting all over the globe, covered a range of approaches including art therapy, visual art therapy, therapeutic writing therapy, reminiscence activity, and cognitive behavioral approach. Most were conducted in weekly basis within 1-to-2-hour duration of session. Cognitive function of older adult in psychosocial intervention group was significantly improved in two studies. Three studies showed no significant improvement at all in the cognitive function, and another one reported success in improving cognitive function over time in the intervention group than in control group. One study did not describe the interaction effect. Different types of cognitive measurement also were used to quantify different domains of cognitive function in the reviewed studies. Conclusion: The idea of using psychosocial intervention for improving cognitive function has begun to increasingly accepted recently. Findings from the limited studies are encouraging, although the outcome of the cognitive function was mixed. Large-scale and longer duration of psychosocial intervention with bigger sample size is warranted for future studies.

Psychosocial care in dementia in European higher education: Evidence from the SiDECar ("Skills in DEmentia Care") project

In dementia care, psychosocial interventions can increase people's quality of life with dementia and their caregivers. Despite their effectiveness, their translation into practice lacks the desirable systematicity. Systematic educational programs on psychosocial interventions in dementia will improve this translation, as it prepares professionals to face the complexity of dementia care. This study aimed to systematically map out the extent to which higher education programs in Europe include teaching activities about psychosocial care of dementia. We collected quantitative and qualitative data about 303 higher education teaching activities on psychosocial care in dementia across Europe. The analysis revealed that the number of teaching activities focusing on psychosocial care in dementia was relative. Although the results reflected UNESCO indications, the teaching activities on psychosocial care in dementia appeared less systematized than optimal. As world health agencies recommend, international higher education systems should consider more psychosocial care topics because they can prepare professionals to respond timely and effectively to dementia patients and caregivers' needs.

Using data linkage for national surveillance of clinical quality indicators for dementia care among Australian aged care users

Care quality has important implications for people with dementia. We examined trends and geographical variation of four clinical quality indicators (CQIs) in Australia. This retrospective cohort study included all people with dementia using Australian government-subsidised aged care in 2008-2016 (n = 373,695). Quality indicator data were derived from linked national aged care, health, and pharmaceutical datasets. Negative binomial regression modelling assessed trends in CQI performance over time (2011-2016) and funnel plots examined geographical variation in performance. The incidence rate of antipsychotic medicine dispensing decreased slightly from 1.17/1000 person-days to 1.07/1000 person-days (adjusted incidence rate ratio (aIRR) = 0.98, 95%CI 0.98-0.99). Cholinesterase inhibitors and memantine dispensing did not change (aIRR = 1.02, 95%CI 1.00-1.04), while exposure to high sedative load increased slightly from 1.39/1000 person-days to 1.44/1000 person-days (aIRR = 1.01, 95%CI 1.00-1.01). Dementia and delirium-related hospitalisations increased slightly from 0.17/1000 person-days to 0.18/1000 person-days (aIRR = 1.02, 95%CI 1.01-1.03). There was marked variation in cholinesterase inhibitor and memantine dispensing by geographical area (0-41%). There has been little change in four indicators of dementia care quality in Australian aged care users over time. Cholinesterase inhibitor and memantine dispensing varied substantially by geographical region. Existing strategies to improve national performance on these indicators appear to be insufficient, despite the significant impact of these indicators on outcomes for people with dementia.

An analysis of carer burden among family carers of people with and without dementia in Ireland

OBJECTIVE

Despite the policy relevance of carer burden, limited research focuses on family carers' experience of carer burden among different disease groups. This study aimed to examine differences in carer burden among family carers of people with and without dementia.

DESIGN

Secondary data analysis was conducted on a national cross-sectional dataset. Multivariable ordered logistic regression was used to analyze four levels of carer burden (low, mild, moderate, high). The main independent variable was dementia diagnosis, and controls included variables relating to the care recipient, family carer, and context of care.

SETTING

The original survey was funded by Irish Health Service Executive and undertaken by the National Centre for the Protection of Older People in Ireland.

PARTICIPANTS

The original dataset consisted of 2,311 family carers of older people in Ireland. Approximately, one-fifth of this sample had a diagnosis of dementia.

MEASUREMENTS

Carer burden was measured using the standardized 22-item Zarit Burden Interview. Care-recipient dependency was measured using the Activities for Daily Living Scale. Sociodemographic details and information about the context of caring were collected using self-report scales.

RESULTS

In our model, dementia diagnosis and dependency level were significantly associated with carer burden. Family carer and context of care variables including gender, marital status, education, residence, co-residence, and perceived support showed significant relationships with carer burden. Our results highlighted significant differences in carer burden distribution; in particular, family carers of people with dementia were less likely to report low or mild carer burden (-6.95 ppts and -3.64 ppts, respectively) and more likely to report moderate or high carer burden (8.46 ppts and 2.13 ppts, respectively).

CONCLUSION

Our findings suggest that family carers of people with dementia may experience additional challenges associated with caring. Therefore, family carers of people with dementia may require tailored social supports to maintain good health and well-being.

The Integration of Psychosocial Care into National Dementia Strategies across Europe: Evidence from the Skills in DEmentia Care (SiDECar) Project

There is evidence supporting the use of psychosocial interventions in dementia care. Due to the role of policy in clinical practice, the present study investigates whether and how the issue of psychosocial care and interventions has been addressed in the national dementia plans and strategies across Europe. A total of 26 national documents were found. They were analyzed by content analysis to identify the main pillars associated with the topic of psychosocial care and interventions. Specifically, three categories emerged: (1) Treatment, (2) Education, and (3) Research. The first one was further divided into three subcategories: (1) Person-centred conceptual framework, (2) Psychosocial interventions, and (3) Health and social services networks. Overall, the topic of psychosocial care and interventions has been addressed in all the country policies. However, the amount of information provided differs across the documents, with only the category of 'Treatment' covering all of them. Furthermore, on the basis of the existing policies, how the provision of psychosocial care and interventions would be enabled, and how it would be assessed are not fully apparent yet. Findings highlight the importance of policies based on a comprehensive and well-integrated system of care, where the issue of psychosocial care and interventions is fully embedded.

The MAKS-s study: multicomponent non-pharmacological intervention for people with severe dementia in inpatient care - study protocol of a randomised controlled trial

BACKGROUND

Nursing homes accommodate a large number of people with severe dementia. More than 80% of residents with dementia suffer from behavioural and psychological symptoms, that can have consequences on the perceived burden of the formal caregivers. Internationally, the number of studies on non-pharmacological interventions for people with severe dementia is very small. One way to reduce these symptoms is to meet the needs of people with severe dementia. The non-pharmacological group intervention MAKS-s, which we will investigate in this study, is intended to reduce the behavioural and psychological symptoms and to improve the quality of life of such people. Additionally, we will investigate the effects on the burden carried by formal caregivers.

METHODS

With the present study, we will investigate the effectiveness of a multicomponent non-pharmacological intervention for people with severe dementia living in nursing homes (primary target group). A power analysis indicated that 144 dementia participants should initially be included. In addition, a secondary target group (nursing home staff) will be examined with respect to their dementia-related stress experiences. The study will be conducted as a cluster randomised controlled trail in Germany with a 6-month intervention phase. The nursing homes in the waitlist control group will provide "care as usual." The primary endpoints of the study will be the behavioural and psychological symptoms of dementia and the quality of life of people with severe dementia. The total duration of the study will be 18 months. Data will be collected by using observer rating scales.

DISCUSSION

The project has some outstanding quality features. The external validity is high, because it is situated in a naturalistic setting in nursing homes and is being carried out with available nursing employees. Due to this fact, a permanent implementation also seems to be possible. Since the participating nursing homes are disseminated across several German federal states and rural and urban regions, the results should be transferable to the entire population.

TRIAL REGISTRATION

ISRCTN15722923 (Registration date: 07 August 2019).

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.

<p>A Scoping Review and Template Analysis of Manual-Based Complex Interventions in Dementia Care</p>

Purpose

In dementia care, the complexity of psychosocial needs and contextual variables often demands nonpharmacological interventions of a complex nature. The purpose of this scoping review was to investigate (1) how manuals published in refereed journals explaining procedures of complex interventions in dementia care are structured and their content disseminated and (2) to provide recommendations for future manuals.

Methods

A systematic search was conducted using four databases (Embase, PsychInfo, CINAHL and Scopus) following PRISMA-ScR and PICo method. The results were analysed using template analysis aiming to describe the possibility of tailoring the intervention, degree of flexibility of the manual and dissemination elements used in the manual.

Results

A total of 882 records were identified, and 86 full-text articles were assessed. Nine articles containing manuals met the inclusion criteria. All of the included manuals allowed the user to tailor actions in the intervention to specific situations. Two-thirds of the manuals showed a medium degree of flexibility. The types of dissemination elements varied. All used written text, and some used various graphical organisers such as headlines and lists. None used illustrations or audio/video material.

Conclusion

Currently, only few manuals for complex interventions in the field of dementia are published in refereed journals, all disseminated as written text. For future manuals, we suggest considering the inclusion of illustrations and/or audio/video material to describe actions, to allow for tailoring of the intervention, and to maintain a medium or low degree of flexibility by structuring the content hierarchically in phases while providing the user with detailed description of what to do, and how to decide what to.

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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.

Effectiveness of multisensory stimulation in managing neuropsychiatric symptoms in older adults with major neurocognitive disorder: a systematic review

OBJECTIVE

The objective of the review was to synthesize the effectiveness of multisensory stimulation in managing neuropsychiatric symptoms (NPS) in older adults with major neurocognitive disorder (NCD).

INTRODUCTION

Major neurocognitive disorder is characterized by changes in specific cognitive domains with a progressive deterioration in cognitive ability and capacity for independent living. Most older adults with this condition have one or more concomitant symptoms known as NPS. Evidence shows that nonpharmacological therapies have been effective in controlling these symptoms, with multisensory stimulation attracting further investigation.

INCLUSION CRITERIA

The review considered studies on older adults aged 65 years or over with major NCD. The intervention of interest was multisensory stimulation, and the comparator was usual care (e.g. no occupational therapy, no cognitive training, and no art therapy, but with possible control of activities such as looking at photographs or doing quizzes), or another intervention (e.g. occupational therapy, cognitive training and art therapy). Primary outcomes were NPS (agitation, aggression, motor disturbances, mood liability, anxiety, apathy, night-time behaviour, eating disorders, delusion and hallucination). Secondary outcomes were quality of life, functional status in activities of daily living, cognitive status and caregiver burden. Experimental study designs were considered.

METHODS

A broad range of keywords and a three-step search strategy were used to identify potentially eligible published and unpublished studies from January 1990 to June 2016 in major healthcare-related online databases. Studies in English, Spanish and Portuguese were included. Two independent reviewers assessed the methodological quality of eight included studies using the Joanna Briggs Institute (JBI) Critical Appraisal Checklists for Randomized Controlled Trials and Quasi-Experimental Studies. Data were extracted using the standardized data extraction tool from the JBI System for the Unified Management, Assessment and Review of Information (JBI SUMARI) and included details about the interventions, populations, study methods and outcomes of interest. Significant differences were found between participants, interventions, outcome measures (clinical heterogeneity), and designs (methodological heterogeneity). For these reasons, a meta-analysis could not be performed. Therefore, the results have been described in a narrative format.

RESULTS

Eight studies (seven randomized controlled trials and one quasi-experimental study) were included, with a total sample of 238 participants (pre-intervention). Four studies confirmed the effectiveness of multisensory stimulation in domains such as physically nonaggressive behavior, verbally agitated behavior and agitation. However, these effects did not always persist in the long-term. Six studies showed poorly consistent results on the effects of multisensory stimulation in improving mood, with only one displaying significant effects. Similarly, despite poor results, two studies showed benefits concerning anxiety. Participants reported significantly decreased levels of anxiety over the course of the intervention, and this improvement persisted in the long-term. In regard to functional status in activities of daily living, two studies reported an improvement in the short-term. Moreover, the effectiveness in cognitive domains such as memory and attention to surroundings also showed inconsistent results across the seven studies that analyzed this outcome. Two studies reflected an improvement during the intervention, but also reported a gradual decline in the long-term. Only one study observed significantly better results during the intervention that persisted until the follow-up assessment. Apathy, night-time behavior, eating disorders, delusion and hallucination were NPS that were not explored in the studies that met the criteria to be included in this review.

CONCLUSIONS

These findings suggest that multisensory stimulation could be an effective intervention for managing NPS in older adults with major NCD in a mild to severe stage, particularly for managing behavioral symptoms such as agitation. This research provides an indication of the likely effect of the multisensory stimulation on NPS such as agitation and anxiety, as well on cognitive status.

Dementia care in high-income countries

PURPOSE OF REVIEW

To identify recent advances in the field of dementia care in high-income countries.

RECENT FINDINGS

New national and international initiatives identified support the notion of an increased commitment to face the challenge of dementia care. Recent research has documented barriers and facilitators to provide good care, and provided data on the specific needs of caregivers; the needs for better training of general practitioners; the negative influence of behavioural and psychological symptoms of dementia (BPSD); the palliative care needs; and the increased risk of dementia associated with anxiety (the population-attributable fraction of Alzheimer's risk was 6.1%). Significant advances in new technologies applicable in the care of dementia have also been reported.

SUMMARY

The increased awareness of the needs in dementia care is promising, although the Organisation for Economic Co-operation and Development has alerted about the limited implementation of the programmes. Barriers and facilitators identified have implications for both clinical practice and research. Particular implications for psychiatric action have the findings on BPSDs and on the preventive potential of the treatment of anxiety detected in the community. The data on palliative care needs and particularly on the advances of new technologies also have clinical implications.

Clinical practice guidelines on ultrasound-guided fine needle aspiration biopsy of thyroid nodules: a critical appraisal using AGREE II

PURPOSE

To appraise the quality of current guidelines on fine needle aspiration biopsy (FNAB) of thyroid nodules for adults using the AGREE II quality assessment tool.

METHODS

We conducted an online search for guidelines on FNAB of thyroid nodules published between 2013 and October 2018. They were evaluated by four independent reviewers previously trained to apply the AGREE II instrument, which is organized into items and domains. A fifth independent reviewer calculated scores for each domain and guideline as well as inter-appraiser agreement.

RESULTS

Six sets of guidelines were included, respectively, provided by the American Thyroid Association (ATA), the American Association of Clinical Endocrinologists/American College of Endocrinology/Associazione Medici Endocrinologi (AACE/ACE/AME), the Korean Society of Thyroid Radiology (KSThR), the European Thyroid Association (ETA), the American College of Radiology (ACR) and the Korean Society of Radiology and National Evidence-Based Healthcare Collaborating Agency (KSR/NECA). Five out of the six guidelines (ATA, AACE/ACE/AME, ETA, ACR and KSR/NECA) reached a high level of overall quality, having at least five domain scores >60%. An average level of overall quality was achieved in one case (KSThR recommendations). Inter-appraiser agreement ranged from moderate to excellent.

CONCLUSIONS

Overall, the quality of guidelines on FNAB of thyroid nodules is satisfactory when evaluated using the AGREE II instrument.

Translation and Linguistic Validation of the German Challenging Behavior Scale for Formal Caregivers of People With Dementia in Nursing Homes

Background and Purpose: The Challenging Behavior Scale (CBS) measures the behavior of individuals with dementia. The study aims to translate the English CBS into German (CBS-G) and test its linguistic validity. Methods: The two-panel approach was used to translate the CBS. Nursing home staff reviewed the unambiguity and familiarity of the CBS-G items and the adequateness of the examples used to describe the items. Content validity indexes (CVI) and modified kappa (k) coefficients were calculated. Results: Most of the CBS-G items had excellent CVI and k values for both unambiguity and familiarity. All examples were viewed as adequate. Conclusion: A German version of the CBS that is linguistically equivalent to the original CBS is available but needs further testing of its psychometric properties.

Personally tailored activities for improving psychosocial outcomes for people with dementia in long-term care

BACKGROUND

People with dementia who are being cared for in long-term care settings are often not engaged in meaningful activities. Offering them activities which are tailored to their individual interests and preferences might improve their 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 long-term care facilities.∙ 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 16 June 2017 using the terms: personally tailored OR individualized OR individualised OR individual OR person-centred OR meaningful OR personhood OR involvement OR engagement OR engaging OR identity. We also performed additional searches in MEDLINE (Ovid SP), Embase (Ovid SP), PsycINFO (Ovid SP), CINAHL (EBSCOhost), Web of Science (ISI Web of Science), ClinicalTrials.gov, and the World Health Organization (WHO) ICTRP, to ensure that the search for the review was as up to date and as comprehensive as possible.

SELECTION CRITERIA

We included randomised controlled trials and controlled clinical trials offering personally tailored activities. All interventions included an assessment of the participants' present or past preferences for, or interests in, particular activities as a basis for an individual activity plan. Control groups received either usual care or an active control intervention.

DATA COLLECTION AND ANALYSIS

Two authors independently checked the articles for inclusion, extracted data and assessed the methodological quality of included studies. For all 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 eight studies with 957 participants. The mean age of participants in the studies ranged from 78 to 88 years and in seven studies the mean MMSE score was 12 or lower. Seven studies were randomised controlled trials (three individually randomised, parallel group studies, one individually randomised cross-over study and three cluster-randomised trials) and one study was a non-randomised clinical trial. Five studies included a control group receiving usual care, two studies an active control intervention (activities which were not personally tailored) and one study included both an active control and usual care. Personally tailored activities were mainly delivered directly to the participants; in one study the nursing staff were trained to deliver the activities. The selection of activities was based on different theoretical models but the activities did not vary substantially.We found low-quality evidence indicating that personally tailored activities may slightly improve challenging behaviour (standardised mean difference (SMD) -0.21, 95% confidence interval (CI) -0.49 to 0.08; I² = 50%; 6 studies; 439 participants). We also found low-quality evidence from one study that was not included in the meta-analysis, indicating that personally tailored activities may make little or no difference to general restlessness, aggression, uncooperative behaviour, very negative and negative verbal behaviour (180 participants). There was very little evidence related to our other primary outcome of quality of life, which was assessed in only one study. From this study, we found that quality of life rated by proxies was slightly worse in the group receiving personally tailored activities (moderate-quality evidence, mean difference (MD) -1.93, 95% CI -3.63 to -0.23; 139 participants). Self-rated quality of life was only available for a small number of participants, and there was little or no difference between personally tailored activities and usual care on this outcome (low-quality evidence, MD 0.26, 95% CI -3.04 to 3.56; 42 participants). We found low-quality evidence that personally tailored activities may make little or no difference to negative affect (SMD -0.02, 95% CI -0.19 to 0.14; I² = 0%; 6 studies; 589 participants). We found very low quality evidence and are therefore very uncertain whether personally tailored activities have any effect on positive affect (SMD 0.88, 95% CI 0.43 to 1.32; I² = 80%; 6 studies; 498 participants); or mood (SMD -0.02, 95% CI -0.27 to 0.23; I² = 0%; 3 studies; 247 participants). We were not able to undertake a meta-analysis for engagement and the sleep-related outcomes. We found very low quality evidence and are therefore very uncertain whether personally tailored activities improve engagement or sleep-related outcomes (176 and 139 participants, respectively). Two studies that investigated the duration of the effects of personally tailored activities indicated that the intervention effects persisted only during the delivery of the activities. Two studies reported information about adverse effects and no adverse effects were observed.

AUTHORS' CONCLUSIONS

Offering personally tailored activities to people with dementia in long-term care may slightly improve challenging behaviour. Evidence from one study suggested that it was probably associated with a slight reduction in the quality of life rated by proxies, but may have little or no effect on self-rated quality of life. We acknowledge concerns about the validity of proxy ratings of quality of life in severe dementia. Personally tailored activities may have little or no effect on negative affect and we are uncertain whether they improve positive affect or mood. There was no evidence that interventions were more likely to be effective if based on one specific theoretical model rather than another. Our findings leave us unable to make recommendations about specific activities or the frequency and duration of delivery. Further research should focus on methods for selecting appropriate and meaningful activities for people in different stages of dementia.

A critical appraisal of the quality of adult musculoskeletal ultrasound guidelines using the AGREE II tool: an EuroAIM initiative

OBJECTIVES

Our aim was to evaluate the quality of published guidelines on musculoskeletal ultrasound (MSK-US) for adults.

METHODS

Between June and July 2016, we conducted an online search for MSK-US guidelines, which were evaluated by four independent readers blinded to each other using the AGREE II tool. A fifth independent reviewer calculated scores per each domain and agreement between reviewers' scores using the intraclass correlation coefficient (ICC).

RESULTS

Five guidelines were included in this appraisal. They were published between 2001 and 2014. Our appraisal showed intermediate results, with four out of five guidelines scoring "average" as overall quality. Domain 1 (scope and purpose) achieved the highest result (total score = 71.1% ± 18.7%). Domain 6 (editorial independence) had the lowest score (total score = 26.3% ± 19.3%). Interobserver agreement was very good for all the evaluated guidelines (ICC ranged between 0.932 and 0.956).

CONCLUSIONS

Overall, quality of MSK-US guidelines ranges from low to average when evaluated using the AGREE II tool. The editorial independence domain was the most critical, thus deserving more attention when developing future guidelines.

MAIN MESSAGES

• Four of five guidelines on MSK-US had an average quality level. • Scope/purpose had the highest score (71.1% ± 18.7%). • Editorial independence had the lowest score (26.3% ± 19.3%). • Interobserver agreement was very good (ranges: 0.932-0.956).

A critical appraisal of the quality of adult dual-energy X-ray absorptiometry guidelines in osteoporosis using the AGREE II tool: An EuroAIM initiative

Objectives

Dual energy X-ray absorptiometry (DXA) is the most widely used technique to measure bone mineral density (BMD). Appropriate and accurate use of DXA is of great importance, and several guidelines have been developed in the last years. Our aim was to evaluate the quality of published guidelines on DXA for adults.

Methods

Between June and July 2016 we conducted an online search for DXA guidelines, which were evaluated by four independent readers blinded to each other using the AGREE II instrument. A fifth independent reviewer calculated scores per each domain and agreement between reviewers’ scores.

Results

Four out of 59 guidelines met inclusion criteria and were included. They were published between 2005 and 2014. Three out of four guidelines reached a high level of quality, having at least five domain scores higher than 60%. Domain 1 (Scope and Purpose) achieved the highest result (total score = 86.8 ± 3.7%). Domain 6 (Editorial Independence) had the lowest score (total score = 54.7 ± 12.5%). Interobserver agreement ranged from fair (0.230) to good (0.702).

Conclusions

Overall, the quality of DXA guidelines is satisfactory when evaluated using the AGREE II instrument. The Editorial Independence domain was the most critical, thus deserving more attention when developing future guidelines.

Main messages

• Three of four guidelines on DXA had a high quality level (>60%).

• Scope/purpose had the highest score (86.8 ± 3.7%).

• Editorial Independence had the lowest score (54.7 ± 12.5%).

• Interobserver agreement ranged from fair (0.230) to good (0.702).

Electronic supplementary material

The online version of this article (doi:10.1007/s13244-017-0553-6) contains supplementary material, which is available to authorized users.

An evaluation of the CARES® Dementia Basics Program among caregivers

BACKGROUND

In 2014, the state of Oregon established Oregon Care Partners to provide high quality, free training to all dementia caregivers. This study evaluated participants' changes in knowledge, sense of competency in dementia caregiving, and ability to identify person-centered caregiving techniques after completing CARES® Dementia Basics online program, one of the educational resources available through this initiative.

METHODS

A convenience sample of informal and formal caregivers (N = 51) provided data at three points in time; pre-test, post-test, and a follow-up test after an additional 30-day period to determine sustained changes in knowledge, sense of competency, and person-centered care.

RESULTS

From pre-test to post-test, modest improvements were detected in sense of competence in performing dementia care (ps < 0.01) and dementia-based knowledge, F(2, 150) = 7.71, p < 0.001, a multivariate effect size of w 2 = 0.09. Even though improvements in sense of competency were not universal, three out of five individual items demonstrated positive growth from pre-test to post-test as well as four out of the five items from pre-test to follow-up test. Importantly, gains observed in dementia-based knowledge from pre-test to post-test were largely maintained at the 30-day follow-up. No significant changes were found in the correct identification of person-centered techniques after the training F(5, 150) = 1.63, p = 0.19.

CONCLUSIONS

Future research should investigate how best to maintain educational interventions within the caregiving environment and to assess subsequent skill change.

Outcomes of a Two-Component Intervention on Behavioral Symptoms in Persons With Dementia and Symptom Response in Their Caregivers

Purpose: This study evaluated the longitudinal influence of an individualized evidence-based psychoeducational intervention for caregivers on frequency of behavioral symptoms in persons with dementia (PWD) and caregiver reaction to these symptoms. The intervention included information about the disease process using Progressively Lowered Stress Threshold (PLST) content and a family meeting based on Mittelman’s New York University Intervention. Method: A quasi-experimental study design was implemented. The Revised Memory and Behavior Problems Checklist was administered to N = 127 caregiver/care recipient dyads at baseline, 6, 12, and 18 months follow-up. All caregivers were enrolled in the intervention at baseline and followed over 18 months. Linear mixed models were developed to evaluate effects on frequency of behavioral symptoms in PWD and caregiver response. Results: The most frequently occurring behavior was memory problems, although depressive behaviors produced the most negative caregiver responses. Between baseline and 6-month follow-up, there was a significant decrease in frequency of behavioral symptoms. Overall, there was a significant decrease in caregiver’s reaction to behavioral symptoms from baseline to 18-month follow-up.

A telehealth behavioral coaching intervention for neurocognitive disorder family carers

OBJECTIVES

This study examined the differential impact of two telehealth programs for women caring for an older adult with a neurocognitive disorder. Outcomes examined were depressive symptoms, upset following disruptive behaviors, anxious and angry mood states, and caregiving self-efficacy.

METHODS

Women cohabitating with a family member diagnosed with a neurocognitive disorder were assigned via random allocation to either of the following: (1) a 14-week behavioral intervention using video instructional materials, workbook and telephone coaching in behavioral management, pleasant events scheduling, and relaxation or (2) a basic education guide and telephone support comparison condition. Telephone assessments were conducted by interviewers blind to treatment condition at pre-intervention, post-intervention, and 6 months following intervention.

RESULTS

For those providing in-home care at post-treatment, depressive symptoms, upset following disruptive behaviors, and negative mood states were statistically lower in the behavioral coaching condition than in the basic education and support condition. Reliable change index analyses for Beck Depression Inventory II scores favored the behavioral coaching condition. Caregiving self-efficacy scores for obtaining respite and for managing patient behavioral disturbances were significantly higher in the coaching condition. Effect sizes were moderate but not maintained at the 6-month follow-up.

CONCLUSIONS

This study provides some initial evidence for the efficacy of a telehealth behavioral coaching intervention compared with basic education and telephone support. Carers' abilities to maintain strategy use during progressive disorders such as Alzheimer's disease likely require longer intervention contact than provided in the current study. Dementia carers, including those living in rural areas, can benefit from accessible and empirically supported interventions that can be easily disseminated across distances at modest cost.

Quality assessment of osteoporosis clinical practice guidelines for physical activity and safe movement: an AGREE II appraisal

Many osteoporosis clinical practice guidelines are published, and the extent to which physical activity and safe movement is addressed varies. To better inform clinical decision-making, a quality assessment and structured analysis of recommendations was undertaken. Guideline quality varied substantially, and improvement is necessary in physical activity and safe movement recommendations.

PURPOSE

The purpose of the present study is to survey available osteoporosis clinical practice guidelines (CPGs) containing physical activity and safe movement recommendations in order to assess the methodological quality with which they were developed. An analysis of the various physical activity and safe movement recommendations was conducted to determine variability between CPGs.

METHODS

An online literature search revealed 19 CPGs meeting our inclusion criteria. Three independent scorers evaluated CPG quality using the Appraisal of Guidelines for Research and Evaluation version II (AGREE II) instrument. Two separate individuals used a standard table to extract relevant recommendations.

RESULTS

Intra-reviewer AGREE II score agreement ranged from fair to good (intra-class correlation coefficient (ICC) = 0.34 to 0.65). The quality of the 19 included CPGs was variable (AGREE sub-scores: 14 to 100%). CPGs scored higher in the "scope and purpose" and "clarity of presentation" domains. They scored the lowest in "applicability" and "editorial independence." Four CPGs were classified as high quality, ten average quality, and five low quality. Most CPGs recommended weight-bearing, muscle-strengthening, and resistance exercises. Information on exercise dosage, progression, and contraindications was often absent. Immobility and movements involving spinal flexion and/or torsion were discouraged.

CONCLUSIONS

There were several high-quality CPGs; however, variability in quality and lack of specific parameters for implementation necessitates caution and critical examination by readers. CPG development groups should pay special attention to the clinical applicability of their CPGs as well as fully disclosing conflicts of interest. CPGs were in general an agreement regarding safe physical activity and safe movement recommendations. However, recommendations were often vague and the more specific recommendations were inconsistent between CPGs.

European palliative care guidelines: how well do they meet the needs of people with impaired cognition?

OBJECTIVE

Numbers of people dying with cognitive impairment (intellectual disability (ID), dementia or delirium) are increasing. We aimed to examine a range of European national palliative care guidelines to determine if, and how well, pain detection and management for people dying with impaired cognition are covered.

METHODS

Questionnaires were sent to 14 country representatives of the European Pain and Impaired Cognition (PAIC) network who identified key national palliative care guidelines. Data was collected on guideline content: inclusion of advice on pain management, whether cognitively impaired populations were mentioned, assessment tools and management strategies recommended. Quality of guideline development was assessed with the Appraisal of Guidelines Research and Evaluation (AGREE) instrument.

RESULTS

11 countries identified palliative care guidelines, 10 of which mentioned pain management in general. Of these, seven mentioned cognitive impairment (3 dementia, 2 ID and 4 delirium). Half of guidelines recommended the use of pain tools for people with cognitive impairment; recommended tools were not all validated for the target populations. Guidelines from the UK, the Netherlands and Finland included most information on pain management and detection in impaired cognition. Guidelines from Iceland, Norway and Spain scored most highly on AGREE rating in terms of developmental quality.

CONCLUSIONS

European national palliative care guidelines may not meet the needs of the growing population of people dying with cognitive impairment. New guidelines should consider suggesting the use of observational pain tools for people with cognitive impairment. Better recognition of their needs in palliative care guidelines may drive improvements in care.

Assessing the application of non-pharmacological interventions for people with dementia in German nursing homes: feasibility and content validity of the dementia care questionnaire (DemCare-Q)

BACKGROUND

Non-pharmacological interventions are guideline-recommended as initial treatment for people with dementia in nursing homes. In Germany, there is no instrument available to collect standardized data on the application of all of these interventions; an investigation of their use in large-scale samples is not currently possible. This article describes the development and initial testing of a questionnaire (Dementia Care Questionnaire (DemCare-Q)) to assess provided non-pharmacological interventions in residents with dementia in nursing homes that can be completed by nurses.

METHODS

The questionnaire development comprised the following steps to achieve content validity and feasibility: a structured content analysis of the German guideline for the care of people with dementia and challenging behavior in nursing homes and a systematic literature review of projects that implemented these; quantitative expert ratings and calculation of content validity indices; qualitative pre-test with future users using cognitive techniques; quantitative pre-test using frequency analysis of item non-response.

RESULTS

The developed questionnaire covers seven dementia-specific non-pharmacological interventions in nursing homes. Problematic items could be improved by revising them successively, bringing forth a feasible and content valid version of the DemCare-Q. The DemCare-Q enables researchers to collect data on the application of dementia interventions in German nursing homes in large-scale studies.

CONCLUSION

A literature review, expert rating and multi-method pre-test are important steps of questionnaire development. The applied methods ensure content validity and the practicability of the instrument. The publication of this process enhances the transparency of questionnaire design and supports researchers in solving problems in developing questions to assess the application of interventions. Since these are initial steps of questionnaire development, further testing of its reliability is needed.

Longitudinal evaluation of dementia care in German nursing homes: the "DemenzMonitor" study protocol

BACKGROUND

In Germany, the number of people with dementia living in nursing homes is rapidly increasing. Providing adequate care for their special needs is a challenge for institutions and their staff members. Because of the growing number of people with dementia, changes to the conceptual orientation of nursing homes have occurred. These changes include specialized living arrangements and psychosocial interventions recommended for people with dementia. Until now, the provision of dementia care and its association to the residents' behavior and quality of life is not well investigated in Germany. The purpose of this study is to describe the provision of dementia care and to identify resident- as well as facility-related factors associated with residents behavior and quality of life.

METHODS/DESIGN

The DemenzMonitor study is designed as a longitudinal study that is repeated annually. Data will be derived from a convenience sample consisting of nursing homes across Germany. For the data collection, three questionnaires have been developed that measure information on the level of the nursing home, the living units, and the residents. Data collection will be performed by staff members from the nursing homes. The data collection procedure will be supervised by a study coordinator who is trained by the research team. Data analysis will be performed on each data level using appropriate techniques for descriptions and comparisons as well as longitudinal regression analysis.

DISCUSSION

The DemenzMonitor is the first study in Germany that assesses how dementia care is provided in nursing homes with respect to living arrangements and recommended interventions. This study links the acquired data with residents' outcome measurements, making it possible to evaluate different aspects and concepts of care.

Service-related needs of older people with dementia: perspectives of service users and their unpaid carers

BACKGROUND

Dementia is a major cause of disability among older people and constitutes one of the greatest challenges currently facing families and health and social care services in the developed world. In response to trends in dementia prevalence and the impact the condition has on peoples' lives, dementia care has been placed high on the public and political agenda in the United Kingdom. However, despite significant public resources being allocated to combat the impact of the disease, recent evidence indicates that numerous challenges in relation to service provision remain. This study aimed to develop a deeper understanding of the lived experience of people with dementia regarding their service-related needs.

METHOD

The study made use of data gathered through individual semi-structured, narrative interviews conducted with persons with experience of dementia and their unpaid carers.

RESULTS

Although participants were generally satisfied with the services they received, a number of unmet needs related to service provision were identified. In terms of diagnostic procedures the findings of this study indicate the need for early diagnosis delivered through a comprehensive assessment package. The participants also highlighted the need for well-coordinated post-diagnostic support, greater continuity of care concerning the personnel involved, and enhanced access to non-pharmacological interventions to support identity and social engagement.

CONCLUSION

This study contributes to a better understanding of service-related needs of people with dementia in relation to diagnostic procedures and post-diagnostic support.

Animal-Assisted Intervention in Dementia

There is a need to develop nonpharmacological treatments and methods which can serve as alternatives or complements to medications in dementia care. Previous research indicates that animal-assisted intervention (AAI) can be beneficial. The purpose of the present pilot project was to evaluate effects of AAI on quality of life (QoL) in people with dementia in four Swedish nursing homes. A pretest/posttest research design was used. Twenty people (12 women, 8 men; aged 58 to 88) were included. Nine people completed the intervention which comprised 10 training sessions with a certified therapy dog team. QoL improved in the expected direction after the intervention ( p = .035). Even though the effects of AAI may not be discernible over longer periods of time, there are still immediate effects which can promote better QoL for people living with dementia diseases.

Coverage of mental health and substance misuse topics in the Cochrane review system

Aims. To assess the breadth of mental and substance coverage in the Cochrane review system. Methods. All mental health and substance entries were identified from the 2005 to April 2012 Cochrane Database of Systematic Reviews. Results. A total of 1019 entries focused on mental health or substance misuse, with 698 (68.5%) being completed reviews. One out of every five entries focused on serious mental illness/psychosis. Systematic reviews addressing unipolar depression, dementia and certain substance disorders also appeared well-represented. In contrast, a number of impairing disorders frequently seen in practice received less attention, with bipolar disorder, obsessive compulsive disorder (OCD), post-traumatic stress disorder (PTSD) and autism spectrum disorders each accounting for less than 2% of the entries. The majority of interventions reviewed involved medication (57.1%), although this was not the case for a number of childhood-onset disorders. Some diagnostic areas (sleep, anxiety, mood and substance) were addressed by multiple Cochrane review groups (CRGs). Conclusions. The Cochrane Collaboration is well poised to be a strong guiding influence to those seeking to employ evidence-based mental health care. Broadening its diagnostic coverage and diversifying types of intervention reviewed would probably further maximize its impact. A more centralized and directed approach of prioritizing topics could help ensure more comprehensive coverage.

Effectiveness of a multifaceted implementation strategy on physicians' referral behavior to an evidence-based psychosocial intervention in dementia: a cluster randomized controlled trial

BACKGROUND

To evaluate the effectiveness of a multifaceted implementation strategy on physicians' referral rate to and knowledge on the community occupational therapy in dementia program (COTiD program).

METHODS

A cluster randomized controlled trial with 28 experimental and 17 control clusters was conducted. Cluster included a minimum of one physician, one manager, and two occupational therapists. In the control group physicians and managers received no interventions and occupational therapists received a postgraduate course. In the experimental group physicians and managers had access to a website, received newsletters, and were approached by telephone. In addition, physicians were offered one outreach visit. In the experimental group occupational therapists received the postgraduate course, training days, outreach visits, regional meetings, and access to a reporting system. Main outcome measure was the number of COTiD referrals received by each cluster which was assessed at 6 and 12 months after the start of the intervention. Referrals were included from both participating physicians (enrolled in the study and received either the control or experimental intervention) and non-participating physicians (not enrolled but of whom referrals were received by participating occupational therapists). Mixed model analyses were used to analyze the data. All analyses were based on the principle of intention-to-treat.

RESULTS

At 12 months experimental clusters received significantly more referrals with an average of 5,24 referrals (SD 5,75) to the COTiD program compared to 2,07 referrals in the control group (SD 5,14). The effect size at 12 months was 0.58. Although no difference in referral rate was found for the physicians participating in the study, the number of referrals from non-participating physicians (t -2,55 / 43 / 0,02) differed significantly at 12 months.

CONCLUSION

Passive dissemination strategies are less likely to result in changes in professional behavior. The amount of physicians exposed to active strategies was limited. In spite of this we found a significant difference in the number of referrals which was accounted for by more referrals of non-participating physicians in the experimental clusters. We hypothesize that the increase in referrals was caused by an increase in occupational therapists' efforts to promote their services within their network.

TRIAL REGISTRATION

NCT01117285.

Psychosocial interventions for reducing antipsychotic medication in care home residents

BACKGROUND

Antipsychotic medication is regularly prescribed in care homes to control 'behavioural and psychological symptoms of dementia' despite moderate efficacy, significant adverse effects, and available non-pharmacological alternatives.

OBJECTIVES

To evaluate the effectiveness of psychosocial interventions to reduce antipsychotic medication in care home residents.

SEARCH METHODS

The Cochrane Dementia and Cognitive Improvement Group's Specialized Register, MEDLINE, EMBASE, CINAHL, PsycINFO, LILACS, a number of trial registers and grey literature sources were searched on 19th December 2011.

SELECTION CRITERIA

Individual or cluster-randomised controlled trials comparing a psychosocial intervention aimed at reducing antipsychotic medication with usual care in care home residents or comparing two different approaches.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed the retrieved articles for relevance and methodological quality and extracted data. Critical appraisal of studies addressed risk of bias through selection bias, performance bias, attrition bias, and detection bias, as well as criteria related to cluster design. Authors of relevant studies were contacted for additional information.Owing to clinical heterogeneity of interventions, statistical heterogeneity was not assessed and no meta-analysis performed. Study results are presented in a narrative form.

MAIN RESULTS

Four cluster-randomised controlled studies met the inclusion criteria. All of them investigated complex interventions comprising educational approaches. Three studies offered education and training for nursing staff, one study offered multidisciplinary team meetings as main component of the intervention. There was one high-quality study, but overall the methodological quality of studies was moderate. The studies revealed consistent results for the primary end point. All studies documented a decrease of the proportion of residents with antipsychotic drug use or a reduction in days with antipsychotic use per 100 days per resident, respectively. In summary, the reviewed evidence on psychosocial interventions targeting professionals is consistent with a reduction of antipsychotic medication prescription in care home residents. However, owing to heterogeneous approaches, summary effect sizes cannot be determined.

AUTHORS' CONCLUSIONS

There is evidence to support the effectiveness of psychosocial interventions for reducing antipsychotic medication in care home residents. However, the review was based on a small number of heterogeneous studies with important methodological shortcomings. The most recent and methodologically most rigorous study showed the most pronounced effect.

Effects of animal-assisted therapy on behavioral and/or psychological symptoms in dementia: a case report

BACKGROUND

Recently, interest in nonpharmaceutical interventions in dementia care has increased. Animal-assisted therapy has been shown to be one promising intervention but more knowledge is needed. The present article reports on a pilot study involving an 84-year-old woman with vascular dementia who was systematically trained with a therapy dog team for 8 weeks.

METHODS

A quasi-experimental longitudinal interventional design with pre-post measures was used. Data were collected on 3 occasions. Descriptive statistics were used for data analysis.

RESULTS

Some effects on the woman's ability to walk and move were identified. In addition, some effects in the woman's cognitive state were observed.

CONCLUSIONS

Physical, psychological, and/or social training with certified therapy dog teams can have effects on behavioral and psychological symptoms in people living with dementia. Further research is needed.

The development of quality indicators to improve psychosocial care in dementia

BACKGROUND

The evidence for the effectiveness of psychosocial interventions in dementia care is growing but the implementation of available evidence is not automatic. Our objective was to develop valid quality indicators (QIs) for psychosocial dementia care that facilitate the implementation process in various countries and settings.

METHODS

A RAND-modified Delphi technique was used to develop a potential set of QIs. Two multidisciplinary, international expert panels were involved in achieving content and face validity. Consensus on the final set was reached after a conference meeting where a third panel of dementia experts discussed measurability and applicability of the potential set. A retrospective cohort study was conducted to study the feasibility of using the final set in day care centers, hospitals, and nursing homes in Spain and The Netherlands.

RESULTS

A total of 104 recommendations were selected from guidelines and systematic reviews and appraised for their contribution to improving the quality of dementia care by 49 dementia experts. Twenty-five experts attended the conference meeting and reached consensus on a set of 12 QIs representing the key elements of effective psychosocial care, such as shared decision-making and interventions tailored to needs and preferences. Data from 153 patient records showed that all but one QI subitem were applicable to all three settings in both countries.

CONCLUSION

Our multidisciplinary and multinational strategy resulted in a set of unique QIs that aims exclusively at assessing the quality of psychosocial dementia care. Following implementation, these QIs will assist dementia care professionals to individualize and tailor psychosocial interventions.

Sedative load of medications prescribed for older people with dementia in care homes

BACKGROUND

The objective of this study was to determine the sedative load and use of sedative and psychotropic medications among older people with dementia living in (residential) care homes.

METHODS

Medication data were collected at baseline and at two further time-points for eligible residents of six care homes participating in the EVIDEM-End Of Life (EOL) study for whom medication administration records were available. Regular medications were classified using the Anatomical Therapeutic Chemical classification system and individual sedative loads were calculated using a previously published model.

RESULTS

At baseline, medication administration records were reviewed for 115 residents; medication records were reviewed for 112 and 105 residents at time-points 2 and 3 respectively. Approximately one-third of residents were not taking any medications with sedative properties at each time-point, while a significant proportion of residents had a low sedative load score of 1 or 2 (54.8%, 59.0% and 57.1% at baseline and time-points 2 and 3 respectively). More than 10% of residents had a high sedative load score (≥ 3) at baseline (12.2%), and this increased to 14.3% at time-points 2 and 3. Approximately two-thirds of residents (66.9%) regularly used one or more psychotropic medication(s). Antidepressants, predominantly selective serotonin re-uptake inhibitors (SSRIs), were most frequently used, while antipsychotics, hypnotics and anxiolytics were less routinely administered. The prevalence of antipsychotic use among residents was 19.0%, lower than has been previously reported for nursing home residents. Throughout the duration of the study, administration of medications recognised as having prominent sedative adverse effects and/or containing sedative components outweighed the regular use of primary sedatives.

CONCLUSIONS

Sedative load scores were similar throughout the study period for residents with dementia in each of the care homes. Scores were lower than previously reported in studies conducted in long-term care wards which have on-site clinical support. Nevertheless, strategies to optimise drug therapy for care home residents with dementia which rely on clinicians external to the care home for support and medication review are required.