The association between physical dependency and the presence of neuropsychiatric symptoms, with the admission of people with dementia to a long-term care institution: A prospective observational cohort study☆☆This paper was submitted as an entry for the European Academy of Nursing Science's Rosemary Crow award, sponsored by the International Journal of Nursing Studies. The award is open to current doctoral students or recent graduates of the academy's programme

Identifying predictors of transition to a care home for people with dementia: findings from the IDEAL programme

OBJECTIVES

This study investigates factors associated with the person with dementia and the caregiver to identify those associated with an increased risk of transition to a care home.

METHOD

IDEAL data were collected at baseline and at 12- and 24-month follow-up for 1545 people with dementia and 1305 caregivers. Modified Poisson regressions with an offset for 'person years at risk' were used. Person with dementia factors explored were personal characteristics, cognition, health, self- and informant-rated functional ability, and neuropsychiatric symptoms. Caregiver factors explored were personal characteristics, stress, health, and quality of the dyadic relationship.

RESULTS

A 5% people moved into care. Risk of moving into a care home was higher among people with dementia who were ≥80 years, among people with Parkinson's disease dementia or dementia with Lewy bodies, and among those without a spousal caregiver. Poorer cognition and more self-rated or informant-rated functional difficulties increased the risk of moving into care.

CONCLUSION

Factors related to increased dementia severity and greater disability are the primary influences that place people with dementia at greater risk of moving into a care home. Strategies that help to maintain everyday functional ability for people with dementia could help delay people with dementia moving into care.

Older adults preferences for long-term caregivers in China: a discrete choice experiment

OBJECTIVE

Understanding the preferences of old-age adults for their long-term caregivers can improve person-centred health care and the quality of long-term care (LTC). This study examines Chinese older adults' preferences for long-term caregivers.

STUDY DESIGN

This is a cross-sectional study.

METHODS

A national representative discrete choice experiment (DCE) surveyed 2031 adults aged 50-70 across 12 provinces in China. Each DCE scenario described five attributes: type of caregivers, place of LTC, contents of LTC, out-of-pocket payments, and quality of life (QoL). Preferences and the marginal willingness to pay (WTP) were derived using mixed-logit and latent class models.

RESULTS

Older adults displayed higher preferences for long-term caregivers who improve their QoL, incur lower out-of-pocket payments, and provide medical LTC services at home, with the maximum WTP of $22.832 per month. QoL was rated as the most important LTC factor, followed by the place of LTC and the type of caregivers. When the level of QoL improved from poor to good, respondents would be willing to pay $18.375 per month more (95% confidence interval: 16.858 to 20.137), and the uptake rate increased by 76.47%. There was preference heterogeneity among older people with different sex, education, family size, and knowledge of LTC insurance.

CONCLUSION

QoL was the most important factor in older Chinese adults' preference for caregivers. Home care and medical care from formal caregivers was preferred by older adults. We recommend training family caregivers, raising older people's awareness of LTC insurance, and guiding policymakers in developing people-oriented LTC and a multi-level LTC system.

Burden in caregivers of primary care patients with dementia: influence of neuropsychiatric symptoms according to disease stage (NeDEM project)

BACKGROUND

Caregiver burden is related to personal factors and patient characteristics and is greater when neuropsychiatric symptoms (NPSs) are present.

OBJECTIVE

Estimate the prevalence of burden among caregivers of dementia patients and its association with NPSs and identify NPSs causing greater caregiver distress according to dementia stage.

METHODS

A cross-sectional observational study in caregivers of noninstitutionalized dementia patients was conducted. Caregiver variables were sociodemographic, time of care, NPS-associated distress based on the Neuropsychiatric Inventory Caregiver Distress Scale (NPI-D) and burden based on the Zarit Burden Interview (ZBI). Patient variables were time since disease onset, Global Deterioration Scale (GDS) disease stage, functional assessment and NPS presence and intensity according to the Neuropsychiatric Inventory (NPI). The mean ZBI score, prevalence of burden and NPI-D score with 95% CIs at each dementia stage were estimated. Factors associated with burden were identified by multivariate analysis.

RESULTS

Of the 125 caregivers included, 77.6% were women, with a mean age of 60.7 (± 14.3) years; 78.4% (95%CI: 71.0; 86.0) experienced burden. The mean ZBI score was 12.3 (95%CI: 11.6; 12.9) and increased according to NPS number (p = 0.042). The NPSs causing the most burden were disinhibition (93.5%), irritability (87.3%) and agitation (86.1%). Agitation, apathy, and sleep disorders were the NPSs generating the greatest overall caregiver distress; depression (max NPI-D 1.9), hyperactivity (max NPI-D 2.1), and psychosis symptoms (max NPI-D 1.6) generated the greatest distress at stage GDS 3, stages GDS 4-5, and stages GDS 6-7, respectively. The NPI score (OR = 1.0, 95%CI 1.0; 1.1), intensity of irritability (OR = 1.2, 95%CI 1.0; 1.6), disinhibition (OR = 2.6, 95%CI 1.1; 5.8) and hyperactivity subsyndrome (OR = 1.1, 95%CI 1.0; 1.2) were associated with caregiver burden. Other associated factors were female gender (OR = 6.0, 95%CI 1.6; 22.8), ≥ 8 h daily care (OR = 5.6, 95%CI 1.4; 22.8), working outside the home (OR = 7.6, 95%CI 1.8; 31.8), living with the patient (OR = 4.5, 95%CI 1.1; 19.6), kinship (OR = 5.4, 95%CI 1.0; 28.2) and lower patient education (OR = 8.3, 95%CI 2.3; 30.3).

CONCLUSIONS

The burden on caregivers of dementia patients is high and associated with NPS presence and intensity. Disinhibition and irritability caused the highest burden. Depression, hyperactivity and psychosis produce more distress in mild, mild-moderate and severe dementia, respectively.

Feasibility of Telehealth Occupational Therapy for Behavioral Symptoms of Adults With Dementia: Randomized Controlled Trial

IMPORTANCE

Supporting community residency of adults with Alzheimer's disease (AD) is a critical public health initiative. Occupational therapy can contribute to this goal.

OBJECTIVE

To assess the feasibility of a novel telehealth intervention to support occupational engagement in community-residing people with AD.

DESIGN

Single-blind, three-arm, parallel, randomized controlled trial.

SETTING

Occupational therapy delivered through telehealth in participants' homes.

PARTICIPANTS

People with AD who reside in the community with behavioral symptoms and their care partners (dyads).

INTERVENTIONS

(1) HARMONY (Helping older Adults cReate & Manage OccupatioNs successfully), a telehealth intervention that applies principles of individualized guided discovery with environmental cueing for caregivers of persons with AD to promote activity participation and manage behavioral symptoms; (2) standardized training regarding the use of a sensory-based approach in dementia care; and (3) a control, including home safety education and weekly monitoring of behaviors.

OUTCOMES AND MEASURES

Feasibility was assessed as the primary outcome measured by completion of at least 75% of the telehealth sessions. Secondary outcomes included change in functional activity performance and neuropsychiatric behavioral symptoms.

RESULTS

Twenty-eight dyads participated. The intervention was feasible, with high adherence to weekly visits (M number of visits = 5.4 for HARMONY, 4.9 for standardized training, and 4.6 for control), with high participant retention in the intervention arms. HARMONY demonstrated promise in improving patient performance and behavioral symptoms.

CONCLUSIONS AND RELEVANCE

HARMONY is feasibly delivered through telehealth service and has a positive effect on occupational performance and behavioral symptoms of AD. Additional studies are needed to explore effectiveness in a broader population. What This Article Adds: Use of HARMONY for community-residing adults with AD is feasible and has promise for improving functional activity performance and behavioral symptoms, as well as caregiver satisfaction.

Maximising the engagement of older people with mental health needs and dementia with social care

Older people with mental health needs and dementia often face difficulties with daily living and community participation, requiring the intervention of social care services. However, cognitive and emotional needs often mean that mainstream support is not appropriate. In England, mental health support workers may attempt to address these concerns, to prevent mounting care needs and the potential for institutional care. Yet, their work has not been researched to identify good practices and to understand the mechanisms through which they engage older people. A new qualitative study used semi-structured interviews and focus groups with specialist support workers (n = 22), managers (n = 7), homecare staff (n = 4) and service users and carers (n = 6). The latter group were interviewed by co-authors with lived experiences of dementia and care. Participants were recruited from mental health services, home care organisations and third-sector agencies across the North of England in 2020-2021. The study identified three themes that described support worker activities. First, 'building trusting relationships' identified steps to establish the foundations of later interventions. Paradoxically, these may involve misleading clients if this was necessary to overcome initial reluctance, such as by feigning a previous meeting. Second, 're-framing care' referred to how the provision of care was positioned within a narrative that made support easier to engage with. Care framed as reciprocal, as led by clients, and having a positive, non-threatening description would more likely be accepted. Third, 'building supportive networks' described how older people were enabled to draw upon other community resources and services. This required careful staging of support, joint visits alongside workers in other services, and recognition of social stigma. The study was limited by constrained samples and covid context requiring online data collection. The study recommends that support workers have more opportunity for sharing good practice across team boundaries, and improved access to specialist training.

How the Cognitive Status of Older People Affects Their Care Dependency Level and Needs: A Cross-Sectional Study

INTRODUCTION

The decline in health and abilities as a result of the aging process leads to a growing need for care and various forms of support. The aim of this study was to find out the level and the main areas of care dependency among older persons with cognitive impairment versus those without cognitive impairment.

MATERIALS AND METHODS

A cross-sectional study was conducted among 200 older persons hospitalized in the years 2017-2018 at a geriatric ward in Poland. The research took into consideration the socio-demographic variables of the older people (age, sex, marital status, mode of dwelling, health self-evaluation, and loneliness) and the results of the assessment of their functional status, including their physical functional status according to the Barthel scale and the I-ADL, locomotion, the risk of falls and pressure sores, emotional state, cognitive function status, vision, hearing, and the Polish version of the Care Dependency Scale.

RESULTS

People with cognitive impairment significantly more often have poorer results in regard to ADL and I-ADL physical functions, locomotion, risk of depression, falls, pressure sores, as well as hearing and vision problems, than people with good cognitive status. The results of the study indicate that the advancing impairment of cognitive functions in older people has an impact on the level of care dependency.

CONCLUSION

The results of this original research show that persons with cognitive impairment are significantly more often dependent on external assistance in regard to all the needs assessed in the CDS than people without such impairment. The spectrum and number of needs in which the older person requires help grows significantly with the advancement of cognitive impairment. Older people with cognitive impairment who live alone require special support from formal caregivers in their home environment. Identification of the level of dependency and the needs of older people with cognitive impairment is of key importance for planning caregiving resources.

Enabling older people with mental health needs to engage with community social care: A scoping review to inform a theory of change

Despite apparent need, many older people with cognitive impairment and/or mental health needs do not fully engage with social care. This can manifest in different ways, including passive or aggressive attempts to avoid or repel care workers. However, little is known about how to support such individuals in their own homes and deliver effective care. Against this background, we undertook a scoping review with a view to developing a preliminary theory of change suggesting how care might be modified to engage this client group. The most recent search was conducted on 21/04/21. Papers were included if they (i) focused on older people (65+) living at home with social care needs and (ii) described difficulties/problems with the provision/receipt of social care associated with individuals' mental health needs. Twenty-six citations were identified through electronic database searches and reference screening, and the results were charted according to key theory of change concepts (long-term outcomes, preconditions, interventions, rationale and assumptions). All the included papers were related to people with dementia. Four subgroups of papers were identified. The first highlights those external conditions that make it more likely an intervention will be successful; the second describes specific interventions to engage older people who by virtue of their mental health needs have not engaged with social care; the third explores what services can be done to increase service uptake by older people with mental health needs and their caregivers more generally; and the fourth details theoretical approaches to explaining the behaviour of people with dementia. Each provides information that could be used to inform care delivery and the development of interventions to improve engagement with health and social care for these individuals. The study concludes that different framing of engagement difficulties, such as that offered through positioning theory, may assist in future service design.

Comparison of behaviors characteristic of autism spectrum disorder behaviors and behavioral and psychiatric symptoms of dementia

BACKGROUND

Similarities exist in behavioral expression of autism spectrum disorder (ASD) and Alzheimer's disease and related dementias (ADRD). The purpose of this study was to assess presence of behavioral and psychiatric symptoms of dementia (BPSD) and ASD-like behaviors in adults with ADRD.

METHODS

Using a cross-sectional design, data from University of Kentucky Alzheimer's Disease Center participant cohort were used. Hierarchical linear regression was used to assess (1) the relationship between ASD-like behaviors (measured by the Gilliam Autism Rating Scale-Second Edition, GARS-2) and BPSD measured by the Neuropsychiatric Inventory (NPI), and (2) the relationship between ASD-like behaviors and dementia severity (measured by the Clinical Dementia Rating [CDR] sum of boxes), when controlling for BPSD.

RESULTS

Complete data were available for 142 participants. Using α of 0.05, analyses identified ASD behaviors were significantly associated with BPSD severity ratings (r = 0.47; p < 0.001) and dementia severity (r = 0.46; p < 0.001). GARS-2 explained 6.1% (p < 0.001) of variance in CDR sum of boxes when controlling for NPI and other covariates.

DISCUSSION

There is significant overlap in behaviors characteristic of ASD and BPSD as assessed by the NPI and GARS-2, despite the use of these instruments in disparate developmental vs. aging settings. ASD behaviors appear to not be solely present in early childhood as a manifestation of ASD but are also present in older adults with neurodegenerative cognitive impairment. Such associations warrant additional research into causation, assessment, and behavioral interventions to further enable new therapeutic approaches targeting ASD behaviors across the lifespan.

Care home residents with dementia: Prevalence, incidence, and associations with sleep disturbance in an English cohort study

INTRODUCTION

People living with dementia in care homes often have sleep disturbances, but little is known about incidence and importance.

METHODS

We interviewed 1483 participants in 97 care homes and report prevalence, 1-year incidence, and baseline associations of clinically significant sleep disturbance in people with dementia.

RESULTS

Baseline prevalence of clinically significant sleep disturbance was 13.7% (200/1460); 31.3% (457/1462) had them at least once over 16 months. One-year incidence was 25.2%. At baseline, residents with sleep disturbance had lower quality of life (mean difference -4.84; 95% confidence interval [CI] -6.53 to -3.16) and were more frequently prescribed sleep medications (odds ratio 1.75; CI 1.17 to 2.61) than other residents.

DISCUSSION

Approximately one-third of care home residents with dementia have or develop sleep disturbances over 1 year. These are associated with lower quality of life and prescription of sedatives, which may have negative outcomes; therefore, it is important to develop effective treatments.

Entry and Passage Variables Associated with Nursing Home Adjustment in Older Adults with Dementia

A theory-guided non-experimental, descriptive, correlational design was used to evaluate how entry and passage variables were related to nursing home adjustment for individuals with dementia. Older adults with dementia may be unable to speak for themselves, therefore proxy responses of Certified Nursing Assistants (CNAs) provided the data for completion of the Nursing Home Adjustment Scale.¹ Guided by the Meleis' Theory of Transitions, entry level factors (i.e. age, previous residence, gender, and choice), and passage variables (i.e. length of stay, extent of dementia, functional abilities, and depression) were entered into a regression equation as predictors of nursing home adjustment. Information about extent of dementia, functional abilities and depression was derived from the Minimum Data Set (MDS) maintained for all residents per Medicare and Medicaid guidelines. Descriptive and inferential statistics were calculated using IBM Statistical Package for the Social Sciences (SPSS) 26.0 software. Results indicated an inverse relationship between nursing home adjustment and depression as measured by the PHQ-9. There was no support for relationships among other variables. CNA proxy responses were found to be reliable in that they were significantly correlated with nursing responses on the same measure. This study supports the use of CNA proxy responses as a method to evaluate the experience of individuals with dementia.

Optimizing mealtime care for people with dementia from the perspective of formal caregivers: A systematic review of qualitative research

BACKGROUND

As dementia progresses, people with dementia experience many problems during mealtimes that seriously affect their physical, psychological, and social health and quality of life. Formal caregivers play an important role in optimizing mealtime care.

OBJECTIVE

To systematically review and synthesise relevant qualitative studies exploring the experience and perceptions of formal caregivers regarding optimizing mealtime care for people with dementia.

DESIGN

A systematic review of qualitative research.

DATA SOURCES

The PubMed, Web of Science, Cochrane Library, Embase, CINAHL, CNKI, WanFang and Vip databases were systematically searched.

REVIEW METHODS

Two reviewers independently screened the titles and abstracts, extracted the data and performed critical appraisals of each included study. The data synthesis was conducted using thematic analysis.

FINDINGS

A total of 10 studies were included. The formal caregivers included nursing assistants, nurses, speech and language therapists, nursing students, dietitians, a social worker, a professional educator, physiotherapists, health care aides, kitchen staff, diversional therapy assistants and other unidentified care staff. The findings were synthesised into the following 3 analytical themes: (1) tailored rather than standardized; (2) emotional nurturance; and (3) beyond the individual level.

CONCLUSIONS

Mealtimes involve complex physiological and psychological processes. Formal caregivers should develop tailored care practices based on individual patients' preferences and needs. Emotional connection plays a key role and has a positive impact on the mealtime experience. Further research is needed to explore the specific effects of emotional connections on optimizing mealtime care.

Rationale, Design, and Methodology of a Prospective Cohort Study for Coping with Behavioral and Psychological Symptoms of Dementia: The RECage Project

BACKGROUND

Behavioral and psychological symptoms of dementia (BPSD) are quite challenging problems during the dementia course. Special Care Units for people with dementia (PwD) and BPSD (SCU-B) are residential medical structures, where BPSD patients are temporarily admitted, in case of unmanageable behavioral disturbances at home.

OBJECTIVE

RECage (REspectful Caring for AGitated Elderly) aspires to assess the short and long-term effectiveness of SCU-Bs toward alleviating BPSD and improving the quality of life (QoL) of PwD and their caregivers.

METHODS

RECage is a three-year, prospective study enrolling 500 PwD. Particularly, 250 community-dwelling PwDs presenting with severe BPSD will be recruited by five clinical centers across Europe, endowed with a SCU-B, for a short period of time; a second similar group of 250 PwD will be followed by six other no-SCU-B centers solely via outpatient visits. RECage's endpoints include short and long-term SCU-B clinical efficacy, QoL of patients and caregivers, cost-effectiveness of the SCU-B, psychotropic drug consumption, caregivers' attitude toward dementia, and time to nursing home placement.

RESULTS

PwD admitted in SCU-Bs are expected to have diminished rates of BPSD and better QoL and their caregivers are also expected to have better QoL and improved attitude towards dementia, compared to those followed in no-SCU-Bs. Also, the cost of care and the psychotropic drug consumption are expected to be lower. Finally, PwD followed in no-SCU-Bs are expected to have earlier admission to nursing homes.

CONCLUSION

The cohort study results will refine the SCU-B model, issuing recommendations for implementation of SCU-Bs in the countries where they are scarce or non-existent.

Measuring the prevalence of sleep disturbances in people with dementia living in care homes: a systematic review and meta-analysis

Study Objectives

Sleep disturbances are a feature in people living with dementia, including getting up during the night, difficulty falling asleep, and excessive daytime sleepiness and may precipitate a person with dementia moving into residential care. There are varying estimates of the frequency of sleep disturbances, and it is unknown whether they are a problem for the individual. We conducted the first systematic review and meta-analysis on the prevalence and associated factors of sleep disturbances in the care home population with dementia.

Methods

We searched Embase, MEDLINE, and PsycINFO (29/04/2019) for studies of the prevalence or associated factors of sleep disturbances in people with dementia living in care homes. We computed meta-analytical estimates of the prevalence of sleep disturbances and used meta-regression to investigate the effects of measurement methods, demographics, and study characteristics.

Results

We included 55 studies of 22,780 participants. The pooled prevalence on validated questionnaires of clinically significant sleep disturbances was 20% (95% confidence interval, CI 16% to 24%) and of any symptom of sleep disturbance was 38% (95% CI 33% to 44%). On actigraphy using a cutoff sleep efficiency of <85% prevalence was 70% (95% CI 55% to 85%). Staff distress, resident agitation, and prescription of psychotropic medications were associated with sleep disturbances. Studies with a higher percentage of males had a higher prevalence of sleep disturbance.

Conclusions

Clinically significant sleep disturbances are less common than those measured on actigraphy and are associated with residents and staff distress and the increased prescription of psychotropics. Actigraphy appears to offer no benefit over proxy reports in this population.

The 'tipping point': Exploring the factors associated with entry into residential care for people with dementia in Western Australia

BACKGROUND

People with dementia usually prefer to live in the community. Research is needed to identify the 'tipping point' for residential care entry and to highlight how people with dementia can be supported to remain at home as long as possible. Few previous studies have examined caregivers' perceptions and explanations for the reasons people with dementia need to enter residential care in Australia.

AIM

To explore the factors contributing to people with dementia entering residential care in Perth, Western Australia, from the perspectives of informal carers and care staff.

METHOD

This phenomenological study used purposive sampling to recruit informal and formal caregivers of people with dementia. Semi-structured in-depth interviews were conducted with 13 family carers and 11 home care staff. Data were thematically analysed to identify individual, carer and contextual factors that impact on residential care entry.

FINDINGS

The majority of participants identified a combination of factors as the 'tipping point' to residential care entry; a few also identified the cause as a sudden event or specific issue. Factors identified included deterioration related to worsening cognition, changed behaviours and a decline in the performance of activities of daily living; co-occurring health conditions; safety concerns; carer no longer able to meet care needs; impact of providing support becoming too much for the informal carer; lack of family or social support and needing assistance from services that were unavailable or inaccessible. Factors assisting people with dementia to remain living at home longer were family and social support, formal services and dog ownership.

CONCLUSION

This study identified individual, carer and contextual factors that contribute to people with dementia entering residential care in Australia. The 'tipping point' was recognised as when the needs of a person with dementia outweigh the capacity of their informal and formal carers, services and supports to care for them.

A research agenda for promoting continence for people living with dementia in the community: Recommendations based on a critical review and expert-by-experience opinion

Aims and objectives

To identify research undertaken in the last decade addressing continence for people living with dementia (PLWD) in the community. To highlight gaps and develop recommendations for future research, taking into account the experiences and priorities of PLWD, caregivers and healthcare professionals.

Methods

A critical review with an Expert Review Group (ERG) comprising researchers, PLWD and facing continence issues, caregivers and other professional stakeholders. Findings are reported in line with the COREQ and Preferred Reporting Items for Systematic reviews and Meta‐Analyses extension for Scoping Reviews checklists.

Background

Caregivers rate the independent use of the toilet as the most important activity for PLWD to retain. However, in 2009 a review identified shortfalls in knowledge and praxis around promoting continence and managing incontinence for PLWD in the community. As absolute numbers of people with dementia are predicted to increase, it is imperative to examine whether these deficits have been addressed.

Results

Of 3,563 records identified, 57 full‐text articles were reviewed. The ERG developed a conceptual model to summarise research evidence according to the extent of the challenge (neuropathology and clinicopathology, prevalence and incidence), gateways to continence services, effectiveness of interventions, outcomes and the potential influences of personal resources, socio‐cultural factors and environmental contexts.

Conclusions

Research on (in)continence for PLWD in the community is under‐developed and has not increased substantially over the last decade. ERG recommendations for future research included user involvement to identify appropriate quality indicators to assess the effectiveness of interventions.

Relevance to clinical practice

There is insufficient evidence on which to base decisions on continence care for PLWD in the community. Omission from continence care guidelines has the effect of marginalising and silencing this population. User involvement in clinical research and developing practice guidelines has the potential for positive systems change.

The impact of sleep disturbances on care home residents with dementia: the SIESTA qualitative study

OBJECTIVES

Nearly 40% of care home residents who are living with dementia also have symptoms of disturbed sleep. However, the impact of these disturbances is relatively unknown and is needed to indicate whether interventions are warranted; therefore, we aimed to investigate the impact.

DESIGN

One-to-one semi-structured interviews.

SETTINGS

Four UK care homes.

PARTICIPANTS

We interviewed 18 nurses and care assistants about residents with sleep disturbances.

MEASUREMENTS

We used a topic guide to explore staff experience of sleep disturbance in residents with dementia. The interviews were audio recorded and transcribed and then analyzed thematically by two researchers independently.

RESULTS

Staff described that sleep disturbances in most, but not all, residents impacted negatively on the resident, other residents, staff, and relatives. Residents became more irritable or agitated if they had slept badly. They slept in the daytime after a bad night, which then increased their chances of being awake the following night. For some, being sleepy in the day led to falls, missing medication, drinks, and meals. Staff perceived hypnotics as having low efficacy, but increasing the risk of falls and drowsiness. Other residents were disturbed by noise, and staff described stress when several residents had sleep disturbance. Some of the strategies reported by staff to deal with sleep disturbances such as feeding or providing caffeinated tea at night might be counterproductive.

CONCLUSIONS

Sleep disturbances in care home residents living with dementia negatively affect their physical and psychological well-being. These disturbances also disturb other residents and increase stress in staff.

Development and usability of a decision support App for nurses to facilitate aging in place of people with dementia

AIM

The aim of this study was to develop a decision support tool for nurses to facilitate aging in place of people with dementia and to test its usability.

BACKGROUND

Nurses play an important role in detecting practical problems preventing persons with dementia (PwD) from aging in place and advising them on possible solutions. These are complex and challenging tasks for nurses.

METHODS

A mixed methods study was conducted. The content development of the App comprised a literature and internet search, and individual and group interviews with professionals (n = 8) and researchers (n = 5). The technical development was an iterative process in which usability was tested by the project team (n = 4), experts (n = 6), and end-users (n = 9), using heuristic evaluation, a think-aloud approach, and a questionnaire (PSSUQ).

RESULTS

The App contains a structured problem assessment for three problem domains-self-reliance, safety, and informal care-based on validated questionnaires and self-formulated questions. The problem assessment is linked to an overview of possible solutions for the problems detected. Three prototypes have been developed. The users of the third prototype were overall satisfied with the App as they scored on average 1.7 on the PSSUQ (range 1-7 and lower scores indicating higher satisfaction).

CONCLUSIONS

A user-friendly prototype of the decision support App is now available. Users indicated to be very willing to use to App in daily practice. However, besides further technical development, implementation of the App into practice requires evidence supporting its efficacy, feasibility and effectiveness.

Taking a positive spin: preserved initiative and performance of everyday activities across mild Alzheimer's, vascular and mixed dementia

OBJECTIVES

The literature commonly evaluates those daily activities which are impaired in dementia. However, in the mild stages, people with dementia (PwD) are still able to initiate and perform many of those tasks. With a lack of research exploring variations between different dementia diagnoses, this study sought to investigate those daily activities with modest impairments in the mild stages and how these compare between Alzheimer's disease (AD), vascular dementia (VaD) and mixed dementia.

METHODS

Staff from memory assessment services from nine National Health Service trusts across England identified and approached informal carers of people with mild dementia. Carers completed the newly revised Interview for Deteriorations in Daily Living Activities in Dementia 2 assessing the PwD's initiative and performance of instrumental activities of daily living (IADLs). Data were analysed using analysis of variance and Chi-square tests to compare the maintenance of IADL functioning across AD, VaD, and mixed dementia.

RESULTS

A total of 160 carers returned the Interview for Deteriorations in Daily Living Activities in Dementia 2, of which 109, 21, and 30 cared for someone with AD, VaD, and mixed dementia, respectively. There were significant variations across subtypes, with AD showing better preserved initiative and performance than VaD for several IADLs. Overall, PwD showed greater preservation of performance than initiative, with tasks such as preparing a hot drink and dressing being best maintained.

CONCLUSION

Findings can help classify dementia better into subtypes in order to receive bespoke support. It suggests that interventions should primarily address initiative to improve overall functioning. Copyright © 2016 John Wiley & Sons, Ltd.

Rethinking Psychosis in Dementia: An Analysis of Antecedents and Explanations

An in-depth analysis of qualitative data regarding antecedents, consequences, and descriptions of delusions of persons with dementia (PwD) provided by family caregivers is presented. Three broad classifications of reasons given behind types of delusions are included, namely environmental factors, personal factors, and dementia, with dementia being the most prominent factor. We observed an overlap between known cognitive symptoms of dementia and the characteristics of the reported "delusions" in dementia. It therefore appears that what is often classified as a delusion of a seemingly psychotic nature is in fact the PwD's disorientation combined with an attempt to fill in gaps caused by cognitive deficiencies.

Effectiveness of Light Therapy in Cognitively Impaired Persons: A Metaanalysis of Randomized Controlled Trials

OBJECTIVES

To explore the effects of light therapy on behavioral disturbances (BDs), sleep quality, and depression.

DESIGN

Meta-analysis of randomized controlled trials.

SETTING

PubMed, Cochrane Library, Medline, EMBASE, Web of Science, and clinicaltrials.gov of selected randomized controlled trials and previous systematic reviews were searched.

PARTICIPANTS

Cognitively impaired persons.

MEASUREMENTS

Information was extracted on study characteristics, quality assessment, and outcomes. Outcome measures included BDs, sleep quality, and depression.

RESULTS

Nine randomized controlled trials were examined. The results showed that light therapy has a moderate effect on BD (g = -0.61) and depression (g = -0.58) and a small effect on total sleep time at night (g = 0.25). Subgroup analysis indicated that a light intensity of 2,500 lux or greater has a greater effect on depression than an intensity of less than 2,500 lux (P = .03), and the low risk of bias in blinding was superior to the RCTs deemed to be of high or unclear risk of bias in blinding in terms of BD (P = .02).

CONCLUSION

Light therapy can relieve BD, improve sleep quality, and alleviate symptoms of depression for cognitively impaired persons.

Behavioural Changes in Dementia and their Impact on Professional Caregivers: A Grounded Theory Approach

AIM

The present study aimed to explore the impact that changes in behavioural symptoms of people living with dementia have on professional caregiver and resident relationships.

METHOD

A total of 21 interviews were carried out with professional caregivers of people living with dementia. A grounded theory approach was used to investigate everyday experiences of provision of professional care in dementia settings, focussing specifically on the effect of behavioural change on such relationships.

RESULTS

A core category emerged from this analysis: 'Developing behaviour in dementia impacts relationships on a personal and professional level'.

DISCUSSION

Professionals have recognized as part of their everyday practice an eventual deterioration in relationships between themselves as professional caregivers and the residents, but also between the residents and their family members and among residents themselves. Importantly, understanding patients' behaviour and behavioural change was identified as a crucial factor to achieve and sustain good relationships between professionals and residents suffering with dementia.

Facilitating aging in place: A qualitative study of practical problems preventing people with dementia from living at home

Although the majority of people with dementia wish to age in place, they are particularly susceptible to nursing home admission. Nurses can play an important role in detecting practical problems people with dementia and their informal caregivers are facing and in advising them on various ways to manage these problems at home. Six focus group interviews (n = 43) with formal and informal caregivers and experts in the field of assistive technology were conducted to gain insight into the most important practical problems preventing people with dementia from living at home. Problems within three domains were consistently described as most important: informal caregiver/social network-related problems (e.g. high load of care responsibility), safety-related problems (e.g. fall risk, wandering), and decreased self-reliance (e.g. problems regarding self-care, lack of day structure). To facilitate aging in place and/or to delay institutionalization, nurses in community-based dementia care should focus on assessing problems within those three domains and offer potential solutions.

The influence of caregivers and behavioral and psychological symptoms on nursing home placement of persons with Alzheimer's disease: A matched case-control study

OBJECTIVES

Behavioral and psychological symptoms of dementia in individuals with Alzheimer's disease and caregiver characteristics may influence the decision to provide care at home or in a nursing home, though few studies examine this association near the actual time of nursing home placement. Using a matched case-control design, this study investigates the association between (1) total Neuropsychiatric Inventory score, (2) the Neuropsychiatric Inventory-4 (an agitation/aggression subscale), and (3) individual domains of the Neuropsychiatric Inventory and nursing home placement.

METHODS

Data from the South Carolina Alzheimer's disease Registry provides an opportunity to expand the literature by looking at cases at the time of nursing home care eligibility/placement and allowing for propensity-score-matched controls. Cases (n = 352) entered a nursing home within 6 months of study initiation; controls (n = 289) remained in the community. Registry data were combined with caregiver survey data, including the Neuropsychiatric Inventory. Conditional logistic regression was applied.

RESULTS

A 10% increase in the Neuropsychiatric Inventory score implied a 30% increase in odds of nursing home admission (odds ratio: 1.30; 95% confidence interval: 1.14-1.50), having married or male caregivers predicted nursing home placement. Cases versus controls were significantly more likely to have behavioral and psychological symptoms of dementia related to agitation/aggression 1 month prior to nursing home admission.

CONCLUSION

Interventions targeting behavioral and psychological symptoms of dementia without available effective interventions in individuals with Alzheimer's disease and caregiver support services are necessary to prevent or delay nursing home admission.

Differences in quality of life in home-dwelling persons and nursing home residents with dementia - a cross-sectional study

BACKGROUND

Dementia often eventually leads to dependency on others and finally to residential care. However, in Norway about half of the dementia population lives at home, due to individual and political wishes. There is scarce and inconclusive knowledge of how living in a nursing home differs from living at home for persons with dementia (PWDs) with regard to their quality of life (QoL). The first aim of the study was therefore to compare QoL, cognitive and physical functions, social contacts, sleep patterns, physical activity levels, exposure to light, and medication of PWDs in nursing homes and home-dwelling PWDs, and whether living in nursing homes was associated with a lower QoL than living at home for PWDs. A second aim was to examine if possible differences between residencies in QoL were consistent over time.

METHODS

The cross-sectional study was based on baseline data from two RCT studies of PWDs. A total of 15 nursing homes with adapted units for PWDs and 23 adapted day care centres for home-dwelling PWDs recruited 78 and 115 participants respectively. Trained nurses scored sociodemographic data, level of dementia (on the Clinical Dementia Rating scale), amount of medication, and QoL (QUALID). Sleep patterns, physical activity levels, and light exposure were measured by actigraphy. A multiple regression analysis was used to test the association between residency and QoL. The association between residency and change in QoL over time was investigated by linear regression analysis of a subsample with follow-up data.

RESULTS

Home-dwelling PWDs showed significantly higher QoL than PWDs in nursing homes. This difference was maintained even after stratifying on the severity of dementia. Home-dwelling PWDs with moderate dementia showed significantly less use of walking aids, more social contact, higher levels of activity and exposure to daylight, and less use of psychotropic medications. The regression model explained 28 % of the variance in QoL in persons with moderate dementia. However, only residency contributed significantly in the model. Residency also significantly predicted negative change over time in QoL.

CONCLUSION

The study indicated that living at home as long as possible is not only desirable for economic or health political reasons but also is associated with higher QoL for persons with moderate dementia. More studies are needed to investigate how QoL could be increased for PWDs in nursing homes.

Perspectives About Health Care Provision in Dementia Care in Spain: A Qualitative Study Using Focus-Group Methodology

BACKGROUND

The aim of this study is to identify the barriers and facilitators in dementia care with respect to information provision, communication, and collaboration from the perspectives of the person with dementia, family caregivers, and health care professionals over the course of the illness.

METHODS

A qualitative study using Focus-Group methodology was carried out in people with dementia, family caregivers, and health care providers.

RESULTS

The categories that emerged from the analysis were insufficient information provided, specific dementia care needs, and acceptance of long-term care institutionalization from the people with dementia and caregivers' groups and insufficient communication between health care providers, differential information according to disease stage, and home care coordination from the health care providers' groups.

CONCLUSION

The family is a key element in successful care coordination during dementia care provision. New effective strategies including self-management and emergent roles, such as case managers, could bring great benefits to people with dementia, caregivers, and health care providers.

The impact of psychotic symptoms on the persons with dementia experiencing them

OBJECTIVE

To portray the emotional and behavioral reactions of persons with dementia to the delusions and hallucinations they experience, according to the reports of their family caregivers. The article also explores the relationship between those reactions and background variables.

METHODS

Study participants were family caregivers of 74 older persons with a diagnosis of dementia (aged ≥ 65) residing in the community recruited from adult day centers and support groups for caregivers of persons with dementia and by advertising online. Assessments included the Behavioral Pathology in Alzheimer's Disease, the Neuropsychiatric Inventory, the Etiological Assessment of Psychotic Symptoms in Dementia, Activities of Daily Living questionnaire, and the Mini-Mental State Examination.

RESULTS

Findings concerning emotional reactions reveal that close to half of the delusions resulted in discomfort, whereas around 40% did not. We found significant differences in the discomfort associated with different types of delusions, with delusions of abandonment, danger, and infidelity associated with more discomfort than other delusions. Around half of the delusions were associated with a behavioral manifestation.

CONCLUSION

The findings highlight the need to examine the emotional impact of delusions and hallucinations as part of their assessment and as a consideration in treatment decisions.

Small scale homelike special care units and traditional special care units: effects on cognition in dementia; a longitudinal controlled intervention study

BACKGROUND

Evidence shows that living in small scale homelike Special Care Units (SCU) has positive effects on behavioural and psychological symptoms of patients with dementia. Effects on cognitive functioning in relation to care facilities, however, are scarcely investigated. The purpose of this study is to gain more insight into the effects of living in small scale homelike Special Care Units, compared to regular SCU's, on the course of cognitive functioning in dementia.

METHODS

A group of 67 patients with dementia who moved from a regular SCU to a small scale homelike SCU and a group of 48 patients with dementia who stayed in a regular SCU participated in the study. Cognitive and behavioural functioning was assessed by means of a neuropsychological test battery and observation scales one month before (baseline), as well as 3 (post) and 6 months (follow-up) after relocation.

RESULTS

Comparing the post and follow-up measurement with the baseline measurement, no significant differences on separate measures of cognitive functioning between both groups were found. Additional analyses, however, on 'domain clusters' revealed that global cognitive functioning of the small scale homelike SCU group showed significantly less cognitive decline three months after the transfer (p < 0.05). Effect sizes (95% CI) show a tendency for better aspects of cognition in favour of the homelike small scaled SCU group, i.e., visual memory, picture recognition, cognitive decline as observed by representatives and the clustered domains episodic memory and global cognitive functioning.

CONCLUSIONS

While there is no significant longitudinal effect on the progression of cognitive decline comparing small scaled homelike SCU's with regular SCU's for patients with dementia, analyses on the domain clusters and effect sizes cautiously suggest differences in favour of the small scaled homelike SCU for different aspects of cognition.