Pathologizing behavior: Meanings of behaviors in dementia care

[Prevalence of neuropsychiatric symptoms of people with dementia in long-term care units: A secondary analysis]

Prevalence of neuropsychiatric symptoms of people with dementia in long-term care units: A secondary analysis Abstract: Background: In a progress of dementia, most people develop neuropsychiatric symptoms. However, there is little knowledge about the prevalence of these symptoms and their specific characteristics in long-term care. Aims: A differentiated investigation of the prevalence and characteristics of neuropsychiatric symptoms in people with dementia in a long-term care setting. Methods: The prevalence of neuropsychiatric symptoms of people with dementia in a long-term care setting was examined using a secondary analysis of cross-sectional data from the research projects LebenQD I and II and FallDem. The data were collected using the neuropsychiatric inventory - nursing home version. The analysis included data from 699 people with dementia from a total of 21 long-term care facilities in North Rhine-Westphalia. Results: The symptoms agitation/aggression (36%), depression/dysphoria (33%), apathy/indifference (33%), irritability/lability (30%) and aberrant motor behaviour show the highest prevalence. The symptoms hallucinations (9%) and euphoria/elation (6%) have the lowest prevalence. Conclusions: The high prevalence of specific neuropsychiatric symptoms and their characteristics in people with dementia illustrates the need for care-related or psychosocial interventions to counteract the reasons for the occurrence of the symptoms.

Projecting a Critique of Stigma Associated With Dementia on Screen: The Impact of a Canadian Film on the Importance of Relational Caring in the Community

BACKGROUND AND OBJECTIVES

Relational caring has the capacity to reduce stigma associated with dementia by shifting the focus from dysfunction and behavior management, to attending to the interdependencies and reciprocities that underpin caring relationships, and making explicit the centrality of relationships to quality care, growth, and quality of life. Education, particularly arts-based approaches, has been identified as a key strategy to decrease stigma. Yet rarely are the arts utilized in educational initiatives, and particularly so in community care settings. With an interest in redressing this, our team evaluated the impact of a Canadian filmed research-based drama-Cracked: new light on dementia-about stigma associated with people living with dementia and their families.

RESEARCH DESIGN AND METHODS

We conducted interviews with family carers of people living with dementia and formal care providers affiliated with community-based dementia care, and also the general public at 3 and 8 months postscreening.

RESULTS

Our analysis of participants' perceptions/experiences illustrates the effectiveness of Cracked in reducing stigma by demonstrating changes in the understanding of dementia and changes in practice. Our analysis also includes attention to how the film, as a form of cultural production, deepened engagement and facilitated transformation.

DISCUSSION AND IMPLICATIONS

Our evaluation of Cracked demonstrates that it is an effective strategy for decreasing the stigma associated with dementia by promoting relational caring. It also importantly contributes to the theoretical literature that supports film-based approaches to stigma reduction.

The usability of virtual reality to train individuals in responding to behaviors related to dementia

Introduction

Dementia is associated with several behavioral changes globally referred to as Behavioral and Psychological Symptoms of Dementia (BPSD) of which many are recognized to be the expression of unmet needs triggered by environmental factors. BPSD are an extreme source of stress for family care partners and health care providers alike and can be the reason why people living with dementia (PLWD) are placed in long-term care homes (LTCH). The overall goal of this project was to examine whether a virtual environment that includes a virtual LTCH resident with dementia in a lifelike situation could be useful and usable for health care providers and care partners to identify potential triggers to BPSDs while being engaged emotionally with the scenario.

Methods

Twenty-three health care professionals working with PLWD, 25 care partners to PLWD, 27 students in a health-related field, and 11 university/community college faculty members teaching courses relevant to gerontology tested the application which depicted a meal-time scenario. In addition to being asked about the behavioral triggers in the scene, participants were asked about the usefulness and usability of the tool for training. Presence and simulator sickness were also measured.

Results

Results suggest that participants generally felt present and emotionally engaged. They could identify the potential triggers for the observed behaviors in the virtual human with dementia as well as suggest some solutions. The majority (87% of participants) found the tool easy to use. Many participants identified the inability to interact with the virtual humans as a shortfall, and few reported mild to moderate levels of simulator sickness.

Discussion

As the behavioral changes associated with dementia can cause extreme stress for those interacting with PLWD, developing an effective and efficient training tool could significantly improve well-being for all involved. The investigators see the development and testing of an interactive version of this virtual environment as a next step in making this a clinically relevant training tool.

Family and domestic violence policy discourses and narratives: implications for Emergency Departments and communities in rural Australia

BACKGROUND

Australian data has indicated that the frequency and severity of family and domestic violence (FDV) tends to increase with remoteness. Rural communities rely on Emergency Departments (ED) within public hospitals for general health and safety needs. Public health departments within Australia are strongly influenced by Government policies which can define 'health problems' and limit institutional responses to patients presenting with FDV. The current study therefore aimed to critically examine FDV Australian Government policies to explore how policy meanings could potentially impact on ED staff and individuals within rural communities.

METHODS

Foucauldian Discourse Analysis and Policy Narrative Analysis were used to examine 9 policy documents which represented national, state/territory and clinical practice levels. Publication dates ranged from 2006 to 2020.

RESULTS

A total of 8 discourses were identified, with each one providing a unique construction of the target problem and determining the potential agency of health professionals and subjects of FDV. Discourses combined to produce an overall narrative within each policy document. Narrative constructions of the target problem were compared which produced three narrative themes: 1) Deficit Subject Narratives; 2) Object Oriented Narratives; and 3) Societal Narratives.

CONCLUSION

The results reflected a transition in the meaning of FDV within Australian society and over the past decade, with policies trending away from Deficit Subject Narratives and towards Object Oriented or Societal Narratives. Institutional systems, sociohistorical context and broader societal movements may have shaped this transition by stagnating policy meanings or introducing new insights that expanded the possibilities of understanding and action. Narratives produced assumptions which significantly altered the relevance and agency of individuals and groups when applied to a rural ED setting. As FDV was moved out of the clinical space and into the public domain, the agency of health professionals was reduced, while the values and strengths of FDV subjects and rural communities were potentially recognised. Later policies provided contextual specificity and meaning fluidity that could benefit diverse groups within rural areas; however, the expectation for ED staff to learn from their communities and challenge institutionalised approaches to FDV requires careful consideration in relation to rural hospital systems and resources.

Activistic citizenship in nursing homes: co-ownership in the mundane

The traditional narrative of dementia, focused on cognition as constructive of personhood, has been challenged by person-centred care as well as a rights-based citizenship lens. However, reports of everyday discrimination leading to occupational deprivation and pathologising interpretations of people living with dementia in nursing homes highlight the need for further investigation. The purpose of this study was to investigate the transformative power of mundane and relational enactments of citizenship in nursing homes, exploring the potential of adding an activistic lens of citizenship to our interpretive practices. Through an ethnographic study in Norwegian nursing homes, a narrative analysis of fieldnotes and interview transcripts was conducted. Narratives were interpreted using narrative theory, occupational perspectives and theories of citizenship. Findings reveal a phenomenon of shared ownership between residents and staff, and a vulnerable balance between silence and active social and occupational engagement in the nursing homes. Further, they shed light on how group-based assessments of residents' abilities or occupational needs may constrain opportunities, and staffs' options, to facilitate co-ownership. We suggest that a lens of activistic citizenship implies interpreting residents' behaviours as mundane forms of subtle resistance. A professional and ethical responsibility building on such interpretive practices may turn attention towards structures that constrain residents' expressions of citizenship.

Using the Consolidated Framework for Implementation Research to Foster the Adoption of a New Dementia Education Game During the COVID-19 Pandemic

BACKGROUND AND OBJECTIVES

The pandemic of coronavirus disease 2019 challenged educators to move staff education online and explore innovative ways to motivate learning to support dementia care for patients in geriatric settings. This article presents how the Consolidated Framework for Implementation Research (CFIR) was used to support the adoption of an online dementia education game in Canadian hospitals and long-term care homes (LTC). The dementia education was codeveloped with local staff and patient partners to teach practical person-centered care communication techniques.

RESEARCH DESIGN AND METHODS

CFIR guided our strategy development for overcoming barriers to implementation. Research meetings were conducted with practice leaders, frontline health care workers, and a patient partner. Our analysis examined 4 interactive domains: intervention, inner context, outer settings, and individuals involved and implementation process.

RESULTS

Our analysis identified 5 effective strategies: Easy access, Give extrinsic and intrinsic rewards, Apply implementation science theory, Multiple tools, and Engagement of champion. The CFIR provided a systematic process, a comprehensive understanding of barriers, and possible enabling strategies to implement gamified dementia education. Interdisciplinary staff (n = 3,025) in 10 hospitals and 10 LTC played online games. The evaluation showed positive outcomes in knowledge improvement in person-centered dementia care.

DISCUSSION AND IMPLICATIONS

Gamified education in dementia care offers a social experience and a component of fun to promote adoption. In addition, CFIR is useful for engaging stakeholders to conduct project planning and team reflection for implementation. The real-time discussion and adjustment helped overcome challenges and timely meet the needs of multiple organizations.

'Vulnerable Monsters': Constructions of Dementia in the Australian Royal Commission into Aged Care

This paper argues that while regulatory frameworks in aged care authorise restraints to protect vulnerable persons living with dementia from harm, they also serve as normalising practices to control challenging monstrous Others. This argument emerges out of an observed unease in aged care discourse where older people living with dementia are described as 'vulnerable', while dementia behaviours are described as 'challenging'. Using narrative analysis on a case study from the Final Report of the Australian Royal Commission into Aged Care Quality and Safety (RCAC), this paper investigates how the RCAC (re)produced constructions of persons with dementia as 'vulnerable monsters'. Drawing upon monstrous theory about 'unruly and leaky' bodies, extracts from the case study reveal how the RCAC repeated and reinforced monstrous constructions of dementia. Dementia behaviours, particularly 'wandering', were constructed through a dehumanising crisis frame that produced 'challenging' bodies and legitimised 'last resort' normalising practices, such as physical and chemical restraints. In failing to resist monstrous constructions of dementia behaviours, the RCAC accepted and authorised a regime of scaled responses leading to restrictive practices for control of challenging bodies in aged care. Although dementia care and restrictive practices received substantial attention in the RCAC, this paper reveals a missed opportunity for deeper review of institutionalised use of restraints that has relevance for ongoing reform of Australian aged care following conclusion of the RCAC.

A conversational, small-story approach to narrative care for people with dementia living in care institutions: Strategies and challenges

The aim of the paper was to define what narrative care is and identify and discuss everyday conversational narrative care strategies regarding people living with dementia in long-term care institutional settings. To do so, we differentiate between two approaches to narrative care: a big-story approach (reflecting on life stories) and a small-story approach (enacting stories in everyday conservations). The paper is focused on the second approach, which appears to be particularly fit to be used with people living with dementia. We identify three main strategies to implement this approach in everyday care: (1) prompting and sustaining narratives; (2) valuing non-verbal and embodied cues; and (3) constructing narrative environments. Finally, we discuss some training, institutional and cultural barriers and challenges for providing conversational, small story-based narrative care for people living with dementia in long-term care institutions.

Within moments of becoming-everyday citizenship in nursing homes

BACKGROUND

Humans are occupational beings. Our occupational choices depend on the opportunities available to us, and within nursing homes, institutional rules or structures may limit occupational engagement. An everyday citizenship lens acknowledges the importance of people's rights as citizens as well as engagement in mundane aspects of the everyday, highlighting diverse expressions of agency.

AIMS/OBJECTIVES

To show how older residents living with dementia in nursing homes can realize their everyday citizenship.

METHODS

A phenomenologically inspired ethnographic study was conducted in nursing home units in Norway, exploring everyday citizenship through narrative analysis.

RESULTS

Within everyday environments of care, the narratives of May, Janne and Camilla tell stories of spontaneous initiatives towards contribution and responsibilities, highlighting their continuous occupational natures.

CONCLUSION

Becoming can be seen as constitutive of self and identity, through residents' actions and contributions within the mundane and ordinary of everyday life, as an essential part of everyday citizenship.

SIGNIFICANCE FOR PRACTICE

A citizenship of becoming presupposes that institutional perceptions of activities being offered ought to be broadened towards supporting residents' natural desires to do and act within the mundane and ordinary of everyday life.

Implementation and impacts of virtual team-based care planning for older persons in formal care settings: A scoping review

Objective

This scoping review aimed to summarize current knowledge about the implementation, impacts, facilitators and barriers of virtual team-based care planning for older persons in formal care settings (e.g. home and community, primary, long-term and acute care).

Methods

The Joanna Briggs Institute (JBI) methodology was used. The Arksey and O'Malley and Levac, Colquhoun, and O'Brien methodologies provided additional frameworks. Databases accessed included PubMed, EMBASE, CINAHL, AgeLine, PsycInfo and Scopus. Reference lists of selected articles and grey literature retrieved through Google and Google Scholar were also reviewed. Three researchers screened titles, abstracts and conducted full-text reviews. Extracted data were mapped in a table and analysed for summative themes. Older persons and family partners assisted in interpreting findings based on their lived experiences.

Results

A total of 27 studies were included. Virtual team-based care planning led to many positive outcomes for older persons (e.g. decreased depression, reduced falls and improved medication management) and their families (e.g. reduced caregiver stress and improved caregiving skills). Only four studies reported the involvement of older persons and/or families in virtual team-based care planning. Multiple barriers to adopting virtual team-based care planning were found including lack of education/training for older persons and families in using technology.

Conclusion

Despite the multiple advantages that virtual team-based care planning offers for older persons and families, it is important to ensure that this care can be offered to all. There is a need to ensure that health equity is addressed to promote access to care and respond to social determinants of health.

Application of the Person-Centered Care to Manage Responsive Behaviors in Clients with Major Neurocognitive Disorders: A Qualitative Single Case Study

OBJECTIVES

Our study aimed to describe "how" and "why" the person-centered care (PCC) approach was applied within a long-term care (LTC) community to manage responsive behaviors (RBs) in individuals with major neurocognitive disorders.

METHODS

A descriptive holistic single case study design was employed in the context of an LTC community in Quebec, using semi-structured interviews and non-participatory observations of experienced care providers working with clients with RBs, photographing the physical environment, and accessing documents available on the LTC community's public website. A thematic content analysis was used for data analysis.

RESULTS

The findings generated insight into the importance of considering multiple components of the LTC community to apply the PCC approach for managing RBs, including a) creating a homelike environment, b) developing a therapeutic relationship with clients, c) engaging clients in meaningful activities, and d) empowering care providers by offering essential resources.

CONCLUSIONS

Applying and implementing the PCC approach within an LTC community to manage clients' RBs is a long-term multi-dimensional process that requires a solid foundation.

CLINICAL IMPLICATIONS

These findings highlight the importance of considering multiple factors relevant to persons, environments, and meaningful activities to apply the PCC approach within LTC communities to manage RBs.

Waiting for home: The experience of delayed discharge for people with dementia

INTRODUCTION

Individuals who remain in hospital once their health has stabilised experience delayed discharge. This often occurs for people with dementia when care needs exceed what can be managed at home. There is little research that takes into account the experience and needs of these patients. This Interpretive Description (ID) study, theoretically grounded in personhood and social citizenship perspectives, focused on the perspectives of people with dementia experiencing delayed discharge to address this gap in research and to better understand how nursing care can be improved for them.

METHODS

Twenty-one individuals participated in this study: eight patient participants experiencing delayed discharge and living with dementia, six family members, and seven nurses. Data collection methods primarily included participant observations, totalling 100 h of observations. Fourteen semi-structured interviews were also conducted with family members and nurses and with one patient participant. Informal conversations were undertaken with patient participants who did not take part in interviews.

RESULTS

Thematic analysis resulted in three main themes, encapsulating the patients' experiences: (1) Living and Waiting; (2) Distress and Behaviours; and (3) Looking Beyond the Designation. Findings are discussed in the context of the passive nature of delayed discharge care, the need for person-centred care, and prevailing discourses around the behavioural symptoms of dementia.

CONCLUSION

Implications for nursing practice include the need to acknowledge and foster the abilities of people with dementia. The behaviour narrative and labelling prevalent in hospitals must also be challenged. Lastly, nurses need to recognise the significant transition that is the delayed discharge experience, especially for people with dementia. This study advocates for person-centred and inclusive nursing care, where ongoing needs are recognised and addressed, particularly for people with dementia experiencing delayed discharge, who are waiting for home.

The influence of Alzheimer's disease stigma on pain assessment in older persons

INTRODUCTION

Pain of nursing homes residents with Alzheimer's disease remains under detected compared to their cognitively intact counterparts. Communication difficulties may partly explain this poor quality of care but the influence of stigmatization on pain assessment has never been explored.

RESEARCH QUESTION

The objective of this research was to analyze whether a diagnosis label of Alzheimer's disease or the stage of the disease may bias pain assessment scores and empathic reactions of health care staff in nursing homes.

METHODS

Two studies were conducted based on a similar experimental between-subjects design with a video showing an older adult woman experiencing undefined pain. Different labels and vignettes were manipulated to characterize the subject of the video. In the first study, 84 certified nursing assistants were asked to watch the video and then to assess the pain intensity and their empathic reaction. Participants were randomized in two conditions that varied the disease label (Alzheimer's disease vs no diagnosis). In the second study, 67 certified nursing assistants were enrolled who did not participate in the first study. They watched the same video as in the first study and assessed the pain intensity and their empathic reaction. They were randomized in two conditions that varied the stage of the Alzheimer's disease (mild stage vs severe stage).

RESULTS

Alzheimer's disease label had no influence on assessment scores. In contrast, the stage of the disease had a significant effect on the health care staff assessments with severe stage associated with lower pain intensity scores and empathic reactions.

CONCLUSION

These results confirm that the Alzheimer's disease stigma is a real phenomenon that tends to be mainly elicited by the symptoms of the acute phase of the disease. These findings are crucial to better understand the stigma related to Alzheimer's disease and to enhance the pain management of this frail population.

Relational Care, Dementia, and Communication Challenges in Long-Term Care: A Meta-Ethnography

Few studies examine care as a relational process in long-term care, and still fewer describe the participation of residents with dementia. In this article, our objective was to understand the development of knowledge in this area by means of a meta-ethnography. Our search and selection process resulted in six eligible articles. Each documents a qualitative study of resident-staff interactions during care activities in a residential care setting, and includes participants with dementia. Tronto's 4 Phases of Care were used to guide the identification of relational care practices within the articles selected. We identified five translatable concepts across the six studies: (1) doing with versus doing for, (2) staff responsiveness, (3) resident agency, (4) inclusive communication, and (5) time. In our new configuration of relational care, we combine these concepts to delineate an "interactive space" in which the agency of residents and initiative of staff are equally visible.

Improving the appropriateness of psychotropic prescribing for nursing home residents with dementia: an overview of reviews

OBJECTIVES

Psychotropic medications are commonly inappropriately prescribed for people with dementia (PwD) residing in nursing homes. This population is often multi-morbid, receiving multiple medications and therefore at an increased risk of mortality. This overview aimed to collate all synthesised quantitative, qualitative, and mixed-method evidence pertaining to the effectiveness of interventions aimed at reducing inappropriate psychotropic prescribing for nursing home residents with dementia; the perceived barriers and facilitators to the implementation of these interventions; and the attitudes and experiences of stakeholders toward prescribing. Method: An overview of reviews was conducted (PROSPERO protocol registration CRD42020187288). Five databases were systematically searched from January 2010 through June 2020, supplemented by grey literature searching. Reviews presenting evidence pertaining to either randomised controlled trials (RCT) aiming to reduce inappropriate prescribing or qualitative/mixed method studies of stakeholder views, were included.

RESULTS

Of 273 records identified, 11 systematic reviews were included. The quality of reviews ranged from critically low to moderate. There was mixed evidence for the use of education-only interventions. Multicomponent interventions (typically staff education combined with organisational and structural components), medication review, and interventions aimed at cultural change were evidenced as effective compared to care as usual. Stakeholders cited the importance of multidisciplinary collaboration and targeting organisational climate in changing psychotropic prescribing behaviours.

CONCLUSIONS

The inappropriate use of psychotropic medications in nursing homes for PwD is a complex issue with many contextual factors. The evidence suggests a comprehensive approach, targeting organisational climate and multidisciplinary collaboration, along with staff education and training, may be an effective strategy.

Behavioral and Psychological Symptoms of Dementia as a Means of Communication: Considerations for Reducing Stigma and Promoting Person-Centered Care

Dementia has rapidly become a major global health crisis. As the aging population continues to increase, the burden increases commensurately on both individual and societal levels. The behavioral and psychological symptoms of dementia (BPSD) are a prominent clinical feature of Alzheimer’s disease and related dementias (ADRD). BPSD represent a myriad of manifestations that can create significant challenges for persons living with dementia and their care providers. As such, BPSD can result in detriments to social interaction with others, resulting in harm to the psychosocial health of the person with dementia. While brain deterioration can contribute to BPSD as the disease progresses, it may be confounded by language and communication difficulties associated with ADRD. Indeed, when a person with dementia cannot effectively communicate their needs, including basic needs such as hunger or toileting, nor symptoms of pain or discomfort, it may manifest as BPSD. In this way, a person with dementia may be attempting to communicate with what little resources are available to them in the form of emotional expression. Failing to recognize unmet needs compromises care and can reduce quality of life. Moreover, failing to fulfill said needs can also deteriorate communication and social bonds with loved ones and caregivers. The aim of this review is to bring the differential of unmet needs to the forefront of BPSD interpretation for both formal and informal caregivers. The overarching goal is to provide evidence to reframe the approach with which caregivers view the manifestations of BPSD to ensure quality of care for persons with dementia. Understanding that BPSD may, in fact, be attempts to communicate unmet needs in persons with dementia may facilitate clinical care decisions, promote quality of life, reduce stigma, and foster positive communications.

"Uncivilized children" or "victims of dementia": Interpretations of aggression in older assisted living tenants

This study explores interpretations of interpersonal aggression involving older adults, through an analysis of semi-structured interview data from 13 assisted living (AL) tenants and 19 AL service and/or care workers. Differing relations (tenant-tenant and tenant-worker) shape the kinds of tenant actions experienced as problematic and/or aggressive. Tenants and workers invoke communal living, aging, and dementia as explanatory frames, in part to mitigate victimization experiences through normalization and neutralization. This was more prominent among workers, who are less able to enact empowering responses as they sought to keep working in difficult circumstances. Structural constraints, and the power and social hierarchies that contribute to victimization, generate interpretive responses that obscure fulsome and contextualized understandings of the problem while further reinforcing oppressive discourses including a sense of the inevitability of aggression in older adults-especially those living with dementia.

Implementing Gentle Persuasive Approaches dementia education for staff on in-patient medicine units: A program evaluation

Older adults with dementia, when hospitalised, frequently experience responsive behaviours. Staff struggle to manage responsive behaviours without specific education. We aimed to enhance staff knowledge and confidence with care for older adults with dementia and responsive behaviours on medicine units at a Canadian hospital. An online dementia education program was disseminated to staff as part of a broader quality improvement project. Gentle Persuasive Approaches (GPA) encourages staff to reframe responsive behaviours as self-protective expressions of unmet needs and learn to assess their meaning. Participants completed online quantitative and qualitative measures of self-efficacy, competence and knowledge in dementia care at three times: immediate pre-, immediate post- and six to eight weeks post-GPA eLearning. Immediately post-GPA, participants showed significant increases relative to baseline in dementia care self-efficacy, competence and knowledge. Self-efficacy scores increased further eight weeks post-GPA. Before GPA, few participants described dementia-specific strategies for de-escalating a patient’s agitation. Eight weeks post-GPA, participants described application of tailored, person-centred, non-pharmacological interventions and successful application of GPA strategies. GPA eLearning strengthened staff preparedness to interact with older adults experiencing responsive behaviours, thus enhancing their care.

Hearing Assessment and Rehabilitation for People Living With Dementia

Hearing impairment commonly co-occurs with dementia. Audiologists, therefore, need to be prepared to address the specific needs of people living with dementia (PwD). PwD have needs in terms of dementia-friendly clinical settings, assessments, and rehabilitation strategies tailored to support individual requirements that depend on social context, personality, background, and health-related factors, as well as audiometric HL and experience with hearing assistance. Audiologists typically receive limited specialist training in assisting PwD and professional guidance for audiologists is scarce. The aim of this review was to outline best practice recommendations for the assessment and rehabilitation of hearing impairment for PwD with reference to the current evidence base. These recommendations, written by audiology, psychology, speech-language, and dementia nursing professionals, also highlight areas of research need. The review is aimed at hearing care professionals and includes practical recommendations for adapting audiological procedures and processes for the needs of PwD.

Dementia and sexuality in long-term care: Incompatible bedfellows?

Despite the recognized benefits of sexual expression and its importance in the lives of people living with dementia, research demonstrates that there are multiple barriers to its positive expression (e.g., expression that is pleasurable and free of coercion, discrimination, and violence) in RLTC homes. These barriers constitute a form of discrimination based on age and ability, and violate the rights of persons living with dementia to dignity, autonomy, and participation in everyday life and society. Drawing on a human rights approach to dementia and sexual expression, we explored the experiences of diverse professionals, family members, and persons living with dementia with explicit attention to the ways in which macro-level dynamics are influencing the support, or lack thereof, for sexual expression at the micro level. Focus groups and in-depth interviews were conducted with 27 participants, and the collected data were analyzed thematically. While all participants acknowledged that intimacy and sexual expression of persons living with dementia should be supported, rarely is such expression supported in practice. Micro-level factors included negative attitudes of professionals toward sexual expression by persons living with dementia, their discomfort with facilitating intimacy and sexual expression in the context of their professional roles, their anxieties regarding potential negative reactions from family members, and concerns about sanctions for failing to prevent abuse. In our analysis, we importantly trace these micro-level factors to macro-level factors. The latter include the cultural stigma associated with dementia, ageism, ableism, and erotophobia, all of which are reproduced in, and reinforced by, professionals' education, as well as legal and professional standards that exclusively focus on managing and safeguarding residents from abuse. Our analysis demonstrates a complexity that has enormous potential to inform future research that is critically needed for the development of educational initiatives and to promote policy changes in this area.

Family caregiver competence in managing behavioral and psychological symptoms of dementia: A concept synthesis

AIM

This study aimed to identify the attributes of "family caregiver competence in managing behavioral psychological symptoms of dementia".

METHODS

Six electronic databases were searched for studies published between January 1990 and June 2017 with the key words "dementia", "behavioral psychological symptoms of dementia", "caregiver", "coping (managing)", and "competence". From the final fully reviewed 26 articles, descriptions related to family caregiver's dealing with behavioral psychological symptoms of dementia were extracted first. Then, based on Walker and Avant's concept synthesis, the concept of "family caregiver competence in managing behavioral psychological symptoms of dementia" was explored.

RESULTS

Four attributes, namely "Judging", "Empathizing", "Adjusting", and "Reflecting", comprised of ten categories were identified as constituting the concept of family caregiver competence in managing the behavioral psychological symptoms of dementia. As a meta competence, "reflecting" may play a significant role in improving family caregiver competence by interacting with the other dimensions of competence in managing symptoms.

CONCLUSIONS

Based on the suggested conceptual model, education or training programs could be developed to improve family caregiver competence in managing behavioral psychological symptoms of dementia. To refine the attributes found in this study, field studies including observations of and interviews with family caregivers need to be conducted. Studies exploring the associations between these attributes are also of value.

Virtual team-based care planning with older persons in formal care settings: a scoping review protocol

INTRODUCTION

COVID-19 has necessitated greater adoption of virtual care (eg, telephone (audio), videoconference) delivery models. Virtual care provides opportunities for innovative practice in care planning with older persons and meaningful family engagement by synchronously involving multiple care providers. Nevertheless, there remains a paucity of summarising evidence regarding virtual team-based care planning for older persons. The purpose of this scoping review is to summarise evidence on the utilisation of virtual team-based care planning for older persons in formal care settings. Specifically, (1) what has been reported in the literature on the impact or outcomes of virtual team-based care planning? (2) What are the facilitators and barriers to implementation?

METHODS AND ANALYSIS

This scoping review will follow a rigorous and well-established methodology by the Joanna Briggs Institute, supplemented by the Arksey & O'Malley and Levac, Colquhoun, & O'Brien frameworks. A three-step search strategy will be used to conduct a search on virtual team-based care planning for older persons in formal care settings. Keywords and index terms will be identified from an initial search in PubMed and AgeLine, and used to conduct the full search in the databases PubMed, EMBASE, CINAHL, AgeLine, PsycInfo and Scopus. Reference lists of included articles and grey literature retrieved through Google and Google Scholar will also be reviewed. Three researchers will screen titles and abstracts, and will conduct full-text review for inclusion. Extracted data will be mapped in a table.

ETHICS AND DISSEMINATION

Research ethics approval is not required for data collection from publicly accessible information. Findings will be presented at conferences, submitted for open-access publication in a peer-reviewed journal and made accessible to multiple stakeholders. The scoping review will summarise the literature on virtual team-based care planning for the purpose of informing the implementation of a virtual PIECES™ intervention (Physical/Intellectual/Emotional health, Capabilities, Environment, and Social).

Relationship between environmental factors and responsive behaviours in long-term care homes: a secondary data analysis

OBJECTIVE

Responsive behaviours (eg, wandering, resisting care and verbal abuse) are a continuing issue for staff and individuals living in long-term care (LTC) homes. The LTC environment can influence responsive behaviours and is a factor in determining the quality of life for those living there. The ways in which the quality of the environment might influence responsive behaviours has not been investigated yet. We hypothesised that better quality environments would be associated with reduced rates of responsive behaviours. We used a tool that simultaneously encompasses human and structural elements of the environment, a novel approach in this field of research.

DESIGN

Cross-sectional study, using data collected from September 2014 to May 2015 as part of the Translating Research in Elder Care research programme.

SETTING

A representative, stratified (size, owner-operator model and health region) random sample of 76 LTC homes in British Columbia, Alberta, Manitoba.

PARTICIPANTS

13 224 individuals (67.3% females) living in participating LTC homes.

OUTCOME MEASURES

Quality of care unit work environment was assessed using the observable indicators of quality (OIQ) tool. Responsive behaviours were assessed using routinely collected Resident Assessment Instrument-Minimum Data Set V.2.0 data.

RESULTS

Adjusted regression coefficients of overall Aggressive Behaviour Scale score and interpersonal communication were 0.02 (95% CI -0.011 to 0.045), grooming 0.06 (95% CI -0.032 to 0.157), environment-basics 0.067 (95% CI 0.024 to 0.110), odour -0.066 (95% CI -0.137 to -0.004), care delivery -0.007 (95% CI -0.033 to 0.019), environment-access -0.027 (95% CI -0.062 to 0.007), environment-homelike -0.034 (95% CI -0.065 to -0.002) and total OIQ score 0.003 (95% CI -0.004 to 0.010).

CONCLUSIONS

We found small associations between the environmental quality and responsive behaviours in Western Canadian LTC homes. Higher scores on homelikeness were associated with decreased responsive behaviours. Higher scores on basic environmental quality were associated with increased responsive behaviours.

The "Counseling+" Roles of the Speech-Language Pathologist Serving Older Adults With Mild Cognitive Impairment and Dementia From Alzheimer's Disease

Purpose

Persons with dementia and mild cognitive impairment (MCI) are major consumers of services provided by speech-language pathologists (SLPs). These services include not only direct assessment and treatment of communication and swallowing but also counseling, collaboration, prevention, and wellness. These "counseling+" activities can be especially challenging for SLPs to deliver because of the lack of evidence, as well as the complex nature of Alzheimer's disease (AD) and other conditions that cause MCI and dementia.

Method

This tutorial is written by a speech-language pathologist, a neuropsychologist, and a geriatric psychiatrist to provide education, resources, and recommendations for SLPs delivering counseling+ activities to patients with MCI and dementia from AD and related disorders.

Results and Conclusions

We describe counseling+ activities across the continuum of care ranging from educating and conducting cognitive screenings with adults experiencing age-related cognitive decline to supporting end-of-life wishes. Because of their expertise in communication, SLPs can provide an array of important leading and supporting services to patients, their family, and other health care professionals on the care team, such as providing patients with appropriate feedback following a cognitive screening and helping caregivers identify the communicative intent of a responsive behavior. The demand for SLP services for patients with MCI and dementia will grow significantly over the next few decades, necessitating more systematic research and clinical evidence in this area.

Behaviour assessment tools in long-term care homes in Canada: a survey

OBJECTIVE

Many people living in long-term care homes (LTCH) experience changes in behaviour termed the behavioural and psychological symptoms of dementia (BPSD). The valid and reliable assessment of BPSD is essential to guide treatment and monitor the effect of interventions. The aim of this study was to identify behavioural assessment tools implemented in LTCH and factors that impact on their use in clinical care.

METHODS

We completed an online mixed-design survey of 300 randomly selected Canadian LTCH between September and November 2018. Respondents were asked to report tools used, reasons for use, methods of administration, training/supports available, confidence in use and challenges faced. Survey results were summarized descriptively and the correlation between implementation supports and confidence examined. Free-text responses were analysed qualitatively.

RESULTS

Of 300 LTCH invited to participate, 103 completed the survey. Homes reported using a mean 2.2 ± 1.1 (range 0-7) different tools. The two most commonly used tools were the Dementia Observation System (DOS) and Cohen-Mansfield Agitation Inventory (CMAI). Overall confidence in most aspects of tool use was reported to be high, with workload identified as the greatest challenge. Training and supports correlated with confidence in tool use. Qualitative findings indicate tools provide valuable data to understand behaviours, facilitate team communication, target interventions and track outcomes.

CONCLUSIONS

Behavioural assessment tools, in particular a direct observation tool, are widely used in clinical care in Canadian LTCH. Education, enhanced resources, leadership support and applications of technology represent opportunities to improve their use.

A mixed methods study on the manifestations of behavioural symptoms of dementia among veterans with and without posttraumatic stress disorder

AIMS

To explore how behavioural symptoms of dementia are manifested among veterans in residential long-term care settings, in the context of personal, interpersonal/social and environmental triggers and how the manifestations differ between veterans with and without posttraumatic stress disorder.

DESIGN

Secondary analysis using a mixed methods approach.

METHODS

We analysed text data from a stratified random sample of 66 cases derived from the programme evaluation dataset of the Staff Training in Assisted Living Residences-Veterans Health Administration (STAR-VA) intervention from 2013 to 2016, using framework analysis. The detailed behavioural assessment descriptions in this dataset are consistent with contemporary non-pharmacologic symptom management. Qualitative categories were converted to quantitative variables for two group comparisons.

RESULTS

Four patterns emerged linking specific types of triggers and behavioural symptoms: (1) unmet physical needs or emotional distress triggers non-aggressive behaviours; (2) unsolicited direct care approach triggers care refusal, resistance or combativeness; (3) interpersonal interactions interfering with self-direction trigger aggressive behaviours; and (4) uncontrolled stimulation from environments trigger non-aggressive behaviours. The organisational culture of care influenced how staff conceptualised behavioural symptoms. Veterans with co-existing posttraumatic stress disorder and dementia tended to exhibit rejection of care with aggression compared to those with dementia alone.

CONCLUSION

Contextualised accounts of behavioural symptoms of dementia revealed symptom heterogeneity, with different clusters of multi-level triggers arising from specific personal, interpersonal and environmental circumstances. Distinct patterns of symptom manifestations between veterans with and without posttraumatic stress disorder suggest a tailored approach is required to meet each veteran's unique biopsychosocial needs.

IMPACT

Classifying behavioural symptoms with their triggers rather than solely by behaviours provides important new information for developing person-centred, non-pharmacological interventions to improve outcomes for veterans with dementia. Multi-level interventions should be considered to meet veteran's needs that account for their earlier life history and current life circumstances.

Nurses' experiences of caring for persons with dementia experiencing responsive behaviours in an acute hospital: A qualitative descriptive study

OBJECTIVE

To explore nurses' experiences of caring for persons with dementia experiencing responsive behaviours in an acute hospital.

BACKGROUND

Caring for persons with dementia who have an acute medical illness and are experiencing responsive behaviours in acute hospitals can be challenging for nurses. While existing research has explored the experiences of nurses in providing dementia care in this setting, there is limited knowledge about the specific care experiences of nurses when working to meet the needs of persons with dementia who experience responsive behaviours alongside an admitting diagnosis.

METHOD

A qualitative descriptive design was implemented. Semi-structured interviews were carried out with nine nurses working in medical and surgical wards. A thematic analysis approach was used to analyse the data. Ethical approval to conduct the study was received from the writers' university.

RESULTS

Three themes were found: (a) challenges encountered, (b) a person-centred response and (c) dementia preparedness. Key findings about challenges encountered by nurses included: the acute hospital environment; increased need for enhanced knowledge; and emotional challenges. Person-centred responses such as working in partnership with others and reminiscence were identified as strategies to address the challenges. Finally, nurses identified particular interventions that were supportive to them in enhancing their preparedness to meet the needs of persons with dementia who experience responsive behaviours.

CONCLUSIONS

Persons with dementia who are acutely unwell and are experiencing responsive behaviours, within acute hospitals, have specific and individualised care needs. Nurses working in these settings must therefore be supported in developing competence in managing these frequently complex clinical cases, while also providing person-centred care.

IMPLICATION FOR PRACTICE

Nurses' narratives demonstrate that they continue to experience challenges in the presence of responsive behaviours. There is a consequent need for dementia-specific education on person-centred ways to address responsive behaviours within acute hospital settings.

A Feasibility Study of a Multifaceted Walking Intervention to Maintain the Functional Mobility, Activities of Daily Living, and Quality of Life of Nursing Home Residents With Dementia

PURPOSE

The aim of the study was to evaluate the feasibility, acceptability, and efficacy of a multifaceted walking intervention (MWI) aimed to maintain the functional mobility, activities of daily living function, and quality of life of long-term care home residents with dementia.

DESIGN/METHODS

A quasiexperimental time-series design was used. The 4-month intervention provided one-on-one walking 2-4 days a week, guided by an individualized communication care plan and interviews with collaterals and staff.

RESULTS

The MWI was feasible based on high recruitment and adherence rates (86% and 94%, respectively) and highly acceptable to stakeholders. Residents (n = 25) showed significant improvements after the intervention: Timed Up-and-Go (-8.85 seconds, p = .00), Two-Minute Walk Test (27.47 m, p = .00), Functional Independence Measure (0.72, p = .00), and Alzheimer's Disease-Related Quality of Life (2.44, p = .05).

CONCLUSION

The MWI was feasible and improved functional mobility compared to usual care.

CLINICAL RELEVANCE

Physical activity delivered with a person-centered care was feasible and may be beneficial to mitigate decline in long-term care home residents with dementia.

The language of behaviour changes in dementia: A mixed methods survey exploring the perspectives of people with dementia

AIMS

The aim of this study was to explore the opinions of people with dementia, about the language used to describe changes in behaviour associated with dementia.

DESIGN

This study adopted a human rights approach in a mixed methods convergent parallel synthesis design.

METHODS

Online and paper-based questionnaire data were collected between November 2019 and March 2020. A combination of convenience and purposive sampling was used to invite people with dementia to participate.

RESULTS

In total, 54 people completed the survey. There was no clear consensus on a preferred term, but 28.3% preferred the term 'unmet needs' for describing changes in behaviour associated with dementia. Qualitative data revealed important nuances and challenges for researchers and practitioners in relation to terminology for this paradigm. Participants felt that the language we use to talk about changes in behaviour could influence how people with dementia are viewed and treated and how people feel about themselves.

CONCLUSION

The majority of participants were familiar with a range of terminology. There was no universal agreement on terminology, but there was an overall preference for terms that reflect the unmet needs likely to underlie perceived changes in behaviour.

IMPACT

People with dementia raised concerns about the language used to describe changes in behaviour that can occur in dementia. There is scope for improvements in the language used for this paradigm in both research and practice. Following a diagnosis of dementia, clinicians need to take the time to explore an individual's preferences and understandings. They can then share their own understanding about the potential for changed behaviour and if relevant, how any negative impact of this may be minimized.

Les comportements des personnes âgées vivant avec un trouble neurocognitif : l’approche centrée sur les relations pour améliorer l’expérience de tous

Older people living with a major neurocognitive disorder often have difficulty communicating. They may exhibit reactive behaviors, such as vocal or aggressive behaviors, which are manifestations of malaise. These behaviors have consequences for these older people, as well as for their relatives and formal caregivers. This article discusses the relationship-centered approach to improving the experience of each of these persons by stimulating a reflection on what unites us. Then, the principles of this relationship-centered approach are outlined, based on the unique needs of each person, the reciprocity of their relationship, and their common aspirations. The application of these principles to older people living with a neurocognitive disorder who exhibit reactive behaviors is reflected through the adoption of consistent language, the identification of the meanings of behaviors and personalized actions, and the establishment of a care partnership. An example of a process integrating this approach is presented, as well as its possible effects. The adoption of this approach may present several challenges in care settings. To meet these challenges, implementation strategies are described promoting the adoption of this approach and contributing to everyone’s well-being.

Factors Influencing Nurse Assistants' Job Satisfaction in Nursing Homes in Canada and Spain: A Comparison of Two Cross-Sectional Observational Studies

OBJECTIVES

To access associations between job satisfaction and supervisory support as moderated by stress.

METHODS

For this cross-sectional study, data collected from 591 nursing assistants in 42 nursing homes in Canada and Spain were analyzed with mixed-effects regression.

RESULTS

In both countries, stress related to residents' behaviors was negatively associated with job satisfaction, and, in Canada, it moderated the positive association between supervisory support and job satisfaction. Stress related to family conflict issues moderated the positive association of supervisory support and job satisfaction differently in each location: in Canada, greater stress was associated with a weaker association between supervisory support and job satisfaction; in Spain, this was also observed but only when supervisory support was sufficiently weak.

DISCUSSION

Stress was associated with lower job satisfaction and moderated the association of supervisory support and job satisfaction, reinforcing the importance of supervisors supporting nursing assistants, especially during the COVID-19 pandemic.

Stories of violence and dementia in mainstream news media: Applying a citizenship perspective

In this article, we analyze how mainstream news media frames violence in relation to dementia and the consequences of different frames for people living with dementia and their carers. Conceptually, the goal is to bring literature on citizenship and aggression into dialog with each other. Empirically, a total of 141 regional and national English-language mainstream Canadian news media articles (2008-2019) with a focus on dementia, violence, and aggression were analyzed. Analytically, we examine how different actors are portrayed as victims or perpetrators; how their histories (identities, belonging, and exclusion) are told; how dementia is used to explain events; and what types of expert knowledge and authorities are introduced to make sense of stories of violence in relationships of care. Our analysis points to the implications of media narratives for people with dementia as well as carers and researchers seeking to address stigma and call for change.

An analysis of documentation language and word choice among forensic mental health nurses

Documenting patient care is an important part of mental health services. The documentation is expected to be accurate, relevant, and informative for all future readers as it provides details about patients and the care they are receiving. Language can produce positive or negative emotions in individuals, and these emotions can influence their thoughts and actions. Considering this, nursing documentation can impact the future care of patients. In this study, our aim was to analyse the language and words nurses use when documenting about their patients. Through a qualitative review of notes transcribed by mental health nurses in a forensic setting (n = 55), we explored the adjectives and verbs used across a subsection of their documentation over a three-month period. More specifically, we identified the most common words used, looked for patterns in use, and examined the emotional weight - or valence - of word choice. Examination of valence scores of the adjectives and verbs in the notes indicates that while nurses describe their patients in a rather neutral manner overall, some words and phrases are ambiguous and/or repetitive, and have the potential to negatively influence the perceptions of the reader regarding the patient. Clinical implications of patient care are discussed in the context of bias management. Nurses need to consider how word choice is linked to negative prosody and the need to provide additional information to avoid ambiguity. Without such care, notes can be subject to misinterpretation by readers leading to undue labels, stigma, and bias.

The influence of supervisory support, work effectiveness, work empowerment and stress secondary to residents' responsive behaviours on job satisfaction of nursing staff: A multisite cross-sectional study

AIM

To examine the association between stress secondary to residents' responsive behaviours and job satisfaction of nurses and nursing assistants working in nursing homes. To test whether supervisory support, work effectiveness and work empowerment confound this relationship.

BACKGROUND

Understanding how the stress secondary to residents' responsive behaviours influences job satisfaction for staff and determining the factors influencing this relationship are important for retention of staff in nursing homes. The term 'responsive behaviours' refers to the subset of behavioural and psychological symptoms of dementia.

METHODS

Survey responses from 191 nursing assistants and 81 nurses in five nursing homes in Ontario were analysed.

RESULTS

Staff's stress attributed to residents' responsive behaviours was negatively associated with job satisfaction. This direct effect was weakened by more than a third through the confounding net effects of supervisory support, work effectiveness and work empowerment.

CONCLUSION

The work environment created by leaders in nursing homes can lessen the influence of stress secondary to residents' responsive behaviours on staffs' job satisfaction.

IMPLICATIONS FOR NURSING MANAGEMENT

Supervisors need training and education to support and mentor their staff effectively, and to guide their use of evidence-based practices that integrate the patient-centred care approach in order to effectively respond and minimize responsive behaviours.

Aggression and Older Adults: News Media Coverage across Care Settings and Relationships

Systematic, in-depth exploration of news media coverage of aggression and older adults remains sparse, with little attention to how and why particular frames manifest in coverage across differing settings and relationships. Frame analysis was used to analyze 141 English-language Canadian news media articles published between 2008 and 2019. Existing coverage tended towards stigmatizing, fear-inducing, and biomedical framings of aggression, yet also reflected and reinforced ambiguity, most notably around key differences between settings and relations of care. Mainstream news coverage reflects tensions in public understandings of aggression and older adults (e.g., as a medical or criminal issue), reinforced in particular ways because of the nature of news reporting. More nuanced coverage would advance understanding of differences among settings, relationships, and types of actions, and of the need for multifaceted prevention and policy responses based on these differences.

Using touchscreen tablets to support social connections and reduce responsive behaviours among people with dementia in care settings: A scoping review

The use of touchscreen tablets, such as the iPad, offers potential to support the person with dementia staying in a care setting, ranging from a long-term care home to an adult day programme. Although electronic devices are used among people with dementia, a comprehensive review of studies focusing on their impact and how they may be used effectively in care settings is lacking. We conducted a scoping review to summarize existing knowledge about the impact of touchscreen tablets in supporting social connections and reducing responsive behaviours of people with dementia in care settings. Our research team consists of patient partners and family partners, physicians, nurses, a medical student and an academic professor. A total of 17 articles were included in the review. Our analysis identified three ways in which touchscreen tablets support dementia care: (1) increased the person’s engagement, (2) decreased responsive behaviours and (3) positive effect on enjoyment/quality of life for people with dementia. Lessons learned and barriers to the use of touchscreen tablets in the care of people with dementia are described. Overall, only a few studies delineated strategies that helped to overcome barriers to technology adoption in care settings. Knowledge translation studies are needed to identify effective processes and practical tips to overcome barriers and realize the potential of assistive technology in dementia care.

Approach Matters: Linking Practitioner Approaches to Technology Design for People with Dementia

Technology design for dementia is an active and growing area. Though work to date has largely addressed functional needs, there is a growing recognition of the importance of supporting meaningful activities. However, technology for active, rather than passive, engagement is relatively novel beyond specific applications (e.g., music or reminiscence therapy). To better understand how to support active engagement of people with dementia in activities, we interviewed nineteen practitioners. Our findings reveal differing approaches to making sense of the actions of people with dementia, as well as to engaging them in activities. We discuss the importance of tracing epistemological understandings of dementia to different configurations of technology for people living with dementia and provide a practical guide to support designers to do so. Finally, we discuss considerations for the design of dementia technologies around facilitating self-actualization and managing emotional exposure for care-providers.

Female family carers' experiences of violent, abusive or harmful behaviour by the older person for whom they care: a case of epistemic injustice?

Family carers affected by violent, abusive or harmful behaviour by the older person for whom they care face social and epistemic challenges in developing and sharing knowledge about their experiences. These difficulties have contributed to a situation in which there is a paucity of evidence and public discourse about how we understand violence and harm instigated by people who have care needs or are 'vulnerable'. This paper reports the findings of a qualitative study that involved 12 in-depth interviews with female carers affected by violence, abuse or harm. The study was informed theoretically by Miranda Fricker's concept of epistemic injustice which was used as a framework for analysis. There were two principal findings: (1) Carers were sensitive to anticipatory stigma and loss of moral autonomy. As a result, they self-censured what they shared and, at times, were met with subtle but powerful processes of silencing. (2) Carers had limited linguistic and conceptual resources to explain the emotional and social aspects of the harm they experienced, exacerbated by implicit social norms about the 'private' and gendered nature of familial care. To conclude, we discuss the implications of these findings for sociological research and health and social care practice.

Perceptions and needs regarding technologies in nursing homes: An exploratory study

Two of the most salient problems in nursing homes are the responsive behaviours and falls of older people living with Alzheimer's disease and related disorders. Intelligent videomonitoring and mobile applications are potential technologies that may help prevent and manage these problems. However, evidence for the needs for technologies in nursing homes is scarce. This study aimed to explore the perceptions and needs of care managers, and of formal and family caregivers in nursing homes regarding these potential technologies. With an exploratory qualitative design based on Rogers' diffusion of innovation theory, individual interviews and a content analysis were conducted. Results show that the potential users of these technologies consider them relevant in nursing homes. The characteristics that would make these technologies useful in nursing homes are described. These results could be used to develop useful technologies to improve the quality of clinical practice in nursing homes.

Dealing with the behaviour of residents with dementia that challenges: A stepped-wedge cluster randomized trial of two types of dementia-specific case conferences in nursing homes (FallDem)

BACKGROUND

The negative effects of behavioural changes among dementia residents and the consequences for caregivers are a major problem in the care of people with dementia. Case conferences (CC) are recommended as a useful method to understand the underlying causes of the behaviour and to plan tailored interventions OBJECTIVES: The aim of this article is to describe the effects of two dementia-specific CC models on the prevalence of behaviour that challenges and other secondary outcomes.

DESIGN

Stepped-wedge cluster randomized trial.

SETTING

Nursing homes: The inclusion criterion was the participation of at least two units with a minimum of 30 residents who were mainly cared for in the study units.

PARTICIPANTS

A total of 224 residents and 189 staff from six nursing homes in the IdA (Innovative dementia-orientated Assessment system) cohort and 241 residents and 284 staff from six nursing homes in the Neo (Narrative Approach) cohort were included in the study. The inclusion criteria were the following: medical diagnosis of dementia from nursing charts, FAST (Functional Assessment Staging) score > 1, living at least 15 days in the unit, and informed consent.

METHODS

The nursing homes were randomized to the type of intervention and time point of intervention delivery. The two interventions in the form of the case conference models (Welcome-IdA and -Neo) differed in the type of behaviour analysis method. The intervention duration was seven months. The primary outcome was the change in the prevalence of behaviour that challenges. Secondary outcomes were residents' quality of life, prescription of psychotropic medications, formal caregiver burnout, dementia-related stress, and vocational action competence. The outcomes were measured on seven data points every three months. Linear mixed-effects models were used to analyze intervention effects between the control, intervention and follow-up periods.

RESULTS

No differences were found concerning the primary outcome between the control and intervention cohorts for both CC models. Further exploratory data analyses showed a reduction in behaviours such as apathy (18%) and eating disturbances (29%) for the IdA cohort and hallucination (27%) and delusion (28%) in the NEO cohort. Only staff in the IdA cohort demonstrated a reduction in work-related burnout from the control phase to the intervention phase.

CONCLUSION

Specific CC for behaviour that challenges do not decrease the overall prevalence of residents showing changes in behaviour. However, there are indications that the case conferences influence some types of behaviour and reduce the risk factors for work-related burnout.

Conditions and ethical challenges that could influence the implementation of technologies in nursing homes: A qualitative study

AIM

To explore the conditions that may influence the implementation of an interactive mobile application (app) and an intelligent videomonitoring system (IVS) in nursing homes (NHs) and the ethical challenges of their use.

BACKGROUND

There is a lack of knowledge about implementing technologies in NHs and the ethical challenges that might arise. In past studies, nursing care teams expressed the need for technologies offering clinical support. Technologies like an IVS and an app could prove useful in NHs to prevent and manage falls and responsive behaviours.

DESIGN

An exploratory qualitative study was conducted with care managers, family caregivers and formal caregivers in five NHs.

METHODS

Each participant was shown a presentation of a potential app and a short video on an IVS. It was followed by an individual semi-structured interview. A conventional content analysis was performed.

FINDINGS

Potential users found it would be possible to implement these technologies in NHs even if resistance could be expected. To facilitate adoption and achieve clinical benefits, the implementation of technologies should be pilot-tested, and coaching activities should be planned. Ethical risks were considered already present in NHs even without technologies, for example, risks to privacy. Strategies were proposed, for instance, to adapt the code of ethics and procedures. Some potential prejudices about the interest and abilities of older staff, nurses' aides, and family caregivers to use technology were identified.

CONCLUSIONS

Through rigorous and ethical implementation, technologies supporting clinical care processes could benefit older people living in NHs, as well as their relatives and the staff.

IMPLICATIONS FOR PRACTICE

Various strategies are proposed to successfully implement technologies. Effort should be made to avoid prejudices during implementation, and procedures should be adapted to mitigate possible ethical challenges.

How do inpatient psychiatric nurses make sense of and respond to behaviours in dementia? An Interpretative Phenomenological Analysis

Objectives: Existing literature demonstrates that nurses' understanding of behaviours in dementia influences their responses to persons with dementia. However, there is limited research on the psychological processes involved in how nurses make sense of the behaviours and how these impact on responding, and a dearth of such literature from inpatient acute dementia settings. This study explored how inpatient psychiatric nurses make sense of and respond to behaviours in dementia. Method: This study employed Interpretative Phenomenological Analysis (IPA), a qualitative method that explores in detail how participants make sense of their experiences. Eight inpatient psychiatric nurses were recruited from two inpatient services within a National Health Service Mental Health Trust. Semi-structured interviews were conducted to gain an in depth understanding of their experience. Transcripts of the interviews were then analysed using IPA. Results: Four interrelated themes were identified: 'Effort to sense make', 'Pressures of the organisation', 'Balancing personal and professional selves: The underlying emotional connection'; and '"Looking back on it…"'. Conclusions: The study highlighted that sense making is a dynamic process, which occurs through a range of psychological processes and can change moment by moment dependent on the influences on the nurse. It demonstrated that nurses need to be supported to move flexibly through a range of emotional connections, which were found to underlie the negotiations made at work and influence sense making and responding. Nurses may benefit from space to reflect and formulate their understanding of clients, but further research is required to determine the effectiveness of this.