Monitoring quality of care for nursing home residents with behavioral and psychological symptoms related to dementia

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

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

Evaluating the Utility of a Structured Clinical Protocol for Reducing the Impact of Behavioural and Psychological Symptoms of Dementia in Progressive Neurological Diseases: A Pilot Study

Objectives

Behavioural and psychological symptoms of dementia (BPSD) cause significant distress to both aged care residents and staff. Despite the high prevalence of BPSD in progressive neurological diseases (PNDs) such as multiple sclerosis, Huntington's disease, and Parkinson's disease, the utility of a structured clinical protocol for reducing BPSD has not been systematically evaluated in PND populations.

Method

Staff (n = 51) and individuals with a diagnosis of PND (n = 13) were recruited into the study, which aimed to evaluate the efficacy of a PND-specific structured clinical protocol for reducing the impact of BPSD in residential aged care (RAC) and specialist disability accommodation (SDA) facilities. Staff were trained in the clinical protocol through face-to-face workshops, which were followed by 9 weeks of intensive clinical supervision to a subset of staff (“behaviour champions”). Staff and resident outcome measures were administered preintervention and immediately following the intervention. The primary outcome was frequency and severity of BPSD, measured using the Neuropsychiatric Inventory-Nursing Home Version (NPI-NH). The secondary outcome was staff coping assessed using the Strain in Dementia Care Scale (SDCS).

Results

In SDA, significant reductions in staff ratings of job-related stress were observed alongside a statistically significant decrease in BPSD from T1 to T2. In RAC, there was no significant time effect for BPSD or staff coping; however, a medium effect size was observed for staff job stress.

Conclusions

Staff training and clinical support in the use of a structured clinical protocol for managing BPSD were linked to reductions in staff job stress, which may in turn increase staff capacity to identify indicators of resident distress and respond accordingly. Site variation in outcomes may relate to organisational and workforce-level barriers that may be unique to the RAC context and should be systematically addressed in future RCT studies of larger PND samples.

Quality nursing care in dementia specific care units: A scoping review

Background

The concept of quality nursing care in a dementia specific unit is perceived as being subject to the interpretation of individuals, nurses and healthcare organisations. As the number of dementia diagnoses increases, understanding what constitutes quality nursing care within dementia specific care units is vital to inform policy makers and healthcare organisations globally. Efforts to identify quality nursing care and improve dementia care within dementia specific care units, may significantly reduce the financial and emotional burden of care-giving and improve the quality of life for individuals living with dementia. This scoping review aimed to examine current literature to gain an understanding of what constitutes quality nursing care in a dementia specific care unit.

Design and methods

Five electronic databases (CINAHL, MEDLINE, ProQuest, Social Sciences Citation Index and Ovid) were used to search for articles published in English between 2011 and 2016 focusing on a definition of quality nursing care within dementia specific care units. Findings: Twenty journal articles were identified. From these articles, two content themes were identified: Challenges in the provision of quality nursing care in dementia specific care units, and Standardised approach to quality nursing care in a dementia specific care unit. The articles contained the following research designs, controlled pre-test and post-test design ( n = 1), focus group interviews ( n = 1), cross sectional survey ( n = 6), semi structured interviews ( n = 3), narrative review ( n = 1), survey ( n = 2), literature review ( n = 3), systematic review ( n = 1), and prospective longitudinal cohort study ( n = 2).

Conclusions

The concept of quality nursing care in a dementia specific unit remains subject to the interpretation of individuals, nurses and healthcare organisations, with current literature unable to provide a clear definition. Further research into what constitutes quality nursing care in dementia specific care units is recommended.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Special care units and traditional care in dementia: relationship with behavior, cognition, functional status and quality of life - a review

Background

Special care facilities for patients with dementia gain increasing attention. However, an overview of studies examining the differences between care facilities with respect to their effects on behavior, cognition, functional status and quality of life is lacking.

Results

Our literature search resulted in 32 studies published until October 2012. Overall, patients with dementia who lived at special care units (SCUs) showed a significantly more challenging behavior, more agitation/aggression, more depression and anxiety, more cases of global cognitive impairment and a better psychosocial functioning. There was a tendency towards a better functional status in specialized care facilities, and a better quality of life was found in favor of the SCU group compared to the traditional nursing home (n-SCU) group. Longitudinal studies showed an increased number of neuropsychiatric cases, more patients displaying deteriorating behavior and resistance to care as well as less decline in activities of daily living (ADL) in the SCU group compared to the n-SCU group. Patients in small-scale, homelike SCUs showed more agitation and less ADL decline compared to SCU patients.

Conclusion

This review shows that the patient characteristics in SCU and n-SCU settings and, to a minor extent, in SCU and small-scale, homelike SCU settings are different. Over time, there are differences between n-SCU, SCU and small-scale, homelike SCU facilities for some variables.

The clinical problem of neuropsychiatric signs and symptoms in dementia

PURPOSE OF REVIEW

This article reviews behavioral signs and symptoms of dementia that can lead to increased mortality, excessive cognitive and functional disability, early institutionalization, and increased caregiver burnout.

RECENT FINDINGS

Almost all patients with a dementia will develop significant behavioral disturbances at some point over the course of their illness. These behavioral signs and symptoms rarely fit into usual diagnostic classifications or meet full criteria for a formal major psychiatric disorder.

SUMMARY

Treatment of behavioral signs and symptoms of dementia should include both pharmacologic and nonpharmacologic interventions. There are currently no treatments for these disturbances approved by the US Food and Drug Administration. Best judgment should be used in identifying dominant target symptoms and matching them to the most relevant drug class. Implementing nonpharmacologic interventions before the development of neuropsychiatric symptoms may prevent triggers related to a progressively lowered stress threshold and therefore is key in the treatment of all patients with a dementia.