The Rights of Persons With Dementia and Their Meanings

Efficacy of COMPAs, an App Designed to Support Communication Between Persons Living With Dementia in Long-Term Care Settings and Their Caregivers: Mixed Methods Implementation Study

BACKGROUND

Persons living with dementia experience autonomy loss and require caregiver support on a daily basis. Dementia involves a gradual decline in communication skills, leading to fewer interactions and isolation for both people living with dementia and their caregivers, negatively impacting the quality of life for both members of the dyad. The resulting stress and burden on caregivers make them particularly susceptible to burnout.

OBJECTIVE

This study aims to examine the efficacy of Communication Proches Aidants (COMPAs), an app designed following the principles of person-centered and emotional communication, which is intended to improve well-being in persons living with dementia and caregivers and reduce caregiver burden.

METHODS

In this implementation study, volunteer caregivers in 2 long-term care facilities (n=17) were trained in using COMPAs and strategies to improve communication with persons living with dementia. Qualitative and quantitative analyses, semistructured interviews, and questionnaires were completed before and after 8 weeks of intervention with COMPAs.

RESULTS

Semistructured interviews revealed that all caregivers perceived a positive impact following COMPAs interventions, namely, improved quality of communication and quality of life among persons living with dementia and caregivers. Improved quality of life was also supported by a statistically significant reduction in the General Health Questionnaire-12 scores (caregivers who improved: 9/17, 53%; z=2.537; P=.01). COMPAs interventions were also associated with a statistically significant increased feeling of personal accomplishment (caregivers improved: 11/17, 65%; t15=2.430; P=.03; d=0.61 [medium effect size]).

CONCLUSIONS

COMPAs intervention improved well-being in persons living with dementia and their caregivers by developing person-centered communication within the dyad, increasing empathy, and reducing burden in caregivers although most caregivers were unfamiliar with technology. The results hold promise for COMPAs interventions in long-term care settings. Larger group-controlled studies with different populations, in different contexts, and at different stages of dementia will provide a clearer picture of the benefits of COMPAs interventions.

Factors associated with longer hospital admission in elderly patients with major neurocognitive disorder

Background

Major neurocognitive disorder presents many challenges to patients, families and healthcare systems, especially when a patient requires admission to a psychiatric hospital.

Aim

To identify characteristics of older patients with major neurocognitive disorder at risk of prolonged admission in a psychiatric hospital.

Setting

A tertiary psychiatric hospital in Gauteng province, South Africa.

Methods

The authors conducted a retrospective review of the hospital database and clinical files. Clinical and demographic data were collected from the files of 50 inpatients, 60 years and older, who were diagnosed with major neurocognitive disorder and admitted between 2015 and 2019. Anonymised data from patient records were captured on an electronic spreadsheet and analysed using T-tests and analysis of variance (ANOVA) to investigate the relationship between patient characteristics and length of hospital admission.

Results

The mean duration of admission was 18.29 months. Involuntary admission status (β = 0.239, p = 0.049), level of assistance required (moderate level of assistance [β = 0.378, p = 0.005]; high level of assistance [β = 0.336, p = 0.015]), availability of social support (β = -0.319, p = 0.016) and the presence of behavioural or psychological problems (β = 0.437, p = 0.002) were significantly correlated with longer admission. Using a stepwise regression model, the only significant variable associated with a shorter length of stay was the presence of social support (β = -0.512, p = 0.009). Age, type of major neurocognitive disorder and number of comorbidities were not correlated with the duration of admission (p > 0.005).

Conclusion and contribution

Social support plays an important role in the management of patients with major neurocognitive disorder. The findings in this study highlight healthcare shortages and a need for adequate placement facilities in South Africa for patients who have no other form of support.

Flaws in advance directives that request withdrawing assisted feeding in late-stage dementia may cause premature or prolonged dying

Background

The terminal illness of late-stage (advanced) Alzheimer’s and related dementias is progressively cruel, burdensome, and can last years if caregivers assist oral feeding and hydrating. Options to avoid prolonged dying are limited since advanced dementia patients cannot qualify for Medical Aid in Dying. Physicians and judges can insist on clear and convincing evidence that the patient wants to die—which many advance directives cannot provide. Proxies/agents’ substituted judgment may not be concordant with patients’ requests. While advance directives can be patients’ last resort to attain a peaceful and timely dying consistent with their lifelong values, success depends on their being effective and acceptable. A single flaw can provide opponents justification to refuse the directive’s requests to cease assisted feeding.

Aim

This article considers 24 common advance directive flaws in four categories. Process flaws focus on how patients express their end-of-life wishes. Content flaws reflect drafters’ selection of conditions and interventions, and how they are described. Inherent flaws can make advance directives unacceptable to authorities concerned about premature dying. Strategies are needed to compel physicians to write needed orders and to prevent third parties from sabotaging these orders after they are  implemented. The article includes excerpts from “dementia-specific” directives or supplements that exemplify each flaw—mostly from the US and Europe. No directive critiqued here included an effective strategy to resolve this long-debated bioethical conflict: the past directive requests “Cease assisted feeding” but the incapacitated patient apparently expresses the desire to “Continue assisted feeding.” Some opponents to the controversial request, cease assisted feeding, use this conflict as a conceptual wedge to practice hard paternalism. This article proposes a protocol to prevent this conflict from emerging. These strategies may prevent authorities from requiring patients to fulfill authorities’ additional clinical criteria as a prerequisite to honor the requests in patients directives.

Conclusion

This critique of flaws may serve as a guide to drafting and to selecting effective and acceptable advance directives for dementia. It also poses several bioethical and clinical questions to those in authority: Does your paternalistic refusal to honor patients’ wishes respect their self-determination? Protect vulnerable patients from harm? Force patients to endure prolonged suffering? Violate the principles of bioethics? Violate the very foundation of patient-centered care?

Efficacy of care manager-led support for family caregivers of people with dementia during the COVID-19 pandemic: a randomized controlled study

Background

A prolonged COVID-19 pandemic could exacerbate the risk of infection and undesirable effects associated with infection control measures of older people with dementia (PWD), and the care burden of families. In this study, we examined the efficacy of care manager-led information provision and practical support for families of older PWD who need care, regarding appropriate infection prevention, prevention of deterioration of cognitive and physical functions, and preparedness in cases of infection spread or infection during the pandemic.

Methods

Fifty-three family members (aged ≥20 years) who were primary caregivers living with older PWD using public long-term care services were enrolled in an one-month randomized controlled trial. This duration was set based on behavior modification theory and with consideration of ethical issue that the most vulnerable people not benefiting from the intervention. The intervention group (IG) received care manager-led information provision and practical support, and the control group (CG) received usual care. Care burden (primary outcome) was measured using the Zarit Caregiver Burden Interview, and secondary outcomes were analyzed using Patient Health Questionnaire-9 (PHQ9), the Fear of COVID-19 Scale, and salivary α-amylase activity. Data were collected at baseline and after 1 month. Multiple regression analysis was conducted to examine the efficacy of the intervention. The participants evaluated the care managers’ support.

Results

The participants were randomly divided into IG (n = 27) and CG (n = 26) groups. After the intervention, compared with the CG, there was a decrease in PHQ-9 (β = −.202, p = 0.044) and α-amylase activity in saliva (β = −.265, p = 0.050) in IG. IG also showed an increased fear of COVID-19 after the intervention (β = .261, p = 0.003). With the care managers’ support, 57.2% of the participants felt secure in their daily lives and 53.1% agreed that they were able to practice infection prevention suitable for older PWD.

Conclusions

Our findings suggest that the care manager-led intervention may be useful for families of older PWD to enhance behavioral changes in preventing COVID-19 infection and improve their psychological outcomes in the COVID-19 era.

Trial registration

This study was registered on April 2, 2021 (No. UMIN000043820).

Supplementary Information

The online version contains supplementary material available at 10.1186/s12877-022-03371-2.