Small, homelike care environments for older people with dementia: a literature review

Palliative care in small-scale living facilities: a scoping review

BACKGROUND

Innovative small-scale facilities for dementia focus on providing quality of life and maintaining the functional abilities of residents while offering residents a home for life. To fulfill the home-for-life principle, palliative care approaches are necessary to maintain quality of life in these facilities. Few studies have reported on how palliative care is provided to residents in small-scale facilities. The aim of our review is to determine the extent to which palliative care approaches are reported in small-scale facilities.

METHODS

A scoping review of the literature using recommended methods from the Joanna Briggs Institute. Four databases, CINAHL, PubMed, PsycINFO, and Web of Science, were searched for studies published from 1995 to 2023. One reviewer completed the title, abstract and full-text screening and data extraction; two additional team members piloted the screening and extraction process and met with the main reviewer to make decisions about article inclusion and ensure consistency and accuracy in the review process. The extracted data was open-coded and analyzed using thematic analysis. The data was then synthesized into themes using palliative care domains for dementia.

RESULTS

Of the 800 articles obtained in the search, only ten met the inclusion criteria: six from Japan, two from the Netherlands, and one each from Austria and the United States. In most small-scale facilities, palliative care is important, with facilities prioritizing family involvement and person-centred care, minimizing resident discomfort and enhancing residents' remaining abilities until the end of life. The included studies did not discuss palliative care policies or professional staff training in depth.

CONCLUSIONS

This study provides an overview of the literature on palliative care in small-scale facilities for individuals with dementia. Most facilities focus on residents' wishes at the end of life to enhance comfort and provide a home-like environment. However, more research is needed to further understand the quality of palliative care approaches in these homes.

Organizational characteristics of highly specialized units for people with dementia and severe challenging behavior

BACKGROUND

People with dementia and severe challenging behavior in the Netherlands can be temporarily admitted to highly specialized units when their behavior is not manageable in regular dementia special care units (DSCUs). With scarce evidence available for the treatment of these patients, treatment in these units is in a pioneering phase. To gain more insight into these units, this study investigated organizational characteristics, i.e. admission and discharge characteristics, staffing, the physical environment, and the management of severe challenging behavior.

METHODS

Three data collection methods were used: 1) a digital questionnaire to be completed by the unit manager, 2) an interview with the physician responsible for medical care and often another practitioner, and 3) an observation of the physical environment for which the OAZIS-dementia questionnaire was used. Descriptive analysis was used for quantitative data and thematic analysis for qualitative data, after which data was interpreted together. Thirteen units participated, with their sizes ranging from 10 to 28 places.

RESULTS

Patients were mainly admitted from regular DSCUs, home or mental health care, and discharged to regular DSCUs. A multidisciplinary team comprising at least an elderly care physician or geriatrician, psychologist, and nursing staff member and other therapists as needed provided the treatment. Nursing staff hours per patient considerably differed among units. Nursing staff played a central role in the treatment. Competences such as reflectiveness on one's own behavior, and being able to cope with stressful situations were described as relevant for nursing staff. Investing in a stable nursing staff team was described as important. The units varied in whether their work-up was more intuitive or methodological. In the diagnostic phase, observation together with an extensive analysis of the patient's biography was essential. The units used a broad variety of interventions, and all paid attention to sensory stimuli. In the observation of the physical environment, the safety scored well and domesticity relatively low.

CONCLUSION

Highly specialized units show strong heterogeneity in organizational characteristics and management, which can be understood in the light of the pioneering phase. Despite this, similarities were found in nursing staff roles, frequent multidisciplinary evaluation, and attention to sensory stimuli.

Home Through Their Eyes: A Qualitative Exploration of the Meaning of Home for Persons With Dementia and Impact of Physical Environment During Meaning-Making

OBJECTIVES

This study aimed to examine the meaning of home for persons with dementia and the role of the physical environment during their meaning-making process. In response to a growing number of persons with dementia, there has been a strong advocacy for prioritizing the development of dementia-friendly environments within design practice and research agendas, for which "home" has become one of the important loci. However, of the limited studies on the meaning of home from the perspective of those individuals who continue to live in their own homes after developing dementia, even fewer addressed this issue within the Chinese context.

METHODS

Five dyads, persons with dementia and their family caregivers, participated in the qualitative phenomenology study. Ten home visits-2 visits per dyad-were conducted, during which interview data, photographs, and field notes were collected. Phenomenological analysis was applied within and across the data sets.

RESULTS

Three key themes emerged-"Three Dimensions of Home" revealed that "home" goes beyond physical residence and immediate family connections, including meaningful objects and places, enduring relationships, self-identity, and lived experiences.; "The Impact of Physical Environment" and "The Impact of Cognitive Impairment" showed the complex interactions between the environment, cognitive impairment, and meaning-making.

DISCUSSION

An exploration of the essence of meaning of home within the Chinese context, in person-environment relationships with dementia progression, and implications for future research and practice on dementia-related environments and care were further discussed. This study contributes insights into enhancing the well-being of persons with dementia and benefiting their caregivers.

Relationship between staff and quality of care in care homes: StaRQ mixed methods study

Background

Quality of life and care varies between and within the care homes in which almost half a million older people live and over half a million direct care staff (registered nurses and care assistants) work. The reasons are complex, understudied and sometimes oversimplified, but staff and their work are a significant influence.

Objective(s)

To explore variations in the care home nursing and support workforce; how resident and relatives' needs in care homes are linked to care home staffing; how different staffing models impact on care quality, outcomes and costs; how workforce numbers, skill mix and stability meet residents' needs; the contributions of the care home workforce to enhancing quality of care; staff relationships as a platform for implementation by providers.

Design

Mixed-method (QUAL-QUANT) parallel design with five work packages. WP1 - two evidence syntheses (one realist); WP2 - cross-sectional survey of routine staffing and rated quality from care home regulator; WP3 - analysis of longitudinal data from a corporate provider of staffing characteristics and quality indicators, including safety; WP4 - secondary analysis of care home regulator reports; WP5 - social network analysis of networks likely to influence quality innovation. We expressed our synthesised findings as a logic model.

Setting

English care homes, with and without nursing, with various ownership structures, size and location, with varying quality ratings.

Participants

Managers, residents, families and care home staff.

Findings

Staffing's contribution to quality and personalised care requires: managerial and staff stability and consistency; sufficient staff to develop 'familial' relationships between staff and residents, and staff-staff reciprocity, 'knowing' residents, and skills and competence training beyond induction; supported, well-led staff seeing modelled behaviours from supervisors; autonomy to act. Outcome measures that capture the relationship between staffing and quality include: the extent to which resident needs and preferences are met and culturally appropriate; resident and family satisfaction; extent of residents living with purpose; safe care (including clinical outcomes); staff well-being and job satisfaction were important, but underacknowledged.

Limitations

Many of our findings stem from self-reported and routine data with known biases - such as under reporting of adverse incidents; our analysis may reflect these biases. COVID-19 required adapting our original protocol to make it feasible. Consequently, the effects of the pandemic are reflected in our research methods and findings. Our findings are based on data from a single care home operator and so may not be generalised to the wider population of care homes.

Conclusions

Innovative and multiple methods and theory can successfully highlight the nuanced relationship between staffing and quality in care homes. Modifiable characteristics such as visible philosophies of care and high-quality training, reinforced by behavioural and relational role modelling by leaders can make the difference when sufficient amounts of consistent staff are employed. Greater staffing capacity alone is unlikely to enhance quality in a cost-effective manner. Social network analysis can help identify the right people to aid adoption and spread of quality and innovation. Future research should focus on richer, iterative, evaluative testing and development of our logic model using theoretically and empirically defensible - rather than available - inputs and outcomes.

Study registration

This study is registered as PROSPERO CRD42021241066 and Research Registry registration: 1062.

Funding

This award was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme (NIHR award ref: 15/144/29) and is published in full in Health and Social Care Delivery Research; Vol. 12, No. 8. See the NIHR Funding and Awards website for further award information.

A quasi-experimental mixed-method pilot study to check the efficacy of the "SOUND" active and passive music-based intervention on mental wellbeing and residual cognition of older people with dementia and dementia professionals' burnout: a research protocol

Purpose

The SOUND method offers an innovative blended intervention based on music circle-activities and cognitive stimulation approaches which was co-designed by musicians, health professionals, older people with dementia, family caregivers and researchers, for its application in dementia settings. The purpose of the paper is to describe the detailed procedure of the quasi-experimental pilot study.

Method

The experimental phase of SOUND uses a mixed-method design encompassing qualitative and quantitative observations, cognitive testing, self-report and interviewer-assisted questionnaires to investigate the effectiveness of the intervention for 45 people with dementia and 45 professionals (15 in every study country: Italy, Portugal, Romania).

Results

The pilot study will be the first implementation of the SOUND intervention aiming to investigate the feasibility and preliminary effects of the method.

Conclusion

The novelty of SOUND is its multicomponent method, including the most evidenced features for improving the wellbeing of participants.

Home Triad: A New Exploration of Home for People Living With Dementia Based on Lefebvre's Spatial Triad

OBJECTIVES

This article examines a novel theoretical framework, which we term Home Triad, for research and practice involving people living with dementia (PLWD).

BACKGROUND

Most of the existing home-related research on PLWD focuses on interior modifications, home care interventions and models, place attachment, and/or institutional homelike environments. However, limited studies have examined the meaning of home from PLWD's perspective, and even fewer have simultaneously considered the individual experience of PLWD, the external power (e.g., the role of design), and their interaction dynamics in the meaning-making process.

METHODS

We developed home triad based on Lefebvre's spatial triad. Inspired by Chaudhury's home story structure, we conducted a life story analysis of a person living with dementia, "Kai," under four contexts-childhood home, neighborhood and city, daily routine, and attachment-within home triad.

RESULTS

Home triad abstracts "home" with a dialectically interconnected relationship of the conceived, perceived, and lived home. Through PLWD's everyday life, the essence of home is primarily shaped by the interaction between their lived and perceived homes. However, a person's experiences of and participation in home living activities are also planned and/or regulated by different groups of people (caregivers, designers, and policymakers), who play important roles in the conceived home. Critically examining how PLWD's lived and perceived home is constrained or enabled through the conceived home deserves greater future research efforts.

CONCLUSION

A systematic examination of the essence of home for PLWD using home triad can facilitate subsequent research and practice that promote PLWD's health, well-being, and quality of life.

Residential Long-Term Care and the Built Environment: Balancing Quality of Life and Infection Control

OBJECTIVES

This article explores expert insights into residential long-term care (RLTC), specifically regarding the built environment, its impact on infection control (IC) measures and on resident, staff, and family member quality of life.

DESIGN

The interviews discussed in this report form part of a larger mixed methods research design, examining the planning, design, and operation of RLTC. Specifically, this report discusses findings from one aspect of this research, a series of semistructured interviews.

SETTING AND PARTICIPANTS

Interviews were conducted online through video conferencing platform Zoom. The project's steering committee were asked to suggest key organizations involved in IC and RLTC provision and policy, with 23 representatives (17 organizations) being invited to interview. Where representatives were unable to participate, they suggested alternate representatives.

METHODS

The research team conducted 20 interviews with key representatives or "experts" from different aspects of RLTC provision, policy, and IC. A thematic analysis was employed to analyze and generate key themes.

RESULTS

For brevity, the codes that had been mentioned by >5 interviewees, specific to the built environment, IC and quality of life were prioritized, resulting in 16 prioritized themes grouped according to spatial scale.

CONCLUSIONS AND IMPLICATIONS

This research demonstrates the growing awareness of the built environment as a critical partner in the RLTC health and social care model, as well as illustrating the need for a holistic design approach across all key spatial scales to support the health and well-being of older people in RLTC. Further research is needed on various aspects of RLTC, including the impact of care models and setting size on IC, quality of life, and cost implications. RLTC policy needs a more integrated approach to planning and design, specifically around RLTC location. This research suggests that RLTC providers look to evidence-based, inclusive design guidelines to inform the design and retrofit of RLTC. Additionally, the operation and management of space should be considered by providers.

Assessment of innovative living and care arrangements for persons with dementia: a systematic review

BACKGROUND

Alternative forms of housing for persons with dementia have been developed in recent decades. These concepts offer small groups of residents familiar settings combined with efforts to provide normal daily life. The aim of this systematic review is to collate and analyze these more innovative forms of housing regarding residents' quality of life, behavioral aspects, as well as functional, cognitive and emotional aspects.

METHODS

Searches were conducted in PubMed, EMBASE and PsycInfo in November 2020. Studies comparing traditional and more innovative living environments for persons with dementia were eligible. Concepts are described based on the results of additional searches. Risk of bias of included studies was assessed using checklists from the Joanna Briggs Institute.

RESULTS

A total of 21 studies corresponding to 11 different concepts were included, namely Green Houses (USA), Group Living (Sweden), Cantou (France), Group Homes (Japan), Small-scale Group Living (Austria), Special Care Facilities (Canada), Shared-housing Arrangements (Germany), Residential Groups (Germany), Residential Care Centers / Woodside Places (USA/Canada), Small-scale Living (Netherlands/ Belgium), and Green Care Farms (Netherlands). The concepts are broadly similar in terms of care concepts, but partly differ in group sizes, staff qualifications and responsibilities. Several studies indicate that innovative forms of housing may encourage social behavior, preserve activity performance and/or positively influence emotional status compared to more traditional settings, while other studies fail to demonstrate these effects. Some studies also show increased behavioral and psychological symptoms of dementia (BPSD) in residents who live in more innovative housing concepts. The effect on cognition remains indistinct.

DISCUSSION

The positive effects may be attributable to the inherent characteristics, including small group sizes, a stimulating design, and altered staff roles and responsibilities. Arguably, some of these characteristics might also be the reason for increased BPSD. Studies had variable methodological quality and results have to be considered with caution. Future research should examine these effects more closely and should investigate populations' preferences with regards to housing in the event of dementia.

An overview of innovative living arrangements within long-term care and their characteristics: a scoping review

BACKGROUND

Within long-term care, a culture change (e.g. focus on increasing autonomy in everyday life) is leading to the development of innovative living arrangements for older adults. Insight into characteristics of innovative living arrangements, which are described as an alternative to regular nursing homes, is lacking. This review aims to provide an overview of innovative living arrangements and to describe their defining characteristics.

METHODS

A scoping review was performed following the framework of Arksey and O'Malley. The preferred reporting items for systematic reviews and meta-analyses with extension, for scoping reviews (PRISMA-ScR) was also followed. The databases PubMed, PsycInfo, CINAHL, and Web of Science were searched. Articles, published between 2012 and 2023 were included when they presented an innovative living arrangement as an alternative to regular nursing homes. A thematic analysis was performed, describing the physical, social, and organizational environment of the innovative living arrangements.

RESULTS

Fifty-six articles were identified describing seven types of distinct innovative living arrangements: small-scale living, the green house model, shared housing arrangements, green care farms, dementia villages, group homes, intergenerational living, and an 'other' category. The themes included supporting autonomy and creating a small-scale and/or homelike environment, which were emphasized in most innovative living arrangements. Other themes, such as involvement of the community, focus on nature, integration of work tasks, and involvement of family members, were emphasized in a subsection of the described living arrangements. Twenty-eight articles reported on the effects of the innovative living environment on residents, family members, or staff members. Most articles (N = 22) studied resident-related outcomes, focusing mainly on quality of life and aspects of daily life.

CONCLUSION

More insight into the mechanisms of the social and organizational environments is needed, which may lead to greater transparency and homogeneity regarding the description of living arrangements. This review shows that more knowledge is needed about the potential key elements of innovative living arrangements, especially related to their social and organizational environment. This may provide a better guide for developers within long-term care.

Residential Environments for Older Persons: A Comprehensive Literature Review (2005-2022)

BACKGROUND

Independent noninstitutional and institutional residential long-term care environments for older persons have been the subject of significant empirical and qualitative research in the 2005-2022 period. A comprehensive review of this literature is reported, summarizing recent advancements in this rapidly expanding body of knowledge.

PURPOSE AND AIM

This comprehensive review conceptually structures the recent literature on environment and aging to provide conceptual clarity and identify current and future trends.

METHOD AND RESULT

Each source reviewed was classified as one of the five types-opinion piece/essay, cross-sectional empirical investigation, nonrandomized comparative investigation, randomized study, and policy review essay-within eight content categories: community-based aging in place; residentialism; nature, landscape, and biophilia; dementia special care units; voluntary/involuntary relocation; infection control/COVID-19, safety/environmental stress; ecological and cost-effective best practices; and recent design trends and prognostications.

CONCLUSIONS

Among the findings embodied in the 204 literature sources reviewed, all-private room long-term care residential units are generally safer and provide greater privacy and personal autonomy to residents, the deleterious impacts of involuntary relocation continue, family engagement in policy making and daily routines has increased, multigenerational independent living alternatives are increasing, the therapeutic role of nature and landscape is increasingly well-documented, ecological sustainability has increased in priority, and infection control measures are of high priority in the wake of the coronavirus pandemic. Discussion of the results of this comprehensive review sets the stage for further research and design advancements on this subject in light of the rapid aging of societies around the globe.

Evaluation of Dementia-Friendly Initiatives, Small-Scale Homelike Residential Care, and Dementia Village Models: A Scoping Review

OBJECTIVES

Numerous initiatives are emerging to improve the care management of persons suffering from Alzheimer's disease or related disorders (ADRD). The aim of this review is to identify research evaluations of initiatives in long-term care facilities and those making society more inclusive.

DESIGN

Scoping review with systematic search of PubMed.

SETTING AND PARTICIPANTS

Reviewed articles focused on the impact of (1) dementia-friendly initiatives (DFIs), (2) small-scale homelike (SSHL) facilities, and (3) dementia/Alzheimer villages. The intervention targets people (or their carers) with dementia or cognitive impairment.

METHODS

A scoping review was performed on PubMed, including papers published up to November 2022. Further hand-searching from reference lists and the gray literature was carried out.

RESULTS

A total of 477 articles were identified initially, and finally 12 more specifically related to the impact of DFI (n = 4) and SSHL facilities (n = 8) were selected. They included preliminary effectiveness analyses on DFI-related training and awareness intervention and comparative studies on an SSHL model. Scarce but promising results were found on the physical functioning, social participation, and quality of life for older adults living in SSHL facilities compared to those living in conventional nursing homes. No quantitative evaluation on dementia villages was published.

CONCLUSIONS AND IMPLICATIONS

The article highlights the lack of studies providing data on the efficacy of such innovative facilities on clinical, economic, and social outcomes. Such data are essential to better characterize these models and assess their potential efficiency and reproducibility.

A sense of home for people with dementia in a long-term care facility: A design perspective

The study aims to provide new insights into the approach to the spatial design of homelike dementia care facilities. This paper builds on Molony's (2010) findings that home meaning in care facilities is a process of people-place integration, and then proposes that people living with dementia can accomplish this process through their bodily habit. This research adopted an ethnographic case study approach. Three cases from a long-term care facility were studied by using semi-structured interviews and observations. According to the findings, having a sense of home for people living with dementia can be understood as a process of re-establishing people-place integration through their bodily habits in a long-term care facility. As a result, designers can consider which design features can assist people living with dementia in re-establishing this integration through bodily habit to create home feelings in a dementia care facility.

Community expectations of a village for people living with dementia

Small-scale models of dementia care are a progressive approach to improve care for people living with dementia. These models intend to provide a home-like environment with a small number of residents in each living unit, easy access to services and facilities, a dedicated team of staff and flexible routines. This study was undertaken during the construction phase of a new village and provided a unique opportunity to explore expectations of the village among the local community. Twelve community members participated in two sequential online focus groups over a 2-month period. Focus group discussions were recorded, transcribed and analysed using a reflexive thematic analysis approach. Knowledge of the village varied and was informed by familiarity with other village developments and local marketing about the new village. The findings indicate that the community expect the village to provide residents with optimum dementia care, a safe and enabling physical environment and a vibrant daily life where they are engaged in 'normal' activities. While participants expected the village to be self-contained, they also anticipated strong connections with the wider community. Participants acknowledged that the community need dementia education to ensure these interactions are positive. Community expectations of a new village development for people living with dementia are largely positive and often idealistic. Organisations need to consider these expectations when developing new small-scale facilities and be mindful of how they market these developments to foster realistic expectations. While community enthusiasm about dementia care is encouraging, education is needed to ensure the success of the model.

Preferences for attributes of long-term care in dementia: a scoping review of multi-criteria decision analyses

Aim

Long-term care considerations for persons with dementia are complex. Multi-criteria decision analysis (MCDA) methods are increasingly used to support healthcare decisions. The objective of this scoping review was to identify and analyze published MCDAs in which preferences for living and care concepts for persons with dementia are determined.

Subject and methods

A literature search was conducted in PubMed, EMBASE, Web of Science, and Google Scholar in October 2021. Searches were limited to peer-reviewed articles published up to October 14, 2021. The included publications aimed at eliciting care preferences for persons with dementia from patients, relatives, healthcare practitioners or the broader public by means of MCDA.

Results

Ten studies were included of whom seven were published in 2017 or afterwards. In nine studies, a discrete choice experiment (DCE) was conducted. The majority of studies surveyed the general population or caregivers of persons with dementia. Five studies assessed preferences for attributes of home care and two for long-term care facilities. Willingness to pay was addressed in eight studies. Choice task structure and experimental design varied widely. Despite different objectives, strong preferences for continuous care by the same person, organizational aspects, and caregiver expertise were found across studies.

Conclusion

This review shows that MCDA methods have successfully been applied to analyze preferences for living and care arrangements for persons with dementia. The majority of publications report on DCEs, and a variety of different study objectives and methodological approaches have been observed. Further research is needed to inform the design of innovative concepts which are a valuable alternative to existing care options.

Physical environmental designs in residential care to improve quality of life of older people

BACKGROUND

The demand for residential aged care is increasing due to the ageing population. Optimising the design or adapting the physical environment of residential aged care facilities has the potential to influence quality of life, mood and function.

OBJECTIVES

To assess the effects of changes to the physical environment, which include alternative models of residential aged care such as a 'home-like' model of care (where residents live in small living units) on quality of life, behaviour, mood and depression and function in older people living in residential aged care.

SEARCH METHODS

CENTRAL, MEDLINE, Embase, six other databases and two trial registries were searched on 11 February 2021. Reference lists and grey literature sources were also searched.

SELECTION CRITERIA

Non-randomised trials, repeated measures or interrupted time series studies and controlled before-after studies with a comparison group were included. Interventions which had modified the physical design of a care home or built a care home with an alternative model of residential aged care (including design alterations) in order to enhance the environment to promote independence and well-being were included. Studies which examined quality of life or outcomes related to quality of life were included. Two reviewers independently assessed the abstracts identified in the search and the full texts of all retrieved studies.

DATA COLLECTION AND ANALYSIS

Two reviewers independently extracted data, assessed the risk of bias in each included study and evaluated the certainty of evidence according to GRADE criteria. Where possible, data were represented in forest plots and pooled.

MAIN RESULTS

Twenty studies were included with 77,265 participants, although one large study included the majority of participants (n = 74,449). The main comparison was home-like models of care incorporating changes to the scale of the building which limit the capacity of the living units to smaller numbers of residents and encourage the participation of residents with domestic activities and a person-centred care approach, compared to traditional designs which may include larger-scale buildings with a larger number of residents, hospital-like features such as nurses' stations, traditional hierarchical organisational structures and design which prioritises safety. Six controlled before-after studies compared the home-like model and the traditional environment (75,074 participants), but one controlled before-after study included 74,449 of the participants (estimated on weighting). It is uncertain whether home-like models improve health-related quality of life, behaviour, mood and depression, function or serious adverse effects compared to traditional designs because the certainty of the evidence is very low. The certainty of the evidence was downgraded from low-certainty to very low-certainty for all outcomes due to very serious concerns due to risk of bias, and also serious concerns due to imprecision for outcomes with more than 400 participants. One controlled before-after study examined the effect of home-like models on quality of life. The author stated "No statistically significant differences were observed between the intervention and control groups." Three studies reported on global behaviour (N = 257). One study found little or no difference in global behaviour change at six months using the Neuropsychiatric Inventory where lower scores indicate fewer behavioural symptoms (mean difference (MD) -0.04 (95% confidence interval (CI) -0.13 to 0.04, n = 164)), and two additional studies (N = 93) examined global behaviour, but these were unsuitable for determining a summary effect estimate. Two controlled before-after studies examined the effect of home-like models of care compared to traditional design on depression. After 18 months, one study (n = 242) reported an increase in the rate of depressive symptoms (rate ratio 1.15 (95% CI 1.02 to 1.29)), but the effect of home-like models of care on the probability of no depressive symptoms was uncertain (odds ratio 0.36 (95% CI 0.12 to 1.07)). One study (n = 164) reported little or no difference in depressive symptoms at six months using the Revised Memory and Behaviour Problems Checklist where lower scores indicate fewer depressive symptoms (MD 0.01 (95% CI -0.12 to 0.14)). Four controlled before-after studies examined function. One study (n = 242) reported little or no difference in function over 18 months using the Activities of Daily Living long-form scale where lower scores indicate better function (MD -0.09 (95% CI -0.46 to 0.28)), and one study (n = 164) reported better function scores at six months using the Interview for the Deterioration of Daily Living activities in Dementia where lower scores indicate better function (MD -4.37 (95% CI -7.06 to -1.69)). Two additional studies measured function but could not be included in the quantitative analysis. One study examined serious adverse effects (physical restraints), and reported a slight reduction in the important outcome of physical restraint use in a home-like model of care compared to a traditional design (MD between the home-like model of care and traditional design -0.3% (95% CI -0.5% to -0.1%), estimate weighted n = 74,449 participants at enrolment).  The remaining studies examined smaller design interventions including refurbishment without changes to the scale of the building, special care units for people with dementia, group living corridors compared to a non-corridor design, lighting interventions, dining area redesign and a garden vignette.

AUTHORS' CONCLUSIONS

There is currently insufficient evidence on which to draw conclusions about the impact of physical environment design changes for older people living in residential aged care. Outcomes directly associated with the design of the built environment in a supported setting are difficult to isolate from other influences such as health changes of the residents, changes to care practices over time or different staff providing care across shifts. Cluster-randomised trials may be feasible for studies of refurbishment or specific design components within residential aged care. Studies which use a non-randomised design or cluster-randomised trials should consider approaches to reduce risk of bias to improve the certainty of evidence.

How staff characteristics influence residential care facility staff's attitude toward person-centered care and informal care

BACKGROUND

Staff members, and their attitudes, are crucial for providing person-centered care in residential care facilities for people with dementia. However, the literature on the attitudes of nursing staff regarding person-centered care is limited. The objective of this study is to explore the association between staff characteristics (age, education level, years of work experience and function, i.e., care or welfare) and staff attitudes toward perceived person-centered care provision and including informal caregivers in the caregiving process in residential care facilities.

METHODS

A convenience sample of 68 care staff - nurses and nurse assistants - welfare staff members - activity counselors, hostesses, and living room caretakers - of two residential care facilities filled out a questionnaire. Staff attitudes regarding perceived person-centered care were measured with the Person-centered Care Assessment Tool (P-CAT). Staff attitudes regarding informal care provision were measured with the Attitudes Toward Families Checklist (AFC). Multiple linear regression analysis explored the association between variables age, work experience, education, and function (care or welfare).

RESULTS

A higher age of staff was associated with a more negative attitude toward perceived person-centered care and informal care provision. Welfare staff had a more negative attitude toward the inclusion of informal caregivers than care staff. The perceived person-centered care provision of the care and welfare staff was both positive. Work experience and education were not associated with perceived person-centered care provision or informal care provision.

CONCLUSION

This study is one of the first to provide insight into the association between staff characteristics and their attitude toward their perceived person-centered care provision and informal care provision. A higher age of both the care and welfare staff was associated with a more negative attitude toward their perceived person-centered care and informal care provision. Welfare staff had a less positive attitude toward informal care provision. Additionally, future studies, also observational studies and interview studies, are necessary to collect evidence on the reasons for negative attitudes of older staff members towards PCC and informal care giving, to be able to adequately target these reasons by implementing interventions that eliminate or reduce these negative attitudes.

Working at Green Care Farms and Other Innovative Small-Scale Long-Term Dementia Care Facilities Requires Different Competencies of Care Staff

The culture change movement within long-term care in which radical changes in the physical, social and organizational care environments are being implemented provides opportunities for the development of innovative long-term care facilities. The aim of this study was to investigate which competencies care staff working at green care farms and other innovative types of small-scale long-term dementia care facilities require, according to care staff themselves and managers, and how these competencies were different from those of care staff working in more traditional large-scale long-term dementia care facilities. A qualitative descriptive research design was used. Interviews were conducted with care staff (n = 19) and managers (n = 23) across a diverse range of long-term facilities. Thematic content analysis was used. Two competencies were mainly mentioned by participants working in green care farms: (1) being able to integrate activities for residents into daily practice, and (2) being able to undertake multiple responsibilities. Two other competencies for working in long-term dementia care in general were identified: (3) having good communication skills, and (4) being able to provide medical and direct care activities. This study found unique competencies at green care farms, showing that providing care in innovative long-term care facilities requires looking further than the physical environment and the design of a care facility; it is crucial to look at the role of care staff and the competencies they require.

The Prevalence of and Documented Indications for Antipsychotic Prescribing in Irish Nursing Homes

Background: Antipsychotic medications are often used ‘off-licence’ to treat neuropsychiatric symptoms and disorders of aging and to manage behavioural and psychological symptoms of dementia despite the warnings of adverse effects. Objective: To establish the prevalence of and documented indication for antipsychotic medication use in the Irish nursing home setting. Setting: This study was conducted in six nursing homes located in Co. Cork, Ireland. Method: A retrospective, cross-sectional study was employed. All patients who met the inclusion criteria (≥65 years, residing in a nursing home on a long-term basis) were eligible for inclusion. There were 120 nursing home residents recruited to the study. Main Outcome Measure: The prevalence of antipsychotic medication use in nursing home residents (with and without dementia). Results: The overall prevalence of antipsychotic prescribing was found to be 48% and patients with dementia were significantly more likely to be prescribed an antipsychotic compared to those without dementia (67% vs. 25%) (χ² (1, N = 120) = 21.541, p < 0.001). In the cohort of patients with dementia, there was a trend approaching significance (p = 0.052) of decreasing antipsychotic use with increasing age (age 65–74 = 90%; age 75–84 = 71%; age 85 and over = 58%). An indication was documented for 84% of the antipsychotic prescriptions in this cohort. Conclusions: The findings of this study highlight that high rates of antipsychotic medication use remains an issue in Irish nursing homes. Further work should explore factors in influencing prescribing of these medications in such settings.

Understanding the staff behaviours that promote quality for older people living in long term care facilities: A realist review

BACKGROUND

Little is known about how the workforce influences quality in long term care facilities for older people. Staff numbers are important but do not fully explain this relationship.

OBJECTIVES

To develop theoretical explanations for the relationship between long-term care facility staffing and quality of care as experienced by residents.

DESIGN

A realist evidence synthesis to understand staff behaviours that promote quality of care for older people living in long-term care facilities.

SETTING

Long-term residential care facilities PARTICIPANTS: Long-term care facility staff, residents, and relatives METHODS: The realist review, (i) was co-developed with stakeholders to determine initial programme theories, (ii) systematically searched the evidence to test and develop theoretical propositions, and (iii) validated and refined emergent theory with stakeholder groups.

RESULTS

66 research papers were included in the review. Three key findings explain the relationship between staffing and quality: (i) quality is influenced by staff behaviours; (ii) behaviours are contingent on relationships nurtured by long-term care facility environment and culture; and (iii) leadership has an important influence on how organisational resources (sufficient staff effectively deployed, with the knowledge, expertise and skills required to meet residents' needs) are used to generate and sustain quality-promoting relationships. Six theoretical propositions explain these findings.

CONCLUSION

Leaders (at all levels) through their role-modelling behaviours can use organisational resources to endorse and encourage relationships (at all levels) between staff, residents, co-workers and family (relationship centred care) that constitute learning opportunities for staff, and encourage quality as experienced by residents and families.

Telerehabilitation in response to constrained physical distance: an opportunity to rethink neurorehabilitative routines

Ensuring proper dosage of treatment and repetition over time is a major challenge in neurorehabilitation. However, a requirement of physical distancing to date compromises their achievement. While mostly associated to COVID-19, physical distancing is not only required in a pandemic scenario, but also advised for several clinical conditions (e.g. immunocompromised individuals) or forced for specific social contexts (e.g. people living in remote areas worldwide). All these contexts advocate for the implementation of alternative healthcare models. The objective of this perspective is to highlight the benefits of remote administration of rehabilitative treatment, namely telerehabilitation, in counteracting physical distancing barriers in neurorehabilitation. Sustaining boosters of treatment outcome, such as compliance, sustainability, as well as motivation, telerehabilitation may adapt to multiple neurological conditions, with the further advantage of a high potential for individualization to patient's or pathology's specificities. The effectiveness of telerehabilitation can be potentiated by several technologies available to date: virtual reality can recreate realistic environments in which patients may bodily operate, wearable sensors allow to quantitatively monitor the patient's performance, and signal processing may contribute to the prediction of long-term dynamics of patient recovery. Telerehabilitation might spark its advantages far beyond the mere limitation of physical distancing effects, mitigating criticalities of daily neurorehabilitative practice, and thus paving the way to the envision of mixed models of care, where hospital-based procedures are complementarily integrated with telerehabilitative ones.

The Homestead: Developing a Conceptual Framework through Co-Creation for Innovating Long-Term Dementia Care Environments

Alternative care environments for regular nursing homes are highly warranted to promote health and well-being of residents with dementia that are part of an age-friendly and dementia-friendly city and society. Insight is lacking on how to translate evidence-based knowledge from theory into a congruent conceptual model for innovation in current practice. This study reports on the co-creation of an alternative nursing home model in the Netherlands. A participatory research approach was used to co-create a conceptual framework with researchers, practitioners and older people following an iterative process. Results indicate that achieving positive outcomes for people with dementia, (in)formal caregivers, and the community is dependent on how well the physical, social and organizational environment are congruently designed. The theoretical underpinnings of the conceptual model have been translated into "the homestead," which is conceptualized around three main pillars: activation, freedom and relationships. The Homestead Care Model is an illustrative example of how residential care facilities can support the development of age-friendly communities that take into consideration the needs and requirements of older citizens. However, challenges remain to implement radical changes within residential care. More research is needed into the actual implementation of the Homestead Care Model.

‘We go for a homely feel … not the clinical dementia side’: care home managers’ experiences of supporting residents with dementia to orientate and navigate care environments

Living with dementia can adversely affect people's spatial (orientation and navigation) and reality (time, date and place) orientation, which can detrimentally impact on their sense of social inclusion and wellbeing. This is an important challenge to address within United Kingdom (UK) care homes where around 70 per cent of the residents are living with dementia or severe memory problems. Care home managers have some autonomy in decision-making that impacts on the daily functioning of residents and are key in enacting the orientation and navigation agenda within a care home environment. Yet a paucity of literature explores their understanding and experiences of this issue. Contributing to this knowledge gap, our exploratory study examined managers’ current practice of supporting residents with dementia to minimise disorientation and their knowledge of dementia-friendly design principles, guidelines and audit tools. Semi-structured telephone interviews with 12 UK care home managers were conducted. Questions started generally targeting residents’ orientation and navigation abilities, followed by specific questions to draw out strategies used to support residents. Thematic analysis identified three higher-order themes: aligning strategies with needs, intuitive learning and managing within the wider business context. The findings demonstrated that managers perceive dementia to impact on a person's spatial and reality orientation. Consequently, the strategies they chose to adopt were tailored towards alleviating both challenges. However, although managers were aware of some design principles, they frequently relied on intuitive learning and past experiences to inform their choice of interventions, reporting a lack of knowledge and/or time to seek out orientation-specific training and guidance, resulting in a low uptake of guidelines and audit tools in practice. This gap between theory and practice highlights a need for accessible guidelines that integrate strategies with neuropsychological theory, and appropriate training to improve orientation and navigation in care home environments. Managers, staff, business owners, architects and designers all play a key role in implementing orientation guidelines into practice and ensuring dementia-friendly care home environments for residents.

The DemWG study: reducing the risk of hospitalisation through a complex intervention for people with dementia and mild cognitive impairment (MCI) in German shared-housing arrangements: study protocol of a prospective, mixed-methods, multicentre, cluster-randomised controlled trial

INTRODUCTION

Shared-housing arrangements (SHAs) are small, home-like care environments in Germany. Residents are predominantly people with dementia. The risk for all-cause hospitalisation is consistently higher for people with dementia compared with people without dementia and there is currently no evidence-based intervention to reduce the risk of hospitalisation. Thus, the DemWG study investigates whether a complex intervention is effective in reducing hospitalisation (primary outcome), behavioural and psychological symptoms of dementia and falls and for stabilising cognitive functioning and quality of life in people with dementia and mild cognitive impairment (MCI) in German SHAs.

METHODS AND ANALYSIS

Based on the UK Medical Research Council framework 'Developing and evaluating complex interventions', a prospective, mixed-methods, multicentre, cluster-randomised controlled trial combining primary and secondary data analyses as well as quantitative and qualitative research methods is being conducted. The intervention consists of three parts: (A) education of nursing staff in SHAs; (B) awareness raising and continuing medical education (CME) of general practitioners; (C) multicomponent non-pharmacological group intervention MAKS-mk+ ('m'=motor training; 'k'=cognitive training; '+'=fall prevention) for people with dementia and MCI. Randomisation is stratified by the German federal states and type of setting (rural vs urban). Neither the trained professionals nor the participants are blinded. Data are collected at baseline and after 6, 12 and 18 months with standardised instruments. Quantitative data will be analysed by multivariate analyses according to the general linear model, qualitative data using qualitative content analysis. Recruitment is still ongoing until 31 December 2020.

ETHICS AND DISSEMINATION

All procedures were approved by the Ethics Committee of the University of Bremen (Ref. 2019-18-06-3). Informed consent will be obtained before enrolment of participants. Due to findings of previous randomised controlled trials, serious adverse events are not expected. Results will be disseminated in peer-reviewed journal publications and conference presentations.

TRIAL REGISTRATION NUMBER

ISRCTN89825211.

Effects of Assistive Home Technology on quality of life and falls of people with dementia and job satisfaction of caregivers: Results from a pilot randomized controlled trial

OBJECTIVES

Determine the effects of the implementation of Assistive Home Technology (AHT) in group homes on the quality of life (QoL) of people with dementia and on job satisfaction of caregivers.

METHOD

Pilot randomized controlled trial in nine in-patient care group homes (group homes with vs. without AHT). Participants were 54 people with dementia and 25 professionals. Outcome measurements were QoL, fall incidents, needs, use of restraints, job satisfaction, workload, and general health.

RESULTS

Living in a group home with AHT had a positive effect on four QoL domains: 'social isolation', 'having things to do', 'esthetics', and 'quality of life appreciation'. No effects were found on 12 other QoL domains. Fall incidents during bathroom visits were significantly reduced by the application of AHT. During this implementation phase, in the AHT group home, a moderate negative effect was found on caregiver's appreciation of work circumstances. No effects on other outcome measures were found.

CONCLUSION

Positive effects were found on aspects of QoL and fall incidents in the bathroom. The lower caregiver appreciation of work circumstances in the AHT group confirms the importance of intensive support and guidance of personnel during the implementation of AHT.

Empirical development of a typology on residential long-term care units in Germany - results of an exploratory multivariate data analysis

BACKGROUND

Organizational health care research focuses on describing structures and processes in organizations and investigating their impact on the quality of health care. In the setting of residential long-term care, this effort includes the examination and description of structural differences among the organizations (e.g., nursing homes). The objective of the analysis is to develop an empirical typology of living units in nursing homes that differ in their structural characteristics.

METHODS

Data from the DemenzMonitor Study were used. The DemenzMonitor is an observational study carried out in a convenience sample of 103 living units in 51 nursing homes spread over 11 German federal states. Characteristics of living units were measured by 19 variables related to staffing, work organization, building characteristics and meal preparation. Multiple correspondence analysis (MCA) and agglomerative hierarchical cluster analysis (AHC) are suitable to create a typology of living units. Both methods are multivariate and explorative. We present a comparison with a previous typology (created by a nonexplorative and nonmultivariate process) of the living units derived from the same data set.

RESULTS

The MCA revealed differences among the living units, which are defined in particular by the size of the living unit (number of beds), the additional qualifications of the head nurse, the living concept and the presence of additional financing through a separate benefit agreement. We identified three types of living units; these clusters occur significantly with a certain combination of characteristics. In terms of content, the three clusters can be defined as: "house community", "dementia special care units" and "usual care".

CONCLUSION

A typology is useful to gain a deeper understanding of the differences in the care structures of residential long-term care organizations. In addition, the study provides a practical recommendation on how to apply the results, enabling living units to be assigned to a certain type. The typology can be used as a reference for definitions.

Perspectives of Australian family carers of people with dementia on the 'cottage' model of respite: Compared to traditional models of residential respite provided in aged care facilities

The majority of people living with dementia reside in the community and are often reliant on the support of informal carers to do so. Family carers face many challenges in supporting the person with dementia to remain at home, and short-term respite care is a valued service that offers a temporary break from the role. Respite cottages provide short-term care in a residential home-like setting with a limited number of clients and is a more flexible approach to accessing the service. Disproportionate use of cottage respite in Australia suggests this model is preferred over traditional respite within residential aged care facility (RACF) settings, yet limited research exists to compare these models. This study sought to understand the perceptions of carers who had used cottage respite in comparison to other models, and explore the contribution of cottage respite for supporting carers to continue in their role and maintain their care recipient (CR) living at home. Semi-structured interviews were conducted with 126 family carers who had used one of two New South Wales-based respite cottages within a 2-year period; 67 of whom had also used RACF respite. Thematic analysis revealed four main themes around the benefits of cottage respite: (a) an effective essential service, (b) flexibility, (c) familiarity and (d) appropriateness, especially for early stage or younger onset dementia. Carers indicated that the more homely, familiar and intimate cottage model of respite care was preferential to that of the larger, institutional-style RACF respite setting. Carers credited the cottage model of respite service with delaying their need for permanent residential placement by over 12 months. The cottage respite model provides an important avenue to supporting the individual needs of dementia dyads, with potential to delay permanent placement, and should be offered more broadly to provide people with more choice about their care.

How Can Autonomy Be Maintained and Informal Care Improved for People With Dementia Living in Residential Care Facilities: A Systematic Literature Review

Background and Objectives

For people with dementia living in residential care facilities, maintaining autonomy and receiving informal care are important. The objective of this review is to understand how caregiving approaches and physical environment, including technologies contribute to the maintenance of autonomy and informal care provision for this population.

Research Design and Methods

A literature review of peer-reviewed articles published between January 1995 and July 2017 was performed. Realist logic of analysis was used, involving context, mechanism and outcome configurations.

Results

Forty-nine articles were included. The improvement of the relationship between residents and formal/informal caregivers is important. This increases the knowledge (sharing) about the resident and contributes to their autonomy. A social, flexible, and welcoming attitude of the formal caregiver improves the provision of informal care. Specially designed spaces, for instance, therapeutic gardens, create activities for residents that remind them of themselves and contribute to their autonomy. Use of technologies reduces caregiver’s time for primary tasks and therefore enables secondary tasks such as interaction with the residents.

Discussion and Implications

The results revealed how residential care facilities could maintain autonomy of their residents and improve informal care delivery using caregiving approaches and the physical environment including technologies. The results are supporting toward each other in maintaining autonomy and also helped in enhancing informal care provision. For residential care facilities that want to maintain the autonomy of their residents and improve informal care delivery, it is important to pay attention to all aspects of living in a residential care facility.

[Assisted living facilities in inpatient and outpatient settings]

BACKGROUND AND OBJECTIVE

Assisted living (AL) facilities for older people in need of support in outpatient and inpatient settings differ from nursing homes due to the orientation towards autonomy of the residents and the normality of living and everyday routines, very similar to living at home. The conceptual framework, here defined as AL, is characterized by a homelike small-scale environment and the keeping of one's own household and manageability. The presence of personnel in a new personal mix supports qualities, such as social participation, meaningful activities and functional support. The study examined how this frame of reference impacts the quality of life of residents and reflects the perspectives of further development of housing options.

MATERIAL AND METHODS

Over a period of 9 months (2006-2007) 8 AL facilities with 73 residents and a classical nursing home with 18 residents were examined in terms of behavioral competence, subjective well-being, perceived quality of life and objective environment. Established multidimensional person and environment-related assessment instruments were applied. Specific organizational questions were explored through qualitative interviews.

RESULTS

Despite a formal inpatient or outpatient classification, the residents living in AL facilities showed significantly higher values for well-being and showed significantly less agitated, challenging behavior compared to the nursing home. In particular, people with dementia benefited from the specific quality of AL, which is reflected in relevant dimensions.

CONCLUSION

The findings indicate that AL represents a concept that can be used as a basis for new housing offers and a new type of care infrastructure. It provides connecting factors to the leading principle of shared responsibility.

Against environmental anaesthesia: investigating resident engagement with a magnetic participative art installation on a secure care unit

Secure long-term care units come with a unique set of challenges, particularly around exit-seeking behaviour. Arts-based environmental interventions on secure units successfully reduce problematic behaviours, while simultaneously ensuring resident safety and improving resident quality of life. The present arts-based project enhanced a distraction mural intervention to incorporate magnets as a participative arts feature. The project was evaluated through a roundtable discussion with unit staff. Findings showed that in addition to reducing exit-seeking behaviour, the magnets provided an aesthetically engaging set of objects for residents to gather up and hold, to pause and explore, and to create order. Challenges with direct care staff are identified and future ideas for arts-based projects on secure units are considered.

Nursing home care for people with dementia: Update of the design of the Living Arrangements for people with Dementia (LAD)-study

AIM

The aim of the current study is to describe the extended design of the Living Arrangements for people with Dementia (LAD)-study.

BACKGROUND

The demand for long-term care in care homes increases with the growing number of people with dementia. However, quality of care in care homes needs improvement. It is important to monitor quality of care in care homes for the purposes of conducting scientific research, providing input for policy, and promoting practice improvement.

DESIGN

The Living Arrangements for people with Dementia -study monitors changes in - quality of - care in care homes since 2008. With its extended design, the Living Arrangements for people with Dementia -study now also focuses on additional topics that are considered to improve quality of care: implementation of person-centred care, involvement of family carers and volunteers and reducing psychotropic drugs and physical restraints using a multidisciplinary approach.

METHODS

The data collection of the Living Arrangements for people with Dementia -study entails an interview with the manager and questionnaires are completed by care staff, family carers, volunteers, and multidisciplinary team members. This study is partly funded by the Dutch Ministry of Health, Welfare and Sports, grant number 323,088 and partly funded by the participating care homes.

DISCUSSION

Results of the Living Arrangements for people with Dementia -study will shed more light on variables related to quality of care in care homes for people with dementia.

IMPACT

Based on the obtained information, appropriate efforts to improve quality of care can be discussed and implemented. Furthermore, the results of this study guide policy making, because it expands knowledge about the effects of changing policies and exposes topics that need further attention.

TRIAL REGISTRATION

Not applicable. This article does not report the results of a healthcare intervention on human participants.

Useful lessons for the provision of services in long-term care facilities in South Korea: operators' experiences illuminate the phenomenon of working with the elderly in the field

Purpose: The aim of this study was to gain a deeper understanding of elderly long-term care facilities by focusing on insights provided by the operators of these facilities.

Methods: In this phenomenological study, 10 participants who operated nursing home businesses were interviewed. Of the 10 participants, seven had graduated from a nursing programme and three had studied social welfare.

Results: The experiences of facility operators could be organized into four themes: “Starting as a facility operator”, “Dream of an ideal long-term care facility”, “Struggling desperately in practice”, and “Obtaining hope by providing care”. These four themes were divided into 18 subthemes, constituting 96 meaningful statements.

Conclusion: Despite the obvious gap between reality and ideals with regard to caring for residents, operators used a person-centred care strategy for the elderly at their facilities. Our findings indicate that, despite diverse barriers and hardships, participants were encouraged when they offered person-centred healthcare services for the elderly under their care, based on a philosophy of a holistic understanding of humans and respect for human life and dignity. Facility operators who are leaders in the practical field should be involved in the decision/policy-making process, to support health and well-being in the elderly in institutionalized settings.

Clustered domestic model of residential care is associated with better consumer rated quality of care

Objective

To compare consumer rated quality of care among individuals living long-term in homelike clustered domestic and standard models of residential care in Australia.

Design

Cross-sectional study.

Setting

Seventeen residential aged care facilities in four Australian states providing alternative models of care.

Study participants

A sample of individuals with high prevalence of cognitive impairment living in residential care for 12 months or longer, not immediately in palliative care and having a proxy available to provide consent and assist with data collection. Of 901 eligible participants, 541 consented and participated in the study.

Main outcome measure

Consumer rated quality of care was measured using the Consumer Choice Index–6 Dimension instrument (CCI-6D) providing a preference weighted summary score ranging from 0 to 1. The six dimensions of care time, shared-spaces, own-room, outside and gardens, meaningful activities and care flexibility were individually evaluated.

Results

Overall consumer rated quality of care (Mean ∆: 0.138, 95% CI 0.073–0.203 P < 0.001) was higher in clustered domestic models after adjusting for potential confounders. Individually, the dimensions of access to outside and gardens (P < 0.001) and flexibility of care (P < 0.001) were rated significantly better compared to those living in standard model of care.

Conclusions

Homelike, clustered domestic models of care are associated with better consumer rated quality of care, specifically the domains of access to outdoors and care flexibility, in a sample of individuals with cognitive impairment. Including consumer views on quality of care is feasible and should be standard in future evaluations of residential care.

Experiences of family caregivers in green care farms and other nursing home environments for people with dementia: a qualitative study

BACKGROUND

Having a match between a nursing home and the preferences of people with dementia is beneficial for their well-being. It is suggested that innovative types of nursing homes such as small-scale living facilities and green care farms create a better match between their care environment and their residents. However whether this is also reflected into the experiences of informal caregivers is not known. Therefore, this study explores what their positive and negative experiences are with regard to green care farms, other small-scale living facilities, and traditional nursing homes.

METHODS

A qualitative exploratory research design was used. Semi-structured interviews with 43 informal caregivers (2014-2015) were carried out. Topics discussed were: positive and negative experiences with the nursing home and reasons for choice of a particular type of nursing home. Thematic analysis including an iterative process of open, axial and selective coding, was used.

RESULTS

Five themes emerged: (1) physical environment and atmosphere, (2) activities, (3) person-centred care, (4) communication, and (5) staff. Informal caregivers at green care farms were more positive about the physical environment, activities, and person-centred care compared with informal caregivers in the other types of nursing homes. Both positive and negative experiences regarding communication and individual staff members appeared across all types of nursing homes.

CONCLUSIONS

Experiences of informal caregivers with a nursing home are dependent on the type of nursing home. However, experiences were also often related to individual nursing staff and their interpersonal, 'human' qualities.

Organizational factors of fall injuries among residents within German nursing homes: secondary analyses of cross-sectional data

The present study explored risk factors for fall injuries among nursing home residents, with a specific focus on the influence of organizational structure within facilities and their environment, which have been insufficiently investigated in the European context. For the analyses, secondary data collected in 2016 from 220 nursing homes across Germany were used. As a risk adjustment, two separate models were calculated for fall injuries among residents without (N = 7320) and with cognitive impairment (N = 8633). Results showed that residents without cognitive impairment had a decreased risk of fall injuries by 40.1% (P < 0.01), while those with cognitive impairment were at an increased risk of 23.8% (P < 0.05) when living in facilities that had dementia care units. However, disparities were found between federal states for both groups of residents (P < 0.05 vs. P < 0.01, respectively). Similarly, a higher proportion of registered nurses were associated with decreased risk of fall injuries among cognitively impaired residents (45.6%), which differed between federal states (P < 0.01). Facilities with homelike environments had a 16.7% (P < 0.05) lower risk of fall injuries among cognitively impaired residents than did traditionally organized facilities. Further research is needed to explain the disparities between German federal states using representative samples.

More staff = better quality of life for people with dementia? results of a secondary data analysis in German shared-housing arrangements

Background

Shared-housing arrangements (SHAs) in Germany are an alternative care arrangement for people with dementia. They are disconnected from traditional nursing homes and are often situated in ordinary apartment buildings. Community health care providers serve persons with dementia in SHAs, and there is no official regulation regarding the staff-resident ratio. The association between the staff-resident ratio and the quality of life (QoL) of persons with dementia has not yet been investigated in SHAs.

Method

A cross-sectional study was performed in SHAs in Berlin, Germany, using ANCOVA models to analyse whether residents’ QoL (QUALIDEM), as assessed by staff in SHAs, can be explained by the staff-resident ratio, adjusted for residents’ sex, age, length of stay, challenging behaviour (CMAI), cognitive impairment (GDS) and level of care dependency according to the German statutory health care insurance.

Results

In this study, 58 SHAs with 396 residents (mean age 78.4 years, 69.4% female) participated. The staff-resident ratio was 0.2 and 0.6 for registered nurses and certified nursing assistants, respectively. Associations with QoL were found predominantly for challenging behaviour and cognitive impairment. The analysis showed that there was no significant effect of the total staff-resident ratio (p > 0.05) in explaining the variation in residents’ QoL (total and subdomains). In general, the proportion of explained variance was weak (R² <  0.216).

Conclusions

The present study did not show a significant association between staffing and residents’ QoL in SHAs. However, further investigation is required regarding the direct interaction between staff and residents. A main focus should be to educate users about the benefits and disadvantages of shared-housing arrangements.

The Influence of the Physical Environment on Residents With Dementia in Long-Term Care Settings: A Review of the Empirical Literature

Background and Objectives

The physical environment in long-term care facilities has an important role in the care of residents with dementia. This paper presents a literature review focusing on recent empirical research in this area and situates the research with therapeutic goals related to the physical environment.

Research Design and Methods

A comprehensive literature search was conducted in Ageline, PsychINFO, CINAHL, Medline and Google Scholar databases to identify relevant articles. A narrative approach was used to review the literature.

Results

A total of 103 full-text items were reviewed, including 94 empirical studies and 9 reviews. There is substantial evidence on the influence of unit size, spatial layout, homelike character, sensory stimulation, and environmental characteristics of social spaces on residents' behaviors and well-being in care facilities. However, research in this area is primarily cross-sectional and based on relatively small and homogenous samples.

Discussion and Implications

Given the increasing body of empirical evidence, greater recognition is warranted for creating physical environments appropriate and responsive to residents' cognitive abilities and functioning. Future research needs to place greater emphasis on environmental intervention-based studies, diverse sample populations, inclusion of residents in different stages and with multiple types of dementia, and on longitudinal study design.

Perceptions of home in long-term care settings: before and after institutional relocation

Although moving from institutional to home-like long-term care (LTC) settings can promote and sustain the health and wellbeing of older adults, there has been little research examining how home is perceived by older adults when moving between care settings. A qualitative study was conducted over a two-year period during the relocation of residents and staff from an institutional LTC home to a purpose-built LTC home in Western Canada. The study explored perceptions of home amongst residents, family members and staff. Accordingly, 210 semi-structured interviews were conducted at five time-points with 35 residents, 23 family members and 81 staff. Thematic analyses generated four superordinate themes that are suggestive of how to create and enhance a sense of home in LTC settings: (a) physical environment features; (b) privacy and personalisation; (c) autonomy, choice and flexibility; and (d) connectedness and togetherness. The findings reveal that the physical environment features are foundational for the emergence of social and personal meanings associated with a sense of home, and highlight the impact of care practices on the sense of home when the workplace becomes a home. In addition, tension that arises between providing care and creating a home-like environment in LTC settings is discussed.

The Physical Environment of Nursing Homes for People with Dementia: Traditional Nursing Homes, Small-Scale Living Facilities, and Green Care Farms

It is well recognized that the physical environment is important for the well-being of people with dementia. This influences developments within the nursing home care sector where there is an increasing interest in supporting person-centered care by using the physical environment. Innovations in nursing home design often focus on small-scale and homelike care environments. This study investigated: (1) the physical environment of different types of nursing homes, comparing traditional nursing homes with small-scale living facilities and green care farms; and (2) how the physical environment was being used in practice in terms of the location, engagement and social interaction of residents. Two observational studies were carried out. Results indicate that the physical environment of small-scale living facilities for people with dementia has the potential to be beneficial for resident's daily life. However, having a potentially beneficial physical environment did not automatically lead to an optimal use of this environment, as some areas of a nursing home (e.g., outdoor areas) were not utilized. This study emphasizes the importance of nursing staff that provides residents with meaningful activities and stimulates residents to be active and use the physical environment to its full extent.

Care Personnel's Attitudes and Fears Toward Care Robots in Elderly Care: A Comparison of Data from the Care Personnel in Finland and Japan

PURPOSE

The aim of the study was to analyze and compare elderly care personnel attitudes toward care robots in Finland and Japan.

DESIGN

Cross-sectional survey in Finland and Japan.

METHODS

The Finnish sample was collected from care personnel in home care facilities in five municipalities in 2016. The Japanese sample was collected from personnel in two rehabilitative day centers and three residential care homes for the elderly in the north of Honshu Island in 2017. The data were analyzed using basic statistical methods and calculated descriptive statistics (frequencies). Differences between the Finnish and Japanese data have been analyzed using the Mann-Whitney U test.

FINDINGS

Overall, Japanese care personnel assessed the usefulness of robots more positively than did their Finnish counterparts. The data showed substantial national differences in the perceived importance of various potential tasks for care robots. The findings show that there are also certain fears related to the introduction of care robots, in particular among the Finnish care personnel.

DISCUSSION

The data from the Japanese care personnel bring new perspectives to the concept of a close human-robot relationship. The differences seen in the results between Finland and Japan can be partly explained by cultural dissimilarity, but it is also known that Japan is a more developed country with regard to the use of robotics in nursing care. The research highlights the importance of cultural factors when examining the issue of care robotics. The factors affecting fear are a concern that care robots would be used to replace people, the dehumanization of treatment, and an increased loneliness in the elderly. Thus, further research is required to demonstrate the relationship between different cultural factors, and attitudes and conceptions toward care robots.

CLINICAL RELEVANCE

Management plays a key role when implementing robotics. It is important to help care personnel accept care robots, and to diminish any fears that their introduction would make the treatment of elderly people inhumane or in some way add to their loneliness. As such, education is crucial in changing attitudes and making care personnel understand that care robots can perform routine tasks, allowing care personnel to focus on providing improved care and nursing.

Relationships among person-centered care, nursing home adjustment, and life satisfaction: a cross-sectional survey study

ABSTRACTBackground:The purpose of this study was to examine whether a perceived person-centered nursing home environment has a direct relationship with nursing home adjustment and life satisfaction, and whether a perceived person-centered nursing home environment has an indirect relationship with life satisfaction through improved nursing home adjustment.

METHODS

203 nursing home residents who were able to read and speak English and were physically and cognitively able to respond to questionnaires were included in this study. Data were collected from six nursing homes in the Midwestern US.

RESULTS

Higher levels of a perceived person-centered nursing home environment had a significantly direct relationship with increased life satisfaction of residents (β = 0.35), and this relationship was mediated by residents' improved nursing home adjustment (β = 0.10). In-depth exploration using sub-domains of the main variables demonstrated that "safety" and "everydayness" of a person-centered nursing home environment were directly related to higher levels of life satisfaction (β = 0.15 and β = 0.16, respectively); and "everydayness" was related to three sub-domains of nursing home adjustment: better "relationship development," "acceptance of the new residence" (β = 0.32 and β = 0.24, respectively), and lower "depressed mood" (β = 0.05). The positive relationship between "everydayness" and life satisfaction was partially mediated by the "relationship development" sub-domain of nursing home adjustment (β = 0.07).

CONCLUSIONS

The findings provide new evidence for the positive association between person-centered care and nursing home adjustment. The findings also provide insights into the mechanism through which the specific sub-domains of person-centered care and nursing home adjustment operate in the path model.

How Enclosure and Spatial Organization Affect Residents' Use and Experience of a Dementia Special Care Unit: A Case Study

AIM:

We aim to gain insight into how a dementia special care unit is used and experienced by its residents and what design aspects are important therein.

BACKGROUND:

In Flanders, housing for people with dementia evolves toward small-scale, homelike environments. As population aging challenges the affordability of this evolution, architects and other designers are asked to design dementia special care units that offer the advantages of small scaleness within the context of large-scale residential care facilities. How these units are used and experienced is not systematically evaluated.

METHOD:

A case study was conducted in a recently built residential care facility where a dementia special care unit was foreseen on the ground floor, yet after a few months was moved to the top floor. The case study combined architectural analysis, participant observation, and qualitative interviews with residents and care staff.

RESULTS:

Comparing the original situation on the ground floor with the new situation on the top floor highlights how enclosure (physical and visual access to outside and the rest of the facility) and spatial organization affect how residents use and experience a dementia special care unit.

CONCLUSIONS:

Depending on the type and stage of dementia, residents may have different needs for space to move, sensory stimuli, and social contact. In order to meet these different needs, confining residents to a dementia special care unit to the top floor should be avoided unless it is carefully designed, providing sufficient freedom of movement and connection with the outside world.

'Essentially it's just a lot of bedrooms': architectural design, prescribed personalisation and the construction of care homes for later life

This article draws on ethnographic data from a UK Economic and Social Research Council (ESRC) funded study called 'Buildings in the Making'. The project aims to open up the black box of architectural work to explore what happens between the commissioning of architectural projects through to the construction of buildings, and seeks to understand how ideas about care for later life are operationalised into designs. Drawing on recent scholarship on 'materialities of care' and 'practising architectures', which emphasise the salience of material objects for understanding the politics and practices of care, we focus here on 'beds'. References to 'beds' were ubiquitous throughout our data, and we analyse their varied uses and imaginaries as a 'way in' to understanding the embedded nature of architectural work. Four themes emerged: 'commissioning architectures and the commodification of beds'; 'adjusting architectures and socio-spatial inequalities of beds'; 'prescribing architectures and person-centred care beds'; and 'phenomenological architectures and inhabiting beds'. We offer the concept prescribed personalisation to capture how practising architectures come to reconcile the multiple tensions of commodification and the codification of person centred care, in ways that might mitigate phenomenological and serendipitous qualities of life and living in care settings during later life.

Farm-based day care in Norway - a complementary service for people with dementia

Background

Day care services provide meaningful activities and coping experiences in a safe environment for people with dementia, as well as improve quality of life. Such services vary in types and settings. Farm-based day care (FDC) services are described as services that have been adapted from the farm setting, using farm resources to promote health. There is limited knowledge on the service offered in both FDC and regular day care services for people with dementia. The present study aims to investigate FDC in Norway and describe the services and the participants’ care environment.

Materials and methods

We mapped the existing farms offering day care in Norway by the spring 2017 (N=33) and collected information through two cross-sectional surveys (N=32) answered by the service providers at the farms.

Results

The farms included in this survey provided day care services to 227 people with dementia, located in most regions of Norway. The services varied in terms of group size and half of the services had young people with dementia (≤65 years) and people with dementia at an early stage as their primary target group. About half of the staff had health care education (47.5%), and there were staff with agricultural competence available in most FDCs. All farms reported that the participants spent time outdoors every day, and all services, except two, had animals. The providers highlighted the opportunity to choose activities that were individually tailored for each participant, as the diversity of resources in the farm made it possible to organize different activities.

Conclusion

FDC services have similarities in organization, daily structure, and number of health education personnel to other day care services, but differ in type of care environment with a wide range of activities and available resources like farm buildings, gardens, animals, and outdoor areas.

Construct Validity of the Mealtime Scan: A Secondary Data Analysis of the Making Most of Mealtimes (M3) Study

Long-term care (LTC) physical and psychosocial mealtime environments have been inconsistently assessed due to the lack of a standardized measure. The purpose of this study was to examine the construct validity of a new standardized observational measure, the Mealtime Scan (MTS), using the Making Most of Mealtimes data collected on 639 residents in 82 dining rooms in 32 LTC homes. The MTS includes physical, social, and person-centered care summary scales scored from 1 to 8. Mean ratings on these summary scales were moderate for physical (5.6 SD 0.9), social (5.0 SD 0.9), and person-centered care (PCC; 5.5 SD 0.8). Regression analyses determined which items within the MTS were associated with these summary scales: physical - music (B = 0.27, p = 0.04), number of staff passing food (B = -0.11, p = 0.03), number of residents (B = -0.03, p = 0.01); social - social sound (B =  0.31 p < 0.0001), number of residents requiring eating assistance (B = 0.11, p = 0.02); PCC - lighting (B = 0.01 p = 0.04), and total excess noise (B = 0.05, p < 0.0001). The Mealtime Relational Care Checklist (M-RCC) was associated positively with ratings on all three summary scales. Correlations revealed that the MTS summary scales were associated with other constructs: Dining Environment Audit Protocol functionality scale, resident and dining room level M-RCC, Mini Nutritional Assessment- Short Form, and resident Cognitive Performance Scale. These results demonstrate that the MTS summary scales exhibit construct validity, as the ratings were associated with expected observed mealtime characteristics and correlated with dining room and resident level constructs in anticipated directions.

Working in small-scale, homelike dementia care: effects on staff burnout symptoms and job characteristics. A quasi-experimental, longitudinal study

AIM

This paper reports on a quasi-experimental, longitudinal study on the effects of working in a new type of dementia care facility (i.e. small-scale living facilities) on staff burnout symptoms and job characteristics (job autonomy, social support, physical demands and workload).

METHODS

It is hypothesised that nursing staff working in small-scale facilities experience fewer burnout symptoms, more autonomy and social support, and fewer symptoms of physical demands and workload compared with staff in regular wards. Two types of long-term institutional nursing care settings were included: 28 houses in small-scale living facilities and 21 regular psychogeriatric wards in nursing homes. At baseline and at follow-ups after 6 and 12 months nursing staff were assessed by means of self-report questionnaires. In total, 305 nursing staff members were included in the study, 114 working in small-scale living facilities (intervention group) and 191 in regular wards (control group).

RESULTS

No overall effects on burnout symptoms were detected. Significantly fewer physical demands and lower workload were experienced by staff working in small-scale living facilities compared with staff in regular wards. They also experienced more job autonomy. No significant effect was found for overall social support in the total group.

CONCLUSIONS

This study suggests positive effects of the work environment on several work characteristics. Organisational climate differs in the two conditions, which might account for our results. This may influence nursing staff well-being and has important implications for nursing home managers and policy makers. Future studies should enhance our understanding of the influence of job characteristics on outcomes.