Principles of good care for long-term care facilities

Nursing Home Residents With Dementia at End of Life: Emergency Department Visits, Hospitalizations, and Acute Hospital Deaths

Background: Most nursing home (NH) residents do not benefit from health care at an emergency room (ER) or inpatient care at an emergency hospital during the end-of-life period. Therefore, a low number of unplanned admissions during the last month of life are considered good quality of care. Objectives: This study examined ER visits, hospital admissions, and place of death in NH residents with and without dementia in the last month of life, with the aim of answering the question, "Are NH residents with dementia provided with equal health care in their last stage of life?" Design: An observational retrospective study of registry data from all NH residents who died during the years 2015-2019, using health care consumption data from the Stockholm Regional Council, Sweden. Results: Dementia was associated with a higher adjusted odds ratio (aOR) for ER visits (aOR 1.32, p < 0.0001) and acute admissions (aOR 1.30, p < 0.0001) (logistic regression, including sensitivity analysis). Being male, young, and having multiple comorbidities (Charlson Comorbidity Index) and frailty (Hospital Frailty Risk Score) were all independently associated with higher aORs for the same outcomes and also with hospital deaths. Conclusion: Dementia is associated with increased ER referrals and acute in-hospital care. Comorbidities and frailty were strongly associated with an increase in hospital deaths. In addition, men are sent to emergency hospitals more frequently than women, and older residents are sent to the hospital to a lesser extent than younger residents, which cannot be explained by the factors studied.

Developing a Conceptual Framework for an Age-Friendly Health System: A Scoping Review

BACKGROUND

Population aging is usually associated with increased health care needs. Developing an age-friendly health system with special features, structure, and functions to meet the special needs of older people and improving their health status and quality of life is essential. This study aimed to develop a conceptual framework for an age-friendly health system, which would offer a conceptual basis for providing the best possible care for older people in health system to let them experience a successful, healthy, and active aging.

METHODS

A scoping review was used to design the conceptual framework based on Arksey and O'Malley's model, including six stages, with the final stage of using expert's opinions to improve and validate the initial framework. The health system model of Van Olmen, was selected as the baseline model for this framework. Then, by reviewing the available evidence, the characteristics of an age-friendly health system were extracted and incorporated in the baseline mode.

RESULTS

Using the electronic searching, initially 12 316 documents were identified, of which 140 studies were selected and included in this review study. The relevant data were extracted from the 140 studies by two reviewers independently. Most studies were conducted in 2016-2020, and mostly were from United States (33.6%). To have an age-friendly health system, interventions and changes should be performed in functions, components and objectives of health systems. This system aims to provide evidence-based care through trained workforces and involves older people and their families in health policy-makings. Its consequences include better health acre for older people, with fewer healthcare-related harms, greater care satisfaction and increased use of cost-effective health services.

CONCLUSION

To meet the needs of older people, health systems should make interventions in their functions for better performance. In line with these changes, other parts of society should work in harmony and set the health of older people as a top priority to ensure they can have a successful aging.

Non-pharmacological, psychosocial MAKS-s intervention for people with severe dementia in nursing homes: results of a cluster-randomised trial

BACKGROUND

Severe dementia is one of the most challenging conditions when caring for people in nursing homes. A manualised non-pharmacological, psychosocial group intervention especially adapted to the needs of people with severe dementia (PWSDs) is currently still lacking. To close this gap, we adapted the evidence-based multicomponent non-pharmacological MAKS intervention (Motor stimulation, ADL stimulation, Cognitive [german: Kognitive] stimulation, and Social functioning in a group setting) to the special needs of PWSDs called the MAKS-s intervention, where the s stands for severe dementia.

METHODS

In a prospective, multicentre, cluster-randomised trial with a waitlist control group design, 26 nursing homes comprising 152 PWSDs were randomly assigned to either the MAKS-s intervention group (IG) or control group (CG) - 121 PWSDs were still alive after the 6-month intervention period (t6) and included in the intention-to-treat (ITT) sample. The two primary outcomes, behavioural and psychological symptoms (BPSDs, measured with NPI-NH) and quality of life (QoL, measured with QUALIDEM), and the secondary outcome, activities of daily living (ADLs, measured with ADCS-ADL-sev), were assessed at baseline (t0) and at t6. Mixed ANOVAs were computed to investigate possible effects of the MAKS-s intervention on the outcomes.

RESULTS

In the ITT sample, BPSDs and QoL did not change significantly over time, and group assignment did not affect them, although the IG participants had significantly better overall QoL than the CG participants. ADLs decreased significantly over time, but group assignment did not affect them. Analyses in the per protocol (PP) sample showed comparable results, with the exception that the IG participants showed a significantly greater increase in BPSDs than the CG participants did.

DISCUSSION

Under the situational conditions of the Covid-19 pandemic, no beneficial effects of the MAKS-s intervention on BPSDs, QoL, or ADLs were observed. This finding also means that under 'normal circumstances' (i.e., if there had been no pandemic), we could not make any statements about the effect or non-effect of MAKS-s. In order to be able to address the hypotheses formulated here, the study will have to be repeated incorporating helpful experiences of the present study.

TRIAL REGISTRATION

https://doi.org/10.1186/ISRCTN15722923 (Registered prospectively, 07. August 2019).

Disaster Response in Italian Nursing Homes: A Qualitative Study during the COVID-19 Pandemic

Nursing homes (NHs) have been among the care settings most affected by both the virus itself and collateral damage through infection protection and control measures (IPC). However, there is a paucity of research regarding disaster response and preparedness of these institutions. The present study aimed to analyze disaster response and management and to develop prospective strategies for disaster management in NHs. A qualitative survey including (i) residents, (ii) nursing staff, (iii) relatives of residents, and (iv) NHs' medical leads was performed. Data were collected by 45 in-depth interviews. Our results indicate that the shift from resident-centered care towards collective-protective approaches led through the suspending of established care principles to an emergency vacuum: implementable strategies were lacking and the subsequent development of temporary, immediate, and mostly suboptimal solutions by unprepared staff led to manifold organizational, medical, and ethical conflicts against the background of unclear legislation, changing protocols, and fear of legal consequences. IPC measures had long-lasting effects on the health and wellbeing of residents, relatives, and professionals. Without disaster preparedness protocols and support in decision-making during disasters, professionals in NHs are hardly able to cope with emergency situations.

Self- and proxy-rating of the ICECAP-O for people with dementia: A cross-sectional linguistic validation study in Germany and Portugal

BACKGROUND

The capability concept became a recognized approach to the measurement of quality of life. The ICECAP-O for older people aims to measure capabilities and has recently been used in people with dementia (self-rating) and informal carers (substituted judgement). However, linguistic validation studies have so far been lacking.

METHODS

A cross-sectional cognitive interview study with 15 people with dementia (PwD) and 23 informal carers (ICs) was conducted in Germany and Portugal. Respondents were asked to reveal their understanding of the ICECAP-O and the capability approach as well as the response process. A summarising content analysis was performed.

RESULTS

Despite the small sample, our linguistic validation of the German and Portuguese translations detected considerable difficulties or deviations in item comprehension when compared with the intended meaning. In some cases, the item interpretations did not reflect the entire scope of the associated capability dimension, though they were basically correct. Moreover, participants were not able to differentiate some items appropriately from one another, and some misinterpretations occurred. ICs relied mainly on observable behaviour, emotions, or verbal expressions of the PwD. Therefore, ICs found items that ask about the achievement of individual expectations or thoughts about the future difficult to assess. Only very few PwD clearly indicated that they understood the capability approach. ICs in Germany had more difficulties in understanding the capability concept than in ICs Portugal.

DISCUSSION

This linguistic validation study in Germany and Portugal indicates a need for some rephrasing and refinements of the ICECAP-O translated items in both countries to fully encompass some dimensions and avoid misinterpretations. Further studies with larger samples are necessary. Based on our findings, the current German version for ICs' substituted judgement cannot be recommended for this kind of respondents without further advancements.

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.

Why do staff and family think differently about quality of life in dementia? A qualitative study exploring perspectives in care homes

BACKGROUND

Quality of life is important especially in incurable illness. In dementia, we often need proxy reports of quality of life, but we know little about how individuals make their judgements. In care homes, proxies may be staff providing care or relatives, but staff rate quality of life differently to family. To our knowledge, no one has explored this qualitatively, so we used qualitative interviews to explore why staff and family think differently about quality of life.

METHODS

We interviewed 12 staff and 12 relatives who had provided proxy ratings of quality of life for people living with dementia in care homes in the Managing Agitation and Raising Quality of life (MARQUE) study. We asked why they had rated the resident's quality of life as "Very Good, Good, Fair, or Poor." Using thematic analysis, we compared staff and relatives' proxy responses.

RESULTS

For staff, the concept of quality of life was often viewed synonymously with quality of care, influenced by their sense of responsibility and informed by their professional understanding. For relatives, quality of life was often judged in relation to how the person with dementia lived before diagnosis and was influenced by their perception of loss for the person with dementia and their own adjustment.

CONCLUSIONS

Proxy reports were influenced by rater's own contexts and experiences. This can enhance our understanding of widely used research tools, aid the evaluation of intervention outcomes, and indicate possible targets for improving perceived and actual quality of life of people with dementia.

Helpful approaches to older people experiencing mental health problems: a critical review of models of mental health care

Despite growing concerns for the mental health of the older generation most studies focus on mental health care for younger people and there is a lack of knowledge about helpful treatment approaches and models of care for older people. Therefore, the purpose of this review was to answer the question what health care approaches are most helpful for older people experiencing mental health problems. Databases from 2000 to July 2017 were searched with focus on outcome studies, experts' opinions and treatment descriptions. Critical interpretive synthesis was used to analyse and interpret the findings. Four main models of care were found: the medical-psychiatric model which mostly focuses on antipsychotic medication for the treatment of symptoms. Psychotherapeutic and social interventions take into consideration the psychosocial perspectives of mental health problems, but little research has been done on their lasting effect. Research indicates that psychotherapy needs to be adapted to the special needs of older people. Few old people have access to psychotherapy which limits its usefulness. Holistic or integrated models of health care have emerged in recent years. These models focus on both physical and psychosocial well-being and have shown promising outcomes. To reduce antipsychotic medication older people need to be given better access to psychotherapy and social interventions. This presupposes training health care professionals in such treatment methods. The holistic models need to be developed and studied further and given high priority in health care policy.

What is desirable care in the opinion of formal and informal caregivers in nursing-home care for patients with dementia?

Aim

To examine care characteristics related to desirable care as reported by formal and informal caregivers in Dutch Psycho‐geriatric nursing homes for patients with dementia.

Design

Qualitative exploratory study.

Methods

The sample consisted of four nursing homes. In each home, semi‐structured interviews were conducted with a manager, a quality advisor or head nurse, a daily care supervisor and an informal caregiver. The findings were analysed by labelling and coding the text fragments.

Results

The 16 semi‐structured interviews contained 60 discussion items. The 16 items that were shared by the four interviewee categories were clustered into the following six major themes: good quality of care; poor quality of care; elements of a vision; extra hands; bureaucracy; and formal caregivers.

The association between the physical environment and the well-being of older people in residential care facilities: A multilevel analysis

AIMS

To investigate the associations between the quality of the physical environment and the psychological and social well-being of older people living in residential care facilities.

BACKGROUND

Many older people in care facilities have cognitive and physical frailties and are at risk of experiencing low levels of well-being. High-quality physical environments can support older people as frailty increases and promote their well-being. Although the importance of the physical environment for residents' well-being is recognized, more research is needed.

DESIGN

A cross-sectional survey of 20 care facilities from each of which 10 residents were sampled. As the individual resident data were nested in the facilities, a multilevel analysis was conducted.

METHODS

Data were collected during 2013 and 2014. The care facilities were purposely sampled to ensure a high level of variation in their physical characteristics. Residents' demographic and health data were collected via medical records and interviews. Residents' well-being and perceived quality of care were assessed via questionnaires and interviews. Environmental quality was assessed with a structured observational instrument.

RESULTS

Multilevel analysis indicated that cognitive support in the physical environment was associated with residents' social well-being, after controlling for independence and perceived care quality. However, no significant association was found between the physical environment and residents' psychological well-being.

CONCLUSION

Our study demonstrates the role of the physical environment for enhancing the social well-being of frail older people. Professionals and practitioners involved in the design of care facilities have a responsibility to ensure that such facilities meet high-quality specifications.

Psychosocial Intervention Use in Long-Stay Dementia Care: A Classic Grounded Theory

The objective of this study was to develop a substantive grounded theory of staff psychosocial intervention use with residents with dementia in long-stay care. "Becoming a person again" emerged as the core category accounting for staffs' psychosocial intervention use within long-stay care. Interview data were collected from participants in nine Irish long-stay settings: 14 residents with dementia, 19 staff nurses, one clinical facilitator, seven nurse managers, 21 nursing assistants, and five relatives. Constant comparative method guided the data collection and analysis. The researcher's theoretical memos, based on unstructured observation, and applicable extant literature were also included as data. By identifying the mutuality of the participants' experiences, this classic grounded theory explains staff motivation toward psychosocial intervention use within long-stay care. It also explains how institutional factors interact with those personal factors that incline individuals toward psychosocial intervention use.

Cross-cultural adaptation of the German version of the Quality of Life in Alzheimer's Disease scale - Nursing Home version (QoL-AD NH)

Dementia is a chronic and currently incurable syndrome. Therefore, quality of life (QoL) is a major goal when caring for people with dementia (Gibson et al., 2010) and a major outcome in dementia research (Moniz-Cook et al., 2008). The measurement of QoL, especially proxy-rating, is challenging because of the proxy-perspective (Pickard and Knight, 2005), reliability (Dichter et al., 2016), validity (O'Rourke et al., 2015), and responsiveness (Perales et al., 2013). Probably due to these challenges, it has not been possible to show positive effects for QoL in almost all non-pharmacological interventions for people with dementia (Cooper et al., 2012). One recommended (Moniz-Cook et al., 2008) and frequently used instrument is the Quality of Life in Alzheimer's Disease scale (QoL-AD), which was originally developed in the US for community-dwelling people with dementia. The QoL-AD consists of 13 items based on a 4-point Likert scale ranging from "1"=poor to "4"=excellent (Logsdon et al., 1999). The original instrument has been adapted for people living in nursing homes (NH) by Edelmann et al. (2005).

Item distribution, internal consistency and inter-rater reliability of the German version of the QUALIDEM for people with mild to severe and very severe dementia

BACKGROUND

The QUALIDEM is a dementia-specific Quality of life (Qol) instrument that is recommended for longitudinal studies and advanced stages of dementia. Our study aimed to develop a user guide for the German version of the QUALIDEM and to determine the item distribution, internal consistency and inter-rater reliability (IRR) of the German QUALIDEM.

METHODS

A user guide was developed based on cognitive interviews with ten professional caregivers and a focus group with six professional caregivers. The item distribution, internal consistency and IRR were evaluated through a field test including n = 55 (mild to severe dementia) and n = 36 (very severe dementia) residents from nine nursing homes. Individuals with dementia were assessed four times by blinded proxy raters.

RESULTS

A user guide with instructions for the application of the QUALIDEM and definitions and examples for each item was created. Based on the single-measure intra-class correlation coefficient (ICC for absolute agreement), we observed strong IRR for nearly all of the QUALIDEM subscales, with ICCs of at least 0.79. A lower ICC (ICC = 0.64) was only obtained for people with very severe dementia on the 'negative affect' subscale.

CONCLUSIONS

The IRR improved based on the application of the QUALIDEM user guide developed in this study. We demonstrated a sufficient IRR for all subscales of the German version of the QUALIDEM, with the exception of the 'negative affect' subscale in the subsample of people with very severe dementia. The item distribution and internal consistency results highlight the need to develop new informative items for some subscales.

Embedding the perceptions of people with dementia into quantitative research design

PURPOSE

Patient perspectives about quality of life are often found in the results of qualitative research and could be applied to steer the direction of future research. The purpose of this paper was to describe how findings from a body of qualitative research on patient perspectives about quality of life were linked to a clinical administrative dataset and then used to design a subsequent quantitative study.

METHODS

Themes from two systematic reviews of qualitative evidence (i.e., metasyntheses) identified what affects quality of life according to people with dementia. Selected themes and their sub-concepts were then mapped to an administrative dataset (the Resident Assessment Instrument 2.0) to determine the study focus, formulate nine hypotheses, and select a patient-reported outcome. A literature review followed to confirm existence of a knowledge gap, identify adjustment variables, and support design decisions.

RESULTS

A quantitative study to test the association between conflict and sadness for people with dementia in long-term care was derived from metasynthesis themes. Challenges included (1) mapping broad themes to the administrative dataset; (2) decisions associated with inclusion of variables not identified by people with dementia from the qualitative research; and (3) selecting a patient-reported outcome, when the dataset lacked a valid subjective quality-of-life measure.

CONCLUSIONS

Themes derived from a body of qualitative research capturing a target populations' perspective can be linked to administrative data and used to design a quantitative study. Using this approach, the quantitative findings will be meaningful with respect to the quality of life of the target population.

Factors that affect quality of life from the perspective of people with dementia: a metasynthesis

OBJECTIVES

To comprehensively and systematically identify, appraise, and synthesize qualitative research findings on factors that affect quality of life from the perspective of people with dementia.

DESIGN

Systematic review and metasynthesis of primary qualitative studies in published and gray literature that aimed to identify factors that influence quality of life from the perspective of people with dementia. Expert-developed search strategies were applied in nine electronic databases. Reference lists of included articles and literature reviews identified during the search were reviewed. Structured inclusion criteria were applied to screen 5,625 titles and abstracts to identify 11 qualitative studies published from 1975 to April 2012. Two independent reviewers appraised study quality.

SETTING

Primary study recruitment sites included long-term care and community-based settings in the United Kingdom, the United States, Canada, the Netherlands, Ireland, Australia, and Japan.

PARTICIPANTS

A combined sample of 345 people with mild, moderate, and severe dementia.

MEASUREMENTS

The primary studies used interview and focus group methods. Findings from primary studies were synthesized using techniques of taxonomic analysis, constant comparison, and importing concepts.

RESULTS

Four factors and the experience of connectedness or disconnectedness within each factor influenced quality of life according to people with dementia. These factors, and the terms that represent connectedness and disconnectedness, were relationships (together vs alone), agency in life today (purposeful vs aimless), wellness perspective (well vs ill), and sense of place (located vs unsettled). Happiness and sadness were key outcomes of good and poor quality of life, respectively.

CONCLUSION

The four factors identified potentially modifiable areas to improve quality of life for people with dementia, even in the context of worsening cognitive function.

Alternate housing models for older people with disabilities: their clientele, structures and resources in relation to the quality of and satisfaction with care delivery

This paper reports on the study of a subsidy programme that was established in Quebec for alternate housing models (AHMs), which allows private and community organisations to offer housing services within the framework of a partnership with public health-care services. The research objectives were: (a) to compare how facility characteristics and services provided by AHMs and nursing homes (NHs) differ; (b) to examine the personal characteristics of residents living in AHMs; and (c) to compare residents with similar characteristics within AHMs and NHs in terms of unmet needs, quality of care, satisfaction with care and services, and psycho-social adaptation to the residence. A cross-sectional study was undertaken with individually matched groups to assess whether AHMs meet the needs of elders in a way similar to NHs. Overall, residents in both groups had moderate to severe levels of disability and about 60 per cent had mild to severe cognitive problems. While their general features were heterogeneous, the AHMs were more comfortable and homelike than the NHs. The quality of and satisfaction with care was appropriate in both settings, although AHMs performed better. Only one-quarter of residents in both settings, however, evidenced a good level of psycho-social adaptation to their residence. This partnership approach is a good strategy to provide a useful range of housing types in communities that can respond to the needs of elders with moderate to severe disabilities.

Under-recognition of dementia in long-term care homes in Hong Kong

OBJECTIVE

To examine the extent to which dementia in nursing homes is recognized by staff.

METHODS

About 189 residents with very mild to moderate dementia (Clinical Dementia Rating, CDR ≥ 0.5) and Mini-Mental State Examination (MMSE) = 10-24 were recruited from 12 nursing homes in Hong Kong. A senior staff in each home provided information on whether the participant was known to have dementia, and if so, the exact diagnosis. Logistic regression was conducted to predict identification by age, gender, whether for-profit or non-profit home, length of stay, MMSE, CDR, activities of daily living, and use of cholinesterase inhibitors and antipsychotic medications.

RESULTS

It was observed that 42.3% of the sample had mild dementia and 14.8% had moderate dementia. Although identification rates increased with increasing severity of cognitive impairment, only 30.0% of those with mild dementia and 64.3% of those with moderate dementia were known to have dementia by the homes. Identification rates did not differ between for-profit homes and non-profit homes which had regular MMSE screening. Logistic regression analysis showed that only MMSE (OR = 0.85, 95% CI = 0.76-0.95, p = 0.005) and CDR = 2 (as compared with CDR = 0.5; OR = 4.78, 95% CI = 1.23-18.65, p = 0.024) were significantly associated with dementia recognition. No other factors were related to dementia recognition.

CONCLUSIONS

Despite a high prevalence of dementia in long-term care facilities, recognition of dementia as a medical condition in residents by staff was suboptimal, and MMSE screening in some homes did not seem to increase awareness significantly.

The importance of end-of-life care in nursing home settings is not diminished by a disaster

The emphasis in disaster situations is on preserving life, and this goal is both appropriate and laudable. There is a risk, however, that the needs of people who are dying can become lost when there is a sudden surge of people needing acute intervention. There are significant ethical considerations inherent in society's prioritization of care needs across the acute, rehabilitative, and palliative spectrum in general, let alone in a disaster situation. These ethical conundrums are not the focus of this article. Rather, we anchor our discussion on the assumption that care needs are equally valid, and our purpose is to explore the issues that impact the provision of quality end-of-life care in nursing home settings for those who require this care when a disaster occurs. Nursing home residents, in particular, are at heightened risk for experiencing negative disaster-related outcomes due to compromised physical or mental health that requires skilled nursing care. Moreover, within the already vulnerable nursing home population are many people who are receiving palliative end-of-life services when a disaster strikes. Education and training in end-of-life services for nursing home staff, disaster emergency responders, and other lay people is vital to build capacity for adapting the delivery of these services in disaster situations in the interest of equity and human rights. Given the present lack of guidance in the literature as to what end-of-life care looks like when adapted to the context of disaster response, there is also a pressing need for research to inform this discussion. The purpose of this article is to draw attention to this topic and highlight some of the critical issues, gaps, and opportunities.