The more physical inactivity, the more agitation in dementia

Walking Interventions and Sleep Quality of Persons Living With Dementia and Their Family Caregivers: Effects of Different Walking Companions

PURPOSE

To examine the effect of walking interventions on sleep quality of persons with dementia (PWD) and their caregivers (dyads), and how different companions affect results.

METHOD

Forty-five dyads were divided into three groups: a control group and two experimental groups (one with a care attendant, one with a family caregiver). The two experimental groups engaged in 120 minutes of walking per week for 24 weeks.

RESULTS

A significant improvement in sleep quality was observed among PWD in the family caregiver group (Wald χ2 = 4.55, p = 0.033), whereas there was no improvement in the care attendant group. A slight improvement in sleep quality of family caregivers was also found.

CONCLUSION

Findings suggest the importance of creating individualized walking activity plans for dyads, incorporating trust and rapport-building strategies to improve sleep quality. [Journal of Gerontological Nursing, 50(8), 46-56.].

Implementing a new living concept for persons with dementia in long-term care: evaluation of a quality improvement process

BACKGROUND

Improving quality of nursing home care for residents is a constant focus of stakeholders involved within quality improvement projects. Though, achieving change in long-term care is challenging. Process evaluations provide insight into the nature, exposure and experiences of stakeholders and influencing mechanisms for implementation. The aim of this study is to gain insight into the process and facilitating and hindering mechanisms of implementing a quality improvement project that seeks to create a dementia-friendly community with a nursing home at its core.

METHODS

For the process evaluation we planned a case study design with an ethnographic approach. Various research methods were used: qualitative observations, focus groups, interviews and questionnaires for various stakeholders and document review. Data collection and analyses in this study is based on the Consolidated Framework for Implementation Research.

RESULTS

Four main lessons were learned. Firstly, nursing staff are crucial to achieve more freedom for residents. Secondly, high-impact changes in daily care need strong and sustainable focus from the care organisation. Thirdly, dementia-friendly societies should be deployed from multiple actors, which entails long-term collaborations with external stakeholders. Fourthly, the transition to a dementia-friendly society requires meeting spaces for and a focus on both residents and people from the community. Consequently, local residents are shifting from external to internal stakeholders, extending beyond the regular involvement of informal carers and volunteers within the nursing home.

CONCLUSIONS

Nursing homes are part of the local community and provide opportunities to collaborate on a dementia-friendly society. However, the change that is required (promoting freedom, residents' autonomy and the redesign of care processes) is complex and influenced by various mechanisms. Understanding these mechanisms can benefit other care organisations that strive to implement a similar initiative.

Association between freedom of movement and health of nursing home residents with dementia: an exploratory longitudinal study

BACKGROUND

Locked doors remain a common feature of dementia units in nursing homes (NHs) worldwide, despite the growing body of knowledge on the negative effects of restricted freedom on residents. To date, no previous studies have explored the health effects of opening locked NH units, which would allow residents to move freely within the building and enclosed garden. This study examines the association between increased freedom of movement and the health of NH residents with dementia.

METHODS

This longitudinal, pre-post study involved a natural experiment in which NH residents with dementia (N = 46) moved from a closed to a semi-open location. Data on dimensions of positive health were collected at baseline (T0; one month before the relocation), at one (T1), four (T2) and nine (T3) months after the relocation. Linear mixed models were used to examine changes in positive health over time.

RESULTS

Cognition, quality of life and agitation scores improved significantly at T1 and T2 compared to the baseline, while mobility scores decreased. At T3, improvements in agitation and quality of life remained significant compared to the baseline. Activities of daily living (ADL) and depression scores were stable over time.

CONCLUSIONS

Increasing freedom of movement for NH residents with dementia is associated with improved health outcomes, both immediately and over time. These findings add to the growing evidence supporting the benefits of freedom of movement for the overall health of NH residents with dementia.

Integrated flood risk assessment of properties and associated population at county scale for Nebraska, USA

Risk assessment of properties and associated population was conducted for the state of Nebraska, leveraging only open-source datasets. The flood risk framework consisted of interactions among drivers, i.e. hazard, exposure, vulnerability, and response, to assess the risks related to properties and associated populations. To quantify hazard on a county scale, we considered properties at risk of flooding based on a flood score (a higher score represents a greater chance of flooding). Exposure was quantified by considering population density at the county level. We quantified vulnerability under four categories: social, ecological, economic, and health. Response, a relatively newer component in flood risk assessment, was also quantified under three distinct categories: structural, non-structural, and emergency. Overall, we found that counties in eastern Nebraska (Sarpy, Dakota, Wayne, and Adams) have a higher risk of flooding consequences due to more exposure to vulnerable assets such as population and property. The assessment also observed that counties in eastern Nebraska are in the process of improving their flood control measures with dams, levees, and higher insurance coverage that can subdue the risks associated with flooding. The results from this study are anticipated to guide water managers and policymakers in making more effective and locally relevant policies and measures to mitigate flood risks and consequences.

Exploring experiences of times without care and encounters in dementia: protocol for a living and adaptive evidence map

INTRODUCTION

Individuals with dementia spend most of the day without care, without encounters, and usually without activity. Although this has been proven in studies, there is a knowledge gap on how individuals with dementia experience these periods of time. Such knowledge would be highly relevant for health professionals and relatives to develop adequate strategies for dealing with these periods of time. The FreiZeit study aims to reconstruct periods of time without care and encounters from the perspective of individuals with dementia and formal and informal carers. The specific objective of this review is to provide a continuously updated overview of the topical evidence that may be used to guide data synthesis and interpretation within the FreiZeit study.

METHODS AND ANALYSIS

We conduct a living evidence map, based on a comprehensive systematic literature search in MEDLINE/PubMed, CINAHL, PsycINFO/Ovid and Web of Science Core Collection, citation-based searches and web searches. We include studies on times without care and encounters of individuals with dementia from the perspective of individuals with dementia themselves and formal or informal caregivers of any observational study design that were conducted in the institutional and domestic long-term care setting and published as journal article in English, French or German language without any restriction of the publication year. One reviewer screens titles, abstracts and full texts and extracts data. Key characteristics and results of the included studies are charted in a tabular format. The searches will be run and continuously updated throughout the duration of the overarching FreiZeit study (every 6 months for 2 years from 2023 to 2025).

ETHICS AND DISSEMINATION

Ethics approval is not required for this evidence map. We disseminate our findings via journal articles and conference proceedings as well as other formats.

REGISTRATION DETAILS

This review protocol is uploaded on Open Science Framework (OSF; DOI 10.17605/OSF.IO/GDYZ9).

[Development and evaluation of complex interventions in nursing : Application of the medical research council's framework using the example of interventions to prevent physical restraints]

Many nursing interventions are complex. They comprise different intervention elements (components) and aim to change processes or behaviours of individuals or groups. A framework of the British Medical Research Council comprises methodological recommendations for the development and evaluation of complex interventions. This narrative review describes the framework's methodological recommendations using an example of interventions to reduce physical restraints in hospital and long-term care settings, such as bedrails or belts in chairs and beds. In addition to the characteristics of the complex interventions, the development and theoretical foundation of the interventions as well as the feasibility test and evaluation is described.

Effects of Dementia on Outcomes after Cervical Spine Injuries in Elderly Patients: Evaluation of 1512 Cases in a Nationwide Multicenter Study in Japan

We aimed to retrospectively investigate the demographic characteristics and short-term outcomes of traumatic cervical spine injuries in patients with dementia. We enrolled 1512 patients aged ≥ 65 years with traumatic cervical injuries registered in a multicenter study database. Patients were divided into two groups according to the presence of dementia, and 95 patients (6.3%) had dementia. Univariate analysis revealed that the dementia group comprised patients who were older and predominantly female and had lower body mass index, higher modified 5-item frailty index (mFI-5), lower pre-injury activities of daily living (ADLs), and a larger number of comorbidities than patients without dementia. Furthermore, 61 patient pairs were selected through propensity score matching with adjustments for age, sex, pre-injury ADLs, American Spinal Injury Association Impairment Scale score at the time of injury, and the administration of surgical treatment. In the univariate analysis of the matched groups, patients with dementia had significantly lower ADLs at 6 months and a higher incidence of dysphagia up to 6 months than patients without dementia. Kaplan-Meier analysis revealed that patients with dementia had a higher mortality than those without dementia until the last follow-up. Dementia was associated with poor ADLs and higher mortality rates after traumatic cervical spine injuries in elderly patients.

Humans have a basic physical and psychological need to move the body: Physical activity as a primary drive

Physical activity, while less necessary for survival in modern times, is still essential for thriving in life, and low levels of movement are related to numerous physical and mental health problems. However, we poorly understand why people move on a day-to-day basis and how to promote greater energy expenditure. Recently, there has been a turn to understand automatic processes with close examination of older theories of behavior. This has co-occurred with new developments in the study of non-exercise activity thermogenesis (NEAT). In this narrative review, it is hypothesized that psycho-physiological drive is important to understand movement in general and NEAT, specifically. Drive, in short, is a motivation state, characterized by arousal and felt tension, energizing the organism to acquire a basic need. Movement is a biological necessity, like food, water, and sleep, but varies across the lifespan and having the greatest impact before adolescence. Movement meets various criteria for a primary drive: (a) deprivation of it produces feelings of tension, such as an urge or craving, known as affectively-charged motivation states, and particularly the feelings of being antsy, restless, hyper or cooped up, (b) provision of the need quickly reduces tension - one can be satiated, and may even over-consume, (c) it can be provoked by qualities of the environment, (d) it is under homeostatic control, (e) there is an appetite (i.e., appetence) for movement but also aversion, and (f) it has a developmental time course. Evidence for drive has mainly come from children and populations with hyperkinetic disorders, such as those with anorexia nervosa, restless legs syndrome, and akathisia. It is also stimulated in conditions of deprivation, such as bed rest, quarantine, long flights, and physical restraint. It seems to be lacking in the hypokinetic disorders, such as depression and Parkinson's. Thus, drive is associated with displeasure and negative reinforcement, subsuming it within the theory of hedonic drive, but it may fit better within new paradigms, such as the WANT model (Wants and Aversions for Neuromuscular Tasks). Recently developed measurement tools, such as the CRAVE scale, may permit the earnest investigation of movement drive, satiation, and motivation states in humans.

What factors contribute to the need for physical restraint in institutionalized residents in Taiwan?

Background

In Taiwan, physical restraint is commonly used in institutions to protect residents from falling or injury. However, physical restraint should be used cautiously to avoid side effects, such as worse cognition, mobility, depression, and even death.

Objectives

To identify the rate of physical restraint and the associated risk factors in institutionalized residents in Taiwan.

Methods

A community-based epidemiological survey was conducted from July 2019 to February 2020 across 266 residential institutions. Among the estimated 6,549 residents being surveyed, a total of 5,752 finished the study. The questionnaires were completed by residents, his/her family or social workers. The cognition tests were conducted by specialists and a multilevel analysis approach was used to identify cognition/disability/medical history/special nursing care/BPSD risk factors for physical restraints.

Results

Of the 5,752 included institutionalized residents, 30.2% (1,737) had been previously restrained. Older age, lower education level, lower cognitive function, higher dependence, residents with cerebrovascular disease, pulmonary disease, dementia, and intractable epilepsy, all contributed to a higher physical restraint rate, while orthopedic disease and spinal cord injury were associated with a lower physical restraint rate. Furthermore, residents with special nursing care had a higher restraint rate. Residents with most of the behavior and psychological symptoms were also associated with an increased restraint rate.

Conclusions

We studied the rate of physical restraint and associated risk factors in institutionalized residents in Taiwan. The benefits and risks of physical restraint should be evaluated before application, and adjusted according to different clinical situations.

Factors associated with formal and informal resource utilization in nursing home patients with and without dementia: cross-sectional analyses from the COSMOS trial

OBJECTIVES

To investigate the association between clinical, demographic, and organizational factors and formal (health professionals) and informal (relatives) resource utilization in nursing home patients with and without dementia.

METHODS

Baseline data from the multicomponent cluster randomized control COSMOS trial including 33 Norwegian nursing homes and 723 residents with and without dementia. Nursing home staff (n = 117) participated as proxy raters to approximate formal and informal resource use in daily care.

MEASUREMENTS

The primary outcome was the Resource Utilization in Dementia - Formal Care scale to assess formal and informal care time in hours/month regarding basic activities of daily living (ADL), instrumental ADL, and supervision. Secondary outcomes were hours/week spent on formal and informal leisure activities. Behavioral and psychological symptoms in dementia (BPSD) were assessed by the Neuropsychiatric Inventory-Nursing Home version, physical function by the Physical Self-Maintenance Scale, and psychotropic drug use by the Anatomical Therapeutic Chemical classification system. Organizational factors were ward size and staff ratio.

RESULTS

Generalized linear mixed-effect models and two-part modelling revealed an association between increased formal care time and poorer physical function, higher agitation and psychotropic drug use and lower cognitive function (all p < .05). Enhanced formal leisure time was related to better ADL function (p < .05) and smaller wards (p < .05). The family related leisure time was associated with agitation, decline in ADL function, smaller wards, and better staffing ratio (all p < .05). Married patients received more informal direct care (p < .05) and leisure time (p < .05) compared to unmarried/widowed.

CONCLUSION

For nursing home staff, higher agitation and psychotropic drug use, and lower cognitive function, is associated with more direct care time, whereas leisure time activities are less prioritized in people with lower physical function. Informal caregivers' engagement is encouraged by smaller nursing homes and better staff ratio. Therefore, we recommend stakeholders and healthcare professionals to consider these clinical and organizational factors to optimize treatment and leisure time activities in nursing home patients with various needs.

TRIAL REGISTRATION

ClinicalTrials.gov ; NCT02238652.

Physical Activity in People With Dementia Living in Long-Term Care Facilities and the Connection With Environmental Factors and Behavior

This study is conducted in order to gain a better understanding of the relationship between physical activity and agitated behavior among older people with dementia, and physical activity and characteristics of long-term care wards. Data were collected among people with dementia living in long-term care facilities (N = 76) by conducting observations at the wards and distributing questionnaires among professional caregivers. The results show that participants are largely inactive (82.8%) and a significant relation was found between the degree of physical activity and characteristics of the ward such as "taking sufficient time," which relates to the time caregivers take when interacting with residents. This study supports the existing knowledge about the degree of physical activity among people with dementia in long-term care and adds information about the potential influence of organizational factors that could be valuable for daily practice.

Interventions for preventing and reducing the use of physical restraints of older people in general hospital settings

BACKGROUND

Physical restraints, such as bedrails, belts in chairs or beds, and fixed tables, are commonly used for older people in general hospital settings. Reasons given for using physical restraints are to prevent falls and fall-related injuries, to control challenging behavior (such as agitation or wandering), and to ensure the delivery of medical treatments. Clear evidence of their effectiveness is lacking, and potential harms are recognised, including injuries associated with the use of physical restraints and a negative impact on people's well-being. There are widespread recommendations that their use should be reduced or eliminated.

OBJECTIVES

To assess the best evidence for the effects and safety of interventions aimed at preventing and reducing the use of physical restraint of older people in general hospital settings. To describe the content, components and processes of these interventions.

SEARCH METHODS

We searched the Cochrane Dementia and Cognitive Improvement Group's register, MEDLINE (Ovid SP), Embase (Ovid SP), PsycINFO (Ovid SP), CINAHL (EBSCOhost), Web of Science Core Collection (Clarivate), LILACS (BIREME), ClinicalTrials.gov and the World Health Organization's meta-register the International Clinical Trials Registry Portal on 20 April 2022.

SELECTION CRITERIA

We included randomised controlled trials and controlled clinical trials that investigated the effects of interventions that aimed to prevent or reduce the use of physical restraints in general hospital settings. Eligible settings were acute care and rehabilitation wards. We excluded emergency departments, intensive care and psychiatric units, as well as the use of restrictive measures for penal reasons (e.g. prisoners in general medical wards). We included studies with a mean age of study participants of at least 65 years. Control groups received usual care or active control interventions that were ineligible for inclusion as experimental interventions.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected the articles for inclusion, extracted data, and assessed the risk of bias of all included studies. Data were unsuitable for meta-analysis, and we reported results narratively. We used GRADE methods to describe our certainty in the results.

MAIN RESULTS

We included four studies: two randomised controlled trials (one individually-randomised, parallel-group trial and one clustered, stepped-wedge trial) and two controlled clinical trials (both with a clustered design). One study was conducted in general medical wards in Canada and three studies were conducted in rehabilitation hospitals in Hong Kong. A total of 1709 participants were included in three studies; in the fourth study the number of participants was not reported. The mean age ranged from 67 years to 84 years. The duration of follow-up covered the period of patients' hospitalisation in one study (21 days average length of stay) and ranged from 4 to 11 months in the other studies. The definition of physical restraints differed slightly, and one study did not include bedrails. Three studies investigated organisational interventions aimed at implementing a least-restraint policy to reduce physical restraints. The theoretical approach of the interventions and the content of the educational components was comparable across studies. The fourth study investigated the use of pressure sensors for participants with an increased falls risk, which gave an alarm if the participant left the bed or chair. Control groups in all studies received usual care. Three studies were at high risk of selection bias and risk of detection bias was unclear in all studies. Because of very low-certainty evidence, we are uncertain about the effect of organisational interventions aimed at implementing a least-restraint policy on our primary efficacy outcome: the use of physical restraints in general hospital settings. One study found an increase in the number of participants with at least one physical restraint in the intervention and control groups, one study found a small reduction in both groups, and in the third study (the stepped-wedge study), the number of participants with at least one physical restraint decreased in all clusters after implementation of the intervention but no detailed information was reported. For the use of bed or chair pressure sensor alarms for people with an increased fall risk, we found moderate-certainty evidence of little to no effect of the intervention on the number of participants with at least one physical restraint compared with usual care. None of the studies systematically assessed adverse events related to use of physical restraint use, e.g. direct injuries, or reported such events. We are uncertain about the effect of organisational interventions aimed at implementing a least-restraint policy on the number of participants with at least one fall (very low-certainty evidence), and there was no evidence that organisational interventions or the use of bed or chair pressure sensor alarms for people with an increased fall risk reduce the number of falls (low-certainty evidence from one study each). None of the studies reported fall-related injuries. We found low-certainty evidence that organisational interventions may result in little to no difference in functioning (including mobility), and moderate-certainty evidence that the use of bed or chair pressure sensor alarms has little to no effect on mobility. We are uncertain about the effect of organisational interventions on the use of psychotropic medication; one study found no difference in the prescription of psychotropic medication. We are uncertain about the effect of organisational interventions on nurses' attitudes and knowledge about the use of physical restraints (very low-certainty evidence).

AUTHORS' CONCLUSIONS

We are uncertain whether organisational interventions aimed at implementing a least-restraint policy can reduce physical restraints in general hospital settings. The use of pressure sensor alarms in beds or chairs for people with an increased fall risk has probably little to no effect on the use of physical restraints. Because of the small number of studies and the study limitations, the results should be interpreted with caution. Further research on effective strategies to implement a least-restraint policy and to overcome barriers to physical restraint reduction in general hospital settings is needed.

Activity system, schizotypal personality, and mentalization: A study between halted activity and COVID-19 conducted in Henan, China

The pandemic-related lifestyle has potentially imposed crucial disturbances on daily and long-term activities, which, in turn, were associated with thought disturbance. This study investigates how the characteristics of the activity system during pandemic-related restrictions are associated with other psychomental aspects. By focusing on PTSD, mentalization, and schizotypal personality, and by inquiring about the main components of the activity system of 852 college students (Zhengzhou, Henan, China)- including the goals orienting their activity, goals' terms and types, the motivation levels and sources, the activity type and engagement time, the flow of the activity, and how due to pandemic lifestyle-results revealed that the activity system's components have significant associations with PTSD, reflective function, and schizotypal traits. Additionally, some of the activity system's elements have a significant predictive role regarding schizotypal traits. The study considered that the life narrative during the pandemic has been disturbed; hence, this may have a crucial effect on mind coherence. Additionally, the outcomes from the pandemic context will support mental health interventions in other similar contexts where the life narrative is severely affected.

Artificial Intelligence Inheriting the Historical Crisis in Psychology: An Epistemological and Methodological Investigation of Challenges and Alternatives

By following the arguments developed by Vygotsky and employing the cultural-historical activity theory (CHAT) in addition to dialectical logic, this paper attempts to investigate the interaction between psychology and artificial intelligence (AI) to confront the epistemological and methodological challenges encountered in AI research. The paper proposes that AI is facing an epistemological and methodological crisis inherited from psychology based on dualist ontology. The roots of this crisis lie in the duality between rationalism and objectivism or in the mind-body rupture that has governed the production of scientific thought and the proliferation of approaches. In addition, by highlighting the sociohistorical conditions of AI, this paper investigates the historical characteristics of the shift of the crisis from psychology to AI. Additionally, we examine the epistemological and methodological roots of the main challenges encountered in AI research by noting that empiricism is the dominant tendency in the field. Empiricism gives rise to methodological and practical challenges, including challenges related to the emergence of meaning, abstraction, generalization, the emergence of symbols, concept formation, functional reflection of reality, and the emergence of higher psychological functions. Furthermore, through discussing attempts to formalize dialectical logic, the paper, based on contradiction formation, proposes a qualitative epistemological, methodological, and formal alternative by using a preliminary algorithmic model that grasps the formation of meaning as an essential ability for the qualitative reflection of reality and the emergence of other mental functions.

Association of Variation in Behavioral Symptoms With Initial Cognitive Phenotype in Adults With Dementia Confirmed by Neuropathology

IMPORTANCE

Behavioral and psychological symptoms of dementia (BPSDs) in association with amnestic and nonamnestic cognitive phenotypes have not been evaluated across diagnoses of Alzheimer disease pathology (ADP), Lewy body-related pathology (LRP), and mixed pathology (ADP-LRP).

OBJECTIVES

To determine the clinical phenotypes at the initial visit that are associated with the nature and severity of BPSDs in patients with ADP, LRP, and ADP-LRP.

DESIGN, SETTING, AND PARTICIPANTS

This retrospective longitudinal cohort study included 2422 participants with neuropathologically confirmed ADP, LRP, or mixed ADP-LRP in the National Alzheimer Coordinating Center database from June 20, 2005, to September 4, 2019. Participants had a mean (SD) interval of 5.5 (2.8) years from initial visit to autopsy.

MAIN OUTCOMES AND MEASURES

Clinician-determined diagnosis of change across 10 BPSDs (agitation, apathy, depression, delusions, disinhibition, auditory hallucinations, visual hallucinations, irritability, personality change, and rapid eye movement [REM] sleep behavior) and the highest severity score for behavioral change on the Neuropsychiatric Inventory Questionnaire (NPI-Q).

RESULTS

A total of 2422 participants (1187 with ADP, 904 with ADP-LRP, and 331 with LRP) were included in the analysis (1446 men [59.7%]; mean [SD] age, 74.4 [10.1] years). Compared with initial amnestic symptoms, executive symptoms were associated with a higher risk for 7 of the 10 BPSDs (hazard ratio [HR] range, 1.28-2.45), and visuospatial symptoms were associated with a higher risk for 2 of the 10 BPSDs (HR range, 1.91-2.51), but neither were associated with a low risk for any BPSD. Language symptoms were associated with a low risk of onset for 3 of 10 BPSDs (HR range, 0.43-0.79) and a high risk for 1 BPSD (personality change) (HR, 1.42 [95% CI, 1.10-1.83]). Participants with LRP had a lower risk for agitation (HR, 0.74 [95% CI, 0.60-0.92]), disinhibition (HR, 0.78 [95% CI, 0.62-0.99]), and irritability (HR, 0.81 [95% CI, 0.68-0.96]) and a higher risk for apathy (HR, 1.19 [95% CI, 1.02-1.38]), depression (HR, 1.32 [95% CI, 1.12-1.55]), auditory (HR, 2.00 [95% CI, 1.37-2.93]) and visual (HR, 2.78 [95% CI, 2.21-3.49]) hallucinations, and REM sleep behavior changes (HR, 4.77 [95% CI, 3.61-6.31]) compared with the ADP group. The ADP-LRP group had a higher risk for delusions (HR, 1.27 [95% CI, 1.08-1.48]), auditory (HR, 1.62 [95% CI, 1.21-2.15]) and visual (HR, 1.57 [95% CI, 1.30-1.89]) hallucinations, and REM sleep behavior changes (HR, 2.10 [95% CI, 1.63-2.70]) than the ADP group and a lower risk for visual hallucinations (HR, 0.56 [95% CI, 0.45-0.71]) and REM sleep behavior changes (HR, 0.44 [95% CI, 0.34-0.57) than the LRP group. Overall, women showed a lower risk of agitation (HR, 0.86 [95% CI, 0.75-0.98]), apathy (HR, 0.79 [95% CI, 0.71-0.87]), visual hallucinations (HR, 0.76 [95% CI, 0.64-0.90]), irritability (HR, 0.77 [95% CI, 0.69-0.86]), and REM sleep behavior change (HR, 0.45 [95% CI, 0.35-0.58]) and a higher risk of depression (HR, 1.26 [95% CI, 1.13-1.41]). Older age was associated with a lower risk of most BPSDs (HR range, 0.98-0.99) except delusions (HR, 1.00 [95% CI, 1.00-1.01]) and auditory hallucinations (HR, 0.99 [95% CI, 0.97-1.00]) and a low NPI-Q composite score (β = -0.07 [95% CI, -0.08 to -0.05]; P < .001).

CONCLUSIONS AND RELEVANCE

These findings suggest that the risks of BPSDs differ with respect to the initial cognitive phenotype, underlying neuropathology, age, and sex. Awareness of these associations could be helpful in dementia management.

Perspectives of substitute decision-makers and staff about person-centred physical activity in long-term care

INTRODUCTION

This paper aims to explore the care processes that best exemplify person-centred care during physical activity (PA) for long-term care (LTC) residents with dementia from the perspectives of substitute decision-makers (SDMs) and LTC home staff. Little is known about how person-centred care is reflected during PA for residents with dementia, or the barriers and benefits to enacting person-centred care during PA.

METHODS

Semistructured interviews were used to collect SDMs and LTC home staffs' perspectives on the importance of person-centred care during PA from two LTC homes in Canada. The McCormack and McCance person-centredness framework was used to guide thematic content analysis of responses.

RESULTS

SDM (n = 26) and staff (n = 21) identified actions categorized under the sympathetic presence or engagement care processes from the person-centredness framework as most reflecting person-centred care. Benefits of person-centred care during PA were categorized into three themes: functional and physical, behavioural and communication and psychosocial improvements. Barriers to person-centred care during PA identified were lack of time, opportunities for meaningful activity in LTC setting and staff experiences with resident aggression.

SIGNIFICANCE

Understanding the care processes that are most recognized as person-centred care and valued by SDMs and LTC home staff has implications for education and training. Insights into SDMs' care expectations regarding person-centred care can inform staff about which actions should be prioritized to meet care expectations and can foster relationships to the benefit of residents with dementia.

PATIENT AND PUBLIC CONTRIBUTION

Study participants were not involved in the development of research questions, research design or outcome measures of this study.

Exploring life-space in the nursing home. An observational longitudinal study

BACKGROUND

Traditional performance-based measurements of mobility fail to recognize the interaction between the individual and their environment. Life-space (LS) forms a central element in the broader context of mobility and has received growing attention in gerontology. Still, knowledge on LS in the nursing home (NH) remains sparse. The aim of this study was to identify LS trajectories in people with dementia from time of NH admission, and explore characteristics associated with LS over time.

METHODS

In total, 583 people with dementia were included at NH admission and assessed biannually for 3 years. LS was assessed using the Nursing Home Life-Space Diameter. Association with individual (age, sex, general medical health, number of medications, pain, physical performance, dementia severity, and neuropsychiatric symptoms) and environmental (staff-to-resident ratio, unit size, and quality of the physical environment) characterises was assessed. We used a growth mixture model to identify LS trajectories and linear mixed model was used to explore characteristics associated with LS over time.

RESULTS

We identified four groups of residents with distinct LS trajectories, labelled Group 1 (n = 19, 3.5%), Group 2 (n = 390, 72.1%), Group 3 (n = 56, 10.4%), Group 4 (n = 76, 14.0%). Being younger, having good compared to poor general medical health, less severe dementia, more agitation, less apathy, better physical performance and living in a smaller unit were associated with a wider LS throughout the study period.

CONCLUSION

From NH admission most NH residents' LS trajectory remained stable (Group 2), and their daily lives unfolded within their unit. Better physical performance and less apathy emerged as potentially modifiable characteristics associated with wider LS over time. Future studies are encouraged to determine whether LS trajectories in NH residents are modifiable, and we suggest that future research further explore the impact of environmental characteristics.

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

PURPOSE

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

DESIGN/METHODS

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

RESULTS

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

CONCLUSION

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

CLINICAL RELEVANCE

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

Trajectories of physical performance in nursing home residents with dementia

Background

In nursing homes (NH) the prevalence of dementia ranges from 50 to 84% and most residents have extensive physical-performance impairments. However, from time of admission, development of physical performance in NH residents with dementia remains unexplored.

Aims

To explore the overall trend in physical performance, associated characteristics, and groups following distinct trajectories from time of admission, in NH residents with dementia.

Methods

We followed newly admitted NH residents diagnosed with dementia (N = 583) from 47 NHs across Norway for 3 years. Individual assessments were conducted biannually, and main outcome measure was the Short Physical Performance Battery (SPPB). Facility-level characteristics included unit size, staff-to-resident ratio, and quality of the physical environment (Special Care Unit Environmental Quality Scale, SCUEQS).

Results

From time of admission, NH residents with dementia showed a significant overall decline in physical performance. Further, we identified three distinct trajectory groups with significantly different baseline physical-performance status (“good,” “moderate,” and “poor”), differences between groups maintained and all declined across time. Younger age, good general medical health, less-severe dementia, and less musculoskeletal pain were associated with both an average higher overall trend and better baseline group-belonging. Additionally, less apathy and more psychosis were associated with a higher overall trend, and agitation was associated with poorer baseline group-belonging.

Conclusions

To prevent excessive decline in physical performance in this population, NH clinicians should focus efforts specifically on assessment of physical performance at admission and on identification and management of musculoskeletal pain and neuropsychiatric symptoms.

Electronic supplementary material

The online version of this article (10.1007/s40520-020-01499-y) contains supplementary material, which is available to authorized users.

Nonpharmacological Strategies Used By Family Caregivers of Persons With Alzheimer's Disease and Related Dementias as Presented in Blogs

Individuals with Alzheimer's disease and related dementias (ADRD) may exhibit behavioral and psychological symptoms of dementia that can increase the strain experienced by their family caregivers. This strain correlates with increased stress and reduced quality of life for the family caregiver and individual with ADRD. More information is needed regarding the ways in which caregivers manage the caregiving experience in their efforts to reduce strain and maintain or improve quality of life. Many individuals, including dementia caregivers, use web blogs as online journals to share their lived experiences. The current study used blogs written by family caregivers of persons with ADRD to explore strategies used to support their care recipients. Using a qualitative thematic analysis, six themes related to the strategies used by caregivers were identified: Modifying the Physical and Personal Environment; Engaging the Person With ADRD; Seeking Outside Assistance; Using Complementary Therapies; Planning and Organization; and Reminiscing and Traditions. The current findings extend our understanding of strategies for caregiving that are used by and acceptable to family caregivers of persons with ADRD. This information can be used to develop or modify nursing-related interventions and services aimed at improving caregiver strain and quality of life. [Journal of Gerontological Nursing, 45(7), 25-35.].

A Structured Physical Exercise Program Reduces Professional Caregiver's Burden Caused by Neuropsychiatric Symptoms in Acute Dementia Care: Randomized Controlled Trial Results

Physical exercise is an effective treatment approach for neuropsychiatric symptoms (NPS), but it is unknown whether the reduction of NPS has an impact on professional caregiver's burden. A randomized controlled trial in acute dementia care with N = 70 patients, n = 35 per group, was conducted. The intervention group (IG) received an exercise program, the control group a social stimulation program. The RM-ANOVA showed a significant group x time interaction with time effects for the IG and decreased caregiver burden due to the exercise program at follow-up. Physical exercise programs may not only be beneficial for the patients but also for their professional caregivers.

Effects of walking on sundown syndrome in community-dwelling people with Alzheimer's disease

BACKGROUND

Sundown syndrome is an important care issue for people with dementia (PwD) and for family caregivers. Walking is a safe and simple physical activity for most PwD, yet no research has explored the effects of different long-term walking periods on sundown syndrome.

OBJECTIVES

This study aimed to determine the effects of walking on sundown syndrome, and to identify whether different walking time periods would show different effects on sundown syndrome in community-dwelling people with Alzheimer's disease.

METHODS

A quasi-experimental designed study with repeated measurements was conducted. Sixty PwD were recruited and assigned to either the control group or the morning or afternoon walking group according to their caregiver's preference. The participants in the two walking groups completed an average of 120-min walking per week, accompanied by their caregivers. Forty-six achieved the 6-month intervention. Four measurements were taken, one at the pretest and one at weeks 8, 16 and 24. The Chinese version of the Cohen-Mansfield Agitation Inventory, community form (C-CMAI) was used to assess the severity of the sundown syndrome. The generalised estimating equation (GEE) was applied for the longitudinal data analysis.

RESULTS

There was a significant change across the study period (p = .048) in the morning walking group, indicating that the score for sundown syndrome decreased when PwD walked in the morning. Considering group effects, compared to the control group, the C-CMAI scores significantly decreased after 16 weeks of walking in the afternoon walking group (p = .001) and after 24 weeks in both the morning and afternoon walking groups (p = .001), indicating that after PwD had walked for 16 weeks, sundown syndrome ameliorated in the afternoon group and continually decreased after 24 weeks in both the morning and afternoon groups. However, there was no significant group difference between the morning and afternoon walking groups during the 24-week walking intervention.

CONCLUSIONS

The results indicated that both morning walking and afternoon walking are beneficial for ameliorating the symptoms of sundown syndrome; however, walking in the afternoon may have a faster effect on the symptoms than walking in the morning. Walking is a safe, simple, feasible and effective intervention to benefit individuals with sundown syndrome.

IMPLICATIONS FOR PRACTICE

Regularly walking for 30 min a day, four times a week, is beneficial to alleviate sundown syndrome among PwD living in the community. Either morning or afternoon walking is effective for decreasing sundown syndrome, and the longer the walking time, the greater the impact on sundown syndrome.

Prominent physical inactivity in acute dementia care: Psychopathology seems to be more important than the dose of sedative medication

INTRODUCTION

To objectively quantify patients' physical activity and analyze the relationships between physical activity levels, psychopathology, and sedative medication in acute hospital dementia care.

MATERIALS AND METHODS

In this cross-sectional study, we assessed the patients' physical activity based on data collection by hybrid motion sensors attached on their lower back. Daily doses of antipsychotics have been converted to olanzapine-equivalents and daily benzodiazepine medication is reported as diazepam-equivalents. We assessed patients' neuropsychiatric symptoms with the Neuropsychiatric Inventory and the Cohen-Mansfield Agitation Inventory.

RESULTS

We analyzed motion sensor data from 64 patients (MMSE M = 18.6). On average, patients were lying for 11.5 hours, sitting/standing sedentary for 10.3 hours, sitting/standing active for 1.0 hours, and walking for 1.2 hours per day. The analysis revealed no correlations between patients' physical activity and antipsychotic or benzodiazepine medication. More severe neuropsychiatric symptoms were associated with a decrease in the patients' physical activity (r = .32, P = .01). In particular, patients with apathy symptoms were less physically active than patients without apathy symptoms.

DISCUSSION

The results reveal that most of the patients in acute dementia care had very low levels of physical activity. Their physical inactivity may be due to the severity of their neuropsychiatric symptoms, especially apathy. Antipsychotic and benzodiazepine medication appeared to have less impact on patients' physical activity. Dementia care should pay more attention to prevent physical inactivity in patients.

The Multidisciplinary Approach to Alzheimer's Disease and Dementia. A Narrative Review of Non-Pharmacological Treatment

Background: Alzheimer's disease (AD) and dementia are chronic diseases with progressive deterioration of cognition, function, and behavior leading to severe disability and death. The prevalence of AD and dementia is constantly increasing because of the progressive aging of the population. These conditions represent a considerable challenge to patients, their family and caregivers, and the health system, because of the considerable need for resources allocation. There is no disease modifying intervention for AD and dementia, and the symptomatic pharmacological treatments has limited efficacy and considerable side effects. Non-pharmacological treatment (NPT), which includes a wide range of approaches and techniques, may play a role in the treatment of AD and dementia. Aim: To review, with a narrative approach, current evidence on main NPTs for AD and dementia. Methods: PubMed and the Cochrane database of systematic reviews were searched for studies written in English and published from 2000 to 2018. The bibliography of the main articles was checked to detect other relevant papers. Results: The role of NPT has been largely explored in AD and dementia. The main NPT types, which were reviewed here, include exercise and motor rehabilitation, cognitive rehabilitation, NPT for behavioral and psychological symptoms of dementia, occupational therapy, psychological therapy, complementary and alternative medicine, and new technologies, including information and communication technologies, assistive technology and domotics, virtual reality, gaming, and telemedicine. We also summarized the role of NPT to address caregivers' burden. Conclusions: Although NPT is often applied in the multidisciplinary approach to AD and dementia, supporting evidence for their use is still preliminary. Some studies showed statistically significant effect of NPT on some outcomes, but their clinical significance is uncertain. Well-designed randomized controlled trials with innovative designs are needed to explore the efficacy of NPT in AD and dementia. Further studies are required to offer robust neurobiological grounds for the effect of NPT, and to examine its cost-efficacy profile in patients with dementia.

Attendance in Recreational Groups for Persons With Dementia: The Impact of Stimulus and Environmental Factors

OBJECTIVES

Participation in group activities can benefit persons with dementia, alleviating boredom, improving affect, maintaining function, and decreasing problematic behaviors.

METHODS

We describe patterns of attendance of residents with dementia at nursing home activity groups and investigate stimulus and environmental factors that may affect attendance.

RESULTS

Residents participated in 60.8% of the activities, with reasons for nonattendance including refusal (9.7%), not being on the unit (7.8%), being asleep (6.8%), and being involved in activities of daily living and other activities (8.3%). On average, 3.5 other residents not recruited for the study chose to participate in each group session. Group attendance was significantly related to group topic.

IMPLICATION

The need for activities was evident by the attendance of both invited and other residents. Understanding the factors that affect attendance is the first step toward developing procedures to maximize participation in activities in order to decrease loneliness and boredom in this population.

Effects of Physical Activity in Nursing Home Residents with Dementia: A Randomized Controlled Trial

BACKGROUND/AIMS

There is no consensus regarding the optimal nonpharmacological intervention to slow down dementia-related decline. We examined whether physical stimulation interventions were effective in reducing cognitive, physical, mood, and behavioral decline in nursing home residents with dementia.

METHODS

Eighty-seven nursing home residents with dementia were randomly assigned to 3 physical activity interventions: activities of daily living (ADL) training, multicomponent exercise training, or combined multicomponent exercise and ADL training. Outcomes were measured at baseline, and after 3 and 6 months.

RESULTS

A 6-month ADL training benefitted executive functions, physical endurance, and depression among men. Exercise training benefitted only grip strength of participants with mild-to-moderate cognitive impairment. A combined training benefitted functional mobility compared to ADL training, depressive symptoms and agitation compared to exercise training, and physical endurance compared to no physical stimulation.

CONCLUSIONS

ADL training appears to be effective for nursing home residents with moderately severe dementia. It remains unclear whether exercise training is an effective type of stimulation.

Advancing Research on Care Needs and Supportive Approaches for Persons With Dementia: Recommendations and Rationale

The first National Research Summit on Care, Services, and Supports for Persons with Dementia and Their Caregivers was held on October 16-17, 2017, at the National Institutes of Health. In this paper, participants from the Summit Session on Research on Care Needs and Supportive Approaches for Persons with Dementia summarize the state of the science, identify gaps in knowledge, and offer recommendations to improve science and practice in long-term care. Recommendations cover 4 areas focused on persons living with dementia: (1) symptoms (behavioral and psychological symptoms of dementia, function, cognition, and sleep); (2) dementia care settings (physical and social environments, home, and residential care); (3) living with dementia (living well with dementia, living alone with dementia, and living with dementia and intellectual and developmental disabilities); and (4) technology as a cross-cutting theme. The participants identify 10 of the most pressing research issues based on the findings from their collective papers. Final Summit recommendations included those presented by session participants and will be used to advise federal agencies and other organizations that fund research.

Thinking While Moving or Moving While Thinking - Concepts of Motor-Cognitive Training for Cognitive Performance Enhancement

The demographic change in industrial countries, with increasingly sedentary lifestyles, has a negative impact on mental health. Normal and pathological aging leads to cognitive deficits. This development poses major challenges on national health systems. Therefore, it is necessary to develop efficient cognitive enhancement strategies. The combination of regular physical exercise with cognitive stimulation seems especially suited to increase an individual's cognitive reserve, i.e., his/her resistance to degenerative processes of the brain. Here, we outline insufficiently explored fields in exercise-cognition research and provide a classification approach for different motor-cognitive training regimens. We suggest to classify motor-cognitive training in two categories, (I) sequential motor-cognitive training (the motor and cognitive training are conducted time separated) and (II) simultaneous motor-cognitive training (motor and cognitive training are conducted sequentially). In addition, simultaneous motor-cognitive training may be distinguished based on the specific characteristics of the cognitive task. If successfully solving the cognitive task is not a relevant prerequisite to complete the motor-cognitive task, we would consider this type of training as (IIa) motor-cognitive training with additional cognitive task. In contrast, in ecologically more valid (IIb) motor cognitive training with incorporated cognitive task, the cognitive tasks are a relevant prerequisite to solve the motor-cognitive task. We speculate that incorporating cognitive tasks into motor tasks, rather than separate training of mental and physical functions, is the most promising approach to efficiently enhance cognitive reserve. Further research investigating the influence of motor(-cognitive) exercises with different quantitative and qualitative characteristics on cognitive performance is urgently needed.

Combined Effects of Physical Activity and Obesity on Cognitive Function: Independent, Overlapping, Moderator, and Mediator Models

This article reviews studies on physical activity, obesity, and cognition to explore how physical activity and obesity may work independently or together in affecting cognitive function. In particular, we propose six hypotheses derived from four conceptual models to advance our understanding of the combined effects of physical activity and obesity on cognition. The four conceptual models are distinguished by the presumed temporal relationship and the presumed correlation between physical activity and obesity and include an independent model, an overlapping model, a moderator model, and a mediator model. Among the 16 studies testing the effects of physical activity and obesity on cognition in a combined approach, the moderator model, viewing either physical activity or obesity as the potential moderator, was most frequently examined (n = 10), mediator (n = 3) and independent (n = 2) models received relatively less attention, and only a single study used an overlapping model. Results were mixed when considering the moderator, independent, and mediator models. The single study that took an overlapping model approach found support for the model hypothesis. One relevant observation from this review is that the variance within the small extant literature with respect to the choice of conceptual model limits our ability to make assertive conclusions relative to the relations among the examined variables. Given the logic supporting a combined effect of physical activity and obesity on cognition, researchers are encouraged to consider the possible models of the relationship as they design studies to further address this research question.

Engagement of a Person with Dementia Scale: Establishing content validity and psychometric properties

AIM

To develop and psychometrically test the Engagement of a Person with Dementia Scale.

BACKGROUND

It is important to study engagement in people with dementia when exploring the effectiveness of psychosocial interventions that can promote meaningful activity, stimulation and well-being, through an increase in positive emotions and an improvement in quality of life. The Engagement of a Person with Dementia Scale was developed based on current literature and previous research work on a video coding tool to ascertain the effect of psychosocial interventions on engagement in people with dementia.

DESIGN/METHOD

Using the Delphi technique, the content validity of the scale was evaluated by 15 dementia experts and formal/informal dementia carers. Psychometric properties of the scale were evaluated using 131 videos of people with dementia presented with PARO-a therapeutic, interactive, robotic seal-in long-term aged care facilities.

RESULTS

A 10-item scale was established following the rewording, combining and elimination of prospective items, with revisions made to the instructions for using and scoring the scale. An overall consensus with agreement for the scale was established among the panel of experts. The scale demonstrated robust internal consistency, inter-rater and test-retest reliability and convergent and discriminant validity.

CONCLUSION

This study successfully developed the Engagement of a Person with Dementia Scale, with established content validity and psychometric properties. The scale assesses the behavioural and emotional expressions and responses of engagement by people with dementia when partaking in a psychosocial activity in five areas: affective, visual, verbal, behavioural and social engagement.

Wandering in Dementia and Trust as an Anticipatory Action

The increase of dementia makes cognitive disorder a global challenge. Even if wandering is not a symptom of dementia in general, professionals and scientists dominate the definition of wandering as an aimless movement of people with cognitive impairment, mainly dementia. In consequence, professional types of wandering management were elaborated trying to avoid or replace it. However, this can cause negative effects. The article analyses an apparently common informal type of wandering management. It consists of slipping an address paper in the wallet of the ill person. The analysis reveals that this practice is normatively structured by a gift of trust.

Reduced Self-Control after 3 Months of Imprisonment; A Pilot Study

Background: Prison can be characterized as an impoverished environment encouraging a sedentary lifestyle with limited autonomy and social interaction, which may negatively affect self-control and executive function. Here, we aim to study the effects of imprisonment on self-control and executive functions, and we report the change in neuropsychological outcome after 3 months of imprisonment.

Materials and Methods: Participants were 37 male inmates in a remand prison in Amsterdam, Netherlands, who completed six tests of a computerized neuropsychological test battery (the Cambridge Automated Neuropsychological Test Battery) in the first week of arrival. Participants were retested after 3 months of imprisonment. Change in performance was tested using the Wilcoxon Signed-Rank test.

Results: After 3 months of imprisonment, risk taking significantly increased (measured as an increase in the proportion of available points used for betting) and attention significantly deteriorated (measured as increased variability in reaction times on a sustained attention task), with large to medium effect sizes. In contrast, planning significantly improved (measured with a task analog to the Tower of London) with a medium effect size.

Discussion: Our study suggests that 3 months of imprisonment in an impoverished environment may lead to reduced self-control, measured as increased risk taking and reduced attentional performance. This is a significant and societally relevant finding, as released prisoners may be less capable of living a lawful life than they were prior to their imprisonment, and may be more prone to impulsive risk-taking behavior. In other words, the impoverished environment may contribute to an enhanced risk of reoffending.

Evidence-Based Nonpharmacological Practices to Address Behavioral and Psychological Symptoms of Dementia

Background and Objectives

To draw from systematic and other literature reviews to identify, describe, and critique nonpharmacological practices to address behavioral and psychological symptoms of dementia (BPSDs) and provide evidence-based recommendations for dementia care especially useful for potential adopters.

Research Design and Methods

A search of systematic and other literature reviews published from January 2010 through January 2017. Nonpharmacological practices were summarized to describe the overall conceptual basis related to effectiveness, the practice itself, and the size and main conclusions of the evidence base. Each practice was also critically reviewed to determine acceptability, harmful effects, elements of effectiveness, and level of investment required, based on time needed for training/implementation, specialized care provider requirements, and equipment/capital requirements.

Results

Nonpharmacological practices to address BPSDs include sensory practices (aromatherapy, massage, multi-sensory stimulation, bright light therapy), psychosocial practices (validation therapy, reminiscence therapy, music therapy, pet therapy, meaningful activities), and structured care protocols (bathing, mouth care). Most practices are acceptable, have no harmful effects, and require minimal to moderate investment.

Discussion and Implications

Nonpharmacological practices are person-centered, and their selection can be informed by considering the cause and meaning of the individual's behavioral and psychological symptoms. Family caregivers and paid care providers can implement evidence-based practices in home or residential care settings, although some practices require the development of more specific protocols if they are to become widely used in an efficacious manner.

Supporting activity engagement by family carers at home: maintenance of agency and personhood in dementia

An explorative paper to describe how family carers, through the caregiving journey, reaffirm and promote the agency of people with dementia. Agency is an important concept in dementia care and is crucial to the promotion of wellbeing and the delivery of person-centred care. This article is based on one of the key findings of a study that explored family carers' experiences of engaging their relatives in daily activities in domestic settings. Following research governance and ethical approval, 30 in-depth interviews (initial and follow-up) were carried out with 15 resident-carers of people with dementia who were recruited via local community mental health teams. Then five focus groups were conducted with 21 participants accessed through carers support groups. Interviews and focus groups were transcribed, coded and analysed using a grounded theory method. Findings showed the process in which family carers encouraged and sustained a sense of autonomy and control (agency) in their relative's daily activities. Key strategies used by carers included: being non-judgemental; facilitating a sense of worth; taking calculated risks; maintaining the continuity of their relative's identity; enhancing a sense of connection with their relative's role and identity using enjoyable activities; preventing inactivity and attending to the bodily source of the agency. Lack of support for carers could ultimately pose a risk to the maintenance of the agency of people with dementia. This study provides a deeper insight into the process used by home carers to support the agency of people with dementia. This is essential if practitioners are to identify and develop more realistic intervention strategies and to work in effective partnership with family carers. The implications for the creation of dementia-friendly communities are discussed.

Physical restraints and associations with neuropsychiatric symptoms and personal characteristics in residential care: a cross-sectional study

BACKGROUND

Physical restraints are widely used in residential care. The objective was to investigate restraint use and its associations with neuropsychiatric symptoms and personal characteristics in residential care.

METHODS

Data were collected in the South Savo Hospital District from 66 of 68 public or private institutions providing long-term residential care. Nurses assessed the use of physical restraints and neuropsychiatric symptoms (NPS) included in the symptom list of the Neuropsychiatric Inventory (NPI). Drug use was obtained from medical records, and activities of daily living (ADL) were assessed by the nurses according to the Barthel Index.

RESULTS

The total number of persons in residential care was 1386. Any restraint was used for 721 patients (52%) in the preceding 24 h. Bedrails were the most common restraints. In the multivariate analysis, psychotic symptoms (OR 1.94, 95% CI 1.14-3.31) and use of benzodiazepines (OR 1.69, 95% CI 1.18-2.41) were positively associated with restraint use, whereas antipsychotic (OR 0.62, 95% CI 0.44-0.87) and antidepressant drug use (OR 0.64, 95% CI 0.45-0.90) and higher ADL score (OR 0.9, 95% CI 0.92-0.93) were negatively associated. Concomitant use of at least two restraints was associated with high prevalence of hyperactivity NPS symptoms.

CONCLUSIONS

More than half of the residents were exposed to some physical restraint, most frequently bedrails, within the last 24 h. Psychotic symptoms and benzodiazepine use increased while good ADL and antipsychotic or antidepressant use decreased the risk of restraint use. Bedridden persons were the most frequently restrained which may pose an ethical problem. Copyright © 2016 John Wiley & Sons, Ltd.

Structured physical exercise improves neuropsychiatric symptoms in acute dementia care: a hospital-based RCT

Background

The primary objective of this trial is to investigate the effects of a short-term exercise program on neuropsychiatric signs and symptoms in acute hospital dementia care.

Methods

Within a hospital-based randomized controlled trial, the intervention group conducted a 2-week exercise program with four 20-min exercise sessions on 3 days per week. The control group conducted a social stimulation program. Effects on neuropsychiatric signs and symptoms were measured via the Alzheimer’s Disease Cooperative Study-Clinical Global Impression of Change, the Neuropsychiatric Inventory, and the Cohen-Mansfield Agitation Inventory. The antipsychotic and sedative dosage was quantified by olanzapine and diazepam equivalents.

Results

Eighty-five patients were randomized via minimization to an intervention group (IG) and a control group (CG). Seventy patients (82%) (mean age 80 years, 33 females, mean Mini Mental State Examination score 18.3 points) completed the trial. As compared to the CG (n = 35), the IG (n = 35) showed significantly reduced neuropsychiatric signs and symptoms. Especially, agitated behavior and lability improved. There were no between-group differences concerning antipsychotic and benzodiazepine medication.

Conclusions

This exercise program is easily applicable in hospital dementia care and significantly reduces neuropsychiatric signs and symptoms in patients suffering from predominantly moderate stages of dementia.

Trial registration

German Clinical Trial Register DRKS00006740. Registered 28 October 2014.

The Nature and Extent of Physical Restraint-Related Deaths in Nursing Homes: A Systematic Review

OBJECTIVE

The aim of this study is to conduct a systematic review of the published research to examine the extent, nature, and risk factors of mortality due to physical restraint use.

METHOD

In accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) Statement, this review examined all peer-reviewed studies published in English describing mortality due to physical restraint in nursing home residents.

RESULTS

The combined searches yielded 2,016 records of which eight articles were eligible for inclusion. There were 174 deaths due to physical restraint in nursing home residents across the eight studies. Neck compression ( n = 8) was the most common mechanism of harm resulting in death due to mechanical asphyxia.

CONCLUSIONS

Physical restraint is associated with deaths in nursing home residents. Further research is needed to investigate alternative interventions to restraint use.

Sundown Syndrome, Sleep Quality, and Walking Among Community-Dwelling People With Alzheimer Disease

PURPOSES

Sundown syndrome and sleep disturbances cause people with Alzheimer disease (PAD) and caregivers suffering. Studies have indicated that physical exercise could have a positive impact on sundown syndrome, yet no research has ever explored the relationship between walking and sundown syndrome. The aims of this study were to examine the relationship between sundown syndrome and sleep quality, and determine whether the severity of dementia, sleep quality, and weekly duration of walking influenced sundown syndrome, and to assess differences in sundown syndrome and sleep quality in relation to the accompanying walker and weekly duration of walking among people with Alzheimer disease living in the community.

DESIGN

A cross-sectional observation study was conducted.

METHODS

A total 184 participants were recruited from dementia outpatient clinics of several hospitals and long-term care resource management centers in southern Taiwan. The Chinese version of the Cohen-Mansfield Agitation Inventory, Community form was used to assess sundown syndrome, and the Chinese version of the Pittsburgh Sleep Quality Index was used to measure sleep quality. Pearson correlation, multiple regression, and 1-way analysis of variance were performed for data analysis.

RESULTS

The results indicated that sundown syndrome was significantly correlated with sleep quality (r = 0.374), whereas severity of dementia, sleep quality, and weekly duration of walking were influencing factors of sundown syndrome and accounted for a total of 24.8% of the variance (adjusted R² = 0.222, F_6,177 = 9.709). In addition, PAD who walked with relatives showed less sundown syndrome (F_3,180 = 4.435, P = .005) and better sleep quality (F_3,180 = 3.565, P = .015) compared with those walking with nonrelatives. Also, longer walking time led to less sundown syndrome (F_4,179 = 4.351, P = .002) and better sleep quality (F_4,179 = 3.592, P = .008).

CONCLUSIONS

Advanced dementia, poor sleep quality, and shorter weekly duration of walking were the influencing factors of sundown syndrome. Walking with relatives and regular longer walking time could improve sleep quality and alleviate sundown syndrome. It is suggested that a well-designed walking intervention considering these factors could be an appropriate strategy to manage sundown syndrome and sleep quality for PAD and their caregivers.

Preliminary evaluation of a measure for reliable assessment of need for constant visual observation in adults with traumatic brain injury

PRIMARY OBJECTIVE

To develop and provide initial validation of a measure for accurately determining the need for Constant Visual Observation (CVO) in patients with traumatic brain injury (TBI) admitted to inpatient rehabilitation.

RESEARCH DESIGN

Rating scale development and evaluation through Rasch analysis and assessment of concurrent validity.

METHODS AND PROCEDURES

One hundred and thirty-four individuals with moderate-severe TBI were studied in seven inpatient brain rehabilitation units associated with the National Institute for Disability, Independent Living and Rehabilitation Research (NIDILRR) TBI Model System. Participants were rated on the preliminary version of the CVO Needs Assessment scale (CVONA) and, by independent raters, on the Levels of Risk (LoR) and Supervision Rating Scale (SRS) at four time points during inpatient rehabilitation: admission, Days 2-3, Days 5-6 and Days 8-9.

OUTCOMES AND RESULTS

After pruning misfitting items, the CVONA showed satisfactory internal consistency (Person Reliability = 0.85-0.88) across time points. With reference to the LoR and SRS, low false negative rates (sensitivity > 90%) were associated with moderate-to-high false positive rates (29-56%).

CONCLUSIONS

The CVONA may be a useful objective metric to complement clinical judgement regarding the need for CVO; however, further prospective study is desirable to further assess its utility in identifying at-risk patients, reducing adverse events and decreasing CVO costs.

Effect of horticultural therapy on wellbeing among dementia day care programme participants: A mixed-methods study (Innovative Practice)

Fourteen people attending an adult day programme were recruited to a structured horticultural therapy programme which took place over 10 weeks. The effects were assessed using Dementia Care Mapping and questionnaires completed by family carers. High levels of wellbeing were observed while the participants were engaged in horticultural therapy, and these were sustained once the programme was completed. This study adds to the growing evidence on the benefits of horticultural therapy for people with dementia who have enjoyed gardening in the past.

Assessing engagement in people with dementia: a new approach to assessment using video analysis

The study of engagement in people with dementia is important to determine the effectiveness of interventions that aim to promote meaningful activity. However, the assessment of engagement for people with dementia in relation to our current work that uses social robots is fraught with challenges. The Video Coding - Incorporating Observed Emotion (VC-IOE) protocol that focuses on six dimensions of engagement: emotional, verbal, visual, behavioral, collective and signs of agitation was therefore developed. This paper provides an overview of the concept of engagement in dementia and outlines the development of the VC-IOE to assess engagement in people with dementia when interacting with social robots.

Geriatric Psychiatry in Motion – Bringing Physical Exercise to Geriatric Psychiatry

Abstract. Although programs to promote physical activity have been implemented in routine geriatric psychiatry, there are presently no evidence-based recommendations and only few randomized controlled exercise trials have been conducted. Therefore, a program called Geriatric Psychiatry in Motion was established in a psychiatric hospital. The primary objective was to promote physical activity and to investigate the effects of different physical activity programs in elderly psychiatric patients. The following key features were developed and are under investigation: (1) a program to promote general physical activity; (2) specific exercise programs for inpatients; (3) specific programs for outpatient services; and (4) the implementation of an integrative objective mobility and physical activity assessment. The first results show benefits for patients, caregivers as well as hospital staff.

The role of the hippocampus in the pathogenesis of Myalgic Encephalomyelitis/Chronic Fatigue Syndrome (ME/CFS)

Myalgic Encephalomyelitis/Chronic Fatigue Syndrome (ME/CFS) is a severe acquired illness characterized by a profound sensation of fatigue, not ameliorated by rest and resulting in a substantial decrease in the amount and quality of occupational, social and recreational activities. Despite intense research, the aetiology and pathogenesis of ME/CFS is still unknown and no conclusive biological markers have been found. As a consequence, an accepted curative treatment is still lacking and rehabilitation programmes are not very effective, as few patients recover. Increased knowledge of the mechanisms leading to the emergence and maintenance of the illness is called for. In this study, I will put forth an alternative hypothesis to explain some of the pathologies associated with ME/CFS, by concentrating on one of the major strategic organs of the brain, the hippocampus. I will show that the ME/CFS triggering factors also impact the hippocampus, leading to neurocognitive deficits and disturbances in the regulation of the stress system and pain perception. These deficits lead to a substantial decrease in activity and to sleep disorders, which, in turn, impact the hippocampus and initiate a vicious circle of increased disability.

Use of physical restraints in nursing homes: a multicentre cross-sectional study

Background

Although many countries have implemented strict legal rules, the prevalence of physical restraints in nursing homes seems to remain high. In Switzerland, data related to the frequency of physical restraints are scarce and little is known about associations with resident and nursing home characteristics. The aim of this study was to investigate the prevalence and types of physical restraints in nursing homes in two Swiss cantons and to explore whether resident-related and organisational factors are associated with the use of physical restraints.

Methods

We conducted a multicentre cross-sectional study. Twenty nursing homes with 1362 residents from two culturally different cantons were included. Data on physical restraints and residents’ characteristics were extracted from residents’ records (11/2013 to 2/2014). Organisational data were collected by questionnaires addressing nursing home directors or nursing managers. Sample size calculation and outcome analysis took cluster-adjustment into account. Descriptive statistics and multiple logistic regression analysis with nursing homes as random effect were used for investigation.

Results

The prevalence of residents with at least one physical restraint was 26.8 % (95 % confidence interval [CI] 19.8–33.8). Centre prevalence ranged from 2.6 to 61.2 %. Bilateral bedrails were most frequently used (20.3 %, 95 % CI 13.5–27.1). Length of residence, degrees of care dependency and mobility limitation were significantly positively associated with the use of physical restraint, but none of the organisational characteristics was significantly associated.

Conclusion

Approximately a quarter of the nursing home residents included in our study experienced physical restraints. Since variation between nursing homes was pronounced, it seems to be worthwhile to explore nursing homes with particularly low and high use of physical restraints in future research, especially by using qualitative methods. There is a need for effective interventions aiming at restraint-free nursing care. Development of interventional approaches should consider specific residents’ characteristics associated with restraint use.

A systematic review of strategies to foster activity engagement in persons with dementia

Dementia is a growing public health issue. Activity, a positive therapeutic modality, has potential to enhance quality of life and reduce behavioral symptoms in persons with dementia--outcomes eluding pharmacological treatments. However, it is unclear how to effectively engage persons with dementia in activities for them to derive desired benefits. We present a systematic review of 28 studies involving 50 tests of different ways of modifying activities to enhance engagement and reduce behavioral and psychological symptoms for this group. Of 50 tests, 22 (44%) evaluated changes to objects and properties (e.g., introducing activities with intrinsic interest), 6 (12%) evaluated changes to space demands (e.g., lighting, noise levels), 8 (16%) evaluated changes to social demands (e.g., prompts, praise), and 14 (28%) combined two or more activity modifications. No modifications were made to the sequence and timing of activities. Although modifications to objects and properties were the most common, outcomes for engagement and behaviors were mixed. Modifications to space and social demands were less frequently tested, but consistently yielded positive outcomes. No modifications resulted in negative behavioral outcomes or decreased engagement. Methodological strengths of studies included direct observation of outcomes and fidelity assessments. Few studies however involved persons with dementia at home. Our review revealed a growing evidentiary base for different modifications to foster engagement in activities and reduce behavioral and psychological symptoms. Future studies should evaluate how contextual factors (e.g., physical environment, activity type) and caregiver ability to employ activity modifications affect engagement.

Evaluation of a hospital-based day-structuring exercise programme on exacerbated behavioural and psychological symptoms in dementia--the exercise carrousel: study protocol for a randomised controlled trial

BACKGROUND

Conceptual reviews and observational studies describe a link between physical inactivity and behavioural disturbances in people with dementia. Consequently, treatment of these symptoms requires physical activation and pharmacological or physical immobilization should be avoided. The few trials that have been conducted in inpatient dementia care to investigate the effects of exercise on behavioural and psychological symptoms revealed inconsistent results. Due to a lack of evidence, there is a paucity of recommendations for physical activation in this stage of care. Therefore, this trial seeks to investigate the effects of a day-structuring exercise programme on behavioural and psychological symptoms as well as on circadian rhythms of patients with dementia, hospitalized because of their behavioural and psychological disturbances.

METHODS/DESIGN

A single-centre randomised controlled trial will be conducted in three special dementia care units of an old age psychiatry hospital. Enrolled patients will receive either a 2-week exercise programme, or a 2-week social stimulation programme in addition to usual care. Due to the provision of four day-structuring exercise-sessions in the course of an intervention day, the exercise programme for the study group is called exercise-carrousel. Baseline and post-intervention assessment for the primary outcome variable - the overall effects on behavioural and psychological symptoms--will be measured by the Alzheimer's disease Cooperative Study-Clinical Global Impression of Change. The following objectives are set up as secondary outcomes: dimensions of the behavioural and psychological symptoms of dementia (BPSD) and caregiver burden, routine and on-demand psychotropic medication, patients' motor behaviour, diurnal cortisol-levels from saliva probes and brain-derived neurotrophic factor-levels from blood serum.

DISCUSSION

In order to be regarded as an important treatment option for behavioural and psychological symptoms, physical activation in inpatient hospital dementia care requires more evidence and appropriate recommendations. Respecting hospital routines and the intra-daily variability of the patients' motivation and behavioural disturbances in the provision of exercise sessions could lead to higher exercise adherence and better effects on patients' behavioural and psychological symptoms than former trials have presented. The concealment of allocation throughout the trial and the rating of individual exercise exertion present the key challenges and main limitations of this trial.

TRIAL REGISTRATION

DRKS00006740 (German Clinical Trial Register, date of registration: 28 October 2014).