A randomized crossover trial to study the effect of personalized, one-to-one interaction using Montessori-based activities on agitation, affect, and engagement in nursing home residents with Dementia

A meta-analysis of person-centered care interventions for improving health outcomes in persons living with dementia

BACKGROUND

Person-centered care emphasizes the importance of valuing and supporting the humanness of a person living with dementia as compared to focusing heavily on disease symptom management and treatment. The state of the evidence and outcomes from person-centered care is unclear and is an important knowledge gap to address informed evidence-based care for persons living with dementia.

AIMS

To synthesize the evidence on the efficacy of person-centered care in improving health outcomes in people living with dementia.

METHODS

Our search using the following databases: Academic Search Complete, CINAHL, COCHRANE library, EMBASE, MEDLINE, PubMed, and Google Scholar. The methodology quality of the included studies was assessed using a revised Cochrane risk-of-bias tool for randomized trials. Meta-analyses were performed using the DerSimonian and Laird random effects model to investigate the effectiveness of person-centered care on improving health outcomes in persons living with dementia.

RESULTS

Seventeen trials were included in this systematic review and meta-analysis. Person-centered care implementation was found to improve cognitive function (pooled SMD: 0.22; 9CRD420223808975% CI [0.04, 0.41], p = .02) in persons living with dementia, although outcomes including the impact of the care model on activities of daily living, agitation, depression, and quality of life remain inconclusive.

LINKING EVIDENCE TO ACTION

Person-centered care improves the cognitive function of persons living with dementia, which is clinically meaningful and should not be ignored or overlooked in delivering evidence-based care to this population. The findings of this study emphasize the importance of person-centered care implementation among people living with dementia as an approach in improving health outcomes particularly on cognitive function improvement. Person-centered care emphasizes the personhood of individuals living with dementia while respecting their needs, values, and beliefs and is identified as a preferred model of delivering dementia care in all settings as a non-pharmacological approach.

Intersection between person-centred practice and Montessori for dementia and ageing in residential aged care

BACKGROUND

Internationally, person-centred care (PCC) is embedded in the language of regulations and mandated to be practised in residential aged care (RAC). Despite this, PCC has not been fully adopted in RAC in Australia and internationally, and concerns about the quality of care persist. Over the past 2 decades, Montessori for dementia and ageing has been introduced in RAC to support and inform a cultural change towards PCC. This study aimed to examine the intersection between the goals and approaches of Montessori and PCC in RAC.

METHODS

This qualitative descriptive study reports on a secondary analysis of qualitative data from focus groups (FGs) and interviews with residents, family-members, staff, and volunteers from eight RAC homes in Victoria, Australia. Sixteen FGs and 36 interviews were conducted. A qualitative deductive approach using researcher-developed Montessori for dementia and ageing framework for data analysis was applied.

RESULTS

Findings provide support for the intersection between PCC and Montessori with participants' descriptions of PCC aligning with many of the goals and approaches of Montessori. Participants most commonly described Montessori approaches of engagement in daily tasks with purposeful roles and promoting cognitive abilities through multi-sensory stimulation. Least frequently-described approaches included focusing on residents' strengths/abilities, maintaining function, using familiar objects, and guided repetition.

CONCLUSIONS

Findings have important implications for practice to use Montessori as a vehicle that supports and upskills the workforce to deliver care that is person-centred. Future research must examine the resources required to support the implementation and sustainability of Montessori as a vehicle for PCC.

Unlocking the benefits of montessori-based reading activities in nursing home: A multiple baseline study on groups of individuals with severe dementia

OBJECTIVE

Group activities are commonly offered to residents of nursing homes, and increasingly with a person-centred care approach. The aim of this study is to compare the impacts of a Montessori-based reading activity with a more traditional reading activity.

METHOD

A multiple baseline design was used, with 3 groups of 5 older adults with moderate to severe dementia. All sessions were videorecorded and analysed by independent judges, blinded to our hypotheses and conditions. Impacts of the type of activity (storytelling or Montessori-based reading) on verbal interactions, engagement level, affect and behavioural aspects were estimated with both visual analyses and statistical analyses using the between-case standardised mean differences method.

RESULTS

Significant differences were found in favour of the Montessori-based activities with regard to the number of verbal interactions, constructive and passive engagement and positive affect expressed, with moderate to large effect size (from 0.46 to 1.66).

CONCLUSION

The Montessori-based reading group activity really seems to be preferable to a more traditional storytelling activity, with multiple benefits for residents. Depending on the preserved abilities and interests of the participants, it can also be aimed at people with severe dementia.

The Delivery of Person-Centered Care for People Living With Dementia in Residential Aged Care: A Systematic Review and Meta-Analysis

BACKGROUND AND OBJECTIVES

Person-centered care is the gold standard of care for people living with dementia, yet few systematic reviews have detailed how it is delivered in practice. This mixed-methods review aimed to examine the delivery of person-centered care, and its effectiveness, for people living with dementia in residential aged care.

RESEARCH DESIGN AND METHODS

A systematic review and meta-analysis. Eligible studies were identified across 4 databases. Quantitative and qualitative studies containing data on person-centered care delivered to people with dementia living in residential aged care were included. Meta-analysis using a random-effects model was conducted where more than 3 studies measured the same outcome. A narrative meta-synthesis approach was undertaken to categorize verbatim participant quotes into representative themes. Risk of bias was undertaken using quality appraisal tools from the Joanna Briggs Institute.

RESULTS

41 studies were identified for inclusion. There were 34 person-centered care initiatives delivered, targeting 14 person-centered care outcomes. 3 outcomes could be pooled. Meta-analyses demonstrated no reduction in agitation (standardized mean difference -0.27, 95% confidence interval [CI], -0.58, 0.03), improvement in quality of life (standardized mean difference -0.63, 95% CI: -1.95, 0.70), or reduced neuropsychiatric symptoms (mean difference -1.06, 95% CI: -2.16, 0.05). Narrative meta-synthesis revealed barriers (e.g., time constraints) and enablers (e.g., staff collaboration) to providing person-centered care from a staff perspective.

DISCUSSION AND IMPLICATIONS

The effectiveness of person-centered care initiatives delivered to people with dementia in residential aged care is conflicting. Further high-quality research over an extended time is required to identify how person-centered care can be best implemented to improve resident outcomes.

Integrating social support into interventions among the elderly in nursing homes: a scoping review

OBJECTIVES

This study aimed to understand the evidence related to integration of social support into interventions, to identify literature gaps related to social support interventions, and to clarify dimensions of supportive functions, outcomes, and providers among the elderly in nursing homes.

DESIGN

This scoping review followed the approach by Arksey and O'Malley. The Mixed Methods Appraisal Tool V.2018 was used for quality assessment of the studies.

DATA SOURCES

Searches were conducted of the PubMed, ScienceDirect, Public Library of Science, SocioHub, Wiley Online Library and PsycINFO databases for publications from 2010 to 2021.

ELIGIBILITY CRITERIA FOR SELECTING STUDIES

We searched for primary studies and heterogeneous study designs published in English. Eligible studies took place in nursing and care homes and had study populations of elderly adults (older adults, geriatrics, ageing, seniors, older people and those aged 60 years and older).

DATA EXTRACTION AND SYNTHESIS

A data extraction form based on Joanna Briggs Institute's recommendations for scoping reviews was used. Two reviewers independently extracted data and performed quality assessment of the studies. Then, extracted data and quality assessment reports were discussed by all authors.

RESULTS

Thirty-one eligible studies were included in this review. 54.8% of the studies provided interventions for cognitively impaired residents. The top-three outcomes were neuropsychiatric symptoms, physical function and quality of life, respectively. The interventions were performed by nursing home staff (83.9%), other persons with specific qualifications (58.1%) and health volunteers (6.5%). Most studies (90.3%) depicted the integration of emotional and instrumental supportive functions into interventions.

CONCLUSION

The appropriate dimensions of supportive function, mainly emotional and instrumental support, are important to integrate into the social care of elderly people living in nursing homes.

A Spotlight on Adaptation: Preimplementation of Montessori-Based Activity Programming in Long-Term Care Using the Framework for Reporting Adaptations and Modifications-Enhanced (FRAME)

BACKGROUND AND OBJECTIVES

Effectively adapting evidence-based interventions for nursing home (NH) implementation is a critical, yet underexamined, component of improving care quality. Montessori-based activity programming (MAP) is an evidence-based intervention that promotes person-centered care, engages persons living with dementia, and mitigates distress behaviors. Currently, there is sparse evidence of MAP in Department of Veterans Affairs NHs (i.e., community living centers [CLCs]). CLCs differ significantly from community NHs and require adaptations to support MAP use and sustainability. This study uses the Framework for Reporting Adaptations and Modifications-Enhanced (FRAME) to track changes made to MAP as an exemplar for clinicians and implementation scientists. This work fills a gap in adapting interventions through a detailed examination of the adaptation process in NHs.

RESEARCH DESIGN AND METHODS

Qualitative and quantitative data were collected across 8 CLCs (e.g., advisory panel, staff interviews, training evaluations, field notes, and fidelity assessments). We used an iterative, rapid content analytic approach to triangulate findings and identify needed adaptations for the CLC setting.

RESULTS

Thirty-six adaptations were made. Most adaptions occurred during the preimplementation phase, were reactive, focused on training/evaluation, and involved researchers, intervention developers, and practitioners. All were fidelity-consistent with MAP. The most common goal across adaptations was increased reach/engagement of the intervention.

DISCUSSION AND IMPLICATIONS

CLCs and community NHs can use findings to support intervention adaptation, and adapt and implement MAP to improve meaningful engagement for persons living with dementia and other residents. Future research should further evaluate and standardize FRAME for diverse users of complex interventions.

Personally tailored activities for improving psychosocial outcomes for people with dementia in long-term care

BACKGROUND

People with dementia who are being cared for in long-term care settings are often not engaged in meaningful activities. We wanted to know whether offering them activities which are tailored to their individual interests and preferences could improve their quality of life and reduce agitation. This review updates our earlier review published in 2018.

OBJECTIVES

∙ To assess the effects of personally tailored activities on psychosocial outcomes for people with dementia living in long-term care facilities. ∙ To describe the components of the interventions. ∙ To describe conditions which enhance the effectiveness of personally tailored activities in this setting.

SEARCH METHODS

We searched the Cochrane Dementia and Cognitive Improvement Group's Specialized Register, on 15 June 2022. We also performed additional searches in MEDLINE, Embase, PsycINFO, CINAHL, Web of Science, ClinicalTrials.gov, and the World Health Organization (WHO) ICTRP, to ensure that the search for the review was as up-to-date and as comprehensive as possible.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) and controlled clinical trials offering personally tailored activities. All interventions included an assessment of the participants' present or past preferences for, or interest in, particular activities as a basis for an individual activity plan. Control groups received either usual care or an active control intervention.

DATA COLLECTION AND ANALYSIS

Two authors independently selected studies for inclusion, extracted data and assessed the risk of bias of included studies. Our primary efficacy outcomes were agitation and participant quality of life. Where possible, we pooled data across studies using a random effects model.

MAIN RESULTS

We identified three new studies, and therefore included 11 studies with 1071 participants in this review update. The mean age of participants was 78 to 88 years and most had moderate or severe dementia. Ten studies were RCTs (three studies randomised clusters to the study groups, six studies randomised individual participants, and one study randomised matched pairs of participants) and one study was a non-randomised clinical trial. Five studies included a control group receiving usual care, five studies an active control group (activities which were not personally tailored) and one study included both types of control group. The duration of follow-up ranged from 10 days to nine months. In nine studies personally tailored activities were delivered directly to the participants. In one study nursing staff, and in another study family members, were trained to deliver the activities. The selection of activities was based on different theoretical models, but the activities delivered did not vary substantially. We judged the risk of selection bias to be high in five studies, the risk of performance bias to be high in five studies and the risk of detection bias to be high in four studies. We found low-certainty evidence that personally tailored activities may slightly reduce agitation (standardised mean difference -0.26, 95% CI -0.53 to 0.01; I² = 50%; 7 studies, 485 participants). We also found low-certainty evidence from one study that was not included in the meta-analysis, indicating that personally tailored activities may make little or no difference to general restlessness, aggression, uncooperative behaviour, very negative and negative verbal behaviour (180 participants). Two studies investigated quality of life by proxy-rating. We found low-certainty evidence that personally tailored activities may result in little to no difference in quality of life in comparison with usual care or an active control group (MD -0.83, 95% CI -3.97 to 2.30; I² = 51%; 2 studies, 177 participants). Self-rated quality of life was only available for a small number of participants from one study, and there was little or no difference between personally tailored activities and usual care on this outcome (MD 0.26, 95% CI -3.04 to 3.56; 42 participants; low-certainty evidence). Two studies assessed adverse effects, but no adverse effects were observed. We are very uncertain about the effects of personally tailored activities on mood and positive affect. For negative affect we found moderate-certainty evidence that there is probably little to no effect of personally tailored activities compared to usual care or activities which are not personalised (standardised mean difference -0.02, 95% CI -0.19 to 0.14; 6 studies, 632 participants). We were not able to undertake meta-analyses for engagement and sleep-related outcomes, and we are very uncertain whether personally tailored activities have any effect on these outcomes. Two studies that investigated the duration of the effects of personally tailored activities indicated that the intervention effects they found persisted only during the period of delivery of the activities.

AUTHORS' CONCLUSIONS

Offering personally tailored activities to people with dementia in long-term care may slightly reduce agitation. Personally tailored activities may result in little to no difference in quality of life rated by proxies, but we acknowledge concerns about the validity of proxy ratings of quality of life in severe dementia. Personally tailored activities probably have little or no effect on negative affect, and we are uncertain whether they have any effect on positive affect or mood. There was no evidence that interventions were more likely to be effective if based on one theoretical model rather than another. We included three new studies in this updated review, but two studies were pilot trials and included only a small number of participants. Certainty of evidence was predominately very low or low due to several methodological limitations of and inconsistencies between the included studies. Evidence is still limited, and we remain unable to describe optimal activity programmes. Further research should focus on methods for selecting appropriate and meaningful activities for people in different stages of dementia.

Effectiveness of Montessori-based activities on agitation among Asian patients with dementia: A systematic review and meta-analysis

OBJECTIVES

Montessori based activity are supposed to be an effective nonpharmacological intervention in the treatment of agitation in western countries. However, most studies conducted to evaluate the effectiveness of Montessori based activities on agitation in Asian patients were small sample size, as well as inconsistent outcomes, which may limit the reliability of the conclusions. The present pooled analysis, hence, was conducted to evaluate the effectiveness of the activity on agitation related with dementia in Asian patients with dementia.

DESIGN

Prospective randomized clinical studies were included, of which available data was extracted. Outcomes of physical aggressive behaviors, physical nonaggressive behaviors, and verbal aggressive behaviors were pooled for the analysis by weighted mean differences.

DATA SOURCES

Medline, Embase, Cochrane Library, China National Knowledge Infrastructure (CNKI), WanFang, and China Science and Technology Journal Database (VIP).

ELIGIBILITY CRITERIA

Prospective, randomized, controlled clinical studies, conducted to evaluate the effectiveness of the activity on agitation related with dementia in Asian patients with dementia.

DATA EXTRACTION AND SYNTHESIS

Available data including baseline characteristics and interested outcomes from the included literature were extracted independently by 2 investigators. Measuring scales including CMAI and NOSIE were adopted for the efficacy comparison between Montessori based activity and standard activity. Weighted mean difference was used for the pooled analysis.

RESULTS

A total of 460 participants were included in the present meta-analysis. The pooled mean difference agitation for Montessori based activity was -3.86 (95% CI: -7.38 to -0.34, P = 0.03) comparing to standard activity. The pooled mean differences for physical aggressive behaviors, physical nonaggressive behaviors, and verbal aggressive behaviors in Montessori based activity group were -0.82 (95% CI: -1.10 to -0.55; P < 0.00001), -0.81 (95% CI: -1.68 to 0.55; P = 0.07), and 0.38 (95% CI: -0.92 to 1.68; P = 0.57).

CONCLUSIONS

Montessori based activities may reduce the frequency of agitation, especially in physical aggressive behaviors comparing to standard activities in Asian patients with dementia. However, the effectiveness of Montessori based activities on reduction of subcategorized agitated behaviors including physical nonaggressive behaviors, and verbal aggressive behaviors may not be reliable as physical aggressive behaviors.

Don't Bother Trying, They Won't Do It! Effect of Responsive Behaviors on the Montessori Assessment System

OBJECTIVES

The Montessori Assessment System (MAS) is an assessment tool that aims at assessing preserved abilities in persons with moderate to severe dementia and to serve as basis for person-centered interventions. As responsive behaviors are highly frequent in this population, we assessed their possible influence on the MAS administration and results.

METHODS

193 persons with a diagnosis of dementia in the moderate to severe stages living in nursing homes completed the MAS. Responsive behaviors were assessed by the Neuropsychiatric Inventory (NPI).

RESULTS

The NPI scores were heterogeneous, but responsive behaviors were present for at least 5 NPI domains in more than 50% of the participants. While NPI scores had weak relationships with MAS completion time and total score, primarily for the hallucinations, euphoria, and aberrant motor behaviors domains, a large majority of the participants fully completed the MAS.

CONCLUSIONS

The presence of responsive behaviors as assessed by the NPI does not limit MAS administration, despite minor influence on MAS score and completion time.

CLINICAL IMPLICATIONS

The MAS may be applied to persons with moderate to severe dementia presenting responsive behaviors. Assessment of preserved abilities can greatly improve the design of person-centered care plans in this population.

Development of a Quantitative Instrument to Elicit Patient Preferences for Person-Centered Dementia Care Stage 1: A Formative Qualitative Study to Identify Patient Relevant Criteria for Experimental Design of an Analytic Hierarchy Process

Background: Person-centered care (PCC) requires knowledge about patient preferences. This formative qualitative study aimed to identify (sub)criteria of PCC for the design of a quantitative, choice-based instrument to elicit patient preferences for person-centered dementia care. Method: Interviews were conducted with n = 2 dementia care managers, n = 10 People living with Dementia (PlwD), and n = 3 caregivers (CGs), which followed a semi-structured interview guide including a card game with PCC criteria identified from the literature. Criteria cards were shown to explore the PlwD's conception. PlwD were asked to rank the cards to identify patient-relevant criteria of PCC. Audios were verbatim-transcribed and analyzed with qualitative content analysis. Card game results were coded on a 10-point-scale, and sums and means for criteria were calculated. Results: Six criteria with two sub-criteria emerged from the analysis; social relationships (indirect contact, direct contact), cognitive training (passive, active), organization of care (decentralized structures and no shared decision making, centralized structures and shared decision making), assistance with daily activities (professional, family member), characteristics of care professionals (empathy, education and work experience) and physical activities (alone, group). Dementia-sensitive wording and balance between comprehensibility vs. completeness of the (sub)criteria emerged as additional themes. Conclusions: Our formative study provides initial data about patient-relevant criteria of PCC to design a quantitative patient preference instrument. Future research may want to consider the balance between (sub)criteria comprehensibility vs. completeness.

Including ethnic minorities in dementia research: Recommendations from a scoping review

Introduction

Ethnicity influences dementia etiology, prognosis, and treatment, while culture shapes help-seeking and care. Despite increasing population diversity in high-income settlement countries, ethnic minorities remain underrepresented in dementia research. We investigated approaches to enhance the recruitment, and consistent collection and analysis of variables relevant to, ethnic minorities in dementia studies to make recommendations for consistent practice in dementia research.

Methods

We did a scoping review, searching Embase, PsycINFO, Medline, CENTRAL, and CINAHL between January 1, 2010 and January 7, 2020. Dementia clinical and cohort studies that actively recruited ethnic minorities in high-income countries were included. A steering group of experts developed criteria through which high-quality studies were identified.

Results

Sixty-six articles were retrieved (51 observational; 15 experimental). Use of interpreters and translators (n = 17) was the most common method to facilitate participant recruitment. Race and ethnicity (n = 59) were the most common variables collected, followed by information on native language (n = 14), country of birth (n = 9), and length of time in country of settlement (n = 8). Thirty-three studies translated or used a culturally validated instrument. Twenty-three articles conducted subgroup analyses based on ethnicity. Six high-quality studies facilitated inclusion through community engagement, collected information on multiple aspects of ethnic diversity, and adjusted/substratified to analyze the impact of ethnicity on dementia.

Discussion

We make recommendations for consistent recruitment, collection, and reporting of variables relating to ethnic and cultural diversity in dementia research.

Person-Centered Care in Persons Living With Dementia: A Systematic Review and Meta-analysis

BACKGROUND AND OBJECTIVES

The concept of person-centered care has been utilized/adapted to various interventions to enhance health-related outcomes and ensure the quality of care delivered to persons living with dementia. A few systematic reviews have been conducted on the use of person-centered interventions in the context of dementia care, but to date, none have analyzed intervention effect by intervention type and target outcome. This study aimed to review person-centered interventions used in the context of dementia care and examine their effectiveness.

RESEARCH DESIGN AND METHODS

A systematic review and meta-analysis were conducted. We searched through 5 databases for randomized controlled trials that utilized person-centered interventions in persons living with dementia from 1998 to 2019. Study quality was assessed using the National Institute for Health and Clinical Excellence checklist. The outcomes of interest for the meta-analysis were behavioral and psychological symptoms in dementia (BPSD) and cognitive function assessed immediately after the baseline measurement.

RESULTS

In total, 36 studies were systematically reviewed. Intervention types were reminiscence, music, and cognitive therapies, and multisensory stimulation. Thirty studies were included in the meta-analysis. Results showed a moderate effect size for overall intervention, a small one for music therapy, and a moderate one for reminiscence therapy on BPSD and cognitive function.

DISCUSSION AND IMPLICATIONS

Generally speaking, person-centered interventions showed immediate intervention effects on reducing BPSD and improving cognitive function, although the effect size and significance of each outcome differed by intervention type. Thus, health care providers should consider person-centered interventions as a vital element in dementia care.

Montessori mealtimes for dementia: A pathway to person-centred care

PURPOSE

This study examined the impact of a Montessori mealtime intervention for people living with dementia to support the mealtime experience of residents and mealtime care practices of staff in a memory support unit. The mealtime intervention was part of a broader culture change project.

METHOD

An observational research design was used to evaluate changes in the mealtime experience and care practices across three time points (baseline, post-implementation, maintenance), spanning 30 months. Five video recordings of the lunch time service (range: 19-32 min) were analysed. The coding protocol comprised pre-determined indicators related to accepted dimensions of person-centred care. Resident and staff behaviours were quantified across four categories: providing choice and preferences, promoting the social side of eating, supporting independence and showing respect towards residents. Staff behaviours that reflected personal enhancing actions and personal detractors were also coded during each mealtime service.

RESULTS

A significant increase in staff providing residents with the opportunity for choice and a subsequent significant increase in residents demonstrating choice behaviours was evident. Staff and residents both significantly increased their interactional behaviours, with greater social interaction between staff and residents. Staff further demonstrated greater support for mealtime independence that reached and maintained significance during the final two sampling points. Significant gains observed post implementation were largely maintained and, on specific measures, further increased over time. A significant increase in staff use of personal enhancing actions during mealtime care was also evident. Variability in individual staff and resident behaviour highlighted the complexity of mealtime care and culture change processes.

IMPLICATIONS

The study provides novel evidence to support the use of a Montessori mealtime intervention to achieve more person-centred mealtime care, and which resulted in a more respectful, enabling and social dining experience. Clinical implications and direction for future research are presented to build on these findings.

Bringing Art to Life: Social and Activity Engagement through Art in Persons Living with Dementia

OBJECTIVES

The Bringing Art to Life (BATL) program was created as an art therapy intervention to increase social engagement, intergenerational engagement, and creative expression among persons living with dementia (PWD) in an adult day service. This is an evaluation of BATL program efficacy.

METHODS

A modified behavioral observation tool was used to quantify meaningful engagements as recorded in ethnographic field notes and test the hypotheses that: 1) engagements increase across art therapy sessions, and 2) engagements were more social than activity or art related.

RESULTS

The increase in engagement across session was not significant. However, social engagements (M = 9.61, SD 4.6) were more prevalent than art engagements (M = 5.23, SD = 3.1) in each session (t(99) = 9.52,). A thematic analysis of social interactions recorded in the ethnographic field notes revealed themes related to reminiscence.

CONCLUSIONS

The quantitative and qualitative data supported the BATL program as effective in engaging participants in social interaction and art activities. Specifically, quantitative data showed participants were engaged in conversations around reminiscence and discussion of creative expression with students.

CLINICAL IMPLICATIONS

Intergenerational social interaction between PWD and college students is a critical and meaningful part of the BATL program, and the intervention created a safe space with focused activity through engagement with art, and this facilitated PWD in self-expression, including humor, advice, and legacy.

The Rationale and Design of Behavioral Interventions for Management of Agitation in Dementia in a Multi-Site Clinical Trial

BACKGROUND

Agitation and aggression are common in patients with Alzheimer's disease and related dementias and pose a significant burden on patients, caregivers, and the healthcare systems. Guidelines recommend personalized behavioral interventions as the first-line treatment; however, these interventions are often underutilized. The Standardizing Care for Neuropsychiatric Symptoms and Quality of Life in Dementia (StaN) study (ClinicalTrials.gov Identifier # NCT0367220) is a multisite randomized controlled trial comparing an Integrated Care Pathway, that includes a sequential pharmacological algorithm and structured behavioral interventions, with treatment-as-usual to treat agitation in dementia in long-term care and inpatient settings.

OBJECTIVE

To describe the rationale and design of structured behavioral interventions in the StaN study.

METHODS

Structured behavioral interventions are designed and implemented based on the following considerations: 1) personalization, 2) evidence base, 3) dose and duration, 4) measurement-based care, and 5) environmental factors and feasibility.

RESULTS

The process to design behavioral interventions for each individual starts with a comprehensive assessment, followed by personalized, evidence-based interventions delivered in a standardized manner with ongoing monitoring of global clinical status. Measurement-based care is used to tailor the interventions and to integrate them with pharmacotherapy.

CONCLUSION

Individualized behavioral interventions in patients with dementia may be challenging to design and implement. Here we describe a process to design and implement individualized and structured behavioral interventions in the context of a multisite trial in long-term care and inpatient settings. This process can inform the design of behavioral interventions in future trials and in clinical settings for the treatment of agitation in dementia.

What long-term care interventions have been published between 2010 and 2020? Results of a WHO scoping review identifying long-term care interventions for older people around the world

OBJECTIVE

The global population is rapidly ageing. To tackle the increasing prevalence of older adults' chronic conditions, loss of intrinsic capacity and functional ability, long-term care interventions are required. The study aim was to identify long-term care interventions reported in scientific literature from 2010 to 2020 and categorise them in relation to WHO's public health framework of healthy ageing.

DESIGN

Scoping review conducted on PubMed, CINHAL, Cochrane and Google Advanced targeting studies reporting on long-term care interventions for older and frail adults. An internal validated Excel matrix was used for charting.Setting nursing homes, assisted care homes, long-term care facilities, home, residential houses for the elderly and at the community.

INCLUSION CRITERIA

Studies published in peer-reviewed journals between 1 January 2010 to 1 February 2020 on implemented interventions with outcome measures provided in the settings mentioned above for subjects older than 60 years old in English, Spanish, German, Portuguese or French.

RESULTS

305 studies were included. Fifty clustered interventions were identified and organised into four WHO Healthy Ageing domains and 20 subdomains. All interventions delved from high-income settings; no interventions from low-resource settings were identified. The most frequently reported interventions were multimodal exercise (n=68 reports, person-centred assessment and care plan development (n=22), case management for continuum care (n=16), multicomponent interventions (n=15), psychoeducational interventions for caregivers (n=13) and interventions mitigating cognitive decline (n=13).

CONCLUSION

The identified interventions are diverse overarching multiple settings and areas seeking to prevent, treat and improve loss of functional ability and intrinsic capacity. Interventions from low-resource settings were not identified.

Emotional availability in dyads of nursing aide - resident with dementia: Old tool, new perspective

Objectives

This study examined the emotional availability of nursing aide-resident with dementia dyads in a long-term care-facility. Emotional availability refers to the nursing aide’s sensitivity toward the resident, structuring their interactions in a non-intrusive and non-hostile manner and the resident’s responsiveness to and involvement of the nursing aide. The study evaluated the reciprocity in the emotional availability of nursing aides and the residents and examined whether emotional availability varies with the level of difficulty of taking care of the residents and with the context of the interaction.

Method

The study was conducted in three wards in one long-term care-facility. Twenty nursing aides and 40 residents took part in the study. Each nursing aide was videotaped during feeding, structured and unstructured interactions, with two residents, one that was nominated by the head nurse as difficult to take care of and one that was nominated as easy to take care of. The interactions were coded using the emotional availability scales.

Results

Linear mixed-effect model analyses indicated that higher emotional availability of nursing aides was related to higher emotional availability of the residents. Nursing aides’ emotional availability did not vary between “difficult” and “easy” residents or across the three interaction contexts. “Difficult” residents involved their nursing aides less than “easy” residents.

Discussion

The study documented the reciprocal nature of the interaction between nursing aides and residents with dementia. It suggests that nursing aides have an important role in promoting residents’ responsiveness and involvement.

Emerging Perspectives in the Management of Agitation in Alzheimer's Disease and Patients with Dementia

While Alzheimer's disease, the most common cause of dementia, is perhaps best characterized by cognitive decline, more than 90% of patients exhibit behavioural and psychological symptoms of dementia. Agitation in patients with dementia is often difficult to manage, and is associated with increased morbidity and mortality in patients and a heightened caregiver burden. Thus, effective management of dementia-related agitation (DRA) is vital. Care should first be taken to consider and address causes of agitation and aggression, after which non-pharmacological interventions should be employed. If non-pharmacological measures are unsuccessful in reducing DRA then medications should be considered, although none are approved by the Food and Drug Administration for this indication. Electroconvulsive therapy may be a promising option for patients with treatment-refractory DRA, although more studies are needed. While there are several drugs in the pipeline for DRA treatment, results from robust randomized clinical trials are necessary before they can be administered to patients. Thus, clinicians should employ current strategies to manage DRA to ensure holistic care for patients with Alzheimer's disease.

Interactive Effects of Agitation and Cognitive Impairment on Odor Identification in Patients With Late-Life Depression

BACKGROUND

Late-life depression (LLD) is a risk factor for cognitive decline in older adults, and odor identification (OI) deficits are an early indicator of cognitive decline with LLD. However, neuropsychiatric symptoms (NPSs) are common in LLD and are associated with OI deficits. In subjects with LLD, when OI deficits forecast cognitive decline, whether and how NPS affects the relationship between OI and cognition still must be further explored.

OBJECTIVE

To comprehensively explore the potential effects of various NPSs on the relationship between OI and cognition in participants with LLD.

METHODS

There were 167 patients with LLD and 105 normal elderly (NE) participants. The odor identification test (Sniffin' Sticks), cognitive function assessments (global cognition, memory, executive function, attention, language, visual space), and an NPS assessment (the neuropsychiatric inventory questionnaire) were performed on the subjects. In patients with LLD, the relationship among OI, cognition and NPSs was examined using correlation analysis and moderation analysis.

RESULTS

In patients with LLD, OI was positively correlated with cognition (global cognition, memory, executive function, attention, language) and negatively associated with NPSs (agitation and aberrant motor behavior). In NE group, OI was correlated with executive function. Moderation analysis showed that there was an interactive effect of agitation and cognitive impairment (language deficit or attention deficit) on OI in patients with LLD.

CONCLUSION

The coexistence of agitation and language or attention deficit was associated with worse OI in subjects with LLD. Agitation should be considered since OI predicts cognitive decline in patients with LLD.

Degree of personalisation in tailored activities and its effect on behavioural and psychological symptoms and quality of life among people with dementia: a systematic review and meta-analysis

OBJECTIVES

To understand and assess the degree of personalisation of tailored activities for people with dementia (PWD); and to estimate the magnitude of the effects of levels of personalisation on reducing behavioural and psychological symptoms of dementia (BPSD), improving quality of life (QoL) and level of engagement.

DESIGN

Systematic review with meta-analysis.

DATA SOURCES

ProQuest, PubMed, Ovid, Cochrane Library, Web of Science and CINAHL were searched from the start of indexing to May 2020.

ELIGIBILITY CRITERIA

We included randomised controlled trials and quasi-experimental studies assessing the effects of tailored activities for people aged 60 years or older with dementia or cognitive impairment on the outcomes of BPSD, QoL, depression and level of engagement with control groups.

DATA EXTRACTION AND SYNTHESIS

Two researchers screened studies, extracted data and assessed risks of bias. A rating scheme to assess the degree of personalisation of tailored activities was developed to classify tailored activities into high/medium/low groups. Effect sizes were expressed using standardised mean differences at 95% Confidence Interval (CI). Subgroup analyses were conducted to assess whether the degree of personalisation of tailored activities affected outcomes of interest.

RESULTS

Thirty-five studies covering 2390 participants from 16 countries/regions were identified. Studies with a high-level of personalisation interventions (n=8) had a significant and moderate effect on reducing BPSD (standardised mean differences, SMD=-0.52, p<0.05), followed by medium (n=6; SMD=-0.38, p=0.071) and low-level personalisation interventions (n=6; SMD=-0.15, p=0.076). Tailored activities with a high-level of personalisation had a moderate effect size on improving QoL (n=5; SMD=0.52, p<0.05), followed by a medium level (n=3; SMD=0.41, p<0.05) of personalisation.

CONCLUSIONS

To develop high-level tailored activities to reduce BPSD and improve QoL among PWD, we recommend applying comprehensive assessments to identify and address two or more PWD characteristics in designed tailored activities and allow modification of interventions to respond to changing PWD needs/circumstances.

PROSPERO REGISTRATION NUMBER

CRD42020168556.

A pragmatic trial testing a tailored non pharmacologic therapies on nocturnal behavioral and psychological symptoms associated with dementia

We compared the efficacy of tailored non pharmacological therapies (NPT) on specific nocturnal behavioral and psychological symptoms of dementia (BPSD). This retrospective 1-year study included 84 older dependent patients institutionalized in 7 long-term care home. Dedicated assistants, who were taught by experts how to use NPT, were asked to record the occurrence of each BPSD episode, to choose a given NPT on the basis of their knowledge of the patient and the type of BPSD and to estimate its efficacy. Wandering was the most prevalent BPSD followed by agitation/aggression and screaming. The most used therapy was cognitive stimulation, followed by multisensory stimulation, reminiscence and Montessori-based. Regarding wandering, multisensory stimulation was found to be the most efficacious NPT significantly different from Montessori-based, cognitive stimulation or reminiscence. With regards to agitation/aggression or screaming, Montessori-based was found to be the most efficacious NPT significantly different from multisensory stimulation, reminiscence and cognitive stimulation.

Key Intervention Categories to Provide Person-Centered Dementia Care: A Systematic Review of Person-Centered Interventions

Background:

Person-centered care (PCC) is an important concept in many countries’ national guidelines and dementia plans. Key intervention categories, i.e., a taxonomy of person-centered (PC)-interventions, to provide person-centered dementia care, are difficult to identify from literature.

Objective:

This systematic review aimed to identify and categorize published PC-interventions into key intervention categories to guide the provision of person-centered dementia care.

Methods:

Conduct of this systematic review followed Cochrane guidelines. A search of the dimensions ‘Dementia’, ‘Person-Centered Care’, and ‘Intervention’ combined was performed in PubMed, EMBASE, and Web of Science. Study selection was based on 2-stage screening against eligibility criteria, limited to controlled study designs. Information about interventions and outcomes was extracted into an “Effects Table”. The identified PC-interventions were categorized in intervention categories to provide person-centered dementia care.

Results:

Searches identified 1,806 records. 19 studies were included. These covered a range of psychosocial interventions, oftentimes multi-component interventions, which followed heterogeneous approaches. Studies were conducted in long-term care/hospital settings. Nine key intervention categories were identified: social contact, physical activities, cognitive training, sensory enhancement, daily living assistance, life history oriented emotional support, training and support for professional caregivers, environmental adjustments, and care organization.

Conclusion:

Our findings provide a current overview of published PC-interventions in dementia, which followed heterogeneous approaches under the PCC-concept. The heterogeneity made it challenging to identify a well-defined concept of PCC and common key intervention categories. An effectiveness-evaluation of “PC” - including “relationship-centered”-interventions may be valuable, to assess whether an explicit focus on relationships around PCC-interventions yields an added benefit.

PROSPERO-ID: CRD42021225084.

A Digital Platform for Facilitating Personalized Dementia Care in Nursing Homes: Formative Evaluation Study

Background

Care personalization is key to the well-being of people with dementia according to person-centered care. With the development of the internet of things, a large quantity of personal data can be collected securely and reliably, which has the potential to facilitate care personalization for people with dementia. Yet, there are limited assistive technologies developed for this purpose, and the user acceptance of assistive technologies is low in nursing homes. Therefore, through a data-enabled design approach, a digital platform was developed for helping the care team in a nursing home to personalize dementia care, specifically in the management of behavioral and psychological dementia symptoms.

Objective

This study aimed to evaluate the digital platform in a real-life context with potential users from the following two aspects: (1) to explore if the digital platform could help with generating insights on the current state of each person with dementia and (2) to gather feedback on the digital platform from the care team.

Methods

The digital platform was deployed in the nursing home for 7 weeks and the data collected were visualized and presented to the care team via the digital platform. The visualizations were analyzed by the researchers for pattern detection. Meanwhile, the care team was asked to examine the visualizations and were interviewed for the following: (1) if any insights and actions were generated from the examination, (2) the usefulness of the digital platform, and (3) the improvements they would like to see.

Results

The data collected on the digital platform demonstrated its potential for pattern detection. Insights were generated by the care team and categorized into “client level,” “ward level,” and “team level.” The corresponding actions taken by the care team were classified into “investigation” and “implementation.” User acceptance varied across the care team, and three aspects of improvement for the digital platform were identified.

Conclusions

By evaluating the digital platform, this study gained insights on applying data-enabled design for personalizing dementia care; besides, it offers future researchers some recommendations on how to integrate assistive technologies in the nursing home context.

In Quest of Tablet Apps for Elders With Alzheimer's Disease: A Descriptive Review

Caregivers search for mobile device apps that offer meaningful and enjoyable activities to simultaneously enhance the preserved cognitive and functional abilities of those in their care. The purpose of this review article was to describe the current state of tablet apps with which elders with Alzheimer's disease and related forms of dementia may engage as users. Using the keywords "app," "Alzheimer's," and "dementia," a sample of 83 apps was selected from the iTunes Store, Google, and discussion boards of Apple Support Communities. A descriptive content analysis was conducted using a coding scheme on the characteristics of tablet app activity and the requirements for functional abilities of the users. This review found that the activities of the selected apps included games, simple watching and viewing, music and sounds, memory training, learning and information, and social interaction starters. A high-level cognitive and physical ability such as eye-hand coordination is often required to play the majority of the game apps. A few apps are designed specifically for the population. Individuals' variability in cognitive and functional abilities necessitates a person-centered approach in designing and selecting games and activities for apps in order to increase engagement and promote positive experiences in older adults.

Psychologists in Long-Term Care (PLTC) Guidelines for Psychological and Behavioral Health Services in Long-Term Care Settings

To address concerns about limited training of psychologists working in long-term care (LTC) facilities, the Psychologists in Long-Term Care (PLTC) organization published Standards for Psychological Services in Long-Term Care Facilities (Lichtenberg et al., 1998). The expanding evidence base for knowledge and skills, the increasing diversity of LTC residents, and the complexity of presenting problems have compounded the guidance psychologists need when providing services in this setting. In this article, the PLTC Guidelines Revision Task Force presents PLTC guidelines based on the original prescriptive PLTC Standards. The content of the PLTC Standards was updated and the format changed from prescriptive standards to aspirational guidelines. We begin with general guidelines regarding knowledge and skills in LTC (education and training. understanding of LTC systems. end-of-life care), followed by specific guidelines covering the basic psychological service activities in LTC (referral, assessment, treatment, ethical issues, and advocacy). The PLTC Guidelines are designed to provide direction for psychologists who work, or plan to work, in LTC and to guide continuing education pursuits.

Effects of a culturally adapted group based Montessori based activities on engagement and affect in Chinese older people with dementia: a randomized controlled trial

BACKGROUND

The Montessori Method underpinned by the principle of person-centered care has been widely adopted to design activities for people with dementia. However, the methodological quality of the existing evidence is fair. The objectives of this study are to examine the feasibility and effects of a culturally adapted group-based Montessori Method for Dementia program in Chinese community on engagement and affect in community-dwelling people with dementia.

METHODS

This was a two-arm randomized controlled trial. People who were aged 60 years or over and with mild to moderate dementia were recruited and randomly assigned to the intervention group to receive Montessori-based activities or the comparison group to receive conventional group activities over eight weeks. The attendance rates were recorded for evaluating the feasibility. The Menorah Park Engagement Scale and the Apparent Affect Rating Scale were used to assess the engagement and affect during the activities based on observations. Generalized Estimating Equation model was used to examine the intervention effect on the outcomes across the sessions.

RESULTS

A total of 108 people with dementia were recruited. The average attendance rate of the intervention group (81.5%) was higher than that of the comparison group (76.3%). There was a significant time-by-group intervention effect on constructive engagement in the first 10 minutes of the sessions (Wald χ2 = 15.21-19.93, ps = 0.006-0.033), as well as on pleasure (Wald χ2 = 25.37-25.73, ps ≤ 0.001) and interest (Wald χ2 = 19.14-21.11, ps = 0.004-0.008) in the first and the middle 10 minutes of the sessions, adjusted for cognitive functioning.

CONCLUSIONS

This study provide evidence that Montessori-based group activities adapted to the local cultural context could effectively engage community-dwelling Chinese older people with mild to moderate dementia in social interactions and meaningful activities and significantly increase their positive affect.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT04352387. Registered 20 April 2020. Retrospectively registered.

Systematic Review of Randomized Controlled Trials in Australian Nursing Homes from 2000 to 2018

BACKGROUND/OBJECTIVES

High-quality research provides an evidence base for optimal practice care in clinical settings, yet, little is known about the nature and extent of randomized control trials (RCTs) conducted in Australian nursing homes (NHs). Research from other settings and other countries is not necessarily transferable to the Australian NH sector. We sought to identify and describe RCTs conducted in Australia which investigated interventions targeted at improving care for NH residents.

DESIGN

The design of this study comprised a systematic literature search with a narrative review. Studies were included if they were RCTs published after 2000, conducted in an Australian NH, and evaluated a health intervention which may have directly or indirectly benefitted the NH resident.

SETTING

Australian NHs.

PARTICIPANTS

Nursing home residents.

MEASUREMENTS

Jurisdiction (state or territory where the study was conducted), number of NHs recruited in each trial, number of residents included in each trial, intervention characteristics, comparator characteristics, and characteristics of outcome.

RESULTS

Only 43 articles reporting on 39 RCTs were identified. In contrast, 30 Australian musculoskeletal RCTs were published in just 2 years (2011-2012). Most of the RCTs identified were conducted in New South Wales (n = 14), Queensland (n = 10), and Victoria (n = 9). The mean number of NHs included in each trial was 22.4 (standard deviation (SD) = 27.0), with a median of 14.5 (interquartile range (IQR) = 27.8), while the mean number of residents included was 412.4 (SD = 921) with a median of 187 (IQR = 341.0). The most common interventions targeted: managing dementia (n = 20), prevention of falls (n = 7), and addressing mental health issues (n = 6).

CONCLUSION

This review provides evidence of the paucity of high-quality research in the form of RCTs, in the Australian NH setting and demonstrates the need for Australia to improve its research capability in the NH sector.

Monitoring behavioral symptoms of dementia using activity trackers

Tertiary disease prevention for dementia focuses on improving the quality of life of the patient. The quality of life of people with dementia (PwD) and their caregivers is hampered by the presence of behavioral and psychological symptoms of dementia (BPSD), such as anxiety and depression. Non-pharmacological interventions have proved useful in dealing with these symptoms. However, while most PwD exhibit BPSD, their manifestation (in frequency, intensity and type) varies widely among patients, thus the need to personalize the intervention and its assessment. Traditionally, instruments to measure behavioral symptoms of dementia, such as NPI-NH and CMAI, are used to evaluate these interventions. We propose the use of activity trackers as a complement to monitor behavioral symptoms in dementia research. To illustrate this approach we describe a nine week Cognitive Stimulation Therapy conducted with the assistance of a social robot, in which the ten participants wore an activity tracker. We describe how data gathered from these wearables complements the assessment of traditional behavior assessment instruments with the advantage that this assessment can be conducted continuously and thus be used to tailor the intervention to each PwD.

Effectiveness of online dementia caregivers training programs: A systematic review

Over the next thirty years, Alzheimer's disease rates will increase alongside global aging. With the anticipated increase in demand, knowledgeable and skilled dementia caregivers will be in need across the long-term care spectrum. This study is a systematic review of online dementia-based training programs for formal and informal caregivers conducted to analyze evidence for using online training programs. We used the Preferred Reporting Items for Systematic Reviews (PRISMA) method. Methodological quality was assessed by the Cochrane Collaboration Back Review Group criteria. No previously published systematic review has analyzed online dementia training programs among both formal and informal caregivers. A systematic search of Web of Science, PsychInfo, and PubMed resulted in a final sample of (N = 19) studies. Results suggest that online interventions improve the condition and preparedness of caregivers, but future evaluations should consider study designs with multiple time points, control groups, and content that is personalized and interactive.

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

Background and Objectives

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

Research Design and Methods

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

Results

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

Discussion and Implications

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

A cluster-randomized crossover trial of Montessori activities delivered by family carers to nursing home residents with behavioral and psychological symptoms of dementia

OBJECTIVES

One-on-one structured Montessori-based activities conducted with people with dementia can improve agitation and enhance engagement. These activities may however not always be implemented by nursing home staff. Family members may present an untapped resource for enabling these activities. This study aimed to evaluate the impact of the Montessori activities implemented by family members on visitation experiences with people who have dementia.

DESIGN

Cluster-randomized crossover design.

SETTING

General and psychogeriatric nursing homes in the state of Victoria, Australia.

PARTICIPANTS

Forty participants (20 residents and 20 carers) were recruited.

INTERVENTION

During visits, family members interacted with their relative either through engaging in Montessori-based activities or reading a newspaper (the control condition) for four 30-minute sessions over 2 weeks.

MEASUREMENTS

Residents' predominant affect and engagement were rated for each 30-second interval using the Philadelphia Geriatric Center Affect Rating Scale and the Menorah Park Engagement Scale. The Pearlin Mastery Scale was used to rate carers satisfaction with visits. The 15-item Mutuality Scale measured the carers quality of their relationship with the resident. Carers' mood and overall quality of life were measured using the Center for Epidemiological Studies Depression Scale and Carer-QoL questionnaires, respectively.

RESULTS

Linear regressions within the generalized estimating equations approach assessed residents' and carers' outcomes. Relative to the control condition, the Montessori condition resulted in more positive engagement (b = 13.0, 95%CI 6.3-19.7, p < 0.001) and affect (b = 0.4, 95%CI 0.2-0.6, p < 0.001) for the residents and higher satisfaction with visits for carers (b = 1.7, 95%CI 0.45-3.00, p = 0.008). No correction was applied to p-values for multiple comparisons.

CONCLUSION

This study strengthens the evidence base for the use of the Montessori programs in increasing well-being in nursing home residents. The findings also provide evidence that family members are an additional valuable resource in implementing structured activities such as the Montessori program with residents.

Comparative efficacy of non-pharmacological interventions on agitation in people with dementia: A systematic review and Bayesian network meta-analysis

BACKGROUND

Agitation in people with dementia is common and distressing and can lead to increased caregiver burden. However, medications often have adverse reactions and limited effectiveness. Thus, non-pharmacological interventions are being increasingly implemented.

OBJECTIVES

To compare and rank the efficacy of different non-pharmacological interventions in the management of agitation in people with dementia.

DESIGN

Bayesian network meta-analysis.

METHODS

A comprehensive electronic literature search was performed in five English databases and three Chinese databases to identify relevant randomized controlled trials (RCTs) that were published up to January 2019. A random-effects model was selected to conduct traditional meta-analysis to directly examine the efficacy of different non-pharmacological interventions. The consistency model was selected to conduct a network meta-analysis to evaluate the relative effects and rank probability of different non-pharmacological interventions.

RESULTS

A total of 65 RCTs were included in this network meta-analysis involving 11 different non-pharmacological interventions. Network meta-analysis showed that massage therapy, animal-assisted intervention, and personally tailored intervention were associated with more substantial reductions in agitation compared with other interventions and controls.

CONCLUSIONS

Our study confirmed the effectiveness of non-pharmacological interventions for ameliorating agitation in people with dementia and recommended several interventions for clinical practice. Healthcare professionals should be encouraged to apply promising non-pharmacological interventions (e.g. massage therapy, animal-assisted intervention and personally tailored intervention) for people with dementia during routine care.

Effectiveness of DementiAbility Methods: The Montessori Way on agitation in long-term care home residents with dementia in Hong Kong

OBJECTIVE

To investigate the effect of the DementiAbility Methods: The Montessori Way (DMMW) on agitation in long-term care home residents with dementia. The activities using the DMMW are hypothesized to reduce agitation in terms of its frequency and disruptiveness to greater extent than structured social activities as control.

METHODS

Forty-six long-term care home residents with dementia were randomly allocated to receive the DMMW (n = 23) or structured social activities as control (n = 23). Each participant received six intervention sessions of 45 minutes each within 2 weeks, at long-term care home. Agitation in terms of frequency and disruptiveness before and after the intervention were compared.

RESULTS

The results showed that the DMMW resulted in significant reduction in overall frequency and disruptiveness of agitation. The DMMW group had significant reduction in frequency and disruptiveness of verbal aggressive, physical nonaggressive, and physical aggressive behaviors after the intervention.

CONCLUSIONS

The present findings support the potential of the DMMW as a safe and efficacious therapeutic intervention for addressing agitation in long-term care home residents with dementia, relevant to Hong Kong culture.

Engagement and experience of older people with socially assistive robots in home care

Social isolation is one of the most common consequences of older people with dementia, especially for those who live at their own dwellings alone due to limited access to social activities. Research relating to the use of social robots in aged care has increasing attention to facilitating the support to care services for older people with dementia. Particularly less attention has focused on the applicability of social robots in home care services. This paper aims to study the engagement and robot experience of older people with dementia while interacting with a social robot named Betty in the context of home-based care. This paper contributes to the research relating to care service embedded robots by expanding the knowledge regarding longitudinal research in home based care, while there is limited long-term study in this context. The results show that social robots are evident to be able to engage with older people with dementia at home. Consequently, designing social robots in a social context is desirable. While the robots enabled service for the human partner within the social context is possible, there is a need to underpin the concept of personhood to realize personalization of services and its contents to suit individual preferences.

Communication training interventions for family and professional carers of people living with dementia: a systematic review of effectiveness, acceptability and conceptual basis

OBJECTIVES

To update previous reviews and provide a more detailed overview of the effectiveness, acceptability and conceptual basis of communication training-interventions for carers of people living with dementia.

METHOD

We searched CINAHL Plus, MEDLINE and PsycINFO using a specific search and extraction protocol, and PRISMA guidelines. Two authors conducted searches and extracted studies that reported effectiveness, efficacy or acceptability data regarding a communication training-intervention for carers of people living with dementia. Risk of bias was assessed using the Cochrane Collaboration guidelines. Quality of qualitative studies was also systematically assessed.

RESULTS

Searches identified 450 studies (after de-duplication). Thirty-eight studies were identified for inclusion in the review. Twenty-two studies focused on professional carers; 16 studies focused mainly on family carers. Training-interventions were found to improve communication and knowledge. Overall training-interventions were not found to significantly improve behaviour that challenges and caregiver burden. Acceptability levels were high overall, but satisfaction ratings were found to be higher for family carers than professional carers. Although many interventions were not supported by a clear conceptual framework, person-centred care was the most common framework described.

CONCLUSION

This review indicated that training-interventions were effective in improving carer knowledge and communication skills. Effective interventions involved active participation by carers and were generally skills based (including practicing skills and discussion). However, improvements to quality of life and psychological wellbeing of carers and people living with dementia may require more targeted interventions.

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.

Study protocol: A Montessori approach to dementia-related, non-residential respite services in Australia

Given the social burden and significant cost of dementia care in Australia, finding evidence-based approaches that improve outcomes, maintain independence, and reduce the impact on patients and families is essential. Finding effective ways to train and assist the healthcare staff who support these individuals is also critical, as they are considered to be at risk of workplace stress, burnout, and other psychological disturbances which negatively affects standards of care. The current paper describes a protocol for evaluating the effects of a Montessori-based approach to dementia care, in non-residential respite centres. An 18 month prospective observational, cohort controlled design is suggested that will compare participants from a community respite service that has undergone a Montessori-based workplace culture change and those from a service that provides a person-centred 'care as usual' approach. To achieve this, the protocol includes the assessment of participants across multiple variables on a monthly basis including the cognitive, behavioural, and emotional functioning of clients with dementia, levels of caregiver burden experienced by informal carers, and burnout, compassion satisfaction and workplace engagement among respite staff. The protocol also employs a qualitative evaluation of program fidelity. This approach will provide further insight into the potential benefits of early intervention with Montessori approaches for persons living with dementia in the community, their caregivers, and the staff and volunteers who assist them.

Personally tailored activities for improving psychosocial outcomes for people with dementia in long-term care

BACKGROUND

People with dementia who are being cared for in long-term care settings are often not engaged in meaningful activities. Offering them activities which are tailored to their individual interests and preferences might improve their quality of life and reduce challenging behaviour.

OBJECTIVES

∙ To assess the effects of personally tailored activities on psychosocial outcomes for people with dementia living in long-term care facilities.∙ To describe the components of the interventions.∙ To describe conditions which enhance the effectiveness of personally tailored activities in this setting.

SEARCH METHODS

We searched ALOIS, the Cochrane Dementia and Cognitive Improvement Group's Specialized Register, on 16 June 2017 using the terms: personally tailored OR individualized OR individualised OR individual OR person-centred OR meaningful OR personhood OR involvement OR engagement OR engaging OR identity. We also performed additional searches in MEDLINE (Ovid SP), Embase (Ovid SP), PsycINFO (Ovid SP), CINAHL (EBSCOhost), Web of Science (ISI Web of Science), ClinicalTrials.gov, and the World Health Organization (WHO) ICTRP, to ensure that the search for the review was as up to date and as comprehensive as possible.

SELECTION CRITERIA

We included randomised controlled trials and controlled clinical trials offering personally tailored activities. All interventions included an assessment of the participants' present or past preferences for, or interests in, particular activities as a basis for an individual activity plan. Control groups received either usual care or an active control intervention.

DATA COLLECTION AND ANALYSIS

Two authors independently checked the articles for inclusion, extracted data and assessed the methodological quality of included studies. For all studies, we assessed the risk of selection bias, performance bias, attrition bias and detection bias. In case of missing information, we contacted the study authors.

MAIN RESULTS

We included eight studies with 957 participants. The mean age of participants in the studies ranged from 78 to 88 years and in seven studies the mean MMSE score was 12 or lower. Seven studies were randomised controlled trials (three individually randomised, parallel group studies, one individually randomised cross-over study and three cluster-randomised trials) and one study was a non-randomised clinical trial. Five studies included a control group receiving usual care, two studies an active control intervention (activities which were not personally tailored) and one study included both an active control and usual care. Personally tailored activities were mainly delivered directly to the participants; in one study the nursing staff were trained to deliver the activities. The selection of activities was based on different theoretical models but the activities did not vary substantially.We found low-quality evidence indicating that personally tailored activities may slightly improve challenging behaviour (standardised mean difference (SMD) -0.21, 95% confidence interval (CI) -0.49 to 0.08; I² = 50%; 6 studies; 439 participants). We also found low-quality evidence from one study that was not included in the meta-analysis, indicating that personally tailored activities may make little or no difference to general restlessness, aggression, uncooperative behaviour, very negative and negative verbal behaviour (180 participants). There was very little evidence related to our other primary outcome of quality of life, which was assessed in only one study. From this study, we found that quality of life rated by proxies was slightly worse in the group receiving personally tailored activities (moderate-quality evidence, mean difference (MD) -1.93, 95% CI -3.63 to -0.23; 139 participants). Self-rated quality of life was only available for a small number of participants, and there was little or no difference between personally tailored activities and usual care on this outcome (low-quality evidence, MD 0.26, 95% CI -3.04 to 3.56; 42 participants). We found low-quality evidence that personally tailored activities may make little or no difference to negative affect (SMD -0.02, 95% CI -0.19 to 0.14; I² = 0%; 6 studies; 589 participants). We found very low quality evidence and are therefore very uncertain whether personally tailored activities have any effect on positive affect (SMD 0.88, 95% CI 0.43 to 1.32; I² = 80%; 6 studies; 498 participants); or mood (SMD -0.02, 95% CI -0.27 to 0.23; I² = 0%; 3 studies; 247 participants). We were not able to undertake a meta-analysis for engagement and the sleep-related outcomes. We found very low quality evidence and are therefore very uncertain whether personally tailored activities improve engagement or sleep-related outcomes (176 and 139 participants, respectively). Two studies that investigated the duration of the effects of personally tailored activities indicated that the intervention effects persisted only during the delivery of the activities. Two studies reported information about adverse effects and no adverse effects were observed.

AUTHORS' CONCLUSIONS

Offering personally tailored activities to people with dementia in long-term care may slightly improve challenging behaviour. Evidence from one study suggested that it was probably associated with a slight reduction in the quality of life rated by proxies, but may have little or no effect on self-rated quality of life. We acknowledge concerns about the validity of proxy ratings of quality of life in severe dementia. Personally tailored activities may have little or no effect on negative affect and we are uncertain whether they improve positive affect or mood. There was no evidence that interventions were more likely to be effective if based on one specific theoretical model rather than another. Our findings leave us unable to make recommendations about specific activities or the frequency and duration of delivery. Further research should focus on methods for selecting appropriate and meaningful activities for people in different stages of dementia.

The relation between mood, activity, and interaction in long-term dementia care

OBJECTIVE

The aim of the study is to identify the degree of association between mood, activity engagement, activity location, and social interaction during everyday life of people with dementia (PwD) living in long-term care facilities.

METHOD

An observational study using momentary assessments was conducted. For all 115 participants, 84 momentary assessments of mood, engagement in activity, location during activity, and social interaction were carried out by a researcher using the tablet-based Maastricht Electronic Daily Life Observation-tool.

RESULTS

A total of 9660 momentary assessments were completed. The mean age of the 115 participants was 84 and most (75%) were women. A negative, neutral, or positive mood was recorded during 2%, 25%, and 73% of the observations, respectively. Positive mood was associated with engagement in activities, doing activities outside, and social interaction. The type of activity was less important for mood than the fact that PwD were engaged in an activity. Low mood was evident when PwD attempted to have social interaction but received no response.

CONCLUSION

Fulfilling PwD's need for occupation and social interaction is consistent with a person-centred dementia care focus and should have priority in dementia care.

Quantity of Movement as a Measure of Engagement for Dementia: The Influence of Motivational Disorders

Engagement in activities is crucial to improve quality of life in dementia. Yet, its measurement relies exclusively on behavior observation and the influence that behavioral and psychological symptoms of dementia (BPSD) have on it is overlooked. This study investigated whether quantity of movement, gauged with a wrist-worn accelerometer, could be a sound measure of engagement and whether apathy and depression negatively affected engagement. Fourteen participants with dementia took part in 6 sessions of activities: 3 of cognitive games (eg, jigsaw puzzles) and 3 of robot play (Pleo). Results highlighted significant correlations between quantity of movement and observational scales of engagement and a strong negative influence of apathy and depression on engagement. Overall, these findings suggest that quantity of movement could be used as an ancillary measure of engagement and underline the need to profile people with dementia according to their concurrent BPSD to better understand their engagement in activities.

Museums, health and wellbeing research: co-developing a new observational method for people with dementia in hospital contexts

AIMS

The aim of this article is to present a new observational tool for assessing the impacts of museum object handling for people with moderate-to-severe dementia in hospital settings, focusing on wellbeing, social interaction, level of engagement and agitation. This article presents a four-step approach to collaboration towards co-developing the tool, which involved a range of academics, museums professionals, and health and social care partners, and describes the process of integrating multiple perspectives towards common research methodologies.

METHODS

The research team organised a series of meetings and workshops with museum and healthcare partners to identify commonly used assessments and their perspectives on the objectives and possible outcomes of museum object handling activities. These were integrated with findings from a review of current conceptualisations of engagement in people with dementia (PWD) to produce a fit-for-purpose video evaluation method of the health and wellbeing impacts of the museum object handling programmes.

RESULTS

This article presents the Museum Engagement Observation Tool for use in hospital settings for people with moderate-to-severe dementia.

CONCLUSION

This article suggests that collaborative approaches can inform the development of future methods for creative health research and evaluation initiatives and to support this, it outlines the process of development of a new observational tool for people with dementia.

Effectiveness of Occupational Therapy Interventions to Enhance Occupational Performance for Adults With Alzheimer's Disease and Related Major Neurocognitive Disorders: A Systematic Review

OBJECTIVE

The purpose of this systematic review was to describe the evidence for the effectiveness of interventions designed to establish, modify, and maintain occupations for adults with Alzheimer's disease (AD) and related neurocognitive disorders.

METHOD

Titles and abstracts of 2,597 articles were reviewed, of which 256 were retrieved for full review and 52 met inclusion criteria. U.S. Preventive Services Task Force levels of certainty and grade definitions were used to describe the strength of evidence.

RESULTS

Articles were categorized into five themes: occupation-based, sleep, cognitive, physical exercise, and multicomponent interventions. Strong evidence supports the benefits of occupation-based interventions, physical exercise, and error-reduction learning.

CONCLUSION

Occupational therapy practitioners should integrate daily occupations, physical exercise, and error-reduction techniques into the daily routine of adults with AD to enhance occupational performance and delay functional decline. Future research should focus on establishing consensus on types and dosage of exercise and cognitive interventions.

Dementia-related agitation: a review of non-pharmacological interventions and analysis of risks and benefits of pharmacotherapy

Unsurprisingly, the subject of dementia has been a rising matter of public health concerns as people now live longer. World Alzheimer Report 2015, estimate that about 46.8 million people worldwide have dementia. These numbers are projected to almost double every 20 years, reaching 74.7 million in 2030 and 131.5 million in 2050. The modality for treating agitation and other behavioral symptoms in dementia patients has been a challenge. Many years on, there has been no FDA-approved pharmacotherapy in treating dementia-related agitation. This review discusses the current knowledge of non-pharmacological interventions, and analyzes the risks and benefits of pharmacotherapy in the management of dementia-related agitation, as well as providing an anecdotal of the author's clinical experience. This article aims to provide opportunity for increase awareness for clinicians, particularly those with no specialty training in geriatrics medicine but see dementia patients with agitation and other behavioral symptoms from time to time. Likewise, it hopefully will benefit the readers of medical journals to update their existing knowledge on matters relating to the management of dementia-related agitation.

Montessori-Based Activities Among Persons with Late-Stage Dementia: Evaluation of Mental and Behavioral Health Outcomes

OBJECTIVES

Literature regarding Montessori-based activities with older adults with dementia is fairly common with early stages of dementia. Conversely, research on said activities with individuals experiencing late-stage dementia is limited because of logistical difficulties in sampling and data collection. Given the need to understand risks and benefits of treatments for individuals with late-stage dementia, specifically regarding their mental and behavioral health, this study sought to evaluate the effects of a Montessori-based activity program implemented in a long-term care facility.

METHOD

Utilizing an interrupted time series design, trained staff completed observation-based measures for 43 residents with late-stage dementia at three intervals over six months. Empirical measures assessed mental health (anxiety, psychological well-being, quality of life) and behavioral health (problem behaviors, social engagement, capacity for activities of daily living).

RESULTS

Group differences were observed via repeated measures ANOVA and paired-samples t-tests. The aggregate, longitudinal results-from baseline to final data interval-for the psychological and behavioral health measures were as follows: problem behaviors diminished though not significantly; social engagement decreased significantly; capacities for activities of daily living decreased significantly; quality of life increased slightly but not significantly; anxiety decreased slightly but not significantly; and psychological well-being significantly decreased.

CONCLUSION

Improvements observed for quality of life and problem behaviors may yield promise for Montessori-based activities and related health care practices. The rapid physiological and cognitive deterioration from late-stage dementia should be considered when interpreting these results.

Keeping the person with dementia and the informal caregiver together: a systematic review of psychosocial interventions

BACKGROUND

Social support, relationships, and closeness are emphasized as important by both people with dementia and their informal caregivers. Psychosocial interventions might be helpful to reinforce the relationship between a person with dementia and his or her informal caregiver. Therefore, this review explores what types of psychosocial interventions have been provided for people with dementia and their informal caregivers together, and the effectiveness of these interventions.

METHODS

PubMed, PsychInfo, Cinahl, and references of key papers were searched for studies describing a psychosocial intervention for people with dementia and their informal caregivers together. Psychosocial interventions were defined as focusing primarily on psychological or social factors.

RESULTS

A total of seven publications describing six studies were identified as eligible for inclusion in this review. Interventions ranged in focus from skills training to viewing/making art. The methodology of the studies varied, especially regarding the outcome measures used. The results of individual studies were mixed. A narrative synthesis of the included studies is given.

CONCLUSION

Although caregiving dyads emphasize the importance of their relationship, this is mostly not taken into consideration in the design and effect evaluations of the interventions. Improved research is needed on this subject, which focuses on people with dementia living in the community and those living in nursing homes.

Prednosti metode Montessori pri obravnavi oseb z demenco

Uvod: Demenca je kronično obolenje s tendenco upadanja kognitivnih sposobnosti obolelega. Uporaba metod za obvladovanje in trening osnovnih življenjskih aktivnosti, ki omogočajo daljše obdobje samostojnega življenja pacienta z demenco, je v tujini uveljavljena z različnimi novejšimi koomplementarnimi pristopi. Ena izmed uveljavljenih metod je pristop Marie Montessori, prilagojen odraslim pacientom z demenco. V članku je predstavljena metoda montessori pri obravnavi pacienta z demenco in njeni učinki na kakovost življenja pacienta z demenco. Metode: Uporabljena je bila deskriptivna raziskovalna metodologija s pregledom domače in tuje literature. Za prikaz pregleda petih preko spleta dostopnih podatkovnih baz in odločanja o uporabnosti pregledanih virov je bila uporabljena metoda PRISMA. V končni pregled literature je bilo ključenih 19 člankov, objavljenih do maja 2016. Za obdelavo podatkov je bil uporabljen model analize konceptov. Večina zajetih raziskav je bila izvedena v Združenih državah Amerike. Rezultati: Po pregledu raziskav so bila identificirana tri tematska področja: (1) vpliv metode montessori na sodelovanje in prizadevanje, (2) vpliv metode montessori na vedenje, povezano s hranjenjem, in (3) vpliv metode montessori na širšo skupino kognitivnih sposobnosti. Diskusija in zaključek: Kljub majhnemu številu člankov, ki opisujejo uporabo metode montessori pri obravnavi pacientov z demenco, metodo lahko predstavimo kot učinkovito. Avtorji raziskav ugotavljajo, da pristop ne le omogoča ohranjanje kognitivnih sposobnosti, temveč le-te celo izboljšuje.

Effectiveness of person-centered care on people with dementia: a systematic review and meta-analysis

Background

Person-centered care is a holistic and integrative approach designed to maintain well-being and quality of life for people with dementia, and it includes the elements of care, the individual, the carers, and the family.

Aim

A systematic literature review and meta-analysis were undertaken to investigate the effectiveness of person-centered care for people with dementia.

Methods

Literature searches were undertaken using six databases including Medline, EMBASE, CINAHL, PsycINFO, Cochrane Database, and KoreaMed using the following keywords: cognition disorder, dementia, person-centered care, patient-centered care, client-centered care, relationship-centered care, and dementia care. The searches were limited to interventional studies written in English and Korean and included randomized controlled studies and noncontrolled studies for people with dementia living in any setting.

Results

Nineteen interventional studies, including 3,985 participants, were identified. Of these, 17 studies were from long-term care facilities and two studies were from homecare settings. The pooled data from randomized controlled studies favored person-centered care in reducing agitation, neuropsychiatric symptoms, and depression and improving the quality of life. Subgroup analysis identified greater effectiveness of person-centered care when implemented for people with less severe dementia. For agitation, short-term interventions had a greater effect (standardized mean difference [SMD]: −0.434; 95% conference interval [CI]: −0.701 to −0.166) than long-term interventions (SMD: −0.098; 95% CI: −0.190 to 0.007). Individualized activities resulted in a significantly greater beneficial effect than standard care (SMD: 0.513; 95% CI: −0.994 to −0.032). However, long-term, staff education, and cultural change interventions had a greater effect on improving the quality of life for people with dementia (SMD: 0.191; 95% CI: 0.079 to 0.302).

Conclusion

This systematic review and meta-analysis provided evidence for person-centered care in clinical practice for people with dementia. Person-centered care interventions were shown to reduce agitation, neuropsychiatric symptoms, and depression and to improve the quality of life. Person-centered care interventions can effectively reduce agitation for a short term using intensive and activity-based intervention. However, an educational strategy that promotes learning and skill development of internal care staff is needed to enhance patient’s quality of life and to ensure the sustainability of the effects of behavioral problems. The feasibility and effectiveness of the intervention, the severity of patient disease, and intervention type and duration should be considered as part of an intervention design.

[Cognitive disorders and the Montessori method]

Trained in the Montessori method, a team takes a very positive approach to their patients. The nurses base their practice on patients' remaining capacities, helping them work around their impairments. They seek to offer each person the possibility to pursue a social life through individualised treatments.