Awareness in people with severe dementia: review and integration

Supporting Persons With Dementia: Perspectives From Certified Nurse's Assistants

Background and Objectives

Many persons with Alzheimer's disease or related dementias (ADRD) receive care from paid staff in residential communities. The most common staff in these communities are certified nursing assistants (CNAs). Although CNAs have a high number of interactions with residents, and thus the possibility of engaging in social interactions, evidence suggests that they provide limited social support to persons with ADRD. Little is known about the attitudes of CNAs toward providing social support to persons with ADRD and their perception of components of quality social interactions with these individuals.

Research Design and Methods

We conducted a thematic analysis of semistructured interviews with 11 CNAs (91% female participants, mean age 23.6) to understand their perceptions about providing social support to persons with ADRD and the components of effective social interactions.

Results

Our results show that CNAs consider providing social support to be an important part of their role as CNAs. Additionally, participants emphasized the interplay of verbal communication, nonverbal communication, and internal beliefs and attitudes toward persons with ADRD in creating effective social interactions. Participants highlighted multiple barriers to providing residents with social support, including lack of time, lack of training, and the behavioral and psychological symptoms of dementia.

Discussion and Implications

We offer implications for expanding training for CNAs working with persons with dementia and improving policy based on our results.

Assessing awareness in severe Alzheimer's disease

There is an urgent need to understand the nature of awareness in people with severe Alzheimer's disease (AD) to ensure effective person-centered care. Objective biomarkers of awareness validated in other clinical groups (e.g., anesthesia, minimally conscious states) offer an opportunity to investigate awareness in people with severe AD. In this article we demonstrate the feasibility of using Transcranial magnetic stimulation (TMS) combined with EEG, event related potentials (ERPs) and fMRI to assess awareness in severe AD. TMS-EEG was performed in six healthy older controls and three people with severe AD. The perturbational complexity index (PCIST) was calculated as a measure of capacity for conscious awareness. People with severe AD demonstrated a PCIST around or below the threshold for consciousness, suggesting reduced capacity for consciousness. ERPs were recorded during a visual perception paradigm. In response to viewing faces, two patients with severe AD provisionally demonstrated similar visual awareness negativity to healthy controls. Using a validated fMRI movie-viewing task, independent component analysis in two healthy controls and one patient with severe AD revealed activation in auditory, visual and fronto-parietal networks. Activation patterns in fronto-parietal networks did not significantly correlate between the patient and controls, suggesting potential differences in conscious awareness and engagement with the movie. Although methodological issues remain, these results demonstrate the feasibility of using objective measures of awareness in severe AD. We raise a number of challenges and research questions that should be addressed using these biomarkers of awareness in future studies to improve understanding and care for people with severe AD.

Awareness for People With Alzheimer’s Disease: Profiles and Weekly Trajectories

Objective: To understand awareness and fluctuations of awareness in Alzheimer’s disease (AD), it is fruitful to consider the objects of awareness, e.g., cognitive functioning or recognition of the disease, as well as the mechanisms and modes of expression underlying awareness. With a holistic and discourse-centered approach, we aimed to identify different awareness profiles and test whether these profiles were stable or whether transitions from one profile to another occurred over short time intervals.

Methods: Twenty-eight residents of nursing homes with a diagnosis of AD participated in four semistructured interviews at biweekly intervals. These interviews were cluster analyzed to determine profiles of awareness. A Markov chain was applied to model their fluctuation.

Results: Five awareness profiles were observed that differed in terms of objects and underlying processes. Awareness proved to be quite stable for four of the five profiles. Interindividual variability in awareness was also observed through numerous different trajectories that were identified.

Discussion: Self-awareness and disease awareness are characterized by profiles that vary subtly between individuals. Fluctuations in awareness underscore the need to employ assessment intervals that closely reflect daily life in institutions.

Do Daytime Activity, Mood and Unit Tumult Predict Nighttime Sleep Quality of Long-Term Care Residents?

Based on the premise that stressors can have a cumulative effect on people with dementia throughout the day that contributes to negative consequences later in the day, we examined if daytime activity, unit tumult, and mood were associated with sleep quality. A convenience sample of 53 long-term care (LTC) residents participated in this correlational study. Objective sleep quality was measured using actigraphy, and comorbid illness and level of dementia were control variables. Half of the sample had a sleep efficiency that was less than 80% and was awake for more than 90 min at night. Comorbid illness, negative mood at bedtime, and daytime activity level accounted for 26.1% of the variance in total sleep minutes. Census changes and the use of temporary agency staff were associated with poor sleep. Findings suggest daytime activity, mood at bedtime, and unit tumult should be considered when designing and testing interventions to improve sleep quality.

Measuring Awareness in People With Dementia: Results of a Systematic Scoping Review

BACKGROUND

Awareness of the diagnosis or related changes in functioning varies in people with dementia (PwD), with implications for the well-being of PwD and their carers. Measuring awareness in a clinical setting could facilitate tailored support and optimize involvement in personal health and care decisions. This scoping review aimed to identify validated methods of assessing awareness in dementia and appraise their clinical utility.

METHOD

A systematic search was conducted of English-language publications that measured awareness in PwD, in 6 electronic databases. Search terms included dement*, Alzheimer*, Pick disease, and awareness, unawareness, anosognosia, insight, denial, metacognit*, or discrepanc*.

RESULTS

We screened 30,634 articles, finding 345 articles that met our inclusion criteria. We identified 76 measures, most commonly using a discrepancy questionnaire comparing evaluations of function by PwD and an informant. There were 30 awareness measures developed and validated for use in dementia populations but few designed for general clinical use.

CONCLUSIONS

Although we found a range of clinical indications for measuring awareness, there were few studies investigating clinical applications and few tools designed for clinical purposes. Further investigation and development of a person-centered tool could facilitate health and care choices in mild-to-moderate dementia.

Can music enhance awareness in unresponsive people with severe dementia? An exploratory case series using behavioral, physiological and neurophysiological measures

In five people with severe dementia, we measured their behavioral and physiological responses to familiar/unfamiliar music and speech, and measured ERP responses to subject's own name (SON) after exposure to familiar/unfamiliar music or noise. We observed more frequent behavioral responses to personally-significant stimuli than non-personally-significant stumuli, and higher skin temperatures for music than non-music conditions. The control group showed typical ERPs to SON, regardless of auditory exposure. ERP measures were unavailable for the dementia group given challenges of measuring EEG in this population. The study highlights the potential for personally-significant auditory stimuli in enhancing responsiveness of people with severe dementia.

Awareness in severe Alzheimer's disease: a systematic review

Objective: There is limited understanding about how people in the severe stages of Alzheimer's disease (AD) experience and demonstrate awareness. We synthesised all available evidence with the aim of understanding how awareness is preserved or impaired in severe AD and what evidence there is for different levels of awareness according to the levels of awareness framework.Method: A systematic search of the following databases: Embase, PsycINFO, MEDLINE and Web of Science was carried out. A narrative synthesis and analysis was conducted of all included studies. All studies were assessed for quality using the AXIS and CASP tools.Results: Our findings suggest that lower level sensory awareness is relatively maintained in severe AD. Findings for higher level awareness are variable and this may be related to the diversity of methods that have been used to explore awareness in these circumstances.Conclusion: Awareness is complex, heterogeneous and varies significantly between individuals. Environmental and contextual factors have a significant impact on whether awareness is observed in people with severe AD. Adaptation of the environment has the potential to facilitate the expression of awareness while education of caregivers may increase understanding of people with severe AD and potentially improve the quality of care that is received.

Understanding Alzheimer's disease as a disorder of consciousness

People with Alzheimer's disease (AD) demonstrate a range of alterations in consciousness. Changes in awareness of cognitive deficit, self-awareness, and introspection are seen early in AD, and dysfunction of awareness and arousal progresses with increasing disease severity. However, heterogeneity of deficits between individuals and a lack of empirical studies in people with severe dementia highlight the importance of identifying and applying biomarkers of awareness in AD. Impairments of awareness in AD are associated with neuropathology in regions that overlap with proposed neural correlates of consciousness. Recent developments in consciousness science provide theoretical frameworks and experimental approaches to help further understand the conscious experience of people with AD. Recognition of AD as a disorder of consciousness is overdue, and important to both understand the lived experience of people with AD and to improve care.

Awareness of dementia and coping to preserve quality of life: a five-year longitudinal narrative study

Purpose

To examine how people (<65 years) with young-onset dementia (YOD) express awareness of dementia and how they seem to handle awareness as a strategy to preserve quality of life over time.

Method

A longitudinal qualitative study with individuals with YOD was performed with interviews every 6 months over 5 years for a maximum of 10 interviews. The interviews were analysed by modified grounded theory adapted to narrative inquiry.

Results

Awareness is a complex, multidimensional concept. Awareness of dementia is predisposed by personality, life history and established coping styles. The main coping styles during dementia—live in the moment, ignore the dementia, and make the best of it—seem to be rather consistent throughout disease progression. Transitions in the life situation may change the individual’s awareness of dementia.

Conclusion

Unawareness of dementia may have an important adaptive function for preserving quality of life. Increasing awareness of dementia must be approached with reflexivity and great sensitivity.

'It's nice to think somebody's listening to me instead of saying "oh shut up"'. People with dementia reflect on what makes communication good and meaningful

WHAT IS KNOWN ON THE SUBJECT?: People with dementia experience cognitive decline which can affect their ability to communicate with others and consequently getting their needs met. Loneliness and social isolation are associated with depression and anxiety, while difficulties communicating may magnify such difficulties. Enhancing meaningful interactions may support maintenance of valued relationships and positive wellbeing. Although previous research has examined communicative experiences, this has been from the perspectives of professionals or caregivers. Exploring meaningful communication from the perspectives of people with dementia is crucial in supporting relationships and wellbeing. WHAT THE PAPER ADDS TO EXISTING KNOWLEDGE?: People with dementia can be active participants in research. They are aware of their cognitive impairments as well as social interactions and features constituting meaningful communications. People with dementia recognized carers' attempts to understand and empathize with them; allowing them to feel valued and heard, empowering them to maintain interactions. Alternatively, feeling dismissed, inferior or pressured to provide 'correct' responses deterred them from further conversations. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: People with dementia have an awareness of their relationships, communications and preferences. Thus, it is imperative to respect this population and make attempts to understand their communication as they sense this effort even when miscommunications occur. Embrace qualities that facilitate person-centred care within communications is vital as this can preserve valued relationships, support one's needs and enhance wellbeing. Such features include active listening, empathizing, being physically and mentally present, spending time to know the individual and sharing experiences, thoughts and emotions. Abstract Introduction Social isolation can be problematic for people with dementia; understanding what makes communication meaningful may reduce such risk. Scientific rationale Previous research has examined caregivers' or professionals' experiences of meaningful communication. Understanding this from the perspectives of people with dementia could enhance their interactions and wellbeing. Aim Exploring what makes communication meaningful from the perspective of people with dementia. Methods Nine dyadic interactions between a person with dementia and a family carer were filmed. Individuals with dementia watched the footage and reflected on their communications in semi-structured interviews. Results Three superordinate themes emerged. Themes 'sharing moments of emotional connection' and 'empowering one's ability to communicate' related to the experience of feeling connected, understood, valued and heard, allowing further communication. Conversely, 'inhibitors to communication' related feeling disempowered and reduced interactions. Discussion Even when carers could not understand what people with dementia attempted to communicate, their efforts to interact with them were valued and considered meaningful as they reinforce their sense of connectedness. Implications for practice Embracing a person-centred approach by actively attuning to the person and continuously attempting to empathize and understand persons with dementia can help preserve important relationships and allow the person to feel valued and interpersonally connected.

Development of a new tool for the early identification of communication-support needs in people living with dementia: An Australian face-validation study

Language and communication difficulties are common in dementia but limited tools are available for a timely assessment of those individuals who experience these difficulties. The Communication-Support Needs Assessment Tool in Dementia (CoSNAT-D) was developed to assist in (a) the early identification of communication difficulties among people with dementia in the community context; and (b) determining the level of their communication support needs to guide appropriate service access. The CoSNAT-D was developed based on a literature review. The face validity was tested with end-users (people with dementia and support persons of people with dementia) regarding relevance, wording, syntax, appropriateness and comprehensiveness of the items of the tool. Data were collected using semi-structured phone interviews. Seven people with dementia and 15 carers participated in the study. Feedback regarding items' appropriateness was largely positive and minor changes were made to improve comprehensiveness. A new item was added to the original item pool. The interviews highlighted the importance of including people with dementia in the assessment processes and person-centered approaches in this context. The CoSNAT-D presents a first step for the early identification of individual support needs of people living with dementia and communication difficulties who live in the community. Items of the CoSNAT-D have been determined face-valid by end-users. The face-validated version of the tool is currently undergoing further testing to determine additional relevant psychometric properties.

A group intervention to improve quality of life for people with advanced dementia living in care homes: the Namaste feasibility cluster RCT

BACKGROUND

People with advanced dementia who live and die in nursing homes experience variable quality of life, care and dying. There is a need to identify appropriate, cost-effective interventions that facilitate high-quality end-of-life care provision.

OBJECTIVES

To establish the feasibility and acceptability to staff and family of conducting a cluster randomised controlled trial of the Namaste Care intervention for people with advanced dementia in nursing homes.

DESIGN

The study had three phases: (1) realist review and (2) intervention refinement to inform the design of (3) a feasibility cluster randomised controlled trial with a process evaluation and economic analysis. Clusters (nursing homes) were randomised in a 3 : 1 ratio to intervention or control (usual care). The nature of the intervention meant that blinding was not possible.

SETTING

Nursing homes in England providing care for people with dementia.

PARTICIPANTS

Residents with advanced dementia (assessed as having a Functional Assessment Staging Test score of 6 or 7), their informal carers and nursing home staff.

INTERVENTION

Namaste Care is a complex group intervention that provides structured personalised care in a dedicated space, focusing on enhancements to the physical environment, comfort management and sensory engagement.

MAIN OUTCOME MEASURES

The two contender primary outcome measures were Comfort Assessment in Dying - End of Life Care in Dementia for quality of dying (dementia) and Quality of Life in Late Stage Dementia for quality of life. The secondary outcomes were as follows: person with dementia, sleep/activity (actigraphy), neuropsychiatric symptoms, agitation and pain; informal carers, satisfaction with care at the end of life; staff members, person-centred care assessment, satisfaction with care at the end of life and readiness for change; and other data - health economic outcomes, medication/service use and intervention activity.

RESULTS

Phase 1 (realist review; 86 papers) identified that a key intervention component was the activities enabling the development of moments of connection. In phase 2, refinement of the intervention enabled the production of a user-friendly 16-page A4 booklet. In phase 3, eight nursing homes were recruited. Two homes withdrew before the intervention commenced; four intervention and two control homes completed the study. Residents with advanced dementia (n = 32) were recruited in intervention (n = 18) and control (n = 14) homes. Informal carers (total, n = 12: intervention, n = 5; control, n = 7) and 97 staff from eight sites (intervention, n = 75; control, n = 22) were recruited over a 6-month period. Recruitment is feasible. Completion rates of the primary outcome questionnaires were high at baseline (100%) and at 4 weeks (96.8%). The Quality of Life in Late Stage Dementia was more responsive to change over 24 weeks. Even where economic data were missing, these could be collected in a full trial. The intervention was acceptable; the dose varied depending on the staffing and physical environment of each care home. Staff and informal carers reported changes for the person with dementia in two ways: increased social engagement and greater calm. No adverse events related to the intervention were reported.

CONCLUSIONS

A subsequent definitive trial is feasible if there are amendments to the recruitment process, outcome measure choice and intervention specification.

FUTURE WORK

In a full trial, consideration is needed of the appropriate outcome measure that is sensitive to different participant responses, and of clear implementation principles for this person-centred intervention in a nursing home context.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN14948133.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 24, No. 6. See the NIHR Journals Library website for further project information.

Professional caregivers' knowledge, beliefs and attitudes about awareness in advanced dementia: a systematic review of qualitative studies

OBJECTIVES

Awareness can be defined as a response to, or evaluation of, an aspect of one's situation or internal state. Awareness becomes impaired as dementia progresses; however, the exact nature and degree of impairment in advanced dementia remains unclear. The extent to which caregivers understand or make assumptions about the level and nature of awareness in advanced dementia may have a significant impact on their ability to appropriately respond to and care for the person with dementia. This systematic review examines the literature regarding professional caregiver perceptions about awareness in advanced dementia.

DESIGN

A systematic search of online literature databases (PsychInfo, Medline, Embase, CINAHL) was conducted up to January 15, 2018, using a range of search terms related to dementia, awareness and caregiver attitudes.

RESULTS

The systematic review included a total of 10 qualitative studies that were heterogeneous in aspects of design, including analyses. Narrative synthesis was used to integrate results. Four major themes were identified from review of the papers: how professional caregivers defined awareness; professional caregiver beliefs about what influences the expression of awareness; professional caregiver beliefs around how to assess awareness in advanced dementia; and the perceived impact of episodes of increased awareness on the person with dementia and caregiver. Sub-themes were identified within each of these areas.

CONCLUSION

This review highlights the importance of professional caregiver perceptions of awareness in advanced dementia. Supporting professional caregivers to assess and understand the nature of awareness in advanced dementia would improve their approach to care and outcomes for people with dementia.

Measuring awareness in people with dementia: protocol for a scoping review

BACKGROUND

People with dementia (PwD) vary in the degree of awareness they show about their situation, both generally concerning the diagnosis and more specifically around certain aspects or objects of awareness such as awareness of memory impairment, altered daily activities or social functioning. The extent of awareness or lack of awareness has consequences for well-being of PwD and carers, impacting on rates of hospital admission, institutionalization, mood, adjustment to diagnosis, outcomes from intervention and carer burden. An accurate estimation of a person's awareness could therefore be useful in a clinical setting to support PwD and their carers in making appropriate choices for health and care decisions, and could facilitate safe management by health care professionals, e.g. in an acute care setting. There is a range of different approaches to measuring awareness reported in the dementia research literature, with varying estimates of the frequency of lack of awareness, reflecting different methodologies and populations. The majority of the methods have been developed for research purposes and may not be suitable for clinical use. There are no recent scoping or systematic reviews of the available methods.

METHOD

We will conduct a scoping review of published studies that have assessed awareness in people with dementia of all types, and all degrees of severity. The systematic search will include the electronic databases PubMed, Embase, PsycInfo, CINAHL, Web of Science and Cochrane Library, using search terms for dementia ("dement*" or "Alzheimer*" or "Pick's disease") and "awareness", "unawareness", "anosognosia", "insight", "denial", "metacognit*" or "discrepanc*" identified from pilot searches. Findings will be mapped and described according to the method used, the setting and diagnosis and the object of awareness studied if specified. Validated measures will be identified.

DISCUSSION

This scoping review will provide an overview of the methods used to measure awareness in people with dementia, allowing comparison of the methods along with identification of validated measures. The methods or components will be appraised for potential clinical use, and gaps in research will be highlighted.

Improving living and dying for people with advanced dementia living in care homes: a realist review of Namaste Care and other multisensory interventions

BACKGROUND

Seventy percent of people with advanced dementia live and die in care homes. Multisensory approaches, such as Namaste Care, have been developed to improve the quality of life and dying for people with advanced dementia but little is known about effectiveness or optimum delivery. The aim of this review was to develop an explanatory account of how the Namaste Care intervention might work, on what outcomes, and in what circumstances.

METHODS

This is a realist review involving scoping of the literature and stakeholder interviews to develop theoretical explanations of how interventions might work, systematic searches of the evidence to test and develop the theories, and their validation with a purposive sample of stakeholders. Twenty stakeholders - user/patient representatives, dementia care providers, care home staff, researchers -took part in interviews and/or workshops.

RESULTS

We included 85 papers. Eight focused on Namaste Care and the remainder on other types of sensory interventions such as music therapy or massage. We identified three context-mechanism-outcome configurations which together provide an explanatory account of what needs to be in place for Namaste Care to work for people living with advanced dementia. This includes: providing structured access to social and physical stimulation, equipping care home staff to cope effectively with complex behaviours and variable responses, and providing a framework for person-centred care. A key overarching theme concerned the importance of activities that enabled the development of moments of connection for people with advanced dementia.

CONCLUSIONS

This realist review provides a coherent account of how Namaste Care, and other multisensory interventions might work. It provides practitioners and researchers with a framework to judge the feasibility and likely success of Namaste Care in long term settings. Key for staff and residents is that the intervention triggers feelings of familiarity, reassurance, engagement and connection.

STUDY REGISTRATION

This study is registered as PROSPERO CRD42016047512.

Moderate dementia: relational social engagement (RSE) during family visits

OBJECTIVE

This qualitative study seeks evidence of retained social awareness in individuals with moderate dementia residing in care-homes, when engaged in interactive family visits.

METHOD

Speech/non-speech data collected from 10/15-minute video-recorded family interactions of five family groups (12 individuals; 2 sessions per family group) were coded using thematic analysis.

RESULTS

Interactional patterns embedded in familiar bonds provided the context for the superordinate theme: relational social engagement (RSE). This overarched two subthemes: in-step and out-of-step; highlighting that RSE, can occur as a result of both positive and negative familial communication patterns. When familial communication was in-step, despite changed communication pathways, the resident's attempts at social engagement appeared open, relaxed, and responsive. A sense of trust, and familiarity appeared to facilitate reciprocal understanding and the striving of resident family members to retain family group membership. When familial communication was out-of-step, active attempts at reciprocity or open engagement from visiting family members were not observed. At such times, communication became discordant, and frustrated in their efforts to remain an integral part of the family group, the resident appeared disinterested or guarded often retorting with annoyance at visiting family members.

CONCLUSION

The construct of RSE appears specific to prior meaningful relationships, where optimal social awareness and communication, positive and negative, can occur. Currently, dementia assessment and care does not include RSE during family interactions. Implications are discussed.

Severe dementia: relational social engagement (RSE) during family visits

OBJECTIVE

Few studies have utilised observation to investigate retained awareness when individuals with severe dementia interact with family members. Seeking evidence of retained awareness in those with severe dementia, interactive family visits in care homes were observed and analysed.

METHOD

Five family groups (14 individuals) completed 10/15-minute video recorded family interactions. Speech and non-speech interactions were analysed using Thematic Analysis.

RESULTS

One superordinate theme: Distinctive family bonds; overarched two subthemes, in-step and out-of-step describing positive and negative familial interactions. In-step interactions revealed family groups reciprocating social support, having fun together, and willing to go on the ride together. Out-of-step interactions characterised social frustration, non-reciprocity, and sidelining of members with dementia. Although awareness fluctuated, complex awareness was observed in the speech/non-speech expressions of those with dementia. In response, visitors appeared to treat those expressions and behaviours as understandable. Observed outcomes were out-of-step when visitors sought to retain the familiar and in-step when visitors sought to optimise all communication possibilities.

CONCLUSION

Video recorded family interactions and analysis revealed: (a) awareness was retained in the participants with severe dementia beyond assessed levels; and (b) Relational Social Engagement (RSE) occurred within family groups despite positive or negative interactions. Implications are discussed.

Struggling to maintain individuality - Describing the experience of food in nursing homes for people with dementia

PURPOSE OF THE STUDY

To describe the food and dining experience of people with cognitive impairment and their family members in nursing homes.

DESIGN AND METHODS

Interviews and focus groups with people with cognitive impairment and their family members (n=19). Thematic analysis was undertaken using NVivo10 data analysis software package to determine key themes.

RESULTS

The main themes identified tracked a journey for people with cognitive impairment in nursing homes, where they initially sought to have their individual needs and preferences recognised and heard, expressed frustration as they perceived growing barriers to receiving dietary care which met their preferences, and ultimately described a deterioration of the amount of control and choice available to the individual with loss of self-feeding ability and dysphagia.

IMPLICATIONS

Further consideration of how to incorporate individualised dietary care is needed to fully implement person-centred care and support the quality of life of those receiving nursing home care.

Heterogeneity of Cognitive Anosognosia and its Variation with the Severity of Dementia in Patients with Alzheimer's Disease

Currently, the lack of awareness of deficits, i.e., anosognosia, is a major obstacle in the healthcare circuit that delays the diagnosis of Alzheimer's disease (AD). However, a clear framework is lacking in the literature related to this phenomenon in terms of its definition, mechanisms, and objects. The aim of this study is to assess the different levels of cognitive anosognosia using a prediction-performance procedure and to identify the potential correlates of these levels. A sample of patients with probable AD was divided into three groups according to the severity of dementia (mild (MiD), moderate (MoD), and moderately severe (MSD) dementia), ranked according to the results of the Mini-Mental State Examination. We observed the following three scores: the real score, the prediction score, and the anosognosia score. These scores were calculated based on the prediction-performance task MISAwareness from the Dementia Rating Scale for cognitive processes (i.e., Attention, Initiation, Conceptualization, Construction, and Memory). We obtained a strong plateau effect between the MiD and MoD groups for anosognosia scores for actual performance or prediction for both the level of overall functioning and for specific processes. The sole exception was the result for memory processes. Moreover, the profiles of the patients' responses on the Memory subscale were substantially different and, indeed, opposite from those for the other processes. The main results confirm the multidimensionality of anosognosia and its variability with the stage of dementia and specifically implicate memory processes that indicate a cleavage between memory and other cognitive functions.

Shame, hope, intimacy and growth: Dementia distress and growth in families from the perspective of senior aged care professionals

Minimal research explores the impact of dementia and a dementia diagnosis on families from the unique vantage of senior health professionals. The participants of this study, eight senior aged care professionals, provided unique interpretative insights into family dynamics and sense-making on the journey with dementia, and their own role in that journey. Both positive and negative perspectives were sought. Data from semi-structured interviews were analysed using Interpretative Phenomenological Analysis (IPA). One superordinate theme, Dementia naiveté; redefined intimacy, overarched Embarrassed shame; Maintaining hope; Redefining a model of intimacy; and Redefined relational intimacy and growth. Within these themes, the participants shed light on hurtful embarrassment and shame experienced by families associated with the diagnostic label given to a loved one. This label was perceived to either trigger separation, hurt and immobility through ignorance, or precipitate a frenzy of naive yet hopeful energy for seeking that elusive cure. The participants saw their role as one of enacting a new way of connecting what was with what could be. Thus, they modelled advocacy, integral care and relational intimacy. Validation came in witnessing a redefining of intimacy in many families who were able to embrace that holistic and empathic approach to the shifting presentation of dementia. Psychological well-being was observed to occur when families embraced growthful domains, e.g. acceptance, hope, relational closeness and altruistic concern for other families. Implications for future care models are discussed.

How do people in the early stage of Alzheimer’s disease see their future?

Older people fear Alzheimer’s disease. Central to the fear of the disease is the dread of the loss of identity or self. The aim of this study is to investigate the thoughts people in an early stage of Alzheimer’s disease have about their future selves, and the consequences these thoughts have for their temporary lives. The concepts of future and self are understood in terms of the concepts ‘possible selves’ and ‘selfhood’. The participants in the study are two men in their early 60 s. The data consist of four individual interviews and 11 facilitated family conversations including two of their next of kin. The data were collected over a two-year period. The data were interpreted using a hermeneutic analysis inspired by Gadamer. The main findings were the efforts made by the participants to live in the present and their worries about a future as ‘living dead’.

‘I wish they would remember that I forget:’ The effects of memory loss on the lives of individuals with mild-to-moderate dementia

Purpose of study

Due to changing cognitive and functional capabilities, individuals with dementia face challenging care-related issues such as feelings of embarrassment, relationship strain, and symptoms of depression and anxiety. Limited research exists examining individuals with dementia's perceptions and concerns about these issues and how their perspectives can impact the quality and process of their illness experience.

Design and methods

As part of a larger study, individuals with dementia ( n = 114) answered five open-ended questions about their illness experience including: (1) daily routine, (2) concerns about memory loss, (3) relationships with others, (4) fears, and (5) what they wish others understood/knew. For each question, individuals with dementia’s responses were analyzed for common themes within and across questions.

Results

Individuals with dementia commented on a wide range of issues involving their memory loss, including negative emotional impacts, future concerns and illness progression, forgetting, loss of independence, and the negative and positive influences on interpersonal relationships. Across questions, many individuals also stated that their memory loss did not significantly impact their lives.

Implications

Discussion highlights how these findings can be used to expand our understanding of individuals with dementia's illness experience and to develop efficacious interventions for addressing negative aspects of living with memory loss while supporting positive aspects.

Concepts and objects of awareness in Alzheimer’s disease: an updated systematic review

ABSTRACT Objectives To compare and discuss the objects of awareness in Alzheimer’s disease (AD): awareness of cognitive deficits, of functional activities, of social-emotional functioning and behavioral impairment. Methods A search in the PsycINFo, Pilots, PubMed/Medline and ISI electronic databases according to Prisma methodology was performed. We included studies about awareness in people with AD published between 2010 and 2015, with the combination of keywords: “Alzheimer AND awareness of deficits”, “Alzheimer AND anosognosia”, “Alzheimer AND insight”, “dementia AND awareness of deficits”, “dementia AND anosognosia”, “dementia AND insight”. The articles were categorized according to the specific object of awareness. Results Seven hundred and ten records were identified and, after application of the exclusion criteria, 191 studies were retrieved for potential use. After excluding the duplicates, 46 studies were included. Most studies assessed the cognitive domain of awareness, followed by the functional, social-emotional, and behavioral impairment domains. Memory deficits were not sufficient to explain impaired awareness in AD. Longitudinal studies did not find discrepancies between patients and caregivers’ reports, indicating that awareness is not related to cognition. Conflicting findings were observed, including the relation between awareness, mood, severity of disease, and personal characteristics. Conclusions The studies show lack of conceptual consensus and significant methodological differences. The inclusion of samples without differentiation of dementia etiology is associated to symptomatic differences, which affect awareness domains. Awareness in AD is a complex and multidimensional construct. Different objects elicit different levels of awareness.

Bedlam or bliss? Recognising the emotional self-experience of people with moderate to advanced dementia in residential and nursing care

Purpose

– The purpose of this paper is to examine the self-experience of people with moderate to advanced dementia. While people with dementia are widely assumed to lose their sense of self, emotions are preserved long into dementia and some can still discuss their lives, enabling exploration of respondents’ own self-conceptualisation of experience.

Design/methodology/approach

– Ten people, purposively sampled, living in long-term residential or nursing care. A mixed methods design with Interpretative Phenomenological Analysis approach used semi-structured empathetic interviews to explore their experience and continuing goals, using supplementary information from family and others to contextualise core data. Data analysis identified emerging themes and superordinate concepts.

Findings

– Sustained well-being and resistant ill-being emerged as major themes. Findings demonstrated continuity in sense of self, moral awareness and diversity of emotional reactions to living with dementia, associated with their emotional capital.

Research limitations/implications

– The sample was small and limited to well- and moderately funded care homes. How to provide such support in less-well-funded homes needs further research as do reasons for resistant ill-being in advanced dementia.

Practical implications

– Findings suggest care provision for people with advanced dementia which acknowledges individual feelings may support their sustained well-being. Psychological assessments should take closer account of multiple factors in individuals’ situations, including their emotional capital.

Social implications

– Findings suggest everyday care of people with advanced dementia, may sustain their sense of self, well-being and emotional capital.

Originality/value

– By empathically facilitating in-depth expression of individuals’ feelings and views, this research illuminates the personal self-experience of advanced dementia, hitherto little explored.

Residents Perceptions of Friendship and Positive Social Networks Within a Nursing Home

PURPOSE OF THE STUDY

(i) To describe nursing home residents' perceptions of their friendship networks using social network analysis (SNA) and (ii) to contribute to theory regarding resident friendship schema, network structure, and connections between network ties and social support.

DESIGN AND METHODS

Cross-sectional interviews, standardized assessments, and observational data were collected in three care units, including a Dementia Specific Unit (DSU), of a 94-bed Sydney nursing home. Full participation consent was obtained for 36 residents aged 63-94 years. Able residents answered open-ended questions about friendship, identified friendship ties, and completed measures of nonfamily social support.

RESULTS

Residents retained clear concepts of friendship and reported small, sparse networks. Nonparametric pairwise comparisons indicated that DSU residents reported less perceived social support (median = 7) than residents from the other units (median = 17; U = 10.0, p = .034, r = -.51), (median = 14; U = 0.0, p = .003, r = -.82). Greater perceived social support was moderately associated with higher number of reciprocated ties [ρ(25) = .49, p = .013].

IMPLICATIONS

Though some residents had friendships, many reported that nursing home social opportunities did not align with their expectations of friendship. Relationships with coresidents were associated with perceptions of social support. SNA's relational perspective elucidated network size, tie direction, and density, advancing understanding of the structure of residents' networks and flow of subjective social support through that structure. Understanding resident expectations and perceptions of their social networks is important for care providers wishing to improve quality of life in nursing homes.

How family members manage risk around functional decline: the autonomy management process in households facing dementia

Most dementia research investigates the social context of declining ability through studies of decision-making around medical treatment and end-of-life care. This study seeks to fill an important gap in research about how family members manage the risks of functional decline at home. Drawing on three waves of in-depth interviewing in 2012-2014, it investigates how family members in US households manage decline in an affected individual's natural range of daily activities over time. The findings show that early on in the study period affected individuals were perceived to have awareness of their decline and routinely drew on family members for support. Support transformed when family members detected that the individual's deficit awareness had diminished, creating a corresponding increase in risk of self-harm around everyday activities. With a loss of confidence in the individual's ability to regulate his or her own activities to avoid these risks, family members employed unilateral practices to manage the individual's autonomy around his or her activity involvements. These practices typically involved various deceits and ruses to discourage elders from engaging in activities perceived as potentially dangerous. The study concludes by discussing the implications that the social context of interpretive work around awareness and risk plays an important role in how families perceive an elder's functional ability and manage his or her activity involvements.

Effect of unawareness on rehabilitation outcome in a randomised controlled trial of multicomponent intervention for patients with mild Alzheimer's disease

Unawareness of deficit has been shown to affect the outcome of targeted cognitive intervention programmes applied to patients with Alzheimer' disease (AD), but the effects on multimodal therapeutic approaches have not yet been explored. This research investigated the efficacy of the Multi-Intervention Programme (MIP) approach on improving cognitive, functional, affective, and behavioural symptoms in people with mild AD. In addition, we examined whether the presence of unawareness influences the MIP outcomes. Sixty-one mild stage AD patients were randomly assigned to either an experimental group which carried out an MIP individually (48 sessions, 16 weeks duration), combining diverse cognitive tasks, training in daily life and recreational activities, or a waiting list group which did not receive any treatment for the same time period. The efficacy of MIP (vs. waiting list) was tested using various standardised neuropsychological, functional, and behavioural outcome measures. Planned analyses were carried out to determine the effect of unawareness versus awareness on such outcomes. The results showed that patients overall benefited from the MIP in terms of both cognitive and non-cognitive symptoms. AD patients with awareness of deficits showed positive effects on all outcome measures in comparison with the waiting list group, while AD patients with unawareness showed improvements in non-cognitive symptoms only. In conclusion, the presence of unawareness reduces the cognitive and functional effects of MIP in patients with mild AD.

The paradox of dementia: Changes in assimilation after receiving a diagnosis of dementia

This qualitative study used semi-structured interviews to explore how six people talked about their difficulties before and after a dementia diagnosis. Participants' accounts of their memory problems were analysed in terms of the verbal Markers of Assimilation of Problematic Voices Scale. This analysis indicated that after diagnosis some participants were able to integrate aspects of their illness that had previously been too painful, and which had been warded off. The process by which individuals were able to integrate a dementia diagnosis into their sense of self-involved stepping in and out of awareness, with both acceptance and denial featuring in their accounts as they approached and then retreated from addressing the diagnosis. In contrast, other participants resisted moving towards explicitly acknowledging their dementia but were instead able to express concerns about what this movement would entail, for instance voicing their fears that it would mean that they had surrendered. Social support seems to have been crucial in enabling participants to sustain a positive sense of self in the face of this adjustment.

Neurologic aspects of palliative care: the end of life setting

As there are, to date, few curative treatment options for many neurologic diseases, end of life (EOL) care is an important aspect of the treatment of neurologic patients. In the EOL phase, treatment should be aimed at relieving symptoms, maintaining quality of life, and facilitating a peaceful and dignified way of dying. Common signs and symptoms in the EOL phase of neurologic patients are raised intracranial pressure, seizures, confusion, cognitive deficits, and impaired motor function. Supportive treatment of these symptoms (such as analgesic drugs, dexamethasone, antiepileptic and neuroleptic drugs) is of major importance to maintain quality of life as long as possible. Another key aspect of EOL care is EOL decision making, such as withholding or withdrawing life-sustaining treatment, and palliative sedation. The main goal of EOL decision making is the prevention and relief of suffering, even if this might hasten death. Especially in advanced stages of many neurologic diseases, confusion, cognitive deficits, communication deficits, and decreasing levels of consciousness may impair the competence of patients to participate in EOL decision making. Given that patient autonomy is increasingly essential, advance care planning (ACP) at an early stage of the disease should be considered.

The social positioning of older people living with Alzheimer's disease who scream in long-term care homes

This article describes the social positioning of older people living with Alzheimer's disease who scream in a long-term care home. Few studies have focused on the social positions taken by older people, their family and formal caregivers during interaction and their effects on screams. A secondary data analysis was conducted using Harré and Van Langenhove's positioning theory. The results show that older people are capable of positioning and repositioning themselves in relational patterns. Family and formal caregivers position older people who scream according to their beliefs about their lived experience. They also react emotionally to older people and try to influence their behaviors. Understanding the social positioning of older people with Alzheimer's disease brought out their capacities and their caregivers' concerns for their well-being. Interventions should focus on these strengths and on promoting healthy relations in the triads to enhance quality of care in long-term care homes.

A profile of identity in early-stage dementia and a comparison with healthy older people

The aim of the study was to determine whether people in the early stages of dementia experience their sense of identity differently to healthy older people and to examine whether different aspects of identity are related to each other in each group. This was a cross-sectional questionnaire-based study; 50 people with early-stage dementia and 50 age-matched people without dementia completed measures pertaining to different aspects of identity. Measures of mood and self-esteem were also included so that any differences could be taken into account in the analysis. There were very few differences in identity between the groups. After differences in levels of anxiety were accounted for, there were no differences in scores on most measures of identity. However, people in the early stages of dementia scored significantly lower on one subtotal for one measure of identity, whereas healthy older adults reported significantly more identity-related distress than people in the early stages of dementia. For both groups, there were no associations between different aspects of identity. People in the early stages of dementia do not differ much from healthy older adults in terms of their identity. Since healthy older people experience more distress relating to identity, they may be more likely to benefit from some sort of intervention than people in the early stages of dementia. It might be useful to consider identity as consisting of multiple components in future studies, rather than assuming that one aspect of identity represents the overall experience of identity.

Neuropsychological patterns underlying anosognosia in people with cognitive impairment

AIMS

To investigate, in a group of subjects with cognitive impairment, the relationship between anosognosia, in each dimension of insight, and neuropsychological domains.

METHODS

Two hundred and seventy-one subjects affected by cognitive impairment were consecutively enrolled. Anosognosia was evaluated by means of the Clinical Insight Rating Scale (CIRS). The general level of cognitive impairment was evaluated by means of the Mini-Mental State Examination, while 8 cognitive domains were examined by means of neuropsychological tests.

RESULTS

The number of subjects with anosognosia evaluated by means of the CIRS total score as well as those with anosognosia divided according to the reason for visit was higher in moderately cognitively impaired subjects than in mildly cognitively impaired subjects (p < 0.001). A relationship between anosognosia and neuropsychological scores was only found in mild cognitive impairment, with subjects with anosognosia displaying significantly lower Raven's Colored Progressive Matrices Test and Rey Auditory Verbal Learning Test-delayed recall scores than subjects without anosognosia.

CONCLUSIONS

Our study suggests that the relationship between the severity of cognitive deficits and anosognosia in subjects with cognitive impairment is partial and depends on the specific domain of unawareness. Furthermore, in the early phase of cognitive impairment, the presence of specific cognitive deficits suggests that the nature of anosognosia is domain-specific.

The dance of communication: retaining family membership despite severe non-speech dementia

There is minimal research investigating non-speech communication as a result of living with severe dementia. This phenomenological study explores retained awareness expressed through non-speech patterns of communication in a family member living with severe dementia. Further, it describes reciprocal efforts used by all family members to engage in alternative patterns of communication. Family interactions were filmed to observe speech and non-speech relational communication. Participants were four family groups each with a family member living with non-speech communication as a result of severe dementia. Overall there were 16 participants. Data were analysed using thematic analysis. One superordinate theme, Dance of Communication, describes the interactive patterns that were observed during family communication. Two subordinate themes emerged: (a) in-step; characterised by communication that indicated harmony, spontaneity and reciprocity, and; (b) out-of-step; characterised by communication that indicated disharmony, syncopation, and vulnerability. This study highlights that retained awareness can exist at levels previously unrecognised in those living with limited or absent speech as a result of severe dementia. A recommendation for the development of a communication program for caregivers of individuals living with dementia is presented.

Are subjective cognitive complaints relevant in preclinical Alzheimer's disease? A review and guidelines for healthcare professionals

Identifying what makes people vulnerable to developing Alzheimer's disease (AD) is at the forefront of many research programmes, while early diagnosis is the goal in clinical practice. What individuals themselves tell their general practitioners (GPs) is clearly important because these subjective complaints may be a clue that something is wrong. More specifically, subjective cognitive complaints (SCC) may be the first sign of AD in individuals whose cognitive performance on standard neuropsychological tasks is normal for their age. The challenge for researchers in this field is twofold: (a) determining when SCC do or do not predict current cognitive functioning and future dementia; and (b) estimating how relevant they are for patients and their proxies. The current article addresses these issues, while guidelines are also provided in an attempt to help clinicians interpret and make treatment decisions about their patients’ SCC.

AwareCare: development and validation of an observational measure of awareness in people with severe dementia

Signs of sensory and perceptual awareness can be observed in people with very severe dementia, and may be influenced by the extent to which the environment offers appropriate stimulation. We developed an observational tool, AwareCare, which care staff can use to identify signs of awareness in residents with very severe dementia, based on the concept of the Wessex Head Injury Matrix (WHIM). Using WHIM items as a guide, and following focus groups with care staff and family members, an expert panel identified 28 environmental stimuli and 35 response categories for the initial version of AwareCare. After baseline assessments of cognition, well-being and quality of life were taken, 40 residents were observed individually for 30 minutes on 5 occasions. Based on the observational data, 10 stimulus categories and 14 response categories were identified for further analysis and formed the final version of AwareCare. All participants showed awareness to varying degrees. Social stimuli elicited the most responses. Greater awareness was associated with better cognitive function, self-care, mobility, and responsiveness, but not with proxy-rated quality of life. Understanding the nature of awareness in this group is an important element in ensuring appropriate levels of interaction and stimulation, and hence enhancing quality of care.

Neighbourhoods and dementia in the health and social care context: a realist review of the literature and implications for UK policy development

The National Dementia Strategy in England has performed an essential role in transforming health and social care services and improving the commissioning architecture. However, to date, little attention has been paid to understanding the ways in which the outdoor and built environment impacts and intersects with the lives of people with dementia and their carers. One way of better understanding the outdoor and built environment is through a focus on the ‘neighbourhood’ as this is an area of public policy where attempts are being made across disciplines to unpack its meanings, significance and identity. This paper adopts a realist review method to detail the key findings and messages from the body of work that links the experience of living with dementia to the neighbourhood. Our findings from this review are assimilated and defined/presented under three headings, namely: outdoor spaces, built environment, and everyday technologies. These headings and our definitions are not discrete properties and there is some overlap in content. We found no research that sets out to enquire about how people with dementia might define their neighbourhood or that explores everyday neighbourhood practices for those living with the condition. Emerging concepts such as citizenship and, in the UK, the Coalition Government advancement of the ‘Big Society’, promote a vision of civic responsibilities and networked, dementia-capable communities, but evaluation of such initiatives are virtually absent from the literature. The review did uncover some interesting and innovative research methods that extend neighbourhood working, such as the ‘walking interview’. In order to develop a neighbourhood model for dementia, future research should examine the relationship and interaction between the neighbourhood as a social space and as a physical space alongside the active role of people with dementia as ‘place-makers’.

Studying the self in people with dementia: How might we proceed?

The impact of dementia on the self has become the subject of much research over the last few years, mainly due to the implications for support and care for people with dementia. However, there are a number of limitations of this research that make it difficult to integrate the existing evidence and to draw any firm conclusions regarding the persistence of self. This highlights the need for a different approach to studying the self in people with dementia in order to obtain more robust evidence from future studies. This paper attempts to integrate current research using an existing systematic and comprehensive framework of the self, and outlines the advantages and limitations of using such a framework as the basis for future studies.

Sustaining citizenship: People with dementia and the phenomenon of social death

Social death is apparent when people are considered unworthy of social participation and deemed to be dead when they are alive. Some marginalized groups are more susceptible to this treatment than others, and one such group is people with dementia. Studies into discrimination towards older people are well documented and serve as a source of motivation of older people’s social movements worldwide. Concurrently, theories of ageing and care have been forthcoming in a bid to improve the quality of responses to older people in times of need. Included in this theorizing has been the analysis of values and approaches that paid carers convey to citizens who require their help. In this article, the values and approaches of social workers and mental health nurses bring to people with dementia are considered within the context of social life and social death. It is based on a small study that undertook to critically examine how participation of people with dementia was facilitated. A thanatological lens was used to interpret inclusive and exclusive practices which potentially create opportunity for participation or reinforce the loss of citizenship for older people with dementia.

Development of an awareness-based intervention to enhance quality of life in severe dementia: trial platform

Background

Quality of residential care for people with severe dementia is in urgent need of improvement. One reason for this may be the assumption that people with severe dementia are unaware of what is happening to them. However, there is converging evidence to suggest that global assumptions of unawareness are inappropriate. This trial platform study aims to assist care staff in perceiving and responding to subtle signs of awareness and thus enhance their practice.

Methods/Design

In Stage One, a measure of awareness in severe dementia will be developed. Two focus groups and an expert panel will contribute to item and scale development. In Stage Two observational data will be used to further develop the measure. Working in four care homes, we will recruit 40 individuals with severe dementia who have no, or very limited, verbal communication. Data on inter-rater reliability and frequency of all items and exploratory factor analysis will be used to identify items to be retained. Test-retest and inter-rater reliability for the new measure will be calculated. Correlations with scores for well-being and behaviour and with proxy ratings of quality of life will provide an indication of concurrent validity. In Stage Three the new measure will be used in a single blind cluster randomised trial. Eight care homes will participate, with 10 residents recruited in each giving a total sample of 80 people with severe dementia. Homes will be randomised to intervention or usual care conditions. In the intervention condition, staff will receive training in using the new measure and will undertake observations of designated residents. For residents with dementia, outcomes will be assessed in terms of change from baseline in scores for behaviour, well-being and quality of life. For care staff, outcomes will be assessed in terms of change from baseline in scores for attitudes, care practice, and well-being.

Discussion

The results will inform the design of a larger-scale trial intended to provide definitive evidence about the benefits of increasing the sensitivity of care staff to signs of awareness in residents with severe dementia.

Trial Registration

ISRCTN59507580 http://www.controlled-trials.com.