TANDEM: Communication training for informal caregivers of people with dementia

The Effectiveness and Characteristics of Communication Partner Training Programs for Families of People With Dementia: A Systematic Review

BACKGROUND AND OBJECTIVES

Communication partner training (CPT) is essential in dementia care. Despite families being the largest group of community carers, previous reviews primarily focused on formal carers. This study aimed to understand the characteristics and effectiveness of CPT for families of people with dementia.

RESEARCH DESIGN AND METHODS

The systematic review included intervention/protocol studies on dementia CPT for families, excluding formal carers and programs not focused on communication. CINAHL, PsycINFO, SpeechBITE, Medline, SCOPUS, and Embase were searched between November 30 and December 6, 2021. After deduplication, 3,172 records were screened. Quality assessment used JBI Critical Appraisal tools and the Mixed Methods Appraisal Tool. Data synthesis utilized three reporting tools, the International Classification of Functioning, Disability, and Health, and content analysis.

RESULTS

Of 30 studies (27 programs), there were 10 quasi-experimental, 5 RCTs, 4 mixed methods, 4 case studies, 4 qualitative, and 2 protocols. Studies were published between 1998 and 2021 and included 671 family members. Characteristics varied with 7/27 programs including consumers during creation and one program including telehealth. One study included all reporting tool criteria. Programs typically used 4 intervention functions, with 12/27 programs addressing 3 behavior change areas. 33/74 outcome measures targeted the "Environment" of the person with dementia. Studies showed positive improvements in communication skills and knowledge, with mixed results on behavior/psychosocial outcomes. Qualitative results identified improvements in conversation and attitudes.

DISCUSSION AND IMPLICATIONS

CPT for families improves communication outcomes, however, quality of studies varied significantly. Future research should address gaps in telehealth, consumer involvement, and intervention descriptions.

Conversation coaching in dementia: a feasibility study

PURPOSE

Conversation abilities of people with dementia are impacted by cognitive-communication deficits. Communication interventions can improve quality of life by increasing positive interactions and well-being. This study evaluates the feasibility of a conversation coaching intervention for people with dementia and their communication partners.

METHOD

A mixed-method design was used. Thirty-four people were recruited over 12 months; 17 people with dementia and 17 communication partners. Participants with dementia were aged between 62 and 79 years (8 females, 9 males) and the communication partners were aged 33-77 years (5 males, 12 females). This conversation coaching intervention involved two assessment sessions (pre and post intervention) and 6 weekly sessions, alternating between individual and group-based sessions. These were facilitated by two experienced speech and language therapists with a three-month follow-up period. Participants were assessed initially and three months following intervention using Profiling Communication Ability in Dementia (P-CAD), Goal Attainment Scaling, and Capability Index for Older people (ICECAP-O).

RESULTS

Twenty-eight participants completed the conversation coaching intervention. P-CAD scores for people with dementia were maintained at three months for 71% (n = 10) showing no decline in function and 29% (n = 4) showed improvement. Using the Goal Attainment Scaling, all people with dementia and their communication partners reported that this conversation coaching intervention helped them achieve their individual communication goals. Ten (71%) people with dementia rated their well-being as higher on the ICE-CAP-O following intervention with 29% (n = 4) rating no change in well-being from initial assessment. Over three-quarters of communication partners, (79%: n = 11), reported an increased sense of well-being following intervention and 21% (n = 3) had no change in well-being.

CONCLUSIONS

Preliminary outcomes including participant feedback indicate that this conversation coaching intervention is feasible for people with dementia. The communication function and well-being of people with dementia were either maintained or improved. Conversation coaching intervention is collaborative and enhances the retained communication abilities of people living with dementia.

Do communication interventions affect the quality-of-life of people with dementia and their families? A systematic review

OBJECTIVES

Speech, language and communication difficulties are prevalent in all dementia subtypes and are likely to considerably impact the quality-of-life of people with dementia and their families. Communication interventions provided by trained professionals are recommended for this population, but little is known about their quality-of-life outcomes. This review aims to explore the quality-of-life outcomes of communication-related interventions for people with dementia and their families.

METHODS

Seven databases were systematically searched. Reference lists from included studies and relevant systematic reviews were also hand-searched. Primary research with quantitative quality-of-life outcomes were included. Narrative analysis was utilised to identify key intervention features and to describe quality-of-life outcomes.

RESULTS

1,174 studies were identified. Twelve studies were eligible for inclusion. Studies were heterogeneous in location, participant group, methodologies, interventions and outcome measures. Four studies reported increased quality-of-life for people with dementia following intervention. No studies reported increased quality-of-life for family members.

CONCLUSION

Further research is needed in this area. The studies which reported improved quality-of-life involved multi-disciplinary approaches to intervention, involvement of family caregivers, and functional communication intervention. However, data is limited so results should be interpreted with caution. The standardised use of a communication-focused quality-of-life outcome measure would improve sensitivity and comparability of future studies.

Com-mens: a home-based logopaedic intervention program for communication problems between people with dementia and their caregivers - a single-group mixed-methods pilot study

BACKGROUND

Communication difficulties are common in people with dementia, and often present from an early stage. However, direct treatment options for people with dementia that positively influence their daily communication are scarce.

AIMS

To evaluate the potential impact and feasibility of a personalized logopaedic intervention.

METHODS & PROCEDURES

A total of 40 community-dwelling persons with dementia and their caregivers were recruited. Five experienced speech and language therapists (SLTs) delivered the six-session Com-mens intervention at home. Com-mens aims to improve positive communication between people with dementia and their primary caregivers and comprises five elements: interactive history-taking, dynamic observational assessment, education about the consequences of dementia on communication, development and use of personalized communication tools, use motivational, and person-centred strategies by the SLT. We conducted a single-group mixed-methods pilot study with five measurements: baseline, directly after intervention, and at 3, 6 and 9 months follow-up. Semi-structured interviews and questionnaires for Experienced Communication in Dementia, quality of life, psychological well-being and caregiver burden were conducted. Process evaluation was performed by interviewing participants, drop-outs, SLTs and other stakeholders.

OUTCOMES & RESULTS

A total of 32 dyads completed the intervention. Repeated measures analyses revealed no significant changes over time. In the interviews, participants reported a positive impact on their feelings, increased communication skills and better coping with the diagnosis. Participants would recommend the intervention to others. Facilitators were timely delivery, personalized content and adequate reimbursement. Barriers were unfamiliarity with Com-mens among referrers, an overburdened caregiver or disrupted family relationships.

CONCLUSIONS & IMPLICATIONS

This newly developed logopaedic intervention is feasible and has a perceived positive impact on both people with dementia and their caregivers, which is confirmed by a stable pattern over a period of 1 year. Future comparative studies are needed to test the effectiveness of personalized interventions in this patient population.

WHAT THIS PAPER ADDS

What is already known on the subject? SLTs are experts in the field of communication, but even though communication problems are common between people with dementia and their caregivers, there is a lack of logopaedic guidelines and materials for the direct treatment for this population. Interventions that are available either focus on (professional) caregivers only or aim to enhance cognitive functioning and do not target on joined communication. What this paper adds to the existing knowledge? A newly developed intervention called Com-mens can be provided by trained SLTs and takes an average of six 1-h sessions. The intervention is perceived to be valuable and feasible for people with dementia and their caregivers, by the participants themselves, as well as by healthcare professionals and other stakeholders. What are the potential or actual clinical implications of this work? Dissemination of this intervention will give SLTs skills, tools and materials to provide meaningful care to home-dwelling persons with dementia and their caregivers. Also, persons with dementia and their caregivers will receive education and materials that can help them increase their understanding of communication problems, enhance their communication skills and better cope with the communication problems that result from dementia. We consider the Com-mens intervention to be a valuable addition to the field of speech language therapy and dementia.

Project DECIDE, part II: decision-making places for people with dementia in Alzheimer's disease: supporting advance decision-making by improving person-environment fit

BACKGROUND

The UN Convention on the Rights of Persons with Disabilities, and the reformed guardianship law in Germany, require that persons with a disability, including people with dementia in Alzheimer's disease (PwAD), are supported in making self-determined decisions. This support is achieved through communication. While content-related communication is a deficit of PwAD, relational aspects of communication are a resource. Research in supported decision-making (SDM) has investigated the effectiveness of different content-related support strategies for PwAD but has only succeeded in improving understanding, which, although one criterion of capacity to consent, is not sufficient to ensure overall capacity to consent. The aim of the 'spatial intervention study' of the DECIDE project is to examine an innovative resource-oriented SDM approach that focuses on relational aspects. We hypothesise that talking to PwAD in their familiar home setting (as opposed to a clinical setting) will reduce the complexity of the decision-making process and enhance overall capacity to consent.

METHODS

People with a suspected or confirmed diagnosis of dementia in Alzheimer's disease will be recruited from two memory clinics (N = 80). We will use a randomised crossover design to investigate the intervention effect of the decision-making place on capacity to consent. Besides reasoning capacity, which is part of overall capacity to consent and will be the primary outcome, various secondary outcomes (e.g., other aspects of capacity to consent, subjective task complexity, decisional conflict) and suspected moderating or mediating variables (e.g., meaning of home, demographic characteristics) will be assessed.

DISCUSSION

The results of the study will be used to develop a new SDM strategy that is based on relational resources for PwAD. If a change in location achieves the anticipated improvement in capacity to consent, future research should focus on implementing this SDM strategy in a cost-effective manner in clinical practice.

TRIAL REGISTRATION

DRKS00030799 .

The Role of Different Aspects of Communication Behavior in the Assessment of Capacity to Consent

Abstract: Any medical treatment that interferes with physical integrity requires the informed consent of a patient capable of such consent. For people with dementia, the capacity to consent is questioned even in the early course of the disease. Particularly diagnostic instruments like the MacArthur Competence Assessment Tool for Treatment (MacCAT-T) often deny people with dementia the capacity to consent because of high confounding of the results with patients’ verbal abilities. To date, it remains unclear whether not only verbal but also nonverbal communication is associated with assessments of capacity to consent. The current study investigates associations between patients’ verbal and nonverbal communication behaviors as assessed by the measure for Communication Behavior in People with Dementia in Ambulant Settings (CODEMamb) and capacity to consent as assessed by the MacCAT-T. We expected the strongest positive associations for verbal communication behaviors compared to nonverbal communication behaviors. Data of N = 43 patients with dementia ( n = 8 capable of consent) were collected at two different German psychiatric clinics. The results show small to moderate correlations between the overall scores of CODEMamb and MacCAT-T. As expected, correlations were strongest for the verbal CODEMamb subscale. The results support current findings on the dependency of the MacCAT-T on verbal communication. Based on the findings, the discussion addresses how people with dementia can be enabled to make self-determined medical treatment decisions.

Digital tools for delivery of dementia education for caregivers of persons with dementia: A systematic review and meta-analysis of impact on caregiver distress and depressive symptoms

Continuing education for dementia has been shown to be beneficial by improving informal caregiver knowledge, dementia care, management, and caregiver physical and mental health. Technology-based dementia education has been noted to have equivalent effects as in-person education, but with the added benefit of asynchronous and/or remote delivery, which increases accessibility. Using Cochrane review methodology, this study systematically reviewed the literature on technology-based dementia education and its impacts on caregivers. Technology-based delivery included dementia education delivered via the Internet, telephone, telehealth, videophone, computer, or digital video device (DVD). In the review, twenty-eight studies were identified with fourteen included in a meta-analysis, and these data revealed a significant small effect of technologically based dementia education on reducing caregiver depression, and a medium effect on reducing caregiver distress in response to caregivers' observations of behavioral problems displayed by persons with dementia. No evidence was found for a significant effect of the educational intervention on caregiver burden or self-efficacy, which are known to be gendered aspects of caregiving. None of the studies included in the meta-analysis reported separate outcomes for male and female care providers, which has implications for gendered caregiving norms and aspects of care. Registration number: PROSPERO 2018 CRD42018092599.

Communication support needs assessment in dementia (CoSNAT-D): An international content validation study

The decline of language and communication abilities is common among people living with dementia and impacts on many areas of everyday life, including active participation in social activities and decision-making. Despite a growing body of supporting evidence for approaches that address language and communication decline in dementia, the concept of communication rehabilitation is largely neglected in this population. This paper reports on the content validation of a novel tool, the Communication Support Needs Assessment Tool for Dementia (CoSNAT-D). The tool has been developed to assist in the initial identification of communication difficulties and related support needs of people living with dementia. Importantly, the CoSNAT-D is the only available tool that takes a three-way informed approach, considering the view of the person living with dementia, their carer and an administering healthcare professional. Content validity was established between September and December 2018 using a modified Delphi approach. An international expert panel rated 32 items of a face-validated item pool regarding their importance and relevance through an iterative feedback process. Consensus was pre-determined at 70% of agreement for both importance and relevance of an item. Data were analysed using descriptive statistics and qualitative content analysis of comments provided in each round. Twenty-eight experts working in dementia, language and communication participated in the Delphi survey. Qualitative analysis resulted in the addition of five items, of which three reached the required consensus in Round 3. Consensus was established for 35/37 items in three rounds. The pilot version of the CoSNAT-D demonstrates adequate content validity and face validity. The use of the CoSNAT-D may assist a range of healthcare professionals in the decision-making process about appropriate next management steps, and thereby improve the care path for people with dementia and language and communication impairment. The establishment of further psychometric properties is warranted.

Observational assessment of communication to empower patients with dementia to make legally effective decisions - revalidation of CODEMamb

Objectives: Communication enables humans to exercise their rights. Dementia research consistently shows that communication skills decrease as the disease progresses. Nonverbal communication abilities decline more slowly than verbal skills and often become more important as the disease advances. However, resources and deficits in nonverbal and verbal communication behavior differ between persons with dementia and contexts. Knebel et al. proposed the observational assessment tool CODEM_amb that we believe to be the first standardized instrument to differentiate between content-related and relationship aspects of nonverbal communication behavior. Until now, evaluations of CODEM_amb have been exploratory and used small samples.Method: We therefore retested the psychometric criteria of CODEM_amb in persons with a suspected dementia in an ambulatory setting. Data was drawn from 326 older adults (aged 52 - 91) during routine screening in Germany.Results: Our findings support the three-factorial structure of CODEM_amb. Internal consistency of the overall scale and the three subscales of CODEM_amb was high. Correlations with CERAD-NP subscales revealed similarities to CODEM_amb, indicating sufficient convergent validity. Finally, CODEM_amb was able to differentiate between persons according to the stage of their disease.Conclusion: CODEM_amb is a theoretically based, reliable and valid observational assessment tool and its use in ambulatory settings can help foster individual, person-centered communication by identifying the resources of people with dementia, thereby empowering them in rights-exercising situations.

Communication training programmes for informal caregivers of people living with dementia: A systematic review

AIMS AND OBJECTIVES

Current research suggests that communication training programmes for caregivers of people living with dementia can benefit both parties by improving communication, quality of life and stress. Previous reviews in this area focus on mixed samples of formal and informal caregivers. This review aimed to evaluate current research for trainings specifically for informal caregivers, including the research quality and the key training components.

DESIGN AND METHODS

The review followed the PRISMA research reporting checklist. The electronic databases CINAHL, Embase, Medline and Psychinfo and reference lists of included literature were searched for studies relevant to the aims. Of the 45 identified studies, 36 were excluded based on pre-specified criteria. Nine studies were included in the final review and subject to quality appraisal using the Qualsyst tool.

RESULTS

The included studies' programmes averaged 5 to 6 hours in length over four to five sessions, were mostly face to face in both group and individual settings and were developed using various communication and psychological theories. Studies demonstrated variable quality and outcomes, making it difficult to identify optimal components. However, careful consideration of different factors enabled some suggestions for training dose, delivery method, content and outcomes to measure.

CONCLUSIONS

Communication training programmes can benefit people living with dementia and their informal caregivers in outcomes such as communication skills and quality of life. Suggestions are made on the training components that optimise these benefits.

RELEVANCE TO CLINICAL PRACTICE

Given the clear benefits on outcomes such as quality of life, there is a need for communication trainings to be offered in clinical contexts. However, given the limited pool of variable quality research and lack of accessible manuals, it is unlikely that this is the case. Consolidating and widening the evidence through further research is essential in making these trainings more widely available.

Communication skills in nursing home residents with dementia : Results of a prospective intervention study over 21 months

BACKGROUND

The dementia syndrome compromises effective communication and may thus lead to social isolation, psychological distress and decreased quality of life. It is therefore of importance to maintain communication capacity in dementia as long as possible.

MATERIAL AND METHODS

A total of 24 professional caregivers from 8 nursing homes were assigned to train 254 of their respective colleagues using the train-the-trainer program MultiTANDEMplus. As in the 6 control nursing homes, severity of dementia, depressive symptoms and communication capacity were assessed in a total of 358 residents at baseline and 21 months later. Overall, 189 residents completed the study.

RESULTS

Communication capacity declined in control home residents but remained stable in the intervention group although dementia severity increased in both groups. The intervention group exhibited significantly fewer depressive symptoms after the intervention than the control group.

CONCLUSION

A standardized training of communication skills for professional caregivers can stabilize communication capacity and reduce depressive symptoms in nursing home residents. These effects are likely sustainable and could be demonstrated 21 months postintervention.

Development and content validity of the CENEES program - psychoeducation for health staff on neuropsychology of aging

Worldwide life expectancy has increased dramatically in recent years. Also on the rise are incidents of pathologies related to aging, such as Mild Cognitive Impairment (MCI) or Alzheimer's Disease (AD). An inaccurate diagnosis impairs the well-being and the quality of life of patients and their relatives, as well as being a financial burden on the health system. Continued education pertaining to the neuropsychological field is uncommon for health workers involved in general practice. This article aims to present the process of development and content validity of the "CENEES Program - Psychoeducation for Health Staff on The Neuropsychology of Aging". The CENEES Program was developed in six steps which include: literature review, first draft, focal group, adjustments after focal group, judgment analysis (n = 4), and finally the last version. The inter-rater reliability index after judgment analysis was 0.785. The final version of the CENEES Program contains eight meetings, divided into 4 modules: 1) Fundamentals of Neuroscience; 2) Memory; 3) Executive Functions; and 4) Communication. The final meeting was called "Review". The CENEES Program is a new resource to help professionals who work within the general practice field, especially community health workers. As far as we know, there is no psychoeducation program on aging which contains the four subjects that are covered in the CENEES Program. The CENEES Program could assist the workers' daily activities and make them comfortable to offer and build actions in the community. A pilot and follow-up studies are suggested.

Development of the Experienced Communication in Dementia Questionnaire: A Qualitative Study

Communication problems with their caregivers are common in people with dementia. Although interventions for improvement of communication are being developed, a tool to measure how participants experience their communication is lacking. The objective of this article is to describe the development of a questionnaire that measures the "experienced communication" of persons with dementia (ECD-P) as well as of their caregivers (ECD-C). Interviews were conducted with five person with dementia-caregiver dyads who had recently received a new communication intervention. Reflexive thematic analysis was performed on the transcripts using ATLAS.ti. Codes were created, categories and themes were identified, and items for the questionnaires were generated. Selection of items and response scales was done in collaboration with the same dyads. The final version was established after pilot testing with seven other dyads and discussion with five experts in the field of dementia care. Analysis of the transcripts resulted in 212 codes and 17 categories within four themes: caregiver competence, social communication, communication difficulties in daily life, and experienced emotions during conversations. The final version of the ECD-P consists of part 1 with 22 items and 4-point Likert scales, and part 2 with two items and 1 to 10 scales. In the final ECD-C (proxy version), part 1 and part 2 are similar to the ECD-P, while a part 3 was added to assess caregivers' own perspective and emotions (five items). Based on the experiences of people with dementia and their caregivers, we constructed a face-valid questionnaire. This justifies future research to test its clinimetric characteristics.

Virtual reality program to develop dementia-friendly communities in Japan

OBJECTIVES

Dementia-friendly communities promote community coherence and reduce the risk of ageism in the community. This study examined the effects of a Virtual Reality (VR) educational program on participants' attitudes towards dementia and their sense of community related to supporting community-dwelling older adults.

METHODS

We delivered an educational program using a virtual reality platform that provided a first-person perspective of people with dementia in the courtyards of two convenience stores in the Tokyo Metropolitan Area, Japan. We investigated attitudes towards dementia and participants' sense of community before and after the educational program.

RESULTS

There were 42 study participants (average age = 48 years). The total scores of attitudes towards dementia and sense of community changed positively from pre- to postintervention (P = .004 and <.001, respectively).

CONCLUSION

This educational program for understanding dementia could enhance people's support of community members living with dementia.

A survey on the training needs of caregivers in five European countries

AIM

This survey explored caregivers' perceived training needs in 5 European countries (United Kingdom, Greece, Bulgaria, Poland and Italy).

BACKGROUND

Training can enhance the professional capacity of caregivers; however, caregivers' training needs within Europe have not been examined recently.

METHODS

A survey conducted in 2015 captured data from 550 caregivers using a convenience sampling strategy, through a structured questionnaire and additional open-ended items and by conducting statistical and content analysis.

RESULTS

The results indicated basic nursing skills and specialization, as well as training in psychology-related skills like time management, emotion regulation, communication and advanced health care systems as the emerging training needs. There were some country differences in specific training need areas.

CONCLUSIONS

It was concluded that training in basic nursing skills and specialization in nursing specific conditions, in advanced health care systems and in psychology-related skills could add to the professional capacity of European caregivers employed in health and social care.

IMPLICATIONS FOR NURSING MANAGEMENT

The findings inform about employed caregivers' training needs in Europe, which may contribute in the provision of quality care and organisational efficiency in health and social care.

Communication behavior of cognitively impaired older inpatients : A new setting for validating the CODEM instrument

BACKGROUND AND OBJECTIVE

Acutely ill older patients with cognitive impairment represent a major subgroup in acute care hospitals. In this context, communication plays a crucial role for patients' well-being, healthcare decisions, and medical outcomes. As validated measures are lacking, we tested the psychometric properties of an observational instrument to assess Communication Behavior in Dementia (CODEM) in the acute care hospital setting. As a novel feature, we were also able to incorporate linguistic and social-contextual measures.

MATERIAL AND METHODS

Data were drawn from a cross-sectional mixed methods study that focused on the occurrence of elderspeak during care interactions in two German acute care hospitals. A total of 43 acutely ill older patients with severe cognitive impairment (CI group, Mage ± SD = 83.6 ± 5.7 years) and 50 without cognitive impairment (CU group, Mage ± SD = 82.1 ± 6.3 years) were observed by trained research assistants during a standardized interview situation and rated afterwards by use of CODEM.

RESULTS

Factor analysis supported the expected two-factor solution for the CI group, i.e., a verbal content and a nonverbal relationship aspect. Findings of the current study indicated sound psychometric properties of the CODEM instrument including internal consistency, convergent, divergent, and criterion validity.

CONCLUSION

CODEM represents a reliable and valid tool to examine the communication behavior of older patients with CI in the acute care hospital setting. Thus, CODEM might serve as an important instrument for researcher and healthcare professionals to describe and improve communication patterns in this environment.

Practical strategies to help develop dementia-friendly hospital wards

Hospital stays can have significant negative effects for people with dementia. This article explores methods of improving dementia care in general hospital wards. Taking its starting point as the importance of person-centred care, it explores ways of improving the ward environment, meaningful activities, personal history work, involving carers, and identifying and treating delirium. Practical strategies are suggested in each of these areas. The article acknowledges that implementing change can be challenging in NHS settings where wards are understaffed, and time is precious. However, it encourages all nurses working in these settings to recognise the importance of person-centred care for people with dementia and to make even small changes that can have a significant effect.

Exploring supported conversation with familial caregivers of persons with dementia: a pilot study

Background

Dementia can lead to difficulties in communication between caregivers and patients. Teaching conversational strategies has been effective for a wide array of clients with acquired neurologic disorders and their caregivers. Research indicates positive results for Supported Conversation for adults with Aphasia (SCA) secondary to stroke. Applying this method to work with caregivers of individuals with dementia could prove to be a valid intervention tool. This investigation examined the applicability of SCA with individuals with dementia and their familial caregivers.

Method

Four dyads (caregiver and individual with dementia) participated in the SCA program with some adaptation for dementia. The program was 4 weeks with a pre-training and post training assessment. The Measure of Skill in Supported Conversation (MSC) and Measure of Level of Participation in Conversation (MPC) were given to measure the overall effectiveness of SCA at teaching and improving communication, respectively. A qualitative analysis of unproductive coping mechanisms also occurred. The Zarit Burden Interview (ZBI) was given to gauge caregiver burden from pre- to post-training.

Results

MSC and MPC scores were significantly improved from baseline to post training, and a significant reduction in unproductive coping behaviors also occured. ZBI scores were variable across participants.

Conclusions

Results suggest that the SCA has the potential to be used to improve communication between persons with dementia and their caregivers. Findings suggest that further research is warranted into the effectiveness of SCA in dementia.

Trial registration

Retrospectively registered 9/5/2018 ISRCTN17622451.

Working together to learn new oral hygiene techniques: Pilot of a carepartner-assisted intervention for persons with cognitive impairment

We pilot tested a carepartner-assisted intervention to improve oral hygiene in persons with cognitive impairment (participants) and help carepartners become leaders who can adapt approaches that foster participants' ability to develop new skills for oral hygiene care. Following the intervention, we conducted interviews with participants and carepartners to understand their challenges in working together to learn new oral hygiene skills. Participants reported challenges such as frustration using the electric toothbrush correctly, lack of desire to change, uncertainty about correctness of technique, and difficulty sustaining two minutes of toothbrushing. Carepartners reported challenges such as learning a new way of toothbrushing, learning new communication techniques, switching from instructing to working together, learning to balance leading with being too bossy, and being mindful of word choices. Findings suggested that despite challenges, participants were able to learn adaptive strategies to support new oral hygiene behaviors with support of the carepartner as the adaptive leader.

A staff training intervention to improve communication between people living with dementia and health-care professionals in hospital: the VOICE mixed-methods development and evaluation study

Background

Twenty-five per cent of hospital beds are occupied by a person living with dementia. Dementia affects expressive communication and understanding. Health-care professionals report a lack of communication skills training.

Objectives

To identify teachable, effective strategies for communication between health-care professionals and people living with dementia, and to develop and evaluate a communication skills training course.

Design

We undertook a systematic literature review, video-recorded 41 encounters between staff and people with dementia, and used conversation analysis to investigate communication problems and solutions. We designed a communication skills training course using coproduction and multiple pedagogic approaches. We ran a pilot, followed by six courses for health-care professionals. We measured knowledge, confidence and communication behaviours before, immediately after and 1 month after the course, and undertook interviews with participants and managers. Behaviours were measured using blind-rated videos of simulations.

Setting

General hospital acute geriatric medical wards and two hospital clinical skills centres.

Participants

We video-recorded 26 people with dementia and 26 professionals. Ten experts in dementia care, education, simulation and communication contributed to intervention development. Six health-care professionals took part in a pilot course, and 45 took part in the training.

Results

The literature review identified 26 studies describing 10 communication strategies, with modest evidence of effectiveness. Health-care professional-initiated encounters followed a predictable phase structure. Problems were apparent in requests (with frequent refusals) and in closings. Success was more likely when requests were made directly, with high entitlement (authority to ask) and with lowered contingencies (made to sound less difficult, by minimising the extent or duration of the task, asking patients ‘to try’, offering help or proposing collaborative action). Closings were more successful if the health-care professional announced the end of the task, made a specific arrangement, body language matched talk, and through use of ‘closing idioms’. The training course comprised 2 days, 1 month apart, using experiential learning, including lectures, video workshops, small group discussions, simulations (with specially trained actors) and reflections. We emphasised the incorporation of previous expertise and commitment to person-centred care. Forty-four participants returned for the second training day and 43 provided complete evaluation data. Knowledge and confidence both increased. Some behaviours, especially relating to closings, were more commonly used after training. The course was rated highly in interviews, especially the use of simulations, real-life video clips and interdisciplinary learning. Participants reported that they found the methods useful in practice and were using them 1 month after the course finished.

Limitations

Data were from people with moderate to severe dementia, in an acute hospital, during health-care professional-initiated interactions. Analysis was limited to problems and solutions that were likely to be ‘trainable’. Actors required careful preparation to simulate people with dementia. Communication skills training course participants were volunteers, unlikely to be representative of the general workforce, who displayed high levels of baseline knowledge, confidence and skills. Before-and-after evaluations, and qualitative interviews, are prone to bias.

Conclusions

Requests and closings pose particular difficulties for professionals communicating with people with dementia. We identified solutions to these problems and incorporated them into communication skills training, which improved knowledge, confidence and some communication behaviours. Simulation was an effective training modality.

Future work

Further research should investigate a wider range of health, social care and family carers. Conversation analysis should be used to investigate other aspects of health-care communication.

Study registration

The systematic literature review is registered as CRD42015023437.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

Communication Empowerment Framework: An integrative framework to support effective communication and interaction between carers and people living with dementia

Objectives

To demonstrate the power of integrating three theoretical perspectives (Mentalization Theory, Perceptual Control Theory and the Communicative Impact model), which jointly illuminate the communication challenges and opportunities faced by family carers of people with dementia. To point the way to how this framework informs the design and delivery of carer communication and interaction training.

Method

Conceptual synthesis based on a narrative review of relevant literature, supported by examples of family carers.

Results

We use the conceptual models to show how the capacity to mentalize (“holding mind in mind”) offers a greater sense of control over internal and external conflicts, with the result that they can be deescalated in pursuit of mutual goals.

Conclusions

The integrative conceptual framework presented here highlights specific psychological and relational mechanisms that can be targeted through carer training to enhance communication with a person living with dementia.

Working mechanisms of dyadic, psychosocial, activating interventions for people with dementia and informal caregivers: a qualitative study

Background

People living with dementia (PWD) and their informal caregivers often report difficulties in maintaining their usual activities. Several dyadic, psychosocial, activating interventions were developed to create insight into how to cope with limitations in a practical way and to increase skills for maintaining personal activities. Effects of these interventions varied so far. More knowledge on the working mechanisms of activating interventions might help to increase their impact. This study will provide more insights into the working mechanisms of three dyadic, psychosocial, activating interventions as the participating PWD, caregivers, and coaches perceived them during the interventions.

Participants and methods

We used a qualitative design with semi-structured interviews of 34 dyads that included 27 PWD, 34 caregivers, and 19 coaches. The data were analyzed with the constant comparative method.

Results

Many PWD and caregivers found capacity-building approaches beneficial. We identified “empowerment” as the core theme. Three working mechanisms explained why the interventions were perceived as having a beneficial impact: 1) enabling activities without providing false hope; 2) exploring the most important personal activity needs of the PWD and caregivers; and 3) a solution-focused approach to adapt, test, and practice activities. An individualized approach contributed to positive change.

Conclusion

For the overarching working mechanism empowerment, expertise in the field of dementia and psychological skills of coaches seem to be important. Assessing the needs, capacities, and limitations of both the PWD and the caregivers to take part in activities seems to be key, as well as the communication about it and the skills to teach a solution-focused approach. Studies on the impact of psychosocial and activating interventions might benefit from considering outcome measures directed at empowerment, along with aspects such as hope and belief in one’s own capacities versus traditional outcome measures as mood, burden, or quality of life.

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.

A pilot study to evaluate the effectiveness of an individualized and cognitive behavioural communication intervention for informal carers of people with dementia: The Talking Sense programme

BACKGROUND

People with dementia and family carers often experience difficulties communicating together. These difficulties are considered to contribute significantly to the depression, anxiety and negative feelings such as guilt often reported by dementia family carers.

AIMS

To develop and contribute to the theory and evidence base for single-component, psychosocial interventions that address these difficulties by evaluating the effectiveness of the Talking Sense programme which was designed to reflect existing best evidence.

METHODS & PROCEDURES

Talking Sense was delivered as an individualized, one to one, cognitive behavioural approach for developing knowledge, skills, thinking and behaviour of dementia family carers in managing communication difficulties. In this study, a randomized controlled trial compared 27 carers who completed three one-to-one individualized sessions using Talking Sense with 25 carers who received a single, knowledge-only, control discussion.

OUTCOMES & RESULTS

There were no significant differences for the primary outcome measure of carer anxiety and depression as well as carer quality of life and general self-efficacy. Statistically significant results suggested carers receiving the Talking Sense intervention had fewer communication difficulties happening (p = 0.046) and felt more valued by their relatives (p = 0.046). A score close to significance (p = 0.052) suggested they perceived their relatives to be more communicatively competent.

CONCLUSIONS & IMPLICATIONS

The intervention and research design were shown to be effective with low attrition and high adherence to treatment. A non-significant finding for the primary outcome measure does not support the potential for this intervention to effect carer anxiety and depression. The potential for perceived change in the person with dementia, with statistically fewer communication difficulties happening and the carer feeling more valued by their relative, was the most significant finding from this programme of research. Recommendations for further research are made.

Supporting Families Living With Dementia in Rural Areas

BACKGROUND

Family members caring for persons with dementia are subject to multiple types of stress. Psychosocial help is recommended to lighten the emotional burden of care and can be of use in stabilizing the home-care situation. In this study conducted in rural areas in Germany, we tested whether volunteers with a special qualification for the assistance of families caring for dementia patients can support family members more effectively than conventional care companions.

METHODS

In a randomized, controlled trial, 63 family members caring for persons with dementia were aided by specially qualified family companions (experimental intervention) or by conventional care companions (control intervention). The family members' quality of life was the primary endpoint and was evaluated at the end of the study in an intention-to-treat (ITT) analysis with t-tests. In an additional per-protocol (PP) analysis, differences that arose between groups at the outset of the study were accounted for. Secondary endpoints included reduced stress and better integration into the support system.

RESULTS

The ITT analysis revealed no differences between groups in healthrelated quality of life on either the emotional or the somatic scale. The PP analysis, however, showed that the experimental intervention improved the emotional health-related quality of life of the patients' family members compared to the control group. The effect strength was intermediate (d = 0.57; p = 0.047).

CONCLUSION

The difference between the findings of the PP and ITT analyses may be explained in part by the different distribution of severity of dementia in the two groups (experimental and control).

Preliminary study of a communication intervention for family caregivers and spouses with dementia

OBJECTIVE

This study was to designed to examine the feasibility and preliminary outcomes of CARE: Caring About Relationships and Emotions, a 10-week, home-based, intervention to support married couples affected by dementia.

METHODS

Fifteen older couples participated in a single group repeated measures feasibility study. Weekly, video-recorded conversations over 10 weeks were used to rate communication using the Verbal/Nonverbal Interaction Scale for caregivers and care receivers.

RESULTS

Accounting for mental status of care recipients, the ratio of social to unsocial communication showed a significant improvement across sessions-an average of 4.46 points per session [β = 4.46, t(10) = 1.96, p = .039]. Spouse caregiver (CG) communication showed a significant decrease in the number of disabling communications with approximately .65 decreased comments per session [β = 0.654, t(11) = -2.61, p = .024].

CONCLUSIONS

At home dyadic, relationship-focused psychoeducational intervention to improve communication in spouses affected by dementia has the potential to improve communication outcomes. Creative ways of working with couples are needed to help them sustain their relationships and maintain their health.

Art museum-based intervention to promote emotional well-being and improve quality of life in people with dementia: The ARTEMIS project

ARTEMIS (ART Encounters: Museum Intervention Study) is an art-based intervention designed especially for people with dementia and their care partners that involves a combination of museum visits and artistic activity. This paper reports the results of a randomized wait-list controlled study on the influence of the ARTEMIS intervention on the emotional state, well-being, and quality of life of dementia patients. People with mild-to-moderate dementia (n = 44) and their care partners (n = 44) visited the Frankfurt Städel Museum once a week on six pre-arranged occasions. The intervention consisted of six different guided art tours (60 minutes), followed by art-making in the studio (60 minutes). Independent museum visits served as a control condition. A mixed-methods design was used to assess several outcomes including cognitive status, emotional well-being, self-rated aspects of quality of life, and subjective evaluations by informal caregivers. In a pre-post-assessment, we found significant improvements in participants’ self-rated quality of life (t = −3.15, p < .05). In a situational assessment of emotional well-being immediately before and after each of the museum sessions, we were able to demonstrate statistically significant positive changes with medium effect sizes (dcorr = .74–.77). Furthermore, the total Neuropsychiatric Inventory score as well as the affective (depressed mood and anxiety) and apathy subscales were significantly lower after the ARTEMIS intervention (tNPI total = 2.43; tNPI affective = 2.24; tNPI apathy = 2.52; p < .05). The results show that art museum-based art interventions are able to improve the subjective well-being, mood, and quality of life in people with dementia. This promising psychosocial approach deserves further attention in future studies and consideration in community-based dementia care programs.

Testing the effectivity of the mixed virtual reality training Into D'mentia for informal caregivers of people with dementia: protocol for a longitudinal, quasi-experimental study

INTRODUCTION

Informal caregivers for people with dementia (hereafter: caregivers) often feel (over)burdened by the care for a loved one with dementia, and this can have various deleterious effects on both caregivers and patients. Support for caregivers is urgently needed, and for this reason, a dementia simulator (Into D'mentia) was developed in which caregivers experience what it is like to have dementia. The simulator attempts to heighten caregivers' empathy and understanding for the patient and, in turn, diminish their own caregiver burden. The current study evaluates whether the simulator is effective on a number of outcomes.

METHODS AND ANALYSIS

A longitudinal, quasi-experimental study is ongoing in the Netherlands. We aim to recruit 142 caregivers in total divided over two groups: 71 caregivers in the intervention group and 71 caregivers in the control group. All participants will complete interviews and questionnaires at four time points: at baseline, 1 week, 2.5 months and 15 months after the training. The primary outcomes include empathy, caregiver burden, caregiver's sense of competence, social reliance, anxiety, depression and caregivers' subjective and objective health.

ETHICS AND DISSEMINATION

This study is being carried out in agreement with the Declaration of Helsinki, and the protocol has been approved by the local ethics committees.

REGISTRATION DETAILS

This study is registered with The Netherlands National Trial Register (NNTR5856).

Preliminary Psychometric Properties of the Verbal and Nonverbal Interaction Scale: An Observational Measure for Communication in Persons with Dementia

Little attention has been given to sociable/unsociable communication in persons with dementia despite the importance of these behaviors in maintaining engagement in marital relationships. An observational measure of verbal and nonverbal communication in persons with dementia (Verbal and Nonverbal Interaction Scale-CR) who were engaged in conversations with spouses was tested for reliability and validity. Married persons with dementia were video-recorded at home conversing with spouses over 10 weeks (N = 118 recordings). Reliability [inter-coder (.92), test-retest (r =.61-.77), internal consistency (α =.65 -.79)] were adequate. Following an intervention, the Verbal and Nonverbal Interaction Scale-CR predicted improved communication over 10 weeks. The ratio of sociable to unsociable communication improved by 4.46 points per session [β = 4.46, t(10) = 1.96, p =.039]. VNVIS-CR is recommended to describe sociable and unsociable communication in persons with dementia as they engage in conversations with spouses.

CODEMamb - an observational communication behavior assessment tool for use in ambulatory dementia care

INTRODUCTION

Communication improves well-being and quality of life for both people with dementia and their professional and family caregivers. Individualized communication, as required in informed consent procedures and psychosocial interventions, can improve quality of life, especially in ambulatory settings. However, few valid and reliable instruments exist that enable communication to be assessed and communication and behavioral resources to be identified. We, therefore, extended and adapted the newly developed observational instrument CODEM for use in ambulatory settings (CODEM_amb).

METHODS AND RESULTS

Reliability and validity of the new instrument were studied in a total of 171 patients, whereby principal component analysis revealed three important factors: relationship aspects, verbal communication behavior and nonverbal communication behavior. CODEM_amb[Formula: see text]s internal consistency, interrater and retest reliability were satisfactory to excellent. Convergent validity indices, as shown by examining correlations with similar but not identical constructs (CERAD-NP verbal subscales), were medium-high, while the divergent validity index (constructional praxis) was relatively low. The relationship to peer-rating remained nonsignificant. Criterion validity was investigated in groups of patients in accordance with their cognitive status. As expected, verbal communication abilities deteriorate faster than the relationship aspects of communication as the disease progresses.

CONCLUSIONS

In summary, CODEM_amb is a reliable and valid instrument that can be used to collect important information with the ultimate aim of supporting communication with people with dementia.

How do activating interventions fit the personal needs, characteristics and preferences of people with dementia living in the community and their informal caregivers?

Psychosocial interventions aim to mitigate the serious consequences of dementia for the daily life of people with dementia and their informal caregivers. To deliver a person-centred approach, it is crucial to take needs, characteristics and preferences of people with dementia and their informal caregivers into account. However, these factors are generally not systematically checked in order to determine which intervention will be most appropriate. Additionally, little is known about which intervention suits which needs, characteristics and preferences. Therefore, this study examined how three multiple-component, activating dyadic interventions fitted needs, characteristics, and preferences of both the people with dementia and their informal caregivers: the Pleasant Events Program, the Exercise and Support Intervention for People with Dementia and Their Caregivers, and Occupational Therapy. Semi-structured interviews were held with participants in either one of the interventions, 34 dyads and 19 professionals. The constant comparative method was used for the analysis. Five factors influenced the dyad’s ‘fit’: timing, need for activity, lifestyle, apart-or-together and meaning of (lost) activity. The factors ‘timing’ and a ‘need for activity’ were conditional for these activating interventions. Dyads in an early stage of dementia, who were aware of the effects on daily life, were open to a change in routine, and had a need to maintain activities profited from these interventions. Three distinctive factors were important for the fit of one of the three interventions in particular: ‘lifestyle’, ‘apart or together’ and ‘meaning of (lost) activity’. The Pleasant Events Programme and the Exercise and Support intervention properly addressed the need for activities that afforded daily pastimes or structure. The Exercise and Support Intervention addressed the need for physical activity and emphasized shared activity. Occupational Therapy properly addressed the need for self-sufficiency, maintaining activities and adjustment to physical limitations. These factors can contribute to a more person-centred application of the interventions.

Pflegebedürftigkeit und Multimorbidität

Menschen, die derzeit in Pflegeheimen betreut werden, sind in der Regel hochbetagt und fortgeschritten multimorbid. Die Mehrzahl von ihnen ist an Demenz erkrankt. Daher haben sich die Hauptaufgaben der Pflegeheime in den vergangenen 25 Jahren grundlegend verändert. Gute Lebensqualität für die Betroffenen kann nur durch fachgerechte Pflegeleistungen, professionelle geriatrische und palliativmedizinische Behandlung, sowie Kompetenz aller Mitarbeiter in Kommunikation mit Menschen mit Demenz gewährleistet werden.

[Psychotherapeutic work with older patients]

Despite the high prevalence of mental illness in Germany, elderly people are significantly under-represented in psychotherapeutic treatment. This is not only due to their own reservations about psychotherapy but also to a greater extent a reflection of the models of old age in our society. Deficit-oriented theories dating back to the origins of psychotherapy in the last century are still widespread leading to fear of contact with consultants and therapists.The specific methods of psychotherapeutic work with older patients are presented. Methodologically, the treatment of elderly patients with depressive disorders has been elaborately worked out. In addition, detailed psychotherapeutic programs have also been developed for anxiety disorders, trauma-related diseases and dementia. Overall, relatively little research has been done in the field of geriatric psychotherapy despite the fact that from the scientific and clinical perspectives, different approaches or methods, such as cognitive-behavioral therapy, interpersonal therapy, psychodynamic therapy, as well as systemic therapy, can be considered effective and may be applied to the entire spectrum of mental disorders in old age.

CODEM Instrument

Communication and communication behaviors in situational contexts are essential conditions for well-being and quality of life in people with dementia. Measuring methods, however, are limited. The CODEM instrument, a standardized observational communication behavior assessment tool, was developed and evaluated on the basis of the current state of research in dementia care and social-communicative behavior. Initially, interrater reliability was examined by means of videoratings (N = 10 people with dementia). Thereupon, six caregivers in six German nursing homes observed 69 residents suffering from dementia and used CODEM to rate their communication behavior. The interrater reliability of CODEM was excellent (mean κ = .79; intraclass correlation = .91). Statistical analysis indicated that CODEM had excellent internal consistency (Cronbach’s α = .95). CODEM also showed excellent convergent validity (Pearson’s R = .88) as well as discriminant validity (Pearson’s R = .63). Confirmatory factor analysis verified the two-factor solution of verbal/content aspects and nonverbal/relationship aspects. With regard to the severity of the disease, the content and relational aspects of communication exhibited different trends. CODEM proved to be a reliable, valid, and sensitive assessment tool for examining communication behavior in the field of dementia. CODEM also provides researchers a feasible examination tool for measuring effects of psychosocial intervention studies that strive to improve communication behavior and well-being in dementia.

Matched and mismatched appraisals of the effectiveness of communication strategies by family caregivers of persons with Alzheimer's disease

BACKGROUND

Communication problems stemming from Alzheimer's disease (AD) often result in misunderstandings that can be linked with problem behaviours and increased caregiver stress. Moreover, these communication breakdowns also can result either from caregivers' use of ineffective communication strategies, which paradoxically are perceived as helpful, or can occur as a result of not using effective communication strategies that are perceived as unhelpful.

AIMS

The two primary aims were to determine the effectiveness of strategies used to resolve communication breakdowns and to examine whether caregivers' ratings of strategy effectiveness were consistent with evidence from video-recorded conversations and with effective communication strategies documented in the literature.

METHODS & PROCEDURES

Twenty-eight mealtime conversations were recorded using a sample of 15 dyads consisting of individuals with early, middle and late clinical-stage AD and their family caregivers. Conversations were analysed using the trouble-source repair paradigm to identify the communication strategies used by caregivers to resolve breakdowns. Family caregivers also rated the helpfulness of communication strategies used to resolve breakdowns. Analyses were conducted to assess the overlap or match between the use and appraisals of the helpfulness of communication strategies.

OUTCOMES & RESULTS

Matched and mismatched appraisals of communication strategies varied across stages of AD. Matched appraisals by caregivers of persons with early-stage AD were observed for 68% of 22 communication strategies, whereas caregivers of persons with middle- and late-stage AD had matched appraisals for 45% and 55% of the strategies, respectively. Moreover, caregivers of persons with early-stage AD had matched appraisals over and above making matched appraisals by chance alone, compared with caregivers of persons in middle- and late-stage AD.

CONCLUSIONS & IMPLICATIONS

Mismatches illustrate the need for communication education and training, particularly to establish empirically derived evidence-based communication strategies over the clinical course of AD.

Memory and communication support strategies in dementia: effect of a training program for informal caregivers

BACKGROUND

People with dementia have a range of needs that are met by informal caregivers. A DVD-based training program was developed using research-based strategies for memory and communication in dementia. The effectiveness of the training on the caregiver experience and the well-being of the person with dementia was evaluated.

METHODS

A pre-test/post-test controlled trial was undertaken with caregiver-care-recipient dyads living in the community. Measures of the carers' knowledge of memory and communication strategies, burden, positive perceptions of caregiving, and perceptions of problem behaviors were taken pre- and three months post-intervention. The depression and well-being of the person with dementia were also evaluated. Satisfaction with the training and feedback were measured.

RESULTS

Twenty-nine dyads (13 training group, 16 control group) participated. Bonferroni's correction was made to adjust for multiple comparisons, setting α at 0.00385. A significant improvement was found in caregivers' knowledge for the training group compared to the control group (p = 0.0011). The training group caregivers reported a reduction in the frequency of care recipient disruptive behaviors (p = 0.028) and increased perceptions of positive aspects of caregiving (p = 0.039), both at a level approaching significance. The training group care recipients had increased frequency of verbally communicated depressive behaviors at a level approaching significance (p = 0.0126). The frequency of observed depressive behaviors was not significantly different between groups.

CONCLUSIONS

This approach to training for caregivers of people with dementia appears promising for its impact on knowledge and the caregiving experience. Further research could monitor the impact of the training on broader measures of depression and well-being, with a larger sample.