Feasibility and potential effects of interdisciplinary home-based reablement program (I-HARP) for people with cognitive and functional decline: a pilot trial

What works to support carers of older people and older carers? an international evidence map of interventions and outcomes

BACKGROUND

Unpaid carers of older people, and older unpaid carers, experience a range of adverse outcomes. Supporting carers should therefore be a public health priority. Our understanding of what works to support carers could be enhanced if future evaluations prioritise under-researched interventions and outcomes. To support this, we aimed to: map evidence about interventions to support carers, and the outcomes evaluated; and identify key gaps in current evidence.

METHODS

Evidence gap map review methods were used. Searches were carried out in three bibliographic databases for quantitative evaluations of carer interventions published in OECD high-income countries between 2013 and 2023. Interventions were eligible if they supported older carers (50 + years) of any aged recipient, or any aged carers of older people (50 + years).

FINDINGS

205 studies reported across 208 publications were included in the evidence map. The majority evaluated the impact of therapeutic and educational interventions on carer burden and carers' mental health. Some studies reported evidence about physical exercise interventions and befriending and peer support for carers, but these considered a limited range of outcomes. Few studies evaluated interventions that focused on delivering financial information and advice, pain management, and physical skills training for carers. Evaluations rarely considered the impact of interventions on carers' physical health, quality of life, and social and financial wellbeing. Very few studies considered whether interventions delivered equitable outcomes.

CONCLUSION

Evidence on what works best to support carers is extensive but limited in scope. A disproportionate focus on mental health and burden outcomes neglects other important areas where carers may need support. Given the impact of caring on carers' physical health, financial and social wellbeing, future research could evaluate interventions that aim to support these outcomes. Appraisal of whether interventions deliver equitable outcomes across diverse carer populations is critical.

Cognitive rehabilitation for people with mild to moderate dementia

BACKGROUND

Cognitive impairments affect functional ability in people with dementia. Cognitive rehabilitation (CR) is a personalised, solution-focused approach that aims to enable people with mild-to-moderate dementia to manage everyday activities and maintain as much independence as possible.

OBJECTIVES

To evaluate the effects of CR on everyday functioning and other outcomes for people with mild-to-moderate dementia, and on outcomes for care partners. To identify and explore factors that may be associated with the efficacy of CR.

SEARCH METHODS

We searched the Cochrane Dementia and Cognitive Improvement Group Specialised Register, which contains records from MEDLINE, EMBASE, CINAHL, PsycINFO, LILACS, and other clinical trial databases, and grey literature sources. The most recent search was completed on 19 October 2022.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) comparing CR with control conditions and reporting relevant outcomes for the person with dementia and/or the care partner.

DATA COLLECTION AND ANALYSIS

We extracted relevant data from published manuscripts and contacted trial authors if necessary. Within each of the comparisons, we pooled data for each outcome of interest and conducted inverse-variance, random-effects meta-analyses. We evaluated the certainty of the evidence using GRADEpro GDT.

MAIN RESULTS

We identified six eligible RCTs published in English between 2010 and 2022, which together included 1702 participants. The mean age of participants ranged from 76 to 80 and the proportion of male participants was between 29.4% and 79.3%. Most participants, in the studies where the type of dementia was reported, had a diagnosis of Alzheimer's disease (AD; n = 1002, 58.9% of the whole sample, 81.2% of the participants for whom the specific diagnosis was reported). Risk of bias in the individual studies was relatively low. The exception was a high risk of bias in relation to blinding of participants and practitioners, which is not usually feasible with psychosocial interventions.  Our primary outcome of everyday functioning was operationalised in the included studies as goal attainment in relation to activities targeted in the intervention. For our main comparison of CR with usual care, we pooled data for goal attainment evaluated from three perspectives (self-rating of performance, informant rating of performance, and self-rating of satisfaction with performance) at end of treatment and at medium-term follow-up (3 to 12 months). We could also pool data at these time points for 20 and 19 secondary outcomes respectively. The review findings were strongly driven by one large, high-quality RCT.  We found high-certainty evidence of large positive effects of CR on all three primary outcome perspectives at the end of treatment: participant self-ratings of goal attainment (standardised mean difference (SMD) 1.46, 95% confidence interval (CI) 1.26 to 1.66; I2 = 0%; 3 RCTs, 501 participants), informant ratings of goal attainment (SMD 1.61, 95% CI 1.01 to 2.21; I2 = 41%; 3 RCTs, 476 participants), and self-ratings of satisfaction with goal attainment (SMD 1.31, 95% CI 1.09 to 1.54; I2 = 5%; 3 RCTs, 501 participants), relative to an inactive control condition. At medium-term follow-up, we found high-certainty evidence showing a large positive effect of CR on all three primary outcome perspectives: participant self-ratings of goal attainment (SMD 1.46, 95% CI 1.25 to 1.68; I2 = 0%; 2 RCTs, 432 participants), informant ratings of goal attainment (SMD 1.25, 95% CI 0.78 to 1.72; I2 = 29%; 3 RCTs, 446 participants), and self-ratings of satisfaction with goal attainment (SMD 1.19, 95% CI 0.73 to 1.66; I2 = 28%; 2 RCTs, 432 participants), relative to an inactive control condition. For participants at the end of treatment we found high-certainty evidence showing a small positive effect of CR on self-efficacy (2 RCTs, 456 participants) and immediate recall (2 RCTs, 459 participants). For participants at medium-term follow-up we found moderate-certainty evidence showing a small positive effect of CR on auditory selective attention (2 RCTs, 386 participants), and a small negative effect on general functional ability (3 RCTs, 673 participants), and we found low-certainty evidence showing a small positive effect on sustained attention (2 RCTs, 413 participants), and a small negative effect on memory (2 RCTs, 51 participants) and anxiety (3 RCTs, 455 participants).  We found moderate- and low-certainty evidence indicating that at the end of treatment CR had negligible effects on participant anxiety, quality of life, sustained attention, memory, delayed recall, and general functional ability, and at medium-term follow-up on participant self-efficacy, depression, quality of life, immediate recall, and verbal fluency. For care partners at the end of treatment we found low-certainty evidence showing a small positive effect on environmental aspects of quality of life (3 RCTs, 465 care partners), and small negative effects of CR on level of depression (2 RCTs, 32 care partners) and on psychological wellbeing (2 RCTs, 388 care partners).  For care partners at medium-term follow-up we found high-certainty evidence showing a small positive effect of CR on social aspects of quality of life (3 RCTs, 436 care partners) and moderate-certainty evidence showing a small positive effect on psychological aspects of quality of life (3 RCTs, 437 care partners). We found moderate- and low-certainty evidence at the end of treatment that CR had negligible effects on care partners' physical health, psychological and social aspects of quality of life, and stress, and at medium-term follow-up for the physical health aspect of care partners' quality of life and psychological wellbeing.

AUTHORS' CONCLUSIONS

CR is helpful in enabling people with mild or moderate dementia to improve their ability to manage the everyday activities targeted in the intervention. Confidence in these findings could be strengthened if more high-quality studies contributed to the observed effects. The available evidence suggests that CR can form a valuable part of a clinical toolkit to assist people with dementia in overcoming some of the everyday barriers imposed by cognitive and functional difficulties. Future research, including process evaluation studies, could help identify avenues to maximise CR effects and achieve wider impacts on functional ability and wellbeing.

Publication Trends in Reablement - A Scoping Review

Background

Reablement is a holistic and multidisciplinary intervention that can facilitate achievement of service users' goals related to their independence in everyday activities. Reablement has been the subject of increasing scientific activity in recent years. Currently, no review has provided a broad overview of the extent and breadth of international publications in reablement.

Objective

The objectives were 1) to map the volume of reablement publications, how the publications had increased over time, and their geographical distribution, 2) to identify the publication types and designs, 3) to identify publication trends, and 4) to identify knowledge gaps in the current peer-reviewed literature.

Methods

The scoping review approach designed by Arksey and O'Malley was used to identify peer-reviewed articles on reablement. Information was obtained on scientific activity on reablement over a period of more than two decades from five electronic databases and without language restrictions. Data was extracted from the eligible articles and both descriptive analysis and thematic analysis of the data was performed.

Results

A total of 198 articles published from 1999 to August 2022 from 14 countries were identified. There is a continuous interest in the field from countries where reablement has been implemented. An international and historical overview among countries with peer-reviewed publications on reablement is presented, which also partly reflects the countries that have implemented reablement. Most of the research derives from Western countries, in particular from Norway. Varied approaches to publications in reablement were noted with the majority being empirical and quantitative in nature.

Conclusion

The scoping review confirms the continued expansion of the breadth of reablement-focused publications in terms of originating countries, target populations, and research designs. In addition, the scoping review contributes to the knowledge base regarding reablement's research front.

iCare4Me for FTD: A pilot randomized study to improve self-care in caregivers of persons with frontotemporal degeneration

Introduction

A tremendous burden is placed on frontotemporal degeneration (FTD) caregivers who sacrifice their own self-care to manage the functional impairments of their loved one, contributing to high levels of stress and depression. Health coaching provides support for coping with stress while fostering self-care behaviors. We report on preliminary evidence for efficacy of a virtual health coach intervention aimed at increasing self-care.

Methods

Thirty-one caregivers of persons with behavioral variant FTD (bvFTD) were assigned randomly to an intervention group, which included 10 coaching sessions over 6 months plus targeted health information or the control group receiving standard care augmented with the health information. Caregiver self-care (primary outcome), stress, depression, coping, and patient behavioral symptoms were collected at enrollment and 3 and 6 months. Change over time was evaluated between the intervention and control groups using linear mixed-effects models.

Results

There was a significant group-by-time interaction for self-care monitoring (t58 = 2.37, p = 0.02 and self-care confidence (t58 = 2.32, p = 0.02) on the Self-Care Inventory, demonstrating that caregivers who received the intervention improved their self-care over time. Behavioral symptoms were reduced in bvFTD patients whose caregivers received the intervention (t54 = -2.15, p = 0.03).

Discussion

This randomized controlled trial (RCT) shows promise for health coaching as a way to increase support that is urgently needed to reduce poor outcomes in FTD caregivers.

Barriers and facilitating factors influencing implementation of occupational therapy home assessment recommendations: A mixed methods systematic review

INTRODUCTION

Low implementation rates of occupational therapy home assessment recommendations have previously been reported. The objective was to identify and describe the barriers and facilitating factors that influence implementation of home assessment recommendations.

METHODS

A mixed methods systematic review consisting of studies involving adults living in the community who received an occupational therapy home assessment was conducted. Seven databases were last searched in August 2021. Study quality was assessed using the Joanna Briggs Institute (JBI) critical appraisal tools (SUMARI) dependent on study design. Data synthesis followed the convergent integrated approach. Findings were mapped to the theoretical Capability Opportunity Motivation Behaviour (COM-B) model of health behaviour change.

RESULTS

From 5,540 citations, 22 articles met the criteria for the systematic review. Implementation of occupational therapy home assessment recommendations ranged between 55% and 90%. Six synthesised findings were identified. Capability barriers included a patient's cognitive and physical ability. Motivation barriers included a perceived lack of need and stigma; patient reported decreased involvement and lack of choice. Opportunity barriers included limited family or carer involvement, carer stress, level of service provision available, including funding, therapy dosage and timing and environmental restrictions. Overall facilitators included patient-centred care, including choice and understanding need, individualised tailored recommendations, involvement of families and carers, provision of written record and strategies to support implementation. Results were limited by methodological weaknesses in identified studies and heterogeneity in the definition and measurement of implementation impacting on comparison. Specific intervention components were often poorly described.

CONCLUSION

The theoretical model elucidates priority factors to address for promoting implementation of home assessment recommendations. Future high-quality research clearly defining intervention components is required to support short- and long-term implementation of recommendations in the home environment. Behaviour change techniques could be utilised to support home assessment practices in future research.

Exploring the experience of reablement: A systematic review and qualitative evidence synthesis of older people's and carers' views

Concerns from the worldwide ageing population and evidence of poor-quality aged care services have highlighted the need to develop innovative models of aged care which are acceptable to older people, economically sustainable and are safe. Reablement is a relatively new model for aged care that aims to support older people's desires to age independently in their usual place of residence and decrease dependency on aged care services. This qualitative evidence synthesis aimed to explore the experiences of older people and their carers (formal and informal) towards a reablement model of community aged care to ensure services are considerate of older people's needs. A systematic search was conducted across six electronic databases (Medline, Scopus, CINAHL, PsycINFO, Cochrane Library and Google Scholar) from 1990 to September 2021. Qualitative research exploring older people and their carers' experiences and perceptions of the reablement model used in community aged care services were identified. Nineteen articles were included in the synthesis following the screening of 668 abstracts and 56 full texts. Included articles were subject to quality assessment, and the data were synthesised using thematic synthesis. Three analytical themes were generated from the thematic synthesis; (i) reablement is a shift in approach to aged care, (ii) difficulties in developing tangible and meaningful reablement goals, (iii) reablement improves health and well-being. Reablement is generally well-received by older people and their informal carers. However, poor engagement from older people did occur when they had a poor understanding of their role in reablement and when they had not been fully consulted regarding their reablement goals. Current and future reablement services for older people should focus on ensuring an awareness of the processes and principles of reablement and collaboration between practitioner, the older person and their carer when developing goals to increase engagement.

Occupational therapy interventions for adult informal carers and implications for intervention design, delivery and evaluation: A systematic review

Introduction

Informal carers provide vital support for patients, reducing strain on health and social care services. However, caring can detrimentally affect carers’ health and wellbeing, thus policy advocates for improved carer support. Objective: to establish the published international evidence base regarding interventions for carers delivered by occupational therapists.

Method

English language studies published January 2010–January 2021 were identified against predetermined inclusion/exclusion criteria via searches of MEDLINE, EMBASE, CINAHL, PsychINFO, OTSeeker, Scopus, Web of Science and the Cochrane Library. Supplemental strategies: database alerts, hand-searching, searching of included papers’ reference lists and citations, and contacting key authors. Two reviewers completed critical appraisal and produced a textual narrative synthesis of data using a convergent integrated method.

Results

38 papers were included, reporting 21 interventions. Most were dyadic, home-based interventions for carers of people living with dementia. Common intervention components included: assessment and goal-setting, skill training, education, coping strategies, equipment provision, environmental adaptation and signposting. Interventions improved outcomes for carers, however, intervention design and evaluation require careful consideration to maximise carer benefits and capture intervention effects.

Conclusion

Occupational therapist delivered carer interventions enhance support and improve carer outcomes. Intervention and evaluation designs should include careful selection of outcome measures, avoidance of increased carer burden in dyadic interventions and acknowledgement of known barriers and facilitators to both carer and therapist intervention engagement.

Implementing the Dementia Early Stage Cognitive Aids New Trial (DESCANT) intervention: mixed-method process evaluation alongside a pragmatic randomised trial

OBJECTIVES

The DESCANT (Dementia Early Stage Cognitive Aids New Trial) intervention provided a personalised care package designed to improve the cognitive abilities, function and well-being of people with early-stage dementia and their carers, by providing a range of memory aids, together with appropriate training and support. This sub-study aimed to assess implementation and identify contextual factors potentially associated with participant outcomes.

METHOD

A mixed-methods approach was adopted alongside the pragmatic randomised trial. Data were obtained from intervention records and interviews with five dementia support practitioners across seven National Health Service Trusts in England and Wales. A reporting framework was constructed from available literature and data assessed by descriptive statistics and thematic analysis.

RESULTS

Participation and engagement was high with 126 out of 128 participants completing the intervention with packages tailored to individual participants. Misplacing items and poor orientation to date and time were common areas of need. Memory aids frequently supplied included orientation clocks (91%), whiteboards (60%), calendars (43%) and notebooks (32%), plus bespoke items. Intervention duration and timing were broadly consistent with expectations. Variation reflected participants' needs, circumstances and preferences. Qualitative findings suggested a potentially positive impact on the well-being of people with dementia and their carers. Issues associated with successful roll-out of the intervention are explored in the discussion.

CONCLUSION

Successful implementation increased confidence in future findings of the randomised trial. Depending on these, DESCANT may prove a scalable intervention with potential to improve the function and quality of life of people with dementia and their carers.

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

OBJECTIVES

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

DESIGN

Systematic review with meta-analysis.

DATA SOURCES

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

ELIGIBILITY CRITERIA

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

DATA EXTRACTION AND SYNTHESIS

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

RESULTS

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

CONCLUSIONS

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

PROSPERO REGISTRATION NUMBER

CRD42020168556.

Home/community-based interventions to improve function in persons with mild cognitive impairment/early dementia

Persons with mild cognitive impairment/early dementia have a possible 20-year trajectory of disability and dependence with little information on the effectiveness of interventions to improve function. This review investigates the literature of home/community-based interventions for physical and executive function in persons with mild cognitive impairment/early dementia. A 2007-2020 systematic literature search was conducted through PubMed, CINAHL Plus with Full Text and PsycINFO. Of the 1749 articles retrieved, 18 eligible studies were identified and consisted of three types of interventions: cognitive training-only (n = 7), multicomponent (n = 9), and physical activity-only (n = 2). Results showed that the interventions impacting function in persons with cognitive impairment incorporated a visual/written element, technology-based training, caregiver support, and modified duration/increased frequency of interventions. In studies improving function, participants simulated Instrumental Activities of Daily Living. They addressed cognitive function using both objective and subjective cognitive measures. We found gaps in the literature in incorporating race/ethnicity and appropriate socioeconomic status measures.

Integration of Physical Activity in Reablement for Community Dwelling Older Adults: A Systematic Scoping Review

Background

Reablement is a rehabilitative intervention provided to homecare receivers with the aim of improving function and independence. There is limited evidence of the effectiveness of reablement, and the content of these interventions is variable. Physical activity (PA) is known to be important for improving and maintaining function among older adults, but it is unclear how PA is integrated in reablement.

Purpose

To map existing evidence of how PA strategies are integrated and explored in studies of reablement for community dwelling older adults and to identify knowledge gaps.

Methods

An a priori protocol was published. Studies of time-limited, interdisciplinary reablement for community-dwelling older adults were considered for inclusion. Eight databases were searched for studies published between 1996 and June 2020, in addition to reference and citation searches. Study selection and data extraction were made independently by two reviewers.

Results

Fifty-one studies were included. Exercise strategies and practice of daily activities were included in the majority of intervention studies, but, in most cases, little information was provided about the intensity of PA. Interventions aiming to increase general PA levels or reduce sedentary behavior were rarely described. None of the studies explored older adults’, healthcare providers’ or family members’ experiences with PA in a reablement setting, but some of the studies touched upon themes related to PA experiences. Some studies reported outcomes of physical fitness, including mobility, strength, and balance, but there was insufficient evidence for any synthesis of these results. None of the studies reported PA levels among older adults receiving reablement.

Conclusion

There is limited evidence of how PA is integrated and targeted to older adults’ individual needs and preferences in a reablement setting. The feasibility and effectiveness of PA interventions, as well as experiences or barriers related to PA in a reablement setting, should be further investigated.

A pragmatic randomised controlled trial (RCT) and realist evaluation of the interdisciplinary home-bAsed Reablement program (I-HARP) for improving functional independence of community dwelling older people with dementia: an effectiveness-implementation hybrid design

BACKGROUND

A major gap exists internationally in providing support to maintain functional and social independence of older people with dementia living at home. This project evaluates a model of care that integrates evidence-based strategies into a person-centred interdisciplinary rehabilitation package: Interdisciplinary Home-bAsed Reablement Program (I-HARP). Two central aims are: 1) to determine the effectiveness of I-HARP on functional independence, mobility, quality of life and depression among people with dementia, their home environmental safety, carer burden and quality of life, and I-HARP cost-effectiveness; and 2) to evaluate the processes, outcomes and influencing factors of the I-HARP implementation.

METHODS

I-HARP is a 4-month model of care, integrated in community aged care services and hospital-based community geriatric services, and consists of: 1) 8-12 home visits, tailored to the individual client's needs, by an occupational therapist, registered nurse, and other allied health staff; 2) minor home modifications/assistive devices to the value of  60 years with mild to moderate dementia and his/her carer). During Phase I, I-HARP advisory group is established and training of I-HARP interventionists is completed, and the effectiveness of I-HARP is examined using a pragmatic RCT. Phase II, conducted concurrently with Phase I, focuses on the process evaluation of the I-HARP implementation using a realist approach. Semi-structured interviews with participants and focus groups with I-HARP interventionists and participating site managers will provide insights into the contexts, mechanisms and outcomes of I-HARP.

DISCUSSION

I-HARP is being evaluated within the real-world systems of hospital-based and community-based aged care services in Australia. Future directions and strategies for reablement approaches to care for community dwelling people living with dementia, will be developed. The study will provide evidence to inform key stakeholders in their decision making and the use/delivery of the program, as well as influence future systems-thinking and changes for dementia care.

TRIAL REGISTRATION

Australian New Zealand Clinical Trial Registry ACTR N12618000600246 (approved 18/04/2018).