Dissemination and Implementation of Evidence-Based Dementia Care Using Embedded Pragmatic Trials

Factors influencing the commissioning and implementation of health and social care interventions for people with dementia: commissioner and stakeholder perspectives

BACKGROUND

Despite several interventions demonstrating benefit to people living with dementia and their caregivers, few have been translated and implemented in routine clinical practice. There is limited evidence of the barriers and facilitators for commissioning and implementing health and social care interventions for people living with dementia. The aim of the current study was to explore the barriers and facilitators to commissioning and implementing health and social care interventions for people with dementia, using a dementia friendly exercise and physical activity-based intervention (PrAISED [Promoting Activity, Stability and Independence in Early Dementia and Mild Cognitive Impairment]) as a case study.

METHODS

Qualitative semi-structured interviews were conducted with stakeholders from a range of backgrounds including individuals from health and social care, local government, the voluntary and community sector, universities, and research centres in England. The Consolidated Framework for Intervention Research (CFIR) was used to guide the design and analysis.

RESULTS

Fourteen participants took part, including commissioning managers, service managers, partnership managers, charity representatives, commercial research specialists, academics/researchers, and healthcare professionals. Data were represented in 33 constructs across the five CFIR domains. Participants identified a need for greater support for people diagnosed with dementia and their caregivers immediately post dementia diagnosis. Key barriers included cost/financing, the culture of commissioning, and available resources. Key facilitators included the adaptability of the intervention, cosmopolitanism/partnerships and connections, external policy and incentives, and the use of already existing (and untapped) workforces.

CONCLUSION

Several barriers and facilitators for commissioning and implementing health and social care interventions for people with dementia were identified which need to be addressed. Recommended actions to facilitate the commissioning and implementation of dementia friendly services are: 1) map out local needs, 2) evidence the intervention including effectiveness and cost-effectiveness, 3) create/utilise networks with stakeholders, and 4) plan required resources.

Staff Perspectives on Dementia Care in Nursing Homes: A Pre-Implementation, Content Analysis Study Guided by the Practical, Robust Implementation and Sustainability Model

PURPOSE

To assess implementation context prior to the implementation of Dementia Collaborative Coaching (DCC), a person-centered, communication coaching intervention for speech-language pathologists, certified nursing assistants, and people living with dementia in nursing homes.

METHODS

This was a pre-implementation, content analysis of focus groups. Focus group questions and subsequent analysis were guided by the Practical, Robust Implementation and Sustainability Model.

RESULTS

Employees (N = 27) from three nursing homes participated in five focus groups. Five themes from directed content analysis included (a) Dementia Care Needs Improvement; (b) Dementia Collaborative Coaching Appears Promising; (c) Awareness of Necessary Implementation and Sustainability Plans; (d) Regulations Need Accurate Interpretation and Local Dissemination; and (e) Appropriate Staffing Concerns.

CONCLUSION/IMPLICATIONS

Key factors related to the implementation of DCC included a perceived tension for change from staff to improve dementia care, concerns about appropriate staffing, and the need for explicit implementation and sustainability plans. The importance of continuing education with specific attention to temporary staff was also found to be a necessary element to support better uptake of the person-centered intervention. [Journal of Gerontological Nursing, 50(2), 5-9.].

Preparing for pragmatic trials in dementia care: Health equity considerations for nonpharmacological interventions

Inequities with regard to brain health, economic costs, and the evidence base for dementia care continue. Achieving health equity in dementia care requires rigorous efforts that ensure disproportionately affected populations participate fully in-and benefit from-clinical research. Embedding-proven interventions under real-world conditions and within existing healthcare systems have the potential to examine the effectiveness of an intervention, improve dementia care, and leverage the use of existing resources. Developing embedded pragmatic controlled trials (ePCT) research designs for nonpharmacological dementia care interventions involves a plethora of a priori assumptions and decisions. Although frameworks exist to determine whether interventions are "ready" for ePCT, there is no heuristic to assess health equity-readiness. We discuss health equity considerations, case examples, and research strategies across ePCT study domains of evidence, risk, and alignment. Future discussions regarding health equity considerations across other domains are needed.

The Case for Conducting Pragmatic Dementia Care Trials in Medicaid Home and Community-Based Service Settings

Medicaid-funded home and community-based services (HCBSs) reach large numbers of individuals living with dementia who would otherwise reside in nursing homes with Medicaid funding. Medicaid HCBSs also often augment care provided by family and other informal caregivers to individuals living with dementia. Although Medicaid-funded HCBSs are offered in most states in lieu of nursing home care, they have been largely overlooked as health care system partners for implementation and testing of evidence-based dementia care interventions using embedded pragmatic clinical trial (ePCT) designs. In this article, we make the case for the importance of Medicaid-funded HCBSs as dementia care ePCT partners because of the volume of vulnerable clients with dementia served and the potential positive impacts that evidence-based dementia care programs can have on clients and their informal caregivers. This article first characterizes the Medicaid HCBS setting in terms of populations served and organizational arrangements across states. We then characterize strengths and potential limitations presented by Medicaid HCBSs as settings within which to implement dementia care ePCTs, using as a conceptual framework the Pragmatic-Explanatory Continuum Indicator Summary (PRECIS-2) tool and its domains. We draw on our experiences implementing the Care of Persons with Dementia in their Environments (COPE) program in a statewide Medicaid HCBS setting to highlight how these potential ePCT partners can help optimize pragmatic approaches to several PRECIS-2 domains. We found that partners are especially effective in implementing pragmatic ways to determine eligibility for evidence-based dementia care programs; assist with recruitment of eligible individuals; incorporate dementia care interventions into the range of existing HCBSs; and track outcomes relevant to persons living with dementia, caregivers, HCBS providers, and Medicaid insurance stakeholders. We conclude with recommendations for researchers, potential ePCT partners, and policymakers to help facilitate the growth of dementia care ePCTs in Medicaid HCBS settings across the United States.

What interventions keep older people out of nursing homes? A systematic review and meta-analysis

BACKGROUND

Nursing home admission remains a central outcome in many healthcare systems and community-based programs. The objective of this meta-analysis was to determine the efficacy of pharmacological and nonpharmacological interventions in preventing nursing home admission for adults aged 65 years or older.

METHODS

MEDLINE, EMBASE, PsycInfo, CINAHL, and the Cochrane Library were all last searched in March 2022 to identify up-to-date eligible studies for the meta-analysis. Two reviewers screened each abstract independently. In instances where reviewers disagreed as to inclusion, all reviewers convened to review the Abstract to come to a consensus decision regarding inclusion. Two reviewers independently collected data from each report. Disagreements were resolved using group consensus. The first author reviewed the narrative descriptions of intervention components to create a categorization scheme for the various interventions evaluated in selected studies. These categorizations were reviewed with the co-authors (second-fifth) and collapsed to create the final classification of intervention type. Study risk of bias was assessed using an instrument developed based on Agency for Healthcare Research & Quality (AHRQ) guidance. Differences between the percentages of participants in treatment versus control arms was the outcome of interest.

RESULTS

Two-hundred and eighty-three studies with a total of 203,735 older persons were included in the meta-analysis. Specialty geriatrics care (OR = 0.77, 95% CI, 0.60-0.99), multicomponent interventions (OR = 0.82, 95% CI, 0.67-0.99), and cognitive stimulation (OR = 0.60, 95% CI, 0.38-0.96) were associated with less frequent nursing home admission. Home-based and inpatient/discharge management interventions approached statistical significance but were not associated with reduced institutionalization.

CONCLUSIONS

Even in the face of complex care needs, older adults wish to live at home. Effectively disseminating and implementing geriatric care principles across healthcare encounters could achieve a highly valued and preferred outcome in older adulthood: aging in place.

Cost effectiveness of non-drug interventions that reduce nursing home admissions for people living with dementia

INTRODUCTION

Six million Americans live with Alzheimer's disease and Alzheimer's disease and related dementias (AD/ADRD), a major health-care cost driver. We evaluated the cost effectiveness of non-pharmacologic interventions that reduce nursing home admissions for people living with AD/ADRD.

METHODS

We used a person-level microsimulation to model the hazard ratios (HR) on nursing home admission for four evidence-based interventions compared to usual care: Maximizing Independence at Home (MIND), NYU Caregiver (NYU); Alzheimer's and Dementia Care (ADC); and Adult Day Service Plus (ADS Plus). We evaluated societal costs, quality-adjusted life years and incremental cost-effectiveness ratios.

RESULTS

All four interventions cost less and are more effective (i.e., cost savings) than usual care from a societal perspective. Results did not materially change in 1-way, 2-way, structural, and probabilistic sensitivity analyses.

CONCLUSION

Dementia-care interventions that reduce nursing home admissions save societal costs compared to usual care. Policies should incentivize providers and health systems to implement non-pharmacologic interventions.

Remote Technologies to Enhance Service Delivery for Adults: Clinical Research Perspectives

There are many examples of remote technologies that are clinically effective and provide numerous benefits to adults with hearing loss. Despite this, the uptake of remote technologies for hearing healthcare has been both low and slow until the onset of the COVID-19 pandemic, which has been a key driver for change globally. The time is now right to take advantage of the many benefits that remote technologies offer, through clinical, consumer, or hybrid services and channels. These include greater access and choice, better interactivity and engagement, and tailoring of technologies to individual needs, leading to clients who are better informed, enabled, and empowered to self-manage their hearing loss. This article provides an overview of the clinical research evidence-base across a range of remote technologies along the hearing health journey. This includes qualitative, as well as quantitative, methods to ensure the end-users' voice is at the core of the research, thereby promoting person-centered principles. Most of these remote technologies are available and some are already in use, albeit not widespread. Finally, whenever new technologies or processes are implemented into services, be they clinical, hybrid, or consumer, careful consideration needs to be given to the required behavior change of the key people (e.g., clients and service providers) to facilitate and optimize implementation.

Simultaneously Developing Interventions for Low-/Middle-Income and High-Income Settings: Considerations and Opportunities

Most older adults reside in low- and middle-income countries (LMICs) but most research dollars spent on interventions to improve the lives of older adults are awarded to researchers in high-income countries (HICs). One approach to improve the implementation of evidence-based innovations for older adults in LMICs is designing interventions that are relevant to LMICs and HICs simultaneously. We propose that researchers in HICs could partner with stakeholders in an LMIC throughout the intervention design process to better position their intervention for the implementation in that LMIC. We provide an example study from an adaptation of the Resources for Enhancing Caregiver Health II in Vietnam, which did not use this strategy but may have benefited from this strategy. We then turn to several considerations that are important for researchers to contemplate when incorporating this strategy. Finally, we explore incentives for creating interventions that are relevant to both HICs and LMICs for funders, intervention designers, and intervention receivers. Although this is not the only strategy to bring interventions to LMICs, it may represent another tool in researchers' toolboxes to help expedite the implementation of efficacious interventions in LMICs.

It's More Than Language: Cultural Adaptation of a Proven Dementia Care Intervention for Hispanic/Latino Caregivers

Although Hispanic/Latino older adults are at disproportionate and increased risk for Alzheimer's disease and related dementias, few evidence-based supportive care interventions are specifically developed for or adapted for this population. Adapting a supportive care intervention requires more than Spanish language translation; it necessitates an understanding of cultural nuances and care preferences of Hispanic/Latino families and staff who implement the intervention. This article describes the cultural adaptation of the Adult Day Service Plus intervention for delivery by staff to Hispanic/Latino caregivers, which was guided by the cultural adaptation process model. Also, using the Framework for Reporting Adaptations and Modifications-Enhanced, we discuss (a) when modifications were made, (b) who determined the modifications needed, (c) what aspects of the intervention were modified, (d) the relationship to fidelity and how fidelity was maintained, and (e) reasons for modifications. Modifications to the delivery and content were changed to reflect the values and norms of both the Hispanic/Latino staff and the caregivers they serve. As supportive interventions for caregivers are developed and implemented into real-world settings, inclusion of cultural elements may enhance research participation among Hispanic/Latino provider sites, people living with dementia, and their caregivers. Cultural adaptation is an essential consideration when developing, adapting, and implementing previously tested evidence-based interventions. Cultural adaptation offers an important lens by which to identify contextual factors that influence successful adoption to assure equity in the reach of evidence-based programs.

A Web-Based Decision Aid for Caregivers of Persons With Dementia With Firearm Access (Safe at Home Study): Protocol for a Randomized Controlled Trial

BACKGROUND

Firearm safety among individuals with Alzheimer disease and related dementias (ADRD) is an underdiscussed and underresearched concern in the United States, especially given the growing population of community-dwelling adults with ADRD. The "Safety in Dementia" (SiD) web-based decision aid was developed to support caregivers in addressing firearm access; the efficacy of SiD is unknown.

OBJECTIVE

Through the SiD decision aid, the Safe at Home (S@H) study aims to support caregivers in making decisions about home safety that align with their goals and values, and behaviors regarding firearm access for persons with ADRD and firearm access.

METHODS

The S@H study is a 2-armed randomized controlled trial to test the effect of the SiD decision aid on caregivers of community-dwelling adults with ADRD who have firearm access. S@H aims to recruit 500 ADRD caregivers (age ≥18 years, fluent in English or Spanish, and in the United States) through online or social media advertisements and through relevant organizations. Participants are randomized to view SiD or a control website at their own pace; all participants complete web-based questionnaires at baseline, 2 weeks, 2 months, and 6 months. The primary outcome is immediate preparation for decision-making; secondary outcomes include longitudinal decision outcomes and self-reported modifications to firearm access. The relative reach and effectiveness of each recruitment method (online/social media and through relevant organizations) will be assessed by examining differences in caregiver participation, retention rates, and relative cost.

RESULTS

The study enrollment began in May 2022. As of December 2022, a total of 117 participants had enrolled.

CONCLUSIONS

The S@H study is the first randomized trial of a firearm safety decision aid for ADRD caregivers. The results from this study will inform how best to support caregivers in decision-making regarding firearm safety. Further, results may guide approaches for recruiting caregivers and for dissemination of resources.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05173922; https://clinicaltrials.gov/ct2/show/NCT05173922.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/43702.

Implementing the Care of Persons With Dementia in Their Environments (COPE) Intervention in Community-Based Programs: Acceptability and Perceived Benefit From Care Managers' and Interventionists' Perspectives

BACKGROUND AND OBJECTIVES

Nonpharmacologic interventions have demonstrated benefits for people living with dementia and their caregivers. Few studies have evaluated their implementation in real-world settings. Using normalization process theory (NPT), an implementation science framework, this study evaluated the acceptability of the care of persons with dementia in their environments (COPE) intervention by care managers and interventionists implemented in a Medicaid and state-revenue funded home and community-based services (HCBS) program.

RESEARCH DESIGN AND METHODS

NPT and data from 9 care manager focus groups (n = 61) and 2 interventionist focus groups (n = 8) were utilized to understand COPE acceptability to program care managers and interventionists. NPT's 4 criteria, coherence, cognitive participation, collective action, and reflexive monitoring, framed the research questions used to evaluate the intervention's implementation.

RESULTS

Care managers and interventionists demonstrated a shared understanding of COPE aims and the value of practices implemented (coherence). Training by national experts facilitated program buy-in to meet COPE goals and was demonstrated by care managers and interventionists as they used the training to broaden their program involvement (cognitive participation). Operational work done by care managers and interventionists to implement the intervention (collective action) and their shared perceptions of program benefits (reflexive monitoring) contributed to program implementation, families' positive responses to COPE and enhanced sustainability.

DISCUSSION AND IMPLICATIONS

Introducing evidence-based dementia care interventions into HCBS programs strongly depends upon building shared understandings between care managers and interventionists and valuing the contributions of all stakeholders involved in delivering care innovations to people living with dementia and their caregivers.

Usability and Acceptability of Social Robot Pets Among Community-Dwelling Veterans Living With Dementia and Their Caregivers

Social robot pets promote engagement and psychosocial well-being among older adults, yet little is known about their use among community-dwelling Veterans living with dementia. This programmatic evaluation used a within subjects, pre-post design to examine the usability (frequency of use, frequency of caregiver reminders) and acceptability (benefit, satisfaction) of social robot pets among Veterans with dementia (N = 20). An intervention usability and acceptability tool was completed by telephone with family caregivers 3 months after delivery of the pet to the home. Overall, 80% of Veterans used the pet often or daily, while 7 caregivers provided reminders for the Veteran to use the pet. Caregivers indicated that Veterans experienced benefit with the pet, as well themselves. Regarding satisfaction, 89% reported they would recommend a social robot pet to others. Research is needed to expand generalizability, evaluate effects on outcomes, and enhance implementation of social robot pets among Veteran families with dementia.

Development of a Home-Based Stress Management Toolkit for Dementia Caring Dyads: Protocol for a Pilot Intervention Development and Feasibility Study

BACKGROUND

People living with dementia (PLWD) and their care partners (dementia caring dyads) are at a heightened risk of experiencing stress-related symptoms and conditions. Yet, many dyadic stress management interventions have had limited uptake by health care systems and in the community. An intervention that combines simple, safe, easy-to-use, nonpharmacologic tools (eg, animatronic social pets, weighted blankets and garments, aromatherapy and bright light therapy devices, acupressure, and massage tools) that can be used in the home may be a promising approach to promote stress management among dementia caring dyads.

OBJECTIVE

The proposed study aims to develop and user test a dyadic toolkit intervention composed of simple, tangible stress management tools for community-dwelling PLWD and their care partners. This study will also explore the feasibility of collecting several stress-related outcome measures to inform measurement selection for future studies.

METHODS

A human-centered design (HCD) approach will be used to increase the likelihood of developing an intervention that will be translatable to real-world settings. This study consists of 2 phases. The first phase will address the discover, define, and design stages of HCD using qualitative focus groups with dementia caring dyads (N=12-16 dyads). Dyadic focus groups (3-4 groups anticipated) will be convened to understand participants' stress experiences and to co-design a stress management toolkit prototype. Rapid qualitative analysis will be used to analyze focus group data. In phase 2, the toolkit prototype will be user tested for 2 weeks in a new sample to address the validation step of HCD. A within-subjects (n=10 dyads), pre-post design will be used with measures of usability (frequency of toolkit use), feasibility (enrollment and withdrawal rates, adverse events/injuries), and acceptability (satisfaction, benefit) collected via questionnaires (at the end of weeks 1 and 2 of user testing) and focus groups (n=3-4 dyads/group at the end of week 2). The feasibility of collecting participant-reported, stress-related outcomes (neuropsychiatric symptoms of dementia, caregiver stress, dyadic relationship strain) and salivary cortisol as a physiologic measure of stress will be assessed at baseline and after user testing.

RESULTS

This study will yield a working prototype of a stress management toolkit for dementia caring dyads, as well as preliminary data to support the feasibility and acceptability of the intervention. User testing will elucidate areas to refine the prototype and provide data to inform preliminary testing of the intervention. As of September 2022, this study has received institutional ethics board approval with phase 1 recruitment anticipated to begin January 2023.

CONCLUSIONS

Few interventions have focused on combining simple, safe, low burden tools to promote stress management among community-dwelling dementia caring dyads. By involving families and exploring feasibility and acceptability at the onset of development, this intervention will have greater potential to be implemented and sustained in the future.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05465551; https://clinicaltrials.gov/ct2/show/NCT05465551.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

PRR1-10.2196/43098.

Differential race effects of the tailored activity program (TAP) on dementia-related behaviors: A randomized controlled trial

BACKGROUND

Although nonpharmacological approaches are considered first-line treatments for dementia-related behaviors, it is unclear as to their effectiveness for different racial groups. We evaluated the effects of the Tailored Activity Program (TAP) on agitated and aggressive behaviors in Black and White families.

METHODS

We conducted a single-blind, two-arm randomized controlled trial involving Black (N = 90) and White (N = 145) families. TAP involved eight home sessions by occupational therapists who provided activities tailored to abilities and interests and instructed caregivers in their use over 3 months. An attention control group received eight sessions by research assistants who provided disease education and home safety tips. Measures included caregiver ratings of frequency by severity for the agitation and aggression subscales of the Neuropsychiatric Inventory-Clinician (NPI-C) at 3 months (main trial primary outcome), number of completed sessions and time spent, changes in behavioral subcomponents of the subscales (frequency, severity, caregiver distress), and percent improving/worsening.

RESULTS

Black and White families completed similar numbers of treatment sessions, but White dyads averaged nearly two contact hours more than Black dyads (p = 0.008). At 3 months, an interaction effect (treatment by race) indicated significantly greater reductions in frequency by severity scores for the agitation and aggression subscales for Black TAP dyads versus White TAP dyads and White and Black attention control dyads. Also, significant interaction effects favoring TAP Black dyads were observed for select behavioral components. For TAP dyads with elevated baseline agitation/aggression levels (N = 71), 34.5% of Black versus 11.9% of White dyads improved; whereas 2.6% of Black versus 16.7% of White dyads had worsened agitation/aggression scores.

CONCLUSION

Black families compared to White families derived greater behavioral benefits from TAP for PLWD at 3 months despite having less treatment exposure. Examining differential race effects may enhance precision in using nonpharmacological approaches and promote equity in dementia care for underserved populations.

Person-Centered Memory Care Through Montessori for Dementia and Ageing: A Quality Improvement Study

Montessori for Dementia and Ageing (MDA) is a philosophy to support person-centered care (PCC) and autonomy of older adults. This quality improvement project documented outcomes of implementation of the MDA philosophy in a long-term care memory neighborhood. After an initial training session, MDA was implemented with weekly, 2-hour on-site coaching sessions over the course of two semesters (28 weeks) with a community of 20 female persons living with dementia (PWD). Primary outcomes were negative responsive behaviors of PWD, whereas the secondary outcome included percentage of active engagement of PWD. Mean number of negative responsive behaviors was 62.21 at baseline, which decreased to 33.82 at the end of the project per the Cohen-Mansfield Agitation Inventory. At baseline, PWD were actively engaged in 18.15% of observed opportunities, according to the Engage portion of the Resident-Centered Assessment of Interactions with Staff and Engagement Tool. At the end of the project, PWD were actively engaged in 40.56% of observed opportunities. Results suggest that MDA is feasible to implement PCC in a long-term care memory neighborhood. [Journal of Gerontological Nursing, 48(8), 6-9.].

Feasibility and Acceptability of a Remotely Delivered Weighted Blanket Intervention for People Living With Dementia and Their Family Caregivers

The COVID-19 pandemic amplified the need for interventions to support community-dwelling families living with dementia. This study examined the feasibility and acceptability of a remotely delivered weighted blanket intervention for people living with dementia, and the feasibility of collecting outcome measures specific to people with dementia and caregivers. A prospective, within subjects, pre-post design was used; 21 people with dementia and their caregivers participated. Measures of feasibility (days blanket was used for the recommended duration, injuries/adverse events, enrollment, and withdrawal rate, time to recruit sample) and acceptability (tolerability, satisfaction, and benefit perceived by participants with dementia and caregivers) were examined. Feasibility of collecting measures was examined through missing data. Results indicated high feasibility and acceptability. Collecting caregiver completed outcome measures was feasible, but measures completed by self-report by people with dementia was not. Weighted blankets are a promising tool for this population that warrant further examination to determine efficacy.

The need for increased pragmatism in cardiovascular clinical trials

The majority of cardiovascular randomized controlled trials (RCTs) test interventions in selected patient populations under explicitly protocol-defined settings. Although these ‘explanatory’ trial designs optimize conditions to test the efficacy and safety of an intervention, they limit the generalizability of trial findings in broader clinical settings. The concept of ‘pragmatism’ in RCTs addresses this concern by providing counterbalance to the more idealized situation underpinning explanatory RCTs and optimizing effectiveness over efficacy. The central tenets of pragmatism in RCTs are to test interventions in routine clinical settings, with patients who are representative of broad clinical practice, and to reduce the burden on investigators and participants by minimizing the number of trial visits and the intensity of trial-based testing. Pragmatic evaluation of interventions is particularly important in cardiovascular diseases, where the risk of death among patients has remained fairly stable over the past few decades despite the development of new therapeutic interventions. Pragmatic RCTs can help to reveal the ‘real-world’ effectiveness of therapeutic interventions and elucidate barriers to their implementation. In this Review, we discuss the attributes of pragmatism in RCT design, conduct and interpretation as well as the general need for increased pragmatism in cardiovascular RCTs. We also summarize current challenges and potential solutions to the implementation of pragmatism in RCTs and highlight selected ongoing and completed cardiovascular RCTs with pragmatic trial designs.

In this Review, Khan and colleagues discuss the benefits and challenges of including pragmatism in the design, conduct and interpretation of randomized controlled trials (RCTs) for cardiovascular disease and highlight selected ongoing and completed cardiovascular RCTs that incorporate a pragmatic design.

Most cardiovascular randomized controlled trials (RCTs) conducted to date have been ‘explanatory’, that is, designed to study the intervention in optimized conditions with selected patient populations and frequent protocolized assessments.

Although explanatory RCT designs increase validity, they limit the generalizability of trial findings, whereas a ‘pragmatic’ approach to RCTs yields findings more relevant to real-world practice.

In pragmatic RCTs, interventions are tested in patients who are broadly representative of the condition being studied, and the study is aligned with routine clinical care to reduce costs and organizational burden.

Although pragmatic RCTs tend to attenuate estimates of treatment effects, they do provide a more realistic understanding of population-level effectiveness and costs than explanatory trials.

Pragmatic trials can highlight barriers to the implementation of therapies and are better suited than explanatory RCTs to assessing the effects of implementation strategies and health-care policies at the population level.

Widespread implementation of pragmatic trials would require the development of technological infrastructure to collect and share data as well as regulatory guidelines amenable to findings derived from routinely collected data.

Implementation Science Research in Communication Sciences and Disorders: A Scoping Review

PURPOSE

The purpose of this study was to complete a scoping review of implementation science (IS) research in communication sciences and disorders (CSD) over time and to determine characteristics of IS research in CSD.

METHOD

A scoping review was conducted of PubMed and Education Resources Information Center for sources published in English that (a) included CSD practitioners, (b) addressed IS research, and (c) identified a specific evidence-based practice. Resulting sources were systematically examined for study aim, patient populations, implementation framework utilized, setting of the study, implementation strategy examined, and implementation outcome measured.

RESULTS

The majority of the 82 studies that underwent a full-text review (80.5%) were published in 2014 or later. One fourth of the studies were concept papers, and another one fourth focused on context assessment (25.6% of studies, each), 11% focused on designing implementation strategies, and 36.6% focused on testing implementation strategies. The patient population most frequently represented aphasia (21.3%), and most studies (34.4%) were conducted in inpatient medical settings. Nearly half (42.6%) of the nonconcept studies lacked an IS framework. Among implementation strategies identified, approximately one third of studies focused on education and/or training plus another strategy and one fourth focused on education and/or training alone. Implementation outcomes measured typically represented early stages of implementation.

CONCLUSIONS

This scoping review of IS research in CSD described the landscape of IS studies in CSD. IS is intersecting with CSD at a rapid rate, especially since 2014. Future IS research in CSD should adopt an implementation framework a priori and consider the broad range of implementation strategies and outcomes to support the uptake of research into typical practice settings.

Delivering Personalized Recommendations to Support Caregivers of People Living With Dementia: Mixed Methods Study

BACKGROUND

Estimates suggest that 6.2 million Americans aged ≥65 years are living with Alzheimer dementia in 2021, and by 2060, this number could more than double to 13.8 million. As a result, public health officials anticipate a greater need for caregivers of persons with Alzheimer disease or related dementia and support resources for both people living with dementia and their caregivers. Despite the growing need for dementia caregiver support services, there is a lack of consensus regarding how to tailor these services to best meet the heterogeneous needs of individual caregivers. To fill this gap, Care to Plan (CtP), a web-based tool for caregivers of people living with dementia, was developed to provide tailored support recommendations to dementia caregivers.

OBJECTIVE

The aim of this study is to formally explore the feasibility, acceptability, and utility of CtP for 20 family members of people living with dementia within a health system over a 1-month time period using a mixed methods parallel convergent design.

METHODS

A moderately sized health system in the mid-Atlantic region was selected as the site for CtP implementation, where 20 caregivers who were family members of people living with dementia were enrolled. The web-based CtP tool was used by caregivers and facilitated by a health care professional (ie, a senior care navigator [SCN]). Caregivers were given a 21-item review checklist to assess barriers and facilitators associated with reviewing CtP with an SCN. Following the 21-item review checklist, semistructured telephone interviews, which included 18 open-ended questions, focused on the facilitators of and barriers to CtP implementation and recommendations for future implementation.

RESULTS

Quantitative results suggested that 85% (17/20) of caregivers indicated that CtP was helpful and 90% (18/20) would recommend CtP to someone in a similar situation. The qualitative analysis identified 4 themes regarding facilitators of and barriers to implementation: caregiver factors, SCN factors, CtP tool system factors, and recommendations and resources factors.

CONCLUSIONS

CtP was found to be not only feasible but also a valuable tool for caregivers seeking resources for themselves and their people living with dementia. Long-term evaluation findings aim to generate results on how CtP can be integrated into care plans for caregivers and how SCNs can provide additional support for caregivers of people living with dementia over an extended period.

Developing and Testing Remote Implementation for the Changing Talk Online (CHATO) Communication Intervention for Nursing Home Staff: A Pilot Pragmatic Randomized Controlled Trial

Background and Objectives

The Changing Talk (CHAT) communication training effectively reduces elderspeak and subsequent behavioral challenges in residents with dementia in nursing homes (NHs). As part of the pilot pragmatic clinical trial testing Changing Talk: Online Training (CHATO), a new online version, a remote implementation design, and process evaluation were developed to capture contextual factors, ensure fidelity, and determine effective implementation strategies.

Research Design and Methods

The Expert Recommendation for Implementing Change compilation informed this 2-phase approach to develop and test remote implementation. An Advisory Board guided the developmental phase while pilot testing used a cluster-randomized design. Data were analyzed to evaluate NH characteristics; implementation strategies used; CHATO participation, completion, and passing rates; and leadership evaluation.

Results

Five out of 7 NHs were nonprofit with above average quality ratings (M = 4.3 of 5). Staff participants (N = 237) were mostly female (90%), non-Hispanic White (91%), and nursing assistants (46%). Implementation time ranged from 54 to 86 days (M = 70.3, standard deviation [SD] = 9.3), with planning phase ranging from 11 to 29 days (M = 20.1, SD = 6.7), and training phase ranging from 35 to 58 days (M = 50.0, SD = 7.6). A range from 3 to 11 implementation strategies were used by each NH. Assigning champions, including the social worker on the implementation team, utilizing multiple mediums for reminders, giving rewards or public recognition, supporting onsite discussions, and other tailoring strategies were associated with improved outcomes. Participation ranged from 20% to 76%. Over 63% of participants completed training (N = 150) and 87% passed the posttest (N = 130). Leadership evaluations noted staff used CHATO concepts in practice and improved communication culture.

Discussion and Implications

Leadership who took an active role, engaged multiple team members, and varied strategies had better outcomes. Effectiveness of the strategies will be evaluated in a national pragmatic clinical trial testing CHATO’s effects on reducing behavioral and psychological symptoms in dementia care.

Open science in dementia care embedded pragmatic clinical trials

Few dementia care interventions have been translated to healthcare contexts for those who need them. Embedded pragmatic clinical trials (ePCTs) are one design that can expedite the timeframe of research translation to clinical practice. As the National Institutes of Health (NIH) and other funders commit immense new resources to increasing the nation's capacity to conduct dementia care ePCTs, we call on psychologists to employ their extensive expertise in open science to improve the quality of dementia care ePCTs. This article provides several recommendations to enhance the transparency and reporting rigor of ePCTs in dementia care and other chronic disease contexts. We illustrate these recommendations in the context of a recent pilot pragmatic trial known as the Porchlight Project. Porchlight provided training to volunteers who serve clients and caregivers to help them provide more "dementia capable" support. Notably this trial did not include a special effort to make use of open science practices. We discuss the benefits and costs had the Porchlight Project incorporated open science principles. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Dementia caregiving across Latin America and the Caribbean and brain health diplomacy

The prevalence of dementia in Latin America and the Caribbean is growing rapidly, increasing the burden placed on caregivers. Exacerbated by fragile health-care systems, unstable economies, and extensive inequalities, caregiver burden in this region is among the highest in the world. We reviewed the major challenges to caregiving in Latin America and the Caribbean, and we propose regional and coordinated actions to drive future change. Current challenges include the scarcity of formal long-term care, socioeconomic and social determinants of health disparities, gender-biased burdens, growing dementia prevalence, and the effect of the current COVID-19 pandemic on families affected by dementia. Firstly, we propose local and regional short-term strategic recommendations, including systematic identification of specific caregiver needs, testing of evidence-based local interventions, contextual adaptation of strategies to different settings and cultures, countering gender bias, strengthening community support, provision of basic technology, and better use of available information and communications technology. Additionally, we propose brain health diplomacy (ie, global actions aimed to overcome the systemic challenges to brain health by bridging disciplines and sectors) and convergence science as frameworks for long-term coordinated responses, integrating tools, knowledge, and strategies to expand access to digital technology and develop collaborative models of care. Addressing the vast inequalities in dementia caregiving across Latin America and the Caribbean requires innovative, evidence-based solutions coordinated with the strengthening of public policies.

Recommendations to Deliver Person-Centered Long-Term Care for Persons Living With Dementia

Person-centered care (PCC) is the standard for the delivery of long-term services and supports (LTSS). In this article, we summarize the state of the science on meaningful outcomes and workforce development and discuss what is needed to ensure that person-centered LTSS becomes a universal reality. These 2 themes are intimately related: the dementia care workforce’s capacity cannot be improved until care processes and outcomes that are significant to PCC are explicated. The LTSS workforce needs training in PCC as well as pragmatic measures to assess the quality of the care they provide. We conclude with several recommendations for future policy and practice-oriented workforce research.

Facilitators and barriers to implement nurse-led interventions in long-term dementia care: a qualitative interview study with Swiss nursing experts and managers

Background

To support the implementation of nurse-led interventions in long-term dementia care, in-depth knowledge of specific supporting factors and barriers is required. Conditions and structures of caring for people with dementia differ widely, depending on the country and the care context. Our study aimed to describe the experiences and opinions of nursing experts and managers with regard to facilitators and barriers to the implementation of nurse-led interventions in long-term dementia care.

Methods

We conducted a qualitative descriptive study using individual interviews based on qualitative vignettes as a useful stimulus to generate narrations allowing to study peoples’ perceptions and beliefs. The study took place in nursing homes in the German-speaking part of Switzerland and in the Principality of Liechtenstein using purposive sampling. We intended to conduct the interviews face-to-face in a quiet room according to the participant’s choice. However, due to the lockdown of nursing homes during the COVID-19 pandemic in spring 2020, we performed interviews face-to-face and by video. We analysed data thematically following Braun and Clarke to achieve a detailed, nuanced description. To verify our interpretation and to ensure congruence with participants’ perspectives, we conducted member checks. The Standards for Reporting Qualitative Research (SRQR) served to structure our manuscript.

Results

Six dyads of nursing home managers and nursing experts from six nursing homes took part in our study (n = 12). Our thematic analysis yielded seven themes reflecting facilitators and barriers to implementing nurse-led interventions in long-term dementia care: «A common attitude and cohesion within the organization», «Commitment on several levels», «A needs-oriented implementation», «The effect and the public perception of the intervention», «A structured and guided implementation process», «Supporting knowledge and competencies», as well as «Resources for implementing the intervention».

Conclusions

To support the implementation of nurse-led interventions in long-term dementia care, active commitment-building seems essential. It is necessary that the value of the intervention is perceptible.Commitment-building is the precondition to reach the persons involved, such as nursing home managers, nursing staff, residents and relatives. Furthermore, nurses should precisely inform about the intervention. It is necessary that the value of the intervention is perceptible. In addition, nurses should adjust the interventions to the situational needs of people with dementia, thus. Therefore, it is important to support dementia-specific competencies in long-term care. Findings indicate that the barrier is determined by the intervention and its implementation – and not by the behaviour of the person with dementia.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12877-021-02120-1.

Barriers to implementation of STRIDE, a national study to prevent fall-related injuries

BACKGROUND/OBJECTIVES

Evaluations of complex models of care for older adults may benefit from simultaneous assessment of intervention implementation. The STRIDE (Strategies To Reduce Injuries and Develop confidence in Elders) pragmatic trial evaluated the effectiveness of a multifactorial intervention to reduce serious fall injuries in older adults. We conducted multi-level stakeholder interviews to identify barriers to STRIDE intervention implementation and understand efforts taken to mitigate these barriers.

DESIGN

Qualitative interviews with key informants.

SETTING

Ten clinical trial sites affiliated with practices that provided primary care for persons at increased risk for fall injuries.

PARTICIPANTS

Specially trained registered nurses working as Falls Care Managers (FCMs) who delivered the intervention (n = 13 individual interviews), Research Staff who supervised trial implementation locally (n = 10 group interviews, 23 included individuals), and members of Central Project Management and the National Patient Stakeholder Council who oversaw national implementation (n = 2 group interviews, six included individuals).

MEASUREMENTS

A semi-structured interview guide derived from the consolidated framework for implementation research (CFIR).

RESULTS

We identified eight key barriers to STRIDE intervention implementation. FCMs navigated complex relationships with patients and families while working with Research Staff to implement the intervention in primary care practices with limited clinical space, variable provider buy-in, and significant primary care practice staff and provider turnover. The costs of the intervention to individual patients and medical practices amplified these barriers. Efforts to mitigate these barriers varied depending on the needs and opportunities of each primary care setting.

CONCLUSION

The many barriers to implementation and the variability in how stakeholders addressed these locally may have affected the overall STRIDE intervention's effectiveness. Future pragmatic trials should incorporate simultaneous implementation aims to better understand how research interventions translate into clinical care that improves the lives of older adults.

A Cluster Randomized Controlled Trial Testing the Impact of Function and Behavior Focused Care for Nursing Home Residents With Dementia

OBJECTIVE

The purpose of this study was to test the effectiveness of the Function and Behavior Focused Care for the Cognitively Impaired (FBFC-CI) intervention on function, physical activity, and behavioral symptoms among nursing home residents with dementia, and to explore the adoption of the intervention at the facility level.

DESIGN

This study was a clustered, randomized controlled trial with a repeated measures design that was implemented in 12 nursing homes randomized to either treatment (FBFC-CI) or educational control [Function and Behavior Focused Care Education (FBFC-ED)].

SETTING AND PARTICIPANTS

Twelve nursing homes (6 treatment and 6 control) and 336 residents (173 treatment and 163 control) with moderate to severe cognitive impairment.

MEASURES

Outcomes included functional ability (Barthel Index), physical activity (actigraphy and survey), behavioral symptoms (Resistiveness to Care Scale, Cohen-Mansfield Agitation Inventory, Cornell Scale for Depression in Dementia), and psychotropic medication use.

RESULTS

The participants were 82.6 (SD = 10.1) years of age, mostly female, and were moderate to severely cognitively impaired (Mini-Mental State Exam of 7.8, SD = 5.1). There was a significantly greater increase in time spent in total activity (P = .004), moderate activity (P = .012), light activity (P = .002), and a decrease in resistiveness to care (P = .004) in the treatment versus control group at 4 months. There was no change in mood, agitation, and the use of psychotropic medications. There was some evidence of adoption of the intervention at treatment sites.

CONCLUSIONS AND IMPLICATIONS

This study provides some support for the use of the FBFC-CI Intervention to increase time spent in physical activity and decrease resistive behaviors during care commonly noted among nursing home residents with moderate to severe cognitive impairment.

Virtual cognitive stimulation therapy: perspectives of people living with dementia

Cognitive Stimulation Therapy (CST) is a group treatment in which people with mild to moderate dementia participate in 14 activity and discussion sessions. During the COVID-19 pandemic, CST was adapted for online delivery, as virtual-CST (V-CST). To determine the acceptability of online delivery, we piloted a V-CST group, monitored attendance, and assessed qualitative feedback from the participants. Five people with dementia participated. Except for one session with four attendees, all participants attended every session. Qualitative analysis identified four themes that were verified by participants: (1) positive emotional experiences despite dementia, (2) confidence building and related strategies and challenges, (3) enjoyable and stimulating inclusive activities and group dynamics, and (4) appreciation of discussion about current affairs. This pilot study contributes evidence about the acceptability of V-CST. Although access to CST in the United States is limited, expanded delivery of V-CST could fill service gaps.

Effectiveness of the Care of Persons With Dementia in Their Environments Intervention When Embedded in a Publicly Funded Home- and Community-Based Service Program

BACKGROUND AND OBJECTIVES

In the absence of effective pharmacotherapy, there is an urgent need to test evidence-based dementia care interventions using pragmatic trial approaches. We present results from a study in which an evidence-based, nonpharmacologic intervention for persons living with Alzheimer's disease and related dementia (ADRD) and their informal caregivers, Care of Persons with Dementia in their Environments (COPE), was tested in a Medicaid and state revenue-funded home and community-based service (HCBS) program.

RESEARCH DESIGN AND METHODS

Using pragmatic trial design strategies, persons living with ADRD and their caregivers were randomly assigned as dyads to receive COPE plus usual HCBS (COPE; n = 145 dyads) or usual HCBS only (Usual Care or UC; n = 146 dyads). Outcomes were measured prerandomization, and 4 and 12 months postrandomization. Outcomes for persons living with ADRD included functional independence, activity engagement, self-reported quality of life, and behavioral and psychological symptoms. Caregiver outcomes included perceived well-being, confidence using dementia management strategies, and degree of distress caused by behavioral and psychological symptoms.

RESULTS

After 4 months, caregivers receiving COPE reported greater perceived well-being (least squares mean = 3.2; 95% CI: 3.1-3.3) than caregivers receiving UC (3.0; 2.9-3.0; p < .001), and persons living with ADRD receiving COPE, compared to those receiving UC, showed a strong trend toward experiencing less frequent and less severe behavioral and psychological symptoms (9.7; 5.2-14.2 vs 12.7; 8.3-17.1; p = .07). After 12 months, persons living with ADRD receiving COPE were more engaged in meaningful activities (2.1; 2.0-2.1 vs 1.9; 1.9-2.0; p = .02) than those receiving UC.

DISCUSSION AND IMPLICATIONS

Embedding COPE in a publicly funded HCBS program yielded positive immediate effects on caregivers' well-being, marginal positive immediate effects on behavioral and psychological symptoms, and long-term effects on meaningful activity engagement among persons living with ADRD. Findings suggest that COPE can be effectively integrated into this service system, an important step towards widespread adoption.

CLINICAL TRIALS REGISTRATION NUMBER

NCT02365051.