Dementia Care in Eight European Countries: Developing a Mapping System to Explore Systems

Cross-country variations in the caregiver role: evidence from the ENTWINE-iCohort study

BACKGROUND

Globally, economically developed countries face similar ageing demographics and the challenge of a 'care gap', yet they vary due to different care and formal support systems, and different cultural and societal norms around illness and care. The aim of this exploratory study was to examine cross-country variations in caregiver motivations, willingness, values, meaning in life, illness beliefs, and experiences of wellbeing, gain, health-related quality of life, burden and depression, across 6 European countries and Israel. Cross-country differences in the above-mentioned informal caregiver experiences are rarely described.

METHODS

An online survey (ENTWINE-iCohort) was conducted using validated measures wherever possible. This paper utilises data from 879 caregivers and seven countries (Greece, Italy, the Netherlands, Poland, Sweden, the UK, and Israel).

RESULTS

No consistent finding supporting the concurrent relationship between caregiver support policies/country culture and caregiver motivations/willingness was found. Caregivers in countries typically characterised by individualist cultures reported lower familism, higher self-enhancement values, and greater perceived illness threat compared to more collectivist countries. Search for meaning was higher in poorer countries than in wealthier countries. Higher negative caregiver experiences (e.g., burden) and lower positive experiences (e.g., wellbeing) were generally observed in countries with underdeveloped caregiver support as compared to countries with more developed formal support systems.

CONCLUSIONS

Cross-country variations can be explained to varying degrees by national policies around care (or their absence) and country cultural contexts. The results emphasise the importance of formal support services for achieving positive caregiver experiences, and help inform the development of policies and measures to support caregivers in Europe and Israel.

Identifying undergraduate nurses´ learning requirements and teaching strategies in dementia care education: A nominal group technique

AIM

Identify priorities and reach a consensus on student nurses´ learning requirements and the best-suited teaching strategies in dementia care.

BACKGROUND

Dementia has become a global health priority. Nurses are primary service providers for people with dementia, but they may fall short on professional training. Nursing curricula still lacks a clear educational framework for dementia, meaning that nurse educators must make decisions amidst uncertainty.

DESIGN

Nominal group technique based on the conceptual framework proposed by Van de Ven and Delbecq (1972).

METHODS

A structured face-to-face meeting convened in November 2021 involved nine participants who were directly involved in dementia care. The steps in the technique were (a) idea generation, (b) round-robin recording, (c) discussion, (d) voting and ranking, (e) discussion on the vote and (f) re-ranking. Participants answered two nominal questions. Consent, anonymity, feedback and iteration were guaranteed throughout the process.

RESULTS

The nominal group prioritized theoretical understanding of dementia, communication, caregivers´ needs, comprehensive assessment and ethical practice as learning requirements for nursing students. The outstanding teaching strategy discussed included various approaches to experiential learning.

CONCLUSIONS

The nominal group technique process explored learning requirement priorities for student nurses within a specific context. Participants discussed experiential learning as the best-suited teaching strategy. Findings could support nurse educators to design and deliver better dementia education.

Dynamics of Interaction among Professionals, Informal Supporters, and Family Caregivers of People with Dementia along the Dementia Care Pathway: A Nationwide Survey in Japan

This study aims to clarify the dynamics of information provision and human interaction to satisfy the needs of family caregivers. A questionnaire survey consisting of items on information received at and after diagnosis, persons and resources consulted, needs, and caregiver-oriented outcomes was conducted. Among the respondents, 2295 individuals who were caring for people with dementia were divided into quartiles by the time after diagnosis, and differences were statistically analyzed. The time after diagnosis in the first to fourth quartiles was 0.73 ± 0.4, 2.52 ± 0.49, 4.89 ± 0.73, and 10.82 ± 3.7 years, respectively. The number of persons consulted by family caregivers increased significantly from the first to the fourth quartiles (p < 0.001). During this time, attributes of professionals and informal supporters changed depending on the quartile. As time progressed, acceptance of the diagnosis increased, but so did its impact on the lives of family caregivers. These findings revealed differences over time in what family caregivers wanted and the dynamics of interactions that filled their needs. Informal supporters accounted for a significant proportion of the total resources. However, many family caregivers thought the information and support were insufficient. Thus, continuous reform of the care pathway is needed.

Caring for people living with dementia in their own homes: A qualitative study exploring the role and experiences of registered nurses within a district nursing service in the UK

BACKGROUND

In the UK, district nursing services (DNS) deliver care to people intheir own homes and have regular contact with people with dementia. Research conducted with nurses working in similar roles outside the UK suggests their contribution to high quality dementia care is limited by compassion fatigue, lack of dementia training and low levels of confidence. However, there is a paucity of research exploring the role and learning and support needs of nurses within DNS.

OBJECTIVES

The aim was to gain insight into the role and experiences of nurses caring for people living with dementia at home.

METHODS

The study was informed by a descriptive phenomenological approach. Semi-structured interviews were conducted with a purposive sample of ten nurses working in DNS. Data were analysed thematically.

RESULTS

Five main themes were identified: 'Home as a care setting' reflected how delivering home-based care shaped participants experiences of caring for people with dementia; 'Taking it in their stride' revealed how participants adapted and responded to the complexity of care needs for people with dementia; 'Complexity and unpredictability' related to the unpredictable nature of people with dementia's care needs and the impact this had on participants' workloads; 'Expertise and support within the wider team' detailed which networks nurses used for advice and support to manage the complex needs of people living with dementia at home; 'Specialist support' identified the need for structural changes and resources to enable the nurses to deliver the care needed.

CONCLUSIONS

This study enables better understanding of the role of DNS in supporting people with dementia to live at home. This is important for defining how dementia care can become effectively integrated into primary care. Recommendations include improved models of care, which factor in specialist nurses, additional time for home visits and greater emphasis on education and training.

IMPLICATIONS FOR PRACTICE

Improved models of working that factor in additional time and staffing such as specialist nurses in dementia and palliative care would allow DNS to meet the needs of people with dementia more effectively.

Care services for older persons: A scoping review

Introduction

With an increasing life expectancy and proportion of older adults, the number of people in need of care services is also increasing. This study aimed to determine and describe various available care services for older persons reported in literature.

Methods

English-language articles published between the years of 1990 and 2018 in Scopus, ProQuest, PubMed, and Google Scholar databases or search engines were reviewed. The search resulted in 46,927 articles. All selected studies were systematically evaluated and screened based on title, abstract, and full text related to the study's objective. Finally, 246 articles were included in the study. The care services in older persons care systems were identified from the selected articles and were presented in extraction tables. Final conclusions were made based on the types of services provided and their frequency of citation.

Results

The research results showed that numerous systems exist to provide care services for older adults, including long-term care services, home care services, housing for the aged, day care centres, senior centres, nursing homes, and hospice care services. Regarding older adults' care needs and the objectives and missions of each care system, different care services, such as personal care, social support services, medical care services, and nutrition services, have been identified in the service packages.

Conclusion

This study describes the diverse care services available for older persons that have been reported in the literature. Further research in different healthcare systems is required regarding what is most essential and lacking in each setting.

Barriers to Access to Palliative Care in Colombia: A Social Mapping Approach Involving Stakeholder Participation

This study aimed to identify barriers to access to palliative care through a social mapping approach. In Colombia, the barriers to access to palliative care denote an enormous geographic disparity of resources and health needs, making it necessary to conduct community-based participatory research using an approach such as social mapping. A qualitative research design was used. Stakeholders from health insurance companies, regulatory authorities, regional health secretariats, health care professionals, patient and caregiver organizations, scientific societies, and medical journalists from 7 Colombian regions participated. It involved 3 stages. Stage 1: Semi-structured, audio-recorded interviews were conducted with 36 stakeholders and were subsequently transcribed and analyzed. Stage 2: An electronic survey was conducted to obtain feedback on the first outline of the map and the categories that emerged from stage 1. Stage 3: The nominal group technique was used to analyze and validate the barriers to access to palliative care included in the final map. The COREQ checklist was used. Twenty-seven barriers to access to palliative care related to limited availability of medications, stakeholders' poor knowledge of regulations, limited formal education in palliative care, few patients' support networks, patient care fragmentation, few specialized programs of palliative care, and mistaken beliefs about palliative care were identified. Stakeholders' diverse perspectives and opinions were crucial to understanding the development of palliative care in Colombia and its challenges. Better knowledge about palliative care can open opportunities to overcome the barriers identified in this study, directly impacting access to palliative care.

Needs, issues, and expectations on dementia care at home across Europe to inform policy development: Findings from a transnational research study

This qualitative descriptive study explored needs, issues, and expectations on dementia care at home as expressed by relatives of people living with dementia (PwD), health and social care professionals (HSCPs), and members of civil society organisations (CSOs) from four European countries. A focus group methodology integrated with individual semi-structured interviews was adopted to collect data by employing a purposeful sampling method. A total of 13 focus groups and 12 individual interviews were conducted in 2019, involving 65 relatives of PwD, 32 HSCPs, and 23 members of CSOs. Deductive content analysis and findings triangulation were performed to analyse data, and a subgroup of participants confirmed the findings. Relatives need to be (a) informed and trained to cope with changes in PwD, (b) recognised for their caregiving role, and (c) assisted by specialised HSCPs. Professionals who work in partnership with PwD and their relatives call for a reorganisation of available services. CSOs compensate for the lack of proper support, promoting networks, and cooperation with local communities. Several commonalities emerged across countries, highlighting the chance to inform and develop common policies to improve the quality of life of PwD and their relatives across Europe. Policies improving person- and family-centred care and spreading dementia-friendly community concepts and practices are suggested. Strong collaborations between formal and informal services and communities are also needed as well as information on educational strategies to improve the use of resources, promote PwD care, and support PwD relatives' needs.

Support Needs and Expectations of People Living with Dementia and Their Informal Carers in Everyday Life: A European Study

The aim of this study was to describe the needs and expectations of support within everyday life among community-dwelling people living well with an early stage dementia and their informal carers. The study employed a qualitative design. Data were collected in 2018, via four focus group interviews with, in total, 17 people with dementia and 21 informal carers, transcribed and analyzed with manifest content analysis. Needs and expectations of support among persons with dementia were expressed as the importance of “Participation in my own care,” “Attitude of the informal carers,” and “Trusting relationships with informal carers.” Informal carers’ needs and expectations of support were expressed as the importance of “Formal care and services,” “Getting out of a carer mindset,” and “Family context.” The findings from this study highlighted that persons with dementia were well aware of their cognitive impairments and tried to maintain their independence, with both formal and informal care to help remain “being themselves.” Health professionals should acknowledge persons with dementia and informal carers’ well-being, and acknowledge the importance of their needs together with an understanding of the importance of continuity of frontline carers to building trusting relationships.

Persons with Dementia Living at Home or in Nursing Homes in Nine Swedish Urban or Rural Municipalities

The methodology from the "RightTimePlaceCare" study of dementia care was tested locally in terms of relevance, acceptability and attrition. Comparing persons with dementia (PwDs) receiving home care (HC) with PwDs living in nursing homes (NHs), in urban versus rural areas, regarding their health conditions and informal caregiver burden was also done. Standardized measurements regarding sociodemographic, and physical and mental health was used. Questions related to legal guardianship were added. Interviews were conducted with PwDs and their caregivers in HC (n = 88) and in NHs (n = 58). Bivariate and multivariate logistic regression analysis was used. The attrition rate was higher in HC. In the bivariate regression model, for HC and NH, living at home was significantly associated with more severe neuropsychiatric symptoms (p ≤ 0.001) and being cared by a spouse (p = 0.008). In NH, the informal caregivers were significantly younger (p = 0.003) and living in rural areas (p = 0.007) and more often in paid work (p ≤ 0.001). In the multivariate regression model, informal caregivers were significantly younger (p = 0.007) when caring for a PwD in an NH and caregiver burden was significantly higher in HC and in urban areas (p = 0.043). Legal guardianship was very low. Professionals should acknowledge that PwDs in HC have more behavioural problems and caregivers in urban areas report higher caregiver burden.

Advanced dementia: an integrated homecare programme

Objectives

We established an integrated palliative homecare programme for advanced dementia. This study explores patients’ symptoms and quality-of-life and their association with enteral feeding, evaluates the impact of the programme on these parameters and examines familial caregiver burden.

Methods

This is a prospective cohort study. Patients at Functional Assessment Stage 7, with an albumin level <35 g/L, pneumonia or enteral feeding were recruited. At baseline and regular intervals, the multidisciplinary homecare team used the Pain Assessment in Advanced Dementia, Mini Nutritional Assessment and Neuropsychiatric Inventory Questionnaire (NPI-Q) to identify patients’ symptoms, and the Quality of Life in Late-Stage Dementia (QUALID) tool to assess quality-of-life as primary outcomes, stratified by feeding status. The Zarit Burden Interview (ZBI) investigated caregiver burden, stratified by living arrangement and availability of stay-in help. Mann-Whitney U and χ2 tests compared continuous and categorical variables respectively between groups while Wilcoxon signed-rank test compared assessment scores at baseline and on review.

Results

At baseline, 49.2% of the 254 patients had pain, 92.5% were malnourished and 85.0% experienced neuropsychiatric challenges. Patients on enteral feeding had lower NPI-Q score (median=3; IQR 1–6) than orally fed patients ((median=4; IQR 2–7), p=0.004) and higher QUALID score (median=25; IQR 21–30 vs median=21; IQR 17–25 for orally fed patients), p<0.0001, indicating a better quality-of-life for orally fed patients. Both symptoms and quality-of-life improved significantly for the 53 patients reviewed at the fifth month. Median ZBI score for caregivers was 26 (IQR 15–36). Having stay-in help reduced it from 39.5 (IQR 25–49) to 25 (IQR 15–35), p=0.001.

Conclusion

An integrated multidisciplinary palliative homecare team with geriatric training that is accessible all-hours addressed the needs of home-dwelling patients with advanced dementia, improved their quality-of-life and supported families to care for them at home.

Prevalence of dementia diagnoses not otherwise specified in eight European countries: a cross-sectional cohort study

Background

Dementia is a syndrome, with a wide range of symptoms. It is important to have a timely diagnosis during the disease course to reduce the risk of medication errors, enable future care planning for the patient and their relatives thereby optimizing quality of life (QoL). For this reason, it is important to avoid a diagnosis of dementia not otherwise specified (DNOS) and instead obtain a diagnosis that reflects the underlying pathology. The aim of this study was to investigate the prevalence and associated factors of DNOS in persons with dementia living at home or in a nursing home.

Methods

This is a cross-sectional cohort study performed in eight European countries. Persons with dementia aged ≥65 years living at home (n = 1223) or in a nursing home (n = 790) were included. Data were collected through personal interviews with questionnaires based on standardised instruments. Specific factors investigated were sociodemographic factors, cognitive function, and mental health, physical health, QoL, resource utilization and medication. Bivariate and backward stepwise multivariate regression analyses were performed.

Results

The prevalence of DNOS in the eight participating European countries was 16% (range 1–30%) in persons living at home and 21% (range 1–43%) in persons living in a nursing home. These people are more often older compared to those with a specific dementia diagnosis. In both persons living at home and persons living in a nursing home, DNOS was associated with more severe neuropsychiatric symptoms and less use of anti-dementia medication. In addition, persons with DNOS living at home had more symptoms of depression and less use of antidepressant medication.

Conclusions

The prevalence of DNOS diagnosis is common and seems to vary between European countries. People with DNOS are more often older with more severe neuropsychiatric symptoms and receive fewer anti-dementia medication, anxiolytics and antidepressants. This would support the suggestion that a proper and specific diagnosis of dementia could help the management of their disease.

Does the community-based combined Meeting Center Support Programme (MCSP) make the pathway to day-care activities easier for people living with dementia? A comparison before and after implementation of MCSP in three European countries

ABSTRACTBackground:The "pathway to care" concept offers a helpful framework for preparing national dementia plans and strategies and provides a structure to explore the availability and accessibility of timely and effective care for people with dementia and support for their informal carers. Within the framework of the JPND-MEETINGDEM implementation project the pathways to regular day-care activities and the Meeting Centers Support Programme (MCSP), an innovative combined support form for people with dementia and carers, was explored.

METHODS

An exploratory, descriptive, qualitative, cross-country design was applied to investigate the pathways to day care in several regions in four European countries (Italy, Poland, United Kingdom, and the Netherlands).

RESULTS

Before implementation of MCSP, of the four countries the United Kingdom had the most structured pathway to post-diagnostic support for people with dementia. MCSP introduction had a positive impact on the pathways to day-care activities in all countries. MCSP filled an important gap in post-diagnostic care, increasing the accessibility to support for both people with dementia and carers. Key elements such as program of activities, target group, and collaboration between healthcare and social services were recognized as success factors.

CONCLUSIONS

This study shows that MCSP fills (part of) the gap between diagnosis and residential care and can therefore be seen as a pillar of post-diagnostic care and support. Further dissemination of Meeting Centers in Europe may have a multiple impact on the structure of dementia services in European countries and the pathways to day care for people with dementia and their carer(s).

Dementia care and service systems - a mapping system tested in nine Swedish municipalities

Background

In dementia care, it is crucial that the chain of care is adapted to the needs of people with dementia and their informal caregivers throughout the course of the disease. Assessing the existing dementia care system with regard to facilities, availability and utilization may provide useful information for ensuring that the professional dementia care and service system meets the needs of patients and their families from disease onset to end of life.

Methods

The aim of this study was to further develop and test a mapping system, and adapt it to a local context. In addition, the aim was to assess availability and utilization of care activities as well as professional providers’ educational level in nine municipalities under the categories of Screening, the diagnostic procedures, and treatment; Outpatient care facilities; Institutional care and Palliative care. This cross-sectional study was conducted in April through May 2015. Data was derived from the health care and social service systems in nine rural and urban municipalities in two counties in Sweden. The mapping system covered seven categories with altogether 56 types of health care and social service activities.

Results

The mapping system was found to be reliable with minor adaptations to the context mainly in terms of activities. Availability of care activities was common with low utilization regarding Screening, the diagnostic procedures, and treatment; Outpatient care facilities; Institutional care and Palliative care and dementia trained staff was rare. Availability and utilization of care activities and professionals’ educational level was higher concerning screening, the diagnostic procedures and treatment compared with outpatient care facilities, institutional care and palliative care.

Conclusions

The mapping system enables policy makers and professionals to assess and develop health care and social service systems, to be offered proactively and on equal terms to people with dementia and their informal caregivers throughout the course of the disease. The educational level of professionals providing care and services may reveal where, in the chain of care, dementia-specific education for professionals, needs to be developed.

The facilitators and challenges of dying at home with dementia: A narrative synthesis

BACKGROUND:

It is reported that, given the right support, most people would prefer to die at home, yet a very small minority of people with dementia do so. At present, knowledge gaps remain on how best to support end-of-life care at home for people with dementia.

AIM:

To identify and understand the challenges and facilitators of providing end-of-life care at home for people with dementia.

DESIGN:

Narrative synthesis of qualitative and quantitative data.

DATA SOURCES:

The review adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. A systematic literature search was conducted across six electronic databases (AMED, BNI, CINAHL, EMBASE, MEDLINE and PsycINFO) and reference lists of key journals were searched up to July 2017.

RESULTS:

Searches returned 1949 unique titles, of which seven studies met all the eligibility criteria (four quantitative and three qualitative). Six key themes were identified – four facilitators and two challenges. Facilitators included ‘support from health care professionals’, ‘informal caregiver resilience and extended social networks’, ‘medications and symptom management’ and ‘appropriate equipment and home adaptations’. Challenges included ‘issues with professional services’ and ‘worsening of physical or mental health’.

CONCLUSION:

People with dementia may not always require specialist palliative care at the end of life. Further research is required to overcome the methodological shortcomings of previous studies and establish how community development approaches to palliative care, such as compassionate communities, can support families to allow a greater number of people with dementia to die at home.

"We don't have the infrastructure to support them at home": How health system inadequacies impact on long-term care admissions of people with dementia

OBJECTIVES

The influence of healthcare system factors on long-term care admissions has received relatively little attention. We address this by examining how inadequacies in the healthcare system impact on long-term care admissions of people with dementia. This is done in the context of the Irish healthcare system.

METHODS

Thirty-eight qualitative in-depth interviews with healthcare professionals and family carers were conducted. Interviews focused on participants' perceptions of the main factors which influence admission to long-term care. Interviews were analysed thematically.

RESULTS

The findings suggest that long-term care admissions of people with dementia may be affected by inadequacies in the healthcare system in three ways. Firstly, participants regarded the economic crisis in Ireland to have exacerbated the under-resourcing of community care services. These services were also reported to be inequitable. Consequently, the effectiveness of community care was seen to be limited. Secondly, such limits in community care appear to increase acute hospital admissions. Finally, admission of people with dementia to acute hospitals was believed to accelerate the journey towards long-term care.

CONCLUSIONS

Inadequacies in the healthcare system are reported to have a substantial impact on the threshold for long-term care admissions. The findings indicate that we cannot fully understand the factors that predict long-term care admission of people with dementia without accounting for healthcare system factors on the continuation of homecare.

Potentially preventable hospitalizations in dementia: family caregiver experiences

BACKGROUND

Health crises in persons living with dementia challenge their caregivers to make pivotal decisions, often under pressure, and to act in new ways on behalf of their care recipient. Disruption of everyday routines and heightened stress are familiar consequences of these events. Hospitalization for acute illness or injury is a familiar health crisis in dementia. The focus of this study is to describe the lived experience of dementia family caregivers whose care recipients had a recent unplanned admission, and to identify potential opportunities for developing preventive interventions.

METHODS

Family caregivers (n = 20) of people with dementia who experienced a recent hospitalization due to an ambulatory care sensitive condition or fall-related injury completed phone interviews. Interviews used semi-structured protocols to elicit caregivers' reactions to the hospitalization and recollections of the events leading up to it.

RESULTS

Analysis of interview data identified four major themes: (1) caregiver is uncertain how to interpret and act on the change; (2) caregiver is unable to provide necessary care; (3) caregiver experiences a personal crisis in response to the patient's health event; (4) mitigating factors may prevent caregiver crises.

CONCLUSIONS

This study identifies a need for clinicians and family caregivers to work together to avoid health crises of both caregivers and people with dementia and to enable caregivers to manage the health of their care recipients without sacrificing their own health and wellness.

Access to community care for people with dementia and their informal carers : Case vignettes for a European comparison of structures and common pathways to formal care

BACKGROUND

People with dementia and their informal carers often do not receive appropriate professional support or it is not received at the right time.

OBJECTIVES

Description and comparison of common pathways to formal community dementia care in eight European countries as a part of the transnational Actifcare project.

MATERIALS AND METHODS

The German team was responsible for creating an individual case scenario as a starting point. The research teams in Ireland, Italy, the Netherlands, Norway, Portugal, Sweden, and the United Kingdom were then asked to describe a common pathway to formal dementia care by writing their own vignette using the provided individual case scenario.

RESULTS

A transnational qualitative content analysis was used to identify the following categories as being the most important: involved professionals, dementia-specific and team-based approaches, proactive roles, and financial aspects. General practitioners (GPs) are described as being the most important profession supporting the access to formal care in all the involved countries. In some countries other professionals take over responsibility for the access procedure. Dementia-specific approaches are rarely part of standard care; team-based approaches have differing significances in each of the countries. Informal carers are mainly proactive in seeking formal care. The Nordic countries demonstrate how financial support enhances access to the professional system.

CONCLUSION

Enhanced cooperation between GPs and other professions might optimize access to formal dementia care. Team-based approaches focusing on dementia care should be developed further. Informal carers should be supported and relieved in their role. Financial barriers remain which should be further investigated and reduced.

Informal and formal care: Substitutes or complements in care for people with dementia? Empirical evidence for 8 European countries

BACKGROUND

In order to contain public health care spending, European countries attempt to promote informal caregiving. However, such a cost reducing strategy will only be successful if informal caregiving is a substitute for formal health care services. We therefore analyze the effect of informal caregiving for people with dementia on the use of several formal health care services.

STUDY DESIGN

The empirical analysis is based on primary data generated by the EU-project 'RightTimePlaceCare' which is conducted in 8 European countries. 1223 people with dementia receiving informal care at home were included in the study.

METHODS

Using a regression framework we analyze the relationship between informal care and three different formal health care services: the receipt of professional home care, the number of nurse visits and the number of outpatient visits.

RESULTS

The relationship between formal and informal care depends on the specific type of formal care analyzed. For example, a higher amount of informal caregiving goes along with a lower demand for home care services and nurse visits but a higher number of outpatient visits.

CONCLUSION

Increased informal caregiving effectively reduces public health care spending by reducing the amount of formal home care services. However, these effects differ between countries.

Improving the mix of institutional and community care for older people with dementia: an application of the balance of care approach in eight European countries

OBJECTIVES

To examine whether the mix of community and institutional long-term care (ILTC) for people with dementia (PwD) in Europe could be improved; assess the economic consequences of providing alternative services for particular groups of ILTC entrants and explore the transnational application of the 'Balance of Care' (BoC) approach.

METHOD

A BoC study was undertaken in Estonia, Finland, France, Germany, the Netherlands, Spain, Sweden, and the UK as part of the RightTimePlaceCare project. Drawing on information about 2014 PwD on the margins of ILTC admission, this strategic planning framework identified people whose needs could be met in more than one setting, and compared the relative costs of the possible alternatives.

RESULTS

The findings suggest a noteworthy minority of ILTC entrants could be more appropriately supported in the community if enhanced services were available. This would not necessarily require innovative services, but more standard care (including personal and day care), assuming quality was ensured. Potential cost savings were identified in all countries, but community care was not always cheaper than ILTC and the ability to release resources varied between nations.

CONCLUSIONS

This is believed to be the first transnational application of the BoC approach, and demonstrates its potential to provide a consistent approach to planning across different health and social care systems. Better comparative information is needed on the number of ILTC entrants with dementia, unit costs and outcomes. Nevertheless, the findings offer important evidence on the appropriateness of current provision, and the opportunity to learn from different countries' experience.

Professional care providers in dementia care in eight European countries; their training and involvement in early dementia stage and in home care

Knowledge concerning professionals involved in dementia care throughout its trajectory is sparse; the focus has mainly been on nursing-home care and less on home care, diagnosis and treatment of the disease and its complications despite the fact that home care is the most prominent type of care. The aim of this study was to explore and describe professional care providers involved in dementia care and their educational level applying the International Standard Classification of Education (ISCED) and further to investigate practice in the RightTimePlaceCare-countries with regard to screening, diagnostic procedures and treatment of dementia and home care. The findings demonstrate more similarities than differences in terms of type of professionals involved among the countries although untrained staff were more common in some countries. Findings also show that many types of professionals are involved, who to turn to may not be clear, for instance in terms of medical specialities and it may be unclear who bears the ultimate responsibility. The professionals involved in diagnosis, treatment and care are educated to bachelor’s level or above whilst everyday care is provided by people trained at a lower ISCED level or with no formal training. Registered nurses as well as occupational therapists have bachelor’s degrees in most countries, but not in Germany or Estonia. Professionals specifically trained in dementia care are not so common. Further research is needed to reveal not only who provides the diagnostics and treatment, but also how home care is organised and quality assured. Many different types of professionals serve as providers along the trajectory of the disease which may be difficult for the patient and the informal caregiver to cope with.

Life after PACE (Program of All-Inclusive Care for the Elderly): A retrospective/prospective, qualitative analysis of the impact of closing a nurse practitioner centered PACE site

BACKGROUND AND PURPOSE

Caring for frail older adults is a significant healthcare concern as the frailest 10% of the population account for over 70% of healthcare expenditures. Research reveals the use of comprehensive models, such as Program of All-Inclusive Care for the Elderly (PACE), leads to improved functional outcomes for participants and cost savings through decreased utilization. This study examines how closing a PACE program impacts health outcomes of previously enrolled participants.

METHODS

Data were collected every 6 months for 2 years via phone surveys on 34 former participants enrolled in the program at the time of the closure. The survey included questions regarding satisfaction with care, activities of daily living (ADLs), instrumental ADLs (IADLs), emergency department (ED) visits, hospitalizations, and use of home health services. Deaths and nursing home placements were monitored. Outcomes were compared during and post-PACE.

CONCLUSIONS

Higher numbers of ED visits, hospitalizations, and nursing home placements occurred post-PACE. PACE/post-PACE differences in ADL and IADL scores were not significant, nor were death rates. Higher satisfaction existed with PACE versus non-PACE care.

IMPLICATIONS FOR PRACTICE

Comprehensive care programs such as PACE are effective in reducing healthcare utilization, thus limiting costs. Further work is required to maintain, develop, and support comprehensive models similar to PACE.

Perspectives About Health Care Provision in Dementia Care in Spain: A Qualitative Study Using Focus-Group Methodology

BACKGROUND

The aim of this study is to identify the barriers and facilitators in dementia care with respect to information provision, communication, and collaboration from the perspectives of the person with dementia, family caregivers, and health care professionals over the course of the illness.

METHODS

A qualitative study using Focus-Group methodology was carried out in people with dementia, family caregivers, and health care providers.

RESULTS

The categories that emerged from the analysis were insufficient information provided, specific dementia care needs, and acceptance of long-term care institutionalization from the people with dementia and caregivers' groups and insufficient communication between health care providers, differential information according to disease stage, and home care coordination from the health care providers' groups.

CONCLUSION

The family is a key element in successful care coordination during dementia care provision. New effective strategies including self-management and emergent roles, such as case managers, could bring great benefits to people with dementia, caregivers, and health care providers.

Formal support for informal caregivers to older persons with dementia through the course of the disease: an exploratory, cross-sectional study

BACKGROUND

In European countries, knowledge about availability and utilization of support for informal caregivers caring for older persons (≥65 years) with dementia (PwD) is lacking. To be able to evaluate and develop the dementia support system for informal caregivers to PwD, a survey of European support systems and professionals involved is needed. The aim of this study was to explore support for informal caregivers to PwD in European countries. We investigated the availability and utilization of support in each of the participating countries, and the professional care providers involved, through the dementia disease.

METHODS

A mapping system was used in 2010-2011 to gather information about estimations of availability, utilization, and professional providers of support to informal caregivers caring for PwD. Data collected was representing each country as a whole.

RESULTS

There was high availability of counselling, caregiver support, and education from the diagnosis to the intermediate stage, with a decrease in the late to end of life stage. Utilization was low, although there was a small increase in the intermediate stage. Day care and respite care were highly available in the diagnosis to the intermediate stage, with a decrease in the late to end of life stage, but both types of care were utilized by few or no caregivers through any of the disease stages. Professionals specialized in dementia (Bachelor to Master's degree) provided counselling and education, whereas caregiver support for informal caregivers and day care, respite care, and respite care at home were provided by professionals with education ranging from upper secondary schooling to a Master's degree.

CONCLUSIONS

Counselling, caregiver support, and education were highly available in European countries from diagnosis to the intermediate stage of the dementia disease, decreasing in the late/end of life stages but were rarely utilized. Countries with care systems based on national guidelines for dementia care seem to be more aware of the importance of professionals specialized in dementia care when providing support to informal caregivers. Mapping the systems of support for informal caregivers of PwD is a valuable tool for evaluating existing systems, internationally, nationally and locally for policy making.

Living Alone with Alzheimer's Disease and the Risk of Adverse Outcomes: Results from the Plan de Soin et d'Aide dans la maladie d'Alzheimer Study

OBJECTIVES

To examine whether living alone predicted hospitalizations, nursing home admission, weight loss, and death in individuals with mild to moderate Alzheimer's disease (AD) over 2 years of follow-up.

DESIGN

Data are from the Plan de Soin et d'Aide dans la maladie d'Alzheimer study, a 24-month trial with a cluster randomization of memory clinics in two arms: a multidomain intervention and usual care.

SETTING

Memory clinics in France (N = 50).

PARTICIPANTS

Community-dwelling individuals with AD with a Mini-Mental State Examination score between 12 and 26 and an identified caregiver.

MEASUREMENTS

A neurogeriatric evaluation was conducted twice a year in the intervention group and annually in the control group. Hospitalizations, nursing home admission, weight loss, and death occurring during the past year were recorded. Information on sociodemographic characteristics, clinical conditions, therapy, and physical and cognitive status was recorded.

RESULTS

At inclusion, 348 (30.8%) of the 1,131 participants lived alone. Living alone did not increase the risk of mortality or weight loss in individuals with mild to moderate AD, but significant associations with risk of hospitalization (hazard ratio (HR) = 1.33, 95% confidence interval (CI) = 1.01-1.74) and institutionalization (HR = 2.53, 95% CI = 1.84-3.47) were reported. A protective effect of physical function on institutionalization and mortality was found.

CONCLUSION

These results might support clinicians in making decisions about institutionalization of individuals with AD living alone or improving home health care, such as increasing screening and managing functional impairment in this complex population.

Dementia care in European countries, from the perspective of people with dementia and their caregivers

AIM

To investigate persons with dementia and their informal caregivers' views of inter-sectoral information, communication and collaboration throughout the trajectory of dementia care, in eight European countries.

BACKGROUND

Living with dementia and being next of kin to a person with dementia means having to live through stages that have different characteristics, needs, challenges and requirements.

DESIGN

Qualitative research. Focus groups were conducted in England, Estonia, Finland, France, Germany, The Netherlands, Spain and Sweden.

METHODS

Persons with dementia and their informal caregivers (N = 137) participated in focus group interviews during 2011. Content analysis generated a tentative model of information, communication and collaboration for people with dementia and their caregivers, which was then tested.

RESULTS

The core finding was that information, communication and collaboration were to be focused on the persons with dementia and the informal caregivers. Entering into the trajectory of the disease and its consequences was addressed as an important point of departure. The relation to professional care required establishing a trusting relationship, tailor-made intervention and a single person or organization to contact. Professional knowledge and commitment, variation in service and care adapted to needs were important.

CONCLUSION

As focus of care is on the person with dementia and their informal caregivers, a dyadic approach seems most suitable for dementia care. A trusting relationship and a specific person or organization to contact seem to be indicators of best practice, as does adaptation to the needs of the person with dementia and their informal caregiver.

Media portrayal of older people as illustrated in Finnish newspapers

Media portrayals of older people, such as those in newspapers, both inform and reflect public attitudes. By becoming aware of culturally influenced attitudes about older people, and how these attitudes are reflected in the ways older people are viewed, treated, and cared for in society, the healthcare profession can better understand how to provide high-quality care. By applying an ethnographic approach in textual reality, this paper explores how newspaper articles focusing on health portray older people in society, using Finland as an example. The data consist of articles selected from three of the main Finnish daily newspapers during a 3-month period in the spring of 2012. The findings show that, overall, the society regards older people and their care as important. However, there were suggestions of paternalistic attitudes towards older people. Furthermore, the perceptions regarding different groups of older people could lead to the possibility of inequality. The media portrayals of older people worldwide seem to share similarities, although the findings of this study are particularly in accordance with the cultural attributes of the Nordic countries and societies.

The association between positive-negative reactions of informal caregivers of people with dementia and health outcomes in eight European countries: a cross-sectional study

AIM

To describe the associations between positive and negative reactions of informal caregivers of people with dementia and health outcomes across eight European Countries.

BACKGROUND

Caring for someone with dementia may have implications for the caregiver's own health and for the care recipient. These consequences could be associated with caregivers' reactions to the process of care.

DESIGN

Association study based on cross-sectional data.

METHODS

Participants were people with dementia and their informal caregivers living at home or in long-term care institutions. Data were collected between November 2010-April 2012 using the Caregiver Reaction Assessment (with dimensions of self-esteem, lack of family support, financial problems, disrupted schedule and health problems) and associations were sought with informal caregiver burden, quality of life and psychological well-being and with dementia sufferers' neuropsychiatric symptoms, comorbidity and dependency in activities of daily living using correlation coefficients.

RESULTS

Data from 2014 participants were used. Variability across countries was noted, as well as differences between care at home and in long-term care institutions. In general, self-esteem and lack of family support correlated with caregiver burden and psychological well-being. Associations were also found between disrupted schedule and caregiver burden, psychological well-being and quality of life. Health problems were clearly associated with caregiver burden, psychological well-being and quality of life.

CONCLUSION

Study results support links between the reactions of informal caregivers of people with dementia and health outcomes. These may have implications in terms of how services are addressed.

Concept analysis of family homeostasis

AIM

To report a concept analysis of family homeostasis.

BACKGROUND

As family members are a majority of informal caregivers, negative consequences from caregiving duty create a vicious cycle in the family unit resulting in ongoing health crises and care challenges.

DESIGN

Concept analysis.

DATA SOURCES

Forty empirical studies published from 1956-2012 were selected by searching five electronic bibliographical databases and by a manual search conducted from 2012-2013. Search terms included 'family homeostasis', 'homeostasis in family', 'homeostatic care' and 'family equilibrium'. Clinical experiences in nursing practice were used for constructing cases and clinical implications.

METHODS

Walker and Avant's method guided this analysis.

RESULTS

Family homeostasis is defined as the capacity and mechanisms by which equilibrium is re-established in the family after a change occurs. Five critical attributes are identified: (1) predetermined setpoint; (2) self-appraised antecedents; (3) interdependence; (4) tendency to stability; and (5) feedback mechanisms. Antecedents include any type of causative change beyond the tolerable limit, while consequences encompass intermediate and long-term outcomes as well as equilibrium itself.

CONCLUSION

Family homeostasis provides a conceptual rationale of family caregiving. While care recipients remain the primary beneficiaries of healthcare provision, homeostatic mechanisms are required to support the family caregiver's valuable contribution in the caring process to enhance family well-being. Further study should expand the definition and settings of family to reflect healthcare needs of diverse types of families and from the perspectives of different healthcare providers.