Creative Music Therapy in an Acute Care Setting for Older Patients with Delirium and Dementia

Hospital nurses perceived challenges and opportunities in the care of people with dementia: A mixed-methods systematic review

AIM

To synthesise evidence from the literature on hospital nurses' perceived challenges and opportunities in the care of people with dementia.

BACKGROUND

People with dementia often have longer lengths of hospital stay and poorer health outcomes compared to those without dementia. Nurses play a pivotal role in the care of people with dementia. However, there is a scarcity of systematic reviews that synthesise the challenges and opportunities they perceive.

METHODS

A mixed-methods systematic review was conducted with a database search covering Ageline, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Emcare, Embase, Medline, PsycINFO, ProQuest, Scopus and Web of Science in April 2022. In total, 27 articles that met the selection criteria were critically reviewed and included in this systematic review. Data from the selected articles were extracted and synthesised using a convergent segregated approach.

RESULTS

Three main themes and eight subthemes were identified. Theme 1 described nurse-related factors consisting of the lack of capability in dementia care, experiencing multiple sources of stress and opportunities for nurses to improve dementia care. Theme 2 revealed people living with dementia-related factors including complex care needs and the need to engage family carers in care. Theme 3 explained organisation-related factors comprising the lack of organisational support for nurses and people with dementia and opportunities for quality dementia care.

CONCLUSION

Hospital nurses experience multidimensional challenges in the care of people with dementia. Opportunities to overcome those challenges include organisational support for nurses to develop dementia care capability, reduce their stress and partner with the family caregivers.

RELEVANCE TO CLINICAL PRACTICE

Hospitals will need to build an enabling environment for nurses to develop their capabilities in the care of people with dementia. Further research in empowering nurses and facilitating quality dementia care in acute care hospitals is needed.

REPORTING METHOD

The review followed the PRISMA 2020 checklist.

PATIENT OR PUBLIC CONTRIBUTION

No.

'It helps you forget your worries': A pilot study exploring music therapy in the acute hospital aged care setting

OBJECTIVES

Few studies have explored music therapy (MT) in an acute aged care inpatient setting. We aimed to assess feasibility and patient/staff perceptions of an 8-week MT program on an acute geriatric ward.

METHODS

An 8-week in-person MT program, comprising brief receptive musical interventions up to twice-weekly. All patients admitted to the aged care ward were eligible for inclusion. A hard copy survey was used to assess patient and staff perceptions of MT. Themes raised in free-text responses were manually coded within a thematic analysis approach. A mixed methods approach was used to obtain and analyse data relating to feasibility and patient and staff perceptions of the MT intervention.

RESULTS

The 8-week program ran to completion and was delivered to a median of 11 patients (IQR 9-12) each session (median 8 new/day). In total, 10 patients completed surveys, mean age 81.1 (SD 7.7); 60% were women and all had cognitive impairment. Following an MT session, eight of eight responding patients reported feeling happy and eight of eight reported they would recommend MT. Staff respondents (n = 19) reported patients appeared happy (19/19), relaxed (13/19) and all would recommend MT to other patients. Common themes were that MT was followed by improved patient behaviour and mood, and stimulated patients.

CONCLUSIONS

An acute aged care inpatient MT program proves feasible and well-received by staff and patients. Future research may focus on more robust data collection in larger sample sizes, specific types of MT and more in-depth exploration of the patient and carer experiences.

Reimagine the ICU: Healthcare Professionals' Perspectives on How Environments (Can) Promote Patient Well-Being

OBJECTIVE

This study aims (1) to understand the needs and challenges of the current intensive care unit (ICU) environments in supporting patient well-being from the perspective of healthcare professionals (HCPs) and (2) to explore the new potential of ICU environments enabled by technology.

BACKGROUND

Evidence-based design has yielded how the design of environments can advocate for patient well-being, and digital technology offers new possibilities for indoor environments. However, the role of technology in facilitating ICU patient well-being has been unexplored.

METHOD

This study was conducted in two phases. First, a mixed-method study was conducted with ICU HCPs from four Dutch hospitals. The study investigated the current environmental support for care activities, as well as the factors that positively and negatively contribute to patient experience. Next, a co-creation session was held involving HCPs and health technology experts to explore opportunities for technology to support ICU patient well-being.

RESULTS

The mixed-method study revealed nine negative and eight positive patient experience factors. HCPs perceived patient emotional care as most challenging due to the ICU workload and a lack of environmental support in fulfilling patient emotional needs. The co-creation session yielded nine technology-enabled solutions to address identified challenges. Finally, drawing from insights from both studies, four strategies were introduced that guide toward creating technology to provide holistic and personalized care for patients.

CONCLUSION

Patient experience factors are intertwined, necessitating a multifactorial approach to support patient well-being. Viewing the ICU environment as a holistic unit, our findings provide guidance on creating healing environments using technology.

Investigating the impact of music therapy on two in-patient psychiatric wards for people living with dementia: retrospective observational study

BACKGROUND

Music therapy can lift mood and reduce agitation for people living with dementia (PwD) in community and residential care settings, potentially reducing the prevalence of distress behaviours. However, less is known about the impact of music therapy on in-patient psychiatric wards for PwD.

AIMS

To investigate the impact of music therapy on two in-patient psychiatric wards for PwD.

METHOD

A mixed-methods design was used. Statistical analysis was conducted on incidents involving behaviours reported as 'disruptive and aggressive' in 2020, when music therapy delivery varied because of the COVID-19 pandemic. Semi-structured interviews conducted online with three music therapists and eight ward-based staff were analysed using reflexive thematic analysis.

RESULTS

Quantitative findings showed a significant reduction in the frequency of behaviours reported as disruptive and aggressive on days with in-person music therapy (every 14 days) than on the same weekday with no or online music therapy (every 3.3 or 3.1 days, respectively). Qualitative findings support this, with music therapy reported by music therapists and staff members to be accessible and meaningful, lifting mood and reducing agitation, with benefits potentially lasting throughout the day and affecting the ward environment.

CONCLUSIONS

We identified a significant reduction in the occurrence of distress behaviours on days with in-person music therapy when compared with no music therapy. Music therapy was reported to be a valuable intervention, supporting patient mood and reducing agitation. Interventional studies are needed to investigate the impact of music therapy and its optimum mode of delivery.

Co-created decision-making: From co-production to value co-creation in health care

Rare diseases are characterized by a wide diversity of signs and symptoms and vary not only from disease to disease but also from person to person, and living with a disease leads patients to peculiar experiences, without limits of time and space, as they extend to various environments and relationships of their lives. Therefore, the objective of this study is the theoretical interaction between value co-creation (VC) and the stakeholder theory (ST) with the shared decision-making (SDM) health care theory, to enable the analysis of the relationships between patients and their stakeholders in the co-creation of value for decision-making focused on the patient's quality of life. It is configured as a multi-paradigmatic proposal by enabling the analysis of multiple perspectives of different stakeholders in health care. Thus, co-created decision-making (CDM) emerges with emphasis on interactivity of the relationships. As previous studies have already highlighted the importance of holistic care, seeing the patient as a whole and not just the body, studies with CDM will be beneficial for analyses that go beyond the clinical office and doctor-patient relationships, extending to all environments and interactions that add value to the patient's treatment. It was concluded that the essence of this new theory proposed here is neither in patient-centered care nor in patient self-care, but in co-created relationships with and between stakeholders, including non-health care environments that are important to the patient, such as relationships with friends, family, other patients with the same disease, social media, public policies, and the practice of pleasurable activities.

Photo-elicited conversations about meetings with a therapy dog as a tool for communication in dementia care: An observational study

INTRODUCTION

It is well-known that people with dementia living in residential care facilities spend most of their time not engaged in meaningful activities. Being involved in activities can improve their quality of life. Animal-assisted therapy is an activity that can evoke engagement and joy. Another way to create engagement and promote communication between people with dementia and caregivers is to use photos.

METHODS

In this observational study, the researchers combined animal-assisted therapy and photobooks in order to explore whether photos of people with dementia who were engaged in animal-assisted therapy could be used as a tool for communication in dementia care. Ten persons (4 men and 6 women; aged 72-92) with dementia were video recorded during photo-elicited conversations with a dog handler/assistant nurse. The recordings were conducted in two residential care facilities in Sweden during 2017-2018. Each participant was video recorded 2-4 times. The recordings were analysed using The Observed Emotion Rating Scale and The Observational Measurement of Engagement-OME Modified. In addition, the video recordings were interpreted from a hermeneutic perspective.

FINDINGS

The findings showed that the most frequently observed effects were pleasure and general alertness, and the participants were observed to be attentive most of the time. The most common attitude during the conversations was 'somewhat positive'. The hermeneutic interpretations were grouped into four themes: Conveys a structure for the conversation with an inherent beginning and ending; An opportunity to recognise oneself and recall a sense of belonging; Awakens emotions and creates fellowship and Entails confirmation and revitalises their identity.

CONCLUSION

Photobooks can be used by caregivers as a tool for meaningful and joyful communication with people with dementia, even those with severe dementia.

Music Interventions and Delirium in Adults: A Systematic Literature Review and Meta-Analysis

Delirium is a neuropsychiatric syndrome represented by an acute disturbance in attention, awareness and cognition, highly prevalent in older, and critically ill patients, and associated with poor outcomes. This review synthesized existing evidence on the effectiveness of music interventions on delirium in adults, and music interventions (MIs), psychometric assessments and outcome measures used. We searched MEDLINE, PsychINFO, SCOPUS, Clinical Trials and CENTRAL for quantitative designs comparing any MIs to standard care or another intervention. From 1150 studies 12 met the inclusion criteria, and 6 were included in the meta-analysis. Narrative synthesis showed that most studies focused on prevention, few assessed delirium severity, with the majority of studies reporting beneficial effects. The summary relative risk for incident delirium comparing music vs. no music in postsurgical and critically ill older patients was 0.52 (95% confidential interval (CI): 0.20−1.35, I2 = 79.1%, heterogeneity <0.0001) for the random effects model and 0.47 (95% CI: 0.34−0.66) using the fixed effects model. Music listening interventions were more commonly applied than music therapy delivered by credentialed music therapists, and delirium assessments methods were heterogeneous, including both standardized tools and systematic observations. Better designed studies are needed addressing effectiveness of MIs in specific patient subgroups, exploring the correlations between intervention-types/dosages and delirium symptoms.

Music, Mind, Mood, and Mingling in Alzheimer's Disease and Related Dementias: A Scoping Review

BACKGROUND

Music-based interventions may help to alleviate neuropsychiatric symptoms of dementia and promote prosocial interactions between individuals living with dementia and their caregivers. However, current literature does not combine these evidence bases toward explanation of how music-based interventions may alleviate symptoms and promote prosocial interactions.

OBJECTIVE

We conducted a scoping review to address the following question: what do the evidence bases suggest toward how music therapy or music-based therapeutic interventions might promote prosocial interactions between individuals living with dementia and their caregivers?

METHODS

In this review we focused on: 1) quantitative and qualitative evidence of music-based therapies promoting prosocial behaviors in individuals living with dementia, and 2) potential neurobehavioral mechanisms associated with the processes involved with how music may promote prosocial interactions. Databases included PubMed, EBSCOhost's CINAHL and PsycINFO, Cochrane Library (sub-search conducted using ALOIS, the Specialized Register of the Cochrane Dementia and Cognitive Improvement Group), Web of Science, clinicaltrials.gov, ProQuest's Biological Science Collection, the Journal of Music Therapy, Nordic Journal of Music Therapy, and Google Scholar.

RESULTS

Sixteen original research studies were included for evidence synthesis. This scoping review reveals the need to define and clarify mechanisms of prosocial interactions between individuals living with dementia and their caregivers considering biological and social factors. These mechanisms may include dynamic interactions between preserved brain regions associated with music-evoked autobiographical memory recall and shifts from negative to positive mood states.

CONCLUSION

Defining and clarifying how and to what extent music may promote prosocial behaviors using well-designed and well-controlled mixed-methods studies may positively influence the design of interventions to promote prosocial interactions with caregivers.

Challenges of Singapore’s First Acute Geriatric Isolation Facility During the COVID-19 Pandemic

Aim

The COVID-19 pandemic has seen hospitals isolating suspect cases. Geriatric populations are at a risk of severe COVID-19 disease and often present with concomitant geriatric syndromes requiring holistic interdisciplinary care. However, isolation of older people poses challenges to care delivery. This study shares the experience of Singapore’s first acute geriatric isolation facility geriatric PARI (Pneumonia-Acute Respiratory Infection) ward and describes the geriatric-related outcomes and pitfalls in care delivery.

Methods

This is a retrospective cross-sectional study performed in 7 negative pressure isolation rooms in an acute care public hospital in Singapore. 100 patients admitted consecutively to the geriatric PARI ward were included. Patient demographics, presenting symptoms and geriatric-related adverse outcomes associated with hospitalisation were collected and analysed.

Results

Patients’ mean age was 86.4 years (standard deviation [SD]: 6.8) with significant comorbidities being hypertension (81%), hyperlipidaemia (74%) and renal disease (70%). 51% of patients had dementia and 24% had behaviour and psychological symptoms of dementia (BPSD). 27% of patients presented atypically with delirium and 15% presented with a fall. Delirium was associated with restraint use (OR: 3.88; p-value 0.01). Falls rate was 1.64 per 1000 occupied bed. 1 patient screened positive for COVID-19.

Conclusions

The geriatric PARI ward is essential for curbing nosocomial transmission of COVID-19. This is important in the older people with comorbidities who are more likely to develop morbidity and mortality. Our study reveals challenges in delivering person-centred care to the older patients in isolation rooms, especially in the management of delirium and falls prevention. Innovative strategies should be developed to minimise isolation-related adverse outcome.

Overview and Strategy Analysis of Technology-Based Nonpharmacological Interventions for In-Hospital Delirium Prevention and Reduction: Systematic Scoping Review

BACKGROUND

Delirium prevention is crucial, especially in critically ill patients. Nonpharmacological multicomponent interventions for preventing delirium are increasingly recommended and technology-based interventions have been developed to support them. Despite the increasing number and diversity in technology-based interventions, there has been no systematic effort to create an overview of these interventions for in-hospital delirium prevention and reduction.

OBJECTIVE

This systematic scoping review was carried out to answer the following questions: (1) what are the technologies currently used in nonpharmacological technology-based interventions for preventing and reducing delirium? and (2) what are the strategies underlying these currently used technologies?

METHODS

A systematic search was conducted in Scopus and Embase between 2015 and 2020. A selection was made in line with the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR). Studies were eligible if they contained any type of technology-based interventions and assessed delirium-/risk factor-related outcome measures in a hospital setting. Data extraction and quality assessment were performed using a predesigned data form.

RESULTS

A total of 31 studies were included and analyzed focusing on the types of technology and the strategies used in the interventions. Our review revealed 8 different technology types and 14 strategies that were categorized into the following 7 pathways: (1) restore circadian rhythm, (2) activate the body, (3) activate the mind, (4) induce relaxation, (5) provide a sense of security, (6) provide a sense of control, and (7) provide a sense of being connected. For all technology types, significant positive effects were found on either or both direct and indirect delirium outcomes. Several similarities were found across effective interventions: using a multicomponent approach or including components comforting the psychological needs of patients (eg, familiarity, distraction, soothing elements).

CONCLUSIONS

Technology-based interventions have a high potential when multidimensional needs of patients (eg, physical, cognitive, emotional) are incorporated. The 7 pathways pinpoint starting points for building more effective technology-based interventions. Opportunities were discussed for transforming the intensive care unit into a healing environment as a powerful tool to prevent delirium.

TRIAL REGISTRATION

PROSPERO International Prospective Register of Systematic Reviews CRD42020175874; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=175874.

Use of Palliative Care Music Therapy in a Hospital Setting during COVID-19

As many hospitals scaled back integrative therapies during the COVID-19 pandemic, we instead turned to the multifaceted qualities of music to bridge physical and social divides. In this report, we describe palliative care music therapists as frontline providers utilizing evidence-based approaches to support healing and recovery for patients in the intensive care unit, patient and family care at end of life, and staff wellness. We provide examples of music therapy (MT) to promote successful weaning from mechanical ventilation, create bedside rituals and legacy gifts for dying patients and their families, and provide real-time support for overwhelmed staff. Despite barriers brought on by the pandemic, the sensory and emotional immediacy of music bridged social distances at critical moments and addressed "suffering beyond words" among patients, families and health care workers. Our experience reinforced the need for MT as standard of interdisciplinary care during the pandemic and beyond.

Development of an assessment scale for engagement in activities for patients with moderate to severe dementia

BACKGROUND

Various types of therapy, including occupational therapy, are utilised for the treatment of moderate to severe dementia. In order to determine the optimal rehabilitation strategy for such patients and examine the treatment efficacy, an assessment scale for engagement in various group activities that can be easily applied in clinical situations is required. We herein report the development of the Assessment Scale for Engagement in Activities (ASEA) and its clinical utility.

METHODS

The ASEA was developed by nine occupational therapists and a psychiatrist with experience in developing measures for dementia, in accordance with the COSMIN (COnsensus-based Standards for the selection of health status Measurement INstruments) checklist. This assessment comprises 10 items covering four domains: Engagement in the Activity, Interaction, Arousal, and Affect. Participants with moderate to severe dementia who resided in a psychiatric acute phase hospital in Japan were assessed in terms of engagement in activities using the ASEA and Todai-shiki Observational Rating Scale (TORS), and in terms of cognitive function using the Mini-Mental State Examination (MMSE). We examined the internal consistency, inter- and intra-rater reliability, content validity, and concurrent validity of the ASEA.

RESULTS

Cronbach's alpha of the ASEA was 0.889. The overall inter-rater reliability was 0.937 (Spearman rank correlation, P < 0.001), and the intraclass correlation (ICC) for each item was 0.490-0.965 (P < 0.018-0.001). The overall test-retest reliability was 0.778 (Spearman's rank correlation, P < 0.001), and the ICC for each item was 0.498-0.863 (P < 0.023-0.001). The test-retest correlations were significant for almost all items, aside from 'Interaction with others' (P = 0.051). The concurrent validity, examined using the TORS and MMSE, was 0.920 and 0.304 (Spearman's rank correlation, P < 0.001-0.006).

CONCLUSIONS

The ASEA has confirmed reliability and validity, aside from 'Interaction with others' regarding test-retest reliability. Generally, this assessment tool has clinical utility and allows the evaluation of activity engagement among patients with moderate to severe dementia.

Understanding and improving experiences of care in hospital for people living with dementia, their carers and staff: three systematic reviews

Background

Being in hospital can be particularly confusing and challenging not only for people living with dementia, but also for their carers and the staff who care for them. Improving the experience of care for people living with dementia in hospital has been recognised as a priority.

Objectives

To understand the experience of care in hospital for people living with dementia, their carers and the staff who care for them and to assess what we know about improving the experience of care.

Review methods

We undertook three systematic reviews: (1) the experience of care in hospital, (2) the experience of interventions to improve care in hospital and (3) the effectiveness and cost-effectiveness of interventions to improve the experience of care. Reviews 1 and 2 sought primary qualitative studies and were analysed using meta-ethnography. Review 3 sought comparative studies and economic evaluations of interventions to improve experience of care. An interweaving approach to overarching synthesis was used to integrate the findings across the reviews.

Data sources

Sixteen electronic databases were searched. Forwards and backwards citation chasing, author contact and grey literature searches were undertaken. Screening of title and abstracts and full texts was performed by two reviewers independently. A quality appraisal of all included studies was undertaken.

Results

Sixty-three studies (reported in 82 papers) were included in review 1, 14 studies (reported in 16 papers) were included in review 2, and 25 studies (reported in 26 papers) were included in review 3. A synthesis of review 1 studies found that when staff were delivering more person-centred care, people living with dementia, carers and staff all experienced this as better care. The line of argument, which represents the conceptual findings as a whole, was that ‘a change of hospital culture is needed before person-centred care can become routine’. From reviews 2 and 3, there was some evidence of improvements in experience of care from activities, staff training, added capacity and inclusion of carers. In consultation with internal and external stakeholders, the findings from the three reviews and overarching synthesis were developed into 12 DEMENTIA CARE pointers for service change: key institutional and environmental practices and processes that could help improve experience of care for people living with dementia in hospital.

Limitations

Few of the studies explored experience from the perspectives of people living with dementia. The measurement of experience of care across the studies was not consistent. Methodological variability and the small number of intervention studies limited the ability to draw conclusions on effectiveness.

Conclusions

The evidence suggests that, to improve the experience of care in hospital for people living with dementia, a transformation of organisational and ward cultures is needed that supports person-centred care and values the status of dementia care. Changes need to cut across hierarchies and training systems to facilitate working patterns and interactions that enable both physical and emotional care of people living with dementia in hospital. Future research needs to identify how such changes can be implemented, and how they can be maintained in the long term. To do this, well-designed controlled studies with improved reporting of methods and intervention details to elevate the quality of available evidence and facilitate comparisons across different interventions are required.

Study registration

This study is registered as PROSPERO CRD42018086013.

Funding

This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 8, No. 43. See the NIHR Journals Library website for further project information. Additional funding was provided by the NIHR Collaboration for Leadership in Applied Health Research and Care South West Peninsula.

Unmittelbare Reaktionen von Menschen mit Demenz auf individualisierte Musik - Analyse von Verhaltensbeobachtungen im Pflegeheim

Immediate reactions of people with dementia to individualized music - Analysis of behavioral observations in a nursing home Abstract. Background: Due to the increasing prevalence of dementia, there is an urgent need for effective non-pharmacological interventions to improve the quality of life of people with dementia (PwD) and to relieve their carers. Studies show evidence for the benefits of individualized music. However, the immediate reactions to individualized music have not yet been adequately investigated.

AIM

The research objective of the study was the investigation of the immediate effects of an individualized music intervention in a nursing home using a newly developed systematic behavioral observation rating scale.

METHODS

In 153 behavioral observations of 20 PwD, 32 different experiences and behaviors pertaining to 11 categories such as emotional and motor changes which indicate immediate reactions to listening to music were rated.

RESULTS

Participants showed significantly more positive reactions (e. g. joy or relaxation) and less negative reactions immediately after listening to the music compared to before. Moreover, in the course of listening to music, participants showed significantly more positive reactions, most often smiles, movements to music, attentive listening, relaxation and general vigilance / interest / social contact.

CONCLUSIONS

The systematic behavioral observation rating scale proved to be a suitable method for rating the experiences and behaviors of people with dementia. Listening to individualized music seems to be a helpful intervention for PwD in institutional care settings.

Music-based interventions in the acute setting for patients with dementia: a systematic review

PURPOSE

The utilization of non-pharmacological interventions is increasingly recommended in dementia care. Among them, Music-based interventions seem promising options, according with numerous positive studies conducted in long-term care institutions. In this review, we aim to investigate its administration to patients with dementia in a less-researched setting-the acute hospital.

METHODS

A systematic review (PROSPERO registration: 81698), according to PRISMA recommendations, was performed. Embase, PubMed, PsycINFO, ASSIA and Humanities Index were searched from first records to June 2019 and the search was updated in June 2020. Manual screening of journals, trial registries and grey literature was undertaken. Risk of bias was assessed with the Downs and Black (1998) checklist.

RESULTS

345 records were initially retrieved and nine complied with the inclusion criteria. Data on 246 acute inpatients (224 PwD), with a mean age (reported only in 4 studies) varying from 74.1 to 86.5 was presented. Interventions varied significantly and practical details of their administration and development were poorly reported. Overall, quantitative results indicate a trend towards a positive effect in well-being, mood, engagement/relationship and global cognitive function, as well as a reduction in BPSD, resistive care, utilization of pro re nata medication and one-on-one care. Qualitative data also demonstrates acceptability and positive effects of music-based interventions.

CONCLUSION

Despite the lack of robust, adequately powered and controlled trials, identified studies suggest it is feasible to deliver music-based interventions, in the acute setting, to patients with dementia and there is a trend towards positive effects.

How Is Quality of Life Assessed in People With Dementia? A Systematic Literature Review and a Primer for Speech-Language Pathologists

Purpose The purpose of this study was to determine how quality of life (QoL) is measured in people with dementia involved in interventions designed to improve well-being and to explore how those measures align with principles of person-centered care. Method A systematic literature review was conducted utilizing PsychInfo, CINAHL, and PubMed and combinations of the search terms: "dementia," "outcome measure," "creative engagement," "creative intervention," "TimeSlips," "art," "quality of life," and "well-being." The search was limited to studies published in peer-reviewed journals that reported outcomes for people with dementia in response to a creative intervention. Results Across the 24 reviewed studies, 30 different outcome measures were reported including eight self-reported, nine observational, and 13 proxy-reported measures. Self-report of QoL was elicited 16 times, observational measures were reported 17 times, and proxy-reported measures were used 28 times. All measures were used with participants across the dementia severity spectrum. Conclusion Current clinical practice of QoL evaluation does not align well with person-centered care principles of self-determination based on the low proportion of self-report. The previously reported limitations of proxy-report have been in part confirmed with this study. Implications of the findings for speech-language pathologists are discussed.

The effectiveness of interventions to improve the care and management of people with dementia in general hospitals: A systematic review

BACKGROUND

People with dementia are at greater risk of being admitted to hospital where care may not be tailored to their needs. Interventions improving care and management are vital.

AIM

Assess the effectiveness of interventions designed to improve the care and management of people with dementia in hospital.

METHOD

Six medical and trial registry, and grey literature databases were searched (1999-1998/2018). Search terms included "Dementia," "Hospital," and "Intervention" and limited to experimental designs. Interventions designed to improve the care and management of people with dementia in the general hospital setting were examined. Outcomes included behavioural and psychological symptoms of dementia (BPSD), psychosocial, clinical, staff knowledge, and length of hospital stay. The CASP tools, Cochrane risk of bias tool, and GRADE system assessed methodological quality and certainty of evidence.

RESULTS

9003 unique citations were identified; 24 studies were included. Studies were limited in study design and their conduct was at a risk of bias. There is very low-quality evidence that multisensory behaviour therapy reduces BPSD. There is low-quality evidence that a multidisciplinary programme reduces postoperative complications and that robot-assisted therapy, music therapy, multimodal-comprehensive care, person-centred care, and family-centred function-focused care interventions improved staff knowledge, competence, efficacy, and communication. No studies reported reduced length of stay.

CONCLUSIONS

Whilst we found that these interventions improved the care and management of people with dementia in hospital, it was low- to very low-quality evidence. New clinical recommendations cannot be made based on current evidence, and robust trial designs are necessary to inform evidence-based care.

Activity interventions to improve the experience of care in hospital for people living with dementia: a systematic review

Background

An increasingly high number of patients admitted to hospital have dementia. Hospital environments can be particularly confusing and challenging for people living with dementia (Plwd) impacting their wellbeing and the ability to optimize their care. Improving the experience of care in hospital has been recognized as a priority, and non-pharmacological interventions including activity interventions have been associated with improved wellbeing and behavioral outcomes for Plwd in other settings. This systematic review aimed at evaluating the effectiveness of activity interventions to improve experience of care for Plwd in hospital.

Methods

Systematic searches were conducted in 16 electronic databases up to October 2019. Reference lists of included studies and forward citation searching were also conducted. Quantitative studies reporting comparative data for activity interventions delivered to Plwd aiming to improve their experience of care in hospital were included. Screening for inclusion, data extraction and quality appraisal were performed independently by two reviewers with discrepancies resolved by discussion with a third where necessary. Standardized mean differences (SMDs) were calculated where possible to support narrative statements and aid interpretation.

Results

Six studies met the inclusion criteria (one randomized and five non-randomized uncontrolled studies) including 216 Plwd. Activity interventions evaluated music, art, social, psychotherapeutic, and combinations of tailored activities in relation to wellbeing outcomes. Although studies were generally underpowered, findings indicated beneficial effects of activity interventions with improved mood and engagement of Plwd while in hospital, and reduced levels of responsive behaviors. Calculated SMDs ranged from very small to large but were mostly statistically non-significant.

Conclusions

The small number of identified studies indicate that activity-based interventions implemented in hospitals may be effective in improving aspects of the care experience for Plwd. Larger well-conducted studies are needed to fully evaluate the potential of this type of non-pharmacological intervention to improve experience of care in hospital settings, and whether any benefits extend to staff wellbeing and the wider ward environment.

The Roth Project - Music and Memory: A Community Agency Initiated Individualized Music Intervention for People with Dementia

INTRODUCTION

"The Roth Project - Music and Memory" is a music-based intervention program, implemented by the Alzheimer's Association of Central and Western Kansas, which provides a non-pharmacological means for addressing neuropsychiatric symptoms in individuals with dementia.

METHODS

Participants were individuals with dementia who were enrolled in The Roth Project - Music and Memory. Post-intervention surveys were distributed to caregivers of participants which assessed caregiver satisfaction with the program as well as caregiver perception of the impact of individualized music on mood and behavioral symptoms.

RESULTS

Of returned surveys (n = 79), 99% of caregivers indicated they were satisfied or very satisfied with the program and 94% of caregivers perceived participants to like or very much like listening to the music. While a substantial number of participants required assistance with iPod use (95%), the majority of participants were observed to listen to the music with stable or increased frequency over time. Personalized music was observed to improve mood in 78% of cases, with the most frequent benefits being improved overall happiness, decreased anxiety, increased positive emotional expression, and decreased depression.

CONCLUSIONS

The Roth Project - Music and Memory was well received by caregivers and was perceived to benefit mood of individuals with dementia. These results provided ongoing support for individualized music-based interventions and demonstrated that such interventions, when implemented by community agencies, can be well received by those who use them.

Refusal and resistance to care by people living with dementia being cared for within acute hospital wards: an ethnographic study

Background

The acute hospital setting has become a key site of care for people living with dementia. The Department of Health and Social Care recognises that as many as one in four acute hospital beds in the UK will be occupied by a person living with dementia at any given time. However, people living with dementia are a highly vulnerable group within the hospital setting. Following an acute admission, their functional abilities can deteriorate quickly and significantly. Detailed research is required to understand the role and needs of health-care staff caring for this patient population and to explore what constitutes ‘good care’ for people living with dementia within the acute setting.

Objectives

The focus of this study was a common but poorly understood phenomenon within the acute setting: refusal and resistance to care. Our research questions were ‘How do ward staff respond to resistance to everyday care by people living with dementia being cared for on acute hospital wards?’ and ‘What is the perspective of patients and their carers?’.

Design

This ethnography was informed by the symbolic interactionist research tradition, focusing on understanding how action and meaning are constructed within a setting. In-depth evidence-based analysis of everyday care enabled us to understand how ward staff responded to the care needs of people living with dementia and to follow the consequences of their actions.

Setting

This ethnography was carried out on 155 days (over 18 months) in 10 wards within five hospitals across England and Wales, which were purposefully selected to represent a range of hospital types, geographies and socioeconomic catchments.

Participants

In addition to general observations, 155 participants took part directly in this study, contributing to 436 ethnographic interviews. Ten detailed case studies were also undertaken with people living with dementia.

Results

We identified high levels of resistance to care among people living with dementia within acute hospital wards. Every person living with dementia observed within an acute hospital ward resisted care at some point during their admission.

Limitations

Limitations identified included the potential for the Hawthorne or researcher effect to influence data collection and establishing the generalisability of findings.

Conclusions

Ward staff typically interpreted resistance as a feature of a dementia diagnosis, which overshadowed the person. However, resistance to care was typically a response to ward organisation and delivery of care and was typically rational to that person’s present ontology and perceptions. In response, nurses and health-care assistants used multiple interactional approaches that combined highly repetitive language with a focus on completing essential care on the body, which itself had a focus on the containment and restraint of the person in their bed or at their bedside. These approaches to patient care were a response to resistance but also a trigger for resistance, creating cycles of stress for patients, families and ward staff. The findings have informed the development of simple, no-cost innovations at the interactional and organisational level. A further study is examining continence care for people living with dementia in acute hospital settings.

Funding

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

Delirium in Older Persons: Advances in Diagnosis and Treatment

Importance

Delirium is defined as an acute disorder of attention and cognition. It is a common, serious, and often fatal condition among older patients. Although often underrecognized, delirium has serious adverse effects on the individual's function and quality of life, as well as broad societal effects with substantial health care costs.

Objective

To summarize the current state of the art in diagnosis and treatment of delirium and to highlight critical areas for future research to advance the field.

Evidence Review

Search of Ovid MEDLINE, Embase, and the Cochrane Library for the past 6 years, from January 1, 2011, until March 16, 2017, using a combination of controlled vocabulary and keyword terms. Since delirium is more prevalent in older adults, the focus was on studies in elderly populations; studies based solely in the intensive care unit (ICU) and non-English-language articles were excluded.

Findings

Of 127 articles included, 25 were clinical trials, 42 cohort studies, 5 systematic reviews and meta-analyses, and 55 were other categories. A total of 11 616 patients were represented in the treatment studies. Advances in diagnosis have included the development of brief screening tools with high sensitivity and specificity, such as the 3-Minute Diagnostic Assessment; 4 A's Test; and proxy-based measures such as the Family Confusion Assessment Method. Measures of severity, such as the Confusion Assessment Method-Severity Score, can aid in monitoring response to treatment, risk stratification, and assessing prognosis. Nonpharmacologic approaches focused on risk factors such as immobility, functional decline, visual or hearing impairment, dehydration, and sleep deprivation are effective for delirium prevention and also are recommended for delirium treatment. Current recommendations for pharmacologic treatment of delirium, based on recent reviews of the evidence, recommend reserving use of antipsychotics and other sedating medications for treatment of severe agitation that poses risk to patient or staff safety or threatens interruption of essential medical therapies.

Conclusions and Relevance

Advances in diagnosis can improve recognition and risk stratification of delirium. Prevention of delirium using nonpharmacologic approaches is documented to be effective, while pharmacologic prevention and treatment of delirium remains controversial.