Concepts for communication about risk in dementia care: A review of the literature

Risk assessment for people living with dementia: a systematic review

OBJECTIVE

This systematic review identified key components of risk assessment for people with dementia, examined attitudes toward risk identification and risk assessment, and appraised existing risk assessment tools.

METHODS

Systematic searches of five databases on two platforms (EBSCO, OVID) and gray literature databases (Open Grey, Base) were conducted. Studies were screened for inclusion based on predetermined eligibility criteria and quality assessed using the Mixed Methods Appraisal Tool. Findings were tabulated and synthesized using thematic synthesis.

RESULTS

Our review found people with dementia, their family carers, and healthcare professionals differed in how risk is conceptualized, with views being shaped by media perceptions, personal experiences, socio-cultural influences, dementia knowledge, and dementia severity. We found that mobilization (causing falls inside and getting lost outside) is the most frequently identified risk factor. Our findings show people with dementia are generally risk-tolerant, while healthcare professionals may adopt risk-averse approaches because of organizational requirements. We found factors that disrupt daily routines, living and caring arrangements, medication management, and unclear care pathways contribute toward adverse risk events. We discovered that most studies about risk and risk assessment scales did not consider insight of the person with dementia into risks although this is important for the impact of a risk. No risk instrument identified had sufficient evidence that it was useful.

CONCLUSION

Accurate risk assessment and effective communication strategies that include the perspectives of people with dementia are needed to enable risk-tolerant practice. No risk instrument to date was shown to be widely acceptable and useful in practice.

Longitudinal Predictors of Informant-Rated Involvement of People with Dementia in Everyday Decision-Making: Findings from the IDEAL Program

The extent to which people with dementia are involved in everyday decision-making is unclear. We explored informant-rated involvement of people with dementia in everyday decision-making over 2 years and whether functional, behavioral, and psychological factors related to the person with dementia and the caregiver explain variability in involvement of people with dementia in everyday decision-making. We used IDEAL data for 1182 people with dementia and their caregivers. Baseline mean score on the decision-making involvement scale was 31/45; it minimally declined over time. People with dementia who were female, single, and/or whose caregiver was younger had greater involvement in everyday decision-making than those without these characteristics. Better cognition, fewer functional difficulties, fewer neuropsychiatric symptoms, less caregiver stress, and better informant-rated relationship quality were associated with higher involvement in everyday decision-making. Cognitive and functional rehabilitation, and educational resources for caregivers, could prolong involvement of people with dementia in everyday decision-making.

Risk Negotiation With People With Dementia: From Co-designed Paper Version to Implementation Preparation of an Electronic Conversation Tool

The home care workforce provides essential support for older people with dementia to live a life of fulfillment. "Enabling Choices," an evidence-informed conversation tool, aims to negotiate risk around everyday activities between home care workers, people with dementia and their informal carers. This paper describes tool conversion into electronic format and preparation for implementation throughout a large Australian health and aged care service provider, utilizing the Implementation Framework for Aged Care (IFAC). Using codesign principles, the tool was converted from paper-based to electronic format involving frontline, operational and Information Management Services staff, and people with dementia/carers. Focus groups and interviews identified tool acceptability, feasibility, and appropriateness. For implementation preparation, the wider socio-cultural-political context was mapped, and key questions of the IFAC addressed. Environment, workflow, and training requirements were determined, and strategies for behavior change ascertained. Numerous opportunities and challenges exist for the widespread upscale of an evidence-informed tool into practice.

Associations between community participation and types of places visited among persons living with and without dementia: risks perception and socio-demographic aspects

Introduction

Increasingly, literature has focused on community participation in places visited by persons living with and without dementia. Earlier research indicates that multiple factors, including socio-demographic aspects and risk perception may influence community participation.

Aim and methods

This cross-sectional, explorative study aims to inquire into how places visited, socio-demographic aspects and risks perception are associated with self-rated community participation for persons living with and without dementia (n = 70) in Switzerland. Data was collected through face-to-face interviews with questionnaires (ACT-OUT, MoCA, sociodemographic). First, we investigated whether the number of places visited was correlated with self-rated participation; then we added socio-demographic and risks perception factors with a bivariate analysis; and searched for a model using multinomial logistic regressions.

Results

For the group of participants living with dementia, risks of falling (p = .014) and of getting lost (p = .037) were significantly associated with self-rated participation. For the group of participants living without dementia, visiting places outside the home was significantly associated with self-rated participation, especially visiting places in domain D/places for recreational and physical activities (p = .005).

Discussion and conclusions

The results of exploring multiple factors and searching for a model highlights the complexity of community participation as a construct. Risks and visiting places for recreational and physical activities seem to play a role in self-rated participation. Mobile interviews might be better suited to gain in-depth understanding on community participation for persons living with dementia.

Community-based multi-professional child protection decision making: Systematic narrative review

BACKGROUND

Multi-professional approach to child protection decision making is widely promoted by service organisations, although the conditions for this to be effective are little known.

OBJECTIVE

This systematic narrative literature review explored empirical evidence on the implementation of multi-professional child protection decision making in community settings. Of particular interest were the contextual conditions upon which joint working is build (inputs), aspects of interactional functioning (mediators), and the results of working together (outputs).

PARTICIPANTS AND SETTING

Five electronic bibliographic databases were selected for the search. The review was restricted to articles published in peer-reviewed journals, in the English language for ten years, from 1st January 2010 to 31st December 2019. Of the 6934 studies retrieved, 30 studies undertaken in six countries were included.

METHODS

The systematic approach to literature reviewing utilised was 'Systematic Narrative Review'. This approach starts with clearly formulated questions, employs systematic, explicit, and replicable processes for searching the literature to retrieve research, retains quality appraisal limited to publications in peer-reviewed journals, and uses a narrative synthesis.

RESULTS

The analysis outlined key building blocks that form the structure for collaborative decision making and identified cognitive, relational, and behavioural interactional properties that occur when making decisions together. Limitations of the published literature hinder the ability of making robust inferences about outcomes of collaborative decision-making practice.

CONCLUSION

The article discusses the next steps for research and implications for policy and practice for promoting useful multi-professional working in child protection decision making in the community.

Risks as dilemmas for home care staff caring for persons with dementia

OBJECTIVES

Many persons with dementia live at home with support from home care services. Despite this, research is scarce concerning how risks in daily life among persons with dementia are perceived and handled by home care staff. This study aimed to explore how home care staff identify risks in the everyday lives of persons with dementia, and to inquire into how they reasoned about their own actions related to those risks.

METHOD

A qualitative approach was applied for the study. Both individual interviews and focus groups were conducted with home care staff (n = 23). Data was analysed using a constant comparative method.

RESULTS

Identifying, reasoning and acting upon risks in the everyday lives of persons with dementia were related to several dilemmas for the home care staff. These dilemmas are described and elaborated on in three categories: 1) Strategies for tracking risks, 2) Dilemmas concerning where to draw the line and deciding when to act, and 3) Dilemmas when acting on risks.

CONCLUSION

The study provides new knowledge about the dilemmas that staff in home care services may face and how they reason about managing risks in the homes of persons with dementia. The study shows that the staff had to weigh risk and safety against the autonomy of persons with dementia. Based on these findings, we want to highlight the importance of competence among home care staff and the organizational conditions that must exist in order to manage the challenges of risky situations.

Life under lockdown and social restrictions - the experiences of people living with dementia and their carers during the COVID-19 pandemic in England

Background

The impact of COVID-19 restrictions on people living with dementia and their carers is an emerging focus of recent research determining how we can best support this population. People living with dementia have faced service curtailment, increased risk for COVID-19, as well as potential heightened deterioration. This study reports the experiences of people living with dementia and their family carers during the early months of the COVID-19 pandemic in England and the impact on them.

Methods

We recruited and remotely interviewed 30 people living with dementia in their own homes and 31 family carers, via video or telephone call in mid-2020. Data were transcribed and analysed using thematic analysis.

Results

People living with dementia often had a basic understanding of COVID-19 restrictions but could have difficulty translating this into personalised risk-appraisal of their own actions. Managing COVID-19 risks facing people living with dementia at home was largely done by family carers, exemplified by changes to living arrangements, which could strain or sustain caring relationships. Well-established familial caring relationships contributed to the wellbeing of the person living with dementia and their carer, as well as keeping to simple routines that included leaving the home for exercise and stimulation. People living with dementia reported some negative psychological and cognitive effects due to the imposed restrictions, such as increased apathy, irritability, or anxiety, which were fuelled by lack of social engagement.

Conclusions

Structuring routine (remote) social interactions where possible could increase social engagement and improve wellbeing for people living with dementia, especially those with limited familial support in a post-COVID-19 context. As some care relationships had been restructured to manage COVID-19 risks, additional carer strain may emerge as a result of the impact on the independence of the person living with dementia and come to the attention of professionals in health and care services. People living with dementia and their carers highlighted the importance of maintaining or adapting routines which may be useful learning for professionals, although additional support may be necessary for those who are impacted by more severe or worsening symptoms of dementia.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12877-021-02257-z.

User-centered and theory-based design of a professional training program on shared decision-making with older adults living with neurocognitive disorders: a mixed-methods study

BACKGROUND

We know little about the best approaches to design training for healthcare professionals. We thus studied how user-centered and theory-based design contribute to the development of a distance learning program for professionals, to increase their shared decision-making (SDM) with older adults living with neurocognitive disorders and their caregivers.

METHODS

In this mixed-methods study, healthcare professionals who worked in family medicine clinics and homecare services evaluated a training program in a user-centered approach with several iterative phases of quantitative and qualitative evaluation, each followed by modifications. The program comprised an e-learning activity and five evidence summaries. A subsample assessed the e-learning activity during semi-structured think-aloud sessions. A second subsample assessed the evidence summaries they received by email. All participants completed a theory-based questionnaire to assess their intention to adopt SDM. Descriptive statistical analyses and qualitative thematic analyses were integrated at each round to prioritize training improvements with regard to the determinants most likely to influence participants' intention.

RESULTS

Of 106 participants, 98 completed their evaluations of either the e-learning activity or evidence summary (93%). The professions most represented were physicians (60%) and nurses (15%). Professionals valued the e-learning component to gain knowledge on the theory and practice of SDM, and the evidence summaries to apply the knowledge gained through the e-learning activity to diverse clinical contexts. The iterative design process allowed addressing most weaknesses reported. Participants' intentions to adopt SDM and to use the summaries were high at baseline and remained positive as the rounds progressed. Attitude and social influence significantly influenced participants' intention to use the evidence summaries (P < 0.0001). Despite strong intention and the tailoring of tools to users, certain factors external to the training program can still influence the effective use of these tools and the adoption of SDM in practice.

CONCLUSIONS

A theory-based and user-centered design approach for continuing professional development interventions on SDM with older adults living with neurocognitive disorders and their caregivers appeared useful to identify the most important determinants of learners' intentions to use SDM in their practice, and validate our initial interpretations of learners' assessments during the subsequent evaluation round.

Inclusive Decision Making for Falls Prevention: A Discussion Tool for Use With People With Dementia and Their Caregivers

Provision of choice and participation in falls prevention strategies is challenging for people with dementia. This study outlines development of a discussion tool to aid engagement of people with dementia and their caregivers in falls prevention strategies. The tool is based on a literature review of falls prevention and dementia care (1990-2016) and decision aid principles and was trialed over 6 months. A total of 25 community-dwelling people with dementia (M_age = 80 years, SD = 7.7, 52% male) and their caregivers (M_age = 73 years, SD = 12.3, 36% male) underwent falls risk assessment and evaluation of their preparedness to change falls risk behaviors. Most commonly rated, and prioritized for intervention, high falls risk factors were impaired balance/mobility (92%), polypharmacy (60%), and incontinence (56%). This discussion tool facilitated collaboration between people with dementia, their caregivers, and health professionals, to increase uptake of acceptable and feasible evidence-based falls prevention strategies.

Uncertainty and health literacy in dementia care

The number of dementia cases increases with age, and the prevalence of dementia at the age above 80 is approaching 20% in Taiwan. Dementia is not simply a neurological disorder, but also a long-term care issue in public health and a matter of social adaptation. Scientific discoveries about dementia diagnostics, therapeutics, and preventive strategy have become the focus of media attention, but always updated and overwhelmed, which appears to increase rather than decrease the uncertainty and complexity of health communication in dementia care. Health literacy is essential for patients to understand medical information, utilize medical resources, and make shared decisions; however, the capacity to handle health information is often compromised in older adults with cognitive decline. Both ends of the increased uncertainty in dementia science and the reduced capacity in older adults are major challenges in dementia care. Dementia literacy, defined as knowledge and beliefs regarding dementia that aid recognition, management, or prevention, plays a vital role in effective care risk assessment and communication. However, little is known about the current state of dementia literacy among older adults, people with dementia, and their caregivers, and how well the dementia care practice can be implemented at the individual level is questionable. Empowering caregivers with adequate dementia literacy and developing a risk communication model in practice will translate the power of knowledge to effective care strategies, thus ameliorating the caregiver burden and enhancing the life quality of people with dementia in the long run.

Dementia and Parkinson's Disease: Similar and Divergent Challenges in Providing Palliative Care

Dementia and Parkinson's disease are incurable neurological conditions. Patients often experience specific, complex, and varying needs along their disease trajectory. Current management typically employs a multidisciplinary team approach. Recognition is growing that this team approach should also address palliative care issues to optimize quality of life for patient and family caregivers, but it remains unclear how palliative care is best delivered. To inspire future service development and research, we compare the trajectories and conceptualization of palliative care between dementia and Parkinson's disease. Both Parkinson's disease and dementia are characterized by a protracted course, with progressive but fairly insidious development of disability. However, patients with Parkinson's disease may experience relatively stable periods initially but with time, a wide range of debilitating symptoms develops, many of which do not respond well to treatment. Eventually, dementia develops in most Parkinson patients, while motor disability develops in many dementia patients. In both diseases, symptoms such as pain, apathy, sleeping problems, falls, and a high caregiver burden are prevalent. Advance care planning has benefits in terms of being prepared before the disease progresses into a stage with communication problems or severe cognitive impairment. However, for both conditions, the protracted disease trajectories complicate conceptualization of palliative care through different stages of the disease, with pertinent questions such as when to offer what interventions pro-actively. Given the similarities and differences, we should develop palliative approaches that are partially generic and partially disease-specific. These should be integrated seamlessly with disease-specific care. Substantial research is already being performed on dementia palliative care. This may also inform the further development of palliative care for Parkinson's disease, including an evaluation of palliative interventions and services.

The Situated Influence of Chronic Pain Perception on Chinese Older Adults' Self-Management in Home Care

BACKGROUND AND OBJECTIVE

Worldwide, 26 million older adults die from chronic disease, and chronic pain is typically a part of the experience of chronic disease. This study explores the perception of chronic pain for home-dwelling Chinese older adults and its influence on (1) self-management ability and (2) management and reduction of chronic pain.

METHODS

Adopting a qualitative study design, we conducted in-depth interviews with 10 Chinese community-dwelling older adults who experience chronic pain. Half of our informants perceive chronic pain, whereas the other half, diagnosed with Alzheimer's disease, do not report that they perceive chronic pain. Data were analyzed with inductive thematic analysis.

RESULTS

Chronic pain perception plays important roles in (1) defining the challenge of self-management, (2) connecting previous caretaking experience, (3) adjusting the identity of self-management, (4) acquiring support from important others and (5) re-planning self-management arrangements.

CONCLUSION

Pain perception helps to motivate Chinese older adults to face health challenges and regain self-management capacity through adjustments in self-identity and care experience with the support of important others. Pain perception can consolidate the situation of independent living of older adults. It helps to motivate Chinese older adults to face health challenges and regain self-management capacity.

The landscape of dementia inclusivity

A supported community gardening program became appealing and therapeutically beneficial to people living with the impacts of dementia and their carers, despite not targeting either cohort specifically. This paper discusses how this program provides insights into the landscape of dementia inclusivity. The gardens involved were spaces that allowed positive risk-taking opportunities, respectful intersubjectivity and active citizenship. Our research findings indicate that a meaningful response to the rising incidence of dementia may be to build upon social and geographical attributes of community gardens. Understanding the multifaceted nature of a dementia inclusive landscape will enable authentic engagement and rights-based support for people living with the impacts of dementia.