Using meta-ethnography to understand the care transition experience of people with dementia and their caregivers

A palliative care goals model for people with dementia and their family: Consensus achieved in an international Delphi study

BACKGROUND

Advance care planning in dementia includes supporting the person and their family to consider important goals of care. International research reports the importance of psycho-social-spiritual aspects towards end of life.

AIM

To develop a multidimensional international palliative care goals model in dementia for use in practice.

DESIGN

International Delphi study integrating consensus and evidence from a meta-qualitative study. The Delphi panel rated statements about the model on a 5-point agreement scale. The criteria for consensus were pre-specified.

SETTING/PARTICIPANTS

Seventeen researchers from eight countries developed an initial model, and 169 candidate panellists were invited to the international online Delphi study.

RESULTS

Panellists (107; response 63.3%) resided in 33 countries. The model comprised four main care goals: (1) Comfort ensured; (2) Control over function maintained; (3) Identity protected and personhood respected and (4) Coping with grief and loss-person and caregiver supported. The model reflects how needs and care goals change over time with the progression of dementia, concluding with bereavement support. The first version of the model achieved a consensus after which it was slightly refined based on feedback. We did not achieve a consensus on adding a goal of life prolongation, and on use of the model by people with dementia and family themselves.

CONCLUSION

A new palliative care goals model for people with dementia and their families includes relationship aspects for use by professionals and achieved a consensus among a panel with diverse cultural background. The position of life prolongation in relation to palliative care goals needs further research.

Lost in Transition: Community-Dwelling Partners' Stories of Losing a Spouse to Cognitive Decline and Long-Term Care Facilities

This qualitative narrative study presents three stories told by older community-dwelling partners to spouses moving into long-term care facilities because of cognitive decline. Applying Alvesson and Kärreman's mystery method to these stories reveals that when spouses' caring needs increase, care partners must take on increasing loads of practical work and responsibilities. These partners become lost in the transitions between care work, extended family, and attending to their couplehood. When their spouses move into long-term care, living apart presents new challenges of care and couplehood, each day presenting new and unforeseen tasks to manage. Our findings suggest that if couplehood is to be maintained, well-established habits and work division between the spousal partners are both drivers and barriers. It necessitates agency, creativity from the community-dwelling partner, as well as a supportive extended family and sufficient economic resources. More knowledge is required regarding the interdependent expectations between the next-of-kin, long-term care residents, and caregiving staff members.

Young carers' perspectives on navigating the healthcare system and co-designing support for their caring roles: a mixed-methods qualitative study

OBJECTIVES

Despite young carers (YCs) providing regular and significant care that exceeds what would normally be associated with an adult caregiver, we need to learn more about their experience interacting with the healthcare system. The primary study aims were to (1) describe YC experiences in interacting with the healthcare system and (2) identify types of support YC recognise as potentially helpful to their caring role.

DESIGN AND SETTING

A mixed-methods qualitative study was conducted between March 2022 and August 2022, comprising two phases of (1) semi-structured interviews and focus groups with YCs living in the community to confirm and expand earlier research findings, and (2) a co-design workshop informed by a generative research approach. We used findings from the interviews and focus groups to inform the brainstorming process for identifying potential solutions.

RESULTS

Eight YCs completed either a focus group or an interview, and four continued the study and participated in the co-design activity with 12 participants. Phase 1 resulted in three overarching themes: (1) navigating the YC role within the healthcare system; (2) being kept out of the loop; and (3) normalising the transition into caregiving. Phase 2 identified two categories: (1) YC-focused supports and (2) raising awareness and building capacity in the healthcare system.

CONCLUSION

Study findings revealed the critical role that YCs play when supporting their families during pivotal interactions in the healthcare system. Like their older caregiver counterparts, YCs struggle to navigate, coordinate and advocate for their family members while juggling their needs as they transition from adolescence to adulthood. This study provides important preliminary insights into YCs encountering professionals, which can be used to design and implement national support structures.

Cumulative Disempowerment: How Families Experience Older Adults' Transitions into Long-Term Residential Care

Although emerging research links family experiences with long-term residential care (LTRC) transitions to structural features of health care systems, existing scholarship inadvertently tends to represent the transition as an individual problem to which families need to adjust. This secondary qualitative analysis of 55 interviews with 22 family members caring for an older adult engages a critical gerontological lens. A concept of cumulative, structural empowerment informs this analysis of families' experiences across a broad continuum of older adults' moves into LTRC. Leading up to transitions, families have little power over home care services, and family members have little control over their involvement in care provision. Some families respond by making choices to refuse publicly provided service options, therein both resisting and reinforcing broader relations of power. Expectations for family involvement in LTRC placement decisions were incongruent with some families' experiences, reinforcing a sense of powerlessness compounded by the speed with which these decisions needed to be made. A broad temporal analysis of transitions highlights LTRC transitions as a process of cumulative family disempowerment connected to broader formal care structures alongside emphases on aging in place and familialism that characterize LTRC as the option of last resort.

Vigilance, risk, and service use among caregivers of people living with dementia

OBJECTIVE

The purpose of this investigation was to understand the dynamics among dementia caregiving, vigilance, and home and community-based service use.

METHODS

This paper is derived from a larger, mixed-methods study on caregiving. We used a descriptive qualitative approach to analyze interview data of 30 family caregivers of relatives with dementia.

RESULTS

We found five domains of vigilance in which caregivers felt "on duty": ensuring attentiveness, ensuring safety, ensuring resources, ensuring healthcare, and ensuring closeness. Formal service use did not necessarily give caregivers relief from vigilance, with the language of risk often employed by caregivers.

CONCLUSION

Because service use could contribute to feelings of vigilance, rather than give caregivers a break from a sense of watchfulness, these findings support calls for dementia-specific training for service providers. In future caregiving research, the relationship between vigilance, caregiver distress, and role captivity should be explored.

Dementia caregiver burdens predict overnight hospitalization and hospice utilization

OBJECTIVES

To determine sociodemographics and caregiver burdens associated with overnight hospitalization, hospice utilization, and hospitalization frequency among persons with dementia (PWD).

METHODS

Cross-sectional analysis of PWD (n = 899) of the National Health and Aging Trends Study linked to the National Study of Caregiving. Logistic and proportional odds regression determined the effects of caregiver burdens on overnight hospitalization, hospice use, and hospitalization frequency. Differences between PWD alive not-alive groups were compared on overnight hospitalization and frequency.

RESULTS

Alive PWD (n = 804) were 2.36 times more likely to have an overnight hospital stay (p = 0.004) and 1.96 times more likely to have multiple hospitalizations when caregivers found it physically difficult to provide care (p = 0.011). Decedents aged 65-74 (n = 95) were 4.55 times more likely to experience overnight hospitalizations than 85+, hospitalizations were more frequent (odds ratio [OR] = 4.84), and there was a significant difference between PWD alive/not alive groups (p = 0.035). Decedents were 5.60 times more likely to experience an overnight hospitalization when their caregivers had financial difficulty, hospitalizations were more frequent when caregivers had too much to handle (OR = 8.44) and/or no time for themselves (OR = 10.67). When caregivers had no time for themselves, a significant difference between alive/not alive groups (p = 0.018) was detected in hospitalization frequency. PWD whose caregivers had emotional difficulty helping were 5.89 times more likely to utilize hospice than caregivers who did not report emotional difficulty.

SIGNIFICANCE OF RESULTS

Care transitions among PWD at the end of life are impacted by the circumstances and experiences of their caregivers. Subjective caregiver burdens represent potentially modifiable risks for undesired care transitions and opportunities for promoting hospice use. Future work is warranted to identify and address these issues as they occur.

Older adults and family caregivers’ experience of digital health technology in frailty care: A systematic review and meta-ethnography protocol

Background: Digital health technology has been identified as a valuable tool to support older adults with frailty needs in their home setting. Despite the numerous technologies and evaluations of these innovations, a synthesis of the older person and family caregivers’ experience using technology for support self-management has not been conducted to date.

Methods and analysis: A systematic review and meta-ethnography will be conducted in accordance with the PRISMA and eMERGe reporting guidelines. Four peer-reviewed empirical evidence databases will be searched (Medline (Ovid), CINAHL, EMBASE, PsycINFO) using a defined search strategy. Studies containing qualitative data on the experiences of older people or family caregivers of using digital health technology to support frailty care will be included. Covidence software will be used to screen studies and extract data. The Critical Appraisal Skills Programme (CASP) checklist for qualitative research will be used by two independent reviewers to appraise all included papers. A meta-ethnography will be undertaken in accordance with the seven-phase method described by Noblit and Hare: (1) Getting started, (2) Deciding what is relevant to the initial interest, (3) Reading the studies, (4) Determining how the studies are related, (5) Translating the studies into one another, (6) Synthesizing translations and (7) Expressing the synthesis.

Discussion: To the best of our knowledge, this will be the first systematic review to integrate and synthesize the findings of qualitative studies of older citizens’ experience of digital health technology. The findings of this meta-ethnography will endeavour to inform future research, policy and clinical practice. In particular, the results will help to inform the design of future digital health technology to meet the needs of older adults.

PROSPERO registration number: CRD42022314608.

Fear of Incompetence in Family Caregivers and Dementia Care Transitions

Research on interpersonal interaction dynamics in relationships between persons with dementia and their family caregivers has been limited. We examine the role of these dynamics in decisions to transition a family member from home care to congregate care, with a particular focus on the role of fear of incompetence. Fear of incompetence is the fear of being unable to interact, communicate in a meaningful way, or take care of a close family member with dementia. In this study (N  =  350 family caregivers), perceived negative changes in the family member with dementia predicted increased perceived dependency, which predicted both increased caregiver burden and greater fear of incompetence in caregivers, which, in turn, predicted stronger care transition desire. Strategies should be aimed not only at reducing dependency of the care recipient but also teaching family caregivers interaction skills that decrease their fear of interactional incompetence and thus promote home care continuation.

Older adults and family caregivers’ experience of digital health technology in frailty care: A systematic review and meta-ethnography protocol

Background: Digital health technology has been identified as a valuable tool to support older adults with frailty needs in their home setting. Despite the numerous technologies and evaluations of these innovations, a synthesis of the older person and family caregivers’ experience using technology for support self-management has not been conducted to date. Methods and analysis: A systematic review and meta-ethnography will be conducted in accordance with the PRISMA and eMERGe reporting guidelines. Four peer-reviewed empirical evidence databases will be searched (Medline (Ovid), CINAHL, EMBASE, PsycINFO) using a defined search strategy. Studies containing qualitative data on the experiences of older people or family caregivers of using digital health technology to support frailty care will be included. Covidence software will be used to screen studies and extract data. The Critical Appraisal Skills Programme (CASP) checklist for qualitative research will be used by two independent reviewers to appraise all included papers. A meta-ethnography will be undertaken in accordance with the seven-phase method described by Noblit and Hare: (1) Getting started, (2) Deciding what is relevant to the initial interest, (3) Reading the studies, (4) Determining how the studies are related, (5) Translating the studies into one another, (6) Synthesizing translations and (7) Expressing the synthesis. Discussion: To the best of our knowledge, this will be the first systematic review to integrate and synthesize the findings of qualitative studies of older citizens’ experience of digital health technology. The findings of this meta-ethnography will endeavour to inform future research, policy and clinical practice. In particular, the results will help to inform the design of future digital health technology to meet the needs of older adults. PROSPERO registration number: Submitted 05/04/2022 and currently under review.