Exploring the meaning of everyday life, for those suffering from dementia

Grief and loss in people living with dementia: a review and metasynthesis of qualitative studies

OBJECTIVES

This review seeks to synthesise qualitative studies that focus on the experience of grief and loss in people living with dementia.

METHODS

Included studies were quality appraised, synthesised and analysed using inductive thematic analysis.

RESULTS

19 studies were selected for inclusion in the final review and metasynthesis, including 486 participants (115 participants living with dementia, 152 family carers, 219 professionals). Five key dimensions of grief in people living with dementia were identified during the analysis process: grieving for the person I used to be, grieving for how others see me, grieving for the person I will become, grieving for those who have died and what helps me with my grief.

CONCLUSION

It is evident that people living with dementia can experience grief related to a range of previous, current and anticipated losses. Many of the studies included in this review did not directly include people living with dementia in their research and did not ask participants directly about their experience of grief and loss. As grief is a highly personal and individual experience, further research addressing the experience of grief that directly includes participants living with dementia is required, in order to improve awareness of grief-related needs and to develop and deliver support to meet these needs.

Protocol of a feasibility randomised controlled trial of Empowered Conversations: training family carers to enhance their relationships and communication with people living with dementia

Background

Communication difficulties can cause frustration, low mood, and stress for people living with dementia and their carer. Carers should be offered training on adapting their communication skills. However, it is not common for skills-based education to examine emotional aspects of care and the effect of dementia on relationships. The Empowered Conversations (EC) training course was developed in response to a gap in service provision and has been adapted to a virtual format (Zoom). It addresses the specific psychological, relationship, and communication needs of informal and family dementia carers. The primary aim of the study is to investigate the feasibility of conducting a multi-centre randomised controlled evaluation trial of EC. Secondary aims include exploring the acceptability of delivering the intervention online and examining the optimum way of establishing cost-effectiveness.

Methods

The feasibility trial uses a pragmatic data-collector blind parallel two-group RCT design with two arms (EC intervention plus treatment as usual, and treatment as usual waitlist control). There will be a 2:1 allocation in favour of the EC-training intervention arm. 75 participants will complete baseline outcome measures exploring their role as a carer, including their physical and mental health, attitudes to caring, quality of life, and use of health and social care services. These will be repeated after six-months. Participants allocated to the treatment group who complete the course will be invited to participate in a qualitative interview discussing their experience of EC.

Conclusions

The study will investigate recruitment pathways (including facilitators and barriers to recruitment), estimate retention levels and response rates to questionnaires, obtain additional evidence regarding proof of concept, and consider the most appropriate primary outcome measures and methods for evaluating cost-effectiveness. The results of the feasibility study will be used to inform the development of a multicentre randomised controlled trial in the United Kingdom.

Registration

ISRCTN15261686 (02/03/2022).

The longitudinal relationship between meaning in life, depressive symptoms, life satisfaction, and cognitive functioning for older adults with Alzheimer's disease

Studies show the importance of the personal experience of meaning in life for older adults, but adults with dementia have been largely excluded from this research. The current study examined the longitudinal predictive effect of meaning in life for the psychological and cognitive functioning of older adults with Alzheimer's disease and whether cognitive decline predicted presence of meaning in life. On three yearly measurement occasions, presence of meaning in life, depressive symptoms, life satisfaction, and cognitive functioning were assessed in structured interviews with a convenience sample of 140 older adults with Alzheimer's disease from nine nursing homes in Belgium. Cross-lagged panel and latent growth curve models were used to analyze the longitudinal relationships between the variables. Over the three measurement waves, participants with higher presence of meaning reported lower depressive symptoms one year later. Presence of meaning and life satisfaction predicted each other over time, but only between the first and second wave. The analyses showed no strong evidence for a longitudinal association between meaning in life and cognitive functioning in either direction. The findings emphasize the importance of the experience of meaning in life for the psychological functioning of older adults with Alzheimer's disease. The lack of evidence for associations between meaning and cognitive functioning questions the prevailing view that intact cognitive abilities are a necessity for experiencing meaning. More attention to the potential of meaning interventions for persons with dementia is warranted.

Die Angst vor dem Sinnverlust nach der Diagnose Demenz. Eine Rekonstruktion unter Bezug auf Susan Wolf

Verbunden mit dem drohenden Verlust von kognitiven Kapazitäten und der Veränderung der eigenen Persönlichkeit, ist zu vermuten, dass bei Demenzerkrankungen ein Sinnverlust vom Erkrankten befürchtet wird. Es ist Aufgabe dieses Papers aufzuklären, was es mit einer solch meist diffus empfundenen Angst auf sich hat. Dazu wird ein Deutungsangebot gemacht, das auf die Sinnkonzeption Susan Wolfs zurückgreift. Es wird gezeigt, dass es möglich ist, bis zu einem gewissen Grad der Demenz ein sinnvolles Leben zu führen – ein Leben, bei dem subjektiv Anziehendes und rational (bzw. objektiv) Wertvolles zusammengreifen müssen. Dies ist möglich, weil ein Mensch mit Demenz noch über entsprechende Fähigkeiten der Wertschätzung verfügt und eine Hilfsbedürftigkeit der Befähigung zu einem sinnvollen Leben nicht widerspricht. Bei einer sehr schweren Beeinträchtigung der kognitiven Kapazitäten wird es hingegen nicht mehr möglich sein, ein solches Leben zu leben; die solcherart erkrankte Person wird dies aber auch nicht mehr vermissen. Wenn das, was man mit der Demenzerkrankung zu verlieren befürchtet, durch das Sinnverständnis Wolfs getroffen ist, dann sollte man diese Überlegungen bei der Beurteilung einer empfundenen Angst berücksichtigen.

Continuing to Participate in the Dance of Life as Oneself: The Lived Experience of Meaning in Life for Older Adults With Alzheimer's Disease

BACKGROUND AND OBJECTIVES

Meaning in life is an important aspect of positive psychological functioning for older adults. Limited work suggests the relevance of the experience of meaning for people with dementia, but research into this experience from their personal perspective is lacking. The current study provides an in-depth investigation of the lived experience of meaning in life for older adults with Alzheimer's disease.

RESEARCH DESIGN AND METHODS

The study was conducted following the phenomenological reflective lifeworld approach. In-depth interviews were conducted with 16 older adults (+65) with Alzheimer's disease living either at home or in a nursing home in Belgium. Data analysis was an iterative process aimed at illuminating the constituents and essence of the phenomenon.

RESULTS

The essence of the experience of meaning in life for participants was understood as "continuing to participate in the dance of life as oneself." This experience was further clarified in four closely intertwined constituents: (a) feeling connected and involved, (b) continuing everyday life as oneself, (c) calmly surrendering and letting go, and (d) desiring freedom, growth, and invigoration.

DISCUSSION AND IMPLICATIONS

Our findings contribute to a deeper understanding of meaning in life as experienced by older adults with Alzheimer's disease themselves. They emphasize the relevance of the concept for psychological dementia research and offer original insight for the inclusion of meaning in life as an important aspect of holistic dementia care.

A feasibility study of the impact of a communication-skills course, 'Empowered Conversations', for care partners of people living with dementia

Objectives

To examine the feasibility, acceptability and impact of an experiential course for family care partners of people living with dementia, Empowered Conversations (EC). This study aimed to assess the impact of participation in an EC course on care partner stress levels, communication and mentalization (a form of relational-based empathy).

Method

This study uses an uncontrolled pre–post-follow-up design. Follow-up was at 4-months after the initial EC session where baseline data were collected. One hundred and fifty-nine care partners were recruited. EC is a training course that has been designed to improve care partner communication, well-being and relationships. It is based on an integrative framework that targets the specific psychological, relationship and communication needs of carers. This framework informs targeted strategies and interactive exercises that facilitate carers to consider the goals and emotions of those they are caring for, alongside their own goals and emotions, and to use this to maximize good communication.

Results

Stress was significantly reduced across the three time points. Communication significantly improved across time. There were no significant changes in reflective functioning (mentalization).

Discussion

This study provides preliminary evidence that a communication-skills training course for care partners of people living with dementia is an acceptable and feasible intervention and has an impact both post-intervention and at follow-up. These findings require validation in a rigorous, randomized study.

Coping with Everyday Life for Home-Dwelling Persons with Dementia: A Qualitative Study

Aim

This study aimed to gain insight into factors that influence everyday coping strategies as described by persons with early to intermediate dementia.

Background

Living with dementia presents difficulties coping with everyday life. This study focuses on coping with everyday life for persons with mild to moderate dementia in order to facilitate their ability to live at home.

Design

A qualitative study.

Methods

Individual interviews with 12 persons with dementia were conducted in their own homes.

Findings

Coping with everyday life can be influenced by the experience of the diagnostic process and by information about dementia. It can also be affected by stigmatization of persons with dementia, as well as by challenges in everyday life. In addition, challenges in receiving help may include poor continuity of services and healthcare staff with limited competence. By contrast, person-centered care led to positive experiences that supported everyday coping skills. Most of the respondents wanted to participate in day care several days a week. Other positive experiences were making new friends and participating in meaningful activities; such experiences could enhance to coping strategies.

Conclusion

To strengthen everyday coping for persons with dementia living at home, there is a need for openness about the disease. Follow-up for persons with dementia must be carried out by reputable professionals trained and educated in dementia care. Finally, the municipalities must have contact persons, dementia coordinator/-team, who are available for persons with dementia at the time of diagnosis position and afterwards.

Participation as means for adaptation in dementia: a conceptual model

OBJECTIVES

There are a number of conceptual models of dementia, capturing a range of biopsychosocial factors. Few integrate the lived experience of dementia. The aim of this study was to develop a conceptualisation grounded in the first-hand accounts of living with the condition and reflecting its complexity.

METHOD

The study was conducted within an explanatory, critical realist paradigm. An overarching narrative approach, informed by a previously completed systematic review and metasynthesis of research on the lived experience of dementia and the assumptions of complexity theory, was used to guide data collection and analysis. Data were contributed by 31 adults, including 12 people living with dementia and 19 family caregivers.

RESULTS

The experience of living with dementia was conceptualised as a process of adaptation through participation, emerging from ongoing, dynamic and nonlinear interactions between the adaptive capacity of a person with dementia and the adaptive capacity within the environment. The proposed conceptual model describes contexts and mechanisms which shape this capacity. It identifies a range of potential outcomes in dementia. These outcomes reflect interactions and the degree of match between the adaptive capacity of a person and the adaptive capacity within the environment.

CONCLUSION

By recognising and exploring the potential for adaptation and enduring participation in dementia, findings of this research can support practitioners in facilitating positive outcomes for people affected by the condition.

Can Family Caregivers Provide Life Review to Reduce Depression in Older Adults With Dementia?

Life review (LR) therapy has received considerable support as an effective treatment for depression among older adults. Researchers believe that providing LR does not require extensive training and can be done by family members who are not psychiatric professionals. If so, then training family caregivers to provide LR is a potential strategy for alleviating the shortage of resources for treating depression among the growing population of older adults experiencing depression. A pilot study that explored the feasibility of that strategy had mixed results. Seventeen (89%) of 19 caregiver-care recipient dyads completed the current study, and caregivers provided the LR with self-reported fidelity. However, there was lack of statistically significant improvement in this convenience sample. Implications are provided for future assessments of this strategy with a larger study of caregiver and care recipient dyads. [Journal of Gerontological Nursing, 46(2), 41-48.].

Discovering the memory thief: MOOC participants' personal experiences of dementia

Dementia is one of the greatest social issues of our time. There are brief explorations of experiences of dementia in the literature, however this study seeks to further explore the experiences of the general public in relation to dementia. This study aimed to characterise experiences of dementia in the general population. This characterisation was achieved by developing and opening a massive open online course on dementia, which collected information from participants who responded to the question "share your own personal experience of dementia". This data was then analysed by two researchers using Framework Analysis. Four themes (the condition, caring, perception, and control) and indicative quotes are presented and discussed. Experiences of dementia are positive as well as negative. Findings update understanding of these experiences and demonstrate new insights.

‘… This is my home and my neighbourhood with my very good and not so good memories’: The story of autobiographical place-making and a recent life with dementia

As part of the wider Neighbourhoods and Dementia Study, co-researchers from the Open Doors Research Group (based in Salford, UK) produced a series of three films with the title ‘The Changing Face of our Neighbourhood’. These films were subsequently placed on ‘YouTube’ and document co-researchers’ storied experiences of Salford and the industrial, economic and social changes that have occurred over the inquiry group’s lifetime. Drawn directly from this autobiographical and socio-generational work, this article focuses on the experience of lead author Lesley Calvert, who was diagnosed with dementia in 2013 and has been a member of the Open Doors Research Group since 2014. Lesley grew up and worked as a district nurse for almost 40 years, remaining close to her place of birth in Salford all her life. In this article, Lesley draws upon her autobiographical narrative which she shares in the three films to describe the intersections between biography, place-making, belonging and dementia. The article concludes with the importance of democratising the research space and why academic researchers need to create opportunities for personal stories to be told, heard and acted upon.

Thematic analysis of blog narratives written by people with Alzheimer's disease and other dementias and care partners

Limited research takes a socio-biographical approach to study the experiences and perspectives of individuals affected by Alzheimer’s disease and related dementias. The purpose of this study was to thematically analyze blog narratives written by people with Alzheimer’s disease and related dementia and care partners in order to increase understanding of their experiences. Nineteen blogs written by people with Alzheimer’s disease and related dementia and 44 blogs written by care partners were analyzed. The first two authors utilized line-by-line open coding to analyze five posts from each group for the development of a codebook. Using NVivo software, the first author proceeded to code the remaining blogs for emergent themes and subcategories. Emergent themes included (1) effects of Alzheimer’s disease and related dementia on the person with Alzheimer’s disease and related dementia and/or the care partner; (2) seeing the positives; (3) feeling out of control; (4) advocacy and empowerment; (5) coping mechanisms and compensatory strategies; and (6) candid descriptions of experiences with Alzheimer’s disease and related dementia. These themes also encompassed numerous subcategories that are discussed in this paper. Results from this study provide insights into the experiences of individuals affected by Alzheimer’s disease and related dementia. Writers discussed several topics that are consistent with research on illness narratives of individuals with chronic diseases, including loss of identity, strategies for coping, and poignant descriptions of life with the disease. This study provides information in the form of overlapping themes from first-person perspectives of numerous individuals affected by Alzheimer’s disease and related dementia. This type of data is crucial to understand the experiences of people who live with ADRD.

Dementia-friendly design of television news broadcasts

Purpose

The purpose of this paper is to understand factors that affect viewing of television news programmes by people living with dementia, and to identify dementia-friendly design principles for television news programmes and factors for personalising object-based media broadcast.

Design/methodology/approach

Extensive public involvement comprising two discussion groups with people with dementia and family carers informed the study design and provided supplementary secondary data. Primary data collection comprised a focus group interview with people with dementia (n=4) and family carers (n=4). Past viewing experiences and perceived barriers and facilitators to viewing television were explored. Participants commented on an array of video clips comprising varying segments of fictional news programmes, plus control versions of each segment.

Findings

Four themes were identified: content (general comments, context, type of media and pace); presenter (body language, clothing and accent); background (location and studio appearance); and technical aspects (graphics, sound, colours, camera, transitions, general issues).

Research limitations/implications

Limitations included a modest sample size which is offset by exemplary public involvement in informing the study design.

Practical implications

Measures ensured research involvement and participation was made accessible to people living with dementia.

Social implications

Participants benefited from sharing views with peers and expressed enhanced wellbeing from knowing their participation could lead to improved television viewing, an important social occupation, for people with dementia in the future.

Originality/value

This study is the first to be published which focusses on dementia-friendly television news programmes.

Living With Dementia: A Meta-synthesis of Qualitative Research on the Lived Experience

Purpose of the Study

To identify and examine the published qualitative research evidence relative to the experience of living with dementia.

Design and Methods

Metasynthesis was used as the methodological framework to guide data collection and analysis.

Results

Three themes were identified. The first theme considered the main condition-related changes experienced by people with dementia (PWD) and showed how these are interlinked and impact upon various areas of people’s lives. The second theme indicated that amidst these changes, PWD strive to maintain continuity in their lives by employing various resources and coping strategies. The third theme underlined the role of contextual factors. The reviewed evidence indicates that, the emerging experience of PWD and their potential to adjust to the continuous changes is influenced by access to and quality of both personal and contextual resources which remain in a constant, transactional relationship to each other.

Implications

The findings were interpreted and discussed in the context of relevant theoretical frameworks and research evidence. It was considered that current evidence and findings presented in this review can be further explored and expanded upon in a more systematic way through research conducted within the theoretical framework of dynamic systems theory. Further research would be also beneficial to explore the subjective experience of dementia from a participatory perspective. Exploring the application of these theoretical standpoints would contribute to the current state of knowledge and offer both PWD and carers fresh perspective on the nature of change and potential for adaptability in dementia.

Assessing BPSD with the support of the NPI-NH: a discourse analysis of clinical reasoning

ABSTRACTBackground:The ability of nursing staff to assess and evaluate behavioral and psychological symptoms of dementia (BPSD) to determine when intervention is needed is essential. In order to assist with the assessment process, the current use of the Neuropsychiatric Inventory Nursing Home version (NPI-NH) is internationally accepted. Even though the NPI-NH is thoroughly validated and has several advantages, there are also various challenges when implementing this system in practice. Thus, the aim of this study was to explore clinical reasoning employed by assistant nurses when utilizing the NPI-NH as a tool to assess frequency and severity of BPSD in individuals with advanced dementia.

METHOD

Twenty structured assessment sessions in which assistant nurses used the NPI-NH were audio recorded and analyzed with a discourse analysis focusing on the activities in the communication.

RESULTS

Four categories were identified to convey assistant nurses' clinical reasoning when assessing and evaluating BPSD using the NPI-NH: considering deteriorations in ability and awareness, incorporating individual and contextual factors, overcoming variations in behaviors and ambiguous formulations in the instrument, and sense-making interactions with colleagues.

CONCLUSION

The NPI-NH served as a supportive frame and structure for the clinical reasoning performed during the assessment. The clinical reasoning employed by assistant nurses became a way to reach a consensual and broader understanding of the individual with dementia, with the support of NPI-NH as an important framework.

Investigating poor insight in Alzheimer’s disease

Persons with Alzheimer’s disease (AD) often seem to have a poor insight into the functional deficits brought about by the dementing process. There are many indications that preserved insight into deficits in dementia is of advantage to a person with AD. Various research approaches have been adopted to investigate poor insight related to AD. The purpose of this article was to present various research approaches for investigating poor insight into deficits in AD. The study is based on a literature survey. The findings show that concept of poor insight has been investigated in detail from different perspectives. Each one of the perspectives found, the neuropsychological, the psychological and the socio-psychological, has its merits, but none of them has yet led to study results that make us fully understand what poor insight implies and involves. We need integrated knowledge from the different perspectives, and in multidisciplinary research settings we believe that such knowledge could be developed.

Which medical and social decision topics are important after early diagnosis of Alzheimer's Disease from the perspectives of people with Alzheimer's Disease, spouses and professionals?

BACKGROUND

The relevance of early decision making will rise with increasing availability of early detection of Alzheimer's disease (AD) using brain imaging or biomarkers.

RESULTS

Five people with mild AD, six relatives and 13 healthcare professionals with experience in the management of AD were interviewed in a qualitative study regarding medical and social decision topics that emerge after early diagnosis of Alzheimer's disease. Medical treatment, assistance in everyday life and legal issues emerged as the main decision topics after an early diagnosis of AD. People with AD mostly got in contact with the health and social care system through the initiative of their spouses. They were usually aware of their illness and most received antidementia drugs and/or behavioural interventions. Following diagnosis people with AD received support by their spouses. Healthcare professionals were aware of the risk of excessive demand on relatives due to supporting their family member with AD. In the opinion of healthcare professionals legal issues should be arranged in time before patients lose their decisional capacity. In addition, people with AD and spouses reported various coping strategies, in particular "carry on as normal" after diagnosis but mostly are reluctant to actively plan for future stages of the disease.

CONCLUSIONS

Due to the common desire to "carry on as usual" after a diagnosis of AD, many people with AD and spouses may miss the opportunity to discuss and decide on important medical and social topics. A structured approach e.g. a decision aid might support people with AD and spouses in their decision making process and thereby preserve persons' with AD autonomy before they lose the capacity in decision-making.

Family Physician-Case Manager Collaboration and Needs of Patients With Dementia and Their Caregivers: A Systematic Mixed Studies Review

PURPOSE

Dementia case management (CM) in primary care is a complex intervention aimed at identifying the various needs of patients with dementia and their caregivers, as well as the organization and coordination of care. A key element of CM is the collaboration of family physicians with case managers. We conducted a systematic mixed-studies review to identify the needs of the patient-caregiver dyad and the effects of CM.

METHODS

We searched MEDLINE, PsycINFO, and EMBASE up to October 2014, regardless of the study design. Our main outcomes were needs of patients and their caregivers and the effects of CM on these needs. We used narrative syntheses to develop a taxonomy of needs and to describe the effects of CM on those needs. We used meta-analysis to calculate the prevalence of needs and the standardized mean differences to evaluate the effects of CM on the needs identified.

RESULTS

Fifty-four studies were included. We identified needs of the patient-caregiver dyad and needs of the patient and caregiver individually. CM addressed the majority of the identified needs. Still, some very common needs (eg, early diagnosis) are overlooked while other needs (eg, education on the disease) are well addressed. Fully establishing the value of CM is difficult given the small number of studies of CM in primary care.

CONCLUSIONS

There is good evidence that case managers, in collaboration with family physicians, have a pivotal role in addressing the needs of the patient-caregiver dyad.

Care pathways for dementia: current perspectives

Uncertainty appears to typify the experience of living with dementia. With an uncertain illness trajectory and unpredictable levels of deterioration and stability in symptoms, people with a diagnosis of dementia may live with uncertainty and anxiety and find it hard to make plans or decisions for their future. People with memory problems and caregivers seeking a diagnosis of dementia may also potentially find themselves navigating a labyrinth-like maze of services, practitioners, assessments, and memory tests, with limited understanding of test scores and little information about what support is available. In this context of uncertainty, the apparent clarity and certainty of a “dementia care pathway” may be attractive. However, the term “dementia care pathway” has multiple and overlapping meanings, which can potentially give rise to further confusion if these are ill-defined or a false consensus is presumed. This review distinguishes four meanings: 1) a mechanism for the management and containment of uncertainty and confusion, useful for the professional as well as the person with dementia; 2) a manual for sequencing care activities; 3) a guide to consumers, indicating eligibility for care activities, or a guide to self-management for dementia dyads, indicating the appropriateness of care activities; and 4) a manual for “walking with” the person. Examples of these approaches are presented from UK dementia services with illustrations of existing care pathways and associated time points, specifically focusing on: 1) early symptom identification and first service encounters, 2) assessment process, 3) diagnostic disclosure, 4) postdiagnostic support, and 5) appropriate interventions. We review the evidence around these themes, as well as discuss service pathways and referral routes used by some services in England and internationally. We conclude that the attraction of the term “care pathway” is seductive, but caution is needed in taking shared understandings for granted.

Stories about life narrated by people with Alzheimer's disease

AIM

To explore how people with Alzheimer's disease present their life story.

BACKGROUND

Life story work is a key concept in a person-centred care. An important aspect in understanding the subjective experience and supporting the identity of people with dementia is to listen to their life stories.

DESIGN

A narrative design with interviews was used.

METHOD

Nine participants with Alzheimer's disease were encouraged to tell about their lives from childhood, adult life, to present life and about their thoughts on the future. The interviews were conducted between September 2010-March 2011 in the participants' homes, with their spouses present and were analysed with a method for analysis of narratives.

FINDINGS

Contentment, Connectedness, Self-reliance and Personal growth were identified as core dimensions in the participants' life stories and shown like threads throughout life, from childhood, adult life to present life. All participants expressed an overall contentment with life, and connectedness was related to their relation with significant persons and to be included in the local community. Self-reliance was expressed as a strong confidence in the own ability and an overall curiosity throughout life as a sustained quest for personal growth.

CONCLUSIONS

It is important for healthcare professionals, who work with people with dementia, to understand that people with Alzheimer's disease can maintain an overall trusting and hopeful approach to life. It is also important to use life story work to enhance feelings of being connected to the world and thereby support their identity and sense of self.

Shifting patterns of everyday activity in early dementia: experiences of men and their families

In this article we draw from a larger study to examine experiences of two men and their families as they negotiate changing patterns of everyday activity in the months after receiving a diagnosis of dementia. We conducted in-depth interpretive phenomenological analysis of interview and observational data that were gathered from the men and various members of their families (n = 7) over a period several months. Findings are presented as three themes: The best kind of man (highlighting participants' historical positioning); It's a little different now (recognizing challenges posed by the dementia); and You have to do something (showing how the men and their families responded to and accommodated these challenges). We discuss these findings in terms of how everyday activity is not only important for supporting personhood in dementia, but it also contributes to sustaining family identity, and does so in a way that is deeply influenced by gender and masculinity.

Making sense of nonsense: experiences of mild cognitive impairment

Alzheimer's disease (AD) is a stigmatised condition popularly assumed to be a death sentence for diagnosed individuals. Consequently, people with AD are often deemed incapable (and perhaps unworthy) of contributing to the social discourse surrounding their illness experience. Data from qualitative interviews with 18 people diagnosed with the potential precursor of AD known as mild cognitive impairment (MCI) are examined. Using grounded theory methods, analysis revealed overarching themes of uncertainty concerning definitions of memory loss, MCI, and AD as well as distinctions between normal ageing and dementia. While this confusion over the terminology and prognosis mirrors the lack of scientific consensus about nosology and appropriate treatment regimens, such ambiguity creates social and psychological tensions for diagnosed individuals. Arguably, participants' unequivocal fear of and subsequent desire to differentiate their experiences from Alzheimer's, however, stems from the exclusively negative social constructions of AD. Drawing from Goffman, these findings demonstrate the psychosocial impact of 'framing contests' and how 'courtesy stigma' can apply not only to associated persons but also associated conditions, such as MCI to AD. Given the underlying nosological creep - or medicalisation - of the recent diagnostic guidelines proposing two new pre-dementia stages, understanding the illness narratives of MCI is critical.

Psychosocial factors that shape patient and carer experiences of dementia diagnosis and treatment: a systematic review of qualitative studies

BACKGROUND

Early diagnosis and intervention for people with dementia is increasingly considered a priority, but practitioners are concerned with the effects of earlier diagnosis and interventions on patients and caregivers. This systematic review evaluates the qualitative evidence about how people accommodate and adapt to the diagnosis of dementia and its immediate consequences, to guide practice.

METHODS AND FINDINGS

We systematically reviewed qualitative studies exploring experiences of community-dwelling individuals with dementia, and their carers, around diagnosis and the transition to becoming a person with dementia. We searched PubMed, PsychINFO, Embase, CINAHL, and the British Nursing Index (all searched in May 2010 with no date restrictions; PubMed search updated in February 2012), checked reference lists, and undertook citation searches in PubMed and Google Scholar (ongoing to September 2011). We used thematic synthesis to identify key themes, commonalities, barriers to earlier diagnosis, and support identified as helpful. We identified 126 papers reporting 102 studies including a total of 3,095 participants. Three overarching themes emerged from our analysis: (1) pathways through diagnosis, including its impact on identity, roles, and relationships; (2) resolving conflicts to accommodate a diagnosis, including the acceptability of support, focusing on the present or the future, and the use or avoidance of knowledge; and (3) strategies and support to minimise the impact of dementia. Consistent barriers to diagnosis include stigma, normalisation of symptoms, and lack of knowledge. Studies report a lack of specialist support particularly post-diagnosis.

CONCLUSIONS

There is an extensive body of qualitative literature on the experiences of community-dwelling individuals with dementia on receiving and adapting to a diagnosis of dementia. We present a thematic analysis that could be useful to professionals working with people with dementia. We suggest that research emphasis should shift towards the development and evaluation of interventions, particularly those providing support after diagnosis.

Community-dwelling persons with dementia: what do they need? What do they demand? What do they do? A systematic review on the subjective experiences of persons with dementia

OBJECTIVES

Including the perspectives of persons with dementia (PwD) is essential in order to organize care structures for them. With this systematic review, we set out to screen the existing scientific evidence on self-expressions of community-dwelling individuals with dementia in order to provide a research base for developing an intervention for persons in early stages of the disease. The leading research questions for this review are: What needs do PwD living at home express? What are their subjective demands? What do they do to cope with their situation?

METHODS

We performed a systematic literature review of review publications on subjective experiences of PwD. The publications were analysed using MAXQDA 10 to perform a thematic analysis.

RESULTS

We identified 41 relevant reviews, of which 6 met our inclusion criteria. PwD experience the whole range of human emotions. Their needs and demands do not differ significantly from those of other groups of patients with chronic conditions. Coming to terms with the disease and maintaining normality appeared to be major themes. With regard to expectations from the side of professional health care, the need for accompanying, continuous support and counselling appeared to be central. Furthermore, disclosure of diagnosis represents a critical stage for PwD, but our findings indicated that they prefer to be included in this process.

CONCLUSIONS

PwD are well able to express their needs. They should be included in research since they can provide valuable findings. Furthermore, those findings should be implemented in applied dementia care.

Professional Caregivers' Perceptions on how Persons with Mild Dementia Might Experience the Usage of a Digital Photo Diary

Cognitive impairments influence the possibility of persons with dementia to remember daily events and maintain a sense of self. In order to address these problems a digital photo diary was developed to capture information about events in daily life. The device consisted of a wearable digital camera, smart phone with Global Positioning System (GPS) and a home memory station with computer for uploading the photographs and touch screen. The aim of this study was to describe professional caregiver's perceptions on how persons with mild dementia might experience the usage of this digital photo diary from both a situation when wearing the camera and a situation when viewing the uploaded photos, through a questionnaire with 408 respondents. In order to catch the professional caregivers' perceptions a questionnaire with the semantic differential technique was used and the main question was "How do you think Hilda (the fictive person in the questionnaire) feels when she is using the digital photo diary?". The factor analysis revealed three factors; Sense of autonomy, Sense of self-esteem and Sense of trust. An interesting conclusion that can be drawn is that professional caregivers had an overall positive view of the usage of digital photo diary as supporting autonomy for persons with mild dementia. The meaningfulness of each situation when wearing the camera and viewing the uploaded pictures to be used in two different situations and a part of an integrated assistive device has to be considered separately. Individual needs and desires of the person who is living with dementia and the context of each individual has to be reflected on and taken into account before implementing assistive digital devices as a tool in care.

Managing identity in early-stage dementia: maintaining a sense of being valued

Focusing on loss or maintenance of identity in persons with dementia may affect how they are approached and cared for. We performed a longitudinal study of 17 elderly persons with early-stage dementia with the aim of exploring changes in the experience of living with dementia. The major theme – a struggle to be valued – was clearly present in follow-up interviews. However, we observed a gradual shift in the concept of being valued: a shift from ‘being valued for what you do’ toward ‘being valued for who you are’. This progression represents a shift from performance-related core values of identity to those that are existentially related. These findings suggest that the self can be maintained by adjusting to loss.

A Bio-Psycho-Social model enhances young adults’ understanding of and beliefs about people with Alzheimer's disease: A case study

The incidence of Alzheimer's disease (AD) is predicted to grow by multiples in the coming decades, and today's young adults will be formal and/or informal caregivers in unprecedented numbers. Their ability to support the independence and well-being of people with AD will depend on their ability to identify intact social and cognitive abilities, selfhood, and needs of people with AD. This case study, conducted in an undergraduate seminar, provides preliminary, suggestive evidence for the educational advantages of a Bio-Psycho-Social approach to understanding these aspects of people with AD. Findings revealed a striking increase in students’ accurate understanding of: (1) the losses due to AD; (2) intact positive qualities in and inaccurate negative stereotypes about people with AD; and (3) important needs of people with AD. These are discussed in light of extant theory. The application of this approach in the case of one student and her family is explored.

Managing mealtime tasks: told by persons with dementia

AIM

To capture the self-description of managing mealtime tasks by persons with dementia.

BACKGROUND

There are several factors that negatively affect food intake in persons with dementia that may increase the risk of developing malnutrition. Difficulties in managing daily activities increase gradually and mealtime tasks like food shopping, cooking and eating often become troublesome. Still, little is known about how persons with dementia themselves experience this issue.

DESIGN

A qualitative study with an ethnographic approach.

METHOD

Ten women and five men aged 69-86 with dementia were interviewed. Interviews were carried out in the informants' own homes and a thematic analysis was performed.

RESULTS

The informants described that they wanted to be independent and that the memory loss was not affecting them to a great extent. Old habits and routines, as well as newly developed strategies, helped them manage mealtime tasks despite the disease. Informants were satisfied with their current situation, even though it sometimes meant that they had changed their way of managing mealtime tasks, for instance receiving meals-on-wheels.

CONCLUSIONS

Persons with dementia seem to be able to manage mealtime tasks and these activities were based on old habits and routines. Independence was highly valued and managing mealtime tasks seems to be one way to appear independent.

RELEVANCE TO CLINICAL PRACTICE

It is important for caregivers to understand that persons with dementia might not express difficulties in managing mealtime tasks for fear of losing their independence. It is, therefore, important to create a trustful relationship even before problems arise to be able to support the persons when necessary.

Wellbeing among people with dementia and their next of kin over a period of 3 years

Little is known about the dyadic experience over time of people with dementia and their next of kin. The aim of this study was to investigate the state of mind of people with dementia, their next of kin's experience of burden and satisfaction, and factors associated with these experiences over a 3-year period. The sample consisted of 32 people with dementia living at home with family caregivers in the south of Sweden. Data were collected during the period 2004-2007 and consisted of patients self reports (GDS), dementia nurse assessment (MMSE, Berger and ADL) and next-of-kin assessment (patient's state of mind and care provision). Data also consisted of next-of-kin's self reports concerning health, burden and satisfaction. The result showed that patients' state of mind was mainly positive at baseline but a deterioration was seen over time in the patient's mood and cognitive functioning together with an increase in ADL-dependency and suspected depression. Dependency in personal ADL entailed a higher risk of being in a negative state of mind. For next of kin the experience of burden increased while satisfaction decreased over the 3 years. The inter-relationship between the patients' mood and the caregiver's satisfaction and burden seems to get stronger over time. At baseline caregiver burden was mainly related to the next of kins' general health and to patient behaviours that were difficult to handle. During the progression of the disease caregiver satisfaction becomes increasingly related to patient state of mind and dependency. There is, however, a need for more research focusing on the specific inter-relational aspects as previous studies have mainly focused on either the situation for the person with dementia or on the caregiver.

Subthreshold depression: characteristics and risk factors among vulnerable elders

OBJECTIVES

This study examines symptoms of subthreshold depression among older adults in congregate housing, compared with their nondepressed peers, and tests a conceptual model of subthreshold depression. Hypotheses included that subthreshold depression would be characterized and distinguished by low energy, social withdrawal, and depletion, rather than sadness, and that subthreshold depressed elders would be distinguished by poorer health and functioning, loneliness, and grieving a recent loss.

METHOD

A self-administered survey was followed by a diagnostic interview by telephone to (N = 166) white and African-American residents of independent and assisted living apartments from six retirement communities, average age 82.9 years. The Mini International Neuropsychiatric Interview (MINI) determined depression status. The 30-item Geriatric Depression Scale was used to measure symptoms.

RESULTS

Forty-six individuals (27.7%) were identified as subthreshold depressed, seven as suffering from major depression, and 113 as non-depressed. Subthreshold depression was characterized by low energy, difficulty with initiative, worries about the future, lack of positive affect, sadness and irritability. Negative affect symptoms such as sadness and irritability best discriminated the subthreshold group from the nondepressed. Risk factors for subthreshold depression in this sample included less education, lower socio-economic status, African-American race, grieving, and social loneliness.

CONCLUSION

Subthreshold depression in this group of residents of congregate housing was similar to the depletion experienced by many nondepressed elders, but further characterized by negative affect and lack of hope for the future. Social factors, such as socioeconomic status and personal losses, constituted greater risks for subthreshold depression than did health and functioning.

What is meaningful activity for people with dementia living in care homes? A comparison of the views of older people with dementia, staff and family carers

BACKGROUND

Older people with dementia living in care homes often lack appropriate activities. Although homes are expected to offer a range of activities to meet residents' needs, little is known about what makes activities meaningful for people with dementia. This study explores concepts of meaningful activity, as defined by older people with dementia living in care homes, staff and family carers.

METHOD

This qualitative study used focus groups including 17 residents, 15 staff and eight family carers from three care homes. Transcripts of the groups were subjected to thematic content analysis using a grounded theory approach.

RESULTS

Four activity themes emerged -- 'reminiscence', 'family and social', 'musical' and 'individual'. There were also two related themes -- 'lack of meaningful activity' and 'what makes activity meaningful'. Residents found meaning in activities that addressed their psychological and social needs, which related to the quality of the experience of an activity rather than specific types of activities. In contrast, staff and family carers viewed activities that maintained physical abilities as meaningful.

CONCLUSION

People with dementia staff and carers had differing views about what made activities meaningful. Organisational limitations and social beliefs limited the provision of meaningful activities for this population. The study also indicates areas for improving activity provision in care homes.

Suffering from dementia - the patient's perspective: a review of the literature

BACKGROUND

Among the general public there is a deep fear of developing dementia, which has led to an increasing number of people "at risk" seeking ways (such as advance directives) to avoid undergoing progressive mental decline. The views of people with dementia are vital in obtaining a real answer to the question of how the disease affects people's lives and whether it actually involves the suffering that so many fear.

METHOD

A review of the international literature is provided on what is known about living through dementia from the patient's perspective.

RESULTS

A total of 50 papers met the inclusion criteria. The findings of these reviewed papers give insight into the impact of dementia and the ways that those who have it deal with its effects by using different coping strategies. The literature on the perspective of the patient gives no solid support to the widespread assumption that dementia is necessarily a state of dreadful suffering. Although the impact of dementia and the experiences of loss resulting in multiple "negative" emotions cannot be denied, our findings also indicate that people do not undergo the disease passively and use both emotion-oriented and problem-oriented coping strategies to deal with its challenges. The experiences of living through dementia as told by the sufferers appear to yield a more subtle picture than the assumptions made by the general public.

CONCLUSION

The overview provides a good starting point for improving the adjustment of care to the experience and wishes of people with dementia.

Living with dementia from the perspective of older people: is it a positive story?

Dementia, even at an early stage, may pose problems and challenge one's quality of life. Having accurate knowledge of what one experiences when living with dementia is important for developing proactive care for individuals with dementia and their families. The aim of our Grounded Theory study was to explore what it means for elderly people to live with early-stage dementia. We interviewed 20 elderly people with probable mild dementia and their family members. Living with dementia was often presented as a positive narrative, one that told of only minor problems and which stressed abilities and contentment with life. Being valued, rather than losing one's cognition or identity was central in their experience. More in-depth analyses of participants' narratives revealed, however, that they were constantly balancing their feelings of value and worthlessness, struggling to remain someone of value. This struggle was prompted by threats posed by dementia and by the persons' interactions with others. Superficially, a positive narrative may be understood as a lack of awareness or as denial due to cognitive loss. Our findings suggest, however, that we should look beyond this superficial view and seek to understand the narrative as an expression of one's attempt to counterbalance devaluation.

Conducting qualitative interview research with people with expressive language difficulties

Despite the increasing application of qualitative interviewing and analysis approaches, individuals with expressive language difficulties are still frequently excluded from such research. In this article, the authors seek to clarify the role for and importance of conducting qualitative interviews with respondents with impaired expressive language. They review current research with reference to studies conducted with individuals with intellectual disabilities or dementia, or those who have experienced stroke or traumatic brain injury, and identify deficits within existing research. They consider the challenges and difficulties that contribute to the limited inclusion of individuals with impaired expressive communication in qualitative interviews and discuss the way forward with suggestions of possible means of overcoming these obstacles. They argue that a willingness to adapt methods appropriately and to modify expectations is an important factor in ensuring that researchers hear the voice of respondents with expressive language deficits.

Living with early-stage dementia: a review of qualitative studies

AIM

This paper presents a literature review whose aim was to provide better understanding of living with early-stage dementia.

BACKGROUND

Even in the early stages, dementia may challenge quality of life. Research on early-stage dementia is mainly in the domain of biomedical aetiology and pathology, providing little understanding of what it means to live with dementia. Knowledge of the lived experience of having dementia is important in order to focus pro-active care towards enhancing quality of life. Qualitative research is fundamentally well suited to obtaining an insider's view of living with early-stage dementia.

METHOD

We performed a meta-synthesis of qualitative research findings. We searched MEDLINE, CINAHL, and PsycINFO and reviewed the papers cited in the references of pertinent articles, the references cited in a recently published book on the subjective experience of dementia, one thesis, and the journal Dementia. Thirty-three pertinent articles were identified, representing 28 separate studies and 21 different research samples. Findings were coded, grouped, compared and integrated.

FINDINGS

Living with dementia is described from the stage a person discovers the memory impairment, through the stage of being diagnosed with dementia, to that of the person's attempts to integrate the impairment into everyday life. Memory loss often threatens perceptions of security, autonomy and being a meaningful member of society. At early stages of memory loss, individuals use self-protecting and self-adjusting strategies to deal with perceived changes and threats. However, the memory impairment itself may make it difficult for an individual to deal with these changes, thereby causing frustration, uncertainty and fear.

CONCLUSIONS

Our analysis supports the integration of proactive care into the diagnostic process, because even early-stage dementia may challenge quality of life. Moreover, this care should actively involve both the individual with dementia and their family so that both parties can adjust positively to living with dementia.

Preservation of self in people with dementia living in residential care: A socio-biographical approach

The maintenance of self in dementia is associated with socio-biographical factors. The theoretical literature suggests that interpersonal relationships, the social context, and the generation of stories are important in maintenance of self. Empirical research on self in dementia supports this but has been predominantly conducted with participants living in the community. Living in residential care brings additional threats to self. This paper presents a study examining the relevance of a socio-biographical theory of self to people with dementia living in residential care. Between 3 and 8 tape-recorded and transcribed unstructured interviews were conducted with 14 people with dementia who were living in 4 residential homes throughout England and Wales, over a 6-24-month period. They were analysed using an interpretive biographical methodology. The results provide evidence to support the relevance of a socio-biographical theory of self to this group. Relationships with family, other residents and care home staff were important for maintenance of self. Social roles related to work, being part of a family, caring for others and being cared for, were particularly significant for self in this group. The creation of a life story, stories of selected life events, and the telling of stories with possible metaphorical interpretations were also important for the maintenance of self. The results also suggest that psychological and embodied factors may be relevant to the self in dementia. The study suggests that staff working in residential homes should consider these elements if they are to provide care that supports maintenance of self for people with dementia. Implications for future research are discussed.

Capacity for decision-making in Alzheimer's disease: selfhood, positioning and semiotic people

The aim of this article is to explore some of the ethical issues surrounding the assessment and determination of capacity of people with dementia in light of their meaning-making ability as shown through discourse. Discourse analysis, two illustrative cases, social construction theory and positioning are used to highlight some of the ethical dilemmas involved in basing a determination of capacity on the diagnosis of dementia and neuropsychological tests of cognitive function. Although neuropsychological tests have their place in assessing some aspects of cognitive function, aspects cognition such as meaning-making ability and selfhood cannot be assessed in a standard format. In dementia, there can be a differential impairment of recall memory while the personality, values and substantial long-term memory remain intact, as does implicit memory for recent events. People with dementia are vulnerable to being negatively positioned, thereby unfairly undermining their rights to make decisions about aspects of their lives. Assessing the capacity of a person with dementia to engage in decision-making is presently in need of examination so as to take into account the person's meaning-making ability and selfhood. Incorrect negative positioning, based on the diagnosis and defects in recall memory, can obscure intact cognitive abilities that allow a person to make decisions about aspects of living, creating the possibility of lasting harm being inflicted on the person with dementia.