A comprehensive intervention following the clinical pathway of eating and swallowing disorder in the elderly with dementia: historically controlled study

Nutritional Care for Institutionalized Persons with Dementia: An Integrative Review

BACKGROUND

Older people are at risk of malnutrition, especially when they suffer from cognitive impairment. Guidelines that orient nursing care in this regard need to be updated. The aim of this review is to address the best available evidence on interventions that can benefit nutritional nursing care for institutionalized older adults with dementia.

METHODS

Integrative review using the Dimensions and Eureka search engines, and the PubMed, Embase, Scielo, CINAHL, and ScienceDirect databases. We searched from the year 2015 through to 2021. We employed the MMAT guidelines for mixed, qualitative, and quantitative studies, and the PRISMA, CASP, and JBI guidelines to value the reviews.

RESULTS

A total of 55 studies met the inclusion criteria. The best available evidence to support nutritional nursing care for institutionalized older adults with dementia highlights several aspects related to the assessment and caring interventions that are focused on people with dementia, their caregivers, and their context.

CONCLUSIONS

Both the assessment and nutritional care interventions for older people with dementia should consider the patient-caregiver dyad as the subject of care and understand the context as a fundamental part of it. The analysis of the context should look further than the immediate environment.

Clinical decision-making using an assessment protocol of swallowing function after aspiration pneumonia: a comparative retrospective study

Objective: Aspiration pneumonia is a challenge in Japan, with many elderly citizens; however, there are insufficient experts on swallowing. Non-expert doctors may suspend oral intake for an overly long period because of the fear of further aspiration. We devised and modified an assessment protocol for swallowing function with reference to the Japanese and American practical guidelines for dysphagia. This study aimed to demonstrate clinical decision-making using the protocol by reporting the results of decisions on the safe and timely restart of adequate food intake for patients with aspiration pneumonia. Patients and Methods: This comparative retrospective study included 101 patients hospitalized with aspiration pneumonia between April 2015 and November 2017. We compared the parameters of patients for whom decisions on resumption of oral intake were aided by our protocol against those of patients from the previous year when the protocol was not used. We counted the days until either resumption of oral intake or events of aspiration/choking. Results: The duration of days until oral intake in the two groups was 1.64 ± 2.34 days in the protocol group (56 patients) and 2.09 ± 2.30 days in the control group (45 patients) (P=0.52). The adverse events of aspiration/choking were less frequent in the protocol group (5 vs. 15, odds ratio (OR) 0.32, P<0.001) as compared to the control group. The protocol group showed a significant reduction in aspiration/choking (OR 0.19, P<0.01). Conclusion: Clinical decision-making based on the protocol seems to help non-expert doctors make informed decisions regarding resuming oral intake after aspiration pneumonia.

Identification and Prognostication of End-of-Life State Using a Japanese Guideline-Based Diagnostic Method: A Diagnostic Accuracy Study

Purpose

Prognostic uncertainty can be a barrier to providing palliative care. Accurate prognostic estimation for patients at the end of life is challenging. This study aimed to evaluate the accuracy of end-of-life diagnosis using our unique diagnostic method.

Patients and Methods

A retrospective longitudinal observational study was conducted through collaboration among three medical facilities in a rural super-aged community in Japan. In 2007, we established a unique end-of-life diagnostic process comprising (1) physicians' judgement, (2) disclosure to patients, and (3) discussion at an end-of-life case conference (EOL-CC), based on Japanese end-of-life-related guidelines. Research subjects were consecutive patients discussed in EOL-CC between January 1, 2010, and September 30, 2017. The primary outcome was mortality within 6 months after the initial EOL-CC decision. Sensitivity, specificity, and diagnostic odds ratio were calculated using EOL-CC diagnosis (end-of-life or non-end-of-life) as an index test and overall survival (<6 months or ≥6 months) as a reference standard.

Results

In total, 315 patients were eligible for survival analysis (median age 89, range 54-107). The study population was limited to patients with severe conditions such as advanced cancer, organ failures, advanced dementia with severe deterioration in functioning. EOL-diagnosis by our methods was associated with much lower survival rate at 6 months after EOL-CC than non-EOL-diagnosis (6.9% vs 43.5%; P < 0.001). Of the patients, 297 were eligible for diagnostic accuracy analysis (median age 89, range 54-107). The EOL-diagnosis showed high sensitivity (0.95; 95% confidence interval [CI] 0.92-0.97) but low specificity (0.35; 95% CI 0.20-0.53) against the outcomes. It also showed a high diagnostic odds ratio (10.32; 95% CI 4.08-26.13).

Conclusion

The diagnostic process using the Japanese end-of-life guidelines had tolerable accuracy in identification and prognostication of end of life.

Construction of Clinical Pathway Information Management System under the Guidance of Evidence-Based Medicine

This study focuses on clinical pathways guided by evidence-based medicine (EBM). With the clinical pathway as the center, the subjective and objective medical knowledge of medical staff are collected, and a clinical pathway management system guided by EBM is established through a unified process; user demand analysis; main considerations; implementation, evaluation, and monitoring of the clinical path; and dictionary maintenance, to help hospitals fully regulate medical behaviors. Next, the study displays the path access prompt box, area 1 management page, table management page, exit prompt box, mutation record page, doctor order interface, revocation of execution, and monitoring interface, and the system designed is compared with the Beijing Shankang Technology (ASK) clinical data management system in terms of user experience. The results showed that the reporting rate of medical adverse events in the system in this study was 0.21%, and the work efficiency was increased by 14%. In terms of users' satisfaction, the hospital managers' satisfaction was 84 ± 5.36%, and it was 95 ± 4.72% for medical staff and 88 ± 4.91% for system administrators, superior to the ASK system; the differences were statistically significant (P < 0.05). In conclusion, the clinical pathway information management system is in line with the working environment of medical staff, and the synchronous monitoring and management of medical quality are achieved through digital means, which can reduce the occurrence of medical adverse events and improve the work efficiency of medical staff.

Optimizing mealtime care for people with dementia from the perspective of formal caregivers: A systematic review of qualitative research

BACKGROUND

As dementia progresses, people with dementia experience many problems during mealtimes that seriously affect their physical, psychological, and social health and quality of life. Formal caregivers play an important role in optimizing mealtime care.

OBJECTIVE

To systematically review and synthesise relevant qualitative studies exploring the experience and perceptions of formal caregivers regarding optimizing mealtime care for people with dementia.

DESIGN

A systematic review of qualitative research.

DATA SOURCES

The PubMed, Web of Science, Cochrane Library, Embase, CINAHL, CNKI, WanFang and Vip databases were systematically searched.

REVIEW METHODS

Two reviewers independently screened the titles and abstracts, extracted the data and performed critical appraisals of each included study. The data synthesis was conducted using thematic analysis.

FINDINGS

A total of 10 studies were included. The formal caregivers included nursing assistants, nurses, speech and language therapists, nursing students, dietitians, a social worker, a professional educator, physiotherapists, health care aides, kitchen staff, diversional therapy assistants and other unidentified care staff. The findings were synthesised into the following 3 analytical themes: (1) tailored rather than standardized; (2) emotional nurturance; and (3) beyond the individual level.

CONCLUSIONS

Mealtimes involve complex physiological and psychological processes. Formal caregivers should develop tailored care practices based on individual patients' preferences and needs. Emotional connection plays a key role and has a positive impact on the mealtime experience. Further research is needed to explore the specific effects of emotional connections on optimizing mealtime care.

Nutritional Intake and Meal Composition of Patients Consuming Texture Modified Diets and Thickened Fluids: A Systematic Review and Meta-Analysis

Texture-modified diets (TMDs) play an important role in ensuring safety for those with dysphagia but come with risks to nutrition and quality of life. The use of TMDs has been addressed with the increasing prevalence of dysphagia in previous decades. However, there is limited literature that investigates the nutrition perspectives of TMD consumers. This review summarises the nutrition outcomes of adults consuming TMDs and thickened fluids (TFs) and identifies the limitations of TMD and TF productions. A systematic database search following PICO criteria was conducted using Cochrane Central (via Ovid), MEDLINE, CINAHL, EMBASE, and Scopus databases. Nutrition intake, meal consumption, adequacy, and meal composition were identified as relevant outcomes. 35 studies were included for analysis. Consumption of TMDs demonstrated a poorer intake compared to regular diets, in particular significant in energy and calcium. Meta-analysis of mean differences showed favourable effects of shaped TMDs on both energy (−273.8 kJ/d; 95%CI: −419.1 to −128.6, p = 0.0002) and protein (−12.4 g/d; 95%CI: −17.9 to −6.8, p < 0.0001) intake compared to traditional cook-fresh TMDs. Nutrition intake was compromised in TMD consumers. Optimisation of nutrition intake was achievable through enrichment and adjusting meal texture and consistency. However, the heterogeneity of studies and the missing verification of the consistencies lead to difficulty in drawing conclusions regarding particular texture or intervention.

Informal dementia caregivers' experiences and perceptions about mealtime care: A qualitative evidence synthesis

AIMS

To systematically identify, evaluate and synthesize the available qualitative evidence on the mealtime care experiences of informal caregivers of people with dementia.

DESIGN

A qualitative evidence synthesis using the Thomas and Harden method.

DATA SOURCES

All qualitative and mixed-method studies in English and Chinese were retrieved from PubMed, Web of Science, Embase, Cochrane, CINAHL, CNKI, WanFang, and Vip from the inception of each database until November 2019.

REVIEW METHODS

Two researchers independently selected the studies using qualitative assessment and review instruments for quality evaluation and thematic synthesis for the data analysis.

RESULTS

Ten studies were chosen for this review. The analytical themes identified included injecting a new element, moving forward in the challenge and external supports facilitating better coping.

CONCLUSION

Community nurses should effectively use resources to provide food-related information and services to families with dementia. Future research should combine informal caregiver experiences and clinical skills to develop high-quality interventions to improve the quality of mealtimes.

IMPACT

The findings established that informal caregivers experienced not only changes in their roles and concerns but also emotional changes. Informal caregivers develop different coping strategies to adapt to feeding issues without professional support. Although informal caregivers attach great importance to mealtimes and nutrition issues, they experience a lack of information and support services. Community nurses can provide more economical, practical, and accessible information resources based on informal caregivers' perceptions of mealtime care. Future interventions need to be more aware of the importance of dyad or family-centred support services.

Cause of death in autopsy-confirmed dementia disorders

BACKGROUND AND PURPOSE

Dementia disorders predispose for lethal complications and decrease life expectancy. A more profound knowledge regarding end-stage conditions in dementia could therefore ameliorate treatment and care of these patients.

METHODS

Autopsy reports on 207 deceased individuals with clinically diagnosed neurocognitive disorder/dementia and on 200 neurocognitively healthy individuals of the same age range were studied. Autopsy results, especially cause of death, were compared between the dementia and the control groups.

RESULTS

The two most frequent causes of death in the dementia population were pneumonia (34.3%) and acute myocardial infarction (30.4%). This result differed from that of the control group, in which acute myocardial infarction (42.5%) accounted for most events of deaths, followed by circulatory failure (12.5%). The leading cause of death varied amongst dementia subtypes. Further, in Alzheimer's disease pneumonia was more frequent in severe/advanced cases whilst acute myocardial infarction was more common in milder cases.

CONCLUSIONS

Cause of death differed between the demented and the general population of the same age and between subtypes of dementia. Alzheimer's disease severity was reflected in different final conditions. The findings have relevance for the final stage care and treatment in dementia disorders.

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

BACKGROUND

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

AIM

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

METHOD

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

RESULTS

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

CONCLUSIONS

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

Hydration Interventions for older people living in residential and nursing care homes: overview of the literature

INTRODUCTION

Care home populations experiencing high levels of multi-morbidity and dementia require support from caregivers to meet their hydration requirements. This article provides an overview of literature related to hydration interventions and highlights gaps in knowledge.

SOURCES OF DATA

This paper draws on UK-focused literature from Applied Social Sciences Index and Abstracts (ASSIA), CINAHL, Medline, Proquest Hospital Premium Collection, Cochrane Library and RCN databases on hydration interventions for older people living with multi-morbidity and dementia in care homes.

AREAS OF AGREEMENT

Fluid intake is too low in care home residents, and no single hydration intervention is effective in addressing the complex problems that older residents present.

AREAS OF CONTROVERSY

There is a lack of consensus about how much fluid an older person should consume daily for optimum health. There is also lack of agreement about what interventions are effective in supporting individuals with complex physical and cognitive problems to achieve daily fluid intake targets.

GROWING POINTS

To improve hydration care for residents, care home teams should be competent in the delivery of hydration care, and work closely with integrated multi-professional healthcare specialists to provide proactive case management.

AREAS TIMELY FOR DEVELOPING RESEARCH

There is a need for understanding of what hydration practices and processes are effective for care home residents and including these in multi-component interventions.

Antithrombotic therapies for elderly patients: handling problems originating from their comorbidities

Compared with younger people, elderly people have higher risks for both thrombosis and bleeding. Furthermore, comorbidities frequently found in elderly patients complicate the management of antithrombotic therapy. Thus, when treating these patients, physicians often find it difficult to incorporate the principles of evidence-based medicine and must determine the best treatment option for each patient. Recently, in the fields of cerebrovascular and cardiovascular diseases, researchers have been rapidly accumulating new data regarding antithrombotic therapy, particularly in the areas of direct oral anticoagulants (DOACs) and dual antiplatelet therapy (DAPT). However, information related to elderly patients receiving antithrombotic therapy is still relatively limited. There are also more and more publications describing how antithrombotic therapy affects the pathogenesis of non-thrombotic diseases. Similarly, the number of reports concerning adherence to this therapy has been increasing lately. However, no review articles detailing these findings have yet been published. In actual clinical practice, antithrombotic therapy in the elderly is not a treatment strategy targeted to only one organ or disease. Rather, it requires an interdisciplinary approach aimed at maintaining the overall health of the patient. Thus, to assist physicians’ decision-making processes for elderly patients, an overview of recent findings related to the evidence regarding concomitant medications, the secondary benefits of antithrombotic therapy for patients with comorbidities, and evidence regarding medication adherence is provided.