The effectiveness of community-based coordinating interventions in dementia care: a meta-analysis and subgroup analysis of intervention components

Pilot of a multicomponent program for people with dementia and their care partners: Health services staff expectations, experiences and observations

There is increased recognition of the need to improve post-diagnostic pathways for people with dementia and their care partners living in the community to access rehabilitation services to support independence and wellbeing. However, there is minimal evidence on implementing rehabilitation services for this population. The study aimed to present the expectations and experiences of allied health staff involved in piloting the Sustainable Personalised Interventions for Cognition, Care and Engagement (SPICE) program based at an outpatient clinic of a public rehabilitation hospital. Over twelve weeks, the program combines small group and dyadic evidence-based interventions including cognitive stimulation therapy, occupational therapy, physical activity, care partner education, and dietetics. A qualitative exploratory methodology was used with pre- and post-program interviews conducted with ten allied health staff. Questions were designed to elicit the expected and actual benefits and challenges of the initial implementation of the multicomponent program. The multidisciplinary team were motivated by the potential for the SPICE program to meet an important service gap, and confident people with dementia and their care partners would benefit. Staff reported enjoyment, satisfaction, and confidence in delivering the program, and believed the multiple components had synergistic effects on participants, particularly regarding social connection and functional engagement. While staff had pre-program concerns regarding retention, participant fatigue, and managing challenging situations, these were not realised. At times, staff observed program intensity to cause unintended stress for some care partners. Resourcing and strategies to ensure sustainability were identified as important by staff, as well as the need for ongoing support to participants post-program. Overall, the SPICE program exceeded expectations and was rewarding for staff. Further work to refine and evaluate the program is necessary to support its potential to continue providing dementia rehabilitation to promote the independence and wellbeing of people with dementia and care partners living in the community.

Palliative Care Coordination Interventions for Caregivers of Community-Dwelling Individuals with Dementia: An Integrative Review

Alzheimer's disease is a serious illness with a protracted caregiving experience; however, care coordination interventions often lack the inclusion of palliative care. The purpose of this integrative review is to identify and synthesize existing care coordination interventions that include palliative care for individuals with dementia and their caregivers living in community settings. The Whittemore and Knafl framework guided the review, with data analysis guided by the SELFIE framework domains. Study quality was assessed using the Mixed Methods Appraisal Tool, while the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines informed reporting results. Nine care coordination interventions involving family caregivers across eighteen publications were identified. Only a single intervention explicitly mentioned palliative care, while the remaining interventions included traditional palliative care components such as advance care planning, symptom management, and emotional support. Many of the identified interventions lacked theoretical grounding and were studied in non-representative, homogeneous samples. Further research is needed to understand the lived experiences of people with dementia and their caregivers to alleviate care coordination burden.

Promising algorithms to perilous applications: a systematic review of risk stratification tools for predicting healthcare utilisation

OBJECTIVES

Risk stratification tools that predict healthcare utilisation are extensively integrated into primary care systems worldwide, forming a key component of anticipatory care pathways, where high-risk individuals are targeted by preventative interventions. Existing work broadly focuses on comparing model performance in retrospective cohorts with little attention paid to efficacy in reducing morbidity when deployed in different global contexts. We review the evidence supporting the use of such tools in real-world settings, from retrospective dataset performance to pathway evaluation.

METHODS

A systematic search was undertaken to identify studies reporting the development, validation and deployment of models that predict healthcare utilisation in unselected primary care cohorts, comparable to their current real-world application.

RESULTS

Among 3897 articles screened, 51 studies were identified evaluating 28 risk prediction models. Half underwent external validation yet only two were validated internationally. No association between validation context and model discrimination was observed. The majority of real-world evaluation studies reported no change, or indeed significant increases, in healthcare utilisation within targeted groups, with only one-third of reports demonstrating some benefit.

DISCUSSION

While model discrimination appears satisfactorily robust to application context there is little evidence to suggest that accurate identification of high-risk individuals can be reliably translated to improvements in service delivery or morbidity.

CONCLUSIONS

The evidence does not support further integration of care pathways with costly population-level interventions based on risk prediction in unselected primary care cohorts. There is an urgent need to independently appraise the safety, efficacy and cost-effectiveness of risk prediction systems that are already widely deployed within primary care.

Community-based person-centred integrated care (PIC) networks for healthy ageing in place: a scoping review protocol

INTRODUCTION

The economic case for preventive care delivered in or near citizens' homes is strong, and there is growing evidence of the role of local-level support in supporting people's health and well-being as they age. However, effective and consistent delivery of person-centred integrated care (PIC) at the community level remains elusive. Previous systematic reviews have focused on specific processes such as case management, but none have focused on the operational delivery of community-based care networks. In this study, we aim to identify what practice-based models of PIC networks exist at the local/neighbourhood level and what evidence is available as to their effectiveness for healthy ageing in place.

METHODS AND ANALYSIS

We will undertake a scoping review following the framework proposed by Arksey and O'Malley and updated guidance by the Joanna Briggs Institute. Peer-reviewed sources will be identified through searches of seven databases, and relevant grey literature will be identified through websites of policy and voluntary sector organisations focused on integrated care and/or healthy ageing. Data from included studies will be extracted for relevance to the research questions, including aims and anticipated outcomes of network models, financial and management structures of networks, and evidence of evaluation. Summary tables and narrative comparisons of key PIC network features across settings will be presented.

ETHICS AND DISSEMINATION

As no primary data will be collected, ethical approval is not required to conduct this scoping review. In addition to publication as a peer-reviewed article, the results of this review will be summarised as shorter discussion papers for use in follow-up research.

Collaborative Care Models of Primary Care Clinics for People with Early-Stage Dementia: A Cross-Sectional Survey of Primary Care Physicians in Japan

Objectives

This study explored collaboration models between primary care physicians (PCPs) and care managers (CMs) and assessed each model's potential in meeting the support needs of individuals with early-stage dementia.

Methods

In 2022, a cross-sectional survey was conducted among the PCPs in Tokyo. The data regarding the participant and clinic characteristics and daily practices for individuals with early-stage dementia were collected. The clinical collaborative practice was classified using a latent class analysis; comparisons were made between the identified classes based on 14 items in seven domains of support.

Results

Two collaborative and one stand-alone models were identified. The former varied in the professionals' roles, with one led by PCPs and the other by CMs. We named them PCP-led, CM-led, and stand-alone models, accounting for 46.4%, 32.8%, and 20.6% of the clinics, respectively. The PCP-led clinics were significantly more likely to provide support than the stand-alone ones across five domains: cognitive function, care planning, carers' support, information, and social health. The CM-led model clinics generally fell between those of the other two models.

Conclusion

Different leadership styles exist in the PCP-CM collaborations in care delivery for people with early-stage dementia. This collaboration offers distinct advantages for clinics in addressing their needs.

A Paradigm Shift on Deinstitutionalization and Dementia Care: A Narrative Review

This narrative explores the impact of deinstitutionalization policies on the quality of life and care outcomes for individuals with Alzheimer's disease and related dementias. We offer a historical perspective on these policies, their implications on dementia care, and the barriers to deinstitutionalization. The potential benefits of deinstitutionalization, such as improved quality of life and access to community-based support and services, are highlighted. Challenges and controversies surrounding safety, caregiver burden, and resource allocation are also examined. Ethical considerations related to the autonomy and decision-making capacity of people living with dementia are discussed. We present best practices and innovative models in dementia care that balance deinstitutionalization with appropriate care. We further put forth recommendations for future research and policy development in dementia care and deinstitutionalization, emphasizing the need for a balanced approach that respects the autonomy and preferences of people living with dementia while ensuring their safety and well-being.

Competency development for a volunteer navigation program to support caregivers of people living with dementia: A modified e-Delphi method

Caregivers of people living with dementia are pillars of the care community. Providing them with adequate support throughout their caregiving journey is essential to their quality of life and may also contribute to improving the care of people living with dementia. Nav-CARE (Navigation - Connecting, Advocating, Resourcing, Engaging) is a volunteer-led navigation program that provides support to older adults with life-limiting illnesses who are living in the community. However, Nav-CARE does not provide support directly to caregivers of people living with dementia. To adapt Nav-CARE to support caregivers, we needed to establish caregivers' needs and the competencies volunteer navigators should be trained in to support caregivers to meet these needs. To do so, a modified e-Delphi method was utilized, which consisted of administering three sequential questionnaires to a panel of 35 individuals with expertise in a variety of dementia related domains. Through this, two final lists of 46 caregivers' needs and 41 volunteer competencies were established to inform the development of volunteer navigator training curriculum. Findings suggest that trained volunteer navigators may be able to support caregivers of people living with dementia throughout the disease trajectory and can be used to inform the development of future dementia navigation programs.

Examining nursing processes in primary care settings using the Chronic Care Model: an umbrella review

BACKGROUND

While there is clear evidence that nurses can play a significant role in responding to the needs of populations with chronic conditions, there is a lack of consistency between and within primary care settings in the implementation of nursing processes for chronic disease management. Previous reviews have focused either on a specific model of care, populations with a single health condition, or a specific type of nurses. Since primary care nurses are involved in a wide range of services, a comprehensive perspective of effective nursing processes across primary care settings and chronic health conditions could allow for a better understanding of how to support them in a broader way across the primary care continuum. This systematic overview aims to provide a picture of the nursing processes and their characteristics in chronic disease management as reported in empirical studies, using the Chronic Care Model (CCM) conceptual approach.

METHODS

We conducted an umbrella review of systematic reviews published between 2005 and 2021 based on the recommendations of the Joanna Briggs Institute. The methodological quality was assessed independently by two reviewers using the AMSTAR 2 tool.

RESULTS

Twenty-six systematic reviews and meta-analyses were included, covering 394 primary studies. The methodological quality of most reviews was moderate. Self-care support processes show the most consistent positive outcomes across different conditions and primary care settings. Case management and nurse-led care show inconsistent outcomes. Most reviews report on the clinical components of the Chronic Care Model, with little mention of the decision support and clinical information systems components.

CONCLUSIONS

Placing greater emphasis on decision support and clinical information systems could improve the implementation of nursing processes. While the need for an interdisciplinary approach to primary care is widely promoted, it is important that this approach not be viewed solely from a clinical perspective. The organization of care and resources need to be designed to support contributions from all providers to optimize the full range of services available to patients with chronic conditions.

PROSPERO REGISTRATION

CRD42021220004.

Case Management-based Collaborative Care Model Associated with improvement in neuropsychiatric outcomes in community-dwelling people living with dementia

BACKGROUND

This study aimed to explore the association between adherence of collaborative care model and short-term deterioration of BPSD after controlling patient and caregiver factors.

METHODS

This retrospective case-control study enrolled 276 participants who were newly diagnosed with dementia and BPSD. A dementia collaborative care team interviewed patients and caregivers to form a care plan and provided individualized education or social resource referrals. A multivariate logistic regression model with backward selection was used to test factors associated with BPSD deterioration, defined as worse neuropsychiatric inventory (NPI) scores 1 year after joining the care model.

RESULTS

Male sex (odds ratio [OR] = 0.45; 95% confidence interval [CI] = 0.25-0.84) and higher clinical dementia rating scale sum of boxes scores (CDR-SOB) (OR = 0.90; 95% CI = 0.83-0.98) were protective factors, whereas spouse caregivers and withdrawals from the care model (OR = 3.42; 95% CI = 1.28-9.15) were risk factors for BPSD deterioration.

CONCLUSIONS

Our study showed that both patient and caregiver factors were associated with deterioration of BPSD. The case manager-centered dementia collaborative care model is beneficial for the management of BPSD. Healthcare systems may consider implementing a case management model in clinical dementia care practice.

Care coordination across healthcare systems: development of a research agenda, implications for practice, and recommendations for policy based on a modified Delphi panel

OBJECTIVE

For large, integrated healthcare delivery systems, coordinating patient care across delivery systems with providers external to the system presents challenges. We explored the domains and requirements for care coordination by professionals across healthcare systems and developed an agenda for research, practice and policy.

DESIGN

The modified Delphi approach convened a 2-day stakeholder panel with moderated virtual discussions, preceded and followed by online surveys.

SETTING

The work addresses care coordination across healthcare systems. We introduced common care scenarios and differentiated recommendations for a large (main) healthcare organisation and external healthcare professionals that contribute additional care.

PARTICIPANTS

The panel composition included health service providers, decision makers, patients and care community, and researchers. Discussions were informed by a rapid review of tested approaches to fostering collaboration, facilitating care coordination and improving communication across healthcare systems.

OUTCOME MEASURES

The study planned to formulate a research agenda, implications for practice and recommendations for policy.

RESULTS

For research recommendations, we found consensus for developing measures of shared care, exploring healthcare professionals' needs in different care scenarios and evaluating patient experiences. Agreed practice recommendations included educating external professionals about issues specific to the patients in the main healthcare system, educating professionals within the main healthcare system about the roles and responsibilities of all involved parties, and helping patients better understand the pros and cons of within-system and out-of-system care. Policy recommendations included supporting time for professionals with high overlap in patients to engage regularly and sustaining support for care coordination for high-need patients.

CONCLUSIONS

Recommendations from the stakeholder panel created an agenda to foster further research, practice and policy innovations in cross-system care coordination.

Contextual Factors Associated with Abuse of Home-Dwelling Persons with Dementia: A Cross-Sectional Exploratory Study of Informal Caregivers

One in six community-dwelling older adults experience elder abuse yearly, and persons with dementia are especially at risk. Although many risk factors for elder abuse have been identified, there are still knowledge gaps concerning risk and protective factors. This cross-sectional survey among Norwegian informal caregivers (ICGs) aimed to find individual, relational, and community factors associated with psychological and physical abuse of home-dwelling persons with dementia. This study involved 540 ICGs and was conducted from May to December 2021. Statistical analysis using penalized logistic regression with lasso was performed to find covariates associated with psychological and physical elder abuse. The most prominent risk factor for both subtypes of abuse was the caregiver being a spouse. In addition, risk factors for psychological abuse were having a higher caregiver burden, experiencing psychological aggression from the person with dementia, and the person with dementia being followed up by their general practitioner. For physical abuse, the protective factors were the ICG being female and having an assigned personal municipal health service contact, while the risk factors were the ICG attending a caregiver training program and experiencing physical aggression from the person with dementia and the person with dementia having a higher degree of disability. These findings add to the existing knowledge of risk and protective factors in elder abuse among home-dwelling persons with dementia. This study provides relevant knowledge for healthcare personnel working with persons with dementia and their caregivers and for the development of interventions to prevent elder abuse.

Comorbidity and Management of Concurrent Psychiatric and Medical Disorders

Aging increases susceptibility to medical and psychiatric comorbidity via interrelated biological, psychological, and social mechanisms. Mental status changes or other psychiatric symptoms occurring in older adults with medical disorders most often result from delirium, depression, or the onset of Alzheimer's disease and related dementias (ADRD). Clinicians can use evidence-based tools to evaluate such symptoms including the 4A's Test for delirium, the Saint Louis University Mental Status Exam, and the Geriatric Depression Scale. Innovative models such as collaborative care can improve the outcome of care of older adults with medical disorders requiring treatment for depression or ADRD..

Identifying Primary Care Models of Dementia Care that Improve Quality of Life for People Living with Dementia and their Care Partners: An Environmental Scan

Dementia is a growing concern in Canada, affecting peoples' health and raising the cost of care. Between June and October 2019, we conducted an environmental scan to identify primary care models, strategies, and resources for dementia care from 11 pre-selected countries and assess their impact on quality-of-life measures. Search strategies included a rapid scoping review, grey literature search, and discussions with stakeholders. Eighteen primary care-based models of dementia care were identified. Common factors include team-based care, centralized care/case coordination, individual treatment plans, a stepped-care approach, and support for care partners. Five provinces had released a dementia strategy. Evidence of positive outcomes supported primary care-based models for dementia care, although only one model demonstrated evidence of impact on quality of life. Although these findings are encouraging, further research is needed to identify primary care-based models of dementia care that demonstrably improve quality of life for people living with dementia and their care partners.

Diabetes management in people living with dementia in Japan: a qualitative exploration

BACKGROUND

Dementia and diabetes are highly prevalent among the older society in Japan. People living with dementia (PLWD) often face hurdles in managing diabetes. This study explored the perspectives of healthcare providers in Japan regarding diabetes management in PLWD.

METHODS

We conducted a qualitative study using in-depth interviews as a data collection method. A total of 15 physicians and nurses were interviewed. A qualitative content analysis of the codes was performed to generate the themes.

RESULTS

The major themes focused on the management of medications/therapeutic regimen, difficulties of continuing health care, emotional aspects of PLWD for adherence to lifestyle modification, and varying direction and degree of family support for diabetes care.

CONCLUSION

PLWD in Japan face challenges in medication management, food restriction, and lifestyle modification. Policies to engage home visit care workers in medication management, consideration of the emotional aspect of PLWD, and utilisation of social support might help in the proper management of diabetes in PLWD.

Transcending inequities in dementia care in Black communities: Lessons from the maximizing independence at home care coordination program

Purpose

We examine care partners’ experience of the Maximizing Independence at Home (MIND) intervention, a multicomponent, home-based dementia care coordination program designed to provide high quality, wholistic care coordination for people and families living with dementia. The goal of the study was to understand 1. the unique dementia-related needs of Black care partners and barriers and challenges to caregiving experienced within the Black community, 2. perceived benefits of the MIND program, and 3. ways to improve the program and make it more culturally responsive to the Black community.

Method

We conducted three focus groups totaling 20 care partners of people living with dementia; who participated in the MIND intervention (2014–2019); all Black/African American and English speaking. Verbatim transcriptions were independently analyzed line-by-line by two coders using inductive approaches.

Findings

Participants noted three overarching themes related to dementia care needs and challenges in the Black community: difficulty finding and accessing dementia information and relevant services and supports; familial conflict/lack of sibling and familial support; and lack of effective communication about dementia within Black Communities. Regarding MIND at home program benefits, four themes emerged: 1. perceived to help locate resources (formal and informal); 2. provided care partners an opportunity for socialization and interaction; 3. included comprehensive assessments and helpful linked information; and 4. resulted in a “much needed break for care partners.” Increased diversity of the MIND program personnel, greater clarity and consistency in MIND program promotion, and better communications were themes for how the program could be improved.

Conclusion

Care partners participating in the MIND program perceived common benefits in aspects related to care for the persons living with dementia as well as benefits to themselves, believed the program addressed important challenges and gaps in education, services, and social support, and could be enhanced in its delivery and cultural responsiveness.

Rate of conversion from mild cognitive impairment to dementia in a Thai hospital-based population: A retrospective cohort

Introduction

Mild cognitive impairment (MCI) is the state between normal cognition and dementia. This study objective was to estimate an average 1-year rate of conversion from MCI to dementia and explore the associated factors of conversion in a hospital-based cohort.

Methods

A retrospective cohort study of participants with MCI was conducted in a tertiary care hospital in Thailand. Two hundred fifty participants, 50 years of age or older, were enrolled.

Results

An average 1-year conversion rate from MCI to dementia was 18.4%. MCI patients who converted to dementia were likely older (P < .001), predominantly female (P = .028), vitamin D deficient (P = .012), and associated with lower Mini-Mental State Examination (MMSE) and Montreal Cognitive Assessment (MoCA) scores during first assessments (P < .001, P < .001 respectively) and follow-up assessments (P < .045, P < .001 respectively). We conducted two models of multivariate analysis, using binary logistic regression. In the first model, adjusted for age, sex, education, vitamin D deficiency, and first assessment MMSE scores, we found that underlying vitamin D deficiency (odds ratio [OR] = 3.13, 95% confidence interval [CI] 1.04 to 9.44) and first assessment MMSE scores (OR = 0.83, 95% CI 0.73 to 0.93) were significantly associated with conversion to dementia. In the second model, adjusted for age, sex, education, vitamin D deficiency and first assessment MoCA scores, only first assessment MoCA scores (OR = 0.58, 95% CI 0.45 to 0.76) were significantly associated with conversion to dementia.

Discussion

The 1-year conversion rate from MCI to dementia was 18.4%. MMSE and MoCA were useful tools to assess baseline cognitive status in MCI patients and predict dementia progression. The association between vitamin D deficiency and risk of conversion from MCI to dementia requires further investigations.

Implementing post diagnostic dementia care in primary care: a mixed-methods systematic review

OBJECTIVES

Concentrating post-diagnostic dementia care in primary care may lead to better and more cost-effective care closer to home. We aimed to assess which intervention components and contextual factors may contribute to the successful delivery and implementation of primary care-led post-diagnostic dementia care.

METHODS

Mixed-methods systematic review. We searched five databases (inception-March 2019) with reference list screening and citation tracking. We included studies evaluating post-diagnostic dementia care interventions where primary care had a significant role in dementia care, which assessed one or more implementation elements (acceptability, feasibility, adoption, sustainability, reach, costs, appropriateness or fidelity). Two authors independently critically appraised studies.

RESULTS

Out of 4528 unique references, we screened 380 full texts and included 49 evaluations of services collecting implementation process data. Most services had high acceptability ratings. The most acceptable components were information provision, social and emotional support and links to community organisations. Feasibility was chiefly influenced by provider engagement and leadership, building dementia care capacity, sufficient resources/funding and collaboration. Care quality was maximised through adding capacity from a dementia-specific health professional. On the basis of limited data, costs for various primary care-led models did not substantially differ from each other.

CONCLUSION

A range of primary care-led dementia care models appear feasible and acceptable. Future services should: add dementia-focussed health professionals into primary care, develop primary care leadership and provide sufficient funding and collaboration opportunities. Information, community service links and social and ongoing support should be part of services. Further exploration of service reach and formalised fidelity assessment are needed.

Effects of case management intervention for people with dementia and their carers: A systematic review and meta-analysis of experimental studies

BACKGROUND

Case management has been developed and suggested as a method for improving the quality of dementia care by optimising care service and delivery using a feasible and cost-effective approach. However, the effects of case management for improving dementia care remain inconclusive.

AIM

To analyse the efficacy of case management interventions for people with dementia and their carers.

DESIGN

Systematic review and meta-analysis.

METHODS

This study conducted a systematic review of the literature from January 1, 2002, to March 15, 2021, indexed in the following databases: Academic Search Complete, CINAHL, Cochrane Library, EMBASE, MEDLINE, PubMed, OVID, and Web of Science. Intervention studies examining patients with dementia and their carers published in the English language were included. The methodological quality of included studies was evaluated using the PEDro scale. The meta-analysis was performed using a random-effects model to calculate the pooled standardised mean difference (SMD) of case management intervention outcomes for both people with dementia (cognitive function, neuropsychiatric symptoms, and quality of life) and their carers (carer burden). Stata 16.0 was used for statistical analysis.

RESULTS

A total of eight studies met the eligibility criteria for this study. The results of the quantitative analysis, ranging from 6 to 18 months, showed no significant effect on cognitive function, quality of life over 12 months and longer, and carer burden over time between groups with and without intervention. However, significant improvements were observed for neuropsychiatric symptoms over 12 months and longer and quality of life at six months in the case management group.

CONCLUSION

Case management appears to have the potential to improve the health outcomes among people with dementia. However, these conclusions are limited due to the lack of conducted studies. Future work examining intervention outcomes remains necessary to explore the effects of interventions on the mental and physical wellbeing of carers.

The compound role of a coordinator for home-dwelling persons with dementia and their informal caregivers: qualitative study

Background

As the number of persons with dementia is increasing, there has been a call for establishing sustainable clinical pathways for coordinating care and support for this group. The LIVE@Home.Path trial is a multicomponent, multi-disciplinary intervention combining learning, innovation, volunteer support and empowerment. To implement the intervention, a municipal coordinator has a crucial role. Implementation research on multicomponent interventions is complex and we conducted a qualitative study, aiming to explore the coordinator role and how a coordinator may empower persons with dementia in decision-making processes.

Methods

Qualitative program evaluation combined with a hermeneutic interpretive approach was chosen as methodological approach. Sixteen dyads, consisting of the person with dementia and their main informal caregiver received the intervention by two coordinators. Of these, six dyads, three informal caregivers alone and the two care coordinators along with their leader, in sum, eighteen persons, participated in in-depth or focus group interviews, sharing their experiences after 6 months intervention.

Results

We found that the coordinators fulfilled three functions for the participating dyads: being a safety net, meaning that the dyads might have little needs at the moment, but found safety in a relation to someone who might help if the situation should change; being a pathfinder, meaning that they supported the dyads in finding their way through the complicated system of care and support services; being a source for emotional care and support, meaning that they listened, acknowledged and gave counsel in times of distress. The coordinators emphasized that a trusting leader and work environment was crucial for them to fulfill these functions. We also found that it was challenging for the coordinators to build a relation to the persons with dementia in order to pursue genuine empowerment in decision-making processes.

Conclusion

We found the framework for follow-up to be a feasible starting point for establishing empowering coordination and a sustainable care pathway for persons with dementia and their informal caregivers. More meeting points between coordinator and person with dementia should be pursued in order to fulfill the persons’ fundamental rights to participate in decision-making processes.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-020-05913-z.

What works in managing complex conditions in older people in primary and community care? A state-of-the-art review

The number of older people living with complex health conditions is increasing, with the majority of these managed in primary and community settings. Many models of care have been developed to support them, however, there is mixed evidence on their value and they include multiple overlapping components. We aimed to synthesise the evidence to learn what works for managing complex conditions in older people in primary and community care. We carried out a state-of-the-art review of systematic reviews. We searched three databases (January 2009 to July 2019) for models of primary and community care for long-term conditions, frailty, multimorbidity and complex neurological conditions common to older people such as dementia. We narratively synthesised review findings to summarise the evidence for each model type and identify components which influenced effectiveness. Out of 2,129 unique titles and abstracts, 178 full texts were reviewed and 54 systematic reviews were included. We found that the models of care were more likely to improve depressive symptoms and mental health outcomes than physical health or service use outcomes. Interventions including self-management, patient education, assessment with follow-up care procedures, and structured care processes or pathways had greater evidence of effectiveness. The level of healthcare service integration appeared to be more important than inclusion of specific professional types within a team. However, more experienced and qualified nurses were associated with better outcomes. These conclusions are limited by the overlap between reviews, reliance on vote counting within some included reviews and the quality of study reports. In conclusion, primary and community care interventions for complex conditions in older people should include: (a) clear intervention targets; (b) explicit theoretical underpinnings; and (c) elements of self-management and patient education, structured collaboration between healthcare professionals and professional support. Further work needs to determine the optimal intensity, length, team composition and role of technology in interventions.

Family Caregiving for Older Adults

Family members are the primary source of support for older adults with chronic illness and disability. Thousands of published empirical studies and dozens of reviews have documented the psychological and physical health effects of caregiving, identified caregivers at risk for adverse outcomes, and evaluated a wide range of intervention strategies to support caregivers. Caregiving as chronic stress exposure is the conceptual driver for much of this research. We review and synthesize the literature on the impact of caregiving and intervention strategies for supporting caregivers. The impact of caregiving is highly variable, driven largely by the intensity of care provided and the suffering of the care recipient. The intervention literature is littered with many failures and some successes. Successful interventions address both the pragmatics of care and the emotional toll of caregiving. We conclude with both research and policy recommendations that address a national agenda for caregiving.

Effectiveness of different post-diagnostic dementia care models delivered by primary care: a systematic review

BACKGROUND

Global policy recommendations suggest a task-shifted model of post-diagnostic dementia care, moving towards primary and community-based care. It is unclear how this may best be delivered.

AIM

To assess the effectiveness and cost-effectiveness of primary care-based models of post-diagnostic dementia care.

DESIGN AND SETTING

A systematic review of trials and economic evaluations of post-diagnostic dementia care interventions where primary care was substantially involved in care plan decision making.

METHOD

Searches were undertaken of MEDLINE, PsychINFO, EMBASE, Web of Science, and CINAHL (from inception to March 2019). Two authors independently critically appraised studies and inductively classified interventions into types of care models. Random effects meta-analysis or narrative synthesis was conducted for each model where appropriate.

RESULTS

From 4506 unique references and 357 full texts, 23 papers were included from 10 trials of nine interventions, delivered in four countries. Four types of care models were identified. Primary care provider (PCP)-led care (n = 1) led to better caregiver mental health and reduced hospital and memory clinic costs compared with memory clinics. PCP-led care with specialist consulting support (n = 2) did not have additional effects on clinical outcomes or costs over usual primary care. PCP-case management partnership models (n = 6) offered the most promise, with impact on neuropsychiatric symptoms, caregiver burden, distress and mastery, and healthcare costs. Integrated primary care memory clinics (n = 1) had limited evidence for improved quality of life and cost-effectiveness compared with memory clinics.

CONCLUSION

Partnership models may impact on some clinical outcomes and healthcare costs. More rigorous evaluation of promising primary care-led care models is needed.

"Current dementia care: what are the difficulties and how can we advance care globally?"

BACKGROUND

Dementia is a growing global public health concern, with post-diagnostic care often very limited. Depending on where people live, both within a country and depending on high-, middle-, and low-income countries, they might also face barriers in accessing the right care at the right time. Therefore, it is important to highlight recent evidence on the facilitators and barriers to dementia care, but also evidence on how to move dementia care forward.

MAIN TEXT

Current dementia care is subject to several inequalities, including living in rural regions and being from a minority ethnic background. Evidence in this collection highlights the issues that both people living with dementia and unpaid carers are facing in accessing the right care, with evidence from Australia, Canada, Uganda, to the Netherlands, and further afield. Providing improved dementia-specific training to health care professionals and supporting medication and reablement interventions have been identified as possible ways to improve dementia care for all.

CONCLUSIONS

This special issue focuses on recent evidence on inequalities in dementia care across the globe and how dementia care can be advanced in various areas.

Measures for the integration of health and social care services for long-term health conditions: a systematic review of reviews

Background

As people are living longer with higher incidences of long-term health conditions, there is a move towards greater integration of care, including integration of health and social care services. Integrated care needs to be comprehensively and systematically evaluated if it is to be implemented widely. We performed a systematic review of reviews to identify measures which have been used to assess integrated care across health and social care services for people living with long-term health conditions.

Methods

Four electronic databases (PUBMED; MEDLINE; EMBASE; Cochrane library of systematic reviews) were searched in August 2018 for relevant reviews evaluating the integration of health and social care between 1998 and 2018. Articles were assessed according to apriori eligibility criteria. A data extraction form was utilised to collate the identified measures into five categories.

Results

Of the 18 articles included, system outcomes and process measures were most frequently identified (15 articles each). Patient or carer reported outcomes were identified in 13 articles while health outcomes were reported in 12 articles. Structural measures were reported in nine articles. Challenges to measuring integration included the identification of a wide range of potential impacts of integration, difficulties in comparing findings due to differences in study design and heterogeneity of types of outcomes, and a need for appropriate, robust measurement tools.

Conclusions

Our review revealed no shortage of measures for assessing the structures, processes and outcomes of integrated care. The very large number of available measures and infrequent use of any common set make comparisons between schemes more difficult. The promotion of core measurement sets and stakeholder consultation would advance measurement in this area.

A comprehensive meta-review of systematic reviews and meta-analyses on nonpharmacological interventions for informal dementia caregivers

Background

Many reviews with conflicting findings on dementia caregiver interventions have been published. A meta-review was conducted to synthesize the findings of systematic reviews and meta-analyses.

Methods

MEDLINE, PsycINFO, CINAHL and Cochrane Library were searched to identify reviews published during 2006–2018.

Results

Sixty reviews covering > 500 intervention studies were selected and appraised with Assessment of Multiple Systematic Reviews (AMSTAR) II. The great majority of studies were of low quality according to AMSTAR II, but quality factors appeared unrelated to the conclusions obtained. Depression was most modifiable, with effects found across a spectrum of interventions (psychoeducation, counseling/psychotherapy, occupational therapy, mindfulness-based interventions, multicomponent interventions, etc.). Evidence of intervention effect was also found for quality of life (psychoeducation), mastery (psychoeducation, occupational therapy and multicomponent interventions) and communication skills (communication training). Null or weak results were found for anxiety, social support and burden. Support groups and respite were generally ineffective. There was no evidence that dyadic programs were better than caregiver-only programs, or that programs delivered individually or in groups would differ in their impacts. The evidence also does not support multicomponent interventions to have broader impacts than single-component programs. Methodological issues in the existing reviews (e.g., selective use of studies to serve different research purposes and inconsistent classification of interventions) were noted and taken into account when interpreting findings.

Conclusions

This meta-review clarified variations in review methodology and identified a few potent groups of intervention (most notably psychoeducation, psychotherapy, occupational therapy, and multicomponent interventions), although no intervention type had broad effects on caregiver outcomes. We note that improvements are needed in the reporting of intervention studies and in making the classification of interventions more transparent and consistent. We further recommend fewer and larger-scale reviews and more attention to positive outcomes in order to better inform the field. Developing interventions with broader impacts and packaging them to meet caregivers’ changing needs in the course of dementia should be a priority for researchers and practitioners.

Barriers to dementia diagnosis and care in China

In China, the ageing population and the prevalence of dementia are projected to escalate significantly by 2050 resulting in a substantial increase in health and economic burden on caregivers, healthcare facilities, healthcare providers and communities. There is no published national dementia policy or strategy in China. This case report describes significant barriers contributing to diagnostic problems and inadequate care of dementia through the case of an older female in rural China, whose condition deteriorated due to neuropsychiatric and functional symptoms of undiagnosed dementia. Intersectoral collaboration between care organisations facilitated delivery of a non-pharmacological intervention programme which was associated with improvements in the patient's functional and neuropsychiatric symptoms. The case demonstrates that recruitment and training of a wider range of health and care professionals and caregivers in a systematic approach to non-pharmacological interventions could help overcome barriers to the specialised care needs of people with dementia where resources are lacking.

Factors Influencing Emergency Care by Persons With Dementia: Stakeholder Perceptions and Unmet Needs

BACKGROUND/OBJECTIVES

People with dementia (PwD) frequently use emergency care services. To mitigate the disproportionately high rate of emergency care use by PwD, an understanding of contributing factors driving reliance on emergency care services and identification of feasible alternatives are needed. This study aimed to identify clinician, caregiver, and service providers' views and experiences of unmet needs leading to emergency care use among community-dwelling PwD and alternative ways of addressing these needs.

DESIGN

Qualitative, employing semistructured interviews with clinicians, informal caregivers, and aging service providers.

SETTING

Wisconsin, United States.

PARTICIPANTS

Informal caregivers of PwD (n = 4), emergency medicine physicians (n = 4), primary care physicians (n = 5), geriatric healthcare providers (n = 5), aging service providers (n = 6), and community paramedics (n = 3).

MEASUREMENTS

Demographic characteristics of participants and data from semistructured interviews.

FINDINGS

Four major themes were identified from interviews: (1) system fragmentation influences emergency care use by PwD, (2) informational, decision-making, and social support needs influence emergency care use by PwD, (3) emergency departments (EDs) are not designed to optimally address PwD and caregiver needs, and (4) options to prevent and address emergency care needs of PwD.

CONCLUSION

Participants identified numerous system and individual-level unmet needs and offered many recommendations to prevent or improve ED use by PwD. These novel findings, aggregating the perspectives of multiple dementia-care stakeholder groups, serve as the first step to developing interventions that prevent the need for emergency care or deliver tailored emergency care services to this vulnerable population through new approaches. J Am Geriatr Soc 67:711-718, 2019.