A framework for rehabilitation for older adults living with dementia

Impact of a short-duration experiential learning activity on DPT students' attitudes toward patients living with a dementia

Healthcare practitioners (HCP) have expressed inadequate preparation in providing care to patients living with a dementia. Research suggests experiential learning activities (ELAs) can improve HCP knowledge and comfort toward this population. The purpose of this study was to evaluate the impact of a short-duration (2-hour) dementia ELA on Doctor of Physical Therapy (DPT) students' knowledge and comfort toward individuals living with a dementia. Participants included a sample of first-year DPT students (n=82).  In this pre-experimental, single-site, longitudinal study, students participated in an ELA at a memory care facility. They completed a dementia knowledge and comfort survey pre-(T1) and post-ELA(T2), as well as prior to their first clinical experience (nine months post-ELA; T3). Pre- and post-survey analysis demonstrated significant improvements between T1 to T2 and T1 to T3 with overall effect sizes ranging from very large (d=1.256) to huge (d=1.520). There were no significant differences between T2 to T3 analysis. Students demonstrated positive improvements in attitudes toward individuals living with a dementia following this ELA. Improvements were maintained over time. An ELA as short as two hours may improve person-centered care for patients living with a dementia. These types of activities should be considered for inclusion in DPT curricula.

Multimorbidity analysis with low condition counts: a robust Bayesian approach for small but important subgroups

BACKGROUND

Robustly examining associations between long-term conditions may be important in identifying opportunities for intervention in multimorbidity but is challenging when evidence is limited. We have developed a Bayesian inference framework that is robust to sparse data and used it to quantify morbidity associations in the oldest old, a population with limited available data.

METHODS

We conducted a retrospective cross-sectional study of a representative dataset of primary care patients in Scotland as of March 2007. We included 40 long-term conditions and studied their associations in 12,009 individuals aged 90 and older, stratified by sex (3039 men, 8970 women). We analysed associations obtained with Relative Risk (RR), a standard measure in the literature, and compared them with our proposed measure, Associations Beyond Chance (ABC). To enable a broad exploration of interactions between long-term conditions, we built networks of association and assessed differences in their analysis when associations are estimated by RR or ABC.

FINDINGS

Our Bayesian framework was appropriately more cautious in attributing association when evidence is lacking, particularly in uncommon conditions. This caution in reporting association was also present in reporting differences in associations between sex and affected the aggregated measures of multimorbidity and network representations.

INTERPRETATION

Incorporating uncertainty into multimorbidity research is crucial to avoid misleading findings when evidence is limited, a problem that particularly affects small but important subgroups. Our proposed framework improves the reliability of estimations of associations and, more in general, of research into disease mechanisms and multimorbidity.

FUNDING

National Institute for Health and Care Research.

The Care Needs of Patients With Cognitive Impairment in Late-Stage Parkinson's Disease

BACKGROUND

Cognitive impairment is common in Parkinson's disease (PD), but care needs and resource use for those with significant cognitive impairment are not well established.

METHODS

675 participants with PD from the international Care of Late-Stage Parkinsonism (CLaSP) study were grouped into those without (n = 333, 49%) and with cognitive impairment (MMSE < 24/30 or diagnosis of dementia or Mild Cognitive Impairment; n = 342, 51%) and their clinical features, care needs and healthcare utilisation compared. The relationship between cognition and healthcare consultations was investigated through logistic regression.

RESULTS

Cognitive impairment was associated with more motor and non-motor symptoms, less antiparkinsonian but higher rates of dementia and antipsychotic medication, worse subjective health status and greater caregiver burden. A considerable proportion did not have a pre-established cognitive diagnosis. Care needs were high across the whole sample but higher in the cognitive impairment group. Home care and care home use was higher in the cognitive impairment group. However, use of healthcare consultations was similar between the groups and significantly fewer participants with cognitive impairment had had recent PD Nurse consultations. Worse cognitive impairment was associated with lower frequency of recent PD nurse and multidisciplinary therapy consultation (physiotherapy, massage, occupational therapy, speech training and general nursing).

CONCLUSIONS

Those with cognitive impairment have more severe PD, higher care needs and greater social care utilisation than those with normal cognition, yet use of health care services is similar or less. Cognitive impairment appears to be a barrier to PD nurse and multidisciplinary therapy consultations. This challenges current models of care: alternative models of care may be required to serve this population.

PLAIN LANGUAGE SUMMARY

Parkinson's disease is a long-term progressive health condition. Over time, many people with Parkinson's develop problems with thinking and memory, called cognitive impairment. This can negatively impact the daily lives of the person with Parkinson's and their caregiver. It is also thought to be a barrier to accessing healthcare. How people with Parkinson's who have cognitive impairment use healthcare and detail of their care needs is not well known.We analysed data from a large sample of people with advanced Parkinson's from six European countries to investigate their symptoms, care needs and healthcare use. We compared those with cognitive impairment to (342 people) to those without cognitive impairment (333 people).We found that those with cognitive impairment had more severe Parkinson's across a range of symptoms compared to those without cognitive impairment. They also had more care needs, reported their health status to be worse, and their caregivers experienced greater strain from caring. Whilst use of other healthcare services was similar between the two groups, those with cognitive impairment were less likely to have recently seen a Parkinson's nurse than those without cognitive impairment. Further analysis showed an association between cognitive impairment and not having seen a Parkinson's nurse or therapist recently, taking psychiatric symptoms, functional disability and care home residence into account. Therapists included were physiotherapy, massage, occupational therapy, speech training and general nursing. These findings highlight unmet need. We suggest that healthcare should be more targeted to help this group of people, given their higher care needs.

Topical Cellular/Tissue and Molecular Aspects Regarding Nonpharmacological Interventions in Alzheimer's Disease-A Systematic Review

One of the most complex and challenging developments at the beginning of the third millennium is the alarming increase in demographic aging, mainly-but not exclusively-affecting developed countries. This reality results in one of the harsh medical, social, and economic consequences: the continuously increasing number of people with dementia, including Alzheimer's disease (AD), which accounts for up to 80% of all such types of pathology. Its large and progressive disabling potential, which eventually leads to death, therefore represents an important public health matter, especially because there is no known cure for this disease. Consequently, periodic reappraisals of different therapeutic possibilities are necessary. For this purpose, we conducted this systematic literature review investigating nonpharmacological interventions for AD, including their currently known cellular and molecular action bases. This endeavor was based on the PRISMA method, by which we selected 116 eligible articles published during the last year. Because of the unfortunate lack of effective treatments for AD, it is necessary to enhance efforts toward identifying and improving various therapeutic and rehabilitative approaches, as well as related prophylactic measures.

Association Between Cognitive Impairment and Repeat Fractures in Medicare Beneficiaries Recently Hospitalized for Hip Fracture

BACKGROUND

Repeat fractures contribute substantially to fracture incidents in older adults. We examined the association between cognitive impairment and re-fractures during the first 90 days after older adults with hip fractures were discharged home from a skilled nursing facility rehabilitation short stay.

METHODS

Multilevel binary logistic regression was used to analyze 100% of U.S. national postacute-care fee-for-service Medicare beneficiaries who had a hospital admission for hip fracture from January 1, 2018, to July 31, 2018; were admitted for a skilled nursing facility stay within 30 days of hospital discharge; and were discharged to the community after a short stay. Our primary outcome was rehospitalization for any re-fractures within 90 days of skilled nursing facility discharge. Cognitive status assessed at skilled nursing facility admission or before discharge was classified as either intact or having mild or moderate/severe impairment.

RESULTS

In 29 558 beneficiaries with hip fracture, odds of any re-fracture were higher in those with minor (odds ratio: 1.48; 95% confidence interval: 1.19-1.85; p < .01) and moderate/major cognitive impairment (odds ratio: 1.42; 95% confidence interval: 1.07-1.89; p = .0149) than in those classified as intact.

CONCLUSIONS

Beneficiaries with cognitive impairment were more likely than their counterparts with no cognitive impairment to experience re-fractures. Community-dwelling older adults with minor cognitive impairment may experience a higher likelihood of experiencing a repeat fracture leading to rehospitalization.

Qualitative research concerning physiotherapy approaches to encourage physical activity in older adults with dementia

BACKGROUND

Physical exercise is known to improve the level of activities of daily living and physical function in people with dementia; however, symptoms of dementia often pose challenges when implementing physical therapy. This study aimed to elucidate how physiotherapists (PTs) engage with older adults with dementia to encourage exercise and participation in physical activity.

METHODS

In this qualitative study, four PTs working with older adults with dementia in long-term care facilities in Japan were recruited and interviewed. We used a modified grounded theory approach to assess how PTs engaged with older adults with dementia during physiotherapy sessions.

RESULTS

Based on PT responses, five categories of engagement were identified: "make structured preparations for clients to begin physical activity," "link exercise therapy to a client's daily life," "discover changes in daily life," "ascertain cognitive function," and "accommodate client differences." Concepts were derived under each category. The category "make structured preparations for clients to begin physical activity" served as a preceding stage for PTs to engage with older adults with dementia. PTs linked exercise therapy to each client's daily life activities to encourage voluntary participation in daily physical activity. PTs ensured the performance of routine patterns of movement and modified these movement patterns per clients' differing paces.

CONCLUSION

PTs provided exercise and movement training based on various degrees of client involvement and made structured preparations for clients to begin physical activity that were linked to exercise therapy. Our findings may prompt PTs to encourage older people with dementia to participate in physical therapy and benefit from exercise.

The Efficacy and Safety of Physiotherapy in People with Dementia: A Systematic Review

BACKGROUND

Physiotherapy has become increasingly relevant as a new therapeutic intervention for dementia. However, it is unclear which interventions are the most suitable.

OBJECTIVE

This study sought to summarize and critically appraise the evidence on physiotherapy interventions in dementia.

METHODS

A systematic review conducted using CENTRAL, MEDLINE, and PEDro databases, from their inception to July 2022, identified all experimental studies of dementia that included physiotherapy interventions.

RESULTS

Of 194 articles included, the most frequently used interventions were aerobic training (n = 82, 42%), strength training (n = 79, 41%), balance training (n = 48, 25%), and stretching (n = 22, 11%). These were associated with a positive effect on several motor and cognitive outcomes. A total number of 1,119 adverse events were reported.

CONCLUSION

Physiotherapy has several motor and cognitive benefits in dementia. Future research should focus on establishing a physiotherapy prescription protocol for people with mild cognitive impairment and for each stage of dementia.

Education and training interventions for physiotherapists working in dementia care: a scoping review

OBJECTIVES

Physiotherapy plays a key role in many aspects of dementia care, most notably in maintaining mobility. However, there is a lack of dementia care training at undergraduate and postgraduate level, and more importantly, a paucity of evidence as to what constitutes effective dementia education and training for physiotherapists. The aim of this scoping review was to explore and map the evidence, both quantitative and qualitative, relating to education and training for physiotherapists.

DESIGN

This scoping review followed the Joanna Briggs Institute methodology for scoping reviews. A chronological narrative synthesis of the data outlined how the results relate to the objectives of this study.

SETTING

All studies, both quantitative and qualitative on dementia education and training conducted in any setting, including acute, community care, residential or any educational setting in any geographical area were included.

PARTICIPANTS

Studies that included dementia education and training for both qualified and student physiotherapists were considered RESULTS: A total of 11 papers were included in this review. The principal learning outcomes evaluated were knowledge, confidence, and attitudes. Immediate post- intervention scores showed an improvement in all three outcomes. The Kirkpatrick four level model was used to evaluate the level of outcome achieved. Most educational interventions reached Kirkpatrick level 2, which evaluates learning. A multi-modal approach, with active participation and direct patient involvement seems to enhance learning.

CONCLUSIONS

Allowing for the heterogeneity of intervention design and evaluation, some common components of educational interventions were identified that led to positive outcomes. This review highlights the need for more robust studies in this area. Further research is needed to develop bespoke dementia curricula specific to physiotherapy. CONTRIBUTIONS OF THE PAPER.

Association of Dementia Severity and Caregiver Support With Early Discharge From Home Health

INTRODUCTION

The objective of this study was to examine the relationship between dementia severity and early discharge from home health.

METHODS

This was a retrospective study of 100% national Medicare home health da ta files (2016-2017). Multilevel logistic regression was used to study the relationship of dementia severity, caregiver support, and medication assistance with early discharge from home health.

RESULTS

The final cohort consisted of 91 302 Medicare beneficiaries with an ADRD diagnosis. A pattern of early discharge rates across dementia severity levels was not demonstrated. The relative risk for early discharge was lower for individuals who needed assistance with medication and for those with unmet caregiver needs.

DISCUSSION

The findings of this study do not support the hypothesis that dementia severity contributes to early discharge from home health. Further research is needed to fully understand key factors contributing to early discharge from home health.