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

Effectiveness of a health education program for people with dementia and their family caregivers: An intervention by nurse practitioners

PURPOSE

This study assesses the effectiveness of a health education program on caregiving outcomes for people with dementia and their families.

METHODS

This quasi-experimental study involved 250 people with dementia and their family caregivers. Behavioral problems in people with dementia were assessed using the Chinese version of the Cohen-Mansfield Agitation Inventory-community form. Family caregiver outcomes were measured using the Agitation Management Self-Efficacy Scale, Caregiver Preparedness Scale, Competence Scale, and Community Resource Awareness and Utilization Assessment.

RESULTS

Following the intervention, the experimental group demonstrated significant improvements in terms of self-efficacy, preparedness, competence, and awareness and utilization of community resources among family caregivers. Additionally, the experimental group exhibited lower levels of behavioral problems among people with dementia.

CONCLUSIONS

This study helped improve caregiving outcomes for people with dementia and their family caregivers. Therefore, outpatient healthcare providers can utilize these findings to enhance care for this population.

[Dementia Care Nurses in the networked care of people with dementia: a qualitative evaluation study]

Dementia Care Nurses in the networked care of people with dementia: A qualitative evaluation study Abstract: Background: To coordinate networked dementia care counselling concepts with case management (CM) structures are recommended. This approach has been explored and evaluated within the Dementia Care Nurse project in Saxony-Anhalt. Studies on the implementation of CM are mostly limited to cooperation between case managers and medical and nursing professional groups. Networking processes with all stakeholders involved in dementia care have hardly been described so far. Objective: The aim was to describe the experienced collaboration with Dementia Care Nurses (DCNs) from the perspective of the participating cooperation partners and to derive approaches for the continuation of the DCNs in routine care. Method: Eight semi-structured interviews were conducted with cooperation partners from the health and social care sector who participated in the DCN project. The interviews were analysed for content. Results: The interviews were evaluated by content analysis. Results: Overall, the interviewed cooperation partners rated the collaboration with the DCNs in the project as positive, especially the proactive approach and the continuous support of people with dementia. The continuation in routine care depends on the institutional location and the qualification of the DCNs. Conclusion: The commitment of DCNs enables a more demand-oriented involvement of relevant stakeholders in the individual planning of dementia care.

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.

Home and Community-Based Service Use Varies by Health Care Team and Comorbidity Level of Veterans with Dementia

Home and community-based services (HCBSs) such as home care and adult day centers are vital to supporting adults with dementia in community settings. We investigated whether HCBS use (use of both home care and adult day, use of one service, and use of neither service) varied between adults receiving care from three types of health-care teams with case management from social workers and nurses, and by comorbidity level, using 2019 data of 143,281 patients with dementia in the Veterans Health Administration. We compared HCBS use by patients' type of case-managed team (Home-Based Primary Care, geriatrics-based primary care, and dementia-focused specialty care) to patients in none of these teams, stratified by patients' non-dementia comorbidities (<4 or ≥4). Each type of health-care team was associated with both home care and adult day services, at each level of comorbidity. Home-Based Primary Care was most consistently associated with other forms of HCBS use, followed by Dementia Clinics and geriatrics-based primary care, for patients with ≥4 non-dementia comorbidities. Our findings suggest that case management in primary and specialty care settings is a contributor to the use of critical community supports by patients with the most complex needs.

E-bibliotherapy for improving the psychological well-being of informal caregivers of people with dementia: a randomized controlled trial protocol

BACKGROUND

Providing informal care for individuals with dementia is frequently a challenging and demanding experience that can have detrimental effects on the psychological well-being of caregivers. Regrettably, community-based caregiver services often prove inadequate, highlighting the necessity for innovative approaches to support caregivers.

AIM

To test the efficacy of e-bibliotherapy in improving the psychological well-being of informal caregivers of people with dementia.

METHOD

The study is divided into two phases. In phase 1, the research team will co-design the e-bibliotherapy app with caregivers. In phase 2, a randomized controlled trial will be conducted among 192 informal caregivers of people with dementia in Hong Kong. Caregivers will be randomly assigned to either the e-bibliotherapy group or the control group using simple randomization. Outcome measures will encompass caregivers' psychological well-being, caregiving appraisal, mental health, saliva cortisol levels as an indicator of stress, and health-related quality of life for caregivers. Data will be collected at baseline, immediately post intervention, and 3 months and 6 months post intervention. General linear mixed model will be employed to analyze intervention effects. Qualitative interviews will be undertaken to explore caregiver experiences within this study and evaluate intervention acceptability using conventional content analysis methods.

DISCUSSION

This study represents a pioneering effort in utilizing e-bibliotherapy to enhance the psychological well-being of informal caregivers of individuals with dementia, addressing the existing gap in caregiver services and facilitating knowledge dissemination within the community.

TRIAL REGISTRATION

The trial has been registered on ClinicalTrial.gov (Ref: NCT05927805).

Vascular cognitive impairment: When memory loss is not the biggest challenge

OBJECTIVES

Vascular cognitive impairment is the second most common type of cognitive impairment. Care needs of community-dwelling people with vascular cognitive impairment and their caregivers have not been thoroughly studied. Therefore, we aimed to explore care needs of people with vascular cognitive impairment and their family caregivers.

DESIGN

A qualitative interview study.

SETTING AND PARTICIPANTS

Participants were purposefully sampled community-dwelling people with vascular cognitive impairment and their family caregivers.

METHODS

Interviews were audiotaped and transcribed verbatim. Analysis and data collection followed an iterative process, until data saturation was achieved. We conducted 18 interviews (nine people with vascular cognitive impairment and nine caregivers), concerning 13 unique people with vascular cognitive impairment. We analyzed the data using inductive thematic analysis following the Braun & Clark method. The study was reported in accordance with the COREQ criteria.

FINDINGS

Five themes were identified in the care needs reported by people with vascular cognitive impairment and family caregivers: (1) Specific information need with subtheme (1A) No memory problem, no dementia? (2) Being respected as a person, (3) Differing concerns about the future, (4) The roles of the caregiver and (5) Decisiveness from professional healthcare.

CONCLUSIONS AND IMPLICATIONS

The care needs of people with vascular cognitive impairment and their caregivers were affected by (a lack of knowledge about) the characteristic symptoms of this condition. Participants equated cognitive impairment or dementia to memory loss ("Alzheimerization"), although memory loss was not their biggest challenge. People with vascular cognitive impairment and caregivers preferred resolute and decisive healthcare professionals. These professionals activate the person with vascular cognitive impairment who lacks initiative and diminishe role conflict of the caregiver. Care for people with vascular cognitive impairment and their caregivers could be improved by providing tailored information, promoting awareness of neuropsychiatric symptoms, particularly apathy, and by healthcare professionals providing more guidance in decision-making.

Perceived barriers and solutions by generalist physicians to work towards timely young-onset dementia diagnosis

Objectives: Timely diagnosis of young-onset dementia (YOD) is an important prerequisite to initiate appropriate support. However, YOD diagnosis is often late. We aimed to explore the perspectives of referring general practitioners and occupational physicians, to better understand their barriers to YOD diagnosis and reveal potential solutions to facilitate timely diagnosis.Methods: We conducted 16 semi-structured qualitative interviews with general practitioners and occupational physicians in the Netherlands. Inductive thematic analysis was applied to the transcripts with a team including researchers from various (clinical) backgrounds.Results: Thematic analysis revealed three themes related to: (1) disease characteristics that hinder YOD recognition, being the low incidence and the fact that they mimic other prevalent conditions like burn-out and depression; (2) physicians' attitudes that delay YOD diagnosis, as fear of mis-diagnosis and therapeutic nihilism; and (3) proposed solutions to navigate the challenging YOD diagnostic trajectory including monitoring people with depression and burn-out to consider YOD when recovery stagnates, and more effective interprofessional collaboration.Conclusion: In this study, referring physicians confirmed barriers known to YOD diagnosis and suggested potential solutions to improve YOD diagnosis. Future prospective studies in people with a primary diagnosis of depression or burn-out may show whether these interventions are potentially effective.

Use of the patient portal among older adults with diagnosed dementia and their care partners

INTRODUCTION

Care partners are at the forefront of dementia care, yet little is known about patient portal use in the context of dementia diagnosis.

METHODS

We conducted an observational cohort study of date/time-stamped patient portal use for a 5-year period (October 3, 2017-October 2, 2022) at an academic health system. The cohort consisted of 3170 patients ages 65+ with diagnosed dementia with 2+ visits within 24 months. Message authorship was determined by manual review of 970 threads involving 3065 messages for 279 patients.

RESULTS

Most (71.20%) older adults with diagnosed dementia were registered portal users but far fewer (10.41%) had a registered care partner with shared access. Care partners authored most (612/970, 63.09%) message threads, overwhelmingly using patient identity credentials (271/279, 97.13%).

DISCUSSION

The patient portal is used by persons with dementia and their care partners. Organizational efforts that facilitate shared access may benefit the support of persons with dementia and their care partners. Highlights Patient portal registration and use has been increasing among persons with diagnosed dementia. Two thirds of secure messages from portal accounts of patients with diagnosed dementia were identified as being authored by care partners, primarily using patient login credentials. Care partners who accessed the patient portal using their own identity credentials through shared access demonstrate similar levels of activity to patients without dementia. Organizational initiatives should recognize and support the needs of persons with dementia and their care partners by encouraging awareness, registration, and use of proper identity credentials, including shared, or proxy, portal access.

Primary care physicians' perspectives and challenges on managing multimorbidity for patients with dementia: a Japan-Michigan qualitative comparative study

BACKGROUND

Multimorbidity management can be extremely challenging in patients with dementia. This study aimed to elucidate the approaches of primary care physicians in Japan and the United States (US) in managing multimorbidity for patients with dementia and discuss the challenges involved.

METHODS

This qualitative study was conducted through one-on-one semi-structured interviews among primary care physicians, 24 each from Japan and Michigan, US. Thematic and content analyses were performed to explore similarities and differences among each country's data.

RESULTS

Primary care physicians in Japan and Michigan applied a relaxed adherence to the guidelines for patients' chronic conditions. Common challenges were the suboptimal consultation time, the insufficient number or ability of care-coordinating professionals, patients' conditions such as difficulties with self-management, living alone, behavioral issues, and refusal of care support. Unique challenges in Japan were free-access medical systems and not being sure about the patients' will in end-of-life care. In Michigan, physicians faced challenges in distance and lack of transportation between clinics and patients' homes and in cases where patients lacked the financial ability to acquire good care.

CONCLUSIONS

To improve the quality of care for patients with multimorbidity and dementia, physicians would benefit from optimal time and compensation allocated for this patient group, guidelines for chronic conditions to include information regarding changing priority for older adults with dementia, and the close collaboration of medical and social care and community resources with support of skilled care-coordinating professionals.

[Support needs of caregivers of people with dementia: An integrative literature review]

Support needs of caregivers of people with dementia: An integrative literature review Abstract: Background: Family caregivers are of great importance in the home care for people with dementia. The care and related stress can have a negative impact on their health. The CSNAT (German: KOMMA) is an approach to support family caregivers in palliative home care that could be used for this group of people. Aim: The aim was to identify support needs for caregivers of people with dementia in the literature and compare these with those that formed the basis for the development of the KOMMA approach. Method: We performed an integrative review. Literature research was conducted in February and March 2021 in the MEDLINE, CINAHL and PsycInfo databases. Relevant studies were identified and assessed using inclusion and exclusion criteria. Using MAXQDA, the data were assigned to categories with a content analytic procedure. Results: 23 studies were included that had been published with peer review procedure. Compared to the KOMMA approach, family caregivers show divergent support needs in the areas of (in)formal assistance, access to knowledge, managing physical and mental health conditions, maintaining the relationship, (temporarily) relinquishing the caregiving role and social integration. Conclusion: The KOMMA tool for identifying support needs cannot be directly adopted for this group of caregivers in its present form. However, given the richness of identified support needs, the development of a person-centered and needs-oriented assessment seems important.

Dynamics of Interaction among Professionals, Informal Supporters, and Family Caregivers of People with Dementia along the Dementia Care Pathway: A Nationwide Survey in Japan

This study aims to clarify the dynamics of information provision and human interaction to satisfy the needs of family caregivers. A questionnaire survey consisting of items on information received at and after diagnosis, persons and resources consulted, needs, and caregiver-oriented outcomes was conducted. Among the respondents, 2295 individuals who were caring for people with dementia were divided into quartiles by the time after diagnosis, and differences were statistically analyzed. The time after diagnosis in the first to fourth quartiles was 0.73 ± 0.4, 2.52 ± 0.49, 4.89 ± 0.73, and 10.82 ± 3.7 years, respectively. The number of persons consulted by family caregivers increased significantly from the first to the fourth quartiles (p < 0.001). During this time, attributes of professionals and informal supporters changed depending on the quartile. As time progressed, acceptance of the diagnosis increased, but so did its impact on the lives of family caregivers. These findings revealed differences over time in what family caregivers wanted and the dynamics of interactions that filled their needs. Informal supporters accounted for a significant proportion of the total resources. However, many family caregivers thought the information and support were insufficient. Thus, continuous reform of the care pathway is needed.

A scoping review of dementia caregiving for Korean Americans and recommendations for future research

OBJECTIVES

This scoping review aims to examine the caregiving experiences of Korean American caregivers of persons with dementia.

METHODS

A comprehensive electronic search was conducted within 5 databases (PubMed, CINAHL, Web of Science, Embase, PsycINFO-ProQuest) for papers published from 01/01/00 -01/24/22. Seventeen articles met the inclusion criteria. Thematic analysis was used to summarize key findings from these papers.

RESULTS

Most Korean American dementia caregivers were immigrants and wives/daughters/daughters-in-law. Two themes emerged: 1) how Korean American caregivers perceived their caregiving experiences, and 2) how Korean American caregivers perceived their caregiving support services. Korean American caregivers often experience poor mental health and burden. Social support and familism were found to be two of the most important factors that determine their attitudes toward caregiving. Most reported barriers to utilizing public services. Challenges in finding culturally relevant resources were common.

CONCLUSIONS

Dementia caregiving is a significant public health problem facing Korean Americans. Recommendations for future research are provided.

Home health care of Iranian elderly with dementia: Study protocol for guideline adaptation

BACKGROUND

Advanced stages of dementia interfere with elderly self-care. Consequently, they need caregivers who take responsibility for their care in the long-term. Restrictions to the caregiver's access to information, resources, and organizational support have created problems in their caregiver role, which is why the World Health Organization (WHO) emphasizes caring for caregivers by providing evidence-based information and training programs. As there is no clinical practice guideline for home care in the Islamic Republic of Iran, this study aims to develop a home health care guideline for the elderly with dementia.

MATERIALS AND METHODS

The ADAPTE process provided by the Guidelines International Network was considered as the basis. In order to identify the care needs of Iranian patients with dementia, semi-structured interviews were added to this guideline.

DISCUSSION

The identification and implementation of the perspectives of patients and caregivers during the process of guidelines adaptation increase the applicability of the guidelines. Improved quality of life for the patients in their place of residence is one of the expected consequences of this guideline's implementation. The developed guidelines will be used at home health care centers, and dementia and Alzheimer's associations in Iran.

Diagnosis and Care Use for People with Young-Onset Dementia in Primary Care in the Netherlands

BACKGROUND

Timely diagnosis and adequate care is important for persons with young-onset dementia (YOD) and their caregivers, due to the high impact of the disease. Initiating care can be difficult for the general practitioner (GP) and other healthcare professionals.

OBJECTIVE

Provide insight in the care use of persons with YOD and identify factors influencing care use.

METHODS

A primary care register was used for this study. Information on the care use of persons with YOD was extracted from the GPs written notes. Information entailed time until start of care use, reasons and factors influencing the GP's decision, and reasons and factors influencing actual care use were included. Analyses included quantitative explorative descriptive analyses, and qualitative manifest content analyses.

RESULTS

75 persons with YOD were included in this study. The main reason for GPs to refer for diagnosis was concerns of caregivers. After diagnosis, 72% of the persons were assigned a case manager, 42.7% received day care, and 44% were admitted to a long-term care facility. A higher percentage of persons without a case manager was admitted to a long-term care facility (64%) compared to the persons with a case manager (36%). Reasons for not initiating care were reluctancy of the persons with YOD or their caregivers, the person deceased, or because the GP did not refer for care.

CONCLUSION

Care use differed between persons due to different needs and reasons. Although most persons with YOD receive care in the years after diagnosis, there are still factors that could be improved.

Care Need Combinations for Dementia Patients with Multiple Chronic Diseases

Purpose

The purpose of this study was to find care need combinations for dementia patients with multiple chronic diseases and their caregivers.

Patients and Methods

A cross-sectional study was conducted with 83 patients who had multiple chronic diseases. Variables from patients included age, gender, severity of clinical dementia rating, feeding, hypnotics, mobility, getting lost, mood symptoms, and behavioral and psychological symptoms. Moreover, 26 types of care needs were included in this study. The Apriori algorithm was employed to first identify care need combinations and then to find the relationships between care needs and variables from dementia patients with multiple chronic diseases.

Results

Six rules were generated for care need combinations. Four care needs could be formed as a basic care need bundle. Moreover, two additional care needs could be added to provide a wider coverage for patients. In the second stage, 93 rules were found and categorized into three groups, including 2, 6, and 28 general rules with support of 30% but less than 40%, 20% but less than 30%, and 10% but less than 20%, respectively. When the support value is 10% but less than 20%, more variables from patients were found in rules which help the dementia collaborative care team members provide tailor-made care need bundles.

Conclusion

Four basic care needs were social resources referral and legal support (Care (1)), drug knowledge education (Care (3)), memory problem care (Care (5)), and fall prevention (Care (8)). Besides, disease knowledge education (Care (2)) and hypertension care (Care (16)) were frequent unmet needs in this specific population. Moreover, care for the mood of the caregiver (Care (11)) should be considered especially in dementia patients with preserved ambulatory function or with symptoms of hallucination. The collaborative care team should pay more attention to those care needs when assessing this specific population.

Comparing the Diagnostic Value of Four Dementia Tests in the Amnestic and Healthy Elderly

Introduction

This study aimed to compare the diagnostic value of four questionnaires for the diagnosis of neurocognitive disorders (NCDs) in the elderly.

Methods

In this project, people older than 60 years who lived in Tehran were investigated. A total of 99 literate cases were enrolled in the study, and four questionnaires, including functional assessment staging tool (FAST), abbreviated mental test score (AMTS), mini-mental state examination (MMSE), and modified Persian test of elderly for assessment of cognition and executive function (PEACE) were completed for them. They were then referred to a neuropsychiatrist, and the status of their cognition and neurobehavior was determined. The specialists were blinded to the results of the tests.

Results

Of the 99 participants studied, 39 cases were healthy, eight cases had mild Alzheimer's disease, 38 had amnesic MCI, five cases had secondary dementia, and nine cases had mixed vascular dementia and Alzheimer's disease. The area under the ROC curve for distinguishing the healthy group from the rest of the population was 0.692, 0.629, 0.734, and 0.751 for the FAST, AMTS, MMSE, and NBCSS questionnaires, respectively.

Conclusion

MMSE and NBCSS tests had better diagnostic power than the other two tests to distinguish the healthy group from the rest of the population.

Collaboration and coordination of health and care services for older people with dementia by multidisciplinary health and care providers: a scoping review protocol

INTRODUCTION

Collaboration and coordination of health and care services are key to catering for the diverse needs of a growing population of older people with dementia. When multidisciplinary health and care providers work together, they have the possibility to use resources in a fair, accurate and effective way and thereby do the right thing, at the right time, for the right individual. The aim of this scoping review is to map how different care-providing agencies collaborate and coordinate health and care services for older people with dementia.

METHODS AND ANALYSIS

A scoping review will be carried out following the proposed methodology by Joanna Briggs Institute and reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses-Scoping Review Extension guidelines. Systematic searches will be carried out in scientific databases. Studies published within the last 10 years will be included based on certain eligibility criteria. All included studies will be critically appraised using the Research Pyramid. Data from included studies will be charted and subjected to content analysis.

ETHICS AND DISSEMINATION

Ethics approval is not required for scoping reviews. The dissemination of findings will be conducted through conference presentations and publication in international scientific journals.

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.

Case management for people with dementia living at home and their informal caregivers: A scoping review

Case management is a complex intervention aimed at addressing a variety of health needs of people in their social environment. Case management for people with dementia is often poorly defined and insufficiently described. The crucial process steps are often not well understood. We aim to map and compare the key components, processes and contextual factors of case management programmes for dementia and to explore aspects of the interventions' generalisability. Our search covered the databases PubMed, CINAHL, Cochrane and GeroLit, as well as policy papers from international organisations. We included qualitative, quantitative and mixed-methods studies in the English or German language that was published between 1999 and 2020. The programmes were analysed according to programme characteristics, case management intervention and the structural and processing conditions. We identified 67 studies dealing with 25 programmes. Approximately half of the programmes were investigated in randomised controlled trials, two programmes used a mixed-methods design and the remaining were the subject of pre-post cohort studies. Participants in the studies were predominantly dyads of people with dementia and their informal caregivers. About half of the programmes reported a theoretical framework. All the programmes were derived from case management approaches or referred to such approaches. Despite huge differences in implementation, all the programmes covered the case management steps. In 14 out of 25 programmes, case management was carried out without additional intervention, the other programmes provided mainly education and training for informal caregivers. Costs of the case management interventions were stated in more than half of the programmes.The effectiveness and generalisability of dementia-specific case management interventions could be enhanced if the framework introduced in the review was used in the future by policy, practice and research.

Help-Seeking in Informal Family Caregivers of People with Dementia: A Qualitative Study with iSupport as a Case in Point

Supportive measures and training interventions can improve the care of people with dementia and reduce the burden on informal caregivers, whose needs remain largely unmet. iSupport is an evidence-based online intervention developed by the World Health Organization to provide support and self-guided education to informal family caregivers of people with dementia. This qualitative study explored barriers and facilitators in the access and use of supportive measures for family caregivers of people with dementia living in Southern Switzerland (Ticino). We conducted five focus groups and explored experiences, beliefs, and attitudes toward seeking help (SH), and used thematic analysis to identify key themes. Participants (N = 13) reported a general reluctance to SH. We identified four main barriers to SH: high level of burden; sense of duty; fear of being misunderstood by others; and difficulty in reaching information. We also identified facilitators of help seeking behaviors and unveiled the need of caregivers to be assisted by a dementia case manager to facilitate access to support resources. Local services and interventions should be adapted to caregivers’ needs and expectations, with the aim of facilitating the acceptance of, access to, and service integration of existing and future support measures, including iSupport.

Care partner needs of people with neurodegenerative disorders: What are the needs, and how well do the current assessment tools capture these needs? A systematic meta-review

OBJECTIVES

The burden on care partners, particularly once dementia emerges, is among the greatest of all caregiving groups. This meta-review aimed to (1) synthesis evidence on the self-reported needs of care partners supporting people living with neurodegenerative disorders; (2) compare the needs according to care partner and care recipient characteristics; and (3) determine the face validity of existing care partner needs assessment tools.

METHODS

We conducted a systematic review of reviews involving a thematic synthesis of care partner needs and differences in needs according to demographic and other characteristics. We then conducted a gap analysis by identifying the themes of needs from existing needs assessment tools specific to dementia and cross-matching them with the needs derived from the thematic synthesis.

RESULTS

Drawing on 17 published reviews, the identified range of needs fell into four key themes: (1) knowledge and information, (2) physical, social and emotional support, (3) care partner self-care, and (4) care recipient needs. Needs may differ according to disease trajectory, relationship to the care recipient, and the demographic characteristics of the care partner and recipient. The 'captured needs' range between 8% and 66% across all the included needs assessment tools.

CONCLUSIONS

Current tools do not fully or adequately capture the self-identified needs of care partners of people living with neurodegenerative disorders. Given the high burden on care partners, which has been further exacerbated by the COVID-19 (SARS CoV-2) pandemic, the needs assessment tools should align with the self-reported needs of care partners throughout the caregiving trajectory to better understand unmet needs and target supportive interventions.

Slowing dementia symptoms - a qualitative study on attitudes and experiences of general practitioners in Germany

BACKGROUND

There is currently no cure for dementia but general practitioners (GPs) have therapeutic options available to counteract the progression of mild cognitive impairment, including drug and non-drug treatment. So far, few studies have investigated treatment strategies preferred by GPs.

OBJECTIVES

This study aimed to gain an overview of GPs' attitudes towards influencing the progression of dementia, their involvement regarding dementia prevention and perceived effective approaches. It also elucidated the challenges experienced by GPs and desired optimisation measures towards reinforcing secondary prevention.

METHODS

Between June 2020 and March 2021, 64 semi-standardised interviews amongst GPs were conducted in all federal states of Germany. Thirty interviews were carried out in person and 34 by phone. The data were analysed according to qualitative content analysis.

RESULTS

Many interviewees see great importance in secondary dementia prevention and believe they could make an effective contribution, some of them using non-drug approaches. GPs play a role in guiding patients and relatives towards support services. Some doctors consider drug treatment as the only option towards influencing the progression of dementia, showing low expectations on self-efficacy. Interdisciplinary collaboration is a frequent challenge, which often conflicts with a coherent treatment strategy.

CONCLUSION

Many GPs feel confident about influencing the progression of dementia and believe they can intervene effectively, using various (non-drug) treatment measures and referrals to support services. GPs perceive challenges, including obstacles in interdisciplinary collaboration and negative impacts after drug administration. To improve the conditions for GP intervention, it depends on expanding interdisciplinary collaboration and care strategies.

"Captive by the Uncertainty"-Experiences with Anticipatory Guidance for People Living with Dementia and Their Caregivers at a Specialty Dementia Clinic

BACKGROUND

After a diagnosis of Alzheimer's disease and related disorders, people living with dementia (PWD) and caregivers wonder what disease trajectory to expect and how to plan for functional and cognitive decline. This qualitative study aimed to identify patient and caregiver experiences receiving anticipatory guidance about dementia from a specialty dementia clinic.

OBJECTIVE

To examine PWD and caregiver perspectives on receiving anticipatory guidance from a specialty dementia clinic.

METHODS

We conducted semi-structured interviews with PWD, and active and bereaved family caregivers, recruited from a specialty dementia clinic. Interviews were recorded, transcribed, and systematically summarized. Thematic analysis identified anticipatory guidance received from clinical or non-clinical sources and areas where respondents wanted additional guidance.

RESULTS

Of 40 participants, 9 were PWD, 16 were active caregivers, and 15 were bereaved caregivers. PWD had a mean age of 75 and were primarily male (n = 6/9); caregivers had a mean age of 67 and were primarily female (n = 21/31). Participants felt they received incomplete or "hesitant" guidance on prognosis and expected disease course via their clinicians and filled the gap with information they found via the internet, books, and support groups. They appreciated guidance on behavioral, safety, and communication issues from clinicians, but found more timely and advance guidance from other non-clinical sources. Guidance on legal and financial planning was primarily identified through non-clinical sources.

CONCLUSION

PWD and caregivers want more information about expected disease course, prognosis, and help planning after diagnosis. Clinicians have an opportunity to improve anticipatory guidance communication and subsequent care provision.

Needs of patients with dementia and their caregivers in primary care: lessons learned from the Alzheimer plan of Quebec

BACKGROUND

Persons living with dementia have various health and social care needs and expectations, some which are not fully met by health providers, including primary care clinicians. The Quebec Alzheimer plan, implemented in 2014, aimed to cover these needs, but there is no research on the effect this plan had on the needs and expectations of persons living with dementia. The objective of this study is to identify persons living with dementia and caregivers' met and unmet needs and to describe their experience.

METHODS

This is a sequential mixed methods explanatory design: Phase 1: cross-sectional study to describe the met and unmet health and social care needs of community-dwelling persons living with dementia using Camberwell Assessment of Need of the Elderly and Carers' Assessment for Dementia tools. Phase 2: qualitative descriptive study to explore and understand the experiences of persons living with dementia and caregivers with the use of social and healthcare services, using semi-structured interviews. Data from phase 1 was analyzed with descriptive statistics, and from phase 2, with inductive thematic analysis. Results from phases 1 and 2 were compared, contrasted and interpreted together.

RESULTS

The mean total number of needs reported by the patients was 5.03 (4.48 and 0.55 met and unmet needs, respectively). Caregivers had 0.52 met needs (3.16 unmet needs). The main needs for both were memory, physical health, eyesight/hearing/communication, medication, looking after home, money/budgeting. Three categories were mentioned by the participants: Persons living with dementia and caregiver's attitude towards memory decline, their perception of community health services and of the family medicine practice.

CONCLUSIONS

Our study confirms the findings of other studies on the most common unmet needs of the patients and caregivers that are met partially or not at all. In addition, the participants were satisfied with access to care, and medical services in primary practices, being confident in their family. Our results indicate persons living with dementia and their caregivers need a contact person, a clear explanation of their dementia diagnosis, a care plan, written information on available services, and support for the caregivers.

The Cultural Diversity of Dementia Patients and Caregivers in Primary Care Case Management: a Pilot Mixed Methods Study

CONTEXT

The Canadian reality of dementia care may be complicated by the cultural diversity of patients and their informal caregivers.

OBJECTIVES

To what extent do needs differ between Canadian- and foreign-born patients and caregivers? What are their experiences with the illness in primary care case management?

METHODS

Mixed methods, sequential explanatory design (a cross-sectional study, followed by a qualitative descriptive study), involving 15 pairs of patients and caregivers.

RESULTS

Foreign-born patients had more needs compared to their Canadian-born counterparts. Foreign-born caregivers reported more stress, more problems, and increased need for services. However, the reported experiences of Canadian- vs. foreign-born individuals were similar.

CONCLUSION

The results remain hypothesis-generating. The present pilot illustrated the suitability of mixed methods to this area of study, which deserves further investigation to better serve all members of a population already vulnerable by age and disease.

Optimizing the diagnosis and management of dementia within primary care: a systematic review of systematic reviews

Background

To understand how best to approach dementia care within primary care and its challenges, we examined the evidence related to diagnosing and managing dementia within primary care.

Methods

Databases searched include: MEDLINE, Embase, PsycINFO and The Cochrane Database of Systematic Reviews from inception to 11 May 2020. English-language systematic reviews, either quantitative or qualitative, were included if they described interventions involving the diagnosis, treatment and/or management of dementia within primary care/family medicine and outcome data was available. The risk of bias was assessed using AMSTAR 2. The review followed PRISMA guidelines and is registered with Open Science Framework.

Results

Twenty-one articles are included. The Mini-Cog and the MMSE were the most widely studied cognitive screening tools. The Abbreviated Mental Test Score (AMTS) achieved high sensitivity (100 %, 95 % CI: 70-100 %) and specificity (82 %, 95 % CI: 72-90 %) within the shortest amount of time (3.16 to 5 min) within primary care. Five of six studies found that family physicians had an increased likelihood of suspecting dementia after attending an educational seminar. Case management improved behavioural symptoms, while decreasing hospitalization and emergency visits. The primary care educational intervention, Enhancing Alzheimer’s Caregiver Health (Department of Veterans Affairs), was successful at increasing carer ability to manage problem behaviours and improving outcomes for caregivers.

Conclusions

There are clear tools to help identify cognitive impairment in primary care, but strategies for management require further research. The findings from this systematic review will inform family physicians on how to improve dementia diagnosis and management within their primary care practice.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12875-021-01461-5.

Community-based dementia care re-defined: Lessons from Iceland

Studies of families caring for persons with dementia living at home often reflect feelings of being forgotten and abandoned by the authorities to shoulder the responsibility for care-giving. This has increased interest in how formal services can better support these families. This article analyses how health and social care professionals envision the needs of families of persons with dementia living in the community. It also describes the contributions of the formal care system to these families. The study design was qualitative. It involved interviews with professionals (N = 20), field observations from the settings where they worked, and public documents addressing care-giving for people with dementia. Data were analysed using the framework method. The findings reflected how those providing services to persons experiencing cognitive changes mainly understood the services as specialised. They focused on the diagnosis and treatment of the individual with dementia. They considered other aspects of care, such as attending to practical issues of daily life, to be a private matter, for which the family was responsible. In later stages of dementia, specialised day programs become available, offering rehabilitation to motivate positive daily living-for both the person experiencing dementia and family-centred supporters. Professionals in the field described primary care, community-based healthcare and home care services as poorly equipped to support these families. Participants acknowledged that families were often under a lot of stress and might need more support earlier in the illness. However, they saw themselves as powerless. Towards the end of the data collection, services were being re-designed to emphasise the role of primary care. In light of its holistic and family-centred approach, primary care may be well placed to integrate relational understanding of living with dementia and specialised knowledge of dementia treatment.

Primary dementia care based on the individual needs of the patient: study protocol of the cluster randomized controlled trial, DemStepCare

Background

Most people with dementia (PwD) are cared for at home, with general practitioners (GPs) playing a key part in the treatment. However, primary dementia care suffers from a number of shortcomings: Often, diagnoses are made too late and therapies by GPs do not follow the guidelines. In cases of acute crises, PwD are too often admitted to hospital with adverse effects on the further course of the disease.

The aim of this study is to implement and evaluate a new GP-based, complex dementia care model, DemStepCare. DemStepCare aims to ensure demand-oriented, stepped care for PwD and their caregivers.

Methods/design

In a cluster randomized controlled trial, the care of PwD receiving a complex intervention, where the GP is supported by a multi-professional team, is compared to (slightly expanded) usual care.

GPs are clustered by GP practice, with 120 GP practices participating in total. GP practices are randomized to an intervention or a control group. 800 PwD are to be included per group. Recruitment takes place in Rhineland-Palatinate, Germany. In addition, a second control group with at least 800 PwD will be formed using aggregated routine data from German health insurance companies. The intervention comprises the training of GPs, case management including repeated risk assessment of the patients’ care situation, the demand-oriented service of an outpatient clinic, an electronic case record, external medication analyses and a link to regional support services. The primary aims of the intervention are to positively influence the quality of life for PwD, to reduce the caregivers’ burden, and to reduce the days spent in hospital. Secondary endpoints address medication adequacy and GPs’ attitudes and sensitivity towards dementia, among others.

Discussion

The GP-based dementia care model DemStepCare is intended to combine a number of promising interventions to provide a complex, stepped intervention that follows the individual needs of PwD and their caregivers. Its effectiveness and feasibility will be assessed in a formative and a summative evaluation.

Trial registration

German Register of Clinical Trials (Deutsches Register Klinischer Studien, DRKS), DRKS00023560. Registered 13 November 2020 - Retrospectively registered. HTML&TRIAL_ID=DRKS00023560.

User-centered and theory-based design of a professional training program on shared decision-making with older adults living with neurocognitive disorders: a mixed-methods study

BACKGROUND

We know little about the best approaches to design training for healthcare professionals. We thus studied how user-centered and theory-based design contribute to the development of a distance learning program for professionals, to increase their shared decision-making (SDM) with older adults living with neurocognitive disorders and their caregivers.

METHODS

In this mixed-methods study, healthcare professionals who worked in family medicine clinics and homecare services evaluated a training program in a user-centered approach with several iterative phases of quantitative and qualitative evaluation, each followed by modifications. The program comprised an e-learning activity and five evidence summaries. A subsample assessed the e-learning activity during semi-structured think-aloud sessions. A second subsample assessed the evidence summaries they received by email. All participants completed a theory-based questionnaire to assess their intention to adopt SDM. Descriptive statistical analyses and qualitative thematic analyses were integrated at each round to prioritize training improvements with regard to the determinants most likely to influence participants' intention.

RESULTS

Of 106 participants, 98 completed their evaluations of either the e-learning activity or evidence summary (93%). The professions most represented were physicians (60%) and nurses (15%). Professionals valued the e-learning component to gain knowledge on the theory and practice of SDM, and the evidence summaries to apply the knowledge gained through the e-learning activity to diverse clinical contexts. The iterative design process allowed addressing most weaknesses reported. Participants' intentions to adopt SDM and to use the summaries were high at baseline and remained positive as the rounds progressed. Attitude and social influence significantly influenced participants' intention to use the evidence summaries (P < 0.0001). Despite strong intention and the tailoring of tools to users, certain factors external to the training program can still influence the effective use of these tools and the adoption of SDM in practice.

CONCLUSIONS

A theory-based and user-centered design approach for continuing professional development interventions on SDM with older adults living with neurocognitive disorders and their caregivers appeared useful to identify the most important determinants of learners' intentions to use SDM in their practice, and validate our initial interpretations of learners' assessments during the subsequent evaluation round.

CCCDTD5: Individual and community-based psychosocial and other non-pharmacological interventions to support persons living with dementia and their caregivers

INTRODUCTION

Current pharmacological therapies for dementia have limited efficacy. Thus it is important to provide recommendations on individual and community-based psychosocial and non-pharmacological interventions for persons living with dementia (PLWDs) and their caregivers.

METHODS

Phase 1: A systematic review for developing recommendations on psychosocial and non-pharmacological interventions at the individual and community level for PLWDs and their caregivers. Phase 2: Rating of recommendations using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) guidelines. Phase 3: Delphi process (>50 dementia experts) for approving recommendations by the 5th Canadian Consensus Conference on the Diagnosis and Treatment of Dementia (CCCDTD5).

RESULTS

The CCCDTD5 approved the following recommendations: Exercise (1B) and group cognitive stimulation for PLWDs (2B), psychosocial and psychoeducational interventions for caregivers (2C), development of dementia friendly organization and communities (2C), and case management for PLWDs (2B).

DISCUSSION

The CCCDTD5 provides for the first time, evidence-based recommendations on psychosocial and non-pharmacological interventions for PLWDs and their caregivers that can inform evidence-based policies for PLWDs in Canada.

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.

The Role of Care Navigators Working with People with Dementia and Their Caregivers

BACKGROUND

Care navigation is an approach to personalized care management and care coordination that can help overcome barriers to care. Care navigation has not been extensively studied in dementia, where health care workforce innovations are needed as a result of increasing disease prevalence and resulting costs to the health care system.

OBJECTIVE

To identify facilitators and barriers to care navigation in dementia and to assess dementia caregiver satisfaction with care navigation.

METHODS

Methods include qualitative research (interviews, focus groups, observations) with "Care Team Navigators" (CTNs) who were part of a dementia care navigation program, the Care Ecosystem, and a quantitative survey with caregivers about their experiences with CTNs. Transcripts were analyzed to identify themes within the data.

RESULTS

CTNs identified the following facilitators to care navigation in dementia: working closely with caregivers; providing emotional support; tailoring education and resources; and coordinating with a clinical team around issues ranging from clinical questions to financial and legal decision-making. The barriers CTNS identified included burn-out, the progressive nature of the disease; coordinating with primary care providers; and identifying resources for dyads who are low-income, do not speak English, or live in rural areas. Caregivers across both sites highly rated CTNs, though satisfaction was higher among those in Nebraska and Iowa.

CONCLUSIONS

Innovative approaches to care delivery in dementia are crucial. Care navigation offers a feasible model to train unlicensed people to deliver care as a way to deliver larger-scale support for the growing population of adults living with dementia and their caregivers.

Key Lessons Learned in the Strategic Implementation of the Primary Care Collaborative Memory Clinic Model: A Tale of Two Regions

BACKGROUND

Primary care collaborative memory clinics (PCCMCs) address existing challenges in dementia care by building capacity to meet the needs of persons living with dementia within primary care. This paper describes the strategic implementation of the PCCMC care model in two regions within Ontario.

METHODS

Evaluation of this initiative included the completion of individual interviews (N = 32) with key informants to identify impacts associated with the PCCMCs and tracking of all referrals and assessments completed in the first nine months of clinic implementation.

RESULTS

The qualitative analysis of interview transcripts generated five major themes: (1) earlier identification of dementia and intervention; (2) increased capacity for dementia care within primary care; (3) better patient and caregiver experience with care; (4) improved continuity, integration and coordination and improved care; and (5) system efficiencies. Across both regions, 925 patients were referred to PCCMCs, of which 631 (68%) had been assessed during the evaluation period.

CONCLUSIONS

Strategic, regional implementation of PCCMCs provides a significant opportunity to support better integrated and coordinated dementia care.

Recommendations of the 5th Canadian Consensus Conference on the diagnosis and treatment of dementia

Since 1989, four Canadian Consensus Conferences on the Diagnosis and Treatment of Dementia (CCCDTD) have provided evidence-based dementia guidelines for Canadian clinicians and researchers. We present the results of the 5th CCCDTD, which convened in October 2019, to address topics chosen by the steering committee to reflect advances in the field, and build on previous guidelines. Topics included: (1) utility of the National Institute on Aging research framework for clinical Alzheimer's disease (AD) diagnosis; (2) updating diagnostic criteria for vascular cognitive impairment, and its management; (3) dementia case finding and detection; (4) neuroimaging and fluid biomarkers in diagnosis; (5) use of non-cognitive markers of dementia for better dementia detection; (6) risk reduction/prevention; (7) psychosocial and non-pharmacological interventions; and (8) deprescription of medications used to treat dementia. We hope the guidelines are useful for clinicians, researchers, policy makers, and the lay public, to inform a current and evidence-based approach to dementia.

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.

Social Determinants of Health: Underreported Heterogeneity in Systematic Reviews of Caregiver Interventions

Background and Objectives

Although most people have some experience as caregivers, the nature and context of care are highly variable. Caregiving, socioeconomic factors, and health are all interrelated. For these reasons, caregiver interventions must consider these factors. This review examines the degree to which caregiver intervention research has reported and considered social determinants of health.

Research Design and Methods

We examined published systematic reviews and meta-analyses of interventions for older adults with age-related chronic conditions using the PRISMA and AMSTAR 2 checklists. From 2,707 papers meeting search criteria, we identified 197 potentially relevant systematic reviews, and selected 33 for the final analysis.

Results

We found scant information on the inclusion of social determinants; the papers lacked specificity regarding race/ethnicity, gender, sexual identity, socioeconomic status, and geographic location. The majority of studies focused on dementia, with other conditions common in later life vastly underrepresented.

Discussion and Implications

Significant gaps in evidence persist, particularly for interventions targeting diverse conditions and populations. To advance health equity and improve the effectiveness of interventions, research should address caregiver heterogeneity and improve assessment, support, and instruction for diverse populations. Research must identify aspects of heterogeneity that matter in intervention design, while recognizing opportunities for common elements and strategies.

Abuse in the caregiving relationship between older people with memory disorders and family caregivers: A systematic review

AIM

To synthesize what is known about elder abuse and relationship factors associated with abuse between caregivers and older people with memory disorders at home.

BACKGROUND

Concerns about abuse in the caring relationship between older people with memory disorders and family caregivers have increased. Abuse is associated with negative outcomes on older people's health, quality of life, and zest for life. Abuse in the caring relationship manifests in financial exploitation, neglect, mistreatment, and physical issues.

DESIGN

Systematic review.

DATA SOURCES

Databases including Scopus, PubMed/Medline, SveMed⁺ , Cinalh, SonINDEX, and ProQuest were searched using keywords about abuse in the caring relationship between older people with memory disorders and family caregivers at home. Articles published between 2005-2019 were retrieved and underwent data analysis and knowledge synthesis.

REVIEW METHODS

The review was presented under the categories of the dyadic approach of elder abuse in connection with the role of caregiver (risk) and care recipient (vulnerability) by Fulmer et al. (2005).

RESULTS

The search process led to 12 quantitative studies, including an intervention, a prospective, nine surveys, and a cross-sectional structural interview. Findings were synthesized and presented under 'personal', 'physical and psychological', and 'social' domains indicating the bilateral roles of caregiver and care recipient leading to abuse.

CONCLUSION

This review depicted factors influencing abuse in the caring relationship between older people with memory disorders and their family caregivers at home. They included family caregivers' psychological issues, knowledge of memory disorders and modifications, previous caring relationship, social support, number of care recipients, and care recipients' functional level.

IMPACT

This review identifies what influences elder abuse by family caregivers using the dyadic approach and explains how abuse can be prevented through suggested strategies. The review findings are relevant to multidisciplinary healthcare providers and can guide the provision of support, screening and assessment, educational programs, and legislative initiatives.

Features of primary care practice influence emergency care-seeking behaviors by caregivers of persons with dementia: A multiple-perspective qualitative study

BACKGROUND

Persons with dementia use emergency department services at rates greater than other older adults. Despite risks associated with emergency department use, persons with dementia and their caregivers often seek emergency services to address needs and symptoms that could be managed within primary care settings. As emergency departments (EDs) are typically sub-optimal environments for addressing dementia-related health issues, facilitating effective primary care provision is critical to reduce the need for, or decision to seek, emergency services. The aim of this study is to explore how features of primary care practice influence care-seeking decisions by community-dwelling persons with dementia and familial caregivers.

METHODS

Semi-structured qualitative interviews were conducted with 27 key dementia-care stakeholders (10 primary care/geriatrics providers, 5 caregivers, 4 emergency medicine physicians, 5 aging service providers, and 3 community paramedics) from multiple health systems. Transcripts from audio recordings were analyzed using a thematic analysis framework to iteratively code and develop emergent themes. Features of primary care were also synthesized into lists of tangible factors leading to emergency care-seeking and those that help prevent (or decrease the need for) ED use.

FINDINGS

Stakeholders identified eight categories of features of primary care encompassing the clinical environment and provision of care. These collapsed into four major themes: (1) clinic and organizational features-including clinic structure and care team staffing; (2) emphasizing proactive approaches to anticipate needs and avoid acute problems-including establishing goals of care, preparing for the future, developing provider-patient/provider-caregiver relationships, and providing caregiver support, education, and resources to help prevent emergencies; (3) health care provider skills and knowledge of dementia-including training and diagnostic capabilities; and (4) engaging appropriate community services/resources to address evolving needs.

CONCLUSIONS

Features of primary care practice influence decisions to seek emergency department care at the system, organizational/clinic, medical, and interpersonal levels, particularly regarding proactive and reactive approaches to addressing dementia-related needs. Interventions for improving primary care for persons with dementia and their caregivers should consider incorporating features that facilitate proactive family-centered dementia care across the four identified themes, and minimize those leading to caregiver decisions to utilize emergency services.

Care Needs of Community-Residing Male Patients with Vascular Cognitive Impairment

PURPOSE

The aim of this study was to identify the care needs of male patients with vascular cognitive impairment (VCI) and their caregivers.

PATIENTS AND METHODS

This cross-sectional study enrolled 389 male patients with VCI and their caregivers who were cared for by the dementia collaborative care team at Changhua Christian Hospital, Taiwan. Fifteen care needs consisting of most of quality measures for people living with dementia and their caregivers were developed by the care team. Through face-to-face evaluations, individualized care needs were collected. The Apriori algorithm was used to identify care bundles for the patients and their caregivers.

RESULTS

Six basic care needs for patients and their caregivers were identified, including appropriate schedule of activities, regular outpatient follow-up treatment, introduction and referral of social resources, referral to family support groups and care skills training, care for the mood of the caregiver, and health education for dementia and behavioral and psychological symptoms of dementia. Compared to subjects with all dementia subtypes from the previous studies, care for the mood of the caregiver was an important and frequent care need for the male patients with VCI and their caregivers. A comparison among the study and similar studies was made to highlight the strength of this study concentrating on the precise selection of care needs.

CONCLUSION

Collaborative dementia care teams should monitor for caregivers' depression and include this care need into the care bundle when assessing male subjects with VCI.

A Decade of Dementia Care Training: Learning Needs of Primary Care Clinicians

INTRODUCTION

Limited knowledge of dementia among health professionals is a well-documented barrier to optimal care. This study examined the self-perceived challenges with dementia care and learning needs among primary care clinicians and assessed whether these were associated with years of practice and perceived preparedness for dementia care.

METHODS

Participants were multi-disciplinary clinicians attending a 5-day team-based dementia education program and physicians attending a similar condensed continuing medical education workshop. Pre-education, they completed an online survey in which they rated (5-point scales): interest in learning about various dementia-related topics, perceived challenges with various dementia-related practice activities and preparedness for dementia care, provided additional dementia-related topics of interest, number of years in clinical practice, and discipline.

RESULTS

Thirteen hundred surveys were completed across both education programs. Mean ratings of preparedness for dementia care across all respondents reflected that they felt somewhat prepared for dementia care. Challenge ratings varied from low to very challenging and mean ratings reflected a high level of interest in learning more about all of the dementia-related topics; significant differences between disciplines in these ratings were identified. In most cases, perceived challenges and learning needs were not correlated with number of years in clinical practice, but in some cases lower ratings of preparedness for dementia care were associated with higher ratings of the challenges of dementia care.

DISCUSSION

Clinicians perceived that their formal education had not prepared them well for managing dementia and desired more knowledge in all topic areas, regardless of years in practice. Implications for education are discussed.

Using The Apriori Algorithm To Classify The Care Needs Of Patients With Different Types Of Dementia

PURPOSE

To elucidate specific combinations of care needs for people living with dementia (PLWD) and their caregivers according to specific subtypes of dementia.

PATIENTS AND METHODS

A cross-sectional study at memory clinics in Changhua Christian Hospital, Taiwan, was conducted. Five hundred and eight people living with dementia and their caregivers joined the dementia collaborative care model. The care team established 15 care needs containing most of quality measures for PLWD and their caregivers. Individualized care plans including different combinations of care needs were addressed through face-to-face assessments. Apriori algorithm was used to find specific combinations of care needs for particular groups of PLWD and their caregivers.

RESULTS

This study identified the basic care needs of PLWD and caregivers including appropriate scheduling of activities, regular outpatient follow-up treatment, introduction and referral of social resources, referral to family support groups and care skills training, and health education for dementia and behavioral and psychological symptoms of dementia. Patients with Alzheimer's dementia required more care to prevent traffic accidents and getting lost, while patients with vascular dementia required more care to prevent falls. The older (≥75 years old) PLWD were associated with more needs of fall prevention and care for the mood of the caregiver, especially in the female patients with mild Alzheimer's dementia (CDR = 1).

CONCLUSION

Bundling the needed care needs might be a more effective means to care for a wide variety of patients with dementia.

The needs of informal caregivers and barriers of primary care workers toward dementia management in primary care: a qualitative study in Beijing

BACKGROUND

Informal caregivers of people with dementia in Beijing are increasingly called upon to provide home-based care for their patients due to the increasing number of dementia patients and the shortage of standardized institutional solutions of care for patients in China. This study aimed to clarify the needs of informal caregivers and barriers of primary care workers toward dementia management in primary care in Beijing to provide references that may help to improve the care and services provided to individuals with dementia and their family caregivers residing in urban China.

METHODS

A mixed-methods approach was used in this study. We performed individual in-depth interviews with 10 informal caregivers. Moreover, we carried out focus group interviews with 29 primary care workers. Content analysis was used to separately identify themes and codes. Discrepancies were discussed until final agreement was achieved.

RESULTS

Three themes representing the core attitudes of informal caregivers and primary care workers were identified: care knowledge and skills, psychological counseling, and collaborative management. Most primary care workers believed that the management of dementia patients in primary care was necessary. However, due to the heavy work load and different medical specialties involved, these workers were unable to manage it.

CONCLUSIONS

Professional training focused on dementia for primary care workers should be strengthened. At the same time, the establishment of a community-based dementia team management model that includes specialists, community health service centers (CHSCs), and community committees should be explored.

Health conditions and unmet needs for assistance to perform activities of daily living among older adults with dementia in Chile

OBJECTIVE

This study aims to address gaps in health conditions and unmet needs in daily activities between people with dementia (PWD) and without dementia in a developing country and to identify the variables associated with unmet needs among PWD to guide practitioners and policymakers in dealing with an increased burden of dementia.

METHODS

Nationally representative data on 4655 Chileans age 60 and over were used to compare health conditions and unmet needs in daily life activities between individuals with (N = 455, 9.6%) and without dementia. Regression analysis was conducted to identify the variables associated with unmet needs among PWD.

RESULTS

Overall, PWD had worse health and needed greater assistance in performing daily activities than people without dementia. Among PWD, being male was associated with more unmet needs, in both activities of daily living (ADL) and instrumental ADL. Lower educational level and fewer caregivers were associated with more unmet needs for ADL, while inferior functional ability was associated with more unmet needs for instrumental ADL.

CONCLUSIONS

The results from this study call for action by practitioners and policymakers to foster caregiver training, increase supportive services, and advance care planning for PWD.

Barriers and facilitators for GPs in dementia advance care planning: A systematic integrative review

BACKGROUND

Due to the disease's progressive nature, advance care planning (ACP) is recommended for people with early stage dementia. General practitioners (GPs) should initiate ACP because of their longstanding relationships with their patients and their early involvement with the disease, however ACP is seldom applied.

AIM

To determine the barriers and facilitators faced by GPs related to ACP with people with dementia.

DATA SOURCES

We systematically searched the relevant databases for papers published between January 1995 and December 2016, using the terms: primary healthcare, GP, dementia, and ACP. We conducted a systematic integrative review following Whittemore and Knafl's method. Papers containing empirical data about GP barriers and/or facilitators regarding ACP for people with dementia were included. We evaluated quality using the Mixed-Method-Appraisal-Tool and analyzed data using qualitative content analysis.

RESULTS

Ten qualitative, five quantitative, and one mixed-method paper revealed four themes: timely initiation of ACP, stakeholder engagement, important aspects of ACP the conversation, and prerequisites for ACP. Important barriers were: uncertainty about the timing of ACP, how to plan for an uncertain future, lack of knowledge about dementia, difficulties assessing people with dementia's decisional capacities, and changing preferences. Facilitators for ACP were: an early start when cognitive decline is still mild, inclusion of all stakeholders, and discussing social and medical issues aimed at maintaining normal life.

CONCLUSION

Discussing future care is difficult due to uncertainties about the future and the decisional capacities of people with dementia. Based on the facilitators, we recommend that GPs use a timely and goal-oriented approach and involve all stakeholders. ACP discussions should focus on the ability of people with dementia to maintain normal daily function as well as on their quality of life, instead of end-of-life-discussions only. GPs need training to acquire knowledge and skills to timely initiate collaborative ACP discussions.

Professionals' Use of a Multidisciplinary Communication Tool for Patients With Dementia in Primary Care

In this descriptive study, the use of a professional e-communication tool, Congredi, is evaluated. Ninety-six Congredi records of patients with dementia could be divided into the subgroups low-complex care (n = 43) and high-complex care (n = 53). If Congredi is an adequate communication tool for professionals, the changing involvement of caregivers must also be reflected within the two subgroups. We hypothesized that use would be more intensive in the high-complex group in comparison with the low-complex group. Data were gathered during 42 weeks. Results showed that the mean number of care activities in the high-complex group was significantly higher than in the low-complex group (10.43 vs 5.61, P = .001). The number of professionals involved with the high-complex care group (3.58) was higher compared to the low-complex care group (2.51) (P = .000). The most frequent use was by case managers and nurses (43.4%) in the high-complex group and by several case managers (41.9%) in the low-complex group. It was concluded that professionals used Congredi adequately in the multidisciplinary care of patients with dementia because the changing involvement of caregivers and the level of care activities were reflected in the use of Congredi.

Improving Prediction of Dementia in Primary Care

PURPOSE

The Mini-Mental State Examination (MMSE) is one of the most widely used instruments to screen for cognitive deficits; however, this instrument alone is not sensitive enough to detect early symptoms of dementia. We aimed to investigate whether additionally using the Visual Association Test (VAT) improves the predictive value of the MMSE score for development of dementia.

METHODS

Analyses were based on data from 2,690 primary care patients aged 70 to 78 years who participated in the Prevention of Dementia by Intensive Vascular Care (preDIVA) trial. We assessed change in the 30-point MMSE score over 2 years and the VAT score at 2 years-dichotomized as perfect (6 points) or imperfect (≤5 points)-and evaluated the predictive values of these tests for a diagnosis of dementia in the subsequent 4 to 6 years. Data were analyzed with logistic regression analysis.

RESULTS

Patients having a decline of 2 points or more in total MMSE score over 2 years had an odds ratio of 3.55 (95% CI, 2.51-5.00) for developing dementia. Patients having the same decline in MMSE score plus an imperfect VAT score had an odds ratio of 9.55 (95% CI, 5.89-15.41) for developing dementia. A 1-point decline in MMSE score increased odds of dementia only when the VAT score was imperfect. Dementia risk for patients with a 2- or 3-point decrease in MMSE score and a perfect VAT score did not differ significantly from the average risk of the cohort as a whole.

CONCLUSIONS

Administering the VAT in patients with a small decline on the MMSE over a 2-year period has substantial incremental value for identifying those at elevated risk for developing dementia. This simple test may help distinguish older adults who need further cognitive examination from those in whom a watchful waiting policy is justified.

Usefulness of carer-held records to support informal caregivers of patients with dementia who live at home

AIM

It is unclear whether carer-held records (CHR) are useful for patients with dementia. In this study, we evaluated the usefulness of the CHR for patients with dementia at the municipal level.

METHODS

Candidates for CHR use in this study were informal caregivers of patients with dementia who lived at home in Kawanishi, Japan. CHR users were those who are involved in the patient's care and treatment, such as informal caregivers, family physicians, dementia specialists, care professionals, and care service coordinators, known as ‛care managers' in Japan. Collaborative meetings were held every month mainly to help users, especially care managers, learn how to effectively use CHR. We surveyed informal caregivers before and 1.5 years after the start of CHR use to evaluate whether CHR improved collaboration and information provision. The Zarit Caregiver Burden Interview and Dementia Behaviour Disturbance Scale were also administered. We divided the informal caregivers who continued CHR use for 1.5 years into two subgroups based on whether their care manager attended the collaborative meetings at least twice. In addition, we divided informal caregivers into three subgroups depending on their relationship to the patient: spouse, child, or daughter-in-law.

RESULTS

The study initially consisted of 201 informal caregivers. Among them, 74 informal caregivers continued CHR use for 1.5 years. The information provision score significantly improved after CHR use for all informal caregivers. The collaboration score significantly improved after CHR use only for informal caregivers whose care managers attended at least two collaborative meetings. The Zarit Caregiver Burden Interview score significantly improved after CHR use for daughter-in-law caregivers. The Dementia Behaviour Disturbance Scale scores did not significantly improve after CHR use.

CONCLUSIONS

CHR were useful for informal caregivers of patients with dementia. However, care managers need to teach informal caregivers how to properly use CHR.

Geriatric Cooperatives in Southwestern Ontario: A novel way of increasing inter-sectoral partnerships in the care of older adults with responsive behaviours

Established in 2010, Geriatric Cooperatives support the evolving Behavioural Supports Ontario (BSO) programme in the South West Local Health Integration Network. Geriatric Cooperatives bring together members representing relevant cross-sectoral services and are tasked with identifying system gaps associated with the BSO target population as well as developing work plans specific to their local area, leveraging local capacity, and co-ordinating and improving linkages between sectors and services. The purpose of this study was to evaluate the partnerships formed over time within these Cooperatives in order to inform their ongoing development and sustainability. In 2012 and in 2015, Geriatric Cooperative members were invited to complete the Partnership Self-Assessment Tool (PSAT), a valid and reliable tool for evaluating collaborative processes and identifying areas in need of improvement. Scoring the PSAT involves the calculation of mean scores (ranging from 1 to 5) for each of six dimensions describing effective collaboration; higher mean scores reflect better functioning. Two psychometrically sound versions of the PSAT exist; the shorter version (PSAT-S) scores fewer items in three dimensions. Survey response rates for the three Cooperatives that were evaluated in both 2012 and 2015 were 70% in 2012 and 36% in 2015; 57% of members who completed the survey in 2015 were new Cooperative members. Both years, more than 25% of respondents selected "don't know" for three of the nine items used to score the administration and management dimension. Both PSAT and PSAT-S mean dimension scores across both years reflected that more effort is needed to maximise collaborative potential. Use of the PSAT has promoted a better understanding of how partnerships are functioning. Knowledge of where more work is required along with effective strategies to overcome weak areas and gaps in functioning has the potential to ensure that these Cooperatives are successful.