Attitudes of older people with mild dementia and mild cognitive impairment and their relatives about falls risk and prevention: A qualitative study

How do care partners overcome the challenges associated with falls of community-dwelling older people with dementia? A qualitative study

BACKGROUND AND OBJECTIVES

Previous studies have found that falls among community-dwelling older people with dementia negatively impact the health and well-being of their relative/friend care partners. Limited studies have explored the challenges care partners experience because of older people's falls (including fall incidents and fall risks). We sought to investigate care partners' experiences of these challenges and how care partners responded.

METHODS

We conducted an inductive thematic analysis of 48 dementia care partner interviews (age range: 33-86, mean: 61, 70.8% women; 58.3% adult children; 29.2% spouse; 62.5% completed college; 25% people of color), conducted after a health crisis of older people with dementia from three local university-affiliated hospitals in the United States.

FINDINGS

Care partners reported that falls in older people with dementia can intensify overall care demands and lead to self-sacrificing behaviors, dissatisfaction with healthcare providers, conflicts with care recipients, and intense emotions. Care partners described several adaptations to mitigate these impacts, including practicing acceptance, approaching falls as an opportunity for learning, facilitating collaborations within formal/informal care networks, collaborating with older people with dementia to balance autonomy and safety, and modifying the physical environment.

DISCUSSIONS AND IMPLICATIONS

Falls among older people with dementia are a significant stressor and an important activation stimulus for their care partners. Our findings suggest that care partners are "second clients" and "competent collaborators." As they provide important insights about fall prevention, care partners should be engaged to co-design new multi-level interventions to facilitate collaborations among care networks, older people with dementia, and service providers.

Social participation in the promoting activity, independence and stability in early dementia (PrAISED), a home-based therapy intervention for people living with dementia: a realist evaluation

BACKGROUND

Interventions promoting social activity may reduce behavioural psychological symptoms and improve quality of life in people living with dementia. This study aimed to identify social benefits for participants living with dementia in the context of Promoting Activity, Independence and Stability in Early Dementia (PrAISED), an exercise intervention programme promoting physical activity and independence in participants living with dementia in England.

METHODS

This was a multi-method realist evaluation undertaking secondary analysis of data collected during the PrAISED process evaluation, including qualitative interviews with participants with dementia, caregivers and therapists, personal notes of researchers, and video recordings of therapy sessions. The study consisted of four phases: (1) Setting operational definition of social outcomes in PrAISED; (2) Developing Context, Mechanisms, Outcome (CMO) configurations; (3) Testing and refining CMOs; and (4) Synthesising definitive CMOs into a middle range theory.

RESULTS

Two CMOs were identified. (1) When therapists were able to make therapy sessions engaging and had the caregivers' support, the participants experienced therapy sessions as an opportunity to achieve goals in areas they were interested in. They also found the sessions enjoyable. This all led to the participants being highly engaged in their social interactions with the therapists. (2) When the participants realised that they were gaining benefits and progress through the PrAISED intervention, such as increased balance, this boosted their confidence in physical ability. It might also reduce caregivers' risk-aversion/gatekeeping attitude, which in turn would lead to participants' increased participation in social activities.

CONCLUSION

The PrAISED intervention supported social participation in participants living with dementia. Under certain circumstances, home-based therapy interventions can be beneficial for social health (regardless of physical health gains). Given the limitations of currently available outcome measures to assess social participation, qualitative methods should be used to explore social health outcomes.

RCT-based Social Return on Investment (SROI) of a Home Exercise Program for People With Early Dementia Comparing In-Person and Blended Delivery Before and During the COVID-19 Pandemic

Regular exercise and community engagement may slow the rate of function loss for people with dementia. However, the evidence is uncertain regarding the cost-effectiveness and social return on investment (SROI) of home exercise with community referral for people with dementia. This study aimed to compare the social value generated from the in-person PrAISED program delivered before March 2020 with a blended PrAISED program delivered after March 2020. SROI methodology compared in-person and blended delivery formats of a home exercise program. Stakeholders were identified, a logic model was developed, outcomes were evidenced and valued, costs were calculated, and SROI ratios were estimated. Five relevant and material outcomes were identified: 3 outcomes for patient participants (fear of falling, health-related quality of life, and social connection); 1 outcome for carer participants (carer strain), and 1 outcome for the National Health Service (NHS) (health service resource use). Data were collected at baseline and at 12-month follow-up. The in-person PrAISED program generated SROI ratios ranging from £0.58 to £2.33 for every £1 invested. In-person PrAISED patient participants gained social value from improved health-related quality of life, social connection, and less fear of falling. In-person PrAISED carer participants acquired social value from less carer strain. The NHS gained benefit from less health care service resource use. However, the blended PrAISED program generated lower SROI ratios ranging from a negative ratio to £0.08:£1. Compared with the blended program, the PrAISED in-person program generated higher SROI ratios for people with early dementia. An in-person PrAISED intervention with community referral is likely to provide better value for money than a blended one with limited community referral, despite the greater costs of the former.Trial registration: ISRCTN Registry ISRCTN15320670.

Promoting Activity, Independence, and Stability in Early Dementia and mild cognitive impairment (PrAISED): randomised controlled trial

OBJECTIVE

To determine the effectiveness of an exercise and functional activity therapy intervention in adults with early dementia or mild cognitive impairment compared with usual care.

DESIGN

Randomised controlled trial.

SETTING

Participants' homes and communities at five sites in the United Kingdom.

PARTICIPANTS

365 adults with early dementia or mild cognitive impairment who were living at home, and family members or carers.

INTERVENTION

The intervention, Promoting activity, Independence, and Stability in Early Dementia and mild cognitive impairment (PrAISED), was a specially designed, dementia specific, rehabilitation programme focusing on strength, balance, physical activity, and performance of activities of daily living, which was tailored and progressive and addressed risk and the psychological needs of people with dementia. Up to 50 therapy sessions were provided over 12 months. The control group received usual care plus a falls risk assessment. Procedures were adapted during the covid-19 pandemic.

MAIN OUTCOME MEASURES

The primary outcome was score on the carer (informant) reported disability assessment for dementia scale 12 months after randomisation. Secondary outcomes were self-reported activities of daily living, physical activity, quality of life, balance, functional mobility, fear of falling, frailty, cognition, mood, carer strain, service use at 12 months, and falls between months 4 and 15.

RESULTS

365 patient participants were randomised, 183 to intervention and 182 to control. The median age of participants was 80 years (range 65-95), median Montreal cognitive assessment score was 20 out of 30 (range 13-26), and 58% (n=210) were men. Intervention participants received a median of 31 therapy sessions (interquartile range 22-40) and reported completing a mean 121 minutes of PrAISED exercise each week. Primary outcome data were available for 149 intervention and 141 control participants. Scores on the disability assessment for dementia scale did not differ between groups: adjusted mean difference -1.3, 95% confidence interval -5.2 to 2.6; Cohen's d effect size -0.06, 95% confidence interval -0.26 to 0.15; P=0.51). Upper 95% confidence intervals excluded small to moderate effects on any of the range of outcome measures. Between months 4 and 15 the intervention group experienced 79 falls and the control group 200 falls (adjusted incidence rate ratio 0.78, 95% confidence interval 0.5 to 1.3; P=0.3).

CONCLUSION

The intensive PrAISED programme of exercise and functional activity training did not improve activities of daily living, physical activity, or quality of life; reduce falls; or improve any other secondary health status outcomes, despite good uptake. Future research should consider alternative approaches to maintaining ability and wellbeing in people with dementia.

TRIAL REGISTRATION

ISRCTN Registry ISRCTN15320670.

Risk factors associated with home care safety for older people with dementia: family caregivers' perspectives

BACKGROUND

Many older people with dementia currently prefer home care; however, homes are neither professionally designed nor regulated like health care facilities, and home care is more prone to safety incidents. Many studies have examined home care safety for older people with dementia. However, factors contributing to safety incidents in home care have not been adequately considered. This study explored the risk factors for home care safety for older people with dementia based on the perspective of family caregivers.

METHODS

This study used a qualitative research approach; a total of 24 family caregivers were interviewed face-to-face and semi-structured from February 2022 to May 2022, and the Colaizzi seven-step phenomenological research method was used to analyze the data and refine the themes.

RESULTS

Safety risks in home care for older people with dementia stem from five areas: poor health of older people with dementia, dementia symptoms, unsafe home environment, the insufficient caring ability of family caregivers, and lack of safety awareness of family caregivers.

CONCLUSION

The risk factors for home care safety for older people with dementia are complex. And as the primary caregivers of older people with dementia, the caregiving ability and safety awareness of family caregivers primarily determine the safety of home care for older people with dementia. Therefore, when addressing home care safety for older people with dementia, the focus should be on providing targeted education programs and support services for family caregivers of older people with dementia.

Caregivers' fear of older care recipients falling: A systematic review of qualitative studies

OBJECTIVE

This qualitative systematic review aimed to describe informal caregivers' and health personnel's experiences of the FOF (fear of falling) of older adults under their care.

METHODS

A systematic search of databases included not only the PubMed, Embase, CINAHL, PsycINFO, Web of Science, and Cochrane Library but also the Chinese databases of CNKI, WanFang, and Vip. The Critical Appraisal Skills Programme (CASP) tool was used to assess the quality of the included studies.

RESULTS

In total, 17 studies were included in the systematic evaluation. Four themes were identified, and an evidence model was developed that includes multiple attributions of FOF, management strategies for fall prevention, dynamic challenges and adaptation, and external support and unmet needs.

CONCLUSIONS

The fear of falling felt by informal caregivers and health personnel is mainly affected by internal factors in older adults, and harms the health of older adults through overprotective behavior. Thus, there is an urgent need of external support to improve the quality of life and promote the healthy aging of older adults.

Perceptions of people with Parkinson's and their caregivers of falling and falls-related healthcare services- a qualitative study

INTRODUCTION

Falls are common in Parkinson's disease, and a recognised research priority. Falls lead to physical and psychological morbidity in people with Parkinson's disease and their caregivers, however, those with cognitive impairment/ dementia and caregivers have often been excluded from previous studies. This qualitative study explored how people with Parkinson's disease and their family caregivers understood and experienced falling and healthcare services relating to falls prevention and management.

METHODS

A varied and purposive sample of 20 people with Parkinson's disease (40% confirmed or suspected cognitive impairment/ dementia) and 18 caregivers took part in semi-structured interviews. Eight people with Parkinson's disease and their caregivers were interviewed as a dyad, 22 participants were interviewed alone. Interviews were analysed through inductive thematic analysis.

RESULTS

Four themes were developed: (i) struggling with thoughts and feelings about falling, (ii) recognising and managing risks surrounding falling, (iii) navigating health and care provision for falling, and (iv) changing as a couple due to falling. Different aspects of falls provoked a range of negative emotions and a variety of coping strategies were adopted. Falls and trying to avoid falls burdened a couple in a number of ways; beyond physical health they also affected functioning, physiological wellbeing, and relationships. Dyads analysed falls to understand their aetiology and described working together to manage them. This often happened in the absence of adequate support and advice with little involvement of healthcare professionals. When cognitive impairment/ dementia was present this brought additional challenges to falls management, with caregivers taking on a greater and more frustrating role.

CONCLUSION

Dyads required relevant falls-related information and the difficulties associated with cognitive decline should be recognised by researchers and healthcare professionals. Dyads required support in attributing reasons for falls, and increased awareness of healthcare professionals' different roles to improve patient- professional communication and facilitate patient-centred care.

A mixed methods systematic review of informal caregivers' experiences of fall risk among community-dwelling elders with dementia

Evidence on effective fall prevention strategies for community-dwelling elders with dementia is limited, although these elders are at high risk of falling. Informal caregivers may play an essential role in managing fall risk for elders with dementia. Thus, understanding caregiver's experiences is critically important. This systematic review aims to (a) identify caregivers' perceptual, emotional and behavioural responses to fall risk in elders with dementia and (b) examine the outcomes and effects of caregiver behavioural responses. A mixed methods systematic review of 10 databases (PubMed, PsycINFO, CINAHL, Social Service Abstracts, Social Work Abstracts, EMBASE, Web of Science, Scopus, Cochrane Library and TRIP Medical Database) was conducted. We searched English language, peer-review articles (January 1, 1985-March 20, 2020) that met the predefined inclusion/exclusion criteria. Study quality was assessed using the Mixed Methods Appraisal Tool. Data were analysed using thematic synthesis techniques. Twenty-nine studies were included. Six analytic themes were generated concerning caregivers' perceptual, emotional and behavioural responses: (a) fear of the negative health consequences of falls; (b) limited insights into factors contributing to falls; (c) varying expectations of managing fall risk; (d) multi-level efforts; (e) struggling with responsibilities; and (f) inaction and withdrawal. The findings about the outcomes and effects of caregivers' behaviours were synthesised into three analytic themes: (a) multi-faceted outcomes; (b) uncertain and inconsistent evidence; and (c) unclear associations. The study generated new insights in understanding caregivers' responses of fall risk among community-dwelling elders with dementia and identified significant gaps in examining the impact of caregivers' responses and what shapes these responses. Investment in understanding caregivers' perspectives will inform future interventions and policies to reduce negative outcomes for elders, caregivers and care systems.

A personalized approach empowering successful aging: Patient perspective on fall prevention education

BACKGROUND

Falls are the leading cause of fatal injury, and the most common cause of nonfatal trauma, among older adults. However, patient perspectives on preferences for obtaining fall education are not well reported.

OBJECTIVE

To identify components of successful fall prevention education.

DESIGN

Prospective qualitative study.

SETTING

Tertiary care center; institutional.

PARTICIPANTS

Adults aged 65 years or older with a history of falls who received services from inpatient trauma or outpatient geriatric services.

INTERVENTIONS

One-hour face-to-face semistructured interview.

MAIN OUTCOME MEASURE

Semistructured interviews sought to determine participants' history of fall education and perceived strengths and weaknesses of various formats of fall education.

RESULTS

Nearly all participants (9/10) indicated they had not received fall prevention education of any kind. Many participants (6/10) reported that, despite not receiving any formal education about falls, they had either given or received information about falls from other older adults in their communities. Participants indicated that framing fall education as a part of healthy aging would be more desirable and mentioned involving participants' families as part of the education. The majority of participants (7/10) suggested fall education be delivered through in-person discussion with providers, and most (9/10) indicated this would provide a personalized approach with opportunity for questions. Participants specified fall education should consist of both environmental modifications (5/10) and awareness of one's surroundings (4/10).

CONCLUSIONS

Despite histories of falls, nearly all participants reported they had not received formal fall education. However, many indicated they received fall information informally through their communities. Participants agreed successful fall prevention education would be delivered in an empowering way by a trusted member of the care team.

Evaluation of a balance and mobility program for older adults at risk of falling: a mixed methods study

RATIONAL, AIMS, AND OBJECTIVES

The FallProof Balance and Mobility Program is a multifactorial fall prevention intervention that targets intrinsic risk factors such as muscle strength, balance, gait, and posture. Using mixed methods, we evaluated the implementation of the program for older adults at high risk of falling in the community.

METHODS

A pre-post program evaluation and semi-structured interviews were used to evaluate FallProof Balance and Mobility Program offered to older adults who were recurrent fallers. Over a 1-year period, the 12-week program was offered five times. Feasibility, acceptability, and outcome evaluation along with semi-structured interviews were done. Over the course of the evaluation, participants were evaluated three times (baseline, 12, and 16 weeks).

RESULTS

Of the 19 participants, who enrolled in the program, 16 completed the program and 12 attended at least 80% of the classes. Fourteen participants had mildly impaired cognition (Montreal Cognitive Assessment <26). Large gains (effect size 0.90) were seen with self-management (Partner-in-Health Scale). Participants were very satisfied with the program. Three themes emerged from the semi-structured interviews: (a) fall-related benefits, (b) variety of activities and motivating instructors, and (c) deterrents to participation.

CONCLUSION

Findings provided insights into pragmatic issues of implementing a balance and mobility program for older adults at risk of falling. The FallProof program was found to be feasible and acceptable in a small cohort of older adults from the community.

Stroke Rehabilitation for Falls and Risk of Falls in Southeast Asia: A Scoping Review With Stakeholders' Consultation

Background: Research on rehabilitation for falls after stroke is warranted. However, published evidence on fall interventions with stroke survivors is limited and these are mainly international studies that may be less relevant for Southeast Asia. Objective: This review aims to systematically identify literature related to stroke rehabilitation for falls and risk of falls in Southeast Asia. Methods: A scoping review with stakeholders' consultation was implemented. An electronic search was conducted up to December 2020 on 4 databases (Medline, CINAHL, Scopus, ASEAN Citation Index). Only original studies conducted in Southeast Asia were selected. Results: The initial search yielded 3,112 articles, however, only 26 were selected in the final analysis. Most of the articles focused on physical rehabilitation and implemented conventional therapies. While the literature may reflect practice in Southeast Asia, stakeholders perceived that the literature was inadequate to show true practice, was not informative and missed several aspects such as functional, cognitive, and psychological interventions in managing falls. Individual-centric interventions dominated the review while community-based and environmental-focused studies were limited. Majority of the articles were written by physiotherapists while others were from physicians, occupational therapists, and an engineer but few from other healthcare practitioners (i.e., speech therapists, psychologists) or disciplines interested in falls. Conclusions: Falls prevention among stroke survivors has received a lack of attention and is perceived as an indirect goal in stroke rehabilitation in Southeast Asia. More innovative research adopted from falls research with older people is needed to advance falls prevention and intervention practice with stroke survivors.

The Rose-Colored Glasses of Geriatric Fall Patients: Inconsistencies Between Knowledge of Risk Factors for and Actual Causes of Falls

Background

Falls are the leading cause of fatal injury, and most common cause of non-fatal trauma, among older adults. We sought to elicit older patient's perspectives on fall risks for the general population as well as contributions to any personal falls to identify opportunities to improve fall education.

Methods

Ten patients with a history of falls from inpatient trauma and outpatient geriatric services were interviewed. Transcripts were analyzed independently by five individuals using triangulation and constant comparison (NVivo11, QSR International) to compare fall risks to fall causes.

Results

All patients reported that either they (9/10 participants) or someone they knew (8/10) had fallen. Despite this, only two personally worried about falling. Patient perceptions of fall risks fell into seven major themes: physiologic decline (8/10); underestimating limitations (7/10); environmental hazards (7/10), lack of awareness/rushing (4/10), misuse/lack of walking aids (3/10); positional transitions (2/10), and improper footwear (1/10). In contrast, the most commonly reported causes of personal falls were lack of awareness/rushing (7/10), environmental hazards (3/10), misuse/lack of walking aids (2/10), improper footwear (2/10), physiologic decline (2/10), underestimating limitations (1/10) and positional transitions (1/10). In general tended to attribute their own falls to their surroundings and were less likely to attribute physical or psychological limitations.

Conclusion

Despite participants identifying falls as a serious problem, they were unlikely to worry about falling themselves. Participants were able to identify common fall risks. However, when speaking about personal experience, they were more likely to blame environmental hazards or rushing, and minimized the role of physiologic decline and personal limitations.

Adherence to exercise interventions in older people with mild cognitive impairment and dementia: A systematic review and meta-analysis

Adherence to physical exercise is associated with multiple benefits in people with mild cognitive impairment (MCI) and dementia. Given the gap in research, this systematic literature review aimed to determine in the context of exercise intervention studies for people with MCI and dementia: 1. How adherence is defined, monitored and recorded; 2. Adherence rates; 3. Attrition, compliance and adverse events and 4. Intervention characteristics associated with adherence. Embase, Medline, PsychInfo, SPORTDiscus, AMED, CINAHL and the International Bibliography of Social Sciences were searched in November 2018. The data were analyzed through descriptive and correlation/inferential statistics. Forty-one studies were included, 34 involving participants with dementia (n = 2149) and seven participants with MCI (n = 970). Half of the studies operationally defined adherence. Mean adherence rate was 70% [CI, 69-73%]. Adherence was significantly associated with endurance/resistance training, and interventions not including walking. The review found a lack of consistency around reporting of adherence and of key variables mediating adherence, including compliance, attrition and adverse events. Further research using more reliable measures is needed to confirm whether a correlation exists between length of interventions and adherence in participants with MCI and dementia and to identify the factors or strategies that mediate adherence in this population. Relevant implications for practice include a consideration in the development of new interventions of elements associated with higher adherence in this review, such as endurance/resistance training, and the provision of exercise in group formats.

Client, caregiver, volunteer, and therapist views on a voluntary supported group exercise programme for older adults with dementia

Background

Existing group exercise programmes, or other services offered to maintain physical activity levels, are typically not developed specifically for older adults with dementia. The aim of this study was to gain knowledge about perceptions of a newly developed volunteer supported group exercise programme for older adults with dementia, and any barriers that may have affected participation and compliance.

Methods

Seven (six face-to-face and one by email) interviews were conducted with (i) older adults and volunteers participating in a pilot 12-week group exercise programme, (ii) caregivers, and (iii) therapists leading the group sessions. Interview transcriptions were systemised by use of NVivo 8 and analysed by use of Systematic Text Condensation method.

Results

The theme “building relationships” represents the reason why attending this group was important for the participants. The findings suggest that how we organize exercise groups is important, with some sort of extra support, to ensure that persons will begin and continue to participate in new activities outside their homes.

Conclusions

This study showed that it is possible to involve home-dwelling persons with cognitive decline and dementia in group exercise sessions. The role of building relationships was the major factor for successful participation. Providing support and ensuring motivation for persons attending the group outside their homes was essential, both for them and their caregivers. Service providers should not underestimate the importance of building relationships between persons involved in service offers.

Harwood R, das Nair R, Logan P, Goldberg S, Booth V, Vedhara K, Godfrey M, Dunlop M, van der Wardt V. External Validation of the 'PHYT in Dementia', a Theoretical Model Promoting Physical Activity in People with Dementia

Physical activity is beneficial for people with dementia. We previously developed a theoretical model to explain behaviour change in physical activity in dementia (PHYT-in-dementia). This study aimed to externally validate the model. Validation occurred through the process evaluation of a programme promoting activity in people with dementia (PrAISED 2). Twenty participants with dementia and their carers were interviewed to investigate their experience of the programme. The data were analysed through content analysis. The original constructs of the model were used as initial codes and new codes were generated, if elicited from the data. The constructs were also ranked, based on their frequency in the interviews. All of the original model constructs were validated and two novel constructs created: 'personal history' and 'information/knowledge'. Certain constructs (e.g., support) were more frequently mentioned than others (e.g., personal beliefs). We suggested modifications and integrated them into a revised model. The PHYT-in-dementia recognised that dementia has an impact on motivation to initiate and maintain behaviour change over time. The model advocates that interventions adopt a more holistic approach than traditional behaviour change strategies. The suggested revisions require further validation to accurately predict behaviour change in physical activity in people with dementia.

Promoting activity, Independence and stability in early dementia (PrAISED): a, multisite, randomised controlled, feasibility trial

Background

We tested the feasibility of delivering and evaluating a complex therapy intervention which aimed to promote activity and independence for people with early dementia (PrAISED). Feasibility questions were on: recruitment, randomisation, intervention delivery, adherence and withdrawals, level of supervision required, adverse events, data collection and sample size assumptions.

Methods

We conducted a three-arm, multi-site, single-blind, randomised controlled feasibility trial. Eligibility criteria were aged 65 years or older, diagnosed mild dementia or mild cognitive impairment, able to walk without human help, and communicate in English, no co-morbidities that prevented participation in cognitive assessment and capacity to give consent. Participants were recruited from Memory Assessment Service clinics and the ‘Join Dementia Research’ register.

Patient participants were randomised 1:1:1 to a high intensity supervision PrAISED intervention, moderate intensity supervision PrAISED intervention or brief falls prevention assessment and advice (control). The PrAISED intervention aimed for participants to complete three hours of PrAISED exercises a week for 12 months. It included individualised activity and exercise plans and supervised exercises with regular re-assessment and progression, and was delivered by occupational therapists, physiotherapists and rehabilitation support workers. Primary efficacy outcome was the Disability Assessment for Dementia (DAD), measured after 12 months. Secondary outcomes included physical activity, quality of life, mood, cognition, strength, balance, rate of falls, frailty and carer strain. Falls and activity were ascertained by monthly diary.

Results

Between September 2016 and March 2017 we recruited 60 patient participants and 54 carer participants from two sites. Forty-nine patient participants completed a follow-up interview. Feasibility outcomes were mostly satisfactory, including recruitment and retention, intervention delivery and data completeness for most scales used. We could not maintain blinding of researchers at follow-up and experienced difficulties collecting data using some questionnaires and devices. Participants only completed a mean 77 (moderate supervision) and 71 (high supervision) minutes per week of PrAISED exercises over 12 months. We recorded 19 adverse events, none serious and related to the intervention.

Conclusion

We conclude that with some adjustments to the trial protocol, it is feasible to deliver the PrAISED intervention and conduct a trial.

Trial registration

ClinicalTrials.gov: NCT02874300 (first posted 22nd August 2016), ISRCTN: 10550694 (date assigned 31st August 2016).

Carers' concern for older people falling at home: an integrative review

Falls, the leading cause of injury and death among older people, can have a significant psychosocial impact on carers. Carers play a crucial role in caring for older persons at home and in fall prevention. This review, which included 15 studies, aimed to identify carers' concern about older people falling and its impact. We identified that most carers had concerns about repeated falls in older people, unknown consequences of falls and care recipients' non-adherence to fall prevention advice. These concerns, in turn, affect carers' physical and psychological health, lifestyle, caregiving burden and use of fall prevention strategies. This paper highlights the importance of recognising carers' fall concern so as to identify carers' needs and awareness of fall prevention in older people living at home. Greater insight into carers' fall concern could facilitate the implementation of new strategies to manage older people's fall risk as well as improve carers' well-being.

What enables older people to continue with their falls prevention exercises? A qualitative systematic review

OBJECTIVES

To review the qualitative literature that explores the barriers and facilitators to continued participation in falls prevention exercise after completion of a structured exercise programme.

DESIGN

A systematic literature review with thematic synthesis of qualitative studies exploring older adults' experiences of continued participation in falls prevention exercise.

DATA SOURCES

Comprehensive searches were conducted in MEDLINE, PSYCHinfo, AMED, ASSIA, CINAHL and EMBASE from inception until November 2017. Additional studies were identified via searches of reference lists and citation tracking of relevant studies.

ELIGIBILITY CRITERIA

Qualitative or mixed methods studies exploring experiences of community-dwelling older adults (65 years and over) participation in a falls prevention exercise programme including their experience of ongoing participation in exercise after the completion of a structured exercise programme.

DATA EXTRACTION AND SYNTHESIS

Key characteristics including aim, participant characteristics, method of data collection, underpinning qualitative methodology and analytical approach were extracted and independently checked. Thematic synthesis was used to integrate findings.

RESULTS

From 14 studies involving 425 participants, we identified three descriptive themes: identity, motivators/deterrents and nature of the intervention and one overarching analytical theme: agency.

CONCLUSIONS

Older people have their own individual and meaningful rationale for either continuing or stopping exercise after completion of a structured falls prevention exercise programme. Exploring these barriers and facilitators to continued exercise is key during the intervention phase. It is important that health care professionals get to know the older person's rationale and offer the best evidence-based practice and support to individuals, to ensure a smooth transition from their structured intervention towards longer-term exercise-related behaviour.

PROSPERO REGISTRATION NUMBER

CRD42017082637.

Perspectives of healthcare professionals in England on falls interventions for people with dementia: a qualitative interview study

OBJECTIVE

To explore the experiences of healthcare professionals working in falls prevention and memory assessment services in providing assessments and interventions for falls risk reduction in people with dementia.

DESIGN

This is a qualitative study using 19 semistructured interviews. Interviews were analysed through thematic analysis.

SETTING

Community-based falls and memory assessment services in the East Midlands, UK.

PARTICIPANTS

Nurses (n=10), physiotherapists (n=5), occupational therapists (n=3) and a psychiatrist (n=1).

RESULTS

Three substantive themes were identified: challenges posed by dementia, adaptations to make falls prevention appropriate for people with dementia and organisational barriers. Patients' poor recall, planning and increased behavioural risk associated with dementia were key problems. Healthcare professionals provided many suggestions on how to overcome these challenges, such as adapting exercise interventions by using more visual aids. Problems associated with cognitive impairment created a need for additional support, for instance longer interventions, and supervision by support workers, to enable effective intervention, yet limited resources meant this was not always achievable. Communication between mental and physical health teams could be ineffective, as services were organised as separate entities, creating a reliance on third parties to be intermediaries. Structural and organisational factors made it difficult to deliver optimal falls prevention for people living with dementia.

CONCLUSIONS

Healthcare professionals experience challenges in providing falls prevention to people with dementia at the individual and organisational levels. Interventions can be adapted for people with dementia, but this requires additional resources and improved integration of services. Future research is needed to develop and test the effectiveness and cost-effectiveness of such services.

Promoting activity, independence and stability in early dementia and mild cognitive impairment (PrAISED): development of an intervention for people with mild cognitive impairment and dementia

This series of articles for rehabilitation in practice aims to cover a knowledge element of the rehabilitation medicine curriculum. Nevertheless, they are intended to be of interest to a multidisciplinary audience. The competency addressed in this article is an understanding of how to develop an intervention for people with mild cognitive impairment and dementia to promote their independence, stability, and physical activity.

INTRODUCTION

Older adults with dementia are at a high risk of falls. Standard interventions have not been shown to be effective in this patient population potentially due to poor consideration of dementia-specific risk factors. An intervention is required that addresses the particular needs of older people with dementia in a community setting.

METHODS

We followed guidelines for the development of an intervention, which recommend a structured approach considering theory, evidence and practical issues. The process used 15 information sources. Data from literature reviews, clinician workshops, expert opinion meetings, patient-relative interviews, focus groups with people with dementia and clinicians, a cross-sectional survey of risk factors, a pre-post intervention study and case studies were included. Data were synthesized using triangulation to produce an intervention suitable for feasibility testing. Practical consideration of how an intervention could be delivered and implemented were considered from the outset.

RESULTS

Elements of the intervention included individually tailored, dementia-appropriate, balance, strength and dual-task exercises, functional training, and activities aimed at improving environmental access, delivered using a motivational approach to support adherence and long-term continuation of activity. We focussed on promoting safe activity rather than risk or prevention of falls.

CONCLUSION

We used a systematic process to develop a dementia-specific intervention to promote activity and independence while reducing falls risk in older adults with mild dementia.

The impact of early psychosocial intervention on self-efficacy of care recipient/carer dyads living with early-stage dementia-A mixed-methods study

AIM

To evaluate the effect of a targeted community-based psychosocial intervention on self-efficacy outcomes for care recipient/carer dyads living with early-stage dementia.

BACKGROUND

There is increasing interest in the role of self-efficacy and self-management structures in determining positive outcomes for people with dementia. The assumption is that care recipient/carer dyads who receive early support to identify and adjust to dementia-related changes will cope better in the long term.

DESIGN

An explanatory sequential mixed-method design was employed. Primarily quantitative with qualitative data providing a supportive secondary role to expand on and illuminate the quantitative findings.

METHODS

Eighty-eight dyads were recruited and allocated on a regional basis to an intervention or control group. Intervention group dyads received the Early Diagnosis Dyadic Intervention. Control group dyads received two information manuals. Quantitative data were collected at three time points. Qualitative data were collected via evaluation questionnaires and semistructured interviews.

RESULTS

Intervention structure, content, and delivery were acceptable to the dyads but few quantitative self-efficacy findings reached statistical significance. Improvements in self-efficacy were evident in the postintervention evaluation qualitative responses where dyads expressed greater confidence in identifying and accessing community support.

CONCLUSION

There is an urgent need for effective psychosocial interventions to help reduce the impact of dementia symptoms on patients, carers, and society. This study makes an important contribution to our understanding of the capacity of psychosocial interventions to improve self-efficacy outcomes for care recipient/carer dyads with early-stage dementia while also illustrating the challenges associated with measuring self-efficacy in the early stages of the condition.

A development study and randomised feasibility trial of a tailored intervention to improve activity and reduce falls in older adults with mild cognitive impairment and mild dementia

BACKGROUND

People with dementia progressively lose abilities and are prone to falling. Exercise- and activity-based interventions hold the prospect of increasing abilities, reducing falls, and slowing decline in cognition. Current falls prevention approaches are poorly suited to people with dementia, however, and are of uncertain effectiveness. We used multiple sources, and a co-production approach, to develop a new intervention, which we will evaluate in a feasibility randomised controlled trial (RCT), with embedded adherence, process and economic analyses.

METHODS

We will recruit people with mild cognitive impairment or mild dementia from memory assessment clinics, and a family member or carer. We will randomise participants between a therapy programme with high intensity supervision over 12 months, a therapy programme with moderate intensity supervision over 3 months, and brief falls assessment and advice as a control intervention. The therapy programmes will be delivered at home by mental health specialist therapists and therapy assistants. We will measure activities of daily living, falls and a battery of intermediate and distal health status outcomes, including activity, balance, cognition, mood and quality of life. The main aim is to test recruitment and retention, intervention delivery, data collection and other trial processes in advance of a planned definitive RCT. We will also study motivation and adherence, and conduct a process evaluation to help understand why results occurred using mixed methods, including a qualitative interview study and scales measuring psychological, motivation and communication variables. We will undertake an economic study, including modelling of future impact and cost to end-of-life, and a social return on investment analysis.

DISCUSSION

In this study, we aim to better understand the practicalities of both intervention and research delivery, and to generate substantial new knowledge on motivation, adherence and the approach to economic analysis. This will enable us to refine a novel intervention to promote activity and safety after a diagnosis of dementia, which will be evaluated in a definitive randomised controlled trial.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT02874300; ISRCTN 10550694.