Communicating with individuals with dementia. The impaired person's perspective

Psychotropic Medication Prescribing Practice Among Residents With Dementia in Nursing Homes: A Person-Centered Care Approach

Despite multiple national initiatives to improve quality of life in nursing home (NH) residents with dementia, inefficiencies still exist regarding inappropriate psychotropic medication use to manage communication of distress. The goals of the current article are to: (a) create a person-centered care plan/process for NH community staff to manage challenging dementia behaviors; (b) provide guidelines for geriatric practitioners (GPs) to decrease psychotropic medication use in residents with dementia; (c) discuss organizational culture and its relationship to the management of non-cognitive neuropsychiatric symptoms (NPS) of dementia; and (d) emphasize nonpharmacological approaches as first-line treatment of NPS in NH residents with dementia. [Journal of Gerontological Nursing, 46(2), 9-17.].

Use of Checklists in Reviews of Health Economic Evaluations, 2010 to 2018

OBJECTIVE

It is useful for reviewers of economic evaluations to assess quality in a manner that is consistent and comprehensive. Checklists can allow this, but there are concerns about their reliability and how they are used in practice. We aimed to describe how checklists have been used in systematic reviews of health economic evaluations.

METHODS

Meta-review with snowball sampling. We compiled a list of checklists for health economic evaluations and searched for the checklists' use in systematic reviews from January 2010 to February 2018. We extracted data regarding checklists used, stated checklist function, subject area, number of reviewers, and issues expressed about checklists.

RESULTS

We found 346 systematic reviews since 2010 that used checklists to assess economic evaluations. The most common checklist in use was developed in 1996 by Drummond and Jefferson, and the most common stated use of a checklist was quality assessment. Checklists and their use varied within subject areas; 223 reviews had more than one reviewer who used the checklist.

CONCLUSIONS

Use of checklists is inconsistent. Eighteen individual checklists have been used since 2010, many of which have been used in ways different from those originally intended, often without justification. Different systematic reviews in the same subject areas would benefit from using one checklist exclusively, using checklists as intended, and having 2 reviewers complete the checklist. This would increase the likelihood that results are transparent and comparable over time.

Dementia and advance directives: some empirical and normative concerns

The authors of the paper 'Advance euthanasia directives: a controversial case and its ethical implications' articulate concerns and reasons with regard to the conduct of euthanasia in persons with dementia based on advance directives. While we agree on the conclusion that there needs to be more attention for such directives in the preparation phase, we disagree with the reasons provided by the authors to support their conclusions. We will outline two concerns with their reasoning by drawing on empirical research and by providing reasons that contradict their assumptions about competence of people with dementia and the (un)importance of happiness in reasoning about advance directives of people with dementia. We will draw attention to the important normative questions that have been overstepped in their paper, and we will outline why further research is required.

A protocol to evaluate the impact of involvement of older people with dementia and age-related hearing and/or vision impairment in a multi-site European research study

PLAIN ENGLISH SUMMARY

Involving older people with dementia in research is increasingly recognised as important to ensure that research is relevant and beneficial for older people with dementia. But researchers need to know how best to involve older people with dementia and to be able to show the benefits of involving older people with dementia in dementia research.This paper describes a research plan to explore the involvement of older people with dementia and age-related hearing and/or vision impairment in a European research project investigating the combined impact of dementia with hearing and/or vision impairment. We set up four Research User Groups (RUGs) of older people with dementia with age-related hearing and/or vision impairment and their carers based in the UK, France, Cyprus and Greece to advise our researchers. We provided training to group members to support their input to the research.We will use a questionnaire and interview people in our RUGs to understand what they thought of the training and their experiences of being part of the RUG. We will also interview researchers to understand if they thought the advice from the groups was useful.This study will help us to understand how to effectively involve older people with dementia and age-related hearing and/or vision impairment in research and what the benefits of involving older people with dementia in research are.

ABSTRACT

Background Research to prevent and treat dementia is an international priority. Involvement of older people with dementia in the research is important to ensure the relevance and utility of the research outcomes in clinical practice to them. Efforts to involve such people in research are growing due to increased recognition of the usefulness of incorporating the views of older people with dementia into the research process. Research User Groups (RUGs) of older people with dementia and carers for people with dementia were set up in UK (Manchester), France (Nice), Cyprus (Nicosia) and Greece (Athens) to advise on the research. We report a protocol for a study which aims to evaluate i) the perceptions of RUG members of the usefulness of Research Awareness Training that was provided to support their involvement in the research and ii) perceived impacts of the involvement of older people with dementia and age-related hearing and/or vision impairment on research from the point of view of RUG members and researchers. Methods Both qualitative and quantitative methods will be used to evaluate the acceptability, appropriateness and satisfaction with Research Awareness Training and the perceived impact of involvement of RUGs on research. Focus groups interviews with RUG members and one to one interviews with both RUG members (n = 24) and researchers (n = 6) will be conducted to understand the perceived impacts of patient and public involvement on research from the point of view of older people with dementia, carers and researchers. Any comparative differences in cultural, attitudinal and environmental differences between RUGs in outcomes of training and impact across the four European sites will be reported. Discussion This study is unique in its exploration of the impact of the involvement of older people with dementia and age-related hearing and/or vision impairment in a large multi-site European dementia research study. This work will be crucial in informing understanding of how to effectively involve older people with dementia and age-related hearing and/or vision impairment and carers in dementia research to ensure research addresses the needs and priorities of older people with dementia and age-related hearing and/or vision impairment.

Impact of the Sonas Programme on Communication over a Period of 24 Weeks in People with Moderate-to-Severe Dementia

Objectives

The primary aim was to examine how communication abilities changed over time among nursing home residents with moderate-to-severe dementia who were attending the Sonas programme and to explore whether changes in communication abilities were related to cognitive ability.

Method

A longitudinal secondary descriptive study method was employed, where 56 people with moderate-to-severe dementia attended a 45-min Sonas group session twice a week for 24 weeks. The Threadgold Communication Tool (TCT) was completed every 4 weeks.

Results

The impact of the Sonas programme on communication showed a significant non-linear trend in the TCT, with an increase in communication abilities during the first 16 weeks, regardless of the level of the residents' cognitive abilities. Thereafter it levelled out. No interaction was found between time and the frequency of attendances at Sonas sessions. Both verbal and non-verbal communication increased from the baseline, with non-verbal communication increasing quickly and verbal communication increasing marginally.

Conclusion

Communication abilities increased with the time of the intervention, but the peak was achieved after 16 weeks, after which the effect levelled out. This suggest that the Sonas programme should be used for a period of at least 16 weeks before evaluating its effect.

Epistemic injustice in dementia and autism patient organizations: An empirical analysis

Patient organizations (POs) represent patient collectives in health care policy. The inclusion of people with a 'neuro-psychiatric' condition poses a particular challenge for the organizational processes and political representation of such collectives. In recent years, new POs (POs of) have been established in the field of autism spectrum disorder and dementia that advocate a different agenda and have a different organizational structure than traditional POs (POs for). The divide between these two types of POs indicates a different standpoint with regard to who should be included on an organizational level, which voices are accepted and who should represent these voices on the political level. The inclusion and exclusion of voices needs to be normatively justified in order to be regarded legitimate representation of such a collective. With the help of Miranda Fricker's theory of epistemic injustice, we scrutinize whether and, if so, which types of epistemic injustices (wrongdoings to a person as a knower) can be found within POs' practices and the political field in which they operate, by analyzing 37 interviews with PO representatives, their members and policy makers. Our in-depth analysis indicates that persistent stereotypes hamper the inclusion of affected members both within POs and on the health political level. Being affected causes distrust in having the 'capacity to know' in a two-fold way; it is assumed that those who can represent themselves are "not affected enough" to present valuable insights into the condition and those who have difficulties to express themselves due to their condition are excluded because of their affectedness. We conclude that our analysis of the epistemic practices of POs serves as a good starting point to address these shortcomings from a theoretical and practical perspective and offers a valuable starting point for bioethics to understand unjust structures in the health political context.

Evaluating dementia home care practices: The reification of care norms

This critical ethnographic study examined how power relations shape the nature and enactment of caregivers' evaluation of home-based dementia care practices. As the home care sector continues to evolve and prepare itself as a key element in caring for people living with dementia and their families, this study grounds our understanding of how dementia home care practices are enacted and evaluated, particularly at the interface of formal and familial caregiving. The critical finding from our data is that not all evaluations of care practices were considered equally meaningful or relevant, and, moreover, their significance depended on whether the evaluation was made by someone in a position of power. Renewed awareness of and attention to power relations, such as class and gender, are implicated in the evaluation of care practices. Consequently, challenging how power is enacted in ways that (re)produces and reifies care norms is vital in order to foster equitable and supportive partnerships in home-based dementia care.

Personhood in dementia care

Dementia has been understood primarily as a biomedical phenomenon with a trajectory of irrevocable decline related to neurodegenerative changes. However, growing evidence suggests that the performance and behaviour of persons with dementia are not exclusively determined by neuropathology but are also influenced by personal histories, social interactions and social contexts. This evidence shifts attention from the disease process to the need for a more in-depth understanding of the place of personhood in dementia care. Despite its intuitive appeal however, there is limited empirical research grounding this approach to care. This article articulates a framework for organizing research in this area that is based on a critical review and synthesis of research. It encompasses three interrelated and intersecting domains of inquiry: the subjective experience of the person with dementia, the immediate interactional environment and the broader socio-cultural context. Each domain encapsulates a unique but interrelated dimension of a person-centred approach to dementia care.

Working together with persons with early stage dementia and their family members to design a user-friendly technology-based support service

This article describes how researchers, practitioners and technicians in West Sweden worked together with older people with early stage dementia and their family members to develop a user-friendly technology-based information, education and support service, based on the generic ACTION participatory design model. Ways of working in partnership with older people with early stage dementia and their family members are explored, and key lessons learned are highlighted. The overriding message is that elders with early stage dementia can be actively involved throughout the entire research and development process. Essential prerequisites are time and ongoing support by skilled practitioners and family members. Preliminary findings reveal that older people with early stage dementia can learn and benefit from user-friendly technology, especially when used together with others in a similar situation.

Expressive bodies: demented persons’ communication in a dance therapy context

Dementia is a disease that brings with it various limitations in the afflicted person’s communication with others. The purpose of this study is to explore, not the limitations, but the capacity of the demented person to communicate under conditions that differ from the everyday life of the care institution. Group dance therapy sessions with elderly, demented persons were video-taped and analysed with a focus on how verbal and non-verbal modes of communication were used by the participants. The ways the demented persons use body movements, free dance movements, speech and singing in different combinations is described and discussed in terms of different expressive modes, where body movements are used to substitute or support speech as well as to express thoughts, memories and emotions. The results from the study indicate that under conditions that allow for different modes of expression, the communication of the demented person can be found to be rich and varied in expression and content.

Articulating the strategies for maximising the inclusion of people with dementia in qualitative research studies

It is essential to understand the experience of living with dementia from the perspective of the person with dementia so that services can be appropriately constructed. This review paper, drawing on prior work, identifies key strategies for the meaningful inclusion of persons with dementia within qualitative research studies, it examines the articulation of these strategies and shares how these strategies were operationalised within one national research study in Ireland. Strategies within the literature were categorised and then synthesized into a guide consisting of four main areas; gaining COnsent, maximizing Responses, Telling the story, and Ending on a high (CORTE). The CORTE guideline was used to as a tool for analysing relevant research reports. CORTE is a synthesized account of grouped strategies that could be used to maximize the meaningful involvement of persons with dementia and can also provide a guide for reporting the strategies used so that researchers can learn from each other.

Care-givers’ perspectives of occupational engagement of persons with dementia

Meaningful engagement in activity is associated with the maintenance of health and wellbeing, but reduced activity participation is common among persons with dementia. Family care-givers play an important role in engaging their relatives with dementia in activities but little is known about their perception of occupational engagement. This study aimed to examine care-givers’ perception of occupational performance of their relatives from three aspects: person, occupation and environment. Adopting a qualitative methodology, semi-structured and in-depth interviews were conducted with 14 family care-givers. Care-givers were also asked to document the activity patterns of their relative, using the Activity Card Sort Hong Kong version (ACS-HK). The ACS-HK findings suggested that high-demand leisure activities were mostly retained (61%) while instrumental activities of daily living were the least retained (37%). Qualitative analysis revealed that care-givers’ perception of activity participation was intertwined with their motives and behaviours to get their relatives engaged in activities. Care-givers acknowledged occupational engagement as a means of maintaining wellness and used various strategies to encourage their relative's activity participation. Apathy and passivity, however, are difficult to deal with. Also, activity decisions appear to depend on the availability of support resources and a balance between safety concern and risk-taking. Clinical practitioners could assist care-givers by suggesting activity strategies and providing support resources for continued engagement of their relative in activities.

How to evaluate quality of care from the perspective of people with dementia: An overview of the literature

This article reviews the literature on the inclusion of the perspective of people with dementia when evaluating quality of care. The few identified relevant studies suggest that there is consensus that people with mild to moderate dementia are able to talk about their experiences with care with clarity and insight. A minimum level of orientation to place, attention and language skills in the person with dementia are important for a successful subjective evaluation. On the basis of the relevant literature, we additionally formulated practical guidelines useful when one aims to collect information with interviewing, self-administered questionnaires, or focus groups from people with dementia to assess quality of care. In people with mild to moderate dementia, assessment of quality of care can best be done by individual interviewing and focus groups. Further research is needed to ascertain what people with dementia find important in relation to quality of care.

Methods to Enhance Verbal Communication between Individuals with Alzheimer's Disease and Their Formal and Informal Caregivers: A Systematic Review

Alzheimer's disease is the leading cause of dementia in older adults. Although memory problems are the most characteristic symptom of this disorder, many individuals also experience progressive problems with communication. This systematic review investigates the effectiveness of methods to improve the verbal communication of individuals with Alzheimer's disease with their caregivers. The following databases were reviewed: PsychINFO, CINAHL, EMBASE, MEDLINE, REHABDATA, and COMDIS. The inclusion criteria were: (i) experimentally based studies, (ii) quantitative results, (iii) intervention aimed at improving verbal communication of the affected individual with a caregiver, and (iv) at least 50% of the sample having a confirmed diagnosis of Alzheimer's disease. A total of 13 studies met all of the inclusion criteria. One technique emerged as potentially effective: the use of memory aids combined with specific caregiver training programs. The strength of this evidence was restricted by methodological limitations of the studies. Both adoption of and further research on these interventions are recommended.

Doing as much as I can do: the meaning of activity for people with dementia

While it is assumed that persons with dementia benefit from being involved in meaningful activity, research examining this claim is limited. In particular, how individuals with dementia perceive this involvement is poorly understood. Therefore, the purpose of this research is to determine what constitutes meaningful activity from the perspective of persons with dementia, and to explore how they perceive its significance in their lives. We conducted an interpretive phenomenological analysis of multiple interviews and participant observation conducted with eight community-dwelling elders with mild to moderate dementia. For several participants, the single most important driving force in their lives was being active, doing as much as they possibly could. They were involved in a wide range of activities including leisure pastimes, household chores, work-related endeavors, and social involvements. These activities were meaningful in three ways: Through their involvement, participants experienced feelings of pleasure and enjoyment; felt a sense of connection and belonging; and retained a sense of autonomy and personal identity. Findings suggest that familiarity of the social and physical environment promotes involvement in activities. This provides a sense of continuity for people with dementia, with implications for their quality of life and personhood. Further implications of these findings for dementia care and future research are discussed.

Increasing Social Communication in Persons With Dementia

Communication difficulties between caregivers and persons with dementia (PWDs) may increase stress, resulting in behavior problems. Kitwood’s theory of dementia care suggests that successful collaborative communication increases well-being and quality of life in PWDs. This study aimed to determine if individualized communication prescriptions (ways interviewers might facilitate collaborative communication) are effective for doing so. Ten PWDs were interviewed; individualized communication prescriptions developed then implemented in a second interview. No increase in number of words used by PWDs occurred in interview 2; however, PWDs’ words per topic significantly increased and number of topics needed to sustain a 15-minute conversation significantly decreased in the second interview. Systematic, individualized communication strategies may encourage PWDs to express their needs, preferences, and ideas.

Family strategies for supporting involvement in meaningful activity by persons with dementia

Involvement in meaningful activity may be helpful for those with dementia, although it is a poorly understood phenomenon among those living in the community with family members. An interpretive phenomenological study was conducted with eight families to determine how family members support involvement in activity of persons with dementia and what it means to families. Repeated individual interviews were conducted with the person with dementia and a family member; they were asked to tell stories about their usual activities, to consider the impact of the dementia on everyday life and what they did to cope with difficulties. They were also observed taking part in everyday activities. Analysis revealed three strategies used by families to support activity: (a) reducing demands, (b) guiding, and (c) accompanying. These strategies allowed families to sustain meaning for both the person with dementia and the family itself. Significance for practice and ideas for future research are discussed.

Effects of snoezelen, integrated in 24 h dementia care, on nurse-patient communication during morning care

OBJECTIVE

To investigate the effectiveness of snoezelen, integrated in 24-hour care, on the communication of Certified Nursing Assistants (CNAs) and demented nursing home residents during morning care.

METHODS

A quasi-experimental pre- and post-test design was conducted, comparing sic psychogeriatric wards, that implemented snoezelen, to six control wards, that continued in giving usual care. Measurements were performed at baseline and 18 months after a training 'snoezelen for caregivers'. Independent assessors analysed 250 video-recordings directly from the computer, using an adapted version of the Roter Interaction Analysis System (RIAS) and non-verbal measurements.

RESULTS

Trained CNAs showed a significant increase of resident-directed gaze, affective touch and smiling. The total number of verbal utterances also increased (more social conversation, agreement, talking about sensory stimuli, information and autonomy). Regarding residents, a significant treatment effect was found for smiling, CNA-directed gaze, negative verbal behaviours (less disapproval and anger) and verbal expressed autonomy.

CONCLUSION

The implementation of snoezelen improved the actual communication during morning care.

PRACTICE IMPLICATIONS

Teaching CNAs to provide snoezelen has added value for the quality of care. Morning care by trained CNAs appeared to take more time. This suggests that (some) time investment might be required to achieve positive effects on CNA- resident communication.

Finding the balance: living with memory loss

Since the late 1980s, it has been increasingly recognized that the experiences of people with dementia have been omitted from research in the area of dementia and memory loss. More recently, it has been accepted that people with dementia have insight into their condition and, therefore, the ability to contribute to research. A qualitative research project was undertaken with nine participants to explore the experiences and coping strategies of people with dementia. Interviews were undertaken and the data analysed using thematic analysis. Three major themes emerged: coming to terms with memory loss, maintaining control and independence, and the impact of illness on relationships. Understanding the reality for people is essential given that representations of the catastrophic impact of dementia generate high levels of anxiety and depression. Implications for nurses' practice include the need for skilled, well-paced, sensitive and ongoing information about the condition, along with the need to recognize and support the active coping strategies of people with memory loss.

Compiling life history resources for older adults in institutions: development of a guide

Focus groups were conducted for nursing staff, visiting family members, and residents of a long-term care facility, with the purpose of developing a guide for compiling a life history resource. When compiling the proposed guideline, one must consider not only the topics to include, but also the process of collecting the information and the format for presentation. A key finding was that members of all three groups believed that the process of sharing and collecting life history information was an important step in promoting and enhancing the relationship between nursing staff and residents, and nursing staff and residents' families.

Exploring the meaning of everyday life, for those suffering from dementia

Living with dementia means struggling to preserve a sense of self, to retain (and reevaluate) one's values in a new situation, and to search for a new way of life. This study explored the meaning of everyday life as expressed by 11 people suffering from dementia. Data were collected through interviews with people in the early stage of a diagnosed dementia disease. The findings indicate that many people with dementia feel shame, sorrow, and sadness when their life with the disease begins but also indicate prospects of a more manageable life. Since the reaction and adjustment to dementia differs from person to person, professional caregivers need to use a case-specific approach in the provision of care.

Giving voice to persons living with dementia: the researcher's opportunities and challenges

Few qualitative studies have examined the experiences of persons living with dementia and little has been written about the opportunities and challenges for the researchers. This article challenges the assumption of dwindling personhood among persons with dementia. Methodological challenges which may be encountered by qualitative researchers are outlined and specific strategies for addressing these challenges are described including: modifying consent/assent procedures, adjusting sample size, facilitating communication, and making the most of the data.

Critical issues in interviewing people with traumatic brain injury

People with cognitive impairments often cannot effectively recall and articulate experiences, feelings, and perceptions. Therefore, interviewing them can be fraught with pragmatic and methodological difficulties. Given this situation, the authors' experience in a study on the allocation of rehabilitative services to survivors of traumatic brain injury is discussed. Participants had physiological impairments affecting their ability to focus on interview questions. The authors discuss the unique challenges, including participants' recall of events, intolerance to stimuli, and image management and offer strategies for mitigating these concerns. The traditional view that reality is captured only in the subjective accounts of articulate people who can remember events in a precise and reflective manner is challenged.

Content validity for dementia of three generic preference based health related quality of life instruments

A semi-structured interview was conducted with dementia patients and their caregivers in order to explore which aspects of quality of life were perceived as relevant and important. These aspects of quality of life were compared with the content of three generic utility-based quality of life instruments: European Quality of Life Instrument, Health Utilities Index, and Quality of Well-Being (QWB) Scale. Twenty patients with mild dementia and 20 caregiver volunteers provided narrative data derived from interviews that were analyzed using a modified Grounded Theory method of analysis. Essential attributes of dementia quality of life identified by the respondents were missing in the three utility-based quality of life instruments selected for the study. Patients provided a wider range of attributes than the instruments including some attributes not described by caregivers. Of the three utility-based measures, the QWB scale included the largest number of quality of life attributes but still missed many. Compared to the respondent generated attributes all three utility-based quality of life instruments have important shortcomings in content validity.

Testing an intervention to reduce assaults on nursing assistants in nursing homes: a pilot study

Nursing home staffs frequently encounter physical and emotional violence directed toward them by residents. This article addresses the problem from an occupational health perspective and describes a pilot study focused an educational intervention to reduce resident assaults on certified nursing assistants (CNAs) in nursing homes. After a 4-hour education intervention, the study CNAs reported fewer physical assaults by residents and increased levels of knowledge and confidence in their ability to manage residents' aggressive behavior compared with a similar CNA group. Limitations include a small convenience sample who works only the day shift. Results support education and training as effective in reducing resident physical assaults and enhancing nursing home safety. Further research should investigate assaultive resident behavior and evaluate the effectiveness of interventions to prevent, reduce, and manage violence in nursing homes.

'They never told us anything': postdischarge instruction for families of persons with brain injuries

This article reports on an analysis of why some families of survivors of traumatic brain injury (TBI) do not perceive that they were prepared for the postdischarge experience, despite discharge planning and teaching by rehabilitation hospital staff and third-party insurance adjusters. Findings are presented of a research study involving single interviews with seven families of survivors of TBI and interviews with four focus groups of healthcare professionals and third-party insurance adjusters who had cared, or were currently caring, for the injured person. Most family members did not recall being taught about what to expect or resources available to them. Healthcare professionals and insurance adjusters, however, stated that extensive discharge planning and multidisciplinary teaching conferences with patients and their families had been held before the patients were discharged. Reasons for such a discrepancy in perceptions are suggested. Implications of these findings for healthcare professionals who conduct discharge teaching in rehabilitation facilities are identified.

Communication from individuals with advanced DAT: can it provide clues to their sense of self-awareness and well-being?

Often communication from people with advanced dementia of the Alzheimer type (DAT) is regarded as incoherent and meaningless. However, with careful listening and observation, such communication often becomes more understandable. To better understand DAT communication, the investigators designed an exploratory qualitative study to videotape and critically analyze conversations between a clinical nurse specialist and 15 subjects with DAT ranging from mild to severe. One of the findings was that, even in later stages, indications were given that subjects had self-awareness of their cognitive decline. The investigators further examined the communication of the five most cognitively impaired subjects for other indications of self-awareness and well-being. To demonstrate this premise of awareness of cognitive decline and self in the later stages of DAT, excerpts from communication received from five subjects with advanced cognitive impairment are presented.