Patient navigation programs for people with dementia, their caregivers, and members of the care team: a scoping review

OBJECTIVE

The main objective of this review was to map the literature on the characteristics of patient navigation programs for people with dementia, their caregivers, and members of the care team across all settings. The secondary objective was to map the literature on the barriers and facilitators for implementing and delivering such patient navigation programs.

INTRODUCTION

People with dementia have individualized needs that change according to the stage of their condition. They often face fragmented and uncoordinated care when seeking support to address these needs. Patient navigation may be one way to help people with dementia access better care. Patient navigation is a model of care that aims to guide people through the health care system, matching their unmet needs to appropriate resources, services, and programs. Organizing the available information on this topic will present a clearer picture of how patient navigation programs work.

INCLUSION CRITERIA

This review focused on the characteristics of patient navigation programs for people living with dementia, their caregivers, and the members of the care team. It excluded programs not explicitly focused on dementia. It included patient navigation across all settings, delivered in all formats, and administered by all types of navigators if the programs aligned with this review's definition of patient navigation. This review excluded case management programs.

METHODS

This review was conducted in accordance with JBI methodology for scoping reviews. MEDLINE, CINAHL, APA PsycINFO, Embase, and ProQuest Nursing and Allied Health databases were searched for published full-text articles. A gray literature search was also conducted. Two independent reviewers screened articles for relevance against the inclusion criteria. The results are presented in a Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) flow diagram, and the extracted data are presented narratively and in tabular format.

RESULTS

Thirty-nine articles describing 20 programs were included in this review. The majority of these articles were published between 2015 and 2020, and based out of the United States. The types of sources included randomized controlled trials, quasi-experimental studies, and qualitative exploratory studies, among others. All programs provided some form of referral or linkage to other services or resources. Most dementia navigation programs included an interdisciplinary team, and most programs were community-based. There was no consistent patient navigator title or standard delivery method. Commonly reported barriers to implementing and delivering these programs were navigator burnout and a lack of coordination between stakeholders. Commonly reported facilitators were collaboration, communication, and formal partnerships between key stakeholders, as well as accessible and flexible program delivery models.

CONCLUSIONS

This review demonstrates variety and flexibility in the types of services patient navigation programs provided, as well as in the modes of service delivery and in navigator title. This information may be useful for individuals and organizations looking to implement their own programs in the future. It also provides a framework for future systematic reviews that seek to evaluate the effectiveness or efficacy of dementia navigation programs.

Toward Pre-Diagnostic Detection of Dementia in Primary Care

Background: Preventing dementia warrants the pragmatic engagement of primary care. Objective: This study predicted conversion to dementia 12 months before diagnosis with indicators that primary care can utilize within the practical constraints of routine practice. Methods: The study analyzed data from the Alzheimer’s Disease Neuroimaging Initiative (Total sample = 645, converting participants = 54). It predicted the conversion from biological (plasma neurofilament light chain), cognitive (Trails Making Test– B), and functional (Functional Activities Questionnaire) measures, in addition to demographic variables (age and education). Results: A Gradient Booster Trees classifier effectively predicted the conversion, based on a Synthetic Minority Oversampling Technique (n = 1,290, F1 Score = 92, AUC = 94, Recall = 87, Precision = 97, Accuracy = 92). Subsequent analysis indicated that the MCI False Positive group (i.e., non-converting participants with cognitive impairment flagged by the model for prospective conversion) scored significantly lower on multiple cognitive tests (Montreal Cognitive Assessment, p < 0.002; ADAS-13, p < 0.0004; Rey Auditory Verbal Learning Test, p < 0.002/0.003) than the MCI True Negative group (i.e., correctly classified non-converting participants with cognitive impairment). These groups also differed in CSF tau levels (p < 0.04), while consistent effect size differences emerged in the all-pairwise comparisons of hippocampal volume and CSF Aβ1 - 42. Conclusion: The model effectively predicted 12-month conversion to dementia and further identified non-converting participants with MCI, in the False Positive group, at relatively higher neurocognitive risk. Future studies may seek to extend these results to earlier prodromal phases. Detection of dementia before diagnosis may be feasible and practical in primary care settings, pending replication of these findings in diverse clinical samples.

Feasibility and acceptability evaluation of the Promoting Independence in Dementia (PRIDE) intervention for living well with dementia

OBJECTIVES

Post-diagnostic psychosocial interventions could play an important role in supporting people with mild dementia remain independent. The Promoting Independence in Dementia (PRIDE) intervention was developed to address this.

METHOD

The mixed methods non-randomized, pre-post feasibility study occurred across England. Facilitators were recruited from the voluntary sector and memory services. Participants and their supporters took part in the three-session intervention. Outcome measures were collected at baseline and follow-up. To evaluate acceptability, focus groups and interviews were conducted with a subsample of participants and facilitators.

RESULTS

Contextual challenges to delivery including national research governance changes, affected recruitment of study sites. Thirty-four dyads consented, with 14 facilitators providing the intervention. Dyads took part in at least two sessions (79%), and 73% in all three. Outcome measures were completed by 79% without difficulty, with minimal missing data. No significant changes were found on pre and post assessments. Post hoc analysis found moderate effect size improvements for self-management (SMAS instrument) in people with dementia (d = 0.41) and quality of life (EQ5D measure) in carers (d = 0.40). Qualitative data indicated that dyads found PRIDE acceptable, as did intervention facilitators.

CONCLUSIONS

The three-session intervention was well accepted by participant-dyads and intervention facilitators. A randomized controlled trial of PRIDE would need to carefully consider recruitment potential across geographically varied settings and site stratification according to knowledge of contextual factors, such as the diversity of post-diagnostic services across the country. Letting sites themselves be responsible for identifying suitable intervention facilitators was successful. The self-report measures showed potential to be included in the main trial.

Health promotion intervention for people with early-stage dementia: A quasi-experimental study

INTRODUCTION

With the limited advancements in medical treatment, there is a growing need for supporting people with early-stage dementia adjust to their diagnosis and improve their quality of life. This study aimed to investigate the effects of a 12-week health promotion course for people with early-stage dementia.

METHODS

Quasi-experimental, single group, pretest-posttest design. A total of 108 persons with dementia participated in this study, and for each participant, a carer was interviewed. The 12-week health promotion intervention consisted of 2-hr sessions at weekly intervals. Outcome measures were cognition, measured by Mini-Mental State Examination, personal, and instrumental activities of daily living (P-ADL and I-ADL), measured by Lawton and Brody's Physical Self-Maintenance Scale and Instrumental Activities of Daily Living Scale, self-rated health, measured by the European Quality of life Visual Analogue Scale, depressive symptoms, measured by the Cornell Scale for Depression in Dementia, and neuropsychiatric symptoms, measured by The Neuropsychiatric Inventory. Assessments were conducted at baseline and at follow-up 1-2 months postintervention.

RESULTS

The results demonstrate a small but statistically significant improvement in depressive symptoms (p = .015) and in self-rated health (p = .031). The results also demonstrated a small statistically significant decline in the participants' I-ADL (p = .007). The participants' cognitive function, P-ADL, and neuropsychiatric symptoms were stable during the 4-month follow-up.

CONCLUSION

This study demonstrates promising results with regard to the benefit of attending a 12-week health promotion intervention in promoting health and well-being in people with early-stage dementia. With the majority of participants with early-stage dementia living at home without any healthcare services in a vulnerable stage of the condition, this study makes an important contribution to highlighting the need for, and benefit of, educational approaches for this population.

The Effects of Self-Care Intervention Programs for Elderly with Mild Cognitive Impairment

This study examined the effects of a self-care intervention program on self-efficacy, dementia-preventive behavior, cognitive function, depression, and quality of life in elderly with mild cognitive impairment. The study employed a quasi-experimental study design using a nonequivalent control group pre-post. Data were analyzed using the chi-square test, independent t-test, and repeated-measures ANOVA. The results of the study showed that the program reduced dementia risk and strengthened self-care ability in older adults with MCI.

The development of the Promoting Independence in Dementia (PRIDE) intervention to enhance independence in dementia

OBJECTIVE

Support after a diagnosis of dementia may facilitate better adjustment and ongoing management of symptoms. The aim of the Promoting Independence in Dementia (PRIDE) study was to develop a postdiagnostic social intervention to help people live as well and as independently as possible. The intervention facilitates engagement in evidence-based stimulating cognitive, physical and social activities.

METHODS

Theories to promote adjustment to a dementia diagnosis, including theories of social learning and self-efficacy, were reviewed alongside self-management and the selective optimization model, to form the basis of the intervention. Analyses of two longitudinal databases of older adults, and qualitative analyses of interviews of older people, people with dementia, and their carers about their experiences of dementia, informed the content and focus of the intervention. Consensus expert review involving stakeholders was conducted to synthesize key components. Participants were sourced from the British NHS, voluntary services, and patient and public involvement groups. A tailored manual-based intervention was developed with the aim for this to be delivered by an intervention provider.

RESULTS

Evidence-based stimulating cognitive, physical, and social activities that have been shown to benefit people were key components of the proposed PRIDE intervention. Thirty-two participants including people with dementia (n=4), carers (n=11), dementia advisers (n=14), and older people (n=3) provided feedback on the drafts of the intervention and manual. Seven topics for activities were included (eg, "making decisions" and "getting your message across"). The manual outlines delivery of the intervention over three sessions where personalized profiles and plans for up to three activities are developed, implemented, and reviewed.

CONCLUSION

A manualized intervention was constructed based on robust methodology and found to be acceptable to participants. Consultations with stakeholders played a key role in shaping the manualized PRIDE intervention and its delivery. Unlike most social interventions for dementia, the target audience for our intervention is the people with dementia themselves.

Effects of an Interdisciplinary Care Team on the Management of Alzheimer's Disease in China

The current study aimed to evaluate the multidimensional effects of an interdisciplinary care team in patients with Alzheimer's disease (AD). A total of 129 patients with AD were randomly assigned to an interdisciplinary care group (n = 69) or usual care group (n = 60). Behavioral and psychological symptoms of patients with AD were measured during a 6-month treatment period. No differences were found in the baseline characteristics between the interdisciplinary care and usual care groups. Compared to usual care, interdisciplinary care greatly increased patients' activities of daily living (ADL) scores when measured at 3 and 6 months (p < 0.001). Findings provide evidence that an interdisciplinary care team approach is beneficial in improving ADL performance; thus, an interdisciplinary care team should be implemented in the care arrangements for patients with AD. [Journal of Gerontological Nursing, 45(5), 39-45.].

Younger Onset Dementia

This literature review focused on the experience, care, and service requirements of people with younger onset dementia. Systematic searches of 10 relevant bibliographic databases and a rigorous examination of the literature from nonacademic sources were undertaken. Searches identified 304 articles assessed for relevance and level of evidence, of which 74% were academic literature. The review identified the need for (1) more timely and accurate diagnosis and increased support immediately following diagnosis; (2) more individually tailored services addressing life cycle issues; (3) examination of the service needs of those living alone; (4) more systematic evaluation of services and programs; (5) further examination of service utilization, costs of illness, and cost effectiveness; and (6) current Australian clinical surveys to estimate prevalence, incidence, and survival rates. Although previous research has identified important service issues, there is a need for further studies with stronger research designs and consideration of the control of potentially confounding factors.

A Review of Self-Management Interventions for People With Dementia and Mild Cognitive Impairment

Self-management offers a way of helping people with dementia or mild cognitive impairment (MCI) to play an active role in managing their condition. Barlow, Wright, Sheasby, Turner, and Hainsworth have defined self-management as the "individual's ability to manage the symptoms, treatment, physical and psychosocial consequences and life style changes inherent in living with a chronic condition." Although commonly used in other chronic health conditions, there has been relatively little exploration of the role of self-management in dementia or MCI. This review aimed to identify group-based psychosocial interventions for people with dementia or MCI that incorporate significant elements of self-management. Fifteen interventions were included in the review: 12 for people with dementia and 3 for participants with MCI. In both the dementia and MCI interventions, the most commonly included self-management components were information, communication, and social support, and skills training. The review findings indicate that components of self-management have been incorporated into group-based interventions for people with dementia and MCI. Further studies are needed to address the methodological limitations of the included studies and to determine the effectiveness of self-management interventions with these populations.

Help yourself: perspectives on self-management from people with dementia and their caregivers

Self-management interventions are increasingly offered to people with chronic health conditions. However, there has been limited exploration of how applicable such an approach is in early stage dementia. In this study we explored the views of people with dementia and family caregivers on the use of self-management in dementia. We conducted semistructured interviews with 13 people with early stage dementia and 11 caregivers. We analyzed transcripts using thematic analysis. We found eight themes in the analysis, and they indicated that self-management occurs in the context of peoples' family and social relationships as well as relationships with professional services. Six of the themes involved barriers to and facilitators of self-management. It is evident from these findings that people with dementia and caregivers use self-management techniques. Their use of such techniques could be enhanced by the development of interventions designed to help people with dementia to develop their self-management skills.

Mediterranean diet interventions to prevent cognitive decline--opportunities and challenges

Cognitive decline has a profound impact on the health and quality of life of older people and their caregivers. Exploring mechanisms to delay cognitive decline has become an urgent economic priority, given the projected changes in population demographics. Systematic reviews and meta-analyses of observational studies suggest that adherence to a Mediterranean Diet (MD) is associated with reduced cognitive decline, but such an observation needs to be tested in randomised controlled trials. Intervention evidence is currently limited, and future studies need to be adequately powered, with careful attention given to choice of participants, outcomes being assessed, study duration and strategies to achieve compliance. Alongside these studies, consideration has to be given to how best promote and encourage dietary change in older people in general, and particularly in those experiencing the early stages of cognitive decline, as there may be specific factors that need to be considered when designing lifestyle behaviour change interventions in this group.

Expressed Sense of Self by People With Alzheimer’s Disease in a Support Group Interpreted in Terms of Agency and Communion

The self is constructed in cooperation with other people and social context influences how people perceive and express it. People with Alzheimer’s disease (AD) often receive insufficient support in constructing their preferred selves, but little is known about how they express themselves together with other people with AD. In accordance with Harré’s social constructionist theory of self, this study aimed to describe how five people with mild and moderate AD express their Self 2 (i.e., their personal attributes and life histories) in a support group with a facilitator experienced in communicating with people with AD. The participants’ expressions of their Self 2 were analyzed with qualitative abductive content analysis and interpreted in terms of agency and communion and a lack of agency and communion. The findings highlight the importance of supporting a sense of agency and communion when assisting people with AD in constructing their self.

Encouraging lifestyle behaviour change in mild cognitive impairment patients: development of appropriate educational material

OBJECTIVES

A healthy lifestyle may help maintain cognitive function and reduce the risk of developing dementia. This study employed a focus group approach in order to gain insight into opinions of mild cognitive impairment (MCI) patients, caregivers (CG) and health professionals (HP) regarding lifestyle and its relationship with cognition. The qualitative data were used to design, develop and pilot test educational material (EM) to help encourage lifestyle behaviour change.

METHOD

Data gathering phase: structured interviews were conducted with HP (n = 10), and focus groups with MCI patients (n = 24) and CG (n = 12). EM was developed and pilot tested with a new group of MCI patients (n = 21) and CG (n = 6).

RESULTS

HP alluded to the lack of clinical trial evidence for a lifestyle and MCI risk link. Although they felt that lifestyle modifications should be recommended to MCI patients, they appeared hesitant in communicating this information and discussions were often patient-driven. MCI patients lacked awareness of the lifestyle cognition link. Participants preferred EM to be concise, eye-catching and in written format, with personal delivery of information favoured. Most pilot testers approved of the EM but were heterogeneous in terms of lifestyle, willingness to change and support needed to change.

CONCLUSION

MCI patients need to be made more aware of the importance of lifestyle for cognition. EM such as those developed here, which are specifically tailored for this population would be valuable for HP who, currently, appear reticent in initiating lifestyle-related discussions. Following further evaluation, the EM could be used in health promotion activities targeting MCI patients.

Managing memory impairment in patients with Alzheimer’s disease

SUMMARY Memory impairment in patients with Alzheimer’s disease (AD) may be treated with cholinesterase inhibitors. Attention, alertness, initiative and memory (indirectly) may be treated with memantine. In addition to pharmacologic treatments, nonpharmacologic treatments, including external systems and devices, participation in social activities and exercise, as well as the use of habits, pictures and strategies, improve memory. We believe that although memory loss cannot be halted, both pharmacologic and nonpharmacologic treatments may help to improve AD patients’ memory and allow them to continue independent activities. Patients with mild cognitive impairment due to AD may be treated with nonpharmacologic therapies and with off-label cholinesterase inhibitors.

Individualized skills training program for community-dwelling adults with mild Alzheimer's disease

The increasing incidence of Alzheimer's disease (AD) has created an enormous challenge to nurses. Nonpharmacological interventions that promote functional independence at home are vital to improving quality of life for individuals with AD and their caregivers. The purpose of this study was to explore the effectiveness of a skills training program for individuals with mild AD in the home setting. Although none of the participants achieved total independence in performing the meal task, all decreased their need for task prompting. The goal for this population may be to preserve and encourage a more functional state rather than to achieve total independence.

Model for the First NIH-funded Center of Excellence in End-of-Life Research

Centers of excellence are widely acknowledged as a mechanism to promote scientific advances in a particular field of science, but until recently there have been no end-of-life or palliative care research centers funded by the National Institutes of Health (NIH). The purpose of this article is to describe aims, framework, and organizational structure of the first NIH-funded Center of Excellence on end-of-life research, the Center for End-of-Life Transition Research (CEoLTR), and the advances in end-of-life research that the CEoLTR will facilitate. The teams of researchers involved in the CEoLTR have grown impressively since it was funded in 2007. Collectively, the teams are on target to accomplish all of the original goals for this five year award.

Evidence supporting technology-based interventions for people with early-stage Alzheimer's disease

Innovative uses of technology offer many exciting possibilities for better care and improved quality of life for people with Alzheimer's disease and their families. This article provides empirical evidence through a systematic review of 10 studies involving technological advances. Although the studies reported have a small number of participants, the early results are positive. We believe the use of technology has the potential to save health care costs, ease caregiver stress, and help people with dementia live better, safer, and more fulfilling lives.