Development of a person-centered caregiver singing model for formal caregivers of people living with dementia in South Africa

This action research study explored the co-design of a person-centered caregiver singing (PCCS) protocol and caregivers' experiences of applying the PCCS intervention with people living with dementia. Eight caregivers across two care homes participated in four iterative cycles aimed at refining the training. Qualitative data collected from semi-structed group interviews, individual interactions and researcher reflections were analysed via thematic analysis which informed the refinements to the training protocol. A Person-Centered Caregiver Singing Model was developed from the thematic findings relating to caregivers' experiences of applying the PCCS intervention: enhanced caregiver capabilities, resident's wellbeing, improved relationship, the positive ecological shift, and ease of caregiving. PCCS fostered caregivers' empathy and self-efficacy, helping them better attune to and meet the needs of people with dementia. Findings suggest music therapists could share music therapy-informed skills with caregivers for use in daily care. Further research would be beneficial to understand the relationship between live music interventions and caregivers' self-efficacy and empathy, and to explore the training barriers in South Africa.

Training formal caregivers in the use of live music interventions during personal care with persons living with dementia: a systematic mixed studies review

OBJECTIVES

To examine research on the training of formal caregivers in live music interventions within care situations with persons with dementia.

METHODS

This review was registered with PROSPERO (CRD42020196506). PubMed, PsycINFO (Ovid), MEDLINE, Discovery EBSCO, Embase, CINAHL (Complete), AMED and ProQuest Dissertations and Theses Global were searched in September 2020 and again in October 2022. English, peer-reviewed studies on formal caregivers trained in using live music when caring one-on-one with persons with dementia were included. The Mixed Methods Assessment Tool (MMAT) was employed to assess quality, and narrative synthesis with effect sizes (Hedges-g) and thematic analysis were used for quantitative and qualitative studies respectively.

RESULTS

Nine studies (four qualitative, three quantitative, two mixed methods studies) were included. Quantitative studies demonstrated significant differences for music training on outcomes measuring agitation and emotional expression. Thematic analysis yielded five themes: emotional wellbeing; mutual relationship; shifts in caregivers' experiences; care environment; and insights into person-centered care.

CONCLUSION

Training for staff in live music interventions may benefit the delivery of person-centered care by supporting communication, easing care, and capacitating caregivers to meet the needs of persons with dementia. Findings appeared context specific due to high heterogeneity and small sample sizes. Further research on quality of care and caregiver outcomes, and sustainability of training is recommended.

Using Evidence: A Nursing Assessment Protocol for Acute Geropsychiatric Patients

INTRODUCTION

The Centers for Disease Control and Prevention estimates that approximately 20% of the United States population lives with at least one mental health issue. The most common mental illnesses affecting older Americans include anxiety, cognitive, and mood disorders. These patients may exhibit behaviors indicating agitation or anxiety during necessary hospital stays that warrant de-escalation techniques and appropriate medications to help manage emergent symptoms.

AIMS

This quality improvement intervention was intended to demonstrate enhancement of the nursing assessment and reassessment of patients demonstrating symptoms of agitation and anxiety requiring intervention.

METHODS

Assessment of the established nursing practice demonstrated compromised patient safety and led to planning and implementation of a new practice standard that incorporated an evidence-based tool. Nurses utilized a protocol that employed the Pittsburgh Agitation Scale to augment documentation of the nursing assessment for patients exhibiting symptoms of marked anxiety and agitation.

RESULTS

Following a 3-month trial, chart audits were completed to assess results of the protocol's implementation. Significant improvement was noted in the nursing assessment process as evidenced in required documentation of nursing assessment and reassessment including use of the protocol.

CONCLUSIONS

Implementing standards to guide nursing care can support both patient safety and professional practice.

Nurses' decision-making related to administering as needed psychotropic medication to persons with dementia: an empty systematic review

Behavioural and psychological symptoms of dementia occur in approximately 75% of people with dementia admitted to acute care. Acute care nurses' decision-making regarding administering 'as needed' (pro re nata or PRN) psychotropic medications to persons with dementia are not well understood. This is an important clinical concern because 'as needed' medications are given at the discretion of the nurse. A comprehensive, systematic search and screen for studies that explored nurses' decision-making related to administering as needed psychotropic medication to persons with dementia in acute care settings was conducted. No studies that reported nurses' decision-making related to administration of as needed psychotropic medications to hospitalized persons with dementia were identified. In light of this, we present a discussion based on a narrative review of what is known on this topic from other settings, based on papers found in our original review. We will briefly explore what is needed in future research to address the gap in knowledge about nurse' decision-making related to administering as needed psychotropic medications. IMPLICATIONS FOR PRACTICE: Research is needed to understand and inform the decision-making process in the administration of as needed psychotropic medications to hospitalized persons with dementia.

Exploring acute care nurses' decision-making in psychotropic PRN use in hospitalised people with dementia

AIMS AND OBJECTIVES

To understand how acute care nurses make decisions about administering "as-needed" (PRN) psychotropic medications to hospitalised people with dementia (PWD).

BACKGROUND

Behavioural and psychological symptoms of dementia occur in approximately 75% of PWD admitted to acute care. Despite this, few studies provide insight into the use and prevalence of psychotropic use in acute care.

DESIGN

A qualitative descriptive design was used to explore acute care nurses' decision-making about PRN psychotropic medication administration to PWD.

METHODS

Semi-structured interviews were conducted with eight nurses from three acute care medical units in a large tertiary hospital in Western Canada. Conventional content analysis was used to develop three themes that reflect nurses' decision-making related to administering PRNs to hospitalised PWD. COREQ guidelines were followed.

RESULTS

Three themes of legitimising control, making the patient fit and future telling were developed. Legitimising control involved medicating undesirable behaviours to promote the nurses' perceptions of safety. Making the patient fit involved maintaining routine and order. Future telling involved pre-emptively medicating to prevent undesirable behaviours from escalating. Nurses provided little to no mention of assessing for physical causes contributing to behaviours. PRNs were seen as a reasonable alternative to physical restraints and were frequently used. Additionally, organisational and unit routines greatly influenced nurses' decision-making.

CONCLUSIONS

These findings provide an initial understanding of how nurses make decisions to administer PRN medications to hospitalised older people and may inform prescribing practices. There were novel findings about the lack of assessment prior to PRN administration, and the nurses' collective response in decision-making. More research is needed to better understand the complexities of nurses' decision-making, to assist in the development of interventions for nursing practice.

PRN Medicines Management for Psychotropic Medicines in Long-Term Care Settings: A Systematic Review

Many medications are prescribed and administered PRN (pro re nata, as needed). However, there are few integrative reviews to inform PRN psychotropic medication use in long-term care facilities and nursing or care homes. Accordingly, this integrative systematic review aimed to improve our understanding of PRN medicines management with a focus on psychotropic medications (antipsychotics, sedatives, anxiolytics, and hypnotics) in long-term care settings. Keywords relating to PRN in English, Norwegian, and Spanish were used, and articles published between 2009 and 2019 were retrieved. Based on the inclusion criteria, eight articles were used for data analysis and synthesis. This review offers a description of PRN prescription and administration of psychotropic medications in long-term care. Variations were observed in the management of PRN psychotropic medications based on residents’ underlying health conditions and needs, duration of use, and changes between medications and doses. Neither the reasons for PRN prescription and administration nor the steps taken to identify and manage any associated adverse reactions or adverse drug events were reported. Further initiatives are needed to improve PRN medicines management to explore factors that affect PRN prescription and administration and to develop appropriate PRN guidelines to prevent harm and improve the safety of people living in long-term care facilities.

Finding the fundamental needs behind resistance to care: Using the Fundamentals of Care Practice Process

A person living with Alzheimer's disease (PA) can experience difficulty during bodily care and therefore may show resistance to care behaviours (RTCBs). Nurses must take a clinical approach to planning care that meets the person's needs. Therefore, it is necessary to identify training strategies for bedside nurses and nursing students.

AIMS AND OBJECTIVES

To describe and discuss how the FOC practice process (FOC-PP) can help nurses understand PAs who show RTCBs during bodily care.

BACKGROUND

Resistance to care behaviour phenomenon and the importance of bodily care as fundamental care are described. The FOC-PP enables nurses to apply the FOC framework in their practice.

DESIGN

This discursive paper is based on the literature of the FOC framework and PP.

METHOD

A clinical scenario that develops through the five stages of the FOC-PP.

RESULTS

The scenario centres on Mrs. Emily Morgan, 81, who lives in a nursing home and is not receiving the bodily care that she needs. Camille, a nursing student, and her supervisor Florence collaborate with Mrs. Morgan's family to improve the quality of her care. Three particular aspects of nursing practice based on the FOC-PP are described: the critical thinking process, relational process and pedagogical process.

CONCLUSION

The FOC-PP promotes holistic care centred on the person and his or her needs and encourages the nurse to use his or her skills and knowledge. All these dimensions are fundamental for high-quality nursing care.

RELEVANCE TO CLINICAL PRACTICE

Mrs. Morgan's scenario enables us to perceive that the FOC-PP is very useful for nursing students and bedside nurses. However, given the amount of specific and diverse knowledge required by the FOC-PP, it is necessary to identify avenues for teaching them. Using clinical scenarios could facilitate the integration of the FOC-PP, with taking into account the specific characteristics of individual clients.

Patient Safety and Pro Re Nata Prescription and Administration: A Systematic Review

PRN is the acronym for 'pro re nata,' written against prescriptions whose administration should be based on patients' needs, rather than at set times. The aim of this systematic review was to explore safety issues and adverse events arising from PRN prescription and administration. Electronic databases including Scopus, PubMed [including Medline], Embase, Cinahl, Web of Science and ProQuest were systematically searched to retrieve articles published from 2005 to 2017.

SELECTION CRITERIA

we included all randomized controlled trials (RCTs) and studies with comparison groups, comparing PRN prescription and administration with scheduled administration, where safety issues and adverse events were reported. The authors independently assessed titles, abstracts and full-texts of retrieved studies based on inclusion criteria and risk of bias. Results were summarised narratively. The search identified 7699 articles. Title, abstract and full-text appraisals yielded 5 articles. The included studies were RCTs with one exception, a pre-test post-test experimental design. Patient populations, interventions and outcomes varied. Studies compared patient-controlled or routine administration with PRN and one trial assessed the effect of a practice guideline on implementation of PRN administration. More analgesia was administered in the patient-controlled than the PRN arms but pain reduction was similar. However, there was little difference in administration of psychotropic medicines. No differences between patient-controlled and PRN groups were reported for adverse events. The PRN practice guideline improved PRN patient education but non-documentation of PRN administration increased. This systematic review suggests that PRN safety issues and adverse events are an under-researched area of healthcare practice. Variations in the interventions, outcomes and clinical areas make it difficult to judge the overall quality of the evidence. Well-designed RCTs are needed to identify any safety issues and adverse events associated with PRN administration.

Antipsychotic drug use in nursing home residents with and without dementia: keep an eye on the pro re nata medication

Behavioral and psychological symptoms of dementia often lead to the prescription of antipsychotics, especially in nursing homes, but their use remains controversial. This study aimed to assess antipsychotic drug use in residents with dementia compared with those without dementia. Data were obtained through the cross-sectional 'inappropriate medication in patients with renal insufficiency in nursing homes' (IMREN) study including data from 21 nursing homes. Descriptive statistics were used and factors associated with the prescription of antipsychotics were identified by logistic regression. Overall, 57.5% of the 837 residents had a diagnosis of dementia and 47.0% of residents with dementia and 19.5% of those without dementia received antipsychotics. 35.9% of all antipsychotics in residents with dementia were prescribed as pro re nata (PRN) compared with 23.0% for residents without dementia. Typical antipsychotics were prescribed more commonly than atypical ones. The adjusted logistic regression showed a significant association between the prescription of antipsychotics and dementia (odds ratio: 3.58, 95% confidence interval: 2.45-5.25) as well as severe care dependency (odds ratio: 1.68, 95% confidence interval: 1.10-2.55). Despite safety warnings, antipsychotics are still frequently prescribed to residents with dementia. Almost half received antipsychotics and about a third of the antipsychotics are prescribed as PRN. Further studies should assess the use of PRN antipsychotics and guidelines for PRN prescriptions are clearly needed.

Impact of a Videoconference Educational Intervention on Physical Restraint and Antipsychotic Use in Nursing Homes: Results From the ECHO-AGE Pilot Study

OBJECTIVES

US nursing homes care for increasing numbers of residents with dementia and associated behavioral problems. They often lack access to specialized clinical expertise relevant to managing these problems. Project ECHO-AGE provides this expertise through videoconference sessions between frontline nursing home staff and clinical experts at an academic medical center. We hypothesized that ECHO-AGE would result in less use of physical and chemical restraints and other quality improvements in participating facilities.

DESIGN

A 2:1 matched-cohort study comparing quality of care outcomes between ECHO-AGE facilities and matched controls for the period July 2012 to December 2013.

SETTING

Eleven nursing homes in Massachusetts and Maine.

PARTICIPANTS

Nursing home staff and a hospital-based team of geriatrician, geropsychiatrist, and neurologist discussed anonymized residents with dementia.

INTERVENTION

Biweekly online video case discussions and brief didactic sessions focused on the management of dementia and behavior disorders.

MEASUREMENTS

The primary outcome variables were percentage of residents receiving antipsychotic medications and the percentage of residents who were physically restrained. Secondary outcomes included 9 other quality of care metrics from MDS 3.0.

RESULTS

Residents in ECHO-AGE facilities were 75% less likely to be physically restrained compared with residents in control facilities over the 18-month intervention period (OR = 0.25, P = .05). Residents in ECHO-AGE facilities were 17% less likely to be prescribed antipsychotic medication compared with residents in control facilities (OR = 0.83, P = .07). Other outcomes were not significantly different.

CONCLUSION

Preliminary evidence suggests that participation in Project ECHO-AGE reduces rates of physical restraint use and may reduce rates of antipsychotic use among long-term nursing home residents.

Agitation and Irritability in Alzheimer's Disease: Evidenced-Based Treatments and the Black-Box Warning

More than five million Americans suffer from Alzheimer's disease (AD), and this number is expected to triple by 2050. While impairments in cognition, particularly memory, are typically the defining features of the clinical syndrome, behavioral symptoms are extremely common, affecting up to 90% of patients. Behavioral symptoms in AD can be difficult to manage and may require a combination of non-pharmacological and pharmacological approaches. The latter is complicated by FDA "black-box warnings" for the medication classes most often used to target these symptoms, and currently there are initiatives in place to limit their use. In this review, we describe common behavioral symptoms of AD-with a particular focus on the challenging symptoms of "agitation" and "irritability"-and discuss evidence-based approaches to their management. Ultimately, multidimensional approaches must be tailored to the patient and their environment, though evidence-based practices should define the treatment of agitation and irritability in AD.