Maturation of the MOUTh Intervention: From Reducing Threat to Relationship-Centered Care

Association between Dementia Severity and Oral Hygiene Management Issues in Older Adults with Alzheimer's Disease: A Cross-Sectional Study

Oral hygiene management issues vary across types and clinical stages of dementia. We aimed to clarify the issues related to oral hygiene management in older adults with Alzheimer's disease (AD) according to stages defined by the Functional Assessment Staging of Alzheimer's Disease (FAST). In all, 397 records (45 men and 352 women; average age, 86.8 years; age range, 65-106) from older adults with AD were used for the cross-sectional study. We used data from a cohort of older adults (≥65 years old) who required long-term care and lived in the Omorimachi area of Yokote City, Akita Prefecture, Japan. Multilevel logistic regression analysis was conducted to examine the associations of the FAST stage, set as the exposure variable, with oral hygiene management parameters set as outcome variables. Compared to the reference category (combined FAST stage 1-3), FAST stages 6 and 7 had significantly higher odds ratios for refusal of oral health care, dependence in performing oral health care, and rinsing and gargling disability. FAST stages 4 and 7 were associated with dental plaque accumulation. Oral health care for older adults with AD should be planned appropriately according to dementia severity.

Body care of older people in different institutionalized settings: A systematic mapping review of international nursing research from a Scandinavian perspective

Body care is considered a key aspect of nursing and imperative for the health, wellbeing, and dignity of older people. In Scandinavian countries, body care as a professional practice has undergone considerable changes, bringing new understandings, values, and dilemmas into nursing. A systematic mapping review was conducted with the aims of identifying and mapping international nursing research on body care of older people in different institutionalized settings in the healthcare system and to critically discuss the dominant assumptions within the research by adapting a problematization approach. Most identified papers reported on empirical research with a biomedical approach focusing on outcome and effectiveness. Conceptual papers, papers with a focus on the perspectives of the older people, or contextual and material aspects were lacking. The research field is dominated by four dominant assumptions: Body care as an evidence-based practice, body care as a relational ethical practice, the body as a body-object and a body-subject, the objects in the body care practices as nonrelational materialities. Given the complexities of professional body care practices, there is a need for other research designs and theoretical perspectives within nursing that expand our understanding of body care taking into consideration the multiple social and material realities.

Integrating oral care into nursing practice in care homes

This article details a narrative review that explored the barriers to and facilitators of integration of oral care into nursing practice in care homes to enhance nurses' delivery of oral care. Three themes were identified: gaps in oral care protocols and the complexity of nursing oral care; how interprofessional collaboration and education can improve oral care; and limitations and unresolved issues in nurses' oral care training. The review found that interprofessional collaboration and education were important in normalising oral care practice and nurse leadership in care homes. Nurse-led interprofessional oral care could enhance the quality of care in care homes by advancing interprofessional collaboration and education, coordinating care and improving organisational support.

Dementia and dignity of identity: A qualitative evidence synthesis

In the late stages of dementia, individuals rely on others for their wellbeing and this creates an ethical imperative for responsive dementia care. Through a qualitative evidence synthesis of literature on what constitutes responsive dementia care, we identified dignity of identity as a central theme. Dignity of identity is the status each of us holds in relation to others and reflects our past experiences and our aspirations for the future. We did a qualitative evidence synthesis of 10 qualitative studies conducted with a total of 149 research participants, 95 of whom had dementia, and 54 of whom were paid and family member caregivers to people with dementia. Using "new materialism disability studies" as our theoretical framework, we illustrate how environments, both material and discursive, shape the abilities of people with dementia in residential care settings (RSCs) to live well and we use our findings to point to ways forward in dignity of identity-enhancing dementia care practice. Echoing the literature, we observe that people with dementia have the virtual capacity to live with dignity of identity and illustrate how material conditions and discourse influence the transition of dignity of identity in people with dementia from a virtual capacity to an actual capacity and how demonstrated capacity in turn influences material conditions and discourse surrounding care for people with dementia in RSCs. We call for a greater acknowledgement within literature on dignity and dementia of structural barriers to dignity of identity-enhancing care. The COVID-19 pandemic has shown us the fatal consequences of insufficient material conditions in RCSs and we hope that on a societal level there is improvement to both the material conditions in RCSs as well as an improvement in discourse about those who live and work in RCSs.

Behaviors of care providers and resistiveness to oral care of persons living with dementia

Since care providers' behavior could be related to resistiveness to care (RTC) among persons living with dementia, developing care providers' behavioral strategies to reduce or prevent RTC is required. This study examined whether care providers' person-centered or task-centered behaviors were related to RTC. A secondary data analysis was conducted using 70 videos of 23 persons living with dementia who received routine oral care in long-term care settings. Data were analyzed using linear mixed models. Among task-centered behaviors, "physically controlling" significantly increased RTC. For person-centered behaviors, "cooperatively negotiating" increased RTC, while "assessing comfort" decreased RTC. Care providers need to consider the comfort or needs of persons living with dementia rather than physically controlling them in oral care situations. These findings may offer insight into the context of RTC occurrences to provide more comfortable oral care for persons living with dementia.

Mouth Care in Assisted Living: Potential Areas for Improvement

BACKGROUND

Poor oral care may lead to systemic disease, and there is evidence that assisted living (AL) residents lack quality oral care; in AL, poor care may be due to staff knowledge and attitudes, as well as organizational barriers to providing care.

OBJECTIVES

Determine AL staff knowledge and attitudes regarding mouth care and barriers to changing care.

DESIGN

Self-administered repeated-measures questionnaires completed before and after oral care training.

SETTING AND PARTICIPANTS

A total of 2012 direct care staff and administrators from 180 AL communities.

METHODS

Nine knowledge questions and 8 attitude and practice intention questions, and open-ended questions regarding training and obstacles to providing oral care.

RESULTS

Overall, 2012 participants completed pretraining questionnaires, and 1977 completed posttraining questionnaires. Baseline knowledge was high, but staff were not uniformly aware of the systemic-oral link whereby mouth care affects pneumonia and diabetes. Almost all staff reported learning a new technique (96%), including for residents who resist care (95%). Suggested areas to improve mouth care included having more hands-on experience. The primary perceived obstacles to care centered around residents who resist care and a lack of time.

CONCLUSIONS AND IMPLICATIONS

Based on reports of having benefitted from training, AL staff overwhelmingly noted that new knowledge was helpful, suggesting the benefit of skills-based training, especially in dementia care. Mouth care in AL has been sorely understudied, and merits additional attention.

What is it about carer-led oral hygiene interventions for people with intellectual disabilities that work and why? A realist review

OBJECTIVES

To undertake a realist review of carer-led oral hygiene interventions for people with intellectual disabilities. This was run parallel with a Cochrane Review.

METHODS

Realist review methods were followed. This was characterized by an iterative process of developing and refining theories of how interventions might work, expressed as context-mechanism-outcome configurations. The steps included identifying candidate theories with local and international expert consultation before applying an iterative search strategy. Selection criteria were applied for screening of the abstracts and 10% of the included full texts were screened by the three review members, independently, to ensure adherence to the criteria. Data were extracted in NVivo and synthesized qualitatively to confirm, refute or refine theories about what works, why, in what circumstances and for whom.

RESULTS

Of the 697 potential sources, 112 studies progressed to full-text screening, and 58 of those were included in the review. These 58 studies found evidence to support six theories about carer-led oral hygiene interventions for people with intellectual disabilities, from a starting point of ten candidate theories. This realist review found evidence to support the contention that, in order for carer-led oral hygiene interventions for people with ID to succeed, there is a need for adequate resources and a system-level approach; involving carers in design and implementation; tailoring of training to suit carers' needs and work environments; clearly stating how interventions are expected to work; specifying goals with achievable steps for carers to follow; providing carers with support and feedback on their efforts; acknowledging the physical and emotional toll caring for people with intellectual disabilities has on the well-being of carers; and repeating training.

CONCLUSIONS

The theories from this realist review will direct future interventions by suggesting the mechanisms and contexts that are important to achieve the intended outcome of improved oral health for people with intellectual disabilities. These are, of course, propositions intended for testing, rather than proven. The parallel use of Cochrane and realist methods provides a unique richness to our hypothesis of what works, for whom, when and how.

Implementation of an Evidence-Based Oral Care Protocol to Improve the Delivery of Mouth Care in Nursing Home Residents

The current project assessed the oral health of residents in a long-term care (LTC) facility, implemented a new evidence-based oral care protocol, and trained nursing staff about oral hygiene for older adults. A pre-/post-intervention design was used to measure knowledge, skills, and attitudes among 29 staff members. The oral health outcomes of 10 LTC residents without dysphagia were assessed after 14 days of protocol use. Knowledge improved from a mean total pre-test score of 88.8 to a mean total post-test score of 97.7 (Z = -2.308, p = 0.021). The Oral Health Assessment Tool measured oral health outcomes at three time points in 10 older adults, and statistically significant improvement in oral health was identified (p = 0.001). Nursing home staff play an important role in improving oral hygiene of older adults in LTC facilities by routinely using an easy to follow oral health protocol twice daily. [Journal of Gerontological Nursing, 46(5), 33-39.].

Description of Process and Content of Online Dementia Coaching for Family Caregivers of Persons with Dementia

Family caregivers of persons with dementia encounter resistance to care behaviors (RCBs). The purpose of this methods paper was to describe the process and content of six weekly 60-min caregiver coaching sessions delivered synchronously through an online platform to 26 family caregivers of persons with dementia. All session notes were analyzed for process; two coaching sessions from five purposely-selected participants were transcribed and analyzed thematically for content. The six sessions followed an overall pattern. The first session included the most teaching and goal-setting; the coaches also queried the family caregiver about the premorbid personality, work history, and interpersonal attributes of the person with dementia. Sessions two through five were the most active coaching sessions; previously suggested strategies were evaluated and tailored; caregivers also role-played with the coaches and developed scripts designed to curtail RCB. The sixth session served as a review of successful caregiver strategies and concluded the coaching relationship. Four primary content themes emerged in the coaching process: (1) education; (2) caregiver communication; (3) affirmation of the caregiver; and (4) individualized strategies. These four content categories were used throughout the coaching process and were interwoven with each other so that the participant knew why the behavior was occurring, how to verbally address it, how to use a strategy effectively, and affirmation of the result. The coaching process and content demonstrated alignment with person-centered practices and relationship-centered care.

Randomised clinical trial: Efficacy of strategies to provide oral hygiene activities to nursing home residents with dementia who resist mouth care

OBJECTIVES

The purpose of this study was to test the efficacy of MOUTh (Managing Oral Hygiene Using Threat Reduction), a nonpharmacologic, relationship-based intervention vs. control on 2 primary outcomes for nursing home (NH) residents with dementia who resisted mouth care: (i) reduction in the occurrence and intensity of care-resistant behaviours (CRBs) and (ii) improvement in oral health. Two secondary outcomes were also examined: (i) the duration of mouth care and (ii) the completion of oral hygiene activities.

BACKGROUND

Persons with dementia who exhibit CRBs are at risk for inadequate mouth care and subsequent systemic illnesses.

MATERIALS AND METHODS

The study used a randomised repeated measures design. Recruitment occurred in 9 nursing homes that varied in size, ownership, reimbursement patterns and location. One hundred and one nursing home residents with dementia were randomised at the individual level to experimental (n = 55) or control groups (n = 46). One hundred participants provided data for the analyses.

RESULTS

Compared to the control group, persons in the experimental group had twice the odds of allowing mouth care and completing oral hygiene activities; they also allowed longer duration of mouth care (d = 0.56), but showed only small reductions in the intensity of CRBs (d = 0.16) and small differential improvements in oral health (d = 0.18).

CONCLUSION

The data suggest that this intervention facilitates mouth care among persons with dementia. The management of refusal behaviour may be a clinically more realistic approach than reducing or eradicating refusals.

Effective strategies to motivate nursing home residents in oral care and to prevent or reduce responsive behaviors to oral care: A systematic review

BACKGROUND

Poor oral health has been a persistent problem in nursing home residents for decades, with severe consequences for residents and the health care system. Two major barriers to providing appropriate oral care are residents' responsive behaviors to oral care and residents' lack of ability or motivation to perform oral care on their own.

OBJECTIVES

To evaluate the effectiveness of strategies that nursing home care providers can apply to either prevent/overcome residents' responsive behaviors to oral care, or enable/motivate residents to perform their own oral care.

MATERIALS AND METHODS

We searched the databases Medline, EMBASE, Evidence Based Reviews-Cochrane Central Register of Controlled Trials, CINAHL, and Web of Science for intervention studies assessing the effectiveness of eligible strategies. Two reviewers independently (a) screened titles, abstracts and retrieved full-texts; (b) searched key journal contents, key author publications, and reference lists of all included studies; and (c) assessed methodological quality of included studies. Discrepancies at any stage were resolved by consensus. We conducted a narrative synthesis of study results.

RESULTS

We included three one-group pre-test, post-test studies, and one cross-sectional study. Methodological quality was low (n = 3) and low moderate (n = 1). Two studies assessed strategies to enable/motivate nursing home residents to perform their own oral care, and to studies assessed strategies to prevent or overcome responsive behaviors to oral care. All studies reported improvements of at least some of the outcomes measured, but interpretation is limited due to methodological problems.

CONCLUSIONS

Potentially promising strategies are available that nursing home care providers can apply to prevent/overcome residents' responsive behaviors to oral care or to enable/motivate residents to perform their own oral care. However, studies assessing these strategies have a high risk for bias. To overcome oral health problems in nursing homes, care providers will need practical strategies whose effectiveness was assessed in robust studies.

Revising the Resistiveness to Care Scale

BACKGROUND AND PURPOSE

The Resistiveness to Care Scale for Dementia of the Alzheimer's Type was developed to quantify care-resistant behavior. The purpose of this article is to explain how the instrument was modified and tested in two clinical studies that examined interventions to improve the oral hygiene of persons with dementia who resist care.

METHODS

After pilot testing, the revised instrument (RTC-r) was used in 7 facilities (N = 83 residents). Systematic training procedures were implemented to preserve reliability.

RESULTS

Clinical validity was confirmed throughout the pilot and interventional studies. Reliability was assessed using inter-rater reliability, which ranged from 0.87 (p < .001) to 1.0 (p < .001) across 2,328 mouth care observations.

CONCLUSIONS

The RTC-r validly and reliably measures care-resistant behavior in persons with dementia.