PROTOCOL: Factors influencing the implementation of non-pharmacological interventions for behaviours and psychological symptoms of dementia in residential aged care homes: A systematic review and qualitative evidence synthesis

This is a protocol for a Cochrane Review. The objectives are as follows. This paper aims to describe a protocol for a systematic review that will synthesise the qualitative evidence regarding factors influencing the implementation of non-pharmacological interventions (NPIs) for behavioural and psychological symptoms of dementia (BPSD) management in residential aged care homes (RACHs). The planned systematic review aims to answer the research question: 'What are the factors influencing the implementation of NPIs in the management of BPSD at RACHs?'. Additionally, the planned systematic review also aims to generate recommendations to guide stakeholders (e.g., clinicians and aged care staff) and policymakers in the implementation of NPIs for managing BPSD at RACHs.

Residential aged care staff perceptions and responses towards neuropsychiatric symptoms: a mixed methods analysis of electronic healthcare records

OBJECTIVES

To investigate electronic care notes to better understand reporting and management of neuropsychiatric symptoms (NPS) by residential aged care (RAC) staff.

METHODS

We examined semi-structured care notes from electronic healthcare notes of 77 residents (67% female; aged 67-101; 79% with formal dementia diagnosis) across three RAC facilities. As part of standard clinical practice, staff documented the NPS presentation and subsequent management amongst residents. Using a mixed-method approach, we analyzed the type of NPS reported and explored care staff responses to NPS using inductive thematic analysis.

RESULTS

465 electronic care notes were recorded during the 18-month period. Agitation-related behaviors were most frequently reported across residents (48.1%), while psychosis (15.6%), affective symptoms (14.3%), and apathy (1.3%) were less often reported. Only 27.5% of the notes contained information on potential causes underlying NPS. When faced with NPS, care staff responded by either providing emotional support, meeting resident's needs, removing identified triggers, or distracting.

CONCLUSION

Results suggest that RAC staff primarily detected and responded to those NPS they perceived as distressing. Findings highlight a potential under-recognition of specific NPS types, and lack of routine examination of NPS causes or systematic assessment and management of NPS. These observations are needed to inform the development and implementation of non-pharmacological interventions and care programs targeting NPS in RAC.

Supplemental data for this article is available online at https://doi.org/10.1080/13607863.2022.2032597 .

Korean Family Caregivers' Experiences With Managing Behavioral and Psychological Symptoms of Dementia: Keeping Harmony in Daily Life

Behavioral and psychological symptoms of dementia (BPSD) are symptoms of dementia that family care-givers find difficult to manage. Competence in managing BPSD differs according to individual family caregiver. The current study investigated the competence in managing BPSD, focusing on family caregivers who were recognized as managing them well. Twenty-four Korean family caregivers (83% female, mean age = 67 years) living with persons with dementia (PWD) were interviewed. Four themes were derived from the content analysis: Entering and Looking into the World of PWD, Keeping Daily Life in Harmony With BPSD, Becoming an Expert in BPSD, and Balancing Between Caregiving and Myself. Family caregivers minimized the impact of BPSD and maintained life balance. As a result, they were able to continue a harmonious life with PWD. [Research in Gerontological Nursing, xx(x), xx-xx.].

Implementation of the Evidence Integration Triangle for behavioral and psychological symptoms of dementia (EIT-4-BPSD) in care communities

BACKGROUND

Federal regulations stipulate that behavioral interventions be used for behavioral and psychological symptoms of distress in dementia (BPSD). Care community staff have difficulty implementing these approaches.

PURPOSE

This study tested an implementation strategy, the Evidence Integration Triangle for BPSD (EIT-4-BPSD), for assisting staff in the use of evidence-based behavioral approaches for BPSD.

METHODS

About 55 care communities were randomized to EIT-4-BPSD or usual care; 553 residents were enrolled. The implementation strategy was delivered by research facilitators, staff, stakeholders, and champions over 12 months. It involved four components: Environment and policy assessments; Staff education; Establishment of person-centered care plans; and Mentoring and motivating staff. The implementation strategy was evaluated using the Reach, Effectiveness, Adoption, Implementation, Maintenance model.

FINDINGS

There was no evidence for resident or care community effectiveness. There was evidence of adoption and implementation.

DISCUSSION

EIT-4-BPSD was helpful as an implementation strategy and staff altered how care was provided.

Pilot Study of a Digital Screen-Based Calming Device for Managing Resistance During Morning and Evening Care of Persons With Dementia

Resistance to care is among the most common behaviors exhibited by persons with dementia (PwD). Resistance to care is a barrier to safety and comfort of PwD and caregivers. Nonpharmacological interventions are recommended as first-line management. In the current study, 13 long-term care (LTC) residents aged 74 to 100 years with a history of behavioral and psychological symptoms of dementia (BPSD) were randomized to intervention (n = 7) and control (n = 6) groups. On Days 1 to 3, the intervention group received usual care plus exposure to MindfulGarden (MG), a novel digital calming device during morning and evening care, activities widely recognized as problematic for PwD and staff; the control group received usual care only. On Day 4, both groups were exposed to MG with verbal prompting. Trends in the data suggest that MG reduced BPSD and duration of care in the morning and may be a useful tool in management of resistance to routine care in PwD in LTC settings. [Journal of Gerontological Nursing, 47(11), 15-21.].

Entry and Passage Variables Associated with Nursing Home Adjustment in Older Adults with Dementia

A theory-guided non-experimental, descriptive, correlational design was used to evaluate how entry and passage variables were related to nursing home adjustment for individuals with dementia. Older adults with dementia may be unable to speak for themselves, therefore proxy responses of Certified Nursing Assistants (CNAs) provided the data for completion of the Nursing Home Adjustment Scale.¹ Guided by the Meleis' Theory of Transitions, entry level factors (i.e. age, previous residence, gender, and choice), and passage variables (i.e. length of stay, extent of dementia, functional abilities, and depression) were entered into a regression equation as predictors of nursing home adjustment. Information about extent of dementia, functional abilities and depression was derived from the Minimum Data Set (MDS) maintained for all residents per Medicare and Medicaid guidelines. Descriptive and inferential statistics were calculated using IBM Statistical Package for the Social Sciences (SPSS) 26.0 software. Results indicated an inverse relationship between nursing home adjustment and depression as measured by the PHQ-9. There was no support for relationships among other variables. CNA proxy responses were found to be reliable in that they were significantly correlated with nursing responses on the same measure. This study supports the use of CNA proxy responses as a method to evaluate the experience of individuals with dementia.

A proposal for a novel approach to reduce burdens of care for people with dementia: A hypothesis

Cognitive impairment of dementia patients affects their ability to communicate and cooperate with care. Dementia patients need a specialized communication to increase their cooperation during daily care and a scale to measure cooperation with care. To improve communication, we created and applied a digital communication platform (DCP) in an observational study. To measure cooperation with care, we created and tested psychometric properties of the Cooperation with Care Scale-Revised (CWCS-R) in an institutional review board-approved 6-week prospective study. DCP intervention was associated with decreased agitation and use of psychotropic medications for nursing home (NH) dementia patients. CWCS-R is both a reliable and valid tool to measure cooperation with care in NH dementia patients. Innovations in communication with dementia patients and a scale to measure cooperation with care could reduce burdens of care and improve quality of life for patients, their family members, and staff. It may potentially help decrease cost of dementia care.

The Columbia Behavior Scale for Dementia (CBS-8): Validity and Reliability of a Rapidly Administered New Instrument for Dementia-Related Behaviors in Long-Term Care Settings

We developed and evaluated the psychometric properties of the Columbia Behavior Scale for Dementia (CBS-8), a rapid instrument that assesses positive symptoms, to enhance behavioral and psychological symptoms of dementia (BPSD) assessment and treatment in long-term care. Psychometric analyses were performed on CBS-8 data from residents (N = 350, age ≥50 years) in 47 Maryland long-term care facilities referred for neurocognitive and mood evaluation. The CBS-8 demonstrated acceptable internal consistency (α = 0.78) and strong interrater reliability (intraclass correlation coefficient = 1.00). CBS-8 scores were correlated with greater cognitive impairment severity (r = -0.34). The diagnosis of dementia with behavioral disturbance had higher CBS-8 scores than other dementia types (e.g., vascular, unspecified) (p < 0.001, η² = 0.40). Three CBS-8 factors-motor disinhibition, aggression, and psychosis-explained 65% of the variance in overall BPSD. The CBS-8 could enhance BPSD tracking and treatment, strengthen interdisciplinary collaboration, and aid nursing homes in meeting regulations on unnecessary medication use. [Research in Gerontological Nursing, 14(3), 160-168.].

DEMENTIA IN INSTITUTIONALIZED ELDERLY: A NURSING TEAM’S EXPERIENCES AND PERCEPTIONS

ABSTRACT Objective: to understand nursing workers' experiences with the nursing care provided to elderly individuals with dementia living in a long-term care facility. Method: comprehensive qualitative study conducted in a long-term care facility located in Joinville, Santa Catarina, Brazil, from July to September 2018. Thirteen nursing technicians and one nurse participated. Data were collected using questionnaires, field diaries, individual interviews, and participatory observation. Thematic content analysis was used to interpret content. Results: three themes emerged from data analysis: "Knowledge acquired with practice and gap existing in the care provided to institutionalized elderly individuals with dementia"; "Individualized care provided to elderly individuals and bonding"; and "Conflicts the nursing staff faces when reconciling care needs, the time available, and the facility's routines". These themes originated the central theme: Meanings assigned to the nursing care provided to institutionalized elderly individuals with dementia. By sharing information regarding care actions that obtained positive results, the staff perceived the importance of an individualized approach and of establishing bonds as a therapeutic process. Gaps were identified in the professionals' knowledge regarding how to provide hygiene care when individuals become aggressive, agitated, or resist care. Conclusion: health workers' experience is a source of evidence for evidence-based practice and is also essential to fill in existing gaps between knowledge and care delivery.

DEMENTIA IN INSTITUTIONALIZED ELDERLY: A NURSING TEAM’S EXPERIENCES AND PERCEPTIONS

ABSTRACT Objective: to understand nursing workers' experiences with the nursing care provided to elderly individuals with dementia living in a long-term care facility. Method: comprehensive qualitative study conducted in a long-term care facility located in Joinville, Santa Catarina, Brazil, from July to September 2018. Thirteen nursing technicians and one nurse participated. Data were collected using questionnaires, field diaries, individual interviews, and participatory observation. Thematic content analysis was used to interpret content. Results: three themes emerged from data analysis: "Knowledge acquired with practice and gap existing in the care provided to institutionalized elderly individuals with dementia"; "Individualized care provided to elderly individuals and bonding"; and "Conflicts the nursing staff faces when reconciling care needs, the time available, and the facility's routines". These themes originated the central theme: Meanings assigned to the nursing care provided to institutionalized elderly individuals with dementia. By sharing information regarding care actions that obtained positive results, the staff perceived the importance of an individualized approach and of establishing bonds as a therapeutic process. Gaps were identified in the professionals' knowledge regarding how to provide hygiene care when individuals become aggressive, agitated, or resist care. Conclusion: health workers' experience is a source of evidence for evidence-based practice and is also essential to fill in existing gaps between knowledge and care delivery.

Calming the Agitated Patient: Providing Strategies to Support Clinicians

Agitation is a symptom of many medical and psychiatric disorders that can manifest along a spectrum of severity. Agitation often delays treatment onset, potentially impacting morbidity and mortality, and may require emergency interventions. Management of acute agitation centers around three main goals: early recognition and treatment of the underlying etiology, rapid control of the behavior, and prevention of harm to the patient and personnel. Nurses should increase use of validated techniques, including frequent and sufficient reality orientation, validation therapy, and strategies that improve the individual's quality of life.

Gender differences in presentation and management of behavioral and psychological symptoms associated with dementia among nursing home residents with moderate to severe dementia

Lack of identification and management of behavioral and psychological symptoms of dementia (BPSD) can negatively impact female residents. The purpose of this secondary data analysis was to explore gender differences in presentation and management of BPSD and quality of interactions between residents and staff. A total of 553 residents from 55 nursing homes were included. Males exhibited more apathy and sexually inappropriate behavior and females exhibited more anxiety and sadness. Anxiety and sexually inappropriate behavior were more likely to be addressed in care plans for males than females. There was no difference in how staff interacted with males or females.

The Quality of Interactions Between Staff and Residents With Cognitive Impairment in Nursing Homes

BACKGROUND

Positive and effective staff-resident interactions are imperative to adequately assess and meet the needs of cognitively impaired residents in nursing homes and optimize their quality of life.

AIM

The purpose of this study was to quantify, describe, and analyze the interaction between staff and cognitively impaired residents in nursing homes, using the Quality of Interaction Schedule (QuIS).

METHOD

This descriptive analysis utilized baseline data from the first 2 cohorts in a randomized clinical trial including 341 residents from 35 nursing homes.

RESULTS

Five hundred fifty-six staff-resident interactions were evaluated; majority were positive (n = 466, 83.8%) and the remaining were either neutral (n = 60, 10.8%) or negative (n = 30, 5.4%). The quality of interactions varied by interaction location, interpersonal distance, and resident participation.

CONCLUSION

Future research should focus on decreasing the negative/neutral interactions and explore staff characteristics (eg, gender, level of experience) and facility factors (eg, size, ownership) that might influence the quality of interactions.

Reducing Psychotropic Drug Use in Nursing Homes in Belgium: An Implementation Study for the Roll-Out of a Practice Improvement Initiative

BACKGROUND AND OBJECTIVE

Psychotropic drug use is high in nursing homes in Belgium. A practice improvement initiative (including education, professional support and the transition towards person-centred care) achieved significant reductions in psychotropic drug use. The initiative outline was transcribed into a general intervention template, and consequently implemented in five nursing homes (in mixed locations and with a mixed character) in preparation for a future broader roll-out in Belgium. The impact of the intervention on the use of psychotropic drugs in these five nursing homes is reported in this paper.

METHODS

The general intervention template was fitted into the individual nursing home setting. Education for the nursing home personnel on psychotropic drugs and non-pharmacological alternatives, as well as details for a transition to person-centred care was provided. Psychotropic drug use was recorded using a dynamic cohort study design with cross-sectional observations (November 2016-November 2017).

RESULTS

At baseline, participants' (n = 677) mean age was 85.6 years (range 54-109 years), with 72.6% female. Mean medication intake was 8.5 (range 1-22), predominantly central nervous system drugs (Anatomic Therapeutic Chemical classification N, 88.8%). Long-term (> 3 months) psychotropic drug use (62.0%) and concomitant psychotropic drug use (31.5% taking two or more medications) were high. After 12 months, the prevalence of long-term psychotropic drug use decreased significantly (from 62.0 to 52.9%, p < 0.001), likewise the combined use of psychotropic drugs (from 31.5 to 24.0%, p = 0.001). The decrease in the prevalence of antidepressant and hypnosedative use was significant (respectively, from 32.2 to 23.4%, p < 0.001, and from 35.3 to 28.7%, p = 0.006) in contrast to antipsychotic use (from 17.1 to 15.9%, p = 0.522).

CONCLUSIONS

The stand-alone adaptation of the previously reported initiative using a general template was possible. This intervention resulted in a significant decrease in psychotropic drug use (predominantly hypnosedatives and antidepressants) among nursing home residents after 12 months.

Understanding Frontotemporal Disease Progression and Management Strategies

Dementia is defined as loss of intellectual functions, including thinking, remembering, and reasoning. Cognitive deficits are severe enough to interfere with an individual's daily functioning. Frontotemporal dementia (FTD) is a result of degeneration of the frontal and/or temporal lobes of the brain. FTD is a leading cause of early-onset dementia in approximately 10% of dementia cases. FTD presents in the fourth and fifth decades as progressive changes in personality, affect, and behavior. The etiology of FTD is unknown; treatment focuses on behavioral and symptom management. Early recognition of FTD and knowledge of interventional strategies are needed to support families and caregivers.

Reliability and Validity of the Care Plan Checklist for Evidence of Person-Centered Approaches for Behavioral and Psychological Symptoms Associated With Dementia

PURPOSE

The purpose of this study was to test the reliability and validity of the Care Plan Checklist for Evidence of Person-Centered Approaches for Behavioral and Psychological Symptoms Associated with Dementia (BPSD).

METHODS

This study used baseline data from the first cohort of a larger randomized clinical trial testing the implementation of the Evidence of Integration Triangle for BPSD. Fourteen settings volunteered to participate, 8 from Maryland and 6 from Pennsylvania, and a total of 137 residents were recruited. In addition to completing the Care Plan Checklist for Evidence of Person-Centered Approaches for BPSD, assessments of depressive symptoms (Cornell Scale for Depression in Dementia), resistiveness to care (Resistiveness to Care Scale), and agitation (Cohen-Mansfield Agitation Inventory) were also completed on each participant. Reliability was tested based on evidence of internal consistency and inter-rater reliability. Construct validity was tested using a Rasch measurement model to determine item fit and hypothesis testing using bivariate correlations. Item mapping was also performed.

RESULTS

The majority of the sample was female (69%), Caucasian (69%), non-Hispanic (98%), and not married (78%). The mean age of the sample was 82.01 years (standard deviation = 11.44). There was evidence of reliability based on internal consistency with a Cronbach alpha of 0.96 and inter-rater reliability with correlations between 2 evaluators of r = 0.93, P = .001. There was evidence of validity of the scale based on item fit as the infit statistics and outfit statistics were all within the acceptable range with the exception of the outfit statistic for the item focused on sexually inappropriate behaviors. Lastly, there was evidence of significant relationships between the Care Plan Checklist for Evidence of Person-Centered Approaches for BPSD and the Cornell Scale for Depression in Dementia (r = 0.38, P < .001) and the Cohen-Mansfield Agitation Inventory (r = 0.44, P < .001). There was not a significant relationship between resistiveness to care and scores on the Care Plan Checklist for Evidence of Person-Centered Approaches for BPSD (r = -0.02, P = .86). There were 78 care plans that were so low in evidence of using appropriate interventions that they could not be differentiated.

CONCLUSIONS

There was sufficient evidence for the reliability and validity of the Care Plan Checklist for Evidence of Person-Centered Approaches for BPSD. Additional items should be considered to better differentiate those low on the Checklist for Evidence of Person-Centered Approaches for BPSD.