Achieving Prudent Dementia Care (Palliare): An International Policy and Practice Imperative

Implementation of the Macao dementia policy: a scoping review for the way forward

Background

The implementation of dementia policy is a complex process of translating policy goals to actions to address the changing needs of people living with dementia. Leveraging on others' experiences would help policy decision-makers and actors better prepare for the challenges.

Purpose

This study explored the development, the implementation and the impact of the dementia policy in Macao, a "role model" recognized by the Alzheimer's Disease International.

Methods

A scoping review of policies, strategies, and news articles, as well as scholarly work from 6 scientific databases dated till March 2023 was conducted under the guidance of the Health Policy Triangle Framework.

Results

According to 284 documents, the dementia policy in Macao, driven by government leadership and supported with public-private partnership, aimed to integrate health and social services to achieve the goals of "Early prevention, Early detection, Early diagnosis, Early treatment and Early support." Promoting the preparedness according to the dementia burden trajectory, empowering the public and the service providers with training and education, and encouraging services-related research were among the key actions. With major changes in dementia care configuration, a dementia service network, a dementia-friendly community and a one-stop service model for disease screening, diagnosis, treatment and support have been developed.

Discussion

Reconfiguring existing resources in the health and social services to form an integrated service network at the community level could be considered a priority of action. Continuous engagement, collaboration and empowerment at different levels across these sectors is crucial for the sustainability of a dementia policy.

A palliative care goals model for people with dementia and their family: Consensus achieved in an international Delphi study

BACKGROUND

Advance care planning in dementia includes supporting the person and their family to consider important goals of care. International research reports the importance of psycho-social-spiritual aspects towards end of life.

AIM

To develop a multidimensional international palliative care goals model in dementia for use in practice.

DESIGN

International Delphi study integrating consensus and evidence from a meta-qualitative study. The Delphi panel rated statements about the model on a 5-point agreement scale. The criteria for consensus were pre-specified.

SETTING/PARTICIPANTS

Seventeen researchers from eight countries developed an initial model, and 169 candidate panellists were invited to the international online Delphi study.

RESULTS

Panellists (107; response 63.3%) resided in 33 countries. The model comprised four main care goals: (1) Comfort ensured; (2) Control over function maintained; (3) Identity protected and personhood respected and (4) Coping with grief and loss-person and caregiver supported. The model reflects how needs and care goals change over time with the progression of dementia, concluding with bereavement support. The first version of the model achieved a consensus after which it was slightly refined based on feedback. We did not achieve a consensus on adding a goal of life prolongation, and on use of the model by people with dementia and family themselves.

CONCLUSION

A new palliative care goals model for people with dementia and their families includes relationship aspects for use by professionals and achieved a consensus among a panel with diverse cultural background. The position of life prolongation in relation to palliative care goals needs further research.

Factors Associated With Family Caregiver Burden of Home-Dwelling Patients With Advanced Dementia

OBJECTIVES

To realize patients' preferences for home death, this study aimed to identify factors associated with family caregiver burden of home-dwelling patients with advanced dementia and examine its relationship with end-of-life care treatment decisions.

DESIGN

A prospective cohort study.

SETTING AND PARTICIPANTS

Patient-family caregiver dyads enrolled in a home-based palliative care program for patients with advanced dementia, with family caregiver burden assessed using the Zarit Burden Interview (ZBI) on enrolment, were included.

METHODS

Independent variables included sociodemographic data, patients' clinical phase, symptom severity, quality of life, informal paid help availability, and community resources utilized. Dependent variable was continuous ZBI scores and ZBI scores dichotomized into <24 and ≥24 for predicting depression risk. Place of death and interventions received 2 weeks before death were also collected. Data were analyzed using multivariate linear and logistic regression.

RESULTS

From October 2014 to December 2020, a total of 377 family caregivers were assessed with ZBI. Median score was 25 (IQR 15-36), and 54.4% of them were at risk of depression. Younger family caregivers had higher ZBI scores (β = -0.22, 95% CI -0.38, -0.07), with the depression risk doubling for family caregivers aged <60 years (OR 2.13, 95% CI 1.33, 3.43). Absence of informal paid help also increased the ZBI scores (β = -9.04, 95% CI -14.86, -3.22) and depression risk (OR 2.50, 95% CI 1.03, 6.09). In addition, caregivers' ZBI scores increased with patients' neuropsychiatric symptom severity (β = 0.49, 95% CI 0.08, 0.89), and caregivers of clinically unstable patients had a higher depression risk (OR 1.80, 95% CI 1.03, 3.12). Baseline caregiver burden was not associated with treatment decisions made at the end of life.

CONCLUSIONS AND IMPLICATIONS

Younger family caregivers caring for clinically unstable patients with severe neuropsychiatric symptoms experienced greater burden without informal paid help. For end-of-life care at home in advanced dementia to be tenable, relevant national agencies and stakeholders are recommended to work collectively to support family caregivers holistically.

Designing Dementia Care Pathways to Transform Non Dementia-Friendly Hospitals: Scoping Review

People with dementia (PwD) occupy around 25% of the hospital beds. Once PwD are admitted to hospitals, their cognitive impairment is not considered in most of the cases. Thus, it causes an impact on the development of the disease becoming a stressful situation as care plans are not adapted to PwD. The aim of this study was to explore the published core elements when designing a dementia care pathway for hospital settings. A scoping review was conducted to provide an overview of the available research evidence and identify the knowledge gaps regarding the topic. This review highlights person-centered care, compassionate care and end-of-life process as some of the key elements that should integrate the framework when designing a dementia care pathway. Architectonical outdoor and indoor hospital elements have also been found to be considered when adapting the healthcare context to PwD. Findings provide information about the key points to focus on to successfully design dementia interventions in hospital environments within available resources, mostly in those contexts in which national dementia plans are in its infancy. Hospitals should transform their patients’ routes and processes considering the increasing demographic changes of people with cognitive impairment.

Developing a dementia inclusive hospital environment using an Integrated Care Pathway design: research protocol

People with dementia occupy 25% of the hospital beds. When they are admitted to hospitals their cognitive impairment is not considered in most of the cases. Some European and North American countries already have experience of implementing national plans about Alzheimer's disease and dementia. However South European countries such as Spain are in the early stages. The aim of this study is to design an Integrated Care Pathway to adapt the hospital environment and processes to the needs of people with dementia and their caregivers, generating a sense of confidence, increasing their satisfaction and protecting them from potential harmful situations. This study uses King's Fund Dementia Tool to assess the hospital environment and develop a continous improvement process. People with dementia, families, caregivers and healthcare staff will evaluate the different settings in order to provide guidance based on patient needs. Person-centred care, prudent healthcare and compassionate care are the conceptual framework of this care pathway. The implementation and evaluation of this research protocol will provide information about how to successfully design dementia interventions in a hospital environment within available resources in those contexts where dementia plans are in its infancy, as only around 15% of all states worldwide have currently designed a concise dementia national plan.

Introduction to living with advanced dementia series

This is the introductory article in a six-part series in Nursing Older People exploring the nursing care of people living with advanced dementia. It discusses the complex and progressive array of nursing required to meet the needs of individuals, the provision of personal care, learning and leadership, meaningful activity, and palliative and end of life care. A main theme of the series is the exceptional nursing skills and knowledge required to deliver evidence-informed care with compassion and respect for people living with advanced dementia. This introductory article provides background information to contextualise advanced dementia and identify the main challenges facing nurses, nurse educators and nurse leaders.

Changing needs in advanced dementia

This is the first article in a six-part series in Nursing Older People exploring the nursing care of people living with advanced dementia. This article discusses the changes that may occur as dementia progresses, from the perspective of the individual, their family and other carers. A person living with advanced dementia is likely to experience physical, cognitive and social changes that can be profound and debilitating. Healthcare needs intensify as new and co-existing issues result in increasing dependency on others for support with activities of daily living. These activities can include eating, drinking, mobility and personal care. Consequently, family carers may find their role has to develop and change to provide increasing support in response to these complex needs. These increasing needs can result in care transitions to hospitals or care homes. Careful and collaborative management of care is crucial to maintain quality of life for the person with dementia and family carers.

The relationship between frailty, functional dependence, and healthcare needs among community-dwelling people with moderate to severe dementia

This paper examines the healthcare needs of community-dwelling older people living in Porto, Portugal, diagnosed with moderate or severe dementia, linked to functional dependency, cognitive decline, limitations in the activities of daily life, and frailty levels. A sample of 83 participants was recruited. Data were collected between 2013 and 2017. A sociodemographic questionnaire, the Clinical Dementia Rating (CDR), the Barthel Index (BI), the Lawton and Brody Instrumental Activities of Daily Living (IADL) Scale, and the Edmonton Frail Scale (EFS) were used. A set of 26 healthcare needs was defined to support the assessment. The Pearson chi-square or Fisher's exact test (as appropriate) was used to examine the association of the needs (unmet and met) with the levels of dementia and frailty. Participants were diagnosed previously with moderate or severe dementia and benefited from a structured home-care program. There was a high number rated as "severe dementia," "fully dependent," "severely or fully dependent in the activities of daily living (ADL)," and "severe frailty." There were statistically significant differences among needs identified in people with moderate or severe dementia and moderate or severe frailty. The most prevalent healthcare needs in the sample were food preparation, medication/taking pills, looking after their home, toilet use, sensory problems, communication/interaction, bladder, bowels, eating and drinking, memory, sleeping, and falls prevention. In particular, the study identifies a set of needs that are present simultaneously in both frailty and dementia stages. This study underlines that despite well-structured home-care programs for people with dementia, unmet health needs remain. Timely healthcare needs assessment may help professionals to avoid fragmented care and to tailor quality-integrated interventions, including the emotional and psychological balance of the caregiver.

A cross-sectional study of family caregiver burden and psychological distress linked to frailty and functional dependency of a relative with advanced dementia

Psychological health of caregivers of people with dementia is a major public concern. This study sought to determine the relationship between caregiver burden, psychological distress, frailty and functional dependency of a relative with advanced dementia. Persons with dementia and their caregivers (102 dyads) participated in this Portuguese community based cross-sectional study. Data were collected using the Clinical Dementia Rating Scale, a sociodemographic questionnaire, the Zarit Burden Interview, the Brief Symptoms Inventory and the Edmonton Frail Scale. Alzheimer's disease was the most common type of dementia among the recipients of care, who showed moderate (42.2%) to severe (52.9%) dementia. Among them 35.3% exhibited moderate and 45.1% severe frailty. Family caregivers reported moderate (76.5%) to severe burden (18.6%). Psychological distress was very high among family caregivers. Results show that people with dementia exhibited moderate (35.3%) or severe frailty (45.1%) and that a severe frailty was found in people with moderate dementia. A one-way ANOVA was conducted between the Global Severity Index and some sociodemographic variables. ANOVA reached p < .01 for employment status of the caregiver, assistance and professional support, and psychiatric history; and p = 0.01 for caregiver age and years of caregiving. Although caregivers reported benefit from the supportive approach offered by the multidisciplinary home care team, high levels of distress and associated burden were found, which might decrease their capacity to care for the person with dementia and their own health and well-being.

The provision of accredited higher education on dementia in six European countries: An exploratory study

BACKGROUND

The World Health Organization has identified developing the knowledge and skills of healthcare professionals who are involved in dementia care as a priority. Most healthcare professionals lack the necessary knowledge, skills and understanding to provide high quality dementia care. While dementia education amongst most UK university health and social care programmes is inconsistent, we know little about the provision of dementia education in European universities.

OBJECTIVES

To examine the provision of accredited higher education on dementia in European countries, to illustrate that it is highly variable despite universities being the major provider of education for healthcare professionals internationally.

DESIGN

An exploratory research design was used.

SETTINGS

The providers of higher education undergraduate and postgraduate programmes in the Czech Republic, Portugal, Scotland, Slovenia, Spain, Sweden.

PARTICIPANTS

Higher Education Institutions who provide undergraduate and postgraduate education in the fields of nursing, medicine, psychology, social work, physiotherapy, occupational therapy, and gerontology in six European countries.

METHODS

The data was collected using a structured questionnaire. Researchers in each country conducted an internet-based search using the websites of Higher Education Institutions to identify existing accredited dementia education.

RESULTS

These searches revealed a lack of dementia education in undergraduate health and social care study programmes. Three of the six countries offered postgraduate study programmes on dementia. There was a significant variation amongst the countries in relation to the provision of dementia education at undergraduate, postgraduate and doctoral levels.

CONCLUSIONS

Dementia is a global challenge and educating and upskilling the workforce is a policy imperative. To deliver the best dementia care, investment in interprofessional evidence-based education is required if we are to respond effectively and compassionately to the needs of people living with dementia and their families. Higher Education Institutions have an important role to play in equipping health and social care professionals with the knowledge, skills and understanding to respond to this imperative.