Cognitive interventions in patients with dementia living in long-term care facilities: Systematic review and meta-analysis

BackgroundPrevious reviews and meta-analyses demonstrated effects of cognitive interventions in dementia, but none specifically considered residents with dementia in long-term care (LTC) facilities.ObjectiveTo analyse the efficacy of cognitive interventions in institutionalised individuals with dementia.MethodsAfter identifying 27 articles, a systematic review was performed. A meta-analysis was calculated for 15 studies of the randomized controlled trials regarding effects on relevant outcomes. Fixed-effects meta-analyses were conducted using standardized mean differences (SMD) of changes from baseline pooled using the inverse variance method.ResultsWhen comparing cognitive interventions to passive control groups, the meta-analysis revealed significant moderate effects on global cognition (SMD = 0.47, 95% CI 0.27–0.67), autobiographical memory (0.67, 0.02–1.31), and behavioral and psychological symptoms in dementia (BPSD; 0.71, 0.06–1.36). Significant small effects were detected for quality of life (QoL; 0.37, 0.05–0.70). Moderate effects on activities of daily living (0.28; −0.02 to 0.58) failed to reach significance; no effects were found on depression (0.22; −0.08 to 0.51). Significant moderate effects of global cognition (0.55; 0.22–0.89) and depression (0.64; 0.21–1.07) were also found for cognitive interventions contrasting active control groups. No harmful events related to the participation in the interventions were observed.ConclusionCognitive interventions are safe and effective for residents with dementia in LTC. However, while it seems clear that cognitive benefits can specifially be assigned to these forms of intervention, further research is necessary to clarify whether the effects on BPSD and QoL reflect unspecific changes due to additional attention. Furthermore, future studies will have to determine which intervention type yields the largest benefits.     

End-of-life care in assisted living and related residential care settings: comparison with nursing homes

OBJECTIVES: To define the current state of end-of-life care in residential care/assisted living (RC/AL) facilities and nursing homes (NHs) and to compare these two types of care settings. DESIGN: Interviews of staff and family informants about deaths that occurred during a longitudinal study. SETTING: Fifty-five RC/AL facilities and 26 NHs in Florida, Maryland, New Jersey, and North Carolina. PARTICIPANTS: Two hundred twenty-four staff and family informants that best knew the 73 RC/AL residents and 72 NH residents who died in or within 3 days after discharge from a study facility. MEASUREMENTS: Telephone interviews conducted with the facility staff member who knew the decedent best and the family member who was most involved in care during the last month of life of the decedent. Data were collected on circumstances of death, perceptions of dying process, cause of death, care during the last month of life, mood, discomfort, and family satisfaction. RESULTS: Most decedents died in the facility where they had resided, and more than half of the subjects were alone when they died. Greater proportions of staff and family in the NHs knew that the resident's death was only days or weeks away. Both RC/AL and NH residents experienced few highly negative moods, and even on their most uncomfortable day, the overall discomfort was low for residents in both facility types. Summary ratings of family satisfaction were significantly higher for the RC/AL (32.1) than the NH (41.2) group (P=.016). CONCLUSION: These data suggest that end-of-life care in RC/AL settings appears similar in process and outcomes to that provided in NHs. Thus, aging and dying-in-place can effectively occur in RC/AL.     

Under-detection of pain in elderly nursing home residents with moderate to severe dementia

Background/PurposeElderly patients who are cognitively impaired tend to have a decreased ability to communicate and report pain, which results in the under-detection and under-treatment of pain. This study aimed to describe the prevalence of pain in elderly patients with moderate to severe dementia who were residing in nursing homes and to determine the factors associated with pain.MethodsElderly patients older than 60 years of age with Mini-mental State Examination (MMSE) scores of <20 who were resident in three selected nursing homes were recruited. Demographic data and comorbidity were recorded. Information about treatment with analgesic drugs, physical restraints, the presence of depression, and behavioral disturbances was collected from medical records and from health care workers. Pain was assessed using the Chinese version of the Pain Assessment in Advanced Dementia Scale (PAINAD-C).ResultsA total of 309 residents with a mean ± SD age of 85 ± 7.5 years and a mean ± SD MMSE score of 9.6 ± 6.3 were included in the study. A total of 61.5% (190) of patients experienced pain as defined by a PAINAD-C score of ≥2. Only 30.7% (95) of patients were treated with analgesic drugs. Univariate analysis showed that a lower MMSE score, male sex, poor mobility level, treatment with psychotropic drugs, use of physical restraints, presence of physical aggression, and being uncommunicative were associated with pain. The major factors associated with pain were the use of physical restraints [odds ratio (OR) 3.1], the presence of physical aggression (OR 2.55), male sex (OR 2), and poor MMSE score (OR 0.94).ConclusionPain is highly prevalent among nursing home residents with moderate to severe dementia and is associated with the use of restraints. However, only half of the patients in this study were treated with analgesic drugs. An improvement in the caregivers' knowledge of pain assessment together with the provision of adequate treatment for pain is necessary in the care of these groups of patients with dementia.     

Factors influencing quality of life of elderly people with dementia and care implications: A systematic review

BackgroundIdentifying factors associated with Quality of Life (QoL) of elderly people with dementia could contribute to finding pathways to improve QoL for elderly people in dementia.AimThis paper systematically reviews all possible factors that influence QoL of elderly people with dementia, identifies how these factors are different by different stages of dementia and living settings, and explores how the influencing factors could be perceive differently by elderly people with dementia, family members, and caregivers.MethodPubMed, PsycINFO, Web of Science and DelphiS searches from 2000 to 2015 and hand searches of publication lists, reference lists and citations were used to identify primary studies on ‘quality of life’ and ‘dementia’ elderly people.ResultsThe results suggest that there are a complex variety of factors influencing QoL of elderly people with dementia, and the factors cover demographic, physical, psychological, social, and religious aspects. And the factors influencing QoL of elderly people with dementia are different in different living settings (care institutions and communities) as well as different people’s perspectives (elderly people with dementia, family members and care staff). Environmental factors and quality of care are important for elderly people in care institutions; while religious seem to only affect QoL of those living in communities. However, this review fails to comprehensively identify unique or common factors associated QoL in dementia across three stages. Further study should pay more attention to comparing factors associated with QoL in dementia across three stages of dementia.     

Palliative care for patients with dementia in long-term care

Seventy percent of people in the United States who have dementia die in the nursing home. This article addresses the following topics on palliative care for patients with dementia in long-term care: (1) transitions of care, (2) infections, other comorbidities, and decisions on hospitalization, (3) prognostication, (4) the evidence for and against tube feeding, (5) discussing goals of care with families/surrogate decision makers, (6) types of palliative care programs, (7) pain assessment and management, and (8) optimizing function and quality of life for residents with advanced dementia.     

Risk factors for falls in people with and without a diagnose of dementia living in residential care facilities: a prospective study

People with dementia are at increased risk of falling. The purpose of this study was to identify predisposing risk factors for falls in older people with and without a diagnose of dementia living in residential care facilities, and to compare the results. Eighty-three residents without dementia (mean age ± S.D.; 83.5 ± 7.1 years) and 103 with dementia (83.6 ± 6.3 years) in Umeå, Sweden, participated. The baseline assessment included probable risk factors like walking ability, diagnoses and treatment with drugs. The follow-up period was 6 months. In people with dementia, the fall rate was higher (crude incidence rate ratio 2.55, 95% CI 1.60–4.08) and a larger proportion experienced falls (62% versus 41%). In the group without dementia 54.8% of the variation in falls was explained by a model including orthostatism, “women walking with aid”, and treatment with Angiotensin Converting Enzyme (ACE) inhibitors. In the group with dementia 25.5% of the variation in falls was explained by a model including “man walking with aid”. Our results show that with the same set of common risk factors for falls a considerably lower proportion of the variation in falls can be explained in the group of people with dementia.     

The reclassification of elderly people following admission to residential aged care

Objectives: To determine the incidence of, and factors associated with, the reclassification of level of care needs of older people following admission to a residential aged care facility (RACF) in Tasmania. Method: Focus group discussions with 11 Directors of Nursing of RACFs were conducted to inform the development of a questionnaire, which was administered to all residential aged care providers in the State. Results: More than 10% of elderly people admitted to a RACF in Tasmania are subject to a reclassification from high to low care or vice versa within 60 days of admission. The study also revealed a number of variables associated with reclassification. Conclusions: Reclassification of residents is often considered to be a ‘significant problem’. To reduce the incidence of reclassification many RACFs conduct their own assessments. Dementia, admission of hospital inpatients and greater than 6 months since an ACAT assessment represent the key predictors of reclassification.     

Rituals of visiting people with dementia in residential care

Objectives : Visiting a family member with dementia in residential care can be an unpredictable and stressful experience, particularly in the early days of admission and little is known of how carers lessen their distress during this time. Method : A qualitative study of 25 family carers was carried out in which the carers were interviewed on three occasions for more than a year from shortly after their relative entering residential care. Three carer focus groups were also undertaken. Results : Many family carers developed routines in their visiting that indicated five different forms of ritual: repetitive visiting patterns, formalised elements to visits, symbolic caregiving, reward giving and visit reframing. These routines helped carers manage the experience of visiting. From the accounts of family members, residential staff often seemed unaware of the significance of the rituals and unknowingly discouraged them. Conclusion : These findings suggest that visiting involves complex processes that are insufficiently understood and their value underestimated. Strategies are discussed for assisting family carers to sustain their visiting practices. Further research is needed in this area to provide guidance for family members and those working in residential care. Key words: Dementia, ritual, residential care, caregiving, visiting, relationships, communication     

Comparison of sit-to-stand strategies used by older adults and people living with dementia

Physiotherapists routinely retrain sit-to-stand (STS) during rehabilitation using strategies such as sliding forward, moving the feet backwards, leaning forward, and pushing through the armrests. It is unknown if people living with dementia use the same strategies as other older adults and if a table positioned in front alters their performance. Twenty participants 65 years or older (10 with Alzheimer's disease or mixed dementia; 10 without dementia) performed six STS trials from a standard chair with armrests, including three trials without and three with a table in front. Trials were digitally recorded and the starting position and type and order of strategies used were rated by a blinded assessor. Starting position was similar between the groups. The most common strategy was leaning forward (119 out of 120 trials) while the least used was sliding forward (four out of 120 trials). People living with dementia used significantly more strategies (p = 0.037), pushed through the armrests more than older adults (p = 0.038) and moved feet backwards more frequently in trials without the table in front (p = 0.010). Presence of the table had no significant effect on STS performance of older adults (p > 0.317). Our results demonstrated that people living with dementia had a similar starting position but used more strategies to stand up, pushing through their arms more than older adults without dementia and moved their feet backwards more often when no table was in front. People living with dementia should be provided with chairs with armrests and space to move feet backwards.     

The quality of residential and nursing-home care for people with dementia

OBJECTIVES: to determine the environmental quality of community-based residential and nursing care for people with dementia. DESIGN: survey of a stratified random sample of care homes. SETTINGS: forty-six registered residential and nursing homes in a single health district. MAIN OUTCOME MEASURES: scales for the assessment of environments for people with dementia, including care practices, social activities, social facilities, reality orientation cues, physical condition and space availability. RESULTS: over 90% of the homes had high quality scores on at least two measures. Provision of reality orientation cues was usually poor. Nursing homes catering specifically for 'the elderly mentally infirm' had more restrictive care practices, whilst local-authority residential homes had a better provision of recreational facilities. Private sector homes were in much better condition than public sector homes but their care practices were more institutional--this may be related to the provision of nursing and elderly mentally infirm care almost exclusively by the private sector. CONCLUSIONS: the environmental quality of community-based residential care is generally good, but improvements could be made, particularly with reality orientation cues.     

Nurse led care coordination: Trial protocol and development of a best practice resource guide for a cluster controlled clinical trial in Australian aged care facilities

In this paper we describe (i) the protocol for a cluster controlled clinical trial of nurse led care coordination in residential aged care facilities (RACF); and (ii) the development and content of a best practice resource guide to be implemented as part of this trial. We used published systematic reviews of quantitative studies, existing resources and multidisciplinary expert opinion to develop an intervention for testing in a cluster controlled trial (Australian and New Zealand Clinical Trials Registry Number 12611000933954). The trial will determine whether care coordination of multiple evidenced based strategies can improve quality of life and reduce hospitalization rates amongst people living in RACF. Central to the intervention arm of the trial are two components: (i) experienced nurse practitioners responsible for resident care and (ii) a best practice guide for the care processes being delivered and coordinated by those nurses. In this paper we outline how this practice guide, which is published herein, was refined through consultative processes and practitioner testing.     

Quality and safety in residential aged care: an evaluation of a national quality indicator programme

Background

In Australia, 243 000 individuals live in approximately 2700 residential aged care facilities yearly. In 2019, a National Aged Care Mandatory Quality Indicator programme (QI programme) was implemented to monitor the quality and safety of care in facilities.

Aim

To examine the validity of the QI programme indicators using explicit measure review criteria.

Methods

The QI programme manual and reports were reviewed. A modified American College of Physicians Measure Review Criteria was employed to examine the QI programme's eight indicators. Five authors rated each indicator on importance, appropriateness, clinical evidence, specifications and feasibility using a nine-point scale. A median score of 1–3 was considered to not meet criteria, 4–6 to meet some criteria and 7–9 to meet criteria.

Results

All indicators, except polypharmacy, met criteria (median scores = 7–9) for importance, appropriateness and clinical evidence. Polypharmacy met some criteria for importance (median = 6, range 2–8), appropriateness (median = 5, range 2–8) and clinical evidence (median = 6, range 3–8). Pressure injury, physical restraints, significant unplanned weight loss, consecutive unplanned weight loss, falls and polypharmacy indicators met some criteria for specifications validity (all median scores = 5) and feasibility and applicability (median scores = 4 to 6). Antipsychotic use and falls resulting in major injury met some criteria for specifications (median = 6–7, range 4–8) and met criteria for feasibility and applicability (median = 7, range 4–8).

Conclusions

Australia's National QI programme is a major stride towards a culture of quality promotion, improvement and transparency. Measures' specifications, feasibility and applicability could be improved to ensure the programme delivers on its intended purposes.     

Initiating advance care planning on end-of-life issues in dementia: Ambiguity among UK and Dutch physicians

BackgroundIn dementia, advance care planning (ACP) of end-of-life issues may start as early as possible in view of the patient’s decreasing ability to participate in decision making. We aimed to assess whether practicing physicians in the Netherlands and the United Kingdom who provide most of the end-of-life care, differ in finding that ACP in dementia should start at diagnosis.MethodsIn a cross-sectional study, we surveyed 188 Dutch elderly care physicians who are on the staff of nursing homes and 133 general practitioners from Northern Ireland. We compared difference by country in the outcome (perception of ACP timing), rated on a 1–5 agreement scale. Regression analyses examined whether a country difference can be explained by contrasts in demographics, presence, exposure and role perceptions.ResultsThere was wide variability in agreement with the initiation of ACP at dementia diagnosis, in particular in the UK but also in the Netherlands (60.8% agreed, 25.3% disagreed and 14.0% neither agreed, nor disagreed). Large differences in physician characteristics (Dutch physicians being more present, exposed and adopting a stronger role perception) hardly explained the modest country difference. The perception that the physician should take the initiative was independently associated with agreeing with ACP at diagnosis.ConclusionsThere is considerable ambiguity about initiating ACP in dementia at diagnosis among physicians practicing in two different European health care systems and caring for different patient populations. ACP strategies should accommodate not only variations in readiness to engage in ACP early among patient and families, but also among physicians.