Care staff training based on person-centered care and dementia care mapping,and its effects on the quality of life of nursing home residents with dementia

Objectives: To assess the effects of care staff training based on person-centered care (PCC) and dementia care mapping (DCM) on the quality of life (QOL) of residents with dementia in a nursing home.

Methods: An intervention of staff training based on PCC and DCM was conducted with 40 care staff members at a geriatric nursing home. The effects of the staff training on the QOL of residents with dementia were evaluated by the DCM measurements of 40 residents with dementia three times at about one-month intervals (first, baseline; second, pre-intervention; third, post-intervention).

Results: The well-being and ill-being values (WIB values) of the residents with dementia measured by DCM were not different between the first and second rounds before the staff training (p = 0.211). Meanwhile, the WIB values increased from the first and second rounds to the third post-intervention round (p = 0.035 and p < 0.001, respectively); over 50% of the residents had better WIB values. The behavior category ‘interactions with others’ in DCM also demonstrated a significant increase in the third round compared to the first round (p = 0.041).

Conclusion: Staff training based on PCC and DCM could effectively improve the QOL of residents with dementia.     

Dementia Care Mapping (DCM): initial validation of DCM 8 in UK field trials

OBJECTIVES: This paper describes DCM 8 and reports on the initial validation study of DCM 8. METHODS: Between 2001-2003, a series of international expert working groups were established to examine various aspects of DCM with the intention of revising and refining it. During 2004-2005 the revised tool (DCM 8) was piloted in seven service settings in the UK and validated against DCM 7th edition. RESULTS: At a group score level, WIB scores and spread of Behavioural Category Codes were very similar, suggesting that group scores are comparable between DCM 7 and 8. Interviews with mappers and focus groups with staff teams suggested that DCM 8 was preferable to DCM 7th edition because of the clarification and simplification of codes; the addition of new codes relevant to person-centred care; and the replacement of Positive Events with a more structured recording of Personal Enhancers. CONCLUSIONS: DCM 8 appears comparable with DCM 7th edition in terms of data produced and is well received by mappers and dementia care staff.     

Influence of cognitive impairment, functional impairment and care setting on dementia care mapping results

Quality of life (QOL) for people with dementia has become a major focus over the past decade. Dementia care mapping (DCM) is an observational measure of quality of care given by staff in formal care settings, as well as a measure of QOL that has been used in many studies of people with dementia in residential care settings. However, the method itself has not been rigorously studied in a scientific manner. For this report, mapping data were collected for 166 persons with dementia in three types of care settings: special care facilities that are licensed nursing homes, assisted living facilities, and adult day centers. The relationships between DCM and several independent variables including cognitive status, functional status, care setting, depression, length of stay, and co-morbid illnesses were assessed. Both cognitive status and functional status were found to be associated with DCM scores. Moreover, DCM was sensitive in differentiating among persons with four levels of cognitive impairment. Implications for practice are discussed.     

The feasibility and validity of care mapping in the clinical neurosciences

Dementia Care Mapping (DCM) is an observational tool and process that is widely used in dementia care in measuring and improving person-centred care (PCC). DCM was previously piloted on a neurorehabilitation ward, where it was found to be feasible and acceptable in this setting. Following this, a new modified tool and accompanying manual were developed: Care Mapping – Neurorehabilitation (DCM-NR). The current study aimed to assess the feasibility and validity of DCM-NR by piloting its use in a range of clinical neuroscience settings. A mixed-methods design was used employing both quantitative and qualitative techniques. The new DCM-NR was found to be feasible for use both in terms of the suitability of its coding system and the implementation process. DCM-NR was shown to have a moderate level of concurrent validity with participants' self-report of PCC. Participants' subjective reports on their experiences of care provided validation for the areas of psychological need observed in DCM-NR. The results of this study indicate that DCM-NR is feasible and valid for use in a range of clinical neuroscience settings. Further longitudinal research is required to evaluate the impact of DCM-NR on PCC practices over time.     

The feasibility of Dementia Care Mapping (DCM) on a neurorehabilitation ward

Person-centred care (PCC) is recommended when working with patients with neurological difficulties. Despite this, to date there has been no appropriate methodology for assessing or developing PCC in neurorehabilitation settings. Dementia Care Mapping (DCM) is a well-established tool for assessing and developing PCC in dementia settings and the current study investigated the feasibility of applying DCM on an acute neurorehabilitation ward. DCM procedure and coding required minor adaptations for use in this setting and further recommended adaptations were subsequently identified. It was found that the DCM coding system was generally suitable and could identify strengths, weaknesses and areas for development in ward care. Q-methodology identified that staff views endorsed the feasibility of using DCM in neurorehabilitation, with staff reporting that they found DCM useful and relevant to their work. DCM could be further developed for this setting by amendments to the behaviour coding system, concept and coding of person-centred care, and a population-specific manual. DCM is a promising methodology to develop and promote PCC in neurorehabilitation.     

The first use of dementia care mapping in the care for older people with intellectual disability: a process analysis according to the RE-AIM framework

ABSTRACT

Introduction: The aging of the population with intellectual disability (ID), with associated conseqences as dementia, creates a need for evidence-based methods to support staff. Dementia Care Mapping (DCM) is perceived to be valuable in dementia care and promising in ID-care. The aim of this study was to evaluate the process of the first use of DCM in ID-care.

Methods: DCM was used among older people with ID and care-staff in 12 group homes of six organisations. We obtained data on the first use of DCM in ID-care via focus-group discussions and face-to-face interviews with: care-staff (N = 24), managers (N = 10), behavioural specialists (N = 7), DCM-ID mappers (N = 12), and DCM-trainers (N = 2). We used the RE-AIM framework for a thematic process-analysis.

Results: All available staff (94%) participated in DCM (reach). Regarding its efficacy, staff considered DCM valuable; it provided them new knowledge and skills. Participants intended to adopt DCM, by continuing and expanding its use in their organisations. DCM was implemented as intended, and strictly monitored and supported by DCM-trainers. As for maintenance, DCM was further tailored to ID-care and a version for individual ID-care settings was developed, both as standards for international use. To sustain the use of DCM in ID-care, a multidisciplinary, interorganisational learning network was established.

Conclusion: DCM tailored to ID-care proved to be an appropriate and valuable method to support staff in their work with aging clients, and it allows for further implementation. This is a first step to obtain an evidence-based method in ID-care for older clients.     

Dementia Care Mapping as a research tool for measuring quality of life in care settings: psychometric properties

BACKGROUND: There are a paucity of validated measures focusing on quality of life for people with dementia in care facilities. METHOD: The current study evaluated the internal consistency of Dementia Care Mapping (DCM) in a group of 123 people with dementia residing in care facilities and further evaluated the test retest reliability and concurrent validity of key DCM constructs in an additional group of 54 residents. RESULTS: The results show good internal consistency. Well-ill being score was significantly correlated with an informant rated quality of life measure (r = 0.73, p < 0.0001) and showed good test retest reliability (r = 0.55, p < 0.0001). An abbreviated assessment period focusing on the hour before lunch showed significant correlation with the total assessment period (well-ill being score r = 0.5, p = 0.02). CONCLUSION: The current study indicates that DCM is a valid tool for the longitudinal evaluation of quality of life in people with dementia in care settings and that some abbreviation of the method may facilitate its use more widely.     

Determining the efficacy of Dementia Care Mapping as an outcome measure and a process for change: a pilot study

Dementia Care Mapping (DCM) is increasingly being promoted world-wide as a useful approach in assisting staff to improve the well-being of residents with dementia. While DCM is employed as an outcome measure of well-being and as a process to assist staff improve quality of care, it has not been subject to the rigorous scrutiny of a controlled trial to establish its efficacy as an outcome measure, or as an intervention. In 2005 the authors were awarded an Australian Health Minister's Grant to conduct a randomised control trial of DCM in 15 residential dementia care units across the city of Sydney, Australia. This paper reports on a pilot study conducted with 35 dementia care residents in three secure residential care units in the state of New South Wales, Australia, prior to the controlled trial. The main aims of the pilot were to determine the sensitivity of DCM against the validated baseline and outcome measures selected for the trial and to evaluate the utility of the research plan. The utility of the research plan was established. Whilst a significant improvement was shown in staff interactions with residents over time, there was no evidence that DCM improved the residents' quality of life and well-being in relation to physical and cognitive functioning, although there was a reduction in the residents' levels of agitation and depression. While as a research tool DCM needs further refinement to match the strength of validated outcome measures that more accurately assess the residents' well-being, DCM procedures improved staff's attention to monitoring and attending to the residents' well-being.     

The needs of older people with dementia in residential care

BACKGROUND: People with dementia often move into care homes as their needs become too complex or expensive for them to remain in their own homes. Little is known about how well their needs are met within care homes. METHOD: The aim of this study was to identify the unmet needs of people with dementia in care and the characteristics associated with high levels of needs. Two hundred and thirty-eight people with dementia were recruited from residential care homes nationally. Needs were identified using the Camberwell Assessment of Needs for the Elderly (CANE). RESULTS: Residents with dementia had a mean of 4.4 (SD 2.6) unmet and 12.1 (SD 2.6) met needs. Environmental and physical health needs were usually met. However, sensory or physical disability (including mobility problems and incontinence) needs, mental health needs, and social needs, such as company and daytime activities, were often unmet. Unmet needs were associated with psychological problems, such as anxiety and depression, but not with severity of dementia or level of dependency. CONCLUSION: Mental health services and residential home staff need to be aware that many needs remain unmet and much can be done to improve the quality of life of the residents with dementia.     

Time use and costs of institutionalised elderly persons with or without dementia: results from the Nordanstig cohort in the Kungsholmen Project--a population based study in Sweden

BACKGROUND: The aging of the population has become a worldwide phenomenon. This leads to increased demand for services and with limited resources it is important to find a way to estimate how resources can be match to those with greatest need. AIMS: To analyse time use and costs in institutional care in relation to different levels of cognitive and functional capacity for elderly persons. METHODS: The population consisted of all institutionalised inhabitants, 75 + years, living in a rural community (n = 176). They were clinically examined by physicians and interviewed by nurses. Staff and informal care-giving time was examined with the RUD (Resource Utilization in Dementia) instrument. RESULTS: Tobit regression analyses showed that having dementia increased the amount of ADL care time with 0.9 h when compared to those not having dementia, whereas each loss of an ADL function (0-6) added 0.6 h of ADL care time. Analysing the total care time use, the presence of dementia added more than 9 h, while each loss of one ADL function added 2.9 h. There were some informal care contributions, however with no correlation to severity in dependency. The estimated cost for institutional care increased with more than 85% for people being dependent in 5-6 ADL activities compared to persons with no functional dependency, and with 30% for persons with dementia compared to the non-demented. CONCLUSION: There is a variation in time use in institutional settings due to differences in ADL dependency but also whether dementia is present or not. This variation has implications for costs of institutional care.     

The efficacy of Dementia Care Mapping as an audit tool: Report of a 3-year British NHS evaluation

Dementia Care Mapping (DCM, Kitwood & Bredin, 1994a) was incorporated into the Quality Assurance Strategy of an urban British Mental Health (NHS) Trust. Its role as an audit of the outcome of the care process in formal dementia care settings was evaluated. DCM was used in two day hospitals, an assessment ward, two respite care units and four continuing care units over three annual evaluation cycles. This equated to approximately 1,614 hours of mapping over the three cycles. The way in which DCM was used is described in detail. The results were generally very positive with improvements in the quality of care practice being demonstrated. Although anxious about the observational nature of DCM, staff viewed it as a positive means of improving quality of care. DCM is seen as being a highly appropriate audit tool to use in NHS formal dementia care settings. Information on the experience of managing a DCM project is shared.     

Decline in quality of life for patients with severe dementia following a ward merger

The effect of a ward merger on the quality of life of patients with severe dementia in a mental hospital was investigated by means of the observational method of dementia care mapping (DCM). Nineteen patients in two long-stay wards were included in the study prior to the merger. Fourteen of these were observed in the merged ward, together with five newly admitted patients. Key DCM indicators showed that the quality of life of patients included in both phases of the study had declined significantly. This may be explained, in part at least, in terms of a cycle of demoralization and depersonalization' in the interaction of staff and patients. Further research is required into the dynamics of this cycle.     

Care services for dementia patients: predictors for service utilization

Aim. The objective of this study was to examine service utilization figures among a representative sample of demented patients and to determine whether sociodemographic and health-related variables are associated with care utilization. Method. The study population was derived from a population-based, two-stage cross-sectional study in The Netherlands and consisted of 102 demented subjects. Four levels of care intensity were used: level 1, no use of professional care; level 2, use of one or more types of professional care by community-dwelling subjects; level 3, residential living in homes for the aged; level 4, long-term care in specialized nursing homes. Sociodemographic variables and variables related to mental and physical health, functional dependency and severity of dementia were studied as determinants of levels of care. Results. Eighty-two per cent of the study subjects used one or more types of formal care and 55% were institutionalized. Multivariate analysis yielded age, severity of dementia, somatic disorders, dependency in terms of ADL and martial status as predictors of higher levels of care. Sets of predictors differed across different care levels. Conclusions. The findings point to the importance of the social network and the relevance of general medical treatment and an active approach towards decreasing the impact of ADL dependency in demented subjects. © 1997 John Wiley & Sons, Ltd.     

Cost-effectiveness of a collaborative dementia care management—Results of a cluster-randomized controlled trial

IntroductionThe purpose of this study was to determine the cost-effectiveness of collaborative dementia care management (DCM).MethodsThe cost-effectiveness analysis was based on the data of 444 patients of a cluster-randomized, controlled trial, conceptualized to evaluate a collaborative DCM that aimed to optimize treatment and care in dementia. Health-care resource use, costs, quality-adjusted life years (QALYs), and incremental cost per QALY gained were measured over a 24-month time horizon.ResultsDCM increased QALYs (+0.05) and decreased costs (?569€) due to a lower hospitalization and a delayed institutionalization (7 months) compared with usual care. The probability of DCM being cost-effective was 88% at willingness-to-pay thresholds of 40,000€ per QALY gained and higher in patients living alone compared to those not living alone (96% vs. 26%).DiscussionDCM is likely to be a cost-effective strategy in treating dementia and thus beneficial for public health-care payers and patients, especially for those living alone.     

Who needs psychogeriatric continuing care?

A survey of the degree of mental impairment, physical disability and behavioural problems was undertaken in residents in psychogeriatric continuing care beds at Friern Hospital (n=96) and Islington Local Authority old people's homes (OPHs) (n = 104). High levels of dependency were identified, particularly in those subjects with a clinical diagnosis of dementia, who constituted 80% of the hospital sample and 43% in OPHs. Precipitants of admission differed between the hospital and OPH groups (incontinence, aggression and wandering vs poor self-care and living alone), both for the total sample and for those subjects with a clinical diagnosis of dementia. Subjects with dementia in the two settings, however, showed similarly high levels of dependency and behavioural problems. The implications of these findings for planned local reprovision of continuing psychogeriatric care and for the future development of local authority residential care are discussed.     

The needs of people with dementia in care homes: the perspectives of users, staff and family caregivers

ABSTRACTBackground: People with dementia in care homes are at risk of having their views ignored and decisions are often made on their behalf by care home staff and family carers. The aim of this study was to compare the ratings of needs of older people with dementia living in care homes, as assessed by the older person themselves, a family caregiver, and the staff of the care home.Method: The Camberwell Assessment of Need for the Elderly (CANE) was completed for 238 residents with dementia by care staff. In addition, 149 users and 81 family caregivers also completed the assessment of the person's met and unmet needs.Results: Many users were able to report their met and unmet needs despite having moderately severe dementia. The views of the person with dementia were commonly in agreement with the staff and family carers' views. However, user and carer pairs had the lowest average percentage agreement of 63% compared to that of 77% between user and staff pairs. In particular, users reported relatively higher unmet needs for psychological distress, company and information, and high unmet needs for daytime activities and eyesight/hearing problems.Conclusions: Users' views on their needs should be sought even when the person has dementia and lives in a care home. Reliance solely on assessment by staff or carers may lead to under recognition of unmet needs.     

A quasi-experimental design trial exploring the effect of a partnership intervention on family and staff well-being in long-term dementia care

Objectives: This study sought to explore the effect of the family involvement in care (FIC) intervention on family and staff well-being over a nine-month period in a long-term care (LTC) facility providing dementia care.

Method: A quasi-experimental design with randomised allocation of two LTC sites but not the participants was employed. Family caregivers (n?=?57) of residents with dementia and staff (n?=?59) from two LTC facilities in Queensland, Australia, were recruited. Participants were assessed once pre-intervention and three times post-intervention for knowledge, stress and satisfaction outcomes. Between-group and within-group effects were analysed using ANOVAs at <0.05 level of significance. Pre- and post-intervention interviews from a purposive sample of family caregivers were also conducted to enhance understanding of FIC benefits.

Results: Beneficial intervention effects associated with family caregivers’ knowledge of dementia were found (p?p?p?

Conclusion: Participation in the FIC intervention improved family caregiver knowledge. The major barrier to the success of the partnership intervention in achieving beneficial long-term psychosocial effects for family and staff caregivers was lack of resources and leadership required to support collaboration between family and staff, mainly due to environment and structural changes. This study contributes to our understanding of the importance of partnerships in promoting family involvement in dementia care.     

Promoting value in dementia care: Staff,resident and family experience of the capabilities model of dementia care

Objectives: This Australian study examined individual experiences of the implementation of the Capabilities Model of Dementia Care (CMDC) and subsequent outcomes for the care of residents with dementia living in long-term care. Furthermore, this study aimed to explore those factors that facilitated and inhibited the implementation of the new model of care.

Methods: The CMDC was developed and then tested in a non-randomised clinical trial. Staff, residents and family experiences of their involvement and perceptions of the model were captured at the end of 12 months. Semi-structured interviews and focus groups were conducted with the 25 participants (12 nursing staff, 6 residents with dementia, 7 family members). Questions varied depending on the participant group but were designed to assess experiences of and changes to care during the intervention. Inductive thematic analysis was used to identify the experiences of the implementation of the CMDC.

Results: Five themes included: general reflections on nursing care, implementation of the CMDC intervention, positive outcomes of the CMDC intervention, challenges in the implementation of the CMDC, difficulty sustaining care and tensions between participants’ perspectives of care.

Conclusion: Positive change resulted from implementation of the CMDC, however, staff mentorship was identified as a key to sustaining changes in practice.     

Defining severe dementia with the Minimum Data Set

BACKGROUND: Accurately defining severe dementia is important for care and prognosis, but is not explicitly included in the Minimum Data Set (MDS). OBJECTIVE: To define severe dementia using the MDS, we used data for nursing home residents with moderate to severe dementia. METHODS: Two cross-sectional studies enrolled 175 residents; 89 residents from one US Veterans Affairs nursing home, and 86 residents from nine Dutch nursing homes. Measurements included the Cognitive Performance Scale (CPS; range: 0-6), activities of daily living (ADL) dependency, and the Bedford Alzheimer Nursing Severity-Scale (BANS-S; range: 7-28), a staging instrument specific for severe dementia. RESULTS: Half of the residents received CPS scores of 5, and their BANS-S scores varied widely. There was fair agreement (kappa=0.36) between severe cognitive impairment as defined by the CPS (scores 5 and 6) and the BANS-S (score 17 or higher). Addition of an ADL dependency requirement to the CPS definition improved agreement (kappa=0.75). The observed patterns were similar but more obvious for US residents than for Dutch residents. CONCLUSION: Cognitively impaired residents comprise a heterogeneous group with a wide variety of function. Restriction with respect to ADL dependency allows for distinction between moderate and severe dementia. We propose the following MDS-based definition of severe dementia: a CPS score of 5 or 6 with a minimum score of at least 10 points on the MDS ADL-Short Form.