End-of-life care for older adults with dementia living in group homes in Japan

Aim:  The aim of this study was to elucidate the components of end-of-life care provided to older adults with dementia who live in group homes (GHs) in Japan.
Introduction:  The number of GHs in Japan is rapidly increasing. Although GHs were originally not established to care for elderly people with advanced-stage dementia, many residents remain in the GH even after their stage of dementia advances; thus, end-of-life care is required.
Methods:  Interviews were conducted with seven GH administrators on their experience in providing end-of-life care to their residents. The constant comparative approach was used for data collection and analysis.
Findings:  Four themes emerged as essential components of end-of-life care in the GH setting: (i) maintaining a familiar lifestyle; (ii) minimizing physical and mental discomfort; (iii) proactively utilizing desirable medical care; and (iv) collaborating with family members.
Conclusion:  The combination of the four components seems to be a unique characteristic of end-of-life care in GHs in Japan. These findings may be used to establish a framework for end-of-life care at GHs.     

Implementation of the abilities-focused approach to morning care of people with dementia by nursing staff

Background.  The efficacy of the abilities-focused approach to morning care has been demonstrated in two studies. However, the extent to which nurses are aware of and actually implement abilities-focused interventions in day-to-day practice is not known.
Aim.  The study aimed to determine the type and number of abilities-focused interventions delivered by nursing staff to residents with dementia during morning care.
Methods.  A one-group repeated measure design was used. Seventy-nine nursing staff attended an educational session to instruct them in the application of abilities-focused interventions. Data on the type and number of interventions used by nurses were obtained before, after and 3-months following attendance at the session. Data were collected through participants' self-report and observation.
Results.  Most nursing staff used abilities-focused interventions when providing morning care. Introduction to resident, orientation to resident and conversation with resident were three types of interventions most often applied over time. The number of interventions implemented increased after attendance at the education session and returned to baseline level at 3-month follow-up.
Conclusions.  Future research is recommended to examine the long-term effects of alternative designs of educational sessions.     

The impact of residential respite care on the behaviour of older people with dementia: literature review

Aim.  The aim of this review was to examine the impact of residential respite care on the behaviour displayed by older people with dementia.
Background.  Relocation of older people with dementia to a different care setting could have a negative impact on their behaviour. If such a response is anticipated, a short-term admission to a residential aged care facility for respite care would appear to be futile for the older person and their home caregiver. Therefore, it is important to know what the outcomes of residential respite care are in relation to behaviour for older people with dementia.
Methods.  A literature search was undertaken and papers emerged from a range of disciplines. The search terms 'respite'; 'respite care'; 'residential respite care'; 'short-stay', 'short-term', 'overnight stays/admissions', 'behav*' and various combinations of these terms were used to find relevant publications in English from Ageline, CINAHL, Medline and, Psychinfo databases dating from 1966. Other key publications were located when searching through the reference lists of retrieved publications. A limited body of literature on residential respite care for older people with dementia was revealed.
Results.  Six studies were identified, which met the criteria of residential respite care as the intervention and behaviour as an outcome.
Conclusions.  The studies had a variety of methodological limitations and produced contradictory findings. The strength of the studies was the reporting of outcomes for respite recipients who are usually overlooked in the outcomes for respite research.
Relevance to clinical practice.  Residential respite care has great anecdotal support but more empirical and evaluative research is needed on outcomes for the respite recipients.     

Healthcare staffs’ experiences and perceptions of caring for people with dementia in the acute setting: Qualitative evidence synthesis

BackgroundDementia is a global issue, with increasing prevalence rates impacting on health services internationally. People with dementia are frequently admitted to hospital, an environment that may not be suited to their needs. While many initiatives have been developed to improve their care in the acute setting, there is a lack of cohesive understanding of how staff experience and perceive the care they give to people with dementia in the acute setting.ObjectivesThe aim of this qualitative synthesis was to explore health care staffs’ experiences and perceptions of caring for people with dementia in the acute setting. Qualitative synthesis can bring together isolated findings in a meaningful way that can inform policy development.SettingsA screening process, using inclusion/exclusion criteria, identified qualitative studies that focused on health care staff caring for people with dementia in acute settings.ParticipantsTwelve reports of nine studies were included for synthesis. Data extraction was conducted on each report by two researchers.MethodsFramework synthesis was employed using VIPS framework, using Values, Individualised, Perspective and Social and psychological as concepts to guide synthesis. The VIPS framework has previously been used for exploring approaches to caring for people with dementia. Quality appraisal was conducted using Critical Appraisal Skills Programme (CASP) and NVivo facilitated sensitivity analysis to ensure confidence in the findings.ResultsKey themes, derived from VIPS, included a number of specific subthemes that examined: infrastructure and care pathways, person-centred approaches to care, how the person interacts with their environment and other patients, and family involvement in care decisions. The synthesis identified barriers to appropriate care for the person with dementia. These include ineffective pathways of care, unsuitable environments, inadequate resources and staffing levels and lack of emphasis on education and training for staff caring for people with dementia.ConclusionsThis review has identified key issues in the care of people with dementia in the acute setting: improving pathways of care, creating suitable environments, addressing resources and staffing levels and placing emphasis on the education for staff caring for people with dementia. Recommendations are made for practice consideration, policy development and future research. Leadership is required to instil the values needed to care for this client group in an effective and personcentred way. Qualitative evidence synthesis can inform policy and in this case, recommends VIPS as a suitable framework for guiding decisions around care for people with dementia in acute settings.     

Impact of community care in enabling older people with complex needs to remain at home

Aim.  This aim of the study was to explore the impact of community care in enabling older people with complex needs to remain at home.
Background.  Changing demographic trends and successive government policies have led to an increase in the number of older people with complex needs residing in the community.
Design.  A qualitative approach using semi-structured interviews was used to collect data from older people ( n  = 17) and carers ( n  = 14).
Method.  Social workers were asked to identify community dwelling older people (65+ years) with multiple needs requiring interventions from a range of health and social care practitioners.
Results.  Community care enabled older people with complex needs who would otherwise have required residential or nursing home care to remain in their own homes. This was the expressed wish of both the older people and carers interviewed.
Conclusions.  The provision of high-quality community care for older people is a globally significant challenge and one that requires creative solutions, both at a local and strategic level.
Relevance to clinical practice.  Nurses and other health and social care professionals need to understand the significance of 'home' for older people and take steps to ensure that additional and appropriate resources are targeted towards community care.     

A literature review on fatigue among older people in pain: prevalence and predictors

Objective.  The aim of the study was to survey existing research about fatigue among older people with chronic non-malignant pain.
Method.  A structured literature review was carried out using the Medline database. The terms 'fatigue' and 'tiredness' were used synonymously. These subject headings were combined with pain. A literature search was made in 2004 and included articles back to 1995.
Results.  The review of studies from the last decade resulted in 11 articles of relevance. The result showed that fatigue was common among older people and even more common among those in pain. However, there was discordance regarding the prevalence, and the figures ranged from 30% to 98%. Fatigue was found to be associated above all with pain, functional limitations/functioning, and low quality of life. No articles were found focusing on interventions against fatigue.
Conclusions.  Fatigue is common in old age and even more common when people are in pain. However, knowledge seems to be sparse especially regarding interventions in daily care. Thus, more studies are needed that focus on fatigue to get firm evidence about the prevalence among older people in pain. In addition, studies about interventions against fatigue are urgently needed so that the care of older people can include actions against fatigue and to improve quality of life.
Relevance to clinical practice.  It is of importance that fatigue is not ignored in the care of older people. By intervening against symptoms such as fatigue it will most likely ease the pain and improve quality of life.     

Best practice interventions to improve the management of older people in acute care settings: a literature review

AIM: This paper is a report of a literature review of experimental evidence describing interventions to manage the older adult in the acute care hospital setting. BACKGROUND: Older people are increasingly being cared for in a system largely geared towards acute care. This approach is often inadequate to meet the needs of older patients with chronic and complex conditions. In response to these challenges, evidence-based interventions are required to improve health outcomes. METHOD: The MEDLINE and CINAHL databases and the Internet were searched using the keywords elderly, older, geriatric and aged care. Studies published between 1985 and 2006 were included if they reported, in English, a controlled trial of an intervention designed to improve the management of older adults in the acute care setting. The findings were synthesized using the method of a modified integrative literature review. FINDINGS: Only 26 controlled trials met the inclusion criteria. The following elements of interventions appear critical in providing optimal health outcomes for older people admitted to acute care: (1) a team approach to care delivery either directly in a designated unit for older patients or indirectly using gerontological expertise in a consultancy model; (2) targeted assessment techniques to prevent complications; (3) an increased emphasis on discharge planning and (4) enhanced communication between care providers across the care continuum. CONCLUSION: A multidisciplinary team approach, using gerontological expertise, in acute care settings is recommended to improve the care of older patients. Care delivery should occur in a specially designed unit, with communication strategies that emphasize discharge planning.     

Tactile stimulation associated with nursing care to individuals with dementia showing aggressive or restless tendencies: an intervention study in dementia care

Aim.  This study aimed to describe from documentation both the caregivers' experiences of giving tactile stimulation to five people with moderate-to-severe dementia and who showed aggressive or restless tendencies, and the changes seen in them.
Background.  Clinical experiences indicate that tactile stimulation can contribute to a feeling of trust and confirmation as well as to improving communication, promoting relaxation and easing pain. There is, however, very little scientific documentation of the effects of touch massage for people with dementia.
Design.  From caregivers' documentation (28 weeks) of experiences, the giving of tactile stimulation to five randomly selected people with dementia showing aggressive or restless tendencies and the subsequent changes noticed.
Method.  The documentation was analysed by using qualitative content analysis.
Results.  All residents displayed signs of positive feelings and relaxation. The caregivers stated that they felt able to interact with the residents in a more positive way and that they felt they had a warmer relationship with them.
Conclusion.  Tactile stimulation can be seen as a valuable way to communicating non-verbally, of giving feedback, confirmation, consolation or a feeling of being valuable and taken care of.
Relevance to clinical practice.  Tactile stimulation has to be administered with respect and care, and given from a relational ethics perspective. Otherwise, there is a risk that tactile stimulation will be used merely as a technique instead of as a part of an effort to achieve optimal good, warm nursing care.     

Experiences of physical strain during person transfer situations in dementia care units

Caring for residents with dementia impose a higher challenge and workload on the nursing staff because of a higher degree of motor function and cognitive decline among the residents. Training in person transfer tasks for nursing staff has mostly been concentrated on ergonomics irrespective of the nature of the resident's functional decline. An increased knowledge about the nursing staffs' experiences of physical workload in dementia care and in how to reduce their physical strain is needed.
Aim:  The aim of the study was to describe nurse's aids' experiences of physical strain during person transfer tasks at dementia care units.
Method:  Four focus group interviews with altogether 16 nurses' aids, working at special care units for people with dementia, were performed.
Results:  The results show that knowledge about the disease and personality of residents in dementia care units can help to decrease the physical strain on nurses' aids in person transfer situations.
Nurse's aids need to be flexible when performing transfer tasks to accommodate variations in the resident's functional ability. Physical strain associated with person transfer tasks is not related to the weight of the resident. Misunderstandings because of cognitive decline and communication problems increase physical strain on nurses' aids. Specialized training in person transfer tasks is needed for nurse's aids working in dementia care.
Conclusions:  These results may serve to guide physiotherapists working in dementia care units in assessing residents' functional ability, in when to use assistive devices and mobility aids and in training and supervising nurse's aids in person transfer tasks.     

Foot health in older people and the nurses' role in foot health care–a review of literature

Scand J Caring Sci; 2010; 24; 194–201
Foot health in older people and the nurses' role in foot health care–a review of literature
Aims:  To describe foot health in older people and the role of nurses in foot health care. There is value in developing preventive measures in foot health care in older people, in creating educational programmes for nurses of foot care and in developing foot health evaluation instrument for nurses.
Methods:  The literature was retrieved from the Medline and CINAHL databases between 1980 and January 2008. Altogether 35 articles were reviewed.
Findings:  Based on the review, older people have a variety of foot health problems. Nurses have a theoretical knowledge of foot care, but they do not consider their clinical skills adequate.
Conclusions:  Future research should focus on evaluating in which areas of foot care nurses' knowledge is strongest and how effective their foot caring activities are. Nurses work closely with older people and are in a position to identify and prevent their foot health problems.     

Engaging older people with dementia in research: myth or possibility

Aim.  The aim of this paper was to explore a range of strategies that were used to enable older people with dementia to become actively engaged in research 'with' rather than 'on' them.
Background.  It is well recognized that the prevalence of dementia in older adults is increasing. This increase is reflected by a huge rise in the amount of research in this area. The biomedical model continues to dominate dementia research; however, the last two decades have seen an increased interest in studies that seek the views of people with dementia. A review of literature that has actively engaged people with dementia suggests that research can be conducted in such ways that are both ethical and meaningful. These studies demonstrate that this group has a valuable contribution to research studies.
Discussion.  This literature establishes that it is possible to engage people with dementia in research, the majority of studies have tended to focus on those in the earlier stages of the disease. This paper demonstrates, through the use of a set of criteria which were specifically developed to evaluate this type of work, how people even with advanced dementia were engaged in research about their experience of acute hospital care in ways that were both meaningful and ethical.
Conclusion.  This paper demonstrates that it is possible to actively engage older people with dementia, even those in the more advanced stages of the disease, in research. It is essential that researchers understand ethical principles and are able to apply these sensitively and flexibly.     

Helping a Man with Leprosy: A Case Study

PURPOSE.  This case study illustrates nursing diagnoses and interventions for a man with leprosy.
DATA SOURCES.  Data sources were published literature on the disease of leprosy, and the experience and expertise of the authors in working with people with leprosy.
DATA SYNTHESIS.  Data were synthesized using the standardized nursing languages of North American Nursing Diagnosis Association International and the Nursing Interventions Classification. The accuracy of the diagnoses and the appropriateness of the nursing interventions were supported by the positive health outcomes of the patient.
CONCLUSIONS.  Although leprosy has been eradicated in some countries, the risk of new cases is present anywhere that Mycobacterium leprae still exists. The recommended treatment of multibacilar polychemotherapy has lowered the rate of new cases in Brazil.
IMPLICATIONS FOR NURSING PRACTICE.  Nurses need to incorporate evidence-based practice interventions for leprosy-based wound care, and nurses should encourage persons with leprosy to maintain regular medical care with multibacilar polychemotherapy.     

The risk to enduring relationships following the move to a care home

Aim.  To explore findings from a study which investigated the meanings that older people attributed to their experiences of living in a care home and consequently the risks that they identify in this.
Background.  There is evidence from this and other studies that being able to engage in long-time friendships is important to older people. The move to a care home has the potential to disrupt these relationships and there is a risk of breakdown of the friendships that have been valued throughout life.
Method.  A hermeneutic inquiry that explored the meaning that eight older people ascribed to their life in the care home. This paper focuses on the narratives that concerned relationships with long-time friends and the risks to these relationships.
Results.  The paper highlights the importance of engaging in meaningful relationships with other people. The participant's stories illuminated the importance of maintaining friendships following the move to a care home and how these had had a positive impact on their lives in that setting. With advancing age and increasing frailty the participants were acutely aware that their friendships were vulnerable to breakdown and they implemented a range of strategies to sustain their relationships with these people.
Conclusion.  The findings point to the importance of acknowledging the value of long-time friendships to older people and the need to support them in their efforts to sustain these relationships and reduce risks to them.     

Pain assessment in older people with dementia: literature review

Title.  Pain assessment in older people with dementia: literature review.
Aim.  This paper is a report of a literature review conducted to identify barriers to successful pain assessment in older adults with dementia and possible strategies to overcome such barriers.
Background.  Pain is frequently undetected, misinterpreted, or inaccurately assessed in older adults with cognitive impairment. These people are often unable to articulate or convey how they feel and are often perceived as incapable of experiencing or recalling pain.
Data sources.  Searches were conducted of CINAHL, Medline and other databases for the period 1993–2007 using the search terms pain, dementia, assess*, barrier* and obstacle*.
Methods.  Studies were critically appraised by two independent reviewers. Data were extracted using instruments specifically developed for the review. Studies were categorized according to levels of evidence defined by the Australian National Health and Medical Research Council and Joanna Briggs Institute.
Results.  Perceived barriers to successful pain assessment in people with dementia included lack of recognition of pain, lack of sufficient education and/or training, misdiagnosis or late diagnosis, and non-use of assessment tools. Barriers related to people with dementia included insufficient evidence, the possibility of a 'no pain' subset of people with dementia, type of pain, and stoical attitudes. Strategies proposed as means of overcoming these barriers included knowing the person, knowing by diversity/intuitive perception, education and training, and use of adequate tools.
Conclusion.  More extensive education and training about the relationship between pain and dementia are urgently needed, as is the development and implementation of an effective pain assessment tool specifically designed to detect and measure pain in older adults with all stages of dementia.     

Urinary incontinence in older adults receiving home care diagnosis and strategies

Introduction:  Urinary incontinence (UI) is a major health problem mostly affecting older people. With the shift toward healthcare delivery in the home setting, it is necessary for home healthcare workers to know how to manage UI in the elderly. Little is known about the care for patients receiving home care suffering from UI. The aim of this study was to assess the prevalence of UI in older adults receiving home care and to gain insight into caring for patients with UI.
Method:  A cross-sectional survey using data from the Dutch National Prevalence Measurement of Health Care Problems was conducted.
Results:  Of the 2866 patients, 46% were suffering from UI. In 49% of these patients the type of UI was diagnosed. Patients with a diagnosis suffered more from their UI and were offered more strategies when compared with patients without a diagnosis. Most patients used pads. Relatively few patients were offered bladder training or pelvic floor muscle exercises (PFME).
Discussion:  Urinary incontinence is a highly prevalent condition in older patients receiving home care. In half of the patients with UI no diagnosis regarding the type of incontinence was made. However, to treat or manage UI it is essential to assess the type of UI, as UI is treatable even in older people. As this study had a cross-sectional design, only strategies being offered at a fixed point in time are documented.
Conclusion:  Despite studies reporting the success of behavioural interventions for adults suffering from UI, most patients use pads. With the aging of the population and the increasing number of older adults suffering from UI, home care agencies need to acquire the knowledge and skills to address UI.     

Issues concerning the on-going care of patients with comorbidities in acute care and post-discharge in Australia: a literature review

BACKGROUND: Advances in medical science and improved lifestyles have reduced mortality rates in Australia and most western countries. This has resulted in an ageing population with a concomitant growth in the number of people who are living with chronic illnesses. Indeed a significant number of younger people experience more than one chronic illness. Large numbers of these may require repeated admissions to hospital for acute or episodic care that is superimposed upon the needs of their chronic conditions. AIM: To explore the issues that circumscribe the complexities of caring for people with concurrent chronic illnesses, or comorbidities, in the acute care setting and postdischarge. METHODS: A literature review to examine the issues that impact upon the provision of comprehensive care to patients with comorbidities in the acute care setting and postdischarge. FINDINGS: Few studies have investigated this subject. From an Australian perspective, it is evident that the structure of the current health care environment has made it difficult to meet the needs of patients with comorbidities in the acute care setting and postdischarge. This is of major concern for nurses attempting to provide comprehensive care to an increasingly prevalent group of chronically ill people. CONCLUSION: Further research is necessary to explore how episodic care is integrated into the on-going management of patients with comorbidities and how nurse clinicians can better use an episode of acute illness as an opportunity to review their overall management.     

Improving the oral health of older people in long-term residential care: a review of the literature

Background.  Unrefutable evidence now links poor oral health with the development of preventable systemic illnesses and debilitating conditions that threaten quality of life and life itself. This is especially significant for an increasing older population who are dependent on others for care.
Aims and objectives.  The majority of studies analysing the oral health of older dependent people in long-term residential care have been undertaken by dental professionals. This critical literature review examines the issue from a nursing perspective because nursing care providers have a fundamental role in daily oral health provision for dependent residents.
Conclusions.  Multiple barriers were found to negatively impact on daily oral healthcare provision, including lack of care provider education, oral health values, availability of resources, implementation of supportive policies, documentation and oral health assessment tools.
Relevance to clinical practice.  The nursing profession, at all levels, must become pro-active in removing financial, political and workforce barriers that impact negatively on oral health outcomes. A multi-faceted approach is required to address these barriers, including development and implementation of oral health education programmes, assessment screening tools, care plans, documentation, supply of oral hygiene aids and the appointment of oral care 'champions'.