July 2, 2019

Calls for Abstracts


The Government of Canada Releases Canada’s First Dementia Strategy
A Dementia Strategy for Canada: Together We Aspire

The Honourable Ginette Petitpas Taylor, Minister of Health announced the release of A Dementia Strategy for Canada: Together We Aspire. This first national dementia strategy focuses on preventing dementia, advancing therapies, and finding a cure, as well as improving the quality of life of people living with dementia and caregivers. Budget 2019 proposed $50 million in funding to help advance the Strategy.

New article by Shannon Scott
Health care stakeholder perspectives regarding the role of a patient navigator during transition to adult care.
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G. Dimitropoulos, E. Morgan-Maver, B. Allemang, et al.
BMC Health Serv Res 2019 Jun 17;19(1):390-019-4227-6
Transition to adult care represents a vulnerable period for young people with special health care needs as they navigate multiple life transitions and developmental issues. Patient navigators are a promising intervention designed to facilitate the transfer from pediatric to adult care. However, consistent definitions, key tasks, roles and responsibilities are lacking in guiding the scope of practice and the implementation of patient navigators. METHODS: Fundamental qualitative description was utilized in this study to identify perceptions from health care providers about implementing a patient navigator service for young people with special health care needs in transition to adult care. A purposive sample of health care providers with a variety of backgrounds within pediatric and adult systems in Alberta, Canada were recruited. Semi-structured interviews with participants were analyzed using thematic analysis to inductively identify perceptions regarding the role of patient navigators. RESULTS: A total of 43 health care providers highlighted the need for a patient navigator service to encompass 4 key stages for young people with special health care needs transitioning from pediatric to adult services: (1) identification of young people with special health care needs and families requiring support, (2) preparation for transfer, (3) health system navigation and, (4) post-transfer support. CONCLUSIONS: The results of this qualitative study provide guidance for the development of patient navigator interventions for young people with special health care needs, as well as provide support for current transition services offered across Canada.

Calls for Abstracts

12th Annual Conference on the Science of Dissemination and Implementation in Health

4-6 December 2019, Arlington, VA
The Annual Conference on the Science of Dissemination and Implementation in Health (D&I), co-hosted by the National Institutes of Health (NIH) and AcademyHealth, helps realize the full potential of evidence to optimize health and health care by bridging the gap between research, practice, and policy.

META: A pragmatic workshop series on Moving Evidence to Action to improve patient outcomes

26-28 November, Edmonton AB
WORKSHOP PRESENTATIONS at META 2019 are to be 3.0 hours in length each. At least 25% of the workshop must be interactive. Audience size is typically 16-22 people. A computer, projector and large screen will be available in the room.


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Health Care Administration and Organization
Health Care Innovation and Quality Assurance
Research Practice and Methodology


A description of a tailored knowledge translation intervention delivered by knowledge brokers within public health departments in Canada.
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M. Dobbins, L. Greco, J. Yost, R. Traynor, K. Decorby-Watson and R. Yousefi-Nooraie.
Health Res Policy Syst 2019 Jun 20;17(1):63-019-0460-z
While there is an expectation to demonstrate evidence-informed public health there is an ongoing need for capacity development. The purpose of this paper is to provide a description of a tailored knowledge translation intervention implemented by knowledge brokers (KBs), and reflections on the factors that facilitated or hindered its implementation. METHODS: The 22-month knowledge translation intervention, implemented by two KBs, sought to facilitate evidence-informed public health decision-making. Data on outcomes were collected using a knowledge, skills and behavioural assessment survey. In addition, the KBs maintained reflective journals noting which activities appeared successful or not, as well as factors related to the individual or the organisation that facilitated or hindered evidence-informed decision-making. RESULTS: Tailoring of the knowledge translation intervention to address the needs, preferences and structure of each organisation resulted in three unique interventions being implemented. A consistent finding across organisations was that each site needed to determine where evidence-informed decision-making ‘fit’ within pre-existing organisational processes. Components of the intervention consistent across the three organisations included one-to-one mentoring of teams through rapid evidence reviews, large group workshops and regular meetings with senior management. Components that varied included the frequency of the KB being physically onsite, the amount of time staff spent with the KB and proportion of time spent one-to-one with a KB versus in workshops. Key facilitating factors for implementation included strong leadership, influential power of champions, supportive infrastructure, committed resources and staff enthusiasm. CONCLUSIONS: The results of this study illustrate the importance of working collaboratively with organisations to tailor knowledge translation interventions to best meet unique needs, preferences, organisational structures and contexts. Organisational factors such as leadership, champions and supportive infrastructure play a key role in determining the impact of the knowledge translation interventions. Future studies should explore how these factors can be fostered and/or developed within organisations. While KBs implemented the knowledge translation intervention in this study, more research is needed to understand the impact of all change agent roles including KBs, as well as how these roles can be maintained in the long-term if proven effective.

Visual Abstracts to Disseminate Geriatrics Research Through Social Media.
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L. A. Lindquist and V. Ramirez-Zohfeld.
J Am Geriatr Soc 2019 Jun;67(6):1128-1131
Dissemination of cutting-edge geriatrics-focused research is essential for academic geriatrics researchers, clinicians, and older adults and their caregivers. Social media channels, such as Twitter, provide a means of quickly reaching a wide array of users, globally. Besides standard tweets with links to research articles, visual abstracts are a means of delivering research results visually to end users succinctly. We compared the use of a standard tweet with a linked article with a tweet that held an added visual abstract, for a recent Journal of the American Geriatrics Society article. While the standard tweet received 24 984 impressions with 17 retweets and 36 likes over 8 days, the visual abstract inclusive tweet received 168 447 impressions with 81 retweets and 100 likes in 4 days. To assist researchers on future visual abstract development, we provide a framework and real-world guide on translation of research abstracts into visual abstracts. We hope that by providing evidence and the means to create visual abstracts, researchers in geriatrics may be empowered to disseminate their research through this method and potentially advance the care of older adults worldwide.

Patient and Public Engagement in Integrated Knowledge Translation Research: Are we there yet?
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D. Banner, M. Bains, S. Carroll, et al.
Res Involv Engagem 2019 Feb 12;5:8-019-0139-1. eCollection 2019
There have been many attempts to improve how healthcare services are developed and delivered. Despite this, we know that there are many gaps and differences in practice and that these can lead to poor patient outcomes. In addition, there are also concerns that research is being undertaken that does not reflects the realities or needs of those using healthcare services, and that the use of research findings in practice is slow. As such, shared approaches to research, such as integrated knowledge translation, are being used.Integrated knowledge translation (IKT) is a research approach that brings together researchers, along with other stakeholders that have knowledge about a particular healthcare issue. Stakeholders may include healthcare providers and policy-makers. More recently, there has been a growing awareness of the need to include patients and members of the public within research processes. These collaborative and patient-oriented research approaches are seen as a way to develop research that tackles ongoing gaps in practice and reflect the insights, needs and priorities of those most affected by health research outcomes. Despite great support, little is known about how these major research approaches are connected, or how they may bring about improvements in the development and use of research evidence. In this paper, we examine how IKT and patient engagement processes are linked, as well as exploring where differences exist. Through this, we highlight opportunities for greater patient engagement in IKT research and to identify areas that need to be understood further. Abstract: Healthcare organizations across the world are being increasingly challenged to develop and implement services that are evidence-based and bring about improvement in patient and health service outcomes. Despite an increasing emphasis upon evidence-based practice, large variations in practice remain and gaps pervade in the creation and application of knowledge that improves outcomes. More collaborative models of health research have emerged over recent years, including integrated knowledge translation (IKT), whereby partnerships with key knowledge users are developed to enhance the responsiveness and application of the findings. Likewise, the meaningful engagement of patients, in addition to the inclusion of patient-reported outcomes and priorities, has been hailed as another mechanism to improve the relevance, impact and efficiency of research.Collectively, both IKT and patient engagement processes provide a vehicle to support research that can address health disparities and improve the delivery of effective and responsive healthcare services. However, the evidence to support their impact is limited and while these approaches are inextricably connected through their engagement focus, it is unclear how IKT and patient engagement processes are linked conceptually, theoretically, and practically. In this paper, we will begin to critically examine some of the linkages and tensions that exist between IKT and patient-engagement for research and will examine potential opportunities for IKT researchers as they navigate and enact meaningful partnerships with patients and the public.

Process outcomes of a multifaceted, interdisciplinary knowledge translation intervention in aged care: results from the vitamin D implementation (ViDAus) study.
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P. Walker, A. Kifley, S. Kurrle and I. D. Cameron.
BMC Geriatr 2019 Jun 25;19(1):177-019-1187-y
Vitamin D supplement use is recommended best practice in residential aged care facilities (RACFs) for the prevention of falls, however has experienced delays in uptake. Following successful international efforts at implementing this evidence into practice, the ViDAus study sought to replicate this success for the Australian context. The aim of this paper is to report on the process outcomes of implementing this intervention. METHODS: Forty-one RACFs were engaged in a multifaceted, interdisciplinary knowledge translation intervention. This focused on raising awareness to improve knowledge on vitamin D, and supporting facilities to identify barriers and implement locally devised strategies to improve the uptake of evidence based practice (EBP). RESULTS: Staff members of participating facilities (n = 509 including nursing, care and allied health staff) were well engaged and accepting of the intervention, though engagement of servicing general practitioners (GPs) (n = 497) and pharmacists (n = 9) was poor. Facilities each identified between three and eight strategies focused on raising awareness, identifying residents to target for vitamin D and creating referral pathways depending upon their own locally identified barriers and capacity. There was variable success at implementing these over the 12-month intervention period. Whilst this study successfully raised awareness among staff, residents and their family members, barriers were identified that hindered engagement of GPs. CONCLUSIONS: The intervention was overall feasible to implement and perceived as appropriate by GPs, pharmacists, facility staff, residents and family members. More facilitation, higher-level organisational support and strategies to improve RACF access to GPs however were identified as important improvements for the implementation of vitamin D supplement use. TRIAL REGISTRATION: Retrospectively registered (ANZCTR ID: ACTRN12616000782437 ) on 15 June 2016.


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Health Care Administration and Organization

Significance of advance care planning in nursing homes: views from patients with cognitive impairment, their next of kin, health personnel, and managers.
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T. J. L. Saevareid, R. Forde, L. Thoresen, L. Lillemoen and R. Pedersen.
Clin Interv Aging 2019 May 29;14:997-1005
Advance care planning (ACP) performed by regular staff, which also includes patients with cognitive impairment and their next of kin, is scarcely studied. Thus, we planned an implementation study including key stakeholders (patients, next of kin, and health care personnel) using a whole-ward/system approach to ACP. We explored how they experienced ACP and its significance. Patients and methods: This qualitative study is part of a mixed-method implementation study of ACP. In four nursing homes, we did qualitative interviews and audio-recordings of meetings. We completed 20 individual semistructured interviews with participants soon after ACP conversations. The interviews included patients with cognitive impairment, their next of kin, and health care personnel. We also conducted four focus group interviews with staff and managers in the nursing homes and audio-recorded four network meetings with the project teams implementing ACP. Results: All participants appreciated taking part in ACP. Patients and next of kin focused more on the past and present than future treatment preferences. Still, ACP seemed to contribute to a stronger patient focus on end-of-life conversations. More generally, ACP seemed to contribute to valuable information for future decision-making, trusting relations, improved end-of-life communication, and saving time and resources. Conclusion: Safeguarding a strong patient focus on ACP and fostering a person-centered care culture in nursing home wards seem to be achievable through implementation of ACP that includes regular staff, patients with cognitive impairment, and their next of kin.

Designing and pilot testing of a leadership intervention to improve quality and safety in nursing homes and home care (the SAFE-LEAD intervention).
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T. Johannessen, E. Ree, T. Stromme, I. Aase, R. Bal and S. Wiig.
BMJ Open 2019 Jun 17;9(6):e027790-2018-027790
To describe the design of a leadership intervention for nursing home and home care, including a leadership guide for managers to use in their quality and safety improvement work. The paper reports results from the pilot test of the intervention and describes the final intervention programme. DESIGN: Qualitative design, using the participation of stakeholders. METHODS: The leadership guide and intervention were designed in collaboration with researchers, coresearchers and managers in nursing homes and home care organisations, through workshops and focus group interviews. The pilot test consisted of three workshops with managers working on the leadership guide, facilitated and observed by researchers, and evaluated by means of observation and focus group interviews with the participants. The analysis combined the integration of data from interviews and observations with directed content analysis. SETTING: Norwegian nursing homes and home care services. PARTICIPANTS: Managers at different levels in three nursing homes and two home care services, coresearchers, and patient and next-of-kin representatives. RESULTS: The managers and coresearchers suggested some revisions to the leadership guide, such as making it shorter, and tailoring the terminology to their setting. Based on their suggestions, we modified the intervention and developed learning resources, such as videos demonstrating the practical use of the guide. Evaluation of the pilot test study showed that all managers supported the use of the guide. They adapted the guide to their organisational needs, but found it difficult to involve patients in the intervention. CONCLUSIONS: A participatory approach with stakeholders is useful in designing a leadership intervention to improve quality and safety in nursing homes and home care, although patient participation in its implementation remains difficult. The participatory approach made it easier for managers to adapt the intervention to their context and to everyday quality and safety work practice.

Integration of Palliative Care and Infection Management at End-of-Life in US Nursing Homes.
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P. W. Stone, M. Agarwal, F. Ye, M. Sorbero, S. C. Miller and A. W. Dick.
J Pain Symptom Manage 2019 Jun 10
Infections in nursing home (NH) residents are often terminal illnesses. Integration of palliative care (PC) and infection management (IM), is a new concept that can help reduce burdensome treatments and improve quality of care for NH residents at the end-of-life. OBJECTIVES: To develop measures of integration, describe the integration in US NHs, and examine predictors of integration. METHODS: A nationally representative sample of NHs was surveyed. An instrument to measure integration was tested using factor analyses. Descriptive analyses were conducted of each integration factor, construct validity was examined using correlations between the integration factors and validated measures of PC and IM, and multivariable linear regression models were developed to identify NH characteristics associated with integration. RESULTS: 892 NH surveys were returned (49% response rate), 859 with complete data. Three integration factors were identified: Patient Involvement in Care Planning (Involvement), Formalized Advance Care Planning (Advance Care Planning), and Routine Practices of Integration (Routine Practices). The highest level of integration in NHs was reported for Involvement (mean (mu) = 73.2, Standard error (SE) = 1.57), with lower rates for Advance Care Planning and Routine Practices (respectively mu = 34.1, SE = 1.05; mu = 31.4, SE = 1.48). Each integration measure was weakly, positively associated with the PC and IM measures (r </= 0.25, P</= 0.01). There were few associations between NH characteristics and integration. CONCLUSION: Integration is a distinct concept that is associated but different from PC and IM. Results serve as a baseline assessment of integration in NHs. Continued refinement of the integration instrument is recommended as is studying if higher integration leads to better resident outcomes.

Perception Versus Performance of Swallow Function in Residents of Long-Term Care.
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A. M. Namasivayam-MacDonald, C. M. Steele and H. H. Keller.
Am J Speech Lang Pathol 2019 Jun 13:1-8
The purpose of this study was to determine if older adults residing in long-term care were able to accurately self-report their swallowing status by comparing subjective complaints of dysphagia and objective methods of swallowing screening. Method Data were collected from 397 residents of long-term care ( M age = 86.8 years +/- 7.8; 263 female). Cognitive impairment scores were collected, and each resident was asked (a) if they thought they had a swallowing problem, (b) if they coughed/choked when they ate, and (c) if they coughed/choked when they drank. These responses were compared to results of a swallowing screening tool and mealtime observations of coughing and choking. Results Residents who reported swallowing difficulties (10%, n = 41) were 8 times more likely to fail the swallowing screening ( p < .001); however, 80% of residents who failed the swallowing screening did not previously report that swallowing was an issue. There was no significant association between self-reports of coughing and choking at meals and observations. There was no difference in level of cognition between residents who accurately reported swallowing status and those who were inaccurate. Conclusions Residents are largely unable to accurately self-report swallowing difficulties and also have difficulty accurately reporting incidences of coughing and choking. These findings suggest that concerted efforts are required to implement regular, formal swallowing screening protocols in long-term care to objectively identify those at risk.

Peer-enabled staff training in residential care settings as means for promoting person-centred dementia care.
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S. H. J. du Toit, Y. L. Chan, G. M. Jessup and J. Weaver.
Aging Ment Health 2019 Jun 10:1-10
Person-centred care (PCC) is regarded as best practice within dementia care, however there is a gap between the understanding and the implementation of this type of care practice. The Peer Enablement Program (PEP) incorporates a group problem solving model for promoting PCC of residents with moderate to advanced dementia living in care facilities. Objective: Trained PEP facilitators introduced the program to selected staff from an organisation with 99 facilities across Australia. The objective of this study was to identify what particular aspects of the PEP these facilitators valued for advancing PCC and care culture change. Method: An embedded mixed methods study design guided this investigation. The qualitative component of the study focussed on the insights of the nine PEP facilitators who presented the workshops. This information was supported and contrasted with descriptive data generated from 322 workshop feedback forms by attendees over the course of the three workshops presented nationally. Results: Facilitators identified peer support as the most valued aspect of the PEP. It promoted collaboration among attendees; supported development of their occupational identities as transformational leaders; and created communities of practice with potential to sustain advances in PCC. Conclusions: The PEP has the potential to advance PCC. Further research is needed to evaluate the long-term sustainability of these advances and to determine if this program can be utilised more widely, both in a national and international context.

From fragmentation toward integration: a preliminary study of a new long-term care policy in a fast-aging country.
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T. Y. Chiu, H. W. Yu, R. Goto, et al.
BMC Geriatr 2019 Jun 7;19(1):159-019-1172-5
Taiwan, one of the fastest-aging countries in the world, started implementing version 1.0 of its long-term care (LTC) plan in 2008. In 2017, LTC Plan 2.0 began a new era with its goal to integrate Taiwan’s fragmented LTC service system. LTC Plan 2.0 also aims to establish an integrated community-based LTC system incorporating both health care and disability prevention. This three-tier model consists of the following: two LTC services with a day-care center as their base and case management (Tier A), a day-care center and a single LTC service (Tier B), and LTC stations that provide primary prevention services and respite services for frail community-dwelling older adults to prevent further disabilities (Tier C). A defined cluster of agencies in a local area works together as a Tier ABC team. LTC Plan 2.0 is a new policy for Taiwan, and hence it is important to understand the agencies’ initial difficulties with implementation and identify future challenges to help further policy development. METHODS: This preliminary study explored the challenges to implementing LTC 2.0 through in-depth interviews based on Evashwick’s integration mechanisms with representatives from three service teams. We interviewed three chief executive officers and three case managers. RESULTS: We found that the LTC Plan 2.0 mechanisms for service integration have been insufficiently implemented. Recommendations include (1) Build up the trust between agencies and government, avoid duplication of LTC services within Tier ABC team, and encourage agencies within a team to create a shared administrative system with the same mission and vision. (2) Clarify the roles and responsibilities of government care managers and agency case managers. (3) Provide an integrated information system and create an official platform for sharing client records across different agencies and caregivers. (4) Establish a tool and platform to track the budget and payment across different levels of service as soon as possible. CONCLUSION: There is an increased demand for LTC services in Taiwan because of its rapidly aging population. Our findings shed some light on the challenges to developing integrated LTC services and thus may help both policymakers and service providers find ways to overcome these challenges.

A collective case study of the features of impactful dementia training for care home staff.
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C. A. Surr, C. Sass, M. Drury, et al.
BMC Geriatr 2019 Jun 25;19(1):175-019-1186-z
Up to 80% of care home residents have dementia. Ensuring this workforce is appropriately trained is of international concern. Research indicates variable impact of training on a range of resident and staff outcomes. Little is still known about the most effective approaches to the design, delivery and implementation of dementia training. This study aimed to investigate the features and contextual factors associated with an effective approach to care home staff training on dementia. METHODS: An embedded, collective case study was undertaken in three care home provider organisations who had responded to a national training audit. Data collected included individual or small group interviews with training leads, facilitators, staff attending training, managers, residents and their relatives. Observations of care practice were undertaken using Dementia Care Mapping. Training delivery was observed and training materials audited. A within case analysis of each site, followed by cross case analysis using convergence coding was undertaken. RESULTS: All sites provided bespoke, tailored training, delivered largely using face-to-face, interactive methods, which staff and managers indicated were valuable and effective. Self-study booklets and on-line learning where were used, were poorly completed and disliked by staff. Training was said to improve empathy, knowledge about the lived experience of dementia and the importance of considering and meeting individual needs. Opportunities to continually reflect on learning and support to implement training in practice were valued and felt to be an essential component of good training. Practice developments as a result of training included improved communication, increased activity, less task-focussed care and increased resident well-being. However, observations indicated positive well-being and engagement was not a consistent experience across all residents in all sites. Barriers to training attendance and implementation were staff time, lack of dedicated training space and challenges in gaining feedback on training and its impact. Facilitators included a supportive organisational ethos and skilled training facilitation. CONCLUSIONS: Effective training is tailored to learners’, delivered face-to-face by an experienced facilitator, is interactive and is embedded within a supportive organisational culture/ethos. Further research is needed on the practical aspects of sustainable and impactful dementia training delivery and implementation in care home settings.

Contradictions in information technology mediated work in long-term care: An activity theoretic ethnographic study.
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S. Qian, P. Yu and A. Bhattacherjee.
Int J Nurs Stud 2019 Jun 8;98:9-18
The growing demand for aged care services coupled with a global shortage of skilled nursing staff has hindered long-term care facilities’ ability to provide necessary services to their residents. Healthcare information technology is expected to mitigate this challenge by streamlining nursing work, while also improving quality of care and productivity. OBJECTIVES: This study set out to examine how nurses and care workers work, the role of information technology (IT) in their work and what contradictions they face in their IT mediated work. DESIGN: Ethnographic study informed by six components of activity theory: subject, object, tool, rule, community and division of labor. SETTING: Eight care units in two long-term care facilities in Australia. PARTICIPANTS: Eleven staff from two long-term care facilities including registered nurses (n=2), endorsed enrolled nurses (n=5) and personal care workers (n=4) participated in this study. METHODS: Participants were shadowed during morning shifts (6:30 am to 3:00 pm). A total of 24 morning shifts were observed over four months. Field notes were created based on observational data and informal interviews, in addition to document review. RESULTS: Through the lens of activity theory, the work activity system of nurses and care workers in the long-term care facilities consisted of the subject (nurses and care workers), their object (resident care), tools used for work including IT, rules of work, community, and division of labor. These components interacted through work processes; therefore, a “process” component was added in the activity system. Special attention was given to the role of IT as the conduit of information in the work processes. Although IT helped track medication rounds, automated documentation and communication among the staff, it introduced contradictions. Seven contradictions involving IT were identified, including contradictions within the IT tool, between the IT tool and the object of work, between the subjects and documentation rules, between the work activity system using paper records and the system using IT, and between the activity system within the long-term care facility and the pharmacists’ work activity system outside the facility. CONCLUSIONS: Activity theory provided a theoretic framework to model the work activity system of nurses and care workers. Information technology played an important role in supporting information flow in this system, however it also caused contradictions.

Generation of a function affect model for residents with advanced dementia.
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E. Chang, M. Edenborough, D. Nicholls, A. Johnson, S. Brownhill and J. Simard.
Int J Nurs Pract 2019 Apr;25(2):e12718
This article presents the generation of a model of care encompassing “function” and “affect” based on findings from a 2011 research project aimed at improving care delivery for people with advanced dementia. Objectives were to provide comprehensive and sustainable care, honouring and respecting the person. BACKGROUND: Dementia is a debilitating, progressive, and terminal disease with a trajectory ranging from approximately 3 to 16 years, yet attention to end-of-life care, promoting comfort, alleviating suffering, and maximizing quality of life is frequently overlooked for people living in the advanced stages of the disease. METHODS: The research project from which the model was drawn used a three-phase mixed methods approach at three residential aged care facilities (nursing homes) providing high care in New South Wales, Australia. Thematic analysis was elicited from focus group discussions with staff, family members, and carers of residents. FINDINGS: Themes describe distinct dimensions of a model of care: “function” (dedication, designation, and deliberation) and “affect” (the personal outcomes revealed in relaxation, stimulation, and transformation). CONCLUSION: Reframing nursing practice from task and disease orientation to person centred and relationship focused is essential in meeting the complete needs of people with advanced dementia. This transformational model of care may be useful in adapting to other end-of-life care settings.

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Health Care Innovation and Quality Assurance

Nursing Home Characteristics Associated With Implementation of an Advance Care Planning Video Intervention.
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L. Loomer, E. McCreedy, E. Belanger, et al.
J Am Med Dir Assoc 2019 Jul;20(7):804-809.e1
Advance care planning (ACP) is important to ensure that nursing home (NH) residents receive care concordant with their goals. Video interventions have been developed to improve the process of ACP. Yet, little is known about which NH characteristics are associated with implementation of ACP video interventions in clinical practice. Our objective was to examine NH-level characteristics associated with the implementation of an ACP video intervention as part of the Pragmatic trial of Video Education in Nursing Homes (PROVEN) trial. DESIGN: Cross-sectional study of NHs in PROVEN. SETTING AND PARTICIPANTS: 119 NHs randomized to receive the ACP video intervention. MEASUREMENTS: The outcomes were the proportion of short- (/=100 days) NH residents who were (1) offered to watch a video and (2) shown a video, aggregated to the NH-level, and measured using electronic forms of video offers. The association between outcomes and NH facility characteristics (eg, staffing, resident acuity) and participation in other aspects of the PROVEN trial (eg, monthly check-in calls) were estimated using multivariate linear regression models. NH characteristics were measured using data from Online Survey Certification and Reporting data, Long-term Care: Facts on Care in the US and NH Compare. RESULTS: Offer rates were 69% [standard deviation (SD): 28] for short-stay and 56% (SD: 20) for long-stay residents. Show rates were 19% (SD: 21) for short-stay and 17% (SD: 17) for long-stay residents. After adjusting for NH characteristics, compared to 1-star NHs, higher star-rated NHs had higher offer rates. Champions’ participation in check-in calls was positively associated with both outcomes for long-stay residents. CONCLUSIONS/IMPLICATIONS: Lower-quality NHs seem unable to integrate a novel ACP video education program into routine care processes. Ongoing support for and engagement with NH staff to champion the intervention throughout implementation is important for the success of a pragmatic trial within NHs.

Towards successful digital transformation through co-creation: a longitudinal study of a four-year implementation of digital monitoring technology in residential care for persons with dementia.
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J. Dugstad, T. Eide, E. R. Nilsen and H. Eide.
BMC Health Serv Res 2019 Jun 10;19(1):366-019-4191-1
Implementation of digital monitoring technology systems is considered beneficial for increasing the safety and quality of care for residents in nursing homes and simultaneously improving care providers’ workflow. Co-creation is a suitable approach for developing and implementing digital technologies and transforming the service accordingly. This study aimed to identify the facilitators and barriers for implementation of digital monitoring technology in residential care for persons with dementia and wandering behaviour, and explore co-creation as an implementation strategy and practice. METHODS: In this longitudinal case study, we observed and elicited the experiences of care providers and healthcare managers in eight nursing homes, in addition to those of the information technology (IT) support services and technology vendors, during a four-year implementation process. We were guided by theories on innovation, implementation and learning, as well as co-creation and design. The data were analysed deductively using a determinants of innovation framework, followed by an inductive content analysis of interview and observation data. RESULTS: The implementation represented radical innovation and required far more resources than the incremental changes anticipated by the participants. Five categories of facilitators and barriers were identified, including several subcategories for each category: 1) Pre-implementation preparations; 2) Implementation strategy; 3) Technology stability and usability; 4) Building competence and organisational learning; and 5) Service transformation and quality management. The combination of IT infrastructure instability and the reluctance of the IT support service to contribute in co-creating value with the healthcare services was the most persistent barrier. Overall, the co-creation methodology was the most prominent facilitator, resulting in a safer night monitoring service. CONCLUSION: Successful implementation of novel digital monitoring technologies in the care service is a complex and time-consuming process and even more so when the technology allows care providers to radically transform clinical practices at the point of care, which offers new affordances in the co-creation of value with their residents. From a long-term perspective, the digital transformation of municipal healthcare services requires more advanced IT competence to be integrated directly into the management and provision of healthcare and value co-creation with service users and their relatives.

Evaluating the design and implementation of the whole systems integrated care programme in North West London: why commissioning proved (again) to be the weakest link.
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J. Smith, G. Wistow, H. Holder and M. Gaskins.
BMC Health Serv Res 2019 Apr 15;19(1):228-019-4013-5
Commissioning is a term used in the English National Health Service (NHS) to refer to what most health systems call health planning or strategic purchasing. Drawing on research from a recent in-depth mixed methods study of a major integrated care initiative in North West London, we examine the role of commissioning in attempts to secure large-scale change within and between health and social care services to support the delivery of integrated care for people living with complex long-term conditions. METHODS: We analysed data collected in semi-structured interviews, surveys, workshops and non-participant observations using a thematic framework derived both deductively from the literature on commissioning and integrated care, as well as inductively from our coding and analysis of interview data. RESULTS: Our findings indicate that commissioning has significant limitations in enabling large-scale change in health services, particularly in engaging providers, supporting implementation, and attending to both its transactional and relational dimensions. CONCLUSIONS: Our study highlights the consequences of giving insufficient attention to implementation, and especially the need for commissioners to enable, support and performance manage the delivery of procured services, while working closely with providers at all times. We propose a revised version of Ovretveit’s cycle of commissioning that gives greater emphasis to embedding effective implementation processes within models of commissioning large-scale change.

Deprescribing antipsychotics for behavioural and psychological symptoms of dementia and insomnia: Evidence-based clinical practice guideline.
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L. M. Bjerre, B. Farrell, M. Hogel, et al.
Can Fam Physician 2018 Jan;64(1):17-27
To develop an evidence-based guideline to help clinicians make decisions about when and how to safely taper and stop antipsychotics; to focus on the highest level of evidence available and seek input from primary care professionals in the guideline development, review, and endorsement processes. METHODS: The overall team comprised 9 clinicians (1 family physician, 1 family physician specializing in long-term care, 1 geriatric psychiatrist, 2 geriatricians, 4 pharmacists) and a methodologist; members disclosed conflicts of interest. For guideline development, a systematic process was used, including the GRADE (Grading of Recommendations Assessment, Development and Evaluation) approach. Evidence was generated from a Cochrane systematic review of antipsychotic deprescribing trials for the behavioural and psychological symptoms of dementia, and a systematic review was conducted to assess the evidence behind the benefits of using antipsychotics for insomnia. A review of reviews of the harms of continued antipsychotic use was performed, as well as narrative syntheses of patient preferences and resource implications. This evidence and GRADE quality-of-evidence ratings were used to generate recommendations. The team refined guideline content and recommendation wording through consensus and synthesized clinical considerations to address common front-line clinician questions. The draft guideline was distributed to clinicians and stakeholders for review and revisions were made at each stage. RECOMMENDATIONS: We recommend deprescribing antipsychotics for adults with behavioural and psychological symptoms of dementia treated for at least 3 months (symptoms stabilized or no response to an adequate trial) and for adults with primary insomnia treated for any duration or secondary insomnia in which underlying comorbidities are managed. A decision-support algorithm was developed to accompany the guideline. CONCLUSION: Antipsychotics are associated with harms and can be safely tapered. Patients and caregivers might be more amenable to deprescribing if they understand the rationale (potential for harm), are involved in developing the tapering plan, and are offered behavioural advice or management. This guideline provides recommendations for making decisions about when and how to reduce the dose of or stop antipsychotics. Recommendations are meant to assist with, not dictate, decision making in conjunction with patients and families.

Quasi-experimental evaluation of a multifaceted intervention to improve quality of end-of-life care and quality of dying for patients with advanced dementia in long-term care institutions.
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R. Verreault, M. Arcand, L. Misson, et al.
Palliat Med 2018 Mar;32(3):613-621
Improvement in the quality of end-of-life care for advanced dementia is increasingly recognized as a priority in palliative care. AIM: To evaluate the impact of a multidimensional intervention to improve quality of care and quality of dying in advanced dementia in long-term care facilities. DESIGN: Quasi-experimental study with the intervention taking place in two long-term care facilities versus usual care in two others over a 1-year period. The intervention had five components: (1) training program to physicians and nursing staff, (2) clinical monitoring of pain using an observational pain scale, (3) implementation of a regular mouth care routine, (4) early and systematic communication with families about end-of-life care issues with provision of an information booklet, and (5) involvement of a nurse facilitator to implement and monitor the intervention. Quality of care was assessed with the Family Perception of Care Scale. The Symptom Management for End-of-Life Care in Dementia and the Comfort Assessment in Dying scales were used to assess the quality of dying. PARTICIPANTS: A total of 193 residents with advanced dementia and their close family members were included (97 in the intervention group and 96 in the usual care group). RESULTS: The Family Perception of Care score was significantly higher in the intervention group than in the usual care group (157.3 vs 149.1; p = 0.04). The Comfort Assessment and Symptom Management scores were also significantly higher in the intervention group. CONCLUSIONS: Our multidimensional intervention in long-term care facilities for patients with terminal dementia resulted in improved quality of care and quality of dying when compared to usual care.

Effects on pain of a stepwise multidisciplinary intervention (STA OP!) that targets pain and behavior in advanced dementia: A cluster randomized controlled trial.
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M. J. C. Pieper, J. T. van der Steen, A. L. Francke, E. J. A. Scherder, J. W. R. Twisk and W. P. Achterberg.
Palliat Med 2018 Mar;32(3):682-692
Pain in nursing home residents with advanced dementia remains a major challenge; it is difficult to detect and may be expressed as challenging behavior. STA OP! aims to identify physical and other needs as causes of behavioral changes and uses a stepwise approach for psychosocial and pharmacological management which was effective in improving challenging behavior. AIM: To assess whether implementation of the stepwise multidisciplinary intervention also reduces pain and improves pain management. DESIGN: In a cluster randomized controlled trial (Netherlands National Trial Register NTR1967), healthcare professionals of intervention units received the stepwise training, while training of the control group focused on knowledge and skills without the stepwise component. Observed and estimated pain was assessed at baseline and at 3 and 6 months post-intervention. Logistic generalized estimating equations were used to test treatment and time effects. SETTING/PARTICIPANTS: A total of 21 clusters (single nursing home units) in 12 Dutch nursing homes included 288 residents with advanced dementia (Global Deterioration Scale score 5, 6, or 7): 148 in the intervention and 140 in the control condition. RESULTS: The multilevel modeling showed an overall effect of the intervention on observed pain but not on estimated pain; Pain Assessment Checklist for Seniors with Limited Ability to Communicate-Dutch version, mean difference: -1.21 points (95% confidence interval: -2.35 to -0.06); Minimum Dataset of the Resident Assessment Instrument pain scale, mean difference: -0.01 points (95% confidence interval: -0.36 to 0.35). Opioid use increased (odds ratio = 3.08; 95% confidence interval: 1.08-8.74); paracetamol use did not (odds ratio = 1.38; 95% confidence interval: 0.71-2.68). CONCLUSION: STA OP! was found to decrease “observed” pain but not estimated pain. Observing pain-related behavior might help improve pain management in dementia.

Would reframing aged care facilities as a ‘hospice’ instead of a ‘home’ enable older people to get the care they need?
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J. L. Phillips and D. C. Currow.
Collegian 2017;24(1):1-2.
‘Home’ is a concept that is central to our sense of self. It is about belonging and having an environment that is uniquely one’s own, reflecting one’s personality and provides security (Collier, Phillips, & Iedema, 2015). In hospice and/or palliative care, the concept of ‘home’ is important to many people in terms of where their care is provided and, for some, also where they actually die (Agar et al., 2008). Most people indicate that institutional care beyond an acute illness is a less preferable place of care and that they ideally want to spend as many days as possible at home.

The development of Nursing Quality Care Process Metrics and Indicators for use in Older Persons Care Settings: A Delphi-Consensus Study.
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F. Murphy, O. Doody, R. Lyons, et al.
J Adv Nurs 2019 Jun 25
To develop a suite of nursing quality care process metrics and indicators for older persons care settings in Ireland. BACKGROUND: Regulatory investigations of health system failures highlight non-adherence to clinical guidelines and standards resulting in deficiencies in nursing care delivery. Limited attention has been paid to measuring nursing care processes particularly in the care of older people. Quality care process metrics can facilitate measurement of nurse sensitive measures of care. DESIGN: A scoping literature review and modified Delphi-Consensus Technique. METHODS: A scoping review of literature published between January 2007 – January 2017 was conducted to identify nursing process metrics and indicators. The Delphi-Consensus phase incorporated a four-round electronic survey of 404 nurses and a consensus meeting with 13 stakeholders working in Older Persons Care Settings in Ireland. FINDINGS: From the review, 33 potential metrics were identified. After all Delphi survey rounds, 20 metrics and 90 associated indicators were selected by the nurses. Following the consensus meeting, 19 metrics and 80 indicators were included in the final suite of nursing quality care process metrics and indicators. CONCLUSION: Developing this suite of Nursing Quality Care Process Metrics and Indicators for use in Older Persons Care Settings provided consensus on what nursing processes should be measured to improve the quality and safety of care delivery. IMPACT: The nursing processes identified, provide a framework for future research and educational programmes in the care of older persons. Although conducted in the Irish healthcare system, there is potential for adoption or adaption in other healthcare settings. This article is protected by copyright. All rights reserved.

Application of the GheOP3S-tool in nursing home residents: acceptance and implementation of pharmacist recommendations.
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K. Foubert, P. Muylaert, E. Mehuys, A. Somers, M. Petrovic and K. Boussery.
Acta Clin Belg 2019 Jun 26:1-9
The prevalence of potentially inappropriate prescribing (PIP) among nursing home (NH) residents is high. This study aimed to investigate the acceptance and implementation of pharmacist recommendations based on a screening tool for PIP, the Ghent Older People’s Prescriptions community Pharmacy Screening (GheOP(3)S)-tool. Setting and method: Prospective observational study in NH residents (>/= 70 years, using >/= 5 medications) with a 3-month follow-up period. A pharmacist screened the medication lists using the GheOP(3)S-tool and formulated recommendations to reduce PIP. The acceptance of recommendations discussed during face-to-face pharmacist-general practitioner (GP) meetings was recorded. Implementation was examined by comparing baseline and follow-up medication lists. A pre-post comparison of the number of chronic medications and GheOP(3)S-criteria; the anticholinergic and sedative burden quantified by the Drug Burden Index (DBI); and medication costs was performed. Results: Screening with the GheOP(3)S-tool resulted in 168 pharmacist recommendations for 50 NH residents, mainly to stop (78.0%) and to substitute (14.3%) medications. Ninety-three % (156/168) of recommendations were considered relevant. GPs acceptance rate was 44.9%. Fifty-four % of all accepted recommendations were implemented. At follow-up, the number of chronic medications (p = 0.007), and DBI scores (p = 0.004) significantly differed from baseline. There was no significant decrease in the number of GheOP(3)S-criteria (p = 0.075) and medication costs (p > 0.05). Conclusion: The acceptance and implementation of pharmacist recommendations were relatively low. Future studies should increase the involvement of patients and all health-care providers. Interdisciplinary collaboration with sufficient education for all disciplines and patients is essential.

A Systematic Literature Review of Efficiency Measurement in Nursing Homes.
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A. Tran, K. H. Nguyen, L. Gray and T. Comans.
Int J Environ Res Public Health 2019 Jun 20;16(12):10.3390/ijerph16122186
As our population ages at an increasing rate, the demand for nursing homes is rising. The challenge will be for nursing homes to maintain efficiency with limited resources while not compromising quality. This study aimed to review the nursing home efficiency literature to survey the application of efficiency methods and the measurements of inputs, outputs, facility characteristics and operational environment, with a special focus on quality measurement. Methods: We systematically searched three databases for eligible studies published in English between January 1995 and December 2018, supplemented by an exhaustive search of reference lists of included studies. The studies included were available in full text, their units of analysis were nursing homes, and the analytical methods and efficiency scores were clearly reported. Results: We identified 39 studies meeting the inclusion criteria, of which 31 accounted for quality measures. Standard efficiency measurement techniques, data envelopment analysis and stochastic frontier method, and their specifications (orientation, returns to scale, functional forms and error term assumptions) were adequately applied. Measurements of inputs, outputs and control variables were relatively homogenous while quality measures varied. Notably, most studies did not include all three quality dimensions (structure, process and outcome). One study claimed to include quality of life; however, it was not a well-validated and widely used measure. The impacts of quality on efficiency estimates were mixed. The effect of quality on the ranking of nursing home efficiency was rarely reported. Conclusions: When measuring nursing home efficiency, it is crucial to adjust for quality of care and resident’s quality of life because the ultimate output of nursing homes is quality-adjusted days living in the facility. Quality measures should reflect their multidimensionality and not be limited to quality of throughput (health-related events). More reliable estimation of nursing home efficiencies will require better routine data collection within the facility, where well-validated quality measures become an essential part of the minimum data requirement. It is also recommended that different efficiency methods and assumptions, and alternative measures of inputs, outputs and quality, are used for sensitivity analyses to ensure the robustness and validity of findings.

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Research Practice and Methodology

Global Long-Term Care Research: A Scientometric Review.
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L. Fu, Z. Sun, L. He, F. Liu and X. Jing.
Int J Environ Res Public Health 2019 Jun 12;16(12):10.3390/ijerph1612207
Since the early 1960s, long-term care (LTC) has attracted a broad range of attention from public health practitioners and researchers worldwide and produced a large volume of literature. We conducted a comprehensive scientometric review based on 14,019 LTC articles retrieved from the Web of Science Core Collection database from 1963 to 2018, to explore the status and trends of global LTC research. Using CiteSpace software, we conducted collaboration analysis, document co-citation analysis, and keyword co-occurrence analysis. The results showed a rapid increase in annual LTC publications, while the annual citation counts exhibited an inverted U-shaped relationship with years. The most productive LTC research institutions and authors are located primarily in North American and European countries. A simultaneous analysis of both references and keywords revealed that common LTC hot topics include dementia care, quality of care, prevalence and risk factors, mortality, and randomized controlled trial. In addition, LTC research trends have shifted from the demand side to the supply side, and from basic studies to practical applications. The new research frontiers are frailty in elderly people and dementia care. This study provides an in-depth understanding of the current state, popular themes, trends, and future directions of LTC research worldwide.

Recommended Common Data Elements for International Research in Long-Term Care Homes: Exploring the Workforce and Staffing Concepts of Staff Retention and Turnover.
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F. Zuniga, C. H. Chu, V. Boscart, et al.
Gerontol Geriatr Med 2019 May 10;5:2333721419844344-Dec
The aim of this review is to develop a common data element for the concept of staff retention and turnover within the domain of workforce and staffing. This domain is one of four core domains identified by the WE-THRIVE (Worldwide Elements to Harmonize Research in Long-Term Care Living Environments) group in an effort to establish an international, person-centered long-term care research infrastructure. A rapid review identified different measurement methods to assess either turnover or retention at facility level or intention to leave or stay at the individual staff level. The selection of a recommended measurement was guided by the WE-THRIVE group’s focus on capacity rather than deficits, the expected availability of internationally comparable data, and the goal to provide a short, ecologically viable measurement. We therefore recommend to measure staff’s intention to stay with a single item, at the individual staff level. This element, we argue, is an indicator of staff stability, which is important for reduced organizational cost and improved productivity, positive work environment, and better resident-staff relationships and quality of care.

Conducting Clinical Research in Post-acute and Long-term Nursing Home Care Settings: Regulatory Challenges.
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A. M. Gustavson, C. Drake, A. Lakin, et al.
J Am Med Dir Assoc 2019 Jul;20(7):798-803
Despite multiple initiatives in post-acute and long-term nursing home care settings (NHs) to improve the quality of care while reducing health care costs, research in NHs can prove challenging. Extensive regulation for both research and NHs is designed to protect a highly vulnerable population but can be a deterrent to conducting research. This article outlines regulatory challenges faced by NHs and researchers, such as protecting resident privacy as well as health information and obtaining informed consent. The article provides lessons learned to help form mutually beneficial partnerships between researchers and NHs to conduct studies that grow and advance NH research initiatives and clinical care.

Usability and acceptability of four systematic review automation software packages: a mixed method design.
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G. Cleo, A. M. Scott, F. Islam, B. Julien and E. Beller.
Syst Rev 2019 Jun 20;8(1):145-019-1069-6
New software packages help to improve the efficiency of conducting a systematic review through automation of key steps in the systematic review. The aim of this study was to gather qualitative data on the usability and acceptability of four systematic review automation software packages (Covidence, SRA-Helper for EndNote, Rayyan and RobotAnalyst) for the citation screening step of a systematic review. METHODS: We recruited three volunteer systematic reviewers and asked them to use allocated software packages during citation screening. They then completed a 12-item online questionnaire which was tailored to capture data for the software packages used. FINDINGS: All four software packages were reported to be easy or very easy to learn and use. SRA-Helper for EndNote was most favoured by participants for screening citations and Covidence for resolving conflicts. Overall, participants reported that SRA-Helper for EndNote would be their software package of choice, primarily due to its efficiency. CONCLUSION: This study identified a number of considerations which systematic reviewers can use as a basis of their decision which software to use when performing the citation screening and dispute resolution steps of a systematic review.

Reflecting on the research encounter for people in the early stages of dementia: Lessons from an embedded qualitative study.
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M. Abendstern, K. Davies, F. Poland, et al.
Dementia (London) 2019 Jun 13:1471301219855295
Gathering meaningful data from people with dementia presents challenges to researchers involved in both qualitative and quantitative studies. Careful planning and implementation are required, including skilful and sympathetic management by the researcher who must pay attention to the cognitive challenges experienced by the person with dementia. These challenges are particularly evident when conducting structured interviews using standardised measures. This paper presents the findings of an embedded qualitative study undertaken within a pragmatic randomised controlled trial. The novel method involves nesting a qualitative analysis within a quantitative study by recording incidental conversation during structured interviews, requiring no additional data collection. The method shone a light on the formal interview process itself, something rarely revealed outside the interview setting. It provided a unique insight into the challenges posed by research participation for people in early-stage dementia. Analysis revealed three main themes relating to dementia as a condition and to the research design. First, people with dementia contributed very few conversational comments during the structured interviews. Second, the context of the interview, that is: managing the conversational interchange, responding to direct and often sensitive questions and making decisions about day-to day-feelings and experiences was difficult for participants to manage. Third, people in early stage dementia struggled with the content of the structured interviews due to their linguistic and cognitive demands. The findings raise questions about how people with dementia are included in research and the methods employed to gather accurate data with minimal inconvenience and stress for research participants.

Investigating and Remediating Selection Bias in Geriatrics Research: The Selection Bias Toolkit.
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H. R. Banack, J. S. Kaufman, J. Wactawski-Wende, B. R. Troen and S. D. Stovitz.
J Am Geriatr Soc 2019 Jun 18
Selection bias is a well-known concern in research on older adults. We discuss two common forms of selection bias in aging research: (1) survivor bias and (2) bias due to loss to follow-up. Our objective was to review these two forms of selection bias in geriatrics research. In clinical aging research, selection bias is a particular concern because all participants must have survived to old age, and be healthy enough, to take part in a research study in geriatrics. DESIGN: We demonstrate the key issues related to selection bias using three case studies focused on obesity, a common clinical risk factor in older adults. We also created a Selection Bias Toolkit that includes strategies to prevent selection bias when designing a research study in older adults and analytic techniques that can be used to examine, and correct for, the influence of selection bias in geriatrics research. RESULTS: Survivor bias and bias due to loss to follow-up can distort study results in geriatric populations. Key steps to avoid selection bias at the study design stage include creating causal diagrams, minimizing barriers to participation, and measuring variables that predict loss to follow-up. The Selection Bias Toolkit details several analytic strategies available to geriatrics researchers to examine and correct for selection bias (eg, regression modeling and sensitivity analysis). CONCLUSION: The toolkit is designed to provide a broad overview of methods available to examine and correct for selection bias. It is specifically intended for use in the context of aging research.

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Improved patient participation through advance care planning in nursing homes-A cluster randomized clinical trial.
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T. J. L. Saevareid, L. Thoresen, E. Gjerberg, L. Lillemoen and R. Pedersen.
Patient Educ Couns 2019 Jun 6
To improve patient participation in advance care planning in nursing homes where most patients have some degree of cognitive impairment. METHODS: This was a pair-matched cluster randomized clinical trial with eight wards in eight Norwegian nursing homes. We randomized one ward from each of the matched pairs to the intervention group. We included all patients above 70. The primary outcome was prevalence of documented patient participation in end-of-life treatment conversations. The intervention included implementation support using a whole-ward approach where regular staff perform advance care planning and invite all patients and next of kin to participate. RESULTS: In intervention group wards the patients participated more often in end-of-life treatment conversations (p<0.001). Moreover, the patient’s preferences, hopes AND worries (p=0,006) were more often documented, and concordance between provided TREATMENT and patient preferences (p=0,037) and next of kin participation in advance care planning with the patient (p=0,056) increased. CONCLUSION: Improved patient participation – also when cognitively impaired – is achievable through advance care planning in nursing homes using a whole-ward approach. PRACTICE IMPLICATIONS: Patients with cognitive impairment should be included in advance care planning supported by next of kin. A whole-ward approach may be used to implement advance care planning. TRIAL REGISTRATION: ISRCTN registry (ID ISRCTN69571462) – retrospectively registered.

Determinants of the quality of care relationships in long-term care – a participatory study.
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A. Scheffelaar, M. Hendriks, N. Bos, K. Luijkx and S. van Dulmen.
BMC Health Serv Res 2019 Jun 14;19(1):389-019-4195-x
The quality of the care relationship between a client and a professional is important in long-term care, as most clients depend on support for a lengthy period. The three largest client groups who receive long-term care in the Netherlands are older adults who are physically or mentally frail, people with mental health problems and people with intellectual disabilities. There is little clarity about how generic and variable the determinants of the quality of care relationships are across these client groups. The aim of this study is to explore and compare the determinants of the quality of care relationships in these three client groups in long-term care. METHODS: This participatory study involving clients as co-researchers was held in three healthcare organizations, each providing long-term care to one client group. The research was conducted by three teams consisting of researchers and co-researchers. We interviewed clients individually and professionals in focus groups. The focus was on care relationships with professionals where there is weekly recurring contact for at least 3 months. Clients and professionals were selected using a convenience sample. The interviews were coded in open, axial and selective coding. The outcomes were compared between the client groups. RESULTS: The study sample consisted of 30 clients and 29 professionals. Determinants were categorized into four levels: client, professional, between client and professional, and context. The findings show that the majority of the determinants apply to the care relationships within all three client groups. At the professional level, eleven generic determinants were found. Eight determinants emerged at the client level of which two were found in two client groups only. At the level between a client and a professional, six determinants were found of which one applied to mental healthcare and disability care only. Five determinants were found at the contextual level of which two were specific for two client groups. CONCLUSIONS: The study yielded a variety of determinants that came to the fore in all three client groups in long-term care. This suggests that including a homogenous client group from a single care setting is not necessary when studying the quality of long-term care relationships.

Does Structured Exercise Improve Cognitive Impairment in People with Mild to Moderate Dementia? A Cost-Effectiveness Analysis from a Confirmatory Randomised Controlled Trial: The Dementia and Physical Activity (DAPA) Trial.
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I. Khan, S. Petrou, K. Khan, et al.
Pharmacoecon Open 2019 Jun;3(2):215-227
Previous studies suggest that physical exercise could slow dementia progression. However, evidence for the cost effectiveness of structured exercise is conflicting and based on small trials. OBJECTIVES: The objective of this study was to compare the cost effectiveness of a tailored, structured, moderate- to high-intensity exercise programme versus usual care in people with mild to moderate dementia. METHODS: An economic evaluation was conducted from the UK National Health Service and personal social services perspective, based on data from a large randomised controlled trial. The primary clinical outcome was the participant reported ADAS-Cog (Alzheimer’s Disease Assessment Scale-Cognitive Subscale) at 12 months. Costs ( pound; 2014-2015 prices) were collected prospectively over a 12-month follow-up period. A bivariate regression of costs and quality-adjusted life-years (QALYs), with multiple imputation of missing data, was conducted with the view to estimating the incremental cost per QALY gained and the incremental net monetary benefit (INMB) associated with the exercise programme plus usual care versus usual care. Sensitivity analyses were undertaken to assess the impact of uncertainty surrounding aspects of the economic evaluation, and pre-specified subgroup analyses explored heterogeneity in the cost-effectiveness results. RESULTS: Participants (n = 494) were randomised to exercise plus usual care or usual care only. By 12 months the mean ADAS-Cog score had worsened slightly to 25.2 (standard deviation [SD] 12.3) in the exercise arm and 23.8 (SD 10.4) in the usual care: difference – 1.4, 95% confidence interval (CI) – 2.6 to – 0.2 (p = 0.03). The mean (standard error [SE]) costs over 12 months for experimental versus control was pound5945 (US$7856) versus pound4597 (US$6574), respectively; (difference: pound1347 [$1926]; p = 0.0426). Mean (SE) QALY estimates were 0.787 (0.012) versus 0.826 (0.019), respectively (p = 0.090). The probability that the exercise programme is cost effective was < 1% across cost-effectiveness thresholds. INMBs ranged between – pound2601 (US$3719) and pound2158 (US$3086) at cost-effectiveness thresholds between pound15,000 (US$21,450) and pound30,000 (US$42,900) per QALY. The cost-effectiveness results remained robust to several sensitivity and subgroup analyses. CONCLUSIONS: Building on the clinical results of the trial, which showed that the structured exercise programme evaluated does not slow cognitive impairment in people with mild to moderate dementia, this economic evaluation shows that the programme is not cost effective.

Effects of Exergaming in People with Dementia: Results of a Systematic Literature Review.
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J. van Santen, R. M. Droes, M. Holstege, et al.
J Alzheimers Dis 2018;63(2):741-760
Physical exercise benefits functioning, health, and well-being. However, people living with dementia in particular hardly engage in exercise. Exergaming (exercise and gaming) is an innovative, fun, and relatively safe way of exercising in a virtual reality or gaming environment. It may help people living with dementia overcome barriers they can experience regarding regular exercise activities. OBJECTIVE: This systematic literature review aims to provide an overview of the cost-effectiveness of exergaming and its effects on physical, cognitive, emotional, and social functioning, as well as the quality of life in people living with dementia. METHODS: PubMed, Embase, Cinahl, PsycINFO, the Cochrane Library, and the Web of Science Core Collection were searched. Selection of studies was carried out by at least two independent researchers. RESULTS: Three studies were found to be eligible and were included in this review. Two of these showed some statistically significant effects of exergaming on physical, cognitive, and emotional functioning in people living with dementia, although based on a very small sample. No articles were found about the cost-effectiveness of exergaming. CONCLUSIONS: Only a few controlled studies have been conducted into the effectiveness of exergaming, and these show very little significant benefits. More well-designed studies are necessary to examine the effects of exergaming.

The Effectiveness of Biographical Approaches in Long-Term Care: A Systematic Review.
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L. Menn, S. Corsten, N. Lauer and S. J. Wallace.
Gerontologist 2019 Jun 8
Older adults in long-term residential aged care experience loneliness and reduced quality of life (QoL). Biographical approaches use the recall of the past events to increase self-efficacy, promote acceptance, and improve QoL. The aim of the systematic review was to examine the effectiveness of biographical approaches in improving the QoL of older adults in long-term residential aged care. RESEARCH DESIGN AND METHODS: This systematic review was conducted in accordance with PRISMA guidelines, using databases Medline, CINAHL, and the Cochrane Library. A 2-phase search strategy was used to identify research literature relating to the use of biographical interventions. Narrative analysis was used to synthesize results. RESULTS: Twenty-one studies met inclusion criteria for this review, comprising both group and individual interventions. The findings were inconsistent. Subjective elements of QoL of older adults improved in a narrow majority of the studies. Of a total of 21 outcomes investigated in group interventions, 11 resulted in significant improvements in QoL. The 16 outcomes of the individual interventions resulted in 10 significant improvements. The most significant influence was observed in life satisfaction. Group reminiscence also had a particularly strong influence on self-esteem. DISCUSSION AND IMPLICATIONS: Although benefits were observed, it remains unclear why some interventions led to improvements in subjective elements of QoL and others did not. Exploration of the participant perspective through qualitative data collection and more detailed description of interventions in future studies could lead to a better understanding of the treatment components that are related to improved outcomes for older adults.

Cultural Understandings of Dementia in Indigenous Peoples: A Qualitative Evidence Synthesis.
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K. Jacklin and J. Walker.
Can J Aging 2019 Jun 10:1-15
Age-related dementias present a significant health concern in Canada, particularly for Indigenous communities, in which rates of dementia are estimated to be 34 per cent higher than in the general Canadian population. This article reports on a qualitative evidence synthesis of available literature concerning cultural understandings of dementia in Indigenous peoples in Canada. Key findings suggest that although exploration of this topic is on the rise in Canada, there remains a paucity of research on this topic, particularly among the Inuit and Metis. The synthesis of the literature found that dementia is viewed as a natural part of the life cycle by many Indigenous people; and although this presents significant challenges for caregivers, informal and community models of care are routinely practiced. This synthesis will be useful for health care providers and organizations that are searching for appropriate approaches to respond to the needs of Indigenous patients and families experiencing dementia

Advance care planning in different settings for people with dementia: A systematic review and narrative synthesis.
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A. J. Kelly, T. Luckett, J. M. Clayton, L. Gabb, S. Kochovska and M. Agar.
Palliat Support Care 2019 Jun 10:1-13
Advance care planning (ACP) is identified as being an important process for people with dementia. However, its efficacy for improving outcomes relevant for the individual, carers and the health system has yet to be established.AimWe conducted a systematic review with the aims of testing the efficacy of ACP for people with dementia and describing the settings and population in which it has been evaluated. METHODS: A search was completed of electronic databases in August 2016. Articles were included if they described interventions aimed at increasing planning for future care of people with dementia, delivered to the person with dementia, their carers and/or health professionals. RESULTS: Of 4,772 articles returned by searches, 30 met the inclusion criteria, testing interventions in nursing home (n= 16) community (n = 10) and acute care (n = 4) settings. Only 18 interventions directly involved the person with dementia, with the remainder focusing on surrogate decision-makers. In all settings, interventions were found effective in increasing ACP practice. In nursing homes, ACP was found to influence care and increase the concordance between end of life wishes and care provided. Interventions in the community were found to improve patient quality of life but were not shown to influence concordance. CONCLUSION: Future research should focus on ways to involve people with dementia in decision-making through supported means.

Prevalence and Duration of Use of Medicines Recommended for Short-Term Use in Aged Care Facility Residents.
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L. M. Kalisch Ellett, G. M. Kassie, N. L. Pratt, M. Kerr and E. E. Roughead.
Pharmacy (Basel) 2019 Jun 6;7(2):10.3390/pharmacy7020055
Multiple studies have assessed the appropriateness of the use of medicines for nursing home residents; however, few have included duration of use in their assessment. The aim of this study was to assess the level and duration of use of medications recommended for short-term use in residents of aged care facilities in Australia. METHODS: Australian Government Department of Veterans’ Affairs (DVA) administrative claims data were used for this study. Veterans eligible for all health services subsidised by DVA were followed for one year from 1 July 2015 to 30 June 2016. The number of days covered for each medicine was calculated by multiplying the number of prescriptions dispensed during the year by the pack duration for the medicine. The pack duration was calculated by dividing the quantity supplied at each dispensing by the usual number of doses per day in older people according to Australian prescribing guidelines. The proportion of patients using each medicine and the number of days covered during the study period were determined. RESULTS: 14, 237 residents met the inclusion criteria. One in five participants were dispensed antipsychotics, and the median duration of use was 180 days in the one-year period. More than one-third were dispensed a benzodiazepine, and the median duration of use was 240 days in the year. Half were dispensed an opioid analgesic with a median duration of use of 225 days in the year. Fifty-two percent were dispensed proton pump inhibitors with a median duration of use of 360 days in the year. A quarter received an antibiotic recommended for the management of urinary tract infection, with a median duration of use of 14 days in the year. CONCLUSION: Long-term use of antipsychotics, benzodiazepines, opioid analgesics and proton pump inhibitors is common in aged care residents. Ensuring appropriate duration of use for these medicines is necessary to reduce risk of harm.

Living and dying with advanced dementia: A prospective cohort study of symptoms, service use and care at the end of life.
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E. L. Sampson, B. Candy, S. Davis, et al.
Palliat Med 2018 Mar;32(3):668-681
Increasing number of people are dying with advanced dementia. Comfort and quality of life are key goals of care. AIMS: To describe (1) physical and psychological symptoms, (2) health and social care service utilisation and (3) care at end of life in people with advanced dementia. DESIGN: 9-month prospective cohort study. SETTING AND PARTICIPANTS: Greater London, England, people with advanced dementia (Functional Assessment Staging Scale 6e and above) from 14 nursing homes or their own homes. MAIN OUTCOME MEASURES: At study entry and monthly: prescriptions, Charlson Comorbidity Index, pressure sore risk/severity (Waterlow Scale/Stirling Scale, respectively), acute medical events, pain (Pain Assessment in Advanced Dementia), neuropsychiatric symptoms (Neuropsychiatric Inventory), quality of life (Quality of Life in Late-Stage Dementia Scale), resource use (Resource Utilization in Dementia Questionnaire and Client Services Receipt Inventory), presence/type of advance care plans, interventions, mortality, place of death and comfort (Symptom Management at End of Life in Dementia Scale). RESULTS: Of 159 potential participants, 85 were recruited (62% alive at end of follow-up). Pain (11% at rest, 61% on movement) and significant agitation (54%) were common and persistent. Aspiration, dyspnoea, septicaemia and pneumonia were more frequent in those who died. In total, 76% had ‘do not resuscitate’ statements, less than 40% advance care plans. Most received primary care visits, there was little input from geriatrics or mental health but contact with emergency paramedics was common. CONCLUSION: People with advanced dementia lived with distressing symptoms. Service provision was not tailored to their needs. Longitudinal multidisciplinary input could optimise symptom control and quality of life.

Effectiveness of advance care planning with family carers in dementia nursing homes: A paired cluster randomized controlled trial.
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K. Brazil, G. Carter, C. Cardwell, et al.
Palliat Med 2018 Mar;32(3):603-612
In dementia care, a large number of treatment decisions are made by family carers on behalf of their family member who lacks decisional capacity; advance care planning can support such carers in the decision-making of care goals. However, given the relative importance of advance care planning in dementia care, the prevalence of advance care planning in dementia care is poor. AIM: To evaluate the effectiveness of advance care planning with family carers in dementia care homes. DESIGN: Paired cluster randomized controlled trial. The intervention comprised a trained facilitator, family education, family meetings, documentation of advance care planning decisions and intervention orientation for general practitioners and nursing home staff. SETTING/PARTICIPANTS: A total of 24 nursing homes with a dementia nursing category located in Northern Ireland, United Kingdom. Family carers of nursing home residents classified as having dementia and judged as not having decisional capacity to participate in advance care planning discussions. RESULTS: The primary outcome was family carer uncertainty in decision-making about the care of the resident (Decisional Conflict Scale). There was evidence of a reduction in total Decisional Conflict Scale score in the intervention group compared with the usual care group (-10.5, 95% confidence interval: -16.4 to -4.7; p < 0.001). CONCLUSION: Advance care planning was effective in reducing family carer uncertainty in decision-making concerning the care of their family member and improving perceptions of quality of care in nursing homes. Given the global significance of dementia, the implications for clinicians and policy makers include them recognizing the importance of family carer education and improving communication between family carers and formal care providers.

Incidence of Dementia and Alzheimer Disease Over Time: A Meta-Analysis.
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S. Gao, H. N. Burney, C. M. Callahan, C. E. Purnell and H. C. Hendrie.
J Am Geriatr Soc 2019 Jun 20
Population-based incidence estimates of dementia and Alzheimer disease (AD) provide important information for public health policy and resource allocation. We conducted a meta-analysis of published studies that reported age-specific incidence rates of dementia and AD to determine whether dementia and AD incidence rates are changing over time. DESIGN: PubMed and MEDLINE were searched for publications through June 30, 2017, using key words “dementia”, “Alzheimer”, and “incidence.” Inclusion criteria for the meta-analysis are: (1) population-based studies using personal interviews and direct examinations of the study subjects, (2) standardized clinical diagnosis criteria, (3) reporting age-specific incidence rates, (4) published in English, and (5) sample size of 500 or greater and length of follow-up of 2 years or greater. Mixed-effects models were used to determine the association between birth year and incidence rates. MEASUREMENTS: Age-specific dementia/AD incidence rates and their standard errors reported in each study. RESULTS: Thirty-eight articles with 53 cohorts on dementia incidence and 31 articles with 35 cohorts on AD incidence met the inclusion criteria. There were significant associations between later birth years and decreased dementia incidence rates in all three age groups (65-74, 75-84, and 85 years and older). There were no significant associations between birth year and AD incident rates in any of the three age groups. In particular, AD incidence rates reported from Western countries stayed steady in all age groups, while studies in non-Western countries showed significantly increased AD incidence rates for the 65 to 74 years age group (odds ratio = 2.78; P = .04), but a nonsignificant association for the 75 to 84 or 85 years and older groups. CONCLUSION: Dementia incidence declined over the past four decades, but AD incidence did not decline. Further research, especially from non-Western countries, is needed to elucidate the mechanism underlying the trends in dementia and AD incidence over time.

Association between environmental stimulation and apathy in nursing home residents with dementia.
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Y. L. Jao, W. Liu, K. Williams, H. Chaudhury and J. Parajuli.
Int Psychogeriatr 2019 Jun 26:1-12
Prior research and theories established the link between care environments and apathy. Yet, empirical evidence on how environmental stimulation impacts apathy is lacking. This study examined the association between environmental stimulation and apathy in nursing home residents with dementia. DESIGN: This repeated-measure study analyzed 104 video observations of staff caregiver-resident interactions. SETTING: 12 nursing homes. PARTICIPANTS: 63 unique staff caregiver-resident dyads that involved 42 caregivers and 44 residents with moderate to severe dementia. MEASUREMENTS: Second-by-second behavioral coding using Noldus Observer software was conducted to assess apathy and environmental stimulation, using the Person-Environment Apathy Rating scale. The environment subscale includes six items: stimulation clarity, stimulation strength, stimulation specificity, interaction involvement, physical accessibility, and environmental feedback. The apathy subscale includes six items: facial expression, eye contact, physical engagement, purposeful activity, verbal tone, and verbal expression. Multilevel linear models were used for analysis. RESULTS: Results showed that apathy was not associated with the overall quality of environmental stimulation but was significantly associated with stimulation specificity (coefficient = -2.23, p = 0.049). However, the association was not significant after controlling for resident characteristics (p = 0.082). In addition, higher levels of environmental feedback were associated with lower apathy levels (coefficient = -2.14, p = 0.001). The association remained significant after controlling for resident characteristics (coefficient = -1.65, p = 0.014). CONCLUSION: Findings reveal that when environmental stimulation is individually tailored and prompts engagement, residents are less apathetic. This study highlights the effect of environmental stimulation on apathy. Future research should explore interventions that modify environmental stimulation to reduce apathy and improve dementia care.

Evaluation of a Companion Robot for Individuals With Dementia: Quantitative Findings of the MARIO Project in an Irish Residential Care Setting.
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E. Barrett, M. Burke, S. Whelan, et al.
J Gerontol Nurs 2019 Jul 1;45(7):36-45
The current study focuses on the short-term effect of MARIO, a social robot, on quality of life, depression, and perceived social support in persons with dementia (PWD) and evaluates their acceptability of MARIO. Ten PWD in one nursing home took part in a 4-week pilot study, where each participant had up to 12 sessions with MARIO. Sessions comprised engagement in music, news, reminiscence, games, and calendar applications. Standardized questionnaires were administered before and after the 4-week period. Participants had a sustained interest in MARIO during their interactions and an acceptance of MARIO’s appearance, sound, and applications. Consequently, participants spent more time socially engaged. No statistically significant differences were found in quality of life, depression, and perceived social support. PWD can engage with a social robot in a real-world nursing home. Future research should incorporate a larger sample and longer intervention period.

Prevalence of dementia diagnoses not otherwise specified in eight European countries: a cross-sectional cohort study.
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C. Lethin, I. Rahm Hallberg, A. Renom Guiteras, et al.
BMC Geriatr 2019 Jun 24;19(1):172-019-1174-3
Dementia is a syndrome, with a wide range of symptoms. It is important to have a timely diagnosis during the disease course to reduce the risk of medication errors, enable future care planning for the patient and their relatives thereby optimizing quality of life (QoL). For this reason, it is important to avoid a diagnosis of dementia not otherwise specified (DNOS) and instead obtain a diagnosis that reflects the underlying pathology. The aim of this study was to investigate the prevalence and associated factors of DNOS in persons with dementia living at home or in a nursing home. METHODS: This is a cross-sectional cohort study performed in eight European countries. Persons with dementia aged >/=65 years living at home (n = 1223) or in a nursing home (n = 790) were included. Data were collected through personal interviews with questionnaires based on standardised instruments. Specific factors investigated were sociodemographic factors, cognitive function, and mental health, physical health, QoL, resource utilization and medication. Bivariate and backward stepwise multivariate regression analyses were performed. RESULTS: The prevalence of DNOS in the eight participating European countries was 16% (range 1-30%) in persons living at home and 21% (range 1-43%) in persons living in a nursing home. These people are more often older compared to those with a specific dementia diagnosis. In both persons living at home and persons living in a nursing home, DNOS was associated with more severe neuropsychiatric symptoms and less use of anti-dementia medication. In addition, persons with DNOS living at home had more symptoms of depression and less use of antidepressant medication. CONCLUSIONS: The prevalence of DNOS diagnosis is common and seems to vary between European countries. People with DNOS are more often older with more severe neuropsychiatric symptoms and receive fewer anti-dementia medication, anxiolytics and antidepressants. This would support the suggestion that a proper and specific diagnosis of dementia could help the management of their disease.

The Flooring for Injury Prevention (FLIP) Study of compliant flooring for the prevention of fall-related injuries in long-term care: A randomized trial.
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D. C. Mackey, C. C. Lachance, P. T. Wang, et al.
PLoS Med 2019 Jun 24;16(6):e1002843
Fall-related injuries exert an enormous health burden on older adults in long-term care (LTC). Softer landing surfaces, such as those provided by low-stiffness “compliant” flooring, may prevent fall-related injuries by decreasing the forces applied to the body during fall impact. Our primary objective was to assess the clinical effectiveness of compliant flooring at preventing serious fall-related injuries among LTC residents. METHODS AND FINDINGS: The Flooring for Injury Prevention (FLIP) Study was a 4-year, randomized superiority trial in 150 single-occupancy resident rooms at a single Canadian LTC site. In April 2013, resident rooms were block randomized (1:1) to installation of intervention compliant flooring (2.54 cm SmartCells) or rigid control flooring (2.54 cm plywood) covered with identical hospital-grade vinyl. The primary outcome was serious fall-related injury over 4 years that required an emergency department visit or hospital admission and a treatment procedure or diagnostic evaluation in hospital. Secondary outcomes included minor fall-related injury, any fall-related injury, falls, and fracture. Outcomes were ascertained by blinded assessors between September 1, 2013 and August 31, 2017 and analyzed by intention to treat. Adverse outcomes were not assessed. During follow-up, 184 residents occupied 74 intervention rooms, and 173 residents occupied 76 control rooms. Residents were 64.3% female with mean (SD) baseline age 81.7 (9.5) years (range 51.1 to 104.6 years), body mass index 25.9 (7.7) kg/m2, and follow-up 1.64 (1.39) years. 1,907 falls were reported; 23 intervention residents experienced 38 serious injuries (from 29 falls in 22 rooms), while 23 control residents experienced 47 serious injuries (from 34 falls in 23 rooms). Compliant flooring did not affect odds of >/=1 serious fall-related injury (12.5% intervention versus 13.3% control, odds ratio [OR]: 0.98, 95% CI: 0.52 to 1.84, p = 0.950) or >/=2 serious fall-related injuries (5.4% versus 7.5%, OR: 0.74, 95% CI: 0.31 to 1.75, p = 0.500). Compliant flooring did not affect rate of serious fall-related injuries (0.362 versus 0.422 per 1,000 bed nights, rate ratio [RR]: 1.04, 95% CI: 0.45 to 2.39, p = 0.925; 0.038 versus 0.053 per fall, RR: 0.81, 95% CI: 0.38 to 1.71, p = 0.560), rate of falls with >/=1 serious fall-related injury (0.276 versus 0.303 per 1,000 bed nights, RR: 0.97, 95% CI: 0.52 to 1.79, p = 0.920), or time to first serious fall-related injury (0.237 versus 0.257, hazard ratio [HR]: 0.92, 95% CI: 0.52 to 1.62, p = 0.760). Compliant flooring did not affect any secondary outcome in this study. Study limitations included the following: findings were specific to 2.54 cm SmartCells compliant flooring installed in LTC resident rooms, standard fall and injury prevention interventions were in use throughout the study and may have influenced the observed effect of compliant flooring, and challenges with concussion detection in LTC residents may have prevented estimation of the effect of compliant flooring on fall-related concussions. CONCLUSIONS: In contrast to results from previous retrospective and nonrandomized studies, this study found that compliant flooring underneath hospital-grade vinyl was not effective at preventing serious fall-related injuries in LTC. Future studies are needed to identify effective methods for preventing fall-related injuries in LTC. TRIAL REGISTRATION: ClinicalTrials.gov: NCT01618786.

Twenty-Four Months’ Resistance and Endurance Training Improves Muscle Size and Physical Functions but Not Muscle Quality in Older Adults Requiring Long-Term Care.
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A. Yoshiko, T. Kaji, H. Sugiyama, T. Koike, Y. Oshida and H. Akima.
J Nutr Health Aging 2019;23(6):564-570
To assess the effects of 24 months training on muscle quality, size, strength, and gait abilities in older adults who need long-term care. DESIGN: Non-randomized controlled trial Setting: Kawai Rehabilitation Center and Kajinoki Medical Clinic. PARTICIPANTS: Ten older participants who needed long-term care (age, 76.7 +/- 5.6 years) were participated as training group (Tr-group) and 10 older men and women who did not require long-term care (age, 72.9 +/- 6.6 years) comprised the control group (Cont-group). INTERVENTION: Tr-group performed resistive and endurance exercises once or twice a week for 24 months. MEASUREMENTS: Using ultrasound images, echo intensity (EI) and muscle thickness were measured in the rectus femoris and biceps femoris as an index of muscle quality and size. Physical performance was measured before and after the training; performance parameters included knee extension peak torque, 5-m normal and maximal walk test, sit-to-stand and timed up and go test. RESULTS: After the training, there was no change in EI, while BF thickness was increased (pre; 1.82 +/- 0.29 cm, 24 months; 2.14 +/- 0.23 cm, p < 0.05) in Tr-group. Walk-related performances were improved after the training in Tr-group (i.e. 5-m walk test and timed up and go test). The percent change of knee extension peak torque explained the percent change of EI in the rectus femoris (regression coefficient = 1.24, R = 0.91, adjusted R2 = 0.82, p < 0.001). CONCLUSIONS: Twenty-four months’ training induced muscle hypertrophy and improved physical functions. Increased muscle quality in the rectus femoris could be a key to improved knee extension peak torque, with the potential to eventually reduce the need for long-term care in older individuals.

Development and Validation of the Nursing Home Care-related Quality of Life Scale.
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E. Cho, K. Lee, D. Min, S. J. Chang, J. Kim and H. Kim.
J Am Med Dir Assoc 2019 Jun 20
We developed an instrument to assess nursing home residents’ quality of life (QOL), with a focus on QOL-related factors modifiable through nursing home care, within the South Korean context; then, we tested its validity and reliability. DESIGN: The scale was constructed through a literature review, qualitative interviews, expert panel review, and a focus group interview; then, it was validated through survey research. SETTING AND PARTICIPANTS: Residents (N = 667) from 42 nursing homes in South Korea participated in scale validation. METHODS: Ninety-nine items across 5 dimensions were initially drafted through a literature review and qualitative interview data. The expert panel review and a focus group interview yielded a scale with 31 items across 3 dimensions. Next, using survey data from nursing home residents, we examined the construct and concurrent validity and reliability (using Kuder-Richardson 20) of the 31-item QOL scale. RESULTS: Through a series of factor analyses, the 31 items were reduced to 17 items across 2 dimensions: Environment and Services (13 items) and Social Interaction (4 items). This 17-item scale was further examined for model fitness and reliability. The scale had acceptable to good fit (root mean square error of approximation = 0.07 and 0.07; comparative fit index = 0.83 and 0.98 for Environment and Services and Social Interaction, respectively), and good concurrent validity and internal consistency (Kuder-Richardson 20 = 0.72). CONCLUSIONS AND IMPLICATIONS: This 17-item scale is a valid and reliable tool to assess nursing home residents’ QOL in South Korea, with a focus on factors modifiable through nursing home care. Through more research to test its usefulness, validity, and reliability, the scale can be used as an index of nursing home care quality and contribute to the development of strategies to improve nursing home residents’ QOL.

Managing Paratonia in Persons With Dementia: Short-term Effects of Supporting Cushions and Harmonic Techniques.
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B. Van Deun, N. Van Den Noortgate, A. Van Bladel, K. De Weerdt and D. Cambier.
J Am Med Dir Assoc 2019 Jun 18
Paratonia, a form of hypertonia typically seen in dementia, is often associated with difficulties in positioning and daily care. No evidence-based therapy or clinical guideline for management is available. In this study, the short-term effect of harmonic techniques (HT) and supporting cushions (SC) on paratonia was explored. DESIGN: This was a multicenter interventional clinical trial with AB/BA crossover design. Each intervention (SC or HT) was subsequently implemented over 1 week in each of the participants. SETTING AND PARTICIPANTS: The study included 22 participants with moderate to severe paratonia from 9 different nursing homes in Flanders, Belgium. METHODS: Measurements of biceps brachii and rectus femoris muscle tone (MyotonPRO), maximal elbow and knee extension (goniometer), and pain (Pain Assessment Checklist for Seniors With Limited Ability to Communicate) were performed on 3 different days within 1 week. The effect of HT on nursing care was evaluated with the Pain Assessment Checklist for Seniors With Limited Ability to Communicate and visual analog scale ratings of discomfort items. RESULTS: After 30 minutes of positioning with SC, participants had lower biceps brachii muscle tone (P = .041) and higher maximal elbow extension (P = .006) than without SC. After a 30-minute session of HT, a significant increase in biceps brachii muscle tone (P = .032) and maximal extension of elbow (P < .001) and knee (P = .028) was found. Pain (P = .003) and discomfort (P = .001 to P = .019) during morning care were significantly lower when care was preceded by 30 minutes of HT. CONCLUSIONS/IMPLICATIONS: This explorative study revealed beneficial short-term effects on range of motion for both SC and HT and a positive effect of SC on upper limb muscle tone. Beneficial effects of HT were found on resident’s pain and caregiver’s discomfort during care. The results of the present study are encouraging and can contribute to the development of evidence-based interventions for paratonia.

Effects of a Texture-Modified, Enriched, and Reshaped Diet on Dietary Intake and Body Weight of Nursing Home Residents with Chewing and/or Swallowing Problems: An Enable Study.
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A. Ott, M. Senger, T. Lotzbeyer, O. Gefeller, C. C. Sieber and D. Volkert.
J Nutr Gerontol Geriatr 2019 Jun 21:1-16
This proof-of-concept study investigated the effects of an innovative nutrition concept, comprising texture modification, enrichment, and reshaping, on dietary intake and nutritional status of 16 nursing home residents with chewing and/or swallowing problems (mean age 86.5 +/- 7.4 years) in a pre-test post-test design. During 6 weeks with usual texture-modified diet (P1) energy and protein intake were constant. After the implementation of the innovative diet, daily energy intake increased by 204.2 (median) [interquartile range 95.8-444.4] kcal (P = 0.011), and protein intake by 18.3 [9.9-26.3] g (P < 0.001) and remained constant during the following 6 weeks (P2). Body weight decreased during P1 (-0.5 [-1.4 to 0.2] kg), and increased during P2 (+1.1 [0.0 to 1.7] kg, P = 0.004). The present nutrition concept turned out to be a promising strategy for nutritional management of chewing and/or swallowing problems, however, the effects need to be confirmed in larger studies.

Understanding the Barriers and Enablers to Using Outdoor Spaces in Nursing Homes: A Systematic Review.
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M. E. L. van den Berg, M. Winsall, S. M. Dyer, F. Breen, M. Gresham and M. Crotty.
Gerontologist 2019 May 24
Despite acknowledged benefits of residents in nursing homes spending time outdoors, little is known about factors related to their use of outdoor space. This systematic review summarizes reported barriers and enablers to nursing home residents’ use of outdoor spaces. RESEARCH DESIGN AND METHODS: Multiple databases were searched to May 2018. Qualitative or mixed methods studies describing barriers/enablers to use of outdoor areas by residents of nursing homes (aged 65 years and older), as reported by residents, staff, or family members were included. Study quality rating, thematic analysis, and stratified analyses were performed and confidence in findings assessed using GRADE-CERQual. RESULTS: Twenty-four studies were included. Nineteen collected data from residents, 15 from staff/caregivers, 7 from families. Major themes and key findings concerned: design of the outdoor area (importance of garden greenery and built features), safety concerns and staffing issues, weather and seasons (appropriate shade and shelter), design of the main building (easy to open doors and nearby access points) and social activities. CONCLUSIONS AND IMPLICATIONS: Providing gardens with seasonal plants and interactive features, weather protected seating, manageable doors at accessible thresholds, planned social activities, and appropriate clothing are fundamental to facilitate nursing home residents’ access to the outdoors. Cultural change at an organizational level, addressing perceptions of safety as a barrier is important. Incorporation of the recommendations in this review by architects, facility managers, and policy makers in the design and management of nursing homes, may increase use of outdoor areas and improve the quality of life of residents. REGISTRATION: The protocol is registered in Prospero (CRD42018100249).

Factors Associated With Symptom Relief in End-of-Life Care in Residential Care Homes: A National Register-Based Study.
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S. Andersson, K. Arestedt, O. Lindqvist, C. J. Furst and M. Brannstrom.
J Pain Symptom Manage 2018 May;55(5):1304-1312
Residential care homes (RCHs) are a common place of death. Previous studies have reported a high prevalence of symptoms such as pain and shortness of breath among residents in the last week of life. OBJECTIVES: The aim of the study was to explore the presence of symptoms and symptom relief and identify factors associated with symptom relief of pain, nausea, anxiety, and shortness of breath among RCH residents in end-of-life care. METHODS: The data consisted of all expected deaths at RCHs registered in the Swedish Register of Palliative Care (N = 22,855). Univariate and multiple logistic regression analyses were conducted. RESULTS: Pain was reported as the most frequent symptom of the four symptoms (68.8%) and the one that most often had been totally relieved (84.7%) by care professionals. Factors associated with relief from at least one symptom were gender; age; time in the RCH; use of a validated pain or symptom assessment scale; documented end-of-life discussions with physicians for both the residents and family members; consultations with other units; diseases other than cancer as cause of death; presence of ulcers; assessment of oral health; and prescribed pro re nata injections for pain, nausea, and anxiety. CONCLUSION: Our results indicate that use of a validated pain assessment scale, assessment of oral health, and prescribed pro re nata injections for pain, nausea, and anxiety might offer a way to improve symptom relief. These clinical tools and medications should be implemented in the care of the dying in RCHs, and controlled trials should be undertaken to prove the effect.

Smiling matters: oral health care in care homes (UK)

Care Quality Commission, June 2019
Over a four month period from October 2018 to January 2019 CQC dental inspectors visited 100 care home services across England to investigate the state of oral health care. The report publishes the findings of this review and calls for improvements in this area.

“Conversation Ready”: A Framework for Improving End-of-Life Care (Second Edition)

Sokol-Hessner L, Zambeaux A, Little K, Macy L, Lally K, McCutcheon Adams K.
Boston, Massachusetts: Institute for Healthcare Improvement; 2019
This white paper presents IHI’s “Conversation Ready” approach to help health care organizations and clinicians provide respectful end-of-life care that is concordant with patients’ stated goals, values, and preferences.
The framework is relevant whether you are a leader in a large hospital, a social worker in the community, a doctor in a clinic, or a palliative care nurse in a skilled nursing facility.
The second edition is an update of the original 2015 white paper, based on additional learning from several years of work with dozens of diverse health care organizations and hundreds of health care professionals.

Behavioural Supports Ontario-Dementia Observation System

Behavioural Support Integrated Teams (BSIT) Collaborative, 2019
The Behavioural Supports Ontario Provincial Coordinating Office (BSO PCO) is pleased to announce the release of the BSO-DOS© (Behavioural Supports Ontario-Dementia Observation System). Working in collaboration with Dr. Lori Schindel Martin (author of the original DOS), the BSO PCO has had the privilege to lead a project to update and standardize the DOS. Throughout the project, the provincial DOS Working Group consulted and gained feedback from over 350 health care professionals and individuals with lived experience from across Canada. This collaborative work produced the new enhanced, standardized DOS; now called the BSO-DOS© (Behavioural Supports Ontario-Dementia Observation System

Supporting Successful and Sustainable Transitions into Long-Term Care for Older Adults with Responsive Behaviours/Personal Expressions

Behavioural Support Integrated Teams (BSIT) Collaborative, 2019
In the fall of 2017, the Behavioural Supports Integrated Teams(BSIT) Collaborative began to gather information on critical elements for supporting transitions for the Behavioural Supports Ontario (BSO) target population1 into long-term care (LTC) homes. Drawing on the themesthat emerged from the September 2015 Ontario’s Best Practice Exchange Catalyst Event, at each monthly meeting the collaborative members shared their perspectives on critical elementsforsupporting person and family-centred transitionsfrom their professional and/or lived experiences. Using the Behavioural Support Integrated Teams Transition Framework, members discussed and determined essential componentsthroughout the experience of transitioning from either the community or hospital into a LTC home which were incorporated into a guiding checklist. All identified critical elements were grounded in the philosophy of person and family-centred care; including creative strategiesimplemented by various BSO teams and their key collaboratorsto overcome potential barriers and challenges.


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Fundamentals Of Implementation Science, University Of Washington Department Of Global Health E-Learning Program (Online)

16 September-1 December
Instructor: Arianna Means
Fundamentals of Implementation Science, taught by Dr. Arianna Means, is a collaborative, interactive, online course that provides students with an introduction to the emerging field of implementation research through lectures from global health leaders and opportunities to apply lessons learned on topics of global health importance. You’ll learn how to use a systematic, scientific approach to find out “what works” and convey this information with greater speed, fidelity, quality, and efficiency to those who need it. Learn how to translate scientific research and data into on-the-ground policies and programs. This course also gives an overview of the emerging field of implementation research, by outlining methodologies and reviewing experiential case studies from global health leaders.

Evidence-based strategies for writing in healthcare

8 October 08:30 15:30, University of Alberta, Edmonton, AB
Instructor: Karen Schriver
The purpose of this workshop is to provide guideline producers and users with evidence-based writing principles to enhance their writing. Quality writing can help healthcare providers and patients understand, use, and act upon the recommendations, increasing the chances for the adoption of knowledge.

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SCIE Integrated care research and practice (UK)

This resource aims to support the planning, commissioning and delivery of coordinated person-centred care. Based on the integration logic model, it brings together the evidence base and practice guidance on what good integrated care looks like. The resource will help you gain a better understanding of, and navigate through, the wealth of available research and practice evidence. Designed as a practical tool, it will support the drive towards improvement and innovation. The resource will be updated regularly to include resources and tools from national partners and elsewhere.

NHS Delayed transfer of care (DTOC) improvement tool

This tool has been developed to enable trusts, clinical commissioning groups and local authorities to understand where delayed transfers of care are in their area or system.

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Writing Lessons: Practicing What We Preach

Promising development at CIHR: an early career researcher on the governing council

Bridging the Gap: Knowledge Synthesis in supporting evidence-informed decision-making

A new fix for long-term care (US)

AHS creates an online directory featuring continuing care facility information in Alberta.

The Elderly Are Getting Complex Surgeries. Often It Doesn’t End Well.

I’ve noticed a change in my colleague’s behaviour. What should I do?

Time to End the Manel Tradition

Final Report of the Advisory Council on the Implementation of National Pharmacare

To Save The Science Poster, Researchers Want To Kill It And Start Over

Engaging NHS staff in research

More than 150 groups apply to become Ontario Health Teams as competition for care intensifies

How dementia robbed me of my love of cooking

New toolkit guides health-care professionals to assess dementia
in a new way

Pulling Back The Curtain On Alzheimer’s, Through Its Lighter And Darker Moments

Residents in care homes ‘missing out on dental care’ (UK)

How To Be a Great Moderator

At 75, Taking Care of Mom, 99: ‘We Did Not Think She Would Live This Long’

Improving the quality of life of aged care residents through the joy of food.

The Difficulty With Studying Challenging Behavior.

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Senior Implementation Research Scientist, RTI International

Research Triangle Park NC, Washington DC, Waltham, MA, or Seattle, WA
Applicants must be legally authorized to work in the United States
DEADLINE: Open until filled
RTI International is recruiting for a Senior Implementation Research Scientist within their Social Policy, Health and Economics Research Unit. This individual will be tasked with applying implementation science methods to the design and execution of research and evaluation projects and tasks encompassing health, healthcare, and social welfare.

Research Fellow – Rare Dementia Support Project

Economic and Social Research Council National Institute for Health Research (ESRC-NIHR)
University of Nipissing, North Bay, ON
DEADLINE: 1 September
The successful candidate will join the School of Social Work, Faculty of Education and Professional Studies, which is collaborating with University College London (UCL) and Bangor University, Wales. The project team includes: Sebastian Crutch (PI), Paul Camic, Roberta McKee-Jackson, Joshua Stott (University College London), Mary Pat Sullivan (Nipissing University), Gill Windle, Rhiannon Tudor Edwards, Zoe Hoare (Bangor University).

The successful candidate will be expected to commence 1st November, 2019. The post is available for 12 months in the first instance with the opportunity for renewal for another 36 months.

The Project Team will carry out the first major study of the value of support groups for people living with or caring for someone with a rare form of dementia. Working closely with Dr. Mary Pat Sullivan, the Research Fellow will develop research that considers the unique Northern Ontario perspective of the impact of living with rare dementias. The candidate will also contribute to the broader programme of work with colleagues in London and Bangor.

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