Aging

Collection of articles on Aging is available here.

Stigma Reduction Interventions of Dementia: A Scoping Review.
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Bacsu JD, Johnson S, O’Connell ME, Viger M, Muhajarine N, Hackett P, et al.
Canadian journal on aging = La revue canadienne du vieillissement. 2022 Jun;41(2):203–13.
Despite its global importance and the recognition of dementia as an international public health priority, interventions to reduce stigma of dementia are a relatively new and emerging field. The purpose of this review was to synthesize the existing literature and identify key components of interventions to reduce stigma of dementia. We followed Arksey and O’Malley’s scoping review process to examine peer-reviewed literature of interventions to reduce dementia-related stigma. A stigma-reduction framework was used for classifying the interventions: education (dispel myths with facts), contact (interact with people with dementia), mixed (education and contact), and protest (challenge negative attitudes). From the initial 732 references, 21 studies were identified for inclusion. We found a variety of education, contact, and mixed interventions ranging from culturally tailored films to intergenerational choirs. Findings from our review can inform the development of interventions to support policies, programs, and practices to reduce stigma and improve the quality of life for people with dementia.

Exploring changes to resident thriving and associated factors in Swedish nursing homes: A repeated cross-sectional study
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Baxter R, Lövheim H, Björk S, Sköldunger A, Edvardsson D.
International Journal of Geriatric Psychiatry [Internet]. 2022 May.
ABSTRACT Objective This study aimed to explore changes to resident thriving in Swedish nursing homes over a five-year period and describe changes in associated factors. Methods Cross-sectional data were collected from a randomised sample of Swedish nursing homes in 2013/2014 (baseline) and 2018/2019 (follow-up). Descriptive statistics, independent samples t-tests, and chi squared tests were used to statistically evaluate differences between the samples. Simple and multiple linear regression analyses were used to explore associations between thriving and the study variables. Results Resident characteristics were relatively consistent between the full baseline (N=4831) and follow-up (N=3894) samples. Within a sub-sample of nursing homes that participated in both data collections mean thriving scores were found to have increased from 152.9 to 155.2 (p = <.003; d = .09) and overall neuropsychiatric index scores had decreased from 16.0 to 14.3 (p = <.004; d = .09), as had the prevalence of several neuropsychiatric symptoms. Thriving was found to have a positive association with the neuropsychiatric symptom of elation/euphoria, and negative associations with the symptoms of aggression/agitation, depression/dysphoria, apathy, and irritability. Conclusions The results show an increase in overall thriving scores and a decrease in overall neuropsychiatric scores between baseline and follow-up. This study confirmed associations between thriving and certain neuropsychiatric symptoms and established comparative knowledge regarding changes in resident thriving, characteristics, and symptom prevalence. These findings could inform future care and organisational policies to support thriving in nursing homes, particularly among residents at risk of lower thriving due to cognitive impairment or neuropsychiatric symptoms. This article is protected by copyright. All rights reserved.

Transitional Care Interventions for Older Residents of Long-term Care Facilities: A Systematic Review and Meta-analysis.
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Birtwell K, Planner C, Hodkinson A, Hall A, Giles S, Campbell S, et al.
JAMA network open. 2022 May;5(5):e2210192.
IMPORTANCE: Residents of long-term care facilities (LTCFs) experience high hospitalization rates, yet little is known about the effects of transitional care interventions for these residents. OBJECTIVE: To assess the association of transitional care interventions with readmission rates and other outcomes for residents of LTCFs who are 65 years and older and LTCF staff and to explore factors that potentially mitigate the association. DATA SOURCES: MEDLINE, EMBASE, PsycINFO, Cochrane Central Register of Controlled Trials, and Cumulative Index to Nursing and Allied Health Literature were searched for English-language studies published until July 21, 2021. Associated qualitative studies were identified using aspects of the CLUSTER (citations, lead authors, unpublished materials, searched Google Scholar, tracked theories, ancestry search for early examples, and follow-up of related projects) methodology. STUDY SELECTION: Controlled design studies evaluating transitional care interventions for residents of LTCFs 65 years and older were included. Records were independently screened by 2 reviewers; disagreements were resolved through discussion and involvement of a third reviewer. From 14 538 records identified, 15 quantitative and 4 qualitative studies met the eligibility criteria. DATA EXTRACTION AND SYNTHESIS: The study followed the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines. Data were extracted by one reviewer and checked by a second reviewer. Fixed-effect and random-effects models were used according to the number of studies reporting the outcomes of interest. MAIN OUTCOMES AND MEASURES: The primary outcome consisted of 30-, 60-, and 90-day readmission rates (hospital and emergency department [ED]). Other outcomes included length of stay, functional independence (Barthel score), and quality of life. The I2 statistic was used to quantify heterogeneity. RESULTS: Of 14 538 records identified from searches, 15 quantitative studies (totaling 32 722 participants or records) and 4 qualitative studies were included. People allocated to transitional care interventions were 1.7 times less likely to be readmitted to the hospital or ED compared with those in control groups (14 studies; odds ratio, 1.66 [95% CI, 1.18-2.35]; I2 = 81% [95% CI, 70%-88%]). Length of stay in the ED was significantly decreased for intervention groups (3 studies; standardized mean difference, -3.00 [95% CI, -3.61 to -2.39]; I2 = 99% [95% CI, 98%-99%]). There were no significant differences for other outcomes. Factors associated with outcomes included communication and referral processes between health care professionals. CONCLUSIONS AND RELEVANCE: Emerging evidence suggests that transitional care interventions are associated with lower readmissions for residents of LTCFs 65 years and older. Despite this and with aging populations, investment in such interventions has been remarkably low across most countries.

Impact of Psychotic Symptoms and Concurrent Neuropsychiatric Symptoms on the Quality of Life of People With Dementia Living in Nursing Homes.
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Choi A, Martyr A, Clare L, Fossey J, Khan Z, McDermid J, et al.
Journal of the American Medical Directors Association. 2022 May.
OBJECTIVES: The aim of the present study was to determine whether psychotic symptoms in people with dementia (PwD) living in nursing homes were associated with reduced quality of life and to understand the additional impact of other concurrent neuropsychiatric symptoms on QoL. DESIGN: Cross-sectional cohort study (using data from WHELD cohort). SETTINGS AND PARTICIPANTS: 971 PwD living in nursing homes participating in the WHELD study. METHODS: The Neuropsychiatric Inventory-Nursing Home (NPI-NH) version was completed by informant interview. We compared mean differences in proxy-rated QoL scores (DEMQOL-Proxy) for PwD experiencing or not experiencing delusions and for PwD experiencing or not experiencing hallucinations. Backward multiple regression was used to determine the added contributions of agitation (Cohen-Mansfield Agitation Inventory), anxiety (NPI-NH-Anxiety), depression (Cornell Scale for Depression in Dementia), dementia severity (Clinical Dementia Rating-sum of boxes score), pain (Abbey Pain Scale), and antipsychotic prescription. Mediation analysis was conducted for agitation, anxiety, and depression. RESULTS: Presence of both delusions (P < .001, B = -8.39) and hallucinations (P < .001, B = -7.78) was associated with poorer QoL. Both associations remained significant after controlling for other factors. Agitation, anxiety, and depression partially mediated the relationship between each psychotic symptom and QoL. CONCLUSIONS AND IMPLICATIONS: Delusions and hallucinations in PwD are associated with poorer QoL among PwD living in nursing homes. The effects remain significant after adjusting for confounding variables. Direct effects of each symptom maintained significance despite significant mediation by concurrent neuropsychiatric symptoms.

Effects of an emotional support programme on older adults living in nursing homes: A quasi-experimental study.
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Cui M, Miao W, Chen J, Yang W, Geng Z, Qian X, et al.
Geriatric nursing (New York, NY). 2022 May;45:180–7.
This study aimed to examine the feasibility and validity of an emotional support programme developed for older adults living in nursing homes, using a quasi-experimental design. Older adults in the intervention group attended a 12-week emotional support programme while those in the control group received usual care. Outcome variables, assessed at baseline and at 1-month and 3-month follow ups, included nursing home adjustment, perceived social support, and quality of life. Group-by-time interaction effects were found concerning nursing home adjustment and perceived social support. Significant improvements in the two variables were observed in the intervention group, but no significant difference was found in quality of life. The emotional support programme based on social learning theory resulted in significant improvements in nursing home adjustment and perceived social support. To respond to the demands of an ageing society, further studies are needed on this topic.

Mobility during walking and incidence and risk factors for mobility decline among institutionalized older adults: A two-year longitudinal study.
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de Araújo JRT, Jerez-Roig J, Machado DG da S, Ferreira LM de BM, de Lima KC.
Archives of gerontology and geriatrics. 2022 Apr;101:104702.
OBJECTIVE: To analyze the trajectory of changes in mobility during walking (i.e., maintenance and recovery) of institutionalized older adults and verify the incidence and risk factors for mobility decline. METHODS: A two-year longitudinal prospective study was conducted with 358 participants aged ≥ 60 years and institutionalized in ten nursing homes in Natal-RN (Brazil). Mobility was assessed using the “walking” item of the Barthel index. Sociodemographic, institution-related, and health-related variables were considered at baseline. Poisson regression was used to build a multiple model. RESULTS: The incidence of mobility decline during walking was 10.6% (95% confidence interval [95% CI] = 7.4 to 13.8) after 12 months and 37.7% (95% CI = 18.0 to 26.6) after 24 months. Age ≥ 83 years (relative risk = 1.58; 95% CI = 1.24 to 2.02; p < 0.001) and hospitalization (relative risk = 3.16; 95% CI = 1.55 to 6.45; p = 0.002) were predictors of mobility decline. The rate of mobility maintenance was 31.8% after 12 months (95% CI = 31.8 to 42.9) and 23.2% after 24 months (95% CI = 26.8 to 38.5). Also, the rate of recovery was 2.5% (95% CI = 1.0 to 5.0) and 1% (95% CI = 0.2 to 2.6) after 12 and 24 months, respectively. CONCLUSION: The trajectory of mobility during walking of institutionalized older adults in northeastern Brazil was dynamic (i.e., increasing incidence of mobility decline after 24 months) and associated with advanced age and hospitalization. The chances of recovering walking performance are minimal, and maintenance of independent mobility is challenging.

Challenges and Strategies Regarding Sedation at the End of Life in Hospitals and Nursing Homes.
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Grüne B, Meesters S, Bausewein C, Schildmann E.
Journal of pain and symptom management. 2022 Apr;63(4):530–8.
CONTEXT: Sedation is an accepted, but controversially discussed and challenging measure to treat suffering at the end of life. Although most people die in hospitals or nursing homes, little is known how professionals in these settings deal with sedatives and sedation at the end of life. OBJECTIVES: To explore 1) challenges regarding use of sedatives and sedation at the end of life in hospitals and nursing homes, and 2) strategies, and supportive measures to meet these challenges, as perceived by nurses and physicians. METHODS: Multicenter qualitative interview study. Forty-nine participants: 12 general practitioners and 12 nurses from five nursing homes, 12 physicians, and 13 nurses from five hospital departments (hematology/oncology (n = 2), neurology, geriatrics, gynecology). Semi-structured qualitative interviews. Data analysis guided by framework approach. RESULTS: Perceived challenges relate to three levels of the care situation: individual, interaction with others, and work environment. The main challenge was defining the adequate timing and/or dose. Other challenges, e.g., disagreements regarding indication or legal uncertainties, were highly interrelated, and strongly associated with this major challenge. Reported strategies and supportive measures to address challenges also corresponded to the three interrelated levels. Major named strategies were education and training, joint decision-making within the team and regular discussion with the patient and family. On the level work environment, no implemented strategies, but wishes for change were identified. CONCLUSION: To meet the identified challenges in a sustainable way and enable continuous improvement of quality of care, best practice recommendations, and other supportive measures have to address all identified levels of challenges.

A Systematic Review of Tools Assessing the Perspective of Caregivers of Residents With Dementia.
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Harper AE, Rouch S, Leland NE, Turner RL, Mansbach WE, Day CE, et al.
Journal of applied gerontology : the official journal of the Southern Gerontological Society. 2022 Apr;41(4):1196–208.
In collaboration with stakeholders, we conducted a systematic review of psychometric evidence for self-report tools measuring the perspective of family caregivers of nursing home residents with dementia. Our rationale for this review was based on evidence that nonpharmacological interventions can ameliorate dementia symptoms in nursing home residents. Such interventions require caregiver participation, which is influenced by perspectives. Yet, no existing tool measures the multidomain caregiver perspective. Our review followed Preferred Reporting Items for Systematic Reviews and Meta-Analyses protocol. The final sample included 42 articles describing 33 tools measuring domains of nursing home dementia care such as behavioral and psychological symptoms of dementia, resident quality of life, dementia-specific knowledge, communication, and medication use. We uncovered evidence gaps for tools measuring dementia-specific knowledge, communication, and medication use, all of which were important to our stakeholders. Future research should focus on development of psychometrically sound tools in alignment with the multidomain caregiver perspective.

The Stability of Nursing Home Residents’ Ratings of Importance of Recreation Preferences Over One Year.
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Heid AR, Abbott KM, Rovine MJ, Eshraghi K, Madrigal C, Crumbie V, et al.
Journal of applied gerontology : the official journal of the Southern Gerontological Society. 2022 May;7334648221089239.
Long-term stability of nursing home (NH) residents’ everyday preference remains unknown. We examined 1-year stability in reports of importance of 34-recreational activity preferences (8-MDS 3.0 Section F items; 26-Preferences for Everyday Living Inventory-NH items) by NH residents (N = 161). We examined mean differences on demographic and clinical characteristics of residents for preferences showing change. Importance ratings of preferences were highly stable over 1-year, with 91% of items retaining the same valence of importance for the majority of the sample (<20% change). Three preferences showed greater change. More functionally able residents were more likely to change their importance on “being with groups of people,” and older residents were more likely to change their preferences for being “involved in religious practices” and “around animals such as pets”. Overall, annual assessments of recreational activity preferences capture an accurate representation of preferences with reassessment only needed in a few circumstances.

Empowering people with dementia via using intelligent assistive technology: A scoping review.
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Löbe C, AboJabel H.
Archives of gerontology and geriatrics. 2022 Mar;101:104699.
OBJECTIVES: Over the past decade, the idea has been promoted that intelligent assistive technology (IAT) can empower people with dementia. As a new area of inquiry, however, the concept of empowerment and the impact of IAT in this context are still unclear. Therefore, we conducted a scoping review to examine the conceptualizing and measuring of empowerment, as well as to understand the impact of IAT on empowering people with dementia in the existing studies. DESIGN: A scoping review was performed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, using the following databases: Pubmed, Cochrane Library, Web of Science, and Science Direct. In addition, a manual search was also conducted in Google Scholar to identify further articles. RESULTS: A total of 28 articles examining the empowerment of people with dementia via IAT met the inclusion criteria. Most had a cross-sectional (43%) or interventional/experimental design (39%). A little more than half (54%) were qualitative studies. We observed inconsistencies in the conceptualization and measurement of the concept of empowerment in the included studies; as such, the exact role of IAT in this context remains somewhat unclear. However, most of the studies suggest that IAT can empower people with mild/moderate dementia by enhancing their capacity to live more independently with privacy for a longer period of time. CONCLUSIONS: Future research should focus on developing a clear definition of the concept of empowerment, as well as developing a reliable and valid tool for measuring it.

Sunbeam Program Reduces Rate of Falls in Long-Term Care Residents With Mild to Moderate Cognitive Impairment or Dementia: Subgroup Analysis of a Cluster Randomized Controlled Trial.
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Mak A, Delbaere K, Refshauge K, Henwood T, Goodall S, Clemson L, et al.
Journal of the American Medical Directors Association. 2022 Feb.
OBJECTIVES: The Sunbeam trial significantly reduced falls in long-term aged care (LTC) residents. The current study’s primary objective was to undertake subgroup analysis of the Sunbeam trial, to determine whether the intervention was effective for reducing falls in LTC residents with mild-moderate cognitive impairment/dementia. Secondary objectives were to determine intervention effects on cognitive and physical function. DESIGN: Subgroup analysis of a cluster randomized controlled trial (RCT). SETTING AND PARTICIPANTS: Permanent residents of LTC in Australia who participated in the Sunbeam trial with Addenbrooke’s Cognitive Examination-Revised (ACE-R) scores <83 (Mini-Mental State Examination >14 = main trial inclusion criteria). METHODS: Of 221 participants, 148 had an ACE-R <83 and were included in this study. Sixteen LTC residences (clusters) were randomized to receive either the Sunbeam program or usual care. The Sunbeam program involved two 1-hour sessions/week of tailored and progressive resistance and balance training for 25 weeks followed by a maintenance program (two 30-min sessions/week of nonprogressive exercise for 6 months). Assessments were conducted at baseline, 6 months, and 12 months. Falls were recorded using routinely collected data from the LTC incident management systems. RESULTS: Rate of falls (50%) and risk of falls (31%), multiple falls (40%), and injurious falls (44%) were reduced in the intervention group. The intervention group had significantly better balance (static and dynamic) and sit-to-stand ability when compared with the control group at 6 months and significantly better dynamic balance at 12 months. There were no serious adverse events. CONCLUSIONS AND IMPLICATIONS: The Sunbeam Program significantly reduced falls and improved physical performance in cognitively impaired LTC residents. This is a novel and important finding, as many previous studies have excluded people with cognitive impairment/dementia and inconsistent findings have been reported when this population has been studied. Our findings suggest that progressive resistance and balance exercise is a safe and effective fall prevention intervention in LTC residents with mild-moderate cognitive impairment/dementia.

Dementia-friendly communities: The involvement of people living with dementia.
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Mathie E, Antony A, Killett A, Darlington N, Buckner S, Lafortune L, et al.
Dementia (London, England). 2022 May;21(4):1250–69.
BACKGROUND: Dementia Friendly Communities (DFCs) offer an approach to community engagement to improve the lives of people living with dementia and their family supporters. The involvement of those living with dementia is key to creating successful DFCs. This paper examines how people affected by dementia were involved in developing and designing DFCs in England, and the impact of their involvement. METHODS: This study used a mixed method case study design in six DFCs in England. Data collection involved documentary analysis, a survey, and interviews and focus groups with service providers and people living with dementia and their supporters. FINDINGS: All six DFCs aspired to involve people living with dementia and their family supporters, but often relied on a small number of people living with dementia. The range of involvement activities in DFCs included Steering Group meetings, wider public consultations, and enabling feedback through data collection methods such as surveys and ‘ad hoc’ conversations. Organisations within the DFCs with experience of public consultation offered structured opportunities for involvement. There was no evidence of people living with dementia initiating or co-leading the organisation, its direction and/or the activities of the DFCs. CONCLUSION: The involvement of people living with dementia in DFCs went beyond rhetoric, with some evidence of context sensitive and meaningful participation. Approaches towards involvement should focus on involvement in strategic planning, and on harnessing expertise in delivering different involvement activities to optimise participation of a greater breadth of people living with dementia. Engagement with local organisations who work with, and for, people living with dementia, and dedicating the resources needed for involvement work, are crucial for creating DFCs. The success of DFCs are determined by how the needs of people living with dementia are identified, discussed and reviewed by those within the community who are most affected.

Intercultural care for people of migrant origin with dementia – A literature analysis.
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Monsees J, Schmachtenberg T, René Thyrian J.
Dementia (London, England). 2022 May;14713012221086702.
BACKGROUND: Close to 12 million people of migrant origin who are 65 years or older live in different European countries. In the European Union (EU) and the European Free Trade Association (EFTA) countries, approximately half a million are estimated to have dementia. This rate is expected to increase in the coming decades. People of migrant origin who develop dementia and their families face challenges people without migration backgrounds do, but due to cultural differences, additional challenges may arise. There is an increasing need for interculturally sensitive care. There is research on certain aspects of intercultural care and this study will be a comprehensive summary of current topics in intercultural care. RESEARCH QUESTION: What factors of intercultural care for people of migrant origin with dementia can be identified? What requirements and aspects are necessary to ensure intercultural care? METHOD: A systematic literature analysis in the databases PubMed, PsycInfo and Psychology and Behavioural Sciences Collection was conducted. FINDINGS: Thirty-nine articles were eligible for analysis. Enhancement in the areas diagnostics, education and information, healthcare services and healthcare professionals to ensure intercultural care is needed. DISCUSSION: Current evidence supports the need for (a) thorough education of people of migrant origin with dementia, their families and healthcare professionals, (b) collaborations among everyone involved, (c) embracing different cultures in healthcare services, (d) the implementation of a care navigator functioning as a contact person and connecting all relevant parties with one another and (e) dementia testing suitable to the target group to ensure culturally sensitive and appropriate care for people of migrant origin with dementia and their families.

Repeat hospital transfers among long stay nursing home residents: a mixed methods analysis of age, race, code status and clinical complexity.
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Vogelsmeier A, Popejoy L, Fritz E, Canada K, Ge B, Brandt L, et al.
BMC health services research. 2022 May;22(1):626.
BACKGROUND: Nursing home residents are at increased risk for hospital transfers resulting in emergency department visits, observation stays, and hospital admissions; transfers that can also result in adverse resident outcomes. Many nursing home to hospital transfers are potentially avoidable. Residents who experience repeat transfers are particularly vulnerable to adverse outcomes, yet characteristics of nursing home residents who experience repeat transfers are poorly understood. Understanding these characteristics more fully will help identify appropriate intervention efforts needed to reduce repeat transfers. METHODS: This is a mixed-methods study using hospital transfer data, collected between 2017 and 2019, from long-stay nursing home residents residing in 16 Midwestern nursing homes who transferred four or more times within a 12-month timeframe. Data were obtained from an acute care transfer tool used in the Missouri Quality Initiative containing closed- and open-ended questions regarding hospital transfers. The Missouri Quality Initiative was a Centers for Medicare and Medicaid demonstration project focused on reducing avoidable hospital transfers for long stay nursing home residents. The purpose of the analysis presented here is to describe characteristics of residents from that project who experienced repeat transfers including resident age, race, and code status. Clinical, resident/family, and organizational factors that influenced transfers were also described. RESULTS: Findings indicate that younger residents (less than 65 years of age), those who were full-code status, and those who were Black were statistically more likely to experience repeat transfers. Clinical complexity, resident/family requests to transfer, and lack of nursing home resources to manage complex clinical conditions underlie repeat transfers, many of which were considered potentially avoidable. CONCLUSIONS: Improved nursing home resources are needed to manage complex conditions in the NH and to help residents and families set realistic goals of care and plan for end of life thus reducing potentially avoidable transfers.

Promoting dignity and well-being in residential care facilities: Older persons’ perceptions and experiences of important aspects and associated factors

Roos, Charlotte
Dalarna University, School of Health and Welfare; 2022
The overall aim of this thesis was to increase knowledge regarding the perceptions and experiences of aspects and factors associated with perceived dignity and well-being among older persons living in residential care facilities. Study I describes residents’ perceptions and experiences regarding important aspects of experiencing dignity and well-being. Study II examines the associations between perceptions of dignity and well-being and the attitudes of staff, the indoor-outdoor-mealtime environments and individual factors for residents. Study III examines the same associations as Study II over a three-year period. Study IV examines residents’ perceptions of empowerment, person-centred climate and life satisfaction before and after a caregiver intervention concerning the Swedish national fundamental values of dignity and well-being.

Methods: The studies were performed in residential care facilities in Sweden. The participants were residents living in these facilities. Study I is a qualitative study that used semi-structured interviews to collect data. Data were analysed using qualitative content analysis. Study II, a cross-sectional study, and Study III, a longitudinal study, are based on national questionnaire data from the Swedish National Board of Health and Welfare. Data from 2016, 2017 and 2018 were used and analysed using descriptive statistics and ordinal logistic regression models. Study IV is a cluster-randomized controlled trial with a pre-and post-test design. Data were collected using the Patient Empowerment Scale, the Person-centred Climate Questionnaire – patient version, the Life Satisfaction Questionnaire and the EQ-5D questionnaire. Data were analysed using descriptive statistics, the Chi-square test, the Wilcoxon signed-rank test, the Mann-Whitney U test and generalized estimating equation models.

Findings: To experience dignity and well-being it was important for residents to feel that they still matter. To feel this, it was vital to be able to manage daily life, to have influence and to belong to a social context (I). Residents who had experienced disrespectful attitudes of staff, who did not thrive in the indoor-outdoor-mealtime environments, who rated their health and mobility as poor, and who were diagnosed with dementia had higher odds of being dissatisfied with aspects of dignity and well-being (II). These associations were persistent over a three-year period (III). After an intervention concerning the Swedish national fundamental values of dignity and well-being, the residents in the intervention group reported higher scores for perceived empowerment, person-centred climate and life satisfaction (IV).

Conclusion: To promote dignity and well-being, the attitudes of staff, the indoor-outdoor-mealtime environments and the individual factors of poor health, poor mobility and a dementia diagnosis need to be targeted. The Person-centred practice framework, targeting the prerequisites of staff and the care environment, could be used as a theoretical framework for designing improvement strategies that aim to promote dignity and well-being. First-line managers and registered nurses in residential care facilities have different knowledge and skills. They therefore need to work together as a team when developing improvement strategies that aim to promote the dignity and well-being of residents. In addition, residents should be included on the team given their knowledge regarding what is important for promoting dignity and well-being.