Views of people living with dementia and their families/care partners: helpful and unhelpful responses to behavioral changes.

OBJECTIVES: This study investigated the views of people living with dementia and their families/care partners on (i) what they find helpful or unhelpful regarding behavioral changes, i.e. which coping strategies they used for themselves and/or which responses from others, and (ii) what they consider to be appropriate terminology to describe behavioral changes. DESIGN & SETTING: One-on-one semi-structured interviews were conducted with people living with dementia and families/care partners face to face, online, or over the telephone. MEASUREMENTS: Data from open-ended questions were analyzed inductively. Common themes were derived from the data using an iterative approach. RESULTS: Twenty-one people living with dementia and 20 family members/care partners were interviewed. Four main themes were derived for helpful responses, and three main themes for unhelpful responses. Helpful responses included providing clear professional support pathways and supportive environments where people living with dementia can engage in physical, cognitive, social, and spiritual activities. Unhelpful responses included discriminatory treatment from others and use of medicalized terminology. Views toward terminology varied; people with lived experience most favored using "changed behaviors" over other terminology. Areas for improvement included targeting dementia stigma, societal education on dementia, and building confidence in people living with dementia by focusing on living well with dementia. CONCLUSION: Knowledge of the views of people living with dementia may assist healthcare professionals to provide more appropriate care for people living with dementia.

Outcomes of Person-centered Care for Persons with Dementia in the Acute Care Setting: A Pilot Study.

OBJECTIVES: This pilot study assessed clinical outcomes and quality care for persons with dementia in an acute hospital with PCC, compared with usual care. METHODS: Forty-seven consented persons 60 years and over with dementia were assigned to PCC (n = 26) or usual care (control) (n = 21). Hospital nurses and allied health staff received 3 h of face-to-face education in PCC, and practice support by four PCC-trained nurse champions. Control group staff received 3 h of face-to-face education on dementia and delirium care clinical guidelines. Primary outcomes behavioral/neuropsychiatric symptoms and care quality were analyzed based on repeated measures at baseline (Time 1), 4-5 days after baseline (Time 2) and day 8-10 after baseline (Time 3) where available. RESULTS: Compared with controls, at Time 2 PCC produced statistically significant improvements in behavioral/neuropsychiatric symptoms (adjusted p = .036) and care quality (adjusted p = .044). Where length of stay exceeded 8 days after baseline (Time 3), there was a sustained improvement in quality care (p = .007), but not in behavioral/neuropsychiatric symptoms (p = .27). CONCLUSIONS: PCC can improve care quality for persons with dementia; nursing; agitation; paid caregivers with dementia and reduce behavioral/neuropsychiatric symptoms during short hospital stays. CLINICAL IMPLICATIONS: Hospital systems need to support PCC to reduce behavioral/neuropsychiatric symptoms in dementia during long hospital stays.

Effectiveness of Dementia Care Mapping™ to reduce agitation in care home residents with dementia: an open-cohort cluster randomised controlled trial.

OBJECTIVES: Agitation is common and problematic in care home residents with dementia. This study investigated the (cost)effectiveness of Dementia Care Mapping™ (DCM) for reducing agitation in this population. METHOD: Pragmatic, cluster randomised controlled trial with cost-effectiveness analysis in 50 care homes, follow-up at 6 and 16 months and stratified randomisation to intervention (n = 31) and control (n = 19). Residents with dementia were recruited at baseline (n = 726) and 16 months (n = 261). Clusters were not blinded to allocation. Three DCM cycles were scheduled, delivered by two trained staff per home. Cycle one was supported by an external DCM expert. Agitation (Cohen-Mansfield Agitation Inventory (CMAI)) at 16 months was the primary outcome. RESULTS: DCM was not superior to control on any outcomes (cross-sectional sample n = 675: 287 control, 388 intervention). The adjusted mean CMAI score difference was -2.11 points (95% CI -4.66 to 0.44, p = 0.104, adjusted ICC control = 0, intervention 0.001). Sensitivity analyses supported the primary analysis. Incremental cost per unit improvement in CMAI and QALYs (intervention vs control) on closed-cohort baseline recruited sample (n = 726, 418 intervention, 308 control) was £289 and £60,627 respectively. Loss to follow-up at 16 months in the original cohort was 312/726 (43·0%) mainly (87·2%) due to deaths. Intervention dose was low with only a quarter of homes completing more than one DCM cycle. CONCLUSION: No benefits of DCM were evidenced. Low intervention dose indicates standard care homes may be insufficiently resourced to implement DCM. Alternative models of implementation, or other approaches to reducing agitation should be considered.

Prolonged use of antipsychotic medications in long-term aged care in Australia: a snapshot from the HALT project.

OBJECTIVES: Use of antipsychotic drugs in long-term aged care (LTC) is prevalent and commonly exceeds the recommended duration, but contributors to this problem are not well understood. The objective of this study is to provide a snapshot of the features of and contributors to prolonged use of antipsychotic medications (>12 weeks) among a sample of LTC residents. DESIGN: We present retrospective and baseline data collected for the Australian Halting Antipsychotic Use in Long-Term Care (HALT) single-arm longitudinal deprescribing trial. SETTING: Twenty-four long-term care facilities in Sydney, Australia. PARTICIPANTS: The HALT study included 146 older people living in 24 Sydney LTC homes who had been prescribed a regular antipsychotic medication for at least 3 months at baseline. MEASUREMENTS: Detailed file audit was conducted to identify the date and indication recorded at initial prescription, consenting practices, longitudinal course of prescribing, and recommendations for review of antipsychotic medication. Behavioural and psychological symptoms of dementia (BPSD) and functional dependence at baseline were assessed via LTC staff interview. Cognition at baseline was assessed in a participant interview (where possible). RESULTS: Antipsychotics were prescribed for 2.2 years on average despite recommendations by a doctor or pharmacist for review in 62% of cases. Consent for antipsychotic prescription was accessible for only one case and contraindications for use were common. Longer use of antipsychotics was independently associated with higher dose of the antipsychotic drug and greater apathy, but not with other BPSD. CONCLUSION: Antipsychotic medications appeared to be prescribed in this sample as a maintenance treatment in the absence of active indicated symptoms and without informed consent. Standard interventions, including recommendations for review, had been insufficient to ensure evidence-based prescribing.

Deprescribing cholinesterase inhibitors and memantine in dementia: guideline summary.

INTRODUCTION: Cholinesterase inhibitors (ChEIs) and memantine are medications used to treat the symptoms of specific types of dementia. Their benefits and harms can change over time, particularly during long term use. Therefore, appropriate use of ChEIs and memantine involves both prescribing these medications to individuals who are likely to benefit, and deprescribing (withdrawing) them from individuals when the risks outweigh the benefits. We recently developed an evidence-based clinical practice guideline for deprescribing ChEIs and memantine, using robust international guideline development processes. MAIN RECOMMENDATIONS: Our recommendations aim to assist clinicians to: identify individuals who may be suitable for a trial of deprescribing ChEIs and memantine (such as those who do not have an appropriate indication, those who have never experienced a benefit, those who appear to be no longer benefitting, and those who have severe or end-stage dementia); and taper treatment and monitor individuals during the deprescribing process. CHANGES IN MANAGEMENT AS A RESULT OF THE GUIDELINE: Deprescribing ChEIs and memantine through shared decision making with individuals and their caregivers by: ▶determining their treatment goals; ▶discussing benefits and harms of continuing and ceasing medication, from the start of therapy and throughout; and ▶engaging them in monitoring after discontinuation, while informing carers that the individual will continue to decline after discontinuation. This approach may reduce adverse drug reactions and medication burden, leading to improved quality of life in people with dementia.

Why deprescribing antipsychotics in older people with dementia in long-term care is not always successful: Insights from the HALT study.

INTRODUCTION: Antipsychotic medications are commonly used to manage behavioural and psychological symptoms of dementia despite their side effects and harms. While the Halting Antipsychotic Use in Long-Term care (HALT) deprescribing trial was successful at reducing antipsychotic use, 19% of participants had their antipsychotics represcribed or never reached a dose of zero. The aim of this study was to investigate the reasons for represcription of antipsychotic medication and factors associated with ongoing antipsychotic use, relating to care staff requests and perceived behavioural changes. MATERIALS AND METHODS: Thirty-nine of 133 HALT participants never ceased their antipsychotic medication or were represcribed a regular or pro re nata (PRN) antipsychotic after initial deprescribing. The views of nursing staff, general practitioner, and family on the circumstances leading up to these outcomes were collected via a questionnaire-based approach. This information was triangulated with observation and detailed file audit (including progress notes, medical notes, medication charts, incident reports, and hospital discharge summaries). A consensus panel reconstructed the represcribing context. RESULTS: Nurses were the most common drivers of represcribing (63.2%), followed by family members (39.5%), GPs (23.7%), specialists (13.2%), and hospital staff (10.5%). There were multiple drivers for antipsychotic use in 46.2% of participants. Increased agitated and aggressive behaviours were the most commonly reported reasons for represcribing even though these changes were not identified over time on objective measures. Consent and dosage practices remained poor despite education. DISCUSSION: Nursing staff are the key drivers of deprescribing particularly in response to perceived worsening agitation and aggression among male residents. The train-the-trainer model used in the HALT trial may have been insufficient on its own to improve staff competence and confidence in applying nonpharmacological approaches when responding to behaviour change.

Health-related quality of life in people with advanced dementia: a comparison of EQ-5D-5L and QUALID instruments.

BACKGROUND: Assessing health-related quality of life (HRQOL) in people with advanced dementia is challenging but important for informed decision-making. Proxy measurement of this construct is difficult and is often rated lower than self-report. Accurate proxy rating of quality of life in dementia is related to identification of concepts important to the person themselves, as well as the sensitivity of the measures used. The main aim of this study was to compare the performance of two instruments-QUALID and EQ-5D-5L-on measuring HRQOL in people with advanced dementia. METHODS: In a sub-study nested within a cluster-RCT we collected proxy(nurse)-completed EQ-5D-5L and QUALID measures at baseline, 3, 6, 9 and 12 months' follow-up for people with advanced dementia, residing in 20 nursing homes across Australia. Spearman's rank correlations, partial correlations and linear regressions were used to assess the relationship between the HRQOL instrument scores and their changes over time. RESULTS: The mean weight from 284 people for the EQ-5D-5L and QUALID at baseline were 0.004 (95% CI - 0.026, 0.033) and 24.98 (95% CI 24.13, 25.82), respectively. At 12 months' follow-up, 115 participants remained alive. EQ-5D-5L weights and QUALID scores at baseline and at follow-up were moderately correlated (r = - 0.437; p < 0.001 at 12 months). Changes within QUALID and EQ-5D-5L across the same follow-up periods were also correlated (r = - 0.266; p = 0.005). The regression analyses support these findings. CONCLUSION: Whilst these quality of life instruments demonstrated moderate correlation, the EQ-5D-5L does not appear to capture all aspects of quality of life that are relevant to people with advanced dementia and we cannot recommend the use of this instrument for use within this population. The QUALID appears to be a more suitable instrument for measuring HRQOL in people with severe dementia, but is not preference-based, which limits its application in economic evaluations of dementia care.

Can an observational pain assessment tool improve time to analgesia for cognitively impaired older persons? A cluster randomised controlled trial.

OBJECTIVE: The primary objective of the study was to measure the impact of an observational pain assessment dementia tool on time from ED arrival to first dose of analgesic medicine. METHODS: A multisite cluster randomised controlled trial was conducted to test the Pain Assessment in Advanced Dementia (PAINAD) tool. Patients aged 65 years or older suspected of a long bone fracture were screened for cognitive impairment using the Six-Item Screening (SIS) tool. Patients scoring 4 or less on SIS (intervention sites) were assessed for pain using PAINAD. Control sites, assessed pain using standard methods. The primary outcome was time to first dose of analgesia and was analysed on an intention-to-treat basis with a sensitivity analysis. RESULTS: We enrolled 602 patients, of which 323 (54%) were at intervention sites (n=4). The median time to analgesia was 82 min (IQR 45-151 min). There was no statistically significant difference in median time to analgesia for intervention 83 (IQR 48-158 min) and non-intervention 82 min (IQR 41-147 min) sites (p=0.414). After adjusting for age, fracture type, arrival mode and triage category, there remained no significant difference in time to analgesia (HR 0.97, 95% CI 0.80 to 1.17, p=0.74). Of the 602 patients enrolled, 273 actually had cognitive impairment. A sensitivity analysis demonstrated patients at intervention sites received analgesia 13 min sooner (90 vs 103 min, p=0.91). CONCLUSION: Use of the PAINAD was not associated with a shorter time to analgesia, although there was a clinically important but non-significant improvement in the cognitively impaired patient group. Further research is needed to address this clinically important and complex issue.

Halting Antipsychotic Use in Long-Term care (HALT): a single-arm longitudinal study aiming to reduce inappropriate antipsychotic use in long-term care residents with behavioral and psychological symptoms of dementia.

BACKGROUND: Inappropriate use of antipsychotic medications to manage Behavioral and Psychological Symptoms of Dementia (BPSD) continues despite revised guidelines and evidence for the associated risks and side effects. The aim of the Halting Antipsychotic Use in Long-Term care (HALT) project is to identify residents of long-term care (LTC) facilities on antipsychotic medications, and undertake an intervention to deprescribe (or cease) these medicines and improve non-pharmacological behavior management. METHODS: LTC facilities will be recruited across Sydney, Australia. Resident inclusion criteria will be aged over 60 years, on regular antipsychotic medication, and without a primary psychotic illness or very severe BPSD, as measured using the Neuropsychiatric Inventory (NPI). Data collection will take place one month and one week prior to commencement of deprescribing; and 3, 6 and 12 months later. During the period prior to deprescribing, training will be provided for care staff on how to reduce and manage BPSD using person-centered approaches, and general practitioners of participants will be provided academic detailing. The primary outcome measure will be reduction of regular antipsychotic medication without use of substitute psychotropic medications. Secondary outcome measures will be NPI total and domain scores, Cohen-Mansfield Agitation Inventory scores and adverse events, including falls and hospitalizations. CONCLUSION: While previous studies have described strategies to minimize inappropriate use of antipsychotic medications in people with dementia living in long-term care, sustainability and a culture of prescribing for BPSD in aged care remain challenges. The HALT project aims to evaluate the feasibility of a multi-disciplinary approach for deprescribing antipsychotics in this population.

Emergency nurses' evaluation of observational pain assessment tools for older people with cognitive impairment.

AIMS AND OBJECTIVES: To explore emergency nurses' perceptions of the feasibility and utility of Pain Assessment in Advanced Dementia tool in people over 65 with cognitive impairment. The Pain Assessment in Advanced Dementia tool was then compared with The Abbey Pain Scale, Doloplus-2 and PACSLAC. The objective was to determine which observational pain assessment tool was the most appropriate for the emergency department context and the cognitively impaired older person. BACKGROUND: The number of older people with cognitive impairment conditions, such as dementia, presenting to the emergency department is increasing. Approximately 28% of people over 65 years who present will have cognitive impairment. Older people with cognitive impairment often receive suboptimal pain management in the ED. There is limited evidence of the use and/or appropriateness of dementia-specific pain observation assessment tools in the ED. DESIGN: This was a multicentre exploratory qualitative study, which was conducted within a constructivist paradigm. METHODS: Focus group interviews were conducted with nurses across three hospital emergency departments. Data were subject to thematic analysis. RESULTS: Six focus groups were conducted with 36 nurses over a 12-week period. Four themes emerged from the analysis: 1) cognitive impairment is a barrier to pain management; 2) PAINAD gives structure to pain assessment; 3) PAINAD assists to convey pain intensity; and 4) selection of an appropriate observational pain assessment tool. CONCLUSIONS: This study identified that emergency nurses find it challenging to detect, assess and manage pain in cognitively impaired people. While the use of the PAINAD helped to address these challenges compared to other tools, nurses also identified the important role that family and carers can play in pain assessment and management for older people with cognitive impairment. RELEVANCE TO CLINICAL PRACTICE: This study has generated new knowledge that has broad application across clinical settings, which can assist to transform pain management practice and reduce human suffering. The use of an observational pain assessment tool can provide for greater practice consistency for patients with communication difficulties. Pain management for older people with cognitive impairment is best achieved by the use an appropriate observational pain assessment tool and with a multidisciplinary approach that includes the person and their family/carer.

Development and Validation of a Short Version of the Cornell Scale for Depression in Dementia for Screening Residents in Nursing Homes.

OBJECTIVES: To develop and validate a short version of the Cornell Scale for Depression in Dementia (CSDD-19) for routine detection of depression in nursing homes. SETTING: Australian nursing homes. METHODS: A series of cross-sectional studies were conducted involving: 1) descriptive analysis of pooled data from five nursing home studies that used the CSDD-19 (N = 671) to identify patterns of responses and missing data on individual CSDD items; 2) analysis of four of the five studies (N = 556) to assess CSDD-19 for unidimensionality, item fit, and differential item functioning using Rasch modeling to develop a shorter version, the CSDD-4; 3) validation of the CSDD-4 against the DSM-IV using the fifth study of 115 residents and through expert consultations; and 4) evaluation of the clinical utility of CSDD-4 using an independent cohort of 92 nursing home residents. RESULTS: Four items from the original CSDD-19 were found to be most suitable for depression screening: anxiety, sadness, lack of reactivity to pleasant events, and irritability. The CSDD-4 highly correlated with the original scale (N = 474, r = 0.831, p < 0.001), with acceptable internal consistency (Cronbach's alpha = 0.70). At the cutoff score of less than 2, sensitivity and specificity of CSDD-4 were 81% and 51%, respectively, for the independent cohort (N = 92), of whom 50% had dementia. The CSDD-4 had an area under the curve (AUC) of 0.73 (z = 3.47, p < 0.001), which was compatible with the CSDD-19 (AUC = 0.69, z = 2.89, p < 0.01). CONCLUSIONS: The CSDD-4 is valid for routine screening of depression in nursing homes. Its adoption is feasible and practical for nursing home staff, and may facilitate more comprehensive assessment and management of depression in nursing home residents.

Coaching in self-efficacy improves care responses, health and well-being in dementia carers: a pre/post-test/follow-up study.

BACKGROUND: Maintaining the health and well-being of family carers of people with dementia is vital, given their potential for experiencing burden associated with the role. The study aimed to help dementia carers develop self-efficacy, be less hassled by the caring role and improve their health and well-being with goal-directed behaviour, by participating in an eight module carer coaching program. METHODS: The study used mixed methods in a pre/post-test/follow-up design over 24 months, with assignment of consented dementia carers to either individualised (n = 16) or group coaching (n = 32), or usual carer support services (n = 43), depending on preference. Care-giving self-efficacy and hassles, carer health, well-being and goal-directed behaviours were assessed over time. Analysis of Variance (ANOVA) was used to compare changes over time and the effects of coaching on carer self-efficacy, hassles and health, using the Univariate General Linear Model (GLM). RESULTS: All carers were hassled by many aspects of caring at baseline. Participants receiving coaching reported non-significant improvements in most areas of self-efficacy for caring, hassles associated with caring and self-reported health at post-test and follow-up, than did carers receiving usual carer support. Group coaching had greater success in helping carers to achieve their goals and to seek help from informal and formal support networks and services. CONCLUSION: The study outcomes were generally positive, but need to be interpreted cautiously, given some methodological limitations. It has been shown, however, that health staff can assist dementia carers to develop self-efficacy in better managing their family member's limitations and behaviour, seek help from others and attend to their health. Teaching carers to use goal-directed behaviour may help them achieve these outcomes.

The effectiveness of interventions designed to reduce medication administration errors: a synthesis of findings from systematic reviews.

AIM: The aim of this overview was to examine the effectiveness of interventions designed to improve patient safety by reducing medication administration errors using data from systematic reviews. BACKGROUND: Medication administration errors remain unacceptably high despite the introduction of a range of interventions aimed at enhancing patient safety. Systematic reviews of strategies designed to improve medication safety report contradictory findings. A critical appraisal and synthesis of these findings are, therefore, warranted. METHODS: A comprehensive three-step search strategy was employed to search across 10 electronic databases. Two reviewers independently examined the methodological rigour and scientific quality of included systematic reviews using the Assessment of Multiple Systematic Reviews protocol. RESULTS: Sixteen systematic reviews were eligible for inclusion. Evidence suggest that multifaceted approaches involving a combination education and risk management strategies and the use of bar code technology are effective in reducing medication errors. CONCLUSION: More research is needed to determine the benefits of routine double-checking of medications during administration by nurses, outcomes of self-administration of medications by capable patients, and associations between interruptions and medications errors. IMPLICATIONS FOR NURSING MANAGEMENT: Medication-related incidents must be captured in a way that facilitates meaningful categorisation including contributing factors, potential and actual/risk of harm and contextual information on the incident.

The clinical utility of the Cornell Scale for Depression in Dementia as a routine assessment in nursing homes.

OBJECTIVE: To examine the clinical utility of the Cornell Scale for Depression in Dementia (CSDD) in nursing homes. SETTING: 14 nursing homes in Sydney and Brisbane, Australia. PARTICIPANTS: 92 residents with a mean age of 85 years. MEASUREMENTS: Consenting residents were assessed by care staff for depression using the CSDD as part of their routine assessment. Specialist clinicians conducted assessment of depression using the Semi-structured Clinical Diagnostic Interview for DSM-IV-TR Axis I Disorders for residents without dementia or the Provisional Diagnostic Criteria for Depression in Alzheimer Disease for residents with dementia to establish expert clinical diagnoses of depression. The diagnostic performance of the staff completed CSDD was analyzed against expert diagnosis using receiver operating characteristic (ROC) curves. RESULTS: The CSDD showed low diagnostic accuracy, with areas under the ROC curve being 0.69, 0.68 and 0.70 for the total sample, residents with dementia and residents without dementia, respectively. At the standard CSDD cutoff score, the sensitivity and specificity were 71% and 59% for the total sample, 69% and 57% for residents with dementia, and 75% and 61% for residents without dementia. The Youden index (for optimizing cut-points) suggested different depression cutoff scores for residents with and without dementia. CONCLUSION: When administered by nursing home staff the clinical utility of the CSDD is highly questionable in identifying depression. The complexity of the scale, the time required for collecting relevant information, and staff skills and knowledge of assessing depression in older people must be considered when using the CSDD in nursing homes.

Validity of the geriatric depression scale and the collateral source version of the geriatric depression scale in nursing homes.

BACKGROUND: Depression is a common psychiatric disorder in older people. The study aimed to examine the screening accuracy of the Geriatric Depression Scale (GDS) and the Collateral Source version of the Geriatric Depression Scale (CS-GDS) in the nursing home setting. METHODS: Eighty-eight residents from 14 nursing homes were assessed for depression using the GDS and the CS-GDS, and validated against clinician diagnosed depression using the Semi-structured Clinical Diagnostic Interview for DSM-IV-TR Axis I Disorders (SCID) for residents without dementia and the Provisional Diagnostic Criteria for Depression in Alzheimer Disease (PDCdAD) for those with dementia. The screening performances of five versions of the GDS (30-, 15-, 10-, 8-, and 4-item) and two versions of the CS-GDS (30- and 15-item) were analyzed using receiver operating characteristic (ROC) curves. RESULTS: Among residents without dementia, both the self-rated (AUC = 0.75-0.79) and proxy-rated (AUC = 0.67) GDS variations performed significantly better than chance in screening for depression. However, neither instrument adequately identified depression among residents with dementia (AUC between 0.57 and 0.70). Among the GDS variations, the 4- and 8-item scales had the highest AUC and the optimal cut-offs were >0 and >3, respectively. CONCLUSIONS: The validity of the GDS in detecting depression requires a certain level of cognitive functioning. While the CS-GDS is designed to remedy this issue by using an informant, it did not have adequate validity in detecting depression among residents with dementia. Further research is needed on informant selection and other factors that can potentially influence the validity of proxy-based measures in the nursing home setting.

Multiple perspectives on quality of life for residents with dementia in long term care facilities: protocol for a comprehensive Australian study.

BACKGROUND: Dementia is a chronic illness without cure or effective treatment, which results in declining mental and physical function and assistance from others to manage activities of daily living. Many people with dementia live in long term care facilities, yet research into their quality of life (QoL) was rare until the last decade. Previous studies failed to incorporate important variables related to the facility and care provision or to look closely at the daily lives of residents. This paper presents a protocol for a comprehensive, multi-perspective assessment of QoL of residents with dementia living in long term care in Australia. A secondary aim is investigating the effectiveness of self-report instruments for measuring QoL. METHODS: The study utilizes a descriptive, mixed methods design to examine how facility, care staff, and resident factors impact QoL. Over 500 residents with dementia from a stratified, random sample of 53 facilities are being recruited. A sub-sample of 12 residents is also taking part in qualitative interviews and observations. CONCLUSIONS: This national study will provide a broad understanding of factors underlying QoL for residents with dementia in long term care. The present study uses a similar methodology to the US-based Collaborative Studies of Long Term Care (CS-LTC) Dementia Care Study, applying it to the Australian setting.

PerCEN trial participant perspectives on the implementation and outcomes of person-centered dementia care and environments.

BACKGROUND: Well-being and various forms of agitation in people with dementia can be improved in a person-centered long-term care setting. Data obtained during the Person-Centered Dementia Care and Environment (PerCEN) randomized controlled trial shed light on the factors that influenced the adoption and outcomes of person-centered interventions in long-term care from the perspective of study participants. METHODS: Data were obtained from PerCEN participants: individual semi-structured interviews with care managers (29), nurses and care staff (70); telephone surveys with family members (73); staff reports of care approaches; and 131 field note entries recorded by the person-centered care and environment facilitators. Data were interpreted inductively using content analysis, code building, theme development, and synthesis of findings. RESULTS: All data sources confirmed that, when adopted, the person-centered model increased the number and variety of opportunities for resident interaction, improved flexibility in care regimens, enhanced staff's attention to resident needs, reduced resident agitation, and improved their well-being. Barriers and enablers for the person-centered model related to leadership, manager, staff and family appreciation of the model, staff's capacity, effective communication and team work among direct care staff, care service flexibility, and staff education on how to focus care on the person's well-being. CONCLUSIONS: Successful knowledge translation of the person-centered model starts with managerial leadership and support; it is sustained when staff are educated and assisted to apply the model, and, along with families, come to appreciate the benefits of flexible care services and teamwork in achieving resident well-being. The Australian New Zealand Clinical Trials Registry number is ACTRN 12608000095369.

Emergency nurses' perceptions of the role of confidence, self-efficacy and reflexivity in managing the cognitively impaired older person in pain.

AIMS AND OBJECTIVES: The study aimed to explore the practice of care among emergency nurses caring for older persons with cognitive impairment and who presented in pain from a long bone fracture, to highlight nurse confidence and self-efficacy in practice. BACKGROUND: Cognitive impairment is an issue increasingly facing emergency departments. Older persons with cognitive impairment have complex care needs, requiring effective clinical decision-making and provision of care. Nurse confidence and self-efficacy are critical to meeting the necessary standards of care for this vulnerable patient group. DESIGN: A multi-centre study. METHODS: The study was undertaken across four emergency departments in Sydney, Australia. Sixteen focus group discussions were conducted with 80 emergency departments of nurses. RESULTS: Four main themes emerged: confidence and self-efficacy through experience; confidence and self-efficacy as a balancing act; confidence and self-efficacy as practice; and confidence and self-efficacy and interpersonal relations. CONCLUSIONS: Our findings demonstrate that confidence, self-efficacy and reflexivity enabled the delivery of appropriate, timely and compassionate care. Further, confidence and self-efficacy within nursing praxis relied on clinical experience and reflective learning and was crucial to skill and knowledge acquisition. RELEVANCE TO CLINICAL PRACTICE: Our research suggests that confidence, self-efficacy and reflexivity need to be developed and valued in nurses' careers to better meet the needs of complex older persons encountered within everyday practice.

Validation of a clinical leadership qualities framework for managers in aged care: a Delphi study.

AIMS AND OBJECTIVES: To establish validity of a clinical leadership framework for aged care middle managers (The Aged care Clinical Leadership Qualities Framework). BACKGROUND: Middle managers in aged care have responsibility not only for organisational governance also and operational management but also quality service delivery. There is a need to better define clinical leadership abilities in aged care middle managers, in order to optimise their positional authority to lead others to achieve quality outcomes. DESIGN: A Delphi method. METHODS: Sixty-nine experts in aged care were recruited, representing rural, remote and metropolitan community and residential aged care settings. Panellists were asked to rate the proposed framework in terms of the relevance and importance of each leadership quality using four-point Likert scales, and to provide comments. Three rounds of consultation were conducted. The number and corresponding percentage of the relevance and importance rating for each quality was calculated for each consultation round, as well as mean scores. Consensus was determined to be reached when a percentage score reached 70% or greater. RESULTS: Twenty-three panellists completed all three rounds of consultation. Following the three rounds of consultation, the acceptability and face validity of the framework was confirmed. CONCLUSIONS: The study confirmed the framework as useful in identifying leadership requirements for middle managers in Australian aged care settings. The framework is the first validated framework of clinical leadership attributes for middle managers in aged care and offers an initial step forward in clarifying the aged care middle manager role. RELEVANCE TO CLINICAL PRACTICE: The framework provides clarity in the breadth of role expectations for the middle managers and can be used to inform an aged care specific leadership program development, individuals' and organisations' performance and development processes; and policy and guidelines about the types of activities required of middle managers in aged care.

Expectations and experiences of older people and their carers in relation to emergency department arrival and care: A qualitative study in Australia.

Although older people frequently present to the emergency department (ED), little is known about their experiences in this setting, despite increasing attendance rates reported in this population internationally. This study explores the experiences of older people and their carers leading to and during ED care in a metropolitan university hospital in Sydney, Australia. The study forms part of a larger prospective exploratory study on this topic. Individual in-depth interviews were conducted with 10 people over 65 years of age who had a chronic illness and their carers one month after they presented to the ED. Interviews were transcribed verbatim and analyzed using general interpretive methods. The results revealed that the participants presented to the ED as a result of escalating symptoms and on their general practitioner's advice. Participants felt uninformed about ED procedures, therefore, families/carers felt the need to advocate for information and basic services. Participants were grateful for the care received and mindful of the busy environment. To meet the expectations of older people, nurses need to provide timely information and advise carers how they can assist.