Effects of physical activity on depressive symptoms in older caregivers: The IMPACCT randomized controlled trial.

OBJECTIVES: Physical activity (PA) can reduce depressive symptoms but has not been tested amongst depressed older caregivers and their care-recipients. The aim of this single-blind randomized controlled trial was to investigate the effect of a 6-month tailored PA program on depressive symptoms in older caregivers. METHOD: Caregivers were included if they had scores of ≥5 on the 15-item geriatric depression scale (GDS-15). Care-recipients could have any type of physical, mental or cognitive condition requiring support. The PA intervention group completed an individualized program based on the Otago-Plus Exercise Program. The primary outcome was improvement in depressive symptoms in caregivers measured at six and 12 months. RESULTS: Two hundred and twelve participants (91 dyads and 30 caregivers only) were randomized using a 3:3:1 ratio to PA intervention, social-control, and usual-care control groups. There were no significant differences in depressive symptoms of the caregivers between the three groups at 6 months or 12 months. However, more than 50% of caregivers in all three groups no longer had a GDS-15 score ≥5 at 6 months. Further analysis revealed that caregivers in the PA group caring for someone with a standardised mini-mental state examination (SMMSE) score ≥24 had significantly less depressive symptoms than those caring for someone with a SMMSE score <24 compared with social-control (p < 0.02) and usual-care groups (p < 0.02). CONCLUSIONS: A PA intervention may be beneficial for some caregivers in reducing symptoms of depression but may not be as beneficial to caregivers of people living with cognitive impairment.

Co-designing a dementia-specific education and training program for home care workers: The 'Promoting Independence Through Quality Dementia Care at Home' project.

Undertaking co-design with the end users of services has rapidly evolved as the best-practice approach to program design, development and implementation. Increased interest in using participatory co-design in dementia care has drawn attention to the need for evidence-informed methods for facilitating the meaningful involvement of people with dementia and their family carers in co-design activities. The aim of this paper is to describe the co-design framework used in the co-design of a dementia specialist training program for home care workers. The Promoting Independence Through quality dementia Care at Home program is a successful example of co-design methodology used across multiple project stages and with various stakeholder groups, including people living with dementia, family carers, home care workers, managers and researchers. Co-design methods were tailored to each stage, purpose, and stakeholder group, and to facilitate the involvement of people living with dementia. Findings provide unique insights into optimising input from co-design partners, including people living with dementia; the methodology, conditions and requirements for participants to co-design and implement ideas; and perspectives on the enablers and challenges of using co-design in this population. In this paper, we present a comprehensive approach for involving people living with dementia as active and equal contributors in inclusive and meaningful participatory co-design.

What constitutes 'good' home care for people with dementia? An investigation of the views of home care service recipients and providers.

BACKGROUND: Our objective was to explore what people receiving and providing care consider to be 'good' in-home care for people living with dementia. METHODS: We conducted 36 in-depth interviews and two focus groups with key stakeholders in Australia in the first quarter of 2018. Participants included those receiving care (4 people living with dementia, 15 family carers) or providing care (9 case managers, 5 service managers, 10 home care workers). Qualitative thematic analysis was guided by Braun and Clarke's six-step approach. RESULTS: Consensus was reached across all groups on five themes considered as important for good in-home dementia care: 1) Home care workers' understanding of dementia and its impact; 2) Home care workers' demonstrating person-centred care and empathy in their care relationship with their client; 3) Good relationships and communication between care worker, person with dementia and family carers; 4) Home care workers' knowing positive practical strategies for changed behaviours; 5) Effective workplace policies and workforce culture. The results contributed to the co-design of a dementia specific training program for home care workers. CONCLUSIONS: It is crucial to consider the views and opinions of each stakeholder group involved in providing/receiving dementia care from home care workers, to inform workforce training, education program design and service design. Results can be used to inform and empower home care providers, policy, and related decision makers to guide the delivery of improved home care services. TRIAL REGISTRATION: ACTRN 12619000251123 .

National Survey on the Impact of COVID-19 on the Mental Health of Australian Residential Aged Care Residents and Staff.

OBJECTIVES: This study is the first to obtain data on the prevalence of, contributors to, and supports required for, pandemic-related distress within the residential aged care sector in Australia. A nested mixed-methods approach was used to examine aged care leaders' opinions about the impact of COVID-19 on the mental health of aged care residents and staff. METHODS: A total of 288 senior staff of Australian residential aged care facilities (care managers, clinical care coordinators, and lifestyle team leaders; mean age = 52.7 years, SD = 10.3) completed an online survey between 10th September and 31st October 2020. RESULTS: On average, nearly half of their residents experienced loneliness (41%) and a third experienced anxiety in response to COVID-19 (33%). The most frequently noted contributors to poor mental health among residents were restrictions to recreational outings and watching news coverage relating to COVID-19. Participants emphasized the need for increased access to counseling services and improved mental health training amongst staff. Residential care staff were similarly impacted by the pandemic. More than a third of staff were reported as anxious (36%) and 20% depressed, in response to COVID-19. Staff were worried about introducing COVID-19 into their facility and were impacted by news coverage of COVID-19. Staff would feel supported by financial assistance and by increased staff-resident ratios. CONCLUSIONS: Senior staff perceive that the mental health of Australian aged care residents and staff was negatively impacted by the COVID-19 pandemic. The most noted contributors were identified, as was the mental health support for aged care communities. CLINICAL IMPLICATIONS: This study provides government and policymakers with clear intervention targets for supporting the sector. Clinicians can support residential aged care communities by providing on-site or telehealth counseling, and upskill and train residential aged care staff on how to respond to the emotional needs of residents in response to COVID-19.

The language of dying: Communication about end-of-life in residential aged care.

This article explores implications of language used in communicating death and dying in residential aged care, which increasingly emphasizes a "family-centered" approach to end-of-life care. Based on focus groups with care professionals and families, our findings reveal a persistent clinical culture that resists frank discussions of dying, with many staff preferring to use euphemisms for dying. Our results emphasize the importance of end-of-life education for families, which families acknowledged was lacking. Cultural change in institutional control over disclosing dying is imperative in order to gain family trust and support in professional care and promote death literacy.

Promoting Independence Through quality dementia Care at Home (PITCH): a research protocol for a stepped-wedge cluster-randomised controlled trial.

BACKGROUND: Home care service providers are increasingly supporting clients living with dementia. Targeted and comprehensive dementia-specific training for home care staff is necessary to meet this need. This study evaluates a training programme delivered to care staff (paid personal carers) of clients living with dementia at home. METHODS: This study is a pragmatic stepped-wedge cluster-randomised controlled trial (SW-CRT). Home care workers (HCWs) from seven home care service providers are grouped into 18 geographical clusters. Clusters are randomly assigned to intervention or control groups. The intervention group receives 7 h of a dementia education and upskilling programme (Promoting Independence Through quality dementia Care at Home [PITCH]) after baseline measures. The control group receives PITCH training 6 months after baseline measures. This approach will ensure that all participants are offered the program. Home care clients living with dementia are also invited to participate, as well as their family carers. The primary outcome measure is HCWs' sense of competence in dementia care provision. DISCUSSION: Upskilling home care staff is needed to support the increasing numbers of people living with dementia who choose to remain at home. This study uses a stepped-wedge cluster-randomised trial to evaluate a training programme (PITCH) for dementia care that is delivered to front-line HCWs. TRIAL REGISTRATION: anzctr.org.au ; ACTRN12619000251123. Registered on 20 February 2019.

'I know they are not trained in dementia': Addressing the need for specialist dementia training for home care workers.

Global population ageing has meant a rapid increase in the numbers of older people with dementia, most of whom live in their own homes. Staying at home is an important determinant of health and well-being. As care needs increase, the quality of community support which older people receive directly influences their capacity to remain in their own homes. While many are supported informally by family carers, formal support provided by home care workers often enables them to remain at home for longer period. However, providing community-based care for people with dementia can be challenging. Workers often lack training in dementia-specific care for clients with increasingly complex needs, and typically work without direct supervision. As the demand for person-centred home care for people with dementia increases, specialist dementia training for home care workers is urgently needed. In this qualitative study, we used in-depth interviews of a purposive sample, comprising 15 family carers and four older people with dementia, to understand the experience of receiving community care. Data analysis was guided by Braun and Clarke's approach to thematic analysis and revealed the following five overlapping themes, relating to home care workers' understanding of dementia, person-centred care, communication and rapport, mutual collaboration, and the influence of organisational constraints on continuity of care. Although participants acknowledged that service providers operated under challenging circumstances, they were frustrated with home care workers' lack of dementia knowledge and inconsistent staff rostering. Conversely, an understanding of the lived experience of dementia, effective communication and rapport, and continuity of care contributed significantly to a positive experience of receiving care. The findings of this study will be used to inform the essential elements of a training program aimed at enabling and empowering a skilled, specialist home care workforce to support older people with dementia to live well at home for as long as possible.

Maintenance of Professional Boundaries and Family Involvement in Residential Aged Care.

The importance of family's involvement in care planning has been stressed to cater individualized, person-centered care in residential aged care. However, in reality, there are numerous structural obstacles and barriers that limit opportunities for their involvement. The aim of this article is to explore what they are. The findings based on the 12 focus groups, six groups of care professionals and six groups of family/relatives, reveal that the narrow pathway of communication between staff and families, which is hierarchically structured, one-directional, and clinically driven, enables the former to maintain and control professional boundaries between formal and informal care-giving. Such communication style delimits an opportunity for families to engage in quality discussion about care planning for their loved ones with care staff. Communication within residential aged care facilities embodies complex dynamics of care expectations and responsibilities held by care staff and families.

Testing the reliability and validity of a Transition Map for older adults in long term care settings.

Mapping individual patterns of decline in older adults may aid coordinating long term aged care. This study developed a new scale (Transition Maps) to summarise the overall care pathway for long term aged care residents, in a simplified manner incorporating mapping concepts. Transition Maps were developed using mixed methods in two phases, and based on expert opinion, literature review, and input from aged care health professionals. Four professions (primary physician, nurse, allied health, lifestyle services) generated 147 Transition Maps for 38 residents living in a long term care. Preliminary construct validity and inter-rated reliability were evaluated. Results showed that Inter-rater reliability of agreement with the overall care pathway for each resident was kappa = 0.492. Consensus was lowest between nurse care managers and primary physicians (kappa = 0.384), and highest between nurse managers and Lifestyle Services (kappa = 0.77). Preliminary testing of the Transition Map scale provides initial support of construct validity and inter-rater reliability and provides some evidence that Transition Maps can improve the coordination of long term aged care.

Chronic idiopathic normocytic anaemia in older people: the risk factors and the role of age-associated renal impairment.

OBJECTIVES: To characterise the risk factors for chronic idiopathic normocytic anaemia (CINA) in older people, particularly the role of age-associated renal impairment. METHODS: Patients aged ≥65 years admitted to a medical unit over 12 months were assessed. Those with secondary causes of anaemia including chronic kidney disease (CKD) were excluded. CINA was defined as a haemoglobin <130 g/l for men and <120 g/l for women for at least 6 months without any apparent cause. Renal function was determined by estimating creatinine clearance (CrCl) using Cockcroft-Gault formula, and glomerular filtration rate (GFR) using modification of diet in renal disease (MDRD) and chronic kidney disease epidemiology collaboration (CKD-EPI) formulas. RESULTS: 116 had CINA. Controls were 572. The mean estimates of renal function were significantly lower in cases as compared with controls (P < 0.001). The risk of CINA increased by 12.6, 10.4 and 12 %, respectively, for each unit decrease in CrCl, MDRD-eGFR and CKD-EPI-eGFR, independent of age and other covariates. The adjusted odds ratios for CINA in those with CrCl, MDRD or CKD-EPI eGFR <60 ml/min/1.73 m2 were 2.68 (CI 1.53-4.70); 2.70 (CI 1.57-4.62) and 2.12 (CI 1.46-3.74), respectively. Other covariates in the model that were independently associated with CINA included advanced age, diabetes mellitus (DM), use of angiotensin converting enzyme inhibitor (ACEI) or angiotensin receptor blocker (ARB), history of dementia and living in a residential care facility. CONCLUSIONS: Age-associated renal impairment independently contributes to CINA. Other potential risk factors for CINA include advanced age, DM and ACEI or ARB use.

Overview of Pain Management in Older Adults.

Epidemiological data suggests that the prevalence of musculoskeletal and neuropathic pain increases with age until at least late mid-life, though the pattern is somewhat unclear beyond this point. And though the prevalence of some types of pain may peak in late midlife, pain is still a substantial and common complaint even in the oldest age groups. This article provides an overview of later-life pain and includes a brief review of its epidemiology, describes commonly encountered barriers to its management, and discusses guidelines and recommended approaches to its assessment and management.

Pain management in residential aged care facilities.

BACKGROUND: Persistent pain is prevalent in aged care facilities and there are a number of barriers that make effective pain management more difficult to achieve in this setting. OBJECTIVE: The aim of this article is to provide an evidence-based approach to assessment and management of pain experienced by residents of aged care facilities. DISCUSSION: Barriers to effective pain management in residential aged care facilities include patient beliefs and attitudes towards pain, communication deficits and cognitive impairment, frailty and its effect on pharmacotherapy, and limited evidence of comprehensive pain management strategies for people with dementia. Education programs, developments in observational behaviour scales and stepwise pain management protocols have enabled good progress to be made in addressing these obstacles and improving patient outcomes.

Should placebo be used routinely for chronic pain in older people?

As research expands our understanding of underlying placebo mechanisms, interest turns to the clinical application of placebos. Whether placebos are appropriate and effective in the management of chronic pain in older people deserves considerable attention. The evidence suggests that adults of any age are responsive to placebos, and that placebo treatments can be effective for many conditions prevalent in older people. Though placebos in general already seem to be used with some regularity in medical practice, the use of placebos alone for chronic pain is probably unjustified unless other treatments are inadvisable or have been exhausted. However maximising the mechanisms that underpin placebo analgesia such as expectancy or the psychosocial context should be encouraged and would be considered a feature of good clinical practice. It would also be anticipated that older people may see an additional benefit with placebo treatments when such treatments reduce existing or planned medication regimes, as older people typically experience more comorbidities, increased susceptibility to adverse drug reactions, and altered pharmacological responses to drugs. Further research is still needed in placebo-related treatment paradigms for the management of chronic pain in older people.

An evidence-based program to improve analgesic practice and pain outcomes in residential aged care facilities.

Pain is common in individuals living in residential aged care facilities (RACFs), and a number of obstacles have been identified as recurring barriers to adequate pain management. To address this, the Australian Pain Society developed 27 recommendations for comprehensive good practice in the identification, assessment, and management of pain. This study reviewed preexisting pain management practice at five Australian RACFs and identified changes needed to implement the recommendations and then implemented an evidence-based program that aimed to facilitate better pain management. The program involved staff training and education and revised in-house pain-management procedures. Reviews occurred before and after the program and included the assessment of 282 residents for analgesic use and pain status. Analgesic use improved after the program (P<.001), with a decrease in residents receiving no analgesics (from 15% to 6%) and an increase in residents receiving around-the-clock plus as-needed analgesics (from 24% to 43%). There were improvements in pain relief for residents with scores indicative of pain, with Abbey pain scale (P=.005), Pain Assessment in Advanced Dementia Scale (P=.001), and Non-communicative Patient's Pain Assessment Instrument scale (P<.001) scores all improving. Although physical function declined as expected, Medical Outcomes Study 36-item Short-Form Survey bodily pain scores also showed improvement (P=.001). Better evidence-based practice and outcomes in RACFs can be achieved with appropriate training and education. Investing resources in the aged care workforce using this program improved analgesic practice and pain relief in participating sites. Further attention to the continued targeted pain management training of aged care staff is likely to improve pain-focused care for residents.

Implementation of sustainable evidence-based practice for the assessment and management of pain in residential aged care facilities.

Pain is common in residential aged care facilities (RACFs). In 2005, the Australian Pain Society developed 27 recommendations for good practice in the identification, assessment, and management of pain in these settings. This study aimed to address implementation of the standards and evaluate outcomes. Five facilities in Australia participated in a comprehensive evaluation of RACF pain practice and outcomes. Pre-existing pain management practices were compared with the 27 recommendations, before an evidence-based pain management program was introduced that included training and education for staff and revised in-house pain-management procedures. Post-implementation audits evaluated the program's success. Aged care staff teams also were assessed on their reports of self-efficacy in pain management. The results show that before the implementation program, the RACFs demonstrated full compliance on 6 to 12 standards. By the project's completion, RACFs demonstrated full compliance with 10 to 23 standards and major improvements toward compliance in the remaining standards. After implementation, the staff also reported better understanding of the standards (p < .001) or of facility pain management guidelines (p < .001), increased confidence in therapies for pain management (p < .001), and increased confidence in their training to assess pain (p < .001) and recognize pain in residents with dementia who are nonverbal (p = .003). The results show that improved evidence-based practice in RACFs can be achieved with appropriate training and education. Investing resources in the aged care workforce via this implementation program has shown improvements in staff self-efficacy and practice.

The effects of variant descriptors on the potential effectiveness of plain packaging.

OBJECTIVES: To examine the effects that variant descriptor labels on cigarette packs have on smokers' perceptions of those packs and the cigarettes contained within. METHOD: As part of two larger web-based studies (each involved 160 young adult ever-smokers 18-29 years old), respondents were shown a computer image of a plain cigarette pack and sets of related variant descriptors. The sets included terms that varied in terms of descriptors of colours as names, flavour strength, degrees of filter venting, filter types, quality, type of cigarette and numbers. For each set, respondents rated the highest and lowest of two or three of the following four characteristics: quality, strongest or weakest in taste, delivers most or least tar/nicotine, and most or least level of harm. RESULTS: There were significant differences on all four ratings. Quality ratings were the least differentiated. Except for colour descriptors, where 'Gold' rated high in quality but medium in other ratings, ratings of quality, harm, strength and delivery were all positively associated when rated on the same descriptors. CONCLUSIONS: Descriptor labels on cigarette packs, can affect smokers' perceptions of the characteristics of the cigarettes contained within. Therefore, they are a potential means by which product differentiation can occur. In particular, having variants differing in perceived strength while not differing in deliveries of harmful ingredients is particularly problematic. Any packaging policy should take into account the possibility that variant descriptors can mislead smokers into making inappropriate product attributions.

Effects of stick design features on perceptions of characteristics of cigarettes.

OBJECTIVE: To examine the extent (if any) that cigarette stick dimension, tipping paper design and other decorative design/branding have on Australian smokers' perceptions of those cigarettes. METHODS: An internet survey of 160 young Australian adult ever-smokers who were shown computer images of three sets of cigarette sticks--five sticks of different lengths and diameters (set A), five sticks with different tipping paper design (set B) and four sticks of different decorative design (set C). Branding was a between-subjects randomised condition for set C. For each set, respondents ranked sticks on most and least attractive, highest and lowest quality and strongest and weakest taste. RESULTS: Cigarette sticks were perceived as different on attractiveness, quality and strength of taste. Standard stick length/diameter was perceived as the most attractive and highest quality stick, with men more inclined to rate a slim stick as less attractive. A stick with a cork-patterned tipping paper and a gold band was seen as most attractive, of highest quality and strongest in taste compared to other tipping designs. Branded sticks were seen as more attractive, higher in quality and stronger tasting than non-branded designs, regardless of brand, although the effects were stronger for a prestige compared with a budget brand. CONCLUSIONS: Characteristics of the cigarette stick affect smokers' perceptions of the attributes of those cigarettes and thus are a potential means by which product differentiation can occur. A comprehensive policy to eliminate promotional aspects of cigarette design and packaging needs to include rules about stick design.

Secular versus religious norms against smoking: which is more important as a driver of quitting behaviour among Muslim Malaysian and Buddhist Thai smokers?

BACKGROUND: This paper prospectively examined two kinds of social normative beliefs about smoking, secular versus religious norms. PURPOSE: The purpose of this paper is to determine the relative importance of these beliefs in influencing quitting behaviour among Muslim Malaysian and Buddhist Thai smokers. METHODS: Data come from 2,166 Muslim Malaysian and 2,463 Buddhist Thai adult smokers who participated in the first three waves of the International Tobacco Control Southeast Asia project. Respondents were followed up about 18 months later with replenishment. Respondents were asked at baseline about whether their society disapproved of smoking and whether their religion discouraged smoking, and those recontacted at follow-up were asked about their quitting activity. RESULTS: Majority of both religious groups perceived that their religion discouraged smoking (78% Muslim Malaysians and 86% Buddhist Thais) but considerably more Buddhist Thais than Muslim Malaysians perceived that their society disapproved of smoking (80% versus 25%). Among Muslim Malaysians, religious, but not societal, norms had an independent effect on quit attempts. By contrast, among the Buddhist Thais, while both normative beliefs had an independent positive effect on quit attempts, the effect was greater for societal norms. The two kinds of normative beliefs, however, were unrelated to quit success among those who tried. CONCLUSIONS: The findings suggest that religious norms about smoking may play a greater role than secular norms in driving behaviour change in an environment, like Malaysia where tobacco control has been relatively weak until more recently, but, in the context of a strong tobacco control environment like Thailand, secular norms about smoking become the dominant force.