Health impact of the first and second wave of COVID-19 and related restrictive measures among nursing home residents: a scoping review.

BACKGROUND AND OBJECTIVES: COVID-19 disproportionally affects older adults living in nursing homes. The purpose of this review was to explore and map the scientific literature on the health impact of COVID-19 and related restrictive measures during the first and second wave among nursing home residents. A specific focus was placed on health data collected among nursing home residents themselves. RESEARCH DESIGN AND METHODS: In this study, best practices for scoping reviews were followed. Five databases were systematically searched for peer-reviewed empirical studies published up until December 2020 in which data were collected among nursing home residents. Articles were categorized according to the type of health impact (physical, social and/or psychological) and study focus (impact of COVID-19 virus or related restrictive measures). Findings were presented using a narrative style. RESULTS: Of 60 included studies, 57 examined the physical impact of COVID-19. All of these focused on the direct impact of the COVID-19 virus. These studies often used an observational design and quantitative data collection methods, such as swab testing or reviewing health records. Only three studies examined the psychological impact of COVID-19 of which one study focused on the impact of COVID-19-related restrictive measures. Findings were contradictory; both decreased and improved psychological wellbeing was found during the pandemic compared with before. No studies were found that examined the impact on social wellbeing and one study examined other health-related outcomes, including preference changes of nursing home residents in Advanced Care planning following the pandemic. DISCUSSION AND IMPLICATIONS: Studies into the impact of the first and second wave of the COVID-19 pandemic among nursing home residents predominantly focused on the physical impact. Future studies into the psychological and social impact that collect data among residents themselves will provide more insight into their perspectives, such as lived experiences, wishes, needs and possibilities during later phases of the pandemic. These insights can inform policy makers and healthcare professionals in providing person-centered care during the remaining COVID-19 pandemic and in future crisis periods.

Care Staff's Sense-making of Intimate and Sexual Expressions of People with Dementia in Dutch Nursing Homes.

OBJECTIVES: The Person-centered Care (PCC) philosophy emphasizes close care relationships to enable care professionals to recognize the needs of nursing home residents with dementia. This study explored how care professionals make sense of resident behavior with regard to intimacy and sexuality. METHODS: 26 nursing home care professionals (15 Nurses, 9 Health Care Professionals and 2 Managers) completed in-depth interviews that were subjected to an Interpretative Phenomenological Analysis (IPA). RESULTS: Three thematic layers were identified. 1. Care Professionals pursue a "true" understanding of intimate and sexual behavior that underpins a resident's expression. 2. When care professionals feel the need to protect themselves, they can reframe a specific care relation in order to continue care. 3. The social context around the resident, from family to professionals (i.e. peers), influences interpretation of behavior and, consequently, the provision of care. CONCLUSIONS: Intimate and sexual expressions of residents can put care relations under pressure. Care relations that lack professional distance may compromise care professionals' judgments, impede their natural boundaries and decrease their well-being. CLINICAL IMPLICATIONS: Along with implementing PCC principles, organizations should empower staff to develop, discuss and include self-reflection skills and personal boundaries within their work.

Love, Intimacy and Sexuality in Residential Dementia Care: A Client Perspective.

Objectives: Residential care facility (RCF) residents with dementia are highly dependent on care. This can influence their experience of intimacy and sexuality. The perspective of residents and their spouses with regard to love, intimacy, and sexuality were explored and analyzed.Methods: The study was designed using the IPA methodology. Eight in-depth interviews were held with 12 participants: four couples and four individual residents with dementia.Results: Varied stories were shared; however, dementia had a great impact on all of them. Love, intimacy, and being together were considered fundamentally important by both couples and individual participants, although profound dilemmas were encountered. While only one couple experienced physical sexuality within the RCF, other participants reported that love and being intimate were the most important aspects of their current relationship. Regarding the possibility of fulfilling their needs within the RCF, a secure feeling of privacy was considered to be important, but was absent at the time of the survey.Conclusions: Although challenging to appropriately facilitate at RCFs, love, intimacy, and sexuality are still important aspects for residents with dementia and their spouses.Clinical implications: This study addresses these dilemmas and ads to the normalization of love, intimacy, and sexuality within RCF settings; the findings will hopefully improve the wellbeing of residents with dementia and that of their spouses.

[COVID-19 outbreak in nursing homes: what can be learned from the literature about other disasters or crisis situations?] / Uitbraak COVID-19 in de verpleeghuiszorg.

Long-term care for older adults is highly affect by the COVID-19 outbreak. The objective of this rapid review is to understand what we can learn from previous crises or disasters worldwide to optimize the care for older adults in long term care facilities during the outbreak of COVID-19. We searched five electronic databases to identify potentially relevant articles. In total, 23 articles were included in this study.Based on the articles, it appeared that nursing homes benefit from preparing for the situation as best as they can. For instance, by having proper protocols and clear division of tasks and collaboration within the organization. In addition, it is helpful for nursing homes to collaborate closely with other healthcare organizations, general practitioners, informal caregivers and local authorities. It is recommended that nursing homes pay attention to capacity and employability of staff and that they support or relieve staff where possible. With regard to care for the older adults, it is important that staff tries to find a new daily routine in the care for residents as soon as possible. Some practical tips were found on how to communicate with people who have dementia. Furthermore, behavior of people with dementia may change during a crisis. We found tips for staff how to respond and act upon behavior change. After the COVID-19 outbreak, aftercare for staff, residents, and informal caregivers is essential to timely detect psychosocial problems.The consideration between, on the one hand, acute safety and risk reduction (e.g. by closing residential care facilities and isolating residents), and on the other hand, the psychosocial consequences for residents and staff, were discussed in case of other disasters. Furthermore, the search of how to provide good (palliative) care and to maintain quality of life for older adults who suffer from COVID-19 is also of concern to nursing home organizations. In the included articles, the perspective of older adults, informal caregivers and staff is often lacking. Especially the experiences of older adults, informal caregivers, and nursing home staff with the care for older adults in the current situation, are important in formulating lessons about how to act before, during and after the coronacrisis. This may further enhance person-centered care, even in times of crisis. Therefore, we recommend to study these experiences in future research.

[Perspectives of stakeholders on technology use in the care of community-living older adults with dementia]. / Perspectieven van stakeholders over het gebruik van technologie in de zorg voor thuiswonende ouderen met dementie.

Although technology has the potential to promote aging in place among community-living older adults with dementia, the use remains scarce. In this literature study we provide an overview of perspectives (i.e., needs, wishes, attitudes, possibilities, and difficulties) of different stakeholders on technology use in the care for community-living older adults with dementia. After selection, 46 studies were included. We mainly found perspectives of informal caregivers and, to a lesser extent, of persons with dementia and formal caregivers. Shared perspectives were, among other things, ease of use, stability and flexibility of technology, importance of privacy, and confidentiality. Among older adults, fun and pleasure, in addition to enhancing freedom and independence, facilitates technology use. Informal caregivers' peace of mind and relief of burden also appeared to be important in using technologies. Formal caregivers value the potential of technologies to improve monitoring and communication. Insight in perspectives of stakeholders are essential to enhance the use of technology in the care for community-living older adults with dementia.

Development of an evaluation tool for geriatric rehabilitation care.

BACKGROUND: Geriatric rehabilitation care (GRC) is short-term and multidisciplinary rehabilitation care for older vulnerable clients. Studies were conducted about its effects. However, elements that influence the quality of GRC have not been studied previously. METHODS: In this study realist evaluation is used to find out which are the mechanisms and outcomes and which (groups of) persons are the context for GRC, according to GRC professionals. The mechanisms, outcomes and context of GRC were explored in three consecutive phases of qualitative data gathering, i.e. individual interviews, expert meeting, and focus groups. RESULTS: Eight mechanisms - client centeredness, client satisfaction during rehabilitation, therapeutic climate, information provision to client and informal care givers, consultation about the rehabilitation (process), cooperation within the MultiDisciplinary Team (MDT), professionalism of GRC professionals, and organizational aspects - were found. Four context groups-the client, his family and/or informal care giver(s), the individual GRC professional, and the MDT-were mentioned by the respondents. Last, two outcome factors were determined, i.e. client satisfaction at discharge and rehabilitation goals accomplished. CONCLUSIONS: In order to translate these insights into a practical tool that can be used by MDTs in the practice of GRC, identified mechanisms, contexts, and outcomes were visualized in a GRC evaluation tool. A graphic designer developed an interactive PDF which is the GRC evaluation tool. This tool may enable MDTs to discuss, prioritize, evaluate, and improve the quality of their GRC practice.

The influence of organizational factors on the attitudes of residential care staff toward the sexuality of residents with dementia.

BACKGROUND: The attitudes of care staff toward the sexuality of residents with dementia they care for is assumed to influence the residents' expression of their sexuality in the way they want. This paper examines the effect of organizational factors, person-centered care, and the culture of the organization on the attitudes of care staff toward the sexuality of residents with dementia in residential care facilities (RCF) . METHODS: Care staff in different functions at six RCF organizations (N = 187) participated. Using a survey, we gathered information on demographics and care-staff careers, attitudes toward resident sexuality, the culture of the organization, person-centered care, and knowledge of resident sexuality. Ordinary least square (OLS) hierarchical analyses were performed to analyze results. RESULTS: Care staff attitudes were found to be positively affected by person-centered care, and marginally positively affected by a supportive culture in the organization, Moreover, knowledge of resident sexuality positively affected care staff 'attitudes toward resident sexuality, and the presence of policy regarding resident sexuality affected them negatively . CONCLUSIONS: Despite different study limitations, these results give a first insight in a broad perspective on care staff attitudes toward resident sexuality. In addition to improving knowledge of the care staff, enhancing person-centered care and a supportive culture in the organization will improve care-staff attitudes toward resident sexuality.

Diversity in Older Adults' Use of the Internet: Identifying Subgroups Through Latent Class Analysis.

BACKGROUND: As for all individuals, the Internet is important in the everyday life of older adults. Research on older adults' use of the Internet has merely focused on users versus nonusers and consequences of Internet use and nonuse. Older adults are a heterogeneous group, which may implicate that their use of the Internet is diverse as well. Older adults can use the Internet for different activities, and this usage can be of influence on benefits the Internet can have for them. OBJECTIVE: The aim of this paper was to describe the diversity or heterogeneity in the activities for which older adults use the Internet and determine whether diversity is related to social or health-related variables. METHODS: We used data of a national representative Internet panel in the Netherlands. Panel members aged 65 years and older and who have access to and use the Internet were selected (N=1418). We conducted a latent class analysis based on the Internet activities that panel members reported to spend time on. Second, we described the identified clusters with descriptive statistics and compared the clusters using analysis of variance (ANOVA) and chi-square tests. RESULTS: Four clusters were distinguished. Cluster 1 was labeled as the "practical users" (36.88%, n=523). These respondents mainly used the Internet for practical and financial purposes such as searching for information, comparing products, and banking. Respondents in Cluster 2, the "minimizers" (32.23%, n=457), reported lowest frequency on most Internet activities, are older (mean age 73 years), and spent the smallest time on the Internet. Cluster 3 was labeled as the "maximizers" (17.77%, n=252); these respondents used the Internet for various activities, spent most time on the Internet, and were relatively younger (mean age below 70 years). Respondents in Cluster 4, the "social users," mainly used the Internet for social and leisure-related activities such as gaming and social network sites. The identified clusters significantly differed in age (P<.001, ω2=0.07), time spent on the Internet (P<.001, ω2=0.12), and frequency of downloading apps (P<.001, ω2=0.14), with medium to large effect sizes. Social and health-related variables were significantly different between the clusters, except social and emotional loneliness. However, effect sizes were small. The minimizers scored significantly lower on psychological well-being, instrumental activities of daily living (iADL), and experienced health compared with the practical users and maximizers. CONCLUSIONS: Older adults are a diverse group in terms of their activities on the Internet. This underlines the importance to look beyond use versus nonuse when studying older adults' Internet use. The clusters we have identified in this study can help tailor the development and deployment of eHealth intervention to specific segments of the older population.

Older Adults' Reasons for Using Technology while Aging in Place.

BACKGROUND: Most older adults prefer to age in place, and supporting older adults to remain in their own homes and communities is also favored by policy makers. Technology can play a role in staying independent, active and healthy. However, the use of technology varies considerably among older adults. Previous research indicates that current models of technology acceptance are missing essential predictors specific to community-dwelling older adults. Furthermore, in situ research within the specific context of aging in place is scarce, while this type of research is needed to better understand how and why community-dwelling older adults are using technology. OBJECTIVE: To explore which factors influence the level of use of various types of technology by older adults who are aging in place and to describe these factors in a comprehensive model. METHODS: A qualitative explorative field study was set up, involving home visits to 53 community-dwelling older adults, aged 68-95, living in the Netherlands. Purposive sampling was used to include participants with different health statuses, living arrangements, and levels of technology experience. During each home visit: (1) background information on the participants' chronic conditions, major life events, frailty, cognitive functioning, subjective health, ownership and use of technology was gathered, and (2) a semistructured interview was conducted regarding reasons for the level of use of technology. The study was designed to include various types of technology that could support activities of daily living, personal health or safety, mobility, communication, physical activity, personal development, and leisure activities. Thematic analysis was employed to analyze interview transcripts. RESULTS: The level of technology use in the context of aging in place is influenced by six major themes: challenges in the domain of independent living; behavioral options; personal thoughts on technology use; influence of the social network; influence of organizations, and the role of the physical environment. CONCLUSION: Older adults' perceptions and use of technology are embedded in their personal, social, and physical context. Awareness of these psychological and contextual factors is needed in order to facilitate aging in place through the use of technology. A conceptual model covering these factors is presented.

What it Takes to Successfully Implement Technology for Aging in Place: Focus Groups With Stakeholders.

BACKGROUND: There is a growing interest in empowering older adults to age in place by deploying various types of technology (ie, eHealth, ambient assisted living technology, smart home technology, and gerontechnology). However, initiatives aimed at implementing these technologies are complicated by the fact that multiple stakeholder groups are involved. Goals and motives of stakeholders may not always be transparent or aligned, yet research on convergent and divergent positions of stakeholders is scarce. OBJECTIVE: To provide insight into the positions of stakeholder groups involved in the implementation of technology for aging in place by answering the following questions: What kind of technology do stakeholders see as relevant? What do stakeholders aim to achieve by implementing technology? What is needed to achieve successful implementations? METHODS: Mono-disciplinary focus groups were conducted with participants (n=29) representing five groups of stakeholders: older adults (6/29, 21%), care professionals (7/29, 24%), managers within home care or social work organizations (5/29, 17%), technology designers and suppliers (6/29, 21%), and policy makers (5/29, 17%). Transcripts were analyzed using thematic analysis. RESULTS: Stakeholders considered 26 different types of technologies to be relevant for enabling independent living. Only 6 out of 26 (23%) types of technology were mentioned by all stakeholder groups. Care professionals mentioned fewer different types of technology than other groups. All stakeholder groups felt that the implementation of technology for aging in place can be considered a success when (1) older adults' needs and wishes are prioritized during development and deployment of the technology, (2) the technology is accepted by older adults, (3) the technology provides benefits to older adults, and (4) favorable prerequisites for the use of technology by older adults exist. While stakeholders seemed to have identical aims, several underlying differences emerged, for example, with regard to who should pay for the technology. Additionally, each stakeholder group mentioned specific steps that need to be taken to achieve successful implementation. Collectively, stakeholders felt that they need to take the leap (ie, change attitudes, change policies, and collaborate with other organizations); bridge the gap (ie, match technology with individuals and stimulate interdisciplinary education); facilitate technology for the masses (ie, work on products and research that support large-scale rollouts and train target groups on how to use technology); and take time to reflect (ie, evaluate use and outcomes). CONCLUSIONS: Stakeholders largely agree on the direction in which they should be heading; however, they have different perspectives with regard to the technologies that can be employed and the work that is needed to implement them. Central to these issues seems to be the tailoring of technology or technologies to the specific needs of each community-dwelling older adult and the work that is needed by stakeholders to support this type of service delivery on a large scale.

Intimacy and sexuality of nursing home residents with dementia: a systematic review.

BACKGROUND: Considering people with dementia, increasing cognitive, physical, and environmental impairments can impede the capacity to express and experience intimacy and sexuality. When a move to a residential (nursing) home becomes inevitable, increasing dependency can influence this even more. The aim of the review is to provide a structured overview of all elements of intimacy across the full spectrum of intimacy and sexuality in people with dementia, living in specialist residential care. METHODS: A systematic search and review were conducted. Research published between 1990 and 2013 was identified in the electronic databases: Pubmed, PsychInfo, and Medline. Inclusion and exclusion criteria were predefined. Selected studies were assessed on quality, using the Mixed METHODS Appraisal Tool. RESULTS: Twelve of the 215 initially retrieved unique research publications were selected. A varied range of studies were found; these studies differed in design, research quality, searched population, and research theme. Different themes emerged: intimate and sexual behavior, knowledge and attitudes, capacity to consent and care culture, and staff training and guidelines. CONCLUSIONS: Although results were found in a wide range of intimate and sexual behavior, knowledge, attitudes and needs of others, and descriptions of culture in residential and nursing homes, the perspective of residents was lacking in literature. Also a "protective" care paradigm was found throughout. Future research is needed to highlight resident perspective and develop training opportunities and guidelines for care staff.

Explaining quality of life of older people in the Netherlands using a multidimensional assessment of frailty.

PURPOSE: Although frailty was originally a medical concept, nowadays more and more researchers are convinced of its multidimensional nature, including a psychological and social domain of frailty as well as a physical domain. The objective of this study was to test the hypothesis that the prediction of quality of life by physical frailty components is improved by adding psychological and social frailty components. METHODS: This cross-sectional study was carried out with a sample of Dutch citizens. A total of 1,031 people aged 65 years and older completed a Web-based questionnaire containing the Tilburg Frailty Indicator for measuring physical, psychological, and social frailty, and the WHOQOL-BREF for measuring four quality of life domains (physical health, psychological, social relations, environmental). RESULTS: The findings show that the prediction of all quality of life domains by eight physical components of frailty was improved after adding four psychological and three social frailty components. The psychological frailty component 'feeling down' significantly improved the prediction of all four quality of life domains, after controlling for the effects of background characteristics and all other frailty components. CONCLUSION: This study emphasizes the importance of a multidimensional assessment of frailty in the prediction of quality of life in older people.

Supporting autonomy for people with dementia living in nursing homes: A rapid realist review.

BACKGROUND: For people with dementia living in nursing homes, autonomy is important. However, they experience difficulty with being heard as an autonomous person, as well as with expressing their preferences and choices. The question is how to support their autonomy. OBJECTIVE: Despite extensive efforts to support autonomy in daily care for people with dementia living in nursing homes, we do not know exactly what works for whom, in which context, how and why. The objective of this realist review is to explore what is known in literature on autonomy support interventions for people with dementia in nursing homes. DESIGN: A rapid realist review of literature. REVIEW METHODS: To understand how autonomy is supported, a realist approach was applied that entailed identifying the research question, searching for information, performing a quality appraisal, extracting data, synthesizing the evidence and validating the findings with a panel of experts. Causal assumptions were derived from articles found in four bibliographic databases (PubMed, PsychInfo, Cochrane and CINAHL) leading to context (C)-mechanism (M)-outcome (O) configurations. RESULTS: Data extraction from the included articles ultimately resulted in sixteen CMO configurations on four themes: a. preferences and choice: interventions for supporting autonomy in nursing homes and their results, b. personal characteristics of residents and family: people with dementia and their family being individuals who have their own character, habits and behaviors, c. competent nursing staff each having their own level of knowledge, competence and need for support, and d. interaction and relationships in care situations: the persons involved are interrelated, continuously interacting in different triangles composed of residents, family members and nursing staff. CONCLUSION: The findings showed that results from interventions on autonomy in daily-care situations are likely to be just as related not only with the characteristics and competences of the people involved, but also to how they interact. Autonomy support interventions appear to be successful when the right context factors are considered.

Patients' experiences of the quality of long-term care among the elderly: comparing scores over time.

BACKGROUND: Every two years, long-term care organizations for the elderly are obliged to evaluate and publish the experiences of residents, representatives of psychogeriatric patients, and/or assisted-living clients with regard to quality of care. Our hypotheses are that publication of this quality information leads to improved performance, and that organizations with substandard performance will improve more than those whose performance is relatively good. METHODS: The analyses included organizational units that measured experiences twice between 2007 (t(0)) and 2009 (t(1)). Experiences with quality of care were measured with Consumer Quality Index (CQI) questionnaires. Besides descriptive analyses (i.e. mean, 5(th) and 95(th) percentile, and 90% central range) of the 19 CQI indicators and change scores of these indicators were calculated. Differences across five performance groups (ranging from 'worst' to 'best') were tested using an ANOVA test and effect sizes were measured with omega squared (ω(2)). RESULTS: At t0 experiences of residents, representatives, and assisted-living clients were positive on all indicators. Nevertheless, most CQI indicators had improved scores (up to 0.37 change score) at t(1). Only three indicators showed a minor decline (up to -0.08 change score). Change scores varied between indicators and questionnaires, e.g. they were more profound for the face-to-face interview questionnaire for residents in nursing homes than for the other two mail questionnaires (0.15 vs. 0.05 and 0.04, respectively), possibly due to more variation between nursing homes on the first measurement, perhaps indicating more potential for improvement. A negative relationship was found between prior performance and change, particularly with respect to the experiences of residents (ω(2) = 0.16) and assisted-living clients (ω(2) = 0.15). However, the relation between prior performance and improvement could also be demonstrated with respect to the experiences reported by representatives of psychogeriatric patients and by assisted-living clients. For representatives of psychogeriatric patients, the performance groups 1 and 2 ([much] below average) improved significantly more than the other three groups (ω(2) = 0.05). CONCLUSIONS: Both hypotheses were confirmed: almost all indicator scores improved over time and long-term care organizations for the elderly with substandard performance improved more than those with a performance which was already relatively good.

Testing an integral conceptual model of frailty.

AIM: This paper is a report of a study conducted to test three hypotheses derived from an integral conceptual model of frailty. BACKGROUND: The integral model of frailty describes the pathway from life-course determinants to frailty to adverse outcomes. The model assumes that life-course determinants and the three domains of frailty (physical, psychological, social) affect adverse outcomes, the effect of disease(s) on adverse outcomes is mediated by frailty, and the effect of frailty on adverse outcomes depends on the life-course determinants. METHODS: In June 2008 a questionnaire was sent to a sample of community-dwelling people, aged 75 years and older (n = 213). Life-course determinants and frailty were assessed using the Tilburg frailty indicator. Adverse outcomes were measured using the Groningen activity restriction scale, the WHOQOL-BREF and questions regarding healthcare utilization. The effect of seven self-reported chronic diseases was examined. RESULTS: Life-course determinants, chronic disease(s), and frailty together explain a moderate to large part of the variance of the seven continuous adverse outcomes (26-57%). All these predictors together explained a significant part of each of the five dichotomous adverse outcomes. The effect of chronic disease(s) on all 12 adverse outcomes was mediated at least partly by frailty. The effect of frailty domains on adverse outcomes did not depend on life-course determinants. CONCLUSION: Our finding that the adverse outcomes are differently and uniquely affected by the three domains of frailty (physical, psychological, social), and life-course determinants and disease(s), emphasizes the importance of an integral conceptual model of frailty.

Family caregiver perspectives on social relations of elderly residents with dementia in small-scale versus traditional long-term care settings in the Netherlands and Belgium.

AIMS AND OBJECTIVES: To provide insight into family caregiver perspectives on social relations within the 'caregiving triangle' between family caregiver, professional caregiver and elderly resident with dementia. Results were compared between traditional versus small-scale long-term care settings in the Netherlands and Belgium. BACKGROUND: Residential dementia care is shifting towards a more holistic and person-centred approach. Until now, little is known about family caregiver perspectives. DESIGN: A quasi-experimental longitudinal design. METHODS: This study was part of a larger research project focusing on the quality of life of residents with dementia in traditional and small-scale settings (n = 179). This study focused on family caregivers related to these residents (n = 64). They filled in a questionnaire containing 25 items (baseline and after 12 months) related to their perspectives on the interaction within the 'caregiving triangle'. Analyses were performed using mixed models and logistic regression. RESULTS: Compared to traditional settings, family caregivers of relatives with dementia living in small-scale settings had more contact with the professional caregivers, were more satisfied with this contact and felt that staff paid more attention to their feelings as family members. They also reported that staff showed better listening skills towards the residents. Furthermore, compared to those in Belgium, family caregivers in the Netherlands perceived staff to be less hurried and more accepting of help from family and felt that staff more often takes the resident seriously. CONCLUSION: In the move towards more person-centred care for residents with dementia, this study finds preliminary evidence for the importance of integrating the family perspective. RELEVANCE TO CLINICAL PRACTICE: Gaining more insight into the perspectives of family caregivers on the social relations within the 'caregiving triangle' may provide knowledge about the importance of the social system surrounding elderly residents with dementia and can provide pointers for future research.

Exploring how residential care facilities can enhance the autonomy of people with dementia and improve informal care.

BACKGROUND AND OBJECTIVES: Residential care facilities (RCFs) strive to enhance autonomy for people with dementia and to enhance informal care provision, although this is difficult. This study explored how RCF staff can enhance autonomy and improve informal care by looking at the influence of interactions (contact and approachability between residents, staff members and informal caregivers) and the physical environment, including the use of technologies. RESEARCH DESIGN AND METHODS: A realist evaluation multiple-case study was conducted using document analyses, eight semi-structured interviews with staff members and relatives and 56 hours of observations of residents across two RCFs aiming to provide person-centred care. Realist logic of analysis was performed, involving Context-Mechanism-Outcome configurations. FINDINGS: The behaviour, attitudes and interactions of staff members with residents and informal caregivers appeared to contribute to the autonomy of people with dementia and enhance informal care provision. The physical environment of the RCFs and the use of technologies were less relevant to enhancing autonomy and informal care provision, although they can support staff members in providing person-centred care in daily practice. DISCUSSION AND IMPLICATIONS: The findings add to those of other studies regarding the importance of interaction between residents, staff members and informal caregivers. The findings provide insight for other RCFs on how successfully to enhance autonomy for their residents and to improve informal care provision, as well as, more broadly, how to implement person-centred care.

Engaging citizens in local health policymaking. A realist explorative case-study.

BACKGROUND: Municipalities have been trying to involve citizens as citizen participation is thought to improve municipalities' accountability, the quality of services, and to align policies and services to communities' needs. This study examined citizens' participation preferences in policymaking by investigating their health policy priorities, expectations of involvement, and required support. METHODS: For this case-study the realist evaluation approach was applied to focus groups with citizens and to a workshop with a local panel consisting of professionals, citizens and citizen representatives. RESULTS: This study showed that citizens want to be involved in (health) policymaking with the aim of improving their communities' quality of life and living environment and prioritised local services and amenities (e.g. suitable housing, public transport, health and care services). Instead, professionals' priorities were focussed on singular public health issues related to prevention and lifestyle factors. The results also show that citizens felt responsible for driving citizen participation and representing community needs to the municipality, but needed the municipality to improve their communication and accessibility in order to do so successfully. Furthermore, the professionals on the panel indicated that they needed training on how to reach out to citizens. Such training should highlight how to better align their language to citizens' lived experiences. They also wanted their organisations to provide more space, flexibility and resources to build relationships with citizens in order to provide improved communication and accessibility to citizens. CONCLUSION: The difference in priorities between citizens and professionals highlights the importance of involving citizens in policymaking. Moreover, citizens' involvement can act as a lever for change to bring a wider range of services and policy sectors together and has the potential to better align policies to citizens' lived experiences and hopefully increase the democratic legitimacy of policymaking. However, to fulfil such potential municipalities will need to invest in improving their accessibility and communication with communities.

"Precious Time Together Was Taken Away": Impact of COVID-19 Restrictive Measures on Social Needs and Loneliness from the Perspective of Residents of Nursing Homes, Close Relatives, and Volunteers.

During the COVID-19 outbreak in March 2020, restrictive measures (e.g., prohibiting physical visits and group activities) were introduced in nursing homes to protect older residents. Although the importance of social contacts and social activities to fulfill social needs and avoid loneliness is known, these were challenged during the pandemic. This qualitative study specifically focused on how residents, close relatives, and volunteers in nursing homes experienced the restrictive measures in retrospect and gained insights into the impact of the restrictive measures on social needs and loneliness, and the lessons that could be learned. Thirty semi-structured, face-to-face interviews with residents and close relatives, and one online focus group with ten volunteers, were conducted. Recruitment took place at psychogeriatric and somatic units in the Northern, Eastern and Southern regions of the Netherlands and Flanders, Belgium. The interviews and focus group were transcribed verbatim, and an open, inductive approach was used for analysis. Alternative ways of social contact could not fully compensate for physical visits. Generally, participants reported that it was a difficult time, indicated by feelings of loneliness, fear, sadness, and powerlessness. A great diversity in loneliness was reported. The most important reasons for feeling lonely were missing close social contacts and social activities. The diversity in the impact of restrictive measures depended on, e.g., social needs, coping strategies, and character. Restrictive COVID-19 measures in nursing homes resulted in negative emotions and unmet social needs of residents, close relatives, and volunteers. During future outbreaks of the COVID-19 virus or another virus or bacterium, for which restrictive measures may be needed, nursing homes should actively involve residents, close relatives, and volunteers to balance safety, self-determination, and well-being.

Quality of life of residents with dementia in long-term care settings in the Netherlands and Belgium: design of a longitudinal comparative study in traditional nursing homes and small-scale living facilities.

BACKGROUND: The increase in the number of people with dementia will lead to greater demand for residential care. Currently, large nursing homes are trying to transform their traditional care for residents with dementia to a more home-like approach, by developing small-scale living facilities. It is often assumed that small-scale living will improve the quality of life of residents with dementia. However, little scientific evidence is currently available to test this. The following research question is addressed in this study: Which (combination of) changes in elements affects (different dimensions of) the quality of life of elderly residents with dementia in long-term care settings over the course of one year? METHODS/DESIGN: A longitudinal comparative study in traditional and small-scale long-term care settings, which follows a quasi-experimental design, will be carried out in Belgium and the Netherlands. To answer the research question, a model has been developed which incorporates relevant elements influencing quality of life in long-term care settings. Validated instruments will be used to evaluate the role of these elements, divided into environmental characteristics (country, type of ward, group size and nursing staff); basic personal characteristics (age, sex, cognitive decline, weight and activities of daily living); behavioural characteristics (behavioural problems and depression); behavioural interventions (use of restraints and use of psychotropic medication); and social interaction (social engagement and visiting frequency of relatives). The main outcome measure for residents in the model is quality of life. Data are collected at baseline, after six and twelve months, from residents living in either small-scale or traditional care settings. DISCUSSION: The results of this study will provide an insight into the determinants of quality of life for people with dementia living in traditional and small-scale long-term care settings in Belgium and the Netherlands. Possible relevant strengths and weaknesses of the study are discussed in this article. TRIAL REGISTRATION: ISRCTN: ISRCTN23772945.