Implementing an oral health policy in long-term care facilities for older adults in Flanders, Belgium: The Oral Health Care Track.

BACKGROUND: The oral health of care-dependent older people living in residential care facilities is generally suboptimal. To facilitate adequate daily oral care and timely referral to a dental professional, studies emphasise the need for sustainable, structured oral healthcare policies in aged care organisations. The effect of such interventions is often limited or uncertain owing to a lack of understanding of how effective the integration and implementation of the policy has been within the facilities. This study reports on the development of a method to adequately implement an oral healthcare policy in long-term care organisations for older adults. MATERIALS AND METHODS: An intervention mapping protocol was used to develop a theory- and practise-based methodology. This step-by-step approach combined findings from a literature review, experiences from earlier projects and behaviour change theories in a multilevel programme. RESULTS: Intervention mapping yielded a systematic programme for implementing an oral healthcare policy in aged care organisations. The Oral Health Care Track or "De Mondzorglijn" comprises seven phases, each subdivided into several tasks. The programme's implementation is guided by oral healthcare coaches. CONCLUSION: By using intervention mapping, it was possible to combine behaviour change theories, information derived from needs assessment and earlier experiences into a comprehensive programme to improve the oral health and quality of life of older residents in residential care facilities. Further research is needed to evaluate the use of coaches in the implementation of the Oral Health Care Track.

Evaluation of the extent of plaque removal and users' experience of alternative toothbrushes: A randomized single-blind crossover study.

INTRODUCTION: In residential care, tooth brushing with a manual toothbrush can be challenging because of technical difficulties, time consumption and poor patient cooperation, resulting in a sub-optimal cleaning. The study aimed at comparing the efficiency in plaque removal, brushing time and users' experience between three toothbrushes: a single-headed conventional manual toothbrush, a triple-headed manual toothbrush and a U-shaped electric toothbrush. METHODS: This was a single-blind crossover study with three pre-post-test conditions. Participants were 26 dental students divided into fixed pairs to play the role of caregivers and care receivers. Pre/post plaque scores were determined by two independent investigators according to the Quigley-Hein Plaque Index (QHI). Questionnaires evaluated participants' experiences. Statistical tests of significances of differences and ANOVA were performed. RESULTS: Results showed that plaque removal was more effective for the manual toothbrush and the triple-headed toothbrush compared to the U-shaped electric toothbrush (p < 0.001). Brushing time was the longest for the single manual toothbrush (149 s). The U-shaped electric toothbrush showed significantly better results for aspects related to comfort and salivation. The manual and triple-headed toothbrush showed better results for aspects related to cleanliness and motivation to use. CONCLUSION: Notwithstanding its favourable comfort, tooth plaque removal is not enhanced by a U-shaped electric toothbrush. The triple-headed and single-headed toothbrushes reduced plaque more substantially than the U-shaped toothbrush. In addition, the triple-headed manual toothbrush was not only effective in plaque removal, but also had a shorter brushing time and was easy to use, being an adequate alternative for care-dependent patient groups.

Factors associated with informal caregiver's ability to continue care: a subgroup analysis.

BACKGROUND/OBJECTIVE: maintaining informal caregiver's ability to continue care can prevent early institutionalisation and decrease health care costs, contributing to sustainable health care. This study aims to identify factors associated with informal caregiver's ability to continue care across several degrees of cognitive decline and risk of burden. METHODS: this is a cross-sectional study that collected nationwide data on frail older people and their informal caregivers living in the community. Instruments used were InterRAI Home Care, Zarit Burden Interview and questionnaire for the informal caregiver. Multivariate logistic regression analyses and a stratification of the population were performed. RESULTS: a total of 8,309 people had at least one primary caregiver, and a majority of them were able to continue care (68.2%). Cognitive impairment was a risk factor for being able to continue care, even the borderline (odds ratios (ORs): 0.72; 95% CI: 0.61-0.85) or mild condition (OR: 0.52; 95% CI: 0.43-0.61). Protective factors like social participation of older people, strong family support and availability of a secondary caregiver showed the highest association in subgroups with mild cognitive impairment (ORs: 2.20, 2.08, 1.64) and in subgroups at low risk of burden (ORs: 1.91, 2.77, 1.64). CONCLUSION: factors associated with informal caregiver's ability to continue care vary across several degrees of cognitive decline and risk of burden. Interventions related to family and social support resources are recommended, and informal caregivers at a lower level of risk may benefit most. Supportive counselling should be proactively provided to informal caregivers, considering the changes of associated factors with the ongoing caregiving situation.

Assessment of oral health in older adults by non-dental professional caregivers-development and validation of a photograph-supported oral health-related section for the interRAI suite of instruments.

OBJECTIVES: An optimized oral health-related section and a video training were developed and validated for the interRAI suite of instruments. The latter is completed by professional non-dental caregivers and used in more than 40 countries to assess care needs of older adults. METHODS: The optimized oral health-related section (ohr-interRAI) consists of nine items and a video training that were developed in consecutive phases. To evaluate psychometric properties, a study was conducted in 260 long-term care residents. Each resident was assessed by a dentist and by four caregivers (two who received the video training, two who did not). RESULTS: Mean kappa values and percent agreement between caregivers and dentist ranged between κ = 0.60 (80.2%) for dry mouth and κ = 0.13 (54.0%) for oral hygiene. The highest inter-caregiver agreement was found for dry mouth with κ = 0.63 [95% CI: 0.56-0.70] (81.6%), while for the item palate/lips/cheeks only κ = 0.27 [95% CI: 0.18-0.36] (76.7%) was achieved. Intra-caregiver agreement ranged between κ = 0.93 [95% CI: 0.79-1.00] (96.4%) for dry mouth and κ = 0.45 [95% CI: 0.06-0.84] (82.8%) for gums. Logistic regression analysis showed only small differences between caregivers who watched the video training and those who did not. CONCLUSIONS: Psychometric properties of the optimized ohr-interRAI section were improved compared to previous versions. Nevertheless, particularly the items based on inspection of the mouth require further refinement and caregiver training needs to be improved. CLINICAL RELEVANCE: Valid assessment of oral health by professional caregivers is essential due to the impaired accessibility of regular dental care for care-dependent older adults.

Comparing the case-mix of frail older people at home and of those being admitted into residential care: a longitudinal study.

BACKGROUND: In order to optimize interventions and services in the community, it is important to identify the profile of persons who are able to stay at home and of those who are being admitted into residential care. Understanding their needs and their use of resources is essential. The main objective of the study is to identify persons who are likely to enter residential care based upon their needs and resource utilization, so that care providers can plan interventions effectively and optimize services and resources to meet the persons' needs. METHODS: This is a longitudinal quasi-experimental study. The data consists of primary data from the community setting collected every six months during the period of 2010-2016. Interventions had the goal of keeping older people longer at home. Participants were at least 65 years old and were living in the community. The interRAI Resource Utilization Group system (RUG-III) was used to calculate the case-mix indexes (CMI) of all participants. Comparisons were made between the case-mix of those who were still living at home and those who were admitted into residential care at follow-up. RESULTS: A total of 10,289 older persons participated in the study (81.2 ± 7.1 yrs., 69.1% female). From this population, 853 participants (8.3%) were admitted into residential care. The CMI of the persons receiving night care at home were the highest (1.6 at baseline and 1.7 at the entry point of residential care), followed by persons receiving occupational therapy (1.5 at baseline and 1.6 at the entry point of residential care) and persons enrolled in case management interventions with rehabilitation (1.4 at baseline and 1.6 at the entry point of residential care). The CMIs at follow-up were significantly higher than at baseline and the linear regression model showed that admission to residential care was a significant factor in the model. CONCLUSIONS: The study showed that the RUG-III system offers possibilities for identifying persons at risk of institutionalization. Interventions designed to avoid early nursing home admission can make use of the RUG-III system to optimize care planning and the allocation of services and resources. Based on the RUG-III case-mix, resources can be allocated to keep older persons at home longer, bearing in mind the complexity of care and the availability of services in the community.

Assessment of oral health conditions presented in photographs - is there a difference between dentists and non-dental professional caregivers?

BACKGROUND: Photographs can help non-dental professional caregivers to identify problems when inspecting the mouth of care-dependent older individuals. This study evaluated whether the assessment of oral health-related conditions presented in photographs differed between dentists and non-dental professional caregivers. MATERIALS AND METHODS: One-hundred-and-seventy-nine photographs were taken from long-term care facility residents and from patients at the Department of Dentistry of a University Hospital. The following oral health aspects were depicted: denture hygiene, oral hygiene, teeth, gums, tongue and palate/lips/cheeks. Collection continued until for each oral health aspect a pool of photographs was available that showed conditions from perfect health and hygiene to severe problems. A segmented Visual Analogue Scale was applied to assess the conditions presented in the photographs. Each photograph was assessed by each participant of this study. The benchmark was established by three dentists with academic-clinical expertise in gerodontology, special needs dentistry and periodontology. For each photograph, they provided a collective score after reaching consensus. Photographs were assessed individually by 32 general dentists and by 164 non-dental professional caregivers. Linear mixed effects models and generalized linear mixed effects models were fitted and mean squared errors were computed to quantify differences between both groups. RESULTS: For the different oral health aspects, absolute distances from the benchmark scores were 1.13 (95%CI:1.03-1.23) to 1.51 (95%CI:1.39-1.65) times higher for the caregivers than for the dentists. The odds to overestimate the condition were higher for the caregivers than the dentists for oral hygiene (OR = 0.72, 95%CI = 0.62-0.84) and teeth (OR = 0.74; 95%CI = 0.61-0.88). The odds to underestimate the condition were higher for the caregivers than the dentists for gums (OR = 1.39; 95%CI:1.22-1.59) and palate/lips/cheeks (OR = 1.22; 95%CI = 1.07-1.40). Over all assessments, the variance in caregiver scores was 1.9 (95%CI:1.62-2.23) times higher than that for the dentists. CONCLUSION: Small but significant differences were found between dentists and non-dental professional caregivers assessing oral health-related conditions presented in photographs. When photographs are used to aid non-dental professional caregivers with the oral health assessment, these visualizations should be complemented with comments to facilitate accurate interpretation.

Caring for a frail older person: the association between informal caregiver burden and being unsatisfied with support from family and friends.

BACKGROUND/OBJECTIVE: although informal caregivers (ICG) find caring for a relative mainly satisfying, it can be difficult at times and it can lead to a state of subjective burden characterised by -among others- fatigue and stress. The objective of this study is to analyse the relationship between perceived social support and subjective burden in providing informal care to frail older people. METHODS: a descriptive cross-sectional study was conducted using data from a large nationwide longitudinal effectiveness study. Pearson correlations were calculated between the variables for support and burden. Logistic regression models were applied to determine the association between being unsatisfied with support and burden, taking into account multiple confounding variables. RESULTS: of the 13,229 frail older people included in this study, 85.9% (N = 11,363) had at least one informal caregiver. Almost 60% of the primary informal caregivers manifested subjective burden, measured with the 12-item Zarit-Burden-Interview (ZBI-12). The percentage of informal caregivers that were unsatisfied with support from family and friends was on average 11.5%. Logistic regression analysis showed that being unsatisfied with support is associated with burden (OR1.85; 95%CI1.53-2.23). These results were consistent for the three groups of impairment level of the frail older persons analysed. CONCLUSIONS: the association between perceived social support and subjective caregiver burden was explored in the context of caring for frail older people. ICGs who were unsatisfied with support were more likely to experience burden. Our findings underline the importance of perceived social support in relation to caregiver burden reduction. Therefore efforts to improve perceived social support are worth evaluating.

The oral health-related section of the interRAI: Evaluation of test content validity by expert rating and assessment of potential reasons for inaccurate assessments based on focus group discussions with caregivers.

OBJECTIVES: To explore the failure of the oral health-related section of the interRAI (ohr-interRAI), this study investigated test content validity (A.) and reasons for inaccurate assessments (B.). BACKGROUND: Poor oral health negatively affects quality of life and is associated with a number of systemic diseases. The interRAI instruments, internationally used for geriatric assessment, should accurately detect oral conditions that require care. Previous research showed that the ohr-interRAI and related precursor versions do not achieve this goal. MATERIALS AND METHODS: (A.) A group of 12 experts rated completeness, relevance, clarity of wording and feasibility of the ohr-interRAI. Content validity indices were calculated per item (threshold 0.78). (B.) Focus group discussions with 23 caregivers were organized. A semi-structured question guide made sure that all topics of interest were covered. Qualitative content structuring analysis was applied after transcription. RESULTS: (A.) Experts agreed on the relevance of the items on chewing, pain, gingival inflammation and damaged teeth. They regarded none of the items as worded clearly and only prosthesis use and pain were considered to be assessable by untrained caregivers. All experts agreed that the ohr-interRAI was incomplete. (B.) Focus group discussions revealed that in the care environment oral health had low priority. Aspects related to the ohr-interRAI itself and aspects related to the assessment situation impeded the oral health assessment. The approach of the caregivers to complete the ohr-interRAI was inappropriate to accurately detect oral care needs. CONCLUSIONS: Findings challenge test content validity of the ohr-interRAI and reveal reasons for inaccurate assessments.

Does using the interRAI Palliative Care instrument reduce the needs and symptoms of nursing home residents receiving palliative care?

OBJECTIVE: This study aimed to evaluate whether using the interRAI Palliative Care instrument (the interRAI PC) in nursing homes is associated with reduced needs and symptoms in residents nearing the end of their lives. METHOD: A quasi-experimental pretest-posttest study using the Palliative care Outcome Scale (POS) was conducted to compare the needs and symptoms of residents nearing the end of their lives in the control and intervention nursing homes. Care professionals at the intervention nursing homes filled out the interRAI PC over the course of a year for all residents aged 65 years and older who were nearing the end of their lives. This intervention was not implemented in the control nursing homes. RESULTS: At baseline, POS scores in the intervention nursing homes were lower (more favorable) than in the control nursing homes on the items "pain", "other symptoms", "family anxiety", and the total POS score. Posttest POS scores for "wasted time" were higher (less favorable) than pretest scores in the intervention nursing homes. In the intervention nursing homes where care professionals did not have prior experience with the interRAI Long-Term Care Facilities (LTCF) assessment instrument (n = 8/15), total POS scores were lower (more favorable) at posttest. SIGNIFICANCE OF RESULTS: One year after introducing the interRAI PC, no reduction in residents' needs and symptoms were detected in the intervention nursing homes. However, reductions in needs and symptoms were found in the subgroup of intervention nursing homes without prior experience with the interRAI LTCF instrument. This may suggest that the use of an interRAI instrument other than the interRAI PC specifically can improve care. Future research should aim at replicating this research with a long-term design in order to evaluate the effect of integrating the use of the interRAI PC in the day-to-day practices at nursing homes.

A comprehensive grid to evaluate case management's expected effectiveness for community-dwelling frail older people: results from a multiple, embedded case study.

BACKGROUND: Case management is a type of intervention expected to improve the quality of care and therefore the quality of life of frail, community-dwelling older people while delaying institutionalisation in nursing homes. However, the heterogeneity, multidimensionality and complexity of these interventions make their evaluation by the means of classical approaches inadequate. Our objective was twofold: (i) to propose a tool allowing for the identification of the key components that explain the success of case management for this population and (ii) to propose a typology based on the results of this tool. METHODS: The process started with a multiple embedded case study design in order to identify the key components of case management. Based on the results of this first step, data were collected among 22 case management interventions, in order to evaluate their expected effectiveness. Finally, multiple correspondence analyses was conducted to propose a typology of case management. The overall approach was informed by Wagner's Chronic Care Model and the theory of complexity. RESULTS: The study identified a total of 23 interacting key components. Based on the clustering of response patterns of the 22 case management projects included in our study, three types of case management programmes were evidenced, situated on a continuum from a more "socially-oriented" type towards a more "clinically-oriented" type of case management. The type of feedback provided to the general practitioner about both the global geriatric assessment and the result of the intervention turned out to be the most discriminant component between the types. CONCLUSION: The study design allowed to produce a tool that can be used to distinguish between different types of case management interventions and further evaluate their effect on frail older people in terms of the delaying institutionalisation, functional and cognitive status, quality of life and societal costs.

Evaluation of plaque removal by a single-headed versus a triple-headed manual toothbrush using different plaque assessment tools.

Background: Dental plaque is a common issue that can be effectively managed with proper oral hygiene practices and regular oral health care. The aim of this crossover study was to assess dental plaque using different methods (digital and clinical plaque scores) and evaluate the effectiveness of toothbrushing with a triple-headed manual toothbrush compared to a single-headed manual toothbrush in removing dental plaque. Methods: Plaque staining was performed to assess dental plaque amounts before and after brushing with the triple-headed (test) and single-headed (control) manual toothbrush in 21 study participants after plaque was allowed to accumulate for 48 hours. Dental plaque was scored both clinically as well as digitally. Results: Toothbrushing with a manual single-headed toothbrush and a triple-headed toothbrush was found to be equally effective when comparing plaque removal ability. Brushing time was shorter when using a triple-headed toothbrush, compared to a single-headed toothbrush. Conclusion: The triple-headed manual toothbrush may be a good alternative to the single-headed manual toothbrush for certain patient groups.

Contexte: La plaque dentaire est un problème courant qui peut être géré efficacement en adoptant de bonnes pratiques d'hygiène buccale et en obtenant régulièrement des soins buccodentaires. L'objectif de cette étude croisée était d'évaluer l'état de la plaque dentaire à l'aide de différentes méthodes (cotes de plaque numériques et cliniques) et d'évaluer l'efficacité du brossage à l'aide d'une brosse à dents manuelle à 3 côtés comparativement au brossage avec une brosse à dents manuelle à 1 côté pour éliminer la plaque dentaire. Méthodes: On a coloré la plaque dentaire pour en évaluer la quantité avant et après le brossage avec une brosse à dents manuelle à 3 côtés (essai) et à 1 côté (contrôle) parmi les 21 participants à l'étude après avoir laissé la plaque s'accumuler pendant 48 heures. On a attribué une cote clinique et numérique à la plaque dentaire. Résultats: Le brossage avec une brosse à dents manuelle à 3 côtés s'est révélé tout aussi efficace que le brossage avec une brosse manuelle à 1 côté sur le plan de l'élimination de la plaque. Le temps de brossage était plus court avec une brosse à dents à 3 côtés qu'avec une brosse à dents à 1 côté. Conclusion: Pour certains groupes de patients, la brosse à dents à 3 côtés peut être une bonne alternative à la brosse à dents ordinaire.

Nursing home residents' perspectives on oral health: An in-depth interview study.

Background: Oral health is associated with general health and care dependency, but is often neglected in nursing homes. Integration of oral care into general care is necessary, but is hampered by multiple barriers at different levels. This study is part of research into the implementation of the new Oral Health Section for use within the interRAI Long-Term Care Facilities instrument, which is used to assess care needs of nursing home residents. This new Oral Health Section evaluates nine aspects of oral health and results in two Collaborative Action Points. Objective: To identify residents' perspectives on oral health, oral care, and on the assessment of their oral health using the new Oral Health Section. Design: Qualitative design using in-depth interviews. Settings: Three nursing homes. Participants: Residents were selected using purposeful sampling in nursing homes participating in research evaluating the use of the new Oral Health Section. The selection was based on their oral status for maximum variation and on their cognitive performance score. Twenty-two residents from three Flemish nursing homes agreed to participate. Methods: Residents' oral health was assessed using the new Oral Health Section and dental indices. In-depth interviews were conducted, including the validated short-form Oral Health Impact Profile to evaluate the impact of oral conditions on residents' well-being. The interviews were coded and analysed by three researchers and mapped into a model to understand participants' oral health behaviours. Results: Low Oral Health Impact Profile scores indicated a low impact of oral health issues on participants' lives. However, despite 77.3 % of the participants reporting satisfaction with their oral health, 86.4 % had poor oral hygiene and 68.2 % required referral to a dentist, suggesting a tendency to overestimate their oral health. Their oral health behaviour was determined by a lack of oral health knowledge (Capability), positive attitudes towards oral health and autonomy (Motivation), upbringing and social support (Opportunity). Participants considered assessments with the new Oral Health Section acceptable. Conclusions: This study shows how older people perceive their oral health and oral healthcare. Understanding their wishes and needs will not only facilitate their involvement in their oral care, but is also likely to enable the improvement of their oral hygiene and the development of effective oral care strategies for the future. Policy makers and managers of care organisations may use these results to foster integration of oral care guidelines into care protocols within nursing homes, including collaboration with dentists and dental hygienists. Tweetable abstract: Oral health assessments with the new Oral Health Section for use within interRAI were positively perceived by nursing home residents.

Feasibility, acceptability and potential helpfulness of the PROACTIVE intervention in Flanders, Belgium: A survey study.

BACKGROUND/OBJECTIVES: This study aimed to explore the feasibility of a Flemish adaptation of the New York University Caregiver Intervention (i.e., PROACTIVE intervention) modifying the recruitment and intervention content for informal caregivers of people with early cognitive decline, and across different subgroups. A feasibility study is necessary in order to reduce research waste for intervention adaptation and evaluation. METHODS: Researchers constructed, tested, and sent out a survey consisting of 43 questions on the following topics: awareness of symptoms of early cognitive decline, levels of cognitive performance using the updated Cognitive Performance Scale (CPS2), acceptability, and potential helpfulness of the intervention, and sociodemographic characteristics. Quantitative data were analyzed using descriptive statistics and logistic regression with SAS 9.4©. Qualitative data were analyzed using an inductive content analysis. RESULTS: A total of 463 informal caregivers completed the survey (mean age 58.8 ± 11.8, 83.6% female). Among them, 230 respondents who cared for people with cognitive decline indicated they would probably or certainly participate in the study. Identified factors influencing the recruitment were cognition, co-habitation, education, and employment status. Over half of the target caregivers indicated almost all services from the intervention could satisfy their needs. A majority perceived the PROACTIVE intervention would be helpful (69.4%), especially the CPS2 = 3 (76.1%) and CPS2 = 4 (74.1%) subgroups. CONCLUSION: The recruitment of target participants for a subsequent RCT evaluation study is feasible, and identified associated factors should be considered during the recruitment process. The PROACTIVE intervention and core components except 'peer-group participation' were perceived as helpful by most caregivers. The CPS2 = 3-4 subgroups were most accepting of the intervention and were most likely to benefit from the intervention.

The Implementation of Integrated Health Information Systems - Research Studies from 7 Countries Involving the InterRAI Assessment System.

Introduction: In the past years, governments from several countries have shown interest in implementing integrated health information systems. The interRAI Suite of instruments fits this concept, as it is a set of standardised, evidence-based assessments, which have been validated for different care settings. The system allows the electronic transfer of information across care settings, enabling integration of care and providing support for care planning and quality monitoring. The main purpose of this research is to describe the recent implementation process of the interRAI instruments in seven countries: Belgium, Switzerland, France, Ireland, Iceland, Finland and New Zealand. Methods: The study applied a case study methodology with the focus on the implementation strategies in each country. Principal investigators gathered relevant information from multiple sources and summarised it according to specific aspects of the implementation process, comparing them across countries. The main implementation aspects are described, as well as the main advantages and barriers perceived by the users. Results: The seven case studies showed that adequate staffing, appropriate information technology, availability of hardware, professional collaboration and continuous training are perceived as important factors which can contribute to the implementation of the interRAI instruments. In addition, the use of electronic standardised assessment instruments such as the interRAI Suite provided evidence to improve decision-making and quality of care, enabling resource planning and benchmarking. Conclusion: In practice, the implementation of health information systems is a process that requires a cultural shift of policymakers and professional caregivers at all levels of health policy and service delivery. Information about the implementation process of the interRAI Suite in different countries can help investigators and policymakers to better plan this implementation. This research sheds light on the advantages and pitfalls of the implementation of the interRAI Suite of instruments and proposes approaches to overcome difficulties.

Optimising the care for older persons with complex chronic conditions in home care and nursing homes: design and protocol of I-CARE4OLD, an observational study using real-world data.

INTRODUCTION: In ageing societies, the number of older adults with complex chronic conditions (CCCs) is rapidly increasing. Care for older persons with CCCs is challenging, due to interactions between multiple conditions and their treatments. In home care and nursing homes, where most older persons with CCCs receive care, professionals often lack appropriate decision support suitable and sufficient to address the medical and functional complexity of persons with CCCs. This EU-funded project aims to develop decision support systems using high-quality, internationally standardised, routine care data to support better prognostication of health trajectories and treatment impact among older persons with CCCs. METHODS AND ANALYSIS: Real-world data from older persons aged ≥60 years in home care and nursing homes, based on routinely performed comprehensive geriatric assessments using interRAI systems collected in the past 20 years, will be linked with administrative repositories on mortality and care use. These include potentially up to 51 million care recipients from eight countries: Italy, the Netherlands, Finland, Belgium, Canada, USA, Hong Kong and New Zealand. Prognostic algorithms will be developed and validated to better predict various health outcomes. In addition, the modifying impact of pharmacological and non-pharmacological interventions will be examined. A variety of analytical methods will be used, including techniques from the field of artificial intelligence such as machine learning. Based on the results, decision support tools will be developed and pilot tested among health professionals working in home care and nursing homes. ETHICS AND DISSEMINATION: The study was approved by authorised medical ethical committees in each of the participating countries, and will comply with both local and EU legislation. Study findings will be shared with relevant stakeholders, including publications in peer-reviewed journals and presentations at national and international meetings.

Interventions to delay institutionalization of frail older persons: design of a longitudinal study in the home care setting.

BACKGROUND: Older people usually prefer staying at home rather than going into residential care. The Belgian National Institute for Health and Disability Insurance wishes to invest in home care by financing innovative projects that effectively help older people to stay at home longer. In this study protocol we describe the evaluation of 34 home care projects. These projects are clustered according to the type of their main intervention such as case management, night care, occupational therapy at home and psychological/psychosocial support. The main goal of this study is to identify which types of projects have the most effect in delaying institutionalization of frail older persons. METHODS/DESIGN: This is a longitudinal intervention study based on a quasi-experimental design. Researchers use three comparison strategies to evaluate intervention--comparison among different types of projects, comparisons between older persons in the projects and older persons not benefiting from a project but who are still at home and between older persons in the projects and older persons who are already institutionalized. Projects are asked to include clients who are frail and at risk of institutionalization. In the study we use internationally validated instruments such as the interRAI Home Care instrument, the WHO-QOL-8 and the Zarit Burden Interview-12. These instruments are filled out at baseline, at exit from the project and 6 months after baseline. Additionally, caregivers have to do a follow-up every 6 months until exit from the project. Criteria to exit the cohort will be institutionalization longer than 3 months and death. The main analysis in the study consists of the calculation of incidence rates, cumulative incidence rates and hazard rates of definitive institutionalization through survival analyses for each type of project. DISCUSSION: This research will provide knowledge on the functional status of frail older persons who are still living at home. This is important information to identify determinants of risk for institutionalization. The identification of effective home care projects in delaying institutionalization will be useful to inform and empower home care providers, policy and related decision makers to manage and improve home care services.

Physical activity, fear avoidance beliefs and level of disability in a multi-ethnic female population with chronic low back pain in Suriname: A population-based study.

BACKGROUND: Chronic low back pain (CLBP) is an important cause for reduced daily physical activity (PA) and loss of quality of life, especially in women. In Suriname, a middle-income country in South America, the relationship between PA and CLBP is still unknown. AIMS: To assess the level of PA in women with CLBP of different ethnicity, and to identify whether fear avoidance beliefs (FAB), disability, co-occurring musculoskeletal pain sites and various sociodemographic and lifestyle factors were associated with self-reported PA. METHODS: A cross-sectional community-based house-to-house survey was conducted between April 2016 and July 2017. The survey followed the Community Oriented Program for Control of Rheumatic Diseases methodology. Selection criteria were being female of Asian-Surinamese, African-Surinamese or of Mixed ethnicity and aged 18 or older, living in an urban area, and reporting CLBP. Data was collected on PA, FAB, disability, co-occurring musculoskeletal pain sites, CLBP intensity and sociodemographic and lifestyle factors. RESULTS: Urban adult women with current CLBP (N = 210) were selected. Nearly 57% of the population met the WHO recommendation on PA, with work-related PA as the largest contributor to total self-reported PA. Most women showed low FAB scores (FABQ-Work ≤34 (96.2%) and FABQ-PA ≤14 (57.6%)) and low disability levels (Oswestry Disability Index ≤20 (62.4%)). An inverse association between total PA and FABQ-Work (OR = 0.132, CI: 0.023; 0.750) was found. In contrast, total PA had a significant, positive association with disability (OR = 2.154, CI: 1.044; 4.447) and workload (OR = 2.224, CI: 1.561; 3.167). All other variables showed no association with total PA. CONCLUSION: This was the first study in Suriname reporting that 43.3% of urban adult women with CLBP were physically inactive. Total self-reported PA is influenced by FABQ-Work, average to heavy workload and moderate to severe disability. In this study, PA-Work was the major contributor to total PA. Therefore, future longitudinal studies should evaluate different types and aspects of PA in relation to CLBP management.

Perceptions on Oral Care Needs, Barriers, and Practices Among Managers and Staff in Long-Term Care Settings for Older People in Flanders, Belgium: A Cross-sectional Survey.

Background and Objectives: This study aimed to explore oral health perception and oral care needs, barriers, and current practices as perceived by managers and staff in long-term care organizations for older people in Flanders. Research Design and Methods: This is a cross-sectional study where 2 questionnaires were developed, one for managers and one for caregivers, and were validated in Flemish long-term care organizations. Descriptive analyses and multivariable generalized linear models evaluated the main outcomes and their associations with determinants such as the size of the organization, the presence of an oral health policy, collaboration with a dentist, among others. Results: A total of 145 managers and 197 caregivers completed the questionnaire. More than 50% of caregivers and managers perceived their residents' oral health as mediocre to good. Collaboration with a dentist (B = 0.84) and oral health care involvement (B = 0.08) within the organization showed a strong association with a positive perception of oral health. Lack of time (57%) and care resistance (70%) were the most important barriers perceived by caregivers. Guidelines concerning oral care were not available or were unknown to 52% of the caregivers. Having an oral health policy within the organization was strongly associated with the correct use of guidelines for daily care of natural teeth (B = 1.25) and of dental prosthesis (B = 1.15). Discussion and Implications: The results emphasize that collaborating with a dentist and the presence of an oral health policy in care organizations are important for a positive perception of the oral health of the residents and for the adoption of guidelines by caregivers and managers. In addition, training on handling care refusal should be included in the overall training. These results are crucial input for the development of a methodology for implementing a structured oral care policy in long-term care facilities.

Development and evaluation of an intervention on suPpoRting infOrmal cAregivers of older people with early CogniTIVe declinE (PROACTIVE): a study protocol based on the Medical Research Council framework.

INTRODUCTION: Caring for people with cognitive problems can have an impact on informal caregivers' health and well-being, and especially increases pressure on healthcare systems due to an increasing ageing society. In response to a higher demand of informal care, evidence suggests that timely support for informal caregivers is essential. The New York University Caregiver Intervention (NYUCI) has proven consistent effectiveness and high adaptability over 30 years. This study has three main objectives: to develop and evaluate the Flemish adaptation of the NYUCI in the context of caregiving for older people with early cognitive decline; to explore the causal mechanism of changes in caregivers' health and well-being and to evaluate the validity and feasibility of the interRAI Family Carer Needs Assessment in Flanders. METHODS AND ANALYSIS: Guided by Medical Research Council framework, this study covers the development and evaluation phases of the adapted NYUCI, named PROACTIVE-suPpoRting infOrmal cAregivers of older people with early CogniTIVe declinE. In the development phase, we will identify the evidence base and prominent theory, and develop the PROACTIVE intervention in the Flemish context. In the evaluation phase, we will evaluate the PROACTIVE intervention with a pretest and posttest design in 1 year. Quantitative data will be collected with the BelRAI Screener, the BelRAI Social Supplement and the interRAI Family Carer Needs Assessment at baseline and follow-up points (at 4, 8 and 12 months). Qualitative data will be collected using counselling logs, evaluation forms and focus groups. Quantitative data and qualitative data will be analysed with SAS 9.4 software and NVivo software, respectively. Efficacy and process evaluation of the intervention will be performed. ETHICS AND DISSEMINATION: This study has been approved by the Ethics Committee of KU Leuven with a dossier number G-2020-1771-R2(MAR). Findings will be disseminated through community information sessions, peer-reviewed publications and national and international conference presentations.