How can dementia diagnosis and care for Aboriginal and Torres Strait Islander people be improved? Perspectives of healthcare providers providing care in Aboriginal community controlled health services.

BACKGROUND: Aboriginal and/or Torres Strait Islander people experience dementia at a rate three to five times higher than the general Australian population. Aboriginal Community Controlled Health Services (ACCHSs) have a critical role to play in recognising symptoms of cognitive impairment, facilitating timely diagnosis of dementia, and managing the impacts of dementia. Little is known about the barriers and enablers to Aboriginal people receiving a timely dementia diagnosis and appropriate care once diagnosed. This study aims to explore, from the perspective of healthcare providers in the ACCHS sector across urban, regional and remote communities, the barriers and enablers to the provision of dementia diagnosis and care. METHODS: A qualitative study involving semi-structured interviews with staff members working in the ACCHS sector. Aboriginal Health Workers, General Practitioners, nurses, practice or program managers, and Chief Executive Officers were eligible to participate. Consenting ACCHS staff completed a telephone interview administered by a trained interviewer. Interviews were audio-recorded, transcribed, and analysed using qualitative content analysis. RESULTS: Sixteen staff from 10 ACCHSs participated. Most participants perceived their communities had a limited understanding of dementia. Symptoms of dementia were usually noticed by the GP or another healthcare worker at the ACCHS who had an ongoing relationship with the person. Most participants reported that their service had established referral pathways with either hospital-based geriatricians, geriatricians located with aged care assessment teams, or specialists who visited communities periodically. Key enablers to high quality dementia care included the use of routine health assessments as a mechanism for diagnosis; relationships within communities to support diagnosis and care; community and family relationships; comprehensive and holistic care models; and the use of tailored visual resources to support care. Key barriers to high quality care included: denial and stigma; dementia being perceived as a low priority health condition; limited community awareness and understanding of dementia; lack of staff education and training about dementia; and numerous gaps in service delivery. CONCLUSIONS: Substantially increased investments in supporting best-practice diagnosis and management of dementia in Aboriginal communities are required. ACCHSs have key strengths that should be drawn upon in developing solutions to identified barriers to care.

Evaluating the Efficacy of the "Support for Life" Program for People with Dementia and Their Families and Carers' to Enable Them to Live Well: A Protocol for a Cluster Stepped Wedge Randomized Controlled Trial.

INTRODUCTION: Assistance provided to support people living with dementia and carers is highly valued by them. However, current support systems in Australia are disjointed, inaccessible to all, poorly coordinated, and focus on dysfunction rather than ability. Support workers for people with dementia are in short supply, and there is little consistency in their roles. To address this large service gap and unmet need, we have developed an evidence-based optimized model of holistic support for people with dementia and their carers and families. This article describes the "Support for Life" model intervention. METHODS: A stepped wedge cluster randomized controlled trial will be conducted over 3 years across three Australian states. One hundred participants with dementia and/or their carers/family members will be randomly selected from community health center client lists in each state to receive either the dementia "Support for Life" intervention (Group A) or routine care (Group B). Group A participants will have access to the intervention from year 1. Group B participants will continue to receive usual care and will not be denied information on dementia or dementia services in year 1. In year 2, Group B participants will have access to the intervention. A highly trained expert dementia support worker will provide the "Support for Life" intervention, which is a flexible, individually tailored, holistic support that is relationship-centered, focused on enablement as opposed to dysfunction, and facilitate participants' continued engagement in their community and the workforce. Additionally, dementia education, information resources, advocacy, and practical support to navigate and access dementia services and health care will be provided. The mode of support will include face to face, telephone, and internet interaction on an "as needed basis" for 12 months. The primary hypothesis is that the intervention will improve the quality of life of people with dementia and the health and well-being of carers/family through facilitating the continuation and enhancement of regular daily activities. Secondary hypotheses will examine other health and service usage outcomes. The outputs will also include a health economic analysis to investigate the costs (and savings) of any associated reduction in unnecessary health services use and delay in accessing permanent residential aged care. TRIAL REGISTRATION NUMBER: Australian and New Zealand Clinical Trials Registry: ACTRN12616000927426p.

What is the effectiveness of the support worker role for people with dementia and their carers? A systematic review.

BACKGROUND: Dementia is progressive in nature and the associated functional decline inevitably leads to increasing dependence on others in areas of daily living. Models of support have been developed and implemented to assist with adjusting to living with memory loss and functional decline; to navigate the health and aged care system; and to access services. We undertook a systematic review of international literature on key worker type support roles to identify essential components and ascertain how the role can be best utilised to assist community-dwelling people with dementia and their carers. This review of support roles is the first to our knowledge to include both quantitative and qualitative studies and all models of support. METHOD: A systematic review of studies written in English and published between January 2003 and December 2014. Data sources were Medline, PsychInfo and CINAHL, internet, expert consultation and reference lists of included studies. After screening articles to ensure that they reported on a key worker type support role, involved carers and or people with dementia living at home and removing duplicates, eligible papers were appraised and evaluated. RESULTS: Thirty six studies were eligible for inclusion in the review. Eligible studies were divided into type of support roles and study type. The heterogeneity of included studies and high risk of bias made a meta-analysis inappropriate and it was therefore difficult to draw overall conclusions. However, essential components shared across support worker models that demonstrated a positive impact on carer burden and improved quality of life included: long term intervention, face to face contact, individualised education and support based on needs, multi-disciplinary teams, collaborative input, health/clinical background of support workers, ongoing follow up and inter professional and inter-sectoral collaborations. There was a lack of studies assessing cost-effectiveness. CONCLUSIONS: Studies that include a high quality evaluation of holistic, tailored models of support that identify which components of support produce the most valuable outcomes to assist people with dementia and their carers and families to continue to live meaningful lives are needed. There is also a need for a cost effectiveness evaluation of support worker roles. TRIAL REGISTRATION: PROSPERO international prospective register of systematic reviews: PROSPERO 2014 CRD42014013992 .

Families' experiences of their interactions with staff in an Australian intensive care unit (ICU): a qualitative study.

OBJECTIVE: Nursing is characterised as a profession that provides holistic, person-centred care. Due to the condition of the critically ill, a family-centred care model is more applicable in this context. Furthermore, families are at risk of emotional and psychological distress, as a result of the admission of their relative to intensive care. The families' experiences of their interactions in intensive care have the potential to enhance or minimise this risk. This paper presents a subset of findings from a broader study exploring families of critically ill patients' experiences of their interactions with staff, their environment, the patient and other families, when their relative is admitted to an Australian intensive care unit. By developing an understanding of their experience, nurses are able to implement interventions to minimise the families' distress, while providing more holistic, person- and family-centred care. RESEARCH DESIGN: The study was a qualitative enquiry that adopted the grounded theory approach for data collection and analysis. In-depth interviews with family members occurred between 2009 and 2011, allowing the thoughts on interactions experienced by those families, to be explored. Data were analysed thematically. Twelve family members of 11 patients participated in this study. SETTING: This study was undertaken in a mixed intensive care unit of a large metropolitan hospital in Australia. FINDINGS: Interactions experienced by families of the critically ill primarily revolved around seeking information and becoming informed. Further examination of the interviews suggested that staff interacted in supportive ways due to their communication and interpersonal skills. However, families also experienced unsupportive interactions as a result of poor communication. CONCLUSION: Facilitating communication and interacting in supportive ways should help alleviate the anxiety and distress experienced by families of the critically ill in the intensive care unit.

Introducing the bio-psycho-social-physical model of dementia through a collective case study design.

AIMS AND OBJECTIVES: To provide evidence for the development of a physical domain attached to the well-known bio-psycho-social model of dementia. The objectives were to develop a set of international case studies that followed a trajectory approach, from prevention to end-of-life care. BACKGROUND: In the UK the bio-psycho-social model has informed the shape of the National Institute for Health and Clinical Excellence and the Social Care Institute for Excellence 'dementia' guideline. However, limited attention has been paid to outlining and describing a physical domain of dementia, a discrepancy that informed the rationale for this study. DESIGN: A collective case study design was used to address the research aim and objectives. METHODS: Case studies from along the trajectory of dementia were provided by an international team of contributors from an inter-disciplinary background comprising nursing (general and mental health), social work and social science. RESULTS: The team's synthesis and analysis of the six case studies generated five repeating themes with each theme becoming components of a 'physical' domain of dementia. The five identified physical components were: (1) physical well-being, (2) physical health and examination, (3) physical care, (4) physical treatment and (5) physical environment. CONCLUSIONS: The development of a bio-psycho-social-physical model of dementia presents a holistic and culturally sensitive approach to understanding the experience of living with dementia, and to providing care and support in a variety of situations and contexts. RELEVANCE TO CLINICAL PRACTICE: The physical domain of dementia has particular relevance to nursing and nursing practice, such as providing physical care at the end-of-life. The interplay between the biological-psychological-social-physical domains of dementia and the trajectory of dementia could form the basis of clinical decision-making and practice.

Changes in oxygenation in mechanically ventilated critically ill patients following hyperbaric treatment.

BACKGROUND: Some ventilated intensive care unit (ICU) patients may experience reduced oxygenation following hyperbaric oxygen treatment (HBOT). METHODS: In a prospective, single-centre, observational study, we documented changes in oxygenation and the need for associated changes in ventilator settings in 25 consecutive, mechanically ventilated ICU patients immediately post-treatment and 1, 2, 3 and 6 hours following 61 HBOT sessions. The primary outcome measure of oxygenation was the ratio of arterial partial pressure of oxygen (P(a)O2) against the level of inspired oxygen (F(i)O2), P(a)O2/F(i)O2. RESULTS: Following HBOT, the P(a)O2/F(i)O2 ratio decreased by 27% on return to ICU (P < 0.001, 95% confidence intervals (CI) 20.6 to 34.2); 22% at 1 hour post-HBOT (P < 0.001, 95% CI 15.1 to 28.6); and 8% at 2 hours post (P = 0.03, 95% CI 0.8 to 14.4). The ratio showed no significant differences from pre-HBOT at 3 and 6 hours post-HBOT. P(a)O2/F(i)O2 ratio changes necessitated adjustments to ventilation parameters upon return to ICU following 30 of 61 HBOT sessions in 17 out of the 25 patients. The most common ventilation parameter altered was F(i)O2 (n = 20), increased by a mean of +0.17 (95% CI 0.11 to 0.23) above baseline for two hours following HBOT. CONCLUSIONS: Following HBOT, oxygenation is reduced in a majority of mechanically ventilated ICU patients and requires temporary alterations to mechanical ventilation settings. Further study to identify predictive characteristics and to determine causation for those at risk of needing ventilation alterations is required.