Evidence-based Medication knowledge Brokers in Residential Aged CarE (EMBRACE): protocol for a helix-counterbalanced randomised controlled trial.

INTRODUCTION: Clinical practice guidelines recommend against the routine use of psychotropic medications in residential aged care facilities (RACFs). Knowledge brokers are individuals or groups who facilitate the transfer of knowledge into practice. The objective of this trial is to evaluate the effectiveness and cost-effectiveness of using knowledge brokers to translate Australia's new Clinical Practice Guidelines for the Appropriate Use of Psychotropic Medications in People Living with Dementia and in Residential Aged Care. METHODS AND ANALYSIS: The Evidence-based Medication knowledge Brokers in Residential Aged CarE (EMBRACE) trial is a helix-counterbalanced randomised controlled trial. The 12-month trial will be conducted in up to 19 RACFs operated by four Australian aged care provider organisations in Victoria, New South Wales, Western Australia and Queensland. RACFs will be randomised to receive three levels of implementation strategies (knowledge broker service, pharmacist-led quality use of medications education activities and distribution of the Guidelines and supporting materials) across three medication contexts (antipsychotics, benzodiazepines and antidepressants). Implementation strategies will be delivered by an embedded on-site aged care pharmacist working at a system level across each participating RACF. All RACFs will receive all implementation strategies simultaneously but for different medication contexts. The primary outcome will be a composite dichotomous measure of 6-month RACF-level concordance with Guideline recommendations and good practice statements among people using antipsychotics, benzodiazepines and antidepressants for changed behaviours. Secondary outcomes will include proportion of residents with Guideline concordant use of antipsychotics, benzodiazepines and antidepressants measured at the RACF-level and proportion of residents with psychotropic medication use, hospitalisation, falls, falls with injury, polypharmacy, quality of life, activities of daily living, medication incidents and behavioural incidents measured at the RACF-level. DISCUSSION: The EMBRACE trial investigates a novel guideline implementation strategy to improve the safe and effective use of psychotropic medications in RACFs. We anticipate that the findings will provide new information on the potential role of knowledge brokers for successful and cost-effective guideline implementation. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry (ANZCTR): ACTRN12623001141639. Registered 6 November 2023 - retrospectively registered, https://www.anzctr.org.au/TrialSearch.aspx .

Australian National Aged Care Classification behaviour assessment and people living with dementia in residential aged care: Inclusive language for reform?

OBJECTIVE: To examine the language of the behaviour assessment in the new Australian National Aged Care Classification (AN-ACC) funding instrument. We explored whether the (BRUA) will support an inclusive and progressive approach for people living with dementia in residential aged care. METHODS: Databases were searched to identify publicly available literature relating to the development of the AN-ACC and BRUA, and hand searches of reference lists and selected websites were completed to identify additional grey literature, dementia language and best practice guidelines. Criteria for language use were extracted and compared with the BRUA in the light of the current national aged care reform agenda, as well as research with and perspectives of people with lived experience of dementia. RESULTS: The language within the BRUA did not align with international dementia language guidelines, and the content presented was disrespectful to those with lived experience. The assessment appears inconsistent with international best practices and is potentially discriminatory within the aged care cohort. CONCLUSIONS: The BRUA is intended as a funding instrument and not as a care planning tool, yet the negative representation of the lived experience of people with dementia embedded within a mandated assessment is likely to influence industry practice by condoning unsuitable language and attitudes amongst assessors, providers and staff. For better alignment with the current positive agenda for aged care reform in Australia, we recommend continued review and updating of this tool to avoid unintended consequences.

Tailored Exercise and Home Hazard Reduction Program for Fall Prevention in Older People With Cognitive Impairment: The i-FOCIS Randomized Controlled Trial.

BACKGROUND: The evidence to support effective fall prevention strategies in older people with cognitive impairment (CI) is limited. The aim of this randomized controlled trial (RCT) was to determine the efficacy of a fall prevention intervention in older people with CI. METHOD: RCT involving 309 community-dwelling older people with CI. The intervention group (n = 153) received an individually prescribed home hazard reduction and home-based exercise program during the 12-month study period. The control group (n = 156) received usual care. The primary outcome was rate of falls. Secondary outcomes included faller/multiple faller status, physical function, and quality of life. RESULTS: Participants' average age was 82 years (95% CI 82-83) and 49% were female. There was no significant difference in the rate of falls (incidence rate ratio [IRR] 1.05; 95% confidence interval [95% CI] 0.73-1.51). A sensitivity analysis, controlling for baseline differences and capping the number of falls at 12 (4 participants), revealed a nonsignificant reduction in fall rate in the intervention group (IRR 0.78; 95% CI 0.57-1.07). Analyses of secondary outcomes indicated the intervention significantly reduced the number of multiple fallers by 26% (RR 0.74; 95% CI 0.54-0.99) when adjusting for baseline differences. There was a differential impact on falls in relation to physical function (interaction term p-value = .023) with a significant reduction in fall rate in intervention group participants with better baseline physical function (IRR 0.60; 95% CI 0.37-0.98). There were no significant between-group differences for other secondary outcomes. CONCLUSIONS: This intervention did not significantly reduce the fall rate in community-dwelling older people with CI. The intervention did reduce the fall rate in participants with better baseline physical function. CLINICAL TRIALS REGISTRATION NUMBER: Australian and New Zealand Trials Registry ACTRN12614000603617.

A Comprehensive Review of the Quality and Feasibility of Dementia Assessment Measures: The Dementia Outcomes Measurement Suite.

The diagnosis of dementia and the management of its associated symptoms are aided by high-quality assessment tools. However, there is disagreement on the optimal tools among abundant alternatives and lack of consistent quality standards across the different domains of dementia-related change (ie, cognition, severity, function, behavioral and psychological symptoms, delirium, quality of life). Standardization is difficult because the relevance of a measurement tool for health professionals may depend on the clinical setting and on the dementia type and severity. To address this need, we conducted a comprehensive and clinically relevant evidence-based review of dementia-related tools and present a set of recommended tools, the Dementia Outcomes Measurement Suite. The review revealed that considerable development has occurred in terms of assessment of persons with mild cognitive impairment, executive dysfunction, cognitively mediated functional change, and apathy. More research is needed to develop and validate tools to assess health-related quality of life and specific symptoms of dementia including anxiety, wandering, and repetitive vocalizations. This extensive overview of the quality of different measures may serve as a guide for health professionals clinically and for researchers developing new or improved dementia assessment tools.

Measurement of Functional Cognition and Complex Everyday Activities in Older Adults with Mild Cognitive Impairment and Mild Dementia: Validity of the Large Allen's Cognitive Level Screen.

OBJECTIVE: To explore the validity of the Large Allen's Cognitive Level Screen-5 (LACLS-5) as a performance-based measure of functional cognition, representing an ability to perform complex everyday activities in older adults with mild cognitive impairment (MCI) and mild dementia living in the community. METHODS: Using cross-sectional data from the Sydney Memory and Ageing Study, 160 community-dwelling older adults with normal cognition (CN; N = 87), MCI (N = 43), or dementia (N = 30) were studied. Functional cognition (LACLS-5), complex everyday activities (Disability Assessment for Dementia [DAD]), Assessment of Motor and Process Skills [AMPS]), and neuropsychological measures were used. RESULTS: Participants with dementia performed worse than CN on all clinical measures, and MCI participants were intermediate. Correlational analyses showed that LACLS-5 was most strongly related to AMPS Process scores, DAD instrumental activities of daily living subscale, Mini-Mental State Exam, Block Design, Logical Memory, and Trail Making Test B. Multiple regression analysis indicated that both cognitive (Block Design) and functional measures (AMPS Process score) and sex predicted LACLS-5 performance. Finally, LACLS-5 was able to adequately discriminate between CN and dementia and between MCI and dementia but was unable to reliably distinguish between CN and MCI. CONCLUSION: Construct validity, including convergent and discriminative validity, was supported. LACLS-5 is a valid performance-based measure for evaluating functional cognition. Discriminativevalidity is acceptable for identifying mild dementia but requires further refinement for detecting MCI.

Performance-Based Assessment of Instrumental Activities of Daily Living: Validation of the Sydney Test of Activities of Daily Living in Memory Disorders (STAM).

OBJECTIVES: The distinction between dementia and mild cognitive impairment (MCI) relies upon the evaluation of independence in instrumental activities of daily living (IADL). Self- and informant reports are prone to bias. Clinician-based performance tests are limited by long administration times, restricted access, or inadequate validation. To close this gap, we developed and validated a performance-based measure of IADL, the Sydney Test of Activities of Daily Living in Memory Disorders (STAM). DESIGN: Prospective cohort study (Sydney Memory and Ageing Study). SETTING: Eastern Suburbs, Sydney, Australia. PARTICIPANTS: 554 community-dwelling individuals (54% female) aged 76 and older with normal cognition, MCI, or dementia. MEASUREMENTS: Activities of daily living were assessed with the STAM, administered by trained psychologists, and the informant-based Bayer-Activities of Daily Living Scale (B-ADL). Depressive symptoms were measured with the Geriatric Depression Scale (15-item version). Cognitive function was assessed with a comprehensive neuropsychological test battery. Consensus diagnoses of MCI and dementia were made independently of STAM scores. RESULTS: The STAM showed high interrater reliability (r = 0.854) and test-retest reliability (r = 0.832). It discriminated significantly between the diagnostic groups of normal cognition, MCI, and dementia with areas under the curves ranging from 0.723 to 0.948. A score of 26.5 discriminated between dementia and nondementia with a sensitivity of 0.831 and a specificity of 0.864. Correlations were low with education (r = 0.230) and depressive symptoms (r = -0.179), moderate with the B-ADL (r = -0.332), and high with cognition (ranging from r = 0.511 to r = 0.594). The mean time to complete the STAM was 16 minutes. CONCLUSIONS: The STAM has good psychometric properties. It can be used to differentiate between normal cognition, MCI, and dementia and can be a helpful tool for diagnostic classification both in clinical practice and research.

Estimating functional cognition in older adults using observational assessments of task performance in complex everyday activities: A systematic review and evaluation of measurement properties.

Functional cognition is a relatively new concept in assessment of older adults with mild cognitive impairment or dementia. Instruments need to be reliable and valid, hence we conducted a systematic review of observational assessments of task performance used to estimate functional cognition in this population. Two separate database searches were conducted: firstly to identify instruments; and secondly to identify studies reporting on the psychometric properties of the instruments. Studies were analysed using a published checklist and their quality reviewed according to specific published criteria. Clinical utility was reviewed and the information formulated into a best evidence synthesis. We found 21 instruments and included 58 studies reporting on measurement properties. The majority of studies were rated as being of fair methodological quality and the range of properties investigated was restricted. Most instruments had studies reporting on construct validity (hypothesis testing), none on content validity and there were few studies reporting on reliability. Overall the evidence on psychometric properties is lacking and there is an urgent need for further evaluation of instruments.

Can a tailored exercise and home hazard reduction program reduce the rate of falls in community dwelling older people with cognitive impairment: protocol paper for the i-FOCIS randomised controlled trial.

BACKGROUND: The rate of falls in community dwelling older people with cognitive impairment (CI) is twice that of a cognitively intact population, with almost two thirds of people with CI falling annually. Studies indicate that exercise involving balance and/or a home hazard reduction program are effective in preventing falls in cognitively intact older people. However the potential benefit of these interventions in reducing falls in people with CI has not been established.This randomised controlled trial will determine whether a tailored exercise and home hazard reduction program can reduce the rate of falls in community dwelling older people with CI. We will determine whether the intervention has beneficial effects on a range of physical and psychological outcome measures as well as quality of life of participants and their carers. A health economic analysis examining the cost and potential benefits of the program will also be undertaken. METHODS AND DESIGN: Three hundred and sixty people aged 65 years or older living in the community with CI will be recruited to participate in the trial. Each will have an identifiable carer with a minimum of 3.5 hours of face to face contact each week.Participants will undergo an assessment at baseline with retests at 6 and 12 months. Participants allocated to the intervention group will participate in an exercise and home hazard reduction program tailored to their cognitive and physical abilities.The primary outcome measure will be the rate of falls which will be measured using monthly falls calendars. Secondary outcome measures will include the risk of falling, quality of life, measures of physical and cognitive function, fear of falling and planned and unplanned use of health services. Carers will be followed up to determine carer burden, coping strategies and quality of life. DISCUSSION: The study will determine the impact of this tailored intervention in reducing the rate of falls in community dwelling older people with CI as well as the cost-effectiveness and adherence to the program. The results will have direct implications for the design and implementation of interventions for this high-risk group of older people. TRIAL REGISTRATION: The protocol for this study is registered with the Australian New Zealand Clinical Trials Registry - ACTRN12614000603617.

A feasibility study and pilot randomised trial of a tailored prevention program to reduce falls in older people with mild dementia.

BACKGROUND: People with dementia have a disproportionately high rate of falls and fractures and poorer outcomes, yet there is currently no evidence to guide falls prevention in this population. METHODS: A randomised trial design was used to test feasibility of study components and acceptability of a home hazard reduction and balance and strength exercise fall prevention program. The program was tailored to participant's individual cognitive levels and implemented as a carer-supported intervention. Feasibility of recruitment, retention and implementation of intervention were recorded through observation and documented in field notes. Adherence, carer burden and use of task simplification strategies were also monitored. Outcome measures, collected at 12 weeks included physiological, fear of falling, cognitive and functional measures. RESULTS: Recruitment was achievable but may be more challenging in a multisite trial. Twenty two dyads of persons with mild dementia and their carers were randomised to intervention or usual care control group. Of 38 dyads referred to the study, there was a high rate of willingness to participate, with 6 (16%) declining and 10 (26%) not meeting inclusion criteria. The intervention was well received by participants and carers and adherence to both program components was very good. All participants implemented some home safety recommendations (range 19-80%) with half implementing 50% or more. At the end of 12 weeks, 72% of the intervention group were exercising. Both the rate of falling and the risk of a fall were lower in the intervention group but these findings were not significant (RR= 0.50 (95% CI 0.11-2.19). There were no differences in physiological outcome measures between the control and intervention groups. However results were influenced by the small study size and incomplete data primarily in the intervention group at follow up. CONCLUSIONS: The pilot study was feasible and acceptable to people with mild dementia and their carers. The lessons learnt included: recruitment for a larger trial will require multiple approaches; home safety recommendations should provide a greater emphasis on environmental use compared with behavioural change; strategies to ensure an adequate dosage of exercise should be further explored. We recommend that intervention delivery incorporate an integrated occupational therapy and physiotherapy approach and that carers be provided with an individualised session to enhance dementia-specific skills in management and communication. A refined intervention should be tested in a randomised trial with an adequately powered sample size. TRIAL REGISTRATION: Australia and New Zealand Clinical Trials Registry 126100001049066.

Validation of the Iconographical Falls Efficacy Scale in cognitively impaired older people.

BACKGROUND: This study evaluated psychometric properties of the Iconographical Falls Efficacy Scale (Icon-FES) to measure fear of falling in cognitively impaired older people. Icon-FES uses pictures as visual cues to prompt responses. METHODS: A total of 50 community-dwelling older people with moderate cognitive impairment were assessed on Icon-FES, Falls Efficacy Scale-International, and various physical and cognitive measures. RESULTS: Overall structure and measurement properties of Icon-FES, as evaluated with item response theory, were good. Internal consistency was high (Cronbach's alpha = 0.97). Distribution was near normal, indicating absence of floor and ceiling effects. Icon-FES construct validity was supported by its relation with Falls Efficacy Scale-International (r = .68, p < .001) and its ability to discriminate between groups relating to fall risk factors (gender, balance, falls). Scores were not affected by different levels of cognitive functioning, as assessed with the Mini-Mental State Examination and Trail Making Test. CONCLUSIONS: Icon-FES is the first measure of fear of falling that compensates for reduced abstract abilities by using pictures to match the verbal descriptions. This study supports its feasibility, reliability, and validity to assess fear of falling in people with moderate cognitive impairment or dementia living in the community. Compared with Falls Efficacy Scale-International, Icon-FES was better at identifying participants with higher fall risk and did not show a floor effect likely due to a greater range of physically challenging activities.