A rehabilitation intervention to improve recovery after an episode of delirium in adults over 65 years (RecoverED): study protocol for a multi-centre, single-arm feasibility study.

BACKGROUND: Delirium affects over 20% of all hospitalised older adults. Delirium is associated with a number of adverse outcomes following hospital admission including cognitive decline, anxiety and depression, increased mortality and care needs. Previous research has addressed prevention of delirium in hospitals and care homes, and there are guidelines on short-term treatment of delirium during admission. However, no studies have addressed the problem of longer-term recovery after delirium and it is currently unknown whether interventions to improve recovery after delirium are effective and cost-effective. The primary objective of this feasibility study is to test a new, theory-informed rehabilitation intervention (RecoverED) in older adults delivered following a hospital admission complicated by delirium to determine whether (a) the intervention is acceptable to individuals with delirium and (b) a definitive trial and parallel economic evaluation of the intervention are feasible. METHODS: The study is a multi-centre, single-arm feasibility study of a rehabilitation intervention with an embedded process evaluation. Sixty participants with delirium (aged > 65 years old) and carer pairs will be recruited from six NHS acute hospitals across the UK. All pairs will be offered the intervention, with follow-up assessments conducted at 3 months and 6 months post-discharge home. The intervention will be delivered in participants' own homes by therapists and rehabilitation support workers for up to 10 intervention sessions over 12 weeks. The intervention will be tailored to individual needs, and the chosen intervention plan and goals will be discussed and agreed with participants and carers. Quantitative data on reach, retention, fidelity and dose will be collected and summarised using descriptive statistics. The feasibility outcomes that will be used to determine whether the study meets the criteria for progression to a definitive randomised controlled trial (RCT) include recruitment, delivery of the intervention, retention, data collection and acceptability of outcome measures. Acceptability of the intervention will be assessed using in-depth, semi-structured qualitative interviews with participants and healthcare professionals. DISCUSSION: Findings will inform the design of a pragmatic multi-centre RCT of the effectiveness and cost-effectiveness of the RecoverED intervention for helping the longer-term recovery of people with delirium compared to usual care. TRIAL REGISTRATION: The feasibility study was registered: ISRCTN15676570.

Embracing Cultural Diversity - Leadership Perspectives on Championing Meaningful Engagement for Residents Living with Advanced Dementia.

Resource constraints and high staff turnover are perceived as substantial barriers to high quality residential aged care. Achieving relationship-focused, person-centered care (PCC) is an ongoing challenge. This paper reports on an international project that explored how residential care leadership understand meaningful engagement for residents with dementia from culturally and linguistically diverse (CALD) backgrounds. This paper critically appraises the process, and outcomes, of an adapted Delphi method. Participants were the residential care leadership (i.e. staff in supervisory capacity) from four international facilities. Participation in the Delphi process was limited even though surveys were designed to require minimal time for completion. No participants opted for the alternative option of being interviewed. Findings indicate that residential care leadership recognised the importance of meaningful engagement for residents from CALD backgrounds. Limitations of time, resources and policy infrastructure were cited as barriers to achieving PCC. These findings suggest that facility leadership understand the importance of PCC, but identify multiple barriers rather than enablers for delivering PCC. Alternative methods, such as collecting data in interactive sessions allowing real-time discussion should be initiated to more effectively engage residential care leaders for a collaborative approach to explore PCC practices.

The Multisensory Environment (MSE) in Dementia Care: Examining Its Role and Quality From a User Perspective.

BACKGROUND: Multisensory environments (MSEs) for people with dementia have been available over 20 years but are used in an ad hoc manner using an eclectic range of equipment. Care homes have endeavored to utilize this approach but have struggled to find a design and approach that works for this setting. AIMS: Study aims were to appraise the evolving concept of MSEs from a user perspective, to study the aesthetic and functional qualities, to identify barriers to staff engagement with a sensory environment approach, and to identify design criteria to improve the potential of MSE for people with dementia. METHODS: Data were collected from 16 care homes with experience of MSE using ethnographic methods, incorporating semi-structured interviews, and observations of MSE design. Analysis was undertaken using descriptive statistics and thematic analysis. RESULTS: Observations revealed equipment that predominantly stimulated vision and touch. Thematic analysis of the semi-structured interviews revealed six themes: not knowing what to do in the room, good for people in the later stages of the disease, reduces anxiety, it's a good activity, design and setting up of the space, and including relatives and care staff. CONCLUSION: Few MSEs in care homes are designed to meet needs of people with dementia, and staff receive little training in how to facilitate sessions. As such, MSEs are often underused despite perceived benefits. Results of this study have been used to identify the design principles that have been reviewed by relevant stakeholders.

Multisensory stimulation to improve functional performance in moderate to severe dementia--interim results.

Dementia is a growing problem worldwide and interventions to effectively manage and promote function are urgently required. Multisensory environments (MSEs) have been used extensively with people with dementia; however, no studies have been conducted to explore the efficacy of sensory stimulation on functional performance. This study explores to what extent multisensory stimulation influences functional performance in people with moderate-to-severe dementia using an MSE compared with a control activity. Thirty participants with moderate-to-severe dementia were recruited from the South of England. Following baseline assessment and design of a bespoke intervention, each participant attended their allocated intervention (3 x week, for 4 weeks). Assessments were carried out pre and postsession using the Assessment of Motor and Process Skills. Results indicate significant improvement in functional performance in both the MSE and the control activity. Findings support the use of MSEs as a strategy for enhancing functional performance in dementia.

Exploring the multi-sensory environment as a leisure resource for people with complex neurological disabilities.

The problems experienced by people with neurological disabilities create barriers to participation in leisure activities. Particular common features include cognitive deficits (attention, executive functioning, language and memory), functional difficulties (in activities of daily living), psychomotor impairment (dyspraxia and poor co-ordination), and behavioural difficulties (aggression, agitation, and wandering). The Multi-sensory environment (MSE) has the potential to accommodate some of these problems experienced by people with neurological disabilities and, as such, is a valuable leisure resource. Multi-sensory activity can address individual sensory needs, such as offering a stronger stimulus if initial attempts are unnoticed, and be offered alongside familiar activities and routines to enhance sensory awareness. If the complexity of the activity, individual needs, and MSE demands are matched, engagement in this activity may be achieved. The Pool Activity Level Occupational Profiling Tool can provide a protocol from which MSE activity may be facilitated. By using this tool the MSE fits well within the World Health Organisation International Classification of functioning, Disability and Health by facilitating participation and reducing environmental barriers.

The effects of Snoezelen (multi-sensory behavior therapy) and psychiatric care on agitation, apathy, and activities of daily living in dementia patients on a short term geriatric psychiatric inpatient unit.

A randomized, controlled, single-blinded, between group study of 24 participants with moderate to severe dementia was conducted on a geriatric psychiatric unit. All participants received pharmacological therapy, occupational therapy, structured hospital environment, and were randomized to receive multi sensory behavior therapy (MSBT) or a structured activity session. Greater independence in activities of daily living (ADLs) was observed for the group treated with MSBT and standard psychiatric inpatient care on the Katz Index of Activities of Daily Living (KI-ADL; P = 0.05) than standard psychiatric inpatient care alone. The combination treatment of MSBT and standard psychiatric care also reduced agitation and apathy greater than standard psychiatric inpatient care alone as measured with the Pittsburgh Agitation Scale and the Scale for the Assessment of Negative Symptoms in Alzheimer's Disease (P = 0.05). Multiple regression analysis predicted that within the multi-sensory group, activities of daily living (KI-ADL) increased as apathy and agitation reduced (R2 = 0.42; p = 0.03). These data suggest that utilizing MSBT with standard psychiatric inpatient care may reduce apathy and agitation and additionally improve activities of daily living in hospitalized people with moderate to severe dementia more than standard care alone.

Evaluation of a model of nursing care for older patients using participatory action research in an acute medical ward.

AIMS AND OBJECTIVES: The main aim of this study was to improve the quality of nursing care for older acutely ill hospitalized medical patients through developing, implementing and evaluating a new model of care using a participatory action research process. BACKGROUND: One of the challenges of nursing today is to meet the health-care needs of the growing older population. It is important to consider what quality of nursing care means to older patients if nurses are to address gaps between their own perceptions and those of older patients themselves and to consider conceptual models of care appropriate for older patients care in order to improve the quality of care provided. DESIGN: This study is a mixed method triangulated study, involving the use of both quantitative and qualitative methods through participatory action research methodology to establish an evidence-base for an evolving model of care. METHODS: The model was tested on 60 acutely ill patients aged at least 65 years. The medical ward nurses selected a key reference group including the researcher to facilitate the participatory action research process to develop, implement and evaluate a new model of care based on Orem's self-care model incorporating the Nurses Improving Care to Health System Elders Faculty (Am J Nurs 1994; 94:21) medication protocol to improve the nursing care provided for acutely ill older patients. RESULTS: The participatory action research process resulted in improved heath-care outcomes for the patients, such as significant improvements in activities of daily living capabilities between admission to discharge, significant improvements in knowledge levels regarding their medication regimes, as well as increased satisfaction with nursing care activities as perceived by older patients and nursing staff. The implementation of educational sessions during the model of care improved the older patient's functional activities and knowledge levels of their medication regime prior to discharge. In addition, by repeatedly explaining procedures, nurses became more involved with their individual patient's care, developing a patient-centred care relationship based on Orem's self-care model. CONCLUSIONS: This study demonstrates the efficacy of a new model of nursing care in improving the quality of nursing care for older patients in the acute medical ward setting. RELEVANCE TO CLINICAL PRACTICE: This study is significant because of its evidence-base and demonstrates how the participatory action research process empowered nurses to make sustainable changes to their practice. The nurses in the study wanted to affect change. The planned change was not dictated by management, but was driven by the clinical nursing staff at the 'grass roots' level. Therefore, being involved in the decision-making process provided an incentive to actively implement change.