Improving continence management for people with dementia in the community in Aotearoa, New Zealand: Protocol for a mixed methods study.

BACKGROUND: The number of people living with dementia (PLWD) in Aotearoa New Zealand (NZ) was estimated at 96,713 in 2020 and it is anticipated that this number will increase to 167,483 by 2050, including an estimated 12,039 Maori (indigenous people of NZ) with dementia. Experiencing urinary incontinence (UI) or faecal incontinence (FI) is common for PLWD, particularly at the later stages of the disease. However, there is no robust estimate for either prevalence or incidence of UI or FI for PLWD in NZ. Although caregivers rate independent toilet use as the most important activity of daily living to be preserved, continence care for PLWD in the community is currently not systematised and there is no structured care pathway. The evidence to guide continence practice is limited, and more needs to be known about caregiving and promoting continence and managing incontinence for PLWD in the community. This project will seek to understand the extent of the challenge and current practices of health professionals, PLWD, caregivers and family; identify promising strategies; co-develop culturally appropriate guidelines and support materials to improve outcomes; and identify appropriate quality indicators so that good continence care can be measured in future interventions. METHODS AND ANALYSIS: A four-phase mixed methods study will be delivered over three years: three phases will run concurrently, followed by a fourth transformative sequential phase. Phase 1 will identify the prevalence and incidence of incontinence for PLWD in the community using a cohort study from standardised home care interRAI assessments. Phase 2 will explore continence management for PLWD in the community through a review of clinical policies and guidance from publicly funded continence services, and qualitative focus group interviews with health professionals. Phase 3 will explore experiences, strategies, impact and consequences of promoting continence and managing incontinence for PLWD in the community through secondary data analysis of an existing carers' study, and collecting new cross-sectional and longitudinal qualitative data from Maori and non-Maori PLWD and their caregivers. In Phase 4, two adapted 3-stage Delphi processes will be used to co-produce clinical guidelines and a core outcome set, while a series of workshops will be used to co-produce caregiver resources.

The experiences of carers in supporting a person living with dementia to participate in virtual cognitive stimulation therapy during the COVID-19 pandemic.

OBJECTIVES: Cognitive stimulation therapy (CST) is an evidence-based group intervention for people with dementia. In response to the COVID-19 pandemic, many existing CST groups moved virtually and this required carers of people living with dementia to assist with setting up the appropriate technology. This study aimed to explore the roles and experiences of carers in accessing virtual CST (vCST). METHODS: This qualitative study used semi-structured individual interviews, via telephone or videoconference, to explore the roles and experiences of carers. Interviews were recorded, transcribed verbatim and thematically analysed. RESULTS: Twelve family carers (age: 51-75 years) reported a range of experiences, from novice to expert knowledge in terms of accessing digital devices (mainly laptops and iPads) and connecting to Zoom. Accessing vCST provided carers an immediate application of new knowledge. Carers reported positive responses to vCST that provided their family member living with dementia with social contact and cognitive stimulation during lockdown. CONCLUSION: Accessing vCST required carers to have an existing adequate level of technological competence in order to learn and use the Zoom platform. Adult learning principles can be used to improve carers' digital literacy required for vCST and other telehealth initiatives.

To crush, or not to crush? Unauthorised covert administration of medication in nursing homes.

BACKGROUND AND OBJECTIVES: This study aimed to explore the experiences and perceptions of nursing home staff and residents of unauthorised covert administration of medication. Prior studies identify that covert medication administration (crushing medication to administer in food or drink) is common in nursing home settings. Still, few recognise that this practice may occur without consultation or clinical authorisation. DESIGN: An exploratory qualitative study was conducted with nursing home staff and residents as part of a more extensive mixed-methods study on medication omissions and clinical decision-making. METHODS: We conducted a qualitative study using focus groups and semi-structured interviews across four geographical areas in New Zealand to better understand nursing home staff and residents' experiences and perspectives on covert administration. Semi-structured interviews took place with 11 Clinical managers/leads and one senior Registered Nurse; role specific focus groups were held with Registered Nurses (n = 6), Health Care Assistants (n = 14), and Residents (n = 12). Data were analysed using thematic analysis. FINDINGS: Participants described covert administration as a practical option if a nursing home resident refused medication but recognised it was a deception that carried ethical and clinical risks, particularly when unauthorised. Participants felt that unauthorised covert administration stemmed from doubts about residents' competence and the competing demands staff face during medication administration. Staff, who typically relied on advice from their pharmacies around which medications were safe to crush, expressed a need for more education. CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: This study provides evidence that unauthorised covert administration of medications is an ongoing practice, using New Zealand nursing homes as an example. The results emphasise that nursing home staff and residents are aware that this practice carries ethical and clinical risks and requires a certified process to legitimise its authorised form.

Medication omission rates in New Zealand residential aged care homes: a national description.

BACKGROUND: A medication omission is an event where a prescribed medication is not taken before the next scheduled dose. Medication omissions are typically classed as errors within Residential Aged Care (RAC) homes, as they have the potential to lead to harm if poorly managed, but may also stem from good clinical decision-making. This study aimed to quantify the incidence, prevalence, and types of medication omissions in RAC homes on a national scale, using a New Zealand-based sample. METHODS: We conducted retrospective pharmacoepidemiology of de-identified medication administration e-records from December 1st 2016 to December 31st 2017. Four tiers of de-identified data were collected: RAC home level data (ownership, levels of care), care staff level data (competency level/role), resident data (gender, age, level of care), and medication related data (omissions, categories of omissions, recorded reasons for omission). Data were analysed using SPSS version 24 and Microsoft Excel. RESULTS: A total of 11, 015 residents from 374 RAC homes had active medication charts; 8020 resided in care over the entire sample timeframe. A mean rate of 3.59 medication doses were omitted per 100 (±7.43) dispensed doses/resident. Seventy-three percent of residents had at least one dose omission. The most common omission category used was 'not-administered' (49.9%), followed by 'refused' (34.6%). The relationship between ownership type and mean rate of omission was significant (p = 0.002), corporate operated RAC homes had a slightly higher mean (3.73 versus 3.33), with greater variation. The most commonly omitted medications were Analgesics and Laxatives. Forty-eight percent of all dose omissions were recorded without a comment justifying the omission. CONCLUSIONS: This unique study is the first to report rate of medication omissions per RAC resident over a one-year timeframe. Although the proportion of medications omitted reported in this study is less than previously reported by hospital-based studies, there is a significant relationship between a resident's level of care, RAC home ownership types, and the rate of omission.

Pharmacoepidemiology of medications omitted in New Zealand Residential Aged Care Homes.

OBJECTIVE: To investigate the dispensing, administration and omission of medications in residential aged care (RAC) homes in New Zealand (NZ). METHODS: Secondary data from a medication management database were analysed, to identify the most frequently omitted regular medications and commonly reported reasons for omissions in a sample of 11 015 residents across 374 RAC homes. RESULTS: Overall, 3.59 medication doses were omitted per 100 (±7.4) prescribed doses per resident (SD 7.43). Common regular medications omitted ranged from analgesics to psychotropic medications. Recording of justifications for medication omissions was inconsistent-only 48% of omissions had a recorded reason. CONCLUSIONS: A wide range of medications are regularly prescribed and administered to RAC home residents in NZ. Omitted doses are frequently recorded without a justification. Inconsistent recording of omissions can increase potential for error, particularly in relation to psychotropic medications. More consistent recording may help staff to maintain a high standard of quality care.

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.

Oral status, cognitive function and dependency among New Zealand nursing home residents.

OBJECTIVES: To investigate clinical oral disease and its association with cognitive function and dependency among older New Zealanders in residential aged care. MATERIAL AND METHODS: National survey of oral health in aged residential care throughout New Zealand. We classified residents into 1 of 3 levels of care: "low dependency care (or assisted living)"; "high dependency care"; or "specialist dementia care/psychogeriatric care." The Abbreviated Mental Test characterised cognitive function as "unimpaired" (scores of 7-10), "moderately impaired" (4-6) or "severely impaired" (0-3). Intra-oral examinations were conducted, along with a computer-assisted personal interview. RESULTS: Most of the 987 clinically examined participants were either at low or high dependency care level, with another 1 in 6 in psychogeriatric care. Almost half overall had severely impaired cognitive function. Just under half of the sample had 1 or more natural teeth remaining. Negative binomial regression modelling showed that the number of carious teeth was lower among women and higher among those who were older, those with more teeth and in those with severely impaired cognitive function. Oral debris scores (representing plaque biofilm and other soft deposits on teeth) were higher in men, those with more teeth, and in those with severely impaired cognitive function. CONCLUSIONS: Impaired cognitive function is a risk indicator for both dental caries and oral debris in aged residential care.

Using Robots at Home to Support Patients With Chronic Obstructive Pulmonary Disease: Pilot Randomized Controlled Trial.

BACKGROUND: Socially assistive robots are being developed for patients to help manage chronic health conditions such as chronic obstructive pulmonary disease (COPD). Adherence to medication and availability of rehabilitation are suboptimal in this patient group, which increases the risk of hospitalization. OBJECTIVE: This pilot study aimed to investigate the effectiveness of a robot delivering telehealth care to increase adherence to medication and home rehabilitation, improve quality of life, and reduce hospital readmission compared with a standard care control group. METHODS: At discharge from hospital for a COPD admission, 60 patients were randomized to receive a robot at home for 4 months or to a control group. Number of hospitalization days for respiratory admissions over the 4-month study period was the primary outcome. Medication adherence, frequency of rehabilitation exercise, and quality of life were also assessed. Implementation interviews as well as benefit-cost analysis were conducted. RESULTS: Intention-to-treat and per protocol analyses showed no significant differences in the number of respiratory-related hospitalizations between groups. The intervention group was more adherent to their long-acting inhalers (mean number of prescribed puffs taken per day=48.5%) than the control group (mean 29.5%, P=.03, d=0.68) assessed via electronic recording. Self-reported adherence was also higher in the intervention group after controlling for covariates (P=.04). The intervention group increased their rehabilitation exercise frequency compared with the control group (mean difference -4.53, 95% CI -7.16 to -1.92). There were no significant differences in quality of life. Of the 25 patients who had the robot, 19 had favorable attitudes. CONCLUSIONS: This pilot study suggests that a homecare robot can improve adherence to medication and increase exercise. Further research is needed with a larger sample size to further investigate effects on hospitalizations after improvements are made to the robots. The robots could be especially useful for patients struggling with adherence. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry ACTRN12615000259549; http://www.anzctr.org.au (Archived by WebCite at  http://www.webcitation.org/6whIjptLS).

Homecare Robots to Improve Health and Well-Being in Mild Cognitive Impairment and Early Stage Dementia: Results From a Scoping Study.

OBJECTIVES: This scoping study is the first step of a multiphase, international project aimed at designing a homecare robot that can provide functional support, track physical and psychological well-being, and deliver therapeutic intervention specifically for individuals with mild cognitive impairment. DESIGN: Observational requirements gathering study. PARTICIPANTS AND SETTINGS: Semistructured interviews were conducted with 3 participant groups: (1) individuals with memory challenges, mild cognitive impairment (MCI), or mild dementia (patients; n = 9); (2) carers of those with MCI or dementia (carers; n = 8); and (3) those with expertise in MCI or dementia research, clinical care, or management (experts; n = 16). Interviews took place at the university, at dementia care facilities or other workplaces, at participant's homes, or via skype (experts only). MEASUREMENTS: Semistructured interviews were conducted, transcribed, and reviewed. RESULTS: Several key themes were identified within the 4 topics of: (1) daily challenges, (2) safety and security, (3) monitoring health and well-being, and (4) therapeutic intervention. CONCLUSIONS: A homecare robot could provide both practical and therapeutic benefit for the mildly cognitively impaired with 2 broad programs providing routine and reassurance; and tracking health and well-being. The next phase of the project aims to program homecare robots with scenarios developed from these results, integrate components from project partners, and then test the feasibility, utility, and acceptability of the homecare robot.

Benefits and problems of health-care robots in aged care settings: A comparison trial.

AIM: This study investigated whether multiple health-care robots could have any benefits or cause any problems in an aged care facility. METHOD: Fifty-three residents and 53 staff participated in a non-randomised controlled trial over 12 weeks. Six robots provided entertainment, communication and health-monitoring functions in staff rooms and activity lounges. These settings were compared to control settings without robots. RESULTS: There were no significant differences between groups in resident or staff outcomes, except a significant increase in job satisfaction in the control group only. The intervention group perceived the robots had more agency and experience than the control group did. Perceived agency of the robots decreased over time in both groups. Overall, we received very mixed responses with positive, neutral and negative comments. CONCLUSIONS: The robots had no major benefits or problems. Future research could give robots stronger operational roles, use more specific outcome measures, and perform cost-benefit analyses.

Lounging with robots--social spaces of residents in care: A comparison trial.

AIMS: To investigate whether robots could reduce resident sleeping and stimulate activity in the lounges of an older persons' care facility. METHODS: Non-randomised controlled trial over a 12-week period. The intervention involved situating robots in low-level and high-dependency ward lounges and a comparison with similar lounges without robots. A time sampling observation method was utilised to observe resident behaviour, including sleep and activities over periods of time, to compare interactions in robot and no robot lounges. RESULTS: The use of robots was modest; overall 13% of residents in robot lounges used the robot. Utilisation was higher in the low-level care lounges; on average, 23% used the robot, whereas in high-level care lounges, the television being on was the strongest predictor of sleep. CONCLUSION: This study found that having robots in lounges was mostly a positive experience. The amount of time residents slept during the day was significantly less in low-level care lounges that had a robot.

Is psychotropic medication use related to organisational and treatment culture in residential care.

PURPOSE: The purpose of this paper is to establish the relationship between organisational culture and psychotropic medication use in residential care. DESIGN/METHODOLOGY/APPROACH: Cross-sectional analyses of staff and resident's record survey in residential aged care facilities in Auckland, New Zealand (NZ). The competing values framework categorised organisational culture as clan, hierarchical, market driven or adhocracy and was completed by all staff. The treatment culture tool categorised facilities as having resident centred or traditional culture and was completed by registered nursing staff and general practitioners (GP). Functional and behavioural characteristics of residents were established by staff report and health characteristics and medications used were ascertained from the health record. Multiple regression was used to test for associations between measures of culture with psychotropic medication use (anxiolytics, sedatives, major tranquillisers). FINDINGS: In total 199 staff, 27 GP and 527 residents participated from 14 facilities. On average 8.5 medications per resident were prescribed and 42 per cent of residents received psychotropic medication. Having a diagnosis of anxiety or depression (odds ratio (OR) 3.18, 95 per cent confidence interval (CI) 1.71, 5.91), followed by persistent wandering (OR 2.53, 95 per cent CI 1.59, 4.01) and being in a dementia unit (OR 2.45, 95 per cent CI 1.17, 5.12) were most strongly associated with psychotropic use. Controlling for resident- and facility-level factors, health care assistants' assignation of hierarchical organisational culture type was independently associated with psychotropic medication use, (OR 1.29, CI 1.08, 1.53) and a higher treatment culture score from the GP was associated with lower use of psychotropic medication (OR 0.95, CI 0.92, 0.98). ORIGINALITY/VALUE: Psychotropic medication use remains prevalent in residential care facilities in NZ. Interventions aimed at changing organisational culture towards a less hierarchical and more resident-centred culture may be another avenue to improve prescribing in residential aged care.

Recruiting older people for research through general practice: the Brief Risk Identification Geriatric Health Tool trial.

AIM: To describe successful methods of recruitment and identify practice characteristics related to increased recruitment of older people for a randomised controlled trial. METHODS: General practices in three regions of New Zealand and community-dwelling patients aged 75+ were recruited for the Brief Risk Identification Geriatric Health Tool trial. General practitioners (GPs) were faxed invitations with telephone follow-up. Reply-paid cards with telephone follow-up were used to invite older people. GP and practice characteristics were examined in relationship to recruitment rate. RESULTS: During 2007-2008, 158 of 438 GPs (36%) in 60 of 116 practices approached (52%) were recruited. Regional variation was marked and 3893 of 8308 invited (49%) older people were recruited. The GP's length of time at the practice and training in New Zealand was associated with recruitment success. CONCLUSIONS: Despite variability in practice recruitment, a reasonably large and representative sample of older people was recruited through general practices.

Promoting independence in residential care: successful recruitment for a randomized controlled trial.

OBJECTIVES: To describe the recruitment strategy and association between facility and staff characteristics and success of resident recruitment for the Promoting Independence in Residential Care (PIRC) trial. DESIGN: Cross-sectional study of staff and facility characteristics and recruitment rates within facilities with calculation of cluster effects of multiple measures. SETTING AND PARTICIPANTS: Staff of low-level dependency residential care facilities and residents able to engage in a physical activity program in 2 cities in New Zealand. MEASURES: A global impression of staff willingness to facilitate research was gauged by research nurses, facility characteristics were measured by staff interview. Relevant outcomes were measured by resident interview and included the following: (1) Function: Late Life FDI scale, timed-up-and-go, FICSIT balance scale and the Elderly Mobility Scale; (2) Quality of Life: EuroQol quality of life scale, Life Satisfaction Index; and (3) falls were assessed by audit of the medical record. Correlation between recruitment rates, facility characteristics and global impression of staff willingness to participate were investigated. Design effects were calculated on outcomes. RESULTS: Forty-one (85%) facilities and 682 (83%) residents participated, median age was 85 years (range 65-101), and 74% were women. Participants had complex health problems. Recruitment rates were associated (but did not increase linearly) with the perceived willingness of staff, and were not associated with facility size. Design effects from the cluster recruitment differed according to outcome. CONCLUSIONS: The recruitment strategy was successful in recruiting a large sample of people with complex comorbidities and high levels of functional disability despite perceptions of staff reluctance. Staff willingness was related to recruitment success.

Does functionally based activity make a difference to health status and mobility? A randomised controlled trial in residential care facilities (The Promoting Independent Living Study; PILS).

OBJECTIVES: to determine whether a repetitive activities of daily living (ADL) activity programme improves health status, life satisfaction and mobility for older people living in residential care. DESIGN: cluster randomised controlled trial. SETTING: five low-level dependency residential care homes in Auckland, New Zealand. PARTICIPANTS: one hundred and forty-nine older residents (mean age 84.7 years). INTERVENTION: trained research staff worked with residents in intervention wards to set a goal and complete a functional assessment for each resident. They then designed an individualised activity programme based on ADL and worked with residential care home staff to implement the programme into daily activities of residents. MEASUREMENTS: mobility: timed-up-and-go (TUG); life satisfaction: late life satisfaction index (LSI-Z); and health status: SF-36 were assessed at baseline, 3- and 6-months follow-up. RESULTS: in the intervention group the SF-36 total physical component summary (PCS) score improved at 3 months in comparison with the control group. There was no difference between groups on mobility measures at any time, nor any measures at 6-months follow-up. Significant contamination is likely to have affected the 6-month follow-up measures. CONCLUSIONS: a repetitive ADL exercise programme may improve health status in the short term in a group of frail older people living in residential care. Further research is needed to establish sustainability of change.