Tailored videoconferencing counselling program to support family carers of people living with dementia during the transition to permanent residential care: a pilot and feasibility randomised trial.

BACKGROUND: Decisions surrounding the permanent residential care placement of people living with dementia can be stressful and distressing; however, providing access to targeted information and support prior to placement may help carers better cope. This mixed methods study aimed to test the feasibility, acceptability, and potential benefits of providing a tailored, individual counselling program (the Residential Care Transition Module), delivered via videoconferencing, to Australian family carers of a relative with dementia during the transition to permanent residential care. METHODS: A total of 18 family carers were randomly allocated to receive either the counselling intervention (six sessions delivered over 12 weeks) or a check-in call, delivered by a trained Transition Counsellor. Both groups received help-sheets about residential care, coping with placement, and managing feelings. Carers completed online surveys about stress, guilt, anxiety, depression, grief, and support for caring at baseline and four months post-baseline. Carers were also invited to participate in semi-structured exit interviews, conducted after follow-up surveys were completed. Process data relating to recruitment, retention, intervention dose and delivery were collected via logs. Quantitative data were analysed using descriptive statistics and repeated measures ANOVA. Qualitative data, relating to feasibility, acceptability, and perceived benefits of the program, were analysed using the 'framework' approach developed by the Medical Research Council to inform the process evaluation of complex interventions. RESULTS: Qualitative findings indicated that delivery of the counselling program during the transition period was deemed by participants to be feasible and acceptable. Delivery via videoconferencing was deemed convenient and acceptable, with few technical issues. The skills and knowledge of the Transition Counsellor were perceived to be important mechanisms of impact. Though not statistically significant, promising quantitative findings were identified in terms of reduced carer stress and guilt and improved support for caring. CONCLUSIONS: Delivery of a tailored counselling program via videoconferencing to family carers of people living with dementia during the transition to residential care was feasible and acceptable. The program has the potential to improve transitional support to family carers. TRIAL REGISTRATION: This study was registered in the Australian New Zealand Clinical Trials Registry: ACTRN12621001462875.

Telehealth Cognitive Behavior Therapy to Reduce Anxiety in People Living with Cognitive Impairment: A Randomized Feasibility Pilot Study.

OBJECTIVES: To evaluate the feasibility of telehealth-based cognitive behavior therapy for people living with cognitive impairment experiencing anxiety (Tele-CBT), and to assess whether this leads to improvements in anxiety, depression, and quality of life post-intervention. METHODS: This was a single-blind randomized feasibility pilot trial of the Tele-CBT versus usual care. People living with mild cognitive impairment or dementia experiencing anxiety were recruited and randomized to receive Tele-CBT (n = 5) or continue usual care (n = 5). Feasibility data comprised recruitment uptake and retention, adherence, and ease of use. Outcomes of anxiety (primary outcome - Rating Anxiety in Dementia; RAID), depression, stress, and quality of life were measured pre- and post-intervention. RESULTS: Intervention feasibility was demonstrated through minimal attrition, acceptability, and ease of use via videoconferencing. Both groups showed a decrease of anxiety symptoms (RAID) from baseline to post-assessment. CONCLUSIONS: The Tele-CBT program was acceptable to use via videoconferencing. Reduced anxiety symptoms were observed in both groups at post-. An RCT with a larger sample is required to determine the efficacy and implementation of the intervention. CLINICAL IMPLICATIONS: This study indicates the feasibility of videoconference CBT to address anxiety experienced by people living with cognitive impairment with minimal assistance from support persons.

Prototype development of the Mental Health benchmarking Industry Tool for residential aged Care (MHICare Tool): a protocol paper of a two-stage sequential and mixed methods codesign study.

OBJECTIVES: Current mental health practices for people living in residential aged care (RAC) facilities are poor. In Australia, there are no mechanisms to monitor and promote mental health for people living in RAC, including those who experience changed behaviours and psychological symptoms. The aim of this study is to improve current practices and mental health outcomes for people living in RAC facilities by codesigning a Mental Health benchmarking Industry Tool for residential aged Care (MHICare Tool). METHODS: A two-stage sequential and mixed methods codesign methodology will be used. Stage 1 will include qualitative interviews and focus groups to engage with residents, family/care partners and RAC staff to ascertain mental healthcare practices and outcomes of greatest significance to them. Adapted concept mapping methods will be used to rank identified issues of concern in order of importance and changeability, and to generate draft quality indicators. Stage 2 will comprise a Delphi procedure to gain the wider consensus of expert panel views (aged care industry, academic, clinical) on the performance indicators to be included, resulting in the codesigned MHICare Tool. ETHICS AND DISSEMINATION: This study has been reviewed and approved by the University of Queensland Human Research Ethics Committee (HREC/2019002096). This project will be carried out according to the National Statement on Ethical Conduct in Human Research (2007). The study's findings will be published in peer-reviewed journals and disseminated at national and international conferences and through social media. CONCLUSION: This protocol reports structured methods to codesign and develop a mental health performance indicator tool for use in Australian RAC.

Designing an Informatics Infrastructure for a National Aged Care Medication Roundtable.

In the residential aged care sector medication management has been identified as a major area of concern contributing to poor outcomes and quality of life for residents. Monitoring medication management in residential aged care in Australia has been highly reliant on small, internal audits. The introduction of electronic medication administration systems provides new opportunities to establish improved methods for ongoing, timely and efficient monitoring of a range of medication indicators, made more meaningful by linking medication data with resident characteristics and outcomes. Benchmarking contemporary medication indicators provides a further opportunity for improvement and is most effective when indicator data are adjusted to take account of confounding factors, such as residents' characteristics and health conditions. Roundtables provide a structure for sharing and discussing indicator data in a trusted and supportive environment and encourage the identification of strategies which may be effective in improving medication management. This paper describes a new project to establish, implement and evaluate a National Aged Care Medication Roundtable.

Steps to implementation: Understanding barriers and enablers for implementing Arts on Prescription at Home for people impacted by dementia.

ISSUE ADDRESSED: Arts on Prescription at Home (AoP@Home) involves a professional artist visiting a person with dementia and their informal carer(s) in their own home to engage them in participatory art making. While there is evidence for the use of these programs, more work is needed to facilitate effective implementation. This study explored contextual barriers and enablers to implementation of AoP@Home within a real-world community aged care service. METHODS: Two remote focus groups were conducted at a community aged care provider in Sydney, Australia. Key stakeholders (n = 14) were recruited, representing: people with dementia, informal (family) carers, AoP artists, service referrers and community service managers. Focus group transcripts were analysed using qualitative content analysis and mapped onto the Consolidated Framework for Implementation Research (CFIR). Outcomes were reviewed against the Expert Recommendations for Implementing Change (ERIC) strategy compilation to inform development of a tailored implementation strategy. RESULTS: Four overarching themes described the range of barriers and enablers to AoP@Home implementation: (1) "I don't know enough about it" (awareness and engagement within the sector), (2) artists delivering programs, (3) awareness and engagement of people impacted by dementia, (4) practicalities of implementation. All five domains of the CFIR were represented across the four themes. The ERIC compilation provided a list of practical strategies for implementation of AoP@Home. CONCLUSIONS: The implementation of psychosocial interventions for people living with dementia within a community aged care service is complex and multifactorial. So what?: Organisations planning implementation should consider conducting their own pre-implementation analysis to identify context-specific strategies.

A single-blind, parallel-group randomised trial of a Technology-assisted and remotely delivered Cognitive Behavioural Therapy intervention (Tech-CBT) versus usual care to reduce anxiety in people with mild cognitive impairment and dementia: study protocol for a randomised trial.

BACKGROUND: Anxiety is commonly experienced by people living with mild cognitive impairment (MCI) and dementia. Whilst there is strong evidence for late-life anxiety treatment using cognitive behavioural therapy (CBT) and delivery via telehealth, there is little evidence for the remote delivery of psychological treatment for anxiety in people living with MCI and dementia. This paper reports the protocol for the Tech-CBT study which aims to investigate the efficacy, cost-effectiveness, usability and acceptability of a technology-assisted and remotely delivered CBT intervention to enhance delivery of anxiety treatment for people living with MCI and dementia of any aetiology. METHODS: A hybrid II single-blind, parallel-group randomised trial of a Tech-CBT intervention (n = 35) versus usual care (n = 35), with in-built mixed methods process and economic evaluations to inform future scale-up and implementation into clinical practice. The intervention (i) consists of six weekly sessions delivered by postgraduate psychology trainees via telehealth video-conferencing, (ii) incorporates voice assistant app technology for home-based practice, and (iii) utilises a purpose-built digital platform, My Anxiety Care. The primary outcome is change in anxiety as measured by the Rating Anxiety in Dementia scale. Secondary outcomes include change in quality of life and depression, and outcomes for carers. The process evaluation will be guided by evaluation frameworks. Qualitative interviews will be conducted with a purposive sample of participants (n = 10) and carers (n = 10), to evaluate acceptability and feasibility, as well as factors influencing participation and adherence. Interviews will also be conducted with therapists (n = 18) and wider stakeholders (n = 18), to explore contextual factors and barriers/facilitators to future implementation and scalability. A cost-utility analysis will be undertaken to determine the cost-effectiveness of Tech-CBT compared to usual care. DISCUSSION: This is the first trial to evaluate a novel technology-assisted CBT intervention to reduce anxiety in people living with MCI and dementia. Other potential benefits include improved quality of life for people with cognitive impairment and their care partners, improved access to psychological treatment regardless of geographical location, and upskilling of the psychological workforce in anxiety treatment for people living with MCI and dementia. TRIAL REGISTRATION: This trial has been prospectively registered with ClinicalTrials.gov: NCT05528302 [September 2, 2022].

The impact of a cognitive impairment support program on patients in an acute care setting: a pre-test post-test intervention study.

BACKGROUND: Patients with cognitive impairment are at greater risk of hospital acquired complications, longer hospital stays, and poor health outcomes compared to patients without cognitive impairment. The Cognitive Impairment Support Program is a multi-disciplinary approach to improve screening rates and awareness of patients with cognitive impairment and guide clinician response and communication during their hospitalisation to improve health outcomes. OBJECTIVE: This study evaluated the impact of implementing the Cognitive Impairment Support Program on patient hospital acquired complications, patient reported quality of life and staff satisfaction in an outer metropolitan hospital. DESIGN: A pre-test post-test design was used to collect data in two 6-month time periods between March 2020 and November 2021. PARTICIPANTS: Patients aged ≥ 65 years, admitted to a participating ward for > 24 h. INTERVENTION: The Cognitive Impairment Support Program consisted of four components: cognitive impairment screening, initiation of a Cognitive Impairment Care Plan, use of a Cognitive Impairment Identifier and associated staff education. MEASURES: The primary outcome was hospital acquired complications experienced by patients with cognitive impairment identified using clinical coding data. Secondary outcomes were patient quality of life and a staff confidence and perceived organisational support to care for patients with cognitive impairment. RESULTS: Hospital acquired complication rates did not vary significantly between the two data collection periods for patients experiencing cognitive impairment with a 0.2% (95% confidence interval: -5.7-6.1%) reduction in admissions with at least one hospital acquired complication. Patients in the post intervention period demonstrated statistically significant improvements in many items in two of the Dementia Quality of Life Measure domains: memory and everyday life. The staff survey indicated statistically significant improvement in clinical staff confidence to care for patients with cognitive impairment (p = 0.003), satisfaction with organisational support for patients (p = 0.004) and job satisfaction (p ≤ 0.001). CONCLUSION: This study provides evidence that a multicomponent Cognitive Impairment Support Program had a positive impact on staff confidence and satisfaction and patient quality of life. Broader implementation with further evaluation of the multicomponent cognitive impairment intervention across a range of settings using varied patient outcomes is recommended.

Quality and safety in residential aged care: an evaluation of a national quality indicator programme.

BACKGROUND: In Australia, 243 000 individuals live in approximately 2700 residential aged care facilities yearly. In 2019, a National Aged Care Mandatory Quality Indicator programme (QI programme) was implemented to monitor the quality and safety of care in facilities. AIM: To examine the validity of the QI programme indicators using explicit measure review criteria. METHODS: The QI programme manual and reports were reviewed. A modified American College of Physicians Measure Review Criteria was employed to examine the QI programme's eight indicators. Five authors rated each indicator on importance, appropriateness, clinical evidence, specifications and feasibility using a nine-point scale. A median score of 1-3 was considered to not meet criteria, 4-6 to meet some criteria and 7-9 to meet criteria. RESULTS: All indicators, except polypharmacy, met criteria (median scores = 7-9) for importance, appropriateness and clinical evidence. Polypharmacy met some criteria for importance (median = 6, range 2-8), appropriateness (median = 5, range 2-8) and clinical evidence (median = 6, range 3-8). Pressure injury, physical restraints, significant unplanned weight loss, consecutive unplanned weight loss, falls and polypharmacy indicators met some criteria for specifications validity (all median scores = 5) and feasibility and applicability (median scores = 4 to 6). Antipsychotic use and falls resulting in major injury met some criteria for specifications (median = 6-7, range 4-8) and met criteria for feasibility and applicability (median = 7, range 4-8). CONCLUSIONS: Australia's National QI programme is a major stride towards a culture of quality promotion, improvement and transparency. Measures' specifications, feasibility and applicability could be improved to ensure the programme delivers on its intended purposes.

Clinical indicators of acute deterioration in persons who reside in residential aged care facilities: A rapid review.

PURPOSE: To identify the clinical indicators of acute deterioration in residents and the factors that influence residential aged care facility staff's identification of these. DESIGN: Rapid review and narrative synthesis. METHODS: The WHO and Cochrane Rapid Review Methods Group recommendations guided the review processes. CINAHL, Medline, PubMed, and the Cochrane Library were searched from 2000 to January 2022. Data related to clinical indicators of deterioration were categorized using the Airway, Breathing, Circulation, Disability, Exposure assessment framework, and factors influencing detection were grouped as consumer (resident and family), aged care workforce, and organization factors. RESULTS: Twenty publications were included of which 14 informed clinical indicators; nine highlighted factors that influence staff's identification of these and three informed both. Included article were collectively below moderate quality. Most clinical indicators were grouped into the 'Disability' category with altered level of consciousness, behavior, and pain identified most frequently. Few studies reported more traditional indicators of deterioration used in the general population - changes in vital signs. The most common factors influencing the detection of acute deterioration were organizational and workforce-related including resource, knowledge, and confidence deficits. CONCLUSION: Findings suggest subtle changes in resident's health status, rather than focusing primarily on physiologic parameters used in early warning tools for acute care settings, should be recognized and considered in the design of early warning tools for residential aged care facilities. CLINICAL RELEVANCE: Early warning tools sensitive to the unique needs of residents and support for aged care facility staff are recommended to improve the capacity of aged care facility care staff to identify and manage acute deterioration early to avoid hospitalization.

Characteristics and value of 'meaningful activity' for people living with dementia in residential aged care facilities: "You're still part of the world, not just existing".

Most residential aged care facilities support residents to participate in activities and the importance of activities that are suited to individual preferences and abilities is widely acknowledged. Participating in activities, including those considered to be 'meaningful' has the potential to improve residents' quality of life. However, what makes activities meaningful for people living with dementia in residential aged care facilities is unclear. The aim of this study was to understand the key characteristics of 'meaningful activity' in residential aged care facilities and the perceived value of residents participating in these activities. Using a qualitative study design, this study explored 'meaningful activities' from the perspectives of people living with dementia in residential aged care facilities, their family members and staff. Across four residential aged care facilities, residents (n = 19) and family members (n = 17) participated in individual interviews while staff (n = 15) participated in focus group interviews. Interviews were recorded, transcribed and analysed using a qualitative content analysis approach. Participant responses suggest that the meaning of an activity is subjective, varying over time and between individuals. Key characteristics of an activity that makes it meaningful include being enjoyable, social and engaging, aligning with the persons' interests, preferences, and abilities. To be considered meaningful, activities need to do more than occupy the person. The activity needs to be linked to a personally relevant goal and an aspect of the individuals' identity. Participating in 'meaningful activities' was perceived as valuable to encourage participation and socialising, provide a sense of normality for residents and improve their wellbeing. The findings of this study further our understanding of the concept of 'meaningful activity' for people living with dementia in residential aged care facilities. Understanding the key attributes of 'meaningful activity' can also provide practical guidance for those supporting people with dementia to participate in these types of activities.

The Use of Balanced Scorecards in Mental Health Services: an Integrative Review and Thematic Analysis.

Performance management of mental health services (MHS) through quality reporting of strategic indicators and goals is essential to improve efficiency and quality of care. One such method is the balanced scorecard (BSC). This integrative review of peer-reviewed and industry implemented BSCs in MHS aims to inform future development of a more comprehensive mental health-focused benchmarking tool. A two-part systematic literature search consisted of peer-reviewed published literature on MHS specific BSCs utilising the PRISMA guidelines in addition to industry published BSCs available online. A total of 17 unique BSCs were identified. A total of 434 indicators were subject to thematic analysis identifying 11 key themes: prevalence, accessibility, services provided, clinical outcomes, client satisfaction, client involvement, staff motivation, staffing levels, governance and compliance, development, and costs and revenue. These themes represented the measures that MHS believed measured key performance criteria in alignment with their organisational objectives.

Barriers and enablers to the delivery and implementation of the tailored activity programme in Australia: Perspectives of occupational therapists and their managers.

BACKGROUND: Prior to implementing new programmes or practices, it is essential to understand the context, barriers and enablers to support successful use. The tailored activity programme (TAP) is an evidence-based intervention provided by occupational therapists to support community-dwelling people living with dementia and their carers. The programme was developed in the United States, and although it is not currently available for routine use in Australia, its implementation would address the needs of many Australians with dementia and their carers. AIM: The aim of the study is to understand the perspectives of occupational therapists and their managers regarding barriers and enablers to the delivery and implementation of the TAP in Queensland, Australia. METHODS: A qualitative descriptive methodology was employed. Semistructured interviews were undertaken with occupational therapists (n = 18) who work with community-dwelling people with dementia and their carers, and their managers (n = 10). Participants were recruited from a range of organisations across Queensland, and they were asked about potential barriers and enablers to implementing TAP. Interviews were recorded and transcribed verbatim. Data were mapped using framework analysis whilst remaining open to other themes. FINDINGS: Themes were identified, and facilitating factors included the close alignment of TAP with occupational therapists' scope of practice; their acceptance of, and optimism about the programme and its perceived benefits including improved client outcomes; and an opportunity for occupational therapists to further develop their skills. Managerial support and carers' readiness and willingness to participate were also identified as important factors for success, whereas barriers were cost to clients and the capacity of the occupational therapy workforce to provide TAP. CONCLUSION: Occupational therapists and their managers expressed enthusiasm for TAP and awareness of its likely benefits, while also identifying barriers that will need to be addressed if implementation of the programme is to be successful in Australia.

Residential aged care staff perceptions and responses towards neuropsychiatric symptoms: a mixed methods analysis of electronic healthcare records.

OBJECTIVES: To investigate electronic care notes to better understand reporting and management of neuropsychiatric symptoms (NPS) by residential aged care (RAC) staff. METHODS: We examined semi-structured care notes from electronic healthcare notes of 77 residents (67% female; aged 67-101; 79% with formal dementia diagnosis) across three RAC facilities. As part of standard clinical practice, staff documented the NPS presentation and subsequent management amongst residents. Using a mixed-method approach, we analyzed the type of NPS reported and explored care staff responses to NPS using inductive thematic analysis. RESULTS: 465 electronic care notes were recorded during the 18-month period. Agitation-related behaviors were most frequently reported across residents (48.1%), while psychosis (15.6%), affective symptoms (14.3%), and apathy (1.3%) were less often reported. Only 27.5% of the notes contained information on potential causes underlying NPS. When faced with NPS, care staff responded by either providing emotional support, meeting resident's needs, removing identified triggers, or distracting. CONCLUSION: Results suggest that RAC staff primarily detected and responded to those NPS they perceived as distressing. Findings highlight a potential under-recognition of specific NPS types, and lack of routine examination of NPS causes or systematic assessment and management of NPS. These observations are needed to inform the development and implementation of non-pharmacological interventions and care programs targeting NPS in RAC.Supplemental data for this article is available online at https://doi.org/10.1080/13607863.2022.2032597 .

Frequency of changed behaviours in residential aged care and common mitigation strategies - A retrospective review of behavioural report logs.

BACKGROUND: Changed behaviours in residential aged care facilities (RACF) are frequently reported in the literature. How RACF staff routinely respond to these observed changed behaviours represents a significant gap. OBJECTIVE: To analyse the frequency of changed behaviour reported within RACF behavioural report logs and to ascertain how staff typically manage these behaviours. METHODS: Residents (N = 25) with varying levels of cognitive function were recruited from a 160 bed RACF in Queensland, Australia. A retrospective analysis of behavioural report logs was conducted to elucidate prevalence of reported changed behaviours as categorised by RACF staff. Thematic analysis of staff recorded behavioural mitigation strategies was used to categorise staff actions. A case analysis was also conducted to highlight the challenges faced by RACF staff managing persistent acute changed behaviours using identified common mitigation strategies. The STROBE guidelines were followed for reporting. RESULTS: There were 395 behaviours recorded in a two-month period. Physical agitation, interfering while wandering, trying to get to inappropriate places, verbal refusal of care, physical aggression, and verbal disruption were most frequently reported by staff. Management strategies included redirection, PRN psychotropic medication, reassurance, routine care practices, offering of beverages, repositioning, and rarely analgesia. A 24-h case analysis highlighted how staff utilised redirection and multiple doses of a PRN benzodiazepine with limited effectiveness. CONCLUSION: This study reveals current mitigation strategies employed by RACF staff in response to acute changed behaviours often associated with dementia. Agitation and wandering are prevalent and are difficult for staff to manage effectively. RELEVANCE TO CLINICAL PRACTICE: This study highlights that careful consideration should be taken to avoid overuse of PRN benzodiazepines in management of changed behaviours. Short-term mitigation strategies, such as redirection, may not be effective if underlying causes such as pain, physiological, mental, emotional, or social needs are not met. PATIENT AND PUBLIC CONTRIBUTION: A RACF participated in project design and review.

Hospital nurses' management of agitation in older cognitively impaired patients: do they recognise pain-related agitation?

BACKGROUND: cognitively impaired hospital patients often experience agitation and aggression due to pain. Agitation complicates care, increasing the risk of adverse outcomes and patient-to-nurse violence. Managing agitation is challenging for nurses. Literature suggests they may rely on antipsychotics while missing other more appropriately targeted treatments. However, nurses' management of agitation remains unclear and under-researched. OBJECTIVE: the aim of this study was to investigate hospital nurses' management of agitation in older cognitively impaired patients with pain. DESIGN: this was a descriptive correlational study using virtual simulation. SETTING AND PARTICIPANTS: a total of 274 registered medical and surgical nurses from 10 public hospitals in Queensland, Australia participated in the study. METHODS: nurses undertook a virtual simulation requiring them to manage agitation in a patient with dementia and an injury. Nurses also completed a post-simulation questionnaire. Their simulation performances were correlated with demographics such as seniority, workplace, training, experience and gerontology-specific knowledge. Constructed from an original, validated vignette, the simulation included branching pathways, video scenarios and an avatar that could converse with participants. RESULTS: thirteen nurses (4.7%) recognised and treated the virtual patient's agitation as pain-related. Most nurses (89%) gave antipsychotics of which 207 (78%) gave these first-line and 102 (38%) used them twice. Independent of other variables, nurses most likely to diagnose pain were dementia-unit nurses (OR = 8.7), surgical-unit nurses (OR = 7.3) and senior nurses (OR = 5). CONCLUSIONS: hospital nurses predominately managed agitation with antipsychotics, a decision that most made after undertaking inadequate patient assessments. This confirmed a common gap in practice that may lead to the missing of pain in the clinical care of agitated patients with dementia and/or delirium.

Creating 'Partnership in iSupport program' to optimise family carers' impact on dementia care: a randomised controlled trial protocol.

BACKGROUND: The majority of people with dementia are cared for by their family members. However, family carers are often unprepared for their caring roles, receiving less education and support compared with professional carers. The consequences are their reduced mental and physical health and wellbeing, and that of care recipients. This study protocol introduces the 'Partnership in iSupport program' that includes five interventional components: managing transitions, managing dementia progression, psychoeducation, carer support group and feedback on services. This health services research is built on family carer and dementia care service provider partnerships. The aims of the study are to evaluate the effectiveness, cost-effectiveness and family carers' experiences in the program. METHODS: A multicentre randomised controlled trial will be conducted with family carers of people living with dementia from two tertiary hospitals and two community aged care providers across three Australian states. The estimated sample size is 185 family carers. They will be randomly assigned to either the intervention group or the usual care group. Outcomes are measurable improvements in quality of life for carers and people with dementia, caregiving self-efficacy, social support, dementia related symptoms, and health service use for carers and their care recipients. Data will be collected at three time points: baseline, 6 months and 12 months post-initiation of the intervention. DISCUSSION: This is the first large randomised controlled trial of a complex intervention on health and social care services with carers of people living with dementia in real-world practice across hospital and community aged care settings in three Australian states to ascertain the effectiveness, cost-effectiveness and carers' experiences of the innovative program. We expect that this study will address gaps in supporting dementia carers in health and social care systems while generating new knowledge of the mechanisms of change in the systems. Findings will strengthen proactive health management for both people living with dementia and their carers by embedding, scaling up and sustaining the 'Partnership in iSupport program' in the health and social care systems. TRIAL REGISTRATION: The Australian New Zealand Clinical Trials Registry (ANZCTR). ACTRN12622000199718 . Registered February 4th, 2022.

Facilitated case conferences on end-of-life care for persons with advanced dementia-a qualitative study of interactions between long-term care clinicians and family members.

BACKGROUND: Prognostic uncertainty and the need for proxy decision-making owing to cognitive impairment in advanced dementia, adds complexity to end-of-life care planning within the long-term care setting. Case conferences provide a structure to facilitate difficult conversations and an opportunity for family and clinicians to engage in prospective planning, and reach agreement on goals of end-of-life care. OBJECTIVE: To explore interactions between multidisciplinary healthcare clinicians and families during facilitated case conferences on end-of-life care for residents with advanced dementia. METHODS: A qualitative approach was used. Transcripts of audio-recorded case conferences facilitated by a trained registered nurse were coded by two independent researchers and analysed inductively. Transcripts were selected from an available pool until thematic saturation was reached. Emerging themes were confirmed with the wider research group. RESULTS: Thematic saturation was reached after 25 transcripts. An overarching theme concerned the ways in which clinicians and families bridged medical and person-centred perspectives. Subthemes included: details of day-to-day care versus establishing overall goals of care; expression of emotion versus retreat from emotion; and missed opportunities versus expressed cues. Successful facilitation served to 'bridge the gap' between family and clinicians. CONCLUSION: Facilitation of case conferences for residents with advanced dementia should focus on ensuring that: clinicians do not miss opportunities to discuss end-of-life care; discussions on the minutiae of care regularly return to the resident's broader goals of care; and information on dementia and treatments provided by clinicians is integrated with advice by family members regarding the resident's premorbid values and likely preferences.

The role of experiential knowledge in hospital nurses' management of pain-related agitation in people with dementia: An expert performance simulation study.

BACKGROUND: Pain-related agitation in hospital patients with dementia presents a diagnostic challenge as patients often cannot explain their agitation. Generally, a deductive process is required of staff, culminating in an analgesic trial. However, evidence suggests the deductions of hospital nurses may be flawed because they may not associate agitation in dementia with painful conditions, thereby missing key clinical cues. While analytical rule-based deduction applies explicit formal knowledge, cognitive scientists argue that tacit experiential knowledge, i.e., the unconscious classification of available cues, is equally important and is always involved. AIM: To identify the cognitive characteristics unique to nurses who accurately recognise pain-related agitation in a patient with dementia compared with nurses who do not. METHODS: In this descriptive multivariate study, registered acute-care nurses undertook an original computerised virtual simulation requiring them to identify and manage pain-related agitation in a standardised patient with dementia. Process tracing methods captured nurses' simulation performances alongside their retrospective accounts of thinking. These were correlated with demographic characteristics related to seniority, workplace, training, experience and knowledge captured on a questionnaire. Dual processing theory enabled interpretation of intuitive and analytical cognitive processes. FINDINGS: Registered medical and surgical nurses (N = 274) participated from 10 hospitals. Although formal knowledge about pain in dementia was high (88%), only 13(4.7%) nurses identified pain-related agitation from an injury. These individuals took the longest and used the most cues, undertaking a detailed deductive search. Their recognition of pain-related cues demonstrated accurate experiential knowledge while another 16 nurses identified a fracture without linking the injury to agitation. Over three quarters (78%) of nurses decided on initial antipsychotic treatment. They were quick to decide, using the fewest cues, suggesting agitation was recognised as typical and familiar, with the solution well-known (albeit ineffective). Independent of other variables, nurses working in dementia-specific units, surgical units or with more seniority had increased odds of recognising pain, revealing the influence of workplace experience. However, most surgical and dementia-unit nurses did not recognise pain. CONCLUSIONS: Hospital nurses have difficulty recognising when agitation in a patient with dementia is caused by pain. High formal knowledge about pain in dementia may not be sufficient to enable clinical recognition of pain in patients. Instead, nurses with experience in specific workplaces or senior roles may be better equipped to recognise pain-related agitation and deploy evidence-based approaches for agitation in a patient with dementia. Overall, these results lend support to the influence of experiential knowledge on performance. TWEETABLE ABSTRACT: In a virtual simulation, registered nurses with high formal knowledge about pain in dementia lacked the experience required to recognise pain-related agitation in a patient with dementia.

Non-pharmacological interventions for neuropsychiatric symptoms of dementia in residential aged care settings: An umbrella review.

BACKGROUND: Prevalence of neuropsychiatric symptoms amongst people living with dementia in residential aged care is high. Their presence is associated with poorer quality of life for residents and higher burden of care for staff. Existing reviews have not focused on the evaluation of efficacy of non-pharmacological interventions in specific population settings (community vs. residential aged care). OBJECTIVES: To determine the efficacy of non-pharmacological interventions to manage neuropsychiatric symptoms of dementia in residential aged care settings. DESIGN: An umbrella review was conducted. DATA SOURCES: PubMed/Medline, Embase, Cochrane Library and Web of Science were searched for eligible reviews in December 2019, February 2020 and June 2021. METHODS: Two authors independently screened titles and abstracts, and assessed full-text reviews for eligibility. The quality of reviews was appraised with 'AMSTAR-2: A Measurement tool to assess systematic reviews'. Narrative summaries grouped findings by intervention domains. RESULTS: From 1362 systematic reviews identified, 26 met the inclusion criteria. Of these, 10 focused on person tailored interventions, six on sensory stimulation interventions, three on environmental interventions, three on exercise interventions, and four on multiple intervention types. Quality ratings identified reviews to be of mostly moderate quality (73%). The majority or reviews reported positive results but not all were statistically significant. Tailored interventions that included music and social elements appeared to be most beneficial for depressive symptoms and mood. Furthermore, outcome measures and intervention protocols were highly heterogeneous across interventions. CONCLUSIONS: The findings of this umbrella review suggest that combining different types of interventions and tailoring them to the personal experiences of the resident is recommended. A more standardised approach for outcome measures used is vital to assess efficacy and allow comparison of future non-pharmacological interventions.

Long-term care placement: The transitional support needs and preferences of spousal dementia caregivers.

BACKGROUND AND OBJECTIVES: Many spousal caregivers experience stress, depression, loneliness, guilt and grief when placing a partner with dementia into long-term care. However, there is little research about their transitional support experiences, needs and preferences. This study aimed to gain a deeper understanding of these issues from spousal caregiver and long-term care facility staff perspectives, to inform subsequent support and intervention development. RESEARCH DESIGN AND METHODS: Semi-structured interviews and small group discussions were held separately with spousal caregivers (n = 9) and care facility staff (n = 11). Criterion and variation sampling aimed to ensure a range of experiences and perspectives. The 'Framework' approach was utilised for data analysis. Interpretation was with respect to underpinning models of stress-grief process in dementia caregiving. FINDINGS: A range of informational, psychoeducational and psychosocial supports were identified to help spousal caregivers cope better with the stressors and losses experienced throughout the transition from home to long-term care. Improved education about disease progression, information relating to long-term care provision, peer support and dementia-specific grief counselling were deemed important. Opportunities for better support within care facilities were also identified. Support should be tailored to individual needs and preferences. DISCUSSION AND IMPLICATIONS: The findings suggest a supportive care framework be developed, encompassing the trajectory from assessment for and admission into long-term care to end-of-life and post-bereavement support. Spousal caregivers should have their support needs assessed by trained health or social care professionals and be offered a range of support options as appropriate.