Living Well with Dementia: Feeling Empowered through Interaction with Their Social Environment.

This study was designed to advance our understanding of how feelings of empowerment in people living with dementia still residing at home can be promoted. We conducted qualitative interviews with 12 participants with mild-to-moderate stages of dementia in Germany and Spain as part of a European study on mindful design for dementia. A qualitative thematic content analysis was performed to elicit the key features of the experience reported by the interviewees. Three overarching categories were identified: the first category 'experiencing changes in personal life and coping with changes in life' covered losses and coping strategies; the second category 'retaining a sense of usefulness' included social participation and the need for activities with others; the third category 'feeling empowered' covered reflections on lifetime achievements, accomplishments in the present life, being in control and self-worth. Participants placed a strong emphasis on continuity and on the importance of making active decisions and meaningful social contributions. Empowerment within the person living with dementia was achieved through their interactions with their social environment, including the significance of communication about their needs and wishes and enabling shared decision-making and interactions with others in reciprocity.

An Investigation of the Wishes, Needs, Opportunities and Challenges of Accessing Meaningful Activities for People Living with Mild to Moderate Dementia.

Many people are keen to be actively involved in social life and activities, but even at an early stage, dementia can have a negative impact on social participation and access to leisure activities. As part of the IDoService project, this study has investigated people's needs and wishes, barriers and facilitators to identify opportunities for improving access to meaningful activities. Individual and focus group interviews were conducted with 5 people living with mild to moderate dementia, 2 familial and 2 professional care partners, as well as 12 people working in the field of dementia and/or community activities. Thematic analysis has highlighted the benefits of participating in meaningful activities, such as empowerment and pride, social contacts, and feeling useful to others. A number of barriers to participation relating to individual and environmental factors were reported. Even where participants praised dementia-friendly activities and facilities, they advocated activities inclusive for all and mentioned that some people might be reluctant to participate in dementia-labelled activities because they may not be suitable for their needs. These results indicate the need for developing tailored opportunities for people with mild to moderate dementia and provide valuable insights for researchers, service providers, policymakers and charities wanting to improve access.

[Current aspects on the antipsychotic treatment of older people with schizophrenia spectrum disorders]. / Aktuelle Aspekte zur antipsychotischen Behandlung älterer Menschen mit Erkrankungen des schizophrenen Spektrums.

BACKGROUND: From a geriatric perspective, the use of antipsychotic drugs (AP) is associated with significant risks in addition to their known effects. These include unfavorable interactions with geriatric syndromes, such as immobility and risk of falling, and potentially increased mortality, at least in certain patient groups. With reference to this the current state of knowledge on treatment with AP in older people with schizophrenia spectrum disorders is summarized with a focus on the typical multimorbidity of geriatric patients. METHODS: Narrative review with special consideration of guidelines and consensus papers from German speaking countries and a PubMed-supported literature search for current systematic reviews and meta-analyses. RESULTS: Antipsychotic agents are an essential part of a comprehensive treatment concept for schizophrenia with well-documented evidence. In geriatric patients adaptations under gerontopharmacological aspects are necessary. A sufficient data basis for evidence-based recommendations for the treatment of multimorbid and frail geriatric patients does not exist. CONCLUSION: An effective and as safe as possible treatment with AP requires a careful risk-benefit assessment, combined with an individual adaptation regarding the substance applied, dose and treatment duration in an interdisciplinary/multiprofessional context.

This is Me: Evaluation of a boardgame to promote social engagement, wellbeing and agency in people with dementia through mindful life-storytelling.

Receiving a dementia diagnosis is a difficult experience for most people and often affects their wellbeing negatively. To support people's wellbeing, in a therapeutic context, life-storytelling, reminiscence and mindfulness are used with people with dementia. In an everyday context, traditional games are used as a resource for stimulating memory, cognition and social activity. While an increasing number of creative strategies are available to support people with dementia, the area of board games design and their effect on wellbeing is underexplored. This paper reports on the evaluation of the This is Me (TIM) mindful life-storytelling board game by the European project MinD. Using a co-design methodology, TIM was developed with and for people with mild to moderate dementia to support their wellbeing by enhancing self-empowerment and social engagement. A focus group methodology was used to evaluate TIM with 50 people with dementia and 19 carers across four countries. TIM was evaluated with regard to the usability and experience of the design as well as people's emotional wellbeing, social engagement and agency. The thematic analysis demonstrated that the combination of life-storytelling and mindfulness allowed players to engage in meaningful social interaction and, as a result, they reported enjoyment, learning, more acceptance of the past and present situation, and that they perceived looking forward into the future together with others as helpful. The study demonstrates that design can be a useful means to support people with dementia in aspects of emotional wellbeing, social engagement and a sense of agency.

Adherence and acceptance of a home-based telemonitoring application used by multi-morbid patients aged 65 years and older.

INTRODUCTION: Currently, there are only a small number of comprehensive study results on adherence and acceptance of telemonitoring applications (TMAs) regarding multi-morbid older patients. The ATMoSPHAERE study aimed to develop an information and communication platform for an intersectoral networking of, for example, general practitioners, therapists, social services and the multi-morbid older patient. METHODS: The study presented was designed as a longitudinal bicentric intervention study which focused on multi-morbid patients aged ≥65 years using home-based telemedical measurement and input devices. The development and testing of this TMA aimed to optimise patients' health care through intersectoral networking of all treating actors. Quantitative methods of data collection and analysis were used. RESULTS: Patients who completed the study were significantly younger than drop-outs and non-participants. The mental health of study patients significantly improved between the beginning and end of TMA use. The main reason for non-participation in the study was the high time expenditure when participating in the study. No perceived (information) benefits for health and insufficient content variety were the main reasons for drop-out. Appropriateness and handling of TMAs must be aligned with the needs of the heterogeneous user group of multi-morbid patients in order to increase acceptance and the added value of TMAs. Telemonitoring hardware should be oriented on functional capabilities of the older target group. Telemonitoring software content requires an individual, disease-specific approach for patients. The TMA should be unobtrusively integrated into usual daily life and be used to an appropriate extent according to the underlying disease in order to avoid stressing patients. With regard to adherence concerning TMAs, it is crucial to provide a contact person who is always available for patients having problems handling TMAs. Health concerns and questions can thus be addressed early, providing a feeling of safety in the care process. DISCUSSION: User acceptance of TMAs is an essential indicator and driver for use and for future implementation efforts in health care. In order to achieve maximum user centricity in development processes, patients must be involved as experts, co-designers and future users, considering their needs and perceptions.

[Importance of psychotherapeutically oriented treatment procedures in geriatric psychiatry and psychotherapy]. / Stellenwert der psychotherapeutisch mitgeprägten Behandlungsverfahren in der Gerontopsychiatrie und -psychotherapie.

There is an increasing body of evidence for occupational and art therapies for treatment of severe mental illness in old age, such as geriatric depression, dementia and delirium. The individualized intervention strategies activate the patients' skills and activities in various ways and enhance psychological processes such as awareness of thoughts and activities, experiences and feelings of self-determination and autonomy. They may also encourage the patients' willingness to participate in multimodal treatment and to agree to pharmacotherapy and psychotherapy.

Independent Use of a Home-Based Telemonitoring App by Older Patients With Multimorbidity and Mild Cognitive Impairment: Qualitative Study.

BACKGROUND: The management of multimorbidity is complex and patients have a high burden of disease. When symptoms of dementia also appear, it becomes even more difficult for patients to cope with their everyday lives and manage their diseases. Home-based telemonitoring may support older patients with multimorbidity and mild cognitive impairment (MCI) in their regular monitoring and self-management. However, to date, there has been no investigation into whether patients with MCI are able to operate a telemonitoring app independently to manage their own diseases. This question has become even more important during the current COVID-19 pandemic to maintain high-quality medical care for this patient group. OBJECTIVE: We examined the following research questions: (1) How do patients with MCI assess the usability of the telemonitoring app? (2) How do patients with MCI assess the range of functions offered by the telemonitoring app? (3) Was there an additional benefit for the patients with MCI in using the telemonitoring app? (4) Were patients with MCI able to use the telemonitoring app independently and without restrictions? (5) To what extent does previous experience with smartphones, tablets, or computers influence the perceived ease of use of the telemonitoring app? METHODS: We performed a formative evaluation of a telemonitoring app. Therefore, we carried out a qualitative study and conducted guided interviews. All interviews were audio-recorded, transcribed verbatim, and analyzed using the Mayring method of structured content analysis. RESULTS: Twelve patients (8 women, 4 men) were interviewed; they had an average age of 78.7 years (SD 5.6) and an average Mini-Mental State Examination score of 24.5 (SD 1.6). The interviews lasted between 17 and 75 minutes (mean 41.8 minutes, SD 19.4). Nine patients reported that the telemonitoring app was easy to use. All respondents assessed the range of functions as good or adequate. Desired functionalities mainly included more innovative and varied educational material, better fit of the telemonitoring app for specific needs of patients with MCI, and a more individually tailored content. Ten of the 12 patients stated that the telemonitoring app had an additional benefit for them. Most frequently reported benefits included increased feeling of security, appreciation of regular monitoring of vital parameters, and increased independence due to telemonitoring. Eight patients were able to operate the app independently. Participants found the app easy to use regardless of whether they had prior experience with smartphones, tablets, or computers. CONCLUSIONS: The majority of examined patients with MCI were capable of operating the telemonitoring app independently. Crucial components in attaining independent use were comprehensive personal support from the start of use and appropriate design features. This study provides initial evidence that patients with MCI could increasingly be considered as a relevant user group of telemonitoring apps.

[Complex treatment of severe mental illnesses in old age]. / Komplexbehandlung bei schweren psychischen Erkrankungen im Alter ­ eine Positionsbestimmung.

BACKGROUND: The needs for assistance, support and treatment of older people with severe mental illnesses (SMI) are very high and linked to additional age-associated somatic diseases and impairments. Old people prefer to live independently in their own homes and to receive necessary treatment and support there; however, a resettlement in a residential nursing home is often necessary due to a lack of alternatives. OBJECTIVE: What is the current treatment reality in Germany for old people with SMI in their own homes and in residential nursing homes? How can coercive measures in this context be prevented? METHODS: Selected results from the scientific literature on psychogeriatric care models in older people with SMI are summarized and discussed. RESULTS: Multiprofessional psychogeriatric complex treatment models for older patients that include home visits and are adapted to the severity of mental disease are not available in Germany due to the lack of cross-sectoral network structures. Around 30% of the 730,000 nursing home residents in Germany experience coercive practices, whereas person-centered nursing concepts as well as guideline conform and individualized nonpharmacological treatment strategies and milieu therapeutic concepts are not sufficiently available. CONCLUSION: The German healthcare system is in urgent need of multiprofessional psychogeriatric home treatment models in old people with severe mental illness in order to prevent worsening of psychiatric and somatic symptoms, to maintain individual social involvement, to strengthen individual autonomy and participative decision making and to protect from coercion. Multiprofessional expertise is essential as well as effective age-appropriate service models with multiprofessional teams delivering domiciliary visits and connecting complementary services for individual treatment requirements as part of the German health care system.

Health-related quality of life in elderly, multimorbid individuals with and without depression and/or mild cognitive impairment using a telemonitoring application.

PURPOSE: Multimorbidity leads to decreasing health-related quality of life (HRQoL). Telemedicine may help to improve HRQoL. The present study was conducted to show (I) differences in HRQoL and changes in HRQoL over time in elderly, multimorbid individuals with and without depression and/or mild cognitive impairment (MCI) using a telemonitoring application (TMA) and (II) associations between engagement with measurements by study participants using a TMA and changes in their HRQoL. METHODS: The present feasibility study was part of a longitudinal intervention study. Recruited general practitioners (GPs) enrolled individuals and assigned them to risk groups according to absence/presence of depression and/or MCI. Depression was assessed using the Geriatric Depression Scale (GDS-15), MCI using the Mini-Mental State Examination (MMSE), and HRQoL using the SF-12. The TMA consisted of tablets, software, and measuring devices. Measured vital data were transferred to a care and case manager for monitoring and possible intervention. RESULTS: Nine GPs recruited 177 individuals, 97 of whom were included in the HRQoL analysis. Significantly lower physical and mental component summary (PCS/MCS) scores were revealed in study participants with depression, and with both depression and MCI, compared to participants with no mental disorders. PCS scores did not differ between study dates, but MCS scores had significantly increased over time. Participants' engagement with measurements was significantly associated with an increased MCS score, but not with the PCS score. DISCUSSION: Depression and/or MCI are negatively associated with the HRQoL of elderly, multimorbid people using a TMA. Engagement of individuals with vital data measurements via a TMA may increase their mental HRQoL. Mentally impaired people should be closely involved as co-designers and experts in development processes of TMAs to benefit from tailored solutions. An individual's increased mental HRQoL can be a decisive factor in their engagement with a GP treatment regimen and telemonitoring processes.

Assessing the generalisability of a multicentre qualitative dementia research: the experience and challenges faced by the MinD project in Europe.

Background: Generalisation of findings is an important aspect of research and essential for evidence-based practice. While generalisation is common in quantitative research, there is a lack of generalisability in qualitative research. This paper presents the experience and challenges faced by the Designing for People with Dementia (MinD) project in meeting the requirements to strengthen the generalisation of findings on the lived experience of people living with dementia and their engagement to co-create designs to empower their everyday living.   Methods: Polit and Beck (2010)'s strategies to generalise qualitative findings were applied: (1) replication in sampling; (2) replication of studies; (3) meta-synthesis of findings; (4) reflexivity and conceptualization; (5) immersion with the data; and (6) thick description. Results: While it is possible to increase the generabilisabilty of qualitative evidence through the replication of the sampling to attain a large, heterogeneous sample in different and multiple contexts and environments; implementation of sound and robust research; conducting in-depth analysis and interpretation collaboratively for emergent themes; and meeting the thick description requirement, there are challenges that the project team faced in implementing some of the Polit and Beck's strategies because of the condition, namely dementia, that our participants are having. Other challenges faced were: the language and cultural diversity in the team; diverse  work and organisational procedures; and the inter-disciplinary differences relating to the methods of enquiry, approaches and techniques to conduct research. These challenges will need to be identified and addressed at the start of the project with a strong leadership to ensure a seamless journey to complete the project successfully. Trust between the researchers and participants, and time to build this trust are critical to recruitment and participation in the study; these factors are of utmost important in research involving participants with condition such as dementia.

["I Indeed Consider it to be a Temporary Solution" - A Qualitative Analysis of the Conditions and Obstacles to Implementation of Psychiatric Home-Treatment in Berlin and Brandenburg]. / "Ich sehe es tatsächlich als Zwischenschritt" ­ eine qualitative Analyse der Implementierungsbedingungen und -hürden von Stationsäquivalenter Behandlung in Berlin und Brandenburg.

OBJECTIVE: The obstacles to implementation of a German variation of psychiatric Home-Treatment (HT), called "Inpatient Equivalent Home-Treatment" (IEHT) are examined. METHOD: 43 employees from 11 psychiatric hospitals in the federal states of Berlin and Brandenburg were questioned using interviews and focus groups. A thematic analysis was conducted using the socio-institutional theoretical model. RESULTS: At system-level, implementation is hampered by an inadequate service definition, staff shortages, as well as performance assessments by health insurances. This leads to reluctant implementation at hospital-level with insufficient staffing of the teams. Other barriers include a lack of mobile devices for documentation and team communication. At the level of employees, poor information, and cooperation as well as unclear assignment of tasks are impeding factors. CONCLUSION: For a more needs-oriented, flexible, and nationwide introduction of HT according to IEHT, improvements to the underlying framework conditions and further research addressing efficacy, effectiveness and implementation are necessary.

[Palliative care of persons with dementia and delirium]. / Palliativmedizinische Aspekte der Versorgung von Menschen mit Demenz und Delir.

The number of people with dementia and delirium not induced by alcohol and other psychoactive substances has significantly increased during the last decades and will rise further in the future, particularly in the oldest old. In the vast majority of cases dementia is characterized by a progressive course with shortened life expectancy and a lack of curative treatment options. Delirium will remit in many cases; however, in a substantial proportion of patients the further course is unfavorable. Life expectancy is greatly reduced in these patients, mostly in association with advanced dementia and age-related multimorbidity. Intensified inclusion of palliative medical care aspects in the planning of treatment is indicated in the context of advanced and incurable conditions associated with a presumably clearly reduced life expectancy. The aim is to achieve the best possible relief of distressing somatic and psychiatric symptoms for the sake of the patients and their families. The competencies of psychiatry and palliative care can complement each other in this respect. In addition, there is a need for healthcare policy measures beyond the associated interdisciplinary opportunities and challenges in order to establish the necessary healthcare structures.

A 24-week double-blind placebo-controlled study of the efficacy and safety of the AMPA modulator S47445 in patients with mild to moderate Alzheimer's disease and depressive symptoms.

INTRODUCTION: S47445 is a novel positive allosteric modulator of alpha-amino-3-hydroxy-5-methyl-4-isoxazole-propionic acid receptors that may emerge as a favorable candidate for the symptomatic treatment of cognitive and depressive disorders in patients suffering from Alzheimer's disease (AD) of mild to moderate severity and with depressive symptoms. METHODS: For this double-blind, placebo-controlled 24-week phase II trial, 520 outpatients aged between 55 and 85 years, with probable AD at mild to moderate stages (a Mini-Mental State Examination score of 24-15 inclusive) and exhibiting depressive symptoms (Cornell Scale for Depression in Dementia [CSDD] ≥ 8) were recruited in twelve countries and randomized to 3 doses of S47445 (5-15-50 mg) or placebo. The primary end point was the change from baseline in the 11-item Alzheimer's Disease Assessment Scale-Cognitive subscale (ADAS-Cog) total score at week 24. Secondary measures included the Disability Assessment for Dementia, Mini-Mental State Examination, ADAS-Cog 13-item, CSDD, Clinical Global Impression of Change (Alzheimer's Disease Cooperative Study-CGIC), Neuropsychiatric Inventory (NPI), and safety criteria. RESULTS: Baseline characteristics were comparable between the 4 groups. After 24 weeks, no statistically significant treatment difference was demonstrated between S47445 (5, 15 or 50 mg/d) and placebo on cognition (ADAS-Cog), function (Disability Assessment for Dementia), or depressive symptoms (CSDD). An improvement on neuropsychiatric symptoms assessed by NPI was evidenced at the lower dose 5 mg/d (Δ -2.55, P = .023, post hoc analysis) compared to placebo. CSDD and total NPI scores improved in all groups including placebo. There were no specific and/or unexpected safety signals observed with any of the S47445 doses. DISCUSSION: S47445 administered for 24 weeks was safe and well tolerated by patients with mild to moderate AD; the compound did not show significant benefits over placebo on cognition, function, or depressive symptoms.

[Reasons for non-acceptance and non-use of a home telemonitoring application by multimorbid patients aged 65 years and over]. / Motive für die Nichtakzeptanz und Nichtnutzung einer Telemonitoring-Anwendung im häuslichen Umfeld durch multimorbide Patienten über 65 Jahre.

BACKGROUND: User acceptance is a key indicator and driver for the use and implementation of telemonitoring applications (TMA) in healthcare. Despite various positive effects that previous studies have revealed for users of TMA, there are always patients who discontinue their participation in a telemedicine study or even decline participation. There is little evidence for the reasons for non-acceptance and non-use of TMA, especially in multimorbid patients at the age of 65 and over in their home environment. To close this research gap, this sub-study focuses on patient-reported reasons for non-acceptance and non-use of TMA in the home environment. METHODS: This study follows a mixed-method approach and focuses on patients' perspective. Quantitative data collection took place via computer-assisted telephone interviews among all drop-outs and non-participants. Qualitative data were collected via semi-structured interviews with drop-out patients and non-users. Eligible patients were recruited consecutively by general practitioners, informed and included in the study according to the inclusion criteria. Amongst others, patients measured their vital signs (blood pressure, heart frequency, oxygen saturation, weight) via telemedical measures and sent them via tablet to a Care Coordination Center to ascertain the need for intervention. Collected data on non-acceptance and non-use of TMA were analyzed quantitatively and qualitatively. RESULTS: Nine general practices in two German cities included a total of 177 patients according to the inclusion criteria. During the study, 61 study participants (34.5 %) dropped out, 80 patients (31.1 %) declined participation in the study. Drop-outs and non-participants were significantly older than active participants (p=.004 and p=.001, respectively). Predominant reasons for drop-out were the lack of the perceived added value and the content-related variety of the program on the patient's tablet, the missing interest/need for telemedical monitoring as well as the time spent participating in the study. Patients living alone, single and widowed patients reported significantly more difficulties in handling the hardware (tablet) (p=.040) and the program (Motiva) (p=.013) than married and cohabiting patients. These reasons were also reported mainly by female patients, patients aged 75 years and over, and those with a low level of education. CONCLUSION: In order to increase the acceptance and the added value of TMA for patients, the individual needs of the future target group should be analyzed at the beginning of the development. To ensure maximum user centricity, individual development steps should be continuously evaluated by the target group. TMA should be adapted to the functional abilities of elderly, multimorbid patients through, e. g., an appropriate design of the content, which is tailored to patients' individual needs. TMA should be used to an appropriate degree to avoid overburdening and should fit unobtrusively into patients' usual daily routine. For patient-specific acceptance of TMA, easy handling of the telemedical measuring and input devices is as important as the variety of offers on the platform and personal contact for technical queries. Special attention should be paid to patients who live alone, women, elderly patients over 75 years of age, and poorly educated patients in order to ensure full and easy access to technology-based telemonitoring for their own healthcare.

Effects of an animal-assisted intervention on social behaviour, emotions, and behavioural and psychological symptoms in nursing home residents with dementia.

AIM: The positive effects of animal-assisted interventions (AAIs) in people with dementia have been frequently reported in the literature. However, it remains unclear if the positive effects are directly due to the presence of the animal. The aim of this study was to investigate if the inclusion of an animal adds value to psychosocial interventions for people with dementia. METHODS: The study followed a within-subject design with two studied conditions (AAI and control intervention) and several measurement points (baseline (i.e. at beginning of the intervention), after 3 months, and after 6 months). Nineteen nursing home residents with dementia participated in the AAI (with a dog) and the control intervention. Both interventions were delivered as weekly group sessions over a period of 6 months. Outcomes examined were social interaction, emotional expression, and behavioural and psychological symptoms. These outcomes were evaluated by using video recordings at baseline and after 3 and 6 months. RESULTS: Nineteen patients with moderate to moderately severe dementia who lived in two nursing homes in Germany were included. During the AAI, we detected significantly longer and more frequent periods of positive emotions (pleasure) and social interaction (e.g. touch, body movements) than during the control intervention. CONCLUSION: The presence of a dog appears to have beneficial effects on psychosocial intervention for people with dementia.

Antidepressant pharmacotherapy in old-age depression-a review and clinical approach.

PURPOSE: Depression in old age is a disabling disease associated with functional and cognitive decline severely affecting quality of life. Studies specifically investigating antidepressant treatment for this special cohort of patients remain scarce and results are often conflicting. A narrative literature review was undertaken, synthesizing findings from published studies, systematic reviews, and treatment guidelines specifically conducted in elderly depressed patients to summarize implications and current recommendations as well as gaps in evidence for old-age pharmacologic treatment. METHODS: PubMed and Medline databases were searched for articles from July 2011 to July 2016. Only RCTs, meta-analyses, systematic reviews, and treatment guidelines focussing on the effect of antidepressant pharmacotherapy in old-aged participants were extracted, analysed, and discussed. The search resulted in a total of 26 articles. RESULTS: Selective serotonin reuptake inhibitors (SSRIs) and other second-generation antidepressants are recommended for first-line treatment of old-age depression. The differences in efficacy and tolerability within different substances and substance classes are minimal or non-existent. Tricyclic antidepressants (TCAs) are only considered for second-line treatment, due to their cardiac risk profile and anticholinergic effects. In treatment-resistant depression, augmentation therapy options include lithium and atypical antipsychotics. CONCLUSIONS: There is convincing evidence that antidepressants are efficacious in the treatment of old-age depression and that rationales are necessary for treatment planning. However, evidence-based data on recovery and remission rates in old-age depression specific to certain antidepressant drugs are still missing in trials and are of great importance for pharmacological treatment of old-age depression in daily clinical practice.