Is elderspeak communication in simulated hospital dementia care congruent to communication in actual patient care? A mixed-methods pilot study.

AIMS: Simulation offers a feasible modality to prepare nurses for challenges communicating with patients with dementia. Elderspeak communication is speech that sounds like baby talk and can lead to rejection of care by patients with dementia. However, it is unknown if simulation can be used to capture elderspeak communication in dementia care. The purpose of this mixed-methods study was to determine if simulation accurately captures elderspeak communication by nursing staff in hospital dementia care. DESIGN: A 3-part mixed-methods design in which (1) three dementia care simulations were designed and validated by a panel of experts, (2) communication by nursing staff completing each simulation was quantitatively compared to communication during actual patient care, and (3) views on the realism were explored using within- and across-case coding. METHODS: Three simulations using different modalities (manikin, role-play, and standardised patient) were designed and validated with eight experts using the Lynn Method. Ten nursing staff were audio-recorded and their communication was coded for elderspeak communication. Results for each simulation were compared using Wilcoxon signed-rank test to recordings taken during actual dementia care encounters. Debriefings were coded for realism and results were converged. RESULTS: The average time using elderspeak during naturalistic care was 29.9% (SD = 20.9%) which did not differ from the average amount of elderspeak used across the three simulations modalities which ranged from 29.1% to 30.4%. Qualitative results suggested a lack of realism with the manikin condition and the nursing staff indicated preference for the simulation with the standardised patient. CONCLUSIONS: Communication elicited in the dementia care simulations was congruent to communication produced in actual dementia care but preference was for the standardised patient. IMPLICATIONS FOR PATIENT CARE: Elderspeak communication can be accurately produced in the simulated environment which indicates that simulation is a valid method for person-centred communication training in nursing staff. IMPACT: Simulation offers a feasible modality to prepare nurses for challenges communicating with patients with dementia. Elderspeak communication is speech that sounds like baby talk and can lead to rejection of care by patients with dementia. However, it is unknown if simulation can be used to capture elderspeak communication in dementia care. Elderspeak communication captured in the simulated environment was congruent to communication nursing staff use during actual patient care to hospitalised persons living with dementia. This study empirically identifies that communication is elicited in similar patterns by nursing staff in the simulated environment compared to the naturalistic care environment which demonstrates that simulation can be used as a valid tool for education and research on person-centred communication. REPORTING METHODS: STROBE. PATIENT OR PUBLIC CONTRIBUTION: No Patient or Public Contribution.

Best practices for communication while wearing facemasks: A scoping review.

INTRODUCTION: Facemasks are an important piece of personal protective equipment (PPE) to mitigate the spread of respiratory illnesses, but they can impede communication between patients and healthcare providers. The purpose of this scoping review is to identify effective communication practices while wearing facemasks. DESIGN: Scoping review using a systematic search of articles from the PubMed, CINAHL, and Embase databases. METHODS: The PEO (population, exposure, outcome) methodology was selected for this systematic scoping review. The population of interest (P) includes humans of all ages (children, adults, and older adults); the exposure of interest (E) is PPE that covers the mouth (i.e., facemasks); and the outcome of interest (O) is successful or unsuccessful communication practices. The Johns Hopkins Evidence-Based Practice for Nurses and Healthcare Professionals appraisal guidelines were used to determine the level and quality of the research. RESULTS: Thirty-nine articles met the inclusion criteria. Seventeen of these were high- or good-quality research studies, and the remaining 22 were non-research articles included with separate analysis as part of the scoping review. The 17 articles encompassed 2656 participants. The highest quality evidence indicated that standard surgical masks have the least impact on speech perception compared to other non-transparent mask types, and that recognizing emotions is less accurate with facemasks, necessitating compensatory actions (i.e., reducing extraneous noise, using a microphone to amplify voice, and employing clear speech). Evidence was contradictory regarding the use of transparent masks. Evidence was of limited quality for other non-verbal and verbal communication strategies. CONCLUSION: Awareness of communication challenges is crucial when wearing facemasks. More high-quality studies are needed to evaluate communication techniques when speakers are wearing facemasks. Basic strategies such as selecting an appropriate mask type, reducing extraneous noise, using microphones, verbalizing emotions, and employing clear speech appear to be beneficial. CLINICAL RELEVANCE: The findings of this scoping review highlight the importance of considering communication challenges while wearing facemasks in the healthcare settings. The review suggests that selecting an appropriate mask type, reducing extraneous noise, verbalizing emotions, and employing clear speech are some strategies that may be effective in mitigating the impact of facemasks on communication between patients and healthcare providers.

Developing and Testing Remote Implementation for the Changing Talk Online (CHATO) Communication Intervention for Nursing Home Staff: A Pilot Pragmatic Randomized Controlled Trial.

Background and Objectives: The Changing Talk (CHAT) communication training effectively reduces elderspeak and subsequent behavioral challenges in residents with dementia in nursing homes (NHs). As part of the pilot pragmatic clinical trial testing Changing Talk: Online Training (CHATO), a new online version, a remote implementation design, and process evaluation were developed to capture contextual factors, ensure fidelity, and determine effective implementation strategies. Research Design and Methods: The Expert Recommendation for Implementing Change compilation informed this 2-phase approach to develop and test remote implementation. An Advisory Board guided the developmental phase while pilot testing used a cluster-randomized design. Data were analyzed to evaluate NH characteristics; implementation strategies used; CHATO participation, completion, and passing rates; and leadership evaluation. Results: Five out of 7 NHs were nonprofit with above average quality ratings (M = 4.3 of 5). Staff participants (N = 237) were mostly female (90%), non-Hispanic White (91%), and nursing assistants (46%). Implementation time ranged from 54 to 86 days (M = 70.3, standard deviation [SD] = 9.3), with planning phase ranging from 11 to 29 days (M = 20.1, SD = 6.7), and training phase ranging from 35 to 58 days (M = 50.0, SD = 7.6). A range from 3 to 11 implementation strategies were used by each NH. Assigning champions, including the social worker on the implementation team, utilizing multiple mediums for reminders, giving rewards or public recognition, supporting onsite discussions, and other tailoring strategies were associated with improved outcomes. Participation ranged from 20% to 76%. Over 63% of participants completed training (N = 150) and 87% passed the posttest (N = 130). Leadership evaluations noted staff used CHATO concepts in practice and improved communication culture. Discussion and Implications: Leadership who took an active role, engaged multiple team members, and varied strategies had better outcomes. Effectiveness of the strategies will be evaluated in a national pragmatic clinical trial testing CHATO's effects on reducing behavioral and psychological symptoms in dementia care.

Elderspeak communication and pain severity as modifiable factors to rejection of care in hospital dementia care.

BACKGROUND: Rejection of care (RoC) occurs when persons living with dementia (PLWD) withstand or oppose the efforts of their caregiver. Improvements in hospital dementia care are needed, and one way to address this need is by identifying factors that lead to RoC, particularly those that are modifiable. Elderspeak communication is an established antecedent to RoC among PLWD in nursing homes. The purpose of this study was to extend these results to acute care settings by determining the impact of elderspeak communication by nursing staff on RoC by hospitalized PLWD. METHODS: Care encounters between nursing staff and PLWD were audio-recorded, transcribed verbatim, and coded for semantic, pragmatic, and prosodic features of elderspeak. RoC behaviors was scored in real-time using the Resistiveness to Care Scale. A Bayesian repeated-measures hurdle model was used to evaluate the association between elderspeak and both the presence and severity of RoC. RESULTS: Eighty-eight care encounters between 16 PLWD and 53 nursing staff were audio-recorded for elderspeak and scored for RoC. Nearly all (96.6%) of the encounters included some form of elderspeak. Almost half of the care encounters (48.9%) included RoC behaviors. A 10% decrease in elderspeak was associated with a 77% decrease in odds of RoC (OR = 0.23, 95% CI = 0.03, 0.68) and a 16% decrease ( e ß =  0.84, CI = 0.73, 0.96) in the severity of RoC. A one-unit decrease in pain severity was associated with 73% reduced odds of RoC (OR = 0.27, CI = 0.12, 0.45) and a 28% decrease ( e ß =  0.72, CI = 0.64, 0.80) in the severity of RoC. CONCLUSIONS: Both elderspeak by nursing staff and RoC by PLWD are present and pervasive in acute care. Pain and elderspeak are two modifiable factors of RoC in hospitalized PLWD. Person-centered interventions are needed that address communication practices and pain management for hospitalized PLWD.

Understanding Elderspeak: An Evolutionary Concept Analysis.

BACKGROUND AND OBJECTIVES: Elderspeak is an inappropriate simplified speech register that sounds like baby talk and is used with older adults, especially in health care settings. Understanding the concept of elderspeak is challenging due to varying views about which communicative components constitute elderspeak and whether elderspeak is beneficial or harmful for older adults. RESEARCH DESIGN AND METHODS: Rodgers' evolutionary concept analysis method was used to evaluate the concept of elderspeak through identification of elderspeak's attributes, antecedents, and consequences. A systematic search using the PubMed, CINAHL, PsycINFO, and Embase databases was completed. RESULTS: Eighty-three theoretical or research articles from 1981 to 2020 were identified. Elderspeak characteristics were categorized by semantic, syntactic, pragmatic, paralinguistic, and nonverbal attributes. The primary antecedent to elderspeak is implicit ageism, in which old age cues and signs of functional or cognitive impairment led to simplified communication, usually from a younger caregiver. Research studies varied in reporting whether elderspeak facilitated or interfered with comprehension by older adults, in part depending on the operational definition of elderspeak and experimental manipulations. Exaggerated prosody, a key feature of elderspeak, was found to reduce comprehension. Elderspeak was generally perceived as patronizing by older adults and speakers were perceived as less respectful. In persons with dementia, elderspeak also increases the probability of resistiveness to care, which is an important correlate of behavioral and psychological symptoms of dementia. DISCUSSION AND IMPLICATIONS: Based on this concept analysis, a new definition of elderspeak is proposed, in which attributes that have been found to enhance comprehension are differentiated from those that do not. Recommendations for consistent operationalization of elderspeak in future research are made.

Changing Talk Online: Protocol for a cluster pragmatic trial testing communication education to reduce behavioral and psychological symptoms of dementia in nursing home care.

Nursing home (NH) care of persons living with dementia is often made challenging by behavioral and psychological symptoms of dementia (BPSD) such as aggression, vocal outbursts, wandering, and withdrawal that occur due to cognitive and communication changes. Staff frequently communicate to NH residents using "elderspeak" which is patronizing speech similar to baby talk. Residents respond to elderspeak with increased BPSD that prompts use of psychotropic medication to control symptoms. The Changing Talk (CHAT) training educates staff about effective, person-centered communication strategies and reduces elderspeak by staff and subsequent BPSD among residents. This study will test effects of an adapted online version (CHATO) increasing access and dissemination of education to busy staff across diverse care settings. Nursing homes (N = 128) will be stratified and then randomized to CHATO education (n = 64) or to the control group (n = 64). Data on behavioral symptoms (primary outcomes) and psychotropic medication use (secondary outcomes) will be extracted from the Center for Medicare and Medicaid Services Minimum Data Set before and after education and will be compared between the groups using generalized linear mixed modeling. It is hypothesized that after completing the CHATO education residents will have reduced behavioral symptoms and psychotropic medication use compared to residents in control NHs. Additionally, factors related to NH participation and cost of the intervention will be determined. The overall goal of this study is to prepare for large scale dissemination and implementation of the evidence-based nonpharmacological CHATO intervention to reduce BPSD in residents with dementia across long-term care settings.

Satisfaction, utilization, and feasibility of a telehealth intervention for in-home dementia care support: A mixed methods study.

BACKGROUND: Technology can enhance support for families caring for persons living with dementia but must be acceptable to be adopted. The FamTechCare clinical trial engaged caregivers in video recording care encounters that were reviewed by an expert panel who provided tailored feedback. The intervention reduced caregiver depression and improved caregiver competence. This mixed methods study reports on caregiver satisfaction and utilization of the intervention and expert panel evaluation of the intervention. METHODS: A convergent parallel mixed methods design was used to evaluate the satisfaction, usability, and feasibility of the FamTechCare intervention. In the multisite randomized controlled trial, caregiver-person living with dementia dyads were randomized to the FamTechCare video support or attention control telephone support groups. Caregivers completed a satisfaction survey at the completion of the 3-month trial. Utilization was evaluated using the number and duration of videos submitted and calls received by caregivers. Relationships between participant characteristics and their satisfaction and utilization were evaluated. Feasibility of the intervention was assessed through content analysis of interviews with the expert panel. RESULTS: The majority of caregivers in both groups reported benefits from participation. More FamTechCare caregivers found the interventionist support to be helpful (p = 0.001) and effective (p = 0.020) compared to attention control caregivers. FamTechCare caregivers of persons with more severe dementia were more likely to report that video recording intruded on their privacy (p = 0.050). Caregiver age, gender, education, dyad relationship, rural status, and type and severity of dementia were not associated with ratings of acceptability, ease of use, or intervention utilization. The expert panel described the FamTechCare intervention as useful and identified adaptations to enhance feasibility. CONCLUSION: Regardless of age, gender, and relationship, caregivers found the intervention acceptable and easy to use and rated the expert feedback as effective in addressing care challenges. Further adaptation may be needed for FamTechCare to be readily implemented.

Moving Online: A Pilot Clinical Trial of the Changing Talk Online Communication Education for Nursing Home Staff.

BACKGROUND AND OBJECTIVES: Staff-resident communication is a critical part of nursing home (NH) care. Reducing elderspeak and increasing person-centered communication has been shown to reduce behavioral symptoms experienced by persons living with dementia. An online version of a successful classroom-based communication-training program that reduced staff elderspeak and resident behavioral symptoms was evaluated. The objective of this study was to establish feasibility and determine the preliminary effects of the online program in preparation for a national pragmatic clinical trial. RESEARCH DESIGN AND METHODS: Seven NHs were randomized to immediate intervention or wait-list control conditions. The NHs were provided with the web-based training program that staff individually accessed. Primary outcomes were knowledge scores and communication ratings of a video-recorded interaction, using pre- to posttraining comparisons. RESULTS: Knowledge increased from a mean pretest score of 61.9% (SD = 20.0) to a mean posttest score of 84.6% (SD = 13.5) for the combined group. Knowledge significantly improved between Time 1 and Time 2 for the immediate intervention participants (p < .001), but not for the wait-list control participants (p = .091), and this difference was statistically significant (p < .001). Ability to recognize ineffective, inappropriate, nonperson-centered, and elderspeak communication improved after training (p < .001). The magnitude of improvement in communication recognition was comparable to that of the original classroom format. DISCUSSION AND IMPLICATIONS: The adapted communication intervention was feasible and improved knowledge and communication. Online instruction can improve access to quality education and is an effective means to improve dementia care by overcoming barriers to in-person training. Clinical Trials Registration Number: NCT03849937.

Cost-effectiveness of a telehealth intervention for in-home dementia care support: Findings from the FamTechCare clinical trial.

Determining the cost-effectiveness of technological interventions is a crucial aspect in assuring these interventions can be adopted. The FamTechCare intervention is an innovative telehealth support that links family caregivers of persons living with dementia to tailored feedback from dementia care experts based on caregiver-initiated video recordings of challenging care situations. The FamTechCare intervention has demonstrated significant reductions in caregiver depression and increases in caregiver competence when compared to standard telephone support. The purpose of this article is to report on the cost-effectiveness of the FamTechCare telehealth intervention. Process-based costing and a cost-effectiveness analysis using the incremental cost-effectiveness ratio (ICER) was completed with 68 caregiver and person living dementia with dyads. The cost of the 12-week FamTechCare telehealth intervention was found to be greater ($48.43 per dyad per week) due to the telehealth equipment, recording application, and expert panel time compared with the telephone support intervention ($6.96 per dyad per week). The ICER was $18.51 for caregiver depression and $36.31 for caregiver competence indicating that it cost no more than $36.38 per dyad per week over 12 weeks to achieve significant improvement in depression and competence in the FamTechCare caregivers compared to the telephone support caregivers. The FamTechCare intervention appears to be cost-effective when compared to the telephone support intervention and remains near the willingness-to-pay threshold for caregivers providing in-home dementia care support.

Effects of a Video-based Intervention on Caregiver Confidence for Managing Dementia Care Challenges: Findings from the FamTechCare Clinical Trial.

OBJECTIVES: The Supporting Family Caregivers with Technology trial tested the FamTechCare video support intervention against telephone support. Dementia caregivers' video-recorded challenging care encounters and an interdisciplinary team provided tailored feedback. This paper reports on the effects of the intervention on caregiver confidence in managing priority challenges, a secondary outcome of this non-blinded parallel randomized controlled trial. METHODS: Caregiver/person living with dementia dyads were randomized to the experimental FamTechCare video support (n = 43) or attention control telephone support (n = 41) groups. Caregivers providing in-home care to a person living with mild or more severe dementia were eligible. Caregivers identified three priority challenges using the Caregiver Target Problems Questionnaire and rated the frequency and severity of each challenge and their confidence managing the challenge at baseline and 3-months. Challenges were classified using the FamTechCare Technology-supported Dementia Care Typology. Effects on confidence were compared between groups using the Wilcoxon rank-sum test and within groups using the Wilcoxon signed-rank test. RESULTS: Caregiver priority challenges included managing dementia behaviors, understanding disease expectations, and performing activity of daily living care. Improvements were observed across the three categories in both groups; however, not all changes were statistically significant. No significant differences were identified between groups. CONCLUSION: Caregivers in the FamTechCare group reported benefit across all priority challenges including managing dementia behaviors, understanding disease expectations, and performing activity of daily living care. CLINICAL IMPLICATIONS: Innovative technology provides new opportunities to support family caregivers in dementia home care. Video-recording can be used to enhance support for family caregivers facing care challenges.

Supporting Family Caregivers With Technology for Dementia Home Care: A Randomized Controlled Trial.

BACKGROUND AND OBJECTIVES: The number of persons living with dementia (PLWD) in the United States will reach 16 million by 2050. Behavioral and psychological symptoms of dementia challenge family caregivers and contribute to negative caregiver outcomes such as burden and depression. Available technology can support the delivery of effective interventions to families providing dementia care at home. The Supporting Family Caregivers with Technology for Dementia Home Care (FamTechCare) randomized controlled trial evaluated the effects of a telehealth intervention on caregiver outcomes. RESEARCH DESIGN AND METHODS: The FamTechCare intervention provides tailored dementia-care strategies to in-home caregivers based on video recordings caregivers submit of challenging care situations. An expert team reviews the videos and provides individualized interventions weekly for the experimental group. In the telephone-support attention control group, caregivers receive feedback from an interventionist via the telephone based on caregiver retrospective recall of care challenges. Effects of the intervention on caregiver outcomes, including burden, depression, sleep disturbance, competence, desire to institutionalize the PLWD, and caregiver reaction to behavioral symptoms were evaluated by fitting linear mixed regression models to changes in the outcomes measured at 1 and 3 months. RESULTS: FamTechCare caregivers (n = 42) had greater reductions in depression (p = .012) and gains in competence (p = .033) after 3 months compared to the attention control group (n = 41). Living in rural areas was associated with a reduction in depression for FamTechCare caregivers (p = .002). Higher level of education was associated with greater improvements or lesser declines in burden, competence, and reaction to behavioral symptoms for both the FamTechCare and attention control caregivers. DISCUSSION AND IMPLICATIONS: This research demonstrated benefits of using available technology to link families to dementia care experts using video-recording technology. It provides a foundation for future research testing telehealth interventions, tailored based on rich contextual data to support families, including those in rural or remote locations.

Effectiveness of active and passive warming for the prevention of inadvertent hypothermia in patients receiving neuraxial anesthesia: A systematic review and meta-analysis of randomized controlled trials.

OBJECTIVE: Perioperative hypothermia is a common complication of anesthesia that can result in negative outcomes. The purpose of this review is to answer the question: Does the type of warming intervention influence the frequency or severity of inadvertent perioperative hypothermia (IPH) in surgical patients receiving neuraxial anesthesia? DESIGN: Systematic review and meta-analysis. SETTING: Perioperative care areas. PATIENTS: Adults undergoing surgery with neuraxial anesthesia. INTERVENTION: Perioperative active warming (AW) or passive warming (PW). MEASUREMENTS: PubMed, CINAHL, Embase, and Cochrane Central Register of Controlled Trials were searched. Inclusion criteria were: randomized controlled trials; adults undergoing surgery with neuraxial anesthesia; comparison(s) of AW and PW; and temperature measured at end of surgery/upon arrival in the Postanesthesia Care Unit. Exclusion criteria were: no full-text available; not published in English; studies of: combined neuraxial and general anesthesia, warm intravenous or irrigation fluids without using AW, and rewarming after hypothermia. Two independent reviewers screened abstracts and titles, and selected records following full-text review. The Cochrane Collaboration's tool for assessing risk of bias was used to evaluate study quality. A random-effects model was used to calculate risk ratios for dichotomous data and mean differences for continuous data. MAIN RESULTS: Of 1587 records, 25 studies (2048 patients) were included in the qualitative synthesis. Eleven studies (1189 patients) comparing AW versus PW were included in the quantitative analysis. Meta-analysis found that intraoperative AW is more effective than PW in reducing the incidence of IPH during neuraxial anesthesia (RR=0.71; 95% CI 0.61-0.83; p<0.0001; I2=32%). The qualitative synthesis revealed that IPH continues despite current AW technologies. CONCLUSIONS: During neuraxial anesthesia, AW reduces IPH more effectively than PW. Even with AW, IPH persists in some patients. Continued innovation in AW technology and additional comparative effectiveness research studying different AW methods are needed.