Community Occupational Therapy for people with dementia and family carers (COTiD-UK) versus treatment as usual (Valuing Active Life in Dementia [VALID]) study: A single-blind, randomised controlled trial.

BACKGROUND: We aimed to estimate the clinical effectiveness of Community Occupational Therapy for people with dementia and family carers-UK version (Community Occupational Therapy in Dementia-UK version [COTiD-UK]) relative to treatment as usual (TAU). We hypothesised that COTiD-UK would improve the ability of people with dementia to perform activities of daily living (ADL), and family carers' sense of competence, compared with TAU. METHODS AND FINDINGS: The study design was a multicentre, 2-arm, parallel-group, assessor-masked, individually randomised controlled trial (RCT) with internal pilot. It was conducted in 15 sites across England from September 2014 to January 2018. People with a diagnosis of mild to moderate dementia living in their own home were recruited in pairs with a family carer who provided domestic or personal support for at least 4 hours per week. Pairs were randomised to either receive COTiD-UK, which comprised 10 hours of occupational therapy delivered over 10 weeks in the person with dementia's home or TAU, which comprised the usual local service provision that may or may not include standard occupational therapy. The primary outcome was the Bristol Activities of Daily Living Scale (BADLS) score at 26 weeks. Secondary outcomes for the person with dementia included the following: the BADLS scores at 52 and 78 weeks, cognition, quality of life, and mood; and for the family carer: sense of competence and mood; plus the number of social contacts and leisure activities for both partners. Participants were analysed by treatment allocated. A total of 468 pairs were recruited: people with dementia ranged from 55 to 97 years with a mean age of 78.6 and family carers ranged from 29 to 94 with a mean of 69.1 years. Of the people with dementia, 74.8% were married and 19.2% lived alone. Of the family carers, 72.6% were spouses, and 22.2% were adult children. On randomisation, 249 pairs were assigned to COTiD-UK (62% people with dementia and 23% carers were male) and 219 to TAU (52% people with dementia and 32% carers were male). At the 26 weeks follow-up, data were available for 364 pairs (77.8%). The BADLS score at 26 weeks did not differ significantly between groups (adjusted mean difference estimate 0.35, 95% CI -0.81 to 1.51; p = 0.55). Secondary outcomes did not differ between the groups. In total, 91% of the activity-based goals set by the pairs taking part in the COTiD-UK intervention were fully or partially achieved by the final COTiD-UK session. Study limitations include the following: Intervention fidelity was moderate but varied across and within sites, and the reliance on primarily proxy data focused on measuring the level of functional or cognitive impairment which may not truly reflect the actual performance and views of the person living with dementia. CONCLUSIONS: Providing community occupational therapy as delivered in this study did not improve ADL performance, cognition, quality of life, or mood in people with dementia nor sense of competence or mood in family carers. Future research should consider measuring person-centred outcomes that are more meaningful and closely aligned to participants' priorities, such as goal achievement or the quantity and quality of activity engagement and participation. TRIAL REGISTRATION: Current Controlled Trials ISRCTN10748953.

Measuring fidelity of delivery of the Community Occupational Therapy in Dementia-UK intervention.

BACKGROUND: Interpreting data about intervention effectiveness requires an understanding of which intervention components were delivered and whether they were delivered as planned (fidelity of delivery). These studies aimed to develop a reliable measure for assessing fidelity of delivery of the Community Occupational Therapy in Dementia-UK intervention (COTiD-UK) (Study 1) and measure fidelity of delivery of COTiD-UK across sessions, sites and occupational therapists (Study 2). METHODS: The studies used a longitudinal observational design nested within a multi-site randomised controlled trial. Where practicable, all intervention sessions were audio-recorded. Fidelity checklists and coding guidelines were developed, piloted and refined until good agreement was achieved between two coders. Ten percent of sessions were purposively sampled from 12 sites and 31 occupational therapists. Transcripts were coded using checklists developed in Study 1; 10% of sets of intervention session transcripts were double coded to ensure that agreement was maintained. Percentages of components that were delivered were calculated for each session, site and occupational therapist. RESULTS: A reliable measure of fidelity of delivery for COTiD-UK was developed after several rounds of piloting and amendments. COTiD-UK was delivered with moderate fidelity across all six sessions (range: 52.4-75.5%). The mean range of fidelity varied across sites (26.7-91.2%) and occupational therapists (26.7-94.1%). CONCLUSIONS: A reliable, systematic method for measuring fidelity of delivery of COTiD-UK was developed and applied, and can be adapted for use in similar interventions. As COTiD-UK was delivered with moderate fidelity, there is a reasonable degree of confidence that intervention effects were attributable to COTiD-UK.

Enablers and challenges to occupational therapists' research engagement: A qualitative study.

INTRODUCTION: To develop occupational therapy's evidence base and improve its clinical outcomes, occupational therapists must increase their research involvement. Barriers to research consumption and leadership are well documented, but those relating to delivering research interventions, less so. Yet, interventions need to be researched within practice to demonstrate their clinical effectiveness. This study aims to improve understanding of challenges and enablers experienced by occupational therapists who deliver interventions within research programmes. METHOD: Twenty-eight occupational therapists who participated in the Valuing Active Life in Dementia (VALID) research programme reported their experiences in five focus groups. Data were analysed thematically to identify key and subthemes. RESULTS: Occupational therapists reported that overwhelming paperwork, use of videos, recruitment and introducing a new intervention challenged their research involvement, whereas support, protected time and a positive attitude enabled it. The impact of these challenges and enablers varied between therapists and organisations. CONCLUSION: Challenges and enablers to research involvement can be identified but must be addressed within individual and organisational contexts. Multifaceted collective action to minimise challenges and maximise enablers can facilitate clinicians' involvement in research. Using this approach should enable occupational therapists to increase their research involvement, thus demonstrating the clinical effectiveness of their interventions.

Evaluation of the 'Ladder to the Moon, Culture Change Studio Engagement Programme' staff training: Two quasi-experimental case studies.

AIM: To evaluate the impact of the CCSEP on care home staff in two care settings for older people in one nursing home and one residential home. BACKGROUND: Care homes provide personal care and accommodation for older people. The English Dementia Strategy aims to improve the quality of service provision for people with dementia. This includes specific mention of improving the quality of life in care homes and as such includes objectives related to developing the workforce knowledge and skills. The Ladder to the Moon Culture Change Studio Engagement Programme (CCSEP) is a staff training approach based on the Positive Psychology framework that uses theatre- and film-based activities. METHODS: This study used a wait-list controlled design. However, the data analysis plan was amended to reflect difficulties in data collection, and a quasi-experimental case study approach was consequently utilised. Outcome measures for staff attitudes and beliefs were as follows: Sense of Competence in Dementia Care Staff; Approaches to Dementia Questionnaire; Job Satisfaction Index; Brief Learning Transfer System Inventory; and Scale of Positive and Negative Experience. The Quality of Interaction Schedule (QUIS) was used to observe changes in staff-resident interaction. RESULTS: Fifty staff in two care homes completed the questionnaires and forty-one undertook formal CCSEP training. In Home A (nursing home), there was no significant change in any of the measures. In Home B (residential home), the QUIS showed an increase in positive interactions post intervention; a significant increase in the Building Relationship subscale of Sense of Competence; and a significant increase in staff sense of hopefulness towards people with dementia. The Brief Learning Transfer System Inventory showed a significant decrease post-intervention. The intervention did not significantly affect the happiness or job satisfaction of care home staff. CONCLUSION: The results of this study provide tentative evidence about the efficacy of this staff training programme. Some significant improvement in staff attitudes to people with dementia, staff sense of competence and positive staff-resident interactions were found in one of two homes. It is likely that the organisational problems affecting the other care home limited the implementation and therefore efficacy of the intervention there. The results therefore suggest that when a supportive management structure is in place, CCSEP may be more effective in improving staff attitudes, sense of competence and interactions with residents.

Causes of nursing home placement for older people with dementia: a systematic review and meta-analysis.

BACKGROUND: Up to half of people with dementia in high income countries live in nursing homes and more than two-thirds of care home residents have dementia. Fewer than half of these residents report good quality of life and most older people are anxious about the prospect of moving into a nursing home. Robust evidence is needed as to the causes of admission to nursing homes, particularly where these risk factors are modifiable. METHODS: We conducted a systematic literature search to identify controlled comparison studies in which the primary outcome was admission to nursing home of older adults with dementia. Identified studies were assessed for validity and 26 (17 cohort and 9 case-control) were included. Qualitative and quantitative analyses were conducted, including meta-analysis of 15 studies. RESULTS: Poorer cognition and behavioral and psychological symptoms of dementia (BPSD) were consistently associated with an increased risk of nursing home admission and most of our meta-analyses demonstrated impairments in activities of daily living as a significant risk. The effects of community support services were unclear, with both high and low levels of service use leading to nursing home placement. There was an association between caregiver burden and risk of institutionalization, but findings with regard to caregiver depression varied, as did physical health associations, with some studies showing an increased risk of nursing home placement following hip fracture, reduced mobility, and multiple comorbidities. CONCLUSION: We recommend focusing on cognitive enhancement strategies, assessment and management of BPSD, and carer education and support to delay nursing home placement.