Transition from driving to driving-cessation: experience of older persons and caregivers: a descriptive qualitative design.

BACKGROUND: For some older persons, driving is essential to maintain their daily activities and engagement with society. Unfortunately, some will have to stop driving, as they age. Driving-cessation is an important transition for older persons and caregivers, well known to cause significant challenges and consequences. This study aimed to describe the experience of older persons and caregivers in the transition from driving to ceasing to drive. METHODS: Within a descriptive qualitative design, semi-structured interviews were undertaken with older persons (n = 8) and caregivers (n = 6) from the city of Québec (Quebec, Canada), from November 2020 to March 2021. Using an inductive approach, the qualitative data was analyzed with the content analysis method. RESULTS: Some older persons had never thought they might someday lose their driver's license. The process of legislative assessment was unknown by almost all older persons and caregivers. The process was therefore very stressful for the research participants. Driving-cessation is a difficult transition that is associated with loss of independence, freedom, spontaneity, and autonomy. Qualitative analysis of data showed different factors that positively or negatively influence the experience of ceasing to drive, such as the older person's ownership of the decision, the presence of a network of friends and family, and self-criticism. There was significant impact related to driving-cessation for caregivers, such as assuming the entire burden of travel, psychologically supporting older persons in their grief, and navigating the driver's licensing system. CONCLUSIONS: These study results could help organizations and healthcare professionals to better accompany and support older drivers and caregivers in the transition from driving to driving-cessation. TRIAL REGISTRATION: None.

Job Satisfaction for Caregivers and Other Employees in Innovative Long-Term Care Homes for Residents With Cognitive Problems.

New housing models have emerged in Europe, Australia, the United States, and Canada. Intended for individuals with neurocognitive disorders, these models are characterized by a philosophy centered on the person, self-determination, liberty of choice, flexibility of care, acceptance of risk, and autonomy. Work and care are organized according to the pace and preferences of residents. The current multiple case study highlights the main sources of job satisfaction for caregivers and other employees in four innovative residential settings. Five themes are addressed as perceived by 58 employees: Work Motivation, Work Organization, Collaboration and Decision-Making Latitude, Quality of Work Life, and Continuing Education. These data will help inform clinical staff, policymakers, and the scientific community about clinical and organizational practices that contribute to job satisfaction in innovative residential settings. [Journal of Gerontological Nursing, 49(10), 36-43.].

The OptimaMed intervention to reduce medication burden in nursing home residents with severe dementia: results from a pragmatic, controlled study.

BACKGROUND: Nursing home (NH) residents with severe dementia use many medications, sometimes inappropriately within a comfort care approach. Medications should be regularly reviewed and eventually deprescribed. This pragmatic, controlled trial assessed the effect of an interprofessional knowledge exchange (KE) intervention to decrease medication load and the use of medications of questionable benefit among these residents. METHODS: A 6-month intervention was performed in 4 NHs in the Quebec City area, while 3 NHs, with comparable admissions criteria, served as controls. Published lists of "mostly", "sometimes" or "exceptionally" appropriate medications, tailored for NH residents with severe dementia, were used. The intervention included 1) information for participants' families about medication use in severe dementia; 2) a 90-min KE session for NH nurses, pharmacists, and physicians; 3) medication reviews by NH pharmacists using the lists; 4) discussions on recommended changes with nurses and physicians. Participants' levels of agitation and pain were evaluated using validated scales at baseline and the end of follow-up. RESULTS: Seven (7) NHs and 123 participants were included for study. The mean number of regular medications per participant decreased from 7.1 to 6.6 in the intervention, and from 7.7 to 5.9 in the control NHs (p-value for the difference in differences test: < 0.05). Levels of agitation decreased by 8.3% in the intervention, and by 1.4% in the control NHs (p = 0.026); pain levels decreased by 12.6% in the intervention and increased by 7% in the control NHs (p = 0.049). Proportions of participants receiving regular medications deemed only exceptionally appropriate decreased from 19 to 17% (p = 0.43) in the intervention and from 28 to 21% (p = 0.007) in the control NHs (p = 0.22). The mean numbers of regular daily antipsychotics per participant fell from 0.64 to 0.58 in the intervention and from 0.39 to 0.30 in the control NHs (p = 0.27). CONCLUSIONS: This interprofessional intervention to reduce inappropriate medication use in NH residents with severe dementia decreased medication load in both intervention and control NHs, without important concomitant increase in agitation, but mixed effects on pain levels. Practice changes and heterogeneity within these 7 NHs, and a ceiling effect in medication optimization likely interfered with the intervention. TRIAL REGISTRATION: The study is registered at ClinicalTrials.gov: # NCT05155748 (first registration 03-10-2017).

It's all about cognitive trajectory: Accuracy of the cognitive charts-MoCA in normal aging, MCI, and dementia.

BACKGROUND: The Montreal Cognitive Assessment (MoCA) is an established cognitive screening tool in older adults. It remains unclear, however, how to interpret its scores over time and distinguish age-associated cognitive decline (AACD) from early neurodegeneration. We aimed to create cognitive charts using the MoCA for longitudinal evaluation of AACD in clinical practice. METHODS: We analyzed data from the National Alzheimer's Coordinating Center (9684 participants aged 60 years or older) who completed the MoCA at baseline. We developed a linear regression model for the MoCA score as a function of age and education. Based on this model, we generated the Cognitive Charts-MoCA designed to optimize accuracy for distinguishing participants with MCI and dementia from healthy controls. We validated our model using two separate data sets. RESULTS: For longitudinal evaluation of the Cognitive Charts-MoCA, sensitivity (SE) was 89%, 95% confidence interval (CI): [86%, 92%] and specificity (SP) 79%, 95% CI: [77%, 81%], hence showing better performance than fixed cutoffs of MoCA (SE 82%, 95% CI: [79%, 85%], SP 68%, 95% CI: [67%, 70%]). For current cognitive status or baseline measurement, the Cognitive Charts-MoCA had a SE of 81%, 95% CI: [79%, 82%], SP of 84%, 95% CI: [83%, 85%] in distinguishing healthy controls from mild cognitive impairment or dementia. Results in two additional validation samples were comparable. CONCLUSIONS: The Cognitive Charts-MoCA showed high validity and diagnostic accuracy for determining whether older individuals show abnormal performance on serial MoCAs. This innovative model allows longitudinal cognitive evaluation and enables prompt initiation of investigation and treatment when appropriate.

Acceptability of videoconferencing to preserve the contact between cognitively impaired long-term care residents and their family caregivers: A mixed-methods study.

Visiting restrictions had to be imposed to prevent the spread of the COVID-19 virus and ensure the safety of long-term care home (LTCH) residents. This mixed method study aimed to explore residents' and family caregivers' acceptability of electronic tablets used to preserve and promote contact. Semi-structured individual interviews with 13 LTCH residents and 13 family caregivers were done to study their experiences, as well as the challenges and resources encountered in the implementation and use of videoconferencing. They had to rate, on a scale from 0 to 10, each of the 6 Theoretical Framework of Acceptability' constructs of the acceptability of the intervention. The results confirm acceptability of videoconferencing, giving residents and caregivers the opportunity to talk to and see each other during the pandemic. Videoconferencing had some benefits, such as being less expensive, and taking less time and effort for family caregivers.

Assessing facilitating conditions and barriers for innovation implementation in Canadian long-term care homes: a research protocol.

BACKGROUND: The COVID-19 pandemic has profoundly affected the health and care of older adults, with particularly negative consequences for those residing in long-term care homes (LTCH) and retirement homes (RH). To inform the implementation of interventions with the most potential for impact, Healthcare Excellence Canada identified six promising practices and policy options that can be introduced to ensure that LTCH and RH are better prepared for potential future outbreaks. A total of 22 implementation science teams (ISTs) were funded to support LTCH and RH across Canada in their implementation of these practices. This study aims to identify the enablers and barriers to the successful implementation of evidence-based practices and the impact of intervention in LTCH and RH across Canada. METHODS: A survey-based longitudinal correlational design will be used. The Organizational Readiness for Knowledge Translation (OR4KT) tool will be used to assess the readiness of LTCH and RH to implement the selected practice. The OR4KT includes 59 questions and takes about 15 min to complete. Five to ten respondents per organization, holding different job positions, will be invited by the ISTs to complete the OR4KT in 91 LTCH or RH across Canada at the beginning of the project (T1) and 6 months after the first measurement (T2). DISCUSSION: The study will provide a benchmark for assessing the readiness of LTCH and RH to implement evidence-based practices. It will also inform decision-makers about barriers and facilitators that influence the integration of promising practices in these organizations.

Road safety of older drivers and the nursing profession: A scoping review.

BACKGROUND: Population ageing will lead to an increase in the number of older drivers. The ageing process can affect older adults' driving ability. Nurses can play a major role in identifying potentially at-risk drivers and providing guidance about driving safety and cessation, but their role remains somewhat unknown. OBJECTIVE: This scoping review aims to present the scientific literature in relation to the nursing profession in the field of road safety. DESIGN: CINAHL and PubMed databases were used to identify quantitative, qualitative, mixed methods or clinical practice guideline articles that referred to the role of nurses in older people's road safety and were published in English or French languages between January 1990 and August 2020. Ten (10) articles met the inclusion criteria and were analysed. RESULTS: Analysis of included articles revealed one main theme: Nurses' and NPs' roles in the mobility continuum. Results showed that nurses and nurse practitioners (NPs) often see older drivers in their clinical practice and that they have the competencies to screen and assess their fitness to drive. They are well positioned to discuss age-related changes, fitness to drive and a driving retirement plan with their older patients, but they are not confident when addressing this issue. Few older adults have discussed their driving abilities with healthcare professionals, but they would be willing to discuss this if the subject were brought up. CONCLUSIONS: This scoping review highlighted the paucity of research addressing the role of the nurse in road safety. More research is needed to adequately document this role.

A nursing mentoring programme on non-pharmacological interventions against BPSD: Effectiveness and use of antipsychotics-A retrospective, before-after study.

Behavioural and psychological symptoms of dementia (BPSD) are common and have significant implications for patients and caregivers. Non-pharmacological interventions (NPI) have shown to be effective in the management of BPSD. However, the use of antipsychotics to treat BPSD remains ubiquitous. This retrospective, before-after study aimed to examine whether a nurse mentoring programme promoting NPI for BPSD management had a significant association with the use of antipsychotics in older adults with major neurocognitive disorders residing in different settings. Results obtained from the medical files of 134 older adults having benefitted from the mentoring programme demonstrate that this intervention significantly reduced BPSD. The effect on antipsychotics use was modest: a 10% reduction in the use of antipsychotics has been observed among patients for which the NPI were effective. However, the use of antipsychotics remained widespread despite the nursing recommendations of the mentoring team of the Center of Excellence on Aging in Quebec (CEVQ).

The PREvention Program for Alzheimer's RElated Delirium (PREPARED) cluster randomized trial: a study protocol.

BACKGROUND: Delirium is a significant cause of morbidity and mortality among older people admitted to both acute and long-term care facilities (LTCFs). Multicomponent interventions have been shown to reduce delirium incidence in the acute care setting (30-73%) by acting on modifiable risk factors. Little work, however, has focused on using this approach to reduce delirium incidence in LTCFs. METHODS: The objective is to assess the effectiveness of the multicomponent PREPARED Trial intervention in reducing the following primary outcomes: incidence, severity, duration, and frequency of delirium episodes in cognitively impaired residents. This 4-year, parallel-design, cluster randomized study will involve nursing staff and residents in 45-50 LTCFs in Montreal, Canada. Participating public and private LTCFs (clusters) that provide 24-h nursing care will be assigned to either the PREPARED Trial intervention or the control (usual care) arm of the study using a covariate constrained randomization procedure. Approximately 400-600 LTC residents aged 65 and older with dementia and/or cognitive impairment will be enrolled in the study and followed for 18 weeks. Residents must be at risk of delirium, delirium-free at baseline and have resided at the facility for at least 2 weeks. Residents who are unable to communicate verbally, have a history of specific psychiatric conditions, or are receiving end-of-life care will be excluded. The PREPARED Trial intervention consists of four main components: a decision tree, an instruction manual, a training package, and a toolkit. Primary study outcomes will be assessed weekly. Functional autonomy and cognitive levels will be assessed at the beginning and end of follow-up, while information pertaining to modifiable delirium risk factors, medical consultations, and facility transfers will be collected retrospectively for the duration of the follow-up period. Primary outcomes will be reported at the level of intervention assignment. All researchers analyzing the data will be blinded to group allocation. DISCUSSION: This large-scale intervention study will contribute significantly to the development of evidence-based clinical guidelines for delirium prevention in this frail elderly population, as it will be the first to evaluate the efficacy of a multicomponent delirium prevention program translated into LTC clinical practice on a large scale. TRIAL REGISTRATION: NCT03718156 , ClinicalTrials.gov .

A Delphi study to identify prehospital and emergency department trauma care modifiers for older adults.

Background: Older patients (age ≥ 65 yr) with trauma have increased morbidity and mortality compared to younger patients; this is partly explained by undertriage of older patients with trauma, resulting in lack of transfer to a trauma centre or failure to activate the trauma team. The objective of this study was to identify modifiers to the prehospital and emergency department phases of major trauma care for older adults based on expert consensus. Methods: We conducted a modified Delphi study between May and September 2019 to identify major trauma care modifiers for older adults based on national expert consensus. The panel consisted of 24 trauma care professionals from across Canada from the prehospital and emergency department phases of care. The survey consisted of 16 trauma care modifiers. Three online survey rounds were distributed. Consensus was defined a priori as a disagreement index score less than 1. Results: There was a 100% response rate for all survey rounds. Three new trauma care modifiers were suggested by panellists. The panel achieved consensus agreement for 17 of the 19 trauma care modifiers. The prehospital modifier with the strongest agreement to transfer to a trauma centre was a respiratory rate less than 10 or greater than 20 breaths/min or need for ventilatory support. The emergency department modifier with the strongest level of agreement was obtaining 12-lead electrocardiography following the primary and secondary survey. Conclusion: Using a modified Delphi process, an expert panel agreed on 17 trauma care modifiers for older adults in the prehospital and emergency department settings. These modifiers may improve the delivery of trauma care for older adults and should be considered when developing local and national trauma guidelines.

Contexte: Les polytraumatisés âgés (≥ 65 ans) sont exposés à un risque plus grand de morbidité et de mortalité comparativement aux jeunes polytraumatisés; cela s'explique en partie par un triage inadéquat des patients âgés victimes de traumatismes, qui fait en sorte qu'on ne les oriente pas vers un centre de traumatologie ou qu'on ne fait pas intervenir l'équipe de traumatologie. L'objectif de la présente étude était d'identifier les éléments de soins à modifier au stade préhospitalier et en médecine d'urgence lors de la prise en charge des cas de traumatismes graves chez les adultes âgés, sur la base d'un consensus d'experts. Méthodes: Nous avons procédé à une analyse Delphi modifiée entre mai et septembre 2019 pour recenser les éléments de soins à modifier chez les polytraumatisés âgés à partir d'un consensus national d'experts. Le panel d'experts se composait de 24 professionnels en traumatologie du Canada entier chargés des soins au stade préhospitalier et en médecine d'urgence. Le questionnaire portait sur 16 éléments à modifier en traumatologie. Trois questionnaires successifs ont été distribués en ligne. Le consensus était défini a priori par un indice de désaccord inférieur à 1. Résultats: Le taux de réponse a été de 100 % pour les 3 questionnaires. Les membres du comité ont suggéré 3 nouveaux éléments à modifier. Le comité est arrivé à un consensus pour 17 des éléments à modifier sur 19. L'élément préhospitalier ayant fait l'objet du plus solide consensus concernant le transfert vers un centre de traumatologie était une fréquence respiratoire inférieure à 10 ou supérieure à 20 respirations/minute ou la nécessité d'une assistance respiratoire. L'élément à modifier parmi les soins prodigués à l'urgence ayant fait l'objet du plus solide consensus après les 2 premiers questionnaires était l'obtention d'un électrocardiogramme à 12 dérivations. Conclusion: À l'aide d'une analyse Delphi modifiée, un comité d'expert s'est entendu sur 17 éléments de soins à modifier chez les polytraumatisés âgés au stade préhospitalier et en médecine d'urgence. Ces éléments pourraient améliorer les soins aux adultes âgés et méritent d'être pris en compte lors de la création de lignes directrices locales et nationales en traumatologie.

Predictors of delirium in older patients at the emergency department: a prospective multicentre derivation study.

OBJECTIVE: The objective of this study was to identify the predictors of incident delirium in this high-risk population. METHODS: This study was a planned sub-analysis of the INDEED multicentre cohort study. We recruited patients aged ≥ 65, independent/semi-independent, with an emergency department (ED) length of stay ≥ 8 h and admitted to any hospital ward. Patients were followed up during their ED stay up to 24 h after ward admission. Sociodemographic characteristics, comorbidities, functional status (OARS), illness severity, level of frailty, cognitive status (TICS-m) and ED/patient environment evaluation were collected during initial interview. Patients were screened for delirium twice a day using the Confusion Assessment Method. Multivariate logistic regression was performed to identify the predictors of delirium. RESULTS: Incident delirium was detected in 68 patients of the 612 patients included (11%). Initially, seven candidate predictors were included in a regression model, of which four were retained using a stepwise selection procedure. Presence of cognitive impairment at baseline (OR 3.6, p < 0.001), absence of mobilization during the whole ED length of stay (OR 3.3, p = 0.002), longer ED length of stay (OR 1.02, p = 0.006) were associated with a higher risk of incident delirium while higher functional status was associated with a lower risk (OR 0.8, p < 0.001). CONCLUSION: More work is needed to determine which tool(s) are most appropriate for the ED use to increase delirium screening compliance among health professionals working in this department. It is really the first step to be able to suggest interventions to decrease delirium incidence.

RéSUMé: OBJECTIF: L'objectif de cette étude était d'identifier les prédicteurs du délirium incident dans cette population à hautrisque. MéTHODES: Cette étude était une sous-analyse planifiée de l'étude de cohorte multicentrique INDEED. Nous avons recruté des patients âgés de ≥ 65 ans, indépendants/semi-indépendants, ayant une durée de séjour au département d'urgence (DU) ≥ 8 h et admis dans n'importe quel service. Les patients ont été suivis pendant leur séjour aux urgences jusqu'à 24 h après leur admission. Les caractéristiques sociodémographiques, les comorbidités, l'état fonctionnel (OARS), la gravité de la maladie, le niveau de fragilité, l'état cognitif (TICS-m) et l'évaluation de l'environnement des urgences/patients ont été recueillis lors de l'entretien initial. Les patients ont été soumis à un dépistage du délirium deux fois par jour à l'aide de la méthode d'évaluation de la confusion. Une régression logistique multivariée a été effectuée pour identifier les prédicteurs de délirium. RéSULTATS: Le délirium incident a été détecté chez 68 des 612 patients inclus (11%). Au départ, sept prédicteurs candidats ont été inclus dans un modèle de régression, dont quatre ont été retenus par une procédure de sélection par étapes. La présence d'un déficit cognitif initial (RC 3,6, p < 0,001), l'absence de mobilisation pendant toute la durée du séjour à l'urgence (RC 3,3, p = 0,002), une durée de séjour plus longue à l'urgence (RC 1,02, p = 0,006) étaient associées à un risque plus élevé de délirium incident, tandis qu'un état fonctionnel plus élevé était associé à un risque plus faible (RC 0,8, p < 0,001). CONCLUSIONS: Des travaux supplémentaires sont nécessaires pour déterminer quel(s) outil(s) sont les plus appropriés au DU afin d'accroître le dépistage du délirium par les professionnels de santé travaillant dans ce service. C'est vraiment la première étape pour pouvoir proposer des interventions visant à diminuer l'incidence du délirium.

User-centered and theory-based design of a professional training program on shared decision-making with older adults living with neurocognitive disorders: a mixed-methods study.

BACKGROUND: We know little about the best approaches to design training for healthcare professionals. We thus studied how user-centered and theory-based design contribute to the development of a distance learning program for professionals, to increase their shared decision-making (SDM) with older adults living with neurocognitive disorders and their caregivers. METHODS: In this mixed-methods study, healthcare professionals who worked in family medicine clinics and homecare services evaluated a training program in a user-centered approach with several iterative phases of quantitative and qualitative evaluation, each followed by modifications. The program comprised an e-learning activity and five evidence summaries. A subsample assessed the e-learning activity during semi-structured think-aloud sessions. A second subsample assessed the evidence summaries they received by email. All participants completed a theory-based questionnaire to assess their intention to adopt SDM. Descriptive statistical analyses and qualitative thematic analyses were integrated at each round to prioritize training improvements with regard to the determinants most likely to influence participants' intention. RESULTS: Of 106 participants, 98 completed their evaluations of either the e-learning activity or evidence summary (93%). The professions most represented were physicians (60%) and nurses (15%). Professionals valued the e-learning component to gain knowledge on the theory and practice of SDM, and the evidence summaries to apply the knowledge gained through the e-learning activity to diverse clinical contexts. The iterative design process allowed addressing most weaknesses reported. Participants' intentions to adopt SDM and to use the summaries were high at baseline and remained positive as the rounds progressed. Attitude and social influence significantly influenced participants' intention to use the evidence summaries (P < 0.0001). Despite strong intention and the tailoring of tools to users, certain factors external to the training program can still influence the effective use of these tools and the adoption of SDM in practice. CONCLUSIONS: A theory-based and user-centered design approach for continuing professional development interventions on SDM with older adults living with neurocognitive disorders and their caregivers appeared useful to identify the most important determinants of learners' intentions to use SDM in their practice, and validate our initial interpretations of learners' assessments during the subsequent evaluation round.

Functional and cognitive decline in older delirious adults after an emergency department visit.

BACKGROUND: the aim of this study was to evaluate the impact of emergency department (ED) stay-associated delirium on older patient's functional and cognitive status at 60 days post ED visit. METHODS: this study was part of the multi-centre prospective cohort INDEED study. This project took place between March 2015 and July 2016 in five participating EDs across the province of Quebec. Independent non-delirious patients aged ≥65, with an ED stay ≥8 hours, were monitored for delirium until 24 hours post ward admission. A 60-day follow-up phone assessment was conducted. Participants were screened for delirium using the Confusion Assessment Method. Functional and cognitive statuses were assessed at baseline and at the 60-day follow-up using OARS and TICS-m. RESULTS: a total of 608 patients were recruited, 393 of which completed the 60-day follow-up. The Confusion Assessment Method was positive in 69 patients (11.8%) during ED stay or within the first 24 hours following ward admission. At 60 days, delirium patients experienced an adjusted loss of -2.9/28 [95%CI: -3.9, -2.0] points on the OARS scale compared to non-delirious patients who lost -1.6 [95%CI: -1.9, -1.3] (P = 0.006). A significant adjusted difference in cognitive function was also noted at 60 days, as TICS-m scores in delirious patients decreased by -1.6 [95%CI: -3.5, 0.2] compared to non-delirious patients, who showed a minor improvement of 0.5 [95%CI: -0.1, 1.1] (P = 0.03). CONCLUSION: seniors who developed ED stay-associated delirium have lower baseline functional and cognitive status than non-delirious patients, and they will experience a more significant decline at 60 days post ED visit.

Fondamentaux des soins : un cadre et un processus pratique pour répondre aux besoins physiques, psychosociaux et relationnels des personnes soignées.

Since 2008, an international group has been helping to promote a better response to the fundamental needs of individuals receiving care. This group provides a framework on the fundamentals of care that focuses on the relationship between the nurse, the individual being cared for, and his or her relatives, as well as on the response to the patient’s physical, psychosocial, and relational needs. A practice process supports the concrete application of this framework. The purpose of this discursive article is to present the French translation of the Fundamentals of Care Framework and its Practice Process. To begin with, the translation process will be briefly explained. Next, the Fundamentals of Care Framework and the stages in its Practice Process will be presented. To help the reader better understand the proposal, a clinical illustration will be used to present the situation of Mr. Perron, who is living with Alzheimer’s disease, and his spouse, who is his family caregiver. Finally, the article discusses the usefulness of the Fundamentals of Care Framework and its Practice Process in terms of the four main areas of the discipline of nursing : practice, management, training, and research. This article paves the way for the development of knowledge on the fundamentals of care in the French-speaking world.

Professional training on shared decision making with older adults living with neurocognitive disorders: a mixed-methods implementation study.

BACKGROUND: Shared decision making with older adults living with neurocognitive disorders is challenging for primary healthcare professionals. We studied the implementation of a professional training program featuring an e-learning activity on shared decision making and five Decision Boxes on the care of people with neurocognitive disorders, and measured the program's effects. METHODS: In this mixed-methods study, we recruited healthcare professionals in family medicine clinics and homecare settings in the Quebec City area (Canada). The professionals signed up for training as a continuing professional development activity and answered an online survey before and after training to assess their knowledge, and intention to adopt shared decision making. We recorded healthcare professionals' access to each training component, and conducted telephone interviews with a purposeful sample of extreme cases: half had completed training and the other half had not. We performed bivariate analyses with the survey data and a thematic qualitative analysis of the interviews, as per the theory of planned behaviour. RESULTS: Of the 47 participating healthcare professionals, 31 (66%) completed at least one training component. Several factors restricted participation, including lack of time, training fragmentation into several components, poor adaptation of training to specific professions, and technical/logistical barriers. Ease of access, ease of use, the usefulness of training content and the availability of training credits fostered participation. Training allowed Healthcare professionals to improve their knowledge about risk communication (p = 0.02), and their awareness of the options (P = 0.011). Professionals' intention to adopt shared decision making was high before training (mean ± SD = 5.88 ± 0.99, scale from 1 to 7, with 7 high) and remained high thereafter (5.94 ± 0.9). CONCLUSIONS: The results of this study will allow modifying the training program to improve participation rates and, ultimately, uptake of meaningful shared decision making with patients living with neurocognitive disorders.

Finding the fundamental needs behind resistance to care: Using the Fundamentals of Care Practice Process.

A person living with Alzheimer's disease (PA) can experience difficulty during bodily care and therefore may show resistance to care behaviours (RTCBs). Nurses must take a clinical approach to planning care that meets the person's needs. Therefore, it is necessary to identify training strategies for bedside nurses and nursing students. AIMS AND OBJECTIVES: To describe and discuss how the FOC practice process (FOC-PP) can help nurses understand PAs who show RTCBs during bodily care. BACKGROUND: Resistance to care behaviour phenomenon and the importance of bodily care as fundamental care are described. The FOC-PP enables nurses to apply the FOC framework in their practice. DESIGN: This discursive paper is based on the literature of the FOC framework and PP. METHOD: A clinical scenario that develops through the five stages of the FOC-PP. RESULTS: The scenario centres on Mrs. Emily Morgan, 81, who lives in a nursing home and is not receiving the bodily care that she needs. Camille, a nursing student, and her supervisor Florence collaborate with Mrs. Morgan's family to improve the quality of her care. Three particular aspects of nursing practice based on the FOC-PP are described: the critical thinking process, relational process and pedagogical process. CONCLUSION: The FOC-PP promotes holistic care centred on the person and his or her needs and encourages the nurse to use his or her skills and knowledge. All these dimensions are fundamental for high-quality nursing care. RELEVANCE TO CLINICAL PRACTICE: Mrs. Morgan's scenario enables us to perceive that the FOC-PP is very useful for nursing students and bedside nurses. However, given the amount of specific and diverse knowledge required by the FOC-PP, it is necessary to identify avenues for teaching them. Using clinical scenarios could facilitate the integration of the FOC-PP, with taking into account the specific characteristics of individual clients.

Serial Ottawa 3DY assessments to detect delirium in older emergency department community dwellers.

BACKGROUND: delirium is associated with increased morbidity and mortality among older emergency department (ED) patients. When using physician gestalt, delirium is missed in the majority of patients. The Ottawa 3DY (O3DY) has been validated to detect cognitive dysfunction among older ED patients. OBJECTIVES: to determine the sensitivity and specificity of serial O3DY assessments to detect delirium in older ED patients. DESIGN: a prospective observational multicenter cohort study. SETTING: four Quebec EDs. PARTICIPANTS: independent or semi-independent older patients (age ≥ 65 years) with an ED stay of at least 8 hours that required hospitalisation. MEASUREMENTS: eligible patients were evaluated using serial O3DY assessments at least 6 hours apart. The primary outcome was delirium after at least 8 hours in the ED. The reference standard for delirium assessment was the confusion assessment method (CAM). The sensitivity and specificity of the serial O3DY to detect delirium were calculated. RESULTS: we enrolled 301 patients (mean age 77 years, 49.5% male, 3.0% with a history of mild dementia). Thirty patients (10.0%) were CAM positive for delirium. Patients had a median of three O3DY assessments. Serial O3DY evaluations to detect delirium among patients with at least one abnormal O3DY had a sensitivity of 86.7% (95% confidence interval-CI 69.3-96.2%) and a specificity of 44.3% (95%; CI 38.3-50.4%). CONCLUSION: serial O3DY testing demonstrates good sensitivity as a screening tool to detect delirium among older adult patients with prolonged ED lengths of stay. Emergency physicians should consider the use of the serial O3DY over clinician gestalt to improve delirium detection.

Unrecognized Incident Delirium in Older Emergency Department Patients.

BACKGROUND: It is documented that health professionals from various settings fail to detect > 50% of delirium cases. OBJECTIVE: This study aimed to describe the proportion of unrecognized incident delirium in five emergency departments (EDs). Secondary objectives were to compare the two groups (recognized/unrecognized) and assess the impact of unrecognized delirium at 60 days regarding 1) unplanned consultations and 2) functional and cognitive decline. METHOD: This is a sub-analysis of a multicenter prospective cohort study. Independent patients aged ≥ 65 years who tested negative for delirium on the initial interview with an ED stay ≥ 8 h were enrolled. Patients were assessed twice daily using the Confusion Assessment Method (CAM) and the Delirium Index up to 24 h into hospital admission. Medical records were reviewed to assess whether delirium was recognized or not. RESULTS: The main study reported a positive CAM in 68 patients. Three patients' medical files were incomplete, leaving a sample of 65 patients. Delirium was recognized in 15.4% of our participants. These patients were older (p = 0.03) and female (p = 0.01) but were otherwise similar to those with unrecognized delirium. Delirium Index scores were higher in patients with recognized delirium (p = 0.01) and they experienced a more important functional decline at 60 days (p = 0.02). No association was found between delirium recognition and health care services utilization or decline in cognitive function. CONCLUSIONS: This study confirms reports of high rates of missed or unrecognized delirium (84.6%) in ED patients compared to routine structured screening using the CAM performed by a research assistant. Patients with recognized delirium were older women with a greater severity of symptoms and experienced a more significant functional decline at 60 days.

Reducing complexity of patient decision aids for community-based older adults with dementia and their caregivers: multiple case study of Decision Boxes.

OBJECTIVES: To identify patient decision aids' features to limit their complexity for older adults with dementia and their family caregivers. DESIGN: Mixed method, multiple case study within a user-centred design (UCD) approach. SETTING: Community-based healthcare in the province of Quebec in Canada. PARTICIPANTS: 23 older persons (aged 65+ years) with dementia and their 27 family caregivers. RESULTS: During three UCD evaluation-modification rounds, participants identified strengths and weaknesses of the patient decision aids' content and visual design that influenced their complexity. Weaknesses of content included a lack of understanding of the decision aids' purpose and target audience, missing information, irrelevant content and issues with terminology and sentence structure. Weaknesses of visual design included critics about the decision aids' general layout (density, length, navigation) and their lack of pictures. In response, the design team implemented a series of practical features and design strategies, comprising: a clear expression of the patient decision aids' purpose through simple text, picture and personal stories; systematic and frequent use of pictograms illustrating key points and helping structure patient decision aids' general layout; a glossary; removal of scientific references from the main document; personal stories to clarify more difficult concepts; a contact section to facilitate implementation of the selected option; GRADE ratings to convey the quality of the evidence; a values clarification exercise formatted as a checklist and presented at the beginning of the document to streamline navigation; involvement of a panel of patient/caregiver partners to guide expression of patient priorities; editing of the text to a sixth grade reading level; UCD process to optimise comprehensiveness and relevance of content and training of patients/caregivers in shared decision-making. CONCLUSIONS: The revised template for patient decision aids is designed to meet the needs of adults living with dementia and their caregivers better, which may translate into fewer evaluation-modification rounds.

Validation of the O3DY French Version (O3DY-F) for the Screening of Cognitive Impairment in Community Seniors in the Emergency Department.

BACKGROUND: It is recommended that older patients undergo systematic mental status screening when presenting to the emergency department (ED). However, the tools available are not necessarily adapted to the ED environment, therefore, quicker and easier tools are needed. OBJECTIVES: The purpose of this study is to validate the Ottawa 3DY-French (O3DY-F) Scale as a screening tool for delirium and cognitive impairment in a French-speaking cohort. METHOD: This multicenter prospective study was conducted in four hospitals across the province of Quebec. Inclusion criteria were: age ≥ 65 years, ED stay ≥ 8 h, awaiting admission to a care unit, and independent or semi-independent in their daily living activities. Cognitive status was assessed during the initial interview using the Telephone Interview for Cognitive Screening-modified (TICS-m) and the O3DY-F scale. Comparisons were made between the O3DY-F and the TICS-m and Confusion Assessment Method (CAM) to assess the sensitivity and specificity of the O3DY-F for the detection of cognitive impairment and delirium. RESULTS: A total of 313 patients were included in this study, 139 of which had a positive O3DY-F. When compared with the CAM, the O3DY-F had a sensitivity of 84.2% (95% confidence interval [CI] 60.4-96.6) and a specificity of 58.2% (95% CI 52.3-63.9) for the detection of prevalent delirium. The O3DY-F had a sensitivity of 76.2% (95% CI 66.7-84.8) and a specificity of 67.6% (95% CI 61.0-73.6) for cognitive impairment (defined as a TICS-m < 27). CONCLUSION: The O3DY-F is a useful and effective tool to screen for delirium and undetected cognitive impairment among a French-speaking cohort in the ED.