Health Care Personnel’s Perspective on Potential Electronic Health Interventions to Prevent Hospitalizations for Older Persons Receiving Community Care: Qualitative Study

Background: The use of electronic health (eHealth) interventions is suggested to help monitor and treat degenerative and chronic diseases through the use of sensors, alarms, and reminders and can potentially prevent hospitalizations for home-dwelling older persons receiving community care. It is increasingly recognized that the health care personnel’s acceptance of a technological application remains a key challenge in adopting an intervention, thus interventions must be perceived to be useful and fit for purpose by the actual users. Objective: The aim of this study was to identify and explore the perspectives of managers and health care personnel in community care regarding the use of eHealth interventions in terms of prevention of hospitalizations for home-dwelling older persons receiving community care. Methods: A case study with a qualitative approach was carried out in community care in a Norwegian municipality, comprising individual interviews and focus group interviews. A total of 5 individual interviews and 2 focus group interviews (n=12) were undertaken to provide the health care personnel’s and managers’ perspective regarding the use of eHealth interventions, which could potentially prevent hospitalizations for home-dwelling older persons receiving community care. Data were analyzed by way of systematic text condensation, as described by Malterud. Results: The data analysis of focus group interviews and individual interviews resulted in 2 categories: potential technological applications and potential patient groups. Discussions in the focus groups generated several suggestions and wishes related to technical applications that they could make use of in their day-to-day practice. The health care personnel warranted tools and measures to enhance and document their clinical observations in contact with patients. They also identified patient groups, such as patients with chronic obstructive pulmonary disease or dehydration or urinary tract infections, for whom hospitalizations could potentially have been prevented. Conclusions: We have shown that the health care personnel in community care warrant various technological applications that have the potential to improve quality of care and resource utilization in the studied municipality. We have identified needs and important matters in practice, which are paramount for acceptance and adoption of an intervention in community care.publishedVersio

Sosial kapital og stressrelaterte lidelser for ansatte i sykehjemssektoren i Norge

Bakgrunn: Den demografiske endringen i befolkningen vil medføre en utfordring for helsetjenestetilbudet generelt og innen innenfor sykehjemssektoren spesielt i tiden som kommer. I denne studien vil sammenhenger mellom sosial kapital og stressrelaterte helseplager blant ansatte innenfor sykehjemssektoren bli undersøkt. Metode: 197 helsepersonell fra fire ulike sykehjem inngikk i studien hvor stressrelaterte helseplager ble målt ved å anvende Hopkins Symtoms Check List (HSCL-10) og sosial kapital ved QPS-Nordic for psykososiale faktorer i arbeidslivet. Data ble analysert ved faktoranalyser(konstruksjon av sosial kapital), samt via korrelasjonsanalyse og multiple regresjonsanalyser.Resultat: Det foreligger en signifikant sammenheng mellom sosial kapital og stressrelaterte lidelser blant ansatte i sykehjemssektoren.  Den vertikale relasjonen (leder-ansatt) er nært knyttet til forekomsten av stressrelaterte lidelser blant sykehjemsansatte, og da slik at vertikal rettferdighet framstår som den sterkeste prediktoren.Konklusjon: Resultatene støtter ideen om i sterkere grad å vektlegge relasjonelle forhold generelt, og utvikling av gode vertikale relasjoner i organisasjonen spesielt, i organisasjonsutviklingen innenfor helsevesenet Norge

What are the key contextual factors when preparing for successful implementation of assistive living technology in primary elderly care? A case study from Norway

Objective To identify contextual factors at different organisational levels to guide the implementation of an assistive living technology intervention in Norwegian primary home care. Design A single embedded case study design was carried out in an urban municipality in Western Norway to get an overview of key contextual factors from the municipality’s perspective. Data collection and analysis The data collection was based on a triangulation of methods involving document analysis, semi-structured individual interviews and focus group interviews to get a broad insight when preparing for an intervention. Data were collected on three levels of the healthcare system: (1) national policy documents and regulations (macro), (2) five individual interviews with senior managers and municipal strategy documents (meso) and (3) two focus group interviews with nurses and nurse managers in direct patient care (micro). The Model for Understanding Success in Quality framework was used as a guide in the data analysis. Results The main contextual factors identified were external motivators and project sponsorship (macro level); leadership, workforce focus and maturity (meso level);and motivation to change and maturity (micro level). Strategies developed in policy documents affected upper management in the municipality, but healthcare personnel at the micro level were not so familiar with strategies and emphasis on assistive living technologies. Healthcare personnel in our study were motivated to use technological solutions, but lack of data infrastructure and resource availability hindered this. Conclusions Aligning interests across multiple stakeholders remain a challenge when planning for an assistive living technology intervention in primary care. In the studied municipality, integration of technological solutions into healthcare services was more a vision than a reality because of a low level of organisational readiness.publishedVersio

Apathy and its response to antipsychotic review and non-pharmacological interventions in people with dementia living in nursing homes : WHELD, A factorial cluster randomised controlled trial

Objectives: Apathy is common, impactful, and difficult to manage in people with dementia. We evaluated the efficacy of non-pharmacological interventions, exercise and social interaction, in combination with antipsychotic review, to reduce apathy in people with dementia living in nursing homes in a cluster randomised controlled trial (RCT). Methods: Well-being and health for people with dementia (WHELD) programme included a 2X2X2 factorial cluster RCT involving people with dementia living in 16 nursing homes in UK. All homes received training in person-centred care, and were randomised to receive antipsychotic review, social interaction, and exercise, either alone or in combinations. Apathy was one of the secondary outcomes of the WHELD trial, and it was measured by the Neuropsychiatric Inventory-nursing home version at baseline and nine months (N=273). We employed multilevel mixed effects linear regression models to assess the impact of the interventions on apathy. Results: Prevalence of apathy was 44.0% (n=120; 95% CI 38.1-49.9%) at baseline. Severity of apathy had significant positive correlations with dementia severity, neuropsychiatric symptoms, depressive symptoms, agitation, and the needs of the people with dementia (p<0.001). Antipsychotic review reduced antipsychotic use, but it significantly increased apathy (β=5.37; SE=0.91; p<0.001). However, antipsychotic review in combination with either social interaction (β=-5.84; SE=1.15; p<0.001) or exercise (β=-7.54; SE=0.93; p<0.001) significantly reduced apathy. Conclusions: Antipsychotic review can play a significant role in improving apathy in people with dementia living in nursing homes, when combined with psychosocial interventions such as social interaction and exercise. Guidance must be adapted to reflect this subtlety in care

Quality and safety in the transitional care of the elderly (phase 2): the study protocol of a quasi-experimental intervention study for a cross-level educational programme

Introduction: Transitional care and patient handover are important areas to ensure quality and safety in elderly healthcare services. Previous studies showed that healthcare professionals have little knowledge of the setting they are transferring patients to and a limited understanding of roles and functions; these constitute barriers to effective communication and shared care responsibilities across levels of care. Aim: The main objective is to implement a cross-level education-based intervention programme with healthcare professionals aimed at (1) increasing professionals’ awareness and competencies about quality and safety in the transitional care of the elderly; (2) creating a discussion platform for knowledge exchange and learning across levels and units of care and (3) improving patient safety culture, in particular, in transitional care. Methods and analysis: A quasi-experimental control group study design with an intervention group and a control group; this includes a pretest, post-test and 1-year follow-up test assessment of patient safety culture. Qualitative data will be collected during the intervention programme and between the measurements. The study design will be beneficial for addressing the effects of the cross-level educational intervention programme on reports of patient safety culture and for addressing the feasibility of the intervention measures. Ethics and dissemination: The study has been approved by the Regional Committees for Medical and Health Research Ethics in Norway, Ref. No. 2011/1978. The study is based on informed written consent; informants can withdraw from the study at any point in time. The results will be disseminated at research conferences, in peer review journals and through public presentations outside the scientific community.Norges Forskningsråd: 204637.publishedVersio

Health promotion in early-stage dementia – user experiences from an educative intervention

Educating and supporting people with early-stage dementia has gained increased focus worldwide as a response to an aging population and limited advancements in the medical treatment of the condition. The aim of this study was to explore the experiences of people with early-stage dementia who were provided with support and information through a 12-week health promotion course and identify elements of the intervention potentially contributing to coping and adjustment to the condition. Data was collected through individual semi-structured interviews with 32 people with dementia after they had attended the course. For each participant, a care partner was also interviewed. The data were analyzed using systematic text condensation. Three main categories emerged from the analysis. These were: (I) bridging the post-diagnostic information gap, (II) facilitating health behavior changes, and (III) new perspectives on living with the condition. The results demonstrated that the intervention was well-received by the participants. Learning about dementia, meeting others in the same situation, and focusing on maintaining a healthy lifestyle was particularly highlighted, as was promoting family communication.publishedVersio

The association between aspects of carer distress and time until nursing home admission in persons with Alzheimer’s disease and dementia with Lewy bodies

Objective: The aim of this study was to explore the association between specific aspects of carer distress and time until nursing home admission (NHA) in people with mild dementia. Design: Prospective cohort study. Setting: Participants were recruited from the Dementia Study of Western Norway (DemVest). Participants: This study included 107 participants admitted to a nursing home who were diagnosed with Alzheimer’s disease (AD, n = 64) and dementia with Lewy bodies (DLB, n = 43) and their primary carers. Measurements: The Relative Stress Scale (RSS) was used to assess the level of reported distress in carers. Adjusted partial least square (PLS) prediction analysis of baseline items of the RSS was used to study the associations between individual items of the RSS and time until NHA. Results: Carer distress is an important contributor to early NHA, explaining 19.3% of the total variance of time until NHA in the model without covariates. In the adjusted PLS model, the most important RSS predictors of time until NHA were feeling frustrated (estimate = −137; CI, −209, −64.5), having limitations on social life (estimate = −118; CI, −172, −64), not being able to get away on vacation (estimate −116; CI, −158.3, −73.7), and feeling unable to cope with the situation (estimate = −63; CI, −122.6, −3.4). Conclusions: Preservation of the informal care capacity represents important steps for improving the management of resources in dementia care. This study identifies aspects of carer distress associated with a shorter time until NHA. Looking beyond the sum score of the RSS helps promote the development of flexible and tailored interventions and perhaps delay NHA.publishedVersio

Exploring the trajectories of quality of life and its covariates in nursing home residents: A longitudinal study

Background: There is no cure for dementia and appropriate care should be offered to improve or maintain quality of life for those living with dementia. Objectives: To identify groups of residents following similar trajectories of quality of life after nursing home admission, to examine which resident, staff, and organizational characteristics at baseline differ between the identified groups, and to assess the associations between the trend in quality of life and the same characteristics measured at baseline and over the study period. Design: A prospective, observational, longitudinal cohort design over 30 months. Setting: Nursing homes in Norway. Participants: Residents admitted to nursing homes. Measurements: Resident data on quality of life, dementia, pain, activities of daily living, physical health, neuropsychiatric symptoms, medication, and demographic characteristics were obtained by interviews. Unit characteristics and the staff data on person-centered care, psychosocial factors, and job satisfaction were obtained by questionnaires and interviews. The physical environment of the unit was assessed by structured observation. Results: 694 residents admitted to a nursing home and 1161 staff from 175 nursing home units participated. Three resident groups following similar trajectories in quality of life were identified by growth mixture model; good quality of life (53.6%), moderate quality of life (32.9%), and poor quality of life (13.4%). All groups’ quality of life decreased over time. More pain, more severe dementia, and more affective symptoms at baseline were associated with belonging to the poor quality of life group. Overall decline in quality of life was associated with more severe dementia, more pain, poorer function in activities of daily living, more severe neuropsychiatric symptoms among residents, and poorer job satisfaction among staff. Conclusion: Reducing pain, reducing NPS, improving activities of daily living for the residents, and improving the staff’s job satisfaction may be factors of importance to improve the residents’ quality of life.The REDIC-NH study was administrated by the Centre for Old Age Psychiatric Research, Innlandet Hospital Trust, and was initiated by the Norwegian Health Directorate, which also provided funding for the data collection. The first author’s Ph. D. study was funded by the Research Council of Norway.publishedVersio

Impact of person-centred care training and person-centred activities on quality of life, agitation, and antipsychotic use in people with dementia living in nursing homes: a cluster-randomised controlled trial

Background Agitation is a common, challenging symptom affecting large numbers of people with dementia and impacting on quality of life (QoL). There is an urgent need for evidence-based, cost-effective psychosocial interventions to improve these outcomes, particularly in the absence of safe, effective pharmacological therapies. This study aimed to evaluate the efficacy of a person-centred care and psychosocial intervention incorporating an antipsychotic review, WHELD, on QoL, agitation, and antipsychotic use in people with dementia living in nursing homes, and to determine its cost. Methods and findings This was a randomised controlled cluster trial conducted between 1 January 2013 and 30 September 2015 that compared the WHELD intervention with treatment as usual (TAU) in people with dementia living in 69 UK nursing homes, using an intention to treat analysis. All nursing homes allocated to the intervention received staff training in person-centred care and social interaction and education regarding antipsychotic medications (antipsychotic review), followed by ongoing delivery through a care staff champion model. The primary outcome measure was QoL (DEMQOL-Proxy). Secondary outcomes were agitation (Cohen-Mansfield Agitation Inventory [CMAI]), neuropsychiatric symptoms (Neuropsychiatric Inventory–Nursing Home Version [NPI-NH]), antipsychotic use, global deterioration (Clinical Dementia Rating), mood (Cornell Scale for Depression in Dementia), unmet needs (Camberwell Assessment of Need for the Elderly), mortality, quality of interactions (Quality of Interactions Scale [QUIS]), pain (Abbey Pain Scale), and cost. Costs were calculated using cost function figures compared with usual costs. In all, 847 people were randomised to WHELD or TAU, of whom 553 completed the 9-month randomised controlled trial. The intervention conferred a statistically significant improvement in QoL (DEMQOL-Proxy Z score 2.82, p = 0.0042; mean difference 2.54, SEM 0.88; 95% CI 0.81, 4.28; Cohen’s D effect size 0.24). There were also statistically significant benefits in agitation (CMAI Z score 2.68, p = 0.0076; mean difference 4.27, SEM 1.59; 95% CI −7.39, −1.15; Cohen’s D 0.23) and overall neuropsychiatric symptoms (NPI-NH Z score 3.52, p < 0.001; mean difference 4.55, SEM 1.28; 95% CI −7.07,−2.02; Cohen’s D 0.30). Benefits were greatest in people with moderately severe dementia. There was a statistically significant benefit in positive care interactions as measured by QUIS (19.7% increase, SEM 8.94; 95% CI 2.12, 37.16, p = 0.03; Cohen’s D 0.55). There were no statistically significant differences between WHELD and TAU for the other outcomes. A sensitivity analysis using a pre-specified imputation model confirmed statistically significant benefits in DEMQOL-Proxy, CMAI, and NPI-NH outcomes with the WHELD intervention. Antipsychotic drug use was at a low stable level in both treatment groups, and the intervention did not reduce use. The WHELD intervention reduced cost compared to TAU, and the benefits achieved were therefore associated with a cost saving. The main limitation was that antipsychotic review was based on augmenting processes within care homes to trigger medical review and did not in this study involve proactive primary care education. An additional limitation was the inherent challenge of assessing QoL in this patient group. Conclusions These findings suggest that the WHELD intervention confers benefits in terms of QoL, agitation, and neuropsychiatric symptoms, albeit with relatively small effect sizes, as well as cost saving in a model that can readily be implemented in nursing homes. Future work should consider how to facilitate sustainability of the intervention in this setting

Self-management and HeAlth Promotion in Early-stage dementia with e-learning for carers (SHAPE): Study protocol for a multi-centre randomised controlled trial

Background: With an increasing number of people with dementia worldwide and limited advancement in medical treatments, the call for new and cost-effective approaches is crucial. The utility of self-management has been proven in certain chronic conditions. However, very little work has been undertaken regarding self-management in people with dementia. Methods: The SHAPE trial will include 372 people with mild to moderate dementia to evaluate the effectiveness and cost-effectiveness of an educational programme combining approaches of self-management, health promotion, and e-learning for care partners. The study is a multi-site, single-randomised, controlled, single-blinded trial with parallel arms. The intervention arm is compared with treatment as usual. The intervention comprises a 10-week course delivered as group sessions for the participants with dementia. The sessions are designed to develop self-management skills and to provide information on the nature of the condition and the development of healthy behaviours in a supportive learning environment. An e-learning course will be provided for care partners which covers similar and complementary material to that discussed in the group sessions for the participant with dementia. Discussion: This trial will explore the effect of the SHAPE group intervention on people with mild to moderate dementia in terms of self-efficacy and improvement in key health and mental health outcomes and cost-effectiveness, along with carer stress and knowledge of dementia. Trial registration: ClinicalTrials.gov Identifier: NCT04286139, registered prospectively February 26, 2020, https://clinicaltrials.gov/ct2/show/NCT0428613