A cluster-randomised trial of staff education to improve the quality of life of people with dementia living in residential care: the DIRECT study

Background

The Dementia In Residential care: EduCation intervention Trial (DIRECT) was conducted to determine if delivery of education designed to meet the perceived need of GPs and care staff improves the quality of life of participants with dementia living in residential care.

Methodology/Principal Findings

This cluster-randomised controlled trial was conducted in 39 residential aged care facilities in the metropolitan area of Perth, Western Australia. 351 care facility residents aged 65 years and older with Mini-Mental State Examination ≤24, their GPs and facility staff participated. Flexible education designed to meet the perceived needs of learners was delivered to GPs and care facility staff in intervention groups. The primary outcome of the study was self-rated quality of life of participants with dementia, measured using the QOL-Alzheimer''s Disease Scale (QOL-AD) at 4 weeks and 6 months after the conclusion of the intervention. Analysis accounted for the effect of clustering by using multi-level regression analysis. Education of GPs or care facility staff did not affect the primary outcome at either 4 weeks or 6 months. In a post hoc analysis excluding facilities in which fewer than 50% of staff attended an education session, self-rated QOL-AD scores were 6.14 points (adjusted 95%CI 1.14, 11.15) higher at four-week follow-up among residents in facilities randomly assigned to the education intervention.

Conclusion

The education intervention directed at care facilities or GPs did not improve the quality of life ratings of participants with dementia as a group. This may be explained by the poor adherence to the intervention programme, as participants with dementia living in facilities where staff participated at least minimally seemed to benefit.

Trial Registration

ANZCTR.org.au ACTRN12607000417482     

Estudio preliminar de la efectividad de la terapia asistida con perros en personas de la tercera edad

IntroductionAnimal-assisted therapy is increasingly present in several educational and health areas. The aim of this study is to assess the effectiveness of such interventions in the elderly population living in residential settings.Materials and methodsA 12-week dog-assisted intervention program was designed, with 16 participants from a nursing home divided into an experimental group and a control group.ResultsSeveral physical and psychological variables were assessed before and after the intervention. While there were no significant differences in the control group, the experimental group improved significantly after participating in the program.DiscussionThe results support the hypothesis that animal-assisted interventions may be beneficial for residents in elderly care homes.     

Oral hygiene care status of elderly with dementia and in residential aged care facilities

doi: 10.1111/j.1741‐2358.2011.00472.x
Oral hygiene care status of elderly with dementia and in residential aged care facilities Objective: To explore the effectiveness of oral hygiene care on plaque and gingival status of residents with dementia. Background: Oral hygiene and oral hygiene care has been reported to be poor among the institutionalised elderly with dementia. The severity of oral diseases has been shown to increase with the severity of physical and cognitive impairment related with dementia. Little research has been carried out on plaque and gingival status of elderly with dementia and the impact of disability related with dementia on oral health in residential aged care facilities (RACF). Materials and methods: A cross‐sectional study of 205 elderly residing in RACF in Perth. Results: Forty‐one percent of the residents in RACF had dementia. Sixty percent of the residents with dementia and 75% of the residents with an Activities of Daily Living Oral Health score of D were assisted with oral care. Mean plaques scores and extent of gingival inflammation were higher for residents in the DD and D subgroups and resident with dementia. Residents assisted with brushing had higher mean plaque score and more moderate gingival inflammation. Conclusion: Oral hygiene care status in residents with dementia was poor despite the fact that oral care assistance was being provided.     

Multifaceted shared care intervention for late life depression in residential care: randomised controlled trial

ObjectiveTo evaluate the effectiveness of a population based, multifaceted shared care intervention for late life depression in residential care.DesignRandomised controlled trial, with control and intervention groups studied one after the other and blind follow up after 9.5 months.SettingPopulation of residential facility in Sydney living in self care units and hostels.Participants220 depressed residents aged ⩾65 without severe cognitive impairment.InterventionThe shared care intervention included: (a) multidisciplinary consultation and collaboration, (b) training of general practitioners and carers in detection and management of depression, and (c) depression related health education and activity programmes for residents. The control group received routine care.ResultsIntention to treat analysis was used. There was significantly more movement to “less depressed” levels of depression at follow up in the intervention than control group (Mantel-Haenszel stratification test, P=0.0125). Multiple linear regression analysis found a significant intervention effect after controlling for possible confounders, with the intervention group showing an average improvement of 1.87 points on the geriatric depression scale compared with the control group (95% confidence interval 0.76 to 2.97, P=0.0011).ConclusionsThe outcome of depression among elderly people in residential care can be improved by multidisciplinary collaboration, by enhancing the clinical skills of general practitioners and care staff, and by providing depression related health education and activity programmes for residents.

Key messages

• Large numbers of depressed elderly people live in residential care but few receive appropriate management
• A population based, multifaceted shared care intervention for late life depression was more effective than routine care in improving depression outcome
• The outcome of late life depression can be improved by enhancing the clinical skills of general practitioners and care staff and by providing depression related health education and activity programmes for residents
• The intervention needs further refining and evaluation to improve its effectiveness and to determine how best to implement it in other residential care settings

     

Quality of care in unlicensed homes for the aged in the Eastern Townships of Quebec

BACKGROUND: The recent proliferation of unlicensed homes for the aged in Quebec, coupled with the increased needs of the population they serve, has raised concerns about the quality of case these homes provide. The authors compared the quality of care in unlicensed homes with that in licensed long-term care facilities in a region of Quebec. METHODS: The study involved 301 impaired people aged 65 and over in 88 residential care facilities (52 unlicensed, 36 licensed) in the Eastern Townships of Quebec. Study participants were chosen according to a 2-stage sampling scheme: stratified sampling of the primary units (facilities) and random sampling of the secondary units (residents). Quality of care was measured using the QUALCARE scale, a multidimensional instrument that uses a 5-point scale to assess 6 dimensions of care: environmental, physical, medical management, psychosocial, human rights and financial. A mean score of more than 2 was considered indicative of inadequate care. RESULTS: Overall, the quality of care was similar in the unlicensed and licensed facilities (mean global score 1.61 [standard error of the mean (SEM) 0.06] and 1.47 [SEM 0.09] respectively). Examination of dimension-specific quality-of-care scores revealed that the unlicensed homes performed worse than the licensed facilities in 2 areas of care: physical care (mean score 1.80 [SEM 0.08] v. 1.51 [SEM 0.09] respectively, p = 0.017) and medical management (1.37 [SEM 0.06] v. 1.14 [SEM 0.05], p = 0.004). The dimension-specific scores also revealed that both types of homes lacked appropriate attention to the psychosocial aspect of care. Overall, 25% of the facilities provided inadequate care to at least one resident. This situation was especially prevalent among homes with fewer than 40 residents, where up to 20% of the residents received inadequate care. INTERPRETATION: Most of the unlicensed homes for the aged that were studied delivered care of relatively good quality. However, some clearly provided inadequate care.     

Regulación de la expresión sexual de los mayores ingresados en residencias: la visión de los profesionales

Introduction

The purpose of this study is to determine the opinion of professionals working in residential aged care facilities on the regulation of sexuality in these settings.

Materials and methods

Fifty-three professionals from five residential aged care facilities located in the metropolitan area of Barcelona answered several questions regarding the advisability of establishing measures for the regulation of sexuality in RACFs, the elements that could contribute to this, and the aspects that such regulations should consider.

Results

Around 50% of the participants recognized the advisability of having some type of measures for sexuality regulation in residential aged care facilities. According to their responses this should be developed taking into account professional opinions, but also the points of view of the residents and their relatives. The most frequently mentioned regulations were those that ensured that any kind of sexually charged situation occurred in a private environment. The development of strategies are suggested to distinguish those people with dementia that are competent to consent to sexual acts from those who are not.

Conclusions

The opinion of professionals working in RACFs regarding the advisability of establishing measures for sexuality regulation seems to be considerably divided. Thus, whilst around 50% of them recognize their potential usefulness, the other half consider them unnecessary or even counterproductive for the sexual freedom of residents. Associating regulation with prohibition and sexuality with sexual activity was not uncommon among the responses of the participants.     

Oral health care issues in aged care facilities in Western Australia: resident and family caregiver views

Objective: To investigate resident and family perceptions and attitudes towards oral health care and access to dental services for aged care facility residents. Method: Focus groups and individual interviews with residents and family caregivers were conducted at aged care facilities in the Perth Metropolitan Area, Western Australia. Results: There were 30 participants from twelve aged care facilities (21 residents and nine family caregivers). Five focus groups comprising both residents and family caregivers were conducted in addition to three face‐to‐face interviews with residents. Both groups considered oral health very important to overall health and quality of life. Family caregivers noted a lack of dental check‐ups and specialised professional oral care, particularly in high‐care facilities. Low care residents were more likely to have regular dental check‐ups or dental treatment and off‐site dental visits were straightforward due to their mobility and family member assistance. Family caregivers noted time limitations and lack of expertise in oral health care amongst staff in high‐care facilities, and the challenges of maintaining oral care for residents with poor mobility or cognitive impairment. It was considered important that staff and management liaise with family caregivers and family members in provision of oral care. Conclusion: Regular oral care, assessment and treatment were considered limited, particularly for residents in high care. There is a need for comprehensive, ongoing oral health programmes involving appropriately trained and empathetic dental health professionals and staff to improve oral health care in Perth’s aged care facilities.     

Factors associated with self and informant ratings of the quality of life of people with dementia living in care facilities: a cross sectional study

Background

There is no consensus regarding the optimal approach to assessment of the quality of life of people with dementia. We undertook the present study to describe and determine the factors associated with ratings of the quality of life of a cohort of people with dementia living in a residential care facility.

Methodology/Principal Findings

351 people with dementia living in residential care facilities, and their staff and family informants participated in this cross sectional observational study. Quality of life was measured using self (Quality of Life in Alzheimer''s Disease [QoL-AD] scale), and informant (QoL-AD and Alzheimer''s Disease Related QoL Scale) reports. 226 people (64%) with dementia (median MMSE 17; 12–21) were able to self rate the QoL-AD scale and these subjects'' ratings were compared to ratings by staff and family. Both staff and family informant ratings of the QoL-AD underestimated self ratings (mean difference −7.8, 95% CI −8.8, −6.7 for staff rated QoL-AD; and mean difference −7.2, 95% CI −8.5, −6.0 for family rated QoL-AD). Self ratings of QoL were lower among people who were restrained, had fallen or had pain. Informant ratings of the QoL of the participants with dementia were consistently and significantly lower for people with severe cognitive impairment, who had fallen, had presence of neuropsychiatric symptoms, or where care giver distress was present. Documented restraint, reported pain and neuropsychiatric symptoms were independently associated with lower self rating of the QoL-AD in multivariate models. Cognitive impairment, case conferencing, hospitalizations and neuropsychiatric symptoms were found to be independently associated with staff rated ADRQL.

Conclusions

The majority of people with dementia living in residential care facilities can rate their own QoL. Informant ratings underestimate self ratings of QoL of people with dementia, and appear to be associated with factors which are not associated with self ratings.     

The Effects of Hand Massage on Stress and Agitation Among People with Dementia in a Hospital Setting: A Pilot Study

Agitation in people with dementia is a growing concern as it causes distress for both patients and their nurses and may contribute to relational disorders. Previous studies involving patients with dementia living in long-term care facilities have reported decreased agitation following massage. The objective of this pilot study was to investigate the effect of hand massage on agitation and biological markers of stress in patients with dementia hospitalized in an acute geriatric psychiatry service. In this randomized controlled trial we included 40 agitated patients with dementia with an intervention group and a control group. The study is designed to test the effect of seven hand massages over three continuous weeks on agitation and levels of salivary cortisol (sC) and alpha-amylase (sAA). Compared to the control group, the intervention group exhibited larger increases in sC and sAA at week 1 from before to after the massage, but larger decreases at week 2 and 3, with a significant group effect for sAA at week 2. Agitation scores were not significantly different between the groups but tended to decrease more in the intervention group than the control group. This study provides first encouraging results suggesting that hand massage might have beneficial effects on stress and agitation in hospitalized patients with dementia. It also highlights the challenges associated with conducting such studies with this complex patient population. Further studies are needed to confirm these findings and the benefits of hand massage as part of routine care for patients with dementia.     

Reducing inappropriate, anticholinergic and psychotropic drugs among older residents in assisted living facilities: study protocol for a randomized controlled trial

ABSTRACT: BACKGROUND: Use of inappropriate drugs is common among institutionalized older people. Rigorous trials investigating the effect of the education of staff in institutionalized settings on the harm related to older people's drug treatment are still scarce. The aim of this trial is to investigate whether training professionals in assisted living facilities reduces the use of inappropriate drugs among residents and has an effect on residents' quality of life and use of health services. Methods and design During years 2011 and 2012, a sample of residents in assisted living facilities in Helsinki (approximately 212) will be recruited, having offered to participate in a trial aiming to reduce their harmful drugs. Their wards will be randomized into two arms: one, those in which staff will be trained in two half-day sessions, including case studies to identify inappropriate, anticholinergic and psychotropic drugs among their residents, and two, a control group with usual care procedures and delayed training. The intervention wards will have an appointed nurse who will be responsible for taking care of the medication of the residents on her ward, and taking any problems to the consulting doctor, who will be responsible for the overall care of the patient. The trial will last for twelve months, the assessment time points will be zero, six and twelve months. The primary outcomes will be the proportion of persons using inappropriate, anticholinergic, or more than two psychotropic drugs, and the change in the mean number of inappropriate, anticholinergic and psychotropic drugs among residents. Secondary endpoints will be, for example, the change in the mean number of drugs, the proportion of residents having significant drug-drug interactions, residents' health-related quality of life (HRQOL) according to the 15D instrument, cognition according to verbal fluency and clock-drawing tests and the use and cost of health services, especially hospitalizations. DISCUSSION: To our knowledge, this is the first large-scale randomized trial exploring whether relatively light intervention, that is, staff training, will have an effect on reducing harmful drugs and improving QOL among institutionalized older people Trial registration ACTRN12611001078943.     

The effects of immersive garden experience on the health care to elderly residents with mild-to-moderate cognitive impairment living in nursing homes after the COVID-19 pandemic

Elderly patients living in long-term care facilities have been restricted from leaving to comply with social distancing guidelines during the COVID-19 pandemic. This has led to a worsening of disorders, such as anxiety and depression. This study aims to understand the health benefits of an immersive garden experience to elderly nursing home residents with mild-to-moderate cognitive impairments. Virtual reality devices were used to provide immersive garden experiences for the residents who were unable to go outside. The heart rate and heart rate variability (HRV) data of the participants of the participants were collected using biofeedback instruments, and changes in the low frequency/high frequency (LF/HF) and the standard deviation of the NN interval (SDNN) values caused by immersive garden experiences were discussed. The results show that the immersive garden experiences were beneficial to these elderly residents. Within 6 min of completing the experiment, we found that the heart rates of participants had dropped slightly, while SDNN and HF values continued to rise. SDNN values before and after the experiment demonstrated a statistically significant improvement. Furthermore, participants expressed their satisfaction with the video intervention program. The results indicated that nursing homes can provide immersive landscape experiences to help increase HRV and SDNN of their elderly residents. This will not only help these residents recall beautiful memories of their past, but will also improve their quality of life.

     

Organisational Culture in Residential Aged Care Facilities: A Cross-Sectional Observational Study

Background

Organisational culture is increasingly recognised as important for provision of high-quality long-term care. We undertook this study to measure organisational culture in residential aged care facilities in two Australian states.

Methodology/Principal Findings

Cross-sectional observational study in 21 residential aged care facilities in Western Australia (n = 14) and Queensland (n = 7), Australia. Staff and next-of-kin of residents participated. Measurement comprised surveys of facility staff and residents'' next-of-kin, and structured observation of indicators of care quality. Staff tended to rate organisational culture positively. Some qualitative feedback from staff emphasised negative perceptions of communication, leadership and teamwork. Staffing levels were perceived as a dominant challenge, threatening care quality. Direct observation revealed variability within and between facilities but suggested that most facilities (n = 12) were in the typical range, or were quality facilities (n = 8).

Conclusion

There was scope to strengthen organisational culture in participating aged care facilities.     

Aged care staff perspectives on oral care for residents: Western Australia

Objective: To determine manager and staff perceptions of oral health and dental service issues for residents in aged care facilities in the Perth Metropolitan Area, Western Australia. Design: Focus groups and face‐to‐face semi‐structured interviews with aged care facility managers and staff. Setting and subjects: Personnel at 12 facilities (high‐level and low‐level care) located in the Perth Metropolitan Area participated in the study. Interviews were conducted with 14 facility managers. Focus groups and face‐to‐face interviews were conducted with 40 facility staff. Results: Managers and staff had similar views regarding most issues. While resident oral health was considered important, regular oral care programmes were limited or lacking. In general, high care facility residents did not have regular dental checkups, while those in low‐level care facilities usually visited their own dentist for checkups or treatment. Barriers to maintaining regular oral care included: resident non‐compliance; financial concerns; lack of co‐operation from family; mobility issues; and lack of interest from dental professionals. Suggested improvements to current services included regular on‐site visits, staff education and specialised dental professionals. Conclusion: Residents face many barriers to maintenance of adequate oral health care, particularly those who are functionally dependent and cognitively impaired. There is an urgent need for appropriate oral care programmes for aged care residents, which include dentists with aged care experience and continuing education for facility staff. Any major programmes should be evaluated carefully.     

Effects of multidisciplinary integrated care on quality of care in residential care facilities for elderly people: a cluster randomized trial

Background:

Sophisticated approaches are needed to improve the quality of care for elderly people living in residential care facilities. We determined the effects of multidisciplinary integrated care on the quality of care and quality of life for elderly people in residential care facilities.

Methods:

We performed a cluster randomized controlled trial involving 10 residential care facilities in the Netherlands that included 340 participating residents with physical or cognitive disabilities. Five of the facilities applied multidisciplinary integrated care, and five provided usual care. The intervention, inspired by the disease management model, consisted of a geriatric assessment of functional health every three months. The assessment included use of the Long-term Care Facility version of the Resident Assessment Instrument by trained nurse-assistants to guide the design of an individualized care plan; discussion of outcomes and care priorities with the family physician, the resident and his or her family; and monthly multidisciplinary meetings with the nurse-assistant, family physician, psychologist and geriatrician to discuss residents with complex needs. The primary outcome was the sum score of 32 risk-adjusted quality-of-care indicators.

Results:

Compared with the facilities that provided usual care, the intervention facilities had a significantly higher sum score of the 32 quality-of-care indicators (mean difference − 6.7, p = 0.009; a medium effect size of 0.72). They also had significantly higher scores for 11 of the 32 indicators of good care in the areas of communication, delirium, behaviour, continence, pain and use of antipsychotic agents.

Interpretation:

Multidisciplinary integrated care resulted in improved quality of care for elderly people in residential care facilities compared with usual care.

Trial registration:

www.controlled-trials.com trial register no. ISRCTN11076857.The quality of care provided in residential care facilities is under pressure worldwide.¹ Facilities are frequently understaffed, and the complexity of care needed by residents increases while expertise of staff does not necessarily keep pace.^2,3 Although most care organizations want to innovate and improve quality of care, many lack expertise or financial resources needed to do so.^4,5 Family physicians are responsible for medical care in residential care facilities in the Netherlands. However, they do not regard themselves as suited for systematic management of chronic diseases and disabilities associated with frail health.⁶About 10% of elderly people aged 75 or older in the Netherlands live in residential care facilities.^7,8 These facilities were established to offer sheltered living for elderly people who are disabled but still relatively healthy. Because of the growing elderly population, the characteristics of elderly people living in residential care facilities have become more comparable to those of people in nursing homes, who need complex care. Residential care facilities in the Netherlands are comparable to residential care facilities in Canada, are publicly funded and are subject to government inspection and approval. Over 70% of the residents need professional care, such as assistance with activities of daily living, nursing care (e.g., medication, wound care) and housekeeping. They have multiple chronic diseases and associated disabilities.^9–12Effective interventions for chronic illnesses generally rely on a multidisciplinary team approach. The elements of this approach include structured geriatric assessment, protocol-based regulation of medications, support for self-reliance and intensive follow-up. The closely related disease management model comprises coordination of care, steering of the care process and patient empowerment.¹³ This model is strongly recommended by Bodenheimer and colleagues to improve the health and quality of life of chronically ill patients.¹⁴ However, no studies have as yet been undertaken to evaluate the effects of disease management on functional health and quality of care for elderly people in residential care facilities who have physical or cognitive disabilities.We developed an approach to multidisciplinary integrated care inspired by the disease management model. The objective of our study was to determine the effects of multidisciplinary integrated care on quality of care and quality of life for elderly people in residential care facilities.     

La participación de personas con demencia en las reuniones del plan de atención individualizada: impacto en el bienestar y la calidad del cuidado

Introduction

An individualised intervention plan (IIP) offers a new paradigm in the care of the elderly with dementia, with the aim of increasing their quality of life through personalisation, respect for their freedom, and their participation in the decisions that affect their lives.

Objective

To evaluate the impact of the residential home patient with dementia and their quality of care when they take part in the interdisciplinary meeting in which their care plan is decided.

Material and methods

A total of 52 elderly patients with dementia took part in the study. They were distributed into two groups, one experimental (37 residents) and another control (15 residents). The Dementia Care Mapping (DCM) tool was used to assess the well-being and quality of care of the residents. This tool was used twice, before and after the intervention.

Results

The well-being of the resident, evaluated using the DCM, was similar before and after the intervention in the experimental group. No differences were observed either on comparing the control and experimental groups. However, some indicators of carer behaviour were different before and after the intervention, and when the control and experimental group were compared.

Conclusion

The inclusion of elderly persons with dementia in their IIP meeting had a positive effect in the interaction of the staff with the residents, but not on the well-being of the resident.     

Expresión sexual y regulación de la sexualidad en residencias de personas mayores

Objectives

The study had three objectives: (a) To determine how staff perceives the frequency of different sexual expressions in long-term care facilities for older people; (2) to quantify policies aimed at guaranteeing residents’ sexual rights in such institutions, and (3) to determine factors influencing the presence of these kind of policies.

A cluster randomised controlled trial of an occupational therapy intervention for residents with stroke living in UK care homes (OTCH): study protocol

ABSTRACT: BACKGROUND: The occupational therapy (OT) in care homes study (OTCH) aims to investigate the effect of a targeted course of individual OT (with task training, provision of adaptive equipment, minor environmental adaptations and staff education) for stroke survivors living in care homes, compared to usual care. METHODS/DESIGN: A cluster randomised controlled trial of United Kingdom (UK) care homes (n?=?90) with residents (n?=?900) who have suffered a stroke or transient ischaemic attack (TIA), and who are not receiving end-of-life care. Homes will be stratified by centre and by type of care provided and randomised (50:50) using computer generated blocked randomisation within strata to receive either the OT intervention (3 months intervention from an occupational therapist) or control (usual care). Staff training on facilitating independence and mobility and the use of adaptive equipment, will be delivered to every home, with control homes receiving this after the 12 month follow-up.Allocation will be concealed from the independent assessors, but the treating therapists, and residents will not be masked to the intervention. Measurements are taken at baseline prior to randomisation and at 3, 6 and 12 months post randomisation. The primary outcome measure is independence in self-care activities of daily living (Barthel Activities of Daily Living Index). Secondary outcome measures are mobility (Rivermead Mobility Index), mood (Geriatric Depression Scale), preference based quality of life measured from EQ-5D and costs associated with each intervention group. Quality adjusted life years (QALYs) will be derived based on the EQ-5D scores. Cost effectiveness analysis will be estimated and measured by incremental cost effectiveness ratio. Adverse events will be recorded. DISCUSSION: This study will be the largest cluster randomised controlled trial of OT in care homes to date and will clarify the currently inconclusive literature on the efficacy of OT for stroke and TIA survivors residing in care homes. TRIAL REGISTRATION: ISRCTN00757750.     

Community occupational therapy for older patients with dementia and their care givers: cost effectiveness study

Objective To assess the cost effectiveness of community based occupational therapy compared with usual care in older patients with dementia and their care givers from a societal viewpoint.Design Cost effectiveness study alongside a single blind randomised controlled trial.Setting Memory clinic, day clinic of a geriatrics department, and participants’ homes.Patients 135 patients aged ≥65 with mild to moderate dementia living in the community and their primary care givers.Intervention 10 sessions of occupational therapy over five weeks, including cognitive and behavioural interventions, to train patients in the use of aids to compensate for cognitive decline and care givers in coping behaviours and supervision.Main outcome measures Incremental cost effectiveness ratio expressed as the difference in mean total care costs per successful treatment (that is, a combined patient and care giver outcome measure of clinically relevant improvement on process, performance, and competence scales) at three months after randomisation. Bootstrap methods used to determine confidence intervals for these measures.Results The intervention cost €1183 (£848, $1738) (95% confidence interval €1128 (£808, $1657) to €1239 (£888, $1820)) per patient and primary care giver unit at three months. Visits to general practitioners and hospital doctors cost the same in both groups but total mean costs were €1748 (£1279, $2621) lower in the intervention group, with the main cost savings in informal care. There was a significant difference in proportions of successful treatments of 36% at three months. The number needed to treat for successful treatment at three months was 2.8 (2.7 to 2.9).Conclusions Community occupational therapy intervention for patients with dementia and their care givers is successful and cost effective, especially in terms of informal care giving.     

Life- and person-centred help in Mecklenburg-Western Pomerania, Germany (DelpHi): study protocol for a randomised controlled trial

ABSTRACT: BACKGROUND: The provision of appropriate medical and nursing care for people with dementia is a major challenge for the healthcare system in Germany. New models of healthcare provision need to be developed, tested and implemented on the population level. Trials in which collaborative care for dementia in the primary care setting were studied have demonstrated its effectiveness. These studies have been conducted in different healthcare systems, however, so it is unclear whether these results extend to the specific context of the German healthcare system. The objective of this population-based intervention trial in the primary care setting is to test the efficacy and efficiency of implementing a subsidiary support system on a population level for persons with dementia who live at home. Methods and study design The study was designed to assemble a general physician-based epidemiological cohort of people above the age of 70 who live at home (DelpHi cohort). These people are screened for eligibility to participate in a trial of dementia care management (DelpHi trial). The trial is a cluster-randomised, controlled intervention trial with two arms (intervention and control) designed to test the efficacy and efficiency of implementing a subsidiary support system for persons with dementia who live at home. This subsidiary support system is initiated and coordinated by a dementia care manager: a nurse with dementia-specific qualifications who delivers the intervention according to a systematic, detailed protocol. The primary outcome is quality of life and healthcare for patients with dementia and their caregivers. This is a multidimensional outcome with a focus on four dimensions: (1) quality of life, (2) caregiver burden, (3) behavioural and psychological symptoms of dementia and (4) pharmacotherapy with an antidementia drug and prevention or suspension of potentially inappropriate medication. Secondary outcomes include the assessment of dementia syndromes, activities of daily living, social support health status, utilisation of health care resources and medication. DISCUSSION: The results will provide evidence for specific needs in ambulatory care for persons with dementia and will show effective ways to meet those needs. Qualification requirements will be evaluated, and the results will help to modify existing guidelines and treatment paths. Trial registration NCT01401582.     

Equine-Assisted Intervention for People with Dementia

The purpose of this exploratory study was to determine the feasibility and effectiveness of using guided interactions with horses as a nonpharmaceutical intervention to improve the physiological and behavioral states of persons with dementia. A convenience sample of persons with dementia was recruited from an adult day health center (n = 16). A multi-component intervention was implemented comprised of opportunities for grooming, painting, and leading horses. Using a randomized pretest-posttest crossover design, researchers compared participants receiving the equine-assisted intervention with participants receiving treatment as usual. Older persons with Alzheimer's disease and related dementias engaged positively in animal-assisted therapy with horses. A reduction in behavioral problems was found post intervention in contrast to the comparison group. Pre-intervention measures showed that participants exhibited lower levels of disruptive behaviors compared with the control group on the days they were scheduled to work with the horses. Interestingly, cortisol levels, used as a physiological measure of coping with stress, were elevated after the intervention in participants with higher Mini Mental State Examination scores. Equine-assisted interventions are feasible and possibly beneficial for adults with Alzheimer's disease or a related dementia disorder, such as those enrolled in adult day health programs. Future studies should utilize multiple methods of assessing impact and include process measures to delineate which specific activities seem to provide the most benefit.