Belinda Parke

Facilitators and barriers to safe emergency department transitions for community dwelling older people with dementia and their caregivers: a social ecological study.

BACKGROUND Internationally, older adults visit the ED at a rate higher than other age groups. Little attention has been given to ED care for older people with dementia, although concern for such care is growing with the increasing number of individuals worldwide affected by this significant disabling problem. It is critical to understand ED transitional processes and consequences because the complexity of dementia care poses multiple challenges to optimizing safety, effectiveness and quality of care during admission, assessment, and treatment in this setting. METHOD Using an interpretive, descriptive exploratory design with three iterative, interrelated phases, we conducted interviews, created a photographic narrative journal (PNJ), and finally held photo elicitation focus groups to identify factors that facilitate or impede safe transitional care for community dwelling older adults with dementia in two Canadian emergency departments, and to identify practice solutions for nurses. We purposively sampled to recruit ten older adult-family caregiver dyads, ten ED RNs, and four Nurse Practitioners. Data were analyzed using constant comparative analysis. RESULTS Four interconnected reinforcing consequences emerged from our analysis: being under-triaged; waiting and worrying about what was wrong; time pressure with lack of attention to basic needs; and, relationships and interactions leading to feeling ignored, forgotten and unimportant. Together these consequences stem from a triage system that does not recognize atypical presentation of disease and illness. This potentiated a cascade of vulnerability in older people with dementia and their caregivers. Nurses experienced time pressure challenges that impeded their ability to be responsive to basic care needs. CONCLUSIONS In an aging population where dementia is becoming more prevalent, the unit of care in the ED must include both the older person and their family caregiver. Negative reinforcing consequences can be interrupted when nurses communicate and engage more regularly with the older adult-caregiver dyad to build trust. System changes are also needed to support the ability of nurses to carry out best practices.

The care of older adults in hospital: if it's common sense why isn't it common practice?

AIMS AND OBJECTIVES To present three converging myths that underlie the perception that nursing care for older persons in hospital is simple in comparison with its actual complexity. BACKGROUND Literature provides strong evidence indicating that the myths we discuss inherently arise from ageism, the social value of older patients and the economic burden of being an older patient in hospital. These powerful social discourses promote harm to older patients. Harm emerges from both the omission of gerontological nursing knowledge and skill and the commission of acts that unintentionally harm. A corresponding ethical challenge results for acute care nurses. DESIGN A discursive paper. METHODS We illuminate gerontological issues by discussing three myths. In myth one, we detail four clusters of distinguishing characteristics in older hospitalised people. In the second myth, we challenge the idea that the role of the acute care hospital is to attend only to acute medical concerns. Finally, in the third myth, we address the issue of incorporating functional assessment into the acute care nursing assessment. We argue that functional assessment is poorly integrated and becomes acceptable only as long as the medical regimen is managed appropriately. CONCLUSION Safe quality care in hospital for older adults requires a hybrid practice that integrates acute care specialty knowledge with gerontological nursing knowledge and skill. Clinical reasoning that integrates this type of nursing knowledge can prevent harm. RELEVANCE TO CLINICAL PRACTICE Integrating key elements of acute care nursing specialty knowledge with gerontological nursing principles aids to prevent the omission of care that is known to be harmful to older people. Conversely, the commission of gerontologically sensitive acute care can enhance safety and promote quality care in hospital.

Contextual factors influencing success or failure of emergency department interventions for cognitively impaired older people: a scoping and integrative review

AIM This paper is a report of a scoping review of research on cognitive impairment in older adults who visit Emergency Departments of acute care hospitals, followed by an integrative review that included a quality assessment to determine the effectiveness of interventions for this population. BACKGROUND Being old and cognitively impaired in the Emergency Department--a fast-paced intervention system--is a complex phenomenon that challenges many healthcare professionals. The rise in the incidence and prevalence of dementia will have a large impact on healthcare systems. DATA SOURCES MEDLINE, EMBASE, CINAHL, PsycInfo, AgeLine, Abstracts in Social Gerontology, the Cochrane Database of Systematic Reviews, the Cochrane Central Register of Controlled Trials and Google Scholar between 1990 and 2008, for qualitative or quantitative studies reporting extractable data on delirium or dementia in non-institutionalized older people (65+ years) in the Emergency Department. REVIEW METHODS Titles screened by a project researcher and checked against inclusion criteria by another researcher. Two reviewers completed independent data extraction and synthesis of included studies. Quality assessment occurred using the Critical Appraisal Skills Programme Tools. RESULTS Fifteen studies met the inclusion criteria for integrative review. Analysis of these studies indicates that the prevalence of cognitive impairment is high and improvements are needed. Contextual details and relevant features of an appropriate intervention are poorly explained. CONCLUSION Although the prevalence and incidence of cognitive impairment is recognized, appropriate interventions and programmatic responses remain elusive. Quality improvements require more thorough examination of emergency department context to identify modifiable influencing factors that are transferable across settings.

A Novel Visual Method for Studying Complex Health Transitions for Older People Living With Dementia

Understanding the complexity of health services for older people living with dementia is a challenging research endeavor. We discuss a novel research approach that combines photographic methods with storyboarding techniques to understand the views of older people living with dementia who encounter the emergency department. A social ecological theoretical position was taken to study relationships between health care systems and processes and the social arrangements of those receiving care. The research approach uncovers complex contextual factors in health care systems that are amenable to change. The approach strengthens the contribution of older people living with dementia to have their voice included in research endeavors.

Evidence-Based Evaluation of Staircase Architectural Design to Reduce the Risk of Falling for Older Adults

The impact of an increasingly aging population warrants accommodations in home architectural design. Focusing on the staircase design criteria as part of the home environment, this article presents an integrated evidence-based staircase evaluation for home staircase design to reduce the risk of falling for older adults (those 65 years and older). The staircase evaluation has been developed by dividing the staircase into four design elements: handrail design, step design, staircase geometric design, and lighting. Each element is divided into several features that define its architectural design. For example, the step design element is further divided into four features: going depth, riser height, nosing, and step finishing material. A hierarchical list is provided based on an evidence-based comparison of various scenarios for each feature. The hierarchical list presents the comparative effect of each scenario on reducing the risk of falling for older adults.

The challenge of dementia care knowledge exchange: Key factors in a national approach

We report a dementia knowledge-to-practice exchange activity to describe the process undertaken to improve care and support for older adults living with dementia. We describe the team’s early development and decision-making process (including its early focus on family physicians), and eventual creation of a Dementia Pocket Card tool. The tool can support health professionals and families with dementia case-finding, assessment, diagnosis and appropriate service provision.

The dementia-friendly emergency department: An innovation to reducing incompatibilities at the local level

Emergency Departments (EDs) are an integral part of the Canadian healthcare system. Older people living with dementia challenge EDs. They have complex health profiles that pose multiple challenges for staff. The current one-size-fits-all approach that aids efficiency in a technologically dependent hospital setting may not always serve older people living with dementia, their caregivers, or staff well. The premise that older people living with dementia are a problem for Canadian EDs must be reconsidered. Understanding the complexity of the situation is aided by the dementia-friendly ED framework. We propose one way to enhance communication between those living with dementia who receive ED services and those providing the service.

Know me – A new person-centered approach for dementia-friendly emergency department care

A visit to an emergency department can be a disorientating experience for someone with dementia. Empowered caregivers can mitigate harm stemming from communication issues to support a successful emergency department visit. A qualitative study determined the feasibility of the structure, format, and content of eight hospital-readiness communication tools. Data collection involved English and French-language caregiver focus groups in two Canadian provinces. Study findings have the potential to (a) improve safety in emergency care to older people with dementia and their caregivers, and (b) offer cost-effective communication tools for web-based knowledge translation activity in acute care.

Hospital readiness communication tools: A feasibility study

developed by clinicians affiliated with a long term care provider in PA, was conceptualized, implemented and researched in an active clinical care setting, and thus, represents a viable solution to the growing challenge of improving function for individuals with dementia through rehabilitation services. The NET model incorporates person centered care practices into therapy interventions that draw upon functionally based, familiar activities and are delivered in an environment that supports engagement by individuals with cognitive impairment. Therapists using the NET model receive specialized training and support to increase knowledge about dementia and efficacy in working with this population, and are supported by an coordinated team approach to care. Research on the model has revealed that NET rehabilitation services result in significantly greater engagement in the therapy process and improved functional outcomes. In addition, therapists trained in NET demonstrate improved knowledge and efficacy in their work with individuals with dementia. This presentation will begin by exploring the challenges associated with successfully providing rehabilitation services to individuals with cognitive impairment and the growing need for this type of care. We will then provide participants with an introduction to the NET model and the key dementia care practices that are integrated into therapy services. Finally, we will review the findings from the NET research project conducted in 3 skilled nursing home based rehabilitation programs, exploring the impact on both therapists and clients involved in the NET program. The study looked at outcomes for 46 therapists, i.e. physical, occupational and speech therapists, and 85 short term rehabiliation patients with moderate to severe dementia over the course of 12 weeks and documented positive outcomes in patient engagement and function, as well as therapist knowledge and efficacy in dementia care. Next steps for the NET program and the current challenges to this kind of work within short term rehabiliation systems will be discussed. Specific focus will be on the operational and financial challenges associated with enhanced rehabilitation care for individuals with dementia.

EVIDENCE-BASED ASSESSMENT OF GEOMETRICAL STAIRCASE CONFIGURATIONS FOR OLDER ADULTS

Maintaining safety for older adults aged 65 years and older is a challenge that could be addressed by applying conscious design. Accordingly, the concept of creating a home environment which enhances safety for older adults becomes essential. Considering that staircases vary widely in their geometrical configurations, this paper presents an evidence-based assessment for geometrical staircase configurations from the perspective of reducing the risk of falling for older adults. The methodology is divided into two stages: 1) identifying the most common geometrical home staircase configurations, which include U-shape stairs, quarter turn stairs, straight stairs with landing, straight stairs without landing, helical stairs, spiral stairs, and composite stairs; 2) investigating the associated risk of falling for each geometrical staircase configuration through developing an evidence-based comparison for the proposed geometrical staircase configurations. The output of this paper is a hierarchical listing for geometrical staircase configurations which is arranged from lowest to highest reduction in risk of falling for older adults.