Susan E. Slaughter

Special care facility compared with traditional environments for dementia care: a longitudinal study of quality of life.

Objectives: To compare the effect of a specialized care facility (SCF) on quality of life (QoL) for residents with middle‐ to late‐stage dementia over a 1‐year period with residence in traditional institutional facilities.

Consent and Assent to Participate in Research from People with Dementia

Conducting research with vulnerable populations involves careful attention to the interests of individuals. Although it is generally understood that informed consent is a necessary prerequisite to research participation, it is less clear how to proceed when potential research participants lack the capacity to provide this informed consent. The rationale for assessing the assent or dissent of vulnerable individuals and obtaining informed consent by authorized representatives is discussed. Practical guidelines for recruitment of and data collection from people in the middle or late stage of dementia are proposed. These guidelines were used by research assistants in a minimal risk study.

What is a health expectation? Developing a pragmatic conceptual model from psychological theory

Introduction  Examination of the existing literature in respect of health expectations revealed both ambiguity in relation to terminology, and relatively little work in respect of how abstract theories of expectancy in the psychological literature might be used in empirical research into the influence of expectations on attitudes and behaviours in the real world. This paper presents a conceptual model for the development of health expectations with specific reference to Alzheimers disease.

Making the most of mealtimes (M3): grounding mealtime interventions with a conceptual model.

In this issue of the journal, Whear and colleagues1 present the results of a systematic review focused on mealtime interventions in long term care (LTC) and their effect on behavioral and psychological symptoms of dementia (BPSD) (e.g., fear, agitation). In a companion article2 these authors focus on nutritional outcomes of mealtime interventions. Key findings from both of these systematic reviews are that: 1) there is the potential to positively influence nutrition parameters and BPSD by changing the mealtime environment, 2) quality of these studies is generally poor due to small sample sizes, lack of randomization, and inadequate control for confounding factors within resident, staff and organizational levels, and 3) interventions are only briefly articulated, limiting understanding of how they work and how they can be replicated in typical LTC homes. The authors recommend that high quality studies be conducted to demonstrate the value of these interventions for improving nutritional health and quality of life of residents.1,2 We would add to this recommendation that intervention research needs to be based on a conceptual framework grounded in current evidence that demonstrates that there are several influences on the varied activities (e.g., arriving, eating, waiting socializing) that occur during a mealtime3 and that there are several intermediate (e.g. BPSD, food intake, strength) and ultimate outcomes (e.g., nutritional status, comorbidity, quality of life, functional ability, mortality) to consider. Mealtime is a complex process with multiple levels of influence including residents, staff, home and government.3 For example, organizational practices around when the dining room is open for meals can result in rushed mealtimes and if staffing is short or staff are drawn away from assisting others to encourage an agitated resident to remain at the table, all meal participants, including staff, are affected. Fully understanding the problem and its determinants is needed to design interventions that have the greatest impact.4

Incidence and predictors of excess disability in walking among nursing home residents with middle-stage dementia: a prospective cohort study.

BACKGROUND Inability to walk compromises the well-being of the growing number of nursing home residents with dementia. The purpose of this study was to estimate the incidence and identify predictors of walking disability that may be remediable. METHODS A cohort was followed fortnightly for a year in 15 nursing homes in western Canada. The study participants comprised 120 ambulatory residents with middle-stage Alzheimers, vascular or mixed dementia. Standardized measures of potential predictors of disability included the Charlson Comorbidity Index, Global Deterioration Scale, and Professional Environment Assessment Protocol. Walking disability was defined as using a wheelchair to go to meals in the dining room. RESULTS Incidence of walking disability was 40.8% (95% confidence interval (CI): 32.7-50.2). Approximately half of this (27.0%; 95% CI: 19.7-36.5) was excess disability. Residents with more advanced dementia and living in a less supportive nursing home environment experienced an increased hazard of walking disability (Hazard Ratio (HR): 2.1; 95% CI: 1.2-3.8 and HR: 2.4; 95% CI: 1.3-4.4 respectively). After adjusting for age, comorbidity and stage of dementia, predictors of excess disability in walking included using antidepressants (HR: 2.2; 95% CI: 1.02-4.6), and not using cognitive enhancers (HR: 2.6; 95% CI: 1.03-6.4). CONCLUSIONS Over half of walking disability in nursing home residents with middle-stage dementia may be modifiable. Creating supportive environments, ensuring access to cognitive enhancer drugs, and preventing and treating depression and the adverse effects of antidepressants, may help to reduce walking disability and excess disability.

The care unit in nursing home research: Evidence in support of a definition

BackgroundDefining what constitutes a resident care unit in nursing home research is both a conceptual and practical challenge. The aim of this paper is to provide evidence in support of a definition of care unit in nursing homes by demonstrating: (1) its feasibility for use in data collection, (2) the acceptability of aggregating individual responses to the unit level, and (3) the benefit of including unit level data in explanatory models.MethodsAn observational study design was used. Research (project) managers, healthcare aides, care managers, nursing home administrators and directors of care from thirty-six nursing homes in the Canadian prairie provinces of Alberta, Saskatchewan and Manitoba provided data for the study. A definition of care unit was developed and applied in data collection and analyses. A debriefing session was held with research managers to investigate their experiences with using the care unit definition. In addition, survey responses from 1258 healthcare aides in 25 of the 36 nursing homes in the study, that had more than one care unit, were analyzed using a multi-level modeling approach. Trained field workers administered the Alberta Context Tool (ACT), a 58-item self-report survey reflecting 10 organizational context concepts, to healthcare aides using computer assisted personal interviews. To assess the appropriateness of obtaining unit level scores, we assessed aggregation statistics (ICC(1), ICC(2), η2, and ω2), and to assess the value of using the definition of unit in explanatory models, we performed multi-level modeling.ResultsIn 10 of the 36 nursing homes, the care unit definition developed was used to align the survey data (for analytic purposes) to specific care units as designated by our definition, from that reported by the facility administrator. The aggregation statistics supported aggregating the healthcare aide responses on the ACT to the realigned unit level. Findings from the multi-level modeling further supported unit level aggregation. A significantly higher percentage of variance was explained in the ACT concepts at the unit level compared to the individual and/or nursing home levels.ConclusionsThe statistical results support the use of our definition of care unit in nursing home research in the Canadian prairie provinces. Beyond research convenience however, the results also support the resident unit as an important Clinical Microsystem to which future interventions designed to improve resident quality of care and staff (healthcare aide) worklife should be targeted.

Mobility of Vulnerable Elders (MOVE): study protocol to evaluate the implementation and outcomes of a mobility intervention in long-term care facilities

BackgroundAlmost 90% of residents living in long-term care facilities have limited mobility which is associated with a loss of ability in activities of daily living, falls, increased risk of serious medical problems such as pressure ulcers, incontinence and a significant decline in health-related quality of life. For health workers caring for residents it may also increase the risk of injury. The effectiveness of rehabilitation to facilitate mobility has been studied with dedicated research assistants or extensively trained staff caregivers; however, few investigators have examined the effectiveness of techniques to encourage mobility by usual caregivers in long-term care facilities.Methods/DesignThis longitudinal, quasi-experimental study is designed to demonstrate the effect of the sit-to-stand activity carried out by residents in the context of daily care with health care aides. In three intervention facilities health care aides will prompt residents to repeat the sit-to-stand action on two separate occasions during each day and each evening shift as part of daily care routines. In three control facilities residents will receive usual care. Intervention and control facilities are matched on the ownership model (public, private for-profit, voluntary not-for-profit) and facility size. The dose of the mobility intervention is assessed through the use of daily documentation flowsheets in the health record. Resident outcome measures include: 1) the 30-second sit-to-stand test; 2) the Functional Independence Measure; 3) the Health Utilities Index Mark 2 and 3; and, 4) the Quality of Life - Alzheimers Disease.DiscussionThere are several compelling reasons for this study: the widespread prevalence of limited mobility in this population; the rapid decline in mobility after admission to a long-term care facility; the importance of mobility to quality of life; the increased time (and therefore cost) required to care for residents with limited mobility; and, the increased risk of injury for health workers caring for residents who are unable to stand. The importance of these issues is magnified when considering the increasing number of people living in long-term care facilities and an aging population.Trial RegistrationThis clinical trial is registered with ClinicalTrials.gov (trial registration number: NCT01474616).

Mobility of Vulnerable Elders Study: Effect of the Sit-to-Stand Activity on Mobility, Function, and Quality of Life

OBJECTIVES The aim of this study is to assess the effect of the sit-to-stand activity on the mobility, function, and health-related quality of life of nursing home residents with dementia. DESIGN A longitudinal quasi-experimental intervention study with intervention and control groups. SETTING The study was conducted in 7 nursing homes (4 intervention; 3 control) in Edmonton, Canada. PARTICIPANTS Eligible residents had a diagnosis of dementia and were able to transfer independently, or with the assistance of 1 person. INTERVENTION Health care aides prompted residents to repeat the sit-to-stand activity daily during care routines on day and evening shifts. MEASUREMENTS Mobility was measured using the 30-second sit-to-stand test and the time to complete one sit-to-stand. Function (Functional Independence Measure), health status (Health Utilities Index Mark 2 & 3) and disease-specific quality of life (Quality of Life-Alzheimers Disease instrument) were also measured. Outcome measures were collected at baseline, and at 3 and 6 months. The covariates cognition, depression, and medical instability were derived from the Resident Assessment Instrument Minimum Data Set (Version 2.0), and the facility context covariate was measured using the Alberta Context Tool. RESULTS A total of 111 residents completed the 6-month trial (56 intervention; 55 control). Residents in the intervention facilities maintained mobility, as measured by the time to complete one sit-to-stand (P = .01), and experienced a slower functional decline, as measured by the Functional Independence Measure (P = .01), from baseline to 6 months compared with residents in the control facilities, after adjusting for age, sex, cognition, depression, medical instability, and context. CONCLUSIONS Maintaining the ability to transfer using the sit-to-stand activity is a promising means of optimizing the mobility and function for residents with dementia in nursing homes.

Making the Most of Mealtimes (M3): protocol of a multi-centre cross-sectional study of food intake and its determinants in older adults living in long term care homes

BackgroundOlder adults living in long term care (LTC) homes are nutritionally vulnerable, often consuming insufficient energy, macro- and micronutrients to sustain their health and function. Multiple factors are proposed to influence food intake, yet our understanding of these diverse factors and their interactions are limited. The purpose of this paper is to fully describe the protocol used to examine determinants of food and fluid intake among older adults participating in the Making the Most of Mealtimes (M3) study.MethodsA conceptual framework that considers multi-level influences on mealtime experience, meal quality and meal access was used to design this multi-site cross-sectional study. Data were collected from 639 participants residing in 32 LTC homes in four Canadian provinces by trained researchers. Food intake was assessed with three-days of weighed food intake (main plate items), as well as estimations of side dishes, beverages and snacks and compared to the Dietary Reference Intake. Resident-level measures included: nutritional status, nutritional risk; disease conditions, medication, and diet prescriptions; oral health exam, signs of swallowing difficulty and olfactory ability; observed eating behaviours, type and number of staff assisting with eating; and food and foodservice satisfaction. Function, cognition, depression and pain were assessed using interRAI LTCF with selected items completed by researchers with care staff. Care staff completed a standardized person-directed care questionnaire. Researchers assessed dining rooms for physical and psychosocial aspects that could influence food intake. Management from each site completed a questionnaire that described the home, menu development, food production, out-sourcing of food, staffing levels, and staff training. Hierarchical regression models, accounting for clustering within province, home and dining room will be used to determine factors independently associated with energy and protein intake, as proxies for intake. Proportions of residents at risk of inadequate diets will also be determined.DiscussionThis rigorous and comprehensive data collection in a large and diverse sample will provide, for the first time, the opportunity to consider important modifiable factors associated with poor food intake of residents in LTC. Identification of factors that are independently associated with food intake will help to develop effective interventions that support food intake.Trial RegistrationClinicalTrials.gov ID: NCT02800291, retrospectively registered June 7, 2016.

Identification of hearing loss among residents with dementia: Perceptions of health care aides

Effective communication can be difficult when working with individuals with dementia and hearing loss. Given the high prevalence of both dementia and hearing loss among individuals in long term care, direct care providers in this setting, will almost certainly confront frequent communication challenges. To understand health care aide perspectives of caring for residents with dementia and hearing loss, 12 health care aides from five nursing homes participated in audio-recorded, semi-structured interviews. Transcripts were coded and themes were identified. Health care aides reported the difficulties in distinguishing the relative contributions of hearing loss and dementia to communication breakdowns. They reported that familiarity with residents helped them differentiate between sensory versus cognitive impairments in conversations with residents. Although able to identify strategies to support communication, communication difficulty complicated both their provision of care and support of quality of life for residents with dementia and hearing loss. Suggestions for practice and education are provided.