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P24. Treatment and management of dementia

Detailed programme and abstracts

P24.1. What do healthcare professionals do when the patient with dementia says ‘no’ to a healthcare procedure?

O’BRIEN Becca, ALLWOOD Rebecca, BEEKE Suzanne PILNICK Alison, GOLDBERG, Sarah, HARWOOD Rowan

Background: Poor communication is a barrier to processes essential for good treatment and care.  People with dementia and those who work with them can experience difficulties in communicating and interacting.  Much of healthcare involves a healthcare professional requesting an action from a patient (for example, to stand up or to open their mouth).  People with dementia often initially refuse these requests for action.

Aims: To identify the communication skills that healthcare professionals use when a request for action is refused by the patient with dementia.

Methods: Non-participant observational study using video recorded data of conversations between healthcare professionals and patients with dementia in the acute hospital analysed using conversation analysis. 

Results: 41 naturally occurring communications between healthcare professionals (nurses, doctors and therapists) and patients with dementia were video recorded between September and December 2015.   All the patients were identified as having some degree of communication impairment.  The analysis identified techniques healthcare professionals use (whilst behaving in a person-centred way) that appear to make the patient with dementia more or less likely to agree to a request for action.  Examples include how the healthcare professional displays their entitlement to make the request, use of simple directives, making the task appear less onerous and suggestions of joint action.  In the presentation, selected video recordings will be shown to illustrate findings.

Discussion: How we frame requests to patients with dementia will influence the likelihood of the patient granting that request.  If the patient lacks capacity and completion of the task is in the patient’s best interest, then healthcare professionals need to use communication to maximise their chances of successfully completing the task. 

Conclusion: Healthcare is delivered through communication.  This study has identified practical ways healthcare professionals can improve their communication with patients with dementia.

P24.2. How does dementia-friendly healthcare in hospitals influence patient outcomes? A realist evaluation

HANDLEY Melanie, BUNN Frances, GOODMAN Claire

Background: Hospitals in England are committed to improving outcomes for patients with dementia. Dementia-friendly healthcare at patient level recognises the difficulties faced by patients with dementia and adapts provision. A range of approaches have been used to achieve dementia-friendly healthcare. This study aimed to understand how these approaches work to improve patient outcomes.

Method: A realist evaluation with two hospital sites as case studies. Data collection involved observation, interviews, and documentary review over 3 months. Realist evaluation is a theory-driven approach that recognises the context-dependent nature of complex interventions. An evidence review (Handley et al 2015) informed study focus.  Ethics and research governance were obtained.

Findings: Evidence was gathered from interviews (n=42), non-participant observation (80 hours), medical notes review (n=28), and documentary review.  Analysis is ongoing and will be complete by the time of the presentation.  Findings demonstrated what needs to be in place for staff to be able to recognise and act in response to patient behaviours.  For example, staff knowledgeable in dementia care and with authority to act (context) were more likely to recognise expressions of pain (mechanism) prompting timely administration of analgesics (outcome). A preoccupation with risk (context) prioritised activities which limited patient movement (mechanism) supporting patient safety, but impacting on their choices (outcome). How the staff and organisation valued dementia care as core work (context) influenced how dementia care was prioritised (mechanism) affecting how patient needs were recognised and care modified (outcome).

Conclusion: Understanding what, in addition to education and training, supports staff to recognise, value, and respond to patient behaviours as communication is important. This is most evident where patients expressed pain, behaviour that challenges, and distress.  Findings suggest the elements of dementia-friendly interventions that gave staff confidence in their competence and where the organisation legitimises this work are key to improved patient outcomes.

This work was supported by funding from the Alzheimer’s Society (grant number ALZSOC-PhD-2013-025).

P24.3. What do we know about behavioural crises in dementia? A systematic review

BACKHOUSE Tamara, CAMINO Julieta, MIOSHI Eneida

Background: Behavioural crises in dementia regularly require external intervention from professionals. Dementia related behaviours can affect the person’s everyday life and that of their carers. Behavioural crises are represented by a wide variety of symptoms and are reported as a main reason for hospital admission. Little is known about the factors that are associated with them.

Aim: To determine the factors associated with dementia-related behavioural crises.

Methods: We searched MEDLINE, CINAHL, PsycINFO, EMBASE and AMED databases. An additional lateral search including reference lists was conducted. A crisis for the purpose of this review was defined as “a process where there is a stressor(s) that causes an imbalance requiring an immediate decision which leads to a desired outcome and therefore crisis resolution”.

Results: Out of the 5554 records identified, 24 articles (18 distinct studies) met the eligibility criteria. Aggression and agitation were the most common behaviours triggering crises. Thirteen out of the 18 studies (72%) reported people with dementia residing in their own home prior to crisis point, 12/18 (67%) in long-term care, and 5/18 (28%) in hospitals. Behavioural crises were the catalyst for admissions to psychiatric inpatient settings, special-care units for dementia, long-term care, or for referrals to psychiatric community services. In 50% of studies, crisis interventions included both pharmacological and non-pharmacological approaches, with 28% providing pharmacological interventions only.

Conclusion: Dementia-related behavioural crises are often precipitated by aggression and agitation and occur in both family and care home settings. Interventions to reduce the likelihood of people with dementia-related behaviours reaching crisis point need to focus on both settings and incorporate aggression and agitation management. Our results provide detailed information about dementia-related behavioural crises.

P24.4. Short-term response is not predictive of long-term response to acetylcholinesterase inhibitors in old age subjects with Alzheimer’s disease: a “real world” study

BARONI Marta, BOCCARDI Virginia, SMIRNE Nicoletta, CLODOMIRO Alessandra, ERCOLANI Sara, LONGO Annalisa, RUGGIERO Carmelinda, BRUNI Amalia, MECOCCI Patrizia

Background: Most of clinical guidelines recommend discontinuing treatment with cholinesterase inhibitors (ChEIs) in patients with Alzheimer’s disease (AD) who do not show an initial response to therapy as evaluated with the Mini-Mental State Examination (MMSE) scale. However, understanding the relationship between the initial response to ChEI treatment and the subsequent course of the disease is extremely important in clinical practice, but evidence is limited, particularly in the old-old population.

Objective: We aimed at investigating the relationship between short-term and long-term response to ChEI therapy in old age subjects with AD in a “real life” setting.

Methods: This is a retrospective longitudinal study of 628 old age subjects (≥65 years old) with AD and treated with ChEIs over three-year follow-up. The sample was divided into “young-old” (≤75 years) and “old-old” (≥76 years) according to age, and as “responder” and “non-responder” according to the initial (i.e., after three months) response to treatment. Cognitive and functional evaluation was performed by means of MMSE and ADL/IADL, respectively.

Results: In the long run, subjects considered as non-responders showed a lower rate of cognitive decline as compared with responders, with a mean annual decline at MMSE of 1.0 point versus 1.6 points (p < 0.0001), respectively. Old-old nonresponders had a slower rate of cognitive (p < 0.0001) and functional decline (p < 0.0001) as compared with responders after three years of observation.

Conclusion: Discontinuing ChEI treatment solely for the absence of an initial response is not appropriate, especially in old-old subjects.

P24.5. The contribution of complementary therapy within the care of nursing home residents experiencing later stage dementia: an action research study

MITCHELL Bryan

This study responds to the need for therapeutic interventions with demonstrable benefit for individuals with dementia. Current estimates suggest that there are over 90,000 people in Scotland with dementia, 40% of whom will be admitted to care homes when the condition advances. Known variations in the standard of nursing home practice and calls to develop and deliver evidence informed advanced dementia care gave impetus to this study. In particular, an intervention was sought that had potential to positively influence the experience of care and contribute to the management of dementia related symptoms and behaviours.

The aim of this mixed method action research study was to collaboratively introduce and explore the perceived benefits of complementary therapy as an intervention for nursing home residents with later stage dementia. The project involved two action cycles. Cycle 1 explored the views of 21 staff and family members on the acceptability and possible uses of complementary therapy within the care of nursing home residents with later stage dementia. Five individual case studies were undertaken to test how the introduction of selected complementary therapies could be achieved in practice and to explore the perceived contribution to residents, including impact on neuropsychiatric behaviours. The experience and practicalities of introducing complementary therapy was then reflected on with staff during a focus group and family during telephone interviews. Mindful of Cycle 1 findings, Cycle 2 collaboratively developed principles of implementation with care staff that was inclusive of family. Selected complementary therapies were then implemented into practice and further tested with 10 individuals.

The findings demonstrate that staff and family perceive the use of complementary therapy to be supportive of an individual’s physical and emotional needs. The neuropsychiatric inventory questionnaire used during the case study and implementation objectives indicated a reduction in neuropsychiatric behaviours related to dementia. An unexpected finding was that staff and family consider the use of complementary therapy to be an intervention that reduces a sense of loneliness. 

P24.6. How does utilization of health care services change in people with dementia served by dementia care networks in Germany – results of the DemNet-D-Study

THYRIAN Jochen René, MICHALOWSKY Bernhard, HERTEL Johannes, WÜBBELER Markus, HOLLE Bernhard, SCHÄFER-WALKMANN Susanne, WOLF-OSTERMANN Karin, HOFFMANN Wolfgang

Background: There is some scientific evidence, that a Dementia Care Network (DCN) can be effective in improving treatment and care for People with Dementia (PwD), especially in integrating people into the specialized dementia care system in Germany. Furthermore, existing DCN seem to serve a diverse population of PwD in primary care, highlighting their importance as a health service infrastructure. However, there is no common definition for DCN. They are very heterogeneous and there is no general, longitudinal evidence for the effects of DCN on PwD served by them. Therefore, we describe changes in utilization of health services by people with dementia served by dementia care networks in Germany and factors associated with those changes over time.

Methods: Primary data was assessed in n=560 people with dementia and their caregiver supported by DCNs in Germany; sociodemography, clinical variables, utilization of services; DCN were characterized according to their governance. The study design was an observational study with face-to-face interviews at two time points over a period of one year. Data was assessed via semi-structured interviews by trained interviewers at the participants’ homes; descriptive statistics and significance testing for differences from baseline to follow-up, logistic regression modeling to identify predictive variables for utilization at follow-up.

Results: Utilization of health services by PwD served in DCN is consistently higher than in the general population and does not significantly change over time. The strongest predictor of utilization of any service after one year was the use of this service at baseline (OR from 3.23 to 44.16). Higher activities of daily functioning increased the chances to utilize specialist physicians (OR=1.32) or occupational therapy (OR=1.24) significantly. Being a female decreased chances to utilize specialist physicians (OR=0.37) and increased the chances to utilize no services (OR=0.57).

Conclusions: PwD benefit from participation in DCN since they do generally utilize health care services more often, physicians should be involved in DCN, the type of network is of less importance for utilization. There is a gender bias in utilization even in this specialized setting.

 

 
 

Last Updated: Tuesday 24 October 2017

 

 
  • Acknowledgements

    The 27th AE Conference in Berlin received funding under an operating grant from the European Union’s Health Programme (2014-2020). Alzheimer Europe and Deutsche Alzheimer Gesellschaft e.V. gratefully acknowledge the support of all conference sponsors.
  • European Union
  • Roche
 
 

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