Psychosocial interventions offer opportunities to improve care for people with dementia in care homes. However, implementation is often led by staff who are not well prepared for the role. Some ...interventions use external experts to support staff. However little is known about external expert, care home staff and manager perceptions of such support. This paper addresses this gap.
Multi-methods study within a process evaluation of a cluster randomised controlled trial of Dementia Care Mapping™ (DCM). Interviews were conducted with six external experts who also completed questionnaires, 17 care home managers and 25 care home staff responsible for DCM implementation. Data were analysed using descriptive statistics and template analysis.
Three themes were identified: the need for expert support, practicalities of support and broader impacts of providing support. Expert support was vital for successful DCM implementation, although the five-days provided was felt to be insufficient. Some homes felt the support was inflexible and did not consider their individual needs. Practical challenges of experts being located at a geographical distance from the care homes, limited when and how support was available. Experts gained knowledge they were able to then apply in delivering DCM training. Experts were not able to accurately predict which homes would be able to implement DCM independently in future cycles.
An external expert may form a key component of successful implementation of psychosocial interventions in care home settings. Future research should explore optimal use of the expert role.
Psychosocial person-centred interventions are considered best practice for addressing complex behaviours and care needs such as agitation and anxiety, and for improving the quality of life of people ...with dementia in care homes. Dementia Care Mapping (DCM™) is an established practice development tool and process aimed to help care home staff deliver more person-centred care. To date, few studies have evaluated the efficacy of DCM™ and have found mixed results. These results are suggested to be the outcome of intervention implementation, which may be impacted by a range of factors. This study reports the barriers and facilitators to DCM™ implementation in care homes found during the process evaluation conducted as part of a randomized controlled trial.
Eighteen of the 31 DCM™ intervention care homes were recruited to participate in the embedded process evaluation. Semi-structured interviews were conducted with 83 participants, comprising care home managers, trained DCM™ users (mappers), expert external mappers, staff members, relatives, and residents.
Barriers and facilitators to DCM™ implementation were found at the mapper level (e.g. motivation and confidence), the DCM™ intervention level (e.g. understanding of DCM™) and the care home level (e.g. staffing issues, manager support). Further barriers caused by the burden of trial participation were also identified (e.g. additional paperwork).
Implementing DCM™ is complex and a greater consideration of potential barriers and facilitators in planning future studies and in practice could help improve implementation.
Current Controlled Trials ISRCTN82288852 , registered 16/01/2014.
Background
The COVID‐19 pandemic has put tremendous pressures on nursing homes, but there is limited direct data evaluating the impact on residents or prescribing practices
Method
As part of our ...clinical trial programme in nursing homes we have baseline data from 971 residents across 69 nursing homes collected in 2016/17 prior to the pandemic, and from 747 participants across 149 nursing homes from the baseline assessment of our COIVD WHELD RCT collected in 2021/22. In both studies the frequency if antipsychotic prescriptions was recorded and the Neuropsychiatric Inventory Nursing Home version was completed.
Results
The average age of residents (84.5 v 85.1) and gender balance (71%F v 69% F) was similar in both cohorts. In the current study 64% of participating nursing homes had experienced a COVID‐19 outbreak. There were fewer people with severe dementia in the COVID WHELD Cohort (6.7% v 23%). Antipsychotic usage was 55% higher in the COVID WHELD cohort compared to the original WHELD cohort (28% v 18%), with 25% of nursing homes having prescription rates >40%, but the rates of neuropsychiatric symptoms were similar in the 2 studies. To ensure that the results were not confounded by the lower number of people with severe dementia in the COVID WHELD cohort, a further comparison was undertaken for people with moderate/moderately severe dementia, with very similar results. We undertook an additional analysis comparing nursing homes above and below prescription rates of 20% (the pre‐COVID level of prescribing). Nursing homes with increased antipsychotic prescribing had significantly higher levels of overall neuropsychiatric symptoms on the NPI (p = 0.02), and significantly higher levels of agitation (p = 0.02) compared to nursing homes with lower prescribing rates. There were also 31% more staff sick days in the higher prescribing nursing homes.
Conclusion
There is a substantial increase in antipsychotic prescriptions in 50% of nursing homes since the onset of the COVID‐19 pandemic, associated in those nursing homes with an increase in neuropsychiatric symptoms. This will need to be a major focus as we begin to move forward from the pandemic.
Pimavanserin is a selective 5-HT2A receptor inverse agonist and antagonist approved in the USA for the treatment of hallucinations and delusions associated with Parkinson's disease psychosis. No safe ...or effective pharmacological treatment is approved for psychosis in patients with Alzheimer's disease. Therefore, we aimed to evaluate the safety, tolerability, and efficacy of pimavanserin versus placebo in patients with Alzheimer's disease psychosis.
We did a phase 2, randomised, double-blind, placebo-controlled, single-centre (with multiple affiliated nursing home sites across the UK) study. We included participants of either sex who were aged 50 years or older with possible or probable Alzheimer's disease and psychotic symptoms including visual or auditory hallucinations, delusions, or both. Participants were randomly assigned (1:1) to 12 weeks of oral treatment with either pimavanserin (two 17 mg tablets daily) or placebo, with use of permuted block sizes of four and stratified by baseline Mini-Mental State Examination (MMSE) total score (<6 or ≥6) and Neuropsychiatric Inventory–Nursing Home version (NPI–NH) psychosis score (<12 or ≥12). Participants, caregivers, the study sponsor, and study personnel at the clinic site were masked to treatment assignment. The primary endpoint was mean change from baseline to week 6 in the NPI–NH psychosis score for pimavanserin versus placebo in the modified intention-to-treat population. Sustained benefit and safety of pimavanserin were assessed through week 12. This study is registered at ClinicalTrials.gov, number NCT02035553.
Between Jan 16, 2014, and Oct 27, 2016, 345 participants across 133 nursing homes were screened, of whom 181 were randomly assigned treatment (n=90 pimavanserin and n=91 placebo). 178 participants were included in the modified intention-to-treat population. Mean total baseline NPI–NH psychosis scores were 9·5 (SD 4·8) for the pimavanserin group and 10·0 (5·6) for the placebo group. Mean change in the NPI–NH psychosis score at week 6 was −3·76 points (SE 0·65) for pimavanserin and −1·93 points (0·63) for placebo (mean difference −1·84 95% CI −3·64 to −0·04, Cohen's d=−0·32; p=0·045). By week 12, no significant advantage for pimavanserin versus placebo was observed for the overall study population (treatment difference −0·51 95% CI −2·23 to 1·21; p=0·561). Common adverse events were falls (21 23% of 90 participants in the pimavanserin group vs 21 23% of 91 in the placebo group), urinary tract infections (20 22% vs 25 28%), and agitation (19 21% vs 13 14%). Eight (9%) participants on pimavanserin and 11 (12%) on placebo discontinued treatment because of adverse events. No detrimental effect was observed on cognition or motor function in either group.
Pimavanserin showed efficacy in patients with Alzheimer's disease psychosis at the primary endpoint (week 6) with an acceptable tolerability profile and without negative effect on cognition. Further follow-up to week 12 did not show significant advantage for pimavanserin versus placebo.
ACADIA Pharmaceuticals.
Digital approaches to delivering person-centered care training to nursing home staff have the potential to enable widespread affordable implementation, but there is very limited evidence and no ...randomized controlled trials (RCTs) evaluating digital training in the nursing home setting. The objective was to evaluate a digital person-centered care training intervention in a robust RCT.
We conducted a 2-month cluster RCT in 16 nursing homes in the United Kingdom, randomized equally to receive a digitally adapted version of the WHELD person-centered care home training program with virtual coaching compared to the digital training program alone.
The study was conducted in UK nursing homes. There were 175 participants (45 nursing home staff and 130 residents with dementia).
The key outcomes were the well-being and quality of life (QoL) of residents with dementia and the attitudes and knowledge of nursing home staff.
There were significant benefits in well-being (t = 2.76, P = .007) and engagement in positive activities (t = 2.34, P = .02) for residents with dementia and in attitudes (t = 3.49, P = .001), including hope (t = 2.62, P = .013) and personhood (t = 2.26, P = .029), for staff in the group receiving digital eWHELD with virtual coaching compared to the group receiving digital learning alone. There was no improvement in staff knowledge about dementia.
The study provides encouraging initial clinical trial evidence that a digital version of the WHELD program supported by virtual coaching confers significant benefits for care staff and residents with dementia. Evidence-based digital interventions with remote coaching may also have particular utility in supporting institutional recovery of nursing homes from the COVID-19 pandemic.
Background
Implementation of evidence‐based training into real world practice in nursing home settings is a major challenge. Digital approaches provide real potential to addressing the barriers, ...particularly over the difficult period of the COVID‐19 pandemic.
Method
iWHELD is a first‐of‐its‐kind digital programme evolving the principles of the WHELD intervention combining person centred care, social interaction, and antipsychotic review, combining virtual coaching with a digital resource for nursing homes. The intervention utilising a Dementia Champion model supported by live virtual coaching set within a digital resource hub and peer networking platform was compared to usual care in a 16‐week randomised control cluster study of 741 people with dementia across 149 nursing homes in the UK. The initial outcomes evaluated are the use of antipsychotic drugs and neuropsychiatric symptoms (using the Neuropsychiatric Inventory NH).
Result
36/72 (53%) of nursing homes allocated to the active treatment arm engaged successfully with the digital intervention, with 563 residents completing the treatment period. The average age of residents was 84.5 years, 71% were female, and there were no significant differences between treatment arms. There was a significant reduction in antipsychotic use in the digital iWHELD treatment group from 49% to 31% compared to no change in the group receiving usual care (p = 0.046). Initial analysis of neuropsychiatric symptoms indicates a non‐significant improvement in the intervention group compared to those receiving usual care.
Conclusion
The current RCT using an online programme with live virtual coaching delivered through a Dementia Champion achieved better than 50% engagement, which compares favourably with previous studies of digital interventions in other therapeutic areas. The intervention also achieved significant reductions in antipsychotic use without any worsening of neuropsychiatric symptoms, and provides an important potential approach to safely reducing the rise in antipsychotic use in nursing home residents with dementia that has become a major challenge during the COVID‐19 pandemic.
The aim of the present study was to determine whether psychotic symptoms in people with dementia (PwD) living in nursing homes were associated with reduced quality of life and to understand the ...additional impact of other concurrent neuropsychiatric symptoms on QoL.
Cross-sectional cohort study (using data from WHELD cohort).
971 PwD living in nursing homes participating in the WHELD study.
The Neuropsychiatric Inventory–Nursing Home (NPI-NH) version was completed by informant interview. We compared mean differences in proxy-rated QoL scores (DEMQOL-Proxy) for PwD experiencing or not experiencing delusions and for PwD experiencing or not experiencing hallucinations. Backward multiple regression was used to determine the added contributions of agitation (Cohen-Mansfield Agitation Inventory), anxiety (NPI-NH-Anxiety), depression (Cornell Scale for Depression in Dementia), dementia severity (Clinical Dementia Rating-sum of boxes score), pain (Abbey Pain Scale), and antipsychotic prescription. Mediation analysis was conducted for agitation, anxiety, and depression.
Presence of both delusions (P < .001, B = –8.39) and hallucinations (P < .001, B = –7.78) was associated with poorer QoL. Both associations remained significant after controlling for other factors. Agitation, anxiety, and depression partially mediated the relationship between each psychotic symptom and QoL.
Delusions and hallucinations in PwD are associated with poorer QoL among PwD living in nursing homes. The effects remain significant after adjusting for confounding variables. Direct effects of each symptom maintained significance despite significant mediation by concurrent neuropsychiatric symptoms.
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