訪問診療を受ける在宅認知症患者の行動心理症状と関連要因の検討 横断調査研究(OHCARE study)
方法:包括的在宅医療確立を目指したレジストリー研究(Osaka Home Care Registry study:OHCARE)に登録された訪問診療を受ける65歳以上の全患者の内,認知症患者110名(82.0歳±11.3歳)を対象とした.診療記録,主治医意見書より情報収集し,要介護度,BPSD,治療,社会サービスについて解析を行った.
Objective: This study aimed to verify the validity and reliability of the seamless care for elderly dementia patients in community-based integrated care scale.
Method: A questionnaire survey was administered to 1,370 nurses at 137 hospitals for community-based care.
Results:We obtained 570 valid responses (41.6%). There were no question items indicating floor and ceiling effects. An exploratory factor analysis revealed that seamless care consisted of the following six factors: "utilizing the advantages of multiple occupations," "considering the current state of a patient's family," "maintaining a patient's gentle daily life," "aiming to improve a patient's daily living behavior according to cognitive function," "medical management for a patient after being discharged," and "cooperation with medical social workers from the beginning of hospitalization." No question items had factor loadings less than .400. Because the α value of each factor was not less than .800, the internal consistency of this scale could be verified. In a confirmatory factor analysis, the comparative fit index values were .905 and above .900, and the root mean square error of approximation value was .065.
Conclusion: The validity and reliability of this scale were verified. This scale should be used to fulfill functions required for hospitals for community-based care to cope with elderly dementia patients.
認知症高齢者を地域で支える : 実践事例 認知症の人への診断後の心理的支援とピアサポート
The Last Week of Life of Nursing Home Residents With Advanced Dementia: A Retrospective Study
BMC Palliat Care
Background: Barriers to palliative care still exist in long-term care settings for older people, which can mean that people with advanced dementia may not receive of adequate palliative care in the last days of their life; instead, they may be exposed to aggressive and/or inappropriate treatments. The aim of this multicentre study was to assess the clinical interventions and care at end of life in a cohort of nursing home (NH) residents with advanced dementia in a large Italian region.
Methods: This retrospective study included a convenience sample of 29 NHs in the Lombardy Region. Data were collected from the clinical records of 482 residents with advanced dementia, who had resided in the NH for at least 6 months before death, mainly focusing on the 7 days before death.
Results: Most residents (97.1%) died in the NH. In the 7 days before death, 20% were fed and hydrated by mouth, and 13.4% were tube fed. A median of five, often inappropriate, drugs were prescribed. Fifty-seven percent of residents had an acknowledgement of worsening condition recorded in their clinical records, a median of 4 days before death.
Conclusions: Full implementation of palliative care was not achieved in our study, possibly due to insufficient acknowledgement of the appropriateness of some drugs and interventions, and health professionals' lack of implementation of palliative interventions. Future studies should focus on how to improve care for NH residents.
Discrepancy in the Perception of Symptoms of Cognitive Decline Between Older Adults and Their Family Members: Results of the Toyama Dementia Survey
Background: Early consultation is important to delay the onset of dementia. The present study aimed to explore the reasons for delaying a consultation of dementia while focusing on the differences in the perception of cognitive decline between older adults and their family members.
Methods: A group of 663 older adults aged ≥65 years and living with family members in Toyama Prefecture was surveyed. The questionnaires included items that measured changes in cognitive function noticed by older adults and their family members, and the Revised Hasegawa Dementia Scale (HDS-R). The degrees of consistency on the perception of mental changes that accompanied cognitive decline were measured using the Kappa statistic.
Results: Both older adults and their family members were well aware of "forgetfulness" as a symptom of cognitive decline. Only the perception of "loss of appetite" at the late stage of cognitive decline was consistent between older adults and their family (κ = 0.707). When older adults often noticed their own forgetfulness, their mean HDS-R score was 22.7, whereas that of the family members was 14.7. The combinations of perception of forgetfulness by older adults and their family members, and the mean HDS-R scores were unaware/unaware (mean HDS-R score = 27.0), aware/unaware (mean HDS-R score = 24.9), aware/aware (mean HDS-R score = 15.5), and unaware/aware (mean HDS-R score = 13.0).
Conclusions: There were discrepancies in the perception of cognitive decline between older adults and their family members. Cognitive decline had progressed by the time that family members had noticed the symptom of forgetfulness in their older adult relatives. The perception gap regarding cognitive decline deters consultation of dementia.
Measuring Fidelity of Delivery of the Community Occupational Therapy in Dementia-UK Intervention
Interpreting data about intervention effectiveness requires an understanding of which intervention components were delivered and whether they were delivered as planned (fidelity of delivery). These studies aimed to develop a reliable measure for assessing fidelity of delivery of the Community Occupational Therapy in Dementia-UK intervention (COTiD-UK) (Study 1) and measure fidelity of delivery of COTiD-UK across sessions, sites and occupational therapists (Study 2).
The studies used a longitudinal observational design nested within a multi-site randomised controlled trial. Where practicable, all intervention sessions were audio-recorded. Fidelity checklists and coding guidelines were developed, piloted and refined until good agreement was achieved between two coders. Ten percent of sessions were purposively sampled from 12 sites and 31 occupational therapists. Transcripts were coded using checklists developed in Study 1; 10% of sets of intervention session transcripts were double coded to ensure that agreement was maintained. Percentages of components that were delivered were calculated for each session, site and occupational therapist.
A reliable measure of fidelity of delivery for COTiD-UK was developed after several rounds of piloting and amendments. COTiD-UK was delivered with moderate fidelity across all six sessions (range: 52.4–75.5%). The mean range of fidelity varied across sites (26.7–91.2%) and occupational therapists (26.7–94.1%).
A reliable, systematic method for measuring fidelity of delivery of COTiD-UK was developed and applied, and can be adapted for use in similar interventions. As COTiD-UK was delivered with moderate fidelity, there is a reasonable degree of confidence that intervention effects were attributable to COTiD-UK.
Co-designing Technology With People With Dementia and Their Carers: Exploring User Perspectives When Co-Creating a Mobile Health Application
International Journal of Older People Nursing
Aims: To explore the perspectives of those involved in co-designing a mobile application with people with dementia and their carers.
Background: People with dementia suffer physical and psychological problems as their illness progresses and require a range of health and social care services to meet their needs. Mobile applications are being developed to support individuals to manage long-term conditions, but patients and carers are not always involved in designing this technology, which can lead to poor quality health apps. A digital initiative was launched to involve people with dementia and their carers in creating a mobile app that would support communication and enable them to share memories together.
Design: An exploratory, descriptive approach was used.
Methods: In-depth interviews with people with dementia, their carers, and others involved in co-creating a mobile health application were conducted. Data analysis was undertaken using the framework approach.
Results: The views of people with dementia, their carers, and project staff were similar regarding the complexity of the co-design process, and the value the mobile app had for people with dementia and their families. Being involved in co-production seemed to have numerous benefits for people with dementia and their carers as they gained new knowledge and skills, friendships, and a sense of achievement in creating a unique app that would benefit many people. The app also appeared useful in stimulating memory and cognitive function, aiding communication, and providing a sense of normalcy for people living with dementia and their carers.
Conclusion: Mobile health applications can facilitate interaction between people with dementia and their carer network that could improve their quality of life. Further research on which co-design process is best suited to people with dementia and whether technology created via this participatory method is more effective or not in improving health outcomes is required.
Implications for practice: Nurses should have knowledge of and education about technology and how it can promote health and wellbeing of persons with dementia. Nurses who care for people with dementia and their families should support them in taking part in or leading the design of technologies that meet their needs. Participatory design methods should be taught in nursing education so the profession can provide guidance to patients and their families on co-creating health products and services.
A Mobile-Based Screening System for Data Analyses of Early Dementia Traits Detection
Journal of Medical Systems
Existing early detection methods that deal with the pre-diagnosis of dementia have been criticised as not being comprehensive as they do not measure certain cognitive functioning domains besides being inaccessible. A more realistic approach is to develop a comprehensive outcome that includes cognitive functioning of dementia, as this will offer a robust and unbiased outcome for an individual. In this research, a mobile screening application for dementia traits called DementiaTest is proposed, which adopts the gold standard assessment criteria of Diagnostic and Statistical Manual of Mental Disorders (DSM-V). DementiaTest is implemented and tested on the Android and IOS stores. More importantly, it collects data from cases and controls using an easy, interactive, and accessible platform. It provides patients and their family with quick pre-diagnostic reports using certain cognitive functioning indicators; these can be utilized by general practitioners (GPs) for referrals for further assessment in cases of positive outcomes. The data gathered using the new application can be analysed using Artificial Intelligence methods to evaluate the performance of the screening to pinpoint early signs of the dementia.
Identifying Undetected Dementia in UK Primary Care Patients: A Retrospective Case-Control Study Comparing Machine-Learning and Standard Epidemiological Approaches
BMC Medical Informatics and Decision Making
Background: Identifying dementia early in time, using real world data, is a public health challenge. As only two-thirds of people with dementia now ultimately receive a formal diagnosis in United Kingdom health systems and many receive it late in the disease process, there is ample room for improvement. The policy of the UK government and National Health Service (NHS) is to increase rates of timely dementia diagnosis. We used data from general practice (GP) patient records to create a machine-learning model to identify patients who have or who are developing dementia, but are currently undetected as having the condition by the GP.
Methods: We used electronic patient records from Clinical Practice Research Datalink (CPRD). Using a case-control design, we selected patients aged >65y with a diagnosis of dementia (cases) and matched them 1:1 by sex and age to patients with no evidence of dementia (controls). We developed a list of 70 clinical entities related to the onset of dementia and recorded in the 5 years before diagnosis. After creating binary features, we trialled machine learning classifiers to discriminate between cases and controls (logistic regression, naïve Bayes, support vector machines, random forest and neural networks). We examined the most important features contributing to discrimination.
Results: The final analysis included data on 93,120 patients, with a median age of 82.6 years; 64.8% were female. The naïve Bayes model performed least well. The logistic regression, support vector machine, neural network and random forest performed very similarly with an AUROC of 0.74. The top features retained in the logistic regression model were disorientation and wandering, behaviour change, schizophrenia, self-neglect, and difficulty managing.
Conclusions: Our model could aid GPs or health service planners with the early detection of dementia. Future work could improve the model by exploring the longitudinal nature of patient data and modelling decline in function over time.
How Can Autonomy Be Maintained and Informal Care Improved for People With Dementia Living in Residential Care Facilities: A Systematic Literature Review
Background and objectives: For people with dementia living in residential care facilities, maintaining autonomy and receiving informal care are important. The objective of this review is to understand how caregiving approaches and physical environment, including technologies contribute to the maintenance of autonomy and informal care provision for this population.
Research design and methods: A literature review of peer-reviewed articles published between January 1995 and July 2017 was performed. Realist logic of analysis was used, involving context, mechanism and outcome configurations.
Results: Forty-nine articles were included. The improvement of the relationship between residents and formal/informal caregivers is important. This increases the knowledge (sharing) about the resident and contributes to their autonomy. A social, flexible, and welcoming attitude of the formal caregiver improves the provision of informal care. Specially designed spaces, for instance, therapeutic gardens, create activities for residents that remind them of themselves and contribute to their autonomy. Use of technologies reduces caregiver's time for primary tasks and therefore enables secondary tasks such as interaction with the residents.
Discussion and implications: The results revealed how residential care facilities could maintain autonomy of their residents and improve informal care delivery using caregiving approaches and the physical environment including technologies. The results are supporting toward each other in maintaining autonomy and also helped in enhancing informal care provision. For residential care facilities that want to maintain the autonomy of their residents and improve informal care delivery, it is important to pay attention to all aspects of living in a residential care facility.