Advancing dementia care through implementation science: global and Australian perspectives

Objectives: The number of people who will require institutional care for dementia is rapidly rising. This increase raises questions about how the workforce can meet the challenge of providing quality care. A promising psychological concept that could improve staff and care recipient outcomes is staff sense of competence in their capacity to provide dementia care. The purpose of this study was to elucidate the relative importance of staff factors associated with sense of competence.Method: Sixty-one Australian dementia care staff (mostly nurses, 69%; and allied health, 21%) were recruited. Measures included the Sense of Competence in Dementia Care Staff (criterion) and standardised measures of empirically derived predictors: training, knowledge, attitudes and person-centred care strategies.Results: Standard multiple regression revealed that 33.9% of the variance in sense of competence was explained by the combination of the four predictors. Attitudes and person-centred strategies each uniquely explained a moderate amount of variance, while training and knowledge were not significant predictors of sense of competence.Conclusion: A positive attitude towards people with dementia, and stronger intentions to implement person-centred care strategies, predicted a greater sense of competence to provide care, whereas knowledge and training, commonly believed to be important contributors to sense of competence in dementia care, did not predict this outcome. Investing in strategies that address staff attitude and encourage person-centred care could influence sense of competence, and by extension, dementia care.

This individual symposium presentation will provide case examples of three “hybrid effectiveness” trials in dementia care in different care settings including community-based and residential long-term care settings, each of which incorporate implementation methods alongside traditional evaluations of effectiveness. We offer considerations related to conceptualization, study design, sampling, data collection, and analysis that may guide gerontologists who aspire to adopt hybrid effectiveness designs in their own work. We conclude with methodological recommendations to incorporate an implementation science lens throughout the lifecycle of gerontological (and/or dementia care) intervention development. By applying key principles from implementation science throughout the intervention development process, a truncated and more efficient implementation pipeline may be achievable in gerontological research. Moreover, incorporation of implementation science methods into standard intervention development and testing methodologies will result in older persons, their families, healthcare providers, and communities having the best evidence available at their disposal.

IntroductionThe quality of long-term care provided to people with dementia (PwD) in care homes can be improved by implementing person-centered care. Family carers of PwD living in care homes are an important part of person-centered care. However, they often experience high levels of burden, even when a family member with dementia lives in a care home. This study examines trends in the involvement of family carers and their perceived role, role overload and self-efficacy.MethodsData from the Living Arrangements for People with Dementia study, a cross-sectional monitoring study that evaluates developments in care for PwD in care homes in the Netherlands, with four measurement cycles between 2008-2017 was used. Data from the three most current measurement cycles were used, with respectively 144, 47 and 49 participating care homes and 888, 392 and 401 participating family carers. Family involvement was measured by the number of hours per week that family carers visited the PwD and the type of activities they undertook. Perceived caregiving role was measured with the Family Perceptions of Caregiving Role instrument. We used the Self-Perceived Pressure by Informal Care to measure role overload and a 37-item questionnaire was used to measure self-efficacy. We investigated the changes over time (e.g., measurement cycles) of these measures.ResultsThe number of hours that family carers visited the PwD did not change over time. However, there was a trend towards an increase in the variety of activities they undertook. Their perceived caregiving role did not change over time. Self-efficacy of family carers increased over time and they reported more feelings of role overload.ConclusionsDuring the past decade, there has been an increasing trend towards family carers doing more diverse activities with PwD in carer homes. Family carers did feel more competent in their caring role, although their feelings of role overload also increased. Continuing attention is therefore needed for the psychological well-being of family carers after a person with dementia moves to a care home.

Translational research: The ingredients are only the start of the recipe for better dietetic practice

With the passage of the National Alzheimer's Project Act (NAPA) in 2011 and the National Plan to Address Alzheimer's Disease in the U.S., federal funding support for dementia care science increased exponentially. The National Institute on Aging (NIA), in keeping with National Plan's goal of effectively treating and preventing Alzheimer's disease and Alzheimer's Disease Related Dementias (AD/ADRD) by 2025, created a series of research milestones to track success. One of these is research milestone 13.H: Create research programs to evaluate novel and innovative dissemination and implementation methods to scale up promising practices in dementia care across settings and across the disease severity spectrum. The objective of this presentation is to summarize scientific advancements in the dissemination and implementation of dementia care innovations. This presentation uses narrative review and case study methods to assess the state-of-the-science of dementia care implementation and dissemination and to identify recommendations to continue to propel the field forward so that the ultimate goal of ensuring people living with dementia and their carers can benefit from evidence-based programs, services, and innovations are more readily achieved. Although a range of efforts exist documenting dissemination and implementation efforts of dementia care interventions, a range of barriers have been identified in the literature, including staff training requirements, length, complexity, little alignment with operations and daily workflow, and lack of incentivization/reimbursement. Within the framework of the NIH Stage Model of Behavioral Intervention Development, several methodological strategies could be applied to dementia care intervention design, testing, and dissemination/implementation to expedite the translation of evidence into real-world contexts. Designing dementia care interventions with the intent of implementation at the earliest stages of development is critical. Key methodological strategies to expedite the translational "pipeline" of dementia care science include the identification, measurement, and testing of mechanisms of action; use of process evaluations; application of advanced intervention design methodologies such as the Multiphase Optimization Strategy, Sequential Multiple Assignment Randomized Trials, and hybrid-effectiveness studies; and incorporation of person-centered outcome measures.

It is well established that the actions and behaviour of dementia care workers are fundamental to the wellbeing of the people they care for. Not only do they deal with basic healthcare needs, but they also perform a vital psycho-social function by providing-through their regular presence-an underlying continuity for residents. This has been shown to improve well-being, particularly for those in the advanced stages of dementia. It has also been suggested that there are additional psycho-social benefits of such contact which can directly influence the need for anti-psychotic medication. However, unlike most other healthcare and medical settings, the specialised and often difficult interactions that dementia care workers handle every day have not yet been the subject of detailed micro-level analysis. This is particularly significant because much of the impact that care-workers have relates to the way in which they interact with the people they care for. Not having a clear understanding of how their interactions 'work' at the micro-level-particularly ones that are specific to dementia care settings, and that care workers report to be difficult or challenging-means that any training interventions that are developed may not resonate with their real-world experience, and ultimately run the risk of failing. This video-based observational study aims to provide a detailed micro-exploration of problematic and challenging interactions involving care-workers and people living with dementia. The study is based in the UK and will involve up to 20 dementia care staff and 60 people living with dementia. Fieldwork will be conducted in 5 dementia care home and community-based dementia day care settings using naturalistic observational methods (primarily video-ethnography). Data will be analysed using Conversation Analysis (CA).

Knowledge generated in occupational science has been envisioned as having transformative potential for societal change, especially in supporting and empowering under-resourced communities. However, a key gap in occupational science scholarship is translating evidence so it can be used to address real-world problems. The field of implementation science was established to address knowledge-to-practice gaps in a variety of disciplines facing this challenge. In this commentary, we discuss how implementation science can contribute to closing the knowledge-to-practice gap in occupational science, with a focus on how implementation science can support alignment between applied evidence in occupational science and the contexts in which it can be used to inform multi-level practices. We propose that collaborations between occupational science and implementation science scholars could enhance the pragmatic value of occupational science findings by helping move occupational science evidence about occupation and its relationship to well-being and health from research arenas to real-world contexts where it could have an outsized impact.

The purpose of this study was to complete a scoping review of implementation science (IS) research in communication sciences and disorders (CSD) over time and to determine characteristics of IS research in CSD. A scoping review was conducted of PubMed and Education Resources Information Center for sources published in English that (a) included CSD practitioners, (b) addressed IS research, and (c) identified a specific evidence-based practice. Resulting sources were systematically examined for study aim, patient populations, implementation framework utilized, setting of the study, implementation strategy examined, and implementation outcome measured. The majority of the 82 studies that underwent a full-text review (80.5%) were published in 2014 or later. One fourth of the studies were concept papers, and another one fourth focused on context assessment (25.6% of studies, each), 11% focused on designing implementation strategies, and 36.6% focused on testing implementation strategies. The patient population most frequently represented aphasia (21.3%), and most studies (34.4%) were conducted in inpatient medical settings. Nearly half (42.6%) of the nonconcept studies lacked an IS framework. Among implementation strategies identified, approximately one third of studies focused on education and/or training plus another strategy and one fourth focused on education and/or training alone. Implementation outcomes measured typically represented early stages of implementation. This scoping review of IS research in CSD described the landscape of IS studies in CSD. IS is intersecting with CSD at a rapid rate, especially since 2014. Future IS research in CSD should adopt an implementation framework a priori and consider the broad range of implementation strategies and outcomes to support the uptake of research into typical practice settings.

PurposeIn dementia care, the complexity of psychosocial needs and contextual variables often demands nonpharmacological interventions of a complex nature. The purpose of this scoping review was to investigate (1) how manuals published in refereed journals explaining procedures of complex interventions in dementia care are structured and their content disseminated and (2) to provide recommendations for future manuals.MethodsA systematic search was conducted using four databases (Embase, PsychInfo, CINAHL and Scopus) following PRISMA-ScR and PICo method. The results were analysed using template analysis aiming to describe the possibility of tailoring the intervention, degree of flexibility of the manual and dissemination elements used in the manual.ResultsA total of 882 records were identified, and 86 full-text articles were assessed. Nine articles containing manuals met the inclusion criteria. All of the included manuals allowed the user to tailor actions in the intervention to specific situations. Two-thirds of the manuals showed a medium degree of flexibility. The types of dissemination elements varied. All used written text, and some used various graphical organisers such as headlines and lists. None used illustrations or audio/video material.ConclusionCurrently, only few manuals for complex interventions in the field of dementia are published in refereed journals, all disseminated as written text. For future manuals, we suggest considering the inclusion of illustrations and/or audio/video material to describe actions, to allow for tailoring of the intervention, and to maintain a medium or low degree of flexibility by structuring the content hierarchically in phases while providing the user with detailed description of what to do, and how to decide what to.

Purpose: The purpose of this study was to report the clinical outcomes of delayed speech-language pathology intervention in an individual with Alzheimer's disease and highlight implementation barriers in dementia care. Method: A 63-year-old man diagnosed with Alzheimer's disease went 4.5 years without a speech-language consultation, despite declining cognitive-linguistic abilities noted by his neurologist. Neither he nor his care partner received guidance on interventions, leading the care partner to independently seek services, self-referring to a speech-language pathology clinic where a comprehensive cognitive-communication evaluation was completed. Following the evaluation, a person-centered intervention was implemented incorporating cognitive-communication strategies and care partner training, providing specific methods to enhance communication with the goal of improving quality of care (QoL). Results: The evaluation revealed that, despite severe cognitive impairment and notable word-finding difficulties, he had relatively intact syntactic and grammatical language skills. However, the patient lacked compensatory communication strategies, which hindered his ability to convey overall message effectively, resulting in frequent communication breakdowns. Following speech-language pathology intervention, the patient demonstrated improved functional communication abilities, and both he and his care partner reported enhanced QoL, as documented through standardized outcome measures. Conclusions: This case presentation demonstrates that despite delayed speech-language pathology intervention, individuals with severe dementia and their care partners could benefit from person-centered intervention approaches targeted at communication, safety, and social connection. This case presentation is also a call to action for health care systems to develop standardized clinical pathways where speech-language pathology referrals are initiated early in the progression of the condition.

PMH15 COST-EFFECTIVENESS OF THE MANAGING AGITATION AND RAISING QUALITY OF LIFE IN DEMENTIA (MARQUE) INTERVENTION FOR AGITATION SYMPTOMS IN PEOPLE WITH DEMENTIA IN CARE HOMES

BackgroundCurrent evidence favours a shift away from pharmacological to non‐pharmacological approaches for the prevention and management of non‐cognitive symptoms of dementia. With the limited effectiveness of pharmacological treatments and their risk of adverse effects, it is imperative to understand the effectiveness of non‐pharmacological approaches to dementia care and lived experience. However, there has been little work to date to adapt non‐pharmacological approaches in partnership with Indigenous people. The current model of dementia care is unsafe and inadequate and continued inaction will only lead to continued harm. The primary aim of this research was to develop an implementation‐ready approach to Indigenous‐centered dementia care that has been co‐designed with partnering Indigenous communities.MethodThis study prioritized ethical engagement with Indigenous community members. Participants were recruited through community social media and newsletters. Data were co‐analysed using Indigenous approaches to thematic qualitative analysis to draft a preliminary structure for the Indigenous‐centred dementia care approach. A modified Nominal Group Technique was held with a group of health care providers and decision makers that led to agreement on content and design, as well as the development of training materials for facilitators.ResultFour focus groups (five Indigenous participants with experience of dementia/group) were completed between October and December 2024 for participants to discuss potential content and modes of delivery of an Indigenous‐centred dementia care intervention. Participants identified the need for: 1) culturally‐specific brain health education that includes information on what dementia is; 2) Indigenous‐specific risk identification and dementia prevention; 3) dementia‐friendly Indigenous cultural and spiritual ceremonies; 4) programs for community and facility‐living seniors that involved the traditions of local Indigenous Nations (e.g. jigging, beading, etc); and 5) in‐depth training for staff to deliver the programming.ConclusionThis work will impact numerous populations that need culturally specific approaches to dementia care policy and planning by informing an ethical process to engaging with diverse populations. This work can help health and continuing care services provide community‐specific approaches to non‐pharmacological dementia care.

Using Implementation Science to Optimize the Uptake of Evidence-Based Medicine into Dermatology Practice

The primary aim of this pragmatic stepped-wedge cluster RCT was to determine the efficacy of a co-designed dementia specialist training program (the PITCH program) for home care workers (HCWs) to improve their confidence and knowledge when providing care for clients living with dementia. HCWs who provided care to clients with dementia were recruited from seven home care service provider organisations in Australia between July 2019 and May 2022, and randomised into one of 18 clusters. The primary outcome was HCW's sense of self-competence in providing care services to people living with dementia at 6months post PITCH training measured by the Sense of Competence in Dementia Care Staff (SCIDS) Scale. Two hundred and thirteen HCWS completed baseline assessment and almost half (48.4%) completed all three study assessments. HCWs in clusters that received PITCH training had significantly higher sense of competence (measured by SCIDS) than those who had not received PITCH training. Post hoc analysis revealed that face-to-face PITCH training consistently resulted in improvements in the HCWs sense of competence, dementia attitudes and knowledge when compared to online training and when compared to no training. PITCH training had no effect on the sense of strain HCWs felt in delivering dementia care. Given the majority of care for people living with dementia is provided at home by family carers supported by HCWs, it is essential that HCWs receive training that improves their skills in dementia care. This study is an important step towards better care at home for people living with dementia.

Education and training in residential dementia care in Australia: needs, provision and directions