Dementia care from behind the mask? Maintaining well-being during COVID-19 pandemic restrictions: Observations from Dementia Care Mapping on NHS mental health hospital wards in Wales.

WHAT IS KNOWN ON THE SUBJECT?: Coronavirus disease 2019 (COVID-19) is a new infectious disease that has spread across the world and infected a large number of people many of whom have died. People with moderate to severe dementia are at very high risk of becoming infected as the disease mainly impacts on older people with other health problems and once infected the person with dementia is more likely to become seriously ill than other people. To prevent infection, people are required to wear masks and isolate from contact with others. It is believed that these measures can reduce the quality of life and general well-being of people with moderate to severe dementia in hospital or social care. This belief has not yet been demonstrated by research. WHAT DOES THIS PAPER ADD TO THE EXISTING KNOWLEDGE?: We show that people with moderate to severe dementia receiving care on mental health hospital wards and subject to strict infection prevention measures can still achieve high levels of well-being. We show that mental health nurses alter the focus of their care to deliberately overcome the challenges and particularly the restrictions on visiting by families. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: We believe that the changes in practice we observed can occur in other healthcare and social care settings and that whilst restrictions remain in place care staff can protect and possibly enhance well-being for people with moderate to severe dementia. ABSTRACT: Introduction The effect of coronavirus (COVID-19) on people living with dementia is potentially severe in its clinical impacts. More widely, for this vulnerable group, the social restrictions to limit the spread of infection may be emotionally and psychologically damaging. Aim To explore the impact of restrictions on well-being for people with moderate to severe dementia in acute mental health hospital care. Method "Dementia Care Mapping" was the observational tool used to determine well- or ill-being. Observations were undertaken in two mental health hospital wards during a time of restrictions and the use of personal protective equipment. Results We report levels of well-being that are higher than might be expected alongside a change in the focus of psychological care delivered through mental health nursing interventions aimed at enhancing well-being. Discussion-We postulate that mental health nurses faced with an unprecedented challenge respond by changing practice to mitigate for infection prevention measures and to compensate for family absence. Implications for practice We suggest that the desirable enhancing actions by nursing staff which raise well-being in these hospital settings are readily transferable to other settings that are aiming to maintain well-being but also practising under COVID-19 restrictions.

Same map, different direction - Exploring new opportunities that dementia care mapping™ can offer to acute mental health admission wards for older people - Innovative practice.

Dementia Care Mapping™ is widely acknowledged as the gold standard observational method that can support the introduction of person centred care into a variety of settings ( http://www.bradford.ac.uk/health/dementia/dementia-care-mapping/ ). It encourages care staff to think about how the person with dementia is experiencing the care provided and the care setting. It has been shown to raise care staff awareness sufficiently to bring about improvements in care. In this paper, we describe a programme of work in North Wales that seeks to find innovative ways to use Dementia Care Mapping™, in acute mental health admission wards for people affected by dementia, and we set out some of those innovations.

Sexual Safety for In-Patient Mental Health Care-The Democratic Diagnosis of Change.

This article discusses a co-produced qualitative understanding aimed at reducing the risk of sexual violence within mental health in-patient settings. It describes the first stages of testing a new approach which democratises organisational change as, people who use mental health services take the lead in partnership working with those who provide services. The article sets out 'TODAYICAN' (and its second-generation iteration, 'TODAYWECAN') as emerging approaches towards change. In particular, the article focusses upon the 'diagnose' component of the approach and reports findings from a mixed methods qualitative methodology. In doing so the article offers a conceptualisation of in-patient sexual safety in a mental health context drawn from the perspectives of people who use or provide in-patient services. The article also outlines where the consensus rests on what needs to change to make sexual safety an 'always event' whilst, critically analysing where the two groups differed in their views.

Glycogen synthase kinase 3 beta alters anxiety-, depression-, and addiction-related behaviors and neuronal activity in the nucleus accumbens shell.

Psychiatric disorders such as anxiety, depression and addiction are often comorbid brain pathologies thought to share common mechanistic biology. As part of the cortico-limbic circuit, the nucleus accumbens shell (NAcSh) plays a fundamental role in integrating information in the circuit, such that modulation of NAcSh circuitry alters anxiety, depression, and addiction-related behaviors. Intracellular kinase cascades in the NAcSh have proven important mediators of behavior. To investigate glycogen-synthase kinase 3 (GSK3) beta signaling in the NAcSh in vivo we knocked down GSK3beta expression with a novel adeno-associated viral vector (AAV2) and assessed changes in anxiety- and depression-like behavior and cocaine self-administration in GSK3beta knockdown rats. GSK3beta knockdown reduced anxiety-like behavior while increasing depression-like behavior and cocaine self-administration. Correlative electrophysiological recordings in acute brain slices were used to assess the effect of AAV-shGSK3beta on spontaneous firing and intrinsic excitability of tonically active interneurons (TANs), cells required for input and output signal integration in the NAcSh and for processing reward-related behaviors. Loose-patch recordings showed that TANs transduced by AAV-shGSK3beta exhibited reduction in tonic firing and increased spike half width. When assessed by whole-cell patch clamp recordings these changes were mirrored by reduction in action potential firing and accompanied by decreased hyperpolarization-induced depolarizing sag potentials, increased action potential current threshold, and decreased maximum rise time. These results suggest that silencing of GSK3beta in the NAcSh increases depression- and addiction-related behavior, possibly by decreasing intrinsic excitability of TANs. However, this study does not rule out contributions from other neuronal sub-types.

Care to talk? A framework for appreciative conversations about dementia: Innovative practice.

When people with dementia are admitted to hospital, both they and their carers and families have crucial roles to play. They should be positioned as the only true experts in the unique individuality of the person and brought into the nursing process as an equal partner in care. 'Care to Talk' is a conversational model developed through Appreciative Inquiry to facilitate this way of working. The model, its development and outcomes are discussed.

Transgender, Mental Health, and Older People: An Appreciative Approach Towards Working Together.

It cannot be assumed by healthcare providers that transgender people routinely receive care and treatment that is of the quality and sensitivity that should be expected. In particular there are concerns from within the transgender community that they experience discrimination and disrespect from both individual practitioners and the healthcare system as a whole. This causes an avoidance of contact that is undesirable for both users and providers of healthcare services. Older transgender people are vulnerable to a range of mental health problems and, like all elderly, increasingly to dementia; failure to access specialist services in a timely manner may result in unnecessary distress and potentially to crisis. This paper reports on the use of an appreciative inquiry approach towards identifying the opportunities for one health board in North Wales to work more closely with older members of the transgender community it serves.

Dementia RED (Respect Empathy Dignity): Collaborating to build dementia supportive communities in North Wales--reporting on a pilot project (innovative practice).

There is increasing interest in developing dementia supportive communities world wide. Dementia RED (Respect Empathy Dignity) is a unique example from North Wales which is based on the twin concepts of people living with dementia as citizens in their community and developing 'bottom up' rather than 'top down' approaches to dementia supportive communities. Most people with dementia prefer to live at home thus making community connectivity key to maintaining healthy relationships and wellbeing. For those living with dementia, the community plays a pivotal role in providing value, meaning, purpose and acceptance. Building dementia supportive communities helps to raise awareness about dementia in the community through engagement and from identifying champions in the locality to voice issues. Dementia RED is an initiative and service which helps to develop such a philosophy in creating a dementia supportive community.

'Doing things differently'--working towards distributed responsibility within memory assessment services.

OBJECTIVES: To compare initial diagnostic hypotheses made by Allied Health Professionals (AHP) (mental health nurses, occupational therapists and social workers) with subsequent formal multidisciplinary formulation based upon the full possession of investigations, neuropsychological tests and brain imaging. Design Prospective analysis. DESIGN: Prospective analysis. SETTING: Home-based assessments, secondary care based multidisciplinary memory clinic. PARTICIPANTS: 90 consecutive referrals over a 3-month period. RESULTS: Fifty eight patients (64.4%) were diagnosed by the multi-disciplinary team as having a dementia. Twenty (34%) were classified as Alzheimer's disease, 28 (49%) of mixed sub-type and 9 (16%) of vascular origin. Together, AHP's were able to detect dementia with 91% accuracy (Kappa 0.81) sensitivity was 0.88 and specificity 0.97. The diagnostic accuracy for each professional group ranged from 88% to 93% (Kappa 74-90%). CONCLUSIONS: In this study, structured initial assessment by AHP's working in a Memory Assessment Service was shown to be an accurate method of determining a diagnosis of cognitive impairment, when compared with formal MDT judgment. It is suggested that such distributed responsibility affords a viable option for the future detection of early dementia.

Transcultural influences in dementia care: observations from a psychosocial intervention study.

BACKGROUND: Various models of intervention for caregivers of patients with dementia have been described. There has been little direct comparison of cultural differences between countries and the effect any differences may exert on the outcome of caregiver interventions. AIMS: The aims of the three-country study (USA, Australia and the UK) were to assess whether caregiver interventions can still be successful when anti-dementia drugs are provided to patients, and whether a caregiver intervention can be successfully implemented using the same methods in three different English-speaking countries. In this paper, the cultural differences and similarities between the three countries are examined. METHOD: Randomised, controlled trial involving 158 patients and their caregivers (divided equally across three centres, New York, Sydney and Manchester) with all the patients receiving donepezil and the caregivers randomised to a caregiver intervention or treatment as usual. RESULTS: There were few differences between countries in the main outcome measures, and no differences between the treatment-as-usual group and the intervention, but interesting cultural nuances were observed between groups. Despite these differences, the caregiver intervention was associated with positive results on caregiver depression across all the countries. CONCLUSIONS: This first multinational carer intervention study has emphasised the similarities between the three countries whilst highlighting crucial differences which may be important when planning cross-cultural studies in the future. The positive results achieved on caregiver depression were replicated across the three centres.

Counting costs. Patients will suffer from limits on Alzheimer's drugs.

Draft guidelines from the National Institute for Health and Clinical Excellence (NICE), currently out for consultation, have suggested that drugs for the treatment of Alzheimer's disease should not be prescribed on the NHS. If this becomes policy, much of the proactive work in dementia care could be lost.

Changing attitudes in dementia care and the role of nurses.

Dementia care has been seen as a low priority, but with an estimated 700,000 people in the UK with dementia and an ageing population this is changing. The Alzheimer's Society will be holding events this week to raise awareness of dementia, sending a strong message to policy makers that dementia is a serious health issue. Nurses have also become active in fighting the old degenerative model of dementia and promoting the concept of person-centred care.