End-of-life care in German and Dutch nursing homes: a cross-sectional study on nursing home staff's perspective in 2022.

BACKGROUND: As society ages, the need for nursing home care is steadily increasing and end-of-life care of nursing home residents has become increasingly more important. End-of-life care differs between Germany and the neighbouring Netherlands. For example, a much higher proportion of German compared to Dutch nursing home residents is hospitalized at the end of life. Therefore, the aim of this study was to evaluate end-of-life care in German and Dutch nursing homes. METHODS: In this cross-sectional study, a postal survey was sent to 600 randomly selected German and Dutch nursing homes each and addressed to the nursing staff management. Participants were asked to estimate the percentage of nursing home residents whose wishes for emergency situations (e.g. cardiopulmonary resuscitation) are known and to indicate whether facilities offer advanced care planning (ACP). They were also asked to estimate whether general practitioners (GPs)/elder care physicians (ECPs) and nursing home staff are usually well trained for end-of-life care. Finally, participants were asked to estimate the proportion of nursing home residents who die in hospital rather than in the nursing home and to rate overall end-of-life care provision. RESULTS: A total of 301 questionnaires were included in the analysis; 199 from German and 102 from Dutch nursing homes (response 33.2% and 17.0%). German participants estimated that 20.5% of residents die in the hospital in contrast to the Dutch estimation of 5.9%. In German nursing homes, ACP is offered less often (39.2% in Germany, 75.0% in the Netherlands) and significantly fewer wishes for emergency situations of residents were known than in Dutch nursing homes. GPs were considered less well-trained for end-of-life care in Germany. The most important measures to improve end-of-life care were comparable in both countries. CONCLUSION: Differences in (the delivery and knowledge of) end-of-life care between Germany and the Netherlands could be observed in this study. These could be due to structural differences (ECPs available 24/7 in the majority of Dutch nursing homes) and cultural differences (more discussion on quality of life versus life-sustaining treatments in the Netherlands). Due to these differences, a country-specific approach is necessary to improve end-of-life care.

Differences in emergency department visits and hospitalization between German and Dutch nursing home residents: a cross-national survey.

PURPOSE: Assessing and comparing German and Dutch nursing home perspectives on residents' hospital transfers. METHODS: Cross-sectional study among German and Dutch nursing homes. Two surveys were conducted in May 2022, each among 600 randomly selected nursing homes in Germany and the Netherlands. The questionnaires were identical for both countries. The responses were compared between the German and Dutch participants. RESULTS: We received 199 German (response: 33.2%) and 102 Dutch questionnaires (response: 17.0%). German nursing homes estimated the proportion of transfers to hospital during 1 year to be higher than in Dutch facilities (emergency department visits: 26.5% vs. 7.9%, p < 0.0001; hospital admissions: 29.5% vs. 10.5%, p < 0.0001). In German nursing homes, the proportion of transfers to hospital where the decision was made by the referring physician was lower than in the Dutch facilities (58.8% vs. 88.8%, p < 0.0001). More German nursing homes agreed that nursing home residents are transferred to the hospital too frequently (24.5% vs. 10.8%, p = 0.0069). German nursing homes were much more likely than Dutch facilities to believe that there was no alternative to transfer to a hospital when a nursing home resident had a fall (66.3% vs. 12.8%, p < 0.0001). CONCLUSION: German nursing home residents are transferred to hospital more frequently than Dutch residents. This can probably be explained by differences in the care provided in the facilities. Future studies should, therefore, look more closely at these two systems and examine the extent to which more intensive outpatient care can avoid transfers to hospital.

The effects of individual music therapy in nursing home residents with dementia to improve general well-being: study protocol of a randomized controlled trial.

BACKGROUND: Dementia is often associated with Neuropsychiatric Symptoms (NPS) such as agitation, depression, hallucinations, anxiety, that can cause distress for the resident with dementia in long-term care settings and can impose emotional burden on the environment. NPS are often treated with psychotropic drugs, which, however, frequently cause side effects. Alternatively, non-pharmacological interventions can improve well-being and maintain an optimal quality of life (QoL) of those living with dementia. Other QoL related outcomes, such as pain, discomfort and sleep disruption are relevant outcomes in music trials as well. Music therapy is a non-pharmacological intervention that can reduce NPS and improve well-being, and its associated symptoms in dementia. METHODS: The research will be conducted at eight nursing home facilities of a health care organization in the Netherlands. A sample size of 30 in each group (experimental and control group) is required, totalling 60 residents increased to 80 when considering expected drop out to follow up. The participants in the intervention group receive 30 min of individual music therapy (MT) in their own room by a music therapist twice a week for 12 weeks. The participants in the control group will receive 30 min of individual attention in their own room by a volunteer twice a week for 12 weeks. Assessments will be done at baseline, 6 weeks and 12 weeks. An independent observer, blinded for the intervention or control condition, will assess directly observed well-being (primary outcome) and pain (secondary outcome) before and after the sessions. Nurses will assess other secondary outcomes unblinded, i.e., perceived quality of life and NPS, both assessed with validated scales. The sleep duration will be indirectly assessed by a wrist device called MotionWatch. Information about psychotropic drug use will be derived from electronic medical chart review. DISCUSSION: The main purpose of this study is to assess the effects of individual music therapy on directly observed well-being controlled for individual attention in nursing home residents with dementia with NPS. The outcomes refer to both short-term and long-term effects consistent with therapeutic goals of care for a longer term. We hope to overcome limitations of previous study designs such as not blinded designs and music facilitators that were not only music therapists but also occupational therapists and nurses. This study should lead to more focused recommendations for practice and further research into non-pharmacological interventions in dementia such as music therapy. TRIAL REGISTRATION: The trial is registered at the International Clinical Trials Registry Platform (ICTRP) search portal in the Netherlands Trial Registration number NL7708, registration date 04-05-2019.

Effects of a music therapy and music listening intervention for nursing home residents with dementia: a randomized controlled trial.

Introduction: The aim of the present study was to evaluate the effects of an individual music therapy intervention and an individual music listening intervention on neuropsychiatric symptoms and quality of life in people with dementia living in a nursing home and on professional caregiver's burden to be able to make statements about their specific value of application in clinical practice. Methods: A multicenter single blind randomized controlled trial with three groups was performed: an individual music therapy intervention (IMTI) group (n = 49), an individual music listening intervention (IMLI) group (n = 56) and a control group (n = 53) receiving usual care. The interventions were given during three weeks, three times a week on non-consecutive days during 30-45 minutes for in total nine sessions. The endpoint of the study is the difference from baseline to interim (1,5 week), post-intervention (3 weeks) and follow-up (6 weeks) in reported scores of problem behaviour (NPI-NH) and quality of life (Qualidem) in people with dementia and occupational disruptiveness (NPI-NH) in care professionals. Results: In total 158 people with dementia were randomized to one of the two intervention groups or the control group. Multilevel analyses demonstrated that hyperactive behaviour assessed by the NPI-NH was significantly more reduced for the IMLI group at follow up and that restless behaviour assessed by the Qualidem was significantly more reduced for the IMTI group at post and follow-up measurement compared to the control group. No significant effects between groups were found in other NPI-NH clusters or Qualidem subscales. Conclusion: In conclusion, because we found no convincing evidence that the IMTI or IMLI is more effective than the other both interventions should be considered in clinical practice. For the future, we advise further research into the sustainability of the effects with alternative designs, like a single case experimental design.

The prognosis of delirium in older outpatients.

BACKGROUND: Delirium is a common and serious neuropsychiatric disorder. The prognosis of delirium in older patients living at home has not been studied often before. The aim of this study is to examine the prognosis of delirium in patients attending a memory clinic of a psychiatric hospital. METHOD: The study population consisted of 85 outpatients diagnosed with delirium between October 2013 and October 2014. Seventeen patients had already been diagnosed as having dementia. Three months after the diagnosis, consenting patients underwent a follow-up visit. We recorded delirium status (remitted or not), new dementia diagnosis, subjective cognitive functioning compared to baseline and to before delirium, level of daily functioning, and place of residence. RESULTS: After 3 months, 45 (53%) had recovered from delirium, 19 (22,4%) had persistent/recurrent delirium, 12 (14%) patients had died, and another nine (11%) could not be revisited for other reasons than death. None of the 64 re-examined patients reported that their cognitive functioning had recovered to the pre-delirium level, and the mean level of daily functioning did not substantially improve either. The rate of diagnosed dementia increased to 63.8%, and 18 patients (28.1%) had moved to a nursing home. CONCLUSIONS: Delirium in older outpatients has a poor prognosis. A larger study on the risk factors of the prognosis of delirium in older persons living at home is advised.

Patterns of psychotropic drug prescriptions and general practice consultations among community-dwelling older people with dementia during the first two years of the COVID-19 pandemic.

BACKGROUND: The COVID-19 pandemic and subsequent lockdown measures had serious implications for community-dwelling older people with dementia. While the short-term impacts of the pandemic on this population have been well studied, there is limited research on its long-term impacts. Quantifying the long-term impacts may provide insights into whether healthcare adaptations are needed after the acute phase of the pandemic to balance infection prevention measures with healthcare provision. This study aims to examine patterns of psychotropic drug prescriptions and general practice consultations in community-dwelling older people with dementia during the first two years of the pandemic. METHODS: We utilised routine electronic health records from three Dutch academic general practice research networks located in the North, East, and South, between 2019 and 2021. We (1) compared the weekly prescription rates of five groups of psychotropic drugs and two groups of tracer drugs, and weekly general practice consultation rates per 1000 participants, between the first two years of the pandemic and the pre-pandemic phase, (2) calculated changes in these rates during three lockdowns and two relaxation phases relative to the corresponding weeks in 2019, and (3) employed interrupted time series analyses for the prescription rates. Analyses were performed for each region separately. RESULTS: The study population sizes in the North, East, and South between 2019 and 2021 were 1726 to 1916, 93 to 117, and 904 to 960, respectively. Data from the East was excluded from the statistical analyses due to the limited sample size. During the first two years of the pandemic, the prescription rates of psychotropic drugs were either lower or similar to those in the pre-pandemic phase, with differences varying from -2.6‰ to -10.2‰. In contrast, consultation rates during the pandemic were higher than in the pre-pandemic phase, increasing by around 38‰. CONCLUSIONS: This study demonstrates a decrease in psychotropic drug prescriptions, but an increase in general practice consultations among community-dwelling older people with dementia during the first two years of the pandemic. However, reasons for the decrease in psychotropic drug prescriptions are unclear due to limited information on the presence of neuropsychiatric symptoms and the appropriateness of prescribing.

Comparison of medical care needs and actual care in German and Dutch nursing home residents: A cross-sectional study conducted in neighboring European countries.

OBJECTIVE: Assessing and comparing characteristics of German and Dutch nursing homes, their residents as well as residents' medical care needs and the actual provision of care. METHODS: Two surveys were conducted among 600 randomly selected nursing homes each from Germany and the Netherlands. Questionnaires were mailed in May 2022. Responses were compared between German and Dutch respondents. RESULTS: We received 199 German (response: 33.2%) and 102 Dutch questionnaires (response: 17.0%). Residents' characteristics were comparable in both countries. While German nursing homes rated residents' general medical care needs higher than Dutch facilities (87.9% vs. 78.4%), the reverse was true for dental care needs (81.4% vs. 71.1%). For all 4 medical specialties surveyed, German nursing homes saw a need for treatment more frequently than Dutch facilities, e.g., 48.3% vs. 11.7% for neurology. In addition, Dutch nursing homes significantly more often considered general practitioners/elder care physicians (GPs/ECPs) to be able to cover these needs. The number of GP/ECP contacts per resident per year was similar in both countries (Germany: 26.5; Netherlands: 28.7). Almost all Dutch facilities had permanently employed allied health professionals (e.g. physiotherapists), whereas this was rarely the case in Germany. CONCLUSIONS: We observed large differences in nursing home residents' medical care. It appears that GPs/ECPs in the Netherlands cover needs deemed to require specialist consultations in Germany. Some differences between countries can possibly be explained by system-cultural differences. Future studies should therefore look closely at the process of medical care provision and its quality in nursing homes in both countries.

Effects of the DICE Method to Improve Timely Recognition and Treatment of Neuropsychiatric Symptoms in Early Alzheimer's Disease at the Memory Clinic: The BEAT-IT Study.

BACKGROUND: Neuropsychiatric symptoms (NPS) are highly prevalent in Alzheimer's disease (AD) and are associated with negative outcomes. However, NPS are currently underrecognized at the memory clinic and non-pharmacological interventions are scarcely implemented. OBJECTIVE: To evaluate the effectiveness of the Describe, Investigate, Create, Evaluate (DICE) method™ to improve the care for NPS in AD at the memory clinic. METHODS: We enrolled sixty community-dwelling people with mild cognitive impairment or AD dementia and NPS across six Dutch memory clinics with their caregivers. The first wave underwent care as usual (n = 36) and the second wave underwent the DICE method (n = 24). Outcomes were quality of life (QoL), caregiver burden, NPS severity, NPS-related distress, competence managing NPS, and psychotropic drug use. Reliable change index was calculated to identify responders to the intervention. A cost-effectiveness analysis was performed and semi-structured interviews with a subsample of the intervention group (n = 12). RESULTS: The DICE method did not improve any outcomes over time compared to care as usual. Half of the participants of the intervention group (52%) were identified as responders and showed more NPS and NPS-related distress at baseline compared to non-responders. Interviews revealed substantial heterogeneity among participants regarding NPS-related distress, caregiver burden, and availability of social support. The intervention did not lead to significant gains in quality-adjusted life years and well-being years nor clear savings in health care and societal costs. CONCLUSION: The DICE method showed no benefits at group-level, but individuals with high levels of NPS and NPS-related distress may benefit from this intervention.

The longitudinal patterns of psychotropic drug prescriptions for subpopulations of community-dwelling older people with dementia: electronic health records based retrospective study.

BACKGROUND: Studies focusing on patterns of psychotropic drug prescriptions (PDPs) for subpopulations of community-dwelling older people with dementia are lacking. OBJECTIVE: The aim of this study was to identify the longitudinal patterns of PDPs in subpopulations. METHODS: This retrospective study used electronic health records from general practitioners (GPs) in the Netherlands. People (N = 1278) firstly diagnosed with dementia between 2013 and 2015, aged 65 years or older, were selected and categorized into four subpopulations: community-dwelling (CD) group throughout follow-up, ultimately admitted to nursing homes (NH) group, ultimately died (DIE) group, and ultimately deregistered for unclear reasons (DeR) group. Generalised estimating equations were used to estimate the patterns of psychotropic drug prescriptions, after the diagnosis of dementia for a five-year follow-up, and 0-3 months before institutionalisation or death. RESULTS: Over the five-year follow-up, antipsychotic prescriptions increased steadily in CD (OR = 1.07 [1.04-1.10]), NH (OR = 1.10 [1.04-1.15]), and DIE (OR = 1.05 [1.02-1.08]) groups. Similarly, prescriptions of antidepressants also showed upward trends in CD (OR = 1.04 [1.02-1.06]), NH (OR = 1.10 [1.02-1.18]), and DIE (OR = 1.04 [1.00-1.08]) groups. The other psychotropic drugs did not show clear changes over time in most of the subpopulations. In the three months before institutionalisation, antipsychotic prescriptions increased (OR = 2.12 [1.26-3.57]) in the NH group compared to prior periods. Likewise, before death, prescriptions of antipsychotics (OR = 1.74 [1.28-2.38]) and hypnotics and sedatives (OR = 2.11 [1.54-2.90]) increased in the DIE group, while anti-dementia drug prescriptions decreased (OR = 0.42 [0.26-0.69]). CONCLUSIONS: After community-dwelling older people are diagnosed with dementia, all subpopulations' prescriptions of antipsychotics and antidepressants increase continuously during the follow-up. While we cannot judge whether these prescriptions are appropriate, GPs might consider a more reluctant use of psychotropic drugs and use alternative psychosocial interventions. Additionally, antipsychotic prescriptions rise considerably shortly before institutionalisation or death, which might reflect that older people experience more neuropsychiatric symptoms during this period.

A Qualitative Evaluation of the Implementation of an Oral Care Program in Home Care Nursing.

An Oral Care Program (OCP) was implemented in home care nursing teams in a northern province of the Netherlands to improve the oral health and hygiene of older people who make use of formal home care in 2018-2019. The aim of the current study was to evaluate the experiences of the stakeholders involved (older people, home-care nurses and dental hygienists) and to report the experienced impact of OCP, with a qualitative approach. Three dental hygienists, nine home care nurses, and eight older people were interviewed with semi-structured interviews, which were audio recorded, transcribed and analyzed using thematic analysis. The codes derived were grouped into nine main themes. OCP was experienced as mostly positive by all stakeholders involved. The educational part lead to more awareness towards oral care, but should be repeated regularly. Personalized oral care plans for older people were experienced positively, however, obtaining oral care behavior changes appeared to be difficult. Collaboration between dental hygienists and home care nurses lead to a positive experience from both sides The method and intensity of collaboration varied between the teams. To provide better access to oral health care for older people in the community, a long term collaboration between home care nursing teams and dental care professionals in their working area should be established.

Well-being, multidisciplinary work and a skillful team: essential elements of successful treatment in severe challenging behavior in dementia.

OBJECTIVE: Conceptualize successful treatment of persons with dementia and severe challenging behavior as perceived by professionals. METHODS: In this concept mapping study 82 experts in dementia care participated. The study followed two phases of data collection: (1) an online brainstorm where participants completed the focus prompt: 'I consider the treatment of people with severe challenging behavior in dementia successful if.'; (2) individual sorting and rating of the collected statements followed by data analysis using multidimensional scaling and hierarchical cluster analysis, resulting in a concept map. RESULTS: Three clusters were identified, the first addressing treatment outcomes and the latter two addressing treatment processes, each divided into sub-clusters: (1) well-being, comprising well-being of the person with dementia and all people directly involved; (2) multidisciplinary analysis and treatment, comprising multidisciplinary analysis, process conditions, reduction in psychotropic drugs, and person-centered treatment; and (3) attitudes and skills of those involved, comprising consistent approach by the team, understanding behavior, knowing how to respond to behavior, and open attitudes. CONCLUSIONS: Successful treatment in people with dementia and severe challenging behavior focuses on well-being of all people involved wherein attention to treatment processes including process conditions is essential to achieve this.

Soundscape Awareness Intervention Reduced Neuropsychiatric Symptoms in Nursing Home Residents With Dementia: A Cluster-Randomized Trial With MoSART.

OBJECTIVES: Auditory environments as perceived by an individual, also called soundscapes, are often suboptimal for nursing home residents. Poor soundscapes have been associated with neuropsychiatric symptoms (NPS). We evaluated the effect of the Mobile Soundscape Appraisal and Recording Technology sound awareness intervention (MoSART+) on NPS in nursing home residents with dementia. DESIGN: A 15-month, stepped-wedge, cluster-randomized trial. Every 3 months, a nursing home switched from care as usual to the use of the intervention. INTERVENTION: The 3-month MoSART+ intervention involved ambassador training, staff performing sound measurements with the MoSART application, meetings, and implementation of microinterventions. The goal was to raise awareness about soundscapes and their influence on residents. SETTING AND PARTICIPANTS: We included 110 residents with dementia in 5 Dutch nursing homes. Exclusion criteria were palliative sedation and deafness. METHODS: The primary outcome was NPS severity measured with the Neuropsychiatric Inventory-Nursing Home version (NPI-NH) by the resident's primary nurse. Secondary outcomes were quality of life (QUALIDEM), psychotropic drug use (ATC), staff workload (workload questionnaire), and staff job satisfaction (Maastricht Questionnaire of Job Satisfaction). RESULTS: The mean age of the residents (n = 97) at enrollment was 86.5 ± 6.7 years, and 76 were female (76.8%). The mean NPI-NH score was 17.5 ± 17.3. One nursing home did not implement the intervention because of staff shortages. Intention-to-treat analysis showed a clinically relevant reduction in NPS between the study groups (-8.0, 95% CI -11.7, -2.6). There was no clear effect on quality of life [odds ratio (OR) 2.8, 95% CI -0.7, 6.3], psychotropic drug use (1.2, 95% CI 0.9, 1.7), staff workload (-0.3, 95% CI -0.3, 0.8), or staff job satisfaction (-0.2, 95% CI -1.2, 0.7). CONCLUSIONS AND IMPLICATIONS: MoSART+ empowered staff to adapt the local soundscape, and the intervention effectively reduced staff-reported levels of NPS in nursing home residents with dementia. Nursing homes should consider implementing interventions to improve the soundscape.

Feasibility, usability and clinical value of intensive longitudinal diary assessments in older persons with cognitive impairment and depressive symptoms.

OBJECTIVES: To evaluate the feasibility, usability and clinical value of daily diary assessments combined with actigraphy in older persons with cognitive impairment. METHODS: For 63 days, patients ≥60 years with cognitive impairments filled out a daily diary (including standardized questionnaires and cognitive test battery), and wore an actiwatch (sleep). After the study, participants and clinicians received personal feedback about patterns and daily triggers of depressive symptoms, sleep and cognitive performance. We assessed feasibility (participation rate, compliance and subjective burden), usability (variability and floor- or ceiling effects) and clinical value for patients and their clinicians (questionnaires). RESULTS: Of 96 eligible patients, 13 agreed to participate (13.5%). One patient dropped out after 2 days, another after 37 days, and another did not complete the cognitive test battery. Compliance rate was high (6.7-10% missing values). Subjective burden was relatively low. Time-series data showed sufficient variability and no floor- or ceiling effects, except for one relevant ceiling effect on the One Back task. The personal feedback report was considered insightful by 4 out of 11 participants and 5 out of 7 clinicians. CONCLUSION: Daily assessments are suitable for a minority of cognitively impaired older persons, but is helpful to increase insight into their symptoms.

Losing hope or keep searching for a golden solution: an in-depth exploration of experiences with extreme challenging behavior in nursing home residents with dementia.

BACKGROUND: Situations of extreme challenging behavior such as very frequent and/or severe agitation or physical aggression in nursing home residents with dementia can be experienced as an impasse by nursing home staff and relatives. In this distinct part of our WAALBED (WAAL-Behavior-in-Dementia)-III study, we aimed to explore these situations by obtaining the experiences and perspectives of nursing home staff and relatives involved. This can provide a direction in providing tools for handling extreme challenging behavior of nursing home residents with dementia and may improve their quality of life. METHODS: Qualitative multiple case study with individual interviews and focus group discussions. Interviewees were elderly care physicians, psychologists, care staff members, unit managers and relatives (n = 42). They were involved with nursing home residents with dementia and extreme challenging behavior living on dementia special care units in the Netherlands. For these residents, external consultation by the Centre for Consultation and Expertise was requested. Audio-recordings of the interviews were transcribed verbatim and analyzed with thematic analysis, including conventional content analysis. RESULTS: Seven cases were included. Forty-one individual interviews and seven focus group discussions were held. For six stakeholder groups (resident, relative, care staff, treatment staff, nursing home staff, and the organization), three main factors could be identified that contributed to experiencing a situation of extreme challenging behavior as an impasse: 1) characteristics and attitudes of a stakeholder group, 2) interaction issues within a stakeholder group and 3) interaction issues among (groups of) stakeholders. The experienced difficulties with the resident's characteristics, as well as suboptimal interdisciplinary collaboration and communication among the nursing home staff are remarkable. Nursing home staff kept searching for a golden solution or lost hope. CONCLUSIONS: This study offers important insights into situations of extreme challenging behavior in nursing home residents with dementia and offers caregivers targets for improving care, treatment and interdisciplinary collaboration, such as working uniformly and methodically.

Psychotropic drug treatment for agitated behaviour in dementia: what if the guideline prescribing recommendations are not sufficient? A qualitative study.

BACKGROUND: Agitation is a common challenging behaviour in dementia with a negative influence on patient's quality of life and a high caregiver burden. Treatment is often difficult. Current guidelines recommend restrictive use of psychotropic drug treatment, but guideline recommendations do not always suffice. OBJECTIVE: To explore how physicians decide on psychotropic drug treatment for agitated behaviour in dementia when the guideline prescribing recommendations are not sufficient. METHODS: We conducted five online focus groups with a total of 22 elderly care physicians, five geriatricians and four old-age psychiatrists, in The Netherlands. The focus groups were thematically analysed. RESULTS: We identified five main themes. Transcending these themes, in each of the focus groups physicians stated that there is 'not one size that fits all'. The five themes reflect physicians' considerations when deciding on psychotropic drug treatment outside the guideline prescribing recommendations for agitated behaviour in dementia: (1) 'reanalysis of problem and cause', (2) 'hypothesis of underlying cause and treatment goal', (3) 'considerations regarding drug choice', (4) 'trial and error' and (5) 'last resort: sedation'. CONCLUSION: When guideline prescribing recommendations do not suffice, physicians start with reanalysing potential underlying causes. They try to substantiate and justify medication choices as best as they can with a hypothesis of underlying causes or treatment goal, using other guidelines, and applying personalised psychotropic drug treatment.

Cost-effectiveness of dementia training for caregivers in caregiver-patient dyads: A randomized controlled study.

Introduction: We evaluated the cost-effectiveness of the "More at Home with Dementia" intervention, a multicomponent training program for co-residing caregivers of people with dementia (PwDs). Methods: We performed a two-armed randomized controlled trial with an intervention and a control group. Participants were community-dwelling caregivers living with a person with dementia (59 randomized to intervention and 50 to control arm). The training program lasted 5 days and took place in a holiday accommodation. Quality-adjusted life-years (QALYs) were calculated using the EuroQol-5 Dimensions 3 Levels (EQ-5D-3L) for caregivers and PwDs. Costs for informal and formal social care, as well as health care, were collected at four times over a 6-month period from baseline. Information on nursing home admission or death was collected for 2 years after baseline. Results: QALYs for caregivers and PwDs added together were 0.12 higher in the intervention group compared with the control group (P = .11). After 1 year, there tended to be fewer nursing home admissions in the intervention group, but this difference was lost by 2 years (P = .19). The cost of the intervention was estimated at €1000 (USD 1090) per dyad. Compared with the control group, the intervention group used other health care and formal social care significantly less for a year after baseline (P = .02 and .001, respectively). The estimated decrease in total costs was €10,437 (P = .07), with an estimated 96% probability that the intervention was cost-effective vs usual care. Discussion: The multicomponent "More at Home with Dementia" training program is effective and appears to save costs compared with usual care. Savings appear to be achieved by delaying nursing home admissions and by reducing the use of other care resources. Further research is also needed to clarify if this intervention is effective for caregivers who do not live with a PwD, such as adult children, and for the caregivers of patients with other debilitating chronic diseases. At the same time, effort is advised to implement caregiver training in standard care programs.

Distancing Measures and Challenges Discussed by COVID-19 Outbreak Teams of Dutch Nursing Homes: The COVID-19 MINUTES Study.

The most severe COVID-19 infections and highest mortality rates are seen among long-term care residents. To reduce the risk of infection, physical distancing is important. This study investigates what physical distancing measures were discussed by COVID-19 outbreak teams of Dutch long-term care organizations and what challenges they encountered. The COVID-19 MINUTES study is a qualitative multi-center study (n = 41) that collected minutes of COVID-19 outbreak teams from March 2020 to October 2021. Textual units about distancing measures were selected and analyzed using manifest content analysis for the first wave: early March-early May 2020; the intermediate period of 2020: mid-May-mid-September 2020; and the second wave: late September 2020-mid-June 2021. During all periods, COVID-19 outbreak teams often discussed distancing visitors from residents. Moreover, during the first wave they often discussed isolation measures, during the intermediate period they often discussed distancing staff and volunteers from residents, and during both the intermediate period and the second wave they often discussed distancing among residents. During all periods, less often admission measures were discussed. Challenges persisted and included unrest among and conflicts between visitors and staff, visitors violating measures, resident non-adherence to measures, and staffing issues. The discussed distancing measures and corresponding challenges may guide local long-term care and (inter)national policymakers during the further course of the COVID-19 pandemic, outbreaks of other infectious diseases, and long-term care innovations.

Evaluation of an Oral Care Program to Improve the Oral Health of Home-Dwelling Older People.

The aim of this study was to evaluate the impact of the implementation of an Oral Care Program on home care nurses' attitudes and knowledge about oral health (care) and the impact on older people's oral health. A pre-post study, without a control group, was conducted. A preventive Oral Care Program (OCP) was designed, focusing on home care nurses and older people, in collaboration with dental hygienists. Implementation was measured with questionnaires at baseline and after 6 months for home care nurses; for older people, implementation was measured at baseline and after 3 months with the Oral Health Assessment Tool and a questionnaire about oral (self) care between January 2018 and September 2019. Although the study design has limitations, the oral health of older people improved significantly after 3 months and the OCP was most beneficial for people with full dentures. The OCP improved knowledge and attitude of home care nurses. The program fitted well with the daily work routines of home care nurses. Individual-centered care plans for older people, education of home care nurses and the expertise of the dental hygienists have added value in home care nursing. Future implementations should focus on older people with natural teeth.

Implementing a Personalized Integrated Stepped-Care Method (STIP-Method) to Prevent and Treat Neuropsychiatric Symptoms in Persons With Dementia in Nursing Homes: Protocol for a Mixed Methods Study.

BACKGROUND: Neuropsychiatric symptoms occur frequently in many nursing home residents with dementia. Despite the availability of multidisciplinary guidelines, neuropsychiatric symptoms are often inadequately managed. Three proven effective methods for managing neuropsychiatric symptoms were integrated into a single intervention method: the STIP-Method, a personalized integrated stepped-care method to prevent and treat neuropsychiatric symptoms. The STIP-Method comprises 5 phases of clinical reasoning to neuropsychiatric symptoms and 4 stepped-care interventions and is supported with a web application. OBJECTIVE: This study aims to identify the facilitators and barriers in the implementation of the STIP-Method in nursing homes. METHODS: A mixed methods design within a participatory action research was used to implement the STIP-Method in 4 facilities of 2 Dutch nursing home organizations. In total, we aimed at participation of 160-200 persons with dementia and expected an intervention fidelity of 50% or more, based on earlier studies regarding implementation of effective psychosocial interventions to manage neuropsychiatric symptoms. All involved managers and professionals were trained in the principles of the STIP-Method and in using the web application. An advisory board of professionals, managers, and informal caregivers in each facility supported the implementation during 21 months, including an intermission of 6 months due to the COVID-19 pandemic. In these 6-weekly advisory board meetings, 2 researchers stimulated the members to reflect on progress of the implementation by making use of available data from patient records and the web application. Additionally, the 2 researchers invited the members to suggest how to improve the implementation. Data analysis will involve (1) analysis of facilitators and barriers to the implementation derived from verbatim text reports of advisory board meetings to better understand the implementation process; (2) analysis of patient records in accordance with multidisciplinary guidelines to neuropsychiatric symptoms: personalized, interdisciplinary, and proactive management of neuropsychiatric symptoms; (3) evaluation of the web application in terms of usability scores; (4) pre- and postimplementation analysis of patient records and the web application to evaluate the impact of the STIP-Method, such as changes in neuropsychiatric symptoms and informal caregiver burden. RESULTS: We enrolled 328 persons with dementia. Data collection started in July 2019 and ended in December 2021. The first version of this manuscript was submitted in October 2021. The first results of data analysis are expected to be published in December 2022 and final results in June 2023. CONCLUSIONS: Our study may increase understanding of facilitators and barriers to the prevention and treatment of neuropsychiatric symptoms in nursing home residents with dementia by implementing the integrated STIP-Method. The need for well-designed implementation studies is of importance to provide nursing homes with optimal tools to prevent and treat neuropsychiatric symptoms. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/34550.