A bayesian network meta-analysis to explore modifying factors in randomized controlled trials: what works for whom to reduce depression in nursing home residents?

BACKGROUND: Reviews of depression interventions in nursing home residents resulted in positive findings. However, because of the heterogeneity of the studies, it remains unclear what works for whom. Considering moderator effects may contribute to a comprehensive understanding of depression treatment in residents. Therefore, this study aims to review depression interventions, examining moderator effects of (1) residents' factors, and (2) components specific of interventions. METHODS: A Bayesian network meta-analysis of randomized controlled trials primarily aimed at reducing depressive symptoms among residents was conducted. First, intervention types, e.g., exercise interventions, were compared to care as usual. Second, meta-regression analyses were conducted for moderator effects of residents' factors (i.e., severity of depressive symptoms, physical dependency, and cognitive impairment) and components identified as specific to an intervention (e.g., music, creativity, positivity). RESULTS: Our search across six databases resulted in 118 eligible studies: 16 on neurobiological interventions, 102 on non-pharmacological interventions. Compared to care as usual, cognitive interventions, such as cognitive behavioral therapy and goal-oriented therapy, showed the strongest effects (MD = -1.00, 95% CrI [-1.40 to -0.66]). Furthermore, the severity of depressive symptoms moderated the effect of interventions (ƅ = -0.63, CrI 95% [-1.04 to -0.22]), while none of fifteen identified intervention-specific components did. In residents with a depression diagnosis, there were larger effect sizes for interventions including daily structure, psychoeducation, healthy food, creativity, positivity, and an activating/encouraging environment, whereas interventions focusing on distraction and relaxation had larger effect sizes in those residents without. CONCLUSIONS: By examining the moderator effects, we provided an integrative perspective on the observed variations in effects across different target groups, and components of depression interventions. This approach underscores the complex nature of interventions, emphasizing the need for continued transdisciplinary research, and the exploration of potential moderators. Future investigations should carefully assess residents' factors and choose interventions and their components accordingly.

Personality assessment in nursing home residents with mental and physical multimorbidity: two informant perspectives.

OBJECTIVES: In older patients with mental and physical multimorbidity (MPM), personality assessment is highly complex. Our aim was to examine personality traits in this population using the Hetero-Anamnestic Personality questionnaire (HAP), and to compare the premorbid perspective of patients' relatives (HAP) with the present-time perspective of nursing staff (HAP-t). DESIGN: Cross-sectional. SETTING: Dutch gerontopsychiatric nursing home (GP-NH) units. PARTICIPANTS: Totally, 142 GP-NH residents with MPM (excluding dementia). MEASUREMENTS: NH norm data of the HAP were used to identify clinically relevant premorbid traits. Linear mixed models estimated the differences between HAP and HAP-t trait scores (0-10). Agreement was quantified by intraclass correlation coefficients (ICCs). All HAP-HAP-t analyses were corrected for response tendency (RT) scores (-10-10). RESULTS: 78.4% of the patients had at least one premorbid maladaptive trait, and 62.2% had two or more. Most prevalent were: "disorderly" (30.3%), "unpredictable/impulsive" (29.1%) and "vulnerable" (27.3%) behavior. The RT of relatives appeared significantly more positive than that of nursing staff (+1.8, 95% CI 0.6-2.9, p = 0.002). After RT correction, the traits "vulnerable", "perfectionist" and "unpredictable/impulsive" behavior scored higher on the HAP than HAP-t (respectively +1.2, 95% CI 0.6-1.7, p < 0.001; +2.1, 95% CI 1.3-2.8, p < 0.001; +0.6, 95% CI 0.1-1.1, p = 0.013), while "rigid" behavior scored lower (-0.7, 95% CI -1.3 to -0.03, p = 0.042). Adjusted ICCs ranged from 0.15 to 0.58. CONCLUSIONS: Our study shows high percentages of premorbid maladaptive personality traits, which calls for attention on personality assessment in MPM NH residents. Results also indicate that the HAP and HAP-t questionnaires should not be used interchangeably for this patient group in clinical practice.

The development and feasibility evaluation of a program to identify and manage apathy in people with dementia: the SABA program.

OBJECTIVES: To develop and evaluate feasibility of a program for family and professional caregivers to identify and manage apathy in people with dementia: the Shared Action for Breaking through Apathy program (SABA). METHODS: A theory- and practice-based intervention was developed and tested among ten persons with apathy and dementia in two Dutch nursing homes from 2019 to 2021. Feasibility was evaluated with interviews with family caregivers (n = 7) and professional caregivers (n = 4) and two multidisciplinary focus groups with professional caregivers (n = 5 and n = 6). RESULTS: SABA was found feasible for identifying and managing apathy. Caregivers mentioned increased knowledge and awareness regarding recognizing apathy and its impact on their relationship with the person with apathy. They experienced increased skills to manage apathy, a greater focus on small-scale activities and increased appreciation of small moments of success. The content, form and accessibility of the program's materials were considered facilitating by all stakeholders, as was the compatibility of the procedures with the usual way of working. The expertise and involvement of stakeholders, staff stability and the support of an ambassador and/or manager were facilitating, while insufficient collaboration was a barrier. Organizational and external aspects like not prioritizing apathy, staff discontinuity, and the Covid-19 pandemic were perceived as barriers. A stimulating physical environment with small-scale living rooms, and access to supplies for activities were considered facilitating. CONCLUSIONS: SABA empowers family and professional caregivers to successfully identify and manage apathy. For implementation, it is important to take into account the facilitators and barriers resulting from our study.

Evaluation of the SPAN intervention for people living with young-onset dementia in the community and their family caregivers: a randomized controlled trial.

OBJECTIVES: To evaluate the effectiveness of the SPAN-intervention, a psychosocial intervention aiming at improving a sense of usefulness and engaging in meaningful activities, for community-dwelling people living with young-onset dementia (YOD) and their family caregivers. METHODS: A cluster-randomized controlled trial with two parallel groups (SPAN-intervention vs. care as usual) with assessments at baseline and five-month follow-up was performed. Sixty-one persons living with YOD and their family caregivers were included (SPAN-intervention group: n = 35; care as usual group: n = 26). Outcomes included, for the person living with YOD, empowerment (operationalized by self-management abilities using the SMAS-30; primary outcome), quality of life, neuropsychiatric symptoms, disability, apathy; and, for the family caregiver, quality of life, emotional distress, sense of competence. Data were analyzed using linear mixed models. RESULTS: We found no statistically significant effects of the SPAN-intervention on empowerment, nor on the secondary outcome measures for persons living with YOD or their family caregivers. CONCLUSION: Although the SPAN-intervention may provide concrete opportunities to engage in activities and stimulate reciprocity, such as meaningful social activities, this study did not demonstrate intervention effects. Additional qualitative evaluations may provide more insight into the implementation process and experiences of people living with YOD and their family caregivers.This trial was registered at ClinicalTrials.gov (NCT02937883).

Psychometric Validation of the Portuguese Version of the Sexual Self-Consciousness Scale (SSCS).

The Sexual Self-Consciousness Scale (SSCS) is an instrument for assessing dispositional propensities for self-consciousness experienced in a sexual context, with wide application in both clinical and research settings. The objective of the current study was to test some psychometric characteristics of the Portuguese version of the SSCS using a convenience sample of 210 men and 210 women. Participants completed a sociodemographic questionnaire and the Portuguese version of the SSCS. A subsample of 87 participants was assessed at a second time point after a 2-week period for measuring test-retest reliability of the instrument. Confirmatory factor analysis identified two factors and replicated the structure of the original instrument. Measurement invariance was confirmed for men and women with overall index scores indicating a good fit in all models. Reliability analyses indicated that the factors possessed both satisfactory internal consistency and stability over time. The Portuguese version of the SSCS was shown to be a useful and adequate instrument to assess dispositional propensities for self-consciousness in sexual situations within the Portuguese-speaking population.

Identifying and managing apathy in people with dementia living in nursing homes: a qualitative study.

BACKGROUND: Although apathy is common in people with dementia and has profound negative effects, it is rarely diagnosed nor specifically treated in nursing homes. The aim of this study is to explore experiences in identifying and managing apathy from the perspectives of people with dementia and apathy (PwA), family caregivers (FCs) and professional caregivers (PCs). METHODS: Descriptive qualitative study with purposive sampling, comprising eleven semi-structured in-depth interviews with PwA, FCs or PCs and focus groups with twelve PCs in Dutch nursing homes. Seventeen additional in-depth interviews with caregivers were held, after signals of increasing apathy during the first Covid-19 lockdown. Using an inductive approach, data was analysed thematically to explore the experiences in identifying and managing apathy from the perspective of different stakeholders. RESULTS: Three themes were identified: 1) the challenge to appraise signals, 2) the perceived impact on well-being, 3) applied strategies to manage apathy. Although participants described apathy in line with diagnostic criteria, they were unfamiliar with the term apathy and had difficulties in appraising signals of apathy. Also, the perceived impact of apathy varied per stakeholder. PwA had difficulties reflecting on their internal state. FCs and PCs experienced apathy as challenging when it reduced the well-being of PwA or when they themselves experienced ambiguity, frustration, insecurity, disappointment or turning away. Dealing with apathy required applying specific strategies that included stimulating meaningful contact, adjusting one's expectations, and appreciating little successes. CONCLUSIONS: When addressing apathy in nursing homes, it is important to consider that a) all stakeholders experience that appraising signals of apathy is challenging; b) apathy negatively influences the well-being of people with dementia and especially their FCs and PCs; and c) FCs and PCs can successfully, albeit temporarily, manage apathy by using specific strategies.

Sample size for partially nested designs and other nested or crossed designs with a continuous outcome when adjusted for baseline.

In a randomized controlled trial, outcomes of different subjects may be independent at baseline, but correlated at a follow-up measurement due to treatment. This treatment-related clustering at follow-up can arise for instance because the treatment is given in a group or because subjects are treated individually but by the same therapist (therapist effect). There is substantial literature on the design and analysis of such trials when estimation of the intervention effect is based on a follow-up measurement (eg, directly after treatment or at a later time point). However, often the baseline measurement of the outcome is highly correlated with the follow-up measurement, and this information can be used in the analysis. For a randomized design with a baseline and a follow-up measurement, we compare sample size requirements for analyses with and without adjustment for this baseline measure. We show that adjusting for baseline reduces required sample size. This reduction depends on the variance of the difference between arms at baseline, the variance of this difference at follow-up, and the correlation between the two. From this, we derive sample size formulas for partially or fully nested designs, and cluster randomized trials with treatment as a partially or fully cross-classified factor. Also, we discuss situations where clusters are already present at baseline or where treatment by cluster interaction is present. For the partially nested design, we work out practical design considerations (eg, use of content-matter input, design factors and optimal allocation ratio) and investigate small sample properties of the sample size formula.

Informal antidepressant strategies for nursing home residents: two group concept mapping studies.

OBJECTIVES: To identify and structure potential informal antidepressant strategies that can be used in daily practice for nursing home residents alongside formal treatments. METHODS: In a first Group Concept Mapping study, residents, relatives, and professional caregivers (N = 124) brainstormed on strategies residents could use to prevent or alleviate depression. In a second study, the same participants (N = 110) reported strategies for use by others. Furthermore, participants rated the expected effectiveness and feasibility of the suggested strategies. Simultaneously, all strategies were sorted by experts and clustered using multidimensional scaling and hierarchical cluster analysis. RESULTS: Six clusters emerged for strategies by residents themselves and five clusters for strategies by others. For residents' strategies, the clusters Being socially connected and Participating in activities were perceived as most effective, as was the cluster Offering personal attention for strategies by others. Participants perceived Creating a healthy living environment as the most feasible cluster executed by residents. Within strategies by others, the clusters Offering personal attention, Using positive treatment/approach, and Using or adapting the physical environment were perceived as the most feasible. CONCLUSION: The results indicated the importance of social connectedness, a personalized and positive approach by significant others, and tailored activity programs. The results also suggest that adaptations to the physical environment within nursing homes may be an easy applicable strategy to prevent or alleviate depression in residents. Although more research is needed, these findings may guide daily practice and the development of interventions that include informal strategies.Supplemental data for this article can be accessed online at https://doi.org/10.1080/13607863.2022.2057427 .

The Significance of Pets for Vulnerable Older Adults during the COVID-19 Pandemic: An Explorative Qualitative Study.

Older adults receiving long-term care at home (LTCH-clients) were impacted by the COVID-19 pandemic and its countermeasures. Previous research suggests that pets can mitigate some of the pandemic's impacts for older adults but results are contradictory. Our aim was to investigate experiences of LTCH-clients and the significance of their pets during the pandemic. Accounting for saturation, semi-structured interviews were conducted with five LTCH-clients and four family caregivers of LTCH-clients with dementia. Participants were asked about their experiences with COVID-19 and the significance of LTCH-clients' pets during the pandemic. Two researchers performed thematic analyses in ATLAS.ti using open coding and an iterative-inductive approach. All participants reported negative experiences as a result of COVID-19 countermeasures. Results suggested that caring for pets provided pet owners with structure, which may have contributed to a sense of stability and continuity. Our outcomes underlined an important role of pets for LTCH-clients both before and during the pandemic.

Promoting empowerment for people living with dementia in nursing homes: Development and feasibility evaluation of an empowerment program.

OBJECTIVES: This article describes the development and feasibility evaluation of an empowerment program for people living with dementia in nursing homes. METHODS: Development and feasibility evaluation of the empowerment program was guided by the British Medical Research Council's (MRC) framework. In the developmental phase, we used intervention mapping to develop the theory- and evidence-based intervention. During the feasibility phase, two care teams utilised the program from September to December 2020. We evaluated the feasibility in terms of demand, acceptability, implementation, practicality, integration and limited efficacy. FINDINGS: This study showed that, according to healthcare professionals, the program was feasible for promoting empowerment for people living with dementia in a nursing home. Healthcare professionals mentioned an increased awareness regarding the four themes of empowerment (sense of identity, usefulness, control and self-worth), and greater focus on the small things that matter to residents. Healthcare professionals experienced challenges in involving family caregivers. CONCLUSION: An important step is to take into account the implementation prerequisites that follow from our findings, and to further investigate feasibility, as the use of the program and data collection was hindered by the COVID-19 pandemic. Subsequent research could investigate the effects of the empowerment program.

Stimuli changes and challenging behavior in nursing homes during the COVID-19 pandemic.

BACKGROUND: COVID-19 restrictions in nursing homes resulted in a reduction in stimuli for residents. This study aimed to explore observed effects of changes in stimuli, both targeted (e.g., planned recreational activities) and untargeted (e.g., spontaneous noise), on challenging behavior in nursing home residents during COVID-19 anti-pandemic measures. METHODS: In an online survey, nursing home healthcare professionals in the Netherlands provided their perspectives on the effects of the reduction in untargeted stimuli on residents with mild, advanced, or no dementia, and on different types of challenging behavior (i.e., psychotic, depressed, anxious, agitated, or apathetic behavior). Additionally, we asked participants' opinions about strategies for limiting untargeted stimuli and for adjusting targeted stimuli for optimal management of challenging behaviors. RESULTS: In total, 199 professionals completed the survey. Residents with advanced dementia and those with psychotic and agitated behavior seemed to benefit from the reductions in stimuli not specifically targeted at the resident. In contrast, residents without dementia and those with depressive and apathetic behavior seemed to be negatively affected by reductions in untargeted stimuli. Participants would like to continue reducing untargeted stimuli in the future (e.g., limiting the use of corridors adjacent to residents' rooms) and to adapt existing or introduce new initiatives involving targeted stimuli (e.g., small-scale, individually tailored activities). Responses to open-ended questions revealed additional initiatives that could be useful in nursing home care. CONCLUSIONS: This study provided lessons to learn from the COVID-19 measures in nursing homes. While many residents may have been negatively affected by the restrictions imposed during the pandemic, specific resident groups may have benefitted from the reduction in untargeted stimuli and from the adjustments made to daily activities. Various strategies and initiatives used in nursing homes during the pandemic seem promising for meeting individual needs in managing challenging behavior. These findings suggest that certain stimuli may affect specific resident groups differently. This underlines the importance of finding the right balance between stimuli and tranquility, tailored to the needs of individual residents. It is important to consider the stimuli present in nursing homes, whether targeted or untargeted, when analyzing and treating challenging behavior.

Empowerment for people living with dementia: An integrative literature review.

BACKGROUND AND OBJECTIVES: Although the concept of empowerment seems useful for good care and support for people living with dementia, there is a lack of understanding of the process of empowerment. Therefore, more insight is needed into the concept of empowerment, and the environment's role in the empowerment process. RESEARCH DESIGN AND METHODS: We performed an integrative literature review (PubMed, CINAHL, PsychINFO), including studies that addressed empowerment for people living with dementia in their title or abstract. Using qualitative data analysis software ATLAS.ti, we applied open codes to describe all relevant aspects of included articles. Common themes and categories were identified using inductive reasoning and constant comparison. RESULTS: Sixty-nine articles were included. We identified four themes: (1) description of the state of being empowered, (2) the process of empowerment, (3) contribution of the environment to the empowerment process, and (4) effects on other variables. We combined these results with the conceptual framework of our previous qualitative study on the definition of empowerment for people living with dementia based on stakeholders' perspectives. Subsequently, the combined information of both studies was visualized in a revised conceptual framework. DISCUSSION AND IMPLICATIONS: This literature review provides more details as to the role of the environment for empowerment of people living with dementia and suggests that empowerment can be considered a dynamic process, taking place through interaction between the person living with dementia and their environment. Our revised conceptual framework of empowerment can serve as a basis for future studies on empowerment for people living with dementia, and to support (in)formal caregivers in the empowerment process.

The effects of Animal Assisted Therapy on autonomic and endocrine activity in adults with autism spectrum disorder: A randomized controlled trial.

OBJECTIVE: Stress and its sequelae are very common in adults with autism spectrum disorder (ASD) without an intellectual disability (ID). Animal-assisted therapy (AAT) has shown physiological stress-reductive effects in children with ASD. The aim of the current study was to examine the acute psychophysiological response to an AAT session, and to examine the longer-term stress-physiological effects of the intervention, up until 10 weeks post-treatment, in comparison to waiting-list controls. METHOD: A randomized controlled trial with pre-intervention (T0), post-intervention (T1: 10 weeks) and follow-up (T2: 20 weeks) measurements of neuroendocrine and cardiovascular measures, was conducted in 53 adults with ASD (N = 27 in intervention arm; N = 26 in control arm). Within the intervention group, stress-physiological data were collected during the 5th therapy session (acute effects). Data were analyzed with mixed models for outcome measures cortisol, alpha-amylase, heart rate variability and sympathetic activity. RESULTS: The AAT interventional session was significantly associated with reduced cortisol levels (ß = -0.41, p = .010), while parasympathetic and sympathetic cardiovascular activity remained unaltered. No significant changes were found for stress-physiological measures at post-treatment time points. CONCLUSIONS: Acute stress reduction, reflected in significant reduction in cortisol levels, was found during an AAT session in adults with ASD, without ID. More research is needed to explore to what extent the specific factors of AAT have contributed to the decrease in cortisol and whether stress reduction is possible for the longer-term.

The association between specific activity components and depression in nursing home residents: the importance of the social component.

OBJECTIVES: To longitudinally explore the association between activities and depressive symptoms of nursing home (NH) residents, taking into account that each activity may contain multiple components (physical, creative, social, cognitive, and musical). METHOD: Study with a baseline and two follow-ups (four and eight months). Participants were forty physically frail residents of four NHs in the Netherlands. Residents were interviewed about depressive symptoms (CES-D) and activities they conducted over the previous week. Three researchers independently rank ordered each activity on the degree to which it could be regarded as having physical, creative, social, cognitive, and musical components. Accounting for the rank score and the time the resident spent on that activity, residents were categorized per activity component into four levels: absent, low, medium, and high. RESULTS: Mixed models predicting depressive symptoms from individual activity components showed significant associations for the social and cognitive components. Compared with the lowest activity level, the analyses showed fewer depressive symptoms for all higher levels of the social and cognitive components. However, a mixed model adjusted for all activity components showed no unique effect of the cognitive component or other components, while the effects of the social component remained significant. The analyses did not show differences between the time points. CONCLUSION: The results suggest that the effects of activities on depressive symptoms might be mainly explained by their social component. It is, thus, important to always stimulate social involvement and interaction when developing and applying depression interventions. However, intervention research is needed to confirm these findings.

Defining empowerment for older people living with dementia from multiple perspectives: A qualitative study.

BACKGROUND AND OBJECTIVES: The concept of empowerment seems promising for people living with dementia to live their life as they want to for as long as possible. Therefore, this study aimed to explore what the concept of empowerment means and includes for people living with dementia from the perspectives of people living with dementia themselves, their informal caregivers, and healthcare professionals. RESEARCH DESIGN AND METHODS: Qualitative research using focus group discussions and individual interviews with people living with dementia (n = 15), informal caregivers (n = 16) and healthcare professionals (n = 46) to explore perspectives on empowerment. Audio-recordings were transcribed verbatim, and separately analyzed by two researchers using inductive thematic analysis. RESULTS: Four themes were identified as important aspects of empowerment: (1) having a sense of personal identity, (2) having a sense of choice and control, (3) having a sense of usefulness and being needed, and (4) retaining a sense of worth. Based on these themes, a conceptual framework of empowerment for older people living with dementia was developed. Empowerment takes place within the person living with dementia, but is achieved through interaction with their environment. The four themes seem to be important both at home and in nursing homes, and in different stages of dementia. However, practical detailing of support differed. DISCUSSION AND IMPLICATIONS: Our empowerment framework may provide a basis for developing interventions to empower people living with dementia and to strengthen (in)formal caregivers in this empowerment process. Support for people living with dementia must be adjusted to their personal situation and individual capabilities.

Challenging behavior of nursing home residents during COVID-19 measures in the Netherlands.

OBJECTIVES: From the perspective of the nursing home (NH) practitioners, to gain understanding of (1) whether challenging behavior in NH residents changed during the COVID-19 measures, (2) whether the practitioners' involvement in the treatment of challenging behavior changed, (3) what can be learned from the experience of NH staff. METHODS: A mixed methods study with a survey in 323 NH practitioners (psychologists, elderly care physicians, nurse practitioners) in the Netherlands, and in-depth interviews in 16 NH practitioners. Nonparametric analyses were used to compare estimated proportions of residents with increased and with decreased challenging behavior. Content analyses were conducted for open-ended questions and in-depth interviews. RESULTS: Participants reported changes in challenging behavior with slightly higher proportions for increased (Q1/Mdn/Q3: 12.5%, 21.7%, 30.8%) than for decreased (8.7%, 14.8%, 27.8%, Z = -2.35, p = .019) challenging behavior. Half of the participants reported that their work load increased and work satisfaction worsened during the measures. Different strategies were described to respond to the effects of COVID-19 measures, such as video calls, providing special areas for residents to meet their loved ones, adjusting activities, and reducing the exposure to negative news. CONCLUSIONS: Because COVID-19 measures resulted in both increased and decreased challenging behavior in NH residents, it is important to monitor for their potential long lasting effects. Increased work load and worsened work satisfaction of the NH staff, together with the changes in type of challenging behavior, indicate that the harmful effects of the anti-pandemic measures should be taken seriously.

Three Diagnoses for Problematic Hypersexuality; Which Criteria Predict Help-Seeking Behavior?

This study aimed to assess the best combination of indicators of problematic hypersexuality (PH), in a survey (n = 58,158) targeting individuals wondering if they were sex addicted. The survey allowed for testing of criteria from three theoretical models used to conceptualize PH. Factor analyses for women and men yielded an interpretable grouping of indicators consisting of four factors. In subsequent logistic regressions, these factors were used as predictors for experiencing the need for help for PH. The factors Negative Effects and Extreme positively predicted experiencing the need for help, with Negative Effects as the most important predictor for both women and men. This factor included, among others, withdrawal symptoms and loss of pleasure. The Sexual Desire factor negatively predicted the need for help, suggesting that for the targeted population more sexual desire leads to less PH. The Coping factor did not predict experiencing the need for help. Outcomes show that a combination of indicators from different theoretical models best indicates the presence of PH. Therefore, a measurement instrument to assess existence and severity of PH should consist of such a combination. Theoretically, this study suggests that a more comprehensive model for PH is needed, surpassing existing conceptualizations of PH.