Predictability of Neutrophil to Lymphocyte Ratio in preoperative elderly hip fracture patients for post-operative short-term complications: a retrospective study.

PURPOSE: Neutrophil to Lymphocyte Ratio (NLR) is a simple biomarker of systemic inflammatory response. We investigated predictability of NLR for early adverse outcome after surgery for hip fracture in elderly population. METHODS: We reviewed a total of 971 elderly patients with hip fracture who underwent emergency surgery between January 2017 and July 2020 in the Department of Orthopaedics Surgery at the Wollongong Hospital. After considering exclusion criteria, data from a total of 834 patients included in our study. Socio-demographic data, NLR in admission, updated Charlson comorbidity index (uCCI), biochemical markers, mortality rate and 15 short term post-operative complications were collected to determine predictability of NLR for post-operative complications and mortality. RESULTS: After hip surgery, Hospital in-patient case fatality rate was 3.7% (31). In addition, 63.1% (511) of the patients had at least one complication or more. Logistic regression demonstrated that raised NLR (P-value < 0.001, OR 1.05) and uCCI≥4 (P-Value < 0.001, OR 1.75) are associated with post-operative complications. Moreover, decreased haemoglobin was associated with adverse effects (P-value < 0.001, OR 0.97). No association was found for any of these variables with in-patient mortality except for albumin (P-value: 0.03). In addition, despite significant association, ROC analyses showed a low predictability for each of the above variables including NLR (AUC 0.59) for post-operative complications. CONCLUSIONS: Despite significant association, NLR was unable to prognosticate early adverse outcomes. However, it can be considered as a risk factor in admission for postoperative complications in combination with other risk factors and clinical context.

Cannabidiol as a Treatment for Neurobiological, Behavioral, and Psychological Symptoms in Early-Stage Dementia: A Double-Blind, Placebo-Controlled Clinical Trial Protocol.

Rationale: The slowing of disease progression in dementia in the early stages of diagnosis is paramount to improving the quality of life for those diagnosed and their support networks. Accumulating evidence suggests that CBD, a constituent of Cannabis sativa, is associated with neuroprotective, neuroendocrine, and psychotherapeutic effects, suggesting that it may be beneficial to dementia treatment. However, no published human study to date has examined this possibility. This trial aims to determine whether daily treatment with CBD over a 12-week period is associated with improved neurobiological, behavioral, and psychological outcomes in individuals living with early-stage dementia. Methods: Sixty participants with early-stage dementia will be recruited for a randomized, double-blind, placebo-controlled clinical trial. Participants will be randomized into either 99.9% pure CBD or placebo treatment conditions and administered two capsules per day for 12 weeks. Participants will commence a 200 mg/day dose for 2 weeks before escalating to 300 mg/day for the remaining 10 weeks. Neuroimaging and blood-based neuroendocrine profiles will be assessed at baseline and post-treatment. Psychological and behavioral symptoms will be assessed at baseline, 6 weeks, and post-treatment. Monitoring of health and side-effects will be conducted through weekly home visits. Discussion: This study is among the first to investigate the effects of isolated CBD in improving neuroanatomical and neuroendocrine changes, alongside psychological symptoms, during the early stages of dementia diagnosis. The outcomes of this trial have the capacity to inform a potential novel and accessible treatment approach for individuals living with early-stage dementia, and in turn, improve quality of life, prognoses, and treatment outcomes. Trial Registration: This trial has been registered with the Therapeutic Goods Administration (CT-2020-CTN-03849-1v2) and the Australian and New Zealand Clinical Trials Registry (ACTRN12621001364864).

Under-coding of dementia and other conditions indicates scope for improved patient management: A longitudinal retrospective study of dementia patients in Australia.

BACKGROUND: Under-coding of dementia during hospitalisation results in an inability to identify all patients with dementia using hospital administrative data. Clinical coding can be viewed as a proxy for management; therefore, under-coding indicates dementia was not considered in the patient's management. While under-coding of dementia is well established, there is sparse evidence on whether dementia is coded in subsequent hospitalisations among patients with a known diagnosis. OBJECTIVE: (a) To describe patterns of dementia coding over 5 years after a first-coded (i.e. index) admission for dementia; (b) to identify factors associated with clinical coding of dementia; and (c) to identify patient subgroups at risk of not being coded to inform future interventions to improve hospital identification and management of dementia. METHOD: Retrospective study of longitudinal hospital data from 1 July 2006 to 30 June 2015 for 7919 patients hospitalised during the 5 years' post-index admission for dementia in a regional local health district of New South Wales, Australia. RESULTS: Dementia was coded in 63.9% of admissions in the 12 months following index admission for dementia; this decreased to 53.7% after 5 years. Patients were 20% more likely to have dementia actively managed when it co-occurred with delirium. Under-coding varied across conditions, with dementia more likely to be coded in admissions for falls and pneumonitis, and less likely for heart failure, pneumonia and urinary tract infection (UTI). CONCLUSION: The frequency with which dementia was not coded highlights opportunities to improve identification and management of dementia through dementia-specific care, enhanced clinical protocols, and interventions focused around heart failure, pneumonia and UTI admissions.

Food anthocyanins decrease concentrations of TNF-α in older adults with mild cognitive impairment: A randomized, controlled, double blind clinical trial.

BACKGROUND & AIMS: Vascular function, blood pressure and inflammation are involved in the pathogenesis of major chronic diseases, including both cardiovascular disease (CVD) and mild cognitive impairment (MCI). This study investigated the effects of food anthocyanins on microvascular function, 24-h ambulatory blood pressure (ABP) and inflammatory biomarkers in older adults with MCI. METHODS AND RESULTS: Thirty-one participants with MCI [19 female, 12 male, mean age 75.3 (SD 6.9) years and body mass index 26.1 (SD 3.3) kg/m2], participated in a randomized, controlled, double-blind clinical trial (Australian New Zealand Clinical Trials Registry: ACTRN12618001184268). Participants consumed 250 mL fruit juice daily for 8 weeks, allocated into three groups: a) high dose anthocyanins (201 mg); b) low dose anthocyanins (47 mg); c) control. Microvascular function (Laser Speckle Contrast Imaging combined with a post-occlusive reactive hyperaemia test), 24h ABP and serum inflammatory biomarkers were assessed before and after the nutritional intervention. RESULTS: Participants in the high anthocyanins group had a reduction in serum tumor necrosis factor alpha (TNF-α) (P = 0.002) compared to controls and the low anthocyanins group (all P's > 0.05). Serum IL-6, IL-1ß, c-reactive protein, and parameters of microvascular function and 24h ABP were not altered by any treatment. CONCLUSION: A daily high dose of fruit-based anthocyanins for 8 weeks reduced concentrations of TNF-α in older adults with MCI. Anthocyanins did not alter other inflammatory biomarkers, microvascular function or blood pressure parameters. Further studies with a larger sample size and longer period of follow-up are required to elucidate whether this change in the immune response will alter CVD risk and progression of cognitive decline.

Hospitalisation for medication misadventures among older adults with and without dementia: A 5-year retrospective study.

OBJECTIVES: To compare rates and trends in hospital admissions due to medication misadventure for older adults (≥65 years) with and without dementia. METHODS: A retrospective analysis of hospital admissions that occurred between 2012 and 2016, for medication misadventures among older adults living in regional Australia. RESULTS: Medication misadventures contributed to 10 555 (4.6%) of the total 228 165 admissions for older adults over the study period. Among these admissions, older adults with dementia were three times more likely to be hospitalised with medication misadventures (14.0%), than their non-dementia counterparts (4.2%). Medication misadventures relating to "anticoagulants" and "opioids/related analgesics" accounted for the majority of admissions (24.3% dementia vs 30.7% non-dementia). CONCLUSIONS: This study highlights that the proportion of older adults hospitalised for a medication misadventure is much higher among those with dementia, than those without dementia. Strategies should target older adults, and especially those with dementia, to reduce medication-related harm and improve patient safety.

Evaluation of the impact of a post-hospital discharge Transitional Aged Care Service on frailty, malnutrition and functional ability.

AIM: To investigate the relationship between nutritional status, functional ability and frailty in older adults participating in a 12-week Transitional Aged Care Service program. METHODS: A retrospective analysis of a clinical cohort of older adults aged 65+ years after hospital discharge. At entry into the program and at completion, nutritional status was measured using the Mini Nutritional Assessment (MNA), frailty status was measured using the Groningen Frailty Indicator and functional ability was measured using the Modified Barthel Index (MBI). Demographic data were obtained from electronic medical records. RESULTS: Baseline data were available for 115 participants (mean age = 81.7 (SD =7.9) years; 20.9% classified as malnourished and 89.6% as frail). A positive association was found between nutritional status and frailty (r = 0.298; P = 0.001), and frailty and functional ability (r = 0.204; P = 0.029). Multiple regression analysis, accounting for the cofounders of baseline MNA, MBI, age, gender, length of hospital stay and living situation, found that nutritional status and functional ability were able to indicate the presence of frailty on admission to the program (P = 0.002, P = 0.007, respectively). In those program completers (n = 79), significant improvements were found in nutritional status, frailty and functional ability (P < 0.0005). CONCLUSIONS: Nutrition status, frailty and functional ability are closely and positively related, and should therefore be considered simultaneously in rehabilitation for older adults. A post-hospital transitional program with a multidisciplinary approach significantly improved all three outcomes, suggesting its value in enabling frail older people to remain independent for as long as possible.

Breakthrough Medication in Unresponsive Palliative Care Patients: Indications, Practice, and Efficacy.

CONTEXT: An unresponsive patient's need and their response to breakthrough medication is determined by clinical assessment and/or observational measures. How closely these methods match the patient's experience is unknown. OBJECTIVES: Determine the efficacy and effectiveness of breakthrough medication in unresponsive patients and the perception of patient comfort made by nurses and family. METHODS: A prospective study of breakthrough medication in unresponsive patients. The Richmond Agitation-Sedation Scale (RASS) and Patient Comfort Score (PCS) were compared with time-matched Bispectral Index (BIS) Scores. The effects of opioid vs. opioid + benzodiazepine breakthroughs and the relation between synchronous nurse and family measurements of the PCS were evaluated. Analysis of variance and paired t-tests were used for BIS analyses and nonparametric Mann-Whitney tests for RASS and PCS. RESULTS: Significant reductions at 30 and 60 minutes after breakthrough medication were noted for BIS (P < 0.0004), RASS (P = 0.043 and 0.004, respectively), and PCS (P < 0.0004). A direct comparison of the effect of opioid breakthrough medication vs. opioid plus benzodiazepine revealed no significant difference (BIS, P = 0.512; RASS, P = 0.195; PCS, P = 0.119). Of the 157 synchronous nurse and family measures of patient comfort, families rated patient discomfort significantly higher than nurses (P < 0.0004). CONCLUSION: This study provides additional evidence for the efficacy and effectiveness of breakthrough medication and the merit of observational measures in determining a patient's response. The onset of action is evident at 30 minutes after injection. Family assessment of patient comfort may be more nuanced than that of nurses, and they not uncommonly rate patient discomfort higher than nurses.

Qualitative study of patients and health-care professionals' views on the efficacy of the nutrition as medication oral nutrition supplement program.

AIM: The use of concentrated oral nutrition supplements dispensed in small volumes throughout the day at medication rounds is a common nutrition support strategy. Often termed 'Nutrition as Medication' or NAM, it is associated with excellent rates of patient consumption. However, administration of NAM has been described as suboptimal. The aim of the present study was to identify and explore factors influencing the efficacy of the NAM program from a qualitative perspective. This included exploring issues relating to knowledge, administration and patient consumption from a patient and health professional perspective. METHODS: Semistructured interviews with patients (n = 7) and eight focus groups with nursing, medical, pharmacy and dietetic staff (n = 63) were conducted. Interviews were conducted in the workplace and were recorded and transcribed verbatim. Data were analysed from a realist theoretical position using the thematic framework approach. RESULTS: Five themes were identified that impact on the efficacy of the NAM program. These include the need for clear role delineation among health professionals regarding responsibility for each aspect of NAM. Other themes that emerged included misconceptions about the importance and relevance of the treatment; perceptions of poor palatability and issues associated with the logistics of providing the supplements within the hospital setting. CONCLUSIONS: Dietitians should be aware that there are a range of factors that influence the efficacy of the NAM strategy, including the knowledge and values of individual health professional staff. In addition, increased awareness is required by dietitians regarding the structural barriers to administration and receiving of NAM at the ward level.

Feasibility of home-based dietetic intervention to improve the nutritional status of older adults post-hospital discharge.

AIM: To determine if a model of home-based dietetic care improves dietary intake and weight status in a specific group of older adults post-hospitalisation. METHODS: The Department of Veterans' Affairs clients aged 65 years and over were recruited from hospitals in a regional area of New South Wales, Australia (n = 32 men, n = 36 women). Nutritional status was assessed at home at baseline (within two weeks post-discharge) and three months post-discharge using a diet history, a food frequency checklist and Mini Nutritional Assessment (MNA). Personalised dietary advice was provided by a single dietitian according to participants' nutritional status. RESULTS: Mean body weight improved significantly (P = 0.048), as well as mean MNA score (21.9 ± 3.5 vs 25.2 ± 3.1) (P < 0.001). Mean energy, protein and micronutrient intakes were adequate at baseline and three months, except for vitamin D. At three months, the underweight group (body mass index (BMI) < 23 kg/m2 ) had significantly higher mean protein intake per body weight (1.7 ± 0.4 g/kg) compared to those who were a desirable weight (BMI 23-27 kg/m2 ) (1.4 ± 0.3 g/kg) or overweight (BMI>27 kg/m2 ) (1.1 ± 0.3 g/kg) peers (P < 0.001). There was significant improvement in energy intake contributed from oral nutrition supplements (+95.5 ± 388.2 kJ/day) and milk (+259.6 ± 659.8 kJ/day). CONCLUSIONS: Dietetic intervention improved nutritional status 3 months after hospital discharge in older adults living in the community.

Correlation Between Observational Scales of Sedation and Comfort and Bispectral Index Scores.

CONTEXT: When palliative care patients enter the phase of unconsciousness preceding death, it is standard practice to initiate or continue a subcutaneous infusion of an opioid plus or minus a sedative. The doses are determined somewhat empirically and adjustments are based on clinical assessment and observational measures of sedation and comfort. Following reports that these observational measures could be misleading, this study assesses their validity by comparing them with an objective measure of sedation, the Bispectral Index Score (BIS). OBJECTIVE: The objective of this study was to determine the validity of the Richmond Agitation and Sedation Scale (RASS) and the Patient Comfort Score (PCS) in assessing sedation and comfort in unconscious patients. METHODS: Forty eligible and consenting patients were monitored from the onset of unconsciousness (unresponsiveness) until death. Measures of sedation (RASS) and comfort (PCS) were made by the attending nurse every four hours. Correlation coefficients examined the relationship between fourth hourly RASS and PCS and time-matched BISs. RESULTS: A significant correlation was found between RASS and BIS and PCS and BIS. Sedation and comfort scores were concentrated at the lower end of the respective scales, whereas time-matched BISs were widely scattered with scores ranging from near full awareness to deep sedation. CONCLUSIONS: Compared with BIS, both RASS and PCS appear to be relatively blunt instruments at the lower end of their respective scales. Due caution should be taken interpreting and making clinical decisions based solely on the RASS and PCS and, by extension, other observational measures of patient comfort and sedation.

Consumption of anthocyanin-rich cherry juice for 12 weeks improves memory and cognition in older adults with mild-to-moderate dementia.

PURPOSE: Dietary flavonoids, including anthocyanins, may positively influence cognition and may be beneficial for the prevention and treatment of dementia. We aimed to assess whether daily consumption of anthocyanin-rich cherry juice changed cognitive function in older adults with dementia. Blood pressure and anti-inflammatory effects were examined as secondary outcomes. METHODS: A 12-week randomised controlled trial assessed cognitive outcomes in older adults (+70 year) with mild-to-moderate dementia (n = 49) after consumption of 200 ml/day of either a cherry juice or a control juice with negligible anthocyanin content. Blood pressure and inflammatory markers (CRP and IL-6) were measured at 6 and 12 weeks. ANCOVA controlling for baseline and RMANOVA assessed change in cognition and blood pressure. RESULTS: Improvements in verbal fluency (p = 0.014), short-term memory (p = 0.014) and long-term memory (p ≤ 0.001) were found in the cherry juice group. A significant reduction in systolic (p = 0.038) blood pressure and a trend for diastolic (p = 0.160) blood pressure reduction was evident in the intervention group. Markers of inflammation (CRP and IL-6) were not altered. CONCLUSION: Inclusion of an anthocyanin-rich beverage may be a practical and feasible way to improve total anthocyanin consumption in older adults with mild-to-moderate dementia, with potential to improve specific cognitive outcomes.

Factors influencing deprescribing for residents in Advanced Care Facilities: insights from General Practitioners in Australia and Sweden.

BACKGROUND: General Practitioners (GPs) are responsible for primary prescribing decisions in most settings. Elderly patients living in Advanced Care Facilities (ACFs) often have significant co-morbidities to consider when selecting an appropriate drug therapy. Careful assessment is required when considering appropriate medication use in frail older patients as they have multiple diseases and thus multiple medication. Many physicians seem reluctant to discontinue other physicians' prescriptions, resulting in further polypharmacy. Therefore it is relevant to ascertain and synthesise the GP views from multiple settings to understand the processes that might promote appropriate deprescribing medications in the elderly. The aims of this study were to 1) compare and contrast behavioural factors influencing the deprescribing practices of GPs providing care for ACF residents in two separate countries, 2) review health policy and ACF systems in each setting for their potential impact on the prescribing of medications for an older person in residential care of the elderly, and 3) based on these findings, provide recommendations for future ACF deprescribing initiatives. METHODS: A review and critical synthesis of qualitative data from two interview studies of knowledge, attitudes, and behavioural practices held by GPs towards medication management and deprescribing for residents of ACFs in Australia and Sweden was conducted. A review of policies and health care infrastructure was also carried out to describe the system of residential aged care in the both countries. RESULTS: Our study has identified that deprescribing by GPs in ACFs is a complex process and that there are numerous barriers to medication reduction for aged care residents in both countries, both with similarities and differences. The factors affecting deprescribing behaviour were identified and divided into: intentions, skills and abilities and environmental factors. CONCLUSIONS: In this study we show that the GPs' behaviour of deprescribing in two different countries is much dependent on the larger health care system. There is a need for more education to both GPs and ACF staff as well as better cooperation between the different health care systems and appropriate monetary incentives for elderly care to achieve better conditions for deprescribing practice.

Efficacy of a progressive resistance exercise program to increase toe flexor strength in older people.

BACKGROUND: Reduced toe flexor strength is an independent predictor of falls in older people. However it is unknown whether strengthening programs can restore toe flexor strength in older individuals. The aim of this study was to investigate whether a progressive resistance training program, focused specifically on the foot muscles, could improve toe flexor strength in community-dwelling older people. METHODS: After baseline testing, 85 men and women (age range 60-90years) were randomized to either a supervised, progressive resistance training (n=43) or a home-based exercise (n=42) group for 12weeks. A further 32 participants were recruited for a control group. The primary outcome measures were hallux and lesser toe flexor strength pre- and post-intervention. Secondary outcome measures were exercise compliance, components of the Foot Health Status Questionnaire and single-leg balance time. FINDINGS: Average class attendance was 89% with 68 participants from the two intervention groups (80%) completing the follow-up assessments. Participants in the supervised, progressive resistance training group significantly increased their toe strength (up to 36%; P<0.02), whereas there was no change in toe strength in either the home-based or control groups. This increased toe strength was accompanied by a significant improvement in perceived general foot health and single-leg balance time compared to the other groups (P<0.05). INTERPRETATION: Progressive resistance exercises are a viable intervention to increase toe flexor strength in older adults. A clinical trial is now required to determine whether this intervention can reduce the number of falls suffered by older adults.

Barricades and brickwalls--a qualitative study exploring perceptions of medication use and deprescribing in long-term care.

BACKGROUND: The co-administration of multiple drugs (polypharmacy) is the single most common cause of adverse drug events in the older population, and residents of long-term care facilities (LTCFs) are at particularly high risk of medication harm. 'Deprescribing'--the withdrawal of an inappropriate medication with goal of managing polypharmacy and improving outcomes--may improve the quality of life of LTCF residents. The RELEASE study sought to explore perceptions of medication use and the concept of deprescribing in LTCFs. METHODS: Focus groups and interviews were conducted with General Practitioners (GPs), pharmacists, nursing staff, residents and their relatives within three LTCFs in the Illawarra-Shoalhaven region of NSW, Australia. Audiotapes were transcribed verbatim and, using the Integrative Model of Behaviour Prediction as a framework, thematic analysis of transcripts was conducted using QSR NVivo 10. RESULTS: Participants acknowledged the burden of too many medications (time to administer, physical discomfort, cost), yet displayed passivity towards medication reduction. Residents and relatives lacked understanding of medicine indications or potential harms. Willingness to initiate and accept medication change was dependent on the GP, who emerged as a central trusted figure. GPs preferred 'the path of least resistance', signalling systems barriers (poor uniformity of LTCF medical records, limited trained LTCF personnel); time constraints (resident consultations, follow-up with specialists and family); and the organisation of care (collaborating with LTCF staff, pharmacists and prescribing specialists) as obstacles to deprescribing. CONCLUSIONS: Targeted engagement is required to raise awareness of the risks of polypharmacy in LTCFs and encourage acceptance of deprescribing amongst residents and their relatives. GPs are integral to the success of deprescribing initiatives within this sector.

Feasibility of implementing routine nutritional screening for older adults in Australian general practices: a mixed-methods study.

BACKGROUND: Nutrition screening in older adults is not routinely performed in Australian primary care settings. Low awareness of the extent of malnutrition in this patient group, lack of training and time constraints are major barriers that practice staff face. This study aimed to demonstrate the feasibility of including a validated nutrition screening tool and accompanying nutrition resource kit for use with older patients attending general practice. Secondary aims were to assess nutrition-related knowledge of staff and to identify the extent of malnutrition in this patient group. METHODS: Nine general practitioners, two general practice registrars and 11 practice nurses from three participating general practices in a rural, regional and metropolitan area within a local health district of New South Wales, Australia were recruited by convenience sampling. RESULTS: Four key themes were determined regarding the feasibility of performing MNA -SF: ease of use; incorporation into existing practice; benefit to patients' health; and patients' perception of MNA-SF. Two key themes related to the nutrition resource kit: applicability and improvement. These findings were supported by open ended questionnaire responses. Knowledge scores of staff significantly improved from baseline (52% to 66%; P < 0.05). Of the 143 patients that had been screened, 4.2% (n = 6) were classified as malnourished, 26.6% (n = 38) 'at risk' of malnutrition and 69.2% (n = 99) as well-nourished. CONCLUSION: It is feasible to include the MNA-SF and a nutrition resource kit within routine general practice, but further refinement of patients' electronic clinical records in general practice software would streamline this process.

Development and pilot testing of a decision aid for drivers with dementia.

BACKGROUND: An increasing number of older adults drive automobiles. Given that the prevalence of dementia is rising, it is necessary to address the issue of driving retirement. The purpose of this study is to evaluate how a self-administered decision aid contributed to decision making about driving retirement by individuals living with dementia. The primary outcome measure in this study was decisional conflict. Knowledge, decision, satisfaction with decision, booklet use and booklet acceptability were the secondary outcome measures. METHODS: A mixed methods approach was adopted. Drivers with dementia were recruited from an Aged Care clinic and a Primary Care center in NSW, Australia. Telephone surveys were conducted before and after participants read the decision aid. RESULTS: Twelve participants were recruited (mean age 75, SD 6.7). The primary outcome measure, decisional conflict, improved following use of the decision aid. Most participants felt that the decision aid: (i) was balanced; (ii) presented information well; and (iii) helped them decide about driving. In addition, mean knowledge scores improved after booklet use. CONCLUSIONS: This decision aid shows promise as an acceptable, useful and low-cost tool for drivers with dementia. A self-administered decision aid can be used to assist individuals with dementia decide about driving retirement. A randomized controlled trial is underway to evaluate the effectiveness of the tool.

Development and evaluation of the REACH (recognise end of life and care holistically) out in dementia toolkit.

AIM: To identify evidence based signs and symptoms indicative of end stage dementia, and develop the REACH toolkit as an aid for staff to consider a palliative approach. METHOD: A systematic literature review was conducted of policy, position documents, guidelines and publications from 1988 to 2011. Inclusion criteria were any report or article identifying the signs and symptoms of end stage dementia which were associated with increased mortality and morbidity. RESULTS: Eight signs and symptoms associated with worsening function and increased mortality were identified. These were incorporated into a toolkit. Experienced clinicians reviewed the toolkit. It was then trialled in six aged care facilities (ACFs) and as a result of the trial 182 residents with dementia were identified as being at the end stage. CONCLUSIONS: Use of the toolkit improved the recognition of end stage dementia among staff in ACFs.