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Background: Antibiotics are often inappropriately prescribed for urinary tract infections (UTIs) in nursing home (NH) residents. Research emphasises the importance of prescribing antibiotics only if there are UTI‐related signs and symptoms (S&S). However, for many NH residents it is challenging to find out whether such S&S are present, for example due to cognitive disorders. Objectives: To provide insight into the assessment of UTI‐related S&S in NH residents with impaired awareness or ability to communicate S&S, and to develop supportive tools for the observation of UTI‐related S&S in this subgroup of NH residents, by nursing staff. Methods: We performed a practice‐based study using mixed methods. Data of 295 cases of suspected UTI were analysed to determine how often UTI‐related S&S were 'not assessed/non‐assessable' in residents with and without dementia. Barriers and facilitators in observing UTI‐related S&S in NH residents with impaired awareness or ability to communicate S&S were derived from interviews and focus groups with nursing staff. Literature review, focus group data, additional telephone interviews and questionnaires with nursing staff were used in a step‐by‐step process, including pilot testing, to develop supportive tools for the observation of UTI‐related S&S. Results: UTI‐related S&S were assessable in the majority of NH residents with dementia. The proportion 'not assessed/non‐assessable' S&S in residents with dementia increased with increasing severity of dementia. In residents with very severe dementia, up to 58% of the S&S were 'not assessed/non‐assessable'. Knowing the resident, working methodologically, and being sufficiently skilled to interpret observations in residents facilitate the assessment of UTI‐related S&S. Insights acquired during the different study elements resulted in the development of an observation checklist and a 24‐h observation tool. Conclusions: The more NH residents have impaired awareness of ability to communicate S&S, the more difficult it seems to be to assess UTI‐related S&S. The observation checklist and 24‐h observation tool developed in the current study may support nursing staff in their observation of UTI‐related S&S in this group of NH residents. [ABSTRACT FROM AUTHOR]

Objective: The objective was to describe end-of-life treatment decisions for patients dying with dementia in various stages of dementia in long-term care facilities in the Netherlands with elderly care physicians responsible for treatment and care.Methods: We present data collected in the nationally representative Dutch End of Life in Dementia study (2007-2011). Within 2 weeks after death, 103 physicians completed questionnaires about the last phase of life in 330 residents with dementia who resided in 1 of 34 participating long-term care facilities. We used descriptive statistics.Results: Advance directives were rare (4.9%). A minority was hospitalized (8.0%) in the last month (mainly for fractures) or received antibiotics (24.2%) in the last week (mainly for pneumonia). Four residents received tube feeding or rehydration therapy in the last week. In almost half of the residents (42.3%), decisions were made not to start potentially life-prolonging treatment such as hospital transfer and artificial nutrition and hydration. In more than half of the residents (53.7%), decisions were made to withdraw potentially life-prolonging treatment such as artificial nutrition and hydration and medication. Antibiotics were more frequently prescribed for residents with less advanced dementia, but otherwise there were no differences in treatment decisions between residents with advanced and less advanced dementia.Conclusions: Physicians often withhold potentially burdensome life-prolonging treatment in nursing home residents in all stages of dementia in the Netherlands. This suggests that the physicians feel that a palliative care approach is appropriate at the end of life in dementia in long-term care. Copyright © 2016 John Wiley & Sons, Ltd. StartCopTextCopyright © 2016 John Wiley & Sons, Ltd. [ABSTRACT FROM AUTHOR]

Background: The management of pain in long-term care (LTC) residents with dementia is complex. A prospective exploratory study was conducted to describe the course of pain and pain management strategies following a guideline-based pain assessment procedure in LTC residents with pain and dementia.Measures: Pain observations with the Mobilization Observation Behaviour Intensity Dementia (MOBID-2) Pain Scale, a review of the electronic patient file and pharmacy files and physical examination of LTC residents with pain and dementia.Intervention: Communication of the assessment results to the attending physician including guideline-based treatment recommendations.Outcomes: After three months, complete follow-up data were obtained for 64 residents. Pain intensity was significantly reduced (P < 0.001). The proportion of residents with persistent pain was 58% and the total number of analgesic prescriptions did not change significantly.Conclusions: There is room for improvement regarding pain management in LTC residents with pain and dementia, and performance feedback seems a promising strategy to explore further. [ABSTRACT FROM AUTHOR]

Objectives Burdensome symptoms frequently develop as part of the dementia trajectory and influence quality of life. We explore the course of symptoms and their treatment during nursing home stay to help target adequate symptom management. Design Data were collected as part of the Dutch End of Life in Dementia study, a longitudinal observational study with up to 3.5 years of follow-up. Physicians performed assessments at baseline, semiannually, and shortly after death of pain, agitation, shortness of breath, and treatment provided for these symptoms. Setting Long-term care facilities (28) in the Netherlands. Participants Newly admitted nursing home residents (372) in variable stages of dementia. Measurements We described prevalence and course of symptoms, and treatment provided for these symptoms. We used generalized estimating equations to evaluate the longitudinal change in symptoms and their treatment, and the associations between the symptoms of pain and agitation, as well as between stage of dementia and symptoms. Results Pain was common (varying from 47% to 68% across the semiannual assessments) and frequently persistent (36%–41% of all residents); it increased to 78% in the last week of life. Agitation was the most common symptom (57%–71%), and also frequently persistent (39%–53%), yet it decreased to 35% in the last week of life. Shortness of breath was less common (16%–26%), but it increased to 52% at the end of life. Pain was not significantly associated with agitation. Advanced dementia was associated with more pain only. Treatment changed in particular at the end of life. Pain was treated mostly with acetaminophen (34%–52%), and at the end of life with parenteral opioids (44%). Agitation was mostly treated nonpharmacologically (78%–92%), and at the end of life anxiolytics were the most frequently prescribed treatment (62%). Overall, aerosolized bronchodilators were the most frequently prescribed treatment for shortness of breath (29%–67%), but at the end of life, this was morphine (69%). Conclusion Pain and agitation were common and frequently persisted in residents with dementia during nursing home stay, but symptom management intensified only at the end of life. Symptom control may be suboptimal from admission, and a stronger focus on symptom control is needed at an earlier stage than the end of life. [ABSTRACT FROM AUTHOR]

Objectives The objective of this study is to explore factors that elucidate reasons for psychotropic drug (PD) prescription for neuropsychiatric symptoms (NPS) in nursing home (NH) residents with dementia. Design A qualitative study using a grounded theory approach. Setting Twelve NHs in The Netherlands. Participants Fifteen physicians and 14 nurses. Measurements Individual, face-to-face, in-depth semistructured interviews. Interviews were audio recorded, transcribed, and qualitatively analyzed using Atlas.ti. Results The qualitative analysis revealed 4 emerging themes with factors either or both enhancing or limiting PD prescription, which we used to develop a conceptual framework. First, the mindset of physicians and nurses toward NPS and PDs appeared to contribute. Second, inadequate knowledge of and experience with NPS and limited people skills of nurses may induce PD prescription. Also, knowledge of effectiveness and side effects of PDs from education, literature, and guidelines, and previous personal experiences was considered relevant. Third, effective communication and cooperation between professionals and with family may improve the appropriateness of PD prescription. Fourth, external factors including staffing issues, nursing home setting, access to consultants, national and local policies, and zeitgeist were considered to affect PD prescription. Conclusion We have developed a conceptual framework explaining how different factors influence PD prescription. This provides opportunities for improving PD prescription in NH residents with dementia. [ABSTRACT FROM AUTHOR]

Background: Current guidelines and theories on the origin of challenging behaviour in dementia indicate that a structured multidisciplinary approach to its management is necessary. In the Grip on Challenging Behaviour study, a care programme was developed to improve the management of challenging behaviour. Method: In developing the care programme, the overlapping parts of dementia care guidelines were supplemented with discipline-specific parts. Three meetings with experts were arranged to further develop the structure of the care programme and to ensure a good fit with practice. Results: The care programme consists of four steps: detection, analysis, treatment, and evaluation. For each step, forms were developed to guide and structure the process and assign responsibilities for each discipline. As well as a description of the development and the content of the care programme, this paper presents two case studies in which the programme was used. Conclusion: The Grip on Challenging Behaviour care programme provides a way for dementia special care units to manage challenging behaviour in a structured way and with a multidisciplinary approach making use of their own resources. [ABSTRACT FROM AUTHOR]

Abstract: Objectives: The Grip on Challenging Behavior care program was developed using the current guidelines and models on managing challenging behavior in dementia in nursing homes. It was hypothesized that the use of the care program would lead to a decrease in challenging behavior and in the prescription of psychoactive drugs without increase in use of restraints. Design: A randomized controlled trial was undertaken using a stepped-wedge design to implement the care program and to evaluate the effects. An assessment of challenging behavior and psychoactive medication was undertaken every 4 months on all participating units followed by the introduction of the care program in a group of 3 to 4 units. A total of 6 time assessments took place over 20 months. Setting: Seventeen dementia special care units of different nursing homes. Participants: A total of 659 residents of dementia special care units. All residents with dementia on the unit were included. Units were assigned by random allocation software to 1 of 5 groups with different starting points for the implementation of the care program. Intervention: A care program consisting of various assessment procedures and tools, which ensure a multidisciplinary approach and which structure the process of managing challenging behavior in dementia. Measurements: Challenging behavior was measured using the Cohen-Mansfield Agitation Inventory (CMAI) and the Neuropsychiatric Inventory. Research assistants (blinded for intervention status of the unit) interviewed nurses on the units about challenging behavior. Data on psychoactive drugs and restraints were retrieved from resident charts. Results: A total of 2292 assessments took place involving 659 residents (1126 control measurements, 1166 intervention measurements). The group of residents who remained in the intervention condition compared with the group in the control condition differed significantly in the CMAI change scores between successive assessments [–2.4 CMAI points, 95% confidence interval (CI) –4.3 to –0.6]. No significant effects were found for the control-to-intervention group compared with the group who remained in the control group (0.0 CMAI points, 95% CI –2.3 to 2.4). Significant effects were found on 5 of the 12 Neuropsychiatric Inventory items and on the use of antipsychotics (odds ratio 0.54, 95% CI 0.37– 0.80) and antidepressants (odds ratio 0.65, 95% CI 0.44–0.94). No effect on use of restraints was observed. Conclusions: The Grip on Challenging behavior program was able to diminish some forms of challenging behavior and the use of psychoactive drugs. [Copyright &y& Elsevier]