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OBJECTIVE: To investigate whether an electronic health record (EHR)-integrated decision tool, combined with supportive interventions, results in more appropriate antibiotic prescribing in nursing home (NH) residents with suspected urinary tract infection (UTI), without negative consequences for residents.DESIGN: Cluster randomized controlled trial with NHs as the randomization unit; intervention group NHs received the EHR-integrated decision tool and supportive interventions, and control group NHs provided care as usual.SETTING AND PARTICIPANTS: 212 residents with suspected UTI, from 16 NHs in the Netherlands.METHODS: Physicians collected data at index consultation (ie, UTI suspicion) and during a 21-day follow-up period (March 2019-March 2020). Overall antibiotic prescribing data at NH level, 12 months prior to and during the study, was derived from the electronic prescribing system. The primary study outcome was the percentage of antibiotic prescriptions for suspected UTI that was appropriate, at index consultation. Secondary study outcomes included changes in treatment decision, complications, UTI-related hospitalization, and mortality during follow-up; and pre-post study changes in antibiotic prescribing at the NH level.RESULTS: 295 suspected UTIs were included (intervention group: 189; control group: 106). The between-group difference in appropriate antibiotic prescribing was 13% [intervention group: 62%, control group: 49%; adjusted odds ratio (OR) 1.43, 95% CI 0.57-3.62]. In both groups, complications (2% vs 3%), UTI-related hospitalization (2% vs 1%), and possible UTI-related mortality (2% vs 2%) were rare. The pre-post study difference in antibiotic prescriptions per 1000 resident-care days was -0.95 in the intervention group NHs and -0.05 in the control group NHs (P = .02).CONCLUSION AND IMPLICATIONS: Although appropriate antibiotic prescribing improved in the intervention group, this does not provide sufficient evidence for our multidisciplinary intervention. Despite this inconclusive result, our intervention could potentially still be effective, because we established a large reduction in the number of antibiotic prescriptions in the intervention group.

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.

Objectives:On May 11, the Dutch Government allowed 26 nursing homes to welcome 1 visitor per resident, after 2 months of lockdown. The study aimed to monitor in-depth the feasibility of the regulations and their impact on the well-being of residents, their visitors, and healthcare staff.Design:Mixed-methods study in 5 of the 26 facilities; the facilities were affiliated to an academic network of nursing homes.Participants:Visitors and healthcare professionals.Intervention:Allowing visitors using local regulations based on national guidelines.Measurements:Digital questionnaire, analyzing documentation such as infection prevention control protocols, attending meetings of COVID-19 crisis teams, in-depth telephone or in-person interviews with visitors and healthcare professionals, and on-site observations.Results:National guidelines were translated with great variety into local care practice. Healthcare professionals agreed that reopening would increase the well-being of the residents and their loved ones. However, there were also great worries for increasing workload, increasing the risk of emotional exhaustion, and the risk of COVID-19 infections. Compliance with local regulations was generally satisfactory, but maintaining social distance and correctly wearing face masks appeared to be difficult. Care staff remained ambivalent for fear of infections. In general, allowing visitors was experienced as having a positive impact on the well-being of all stakeholders. Nevertheless, some residents with dementia showed negative effects.Conclusion:The complete lockdown of Dutch nursing homes had a substantial impact on the well-being of the residents. The reopening was welcomed by all stakeholders, but provided a high organizational workload as well as feelings of ambivalence among care staff. In the second wave, a more tailored approach is being implemented. However, facilities are sometimes still struggling to find the right balance between infection control and well-being.

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.

To examine the impact of COVID-19 measures on residents of long-term care institutions, two surveys were conducted in the spring of 2020. Leontjevas et al. (study 1) inventoried practitioners' opinions, Van der Roest et al. (study 2) opinions of care workers, family, and residents without severe cognitive impairments. This article describes the combined results on social interaction and loneliness, challenging behaviour and mood, and lessons learned. In study 1, an online survey distributed to nursing home psychologists, they were asked to complete it anonymously and share the link with their fellow elderly care physicians and nurse specialists. 16 participants were then interviewed via video calling. In study 2, three hundred and fifty-seven care organizations were invited to recruit residents without severe cognitive impairments, family members and care workers for participating in a digital, anonymous survey (Study 2). The completed surveys of 323 practitioners (study 1) and 193 residents, 1609 family members and 811 employees (study 2) were included in the analyses. Social contacts of residents had changed in frequency and form compared to before the COVID-measures. Many residents experienced some loneliness during the visit ban, especially residents without cognitive impairments. There were both an increase and a decrease in challenging behaviour and affect. Several strategies used to reduce the effects of COVID-19 measures on well-being, were considered maintainable. Our studies confirmed a major impact of the COVID-19 measures on the wellbeing of long-term care residents, but also showed successful strategies of practitioners that can benefit future practice.Om de impact van de COVID-19-maatregelen op bewoners van instellingen voor langdurige zorg te onderzoeken, hielden we in het voorjaar van 2020 twee enquêtes. Leontjevas en collega’s (studie 1) inventariseerden de mening van behandelaren en Van der Roest en collega’s (studie 2) die van zorgmedewerkers, familie en bewoners zonder ernstige cognitieve beperkingen. Dit artikel beschrijft de gecombineerde resultaten over sociale contacten en eenzaamheid, probleemgedrag en affect, en door professionals opgedane inzichten om toe te passen in de toekomst (lessons learned). Verpleeghuispsychologen zijn gevraagd een online enquête, anoniem in te vullen en de link te delen met hun collega-artsen ouderengeneeskunde en verpleegkundig specialisten. Zestien deelnemers zijn vervolgens geïnterviewd via beeldbellen (studie 1). Daarnaast zijn 357 zorgorganisaties uitgenodigd om bewoners zonder ernstige cognitieve beperkingen, naasten en zorgmedewerkers aan een digitale, anonieme enquête te laten deelnemen (studie 2). De ingevulde enquêtes van 323 behandelaren (studie 1) en 193 bewoners, 1609 naasten en 811 medewerkers (studie 2) zijn meegenomen in de analyses. Sociale contacten van bewoners waren veranderd in frequentie en vorm ten opzichte van vóór de maatregelen. Veel bewoners ervaarden eenzaamheid tijdens het bezoekverbod, vooral bewoners zonder cognitieve beperkingen. Er bleek zowel een toename als afname van probleemgedrag en affecten. Verschillende strategieën, ingezet om effecten van COVID-19 maatregelen op welbevinden te verminderen, wilde men behouden. Onze studies toonden een impact van de COVID-19 maatregelen op het welbevinden van bewoners, maar toonden ook succesvolle strategieën van professionals waar zorgverleners in de toekomst voordeel mee kunnen doen.

The measures taken in Dutch nursing homes during the first wave of the COVID-19 pandemic resulted in both an increase and a decrease of challenging behavior in nursing home residents. Staff undertook various initiatives to reduce the negative effects. For example, video calling between residents and their relatives was facilitated. In addition, initiatives in digital care (telehealth) were deployed. The aim of this study was to explore nursing home practitioners' experiences with online communication between residents and relatives, working remotely in general and the remote treatment of challenging behavior in particular. One hundred and seventy-five nursing home professionals (psychologists, elderly care specialists, nursing specialists, daytime activities coordinators) completed an online questionnaire at the end of 2020/start of 2021. Open and closed questions showed that face-to-face contacts are preferred over online communication. Online communication was mainly seen as a (meaningful) addition. Although professionals wanted to continue some of their work remotely, and found this efficient and workload-reducing, they felt that this could impair their job satisfaction and the quality of care. For remote work and remote treatment, each task needs to be evaluated on whether it can be performed properly and whether that results in good care. More research into online communication, remote working and digital care in nursing homes is needed.De maatregelen in Nederlandse verpleeghuizen tijdens de eerste golf van de COVID-19-pandemie leidden tot zowel een toename als een afname van probleemgedrag bij verpleeghuisbewoners. Medewerkers ondernamen diverse initiatieven om de negatieve effecten te verminderen. Zo werd beeldbellen tussen bewoners en hun naasten gefaciliteerd. Daarnaast werden initiatieven op het gebied van digitale zorg (telehealth) ingezet. Doel van dit onderzoek was het verkennen van ervaringen van verpleeghuisprofessionals met onlinecommunicatie tussen bewoners en naasten, het werken op afstand in het algemeen en de behandeling van probleemgedrag op afstand in het bijzonder. Honderdvijfenzeventig verpleeghuisprofessionals (psychologen, specialisten ouderengeneeskunde, verpleegkundig specialisten, medewerkers- welzijn en -dagbesteding) vulden eind 2020/begin 2021 een onlinevragenlijst in. Uit open en gesloten vragen bleek dat face-to-face-contacten de voorkeur genieten boven onlinecommunicatie. Onlinecommunicatie werd vooral als (zinvolle) aanvulling gezien. Hoewel professionals een deel van hun werk op afstand wilden voortzetten, en dit efficiënt en werkdrukverlagend vonden, vonden ze dat dit hun werkplezier en de kwaliteit van zorg kan verslechteren. Voor werken op afstand in het algemeen en behandelen op afstand in het bijzonder, moet steeds per taak beoordeeld worden wat goed uitvoerbaar is en tot goede zorg leidt. Meer onderzoek naar onlinecommunicatie, werken op afstand en behandelen op afstand in verpleeghuizen, is nodig.

Contains fulltext : 243574.pdf (Publisher’s version ) (Open Access) AIMS: Establishing the prevalence of inappropriate sexual behaviour, concurrent challenging behaviours and the determinants of inappropriate sexual behaviour among patients with acquired brain injury ≤65 years of age in Dutch nursing homes. DESIGN: Cross-sectional, observational study in acquired brain injury special care units spreads throughout the country. METHODS: Nursing homes were recruited through the national expertise network for patients with severe acquired brain injury, regional brain injury teams and by searching the Internet. Patient characteristics were collected through digital questionnaires. Inappropriate sexual behaviour was assessed with the St. Andrews Sexual Behaviour Assessment, concurrent challenging behaviours with the NeuroPsychiatric Inventory-Nursing Home Version and the Cohen-Mansfield Agitation Inventory, cognition with the Mini-Mental State Examination and activities of daily living with the Disability Rating Scale. Psychotropic drug use was retrieved from the electronic prescription system. Associations between determinants and inappropriate sexual behaviour were examined using multilevel multivariate linear regression model analyses. Data collection started in June 2017 and ended in April 2019. RESULTS: Of the 118 included patients, 38.1% had one or more inappropriate sexual behaviours. Verbal comments (30.1%) and non-contact behaviour (24.8%) were the most prevalent types of inappropriate sexual behaviour. Less severe behaviours were more common than more severe behaviours. The most frequent concurrent challenging behaviours were agitation, aggression and hyperactivity. Physical aggression was associated with more inappropriate sexual behaviour. Being married and pain were associated with less inappropriate sexual behaviour. CONCLUSION: Inappropriate sexual behaviour is prevalent in patients with acquired brain injury ≤65 years of age residing in nursing homes. IMPACT: Inappropriate sexual behaviour may have impact not only on the patients themselves but also on nursing staff. Insight into the magnitude, severity, course and concurrent challenging behaviours, sexuality and quality of life could give direction to the kind of interventions and education that is needed. The ultimate goal is to develop appropriate care for this vulnerable group of patients, specifically psychosocial interventions and appropriate use of psychotropic drugs.

Contains fulltext : 238112.pdf (Publisher’s version ) (Open Access) OBJECTIVES: We investigated the 2-week prevalence and correlates of very frequent physical aggression (PA) and vocalizations in nursing home (NH)-residents with dementia. METHOD/DESIGN: This cross-sectional study used combined data of 2074 NH-residents from four studies, collected from 119 dementia special care units in 26 Dutch NH. Very frequent PA was defined as scoring 6 or 7 on the items 'hitting', pushing', 'biting' and 'kicking' of the Cohen Mansfield Agitation Inventory; very frequent vocalizations as scoring 6 or 7 on 'screaming' and 'making strange noises'. We compared NH-residents with very frequent PA or vocalizations with residents with less frequent PA or vocalizations, assessing correlates using univariate and multivariate multilevel logistic regression analyses. RESULTS: We found a 2-week prevalence of 2.2% (95% confidence interval (CI): 1.63-2.89) of very frequent PA and 11.5% of very frequent vocalizations (95% CI: 10.23-12.98). Very frequent PA was only associated with apathy (odds ratio (OR)=1.93, 95% CI: 1.04-3.61). Correlates of very frequent vocalizations were age (OR = 0.97, 95% CI: 0.951-0.998), dementia severity (overall p-value 0.020), antipsychotic drug use (OR = 1.56, 95% CI: 1.08-2.26), antiepileptic drug use (OR = 2.75, 95% CI: 1.34-5.68) and euphoria (OR = 2.01, 95% CI: 1.22-3.31). CONCLUSION: Characteristics of NH-residents with very frequent PA or very frequent vocalizations differ from those of NH-residents with less frequent PA or vocalizations. Frontal lobe damage, boredom, pain and/or external factors may explain several of the found associations, but further research is necessary. Our findings may contribute to better care for these residents and thereby to improving their quality of life.

Objectives:To evaluate the effect of the PROPER intervention in nursing home residents with dementia on the prevalence of psychotropic drug use and neuropsychiatric symptoms.Design:A cluster-randomized controlled design with two parallel groups (intervention versus usual care) and assessments at 0, 6, 12, and 18 months.Setting:Thirty-one dementia special care units within 13 long-term care organizations in the Netherlands.Participants:Three hundred eighty nursing home residents with dementiaIntervention:The PROPER intervention consisted of a structured and repeated multidisciplinary medication review, supported by education and continuous evaluation.Measurements:Prescriptions of antipsychotics, antidepressants, anxiolytics, and hypnotics, and occurrence of neuropsychiatric symptoms.Results:The prescription of any type of psychotropic drugs increased in the intervention group, and decreased in the control group, with an estimated difference of 3.9 percentage points per 6 months (p = 0.01). Effects for the individual drug groups were minor (differences of 1.6 percentage points and below per 6 months) and not statistically significant. The occurrence of neuropsychiatric symptoms remained stable in both the intervention and control groups during the follow-up of 18 months.Conclusions:The PROPER intervention failed to demonstrate effectiveness in reducing the prevalence of psychotropic drugs. It may be interesting to enrich the intervention with components that address personal attitudes and communication between nursing home professionals, not only with respect to the prescription of psychotropic drugs, but also to neuropsychiatric symptoms.The study has been registered in The Netherlands Trial Register (NTR3569).

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

Establishing the prevalence of neuropsychiatric symptoms (NPS), quality of life and psychotropic drug use in people aged ≤65 years with acquired brain injury in nursing homes.Cross-sectional, observational study among patients aged 18-≤65 years with acquired brain injury admitted to special care units in Dutch nursing homes.According to the Committee on Research Involving Human Subjects in January 2017 this study did not require ethics approval. Nursing homes will be recruited through the national acquired brain injury expertise network for patients with severe brain injury, the regional brain injury teams and by searching the internet. Patient characteristics will be collected through digital questionnaires. Neuropsychiatric symptoms will be assessed with the NeuroPsychiatric Inventory-Nursing Home version, the Cohen-Mansfield Agitation Inventory and the St. Andrews Sexual Behaviour Assessment; cognition with the Mini-Mental State Examination, quality of life with the Quality of Life after Brain Injury Overall Scale and activities of daily living with the Disability Rating Scale. Medication will be retrieved from the electronic prescription system. Data collection commenced in 2017 and will be followed by data analysis in 2019. Reporting will be completed in 2020.Little is known about NPS among patients with acquired brain injury in nursing homes. In patients up to the age of 65 years, only six studies were found on prevalence rates of NPS.Patients with severe acquired brain injury experience lifelong consequences, that have a high impact on them and their environment. Although there is increasing attention for the survival of this vulnerable group of patients, it is also important to enlarge awareness on long-term consequences, specifically the NPS, quality of life and psychotropic drug use in acquired brain injury. Insight into the magnitude of these issues is necessary to achieve appropriate care for these patients.目的: 确定神经精神病症状的患病率(NPS)、住在疗养院的年龄≤65 岁的脑损伤老年人的生活质量和精神药物。 设计: 针对疗养院内年龄在18--≤65 岁的特殊护理病房的脑损伤病人的横段截面观察性研究。 方法: 根据人体研究委员会在2017年一月的报告,本研究不需要道德批准。疗养院将通过数据问卷调查收集病人的特征。神经疾病将根据神经精神病学目录-疗养院版本、Cohen-Mansfield精神激动目录和St. Andrews的性行为评估评估神经精神疾病、认识精神状态检查量表脑损伤后总体评分和残疾评定量表。电子处方系统为开具药物。我们在2017年开始数据收集,并且将在2019 年进行数据分析,2020年完成报告。 讨论: 针对疗养院中脑损伤病人患有神经精神疾病的研究甚少。仅有6项研究针对的是65岁老年人的神经精神疾病患病率。 影响: 严重脑损伤可能会影响病人的一生,不仅对其自身也会其周围环境产生严重的后果。尽管有越来越多的人关注弱势病人群体的生存问题。但也有必要提高其对长期后果的认识,尤其是NPS、生活质量、对后天脑损伤的神经精神药物治疗。深入了解这些疾病的也是为病人提供正确治疗所必要的步骤。.

Background Research suggests that collaborative and tailored approaches with external expertise are important to process implementations. We therefore performed a process evaluation of an intervention using participatory action research, tailored information provision, and external coaching to reduce inappropriate psychotropic drug use among nursing home residents with dementia. The process evaluation was conducted alongside a randomized controlled trial assessing the utility of this approach. Methods We used Leontjevas’ model of process evaluation to guide data collection and analysis, focusing on the relevance and feasibility, extent of performance, and barriers and facilitators to implementation. Data on the relevance and feasibility and on the extent of performance were collected using a questionnaire targeting internal project leaders at nursing homes and our external coaches. Implementation barriers and facilitators were identified by individual semi-structured interviews. The Consolidated Framework for Implementation Research was used to structure and describe the identified barriers and facilitators. Results The intervention was viewed positively, but it was also considered time consuming due to the involvement of many people and designing a tailored action and implementation plan was viewed as complex. The extent of performance differed between nursing homes. Delays in implementation and suboptimal execution of actions may have reduced effectiveness of the RID intervention in some nursing homes. Barriers to implementation were reorganizations, staff turnover, communication issues, unclear expectations, and perceived time pressures. Implementation also depended on the involvement and skills of key stakeholders, and organizations’ readiness to change. Although external coaches stimulated implementation, their additional value was rated variably across organizations. Conclusions Barriers to implementation occurred on several levels and some barriers appear to be inherent to the nursing home environment and could be points of leverage of future implementation trajectories. This underlines the importance of assessing and supporting organizations in their readiness to change. Sensitivity analyses, taking into account the week in which nursing homes started with implementation and the degree to which actions were implemented as intended, will be appropriate in the effect analyses of the trial.

Background To protect nursing home residents, many governments around the world implemented blanket visitor bans in March and April 2020. As a consequence, family caregivers, friends, and volunteers were not allowed to enter nursing homes, while residents were not allowed to go out. Up until now, little is known on the long-term consequences and effects of visiting bans and re-opening of nursing homes. The aim of the study was to assess the long-term effects of the pandemic on residents, family members, and staff, and their preparedness for the next coronavirus wave. Methods A mixed-methods approach was used, consisting of a questionnaire and analyses of documentation (local visiting protocols). Of the 76 nursing home locations that participated in a Dutch national pilot on welcoming visitors back into nursing homes, 64 participated in this follow-up study. Data were collected in September/October 2020. For each nursing home, one contact person completed the questionnaire. Descriptive statistics were calculated for quantitative questionnaire data. Data on open-ended questions, as well as data from the documentation, were analyzed thematically. Results The study demonstrated that the consequences of strict visiting bans do not disappear at the moment the visiting ban is lifted. Although in October 2020, daily life in nursing homes was more “back to normal,” more than one-third of the respondents indicated that they still applied restrictions. Compared to the situation before the pandemic, fewer volunteers were working in the nursing homes, grandchildren visited their relative less often, and visits differed. Conclusions Five months after the visiting ban in Dutch nursing homes had been lifted, it still had an impact on residents, family members, and staff. It is questionable whether nursing homes feel prepared for welcoming visitors in the case of new COVID-19 infections. Nursing homes indicated that they felt prepared for the next wave, while at the same time, they were particularly concerned about staff well-being and vitality. It seems wise to invest in staff well-being. In addition, it seems desirable to think about how to support nursing homes in seeking a balance between infection prevention and well-being of residents, family members, and staff.

Background:Depression is common among nursing home residents and has a considerable impact on their quality of life. Therefore, there has been an increased interest in interventions aiming at the reduction of depression among nursing home residents. These interventions could be categorized into formal and informal depression care. Formal care includes psychosocial, psychotherapeutic and/or (neuro-)biological interventions. Informal care can be provided by nursing home staff, alongside the formal care (e.g., letting sunlight into the room when one believes in the positive effects of daylight). Although many studies have been done about depression treatment in nursing homes, there is still a lack of insight into the effectiveness of interventions and how they differ among specific target groups (e.g., residents with cognitive impairment versus residents with physical disabilities). Moreover, research into informal care is rather rare. More insight is needed into the effect of formal and informal depression care and the mutually reinforcing effects of those strategies on nursing home residents. This insight is essential to better match treatments with residents and to provide a more comprehensive approach to counter depression.Objectives:The aim of this study is to gain insight in the use of formal and informal depression care and their associations with depression among nursing home residents.Design:A six month cohort study will be conducted.Method:Residents will be recruited in nursing homes across the Netherlands and Flanders (Belgium). To measure formal and informal care, newly developed tools will be cross-culturally validated: one to assess the provided formal care in nursing homes, two tools for measuring the used informal strategies. Depression outcomes will be measured with the Geriatric Depression Scale, Cornell Scale for Depression in Dementia, and the Nijmegen-Observer-Rated Depression-scale). Baseline measurements and cross- sectional analyses will be performed and repeated after six months. The intended associations will be assessed using multiple regression analysis.Conclusion:To develop a good depression care policy, a more comprehensive approach is needed and may benefit both residents and staff.

Introduction:For feeling empowered, a sense of identity, usefulness, control, and self-worth is important for people living with dementia. We developed an empowerment intervention called the SPAN+ program to promote empowerment for nursing home residents with dementia. The aim of this study is to evaluate the feasibility of the SPAN+ program for these residents.Methods:Healthcare professionals of two dementia special care units of one care organization worked with the SPAN+ intervention, which lasted for four months (September 2020 – December 2020). During the intervention, they reflected together on the four themes of empowerment for each resident, and set specific goals. Subsequently, they discussed and adjusted these goals with family caregivers and the person living with dementia (when possible). Furthermore, their personal professional development was targeted by specific exercises around the themes of empowerment.We used the method of Bowen and colleagues (2009) to evaluate the feasibility of the SPAN+program in terms of acceptability, demand, implementation, practicality, integration, and possible efficacy.Qualitative data was collected through interviews and a focus group discussion with participating healthcare professionals. Quantitative data was collected through standardized questionnaires filled in by healthcare professionals and family caregivers at baseline and at four- month follow-up.Results:Preliminary results show that the SPAN+ program supports healthcare professionals to increase attention for empowerment of residents living with dementia, by reflecting together with other healthcare professionals on what matters for each individual resident. Difficulties were reported in engaging family caregivers in the SPAN+ program.Conclusion:The SPAN+ program seems valuable to increase the focus of healthcare professionals on a sense of identity, usefulness, control, and self-worth of people living with dementia in a nursing home, and to promote their empowerment.

Challenging behavior is common in nursing home residents, especially in those with dementia. Our previous study suggested that a decrease in environmental stimuli (i.e., events that take place around residents but are not specifically directed at them) in nursing homes due to restrictions during the COVID-19 pandemic, may affect residents differently. To improve future care, the experience of practitioners can be used to learn about the effects of environmental stimuli on challenging behavior in specific resident groups during the pandemic.From the perspective of practitioners, this study aimed to learn from successful initiatives and observed effects of decreased environmental stimuli on challenging behavior in residents during anti-pandemic measures.An online survey among 199 Dutch nursing home practitioners was conducted from November 2020 to January 2021. Practitioners were asked about alleged effects of diminished environmental stimuli in residents with different types of challenging behavior (i.e., psychotic, depressed, anxious, agitated, apathetic) and with mild vs. advanced or without dementia. Also, their opinion about strategies to limit environmental stimuli was explored.Residents with advanced dementia and those with psychotic and agitated behavior seemed to benefit from diminished environmental stimuli. In contrast, residents without dementia and those with depressive and apathetic behavior seemed to be negatively affected by decreased environmental stimuli. Practitioners indicated that they would like to preserve various strategies to limit environmental stimuli in the future such as reducing the use of corridors adjacent to residents’ rooms. Also, they planned to use adjustments and new initiatives regarding organized activities such as an increased use of small-scale and person-oriented activities. Opinions were divided on receiving visitors in the living room and on imposing visiting hours. In open-ended questions, other initiatives were mentioned that can be useful in nursing home care.Various strategies and initiatives in nursing homes during the pandemic seem promising to meet individual needs. While many residents may be negatively affected by restrictions during the pandemic, specific resident groups may benefit from a decrease in environmental stimuli. These findings underline the importance of a good balance between stimuli and rest in the nursing home, tailored to an individual resident.

Our study on challenging behavior in nursing home residents in The Netherlands showed initiatives of nursing home staff regarding telecare during the first COVID-19 pandemic wave. Staff facilitated telecommunication to help residents in staying connected with their loved ones during the visitor ban. To improve the quality of nursing home care in the future, it is important to learn from these experiences. This survey during the second pandemic wave at the end of 2020 aimed to learn, from the perspective of treatment staff, about experiences with telecommunication during the COVID-19 pandemic, telecare for challenging behavior, and working remotely.In total, 175 professionals participated, of whom 69 (39%) were psychologists, 61 (35%) therapeutic activities coordinators, 38 (22%) elderly care physicians or nurse practitioners and 7 other professionals. Responses to open and closed questions showed that face-to-face contacts were preferred above telecommunication. However, most professionals would prefer the continuation of telecommunication for residents and their loved ones after the pandemic in addition to face-to-face contacts.Regarding the management of challenging behavior, psychologists, physicians and nurse practitioners considered it possible to continue several tasks remotely, e.g. consultations, evaluations, and meetings and mutual consultations. The majority of activities coordinators reported that they could not work remotely.In general, working remotely was considered efficient and workload-reducing. However, participants thought that it could worsen their job satisfaction, and the quality of care. The need for more technical support was expressed.To conclude, the COVID-19 pandemic accelerated the move to telecare in nursing homes. It is important to provide a solid infrastructure, to educate and train the staff and residents regarding telecommunication, and to integrate telecare elements in daily workflows. Research is needed on the effects of telecare on job related outcomes, and on the quality of care and the quality of life of residents.

Contains fulltext : 232534.pdf (Publisher’s version ) (Open Access) 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.

Contains fulltext : 240054.pdf (Publisher’s version ) (Open Access) 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.

Objectives:Before drawing conclusions on the contribution of an effective intervention to daily practice and initiating dissemination, its quality and implementation in daily practice should be optimal. The aim of this process evaluation was to study these aspects alongside a randomized controlled trial investigating the effects of a multidisciplinary biannual medication review in long-term care organizations (NTR3569).Design:Process evaluation with multiple measurements.Setting:Thirteen units for people with dementia in six long-term care organizations in the Netherlands.Participants:Physicians, pharmacists, and nursing staff of participating units.Intervention:The PROPER intervention is a structured and biannually repeated multidisciplinary medication review supported by organizational preparation and education, evaluation, and guidance.Measurements:Web-based questionnaires, interviews, attendance lists of education sessions, medication reviews and evaluation meetings, minutes, evaluation, and registration forms.Results:Participation rates in education sessions (95%), medication reviews (95%), and evaluation meetings (82%) were high. The intervention’s relevance and feasibility and applied implementation strategies were highly rated. However, the education sessions and conversations during medication reviews were too pharmacologically oriented for several nursing staff members. Identified barriers to implementation were required time, investment, planning issues, and high staff turnover; facilitators were the positive attitude of professionals toward the intervention, the support of higher management, and the appointment of a local implementation coordinator.Conclusion:Implementation was successful. The commitment of both higher management and professionals was an important factor. This may partly have been due to the subject being topical; Dutch long-term-care organizations are pressed to lower inappropriate psychotropic drug use.

Background Challenging behavior is prevalent in people with dementia residing in nursing homes and places a high burden on the nursing staff of dementia special care units. This study evaluates an educational program for nursing staff for managing challenging behavior: The Educating Nursing Staff Effectively (TENSE) program. This program can be tailored to care organizations’ wishes and needs and combines various learning styles. Objective The aim of this cluster-randomized controlled trial was to examine the short-term (3 months) and long-term (9 months) effects of the TENSE training program on experienced stress, work contentment, and stress reactions at work in nursing staff working in dementia special care units. Design Cluster-randomized controlled trial. Methods Nursing staff members of 18 dementia special care units within nine nursing homes from different Netherlands regions were randomized into an intervention (n = 168) or control (n = 129) group. The TENSE program consisted of a three-day training course and two follow-up sessions after three and six months, respectively. The primary outcome was stress experienced by nursing staff measured with the Utrecht Burnout Scale - C. Secondary outcomes were work contentment and stress reactions at work. Furthermore, process evaluation data on the reach of and compliance with the program and the program's feasibility and relevance were collected. Data were collected between November 2012 and November 2014. Results In general, the participants appreciated the quality and relevance of the TENSE training and evaluated the content of the training as beneficial. The TENSE training had no effect on the components of experienced stress, i.e., emotional exhaustion (p = 0.751), depersonalization (p = 0.701), and personal accomplishment (p = 0.182). Furthermore, no statistically significant effects of the intervention on work contentment and stress reactions at work were found. Conclusions The TENSE training program did not have an effect on experienced stress, work contentment, nor stress reactions at work of nursing staff working in dementia special care units. In future studies, more focus on practicing new skills seems needed. Trial registration: NTR (Dutch Trial Registration) number NTR3620

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.

Depression is highly prevalent in nursing homes residents and affects their quality of life. Both prevalence and impact of depression may decrease when effective guidelines or depression care programs are used, but this appears to be a challenging task. The Self Determination Theory postulates that the realization of complex tasks is being facilitated by meeting three basic human psychosocial needs: autonomy, competence and relatedness to others. This cross-sectional study investigates the relationship between the experienced autonomy, competence and relatedness and the extent to which depression care is given according to guidelines in 46 doctors, 49 psychologists and 53 nurses from 71 Dutch nursing homes. Although autonomy and competence were significantly related to depression care according to guidelines, hierarchical multiple regression analyses with all three basic needs showed a statistically significant result for competence only. The associations don't allow conclusions about causal relationships, longitudinal research will shed light on the direction of the association for competence.Depressie komt bij bewoners van verpleeghuizen vaak voor en tast de kwaliteit van hun leven aan. Als professionals de richtlijnen voor depressiezorg of een op richtlijnen gebaseerd zorgprogramma opvolgen, verminderen zowel ernst als prevalentie van depressie. Deze complexe taak blijkt in de praktijk echter lastig uitvoerbaar. De Zelf Determinatie Theorie stelt dat de uitvoering van complexe taken bevorderd wordt door tegemoet te komen aan drie psychosociale basisbehoeften van mensen. In dit dwarsdoorsnede-onderzoek is de relatie onderzocht tussen deze drie basisbehoeften, namelijk ervaren autonomie, competentie en verbondenheid met collega’s en de mate waarin 46 artsen, 49 psychologen en 53 zorgmedewerkers uit 71 verpleeghuisorganisaties in Nederland depressiezorg volgens richtlijnen vormgaven. Hoewel autonomie en competentie bleken te correleren met de mate waarin depressiezorg volgens richtlijnen vorm kreeg, liet hiërarchische multipele regressieanalyse met alle drie basisbehoeften alleen een statistisch significant resultaat zien voor competentie. Longitudinaal onderzoek kan inzicht geven in de richting van het gevonden verband voor de basisbehoefte competentie.

Contains fulltext : 232401.pdf (Publisher’s version ) (Open Access) OBJECTIVES: Extreme neuropsychiatric symptoms can be a heavy burden for nursing home (NH) residents, relatives, and caregivers. Sometimes, when extreme neuropsychiatric symptoms are considered refractory, continuous palliative sedation is administered. The aim of this study was to explore the trajectory leading to continuous palliative sedation and its administration in NH residents with dementia and refractory neuropsychiatric symptoms. DESIGN: A qualitative interview and explorative study was performed. SETTING AND PARTICIPANTS: Relatives, elderly care physicians, and other staff members involved with 3 NH residents with dementia and extreme refractory neuropsychiatric symptoms who received continuous palliative sedation were interviewed. These NH residents lived on dementia special care units of 3 NHs in the Netherlands. METHODS: Consecutive sampling was used to select participants. Medical files were studied. Semistructured interviews were conducted. Transcriptions were analyzed with thematic analysis, including directed content analysis. RESULTS: Nine in-depth interviews with 13 participants were held. Analysis resulted in 6 main themes, with several subthemes reflecting phases of the continuous palliative sedation trajectory: (1) run-up, describing an unbearable struggle of the resident; (2) turning point, at which hope was lost; (3) considering continuous palliative sedation and administration of intermittent sedation; (4) decision to start continuous palliative sedation based on 1 decisive trigger; (5) administration of continuous palliative sedation with stakeholders experiencing relief; and (6) evaluation. CONCLUSIONS AND IMPLICATIONS: The trajectory leading up to continuous palliative sedation in NH residents with dementia and extreme refractory neuropsychiatric symptoms was complex and burdensome, but the initiation led to relief and contentment for all those involved. This study highlights that continuous palliative sedation can be a valuable treatment option among these residents. A recommendation is to include external consultation in the decision process and to administer intermittent sedation as a preceding step when continuous palliative sedation is considered.

Purpose: To explore the association between apathy and health-related quality of life (HRQoL) from resident and proxy perspectives and whether cognition and depression moderate this relationship. Methods: Secondary analyses with baseline data from a cluster randomized trial on the effects of a care program for depression in Nursing Homes (NHs) were conducted. For HRQoL, the Visual Analogue Scale (VAS) and the Dutch version of the European Quality of Life (EQ-5D) were administered to 521 NH residents, and to professional caregivers reporting from the perspective of the NH resident (Resident–Proxy) and from their own perspective (Proxy–Proxy). Utility scores (U) were calculated for the three perspectives. Apathy, depression, and cognition were measured using the 10-item Apathy Evaluation Scale, the Cornell Scale for Depression in Dementia, and the standardized Mini-Mental State Examination, respectively. Results: Mixed models adjusted for clustering within NH units revealed that apathy was negatively associated with HRQoL both from the Resident–Proxy perspective (EQ-5D VAS: estimated effect, − 0.31, P < 0.001; EQ-5D Utility: − 0.30, P < 0.001) and from the Proxy–Proxy perspective (VAS: − 0.29, P < 0.001; U: − 0.03, P < 0.001), but not from the Resident–Resident perspective (VAS: − 0.05, P = 0.423; Utility: − 0.08, P = 0.161). Controlling for depression and cognition and their interaction terms with apathy did not change the results. Conclusion: Apathy is negatively associated with NH resident HRQoL as reported by proxies. Depression and cognitive functioning do not moderate this association. NH residents do not self-report a relationship between apathy and HRQoL. More research is needed to understand caregiver and NH resident attitudes and underlying assumptions regarding apathy and HRQoL.

Background The phenomena of severe agitation is not well understood and often not adequately treated. Objective This article determines the prevalence and associated factors of severe agitation in nursing home residents with dementia. Methods Secondary data analysis within an observational study in German nursing homes with n = 1,967 participants. We assessed severity of agitation with the Neuropsychiatric Inventory Questionnaire (NPI-Q) and defined the construct of agitation as a composite score of the NPI-Q items agitation/aggression, disinhibition, and irritability/lability; the dependent variable of severe agitation was considered as being present in residents who scored 'severe' in at least one of these symptoms. A binary logistic regression model was calculated to estimate associations. Results The prevalence of severe agitation was 6.3% (n = 124). The strongest associations were found for elation/euphoria (OR 7.6, CI 3.1-18.5), delusions (OR 7.3, CI 4.0-13.2), apathy/indifference (OR 2.8, CI 1.7-4.7), anxiety (OR 2.2, CI 1.2-3.8), nighttime behaviors (OR 2.4, CI 1.4-4.2), motor disturbances (OR 2.4, CI 1.4-4.1), and male sex (OR 2.4. CI 1.3-4.2). Conclusion Severe agitation in nursing home residents with dementia is a relevant clinical issue as approximately 70% of residents have a dementia. Residents with elation/euphoria and delusions may have a stronger risk of showing severe agitation. We consider delusions as a possible cause of agitation and therefore a prelude to agitation. Although it might be possible that elation/euphoria follows from agitation, we hypothesize that the residents first experience elation/ euphoria and exhibit agitation afterwards.

Objectives: This study investigates the relationship between attitudes of care staff and social well-being and challenging behavior of residents in long-term dementia care.Methods: The study was ba...

Objective: Aging societies will bring an increase in the number of long-term care residents with mental-physical multimorbidity. To optimize care for these residents, it is important to study their care needs, since unmet needs lower quality of life. To date, knowledge about care needs of residents with mental-physical multimorbidity is limited. The aim of this study was to explore (un)met care needs of residents with mental-physical multimorbidity and determinants of unmet needs.Methods: Cross-sectional cohort study among 141 residents with mental-physical multimorbidity without dementia living in 17 geronto-psychiatric nursing home units across the Netherlands. Data collection consisted of chart review, semi-structured interviews, (brief) neuropsychological testing, and self-report questionnaires. The Camberwell Assessment of Need for the Elderly (CANE) was used to rate (un)met care needs from residents' and nursing staff's perceptions. Descriptive and multivariate regression analyses were conducted.Results: Residents reported a mean number of 11.89 needs (SD 2.88) of which 24.2% (n = 2.88, SD 2.48) were unmet. Nursing staff indicated a mean number of 14.73 needs (SD 2.32) of which 10.8% (n = 1.59, SD 1.61) were unmet. According to the residents, most unmet needs were found in the social domain as opposed to the psychological domain as reported by the nursing staff. Different opinions between resident and nursing staff about unmet needs was most common in the areas accommodation, company, and daytime activities. Further, nearly half of the residents indicated 'no need' regarding behavior while the nursing staff supposed that the resident did require some kind of support. Depression, anxiety and less care dependency were the most important determinants of unmet needs.Conclusions: Systematic assessment of care needs showed differences between the perspectives of resident and nursing staff. These should be the starting point of a dialogue between them about needs, wishes and expectations regarding care. This dialogue can subsequently lead to the most optimal individually tailored care plan. To achieve this, nurses with effective communication and negotiation skills, are indispensable.

Background:Although formal treatments like antidepressants and psychotherapy may effectively reduce depression in nursing home residents, side effects and poor treatment adherence are common. To improve depression care, it is important to also learn from informal strategies already used successfully in daily practice, alongside or in absence of formal treatment. For example, although not prescribed as formal treatment, a care provider may seat a resident with depression at a table near the window. This may have antidepressant effects due to extra day light or pleasant views from the window.Objectives:To identify, categorize, and prioritize informal antidepressant strategies for residents already used in daily practice as reported by residents themselves, their relatives, and professional caregivers.Method:In the first Group Concept Mapping study, residents, relatives, and professional caregivers (N = 124) brainstormed on strategies to prevent or improve depression that may be performed by residents themselves. In the second study, the same participants (N = 110) reported on strategies others involved in residents’ lives could perform. In a second round of both studies, participants rated the expected effectiveness (N = 54, N = 51 respectively) and feasibility (N = 50 for both studies) of the strategies mentioned. In addition, strategies for both studies were sorted based on similarity in meaning by experts.Results:Six clusters appeared for actions to be undertaken by residents themselves, and five clusters for actions by others. The results showed that, for strategies by residents, the clusters ‘Being socially connected’ and ‘Participating in activities’, and for strategies by others, the cluster ‘Offering personal attention’ stand out the most in terms of high expected effectiveness. The cluster with strategies executed by residents that stood out as the most feasible was ‘Having a healthy living environment’. The most feasible clusters performed by others were ‘Offering personal attention’, ‘Using positive treatment/approach’, and ‘Using or adapting the physical environment’.Conclusion:By using an innovative bottom-up participatory approach, this research shed light on various clusters of useful informal antidepressant strategies for daily practice. To test effectiveness and implementation, research is needed on these antidepressant strategies and their regular use in care.

Objective: Although many nursing home residents with dementia show agitation, hardly any literature is published about very frequent agitation. The WAALBED-III study focuses on the 2-week prevalence and correlates of very frequent agitation in these residents. Design: Cross-sectional study using combined data of four studies. Setting: One hundred nineteen dementia special care units in twenty-six nursing homes in The Netherlands. Participants: Two thousand seventy-four residents with dementia. Measurements: We operationally defined very frequent agitation as having a score of 6 (several times a day) or 7 (several times an hour) on at least five items of the Cohen Mansfield Agitation Inventory (CMAI) combined with a CMAI total score above the 90th percentile. To assess the association of demographic and behavioral characteristics with very frequent agitation, we performed a multivariate multilevel logistic regression analysis. Results: The 2-week prevalence of very frequent agitation was 7.4% (95% CI: 6.374-8.634). Correlates for very frequent agitation were age (OR: 0.967, 95% CI: 0.942-0.992), dementia severity (GDS 6 = OR: 3.636, 95% CI: 1.929-6.875; GDS 7 = OR: 2.951, 95% CI: 1.321-6.588), delusions (OR: 2.480, 95% CI: 1.555-3.956), anxiety (OR: 1.904, 95% CI: 1.259-2.881), euphoria (OR: 3.712, 95% CI: 2.171-6.337) and irritability (OR: 4.411, 95% CI: 2.854-6.816). Conclusions: To our knowledge, this study is the first to report prevalence data and correlates about nursing home residents with very frequent agitation. We found several correlated factors for very frequent agitation. Still, further research is needed for a better understanding of the behavior of this group, and to identify good treatment options.

Background Several efforts have been made to change management of neuropsychiatric symptoms (NPS) in nursing homes, however only few were successful. Numerous barriers to change in healthcare were identified, yet only one conceptual model is known to study their interrelationships. Unfortunately, this model does not discuss specific barriers encountered in nursing home practice. The aim of this study is to explore perceived barriers to change in the management of NPS in nursing homes and to construct a conceptual framework providing insight into the relative importance and interrelationships of these barriers when improving quality of care. Methods Four focus groups were conducted in different dementia special care units of one Dutch nursing home. Participants were either nursing staff, treatment staff or relatives of residents. Qualitative thematic analysis was conducted according to the five phases defined by Braun & Clarke. Finally, a conceptual framework showing the interrelations of barrier-themes was constructed using text fragments of the focus groups. Results We constructed a conceptual framework consisting of eight themes of barriers explaining the extent to which change in NPS-management can be achieved: ‘organizational barriers’, ‘personal barriers’, ‘deficiency of staff knowledge’, ‘suboptimal communication’, ‘inadequate (multidisciplinary) collaboration’, ‘disorganization of processes’, ‘reactive coping’ and ‘differences in perception’. Addressing ‘organizational barriers’ and ‘deficiency of staff knowledge’ is a precondition for change. ‘Suboptimal communication’ and ‘inadequate (multidisciplinary) collaboration’ play a key role in the extent of change achieved via the themes ‘differences in perception’ and ‘disorganization of processes’. Furthermore, ‘personal barriers’ influence all themes - except ‘organizational barriers’ - and may cause ‘reactive coping’, which in turn may lead to ‘difficulties to structure processes’. Conclusions A conceptual framework was created explaining the relationships between barriers towards achieving change focused on improving management of NPS in nursing homes. After this framework has been confirmed and refined in additional research, it can be used to study the interrelatedness of barriers to change, and to determine the importance of addressing them for achieving change in the provided care.

The Act in case of Depression program showed effects on the quality of life and depression in nursing home (NH) residents. We aimed to explore the effects of this complex multidisciplinary program on job satisfaction, job demands, and autonomy in nursing home staff.Four data points from a stepped-wedge cluster-randomized trial on patient outcomes were used for secondary analyses on staff outcomes.Sixteen dementia special care and 17 somatic care units in Dutch NHs.Participants were 717 (90.1%) care staff or trainees, 34 (4.3%) paramedical staff, and 45 (5.7%) other staff members.Intervention describes procedures for nursing staff, activity therapists, psychologists, and physicians. It contains evidence-based pathways for depression assessment, treatment, and monitoring treatment results.Mixed models for intention-to-treat analyses showed no significant changes in job demands, job satisfaction, or autonomy. Models corrected for the ratio of unit residents who received, when indicated, a specific program component revealed reduced job demands and improved job satisfaction and autonomy when treatment procedures were used. A better use of assessment procedures was associated with increased job demands, while conducting monitoring procedures was associated with increased job demands and decreased autonomy.Components of complex care programs may affect the staff outcomes in opposite directions and, taken together, produce a zero-sum or a statistically insignificant effect. While implementing treatment protocols affecting patients directly can also improve job outcomes such as satisfaction and autonomy and decrease job demands, it is possible that other procedures of complex programs may have unfavorable effects on job outcomes. It is important to account for specific components of complex interventions when evaluating intervention effects.

Objectives Establishing the prevalence and determinants of neuropsychiatric symptoms (NPS) in patients with acquired brain injury (ABI) in nursing homes. Design Cross-sectional, observational study. Setting and Participants Patients 18-65 years old with ABI in special care units in Dutch nursing homes. Methods Nursing homes were recruited through the national expertise network for patients with severe ABI, regional brain injury teams, and by searching the Internet. Patient characteristics were collected through digital questionnaires. NPS were assessed with the Neuropsychiatric Inventory-Nursing Home version (NPI-NH) and the Cohen-Mansfield Agitation Inventory (CMAI), cognition with the Mini-Mental State Examination, and activities of daily living with the Disability Rating Scale. Psychotropic drug use (PDU) was retrieved from the electronic prescription system. Individual NPS were clustered. Associations between determinants and NPS were examined using multilevel multivariate linear regression models. Results In a population of 118 patients from 12 nursing homes, 73.7% had 1 or more clinically relevant NPS and 81.3% 1 or more agitated behaviors. The most common NPS were agitation, in particular aberrant motor behavior (24.6%), repetitious sentences/questions (35.5%), and constant requests for attention (34.6%), verbal (33.6%) and physical (50.5%) aggression, and irritability (28.0%). Male patients were more likely to display hyperactivity. Being married was associated with less verbally agitated behavior and pain was associated with a higher CMAI total score. PDU increased the likelihood of a higher NPI-NH total score. Conclusions and Implications NPS are common in patients with ABI ≤65 years of age residing in nursing homes. This is a first step to fill in the knowledge gap concerning NPS in this population. An increasing number of patients with severe ABI may survive the acute phase and will reside many years in nursing homes. It is important to shed more light on these NPS, with regard to course, magnitude, and severity, to ultimately develop appropriate care for this vulnerable group of patients.

Objective: Aging societies will bring an increase in the number of long-term care patients with mental-physical multimorbidity (MPM). This paper aimed to describe the natural course of neuropsychiatric symptoms (NPS) in patients with MPM in the first 8 months after admission to a geronto-psychiatric nursing home (GP-NH) unit. Methods: Longitudinal cohort study among 63 patients with MPM no dementia living in 17 GP-NH units across the Netherlands. Data collection consisted of chart review, semi-structured interviews, and brief neuropsychological testing, among which our primary outcome measure the Neuropsychiatric Inventory (NPI). Descriptive and bivariate analyses were conducted. Results: Our study showed a significant increase of the NPI total score (from 25.3 to 29.3, p = 0.045), and the total scores of a NPI hyperactivity cluster (from 9.7 to 11.8, p = 0.039), and a NPI mood/apathy cluster (from 7.7 to 10.1, p = 0.008). Just over 95% had any clinically relevant symptom at baseline and/or six months later, of which irritability was the most prevalent and persistent symptom and the symptom with the highest incidence. Hyperactivity was the most prevalent and persistent symptom cluster. Also, depression had a high persistence. Conclusions: Our results indicate the omnipresence of NPS of which most were found to be persistent. Therefore, we recommend to explore opportunities to reduce NPS in NH patients with MPM, such as creating a therapeutic milieu, educating the staff, and evaluating patient's psychotropic drug use.

Objectives To prevent and control COVID-19 infections, nursing homes across the world have taken very restrictive measures, including a ban for visitors. These restrictive measures have an enormous impact on residents’ well-being and pose dilemmas for staff, although primary data are lacking. A Dutch guideline was developed to cautiously open nursing homes for visitors during the COVID-19 pandemic. This study reports the first findings on how the guideline was applied in the local context, the compliance to local protocols and the impact on well-being of residents, their family caregivers and staff. Design A mixed-methods cross-sectional study was conducted Setting and participants In total, 26 nursing homes were permitted to enlarge their possibilities for allowing visitors in their facility. These nursing homes were proportionally representative of the Netherlands as they were selected by their local Area Health Authority for participation. At each nursing home, a contact person was selected for participation in the current study. Methods A mixed-method cross-sectional study was conducted, consisting of questionnaire, telephone interviews, analyses of documentation (i.e. local visiting protocols) and a WhatsApp group. Results Variation in local protocols was observed, for example related to the use of personal protective equipment, location and supervision of visits. In general, experiences were very positive. All nursing homes recognized the added value of real and personal contact between residents and their loved ones and indicated a positive impact on well-being. Compliance with local guidelines was sufficient to good. No new COVID-19 infections were reported during this time. Conclusions and implications These results indicate the value of family visitation in nursing homes and positive impact of visits. Based on these results, the Dutch government has decided to allow all nursing homes in the Netherlands to cautiously open their homes using the guidelines. More research is needed on impact and long-term compliance., Positive results from a study of the safety and impact of following national guidelines for nursing home visitors during COVID-19 led the Dutch national government to permit all nursing homes to cautiously allow visitors.

Background Psychotropic drugs are often prescribed to treat neuropsychiatric symptoms in nursing home residents with dementia, despite having limited efficacy and considerable side effects. To reduce the inappropriate prescribing of these psychotropic drugs, various non-pharmacological, psychosocial, person-centered, or multidisciplinary interventions are advocated. However, existing multidisciplinary interventions have shown variable effects, with limited effectiveness often resulting from suboptimal implementation. We hypothesize that an effective intervention needs to fit the local situation of a nursing home and that support should be offered during implementation. Methods We will embed participatory action research within a stepped-wedge cluster randomized controlled trial to study the effects of a tailored intervention and implementation plan to reduce inappropriate psychotropic drug prescribing. Nursing homes will be provided with tailored information about the perceived problems of managing neuropsychiatric symptoms and we will offer coaching support throughout. Alongside the participatory action research, we will perform a process evaluation to examine the quality of the study, the intervention, and the implementation. Our aim is to recruit 600 residents from 16 nursing homes throughout the Netherlands, with measurements taken at baseline, 8 months, and 16 months. Nursing homes will be randomly allocated to an intervention or a deferred intervention group. During each intervention stage, we will provide information about inappropriate psychotropic drug prescribing, neuropsychiatric symptoms, and difficulties in managing neuropsychiatric symptoms through collaboration with each nursing home. After this, a tailored intervention and implementation plan will be written and implemented, guided by a coach. The primary outcome will be the reduction of inappropriate prescribing, as measured by the Appropriate Psychotropic drug use In Dementia index. Secondary outcomes will be the frequency of psychotropic drug use and neuropsychiatric symptoms, plus quality of life. A mixed methods design will be used for the process evaluation. Effects will be assessed using multilevel analyses. The project leader of the nursing home and the coach will complete questionnaires and in-depth interviews. Discussion We anticipate that the proposed tailored intervention with coaching will reduce inappropriate psychotropic drug prescribing for nursing home residents with neuropsychiatric symptoms. This study should also provide insights into the barriers to, and facilitators of, implementation. Trial registration NTR5872, registered on July 2, 2016.

Precious memories (PM) is a life review intervention for depression in older adults with no to mild cognitive decline that has been implemented in multiple nursing homes (NHs) in the Netherlands. Previous research suggested its relevance but questioned its applicability. Therefore, this research aimed to (1) investigate the applicability of PM, and (2) increase its applicability, if necessary. Intervention mapping (IM) was used to achieve these goals: process evaluation through semi-structured interviews with psychologists (n = 11) and clients (n = 2) to identify potential improvements for PM and to set an improvement goal (IM-step 1), three focus groups with stakeholders (n = 20) to specify behaviors necessary to reach the improvement goal (IM-step 2), and selection of behavior change techniques and applications to facilitate attainment of these behaviors (IM-step 3). Results showed that psychologists perceived a high drop-out rate, which was partly due to PM being provided to clients that did not belong to the target group. Although PM was generally considered relevant, psychologists articulated its longer-term effects should be improved. To improve PM&rsquo, s applicability, concrete maintenance strategies were developed aiming to maintain clients&rsquo, well-being by stimulating positive contact with others. Future research must pilot, implement and evaluate these strategies.

Objective: To assess the course of quality of life (QoL) in nursing home residents with dementia and to study its predictors. Methods: This longitudinal, multicenter, observational cohort study with a 2-year follow-up looked at 290 residents with dementia, who lived in 14 dementia special care units in nine nursing homes in the Netherlands. QoL was assessed with the Qualidem, providing a total score and QoL profile with nine subscales. Residents were assessed at five assessments: every 6 months during 2 years. A linear mixed model was used for data analysis. Results: No change was found in the Qualidem total score (range: 0-111) over 2 years. However, a significant increase of QoL over time was seen in the subscales "Care relationship," "Negative affect," "Restless tense behavior," "Positive self-image," "Social isolation," and "Feeling at home." A significant decrease of QoL was seen in the subscales "Positive affect," "Social relations," and "Having something to do." Most predictors of the course of Qol were found for the subscales "Positive self-image" (sex, Global Deterioration Scale, Severe Impairment Battery, Activities of Daily Living, and Neuropsychiatric Inventory) and "Having something to do" (Global Deterioration Scale, Severe Impairment Battery, and Activities of Daily Living). Sex and Neuropsychiatric Inventory at baseline were the predictors found most frequently. Conclusion: The total QoL score was stable over a 2-year period. However, QoL subscales showed multidirectional changes. The largest QoL decline in the subscale "Having something to do" suggests that more attention should be given to useful activities in nursing home care.

Objective: We studied the efficacy of biannual structured medication reviews to improve the appropriateness of psychotropic drug (PD) prescriptions for neuropsychiatric symptoms (NPS) in nursing home patients with dementia.Study Design and Setting: In this randomised controlled trial, the intervention encompassed a structured multidisciplinary medication review by physician, pharmacist and nurse. During this 18-month study, the patient's medical files were assessed every 6 months. The primary outcome was the appropriateness of PD prescriptions defined by the Appropriate Psychotropic drug use In Dementia (APID) index sum score, lower scores indicating more appropriate use.Results: At baseline, 380 patients were included, of which 222 were randomised to the intervention group. Compared to the control group, the APID index sum score in the intervention group improved significantly for all PD prescriptions (-5.28, P = 0.005).Conclusion: We advise the implementation of a structured, repeated medication review with the essential roles of pharmacist, physician and nurse, into daily practice. This work was supported and funded by the Netherlands Organisation for Health Research and Development (ZonMw). Netherlands Trial Register (NTR3569).

Background:We studied the patient and non-patients factors of inappropriate psychotropic drug (PD) prescription for neuropsychiatric symptoms (NPS) in nursing home patients with severe dementia.Methods:In a cross-sectional study, the appropriateness of prescriptions was explored using the Appropriate Psychotropic drug use In Dementia (APID) index sum score. This index assesses information from medical records on indication, evaluation, dosage, drug–drug interactions, drug–disease interactions, duplications, and therapy duration. Various measurements were carried out to identify the possible patient and non-patient factors. Linear multilevel regression analysis was used to identify factors that are associated with APID index sum scores. Analyses were performed for groups of PDs separately, i.e. antipsychotics, antidepressants, anxiolytics, and hypnotics.Results:The sample consisted of 338 patients with a PD prescription that used 147 antipsychotics, 167 antidepressants, 85 anxiolytics, and 76 hypnotics. It was found that older patients and more severe aggression, agitation, apathy, and depression were associated with more appropriate prescriptions. Additionally, less appropriate prescriptions were found to be associated with more severe anxiety, dementia diagnoses other than Alzheimer dementia, more physician time available per patient, more patients per physician, more years of experience of the physician, and higher nurse's workload.Conclusions:The association of more pronounced NPS with more appropriate PD prescriptions implies that physicians should pay more attention to the appropriateness of PD prescriptions when NPS are less manifest. Non-patient-related factors are also associated with the appropriateness of PD prescriptions. However, especially considering that some of these findings are counter-intuitive, more research on the topic is recommended.

Objectives: The aim of this study was to develop an index derived from the Medication Appropriateness Index (MAT) items that is suited for clinical studies evaluating appropriateness of psychotropic drug use (PDU) for neuropsychiatric symptoms (NPS) in patients with dementia in nursing homes and to test its reliability and validity.Study Design and Setting: An expert panel reviewed the MAT items to develop items for appropriateness of PDU; a second, independent, expert panel determined content validity of the items. An interrater reliability study was conducted (N = 54), and a summated index score, based on weighted item scores, was developed to enhance the use in clinical studies. Construct validity was explored using a representative sample of 560 medical records.Results: Five existing MAT items were used, the MAI item "indication" was adjusted, a new item "evaluation" was added, and scoring rules were based on guideline recommendations, to create the Appropriate Psychotropic drugs use In Dementia (APID) index. The second expert panel concluded that all items contributed to the construct "appropriateness." All items and the summated index score had moderate to almost perfect interrater reliability (intraclass correlation coefficient for agreement, 0.577-1). The summated index score showed promising construct validity, for example, no multicollinearity issues were found.Conclusion: The results of this study show that the AHD index is reliable and valid for measuring appropriateness of PDU for NPS in dementia in nursing homes in clinical studies. (C) 2015 Elsevier Inc. All rights reserved.

Item does not contain fulltext BACKGROUND: Caring for people with dementia in dementia special care units is a demanding job. Challenging behaviour is one of the factors influencing the job satisfaction and burnout of care staff. A care programme for the challenging behaviour of nursing home residents with dementia might, next to diminishing the challenging behaviour of residents, improve job satisfaction and reduce the care staff's feelings of burnout. OBJECTIVES: To determine the effects of a care programme for the challenging behaviour of nursing home residents with dementia on the burnout, job satisfaction and job demands of care staff. DESIGN: The care programme was implemented according to a stepped wedge design in which care units were randomly divided over five groups with different time points of starting with implementation. SETTING: 17 Dutch dementia special care units. PARTICIPANTS: Care staff members of the 17 units. INTERVENTION: The care programme consists of an education package and of various structured assessment tools that guide professionals through the multidisciplinary detection, analysis, treatment and evaluation of treatment of challenging behaviour. METHODS: Burnout, job satisfaction and job demands were measured before implementation, halfway through the implementation process and after all the care units had implemented the care programme. Burnout was measured with the Dutch version of the Maslach burnout inventory (UBOS-C, three subscales); job satisfaction and job demands were measured with subscales of the Leiden Quality of Work Questionnaire. Mixed model analyses were used to determine effects. Care staff could not be blinded for the intervention. RESULTS: Of the 1441 questionnaires, 645 were returned (response 45%, 318 control measurements, 327 intervention measurements) by 380 unique care staff members. Significant effects were found on job satisfaction (0.93, 95% CI 0.48-1.38). On the other outcomes, no significant changes in the scores were found. CONCLUSION: Positive effects of using the Grip on Challenging behaviour care programme were found on job satisfaction, without an increase in job demands.

Item does not contain fulltext OBJECTIVES: To determine the prognostic value of apathy for mortality in patients of somatic (SC) and dementia special care (DSC) nursing home (NH) units. DESIGN: Longitudinal design, secondary analyses of a 2-year, cluster-randomized trial with six measurements, approximately 4 months in between. SETTING: SC and DSC-units of Dutch NHs. PARTICIPANTS: NH-patients of seventeen SC-units (n = 342) and sixteen DCS-units (n = 371). MEASUREMENTS: Data were available for 713 NH-patients, 266 of whom died during the study. Apathy was assessed using the 10-item Apathy Evaluation Scale (AES-10) and applied as categorical variable using known cut-off scores as well as dimensional variable. Additionally, depressive symptoms were assessed using the Cornell Scale for Depression in Dementia. RESULTS: Mixed effects cox models using the coxme package in R revealed a higher risk of mortality between two measurements, if apathy was present (hazard ratio (HR) = 1.77; 95% confidence interval (CI] = 1.35-2.31, P < .001). Results remained significant (HR = 1.64; 95% CI = 1.23-2.19, P < .001) when controlled for depressive symptoms. DSC-units and SC-units did not differ (P > .05) in the effect of apathy on mortality. Male gender (HR = 1.67; 95% CI = 1.23-2.27, P < .001), and higher age in years (HR = 1.06; 95% CI = 1.04-1.08, P < .001) were also predictors of mortality. Regarding apathy as a dimensional construct, one standard deviation increase of AES-10 scores was associated with a 62% increase of mortality risk (HR = 1.62, 95% CI = 1.40-1.88, P < .001). CONCLUSIONS: Apathy was associated with mortality over a 4-month period in NH patients, even when controlling for depression. These data suggest that screening and treatment strategies for apathy should be developed for this patient population.