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Pain is often undetected in older people with dementia partly due to a deterioration of cognitive functioning. Observational scales enable the measurement of pain by registering physiological changes, facial expressions, or behaviors. Previous research showed that the Pain Assessment Checklist for Seniors with Limited Ability to Communicate (PACSLAC) is especially useful to measure pain in older people with dementia. PACSLAC was recently translated into Dutch and refined, thus forming PACSLAC-D. The current study uses a different approach to refining PACSLAC by (1) selecting items on the basis of ratings of nursing personnel and (2) applying confirmatory robust maximum likelihood factor analysis and (3) item response theory to investigate the psychometric properties of the selected items. Of the items that nursing personnel frequently registered, 18 valid and reliable items remained. Fourteen of these 18 items were also selected for PACSLAC-D, which confirms that these items are valid and reliable indicators of pain in older people with dementia. Confirmatory factor analysis showed that a 3-factor model is most adequate to describe the data. Differential item functioning analyses indicated that 2 items were biased. Ultimately, a refined version of PACSLAC was created that nursing personnel with different educational backgrounds might use to assess pain in older people with varying degrees of dementia. PERSPECTIVE: This article describes the selection of items of PACSLAC on the basis of ratings of nursing personnel. By comparing this item selection with the items selected for PACSLAC-D, one can confirm that certain items are sound indicators of pain, whereas others need some attention (eg, through the training of raters). [ABSTRACT FROM AUTHOR]

Abstract Background Because of the rapid aging population, the demand for residential care exceeds availability. This paper presents the results of a study that focuses on the demand of elderly people for residential care and determinants (elderly people's personal characteristics, needs and resources) that are associated with this demand. Furthermore, the accuracy of the waiting list as a reflection of this demand has been examined. Methods 67 elderly people waiting for admission into a home for the elderly, are subjected to semi-structured interviews. The data are analyzed by using multivariate statistics. Results Elderly people who indicate that they would refuse an offer of admission into a home for the elderly feel healthier (p = 0.02), have greater self-care agency (p = 0.02) and perceive less necessity of admission (p < 0.01), compared to those who would accept such an offer. Especially the inability to manage everyday activities and the lack of a social network are highly associated with the elderly people's demand for residential care. Furthermore, it is evident that waiting lists for homes for the elderly do not accurately reflect the demand for residential care, since 35% of the elderly people on a waiting list did not actually experience an immediate demand for residential care and stated that they would not accept an offer of admission. Quite a lot of respondents just registered out of a sense of precaution; a strategic decision dictated by current shortages in care provision and a vulnerable health status. Conclusion The results contribute to the understanding of waiting lists and the demand for residential care. It became apparent that not everybody who asks for admission into a home for the elderly, really needed it. The importance of elderly people's resources like social networks and the ability to manage everyday activities in relation to the demand for care became clear. These findings are important because they indicate that resources also play a role in predicting elderly people's demand and as a result can guide the development and the (re)design of adequate health care services.

Non-verbal pain assessment scales are useful tools for pain evaluation in persons with communication disorders and moderate-severe dementia. The Doloplus was one of the first scales to be developed and validated as a pain assessment tool in older adults with dementia. This study aims at evaluating the translation of the Doloplus scale in five languages, as regards test-retest and inter-rater reliability. Results show that both tests are good or excellent for the English, Italian, Portuguese and Spanish versions and moderate for the Dutch version. These results bring a unique opportunity to include the translated Doloplus scale in daily assessment of elderly persons with communication disorders, and future studies should focus on enriching the validation of the scale in each language. [ABSTRACT FROM AUTHOR]

Background: Nursing home care for people with dementia is increasingly organized in small-scale and homelike care settings, in which normal daily life is emphasized. Despite this increase, relatively little is known about residents' characteristics and whether these differ from residents in traditional nursing homes. This study explored and compared characteristics of residents with dementia living in small-scale, homelike facilities and regular psychogeriatric wards in nursing homes, focusing on functional status and cognition.Methods: A cross-sectional study was conducted, including 769 residents with dementia requiring an intensive level of nursing home care: 586 from regular psychogeriatric wards and 183 residents from small-scale living facilities. Functional status and cognition were assessed using two subscales from the Resident Assessment Instrument Minimum Data Set (RAI-MDS): the Activities of Daily Living-Hierarchy scale (ADL-H) and the Cognitive Performance Scale (CPS). In addition, care dependency was measured using Dutch Care Severity Packages (DCSP). Finally, gender, age, living condition prior to admission and length of stay were recorded. Descriptive analyses, including independent samples t- tests and chi-square tests, were used. To analyze data in more detail, multivariate logistic regression analyses were performed.Results: Residents living in small-scale, homelike facilities had a significantly higher functional status and cognitive performance compared with residents in regular psychogeriatric wards. In addition, they had a shorter length of stay, were less frequently admitted from home and were more often female than residents in regular wards. No differences were found in age and care dependency. While controlling for demographic variables, the association between dementia care setting and functional status and cognition remained.Conclusions: Although residents require a similar intensive level of nursing home care, their characteristics differ among small-scale living facilities and regular psychogeriatric wards. These differences may limit research into effects and feasibility of various types of dementia care settings. Therefore, these studies should take resident characteristics into account in their design, for example by using a matching procedure. [ABSTRACT FROM AUTHOR]

OBJECTIVE: To improve quality of care, nursing homes need to assess and monitor their performance. This study aims to gain insight in the availability and contents of publicly accessible quality systems in northwestern Europe and the USA. METHODS: This study employed a systematic search consisting of searching bibliographic sources from 2005 to September 2009, personal communication with experts, a conventional internet search, and hand-searching of references. RESULTS: Ten out of the 14 included countries use a quality systems. There is a large variety in type and number of indicators assessed. In general more attention is paid to the assessment of structure and process indicators, compared to outcome indicators. The countries differ in the way the results are made available to the general public. CONCLUSION: It can be concluded that monitoring and publicizing data on quality of care in nursing homes is becoming increasingly widespread. However, the systems still need further development and refinement. PRACTICE IMPLICATIONS: The systems need to be further developed regarding validity and reliability. Furthermore, the uniformity of the systems should be increased, more attention must be paid to the assessment of patient satisfaction, and additional insight must be gained in the user-friendliness of the systems. [ABSTRACT FROM AUTHOR]

OBJECTIVE: This study was designed to test an internet report card containing information about quality indicators (e.g., pressure ulcers, falls) as well as assessments of consumer satisfaction and of quality of care by the Netherlands Health Care Inspectorate in nursing homes. METHODS: Employing a laboratory-type experimental design, 278 current and future consumers and representatives of nursing homes were asked to make quality assessments based on report cards of imaginary nursing homes. They were also asked their opinions of the report cards. RESULTS: The participants were positive about the internet report card and considered it satisfactory. However, they did make some suggestions for improvement, such as using more understandable terminology. It also became evident that the information on the card must be complete; the omission of information resulted in more negative views of the nursing home. CONCLUSION: The results show that an internet report card can be a useful tool that enables consumers to assess the quality of nursing home care. Further research is needed to examine whether the report card will actually be used by consumers to make decisions regarding nursing home care. PRACTICE IMPLICATIONS: The internet report card is a practical tool that can empower consumers, as it facilitates comparisons between nursing homes. [ABSTRACT FROM AUTHOR]

Background: Numerous transitional care innovations (TCIs) are being developed and implemented to optimize care continuity for older persons when transferring between multiple care settings, help meet their care needs, and ultimately improve their quality of life. Although the implementation of TCIs is influenced by contextual factors, the use of effective implementation strategies is largely lacking. Thus, to improve the implementation of TCIs targeting older persons receiving long-term care services, we systematically developed a set of viable strategies selected to address the influencing factors., Methods: As part of the TRANS-SENIOR research network, a stepwise approach following Implementation Mapping (steps 1 to 3) was applied to select implementation strategies. Building on the findings of previous studies, existing TCIs and factors influencing their implementation were identified. A combination of four taxonomies and overviews of change methods as well as relevant evidence on their effectiveness were used to select the implementation strategies targeting each of the relevant factors. Subsequently, individual consultations with scientific experts were performed for further validation of the process of mapping strategies to implementation factors and for capturing alternative ideas on relevant implementation strategies., Results: Twenty TCIs were identified and 12 influencing factors (mapped to the Consolidated Framework for Implementation Research) were designated as priority factors to be addressed with implementation strategies. A total of 40 strategies were selected. The majority of these target factors at the organizational level, e.g., by using structural redesign, public commitment, changing staffing models, conducting local consensus discussions, and organizational diagnosis and feedback. Strategies at the level of individuals included active learning, belief selection, and guided practice. Each strategy was operationalized into practical applications., Conclusions: This project developed a set of theory and evidence-based implementation strategies to address the influencing factors, along further tailoring for each context, and enhance the implementation of TCIs in daily practice settings. Such work is critical to advance the use of implementation science methods to implement innovations in long-term care successfully., (© 2023. BioMed Central Ltd.)

Background and Objectives: Four interventions to improve care transitions between hospital and home or community settings for older adults were implemented in Leuven, Belgium over the past 4 years. These complex interventions consist of multiple components that challenge their implementation in practice. This study examines the influencing factors, strategies used to address challenges in implementing these interventions, and implementation outcomes from the perspectives of health care professionals involved., Research Design and Methods: This was a qualitative, collective case study that was part of the TRANS-SENIOR research network. Authors conducted semistructured interviews with health care professionals about their perceptions regarding the implementation. Thematic analysis was used, and the Consolidated Framework for Implementation Research guided the final data interpretation., Results: Thirteen participants were interviewed. Participants reported major implementation bottlenecks at the organizational level (resources, structure, and information continuity), while facilitators were at the individual level (personal attributes and champions). They identified engagement as the primary strategy used, and suggested other important strategies for the future sustainability of the interventions (building strategic partnerships and lobbying for policies to support transitional care). They perceived the overall implementation favorably, with high uptake as a key outcome., Discussion and Implications: This study highlights the strong role of health care providers, being motivated and self-driven, to foster the implementation of interventions in transitional care in a bottom-up way. It is important to use implementation strategies targeting both the individual-level factors as well as the organizational barriers for transitional care interventions in the future., (© The Author(s) 2022. Published by Oxford University Press on behalf of The Gerontological Society of America.)

Background: Dementia care at home often involves decisions in which the caregiver must weigh safety concerns with respect for autonomy. These dilemmas can lead to situations where caregivers provide care against the will of persons living with dementia, referred to as involuntary treatment. To prevent this, insight is needed into how family caregivers of persons living with dementia deal with care situations that can lead to involuntary treatment., Objective: To identify and describe family caregivers' experiences regarding care decisions for situations that can lead to involuntary treatment use in persons living with dementia at home., Research Design: A qualitative descriptive interview design. Data were analysed using the Qualitative Analysis Guide of Leuven., Participants and Research Context: A total of 10 family caregivers providing care for 13 persons living with dementia participated in in-depth semi-structured interviews. Participants were recruited by registered nurses via purposive sampling., Ethical Consideration: The study protocol was approved by the Ethics Committee of the University Hospitals Leuven and the Medical Ethical Test Committee Zuyderland., Findings: Family caregivers experience the decision-making process concerning care dilemmas that can lead to involuntary treatment as complicated, stressful and exhausting. Although they consider safety and autonomy as important values, they struggle with finding the right balance between them. Due to the progressive and unpredictable nature of dementia, they are constantly seeking solutions while they adapt to new situations. Family caregivers feel responsible and experience social pressure for the safety of persons living with dementia. They may be blamed if something adverse happens to the persons living with dementia, which increases an already stressful situation. Their experience is influenced by characteristics of the care triad (persons living with dementia, professional and family caregivers) such as practical and emotional support, knowledge, and previous experiences., Discussion and Conclusion: To prevent involuntary treatment, professionals need to proactively inform family caregivers, and they need to support each other in dealing with complex care situations.

Background: Partnerships between family and nursing staff in nursing homes are essential to address residents' needs and wishes. Collaboration is needed to create partnerships; nonetheless, challenges exist., Aim: This study aimed to gain insights into the experiences of families collaborating with staff., Method: Semi-structured interviews were held with 30 family caregivers of nursing home residents with dementia., Findings: Data reflected three themes, which shaped collaboration with staff from families' perspective, 'communication', 'trust and dependency' and 'involvement'., Discussion: Good communication appeared to be a requisite condition for having trust in staff and quality of involvement in residents' life. Good communication was described as having informal contact with staff, which enabled family and staff to build a personal connection. Consequently, this seemed to increase trust and satisfaction regarding involvement., Conclusion: Findings suggest that increasing informal contact and building a personal connection should be a priority for staff in order to improve collaboration and to create partnerships with families.

Aim: This paper reports on a quasi-experimental, longitudinal study on the effects of working in a new type of dementia care facility (i.e. small-scale living facilities) on staff burnout symptoms and job characteristics (job autonomy, social support, physical demands and workload)., Methods: It is hypothesised that nursing staff working in small-scale facilities experience fewer burnout symptoms, more autonomy and social support, and fewer symptoms of physical demands and workload compared with staff in regular wards. Two types of long-term institutional nursing care settings were included: 28 houses in small-scale living facilities and 21 regular psychogeriatric wards in nursing homes. At baseline and at follow-ups after 6 and 12 months nursing staff were assessed by means of self-report questionnaires. In total, 305 nursing staff members were included in the study, 114 working in small-scale living facilities (intervention group) and 191 in regular wards (control group)., Results: No overall effects on burnout symptoms were detected. Significantly fewer physical demands and lower workload were experienced by staff working in small-scale living facilities compared with staff in regular wards. They also experienced more job autonomy. No significant effect was found for overall social support in the total group., Conclusions: This study suggests positive effects of the work environment on several work characteristics. Organisational climate differs in the two conditions, which might account for our results. This may influence nursing staff well-being and has important implications for nursing home managers and policy makers. Future studies should enhance our understanding of the influence of job characteristics on outcomes.

Background: For immobile patients, a body wash in bed is sometimes the only bathing option. Traditionally, the bed bath is performed with water and soap. However, alternatives are increasingly used in health care. Washing without water is one such alternative that has been claimed to offer several advantages, such as improved hygiene and skin condition. This systematic review aims to provide a comprehensive overview of the evidence on outcomes of the washing without water concept compared to the traditional bed bath., Methods: Controlled trials about washing without water outcomes published after 1994 were collected by means of a systematic literature search in CINAHL, Embase, MEDLINE, and PUBMED at the 25th of February, 2016. Additionally, references and citations were searched and experts contacted. Studies were eligible if (1) the study designs included outcomes of washing without water products developed for the full body wash compared to the traditional bed bath, and (2) they were controlled trials. Two researchers independently used a standardized quality checklist to assess the methodological quality of the eligible studies. Finally, outcomes were categorized in (1) physiological outcomes related to hygiene and skin condition, (2) stakeholder-related outcomes, and (3) organizational outcomes in the data synthesis., Results: Out of 33 potentially relevant articles subjected to full text screening, six studies met the eligibility criteria. Only two studies (of the same research group) were considered of high quality. The results of these high quality studies show that washing without water performed better than the traditional bed bath regarding skin abnormalities and bathing completeness. No differences between washing without water and the traditional bed bath were found for outcomes related to significant skin lesions, resistance during bathing and costs in the studies of high quality., Conclusions: There is limited moderate to high quality evidence that washing without water is not inferior to the traditional bed bath. Future research on washing without water is needed and should pay special attention to costs, hygiene, and to stakeholder-related outcomes, such as experiences and value perceptions of patients, nursing staff and family.

Background: Recent evidence suggests that an increase in baccalaureate-educated registered nurses (BRNs) leads to better quality of care in hospitals. For geriatric long-term care facilities such as nursing homes, this relationship is less clear. Most studies assessing the relationship between nurse staffing and quality of care in long-term care facilities are US-based, and only a few have focused on the unique contribution of registered nurses. In this study, we focus on BRNs, as they are expected to serve as role models and change agents, while little is known about their unique contribution to quality of care in long-term care facilities., Methods: We conducted a cross-sectional study among 282 wards and 6,145 residents from 95 Dutch long-term care facilities. The relationship between the presence of BRNs in wards and quality of care was assessed, controlling for background characteristics, i.e. ward size, and residents' age, gender, length of stay, comorbidities, and care dependency status. Multilevel logistic regression analyses, using a generalized estimating equation approach, were performed., Results: 57% of the wards employed BRNs. In these wards, the BRNs delivered on average 4.8 min of care per resident per day. Among residents living in somatic wards that employed BRNs, the probability of experiencing a fall (odds ratio 1.44; 95% CI 1.06-1.96) and receiving antipsychotic drugs (odds ratio 2.15; 95% CI 1.66-2.78) was higher, whereas the probability of having an indwelling urinary catheter was lower (odds ratio 0.70; 95% CI 0.53-0.91). Among residents living in psychogeriatric wards that employed BRNs, the probability of experiencing a medication incident was lower (odds ratio 0.68; 95% CI 0.49-0.95). For residents from both ward types, the probability of suffering from nosocomial pressure ulcers did not significantly differ for residents in wards employing BRNs., Conclusions: In wards that employed BRNs, their mean amount of time spent per resident was low, while quality of care on most wards was acceptable. No consistent evidence was found for a relationship between the presence of BRNs in wards and quality of care outcomes, controlling for background characteristics. Future studies should consider the mediating and moderating role of staffing-related work processes and ward environment characteristics on quality of care.

Background: Nursing home residents are mainly inactive. Nursing staff can encourage residents to perform functional activities during daily care activities. This study examines 1) the extent to which nursing staff perceive that they encourage functional activity in nursing home residents and 2) the associations between these nursing behaviors and professional characteristics, contextual factors, and information-seeking behaviors., Methods: In this cross-sectional study, 368 registered nurses and certified nurse assistants, working in somatic and psychogeriatric wards of forty-one nursing homes throughout the Netherlands participated. Self-reported data were collected with a questionnaire, comprising the MAINtAIN-behaviors, which assesses the extent to which nursing staff encourage functional activities, including different activities of daily living (ADL), household activities, and miscellaneous encouraging activities (e.g., discouraging informal caregivers from taking over activities residents can do themselves). Additional data collected included professional characteristics (e.g., age), contextual factors (e.g., ward type), and information-seeking behaviors (e.g., reading professional journals). Descriptive statistics were used to determine the extent to which functional activities were encouraged. Hierarchical linear regression analyses were performed to determine the associations between the encouragement of functional activities and other factors., Results: Nursing staff perceived that household activities (mean 4.1 (scale range 1-9), SD 1.9) were less often encouraged than ADL (mean 6.9, SD 1.2) or miscellaneous activities (mean 6.7, SD 1.5). The percentage of nursing staff stating that different household activities, ADL, or miscellaneous activities were almost always encouraged ranged from 11 to 45%, 41 to 86%, and 50 to 83% per activity, respectively. The extent to which these activities were encouraged differed for some of the professional characteristics, contextual factors, or information-seeking behaviors, but no consistent pattern in associations emerged., Conclusions: According to nursing staff, household activities are not as often encouraged as ADL or miscellaneous activities. Professional characteristics, contextual factors, and information-seeking behaviors are not consistently associated with the encouragement of functional activity. Nursing staff should also focus on improving the encouragement of household activities. Future research could examine the role of other factors in encouraging functional activity, such as experienced barriers, and assess to what extent the perception of nursing staff corresponds with their actual behavior.

Background: A lack of relationship between direct care staffing levels and quality of care, as found in prior studies, underscores the importance of considering the quality of the work environment instead of only considering staff ratios. Only a few studies, however, have combined direct care staffing with work environment characteristics when assessing the relationship with quality of care in nursing homes., Objectives: To examine the relationship between direct care staffing levels, work environment characteristics and perceived quality of care in Dutch nursing homes., Design: Cross-sectional, observational study in cooperation with the Dutch Prevalence Measurement of Care Problems., Settings: Twenty-four somatic and 31 psychogeriatric wards from 21 nursing homes in the Netherlands., Participants: Forty-one ward managers and 274 staff members (registered nurses or certified nurse assistants) from the 55 participating wards., Methods: Ward rosters were discussed with managers to obtain an insight into direct care staffing levels (i.e, total direct care staff hours per resident per day). Participating staff members completed a questionnaire on work environment characteristics (i.e., ward culture, team climate, communication and coordination, role model availability, and multidisciplinary collaboration) and they rated the quality of care in their ward. Data were analyzed using multilevel linear regression analyses (random intercept). Separate analyses were conducted for somatic and psychogeriatric wards., Results: In general, staff members were satisfied with the quality of care in their wards. Staff members from psychogeriatric wards scored higher on the statement 'In the event that a family member had to be admitted to a nursing home now, I would recommend this ward'. A better team climate was related to better perceived quality of care in both ward types (p≤0.020). In somatic wards, there was a positive association between multidisciplinary collaboration and agreement by staff of ward recommendation for a family member (p=0.028). In psychogeriatric wards, a lower score on market culture (p=0.019), better communication/coordination (p=0.018) and a higher rating for multidisciplinary collaboration (p=0.003) were significantly associated with a higher grade for overall quality of care. Total direct care staffing, adhocracy culture, hierarchy culture, as well as role model availability were not significantly related to quality of care., Conclusions: Our findings suggest that team climate may be an important factor to consider when trying to improve quality of care. Generating more evidence on which work environment characteristics actually lead to better quality of care is needed., (Copyright © 2016 Elsevier Ltd. All rights reserved.)

Background: To provide adequate nursing care it is important for nursing staff to communicate effectively with people with dementia. Due to their limited communication skills, people with dementia have difficulties in understanding communication and expressing themselves verbally. Nursing staff members often report communication difficulties with people with dementia, which emphasises the urgent need for interventions to improve their communication with people in this specific target group., Objectives: To provide an up-to-date overview of communication interventions that are applicable during daily nursing care activities, irrespective of care setting, and to describe the effects on communication outcomes in people with dementia and nursing staff., Design: Systematic literature review DATA SOURCES: The Cochrane Library, CINAHL, PsycINFO, and Pubmed databases were searched for all articles published until the 23rd of February 2016., Review Methods: Papers were included, if: (1) interventions focused on communication between nursing staff and people with dementia and were applicable during daily nursing care; (2) studies were (randomised) controlled trials; (3) papers were written in English, Dutch, or German. Data were extracted on content and communication outcomes of interventions, and on methodological quality of the studies. The data extraction form and methodological quality checklist were based on the Method Guidelines for Systematic Reviews for the Cochrane Back Review Group., Results: Six studies on communication interventions were included. All of the studies incorporated a communication skills training for nursing staff with a broad range in frequency, duration and content. In addition, there was wide variation in the communication outcome measures used. Four studies measured non-verbal communication, all found positive effects on at least some of the communication outcomes. Four studies measured verbal communication, of which three found positive effects on at least one of the measured outcomes. Methodological quality assessment demonstrated a high risk of bias in five of the six studies., Conclusions: Few studies have been identified with wide variation in interventions and outcome measures. In addition, the methodological shortcomings make it difficult, to draw conclusions about the effectiveness. More research is needed to develop and evaluate communication interventions. Additionally, it is useful to reach consensus on defining and measuring communication., (Copyright © 2017 Elsevier Ltd. All rights reserved.)

Objectives: Innovative care environments are developed for people with dementia to encourage person-centered care. This study aims to investigate whether residents of green care farms that provide 24-hour nursing care participate more in (physical) activities and social interaction compared with residents of other nursing homes., Design: Longitudinal observation study., Setting: Nursing homes in the Netherlands (green care farms, traditional nursing homes, and regular small-scale living facilities)., Participants: A total of 115 nursing home residents at baseline, 100 at follow-up., Measurements: Ecological momentary assessments (n = 16,860) were conducted using the Maastricht Electronic Daily Life Observation Tool. Residents living at green care farms were compared with residents living in traditional nursing homes and regular small-scale living facilities. The following aspects were collected for this study: the activity performed by the participant or occurring in his or her vicinity, the engagement in the activity, the level of physical activity during the activity, the physical environment (location where the activity occurred), and the level of social interaction during the activity., Results: In total, 9660 baseline observations and 7200 follow-up observations were conducted. Analyses showed that residents of green care farms significantly more often participated in domestic activities (P = .004, SE = 1.6) and outdoor/nature-related activities (P = .003, SE = 0.9), and significantly less often engaged in passive/purposeless activities (P < .001, SE = 1.7) compared with residents of traditional nursing homes. Furthermore, residents of green care farms had significantly more active engagement (P = .014, SE = 0.9), more social interaction (P = .006, SE = 1.1), and came outside significantly more (P = .010, SE = 1.1) than residents of traditional nursing homes. Residents of green care farms were significantly more physically active (P = .013, SE = 0.8) than were residents of regular small-scale living facilities. No other significant differences were found., Conclusion: Green care farms can be a valuable alternative to traditional nursing homes. They provide an attractive, homelike environment and activities that positively influence engagement and social interaction. Research is needed to study how successful elements of green care farms can be implemented in existing nursing homes., (Copyright © 2016 AMDA – The Society for Post-Acute and Long-Term Care Medicine. Published by Elsevier Inc. All rights reserved.)

Objectives: To develop an internationally accepted research definition of physical restraint., Design: Comprehensive literature search followed by a web-based, three-round, modified Delphi technique comprising reviews and feedback., Setting: Clinical care settings., Participants: An international group of 48 experts consisting of researchers and clinicians from 14 countries who have made sustained contribution to research and clinical application in the field of physical restraint in clinical care., Measurements: Data were collected using an online survey program and one in-person meeting. Results of the online survey and the in-person meeting were used for distribution in subsequent rounds until consensus on a definition was reached. Consensus was defined as 90% of the participating experts agreeing with the proposed definition of physical restraint., Results: Thirty-four different definitions were identified during the literature search and served as a starting point for the modified Delphi technique. After three rounds, 45 (95.7%) of 47 remaining experts agreed with the newly proposed definition: "Physical restraint is defined as any action or procedure that prevents a person's free body movement to a position of choice and/or normal access to his/her body by the use of any method, attached or adjacent to a person's body that he/she cannot control or remove easily.", Conclusion: A multidisciplinary, internationally representative panel of experts reached consensus on a research definition for physical restraints in older persons. This is a necessary step toward improved comparisons of the prevalence of physical restraint use across studies and countries. This definition can further guide research interventions aimed at reducing use of physical restraints., (© 2016, Copyright the Authors Journal compilation © 2016, The American Geriatrics Society.)

Background: To improve the quality of life (QoL) of people with dementia (PwD) living in long-term care facilities, insight into the association between QoL and how people spend their daily lives is urgently needed. This study investigated which aspects of daily life are related to QoL in dementia., Methods: An observational study was conducted. Daily life was assessed with the tablet-based Maastricht Electronic Daily Life Observation-tool (MEDLO-tool). Aspects included activity, engagement in the activity, social interaction, physical effort, mood, and agitation. QoL was assessed by formal nursing caregivers using the Quality of Life-Alzheimer's Disease scale (QoL-AD). A total of 9,660 momentary assessments were conducted., Results: The mean age of the 115 participants was 84 years and most (75%) were women. Bivariate analyses showed that residents with a higher QoL carried out less passive/purposeless activities (25% vs. 38%), were more engaged in active, expressive, and social activities, (40% vs. 27%), had more social interaction (34% vs. 22%), and had better mood scores (scale 1-7, 5.0 vs. 4.8), compared with residents with a lower QoL (all p-values < 0.001). Multivariate analyses showed that having more social interaction and a positive mood are related to a higher QoL., Conclusions: The results underline the importance of social interaction and a positive mood for a higher QoL. Future research should investigate the importance of engagement in activities in more detail.

Aim: To develop and test psychometrically the Basel Extent of Rationing of Nursing Care for Nursing Homes instrument, providing initial evidence on the validity and reliability of the German, French and Italian-language versions., Background: In the hospital setting, implicit rationing of nursing care is defined as the withholding of nursing activities due to lack of resources, such as staffing or time. No instrument existed to measure this concept in nursing homes., Design: Cross-sectional study., Methods: We developed the instrument in three phases: (1) adaption and translation; (2) content validity testing; and (3) initial validity and reliability testing. For phase 3, we analysed survey data from 4748 care workers collected between May 2012-April 2013 from a randomly selected sample of 162 nursing homes in the German-, French- and Italian-speaking regions of Switzerland to provide evidence from response processes (e.g. missing), internal structure (exploratory factor analysis), inter-item inconsistencies (e.g. Cronbach's alpha) and interscorer differences (e.g. within-group agreement)., Results: Exploratory factor analysis revealed a four-factor structure with good fit statistics. Rationing of nursing care was structured in four domains: (1) activities of daily living; (2) caring, rehabilitation and monitoring; (3) documentation; and (4) social care. Items of the social care subscale showed lower content validity and more missing values than items of other subscales., Conclusion: First evidence indicates that the new instrument can be recommended for research and practice to measure implicit rationing of nursing care in nursing homes. Further refinements of single items are needed., (© 2016 John Wiley & Sons Ltd.)

Background: Daily life is a dynamic and multidimensional concept, for which appropriate assessment tools are lacking. This study describes the development of the Maastricht Electronic Daily Life Observation tool (MEDLO-tool), a freely accessible, easy to use, electronic observation tool to assess relevant daily life aspects for nursing home residents with dementia., Methods: (1) Determining relevant aspects of daily life for nursing home residents with dementia based on a literature search and expert interviews; (2) pilot testing observation procedures and operationalizations of the aspects of daily life; and (3) exploring inter-rater reliability and feasibility of the tool in a nursing home facility with 16 residents (56% female, mean age: 77)., Results: The following aspects of daily life are assessed with the MEDLO-tool: (1) activity (activity performed by resident, engagement in this activity, and the degree of physical effort); (2) physical environment (location of the resident and interaction with the physical environment); (3) social interaction (the level and type of social interaction, and with whom this social interaction took place); and (4) emotional well-being (mood and agitation). Each aspect of daily life is observed and scored using standardized scoring options. Agreement on the aspects is high with an average absolute agreement of 86%. Users of the MEDLO-tool indicated that it was feasible in practice and contained clear operationalization of the aspects of daily life., Conclusions: The MEDLO-tool is a promising tool to gain real time insight into the aspects of the daily lives of nursing home residents with dementia.

Objectives: To explore the prevalence and associated factors of involuntary treatment (physical restraints, psychotropic medication, nonconsensual care) in persons with cognitive impairment receiving home care., Design: Cross-sectional survey using association analyses., Setting: Professional home care in the southern part of the Netherlands., Participants: Data were collected on 837 persons with cognitive impairment (mean age 81.6; 60% female)., Measurements: Involuntary treatment was measured using a tool to identify physical restraints, psychotropic medication, and nonconsensual care. Activities of daily living (ADLs) were measured using the ADL Hierarchy subscale of the Resident Assistant Instrument-Minimum Data Set and cognitive status using the Cognitive Performance Scale. Informal caregiver burden was assessed using the Self-Perceived Pressure from Informal Care Scale., Results: Involuntary treatment was used in 39% of the total sample. Most common were nonconsensual care (79%; e.g., concealing medication in food, forcing hygiene) and psychotropic medication (41%). In 7% of the sample, physical restraints (e.g., deep or overturned chair, bilateral full-enclosure bedrails) were used. Caregiver burden, ADL dependency, cognitive status, living alone, and a diagnosis of dementia were strongly associated with involuntary treatment. The family of the person with cognitive impairment most often requested the use of involuntary treatment., Conclusion: Involuntary treatment is often used in persons with cognitive impairment receiving home care in the Netherlands. Future research should focus on understanding and preventing inappropriate involuntary treatment in home care., (© 2016, Copyright the Authors Journal compilation © 2016, The American Geriatrics Society.)

Background: For the treatment of chronic heart failure (HF), both pharmacological and non-pharmacological treatment should be employed in HF patients. Although HF is highly prevalent in nursing home residents, it is not clear whether the recommendations in the guidelines for pharmacological therapy also are followed in nursing home residents. The aim of this study is to investigate how HF is treated in nursing home residents and to determine to what extent the current treatment corresponds to the guidelines., Methods: Nursing home residents of five large nursing home care organizations in the southern part of the Netherlands with a previous diagnosis of HF based on medical records irrespective of the left ventricle ejection fraction (LVEF) were included in this cross-sectional design study. Data were gathered on the (medical) records, which included clinical characteristics and pharmacological- and non-pharmacological treatment. Echocardiography was used as part of the study to determine the LVEF., Results: Out of 501 residents, 112 had a diagnosis of HF at inclusion. One-third of them received an ACE-inhibitor and 40% used a β-blocker. In 66%, there was a prescription of diuretics with a preference of a loop diuretic. Focusing on the residents with a LVEF ≤ 40%, only 46% of the 22 residents used an ACE-inhibitor and 64% a β-blocker. The median daily doses of prescribed medication were lower than those that were recommended by the guidelines. Non-pharmacological interventions were recorded in almost none of the residents with HF., Conclusions: The recommended medical therapy of HF was often not prescribed; if prescribed, the dosage was usually far below what was recommended. In addition, non-pharmacological interventions were mostly not used at all.

Objective: To determine the prevalence of heart failure (HF) in nursing home residents and to gain insight into the clinical characteristics of residents with heart failure., Design: Multi-centre, observational, cross-sectional study., Method: 501 nursing home residents aged 65 years and over, in a department for chronic somatic diseases or a psychogeriatric department, participated in this study. The diagnosis of HF and the related characteristics were based on data collected from clinical examinations for heart failure (including history, physical examination, ECG, cardiac markers and echocardiography), patient records and questionnaires. A panel of two cardiologists and an internist-geriatrician made the final diagnosis of HF., Results: The prevalence of HF in nursing home residents was 33%. Dyspnoea, oedema and a history of cardiac disease were more common in residents with heart failure. Diabetes mellitus and chronic obstructive pulmonary disease also appeared to be more prevalent in this group. In 54% of the residents with HF, the diagnosis had not previously been made. Diagnosis of HF was not confirmed by the expert panel in 31% of residents with a history of HF., Conclusion: Heart failure does indeed appear to be very prevalent in nursing home residents. Heart failure had not been previously diagnosed in many cases but also a previous diagnosis of heart failure could be disproved in many participants. It is therefore important that the diagnostic process for heart failure in nursing home residents be improved.

Background: Heart failure (HF) is expected to be highly prevalent in nursing home residents, but precise figures are scarce. The aim of this study was to determine the prevalence of HF in nursing home residents and to get insight in the clinical characteristics of residents with HF., Methods: The study followed a multi-centre cross-sectional design. Nursing home residents (n = 501) in the southern part of the Netherlands aged over 65 years and receiving long-term somatic or psychogeriatric care were included in the study. The diagnosis of HF and related characteristics were based on data collected from actual clinical examinations (including history, physical examination, ECG, cardiac markers and echocardiography), patient records and questionnaires. A panel of two cardiologists and a geriatrician ultimately judged the data to diagnose HF., Results: The overall prevalence of HF in nursing home residents was 33 %, of which 52 % had HF with preserved ejection fraction. The symptoms dyspnoea and oedema and a cardiac history were more common in residents with HF. Diabetes mellitus, chronic obstructive pulmonary disease (COPD) were also more prevalent in those with HF. Residents with HF had a higher score on the Mini Mental State Examination. 54 % of those with HF where not known before, and in 31 % with a history of HF, this diagnosis was not confirmed by the expert panel., Conclusion: This study shows that HF is highly prevalent in nursing home residents with many unknown or falsely diagnosed with HF. Equal number of HF patients had reduced and preserved left-ventricular ejection fraction., Trial Registration: The Netherlands National Trial Register NTR2663 (27-12-2010).

Background: In nursing home care, new care environments directed towards small-scale and homelike environments are developing. The green care farm, which provides 24-h nursing home care for people with dementia, is one such new care environment. Knowledge is needed on the relation between environmental features of green care farms such as nature, domesticity and offering care in small groups and the influence on the daily lives of residents. The aim of this study is to explore (1) the daily lives of residents, (2) the quality of care and (3) the experiences of caregivers on green care farms compared with other nursing home care environments., Methods/design: An observational longitudinal study including a baseline and a six-month follow-up measurement is carried out. Four types of nursing home care environments are included: (1) large scale nursing home ward, (2) small scale living facility on the terrain of a larger nursing home (3) stand-alone small scale living facility and (4) green care farm. Quality of care is examined through structure, process and outcome indicators. The primary outcome measure is the daily life of residents, assessed by ecological momentary assessments. Aspects of daily life include (1) activity (activity performed by the resident, the engagement in this activity and the degree of physical effort); (2) physical environment (the location of the resident and the interaction with the physical environment); (3) social environment (the level and type of social interaction, and with whom this social interaction took place) and (4) psychological well-being (mood and agitation). In addition, social engagement, quality of life, behavioral symptoms and agitation are evaluated through questionnaires. Furthermore, demographics, cognitive impairment, functional dependence and the severity of dementia are assessed. Semi-structured interviews are performed with caregivers regarding their experiences with the different nursing home care environments., Discussion: This is the first study investigating green care farms providing 24-h nursing home care for people with dementia. The study provides valuable insight into the daily lives of residents, the quality of care, and the experiences of caregivers at green care farms in comparison with other nursing home care environments including small-scale care environments and large scale nursing home wards.

Aims and Objectives: This study investigates health-related quality of life in older patients, over one year following an intensive care unit stay., Background: Health-related quality of life is an important outcome when assessing long-term effectiveness of intensive care treatment, and to assist patients, their relatives and healthcare professionals in making treatment decisions., Design: Prospective non-randomised longitudinal study., Methods: The Short Form Health Survey 36 was administered 1 week after an intensive care stay (retrospective baseline), and after six months and 12 months to the study population and to an age-matched comparison group at recruitment (baseline), and after six months and 12 months. Demographic data, admission diagnosis, length of stay, severity of illness, pain, anxiety, agitation, and intratracheal suctioning, turning and intubation were recorded. Recruitment period: December 2008 to April 2011., Results: Health-related quality of life of the older patients was significantly lower than the comparison group, both before and after the intensive care unit stay, and showed great individual variability. Within group scores, however, were stable over the year. Both physical and mental health scores were lower for the older patients. Renal failure, cardiac surgery and illness severity were associated with lower physical health scores. Cardiovascular illness, intratracheal suctioning and turning were associated with lower mental health scores., Conclusions: Health-related quality of life was lower in older patients than in the age-matched group but remained stable over one year., Relevance to Clinical Practice: Older patients with severe illnesses, acute renal failure or who have had cardiac surgery, need additional support after hospital discharge due to functional restrictions. Discharge planning should ensure that this support would be provided. Special attention should be given to develop and use methods to reduce distress during routine intensive care interventions such as intratracheal suctioning or turning., (© 2015 John Wiley & Sons Ltd.)

Objectives: Research shows that nursing home residents are largely inactive. This inactivity negatively influences physical fitness, and participation in daily activities is known to have a positive influence on physical function and quality of life. Existing research does not provide sufficient insight into the daily activities in which nursing home residents participate. This insight is needed to develop future interventions so as to encourage nursing home residents to participate in daily activities and, thereby, decrease inactivity. The purpose of this study was to obtain insight into daily (in)activities of psychogeriatric and somatic nursing home residents during the day and their body positions during these (in)activities., Design: Cross-sectional observation study., Setting: Nursing homes in the Netherlands (19 psychogeriatric and 11 somatic wards)., Participants: Participants were 723 home residents in 7 nursing homes., Measurements: Observations were conducted using a self-developed observation list. Residents were observed in their wards during 5 random observation times between 7:00 am and 11:00 pm, in which the daily activity and position of the resident during this activity were scored. Percentages of activities and positions were calculated for each observation time., Results: In total, 3282 observations (91% of the intended 3615 observations) were conducted. Nursing home residents of both psychogeriatric and somatic wards were mainly observed partaking in in activities, such as sleeping, doing nothing, and watching TV (range: 45%-77% of the 5 observation times). Furthermore, residents were engaged in activities of daily living (ADLs) (range: 15%-38%) that mainly comprised activities related to mobility (range: 10%-19%) and eating and drinking (range: 2%-17%). Engagement of residents in instrumental ADLs (IADLs) was rarely observed (up to 3%). Residents were largely observed in a lying or sitting position (range: 89%-92%)., Conclusion: Most of the psychogeriatric and somatic nursing home residents spend their day inactive in a lying or sitting position in the ward. To encourage nursing home residents in daily activities in the wards, interventions are needed that (1) focus on increasing ADLs and IADLs, and (2) encourage standing and walking., (Copyright © 2015 AMDA – The Society for Post-Acute and Long-Term Care Medicine. Published by Elsevier Inc. All rights reserved.)

In view of the likelihood that the complexity of care required by those admitted to nursing homes will continue to increase, an expert consensus study was conducted to reach consensus on the competencies which distinguish baccalaureate-educated registered nurses from other nursing staff working in nursing homes. Thirty-one international experts, identified through literature and our professional network, participated in a two-round web-based survey and an expert meeting. Experts reached consensus on 16 desirable competencies, including some not traditionally associated with nursing expertise e.g. being a team leader, role model and coach within the nursing team. These findings suggest that revision of current nursing curricula, nurse training programs and nursing home job profiles might be needed to meet the medically and psychologically complex needs of nursing home residents., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Objectives: To describe care worker-reported quality of care and to examine its relationship with staffing variables, work environment, work stressors, and implicit rationing of nursing care., Design: Cross-sectional study., Setting: National, randomly selected sample of Swiss nursing homes, stratified according to language region and size., Participants: A total of 4311 care workers of all educational backgrounds (registered nurses, licensed practical nurses, nurse aides) from 402 units in 155 nursing homes completed a survey between May 2012 and April 2013., Measurements: Care worker-reported quality of care was measured with a single item; predictors were assessed with established instruments (eg, Practice Environment Scale-Nurse Working Index) adapted for nursing home use. A multilevel logistic regression model was applied to assess predictors for quality of care., Results: Overall, 7% of care workers rated the quality of care provided as rather low or very low. Important factors related to better quality of care were higher teamwork and safety climate (odds ratio [OR] 6.19, 95% confidence interval [CI] 4.36-8.79); better staffing and resources adequacy (OR 2.94, 95% CI 2.08-4.15); less stress due to workload (OR 0.71, 95% CI 0.55-0.93); less implicit rationing of caring, rehabilitation, and monitoring (OR 0.34, 95% CI 0.24-0.49); and less rationing of social care (OR 0.80, 95% CI 0.69-0.92). Neither leadership nor staffing levels, staff mix, or turnover was significantly related to quality of care., Conclusions: Work environment factors and organizational processes are vital to provide high quality of care. The improvement of work environment, support in handling work stressors, and reduction of rationing of nursing care might be intervention points to promote high quality of care in nursing homes., (Copyright © 2015 AMDA – The Society for Post-Acute and Long-Term Care Medicine. Published by Elsevier Inc. All rights reserved.)

Background: Implicit rationing of nursing care refers to the withdrawal of or failure to carry out necessary nursing care activities due to lack of resources, in the literature also described as missed care, omitted care, or nursing care left undone. Under time constraints, nurses give priority to activities related to vital medical needs and the safety of the patient, leaving out documentation, rehabilitation, or emotional support of patients. In nursing homes, little is known about the occurrence of implicit rationing of nursing care and possible contributing factors., Objectives: The purpose of this study was (1) to describe levels and patterns of self-reported implicit rationing of nursing care in Swiss nursing homes and (2) to explore the relationship between staffing level, turnover, and work environment factors and implicit rationing of nursing care., Design: Cross-sectional, multi-center sub-study of the Swiss Nursing Home Human Resources Project (SHURP)., Settings: Nursing homes from all three language regions of Switzerland., Participants: A random selection of 156 facilities with 402 units and 4307 direct care workers from all educational levels (including 25% registered nurses)., Methods: We utilized data from established scales to measure implicit rationing of nursing care (Basel Extent of Rationing of Nursing Care), perceptions of leadership ability and staffing resources (Practice Environment Scale of the Nursing Work Index), teamwork and safety climate (Safety Attitudes Questionnaire), and work stressors (Health Professions Stress Inventory). Staffing level and turnover at the unit level were measured with self-developed questions. Multilevel linear regression models were used to explore the proposed relationships., Results: Implicit rationing of nursing care does not occur frequently in Swiss nursing homes. Care workers ration support in activities of daily living, such as eating, drinking, elimination and mobilization less often than documentation of care and the social care of nursing homes residents. Statistically significant factors related to implicit rationing of care were the perception of lower staffing resources, teamwork and safety climate, and higher work stressors. Unit staffing and turnover levels were not related to rationing activities., Conclusions: Improving teamwork and reducing work stressors could possibly lead to less implicit rationing of nursing care. Further research on the relationship of implicit rationing of nursing care and resident and care worker outcomes in nursing homes is requested., (Copyright © 2015 Elsevier Ltd. All rights reserved.)

Aims and Objectives: This study investigated whether an intensive care unit (ICU) stay is associated with persistent pain, anxiety and agitation in critically ill older patients., Background: Patients hospitalised in the ICU are at risk for experiencing pain, anxiety and agitation, but long-term consequences for older patients have rarely been investigated., Design: Prospective nonrandomised longitudinal study., Methods: Pain, anxiety and agitation, measured with a numeric rating scale (0-10), were assessed in older patients (≥65 years) hospitalised in the medical-surgical ICU of a university hospital. Agitation during the ICU was assessed with the Richmond Agitation-Sedation Scale. Data collection occurred during the ICU, one week after the stay and six and 12 months after hospital discharge. Data were collected from an age-matched community-based comparison group at recruitment and after six and 12 months. Study recruitment took place from December 2008-April 2011., Results: This study included 145 older patients (ICU group) and 146 comparison group participants. Pain was higher in the ICU group one week after discharge, although pain levels in general were low. Both groups reported no or low levels of pain after six and 12 months. Anxiety levels in general were low, although higher in the ICU group one week after ICU discharge. After six and 12 months, anxiety in both groups was comparable. Throughout the study, levels of agitation were similar in both groups., Conclusions: Critically ill older patients did not experience increased pain, anxiety or agitation 12 months after an ICU stay., Relevance to Clinical Practice: This study positively shows that an ICU stay is not associated with persistent pain, anxiety and agitation thus providing additional information to older patients and their families when making intensive care treatment decisions. Adequate management of pain during and after an ICU stay may minimise the suffering of older patients., (© 2015 John Wiley & Sons Ltd.)

Aim: To investigate agreement between: (1) expected reasons and actual reasons for admission of people with dementia according to informal caregivers; (2) scores on measurement instruments prior to admission and the actual reasons for admission according to informal caregivers., Background: Timely admission of people with dementia is a crucial issue. Information is highly warranted on whether informal caregivers are capable of prior identification of causes of admission and, can thus be considered a reliable prospective source on causes of admission., Design: A cohort study among informal caregivers of people with dementia who made a transition to institutional long-term care., Methods: Qualitative data on the expected and actual reasons for admission were collected via open-ended questions at baseline and follow-up. Furthermore, at baseline, data were collected using measurement instruments to measure pre-admission characteristics. Interviews took place between November 2010-April 2012. After categorizing the answers, the agreement between the expected and actual reasons was calculated. Furthermore, bivariate associations were calculated between the actual reasons for admission and scores on corresponding measurement instruments., Results/findings: For most informal caregivers, there was agreement between their statements on the expected reason and the actual reason for admission. A third of the caregivers showed no conformity. Bivariate associations showed that there is also agreement between the actual reasons for admission and scores on corresponding measurement instruments., Conclusion: Informal caregivers can be considered reliable sources of information regarding what causes the admission of a person with dementia. Professional care should anticipate informal caregivers' statements and collaborate with them to strive for timely and appropriate admission., (© 2014 John Wiley & Sons Ltd.)

Aim: To assess which factors are associated with change in quality of life of people with dementia who have recently been admitted to long-term care facilities., Background: Many people with dementia will be admitted to long-term care facilities at some point during their disease. It is currently unknown which factors are associated with improvement and/or deterioration of quality of life immediately following admission., Design: An observational and longitudinal survey., Methods: Data on 343 people with dementia who have been recently admitted to long-term care facilities across eight European countries were collected between November 2010-April 2012. Quality of life was assessed by people with dementia and their proxies using the 'Quality of Life-Alzheimer's Disease scale'. Explanatory variables included cognitive status, comorbidities, activities of daily living, depressive symptoms and neuropsychiatric symptoms. Descriptive and multilevel regression analyses were performed., Results: Better cognitive abilities at baseline were associated with a decrease in self-reported quality of life. Greater dependency and more depressive symptoms at baseline were associated with declined proxy-reported quality of life. Furthermore, an increased dependency and an increase of depressive symptoms between baseline and follow-up were associated with a decreased proxy-reported quality of life. On an individual level, three groups were identified, namely people whose quality of life: (1) decreased; (2) stayed the same; and (3) increased., Conclusion: Cognitive functioning, functional rehabilitation and treatment of depressive symptoms should receive special attention. However, quality of life of people with dementia does not necessarily decrease after institutionalization., (© 2014 John Wiley & Sons Ltd.)

Aim: To explore inter-country variation of factors associated with institutionalization of people with dementia., Background: There is an urgent need for evidence on whether factors associated with admission to institutional dementia care are applicable across healthcare systems, as increasing evidence suggests that these factors could be country-specific., Design: A prospective cohort study., Method: Primary data were collected in eight European countries, at baseline and after 3 months follow-up (November 2010-April 2012). The sample included 2014 dyads of people with dementia and their informal caregivers; 791 patients were recently institutionalized, 1223 patients lived at home and were at risk of institutionalization. Associations between care setting (institution vs. home) and factors shown to influence institutionalization (e.g. cognition, independence in activities of daily life, behaviour) were studied., Results: Considerable differences were found between the eight countries in characteristics of people with dementia who had been recently admitted to ILTC. However, caregiver burden appeared the most consistent factor associated with institutionalization in all analyses. Indications for the importance of independence in activities of daily life were found as well, although country differences may be more prominent for this factor., Conclusion: Evidence was found for two common factors, crucial in the process of institutionalization across countries: caregiver burden and independency in activities of daily life. However, this study also suggests that admission to institutional dementia care is context-specific, as wide variation exists in factors associated with institutionalization across countries. Tailored best-practice strategies are needed to reflect variations in response to these needs., (© 2015 John Wiley & Sons Ltd.)

Aims: To explore the perceptions of informal caregivers and healthcare professionals regarding potential reasons for the institutionalization of older persons with dementia in eight European countries., Background: Healthcare professionals may have an important role in facilitating informal caregivers' decision-making regarding institutionalization. Little is known about the perceptions of informal caregivers and healthcare professionals prior to institutionalization., Design: Cross-sectional survey in eight European countries (November 2010-January 2012)., Methods: Healthcare professionals reported why they clinically judged persons with dementia at risk for institutionalization. Informal caregivers reported potential reasons from their perspectives. Answers were openly coded and categorized. Variation between informal caregivers and healthcare professionals was investigated (agreement on at least one potential reason per case/proportion of maximum attainable kappa)., Results: Judgements of healthcare professionals and informal caregivers on 1160 persons with dementia were included. A total of 22 categories emerged. Approximately 90% of informal caregivers reported potential reasons. In 41% of the cases, informal caregivers and healthcare professionals agreed on at least one reason. Discrepancy was high for potential reasons related to caregiver burden. For the most frequent categories (caregiver burden, caregiver unable to provide care, neuropsychiatric symptoms, overall deterioration, care dependency), 24-41% of the attainable kappa was achieved. Differences between countries emerged indicating more favourable agreement in Finland, Sweden and Estonia and lowest agreement in England and Spain., Conclusion: Agreement between healthcare professionals and informal caregivers on potential reasons for institutionalization was low-to-moderate. Healthcare professionals are challenged to develop a detailed understanding of the perspectives and perceived burden of informal caregivers., (© 2014 John Wiley & Sons Ltd.)

Objectives: Increasing demands in long-term care for older people and a decrease in workforce availability can be expected in the future. These developments challenge the sustainability and quality of long-term care for older people. To address these challenges, long-term care organizations are forced to innovate. The aim of this study is to provide an overview of potential labor-saving and quality-improving innovations long-term care organizations are working on and to assess the self-reported extent of effectiveness., Design: This is a descriptive cross-sectional study., Methods: In total, 32 long-term care organizations in the region of Limburg in The Netherlands were invited to participate in the study. The inventory was performed by means of semistructured interviews with chief executive officers, managers, and staff members of the long-term care organizations. Based on the interview data, all innovations were described in a standardized form and subsequently checked by the participants. All innovations were clustered into product, process, organizational, and marketing innovations., Results: In total, 26 long-term care organizations delivering home and/or institutional long-term care for older people participated in the study. Overall, 228 innovations were identified; some innovations were described in a similar way by different organizations. The majority of innovations were product innovations (n = 96), followed by organizational innovations (n = 75), and process innovations (n = 42). In addition to the main types, 15 other innovations incorporating characteristics of different types of innovations were detected. Little evidence about the effectiveness of the innovations was reported by the organizations., Conclusions: This study shows that a large number and a broad variety of innovations have been implemented or are currently being developed in long-term care organizations for older people. However, according to the organizations, there is relatively little (scientific) evidence confirming the effectiveness of these innovations. More research is needed to evaluate the effects of the innovations and to indicate whether they provide real solutions to future challenges., (Copyright © 2015 AMDA - The Society for Post-Acute and Long-Term Care Medicine. Published by Elsevier Inc. All rights reserved.)

Background: Alongside providing care, informal caregivers of people with dementia often need support and guidance themselves, especially during difficult periods such as the care-transition from home towards a nursing home. Knowledge on needs of informal caregivers during this period is sparse. This study aims to provide insight into problems and needs of informal caregivers caring for people with dementia during care-transition from home-based care to institutional long-term care., Methods: A systematic electronic search in CINAHL, Cochrane, Medline, PsycINFO, Pubmed and Web of Knowledge. All qualitative articles up to September 2013 were considered. The included articles underwent a quality appraisal. Thematic analysis was used to analyze problems and needs described in the articles., Results: Thirteen publications were included providing 14 topics comprising needs and problems of informal caregivers during the care-transition period. The most stated topics were: "emotional concerns" (e.g. grief and shame about the decision), "knowledge/information" (e.g. understanding the care system) and "support" (e.g. need for counseling). Similar topics were found prior and after admission, with examples specific to the either the home or nursing home situation., Conclusions: The care-transition period should be considered a continuum, as similar needs and problems were identified prior and after admission. This should be kept in mind in developing support and guidance for informal caregivers during this process. Whereas currently the situation prior and post admission are seen and treated as adjacent stages, they should be considered one integrated stage. Multicomponent programmes should be offered that are designed in a continuous way, starting prior to admission, and continuing after.

Aims and Objectives: This study examines the utilisation of healthcare resources by critically ill older patients over one year following an intensive care unit stay., Background: Information on healthcare resource utilisation following intensive care unit treatment is essential during times of limited financial resources., Design: Prospective longitudinal nonrandomised study., Methods: Healthcare resource utilisation by critically ill older patients (≥65 years) was recorded during one year following treatment in a medical-surgical intensive care unit. Age-matched community-based participants served as comparison group. Data were collected at one-week following intensive care unit discharge/study recruitment and after 6 and 12 months. Recorded were length of stay, (re)admission to hospital or intensive care unit, general practitioner and medical specialist visits, rehabilitation program participation, medication use, discharge destination, home health care service use and level of dependence for activities of daily living., Results: One hundred and forty-five critically ill older patients and 146 age-matched participants were recruited into the study. Overall, critically ill older patients utilised more healthcare resources. After 6 and 12 months, they visited general practitioners six times more frequently, twice as many older patients took medications and only the intensive care unit group patients participated in rehabilitation programs (n = 99, 76%). The older patients were less likely to be hospitalised, very few transferred to nursing homes (n = 3, 2%), and only 7 (6%) continued to use home healthcare services 12 months following the intensive care unit stay., Conclusions: Critically ill older patients utilise more healthcare resources following an intensive care unit stay, however, most are able to live at home with no or minimal assistance after one year., Relevance to Clinical Practice: Adequate healthcare resources, such as facilitated access to medical follow-up care, rehabilitation programs and home healthcare services, must be easily accessible for older patients following hospital discharge. Nurses need to be aware of the healthcare services available and advise patients accordingly., (© 2015 John Wiley & Sons Ltd.)

Implications for practice and research: To guarantee the safety of residents or patients is the most important justification for physical restraint use, despite the lack of evidence for benefit and safety. Nurses' attitudes were shown to be nearly unchanged over time, while educational interventions seem to be ineffective in reducing restraint use in clinical practice. Research on the influence of nurses' attitudes on the implementation of research evidence in clinical practice is warranted.

Background: The relationship between nurse staffing and quality of care (QoC) in nursing homes continues to receive major attention. The evidence supporting this relationship, however, is weak because most studies employ a cross-sectional design. This review summarizes the findings from recent longitudinal studies., Methods: In April 2013, the databases PubMed, CINAHL, EMBASE, and PsycINFO were systematically searched. Studies were eligible if they (1) examined the relationship between nurse staffing and QoC outcomes, (2) included only nursing home data, (3) were original research articles describing quantitative, longitudinal studies, and (4) were written in English, Dutch, or German. The methodological quality of 20 studies was assessed using the Newcastle-Ottawa scale, excluding 2 low-quality articles for the analysis., Results: No consistent relationship was found between nurse staffing and QoC. Higher staffing levels were associated with better as well as lower QoC indicators. For example, for restraint use both positive (ie, less restraint use) and negative outcomes (ie, more restraint use) were found. With regard to pressure ulcers, we found that more staff led to fewer pressure ulcers and, therefore, better results, no matter who (registered nurse, licensed practical nurse/ licensed vocational nurse, or nurse assistant) delivered care., Conclusions: No consistent evidence was found for a positive relationship between staffing and QoC. Although some positive indications were suggested, major methodological and theoretical weaknesses (eg, timing of data collection, assumed linear relationship between staffing and QoC) limit interpretation of results. Our findings demonstrate the necessity for well-designed longitudinal studies to gain a better insight into the relationship between nurse staffing and QoC in nursing homes., (Copyright © 2014 American Medical Directors Association, Inc. Published by Elsevier Inc. All rights reserved.)

Objective: To identify effective interventions which improve quality of care for people with dementia (PwD) living at home., Methods: MEDLINE-(via PubMed), CINAHL, PsycINFO and ISI Web of Science databases were searched., Inclusion Criteria: (1) randomized controlled trials; (2) published in English-language, peer-reviewed journals between 1990 and 2012; (3) evaluated strategies to improve quality of care for PwD cared at home; and (4) participants older than 65., Results: 23 studies met inclusion criteria. All the studies aimed to improve PwD quality of care and most of them focused on PwD caregivers. Psychoeducational programs are the most frequently assessed interventions and multicomponent interventions produced the most promising results., Conclusion: Due to the great variety of interventions describing specific samples and contexts, comparison of practice effectiveness is difficult. However, cognitive rehabilitation in PwD is effective when applied at an early stage of the disease. Case managers have demonstrated to reduce PwD institutionalization and the use of other community services. The studies were limited by sample heterogeneity, short follow-up or insufficiently detailed description., Practice Implications: To improve PwD homecare, health professionals should educate and support caregivers. Before specific interventional recommendations can be made, further research addressing the limitations of current studies is needed., (Copyright © 2014 Elsevier Ireland Ltd. All rights reserved.)

Background: Small-scale, home-like care environments are increasingly implemented in institutional nursing care as a model to promote resident-directed care, although evidence on its effects is sparse. This study focuses on the effects of small-scale living facilities on the behavior of residents with dementia and use of physical restraints and psychotropic drugs., Methods: A quasi-experimental study was conducted comparing residents in two types of long-term institutional nursing care (i.e., small-scale living facilities and traditional psychogeriatric wards) on three time points: at baseline and follow-ups after six and 12 months. Residents were matched at baseline on cognitive and functional status to increase comparability of groups at baseline. Nurses assessed neuropsychiatric and depressive symptoms, agitation, social engagement, and use of physical restraints using questionnaires. Psychotropic drug use was derived from residents' medical records., Results: In total, 259 residents were included: 124 in small-scale living facilities and 135 controls. Significantly fewer physical restraints and psychotropic drugs were used in small-scale living facilities compared with traditional wards. Residents in small-scale living facilities were significantly more socially engaged, at baseline and after six months follow-up, and displayed more physically non-aggressive behavior after 12 months than residents in traditional wards. No other differences were found., Conclusions: This study suggests positive effects of small-scale living facilities on the use of physical restraints and psychotropic drugs. However, the results for behavior were mixed. More research is needed to gain an insight on the relationship between dementia care environment and other residents' outcomes.

Objectives: To explore reasons for institutionalization of people with dementia according to informal caregivers as well as variation in reasons between countries., Design: An explorative cross-sectional study was conducted in 8 European countries., Setting: Per country, a minimum of 3 long term care facilities, offering care and accommodation as a package, participated in this study. Participating countries were selected to represent different geographic areas in Europe., Participants: Of the 791 informal caregivers involved in the RightTimePlaceCare project of people with dementia who were recently admitted to a long term care facility, 786 were included for this study., Measurements: As part of a semistructured interview, informal caregivers were asked the main reason for institutionalization in an open-ended question. Answers were categorized according to a conventional coding approach. All reasons were then quantified and tested., Results: Mainly patient-related reasons were stated, such as neuropsychiatric symptoms (25%), care dependency (24%), and cognition (19%). Neuropsychiatric symptoms were among the most often mentioned reasons in most countries. Besides patient-related reasons, caregiver burden and the inability of the informal caregiver to care for the patient were stated as reasons (both 15%). Further analyses showed countries differ significantly in reasons according to informal caregivers. Additionally, reasons were analyzed for spouses and child-caregivers, showing that spouses more often stated reasons related to themselves compared with child-caregivers., Conclusion: Multiple reasons contribute to the institutionalization for people with dementia, with several factors that may influence why there were country differences. Variation in the organization of dementia care and cultural aspects, or the relationship between the informal caregiver and person with dementia may be factors influencing the reasons. Because of a wide variation in reasons between countries, no one-size-fits-all approach can be offered to guide informal caregivers when facing the possibility of institutionalization of the person with dementia., (Copyright © 2014 American Medical Directors Association, Inc. Published by Elsevier Inc. All rights reserved.)

Objectives: To explore how quality of life (QoL) and quality of care (QoC) for people with dementia (PwD) vary across 8 European countries; to explore how QoL and QoC for PwD vary across living arrangements; and to assess the association between QoL and QoC., Design: Cross-sectional survey., Setting: Institutional long term care and home care in 8 European countries (England, Estonia, Finland, France, Germany, the Netherlands, Spain, and Sweden)., Participants: PwD receiving formal home care but at risk for admission to an institutional setting, and PwD who were recently admitted., Measurements: QoL was assessed by the PwD and by their best informed proxies using the Quality of Life-Alzheimer's Disease scale (QoL-AD) (range 13-52). QoC was measured using quality of care indicators (eg, the presence of depressive symptoms, the presence of pressure ulcers)., Results: A total of 1123 PwD living at home (mean age 82.2, 63%women) and 791 PwD living in institutional care (mean age 84.1, 74% women) participated. QoL of PwD was most often rated highest in Sweden and England and lowest in Estonia and Spain. No differences in QoL were detected among the settings. For the QoC indicators, no consistent patterns were visible in such a way that certain countries or settings scored "higher" or "lower." The presence of depressive symptoms was most consistently associated with lower QoL (P ≤ .001)., Conclusion: There is great variation in QoL and QoC scores among European countries and settings. To gain insight into the underlying causes of these differences, more knowledge is needed about the effect of different national health care systems and dementia strategies on QoL and QoC indicators. Depressive symptoms were associated with QoL, and executing longitudinal studies investigating which factors are associated with change in QoL is highly recommended., (Copyright © 2014 American Medical Directors Association, Inc. Published by Elsevier Inc. All rights reserved.)