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Introduction: We are conducting a randomised controlled trial (Promoting Activity, Independence and Stability in Early Dementia and Mild Cognitive Impairment - PrAISED 2) to test the effectiveness of an intervention to promote activity and independence amongst people with mild cognitive impairment and early dementia. A process evaluation is needed to determine how the intervention works. This protocol outlines the rationale, aims, objectives and methods of the process evaluation.Methods: The process evaluation will use a mixed-methods design and comprise two studies: An implementation study, examining the process through which PrAISED 2 is delivered, and a study on the mechanisms of impact and context, focussing on the mediating mechanisms that contribute to study outcomes. Integration of separate analyses of quantitative and qualitative data will provide a holistic view of how the PrAISED 2 intervention works.Conclusion: Results from this process evaluation will further the understanding of the factors that can impinge on the success of complex interventions. This will represent invaluable information for researchers undertaking further research around behaviour change among people with cognitive impairment and dementia. [ABSTRACT FROM AUTHOR]

Introduction: Research has established that exercise and physical activity can improve executive functioning, independence and quality of life in people with dementia. A dedicated theory explaining behaviour change in relation to physical activity in people with dementia does not exist. We aimed to develop a theoretical model which can be used to inform effective interventions to promote physical activity in people with dementia.Methods: There were five phases: 1. A search of the literature to identify theories which have been used to explain behaviour change in relation to physical activity in adult populations without a diagnosis of dementia; 2. Description of the theories (and sub-theories) and their main constructs; 3. Synthesis of the constructs; 4. Adaptation of the constructs to dementia; 5. Development and explanation of a model for physical activity in people with dementia (the 'PHYT in dementia').Results: We identified nine theories used to explain behaviour change in relation to physical activity in adult populations without a diagnosis of dementia. Through our synthesis, we identified nine umbrella constructs. We integrated three more dementia-relevant constructs and developed the 'PHYT in dementia'. The model was explained by providing a practical example of its application.Discussion: Based on a scoping review of behaviour change theories in adults without dementia and following adaptation of the constructs from these theories to dementia, we derived a new theoretical model, the 'PHYT in dementia', which includes both individual-level and environment-level constructs. The model needs to be tested empirically, which our research team will do in the process evaluation of the Promoting Activity, Independence and Stability in Early Dementia and Mild Cognitive Impairment (PrAISED 2) study. Results from field-testing will inform refinement of the model. [ABSTRACT FROM AUTHOR]

Background: Person-centred care has been identified as the ideal approach to caring for people with dementia. Developed in relation to long stay settings, there are challenges to its implementation in acute settings. However, international policy indicates that acute care for people with dementia should be informed by the principles of person-centred care and interventions should be designed to sustain their personhood. Objectives: Using Kitwood's five dimensions of personhood as an a priori framework, the aim of this paper was to explore the way in which current approaches to care in acute settings had the potential to enhance personhood in older adults with dementia. Design: Data collected to explore the current experiences of people with dementia, family carers and co-patients (patients sharing the ward with people with mental health problems) during hospitalisation for acute illness were analysed using a dementia framework that described core elements of person centred care for people with dementia. Settings: Recruitment was from two major hospitals within the East Midlands region of the UK, focusing on patients who were admitted to general medical, health care for older people, and orthopaedic wards. Participants: Participants were people aged over 70 on the identified acute wards, identified through a screeing process as having possible mental health problems. 34 patients and their relatives were recruited: this analysis focused on the 29 patients with cognitive impairment. Method: The study involved 72 h of ward-based non-participant observations of care complemented by 30 formal interviews after discharge concerning the experiences of the 29 patients with cognitive impairment. Analysis used the five domains of Kitwood's model of personhood as an a priori framework: identity, inclusion, attachment, comfort and occupation. Results: While there were examples of good practice, health care professionals in acute settings were not grasping all opportunities to sustain personhood for people with dementia. Conclusions: There is a need for the concept of person-centred care to be valued at the level of both the individual and the organisation/team for people with dementia to have appropriate care in acute settings. [ABSTRACT FROM AUTHOR]

Around a quarter of hospital beds in the UK are occupied by patients living with dementia (PWD), and communication impairments are common across all types of dementia, often exacerbated by the hospital environment. Unsurprisingly, healthcare professionals (HCPs) report particular challenges in caring for this patient group, whilst trying to recognise and value their personhood as per the underpinning ethos of person-centred care. However, whilst there is a growing body of research that underlines the importance of communication in dementia care, there is far less that actually examines this communication in real time interaction. Suggestions and pointers for good communication do exist, but these do not tend to be empirically derived, and sometimes conflict with empirical findings. This paper focuses on a specific area of interaction which has previously received very little attention: the way in which healthcare encounters are ended or closed. There is potentially a conflict between a pressure to manage a patient as efficiently as possible, and endeavouring to ensure person-centred care and deal with communication difficulties arising from dementia. Using conversation analysis, we examined forty-one video recordings of HCP/PWD interactions collected from an acute inpatient ward. We identify three phenomena around which there were recurring troubles in our dataset: ‘open-ended pre-closings’, ‘mixed messages’ and ‘non specifics and indeterminate terms’. We conclude that moves towards closing an encounter that appear intuitive to HCPs as competent interactants, and that may represent best practice in other healthcare settings, may in fact serve to confuse a PWD and create difficulties with closings. Our findings underline the importance of examining best practice guidance as it is actually talked into being, using approaches which can unpack the interactional detail involved. They also emphasise the importance of context in the analysis of healthcare delivery, to avoid a ‘one size fits all’ approach. [ABSTRACT FROM AUTHOR]

Background The range and magnitude of potential benefits and harms of antihypertensive treatment in people with dementia has not been previously established. Methods A scoping review to identify potential domains of benefits and harms of antihypertensive therapy in people with dementia was undertaken. Systematic reviews of these domains were undertaken to examine the magnitude of the benefits or harms. Results Potential outcome domains identified in the 155 papers in the scoping review were cardiovascular events, falls, fractures and syncope, depression, orthostatic hypotension, behavioral disturbances, polypharmacy risks, kidney problems, sleep problems, interactions with cholinesterase inhibitors, and pain. The systematic reviews across these domains identified relatively few studies done in people with dementia, and no convincing evidence of safety, benefit, or harm across any of them. Discussion Given the lack of firm evidence of benefits or harm from antihypertensive therapy in people with dementia and the weak evidence for benefits in people over 80 years of age, the current presumption that the favorable evidence drawn from the treatment of nondemented people should be extrapolated to those with dementia is contentious. There is sufficient evidence to warrant particular caution and further research into treatment in this group of patients. [ABSTRACT FROM AUTHOR]

People living with dementia (PLWD) are almost always admitted to the acute hospital for reasons unrelated to their dementia, finding themselves in the unfamiliar environment of a Health Care of Older Persons acute ward. The effect of this environment creates a challenge not just for a PLWD themselves, but also for the staff who care for them. Concerns have been raised by both policy makers and staff about the quality of communication between hospital staff and PLWD. Using conversation analysis, we examined 41 video recordings of healthcare professional (HCP)/PLWD interactions collected across three acute inpatient wards in a large teaching hospital in the UK. In this paper, we focus our analysis on hard-to-interpret talk (talk where there are problems in hearing, speaking and/or understanding), and the ways in which healthcare professionals respond to this. Repair of hard- to- interpret talk is common in ordinary interaction, but we find that HCPs in this setting use a range of approaches to avoid direct repair. These approaches are: the use of non-committal responses and continuers such as 'yeah' or nods; the use of repetitions or partial repetitions; responding to the emotional tone displayed in the PLWD's utterance; closing the current topic and shifting to the next; and treating the PLWD's talk as related to the task at hand. We suggest that the use of these approaches may be one way in which HCPs manage respecting the personhood of the PLWD, by preserving face and enabling a continuation of an interaction in which the PLWD can take an active part. Our paper provides an empirical demonstration of the high level of interactional skill involved in dementia care work. It also illustrates how these skills can be described and specified, and hence incorporated into the recommendations and tips that are produced for communication with PLWD. • Communication between people living with dementia and hospital staff can be challenging. • We focus on hard-to-interpret talk and how healthcare professionals respond to this. • Repair is common in ordinary interaction but appears to be avoided here. • Avoiding repair may help acknowledge the personhood of people living with dementia. • Skills demonstrated here can be described and specified, and are therefore trainable. [ABSTRACT FROM AUTHOR]

A quarter of UK acute hospital beds are occupied by people living with dementia (PLWD). Concerns have been raised by both policy makers and carers about the quality of communication between hospital staff and PLWD. PLWD may experience communication impairments such as word finding difficulties, limited ability to construct coherent narratives and difficulties understanding others. Since much healthcare delivery occurs through talk, healthcare professionals (HCPs) and PLWD are likely to experience increased communication barriers. Consistent with this, HCPs report stress and reduced job satisfaction associated with difficulty communicating with PLWD. HCPs face these challenges whilst striving to deliver person-centred care, respecting the autonomy and wishes of the patient before them. However, best practice recommendations in the field tend not to be based on actual interactional evidence. This paper investigates recurring interactional difficulties around HCP requests to carry out health and social care tasks and subsequent reluctance or refusal on the part of PLWD. Using conversation analysis, we examined 41 video recordings of HCP/PLWD interactions collected across three acute inpatient wards. We identify both the nature of the refusals, and any mitigation offered, and explore the requests preceding them in terms of entitlement and contingency. We also explore the nature of HCP requests which precede PLWD agreement with a course of action. We conclude that several features of requests can be seen to precede acceptance, principally the use of higher entitlement requests, and the lowering of contingencies. Our findings underline the importance of examining the contextual interactional detail involved in the negotiation of healthcare, which here leads to an understanding of how design of HCP requests can impact on an important healthcare activity being carried out. They also emphasise the power of conversation analytic methods to identify areas of frequent interactional trouble in dementia care which have not previously been articulated. • Acute hospital staff need to make requests of their patients living with dementia (83). • Hospital patients living with dementia may refuse important requests in direct ways (85). • This creates a dilemma for staff wishing to deliver respectful and effective care (83). • Some forms of requesting made direct refusal more interactionally relevant (77). • High entitlement requests with lowered contingencies supported request acceptance (83). [ABSTRACT FROM AUTHOR]

The prevalence of fecal incontinence (FI) in care homes is estimated to range from 30% to 50%. There is limited evidence of what is effective in the reduction and management of FI in care homes. Using realist synthesis, 6 potential program theories of what should work were identified. These addressed clinician-led support, assessment, and review; the contribution of teaching and support for care home staff on how to reduce and manage FI; addressing the causes and prevention of constipation; how cognitive and physical capacity of the resident affects outcomes; how the potential for recovery, reduction, and management of FI is understood by those involved; and how the care of people living with dementia and FI is integral to the work patterns of the care home and its staff. Dementia was a known risk factor for fecal incontinence (FI), but how it affected uptake of different interventions or the dementia specific continence and toileting skills staff require, were not addressed in the literature. There was a lack of dementia-specific evidence on continence aids. Most care home residents with FI will be doubly incontinent; there is, therefore, limited value in focusing solely on FI or single causes, such as constipation. Medical and nursing support for continence care is an important resource, but it is unhelpful to create a distinction between what is continence care and what is personal or intimate care. Prompted toileting is an approach that may be particularly beneficial for some residents. Valuing the intimate and personal care work unqualified and junior staff provide to people living with dementia and reinforcement of good practice in ways that are meaningful to this workforce are important clinician-led activities. Providing dementia-sensitive continence care within the daily work routines of care homes is key to helping to reduce and manage FI for this population. [ABSTRACT FROM AUTHOR]