Dementia Care Mapping: the challenge of improving daily practice in nursing homes results of a quasi-experimental trial

Transcription

1 Dementia Care Mapping: the challenge of improving daily practice in nursing homes results of a quasi-experimental trial Halek M. 1,2, Quasdorf, T. 1,2, Trutschel D. 1, Riesner C. 1,2, Dichter M.N. 1,2 1 German Center of Neurodegenerative Diseases (DZNE), Witten 2 School of Nursing Science, Witten/Herdecke University, Witten, Germany Contact: Margareta Halek (Margareta.Halek@dzne.de) Founded partly by Stiftung Wohlfahrtspflege NRW, Johanniter GmbH

2 BACKGROUND Person-centered care (PCC) is a highly recognized concept in dementia research and care. Dementia Care Mapping-method (DCM) = intervention to implement PCC. Studies show heterogeneous results on the effectiveness of DCM on residents challenging behavior and quality of life (Chenoweth et al. 2009, van de Ven et al. 2013, Rockstad et al. 2013). In Germany the DCM-method is widely used but without evidence of effectiveness Seite 2

3 Study aims and questions Strengthening Quality of Life for People with Dementia (LebenQD) (Halek et al. 2013) AIM: to evaluate the effectiveness and implementation of DCM in German NH. Questions: Effects: 1. Does the DCM method positively affect the Qol of people with dementia and reduce their challenging behaviors? 2. Does the DCM method positively affect staff attitudes toward dementia, improve job satisfaction and reduce burnout? Process evaluation: 3. To what extent could the intervention be implemented (degree of implementation)? 4. What are facilitators of and barriers to DCM implementation? Cost-effectiveness: 5. Does the DCM method positively affect the efficiency of dementia care compared to other interventions? Seite 3

4 DESIGN AND METHOD T0 ( ) T1 (month 9-11) T2 (months 21-23) Comparison group A: 3NH Intervention group B: 3 NH Use of DCM since 2009, external DCM mapper Kick of meetings with leaders/ staff about DCM project Training: Basic User: 2 mappers/nh 1.5 day coding session with inhouse DCM trainers First DCM Cycle: 5 hours observation/cross mapping Feedback within 1 Week Action planning within 4 weeks Together with DCM trainer Second DCM Cycle: 8 hours Third DCM Cycle: without DCM trainer Comparison group C: 3 NH Training: 1.5 hour QoL + Qualidem for staff Qualidem-Assessment: All residents within 3 months, by 2 staff members; re-assessment after 6 months re-assessment after 6 months, event related assessment, If necessary case conferences Seite 4

5 MEASUREMENTS DCM intervention QUALIDEM intervention Degree of implementation: Fidelity of implementation (interviews, questionnaire, process documents) Process evaluation Facilitator/barriers: Intervention characteristic Characteristics of individuals (interviews, questionnaires) Team (observation SIMLOG) Characteristic of the institution (DIQ) Process of implementation (process documents) Outcomes Resident: QoL: QoLAD; Qualidem Behaviour: NPI- NH staff: Attitudes (ADQ) Job satisfaction (Copsoq) Burnout (CBI) Control variables Demographic Variables PSMS FAST Medication Dementiaspecific burden (BelaDem) Organisation characterisitics (DIQ) Seite 5

6 SAMPLE CHARACTERISTICS T0 Intervention Group A Intervention Group B Intervention Group C Test results (p-value) Residents with dementia N = 41 N = 52 N = 61 Age, years [x (sd)] 82.5(±6.7) 84.1 (±6.3) 82.6 (±9.2).62 d Women [n (%)] 33 (80) 43 (83) 52 (85).82 c Dementia Diagnoses (yes (%)) 39 (95) 50 (96) 53 (87).14 c Functional Assessment Staging (7) [n (%)] 2 to 6 23 (56) 32 (62) 43 (70).31 c 7 18 (44) 20 (38) 18 (30) Physical Self Maintenance Scale (6-30) [x (sd)] 20.0 (±5.9) 20.4 (±5.5) 18.7 (±5.6).22 b Care dependency levels [n (%)] 1 9 (22) 11 (21) 23 (38).11 c 2 15 (37) 21 (40) 23 (38) 3 17 (41) 20 (38) 13 (21) Use of psychotropic drugs [n (%)] Yes (one) 16 (39) 21 (40) 25 (41).37 c Yes (more than one) 18 (44) 26 (50) 22 (36) No 7 (17) 5 (10) 14 (23) Use of pain medication [n (%)] Yes (one or more) 17 (41) 6 (12) 22 (36).002 c Seite 6

7 Adherence (consistence with Intervention Plan: e.g. all DCM components?) Dose (Amount of Program Content received by Participants: e.g. 3 DCM cycles? ) Participants responsiveness (Ratings of Involvement in the Intervention: e. g. who took part in DCM Feedbacks?) Quality of Delivery (Rating of Effectiveness of Program Content: e.g. Opinion about the Quality of Feedbacks) RESULTS: DEGREE OF IMPLEMENTATION DCM long-term DCM new Qualidem NH 1 NH 2 NH 3 NH 4 NH 5 NH 6 NH 7 NH 8 NH Dusenbury, L., et al. (2003). "A review of research on fidelity of implementation: implications for drug abuse prevention in school settings." Health Educ Res 18(2): Seite 8

8 RESULTS: EFFECT ON QOL-AD No significant effect of DCM No signifcant differences between the three groups linear mixed model: P Fixed effect Time 0.45 Intervention 0.34 Intervention x Time 0.22 Seite 9

9 EFFECT ON QOL-AD Variance between the groups not bigger than between the NH High implementation degree have no influence on QOL-AD Comparable results/ tendency on QUALIDEM scores Seite 10

10 EFFECT ON CHALLENGING BEHAVIOUR No significant differences between the three groups Overall Prevalence ch. Behav. decreases over time (not significant) Prevalence of clinical relevant ch. Behav decreases in group C Seite 11

11 DISCUSSION AND CONCLUSION 1. Cautious interpretation of results because of pilot character, no randomization and small sample/cluster 2. Comparison to other studies Australia (Chenoweth et al. 2009): strong external DCM implementation, strong selection of NH, intervention period 8 months, strong RCT conditions; CMAI, NPI-NH ; Qol (QUALID) Norway (Rokstad et al. 2013): mixed internal/external DCM implementation, no selection criteria for NH, intervention period 10 months, realistic trial; BARS, NPI-Q, Qol (QUALID) Netherlands (Van de Ven et al. 2013) : DCM implementation by trained NH staff, no selection criteria for NH, intervention period 11 month, realistic trial; CMAI, NPI-NH,Qol (QUALIDEM) Germany (Halek et al. 2013): DCM implementation by trained NH staff, no selection criteria for NH, intervention period 18 months, realistic trial; NPI ; QoL (QOL-AD, QUALIDEM) DCM implementation with more external support seems to have better effects Other methods focusing on understanding of the person (VIP, PCC) seems to have similar effects like DCM. Which is the most resource-efficient one? Seite 13

12 DISCUSSION What does it mean: DCM was/was not implemented? FORMAL ELEMENTS OF DCM CHANGE OF ATTITUDES, WAY OF THINKING DOING PCC, DELIVERY OF INTERVENTIONS Seite 14

13 CONCLUSIO Back to the Modeling Step (MRC framework): Results from the implementation process, fidelity and facilitators and barriers: Definition of requirements for successful implementation DCM Revision of the DCM implementation strategy Methodological challenges Development of an approach for assessment of the implementation degree Seite 15

14 CHENOWETH, L., KING, M. T., JEON, Y. H., BRODATY, H., STEIN-PARBURY, J., NORMAN, R., HAAS, M. & LUSCOMBE, G Caring for Aged Dementia Care Resident Study (CADRES) of person-centred care, dementiacare mapping, and usual care in dementia: a cluster-randomised trial. Lancet Neurology, 8, ROKSTAD, A. M., ROSVIK, J., KIRKEVOLD, O., SELBAEK, G., SALTYTE BENTH, J. & ENGEDAL, K The Effect of Person-Centred Dementia Care to Prevent Agitation and Other Neuropsychiatric Symptoms and Enhance Quality of Life in Nursing Home Patients: A 10-Month Randomized Controlled Trial. Dement Geriatr Cogn Disord, 36, VAN DE VEN, G., DRASKOVIC, I., ADANG, E. M., DONDERS, R., ZUIDEMA, S. U., KOOPMANS, R. T. & VERNOOIJ-DASSEN, M. J Effects of dementia-care mapping on residents and staff of care homes: a pragmatic cluster-randomised controlled trial. PLoS One, 8, e HALEK, M., DICHTER, M. N., QUASDORF, T., RIESNER, C., & BARTHOLOMEYCZIK, S. (2013). The effects of dementia care mapping on nursing home residents' quality of life and staff attitudes: design of the quasi-experimental study Leben-QD II. BMC Geriatrics, 13, 53. doi: / Seite 16