Dr Sarah Smith

OBJECTIVES: Increasing diagnostic rates of dementia is a national health priority; to meet this priority, improvement needs to be made to diagnostic services. It has been increasingly recognized that primary can play a significant role in the diagnostic journey for people with dementia, with some diagnostic services entirely located in primary care. This article reviews the extent of the involvement of primary care in diagnostic care pathways for people presenting with memory complaints within England, and presents examples of innovative approaches, which may be of interest to practitioners. METHOD: A rapid review was undertaken to identify articles outlining diagnostic care pathways for dementia involving primary care in England. RESULTS: Six articles relating to pathway evaluations and innovative approaches involving primary care were deemed suitable for inclusion in the review. CONCLUSIONS: The review found examples of diagnostic pathways and innovative practices being implemented in in primary care. These practices aligned to the strategic ambitions of the National Dementia Strategy. However, it was widely acknowledged that there is a need to improve postdiagnostic pathways; in particular, access to postdiagnostic support. This issue is being reflected in contemporary policy initiatives such as the Department of Health's 2016 Joint Declaration on postdiagnostic dementia care and support.

Objectives: We piloted a computerised cognitive training battery in a group of participants with Parkinson's disease without dementia to investigate the relevance of the training to daily life and the feasibility and the acceptability of the tasks. Previous studies of CT have had limited success in the benefits of training, extending to improvements in everyday function. By taking a pragmatic approach and targeting training to the cognitive skills affected by Parkinson's disease (planning, attention, and recollection), whilst using tasks that emulated real-life scenarios, we sought to understand whether participants perceived the training to be effective and to identify the elements of the training that elicited beneficial effects. Methods: Four participants completed a cognitive training session comprising three distinct tasks 5 days a week over two weeks. Participants completed baseline questionnaires examining health-related quality of life, everyday cognition, and apathy before the training period, after the last session, and two weeks after the last session. An interview was held after participants had completed the training. Results: The findings indicated that participants felt the training was acceptable, enhanced their awareness, and encouraged them to monitor their thinking abilities. The group interview indicated that the training was feasible; participants felt the tasks had potential to improve everyday performance, but more supporting information should be provided to facilitate this transfer. Responses to the questionnaires reflected these findings, indicating improvement for some participants' cognition and quality of life. Objective measures supported the subjective reports; there were improvements in some but not all domains. Performance on the planning and recollection tasks improved over the training period, and the evidence for improvement on the attention task was mixed. Conclusion: This study has found that pragmatic computer-based training with real-life outcomes is both feasible and acceptable and should be evaluated more extensively using controlled methods.

Autobiographical memory (AM) concerns the ability to remember past events from one's own life and consists of autobiographical knowledge (personal facts) and autobiographical incidents (personal events). The novelty of this research was to assess both personal factual and personal event AM in Parkinson's disease (PD) for specified lifetime periods. An autobiographical fluency task was used in which participants were asked to recall personal events and personal facts from five separate lifetime periods. Previous findings as well the brain regions affected in PD lead to the hypothesis that Parkinson's patients would recall less autobiographical memories especially for the most recent lifetime periods. Sixteen non-demented and non-depressed Parkinson's patients and sixteen age-education-matched controls participated. The results showed a temporal gradient for the recall of personal events in Parkinson's patients as they recalled fewer events for recent time periods. The PD group also had more difficulties in recalling autobiographical events rather than an autobiographical knowledge. The difficulty in recalling autobiographical events was characterized by overgenerality, with PD patients failing to generate specific episodic memories. © 2009 Elsevier Srl.

Objective: Metamemory is integral for strategizing about memory intentions. This study investigated the prospective memory (PM) deficit in Parkinson's disease (PD) from a metamemory viewpoint, with the aim of examining whether metamemory deficits might contribute to PM deficits in PD. Method: Sixteen patients with PD and 16 healthy older adult controls completed a time-based PM task (initiating a key press at two specified times during an ongoing task), and an event-based PM task (initiating a key press in response to animal words during an ongoing task). To measure metamemory participants were asked to predict and postdict their memory performance before and after completing the tasks, as well as complete a self-report questionnaire regarding their everyday memory function. Results: The PD group had no impairment, relative to controls, on the event-based task, but had prospective (initiating the key press) and retrospective (recalling the instructions) impairments on the time-based task. The PD group also had metamemory impairments on the time-based task; they were inaccurate at predicting their performance before doing the task but, became accurate when making postdictions. This suggests impaired metamemory knowledge but preserved metamemory monitoring. There were no group differences regarding PD patients' self-reported PM performance on the questionnaire. Conclusions: These results reinforce previous findings that PM impairments in PD are dependent on task type. Several accounts of PM failures in time-based tasks are presented, in particular, ways in which mnemonic and metacognitive deficits may contribute to the difficulties observed on the time-based task. © 2011 American Psychological Association.

Instances in which we cannot retrieve information immediately but know that the information might be retrieved later are subjective states that accompany retrieval failure. These are expressed in feeling-of-knowing (FOK) and Tip-of-the-tongue (TOT) experiences. In Experiment 1, participants with Parkinson's disease (PD) and older adult controls were given general questions and asked to report when they experienced a TOT state and to give related information about the missing word. The PD group experienced similar levels of TOTs but provided less correct peripheral information related to the target when in a TOT state. In Experiment 2, participants were given a Semantic (general knowledge questions) and an Episodic (word pairs) FOK task. PD patients failed to accurately predict their future memory performance (FOK) in response to both episodic and semantic cues. Results are interpreted in the context of recent frameworks of memory and metacognition. © 2013 Elsevier Inc.

This study examined the effects of providing cues to facilitate autobiographical memory retrieval in Parkinson's disease. Previous findings have shown that individuals with Parkinson's disease retrieve fewer specific autobiographical memories than older adult controls. These findings are clinically significant since the quality of autobiographical memory is linked to identity and sense of self. In the current study, 16 older adults with Parkinson's disease without dementia and 16 matched older adult controls were given 3 min in which to recall autobiographical memories associated with five different time periods and to give each memory a short title. Participants were later asked to retrieve the memories in three phases: firstly in a free recall phase; secondly in response to general cues (time periods) and finally in response to specific cues (the short titles previously given). The number of memories and the quality of the memory (general or specific) was recorded in each condition. Compared with matched older adult controls, the Parkinson's disease group was impaired in retrieving the memories that they had previously given in the free recall phase and in response to general cues. The performance of the group with Parkinson's disease was only equivalent to the older adults when they retrieved memories in response to self‐generated cues. The findings are discussed in relation to theories of autobiographical memory and the neuropsychology of Parkinson's disease.

© The Author(s), 2019. Cognitive stimulation therapy (CST) is widely used with people with dementia, but there is no evidence of its efficacy in mild cognitive impairment or dementia in Parkinson’s disease (PD-MCI; PDD) or dementia with Lewy bodies (DLB). We aimed to explore the impact of ‘CST-PD’, which is home-based, individualized CST adapted for this population. In a single-blind, randomized controlled exploratory pilot trial (RCT), we randomized 76 participant–dyads [PD-MCI (n = 15), PDD (n = 40), DLB (n = 21) and their care partners] to CST-PD or treatment as usual (TAU). CST-PD involves home-based cognitively stimulating and engaging activities delivered by a trained care partner. Exploratory outcomes at 12 weeks included cognition (Addenbrooke’s Cognitive Evaluation; ACE-III), neuropsychiatric symptoms and function. In care partners, we assessed burden, stress and general health status. Relationship quality and quality of life were assessed in both dyad members. At 12 weeks, the ACE-III showed a nonstatistically significant improvement in the CST-PD group compared with the TAU group, although neuropsychiatric symptoms increased significantly in the former. In contrast, care partners’ quality of life (d = 0.16) and relationship quality (‘satisfaction’, d = 0.01; ‘positive interaction’, d = 0.55) improved significantly in the CST-PD group, and care burden (d = 0.16) and stress (d = 0.05) were significantly lower. Qualitative findings in the CST-PD recipients revealed positive ‘in the moment’ responses to the intervention, supporting the quantitative results. In conclusion, care-partner-delivered CST-PD may improve a range of care-partner outcomes that are important in supporting home-based care. A full-scale follow-up RCT to evaluate clinical and cost effectiveness is warranted.

Objectives: This study aimed to carry out a pilot validation of Affect-GRADIOR, a computer-based emotion recognition test, with older adults. The study evaluated its usability, reliability and validity for the screening of people with Alzheimer´s disease (AD) and amnestic mild cognitive impairment (aMCI). Methods: The test was administered to 212 participants (76.37 ± 6.20 years) classified into three groups (healthy controls, n = 69; AD, n = 84; and aMCI, n = 59) on the basis of detailed neurological, neuropsychological, laboratory and neuro-imaging evidence. Data on usability were collected by means of a questionnaire and automated evaluation. Results: The validated test comprised 53 stimuli and 7 practice items (one per emotion). Participants reported that Affect-GRADIOR was accessible and user-friendly. It had high internal consistency (ordinal Cronbach's α = 0.96). Test-retest reliability correlations were significant and robust (r = 0.840, p < 0.001). Exploratory factor analysis supported a seven-factor model of the emotions assessed (neutral expression, happiness, surprise, disgust, sadness, anger and fear). Receiver operating characteristic curve analyses suggested that the test discriminated healthy older adults from AD and aMCI cases. Correct answer score improved MMSE predictive power from 0.547 to 0.560 (Cox & Snell R

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BACKGROUND: The ability to recognize emotional expression is essential for social interactions, adapting to the environment, and quality of life. Emotion recognition is impaired in people with Alzheimer's disease (AD), thus rehabilitation of these skills has the potential to elicit significant benefits. OBJECTIVE: This study sought to establish whether emotion recognition capacity could be rehabilitated in people with AD. METHODS: Thirty-six participants with AD were assigned to one of three conditions: an experimental group (EG) that received 20 sessions of rehabilitation of emotion recognition and 20 sessions of cognitive stimulation therapy (CST), a control group (CG) that received 40 sessions of CST, and a treatment as usual group (TAU). RESULTS: A positive treatment effect favoring the EG was found; participants were better able to correctly identify emotions (p = 0.021), made fewer errors of commission (p = 0.002), had greater precision of processing (p = 0.021), and faster processing speed (p = 0.001). Specifically, the EG were better able to identify sadness (p = 0.016), disgust (p = 0.005), and the neutral expression (p = 0.014), with quicker processing speed for disgust (p = 0.002). These gains were maintained at one month follow-up with the exception of processing speed for surprise, which improved. CONCLUSION: Capacity to recognize facial expressions of emotions can be improved through specific rehabilitation in people with AD, and gains are still present at a one month follow up. These findings have implications for the design of rehabilitation techniques for people with AD that may lead to improved quality of life and social interactions for this population.

Background: Group-based psychosocial therapy, such as group Cognitive Stimulation Therapy, improves cognition and quality of life in people living with dementia. Neuropsychiatric symptoms and restricted mobility are common complications for people with Parkinson's-related dementia (PRD) and may limit access to, and participation in, group activities. This study describes the development of a condition-specific, home-based psychosocial therapy for people with PRD ready to be trialled in a clinical population. Methods: By means of a multistage process, a draft therapy manual was developed in an iterative manner through collaboration with medical experts, researchers and Patient and Public Involvement (PPI) representatives. In stage 1, an extensive literature search of psychosocial therapies for dementia with potential relevance for Parkinson's disease (PD) was undertaken to select a candidate therapy for adaptation. In stage 2, qualitative feedback from stakeholders and intelligence regarding existing nonpharmacological therapies for cognitive impairment in PD was combined to produce a prototype therapy manual. In stage 3, the manual was field tested in: 1) a home-setting using a 25-item assessment tool; and 2) at a local PD support group with PPI representatives. Based on the feedback from this phase, final design modifications were implemented and a draft therapy manual produced. Results: The manual was developed in an iterative manner. Interview and focus group transcripts identified three enduring themes: manual form and content, therapy acceptability by people with PRD, and companion guidance and support. Major adaptations included: removal of discrete levels of task complexity, removal of images that were potentially hallucinogenic or lacked clarity, and updating of the content. Conclusion: We have successfully developed a Cognitive Stimulation Therapy-based psychosocial therapy specifically adapted for people with PRD. The therapy is ready to trial in a pilot randomized controlled study.

© 2019, The Author(s). Background: Drug-based therapeutic approaches for Parkinson’s disease dementia (PDD) and dementia with Lewy bodies (DLB) are moderately effective and not always tolerated. Tailoring psychosocial approaches in PDD and DLB may offer additional support and improve outcomes. We adapted home-based, care partner-delivered Cognitive Stimulation Therapy (CST) for individuals with PDD or DLB and their care partners (CST-PD). Objectives: To evaluate the feasibility, acceptability, and tolerability of CST-PD. Methods: This randomised controlled trial used mixed methods, including a process evaluation. People with PDD, DLB or mild cognitive impairment in PD (PD-MCI) and their care partners were randomised to 12 weeks of treatment as usual (TAU) or CST-PD. Outcomes were feasibility of the study conduct (i.e., recruitment, retention rate) and acceptability and tolerability of the intervention. Measures included rating scales, researcher field notes, therapy diaries, and exploratory clinical and care partner efficacy measures. Results: The recruitment target was met with 76 consenting participant-dyads. Retention in both arms was high at over 70%. More than 90% of dyads undertook discrete sessions greater than 20 min duration, but the average number of sessions completed was lower than the recommended dose. Acceptability ratings (i.e., interest, motivation and sense of achievement) of the intervention were high. Participants reported no serious adverse events related to the intervention. Conclusions: The field of psychosocial interventions for PDD and DLB is newly emerging, and we demonstrated that this type of intervention is acceptable and well tolerated. Evaluating its clinical effectiveness in a full-scale randomized controlled clinical trial is warranted. Trial registration number: The trial is a psychosocial intervention with an allocated ISRCTN number 11455062.

Introduction In an increasingly aging society, testing hippocampal-dependent cognition in a quick and low resource manner will be crucial in: assessing the potential benefits of lifestyle choices and interventions affecting cognitive ageing (such as those involving exercise, diet, and sleep); detecting pathological aging, such as in Alzheimer’s disease, where hippocampal degeneration occurs relatively early on. Methods Over 300 participants aged 18-89 completed three cognitive tests, namely the Addenbrooke’s Cognitive Examination-III (ACE-III), The Four Mountains Task (4MT), and a new task introduced here, the Spaces and Sequences Episodic Video Task (SSEVT). Hippocampal tissue is particularly vulnerable to aging, and the 4MT and SSEVT were designed to be hippocampal-dependent. Accordingly, we tested the hypothesis that 4MT and SSEVT performance would be significantly compromised by aging. As an initial proof-of-concept exploration of these tests’ ability to detect pathological aging, such as in Alzheimer’s disease, we compared 10 patients with Mild Cognitive Impairment (MCI) with matched subsamples of the older group (Healthy ageing, HA). Results Supporting the hippocampal-aging related hypothesis, 4MT and SSEVT scores showed appreciably stronger age-related declines than ACE-III scores. The middle-aged group (mean: ∼51 years) were significantly worse than the young group (mean: ∼21 years) on the 4MT (Cohen’s d = 0.724) and the SSEVT (Cohen’s d = 0.443); and the older group (mean: ∼71 years) were significantly worse than the middle-aged group on the SSEVT (Cohen’s d = 0.724). Neither pattern was seen for ACE-III. Suggestively, the MCI patients performed worse than the matched HA group on the 4MT (consistent with previous work), and on our novel SSEVT, but not on the ACE-III. Discussion We conclude that the 4MT and SSEVT may be suitable for assessing lifestyle choices and interventions affecting cognitive ageing. We also propose that these findings provide an initial proof-of-concept for these tests’ ability to detect pathological aging in its early stages and support further exploration of this with larger clinical samples.

Background: People with dementia occupy up to one quarter of acute hospital beds. However, the quality of care delivered to this patient group is of national concern. Staff working in acute hospitals report lack of knowledge, skills and confidence in caring for people with dementia. There is limited evidence about the most effective approaches to supporting acute hospital staff to deliver more person-centred care. Objectives: This study aimed to evaluate the efficacy of a specialist training programme for acute hospital staff regarding improving attitudes, satisfaction and feelings of caring efficacy, in provision of care to people with dementia. Design: A repeated measures design, with measures completed immediately prior to commencing training (T1), after completion of Foundation level training (T2: 4-6 weeks post-baseline), and following Intermediate level training (T3: 3-4 months post-baseline). Setting: One NHS Trust in the North of England, UK. Participants: 40 acute hospital staff working in clinical roles, the majority of whom (90%) were nurses. Methods: All participants received the 3.5 day Person-centred Care Training for Acute Hospitals (PCTAH) programme, comprised of two levels, Foundation (1/2 day) and Intermediate (3 days), delivered over a 3-4 month period. Staff demographics and previous exposure to dementia training was collected via a questionnaire. Staff attitudes were measured using the Approaches to Dementia Questionnaire (ADQ), satisfaction in caring for people with dementia was captured using the Staff Experiences of Working with Demented Residents questionnaire (SEWDR) and perceived caring efficacy was measured using the Caring Efficacy Scale (CES). Results: The training programme was effective in producing a significant positive change on all three outcome measures following intermediate training compared to baseline. A significant positive effect was found on the ADS between baseline and after completion of Foundation level training, but not for either of the other measures. Conclusions: Training acute hospital staff in Intermediate level person-centred dementia care is effective in producing significant improvements in attitudes towards and satisfaction in caring for people with dementia and feelings of caring efficacy. Foundation level training is effective in changing attitudes but does not seem to be sufficient to bring about change in satisfaction or caring efficacy.

Background To explore the design, delivery models and identify good and innovative practices in Memory Assessment Services (MAS) in England and Wales. Methods A two-stage service evaluation comprising (1) on-line survey of MAS providers to identify features of the commissioning models, service design, delivery, and challenges alongside examples of good/innovative practice; (2) qualitative case studies using video/telephone interviews with key staff and people who had used the service. Results The 49 respondents to the survey reported a shift in delivery of MAS post COVID and identified key areas for improvement, including a need for specialist staff, support for MCI and rarer dementias, and capacity for post diagnostic support. The 15 case studies illustrated good practice and innovation focusing on post diagnostic support, equity of access, working with external services/service location, MCI and rarer dementia and involving specialist staff. Conclusions The evaluation speaks to the importance of (re)evaluation of services to identify local need and the importance of commissioning based on local need and innovative approaches that my sit outside of ‘typical’ MAS pathways.

Abstract Objectives The aim of this study was to establish the impact of dementia education and training on the knowledge, attitudes and confidence of health and social care staff. The study also aimed to identify the most effective features (content and pedagogical) of dementia education and training. Design Cross-sectional survey study. Data collection occurred in 2017. Settings Health and social care staff in the UK including acute care, mental health community care trusts, primary care and care homes. Participants All health and social care staff who had completed dementia education and training meeting the minimal standards as set by Health Education England, within the past 5 years were invited to participate in an online survey. A total of 668 health and social care staff provided informed consent and completed an online survey, and responses from 553 participants were included in this study. The majority of the respondents were of white British ethnicity (94.4%) and identified as women (88.4%). Outcomes Knowledge, attitude and confidence of health and social care staff. Results Hierarchical multiple regression analysis was conducted. Staff characteristics, education and training content variables and pedagogical factors were found to account for 29% of variance in staff confidence (F=4.13, p<0.001), 22% of variance in attitude (knowledge) (F=3.80, p<001), 18% of the variance in staff knowledge (F=2.77, p<0.01) and 14% of variance in staff comfort (attitude) (F=2.11, p<0.01). Conclusion The results suggest that dementia education and training has limited impact on health and social care staff learning outcomes. While training content variables were important when attempting to improve staff knowledge, more consideration should be given to pedagogical factors when training is aiming to improve staff attitude and confidence.

Ensuring an informed and effective dementia workforce is of international concern, however there remains limited understanding of how this can be achieved. This systematic review aimed to identify factors associated with effective dementia educational programmes. Critical Interpretive Synthesis underpinned by Kirkpatrick’s return on investment model for evaluation of education was applied. One hundred and fifty-two papers of variable quality were included in the review. Common features of more efficacious educational programmes included the need for educational programmes to: be relevant to participants’ role and experience; involve active face-to-face participation; underpin practice-based learning with theory; be delivered by an experienced facilitator; have a total duration of at least eight hours with individual sessions of 90 minutes or more; support application of learning in practice; and provide a structured tool or practice guideline to underpin care practice. Further robust research is required to develop the evidence base; however, the findings of this review have relevance for all working in workforce education.

BACKGROUND: Despite people living with dementia representing a significant proportion of health and social care users, until recently in the United Kingdom (UK) there were no prescribed standards for dementia education and training. This audit sought to review the extent and nature of dementia education and training offered to health and social care staff in the UK against the standards described in the 2015 Dementia Training Standards Framework, which describes the knowledge and skills required of the UK dementia workforce. METHODS: This audit presents national data concerning the design, delivery, target audience, length, level, content, format of training, number of staff trained and frequency of delivery within existing dementia training programmes offered to health and social care staff. The Dementia Training Standards Framework was used as a reference for respondents to describe the subjects and learning outcomes associated with their training. RESULTS: The findings are presented from 614 respondents offering 386 training packages, which indicated variations in the extent and quality of training. Many training packages addressed the subjects of 'person-centred care', 'communication', 'interaction and behaviour in dementia care', and 'dementia awareness'. Few training packages addressed subjects concerning 'pharmacological interventions in dementia care', 'leadership' and 'end of life care'. Fewer than 40% of The Dementia Training Standards Framework learning outcomes targeted to staff with regular contact with people with dementia or in leadership roles were covered by the reported packages. However, for training targeted at increasing dementia awareness more than 70% of the learning outcomes identified in The Dementia Training Standards Framework were addressed. Many training packages are not of sufficient duration to derive impact; although the majority employed delivery methods likely to be effective. CONCLUSIONS: The development of new and existing training and education should take account of subjects that are currently underrepresented and ensure that training reflects the Training Standard Framework and evidence regarding best practice for delivery. Lessons regarding the limitations of training in the UK serve as a useful illustration of the challenge of implementing national dementia training standards; particularly for countries who are developing or have recently implemented national dementia strategies.

This research is drawn from findings that, while Black African and Caribbean people have a higher chance of developing vascular dementia, they are often diagnosed at advanced stages of dementia because they present later to dementia care facilities. This poses significant concerns due to implications for poorer treatment outcomes and higher treatment cost. Interventions to support timely help seeking for dementia have been designed for BAME communities and implemented through diverse healthcare facilities but the challenge of late dementia help seeking persists among the Black African and Caribbean population specifically. Community pharmacies are healthcare facilities conveniently located within the community, thus the potential for timely dementia help seeking support to be provided to the Black African and Caribbean population through this health facility is explored in this research study. A four-stage multi-method investigation was conducted. Starting with a scoping review which explored the range of existing dementia help seeking interventions designed for the BAME population, the research continued with two surveys. One survey provided initial insight into the dementia help seeking behaviour of the Black African and Caribbean people and the other examined the initial disposition of community pharmacists towards providing dementia help seeking support to the target population. The last stage was a qualitative interview study which built on the survey findings to explore the potentials for community pharmacists to offer the needed support. While personal and systemic difficulties experienced on the help seeking journey of the Black African and Caribbean people contributed to their delayed help seeking for dementia, the community pharmacists were willing and believed they were suitably positioned to provide initial as well as ongoing dementia help seeking support to this population. Possible interventions were grouped into community pharmacy-based individual public health engagements, media engagement and wider community engagement, although the community pharmacists envisaged among other factors, a lack of adequate funding as a probable barrier to the implementation of these interventions.

Background Discussing pharmaceutical treatment for dementia is challenging because of variation in disease progression, lack of curative treatments, and communication difficulties. Research in the context of dementia suggests shared decision making is limited, this study examined how dementia medications are discussed in practice. Methods Focused video/audio ethnography of clinical appointments (n = 14), semi-structured interviews with patients/supporters (n = 23) and clinicians (n = 5) were employed to examine communication practices. Results Two themes developed; Framing and understanding of information in the context of uncertainty explores how uncertainties around risks and benefits are understood. ‘Not worth the risk’ or ‘nothing to lose’ presents how patients/supporters and clinicians balance individuals’ contexts/perceived risks/benefits. In the absence of certainty around potential benefits, risk often informed decision-making, particularly for frailer or more vulnerable patients. Conclusions Clinicians should be aware of their influence on decision-making and be cognisant of the way that they frame opinions, which are largely based on clinical experience. Prescribers would benefit from a standardised information source which enables them to describe the likelihood and magnitude of benefits and side effects in a universal way. Accessible information for patients and relatives about the same is also recommended. Patients and relatives make their decisions to take medications in the context of relative uncertainty about the likelihood of benefits, with risk playing a pivotal role in decision making for some.

Background: The health and social care workforce requires access to appropriate education and training to provide quality care for people with dementia. Success of a training programme depends on staff ability to put their learning into practice through behaviour change. This study aimed to investigate the barriers and facilitators to implementation of dementia education and training in health and social care services using the Theoretical Domains Framework (TDF) and COM-B model of behaviour change. Methods: A mixed-methods design. Participants were dementia training leads, training facilitators, managers and staff who had attended training who worked in UK care homes, acute hospitals, mental health services and primary care settings. Methods were an online audit of care and training providers, online survey of trained staff and individual/group interviews with organisational training leads, training facilitators, staff who had attended dementia training and managers. Data were analysed using descriptive statistics and thematic template analysis. Results: Barriers and facilitators were analysed according the COM-B domains. “Capability” factors were not perceived as a significant barrier to training implementation. Factors which supported staff capability included the use of interactive face-to-face training, and training that was relevant to their role. Factors that increased staff “motivation” included skilled facilitation of training, trainees’ desire to learn and the provision of incentives (e.g. attendance during paid working hours, badges/certifications). “Opportunity” factors were most prevalent with lack of resources (time, financial, staffing and environmental) being the biggest perceived barrier to training implementation. The presence or not of external support from families and internal factors such as the organisational culture and its supportiveness of good dementia care and training implementation were also influential. Conclusions: A wide range of factors may present as barriers to or facilitators of dementia training implementation and behaviour change for staff. These should be considered by health and social care providers in the context of dementia training design and delivery in order to maximise potential for implementation.

Background: The Neuropsychiatric Inventory is predicated on the assumption that psychiatric symptoms are manifestations of disease. Biopsychosocial theories suggest behavioural changes viewed as psychiatric may also arise as a result of external behavioural triggers. Knowing the causes of psychiatric is important since the treatment and management of psychiatric symptoms relies on this understanding. Aims: This study sought to understand the causes of psychiatric symptoms recorded in care home settings by investigating qualitatively described symptoms in NPI-NH interviews. Method: The current study examined the NPI-NH interviews of 725 participants across 50 care homes. The qualitatively described symptoms from each of the 12 subscales of the NPI were extracted: 347 interviews included at least one qualitatively described symptom (n=651 descriptions). A biopsychosocial algorithm developed following a process of independent researcher coding (n=3) was applied to the symptom descriptions. This determined whether the description had predominantly psychiatric features, or features that were cognitive or attributable to other causes (i.e. issues with Orientation & Memory, Expressions of Need, Poor Care and Communication or Understandable Reactions) Results: Our findings suggest that the majority (over 80%) of descriptions described symptoms with features that could be attributable to cognitive changes and external triggers (e.g. poor care and communication). Conclusions: The finding suggest that in its current form the NPI-NH may over attribute the incidence of psychiatric symptoms in care homes by overlooking triggers for behavioural changes. Measures of psychiatric symptoms should determine the causes of behavioural changes in order to guide treatments more effectively.

Abstract

Background and objectives: People with dementia occupy around one quarter of general hospital beds, with concerns consistently raised about care quality. Improving workforce knowledge, skills and attitudes is a mechanism for addressing this. However little is known about effective ways of training healthcare staff about dementia. This study aimed to understand models of dementia training most likely to lead to improved practice and better care experiences for people with dementia, and to understand barriers and facilitators to implementation. Method: A collective case study was conducted in three National Health Service Acute Hospital Trusts in England. Multiple data sources were used including interviews with training leads/facilitators, ward managers and staff who had attended training; satisfaction surveys with patients with dementia and/or carers; and observations of care using Dementia Care Mapping. Results: Interactive face-to-face training designed for general hospital staff was valued. Simulation and experiential learning methods were felt to be beneficial by some staff and stressful and distressing by others. Skilled delivery by an experienced and enthusiastic facilitator was identified as important. Staff identified learning and practice changes made following their training. However, observations revealed not all staff had the knowledge, attitudes and skills needed to deliver good care. Patient and carer satisfaction with care was mixed. A major barrier to training implementation was lack of resources. Supportive managers, organisational culture and strong leadership were key facilitators. Conclusion: Dementia training can lead to improved care practices. There are a range of key barriers and facilitators to implementation that must be considered.