Person Centred Care For Dementia People And Its Implementation

Person Centred Care for Dementia People

Discuss about the Reliability and Reliable Change Index.

Dementia is not only related to the Alzheimer’s disease but it also includes other conditions like vascular dementia, dementia with Lewy bodies and frontotemporal degeneration. Most of the people with dementia develop complex conditions due to occurrence of these conditions in a single person. Hence, it would be difficult to manage dementia in a person with single model. In such case, person centred model would be more beneficial because management strategy can be modified based on the condition of the patient. Number of cases of dementia increases with increase in the age of the person. Prevalence of dementia is increasing worldwide due to changes in the demographics. It is well established that dementia increases with age of the person. Hence, it is considered as the normal ageing process. As a result, management of dementia is neglected issue all over the world. It is also evident that prevalence of dementia increases as person approaches death. Hence, it can be concluded that death can be delayed by the management of dementia. Effective model need to be identified to implement at the workplace. Implementation of the dementia care model would be helpful in providing well life to people with dementia (Hunter et al., 2016).     

Person centred care for dementia people is mainly based on the acronym VIPS. Dementia people and their care should be Valued, these people should be treated as Individual, our understanding should corelate with the Perspective of the dementia person and there should be more attention to the Social involvement of the person. More focus should be given to the uniqueness of the individual irrespective of the positive and negative traits of the individuals. More emphasis should be given to the social involvement of the dementia person. Person centred model has unique distinction because it incorporates medical, psychological and spiritual interventions for dementia care. This integrated approach is more beneficial in dementia care because signs and symptoms of the dementia appear due to different reasons and management of this complex condition is not feasible by implementation of single approach. Person centred care promotes rights and dignity of dementia people. It would be helpful in augmenting engagement of the dementia person in the care. Philosophy of person centred care make sure that these people do not consider dementia is end of life. It also provides guidance to medical professionals and family members (Chenoweth et al., 2009). Prior to implementation of the person centred care, both barriers and facilitators of the care will be studied. Efforts will be made to overcome these barriers.  

Components of Person Centred Care

Primary objective of this intervention will be to evaluate effectiveness of the programme in reducing behavioural traits of the dementia person like agitation, depression, augmentation in the quality of life in terms of daily activities and functional capabilities, modifications in the physical and chemical restraint and lessening in the contrary events in the life. Secondary objective of this intervention will be to recognize diversity, superiority and practicability of the person centred care. Organisational factors which endorse and hamper, implementation of the person centred care will be identified.

Implementation of the person-centred care in the facility requires training for the professional caregivers. Training to the professional caregivers will be provided over the period of 15 days. Daily one hour workshop will be conducted and reflective evaluation will be carried out after each workshop session. It will be helpful in assessing progress of caregivers in training and accordingly modifications can be done in the training methods (Kuske et al., 2007). This training will be mainly focused on implementation of sequential pedagogical framework comprising of 1) knowledge translation, 2) knowledge generation and 3) knowledge dissemination. Knowledge generation will include introductory class for person centred intervention theory for all caregivers. Knowledge generation will comprise of reflective evaluation, interactive workshops on identifying, analysing and discussing suitable evidence for the person centred care. Caregiver staff will critically analyse routine activities, environment and resources available for implementation of the person centred care. In knowledge dissemination, caregiver staff will discuss about knowledge gained during workshops. In this exercise, sharing of knowledge and experiences will be augmented which will be beneficial in the overall improvement in the implementation of the person centred care. This intervention will be built on the basis of pervious interventions, hence its design will be optimal for evaluating efficacy of person centred care in person centred care.  

Components of the person centred include 1) doing little extra, 2) developing physical environment suitable for person centred care and 3) evaluating extremely prioritised psychological needs and meeting these needs (Chrzescijanski et al., 2007).

In doing little extra, staff members will be familiarized with the evidence and information related to the thriving themselves in the wellbeing of the dementia patients and family members. Examples of this exercise comprises of offering a cup of coffee, taking for outdoor walk and reporting results from the current sports events. Staff members will be asked to reflect on these activities and document it. Documented activities and experiences may be beneficial in bringing positive behavioural changes (Visser et al., 2008).

Implementing Person Centred Care

Staff members will be familiarised with the evidence and information for creating acceptable physical environment for dementia patients. It will be helpful in the providing quality care and providing respect to patient’s values. Staff will be familiarised with the factors responsible for the distraction of dementia patient’s. Hence, staff may eliminate these distractions and provide home environment for the patient and family members. Staff will be encouraged to discuss with the patients about environment and take their input for changing environment. Staff members will give more focus on the shared areas like living rooms, sitting/dining rooms and corridors (Testad et al.,2010).

Staff members will be familiarised with the evidence and information to identify, assess, accept, and gratify each patient’s extremely prioritised psychological needs. Patient’s life history will be used as tool for prioritising their psychological needs. Staff members will be encouraged to interview patients and family members to recognize favourites, values and behavioural and psychological aspects. Staff will be encouraged to discuss with patient and family members to integrate identified psychological needs in the daily activities. In this process, staff members may plan activities based on the psychological needs of the patient. Staff members will be advised to document all the activities planned to meet psychological needs.        

Exclusively person centred intervention will be provided to the participants based on the VIPS construct (Røsvik 2013). Intervention will be directed to address organisational culture, staff training, endorsement of care planning, management contribution and interest and quality monitoring and improvement systems (Miller et al., 2010). Consideration will also be given to nursing guidelines for providing holistic care to the dementia patients. It will be helpful in overcoming resistance during care and facilitating person centred care. It will be achieved by implementing staff support model like Dementia Care Mapping. Assessment of the effectiveness of the person centred care will be performed by incorporating control participants. Routine care or standard care will be provided to the control participants. Different factors like demographics, socio-cultural, environmental factors, and ethical considerations will be considered during care. Demographic characters like age and gender will be considered. Participants will be categorised in male and female participants because male and female may have varied behavioural traits. Participants will also be categorised based on the age. Participants will be grouped above 80 years and below 80 years. Participants above 80 years of age may require more psychological interventions.

Person centred care may vary based on the socio-cultural aspects of the participants. It is well established that participants in the high socioeconomic class exhibited more engagement in the dementia care and their retention rate is high for dementia care. Cultural acceptance for the persons centred care is the major obstacle and it need to be addressed. This issue will be effectively addressed in the implementation of the person centred care. Physical environment of the residence will be given consideration in implementing person centred care. Environment of the residence should be suitable for the dementia patient. Disturbing environment may have psychological impact on the dementia patient. It can adversely affect implementation of person centred care because psychological disturbance can adversely affect behavioural alterations (Hunter et al., 2015). Ethical issues will be addressesed in the implementation of the person centred care. Caring dementia people is a challenging task because balancing autonomy with safety and well-being will be difficult. Few dementia patients may not accept the fact that they need to depend on others. This dependence may be to maintain their autonomy and live with their specific life values (Smebye et al., 2016).

Evaluation of Person Centred Care

Participants will be selected based on the diagnosis of dementia based on the International Classification of Diseases (ICD). ADL capabilities and cognition will be considered as the diagnostic criteria for the selection of participants. Approval will be taken from the elderly-care physician for inclusion of participants. These patients should have at least two psychiatric and behavioural symptoms. These symptoms include aggression, motor or verbal agitation, psychosis, depression, and apathy (Zuidema et al., 2011). Informed consent will be taken form the participants prior to incorporation in the intervention. Provision will be provided to participants to withdraw from the intervention in case of development of life threatening disease. In the previous studies, high attrition rate was evident in such types of interventions. It might be due to dementia condition and older age. High attrition rate might affect power necessary for statistical significance. This issue will be promptly addressed in this by incorporating more participants. Additional participants will also be selected but not included in the intervention. These additional participants will be incorporated in cases of high rate of attrition. Hence, intension to treat will be promptly addressed in this intervention. Emotional and psychological support will be provided to the participants who wish to withdraw. It would be helpful in more retention of participants in the intervention. It is evident that incorporation of different stakeholders like health professionals, social workers, community members and family members proved beneficial in improving retention in dementia care. Randomisation will be performed based on different criteria like age, gender and socioeconomic status because priority of psychological needs will be different for each population. Baseline data is most important aspect in the analysis of the outcome of the intervention. Randomisation will be useful in establishing baseline data for each group including control group. Randomisation will also be helpful in interpreting and analysing the results. It is evident that influence of personal and professional relationship among patients and caregivers would affect outcome of the intervention (Bramble et al., 2009). Hence, in this intervention precaution will be taken to assign unknown caregivers to the patients.

500 participants will be selected for this intervention. 400 participants will be with diagnosed dementia and 100 participants will be control. All the participants will be within 50 km from the host organisation, hence there will not be difficulty in reaching these participants.

Staff members willing to participate in the person centred care will be selected for the participants because along with medical and nursing knowledge, participants should have capability to apply person specific skills in providing person centred care. Prior to initiation of the intervention, staff members will be written information about the eligibility criteria, aims and objectives of the intervention and purpose of the study. Staff members need to work on permanent basis on the organisation (Schepers et al.,2012). Staff members will be properly familiarised with residence of the patient. It will be helpful for staff member to identify environmental impacts. Hence, staff member can implement alternative approach in individual care (Smith et al., 2012).

Opportunity will be given the staff members to take leadership role in implementation of the person centred care. Staff members with the leadership qualities will be given opportunity to train remaining staff members. In the past, studies were conducted with the enriched opportunities program to produce leaders from the study. It is evident from such studies that these leaders focused on the history, preferences and requirements of the dementia patients along with providing training and education. Efforts of the leaders should be visible verbally and leaders should observe activities of staff members and give them feedback. Feedback to other staff members proved beneficial in providing individualised care. Leaders should implement root cause approach to identify underlying causes of problems. Collaborative decision making has significant impact of the cultural change. Leaders can promote collaborative decision making. Cultural change can improve the individualized care to the dementia patients. Leaders should conduct educational and in-service seminars for all the nursing and allied service staff members. In-service seminars proved beneficial in incorporating person centred care in the actual practice. Leaders should motivate staff members and should make sure that staff members are keeping patients satisfactory and fulfilling their needs which are very important for person centred care (Rokstad et al., 2015; Bender et al., 2017).       

It is well established that interprofessional collaborative practice proved beneficial in augmenting outcome of the person centred care in dementia patients. Collaborative efforts of different professionals proved helpful in broadening their specific professional activities. It proved helpful in the improving focus of diverse professionals to the person centred care and patient’s psychological needs. This shift in the healthcare model can lead to comprehensive and holistic care and positive impact on the quality of healthcare service. This collaborative model will be implemented in the intervention. Dementia is complex disease; hence it should be managed in different aspects like health promotion, prevention of adverse events, cure and rehabilitation (Chenoweth et al., 2009). In implementation of these strategies collaborative work of medical professional, social worker and family member is necessary. Pathological, psychological and physiological aspects of the dementia management require specialised medical professional. However, sustained management and retention in the treatment can be improved by support from the social worker, community members, family and friends. Expertise from varied fields like recreational therapy, psychology, geriatric psychiatry, gerontology, and social work will incorporated in the person centred care.

This intervention will be carried out for six months. During duration of six months regular assessment with the interval of 15 days will be carried out. Based on the outcome of each 15 days, intervention protocol will be modified. In the first three months, main focus will be given to the primary outcomes and in later three months both primary and secondary outcomes will be measured because secondary outcomes will be evident only after positive primary outcomes. Health economic evaluation will be performed to assess the cost-utility analysis over the period of six-months. Cost-utility analysis will be performed for both intervention participants and control participants. Total cost incorporated will comprise of cost incurred for training of staff, travel cost, telephone cost and time spent by the staff in intervention. This intervention design, size of participants and statistical power will give conclusive outcomes of person centred care. Follow up will be performed for a period of 10 months after the completion of the intervention. This is important because few of the practices of the patient centred care requires longer period for its implementation.

Ethical approval will be taken for the organisational research committee. Proposal for the conduct of the intervention will be presented to the ethics committee and suggestions made by the committee will be incorporated in the proposal. Approval letter from the ethical committee will be documented and stored. Data collected during the intervention will be kept confidential. Dignity, respect and safeguard of the participants will be maintained throughout the duration of the intervention.   

Patient centred care in dementia intervention will comprise of chief investigator and co-investigators. These people will have responsibility of management and promotion of the intervention and analysis and interpretation of the outcomes. Data monitoring and ethics committee will be responsible for the safety and ethics of the trial. Intervention Steering Committee will be responsible for the supervision of the intervention which comprises of intervention progress, adherence to protocol and modification of protocol according to the new information. Sponsors will be responsible for ensuring responsibility and accountability of intervention and methodologies of the intervention. 

Demographic and socio-economic data will be collected by providing written form to the patients and family members. Psychological and behavioural data will be collected by providing questionnaires to the patients. Psychological and behavioural traits like capability of activities of daily living, cognitive impairment and neuropsychiatric symptoms will be considered. The Katz ADL-index, Gottfries cognitive scale and Neuropsychiatric Inventory will be used for the measurement of activities of daily living, cognitive impairment and neuropsychiatric symptoms respectively (Edvardsson et al., 2012).

Dementia is a multifaced condition, hence different person may have different opinion about the disease condition and intervention. Henceforward, group interviews along with the individual interviews will be conducted for the patients. In each group interview 4 – 6 participants will be included. This group interview will stimulate broad discussion and exchange of feelings and experiences. Group interviews will be followed by individual interviews. Psychological and behavioural comparison of patients in group interviews and individual interviews will be made. It will be useful in assessing effect of socialisation on psychological and behavioural aspects of the patient. Notes during interviews and audio-video recordings will be maintained for data documentation, analysis and interpretation (Clark et al., 2008).     

A semi-structured interview framework will be prepared for family members and professionals caregivers. Open-ended questions will be included in this framework so that answers will be given more freely. Examples of questions will be 1) what is there feeling about relationship with dementia patient, 2) whether they contributed to the care and how, 3) whether they collaborated with other professional caregivers. Interviews will be audio-recorded for the future references. Important points will be noted down during conversation between dementia patient and professional caregiver (Clark et al., 2008).

There should be effective coordination among staff caregivers, family caregivers and patients to collect the data. All the time, it would be difficult for the staff members to remain present physically with the patients. Patients will be staying at their residence. In such cases, staff members will interact with patient and family members over the phone. Staff members will also communicate through videoconferencing. Family caregivers should play significant role in communication with staff caregivers and other stakeholders of the intervention (Hasson and  Arnetz, 2008). Assessment of behavioural signs and symptoms in the dementia in the patients will be difficult because of alterations in symptoms due to multiple factors. Hence, healthcare caregivers will assess and reassess the patients to get the robust data. In case of quantitative data, average data will be considered for analysis (Ballard and Corbett, 2010).      

After the collection of the data, intervention will follow three steps like observation, feedback and action plan. Caregiver staff member will observe promptly behavioural and psychological aspects of the patient, interpret exact condition of the patient and prepare action plan for providing patient centred dementia care to the patients. Qualitative methods will be applied for assessing feasibility of the process and identifying facilitators and barriers of the process. Quantitative methods will be used for assessing efficacy and efficiency of the intervention.

It is evident that high quality evidence is not available for specific intervention in person centred care in the dementia patients. Hence, existing studies will be reviewed and limitations observed in these studies will be considered in the current intervention. To get the robust results, improvements will be incorporated in this intervention. From the studies in the literature is evident that follow up was not done. Follow up is important aspect in the person centred care for dementia patients. Follow up will be beneficial in the determining durability and outcomes of the intervention. Hence, follow up will be incorporated in this intervention. Planning for advanced care intervention was not evident in the studies from the literature. In case, certain patient is not responding to patient centred care, there should be intention to refer this patient for advanced care intervention (Edvardsson et al., 2008).

In nursing intervention, leaving a patient without total efforts of management is an ethical issue. Hence, in this study prearrangement will be made to implement advanced care intervention. Incorporation of cultural aspects in the person centred care can improve efficiency of intervention. However, in most of the studies, cultural aspects were not incorporated. Cultural values of the participants should be respected. Dignity and humanity of patients should be preserved by using appropriate labels and terminologies. In this intervention, all these cultural aspects will be considered in the implementation of the patient centred care for dementia patients. In few studies, more than one parameter was used to evaluate outcome. In such cases, it would be difficult to select one parameter over the other to make conclusion. Hence, to avoid this confusion one parameter will be used for analysis of specific outcome. It has been established that, non-pharmacological interventions like environmental and cultural factors can affect outcome of the study significantly (Cohen-Mans?eld et al., 2012). However, in most of the studies special attention was not given to these factors. In this study, individual patient’s environmental and cultural factors will be considered while providing patient centred care (Chenoweth et al., 2014).

Data is not available for the extent and qualifications of staff engagement in the implementation of person centred care. This data would be beneficial in recruitment of specific staff in the intervention. In the current intervention, extent of staff engagement in the person centred care will measured and documented. Also, qualifications of each staff members will be documented. This will be useful in identifying suitability of each staff member in person centred care. This data will be corelated with the outcome of the intervention. In case, discrepancy in outcome of same type of population, data for the engagement of staff will be useful in the analysis of the outcome. Guidelines and standardised protocols will be maintained for the activities performed by the staff members. Pharmacological and non-pharmacological approaches can have different outcome. In previous studies, these two interventions were not studied separately (van de Ven et al., 2013). In this intervention, individual outcome of pharmacological and non-pharmacological approaches will be evaluated in addition to the combined outcome of pharmacological and non-pharmacological approaches. This segregated outcome of different approaches is important because activity based person centred care proved more beneficial in the patients with less age.

Different behavioural aspects of the dementia can’t be manged with same type of exposure to the person centred care. Attention was not given to this point in the previously conducted studies. Agitation can be effectively managed by exposing the patients with short term interventions with more frequency. Emotions, depression, and quality of living can be effectively managed by long term interventions (Cohen-Mansfield, 2008). In this intervention, separate interventions will be planned for the different behavioural symptoms. Different types of interventions will be planed for patients with early stage and late stage diagnosis of dementia. Effect of person centred care on family caregivers was not evaluated in the previous studies. This aspect need to be considered to produce sustained outcome of the person centred care. In this intervention, effect of person centred care on the capability of family caregivers will be studied (Rosemond et al., 2012).

Outcomes will be measured to assess effectiveness of the person centred care in dementia patients. Outcomes in this intervention will be categorised in the primary outcome and secondary outcome. These outcomes will be aligned with aims and objectives of the intervention. Primary outcome will measure frequency and severity of the psychological and behavioural symptoms. These symptoms will be measured using Neuropsychiatric Inventory. Cohen-Mans?eld Agitation Inventory will be used to measure agitation scale (Rokstad et al., 2013). Cornell Scale of Depression in Dementia will be used to measure mood scale. Validated dementia quality of life instruments will be used to measure quality of life. Data collection will be performed by the independent researcher and it will blinded. It will address problem of probable bias. Secondary outcome measures will comprise of capabilities of daily living, use of physical, chemical and mechanical restraint. Chemical restraint comprises of antipsychotics, antihistamines and sedatives. Delirium, falls and pressure ulcers will also be measured in secondary outcomes (Smith et al., 2007).

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