1. Interdisciplinary Implementation of Quality Instruments for the Care of Residents with Dementia in Nursing Homes (InDemA) M. Halek, MScN; Prof. Dr. S. Bartholomeyczik 1 Researchteam: Institute of Nursing Science: D. Hardenacke, MScN; C. Krüger, MScN; Dr. H. Mayer Institute of General Practice and Family Medicine: Dr. S. Wilm 1, Dr. G. Bureick 1 principal investigators

2. Initial situation  60% to 90% of residents with dementia show some kind of challenging behaviour  Medical care of residents are provided by GP  Every resident has the right to choose “his” GP – the nurses have to deal with that  About half of carers in NH are registered nurses  Lack:  of knowledge of dementia and dealing with challenging behaviour (nurses and GPs)  of collaboration and communication between nurses and physicians

3. Approaches on solution  For GPs: Dementia Guideline of the German Society for General and Family Medicine (DEGAM) (2008)  For nurses: „General recommendations for dealing with challenging behaviour in people with dementia in nursing homes“ (BMG 2007)  “Understanding diagnostics”: o Identification, description, measurement of challenging behaviour o Searching for triggers for behaviour: Need driven dementia compromised behaviour model (NDB- model) o Case conferences

4. Aims and research question Research question: Is it possible to improve nursing and medical care of residents in nursing homes by a parallel implementation of nursing and medical guidelines? Aims: 1.Improvement at the interface between nursing care and medical care of residents with dementia in nursing homes 2.Improvement of the care and living situation of people with dementia in nursing homes

5. T0T0 T1T1 Training of key persons (nurses) (one day/ 8h) In-house training (nurses) one-time per unit/ 2 h Seven Case conferences per unit IdA as a guidance nurses +GPs Intervention (9 Month) Training of GPs, one-time/ 90 min. Study Process  intervention study, pre-post-test design  May 2008 - February 2010 (22 month)  Goverment-Funded by The German Ministry of Health Peer outreach visits (one-time/45 min.) Information via mail

6. Main Outcomes and measurements  Residents:  improvement of quality of life: QUALIDEM  improvement of challenging behaviour: NPI-NH  Changes in neuroleptica (DDD), hospital admissions: Checklist for Resident’s records  Nurses and GPs:  improvement of the communication between nurses and general practitioners: Questionnaire  reduction of nurses‘ stress/burden: Questionnaire

7. Recruitment and sample Residents contacted n=337 Inclusion criteria fulfilled n=166 Exclusion criteria: Schizophrenia MMSE > 24 Living in Nursing Home min. 2 Month 15 nursing homes, 24 units Nurses contacted n= 374 Response rate (data collection) n= 151 GP contacted n= 116 Participation in trainings n= 40 Estimated sample size for 1st data collection N=183 Estimated sample size N= 90 Estimated sample size N=70 Response rate (data collection) n= 40 Participation in trainings n= 171

8. Cognition (MMSE):  64% of residents have a MMSE-Score < 10 Challenging behaviour (NPI-NH):  Overall rate of challenging behaviour: 90% (median 3 behaviours)  Prevalence:  Aggression/Agitation (50%), Irritability (42%), Apathy (41%), Depression (39%), Anxiety (39%)  Frequency:  frequently/very frequently: Aberrant motor behaviour (96%), Apathy (73%), Anxiety (66%)  Severity:  severe to moderate: Delusion (81%), Hallucination (72%), Aggression/Agitation (69%) Residents´ outcomes

9. Nurses´ Burden  Most stressing behaviour for nurses:  physical aggressive (40%)  Most stressful aspects:  “I haven't enough time for caring for these residents” 67%  “Because, I had to sedate they” 49%  Least stressful aspects (less than 20%):  “Feeling, to be threatened”  “That I don't understand, why the resident behave in this way”  “To be verbally insulted”  40 % of nurses are not satisfied with the care of residents with dementia

10. Aspects of CollaborationNurses %GPs % Satisfaction with the collaboration 4260 Satisfaction with bilateral appreciation 4180 Sufficient time for joint discussion about the residents 4055 Arrangements about the medical and nursing care of residents often enough 5885 Collaboration

11.  Up to date 50 Case Conferences took place  Participation: nurses, nurse assistants, sometimes resident’s family members, occupational therapists, rarely a neurologist  So far GPs did not participate Experiences with Case-Conferences

12.  Residents status not as expected:  Residents highly cognitive impaired  High prevalence of challenging behaviour  Collaboration between GPs and nurses:  Differences between nurses reports and study data  Nurses less dissatisfied as expected  Missing participation of GPs:  No problems with collaboration?  Inappropriate time for case conferences? Discussion

13. Thank you very much for your attention! Margareta.Halek@uni-wh.de