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BACKGROUND: Neuropsychiatric symptoms occur frequently in many nursing home residents with dementia. Despite the availability of multidisciplinary guidelines, neuropsychiatric symptoms are often inadequately managed. Three proven effective methods for managing neuropsychiatric symptoms were integrated into a single intervention method: the STIP-Method, a personalized integrated stepped-care method to prevent and treat neuropsychiatric symptoms. The STIP-Method comprises 5 phases of clinical reasoning to neuropsychiatric symptoms and 4 stepped-care interventions and is supported with a web application. OBJECTIVE: This study aims to identify the facilitators and barriers in the implementation of the STIP-Method in nursing homes. METHODS: A mixed methods design within a participatory action research was used to implement the STIP-Method in 4 facilities of 2 Dutch nursing home organizations. In total, we aimed at participation of 160-200 persons with dementia and expected an intervention fidelity of 50% or more, based on earlier studies regarding implementation of effective psychosocial interventions to manage neuropsychiatric symptoms. All involved managers and professionals were trained in the principles of the STIP-Method and in using the web application. An advisory board of professionals, managers, and informal caregivers in each facility supported the implementation during 21 months, including an intermission of 6 months due to the COVID-19 pandemic. In these 6-weekly advisory board meetings, 2 researchers stimulated the members to reflect on progress of the implementation by making use of available data from patient records and the web application. Additionally, the 2 researchers invited the members to suggest how to improve the implementation. Data analysis will involve (1) analysis of facilitators and barriers to the implementation derived from verbatim text reports of advisory board meetings to better understand the implementation process; (2) analysis of patient records in accordance with multidisciplinary guidelines to neuropsychiatric symptoms: personalized, interdisciplinary, and proactive management of neuropsychiatric symptoms; (3) evaluation of the web application in terms of usability scores; (4) pre- and postimplementation analysis of patient records and the web application to evaluate the impact of the STIP-Method, such as changes in neuropsychiatric symptoms and informal caregiver burden. RESULTS: We enrolled 328 persons with dementia. Data collection started in July 2019 and ended in December 2021. The first version of this manuscript was submitted in October 2021. The first results of data analysis are expected to be published in December 2022 and final results in June 2023. CONCLUSIONS: Our study may increase understanding of facilitators and barriers to the prevention and treatment of neuropsychiatric symptoms in nursing home residents with dementia by implementing the integrated STIP-Method. The need for well-designed implementation studies is of importance to provide nursing homes with optimal tools to prevent and treat neuropsychiatric symptoms. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/34550.

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BACKGROUND: Concern has been raised that the COVID-19 pandemic and consequent social distancing measures may increase neuropsychiatric symptoms in people with dementia. Thus, we developed and delivered an e-learning training course to professional caregivers on using a web-based tool for psychosocial interventions for people with dementia. OBJECTIVE: The aim of our study was to evaluate the feasibility and efficacy of an e-learning course in combination with a web-based tool in addressing neuropsychiatric symptoms of dementia. METHODS: A quasi-experimental design was used in Tokyo, Japan. The e-learning course was delivered three times to professional caregivers between July and December 2020. Caregivers who completed the course assessed the level of neuropsychiatric symptoms in people with dementia using the total score from the Neuropsychiatric Inventory (NPI) via a web-based tool. The primary outcome measures were the number of caregivers who implemented follow-up NPI evaluations by March 2021 and the change in NPI scores from baseline to their most recent follow-up evaluations. As a control group, information was also obtained from professional caregivers who completed a face-to-face training course using the same web-based tool between July 2019 and March 2020. RESULTS: A total of 268 caregivers completed the e-learning course in 2020. Of the 268 caregivers, 56 (20.9%) underwent follow-up evaluations with 63 persons with dementia. The average NPI score was significantly reduced from baseline (mean 20.4, SD 16.2) to the most recent follow-up evaluations (mean 14.3, SD 13.4). The effect size was assumed to be medium (Cohen drm [repeated measures]=0.40). The control group consisted of 252 caregivers who completed a face-to-face training course. Of the 252 caregivers, 114 (45.2%) underwent follow-up evaluations. Compared to the control group, caregivers who completed the e-learning course were significantly less likely to implement follow-up evaluations (χ21=52.0, P<.001). The change in NPI scores did not differ according to the type of training course (baseline-adjusted difference=-0.61, P=.69). CONCLUSIONS: The replacement of face-to-face training with e-learning may have provided professionals with an opportunity to participate in the dementia behavior analysis and support enhancement (DEMBASE) program who may not have participated in the program otherwise. Although the program showed equal efficacy in terms of the two training courses, the feasibility was suboptimal with lower implementation levels for those receiving e-learning training. Thus, further strategies should be developed to improve feasibility by providing motivational triggers for implementation and technical support for care professionals. Using online communities in the program should also be investigated.

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BACKGROUND: A psychosocial dementia care programme for challenging behaviour (DEMBASE® ) was developed in collaboration with a Swedish BPSD-registry team for in-home care services use in Japan. The programme consisted of a web-based tool for the continued assessment of challenging behaviours and interdisciplinary discussion meetings. Effectiveness of the adapted programme was verified through a cluster-randomised controlled trial. The Tokyo Metropolitan Government provided municipal funding to introduce the programme into daily practice beginning in April 2018. OBJECTIVES: To investigate both facilitators and barriers associated with programme implementation. DESIGN: A secondary analysis of qualitative and quantitative data. SETTINGS: Data were collected in naturalistic long-term care settings from April 2018 to March 2019. PARTICIPANTS: A total of 138 professionals and 157 people with dementia participated in the programme. METHODS: Challenging behaviour in persons with dementia was assessed by professionals using a total Neuropsychiatric Inventory score. Data on expected facilitators and barriers were extracted for qualitative analysis from a debriefing meeting between professionals. RESULTS: Of the 157 persons with dementia, 81 (51.6%) received follow-up behavioural evaluations by March 2019. The average level of challenging behaviour was significantly reduced for 81 persons from baseline to their most recent follow-up evaluations. Facilitators included 'programme available for care managers', 'visualised feedback on professionals' work', 'affordable for providers and professionals' and 'media coverage'. Barriers included 'professionals from different organisations', 'unpaid work', 'operation requirement for municipalities' and 'conflict with daily benefit-oriented framework'. CONCLUSIONS: A follow-up evaluation was not fully achieved. Further strategies to address barriers may include the development of a benefit-rewarding scheme for interdisciplinary discussion meetings, an e-learning system capable of substituting training course portions and a cross-municipality training course.

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BACKGROUND: There are no studies on how the same psychosocial dementia care program is adapted to both in-home and residential care settings. OBJECTIVE: To evaluate the time investment required by professionals to implement a psychosocial dementia care program to manage neuropsychiatric symptoms. METHODS: A prospective observational study design was used. The program consisted of 1) a one-day training course, 2) three interdisciplinary discussion meetings in five months, and 3) a web-based tool for the continued assessment of neuropsychiatric symptoms. Care professionals implemented the intervention in in-home (19 in-home care management agencies and 14 multiple in-home service providers) and residential care settings (19 group homes and eight nursing homes) in Japan from October 2019 to February 2020. The level of neuropsychiatric symptoms for the participants was evaluated using the Neuropsychiatric Inventory (NPI: 0-144). The time investment was reported by participating professionals. A total of 125 persons with dementia were included at baseline. RESULTS: Neuropsychiatric symptoms were significantly decreased at the final follow-up in all types of providers (Cohen's drm = 0.44-0.61). The mean (SD) time required for the five-month implementation was 417.9 (219.8) minutes. There was a mean (SD) decrease of 8.6 (14.0) points in the total NPI score among the 103 persons with completed interventions. The time investment was significantly lower in in-home care management agencies than in group homes, and lower in follow-ups than at baseline assessment. CONCLUSION: The program implementation may incur a substantial time investment regardless of setting. An additional benefit scheme to reward the time investment would be helpful to encourage implementation until the follow-ups.

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OBJECTIVES: Sufficient protein intake can decrease undernutrition risk among community-dwelling older adults. This study aimed to increase community-dwelling older adults' daily protein intake with acceptable and applicable protein-enriched bread and readymade meals at home. DESIGN: Double-blind randomized controlled trial of 2 weeks. SETTING: Senior residential center in the Netherlands. PARTICIPANTS: Forty-two community-dwelling elderly residents (≥65 years) participated, with a mean age of 74.0 ± 6.9 years and mean body mass index of 28.5 ± 3.45 kg/m2. INTERVENTION: The intervention group (n = 22) received 5 protein-enriched readymade meals and plentiful protein-enriched bread during 2 weeks, whereas the control group (n = 20) received the regular equivalents during these 2 weeks. MEASUREMENTS: Food intake was assessed by using dietary food record-assisted 24-hour recalls and by weighing meal leftovers. Acceptability of the enriched products was assessed with product evaluation questionnaires and in-depth interviews. RESULTS: Mean intake of food products (g) and energy (kJ) did not differ significantly between the control and the intervention groups. Total daily protein intake in the intervention group was 14.6 g higher than in the control group (87.7 vs 73.1 g/d, P = .004). Expressed in g/kg body weight per day, protein intake was significantly higher in the intervention group than in the control group (1.25 vs 0.99 g/kg/d, P = .003). The enriched products were equally liked, scoring 7.7 of 10.0. The in-depth interviews with participants indicated high acceptability of the enriched products. CONCLUSION: This study showed that community-dwelling older adults' protein intake can be increased to recommended levels with highly acceptable and applicable protein-enriched products that fit into the normal eating pattern. Future studies should investigate whether this effect is maintained in the long-term among a frailer population.

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BACKGROUND: Many older adults are at risk of undernutrition. Dietitians play a key role in the management and treatment of undernutrition, but older adults have difficulties to comply with dietetic recommendations. This qualitative study investigated which barriers older adults experience in adhering to treatment for undernutrition. Current dietetic practices and older adults' experiences were studied, and the potential to use protein-enriched regular products in undernutrition treatment was investigated. METHODS: We interviewed 18 older adults who were under treatment for undernutrition, and 13 dietitians. Semi-structured interview guides were used, and all interviews were audiotaped and transcribed verbatim. The interviews were coded with qualitative analysis software NVivo9, followed by content analysis to formulate main themes. RESULTS: The interviews resulted in seven themes, which related to three main topics: barriers for treating undernutrition in older adults, current dietetic treatment, and new strategies to complement current treatment. Low awareness and a lack of knowledge regarding undernutrition, physical limitations, and loss of appetite were found to be major barriers for treating undernutrition in older adults. Dietitians said to focus mostly on increasing energy and protein intake by recommending the use of regular food products that fit the needs and habits of the patient, before prescribing oral nutritional supplements. Dietitians considered enriched regular products to be useful if they fit with the habits of older adults, the portion sizes were kept small, if products were easy to open and prepare, had good palatability, and were offered in a variety of taste and textures. CONCLUSIONS: Results from the interviews suggest that undernutrition awareness is low among older adults and they lack knowledge on how to manage undernutrition despite efforts taken by dietitians. Enriched regular products could enable older adults to better adhere to undernutrition treatment, provided that these products meet the needs and eating habits of older adults. If protein-enriched food products can replace regular, low-protein variants, older adults do not need to consume more, but can adhere to their usual pattern while consuming more protein.

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Undernutrition risk among community-dwelling older adults is partly caused by inadequate protein intake. Enriching readymade meals with protein could be beneficial in increasing protein intake. Moreover, reduced-size meals could suit older adults with diminished appetite. In this single-blind randomized crossover study with 120 participants (age: 70.5 ± 4.5 y, BMI: 27.2 ± 4.4 kg/m(2)), 60 participants consumed four beef meals and another 60 consumed four chicken meals on four different days, once per week. These meals were produced according to a 2 × 2 factorial design: the protein content was either ∼25 g (lower) or ∼30 g (enriched), and the portion size was either 450 g (normal) or of 400 g (reduced). Palatability evaluation, meal intake, and subsequent satiety ratings after 120 min were measured. No significant differences in palatability among meals were found. While absolute intake (g) of the normal-size meals was significantly higher than that of the reduced-size meals, the relative intake (%) of the served meals did not differ between the four meals. Both protein and energy intakes were significantly higher for the enriched meals, regardless of portion size. Protein intakes were 5.4 g and 5.1 g higher in the normal-size and reduced-size enriched beef meals, respectively, and 6.1 g and 7.1 g higher in the enriched chicken meals, respectively. The normal-size enriched beef meal and reduced-size enriched chicken meal led to slightly but significantly higher ratings of satiety than the non-enriched meals. Due to these mixed satiety findings, separate effects of meal-size reduction and protein enrichment could not be distinguished in this study. The intake findings show that palatable protein-enriched meals support higher protein and energy intakes in vital community-dwelling older adults during a single meal.

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