Rapid increases in population ageing and the associated rise in the prevalence of dementia have created many challenges for the care of older people with dementia. As the majority of people now living in residential aged care facilities (RACFs) now have dementia, the need to maximise the quality of life for this group is increasingly recognised. While such issues have attracted research and policy attention in recent years, the evidence base for practice in dementia care is still underdeveloped. The need for more effective therapeutic interventions to improve the quality of life for older people with dementia is recognised, particularly those living in RACFs. The use of pets is one example of recent attempts to help create a more home-like environment and dog therapy is available in many facilities. Well designed research to demonstrate whether it actually has a positive impact on residents’ quality of life is lacking. This study is the first reported randomised controlled trial investigating dog therapy for people with dementia. Fifty-five older people with mild to moderate dementia living in three residential aged care facilities in the Greater Brisbane area participated in this study. The goal was to identify whether dog therapy accrued any benefits to residents’ well being and compare the benefits, if any, with human-only therapy intervention. The main hypothesis was that dog contact delivered in a small group recreational therapy format would have a beneficial effect on the well being of participants. It was additionally hypothesised that prior and current positive relationships with dogs would be related to improved outcomes of dog therapy and support a human-animal bond explanation of relationship development with the therapy dog(s). Participants were randomly assigned into two groups within each facility: The dog therapy group and a human-only therapy group. Session plans were structured according to a recreational therapy format. Three therapy dogs were used (a miniature Poodle, a Staffordshire Terrier and a German Shepherd Dog) with one dog present at any dog therapy session A before-and-after design was used with concealment of participants at allocation. Mixed methods were used including a panel of seven validated psychometric instruments, an observational measure and a series of four novel questionnaires, dogs for older groups with Alzheimer’s (DOGA), developed de novo specifically to investigate the effects of dog therapy on participants within this study. Measures of mood, quality of life, health and psychosocial functioning, collectively referred to as well-being, detected benefits accruing to dog therapy participants compared with human-only therapy that approached significance (p = .056) with a large effect size (partial eta squared 16.6%). A different measure of mood and apathy showed similar improvement for participants of both therapy types trialed with analyses of a smaller dataset (n = 36) revealing an overall highly significant result (p=.008) and large effect size (partial eta squared = 25.6%) for all participants. To explore the perceptions of care staff to the dog therapy intervention, a self-complete semi-structured questionnaire was completed by a sample of 21 from two of the study facilities. Content analysis revealed that staff overwhelmingly supported dog therapy with a total of 84 comments about benefits and 22 about risks. Responses were categorised and then linked into emergent themes: a temporal dimension, sense of self and increased opportunities for self expression. The opportunity provided by the therapy dog for accessible caring physical contact for participants was identified as important. General recreational therapy goals such as improved mood, reminiscence and increased levels of conversation were reported by staff to continue beyond interventions. The observed risks were: confusion over dog ownership, subsequent worry about losing the dog after sessions, jealousy over the therapy dog and one participant did not enjoy the small group format. Participants described their experiences of contact with the therapy dog as “like” above “attached”. Personal preference explanations are therefore supported, rather than “attachment”, to explain outcomes for participants. This suggests the psychosocial approach has greater relevance here than human-animal bond explanations. Effects of previous dog attachment on outcomes were inconclusive but there was some evidence that participants’ relationship with the therapy dog(s) influenced outcomes, though the nature of that relationship has not been clarified. Recommendations from the study findings are that dog therapy be conducted for people with mild to moderate levels of dementia in groups of 3-11 for a duration of around 10 weeks with sessions for 30 minutes held once or twice weekly and according to a standard format. Opportunities for participants to touch, hug and interact directly with the therapy dog should be maximised without compromising dog welfare. The findings suggest that respect for the personhood of participants is important to the success of the therapy types trialled, which further supports psychosocial therapies involving contact with people or live animals for use with people with dementia over those that minimise or exclude it.

Australia and many other developed communities are ageing rapidly, placing a strain on the delivery of health services. This thesis examines the use of innovative health services management coupled with information and communication technology (ICT) to more efficiently deliver services to disabled older people in the hospital, community and residential care. The hypothesis explored is that ICT can provide clinical services to older people in poorly serviced communities and groups, thus extending the influence and capabilities of specialist health care professionals. The relevance of these studies is predominantly for those people who live outside the metropolitan regions, particularly in remote and rural communities, and also for those frail older people, who because of disability, are unable to travel to specialist health services. There are a series of studies presented in this thesis which have all been published. They have demonstrated that in a community and rural setting, ICT use in the assessment and management of geriatric syndromes such as dementia is valid and practical. This included the validation of commonly used assessment tools via Telehealth. A Telehealth protocol for assessment of Alzheimer's Dementia (AD) was developed and published. The use of ICT to link health services clinical and administrative data for determining stroke outcomes and disability has been evaluated and a resource utilization prediction model developed. Finally, in residential care a survey and a qualitative study of poor uptake of ICT services in hostels and nursing homes revealed insights into ICT perception by the older people in care facilities and their professional staff. The implications and future development of these studies have been discussed, especially barriers to increased uptake of ICT, cost comparisons and the potential of future technologies such as video conferencing mobile phones.

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This thesis argues that truth-telling in high level (nursing home) aged care is a undamentally important aspect of care that ought to reside equally alongside instrumental care. The health of the resident in a nursing home, as with individuals in other care contexts, is directly linked to care provision that allows the resident to be self determining about their care and thus allows them to make reasonable choices and decisions. This qualitative study explores the meaning of truth-telling in the care providerresident dyad in high level (nursing home) aged care. Grounded within the epistemology of social constructionism and the theoretical stance of symbolic interactionism, this study relied on oral and written text from care providers (personal care assistants and registered nurses) and residents. Thematic analysis of data relied on practices within grounded theory to determine their understanding and the conditions and consequences of their understanding about truth-telling in the nursing home. Through an understanding of the relationship-role-residency trinity, truth-telling in high level (nursing home) care comes to be understood. It has been determined that the link between truth-telling and the nature of the care provider-resident (and residents' families) relationship is that both personal carers and nurses in this study premise their understanding of truth disclosure on knowing a resident's (and resident's family's) capacity for coping with the truth and therefore catering for the resident's or family's best interests. The breadth and depth of this knowing and how the relationship is perceived and described determine what care providers will or will not tell. That is, the perceptions both personal carers and nurses have about the relationship - how they describe themselves as 'family like', 'friend' and 'stranger', has implications for the way disclosure operates and is described. Additionally, how care providers perceive and understand their role determines what care providers will or will not tell. That is, the perceptions both carers and nurses have about their own and each other's role - how they describe themselves for example as 'hands-on' carer and 'happy good nurse' has implications for the way disclosure operates and is described. Furthermore, care providers' meaning and understanding of truth-telling in aged care is not possible in the absence of an appreciation of how the care providers give meaning to and come to understand the care circumstance - residency, the aged care facility, the nursing home. That is, the perceptions both personal carers and nurses have about the aged care facility - how they describe residency as 'Home away from Home' (and what this means), as a place of little time and a plethora of situations have implications for the operation of truth-telling as a whole. Recommendations from the study include the implementation of a telling audit to better serve the truth-telling preferences of residents and the reorientation of care practices to emphasise affective care (talk rather than tasks). Furthermore, it is recommended that changes occur to the care provider roles, that care providers define themselves as facilitators rather than protectors, and education be ongoing to improve communication with and care of residents with dementia and those dying. Finally, the language of residency as 'home' needs to capture an alternate philosophy and attendant practices for improved open communication.

Home First is an Ontario transition management approach that attempts to reduce the pressure on hospital and Long Term Care (LTC) beds through early discharge planning, the provision of timely and appropriate home care, and the delay of LTC placement. The purpose of this qualitative descriptive study was to obtain descriptions from South Eastern Ontario Home First clients and their family caregivers of their experiences with and thoughts about care transitions, the provision of care, and the Home First approach. The goal was to enable insight into the Home First approach, care transitions, and the provision of care through access to the perspectives of study participants. Nine semi structured interviews (and one or more follow-up calls for each interview) with Home First clients discharged from hospitals in South East Ontario and their family caregivers were conducted and their content analyzed. All participating Home First clients were pleased to be home from hospital and did not consider LTC placement a positive option. All had family involved with their care and used a mix of formal and informal services to meet their care needs. Four general themes were identified: (a) maintaining independence while responding (or not) to risks, (b) constraints on care provision, (c) communication is key, and (d) relationship matters. Although all Home First clients participating in the study were discharged home successfully, a sense of partnership between health care providers, families, and clients was often lacking. The Home First approach may be successfully addressing hospital alternative level of care issues and getting people home where they want to be, but it is also putting increasing demands on formal and informal community caregivers. There is room for improvement in how well their needs and those of care recipients are being met. Health professionals and policy makers must ask caregivers and recipients about their concerns and provide them with appropriate resources and information if they want them to become true partners on the care team. / Thesis (Master, Rehabilitation Science) -- Queen's University, 2013-05-23 16:10:53.323