This study was an investigation of the complexities and challenges of change in a community-based aged care facility in Western Australia, to reveal the impact and influence of change on the community. It explored the impact of change on both the residents and the senior management team, as leaders of the organisation, and explored how change influenced the redevelopment process and future of the organisation. There is considerable literature on organisational change including the impact of change on the structure, function, process, workforce and leaders of the organisation. There is, however, little literature on organisational change within aged care communities, particularly with an emphasis on the complexities and challenges associated with change within an organisation that is both a business and a home for its residents. The study took the form of a participative action research study, occurring predominantly over two years (2002-2003) with some continuation into a third year (2004). The study had three phases and included two action research cycles and a critical reference group (CRG), comprising the senior management team (SMT) and researcher. It adopted a broadly qualitative methodology, using data from participatory observation and semi-structured interview; however, it did include quantitative and qualitative data from two 'quality of service' surveys for independent living residents and a staff satisfaction survey. The finding of this study are presented as a narrative account of the experiences of the participants. The study reveals that change associated with the redevelopment impacted on residents' wellbeing, described by them as quality of life. / The redevelopment process and associated change also emphasised the importance of communication and explanation with residents to understand elements of quality of life and to monitor and manage the impact of change. The findings of the study highlight the challenge faced by community-based aged care communities classified by government, the industry and the wider community as primarily not-for-profit, to balance financial accountability and social conscience. The perception of benevolence influenced the attitudes of residents and staff and made business accountability more difficult to explain and realise. The study reveals that change also impacted on the structure and function of the organisation as it built its capacity for change. It reshaped the relationship between the Board and senior management team (SMT), which was reported as an improvement in communication, work relations and leadership effectiveness. The development of the leadership team, being the senior management team, was influenced by change and the change process enabled this team to become a competent, confident, cohesive senior team, with a preferred leadership style. A further finding was the realisation of the value and appropriateness of the action research process. It provided tools and processes that were used to plan, act, analyse and reflect on the many aspects of organisational change and enabled the organisation, principally the SMT, to reflect on the impact and influence of change. The research process supported their development as leaders as well as the development of the team. The process of planning, collecting data, analysing data, reflection and action provided a structure and process that they continued to use in their management practices, as new situations continued to arise with the redevelopment process.

This grounded theory study investigated how registered nurses (RNs) managed problem-solving and decision-making in residential aged care facilities (nursing homes) in Western Australia. The outcome of the study was the substantive theory of situational positioning, the process used by the RN participants when they were trying to get things right .In-depth interviews were conducted with 25 purposefully selected registered nurses and nursing home management staff. The interviews were transcribed verbatim, and analysed using the constant comparative method. Other sources of data. guided by theoretical sampling. were selected documents such as government reports regarding aged care, and some field observations. Situational positioning was a process that involved physical. cognitive, emotional, and moral dimensions, and reflected how the RN participants acted and responded when dealing with situations at work. Situational positioning was conceptualised as occurring along two intersecting continua of behaviours, and these behaviours emerged from the data as four interrelated categories. Yielding and confronting represented the poles on a continuum of action-oriented behaviour, with being flexible and being rigid on a continuum that reflected more affective or attitudinal responses. The four categories that made up the positioning continua had both positive and negative meanings in relation to the actions and responses of the participants, depending on the particular situation. Yielding was a conceptual category that reflected participants' comments about stopping a particular action and trying something else or giving up completely and even leaving the situation. f he term confronting was used to describe participants' actions that were based on assertiveness that was seen as a constructive behaviour, or anger that tended to be non-productive. / Being flexible meant that the participants were responsive to changing situational variables, and this was usually seen as a desirable attribute of effective nursing practice in aged care. However, it could also mean being pliant and ready to compromise in order to get through situations when the participants realised that they would be unable to get things right. At the other end of the response axis, the term being rigid was defined as the opposite of being flexible, that is, having firmly fixed or set ways of responding. or a tendency to respond to situations in the same way in all circumstances. The basic psychosocial problem, being unable to get things right, had two properties. One property was temporal, in that the problem occurred when the participants were getting behind or running late because of having insufficient time. usually due to interruptions. The second property of the problem was more qualitative in that contextual and intervening conditions led the participants to feel that they were not doing things properly because of adverse conditions. Conditions that varied .situational positioning were those that led to the participants being unable to get things right, such as having insufficient time. working with unqualified carers. and trying to meet the differing expectations of various stakeholders. Situations that were easy for the participants to manage involved known routines and few, if any. interruptions. In those circumstances, si uational positioning was intuitive and the phases of recognising, prioritizing, and moving on were negotiated quickly. In more complex situations, or when significant interruptions occurred, the participants followed an alternative pathway, which involved recognising that something in the situation changed. then compromising. that is. choosing a new course of action. / Compromising required tolerance, as the participants adjusted their expectations of what could be achieved in the circumstances. Repositioning then occurred belore they moved on to the next task or to the end of their shifts. Moving on. the third phase in the process, involved persevering as they continued trying to get things right. The adverse conditions that prevailed in nursing homes during the time of this study impeded nursing practice and the delivery of consistently good standards of care for all residents. Situational positioning enabled the participants to persevere in their efforts to try to get things right, but their capacity to maintain the effort was eroded by the apparently unrelenting nature of the adverse conditions that existed in nursing homes. The main conclusion of this study was that the RN role in nursing homes in Western Australia was ill-defined, and inefficient in terms of best utilisation of nursing time. Recommendations included a review of the RN role in aged care and implementation of strategies that would enable aged care RNs to focus on their clinical roles.

The need to address the issue of quality in aged care service provision in Australia has received increasing emphasis in recent decades. Particularly since the 1980s, the federal government has played a key role in ensuring that this is the case through the implementation of various reforms and regulatory strategies. In 1998, the national standards monitoring system which had been in place since the mid 1980s was replaced with a new system based on an accreditation model. In contrast to the former system which was wholly controlled by government and involved one-off inspections by government standards monitors, responsibility for managing the new system has been devolved to an independent body, the Aged Care Standards and Accreditation Agency. One of the Agency's primary functions is to assess compliance with the accreditation standards. A key component of the new system is its emphasis on continuous improvement which has been incorporated into the accreditation standards. As a consequence, the new system requires a much greater level of involvement and commitment by providers than previously. In order to continue receiving government funding all facilities had to be accredited by January 1st 2001. This study represents an evaluation of the accreditation system based on the views and experiences of service providers in Western Australia. It explored a number of issues relating to the basic philosophy and principles underlying the new system, the implementation process, the accreditation standards that are used as a basis for assessing service quality and the overall impact of the system on providers. It also sought providers' views about the strengths and limitations of the system and any areas in need of change or improvement. A descriptive design, using in-depth interviews as the method of data collection, was adopted for the study. / Participants from three levels of service provision, namely, facilities, organisations and peak bodies were selected on a stratified purposive basis. A total of 45 informants were interviewed. The findings indicated that, overall, as a regulatory approach the accreditation system was generally supported by providers and was regarded as having a number of positive features, particularly in comparison to the previous system. At the same time a number of concerns were identified. These related in particular to the assessment process, specifically the lack of consistency amongst assessors and the self assessment tool, and to the extent of information and guidance provided by the Agency. Concerns regarding the latter's role in relation to, and extent of independence from, the federal government were also identified. The study also found that the introduction of the system had impacted on providers in a variety of ways, both positive and negative, but particularly in terms of the demands on staff and financial resources. A number of 'broader' level factors, such as funding, nursing shortages and other often competing demands (e.g. assessing residents according to the Resident Classification Scale) were also felt to be impacting on providers' capacity to meet the requirements of the system. These concerns, along with concerns about the way in which the system would develop in the future, appear to have created a degree of uncertainty and in some cases apprehension amongst many providers. Although this study has focused on the experiences of Western Australian service providers, evidence from other reviews of the accreditation system where providers' views have been sought has indicated a widespread similarity in perceptions. This suggests, therefore, that there is a need for further review and refinement of certain aspects of the system as it moves into the second round.

The Residential Aged Care (RAC) industry is the fastest growing sector of the health care industry in Australia, particularly with the needs of people aging eighty five years and over consuming most health care services (Productivity Commission, 2006). This thesis examines the staffing efficiency challenge that is facing the RAC industry in Australia, from the facility managers' perspectives. Staffing efficiency is a crucial component in the success of this industry that is labour intensive, delivering complex services twenty-four hours per day and seven days per week. By achieving staffing efficiencies, facility managers would minimise labour cost expenditures; thus, ensuring sustainability and growth of their organisation in the long run. The literature reviewed revealed limited number of scholarly reviews about staffing efficiencies conducted in Australia. Nevertheless, it highlighted a number of available staffing approaches available overseas which could be of promising results if they were adopted to suit the Australian industry and its operational systems. This thesis explores the prospects of RAC facility managers adopting 'alternative' or 'new' staffing methods in their facilities as one solution for this staffing challenge. In this study, the researcher refers to alternative or new staffing methods as staffing methods that are not currently utilised in the staffing of RAC facilities in Australia. Using an Interpretivist research paradigm, 18 semi-structured interviews were conducted with the participating RAC managers in their work environment. During the interviews, a sample alternative staffing tool, developed prior to the study, was displayed. The data generated were analysed in the context of the RAC industry's environment, operational challenges, and through the theoretical implication of neo-liberalism. This theory provided a vehicle for the analysis of the data generated on staffing within the context of Australia's current economic policies. The generated data revealed little chance of such adoption reflected in a number of findings including: 1) Participants' lack of interest in adopting alternative staffing methods despite their comments on the unsuitability of current tools. 2) Overdependence of the industry on cost cutting measures and monetary performance indicators. 3) Lack of incentives for the adoption of change and 4) Lack of preparedness of RAC facility managers for such change. Thorough analysis of the findings revealed misinterpretation of free-market principles in the currently utilised staffing tools, which links demand of service to the number of individuals requiring care on one hand, and the supply of services available to the number of staff rostered to provide the care, on the other hand. The application of such a principle on the RAC industry is questionable, particularly with the inconsistency in the elderly residents' care needs and the staffing skill mix. A new staffing approach that uses the care required by the elderly individuals and the staffing skills available in the facilities as the basis for the demand and supply principles will provide a plausible solution for facing the staffing challenge. A joint venture between the Australian government and the RAC industry to encourage the adoption of such alternative staffing approach is the recommended way forward for improving staffing efficiencies.

No description available.

An aging population is one common challenge faced by many developed countries including Australia. The Australian government has realised that the existing healthcare system must be improved to provide better support longer-term for the healthcare needs of this population. This research examines one such opportunity by suggesting a reform on how the care needs of residents living in Australian residential aged care facilities (RACF) are assessed. A recent study has shown that the current assessment system, known as the Residential Classification Scale (RCS), is subjected to high administrative procedural overhead costs and significant deviations in assessment results. This thesis documents a technical feasibility study of a novel method aimed to solve issues related to the time demands and subjectivity of the RCS through the design and implementation of a Wireless Sensor Network (WSN). This WSN is engineered to unobtrusively collect data from wireless sensor nodes either embedded in the RACF environment or attached to the resident??s body. The collected data can be potentially used to provide automatic and accurate care level assessments for the resident. The methodology of preparing and conducting the experiments to prove the hypotheses is justified and described, including the experimental instruments and procedures involved. The results show that this WSN surpasses similar research systems in terms of its application scale, the number and types of sensor nodes involved and the complexity of its hardware and firmware architectures. The major contributions of this thesis are: ?? The WSN developed satisfies certain technical requirements to be declared fit for use in a mock Australian RACF. ?? The WSN provides high sensor detection accuracies (between 88% and 100%), superior location tracking capability (94.75%) and activities of daily living inference capability over similar studies. Opportunities for further improvements of this WSN include: ?? Fine tuning the detection accuracy of Passive Infra-red (PIR) motion sensors. ?? Minimising the down time of the sensor nodes due to firmware memory leak. ?? An extra location tracking mechanism to improve location accuracy determination.

An aging population is one common challenge faced by many developed countries including Australia. The Australian government has realised that the existing healthcare system must be improved to provide better support longer-term for the healthcare needs of this population. This research examines one such opportunity by suggesting a reform on how the care needs of residents living in Australian residential aged care facilities (RACF) are assessed. A recent study has shown that the current assessment system, known as the Residential Classification Scale (RCS), is subjected to high administrative procedural overhead costs and significant deviations in assessment results. This thesis documents a technical feasibility study of a novel method aimed to solve issues related to the time demands and subjectivity of the RCS through the design and implementation of a Wireless Sensor Network (WSN). This WSN is engineered to unobtrusively collect data from wireless sensor nodes either embedded in the RACF environment or attached to the resident??s body. The collected data can be potentially used to provide automatic and accurate care level assessments for the resident. The methodology of preparing and conducting the experiments to prove the hypotheses is justified and described, including the experimental instruments and procedures involved. The results show that this WSN surpasses similar research systems in terms of its application scale, the number and types of sensor nodes involved and the complexity of its hardware and firmware architectures. The major contributions of this thesis are: ?? The WSN developed satisfies certain technical requirements to be declared fit for use in a mock Australian RACF. ?? The WSN provides high sensor detection accuracies (between 88% and 100%), superior location tracking capability (94.75%) and activities of daily living inference capability over similar studies. Opportunities for further improvements of this WSN include: ?? Fine tuning the detection accuracy of Passive Infra-red (PIR) motion sensors. ?? Minimising the down time of the sensor nodes due to firmware memory leak. ?? An extra location tracking mechanism to improve location accuracy determination.

Bakgrund: Människor blir idag allt äldre och demenssjukdomar förväntas bli ett växande problem. Inget bot finns men symtom kan hämmas genom farmakologiska behandlingar, dock ofta med flera biverkningar. Personer med demenssjukdom utvecklar ofta beteendeförändringar som kan vara svåra att bemöta för vårdgivare. I och med sjukdomens karaktär och olika förekommande symtom är en god och personcentrerad vård att föredra för att främja vårdtagarens delaktighet och integritet. Syfte: Att sammanställa och beskriva aktuell forskning om vilka effekter musik har som omvårdnadsåtgärd inom demensvård. Metod: Studien är en litteraturöversikt baserad på (n=18) artiklar från tio länder. Databaserna CINAHL, Pubmed och Web of Science användes och de artiklar som inkluderats är av kvantitativ ansats (n=12), kvalitativ ansats (n=5) samt Mixed method (n=1). Efter analys har skillnader och likheter i artiklarnas resultat skapat teman och subteman. Resultat: Musikinterventioner hade positiva effekter, bland annat gällande BPSD, kognitiva funktioner och psykofarmakologisk behandling. Musik kunde även bidra till en ökad samhörighet mellan vårdgivare och personer med demenssjukdom. Anhörigas och vårdgivares uppfattningar om musikens effekter var blandade, åsikterna var dock samstämmiga om att musik bör användas som omvårdnadsåtgärd. Slutsats: Musik har en positiv påverkan på personer med demenssjukdom och BPSD genom att fungera som en personcentrerad åtgärd inom omvårdnaden och bör implementeras mer. / Background: People are growing older and dementia is expected to become an increasing problem. There is no available cure, but symptoms can be inhibited by pharmacological treatments, often with side effects. People with dementia often develop behavioral changes that are difficult to respond to for caregivers. With the nature of the disease and the different symptoms occuring, a person-centered care is preferable to promote participation and integrity. Aim: To conclude current research on the effects of music in the nursing care of people with dementia. Method: A literature review based on (n=18) articles from ten countries. Quantitative (n=12), qualitative (n=5) and mixed method (n=1) articles were used from CINAHL, Pubmed and Web of Science. After the analysis, differences and similarities in the articles created themes and subthemes. Results: Music interventions proved to have positive effects, regarding BPSD, cognitive functions and psychopharmacological treatment. Music could contribute to increased association between caregivers and people with dementia. The caregivers and family members' perceptions of the effects of music were mixed, however, the views were consistent that music should be used as a nursing measure. Conclusion: Music has a positive impact on people with dementia and BPSD by acting as a person-centered nursing measure and should be implemented more.

Through a case study about the impact of IT adoption in a residential aged care organisation, this thesis examines the increasing pressure for service integration as mainstreamed through reform policies. Specifically, the research investigates the role of IT in facilitating the 1997 aged care reform agenda of 'ageing in place' focusing on the levels of transformation from the policy context to the organisational/management context, and to the context of service provision by care staff. A single embedded case study (Yin, 1993) is used in order to meet the general objective to capture the dynamics of the impact of ageing in place in the three social contexts. The research is informed by social constructionism, a theoretical framework that emphasises the significance and effects of language in shaping social realities (Ainsworth, 2001; Hosking, 1999). The framework, therefore, justifies the qualitative analysis of both written (i.e., policy documents) and spoken (i.e., interviews with staff) texts to address meaning in relation to context. Changing technologies can result in altered societal structures (Betz, 2003) at all levels, from the very complex to the very basic. As such, it is important to understand a few basic premises of technology. First, technology is a human invention to improve the well-being of society (Ayres, 1996). Consequently, technological inventions that improve the quality of life are seen by people as a necessity for modern living. In the case of ageing, modernisation and technological advances effectively resulted in people becoming healthier and living longer (Department of Health and Aged Care [DHAC], 2000). Second, technology is a human means to control nature (Betz, 2003). As such, technological advances can be seen as a modernising process of predicting and regulating the effects of the trends existing in the environment, such as ageing. Ageing in the twenty first century presents a challenge to government's development policies because ageing is depicted as a steady force with a long-term economic impact (Johnson, 1999). Third, a technology becomes powerful when it is sponsored by the market (Betz, 2003; Hughes, 1983). Unless a technology is backed by business, it lacks the influence on a large scale. Fourth, technology is used to enable change. By using IT, governments, business and the community are co-operating through a paradigm similar to the business sector. As a result, the service environment is shifting towards more business-like approaches. To sustain the changes brought by a different paradigm and modes of operation, the rhetoric of technology is employed. Therefore, the purpose of the study is to investigate the use of IT in processes of organisational adaptations to reform, which requires the examination of: a) specific meaning of IT as used in long-term care policies for older people since the last structural reform, b) the rationale behind the introduction of a new IT system into a residential care organisation, and c) the meaning of IT as articulated by care staff who have experienced a change in technology. The first paper represents a rhetorical analysis at the macro or policy level. There is a significant influence of a global political actor in developing proactive strategies on ageing, which results in a new, multi-organisational approach in delivering government-subsidised services, such as residential care. Three key institutional texts were selected to represent international to local policy development since the time ageing became a global concern. Since then, ageing is also viewed as a human rights issue. Using Burke's pentad, an analytic framework to analyse rhetoric in texts (Stillar, 1998), these institutional texts are seen to employ the rhetoric of 'technology for sustainability' to justify changes to policy approaches that seek long-term viability. Technology, in the name of sustainable development ensures support for economic growth, which balances the long-term effects of population ageing. The existence of a global force, such as population ageing, allows the intervening powers of the UN in mainstreaming ageing into development policies. Accordingly, it initiates corresponding actions at national (Australian Commonwealth Government) and state (Queensland Government) levels. IT is a medium of communication, knowledge transfer, and standard practice at these levels of actions. The second paper represents a qualitative analysis at the meso or organisational level. This paper explores the cogent rationale in the introduction of a computer-based, care documentation system in a large residential aged care organisation. Twenty two staff, from every level of the organisation, were interviewed to get an insight into the role of IT in substantive changes to organisational structure and modes of service provision. Responses from staff indicate external and internal influence that pressured the organisation to change. In the bid to sustain the future of aged care, the industry is changing through the introduction of new structure of service delivery. The Aged Care Structural Reform instigated a shift towards sustainable service provision that is consumer-driven, with a fixed cost compliance mechanism and performance criteria that are tied to funding. Facing the requirement for evidence to corroborate funding, a residential care organisation changed its structure of service delivery by introducing a new strategic direction. IT is part of this new strategic direction, planning, and operations of a changed service environment. The third paper represents a qualitative analysis at the micro or individual level to examine the impact of IT at frontline service delivery. This study is also based on interviews with twenty-two staff, across the organisational structure; however, this time the focus is more on staff who are involved in providing direct care to older residents at the organisation. The reason behind this is that IT has always been a management tool which handles management priorities such as financial planning and performance monitoring. The themes arising from the interviews indicate discord at the level of service delivery from the introduction of a new technical system. It also points to the idea that staff generally refer to ethical ideas and future promise of the new system. In summary, these three papers attached to this thesis support the notion that the meaning of technology is socially constructed. First, technology in the aged care sector has particular reference to improving or enhancing the well-being of older people, and in this case, the provision of high quality services that fulfil the needs of older people. Second, IT has an important role in meeting the evidence-based requirement, such as in the use of information in manipulating the use of resources required for the ageing population. Third, the meaning of IT is conceived from the context requiring its use such as the need to use resource efficiently to ensure long-term sustainability, which were emphasised in the last reform. Fourth, IT is used to enable structural changes in organisations to implement generic practices originated from the business sector, requiring the use of strong rhetoric such as balance and future. The limit of this case study is that these dimensions of technology can only be applied to the specific context of aged care and is not generalisable to other political contexts. However, the strength of the study rests on the macro-, meso- and micro-analysis of the meaning of technology. Therefore, future studies should investigate and compare the dimensions of technology in other contexts.

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.