Knowledge, attitude, and practices of healthcare professionals and formal caregivers towards non- pharmacological intervention for the management of behaviours and psychological symptoms in Australian aged care residents with dementia: A cross-sectional survey

doi:10.21203/rs.3.rs-3992245/v1

Download PDF

Research Article

Knowledge, attitude, and practices of healthcare professionals and formal caregivers towards non- pharmacological intervention for the management of behaviours and psychological symptoms in Australian aged care residents with dementia: A cross-sectional survey

https://doi.org/10.21203/rs.3.rs-3992245/v1

This work is licensed under a CC BY 4.0 License

Journal Publication

published 27 Oct, 2024

Read the published version in Clinical Gerontologist →

Version 1

posted

You are reading this latest preprint version

Background: Non-pharmacological interventions (NPIs) are the first line options in the management of behaviours and psychological symptoms of dementia (BPSD). However, NPIs are not frequently used in Australian residential aged care homes (RACHs). This study aimed to assess the knowledge, attitude and practice of the healthcare professionals and formal caregivers towards NPIs for the management of BPSD in Australian RACHs.

Method: A cross-sectional, online survey was administered via Qualtrics platform. Information on the knowledge, attitude, and practice towards 25 common types of NPIs was collected from a sample of healthcare professionals and formal caregivers in Australia. Kruskal-Wallis along with Dunn’s post hoc test was used for comparisons among the professions.

Results: Responses from 96 respondents were analysed. Most of the respondents were females (80.2%). Of the 25 types of NPIs assessed, 50- 65% of respondents reported that they were extremely familiar with 15 types of NPIs. About 66% of respondents believed that NPIs are more useful than medicines, and 81% reported NPIs should be tried before medicines. However, only validation therapy was always practiced by more than 50% of the respondents. According to Bloom’s cut-off point, 67% had good knowledge, but only 27% had positive attitude and 34% had good practice towards NPIs. There was moderate correlation between the overall knowledge and practice score (r= 0.68, p < .001) as well as attitude and practice (r = 0.43, p < .001). The mean rank of the knowledge, and practice scores for most NPIs were lower for formal caregivers and allied health professionals than nurses, but the difference was statistically significant for only a few NPIs. Nurses exhibited higher total mean ranks for knowledge, attitude, and practice compared to formal caregivers. However, only the difference in attitude score rankings was statistically significant (p = .016).

Conclusion: Knowledge, attitude, and practice towards NPIs varied among the professions. The knowledge level was good for two thirds of respondents, but less than one third had positive attitude and one third of respondents had good practice. Education and training focusing on the knowledge and attitude are important to bring about practice change.

dementia

residential aged care homes

non-pharmacological

BPSD

caregivers

nurses

physicians

Dementia is an overarching term for various progressive neurodegenerative disorders that affect thinking, memory, language, behaviour, executive functions, and performance of daily activities [1]. Globally, there were 57.4 million people living with dementia in 2019 and this magnitude is projected to increase, reaching 152.8 million in 2050 [2]. In Australia, there was an estimated 401,300, people with dementia in 2022 with this figure projected to be 849,300 by 2058 [3]. More than 68% permanent residents of Australian residential aged care homes (RACHs) had moderate to severe cognitive impairment including dementia [3].

Behaviours and psychological symptoms of dementia or BPSD are defined as “a group of symptoms of disturbed perceptive thought content, mood, or behaviour that include physical aggression, screaming, restlessness, agitation, wandering, culturally inappropriate behaviours, sexual disinhibition, hoarding, cursing, shadowing, anxiety, depression, hallucinations, and delusions” [4]. BPSD management is often considered the most difficult and bothersome aspect of dementia care [5].

Studies have shown a high prevalence of BPSD among residents with dementia (RWD) in RACHs. A systematic review found that the weighted prevalence of BPSD among RWD was 82% over a follow up period of 4 months to 2 years [6]. Two studies conducted in Australian RACHs reported a point prevalence of BPSD among RWD to be 82% [7] and > 90% [8].

BPSD significantly affect the life of the RWD by increasing frequent hospitalisation, early institutionalisation, exposing to the adverse effects of medications, and augmenting a caregiver burden among RACH staff [9, 10]. BPSD affect not only the quality of life of RWD and care staff [11], but also place an economic burden on the RACHs. For example, a recent study showed that agitation was associated with 44% increase in the total annual care cost of RACHs [12].

Currently, NPIs are the gold standard for BPSD management [13, 14]. A meta-analysis assessing the effectiveness of NPIs for the management of BPSD reported an effect size of 0.34 [15], which is even higher than that of antipsychotic medications [16]. Several studies indicated that NPIs such as environmental or noise control, Montessori programs, spiritual practice, aromatherapy practice, and music therapy were found to be effective in the management of BPSD [17–21]. Additionally, dementia clinical guidelines recommend NPIs as the first choice, and only if these NPIs fail after adequate trial, psychotropics are then indicated as a last resort therapy for the management of BPSD [22, 23].

Despite available evidence on the effectiveness of NPIs, they are still reportedly not commonly used in Australian RACHs [24, 25]. In contrast, psychotropics were more commonly prescribed (i.e., 58%) [7]. In Australia, the care of RWD is also a significant concern [26], and a case study from the Royal Commission into Aged Care Quality and Safety found that family members of people with dementia refused repeated request from aged care staff and medical professionals to consent to psychotropic prescribing [27]. Thus, assessing the knowledge, attitudes, and practices of healthcare professionals and formal caregivers regarding NPIs is essential for bringing guidelines recommendation into dementia care practice in Australian RACHs. Therefore, this study aims to evaluate the knowledge, attitudes, and practices of healthcare professionals and formal caregivers in Australian RACHs concerning the use of NPIs for managing BPSD.

A cross-sectional design was employed in this study. We initially adapted the knowledge and practice survey from Cohen-Mansfield et al. which consists of 30 NPIs [28]. From this survey, four knowledge questions covering 25 NPIs, four practice questions containing the same 25 NPIs included in the knowledge questions, and two attitude questions were used [28], and 14 attitude questions were derived from the Theoretical Domains Framework (TDF)-based questionnaire published by Huijd et al [29]. This results in a preliminary version of a survey with a total of 24 questions.

Our survey questionnaire adopted a Likert-type scale to measure the knowledge, attitude, and practice towards NPIs and was developed using Qualtrics platform (version: March 2023). Prior to administration to study participants, the validity, understandability, and flow of the survey was piloted and reviewed by a total of seven people independent to the research team and target respondents. Pilot testers included two dementia consultants (one registered nurse and one physiotherapist) and five researchers (four pharmacy and one public health background).

The final survey consisted of 31 questions and contained four parts- Part I: Demographic information (seven questions), Part II: Knowledge (four questions which contain 25 NPIs), Part III: Attitude (16 questions) and part IV: Practice (four questions which contain 25 NPIs). For knowledge of NPIs, all respondents were asked to rate the level of their awareness with the listed NPIs using the following scale: “1 = Not at all familiar, 2 = Slightly familiar, 3 = Somewhat familiar, 4 = Moderately familiar, 5 = Extremely familiar”. For the practice domain, all respondents were asked to rate the frequency of using NPIs in practice using the scale: 1 = Never, 2 = Rarely, 3 = Occasionally, 4 = often, 5 = Always. For attitude towards NPIs for BPSD, respondents were asked to rate extent of agreement to 16 statements related to NPIs, using a scale of 1 = Strongly disagree, 2 = Somewhat disagree, 3 = Neutral, 4 = Somewhat agree, 5 = Strongly agree.

Sample and setting

This study was conducted in Australian RACHs using convenient sampling and snowballing technique. The target participants were physicians, nurses, formal caregivers, and allied health professionals (e.g., physiotherapist, occupational therapist) who were involved in the management of BPSD at RACHs in Australia. Caregivers in this paper represents formal (paid) caregivers working at RACHs.

Data collection and analysis

Data collection

The survey was distributed and available online from 6 March to 31 August 2023. The Qualtrics-based questionnaire was disseminated to potential participants through different mechanisms including professional association newsletters, aged care providers, professional networks, and through social media. Participants were asked to participate in the survey by answering 31 online anonymous questions.

Data analysis

Data was exported from the Qualtrics platform as an SPSS file after being cleaned, and checked, and then analysed using SPSS version 28 [30]. Descriptive statistics were used to describe the demographics of study participants. The frequency of scores was displayed in the form of bar chart for the knowledge, and practice questions, and tabulated for attitude statements. Since the Shapiro-Wilk test indicated that the data were not normally distributed, we used the Kruskal-Wallis test [31–34] to compare mean rank scores for knowledge, attitude, and practice statements grouped by profession. Then, Dunn’s post hoc test adjusted for by Bonferroni was employed for pairwise comparisons. Spearman correlation conducted to determine the correlation between mean knowledge, attitude, and practice score for study participants. Free text responses were analysed manually, and themes were coded and generated by the first author and then reviewed and confirmed by other authors.

We used Bloom’s cut-off point to categorise the level of knowledge, attitude, and practice of healthcare professionals and caregivers regarding NPIs for managing BPSD as follows: scores of ≥ 80% was marked as good knowledge, positive attitude, and good practice, score of 60–79% was categorised as moderate knowledge, neutral attitude, and fair practice, and scores of less than 60% was considered as low knowledge, negative attitude, and poor practice, respectively [35–41]. Familiarity rating of respondents to each of the 25 NPIs for the four knowledge questions ranged from ‘not at all familiar’ to ‘extremely familiar’. For the analysis purpose, the scale was assigned an ordinal rating score in the range of 1 to 5, where 1 = ‘not at all familiar’, and 5 = ‘extremely familiar’. For each respondent, the knowledge score would range from a minimum of 25 to a maximum of 125 points. Therefore, based on bloom’s cut-off point, the total knowledge score was categorised as ≥ 80% (≥ 100 points) for good knowledge, 60–79% (75–99 points) for moderate knowledge, and < 60% (< 75 points) for low knowledge. Similarly, for attitude responses ‘1’ was assigned for strongly disagree and ‘5’ for strongly agree. For each respondent, the total attitude score would range from a minimum of 16 to a maximum of 80 points. Therefore, the total attitude score was categorised as ≥ 80% (≥ 64 points) for positive attitude, 60–79% (48–63 points) for neutral attitude, and < 60% (< 48 points) for negative attitude. To determine the frequency of agreement to the attitude statement, the five scale responses were combined and reclassified into three categories: disagree, neutral and agree. Lastly, practice rating response to each of the 25 NPIs under the four practice questions ranged from ‘never’ to ‘always’. For the analysis purpose, 1 was assigned for ‘never’ and 5 for ‘always’ responses. Therefore, the total practice score was categorised as ≥ 80 (≥ 100 points) for good practice, 60–79% (75–99 points) for fair practice, and < 60% (< 75 points) for poor practice.

Reliability

In this study, we assessed the internal consistency (IC) of the survey items by using Cronbach’s alpha coefficient. Accordingly, the reliability of the knowledge, practice and attitude statements were .952, .949 and .757, respectively. Generally, a Cronbach’s alpha score of greater than 0.7 is deemed acceptable [42, 43].

A total of 96 respondents completed the survey either in whole or in part. Figure 1 presents a flowchart diagram for the respondents.

Figure 1: Flowchart diagram for survey respondents

Respondents’ demographic details were summarised in Table 1. Survey respondents were mostly nurses (38.5%), aged 35–54 years old (41.7%), and predominantly female (80.2%). More than half of respondents were from South Australia (61.5%) and affiliated with not-for-profit RACHs (62.5%). Half (50%) of the respondents worked in metropolitan areas, and 21.9% had 6–10 years of experience in the management of BPSD.

Table 1

Demographic characteristics of survey respondents (n = 96)
Characteristics	Category	Frequency N (%)
Age	18–34	29 (30.2)
	35–54	40 (41.7)
	≥ 55	27 (28.1)
Gender	Male	19 (19.8)
Gender	Female	77 (80.2)
Speciality	Geriatrician	7 (7.3)
	Registered nurse	24 (25)
	Enrolled nurse	13 (13.5)
	Caregiver	28 (29.2)
	Occupational therapist	7 (7.3)
	Lifestyle and well being	6 (6.3)
	Others ^a	11 (11.5)
Professions	Physicians	10 (10.4)
	Nurses	37 (38.5)
	Caregivers	28 (29.2)
	Allied health professionals	21 (21.9)
States	South Australia	59 (61.5)
	New South Wales	9 (9.4)
	Queensland	1 (1)
	Western Australia	18 (18.8)
	Victoria	9 (9.4)
Location of respondents’ RACHs ^b	Metropolitan	48 (50)
	Regional	39 (40.6)
	Rural and remote	10 (10.4)
Type of RACHs ^c	Government	9 (9.4)
	Not-for-profit	60 (62.5)
	Private	33 (34.4)
Years of experience in RACHs	< 1	10 (10.4)
	1–2	16 (16.7)
	3–5	16 (16.7)
	6–10	21 (21.9)
	11–15	11 (11.5)
	16–20	10 (10.4)
	> 20	12 (12.5)
^a= 4 physiotherapist, 2 physician psychiatrist, 2 social worker, 1 general practitioner, 1 diversional therapist, and 1 pharmacist; ^b=1 respondent work in both metropolitan and regional; ^c= 1 respondent worked in not-for-profit, and private, 1 respondent worked in government, and private, 2 respondents worked in not-for-profit, government, and private.

Table 1: Demographic characteristics of survey respondents (n = 96)

Assessment of knowledge indicated that 50–65% of the survey respondents were extremely familiar with 15 out of 25 NPIs (Fig. 2A-D). However, 80–97% of the survey respondents were at least moderately familiar with 17 out of 25 NPIs. The three least familiar NPIs were spaced retrieval (18.8%), bright light therapy (17.7%) (Fig. 2D), and simulated presence therapy (5.2%) (Fig. 2C). The mean knowledge score for all 25 NPIs was 84.4%. Nurses were ranked higher in the knowledge score than caregivers in 22 NPIs, and allied health professionals in 21 among the total of /25 NPIs (Additional file 1). The difference was statistically significant for modification of activity(s) of daily living to meet individual needs (χ²(3) = 7.849, p = .049), bright light therapy (χ²(3) = 8.909, p = .031) and sensory and cognitive interventions (χ²(3) = 8.117, p = .044). Dunn’s post hoc analysis showed that nurses have higher mean rank of knowledge score than allied health professionals regarding modification of activity(s) of daily living to meet individual needs (p = .033) and bright light therapy (p = .041). However, the difference was not significant for sensory and cognitive interventions. Allied health professionals had higher mean rank of perceived knowledge score than nurses with respect to outdoor interventions, games designed for persons with dementia, pursuing roles done in their previous jobs, and reminiscence therapy, whereas caregivers had higher mean rank of perceived knowledge score than nurses regarding engaging in pleasant activities, video respite, spaced retrieval, but these differences were not statistically significant.

Figure 2A: Frequency of familiarity, and practice of healthcare professionals and caregivers with behaviour support strategies for the management of BPSD in Australian RACHs.

Figure 2B: Frequency of familiarity, and practice of healthcare professionals and caregivers with environmental modification and physical activity interventions for the management of BPSD in Australian RACHs.

Figure 2C: Frequency of familiarity, and practice of healthcare professionals and caregivers with social contact and self-affirming interventions for the management of BPSD in Australian RACHs.

Figure 2D: Frequency of familiarity, and practice of healthcare professionals and caregivers with sensory and cognitive interventions for the management BPSD in Australian RACHs.

Table 2: Attitude of healthcare professionals and caregivers towards non-pharmacological interventions for the management of BPSD in Australian RACHs (n = 83)

Table 2

Attitude of healthcare professionals and caregivers towards non-pharmacological interventions for the management of BPSD in Australian RACHs (n = 83)
	Percentage of respondents
Attitude statements	Disagree	Neutral	Agree
I feel that non-pharmacological interventions are more useful than medications for management of BPSD. ^*	10.1	23.6	66.3
I believe non-pharmacological interventions should always be tried before medications for the management of BPSD.	6.0	13.3	80.8
It is my responsibility to deliver non-pharmacological interventions for people living with dementia.	7.2	9.6	83.2
I feel I am competent to implement non-pharmacological interventions for the management of BPSD.	7.2	13.3	79.5
I feel that more than half of residents who have dementia do not respond to non-pharmacological interventions.	50.6	19.3	30.1
I feel that there are insufficient human resources (i.e., low staff number) to use non-pharmacological interventions for the management of BPSD.	6.0	9.6	84.3
When I deliver non-pharmacological interventions as recommended, I get recognition from my work.	35.0	34.9	30.1
Professionals with whom I work, deliver non-pharmacological interventions as recommended.	8.4	30.1	61.5
I always expect a good outcome from the use of non-pharmacological interventions for the management of BPSD.	18.1	36.1	45.8
I intend to deliver non-pharmacological interventions as recommended in the next three months.	1.2	12	86.7
I feel uncomfortable when I deliver non-pharmacological interventions.	80.7	13.3	6
I have a clear plan of how I will deliver non-pharmacological interventions as recommended.	4.8	27.7	67.4
I feel that decreased resident engagement in activity(s) hinders the use of non-pharmacological interventions.	22.9	22.9	54.2
I feel it is easy to tailor non-pharmacological interventions to resident/patient needs.	24.1	19.3	56.7
The management of the aged care home I work in is helpful with delivering non-pharmacological interventions as recommended.	16.8	32.5	50.6
I feel the government and local authorities provide sufficient support (i.e., funding) to interventions such as non-pharmacological interventions.	57.8	20.5	21.7
^*n = 89 for the first statement

As shown in Table 2, 66.3% of the survey respondents felt that NPIs are more useful than medications, 80.8% agreed that NPIs should always be tried before medications, and 83.2% agreed that it is their responsibility to deliver NPIs. However, 84.3% felt that there are insufficient human resources to implement NPIs, 45.8% agreed that they would expect good outcome from the use of NPIs for the management of BPSD, 50.6% agreed that the management of the aged care home in which they work is supportive in implementing NPIs, and only 21.7% felt that the government and local authorities provide sufficient support (i.e., funding) to NPIs.

Kruskal-Wallis test indicated that there were differences in the mean rank of agreement scores among study participants by profession for five attitude statements. These are ‘I believe non-pharmacological interventions should always be tried before medications for the management of BPSD’ (χ²(3) = 18.9, p < .001), ‘It is my responsibility to deliver non-pharmacological interventions for people living with dementia’ (χ²(3) = 16.5, p < .001), ‘I feel I am competent to implement non-pharmacological interventions for the management of BPSD’ (χ²(3) = 9.5, p = .023), ‘I feel that more than half of residents who have dementia do not respond to non-pharmacological interventions’ (χ²(3) = 9.8 ,p = .021), and ‘I have a clear plan of how I will deliver non-pharmacological interventions as recommended’ (χ²(3) = 9.7, p = .021) (Additional file 3). Post hoc Dunn test adjusted for by Bonferroni indicated higher mean rank of agreement with the statement ‘I believe non-pharmacological interventions should always be tried before medications for the management of BPSD’ among nurses as compared to caregivers (p = .001) and allied health professionals (p = .005). There was higher mean rank score of agreement with the statement ‘It is my responsibility to deliver non-pharmacological interventions for people living with dementia’, among nurses compared to physicians (p = .014), caregivers (p = .006), and allied health professionals (p = .045); higher mean rank score of agreement with the statement ‘I feel I am competent to implement non-pharmacological interventions for the management of BPSD’ among nurses compared to allied health professionals (p = .016); higher mean rank score of agreement with the statement ‘I feel that more than half of residents who have dementia do not respond to non-pharmacological interventions’ among caregivers as compared to physicians (p = .024); higher mean rank score of agreement with the statement ‘I have a clear plan of how I will deliver non-pharmacological interventions as recommended’ among nurses than caregivers (p = .047). Nurses had higher overall mean rank of attitude score than caregivers (p = .008) (Additional file 3). There was moderate correlation between knowledge and practice (r = 0.68, p < .001) as well as attitude and practice mean score (r = 0.43, p < .001).

The result of the practice survey in this study showed that only validation therapy (53.9%) was always practiced by more than 50% of the respondents (Fig. 2C) and only 8 out of 25 NPIs were used at least frequently by greater than 71–90% of respondents. The three most common never practiced interventions were bright light therapy (29.2%), spaced retrieval (18%) (Fig. 2D), and simulated presence therapy (12.4%) (Fig. 2C). The five rarely used interventions were bright light therapy (28.1%) (Fig. 2D), simulated presence therapy (27%) (Fig. 2C), spaced retrieval (23.6%), aromatherapy (21.3%) (Fig. 2D), and outdoor interventions (15.7%) (Fig. 2B). Among the 15 out of 25 types of NPIs which were extremely familiar to at least 50% of respondents, seven (accommodating behaviour, provide orienting stimuli, engaging in pleasant activities, reminiscence therapy, pursuing roles done in their previous jobs, social contact interventions, child representation) were always practiced by less than 30% of respondents, while five NPIs (restructuring routine, behaviour management, environmental modification, physical activity, music therapy) were always practiced by 30–40% of respondents, and three NPIs (modification of activities of daily living to meet individual needs, redirection, validation therapy) were always practiced by 41–54%. Based on the Kruskal-Wallis test, nurses were ranked higher in the practice score than caregivers and allied health professionals in 22 and 21 out of the 25 NPIs, respectively (Additional file 2). The difference was statistically significant for NPIs such as behaviour management (χ²(3) = 10.79, p = .013), modification of activity of daily living to meet individual needs (χ²(3) = 10.01, p = .018), accommodating behaviour (χ²(3) = 8.52, p = .036), outdoor interventions (χ²(3) = 10.88, p = .012) and behavioural support or intervention strategies (χ²(3) = 11.53, p = .009). Post hoc Dunn’s test adjusted by Bonferroni correction showed that nurses had higher mean practice rank than caregivers with respect to behaviour management (p = .018). Nurses also had higher mean practice rank than allied health professionals regarding modification of activity of daily living to meet individual needs (p = .010) and restructuring routines (p = .047). Physicians had a higher mean practice rank than caregivers regarding outdoor interventions (p = .026). Nurses have higher mean rank regarding behavioural support or intervention strategies than allied health professionals (p = .011). However, there was no significant difference regarding accommodating behaviour.

Figure 3 Bloom’s cut-offs point score for the knowledge, attitude, and practice towards non-pharmacological intervention for the management of BPSD in Australian RACHs.

As shown in Fig. 3, using bloom’s cut-off points, 67% of study participants reported good knowledge, 27% noted a positive attitude and 34% scored good practice towards NPI implementation for managing BPSD.

Qualitative free text response analysis about the decision to select disagree/agree/neutral response for a statement “I feel that non-pharmacological interventions are more useful than medications for management of BPSD.”

Forty-one respondents provided further explanation for the reason of their choices of ‘disagree’, ‘agree’, or ‘neutral’. Respondents who provided the reason for selecting their choices regarding the usefulness of NPIs over medications for managing BPSD were mostly nurses (36.6%, both registered and enrolled) followed by caregivers (34.1%) (Additional file 5).

Table 3: Themes and subthemes of the analysis of free text responses on the reasons of choosing to agree, disagree or neutral regarding the usefulness of non-pharmacological interventions over medications to manage BPSD in Australian RACHs.

Table 3

Themes and subthemes of the analysis of free text responses on the reasons of choosing to agree, disagree or neutral regarding the usefulness of non-pharmacological interventions over medications to manage BPSD in Australian RACHs.
Themes	Sub-themes	Type of respondents (n = 41)
Scepticism about the use of medications for BPSD management	Medications have adverse effect.	2 nurses, 2 caregivers, 2 physiotherapists, 2 occupational therapists, and 1 lifestyle and wellbeing coordinator
Scepticism about the use of medications for BPSD management	Medications do not treat/manage the cause of the behaviour.	1 nurse
Expertise needed	Medications need specific health professionals.	1 Physiotherapist
Scepticism about the use of NPIs for BPSD management	NPIs do not always work.	3 nurses, 2 caregivers, 1 lifestyle assistant
	Unsure of whether to choose NPIs.	2 caregivers and 1 nurse
	Both NPIs and medication are useful and have their own pros and cons.	3 caregivers and 1 social worker
Rationale and/ or benefit for considering medications for BPSD management.	Medications have a role after NPIs have been tried.	6 nurses, 4 caregivers, 3 occupational therapists, and 1 social worker
Rationale for considering NPIs for BPSD management.	NPIs are effective for managing BPSD.	7 nurses, and 1 social worker
	Worth trying NPIs before medication to manage BPSD.	3 caregivers, 2 nurses and 2 social workers.
	NPIs are person centred.	2 physicians and 1 caregiver.
	NPIs have no or fewer side effects	2 physicians
	Generic NPIs are easier and less costly.	1 occupational therapist
Necessary conditions for the use of NPIs in BPSD management	Staff training.	2 nurses
	Adequately trained staff ratio	1 nurse
	More attention from the care home setting	1 nurse
	Quality interaction with residents	1 occupational therapist
	Taking responsibility to implement NPIs	1 nurse
	Making the right decision	2 nurses, 1 caregiver and 1 occupational therapist

Six themes and eighteen subthemes were generated from the free text responses (Table 3). The illustrations for each subtheme are presented in Additional file 4. The reasons for choosing NPIs over medications were that NPIs are effective, and person-centred, worth trying first, possess few or no adverse effects and are less costly. However, the necessary condition for implementing NPIs were staff training, adequate staff ratio, support from aged care homes manager, being fully present and engaged in a quality conversation with a resident, an ability to determine when medication or NPIs are needed and taking the ownership of NPIs implementation.

According to the knowledge, attitude and practice model, knowledge is the basis for changing behaviour (practice), and attitudes are the driving force behind this change [44, 45]. In this study, we investigated the knowledge, attitude, and practice of healthcare professionals and caregivers towards NPIs for managing BPSD. Two thirds of respondents had good knowledge but less than one third had positive attitude and only about one third of respondents reported to have good practice.

Knowledge about non-pharmacological interventions for BPSD

Our findings showed that NPIs such as engaging in pleasant activities, redirection, modification of daily living to meet individual needs, music therapy, environmental modification, child representation, provide orienting stimuli, reminiscence therapy, validation therapy, social contact interventions, behaviour management, accommodating behaviour, restructuring routines, physical activity, and pursuing roles done in their previous jobs,were marked as extremely familiar by 50-65% of healthcare professionals and caregivers. This is consistent with findings from the study conducted by Cohen-Mansfield et al., where environmental modification, behaviour change, behaviour accommodation, pleasant events/structured activities, and social contact interventions were of greatest familiarity to the study participants [28]. Our study found that 80-97% of participants were at least moderately familiar with 17 out of 25 NPIs (Figure 2 A-D). This is in line with a Canadian study conducted by Janzen et al., where more than 80% of the study participants (registered nurses, personal support workers, and allied health professionals) were aware of 17 out of 20 NPIs [46].

Similar to the findings of Cohen-Mansfield et al. [28], our respondents reported spaced retrieval and simulated presence therapy are the least familiar NPIs. Bright light therapy was also commonly reported as one of the unfamiliar NPI items by Janzen et al. [46]. These NPIs have different therapeutic purposes and health outcomes. For example, bright light therapy may improve depression and agitation, [47, 48] and sleep outcomes (e.g., sleep continuity, and advancement of delayed sleep timing) in RWD [49], whereas simulated presence therapy may improve refusal behaviour [50].

Our study showed that nurses scored greater knowledge than caregivers and allied health professionals for 22 and 21 out of the 25 NPIs, respectively. Better NPIs knowledge among nurses might explain the free text responses where a higher number of nurses favoured NPIs over medication than caregivers and allied health professionals (Table 3). Nurses’ greater knowledge on NPIs also goes with better attitude than those of caregivers (Additional file 3).

Attitude towards non-pharmacological interventions for BPSD

Our findings indicated that 66% of the respondents felt that NPIs are more useful than medications (Table 2). This figure is much lower than that in Cohen-Mansfield et al. where at least 92% of the respondents (physicians, nurses, and psychologists) agreed with this statement [28]. Furthermore, 78.1% of our respondents agreed that NPIs should always be attempted before resorting to medications (Table 2). This percentage is also lower than the results reported by Cohen-Mansfield et al., where at least 92% of the respondents agreed that NPIs should be used before pharmacological treatments [28]. The variation in these findings is possibly due to the difference in the professional backgrounds of the study participants. In our study, the participants included physicians, nurses, allied health professionals, and caregivers whereas in the Cohen-Mansfield et al., they consisted of physicians, nurses, and psychologists.

There were differences in the agreement levels among study participants by profession for five attitude statements. Higher agreement was noted with using NPIs as first line strategy for BPSD management among nurses as compared to caregivers and allied health professionals. This is in line with the finding reported by Cohen-Mansfield et al. where nurses had higher agreement levels on the attitude favouring NPIs than psychologists, and physicians [28]. In our study, nurses also scored a significantly higher rank of agreement with the responsibility of delivering NPIs for people living with dementia, compared to physicians, caregivers, and allied health professionals. The lowest rank was for physicians while both caregivers and allied health professionals were on a par regarding the responsibility of administering NPIs.

Practice of non-pharmacological interventions for BPSD

Validation therapy was the only NPI marked as always practiced by more than 50% of participants. However, 20 out of 25 types of NPIs were at least used frequently by more than 50% of the survey respondents. This is similar with Janzen et al. in which 15 out of 20 NPIs were used by more than 50% of their study participants [46]. In our study, the top three ‘never practiced’ NPIs, in that order, were bright light therapy, spaced retrieval, and simulated presence therapy. These interventions were also the top three that were not at all familiar to our study participants. The five rarely used interventions were bright light therapy, simulated presence therapy, spaced retrieval, aromatherapy, and outdoor interventions. This is quite similar to Cohen-Mansfield et al. findings where the five least practiced NPIs were Montessori based activities, spaced retrieval, simulated presence therapy, aromatherapy and bright light treatments [51]. The 10 most common NPIs used at least frequently were as follows: redirection (89.9%), behaviour management (86.5%), validation therapy (85.4%), physical activity (82.1%), modification of activities of daily living to meet individual needs (75.3%), music therapy (75.3%), engaging in pleasant activities (75.2%), social contact interventions (71.9%), reminiscence therapy (69.6%), restructuring routine (65.2%), and child representation (65.2%). In comparison, Cohen-Mansfield et al. found that, the 10 most commonly used NPIs were as follows: removal of physical restraints (86%), redirection (83%), monitors for wandering (81%), physical activity (73%), provide orienting stimuli (72%), activity therapy/recreation/structured activities (71%), environmental accommodation of behaviour/environmental modification (66%), restructuring routine (65%), modification of activities of daily living care to meet individual needs (62%), and pet therapy (62%)[51]. This has partial agreement with our findings because two NPI items (e.g., removal of physical restraints, monitors for wandering) listed in the Cohen-Mansfield et al. study were not present in our study, and other NPIs (e.g., provide orienting stimuli, environmental modification, pet therapy) were ranked low in our study. As noted earlier, the variation between studies might have been due to differences in the sample size and characteristics. Separate analysis for physician respondents in our study showed that the top 10 most used NPIs included physical activity, behaviour management, providing orienting stimuli, social contact interventions, pursuing roles done in their previous jobs, redirection, modification of activity(s) of daily living to meet individual needs, accommodating behaviour, outdoor interventions, environmental modifications. This has partial agreement with the findings from Cohen-Mansfield et al. study. This variation may be because two of the 10 most commonly used NPIs in Cohen-Mansfield et al. study were not included in our study [51].

In our study, nurses scored higher rank of practice score than caregivers and allied health professionals in most NPIs. This might have been due to lower training on NPIs among caregivers and allied health professionals as compared to nurses [52-55].

There was moderate positive correlation between knowledge and practice as well as attitude and practice towards NPIs. Additionally, two thirds of our participants had good knowledge but only one thirds had positive attitude, and one thirds having good practice. This suggests that not only increasing the knowledge but also improving the attitude is important in changing practice.

Free text responses on the reason of choosing ‘disagree’, ‘agree’ or ‘neutral’ for the statement “I feel that non-pharmacological interventions are more useful than medications for management of BPSD.”

Analysis of free text responses revealed that ‘NPIs doesn’t work’ was the reason for disagreeing with the statement “I feel that non-pharmacological interventions are more useful than medications for management of BPSD”. On the other hand, except for physicians, the other respondents (two nurses, two caregivers, two physiotherapist and two occupational therapist) noted the adverse effect of medicine as the reason for agreeing with the usefulness of NPIs over medication. All respondents who mentioned the NPIs effectiveness as a reason for agreeing with their usefulness over medications were nurses except for one who was an occupational therapist.

Apart from physicians, eleven respondents mentioned that medications have role in specific patient conditions. The overall number of physicians survey respondents was also low (n = 10) compared to other respondents. Consequently, a more focused study on the place of psychotropic medicines in the management of BPSD from a physician perspective is warranted in Australian RACHs. Overall, the findings of this study suggest that commitment and support from aged care stakeholders such as RACH managers and the government to improve funding, staffing, and training that targets the knowledge and attitude of the RACHs care staff to manage BPSD using NPIs are needed to translate into good practice.

Implication for practice

Our findings may inform aged care providers, clinicians, aged care staff, policy makers, funders, and other stakeholders that there is still a gap on the knowledge, attitude, and practice about NPIs for managing BPSD. Targeted training specifically addressing staff attitudes towards NPIs could be effective in improving practice. Nurses are well positioned to spearhead the multidisciplinary use of NPIs to manage BPSD in RACHs, but they require adequate support from the aged care home managers, and governments. Educating and training caregivers and healthcare professionals on the effectiveness of NPIs compared to medications is essential for fostering positive attitudes and good practice. Sufficient funding and well-trained staff are crucial for optimal NPIs implementation for the management of BPSD in RACHs.

Limitations

The study has some limitations. The cross-sectional design of the study does not permit inferring causality. The sample size was small in comparison to previous studies [28, 51], and the sampling technique was not random involving simple convenience and snowballing techniques. However, efforts have been made by using a number of strategies to increase response rate and sample size, including extending the data collection for several months, reaching out to various professional associations in Australia, such as those for physicians, nurses, gerontology, aged care industry, and allied health professionals as well as using the supervisory team’s networks.

The small sample size studied may have not allowed reaching levels of significance where expected. Therefore, a larger study is needed to confirm our findings. Additionally, most respondents were from South Australia, posing a concern about the lack of generalisability to Australia nationally. Given the scope of study, the findings may not be applicable internationally. Recall bias may have occurred with some responses that require data recollection retrospectively. There is also some gender representation bias in survey responses. Given the low representation of physicians in our study, further research specifically targeting physicians is recommended. Understanding their perspectives and addressing any concerns or barriers they may have, is essential for comprehensive care planning and decision-making. Despite these limitations, our study offers valuable insights through the following strengths. First, a large number of respondents (from five out of the eight states and territories in Australia) completed the free text response box on the reason(s) for choosing or not choosing NPIs over medications. Second, participants were included from various locations (metropolitan, regional, rural, and remote) and settings (government, not-for-profit, private) ensuring a balanced and comprehensive perspective by RACHs. Third, the online questionnaire was piloted before launch.

Knowledge, attitude, and practice towards NPIs varied among the professions. The knowledge level was good for two thirds of respondents, but less than one third had positive attitude leading to only about one third of respondents having good practice. Education and training focusing on the knowledge and attitude are important to bring about practice change.

BPSD: Behaviours and Psychological Symptoms of Dementia

NPIs: Non-pharmacological Interventions

RWD: Resident Living with Dementia

RACHs: Residential Aged Care Homes

Ethical approval and informed consent

The study was approved by University of South Australia (UniSA) Human Research Ethics Committee (HREC) (approval ID: 205135). The survey was completely anonymous, and the participation was voluntary. All participants provided written informed consent online through Qualtrics by checking the “I agree to participate” box.

Consent for publication

Not applicable

Data Availability

Data are available from the primary author upon reasonable requests.

Funding: No public, commercial or not-for-profit sectors provided any specific grant for this paper. However, Hunduma Ayeno is a PhD Candidate supported by the University of South Australia and Australian Government Research Training Program International scholarship.

Competing interests

M Atee is a Research and Practice Lead at ‘The Dementia Centre; a research, education, and consultancy arm of HammondCare, an independent Christian charity which auspices the Dementia Support Australia (DSA) programs – the Dementia Behaviour Management Advisory Service (DBMAS) and the Severe Behaviour Response Teams (SBRT)’. These programs embrace and use multimodal, person centred psychosocial and non-pharmacological interventions as part of their support strategies. The remaining authors have no conflict of interest.

Author contributions

All authors participated in conceptualising and designing the paper. HA drafted the manuscript with the contribution of GK, MA, and TN. All the authors were involved in the critical review the work and have given their approval for the final version to be submitted.

Acknowledgements

The authors would like to acknowledge the University of South Australia and Australian Government Research Training Program International for giving scholarship for giving scholarship covering tuition fees and living allowance to Hunduma Ayeno, the recipient of the scholarship. The authors would also like to thank the participants and the aged care providers for their cooperations during data collection process.

World Health Organisation. Dementia: A public health priority. United Kingdom 2012.
Nichols E, Steinmetz, Jaimie D. Vollset, Stein Emil, et al. Estimation of the global prevalence of dementia in 2019 and forecasted prevalence in 2050: an analysis for the Global Burden of Disease Study 2019. Lancet Public Health. 2022;7(2):e105-e125.
Australian institute of health and welfare A. Dementia in Australia. 2023.
Kozman MN, Wattis J, Curran S. Pharmacological management of behavioural and psychological disturbance in dementia. Hum Psychopharmacol. 2006;21(1):1-12.
NSW Ministry of Health. Extreme Behavioural and Psychological Symptoms of Dementia (BPSD) Project Report. Australia; 2021.
Selbaek G, Engedal K, Bergh S. The prevalence and course of neuropsychiatric symptoms in nursing home patients with dementia: a systematic review. J Am Med Dir Assoc. 2013;14(3):161-9.
McMaster M, Fielding E, Lim D, Moyle W, Beattie E, AusQo LG. A cross-sectional examination of the prevalence of psychotropic medications for people living with dementia in Australian long-term care facilities: issues of concern. Int Psychogeriatr. 2018;30(7):1019-26.
Brodaty H, Draper B, Saab D, Low LF, Richards V, Paton H, et al. Psychosis, depression and behavioural disturbances in Sydney nursing home residents: prevalence and predictors. Int J Geriatr Psychiatry. 2001;16(5):504-12.
Ryu SH, Ha JH, Park DH, Yu J, Livingston G. Persistence of neuropsychiatric symptoms over six months in mild cognitive impairment in community-dwelling Korean elderly. Int Psychogeriatr. 2011;23(2):214-20.
Karg N, Graessel E, Randzio O, Pendergrass A. Dementia as a predictor of care-related quality of life in incaregivers: a cross-sectional study to investigate differences in health-related outcomes between dementia and non-dementia caregivers. BMC Geriatr. 2018;18(1):189.
Hurt C, Bhattacharyya S, Burns A, Camus V, Liperoti R, Marriott A, et al. Patient and Caregiver Perspectives of Quality of Life in Dementia: An Investigation of the Relationship to Behavioural and Psychological Symptoms in Dementia. Dement Geriatr Cogn Disord. 2008;26(2):138-46.
Burley CV, Livingston G, Knapp MRJ, Wimo A, Norman R, Brodaty H. Time to invest in nonpharmacological interventions for behaviours and psychological symptoms associated with dementia. Alzheimer's & Dementia. 2020;16 Suppl 10:e042281.
DSA. Dementia Support Australia: Additional Data Report, No: 4. 2018.
Macfarlane S, Atee M, Morris T, Whiting D, Healy M, Alford M, et al. Evaluating the Clinical Impact of National Dementia Behaviour Support Programs on Neuropsychiatric Outcomes in Australia. Front Psychiatry. 2021;12:652254.
Brodaty H. Meta-Analysis of Nonpharmacological Interventions for Neuropsychiatric Symptoms of Dementia. Am J Psychiatry. 2012;169:946–53.
Rajesh R Tampi*, 2 , Deena J Tampi3, Kathleen Rogers4 & Suganthi Alagarsamy4. Antipsychotics in the management of behavioral and psychological symptoms of dementia: maximizing gain and minimizing harm. Neurodegener DisManag. 2020;10(1):5-8.
Parajuli DR, Kuot A, Hamiduzzaman M, Gladman J, Isaac V. Person-centered, non-pharmacological intervention in reducing psychotropic medications use among residents with dementia in Australian rural aged care homes. BMC Psychiatry. 2021;21(1):36.
Mbakile-Mahlanza L, van der Ploeg ES, Busija L, Camp C, Walker H, O'Connor DW. A cluster-randomized crossover trial of Montessori activities delivered by family carers to nursing home residents with behavioral and psychological symptoms of dementia. Int Psychogeriatr. 2020;32(3):347-58.
Bowles E, Cheras P, Stevens J, Myers S. A survey of aromatherapy practices in aged care facilities in northern NSW, Australia. Int. J. Aromather. 2005;15(1):42-50.
Mallik A. and Pan D. Spirituality Practice as add on Therapy For Dementia Patients in a Geriatric Centre in India. Am. J. Geriatr. Psychiatry. 2013;21(3):Suppl 1:154-155.
Raglio A, Attardo L. Music therapy in dementia. Diagnosis and Management in Dementia. 2020. p. 695-711.
NSW. Assessment and Management of People with Behavioural and Psychological Symptoms of Dementia (BPSD) A Handbook for NSW Health Clinicians. In: Health Mo, editor.: NSW Ministry of Health and the Royal Australian and New Zealand College of Psychiatrists; 2013.
Guideline Adaptation Committee. Clinical Practice Guidelines and Principles of Care for People with Dementia. Guideline Adaptation Committee; 2016.
Ervin K, Cross M, Koschel A. Barriers to managing behavioural and psychological symptoms of dementia: staff perceptions. Collegian. 2014;21(3):201-7.
Anderson H, Kolliakou A, Harwood D, Funnell N, Stewart R, Bishara D. Antipsychotic monitoring in dementia: quality of completion of antipsychotic monitoring forms in an older adult mental health service. BJPsych Bull. 2022;46(5):271-7.
Royal Commission into Aged Care Quality and Safety. Royal Commission into Aged Care Quality and Safety: A summary of final report. 2021.
Cain P, Chejor P, Porock D. Chemical restraint as behavioural euthanasia: case studies from the Royal Commission into Aged Care Quality and Safety. BMC Geriatr. 2023;23(1):444.
Cohen-Mansfield J, Jensen B, Resnick B, Norris M. Knowledge of and attitudes toward nonpharmacological interventions for treatment of behavior symptoms associated with dementia: a comparison of physicians, psychologists, and nurse practitioners. Gerontologist. 2012;52(1):34-45.
Huijg JM, Gebhardt WA, Dusseldorp E, Verheijden MW, van der Zouwe N, Middelkoop BJ, et al. Measuring determinants of implementation behavior: psychometric properties of a questionnaire based on the theoretical domains framework. Implement Sci. 2014;9:33.
Corp. I. IBM SPSS Statistics for Windows, Version 28.0. Armonk, NY: IBM Corp; 2021.
Shanableh S, Zainal H, Alomar M, Palaian S. A national survey of knowledge, attitude, practice, and barriers towards pharmacovigilance and adverse drug reaction reporting among hospital pharmacy practitioners in the United Arab Emirates. J Pharm Policy Pract. 2023;16(1).
Scarano-Pereira JP, Martinino A, Manicone F, Álvarez-García C, Ortega-Donaire L, Clavijo-Chamorro MZ, et al. Young nursing and medical students’ knowledge and attitudes towards sexuality and contraception in two spanish universities: an inferential study. BMC Med Educ. 2023;23(1).
Abu Awwad D, Hill S, Lewis S, Jimenez Y. Knowledge, attitudes and practice of infection prevention and control in the CT suite. BMC Health Serv Res. 2023;23(1).
Dassah ET, Dzomeku VM, Norman BR, Gyaase D, Opare-Addo MNA, Buabeng KO, et al. Attitudes of health care professionals towards interprofessional teamwork in Ashanti Region, Ghana. BMC Med Educ. 2023;23(1).
Alam S, Khan S, Ahsan A, Alam Khan I. A Cross-Sectional Survey of Knowledge, Attitude and Practice (KAP) Among the MBBS Students after a Year of COVID-19 Outbreak. Trends Med. Res. 2021;16(2):30-6.
Ashebir W, Yimer B, Alle A, Teshome M, Teka Y, Wolde A. Knowledge, attitude, practice, and factors associated with prevention practice towards COVID-19 among healthcare providers in Amhara region, northern Ethiopia: A multicenter cross-sectional study. PLOS Glob. Public Health. 2022;2(4).
Wang L, Abualfoul M, Oduor H, Acharya P, Cui M, Murray A, et al. A cross-sectional study of knowledge, attitude, and practice toward COVID-19 in solid organ transplant recipients at a transplant center in the United States. Front Public Health. 2022;10:880774.
Adli I, Widyahening IS, Lazarus G, Phowira J, Baihaqi LA, Ariffandi B, et al. Knowledge, attitude, and practice related to the COVID-19 pandemic among undergraduate medical students in Indonesia: A nationwide cross-sectional study. PLoS One. 2022;17(1):e0262827.
Chand D, Mohammadnezhad M, Khan S. Levels and Predictors of Knowledge, Attitude, and Practice Regarding the Health Hazards Associated With Barber's Profession in Fiji. Inquiry-J Health Car. 2022;59:1-10.
Khaled A, Siddiqua A, Makki S. The Knowledge and Attitude of the Community from the Aseer Region, Saudi Arabia, Toward COVID-19 and Their Precautionary Measures Against the Disease. Risk Manag Healthc Policy. 2020;13:1825-34.
Chan CK, Lam TY, Mohanavel L, Ghani JA, Anuar ASK, Lee CJ, et al. Knowledge, attitude, and practice of white coat use among medical students during clinical practice (LAUNDERKAP): A cross-sectional study. Am J Infect Control. 2023.
Roberta Heale AT. Validity and reliability in quantitative studies. Evid Based Nurs 2015;18(3).
Abdulkader Mohamed R, Abdul Rahim NA, Mohamad SM, Ahmad Yusof H. Validity and reliability of knowledge, attitude, and practice regarding exercise and exergames experiences questionnaire among high school students. BMC Public Health. 2022;22(1):1743.
Xu N, Zhang Y, Zhang X, Zhang G, Guo Z, Zhao N, et al. Knowledge, Attitudes, and Practices of Urban Residents Toward COVID-19 in Shaanxi During the Post-lockdown Period. Front Public Health. 2021;9:659797.
Gao H, Hu R, Yin L, Yuan X, Tang H, Luo L, et al. Knowledge, attitudes and practices of the Chinese public with respect to coronavirus disease (COVID-19): an online cross-sectional survey. BMC Public Health. 2020;20(1):1816.
Janzen S, Zecevic AA, Kloseck M, Orange JB. Managing agitation using nonpharmacological interventions for seniors with dementia. Am J Alzheimers Dis Other Demen. 2013;28(5):524-32.
Onega LL, Pierce TW, Epperly L. Effect of Bright Light Exposure on Depression and Agitation in Older Adults with Dementia. Issues Ment Health Nurs. 2016;37(9):660-7.
Jao Y-L, Wang J, Liao Y-J, Parajuli J, Berish D, Boltz M, et al. Effect of Ambient Bright Light on Behavioral and Psychological Symptoms in People With Dementia: A Systematic Review. Innov. Aging. 2022;6(3).
Faulkner SM, Bee PE, Meyer N, Dijk D-J, Drake RJ. Light therapies to improve sleep in intrinsic circadian rhythm sleep disorders and neuro-psychiatric illness: A systematic review and meta-analysis. Sleep Med Rev. 2019;46:108-23.
Backhouse T, Dudzinski E, Killett A, Mioshi E. Strategies and interventions to reduce or manage refusals in personal care in dementia: A systematic review. Int J Nurs Stud. 2020;109:103640.
Cohen-Mansfield J, Jensen B. Nursing home physicians' knowledge of and attitudes toward nonpharmacological interventions for treatment of behavioral disturbances associated with dementia. J Am Med Dir Assoc. 2008;9(7):491-8.
Clifford C, Doody O. Exploring nursing staff views of responsive behaviours of people with dementia in long-stay facilities. J Psychiatr Ment Health Nurs. 2018;25(1):26-36.
Hussin NS, Karuppannan M, Gopalan Y, Tan KM, Gnanasan S. Exploration of non-pharmacological interventions in the management of behavioural and psychological symptoms of dementia. Singapore Med J. 2021:1-19.
Cohen-Mansfield J, Meschiany G. Israeli nursing home staff perspectives on challenges to quality care for residents with dementia. Geriatric Nursing. 2022;44:15-23.
Kong EH, Kim H, Kim H. Nursing home staff's perceptions of barriers and needs in implementing person-centred care for people living with dementia: A qualitative study. J Clin Nurs. 2022;31(13-14):1896-906.

Competing interest reported. M Atee is a Research and Practice Lead at ‘The Dementia Centre; a research, education, and consultancy arm of HammondCare, an independent Christian charity which auspices the Dementia Support Australia (DSA) programs – the Dementia Behaviour Management Advisory Service (DBMAS) and the Severe Behaviour Response Teams (SBRT)’. These programs embrace and use multimodal, person centred psychosocial and non-pharmacological interventions as part of their support strategies. The remaining authors have no conflict of interest.

Download PDF

Journal Publication

published 27 Oct, 2024

Read the published version in Clinical Gerontologist →

Version 1

posted

You are reading this latest preprint version

Knowledge, attitude, and practices of healthcare professionals and formal caregivers towards non- pharmacological intervention for the management of behaviours and psychological symptoms in Australian aged care residents with dementia: A cross-sectional survey

Status:

Journal Publication

Version 1

Abstract

Figures

Background

Method

Data collection and analysis

Reliability

Results

Discussion

Implication for practice

Limitations

Conclusion

Abbreviations

Declarations

References

Additional Declarations

Supplementary Files

Status:

Journal Publication

Version 1