Title: The Cognitive Daisy (COG-D) for improving care for residents with dementia in care homes: A feasibility RCT
Funder: Department of Health and Social Care

Abstract: Cognitive problems associated with dementia affect a large proportion of older adults living in residential care. Knowledge of cognitive impairments is acknowledged to be important for providing person-centred care (PCC). However, the impact of specific cognitive impairments on residents needs is often overlooked in dementia training and information about residents individual cognitive profiles are frequently underspecified in care-plans, potentially leading to non-PCC. This can lead to reduced resident quality of life and increased behaviours such as agitation - a major cause of staff stress and burnout. The COG-D package was developed to fill this gap. Daisies provide a visual representation of a resident s cognitive strengths and weaknesses in a colourful flower representing five cognitive domains. By viewing a resident s Daisy (highlighting cognitive strengths in white petals and likely cognitive problems in coloured petals) care-staff can flexibly adjust in-the-moment care-decisions and can consult Daisies in care-plans for longer-term planning. The COG-D package includes staff-training, the COG-D assessment and the Petal-By-Petal Guide (listing problem domains and care-recommendations for each cognitive function). This 24-month feasibility cluster randomised controlled trial aims to recruit 8-10 care homes (randomly allocated to intervention or usual care) for investigating the feasibility of conducting a future large-scale cluster RCT to assess the effectiveness and cost-effectiveness of the COG-D intervention in care homes. In intervention homes, staff will complete COG-D Basic training (how to read and use the Daisies) and senior staff Advanced training (how to conduct COG-D assessments and implement COG-D in practice). COG-D assessments of residents (by researchers) will be conducted at the start and end of the intervention phase (6-months), with implementation into practice occurring between. Resident Daisies will be displayed at useful locations (e.g. resident rooms), and included in care-plans. Support for implementation includes weekly hand-over huddles, fortnightly online staff meetings and two care-plan meetings with senior staff. The primary objective is to explore signals of impact on resident well-being. We hypothesise that use of the COG-D will facilitate delivery of improved PCC, leading to reduced resident agitation (measured with Cohen-Mansfield agitation inventory CMAI/CMAI-O) and higher quality of life (QUALID). The secondary objective is to investigate signals of impact on staff well-being. The anticipated impact is that staff training will enhance staff knowledge about residents cognitive problems (COG-D-Questionnaire), enhance self-confidence in providing dementia care (Sense of Competence in Dementia Care Staff (SCIDS)) and reduce work stress (Copenhagen Burn-out Inventory (CBI). These measures will be obtained at baseline and 6 and 9 months post-randomisation. A process evaluation will assess intervention implementation and barriers and facilitators to this through care-plan audits, interviews and focus groups with staff. Feasibility outcomes (including % residents recruited, % COG-D assessments completed; % staff completing basic and advanced training) will be analysed against progression criteria to a full trial. Solutions for remediation will be explored where necessary. Findings will be disseminated in journal publications, conferences, non-technical reports on blogs/website, newsletters. If found to be feasible we will apply for further funding to conduct a large-scale effectiveness trial.

Lay abstract: Changes in the brain are common as we age and are often caused by conditions like dementia. These changes mean that people struggle with things like remembering, paying attention, finding words and making decisions &ndash; these mental processes are known as cognitive abilities. Appreciating how these cognitive changes affect each person and how care staff can best support them forms an important part of good care. For example knowing that someone struggles with making decisions can help you to support make choices at mealtimes. Knowledge about these cognitive changes varies among care-home staff and may not always be taken into account when planning and providing care. The Cognitive Daisy (COG-D) is a package we developed to help staff to assess and plan care around each individual's cognitive abilities. It includes: Staff training on cognition and on how to use COG-D, A cognition assessment (looking at senses, understanding, communication, remembering and attention), A Cognitive Daisy that visually summarises cognitive strengths and difficulties using coloured petals, personalised in each resident s care-plan (see www.cognitivedaisy.co.uk), A Petal-By-Petal Guide of possible ways to support different cognitive difficulties for use in care planning. In our COG-D development work care-home staff found it useful to learn more about their residents' needs and care-home residents were happy to complete the assessments. We now need to understand how COG-D benefits individual residents (e.g. for their quality of life). We also need more data on and how the COG-D package is best carried out in a care-home setting, including what helps and hinders its use. Before we can do a large study, we need to check that our research approach will work and gather information to help us design a future trial. To do this we will carry out what is called a feasibility randomised controlled trial. We will recruit 100 residents in up to 10 care homes. Half of the homes will be chosen at random to continue with usual care and half to use the COG-D package, which will be led by a researcher and supported by staff. We will collect data on residents and staff before and after we introduce COG-D to look for any changes. We will record COG-D use and interview staff, relatives and residents in the COG-D care homes about their experiences and any challenges of using it. We will apply for more funding to conduct a larger trial if these results are promising. Findings will be reported in research journals and at conferences. Health care professionals and members of the public (Patient and Public Involvement) have provided feedback on the usefulness of COG-D in different care communities and on the COG-D materials and they will continue to provide expertise throughout the trial.

Research activity codes: 6.6 PSYCHOLOGICAL AND BEHAVIOURAL
Health categories: NEUROLOGICAL