Hearing and vision health for people with dementia in residential long term care: Knowledge, attitudes and practice in England, South Korea, India, Greece, Indonesia and Australia

Abstract Objectives Up to 90% of people with dementia in long term care (LTC) have hearing and/or vision impairment. Hearing/vision difficulties are frequently under‐recognised or incompletely managed. The impacts of hearing/vision impairment include more rapid cognitive decline, behavioural disturbances, reduced quality of life, and greater care burden. This research investigated LTC staff knowledge, attitudes and practice regarding hearing/vision care needs for residents with dementia. Methods A survey of staff in LTC facilities in England, South Korea, India, Greece, Indonesia and Australia. Respondents used a five‐point scale to indicate agreement or YES/NO response to questions regarding sensory‐cognitive care knowledge (what is known); attitudes (what is thought); practice (what is done). Results Respondents reported high awareness of hearing/vision care needs, although awareness of how to identify hearing/vison difficulties or refer for assessment was low. Most felt that residents were not able to use hearing/vision devices effectively due to poor fit, being poorly tolerated or lost or broken devices. A substantial minority of respondents reported low confidence in supporting use of assistive hearing/vision devices, with lack of training the main reason. Most staff did not undertake routine checking of hearing/vision devices, and it was rare for facilities to have designated staff responsible for sensory needs. Variation among countries was not significant after accounting for staff experience and having received dementia training. Conclusions There is a need to improve sensory support for people with dementia in LTC facilities internationally. Practice guidelines and training to enhance sensory‐cognitive knowledge, attitudes and practice in professional care teams is called for.


| INTRODUCTION
Up to 75% of people in long term care (LTC) have dementia. 1 Up to 90% have hearing impairment (>25 dB HL) 2 and >50% have visual impairment (visual acuity <6/12). 3 Hearing/vision impairments among people with dementia are associated with reduced quality of life and increased agitation, hallucinations, aggression and depression, 4 social isolation 5 cognitive decline 6 and higher care need. 7,8 Identifying and treating hearing/vision impairment may improve outcomes for people with dementia. 9 Unfortunately, hearing/vision impairments are under-identified and under-treated in people in LTC. 3,10 Systematic reviews identified limitations on hearing/vision care in LTC including lack of staff knowledge, under-use of screening tools, poor management of assistive aids (i.e., hearing aids, glasses, lighting) and the complex needs of residents with dementia. [11][12][13] Previously, we undertook an exploration of knowledge, attitude and practice in relation to hearing/vision support for people with dementia in 117 English LTC facilities. 14 Although staff recognised the impact of hearing/vision impairment, they lacked knowledge, skills and training to support hearing/vision needs. Considering global demographic shifts and rising need for LTC worldwide, 15

| Study design and population
A cross-sectional multi-national survey of staff who work with residents with dementia to investigate self-reported knowledge, attitudes and approaches to hearing/vision care. We focused on LTC settings including residential homes which provide accommodation, meals and personal care and 'nursing homes' which employ nurses to support those with complex health needs.
England: Most LCT is user-funded. Only those with assets below means-tested levels receive publicly funded care. Residential care homes and nursing homes include those owned and run by local government, not-for-profit facilities owned by charities and for-profit facilities.  Australia: Access to publicly subsidised LTC is based on meanstested assessment of income and assets. The level of government subsidy is based on individual assessment of care needs. LTC providers include not-for-profit, for-profit and government providers across residential and nursing home services, with not-for-profit organisations being the largest provider (56%).

Respondents:
We invited LTC staff who provide care for residents with dementia, including (i) Nurses and allied health professionals, including occupational therapists, physiotherapists and other trained health care professionals; or (ii) Paid non-professional care workers, including front line care workers and others who assist residents with activities of daily living. We aimed to sample at least 50% of staff at each facility. 16  Greece: We approached three LTC facilities including two residential homes in Thessaly and Evros and a nursing home for people with dementia in Attica; all participated (100% response rate). Australia:

| Data collection
The survey was advertised for one month in all 12 facilities in one notfor-profit organisation. Responses were received from all 12 facilities (100% response rate). A local member of the research team visited the participating facilities to provide information about the study. Managers of participating LTC facilities were asked to approach staff to complete the survey in paper, email, or online questionnaire format.
Consent to participate was implied by completion of the survey.
Ethical approval for the study was obtained from the London-Surrey

| Measures
We recorded size, funding (public/local authority, private or notfor-profit) level of care (residential, nursing home, dementia specialist). 'Public/local authority' refers to homes that are taxpayer funded and government run. 'Private' refers to profit-making enterprises. 'Not-for-profit' refers to homes run by charities including social co-operatives and churches.  and training in dementia.

| RESULTS
Responses were received from 428 workers in six countries (Table 1).
Respondents were mostly female. Around 40% of respondents in Greece and Australia were allied health professional workers ( Figure 1)

| Attitude
Korean respondents were ambivalent, but most respondents agreed hearing/vision screening would be acceptable to residents and would find clinical guidelines for assessment and management of hearing/ vision useful (Figure 3). Apart from Greek respondents, most reported that residents who needed to use a hearing/vision aid did mostly not use them effectively. The most commonly reported reasons for ineffective use were aids not fitting, not being tolerated or being lost/broken.

| Practice
Most English and Indian respondents reported carrying out testing or checking of hearing aids and spectacles ( Figure 4)