Professional care providers in dementia care in eight European countries;their training and involvement in early dementia stage and in home care

Abstract

Knowledge concerning professionals involved in dementia care throughout its trajectory is sparse; the focus has mainly been on nursing-home care and less on home care, diagnosis and treatment of the disease and its complications despite the fact that home care is the most prominent type of care. The aim of this study was to explore and describe professional care providers involved in dementia care and their educational level applying the International Standard Classification of Education (ISCED) and further to investigate practice in the RightTimePlaceCare-countries with regard to screening, diagnostic procedures and treatment of dementia and home care. The findings demonstrate more similarities than differences in terms of type of professionals involved among the countries although untrained staff were more common in some countries. Findings also show that many types of professionals are involved, who to turn to may not be clear, for instance in terms of medical specialities and it may be unclear who bears the ultimate responsibility. The professionals involved in diagnosis, treatment and care are educated to bachelor’s level or above whilst everyday care is provided by people trained at a lower ISCED level or with no formal training. Registered nurses as well as occupational therapists have bachelor’s degrees in most countries, but not in Germany or Estonia. Professionals specifically trained in dementia care are not so common. Further research is needed to reveal not only who provides the diagnostics and treatment, but also how home care is organised and quality assured. Many different types of professionals serve as providers along the trajectory of the disease which may be difficult for the patient and the informal caregiver to cope with.

Keywords

professional care providers dementia home care diagnosis and treatment education screening International Standard Classification of Education standardisation

Introduction

Professional care for persons with dementia diseases is perhaps one of the biggest future challenges for aging societies throughout the world (Ferri et al., 2005; Vellas et al., 2012) requiring planning and reflective use of resources. Thus exploring professional dementia care providers in terms of their profession and educational level in a variety of countries may provide knowledge useful in making decisions about how to staff different parts of the system and maintaining competence. The increasing number of people with dementia related to the worldwide demographic transition puts heavy demands on professional ability to either provide care directly or to support informal caregivers (families/next of kins). The progressive nature of dementia also raises questions about the educational level required to provide appropriate professional care at different stages of the disease. A more detailed knowledge of this along the trajectory of dementia could inform further research and shed light on whether sufficient numbers of staff are trained. Views regarding the required educational level may differ between countries. This would open the way for comparative studies, exploring effectiveness related to education and skill mix, thus allowing learning from each other.

It seems likely that the educational level of the professionals involved in providing care for people with dementia has implications for quality of care. Research findings about the relationship between quality of care and education of staff are not consistent and become even more complicated in cross-national studies (Harrington et al., 2012). Some systematic reviews show significant, weak or no relationship between these aspects (Shin & Bae, 2012; Spilsbury et al., 2011). Other studies indicate that low level of education among staff is related to low quality of care (Havig, Skogstad, Kjekshus, & Romören, 2011). Interpretations given for the lack of consistent findings include differences in design of studies, differences in the terminology employed and the fact that they are mainly cross-sectional (Shin & Bae, 2012; Spilsbury et al., 2011). The research questions addressed mainly concentrate on staff/patient ratios in institutional care of a general type, i.e. nursing-home care. This means that alternative modes of care and, in particular home care, are not examined. Few studies relate specifically to people with dementia. The fact that less is known about staff involved in the early stages of dementia and in home care seems paradoxical since, along the trajectory of the disease, home care is more common than nursing-home care. Thus the focus of this study is on professionals involved in care at early dementia stage and in home care.

In most of the studies there is no further specification of nurses (Harrington et al., 2012; Hyer et al., 2011), nor is their level of education clarified. For instance, the unspecified term nurse can be used to denote different educational levels from upper secondary vocational training to bachelor’s or master’s degrees in nursing of the registered nurses (RN). The term RN may also imply different levels of training. The optimal educational level needed to provide care for people with dementia in different settings is yet to be established although research shows that a higher proportion of nurses with a bachelor’s degree relate to lower mortality in hospital care (Aiken, Clarke, Cheung, Sloane, & Silber, 2003). It is believed that dementia care requires professionals with knowledge of and understanding of the problems the disease cause in order to be able to interpret and meet the needs of those with dementia (Swedish Council on Health Technology Assessment (SBU), 2008; Traynor, Inoue, & Crookes, 2011). This suggests that a high level of education with specific knowledge concerning dementia care and the ability to train and support family caregivers is desirable. It would be helpful to know more about the current practice, in particular in the early stages of dementia and in home care.

Clarifying which professions are involved at different stages of dementia care in different European countries, together with the educational qualifications behind their professional titles and if these include dementia-specific training, will throw some light on the values and realities attributed to skilled care in different parts of the dementia care system in these countries. This can be done by examining the level of education of the providers using the International Standard Classification of Education (ISCED, 2011). This standard classification system provides knowledge about education, vocational or other, from the lowest level to the highest academic level. It seems fair to assume that the higher the level of education of the professionals the more able they are to recognise, interpret, explore and effectively intervene in nursing problems (Aiken, 2011). The ISCED classification is helpful when making comparisons between countries to classify the levels at which vocational training is provided. Additional training specifically addressing dementia care is also of interest since countries differ in their policies regarding whether staff should be specialised in dementia care and whether dementia specific care facilities should be offered (Hallberg et al., 2013). Exploring the level of education and the prevalence of dementia-specific training provides an overview of current practice with a European perspective.

The RightTimePlaceCare (RTCP) study, with its overall aim of improving dementia care and services for European citizens and with a special focus on the development of best practice strategies for the transition from home care to institutional long-term care facilities comprises several parts, so-called work packages (WPs) (www.righttimeplacecare.eu). the assignment within one WP (WP2) was to explore the care and service system including professionals involved in providing care and service (Hallberg et al., 2013); another was to interview patients and their informal caregivers about their quality of life, quality of care and care and service consumed (see Verbeek et al., 2012). To explore the care and service system and professionals involved throughout the trajectory of care a mapping system was developed in a consensus procedure involving the eight countries. The aim was to reveal a general view of the kind of care and service system available for people with dementia, including type of professionals involved in the care activities and throughout the trajectory of the disease.

In all, 50 types of care and service activities were identified and defined in the mapping system (Hallberg et al., 2013, the template can be obtained from the first author). These were sorted into eight categories, varying according to the number of activities related to dementia care: screening, diagnostic procedures and treatment of dementia; outpatient care facilities; care at home; institutional care; palliative care; informal care-giving; supportive actions; and civic activities. The category ‘care at home’ included the broadest range of activities whilst palliative care, informal care-giving and supportive actions had the smallest range (Hallberg et al., 2013). Each activity was defined and presented in the mapping system covering on the one axis the trajectory of dementia and on the other axis availability of the activities agreed to be included. Each country’s research team thereafter filled in the availability of the activity and the professionals involved in providing that specific activity. The professionals involved their educational level and in which activities they were involved have not been analysed or reported until now. Further exploration of professionals, their educational level and the kind of activities they are delivering may be useful in gaining a fuller understanding of current practice.

Aim

The aim of this study was to explore and describe the professionals involved in dementia care and their educational level, applying the ISCED model as well as to investigate practice in the RTCP countries with regard to the early stage of dementia in terms of screening, diagnostic procedures and treatment of dementia and with regard to home care.

Design and context

This study is a cross-country descriptive and comparative study. Eight countries in Europe participated representing east (Estonia (EE)), west (England (Eng)), south (France (FR) and Spain (ES)), north (Finland (FI) and Sweden (SE)) and central Europe (Germany (DE) and the Netherlands (NL)). These countries vary in terms of the financial, healthcare and service systems, age structure of the population and responsibility for providing care for people with dementia (Hallberg et al., 2013). Ethical approval was applied for the entire RTCP study and in accordance with the laws and regulations of each country (see Verbeek et al., 2012).

Methods

The data collection for the study of the care and service systems was carried out in steps that resulted in the mapping system to be used for collecting the information about the care and service system throughout the trajectory of dementia and is described in detail in Hallberg et al. (2013). The steps consisted of establishing a common terminology and a list of activities available to and utilised by people with dementia and of professionals who help them at different stages in the trajectory of the condition. The research teams were instructed to collect information that gave a general view of the dementia care system and professionals involved in the country.

For this study, a list was developed of professions involved in dementia care through the trajectory of the disease in the countries involved (Table 1). This was done using a modified consensus procedure (Jones & Hunter, 1995) in which the WP manager (first author) together with her team made a list of possible professionals involved, their work titles and a definition establishing their level of formal vocational training. The list was then sent to the participating countries where additional possible providers were identified and their level of training described. This procedure continued until agreement was reached about providers and how to define them (Table 1). In the second step, the list of providers was applied to each of the activities presented in the mapping system and in relation to the trajectory of the disease. The mapping system was completed within each country under the leadership of its research team. The research team consulted others in accordance with the country-specific circumstances. This meant, for instance, interviews with managers and providers or the inclusion of equivalent care and service organisations of relevance. Validation of responses was obtained from professionals at the managerial level within relevant organisations, through epidemiological studies and literature reviews if available (for country-specific information see Hallberg et al., 2013). Data were collected between November 2010 and January 2011 and thereafter reviewed by the lead research team and in terms of problems with clarity contact was taken with each country to solve the problem. The data collection thus went on until late spring 2011.

Table 1.

Care providers in dementia care, description of competence.

Term	Description
General practitioner (GP)	Physician who treats patients in a district for all types of diseases.
Specialist physician (geriatrics)	Geriatrician or psycho geriatrician, specialist in geriatrics.
Specialist physician (psychiatry)	Specialist in psychiatry/old age psychiatrist
Specialist physician (neurology)	Specialist in neurology
Registered nurse (RN)	Provides care and service including help with PADL, medical treatments and managing the nursing care team. Diploma in nursing and/or Bachelor of Science in Nursing.
Registered nurse (RN) specialist in dementia care	Has overall responsibility of dementia care in an area/municipality. Provides counselling, supervision, assessments and mediates contacts. Education at advanced level, Care of the elderly (one year master), district nurse (one year master), psychiatric care (one year master).
Community psychiatric nurse (RN)	Supporting older people at home and in nursing/residential homes. Specialist in psychiatry (one year master).
Licensed practical nurse/Auxiliary nurse	Provides care and service including help with IADL and PADL, and in addition minor medical treatment. Healthcare trained at secondary school level.
Nurse aid/Assistant nurse	Provides care and service including help with IADL and PADL. Healthcare trained for less than 6 months.
Carer/Caretaker	Provides care and service including help with IADL and PADL. No official health care training, assistant trained on the job.
Migrant caregiver	Carer recruited from abroad, living with, and providing home-based care and service to older people, in addition serves as a maid.
Support worker	Home carer, psychological supporter or home trainer paid at enhanced nursing assistant/home carer rate. Social care/nursing trained at secondary school level or trained on the job.
Home help officer/Social service officer/Expert rater	Employee who carries out needs assessment prior to decision about home services and care, Bachelor of Science in Social Work.
Case manager/Care manager	Professional (nurse or social worker) function that may include funding and outreach, comprehensive assessment and care planning, coordination of service, service provision, monitoring and evaluation, and in addition meeting special needs.
Social worker	Provides staff management for residential care or home help service, Bachelor of Science in Social Work.
Social work assistant/Social service worker	Performs some tasks similar to social worker. Not trained or trained on the job.
Occupational therapist/Ergo therapist	Provides rehabilitation to achieve optimum level of functional ability. It may include adaptation at home and providing aids and equipment to assist managing everyday activities. Bachelor of Science in Occupational Therapy.
Physiotherapist/Physical therapist	Provides rehabilitation to identify and improve, e.g. disabled movement and function. Bachelor of Science in Physiotherapy.
Psychologist	Provides counselling and help to people with psychological difficulties. Diploma in Psychology or higher level education.
Informal caregiver/Family caregiver	Next of kin, spouse, child, grandchild, other relative or friend provides care on a voluntary basis. Not paid by social services.
Paid informal caregiver	Non-professional, next of kin, spouse, child, grandchild, other relative or friend provides care on a voluntary basis. Paid by social services.

Analysis

For the analysis, the professions identified were assigned an educational level laid down in ISCED (2011) and the profession’s category was subdivided to indicate where there was a specialised training and if it was in dementia care and treatment (Table 2). Two of the authors (IRH and SK) independently sorted the type of professionals into the ISCED levels 3–7; the information was then sent to the research teams in the other countries to check the placement of the professionals in the correct ISCED level and to ensure that it accurately accorded with the country’s educational system. This procedure took place in spring 2013.

Table 2.

Categorisation of care providers according to ISCED level of education and with specialisation in healthcare added.

ISCED level At or above ISCED level	General healthcare training	Specialised health care training	Specialised training in dementia	No formal healthcare training
7; Master’s or equivalent, vocational	Psychologist (psychol), Social worker (SW), Physiotherapist (physioT)	GP, MD psychiatry^a (MD-psych) MD neurology^a (MD-neuro), MD-internal medicine	MD Geriatrics (MD-ger)
6; Bachelor’s or equivalent, vocational	Social worker, Registered nurse^b (RN), Occupational therapist^b (OT), Physiotherapist^b, Health visitor, Case manager	Community psychiatric registered nurse (RN-comm-psych) Home help officer, Case manager, RN prescriber	RN specialists in dementia (RN-dem)
5; Short-cycle tertiary education, vocational	Registered nurses not bachelor‘s level, State examined nurses (SEN) Occupational therapist, not bachelor‘s level	State examined nurses specialists in geriatric (SEN-ger) State examined nurses specialists in psychiatry (SEN-psych)	State examined nurses specialists in dementia care (SEN-dem), not bachelor‘s level
4; Post-secondary non-tertiary, vocational	Licensed practical nurse (LPN)/Auxiliary nurse (Aux-N)
3; Upper secondary, vocational	Nurse aid/Assistant nurse (Ass-N), Support worker (Supp-work)
Below 3	Social work assistant (SW-ass)			Carer, Care assistant, caretaker, migrant caregiver, various organisations such as voluntary org, catering, public support service

MD Psychiatry and MD Neurology; training in dementia is normally part of their special training.

Registered nurses, occupational therapists and physiotherapists are trained at different levels in the 8 European countries.

Finally, for this study professionals involved in activities related to screening, diagnostics and dementia treatment and memory clinics as well as activities included in the category home care were analysed for their ISCED level. The 7 activities as presented in the mapping system and related to the initial stage of dementia are presented in Table 3 and the 14 activities related to home care are presented in Table 4 (Tables 3 and 4 illustrate the Y-axis of the mapping system whilst the X-axis covers the stages of dementia from diagnosis to end of life). The distribution of professionals involved in the activities and their ISCED level of education was sent to the other research teams to be checked and corrected if needed. Thus an iterative process was applied throughout the analyses phase.

Table 3.

Professionals involved in diagnostics, dementia treatment and memory clinics, distributed according to activity and level of education (ISCED).

Task to be performed	Country	ISCED level 7 or above, masters or equivalent, vocational	ISCED level 6, Bachelors or equivalent, vocational	ISCED level 5, short cycle tertiary education, vocational	ISCED level 4 Post-secondary non-tertiary, vocational	ISCED level 3 Upper secondary, vocational	Level 0 Below ISCED level 3, no formal health care training
Dementia screening program/"case finding": Carried out in primary care with the aim of detecting early stages dementia. Different tools might be used	EE NA^a
	FI	GP, MD-ger, MD-neuro, MD-psych	RN-dem
	FR	GP, MD-ger
	DE	GP
	NL	GP	SW		Aux-N/LPN	Ass N, Supp-work
	ES	GP, MD-ger	RN
	SE	GP
	UK	GP	RN, Health visitor^b
Standard diagnostic procedure for dementia disease: National standard diagnostic procedure applied in accordance with standard	EE	GP, MD-psych, MD-neuro, MD-internal med
	FI	GP, MD-ger, MD-neuro	RN-dem
	FR	GP, MD-ger, MD-neuro, MD-psych
	DE	GP, MD-ger, MD-neuro, MD-psych
	NL	GP, MD-ger, MD-psych, MD-neuro, Psychol
	ES	GP, MD-ger, MD-neuro, Psychol	RN
	SE	GP, MD-ger, MD-psych, MD-neuro
	UK	GP, MD-ger, MD-neuro, MD-psych, Psychol	RN, RN-comm-psych, Health visitor
Pharmacological treatment specific to dementia disease: Medication of cognitive symptoms, combined with a likely slowing of disease progression, e.g. cholinesterase inhibitors for improvement of cognition. ATC code N06D	EE	MD-neuro, GP, MD-psych
	FI	MD-ger, MD-neuro
	FR	MD-ger, MD-neuro, MD-psych
	DE	MD-ger, MD-neuro, MD-psych
	NL	GP, MD-ger, MD-psych, MD-neuro	RN
	ES	MD-ger, MD-neuro
	SE	GP, MD-ger, MD-neuro, MD-psych
	UK	GP, MD-ger, MD-neuro, MD-psych	RN prescriber^c
Non-pharmacological treatment: e.g. orientation to reality, reminiscence therapy, tactile massage, cognitive stimulation etc	EE		OT				Carer
	FI		RN, PhysioT, OT		Aux-N/LPN		Civil soc org
	FR	Psychol	OT, PhysioT
	DE			SEN, OT, PhysioT
	NL	Multi-disc team^d
	ES		RN
	SE		OT		LPN/Aux-N	Ass-N
	UK	Psychol	OT
Pharmacological treatment specific to Behavioural Psychological Symptoms of Dementia (BPSD): e.g. psychotropic drugs for aggressive behaviour	EE	MD-psych, MD-intern med
	FI	MD-ger, MD-neuro, GP, MD-psych
	FR	GP, MD-ger, MD-psych, MD-Neuro
	DE	GP, MD-ger, MD-neuro, MD-psych
	NL	GP, MD-ger, MD-psych, MD-neuro, Psychol	RN
	ES	GP, MD-ger, MD-psych, MD-neuro
	SE	GP, MD-ger, MD-neuro, MD-psych
	UK	GP, MD-psych, MD-ger	RN-prescriber
Non-pharmacological treatment specific to BPSD: treatment, e.g. environmental modification, massage, presence of pets, selected music, distraction etc	EE	PhysioT	OT
	FI		RN, OT, PhysioT		Aux-N/LPN
	FR	Psychol	RN, OT, PhysioT			Ass-N
	DE			SEN, OT, PhysioT			Vol-org
	NL	Multi-disc team^a
	ES		RN
	SE		RN		LPN/Aux-N	Ass N
	UK	Psychol	OT, RN, RN-dem, RN-comm-psych, specially trained practioner^e
Memory clinic: Outpatient clinic for examination and treatment of memory impairments, not only suspected dementia diseases	EE NA
	FI	MD-ger, MD-neuro	RN-dem
	FR	Med-ger, MD-neuro, MD-psych, Psychol
	DE	MD-ger, MD-neuro, MD-psych, psychol,
	NL	MD-ger, MD-psych, MD-neuro, Psychol	RN
	ES	MD-ger, MD-neuro, Psychol	RN
	SE	MD-ger, MD-psych, MD-neuro
	UK	MD-psych, MD-ger, MD-neuro, Psychol,	SW, OT, RN				Vol-org

Not available.

Health visitors commonly have training in health or social care at ISCED level 6 and in addition training in health visiting.

Registered nurses eligible to prescribe certain medications.

Usually comprising a physician, psychologist, RN, assistant nurse, OT, Physio-T, SW.

A health professional specially trained in interventions to alter behavioural problems.

Table 4.

Professionals providing home care activities, distributed according to activity and level of education (ISCED).

Tasks to be performed		ISCED level 7, masters or equivalent, vocational	ISCED level 6, Bachelors or equivalent, vocational	ISCED level 5, short cycle tertiary education, vocational	ISCED level 4 Post-secondary non-tertiary, vocational	ISCED level 3 Upper secondary, vocational	Level 0 Below ISCED level 3, no formal health-care training
Needs assessment: Assessment of needs regarding care and social service from any kind of organisation both prior to a formal care decision and whilst receiving care, including determination of eligibility	EE	MD-neuro, GP, SW		RN
	FI		RN-dem, SW, RN
	FR	GP, MD-ger	SW, Case manager^a
	DE	MD-ger, MD-neuro, MD-psych MD, GP		SEN, SEN-ger
	NL	MD-ger, MD-neuro, MD-psych	Case manager^a
	ES	GP, MD-ger, MD-neuro, Psychol	SW, RN
	SE		SW, RN
	UK		SW, OT, Home health expert^a, Case manager^a
Team-based home healthcare: Healthcare provided in the patient’s own home by a multidisciplinary team charged with the treatment and monitoring of the patient with dementia and the caregiver	EE NA^b
	FI	GP, MD-ger	RN		Aux-N/LPN
	FR	GP, MD-ger, Psychol	RN, PhysioT, OT			Ass-N
	DE NA
	NL	Multidisc team^c
	ES	GP, MD-ger, Psychol	SW, RN
	SE	MD-ger, MD-psych	RN-spec, OT		LPN/Aux-N
	UK	GP, MD-psych, MD-ger, Psychol	OT, PhysioT, SW, RN, RN-dem, RN-Comm-psych, Case manager			Supp-work	SW-ass,
Team-based community mental health for older people: Specialist, multidisciplinary team including, e.g. psychiatrist, psychiatric nurse, social worker, occupational therapist, psychologist and sometimes ‘support workers’	EE NA
	FI	MD-psych, MD-ger	RN-psych, SW, OT
	FR	MD-psych, Psychol	RN, OT
	DE NA
	NL	Multidisc team spec with MD-psych
	ES	MD-psych, Psychol	RN-psych, SW
	SE	MD-psych, Psychol,	RN-psych, OT, SW
	UK NA
Home help/care with IADL: Help provided with Instrumental Activities of Daily Living (IADL) at home by paid professionals	EE						Carer, SW-ass
	FI		RN		Aux N/LPN
	FR		RN			Ass-N	Caretaker
	DE			SEN-ger	Aux N/LPN		Carer, Care ass
	NL		RN		LPN/Aux-N	Ass-N	Carer
	ES				Aux-N/LPN		Caretaker
	SE				LPN/Aux-N	Nurse Aid
	UK						Carer
Home help/care with PADL: Help provided with Personal Activities of Daily Living (PADL) at home by paid professionals	EE						Carer, SW-ass
	FI		RN		Aux N/LPN
	FR		RN			Ass-N	Caretaker
	DE		SW	OT, Physio-T, SEN, SEN-ger			Carer
	NL				LPN/Aux-N	Ass-Nurse	Carer
	ES		RN				Carer
	SE		OT		LPN/Aux-N	Ass Nurse
	UK					Supp-work	SW-Ass, Carer
Home nursing care: Nursing care provided at home including, e.g. wound dressing, injections, by RN and/or licensed practical nurse/auxiliary nurse	EE				LPN/Aux-N
	FI		RN		Aux N/LPN
	FR		RN
	DE			SEN, SEN-ger
	NL		RN		LPN/Aux-N
	ES		RN
	SE		RN		LPN/Aux-N	Ass Nurse
	UK		RN
Specialist psychiatric home nursing care: Supervision, support, treatment and monitoring by community psychiatric nurse	EE				LPN/Aux-N
	FI		RN-psych
	FR NA
	DE	MD-Psych, psychol	SW	SEN-ger, SEN-psych	Aux N/LPN
	NL		RN-psych
	ES	MD-psych, Psychol	RN
	SE		RN-psych
	UK		RN-Comm-psych		Aux-N/LPN
Rehabilitation at home: Training at home by an occupational therapist, physiotherapist and/or RN and/or licensed practical nurse/auxiliary nurse to improve or maintain functional ability	EE						Carer
	FI		PhysioT, RN, OT		Aux N/LPN
	FR		RN, OT, PhysioT			Ass-N
	DE			OT, PhysioT	Aux N/LPN		Carer
	NL	Multidisc team
	ES		PhysioT
	SE		OT, PhysioT, RN		LPN/Aux-N	Ass-N
	UK	Psychol	PhysioT, OT, RN, RN-dem, RN-comm-psych		Aux-N/LPN
Mobile comprehensive expert team: Mobile multiprofessional team with expert competence in dementia care, serving as consultants	EE NA
	FI	SAS team^d	RN-dem, RN
	FR NA
	DE	Team of MD, SEN, Case manager
	NL	Multi-disc team
	ES NA
	SE	MD-ger, MD-psych	RN-spec, RN		LPN/Aux-N
	UK NA
Personal safety alarm/Body-born alarm: Technical system allowing disabled people to call for assistance via telephone and/or wireless communication	EE						Specific organisation
	FI	GP	RN, SW		Aux N/LPN
	FR	GP, MD-ger
	DE						Vol welfare-org
	NL	GP, MD-ger, MD-neuro, MD-psych	Case manager, Physio-T
	ES		SW
	SE		SW
	UK		HHEXP SW, RN-Comm-psych, RN, RN-dem				Vol org, Carer
Accompanying service: Service for accompanying a person to appointments, providing transportation and/or shopping	EE						Carer
	FI						Vol org
	FR						Carer, caretaker
	DE						Vol org, migrant carer, carer
	NL		SW			Ass-N	Carer, SW-Ass
	ES					Supp work	Carer, migrant caretaker
	SE					Ass-N
	UK					Supp-work	Vol, Vol org
Housing adaptation: Home adapted to disability, e.g. removal of doorsteps and/or replacement of bathtub by shower	EE						Specific organisation
	FI		Physio, OT, SW
	FR		OT
	DE						Welfare org
	NL	GP, MD-spec,	Case manager, OT, Physio
	ES		SW
	SE		OT
	UK		OT
Home-delivered meals/Meal services/Catering service: A service that delivers cooked meals to disabled and/or older people in their homes	EE						Catering, Carer
	FI						Public supp serv
	FR		SW				Migrant Carer, Public supp-serv, Private Catering
	DE						Vol org
	NL		SW			Supp work	SW-Ass, carer
	ES		SW			Supp work	Carer, migrant carer
	SE				LPN/Aux-N	Nurse aid
	UK					Supp-work	Vol org,
Leisure activities: Use of free time for activities outside the daily routine, e.g. playing cards, visits to the theatre	EE					Supp-work
	FI		OT, RN		Aux N/LPN		Vol org
	FR						Caretaker
	DE			OT		Ass N	Vol org, carer
	NL		SW		LPN/Aux-N	Ass-N	Carer, sw-ass
	ES				Aux N/LPN	Supp work	Carer, migrant carer
	SE				LPN/Aux-N	Ass N
	UK		OT, RN RN-dem, Specialist therapist			Supp-work	Vol org

Case managers and home health experts have healthcare training at ISCED level 6 plus special training for the task. They could be RNs specialised in psychiatry, social workers or similar.

NA means that this kind of service is not available in the country.

The multiprofessional team commonly comprises a physician, psychologist, RN, Ass N, OT, Physio-T, SW.

SAS team includes MD-ger and GPs.

Results

In total there were 21 categories of providers identified as being involved in dementia care two of which were paid or unpaid informal caregivers (Table 1). The range of providers included general practitioners, specialised physicians, RNs (general or specialised), licensed practical nurses, assistant nurses, social workers, occupational therapists, physiotherapists, psychologists, support workers and home help officers (Table 1). Some additional professionals were identified and entered into the template, for instance, home health experts, caretakers and carers (Table 2).

Educational level according to the ISCED system

The ISCED level of the professionals involved in dementia care showed variation with regard to RNs, social workers, physiotherapists and occupational therapists, whilst physicians were educated at the same level in all countries. At ISCED level 7, representing at least a master’s degree or the equivalent, there were physicians and specialists in neurology, psychiatry, general practice or geriatrics and also psychologists (Table 2). Social workers and physiotherapists had a master’s level qualification in Estonia. At ISCED level 6, representing vocational education at bachelor level or the equivalent there were RNs, specialist RNs, social workers, case managers, health visitors, occupational therapists and physiotherapists in most of the countries. In Germany, state examined nurses (SEN) specialist or general, physiotherapists and occupational therapists were educated to ISCED level 5 as were RNs in Estonia.

Level 4 included auxiliary nurses, equivalent to licensed practical nurses (LPN), with post-secondary but not tertiary vocational training. At level 3, professionals with upper secondary vocational training were represented by assistant nurses, nurse aids and support workers. Finally, there was a group of professionals who were unclassified because no formal health care training was required for their tasks. This group included support work assistants, carers, migrant carers, caretakers, people from voluntary organisations and catering organisations or the like.

Professionals involved in screening, diagnosis, treatment and memory clinic

Screening for dementia was a task mainly performed by GPs and in some countries by RNs (Table 3). Screening for dementia was not available in Estonia. In Finland, France and Spain also specialists (geriatricians (ES, FR, FI)), psychiatrists and neurologists (FI) were involved. Finland reported that RNs specialised in dementia provided care and England reported that health visitors were sometimes involved in screening. Only in the Netherlands social workers and nurses with ISCED level 3 and 4 were involved in screening.

Standard procedures to establish the diagnosis, pharmacological treatment for dementia as well as pharmacological treatment for the Behavioural and Psychological Symptoms of Dementia (BPSD) were carried out by GPs or medical specialists in neurology, psychiatry or geriatrics (Table 3). In addition, Spain and England reported that psychologists were involved and Finland, Spain and England reported that RNs were involved in the process of establishing a diagnosis. In Finland, RNs specialist in dementia and in England community psychiatric nurses or health visitors were involved, all educated at ISCED level 6. Pharmacological treatment both for dementia and for BPSD was provided by GPs, MDs specialists in neurology, psychiatry or geriatrics. The Netherlands reported that RNs were involved whilst England reported the involvement of RN prescribers.

Various examples for non-pharmacological treatment were provided in the mapping system in order for each country to respond in accordance with their praxis. In terms of non-pharmacological treatment in general for people with dementia, such as memory orientation, tactile massage, etc. showed more variation in terms of providers (Table 3), ranging from psychologists (FR, ENG) to RNs, occupational therapists, physiotherapists (ISCED levels 5 or 6) and auxiliary nurses/LPNs (FI, SE) to assistant nurses (SE) or providers with no formal education in healthcare (carer, civil social organisations). There was also variation in providers of non-pharmacological treatment for BPSD (exemplified by for instance selected music, environmental modification, distraction, Table 3) ranging from psychologists (FR, ENG) to RNs or specifically trained practitioners, occupational therapists and physiotherapists. RNs specialists in dementia care or community psychiatric nurses provided such treatment in the England. Finland and Sweden reported that auxiliary nurses/LPNs provided such treatment whilst in France and Sweden it was provided also by nurses educated at ISCED level 3. Germany reported that voluntary organisations provided treatment for BPSD in addition to state examined nurses, occupational therapists and physiotherapists.

Memory clinics were staffed by GPs or specialist MDs as described earlier (Table 3). In addition, France, Germany, Spain and England reported that psychologists were the providers and England also reported the involvement of social workers. The providers in Finland were RN specialists in dementia care whilst in Estonia, the Netherlands, England and Spain RNs were providers.

Professionals involved in activities related to home care

The needs assessment prior to provision of professional care varied among the countries particularly in terms of the involvement of physician’s (Table 4). It was provided by GPs or specialist MDs or psychologists (only in ES) in all countries except Sweden, Finland and England. In these countries, needs assessments were carried out by social workers, RNs, RNs specialists in dementia care, occupational therapists (only in England) and home help experts and case managers (only in England). In addition to physicians Estonia, France, the Netherlands and Spain also reported social workers, RNs and case managers (only NL) involved in needs assessment. Germany involved in addition to GPs or specialist MDs, state examined nurses, general or specialists in dementia care. Team-based home healthcare and team-based community mental healthcare were not available in Estonia and Germany. Team-based community mental healthcare was not available in Spain. The teams comprised mainly GPs or specialist MDs, psychologists, RNs, general or specialists, physiotherapists, occupational therapists, social workers and case managers on the team. In addition, Finland and Sweden had auxiliary nurses/LPN on the team. In England, support workers (ISCED level 3) and social work assistants were also part of the team.

For home help with instrumental activities of daily living (IADL) providers ranged from RNs to those with no formal healthcare training, predominantly auxiliary nurses/LPN, except in Estonia where the providers were carers or support workers only. Countries other than Finland and Sweden used people with no formal healthcare training. RNs or SEN (DE) were involved in Finland, France and the Netherlands. The Netherlands and Sweden also used nurse assistants as providers. The pattern was similar for PADL with regard to RNs and social workers, occupational therapists and physiotherapists were also involved in Germany (SEN, SEN-ger) and in Sweden (OT only). Auxiliary nurses/LPN provided home help with personal activities of daily living (PADL) in all the countries except Germany, France and England, the latter having providers at ISCED level 3 (support workers) only. Home nursing care involved a combination of providers, RNs in all countries but Estonia (Germany SEN, SEN-ger) and auxiliary nurses/LPN (not FR, DE, ENG and ES). Assistant nurses were involved only in Sweden. Specialist psychiatric home nursing care involved MDs specialists in psychiatry and psychologist in Germany and Spain and also social workers in Germany. In other countries such care was provided by RNs (ES) or RNs specialists in psychiatry or in community mental health (England). Estonia, Germany and England also used auxiliary nurses/LPN to provide this care. No such care was available in France.

Rehabilitation at home involved a mix of professional providers mainly at ISCED levels 5–6. These were RNs, RNs specialists in dementia or in community psychiatry, physiotherapists, occupational therapists or physiotherapists only (ES). Multidisciplinary teams were available in the Netherlands. In addition to providers at ISCED levels, 5–6 auxiliary nurses/LPN were involved in Finland, Spain, Sweden and England and assistant nurses in France and Sweden. In Estonia, carers were the only providers of rehabilitation at home. Mobile, comprehensive expert teams specialising in dementia care were available in Finland, the Netherlands, Germany and Sweden. In addition, RNs or RNs specialists in dementia were involved in Finland and Sweden and LPNs in Sweden.

Other services to support home care such as accompanying services were provided by staff with no formal healthcare training or by separate organisations apart from the Netherlands (social workers and assistant nurses), England (support workers) and Sweden (assistant nurses). Home-delivered meals were also mainly provided by staff with no formal health care training, whilst social workers were involved in France, the Netherlands and Spain and LPNs in Sweden. Safety alarms were provided by GPs or MD specialists in Finland, France and the Netherlands whilst in other countries this was done by a mixture of professionals at ISCED levels 5–6, mainly not only RNs and social workers, but also specialist RNs, case managers and home health experts. Voluntary organisations were also providers (DE, UK) as were specific organisations in Estonia. Leisure activities involved social workers (NL), occupational therapists and RNs (FI, ES) and dementia-trained RNs (England). In addition, auxiliary nurses/LPNs were involved (NL, ES, SE). Support workers were involved in Estonia and England and assistant nurses in the Netherlands, Spain and Sweden. Carers or voluntary organisations provided such service in France. Such organisations also were involved in all countries but Estonia and Sweden, but in addition to people with formal healthcare training. Housing adaptation was provided by professionals at ISCED levels 5–6 in most countries (FI, FR, NL, ES, SE, Eng) and not only, mainly, involved occupational therapists, but also social workers, case managers and physiotherapists. In the Netherlands, GPs and specialist MDs were involved whilst Germany used welfare organisations and Estonia specific organisations.

Discussion

Overall, the findings indicate more similarities than differences among the eight countries involved. This applies to the level of education to which the staff involved is trained and also the type of professionals involved in the tasks presented here. However, there are also differences which may influence the quality of care provided. As for the categorisation in terms of ISCED level, the education of the staff ranged from master’s level to upper secondary level or below (no formal healthcare training required) (Table 2). The educational level differs particularly for RNs, physiotherapists and occupational therapists, who are reported to be educated at bachelor’s level or the equivalent in all countries but Germany and Estonia (RNs). It is not possible to establish whether this difference has any implications for practice, however, those trained at bachelor’s level are usually trained to work with research, draw on research findings and apply developmental work. Aiken, Clarke, Cheung, Sloane, and Silber (2003) show a higher proportion of nurses with a bachelor’s degree coincides with a lower level of mortality in hospital care. It has also been found that returning to education to get a bachelor’s degree is worthwhile from work life perspective (Spetz & Bates, 2013). As far as we know, no such studies have been carried out in dementia care or geriatric care in general. Social workers and physiotherapists were educated to a higher ISCED level (Master’s level) in Estonia compared to the other countries, which probably strengthens even more the provider’s ability to critically review their work, apply scientific knowledge and, through developmental work, address the challenges this kind of work raises. The findings point to the need for comparative studies to take into consideration not only the titles of the professionals involved, but also their level of education since definitions of a nurse, for instance, may differ and may have implications for quality of care. The impact of the level of education also needs to be explored in this kind of care.

The list of professions involved was comprehensive: in all more than 20 different professions ranging from those trained at masters level or above to those with no formal healthcare training at all were described as being involved in the care provided (Table 1). The findings do not provide information as for proportion of involvement and where the main responsibility lies. The attempt to include such information failed since it became too complex. However, their involvement differs depending on the task to be performed. Thus those trained at a higher level are mainly involved in screening for dementia, diagnostic procedures and pharmacological treatment (Table 3) whilst staff trained at lower levels were reported to be involved in providing help with the IADL, PADL and additional services (Table 4). This number of categories of staff seems reasonable although it may have implications for the care provided, especially in terms of continuity over time. This study reveals only the type of professionals involved in the trajectory of care. The number of staff the patient and the informal caregiver have to encounter may be much larger due to working hours and staff turnover or transfer to other places or the like. The patient and the informal caregiver may have to meet many professionals over the course of life with dementia. Thus the continuity and the opportunity to develop a trusting relationship and provide care well-adapted to the needs of the patient and the support to the informal caregiver may be compromised. It has been suggested, from a study based on services provided in 50 regions of the Netherlands that care needs to be improved in terms of coordination and orientation towards the demands of the consumers and to be less supply-driven (Vollenberg, Schalk, & Merks-Van Brunschot, 2013). Further research is needed to reveal the involvement of professionals, where the main responsibility is placed throughout the trajectory of care, the disease itself and the recipient’s experience of this.

All countries reported the involvement of specialists in general practice, geriatrics, psychiatry and neurology. Dementia screening, standard diagnostic procedures and memory clinics involved specialist medical doctors and in some countries psychologists and RNs/SENs. This is also true of pharmacological treatment addressing cognitive decline or BPSD. The pattern of the eight countries was consistent with some minor differences, for instance, England used RN prescribers and the Netherland LPNs and assistant nurses involved in dementia screening. It cannot be established from the data whether this potential for the involvement of one or more of three alternative specialists in addition to the GP is helpful or not from the patient’s perspective. It may well be that the result is merely a sign of collaborative care tailored to the needs of individuals and not that all four specialists actually encountered the patient (Callahan et al., 2006).

Callahan et al. (2006) showed that care management is effective in terms of the patient’s quality of life and in reducing BPSD and thus the strain on caregivers. It makes sense that GPs are involved as they are meant to form the frontline in healthcare and also act as gate keepers in relation to other specialties. The findings do not reveal whether there are some directions for when a geriatrician, neurologist or psychiatrist should be involved; it may be a case of team work with a care manager in the front line. The findings may indicate that care throughout the trajectory can be developed further taking into account the perspective of the patient and the informal caregiver. These findings are worthy of further research in order to establish best practice. The Alcove project (www.alcove-project.eu) may provide a platform for such a study.

Non-pharmacological treatment in general and non-pharmacological treatment of BPSD show variations in terms of the professionals involved. The definition of such treatment was broad which may be a threat to validity and the results call for a deeper investigation of the methods and the scientific bases for applying them. However, in the Netherlands, it is seemingly a task for a multidisciplinary team whilst in the other countries it is mainly a task for RNs/SENs, occupational therapists or physiotherapists, and in Finland and Sweden it also involves LPNs/auxiliary nurses whilst in Estonia it involves carers and in Germany voluntary organisations. In England and France, this kind of treatment involves psychologists. Thus the variation in terms of educational level is wide bearing in mind that the situation is a serious challenge for caregivers and knowledge about causes and how to intervene is sparse. Non-pharmacological interventions are a matter not only when BPSD has developed, but also for people with dementia in general. Although the evidence base for the efficiency of various techniques is still weak (www.alcove-project.eu) such interventions is needed to provide comfort and adapt the environment to the needs of people with dementia, preventive interventions as part of the care. Once BPSD has developed non-pharmacological intervention is one way to try to alter the behaviour. Kolanowski, Fick, Frazer, and Penrod (2010) emphasised that non-pharmacological interventions require better preparation of staff and that staff often feel unprepared to deal with BPSD efficiently. It is well known that BPSD is a serious challenge for informal caregivers and more knowledge is needed to understand the mechanisms contributing to BPSD and also the effectiveness of interventions aimed at controlling such behaviour (Edberg, Moyle, & Chan, 2012). The evidence base is weak and the lack of standardisation of the intervention method as such and the competence needed to apply it correctly most likely contribute to lack of evidence. It is also noteworthy that not many countries reported the involvement of professionals with specific training in dementia care; only England reported the use of such professionals. Seemingly the responsibility is spread among RNs, occupational therapists and/or physiotherapists. This may raise the question, as with medical specialists, of clarity in terms of responsibility and be helpful in sorting out ineffective non-pharmacological interventions from those that may have a positive impact on the behaviour and the patient’s well-being.

Overall home care showed diversity in terms of the professionals involved in the tasks reported (Table 4), particularly in the provision of help related to IADL and PADL. Auxiliary nurses, assistant nurses and staff with no formal health care education predominated as providers and with RNs or SENs also involved. Countries other than Finland and Sweden used people with no formal health care education. Not many professionals with specific training in dementia care were involved in these tasks. This is noteworthy in the sense that the possibility of detecting problems of a physical or psychosocial character occurs in the daily encounter with the patient and the family caregiver. Education has implications for detecting such problems and also for dealing with them in a professional manner. It has also been shown that work life stress is higher among staff with no formal competence (Engström, Skytt, & Nilsson, 2011). Initiatives have been taken to develop a core competence framework for the dementia care staff in UK (Tsaroucha, Benbow, Kingston, & Le Mesurier, 2011), however no signs of its implementation appeared in this study. To date much research has been carried out in relation to nursing-home care (Harrington et al., 2012) whilst there has been less focus on staffing, and organisation or quality in home care, despite the fact that most people with dementia are cared for at home for a long time, predominantly by informal caregivers that might benefit from professional support in order to deal with challenges they encounter in everyday living. The more that responsibility is directed to family and home care the more important it is to focus on home care organisation and care quality.

Specialised interventions, aimed at supporting the patient and the informal caregiver or formal caregivers with no or only basic healthcare training, are important for the success of home care. Such support could be variously ‘badged’ as ‘needs assessment’ or ‘team-based home health care’, ‘community mental health care for older people’, ‘rehabilitation at home’ or as ‘home nursing care’ or ‘specialist psychiatric home nursing care’. These modes of intervention were reported as being provided by people trained at bachelor’s level or equivalent. They may complement or support those people who are providing everyday care in the home of the patient. In contrast, activities to improve daily life such as accompanying services, home-delivered meals and leisure activities were dominated by staff with no formal healthcare training, volunteers, migrant carer or carers. It may well be that professionals in the specialist teams monitor, transfer knowledge or supervise those involved in daily care activities. This will ensure that the practice is based on the best evidence. Interventions to improve management and knowledge transfer indicate that it is not easy to be sure that the best knowledge is applied in daily practice (Cornes & Manthorpe, 2013).

This study does not shed light on how care is organised, only on who the providers are, related to various tasks. However, research focusing on the organisation and quality control of home care seems to be important for ensuring quality in home care. Research concerning the optimal skill mix and the way knowledge is transferred to those involved in daily practice is necessary to meet the challenge of ensuring high quality home care. Such knowledge may have implications for home care nurses (Tourangeau et al., 2013), retaining nurses in dementia care (Chenoweth, Jeon, Merlyn, & Brodaty, 2010) and for those receiving the care and support.

This study provides an overview of the professionals involved in diagnostics and medical treatment and in the home care of people with dementia in eight European countries. It has limitations in that no data are available on how the responsibility and quality control are distributed among the reported professionals. It has limitations in that a specific reported professional may be only marginally involved in the care and that big variation may be hidden behind an agreed definition for instance of non-pharmacological treatment. It’s strengths, however, include the definition of educational levels, standardised in accordance to the academic level to which a specific professional is trained and in the differentiation of nurses involved in particular tasks. There may be variation in the educational level within a country due to changes of educational systems. The findings, however, reveal a pattern wherein daily hands-on care is often provided by people with a lower educational level or by staff with no formal healthcare education.

Further research is needed to reveal who provides diagnostics and treatment, with what penetration and acceptability, at what costs and with what benefit. In addition, there is much more to learn about how home care is organised, how its quality measured and costed and how it complements and supports the contributions of informal carers and networks. The findings of this study indicate that many professionals of differing professions are ‘providers’ somewhere in the spectrum of dementia care. It may be difficult for the patient and the informal caregiver to cope with the number and potential complexity of these arrangements. Continuity of care are greatly valued and thought to be cost effective. It is striking that training specified as ‘dementia care’ has not become a common feature of the workforce’s qualifications.

Footnotes

Acknowledgement

This study was conducted on behalf of the RightTimePlaceCare Consortium that included the following:

University of Witten/Herdecke (DE): Gabriele Meyer PhD, RN, professor (scientific coordinator, WP 1 leader), Astrid Stephan MScN, RN, Anna Renom-Guiteras, geriatrician, Dirk Sauerland Dr.rer.pol., professor (WP 4 & 6 leader), Dr Ansgar Wübker, Patrick Bremer dipl. oec.

Lund University (SE): Ingalill Rahm Hallberg, professor (WP 2 leader); Ulla Melin Emilsson, professor; Staffan Karlsson, PhD, Christina Bokberg, MSc, Connie Lethin, MSc.

Maastricht University (NL): Jan P.H. Hamers, PhD, RN, professor (WP 3 leader); Basema Afram, MSc; Hanneke C. Beerens, MSc, RN; Michel H.C. Bleijlevens, PhD, PT; Hilde Verbeek, PhD; Sandra M.G. Zwakhalen, PhD, RN; Dirk Ruwaard, MD, PhD, professor.

University of Manchester (UK): David Challis, professor (WP5 leader); Caroline Sutcliffe MSc; Dr David Jolley; Sue Tucker, MSc, RN; Dr Ian Bowns; Brenda Roe, professor; Alistair Burns, professor.

University of Tartu (EE): Kai Saks, MD, PhD, professor (WP 5 leader); Ene-Margit Tiit, PhD, professor; Jelena Leibur, MD, MBA; Katrin Raamat, MA; Angelika Armolik, MA; Teija Tuula Marjatta Toivari, MA, RN.

Gerontôpole, University of Toulouse (FR): Dr Maria Soto; Agathe Milhet; Dr Sandrine Sourdet; Sophie Gillette; Bruno Vellas, professor.

University of Turku (FI): Helena Leino-Kilpi, PhD, RN, professor; Jaana Koskenniemi, MNSc, RN, researcher; Riitta Suhonen, PhD, RN, professor; Matti Viitanen, MD, PhD, professor; Seija Arve, PhD, RN, docent; Minna Stolt, PhD, podiatrist; Maija Hupli, PhD, RN.

Fundació Privada Clinic per la Recerca Biomedica, Hospital Clinic of Barcelona (ES): Adelaida Zabalegui PhD, RN (WP 5 leader); Montserrat Navarro PhD, RN; Esther Cabrera PhD, RN (Tecnocampus Mataró), Ester Risco MNSc, RN; Carme Alvira MScN, RN; Marta Farre MScN, RN; Susana Miguel MScN, RN.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article: The RightTimePlaceCare study is supported by a grant from the European Commission within the 7th framework programme (project 242153).

Ingalill Rahm Hallberg, RN, PhD is a Professor in Health Care Sciences at Lund University, Sweden. Her research focuses broadly on care of the elderly, in particular people with severe illnesses including dementia. She is Professor emeritus at Lund University, Chair of the Pufendorf Institute of Advanced Studies at Lund University. She is Fellow of the European Academy of Nursing Science (FEANS) and Fellow of the American Academy of Nursing (FAAN).

Ester Cabrera, PhD, RN is a Fellow of the European Academy of Nursing Science (EANS) and is currently the Dean of the School of Health Sciences TecnoCampus, University Pompeu Fabra, Barcelona, Spain. Since 1998 she has worked in the area of higher education, teaching in nursing faculties in graduate, master and doctoral programs. Her field of research is elderly and chronicity and she leads a line of research in genetics in cancer and nursing with national and international publications.

David Jolley is a consultant psychiatrist who specialises in the care of older people, and who has clinical appointments in Manchester, Tameside and Gnosall, UK. His research contributions span service development and evaluation, and a range of clinical and care issues related to mental disorder and later life. He is Honorary Reader in the Personal Social Service Research Unit of The University of Manchester, UK.

Katrin Raamat, Master in Social Sciences, is a health social worker. Her focus of interest and study has been palliative care and work with cancer patients for a number of years. During the last 8 years she also worked for people with dementia and their families, being a promoter of educational projects for formal carers of people with dementia. Currently she is working as the Head of Palliation Service of the North Estonia Medical Centre, Tallinn, Estonia.

Anna Renom-Guiteras is a geriatrician and PhD student. She has been engaged in geriatric research involving several European countries and disciplines, focusing on dementia care and on the reduction of potentially inappropriate medications in older adults. Currently, she is working as a research fellow in the Institute of General Practice and Family Medicine, Faculty of Health, University of Witten/Herdecke, Germany.

Hilde Verbeek, PhD is an assistant professor at the department of health services research at Maastricht University, the Netherlands and coordinator of the Academic Collaborative Centre on Care for Older People. Her research is focusing on dementia care within the research program on Innovations in health care for the elderly at CAPHRI School of Public Health and Primary Care, Maastricht University, the Netherlands.

Maria Soto is a Geriatrician, MD, Head of the Alzheimer Acute Ward of the Geriatrics Department in the Toulouse University Hospital, France. Her research focuses on late life Alzheimer's disease with a special interest on neuropsychiatric symptoms. Her research activity is developed in the Alzheimer' Disease Research Center of Gerontopole, France.

Minna Stolt, PhD is a University teacher and post doc researcher in the Department of Nursing Science in University of Turku, Finland. Her research focuses on older people nursing, especially functional ability and foot health of older adults.

Staffan Karlsson, PhD is a Registered Nurse and a senior lecturer. His research focuses on care and services for older people, especially people with dementia. He is an Assistant Professor in the department of Health Sciences, Lund University, Sweden.

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