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Assessing the Effectiveness of an Approach for Vocal Behaviors in Older People Living in Nursing Homes

Primary Purpose

Behavioral Symptoms

Status
Recruiting
Phase
Not Applicable
Locations
Canada
Study Type
Interventional
Intervention
Approach based on the meanings of vocal behaviours
Usual practices
Sponsored by
Centre de Recherche de l'Institut Universitaire de Geriatrie de Montreal
About
Eligibility
Locations
Arms
Outcomes
Full info

About this trial

This is an interventional supportive care trial for Behavioral Symptoms focused on measuring Behavioral and psychological symptoms of dementia, Psychosocial interventions, Well-being, Long-term care facilities, Family and formal caregivers, Partnership

Eligibility Criteria

18 Years - undefined (Adult, Older Adult)All SexesDoes not accept healthy volunteers

Inclusion Criteria:

  • Older people: being 65 years old or more, having a diagnostic of Alzheimer's disease or related disorders, manifesting vocal behaviours daily and having contact with a family caregiver.
  • Family caregivers: being a person that has an emotional and social relation with the older person, visiting her/him at least twice a month, speaking English or French.
  • Formal caregivers: being a registered nurse (RN), licensed practical nurse (LPN), nurses' aide (NA) or another health professional involved at least three times per week in the care of the older person, speaking English or French.

Exclusion Criteria:

  • Older people: having a life expectancy of less than three months
  • Family caregivers: N/A
  • Formal caregivers: having already participated in the trial for another older person.

Sites / Locations

  • CHSLD Laval et Riviera
  • CIUSSS Nord-de-l'Île-de-MontréalRecruiting
  • Residence AngelicaRecruiting
  • CIUSSS Ouest-de-l'Île-de-Montréal
  • Résidence Berthiaume-du-Tremblay
  • Vigi Santé
  • CIUSSS Centre-Sud-de-l'Île-de-MontréalRecruiting

Arms of the Study

Arm 1

Arm 2

Arm Type

Experimental

Active Comparator

Arm Label

Experimental group

Control group

Arm Description

Approach based on the meanings of vocal behaviours

Usual practices of formal caregivers regarding vocal behaviours

Outcomes

Primary Outcome Measures

Change from baseline frequency of vocal behaviors
Cohen-Mansfield Agitation Inventory (CMAI); 29 behaviours on a 7-point Likert scale. Subscale "verbally agitated behaviours" of 6 items; A high score indicates a high frequency; For subscale "verbally agitated behaviours": Average score Min = 1 and Max = 7

Secondary Outcome Measures

Change from baseline frequency of vocal behaviors to follow-up
Cohen-Mansfield Agitation Inventory (CMAI); 29 behaviours on a 7-point Likert scale. Subscale "verbally agitated behaviours" of 6 items; A high score indicates a high frequency; For subscale "verbally agitated behaviours": Average score Min = 1 and Max = 7
Change from baseline in well-being
Quality of Life in Late-Stage Dementia (QUALID); 11 emotional states and activities on a 5-point scale; A low score indicates a better well-being; Average score Min = 11 and Max = 55
Change from baseline in well-being
Quality of Life in Late-Stage Dementia (QUALID); 11 emotional states and activities on a 5-point scale; A low score indicates a better well-being; Average score Min = 11 and Max = 55
Change from baseline in medication use
Medical chart
Change from baseline in medication use
Medical chart
Change from baseline in perceived disruptiveness of vocal behaviors-formal caregivers
Cohen-Mansfield Agitation Inventory (CMAI); 29 behaviours on a 5-point disruptiveness scale. Subscale "verbally agitated behaviours" of 6 items; A high score indicates a significant disruptiveness; For subscale "verbally agitated behaviours": Average score Min = 1 and Max = 6
Change from baseline in perceived disruptiveness of vocal behaviors-formal caregivers
Cohen-Mansfield Agitation Inventory (CMAI); 29 behaviours on a 5-point disruptiveness scale. Subscale "verbally agitated behaviours" of 6 items; A high score indicates a significant disruptiveness; For subscale "verbally agitated behaviours": Average score Min = 1 and Max = 6
Change from baseline in perceived disruptiveness of vocal behaviors-family caregivers
Cohen-Mansfield Agitation Inventory (CMAI); 29 behaviours on a 5-point disruptiveness scale. Subscale "verbally agitated behaviours" of 6 items; A high score indicates a significant disruptiveness; For subscale "verbally agitated behaviours": Average score Min = 1 and Max = 6
Change from baseline in perceived disruptiveness of vocal behaviors-family caregivers
Cohen-Mansfield Agitation Inventory (CMAI); 29 behaviours on a 5-point disruptiveness scale. Subscale "verbally agitated behaviours" of 6 items; A high score indicates a significant disruptiveness; For subscale "verbally agitated behaviours": Average score Min = 1 and Max = 6
Change from baseline in partnership-based decision-making-family caregivers' perspective
Family Perception of Caregiving Role (FPCR); 43 items on a 7-point Likert scale with three subscales. The sub-dimension "characteristics of the role" will be used (23 items); The lower the score, the higher is the partnership; For subscale "characteristics of the role": Average score Min = 1 and Max = 7
Change from baseline in partnership-based decision-making-family caregivers' perspective
Family Perception of Caregiving Role (FPCR); 43 items on a 7-point Likert scale with three subscales. The sub-dimension "characteristics of the role" will be used (23 items); The lower the score, the higher is the partnership; For subscale "characteristics of the role": Average score Min = 1 and Max = 7
Change from baseline in partnership-based decision-making-formal caregivers' perspective
Staff Perception of Caregiving Role (SPCR) questionnaire; 58 items measured on a 7-point Likert scale. Two subscales, "consequence of interactions" (32 items) and "partnership with the family" (26 items); Each one has a separate score; The lower the score, the higher is the partnership; For each subscale: Average score Min = 1 and Max = 7
Change from baseline in partnership-based decision-making-formal caregivers' perspective
Staff Perception of Caregiving Role (SPCR) questionnaire; 58 items measured on a 7-point Likert scale. Two subscales, "consequence of interactions" (32 items) and "partnership with the family" (26 items); Each one has a separate score; The lower the score, the higher is the partnership; For each subscale: Average score Min = 1 and Max = 7
Change from baseline in partnership-based decision-making-formal caregivers' attitudes
Attitudes about Families Checklist (AFC); 16 items measured on a 7-point Likert scale. Three subscales "quieting/disquieting" (5 items), "partner-subordinate" (4 items) and "relevant-irrelevant" (7 items); Each one has a separate score; The higher the score, the more positive is the attitude; For each subscale: Average score Min = 1 and Max = 7
Change from baseline in partnership-based decision-making-formal caregivers' attitude
Attitudes about Families Checklist (AFC); 16 items measured on a 7-point Likert scale. Three subscales "quieting/disquieting" (5 items), "partner-subordinate" (4 items) and "relevant-irrelevant" (7 items); Each one has a separate score; The higher the score, the more positive is the attitude; For each subscale: Average score Min = 1 and Max = 7
Change from baseline in empowerment-formal caregivers
Unique question ("When the older person manifests vocal behaviours, I feel I can do something for her/him"); 100-mm visual analogue scale ranging from Min = 0 (I feel that I cannot do anything for her/him) to Max = 100 (I feel I can always do something for her/him); The higher the score, the higher is the empowerment.
Change from baseline in empowerment-formal caregivers
Unique question ("When the older person manifests vocal behaviours, I feel I can do something for her/him"); 100-mm visual analogue scale ranging from Min = 0 (I feel that I cannot do anything for her/him) to Max = 100 (I feel I can always do something for her/him); The higher the score, the higher is the empowerment.
Change from baseline in empowerment-family caregivers
Unique question ("When my relative manifests vocal behaviours, I feel I can do something for her/him"); 100-mm visual analogue scale ranging from Min = 0 (I feel that I cannot do anything for her/him) to Max = 100 (I feel I can always do something for her/him); The higher the score, the higher is the empowerment.
Change from baseline in empowerment-family caregivers
Unique question ("When my relative manifests vocal behaviours, I feel I can do something for her/him"); 100-mm visual analogue scale ranging from Min = 0 (I feel that I cannot do anything for her/him) to Max = 100 (I feel I can always do something for her/him); The higher the score, the higher is the empowerment.
Cost
Management data

Full Information

First Posted
April 9, 2018
Last Updated
February 7, 2023
Sponsor
Centre de Recherche de l'Institut Universitaire de Geriatrie de Montreal
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1. Study Identification

Unique Protocol Identification Number
NCT03506672
Brief Title
Assessing the Effectiveness of an Approach for Vocal Behaviors in Older People Living in Nursing Homes
Official Title
Assessing the Effectiveness of an Approach Based on the Meanings of Vocal Behaviours in Older People Living With Alzheimer's Disease in Long-term Care Facilities: DECIBELS Project
Study Type
Interventional

2. Study Status

Record Verification Date
February 2023
Overall Recruitment Status
Recruiting
Study Start Date
November 30, 2018 (Actual)
Primary Completion Date
March 2024 (Anticipated)
Study Completion Date
January 2025 (Anticipated)

3. Sponsor/Collaborators

Responsible Party, by Official Title
Principal Investigator
Name of the Sponsor
Centre de Recherche de l'Institut Universitaire de Geriatrie de Montreal

4. Oversight

Studies a U.S. FDA-regulated Drug Product
No
Studies a U.S. FDA-regulated Device Product
No
Data Monitoring Committee
No

5. Study Description

Brief Summary
Between 13 and 60% of older people who live with Alzheimer's disease (ADRD) in long-term care facilities (LTCFs) manifest vocal behaviours (VB) that may seem inappropriate, e.g. moaning, screaming, calling out. These behaviours may indicate ill-being, disturb others, create feelings of powerlessness in family and formal caregivers, and lead to inappropriate medication. Previous efforts to reduce VB have been largely ineffective. A new approach was developed based on finding the underlying reasons for VB through a partnership between family and formal caregivers. The goals are to reduce VB, enhance older people's well-being, and increase family and formal caregivers' empowerment. The approach was tested in a pilot study of 14 triads comprising an older person living with ADRD, a family caregiver and a formal caregiver. The results were promising; overall, it is feasible to implement the approach in LTCF and it has positive effects on older people, family and formal caregivers. Now the investigators propose to assess the clinical and economic impact of the approach in 20 LTCFs with 108 triads like those in the pilot study. The approach will be implemented in 10 randomly selected "experimental" LTCFs; the other 10 (control group) will continue with their usual practices. The investigators will measure VB frequency and the well-being of the older people before, two and four months after starting the implementation. They will also measure the perceived disruptiveness of VB for family and formal caregivers, their ability to work in partnership and their empowerment relative to VB. The investigators will compare data between the control and experimental LTCFs, and calculate cost-effectiveness based on changes in VB frequency. The proposed three-year project aims to improve the well-being of all involved in LTCF by promoting a better understanding of VB and implementing a solution to optimize care. The investigators believe the findings will provide evidence to justify the wider implementation of the approach in LTCF.
Detailed Description
Aim: To assess the clinical and economic effectiveness of an approach based on the meanings of vocal behaviours (VB) in older people living with Alzheimer's disease or related disorders (ADRD) in long-term care facilities (LTCF) using a pragmatic randomized trial complemented by a qualitative component. Background: Vocal behaviours are common in LTCF; 13 to 60% of residents exhibit them. They may indicate ill-being, are associated with overmedication, are disruptive for others, and induce powerlessness in family and formal caregivers. Studies on interventions to reduce VB have shown limited clinical impacts. In previous projects, the investigators developed and pilot tested a novel approach based on the underlying meanings of VB. The systematic approach comprises family-formal caregivers' partnerships which include regular meetings (at least monthly) to identify the meanings behind VB (e.g. pain, anxiety) and to apply personalized interventions (e.g. gardening, humor). A pilot study conducted in five LTCF demonstrated the feasibility and acceptability of the recruitment and data collection methods, as well as the approach implementation using 14 triads, each made up of an older person with ADRD, a family caregiver and a formal caregiver. The approach decreased the frequency of VB, and increased the well-being of the older people with ADRD. The formal and family caregivers perceived the VB as less disruptive, and felt more empowered relative to them. However, the lack of control group precluded measuring effectiveness versus usual practices and costs. Methods: A pragmatic cluster randomized trial will be conducted to assess the effectiveness of the approach based on the results from the pilot study. A concomitant qualitative component will describe process elements that contribute to the measured effects. The investigators will randomize 20 LTCF to either an experimental (approach) or control group (usual practices), and recruit 6 triads in each LTCF for a total of 108 triads (power of 80%, significance 5%, medium effect size and 40% attrition). They will enroll 10 to 20 triads in the qualitative component. They will collect data, before, two (post-implementation) and four months (follow-up) after starting the implementation of the approach, on VB frequency (primary outcome), medication use, well-being of the older people, perceived disruptiveness of the VB, the partnership-based decision-making and the level of empowerment felt by family and formal caregivers. Additionally, they will collect data on the setting (e.g. number of beds, turnover rate), and cost (e.g. trainer, medication). Qualitative data will also be collected with individual semi-structured interviews. The investigators will analyze the effects of the approach using a mixed-model of covariance with baseline measures, and characteristics of participants and settings as covariates. They will also calculate a cost-effectiveness ratio, and do a content analysis of qualitative data. Expected outcomes: This project will provide evidence on the effectiveness of a novel and generalizable approach to increase the well-being of vulnerable older people, as well as family and formal caregivers. If effective, it may be implemented on a larger scale and adapted to other behaviours (e.g. aggressive behaviours), all of which is aligned with recommendations for research in dementia care.

6. Conditions and Keywords

Primary Disease or Condition Being Studied in the Trial, or the Focus of the Study
Behavioral Symptoms
Keywords
Behavioral and psychological symptoms of dementia, Psychosocial interventions, Well-being, Long-term care facilities, Family and formal caregivers, Partnership

7. Study Design

Primary Purpose
Supportive Care
Study Phase
Not Applicable
Interventional Study Model
Parallel Assignment
Masking
Outcomes Assessor
Allocation
Randomized
Enrollment
324 (Anticipated)

8. Arms, Groups, and Interventions

Arm Title
Experimental group
Arm Type
Experimental
Arm Description
Approach based on the meanings of vocal behaviours
Arm Title
Control group
Arm Type
Active Comparator
Arm Description
Usual practices of formal caregivers regarding vocal behaviours
Intervention Type
Other
Intervention Name(s)
Approach based on the meanings of vocal behaviours
Intervention Description
Systematic problem-solving approach involving reflecting, deciding, planning and acting together (family and formal caregivers to reduce vocal behaviours and to increase everyone's well-being.
Intervention Type
Other
Intervention Name(s)
Usual practices
Intervention Description
Usual practices of formal caregivers regarding vocal behaviours
Primary Outcome Measure Information:
Title
Change from baseline frequency of vocal behaviors
Description
Cohen-Mansfield Agitation Inventory (CMAI); 29 behaviours on a 7-point Likert scale. Subscale "verbally agitated behaviours" of 6 items; A high score indicates a high frequency; For subscale "verbally agitated behaviours": Average score Min = 1 and Max = 7
Time Frame
2 months
Secondary Outcome Measure Information:
Title
Change from baseline frequency of vocal behaviors to follow-up
Description
Cohen-Mansfield Agitation Inventory (CMAI); 29 behaviours on a 7-point Likert scale. Subscale "verbally agitated behaviours" of 6 items; A high score indicates a high frequency; For subscale "verbally agitated behaviours": Average score Min = 1 and Max = 7
Time Frame
4 months (follow-up)
Title
Change from baseline in well-being
Description
Quality of Life in Late-Stage Dementia (QUALID); 11 emotional states and activities on a 5-point scale; A low score indicates a better well-being; Average score Min = 11 and Max = 55
Time Frame
2 months
Title
Change from baseline in well-being
Description
Quality of Life in Late-Stage Dementia (QUALID); 11 emotional states and activities on a 5-point scale; A low score indicates a better well-being; Average score Min = 11 and Max = 55
Time Frame
4 months (follow-up)
Title
Change from baseline in medication use
Description
Medical chart
Time Frame
2 months
Title
Change from baseline in medication use
Description
Medical chart
Time Frame
4 months (follow-up)
Title
Change from baseline in perceived disruptiveness of vocal behaviors-formal caregivers
Description
Cohen-Mansfield Agitation Inventory (CMAI); 29 behaviours on a 5-point disruptiveness scale. Subscale "verbally agitated behaviours" of 6 items; A high score indicates a significant disruptiveness; For subscale "verbally agitated behaviours": Average score Min = 1 and Max = 6
Time Frame
2 months
Title
Change from baseline in perceived disruptiveness of vocal behaviors-formal caregivers
Description
Cohen-Mansfield Agitation Inventory (CMAI); 29 behaviours on a 5-point disruptiveness scale. Subscale "verbally agitated behaviours" of 6 items; A high score indicates a significant disruptiveness; For subscale "verbally agitated behaviours": Average score Min = 1 and Max = 6
Time Frame
4 months (follow-up)
Title
Change from baseline in perceived disruptiveness of vocal behaviors-family caregivers
Description
Cohen-Mansfield Agitation Inventory (CMAI); 29 behaviours on a 5-point disruptiveness scale. Subscale "verbally agitated behaviours" of 6 items; A high score indicates a significant disruptiveness; For subscale "verbally agitated behaviours": Average score Min = 1 and Max = 6
Time Frame
2 months
Title
Change from baseline in perceived disruptiveness of vocal behaviors-family caregivers
Description
Cohen-Mansfield Agitation Inventory (CMAI); 29 behaviours on a 5-point disruptiveness scale. Subscale "verbally agitated behaviours" of 6 items; A high score indicates a significant disruptiveness; For subscale "verbally agitated behaviours": Average score Min = 1 and Max = 6
Time Frame
4 months (follow-up)
Title
Change from baseline in partnership-based decision-making-family caregivers' perspective
Description
Family Perception of Caregiving Role (FPCR); 43 items on a 7-point Likert scale with three subscales. The sub-dimension "characteristics of the role" will be used (23 items); The lower the score, the higher is the partnership; For subscale "characteristics of the role": Average score Min = 1 and Max = 7
Time Frame
2 months
Title
Change from baseline in partnership-based decision-making-family caregivers' perspective
Description
Family Perception of Caregiving Role (FPCR); 43 items on a 7-point Likert scale with three subscales. The sub-dimension "characteristics of the role" will be used (23 items); The lower the score, the higher is the partnership; For subscale "characteristics of the role": Average score Min = 1 and Max = 7
Time Frame
4 months (follow-up)
Title
Change from baseline in partnership-based decision-making-formal caregivers' perspective
Description
Staff Perception of Caregiving Role (SPCR) questionnaire; 58 items measured on a 7-point Likert scale. Two subscales, "consequence of interactions" (32 items) and "partnership with the family" (26 items); Each one has a separate score; The lower the score, the higher is the partnership; For each subscale: Average score Min = 1 and Max = 7
Time Frame
2 months
Title
Change from baseline in partnership-based decision-making-formal caregivers' perspective
Description
Staff Perception of Caregiving Role (SPCR) questionnaire; 58 items measured on a 7-point Likert scale. Two subscales, "consequence of interactions" (32 items) and "partnership with the family" (26 items); Each one has a separate score; The lower the score, the higher is the partnership; For each subscale: Average score Min = 1 and Max = 7
Time Frame
4 months (follow-up)
Title
Change from baseline in partnership-based decision-making-formal caregivers' attitudes
Description
Attitudes about Families Checklist (AFC); 16 items measured on a 7-point Likert scale. Three subscales "quieting/disquieting" (5 items), "partner-subordinate" (4 items) and "relevant-irrelevant" (7 items); Each one has a separate score; The higher the score, the more positive is the attitude; For each subscale: Average score Min = 1 and Max = 7
Time Frame
2 months
Title
Change from baseline in partnership-based decision-making-formal caregivers' attitude
Description
Attitudes about Families Checklist (AFC); 16 items measured on a 7-point Likert scale. Three subscales "quieting/disquieting" (5 items), "partner-subordinate" (4 items) and "relevant-irrelevant" (7 items); Each one has a separate score; The higher the score, the more positive is the attitude; For each subscale: Average score Min = 1 and Max = 7
Time Frame
4 months (follow-up)
Title
Change from baseline in empowerment-formal caregivers
Description
Unique question ("When the older person manifests vocal behaviours, I feel I can do something for her/him"); 100-mm visual analogue scale ranging from Min = 0 (I feel that I cannot do anything for her/him) to Max = 100 (I feel I can always do something for her/him); The higher the score, the higher is the empowerment.
Time Frame
2 months
Title
Change from baseline in empowerment-formal caregivers
Description
Unique question ("When the older person manifests vocal behaviours, I feel I can do something for her/him"); 100-mm visual analogue scale ranging from Min = 0 (I feel that I cannot do anything for her/him) to Max = 100 (I feel I can always do something for her/him); The higher the score, the higher is the empowerment.
Time Frame
4 months (follow-up)
Title
Change from baseline in empowerment-family caregivers
Description
Unique question ("When my relative manifests vocal behaviours, I feel I can do something for her/him"); 100-mm visual analogue scale ranging from Min = 0 (I feel that I cannot do anything for her/him) to Max = 100 (I feel I can always do something for her/him); The higher the score, the higher is the empowerment.
Time Frame
2 months
Title
Change from baseline in empowerment-family caregivers
Description
Unique question ("When my relative manifests vocal behaviours, I feel I can do something for her/him"); 100-mm visual analogue scale ranging from Min = 0 (I feel that I cannot do anything for her/him) to Max = 100 (I feel I can always do something for her/him); The higher the score, the higher is the empowerment.
Time Frame
4 months (follow-up)
Title
Cost
Description
Management data
Time Frame
2 months

10. Eligibility

Sex
All
Minimum Age & Unit of Time
18 Years
Accepts Healthy Volunteers
No
Eligibility Criteria
Inclusion Criteria: Older people: being 65 years old or more, having a diagnostic of Alzheimer's disease or related disorders, manifesting vocal behaviours daily and having contact with a family caregiver. Family caregivers: being a person that has an emotional and social relation with the older person, visiting her/him at least twice a month, speaking English or French. Formal caregivers: being a registered nurse (RN), licensed practical nurse (LPN), nurses' aide (NA) or another health professional involved at least three times per week in the care of the older person, speaking English or French. Exclusion Criteria: Older people: having a life expectancy of less than three months Family caregivers: N/A Formal caregivers: having already participated in the trial for another older person.
Central Contact Person:
First Name & Middle Initial & Last Name or Official Title & Degree
Anne Bourbonnais
Phone
1-514-340-3540
Ext
4772
Email
anne.bourbonnais@umontreal.ca
Overall Study Officials:
First Name & Middle Initial & Last Name & Degree
Anne Bourbonnais
Organizational Affiliation
Centre de Recherche de l'Institut Universitaire de Geriatrie de Montreal
Official's Role
Principal Investigator
Facility Information:
Facility Name
CHSLD Laval et Riviera
City
Laval
State/Province
Quebec
ZIP/Postal Code
H3C 3J7
Country
Canada
Individual Site Status
Active, not recruiting
Facility Name
CIUSSS Nord-de-l'Île-de-Montréal
City
Montréal
State/Province
Quebec
ZIP/Postal Code
H2V 4T4
Country
Canada
Individual Site Status
Recruiting
Facility Contact:
First Name & Middle Initial & Last Name & Degree
Anne Bourbonnais
Email
anne.bourbonnais@umontreal.ca
Facility Name
Residence Angelica
City
Montréal
State/Province
Quebec
ZIP/Postal Code
H2V 4T4
Country
Canada
Individual Site Status
Recruiting
Facility Contact:
First Name & Middle Initial & Last Name & Degree
Anne Bourbonnais
Email
anne.bourbonnais@umontreal.ca
Facility Name
CIUSSS Ouest-de-l'Île-de-Montréal
City
Montréal
State/Province
Quebec
ZIP/Postal Code
H3C 3J7
Country
Canada
Individual Site Status
Active, not recruiting
Facility Name
Résidence Berthiaume-du-Tremblay
City
Montréal
State/Province
Quebec
ZIP/Postal Code
H3C 3J7
Country
Canada
Individual Site Status
Active, not recruiting
Facility Name
Vigi Santé
City
Montréal
State/Province
Quebec
ZIP/Postal Code
H3C 3J7
Country
Canada
Individual Site Status
Active, not recruiting
Facility Name
CIUSSS Centre-Sud-de-l'Île-de-Montréal
City
Montréal
State/Province
Quebec
Country
Canada
Individual Site Status
Recruiting
Facility Contact:
First Name & Middle Initial & Last Name & Degree
Anne Bourbonnais
Email
anne.bourbonnais@umontreal.ca

12. IPD Sharing Statement

Plan to Share IPD
No
Links:
URL
http://www.chairepersonneagee.umontreal.ca/en/
Description
Research website of principal investigator

Learn more about this trial

Assessing the Effectiveness of an Approach for Vocal Behaviors in Older People Living in Nursing Homes

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