Mapping implementation strategies of evidence-based interventions for three preselected phenomena in people with dementia—a scoping review

Background Caring for people with dementia is complex, and there are various evidence-based interventions. However, a gap exists between the available interventions and how to implement them. The objectives of our review are to identify implementation strategies, implementation outcomes, and influencing factors for the implementation of evidence-based interventions that focus on three preselected phenomena in people with dementia: (A) behavior that challenges supporting a person with dementia in long-term care, (B) delirium in acute care, and (C) postacute care needs. Methods We conducted a scoping review according to the description of the Joanna Briggs Institute. We searched MEDLINE, CINAHL, and PsycINFO. For the data analysis, we conducted deductive content analysis. For this analysis, we used the Expert Recommendations for Implementation Change (ERIC), implementation outcomes according to Proctor and colleagues, and the Consolidated Framework for Implementation Research (CFIR). Results We identified 362 (A), 544 (B), and 714 records (C) on the three phenomena and included 7 (A), 3 (B), and 3 (C) studies. Among the studies, nine reported on the implementation strategies they used. Clusters with the most reported strategies were adapt and tailor to context and train and educate stakeholders. We identified one study that tested the effectiveness of the applied implementation strategy, while ten studies reported implementation outcomes (mostly fidelity). Regarding factors that influence implementation, all identified studies reported between 1 and 19 factors. The most reported factors were available resources and the adaptability of the intervention. To address dementia-specific influencing factors, we enhanced the CFIR construct of patient needs and resources to include family needs and resources. Conclusions We found a high degree of homogeneity across the different dementia phenomena, the evidence-based interventions, and the care settings in terms of the implementation strategies used, implementation outcomes measured, and influencing factors identified. However, it remains unclear to what extent implementation strategies themselves are evidence-based and which intervention strategy can be used by practitioners when either the implementation outcomes are not adjusted to the implementation strategy and/or the effects of implementation strategies are mostly unknown. Future research needs to focus on investigating the effectiveness of implementation strategies for evidence-based interventions for dementia care. Trial registration The review protocol was prospectively published (Manietta et al., BMJ Open 11:e051611, 2021). Supplementary Information The online version contains supplementary material available at 10.1186/s43058-023-00486-4.


Contributions to the literature
▪ To our knowledge, this study was the first to systematically identify implementation strategies, implementation outcomes, and influencing factors across preselected phenomena in people with dementia in different care settings.▪ Established frameworks were used and enhanced for the analysis (dementia-specific adaptations of the CFIR) to advance the use of a consistent taxonomy in the field of implementation research in dementia care.▪ The identified theory-guided implementation strategies and influencing factors can be used/considered to translate evidence-based knowledge into dementia care practice.▪ Developing and testing discrete, multifaceted, and tailored implementation strategies seems necessary and will increase the impact of implementation studies, not only in dementia care research but also in other fields.

Background
Healthcare for people with dementia appears to be more complex and challenging due to the symptoms of dementia, associated care needs, higher risks, and more frequent complications than for older people without dementia [1][2][3][4].
International studies have found that a high percentage of people with dementia in long-term care settings show behaviors that challenge healthcare professionals, such as agitation or aggression [5,6].This behavior is associated with an increased burden on healthcare professionals [7] and, in the setting of long-term care, increased prescribing of psychotropic drugs for people with dementia [8][9][10].This, in turn, leads to decreased quality of life [11] and a possible increase in adverse effects such as risk of falls, an increase in medication that may lead to a sedated status, and, in the worst case, mortality [12,13].Furthermore, people with dementia are more likely to be hospitalized, have longer hospital stays, develop delirium that is more often undiagnosed, and experience a decline in their capacity to perform the activities of daily living [14][15][16][17][18].As a result, the transition process (here, discharge from hospital to home or nursing home) and postacute care needs are more complex, challenging, and are associated with poorer outcomes than for older people without dementia [19,20].
Internationally, an increasing number of psychosocial evidence-based interventions are focusing on these challenges and aimed at improving care outcomes for people with dementia [21][22][23][24][25]. Study results show that despite the increasing number of evidence-based interventions, patients receive only 30-40% of their care in line with the current scientific evidence, and in 20-25% of patients, there is a risk of harm in care [26].
Furthermore, healthcare professionals report that they implement research findings relatively seldomly in a structured and systematic way in their care practice [27].This implementation gap has been researched thoroughly.For example, regarding the prescription and administration of psychotropic drugs to people with dementia in long-term care to reduce behaviors that challenge healthcare professionals.Although this has been shown to increase mortality since 2005 and there is poor evidence of effectiveness in improving symptoms [12], implementation and provision of evidence-based alternatives such as psychosocial interventions [28] do not appear to be used as a first approach [9,29].This is partly because implementing evidence-based interventions appears to be complex for healthcare staff, and there is often a lack of knowledge about how to implement interventions in a structured way [30][31][32][33].

Implementation models, frameworks, and recommendations
To address this knowledge gap and further advance the implementation of, e.g., evidence-based interventions, various implementation models, frameworks, and recommendations for practitioners, researchers and other stakeholders exist.Among the best known are the Consolidated Framework for Implementation Research (CFIR) [34], the Expert Recommendations for Implementing Change (ERIC) [35,36], and implementation outcomes according to Proctor, Silmere [37], which represent core concepts addressed by implementation implementation outcomes are not adjusted to the implementation strategy and/or the effects of implementation strategies are mostly unknown.Future research needs to focus on investigating the effectiveness of implementation strategies for evidence-based interventions for dementia care.Trial registration The review protocol was prospectively published (Manietta et al., BMJ Open 11:e051611, 2021).
To evaluate the success of an implementation process, it is important to focus on the influencing factors for the implementation.Considering and identifying these factors can help to better select and design the implementation strategy up front [38], make appropriate adjustments during implementation, and gain a better understanding of what did or did not work and how and why after implementation has been completed.The CFIR provides a comprehensive description of these factors, which are divided into five major domains (intervention characteristics, outer setting, inner setting, characteristics of the individuals involved, and the process of implementation) [34].
The ERIC provides a comprehensive overview of 73 relevant implementation strategies that can be used individually or in combination by practitioners and researchers to implement interventions in care, for example [35,36].To assess whether an implementation has been successful and which implementation strategies are more effective, these strategies need to be tested and compared against predetermined implementation outcomes.Proctor, Silmere [37] have provided an overview of eight different implementation outcomes (acceptability, adoption, appropriateness, feasibility, fidelity, implementation cost, penetration, and sustainability), their level of analysis, theoretical basis, salience by implementation stage, and available measurements.

Research questions
To our knowledge, there is no comprehensive, systematized evidence on implementation strategies, implementation outcomes and factors that influence the implementation of evidence-based interventions, which address the three phenomena that arise from the challenges in dementia care described above.Therefore, we developed the following three research questions: ▪ Which implementation strategies are promising for the implementation of evidence-based interventions for three preselected phenomena: (A) behavior that challenges supporting a person with dementia in long-term care, (B) delirium in acute care, and (C) postacute care needs?▪ What are the effects of these implementation strategies on implementation outcomes?▪ What are the factors that influence the implementation of evidence-based interventions?

Methods
We described our methodological approach for the scoping review in our published review protocol [39], and according to Pieper, Ge [40], we reused the text of our review protocol for the methods sections in this publication and made changes in the method section where the process differed between the planned and conducted methodological approach.For reporting our scoping review, we use the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) Checklist [41], as applicable (Supplementary Table 1).Additionally, we used the flow chart of the updated Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA 2020) guidelines [42] to report the three literature searches (A, B, and C).

Search strategies
To identify evidence-based interventions addressing the preselected phenomena (A, B, and C), two researchers (MR and TQ) conducted a narrative literature search in the MEDLINE (via PubMed), CINAHL and PsycINFO (via EBSCO) databases.We identified interventions that have been tested for feasibility and effectiveness and addressed our preselected phenomena.This led to the identification of these three key interventions: the Describe, Investigate, Create and Evaluate (DICE) approach for behavior that challenges supporting a person with dementia in long-term care [43], delirium management interventions (screening, assessment, monitoring, nonpharmacological interventions) [44], and the transitional care model (TCM) for the management of postacute care needs [45].We used these interventions as starting points to develop our search string.
To develop a broad search string, we operationalized the interventions and their components into search terms.We also used other, broader terms for our identified interventions (e.g., person-centered care or transitional care) to avoid limiting ourselves to only those interventions identified up front.We supplemented these with search terms derived from our research questions (population, phenomena, implementation, setting).In addition, we used an initial search (MRM, JIB, CM and DP) in MEDLINE (via PubMed) and key publications to identify free search terms and indexing words.We clustered all of these search terms and indexing words according to the Population, Concept, and Context (PCC) mnemonic [46] and developed three different search strings (Supplemental Tables 2,  3, and 4).The search strings were developed by the researchers (A and B: MRM; C: CM), who have a professional background as nurses and have enhanced expertise in conducting reviews [47][48][49][50][51][52].Furthermore, all three search strings were checked by all researchers (JIB, DP, TQ, MR) according to the Peer Review of Electronic Search Strategies (PRESS) guideline statements [53].The search strings were first developed for MEDLINE (via PubMed) and were adapted for the other two databases (CINAHL and PsycINFO via EBSCO) according to the descriptions of RefHunter V.5.0 [54].Search strategies for all three phenomena (A, B, and C) are reported in Supplementary Tables 2,  3, and 4. We searched MEDLINE (via PubMed), CINAHL, and PsycINFO (via EBSCO) between May and June 2021 and updated the search in June 2023.In addition, we conducted backward and forward citation tracking via reference lists and Google Scholar.

Selection of evidence sources
In the first step, the abovementioned first reviewers of each review (MRM: A and B; CM: C) imported the identified records under three separate Covidence [55] licenses, and records for each search were checked automatically in Covidence for duplicates.In the second step, the titles and abstracts of each search were screened independently by two reviewers (A and B: MRM and JIB; C: CM and DP) against the inclusion and exclusion criteria (Table 1).Discrepancies in the voting were first discussed between reviewers, and if consensus could not be reached, they were discussed and resolved by all researchers (MRM, JIB, CM, DP, TQ, MR) in regular video meetings.Third, full-text screening was conducted by the same two reviewers independently (A and B: MRM and JIB; C: CM and DP), and discrepancies in the voting were discussed and resolved in the same manner as in the title and abstract screening.

Data extraction
Our data extraction form was based on the template for scoping reviews developed by the Joanna Briggs Institute [46].We considered the following aspects: general information (primary and additional publication, country, setting), study design and methods (aim, study design, methods), participants (sites and study population), and intervention (description of the implemented intervention, target population of the intervention).Data extraction for each search was performed independently by two researchers (A and B: MRM and JIB; C: CM and DP).Deviations in the extraction were discussed first between the two researchers and, if a consensus could not be reached, with all researchers (MRM, JIB, CM, DP, TQ, MR) in regular video meetings.

Analysis of the evidence
For the analysis of implementation strategies, implementation outcomes, and factors influencing implementation reported in the identified studies, we used a deductive content analysis approach [56].For this, we derived the categories from ERIC [35,36,57] to analyze the implementation strategies used in the identified studies.Because implementation outcomes were often not explicitly stated and reported in the included studies, we used the outcomes described by Proctor, Silmere [37] to identify and analyze implementation outcomes in the included studies.Additionally, we used the five domains of the Consolidated Framework for Implementation Research (CFIR) and their constructs [34] to analyze the reported influencing factors.
For the coding process of implementation strategies and outcomes, as well as influencing factors, the results of each search were independently coded by two reviewers (A and B: MRM and JIB; C: CM and DP).Afterward, the results for each coding were compared, and discrepancies were discussed in the two groups (A and B; C).Codes that could not be clearly assigned to one category were discussed with all researchers (MRM, JIB, CM, DP, TQ, MR) in a virtual meeting.After the coding process, all codings were peer checked by one of two researchers (TQ or MR) to ensure trustworthiness [58].

Presentation of results
For the presentation of our scoping review results, we mapped the implementation strategies and outcomes, as well as the influencing factors, in the form of 3 tables with tick boxes.In addition, we report further detailed information about the various identified in a descriptive way.

Results
Through our electronic database searches, we identified a total of 362 (A: behavior that challenges supporting a person with dementia in long-term care), 544 (B: delirium in acute care), and 714 records (C: postacute care needs).
Detailed information about the study characteristics (e.g., implemented interventions) of all included studies is provided in Table 2.

Identified implementation strategies
In the included studies that reported implementation strategies, we were able to identify between 4 and 21 ERIC strategies per study (Table 3).

Educational program
The intervention consisted of five 30-45 min educational sessions:

Participants
Intervention/survey name/interview guideline Primary publication: [63] Additional publication: [76,80] Country: UK Setting: nursing homes Aim: to determine the feasibility of the implementation and effectiveness of a dual-purpose pharmacy-health psychology intervention

Partnering for Discharge
The intervention consists of four elements: ▪ My Hospital Guide: a person-centered guide with information for the people with dementia and their relatives about the hospital stay and offers ▪ My Journal: a document with information and questions regarding care and discharge, held by the patient or family ▪ This is me: a document that records the person's background, preferences, and interests The TCM is based on the APN role and includes hospital, home, and discharge components General: ▪ The APN develops goals with the patients and their caregivers, identifies teaching and learning needs,     distribute educational materials, use train the trainer strategies, conduct educational meetings, and work with educational institutions) (Table 3).We identified the most common implementation strategies in two other ERIC clusters.For the cluster develop stakeholder interrelationships, we identified the following implementation strategies: identify and prepare champions (n = 7) [ We were not able to identify 38 of the 73 ERIC implementation strategies.Most implementation strategies were not reported in these clusters: change infrastructure (7 of 8, 88% did not report on mandate change, change record system, create or change credentialing and/or licensure standards, change service sites, change accreditation or membership requirements, start a dissemination organization, or change liability laws), utilize financial strategies (7 of 9, 78% did not report on place innovation on fee for service lists/formularies, alter incentive/ allowance structures, make billing easier, alter patient/ consumer fees, use other payment schemes, develop disincentives, or use capitated payments), and provide interactive assistance (3 of 4, 75% did not report on provide local technical assistance, provide clinical supervision, or centralize technical assistance) (Table 3).
To gain deeper insight into the coding of the implementation strategies, we present examples in Table 4.

Effectiveness of the implementation strategies and outcomes
Only one study tested the effectiveness of the applied implementation strategy [65]: the effectiveness of the EIT-4-BPSD versus education only.In this study, implementation outcomes related to adoption, fidelity, penetration, and sustainability were reported.The effects of the implementation outcome sustainability were compared between both groups (intervention and control).In both groups, a slight increase in the policies and environment in terms of promoting person-centered care was observed.No change was noted in the person-centered design of care plans in either group.Related to other implementation outcomes (adoption, fidelity, and penetration), no results were reported for either group [65].

Identified influencing factors
We identified 28 of the 37 constructs of the CFIR in the included studies (Table 6).In the following, we describe the two most frequently mentioned constructs of each CFIR domain across the different phenomena in dementia care (a, b, and c).Due to the different structuring of the domain inner setting, the most frequent subcodes of the constructs implementation climate and readiness for implementation were also listed (Table 6).

Intervention characteristics
The adaptability of the intervention was the most frequently reported CFIR construct within this domain.The adaptability of the intervention was described in terms of the needs of people with dementia and their relatives [61,64,66,70,71], knowledge that is needed/required [62,78] and interests of professionals [64,78], the userfriendliness of the intervention [66], organizational interests [62], and resources such as time [62,69,78] and staffing [64], as well as local sites where it would be interesting to implement the intervention [81].
Evidence strength and quality of the intervention was described as the second most common CFIR construct (Table 6) and was reported in terms of the perceived evidence strength and quality of the intervention [60,63,64] or related to intervention components such as the specialized staff (e.g., ANPs) and their roles, competencies, and skills [70,71,82]; information materials; documents [70,71]; tools [77]; trainings [63,77]; the environment [71]; and procedures [71].

Outer setting
We identified patient needs and resources as the most reported CFIR construct in this domain.Due to the focus on people with dementia and the importance of relatives as proxies during the care process, we additionally included aspects such as the needs and resources of families (which are not included in the original CFIR).Patient needs and resources were primarily described in relation to dementia [70] and were understood as influencing factors that impact implementation outcomes.For example, learning ability and the ability to coordinate care, the perception of the acute disease regarding severity and the implication of their symptoms [70] were described as influencing factors.In addition, intervention fidelity [70,82], attitudes toward the intervention [70], and the ability to use the intervention and the awareness of the staff to support the use of the intervention [61], as well as patient resources (such as finances, living environment, insurance and medication coverage, access to healthcare, and the social network), were reported as influencing factors [70].
Influencing factors regarding needs and resources of the family were reported in terms of caregiver burden [70,71,82], skills and knowledge of the family (caregiver) related to the care [61,70,77,82], and its coordination [70] as well as the knowledge about [70] and the perception of the disease (acute disease and dementia) [70].In addition, expectations [61] and acceptance of the intervention [70], information about and participation in the intervention and its design [61,64,70,77] were also described as influencing factors regarding the family.
Cosmopolitanism was described as the second most common construct in this domain.Here, the support and involvement of external networks such as the Alzheimer's Association was described as an influencing factor on implementation [67,82].The fragmentation of the healthcare system and therefore the provision of

Adapt and tailor to context
Tailor strategies "EIT allows for differences between communities and encourages tailoring of the implementation process, in contrast to an explanatory trial in which strict adherence to the intervention protocol is maintained" [78] Promote adaptability "The usual training for the STAR-VA program requires two half-day sessions and then four individualized sessions.This would not be a viable plan at the project site.Five monthly sessions were then planned for 30 to 40 min in length, to fit into the workflow of the day." [62] Use data experts "Completed hard copies were entered into SurveyMonkey ™ by ACI staff" [67] Train and educate stakeholders

Conduct ongoing training "Working together, these individuals enact the triad of components of EIT-4-BPSD, which include: (1) participatory implementation via a combination of in-person monthly meetings, weekly emails, and phone interactions between stakeholders and a research facilitator as they develop community goals and work toward achieving those goals…" [78]
Provide ongoing consultation "Fortnightly teleconferences with the site clinical leads were facilitated by the CHOPs project officer.These provided regular mentoring support and the opportunity for clinical leads to report on their progress and share their experiences and solutions throughout the implementation" [67] Develop educational materials "The DNP student provided resource binders containing additional resources on BPSD from the nursing home toolkit website.Binders were placed at each nursing station." [59] Make training dynamic "…conducting education sessions, providing bedside teaching and role-modeling best practices, sourcing resources and maintaining records" [69] Distribute educational materials "The nurses were also given pocket cards for sleep hygiene, the MMSE, and the CAM." [66] Use train the trainer strategies "For the PCC intervention, we employed a train-the-trainer-staff coaching model and engaged staff champions to cocreate and disseminate PCC knowledge among work teams" [61] Conduct educational meetings "The Facilitator CogChamps undertook a very active role in working with the other CogChamps to assist them in making progress with their action plans.They provided direct support by conducting education sessions, providing bedside teaching and role-modeling best practices, sourcing resources and maintaining records" [69] Work with educational institutions "…workshop sessions and facilitated e-learning through the NSW Dementia Competency and Training Network" [67]

Develop stakeholder interrelationships
Identify and prepare champions "For the PCC intervention, we employed a train-the-trainer-staff coaching model and engaged staff champions to cocreate and disseminate PCC knowledge among work teams" [61] Use advisory boards and workgroups "The purpose of the committee is to provide support and guidance regarding the project' s implementation" [68] Use an implementation advisor "Evidence Integration Triangle for Behavioral and Psychological Symptoms of Dementia was implemented by the research nurse facilitator working with the internal champion and stakeholders using the 4-step approach…" [79] Use evaluative and iterative strategies Audit and provide feedback "Members of the research team assisted the Cog-Champs in implementing their action plans by meeting with one or more CogChamp(s) from each ward weekly (face to face and email) to assess progress, provide feedback, and support them over the five-month implementation phase" [69] Develop a formal implementation blueprint "…a project implementation plan written…" [67] Assess for readiness "In phase 1, organizational readiness was assessed,…" [72] care services was also reported as an influencing factor in the studies.In this context, aspects such as lack of cooperation, shared care plans and information exchange between external actors (e.g., primary care physicians, specialist clinics) were mentioned [71,82].

Inner setting
Structural characteristics, culture, and networks and communications were identified as the most mentioned CFIR constructs in this domain.For the constructs implementation climate and readiness for implementation, the subcodes with the most frequent descriptions were learning climate and available resources.
Reported influencing factors within the structural characteristics construct were staff turnover [59,67,72,77], structural changes in medical specialization [72], the physical environment [79], the work organization (e.g., shift work, double shifts and high volume of agency staff ) [69,77], and the level of awareness of cognitive impairment (dementia and delirium) [67].The care setting itself was mentioned as a general influencing factor with an impact on the implementation [69,77].
The construct culture was described as an influencing factor in terms of the culture of the organization in general [79] and management style [61,64].
The construct networks and communications included exchange options such as meetings [62,71], interdisciplinary teamwork [71,72,81], and time points when these options were available [71] during the implementation process as influencing factors.
Within the construct implementation climate, learning climate was the most described subcode, including influencing factors related to space for learning (for example, mentoring or supervision [61,77]), as well as involvement [61,77], support [72,77,81], and acknowledgment [61] of the staff during the implementation process, opportunities to try out new methods [70], and feeling safe [61] while using the intervention even if others (e.g., relatives or colleagues) disagree.
Reported influencing factors within the construct readiness for implementation were more often related to the subcode available resources, which includes time and workload of the staff [59-63, 67, 69, 72, 77-79, 81], staffing level [62,71,77], and resources for training [61].Additionally, the physical environment, such as walking areas and activity rooms [77], and activity materials [77] and finances of the facility were mentioned [77].

Characteristics of individuals
We identified knowledge and beliefs about the intervention and other personal attributes as the most mentioned constructs for this CFIR domain.

Process
In this CFIR construct, we identified the most frequently influencing factors related to engaging.We found influencing factors on engaging in general as well as specific influencing factors related to champions.

Discussion
To our knowledge, this is the first study to systematically identify implementation strategies, implementation outcomes and influencing factors related to the implementation of evidence-based interventions that focus on three preselected phenomena in people with symptoms of dementia or those who have been diagnosed with dementia: (A) behavior that challenges supporting a person with dementia in long-term care, (B) delirium in acute care, and (C) postacute care needs.The strengths of our scoping review are the methodological quality and the systematic and broad scope.Consequently, we can provide a broad and theoretically guided overview of the current state of implementation research in dementia care across different healthcare settings.
In terms of influencing factors, available resources appeared to be one of the most important factors influencing implementation, along with the adaptability of the intervention.This does not come as a surprise since acute care and nursing homes have often struggled with staffing, high staff turnover rates, funding issues, challenges with available equipment, and limited influence on changing the environment, even before the COVID-19 pandemic [85][86][87][88].This could explain why we found hardly any differences in the reported implementation strategies and influencing factors between the different interventions and settings.Accordingly, it appears that these contextual factors tremendously influence the successful implementation of evidence-based interventions due to their general conditions and requirements for implementation under current conditions (e.g., staffing, staff workload, competencies, qualifications, turnover, finances).These current contextual factors can be understood as an implementation-hostile climate [89].To address this challenge, the implementability of healthcare interventions seems to be a crucial point [90], and adapting the intervention to the specific care context and professionals' workflows for higher acceptability will be key for successful implementation [91].This highlights the importance of not developing and evaluating interventions in isolation from implementation strategies [92,93] and/or without a process evaluation [94][95][96].
Furthermore, it seems necessary to critically discuss the added value of implementation research with a sole focus on influencing factors, even when this could lead to the identification of defining implementation strategies [38].Here, a paradigm shift [97] from identifying and describing these influencing factors to developing concrete evidence-based implementation strategies seems necessary.Thus, for the discipline (implementation science) to move forward, it is essential to consolidate innovative study designs [98] and methods (specifically participatory research approaches [99]) to develop discrete, multifaceted, and tailored implementation strategies and to investigate/test their impact on the implementation strategy and outcome itself as well as the effect on intervention outcomes [100].This gap in the current implementation research is confirmed by our results since we were only able to identify one study that tested the effectiveness of an implementation strategy [65].Consequently, the effects of the implementation strategies we identified are still largely unknown, and it seems that implementation research [101] and respective process evaluations to address implementation challenges during the evaluation of an intervention [93] in dementia care have barely evolved in relation to this point.
However, there also seems to be a lack in the reporting of implementation outcomes and the use of psychometrically tested implementation outcome measurements, as well as an inconsistency in the understanding between intervention outcomes and implementation outcomes [47,102,103].For example, in our included studies, implementation outcomes were often not specifically named as such and were not measured with psychometric tested assessments, or it often remained unclear to what extent the measurement of, e.g., gaining knowledge, could be either an implementation outcome or an outcome of an intervention if the focus lies on education.Therefore, it is necessary to improve reporting on implementation strategies and outcomes (in both intervention and implementation studies) to initiate the development of psychometrically tested measurements [102] and, despite the publication of Proctor, Silmere [37] in 2011, to keep in mind the tension between intervention and implementation outcomes [47].
Finally, we were able to identify dementia-specific influencing factors, in particular related to the family, their needs and resources, as a key point during the implementation of evidence-based interventions.This meant that we needed to modify the CFIR (outer setting-patient needs and resources/needs and resources of the family) for our review accordingly.Although the updated version of the CFIR was published in 2022 [104], considering family needs and resources as an influencing factor for implementation does not seem to be included.However, from our perspective, this seems to be a highly relevant factor for older people with and without dementia [105].In addition, other dementia-specific influencing factors also appear to exist for the implementation of interventions that include this population [106].We live in a diverse and global world, and in the health sector, embracing diversity is essential for individuals' health [107,108].Here, it seems to be of interest in future (implementation) research to what extent frameworks such as the CFIR consider factors influencing diverse populations (e.g., people with dementia and/or migrants or ethnic minority groups).In summary, these aspects could lead to further and tailored development of the CFIR as well as the ERIC.

Limitations
Our scoping review has some limitations.As a first step, we derived our search terms from identified exemplary evidence-based dementia care interventions and their components (e.g., DICE) and supplemented them with other, broader terms (e.g., person-centered care).In doing so, we cannot exclude the possibility that we failed to consider very specific interventions addressing our preselected dementia phenomena.However, across the different included studies and thus the different interventions and settings, our results present a very homogeneous picture regarding influencing factors, implementation strategies, and outcomes.Second, by using the ERIC clusters, Proctor's outcomes, and the CFIR domains and constructs, we used specific frameworks and descriptions, which makes it difficult to compare our results with others analyzed with other frameworks and descriptions.However, the ones we used are among the most established due to their high number of citations [57,109].Third, we need to point out that an update of the CFIR [104] and the CFIR Outcomes Addendum [110] were published after the completion of our review (2021).In particular, the update of the CFIR is characterized by a more specific and detailed classification of the different influencing factors (e.g., subdividing patient needs and resources into three different constructs and moving them into the domain of internal setting and persons).Therefore, it would be interesting to compare our results with the results of future dementia-specific studies focusing on influencing factors and using the updated CFIR.It would be interesting to analyze the extent to which the updated CFIR is in line with our understanding of influencing factors.Damschroder, Reardon [104] point out that despite the changes in the updated CFIR version, the constructs can be consistently mapped back to the original CFIR, thus allowing comparison of their conceptualization.
Finally, it should be mentioned that publication bias cannot be excluded; for example, we did not specifically and systematically search for gray literature [111].

Conclusion
Based on the ERIC, the descriptions of Proctor, Silmere [37], and the CFIR, our scoping review provides a broad but systematically conducted and structured overview of the current state of implementation research in dementia care.Furthermore, our review identifies various gaps to be addressed by further implementation research.Our results show that the factors influencing the implementation of evidence-based interventions in dementia care are highly homogeneous, regardless of the evidence-based intervention and/or healthcare setting.In addition, the influencing factors we identified most frequently (available resources and adaptability of the intervention) are factors to be expected in the context of and with an impact on the provision of dementia care.In contrast, we found almost no reports on the effects of the identified implementation strategies.Consequently, to fill this gap, it seems important to test existing implementation strategies, to address tailoring-based awareness for the known influencing factors and to advance implementation science and therefore to be able to make predictions about the effectiveness of implementation strategies.This could further promote the overall translation of evidence-based dementia care practice and sustain a high quality of care for a vulnerable population.

Intervention/survey name/interview guideline Primary publication: [ 61 ]▪▪▪
Additional publications: [74, 75] Country: Australia Setting: residential dementia care home Aim: to understand the inconsistent results of the main study and investigation of factors that enabled and inhibited the implementation of the intervention Study design: process evaluation of a randomized controlled trial ▪ Methods: interviews with care managers, nurses, and care staff, surveys with family members, staff reports, field notes, care plans Sites Residential dementia care homes (n = 38) Study population Care managers (n = 29) ▪ Nurses and care staff (n = 70) ▪ Family members (n = 73) Person-centered care (PCC) and person-centered dementia environment (PCE) PCC consists of: ▪ Educational sessions for the staff with a focus on paying attention to residents' feelings when agitated, person-centered interactions, and personcentered care planning to meet psychosocial needs of the residents ▪ On-site supervision ▪ Telephone support PCE consisted of: ▪ Environmental audit ▪ Audit results regarding safety, accessibility, utility, colors, objects, and familiarity of outdoor and social space were considered, and facilities were modified Target population of the intervention: Nursing and care staff and facilities ▪ Indirect people with dementia aged ≥ 60 years Primary publication: [62] Additional publication: no information Country: USA Setting: long-term care facility Aim: to improve the skills of care staff for the care of people with dementia experiencing behavior that challenges supporting a person with dementia Study design: educational project ▪ Methods: questionnaire Sites ▪ Long-term care facility (n = 1) Study population First educational session: ▪ Staff from all departments (n = 165) Second to fifths educational session:

Study design:▪▪▪▪▪▪▪
open label, mixed method, feasibility study ▪ Methods: interviews, reflective comments via interviews, questionnaire, medication records Sites Nursing homes (n = 5) Study population Nursing home staff (n = 142) ▪ General healthcare staff (n = 22) ▪ People with dementia (n = 108) For nursing home staff, three educational workshops with a focus on person-centered care and the understanding that unmet needs could cause behavior that challenges supporting a person with dementia were conducted Aim of the workshop: to provide staff with skills for the investigation of unmet needs, knowing the person, individualized interventions to meet person needs, understanding that engaging in behavior that challenges supporting a person with dementia is not to be understood as engaging in bad behavior or being a bad person ▪ The training was conducted along the VIPS (Valuing, Individualized, Perspective, and Social) model and included educational elements regarding medication to manage behavior that challenges supporting a person with dementia, guidelines to reduce medication and favor psychosocial interventions and videos, demonstration of person-centered practices, and information about the abovementioned topics; the importance of self-care and good communication among care staff was discussed ▪ Primary healthcare staff received a modified version of the education workshops Medication review: Medication review was provided by two experienced clinical pharmacists ▪ A therapeutic alliance was formed between the clinical pharmacist, the person with dementia and their personal relative Information about the medications and adverse effects were collected ▪ Medication plans were reviewed, with a focus on medications for behavior that challenges supporting a person with dementia, and all other medications ▪ Information and recommendations about the review were provided to the general practitioner in writing and by telephone Target population of the intervention: Nursing home staff ▪ General healthcare staff [general practitioner (trainees), practice nurses, practice-based pharmacist] ▪ People with dementia who received medication to treat behavior that challenges supporting a person with dementia

Sites▪
Acute hospitals (n = 6) Study population ▪ Nursing staff (pre n = 432; post n = 283) ▪ Patients (pre n = 347; post n = 396) Confused Hospitalized Older Persons (CHOPs) The intervention consists of seven principles: ▪ Cognitive screening ▪ Identification and prevention strategies for delirium ▪ Assessment of older people with confusion ▪ Communication to support person-centered care ▪ Staff education related to caring for older people with confusion ▪ Supportive care environments for older people with confusion Target population of the intervention: ▪ Nursing staff ▪ Direct and indirect patients aged ≥ 65 years Primary publication: [69] Additional publication: [68] Country: Australia Setting: acute hospital Aim: to implement a multifaceted practice change intervention to enhance the capacity of the nursing staff to provide quality care Study design: implementation study ▪ Methods: observation, audits, assessments Sites ▪ Wards (n = 6) in one acute hospital Study population ▪ Registered nurses (n = 34) ▪ Patients (n = 181) Cognition Champions (CogChamps) The intervention consisted of three steps: ▪ 2 education workshops for CogChamps ▪ development of an individualized action plan by CogChamps ▪ Implementation of actions plans by CogChamps Target population of the intervention: ▪ Registered nurses with two or more years of clinical experience ▪ Indirect patients aged ≥ 65 years

▪▪▪
Family meeting within 72 h of admission Target population of the intervention: ▪ patients aged ≥ 65 years diagnosed with dementia (primary or additional diagnosis) ▪ family members of patients with diagnosed dementia Primary publication: [71] Additional publication: no information Country: Australia Setting: residential care facility Aim: to evaluate the implementation and effectiveness of the TC CAMP Study design: evaluation (process and outcome) Methods: individual and focus group interviews, file audits (medical records) Sites ▪ 6 restorative care places in a dementia unit in one residential facility Study population ▪ TC Camp staff (n = 7) ▪ Health service staff (n = 7) ▪ Representatives of the facility to which clients were discharged (n = 3) Clients with dementia (n = 11) ▪ Family members/carers (n = 7) Transition Care Cognitive Assessment and Management Pilot (TC CAMP) TC Camp is based on a person-centered approach as a goal-oriented and time-limited healthcare service for people with dementia who were discharged from the hospital TC Camp includes the following components: ▪ Clinical nurse consultant (CNC) [Role of the CNC: Case management including family meetings, cognitive assessment, behavior management, discharge planning, and staff education) ▪ Geriatrician ▪ Occupational therapist ▪ Other health professions if required ▪ Person centered tool "Key to me" ▪ Individualized care/behavioral and discharge plan Target population of the intervention: Patients aged ≥ 65 years with cognitive impairment (MMSE ≤ 24) Additional publication: [82] Country: USA Setting: hospital, postacute setting Aim: to examine barriers and facilitators for implementing a transitional care intervention for cognitively impaired older adults and their caregivers Study design: exploratory qualitative design Methods: case summaries (of each patient caregiver dyad), case conference field notes Sites ▪ Hospitals a Study population Advanced practice nurses (APNs) (n = 3) ▪ Caregivers of patients with dementia (n = 16) ▪ Patients with dementia (n = 15) Transitional Care Model (TCM) et al.Implementation Science Communications (2023) 4:104

Table 2
(continued) Introduction to dementia and the STAR-VA program ▪ (Non)verbal communication with people with/without dementia living in a long-term care facility setting

Table 2 (continued) General information Study design and methods Participants Intervention/survey name/interview guideline Primary publication
: [64] Additional publication: no information Country: USA Setting: nursing homes Aim: to change the culture of care in nursing homes, establishing a person-centered model, and reducing the treatment of behavior that challenges supporting a person with dementia with antipsychotic medications Study design: quality improvement initiative ▪ Methods: survey, chart reviews, questionnaire Sites ▪ One dementia care unit of a nursing home Study population ▪ Administrative team (facility administrator, medical director, director of nursing, human resources, clinical nurse educator, and the scheduler) ▪ Direct care team [doctors n = 3, (hospice) nurse practitioner n = 2, unit nurse manager (n = 1), activity director (n = 1 with two assistants, certified nurse assistants n = 18 and licensed practical nurses n = 10 on the unit, clinical nurse educator, wound care nurse, and social worker] ▪ Residents (n = 39) ▪ Families of the residents a ▪ Nursing home staff [(n = 93), administrator n = 5, director of nursing n = 17, staff nurse n = 18, nursing assistant n = 6, social worker/ social service n = 12, recreation therapist/activity staff n = 17, others n = 10] ▪ Residents (n = 553)

Table 3
Implementation strategies across the different phenomena in dementia care

Table 5
Reported implementation outcomes for the included phenomena in dementia care

Table 6
Influencing factors for the included phenomena in dementia care