Unplanned, urgent and emergency care: what are the roles that EMS plays in providing for older people with dementia? An integrative review of policy, professional recommendations and evidence.

OBJECTIVE: To synthesise the existing literature on the roles that emergency medical services (EMS) play in unplanned, urgent and emergency care for older people with dementia (OPWD), to define these roles, understand the strength of current research and to identify where the focus of future research should lie. DESIGN: An integrative review of the synthesised reports, briefings, professional recommendations and evidence. English-language articles were included if they made any reference to the role of EMS in the urgent or emergency care of OPWD. Preparatory scoping and qualitative work with frontline ambulance and primary care staff and carers of OPWD informed our review question and subsequent synthesis. RESULTS: Seventeen literature sources were included. Over half were from the grey literature. There was no research that directly addressed the review question. There was evidence in reports, briefings and professional recommendations of EMS addressing some of the issues they face in caring for OPWD. Three roles of EMS could be drawn out of the literature: emergency transport, assess and manage and a 'last resort' or safety net role. CONCLUSIONS: The use of EMS by OPWD is not well understood, although the literature reviewed demonstrated a concern for this group and awareness that services are not optimum. Research in dementia care should consider the role that EMS plays, particularly if considering crises, urgent care responses and transitions between care settings. EMS research into new ways of working, training or extended paramedical roles should consider specific needs and challenges of responding to people with dementia.The research was funded / supported by the National Institute for Health Research (NIHR) Collaboration for Leadership in Applied Health Research and Care East of England at Cambridgeshire and Peterborough NHS Foundation Trust.This is the accepted manuscript. The final version is available from BMJ Group at http://dx.doi.org/10.1136/emermed-2014-20394

The place for dementia-friendly communities in England and its relationship with epidemiological need.

OBJECTIVES: The dementia-friendly community (DFC) initiative was set up to enable people living with dementia to remain active, engaged, and valued members of society. Dementia prevalence varies nationally and is strongly associated with the age and sex distribution of the population and level of social deprivation. As part of a wider project to evaluate DFCs, we examined whether there is a relationship between provision of DFCs and epidemiological need. METHODS: Dementia-friendly communities were identified through the formal recognition process of DFC status by the Alzheimer's Society and mapped against areas defined by English Clinical Commissioning Groups. We tested whether provision of a DFC was associated with: (1) dementia prevalence, (2) number of known cases, and (3) known plus estimated number of unknown cases. RESULTS: Of the 209 English Clinical Commissioning Group areas, 115 had at least one DFC. The presence of a DFC was significantly associated with number of known dementia cases (mean difference = 577; 95% CI, 249 to 905; P = 0.001) and unknown dementia cases (mean difference = 881; 95% CI, 349 to 1413; P = 0.001) but not prevalence (mean difference = 0.03; 95% CI, -0.09 to 0.16; P = 0.61). This remains true when controlling for potential confounding variables. CONCLUSIONS: Our findings suggest that DFC provision is consistent with epidemiological-based need. Dementia-friendly communities are located in areas where they can have the greatest impact. A retrospective understanding of how DFCs have developed in England can inform how equivalent international initiatives might be designed and implemented.NIHR Policy Research Programme, PR-R15-0116-2100

How do people with dementia use the ambulance service? A retrospective study in England: The HOMEWARD project

© Author(s) (or their employer(s)) 2018. Re-use permitted under CC BY. Published by BMJ. Objectives An increasing number of older people are calling ambulances and presenting to accident and emergency departments. The presence of comorbidities and dementia can make managing these patients more challenging and hospital admission more likely, resulting in poorer outcomes for patients. However, we do not know how many of these patients are conveyed to hospital by ambulance. This study aims to determine: how often ambulances are called to older people; how often comorbidities including dementia are recorded; the reason for the call; provisional diagnosis; the amount of time ambulance clinicians spend on scene; the frequency with which these patients are transported to hospital. Methods We conducted a retrospective cross-sectional study of ambulance patient care records (PCRs) from calls to patients aged 65 years and over. Data were collected from two ambulance services in England during 24 or 48 hours periods in January 2017 and July 2017. The records were examined by two researchers using a standard template and the data were extracted from 3037 PCRs using a coding structure. Results Results were reported as percentages and means with 95% CIs. Dementia was recorded in 421 (13.9%) of PCRs. Patients with dementia were significantly less likely to be conveyed to hospital following an emergency call than those without dementia. The call cycle times were similar for patients regardless of whether or not they had dementia. Calls to people with dementia were more likely to be due to injury following a fall. In the overall sample, one or more comorbidities were reported on the PCR in over 80% of cases. Conclusion Rates of hospital conveyance for older people may be related to comorbidities, frailty and complex needs, rather than dementia. Further research is needed to understand the way in which ambulance clinicians make conveyance decisions at scene

A qualitative study on conveyance decision-making during emergency call outs to people with dementia: The HOMEWARD project

BackgroundParamedics are increasingly required to make complex decisions as to whether they should convey a patient to hospital or manage their condition at the scene. Dementia can be a significant barrier to the assessment process. However, to our knowledge no research has specifically examined the process of decision-making by paramedics in relation to people with dementia. This qualitative study was designed to investigate the factors influencing the decision-making process during Emergency Medical Services (EMS) calls to older people with dementia who did not require immediate clinical treatment. MethodsThis qualitative study used a combination of observation, interview and document analysis to investigate the factors influencing the decision-making process during EMS calls to older people with dementia. A researcher worked alongside paramedics in the capacity of observer and recruited eligible patients to participate in case studies. Data were collected from observation notes of decision-making during the incident, patient care records and post incident interviews with participants, and analysed thematically.FindingsFour main themes emerged from the data concerning the way that paramedics make conveyance decisions when called to people with dementia: 1) Physical condition; the key factor influencing paramedics’ decision-making was the physical condition of the patient. 2) Cognitive capacity; most of the participants preferred not to remove patients with a diagnosis of dementia from surroundings familiar to them, unless they deemed it absolutely essential. 3) Patient circumstances; this included the patient’s medical history and the support available to them. 4) Professional influences; participants also drew on other perspectives, such as advice from colleagues or information from the patient’s GP, to inform their decision-making.ConclusionThe preference for avoiding unnecessary conveyance for patients with dementia, combined with difficulties in obtaining an accurate patient medical history and assessment, mean that decision-making can be particularly problematic for paramedics. Further research is needed to find reliable ways of assessing patients and accessing information to support conveyance decisions for EMS calls to people with dementia

National Institute for Health Research Policy Research Programme Project Dementia Friendly Communities: The DEMCOM evaluation (PR-R15-0116- 21003)

Final Report: National Institute for Health Research Policy Research Programme Project Dementia Friendly Communities: The DEMCOM evaluation (PR-R15-0116- 21003) As the number of people living with dementia is increasing globally, Dementia Friendly Communities (DFCs) offer one way of providing the infrastructure and support that can enable people affected by dementia to live well. There is no universally agreed definition of a DFC, and DFCs need not be geographical entities. This study adopted a broad definition, recognising that becoming a DFC is an ongoing process only fully achieved when living with dementia is normalised into a community’s culture, language, infrastructure and activities. A DFC can involve a wide range of people, organisations and geographical areas. A DFC recognises that a person with dementia is more than their diagnosis and that everyone has a role in supporting their independence and inclusion. DFCs in England can apply for official recognition by Alzheimer’s Society as working towards dementia friendly status. A growing number of national and international frameworks and guidance is available to communities seeking to become dementia friendly. Evaluations of DFCs are largely descriptive. While work exists on identifying core outcomes of DFC initiatives, there are very few studies that have tested DFC effectiveness or compared current practice with known need. Evidence on cost effectiveness, cost benefit, social value and social return on investment (SRoI) of DFCs is also missing. This study addresses key gaps in the evidence

What Works to Improve and Manage Fecal Incontinence in Care Home Residents Living With Dementia? A Realist Synthesis of the Evidence.

The prevalence of fecal incontinence (FI) in care homes is estimated to range from 30% to 50%. There is limited evidence of what is effective in the reduction and management of FI in care homes. Using realist synthesis, 6 potential program theories of what should work were identified. These addressed clinician-led support, assessment, and review; the contribution of teaching and support for care home staff on how to reduce and manage FI; addressing the causes and prevention of constipation; how cognitive and physical capacity of the resident affects outcomes; how the potential for recovery, reduction, and management of FI is understood by those involved; and how the care of people living with dementia and FI is integral to the work patterns of the care home and its staff. Dementia was a known risk factor for fecal incontinence (FI), but how it affected uptake of different interventions or the dementia specific continence and toileting skills staff require, were not addressed in the literature. There was a lack of dementia-specific evidence on continence aids. Most care home residents with FI will be doubly incontinent; there is, therefore, limited value in focusing solely on FI or single causes, such as constipation. Medical and nursing support for continence care is an important resource, but it is unhelpful to create a distinction between what is continence care and what is personal or intimate care. Prompted toileting is an approach that may be particularly beneficial for some residents. Valuing the intimate and personal care work unqualified and junior staff provide to people living with dementia and reinforcement of good practice in ways that are meaningful to this workforce are important clinician-led activities. Providing dementia-sensitive continence care within the daily work routines of care homes is key to helping to reduce and manage FI for this population

Ambivalence and fluidity in the teenage smoking and quitting experience: lessons from a qualitative study at an English secondary school

Objective: To evaluate a school-based stop smoking pilot project and to understand the teenage experience of smoking and quitting within that context. Design: Flexible design methods. Setting: A Kent (United Kingdom [UK]) secondary school. Methods: Semi-structured interviews analyzed following a grounded theory approach. Results: The main themes that emerged were ambivalence and fluidity. Young people can have mixed feelings towards their smoking behaviour. They experience ambivalence at the societal level in the messages they get about starting and stopping smoking and at the individual level in how they feel about other people smoking. Ambivalence in the quitting process is intensified by the phenomenon of addiction. Fluidity characterizes their way of life; things are not fixed and arrangements open to change. This was reflected in the way they approached coming to appointments. Conclusion: This research contributes a new perspective on the teenage smoking and quitting experience which others working in the field may find useful in characterizing their experience of working with young people. This ambivalence and fluidity suggests that a flexible approach in interventions with young people may be a key to success. </jats:sec

Addressing health inequalities in times of austerity: implementation of a place-based approach in multi-tiered local government.

Aims: This article focuses on how local authorities in England are tackling wider determinants of health and inequalities in their population’s outcomes while budgets for public services are diminishing. Methods: It reports the experience from one case study engaged in rolling out a devolved, place- and asset-based strategy over multiple tiers of local government. Relating these findings to relevant social theory, we draw out aspects of context and mechanisms of change. We offer plausible hypotheses for the experiences observed, which supports transferability and implementation of place-based strategies in other local authority areas struggling with similar challenges. Results: Findings highlight the importance of high-level and political buy-in, as well as the role of the Covid-19 pandemic as a potential catalyst to rollout. Creating the foundations for a new, place-based working was important for achieving coherence amongst partners around what local government was trying to achieve. These included investment in infrastructure, both relational and tangible inputs, such as organisational and human resources, to establish the conditions for systemic change towards early intervention and prevention. Conclusion: This study identified clear foundations for place-based action, plus enablers and barriers to significant transformation of practice towards asset-based approaches between local authorities, partners and the public