Sleep in care homes

Sleep problems in older adults are common and disturbance in sleep is associated with increased mortality. These problems are more pronounced in the care home population because of institutional factors and a high prevalence of frailty and comorbidity. This article reviews the randomized controlled trials undertaken to address sleep problems in care homes. These suggest that standalone therapies – oral melatonin and light therapy – have no effect on sleep but that combination treatments – physical exercise plus sleep hygiene, physical exercise plus sleep hygiene plus light and melatonin plus light – may have positive effects. These effects are more marked for daytime arousal than nocturnal sleep. Practical considerations for care homes are how to maximise light exposure, incorporate exercise into daily routines and minimize night-time disruption for residents. Trials undertaken so far are compromised by small sample size and inappropriate randomization strategies and further research is therefore required

An evaluation of domiciliary rehabilitation for stroke patients after discharge from hospital

Not only can stroke kill, but it can also disable and handicap the survivors. There is no medical treatment for stroke and not all stroke can be prevented. Rehabilitation, to promote recovery, or maintenance, to support those who do not recover, is required. Evidence about the efficacy of stroke rehabilitation is poor. There is little evidence to support many of the specific techniques used, but there is evidence to support the use of organised rehabilitation in hospitals. After leaving hospital there is some evidence that rehabilitation in out-patient departments and at home may be of further help. In this thesis, the results of a study undertaken to add to this slender body of knowledge by comparing domiciliary to hospital-based rehabilitation after hospital discharge are presented and discussed. Overall, no difference was found in terms of survival, institutionalisation, disability or perceived health between a domiciliary and a hospital-based rehabilitation service (day hospitals and out-patient departments). However, young stroke patients who had required considerable amounts of rehabilitation in a Stroke Unit, were best given further therapy at home rather than in out-patient departments, since it improved household and leisure abilities. This result is compatible with the only other controlled study of domiciliary stroke rehabilitation after hospital discharge. For frail elderly patients, the day hospital service may have had advantages over the domiciliary service because death and institutionalisation rates were lower. The latter finding may be spurious, due to allocation bias and small sample size. In view of the expense of day hospitals, more research is required to examine their efficacy. It is concluded that domiciliary rehabilitation is a small step forward for stroke rehabilitation and will benefit some disabled stroke survivors, and may be a more resource-efficient way of treating many others

The effective ingredients of social care support at home for people with dementia: a literature review

Purpose: Formal ties between the theatre and research dissemination have only recently developed and its general efficacy is largely unknown. Here the purpose of this paper is to redress this neglect by examining the effectiveness of a research-based theatrical event in promoting dementia knowledge transfer with a group of front line care workers. The event ran over eight days and consisted of an original theatrical production followed by a chaired audience discussion and workshops. Design/methodology/approach: Questionnaires which had been developed specifically for this evaluation were completed by 863 front line workers on the day of the event, eliciting their profiles and immediate reactions. Three months after the event, 30 completed a follow-up questionnaire and eight were interviewed. Findings: Attendance was well received with high degrees of both cognitive and emotional engagement being expressed in the initial questionnaire. The follow-up evaluation suggested that these positive reactions were sustained over time. However, many taking part in this follow-up thought that their practice had not changed as a result of event attendance. This apparent discrepancy between knowledge transfer and utilisation appeared to be partly the result of the influence of contextual factors in impeding this utilisation within work settings. Originality/value: Evidence is provided on the positive impact of theatre on dementia carers’ working lives. This is sufficient to warrant further applications of this method, provided there is careful attention to embedding the messages in the workplace context and evaluating their efficacy

Social Return on Investment of Home Exercise and Community Referral for People With Early Dementia

Exercise can improve physical function and slow the progression of dementia. However, uncertainty exists around the costeffectiveness of exercise programmes for people with early dementia. The aim of this study was to determine whether a home-based supervised exercise programme (PrAISED – promoting activity, independence, and stability in early dementia) could generate a positive social return on investment (SROI). SROI analysis was conducted as part of a randomised controlled feasibility trial comparing PrAISED with usual care. Wellbeing valuation was used to compare the costs of the programme with the monetised benefits to participants, carers, and healthcare service providers. The PrAISED programme generated SROI ratios ranging from £3.46 to £5.94 for every £1 invested. Social value was created from improved physical activity, increased confidence, more social connection and PrAISED participants using healthcare services less often than usual care. This study found that home-based supervised exercise programmes could generate a positive SROI for people with early dementia. Trial registration: ClinicalTrials.gov: NCT02874300 (first posted 22 August 2016), ISRCTN: 10,550,694 (date assigned 31 August 2016)

Experiences of family carers of older people with mental health problems in the acute general hospital: a qualitative study

Aims To explore the experiences of family carers of people with cognitive impairment during admission to hospital. Background Providing appropriate care in acute hospitals for people with co-morbid cognitive impairment, especially dementia or delirium or both, is challenging to healthcare professionals. One key element is close working with family members. Design Qualitative interview study. Methods Semi-structured interviews with family carers of 34 older people who had been admitted to a UK general hospital and had co-morbid cognitive impairment. Interviews conducted in 2009 and 2010. Analysis was undertaken using Strauss and Corbin's framework. Findings The findings elaborate a core problem, ‘disruption from normal routine’ and a core process, ‘gaining or giving a sense of control to cope with disruption’. Family carers responded to disruption proactively by trying to make sense of the situation and attempting to gain control for themselves or the patient. They tried to stay informed, communicate with staff about the patient and plan for the future. The interaction of the core problem and the core process resulted in outcomes where family members either valued the support of hospital staff and services or were highly critical of the care provided. Conclusion Family carers are not passive in the face of the disruption of hospitalization and respond both by trying to involve themselves in the care and support of their relative and by trying to work in partnership with members of staff. Nurses need to foster this relationship conscientiously

Improving community support for older people’s needs through commissioning third sector services: a qualitative study

Aim: This exploratory study of commissioning third sector services for older people aimed to explore whether service data was fed back to commissioners and whether this could improve intelligence about the population and hence inform future commissioning decisions. Background: Third sector services are provided through charities and non-profit community organisations, and services that assess and advise people for self-management or provide wellbeing support in the community have developed over recent years. Third sector services have an opportunity to reach vulnerable populations and to provide intelligence about them. Some third sector services are state funded (commissioned) in the United Kingdom (UK). While evidence is available about the commissioning of statutory health and social care, as well as private providers, there is limited evidence about how third sector health services are funded. Methods: Participants were recruited from commissioner organisations and third sector organisations, both with an interest in supporting the independence, self-management and wellbeing of older people. Organisations were recruited from five purposively selected sites within one region of England (East Midlands). Semi-structured interviews explored the relationships between commissioners and providers and the nature of funding arrangements, including co-production. Interviews also explored collection of data within the service and how data was fed back to commissioners. Focus groups were held with older people with the potential to benefit from wellbeing services.Results: Commissioning arrangements were varied, sometimes complex, and often involved co-production with the third sector. Commissioners valued third sector organisations for their engagement with the local community, value for money, outreach services and ability to provide information about the community. Assessing the needs and outcomes of individuals was integral to delivery of support and advice to older people. Diverse approaches were used to assess an individual’s needs and outcomes, although there were concerns that some assessment questionnaires may be too complex for this vulnerable group. Assessment and outcomes data were also used to monitor the service contract and there was potential for the data to be summarised to inform commissioning strategies, but commissioners did not report using assessment data in this way. While the policy context encouraged partnerships with third sector organisations and their involvement in decision-making, the relationship with third sector organisations was not valued within contract arrangements, and may have been made more difficult by the tendering process and the lack of analysis of service data.Conclusion: This exploratory study has demonstrated a diversity of commissioning arrangements for third sector services across one region of England. Most commissioners invited co-production; that is, the commissioners sought input from the third sector while specifying details of the service. Service data, including assessments of needs and outcomes, were reported to commissioners, however commissioners did not appear to use this to full advantage to inform future commissioning decisions. This may indicate a need to improve measurement of needs and outcomes in order to improve the credibility of commissioning process

General Practitioners’ views of blood pressure control in people with and without dementia

Introduction: Since 2012, our group has undertaken a programme of research examining the treatment of hypertension in people with dementia. Hypertension is managed by GPs, who are guided by NICE guidelines, which make no mention of different management in people with dementia. We sought to explore the views of GPs on whether they manage hypertension differently in people with dementia. Method: We chose to try using an on-online survey to seek views, with both open and closed questions. We offered vignettes describing 71 and 83 year old women without cognitive impairment or with dementia, and a free text box – comments provided in this box were analysed thematically. Results: Although 427 GPs responded to the questionnaire, this was only 7% of all GPs eligible. Responding GPs were twice as likely not to offer treatment to the patient aged 71 with dementia and a BP above 140/90 (NICE threshold) compared to one without dementia (23.9% vs 11.7%). A similar finding was found when the vignettes involving 83 year old women with and without dementia (using 160/100, the NICE threshold for this age group) where 7.3% would not offer treatment in the woman with dementia compared to 3.3% in those without dementia. The analysis of free text identified four major themes, which were labelled as ‘complex decisions, ‘blood pressure measurement‘, ‘uncertainties around treatment’ and ‘compliance with guidelines’. Discussion: The low response rate in this survey makes the findings potentially unreliable, and other methods of ascertaining GP views, intentions or practices should be considered. Despite this, the findings from this study, in particular the free text comments indicate that the management of hypertension in people with dementia, is likely to be more complex than current guidelines indicate, and we propose that further research and clarification of best practice would be helpful

An evaluation of domiciliary rehabilitation for stroke patients after discharge from hospital

Not only can stroke kill, but it can also disable and handicap the survivors. There is no medical treatment for stroke and not all stroke can be prevented. Rehabilitation, to promote recovery, or maintenance, to support those who do not recover, is required. Evidence about the efficacy of stroke rehabilitation is poor. There is little evidence to support many of the specific techniques used, but there is evidence to support the use of organised rehabilitation in hospitals. After leaving hospital there is some evidence that rehabilitation in out-patient departments and at home may be of further help. In this thesis, the results of a study undertaken to add to this slender body of knowledge by comparing domiciliary to hospital-based rehabilitation after hospital discharge are presented and discussed. Overall, no difference was found in terms of survival, institutionalisation, disability or perceived health between a domiciliary and a hospital-based rehabilitation service (day hospitals and out-patient departments). However, young stroke patients who had required considerable amounts of rehabilitation in a Stroke Unit, were best given further therapy at home rather than in out-patient departments, since it improved household and leisure abilities. This result is compatible with the only other controlled study of domiciliary stroke rehabilitation after hospital discharge. For frail elderly patients, the day hospital service may have had advantages over the domiciliary service because death and institutionalisation rates were lower. The latter finding may be spurious, due to allocation bias and small sample size. In view of the expense of day hospitals, more research is required to examine their efficacy. It is concluded that domiciliary rehabilitation is a small step forward for stroke rehabilitation and will benefit some disabled stroke survivors, and may be a more resource-efficient way of treating many others

Disruption, control and coping: responses of and to the person with dementia in hospital

This qualitative study aimed to gain insight into the experience of hospitalisation from the perspectives of the older person with dementia, their family care-giver and other patients sharing the ward (co-patients). Non-participant observation of care on 11 acute hospital wards was supplemented by 39 semi-structured interviews with 35 family care-givers and four co-patients following discharge. Constant comparative analysis produced the core problem facing all those involved: disruption from normal routine meaning that the experience of hospitalisation was disrupted by the presence and behaviour of the person with dementia. Disruption adversely affected the person with dementia, triggering constructive, disengaged, distressed and neutral behaviours. Using Kitwood's model of person-centred care, these behaviours were interpreted as attempts by the person with dementia at gaining a sense of control over the unfamiliar environment and experience. Family care-givers' lives and experiences both inside and outside the hospital were disrupted by the hospitalisation. They too attempted to gain a sense of control over the experience and to give a sense of control to the patient, co-patients and staff. Co-patients experienced disruption from sharing space with the person with dementia and were left feeling vulnerable and sometimes afraid. They too attempted to gain a sense of control over their situation and give some control by helping the person with dementia, the family care-giver and the staff

Preparatory review of studies of withdrawal of anti-hypertensive medication in older people

Introduction: Since 2012 we have undertaken a programme of research into the management of hypertension in people with dementia. As part of this we are studying the feasibility of withdrawing antihypertensive drugs in people with dementia and well-controlled hypertension, with the aim of them remaining normotensive but avoiding some of the burdens and side-effects of antihypertensive medications. We decided to undertake a preliminary examination of the literature to examine the evidence and safety of antihypertensive withdrawal (not restricted to those with dementia) to determine whether this has already been extensively reviewed, to provide an approximate estimate of the likelihood of success of antihypertensive withdrawal, and to prepare for a systematic review of this literature if required and feasible. Method: For this rapid review, we undertook a search for existing reviews and examined the relevant papers identified, and briefly updated the search once we found that the most recent review was in 2008. Results: One appropriate review (from 2008) yielding seven relevant articles, and one further article were identified, giving eight articles which were examined. Seven of the eight were published more than ten years ago. Six of the eight studies had follow-up data for 1 year or longer. Successful long term (1 year or more) withdrawal of antihypertensive medication was reported in 20-52% of patients. Conclusion: Our review indicates that 22-50% of patients whose blood pressures are currently adequately controlled might be able to withdraw medication without return of long term hypertension. The rapid review approach we took may have missed articles of relevance and so we propose that a systematic review of withdrawal is undertaken. Because much of the data will be old, it should seek data not only on the proportions of patients who remained normotensive at long term follow up using the standards of the day, but should seek data on findings relevant to current guidelines. Only data reporting long term follow up (≥ 1 year) should be included. Data referring to old or discontinued medications should be distinguished