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

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

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

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

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

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

New horizons in the implementation and research of comprehensive geriatric assessment: knowing, doing and the “know-do” gap

In this paper we outline the relationship between the need to put existing applied health research knowledge into practice (the “know-do gap”) and the need to improve the evidence base (the “know gap”) with respect to the health care process used for older people with frailty known as comprehensive geriatric assessment (CGA). We explore the reasons for the know-do gap and the principles of how these barriers to implementation might be overcome. We explore how these principles should affect the conduct of applied health research to close the know gap. We propose that impaired flow of knowledge is an important contributory factor in the failure to implement evidence-based practice in comprehensive geriatric assessment; this could be addressed through specific knowledge mobilisation techniques. We describe that implementation failures are also produced by an inadequate evidence base which requires the co-production of research, addressing not only effectiveness but also the feasibility and acceptability of new services, the educational needs of practitioners, the organisational requirements of services, and the contribution made by policy. Only by tackling these issues in concert and appropriate proportion, will the know and know-do gaps for CGA be closed

Caring for cognitively impaired older patients in the general hospital: A qualitative analysis of similarities and differences between a specialist Medical and Mental Health Unit and standard care wards

Background: Around half of people aged over 70 admitted as an emergency to general hospital have dementia, delirium or both. Dissatisfaction is often expressed about the quality of hospital care. A medical and mental health unit was developed to provide best practice care to cognitively impaired older patients. The Unit was evaluated by randomised controlled trial compared to standard care wards. Part of this evaluation involved structured non-participant observations of a random sub-sample of participants and the recording of field notes. Objectives: The aim of this paper is to compare and contrast the behaviours of staff and patients on the Medical and Mental Health Unit and standard care wards and to provide a narrative account that helps to explain the link between structure, process and reported outcomes. Design: Field notes were analysed using the constant comparison method. Setting: A large hospital within the East Midlands region of the United Kingdom. Participants: Patient participants were aged over 65, and identified by Admissions Unit physicians as being ‘confused’. Most patients had delirium or dementia. Results: Sixty observations (360 hours) were made between March and December 2011. Cognitively impaired older patients had high physical and psychological needs, and were cared for in environments which were crowded, noisy and lacked privacy. Staff mostly prioritised physical over psychological needs. Person-centred care on the Medical and Mental Health Unit was mostly delivered during activity sessions or meal times by activities coordinators. Patients on this unit were able to walk around more freely than on other wards. Mental health needs were addressed more often on the Medical and Mental Health Unit than on standard care wards but most staff time was still taken up delivering physical care. More patients called out repetitively on the Unit and staff were not always able to meet the high needs of these patients. Conclusion: Care provided on the Medical and Mental Health Unit was distinctly different from standard care wards. Improvements were worthwhile, but care remained challenging and consistent good practice was difficult to maintain. Disruptive vocalisation may have been provoked by concentrating cognitively impaired patients on one ward