The domestic and gendered context for retirement

Against a global backdrop of population and workforce ageing, successive UK governments have encouraged people to work longer and delay retirement. Debates focus mainly on factors affecting individuals’ decisions on when and how to retire. We argue that a fuller understanding of retirement can be achieved by recognizing the ways in which individuals’ expectations and behaviours reflect a complicated, dynamic set of interactions between domestic environments and gender roles, often established over a long time period, and more temporally proximate factors. Using a qualitative data set, we explore how the timing, nature and meaning of retirement and retirement planning are played out in specific domestic contexts. We conclude that future research and policies surrounding retirement need to: focus on the household, not the individual; consider retirement as an often messy and disrupted process and not a discrete event; and understand that retirement may mean very different things for women and for men

Prediction of RCF Damage on Underground Metro Lines

London Underground (LUL) is one of the largest metro networks in the world and carried nearly 1.5 billion passengers in 2015. This increasing passenger demand leads to higher axle loads and shorter headways in the railway operations. However, this has a detrimental impact on the damage generated at the wheel-rail interface. In spite of the advances in rolling stock and track engineering, new developments in material manufacturing methods and rail inspection technology, cracking in rails still remains a major concern for infrastructure managers in terms of safety and maintenance costs. In this study, field data from two metro lines on the LUL network was analysed to identify the distribution and severity of the different damage types. Detailed vehicle dynamics route simulations were conducted for the lines and the calculated wheel-rail forces were investigated to assess the applicability current models for the prediction of rail damage on metro lines. These models include the Whole Life Rail Model (WLRM), previously developed for Great Britain (GB) main line tracks, and Shakedown theory. The influence of key factors such as curve radius, different friction conditions, track irregularities and wheel-rail profiles on the wheel-rail contact interface have been evaluated and compared with outputs from simulations on mainline routes. The study found that the contact patch energy (Tγ) and the interaction between wear and RCF in rails were highly influenced by the characteristics of metro tracks. It was also shown that both the Tγ and Shakedown methods can provide successful prediction of damage susceptibility of rails. However, in order to increase the accuracy of damage predictions and to ascertain the severity of different damage types, the duty conditions which are observed by the rail and the changes in contact conditions resulting from the successive vehicle passes should be considered in the modelling

Is preparation for end of life associated with pre-death grief in caregivers of people with dementia?

OBJECTIVES: Family caregivers of people with dementia can experience loss and grief before death. We hypothesized that modifiable factors indicating preparation for end of life are associated with lower pre-death grief in caregivers. DESIGN: Cross-sectional. SETTING: Caregivers of people with dementia living at home or in a care home. PARTICIPANTS: In total, 150 caregivers, 77% female, mean age 63.0 (SD = 12.1). Participants cared for people with mild (25%), moderate (43%), or severe dementia (32%). MEASUREMENTS: Primary outcome: Marwit-Meuser Caregiver Grief Inventory Short Form (MMCGI-SF). We included five factors reflecting preparation for end of life: (1) knowledge of dementia, (2) social support, (3) feeling supported by healthcare providers, (4) formalized end of life documents, and (5) end-of-life discussions with the person with dementia. We used multiple regression to assess associations between pre-death grief and preparation for end of life while controlling for confounders. We repeated this analysis with MMCGI-SF subscales ("personal sacrifice burden"; "heartfelt sadness"; "worry and felt isolation"). RESULTS: Only one hypothesized factor (reduced social support) was strongly associated with higher grief intensity along with the confounders of female gender, spouse, or adult child relationship type and reduced relationship closeness. In exploratory analyses of MMCGI-SF subscales, one additional hypothesized factor was statistically significant; higher dementia knowledge was associated with lower "heartfelt sadness." CONCLUSION: We found limited support for our hypothesis. Future research may benefit from exploring strategies for enhancing caregivers' social support and networks as well as the effectiveness of educational interventions about the progression of dementia (ClinicalTrials.gov ID: NCT03332979)

How do factors of sociodemographic, health literacy and dementia experience influence carers' knowledge of dementia?

BACKGROUND: Dementia is a life limiting disease following a progressive trajectory. As carers often become key decision makers, their knowledge of dementia will have health implications for the person living with dementia as well as carer’s psychological wellbeing. AIM: To explore how sociodemographic factors, health literacy and dementia experience influence family carers knowledge about dementia. METHOD: In this cross-sectional, mixed methods study, we interviewed 150 family carers and assessed their dementia knowledge using the Dementia Knowledge Assessment Scale (DKAS). Linear regression analyses were used to examine whether health literacy, previous experiences of dementia, support group attendance and sociodemographic characteristics predicted knowledge. Sixteen carers also completed qualitative interviews which explored unmet information needs. Transcripts and field notes were thematically analysed. RESULTS: Most participants were partners (47%) or adult children (48%) and cared for someone with severe (32%) or moderate (43%) dementia. Mean DKAS scores were 34.8/50 (SD = 7.0, range = 17–48) reflecting 8/25 incorrect answers. Backwards elimination regression found greater dementia knowledge was associated with greater health literacy for appraising information (coef 3.48, 95% CI (1.38, 5.58); p = 0.001) and more years of education (coef 0.39, 95% CI (0.12, 0.65); p = 0.004). Although not significant, knowledge was slightly lower in those who attended a support group, and a trend was found between ability to understand health information and knowledge. Only 39% accurately identified dementia as life shortening, indicating notable gaps in knowledge. Four qualitative themes were identified; arm yourself with information, ability to steer through information, other experience of dementia can be helpful and the importance of relationships with health care professionals. CONCLUSIONS: In an information age, vast amounts of information are available, but this can bring difficulties. Carers with more years of education and higher health literacy knew more about dementia. Professionals should consider how carers with lower health literacy can be supported through provision of timely, relevant information

Exploring how family carers of a person with dementia manage pre-death grief: A mixed methods study

Objectives Many family carers of a person with dementia experience pre-death grief. We aimed to identify strategies that help carers manage pre-death grief. We hypothesised that emotion and problem focussed styles would be associated with lower, and dysfunctional coping with higher grief intensity. Methods Mixed methods observational study using structured and semi-structured interviews with 150 family carers of people with dementia living at home or in a care home. Most participants were female (77%), caring for a parent (48%) or partner/spouse (47%) with mild (25%), moderate (43%) or severe (32%) dementia. They completed the Marwit-Meuser Caregiver Grief Inventory Short Form and the Brief Coping Orientation to Problems Experienced (Brief-COPE) questionnaire. We asked carers to identify strategies used for managing grief. We recorded field notes for 150 interviews and audio-recorded additional interviews with a sub-sample of 16 participants. Results Correlations indicated that emotion-oriented coping was associated with lower grief (R = −0.341), and dysfunctional coping with higher grief (R = 0.435), with a small association with problem-focused strategies (R = −0.109), partly supporting our hypothesis. Our qualitative themes broadly match the three Brief-COPE styles. Unhelpful strategies of denial and avoidance align with dysfunctional coping strategies. Psychological strategies (including acceptance and humour) and seeking support were consistent with emotion-focused strategies, but we did not identify a theme relating to problem-focused strategies. Conclusion Most carers identified multiple strategies for processing grief. Carers could readily identify supports and services that they found helpful for managing pre-death grief, yet current services appear under-resourced to meet growing demand. (ClinicalTrials.gov ID: NCT03332979)

Do screening tools assess palliative care needs and 12-month mortality in patients admitted to hepatology in-patient wards?

BACKGROUND: Many liver patients have unmet palliative care needs, but liver clinicians are unclear whom to refer to specialist palliative care (SPC). The Supportive and Palliative Care Indicator Tool (SPICT) and the Bristol Prognostic Screening Tool (BPST) could help identify suitable patients, but neither has been tested for this role. This study evaluated their role as screening tools for palliative care needs and for predicting 12-month mortality. METHODS: A case note review of hepatology in-patients, who were not peritransplant and post-transplant status, was conducted in one tertiary unit. Main outcomes were clinical judgement of need for SPC referral, BPST scores, SPICT attribution of caseness and 12-month survival status. Discriminatory ability of tools was assessed using sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV) and area under the receiver operating characteristic (AUROC) curve. RESULTS: 117 medical notes were reviewed for survival analysis, 47 of which were additionally assessed for suitability for SPC referral, using clinical judgement. SPICT (sensitivity=93%; PPV=93%; AUROC=0.933) and BPST (sensitivity=59%, PPV=79%, AUROC=0.693) demonstrated excellent and good performance, respectively, in predicting patients’ need for SPC referral. SPICT and BPST only had moderate ability at predicting death at 12 months (PPV: 54% and 56%, respectively). CONCLUSION: SPICT and BPST show potential as screening tools for identifying patients for referral to SPC. Further work is needed to determine how to implement these tools in a clinical setting

Advanced chronic liver disease in the last year of life: a mixed methods study to understand how care in a specialist liver unit could be improved

Objective: To identify the limitations in palliative care provision in the last year of life for people with liver cirrhosis and potential barriers to and enablers of palliative care. / Design: Mixed methods, including a retrospective case note review, qualitative focus groups and individual interviews. / Setting: A tertiary referral liver centre in the south of England (UK). / Participants: Purposively selected case notes of 30 people with cirrhosis who attended the tertiary referral liver centre and died during an 18-month period; a purposive sample of 22 liver health professionals who participated in either focus groups or individual interviews. / Primary and secondary outcomes: Data collected from case notes included hospital admissions, documented discussions of prognosis and palliative care provision. Qualitative methods explored management of people with cirrhosis, and barriers to and enablers of palliative care. / Results: Participants had high rates of hospital admissions and symptom burden. Clinicians rarely discussed prognosis or future care preferences; they lacked the skills and confidence to initiate discussions. Palliative care provision occurred late because clinicians were reluctant to refer due to their perception that reduced liver function is reversible, poor understanding of the potential of a palliative approach; palliative care was perceived negatively by patients and families. / Conclusions: People dying with cirrhosis have unpredictable trajectories, but share a common pathway of frequent admissions and worsening symptoms as death approaches. The use of clinical tools to identify the point of irreversible deterioration and joint working between liver services and palliative care may improve care for people with cirrhosis