Carers of older people with dementia: assessment and the Carers Act

To Dialyse or not to Dialyse - Is that the Question? A Psychosocial Perspective on Dilemmas Concerning Dialysis for People with Dementia

There is increasing recognition that the organisation of health care into specialist areas of practice can be counterproductive for older people with multiple morbidities and that dementia can raise particular challenges in health care. In the context of treatment for chronic kidney disease, these challenges concern complex decisions about the suitability and efficacy of dialysis and other treatments. This article draws on a literature review to present a psychosocial perspective on these decisions. It considers the value of the concept of 'dementia friendliness' for nephrology practice and suggests how this could provide a valuable frame of reference for the multidisciplinary nephrology team to ensure they are best equipped to work with people living with dementia and their carers and to ensure that the individual patient is truly at the centre of their treatment regime.

Perceptions of unmet needs for community social care services in England. A comparison of working carers and the people they care for

Previous UK research has found expressed unmet need for services by unpaid working carers and among disabled and older people. There are, however, suggestions from research that views on unmet needs for services differ between carers and care-recipients. Working carers in the UK say that the care-recipient is sometimes reluctant to accept services and the few international comparative dyad studies that have been carried out find that carers perceive higher unmet need than care-recipients. Recent policy discussions in England have also recognised that there may be differences of opinion. We collected data in 2013 from working carer/care-recipient dyads in England about perceived need for services for the care-recipient, disability, unpaid care hour provision and individual and socio-demographic characteristics. We find that care-recipients as well as their carers perceive high unmet need for services, although carers perceive higher unmet need. For carers, unmet need is associated with the disability of the carer-recipient and being the daughter or son of the care-recipient; for care-recipients it is associated with unpaid care hours, carers' employment status and carers' health. The majority of dyads agree on need for services, and agreement is higher when the working carer provides care for 10 hours or more hours a week. Services for care-recipients may enable working carers to remain in employment so agreement on needs for services supports the implementation of legislation, policy and practice that has a duty to, or aims to, support carer's employment.

Family carers' accounts of general practice contacts for their relatives with early signs of dementia

The role of families in supporting people with dementia is widely acknowledged in literature and UK government policy. The role of general practice in ensuring early and effective support for people living with mental health problems including dementia is also enshrined in UK policy. As part of a larger study, a total of 122 carers were asked to rate predefined aspects of the primary care response. For some responses they were also asked to provide a reason for their rating. The purpose of this study was to examine carers' accounts of contacts with general practitioners (GPs) and general practice teams when they were first approached with concerns about their relative. Findings suggest that, on average, carers rate the service as being at least ‘good'. However, their accounts describe a wide variety of experiences and demonstrate that expressed satisfaction does not necessarily reflect a satisfactory service. Both practitioner-related and carer-related issues were cited as reasons for their ratings. Implications for practice and research are discussed.

Barriers to implementation of case management for patients with dementia: a systematic mixed studies review

PURPOSE

Results of case management designed for patients with dementia and their caregivers in community-based primary health care (CBPHC) were inconsistent. Our objective was to identify the relationships between key outcomes of case management and barriers to implementation.

METHODS

We conducted a systematic mixed studies review (including quantitative and qualitative studies). Literature search was performed in MEDLINE, PsycINFO, Embase, and Cochrane Library (1995 up to August 2012). Case management intervention studies were used to assess clinical outcomes for patients, service use, caregiver outcomes, satisfaction, and cost-effectiveness. Qualitative studies were used to examine barriers to case management implementation. Patterns in the relationships between barriers to implementation and outcomes were identified using the configurational comparative method. The quality of studies was assessed using the Mixed Methods Appraisal Tool.

RESULTS

Forty-three studies were selected (31 quantitative and 12 qualitative). Case management had a limited positive effect on behavioral symptoms of dementia and length of hospital stay for patients and on burden and depression for informal caregivers. Interventions that addressed a greater number of barriers to implementation resulted in increased number of positive outcomes. Results suggested that high-intensity case management was necessary and sufficient to produce positive clinical outcomes for patients and to optimize service use. Effective communication within the CBPHC team was necessary and sufficient for positive outcomes for caregivers.

CONCLUSIONS

Clinicians and managers who implement case management in CBPHC should take into account high-intensity case management (small caseload, regular proactive patient follow-up, regular contact between case managers and family physicians) and effective communication between case managers and other CBPHC professionals and services.

Case management for dementia in primary health care: a systematic mixed studies review based on the diffusion of innovation model

Background

The purpose of this study was to examine factors associated with the implementation of case management (CM) interventions in primary health care (PHC) and to develop strategies to enhance its adoption by PHC practices.

Methods

This study was designed as a systematic mixed studies review (including quantitative and qualitative studies) with synthesis based on the diffusion of innovation model. A literature search was performed using MEDLINE, PsycInfo, EMBASE, and the Cochrane Database (1995 to August 2012) to identify quantitative (randomized controlled and nonrandomized) and qualitative studies describing the conditions limiting and facilitating successful CM implementation in PHC. The methodological quality of each included study was assessed using the validated Mixed Methods Appraisal Tool.

Results

Twenty-three studies (eleven quantitative and 12 qualitative) were included. The characteristics of CM that negatively influence implementation are low CM intensity (eg, infrequent follow-up), large caseload (more than 60 patients per full-time case manager), and approach, ie, reactive rather than proactive. Case managers need specific skills to perform their role (eg, good communication skills) and their responsibilities in PHC need to be clearly delineated.

Conclusion

Our systematic review supports a better understanding of factors that can explain inconsistent evidence with regard to the outcomes of dementia CM in PHC. Lastly, strategies are proposed to enhance implementation of dementia CM in PHC.

Carer's education groups for relatives with a first episode of psychosis: an evaluation of an eight-week education group

AIM

This study aimed to evaluate an eight-week carers group for people with first episode of psychosis receiving services from the Gloucestershire Recovery in Psychosis Early Intervention Team. Potential benefits for carers were assessed including changes in feelings of stress, isolation, recognition, and of being appreciated and valued.

METHODS

Following completion of the group, all 12 carers participated in an independently facilitated focus group to evaluate the course. Transcripts were imported into the QSR NVivo 8 (QSR International, Doncaster, Victoria, Australia) software package for thematic analysis. An independent coding and correlational analysis of data was used to identify any common themes.

RESULTS

Results identified five key themes reported by carers: the emotional impacts of being a carer (loss, grief, guilt, shock, acceptance), the wider impacts of mental illness within a family (isolation, stigma), the caring role and how this affected relationships (improved relationships), the design of the group (barriers, course content, timing of invitations, moving forward) and the wider impacts of participation (carer education, importance of sharing real-life experiences, navigating the National Health Service).

CONCLUSIONS

Carers reported less isolation, improved confidence, greater understanding of psychosis, reduction in guilt and increased coping in their caring role after the group. Carers reported that they gained new knowledge, obtained support from staff and graduate carers, increased the recognition of their caring role and had improved relationships with their relative with mental illness.

Carer participation in England, Wales and Northern Ireland: A challenge for interprofessional working

Much policy and practice attention has been focused on the participation and involvement of informal carers in service assessment, provision and review. The advent of the National Carers Strategy, the Community Care Delayed Discharge Act, Carers and Disabled Children Act and latterly the Carers (Equal Opportunities) Act have all played their part in giving greater significance to carer involvement. The role of professional cooperation and willingness to see carers as equal partners is a key factor in achieving these objectives. This paper relates details of a study of current carer participation in England, Wales and Northern Ireland and begs a number of important questions as to the challenges for interprofessional working in supporting carer participation.

Caregivers' Aspirations, Realities, and Expectations: The CARE Tool

Caregivers to family and friends are increasingly recognized as essential players in the continued shift of care of dependent populations to the community. Currently, Canadian provincial home care programs have neither a comprehensive policy nor an assessment regarding caregivers' needs. This article describes an assessment tool that takes into account caregivers' reality and conditions and that situates them as essential partners with the formal system and reports on the validation and reliability testing of this tool. Seven sites in Quebec and Nova Scotia involving 40 assessors tested the tool with 168 caregivers. Results suggest that this comprehensive tool enables practitioners to understand caregivers' needs and situations. Focus groups with assessors and interviews with home care administrators revealed that the tool increased worker understanding and awareness of what it means to be a caregiver, ascertained the key caregiver concerns, and identified these needs in rapid succession.

'Not another form!': lessons for implementing carer assessment in health and social service agencies

This article addresses some of the issues that need to be considered in implementing carer assessment in health and social service agencies. It is based on findings from three studies involving the use of the CARE (Caregivers' Aspirations Realities and Expectations) Assessment Tool in Canada, a comprehensive psychosocial instrument. The first study, carried out between 1999 and 2001, was aimed at developing the CARE Tool, and had as one of its objectives to evaluate the feasibility of its implementation into ongoing practice. The second study, conducted between 2000 and 2003, was designed to evaluate the impact of using the CARE Tool, and also had an objective concerning implementation. A third study was undertaken in 2005-2006, in part, to gain more understanding of the barriers and outcomes of implementing carer assessment. All three studies used focus groups and individual interviews as the main data collection method. In all, this article is based on 13 focus groups and five individual interviews with home care professionals and 19 individual interviews with home care managers or supervisory staff, all having experience with carer assessment. Similar themes emerged from the thematic analyses of the data from all three projects. All studies point to the following as preconditions to successful implementation: clarification of carer status within policy and practice; making explicit agency philosophy with regard to the role and responsibilities of families in care and conceptions of carer assessment; and agency buy-in at all levels. Four themes emerged as issues for implementation: integration of the carer assessment tool with existing tools; ensuring training and ongoing supervision; work organisation and resources required for carer assessment; and logistical questions. It would appear essential that a clear rationale for moving towards carer assessment and its place in a global approach to long-term care and carers are essential to its implementation.

Carers' health clinic initiative in Edinburgh: pilot evaluation

Unpaid carers see the Primary Health Care Team as an important source of help, information and support. A pilot Carers' Health Clinic to address the health needs of carers was set up in South West Edinburgh. The Clinic offered carers an assessment of their own health needs and information on a range of support services available to them including referral to a stress management therapist, if appropriate. Although physical health problems identified were mainly minor, the clinic findings indicate that many carers experienced emotional costs which they perceived to have an impact on their health. The Carers' Health Clinic pilot was a successful model, targeting carers who had not previously been in touch with carer support organizations and improving the awareness of carers of their own health needs.

Care Managers’ Time Use: Differences Between Community Mental Health and Older People’s Services in the United Kingdom

Since the community care reforms of the early 1990s, care management in the United Kingdom has become the usual means of arranging services for even the most straightforward of social care needs. This paper presents data from a diary study of care managers’ time use, from a sample of social services commissioning organizations representing the most common forms of care management practiced in England at the end of the 20th century. It compares the working practices of care managers in community mental health service settings to the practices of those situated in older people’s services. Evidence is provided to suggest that while the former follow a more clinical model of care management, those working with older people take an almost exclusively administrative approach to their work. In addition, the multidisciplinary nature of mental health service teams appears to facilitate a more integrated health and social care approach to care management compared to the approach to older people’s services. Further enquiry is needed as to the comparative effectiveness of these different modes of working in each service setting.

Family members’ experience of participation in the needs of assessment when their older next of kin becomes in need of public home help: A qualitative interview study

BACKGROUND

The policy that older people should be able live in their own homes in spite of extensive care and social service needs means that close family members are increasingly involved in help provision. Ways must be found to facilitate their situation. Their participation in the needs assessment of their next of kin may be crucial.

OBJECTIVES

The aim of the study was to illuminate close family members' experience of having an older next of kin becoming in need of public home help, their participation in the needs assessment procedure and the decisions about their next of kins' public home help.

PARTICIPANTS

The sample was 27 close family members (mean age 63, range 42-93 years) chosen by their older needs-assessed next of kin.

METHODS

An interview using a thematic interview guide formed an everyday dialogue jointly constructed by the interviewer and the interviewee. Thereafter an interpretative content analysis was conducted on the transcribed interviews.

RESULTS

One overarching category was illuminated: "Feeling disconfirmed or confirmed in the needs assessment, when feeling pressed by the responsibility and struggling to balance the needs of the family." Four principal categories with sub-categories were derived: (1) Experiencing existential ruminations and the need to help. (2) Help giving and receiving as a difficult balance between needs. (3) Feeling overlooked or acknowledged as having an influence on the needs assessment. (4) Hopes about the home help being fulfilled or dashed.

CONCLUSION

The findings imply that the main focus is on the help seeker, overlooking the contribution of family members representing and providing help. A more holistic needs assessment approach is required with a framework and working methods that involve and support the family as a whole.

The experience of caring for someone over 75 years of age: results from a Scottish General Practice population

AIMS AND OBJECTIVES

To understand the unpaid carers' experiences of looking after someone aged over 75 at all stages of their caring career.

BACKGROUND

The role of, and support for, unpaid carers have become central in the debates surrounding community care in the UK. This paper presents the findings of a study to elicit the complexities of the caring role and inform the Primary Health Care Team to help support carers more effectively.

DESIGNS AND METHODS

A quantitative research design was employed. Carers of people over 75 years of age in a General Practice, who had been previously identified from a screening questionnaire, were sent the Carers Assessment of Difficulties Index, the Carers Assessment of Satisfactions Index and Carers Assessment of Managing Index questionnaires which examine the experience of caring.

RESULTS

From a sample of 247 carers, a 70% response rate (n = 172) was achieved. Satisfactions lay in the quality of care provided; difficulties reflected the potential and actual family tensions generated; coping strategies included reframing difficulties, using humour and practical problem solving. The data show that caregivers' reactions, such as feeling angry about the situation, or the consequences of their involvement, such as tensions within the family, cause them more difficulties than the actual care-giving tasks they perform.

CONCLUSION

This study adds to the understanding of carers' roles by including carers across a range of situations, including those at an early stage of their caring career. Service providers are better able to support carers if they understand the complex interplay of difficulties, rewards and personal coping strategies associated with the caring role.

RELEVANCE TO PRACTICE

The study helps illuminate the less obvious, but important, emotional aspects of carers' difficulties and suggests strategies which service providers may find helpful in assessing carers' needs and determining the appropriate interventions.

The development of a screening tool to identify carers in a general practice by a large-scale mailed survey: the experience in one Scottish general practice

AIMS AND OBJECTIVES

To determine the feasibility of a screening tool to identify carers in a general practice.

BACKGROUND

The need to support informal carers is well established in policy and practice, but many carers continue to lack the support they need. Identifying carers is a fundamental precondition to providing them with support. Studies often recruit carers who are members of carers' organizations or via the care recipient in receipt of services. However, as nearly 60% of carers receive no support from the statutory services, this group of carers may not be representative of the majority of carers. This paper describes the results of a study undertaken to identify a broader group of carers in a general practice in a large Scottish city.

DESIGN AND METHODS

A quantitative research design was employed using a mailed screening survey to identify carers within a general practice. Carers were systematically identified, independent of the care recipient, using a screening tool developed by the researcher which was sent to all adult patients registered with the practice.

RESULTS

The response rate was 69%. Overall, 11% of the surgery population identified themselves as carers with a mean age of 55 years. The carers were involved in a range of caring activities of varying levels and duration.

CONCLUSION

The screening exercise was time consuming and costly. However, it would be feasible and useful to identify carers in smaller groups.

RELEVANCE TO PRACTICE

This study tackles issues that are pertinent to health policy and practice. Carers were systematically identified from a general practice population and included those at an early stage of the caring role, prior to being involved with service providers, as well as those established in their role. If carers are identified early in their caring career the primary health care team is more able to support them proactively.

Supporting carers in paid employment: Developing a needs‐led approach

This paper presents some of the key findings from a study about supporting carers in employment. It describes the qualitative experiences of family carers for older people who are in paid employment, paying particular attention to their views on assessment and service provision. The perspectives of other key stakeholders, including staff from statutory and independent sector agencies, are also considered. Support for carers in employment is one of the five priority action areas underpinning the National Strategy for Carers (DoH, 1999). However, the findings from this study reveal that carers in employment have a limited profile at strategic level and their specific needs are rarely addressed in mainstream health and social care planning processes. The findings also suggest that assessment and care management practices are failing to support carers in relation to their employment aspirations. The effectiveness of health and social care assessments in identifying and exploring the needs of carers in employment is limited and very few separate carer assessments are completed. Carers' first‐hand experiences of service provision are described. Deficits in current services are identified and examples of good practice are highlighted. The paper concludes by outlining the implications for policy and practice. It is suggested that flexible support, underpinned by partnerships between employers and staff from statutory and independent sector agencies, is the key to supporting carers in employment.

Comparing and contrasting the role of family carers and nurses in the domestic health care of frail older people

Care in the community has been constructed on the basis of professional support for carers who, as a result of community care policy that has released highly dependant people from residential care and long-stay wards, are carrying out a wide range of tasks, including complex health care activities. The present paper examines the health care activities currently undertaken by family carers and the way in which they work with, and are supported by, professional nurses in the home. It compares and contrasts the approaches of both groups to care-giving for this client group. The authors conclude by making some suggestions for improving the way in which family carers and nurses work together in the home.

Caring for a relative with dementia: The perceptions of carers and CPNs

Older people with dementia living in the community are most likely to be cared for by other older people, predominantly spouses, who will be at increased risk of stress‐related health problems themselves. Appropriate support of such carers is crucial if carer breakdown and consequent care‐receiver admission to residential homes is to be avoided. This paper examines the experience of older carers of frail older people with dementia and examines the kind of support that is provided to such carers. In practice, the sole source of professional support received by older people in this study was from community psychiatric nurses (CPNs). CPNs' role did not comprise hands‐on care‐giving and family carers carried out most personal/physical and healthcare tasks themselves, aided in some cases by care workers. The paper concludes by suggesting that lack of support for carers in these activities requires redress.

Current awareness in geriatric psychiatry. Bibliography

In order to keep subscribers up-to-date with the latest developments in their field, John Wiley &amp: Sons are providing a current awareness service in each issue of the journal. The bibliography contains newly published material in the field of geriatric psychiatry. Each bibliography is divided into 9 sections: 1 Books, Reviews &amp: Symposia; 2 General; 3 Assessment; 4 Epidemiology; 5 Therapy; 6 Care; 7 Dementia; 8 Depression; 9 Psychology. Within each section, articles are listed in alphabetical order with respect to author. If, in the preceding period, no publications are located relevant to any one of these headings, that section will be omitted