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Brown P, Cooper C, Dening KH, Hoe J, Burton A. An exploration of how specialist dementia nurses perceive and maintain the skills and competencies that frame their specialism: A qualitative survey. Heliyon 2024; 10:e27856. [PMID: 38596077 PMCID: PMC11001773 DOI: 10.1016/j.heliyon.2024.e27856] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2023] [Revised: 03/04/2024] [Accepted: 03/07/2024] [Indexed: 04/11/2024] Open
Abstract
Background UK policy for complex and long-term health conditions including dementia has recommended that specialist nursing intervention is offered across the trajectory of the condition, but there is a lack of agreement regarding the skills and competencies that specialist nurses are expected to possess. Admiral Nurses are the largest UK group of specialist dementia nurses. Objective To explore how Admiral Nurses met and were supported to meet competencies as defined in the Admiral Nurse Competency Framework, and to develop and maintain skills as dementia specialists. Design Cross-sectional, semi-structured survey. Setting Online national survey. Participants Admiral (specialist dementia) Nurses. Methods We co-designed our survey with Admiral Nurses; then invited Admiral Nurses to complete it in 2022-23 Data were analysed thematically. Results 68 (20% of all Admiral Nurses) completed the survey; most were female (85.2%), from a white ethnic group (88.2%); they reported on average 24 years of nursing experience. We identified three themes in responses: 1.Having time and skills for meaningful support, explored how participants were resourced with time and skills to understand and address family carer client needs by active listening, tailoring person-centred support, and "walking alongside" families. 2.Partnering family carers, concerned how they co-designed interventions with family carers, learning from these collaborative partnerships where expertise was shared. 3.Practice and peer-based learning, explored how participants took responsibility for using available training, peer learning and self-reflection to develop their practice. Conclusions Admiral Nurse roles enabled respondents to develop as autonomous practitioners and to access resources that supported them to build and sustain their dementia specialist practice. Learning was practice based, through partnerships with family carer clients, peer support and self-directed learning. Specialist nursing models may help address the global health workforce emergency, through enabling creative practice development and valued roles that support retention of experienced nurses.
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Affiliation(s)
- Pat Brown
- Division of Psychiatry, University College London, London, UK & Dementia UK, London, UK
| | - Claudia Cooper
- Centre for Psychiatry and Mental Health, Wolfson Institute of Population Health, Queen Mary University of London, London, UK, And East London NHS Foundation Trust
| | - Karen Harrison Dening
- School of Health & Life Sciences, De Montfort University, Leicester, Leicestershire & Dementia UK, London, UK
| | - Juanita Hoe
- Geller Institute of Ageing and Memory (GIAM), University of West London, London, UK
| | - Alexandra Burton
- Department of Behavioural Science and Health, University College London, London, UK
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Cooper C, Zabihi S, Akhtar A, Lee T, Isaaq A, Le Novere M, Barber J, Lord K, Rapaport P, Banks S, Duggan S, Ogden M, Walters K, Orgeta V, Rockwood K, Butler LT, Manthorpe J, Dow B, Hoe J, Hunter R, Banerjee S, Budgett J, Duffy L. Feasibility and acceptability of NIDUS-professional, a training and support intervention for homecare workers caring for clients living with dementia: a cluster-randomised feasibility trial. Age Ageing 2024; 53:afae074. [PMID: 38643354 PMCID: PMC11032424 DOI: 10.1093/ageing/afae074] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2023] [Revised: 02/23/2024] [Indexed: 04/22/2024] Open
Abstract
INTRODUCTION In the first randomised controlled trial of a dementia training and support intervention in UK homecare agencies, we aimed to assess: acceptability of our co-designed, manualised training, delivered by non-clinical facilitators; outcome completion feasibility; and costs for a future trial. METHODS This cluster-randomised (2:1) single-blind, feasibility trial involved English homecare agencies. Intervention arm agency staff were offered group videocall sessions: 6 over 3 months, then monthly for 3 months (NIDUS-professional). Family carers (henceforth carers) and clients with dementia (dyads) were offered six to eight complementary, individual intervention sessions (NIDUS-Family). We collected potential trial measures as secondary outcomes remotely at baseline and 6 months: HCW (homecare worker) Work-related Strain Inventory (WRSI), Sense of Competence (SoC); proxy-rated Quality of Life (QOL), Disability Assessment for Dementia scale (DAD), Neuropsychiatric Inventory (NPI) and Homecare Satisfaction (HCS). RESULTS From December 2021 to September 2022, we met agency (4 intervention, 2 control) and HCWs (n = 62) recruitment targets and recruited 16 carers and 16/60 planned clients. We met a priori progression criteria for adherence (≥4/6 sessions: 29/44 [65.9%,95% confidence interval (CI): 50.1,79.5]), HCW or carer proxy-outcome completion (15/16 (93.8% [69.8,99.8]) and proceeding with adaptation for HCWs outcome completion (46/63 (73.0% [CI: 60.3,83.4]). Delivery of NIDUS-Professional costs was £6,423 (£137 per eligible client). WRSI scores decreased and SoC increased at follow-up, with no significant between-group differences. For intervention arm proxy-rated outcomes, carer-rated QOL increased, HCW-rated was unchanged; carer and HCW-rated NPI decreased; DAD decreased (greater disability) and HCS was unchanged. CONCLUSION A pragmatic trial is warranted; we will consider using aggregated, agency-level client outcomes, including neuropsychiatric symptoms.
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Affiliation(s)
- Claudia Cooper
- Centre for Psychiatry and Mental Health, Wolfson Institute of Population Health, Queen Mary University London, London E1 2AB, UK
| | - Sedigheh Zabihi
- Centre for Psychiatry and Mental Health, Wolfson Institute of Population Health, Queen Mary University London, London E1 2AB, UK
| | - Amirah Akhtar
- Centre for Psychiatry and Mental Health, Wolfson Institute of Population Health, Queen Mary University London, London E1 2AB, UK
| | - Teresa Lee
- Centre for Psychiatry and Mental Health, Wolfson Institute of Population Health, Queen Mary University London, London E1 2AB, UK
| | - Abdinasir Isaaq
- Centre for Psychiatry and Mental Health, Wolfson Institute of Population Health, Queen Mary University London, London E1 2AB, UK
| | - Marie Le Novere
- Centre for Psychiatry and Mental Health, Wolfson Institute of Population Health, Queen Mary University London, London E1 2AB, UK
| | - Julie Barber
- Centre for Psychiatry and Mental Health, Wolfson Institute of Population Health, Queen Mary University London, London E1 2AB, UK
| | - Kathryn Lord
- Centre for Psychiatry and Mental Health, Wolfson Institute of Population Health, Queen Mary University London, London E1 2AB, UK
| | - Penny Rapaport
- Centre for Psychiatry and Mental Health, Wolfson Institute of Population Health, Queen Mary University London, London E1 2AB, UK
| | - Sara Banks
- Centre for Psychiatry and Mental Health, Wolfson Institute of Population Health, Queen Mary University London, London E1 2AB, UK
| | - Sandra Duggan
- Centre for Psychiatry and Mental Health, Wolfson Institute of Population Health, Queen Mary University London, London E1 2AB, UK
| | - Margaret Ogden
- Centre for Psychiatry and Mental Health, Wolfson Institute of Population Health, Queen Mary University London, London E1 2AB, UK
| | - Kate Walters
- Centre for Psychiatry and Mental Health, Wolfson Institute of Population Health, Queen Mary University London, London E1 2AB, UK
| | - Vasiliki Orgeta
- Centre for Psychiatry and Mental Health, Wolfson Institute of Population Health, Queen Mary University London, London E1 2AB, UK
| | - Kenneth Rockwood
- Centre for Psychiatry and Mental Health, Wolfson Institute of Population Health, Queen Mary University London, London E1 2AB, UK
| | - Laurie T Butler
- Centre for Psychiatry and Mental Health, Wolfson Institute of Population Health, Queen Mary University London, London E1 2AB, UK
| | - Jill Manthorpe
- Centre for Psychiatry and Mental Health, Wolfson Institute of Population Health, Queen Mary University London, London E1 2AB, UK
| | - Briony Dow
- Centre for Psychiatry and Mental Health, Wolfson Institute of Population Health, Queen Mary University London, London E1 2AB, UK
| | - Juanita Hoe
- Centre for Psychiatry and Mental Health, Wolfson Institute of Population Health, Queen Mary University London, London E1 2AB, UK
| | - Rachael Hunter
- Centre for Psychiatry and Mental Health, Wolfson Institute of Population Health, Queen Mary University London, London E1 2AB, UK
| | - Sube Banerjee
- Centre for Psychiatry and Mental Health, Wolfson Institute of Population Health, Queen Mary University London, London E1 2AB, UK
| | - Jessica Budgett
- Centre for Psychiatry and Mental Health, Wolfson Institute of Population Health, Queen Mary University London, London E1 2AB, UK
| | - Larisa Duffy
- Centre for Psychiatry and Mental Health, Wolfson Institute of Population Health, Queen Mary University London, London E1 2AB, UK
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Hoe J, Profyri E, Kemp C, Manela M, Webster L, Anthony J, Costafreda S, Arrojo F, Souris H, Livingston G. Risk assessment for people living with dementia: a systematic review. Int Psychogeriatr 2024; 36:263-288. [PMID: 38053362 DOI: 10.1017/s1041610223004398] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/07/2023]
Abstract
OBJECTIVE This systematic review identified key components of risk assessment for people with dementia, examined attitudes toward risk identification and risk assessment, and appraised existing risk assessment tools. METHODS Systematic searches of five databases on two platforms (EBSCO, OVID) and gray literature databases (Open Grey, Base) were conducted. Studies were screened for inclusion based on predetermined eligibility criteria and quality assessed using the Mixed Methods Appraisal Tool. Findings were tabulated and synthesized using thematic synthesis. RESULTS Our review found people with dementia, their family carers, and healthcare professionals differed in how risk is conceptualized, with views being shaped by media perceptions, personal experiences, socio-cultural influences, dementia knowledge, and dementia severity. We found that mobilization (causing falls inside and getting lost outside) is the most frequently identified risk factor. Our findings show people with dementia are generally risk-tolerant, while healthcare professionals may adopt risk-averse approaches because of organizational requirements. We found factors that disrupt daily routines, living and caring arrangements, medication management, and unclear care pathways contribute toward adverse risk events. We discovered that most studies about risk and risk assessment scales did not consider insight of the person with dementia into risks although this is important for the impact of a risk. No risk instrument identified had sufficient evidence that it was useful. CONCLUSION Accurate risk assessment and effective communication strategies that include the perspectives of people with dementia are needed to enable risk-tolerant practice. No risk instrument to date was shown to be widely acceptable and useful in practice.
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Affiliation(s)
- Juanita Hoe
- Geller Institute of Ageing and Memory, University of West London, London, UK
- School of Health Sciences, University of London, London, UK
| | - Elena Profyri
- School of Health Sciences, University of London, London, UK
| | - Charlotte Kemp
- School of Health Sciences, University of London, London, UK
| | - Monica Manela
- UCL Division of Psychiatry, University College London, Maple House, London, UK
| | - Lucy Webster
- UCL Division of Psychiatry, University College London, Maple House, London, UK
- Centre for Health Services Studies, University of Kent, Canterbury, Kent, UK
| | - Justine Anthony
- School of Health Sciences, University of London, London, UK
- School of Sport, Exercise and Health Sciences, Loughborough University, Loughborough, Leicestershire, UK
| | - Sergi Costafreda
- UCL Division of Psychiatry, University College London, Maple House, London, UK
- Camden, and Islington NHS Foundation Trust, St Pancras Hospital, London, UK
| | - Frank Arrojo
- Alzheimer's Society Research Network, Alzheimer's Society, London, UK
| | - Helen Souris
- Camden, and Islington NHS Foundation Trust, St Pancras Hospital, London, UK
- Dementia Clinical Network, NHS England and NHS Improvement (London Region, London, UK
| | - Gill Livingston
- UCL Division of Psychiatry, University College London, Maple House, London, UK
- Camden, and Islington NHS Foundation Trust, St Pancras Hospital, London, UK
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Cooper C, Vickerstaff V, Barber J, Phillips R, Ogden M, Walters K, Lang I, Rapaport P, Orgeta V, Rockwood K, Banks S, Palomo M, Butler LT, Lord K, Livingston G, Banerjee S, Manthorpe J, Dow B, Hoe J, Hunter R, Samus Q, Budgett J. A psychosocial goal-setting and manualised support intervention for independence in dementia (NIDUS-Family) versus goal setting and routine care: a single-masked, phase 3, superiority, randomised controlled trial. Lancet Healthy Longev 2024; 5:e141-e151. [PMID: 38310894 PMCID: PMC10834374 DOI: 10.1016/s2666-7568(23)00262-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2023] [Revised: 11/24/2023] [Accepted: 11/28/2023] [Indexed: 02/06/2024] Open
Abstract
BACKGROUND Although national guidelines recommend that everyone with dementia receives personalised post-diagnostic support, few do. Unlike previous interventions that improved personalised outcomes in people with dementia, the NIDUS-Family intervention is fully manualised and deliverable by trained and supervised, non-clinical facilitators. We aimed to investigate the effectiveness of home-based goal setting plus NIDUS-Family in supporting the attainment of personalised goals set by people with dementia and their carers. METHODS We did a two-arm, single-masked, multi-site, randomised, clinical trial recruiting patient-carer dyads from community settings. We randomly assigned dyads to either home-based goal setting plus NIDUS-Family or goal setting and routine care (control). Randomisation was blocked and stratified by site (2:1; intervention to control), with allocations assigned via a remote web-based system. NIDUS-Family is tailored to goals set by dyads by selecting modules involving behavioural interventions, carer support, psychoeducation, communication and coping skills, enablement, and environmental adaptations. The intervention involved six to eight video-call or telephone sessions (or in person when COVID-19-related restrictions allowed) over 6 months, then telephone follow-ups every 2-3 months for 6 months. The primary outcome was carer-rated goal attainment scaling (GAS) score at 12 months. Analyses were done by intention to treat. This trial is registered with the ISRCTN registry, ISRCTN11425138. FINDINGS Between April 30, 2020, and May 9, 2021, we assessed 1083 potential dyads for eligibility, 781 (72·1%) of whom were excluded. Of 302 eligible dyads, we randomly assigned 98 (32·4%) to the control group and 204 (67·5%) to the intervention group. The mean age of participants with dementia was 79·9 years (SD 8·2), 169 (56%) were women, and 133 (44%) were men. 247 (82%) dyads completed the primary outcome, which favoured the intervention (mean GAS score at 12 months 58·7 [SD 13·0; n=163] vs 49·0 [14·1; n=84]; adjusted difference in means 10·23 [95% CI 5·75-14·71]; p<0·001). 31 (15·2%) participants in the intervention group and 14 (14·3%) in the control group experienced serious adverse events. INTERPRETATION To our knowledge, NIDUS-Family is the first readily scalable intervention for people with dementia and their family carers that improves attainment of personalised goals. We therefore recommend that it be implemented in health and care services. FUNDING UK Alzheimer's Society.
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Affiliation(s)
- Claudia Cooper
- Centre for Psychiatry and Mental Health, Wolfson Institute of Population Health, Queen Mary University London, London, UK.
| | - Victoria Vickerstaff
- Research Department of Primary Care and Population Health, University College London, London, UK
| | - Julie Barber
- Department of Statistical Science, University College London, London, UK
| | | | - Margaret Ogden
- Research Network Volunteer, Alzheimer's Society, London, UK
| | - Kate Walters
- Research Department of Primary Care and Population Health, University College London, London, UK
| | - Iain Lang
- St Luke's Campus, University of Exeter, Exeter, UK
| | - Penny Rapaport
- Division of Psychiatry, University College London, London, UK
| | - Vasiliki Orgeta
- Division of Psychiatry, University College London, London, UK
| | - Kenneth Rockwood
- Division of Geriatric Medicine, Dalhousie University, Halifax, NS, Canada
| | - Sara Banks
- Centre for Psychiatry and Mental Health, Wolfson Institute of Population Health, Queen Mary University London, London, UK
| | - Marina Palomo
- Division of Psychiatry, University College London, London, UK
| | - Laurie T Butler
- Faculty of Science and Engineering, Anglia Ruskin University, Chelmsford, UK
| | - Kathyrn Lord
- Centre for Applied Dementia Studies, University of Bradford, Bradford, UK
| | - Gill Livingston
- Division of Psychiatry, University College London, London, UK
| | - Sube Banerjee
- Faculty of Medicine and Health Sciences, University of Nottingham, Nottingham, UK
| | - Jill Manthorpe
- The Policy Institute at King's, King's College London, London, UK
| | - Briony Dow
- National Ageing Research Institute, Melbourne, VIC, Australia
| | - Juanita Hoe
- Geller Institute of Ageing and Memory, School of Biomedical Sciences, University of West London, London, UK
| | - Rachael Hunter
- Research Department of Primary Care and Population Health, University College London, London, UK
| | - Quincy Samus
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University, Baltimore, MD, USA
| | - Jessica Budgett
- Centre for Psychiatry and Mental Health, Wolfson Institute of Population Health, Queen Mary University London, London, UK
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Burton A, Rapaport P, Palomo M, Lord K, Budgett J, Barber J, Hunter R, Butler L, Vickerstaff V, Rockwood K, Ogden M, Smith D, Lang I, Livingston G, Dow B, Kales H, Manthorpe J, Walters K, Hoe J, Orgeta V, Samus Q, Cooper C. Correction: Clinical and cost-effectiveness of a New psychosocial intervention to support Independence in Dementia (NIDUS-family) for family carers and people living with dementia in their own homes: a randomised controlled trial. Trials 2024; 25:18. [PMID: 38167460 PMCID: PMC10759320 DOI: 10.1186/s13063-023-07768-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2024] Open
Affiliation(s)
- Alexandra Burton
- Department of Behavioural Science and Health, University College London, London, UK.
| | - Penny Rapaport
- Division of Psychiatry, University College London, London, UK
| | - Marina Palomo
- Camden and Islington NHS Foundation Trust, London, UK
| | - Kathryn Lord
- The Centre for Applied Dementia Studies, University of Bradford, Bradford, UK
| | - Jessica Budgett
- Division of Psychiatry, University College London, London, UK
| | - Julie Barber
- Department of Statistical Science, University College London, London, UK
| | - Rachael Hunter
- Research Department of Primary Care and Population Health, University College London, London, UK
| | - Laurie Butler
- Faculty of Science and Engineering, Anglia Ruskin University, Cambridge, UK
| | - Victoria Vickerstaff
- Research Department of Primary Care and Population Health, University College London, London, UK
| | - Kenneth Rockwood
- Division of Geriatric Medicine, Dalhousie University, Halifax, Canada
| | - Margaret Ogden
- Alzheimer's Society Research Network Volunteers, London, UK
| | - Debs Smith
- Alzheimer's Society Research Network Volunteers, London, UK
| | - Iain Lang
- College of Medicine and Health, University of Exeter, Exeter, UK
| | - Gill Livingston
- Division of Psychiatry, University College London, London, UK
| | - Briony Dow
- National Ageing Research Institute, Royal Melbourne Hospital, Parkville, VIC, Australia
| | - Helen Kales
- Department of Psychiatry and Behavioral Sciences, UC Davis Health, University of California, California, USA
| | - Jill Manthorpe
- NIHR Policy Research Unit in Health and Social Care Workforce, King's College London, London, UK
| | - Kate Walters
- Research Department of Primary Care and Population Health, University College London, London, UK
| | - Juanita Hoe
- Division of Nursing, School of Health Sciences, City University of London, London, UK
| | - Vasiliki Orgeta
- Division of Psychiatry, University College London, London, UK
| | - Quincy Samus
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University, Baltimore, MD, USA
| | - Claudia Cooper
- Division of Psychiatry, University College London, London, UK
- Camden and Islington NHS Foundation Trust, London, UK
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Abstract
PURPOSE OF REVIEW Dementia policy priorities recommend that people who are living with dementia and their family should have access to support and interventions delivered by dementia specialists, including specialist nurses. However, specialist dementia nursing models and role-related competencies are not clearly defined. We systematically review the current evidence regarding specialist dementia nursing models and their impacts. RECENT FINDINGS Thirty-one studies from across three databases, and grey literature were included in the review. One framework defining specific specialist dementia nursing competencies was found. We did not find convincing evidence of the effectiveness of specialist nursing dementia services, relative to standard models of care from the current, limited evidence base, although families living with dementia valued it. No Randomised Controlled Trial (RCT) has compared the impact of specialist nursing on client and carer outcomes relative to less specialist care, although one nonrandomised study reported that specialist dementia nursing reduces emergency and inpatient service use compared with a usual care group. SUMMARY Current models of specialist dementia nursing are numerous and heterogeneous. Further exploration of the specialist nursing skills and the impact of specialist nursing interventions is needed to usefully inform workforce development strategies and clinical practice.
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Affiliation(s)
- Pat Brown
- Division of Psychiatry, University college London, and Dementia UK
| | | | - Jordan Ayden
- Division of Psychiatry, University College London
| | - Karen Harrison Dening
- Faculty of Health and Life Sciences, De Montfort University, Leicester, and Dementia UK
| | - Juanita Hoe
- Geller Institute of Ageing and Memory (GIAM), University of West London
| | - Claudia Cooper
- Centre for Psychiatry and Mental Health, Wolfson Institute of Population Health, Queen Mary University of London, London, UK
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Hoe J, Trickey A, McGraw C. Caring for people living with dementia in their own homes: A qualitative study exploring the role and experiences of registered nurses within a district nursing service in the UK. Int J Older People Nurs 2023; 18:e12491. [PMID: 35851749 DOI: 10.1111/opn.12491] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2021] [Revised: 05/11/2022] [Accepted: 06/27/2022] [Indexed: 01/13/2023]
Abstract
BACKGROUND In the UK, district nursing services (DNS) deliver care to people intheir own homes and have regular contact with people with dementia. Research conducted with nurses working in similar roles outside the UK suggests their contribution to high quality dementia care is limited by compassion fatigue, lack of dementia training and low levels of confidence. However, there is a paucity of research exploring the role and learning and support needs of nurses within DNS. OBJECTIVES The aim was to gain insight into the role and experiences of nurses caring for people living with dementia at home. METHODS The study was informed by a descriptive phenomenological approach. Semi-structured interviews were conducted with a purposive sample of ten nurses working in DNS. Data were analysed thematically. RESULTS Five main themes were identified: 'Home as a care setting' reflected how delivering home-based care shaped participants experiences of caring for people with dementia; 'Taking it in their stride' revealed how participants adapted and responded to the complexity of care needs for people with dementia; 'Complexity and unpredictability' related to the unpredictable nature of people with dementia's care needs and the impact this had on participants' workloads; 'Expertise and support within the wider team' detailed which networks nurses used for advice and support to manage the complex needs of people living with dementia at home; 'Specialist support' identified the need for structural changes and resources to enable the nurses to deliver the care needed. CONCLUSIONS This study enables better understanding of the role of DNS in supporting people with dementia to live at home. This is important for defining how dementia care can become effectively integrated into primary care. Recommendations include improved models of care, which factor in specialist nurses, additional time for home visits and greater emphasis on education and training. IMPLICATIONS FOR PRACTICE Improved models of working that factor in additional time and staffing such as specialist nurses in dementia and palliative care would allow DNS to meet the needs of people with dementia more effectively.
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Affiliation(s)
- Juanita Hoe
- Division of Nursing, School of Health Sciences, City, University of London, London, UK
| | - Alison Trickey
- Central and North West London NHS Foundation Trust, Gospel Oak Health Centre, London, UK
| | - Caroline McGraw
- Division of Nursing, School of Health Sciences, City, University of London, London, UK
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Abstract
OBJECTIVE Improving dementia diagnosis rates are a key feature of dementia strategy and policy worldwide. This study aimed to explore the experience of carers of people diagnosed with dementia during or following a hospital admission in order to identify factors that had prevented them from seeking help beforehand. Semi-structured interviews were conducted with 12 informal carers including adults caring for a parent, a friend or a spouse diagnosed with dementia between 2010-2019, following an acute hospital admission for a physical health problem, having not sought help previously. MAIN FINDINGS Carers created a 'bubble of normalisation' around themselves and the person living with dementia (PLWD) to reject the label of dementia and protect the PLWD from a loss of independence, discrimination and prejudice they felt would be the result of a diagnosis. Carers struggled to talk to the PLWD about dementia reinforcing denial and stigma. Post-diagnosis carers felt unsupported and questioned the value of diagnosis. PRINCIPAL CONCLUSIONS Stigma related to images of dementia as a disease that takes away independence and identity prevented discussion about dementia between carers and the PLWD. A lack of open discussion about memory concerns between health care professionals and carers also served to delay diagnosis.
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Affiliation(s)
- Michelle Parker
- Division of Nursing, City University of London, London, UK,Michelle Parker, Division of Nursing, City University of London, Northampton Square, London EC1V 0HB, UK.
| | - Sally Barlow
- Division of Nursing, City University of London, London, UK
| | - Juanita Hoe
- Division of Nursing, City University of London, London, UK
| | - Leanne M. Aitken
- School of Health Sciences, City University of London, London, UK,School of Nursing & Midwifery, Griffith University, Australia
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Sacre M, Albert R, Hoe J. What are the experiences and the perceptions of service users attending Emergency Department for a mental health crisis? A systematic review. Int J Ment Health Nurs 2022; 31:400-423. [PMID: 34941023 DOI: 10.1111/inm.12968] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/08/2021] [Indexed: 11/28/2022]
Abstract
Historically, dualistic healthcare systems have resulted in limited mental healthcare provision within physical health settings, with service users reporting poor care specifically while attending emergency departments (EDs) in a mental health crisis. Modern approaches to healthcare recognize these inequalities and are moving towards integrating healthcare systems that allow more holistic and seamless experiences for service users. This mixed-method review examines the experiences and perceptions of service users attending EDs for a mental health crisis. Systematic searches of eight databases on two platforms (EBSCO, OVID) and grey literature databases (Open Grey, Base) were conducted. Studies were systematically screened for inclusion based on predetermined eligibility criteria and quality assessed using the Mixed Methods Appraisal Tool. Findings were tabulated and synthesized using thematic synthesis. Ten studies consisting of qualitative and mixed-method designs were included in the review. Five overarching themes emerged from the synthesis: social constructs, service provider, service provision, effectiveness, and emotional impact. The findings from this review show that service users continue to have negative experiences in EDs due to stigmatizing attitudes and low skill in managing mental health needs, whereas more positive experiences are attributed to the availability of mental health liaison services. Tackling stigma, improving communication and staff training, providing calm environments, and addressing structural issues that promote better interagency working and reduce gaps in services are needed to improve mental health service user experience. Future research should focus on trauma-informed approaches in EDs to improve person-centred care for service users experiencing a mental health crisis.
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Affiliation(s)
- Maya Sacre
- Division of Nursing, School of Health Sciences, City, University of London, London, UK
| | - Rikke Albert
- Tower Hamlets Mental Health Liaison and Psychological Medicine, Royal London Hospital, London, UK
| | - Juanita Hoe
- Division of Nursing, School of Health Sciences, City, University of London, London, UK
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Burton A, Rapaport P, Palomo M, Lord K, Budgett J, Barber J, Hunter R, Butler L, Vickerstaff V, Rockwood K, Ogden M, Smith D, Lang I, Livingston G, Dow B, Kales H, Manthorpe J, Walters K, Hoe J, Orgeta V, Samus Q, Cooper C. Clinical and cost-effectiveness of a New psychosocial intervention to support Independence in Dementia (NIDUS-family) for family carers and people living with dementia in their own homes: a randomised controlled trial. Trials 2021; 22:865. [PMID: 34857029 PMCID: PMC8637036 DOI: 10.1186/s13063-021-05851-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2021] [Accepted: 11/20/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Most people living with dementia want to remain living in their own homes and are supported to do so by family carers. No interventions have consistently demonstrated improvements to people with dementia's life quality, functioning, or other indices of living as well as possible with dementia. We have co-produced, with health and social care professionals and family carers of people with dementia, a new intervention (NIDUS-family). To our knowledge, NIDUS-family is the first manualised intervention that can be tailored to personal goals of people living with dementia and their families and is delivered by facilitators without clinical training. The intervention utilizes components of behavioural management, carer support, psychoeducation, communication and coping skills training, enablement, and environmental adaptations, with modules selected to address dyads' selected goals. We will evaluate the effect of NIDUS-family and usual care on goal attainment, as measured by Goal Attainment Scaling (GAS) rated by family carers, compared to usual care alone at 12-month follow-up. We will also determine whether NIDUS-family and usual care is more cost-effective than usual care alone over 12 months. METHODS A randomised, two-arm, single-masked, multi-site clinical trial involving 297 people living with dementia-family carer dyads. Dyads will be randomised 2:1 to receive the NIDUS-family intervention with usual care (n = 199) or usual care alone (n = 98). The intervention group will be offered, over 1 year, via 6-8 video call or telephone sessions (or face to face if COVID-19 restrictions allow in the recruitment period) in the initial 6 months, followed by telephone follow-ups every 1-2 months to support implementation, with a trained facilitator. DISCUSSION Increasing the time lived at home by people living with dementia is likely to benefit lives now and in the future. Our intervention, which we adapted to include remote delivery prior to trial commencement due to the COVID-19 pandemic, aims to address barriers to living as well and as independently as possible that distress people living with dementia, exacerbate family carer(s) stress, negatively affect relationships, lead to safety risks, and frequently precipitate avoidable moves to a care home. TRIAL REGISTRATION International Standard Randomised Controlled Trials Number ISRCTN11425138 . Registered on 7 October 2019.
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Affiliation(s)
- Alexandra Burton
- Department of Behavioural Science and Health, University College London, London, UK.
| | - Penny Rapaport
- Division of Psychiatry, University College London, London, UK
| | - Marina Palomo
- Camden and Islington NHS Foundation Trust, London, UK
| | - Kathryn Lord
- The Centre for Applied Dementia Studies, University of Bradford, Bradford, UK
| | - Jessica Budgett
- Division of Psychiatry, University College London, London, UK
| | - Julie Barber
- Department of Statistical Science, University College London, London, UK
| | - Rachael Hunter
- Research Department of Primary Care and Population Health, University College London, London, UK
| | - Laurie Butler
- Faculty of Science and Engineering, Anglia Ruskin University, Cambridge, UK
| | - Victoria Vickerstaff
- Research Department of Primary Care and Population Health, University College London, London, UK
| | - Kenneth Rockwood
- Division of Geriatric Medicine, Dalhousie University, Halifax, Canada
| | - Margaret Ogden
- Alzheimer's Society Research Network Volunteers, London, UK
| | - Debs Smith
- Alzheimer's Society Research Network Volunteers, London, UK
| | - Iain Lang
- College of Medicine and Health, University of Exeter, Exeter, UK
| | - Gill Livingston
- Division of Psychiatry, University College London, London, UK
| | - Briony Dow
- National Ageing Research Institute, Royal Melbourne Hospital, Parkville, Victoria, Australia
| | - Helen Kales
- Department of Psychiatry and Behavioral Sciences, UC Davis Health, University of California, California, USA
| | - Jill Manthorpe
- NIHR Policy Research Unit in Health and Social Care Workforce, King's College London, London, UK
| | - Kate Walters
- Research Department of Primary Care and Population Health, University College London, London, UK
| | - Juanita Hoe
- Division of Nursing, School of Health Sciences, City University of London, London, UK
| | - Vasiliki Orgeta
- Division of Psychiatry, University College London, London, UK
| | - Quincy Samus
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University, Baltimore, MD, USA
| | - Claudia Cooper
- Division of Psychiatry, University College London, London, UK
- Camden and Islington NHS Foundation Trust, London, UK
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11
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Tobis S, Jaracz K, Kropińska S, Talarska D, Hoe J, Wieczorowska-Tobis K, Suwalska A. Needs of older persons living in long-term care institutions: on the usefulness of cluster approach. BMC Geriatr 2021; 21:316. [PMID: 34001000 PMCID: PMC8130415 DOI: 10.1186/s12877-021-02259-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2020] [Accepted: 05/04/2021] [Indexed: 12/03/2022] Open
Abstract
Background Long-term care units’ residents do not constitute a homogeneous population. Providing effective care, tailored to individual needs, is crucial in this context. It can be facilitated by suitable tools and methods, which include needs assessment along with the physical, psychological and social aspects of care. We thus applied a cluster approach to identify their putative groupings to enable the provision of tailored care. Methods The needs of 242 residents of care homes in four Polish cities (Poznan, Wroclaw, Bialystok and Lublin), aged 75–102 years (184 females), with the Mini-Mental State Examination (MMSE) score ≥ 15 points, were assessed with the CANE (Camberwell Assessment of Need for the Elderly) questionnaire. Their independence in activities of daily living was evaluated by the Barthel Index (BI), and symptoms of depression by the Geriatric Depression Scale (GDS). The results of MMSE, BI and GDS were selected as variables for K-means cluster analysis. Results Cluster 1 (C1), n = 83, included subjects without dementia according to MMSE (23.7 ± 4.4), with no dependency (BI = 85.8 ± 14.4) and no symptoms of depression (GDS = 3.3 ± 2.0). All subjects of cluster 2 (C2), n = 87, had symptoms of depression (GDS = 8.9 ± 2.1), and their MMSE (21.0 ± 4.0) and BI (79.8 ± 15.1) were lower than those in C1 (p = 0.006 and p = 0.046, respectively). Subjects of cluster 3 (C3), n = 72, had the lowest MMSE (18.3 ± 3.1) and BI (30.6 ± 18,8, p < 0.001 vs. C1 & C2). Their GDS (7.6 ± 2.3) were higher than C1 (p < 0.001) but lower than C2 (p < 0.001). The number of met needs was higher in C2 than in C1 (10.0 ± 3.2 vs 8.2 ± 2.7, p < 0.001), and in C3 (12.1 ± 3.1) than in both C1 and C2 (p < 0.001). The number of unmet needs was higher in C3 than in C1 (1.2 ± 1.5 vs 0.7 ± 1.0, p = 0.015). There were also differences in the patterns of needs between the clusters. Conclusions Clustering seems to be a promising approach for use in long-term care, allowing for more appropriate and optimized care delivery. External validation studies are necessary for generalized recommendations regarding care optimization in various regional perspectives.
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Affiliation(s)
- Sławomir Tobis
- Department of Occupational Therapy, Poznan University of Medical Sciences, ul. Swiecickiego 6, 60-781, Poznan, Poland.
| | - Krystyna Jaracz
- Chair of Nursing, Poznan University of Medical Sciences, ul. Smoluchowskiego 11, 60-179, Poznan, Poland
| | - Sylwia Kropińska
- Geriatrics Unit, Chair and Department of Palliative Medicine, Poznan University of Medical Sciences, Poznan, Poland
| | - Dorota Talarska
- Chair of Preventive Medicine, Poznan University of Medical Sciences, ul. Swiecickiego 6, 60-781, Poznan, Poland
| | - Juanita Hoe
- Division of Nursing, School of Health Sciences, City, University of London, Northampton Square, London, EC1V 0HB, UK
| | - Katarzyna Wieczorowska-Tobis
- Geriatrics Unit, Chair and Department of Palliative Medicine, Poznan University of Medical Sciences, Poznan, Poland
| | - Aleksandra Suwalska
- Department of Mental Health, Chair of Psychiatry, Poznan University of Medical Sciences, ul. Szpitalna 27/33, 60-572, Poznan, Poland
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Stanyon M, Streater A, Coleston-Shields DM, Yates J, Challis D, Dening T, Hoe J, Lloyd-Evans B, Mitchell S, Moniz-Cook E, Poland F, Prothero D, Orrell M. Development of an Evidence-Based Best Practice Model for Teams Managing Crisis in Dementia: Protocol for a Qualitative Study. JMIR Res Protoc 2021; 10:e14781. [PMID: 33502333 PMCID: PMC7875693 DOI: 10.2196/14781] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2019] [Revised: 11/01/2019] [Accepted: 11/05/2019] [Indexed: 11/17/2022] Open
Abstract
Background Teams working in the community to manage crisis in dementia currently exist, but with widely varying models of practice, it is difficult to determine the effectiveness of such teams. Objective The aim of this study is to develop a “best practice model” for dementia services managing crisis, as well as a set of resources to help teams implement this model to measure and improve practice delivery. These will be the best practice tool and toolkit to be utilized by teams to improve the effectiveness of crisis teams working with older people with dementia and their caregivers. This paper describes the protocol for a prospective study using qualitative methods to establish an understanding of the current practice to develop a “best practice model.” Methods Participants (people with dementia, caregivers, staff members, and stakeholders) from a variety of geographical areas, with a broad experience of crisis and noncrisis work, will be purposively selected to participate in qualitative approaches including interviews, focus groups, a consensus workshop, and development and field testing of both the best practice tool and toolkit. Results Data were collected between October 2016 and August 2018. Thematic analysis will be utilized to establish the current working of teams managing crisis in dementia in order to draw together elements of the best practice. Conclusions This is the first study to systematically explore the requirements needed to fulfill effective and appropriate home management for people with dementia and their caregivers at the time of mental health crisis, as delivered by teams managing crisis in dementia. This systematic approach to development will support greater acceptability and validity of the best practice tool and toolkit and lay the foundation for a large scale trial with teams managing crisis in dementia across England to investigate the effects on practice and impact on service provision, as well as the associated experiences of people with dementia and their caregivers. International Registered Report Identifier (IRRID) RR1-10.2196/14781
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Affiliation(s)
- Miriam Stanyon
- Division of Psychiatry and Applied Psychology, School of Medicine, University of Nottingham, Nottingham, United Kingdom
| | - Amy Streater
- Division of Psychiatry and Applied Psychology, School of Medicine, University of Nottingham, Nottingham, United Kingdom.,Research and Development, North East London Foundation Trust, London, United Kingdom
| | - Donna Maria Coleston-Shields
- Division of Psychiatry and Applied Psychology, School of Medicine, University of Nottingham, Nottingham, United Kingdom
| | - Jennifer Yates
- Division of Psychiatry and Applied Psychology, School of Medicine, University of Nottingham, Nottingham, United Kingdom
| | - David Challis
- Division of Psychiatry and Applied Psychology, School of Medicine, University of Nottingham, Nottingham, United Kingdom
| | - Tom Dening
- Division of Psychiatry and Applied Psychology, School of Medicine, University of Nottingham, Nottingham, United Kingdom
| | - Juanita Hoe
- Division of Nursing, School of Health Sciences, University of London, London, United Kingdom
| | | | - Shirley Mitchell
- Research and Innovation, Nottinghamshire Healthcare NHS Foundation Trust, Nottingham, United Kingdom
| | - Esme Moniz-Cook
- Faculty of Health Sciences, University of Hull, Hull, United Kingdom
| | - Fiona Poland
- School of Health Sciences, University of East Anglia, Norwich, United Kingdom
| | - David Prothero
- Research and Development, North East London Foundation Trust, London, United Kingdom
| | - Martin Orrell
- Division of Psychiatry and Applied Psychology, School of Medicine, University of Nottingham, Nottingham, United Kingdom
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Yates J, Stanyon M, Challis D, Coleston-Shields DM, Dening T, Hoe J, Jawahar K, Lloyd-Evans B, Moniz-Cook E, Poland F, Streater A, Trigg E, Orrell M. Developing a model of best practice for teams managing crisis in people with dementia: a consensus approach. BMC Psychiatry 2020; 20:505. [PMID: 33050901 PMCID: PMC7552369 DOI: 10.1186/s12888-020-02899-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2020] [Accepted: 09/28/2020] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Teams delivering crisis resolution services for people with dementia and their carers provide short-term interventions to prevent admission to acute care settings. There is great variation in these services across the UK. This article reports on a consensus process undertaken to devise a Best Practice Model and evaluation Tool for use with teams managing crisis in dementia. METHODS The Best Practice Model and Tool were developed over a three stage process: (i) Evidence gathering and generation of candidate standards (systematic review and scoping survey, interviews and focus groups); (ii) Prioritisation and selection of standards (consultation groups, a consensus conference and modified Delphi process); (iii) Refining and operationalising standards (consultation group and field-testing). RESULTS One hundred sixty-five candidate standards arose from the evidence gathering stage; were refined and reduced to 90 through a consultation group exercise; and then reduced to 50 during the consensus conference and weighted using a modified Delphi process. Standards were then operationalised through a clinical consultation group and field-tested with 11 crisis teams and 5 non-crisis teams. Scores ranged from 48 to 92/100. The median score for the crisis teams was 74.5 (range 67-92), and the median score for non-crisis teams was 60 (range 48-72). CONCLUSIONS With further psychometric testing, this Best Practice Model and Tool will be ideal for the planning, improvement and national benchmarking of teams managing dementia crises in the future.
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Affiliation(s)
- Jennifer Yates
- Institute of Mental Health, Division of Psychiatry and Applied Psychology, School of Medicine, University of Nottingham, Jubilee Campus, Nottingham, NG7 2TU, UK.
| | - Miriam Stanyon
- Institute of Mental Health, Division of Psychiatry and Applied Psychology, School of Medicine, University of Nottingham, Jubilee Campus, Nottingham, NG7 2TU, UK
| | - David Challis
- Institute of Mental Health, Division of Psychiatry and Applied Psychology, School of Medicine, University of Nottingham, Jubilee Campus, Nottingham, NG7 2TU, UK
| | - Donna Maria Coleston-Shields
- Institute of Mental Health, Division of Psychiatry and Applied Psychology, School of Medicine, University of Nottingham, Jubilee Campus, Nottingham, NG7 2TU, UK
| | - Tom Dening
- Institute of Mental Health, Division of Psychiatry and Applied Psychology, School of Medicine, University of Nottingham, Jubilee Campus, Nottingham, NG7 2TU, UK
| | - Juanita Hoe
- Division of Nursing, City University London, London, UK
| | - Kaanthan Jawahar
- Institute of Mental Health, Division of Psychiatry and Applied Psychology, School of Medicine, University of Nottingham, Jubilee Campus, Nottingham, NG7 2TU, UK
| | | | | | | | - Amy Streater
- Institute of Mental Health, Division of Psychiatry and Applied Psychology, School of Medicine, University of Nottingham, Jubilee Campus, Nottingham, NG7 2TU, UK
- Research and Development, North East London NHS Foundation Trust, Ilford, UK
| | - Emma Trigg
- Institute of Mental Health, Division of Psychiatry and Applied Psychology, School of Medicine, University of Nottingham, Jubilee Campus, Nottingham, NG7 2TU, UK
| | - Martin Orrell
- Institute of Mental Health, Division of Psychiatry and Applied Psychology, School of Medicine, University of Nottingham, Jubilee Campus, Nottingham, NG7 2TU, UK
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Parker M, Barlow S, Hoe J, Aitken L. Persistent barriers and facilitators to seeking help for a dementia diagnosis: a systematic review of 30 years of the perspectives of carers and people with dementia. Int Psychogeriatr 2020; 32:1-24. [PMID: 32024558 DOI: 10.1017/s1041610219002229] [Citation(s) in RCA: 36] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
OBJECTIVE To identify barriers and facilitators to help seeking for a dementia diagnosis from the perspective of carers and people with dementia. DESIGN A systematic review of the literature was conducted according to the PRISMA guidelines (PROSPERO protocol registration CRD42018092524). Nine electronic databases were searched for qualitative, quantitative, and mixed methods primary research studies. Two independent reviewers screened titles and abstracts, full texts of eligible studies, and conducted quality appraisal of included articles. A convergent qualitative synthesis approach was used. RESULTS From 7496 articles, 35 papers representing 32 studies from 1986 to 2017 were included. Studies originated from 13 countries across 4 continents. Barriers and facilitators were reported predominantly by carers. A small number of studies included people with dementia. Barriers included denial, stigma and fear, lack of knowledge, normalization of symptoms, preserving autonomy, lack of perceived need, unaware of changes, lack of informal network support, carer difficulties, and problems accessing help. Facilitators included recognition of symptoms as a problem, prior knowledge and contacts, and support from informal network. CONCLUSIONS Studies from a 30-year period demonstrated that barriers to help seeking persist globally, despite increasing numbers of national dementia policies. Barriers and facilitators rarely existed independently demonstrating the complexity of help seeking for a diagnosis of dementia. Multiple barriers compounded the decision-making process and more than one facilitator was often required to overcome them. Multi-faceted interventions to reduce barriers are needed, one approach would be a focus on the development of dementia friendly communities to reduce stigma and empower people with dementia and carers.
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Affiliation(s)
| | - Sally Barlow
- Division of Nursing, City, University of London, London, UK
| | - Juanita Hoe
- Division of Nursing, City, University of London, London, UK
| | - Leanne Aitken
- School of Health Sciences, City, University of London, London, UK
- School of Nursing & Midwifery, Griffith University, Queensland, Australia
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15
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Livingston G, Manela M, O'Keeffe A, Rapaport P, Cooper C, Knapp M, King D, Romeo R, Walker Z, Hoe J, Mummery C, Barber J. Clinical effectiveness of the START (STrAtegies for RelaTives) psychological intervention for family carers and the effects on the cost of care for people with dementia: 6-year follow-up of a randomised controlled trial. Br J Psychiatry 2020; 216:35-42. [PMID: 31298169 DOI: 10.1192/bjp.2019.160] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
BACKGROUND The START (STrAtegies for RelaTives) intervention reduced depressive and anxiety symptoms of family carers of relatives with dementia at home over 2 years and was cost-effective. AIMS To assess the clinical effectiveness over 6 years and the impact on costs and care home admission. METHOD We conducted a randomised, parallel group, superiority trial recruiting from 4 November 2009 to 8 June 2011 with 6-year follow-up (trial registration: ISCTRN 70017938). A total of 260 self-identified family carers of people with dementia were randomised 2:1 to START, an eight-session manual-based coping intervention delivered by supervised psychology graduates, or to treatment as usual (TAU). The primary outcome was affective symptoms (Hospital Anxiety and Depression Scale, total score (HADS-T)). Secondary outcomes included patient and carer service costs and care home admission. RESULTS In total, 222 (85.4%) of 173 carers randomised to START and 87 to TAU were included in the 6-year clinical efficacy analysis. Over 72 months, compared with TAU, the intervention group had improved scores on HADS-T (adjusted mean difference -2.00 points, 95% CI -3.38 to -0.63). Patient-related costs (START versus TAU, respectively: median £5759 v. £16 964 in the final year; P = 0.07) and carer-related costs (median £377 v. £274 in the final year) were not significantly different between groups nor were group differences in time until care home (intensity ratio START:TAU was 0.88, 95% CI 0.58-1.35). CONCLUSIONS START is clinically effective and this effect lasts for 6 years without increasing costs. This is the first intervention with such a long-term clinical and possible economic benefit and has potential to make a difference to individual carers. DECLARATIONS OF INTEREST G.L., Z.W. and C.C. are supported by the UCLH National Institute for Health Research (NIHR) Biomedical Research Centre. G.L. and P.R. were in part supported by the National Institute for Health Research (NIHR) Collaboration for Leadership in Applied Health Research and Care (CLAHRC) North Thames at Bart's Health NHS Trust. The views expressed are those of the author(s) and not necessarily those of the NHS, the NIHR or the Department of Health. Z.W. reports during the conduct of the study; personal fees from GE Healthcare, grants from GE Healthcare, grants from Lundbeck, other from GE Healthcare, outside the submitted work.
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Affiliation(s)
- Gill Livingston
- Professor of Older People's Psychiatry, Division of Psychiatry, UCL; and Camden and Islington NHS Foundation Trust, St Pancras Hospital, UK
| | | | - Aidan O'Keeffe
- Lecturer in Statistics, UCL Statistical Science and PRIMENT Clinical Trials Unit, UCL, UK
| | - Penny Rapaport
- Principal Clinical Psychologist, Division of Psychiatry, UCL, UK
| | - Claudia Cooper
- Professor, Division of Psychiatry, UCL; and Camden and Islington NHS Foundation Trust, St Pancras Hospital, UK
| | - Martin Knapp
- Professor of Social Policy, Personal Social Services Research Unit, London School of Economics & Political Science, UK
| | - Derek King
- Assistant Professorial Research Fellow, Personal Social Services Research Unit, London School of Economics & Political Science, UK
| | - Renee Romeo
- Senior Lecturer in Health Economics, Institute of Psychiatry Psychology and Neuroscience, King's College London, UK
| | - Zuzana Walker
- Professor, Division of Psychiatry, UCL; and Essex Partnership University NHS Foundation Trust, UK
| | - Juanita Hoe
- Senior Clinical Research Associate, Division of Psychiatry, UCL, UK
| | - Cath Mummery
- Consultant Neurologist, Honorary Senior Lecturer, Institute of Neurology, UCL, UK
| | - Julie Barber
- Associate Professor in Medical Statistics, UCL Statistical Science and PRIMENT Clinical Trials Unit, UCL, UK
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Robertson S, Cooper C, Hoe J, Lord K, Rapaport P, Marston L, Cousins S, Lyketsos CG, Livingston G. Comparing proxy rated quality of life of people living with dementia in care homes. Psychol Med 2020; 50:86-95. [PMID: 30691541 PMCID: PMC6945323 DOI: 10.1017/s0033291718003987] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2018] [Revised: 10/31/2018] [Accepted: 12/06/2018] [Indexed: 11/29/2022]
Abstract
BACKGROUND Improving quality of life (QOL) for people with dementia is a priority. In care homes, we often rely on proxy ratings from staff and family but we do not know if, or how, they differ in care homes. METHODS We compared 1056 pairs of staff and family DEMQOL-Proxy ratings from 86 care homes across England. We explored factors associated with ratings quantitatively using multilevel modelling and, qualitatively, through thematic analysis of 12 staff and 12 relative interviews. RESULTS Staff and family ratings were weakly correlated (ρs = 0.35). Median staff scores were higher than family's (104 v. 101; p < 0.001). Family were more likely than staff to rate resident QOL as 'Poor' (χ2 = 55.91, p < 0.001). Staff and family rated QOL higher when residents had fewer neuropsychiatric symptoms and severe dementia. Staff rated QOL higher in homes with lower staff:resident ratios and when staff were native English speakers. Family rated QOL higher when the resident had spent longer living in the care home and was a native English. Spouses rated residents' QOL higher than other relatives. Qualitative results suggest differences arise because staff felt good care provided high QOL but families compared the present to the past. Family judgements centre on loss and are complicated by decisions about care home placement and their understandings of dementia. CONCLUSION Proxy reports differ systematically between staff and family. Reports are influenced by the rater:staff and family may conceptualise QOL differently.
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Affiliation(s)
- S. Robertson
- Division of Psychiatry, University College London, Maple House, 149 Tottenham Court Road, London, W1T 7NF, UK
| | - C. Cooper
- Division of Psychiatry, University College London, Maple House, 149 Tottenham Court Road, London, W1T 7NF, UK
| | - J. Hoe
- Division of Psychiatry, University College London, Maple House, 149 Tottenham Court Road, London, W1T 7NF, UK
| | - K. Lord
- Division of Psychiatry, University College London, Maple House, 149 Tottenham Court Road, London, W1T 7NF, UK
| | - P. Rapaport
- Division of Psychiatry, University College London, Maple House, 149 Tottenham Court Road, London, W1T 7NF, UK
| | - L. Marston
- Division of Psychiatry, University College London, Maple House, 149 Tottenham Court Road, London, W1T 7NF, UK
| | - S. Cousins
- Division of Psychiatry, University College London, Maple House, 149 Tottenham Court Road, London, W1T 7NF, UK
| | - C. G. Lyketsos
- Division of Psychiatry, University College London, Maple House, 149 Tottenham Court Road, London, W1T 7NF, UK
| | - G. Livingston
- Division of Psychiatry, University College London, Maple House, 149 Tottenham Court Road, London, W1T 7NF, UK
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Robertson S, Cooper C, Hoe J, Lord K, Rapaport P, Livingston G. Why do staff and family think differently about quality of life in dementia? A qualitative study exploring perspectives in care homes. Int J Geriatr Psychiatry 2019; 34:1784-1791. [PMID: 31397501 DOI: 10.1002/gps.5193] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2019] [Accepted: 08/06/2019] [Indexed: 11/07/2022]
Abstract
BACKGROUND Quality of life is important especially in incurable illness. In dementia, we often need proxy reports of quality of life, but we know little about how individuals make their judgements. In care homes, proxies may be staff providing care or relatives, but staff rate quality of life differently to family. To our knowledge, no one has explored this qualitatively, so we used qualitative interviews to explore why staff and family think differently about quality of life. METHODS We interviewed 12 staff and 12 relatives who had provided proxy ratings of quality of life for people living with dementia in care homes in the Managing Agitation and Raising Quality of life (MARQUE) study. We asked why they had rated the resident's quality of life as "Very Good, Good, Fair, or Poor." Using thematic analysis, we compared staff and relatives' proxy responses. RESULTS For staff, the concept of quality of life was often viewed synonymously with quality of care, influenced by their sense of responsibility and informed by their professional understanding. For relatives, quality of life was often judged in relation to how the person with dementia lived before diagnosis and was influenced by their perception of loss for the person with dementia and their own adjustment. CONCLUSIONS Proxy reports were influenced by rater's own contexts and experiences. This can enhance our understanding of widely used research tools, aid the evaluation of intervention outcomes, and indicate possible targets for improving perceived and actual quality of life of people with dementia.
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Affiliation(s)
- Sarah Robertson
- Division of Psychiatry, University College London (UCL), London, UK.,School of Psychology, University of Liverpool, Liverpool, UK
| | - Claudia Cooper
- Division of Psychiatry, University College London (UCL), London, UK
| | | | - Kathryn Lord
- Bradford Dementia Group, The University of Bradford, Bradford, UK
| | - Penny Rapaport
- Division of Psychiatry, University College London (UCL), London, UK
| | - Gill Livingston
- Division of Psychiatry, University College London (UCL), London, UK
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Robertson S, Cooper C, Hoe J, Livingston G. [O4–08–01]: DO PAID AND FAMILY CARERGIVERS RATE THE QUALITY OF LIFE OF SOMEONE WITH DEMENTIA LIVING IN A CARE HOME IN THE SAME WAY? Alzheimers Dement 2017. [DOI: 10.1016/j.jalz.2017.07.460] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Affiliation(s)
- Sarah Robertson
- University College LondonLondonUnited Kingdom
- Camden and Islington NHS Foundation TrustLondonUnited Kingdom
| | | | - Juanita Hoe
- University College LondonLondonUnited Kingdom
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Livingston G, Baio G, Sommerlad A, de Lusignan S, Poulimenos S, Morris S, Rait G, Hoe J. Effectiveness of an intervention to facilitate prompt referral to memory clinics in the United Kingdom: Cluster randomised controlled trial. PLoS Med 2017; 14:e1002252. [PMID: 28291781 PMCID: PMC5349651 DOI: 10.1371/journal.pmed.1002252] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2016] [Accepted: 02/03/2017] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND Most people with dementia do not receive timely diagnosis, preventing them from making informed plans about their future and accessing services. Many countries have a policy to increase timely diagnosis, but trials aimed at changing general practitioner (GP) practice have been unsuccessful. We aimed to assess whether a GP's personal letter, with an evidence-based leaflet about overcoming barriers to accessing help for memory problems-aimed at empowering patients and families-increases timely dementia diagnosis and patient presentation to general practice. METHODS AND FINDING Multicentre, cluster-randomised controlled trial with raters masked to an online computer-generated randomisation system assessing 1 y outcome. We recruited 22 general practices (August 2013-September 2014) and 13 corresponding secondary care memory services in London, Hertfordshire, and Essex, United Kingdom. Eligible patients were aged ≥70 y, without a known diagnosis of dementia, living in their own homes. There were 6,387 such patients in 11 intervention practices and 8,171 in the control practices. The primary outcome was cognitive severity on Mini Mental State Examination (MMSE). Main secondary outcomes were proportion of patients consulting their GP with suspected memory disorders and proportion of those referred to memory clinics. There was no between-group difference in cognitive severity at diagnosis (99 intervention, mean MMSE = 22.04, 95% confidence intervals (CIs) = 20.95 to 23.13; 124 control, mean MMSE = 22.59, 95% CI = 21.58 to 23.6; p = 0.48). GP consultations with patients with suspected memory disorders increased in intervention versus control group (odds ratio = 1.41; 95% CI = 1.28, 1.54). There was no between-group difference in the proportions of patients referred to memory clinics (166, 2.5%; 220, 2.7%; p = .077 respectively). The study was limited as we do not know whether the additional patients presenting to GPs had objective as well as subjective memory problems and therefore should have been referred. In addition, we aimed to empower patients but did not do anything to change GP practice. CONCLUSIONS Our intervention to access timely dementia diagnosis resulted in more patients presenting to GPs with memory problems, but no diagnoses increase. We are uncertain as to the reason for this and do not know whether empowering the public and targeting GPs would have resulted in a successful intervention. Future interventions should be targeted at both patients and GPs. TRIAL REGISTRATION Current Controlled Trials ISRCTN19216873.
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Affiliation(s)
- Gill Livingston
- Division of Psychiatry, University College London, London, United Kingdom
- Camden and Islington NHS Foundation Trust, London, United Kingdom
| | - Gianluca Baio
- Department of Statistical Science, University College London, London, United Kingdom
| | - Andrew Sommerlad
- Division of Psychiatry, University College London, London, United Kingdom
- Camden and Islington NHS Foundation Trust, London, United Kingdom
| | - Simon de Lusignan
- Department of Clinical and Experimental Medicine, University of Surrey, Guildford, United Kingdom
| | - Spyridon Poulimenos
- Department of Statistical Science, University College London, London, United Kingdom
| | - Steve Morris
- Department of Applied Health Research, University College London, London, United Kingdom
| | - Greta Rait
- Research Department of Primary Care and Population Sciences, University College London, London, United Kingdom
| | - Juanita Hoe
- Division of Psychiatry, University College London, London, United Kingdom
- Camden and Islington NHS Foundation Trust, London, United Kingdom
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Orrell M, Hoe J, Charlesworth G, Russell I, Challis D, Moniz-Cook E, Knapp M, Woods B, Hoare Z, Aguirre E, Toot S, Streater A, Crellin N, Whitaker C, d’Amico F, Rehill A. Support at Home: Interventions to Enhance Life in Dementia (SHIELD) – evidence, development and evaluation of complex interventions. Programme Grants Appl Res 2017. [DOI: 10.3310/pgfar05050] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
BackgroundDementia is a national priority and this research addresses the Prime Minister’s commitment to dementia research as demonstrated by his 2020 challenge and the new UK Dementia Research Institute. In the UK > 800,000 older people have dementia. It has a major impact on the lives of people with dementia themselves, on the lives of their family carers and on services, and costs the nation £26B per year. Pharmacological cures for dementias such as Alzheimer’s disease are not expected before 2025. If no cure can be found, the ageing demographic will result in 2 million people living with dementia by 2050. People with dementia lose much more than just their memory and their daily living skills; they can also lose their independence, their dignity and status, their confidence and morale, and their roles both within the family and beyond. They can be seen as a burden by society, by their families and even by themselves, and may feel unable to contribute to society. This programme of research aims to find useful interventions to improve the quality of life of people with dementia and their carers, and to better understand how people with dementia can be supported at home and avoid being admitted to hospital.Objectives(1) To develop and evaluate the maintenance cognitive stimulation therapy (MCST) for people with dementia; (2) to develop the Carer Supporter Programme (CSP), and to evaluate the CSP and Remembering Yesterday, Caring Today (RYCT) for people with dementia both separately and together in comparison with usual care; and (3) to develop a home treatment package (HTP) for dementia, to field test the HTP in practice and to conduct an exploratory trial.Methods(1) The MCST programme was developed for people with dementia based on evidence and qualitative work. A randomised controlled trial (RCT) [with a pilot study of MCST plus acetylcholinesterase inhibitors (AChEIs)] compared MCST with cognitive stimulation therapy (CST) only. The MCST implementation study conducted a trial of outreach compared with usual care, and assessed implementation in practice. (2) The CSP was developed based on existing evidence and the engagement of carers of people with dementia. The RCT (with internal pilot) compared the CSP and reminiscence (RYCT), both separately and in combination, with usual care. (3) A HTP for dementia, including the most promising interventions and components, was developed by systematically reviewing the literature and qualitative studies including consensus approaches. The HTP for dementia was evaluated in practice by conducting in-depth field testing.Results(1) Continuing MCST improved quality of life and improved cognition for those taking AChEIs. It was also cost-effective. The CST implementation studies indicated that many staff will run CST groups following a 1-day training course, but that outreach support helps staff go on to run maintenance groups and may also improve staff sense of competence in dementia care. The study of CST in practice found no change in cognition or quality of life at 8-month follow-up. (2) The CSP/RYCT study found no benefits for family carers but improved quality of life for people with dementia. RYCT appeared beneficial for the quality of life of people with dementia but at an excessively high cost. (3) Case management for people with dementia reduces admissions to long-term care and reduces behavioural problems. In terms of managing crises, staff suggested more costly interventions, carers liked education and support, and people with dementia wanted family support, home adaptations and technology. The easy-to-use home treatment manual was feasible in practice to help staff working in crisis teams to prevent hospital admissions for people with dementia.LimitationsGiven constraints on time and funding, we were unable to compete the exploratory trial of the HTP package or to conduct an economic evaluation.Future researchTo improve the care of people with dementia experiencing crises, a large-scale clinical trial of the home treatment manual is needed.ConclusionThere is an urgent need for effective psychosocial interventions for dementia. MCST improved quality of life and was cost-effective, with benefits to cognition for those on AChEIs. MCST was feasible in practice. Both CSP and RYCT improved the quality of life of people with dementia, but the overall costs may be too high. The HTP was useful in practice but requires evaluation in a full trial. Dementia care research may improve the lives of millions of people across the world.Trial registrationsCurrent Controlled Trials ISRCTN26286067 (MCST), ISRCTN28793457 (MCST implementation) and ISRCTN37956201 (CSP/RYCT).FundingThis project was funded by the National Institute for Health Research (NIHR) Programme Grants for Applied Research programme and will be published in full inProgramme Grants for Applied Research; Vol. 5, No. 5. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Martin Orrell
- Department of Mental Health Sciences, University College London, London, UK
| | - Juanita Hoe
- Department of Mental Health Sciences, University College London, London, UK
| | | | - Ian Russell
- Clinical Trials Unit, Swansea University, Swansea, UK
| | - David Challis
- Personal Social Services Research Unit, University of Manchester, Manchester, UK
| | - Esme Moniz-Cook
- Centre of Dementia Research and Practice, University of Hull, Hull, UK
| | - Martin Knapp
- Health and Social Care Department, London School of Economics and Political Science, London, UK
| | - Bob Woods
- North Wales Organisation for Randomised Trials in Health (NWORTH) Clinical Trials Unit, Bangor University, Bangor, UK
| | - Zoe Hoare
- North Wales Organisation for Randomised Trials in Health (NWORTH) Clinical Trials Unit, Bangor University, Bangor, UK
| | - Elisa Aguirre
- Department of Mental Health Sciences, University College London, London, UK
| | - Sandeep Toot
- Research and Development Department, North East London NHS Foundation Trust, London, UK
| | - Amy Streater
- Research and Development Department, North East London NHS Foundation Trust, London, UK
| | - Nadia Crellin
- Research and Development Department, North East London NHS Foundation Trust, London, UK
| | - Chris Whitaker
- North Wales Organisation for Randomised Trials in Health (NWORTH) Clinical Trials Unit, Bangor University, Bangor, UK
| | - Francesco d’Amico
- Health and Social Care Department, London School of Economics and Political Science, London, UK
| | - Amritpal Rehill
- Health and Social Care Department, London School of Economics and Political Science, London, UK
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Hoe J, Jesnick L, Turner R, Leavey G, Livingston G. Caring for relatives with agitation at home: a qualitative study of positive coping strategies. BJPsych Open 2017; 3:34-40. [PMID: 28243464 PMCID: PMC5299384 DOI: 10.1192/bjpo.bp.116.004069] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2016] [Revised: 01/12/2017] [Accepted: 01/16/2017] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Trials of psychological interventions for reducing agitation in people with dementia living at home have been unsuccessful. AIMS To inform future interventions by identifying successful strategies of family carers with relatives with dementia and agitation living at home. METHOD Qualitative in-depth individual interviews were performed with 18 family carers. We used thematic analysis to identify emerging themes. RESULTS Carers described initial surprise and then acceptance that agitation is a dementia symptom and learned to respond flexibly. Their strategies encompassed: prevention of agitation by familiar routine; reduction of agitation by addressing underlying causes and using distraction; prevention of escalation by risk enablement, not arguing; and control of their emotional responses by ensuring their relative's safety then walking away, carving out some time for themselves and using family and services for emotional and practical help. CONCLUSIONS These strategies can be manualised and tested in future randomised controlled trials for clinical effectiveness in reducing agitation in people with dementia living at home. DECLARATION OF INTEREST None. COPYRIGHT AND USAGE © The Royal College of Psychiatrists 2017. This is an open access article distributed under the terms of the Creative Commons Non-Commercial, No Derivatives (CC BY-NC-ND) license.
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Affiliation(s)
- Juanita Hoe
- , PhD, Division of Psychiatry, University College London, London, UK; Camden and Islington NHS Foundation Trust, London, UK
| | - Leah Jesnick
- , MSc, Division of Psychiatry, University College London, London, UK
| | - Rebecca Turner
- , MSc, Division of Psychiatry, University College London, London, UK
| | - Gerard Leavey
- , PhD, The Bamford Centre for Mental Health and Wellbeing, Ulster University, Coleraine, Northern Ireland
| | - Gill Livingston
- , MD, Division of Psychiatry, University College London, London, UK; Camden and Islington NHS Foundation Trust, London, UK
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Charlesworth G, Burnell K, Crellin N, Hoare Z, Hoe J, Knapp M, Russell I, Wenborn J, Woods B, Orrell M. Peer support and reminiscence therapy for people with dementia and their family carers: a factorial pragmatic randomised trial. J Neurol Neurosurg Psychiatry 2016; 87:1218-1228. [PMID: 27521377 PMCID: PMC5099314 DOI: 10.1136/jnnp-2016-313736] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2016] [Accepted: 07/13/2016] [Indexed: 11/12/2022]
Abstract
OBJECTIVE The objective of this study was to evaluate peer support and reminiscence therapy, separately and together, in comparison with usual care for people with dementia and their family carers. DESIGN Factorial pragmatic randomised trial, analysed by treatment allocated, was used for this study. SETTING The trial ran in Community settings in England. PARTICIPANTS People with dementia and their family carers were the participants. INTERVENTIONS Treatment as usual (TAU) plus one of the following: one-to-one peer support to family carers from experienced carers (Carer Supporter Programme; CSP), group reminiscence therapy (Remembering Yesterday, Caring Today; RYCT) for people with dementia and carers, both or neither. MAIN OUTCOME MEASURES Primary outcomes included health-related quality of life (SF-12) for carers and quality of life (QoL-AD) for people with dementia; secondary outcomes included quality of relationship for carers and people with dementia; both were collected by blinded assessors at baseline, 5 and 12 months (primary end point). RESULTS Of 291 pairs recruited, we randomised 145 (50%) to CSP (71% uptake) and 194 (67%) to RYCT (61% uptake). CSP and RYCT, separately or together, were not effective in improving primary outcomes or most secondary outcomes. For CSP versus 'no CSP', adjusted difference in means was 0.52 points on the SF-12 (95% CI -1.28 to 2.32) and -0.08 points on the QoL-AD (95% CI -1.70 to 1.56). For RYCT versus 'no RYCT', the difference was 0.10 points on the SF-12 (95% CI -1.72 to 1.93) and 0.51 points on the QoL-AD (95% CI -1.17 to 2.08). However, carers reported better relationships with the people with dementia (difference 1.11, 95% CI 0.00 to 2.21, p=0.05). Comparison of combined intervention with TAU, and of intervention received, suggested differential impacts for carers and persons with dementia. CONCLUSIONS There is no evidence from the trial that either peer support or reminiscence is effective in improving the quality of life. TRIAL REGISTRATION NUMBER ISRCTN37956201; Results.
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Affiliation(s)
| | - Karen Burnell
- School of Health Sciences and Social Work, University of Portsmouth, Portsmouth, UK
| | | | - Zoe Hoare
- NWORTH Clinical Trials Unit, Bangor University, Bangor, UK
| | - Juanita Hoe
- Division of Psychiatry, University College London, London, UK
| | | | - Ian Russell
- Swansea University Medical School, Swansea, UK
| | | | - Bob Woods
- DSDC Wales, Bangor University, Bangor, UK
| | - Martin Orrell
- Institute of Mental Health, University of Nottingham, Nottingham, UK
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Robertson S, Cooper C, Hoe J, Livingston G. P4‐243: A Systematic Review and Meta‐Analysis Comparing Quality‐Of‐Life Ratings from Family and Paid Caregivers of People With Dementia Residing in Care Homes. Alzheimers Dement 2016. [DOI: 10.1016/j.jalz.2016.06.2335] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
| | | | - Juanita Hoe
- University College LondonLondonUnited Kingdom
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Ledgerd R, Hoe J, Hoare Z, Devine M, Toot S, Challis D, Orrell M. Identifying the causes, prevention and management of crises in dementia. An online survey of stakeholders. Int J Geriatr Psychiatry 2016; 31:638-47. [PMID: 26489696 DOI: 10.1002/gps.4371] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2014] [Revised: 09/05/2015] [Accepted: 09/10/2015] [Indexed: 11/08/2022]
Abstract
BACKGROUND Crisis situations in dementia can lead to hospital admission or institutionalisation. Offering immediate interventions may help avoid admission, whilst stabilising measures can help prevent future crises. OBJECTIVE Our objective was to identify the main causes of crisis and interventions to treat or prevent crisis in persons with dementia based on different stakeholder perspectives. METHODS An online questionnaire was developed to identify the causes of crisis and appropriate interventions in a crisis. Participants included people with dementia, family carers and staff working in health and social care, including emergency and voluntary sectors, and academia. RESULTS The results ranked the main causes of crisis, interventions that can prevent a crisis and interventions that can be useful in a crisis. Wandering, falls and infection were highly rated as risk factors for crises across all stakeholder groups. Consumers rated aggression as less important but severity of memory impairment as much more important than the other groups did. Education and support for family carers and home care staff were highly valued for preventing crises. Well-trained home care staff, communication equipment, emergency contacts and access to respite were highly valued for managing crises. CONCLUSIONS We identified triggers and interventions that different stakeholders see as important for crisis in dementia. Recognition of these may be critical to planning effective and accepted support and care for people with dementia.
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Affiliation(s)
- Ritchard Ledgerd
- Dementia Care Research Centre, North East London NHS Foundation Trust, London, UK
| | - Juanita Hoe
- Division of Psychiatry, University College London, London, UK
| | - Zoë Hoare
- Institute of Medical and Social Care Research, Bangor University, Bangor, UK
| | - Mike Devine
- Dementia Care Research Centre, North East London NHS Foundation Trust, London, UK
| | - Sandeep Toot
- Dementia Care Research Centre, North East London NHS Foundation Trust, London, UK.,Division of Psychiatry, University College London, London, UK
| | | | - Martin Orrell
- Dementia Care Research Centre, North East London NHS Foundation Trust, London, UK.,Institute of Mental Health, University of Nottingham, UK
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Burnell K, Charlesworth G, Feast AR, Hoe J, Poland FM, Orrell M. Peer support interventions for family carers of adults with chronic mental or physical illness who are living at home. Hippokratia 2016. [DOI: 10.1002/14651858.cd010231.pub2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Affiliation(s)
- Karen Burnell
- University of Portsmouth; School of Health Sciences and Social Work (SHSSW); James Watson Building (West) 2 King Richard 1st Road Portsmouth UK PO1 2FR
| | - Georgina Charlesworth
- University College London; Research Department of Clinical, Educational, and Health Psychology; 67-73 Riding House Street 1st Floor, Charles Bell House London UK W1W 7EJ
| | - Alexandra R Feast
- North East London NHS Foundation Trust; Research and Development Department; 1st Floor, Maggie Lilley Suite Goodmayes Hospital, Barley Lane Ilford Essex UK IG3 8XJ
| | - Juanita Hoe
- University College London; Mental Health Sciences Unit; Charles Bell House 67-73 Riding House Street London UK W1W 7EJ
| | - Fiona M Poland
- University of East Anglia; School of Allied Health Professions (AHP) and Health and Social Science Research Institute; Norwich Norfolk UK NR7 4TJ
| | - Martin Orrell
- University of Nottingham; Institute of Mental Health; Triumph Road Nottingham Nottinghamshire UK
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D'Amico F, Rehill A, Knapp M, Aguirre E, Donovan H, Hoare Z, Hoe J, Russell I, Spector A, Streater A, Whitaker C, Woods RT, Orrell M. Maintenance cognitive stimulation therapy: an economic evaluation within a randomized controlled trial. J Am Med Dir Assoc 2016; 16:63-70. [PMID: 25528281 DOI: 10.1016/j.jamda.2014.10.020] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2014] [Accepted: 10/29/2014] [Indexed: 10/24/2022]
Abstract
BACKGROUND Cognitive Stimulation Therapy (CST) is effective and cost-effective for people with mild-to-moderate dementia when delivered biweekly over 7 weeks. AIMS To examine whether longer-term (maintenance) CST is cost-effective when added to usual care. METHODS Cost-effectiveness analysis within multicenter, single-blind, pragmatic randomized controlled trial; subgroup analysis for people taking acetylcholinesterase inhibitors (ACHEIs). A total of 236 participants with mild-to-moderate dementia received CST for 7 weeks. They were randomized to either weekly maintenance CST added to usual care or usual care alone for 24 weeks. RESULTS Although outcome gains were modest over 6 months, maintenance CST appeared cost-effective when looking at self-rated quality of life as primary outcome, and cognition (MMSE) and proxy-rated quality-adjusted life years as secondary outcomes. CST in combination with ACHEIs offered cost-effectiveness gains when outcome was measured as cognition. CONCLUSIONS Continuation of CST is likely to be cost-effective for people with mild-to-moderate dementia.
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Affiliation(s)
- Francesco D'Amico
- Personal Social Services Research Unit, London School of Economics and Political Science, London, UK.
| | - Amritpal Rehill
- Personal Social Services Research Unit, London School of Economics and Political Science, London, UK
| | - Martin Knapp
- Personal Social Services Research Unit, London School of Economics and Political Science, London, UK
| | - Elisa Aguirre
- Dementia Care Research Centre, Research and Development Department, Maggie Lilley Suite, Goodmayes Hospital, North East London NHS Foundation Trust, Ilford, Essex, UK
| | - Helen Donovan
- Clinical Psychology Service, South Essex Partnership NHS Foundation Trust, Healthlink, Bedford, UK
| | - Zoe Hoare
- North Wales Organisation for Randomised Trials in Health (NWORTH), Institute of Medical and Social Care Research, Bangor, Wales
| | - Juanita Hoe
- Division of Psychiatry, University College London, London, UK
| | - Ian Russell
- College of Medicine, Swansea University, Swansea, UK
| | - Aimee Spector
- Research Department of Clinical, Educational and Health Psychology, University College London, London, UK
| | - Amy Streater
- Dementia Care Research Centre, Research and Development Department, Maggie Lilley Suite, Goodmayes Hospital, North East London NHS Foundation Trust, Ilford, Essex, UK
| | - Christopher Whitaker
- North Wales Organisation for Randomised Trials in Health (NWORTH), Institute of Medical and Social Care Research, Bangor, Wales
| | | | - Martin Orrell
- Division of Psychiatry, University College London, London, UK
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Livingston G, Barber J, Rapaport P, Knapp M, Griffin M, Romeo R, King D, Livingston D, Lewis-Holmes E, Mummery C, Walker Z, Hoe J, Cooper C. START (STrAtegies for RelaTives) study: a pragmatic randomised controlled trial to determine the clinical effectiveness and cost-effectiveness of a manual-based coping strategy programme in promoting the mental health of carers of people with dementia. Health Technol Assess 2015; 18:1-242. [PMID: 25300037 DOI: 10.3310/hta18610] [Citation(s) in RCA: 134] [Impact Index Per Article: 14.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Two-thirds of people with dementia live at home, receiving most care from family carers, about 40% of whom have clinically significant depression or anxiety. This impacts on the person with dementia, families and society, predicting care breakdown. There are currently no clinically effective and cost-effective NHS family carer interventions. OBJECTIVES To assess the STrAtegies for RelaTives (START) intervention in the short (4 and 8 months) and long term (1 and 2 years) compared with treatment as usual (TAU). DESIGN Randomised, parallel-group, superiority trial with blinded assessment recruiting participants 2:1 (intervention to TAU) to allow for therapist clustering. SETTING Three UK mental health services and one neurological service. PARTICIPANTS Family carers of people with dementia. INTERVENTION Eight-session manual-based coping intervention delivered by supervised psychology graduates to individuals. MAIN OUTCOME MEASURES Affective symptoms [Hospital Anxiety and Depression Scale-total (HADS-T)] and cost-effectiveness. Secondary measures: anxiety and depression symptoms and caseness, quality of life (QoL), abusive behaviour and long-term care home admission. RESULTS Two hundred and sixty participants were randomised (173 intervention, 87 TAU). We used intention-to-treat analysis in the short term (152 intervention, 77 TAU) and in the long term (140 intervention, 69 TAU). In the short term, the intervention group had lower HADS-T [mean difference -1.80, 95% confidence interval (CI) -3.29 to -0.31; p=0.02] and higher quality-adjusted life-years (QALYs) (mean difference 0.03, 95% CI -0.01 to 0.08). Costs were no different between groups [mean £ 252 (95% CI -£ 28 to £ 565) for intervention group]. The cost-effectiveness acceptability curve showed a greater than 99% chance of being cost-effectiveness at a £ 30,000/QALY willingness-to-pay threshold and a high probability of cost-effectiveness based on the HADS-T score. Carers in the intervention group had less case-level depression [odds ratio (OR) 0.24, 95% CI 0.07 to 0.76], a trend towards reduced case-level anxiety (OR 0.30, 95% CI 0.08 to 1.05), lower Hospital Anxiety and Depression Scale-anxiety (HADS-A) (-0.91, 95% CI -1.76 to -0.07; p = 0.03) and Hospital Anxiety and Depression Scale-depression (HADS-D) (-0.91, 95% CI -1.71 to -0.10; p = 0.03) and higher Health Status Questionnaire (HSQ) QoL (mean difference 4.09, 95% CI 0.34 to 7.83). Group differences in abusive behaviour (OR 0.48, 95% CI 0.18 to 1.27) and the person with dementia's quality of life-Alzheimer's disease (QoL-AD) (mean increase 0.59, 95% CI -0.72 to 1.89) were not significant. In the long term, the intervention group had lower HADS-T (mean difference -2.58, 95% CI -4.26 to -0.90; p = 0.03) and higher QALYs (mean difference 0.03, 95% CI -0.01 to 0.06). Carers in the intervention group had less case-level depression (OR 0.14, 95% CI 0.04 to 0.53), a trend towards reduced case-level anxiety (OR 0.57, 95% CI 0.26 to 1.24), lower HADS-A (-1.16, 95% CI -2.15 to -0.18) and HADS-D (1.45, 95% CI -2.32 to -0.57), and higher HSQ (mean difference 7.47, 95% CI 2.87 to 12.08). Thirty-two (18.7%) people with dementia in the intervention group and 17 (20.2%) in TAU were admitted to a care home (hazard ratio 0.83, 95% CI 0.44 to 1.56; p = 0.56). There were no significant differences between groups in abusive behaviour (OR 0.83, 95% CI 0.36 to 1.94), the person with dementia's QoL-AD (0.17, 95% CI -1.37 to 1.70) or costs (£ 336, 95% CI -£ 223 to £ 895) for intervention group. The probability that the intervention would be seen as cost-effective at £ 30,000/QALY threshold and cost-effectiveness on the HADS-T remained high. CONCLUSIONS The START intervention was clinically effective and cost-effective in the short and longer term. The results are robust to the sensitivity analyses performed. Future work is needed to consider mechanism of action; the effects on people with dementia in clinical terms (cognition, neuropsychiatric symptoms, longer-term care home admission); and on health and social care costs. In addition, we will explore the effects of carer abusive behaviour on the care recipient's care home admission and if this then reduces abusive behaviour. We would also like to implement START and evaluate this implementation in clinical practice. TRIAL REGISTRATION Current Controlled Trials ISCTRN70017938.
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Affiliation(s)
- Gill Livingston
- Division of Psychiatry, University College London, London, UK
| | - Julie Barber
- Department of Statistical Science and PRIMENT Clinical Trials Unit, University College London, London, UK
| | - Penny Rapaport
- Division of Psychiatry, University College London, London, UK
| | - Martin Knapp
- Personal Social Services Research Unit, London School of Economics and Political Science, London, UK
| | - Mark Griffin
- Division of Psychiatry, University College London, London, UK
| | - Renee Romeo
- Institute of Psychiatry, King's College London, London, UK
| | - Derek King
- Personal Social Services Research Unit, London School of Economics and Political Science, London, UK
| | | | | | - Cath Mummery
- Queen Square, University College London Hospitals NHS Foundation Trust, London, UK
| | - Zuzana Walker
- Division of Psychiatry, University College London, London, UK
| | - Juanita Hoe
- Division of Psychiatry, University College London, London, UK
| | - Claudia Cooper
- Division of Psychiatry, University College London, London, UK
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Spector A, Charlesworth G, King M, Lattimer M, Sadek S, Marston L, Rehill A, Hoe J, Qazi A, Knapp M, Orrell M. Cognitive-behavioural therapy for anxiety in dementia: pilot randomised controlled trial. Br J Psychiatry 2015; 206:509-16. [PMID: 25698766 DOI: 10.1192/bjp.bp.113.140087] [Citation(s) in RCA: 51] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2013] [Accepted: 09/18/2014] [Indexed: 11/23/2022]
Abstract
BACKGROUND Anxiety is common and problematic in dementia, yet there is a lack of effective treatments. AIMS To develop a cognitive-behavioural therapy (CBT) manual for anxiety in dementia and determine its feasibility through a randomised controlled trial. METHOD A ten-session CBT manual was developed. Participants with dementia and anxiety (and their carers) were randomly allocated to CBT plus treatment as usual (TAU) (n = 25) or TAU (n = 25). Outcome and cost measures were administered at baseline, 15 weeks and 6 months. RESULTS At 15 weeks, there was an adjusted difference in anxiety (using the Rating Anxiety in Dementia scale) of (-3.10, 95% CI -6.55 to 0.34) for CBT compared with TAU, which just fell short of statistical significance. There were significant improvements in depression at 15 weeks after adjustment (-5.37, 95% CI -9.50 to -1.25). Improvements remained significant at 6 months. CBT was cost neutral. CONCLUSIONS CBT was feasible (in terms of recruitment, acceptability and attrition) and effective. A fully powered RCT is now required.
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Affiliation(s)
- Aimee Spector
- Aimee Spector, PhD, DClinPsy, Georgina Charlesworth, ClinPsyD, PhD, Research Department of Clinical, Educational and Health Psychology, University College London, London; Michael King, MD, PhD, Division of Psychiatry, University College London, London; Miles Lattimer, BSc, North East London NHS Foundation Trust, Goodmayes Hospital, Ilford; Susan Sadek, ClinPsyD, Department of Clinical Psychology, University of East Anglia, Norwich; Louise Marston, PhD, Department of Primary Care and Population Health, University College London, London; Amritpal Rehill, BSc, Personal Social Services Research Unit, London School of Economics and Political Science, London; Juanita Hoe, RMN, PhD, Department of Mental Health Sciences, University College London, London; Afifa Qazi, MBBS, MRCPsych, North East London NHS Foundation Trust, Goodmayes Hospital, Ilford; Martin Knapp, PhD, Personal Social Services Research Unit, London School of Economics and Political Science, London; Martin Orrell, PhD, Division of Psychiatry, University College London, London, UK
| | - Georgina Charlesworth
- Aimee Spector, PhD, DClinPsy, Georgina Charlesworth, ClinPsyD, PhD, Research Department of Clinical, Educational and Health Psychology, University College London, London; Michael King, MD, PhD, Division of Psychiatry, University College London, London; Miles Lattimer, BSc, North East London NHS Foundation Trust, Goodmayes Hospital, Ilford; Susan Sadek, ClinPsyD, Department of Clinical Psychology, University of East Anglia, Norwich; Louise Marston, PhD, Department of Primary Care and Population Health, University College London, London; Amritpal Rehill, BSc, Personal Social Services Research Unit, London School of Economics and Political Science, London; Juanita Hoe, RMN, PhD, Department of Mental Health Sciences, University College London, London; Afifa Qazi, MBBS, MRCPsych, North East London NHS Foundation Trust, Goodmayes Hospital, Ilford; Martin Knapp, PhD, Personal Social Services Research Unit, London School of Economics and Political Science, London; Martin Orrell, PhD, Division of Psychiatry, University College London, London, UK
| | - Michael King
- Aimee Spector, PhD, DClinPsy, Georgina Charlesworth, ClinPsyD, PhD, Research Department of Clinical, Educational and Health Psychology, University College London, London; Michael King, MD, PhD, Division of Psychiatry, University College London, London; Miles Lattimer, BSc, North East London NHS Foundation Trust, Goodmayes Hospital, Ilford; Susan Sadek, ClinPsyD, Department of Clinical Psychology, University of East Anglia, Norwich; Louise Marston, PhD, Department of Primary Care and Population Health, University College London, London; Amritpal Rehill, BSc, Personal Social Services Research Unit, London School of Economics and Political Science, London; Juanita Hoe, RMN, PhD, Department of Mental Health Sciences, University College London, London; Afifa Qazi, MBBS, MRCPsych, North East London NHS Foundation Trust, Goodmayes Hospital, Ilford; Martin Knapp, PhD, Personal Social Services Research Unit, London School of Economics and Political Science, London; Martin Orrell, PhD, Division of Psychiatry, University College London, London, UK
| | - Miles Lattimer
- Aimee Spector, PhD, DClinPsy, Georgina Charlesworth, ClinPsyD, PhD, Research Department of Clinical, Educational and Health Psychology, University College London, London; Michael King, MD, PhD, Division of Psychiatry, University College London, London; Miles Lattimer, BSc, North East London NHS Foundation Trust, Goodmayes Hospital, Ilford; Susan Sadek, ClinPsyD, Department of Clinical Psychology, University of East Anglia, Norwich; Louise Marston, PhD, Department of Primary Care and Population Health, University College London, London; Amritpal Rehill, BSc, Personal Social Services Research Unit, London School of Economics and Political Science, London; Juanita Hoe, RMN, PhD, Department of Mental Health Sciences, University College London, London; Afifa Qazi, MBBS, MRCPsych, North East London NHS Foundation Trust, Goodmayes Hospital, Ilford; Martin Knapp, PhD, Personal Social Services Research Unit, London School of Economics and Political Science, London; Martin Orrell, PhD, Division of Psychiatry, University College London, London, UK
| | - Susan Sadek
- Aimee Spector, PhD, DClinPsy, Georgina Charlesworth, ClinPsyD, PhD, Research Department of Clinical, Educational and Health Psychology, University College London, London; Michael King, MD, PhD, Division of Psychiatry, University College London, London; Miles Lattimer, BSc, North East London NHS Foundation Trust, Goodmayes Hospital, Ilford; Susan Sadek, ClinPsyD, Department of Clinical Psychology, University of East Anglia, Norwich; Louise Marston, PhD, Department of Primary Care and Population Health, University College London, London; Amritpal Rehill, BSc, Personal Social Services Research Unit, London School of Economics and Political Science, London; Juanita Hoe, RMN, PhD, Department of Mental Health Sciences, University College London, London; Afifa Qazi, MBBS, MRCPsych, North East London NHS Foundation Trust, Goodmayes Hospital, Ilford; Martin Knapp, PhD, Personal Social Services Research Unit, London School of Economics and Political Science, London; Martin Orrell, PhD, Division of Psychiatry, University College London, London, UK
| | - Louise Marston
- Aimee Spector, PhD, DClinPsy, Georgina Charlesworth, ClinPsyD, PhD, Research Department of Clinical, Educational and Health Psychology, University College London, London; Michael King, MD, PhD, Division of Psychiatry, University College London, London; Miles Lattimer, BSc, North East London NHS Foundation Trust, Goodmayes Hospital, Ilford; Susan Sadek, ClinPsyD, Department of Clinical Psychology, University of East Anglia, Norwich; Louise Marston, PhD, Department of Primary Care and Population Health, University College London, London; Amritpal Rehill, BSc, Personal Social Services Research Unit, London School of Economics and Political Science, London; Juanita Hoe, RMN, PhD, Department of Mental Health Sciences, University College London, London; Afifa Qazi, MBBS, MRCPsych, North East London NHS Foundation Trust, Goodmayes Hospital, Ilford; Martin Knapp, PhD, Personal Social Services Research Unit, London School of Economics and Political Science, London; Martin Orrell, PhD, Division of Psychiatry, University College London, London, UK
| | - Amritpal Rehill
- Aimee Spector, PhD, DClinPsy, Georgina Charlesworth, ClinPsyD, PhD, Research Department of Clinical, Educational and Health Psychology, University College London, London; Michael King, MD, PhD, Division of Psychiatry, University College London, London; Miles Lattimer, BSc, North East London NHS Foundation Trust, Goodmayes Hospital, Ilford; Susan Sadek, ClinPsyD, Department of Clinical Psychology, University of East Anglia, Norwich; Louise Marston, PhD, Department of Primary Care and Population Health, University College London, London; Amritpal Rehill, BSc, Personal Social Services Research Unit, London School of Economics and Political Science, London; Juanita Hoe, RMN, PhD, Department of Mental Health Sciences, University College London, London; Afifa Qazi, MBBS, MRCPsych, North East London NHS Foundation Trust, Goodmayes Hospital, Ilford; Martin Knapp, PhD, Personal Social Services Research Unit, London School of Economics and Political Science, London; Martin Orrell, PhD, Division of Psychiatry, University College London, London, UK
| | - Juanita Hoe
- Aimee Spector, PhD, DClinPsy, Georgina Charlesworth, ClinPsyD, PhD, Research Department of Clinical, Educational and Health Psychology, University College London, London; Michael King, MD, PhD, Division of Psychiatry, University College London, London; Miles Lattimer, BSc, North East London NHS Foundation Trust, Goodmayes Hospital, Ilford; Susan Sadek, ClinPsyD, Department of Clinical Psychology, University of East Anglia, Norwich; Louise Marston, PhD, Department of Primary Care and Population Health, University College London, London; Amritpal Rehill, BSc, Personal Social Services Research Unit, London School of Economics and Political Science, London; Juanita Hoe, RMN, PhD, Department of Mental Health Sciences, University College London, London; Afifa Qazi, MBBS, MRCPsych, North East London NHS Foundation Trust, Goodmayes Hospital, Ilford; Martin Knapp, PhD, Personal Social Services Research Unit, London School of Economics and Political Science, London; Martin Orrell, PhD, Division of Psychiatry, University College London, London, UK
| | - Afifa Qazi
- Aimee Spector, PhD, DClinPsy, Georgina Charlesworth, ClinPsyD, PhD, Research Department of Clinical, Educational and Health Psychology, University College London, London; Michael King, MD, PhD, Division of Psychiatry, University College London, London; Miles Lattimer, BSc, North East London NHS Foundation Trust, Goodmayes Hospital, Ilford; Susan Sadek, ClinPsyD, Department of Clinical Psychology, University of East Anglia, Norwich; Louise Marston, PhD, Department of Primary Care and Population Health, University College London, London; Amritpal Rehill, BSc, Personal Social Services Research Unit, London School of Economics and Political Science, London; Juanita Hoe, RMN, PhD, Department of Mental Health Sciences, University College London, London; Afifa Qazi, MBBS, MRCPsych, North East London NHS Foundation Trust, Goodmayes Hospital, Ilford; Martin Knapp, PhD, Personal Social Services Research Unit, London School of Economics and Political Science, London; Martin Orrell, PhD, Division of Psychiatry, University College London, London, UK
| | - Martin Knapp
- Aimee Spector, PhD, DClinPsy, Georgina Charlesworth, ClinPsyD, PhD, Research Department of Clinical, Educational and Health Psychology, University College London, London; Michael King, MD, PhD, Division of Psychiatry, University College London, London; Miles Lattimer, BSc, North East London NHS Foundation Trust, Goodmayes Hospital, Ilford; Susan Sadek, ClinPsyD, Department of Clinical Psychology, University of East Anglia, Norwich; Louise Marston, PhD, Department of Primary Care and Population Health, University College London, London; Amritpal Rehill, BSc, Personal Social Services Research Unit, London School of Economics and Political Science, London; Juanita Hoe, RMN, PhD, Department of Mental Health Sciences, University College London, London; Afifa Qazi, MBBS, MRCPsych, North East London NHS Foundation Trust, Goodmayes Hospital, Ilford; Martin Knapp, PhD, Personal Social Services Research Unit, London School of Economics and Political Science, London; Martin Orrell, PhD, Division of Psychiatry, University College London, London, UK
| | - Martin Orrell
- Aimee Spector, PhD, DClinPsy, Georgina Charlesworth, ClinPsyD, PhD, Research Department of Clinical, Educational and Health Psychology, University College London, London; Michael King, MD, PhD, Division of Psychiatry, University College London, London; Miles Lattimer, BSc, North East London NHS Foundation Trust, Goodmayes Hospital, Ilford; Susan Sadek, ClinPsyD, Department of Clinical Psychology, University of East Anglia, Norwich; Louise Marston, PhD, Department of Primary Care and Population Health, University College London, London; Amritpal Rehill, BSc, Personal Social Services Research Unit, London School of Economics and Political Science, London; Juanita Hoe, RMN, PhD, Department of Mental Health Sciences, University College London, London; Afifa Qazi, MBBS, MRCPsych, North East London NHS Foundation Trust, Goodmayes Hospital, Ilford; Martin Knapp, PhD, Personal Social Services Research Unit, London School of Economics and Political Science, London; Martin Orrell, PhD, Division of Psychiatry, University College London, London, UK
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Abstract
BACKGROUND Over 35 million people are estimated to be living with dementia in the world and the societal costs are very high. Case management is a widely used and strongly promoted complex intervention for organising and co-ordinating care at the level of the individual, with the aim of providing long-term care for people with dementia in the community as an alternative to early admission to a care home or hospital. OBJECTIVES To evaluate the effectiveness of case management approaches to home support for people with dementia, from the perspective of the different people involved (patients, carers, and staff) compared with other forms of treatment, including 'treatment as usual', standard community treatment and other non-case management interventions. SEARCH METHODS We searched the following databases up to 31 December 2013: ALOIS, the Specialised Register of the Cochrane Dementia and Cognitive Improvement Group,The Cochrane Library, MEDLINE, EMBASE, PsycINFO, CINAHL, LILACS, Web of Science (including Science Citation Index Expanded (SCI-EXPANDED) and Social Science Citation Index), Campbell Collaboration/SORO database and the Specialised Register of the Cochrane Effective Practice and Organisation of Care Group. We updated this search in March 2014 but results have not yet been incorporated. SELECTION CRITERIA We include randomised controlled trials (RCTs) of case management interventions for people with dementia living in the community and their carers. We screened interventions to ensure that they focused on planning and co-ordination of care. DATA COLLECTION AND ANALYSIS We used standard methodological procedures as required by The Cochrane Collaboration. Two review authors independently extracted data and made 'Risk of bias' assessments using Cochrane criteria. For continuous outcomes, we used the mean difference (MD) or standardised mean difference (SMD) between groups along with its confidence interval (95% CI). We applied a fixed- or random-effects model as appropriate. For binary or dichotomous data, we generated the corresponding odds ratio (OR) with 95% CI. We assessed heterogeneity by the I² statistic. MAIN RESULTS We include 13 RCTs involving 9615 participants with dementia in the review. Case management interventions in studies varied. We found low to moderate overall risk of bias; 69% of studies were at high risk for performance bias.The case management group were significantly less likely to be institutionalised (admissions to residential or nursing homes) at six months (OR 0.82, 95% CI 0.69 to 0.98, n = 5741, 6 RCTs, I² = 0%, P = 0.02) and at 18 months (OR 0.25, 95% CI 0.10 to 0.61, n = 363, 4 RCTs, I² = 0%, P = 0.003). However, the effects at 10 - 12 months (OR 0.95, 95% CI 0.83 to 1.08, n = 5990, 9 RCTs, I² = 48%, P = 0.39) and 24 months (OR 1.03, 95% CI 0.52 to 2.03, n = 201, 2 RCTs, I² = 0%, P = 0.94) were uncertain. There was evidence from one trial of a reduction in the number of days per month in a residential home or hospital unit in the case management group at six months (MD -5.80, 95% CI -7.93 to -3.67, n = 88, 1 RCT, P < 0.0001) and at 12 months (MD -7.70, 95% CI -9.38 to -6.02, n = 88, 1 RCT, P < 0.0001). One trial reported the length of time until participants were institutionalised at 12 months and the effects were uncertain (hazard ratio (HR): 0.66, 95% CI 0.38 to 1.14, P = 0.14). There was no difference in the number of people admitted to hospital at six (4 RCTs, 439 participants), 12 (5 RCTs, 585 participants) and 18 months (5 RCTs, 613 participants). For mortality at 4 - 6, 12, 18 - 24 and 36 months, and for participants' or carers' quality of life at 4, 6, 12 and 18 months, there were no significant effects. There was some evidence of benefits in carer burden at six months (SMD -0.07, 95% CI -0.12 to -0.01, n = 4601, 4 RCTs, I² = 26%, P = 0.03) but the effects at 12 or 18 months were uncertain. Additionally, some evidence indicated case management was more effective at reducing behaviour disturbance at 18 months (SMD -0.35, 95% CI -0.63 to -0.07, n = 206, 2 RCTs I² = 0%, P = 0.01) but effects were uncertain at four (2 RCTs), six (4 RCTs) or 12 months (5 RCTs).The case management group showed a small significant improvement in carer depression at 18 months (SMD -0.08, 95% CI -0.16 to -0.01, n = 2888, 3 RCTs, I² = 0%, P = 0.03). Conversely, the case management group showed greater improvement in carer well-being in a single study at six months (MD -2.20 CI CI -4.14 to -0.26, n = 65, 1 RCT, P = 0.03) but the effects were uncertain at 12 or 18 months. There was some evidence that case management reduced the total cost of services at 12 months (SMD -0.07, 95% CI -0.12 to -0.02, n = 5276, 2 RCTs, P = 0.01) and incurred lower dollar expenditure for the total three years (MD= -705.00, 95% CI -1170.31 to -239.69, n = 5170, 1 RCT, P = 0.003). Data on a number of outcomes consistently indicated that the intervention group received significantly more community services. AUTHORS' CONCLUSIONS There is some evidence that case management is beneficial at improving some outcomes at certain time points, both in the person with dementia and in their carer. However, there was considerable heterogeneity between the interventions, outcomes measured and time points across the 13 included RCTs. There was some evidence from good-quality studies to suggest that admissions to care homes and overall healthcare costs are reduced in the medium term; however, the results at longer points of follow-up were uncertain. There was not enough evidence to clearly assess whether case management could delay institutionalisation in care homes. There were uncertain results in patient depression, functional abilities and cognition. Further work should be undertaken to investigate what components of case management are associated with improvement in outcomes. Increased consistency in measures of outcome would support future meta-analysis.
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Affiliation(s)
- Siobhan Reilly
- Faculty of Health and Medicine, Lancaster UniversityDivision of Health ResearchC07 Furness BuildingLancasterUKLA1 4YG
| | - Claudia Miranda‐Castillo
- Universidad de ValparaísoEscuela de Psicología, Facultad de MedicinaAv Brasil 2140ValparaísoChile
| | - Reem Malouf
- University of OxfordNational Perinatal Epidemiology Unit (NPEU)Old Road CampusOxfordUKOX3 7LF
| | - Juanita Hoe
- University College LondonMental Health Sciences UnitCharles Bell House67‐73 Riding House StreetLondonUKW1W 7EJ
| | - Sandeep Toot
- North East London NHS Foundation Trust, Goodmayes HospitalResearch and Development DepartmentBarley Lane, GoodmayesEssexLondonUKIG3 8XJ
| | - David Challis
- University of ManchesterPersonal Social Services Research UnitDover Street BuildingOxford RoadManchesterUKM13 9PL
| | - Martin Orrell
- University College LondonMental Health Sciences UnitCharles Bell House67‐73 Riding House StreetLondonUKW1W 7EJ
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Livingston G, Barber J, Rapaport P, Knapp M, Griffin M, King D, Romeo R, Livingston D, Mummery C, Walker Z, Hoe J, Cooper C. Long-term clinical and cost-effectiveness of psychological intervention for family carers of people with dementia: a single-blind, randomised, controlled trial. Lancet Psychiatry 2014; 1:539-48. [PMID: 26361313 DOI: 10.1016/s2215-0366(14)00073-x] [Citation(s) in RCA: 57] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2014] [Accepted: 10/06/2014] [Indexed: 11/18/2022]
Abstract
BACKGROUND Two-thirds of people with dementia live at home supported mainly by family carers. These carers frequently develop clinical depression or anxiety, which predicts care breakdown. We aimed to assess the clinical effectiveness (long-term reduction of depression and anxiety symptoms in family carers) and cost-effectiveness of a psychological intervention called START (STrAtegies for RelaTives). METHODS We did a randomised, parallel-group trial with masked outcome assessments in three UK mental-health services and one neurological-outpatient dementia service. We included self-identified family carers of people with dementia who had been referred in the previous year and gave support at least once per week to the person with dementia. We randomly assigned these carers, via an online computer-generated randomisation system from an independent clinical trials unit, to either START, an 8-session, manual-based coping intervention delivered by supervised psychology graduates, or treatment as usual (TAU). The primary long-term outcomes were affective symptoms (Hospital Anxiety and Depression Scale total score [HADS-T]) 2 years after randomisation and cost-effectiveness (health and social care perspectives) over 24 months. Analysis was by intention to treat, excluding carers with data missing at both 12 and 24 months. This trial is registered ISCTRN70017938. FINDINGS From November 4, 2009, to June 8, 2011, we recruited 260 carers. 173 carers were randomly assigned to START and 87 to TAU. Of these 260 participants, 209 (80%) were included in the clinical efficacy analysis (140 START, 69 TAU). At 24 months, compared with TAU the START group was significantly better for HADS-T (mean difference -2·58 points, 95% CI -4·26 to -0·90; p=0·003). The intervention is cost effective for both carers and patients (67% probability of cost-effectiveness at the £20 000 per QALY willingness-to-pay threshold, and 70% at the £30 000 threshold). INTERPRETATION START is clinically effective, improving carer mood and anxiety levels for 2 years. Carers in the control TAU group were seven times more likely to have clinically significant depression than those receiving START. START is cost effective with respect to carer and patient outcomes, and National Institute for Health and Care Excellence (NICE) thresholds. The number of people with dementia is rapidly growing, and policy frameworks assume that their families will remain the frontline providers of (unpaid) support. This cost-neutral intervention, which substantially improves family-carers' mental health and quality of life, should therefore be widely available. FUNDING National Institute for Health Research Health Technology Assessment programme 08/14/06.
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Affiliation(s)
- Gill Livingston
- Division of Psychiatry, University College London, London, UK; Camden and Islington NHS Foundation Trust, St Pancras Hospital, London, UK.
| | - Julie Barber
- Statistical Science and PRIMENT Clinical Trials Unit, University College London, London, UK
| | - Penny Rapaport
- Division of Psychiatry, University College London, London, UK
| | - Martin Knapp
- Personal Social Services Research Unit, London School of Economics and Political Science, London, UK
| | - Mark Griffin
- Statistical Science and PRIMENT Clinical Trials Unit, University College London, London, UK
| | - Derek King
- Personal Social Services Research Unit, London School of Economics and Political Science, London, UK
| | - Renee Romeo
- Institute of Psychiatry, King's College London, London, UK
| | | | - Cath Mummery
- Institute of Neurology, University College London, London, UK
| | - Zuzana Walker
- Division of Psychiatry, University College London, London, UK; North Essex Partnership University NHS Foundation Trust, Chelmsford, UK
| | - Juanita Hoe
- Division of Psychiatry, University College London, London, UK
| | - Claudia Cooper
- Division of Psychiatry, University College London, London, UK; Camden and Islington NHS Foundation Trust, St Pancras Hospital, London, UK
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Orrell M, Toot S, Hoe J, Ledgerd R. P3‐386: UNDERSTANDING AND MANAGING CRISES IN DEMENTIA. Alzheimers Dement 2014. [DOI: 10.1016/j.jalz.2014.05.1480] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Livingston G, Knapp M, Julie B, Cooper C, Rapaport P, Walker Z, Griffin M, King D, Mummery C, Hoe J, Romeo R. P4‐345: THE LONG‐TERM CLINICAL EFFECTIVENESS OF START (STRATEGIES FOR RELATIVES) FOR FAMILY CARERS OF PEOPLE WITH DEMENTIA AND THE EFFECTS ON COST OF CARE. Alzheimers Dement 2014. [DOI: 10.1016/j.jalz.2014.07.115] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
| | - Martin Knapp
- London School of Economics and Political ScienceLondonUnited Kingdom
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Orrell M, Aguirre E, Spector A, Hoare Z, Woods RT, Streater A, Donovan H, Hoe J, Knapp M, Whitaker C, Russell I. Maintenance cognitive stimulation therapy for dementia: single-blind, multicentre, pragmatic randomised controlled trial. Br J Psychiatry 2014; 204:454-61. [PMID: 24676963 DOI: 10.1192/bjp.bp.113.137414] [Citation(s) in RCA: 89] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND There is good evidence for the benefits of short-term cognitive stimulation therapy for dementia but little is known about possible long-term effects. AIMS To evaluate the effectiveness of maintenance cognitive stimulation therapy (CST) for people with dementia in a single-blind, pragmatic randomised controlled trial including a substudy with participants taking acetylcholinesterase inhibitors (AChEIs). METHOD The participants were 236 people with dementia from 9 care homes and 9 community services. Prior to randomisation all participants received the 7-week, 14-session CST programme. The intervention group received the weekly maintenance CST group programme for 24 weeks. The control group received usual care. Primary outcomes were cognition and quality of life (clinical trial registration: ISRCTN26286067). RESULTS For the intervention group at the 6-month primary end-point there were significant benefits for self-rated quality of life (Quality of Life in Alzheimer's Disease (QoL-AD) P = 0.03). At 3 months there were improvements for proxy-rated quality of life (QoL-AD P = 0.01, Dementia Quality of Life scale (DEMQOL) P = 0.03) and activities of daily living (P = 0.04). The intervention subgroup taking AChEIs showed cognitive benefits (on the Mini-Mental State Examination) at 3 (P = 0.03) and 6 months (P = 0.03). CONCLUSIONS Continuing CST improves quality of life; and improves cognition for those taking AChEIs.
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Affiliation(s)
- Martin Orrell
- Martin Orrell, PhD, Elisa Aguirre, PhD, Unit of Mental Health Sciences, University College London, and Research and Development Department, North East London Foundation Trust, Goodmayes Hospital, Ilford; Aimee Spector, PhD, Research and Development Department, North East London Foundation Trust, Goodmayes Hospital, Ilford, and Research Department of Clinical, Educational and Health Psychology, University College London; Zoe Hoare, PhD, North Wales Organisation for Randomised Trials in Health (NWORTH), Institute of Medical & Social Care Research, Bangor; Robert T. Woods, MSc, DSDC Wales, Bangor University, Bangor; Amy Streater, MSc, Unit of Mental Health Sciences, University College London, and Research and Development Department, North East London Foundation Trust, Goodmayes Hospital, Ilford; Helen Donovan, PsyD, Clinical Psychology Service, South Essex Partnership NHS Foundation Trust, Bedford; Juanita Hoe, PhD, Unit of Mental Health Sciences, University College London, and Research and Development Department, North East London Foundation Trust, Goodmayes Hospital, Ilford; Martin Knapp, PhD, Personal Social Services Research Unit, London School of Economics and Political Science; Christopher Whitaker, MSc, North Wales Organisation for Randomised Trials in Health (NWORTH), Institute of Medical & Social Care Research, Bangor; Ian Russell, PhD, Swansea University, College of Medicine, Singleton Park, Swansea, UK
| | - Elisa Aguirre
- Martin Orrell, PhD, Elisa Aguirre, PhD, Unit of Mental Health Sciences, University College London, and Research and Development Department, North East London Foundation Trust, Goodmayes Hospital, Ilford; Aimee Spector, PhD, Research and Development Department, North East London Foundation Trust, Goodmayes Hospital, Ilford, and Research Department of Clinical, Educational and Health Psychology, University College London; Zoe Hoare, PhD, North Wales Organisation for Randomised Trials in Health (NWORTH), Institute of Medical & Social Care Research, Bangor; Robert T. Woods, MSc, DSDC Wales, Bangor University, Bangor; Amy Streater, MSc, Unit of Mental Health Sciences, University College London, and Research and Development Department, North East London Foundation Trust, Goodmayes Hospital, Ilford; Helen Donovan, PsyD, Clinical Psychology Service, South Essex Partnership NHS Foundation Trust, Bedford; Juanita Hoe, PhD, Unit of Mental Health Sciences, University College London, and Research and Development Department, North East London Foundation Trust, Goodmayes Hospital, Ilford; Martin Knapp, PhD, Personal Social Services Research Unit, London School of Economics and Political Science; Christopher Whitaker, MSc, North Wales Organisation for Randomised Trials in Health (NWORTH), Institute of Medical & Social Care Research, Bangor; Ian Russell, PhD, Swansea University, College of Medicine, Singleton Park, Swansea, UK
| | - Aimee Spector
- Martin Orrell, PhD, Elisa Aguirre, PhD, Unit of Mental Health Sciences, University College London, and Research and Development Department, North East London Foundation Trust, Goodmayes Hospital, Ilford; Aimee Spector, PhD, Research and Development Department, North East London Foundation Trust, Goodmayes Hospital, Ilford, and Research Department of Clinical, Educational and Health Psychology, University College London; Zoe Hoare, PhD, North Wales Organisation for Randomised Trials in Health (NWORTH), Institute of Medical & Social Care Research, Bangor; Robert T. Woods, MSc, DSDC Wales, Bangor University, Bangor; Amy Streater, MSc, Unit of Mental Health Sciences, University College London, and Research and Development Department, North East London Foundation Trust, Goodmayes Hospital, Ilford; Helen Donovan, PsyD, Clinical Psychology Service, South Essex Partnership NHS Foundation Trust, Bedford; Juanita Hoe, PhD, Unit of Mental Health Sciences, University College London, and Research and Development Department, North East London Foundation Trust, Goodmayes Hospital, Ilford; Martin Knapp, PhD, Personal Social Services Research Unit, London School of Economics and Political Science; Christopher Whitaker, MSc, North Wales Organisation for Randomised Trials in Health (NWORTH), Institute of Medical & Social Care Research, Bangor; Ian Russell, PhD, Swansea University, College of Medicine, Singleton Park, Swansea, UK
| | - Zoe Hoare
- Martin Orrell, PhD, Elisa Aguirre, PhD, Unit of Mental Health Sciences, University College London, and Research and Development Department, North East London Foundation Trust, Goodmayes Hospital, Ilford; Aimee Spector, PhD, Research and Development Department, North East London Foundation Trust, Goodmayes Hospital, Ilford, and Research Department of Clinical, Educational and Health Psychology, University College London; Zoe Hoare, PhD, North Wales Organisation for Randomised Trials in Health (NWORTH), Institute of Medical & Social Care Research, Bangor; Robert T. Woods, MSc, DSDC Wales, Bangor University, Bangor; Amy Streater, MSc, Unit of Mental Health Sciences, University College London, and Research and Development Department, North East London Foundation Trust, Goodmayes Hospital, Ilford; Helen Donovan, PsyD, Clinical Psychology Service, South Essex Partnership NHS Foundation Trust, Bedford; Juanita Hoe, PhD, Unit of Mental Health Sciences, University College London, and Research and Development Department, North East London Foundation Trust, Goodmayes Hospital, Ilford; Martin Knapp, PhD, Personal Social Services Research Unit, London School of Economics and Political Science; Christopher Whitaker, MSc, North Wales Organisation for Randomised Trials in Health (NWORTH), Institute of Medical & Social Care Research, Bangor; Ian Russell, PhD, Swansea University, College of Medicine, Singleton Park, Swansea, UK
| | - Robert T Woods
- Martin Orrell, PhD, Elisa Aguirre, PhD, Unit of Mental Health Sciences, University College London, and Research and Development Department, North East London Foundation Trust, Goodmayes Hospital, Ilford; Aimee Spector, PhD, Research and Development Department, North East London Foundation Trust, Goodmayes Hospital, Ilford, and Research Department of Clinical, Educational and Health Psychology, University College London; Zoe Hoare, PhD, North Wales Organisation for Randomised Trials in Health (NWORTH), Institute of Medical & Social Care Research, Bangor; Robert T. Woods, MSc, DSDC Wales, Bangor University, Bangor; Amy Streater, MSc, Unit of Mental Health Sciences, University College London, and Research and Development Department, North East London Foundation Trust, Goodmayes Hospital, Ilford; Helen Donovan, PsyD, Clinical Psychology Service, South Essex Partnership NHS Foundation Trust, Bedford; Juanita Hoe, PhD, Unit of Mental Health Sciences, University College London, and Research and Development Department, North East London Foundation Trust, Goodmayes Hospital, Ilford; Martin Knapp, PhD, Personal Social Services Research Unit, London School of Economics and Political Science; Christopher Whitaker, MSc, North Wales Organisation for Randomised Trials in Health (NWORTH), Institute of Medical & Social Care Research, Bangor; Ian Russell, PhD, Swansea University, College of Medicine, Singleton Park, Swansea, UK
| | - Amy Streater
- Martin Orrell, PhD, Elisa Aguirre, PhD, Unit of Mental Health Sciences, University College London, and Research and Development Department, North East London Foundation Trust, Goodmayes Hospital, Ilford; Aimee Spector, PhD, Research and Development Department, North East London Foundation Trust, Goodmayes Hospital, Ilford, and Research Department of Clinical, Educational and Health Psychology, University College London; Zoe Hoare, PhD, North Wales Organisation for Randomised Trials in Health (NWORTH), Institute of Medical & Social Care Research, Bangor; Robert T. Woods, MSc, DSDC Wales, Bangor University, Bangor; Amy Streater, MSc, Unit of Mental Health Sciences, University College London, and Research and Development Department, North East London Foundation Trust, Goodmayes Hospital, Ilford; Helen Donovan, PsyD, Clinical Psychology Service, South Essex Partnership NHS Foundation Trust, Bedford; Juanita Hoe, PhD, Unit of Mental Health Sciences, University College London, and Research and Development Department, North East London Foundation Trust, Goodmayes Hospital, Ilford; Martin Knapp, PhD, Personal Social Services Research Unit, London School of Economics and Political Science; Christopher Whitaker, MSc, North Wales Organisation for Randomised Trials in Health (NWORTH), Institute of Medical & Social Care Research, Bangor; Ian Russell, PhD, Swansea University, College of Medicine, Singleton Park, Swansea, UK
| | - Helen Donovan
- Martin Orrell, PhD, Elisa Aguirre, PhD, Unit of Mental Health Sciences, University College London, and Research and Development Department, North East London Foundation Trust, Goodmayes Hospital, Ilford; Aimee Spector, PhD, Research and Development Department, North East London Foundation Trust, Goodmayes Hospital, Ilford, and Research Department of Clinical, Educational and Health Psychology, University College London; Zoe Hoare, PhD, North Wales Organisation for Randomised Trials in Health (NWORTH), Institute of Medical & Social Care Research, Bangor; Robert T. Woods, MSc, DSDC Wales, Bangor University, Bangor; Amy Streater, MSc, Unit of Mental Health Sciences, University College London, and Research and Development Department, North East London Foundation Trust, Goodmayes Hospital, Ilford; Helen Donovan, PsyD, Clinical Psychology Service, South Essex Partnership NHS Foundation Trust, Bedford; Juanita Hoe, PhD, Unit of Mental Health Sciences, University College London, and Research and Development Department, North East London Foundation Trust, Goodmayes Hospital, Ilford; Martin Knapp, PhD, Personal Social Services Research Unit, London School of Economics and Political Science; Christopher Whitaker, MSc, North Wales Organisation for Randomised Trials in Health (NWORTH), Institute of Medical & Social Care Research, Bangor; Ian Russell, PhD, Swansea University, College of Medicine, Singleton Park, Swansea, UK
| | - Juanita Hoe
- Martin Orrell, PhD, Elisa Aguirre, PhD, Unit of Mental Health Sciences, University College London, and Research and Development Department, North East London Foundation Trust, Goodmayes Hospital, Ilford; Aimee Spector, PhD, Research and Development Department, North East London Foundation Trust, Goodmayes Hospital, Ilford, and Research Department of Clinical, Educational and Health Psychology, University College London; Zoe Hoare, PhD, North Wales Organisation for Randomised Trials in Health (NWORTH), Institute of Medical & Social Care Research, Bangor; Robert T. Woods, MSc, DSDC Wales, Bangor University, Bangor; Amy Streater, MSc, Unit of Mental Health Sciences, University College London, and Research and Development Department, North East London Foundation Trust, Goodmayes Hospital, Ilford; Helen Donovan, PsyD, Clinical Psychology Service, South Essex Partnership NHS Foundation Trust, Bedford; Juanita Hoe, PhD, Unit of Mental Health Sciences, University College London, and Research and Development Department, North East London Foundation Trust, Goodmayes Hospital, Ilford; Martin Knapp, PhD, Personal Social Services Research Unit, London School of Economics and Political Science; Christopher Whitaker, MSc, North Wales Organisation for Randomised Trials in Health (NWORTH), Institute of Medical & Social Care Research, Bangor; Ian Russell, PhD, Swansea University, College of Medicine, Singleton Park, Swansea, UK
| | - Martin Knapp
- Martin Orrell, PhD, Elisa Aguirre, PhD, Unit of Mental Health Sciences, University College London, and Research and Development Department, North East London Foundation Trust, Goodmayes Hospital, Ilford; Aimee Spector, PhD, Research and Development Department, North East London Foundation Trust, Goodmayes Hospital, Ilford, and Research Department of Clinical, Educational and Health Psychology, University College London; Zoe Hoare, PhD, North Wales Organisation for Randomised Trials in Health (NWORTH), Institute of Medical & Social Care Research, Bangor; Robert T. Woods, MSc, DSDC Wales, Bangor University, Bangor; Amy Streater, MSc, Unit of Mental Health Sciences, University College London, and Research and Development Department, North East London Foundation Trust, Goodmayes Hospital, Ilford; Helen Donovan, PsyD, Clinical Psychology Service, South Essex Partnership NHS Foundation Trust, Bedford; Juanita Hoe, PhD, Unit of Mental Health Sciences, University College London, and Research and Development Department, North East London Foundation Trust, Goodmayes Hospital, Ilford; Martin Knapp, PhD, Personal Social Services Research Unit, London School of Economics and Political Science; Christopher Whitaker, MSc, North Wales Organisation for Randomised Trials in Health (NWORTH), Institute of Medical & Social Care Research, Bangor; Ian Russell, PhD, Swansea University, College of Medicine, Singleton Park, Swansea, UK
| | - Christopher Whitaker
- Martin Orrell, PhD, Elisa Aguirre, PhD, Unit of Mental Health Sciences, University College London, and Research and Development Department, North East London Foundation Trust, Goodmayes Hospital, Ilford; Aimee Spector, PhD, Research and Development Department, North East London Foundation Trust, Goodmayes Hospital, Ilford, and Research Department of Clinical, Educational and Health Psychology, University College London; Zoe Hoare, PhD, North Wales Organisation for Randomised Trials in Health (NWORTH), Institute of Medical & Social Care Research, Bangor; Robert T. Woods, MSc, DSDC Wales, Bangor University, Bangor; Amy Streater, MSc, Unit of Mental Health Sciences, University College London, and Research and Development Department, North East London Foundation Trust, Goodmayes Hospital, Ilford; Helen Donovan, PsyD, Clinical Psychology Service, South Essex Partnership NHS Foundation Trust, Bedford; Juanita Hoe, PhD, Unit of Mental Health Sciences, University College London, and Research and Development Department, North East London Foundation Trust, Goodmayes Hospital, Ilford; Martin Knapp, PhD, Personal Social Services Research Unit, London School of Economics and Political Science; Christopher Whitaker, MSc, North Wales Organisation for Randomised Trials in Health (NWORTH), Institute of Medical & Social Care Research, Bangor; Ian Russell, PhD, Swansea University, College of Medicine, Singleton Park, Swansea, UK
| | - Ian Russell
- Martin Orrell, PhD, Elisa Aguirre, PhD, Unit of Mental Health Sciences, University College London, and Research and Development Department, North East London Foundation Trust, Goodmayes Hospital, Ilford; Aimee Spector, PhD, Research and Development Department, North East London Foundation Trust, Goodmayes Hospital, Ilford, and Research Department of Clinical, Educational and Health Psychology, University College London; Zoe Hoare, PhD, North Wales Organisation for Randomised Trials in Health (NWORTH), Institute of Medical & Social Care Research, Bangor; Robert T. Woods, MSc, DSDC Wales, Bangor University, Bangor; Amy Streater, MSc, Unit of Mental Health Sciences, University College London, and Research and Development Department, North East London Foundation Trust, Goodmayes Hospital, Ilford; Helen Donovan, PsyD, Clinical Psychology Service, South Essex Partnership NHS Foundation Trust, Bedford; Juanita Hoe, PhD, Unit of Mental Health Sciences, University College London, and Research and Development Department, North East London Foundation Trust, Goodmayes Hospital, Ilford; Martin Knapp, PhD, Personal Social Services Research Unit, London School of Economics and Political Science; Christopher Whitaker, MSc, North Wales Organisation for Randomised Trials in Health (NWORTH), Institute of Medical & Social Care Research, Bangor; Ian Russell, PhD, Swansea University, College of Medicine, Singleton Park, Swansea, UK
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Abstract
Research into the epidemiological, clinical characteristics and economic impact of dementia is critical to increase understanding and better inform care and policy, and empower people with Alzheimer's disease (AD) and their families to make preparations and timely decisions about accommodation, care and treatment. The LASER-AD longitudinal study of people with AD and their carers has contributed to our understanding of the progression, characteristics and costs of the disease, and to developing tools that help detect dementia earlier, and screen and identify problems experienced by carers. Our work on quality of life shows that even those with severe dementia can report this meaningfully, although family proxy ratings of quality of life do not necessarily mirror the views of the individual. Despite the impact of the disease process, people with AD experience well-being in adversity and still live fulfilling lives. The study highlights the high prevalence and severity of neuropsychiatric symptoms, carer anxiety, depression and abusive behaviour. It informs future directions for possible interventions, in particular the central role of carer coping strategies in predicting carer mental illness. Current research is building on our findings, which have also been used to inform national and international plans for managing people with dementia and their carers.
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Affiliation(s)
- Juanita Hoe
- Mental Health Sciences Unit , University College London , UK
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Knapp M, King D, Romeo R, Schehl B, Barber J, Griffin M, Rapaport P, Livingston D, Mummery C, Walker Z, Hoe J, Sampson EL, Cooper C, Livingston G. Cost effectiveness of a manual based coping strategy programme in promoting the mental health of family carers of people with dementia (the START (STrAtegies for RelaTives) study): a pragmatic randomised controlled trial. BMJ 2013; 347:f6342. [PMID: 24162943 PMCID: PMC3808080 DOI: 10.1136/bmj.f6342] [Citation(s) in RCA: 54] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
OBJECTIVE To assess whether the START (STrAtegies for RelatTives) intervention added to treatment as usual is cost effective compared with usual treatment alone. DESIGN Cost effectiveness analysis nested within a pragmatic randomised controlled trial. SETTING Three mental health and one neurological outpatient dementia service in London and Essex, UK. PARTICIPANTS Family carers of people with dementia. INTERVENTION Eight session, manual based, coping intervention delivered by supervised psychology graduates to family carers of people with dementia added to usual treatment, compared with usual treatment alone. PRIMARY OUTCOME MEASURES Costs measured from a health and social care perspective were analysed alongside the Hospital Anxiety and Depression Scale total score (HADS-T) of affective symptoms and quality adjusted life years (QALYs) in cost effectiveness analyses over eight months from baseline. RESULTS Of the 260 participants recruited to the study, 173 were randomised to the START intervention, and 87 to usual treatment alone. Mean HADS-T scores were lower in the intervention group than the usual treatment group over the 8 month evaluation period (mean difference -1.79 (95% CI -3.32 to -0.33)), indicating better outcomes associated with the START intervention. There was a small improvement in health related quality of life as measured by QALYs (0.03 (-0.01 to 0.08)). Costs were no different between the intervention and usual treatment groups (£252 (-28 to 565) higher for START group). The cost effectiveness calculations suggested that START had a greater than 99% chance of being cost effective compared with usual treatment alone at a willingness to pay threshold of £30,000 per QALY gained, and a high probability of cost effectiveness on the HADS-T measure. CONCLUSIONS The manual based coping intervention START, when added to treatment as usual, was cost effective compared with treatment as usual alone by reference to both outcome measures (affective symptoms for family carers, and carer based QALYs). TRIAL REGISTRATION ISCTRN 70017938.
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Affiliation(s)
- Martin Knapp
- Personal Social Services Research Unit, London School of Economics and Political Science, London WC2A 2AE, UK
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Livingston G, Barber J, Rapaport P, Knapp M, Griffin M, King D, Livingston D, Mummery C, Walker Z, Hoe J, Sampson EL, Cooper C. Clinical effectiveness of a manual based coping strategy programme (START, STrAtegies for RelaTives) in promoting the mental health of carers of family members with dementia: pragmatic randomised controlled trial. BMJ 2013; 347:f6276. [PMID: 24162942 PMCID: PMC3808082 DOI: 10.1136/bmj.f6276] [Citation(s) in RCA: 115] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
OBJECTIVE To assess whether a manual based coping strategy compared with treatment as usual reduces depression and anxiety symptoms in carers of family members with dementia. DESIGN Randomised, parallel group, superiority trial. SETTING Three mental health community services and one neurological outpatient dementia service in London and Essex, UK. PARTICIPANTS 260 carers of family members with dementia. INTERVENTION A manual based coping intervention comprising eight sessions and delivered by supervised psychology graduates to carers of family members with dementia. The programme consisted of psychoeducation about dementia, carers' stress, and where to get emotional support; understanding behaviours of the family member being cared for, and behavioural management techniques; changing unhelpful thoughts; promoting acceptance; assertive communication; relaxation; planning for the future; increasing pleasant activities; and maintaining skills learnt. Carers practised these techniques at home, using the manual and relaxation CDs. MAIN OUTCOME MEASURES Affective symptoms (hospital anxiety and depression total score) at four and eight months. Secondary outcomes were depression and anxiety caseness on the hospital anxiety and depression scale; quality of life of both the carer (health status questionnaire, mental health) and the recipient of care (quality of life-Alzheimer's disease); and potentially abusive behaviour by the carer towards the recipient of care (modified conflict tactics scale). RESULTS 260 carers were recruited; 173 were randomised to the intervention and 87 to treatment as usual. Mean total scores on the hospital anxiety and depression scale were lower in the intervention group than in the treatment as usual group over the eight month evaluation period: adjusted difference in means -1.80 points (95% confidence interval -3.29 to -0.31; P=0.02) and absolute difference in means -2.0 points. Carers in the intervention group were less likely to have case level depression (odds ratio 0.24, 95% confidence interval 0.07 to 0.76) and there was a non-significant trend towards reduced case level anxiety (0.30, 0.08 to 1.05). Carers' quality of life was higher in the intervention group (difference in means 4.09, 95% confidence interval 0.34 to 7.83) but not for the recipient of care (difference in means 0.59, -0.72 to 1.89). Carers in the intervention group reported less abusive behaviour towards the recipient of care compared with those in the treatment as usual group (odds ratio 0.47, 95% confidence interval 0.18 to 1.23), although this was not significant. CONCLUSIONS A manual based coping strategy was effective in reducing affective symptoms and case level depression in carers of family members with dementia. The carers' quality of life also improved. TRIAL REGISTRATION Current Controlled Trials ISCTRN70017938.
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Affiliation(s)
- Gill Livingston
- Mental Health Science, University College London, London W1W 7EJ, UK
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Toot S, Hoe J, Ledgerd R, Burnell K, Devine M, Orrell M. Causes of crises and appropriate interventions: the views of people with dementia, carers and healthcare professionals. Aging Ment Health 2013; 17:328-35. [PMID: 23153294 DOI: 10.1080/13607863.2012.732037] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
The aims of this study were to identify which factors may lead to crisis for people with dementia and their carers and identify interventions these individuals believe could help in crisis. Qualitative study using focus groups to compare the perspectives of people with dementia, family carers and healthcare professionals on causes of crises and crisis interventions. To help in a crisis, people with dementia were favourable towards support from family and friends, access to mobile phones and home adaptations to reduce risks. Carers were keen on assistive technology and home adaptation. Both carers and staff valued carer training and education, care plans and well-coordinated care. Staff were the only group emphasizing more intensive interventions such as emergency home respite and extended hours services. In terms of causes of crises, people with dementia focused on risks and hazards in their home, whereas family carers emphasized carer stress and their own mental health problems. Staff, in contrast were concerned about problems with service organization and coordination leading to crises. Physical problems were less commonly identified as causes of crises but when they did occur they had a major impact. Practical interventions such as home adaptations, assistive technology, education and training for family carers, and flexible home care services were highly valued by service users and their families during times of crisis and may help prevent hospital admissions. Specialist home care was highly valued by all groups.
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Affiliation(s)
- Sandeep Toot
- Department of Mental Health Sciences, University College London, London, UK.
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Charlesworth G, Burnell K, Hoe J, Orrell M, Russell I. Acceptance checklist for clinical effectiveness pilot trials: a systematic approach. BMC Med Res Methodol 2013; 13:78. [PMID: 23758922 PMCID: PMC3702517 DOI: 10.1186/1471-2288-13-78] [Citation(s) in RCA: 55] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2012] [Accepted: 05/29/2013] [Indexed: 03/09/2023] Open
Abstract
Conducting a pilot trial is important in preparing for, and justifying investment in, the ensuing larger trial. Pilot trials using the same design and methods as the subsequent main trial are ethically and financially advantageous especially when pilot and main trial data can be pooled. For explanatory trials in which internal validity is paramount, there is little room for variation of methods between the pilot and main trial. For pragmatic trials, where generalisability or external validity is key, greater flexibility is written into trial protocols to allow for 'real life' variation in procedures. We describe the development of a checklist for use in decision-making on whether pilot data can be carried forward to the main trial dataset without compromising trial integrity. We illustrate the use of the checklist using a pragmatic trial of psychosocial interventions for family carers of people with dementia as a case study.
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Affiliation(s)
- Georgina Charlesworth
- Research Department of Clinical, Educational and Health Psychology, University College London, 1-19 Torrington Place, London WC1E 7HB, UK
- Research and Development Department, North East London NHS Foundation Trust, Goodmayes Hospital, Barley Lane, Ilford, Essex IG3 8XJ, England
| | - Karen Burnell
- School of Health Sciences and Social Work, James Watson (West), 2 King Richard 1st Road, Portsmouth PO1 2FR, England
| | - Juanita Hoe
- UCL Mental Health Sciences Unit, University College London, Charles Bell House, 67-73 Riding House Street, London W1W 7EJ, UK
| | - Martin Orrell
- Research and Development Department, North East London NHS Foundation Trust, Goodmayes Hospital, Barley Lane, Ilford, Essex IG3 8XJ, England
- UCL Mental Health Sciences Unit, University College London, Charles Bell House, 67-73 Riding House Street, London W1W 7EJ, UK
| | - Ian Russell
- West Wales Organization for Rigorous Trials in Health, Swansea University College of Medicine, Singleton Park, Swansea SA2 8PP, Wales
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Aguirre E, Hoare Z, Streater A, Spector A, Woods B, Hoe J, Orrell M. Cognitive stimulation therapy (CST) for people with dementia--who benefits most? Int J Geriatr Psychiatry 2013; 28:284-90. [PMID: 22573599 DOI: 10.1002/gps.3823] [Citation(s) in RCA: 78] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2011] [Accepted: 04/11/2012] [Indexed: 11/06/2022]
Abstract
BACKGROUND The efficacy of cognitive stimulation therapy (CST) has been demonstrated, but little is known about the characteristics of people with dementia, which may predict a more positive response to CST. This study sought to investigate which factors may predict response to CST. METHODS Two hundred and seventy-two participants with dementia took part in a 7-week CST intervention. Assessments were carried out pre-treatment and post-treatment. The results were compared with those of a previous comparable CST randomised control trial. A comparison of mean scores pre-CST and post-CST groups was undertaken, and contributing factors that predicted change in outcomes were examined. RESULTS CST improved cognition and quality of life, and the results showed that the benefits of CST were independent of whether people were taking acetylcholinesteraseinhibitor (AChEI) medication. Increasing age was associated with cognitive benefits, as was female gender. Care home residents improved more than community residents on quality of life, but the community sample seemed to benefit more in relation to behaviour problems. CONCLUSIONS These results demonstrate that CST improves cognition and quality of life for people with dementia including those already on AChEIs. Older age and being female were associated with increased cognitive benefits from the intervention. Consideration should be given to aspects of CST, which may enhance the benefits for people with dementia who are male and those younger than 80 years.
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Affiliation(s)
- E Aguirre
- Mental Health Sciences Department, University College London, Charles Bell House, 67-73 Riding House Street, London, UK.
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Abstract
This article, which is the first in a two-part series, provides an introduction to understanding quantitative research, basic statistics and terminology used in research articles. Critical appraisal of research articles is essential to ensure that nurses remain up to date with evidence-based practice to provide consistent and high-quality nursing care. This article focuses on developing critical appraisal skills and understanding the use and implications of different quantitative approaches to research. Part two of this article will focus on explaining common statistical terms and the presentation of statistical data in quantitative research.
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Affiliation(s)
- Juanita Hoe
- Research Department of Mental Health Sciences, University College London, London.
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Abstract
This article, which is the second in a two-part series, provides an introduction to understanding quantitative research, basic statistics and terminology used in research articles. Understanding statistical analysis will ensure that nurses can assess the credibility and significance of the evidence reported. This article focuses on explaining common statistical terms and the presentation of statistical data in quantitative research.
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Burnell K, Charlesworth G, Feast AR, Hoe J, Poland FM, Orrell M. Peer support interventions for family carers of adults with chronic mental or physical illness who are living at home. THE COCHRANE DATABASE OF SYSTEMATIC REVIEWS 2012. [DOI: 10.1002/14651858.cd010231] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
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Spector A, Orrell M, Lattimer M, Hoe J, King M, Harwood K, Qazi A, Charlesworth G. Cognitive behavioural therapy (CBT) for anxiety in people with dementia: study protocol for a randomised controlled trial. Trials 2012; 13:197. [PMID: 23092336 PMCID: PMC3495021 DOI: 10.1186/1745-6215-13-197] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2012] [Accepted: 10/12/2012] [Indexed: 11/17/2022] Open
Abstract
Background Many people with dementia experience anxiety, which can lead to decreased independence, relationship difficulties and increased admittance to care homes. Anxiety is often treated with antipsychotic medication, which has limited efficacy and serious side effects. Cognitive behavioural therapy (CBT) is widely used to treat anxiety in a range of populations, yet no RCTs on CBT for anxiety in dementia exist. This study aims to develop a CBT for anxiety in dementia manual and to determine its feasibility in a pilot RCT. Methods/design Phase I involves the development of a CBT for anxiety in dementia manual, through a process of (1) focus groups, (2) comprehensive literature reviews, (3) expert consultation, (4) a consensus conference and (5) field testing. Phase II involves the evaluation of the manual with 50 participants with mild to moderate dementia and anxiety (and their carers) in a pilot, two-armed RCT. Participants will receive either ten sessions of CBT or treatment as usual. Primary outcome measures are anxiety and costs. Secondary outcome measures are participant quality of life, behavioural disturbance, cognition, depression, mood and perceived relationship with the carer, and carer mood and perceived relationship with the person with dementia. Measures will be administered at baseline, 15 weeks and 6 months. Approximately 12 qualitative interviews will be used to gather service-users' perspectives on the intervention. Discussion This study aims to determine the feasibility of CBT for people with anxiety and dementia and provide data on the effect size of the intervention in order to conduct a power analysis for a definitive RCT. The manual will be revised according to qualitative and quantitative findings. Its publication will enable its availability throughout the NHS and beyond. Trial registration ISRCTN64806852
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Affiliation(s)
- Aimee Spector
- Department of Clinical, Educational and Health Psychology, University College London, 1-19 Torrington Place, London, UK.
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Godoy GK, Vavere A, Miller JM, Chahal H, Niinuma H, Lemos P, Hoe J, Paul N, Clouse ME, Ramos CD, Lima JA, Arbab-Zadeh A. Quantitative coronary arterial stenosis assessment by multidetector CT and invasive coronary angiography for identifying patients with myocardial perfusion abnormalities. J Nucl Cardiol 2012; 19:922-30. [PMID: 22814771 DOI: 10.1007/s12350-012-9598-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2011] [Accepted: 07/05/2012] [Indexed: 10/28/2022]
Abstract
BACKGROUND Semi-quantitative stenosis assessment by coronary CT angiography only modestly predicts stress-induced myocardial perfusion abnormalities. The performance of quantitative CT angiography (QCTA) for identifying patients with myocardial perfusion defects remains unclear. METHODS CorE-64 is a multicenter, international study to assess the accuracy of 64-slice QCTA for detecting ≥50% coronary arterial stenoses by quantitative coronary angiography (QCA). Patients referred for cardiac catheterization with suspected or known coronary artery disease were enrolled. Area under the receiver-operating-characteristic curve (AUC) was used to evaluate the diagnostic accuracy of the most severe coronary artery stenosis in a subset of 63 patients assessed by QCTA and QCA for detecting myocardial perfusion abnormalities on exercise or pharmacologic stress SPECT. RESULTS Diagnostic accuracy of QCTA for identifying patients with myocardial perfusion abnormalities by SPECT revealed an AUC of 0.71, compared to 0.72 by QCA (P = .75). AUC did not improve after excluding studies with fixed myocardial perfusion abnormalities and total coronary arterial occlusions. Optimal stenosis threshold for QCTA was 43% yielding a sensitivity of 0.81 and specificity of 0.50, respectively, compared to 0.75 and 0.69 by QCA at a threshold of 59%. Sensitivity and specificity of QCTA to identify patients with both obstructive lesions and myocardial perfusion defects were 0.94 and 0.77, respectively. CONCLUSIONS Coronary artery stenosis assessment by QCTA or QCA only modestly predicts the presence and the absence of myocardial perfusion abnormalities by SPECT. Confounding variables affecting the relationship between coronary anatomy and myocardial perfusion likely account for some of the observed discrepancies between coronary angiography and SPECT results.
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Affiliation(s)
- G K Godoy
- Division of Cardiology, Johns Hopkins University, Baltimore, MD, 21287, USA
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Abstract
AIM Screening for peripheral arterial disease, a complication among patients with diabetes, is performed by periodic assessment of ankle-brachial index. We aimed to study the degree of ankle-brachial index change over time and factors associated with significant change. METHOD We assessed difference between two ankle-brachial index measurements over time in a consecutive series of 82 patients with Type 2 diabetes. All patients had ankle-brachial index > 0.9 but ≤ 1.3 for the first measurement, and significant ankle-brachial index decrease was defined as a decrease of > 0.1 in the follow-up measurement compared with the baseline. RESULTS The mean follow-up duration was 27.6 (median 30.0) months. Significant ankle-brachial index decrease was seen in 20.7% of patients, including 5% with follow-up ankle-brachial index of ≤ 0.9, consistent with the diagnosis of peripheral arterial disease. After adjusting for age and gender, higher baseline HbA(1c) and serum creatinine levels, increase in follow-up serum LDL cholesterol levels compared with baseline and history of retinopathy were predictors of significant ankle-brachial index decrease. CONCLUSIONS Our study suggests that, within two years, one in five patients with diabetes and a normal ankle-brachial index may have significant progression of peripheral arterial disease. Annual ankle-brachial index assessment and better control of hyperlipidaemia may thus be required for at-risk patients with poor glycaemic control, renal impairment and retinopathy.
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Affiliation(s)
- J Hoe
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
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Streater A, Spector A, Aguirre E, Hoe J, Hoare Z, Woods R, Russell I, Orrell M. Maintenance Cognitive Stimulation Therapy (CST) in practice: study protocol for a randomized controlled trial. Trials 2012; 13:91. [PMID: 22735077 PMCID: PMC3416711 DOI: 10.1186/1745-6215-13-91] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2012] [Accepted: 06/26/2012] [Indexed: 11/10/2022] Open
Abstract
Background Cognitive Stimulation Therapy (CST) is a psychosocial evidence-based group intervention for people with dementia recommended by the UK NICE guidelines. In clinical trials, CST has been shown to improve cognition and quality of life, but little is known about the best way of ensuring implementation of CST in practice settings. A recent pilot study found that a third of people who attend CST training go on to run CST in practice, but staff identified a lack of support as a key reason for the lack of implementation. Methods/design There are three projects in this study: The first is a pragmatic multi-centre, randomised controlled trial (RCT) of staff training, comparing CST training and outreach support with CST training only; the second, the monitoring and outreach trial, is a phase IV trial that evaluates implementation of CST in practice by staff members who have previously had the CST manual or attended training. Centres will be randomised to receive outreach support. The primary outcome measure for both of these trials is the number of CST sessions run for people with dementia. Secondary outcomes include the number of attenders at sessions, job satisfaction, dementia knowledge and attitudes, competency, barriers to change, approach to learning and a controllability of beliefs and the level of adherence. Focus groups will assess staff members’ perceptions of running CST groups and receiving outreach support. The third study involves monitoring centres running groups in their usual practice and looking at basic outcomes of cognition and quality of life for the person with dementia. Discussion These studies assess the effects of outreach support on putting CST into practice and running groups effectively in a variety of care settings with people with dementia; evaluate the effectiveness of CST in standard clinical practice; and identify key factors promoting or impeding the successful running of groups. Trial registration Clinical trial ISRCTN28793457.
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Affiliation(s)
- Amy Streater
- Unit of Mental Health Sciences, University College London, Charles Bell House, 67-73 Riding House Street, London, UK.
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Hoe J. Review: Marte Meo Counselling: a promising tool to support positive interactions between residents with dementia and nurses in nursing homes. J Res Nurs 2011. [DOI: 10.1177/1744987111414850] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Affiliation(s)
- Juanita Hoe
- Research Department of Mental Health Sciences, University College London, UK,
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Hoe J, Thompson R. Promoting positive approaches to dementia care in nursing. Nurs Stand 2010; 25:47-58. [PMID: 21033596 DOI: 10.7748/ns2010.09.25.4.47.c8001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Abstract
This article provides an overview of factors relevant to dementia care today. The number of people experiencing dementia is increasing and dementia is at the forefront of health policy. The evidence base for person-centred approaches and interventions in dementia is expanding and nurses are central to implementing these across care settings. This is an exciting and challenging time for dementia care and nursing has a major role in leading and developing these changes in practice. The article discusses the importance of wellbeing and the Mental Capacity Act in assessing and caring for people with dementia. Psychosocial and pharmacological approaches to dementia care are described and the need to support carers of people with dementia is emphasised.
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Affiliation(s)
- J Hoe
- Research Department of Mental Health Sciences, University College London, London.
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Aguirre E, Spector A, Hoe J, Russell IT, Knapp M, Woods RT, Orrell M. Maintenance Cognitive Stimulation Therapy (CST) for dementia: a single-blind, multi-centre, randomized controlled trial of Maintenance CST vs. CST for dementia. Trials 2010; 11:46. [PMID: 20426866 PMCID: PMC2867981 DOI: 10.1186/1745-6215-11-46] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2010] [Accepted: 04/28/2010] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Psychological treatments for dementia are widely used in the UK and internationally, but only rarely have they been standardised, adequately evaluated or systematically implemented. There is increasing recognition that psychosocial interventions may have similar levels of effectiveness to medication, and both can be used in combination. Cognitive Stimulation Therapy (CST) is a 7-week cognitive-based approach for dementia that has been shown to be beneficial for cognition and quality of life and is cost-effective, but there is less conclusive evidence for the effects of CST over an extended period. METHODS/DESIGN This multi-centre, pragmatic randomised controlled trial (RCT) to assess the effectiveness and cost-effectiveness of Maintenance CST groups for dementia compares a intervention group who receive CST for 7 weeks followed by the Maintenance CST programme once a week for 24 weeks with the control group who receive CST for 7 weeks, followed by treatment as usual for 24 weeks.The primary outcome measures are quality of life of people with dementia assessed by the QoL-AD and cognition assessed by the ADAS-Cog. Secondary outcomes include the person with dementia's mood, behaviour, activities of daily living, ability to communicate and costs; as well as caregiver health-related quality of life. Using a 5% significance level, comparison of 230 participants will yield 80% power to detect a standardised difference of 0.39 on the ADAS-Cog between the groups. The trial includes a cost-effectiveness analysis from a public sector perspective. DISCUSSION A pilot study of longer-term Maintenance CST, offering 16 weekly sessions of maintenance following the initial CST programme, previously found a significant improvement in cognitive function (MMSE) for those on the intervention group. The study identified the need for a large-scale, multi-centre RCT to define the potential longer-term benefits of continuing the therapy. This study aims to provide definitive evidence of the potential efficacy of maintenance CST and establish how far the long-term benefits can be compared with antidementia drugs such as cholinesterase inhibitors.
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Affiliation(s)
- Elisa Aguirre
- Department of Mental Health Sciences, University College London, Charles Bell House, 67-73 Riding House Street, London, UK
| | - Aimee Spector
- Department of Clinical, Educational and Health Psychology, University College London, 1-19 Torrington Place, London, UK
| | - Juanita Hoe
- Department of Mental Health Sciences, University College London, Charles Bell House, 67-73 Riding House Street, London, UK
| | - Ian T Russell
- North Wales Organisation for Randomised Trials in Health and Social Care, Institute of Medical and Social Care Research, Bangor University, Ardudwy Hall, Normal Site, Holyhead Road, Bangor, UK
| | - Martin Knapp
- Centre for Economics of Mental Health, Institute of Psychiatry, London, UK
| | - Robert T Woods
- Dementia Services Development Centre Wales, Institute of Medical and Social Care Research, Bangor University, Ardudwy Hall, Normal Site, Holyhead Road, Bangor, UK
| | - Martin Orrell
- Department of Mental Health Sciences, University College London, Charles Bell House, 67-73 Riding House Street, London, UK
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Reilly S, Miranda-Castillo C, Sandhu S, Hoe J, Challis D, Orrell M. Case/care management approaches to home support for people with dementia. THE COCHRANE DATABASE OF SYSTEMATIC REVIEWS 2010. [DOI: 10.1002/14651858.cd008345] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
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