Recent Submissions

  • Hospital admissions and place of death of residents of care homes receiving specialist healthcare services: A systematic review without meta-analysis

    Hughes, Jane; Challis, David (2021)
    Abstract Aim To synthesize evidence on the ability of specialist care home support services to prevent hospital admission of older care home residents, including at end of life. Design Systematic review, without meta-analysis, with vote counting based on direction of effect. Data sources Fourteen electronic databases were searched from January 2010 to January 2019. Reference lists of identified reviews, study protocols and included documents were scrutinized for further studies. Review methods Papers on the provision of specialist care home support that addressed older, long-term care home residents? physical health needs and provided comparative data on hospital admissions were included. Two reviewers undertook study selection and quality appraisal independently. Vote counting by direction of effect and binomial tests determined service effectiveness. Results Electronic searches identified 79 relevant references. Combined with 19 citations from an earlier review, this gave 98 individual references relating to 92 studies. Most were from the UK (22), USA (22) and Australia (19). Twenty studies were randomized controlled trials and six clinical controlled trials. The review suggested interventions addressing residents? general health needs (p < .001), assessment and management services (p < .0001) and non-training initiatives involving medical staff (p < .0001) can reduce hospital admissions, while there was also promising evidence for services targeting residents at imminent risk of hospital entry or post-hospital discharge and training-only initiatives. End-of-life care services may enable residents to remain in the home at end of life (p < .001), but the high number of weak-rated studies undermined confidence in this result. Conclusion This review suggests specialist care home support services can reduce hospital admissions. More robust studies of services for residents at end of life are urgently needed. Impact The review addressed the policy imperative to reduce the avoidable hospital admission of older care home residents and provides important evidence to inform service design. The findings are of relevance to commissioners, providers and residents.
  • Care homes for older people

    Dening, Tom (2020)
    The care home sector has changed significantly in recent years: the vast majority of care homes are now in the independent sector, funding of care is complex, with greater reliance on self-funders to ensure profitability, and regulation has shifted to a more targeted model. In terms of the care home population, as most people are admitted at a late stage of their illness trajectory, many have comorbid conditions and multiple needs. Frailty is a dominant issue, often combined with dementia and other problems, e.g. sensory impairment and incontinence. The dimensions of a positive care home culture include a well-managed transition into the home, a commitment to person-centred care, and a well-trained and supported workforce. Over the last few years there has been a growing interest in care homes as major providers of care to some of the UK’s most vulnerable citizens; this includes welcome attention to research.
  • What are the risk factors for malnutrition in older-aged institutionalized adults?

    Stephan, Blossom C. M. (2020)
    Malnutrition is common in older adults and is associated with functional impairment, reduced quality of life, and increased morbidity and mortality. The aim of this study was to explore the association between health (including depression), physical functioning, disability and cognitive decline, and risk of malnutrition. Participants were recruited from nursing homes in Italy and completed a detailed multidimensional geriatric evaluation. All the data analyses were completed using Stata Version 15.1. The study included 246 participants with an age range of 50 to 102 (80.4 ± 10.5). The sample was characterised by a high degree of cognitive and functional impairment, disability, and poor health and nutritional status (according to Mini Nutritional Assessment (MNA), 38.2% were at risk for malnutrition and 19.5% were malnourished). Using a stepwise linear regression model, age (B = −0.043, SE = 0.016, p = 0.010), depression (B = −0.133, SE = 0.052, p = 0.011), disability (B = 0.517, SE = 0.068, p < 0.001), and physical performance (B = −0.191, SE = 0.095, p = 0.045) remained significantly associated with the malnutrition risk in the final model (adjusted R-squared = 0.298). The logistic regression model incorporating age, depression, disability, and physical performance was found to have high discriminative accuracy (AUC = 0.747; 95%CI: 0.686 to 0.808) for predicting the risk of malnutrition. The results of the study confirm the need to assess nutritional status and to investigate the presence of risk factors associated with malnutrition in order to achieve effective prevention and plan a better intervention strategy. © 2020 by the authors. Licensee MDPI, Basel, Switzerland.
  • Developing the React to Falls resources to support care home staff in managing falls

    Jones, Katherine; Balmbra, Jane (2019)
    Objectives: Care home residents are falling three times more often than elderly frail people living in their own homes and as such, the management of falls is an important area for care home staff to consider. This paper outlines the development of the 'React to Falls' training resources to support care home staff in the management of falls. Methods: The 'React to Falls' resources were developed in collaboration with falls prevention researchers, expert clinicians working in the field of falls management in care homes and care home staff and residents. Results: A freely accessible online and paper based resource was developed to meet the needs of different care home settings. Expert clinicians and care homes emphasised the importance of promoting activity and quality life and ensuring the resources were a learning tool that supported positive risk taking. Expert clinicians highlighted the need to convey the importance of continually reacting to reducing risk in the management of falls. Conclusions: This study has developed a set of training resources on falls management to support care home staff to continually react and consider the risks and management of falls. An evaluation of the impact of the resource on care staff behaviour and organisational changes is recommended.
  • Music Interventions for Dementia and Depression in ELderly care (MIDDEL): protocol and statistical analysis plan for a multinational cluster-randomised trial

    Orrell, Martin (2019)
    INTRODUCTION: In older adults, dementia and depression are associated with individual distress and high societal costs. Music interventions such as group music therapy (GMT) and recreational choir singing (RCS) have shown promising effects, but their comparative effectiveness across clinical subgroups is unknown. This trial aims to determine effectiveness of GMT, RCS and their combination for care home residents and to examine heterogeneity of treatment effects across subgroups. METHODS AND ANALYSIS: This large, pragmatic, multinational cluster-randomised controlled trial with a 2x2 factorial design will compare the effects of GMT, RCS, both or neither, for care home residents aged 65 years or older with dementia and depressive symptoms. We will randomise 100 care home units with >/=1000 residents in total across eight countries. Each intervention will be offered for 6 months (3 months 2 times/week followed by 3 months 1 time/week), with extension allowed if locally available. The primary outcome will be the change in the Montgomery-Asberg Depression Rating Scale score at 6 months. Secondary outcomes will include depressive symptoms, cognitive functioning, neuropsychiatric symptoms, psychotropic drug use, caregiver burden, quality of life, mortality and costs over at least 12 months. The study has 90% power to detect main effects and is also powered to determine interaction effects with gender, severity and socioeconomic status. ETHICS AND DISSEMINATION: Ethical approval has been obtained for one country and will be obtained for all countries. Results will be presented at national and international conferences and published in scientific journals. TRIAL REGISTRATION NUMBERS: NCT03496675; Pre-results, ACTRN12618000156280.
  • Improving the quality of life of care home residents with dementia: Cost-effectiveness of an optimized intervention for residents with clinically significant agitation in dementia

    Orrell, Martin (2018)
    INTRODUCTION: To examine whether an optimized intervention is a more cost-effective option than treatment as usual (TAU) for improving agitation and quality of life in nursing home residents with clinically significant agitation and dementia. METHODS: A cost-effectiveness analysis within a cluster-randomized factorial study in 69 care homes with 549 residents was conducted. Each cluster was randomized to receive either the Well-being and Health for people with Dementia (WHELD) intervention or TAU for nine months. Health and social care costs, agitation, and quality of life outcomes were evaluated. RESULTS: Improvements in agitation and quality of life were evident in residents allocated to the WHELD intervention group. The additional cost of the WHELD intervention was offset by the higher health and social care costs incurred by TAU group residents (mean difference, pound2103; 95% confidence interval, -13 to 4219). DISCUSSION: The WHELD intervention has clinical and economic benefits when used in residents with clinically significant agitation.
  • Effects of care assistant communication style on communicative behaviours of residents with dementia: a systematic multiple case study

    Stanyon, Miriam R.; Thomas, Shirley (2018)
    OBJECTIVESTo determine whether varying the communication style of care assistants, encouraging them to use direct instructions and allowing more time for residents' responses influenced the communicative behaviour of care home residents living with dementia.DESIGNThis study used a multiple systematic case study design. Participants were video-recorded during morning care routines in three communication conditions: usual communication, direct instructions and pacing (allowing more time for resident responses). Each dyad acted as its own control.SETTINGThe study took place in a residential care home in the East Midlands, UK.PARTICIPANTSThree dyads (person with dementia/care worker) MEASURES: The level of compliance with instructions was measured. Validated measures were used to rate positive communicative behaviour (engagement with care tasks, eye contact and initiation of interaction) and negative communicative behaviour (e.g. shouting and kicking).RESULTSCare assistants were able to employ direct instructions after brief training. The use of direct instructions was positively correlated with positive communicative behaviour from residents (p < 0.05). The pacing condition was not employed adequately to evaluate effectiveness. Negative communicative behaviour (resistiveness to care) was rare.CONCLUSIONThe use of direct instructions by care assistants holds promise for effective communication with people with dementia and warrants further investigation in larger samples and in varied contexts.
  • Improving trial recruitment in care homes: The falls in care home (FinCH) experience

    Robinson, Katie R. (2018)
    Introduction: Recruitment into large care home studies has been recognised to be particularly challenging1. A ‘Falls in Care Home (CH) Multi-Centred Trial’ (FinCH) was not recruiting residents to time and target, and remedial action was needed. We report an initiative to increase resident recruitment rates.
  • Addressing contamination in rehabilitation research trials

    Robinson, Katie R. (2018)
    Introduction: The Falls in Care Home (FinCH) study is a large (*87 care homes, 1698 resident across 10 UK sites) randomised controlled trial evaluating whether a systematic falls programmes called the Guide To Action Tool (GtACH) reduces falls for care home residents. Large complex rehabilitation trials, such as FinCH, are at risk of contamination bias which can occur when participants in the control group are inadvertently exposed to the intervention. Such trials are also at risk of the intervention being adopted into clinical practice before effectiveness has been established.
  • How are rehabilitation interventions for older adults developed? A systematic review of frameworks that have been used to develop rehabilitation interventions for older adults

    Robinson, Katie R. (2018)
    Background: Interventions that focus on rehabilitation for older adults can be considered complex as they involve a number of interacting components, have multiple outcomes of interest and are influenced by a number of environmental and contextual factors. Interventions initially showing promise in small scale testing are often ineffective when scaled into large multicentre randomised-trials. This could be due to a lack of sound theoretical underpinning and understanding of the intervention through limited development work. The importance of rigorous intervention development prior to formal evaluation has been acknowledged by healthcare researchers and a number of frameworks developed that can inform and facilitate the development process. The Medical Research Council (MRC) guidance provides a structure to the development and evaluation process for complex interventions. However, the guidance is brief and falls short of the detail required for such a complex and diverse field. Are frameworks being used to guide the development process? If so, which and how are they being used for older adult rehabilitation?
  • Supporting effective recruitment in a large rehabilitation trial through a research assistant network

    Robinson, Katie R. (2018)
    Introduction: Falls in Care Home (FinCH) is a large rehabilitation trial evaluating a falls management approach for care home residents with 10 sites across the UK participating. Recruitment is vital to the success of FinCH to ensure an appropriate and sufficient sample of care home staff and residents are included. The challenges of recruitment in the acute setting are widely acknowledged, however recruitment of care homes and residents in care homes is relatively new.
  • Measuring health-related quality of life of care home residents, comparison of self-report with staff proxy responses for EQ-5D-5L and HowRu: protocol for assessing proxy reliability in care home outcome testing

    Dening, Tom (2018)
    INTRODUCTIONResearch into interventions to improve health and well-being for older people living in care homes is increasingly common. Health-related quality of life (HRQoL) is frequently used as an outcome measure, but collecting both self-reported and proxy HRQoL measures is challenging in this setting. This study will investigate the reliability of UK care home staff as proxy respondents for the EQ-5D-5L and HowRu measures.METHODS AND ANALYSISThis is a prospective cohort study of a subpopulation of care home residents recruited to the larger Proactive Healthcare for Older People in Care Homes (PEACH) study. It will recruit residents ≥60 years across 24 care homes and not receiving short stay or respite care. The sample size is 160 participants. Resident and care home staff proxy EQ-5D-5L and HowRu responses will be collected monthly for 3 months. Weighted kappa statistics and intraclass correlation adjusted for clustering at the care home level will be used to measure agreement between resident and proxy responses. The extent to which staff variables (gender, age group, length of time caring, role, how well they know the resident, length of time working in care homes and in specialist gerontological practice) influence the level of agreement between self-reported and proxy responses will be considered using a multilevel mixed-effect regression model.ETHICS AND DISSEMINATIONThe PEACH study protocol was reviewed by the UK Health Research Authority and University of Nottingham Research Ethics Committee and was determined to be a service development project. We will publish this study in a peer-reviewed journal with international readership and disseminate it through relevant national stakeholder networks and specialist societies.
  • Management of a patient with a coccyx ulcer in a nursing home

    Anders, Tessa (2017)
    Older people are at increased risk of developing pressure ulcers. They are also more likely to have comorbidities that increase the challenges of managing such a wound. This article reviews a complex case in which a 77-year-old woman with dementia and incontinence developed an ulcer on her coccyx. The ulcer became infected several times and proved resistant to several types of treatment before negative pressure wound therapy with Nanova was instigated.
  • Optimal healthcare delivery to care homes in the UK: A realist evaluation of what supports effective working to improve healthcare outcomes

    Dening, Tom; Schneider, Justine (2018)
    Introduction: care home residents have high healthcare needs not fully met by prevailing healthcare models. This study explored how healthcare configuration influences resource use. Methods: a realist evaluation using qualitative and quantitative data from case studies of three UK health and social care economies selected for differing patterns of healthcare delivery to care homes. Four homes per area (12 in total) were recruited. A total of 239 residents were followed for 12 months to record resource-use. Overall, 181 participants completed 116 interviews and 13 focus groups including residents, relatives, care home staff, community nurses, allied health professionals and General Practitioners. Results: context-mechanism-outcome configurations were identified explaining what supported effective working between healthcare services and care home staff: (i) investment in care home-specific work that legitimises and values work with care homes; (ii) relational working which over time builds trust between practitioners; (iii) care which ‘wraps around’ care homes; and (iv) access to specialist care for older people with dementia. Resource use was similar between sites despite differing approaches to healthcare. There was greater utilisation of GP resource where this was specifically commissioned but no difference in costs between sites. Conclusion: activities generating opportunities and an interest in healthcare and care home staff working together are integral to optimal healthcare provision in care homes. Outcomes are likely to be better where: focus and activities legitimise ongoing contact between healthcare staff and care homes at an institutional level; link with a wider system of healthcare; and provide access to dementia-specific expertise.
  • Impact of person-centred care training and person-centred activities on quality of life, agitation, and antipsychotic use in people with dementia living in nursing homes: A cluster-randomised controlled trial

    Orrell, Martin (2018)
    BACKGROUNDAgitation is a common, challenging symptom affecting large numbers of people with dementia and impacting on quality of life (QoL). There is an urgent need for evidence-based, cost-effective psychosocial interventions to improve these outcomes, particularly in the absence of safe, effective pharmacological therapies. This study aimed to evaluate the efficacy of a person-centred care and psychosocial intervention incorporating an antipsychotic review, WHELD, on QoL, agitation, and antipsychotic use in people with dementia living in nursing homes, and to determine its cost.METHODS AND FINDINGSThis was a randomised controlled cluster trial conducted between 1 January 2013 and 30 September 2015 that compared the WHELD intervention with treatment as usual (TAU) in people with dementia living in 69 UK nursing homes, using an intention to treat analysis. All nursing homes allocated to the intervention received staff training in person-centred care and social interaction and education regarding antipsychotic medications (antipsychotic review), followed by ongoing delivery through a care staff champion model. The primary outcome measure was QoL (DEMQOL-Proxy). Secondary outcomes were agitation (Cohen-Mansfield Agitation Inventory [CMAI]), neuropsychiatric symptoms (Neuropsychiatric Inventory-Nursing Home Version [NPI-NH]), antipsychotic use, global deterioration (Clinical Dementia Rating), mood (Cornell Scale for Depression in Dementia), unmet needs (Camberwell Assessment of Need for the Elderly), mortality, quality of interactions (Quality of Interactions Scale [QUIS]), pain (Abbey Pain Scale), and cost. Costs were calculated using cost function figures compared with usual costs. In all, 847 people were randomised to WHELD or TAU, of whom 553 completed the 9-month randomised controlled trial. The intervention conferred a statistically significant improvement in QoL (DEMQOL-Proxy Z score 2.82, p = 0.0042; mean difference 2.54, SEM 0.88; 95% CI 0.81, 4.28; Cohen's D effect size 0.24). There were also statistically significant benefits in agitation (CMAI Z score 2.68, p = 0.0076; mean difference 4.27, SEM 1.59; 95% CI -7.39, -1.15; Cohen's D 0.23) and overall neuropsychiatric symptoms (NPI-NH Z score 3.52, p < 0.001; mean difference 4.55, SEM 1.28; 95% CI -7.07,-2.02; Cohen's D 0.30). Benefits were greatest in people with moderately severe dementia. There was a statistically significant benefit in positive care interactions as measured by QUIS (19.7% increase, SEM 8.94; 95% CI 2.12, 37.16, p = 0.03; Cohen's D 0.55). There were no statistically significant differences between WHELD and TAU for the other outcomes. A sensitivity analysis using a pre-specified imputation model confirmed statistically significant benefits in DEMQOL-Proxy, CMAI, and NPI-NH outcomes with the WHELD intervention. Antipsychotic drug use was at a low stable level in both treatment groups, and the intervention did not reduce use. The WHELD intervention reduced cost compared to TAU, and the benefits achieved were therefore associated with a cost saving. The main limitation was that antipsychotic review was based on augmenting processes within care homes to trigger medical review and did not in this study involve proactive primary care education. An additional limitation was the inherent challenge of assessing QoL in this patient group.CONCLUSIONSThese findings suggest that the WHELD intervention confers benefits in terms of QoL, agitation, and neuropsychiatric symptoms, albeit with relatively small effect sizes, as well as cost saving in a model that can readily be implemented in nursing homes. Future work should consider how to facilitate sustainability of the intervention in this setting.TRIAL REGISTRATIONISRCTN Registry ISRCTN62237498.
  • Optimal NHS service delivery to care homes: A realist evaluation of the features and mechanisms that support effective working for the continuing care of older people in residential settings

    Dening, Tom; Schneider, Justine (2017)
    Background: Care homes are the institutional providers of long-term care for older people. The OPTIMAL study argued that it is probable that there are key activities within different models of health-care provision that are important for residents’ health care. Objectives: To understand ‘what works, for whom, why and in what circumstances?’. Study questions focused on how different mechanisms within the various models of service delivery act as the ‘active ingredients’ associated with positive health-related outcomes for care home residents. Methods: Using realist methods we focused on five outcomes: (1) medication use and review; (2) use of out-of-hours services; (3) hospital admissions, including emergency department attendances and length of hospital stay; (4) resource use; and (5) user satisfaction. Phase 1: interviewed stakeholders and reviewed the evidence to develop an explanatory theory of what supported good health-care provision for further testing in phase 2. Phase 2 developed a minimum data set of resident characteristics and tracked their care for 12 months. We also interviewed residents, family and staff receiving and providing health care to residents. The 12 study care homes were located on the south coast, the Midlands and the east of England. Health-care provision to care homes was distinctive in each site. Findings: Phase 1 found that health-care provision to care homes is reactive and inequitable. The realist review argued that incentives or sanctions, agreed protocols, clinical expertise and structured approaches to assessment and care planning could support improved health-related outcomes; however, to achieve change NHS professionals and care home staff needed to work together from the outset to identify, co-design and implement agreed approaches to health care. Phase 2 tested this further and found that, although there were few differences between the sites in residents’ use of resources, the differences in service integration between the NHS and care homes did reflect how these institutions approached activities that supported relational working. Key to this was how much time NHS staff and care home staff had had to learn how to work together and if the work was seen as legitimate, requiring ongoing investment by commissioners and engagement from practitioners. Residents appreciated the general practitioner (GP) input and, when supported by other care home-specific NHS services, GPs reported that it was sustainable and valued work. Access to dementia expertise, ongoing training and support was essential to ensure that both NHS and care home staff were equipped to provide appropriate care. Limitations: Findings were constrained by the numbers of residents recruited and retained in phase 2 for the 12 months of data collection. Conclusions: NHS services work well with care homes when payments and role specification endorse the importance of this work at an institutional level as well as with individual residents. GP involvement is important but needs additional support from other services to be sustainable. A focus on strategies that promote co-design-based approaches between the NHS and care homes has the potential to improve residents’ access to and experience of health care. Funding: The National Institute for Health Research Health Services and Delivery Research programme.
  • Using comprehensive geriatric assessment for quality improvements in healthcare of older people in UK care homes: protocol for realist review within Proactive Healthcare of Older People in Care Homes (PEACH) study

    Dening, Tom (2017)
    INTRODUCTIONCare home residents are relatively high users of healthcare resources and may have complex needs. Comprehensive geriatric assessment (CGA) may benefit care home residents and improve efficiency of care delivery. This is an approach to care in which there is a thorough multidisciplinary assessment (physical and mental health, functioning and physical and social environments) and a care plan based on this assessment, usually delivered by a multidisciplinary team. The CGA process is known to improve outcomes for community-dwelling older people and those in receipt of hospital care, but less is known about its efficacy in care home residents.METHODS AND ANALYSISRealist review was selected as the most appropriate method to explore the complex nature of the care home setting and multidisciplinary delivery of care. The aim of the realist review is to identify and characterise a programme theory that underpins the CGA intervention. The realist review will extract data from research articles which describe the causal mechanisms through which the practice of CGA generates outcomes. The focus of the intervention is care homes, and the outcomes of interest are health-related quality of life and satisfaction with services; for both residents and staff. Further outcomes may include appropriate use of National Health Service services and resources of older care home residents. The review will proceed through three stages: (1) identifying the candidate programme theories that underpin CGA through interviews with key stakeholders, systematic search of the peer-reviewed and non-peer-reviewed evidence, (2) identifying the evidence relevant to CGA in UK care homes and refining the programme theories through refining and iterating the systematic search, lateral searches and seeking further information from study authors and (3) analysis and synthesis of evidence, involving the testing of the programme theories.ETHICS AND DISSEMINATIONThe PEACH project was identified as service development following submission to the UK Health Research Authority and subsequent review by the University of Nottingham Research Ethics Committee. The study protocols have been reviewed as part of good governance by the Nottinghamshire Healthcare Foundation Trust. We aim to publish this realist review in a peer-reviewed journal with international readership. We will disseminate findings to public and stakeholders using knowledge mobilisation techniques. Stakeholders will include the Quality Improvement Collaboratives within PEACH study. National networks, such as British Society of Gerontology and National Care Association will be approached for wider dissemination.TRIAL REGISTRATION NUMBERThe realist review has been registered on International Prospective Register of Systematic Reviews (PROSPERO 2017: CRD42017062601).

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