Alisoun Milne

Screening for dementia in primary care: a review of the use, efficacy and quality of measures.

BACKGROUND Despite evidence that early identification of dementia is of growing policy and practice significance in the U.K., limited work has been done on evaluating screening measures for use in primary care. The aim of this paper is to offer a clinically informed synthesis of research and practice-based evidence on the utility, efficacy and quality of dementia screening measures. METHOD The study has three elements: a review of research literature, a small-scale survey of measures employed in three primary care trusts, and a systematic clinical evaluation of the most commonly used screening instruments. The study integrates data from research and clinical sources. RESULTS The General Practitioner Assessment of Cognition (GPCOG), the Memory Impairment Screen (MIS), and the Mini-Cognitive Assessment Instrument (Mini-Cog) were found to be brief, easy to administer, clinically acceptable, effective, and minimally affected by education, gender, and ethnicity. All three have psychometric properties similar to the Mini-mental State Examination (MMSE). CONCLUSIONS Although the MMSE is widely used in the U.K., this project identifies the GPCOG, MIS and Mini-Cog as clinically and psychometrically robust and more appropriate for routine use in primary care. A coherent review of evidence coupled with an indepth evaluation of screening instruments has the potential to enhance ability and commitment to early intervention in primary care and, as part of a wider educational strategy, improve the quality and consistency of dementia screening.

The effect of bedrails on falls and injury: a systematic review of clinical studies

BACKGROUND around one-fourth of all falls in healthcare settings are falls from bed. The role of bedrails in falls prevention is controversial, with a prevailing orthodoxy that bedrails are harmful and ineffective. OBJECTIVE to summarise and critically evaluate evidence on the effect of bedrails on falls and injury DESIGN systematic literature review using the principles of QuoRoM guidance. SETTING AND SUBJECTS adult healthcare settings REVIEW METHODS using the keyword, bedrail, and synonyms, databases were searched from 1980 to June 2007 for direct injury from bedrails or where falls, injury from falls, or any other effects were related to bedrail use. RESULTS 472 papers were located; 24 met the criteria. Three bedrail reduction studies identified significant increases in falls or multiple falls, and one found that despite a significant decrease in falls in the discontinue-bedrails group, this group remained significantly more likely to fall than the continue-bedrails group; one case-control study found patients who had their bedrails raised significantly less likely to fall; one retrospective survey identified a significantly lower rate of injury and head injury in falls with bedrails up. Twelve papers described direct injury from bedrails. DISCUSSION it is difficult to perform conventional clinical trials of an intervention already embedded in practice, and all included studies had methodological limitations. However, this review concludes that serious direct injury from bedrails is usually related to use of outmoded designs and incorrect assembly rather than being inherent, and bedrails do not appear to increase the risk of falls or injury from falls.

The ‘D’ word: Reflections on the relationship between stigma, discrimination and dementia

Dementia1 is a major cause of disability amongst older people and constitutes one of the most serious challenges facing the older population, their families and health and social care services in t...

Successful ageing in adversity: the LASER–AD longitudinal study

Background: Most models of successful ageing do not allow for the possibility of living “successfully,” despite some degree of cognitive or physical impairment. We reviewed the successful ageing and related quality of life literature to identify their potential predictors. We then tested our hypotheses that wellbeing in adversity would be predicted by mental health (anxiety and depression) and social factors rather than physical health and that it would be stable over time. Method: We interviewed 224 people with Alzheimer’s disease (AD) and their family carers, recruited to be representative of those living with AD in the community. We re-interviewed 122 (73.1% of eligible) participants 18 months later. Our main outcome measure was the perception of the person with AD on their life as a whole. Results: Mean “wellbeing in adversity” scores did not change significantly over time (t = 0.23). Social relationships, subjective mental health, health perception, activities of daily living and baseline wellbeing in adversity were the significant correlates of wellbeing in adversity on univariate analysis. Only baseline wellbeing in adversity and mental health score were significant predictors in our regression analysis. In a well fitting structural equation model, less severe dementia and better health perception predicted fewer mental health problems and social relationships, but were not direct predictors of wellbeing in adversity at 18 months. Conclusion: Successful ageing was common among a cohort of people with dementia. The most important predictors of this were mental health and social relationships, which fully mediated the relationship we found between health perception and wellbeing 18 months later.

Dementia screening and early diagnosis: The case for and against

Over 700,000 people have dementia in the UK. There is increasing policy and practice consensus that early intervention in identifying and treating dementia is beneficial and that much can be done therapeutically and practically to help users and their relatives at an early stage. Research evidences early diagnosis as allowing users the chance to come to terms with it when they can still understand its implications. It also provides an opportunity for key decisions to be made and is what the majority of people want. However, early diagnosis also carries risks: loss of status, acquisition of a stigmatising label, loss of employment and, for a minority, depression. Not all users want to know they have dementia; the diagnosis may also be incorrect. Evidence from the field of medical sociology offers a different perspective on the early intervention debate suggesting not only that targeting ‘well’ older people at possible risk of dementia may be the latest product of surveillance medicine but that efforts to resist being diagnosed may represent strategies to challenge medical intrusion, knowledge and power. Further, the imposition by an older person and their family of their individualised values onto the clinical encounter may be viewed as an attempt to import user generated forms of knowledge into a medically managed process and provide a nuanced approach to defining, and dealing with, risks. Accommodating both perspectives in practice development may hold considerable potential to enhance the nature of care and the quality of lives of people with dementia and their families.

GP attitudes to early diagnosis of dementia: Evidence of improvement

This paper offers a comparative analysis of GPs attitudes towards early diagnosis of dementia in 1997 and 2001. It draws on data from two studies conducted in the same area using the same research instrument. Overall, findings reveal a significantly greater commitment to early diagnosis at Time 2 than at Time 1. More GPs hold positive attitudes and consider early diagnosis to facilitate a number of practical and therapeutic benefits for users and carers. Further, fewer GPs regard early diagnosis as having negative consequences. Findings also support existing evidence about attitudes being underpinned by drivers and barriers. Those GPs who are committed regard it as an opportunity to offer preventive treatment and plan for the future; barriers include limited treatment options. Primary reasons for the attitudinal shift are greater accessibility of psychiatric colleagues, additional investment in support services, and enhanced policy and clinical emphasis on the value of early diagnosis.

Adult Protection Incidence of Referrals, Nature and Risk Factors in Two English Local Authorities

• Summary: This study focused on the incidence of adult protection referrals, the people involved as victims, perpetrators and referrers and the type of abuse in two local authorities in the south-east of England. • Findings: The number of referrals increased over time; those for older people stabilized but those for younger adults were still rising. There was a clear association between location or setting, perpetrator and type of abuse. A referral about someone living in a care home was more likely to identify abuse by multiple staff and institutional abuse or neglect, especially if the individual was an older person with mental health problems. People with learning disabilities were more likely to experience sexual abuse, mainly from other service users or members of their family. Those living in a private home with others, primarily relatives, tended to be at risk of financial, physical or psychological abuse. Older people living alone were particularly vulnerable to financial abuse by family members or, less frequently, home care workers. • Applications : This study suggests that well-developed adult protection procedures identify many more cases than previously estimated. Further research is needed to explain the low level of referrals from mental health services and variation between territories.

Mental health and care homes

Introduction PART 1: THE INSIDE VIEW - LIVING IN A CARE HOME: 1. A residents view 2. A carers account 3. A care home managers view 4. Creative work with residents 5. Hearing the voice of older people with dementia 6. Living with dementia in a care home: a review of research evidence PART 2: THE OUTSIDE VIEW 7. Quality and regulation 8. Funding: paying for residential care for older people 9. Legal aspects 10. Abuse in care homes for older people: the case for safeguards 11. Long term care: an international perspective PART 3: MENTAL HEALTH AND CARE 12. Meeting mental health needs 13. Dementia in care homes 14. Depression in care homes 15. Functional mental illness 16. Psychosocial interventions in care homes 17. Support to care homes 18. Working with minorities in care homes 19. Physical health issues 20. Palliative care and end of life care PART 4: PROMOTING HEALTH AND WELL BEING 21. Promoting health and well-being: good practice inside care homes 22. Good practice: outside the care home 23. Risk and choice 24. Dementia training in care homes 25. My Home Life: exploring the evidence base for best practice LOOKING TO THE FUTURE: CONCLUSIONS 26. Conclusion: key themes and future directions

Planning ahead: meeting the needs of older people with intellectual disabilities in the United Kingdom

Despite the acknowledged increase in the number of older people with intellectual disabilities (ID) in the UK, the age-related health and social care needs of this population have yet to be fully understood and addressed. Although there is some evidence of positive development, the current picture of service provision is characterized by fragmentation and limited choice of resources and specialist care. Policy aims are variably met and inconsistently applied. Research suggests that service planning is often incoherent, that many older people with ID and their carers receive poor quality non-specialist care and that staff are inadequately trained to manage the often multiple and complex needs of this user group. There is a considerable co-joined service development and research challenge in this emerging field. If older people with ID and their carers are to receive quality provision, a coherent and well-funded service planning system is required which is underpinned by articulated agency partnerships, informed by good practice developments in the fields of ID, gerontology and dementia care, and linked to evidence about effective models of care and services. The incorporation of the perspectives of users and carers in the planning process is an essential pre-requisite as is a commitment to the development of effective support across the life course of all individuals with ID.

Challenges of ethical and legal responsibilities when technologies' uses and users change: social networking sites, decision-making capacity and dementia

Successful technologies’ ubiquity changes uses, users and ethicolegal responsibilities and duties of care. We focus on dementia to review critically ethicolegal implications of increasing use of social networking sites (SNS) by those with compromised decision-making capacity, assessing concerned parties’ responsibilities. Although SNS contracts assume ongoing decision-making capacity, many users’ may be compromised or declining. Resulting ethicolegal issues include capacity to give informed consent to contracts, protection of online privacy including sharing and controlling data, data leaks between different digital platforms, and management of digital identities and footprints. SNS uses in healthcare raise additional issues. Online materials acting as archives of ‘the self’ bolster present and future identities for users with compromised capacity. E-health involves actual and potential intersection of data gathered for the purpose of delivering health technological support with data used for social networking purposes. Ethicolegal guidance is limited on the implications of SNS usage in contexts where users have impaired/reduced capacity to understand and/or consent to sharing personal data about their health, medication or location. Vulnerable adults and family/carers face uncertainty in regard to consent, data protection, online identity and legal liabilities. Ethicolegal responsibilities and duties of care of technology providers, healthcare professionals, regulatory bodies and policymakers need clarification.