Aysha Begum

Increased Prevalence of Insomnia and Changes in Hypnotics Use in England over 15 Years: Analysis of the 1993, 2000, and 2007 National Psychiatric Morbidity Surveys

STUDY OBJECTIVES To investigate changes over 15 years in the prevalence of insomnia and its association with demographic characteristics and hypnotic medication use. DESIGN Analysis of 3 cross-sectional national mental health surveys carried out in 1993, 2000, and 2007, which used comparable sampling methods and identical insomnia assessments. SETTING Adults living in private households in England. PATIENTS OR PARTICIPANTS 20,503 people aged 16-64 years. MEASUREMENTS AND RESULTS Insomnia was defined according to 4 different criteria, using relevant questions from the revised Clinical Interview Schedule. Modest increases in insomnia prevalence were found over the survey periods (any symptoms increasing from 35.0% in 1993 to 38.6% in 2007; insomnia diagnosis from 3.1% to 5.8%, respectively). In all 3 surveys, similar strengths of association in relation to all criteria were found, with female gender, increased age, lower educational attainment, depression, unemployment, economic inactivity, and widowed, divorced, or separated status. Prevalence of hypnotic use was double in 2000 (0.8%) compared to 1993 (0.4%); from limited information on selected medications, there was no such increase between 2000 and 2007. The reasons reported for any sleep disturbance over the last month were generally similar across surveys, the most marked change being illness/discomfort increasing as an explanation from 14.3% to 17.4% to 19.0%. CONCLUSIONS In the English general population, insomnia (by any definition) showed a modest but steady increase in prevalence over a 15-year period. Strengths of associations with demographic factors and self-reported reasons for sleep disturbance remained reasonably stable over this period.

Current prevalence of dementia, depression and behavioural problems in the older adult care home sector: the South East London Care Home Survey

BACKGROUND a large and increasing number of older people in the UK are living in care homes. Dementia is a frequent reason underlying admission and determining care needs, but prevalence data are becoming increasingly outdated and reliant on brief screening instruments. OBJECTIVE to describe the prevalence and severity of dementia, depression, behavioural problems and relevant medication use in a representative sample of residential and nursing care home residents. DESIGN/SETTING a survey conducted in 15 randomly selected South East London care homes. Consensus clinical dementia diagnoses were made from multi-source information, and the Clinical Dementia Rating (CDR) Scale applied. Depression was ascertained using the Cornell Depression in Dementia Scale and psychological/behavioural problems using the Neuropsychiatric Inventory (NPI). PARTICIPANTS three hundred and one residents with a mean (SD) age of 83.5 (9.8) and 65.8% female were included. RESULTS dementia (CDR 1-3) prevalence was 75.1% overall, 55.8% in residential homes, 91.0% in residential elderly mentally infirm care and 77.0% in nursing homes. Depression prevalences were 26.5, 22.0 and 29.6%, respectively, and mean (95% CI) NPI severity scores 3.99 (3.47-4.50), 6.34 (5.29-7.39) and 6.10 (5.50-6.70) with 87.3% of the sample exhibiting at least one NPI symptom. Antidepressants were prescribed in 25.6, 25.0 and 41.3%, respectively, and antipsychotics in 7.0, 34.1 and 19.1%. CONCLUSION dementia is substantially more common in care homes than recorded diagnoses would suggest, but studies using brief screening instruments may overestimate prevalence. High prevalences of depressive and/or behavioural symptoms and psychotropic use suggest significant unmet need.

The effect of using high facilitation when implementing the Gold Standards Framework in Care Homes programme: A cluster randomised controlled trial

Background: The provision of quality end-of-life care is increasingly on the national agenda in many countries. In the United Kingdom, the Gold Standards Framework for Care Homes programme has been promoted as a national framework for improving end-of-life care. While its implementation is recommended, there are no national guidelines for facilitators to follow to undertake this role. Aim: It was hypothesised that action learning alongside high facilitation when implementing the Gold Standards Framework for Care Homes programme will result in a reduced proportion of hospital deaths for residents and improvement in the care home staff ability to facilitate good end-of-life care. Design: A cluster randomised controlled trial where 24 nursing homes received high facilitation to enable them to implement the Gold Standards Framework for Care Homes programme. The managers of 12 nursing homes additionally took part in action learning sets. A third group (14 nursing homes) received the ‘standard’ Gold Standards Framework for Care Homes facilitation available in their locality. Setting/participants: In total, 38 nursing homes providing care for frail older people, their deceased residents and their nurse managers. Results: A greater proportion of residents died in those nursing homes receiving high facilitation and action learning but not significantly so. There was a significant association between the level of facilitation and nursing homes completing the Gold Standards Framework for Care Homes programme through to accreditation. Year-on-year change occurred across all outcome measures. Conclusion: There is a danger that without national guidelines, facilitation of the Gold Standards Framework for Care Homes programme will vary and consequently so will its implementation. The nurse manager of a care home must be actively engaged when implementing the Gold Standards Framework for Care Homes programme.

Functional status and all-cause mortality in serious mental illness.

Background Serious mental illness can affect many aspects of an individual’s ability to function in daily life. The aim of this investigation was to determine if the environmental and functional status of people with serious mental illness contribute to the high mortality risk observed in this patient group. Methods We identified cases of schizophrenia, schizoaffective and bipolar disorder aged ≥15 years in a large secondary mental healthcare case register linked to national mortality tracing. We modelled the effect of activities of daily living (ADLs), living conditions, occupational and recreational activities and relationship factors (Health of the Nation Outcome Scale [HoNOS] subscales) on all-cause mortality over a 4-year observation period (2007–10) using Cox regression. Results We identified 6,880 SMI cases (242 deaths) in the observation period. ADL impairment was associated with an increased risk of all-cause mortality (adjusted HR 1.9; 95% CI 1.3–2.8; p = 0.001, p for trend across ADL categories = 0.001) after controlling for a broad range of covariates (including demographic factors, physical health, mental health symptoms and behaviours, socio-economic status and mental health service contact). No associations were found for the other three exposures. Stratification by age indicated that ADLs were most strongly associated with mortality in the youngest (15 to <35 years) and oldest (≥55 years) groups. Conclusions Functional impairment in people with serious mental illness diagnoses is a marker of increased mortality risk, possibly in younger age groups as a marker of negative symptomatology.

Subjective memory impairment in older adults: aetiology, salience and help seeking

Subjective memory impairment (SMI) is one of the key symptoms with which people with early cognitive impairment may present to health services. However, little research has investigated how older people view the symptom, its salience and how often help is sought. The objectives were to investigate (a) factors associated with SMI, (b) salience of SMI in comparison with other symptoms and (c) help seeking for SMI.

Help-seeking Response to Subjective Memory Complaints in Older Adults: Toward a Conceptual Model

PURPOSE Subjective memory complaint is a term used to refer older adults who report memory problems. Extensive literature exists on its etiology and impact on long-term cognitive decline, and some physicians consider it important in the early detection of dementia. Despite the salient features reported by both patients and clinicians, few people seek formal help for this complaint, and little research has investigated the underlying reasons for this. The current study explored beliefs, attitudes, and help-seeking behaviors. DESIGN AND METHODS A qualitative study was carried out comprising of 18 face-to-face in-depth interviews. The primary aim was to compare and contrast experiences between people, who sought formal help (n = 9), recruited from a memory service and those who did not seek formal help (n = 9) recruited from a screened community population. RESULTS The need for both to describe the experiences of an unexplored group and to develop a conceptual help-seeking model prompted the use of thematic framework analysis. Three themes were identified as facilitators and barriers to formal health service use: (a) concern, (b) causation, and (c) perceptions of general practitioner. We identified two further key areas central to shaping help-seeking responses: (a) informal help seeking and (b) alternative pathways to care. IMPLICATIONS These findings suggest that there is a potential for modifying beliefs and attitudes towards help seeking and can inform the development of services and policy to facilitate help seeking and target and provide improved care or treatment when formal help is sought.

Associations between symptoms and all-cause mortality in individuals with serious mental illness

OBJECTIVE To determine if aggression, hallucinations or delusions, and depression contribute to excess mortality risk observed in individuals with serious mental illness (SMI). METHODS We identified SMI cases (schizophrenia, schizoaffective and bipolar disorder) aged≥15years in a large secondary mental healthcare case register linked to national mortality tracing. We modelled the effect of specific symptoms (HoNOS subscales) on all-cause mortality using Cox regression. RESULTS We identified 6880 SMI cases (242 deaths) occurring 2007-2010. Bipolar disorder was associated with reduced mortality risk compared to schizophrenia (HR 0.7; 95% CI 0.4-0.96; p=0.028). Mortality was not significantly associated with hallucinations and delusions or overactive-aggressive behaviour, but was associated with physical illness/disability. There was a positive association between mortality and subclinical depression among individuals with schizophrenia (HR 1.5; 1.1-2.2; p=0.019) but a negative association with subclinical and more severe depression among those with schizoaffective disorder (HR 0.1; 0.02-0.4; p=0.001 and 0.3; 0.1-0.8; p=0.021, respectively). CONCLUSIONS The recognised increased risk of mortality in SMI did not appear to be influenced by severity of hallucinations, delusions, or overactive-aggressive behaviour. Physical illness and lifestyle may need to be addressed and the relationship between depression and mortality requires further investigation.

Subjective cognitive complaints across the adult life span: a 14-year analysis of trends and associations using the 1993, 2000 and 2007 English Psychiatric Morbidity Surveys.

BACKGROUND Cognitive complaints are common in all age groups but most often researched in old age. We aimed to investigate prevalences and time trends over 14 years of subjective memory complaints (SMC) and subjective concentration complaints (SCC) in adults and investigate associations with mood disorders and cognitive function. METHOD Data from three English national mental health surveys carried out in 1993, 2000 and 2007 were analysed. SMC and SCC were measured using the Clinical Interview Schedule-Revised and cognitive function using the modified Telephone Interview for Cognitive Status. RESULTS Both SMC and SCC increased up to middle age and then declined, followed by a second rise in the very oldest age groups. Age-specific prevalence of both increased across survey years but relationships with mental health and cognitive outcomes were relatively stable. CONCLUSIONS Cognitive complaints are most common in middle age and have become more prevalent over time.

Have we forgotten about dementia in care homes? The importance of maintaining survey research in this sector

Dementia is one of the leading causes of disability in later life with substantial societal impact in terms of economic costs [1, 2], many of which arise because of the need for institutional care later in the disorder. A recent report estimated that of the 820,000 people with dementia in the UK, over 30% were living in long-term care institutions with the cost of caring for these individuals amounting to £9 billion per year to the UK economy. However, funding for research into dementia has been substantially less than that for other common chronic disorders [3]. The lack of research funding is also reflected in the fact that only 1.4% of chronic disorder research papers published between 2002 and 2007 were devoted to dementia in contrast to 23.5% on cancer and 17.6% on cardiovascular disease [2]. The intention of the new UK government to prioritise the support of dementia research is therefore to be welcomed. However, even within this field, there has been a lack of investigation into the aspects of dementia care of most economic importance, namely the provision of institutional care and the impact of dementia in these settings. Specifically, a review of publications within the past 10 years, summarised below, has led us to conclude that basic research into dementia impact in UK elderly care homes is becoming increasingly outdated, despite rapidly changing social and political developments regarding the use of and funding for long-term care. There are numerous methodological complexities involved in conducting research with care home residents. First, there is the complexity of care home sampling, given the blurring of service provision (e.g. between ‘residential’ and ‘nursing’ homes). A close working relationship with care homes is key, but presents substantial challenges. One cited reason for a lack of research has been the increase in private sector provision since the 1980s, so that control over access lies with a large number of autonomous owners or managers resulting in random selection of homes being quickly rendered unrepresentative due to refusals [4]. Increased media and political attention to quality of care issues may increase reluctance of care homes to participate in research. Moreover, there are substantial time constraints to staff participation (e. g. to provide informant accounts of behavioural symptoms) in the context of high workload and low staff:resident ratios. Further challenges are also posed in the recruitment of residents who lack capacity to provide informed consent and in identifying an appropriate person to provide consultee consent if there is no relative in close contact. However, failing to include these people risks excluding arguably the most vulnerable members of society [5]. The care home sector in the UK is an environment which has been rapidly changing in terms of organisational structures, relationships between health and social services contributing to referrals and care provision available, all against a background of demographic ageing. Because of this, evidence from conventional cross-sectional surveys cannot be assumed to remain up to date and there is a pressing need for continued research, despite the challenges described above. In order to evaluate this issue, we carried out a systematic review of articles reporting dementia prevalence in any UK care home setting over the last 10 years and, for each article, sought to ascertain the period over which data had been collected. We searched PsycINFO, PubMed, Google Scholar and other relevant data sources using ‘care home’, ‘dementia’ and other related terms as keywords. Furthermore, we manually searched for references within journals. Of 19 reports where dementia prevalence could be ascertained from findings (data available on request), we found only four where the period surveyed was explicitly later than 2000. Of these, Aldred et al. [6] surveyed clinical records from 331 residents in 65 care homes in Leeds in 2002–03 and found a prevalence of 44% for documented dementia and 75% for cognitive impairment from recorded MMSE scores. Hancock et al. [7] carried out a survey of care homes in London, Manchester and North Wales and, from MMSE scores, reported prevalences of 6, 27 and 48% for mild, moderate and severe dementia, respectively. Bowman et al. [8] surveyed 244 BUPA care homes in 2003 using staff questionnaires on residents and reported recorded dementia diagnoses for 31% of residential and 38% of nursing home residents, with respective prevalences of staff-reported confusion/forgetfulness of 60 and 65%. Most recently, Fossey et al. [9] conducted a cluster randomised trial across 12 Elderly Mentally Infirm nursing homes. At baseline, they reported prevalences of 19, 23 and 58% for non/questionable/mild, moderate and severe dementia, respectively. However, eligible sites were those where a minimum of 25% of residents with dementia were taking neuroleptic drugs. In summary, despite the clinical, social and economic importance of the care home sector, 10 years into the 21st century, there has been a paucity of research. Furthermore, forecasts of future dementia prevalence and the associated

The association between subjective memory complaint and objective cognitive function in older people with previous major depression

The goal of this study is to investigate associations between subjective memory complaint and objective cognitive performance in older people with previous major depression–a high-risk sample for cognitive impairment and later dementia. A cross-sectional study was carried out in people aged 60 or over with previous major depression but not fulfilling current major depression criteria according to DSM-IV-TR. People with dementia or Mini-Mental State Examination score less than 17 were excluded. Subjective memory complaint was defined on the basis of a score ≧4 on the subscale of Geriatric Mental State schedule, a maximum score of 8. Older people aged equal or over 60 without any psychiatric diagnosis were enrolled as healthy controls. Cognitive function was evaluated using a series of cognitive tests assessing verbal memory, attention/speed, visuospatial function, verbal fluency, and cognitive flexibility in all participants. One hundred and thirteen older people with previous major depression and forty-six healthy controls were enrolled. Subjective memory complaint was present in more than half of the participants with depression history (55.8%). Among those with major depression history, subjective memory complaint was associated with lower total immediate recall and delayed verbal recall scores after adjustment. The associations between subjective memory complaint and worse memory performance were stronger in participants with lower depressive symptoms (Hamilton Depression Rating Scale score<7). The results suggest subjective memory complaint may be a valid appraisal of memory performance in older people with previous major depression and consideration should be given to more proactive assessment and follow-up in these clinical samples.