David Jolley

Treatment of a Whole Population Sample of Alzheimer’s Disease with Donepezil over a 4-Year Period: Lessons Learned

Background: In the UK it is recommended that acetylcholinesterase inhibitors be restricted to patients with moderate Alzheimer’s disease, and progress monitored within specialist clinics. Objective: To describe a cohort of patients with Alzheimer’s disease from a whole city population treated with donepezil, and to analyse outcomes over 4 years. Methods: Historical cohort design: 88 patients recruited 1997–1998, assessed at baseline with 4-year follow-up, using an agreed protocol and validated measures: survival, retention in treatment, cognition, non-cognitive symptoms, weight change, carer stress. Results: 64.7% remained on treatment beyond 6 months, 57.9% beyond 1 year and 12.5% beyond 4 years. 56% remained alive at 4 years – almost twice the number predicted. Mean MMSE score amongst patients in treatment did not deteriorate over 4 years. Survival, retention in treatment, maintenance/improvement of cognition was greater with high baseline MMSE. Non-cognitive symptoms, carer stress and weight change remained low throughout. Conclusions: A minority of people with dementia from the population (88 of potential 2,000 at outset, 11 by 4 years) received treatment. Benefits for individuals were confirmed, especially for those with mild impairment. Expenditure on medication was modest in a population context. These findings question recent guidance from the National Institute for Clinical Excellence, which would restrict therapy to patients with moderate cognitive impairment.

An examination of factors influencing delayed discharge of older people from hospital

This study aimed to investigate the factors associated with the delayed discharge of older people from hospital and their length of stay (LOS).

National Dementia Strategy: well intentioned--but how well founded and how well directed?

The National Dementia Strategy was published in February 2009. It was eagerly anticipated and has generated a good deal of sustained media interest, widened awareness, and heightened expectation of better help for people with dementia. The three ambitions of the strategy--to raise awareness, facilitate assessment, and improve services--are unquestionably correct; but the assumptions, emphases, and economic predictions are questionable. Encouraging reliance on referral to secondary care centres, and exaggerated claims for the effectiveness of interventions to achieve clinical improvement and cost savings, may lead to disappointment and frustration. The infrastructure of care and treatment of people throughout the course of dementia will be better informed and delivered by a collaborative model which respects the knowledge and commitment contained within families and primary care. Better services will require substantial redirection of resources.

Spirituality and faith in dementia

This study used a standardized instrument, the Royal Free Interview for Religious and Spiritual Beliefs, to investigate the spirituality of a population of people with dementia who scored 12 or more on the Mini Mental State Examination and their carers, who were attending a West Midlands Memory Clinic. Study patients were more likely to be well preserved cognitively, be female, and to be living with their spouse at home, than the clinic population as a whole. The population was predominantly white British and Christian. Both patients and carers found the Royal Free Interview acceptable: they rated their beliefs as strong and considered practices associated with their beliefs to be very important. Both groups described spirituality as evident in everyday experiences and as supportive in relation to life stresses. Service providers should integrate questions about spirituality and faith into routine assessments and structure care plans to accommodate identified spiritual needs.

Professional care providers in dementia care in eight European countries; their training and involvement in early dementia stage and in home care.

Knowledge concerning professionals involved in dementia care throughout its trajectory is sparse; the focus has mainly been on nursing-home care and less on home care, diagnosis and treatment of the disease and its complications despite the fact that home care is the most prominent type of care. The aim of this study was to explore and describe professional care providers involved in dementia care and their educational level applying the International Standard Classification of Education (ISCED) and further to investigate practice in the RightTimePlaceCare-countries with regard to screening, diagnostic procedures and treatment of dementia and home care. The findings demonstrate more similarities than differences in terms of type of professionals involved among the countries although untrained staff were more common in some countries. Findings also show that many types of professionals are involved, who to turn to may not be clear, for instance in terms of medical specialities and it may be unclear who bears the ultimate responsibility. The professionals involved in diagnosis, treatment and care are educated to bachelor’s level or above whilst everyday care is provided by people trained at a lower ISCED level or with no formal training. Registered nurses as well as occupational therapists have bachelor’s degrees in most countries, but not in Germany or Estonia. Professionals specifically trained in dementia care are not so common. Further research is needed to reveal not only who provides the diagnostics and treatment, but also how home care is organised and quality assured. Many different types of professionals serve as providers along the trajectory of the disease which may be difficult for the patient and the informal caregiver to cope with.

The association between physical dependency and the presence of neuropsychiatric symptoms, with the admission of people with dementia to a long-term care institution: A prospective observational cohort study.

BACKGROUND Dementia is a progressive neurological disorder that causes a high degree of dependency. This dependency has been defined as an increased need for assistance due to deterioration in cognition and physical functioning, and changes in behavior. Highly dependent people with dementia are more likely to be institutionalized. OBJECTIVES To investigate the association between specific categories of physical dependency and the presence of neuropsychiatric symptoms in people with dementia admitted to a long-term care institution. DESIGN A prospective observational cohort study. SETTINGS Home care and long-term care institutions in eight European countries. PARTICIPANTS People with dementia living at home but at risk of institutionalization and recently institutionalized people with dementia. METHOD Baseline and 3-month follow-up interviews were performed between November, 2010 and April, 2012. The sample consisted of 116 recently institutionalized dementia sufferers and 949 people with dementia still living at home. Physical dependency was measured using the Katz Activity of Daily Living index, and neuropsychiatric symptoms were assessed through The Neuropsychiatric Inventory. Specific categories of dependency were analyzed by performing a logistic regression analysis. This followed examination of baseline characteristics to define the degree of physical dependency, as factors associated with institutionalization, and evaluation of the same characteristics at 3-month follow-up to detect changes in the degree of physical dependency and neuropsychiatric symptoms associated with recent admission to a long-term care institution. RESULTS Toileting, dressing and continence dependency was higher in institutionalized people than in those receiving home-care. Delusion, hallucination, agitation, anxiety, apathy, motor-disturbances, night-time behavior and eating disorders were also worse in the institutionalized. Logistic regression analysis showed that independent factors significantly associated with being recently institutionalized were toileting (odds ratio=2.3; 95% confidence interval=1.43-3.71) and motor disturbances (odds ratio=1.81; 95% confidence interval=1.15-2.87). CONCLUSIONS This study supports the association between type and degree of physical dependency in people with dementia and long-term institutionalization. Institutionalization is associated with physical dependency and the presence of neuropsychiatric symptoms.

Putting personalisation and integration into practice in primary care

Purpose – The purpose of this article is to discuss the policy developments of integration and personalisation within the context of Primary Care, specifically an innovative Memory Service provided within a General Practice. It examines how these policies work together in this context to deliver a high quality service that is responsive to individual needs in an area of care: memory disorder or dementia, which has often relied heavily on secondary care services.Design/methodology/approach – The article is a case study analysis of integration and personalisation in Primary Care, allowing for examination and elaboration of both concepts as applied in this setting; and their contribution to a better quality care Memory Service. The analysis is produced by independent researchers (MC and NM), background and facts by service personnel (IG, NG and DJ).Findings – The innovative Memory Service operates as a person‐centred facility, integrating into the surgery, expertise that would traditionally be locked into se...

A protocol for a systematic review of effective home support to people with dementia and their carers: Components and impacts

AIM To review the evidence for home support approaches directed at tertiary prevention; ameliorating difficulties and enhancing well-being. BACKGROUND With population ageing dementia represents a significant care challenge with 60% of people with dementia living at home. However, little is known about existing forms of home support and their relative effectiveness. DESIGN A two-stage design: First, an overview of systematic reviews of psychosocial interventions for dementia to identify their components; second, a systematic review of the effectiveness of home support interventions to older people with dementia/their carers. METHODS We will search electronic databases using specific search terms with additional searches of other known studies. Data will be extracted by two reviewers according to pre-determined categories. An initial synthesis will elicit components of interventions from stage 1 and operationalize them in terms of specific techniques. These will then be used in synthesis of data in stage 2, to determine the extent to which each home support intervention relies on these components and distill evidence concerning outcomes. Studies from stage 2 are expected to be methodologically diverse; if so, a narrative approach to synthesis will be taken. Study findings will be explored with Patient, Public and Carer Involvement groups. DISCUSSION The review seeks to develop a theory of home support: how and why interventions may work; in what contexts; and for whom. We will identify effective home support approaches, informing policy-makers and establishing how they might be experienced by people with dementia and their carers.

South Asian older adults with memory impairment: improving assessment and access to dementia care

With increasing international migration, mental health care of migrants and ethnic minorities is a public health priority. South Asian older adults experience difficulties in accessing services for memory impairment, dementia and mental illness. This review examines barriers and facilitators in the pathway to culturally appropriate mental health care.

Gnosall Primary Care Memory Clinic: Eldercare facilitator role description and development.

The Gnosall Primary Care Memory Clinic has been operating since 2006 and adds the skills of a specialist old age psychiatrist to the extensive skills and knowledge available in primary care. Key to the organisation and function of the clinic is the eldercare facilitator, a new role situated in primary care and linking with the specialist and a wide range of other agencies and people. In order to facilitate replication of the model elsewhere, the function, role and competencies of existing and previous eldercare facilitators in the clinic have been reviewed, clarified and related to a competency framework and to similar initiatives in the literature. The selection and training of people with the attributes and skills required to become an eldercare facilitator will determine whether extension of the model is successful elsewhere.