Lee-Fay Low

A systematic review of different models of home and community care services for older persons

BackgroundCosts and consumer preference have led to a shift from the long-term institutional care of aged older people to home and community based care. The aim of this review is to evaluate the outcomes of case managed, integrated or consumer directed home and community care services for older persons, including those with dementia.MethodsA systematic review was conducted of non-medical home and community care services for frail older persons. MEDLINE, PsycINFO, CINAHL, AgeLine, Scopus and PubMed were searched from 1994 to May 2009. Two researchers independently reviewed search results.ResultsThirty five papers were included in this review. Evidence from randomized controlled trials showed that case management improves function and appropriate use of medications, increases use of community services and reduces nursing home admission. Evidence, mostly from non-randomized trials, showed that integrated care increases service use; randomized trials reported that integrated care does not improve clinical outcomes. The lowest quality evidence was for consumer directed care which appears to increase satisfaction with care and community service use but has little effect on clinical outcomes. Studies were heterogeneous in methodology and results were not consistent.ConclusionsThe outcomes of each model of care differ and correspond to the models focus. Combining key elements of all three models may maximize outcomes.

Dementia literacy: Recognition and beliefs on dementia of the Australian public

Dementia is a growing health problem worldwide and in Australia. Little research has been conducted on dementia literacy in the community.

The Sydney Multisite Intervention of LaughterBosses and ElderClowns (SMILE) study: cluster randomised trial of humour therapy in nursing homes

Objectives To determine whether humour therapy reduces depression (primary outcome), agitation and behavioural disturbances and improves social engagement and quality-of-life in nursing home residents. Design The Sydney Multisite Intervention of LaughterBosses and ElderClowns study was a single-blind cluster randomised controlled trial of humour therapy. Setting 35 Sydney nursing homes. Participants All eligible residents within geographically defined areas within each nursing home were invited to participate. Intervention Professional ‘ElderClowns’ provided 9–12 weekly humour therapy sessions, augmented by resident engagement by trained staff ‘LaughterBosses’. Controls received usual care. Measurements Depression scores on the Cornell Scale for Depression in Dementia, agitation scores on the Cohen-Mansfield Agitation Inventory, behavioural disturbance scores on the Neuropsychiatric Inventory, social engagement scores on the withdrawal subscale of Multidimensional Observation Scale for Elderly Subjects, and self-rated and proxy-rated quality-of-life scores on a health-related quality-of-life tool for dementia, the DEMQOL. All outcomes were measured at the participant level by researchers blind to group assignment. Randomisation Sites were stratified by size and level of care then assigned to group using a random number generator. Results Seventeen nursing homes (189 residents) received the intervention and 18 homes (209 residents) received usual care. Groups did not differ significantly over time on the primary outcome of depression, or on behavioural disturbances other than agitation, social engagement and quality of life. The secondary outcome of agitation was significantly reduced in the intervention group compared with controls over 26 weeks (time by group interaction adjusted for covariates: p=0.011). The mean difference in change from baseline to 26 weeks in Blom-transformed agitation scores after adjustment for covariates was 0.17 (95% CI 0.004 to 0.34, p=0.045). Conclusions Humour therapy did not significantly reduce depression but significantly reduced agitation. Trial registration Australian New Zealand Clinical Trials Registry -ACTRN12611000462987.

Use of medications with anticholinergic properties and cognitive function in a young-old community sample.

To examine whether anticholinergic medications have effects on the level of cognitive function or cognitive decline in persons in their early to mid 60s.

Self-Destructive Behaviors in Nursing Home Residents

OBJECTIVES: To validate the Harmful Behaviors Scale (HBS) as a measure of direct and indirect self‐destructive behaviors in nursing home residents and to determine the prevalence of self‐destructive behaviors and their relationship to other variables.

Hormone replacement therapy and cognitive performance in postmenopausal women: a review by cognitive domain

Laboratory, animal and neuroimaging evidences suggest that hormone replacement therapy (HRT) may be beneficial to human cognition. This systematic review includes 26 studies on the association between HRT and cognition and 17 studies on HRT and risk of dementia. It was hypothesised that HRT would have a positive association with cognitive speed and verbal memory and possibly visual memory but not with executive functioning, and would be associated with a decreased risk of dementia. Evidence for HRTs neuroenhancing and neuroprotective properties was also evaluated. There was significant statistical and clinical heterogeneity among studies precluding meta-analysis. Results showed no consistent relationship between HRT and performance in any cognitive domain. Cross-sectional studies tended to report more positive results than longitudinal studies and randomised-controlled trials, particularly in the areas of verbal memory and executive functioning. HRT was associated with decreased risk of dementia in observational studies, but with increased risk in one randomised-controlled trial. Cognitive improvement or maintenance are not secondary benefits of HRT.

Recommended Measures for the Assessment of Behavioral Disturbances Associated With Dementia

OBJECTIVE The study reviewed all the published instruments used for the assessment, diagnosis, screening, and outcomes monitoring/evaluation of behavioral disturbances associated with dementia (BDAD) to recommend a set of psychometrically valid measures for clinicians and researchers to use, across a range of different practice settings. METHODS The study involved a broad scoping search, followed by a series of in-depth literature reviews on 29 instruments using scientific literature databases (MEDLINE, PsycINFO, CINAHL, and the Cochrane Library) and various national, international government, and government agency websites and professional organization websites. External consultations from measurement, clinical and research experts in dementia care, consumer representatives, and policy/decision makers, were sought in selecting the best instruments and in making the final recommendations. FINDINGS Key attributes and psychometric properties of a short list of five instruments were measured against prespecified criteria. The Neuropsychiatry Inventory (NPI) and the Behavioral Pathology in Alzheimers Disease Rating Scale (BEHAVE-AD) were rated as the best measures for assessment of behavioral disturbances, followed by the Consortium to Establish a Registry for Alzheimers Disease-Behavior Rating Scale for Dementia (CERAD-BRSD), the Dementia Behavior Disturbance Scale, and the Neurobehavioral Rating Scale. CONCLUSION The use of valid and standardized outcome measures for the assessment of BDAD is critical for epidemiological studies, prevention, early intervention and treatment of dementia conditions, and funding for relevant healthcare services. The review recommends the NPI and BEHAVE-AD as the most appropriate measures for both clinical and research, whereas the CERAD-BRSD is suited better for research. The review was designed for the Australian context; however, the findings are applicable in other developed countries.

What is the effectiveness of acute hospital treatment of older people with mental disorders

AIM To appraise the effectiveness of acute hospital service delivery in old age psychiatry. METHOD A systematic literature search of the Medline, PsycINFO, CINAHL, EMBASE and Cochrane Collaboration databases was undertaken to obtain articles published in English from 1966 to May 2004 about old age psychiatry services. Articles were excluded if they did not focus on subjects over 60 years of age, did not include quantitative data on outcomes, or if the intervention was purely pharmacological or a specific non-pharmacological technique. The two authors independently assessed data quality. The overall quality of the evidence for the effectiveness of old age mental health service delivery was rated on an evidence hierarchy that has four levels of evidence. RESULTS Forty-six studies were identified that met our criteria. The only randomized controlled trials (RCTs) were of consultation/liaison service provision and delirium prevention and hence the best quality evidence is for interventions to prevent delirium, reduce costs and length of stay (LOS) in medical wards (level II). There is lower quality (level III/IV), albeit consistently positive, evidence that acute hospital treatment by old age psychiatry services is effective. By contrast, there is no evidence (level I) that non-psychiatric hospital medical services improve mental health outcomes. CONCLUSION There are gaps in our knowledge regarding the effectiveness of acute hospital treatment of mental disorders in old age. Multicenter studies involving comparisons of day hospitals, multidisciplinary community teams and acute hospital settings (old age mental health and adult mental health, with and without post-discharge community care) are required.

The relationship between the quality of the built environment and the quality of life of people with dementia in residential care

While there is considerable evidence on the impact of specific design features on problems associated with dementia, the link between the quality of the built environment and quality of life of people with dementia is largely unexplored. This study explored the environmental and personal characteristics that are associated with quality of life in people with dementia living in residential aged care. Data were obtained from 275 residents of 35 aged care homes and analysed using linear regression. The quality of the built environment was significantly associated with the quality of life of the resident measured by global self-report. Environmental ratings were not associated with proxy or detailed self-report ratings. Higher quality of life is associated with buildings that facilitate engagement with a variety of activities both inside and outside, are familiar, provide a variety of private and community spaces and the amenities and opportunities to take part in domestic activities.

The relationship between self-destructive behaviour and nursing home environment

The aim of this study was to explore the relationship between self-destructive behaviour and nursing home environment. We performed a cross-sectional study comprising 647 residents in 11 nursing homes in Sydney, Australia using the Harmful Behaviours Scale (HBS), Abbreviated Mental Test Scale and the Resident Classification Index. The Directors of Nursing completed a questionnaire that rated physical design, staff and resident characteristics and demographics were obtained from nursing home records. On regression analysis a greater number of design features for frail and residents with dementia in general, and increased security measures were associated with greater HBS total score and risk-taking and passive self-harm subscales. A residential environment in which the residents were more functionally dependent and more likely to be in a shared room, managerial policies less geared towards managing difficult behaviour and less staff availability and training were associated with the ‘uncooperativeness’ factor. There were no significant predictors of the other two factors. The relationship between nursing home environment and self-destructive behaviours and the environment is complex and there needs to be an individualized approach to placement.