Phillipa A. Logan

Explaining the barriers to and tensions in delivering effective healthcare in UK care homes: a qualitative study

Objective To explain the current delivery of healthcare to residents living in UK care homes. Design Qualitative interview study using a grounded theory approach. Setting 6 UK care homes and primary care professionals serving the homes. Participants Of the 32 participants, there were 7 care home managers, 2 care home nurses, 9 care home assistants, 6 general practitioners (GPs), 3 dementia outreach nurses, 2 district nurses, 2 advanced nurse practitioners and 1 occupational therapist. Results 5 themes were identified: complex health needs and the intrinsic nature of residents’ illness trajectories; a mismatch between healthcare requirements and GP time; reactive or anticipatory healthcare?; a dissonance in healthcare knowledge and ethos; and tensions in the responsibility for the healthcare of residents. Care home managers and staff were pivotal to healthcare delivery for residents despite their perceived role in social care provision. Formal healthcare for residents was primarily provided via one or more GPs, often organised to provide a reactive service that did not meet residents’ complex needs. Deficiencies were identified in training required to meet residents’ needs for both care home staff as well as GPs. Misunderstandings, ambiguities and boundaries around roles and responsibilities of health and social care staff limited the development of constructive relationships. Conclusions Healthcare of care home residents is difficult because their needs are complex and unpredictable. Neither GPs nor care home staff have enough time to meet these needs and many lack the prerequisite skills and training. Anticipatory care is generally held to be preferable to reactive care. Attempts to structure care to make it more anticipatory are dependent on effective relationships between GPs and care home staff and their ability to establish common goals. Roles and responsibilities for many aspects of healthcare are not made explicit and this risks poor outcomes for residents.

Antihypertensive treatment in people with dementia

BACKGROUND The range and magnitude of potential benefits and harms of antihypertensive treatment in people with dementia has not been previously established. METHODS A scoping review to identify potential domains of benefits and harms of antihypertensive therapy in people with dementia was undertaken. Systematic reviews of these domains were undertaken to examine the magnitude of the benefits or harms. RESULTS Potential outcome domains identified in the 155 papers in the scoping review were cardiovascular events, falls, fractures and syncope, depression, orthostatic hypotension, behavioral disturbances, polypharmacy risks, kidney problems, sleep problems, interactions with cholinesterase inhibitors, and pain. The systematic reviews across these domains identified relatively few studies done in people with dementia, and no convincing evidence of safety, benefit, or harm across any of them. DISCUSSION Given the lack of firm evidence of benefits or harm from antihypertensive therapy in people with dementia and the weak evidence for benefits in people over 80 years of age, the current presumption that the favorable evidence drawn from the treatment of nondemented people should be extrapolated to those with dementia is contentious. There is sufficient evidence to warrant particular caution and further research into treatment in this group of patients.

A systematic mapping review of Randomized Controlled Trials (RCTs) in care homes

BackgroundA thorough understanding of the literature generated from research in care homes is required to support evidence-based commissioning and delivery of healthcare. So far this research has not been compiled or described. We set out to describe the extent of the evidence base derived from randomized controlled trials conducted in care homes.MethodsA systematic mapping review was conducted of the randomized controlled trials (RCTs) conducted in care homes. Medline was searched for “Nursing Home”, “Residential Facilities” and “Homes for the Aged”; CINAHL for “nursing homes”, “residential facilities” and “skilled nursing facilities”; AMED for “Nursing homes”, “Long term care”, “Residential facilities” and “Randomized controlled trial”; and BNI for “Nursing Homes”, “Residential Care” and “Long-term care”. Articles were classified against a keywording strategy describing: year and country of publication; randomization, stratification and blinding methodology; target of intervention; intervention and control treatments; number of subjects and/or clusters; outcome measures; and results.Results3226 abstracts were identified and 291 articles reviewed in full. Most were recent (median age 6 years) and from the United States. A wide range of targets and interventions were identified. Studies were mostly functional (44 behaviour, 20 prescribing and 20 malnutrition studies) rather than disease-based. Over a quarter focussed on mental health.ConclusionsThis study is the first to collate data from all RCTs conducted in care homes and represents an important resource for those providing and commissioning healthcare for this sector. The evidence-base is rapidly developing. Several areas - influenza, falls, mobility, fractures, osteoporosis – are appropriate for systematic review. For other topics, researchers need to focus on outcome measures that can be compared and collated.

The Association of Specific Executive Functions and Falls Risk in People with Mild Cognitive Impairment and Early-Stage Dementia

Background/Aims: Impairment in executive function is associated with a heightened risk for falls in people with mild cognitive impairment (MCI) and dementia. The purpose of this study was to determine which aspects of executive function are associated with falls risk. Methods: Forty-two participants with a mean age of 81.6 years and a diagnosis of MCI or mild dementia completed five different executive function tests from the computerised CANTAB test battery and a comprehensive falls risk assessment. Results: A hierarchical regression analysis showed that falls risk was significantly associated with spatial memory abilities and inhibition of a pre-potent response. Conclusion: The concept of executive function may be too general to provide meaningful results in a research or clinical context, which should focus on spatial memory and inhibition of a pre-potent response.

Paramedic Assessment of Older Adults After Falls, Including Community Care Referral Pathway: Cluster Randomized Trial

Study objective: We aim to determine clinical and cost‐effectiveness of a paramedic protocol for the care of older people who fall. Methods: We undertook a cluster randomized trial in 3 UK ambulance services between March 2011 and June 2012. We included patients aged 65 years or older after an emergency call for a fall, attended by paramedics based at trial stations. Intervention paramedics could refer the patient to a community‐based falls service instead of transporting the patient to the emergency department. Control paramedics provided care as usual. The primary outcome was subsequent emergency contacts or death. Results: One hundred five paramedics based at 14 intervention stations attended 3,073 eligible patients; 110 paramedics based at 11 control stations attended 2,841 eligible patients. We analyzed primary outcomes for 2,391 intervention and 2,264 control patients. One third of patients made further emergency contacts or died within 1 month, and two thirds within 6 months, with no difference between groups. Subsequent 999 call rates within 6 months were lower in the intervention arm (0.0125 versus 0.0172; adjusted difference –0.0045; 95% confidence interval –0.0073 to –0.0017). Intervention paramedics referred 8% of patients (204/2,420) to falls services and left fewer patients at the scene without any ongoing care. Intervention patients reported higher satisfaction with interpersonal aspects of care. There were no other differences between groups. Mean intervention cost was

Developing the principles of chair based exercise for older people: a modified Delphi study

23 per patient, with no difference in overall resource use between groups at 1 or 6 months. Conclusion: A clinical protocol for paramedics reduced emergency ambulance calls for patients attended for a fall safely and at modest cost.

Understanding the theoretical underpinning of the exercise component in a fall prevention programme for older adults with mild dementia: a realist review protocol

BackgroundChair based exercise (CBE) is suggested to engage older people with compromised health and mobility in an accessible form of exercise. A systematic review looking at the benefits of CBE for older people identified a lack of clarity regarding a definition, delivery, purpose and benefits. This study aimed to utilise expert consensus to define CBE for older people and develop a core set of principles to guide practice and future research.MethodsThe framework for consensus was constructed through a team workshop identifying 42 statements within 7 domains. A four round electronic Delphi study with multi-disciplinary health care experts was undertaken. Statements were rated using a 5 point Likert scale of agreement and free text responses. A threshold of 70% agreement was used to determine consensus. Free text responses were analysed thematically. Between rounds a number of strategies (e.g., amended wording of statements, generation and removal of statements) were used to move towards consensus.Results16 experts agreed on 46 statements over four rounds of consultation (Round 1: 22 accepted, 3 removed, 5 new and 17 modified; Round 2: 16 accepted, 0 removed, 4 new and 6 modified; Round 3: 4 accepted, 2 removed, 0 new and 4 modified; Round 4: 4 accepted, 0 removed, 0 new, 0 modified).Statements were accepted in all seven domains: the definition of CBE (5), intended users (3), potential benefits (8), structure (12), format (8), risk management (7) and evaluation (3).The agreed definition of CBE had five components: 1. CBE is primarily a seated exercise programme; 2. The purpose of using a chair is to promote stability in both sitting and standing; 3. CBE should be considered as part of a continuum of exercise for frail older people where progression is encouraged; 4. CBE should be used flexibly to respond to the changing needs of frail older people; and 5. Where possible CBE should be used as a starting point to progress to standing programmes.ConclusionsConsensus has been reached on a definition and a set of principles governing CBE for older people; this provides clarity for implementation and future research about CBE.

P492: Systematic review into motivational strategies that support adherence to exercise for people with mild cognitive impairment (MCI) or dementia

BackgroundOlder adults with mild dementia are at an increased risk of falls. Preventing those at risk from falling requires complex interventions involving patient-tailored strength- and balance-challenging exercises, home hazard assessment, visual impairment correction, medical assessment and multifactorial combinations. Evidence for these interventions in older adults with mild cognitive problems is sparse and not as conclusive as the evidence for the general community-dwelling older population. The objectives of this realist review are (i) to identify the underlying programme theory of strength and balance exercise interventions targeted at those individuals that have been identified as falling and who have a mild dementia and (ii) to explore how and why that intervention reduces falls in that population, particularly in the context of a community setting. This protocol will explain the rationale for using a realist review approach and outline the method.MethodsA realist review is a methodology that extends the scope of a traditional narrative or systematic evidence review. Increasingly used in the evaluation of complex interventions, a realist enquiry can look at the wider context of the intervention, seeking more to explain than judge if the intervention is effective by investigating why, what the underlying mechanism is and the necessary conditions for success. In this review, key rough programme theories were articulated and defined through discussion with a stakeholder group. The six rough programme theories outlined within this protocol will be tested against the literature found using the described comprehensive search strategy. The process of data extraction, appraisal and synthesis is outlined and will lead to the production of an explanatory programme theory.DiscussionAs far as the authors are aware, this is the first realist literature review within fall prevention research and adds to the growing use of this methodology within healthcare. This synthesis of evidence will provide a valuable addition to the evidence base surrounding the exercise component of a fall intervention programme for older adults with mild dementia and will ultimately provide clinically relevant recommendations for improving the care of people with dementia.Systematic review registrationPROSPERO CRD42015030169

Development of an evidence-based complex intervention for community rehabilitation of patients with hip fracture using realist review, survey and focus groups

Introduction: Physical exercise has a positive effect on cognitive functioning, mobility and activities of daily living in people with dementia (Forbes & al., 2013; Pitkala & al., 2013). Most exercise studies employ motivational strategies to support adherence to the exercise intervention but it is unclear how effective these strategies are. The purpose of this systematic literature review was to establish the range and effect of motivational strategies used in exercise studies for people with MCI and dementia. Method: Articles were identified from the following databases: CINAHL, EMBASE, MEDLINE, PsychINFO and Web of Science. Independently, a minimum of two authors assessed relevant articles based on in- and exclusion criteria. Studies using quantitative as well as qualitative methods to evaluate the effectiveness of motivational strategies were included. Results: The review analysed 28 articles that were identified to report the use of motivational strategies in exercise studies and partly evaluated their effectiveness. Employed strategies included supervision of sessions by instructors, caregivers or students, group settings, goal setting, exercise diaries, tailoring of programme, telephone calls and music. The effectiveness of strategies was only evaluated in a minority of the studies (use of group setting, goal setting and music). Discussion: Adherence to exercise intervention and continuation of the physical activity after completion of the intervention is an ongoing issue in exercise research. Given the limited evidence regarding the effectiveness of motivational strategies, tried and new strategies should be evaluated for people with MCI and dementia to ensure optimal support of physical exercise in this group.

A systematic mapping review of outdoor activities and mobility in care homes

Objectives To develop an evidence and theory-based complex intervention for improving outcomes in elderly patients following hip fracture. Design Complex-intervention development (Medical Research Council (MRC) framework phase I) using realist literature review, surveys and focus groups of patients and rehabilitation teams. Setting North Wales. Participants Surveys of therapy managers (n=13), community and hospital-based physiotherapists (n=129) and occupational therapists (n=68) throughout the UK. Focus groups with patients (n=13), their carers (n=4) and members of the multidisciplinary rehabilitation teams in North Wales (n=13). Results The realist review provided understanding of how rehabilitation interventions work in the real-world context and three programme theories were developed: improving patient engagement by tailoring the intervention to individual needs; reducing fear of falling and improving self-efficacy to exercise and perform activities of daily living; and coordination of rehabilitation delivery. The survey provided context about usual rehabilitation practice; focus groups provided data on the experience, acceptability and feasibility of rehabilitation interventions. An intervention to enhance usual rehabilitation was developed to target these theory areas comprising: a physical component consisting of six additional therapy sessions; and a psychological component consisting of a workbook to enhance self-efficacy and a patient-held goal-setting diary for self-monitoring. Conclusions A realist approach may have advantages in the development of evidence-based interventions and can be used in conjunction with other established methods to contribute to the development of potentially more effective interventions. A rehabilitation intervention was developed which can be tested in a future randomised controlled trial (MRC framework phases II and III). Trial registration number ISRCTN22464643, Pre-results.