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Background: Two accepted designs exist for parallel-group cluster-randomised trials (CRTs). Closed-cohort designs follow the same individuals over time with a single recruitment period before randomisation, but face challenges in settings with high attrition. (Repeated) cross-sectional designs recruit at one or more timepoints before and/or after randomisation, collecting data from different individuals present in the cluster at these timepoints, but are unsuitable for assessment of individual change over time. An 'open-cohort' design allows individual follow-up with recruitment before and after cluster-randomisation, but little literature exists on acceptability to inform their use in CRTs. Aim: To document the views and experiences of expert trialists to identify: a) Design and conduct challenges with established parallel-group CRT designs, b) Perceptions of potential benefits and barriers to implementation of open-cohort CRTs, c) Methods for minimising, and investigating the impact of, bias in open-cohort CRTs. Methods: Qualitative consultation via two expert workshops including triallists (n = 24) who had worked on CRTs over a range of settings. Workshop transcripts were analysed using Descriptive Thematic Analysis utilising inductive and deductive coding. Results: Two central organising concepts were developed. Design and conduct challenges with established CRT designs confirmed that current CRT designs are unable to deal with many of the complex research and intervention circumstances found in some trial settings (e.g. care homes). Perceptions of potential benefits and barriers of open cohort designs included themes on: approaches to recruitment; data collection; analysis; minimising/investigating the impact of bias; and how open-cohort designs might address or present CRT design challenges. Open-cohort designs were felt to provide a solution for some of the challenges current CRT designs present in some settings. Conclusions: Open-cohort CRT designs hold promise for addressing the challenges associated with standard CRT designs. Research is needed to provide clarity around definition and guidance on application. [ABSTRACT FROM AUTHOR]

The aim was to provide evidence of mortality and community care costs of people living in care homes and to investigate its association with mental health based on the Mental Health Clustering Tool (MHCT). In an observational study, 5,782 residents living in 104 care homes were followed from 2014 to 2016. Residents were categorised into four groups using the MCHT: three with mental health conditions, 'non-psychotic', 'psychotic' or 'organic'; and one without mental health conditions, 'non-clustered'. Generalised estimating equations were used to explore associations between mean community care costs over 6 months per patient and the clustering of residents into the four groups. Differences in survival rates of residents were plotted using Kaplan–Meier curves and tested with the log-rank test and Cox regression analysis. Community care costs were similar among residents with dementia (£431) and without mental health conditions (£407), while costs were higher among residents with non-psychotic (£762) and psychotic (£1,724) mental health conditions. After adjusting for patient and care home characteristics, residents with dementia were 30 per cent less likely to die compared with residents without mental health conditions. Similarly, residents with psychotic conditions and residents with non-psychotic conditions were 25 and 20 per cent less likely to die, respectively, than residents without mental health conditions. The MHCT seems to provide an informative stratification of care home residents with regards to survival and community care use. [ABSTRACT FROM AUTHOR]

Agitation is common and problematic in care home residents with dementia. This study investigated the (cost)effectiveness of Dementia Care Mapping™ (DCM) for reducing agitation in this population. Pragmatic, cluster randomised controlled trial with cost-effectiveness analysis in 50 care homes, follow-up at 6 and 16 months and stratified randomisation to intervention (n = 31) and control (n = 19). Residents with dementia were recruited at baseline (n = 726) and 16 months (n = 261). Clusters were not blinded to allocation. Three DCM cycles were scheduled, delivered by two trained staff per home. Cycle one was supported by an external DCM expert. Agitation (Cohen-Mansfield Agitation Inventory (CMAI)) at 16 months was the primary outcome. DCM was not superior to control on any outcomes (cross-sectional sample n = 675: 287 control, 388 intervention). The adjusted mean CMAI score difference was –2.11 points (95% CI –4.66 to 0.44, p = 0.104, adjusted ICC control = 0, intervention 0.001). Sensitivity analyses supported the primary analysis. Incremental cost per unit improvement in CMAI and QALYs (intervention vs control) on closed-cohort baseline recruited sample (n = 726, 418 intervention, 308 control) was £289 and £60,627 respectively. Loss to follow-up at 16 months in the original cohort was 312/726 (43·0%) mainly (87·2%) due to deaths. Intervention dose was low with only a quarter of homes completing more than one DCM cycle. No benefits of DCM were evidenced. Low intervention dose indicates standard care homes may be insufficiently resourced to implement DCM. Alternative models of implementation, or other approaches to reducing agitation should be considered. [ABSTRACT FROM AUTHOR]

Objectives: This study explored the experiences of a range of health and social care professionals employed in the role of trainer/coaches to support care home staff to implement a psychosocial intervention for residents living with dementia. It aimed to identify the factors which are pertinent to these roles, in the context of a cascade model of training. Method: A focus group was convened involving dementia trainer/coaches and supervisors who had worked on Well-being and Health for people with Dementia randomised control trial. Twelve participants explored their preparedness for and experiences of their role as 'Well-being and Health for people with Dementia therapists'. They reflected on their perceptions of the resources and support required. The data were transcribed verbatim and subjected to inductive thematic analysis. Results: Three main themes emerged from the data. Within the theme of 'skills in relationship building' were two subthemes of developing trust and getting to know individual staff and each care home. In the second main theme of 'making use of tangible resources' two subthemes relating to using the Well-being and Health for people with Dementia manuals and the supervision of the therapists arose. The third theme, 'being an agent for change' contained three subthemes: effective training methods, creating opportunities for Dementia Champions to reflect and therapists' perceived rewards of their role. Conclusion: The findings provide new insights into the trainer/coach role applicable to the practices of services recruiting, training and providing ongoing professional support to practitioners in-reaching into care homes. [ABSTRACT FROM AUTHOR]

Objectives: To contribute to improvements in the design and delivery of intervention research in care homes by adopting a collaborative approach that listens to the experiences of care home staff who had participated in a clinical trial aimed at optimising and evaluating a psychosocial intervention package for people with dementia. Methods: Qualitative study involving focus group discussions (FGDs) involving 41 staff across 6 care homes with the UK. Inductive thematic analysis was used to identify themes and interpret the data. Results: Three overarching themes emerged as influential: Recognising preparedness; working together and learning more than expected. The findings highlighted the need to be attentive in addressing staff expectations, the value of sustained relationships and recognition of good practice. The FGDs also identified areas of unanticipated learning that staff and managers adopted. Conclusions: The FGDs showed the importance of considering the overall experience of care home staff who are involved in research and the importance of valuing the skills and experience they hold through positive affirmation. There are often unanticipated consequences of research involvement both on staff practice and on relationships which if promoted could help sustain effective ways of working together. [ABSTRACT FROM AUTHOR]

Background: Psychosocial interventions offer opportunities to improve care for people with dementia in care homes. However, implementation is often led by staff who are not well prepared for the role. Some interventions use external experts to support staff. However little is known about external expert, care home staff and manager perceptions of such support. This paper addresses this gap.Methods: Multi-methods study within a process evaluation of a cluster randomised controlled trial of Dementia Care Mapping™ (DCM). Interviews were conducted with six external experts who also completed questionnaires, 17 care home managers and 25 care home staff responsible for DCM implementation. Data were analysed using descriptive statistics and template analysis.Results: Three themes were identified: the need for expert support, practicalities of support and broader impacts of providing support. Expert support was vital for successful DCM implementation, although the five-days provided was felt to be insufficient. Some homes felt the support was inflexible and did not consider their individual needs. Practical challenges of experts being located at a geographical distance from the care homes, limited when and how support was available. Experts gained knowledge they were able to then apply in delivering DCM training. Experts were not able to accurately predict which homes would be able to implement DCM independently in future cycles.Conclusions: An external expert may form a key component of successful implementation of psychosocial interventions in care home settings. Future research should explore optimal use of the expert role. [ABSTRACT FROM AUTHOR]

Purpose: The purpose of this paper is to report on a service evaluation of a competency-based dementia training programme for clinicians to establish its value in improving their knowledge and confidence of dementia care and to explore any resulting changes to practice. Design/methodology/approach: Mixed method quantitative and qualitative data, using rating scales and focus group discussions (FGDs), were collected. Wilcoxon signed-rank test was used to analyse changes in the responses to the rating scales of knowledge and confidence and thematic analysis of FGDs was undertaken to identify staff perceptions of the impact of training on their practice. Findings: In total, 162 qualified and clinical support staff undertook the training. A significant change in knowledge and confidence scores was found on all three scales. In general, feedback on the course was positive. Seven themes, demonstrating the relevance of the training to practice, emerged from the FGDs – experiential training awareness of diagnosis, approach, understanding, communication, risk, changed practice and going forward. Practical implications: Providing competency-based dementia training for large numbers of staff can have a positive effect on the care delivered to patients with dementia. Originality/value: Healthcare organisations have a responsibility to ensure their staff have the training to provide quality care for patients living with dementia. This paper suggests this can be achieved through a collaborative, multi-disciplinary approach involving co-production and best practice guidance. [ABSTRACT FROM AUTHOR]

Objectives: The study aims to understand the factors that care home staff felt enabled or hindered them in continuing to use the well-being and health for people with dementia (WHELD) psychosocial approach in their care home and investigate whether there was sustained activity 9 to 12 months after the study ended.Methods: This qualitative study is part of a wider clinical trial, which demonstrated effectiveness of a psychosocial intervention on quality of life outcomes and neuropsychiatric symptoms for residents. Forty-seven care home staff within nine care homes in the United Kingdom participated in focus groups, between 9 and 12 months after the intervention had finished. Inductive thematic analysis was used to identify themes and interpret the data.Results: The findings highlighted that staff continued to use a range of activities and processes acquired through the research intervention, after the study had ended. Three overarching themes were identified as influential: "recognising the value" of the approach for residents and staff, "being well practiced" with sufficient support and opportunity to consolidate skills prior to the withdrawal of the researchers, and "taking ownership of the approach" to incorporate it as usual care.Conclusions: The WHELD approach can be sustained where the value of the approach is recognised, and sufficient support is provided during initial implementation for staff to build skills and confidence for it to become routine care. Further follow-up is required to understand longer term use and the impact for residents. [ABSTRACT FROM AUTHOR]

Perceived self-efficacy is proposed to impact on the psychological health of dementia care staff. The current study adopted a qualitative methodology to increase understanding of the experiences of self-efficacious care assistants. Purposive sampling identified eight care assistants with high levels of self-efficacy. Data from semi-structured interviews were analysed using interpretative phenomenological analysis. Four themes captured experiences of 'feeling torn' between competing demands when providing care; a sense of 'togetherness and connection', included sub-themes of support, closeness and the value of engaging; 'emotional attunement' to resident's needs, including reciprocity of emotion, personal perspective-taking and empathy as guides to care. The final theme, 'caring as a part of life', described interest, motivation and accepting attitudes as well as caring being part of carers' identity. The themes highlight how staff might manage the dilemmas they face and emphasize important areas for care staff training as well as further research. [ABSTRACT FROM AUTHOR]

Objectives: Carers of people with dementia face barriers in accessing therapy for mental health difficulties. Computerised cognitive behavioural therapy (cCBT) packages can be effective in treating a range of presentations; however, tailored packages for carers' unique needs are lacking. Our aim was to design a cCBT package for carers to address the limitations of previous online interventions, by including users and experts as consultants and collaborators throughout the project. Method: We adopted a three-phase approach to the development process. Firstly, a data-gathering phase in which current literature and best practice was reviewed, and semi-structured interviews conducted with service users, academic and clinical experts. Secondly, a co-production and refinement phase with carers testing materials and providing feedback. Thirdly, a pilot field testing phase of service users and the research team testing the package. Results: The 'Caring For Me and You' package adopted a transdiagnostic approach to take account of the range of difficulties that carers face. The package consisted of 20 short sessions with features built in to engage users and personalise content to meet individuals' needs. Conclusion: User involvement was central to the design of the 'Caring For Me and You' package which is currently being evaluated in a three-arm randomised controlled trial. [ABSTRACT FROM AUTHOR]

Background: Agitation is a common, challenging symptom affecting large numbers of people with dementia and impacting on quality of life (QoL). There is an urgent need for evidence-based, cost-effective psychosocial interventions to improve these outcomes, particularly in the absence of safe, effective pharmacological therapies. This study aimed to evaluate the efficacy of a person-centred care and psychosocial intervention incorporating an antipsychotic review, WHELD, on QoL, agitation, and antipsychotic use in people with dementia living in nursing homes, and to determine its cost.Methods and Findings: This was a randomised controlled cluster trial conducted between 1 January 2013 and 30 September 2015 that compared the WHELD intervention with treatment as usual (TAU) in people with dementia living in 69 UK nursing homes, using an intention to treat analysis. All nursing homes allocated to the intervention received staff training in person-centred care and social interaction and education regarding antipsychotic medications (antipsychotic review), followed by ongoing delivery through a care staff champion model. The primary outcome measure was QoL (DEMQOL-Proxy). Secondary outcomes were agitation (Cohen-Mansfield Agitation Inventory [CMAI]), neuropsychiatric symptoms (Neuropsychiatric Inventory-Nursing Home Version [NPI-NH]), antipsychotic use, global deterioration (Clinical Dementia Rating), mood (Cornell Scale for Depression in Dementia), unmet needs (Camberwell Assessment of Need for the Elderly), mortality, quality of interactions (Quality of Interactions Scale [QUIS]), pain (Abbey Pain Scale), and cost. Costs were calculated using cost function figures compared with usual costs. In all, 847 people were randomised to WHELD or TAU, of whom 553 completed the 9-month randomised controlled trial. The intervention conferred a statistically significant improvement in QoL (DEMQOL-Proxy Z score 2.82, p = 0.0042; mean difference 2.54, SEM 0.88; 95% CI 0.81, 4.28; Cohen's D effect size 0.24). There were also statistically significant benefits in agitation (CMAI Z score 2.68, p = 0.0076; mean difference 4.27, SEM 1.59; 95% CI -7.39, -1.15; Cohen's D 0.23) and overall neuropsychiatric symptoms (NPI-NH Z score 3.52, p < 0.001; mean difference 4.55, SEM 1.28; 95% CI -7.07,-2.02; Cohen's D 0.30). Benefits were greatest in people with moderately severe dementia. There was a statistically significant benefit in positive care interactions as measured by QUIS (19.7% increase, SEM 8.94; 95% CI 2.12, 37.16, p = 0.03; Cohen's D 0.55). There were no statistically significant differences between WHELD and TAU for the other outcomes. A sensitivity analysis using a pre-specified imputation model confirmed statistically significant benefits in DEMQOL-Proxy, CMAI, and NPI-NH outcomes with the WHELD intervention. Antipsychotic drug use was at a low stable level in both treatment groups, and the intervention did not reduce use. The WHELD intervention reduced cost compared to TAU, and the benefits achieved were therefore associated with a cost saving. The main limitation was that antipsychotic review was based on augmenting processes within care homes to trigger medical review and did not in this study involve proactive primary care education. An additional limitation was the inherent challenge of assessing QoL in this patient group.Conclusions: These findings suggest that the WHELD intervention confers benefits in terms of QoL, agitation, and neuropsychiatric symptoms, albeit with relatively small effect sizes, as well as cost saving in a model that can readily be implemented in nursing homes. Future work should consider how to facilitate sustainability of the intervention in this setting.Trial Registration: ISRCTN Registry ISRCTN62237498. [ABSTRACT FROM AUTHOR]

Objectives: To examine the cost of care for people with dementia in institutional care settings, to understand the major cost drivers and to highlight opportunities for service development.Methods: Data on 277 residents with dementia in 16 UK residential or nursing homes were collected. We estimated care and support costs and fitted models to the data. Sensitivity analyses were also conducted.Results: Care home residents cost £792 weekly: 95% of the costs accounted for by direct fees. Hospital contacts contributed the largest proportion of the additional costs. Having an established diagnosis of dementia (b = 0.070; p < 0.05) was associated with higher costs. No association was found between cost and needs (b = -0.002; p = 0.818).Conclusion: The absence of an association between cost and needs emphasizes the importance of a more needs-based costing system which could result in clinical and economic advantages. Copyright © 2016 John Wiley & Sons, Ltd. [ABSTRACT FROM AUTHOR]

Background: Very few interventional studies have directly examined the impact of treatment approaches on health-related quality of life (HRQL) in people with dementia. This is of particular importance in therapies to address behavioural symptoms, where HRQL is often severely affected.Methods: Analysis within the WHELD cluster randomised factorial study in 16 UK care homes examining the impact of person-centred care in combination with antipsychotic review, social interaction and exercise interventions. This study analysed impact on HRQL through the DEMQOL-Proxy.Results: Data on HRQL were available for 187 participants. People receiving antipsychotic review showed a significant worsening in two DEMQOL-Proxy domains (negative emotion: p = 0.02; appearance: p = 0.04). A best-case scenario analysis showed significant worsening for total DEMQOL-Proxy score. Social interaction intervention resulted in a significant benefit to HRQL (p = 0.04). There was no deterioration in HRQL in groups receiving both antipsychotic review and social interaction (p = 0.62).Conclusions: This demonstrates an important detrimental impact of discontinuation of antipsychotics in dementia on HRQL, highlighting the need for careful review of best practice guidelines regarding antipsychotic use and emphasising the importance of providing evidence-based non-pharmacological interventions in conjunction with antipsychotic review. Copyright © 2016 John Wiley & Sons, Ltd. [ABSTRACT FROM AUTHOR]

Objectives:This paper reports on the acceptability and effectiveness of the FITS (Focussed Intervention Training and Support) into Practice Programme. This intervention was scaled up from an earlier cluster randomised-controlled trial that had proven successful in significantly decreasing antipsychotic prescribing in care homes. Method:An in depth 10-day education course in person-centred care was delivered over a three-month period, followed by six supervision sessions. Participants were care-home staff designated as Dementia Care Coaches (DCCs) responsible for implementing interventions in 1 or 2 care homes. The course and supervision was provided by educators called Dementia Practice Development Coaches (DPDCs). Effectiveness data included monitoring antipsychotic prescriptions, goal attainment, knowledge, attitudes and implementation questionnaires. Qualitative data included case studies and reflective journals to elucidate issues of implementation. Results:Of the 100 DCCs recruited, 66 DCCs completed the programme. Pre-post questionnaires demonstrated increased knowledge and confidence and improved attitudes to dementia. Twenty per cent of residents were prescribed antipsychotics at baseline which reduced to 14% (31% reduction) with additional dose reductions being reported alongside improved personalised goal attainment. Crucial for FITS into Practice to succeed was the allocation and protection of time for the DCC to attend training and supervision and to carry out implementation tasks in addition to their existing job role. Evaluation data showed that this was a substantial barrier to implementation in a small number of homes. Discussion and conclusions:The FITS into practice programme was well evaluated and resulted in reduction in inappropriate anti-psychotic prescribing. Revisions to the intervention are suggested to maximise successful implementation. [ABSTRACT FROM PUBLISHER]

Background: Up to 90 % of people living with dementia in care homes experience one or more behaviours that staff may describe as challenging to support (BSC). Of these agitation is the most common and difficult to manage. The presence of agitation is associated with fewer visits from relatives, poorer quality of life and social isolation. It is recommended that agitation is treated through psychosocial interventions. Dementia Care Mapping™ (DCM™) is an established, widely used observational tool and practice development cycle, for ensuring a systematic approach to providing person-centred care. There is a body of practice-based literature and experience to suggests that DCM™ is potentially effective but limited robust evidence for its effectiveness, and no examination of its cost-effectiveness, as a UK health care intervention. Therefore, a definitive randomised controlled trial (RCT) of DCM™ in the UK is urgently needed.Methods/design: A pragmatic, multi-centre, cluster-randomised controlled trial of Dementia Care Mapping (DCM™) plus Usual Care (UC) versus UC alone, where UC is the normal care delivered within the care home following a minimum level of dementia awareness training. The trial will take place in residential, nursing and dementia-specialist care homes across West Yorkshire, Oxfordshire and London, with residents with dementia. A random sample of 50 care homes will be selected within which a minimum of 750 residents will be registered. Care homes will be randomised in an allocation ratio of 3:2 to receive either intervention or control. Outcome measures will be obtained at 6 and 16 months following randomisation. The primary outcome is agitation as measured by the Cohen-Mansfield Agitation Inventory, at 16 months post randomisation. Key secondary outcomes are other BSC and quality of life. There will be an integral cost-effectiveness analysis and a process evaluation.Discussion: The protocol was refined following a pilot of trial procedures. Changes include replacement of a questionnaire, whose wording caused some residents distress, to an adapted version specifically designed for use in care homes, a change to the randomisation stratification factors, adaption in how the staff measures are collected to encourage greater compliance, and additional reminders to intervention homes of when mapping cycles are due, via text message.Trial Registration: Current Controlled Trials ISRCTN82288852 . Registered on 16 January 2014. Full protocol version and date: v7.1: 18 December 2015. [ABSTRACT FROM AUTHOR]

Objective: This study evaluated the impact of antipsychotic review, social interaction, and exercise, in conjunction with person-centered care, on antipsychotic use, agitation, and depression in people with dementia living in nursing homes.Method: A cluster-randomized factorial controlled trial with two replications was conducted in people with dementia in 16 U.K. nursing homes. All homes received training in person-centered care. Eight homes were randomly assigned to antipsychotic review, to a social interaction intervention, and to an exercise intervention for 9 months, with most homes assigned to more than one intervention. The primary outcome measures were antipsychotic use, agitation, and depression. Secondary outcome measures were overall neuropsychiatric symptoms and mortality.Results: Antipsychotic review significantly reduced antipsychotic use by 50% (odds ratio 0.17, 95% confidence interval [CI] 0.05 to 0.60). Antipsychotic review plus the social interaction intervention significantly reduced mortality (odds ratio 0.26, 95% CI 0.13 to 0.51) compared with the group receiving neither. The group receiving antipsychotic review but not the social intervention showed significantly worse outcome in neuropsychiatric symptoms compared with the group receiving neither (score difference +7.37, 95% CI 1.53 to 13.22). This detrimental impact was mitigated by concurrent delivery of the social intervention (-0.44, CI -4.39 to 3.52). The exercise intervention significantly improved neuropsychiatric symptoms (-3.59, 95% CI -7.08 to -0.09) but not depression (-1.21, CI -4.35 to 1.93). None of the interventions had a significant impact specifically on agitation.Conclusions: While reductions in antipsychotic use can be achieved by using a "real world" intervention, this may not be of benefit to people with dementia in the current climate of more judicious prescribing unless nonpharmacological interventions such as social interaction or exercise are provided in parallel. [ABSTRACT FROM AUTHOR]

Objective: To contribute to an optimised training programme for care staff that supports the implementation of evidence-based psychosocial interventions in long-term care.Methods: Qualitative study that involved focus group discussions with 119 care home staff within 16 care homes in the UK. Part of wider clinical trial aimed at developing and evaluating an effective and practical psychosocial intervention and implementation approach for people with dementia in long-term care. Inductive thematic analysis was used to identify themes and interpret the data.Results: The findings highlighted that successful training and support interventions must acknowledge and respond to 'whole home' issues. Three overarching themes emerged as influential: the importance of contextual factors such as staff morale, interpersonal relationships within the home, and experience and perceived value of the proposed intervention.Conclusions: Priority must be given to obtain the commitment of all staff, management and relatives to the training programme and ensure that expectations regarding interaction with residents, participation in activities and the reduction of medication are shared across the care home. [ABSTRACT FROM AUTHOR]

Objective The overall objective is to determine the availability of person-centred intervention and training manuals for dementia care staff with clinical trial evidence of efficacy. Design Interventions were identified using a search of electronic databases, augmented by mainstream search engines, reference lists, hand searching for resources and consultation with an expert panel. The specific search for published manuals was complemented by a search for randomised control trials focussing on training and activity-based interventions for people with dementia in care homes. Manuals were screened for eligibility and rated to assess their quality, relevance and feasibility. Results A meta-analysis of randomised control trials indicated that person-centred training interventions conferred significant benefit in improving agitation and reducing the use of antipsychotics. Each of the efficacious packages included a sustained period of joint working and supervision with a trained mental health professional in addition to an educational element. However, of the 170 manuals that were identified, 30 met the quality criteria and only four had been evaluated in clinical trials. Conclusions Despite the availability of a small number of evidence-based training manuals, there is a widespread use of person-centred intervention and training manuals that are not evidence-based. Clearer guidance is needed to ensure that commissioned training and interventions are based on robust evidence. Copyright © 2014 John Wiley & Sons, Ltd. [ABSTRACT FROM AUTHOR]

Background: People with dementia living in care homes often have complex mental health problems, disabilities and social needs. Providing more comprehensive training for staff working in care home environments is a high national priority. It is important that this training is evidence based and delivers improvement for people with dementia residing in these environments. Well-being and Health for People with Dementia (WHELD) combines the most effective elements of existing approaches to develop a comprehensive but practical staff training intervention. This optimised intervention is based on a factorial study and qualitative evaluation, to combine: training on person-centred care, promoting person-centred activities and interactions, and providing care home staff and general practitioners with updated knowledge regarding the optimal use of psychotropic medications for persons with dementia in care homes. Design: The trial will be a randomised controlled two-arm cluster single blind trial that will take place for nine months across 80 care homes in the United Kingdom. Discussion: The overarching goal of this trial is to determine whether this optimised WHELD intervention is more effective in improving the quality of life and mental health than the usual care provided to people with dementia living in nursing homes. This study will be the largest and best powered randomised controlled trial (RCT) evaluating the benefits of an augmented person-centred care training intervention in care homes worldwide. [ABSTRACT FROM AUTHOR]

Background:Several important systematic reviews and meta-analyses focusing on psychosocial interventions have been undertaken in the last decade. However, they have not focused specifically on the treatment of individual behavioral and psychological symptoms of dementia (BPSD) with personalized interventions. This updated systematic review will focus on studies reporting the effect of personalized psychosocial interventions on key BPSD in care homes.Methods:Systematic review of the evidence for psychosocial interventions for BPSD, focusing on papers published between 2000 and 2012. All care home and nursing home studies including individual and cluster randomized controlled trials (RCTs) and pre-/post-test studies with control conditions were included.Results:641 studies were identified, of which 40 fulfilled inclusion and exclusion criteria. There was good evidence to support the value of personalized pleasant activities with and without social interaction for the treatment of agitation, and reminiscence therapy to improve mood. The evidence for other therapies was more limited.Conclusions:There is a growing body of evidence indicating specific effects of different personalized psychosocial interventions on individual BPSD and mood outcomes. [ABSTRACT FROM PUBLISHER]

Objective:The aims of the study were to report on the development and evaluation of a staff training intervention in dementia care designed for use in the general hospital setting: the ‘Getting to Know Me’ training programme. The study also aimed to undertake initial psychometric analysis on two new outcome scales designed to measure knowledge and confidence in dementia care.Methods:The study comprised two phases. The first phase comprised the design of two questionnaires which are shared within this paper: Confidence in Dementia (CODE) Scale and Knowledge in Dementia (KIDE) Scale. In phase two, staff undertook the ‘Getting to Know Me’ training programme (n= 71). The impact of the programme was evaluated using a pre–post design which explored: (1) changes in confidence in dementia; (2) changes in knowledge in dementia; and (3) changes in beliefs about challenging behaviour.Results:The psychometric properties of the CODE and KIDE scales are reported. Statistically significant change was identified pre–post training on all outcome measures. Clinically meaningful change was demonstrated on the CODE scale.Conclusions:The ‘Getting to Know Me’ programme was well received and had a significant impact on staff knowledge and confidence. Our findings add to a growing evidence base which will be strengthened by further robust studies, the exploration of the impact of staff training on direct patient outcomes, and further identification of ways in which to transfer principles of care from specialist dementia environments into general hospital settings. [ABSTRACT FROM AUTHOR]

Objective:The aims of the study were to report on the development and evaluation of a staff training intervention in dementia care designed for use in the general hospital setting: the ‘Getting to Know Me’ training programme. The study also aimed to undertake initial psychometric analysis on two new outcome scales designed to measure knowledge and confidence in dementia care.Methods:The study comprised two phases. The first phase comprised the design of two questionnaires which are shared within this paper: Confidence in Dementia (CODE) Scale and Knowledge in Dementia (KIDE) Scale. In phase two, staff undertook the ‘Getting to Know Me’ training programme (n= 71). The impact of the programme was evaluated using a pre–post design which explored: (1) changes in confidence in dementia; (2) changes in knowledge in dementia; and (3) changes in beliefs about challenging behaviour.Results:The psychometric properties of the CODE and KIDE scales are reported. Statistically significant change was identified pre–post training on all outcome measures. Clinically meaningful change was demonstrated on the CODE scale.Conclusions:The ‘Getting to Know Me’ programme was well received and had a significant impact on staff knowledge and confidence. Our findings add to a growing evidence base which will be strengthened by further robust studies, the exploration of the impact of staff training on direct patient outcomes, and further identification of ways in which to transfer principles of care from specialist dementia environments into general hospital settings. [ABSTRACT FROM PUBLISHER]

Background: People living in care homes often have complex mental and physical health problems, disabilities and social needs which are compounded by the use of psychiatric and other drugs. In the UK dementia care is a national priority with a vast impact on services. WHELD combines the most effective elements of existing approaches to develop a comprehensive but practical intervention. This will be achieved by training care staff to provide care that is focused on an understanding of the individual and their needs; and by using additional components such as exercise, activities and social interaction to improve mental health and quality of life (QoL) and reduce the use of sedative drugs. Design: Work Package 3 (WP3) is the pilot randomised trial and qualitative evaluation to help develop a future definitive randomised controlled clinical trial. The study design is a cluster randomised 2x2x2 factorial design with two replications in 16 care homes. Each care home is randomized to receive one of the eight possible permutations of the four key interventions, with each possible combination delivered in two of the 16 homes. Each cluster includes a minimum of 12 participants (depending upon size of the care home, the number of people with dementia and the number consenting). Discussion: The overarching goal of the programme is to provide an effective, simple and practical intervention which improves the mental health of, and reduces sedative drug use in, people with dementia in care homes and which can be implemented nationally in all UK care homes as an NHS intervention. [ABSTRACT FROM AUTHOR]

Background Psychosocial interventions can improve behaviour and mood in people with dementia, but it is unclear how to maximise their effectiveness or acceptability in residential settings. Aims To understand what underlies the successful implementation of psychosocial interventions in care homes. Method Systematic review and meta-synthesis of qualitative research. Results The synthesis of 39 qualitative papers revealed that beneficial psychosocial interventions met the needs of people with dementia to connect with others, make a meaningful contribution and reminisce. Successful implementation rested on the active engagement of staff and family and the continuing provision of tailored interventions and support. This necessitated staff time, and raised issues around priorities and risk, but ultimately helped redefine staff attitudes towards residents and the caregiving role. Conclusions The findings from the meta-synthesis can help to inform the development and evaluation of psychosocial interventions in care homes and support their widespread implementation in clinical settings. [ABSTRACT FROM AUTHOR]

Background There are a paucity of validated measures focusing on quality of life for people with dementia in care facilities. Method The current study evaluated the internal consistency of Dementia Care Mapping (DCM) in a group of 123 people with dementia residing in care facilities and further evaluated the test retest reliability and concurrent validity of key DCM constructs in an additional group of 54 residents. Results The results show good internal consistency. Well–ill being score was significantly correlated with an informant rated quality of life measure (r = 0.73, p < 0.0001) and showed good test retest reliability (r = 0.55, p < 0.0001). An abbreviated assessment period focusing on the hour before lunch showed significant correlation with the total assessment period (well–ill being score r = 0.5, p = 0.02). Conclusion The current study indicates that DCM is a valid tool for the longitudinal evaluation of quality of life in people with dementia in care settings and that some abbreviation of the method may facilitate its use more widely. Copyright © 2002 John Wiley & Sons, Ltd. [ABSTRACT FROM AUTHOR]

Investigates the role of vision in the encoding and reproduction of movement. Comparison of kinesthetic reproductions of a kinesthetically presented two-dimensional movement with reproductions where vision was present either during the standard or at reproduction; Findings that the presence of vision during the standard resulted in poorer accuracy and greater underestimation of movement size that when it was absent.

Objective To evaluate the effectiveness of a training and support intervention for nursing home staff in reducing the proportion of residents with dementia who are prescribed neuroleptics. Design Cluster randomised controlled trial with blinded assessment of outcome. Setting 12 specialist nursing homes for people with dementia in London, Newcastle, and Oxford. Participants Residents of the 12 nursing homes; numbers varied during the study period. Intervention Training and support intervention delivered to nursing home staff over 10 months, focusing on alternatives to drugs for the management of agitated behaviour in dementia. Main outcome measures Proportion of residents in each home who were prescribed neuroleptics and mean levels of agitated and disruptive behaviour (Cohen-Mansfield agitation inventory) in each home at 12 months. Results At 12 months the proportion of residents taking neuroleptics in the intervention homes (23.0%) was significantly lower than that in the control homes (42.1%): average reduction in neuroleptic use 19.1% (95% confidence interval 0.5% to 37.7%). No significant differences were found in the levels of agitated or disruptive behaviour between intervention and control homes. Conclusions Promotion of person centred care and good practice in the management of patients with dementia with behavioural symptoms provides an effective alternative to neuroleptics. [ABSTRACT FROM AUTHOR]

Background: Multi-morbidity is an increasing threat to population health and healthcare systems. A high proportion of people living in care homes have dementia, mental illness and/or physical frailty. Thus, this population has high and complex care needs, which require substantial healthcare expenditure. Intervention: An Integrated Care Home Support Service (CHSS) in Oxfordshire, England, combined two evidence based approaches to deliver a stepped care and treatment to meet both physical and mental health needs, called the BRIghTER DAWN programme. These evidenced based approaches trained staff to deliver Dementia Assessment of Wellbeing and Needs (DAWN) and/or a personalised intervention focusing on Building Relationships and Individually Tailored Evaluation and Responses (BRIghTER). Methods: Different data sources and methods were combined in this observational study to perform an economic evaluation of the CHSS. Individual patient data (IPD) on two-year community care utilisation and time alive since admission to a care home were used to calculate community care costs and Life Years (LYs) per patient. Mahalanobis one-to-one propensity score matching (PSM) was used to match 443 residents who received DAWN and/or BrighTER with residents from a control cohort of 5,339 residents with respect to community care costs at baseline, date admitted to a care home, date of birth, mental health cluster codes, gender, and care home. Multiple imputation by predictive mean matching was used to impute missing observations in community care cost at baseline. To reduce remaining confounding, 5,000 bootstrapped samples were generated from the paired dataset and for each one, Generalised Linear Models were specified to estimate incremental community care costs and incremental Lys adjusting for confounders. Difference-in-differences analysis supplemented with inverse probability weighting for propensity score matching was performed to estimate incremental non-elective hospital costs based. A decision model was built to combine the incremental costs and effects from the two different analyses to estimate costs per LY gained and to perform probabilistic sensitivity analysis. Uncertainty was displayed in cost-effectiveness acceptability curves. Results: The CHSS resulted to £575 higher costs and 0.04 more Lys than usual care resulting to an ICER of £13,886, which is considered to be cost-effective under conventional NICE thresholds (i.e. £20,000-£30,000). Looking at the interventions separately, DAWN was even more cost-effective (ICER=£2,081), while DAWN was less cost-effective (ICER=14,837) but still under NICE's threshold. The probability of the interventions to be cost-effective at £20.000 ceiling ration was more than 80%. Discussion: This study demonstrated a series of methods to be used by health economists when dealing with Murphy's law in the economic evaluation of complex interventions. Conclusion: The Integrated Care Home Support Service implemented in Oxfordshire was very likely to be cost-effective. [ABSTRACT FROM AUTHOR]

Introduction: There are 35 million people with dementia worldwide, many of whom live in care homes. For example, in the UK one third of people with dementia live in care home facilites, and a large proportion of these individuals have moderate or severe dementia and have highly complex care needs. An Integrated Care Home Support Service adopted a stepped care model to deliver care and treatment of both physical and mental health problems with the aim of early identification of need. A qualitative study formed part of the overall evaluation of the project and presents an opportunity to enhance understanding of factors which are important to implementing integrated health care initiatives and to determine their impact and sustainability in a routine NHS setting. Methods: Eight focus groups were conducted with a range of stakeholders including Care Home Support Service staff, care homes staff, community physical and mental health teams in the NHS as well as a public and patient involvement group. A total of 39 stakeholders participated in the focus groups to explore their experience of the service, their perception of its impact as well as areas of further development. Results: Thematic analysis identified three key themes. The first theme highlighted the challenges of, and factors to consider when, implementing new models in the care home setting. The second theme reflected the importance of relationship building with stakeholders both outside of the NHS as well as within the organisation. The final theme highlighted the continuing needs of stakeholders including the importance of providing them with training and sharing knowledge. Discussion: There was consistency between the groups regarding the challenges of working into care homes. Whilst CHSS staff, care home staff and NHS teams all recognised the importance of relationship building when implementing services, views of these relationships as well as areas for development differed and needs to form part of project planning. The feasibility of creating more holistic care services was confirmed and the need for on-going review and training to respond to evolving cultural changes was highlighted. Conclusion: This qualitative evaluation with a broad range of stakeholders highlights a number of areas to consider when implementing a model of integrated care in care home settings. [ABSTRACT FROM AUTHOR]

Introduction: A high proportion of people living in care homes have dementia, mental illness and/or physical frailty. An Integrated Care Home Support Service (CHSS) combined two evidence based approaches to deliver a stepped care and treatment to meet both physical and mental health needs, called the BRIghTER DAWN programme. These evidenced based approaches trained staff to deliver Dementia Assessment of Wellbeing and Needs (DAWN) and/or a personalised intervention focusing on Building Relationships and Individually Tailored Evaluation and Responses (BRIghTER). This presentation will outline some preliminary findings which formed part of a large implementation study over an 18 month period. Methods: Staff in the CHSS responded to care home concerns about residents needs for support with pain management and behaviour which staff found challenging and was distressing to residents. Measures, including staff ratings of residents' symptoms, Neuropsychiatric Inventory and Abbey Pain Scale scores were collected from care home residents receiving the BRIghTER DAWN programme as part of care delivery in order to identify their needs and the effectiveness of the stepped care interventions provided. Results: A total of 507 episodes of care were completed across 81 care homes within one county of 102 care homes. The results identify the way in which care homes engaged with the service and the effectiveness of the stepped care approach in this setting. Key well-being needs were identified by the programme and how these were associated with effective clinical interventions. Discussion: The results of this evaluation demonstrates good uptake of an integrated service and successful ways of detecting pain and mental health needs within a care home population. It illustrates how service pathways can be integrated to provide early detection and intervention. Conclusion: A stepped care model of psycho-social interventions can be successfully implemented by an integrated physical and mental health team in reaching into care homes. The findings highlight the effectiveness of this approach in the treatment of pain and challenging behaviour in this context. [ABSTRACT FROM AUTHOR]

There are 35 million people with dementia worldwide, many of whom live in care homes. For example, in the UK one third of people with dementia live in care home facilites, and a large proportion of these individuals have moderate or severe dementia and have highly complex care needs resulting from a combination of cognitive, functional and communication impairments, neuropsychiatric symptoms and medical comorbidity. The aim of the redesigned care home in-reach service in Oxfordshire is to improve the quality of care and health outcomes for people with dementia and enable family and paid carers to feel better supported to deliver their caring role. The model of care combines new ways of working which incorporates a biopsychosocial approach which has been effective in large scale research trials (Fossey, 2006;. Ballard, 2009) and to evaluate the effectiveness of the implementation in a routine NHS setting in the UK. The redesigned service integrates an established Care Home Support Service (physical health/falls prevention team) with a mental health service which can work with all 102 care homes in the county in a responsive and preventative manner. The evaluation of this service uses the RE-AIM framework (Glasgow 1999) to determine the impact on - Reach of the service for indiivudals and services in the county. - Effectiveness in terms of : o Health and well-being for people with dementia who receive the service using routine service outcome data for individuals. o County- wide Service use data - diagnosis rates for dementia, referrals to other services, admissions and length of stay o Family/carer satisfaction - Implementation, Adoption and maintenance factors o By thematic analysis of focus groups of staffs' perception of benefits and difficulties of new model o Service quality data - Economic impact of this model of care. This presentation will outline to key elements of the service redesign and initial findings arising from this 12 month study. [ABSTRACT FROM AUTHOR]

Reports on a study which used dementia care mapping to evaluate the quality of care in ten private sector and seven National Health Service care facilities in Great Britain. Participants; Methods; Results; Conclusion that quality of care needed radical improvement in all facilities.

A correction to the article "The value of personalized psychosocial interventions to address behavioral and psychological symptoms in people with dementia living in care home settings: a systematic review" that was published in the February 2014 issue is presented.

Background: People with dementia living in care homes often have complex mental health problems, disabilities and social needs. Providing more comprehensive training for staff working in care home environments is a high national priority. It is important that this training is evidence based and delivers improvement for people with dementia residing in these environments. Well-being and Health for People with Dementia (WHELD) combines the most effective elements of existing approaches to develop a comprehensive but practical staff training intervention. This optimised intervention is based on a factorial study and qualitative evaluation, to combine: training on person-centred care, promoting person-centred activities and interactions, and providing care home staff and general practitioners with updated knowledge regarding the optimal use of psychotropic medications for persons with dementia in care homes.Design: The trial will be a randomised controlled two-arm cluster single blind trial that will take place for nine months across 80 care homes in the United Kingdom.Discussion: The overarching goal of this trial is to determine whether this optimised WHELD intervention is more effective in improving the quality of life and mental health than the usual care provided to people with dementia living in nursing homes. This study will be the largest and best powered randomised controlled trial (RCT) evaluating the benefits of an augmented person-centred care training intervention in care homes worldwide.Trial Registration: Current controlled trials ISRCTN62237498 Date registered: 5 September 2013. [ABSTRACT FROM AUTHOR]

Background: People living in care homes often have complex mental and physical health problems, disabilities and social needs which are compounded by the use of psychiatric and other drugs. In the UK dementia care is a national priority with a vast impact on services. WHELD combines the most effective elements of existing approaches to develop a comprehensive but practical intervention. This will be achieved by training care staff to provide care that is focused on an understanding of the individual and their needs; and by using additional components such as exercise, activities and social interaction to improve mental health and quality of life (QoL) and reduce the use of sedative drugs.Design: Work Package 3 (WP3) is the pilot randomised trial and qualitative evaluation to help develop a future definitive randomised controlled clinical trial. The study design is a cluster randomised 2x2x2 factorial design with two replications in 16 care homes. Each care home is randomized to receive one of the eight possible permutations of the four key interventions, with each possible combination delivered in two of the 16 homes. Each cluster includes a minimum of 12 participants (depending upon size of the care home, the number of people with dementia and the number consenting).Discussion: The overarching goal of the programme is to provide an effective, simple and practical intervention which improves the mental health of, and reduces sedative drug use in, people with dementia in care homes and which can be implemented nationally in all UK care homes as an NHS intervention.Trial Registration: Current controlled trials ISRCTN40313497. [ABSTRACT FROM AUTHOR]