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Background: Intrusive mental imagery is associated with anxiety and mood instability within bipolar disorder and therefore represents a novel treatment target. Imagery Based Emotion Regulation (IBER) is a brief structured psychological intervention developed to enable people to use the skills required to regulate the emotional impact of these images. Methods: Participants aged 18 and over with a diagnosis of bipolar disorder and at least a mild level of anxiety were randomly assigned (1:1) to receive IBER plus treatment as usual (IBER +TAU) or treatment as usual alone (TAU). IBER was delivered in up to 12 sessions overs 16 weeks. Clinical and health economic data were collected at baseline, end of treatment and 16-weeks follow-up. Objectives were to inform the recruitment process, timeline and sample size estimate for a definitive trial and to refine trial procedures. We also explored the impact on participant outcomes of anxiety, depression, mania, and mood stability at 16-weeks and 32-weeks follow-up. Results: Fifty-seven (28: IBER+TAU, 27: TAU) participants from two sites were randomised, with 50 being recruited within the first 12 months. Forty-seven (82%) participants provided outcome data at 16 and 32-weeks follow-up. Thirty-five participants engaged in daily mood monitoring at the 32-week follow-up stage. Retention in IBER treatment was high with 27 (96%) attending ≥7 sessions. No study participants experienced a serious adverse event. Discussion: The feasibility criteria of recruitment, outcome completion, and intervention retention were broadly achieved, indicating that imagery-focused interventions for bipolar disorder are worthy of further investigation.

BackgroundHearing and vision impairments are among the most common and disabling comorbidities in people living with dementia. Intervening to improve sensory function could be a means by which the lives of people living with dementia may be improved. However, very few studies have tried to ameliorate outcomes in dementia by improving sensory function. This paper describes the multi-step development of a new intervention designed to support hearing and vision function in people living with dementia in their own homes. At the end of the development programme, it is anticipated that a ‘sensory support’ package will be ready for testing in a full scale randomised controlled trial.MethodsThis programme is based on the process of ‘intervention mapping’ and comprises four integrated steps, designed to address the following: (1) scoping the gaps in understanding, awareness and service provision for the hearing and/or vision impairment care needs of people with dementia using a systematic literature review and Expert Reference Group; (2) investigating the support care needs through a literature search, stakeholder surveys, focus groups, semi-structured interviews and an Expert Reference Group, leading to a prototype sensory support package; (3) refining the prototype by additional input from stakeholders using focus groups and semi-structured interviews; and (4) field testing the draft intervention using an open-labelled, non-randomised feasibility study, integrating feedback from people with dementia and their significant others to develop the final intervention ready for full scale definitive trialling. Input from the ‘patient and public voice’ is a cornerstone of the work and will interlink with each step of the development process. The programme will take place in study centres in Manchester, Nicosia and Bordeaux.DiscussionQuantitative and qualitative data analyses will be employed, dependent upon the sub-studies in question. Data from the steps will be integrated with consideration given to weighting of evidence for each step of the programme. This programme represents the logical development of a complex intervention to fulfil an unmet need. It is based on a theoretical framework and will lead to a subsequent full scale efficacy trial. The challenges in integrating the data and addressing the contextual issues across study sites will be scrutinised.

Background Hearing and vision (sensory) impairments are highly prevalent in people with dementia (PwD) and exacerbate the impact of living with dementia. Assessment of sensory or cognitive function may be difficult if people have concurrent dual or triple impairments. Most standard cognitive assessment tests are heavily dependent on having intact hearing and vision, and impairments in these domains may render the assessments unreliable or even invalid. Likewise, dementia may impede on the accurate reporting of symptoms that is required for most hearing and vision assessments. Thus, there is an urgent need for hearing, vision and cognitive assessment strategies to be adapted to ensure that appropriate management and support can be provided. Objective To explore the perspectives of PwD and the care partners regarding the need for accurate hearing, vision and cognitive assessments. Methods We conducted focus groups and semi-structured interviews regarding the clinical assessment for cognitive, hearing and visual impairment. Participants (n = 18) were older adults with mild to moderate dementia and a sensory impairment as well as their care partners (e.g. a family member) (n = 15) at three European sites. The qualitative material was analysed according to Mayring’s summative content analysis approach. Results Participants reported that hearing, vision and cognitive assessments were not appropriate to the complex needs of PwD and sensory comorbidity and that challenges in communication with professionals and conveying unmet needs and concerns by PwD were common in all three types of clinical assessments. They felt that information about and guidance regarding support for the condition was not adequate in the assessments and that information sharing among the professionals regarding the concurrent problems was limited. Professionals were reported as being concerned only with problems related to their own discipline and had limited regard for problems in other domains which might impact on their own assessments. Conclusions The optimal assessment and support for PwD with multiple impairments, more comprehensive, yet easy to understand, information regarding these linked to conditions and corrective device use is needed. Communication among health care professionals relevant to hearing, vision and cognition needs to be improved.

Background There is a major need for longitudinal research examining the experiences of people with dementia and their primary carers, as relatively little is known about how the factors associated with capability to ‘live well’ vary over time. The main aim of the IDEAL-2 study is to investigate how and why, over time, people with dementia and their primary carers might vary in their capability to live well with dementia, whilst exploring both their use of health and care services and their unmet needs. Methods IDEAL-2 will build on the Improving the experience of Dementia and Enhancing Active Life (IDEAL) cohort of 1547 people (who, at recruitment between July 2014 and July 2016, had mild-to-moderate dementia), and their 1283 primary carers in Great Britain. The existing cohort will be enriched with additional participants with mild-to-moderate dementia (and their primary carers where available and willing) from the following groups: people with rarer forms of dementia, and/or those who are ≥90 years or

Sarah C Smith, AA Jolijn Hendriks, Jemma Regan, Nick Black Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK Background: In research in residential care, health-related quality of life (HRQL) is usually measured using either observational methods or standardized questionnaires. DEMQOL-Proxy is a standardized questionnaire measuring HRQL of people with dementia and is usually reported by a family carer. However, not all residents have a family carer who visits often enough to act as a proxy. Objectives: We evaluated the psychometric performance of DEMQOL-Proxy when reported on behalf of people with dementia in residential care by a “trained proxy” (DEMQOL-Proxy-TP). Participants: We recruited a sample of 87 people with dementia living in care homes around the UK. Methods: We used modern psychometric methods (based on the Rasch model) to evaluate DEMQOL-Proxy-TP (on behalf of 85 residents) in a cross-sectional study. We evaluated scale-to-sample targeting, ordering of item thresholds, item fit to the model and differential item functioning (sex, age, type of dementia), local independence, unidimensionality and reliability on the full set of items (31 items) and also a smaller item set (26 items). Results: The smaller item set (DEMQOL-Proxy-TP-26) performed better than the original item set and was found to fit the model (p = 0.68). Nevertheless, 17 items were found to have disordered thresholds, and 24 pairs of items showed local dependency (residual correlations >0.3). There were also some areas where scale-to-sample targeting could be improved. Conclusion: After resolving the identified anomalies, DEMQOL-Proxy-TP can provide adequate measurement of HRQL of people with dementia living in residential care, particularly when no family carer is available. This can be interpreted at the group level but is not yet robust enough for use at the individual level. Future work will compare these results with the psychometric performance of DEMQOL-Proxy reported by family carers and DEMQOL self-reported by the residents. Keywords: dementia, DEMQOL-Proxy, health-related quality of life, Rasch Measurement Theory, trained proxy

Purpose – The purpose of this paper is to systematically appraise the effect of use of interpreters for mental health problems in old age. The primary objective of the review is to assess the impact of a language barrier for assessment and management in relation to mental health problems in the old age. The secondary objectives are to assess the effect of the use of interpreters on patient satisfaction and quality of care, identify good practice and make recommendations for research and practice in the old age mental health. Design/methodology/approach – The following data sources were searched for publications between 1966 and 2011: PubMed, PsycINFO, CINAHL and Cochrane Library. The authors found in previous reviews that a substantial number of papers from developing and non-English speaking countries are published in journals not indexed in mainstream databases, and devised a search strategy using Google which identified a number of papers, which could not be found when the search was limited to scientific data bases only (Farooq et al., 2009). The strategy was considered especially important for this review which focuses on communication across many different languages. Thus, the authors conducted a search of the World Wide Web using Google Scholar, employing the search term Medical Interpreters and Mental Health. The search included literature in all languages. The authors also searched the reference lists of included and excluded studies for additional relevant papers. Bibliographies of systematic review articles published in the last five years were also examined to identify pertinent studies. Findings – Only four publications related specifically to “old age” and 33 addressed “interpreting” and “psychiatry” generally. Four articles presented original research (Parnes and Westfall, 2003; Hasset and George, 2002; Sadavoy et al., 2004; Van de Mieroop et al., 2012). One article (Shah, 1997) reports an “anecdotal descriptive account” of interviewing elderly people from ethnic backgrounds in a psychogeriatric service in Melbourne and does not report any data. Therefore, only four papers met the inclusion and exclusion criteria and present original research in the field of “old age”, “psychiatry” and “interpreting”. None of these papers present UK-based research. One is a quantitative study from Australia (Hasset and George, 2002), the second is a qualitative study from Canada (Sadavoy et al., 2004), in the third paper Van de Mieroop et al. (2012) describe community interpreting in a Belgian old home and the final paper is an American case study (Parnes and Westfall, 2003). Practical implications – Interviewing older patients for constructs like cognitive function and decision-making capacity through interpreters can pose significant clinical and legal problems. There is urgent need for training mental health professionals for developing skills to overcome the language barrier and for interpreters to be trained for work in psychogeriatrics. Social implications – The literature on working through interpreters is limited to a few empirical studies. This has serious consequences for service users such as lack of trust in services, clinical errors and neglect of human rights. Further studies are needed to understand the extent of problem and how effective interpreting and translating services can be provided in the routine clinical practice. It is also essential to develop a standard of translation services in mental health that can be measured for their quality and also efficiency. At present such a quality standard is not available in the UK, unlike Sweden (see www.regeringen.se/sb/d/3288/a/19564). This omission is disturbing – especially when decisions on human rights are being considered as part of the Mental Health Act. Such a standard can best be achieved by collaboration between medical profession and linguists’ professional associations (Cambridge et al., 2012). Originality/value – Whilst translation/interpretation has been addressed more generally in mental health: specific considerations related to old age psychiatry are almost absent. This needs urgent rectification given that a large proportion of older people from BME communities will require translation and interpretation services.

Background:Age-related hearing and vision problems are common among people with dementia and are associated with poorer function, reduced quality of life and increased caregiver burden. Addressing sensory impairments may offer an opportunity to improve various aspects of life for people with dementia.Methods:Electronic databases were searched using key terms dementia, hearing impairment, vision impairment, intervention, and management. Database searches were supplemented by hand searching bibliographies of papers and via consultation with a network of health professional experts. Studies were eligible for inclusion if they included adults aged over 50 with dementia with adult-onset hearing or vision impairment who had received a hearing or vision intervention in relation to cognitive function, rate of decline, psychiatric symptoms, hearing/vision-related disability, quality of life, and/or caregiver burden outcomes. A range of study designs were included. Results were summarized descriptively according to level of evidence and effect sizes calculated where possible. Risk of bias was assessed using Downs and Black's (1998) checklist. The development of the intervention was summarized according to the CReDECI2 scheme. PROSPERO review registration number 2016:CRD42016039737.Results:Twelve papers describing hearing interventions and five papers describing vision interventions were included. Most were of low to moderate quality. One high quality randomized controlled trial of a hearing aid intervention was identified. Hearing interventions included provision of hearing aids, assistive listening devices, communication strategies, hearing aid trouble shooting, and cochlear implantation. Vision interventions included prism lenses, rehabilitation training, and cataract surgery. There was no consistent evidence for the positive impact of hearing/vision interventions on cognitive function, rate of cognitive decline, quality of life, or caregiver burden.Conclusion:Sensory interventions may promote better outcomes, but there is a need for properly powered, controlled trials of hearing and vision interventions on outcomes relevant to people living with dementia.

Barriers to healthcare services experienced by black and minority ethnic (BME) persons with dementia are labelled as “cultural” in existing research. This is a promising shift from an ethno-centric approach to dementia care provision, yet very little research is dedicated to specifically how religion – as distinct from culture – influences healthcare practice. Further consideration of the religion–culture distinction is required; religion and culture are two distinct entities, which inevitably interlink. Cultural themes such as “God's will”, “Religious Ritual” and “Religious Duty”, warrant re-categorisation as “religious”. Sensitivity to the nuances between cultural and religious themes will provide clearer knowledge of how and why BME persons with dementia experience barriers to accessing care services. Further research is needed with regard to the role of religion specifically on dementia care access for BME persons to aim to improve care provision for this underrepresented demographic.

Objective: To investigate how religion influences care pathways for black and minority ethnic individuals with dementia. We conducted a systematic search of the literature to explore how religion affects later presentation to care services, absence of care-seeking and dissatisfaction with care. Exclusion and Inclusion criteria were applied to the research literature. Qualitative and quantitative papers were included. Included studies were assessed independently by four authors according to quality criteria. Two US studies adhered to the final screening stage. Findings from these papers postulated that religion influences care in two polarised ways: (1) Religion hinders access to the traditional health care pathway. (2) Religion assists in positive coping. Collaboration between religious institutions and health care providers is required to improve care referral, provide information dissemination and relieve care-giver burden. UK research in this area is necessary.

IntroductionQuality of life and other key outcomes may be improved by optimising hearing and vision function in people living with dementia. To date, there is limited research assessing the efficacy of interventions aimed at improving hearing and vision in people with dementia. Here, we outline a protocol to field test a newly developed home-based intervention, designed to optimise sensory functioning in people with dementia in three European sites. The results of this study will inform the design and conduct of a full-scale randomised controlled trial (RCT) in five European sites.Methods and analysisIn this multisite, single arm, open label, feasibility study, participants with dementia (n=24) will be assessed for hearing and vision impairments and be prescribed a hearing aid and/or glasses. Each participant will have a study partner (‘dyads’). A subset of dyads will receive ‘sensory support’ from a ‘sensory support therapist’, comprising home visits over 12 weeks. The therapist will offer the following intervention: adherence support for corrective devices; adaptations to the home environment to facilitate sensory function; communication training; and referral to community-based support services. The primary outcomes will be process measures assessing the feasibility, tolerability and acceptability of: (1) the intervention components; (2) the method of implementation of the intervention and (3) the study procedures, including outcome assessment measures. Quantitative data will be collected at baseline and follow-up. Qualitative data using semistructured interviews will be collected postintervention and weekly, using participant diaries. Finally, we will explore a model of cost-effectiveness to apply in the subsequent full-scale trial. This feasibility study is a necessary step in the development of a complex, individualised, psychosocial intervention. The data gathered will allow logistical and theoretical processes to be refined in preparation for a full-scale RCT.Ethics and disseminationEthical approval was obtained in all three participating countries. Results of the field trial will be submitted for publication in a peer-reviewed journal.

A case study comprised of formal interviews, formal observations and informal discussions investigated the motivations and experiences accessing dementia care health and social care services for a Muslim, Pakistani male with dementia. Motivations derived from ‘desperation’ and an inability to access support from family or religious community. Experiences of accessing services were mostly negative. Dementia services were ill-informed about how to support persons with young onset dementia, with pre-existing mental health conditions, from an ethnic minority. Education and training to remove barriers to all dementia care services is required for persons with dementia, their families and within dementia services and religious communities.