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Background: Caring for someone with dementia is one of the most challenging caring roles. The need for support for family caregivers has been recognized for some time but is often still lacking. With an aging population, demand on health and social care services is growing, and the population is increasingly looking to the internet for information and support. Objective: In this review, we aimed to (1) identify the key components of existing internet-based interventions designed to support family caregivers of people with dementia, (2) develop an understanding of which components are most valued by caregivers, and (3) consider the evidence of effectiveness of internet-based interventions designed to support family caregivers of people with dementia. Methods: We conducted a systematic search of online databases in April 2018. We searched reference lists and tracked citations. All study designs were included. We adopted a narrative synthesis approach with thematic analysis and tabulation as tools. Results: We identified 2325 studies, of which we included 40. The interventions varied in the number and types of components, duration and dose, and outcomes used to measure effectiveness. The interventions focused on (1) contact with health or social care providers, (2) peer interaction, (3) provision of information, (4) decision support, and (5) psychological support. The overall quality of the studies was low, making interpretation and generalizability of the effectiveness findings difficult. However, most studies suggested that interventions may be beneficial to family caregiver well-being, including positive impacts on depression, anxiety, and burden. Particular benefit came from psychological support provided online, where several small randomized controlled trials suggested improvements in caregiver mental health. Provision of information online was most beneficial when tailored specifically for the individual and used as part of a multicomponent intervention. Peer support provided in online groups was appreciated by most participants and showed positive effects on stress. Finally, online contact with a professional was appreciated by caregivers, who valued easy access to personalized practical advice and emotional support, leading to a reduction in burden and strain. Conclusions: Although mixed, the results indicate a positive response for the use of internet-based interventions by caregivers. More high-quality studies are required to identify the effectiveness of internet interventions aimed at supporting family caregivers, with particular focus on meeting the needs of caregivers during the different stages of dementia. [J Med Internet Res 2018;20(6):e216]

The British Association for Psychopharmacology (BAP) coordinated a meeting of experts to review and revise its first (2006) Guidelines for clinical practice with anti-dementia drugs. As before, levels of evidence were rated using accepted standards which were then translated into grades of recommendation A to D, with A having the strongest evidence base (from randomized controlled trials) and D the weakest (case studies or expert opinion). Current clinical diagnostic criteria for dementia have sufficient accuracy to be applied in clinical practice (B) and brain imaging can improve diagnostic accuracy (B). Cholinesterase inhibitors (donepezil, rivastigmine, and galantamine) are effective for mild to moderate Alzheimer’s disease (A) and memantine for moderate to severe Alzheimer’s disease (A). Until further evidence is available other drugs, including statins, anti-inflammatory drugs, vitamin E and Ginkgo biloba, cannot be recommended either for the treatment or prevention of Alzheimer’s disease (A). Neither cholinesterase inhibitors nor memantine are effective in those with mild cognitive impairment (A). Cholinesterase inhibitors are not effective in frontotemporal dementia and may cause agitation (A), though selective serotonin reuptake inhibitors may help behavioural (but not cognitive) features (B). Cholinesterase inhibitors should be used for the treatment of people with Lewy body dementias (Parkinson’s disease dementia and dementia with Lewy bodies (DLB)), especially for neuropsychiatric symptoms (A). Cholinesterase inhibitors and memantine can produce cognitive improvements in DLB (A). There is no clear evidence that any intervention can prevent or delay the onset of dementia. Although the consensus statement focuses on medication, psychological interventions can be effective in addition to pharmacotherapy, both for cognitive and non-cognitive symptoms. Many novel pharmacological approaches involving strategies to reduce amyloid and/or tau deposition are in progress. Although results of pivotal studies are awaited, results to date have been equivocal and no disease-modifying agents are either licensed or can be currently recommended for clinical use.

Summary The UK is unusual in providing universal free healthcare in which access to specialists is largely controlled by general practitioners with 24-hour responsibility, throughout the year, for a defined list of patients of all ages. It is generally considered that this gatekeeper function has contributed to the relatively low cost of the National Health Service, but major changes in the organisation and clinical role of general practitioners have occurred, culminating in a new contract that aims to re-orientate general practice towards health promotion, disease prevention and the management of chronic disease. The implications of these changes are discussed.

Aim This article explores the involvement of older people in research and inspection, reflecting on the learning from the recent ‘joint review’ of the National Service Framework for Older People in England. Methodological context Working in 10 different localities, the ‘joint review’ comprised a formal inspection of health and local council services (carried out by the Healthcare Commission, Commission for Social Care Inspection and the Audit Commission) and an externally commissioned university-led research project designed to ascertain the views and experiences of older people living in the 10 inspection sites. In total, 1839 older people were interviewed individually and through focus groups and an additional 4200 older people completed questionnaires. A distinctive feature of the research was the inclusion of a team of older researchers who had undertaken training in research methods in later life. Reflections of the older researchers and other members of the research team on undertaking this large-scale user involvement project were ascertained via a day-long seminar which was tape recorded and transcribed. Learning While many espouse the principle of ‘service user involvement’ in research, there is a need to move beyond the rhetoric of participation and any blanket assumptions about what it means to be an ‘older researcher’, a ‘service user researcher’ or indeed, a ‘professional researcher’. This means ensuring that within any given team (user-controlled or collaborative) there are clear lines of accountability and equal opportunities for individual appraisal, support, and personal or professional development. Such considerations are key to working with ‘older researchers’ and encouraging diversity in the research workforce more generally.

The potential health benefits derived from sustained physical activity in older people are numerous; however, whether exercise promotion should take place in general practice is unsubstantiated. Exercise promotion should use existing research evidence of the advantages of exercise for various conditions, and target those inactive individuals who currently have no intention of changing their level of physical activity. Research has also raised methodological issues and questions about the feasibility of exercise interventions which still need to be tested in exercise trials conducted in general practice.

Asthma is a common chronic disease of the lungs caused by inflammation of the airways affecting 6-7% of the population. Asthma is becoming commoner and there is evidence of under-diagnosis and poor management. Guidelines have been developed aimed at improving quality of care and in reducing social costs of asthma. The paper discusses an approach to implementing guidelines through decision-support system in primary care, based on methods developed in the AIM GAMES-II project. We also describe a prototype system that has been developed and a programme of clinical evaluation.

BACKGROUND. Use of brief screening instruments for detection of psychological morbidity among elderly people is being promoted, although the appropriateness and effectiveness of available instruments have not been evaluated in general practice. AIM. This study set out to determine the outcome of opportunistic use of brief screening instruments for dementia, depression and problem drinking in randomized trials in two group practices in north west London. METHOD. Screening instruments were inserted into a random sample of medical records for people aged 75 years and over in each practice. Medical records of those seen by their general practitioners over a six month period were reviewed for new diagnoses of dementia (or confusion), depression or problem drinking, and the scores obtained on screening instruments noted. The records of all those identified as possibly demented, depressed or drinking heavily were reviewed one year after screening and all relevant referrals and new treatments were noted. RESULTS. In one practice use of screening instruments resulted in a significant increase in the detection of possible dementia, but not of depression. In the second practice screening instruments yielded significantly higher numbers with possible dementia or depression. Heavy drinking was uncommon in either population. There was no difference in the proportions of cases identified by screening instrument or by clinical judgement alone who received treatment or referral. CONCLUSION. These results suggest that in the absence of agreed guidelines and resources, information derived from screening instruments may not alter clinical practice.

The aim of this study was to look at the interrelationship between depression, physical disability and contact with services. In a random sample of 239 people aged 75 years and over from nine general practices in north London, depression (as measured by a shortened version of the comprehensive assessment and referral evaluation schedule) was found to be significantly associated with being a woman, and inability to perform a number of activities of daily living. Consumption of three or more prescribed medicines, a home visit by the general practitioner in the previous three months and contact with health visitors and home helps were all significantly more likely among depressed patients. There were also significant associations between loss of functional abilities, measured using items from an activities of daily living scale, and use of certain services: general practitioner home visits and reduced mobility indoors and both home help and district nurse visits to those with difficulty in bathing. Multiple logistic regression analysis suggested that contact with services was principally associated with loss of mobility, although contact with home helps was independently associated with depression, when adjustment was made for functional impairment.

A survey of patients aged 75 years and over registered with general practitioners in north and north west London was carried out by trained interviewers to investigate cognitive impairment. A random sample of 239 patients was selected for the more detailed home assessment. General practitioners had seen nearly two thirds (65.3%) of their patients aged 75 years and over in the three months prior to the study, the majority of these consultations (82.1%) being initiated by the patient and occurring at the surgery. Half of the patients lived alone (50.2%), nearly one in three had no living siblings (31.9%), a similar proportion had no living children (29.5%), and contact with neighbours and relatives was relatively infrequent. One in five elderly patients had evidence of depression (22.0%) although this appeared to be severe in only two cases, and 36 participants (15.1%) had scores on the mini-mental state examination suggesting cognitive impairment. General practitioners underdiagnosed both dementia and depression. The population contained a small group of people who consumed alcohol on a daily basis (10.5%). This study showed that an annual assessment of elderly people as required by the new general practitioners' contract would yield much new evidence of depression and dementia and assist in the identification of heavy drinkers. Up to 30% of patients aged 75 years and over are likely to require further assessment on the basis of screening tests for depression and cognitive impairment, although it remains unclear to what extent identification of these patients will lead to improvements in outcome for them or their carers.

A random sample of 239 patients aged 75 years and over registered with general practitioners in north and north west London was selected for home assessment to determine the functional abilities and medical problems of this group of patients. Nearly one in five of the patients were incontinent of urine (18.4%), although this was on a daily basis for only 4.1%. Around one in 20 patients were incontinent of faeces (5.9%), yet only one patient had laundry service support. Unassisted mobility outdoors was reported as possible by 81.2% of the patients. Fourteen different types of aids were present in the participants' homes, the commonest being walking sticks, bath aids and stair rails. Only a small proportion of aids seemed to be currently unused. The major functional problems were bathing, housework, shopping, washing and ironing, and cooking main meals, but the level of demand for extra help was low. One in five patients had a hearing aid (19.8%) but for only 30% of these patients was it in continuous use. Polypharmacy was common, with 29.7% of patients taking three or more prescribed medicines. The workload implications of this approach to anticipatory care of elderly people are considerable. In an average practice of 2000 patients with 130 patients aged 75 years and over the primary care team would need over 150 hours of face-to-face contact per year with these patients to fulfil the new contractual obligation and the yield of new information leading to effective medical or social intervention is limited.(ABSTRACT TRUNCATED AT 250 WORDS)

There has been increasing interest in the development of hospital-at-home within the National Health Service (NHS) as a way of shifting resources from secondary to primary care. We describe the development of hospital-at-home schemes in London and draw on data from an evaluation of five such schemes to discuss support for hospital-at-home within the NHS. The study has identified a small but important group of patients who do not want hospital-at-home, as well as resistance to it from some health care professionals and managers, particularly in hospitals. These organizational issues must be taken into account in any evaluation of hospital-at-home, along with issues of quality, outcome and cost. Feasibility studies are needed to identify possible organizational barriers to hospital-at-home and the development work that is required. This service innovation should not be considered in isolation from other services, but rather within the context of a wider debate about the pattern of acute care.

Health services are multi-unit enterprises providing multi-component services, and organisationally are equivalent to very large, diversified companies. Although public health services like Britain's National Health service (NHS) are not for-profit enterprises, they may share characteristics of such enterprises, particularly where these characteristics offer methods of cost-containment. Since all health services, however organised, face the same problem of resources being insufficient to meet demand for health care, they exhibit an underlying tendency towards solving problems in health care using mechanisms borrowed from other industries. This paper attempts to answer the question: to what extent has general practice (family medicine) in Britain's NHS adopted industrial modes of organisation from productive (for-profit) industries?

Background Hospital at home is defined as a service that provides active treatment by health care professionals, in the patient's home, of a condition that otherwise would require acute hospital in-patient care, always for a limited period. Objectives To assess the effects of hospital at home compared with in-patient hospital care. Search strategy We searched the Cochrane Effective Practice and Organisation of Care Group (EPOC) specialised register (November 2004), MEDLINE (1966 to 1996), EMBASE (1980 to 1995), Social Science Citation Index (1992 to 1995), Cinahl (1982 to 1996), EconLit (1969 to 1996), PsycLit (1987 to 1996), Sigle (1980 to 1995) and the Medical Care supplement on economic literature (1970 to 1990). Selection criteria Randomised trials of hospital at home care compared with acute hospital in-patient care. The participants were patients aged 18 years and over. Data collection and analysis Two reviewers independently extracted data and assessed study quality. Main results Twenty two trials are included in this update of the review. Among trials evaluating early discharge hospital at home schemes we found an odds ratio (OR) for mortality of 1.79 95% CI 0.85 to 3.76 for elderly medical patients (age 65 years and over) (n = 3 trials); OR 0.58; 95% CI 0.29 to 1.17 for patients with chronic obstructive pulmonary disease (COPD) (n = 5 trials); and OR 0.78; 95%CI 0.52 to 1.19 for patients recovering from a stroke (n = 4 trials). Two trials evaluating the early discharge of patients recovering from surgery reported an OR 0.43 (95% CI 0.02 to 10.89) for patients recovering from a hip replacement and an OR 1.01 (95% CI 0.37 to 2.81) for patients with a mix of conditions at three months follow-up. For readmission to hospital we found an OR 1.76; 95% CI 0.78 to 3.99 at 3 months follow-up for elderly medical patients (n = 2 trials); OR 0.81; 95% CI 0.55 to 1.19 for patients with COPD (n = 5 trials); and OR 0.96; 95% CI 0.63 to 1.45 for patients recovering from a stroke (n = 3 trials). No significant heterogeneity was observed. One trial recruiting patients following surgery for hernia or varicose veins reported 0/117 versus 2/121 patients were re admitted (Ruckley 1978); another that 2/37 (5%) versus 1/49 (2%) (difference 3%, 95% CI -5% to 12%) of patients recovering from a hip replacement, 4/47 (9%) versus 1/39 (3%) (difference 6%, 95% CI -3% to 15%) of patients recovering from a knee replacment, and 7/114 (6%) versus 13/124 (10%) (difference -4% 95% CI -11% to 3%) of patients recovering from a hysterectomy were readmitted. A third trial analysing surgical and medical patients together reported that 42/159 versus 17/81 patients were readmitted at 3 months (OR 1.34 95% CI 0.66 to 2.20). Allocation to hospital at home resulted in a small reduction in hospital length of stay, but hospital at home increased overall length of care. Patients allocated to hospital at home expressed greater satisfaction with care than those in hospital, while the view of carers was mixed. Authors' conclusions Despite increasing interest in the potential of hospital at home services as a cheaper alternative to in-patient care, this review provides insufficient objective evidence of economic benefit. Early discharge schemes for patients recovering from elective surgery and elderly patients with a medical condition may have a place in reducing the pressure on acute hospital beds, providing the views of the carers are taken into account. For these clinical groups hospital length of stay is reduced, although this is offset by the provision of hospital at home. Future primary research should focus on rigorous evaluations of admission avoidance schemes and standards for original research should aim at assisting future meta-analyses of individual patient data from these and future trials.

Home nebuliser therapy requires sensible supervision to ensure that the nebuliser and the compressor are well matched and that both are in good condition. It can then be acceptable and helpful to appropriately selected patients.

The essential characteristics of British general practice--a defined list of patients for each practitioner, the pivotal role of general practice in controlling access to specialist services, and the primary care team--all are likely to be preserved for the foreseeable future. New government legislation will attempt to increase the accountability of general practitioners, to reward "good practice", and to encourage greater emphasis on preventive activities. This article provides an overview of general practice in the United Kingdom, including administrative issues, reimbursement structures, research directions, and government policies.

The use by non-medical staff of a brief screening instrument (the mini-mental state examination) to detect cognitive impairment among the elderly in primary care is described. Patients aged 75 years and over registered with nine general practices in north and north west London were invited by their general practitioners to take part in the study and 1170 patients participated, a response rate of 90%. The prevalence of possible or probable cognitive impairment (score below 25 on the mini-mental state examination) was 12.8%. Six per cent of patients scored below 19, at which score a high probability of dementia exists, although less than a third of this group had a diagnosis of dementia in their medical records. There was no significant difference between men and women or by social class in the proportion of patients with low scores, but the proportion with dementia rose from 2.5% in those aged 75-79 years to 29.0% among those aged 90 years and over. Under the new general practitioner contract there is a requirement to provide annual services to the elderly, including a 'mental assessment'. In a practice with a list size of 2000 around 130 patients are likely to be aged 75 years and over. Of these around 17 would require further assessment for possible dementia on the basis of results obtained using the mini-mental state examination.

The London Academic Training Scheme (LATS) provides a 1-year training programme in research methods and teaching for GPs who have recently finished vocational training. This paper describes an adult educational approach to learning about research methods through teaching as part of the LATS trainees' weekly academic programme.We aimed to provide and evaluate a course exploring research methodologies used in primary care by a three-step approach to learning, with trainees taking the main role as teachers.Trainees on the LATS programme met for one afternoon each week for one term. During alternate sessions a pair of trainees would deliver a whole afternoon's seminar on one aspect of primary care research methodology. The teaching of each session was evaluated by the whole group, by academic supervisors and by experts.Sessions were scored by participants for content, style of presentation, educational value and enjoyment on a seven-point rating scale where 1 = no value, 4 = neutral and 7 = very valuable. All sessions scored above 4 and usually above 5 for each aspect. Open comments collected showed that trainees greatly appreciated this self-directed approach to learning and teaching.The active involvement of learners as teachers is a practical and rewarding means of using adult educational principles in providing an academic programme.