Depression in residential care

Book reviews

many measures of quality-of-life (QoL) may not be suitable for older people in care homes, and do not cover the most relevant domains for individuals. to describe QoL of older people living in care homes using the SEIQoL-DW and the two 10-point rating scales, and to describe how people were using these measures. we used quantitative methods to describe QoL, and qualitative methods to explore residents' experiences of completing the measures. three care homes in the United Kingdom. twenty residents. residents completed the measures in interviews. We report descriptive statistics for QoL, the most important QoL domains for residents, completion rates and experiences of administering the instruments. the most important QoL domains identified in the SEIQoL-DW were leisure activities; family; relationships; social life; independence and peace and contentment. Physical limitations and difficulty in understanding the instructions and concepts made completing it a challenge. The SEIQoL index was strongly correlated with a single 10-point rating of current QoL (rho = 0.67, P = 0.007). to fully understand residents' QoL, detailed interview-based instruments, administered by an experienced interviewer are needed. To measure current QoL, for example, as an outcome measure, a simple single rating scale may suffice.

The aim of this paper was to compare published studies of care interventions for the management and promotion of continence, with urinary incontinence as the primary focus, in older care home residents. Incontinence is a prevalent and serious problem amongst older people in care homes, with an increasing international focus. MEDLINE and CINAHL searches via OVID (January 1966 to May 2010) were carried out, with studies limited to English language publications only. Included in this search were studies investigating urinary and fecal incontinence in people aged 65 years or older in care homes. Studies on surgical or pharmacological interventions or fecal incontinence alone were excluded. A total of 33 interventional studies were identified. Toileting programs and incontinence pads are the mainstays of treatment, with some studies implying significant economic and labor costs. Drug therapy as an adjunct to toileting programs has so far shown only moderate benefits. Combined physical therapy/behavioral therapies have shown effective short-term improvements. Adaptations to physical environment and staff training techniques might also be paramount. Exercise and Functional Incidental Training programs, although expensive, might provide additional benefit by reducing wetness rates and improving appropriate toileting rates. Combined complex behavioral interventions are now a common feature and their effectiveness for the management of urinary incontinence should be determined in future studies. Studies including long-term effectiveness on maintaining continence with full economic evaluation are also warranted in this population.

In 2017, the United Nations reported that the world's population aged 60 years and over was 962 million people, over twice as many older persons than was reported in 1980. This number is expected to double again by 2050, reaching nearly 2.1 billion older persons. Within this projection, the number of persons aged 80 years or over will increase more than threefold, increasing from 137 million to 425 million (United Nations, 2017). Growing old is often accompanied by a higher prevalence of medical conditions which can result in the development of moderate to severe functional and/or cognitive impairments to the extent that long‐term accommodation and care is needed. According to the Organization for Economic Cooperation and Development (OECD, 2017), across their participating countries, there is on average 46 long‐term care beds per 1000 people aged 65 years and over. Prevention and management of medical conditions and comorbidities typically requires the use of medicines leading to often complex regimes. Polypharmacy, where four or more different medicines are prescribed, may be the unintended consequence. Polypharmacy can be appropriate and necessary, but inappropriate polypharmacy is common in this population. Underprescription may also be a concern, for example, pain medicines for a person unable to express themselves. Prescribing is further complicated by age‐related changes that influence how drugs move around the body and how this impacts on the therapeutic effects of drugs (Kim & Luck Parish, 2017). Nurses caring for older people in care homes play a vital role in the optimization of medicines. As part of a multidisciplinary team, nurses are in the position to closely assess, monitor, and report the need for medicines and any potential or real adverse outcomes of already prescribed medicines (Halvorsen, Stensland, & Granas, 2011). Nurses need to know about evidence‐based interventions to optimize prescribing and the quality of the evidence given the frailty and vulnerability of older people residing in care homes.

Older people residents in care homes that only offer residential care rely on primary health care services for medical and nursing needs. Research has investigated the demands that care homes staff and residents make on general practice, but not the involvement of other members of the primary health care team. This paper describes two consecutive studies completed in 2001 and 2003 that involved focus groups and survey methods of enquiry conducted in two settings: an England shire and inner London. The research questions that both studies had in common were (1) What is the contribution of district nursing and other primary care services to care homes that do not have on-site nursing provision? (2) What strategies promote participation and collaboration between residents, care home staff and NHS primary care nursing staff? and (3) What are the current obstacles and aids to effective partnership working and learning? A total of 74 community-based nurses and care home managers and staff took part in 10 focus groups, while 124 care home managers (73% of the 171 surveyed) and 113 district nurse team leaders (80% of the 142 surveyed) participated in the surveys. Findings from both studies demonstrated that nurses were the most frequent NHS professional visiting care homes. Although care home managers and district nurses believed that they had a good working relationship, they had differing expectations of what the nursing contribution should be and how personal and nursing care were defined. This influenced the range of services that older people had access to and the amount of training and support care home staff received from district nurses and the extent to which they were able to develop collaborative and reciprocal patterns of working. Findings indicate that there is a need for community-based nursing services to adopt a more strategic approach that ensures older people in care homes can access the services they are entitled to and receive equivalent health care to older people who live in their own homes.

In Hong Kong, about 15% of older people (aged 80 and above) live in care homes, one of the highest proportions in the world. During the spread of severe acute respiratory syndrome in 2003, the crude fatality rate for older people in care homes that were infected was 72%. After taking the advice of a team of international experts, the Hong Kong Government implemented comprehensive preventive measures to cope with the future epidemics. This commentary evaluates the effectiveness of these measures in coping with both influenza outbreaks and COVID-19 and suggests the lessons learnt are relevant to both developed and less developed countries? Lockdown in care homes is very effective under two conditions. Healthcare workers must wear surgical masks in the care home. Hospitals must adopt a strict policy to prevent virus transmission by discharged patients. Care homes situated within high-rise residential towers are particularly vulnerable to COVID-19 transmission; their residents can more easily be infected by asymptomatic carriers from the community. Airborne virus can also be transmitted more swiftly in care homes with open-plan layouts. Lockdown had been shown to significantly reduce influenza outbreaks in care homes. On the other hand, lockdown causes loneliness to residents. Care homes allow residents to move freely within the care home though with the risk of spreading the virus by resident who is an asymptomatic carrier. Finally, lockdown may cause family members to have guilty feelings. Family members can only make video call or window visit to residents.

To develop, implement, evaluate, and disseminate an evidence-based, person-centred education program to protect the dignity of care-dependent older people with dementia and continence care needs in care homes. A mixed method two-phase design underpinned by integrated knowledge translation. An education program that frames dignity as the main goal of continence care will be co-designed with a purposive sample of care home staff who provide or supervise continence care for care-dependent older people with dementia in care homes and resident relatives. The program will then be implemented and evaluated in a representative sample of care home staff to determine its clinical relevance, feasibility, acceptability, and effects on staff ratings of dignity in continence care; self-reported continence care practices and the person centeredness of the environment. Data analysis will include descriptive statistics (survey data) and thematic analysis (focus groups). Funding obtained November 2018. Ethics approval obtained May 2019. This protocol outlines a mixed methods integrated knowledge translation protocol designed to translate principles about dignity into practice to improve the care of older people who are at risk of violations to their dignity in care homes. The outcome will be a contextually appropriate, evidence-based education program that protects the dignity of care-dependent older people who have dementia and continence care needs. Based on a sound theoretical model, the education program will be contextually appropriate for use in the care homes setting and contribute to improving the overall quality and safety of care in this setting. It could also support and inform continence care for other individuals who are care dependent. Adopting an integrated knowledge translation approach to the design and delivery of the education program and piloting it will ensure the program is contextually relevant and sustainable.

Age UK clinical lead Lesley Carter says research by the charity shows the impact of the pandemic on older people's mental health. [ABSTRACT FROM AUTHOR] Copyright of Nursing Older People is the property of RNCi and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

Purpose – The purpose of this paper is to outline the learning from an innovative approach to using volunteers as lay assessors in order to secure improvements in the quality of life of older people in care homes. Design/methodology/approach – The paper describes the implementation of pilot lay assessor scheme in Bristol and systematically explores the learning from this case study. Findings – The paper concludes that despite a number of important challenges and limitations, a lay assessor approach, particularly when conducted in close co-operation with a local council, can indeed provide demonstrable quality of life benefits for older people in closed institutions such as care homes. Practical implications – The case study highlights a number of key implications for practice including: it is possible to recruit, motivate and train volunteers to provide a lay assessor scheme; working with a local council and providers of care homes can produce real improvements in quality of life; lay assessor schemes are an important way of “shining a light” into closed institutions; defining quality of life and balancing this with institutional attitudes towards risk can be extremely challenging; and working with care home managers, providing them with ideas and support can be effective in bringing about meaningful change. Originality/value – This case study reports on one of the first volunteer lay assessor initiatives in the country. There has been very little if any reporting or analysis of such schemes. This paper therefore adds significantly to this important are of public policy and provision.

PurposeThe purpose of this paper is to describe the findings from a pilot and a follow-on study in which care assistants in care homes were trained to use sporting memories work to better help and engage with residents with dementia and low mood. Care homes have to support increasingly more fragile people and often the range of activities in the homes do not offer the best engagement between residents and staff to benefit the residents. This is for reasons of time to run activities in a busy home, and because of the need to find financially viable means of running a range of activities. Care assistants in care homes are a group of non-professionally educated workers and are often overlooked for training beyond basic health and safety training to help them improve their work and the care they provide. This work sought to explore whether sporting memories work was viable as an activity to offer in care homes via the training of care assistants.Design/methodology/approachThe paper discusses the evidence from a pilot and then follow-on project in care homes in one city area. In the pilot observation was made of a training session and follow up interviews were undertaken with care home managers to see how the implementation of sporting memories was going. In the follow-on project the support to those undertaking the training was modified to include three learning network sessions. Data were collected on the experience of participants and their use of sporting memories work.FindingsThe findings were that care assistants could be trained in using sporting memories work and they often found it easy to use and fulfilling for them and people they cared for. This was despite the care assistants who participated often not having much interest in sports and little experience in this kind of work. However, practical barriers to maintaining the use of sporting memories work did remain.Research limitations/implicationsThe evidence to date is of case studies of training staff in care homes in the use of sporting memories work, which provides good grounding for proof of the concept and key issues, but further research is needed on the costs and impacts of sporting memories work in care homes. The lack of direct feedback about experiences of care home residents of sporting memories work and its impact on them is a further limitation.Practical implicationsSporting memories work is a flexible and readily adoptable intervention to engage older people in care homes and the evidence to date is that care assistants in care homes can be trained to use this approach to engaging older people. Practical challenges still remain to using sporting memories work in care homes, notably the issue of time for staff to do the work, but it is an approach for care homes to have available to them to match up to the interests of residents.Social implicationsSporting memories work can be an important part of meeting some of the challenges society faces with an ageing population profile and to enhancing the care home environment and care assistants can be trained to use the approach.Originality/valueThis is the first paper to discuss training care home staff in the use of sporting memories work.

Geriatricians and care homes: perspectives from geriatric medicine departments and primary care trusts

BackgroundIn the UK there are almost three times as many beds in care homes as in National Health Service (NHS) hospitals. Care homes rely on primary health care for access to medical care and specialist services. Repeated policy documents and government reviews register concern about how health care works with independent providers, and the need to increase the equity, continuity and quality of medical care for care homes. Despite multiple initiatives, it is not known if some approaches to service delivery are more effective in promoting integrated working between the NHS and care homes. This study aims to evaluate the different integrated approaches to health care services supporting older people in care homes, and identify barriers and facilitators to integrated working.MethodsA systematic review was conducted using Medline (PubMed), CINAHL, BNI, EMBASE, PsycInfo, DH Data, Kings Fund, Web of Science (WoS incl. SCI, SSCI, HCI) and the Cochrane Library incl. DARE. Studies were included if they evaluated the effectiveness of integrated working between primary health care professionals and care homes, or identified barriers and facilitators to integrated working. Studies were quality assessed; data was extracted on health, service use, cost and process related outcomes. A modified narrative synthesis approach was used to compare and contrast integration using the principles of framework analysis.ResultsSeventeen studies were included; 10 quantitative studies, two process evaluations, one mixed methods study and four qualitative. The majority were carried out in nursing homes. They were characterised by heterogeneity of topic, interventions, methodology and outcomes. Most quantitative studies reported limited effects of the intervention; there was insufficient information to evaluate cost. Facilitators to integrated working included care home managers' support and protected time for staff training. Studies with the potential for integrated working were longer in duration.ConclusionsDespite evidence about what inhibits and facilitates integrated working there was limited evidence about what the outcomes of different approaches to integrated care between health service and care homes might be. The majority of studies only achieved integrated working at the patient level of care and the focus on health service defined problems and outcome measures did not incorporate the priorities of residents or acknowledge the skills of care home staff. There is a need for more research to understand how integrated working is achieved and to test the effect of different approaches on cost, staff satisfaction and resident outcomes.

Abuse of older people in care homes is an on-going problem. GPs, as the most frequent practitioner group visiting care homes, have an important role in detecting and reporting abuse. However, there is little research about GPs' experiences of working in care homes and how they work to safeguard residents. To explore the challenges experienced by GPs working in this unique environment and how these impact on safeguarding. An online survey collected qualitative data about GPs' experiences as visiting professionals to care homes, with an emphasis on safeguarding. A thematic analysis identified key themes. In total, 58 completed surveys were returned, with a range of practitioner experience represented (1-30 years). Approximately 70% were GP partners, with the remainder salaried and locum doctors. Over one third reported they had witnessed signs of definite or possible abuse within care homes. Emerging themes related to the complex care home context, in which residents had multiple health needs and GPs had to build multiple relationships with managers, carers, families, and residents. Difficulties in accessing information were reported; residents could not always provide information, GPs had to rely on others for information, and rarely had access to electronic records. GP work in care homes is a complex and skilled role, in which GPs encounter evidence of poor care and abuse. Key themes in respect of barriers and facilitators of good care were highlighted. The reliance on others for information and the need to build relationships with staff/managers may raise tensions in respect of safeguarding practice.

More people with an intellectual disability are now living to older age and there is a paucity of information about this group of people. Mental illness is 2-3 times more prevalent in people with an intellectual disability than in the general community; however, this often goes undiagnosed and undetected. Additional issues complicate assessment if the person is also ageing. Little is known about the prevalence and nature of mental illness in this group of older people. Instruments used to assist in the diagnosis of mental illness in the general community are not suitable for use with individuals who have an intellectual disability. The Developmental Behavioural Checklist for Adults (DBC-A) (Mohr, Tonge & Einfeld, 2005) is a well established screen for psychopathology; however, it has no standardised norms and has not been specifically validated for older adults. Lack of knowledge and inadequate assessment processes can result in inappropriate service delivery and therefore reduced quality of life for older people with an intellectual disability and their carers. The general aim of the research was to contribute knowledge about older people with an intellectual disability and more specifically to investigate their mental health. In addition, the validity of the DBC-A for use with older adults was examined. An epidemiological study of adults aged 55 years and older, who lived in representative areas in South Australia, and who were registered with intellectual disability service agencies, were surveyed. Familiar informants completed a questionnaire booklet (see Appendix A). The Adaptive Behaviour Dementia Questionnaire (ABDQ) (Prasher, Farooq & Holder, 2004) and, for a subset of the participants, the Dementia Screening Questionnaire for Individuals with Intellectual Disability (DSQIID) (Deb, Hare, Bhaumik et al., 2007a) were also completed (see Appendices F and G). There was a participation rate of 91.7% and participants’ ages ranged from 55-86 years, the majority being males (56.6%), except in the oldest cohort. Those aged 55-64 years appears to differ from those who are older and younger. They have more severe intellectual impairments, more chronic health conditions, they are less likely to be engaged in activities, and have fewer relationships. Those older than 65 years are more similar to older people without an intellectual disability except that more live in nursing homes or larger congregate care settings. Standardised normative data was established for the DBC-A for older people. The DBC-A profile showed age-associated decline in psychopathology; however, the intensity of behaviours was higher in older people with more severe cognitive impairment. Significant psychopathology was found in 16% of older adults. There were no gender differences but those with a moderate level of intellectual disability had the highest rates. Being younger, having fewer hours in activity, living in large congregate care and significant life events were all risk factors. Rates of dementia of between 5-7% were found using the ABDQ, DSQIID and respondent report. A dementia screen using items from the DBC-A (DBC-A Dem) identified almost double that number. There was no association between age and dementia status in this study, which differs from other research, as does the lack of relationship between having Down syndrome and dementia status. The results of this study confirm a picture of differential mortality and the presence of a healthy survivor cohort who have fewer chronic health problems and are more likely to have a mild level of intellectual disability. Although there is an age-related decline in the prevalence of mental illness, rates are still one and a half times more than older people who do not have an intellectual disability. With minor amendments, the DBC-A is a valid screening instrument for use with older people with an intellectual disability. It can record changes in a wide range of emotional and behaviour disturbances including those that may affect older people, including dementia. When used with other DBCs for children and adolescents (Einfeld & Tonge, 1995) it provides a simple and familiar way to record psychopathology throughout the lifespan. This offers clinicians, researchers and service providers a means to monitor and maintain the mental health and well-being of older people with an intellectual disability.

Since the introduction of care management in the early 1990s, older people in care homes are supposed to have their ‘care packages’ reviewed on at least an annual basis. The current system of reviewing needs to be understood in the context of an increasingly bureaucratised, deskilled and routinised system of statutory social care. By taking a very narrow consumerist approach to reviews, not only are both Review Officer and service user often alienated from the process, but the system can often add to rather than combat disempowerment. Care home residents are one of the most powerless groups in society with few opportunities to gain control over their living circumstances. The discussion raises the issue of whether residential care home reviews should always seek to involve independent advocates; as policy allows but seldom happens in practice. If this is the case, then this raises further issues of how to ensure such a service is available to all.