Specialist nursing and community support for the carers of people with dementia living at home: an evidence synthesis

Barriers to accessing and receiving mental health care for paid and unpaid carers of older adults

AIM

The aim of this qualitative study was to explore the barriers and facilitators to accessing and receiving mental health care for paid and unpaid carers of older adults.

METHODS

Unpaid and paid carers for older adults in England were interviewed remotely between May and December 2022. Participants were asked about their experiences of mental health needs and support. Reflexive thematic analysis was used to analyse the data.

RESULTS

Thirty-seven carers participated (npaid = 9; nunpaid = 28), with the majority caring for a parent with dementia. Thematic analysis generated four themes: lack of healthcare support, social care system failing to enable time off, personal barriers and unsupportive work culture. Healthcare professionals failed to provide any link to mental health services, including when a dementia diagnosis was received. Structural and organisational barriers were evidenced by carers being unable to take time off from their unpaid caring duties or paid caring role, due to an absence of social care support for their relative.

CONCLUSIONS

This is the first study to have explored the barriers to mental health care and support for paid and unpaid carers for older adults and suggests that structural, organisational and personal barriers cause severe difficulties in accessing required support to care for older relatives, services users and residents.

PUBLIC INVOLVEMENT

Two unpaid carers aided with the development of topic guides, data analysis, interpretation and dissemination. Both were supported and trained to code anonymised transcripts.

Co-design of the EMBED-Care Framework as an intervention to enhance shared decision-making for people affected by dementia and practitioners, comprising holistic assessment, linked with clinical decision support tools: A qualitative study

INTRODUCTION

Shared decision-making intends to align care provision with individuals' preferences. However, the involvement of people living with dementia in decision-making about their care varies. We aimed to co-design the EMBED-Care Framework, to enhance shared decision-making between people affected by dementia and practitioners.

METHODS

A theory and evidence driven co-design study was conducted, using iterative workshops, informed by a theoretical model of shared decision-making and the EMBED-Care Framework (the intervention) for person-centred holistic palliative dementia care. The intervention incorporates a holistic outcome measure for assessment and review, linked with clinical decision-support tools to support shared decision-making. We drew on the Medical Research Council (MRC) guidance for developing and evaluating complex interventions. Participants included people with dementia of any type, current or bereaved family carers and practitioners. We recruited via established dementia groups and research and clinical networks. Data were analysed using reflexive thematic analysis to explore how and when the intervention could enhance communication and shared decision-making, and the requirements for use, presented as a logic model.

RESULTS

Five co-design workshops were undertaken with participants comprising people affected by dementia (n = 18) and practitioners (n = 36). Three themes were generated, comprising: (1) 'knowing the person and personalisation of care', involving the person with dementia and/or family carer identifying the needs of the person using a holistic assessment. (2) 'engaging and considering the perspectives of all involved in decision-making' required listening to the person and the family to understand their priorities, and to manage multiple preferences. (3) 'Training and support activities' to use the Framework through use of animated videos to convey information, such as to understand the outcome measure used to assess symptoms.

CONCLUSIONS

The intervention developed sought to enhance shared decision-making with individuals affected by dementia and practitioners, through increased shared knowledge of individual priorities and choices for care and treatment. The workshops generated understanding to manage disagreements in determining priorities. Practitioners require face-to-face training on the intervention, and on communication to manage sensitive conversations about symptoms, care and treatment with individuals and their family. The findings informed the construction of a logic model to illustrate how the intervention is intended to work.

Interventions for Caregivers of Older Adults with Dementia Living in the Community: A Rapid Review of Reviews

This rapid review of systematic reviews examines non-professional interventions that have been implemented to support family caregivers of older adults with dementia who are living in the community. There is a robust body of empirical literature examining such interventions for family caregivers; therefore, this rapid review includes only systematic reviews. MEDLINE, CINAHL, and EMBASE databases were searched from September 2020 to December 2020, and 19 systematic reviews were selected for a full review. Psychosocial, psychoeducational, social support, and multicomponent interventions consistently show positive impacts on a variety of outcomes. The evidence suggests that multicomponent interventions that are tailored to the needs of individual caregivers are the most impactful interventions and should be utilized in future program development. The most effective combination of interventions is unknown and warrants further investigation. However, the repeated success of psychoeducational, psychosocial, and social support interventions suggests that when used together, they may be a successful combination that contributes to positive impacts on caregivers. This multicomponent intervention should be flexible, as interventions are most effective when they are tailored to the individual needs of caregivers and adapted over time as the needs of the caregiver and person living with dementia change with disease progression.

Effectiveness of interventions designed to mitigate the negative health outcomes of informal caregiving to older adults: an umbrella review of systematic reviews and meta-analyses

OBJECTIVES

This umbrella review aimed to evaluate whether certain interventions can mitigate the negative health consequences of caregiving, which interventions are more effective than others depending on the circumstances, and how these interventions are experienced by caregivers themselves.

DESIGN

An umbrella review of systematic reviews was conducted.

DATA SOURCES

Quantitative (with or without meta-analyses), qualitative and mixed-methods systematic reviews were included.

ELIGIBILITY CRITERIA

Reviews were considered eligible if they met the following criteria: included primary studies targeting informal (ie, unpaid) caregivers of older people or persons presenting with ageing-related diseases; focused on support interventions and assessed their effectiveness (quantitative reviews) or their implementation and/or lived experience of the target population (qualitative reviews); included physical or mental health-related outcomes of informal caregivers.

DATA EXTRACTION AND SYNTHESIS

A total of 47 reviews were included, covering 619 distinct primary studies. Each potentially eligible review underwent critical appraisal and citation overlap assessment. Data were extracted independently by two reviewers and cross-checked. Quantitative review results were synthesised narratively and presented in tabular format, while qualitative findings were compiled using the mega-aggregation framework synthesis method.

RESULTS

The evidence regarding the effectiveness of interventions on physical and mental health outcomes was inconclusive. Quantitative reviews were highly discordant, whereas qualitative reviews only reported practical, emotional and relational benefits. Multicomponent and person-centred interventions seemed to yield highest effectiveness and acceptability. Heterogeneity among caregivers, care receivers and care contexts was often overlooked. Important issues related to the low quality of evidence and futile overproduction of similar reviews were identified.

CONCLUSIONS

Lack of robust evidence calls for better intervention research and evaluation practices. It may be warranted to avoid one-size-fits-all approaches to intervention design. Primary care and other existing resources should be leveraged to support interventions, possibly with increasing contributions from the non-profit sector.

PROSPERO REGISTRATION NUMBER

CRD42021252841; BMJ Open: doi:10.1136/bmjopen-2021-053117.

Effectiveness and sustainability of volunteering with older people living in care homes: A mixed methods systematic review

Older people living in care homes should be considered part of the wider local community; however, little is known about what enables them to connect with people not paid to look after them or family members. Volunteering can complement paid and familial support. While volunteering is common in community settings, care home residents are less likely to benefit from their input. We conducted a mixed methods systematic review and stakeholder consultation that aimed to identify volunteer activities in care homes and evidence for their effectiveness and sustainability. Databases were searched from 2000 to July 2021. Studies of all designs reporting volunteer-led activities with care home residents 65-years or over were included. Data on interventions, study population, study context, outcomes and implementation issues were extracted and synthesised. We identified 36 studies on the use, effectiveness and implementation of volunteering in care homes, although the overall strength of evidence was weak. Resident engagement and mood appeared to improve during volunteer-led activities, but there was little research examining the longer-term impact. Qualitative and stakeholder data suggest considerable investment is needed to initiate and maintain volunteering initiatives, but there are positive benefits for volunteers, residents and staff if an intervention is sustained. Financial cost for care home facilities is unclear. Interventions that address inequalities in accessing volunteer support within the resident population and between facilities should be considered.

Specialist nursing case management support for carers of people with dementia: A qualitative study comparing experiences of carers with and without Admiral Nursing

Carers of people with dementia can experience reduced health and well-being, but little is known about how best to support them. There is some evidence to suggest that case management may improve outcomes for carers but less evidence about the features of case management services that can effectively support carers of people with dementia. Admiral Nursing operates a case management approach staffed by specialist nurses and is the only service of its kind in the United Kingdom dedicated to helping people with dementia and their carers. This paper reports qualitative findings from a mixed methods study of Admiral Nursing. For the qualitative strand of the project, data were collected in focus groups and in-depth interviews with carers of people with dementia (n = 35) and analysed thematically using the framework approach. The aim of this analysis was to understand differences between the experiences of the carers in our sample with and without Admiral Nursing, applying Freeman's model of continuity of care (Freeman et al., Continuity of care, 2000). Participants who had received Admiral Nursing were recruited from two geographical locations and carers without experience of this service were recruited from two different areas. We found that carers in our sample felt 'supported' in circumstances where they received an ongoing service from an Admiral Nurse or other professional with expertise in dementia who was able to develop a meaningful relationship with them over time. We conclude that ongoing support, expertise in dementia and a meaningful relationship are key features of relationship continuity common in carers' reports of feeling supported. Specialist nurses are well placed to provide this continuity.

Resource allocation in dementia care: comparing the views of people with dementia, carers and health and social care professionals under constrained and unconstrained budget scenarios

BACKGROUND

People with dementia and their carers have a wide range of health and social care needs. People with dementia, carers and health and social care professionals (HSCPs) all have different perspectives on dementia care. Differences among these groups are important for commissioners of services and for front-line HSCPs.

OBJECTIVE

To compare the service recommendations of people with dementia and carers with those of HSCPs, under different budgetary conditions.

METHODS

A mixed-methods approach, which builds on the Balance of Care method, was used. Nine workshops were held with 41 participants from three groups: people with dementia, carers and HSCPs. Participants were asked to make decisions on a set of services for case types of dementia under two scenarios: a no budget constraint (NBC) scenario and a budget constraint (BC) scenario.

RESULTS

While each group allocated resources in broadly similar overall proportions, important differences in emphasis emerged: (i) people with dementia and carers placed more emphasis on psychosocial supports than HSCPs; (ii) carers put more emphasis on respite opportunities for carers; and (iii) carers identified residential care as the most suitable setting for the person with dementia more frequently than health care professionals.

CONCLUSION

Our findings suggest that the importance of psychosocial interventions, including counselling and peer support programmes, are currently underestimated by HSCPs. The provision of in-home respite is highly valued by carers. Even with unconstrained resources, some carers do not judge home care to be a viable option for dementia case types with high-level care needs.

Facilitating social coping-'seeking emotional and practical support from others'-as a critical strategy in maintaining the family care of people with dementia

The aim of this study was to identify how the family care of people living with dementia could be supported to make reliance on family care sustainable in the long term despite the impact of stress. A Realist Evaluation (Pawson & Tilley, 1997) was conducted to investigate this aim. An initial review established 'coping' as a primary means of mediating stressors associated with caregiving. However, there was a need to specify which coping approaches/strategies are most effective. In-depth interviews were conducted with a purposive sample of family carers (n = 18) in a suburb in North East England from 2016 to 2017. Analysis of the data revealed 'social coping' (SC) that included an emotional support component as a critical mediator of family carer stress. Several key hindrances to the utilisation of SC, including underpinning causal factors, are explicated. Ways in which these hindrances might be overcome are discussed and guidelines introduced for how family carers, formal providers and practitioners can facilitate SC as a critical coping strategy in sustaining the family care of people with dementia over the long term.

"Nobody Seems to Know Where to Even Turn To": Barriers in Accessing and Utilising Dementia Care Services in England and The Netherlands

BACKGROUND

Accessing post-diagnostic care can be difficult for people with dementia and their informal carers. Little is known, however, about the determinants of barriers to access, and how these might vary between countries. The aim of this study was to explore potential inequalities in access to formal dementia care services between England and the Netherlands, specifically from more disadvantaged areas.

METHODS

This was a mixed-methods study, involving semi-structured qualitative interviews and a carer questionnaire. People with dementia and informal carers were recruited by clinicians. The postal survey was co-produced with people with dementia, informal carers, and health care professionals. The survey asked carers about their own and their relatives with dementia's, social support service usage and financing; as well as how they were made aware of services and whether they required more support. Qualitative transcripts were analysed by two researchers in each country using thematic analysis.

RESULTS

A total of 103 carer questionnaires were received by post and 13 interviews were conducted with people with dementia and family carers between January 2020 and April 2020. Many services were accessed via self-funding. Thematic analysis generated five core themes: Health literacy; Having faith and lack of faith; Service suitability; Structural issues surrounding service provision; and Financing care. One major difference between both country's systems of care were the case manager and network support which people with dementia and carers benefitted from in the Netherlands, which was rarely the case in the UK.

CONCLUSIONS

People with dementia and informal carers need to be supported better in accessing formal dementia care services in both the UK and the Netherlands, whilst some learning can be taken to improve access.

Review of Technology-Supported Multimodal Solutions for People with Dementia

The number of people living with dementia in the world is rising at an unprecedented rate, and no country will be spared. Furthermore, neither decisive treatment nor effective medicines have yet become effective. One potential alternative to this emerging challenge is utilizing supportive technologies and services that not only assist people with dementia to do their daily activities safely and independently, but also reduce the overwhelming pressure on their caregivers. Thus, for this study, a systematic literature review is conducted in an attempt to gain an overview of the latest findings in this field of study and to address some commercially available supportive technologies and services that have potential application for people living with dementia. To this end, 30 potential supportive technologies and 15 active supportive services are identified from the literature and related websites. The technologies and services are classified into different classes and subclasses (according to their functionalities, capabilities, and features) aiming to facilitate their understanding and evaluation. The results of this work are aimed as a base for designing, integrating, developing, adapting, and customizing potential multimodal solutions for the specific needs of vulnerable people of our societies, such as those who suffer from different degrees of dementia.

Informal caregivers and persons with dementia's everyday life coping

This qualitative study explores informal caregivers' experiences of supporting persons with dementia's everyday life coping. In the future, there will be fewer health personnel, increased dementia prevalence and limited nursing home availability. Accordingly, close relatives may be compelled to assume greater care responsibilities. Knowledge concerning persons with dementia's everyday coping from the perspective of informal caregivers remains insufficient, despite these people's importance for those with dementia. This investigation analyses informal caregivers' perceived challenges and pleasures in providing care, how home health care affects everyday life coping and the factors that are most important to informal caregivers in supporting care receivers.

Admiral Nursing-A Model of Specialist Dementia Care in Acute Hospitals

Introduction

The rising prevalence of dementia has led to increased numbers of people with dementia being admitted to acute hospitals. This demand is set to continue due to an increasingly older population who are likely to have higher levels of dependency, dementia, and comorbidity. If admitted to the hospital, people with dementia are at higher risk of poor outcomes during and following a hospital admission. Yet, there remains a significant lack of specialist support within acute hospitals to support people with dementia, their families and hospital staff.

Methods

Admiral Nurses are specialists that work with families affected by dementia and provide consultancy and support to health and social care colleagues to improve the delivery of evidenced based dementia care. Historically, Admiral Nurses have predominantly been based in community settings. In response to the increasing fragmentation of services across the dementia trajectory, the Admiral Nurse model is evolving and adapting to meet the complex needs of families impacted upon by dementia inclusive of acute hospital care.

Results

The Admiral Nurse acute hospital model provides specialist interventions which improve staff confidence and competence and enables positive change by improving skills and knowledge in the provision of person-centred dementia care. The role has the capacity to address some of the barriers to delivering person centred dementia care in the acute hospital and contribute to improvements across the hospital both as a result of direct interventions or influencing the practice of others.

Conclusion

Improving services for people with dementia and their families requires a whole system approach to enable care coordination and service integration, this must include acute hospital care. The increasing numbers of people with dementia in hospitals, and the detrimental effects of admission, make providing equitable, consistent, safe, quality care and support to people with dementia and their families a national priority requiring immediate investment. The inclusion of Admiral Nursing within acute hospital services supports service and quality improvement which positively impacts upon the experience and outcomes for families affected by dementia.

CCCDTD5: Individual and community-based psychosocial and other non-pharmacological interventions to support persons living with dementia and their caregivers

INTRODUCTION

Current pharmacological therapies for dementia have limited efficacy. Thus it is important to provide recommendations on individual and community-based psychosocial and non-pharmacological interventions for persons living with dementia (PLWDs) and their caregivers.

METHODS

Phase 1: A systematic review for developing recommendations on psychosocial and non-pharmacological interventions at the individual and community level for PLWDs and their caregivers. Phase 2: Rating of recommendations using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) guidelines. Phase 3: Delphi process (>50 dementia experts) for approving recommendations by the 5th Canadian Consensus Conference on the Diagnosis and Treatment of Dementia (CCCDTD5).

RESULTS

The CCCDTD5 approved the following recommendations: Exercise (1B) and group cognitive stimulation for PLWDs (2B), psychosocial and psychoeducational interventions for caregivers (2C), development of dementia friendly organization and communities (2C), and case management for PLWDs (2B).

DISCUSSION

The CCCDTD5 provides for the first time, evidence-based recommendations on psychosocial and non-pharmacological interventions for PLWDs and their caregivers that can inform evidence-based policies for PLWDs in Canada.

Recommendations of the 5th Canadian Consensus Conference on the diagnosis and treatment of dementia

Since 1989, four Canadian Consensus Conferences on the Diagnosis and Treatment of Dementia (CCCDTD) have provided evidence-based dementia guidelines for Canadian clinicians and researchers. We present the results of the 5th CCCDTD, which convened in October 2019, to address topics chosen by the steering committee to reflect advances in the field, and build on previous guidelines. Topics included: (1) utility of the National Institute on Aging research framework for clinical Alzheimer's disease (AD) diagnosis; (2) updating diagnostic criteria for vascular cognitive impairment, and its management; (3) dementia case finding and detection; (4) neuroimaging and fluid biomarkers in diagnosis; (5) use of non-cognitive markers of dementia for better dementia detection; (6) risk reduction/prevention; (7) psychosocial and non-pharmacological interventions; and (8) deprescription of medications used to treat dementia. We hope the guidelines are useful for clinicians, researchers, policy makers, and the lay public, to inform a current and evidence-based approach to dementia.

What do family care-givers want from domiciliary care for relatives living with dementia? A qualitative study

In the current ecology of care, social, rather than medical, support is critical in enabling frail older people to live at home. This paper reports findings from a qualitative study about how home care workers (HCWs) support persons with dementia living in the community. Semi-structured qualitative interviews were carried out in England with 14 family care-givers (FCGs) recruited from a single private home care provider. A thematic analysis of the data was undertaken using the constant comparative method. In every instance, it was FCGs who initiated domiciliary care for the person with dementia, highlighting ambiguity about who is the ‘client’. Rather than focusing on the HCWs’ work in undertaking practical tasks and personal care, respondents prioritised HCWs as companions, providing emotional and social support for their relatives. From an organisational perspective, respondents valued the capacity of the provider to deliver a consistent, personal, reliable and punctual service. These attributes were important in supporting their relative's agency and dignity. Respondents described HCWs engaging in skilled and sensitive communication with clients but considered ‘character’ and ‘innate’ caring abilities to be more important than those derived from training. The results highlight the need to acknowledge the family, rather than the individual client, as the functioning unit of care, and to recognise the highly skilled communicative and emotional work undertaken by HCWs.

Developing the New Interventions for independence in Dementia Study (NIDUS) theoretical model for supporting people to live well with dementia at home for longer: a systematic review of theoretical models and Randomised Controlled Trial evidence

PURPOSE

To build an evidence-informed theoretical model describing how to support people with dementia to live well or for longer at home.

METHODS

We searched electronic databases to August 2018 for papers meeting predetermined inclusion criteria in two reviews that informed our model. We scoped literature for theoretical models of how to enable people with dementia to live at home independently, with good life quality or for longer. We systematically reviewed Randomised Controlled Trials (RCTs) reporting psychosocial intervention effects on time lived with dementia at home. Two researchers independently rated risk of bias. We developed our theoretical model through discussions with experts by personal, clinical and academic experiences, informed by this evidence base.

RESULTS

Our scoping review included 52 studies. We divided models identified into: values and approaches (relational and recovery models; optimising environment and activities; family carer skills and support); care strategies (family carer-focused; needs and goal-based; self-management); and service models (case management; integrated; consumer-directed). The 11 RCTs included in our systematic review, all judged at low risk of bias, described only two interventions that increased time people with dementia lived in their own homes. These collectively encompassed all these components except for consumer-directed and integrated care. We developed and revised our model, using review evidence and expert consultation to define the final model.

CONCLUSIONS

Our theoretical model describes values, care strategies and service models that can be used in the design of interventions to enable people with dementia to live well and for longer at home.

TRIAL REGISTRATION

PROSPERO 2018 registration number: CRD42018099693 (scoping review). PROSPERO 2018 registration number: CRD42018099200 (RCT systematic review).

Dementia care-giving and employment: a mixed-studies review on a presumed conflict

Many persons with dementia live at home and are cared for by their relatives. If the relatives are still employed, this can lead to higher burden and losses in their work-life. The interplay between informal care-giving and working is complex. Different studies have explored this issue, but the results have not been yet synthesised. In this mixed-studies review, we elucidate the underlying complexity. Our objective is to identify the factors related to care-giving that influence employment, and to describe their impact on dementia care-givers’ employment. We performed a literature search of primary studies using four databases and one meta-database, and retrieved English- and German-language articles. We used the Mixed Methods Appraisal Tool to assess their methodological quality. Evidence identified was synthesised by a parallel-results convergent synthesis design. We included 55 qualitative, quantitative and mixed-method studies published up to January 2018. The emerging model identified factors linked to the care recipient with dementia, the informal care-giver and the care-giving context. The impacts of these factors on care-givers’ employment are mostly negative (e.g. stopped/reduced work, decreased job performance). Nevertheless, the results provide encouraging insights as working can counterbalance care-giving strain, and managing both roles can enhance care-givers’ wellbeing. Practical efforts should focus on enabling informal care-givers to better manage the balance between care-giving and work responsibilities.

I becomes we, but where is me? The unity-division paradox when caring for a relative with dementia: A qualitative study

BACKGROUND

The number of older people living with dementia is increasing. Admiral Nurses work with these individuals and their families in the UK to manage challenges associated with the condition, providing guidance, advice and reassurance, alongside practical solutions.

AIM

To explore the input of Admiral Nurses as part of people's journey to becoming and being a carer for someone with dementia.

DESIGN

A qualitative study was conducted to describe and understand how Admiral Nurses are experienced and encountered by carers as part of their narrative around supporting a relative with dementia.

METHODS

Semi-structured interviews were conducted with 19 carers between November 2017-April 2018. They lasted between 45 and 90 min. Thematic analysis was used to interpret data.

FINDINGS

An overarching concept of "the unity-division paradox" was derived from the data. This highlights the complex interchange between the carer with (a) the person with dementia, (b) other individuals and (c) external services. Such interactions can make carers feel part of a larger network (unity) but also as if they are on their own, fighting on behalf of the person with dementia (division). This concept was underpinned by the following themes: (a) I becomes we; (b) My private world is encroached by dementia; (c) I'm left navigating an unwieldy system; (d) Are you with or against us?; and (e) Recreating boundaries to rediscover me.

CONCLUSION

The identity and unique characteristics and interests of those caring for a person with dementia may be lost as they encounter tensions associated with the unity-division paradox. Admiral Nurses can help carers feel less alone in managing internal and external struggles by supporting them to do their best for a loved one with dementia.

IMPLICATIONS FOR PRACTICE

Understanding carers' experience and supporting their work may help to increase and sustain their capacity to provide care.

Barriers and facilitators to the implementation of doctor-nurse substitution strategies in primary care: a qualitative evidence synthesis

BACKGROUND

Having nurses take on tasks that are typically conducted by doctors (doctor-nurse substitution, a form of 'task-shifting') may help to address doctor shortages and reduce doctors' workload and human resource costs. A Cochrane Review of effectiveness studies suggested that nurse-led care probably leads to similar healthcare outcomes as care delivered by doctors. This finding highlights the need to explore the factors that affect the implementation of strategies to substitute doctors with nurses in primary care. In our qualitative evidence synthesis (QES), we focused on studies of nurses taking on tasks that are typically conducted by doctors working in primary care, including substituting doctors with nurses or expanding nurses' roles.

OBJECTIVES

(1) To identify factors influencing implementation of interventions to substitute doctors with nurses in primary care. (2) To explore how our synthesis findings related to, and helped to explain, the findings of the Cochrane intervention review of the effectiveness of substituting doctors with nurses. (3) To identify hypotheses for subgroup analyses for future updates of the Cochrane intervention review.

SEARCH METHODS

We searched CINAHL and PubMed, contacted experts in the field, scanned the reference lists of relevant studies and conducted forward citation searches for key articles in the Social Science Citation Index and Science Citation Index databases, and 'related article' searches in PubMed.

SELECTION CRITERIA

We constructed a maximum variation sample (exploring variables such as country level of development, aspects of care covered and the types of participants) from studies that had collected and analysed qualitative data related to the factors influencing implementation of doctor-nurse substitution and the expansion of nurses' tasks in community or primary care worldwide. We included perspectives of doctors, nurses, patients and their families/carers, policymakers, programme managers, other health workers and any others directly involved in or affected by the substitution. We excluded studies that collected data using qualitative methods but did not analyse the data qualitatively.

DATA COLLECTION AND ANALYSIS

We identified factors influencing implementation of doctor-nurse substitution strategies using a framework thematic synthesis approach. Two review authors independently assessed the methodological strengths and limitations of included studies using a modified Critical Appraisal Skills Programme (CASP) tool. We assessed confidence in the evidence for the QES findings using the GRADE-CERQual approach. We integrated our findings with the evidence from the effectiveness review of doctor-nurse substitution using a matrix model. Finally, we identified hypotheses for subgroup analyses for updates of the review of effectiveness.

MAIN RESULTS

We included 66 studies (69 papers), 11 from low- or middle-income countries and 55 from high-income countries. These studies found several factors that appeared to influence the implementation of doctor-nurse substitution strategies. The following factors were based on findings that we assessed as moderate or high confidence.Patients in many studies knew little about nurses' roles and the difference between nurse-led and doctor-led care. They also had mixed views about the type of tasks that nurses should deliver. They preferred doctors when the tasks were more 'medical' but accepted nurses for preventive care and follow-ups. Doctors in most studies also preferred that nurses performed only 'non-medical' tasks. Nurses were comfortable with, and believed they were competent to deliver a wide range of tasks, but particularly emphasised tasks that were more health promotive/preventive in nature.Patients in most studies thought that nurses were more easily accessible than doctors. Doctors and nurses also saw nurse-doctor substitution and collaboration as a way of increasing people's access to care, and improving the quality and continuity of care.Nurses thought that close doctor-nurse relationships and doctor's trust in and acceptance of nurses was important for shaping their roles. But nurses working alone sometimes found it difficult to communicate with doctors.Nurses felt they had gained new skills when taking on new tasks. But nurses wanted more and better training. They thought this would increase their skills, job satisfaction and motivation, and would make them more independent.Nurses taking on doctors' tasks saw this as an opportunity to develop personally, to gain more respect and to improve the quality of care they could offer to patients. Better working conditions and financial incentives also motivated nurses to take on new tasks. Doctors valued collaborating with nurses when this reduced their own workload.Doctors and nurses pointed to the importance of having access to resources, such as enough staff, equipment and supplies; good referral systems; experienced leaders; clear roles; and adequate training and supervision. But they often had problems with these issues. They also pointed to the huge number of documents they needed to complete when tasks were moved from doctors to nurses.

AUTHORS' CONCLUSIONS

Patients, doctors and nurses may accept the use of nurses to deliver services that are usually delivered by doctors. But this is likely to depend on the type of services. Nurses taking on extra tasks want respect and collaboration from doctors; as well as proper resources; good referral systems; experienced leaders; clear roles; and adequate incentives, training and supervision. However, these needs are not always met.

Familial caregivers' experiences with home-visit nursing for persons with dementia who live alone

AIM

The Japanese Comprehensive Strategy to Accelerate Dementia Measures, known as the New Orange Plan, aims to support people with dementia living in their communities. Home-visit nurses (HVN) are expected to play an important role in this comprehensive support system. In this preliminary study, we explored caregivers' experiences before and after implementation of HVN care for persons with dementia who lived alone.

METHODS

This study was a qualitative descriptive design using in-depth interviews with five family caregivers of persons with dementia who lived alone while receiving HVN. Thematic content analysis was undertaken.

RESULTS

Before receiving HVN, caregivers experienced anxiety and embarrassment due to the occurrence of dementia symptoms, and they also experienced considerable isolation and anguish after hearing the diagnosis. After initiating HVN, caregivers gained a feeling of security and an alleviation of psychological stress. They also gained a deeper understanding of the disease and appropriate care for dementia patients. Notably, caregivers perceived not only positive changes in themselves, but also in the recipients, such as improvements in symptoms and quality of life. Finally, caregivers realized that people with dementia can live alone if appropriate services are provided.

CONCLUSION

HVN can have a positive impact on family caregivers involved in dementia care, as well as on the recipients' psychological status. Overall, the experience of HVN made the family caregivers more positive about home care for their family member with dementia. Although further case studies are needed to make definitive conclusions, we believe that HVN could play a key role in the forthcoming New Orange Plan.

Evaluation of an integrated service delivering post diagnostic care and support for people living with dementia and their families

Greater integration of health and social care services is considered vital to ensure sustainable long-term quality provision for the growing numbers of people living with dementia and their families. Integration of services is at the heart of government policy in England. We evaluated a new integrated service for post diagnostic dementia care, funded as a pilot and delivered through a partnership of statutory and voluntary sector health and social care organisations. The service used an adapted Admiral Nursing service model with a workforce of Admiral Nurses (ANs) and Dementia Advisers (DAs). A mixed method approach was used to assess implementation and outcomes. It involved collection of service activity data, carer reported experience survey data, focus group discussions and interviews with the service delivery team, and the management group. Qualitative data was analysed using a framework approach. About 37.8% of the eligible population registered with the service over the 14-month pilot period. The self-referral route accounted for the majority of referrals, and had enabled those not currently receiving specialist dementia care to engage with the service. Carer satisfaction surveys indicated high levels of satisfaction with the service. The caseload management system offered specific benefits. Individual caseloads ensured continuity of care while the integrated structure facilitated seamless transfer between or shared working across AN and DA caseloads. The skill mix facilitated development of the DA role increasing their potential contribution to dementia care. Challenges included managing large workloads and agreeing responsibilities across the skill mix of staff. This model of fully integrated service offers a novel approach to address the problems of fragmented provision by enabling joined-up working across health and social care.

Managing diabetes in people with dementia: a realist review

BACKGROUND

Dementia and diabetes mellitus are common long-term conditions that coexist in a large number of older people. People living with dementia and diabetes may be at increased risk of complications such as hypoglycaemic episodes because they are less able to manage their diabetes.

OBJECTIVES

To identify the key features or mechanisms of programmes that aim to improve the management of diabetes in people with dementia and to identify areas needing further research.

DESIGN

Realist review, using an iterative, stakeholder-driven, four-stage approach. This involved scoping the literature and conducting stakeholder interviews to develop initial programme theories, systematic searches of the evidence to test and develop the theories, and the validation of programme theories with a purposive sample of stakeholders.

PARTICIPANTS

Twenty-six stakeholders (user/patient representatives, dementia care providers, clinicians specialising in dementia or diabetes and researchers) took part in interviews and 24 participated in a consensus conference.

DATA SOURCES

The following databases were searched from 1990 to March 2016: MEDLINE (PubMed), Cumulative Index to Nursing and Allied Health Literature, Scopus, The Cochrane Library (including the Cochrane Database of Systematic Reviews), Database of Abstracts of Reviews of Effects, the Health Technology Assessment (HTA) database, NHS Economic Evaluation Database, AgeInfo (Centre for Policy on Ageing - UK), Social Care Online, the National Institute for Health Research (NIHR) portfolio database, NHS Evidence, Google (Google Inc., Mountain View, CA, USA) and Google Scholar (Google Inc., Mountain View, CA, USA).

RESULTS

We included 89 papers. Ten papers focused directly on people living with dementia and diabetes, and the rest related to people with dementia or diabetes or other long-term conditions. We identified six context-mechanism-outcome (CMO) configurations that provide an explanatory account of how interventions might work to improve the management of diabetes in people living with dementia. This includes embedding positive attitudes towards people living with dementia, person-centred approaches to care planning, developing skills to provide tailored and flexible care, regular contact, family engagement and usability of assistive devices. A general metamechanism that emerges concerns the synergy between an intervention strategy, the dementia trajectory and social and environmental factors, especially family involvement. A flexible service model for people with dementia and diabetes would enable this synergy in a way that would lead to the improved management of diabetes in people living with dementia.

LIMITATIONS

There is little evidence relating to the management of diabetes in people living with dementia, although including a wider literature provided opportunities for transferable learning. The outcomes in our CMOs are largely experiential rather than clinical. This reflects the evidence available. Outcomes such as increased engagement in self-management are potential surrogates for better clinical management of diabetes, but this is not proven.

CONCLUSIONS

This review suggests that there is a need to prioritise quality of life, independence and patient and carer priorities over a more biomedical, target-driven approach. Much current research, particularly that specific to people living with dementia and diabetes, identifies deficiencies in, and problems with, current systems. Although we have highlighted the need for personalised care, continuity and family-centred approaches, there is much evidence to suggest that this is not currently happening. Future research on the management of diabetes in older people with complex health needs, including those with dementia, needs to look at how organisational structures and workforce development can be better aligned to the needs of people living with dementia and diabetes.

STUDY REGISTRATION

This study is registered as PROSPERO CRD42015020625.

FUNDING

The NIHR HTA programme.

Post-diagnostic support for dementia

Purpose

The purpose of this paper is to examine three interpretations of post-diagnostic support (PDS) for dementia, to understand how best to support people recently diagnosed with dementia.

Design/methodology/approach

A sequential mixed-method approach was used which included analysis of the data collected by each sector, a focus group and interviews with PDS linkworkers and other staff.

Findings

All three sectors used a mix of supported self-management workshops and one-to-one PDS, however sectors varied by linkworker’s affiliation, caseload management and client group. Caseload varied greatly between sectors. Stage of disease and socioeconomic make-up of the local population were raised as factors determining the form of PDS offered. Some pillars appeared to be more easily achieved than others. There was a general agreement among all staff that “caseload” was misleading and that a measurement of workload would be preferable. Agile/mobile working was preferred by linkworkers. Even within teams there was variation in perceptions of PDS; some felt the linkworker role to be one of signposting, while others felt more involved with their client group, and for longer than 12 months.

Practical implications

Guidance at the outset of the PDS programme was sparse. The findings of this study should inform future development of the PDS model and a supporting guidance framework.

Originality/value

There is a growing interest in PDS for dementia. However, little is known about what a model of PDS should look like. This study attempts to capture the most important aspects of PDS delivery.

Volunteer peer support and befriending for carers of people living with dementia: An exploration of volunteers' experiences

With ageing populations and greater reliance on the voluntary sector, the number of volunteer-led peer support and befriending services for carers of people with dementia in England is set to increase. However, little is known about the experiences of the volunteers who deliver these interventions, many of whom are former carers. Using in-depth semi-structured interviews with 10 volunteer peer supporters and befrienders, this exploratory study investigated volunteers' experiences of delivering the support, the types of relationships they form with carers and their perceptions of its impact upon them and on carers. Data were analysed using framework analysis. Findings showed that volunteers benefitted from their role due to the 'two-way' flow of support. Experiential similarity and having common interests with carers were considered important to the development of mutually beneficial relationships. Volunteers perceived that carers gained emotional and social support, which in turn improved the carers' coping ability. Being able to see positive changes to carers' lives was important for volunteers to gain enjoyment and satisfaction from their role. However, volunteers also identified challenges with their role, such as dealing with carers' emotions. Future research should investigate ways of reducing potential burden on volunteers and explore the impact of volunteering specifically on former carers of people with dementia.

Effect of preceding home-visit nursing on time to discharge in hospitalization for the treatment of behavioural and psychological symptoms of dementia among patients with limited familial care

BACKGROUND

During hospitalization for behavioural and psychological symptoms of dementia (BPSD), it is imperative to build a support system for each patient in the community for after they obtain symptom remission. To this end, patients lacking adequate family support are less likely to be discharged to their own homes and need stronger support systems to be established. This study therefore investigated the effects of home-visit nursing before admission on time to home discharge among patients with limited familial care who were hospitalized for treatment of BPSD.

METHODS

A single-centre chart review study was conducted on consecutive patients admitted from home between April 2013 and September 2015 for treatment of BPSD and who had lived alone or with a working family member. Time to home discharge was compared between patients who had home-visit nursing before their admission and those who did not.

RESULTS

In total, 58 patients were enrolled in the study, of whom 12 had preceding home-visit nursing (PHN group) and 46 did not (non-PHN group). Patients in the PHN group were younger (77.7 ± 4.9 vs. 84.1 ± 6.1 years, P = 0.0011) and had higher Mini-Mental State Examination scores (16.8 ± 7.2 vs 11.8 ± 7.3, P = 0.0287). A multivariate Cox proportional hazard regression analysis adjusted for age and Mini-Mental State Examination scores showed a higher likelihood of discharge to home in the PHN group (hazard ratio: 3.85; 95% confidence interval: 1.27-11.6;, P = 0.017) than in the non-PHN group.

CONCLUSION

Home-visit nursing before admission of BPSD patients for treatment could improve the rate of discharge to home among patients with limited familial care after subsequent hospitalization. Home-visit nursing could also enhance collaborative relationships between social and hospital-based care systems, and early implementation could improve the likelihood of vulnerable patient types remaining in their own homes for as long as possible.

Meeting psychosocial needs for persons with dementia in home care services - a qualitative study of different perceptions and practices among health care providers

Background

The majority of persons with dementia are home-dwelling. To enable these persons to stay in their own homes as long as possible, a holistic, individual and flexible care is recommended. Despite a requirement for meeting psychological, social and physical needs, home care services seem to focus on patients’ physical needs. Accordingly, the aim of this study was to explore how the psychosocial needs of home-dwelling, older persons with dementia were perceived, emphasized and met by home care services.

Methods

A descriptive, qualitative approach was used. Data were collected through semi-structured focus group interviews with 24 health care providers in home care services from four municipalities. Data were analysed using systematic text condensation.

Results

This study showed major differences in how health care providers perceived the psychosocial needs of older home-dwelling persons with dementia and how they perceived their responsibilities for meeting those psychosocial needs. The differences in the health care providers’ perceptions seemed to significantly influence the provided care. Three co-existing logics of care were identified: the physical need-oriented logic, the renouncement logic and the integrated logic.

Conclusions

The differences in how health care providers perceived the psychosocial needs of persons with dementia and their responsibilities for meeting those needs, influenced how the psychosocial needs were met. These differences indicates a need for a clarification of how psychosocial needs should be conceptualized and who should be responsible for meeting these needs. Further, increased competence and increased consciousness of psychosocial needs and how those needs can be met, are essential for delivering high-quality holistic care that enables persons with dementia to live in their own home for as long as possible.

Electronic supplementary material

The online version of this article (10.1186/s12877-017-0612-3) contains supplementary material, which is available to authorized users.

Healthcare organisation and delivery for people with dementia and comorbidity: a qualitative study exploring the views of patients, carers and professionals

OBJECTIVES

People living with dementia (PLWD) have a high prevalence of comorbidty. The aim of this study was to explore the impact of dementia on access to non-dementia services and identify ways of improving service delivery for this population.

DESIGN

Qualitative study involving interviews and focus groups. Thematic content analysis was informed by theories of continuity of care and access to care.

SETTING

Primary and secondary care in the South and North East of England.

PARTICIPANTS

PLWD who had 1 of the following comorbidities-diabetes, stroke, vision impairment, their family carers and healthcare professionals (HCPs) in the 3 conditions.

RESULTS

We recruited 28 community-dwelling PLWD, 33 family carers and 56 HCPs. Analysis resulted in 3 overarching themes: (1) family carers facilitate access to care and continuity of care, (2) the impact of the severity and presentation of dementia on management of comorbid conditions, (3) communication and collaboration across specialities and services is not dementia aware. We found examples of good practice, but these tended to be about the behaviour of individual practitioners rather than system-based approaches; current systems may unintentionally block access to care for PLWD.

CONCLUSIONS

This study suggests that, in order to improve access and continuity for PLWD and comorbidity, a significant change in the organisation of care is required which involves: coproduction of care where professionals, PLWD and family carers work in partnership; recognition of the way a patient's diagnosis of dementia affects the management of other long-term conditions; flexibility in services to ensure they are sensitive to the changing needs of PLWD and their family carers over time; and improved collaboration across specialities and organisations. Research is needed to develop interventions that support partnership working and tailoring of care for PLWD and comorbidity.

A systematic review of physician retirement planning

BACKGROUND

Physician retirement planning and timing have important implications for patients, hospitals, and healthcare systems. Unplanned early or late physician retirement can have dire consequences in terms of both patient safety and human resource allocations. This systematic review examined existing evidence on the timing and process of retirement of physicians. Four questions were addressed: (1) When do physicians retire? (2) Why do some physicians retire early? (3) Why do some physicians delay their retirement? (4) What strategies facilitate physician retention and/or retirement planning?

METHODS

English-language studies were searched in electronic databases MEDLINE, Web of Science, Scopus, CINAHL, AgeLine, Embase, HealthSTAR, ASSA, and PsycINFO, from inception up to and including March 2016. Included studies were peer-reviewed primary journal articles with quantitative and/or qualitative analyses of physicians' plans for, and opinions about, retirement. Three reviewers independently assessed each study for methodological quality using the Newcastle-Ottawa Scale for quantitative studies and Critical Appraisal Tool for qualitative studies, and a fourth reviewer resolved inconsistencies.

RESULTS

In all, 65 studies were included and analyzed, of which the majority were cross-sectional in design. Qualitative studies were found to be methodologically strong, with credible results deemed relevant to practice. The majority of quantitative studies had adequate sample representativeness, had justified and satisfactory sample size, used appropriate statistical tests, and collected primary data by self-reported survey methods. Physicians commonly reported retiring between 60 and 69 years of age. Excessive workload and burnout were frequently cited reasons for early retirement. Ongoing financial obligations delayed retirement, while strategies to mitigate career dissatisfaction, workplace frustration, and workload pressure supported continuing practice.

CONCLUSIONS

Knowledge of when physicians plan to retire and how they can transition out of practice has been shown to aid succession planning. Healthcare organizations might consider promoting retirement mentorship programs, resource toolkits, education sessions, and guidance around financial planning for physicians throughout their careers, as well as creating post-retirement opportunities that maintain institutional ties through teaching, mentoring, and peer support.

In whose best interests? A case study of a family affected by dementia

Many people with dementia are cared for by family members. Family carers often feel bound to support the person with dementia at the expense of their own needs, which can be neglected. They often experience distress when making decisions, especially over ethical dilemmas when their own interests and those of the person being cared for conflict. This paper presents a case study approach to consider best interests decision making for families affected by dementia. In the case study, a carer is supporting his father to remain living at home although he feels this unsafe and the demands of this cause tension with his family and affect his performance at work.

Comorbidity and dementia: a mixed-method study on improving health care for people with dementia (CoDem)

Background

Among people living with dementia (PLWD) there is a high prevalence of comorbid medical conditions but little is known about the effects of comorbidity on processes and quality of care and patient needs or how services are adapting to address the particular needs of this population.

Objectives

To explore the impact of dementia on access to non-dementia services and identify ways of improving the integration of services for this population.

Design

We undertook a scoping review, cross-sectional analysis of a population cohort database, interviews with PLWD and comorbidity and their family carers and focus groups or interviews with health-care professionals (HCPs). We focused specifically on three conditions: diabetes, stroke and vision impairment (VI). The analysis was informed by theories of continuity of care and access to care.

Participants

The study included 28 community-dwelling PLWD with one of our target comorbidities, 33 family carers and 56 HCPs specialising in diabetes, stroke, VI or primary care.

Results

The scoping review (n = 76 studies or reports) found a lack of continuity in health-care systems for PLWD and comorbidity, with little integration or communication between different teams and specialities. PLWD had poorer access to services than those without dementia. Analysis of a population cohort database found that 17% of PLWD had diabetes, 18% had had a stroke and 17% had some form of VI. There has been an increase in the use of unpaid care for PLWD and comorbidity over the last decade. Our qualitative data supported the findings of the scoping review: communication was often poor, with an absence of a standardised approach to sharing information about a person’s dementia and how it might affect the management of other conditions. Although HCPs acknowledged the vital role that family carers play in managing health-care conditions of PLWD and facilitating continuity and access to care, this recognition did not translate into their routine involvement in appointments or decision-making about their family member. Although we found examples of good practice, these tended to be about the behaviour of individual practitioners rather than system-based approaches; current systems may unintentionally block access to care for PLWD. Pathways and guidelines for our three target conditions do not address the possibility of a dementia diagnosis or provide decision-making support for practitioners trying to weigh up the risks and benefits of treatment for PLWD.

Conclusions

Significant numbers of PLWD have comorbid conditions such as stroke, diabetes and VI. The presence of dementia complicates the delivery of health and social care and magnifies the difficulties that people with long-term conditions experience. Key elements of good care for PLWD and comorbidity include having the PLWD and family carer at the centre, flexibility around processes and good communication which ensures that all services are aware when someone has a diagnosis of dementia. The impact of a diagnosis of dementia on pre-existing conditions should be incorporated into guidelines and care planning. Future work needs to focus on the development and evaluation of interventions to improve continuity of care and access to services for PLWD with comorbidity.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.