Care Home Placement Research Articles

Preventing risk of placement breakdown and hospital admission in the management of distressed behaviour in dementia care: A qualitative case study with family and care-home staff.

Objectives: Behaviours such as hitting-out and declining personal care are commonly exhibited by people living with dementia and are associated with care-giver stress and anxiety and care home placement breakdowns. Traditionally, pharmacological approaches have been used to manage behaviour; however, research indicates limited effectiveness. National guidelines recommend use of non-pharmacological interventions as first line treatment for distress, but further research is required to elucidate the components that lead to improved care for people living with dementia. This study aims to explore what works, examining case studies in which a non-pharmacological clinical intervention, the Newcastle Model, was used to understand and manage distressed behaviour in dementia care within care home settings. Method: A qualitative case study design was used. Three cases were selected from the Edinburgh Behaviour Support Service for their success in preventing care home placement breakdown during a distressed behaviour intervention in NHS Scotland. Family members and staff involved in the interventions within these cases were interviewed (N = 6). Thematic analysis was used to analyse data. Findings: All participants reported positive outcomes from the intervention. Three key themes were identified, each with subthemes. Participants described a supportive, non-judgmental environment which allowed them to integrate knowledge about dementia and tailor interventions to the specific needs of the individual living with dementia. There was also a sense of family and staff coming together to unite with shared goals. A preliminary model of all of themes and their interactions is presented. Conclusion: The study supports use of biopsychosocial, formulation-led approaches in the understanding and treatment of complex behavioural presentations in community care settings. It suggests that clinicians should endeavour to facilitate safe and open environments for care home staff and family members, in order to promote attribution change and person-centered care, and to help mediate differences and conflict between staff and family members.

Community-based complex interventions to sustain independence in older people, stratified by frailty: a systematic review and network meta-analysis.

Sustaining independence is important for older people, but there is insufficient guidance about which community health and care services to implement. To synthesise evidence of the effectiveness of community services to sustain independence for older people grouped according to their intervention components, and to examine if frailty moderates the effect. Systematic review and network meta-analysis. Studies: Randomised controlled trials or cluster-randomised controlled trials. Participants: Older people (mean age 65+) living at home. Interventions: community-based complex interventions for sustaining independence. Comparators: usual care, placebo or another complex intervention. Living at home, instrumental activities of daily living, personal activities of daily living, care-home placement and service/economic outcomes at 1 year. We searched MEDLINE (1946-), Embase (1947-), CINAHL (1972-), PsycINFO (1806-), CENTRAL and trial registries from inception to August 2021, without restrictions, and scanned reference lists. Interventions were coded, summarised and grouped. Study populations were classified by frailty. A random-effects network meta-analysis was used. We assessed trial-result risk of bias (Cochrane RoB 2), network meta-analysis inconsistency and certainty of evidence (Grading of Recommendations Assessment, Development and Evaluation for network meta-analysis). We included 129 studies (74,946 participants). Nineteen intervention components, including 'multifactorial-action' (multidomain assessment and management/individualised care planning), were identified in 63 combinations. The following results were of low certainty unless otherwise stated. For living at home, compared to no intervention/placebo, evidence favoured: multifactorial-action and review with medication-review (odds ratio 1.22, 95% confidence interval 0.93 to 1.59; moderate certainty) multifactorial-action with medication-review (odds ratio 2.55, 95% confidence interval 0.61 to 10.60) cognitive training, medication-review, nutrition and exercise (odds ratio 1.93, 95% confidence interval 0.79 to 4.77) and activities of daily living training, nutrition and exercise (odds ratio 1.79, 95% confidence interval 0.67 to 4.76). Four intervention combinations may reduce living at home. For instrumental activities of daily living, evidence favoured multifactorial-action and review with medication-review (standardised mean difference 0.11, 95% confidence interval 0.00 to 0.21; moderate certainty). Two interventions may reduce instrumental activities of daily living. For personal activities of daily living, evidence favoured exercise, multifactorial-action and review with medication-review and self-management (standardised mean difference 0.16, 95% confidence interval -0.51 to 0.82). For homecare recipients, evidence favoured the addition of multifactorial-action and review with medication-review (standardised mean difference 0.60, 95% confidence interval 0.32 to 0.88). Care-home placement and service/economic findings were inconclusive. High risk of bias in most results and imprecise estimates meant that most evidence was low or very low certainty. Few studies contributed to each comparison, impeding evaluation of inconsistency and frailty. Studies were diverse; findings may not apply to all contexts. Findings for the many intervention combinations evaluated were largely small and uncertain. However, the combinations most likely to sustain independence include multifactorial-action, medication-review and ongoing review of patients. Some combinations may reduce independence. Further research is required to explore mechanisms of action and interaction with context. Different methods for evidence synthesis may illuminate further. This study is registered as PROSPERO CRD42019162195. This award was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme (NIHR award ref: NIHR128862) and is published in full in Health Technology Assessment; Vol. 28, No. 48. See the NIHR Funding and Awards website for further award information.

Community based complex interventions to sustain independence in older people: systematic review and network meta-analysis

ObjectiveTo synthesise evidence of the effectiveness of community based complex interventions, grouped according to their intervention components, to sustain independence for older people.DesignSystematic review and network meta-analysis.Data sourcesMedline, Embase, CINAHL,...

The association of dementia and delirium with health outcomes in a sample of older inpatients in a New Zealand hospital setting

Background Both dementia and delirium are seen frequently in older hospital inpatients. Dementia is present in up to one-third of older hospital inpatients, and delirium also occurs in around one-third of older inpatients, often alongside dementia. Patients’ health outcomes, such as mortality, length of stay, and discharge to a care home, may be worse in patients with dementia and/or delirium. Objective(s) To describe the association of dementia and delirium with health outcomes (length of stay, mortality, care home placement) in a sample of patients from a New Zealand hospital setting. Methods Routinely collected data from a consecutive sample of 2248 older patients assessed in a New Zealand memory service from 2013 to 2021 were extracted to examine the associations of delirium and dementia with patients’ health outcomes: length of stay, care home placement, and mortality. Results Of the 2248 patients assessed, 75% were hospitalised after diagnosis, and half of these had delirium screening in hospital. People with dementia had three times the risk of experiencing delirium (OR=3.0, 95% CI:2.0-4.6, p<0.001). In Pacific people compared to NZ Europeans, the adjusted relative risk ratios for having dementia only or delirium superimposed on dementia, compared to those with neither, were 2.3 (p<0.001) and 2.9 (p<0.001), respectively. Compared to people with neither diagnosis, people with delirium (with or without dementia) had a longer mean length of stay, were two to four times more likely to be placed in a care home, and the risk of death was 1.7-3.1 times higher. Conclusion Delirium is very common in older hospital inpatients and has a major impact on patient outcomes and health costs. Pacific peoples seem to have greater risk of both dementia and delirium, associated with worse clinical outcomes.

1600 COMMUNITY-BASED COMPLEX INTERVENTIONS TO SUSTAIN INDEPENDENCE IN OLDER PEOPLE: SYSTEMATIC REVIEW AND NETWORK META-ANALYSIS

Abstract Introduction Sustaining independence is important for older people, but there is insufficient guidance about which community services to implement. Methods Systematic review and network meta-analysis (NMA; PROSPERO CRD42019162195) to synthesise effectiveness evidence from randomised or cluster-randomised controlled trials of community-based complex interventions to sustain independence for older people (mean age 65+) living at home, grouped according to their intervention components. Main outcomes: Living at home, activities of daily living (ADL), care-home placement, and service/economic outcomes at one year. We searched five databases and two registries, and scanned reference lists. A random-effects NMA was used. We assessed risk of bias, inconsistency, and certainty of evidence. Results We included 129 studies (74,946 participants). Nineteen intervention components, including ‘multifactorial-action’ (individualised care planning), were identified in 63 combinations. Few studies contributed to each comparison. High risk of bias and imprecision meant results were very low certainty (not reported) or low certainty (unless otherwise stated). Findings may not apply to all contexts. For living at home, evidence favoured ‘multifactorial-action and review with medication-review’ (odds ratio (OR) 1.22, 95% CI 0.93 to 1.59; moderate certainty), and three other interventions: ‘multifactorial-action with medication-review’; ‘cognitive training, medication-review, nutrition and exercise’; and ‘ADL, nutrition and exercise’. Four interventions may reduce odds of remaining at home. For instrumental ADL (IADL), evidence favoured ‘multifactorial-action and review with medication-review’ (standardised mean difference (SMD) 0.11, 95% CI 0.00 to 0.21; moderate certainty). Two interventions may reduce IADL. For personal ADL, evidence favoured ‘exercise, multifactorial-action and review with medication-review and self-management’ (SMD 0.16, 95% CI -0.51 to 0.82). Among homecare recipients, evidence favoured addition of multifactorial-action and review with medication-review (SMD 0.60, 95% CI 0.32 to 0.88). Other findings were inconclusive. Conclusions The intervention combinations most likely to sustain independence include multifactorial-action, medication-review and ongoing review of patients. Unexpectedly, some combinations may reduce independence.

Funded hospital discharges to care homes: a cohort study.

Optimising timely discharge from hospitals is an international priority. In 2020, the Coronavirus disease 2019 (COVID-19) pandemic resulted in the United Kingdom Government implementing the Discharge to Assess (D2A) model across England. This funded temporary care home placement to allow further recovery and assessment of care needs outside of the hospital. Determine if older adults discharged from hospital to care homes after implementation of D2A differ in their characteristics or outcomes. Two cohorts of older adults discharged from hospital to care homes pre- and post-implementation of the D2A model (n = 244), with 6months of follow-up. Data were extracted from routinely collected healthcare records. The mean duration of the hospital admission was reduced (29 vs. 23days (P = 0.02)) but discharges to care homes did not increase with implementation of D2A (n = 161 in both cohorts prior to exclusions). In July-December 2020 (post-implementation), 28% of people were living in a private residence 6months post-discharge, compared with 18% in the same period in 2019 (P = 0.09). When those who died were excluded, this changed to 40 vs. 28% (P = 0.19). There was no change in 6-month mortality (26 vs. 35% (P = 0.17)), and no increase in readmission rate (0.48 vs. 0.63 (P = 0.21) readmissions-per-patient over 6months). No differences in key characteristics were found. However, patients were placed in care homes further from admission addresses (17.3 vs. 9.8km (P = 0.00001)). Implementation of D2A did not result in poorer outcomes but was associated with a reduced length of hospital stay.

Predictors of Parent-Child Contact During a Parent’s Incarceration

ABSTRACT Over 2 million people are currently incarcerated – the majority of whom are parents to minor children. The reentry process is often difficult for parents as they navigate reentry challenges such as finding housing and employment while also trying to develop and reestablish relationships with their children. Increased parent-child contact during incarceration is associated with improved incarceration and reentry outcomes for both the parents and their children. Using survey data from 252 parents exiting the prison system, this study uses structural equation modeling to examine predictors of parent-child contact during incarceration. Findings suggest incarcerated parents have higher levels of contact with their children when the parents had less exposure to childhood adversities such as parental incarceration, foster care, and group home placement. Mothers display higher levels of contact with children than fathers; similarly, younger parents display higher levels of contact than older, as do those who had recent contact in the month prior to incarceration compared to those who did not. These findings highlight specific factors and populations for practitioners to target to increase the level of parent-child contact during incarceration.

Comparison of the sociodemographic and clinical characteristics and level of care home placement in Asian and European people with moderate to severe cognitive impairment living in New Zealand

AbstractBackgroundDue to the ageing population in New Zealand (NZ), there will be more people with dementia in need of long‐term care. As a culturally diverse country, the characteristics of different ethnicities need to be understood in order to provide culturally appropriate care. This study aims to compare: 1) the sociodemographic and clinical characteristics, and 2) the level of care home placement in Asian and NZ European people with moderate to severe cognitive impairment living in long‐term care facilities.MethodThe sample included individuals aged≥65 and self‐identified as Asian or NZ European who had received the Long‐Term Care Facility version of interRAI, a standardised and comprehensive geriatric assessment, in 2018. All participants had moderate to severe cognitive impairment defined by a score of ≥ 3 in the Cognitive Performance Scale (range 0‐6). The analysis examined the association of ethnic group with sociodemographic and clinical variables and level of care home placement.ResultThe sample included 7298 older adults (441 Asians, 6857 NZ Europeans). The average age of the sample was 84.1 SD±8.7 (Asian= 83.7 SD±7.7, European= 84.1 SD±8.8, p=0.29), and 57.5% were female (Asian=62.6%, European=57.2%, p=0.08). Logistic regression showed that, compared with NZ Europeans, Asians were more likely to have untreated diabetes (OR=2.14, 95%CI=1.55–2.96); less likely to be overweight/obese (BMI 25–29: OR=0.54, 95%CI=0.41–0.73; BMI 30–40: OR=0.25, 95%CI=0.13–0.46), have hearing loss (OR=0.55, 95%CI=0.44–0.69) and had fewer medical comorbidities (OR=0.39, 95%CI=0.24–0.65). Despite lower comorbidity, Asians with cognitive impairment were more likely to be placed in hospital level care (OR=1.60, 95%CI=1.23–2.08) and less likely to be placed in dementia level of care (OR=0.53, 95%CI=0.36–0.77).ConclusionThe study results demonstrate differences in clinical characteristics and level of care home required for Asians and NZ Europeans living in NZ. Despite lower comorbidity, Asians with cognitive impairment were more likely to be placed in hospital level of care and less likely to be placed in dementia level of care. Additional studies are needed to understand this relationship, and the results may help to generate more culturally tailored health services aimed for people with cognitive impairment.

Challenges faced during the COVID-19 pandemic by family carers of people living with dementia towards the end of life

BackgroundPeople living with dementia account for a large proportion of deaths due to COVID-19. Family carers are faced with making significant and emotive decisions during the pandemic, including decisions about end of life. We aimed to explore the challenges faced by family carers of people living with dementia during the first wave of the COVID-19 pandemic in England, as reported by charity telephone support line staff, who were able to objectively discuss a range of different experiences of many different carers who call the helpline. In particular, we focussed on key concerns and areas of decision making at the end of life.MethodsWe conducted a qualitative study using semi-structured interviews with eight telephone support line staff from two UK based charities who support carers of people living with dementia and those at the end of life. Interviews were conducted in the first wave of the pandemic in England in May–June 2020.ResultsAn overarching theme of uncertainty and reactivity during a crisis was identified, and within this, five main themes were identified: concerns about care transitions, uncertainty in engaging support and help, pandemic-motivated care planning, maintaining the wellbeing of the person living with dementia, and trust, loss of agency and confusion.ConclusionsFamily carers may be reluctant to seek support because of fear of what may happen to their relative, which may include hospitalisation and becoming ill with COVID-19, care home placement, or not being able to be with a relative at the end of life. In some cases, a lack of trust has developed, and instead carers are seeking support from alternative services they trust such as nationally known charities.This study was used to inform the development of a decision aid to support family carers making decisions about care for their relative with dementia during the pandemic, who the lack the capacity to make their own decisions.

Faster disease progression in Parkinson's disease with type 2 diabetes is not associated with increased α-synuclein, tau, amyloid-β or vascular pathology.

Growing evidence suggests a shared pathogenesis between Parkinson's disease and diabetes although the underlying mechanisms remain unknown. The aim of this study was to evaluate the effect of type 2 diabetes on Parkinson's disease progression and to correlate neuropathological findings to elucidate pathogenic mechanisms. In this cohort study, medical records were retrospectively reviewed of cases with pathologically confirmed Parkinson's disease with and without pre-existing type 2 diabetes. Time to disability milestones (recurrent falls, wheelchair dependence, dementia and care home placement) and survival were compared to assess disease progression and their risk estimated using Cox hazard regression models. Correlation with pathological data was performed, including quantification of α-synuclein in key brain regions and staging of vascular, Lewy and Alzheimer's pathologies. Patients with PD and diabetes (male 76%; age at death 78.6±6.2years) developed earlier falls (p<0.001), wheelchair dependence (p=0.004), dementia (p<0.001), care home admission (p<0.001) and had reduced survival (p<0.001). Predating diabetes was independently associated with a two to three-fold increase in the risk of disability and death. Neuropathological assessment did not show any differences in global or regional vascular pathology, α-synuclein load in key brain areas, staging of Lewy pathology or Alzheimer's disease pathology. Pre-existing type 2 diabetes contributes to faster disease progression and reduced survival in Parkinson's disease which is not driven by increased vascular, Lewy or Alzheimer's pathologies. Additional non-specific neurodegeneration related to chronic brain insulin resistance may be involved.

Understanding Caregiver Strain in Parkinsonism-A Mixed Methods Approach.

Parkinsonism, including Parkinson's disease (PD) are progressive neurological conditions. As these condition progress, individuals will need more support with their care needs to maintain independent community-living. Care needs are mainly met by unpaid, informal caregivers, usually close family members or friends. Caregiver strain is thought to lead to the need for care home placement when the caregiver can no longer cope. To understand predictors of caregiver strain and its influence on care home placement for people with moderate to advanced Parkinsonism. This is a convergent mixed methods study. Quantitative data, following an adapted stress-appraisal model, were collected on caregiver profile, tasks performed and causes of caregiver strain. Semi-structured, in-depth interviews were conducted with caregivers of people with PD (PwP) who went into a care home during the study period, to develop a deeper understanding of the caregiver role and the factors influencing caregiver strain. Quantitative data were collected from 115 patient caregiver dyads. Interviews were conducted with 10 caregivers. A model to predict caregiver strain was developed and predictors of caregiver strain were identified, such as functional disability and poor caregiver sleep. Our findings further demonstrate the complexity of carer strain. Particular dimensions are identified that need to be addressed within clinical practice to reduce carer strain and support people with Parkinsonism to remain within their own home for as long as possible.

Predictors of care home placement in people diagnosed with dementia in a New Zealand memory service

AbstractBackgroundAs the global population ages the burden of dementia is expected to rise across all cultures around the world. Much of the social sector costs of dementia care in high income countries is due to residential care. The aim of this study is to investigate the sociodemographic and clinical characteristics that predict care home placement in people diagnosed with dementia at a New Zealand memory service.MethodThis cohort study used routinely collected clinical data gathered on referrals to the Memory Service at Middlemore Hospital in South Auckland between 2013 and 2019. Survival analysis was carried out using Cox regression models to determine significant risk factors and their associations with care home placement.ResultComparison by ethnic group showed that NZ Europeans were on average older compared to Māori and Pacific Islanders, and were more likely to be living alone. As might be expected, age, more severe cognitive impairment and living alone were independently associated with increased risk of care home placement. After adjustment for these factors, Māori and Pacific Islanders were still less likely to be placed in a care home. People diagnosed with mixed dementia were more likely to be placed in a care home than those diagnosed with other dementia subtypes. Prescription of antipsychotics was highly associated with care home placement however we were unable to establish if antipsychotics were prescribed before or after placement.ConclusionThese data will help us to understand differences in adverse outcomes in people with dementia. The ability of Māori and Pacific Islanders to continue to care for their family member with dementia needs to be examined in more detail, as the findings might empower and enable other families to postpone care home placement.

Relationship of Prevalent Fragility Fracture in Dementia Patients: Three Years Follow up Study.

Introduction: dementia increases the risk of falls by 2–3 times and cognitively impaired patients are three times more likely to have hip fracture following a fall when compared to cognitively intact individuals. However, there is not enough evidence that explores the relationship between dementia and fragility fractures. The aim of this study is to explore the relationships of prevalent fragility fracture in patients with dementia admitted with an acute illness to the hospital. Methods: the existing Health Board records were reviewed retrospectively for all patients admitted diagnosed with dementia in the year 2016. All patients were followed up for a maximum of three years. All of the the dementia patients were divided into three groups: group 1—“no fractures”; group 2—“all fractures”; group 3—“fragility fractures”. Clinical outcomes were analysed for hospital stay, discharge destination (new care home), post-discharge hip fracture data, and mortality. Results: dementia patients with a prevalent fracture were significantly older, 62% were women. A significantly higher proportion of dementia patients with prevalent fractures were care home residents and taking a significantly higher number of medications. The mean Charlson comorbidity index was similar in patients with or without fracture. Dementia patients with a prevalent fracture required a new care home and this is significantly higher when compared to those with no fracture. Mortality at one year and three year was not statistically different in patients with or without prevalent fractures. A significantly higher number (21.5%) of dementia patients with prevalent fragility fracture sustained a new hip fracture when compared to those with no prevalent osteoporotic fracture (2.9%) over the three years follow up (p < 0.0001). Conclusion: dementia patients with a prevalent fragility fracture is associated with a statistically significant higher risk of a new care home placement following acute hospital admission. This sub-group is also at risk of a new hip fracture in the next three years. Whilst clinical judgement remains crucial in the care of frail older people, it is prudent to consider medical management of osteoporosis in dementia if deemed to be beneficial following the comprehensive geriatric assessment.

Inpatient hip fractures: understanding and addressing the risk of this common injury.

The impact and outcome of hip fractures are well described for people living in the community, but inpatient hip fracture (IHF) have not been extensively studied. In this study, we examine the patient characteristics, common falls risk factors and clinical outcomes of this condition. Between January 2016 and December 2017, we analysed all inpatient falls that resulted in hip fracture within Aneurin Bevan University Health Board (ABUHB) in Wales. The overall falls rate was 8.7/1000 occupied bed days (OBD). Over the 2years, 118 patients sustained an IHF, giving a rate of 0.12/1000 OBD. The mean age was 81.8 ± 9.5 (range 49-97) years and 60% were women. Most patients (n= 112) were admitted from their own home. Mean Charlson Comorbidity Index and the number of medications on admission were 5.5 ± 1.9 and 8.5 ± 3.7, respectively.Fifty-three patients (45%) sustained the IHF following their first inpatient fall. Twenty-four IHF (20%) occurred within 72h. Mean length of stay was 84.9 ± 55.8days. Only 43% were discharged back to their original place of residence following an IHF; 27% were discharged to a care home (26 new care home discharges), and 30% died as an inpatient. One-year mortality was 54% (n= 64/118). The most common comorbidity was dementia (63%). Mortality and need for care home placement are both much higher after IHF than following community hip fracture. Most people who suffer a hip fracture in hospital have already demonstrated their need for falls risk management by having fallen previously during the same admission.

Health-Promoting Self-Care in Family Caregivers of People With Dementia: The Views of Multiple Stakeholders.

Family carers often experience difficulties managing their own needs, which can lead to ill health. This study aimed to explore the views of carers and other stakeholders about the factors related to health-promoting self-care behavior in family carers of people with dementia. This multimethod qualitative study involved three consultation events with multiple stakeholders (n = 46) and four focus groups with carers (n = 27). Anonymous notes were collected from the consultation events. Focus group discussions were tape recorded and transcribed verbatim. Inductive thematic analysis was used to analyze the data. Two overarching themes were identified and labeled "Services" and "Individual factors." Poor service organization and coordination, lack of respite breaks, lack of continuity of care, poor staff attitudes, as well as difficulty to prioritize own needs, health impact, financial impact, and relationships and feelings were related poorer carer health-promoting self-care behavior. Limited health-promoting self-care often led to situations of crisis, which were related to carers' health issues, need for emergency services, and unanticipated care home placement. Carers require high-quality respite to have more time to themselves, support from better coordinated and compassionate services, and more education and awareness about their own needs. There are several factors that may limit carers' involvement with health-promoting self-care activities, which may affect their own health, on the care provided to their relatives and on service use. Future research and policy need to consider how to better support cares to manage their own health issues.

Prognosis and Neuropathologic Correlation of Clinical Subtypes of Parkinson Disease

Clinical subtyping of Parkinson disease at diagnosis is useful in estimating disease course and survival. Severity and rate of progression of neuropathologies are important determinants of clinical Parkinson subtypes. To provide longitudinal clinical disease-course data and neuropathologic correlation for newly proposed Parkinson disease subtypes. Retrospective cohort study of consecutive patients with autopsy-confirmed Parkinson disease who were regularly seen throughout their disease course by hospital specialists in the United Kingdom and donated their brain at death to the Queen Square Brain Bank between January 2009 and December 2017. Patients with additional neuropathologic diagnoses, monogenic forms of parkinsonism, or insufficiently detailed clinical information were excluded. Based on severity of motor symptoms, rapid eye movement sleep behavior disorder, and autonomic and cognitive function at diagnosis, patients were classified adapting a subtyping classification into mild-motor predominant, intermediate, or diffuse malignant subtypes. Time from diagnosis to disease milestones (recurrent falls, wheelchair dependence, dementia, and care home placement) and death were compared between subtypes, and their risk was estimated using Cox hazard regression models. Severity and distribution of Lewy pathology and Alzheimer disease-related pathology were assessed using staging systems. From a total of 146 patients, 111 patients were included (67 men [60.4%]; mean [SD] age at diagnosis, 62.5 [11.5] years). The diffuse malignant subtype had earlier development of milestones and reduced survival. Cox proportional hazard regression showed an increased adjusted risk of any disease milestone (hazard ratio, 10.90; 95% CI, 5.51-21.58; P < .001) and death (hazard ratio, 3.65; 95% CI, 1.98-6.75; P < .001) in the diffuse malignant group. Age at diagnosis was the only additional variable with statistical significance (adjusted hazard ratio for death, 1.14; 95% CI, 1.11-1.17; P <.001). Staging of Lewy pathology and Alzheimer disease-related pathology did not differ between subtypes, although they showed different rates of progression, and the latter was associated with age at death. Parkinson clinical subtypes at diagnosis may estimate disease course and survival, which may be useful in providing a more accurate prognosis in individual patients in clinical practice and helping to stratify subgroups in clinical trials. Different severity and progression of neuropathologies are important determinants of Parkinson subtypes, and age at diagnosis should be included in future subtype classifications.

Healthy adjustment for new residents with dementia using SettleIN: A feasibility study in UK care homes

This study aimed to develop and explore feasibility of SettleIN, a staff-led programme about healthy adjustment for people with dementia following care home placement. The main foci were intervention feasibility and the impact of the programme on resident quality of life and mood. A manualised intervention developed through consultation with 47 experts was trialled using a mixed-method design. Thirteen new residents with dementia and 24 staff were recruited from six UK care homes. Outcomes were measured at baseline, intervention completion and four-week follow-up. Analysis of staff interviews and field notes is reported. Most experts deemed SettleIN to be well structured, comprehensive and appropriate. However, uptake of SettleIN was low. When implemented, staff emphasised integration ease and staff benefits, but that SettleIN may not be universally suitable. High attrition, most commonly due to death and hospitalisation, and partial results from only four participants meant that there was a lack of support for the positive outcomes. Feasibility problems included a lack of staff time and dependency on families for some components. SettleIN is acceptable to a wide range of stakeholders though does not appear to be feasible in its current form and improvements are recommended. A second pilot phase is required, which will address the reasons for the high attrition rate in this study and amend the methodology accordingly. This is an important work, as a manualised and standardised approach to healthy adjustment in care is unique and could have huge clinical significance if effective.

The Pattern of Hospital Admissions Prior to Care Home Placement in People With Parkinson's Disease: Evidence of a Period of Crisis for Patients and Carers.

Objectives: We hypothesized that the number and length of hospital admissions in people with Parkinson's disease (PD) would increase immediately prior to admission to a care home relative to those who were able to continue living at home or who died. Method: PD patients at Hoehn and Yahr Stages III to V were followed-up over two and a half years with deaths and care home placements recorded. Hospital admissions data were collected over this period. Results: Of 286 patients included in the study, 7.3% entered a care home and 28.3% died. In the final 120 days prior to the study exit point (care home placement, death, or continued living at home), longer hospital stay was significantly associated with care home placement, after adjusting for the competing risk of death. Conclusion: Our data provide evidence that, for many people with PD, a period of crisis is reached immediately prior to care home placement.

What makes extra care housing an appropriate setting for people with dementia? An exploration of staff decision-making.

Extra care housing facilities in the UK are intended to offer a community-based alternative to care home placement. However, little is known about staff’s views of the appropriateness of extra care housing for people with dementia. This paper describes a mixed-methods study which explored this issue using statistical modelling of frontline staff’s recommendations of the best care setting for care home entrants; thematic analysis of transcripts from a simulated Resource Allocation Management Panel meeting; and content analysis of care coordinators’ reasons for not considering extra care housing in actual care home applications. Frontline practitioners saw extra care housing as a valuable alternative for a significant minority of care home entrants. However, extra care housing was not recommended if people needed care at night. Social care managers expressed general support for the idea of extra care housing, but appeared overwhelmingly focused on maintaining people at home and unsure where in the care pathway extra care housing sat. More evidence is needed on whether extra care housing can be an alternative to care homes and how services should be arranged to meet the needs of people living in extra care housing.

Risk of Care Home Placement following Acute Hospital Admission: Effects of a Pay-for-Performance Scheme for Dementia.

IntroductionThe Quality and Outcomes Framework, or QOF, rewards primary care doctors (GPs) in the UK for providing certain types of care. Since 2006, GPs have been paid to identify patients with dementia and to conduct an annual review of their mental and physical health. During the review, the GP also assesses the carer’s support needs, including impact of caring, and ensures that services are co-ordinated across care settings. In principle, this type of care should reduce the risk of admission to long-term residential care directly from an acute hospital ward, a phenomenon considered to be indicative of poor quality care. However, this potential effect has not previously been tested.MethodsUsing English data from 2006/07 to 2010/11, we ran multilevel logit models to assess the impact of the QOF review on the risk of care home placement following emergency admission to acute hospital. Emergency admissions were defined for (a) people with a primary diagnosis of dementia and (b) people with dementia admitted for treatment of an ambulatory care sensitive condition. We adjusted for a wide range of potential confounding factors.ResultsOver the study period, 19% of individuals admitted to hospital with a primary diagnosis of dementia (N = 31,120) were discharged to a care home; of those admitted for an ambulatory care sensitive condition (N = 139,267), the corresponding figure was 14%. Risk factors for subsequent care home placement included older age, female gender, vascular dementia, incontinence, fall, hip fracture, and number of comorbidities. Better performance on the QOF review was associated with a lower risk of care home placement but only when the admission was for an ambulatory care sensitive condition.ConclusionsThe QOF dementia review may help to reduce the risk of long-term care home placement following acute hospital admission.