An evaluation of a specialist multiagency home support service for older people with dementia using qualitative methods.

BACKGROUND: Standard home care support for people with dementia has been criticised in statutory inspection reports, and may lead to unnecessary crises, hospital or care home admissions. OBJECTIVE: To establish whether a specialist multiagency home care service for older people with dementia delivered better quality care than standard services, and how any improvements were achieved. DESIGN: Qualitative study, using semi-structured interviews, focus groups and small group interviews. SETTING: Two demographically similar areas in Nottingham, one served by a specialist home care team, the other by standard services. PARTICIPANTS: Twenty-seven service users, 18 family carers, 17 home care workers, 20 health/social care professionals, across both services. RESULTS: The specialist service demonstrated greater flexibility and responsiveness to the particular needs and circumstances of service users and family carers, who were encouraged to participate in routine decision-making and activities. By sharing responsibilities, the specialist service helped reduce carer stress and prevent crises. These outcomes depended on the configuration of the service, including multidisciplinary health and social services input, careworker autonomy and independence, continuous reassessment of clients' circumstances and preferences and the capacity to develop long-term relationships, through careworker continuity. The standard service, which used a task-orientated approach, lacked these characteristics. CONCLUSIONS: This study provides evidence of the benefits of a specialist multiagency home support service over standard home care, in the opinion of service users, carers and careworkers, and defines the operational model that achieves this. Findings confirm best practice recommendations, based on models of dementia care which emphasise respect for 'personhood'.

Health status and assessed need for a cohort of older people admitted to nursing and residential homes.

OBJECTIVE: to investigate dependency and health status of a cohort of older people admitted for long term nursing or residential care and to compare these findings with assessments conducted by social services departments prior to placement. DESIGN: retrospective cohort study. SETTING: residential, nursing and dual registered homes within Nottingham Health Authority boundaries. SUBJECTS: 205 residents placed over 3 months. MAIN OUTCOME MEASURES: levels of disability, cognitive impairment and behavioural disturbance identified by assessment before and after admission. RESULTS: cognitive impairment and physical disability were significantly higher in nursing homes, although a third of residents in residential care had substantial physical disability. In nursing homes, a quarter of residents had low dependency needs but these had greater cognitive impairment than those in residential homes with the same level of dependency. Most residents had some degree of behavioural disturbance (particularly in nursing homes) and more severe disturbance was associated with greater cognitive impairment and more depressed mood, but not physical disability. A moderate level of agreement was found between preadmission and follow-up assessments of health status. CONCLUSIONS: a case-mix which includes higher dependency residents in residential homes and lower dependency residents in nursing homes is likely to reflect changes in the health status of residents following placement but also suggests that a range of placement criteria were used together, rather than individual indicators of need. Although pre-placement measures of disability and dependency were supported by follow-up assessments, it is essential that the needs of residents in long-term care are adequately monitored and managed, in particular those in residential care with higher dependency needs.

An examination of the attitudes and practice of general practitioners in the diagnosis and treatment of depression in older people.

BACKGROUND: Most depression in older people is managed in primary care settings but can be difficult to diagnose and is often under-treated. This study examined the attitudes and practice of general practitioners in the treatment of late-life depression using antidepressant medication. METHOD: Three hundred and thirty general practitioners in 116 general practices within the Nottingham Health Authority were surveyed. Their responses to a series of attitude statements and clinical vignettes regarding antidepressant prescribing were assessed. RESULTS: Analysis of vignettes showed newer antidepressants to be prescribed much more frequently than older antidepressants, with a substantial increase in the use of SSRIs compared to the results of previous research. Older general practitioners and those who had been in practice for longer were more likely to prescribe tricyclic antidepressants. They were also more likely to identify a need for extra training in treating old age depression, as were those GPs without previous psychiatric training. However, most GPs were confident in treating depression in the elderly although younger GPs were the most confident. CONCLUSIONS: Selective Serotonin Re-Uptake Inhibitors are the preferred drugs in treating certain problematic cases of late-life depression. These results suggest there may be a greater propensity for GPs to prescribe SSRIs although further research is needed to clarify whether this finding can be generalised beyond this study. Most general practitioners felt confident in treating late-life depression, but older doctors, those who had been practising for longer and those without previous psychiatric training, may benefit most from further training.