This small non-randomized study is the first end-of-life care in dementia intervention to report an increase in family satisfaction with a reduction in hospital deaths. This is promising but requires further evaluation in diverse care homes.
The staff require education and support about discussing and implementing plans around care at the end of life in dementia and about cultural issues around death to improve practice. This would enable the staff to implement advance care plans, knowing that they will be supported. Education would encompass communicating the complicated, unpredictable path of dementia near the time of death explicitly but sensitively, including recognising that people often do not hear difficult messages and are unable to take on large quantities of information at once. The staff need to know about the resident's religious and cultural ideas as well as ritual practice.
Objective-To assess the effect of unemployment and early retirement on cigarette smoking, alcohol consumption, and body weight in middle aged British men.Design-Prospective cohort study (British regional heart study.)Setting-One general practice in 24 towns in Britain.Subjects-6057 men aged 40-59 who had been continuously employed for five years before the initial screening. Five years after screening 4412 men had been continuously employed and 1645 had experienced some unemployment or retired.Main outcome measures-Numbers of cigarettes smoked and units of alcohol consumed per week and body mass index (kg/m2).Results-At initial screening significantly higher percentages of men who subsequently experienced non-employment smoked or had high alcohol consumption than of men who remained continuously employed: 43 0% versus 37 0% continuously employed for cigarette smoking (95% confidence interval for difference 3-2% to 9.0%) and 12-1% versus 9 0% for heavy drinking (1.3% to 5-1%). There was no evidence that men increased their smoking or drinking on becoming non-employed. Men non-employed through illness were significantly more likely to reduce their smoking and drinking than men who remained continuously employed. Men who experienced non-employment were significantly more likely to gain over 10% in weight than men who remained continuously employed: 7-5% versus 5 0% continuously employed (0.9% to 4.0%).Conclusions -Loss ofemployment was not associated with increased smoking or drinking but was associated with an increased likelihood of gaining weight. The long term effects of the higher levels of smoking and alcohol consumption before nonemployment should be taken into account when comparing mortality and morbidity in groups of unemployed and employed people.
IntroductionMany cross sectional studies have found that unemployed men are more likely to smoke cigarettes and to consume more alcohol than employed men.'"'0 There are two possible explanations for this: firstly, loss of employment leads to increased smoking and drinking or, secondly, people who lose employment smoke and drink more heavily before losing employment compared with people who remain employed. We have examined these two explanations in a group of middle aged men using prospective data collected as part of the British regional heart study.To overcome the possible effects on smoking and drinking habits of recurrent unemployment (often due to illness) over long periods we restricted our analysis to men who had been continuously employed for the five years before the initial screening. We attempted to control for other background factors that might confound the relation, such as age, social class, area of residence, and reason given for loss of employment. In
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