This study found that over two-fifths of older people with dementia residing in six residential care homes in England were prescribed at least one PIM at each timepoint. Long-term (i.e. >1 month) antipsychotics, NSAID use for >3 months and PPI use at maximum therapeutic dosage for >8 weeks were the most prevalent PIMs. Regular medication review that targets, but is not limited to, these medications is required to reduce PIP in the residential care home setting. The STOPP criteria represent a useful tool to facilitate such review in this patient population.

MethodThis paper focuses on the methods used to recruit people with dementia to a longitudinal study that employed a mixed-method design to track events and care that older people with dementia experienced over two years in six care homes. A staged approach to recruitment was adopted involving separate meetings with staff, residents and relatives. Individual consent was secured with residents with dementia who could consent in the moment and for those without capacity, through mail and follow-up telephone contact with consultees. Data were collected on the frequency of meetings, issues raised by staff, consultees and people with dementia as well as the overall time taken to complete recruitment. ResultsOver five months, 133 older people with dementia were recruited (62% of sampling frame). The recruitment process was supported or hindered by the number of individuals and organisations that needed to be consulted, the care home culture, staff understanding of how people with dementia can be involved in research, and how they interpreted their role as mediators, protectors and gatekeepers. ConclusionsCare homes are isolated communities of care. To achieve the research objectives researchers in the initial stages need to consider the philosophical underpinnings of individual care homes, and the politics of hierarchy both within the care home and between it, and other health professionals.Goodman et al. homes, NHS and Local Authority staff) on good research practice in care home settings.

What is known about the topic• There is policy commitment to closer working between professionals to improve health and social care but the benefits of this are poorly understood at the user ⁄ patient level.• Language and terminology used to capture the process of interprofessional working are imprecise.• There is little evidence linking interprofessional working to explicit outcomes for older people.• It is not clear how different contexts, systems, professionals, agencies, roles and services influence the effectiveness of inter-professional working. What this paper adds• There are different ways to document the process of interprofessional working.• Studies should measure effectiveness and cost effectiveness of interprofessional working.• Integrated models of inter-professional working have the potential to improve processes of care and to reduce hospital use or long-term care moves. AbstractHealth and social care policy in the UK advocates inter-professional working (IPW) to support older people with complex and multiple needs. Whilst there is a growing understanding of what supports IPW, there is a lack of evidence linking IPW to explicit outcomes for older people living in the community. This review aimed to identify the models of IPW that provide the strongest evidence base for practice with community dwelling older people. We searched electronic databases from 1 January 1990-31 March 2008. In December 2010 we updated the findings from relevant systematic reviews identified since 2008. We selected papers describing interventions that involved IPW for community dwelling older people and randomised controlled trials (RCT) reporting user-relevant outcomes. Included studies were classified by IPW models (Case Management, Collaboration and Integrated Team) and assessed for risk of bias. We conducted a narrative synthesis of the evidence according to the type of care (interventions delivering acute, chronic, palliative and preventive care) identified within each model of IPW. We retrieved 3211 records and included 37 RCTs which were mapped onto the IPW models: Overall, there is weak evidence of effectiveness and cost-effectiveness for IPW, although well-integrated and shared care models improved processes of care and have the potential to reduce hospital or nursing ⁄ care home use. Study quality varied considerably and high quality evaluations as well as observational studies are needed to identify the key components of effective IPW in relation to user-defined outcomes. Differences in local contexts raise questions about the applicability of the findings and their implications for practice. We need more information on the outcomes of the process of IPW and evaluations of the effectiveness of different configurations of health and social care professionals for the care of community dwelling older people.

BackgroundThe objective of this study was to determine the sedative load and use of sedative and psychotropic medications among older people with dementia living in (residential) care homes.MethodsMedication data were collected at baseline and at two further time-points for eligible residents of six care homes participating in the EVIDEM-End Of Life (EOL) study for whom medication administration records were available. Regular medications were classified using the Anatomical Therapeutic Chemical classification system and individual sedative loads were calculated using a previously published model.ResultsAt baseline, medication administration records were reviewed for 115 residents; medication records were reviewed for 112 and 105 residents at time-points 2 and 3 respectively. Approximately one-third of residents were not taking any medications with sedative properties at each time-point, while a significant proportion of residents had a low sedative load score of 1 or 2 (54.8%, 59.0% and 57.1% at baseline and time-points 2 and 3 respectively). More than 10% of residents had a high sedative load score (≥ 3) at baseline (12.2%), and this increased to 14.3% at time-points 2 and 3. Approximately two-thirds of residents (66.9%) regularly used one or more psychotropic medication(s). Antidepressants, predominantly selective serotonin re-uptake inhibitors (SSRIs), were most frequently used, while antipsychotics, hypnotics and anxiolytics were less routinely administered. The prevalence of antipsychotic use among residents was 19.0%, lower than has been previously reported for nursing home residents. Throughout the duration of the study, administration of medications recognised as having prominent sedative adverse effects and/or containing sedative components outweighed the regular use of primary sedatives.ConclusionsSedative load scores were similar throughout the study period for residents with dementia in each of the care homes. Scores were lower than previously reported in studies conducted in long-term care wards which have on-site clinical support. Nevertheless, strategies to optimise drug therapy for care home residents with dementia which rely on clinicians external to the care home for support and medication review are required.

Background In England most care homes have no on-site clinician and rely on primary healthcare for end-of-life (EOL) support. The Evidem EOL study focused on end-of-life care for elders with dementia in care homes. Phase 1 found high levels of uncertainty among care home and primary healthcare staff around anticipating and supporting residents dying with or from dementia. This paper presents the piloting of a modified appreciative inquiry (AI) approach within Evidem EOL Phase 2 to facilitate end-of-life care for people with dementia in care homes. Methods A modified AI approach (a strength-based change management tool) was implemented in three purposively sampled care homes over 6 months (January–July 2011). A self-selected team comprising care home staff, a general practitioner and a district nurse from each care home participated in the modified AI intervention: (3 one-hour AI meetings and on-going researcher support.) Through this intervention the teams developed and implemented context specific, participant driven strategies to support EOL care for people with dementia. Results While evaluation is on-going, preliminary findings from thematic analysis of interviews with participants and collected data on use of emergency/acute services reveal: (1) High acceptance of the intervention, creating rapid engagement between participants who did not have a history of working together (2) Greater understanding and appreciation of respective roles and increased collaboration within the team (3) Improved EOL Care evidenced by increased advanced care planning; reduced number of emergency call outs and hospital admissions; increased staff confidence in talking to residents and family about end-of-life issues and wishes. Discussion Long-term sustainability of the intervention remains to be tested. However preliminary findings suggest modified AI is an effective tool to promote integrated working between care home and health services and to improve EOL care for people with dementia in care homes.