The Specialized Early Care for Alzheimer's method of caring for people with dementia: an investigation of what works and how.

BACKGROUND AND RATIONALE: SPECAL is a model of care for people with dementia based on a novel conceptualisation of memory and how this changes in dementia. Carers adapt their communication style to prevent distress and promote well-being for the person with dementia. However, there is limited scientific evidence on the effectiveness of SPECAL. AIM: This study explored mechanisms of SPECAL through a qualitative enquiry with family carers. METHOD: Semi-structured interviews were conducted with family carers who had been coached in SPECAL and applied its principles and practices. Thematic analysis was applied. FINDINGS: All participants had found SPECAL helpful in caring for a person with dementia. The core themes of this positive experience were empathy, harmony and resilience. Synthesis of these themes contributes to a proposed model of the mechanisms of SPECAL. CONCLUSION: In applying SPECAL, carers gained an empathetic insight to the feelings of the person with dementia. This empathy leads to a more harmonious environment, which enhances the carer's resilience.

The origins of a two-tier profession: a nursing school at a Poor Law infirmary.

Niall McCrae, Lecturer, and Katerina Kuzminska, Postgraduate Nursing Student, Florence Nightingale Faculty of Nursing and Midwifery, King's College, London, chart the influences of Nightingale's Poor Law infirmary reforms.

Is it really theoretical? A review of sampling in grounded theory studies in nursing journals.

BACKGROUND: Grounded theory is a distinct method of qualitative research, where core features are theoretical sampling and constant comparative analysis. However, inconsistent application of these activities has been observed in published studies. AIM: This review assessed the use of theoretical sampling in grounded theory studies in nursing journals. DESIGN: An adapted systematic review was conducted. METHOD: Three leading nursing journals (2010-2014) were searched for studies stating grounded theory as the method. Sampling was assessed using a concise rating tool. RESULTS: A high proportion (86%) of the 134 articles described an iterative process of data collection and analysis. However, half of the studies did not demonstrate theoretical sampling, with many studies declaring or indicating a purposive sampling approach throughout. CONCLUSION: Specific reporting guidelines for grounded theory studies should be developed to ensure that study reports describe an iterative process of fieldwork and theoretical development.

Halting health tourism.

The Lagos shuttle it's called. Every week several passengers arrive at Gatwick or Heathrow from Nigeria in the late stages of pregnancy.

Long-term conditions and medically-unexplained symptoms: feasibility of cognitive behavioural interventions within the improving access to Psychological Therapies Programme.

BACKGROUND: Improving access to psychological therapies (IAPT) is a major programme in England to treat common mental health problems, mainly through cognitive behaviour therapy. In 2012, a Pathfinder scheme was launched to develop interventions for people with chronic physical health conditions or medically-unexplained symptoms. AIM: This qualitative component of the evaluation investigated feasibility and acceptability of IAPT provision for people with enduring physical health problems. METHOD: Qualitative interviews were conducted with project leaders in all 14 Pathfinder sites. FINDINGS: Various therapeutic and training interventions were introduced. Most patients received low-intensity, structured therapy, with high-intensity input provided by some Pathfinders for complex cases. Whether the focus was on psychological symptoms or on broader well-being, psychiatric terminology was avoided to improve utilisation. Participants perceived high satisfaction among service-users. Training needs were indicated for IAPT workers in this specialised work. CONCLUSIONS: Cognitive behaviour interventions appeared to be acceptable for people struggling with physical health problems. Robust outcome evidence will be pursued in Phase II.

Vantage point - A private matter.

IMAGINE THAT you have been struggling with depression and your doctor has referred you for cognitive behaviour therapy (CBT). Such treatment is provided on the NHS through the Improving Access to Psychological Therapies (IAPT) programme. But there is a catch; you have been placed on a three-month waiting list.

Community question.

THE BED manager scanned the whiteboard in the busy office of an acute psychiatric ward. 'What about this man, WL?' she asked. 'He's been in for nearly two weeks. Can he go on weekend leave?' The nurse in charge was sceptical, but an urgent admission was imminent, and there was no room. So WL was informed that he was ready for a trial period at home, and his bed was swiftly changed for the new arrival. Such is life in the inner-city psychiatric ward, where demand relentlessly exceeds supply.

Resilience of institutional culture: mental nursing in a decade of radical change.

Mental nursing has continued to be neglected in the history of psychiatry. This paper considers the impact of a decade of radical developments on the role and outlook of nurses in British mental hospitals during the 1930s. The Mental Treatment Act 1930 introduced voluntary admission for early, supposedly treatable cases, although there was paucity of effective treatment. In the mid-1930s shock therapies, administered with great enthusiasm by asylum doctors, promised to cure insanity by physical means. Although these were important milestones in the progress of psychiatry, for the majority of nurses and patients life continued much as before. Despite advances in training, working conditions and therapeutic activity, the institutional culture of nursing was remarkably resilient to the forces of change.

Protected engagement time in mental health inpatient units.

Protected engagement time in mental health inpatient units is a fixed period each day during which administrative activities and visiting are suspended so that nurses can focus on individual patient contact. However, there are a number of barriers to implementing this strategy effectively, which include high workloads, staff shortages and lack of supervision to support therapeutic interventions. This article discusses some of these barriers and suggests that managers of acute psychiatric units should ensure that patients have appropriate emotional support, and that skilled mental health nurses should be supported to devote time to therapeutic interventions.

Cost-effectiveness analyses for mirtazapine and sertraline in dementia: randomised controlled trial.

BACKGROUND: Depression is a common and costly comorbidity in dementia. There are very few data on the cost-effectiveness of antidepressants for depression in dementia and their effects on carer outcomes. AIMS: To evaluate the cost-effectiveness of sertraline and mirtazapine compared with placebo for depression in dementia. METHOD: A pragmatic, multicentre, randomised placebo-controlled trial with a parallel cost-effectiveness analysis (trial registration: ISRCTN88882979 and EudraCT 2006-000105-38). The primary cost-effectiveness analysis compared differences in treatment costs for patients receiving sertraline, mirtazapine or placebo with differences in effectiveness measured by the primary outcome, total Cornell Scale for Depression in Dementia (CSDD) score, over two time periods: 0-13 weeks and 0-39 weeks. The secondary evaluation was a cost-utility analysis using quality-adjusted life years (QALYs) computed from the Euro-Qual (EQ-5D) and societal weights over those same periods. RESULTS: There were 339 participants randomised and 326 with costs data (111 placebo, 107 sertraline, 108 mirtazapine). For the primary outcome, decrease in depression, mirtazapine and sertraline were not cost-effective compared with placebo. However, examining secondary outcomes, the time spent by unpaid carers caring for participants in the mirtazapine group was almost half that for patients receiving placebo (6.74 v. 12.27 hours per week) or sertraline (6.74 v. 12.32 hours per week). Informal care costs over 39 weeks were £1510 and £1522 less for the mirtazapine group compared with placebo and sertraline respectively. CONCLUSIONS: In terms of reducing depression, mirtazapine and sertraline were not cost-effective for treating depression in dementia. However, mirtazapine does appear likely to have been cost-effective if costing includes the impact on unpaid carers and with quality of life included in the outcome. Unpaid (family) carer costs were lower with mirtazapine than sertraline or placebo. This may have been mediated via the putative ability of mirtazapine to ameliorate sleep disturbances and anxiety. Given the priority and the potential value of supporting family carers of people with dementia, further research is warranted to investigate the potential of mirtazapine to help with behavioural and psychological symptoms in dementia and in supporting carers.

Person-centred care: rhetoric and reality in a public healthcare system.

Recent scandals in the NHS have undermined confidence in this institution. A key factor in substandard care is the competing demands on practitioners. Individualised care may be hindered by paternalism and collective organisation, while practitioners are expected to pursue evidence-based practice and person-centred care without acknowledging their differing goals. Drawing on a common theme from major philosophical conflicts in health services, this paper argues that instead of increasing managerial control, organisations should be empowering nurses to provide compassionate, person-centred care.

Sertraline or mirtazapine for depression in dementia (HTA-SADD): a randomised, multicentre, double-blind, placebo-controlled trial.

BACKGROUND: Depression is common in dementia but the evidence base for appropriate drug treatment is sparse and equivocal. We aimed to assess efficacy and safety of two of the most commonly prescribed drugs, sertraline and mirtazapine, compared with placebo. METHODS: We undertook the parallel-group, double-blind, placebo-controlled, Health Technology Assessment Study of the Use of Antidepressants for Depression in Dementia (HTA-SADD) trial in participants from old-age psychiatry services in nine centres in England. Participants were eligible if they had probable or possible Alzheimer's disease, depression (lasting ≥4 weeks), and a Cornell scale for depression in dementia (CSDD) score of 8 or more. Participants were ineligible if they were clinically critical (eg, suicide risk), contraindicated to study drugs, on antidepressants, in another trial, or had no carer. The clinical trials unit at King's College London (UK) randomly allocated participants with a computer-generated block randomisation sequence, stratified by centre, with varying block sizes, in a 1:1:1 ratio to receive sertraline (target dose 150 mg per day), mirtazapine (45 mg), or placebo (control group), all with standard care. The primary outcome was reduction in depression (CSDD score) at 13 weeks (outcomes to 39 weeks were also assessed), assessed with a mixed linear-regression model adjusted for baseline CSDD, time, and treatment centre. This study is registered, number ISRCTN88882979 and EudraCT 2006-000105-38. FINDINGS: Decreases in depression scores at 13 weeks did not differ between 111 controls and 107 participants allocated to receive sertraline (mean difference 1·17, 95% CI -0·23 to 2·58; p=0·10) or mirtazapine (0·01, -1·37 to 1·38; p=0·99), or between participants in the mirtazapine and sertraline groups (1·16, -0·25 to 2·57; p=0·11); these findings persisted to 39 weeks. Fewer controls had adverse reactions (29 of 111 [26%]) than did participants in the sertraline group (46 of 107, 43%; p=0·010) or mirtazapine group (44 of 108, 41%; p=0·031), and fewer serious adverse events rated as severe (p=0·003). Five patients in every group died by week 39. INTERPRETATION: Because of the absence of benefit compared with placebo and increased risk of adverse events, the present practice of use of these antidepressants, with usual care, for first-line treatment of depression in Alzheimer's disease should be reconsidered. FUNDING: UK National Institute of Health Research HTA Programme.