Applying a dyadic outcomes approach to supporting older carers and care-recipients: A qualitative study of social care professionals in England.

There are an estimated 2 million older carers, aged 65 or over, in the UK. Older carers are more likely to care for a co-resident spouse/partner, provide high-intensity support and have their own health problems. The literature suggests that a 'dyadic outcomes approach' to social care (i.e. services and support that seek to understand and improve the quality of life of the older carer and the person they support, individually and together) may be especially beneficial for older carers. Such an approach may be applied in needs assessment and review, service evaluation, planning and delivery, or commissioning. However, there is a paucity of evidence of its effectiveness and feasibility in practice. In this qualitative study, we explored views of social care professionals in England on supporting older carers, as well as the feasibility, potential benefits and challenges of applying a dyadic outcomes approach into policy and practice. Overall, 25 professionals were interviewed between January and July 2021, including social workers, team leads, managers, commissioners and other representatives from local authorities, care providers and carer organisations. Findings indicate that there is limited focus on the specific needs of older carers in practice. Participants recognised the potential benefits of a dyadic approach, including the development of a holistic view that enables an effective response to supporting quality of life, for both carer and care-recipient, and building trust when working to support the caring dyad. Barriers to applying a dyadic approach included data protection and sharing, both within and between organisations; required workforce skills, experience and knowledge; and insufficient and competition-oriented adult social care funding that discourages collaborations between agencies. Despite the potential of the approach to improve the effectiveness of support for older caring dyads, these challenges need to be recognised and addressed if it is to be implemented.

The quality of life of older carers and the people they support: An international scoping review.

Older carers, aged 65 or over, may find it difficult to balance caring while maintaining their own health and quality of life (QoL). For older carers, especially, established approaches to separately identifying, assessing and addressing carers' and care-recipients' needs, may not fully consider the interwoven nature of caregiving relationships and the ways in which community-based social care services may impact the QoL of both parties. The purpose of this scoping review is to identify and synthesise what is already known about the QoL of older carers and care-recipients, considered together, which we refer to as 'dyadic QoL'; both in general, and with regard to the impact of community-based social care. We searched 16 electronic databases and grey literature in October and November 2020. A total 822 items were identified and reviewed based on the inclusion criteria: focusing on older carers and care-recipients from a dyadic perspective and their QoL or well-being, published since 2000 and in English. Fourteen papers were thematically analysed, and the findings were presented under two themes. First, the value of applying an overarching conceptual framework of 'interdependence theory' in understanding dyadic QoL, including two broad approaches: dyadic data analysis and the dynamics of caring relationships. Second, a number of papers highlighted the role of support from family, friends and neighbours and community-based social care services in promoting QoL outcomes of caring dyads. This review emphasised that considering the QoL of carers and care-recipients, together, would potentially improve the understanding of care needs, provision of care services and QoL outcomes. However, there is limited and fragmentary evidence about dyadic QoL or the impact of social care services on dyadic QoL outcomes. Future work is required to explore and evaluate the use of a dyadic approach in social care practice and research.

New horizons in supporting older people's health and wellbeing: is social prescribing a way forward?

Older people's health and care needs are changing. Increasing numbers live with the combined effects of age-related chronic illness or disability, social isolation and/or poor mental health. Social prescribing has potential to benefit older people by helping those with social, emotional or practical needs to access relevant services and resources within the local community. However, researchers have highlighted limitations with the existing evidence-base, while clinicians express concerns about the quality of onward referral services, liability and upfront investment required. The current article provides a critical review of evidence on social prescribing, drawing on the RE-AIM Framework (Glasgow et al., 1999) to identify questions that will need to be addressed in order to inform both the design and delivery of services and the evolving research agenda around social prescribing. We emphasise the need for researchers and planners to work together to develop a more robust evidence-base, advancing understanding of the impacts of social prescribing (on individuals, services and communities), factors associated with variation in outcomes and strategies needed to implement effective and sustainable programmes. We also call on policymakers to recognise the need for investment in allied initiatives to address barriers to engagement in social prescribing programmes, provide targeted support for carers and improve access to older adult mental health services. We conclude that social prescribing has potential to support older people's health and wellbeing, but this potential will only be realised through strategic alignment of research, local level implementation and national policy and investment.

Carer-related research and knowledge: Findings from a scoping review.

The review discussed in this paper provides a unique synthesis of evidence and knowledge about carers. The authors adopted a scoping review methodology drawing on a wide range of material from many different sources published between 2000 and 2016. It offers key insights into what we know and how we know it; reinforces and expands evidence about carers' profile; shows knowledge is uneven, e.g. much is known about working carers, young carers and carers of people with dementia but far less is about older carers or caring for someone with multiple needs. A striking feature of much research is a focus on caring as a set of tasks, rather than a dimension of an, often dyadic, relationship. While there is substantive evidence about the negative impact of caring, the review suggests that links between caring and carer outcomes are neither linear nor inevitable and vary in depth and nature. A reliance on cross-sectional studies using standardised measures is a major weakness of existing research: this approach fails to capture the multidimensionality of the caring role, and the lived experience of the carer. Although research relating to formal support suggests that specific interventions for particular groups of carers may be effective, overall the evidence base is weak. There is a tension between cost-effectiveness and what is valued by carers. Developing robust evaluative models that accommodate this tension, and take account of the dyadic context of caring is a critical challenge. A fundamental deficit of carer-related research is its location in one of two, largely separate, paradigmatic frameworks: the "Gatherers and Evaluators" and the "Conceptualisers and Theorisers." The authors suggest that developing an integrated paradigm that draws on the strengths and methods of existing paradigms, has considerable potential to generate new knowledge and new evidence and extend understanding of care and caring.

What do we know about older former carers? Key issues and themes.

Despite a significant growth in the number older former family carers, they remain largely invisible in carer-related research and literature. To begin to address this deficit, a four-stage literature review was conducted to identify existing knowledge about older former carers. Narrative synthesis of the findings yielded five themes - the concept of 'older former carer', the legacies of caring, influences on the legacies of caring, conceptualising post-caring and support services for older former carers. Critical analysis of these findings suggests that existing evidence has a number of strengths. It highlights the terminological and conceptual confusion in the field, identifies the profound financial and health-related legacies older former carers' experience, the factors which shape these legacies and some of the complexities of bereavement older former carers face. The support needs of older former carers are also illuminated. However, the field is characterised by key weaknesses. The evidence base is fragmented and uneven. In part this reflects lack of definitional consensus and in part the fact that there is much more evidence about some sub-groups, such as carers of relatives admitted to a care home, than others. Methodology-related weaknesses include small sample sizes and a focus on a single, often condition-specific, group of older former carers. An overarching criticism relates to the narrow conceptual/theoretical purview. As post-caring tends to be viewed as one of the final temporal 'stages' of the carer's 'care-giving career', a bifurcatory model of carer/former carer is created, i.e. that a carer actively provides care and a former carer is no longer caring. This constructs being a former carer - namely formerality - as a single fixed state failing to capture its dynamic and shifting nature and constrains the potential of research to generate new knowledge and extend understanding.

Knowledge generation about care-giving in the UK: a critical review of research paradigms.

While discourse about care and caring is well developed in the UK, the nature of knowledge generation about care and the research paradigms that underpin it have been subjected to limited critical reflection and analysis. An overarching synthesis of evidence - intended to promote debate and facilitate new understandings - identifies two largely separate bodies of carer-related research. The first body of work - referred to as Gathering and Evaluating - provides evidence of the extent of care-giving, who provides care to whom and with what impact; it also focuses on evaluating policy and service efficacy. This type of research tends to dominate public perception about caring, influences the type and extent of policy and support for carers and attracts funding from policy and health-related sources. However, it also tends to be conceptually and theoretically narrow, has limited engagement with carers' perspectives and adopts an atomistic purview on the care-giving landscape. The second body of work - Conceptualising and Theorising - explores the conceptual and experiential nature of care and aims to extend thinking and theory about caring. It is concerned with promoting understanding of care as an integral part of human relationships, embedded in the life course, and a product of interdependence and reciprocity. This work conceptualises care as both an activity and a disposition and foregrounds the development of an 'ethic of care', thereby providing a perspective within which to recognise both the challenges care-giving may present and the significance of care as a normative activity. It tends to be funded from social science sources and, while strong in capturing carers' experiences, has limited policy and service-related purchase. Much could be gained for citizens, carers and families, and the generation of knowledge advanced, if the two bodies of research were integrated to a greater degree.

Psycho-educational support for relatives of people with a recent diagnosis of mild to moderate dementia: an evaluation of a 'Course for Carers'.

Currently there are 820,000 people with dementia in the UK, a figure projected to reach 1.7 million by 2050. Policy and practice emphasis on early intervention in dementia and support of family carers foreground a need to explore service efficacy for relatives of those with a recent diagnosis. Existing evidence suggests that psycho-educational interventions can significantly enhance carer well being especially when well targeted and group based. A rolling programme of seven psycho-educational Courses for 'new carers' in one area of England was the subject of a systematic evaluation incorporating a quantitative rating scale and qualitative data. Findings suggest that the Courses achieved a number of intersecting aims: they provided psychological support; offered advice; enhanced coping skills; boosted confidence; increased knowledge; and prepared the carer for the future. That the Courses were designed and delivered by specialist staff - primarily psychologists, offered a social dimension, were time limited and free are noteworthy features. The evaluation suggests that as a model the Course has considerable short and longer term preventive potential; also that it could be replicated elsewhere in the country and achieve similar outcomes.

Help-seeking in relation to signs of dementia: a pilot study to evaluate the utility of the common-sense model of illness representations.

Despite the importance of early diagnosis of dementia, little is known about the factors underlying help-seeking in relation to signs of the condition. In this pilot study, we aimed to examine the potential utility of the common sense model (CSM) of illness representations for understanding lay perceptions of dementia and predicting intentions to seek help in relation to possible signs and symptoms. A secondary aim was to develop a measure of (dementia-related) illness representations as a tool for future research. After reading a vignette describing a "relative" with mild or moderate dementia, participants (N = 118) completed measures of illness representations and help-seeking intentions. Analyses compared perceptions of the mild and moderate vignettes and determined the extent to which illness perceptions differentiated between alternative forms of help-seeking (e.g. seeking professional help vs. help from family members). Results indicated that cognitive deficits were more readily identified as dementia than non-cognitive symptoms; these were commonly attributed to stress or depression. Participants were more likely to indicate an intention to seek professional help if they identified the problem in the vignette as dementia, perceived symptoms as severe, as having serious consequences and as likely to be permanent, but less likely to do so if they identified the problem as stress or attributed symptoms to psychological causes. Our preliminary data suggests that help-seeking may be prevented by inaccurate illness representations or misattribution of symptoms. The CSM may provide a useful framework for understanding perceptions of dementia symptoms and for informing help-seeking pathways.

The effect of bedrails on falls and injury: a systematic review of clinical studies.

BACKGROUND: around one-fourth of all falls in healthcare settings are falls from bed. The role of bedrails in falls prevention is controversial, with a prevailing orthodoxy that bedrails are harmful and ineffective. OBJECTIVE: to summarise and critically evaluate evidence on the effect of bedrails on falls and injury DESIGN: systematic literature review using the principles of QuoRoM guidance. SETTING AND SUBJECTS: adult healthcare settings REVIEW METHODS: using the keyword, bedrail, and synonyms, databases were searched from 1980 to June 2007 for direct injury from bedrails or where falls, injury from falls, or any other effects were related to bedrail use. RESULTS: 472 papers were located; 24 met the criteria. Three bedrail reduction studies identified significant increases in falls or multiple falls, and one found that despite a significant decrease in falls in the discontinue-bedrails group, this group remained significantly more likely to fall than the continue-bedrails group; one case-control study found patients who had their bedrails raised significantly less likely to fall; one retrospective survey identified a significantly lower rate of injury and head injury in falls with bedrails up. Twelve papers described direct injury from bedrails. DISCUSSION: it is difficult to perform conventional clinical trials of an intervention already embedded in practice, and all included studies had methodological limitations. However, this review concludes that serious direct injury from bedrails is usually related to use of outmoded designs and incorrect assembly rather than being inherent, and bedrails do not appear to increase the risk of falls or injury from falls.

GP attitudes to early diagnosis of dementia: evidence of improvement.

This paper offers a comparative analysis of GPs attitudes towards early diagnosis of dementia in 1997 and 2001. It draws on data from two studies conducted in the same area using the same research instrument. Overall, findings reveal a significantly greater commitment to early diagnosis at Time 2 than at Time 1. More GPs hold positive attitudes and consider early diagnosis to facilitate a number of practical and therapeutic benefits for users and carers. Further, fewer GPs regard early diagnosis as having negative consequences. Findings also support existing evidence about attitudes being underpinned by drivers and barriers. Those GPs who are committed regard it as an opportunity to offer preventive treatment and plan for the future; barriers include limited treatment options. Primary reasons for the attitudinal shift are greater accessibility of psychiatric colleagues, additional investment in support services, and enhanced policy and clinical emphasis on the value of early diagnosis.