Admission avoidance hospital at home.

BACKGROUND: Admission avoidance hospital at home provides active treatment by healthcare professionals in the patient's home for a condition that would otherwise require acute hospital inpatient care, and always for a limited time period. This is the fourth update of this review. OBJECTIVES: To determine the effectiveness and cost of managing patients with admission avoidance hospital at home compared with inpatient hospital care. SEARCH METHODS: We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, and CINAHL on 24 February 2022, and checked the reference lists of eligible articles. We sought ongoing and unpublished studies by searching ClinicalTrials.gov and WHO ICTRP, and by contacting providers and researchers involved in the field. SELECTION CRITERIA: Randomised controlled trials recruiting participants aged 18 years and over. Studies comparing admission avoidance hospital at home with acute hospital inpatient care. DATA COLLECTION AND ANALYSIS: We followed the standard methodological procedures expected by Cochrane and the Effective Practice and Organisation of Care (EPOC) Group. We performed meta-analysis for trials that compared similar interventions, reported comparable outcomes with sufficient data, and used individual patient data when available. We used the GRADE approach to assess the certainty of the body of evidence for the most important outcomes. MAIN RESULTS: We included 20 randomised controlled trials with a total of 3100 participants; four trials recruited participants with chronic obstructive pulmonary disease; two trials recruited participants recovering from a stroke; seven trials recruited participants with an acute medical condition who were mainly older; and the remaining trials recruited participants with a mix of conditions. We assessed the majority of the included studies as at low risk of selection, detection, and attrition bias, and unclear for selective reporting and performance bias. For an older population, admission avoidance hospital at home probably makes little or no difference on mortality at six months' follow-up (risk ratio (RR) 0.88, 95% confidence interval (CI) 0.68 to 1.13; P = 0.30; I2 = 0%; 5 trials, 1502 participants; moderate-certainty evidence); little or no difference on the likelihood of being readmitted to hospital after discharge from hospital at home or inpatient care within 3 to 12 months' follow-up (RR 1.14, 95% CI 0.97 to 1.34; P = 0.11; I2 = 41%; 8 trials, 1757 participants; moderate-certainty evidence); and probably reduces the likelihood of living in residential care at six months' follow-up (RR 0.53, 95% CI 0.41 to 0.69; P < 0.001; I2 = 67%; 4 trials, 1271 participants; moderate-certainty evidence). Hospital at home probably results in little to no difference in patient's self-reported health status (2006 patients; moderate-certainty evidence). Satisfaction with health care received may be improved with admission avoidance hospital at home (1812 participants; low-certainty evidence); few studies reported the effect on caregivers. Hospital at home reduced the initial average hospital length of stay (2036 participants; low-certainty evidence), which ranged from 4.1 to 18.5 days in the hospital group and 1.2 to 5.1 days in the hospital at home group. Hospital at home length of stay ranged from an average of 3 to 20.7 days (hospital at home group only). Admission avoidance hospital at home probably reduces costs to the health service compared with hospital admission (2148 participants; moderate-certainty evidence), though by a range of different amounts and using different methods to cost resource use, and there is some evidence that it decreases overall societal costs to six months' follow-up. AUTHORS' CONCLUSIONS: Admission avoidance hospital at home, with the option of transfer to hospital, may provide an effective alternative to inpatient care for a select group of older people who have been referred for hospital admission. The intervention probably makes little or no difference to patient health outcomes; may improve satisfaction; probably reduces the likelihood of relocating to residential care; and probably decreases costs.

Views of people living with dementia and their carers on their present and future: a qualitative study.

BACKGROUND: Dementia leads to multiple issues including difficulty in communication and increased need for care and support. Discussions about the future often happen late or never, partly due to reluctance or fear. In a sample of people living with dementia and carers, we explored their views and perceptions of living with the condition and their future. METHODS: Semi-structured interviews were conducted in 2018-19 with 11 people living with dementia and six family members in England. Interviews were audio-recorded, transcribed and analysed using reflexive thematic analysis. RESULTS: Findings were explored critically within the theory of social death and three themes were developed: (1) loss of physical and cognitive functions, (2) loss of social identity, and (3) social connectedness. Most participants living with dementia and carers wanted to discuss the present, rather than the future, believing a healthy lifestyle would prevent the condition from worsening. Those with dementia wanted to maintain control of their lives and demonstrated this by illustrating their independence. Care homes were often associated with death and loss of social identity. Participants used a range of metaphors to describe their dementia and the impact on their relationships and social networks. CONCLUSION: Focusing on maintaining social identity and connectedness as part of living well with dementia may assist professionals in undertaking advance care planning discussions.

Experiences of intimate continence care and the impact on the family dyad relationship for people living at home with dementia and their co-resident family members.

OBJECTIVES: The experience of providing/receiving intimate continence care between family members can be difficult and emotive. Often, for people living with dementia this seems an area of care overlooked by professionals. This study investigated the experiences of intimate continence care for people living with dementia and their family member (the family dyad), and whether they viewed this as impacting on their relationship. METHOD: Face-to-face interviews were conducted at 6 monthly intervals over a 12-month period with 13 carers (all family members) and one person living with dementia (13 family dyads) in England. Interviews were recorded and transcribed. Analysis of the data was achieved using a descriptive phenomenological method. FINDINGS: Carers' attitudes towards providing intimate continence care revealed a task-focused approach for some but feelings of disgust and distress for others. Four participants (including the participant living with dementia) reported that intimate continence care had strengthened their dyad relationship. However, some carers perceived the care and support received from health and social care practitioners to be insufficient, which placed extra stress on them and adversely affected their family dyad relationship. CONCLUSION: Implications of the study suggest that integrated and effective continence care and support for people living with dementia and their carers could (1) maintain the quality of the family dyad relationship, (2) help keep the person living at home, delaying an unwanted move to a care home and (3) consequently improve overall quality of life for individuals in the family dyad. Assuring integrated and effective continence care should be a priority for service funders and quality assurance regulators.

Dementia and primary care teams: obstacles to the implementation of Portugal's Dementia Strategy.

BACKGROUND: Portugal has a Dementia Strategy that endorses care coordination in the community, but the strategy is not implemented despite there being a network of multidisciplinary primary care clinics that could support it. Recent research into barriers to dementia management in primary care has focused essentially on general practitioners' (GPs) factors and perspectives. A comprehensive triangulated view on the barriers to dementia management emphasising teamwork is missing. AIM: To explore the barriers to the implementation of the Portuguese Dementia Strategy by primary care teams, from the perspectives of service users and professionals. METHODS: Purposive sampling was used to recruit 10 GPs, 8 practice nurses, 4 social workers, 8 people with dementia and 10 family carers from 6 practices in different social contexts within the Lisbon metropolitan area. The analytical framework combined codes derived from the transcripts with codes from the available literature. Themes focused on the access to professionals/community services, care coordination within healthcare teams, and between health and community services. FINDINGS: Several system barriers were identified (undefined roles/coordination within teams, time constraints, insufficient signposting to community services) along with individual barriers (limited competence in dementia, unrecognised autonomy, limited views on social health and quality of life (QoL)), hindering users access to dementia services. CONCLUSION: Enhanced competence in dementia, and nurse-led systematic care of people with dementia and their carers, are necessary. They can be effective in improving the QoL in dementia, but only if associated with better community support.

'It is designed for everybody to find their own level and to improve themselves'; views of older people and instructors of the Falls Management Exercise (FaME) programme.

BACKGROUND: Older adults are at increased risk of falls due to ageing, decreased muscle strength and impaired balance. Clinical trials have demonstrated the efficacy and effectiveness of the Falls Management Exercise (FaME) programme in improving functioning and preventing falls. However, programme completion is often low, impacting the potential benefits of FaME. OBJECTIVE: To explore the barriers and facilitators for participation and completion of the FaME programme from an instructor and participant perspective. METHODS: Semi-structured interviews were conducted with 20 FaME users and seven Postural Stability Instructors from the East Midlands region of England, UK. Interviews were conducted using a topic guide and explored their views of the programme, intended benefits, reasons for participating, instructor's approach and venue facilities. Data were transcribed verbatim and analysed using thematic analysis. Written informed consent was obtained from all participants and instructors. RESULTS: Common themes identified by participants and instructors for adherence related to perceived health benefits, psychological well-being, intervention characteristics, cost, instructors' qualities, opportunity to socialise, venue accessibility and facilities. Further factors such as maintaining independence, discipline, relationship with peers and caring responsibilities influenced participants' engagement with the programme. Instructor factors such as progression were also reported as important predictors. CONCLUSIONS: Instructor and participant factors influence uptake, attendance and adherence of FaME. The findings from this study can inform the development and improvement of additional falls-prevention programmes. It can also guide marketing strategies to promote uptake of exercise-based falls-prevention programmes among older adults.

Disentangling interventions to reduce fear of falling in community-dwelling older people: a systematic review and meta-analysis of intervention components.

PURPOSE: Fear of falling (FoF) is a common and debilitating problem for older people. Most multicomponent interventions show only moderate effects. Exploring the effective components may help in the optimization of treatments for FoF. MATERIALS AND METHODS: In a systematic review of five scientific literature databases, we identified randomized controlled trials with older community-dwelling people that included FoF as an outcome. There was no restriction on types of interventions. Two reviewers extracted information about outcomes and content of interventions. Intervention content was coded with a coding scheme of 68 intervention components. We compared all studies with a component to those without using univariate meta-regressions. RESULTS: Sixty-six studies, reporting on 85 interventions, were included in the systematic review. In the meta-regressions (n = 49), few components were associated with intervention effects at the first available follow up after the intervention, but interventions with meditation, holistic exercises (such as Tai Chi or Pilates) or body awareness were significantly more effective than interventions without these components. Interventions with self-monitoring, balance exercises, or tailoring were less effective compared to those without these components. CONCLUSIONS: The identified components may be important for the design and optimization of treatments to reduce FoF. Implications for rehabilitationFear of falling (FoF) is a common and debilitating issue among older people and multicomponent interventions usually show only small to moderate effects on FoF.This review and meta-analysis investigated 68 intervention components and their relation to intervention effects on FoF.Interventions with meditation, holistic exercises (such as Tai Chi), or body awareness are more effective than interventions without these components.Clinicians aiming to reduce FoF may recommend selected interventions to older people taking into account the current knowledge of intervention components.

Clapping for carers in the Covid-19 crisis: Carers' reflections in a UK survey.

This paper reports and discusses the weekly Clapping for Carers - described as 'front-line heroes' that took place across the United Kingdom during the first national lockdown of the coronavirus pandemic. Data are drawn from a UK-wide online survey of health and social care workers, completed in May to July 2020. The survey received 3,425 responses of which 2,541 were analysed; free-text comments were categorised. One question asked specifically: 'Do you think the "Clap for Carers" was a helpful response from the public?', and 815 comments were provided. Responses were extracted from these 815 free-text comments and categorised as follows: unequivocally Yes, predominantly Yes, mixed feelings, predominantly No and unequivocally No. Most comments revealed mixed feelings about the helpfulness of Clapping with only a minority being entirely supportive. The free-text comments offer some explanations for these views with many feeling that Clapping distracted from the severity of the pandemic and the inadequate resources. The free-text comments reveal workforce concerns that the support demonstrated for the frontline workforce in Clapping might be transitory and that it may not translate into workforce improvements and political commitment to further funding of health and social care. Some saw the value of Clapping as illustrative of community cohesion. There was little mention of Clapping for heroes, and where it was the notion of heroism was rejected. The demonstration of public support in Clapping for Carers may have directly benefitted the public, but only indirectly the workforce. Future recruitment data may help discern if public support has translated into a desire to join the workforce.

Equity-specific effects of interventions to promote physical activity among middle-aged and older adults: results from applying a novel equity-specific re-analysis strategy.

BACKGROUND: Reducing inequalities in physical activity (PA) and PA-associated health outcomes is a priority for public health. Interventions to promote PA may reduce inequalities, but may also unintentionally increase them. Thus, there is a need to analyze equity-specific intervention effects. However, the potential for analyzing equity-specific effects of PA interventions has not yet been sufficiently exploited. The aim of this study was to set out a novel equity-specific re-analysis strategy tried out in an international interdisciplinary collaboration. METHODS: The re-analysis strategy comprised harmonizing choice and definition of outcomes, exposures, socio-demographic indicators, and statistical analysis strategies across studies, as well as synthesizing results. It was applied in a collaboration of a convenience sample of eight European PA intervention studies in adults aged ≥45 years. Weekly minutes of moderate-to-vigorous PA was harmonized as outcome. Any versus no intervention was harmonized as exposure. Gender, education, income, area deprivation, and marital status were harmonized as socio-demographic indicators. Interactions between the intervention and socio-demographic indicators on moderate-to-vigorous PA were analyzed using multivariable linear regression and random-effects meta-analysis. RESULTS: The collaborative experience shows that the novel re-analysis strategy can be applied to investigate equity-specific effects of existing PA interventions. Across our convenience sample of studies, no consistent pattern of equity-specific intervention effects was found. Pooled estimates suggested that intervention effects did not differ by gender, education, income, area deprivation, and marital status. CONCLUSIONS: To exploit the potential for equity-specific effect analysis, we encourage future studies to apply the strategy to representative samples of existing study data. Ensuring sufficient representation of 'hard to reach' groups such as the most disadvantaged in study samples is of particular importance. This will help to extend the limited evidence required for the design and prioritization of future interventions that are most likely to reduce health inequalities.

'Real world' effectiveness of the Falls Management Exercise (FaME) programme: an implementation study.

BACKGROUND: Falls incidence increases with age alongside declines in strength and balance. Clinical trials show that the Falls Management Exercise (FaME) programme improves strength and balance, which can reduce falls and improve physical functioning. OBJECTIVE: To determine if the clinical trial efficacy of FaME translates into effectiveness in non-research settings. DESIGN AND SETTING: An implementation study of FaME in 10 local authorities across the East Midlands region of England. SUBJECTS: Adults aged 65 and over enrolled on a FaME programme. METHOD: Anonymised outcome data collected by the FaME providers were compared at baseline, end of programme and 6 months follow-up using univariate and multivariate analyses. RESULTS: For 348 adults enrolled in programmes and analysed, the mean age was 76.8, 73% were female and 143 (41%) completed ≥75% of classes. Overall confidence in balance, fear of falling, functional reach and timed-up-and-go (all P < 0.001), and turn 180° (P = 0.008) improved significantly at programme completion versus baseline, but improvements were not maintained 6 months later. Falls risk (FRAT score) and total minutes of physical activity did not change significantly though minutes of strength and balance activity increased by 55% at programme completion and was maintained at 6 months. The falls incidence rate ratio (IRR) was non-significantly lower at programme completion (IRR 0.76, 95% Confidence Interval (CI) 0.48,1.21) and follow-up (IRR 0.82 95% CI 0.48,1.39) versus baseline. CONCLUSIONS: There is modest translation of FaME efficacy into effectiveness, but not all effects persist after completion. Strategies to aid adherence and exercise maintenance are important to maximise benefits.

Medical consumerism in the UK, from 'citizen's challenge' to the 'managed consumer'-A symbol without meaning?

BACKGROUND: In Britain's National Health Service (NHS), medical consumerism is disliked by many doctors but managed by NHS leaders. Managed consumers have choices about treatment options, but are expected to help contain costs, improve quality of care, take part in clinical research and advocacy, and increase productivity. There are so many meanings for medical consumerism that it can be categorized, in post-structuralist terms, as a 'symbol without meaning', but meanings are plentiful in the NHS. POLICY EXPECTATIONS: Choices made by discriminating consumers were expected to improve the quality of medical care for all. Extending choice to the many, and not restricting options to the few, would allow gains from choices to accumulate, so that choice would sustain social solidarity. Managed consumerism would in theory, therefore, instil reasonable choices and responsible behaviours in a moralized citizenry, across the nation. The advocates of New Labour's espousal of medical consumerism expected the accumulative effects of customer choices to challenge professional and occupational power, erode the medical model of health and illness, constrain professional judgements, and open the NHS to new ways of working. Almost all their expectations have been thwarted, so far. CONCLUSIONS: Managed consumerism is far from being a meaningless symbol. This discussion paper explores the territory of managed consumerism and suggests realistic ways to make it more effective in shaping the NHS. PATIENT & PUBLIC CONTRIBUTION: We developed the arguments in this discussion paper with insights provided by a lay expert (see Acknowledgements) with experience of consumerism in both public sector management and a disease-related charity.

Intervention Characteristics Associated With a Reduction in Fear of Falling Among Community-Dwelling Older People: A Systematic Review and Meta-analysis of Randomized Controlled Trials.

BACKGROUND AND OBJECTIVES: Fear of falling (FoF) is associated with decreased physical functioning and an increased fall risk. Interventions generally demonstrate moderate effects and optimized interventions are needed. Intervention characteristics, such as setting or delivery method may vary. We investigated which overarching intervention characteristics are associated with a reduction in FoF in community-dwelling older people. RESEARCH DESIGN AND METHODS: A systematic review and meta-analysis of randomized controlled trials (RCTs) in community-dwelling older people without specific diseases was performed. Associations between intervention characteristics and standardized mean differences (SMD) were determined by univariate meta-regression. Sensitivity analyses were performed. RESULTS: Data on 62 RCTs were extracted, 50 intervention groups were included in the meta-analysis. Most intervention characteristics and intervention types were not associated with the intervention effect. Supervision by a tai chi instructor (SMD: -1.047, 95% confidence interval [CI]: -1.598; -0.496) and delivery in a community setting (SMD: -0.528, 95% CI: -0.894; -0.161) were-compared to interventions without these characteristics-associated with a greater reduction in FoF. Holistic exercise, such as Pilates or yoga (SMD: -0.823, 95% CI: -1.255; -0.392), was also associated with a greater reduction in FoF. Delivery at home (SMD: 0.384, 95% CI: 0.002; 0.766) or with written materials (SMD: 0.452, 95% CI: 0.088; 0.815) and tailoring were less effective in reducing FoF (SMD: 0.687, 95% CI: 0.364; 1.011). DISCUSSION AND IMPLICATIONS: Holistic exercise, delivery with written materials, the setting and tailoring potentially represent characteristics to take into account when designing and improving interventions for FoF in community-dwelling older people. PROSPERO international prospective register of systematic reviews, registration ID CRD42018080483.

What is the present role for general practitioners in dementia care? Experiences of general practitioners, patients and family carers in Portugal.

BACKGROUND: Governments are being challenged to integrate at least part of dementia care into primary care. However, little is known about the current role of general practitioners (GPs) regarding dementia care, especially in countries that do not have dementia strategies in place. The aim of this study was to explore the experiences of GPs, persons with dementia and their family carers in Portuguese primary care settings, to better understand GPs' contribution to dementia care. METHODS: A qualitative interview study of participants recruited from six practices in different social contexts within the Lisbon metropolitan area was carried out. Purposive sampling was used to recruit GPs, persons with dementia and carers. Interviews with GPs explored dementia care comprehensiveness, including satisfactory and challenging aspects. Interviews with patients and carers explored the experience of talking to GPs about cognitive impairments and related difficulties and the type of help received. Thematic analysis of interview transcripts was carried out using the framework approach. RESULTS: Five major themes were identified: GPs have a limited contribution to dementia care, the case of advanced dementia, doctor-patient relationships, doctor-carer relationships and management of chronic conditions other than dementia. CONCLUSION: General practitioners seemed to contribute little to dementia care overall, particularly regarding symptom management. The exception was patients with advanced stages of dementia, given that specialists no longer followed them up. Remarkably, GPs seemed to be alone within primary care teams in providing dementia care. These findings strongly suggest that Portuguese primary care is not yet prepared to comply with policy expectations regarding the management of dementia.

Fruit and Vegetable Consumption and Incident Prefrailty and Frailty in Community-Dwelling Older People: The English Longitudinal Study of Ageing.

BACKGROUND: There is limited evidence in the literature regarding associations between fruit and vegetable consumption and risk of frailty. OBJECTIVE: To examine associations between fruit and vegetable consumption and risk of incident frailty and incident prefrailty/frailty. DESIGN: A prospective panel study. SETTING AND SUBJECTS: 2634 non-frail community-dwelling men and women aged 60 years or older from the English Longitudinal Study of Ageing (ELSA). METHODS: Fruit and vegetable consumption/day was measured using a self-completion questionnaire at baseline. Frailty status was measured at baseline and follow-up was based on modified frailty phenotype criteria. Four-year incident frailty was examined among 2634 robust or prefrail participants, and incident prefrailty/frailty was measured among 1577 robust participants. RESULTS: Multivariable logistic regression models adjusted for age, gender, and other confounders showed that fruit and vegetable consumption was not associated with incident frailty risks among robust or prefrail participants. However, robust participants consuming 5-7.5 portions of 80 g per day (odds ratio (OR) = 0.56, 95% confidence interval (CI) = 0.37-0.85, p < 0.01) and 7.5-10 portions per day (OR = 0.46, 95%CI = 0.27-0.77, p < 0.01) had significantly lower risk of incident prefrailty/frailty compared with those consuming 0-2.5 portions/day, whereas those consuming 10 or more portions/day did not (OR = 1.10, 95%CI = 0.54-2.26, p = 0.79). Analysis repeated with fruit and vegetable separately showed overall similar results. CONCLUSIONS: Robust older adults without frailty who eat current U.K. government recommendations for fruit and vegetable consumption (5-10 portions/day) had significantly reduced risks of incident prefrailty/frailty compared with those who only eat small amount (0-2.5 portions/day). Older people can be advised that eating sufficient amounts of fruit and vegetable may be beneficial for frailty prevention.