Causes of nursing home placement for older people with dementia: a systematic review and meta-analysis.

BACKGROUND: Up to half of people with dementia in high income countries live in nursing homes and more than two-thirds of care home residents have dementia. Fewer than half of these residents report good quality of life and most older people are anxious about the prospect of moving into a nursing home. Robust evidence is needed as to the causes of admission to nursing homes, particularly where these risk factors are modifiable. METHODS: We conducted a systematic literature search to identify controlled comparison studies in which the primary outcome was admission to nursing home of older adults with dementia. Identified studies were assessed for validity and 26 (17 cohort and 9 case-control) were included. Qualitative and quantitative analyses were conducted, including meta-analysis of 15 studies. RESULTS: Poorer cognition and behavioral and psychological symptoms of dementia (BPSD) were consistently associated with an increased risk of nursing home admission and most of our meta-analyses demonstrated impairments in activities of daily living as a significant risk. The effects of community support services were unclear, with both high and low levels of service use leading to nursing home placement. There was an association between caregiver burden and risk of institutionalization, but findings with regard to caregiver depression varied, as did physical health associations, with some studies showing an increased risk of nursing home placement following hip fracture, reduced mobility, and multiple comorbidities. CONCLUSION: We recommend focusing on cognitive enhancement strategies, assessment and management of BPSD, and carer education and support to delay nursing home placement.

Identifying the causes, prevention and management of crises in dementia. An online survey of stakeholders.

BACKGROUND: Crisis situations in dementia can lead to hospital admission or institutionalisation. Offering immediate interventions may help avoid admission, whilst stabilising measures can help prevent future crises. OBJECTIVE: Our objective was to identify the main causes of crisis and interventions to treat or prevent crisis in persons with dementia based on different stakeholder perspectives. METHODS: An online questionnaire was developed to identify the causes of crisis and appropriate interventions in a crisis. Participants included people with dementia, family carers and staff working in health and social care, including emergency and voluntary sectors, and academia. RESULTS: The results ranked the main causes of crisis, interventions that can prevent a crisis and interventions that can be useful in a crisis. Wandering, falls and infection were highly rated as risk factors for crises across all stakeholder groups. Consumers rated aggression as less important but severity of memory impairment as much more important than the other groups did. Education and support for family carers and home care staff were highly valued for preventing crises. Well-trained home care staff, communication equipment, emergency contacts and access to respite were highly valued for managing crises. CONCLUSIONS: We identified triggers and interventions that different stakeholders see as important for crisis in dementia. Recognition of these may be critical to planning effective and accepted support and care for people with dementia.

Causes of crises and appropriate interventions: the views of people with dementia, carers and healthcare professionals.

The aims of this study were to identify which factors may lead to crisis for people with dementia and their carers and identify interventions these individuals believe could help in crisis. Qualitative study using focus groups to compare the perspectives of people with dementia, family carers and healthcare professionals on causes of crises and crisis interventions. To help in a crisis, people with dementia were favourable towards support from family and friends, access to mobile phones and home adaptations to reduce risks. Carers were keen on assistive technology and home adaptation. Both carers and staff valued carer training and education, care plans and well-coordinated care. Staff were the only group emphasizing more intensive interventions such as emergency home respite and extended hours services. In terms of causes of crises, people with dementia focused on risks and hazards in their home, whereas family carers emphasized carer stress and their own mental health problems. Staff, in contrast were concerned about problems with service organization and coordination leading to crises. Physical problems were less commonly identified as causes of crises but when they did occur they had a major impact. Practical interventions such as home adaptations, assistive technology, education and training for family carers, and flexible home care services were highly valued by service users and their families during times of crisis and may help prevent hospital admissions. Specialist home care was highly valued by all groups.

Failures in children's protection in Newfoundland and Labrador: from the Hughes (1991) to Markesteyn and Day (2006) inquiries and beyond.

The death in 2003 of Zachary Turner, a child in receipt of children's protection services in Foxtrap, Newfoundland, sparked an independent inquiry into his death. Subsequently, other reviews were completed of children's protection services. These were not the first reviews or inquiries of this kind in Newfoundland and Labrador. In 1991, Justice Samuel Hughes had conducted a public inquiry into children's protection services. This article is a critical historical analysis of selected aspects of children's protection services. The authors uncover repeated failures by government in its child protection systems and discuss implications for future concerns.

The effectiveness of crisis resolution/home treatment teams for older people with mental health problems: a systematic review and scoping exercise.

OBJECTIVE: To assess the effectiveness of crisis resolution/home treatment services for older people with mental health problems. DESIGN: A systematic review was conducted to report on the effectiveness of crisis resolution/home treatment teams (CRHTTs) for older people with mental health problems. As part of the review, we also carried out a scoping exercise to assess the typologies of older people's CRHTTs in practice, and to review these in the context of policy and research findings. RESULTS: The literature contains Grade C evidence, according to the Oxford Centre of Evidence Based Medicine (CEBM) guidelines, that CRHTTs are effective in reducing numbers of admissions to hospitals. Outcomes such as length of hospital stay and maintenance of community residence were reviewed but evidence was inadequate for drawing conclusions. The scoping exercise defined three types of home treatment service model: generic home treatment teams; specialist older adults home treatment teams; and intermediate care services. These home treatment teams seemed to be effectively managing crises and reducing admissions. CONCLUSION: This review has shown a lack of evidence for the efficacy of crisis resolution/home treatment teams in supporting older people with mental health problems to remain at home. There is clearly a need for a randomised controlled trial to establish the efficacy of crisis resolution/home treatment services for older people with mental health problems, as well as a more focussed assessment of the different home treatment service models which have developed in the UK.

Causes of hospital admission for people with dementia: a systematic review and meta-analysis.

OBJECTIVES: To conduct a systematic review and meta-analysis of the literature of the factors leading to hospital admission for people with dementia in comparison with (1) people without dementia acutely admitted and (2) people with dementia in the community. RESULTS: Inpatients with dementia are at an increased risk of crisis owing to physical health-related factors, including orthopedic, respiratory, and urologic, than inpatients who do not have dementia. We also reviewed data that compared people with dementia admitted with those who were not and found that behavioral problems, such as agitation and wandering, placed people with dementia at an increased risk of being admitted. Interestingly, we also found that changes in routine and environment and increased dependency problems in several activities of daily living were associated with a higher risk of hospitalization for people with dementia. CONCLUSIONS: Many older people's crisis teams tend to focus on prevention and reducing psychiatric admissions. This review highlights the need for recognition of the physical health risks in these patients and a low threshold for early treatment in the community. This review highlights the importance of integrated working between services for older people's mental health, primary care, social welfare, intermediate care, and hospital liaison.