PARTNERSHIP NURSING HOME CARE FOR DEMENTIA: THE GLASGOW EXPERIENCE—ONE-YEAR FOLLOW-UP

The outcome of the transfer of 60 elderly patients suffering from dementia from hospital to nursing home care under a partnership contract was reviewed at 6 and 12 months following transfer. The nursing home population had fared badly compared with patients remaining in hospital during the first 3 months. This difference was less evident at 6 months follow-up and had disappeared at 12 months follow-up. It seems that a partnership agreement such as this can deliver a quality of health care at least as good as hospital treatment as long as the transfer is handled carefully. © 1997 John Wiley & Sons, Ltd.     

THE IMPACT OF DAY CARE ON PEOPLE WITH DEMENTIA

Day care services are now widely used by people with dementia. Research on day care has focused on benefits to caregivers. The impact of day care attendance on the person with dementia has been relatively neglected. Caregivers of new attenders at a dementia-specific day centre were asked to describe any change noted in their relative since attendance at the day centre had commenced. Forty-two per cent of new attenders included in the study showed a marked improvement in mood and/or behaviour, attributed by caregivers to day centre attendance, which was maintained in most cases 9 months after initial attendance. All those showing a marked improvement were female. There was a trend for day care responders to live alone though this failed to reach significance at the 5% level. Other factors such as age, degree of cognitive impairment, level of dependency and behavioural disturbance and frequency of day care attendance did not differentiate responders from non-responders. However, female responders tended to have less cognitive impairment than female non-responders. Although the number of subjects in the study is small, the findings have implications for service provision and may indicate directions for future research.     

QUALITY OF CARE,QUALITY OF LIFE AND THE RELATIONSHIP BETWEEN THEM IN LONG-TERM CARE INSTITUTIONS FOR THE ELDERLY

A stratified randomly selected sample of 28 of all elderly long-term care institutions in the Southampton district was studied including private and local authority residential homes, private nursing homes and NHS geriatric and psychogeriatric wards. The manager was interviewed with a 57-item quality of care questionnaire modified from the methodology of Willcockset al. (1987) covering aspects of regime and environment. To assess quality of life, 10% of residents were randomly selected for a series of structured quality of life interviews and Barthel Index determination. A life-history approach was used to build rapport and increase the authenticity of resident responses. Systematic significant differences in quality of care and quality of life were found between sectors. The correlation coefficients between quality of care and morale and between quality of care and dependency were significant (r=0.526,p<0.01;r=0.508,p<0.01 respectively) although the correlation between morale and dependency (r=0.155,p=0.2) was insignificant. High-quality care may be more difficult to provide in facilities for more disabled residents. This may affect their morale but the relationship between morale and dependency is complex.     

THE ROLE OF GENERAL PRACTICE AND THE PRIMARY CARE TEAM IN DEMENTIA DIAGNOSIS AND MANAGEMENT

General practitioners (GPs) and the primary care team are uniquely situated to play a central role both in the diagnosis and ongoing care of dementia. Anecdotal reports and empirical work suggest that GPs face several challenges in fulfilling this role. This paper describes the various roles GPs and the primary care team could play in diagnosis and ongoing management. It then discusses the legitimate anxieties and difficulties faced in fulfilling these roles. The paper concludes with suggestions for how GPs and the primary care team might be supported to maximize their role in dementia diagnosis and management.     

FROM STATES OF CONFUSION TO A NATIONAL ACTION PLAN FOR DEMENTIA CARE: THE DEVELOPMENT OF POLICIES FOR DEMENTIA CARE IN AUSTRALIA

The release of Australia's National Action Plan for Dementia Care in 1992 was the culmination of more than a decade of policy development over which the federal government assumed an increasing role, and the participatory approach fostered under its Social Justice Strategy promoted collectivist and political attempts to address the issues of dementia care. This article begins with an account of four phases of policy development, with the transition from one to the next marked by changes in thinking about dementia care being incorporated into policy and then expressed in programmes and in care practices. In the second part of the article, the goals and structure of the National Action Plan are outlined and its implementation and outcomes discussed. Continuation of the policy climate in which the National Action Plan was formulated is a crucial, but uncertain, factor for future development. © 1997 John Wiley & Sons, Ltd.     

PREDICTORS OF CHANGE AND CONTINUITY IN HOME CARE FOR DEMENTIA PATIENTS

Objective. To investigate predictors of change in the sense of competence of primary caregivers and continuity in home care for dementia patients. Design. A prospective longitudinal study with a follow-up period of 10 months. Setting. Dementia patients living in the community selected by Dutch general practitioners. Subjects. Pairs of demented patients and their primary caregivers (N=138). Main outcome measures. Sense of competence: a 27-item scale (α=0.79) based on issues derived from the family crisis model and the Burden Interview. Continuity in home care is determined by the number of patient's admissions to a nursing or retirement home. Results. Regression analysis revealed that a change in the caregiver's sense of competence was independently predicted by characteristics of the patient, the primary caregiver and the professional social network. A decreased sense of competence was associated with a longer duration of dementia and the patient's more agitated behaviour, the caregiver's higher initial sense of competence and being a female caregiver sharing a household with the demented patient. A positive influence on the change in the sense of competence was found when these females received a professional intervention consisting of support for the caregiver. Reporting to be a Catholic or a Protestant compared with not being religiously involved positively influenced the change in sense of competence. Logistic regression analysis identified that continuity in home care was predicted by characteristics of the demented patient and the professional social network of the patient. Predictors of continuation of home care were: lower severity of dementia, patient's higher ADL impairment, the intervention and involvement of regular home help. Institutionalization was more likely when the patient's behaviour was more apathetic and a district nurse was involved in the care. Conclusions. Caregiver characteristics influenced the change in sense of competence but did not influence the risk for institutionalization. Findings suggest that health professionals should pay attention to the negative consequences of agitated behaviour and to the most vulnerable group, females sharing a household with the demented patient.     

PROFILING THE CARE NEEDS OF THE POPULATION WITH DEMENTIA: A SURVEY IN CENTRAL SCOTLAND

Objective. To demonstrate a low-cost method of producing local information for dementia service planning. Design. (1) Multiservice census. (2) Stratified random sample survey (stratified by setting) to assess needs. Setting. All community and institutional settings in Forth Valley Health Board area. Participants. (1) People age 65+ defined by health and social care professionals as having ‘problems of memory/confusion (as is caused by dementia)’ (N=2060). (2) As (1) excluding those with score <2 on Levin's checklist and no relevant known diagnosis (N=286). Main outcome measures. Coverage of population with dementia against EURODEM prevalence. Place of residence of sufferers. Level of care needs. Main results. Identified population, pro-rating for identifiable non-response, accounted for 78% of EURODEM prevalence. Assuming unidentified 22% to live at home, 45% of total population with dementia were in some form of institutional care. Survey demonstrated high levels of need in local population with dementia known to services. Assistance was required more than once a day with mobility by 48%, personal care by 60%, domestic tasks by 75% and because of behavioural problems by 57%. Assistance was required at night by 59% because of personal care needs and by 54% because of behaviour problems. Conclusion. The value of a broad-based survey ‘snapshot’ across the range of settings was confirmed. It can be accomplished relatively quickly and cheaply and complements information collected in other ways. © 1997 John Wiley & Sons, Ltd.     

THE PROBLEM OF DEMENTIA IN AUSTRALIAN ABORIGINAL AND TORRES STRAIT ISLANDER COMMUNITIES: AN OVERVIEW

The concept of dementia in old age in Australian Aboriginal and Torres Strait Islander communities is intrinsically paradoxical. Firstly, few indigenous people reach old age. Secondly, from some indigenous points of view, dementia is either not recognized as a condition or as a problem, or, in the case of the more disruptive manifestations of cognitive impairment, is perceived as ‘madness’. Moreover, in the wider context of profound political, social and economic inequality experienced by most indigenous people, the western medical category of dementia may appear to be of relatively minor importance. However, government initiatives in aged care generally and dementia care in particular which are designed to address the ageing of the Australian population as a whole also include the nation's older indigenous people. This article—based on a review of published work, supplemented by discussions with indigenous and non-indigenous individuals involved in indigenous aged care and mental health—examines some of the issues surrounding cognitive decline in old age for Aborigines and Torres Strait Islanders. More specifically, it looks at the problems involved in assessing and diagnosing cognitive decline and dementia, especially among people who follow more traditional ways of life, and in providing services to sufferers and their carers. In doing so, it considers some of the relative meanings of ‘old age’, ‘abnormal old age’, ‘mental disorder’, ‘sickness’ and ‘dementia’. © 1997 John Wiley & Sons, Ltd.     

Quality of in-home care,long-term care placement,and the survival of persons with dementia

Purpose of the study: Caregivers of persons with dementia living at home adopt a variety of caregiving styles that vary in quality. Three styles of high-quality care and poor-quality care have been identified. The outcomes, however, of varying styles of caregiving are unknown. Our purpose was to investigate the linkage of quality of care to long-term care placement and survival.

Design and methods: We used a sample of 148 primary caregivers of a relative living at home and needing assistance due to memory or thinking problems. We used items from four existing scales and five new items to construct measures of high-quality and poor-quality care. Long-term care and survival were determined from two follow-ups. Cox proportional hazards regression was used to estimate the relationship of quality of care to long-term care placement and survival.

Results: Poor quality of care increased the risk of long-term care placement, as expected, but high-quality care was not related to placement. Surprisingly, high-quality care increased the risk of death while poor-quality care decreased the risk. Secondary results were: wishful/intrapsychic coping (a dysfunctional type of emotion-focused coping) and long-term care placement shortened the survival; and caregiver personality traits of neuroticism and agreeableness lengthened the survival.

Implications: It is premature to recommend caregiver interventions based on our unexpected findings. Further studies are vital and should include care-recipient impairments and the quality of life of the person with dementia as additional outcomes.     

PSYCHIATRIC MORBIDITY AMONG THE ELDERLY IN A PRIMARY CARE SETTING—REPORT FROM A SURVEY IN SÃO PAULO,BRAZIL

Brazil has been experiencing a steady increase in the elderly population during the past few years, and as a result old age health-related problems are increasing continuously in number. Psychiatric symptoms are among the most prevalent health problems of the elderly and are an important source of distress for patients and carers, being also associated with significant growth in the costs and demand for the provision of health care services. This study aimed to investigate the prevalence of mental health problems among the elderly attending a regional primary care unit in the city of São Paulo, Brazil. A total of 351 patients older than 60 were assessed during a 6-month period with the SRQ-20 (a scale for the detection of minor psychiatric problems), four questions on psychotic symptoms, AMTS (a scale for the assessment of cognitive functioning) and CAGE (a scale for the assessment of alcoholism); demographic variables were also recorded. Subjects' mean age was 71.22 (CI=70.51–71.92) and 83.5% were female. Thirty-two per cent of subjects were considered ‘cases’ as they scored more than 7 on the SRQ-20 (26.8% of total), or more than 1 on the CAGE (1.4% of total), or at least 1 on the questions assessing psychotic symptoms (12.2% of total). There was a significant excess of women among those found to suffer from psychiatric problems (90.1% vs 80.4%). Cases were also more likely to be illiterate (23.4% vs 12.1%) and to have a lower income (2.21 vs 4.01 minimum wages). Depressive symptoms and tension were highly prevalent (72.9% of subjects). Somatic complaints and signs of inefficient functioning were also common (50.4% and 45.9% respectively). Only five patients answered affirmatively two or more CAGE questions and 12.2% scored at least 1 on the questions assessing psychotic symptoms. Cognitive deficit, as determined by the AMTS, was observed in 13.4% of the sample and was associated with ageing, being illiterate and having higher total SRQ-20 scores. We suggest, that the organization of health care services should take into account the needs of this population, and should also emphasize professional training for the correct assessment and treatment of the most frequent mental health problems in old age. © 1997 John Wiley & Sons, Ltd.