Imagined Bodies: architects and their constructions of later life

This article comprises a sociological analysis of how architects imagine the ageing body when designing residential care homes for later life and the extent to which they engage empathetically with users. Drawing on interviews with architectural professionals based in the United Kingdom, we offer insight into the ways in which architects envisage the bodies of those who they anticipate will populate their buildings. Deploying the notions of ‘body work’ and ‘the body multiple’, our analysis reveals how architects imagined a variety of bodies in nuanced ways. These imagined bodies emerge as they talked through the practicalities of the design process. Moreover, their conceptions of bodies were also permeated by prevailing ideologies of caring: although we found that they sought to resist dominant discourses of ageing, they nevertheless reproduced these discourses. Architects’ constructions of bodies are complicated by the collaborative nature of the design process, where we find an incessant juggling between the competing demands of multiple stakeholders, each of whom anticipate other imagined bodies and seek to shape the design of buildings to meet their requirements. Our findings extend a nascent sociological literature on architecture and social care by revealing how architects participate in the shaping of care for later life as ‘body workers’, but also how their empathic aspirations can be muted by other imperatives driving the marketisation of care

A mixed methods systematic review of multimodal non-pharmacological interventions to improve cognition for people with dementia

Objective: Multimodal non-pharmacological interventions have been argued to have the potential to complement current pharmacological approaches to improving quality of life for people living with dementia. The aim of this review was to identify, synthesise and appraise the evidence for the effectiveness of multimodal non-pharmacological interventions for improving cognitive function specifically. Method: After a comprehensive search strategy including grey literature, 26 studies were reviewed. The inclusion criteria concerned adults with a primary diagnosis of dementia. Studies used two or more different modes of intervention, and measured a cognitive outcome. Due to differences in the conceptualisations of the term ‘multimodal’, a typology of modes and methods was developed to facilitate classification of candidate studies. Results: Twenty-one group studies and five case studies were found. Group studies used two or three modes of intervention and multiple methods to implement them. Interventions utilised were cognitive, physical, psychological and psychosocial, nutrition, fasting, gut health, sleep hygiene, stress reduction, detoxification, hormonal health and oxygen therapy. Five individual case studies were found in two separate papers. Each personalised patient treatment utilised in-depth assessments and prescribed up to nine different modes. In 19 (90%) of the 21 group comparisons, participants were reported to have cognitive improvements, stability with their dementia or a delay in their decline. The extent of these improvements in terms of meaningful clinical change was variable. Conclusion: Multimodal non-pharmacological interventions have the potential to complement singular therapeutic approaches by addressing multiple modifiable risk factors currently understood to contribute towards cognitive decline

Self-efficacy of older people using technology to self-manage COPD, hypertension, heart failure or dementia at home : An overview of systematic reviews

Background and Objectives Although telehealth research among the general population is voluminous, study quality is low and results are mixed. Little is known specifically concerning older people and their self-efficacy to engage with and benefit from such technologies. This paper reviews the evidence for which self-care telehealth technology supports the self-efficacy of older people with long-term conditions (LTCs) living at home. Research Design and Methods Following PRISMA guidelines, this overview of systematic reviews focused on four LTCs and the concept of ‘self-efficacy’. Quality was appraised using R-AMSTAR and study evaluation was guided by the PRISMS taxonomy for reporting of self-management support. Heterogeneous data evidencing technology-enhanced self-efficacy were narratively synthesised. Results Five included papers contained 74 primary studies involving 9,004 participants with chronic obstructive pulmonary disease (COPD), hypertension, heart failure or dementia. Evidence for self-care telehealth technology supporting self-efficacy of older people with LTCs living at home was limited. Self-efficacy was rarely an outcome, also attrition and drop-out rates and mediators of support or education. The pathway from telehealth to self-efficacy depended on telehealth modes and techniques promoting healthy lifestyles. Increased self-care and self-monitoring empowered self-efficacy, patient-activation or mastery. Discussion and Implications Future research needs to focus on the process by which the intervention works and the effects of mediating variables and mechanisms through which self-management is achieved. Self-efficacy, patient-activation, and motivation are critical components to telehealth’s adoption by the patient, and hence to the success of self-care in self-management of LTCs. Their invisibility as outcomes is a limitation

Challenge Demcare: management of challenging behaviour in dementia at home and in care homes:Development, evaluation and implementation of an online individualised intervention for care homes; and a cohort study of specialist community mental health care for families

Background: Dementia with challenging behaviour (CB) causes significant distress for caregivers and the person with dementia. It is associated with breakdown of care at home and disruption in care homes. Challenge Demcare aimed to assist care home staff and mental health practitioners who support families at home to respond effectively to CB. Objectives: To study the management of CB in care homes (ResCare) and in family care (FamCare). Following a conceptual overview, two systematic reviews and scrutiny of clinical guidelines, we (1) developed and tested a computerised intervention; (2) conducted a cluster randomised trial (CRT) of the intervention for dementia with CB in care homes; (3) conducted a process evaluation of implementation of the intervention; and (4) conducted a longitudinal observational cohort study of the management of people with dementia with CB living at home, and their carers. Review methods: Cochrane review of randomised controlled trials; systematic meta-ethnographic review of quantitative and qualitative studies. Design: ResCare – survey, CRT, process evaluation and stakeholder consultations. FamCare – survey, longitudinal cohort study, participatory development design process and stakeholder consultations. Comparative examination of baseline levels of CB in the ResCare trial and the FamCare study participants. Settings: ResCare – 63 care homes in Yorkshire. FamCare – 33 community mental health teams for older people (CMHTsOP) in seven NHS organisations across England. Participants: ResCare – 2386 residents and 861 staff screened for eligibility; 555 residents with dementia and CB; 277 ‘other’ residents; 632 care staff; and 92 staff champions. FamCare – every new referral (n = 5360) reviewed for eligibility; 157 patients with dementia and CB, with their carer; and 26 mental health practitioners. Stakeholder consultations – initial workshops with 83 practitioners and managers from participating organisations; and 70 additional stakeholders using eight group discussions and nine individual interviews. Intervention: An online application for case-specific action plans to reduce CB in dementia, consisting of e-learning and bespoke decision support care home and family care e-tools. Main outcome measures: ResCare – survey with the Challenging Behaviour Scale; measurement of CB with the Neuropsychiatric Inventory (NPI) and medications taken from prescriptions; implementation with thematic views from participants and stakeholders. FamCare – case identification from all referrals to CMHTsOP; measurement of CB with the Revised Memory and Behaviour Problems Checklist and NPI; medications taken from prescriptions; and thematic views from stakeholders. Costs of care calculated for both settings. Comparison of the ResCare trial and FamCare study participants used the NPI, Clinical Dementia Rating and prescribed medications. Results: ResCare – training with group discussion and decision support for individualised interventions did not change practice enough to have an impact on CB in dementia. Worksite e-learning opportunities were not readily taken up by care home staff. Smaller homes with a less hierarchical management appear more ready than others to engage in innovation. FamCare – home-dwelling people with dementia and CB are referred to specialist NHS services, but treatment over 6 months, averaging nine contacts per family, had no overall impact on CB. Over 60% of people with CB had mild dementia. Families bear the majority of the care costs of dementia with CB. A care gap in the delivery of post-diagnostic help for families supporting relatives with dementia and significant CB at home has emerged. Higher levels of CB were recorded in family settings; and prescribing practices were suboptimal in both care home and family settings. Limitations: Functionality of the software was unreliable, resulting in delays. This compromised the feasibility studies and undermined delivery of the intervention in care homes. A planned FamCare CRT could not proceed because of insufficient referrals. Conclusions: A Cochrane review of individualised functional analysis-based interventions suggests that these show promise, although delivery requires a trained dementia care workforce. Like many staff training interventions, our interactive e-learning course was well received by staff when delivered in groups with facilitated discussion. Our e-learning and decision support e-tool intervention in care homes, in its current form, without ongoing review of implementation of recommended action plans, is not effective at reducing CB when compared with usual care. This may also be true for staff training in general. A shift in priorities from early diagnosis to early recognition of dementia with clinically significant CB could bridge the emerging gap and inequities of care to families. Formalised service improvements in the NHS, to co-ordinate such interventions, may stimulate better opportunities for practice models and pathways. Separate services for care homes and family care may enhance the efficiency of delivery and the quality of research on implementation into routine care. Future work: There is scope for extending functional analysis-based interventions with communication and interaction training for carers. Our clinical workbooks, video material of real-life episodes of CB and process evaluation tool resources require further testing. There is an urgent need for evaluation of interventions for home-dwelling people with dementia with clinically significant CB, delivered by trained dementia practitioners. Realist evaluation designs may illuminate how the intervention might work, and for whom, within varying service contexts

Whole Systems Dementia Treatment:An Emerging Role in the NHS?

Alzheimer’s disease is increasingly understood as a disease state determined by multiple factors and mechanisms. Besides the usual risk factors of diet, exercise, cognitive stimulation and sleep hygiene, one recent review lists a wide range of other risk factors.[1] Although non–pharmacological treatments for dementia are perhaps less known among medical practitioners, the latest NICE guidance calls for these as a first point of call.[2] An integrative, complementary or ‘whole systems’ approach is designed to activate the body’s inherent healing mechanisms and treat the root cause of illness as well as associated symptoms.[3] Dementia often precedes other chronic conditions such as diabetes and heart disease, and improves through similar pathways of diet and lifestyle changes. Therefore, targeting the causative factors for dementia would have the added benefit of addressing more broadly a wide range of common morbidities in older adults. We aim in this paper to introduce the concept of multimodal treatment for dementia (MT4D), share findings from the literature including case studies, review current NHS treatment in the Lancaster-Morecambe Memory Assessment Service (MAS), identify precedents for transformation in the NHS and offer a research collaboration as a step forward

Good practice in social care for disabled adults and older people with severe and complex needs: evidence from a scoping review

This article reports findings from a scoping review of the literature on good practice in social care for disabled adults and older people with severe and complex needs. Scoping reviews differ from systematic reviews, in that they aim to rapidly map relevant literature across an area of interest. This review formed part of a larger study to identify social care service models with characteristics desired by people with severe and complex needs and scope the evidence of effectiveness. Systematic database searches were conducted for literature published between January 1997 and February 2011 on good practice in UK social care services for three exemplar groups: young adults with life-limiting conditions, adults who had suffered a brain injury or spinal injury and had severe or complex needs, and older people with dementia and complex needs. Five thousand and ninety-eight potentially relevant records were identified through electronic searching and 51 by hand. Eighty-six papers were selected for inclusion, from which 29 studies of specific services were identified. However, only four of these evaluated a service model against a comparison group and only six reported any evidence of costs. Thirty-five papers advocated person-centred support for people with complex needs, but no well-supported evaluation evidence was found in favour of any particular approach to delivering this. The strongest evaluation evidence indicated the effectiveness of a multidisciplinary specialist team for young adults, intensive case management for older people with advanced dementia, a specialist social worker with a budget for domiciliary care working with psycho-geriatric inpatients, and interprofessional training for community mental health professionals. The dearth of robust evaluation evidence identified through this review points to an urgent need for more rigorous evaluation of models of social care for disabled adults and older people with severe and complex needs. Keywords : comorbidity, dementia, disabled people, evidence, multidisciplinary teams, social care

Personalised Medicine for Dementia:Collaborative Research of Multimodal Non-pharmacological Treatment with the UK National Health Service (NHS)

The dominant narrative around dementia argues that progression cannot be halted or reversed. However, evidence on multimodal non-pharmacological treatments formulated around a ‘personalised medicine’ approach challenges this view. This paper reviews the current evidence for dementia prevention utilising such treatments and explains the logic of applying personalised medicine. The functional medicine treatment approach to ‘root cause’ analysis is presented as currently practiced with patients experiencing cognitive decline. We report six case reports including in-depth practitioner evaluations, recommendations and follow-ups. We cover the various presentations of memory and concentration problems and the screening process with advanced functional testing. The case reports appear in a table, followed by 11 key points, insights and findings. To our knowledge, this is the first paper reporting practitioner case reports documenting improvements in symptoms of memory decline in patients from the UK, Greece and New Zealand. Four patients had initial presentations and follow-up improvements verified by standardised screening instruments and/or formal diagnosis. Two patients had symptom improvements verified through selfreport and proxy-report. Practitioners reported improvements through biomarkers (normalisation of serum levels, folate and homocysteine, thyroid function, blood sugar levels), as well as weight loss, decreased blood pressure and reduction in medications. They also reported improved mental, physical, social, energetic, emotional and spiritual functioning. The next phase is an enhanced intervention alongside the existing UK National Health Service memory assessment pathway. This paper advocates for personalised medicine in the UK for persons living with memory problems and dementia, driven by this increasing evidence base