Search

Abstract Background Despite several interventions demonstrating benefit to people living with dementia and their caregivers, few have been translated and implemented in routine clinical practice. There is limited evidence of the barriers and facilitators for commissioning and implementing health and social care interventions for people living with dementia. The aim of the current study was to explore the barriers and facilitators to commissioning and implementing health and social care interventions for people with dementia, using a dementia friendly exercise and physical activity-based intervention (PrAISED [Promoting Activity, Stability and Independence in Early Dementia and Mild Cognitive Impairment]) as a case study. Methods Qualitative semi-structured interviews were conducted with stakeholders from a range of backgrounds including individuals from health and social care, local government, the voluntary and community sector, universities, and research centres in England. The Consolidated Framework for Intervention Research (CFIR) was used to guide the design and analysis. Results Fourteen participants took part, including commissioning managers, service managers, partnership managers, charity representatives, commercial research specialists, academics/researchers, and healthcare professionals. Data were represented in 33 constructs across the five CFIR domains. Participants identified a need for greater support for people diagnosed with dementia and their caregivers immediately post dementia diagnosis. Key barriers included cost/financing, the culture of commissioning, and available resources. Key facilitators included the adaptability of the intervention, cosmopolitanism/partnerships and connections, external policy and incentives, and the use of already existing (and untapped) workforces. Conclusion Several barriers and facilitators for commissioning and implementing health and social care interventions for people with dementia were identified which need to be addressed. Recommended actions to facilitate the commissioning and implementation of dementia friendly services are: 1) map out local needs, 2) evidence the intervention including effectiveness and cost-effectiveness, 3) create/utilise networks with stakeholders, and 4) plan required resources.

Background Sustaining independence is important for older people, but there is insufficient guidance about which community health and care services to implement. Objectives To synthesise evidence of the effectiveness of community services to sustain independence for older people grouped according to their intervention components, and to examine if frailty moderates the effect. Review design Systematic review and network meta-analysis. Eligibility criteria Studies: Randomised controlled trials or cluster-randomised controlled trials. Participants: Older people (mean age 65+) living at home. Interventions: community-based complex interventions for sustaining independence. Comparators: usual care, placebo or another complex intervention. Main outcomes Living at home, instrumental activities of daily living, personal activities of daily living, care-home placement and service/economic outcomes at 1 year. Data sources We searched MEDLINE (1946–), Embase (1947–), CINAHL (1972–), PsycINFO (1806–), CENTRAL and trial registries from inception to August 2021, without restrictions, and scanned reference lists. Review methods Interventions were coded, summarised and grouped. Study populations were classified by frailty. A random-effects network meta-analysis was used. We assessed trial-result risk of bias (Cochrane RoB 2), network meta-analysis inconsistency and certainty of evidence (Grading of Recommendations Assessment, Development and Evaluation for network meta-analysis). Results We included 129 studies (74,946 participants). Nineteen intervention components, including ‘multifactorial-action’ (multidomain assessment and management/individualised care planning), were identified in 63 combinations. The following results were of low certainty unless otherwise stated. For living at home, compared to no intervention/placebo, evidence favoured: multifactorial-action and review with medication-review (odds ratio 1.22, 95% confidence interval 0.93 to 1.59; moderate certainty) multifactorial-action with medication-review (odds ratio 2.55, 95% confidence interval 0.61 to 10.60) cognitive training, medication-review, nutrition and exercise (odds ratio 1.93, 95% confidence interval 0.79 to 4.77) and activities of daily living training, nutrition and exercise (odds ratio 1.79, 95% confidence interval 0.67 to 4.76). Four intervention combinations may reduce living at home. For instrumental activities of daily living, evidence favoured multifactorial-action and review with medication-review (standardised mean difference 0.11, 95% confidence interval 0.00 to 0.21; moderate certainty). Two interventions may reduce instrumental activities of daily living. For personal activities of daily living, evidence favoured exercise, multifactorial-action and review with medication-review and self-management (standardised mean difference 0.16, 95% confidence interval −0.51 to 0.82). For homecare recipients, evidence favoured the addition of multifactorial-action and review with medication-review (standardised mean difference 0.60, 95% confidence interval 0.32 to 0.88). Care-home placement and service/economic findings were inconclusive. Limitations High risk of bias in most results and imprecise estimates meant that most evidence was low or very low certainty. Few studies contributed to each comparison, impeding evaluation of inconsistency and frailty. Studies were diverse; findings may not apply to all contexts. Conclusions Findings for the many intervention combinations evaluated were largely small and uncertain. However, the combinations most likely to sustain independence include multifactorial-action, medication-review and ongoing review of patients. Some combinations may reduce independence. Future work Further research is required to explore mechanisms of action and interaction with context. Different methods for evidence synthesis may illuminate further. Study registration This study is registered as PROSPERO CRD42019162195. Funding This award was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme (NIHR award ref: NIHR128862) and is published in full in Health Technology Assessment; Vol. 28, No. 48. See the NIHR Funding and Awards website for further award information. Plain language summary Which community services are best for helping older people to be independent? Key messages Due to a lack of robust evidence, the benefits and risks of most types of community services for older people are unclear. Individualised care planning, where medication is adjusted and there are regular follow-ups, probably helps people stay living at home. What are community services for older people? There are many kinds of community services for older people. For example, in some services, everyone is given exercise and dietary advice or an individualised care plan. These often aim to help older people age independently. What was the study about? Maintaining independence is important in later life. We wanted to find out which community services work best: to help people stay living at home, and to do day-to-day activities independently. We reviewed findings from previous studies that have tested different community services for older people. We combined these findings and compared different types of service with one another. We rated our confidence in the evidence. What did we find? We found 129 studies with 74,946 people. We found 63 different kinds of service have been studied. The studies were carried out in diverse populations around the world. Individualised care planning, where medication is adjusted and there are regular follow-ups, may help people age independently. It probably increases the chance of staying at home slightly. It may also help with doing day-to-day activities very slightly. Exercise and dietary advice may also help people stay living at home. However, there was some evidence that some services may reduce independence. We do not know what effect most services have. What are the limitations of the evidence? We generally had little confidence in the evidence because studies were small, and information was missing. How current is the evidence? The evidence is up to date to August 2021. Scientific summary Background The number and proportion of older people are growing in the UK and worldwide. Maintaining independence is a goal of community health and care services for older people. The concept of frailty can be used to distinguish between people who remain in robust health in later life and those who are at greater risk of losing independence and needing care. Previous research has suggested that community-based complex interventions are generally effective for supporting independence for older people, but only broad service models have been explored. There is insufficient guidance about which services to implement and the appropriateness of different services for different levels of frailty. We aimed to provide a rigorous, contemporary synthesis of trial evidence to identify how interventions might best be configured to improve outcomes for older people, and inform the commissioning and delivery of evidence-based services. Objectives (list of research questions) Do community-based complex interventions to sustain independence in older people increase living at home, independence and health-related quality of life? Do community-based complex interventions to sustain independence in older people reduce homecare usage, depression, loneliness, falls, hospitalisation, care-home placement, costs and mortality? How should interventions be grouped for network meta-analysis (NMA)? What is the optimal configuration of community-based complex interventions to sustain independence in older people? Do intervention effects differ by a population’s frailty level (robust; pre-frailty; frailty)? Methods Systematic review with NMA of trials evaluating community-based complex interventions to sustain independence in older people (mean age 65 years and over), compared with usual care or another complex intervention meeting our criteria, with follow-up for at least 24 weeks. We followed Cochrane methods, Grading of Recommendations Assessment, Development and Evaluation (GRADE) and Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) NMA guidance. Information sources We searched the following databases and trial registers from inception between 9 and 11 August 2021: Cochrane Central Register of Controlled Trials (CENTRAL) Wiley (1992–); MEDLINE Ovid (1946–); Embase and Embase Classic Ovid (1947–); CINAHL EBSCOhost (1972–); APA PsycINFO Ovid (1806–); US National Institutes of Health Ongoing Trials Register, ClinicalTrials.gov (www.clinicaltrials.gov); World Health Organization, International Clinical Trials Registry Platform (https://trialsearch.who.int). We scanned the reference lists of included studies. Study selection Eligibility criteria Randomised controlled trials (RCTs) or cluster-RCTs. Participants were older people living at home (mean age 65 years or older). Participants living in residential/nursing homes were excluded. With an intervention that: was both initiated and mainly provided in the community included two or more interacting components (intervention practices, structural elements and contextual factors) was targeted at the individual person, with provision of appropriate specialist care focused on sustaining (maintaining or improving) the person’s independence. Usual care, ‘placebo’ or attention control or a different complex intervention which met our criteria were eligible comparators. Outcome data were measured at a minimum 24 weeks (approximately 6 months) time point. Study selection process Two researchers independently evaluated eligibility of records (title and abstract) and reports (full text). Disagreements were resolved by consensus. Data collection process Two researchers independently collected data. Main outcomes Living at home. Activities of daily living (ADL): personal ADL (PADL)/instrumental ADL (IADL). Hospitalisation. Care-home placement. Homecare services (non-healthcare professional) usage. Costs. Cost-effectiveness. Additional outcomes Health status/health-related quality of life. Depression. Loneliness. Falls. Mortality. Data were extracted (including treatment effect estimates) and categorised into three time frames: short term (around 6 months): 24 weeks to 9 months medium term (around 12 months): > 9 months to 18 months long term (around 24 months): > 18 months with the medium term as our main time frame. Intervention grouping We grouped all eligible interventions (including comparators) in preparation for NMA in a three-stage process of coding and summarising based on the Template for Intervention Description and Replication framework, categorisation and grouping. Assessment of frailty Two reviewers with extensive clinical academic frailty expertise (AC and JG) independently categorised study level frailty (robust, pre-frailty, frailty) based on validated measures where available or participant characteristics and study inclusion criteria using the phenotype model as a framework. Risk-of-bias assessment Two reviewers independently assessed risk of bias (RoB) in each result of interest from each included study, using the Revised Cochrane risk-of-bias tool for randomised trials (RoB 2). Data synthesis Meta-analysis was conducted for living at home, PADL, IADL and care-home placement for each of the three time frames separately, and for hospitalisation, health status and depression in the medium term only. Other outcomes were narratively synthesised. Meta-analysis We meta-analysed the extracted effect estimates using modules within Stata. Random-effects meta-analyses were conducted. Initially, for each outcome and time frame, we performed a separate meta-analysis for each type of intervention versus control, to provide summary effectiveness results based only on direct evidence. An NMA was then conducted (for each outcome and time frame separately) using a multivariate random-effects meta-analysis framework via the network module in Stata using restricted maximum likelihood estimation. We produced summary (pooled) effect estimates for each pair of treatments in the network, with 95% confidence intervals (CIs). Based on the results, the ranking of intervention groups was calculated using resampling methods. The consistency assumption (that direct and indirect evidence are consistent with each other) was examined for each treatment comparison where possible and across the whole network. The effect of study-level frailty on each intervention group effect was examined where data allowed. Sensitivity analyses were conducted excluding results at the highest RoB, and funnel plots examined for small-study effects. Confidence in cumulative evidence We used the GRADE framework, adapted for NMA, to rate the certainty of the results of our NMA. Summary of economic evidence We followed the brief economic commentary framework to summarise, compare and contrast the principal findings from the included studies. Results We screened 40,112 records and assessed 973 reports for eligibility. We included 129 studies consisting of 496 reports. The studies assigned 74,946 participants (three studies missing data) to 266 eligible intervention arms. They were predominantly conducted in developed countries and most participants were described as white. Nonetheless, the overall population included a broad range of demographic characteristics. Study populations included all frailty levels. We identified 19 separate components of included interventions which were evaluated in 63 combinations including the absence of all of these components, which we termed available care (ac), and homecare (a common control group in populations where all participants were receiving homecare). Homecare involved frequent visits at home by professionals who typically supported domestic and self-care tasks. Five components were primarily about a process of ascertainment or assessment and planning with subsequent action: multifactorial-action from care planning (a process of individualised multidomain assessment and management) with or without routine review (scheduled, regular follow-ups), medication-review, monitoring and routine risk-screening. The 14 other components and their short labels (bold) were ADL training, providing aids and adaptations, alternative medicine, care voucher provision, cognitive training, health education, physical exercise, formal homecare, engagement in meaningful-activities, nutritional support, psychological (mood) therapy (psychology), social skills training, technology for communication and engagement (telecoms), welfare rights advice. Multifactorial-action was further delineated based on the presence or absence of an embedded medication-review and specific self-management strategies. We judged most results to be at high RoB, primarily due to missing outcome data. This led to serious concerns with RoB for many of the GRADE ratings of evidence. Findings Most networks were small and sparse, with few included studies contributing to most networks. We found little evidence of inconsistency but there was usually low power to detect this. All outcomes except mortality needed to be analysed in two separate NMAs as the networks were disconnected: one with ac as the reference comparator (‘available-care network’) and one with homecare as the reference comparator (‘homecare network’). Estimates are reported here only in comparison with the reference comparator. Comparisons with ac can be thought of as the effect of adding the intervention for a population who are not all receiving any particular care; comparisons with homecare are similarly an alternative intervention for a population already in receipt of homecare without associated reablement or multifactorial-action from care planning. Most estimates were low certainty or very low certainty due to RoB, imprecision or their combination, and we do not describe very low-certainty evidence below. Living at home For living at home in the medium term there were 21 studies (n = 16,937) with 14 intervention groups in the available-care network. There was moderate-certainty evidence that multifactorial-action and review with medication-review probably results in a slight increase in the chance of living at home [odds ratio (OR) 1.22, 95% CI 0.93 to 1.59; moderate certainty]. There was low-certainty evidence that multifactorial-action with medication-review [OR 2.55 (large), 95% CI 0.61 to 10.60]; cognitive training, medication-review, nutrition and exercise [OR 1.93 (large), 95% CI 0.79 to 4.77]; and ADL, nutrition and exercise [OR 1.79 (large), 95% CI 0.67 to 4.76] may result in an increase in the chance of living at home, and that risk-screening; education, multifactorial-action and review with medication-review; and education, multifactorial-action and review with medication-review and self-management may each result in some reduction in chance of living at home. Other comparisons with ac were of very low certainty. In the short- and long-term time frames, results were at best low certainty. For multifactorial-action and review with medication-review; and ADL, nutrition and exercise, estimates were similarly of small increases in the long term but of little to no difference in the short term. There were similar results in other time frames for education, multifactorial-action and review with medication-review and self-management; and risk-screening, but contrasting evidence of reduction followed by an increase in living at home for education, multifactorial-action and review with medication-review. The homecare network for living at home was smaller (five studies, n = 1978 in the medium term). In the short- and medium-term time frames, there was low-certainty evidence that homecare, ADL, multifactorial-action and review with self-management may result in a moderate or large reduction in the chance of living at home compared with homecare alone. Instrumental activities of daily living For the medium-term instrumental activities of daily living (IADL) available-care network there were 16 studies (n = 5309) with 14 intervention groups. Multifactorial-action and review with medication-review was associated with very slightly increased independence in IADL versus ac [standardised mean difference (SMD) 0.11, 95% CI 0.00 to 0.21; moderate-certainty evidence]. Two intervention groups may result in some reduction in IADL: ADL, aids and exercise; and ADL, aids, education, exercise, multifactorial-action and review with medication-review and self-management. There were contrasting findings for multifactorial-action and review with medication-review in the long term, with moderate-certainty evidence of a very slight reduction in IADL (SMD −0.08, 95% CI −0.21 to 0.05). For the homecare network, there was one low certainty finding in the short-term time frame of little to no difference for homecare, ADL, multifactorial-action and review with self-management with all other estimates being very low certainty. Personal activities of daily living For personal activities of daily living (PADL), 20 trials (n = 8583 participants) with 16 intervention groups contributed to the medium-term available-care network. One comparison was judged low certainty. Exercise, multifactorial-action and review with medication-review and self-management may result in a very slight increase in PADL (SMD 0.16, 95% CI −0.51 to 0.82). The homecare network included four trials (n = 632 participants) in the medium term. As for ac, only one comparison with homecare was low certainty: homecare, multifactorial-action and review with medication-review may result in an increase in PADL [SMD 0.60 (moderate), 95% CI 0.32 to 0.88]. Other outcomes For the service outcome of hospitalisation, there were low-certainty estimates of some reductions for education, exercise, multifactorial-action and review with medication-review and self-management; and education, multifactorial-action and review with medication-review; and of an increase for exercise, multifactorial-action and review with medication-review and self-management. For care-home placement, all estimates were rated very low certainty in the medium term. There was some evidence of both increases and decreases in use of homecare services with little pattern (not meta-analysed). For our additional outcomes, there was little evidence of any effect on self-reported health status, only low certainty beneficial findings regarding depression, very little evidence regarding loneliness and more complex interventions were associated with less falling than more falling (12 studies vs. 4 studies). For mortality, there was a large network of 65 studies (n = 38,351) and 41 intervention groups. There was low-certainty evidence of reductions for two, and increases for five, intervention groups. The summary of economic evidence included 39 studies. Based on the conclusions of 22 studies that performed a full economic evaluation, five intervention groups appeared promising compared with a standard intervention or ac from an economic perspective: ADL (medium-term time horizon); homecare, multifactorial-action and review with medication-review and self-management (short-term time horizon); meaningful-activities and education (short- and medium-term time horizon); multifactorial-action and review with medication-review (short- but not medium- or long-term time horizon); and exercise and multifactorial-action with medication-review (long-term time horizon). Summary across outcomes We found evidence that multifactorial-action and review with medication-review probably improves some important outcomes slightly (living at home, IADL), but there was also contradictory evidence for IADL in the long term. For some other intervention groups there was low-certainty evidence that they may improve or worsen particular outcomes but for most intervention groups evidence was either absent or very uncertain. Conclusions Available evidence suggests the community-based complex interventions most likely to sustain independence in older people involve multifactorial-action from multidomain assessment and individualised care planning, routine review and the incorporation of medication-review. There was also some positive evidence for the combination of exercise and nutritional support and multiple other intervention combinations. Decision-makers should be aware that there is plausible evidence that some community-based complex interventions may worsen outcomes such as living at home and ADL independence and that all of these findings are tentative. We recommend the uncertainty in these findings be addressed by: realist synthesis to explore the mechanisms and broader contextual factors relating to individual benefit or harm future robust, large-scale trials which compare alternative interventions with multifactorial-action and review with medication-review future Individual Participant Data meta-analysis (IPDMA) focusing on interventions with multifactorial action to explore factors relating to individual benefit or harm greater reporting of the organisational aspects of intervention implementation in complex intervention research. Study registration This study is registered as PROSPERO CRD42019162195. Funding This award was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme (NIHR award ref: NIHR128862) and is published in full in Health Technology Assessment; Vol. 28, No. 48. See the NIHR Funding and Awards website for further award information.

Regular exercise and community engagement may slow the rate of function loss for people with dementia. However, the evidence is uncertain regarding the cost-effectiveness and social return on investment (SROI) of home exercise with community referral for people with dementia. This study aimed to compare the social value generated from the in-person PrAISED program delivered before March 2020 with a blended PrAISED program delivered after March 2020. SROI methodology compared in-person and blended delivery formats of a home exercise program. Stakeholders were identified, a logic model was developed, outcomes were evidenced and valued, costs were calculated, and SROI ratios were estimated. Five relevant and material outcomes were identified: 3 outcomes for patient participants (fear of falling, health-related quality of life, and social connection); 1 outcome for carer participants (carer strain), and 1 outcome for the National Health Service (NHS) (health service resource use). Data were collected at baseline and at 12-month follow-up. The in-person PrAISED program generated SROI ratios ranging from £0.58 to £2.33 for every £1 invested. In-person PrAISED patient participants gained social value from improved health-related quality of life, social connection, and less fear of falling. In-person PrAISED carer participants acquired social value from less carer strain. The NHS gained benefit from less health care service resource use. However, the blended PrAISED program generated lower SROI ratios ranging from a negative ratio to £0.08:£1. Compared with the blended program, the PrAISED in-person program generated higher SROI ratios for people with early dementia. An in-person PrAISED intervention with community referral is likely to provide better value for money than a blended one with limited community referral, despite the greater costs of the former. Trial registration : ISRCTN Registry ISRCTN15320670.

Abstract Background The potential decrease in daily physical activity associated with the COVID-19 pandemic lockdowns may have a negative impact on people living with dementia. Given the limited literature around the effects of home confinement in people living with dementia, this study investigated changes in physical exercise levels of participants in the intervention arm of the Promoting Activity, Independence and Stability in Early Dementia (PrAISED) Randomised Controlled Trial during the first COVID-19 national lockdown. It hypothesised that participants would maintain physical exercise levels. Methods A repeated measure (three time points) study involving 30 participants (mean age = 78.0 years, 15 male and 15 female, 22 (73.0%) living with their primary caregiver), from four regions in England receiving the PrAISED intervention. PrAISED is an individually tailored intervention of physical exercises and functional activities. Trained therapists deliver therapy sessions over a period of 52 weeks. Study participants received therapy sessions via phone or video calling during the COVID-19 lockdown. This study investigated self-reported minutes of physical exercise recorded on study calendars for the months of February (i.e., baseline – pre-lockdown), May (i.e., T1 – during lockdown), and August (i.e., T2—post-lockdown) 2020. Results Participants reported a statistically significant increase in activity levels between February and May (Wilcoxon Z = -2.013, p = 0.044) and a statistically significant decrease between May and August (Wilcoxon Z = -2.726, p = 0.004). No significant difference was found in the physical activity levels from pre- to post-lockdown (Wilcoxon Z = 0.485, p = 0.620). Conclusion Despite concerns that the restrictions associated with the COVID-19 pandemic might lead to reductions in physical exercise, participants in receipt of the PrAISED intervention increased their amount of physical exercise during lockdown. Our findings support the potential of remote support for people living with dementia to help them maintain physical exercise levels in circumstances where face-to-face service provision is not possible. Trial registration The PrAISED trial and process evaluation have received ethical approval number 18/YH/0059 from the Bradford/Leeds Ethics Committee. The Clinical Trial Identifier for PrAISED is: ISRCTN15320670 ( https://doi.org/10.1186/ISRCTN15320670 ). Registration was made on 04/09/2018.

Abstract Background Restrictions introduced in response to the COVID-19 pandemic led to increased risk of deconditioning in the general population. No empirical evidence of this effect however has been gathered in people living with dementia. This study aims to identify the causes and effects of COVID-19-related deconditioning in people living with dementia. Methods This is a longitudinal phenomenological qualitative study. Participants living with dementia, their caregivers and therapists involved in the Promoting Activity, Independence and Stability in Early Dementia (PrAISED) process evaluation during the COVID-19 pandemic were qualitatively interviewed at two time points: the baseline 2 months after the national lockdown was imposed in England (i.e., May 2020), the follow up 2 months after the first set (i.e. July 2020). The data were analysed through deductive thematic analysis. Results Twenty-four participants living with dementia, 19 caregivers and 15 therapists took part in the study. Two themes were identified: Causes of deconditioning in people living with dementia during the COVID-19 pandemic and effects of deconditioning in people living with dementia during the COVID-19 pandemic. A self-reinforcing pattern was common, whereby lockdown made the person apathetic, demotivated, socially disengaged, and frailer. This reduced activity levels, which in turn reinforced the effects of deconditioning over time. Without external supporters, most participants lacked the motivation / cognitive abilities to keep active. Provided the proper infrastructure and support, some participants could use tele-rehabilitation to combat deconditioning. Conclusion The added risks and effects of deconditioning on people with dementia require considerable efforts from policy makers and clinicians to ensure that they initiate and maintain physical activity in prolonged periods of social distancing. Delivering rehabilitation in the same way as before the pandemic might not be feasible or sustainable and innovative approaches must be found. Digital support for this population has shown promising results but remains a challenge. Trial registration The PrAISED trial and process evaluation have received ethical approval number 18/YH/0059 from the Bradford/Leeds Ethics Committee. The ISRCTN Registration Number for PrAISED is 15320670 .

Exercise can improve physical function and slow the progression of dementia. However, uncertainty exists around the costeffectiveness of exercise programmes for people with early dementia. The aim of this study was to determine whether a home-based supervised exercise programme (PrAISED – promoting activity, independence, and stability in early dementia) could generate a positive social return on investment (SROI). SROI analysis was conducted as part of a randomised controlled feasibility trial comparing PrAISED with usual care. Wellbeing valuation was used to compare the costs of the programme with the monetised benefits to participants, carers, and healthcare service providers. The PrAISED programme generated SROI ratios ranging from £3.46 to £5.94 for every £1 invested. Social value was created from improved physical activity, increased confidence, more social connection and PrAISED participants using healthcare services less often than usual care. This study found that home-based supervised exercise programmes could generate a positive SROI for people with early dementia. Trial registration: ClinicalTrials.gov: NCT02874300 (first posted 22 August 2016), ISRCTN: 10,550,694 (date assigned 31 August 2016).

Abstract Background People with dementia progressively lose cognitive and functional abilities. Interventions promoting exercise and activity may slow decline. We developed a novel intervention to promote activity and independence and prevent falls in people with mild cognitive impairment (MCI) or early dementia. We successfully undertook a feasibility randomised controlled trial (RCT) to refine the intervention and research delivery. We are now delivering a multi-centred RCT to evaluate its clinical and cost-effectiveness. Methods We will recruit 368 people with MCI or early dementia (Montreal Cognitive Assessment score 13–25) and a family member or carer from memory assessment clinics, other community health or social care venues or an online register (the National Institute for Health Research Join Dementia Research). Participants will be randomised to an individually tailored activity and exercise programme delivered using motivational theory to promote adherence and continued engagement, with up to 50 supervised sessions over one year, or a brief falls prevention assessment (control). The intervention will be delivered in participants’ homes by trained physiotherapists, occupational therapists and therapy assistants. We will measure disabilities in activities of daily living, physical activity, balance, cognition, mood, quality of life, falls, carer strain and healthcare and social care use. We will use a mixed methods approach to conduct a process evaluation to assess staff training and delivery of the intervention, and to identify individual- and context-level mechanisms affecting intervention engagement and activity maintenance. We will undertake a health economic evaluation to determine if the intervention is cost-effective. Discussion We describe the protocol for a multi-centre RCT that will evaluate the clinical and cost-effectiveness of a therapy programme designed to promote activity and independence amongst people living with dementia. Trial registration ISRCTN, ISRCTN15320670. Registered on 4 September 2018.

Background: Community hospitals are small hospitals providing local inpatient and outpatient services. National surveys report that inpatient rehabilitation for older people is a core function but there are large differences in key performance measures. We have investigated these variations in community hospital ward performance. Objectives: (1) To measure the relative performance of community hospital wards (studies 1 and 2); (2) to identify characteristics of community hospital wards that optimise performance (studies 1 and 3); (3) to develop a web-based interactive toolkit that supports operational changes to optimise ward performance (study 4); (4) to investigate the impact of community hospital wards on secondary care use (study 5); and (5) to investigate associations between short-term community (intermediate care) services and secondary care utilisation (study 5). Methods: Study 1 – we used national data to conduct econometric estimations using stochastic frontier analysis in which a cost function was modelled using significant predictors of community hospital ward costs. Study 2 – a national postal survey was developed to collect data from a larger sample of community hospitals. Study 3 – three ethnographic case studies were performed to provide insight into less tangible aspects of community hospital ward care. Study 4 – a web-based interactive toolkit was developed by integrating the econometrics (study 1) and case study (study 3) findings. Study 5 – regression analyses were conducted using data from the Atlas of Variation Map 61 (rate of emergency admissions to hospital for people aged ≥ 75 years with a length of stay of

Abstract Background This study explored the feasibility of a randomised controlled withdrawal trial of antihypertensive medication in normotensive people with dementia. Feasibility aspects included response, recruitment, exclusion and drop-out rates, suitability of outcome measures, acceptability of study procedures and an indicative economic evaluation for a randomised controlled trial. Methods A cohort study attempting the withdrawal of antihypertensive drugs where appropriate and a feasibility study of home-based blood pressure monitoring, in people with dementia treated for hypertension, was undertaken. Interviews with participants and carers and an indicative economic evaluation were also undertaken. Results Three hundred and sixty-two primary care practices in the East Midlands were contacted of which only 41 (11% (95%CI 8–15%)) agreed to support the study. These 41 practices posted 940 letters to potential participants. Thirty participants were enrolled in the cohort study of whom 9 were eligible for the antihypertensive withdrawal programme, 20 participated in a home blood pressure monitoring sub-group analysis and 12 took part in an interview study. Twenty-two of those enrolled in the cohort study were followed up at 6 months. The withdrawal programme was acceptable to participants and general practitioners (GPs). The study procedures including assessments and home blood pressure monitoring were acceptable to the participants and their carers. The economic evaluation was not possible. Conclusion A withdrawal trial of antihypertensive medication in normotensive people with dementia may not be feasible in the UK because of low recruitment rates.

Background: This programme of research addressed shortcomings in the care of three groups of older patients: patients discharged from acute medical units (AMUs), patients with dementia and delirium admitted to general hospitals, and care home residents. Methods: In the AMU workstream we undertook literature reviews, performed a cohort study of older people discharged from AMU (Acute Medical Unit Outcome Study; AMOS), developed an intervention (interface geriatricians) and evaluated the intervention in a randomised controlled trial (Acute Medical Unit Comprehensive Geriatric Assessment Intervention Study; AMIGOS). In the second workstream we undertook a cohort study of older people with mental health problems in a general hospital, developed a specialist unit to care for them and tested the unit in a randomised controlled trial (Trial of an Elderly Acute care Medical and mental health unit; TEAM). In the third workstream we undertook a literature review, a cohort study of a representative sample of care home residents and a qualitative study of the delivery of health care to care home residents. Results: Although 222 of the 433 (51%) patients recruited to the AMIGOS study were vulnerable enough to be readmitted within 3 months, the trial showed no clinical benefit of interface geriatricians over usual care and they were not cost-effective. The TEAM study recruited 600 patients and there were no significant benefits of the specialist unit over usual care in terms of mortality, institutionalisation, mental or functional outcomes, or length of hospital stay, but there were significant benefits in terms of patient experience and carer satisfaction with care. The medical and mental health unit was cost-effective. The care home workstream found that the organisation of health care for residents in the UK was variable, leaving many residents, whose health needs are complex and unpredictable, at risk of poor health care. The variability of health care was explained by the variability in the types and sizes of homes, the training of care home staff, the relationships between care home staff and the primary care doctors and the organisation of care and training among primary care doctors. Discussion: The interface geriatrician intervention was not sufficient to alter clinical outcomes and this might be because it was not multidisciplinary and well integrated across the secondary care–primary care interface. The development and evaluation of multidisciplinary and better-integrated models of care is justified. The specialist unit improved the quality of experience of patients with delirium and dementia in general hospitals. Despite the need for investment to develop such a unit, the unit was cost-effective. Such units provide a model of care for patients with dementia and delirium in general hospitals that requires replication. The health status of, and delivery of health care to, care home residents is now well understood. Models of care that follow the principles of comprehensive geriatric assessment would seem to be required, but in the UK these must be sufficient to take account of the current provision of primary health care and must recognise the importance of the care home staff in the identification of health-care needs and the delivery of much of that care. Trial registration: Current Controlled Trials ISRCTN21800480 (AMIGOS); ClinicalTrials.gov NCT01136148 (TEAM). Funding: This project was funded by the NIHR Programme Grants for Applied Research programme and will be published in full in Programme Grants for Applied Research; Vol. 3, No. 4. See the NIHR Journals Library website for further project information.

Background: Brokering of evidence into service delivery is crucial for patient safety. We study knowledge brokering by ‘hybrid’ middle-level managers (H-MLMs), who hold responsibility for clinical service delivery as well as a managerial role, in the context of falls, medication management and transition, in care of older people. Objectives: Generate insight into processes and structures for brokering of patient safety knowledge (PSK) by H-MLMs. Design: We utilise mixed methods: semistructured interviews, social network analysis, observation, documentary analysis, tracer studies and focus groups. Setting: NHS East and NHS West Midlands. Participants: One hundred and twenty-seven H-MLMs, senior managers and professionals, in three hospitals, and external producers of PSK. Main outcome measures: Which H-MLMs broker what PSK, and why? (1) How do H-MLMs broker PSK? (2) What are contextual features for H-MLM knowledge brokering? (3) How can H-MLMs be enabled to broker PSK more effectively in older persons’ care? Results: Health-care organisations fail to leverage PSK for service improvement. Attempts by H-MLMs to broker PSK downwards or upwards are framed by policy directives and professional/managerial hierarchy. External performance targets and incentives compel H-MLMs in clinical governance to focus upon compliance. This diverts attention from pulling knowledge downwards, or upwards, for service improvement. Lower-status H-MLMs, closer to service delivery, struggle to push endogenous knowledge upwards, because they lack professional and managerial legitimacy. There is a difference between how PSK is brokered within ranks of nurses and doctors, due to differences in hierarchal characteristics. Rather than a ‘broker chain’ upwards and downwards, a ‘broken chain’ ensues, which constrains learning and service improvement. Conclusions: Clinical governance is decoupled from service delivery. Brokering knowledge for service improvement is a ‘peopled’ activity in which H-MLMs are central. Intervention needs to mediate interprofessional and intraprofessional hierarchy, which, combined with compliance pressures, engender a ‘broken’ chain for applying PSK for service improvement, rather than a ‘brokering’ chain. Lower-status H-MLMs need to have their legitimacy and disposition enhanced to broker knowledge for service improvement. More informal ‘social mechanisms’ are required to complement clinical governance for development of a brokering chain. More research is needed to (1) examine why some H-MLMs are more disposed and able than others to broker PSK for service improvement, and (2) understand how knowledge brokering might be enhanced so that exogenous and endogenous knowledge is better fused for service improvement. Funding: The National Institute for Health Research Health Services and Delivery Research programme.