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Agitation is common in people living with dementia especially at the end of life. We examined how staff interpreted agitation behavior in people with dementia nearing end of life, how this may influence their responses and its impact on the quality of care. Ethnographic study. Structured and semi-structured non-participant observations (referred to subsequently in this paper as \"structured observations\") of people living with dementia nearing the end of life in hospital and care homes (south-east England) and in-depth interviews with staff, conducted August 2015-March 2017. Three data sources: 1) detailed field notes, 2) observations using a structured tool and checklist for behaviors classed as agitation and staff and institutional responses, 3) staff semi-structured qualitative interviews. We calculated the time participants were agitated and described staff responses. Data sources were analyzed separately, developed continuously and relationally during the study and synthesized where appropriate. We identified two main 'ideal types' of staff explanatory models for agitation: In the first, staff attribute agitated behaviors to the person's \"moral judgement\", making them prone to rejecting or punitive responses. In the second staff adopt a more \"needs-based\" approach in which agitation behaviors are regarded as meaningful and managed with proactive and investigative approaches. These different approaches appear to have significant consequences for the timing, frequency and quality of staff response. While these models may overlap they tend to reflect distinct organizational resources and values. Care worker knowledge about agitation is not enough, and staff need organizational support to care better for people living with dementia towards end of life. Positional theory may help to explain much of the cultural-structural context that produces staff disengagement from people with dementia, offering insights on how agitation behavior is reframed by some staff as dangerous. Such behavior may be associated with low-resource institutions with minimal staff training where the personhood of staff may be neglected.

Background Older adults are at increased risk both of falling and of experiencing accidental domestic fire. In addition to advanced age, these adverse events share the risk factors of balance or mobility problems, cognitive impairment and socioeconomic deprivation. For both events, the consequences include significant injury and death, and considerable socioeconomic costs for the individual and informal carers, as well as for emergency services, health and social care agencies. Secondary prevention services for older people who have fallen or who are identifiable as being at high risk of falling include NHS Falls clinics, where a multidisciplinary team offers an individualised multifactorial targeted intervention including strength and balance exercise programmes, medication changes and home hazard modification. A similar preventative approach is employed by most Fire and Rescue Services who conduct Home Fire Safety Visits to assess and, if necessary, remedy domestic fire risk, fit free smoke alarms with instruction for use and maintenance, and plan an escape route. We propose that the similarity of population at risk, location, specific risk factors and the commonality of preventative approaches employed could offer net gains in terms of feasibility, effectiveness and acceptability if activities within these two preventative approaches were to be combined. Methods/Design This prospective proof of concept study, currently being conducted in two London boroughs, (Southwark and Lambeth) aims to reduce the incidence of both fires and falls in community-dwelling older adults. It comprises two concurrent 12-month interventions: the integration of 1) fall risk assessments into the Brigade's Home Fire Safety Visit and 2) fire risk assessments into Falls services by inviting older clinic attendees to book a Visit. Our primary objective is to examine the feasibility and effectiveness of these interventions. Furthermore, we are evaluating their acceptability and value to key stakeholders and services users. Discussion If our approach proves feasible and the risk assessment is both effective and acceptable, we envisage advocating a partnership model of working more broadly to fire and rescue services and health services in Britain, such that effective integration of preventative services for older people becomes routine for an ageing population.

Protecting or improving the efficiency and effectiveness of services while reducing costs in response to public sector funding reductions is a significant challenge for all public service organisations. Preventing falls in older people is a major public health objective. We propose here an innovative model of community partnership with Fire and Rescue Services assisting falls prevention services to enhance the safety and well-being of older people in local communities through early identification of those who are at risk of injury from a fall or accidental domestic fire.

ABSTRACTObjectivesTo develop a staff training intervention for agitation in people with severe dementia, reaching end-of-life, residing in nursing homes (NHs), test feasibility, acceptability, and whether a trial is warranted. DesignFeasibility study with pre- and post-intervention data collection, qualitative interviews, and focus groups. SettingThree NHs in South East England with dementia units, diverse in terms of size, ownership status, and location. ParticipantsResidents with a dementia diagnosis or scoring ≥2 on the Noticeable Problems Checklist, rated as “severe” on Clinical Dementia Rating Scale, family carers, and staff (healthcare assistants and nurses). InterventionManualized training, delivered by nonclinical psychology graduates focusing on agitation in severe dementia, underpinned by a palliative care framework. MeasurementsMain outcomes were feasibility of recruitment, data collection, follow-up, and intervention acceptability. We collected resident, family carer, and staff demographics. Staff provided data on resident’s agitation, pain, quality of life, and service receipt. Staff reported their sense of competence in dementia care. Family carers reported on satisfaction with end-of-life care. In qualitative interviews, we explored staff and family carers’ views on the intervention. ResultsThe target three NHs participated: 28 (49%) residents, 53 (74%) staff, and 11 (85%) family carers who were eligible to participate consented. Eight-four percent of staff attended ≥3 sessions, and we achieved 93% follow-up. We were able to complete quantitative interviews. Staff and family carers reported the intervention and delivery were acceptable and helpful. ConclusionsThe intervention was feasible and acceptable indicating a larger trial for effectiveness may be warranted.

Background People with severe dementia are often cared for at the end of life in nursing homes or acute hospital wards. In these circumstances, symptoms of agitation such as shouting, aggression, and restlessness are common. Agitation is distressing for the person with dementia and paid and family carers, and it is associated with poorer quality of life. Little is known about the attitudes that family carers have towards agitation in severe dementia. Such attitudes are important because they contribute to the personhood and quality of life of the person living with dementia. Aims To develop knowledge of the attitudes, explanatory models, and coping strategies of family carers around agitation in people with dementia receiving end of life care in hospitals or nursing homes. Methods Across two acute hospital and two nursing home sites, we conducted semi-structured interviews with eight family carers of people with a clinical dementia rating of 2 or 3 (moderate/severe). Interview transcripts were open coded by two researchers. Using an iterative process, our open coding was developed into key themes related to explanatory models and coping strategies. Results Preliminary analysis showed that agitation was often attributed to disease pathology rather than the individual. Coping strategies included limiting visits to times when the person with dementia was unlikely to be agitated. Conclusion Family carers see agitation in people with severe dementia at the end of life as a part of their illness and separate to their personal identity. This functioned as a means of preserving the individual's personhood.

This article, the second in a series on the NHS Institute for Innovation and Improvement's eight high impact actions, reviews the roles played by nurses and local organisations in preventing falls among older people through early intervention and the promotion of active lifestyles.

Purpose - A growing older population with complex care needs, including dementia, are living in care homes. It is important to support researchers in conducting ethical and appropriate work in this complex research environment. The purpose of this paper is to discuss key issues in care homes research including examples of best practice. The intention is to inform researchers across disciplines, leading to more sensitive and meaningful care home research practice. Design/methodology/approach - Experienced care homes researchers were invited to provide methodological insights and details not already reported in their publications. These have been analysed, creating key themes and linked to project publications. Findings - The need for reflexivity was a key finding. In particular, researchers need to: appreciate that the work is complex; see participants as potential research partners; and consider how cognitive and physical frailty of residents, staffing pressures and the unique environments of care homes might impact upon their research. Other challenges include recruitment and consenting people who lack mental capacity. Research limitations/implications - As the care homes research landscape continues to develop and grow, there still remains limited reflection and discussion of methodological issues with a need for a \"safe space\" for researchers to discuss challenges. Originality/value - This review is an updated methodological guide for care homes researchers, also highlighting current gaps in the mechanisms for continuing to share best research practice.