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Clinical and cost-effectiveness of the Managing Agitation and Raising QUality of LifE in dementia (MARQUE) intervention for agitation symptoms in people with dementia in care homes: a single-blind, cluster-randomised controlled trial
- Authors:
- LIVINGSTON Gill, et al
- Journal article citation:
- Lancet Psychiatry, 6(4), 2019, pp.293-304.
- Publisher:
- Elsevier
Background: Many people with dementia living in care homes have distressing and costly agitation symptoms. Interventions should be efficacious, scalable, and feasible. Methods: We did a parallel-group, cluster-randomised controlled trial in 20 care homes across England. Care homes were eligible if they had 17 residents or more with dementia, agreed to mandatory training for all eligible staff and the implementation of plans, and more than 60% of eligible staff agreed to participate. Staff were eligible if they worked during the day providing face-to-face care for residents with dementia. Residents were eligible if they had a known dementia diagnosis or scored positive on screening with the Noticeable Problems Checklist. A statistician independent of the study randomised care homes (1:1) to the Managing Agitation and Raising Quality of Life (MARQUE) intervention or treatment as usual (TAU) using computer-generated randomisation in blocks of two, stratified by type of home (residential or nursing). Care home staff were not masked to the intervention but were asked not to inform assessors. Residents with dementia, family carers, outcome assessors, statisticians, and health economists were masked to allocation until the data were analysed. MARQUE is an evidence-based manualised intervention, delivered by supervised graduate psychologists to staff in six interactive sessions. The primary outcome was agitation score at 8 months, measured using the Cohen-Mansfield Agitation Inventory (CMAI). Analysis of the primary outcome was done in the modified intention-to-treat population, which included all randomly assigned residents for whom CMAI data was available at 8 months. Mortality was assessed in all randomly assigned residents. This study is registered with the ISRCTN registry, number ISRCTN96745365. Findings: Between June 14, 2016, and July 4, 2017, we randomised ten care homes (189 residents) to the MARQUE intervention and ten care homes (215 residents) to TAU. At 8 months, primary outcome data were available for 155 residents in the MARQUE group and 163 residents in the TAU group. At 8 months, no significant differences in mean CMAI scores were identified between the MARQUE and TAU groups (adjusted difference −0·40 [95% CI −3·89 to 3·09; p=0·8226]). In the intervention care homes, 84% of all eligible staff completed all sessions. The mean difference in cost between the MARQUE and TAU groups was £204 (−215 to 623; p=0·320) and mean difference in quality-adjusted life-years was 0·015 (95% CI −0·004 to 0·034; p=0·127). At 8 months, 27 (14%) of 189 residents in the MARQUE group and 41 (19%) of 215 residents in the TAU group had died. The prescription of antipsychotic drugs was not significantly different between the MARQUE group and the TAU group (odds ratio 0·66; 95% CI 0·26 to 1·69, p=0·3880). Interpretation: The MARQUE intervention was not efficacious for agitation although feasible and cost-effective in terms of quality of life. Addressing agitation in care homes might require resourcing for delivery by professional staff of a more intensive intervention, implementing social and activity times, and a longer time to implement change. (Edited publisher abstract)
Prevalence, management, and outcomes of SARS-CoV-2 infections in older people and those with dementia in mental health wards in London, UK: a retrospective observational study
- Authors:
- LIVINGSTON Gill, et al
- Journal article citation:
- Lancet, early cite October 2020,
- Publisher:
- Elsevier
Background: People living in group situations or with dementia are more vulnerable to infection with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Older people and those with multimorbidity have higher mortality if they become infected than the general population. However, no systematic study exists of COVID-19-related outcomes in older inpatients in psychiatric units, who comprise people from these high-risk groups. This study aimed to describe the period prevalence, demographics, symptoms (and asymptomatic cases), management, and survival outcomes of COVID-19 in the older inpatient psychiatric population and people with young-onset dementia in five National Health Service Trusts in London, UK, from March 1 to April 30, 2020.Methods: In this retrospective observational study, the researchers collected demographic data, mental health diagnoses, clinical diagnosis of COVID-19, symptoms, management, and COVID-19-related outcome data of inpatients aged 65 years or older or with dementia who were already inpatients or admitted as inpatients to five London mental health Trusts between March 1 and April 30, 2020, and information about available COVID-19-related resources (ie, testing and personal protective equipment). Patients were determined to have COVID-19 if they had a positive SARS-CoV-2 PCR test, or had relevant symptoms indicative of COVID-19, as determined by their treating physician. This study calculated period prevalence of COVID-19 and analysed patients’ characteristics, treatments, and outcomes.Findings: Of 344 inpatients, 131 (38%) were diagnosed with COVID-19 during the study period (period prevalence 38% [95% CI 33–43]). The mean age of patients who had COVID-19 was 75·3 years (SD 8·2); 68 (52%) were women and 47 (36%) from ethnic minority groups. 16 (12%) of 131 patients were asymptomatic and 121 (92%) had one or more disease-related comorbidity. 108 (82%) patients were compulsorily detained. 74 (56%) patients had dementia, of whom 13 (18%) had young-onset dementia. On average, sites received COVID-19 testing kits 4·5 days after the first clinical COVID-19 presentation. 19 (15%) patients diagnosed with COVID-19 died during the study period, and their deaths were determined to be COVID-19 related. Interpretation: Patients in psychiatric inpatient settings who were admitted without known SARS-CoV-2 infection had a high risk of infection with SARS-CoV-2 compared with those in the community and had a higher proportion of deaths from COVID-19 than in the community. Implementation of the long-standing policy of parity of esteem for mental health and planning for future COVID-19 waves in psychiatric hospitals is urgent. (Edited publisher abstract)
Clinical effectiveness of the START (STrAtegies for RelaTives) psychological intervention for family carers and the effects on the cost of care for people with dementia: 6-year follow-up of a randomised controlled trial
- Authors:
- LIVINGSTON Gill, et al
- Journal article citation:
- British Journal of Psychiatry, 216(1), 2020, pp.35-42.
- Publisher:
- Cambridge University Press
Background: The START (STrAtegies for RelaTives) intervention reduced depressive and anxiety symptoms of family carers of relatives with dementia at home over 2 years and was cost-effective. Aims: To assess the clinical effectiveness over 6 years and the impact on costs and care home admission. Method: The researchers conducted a randomised, parallel group, superiority trial recruiting from 4 November 2009 to 8 June 2011 with 6-year follow-up (trial registration: ISCTRN 70017938). A total of 260 self-identified family carers of people with dementia were randomised 2:1 to START, an eight-session manual-based coping intervention delivered by supervised psychology graduates, or to treatment as usual (TAU). The primary outcome was affective symptoms (Hospital Anxiety and Depression Scale, total score (HADS-T)). Secondary outcomes included patient and carer service costs and care home admission. Results: In total, 222 (85.4%) of 173 carers randomised to START and 87 to TAU were included in the 6-year clinical efficacy analysis. Over 72 months, compared with TAU, the intervention group had improved scores on HADS-T (adjusted mean difference −2.00 points, 95% CI −3.38 to −0.63). Patient-related costs (START versus TAU, respectively: median £5759 v. £16 964 in the final year; P = 0.07) and carer-related costs (median £377 v. £274 in the final year) were not significantly different between groups nor were group differences in time until care home (intensity ratio START:TAU was 0.88, 95% CI 0.58–1.35). Conclusions: START is clinically effective and this effect lasts for 6 years without increasing costs. This is the first intervention with such a long-term clinical and possible economic benefit and has potential to make a difference to individual carers. Declarations of interest: G.L., Z.W. and C.C. are supported by the UCLH National Institute for Health Research (NIHR) Biomedical Research Centre. G.L. and P.R. were in part supported by the National Institute for Health Research (NIHR) Collaboration for Leadership in Applied Health Research and Care (CLAHRC) North Thames at Bart's Health NHS Trust. The views expressed are those of the author(s) and not necessarily those of the NHS, the NIHR or the Department of Health. Z.W. reports during the conduct of the study; personal fees from GE Healthcare, grants from GE Healthcare, grants from Lundbeck, other from GE Healthcare, outside the submitted work. (Edited publisher abstract)
Dementia prevention, intervention, and care
- Authors:
- LIVINGSTON Gill, et al
- Publisher:
- Elsevier
- Publication year:
- 2017
- Pagination:
- 62
Many of dementia's manifestations are now known to be manageable, and while the underlying illness is generally not curable, it might be modifiable with good dementia care. This report summarises evidence-based approaches to dementia and its symptoms, and makes it clear when the available evidence is not definitive. It itemises interventions that can transform the lives of people with dementia and their families; maximising cognition, decreasing distressing associated symptoms, reducing crises, and improving quality of life. Timely diagnosis is a prerequisite to receiving these interventions. Pharmacological, psychological, environmental, and social interventions are included. If these interventions are implemented, people with dementia will have their cognition optimised and they will be less likely to be agitated, depressed, or have troublesome psychotic symptoms, and family carers will have reduced levels of anxiety and depression. It is also important to discuss future decision making as soon as possible with people with dementia and allow them to nominate someone to enact pre-specified wishes or make choices consistent with their values. The report suggests that overall there is good potential for prevention and, once someone develops dementia, for care to be high-quality, accessible, and give value to an underserved, growing population. Effective dementia prevention, intervention, and care could transform the future for society and vastly improve living and dying for individuals with dementia and their families. Acting now on what we already know can make this difference happen. (Edited publisher abstract)
Non-pharmacological interventions for agitation in dementia: systematic review of randomised controlled trials
- Authors:
- LIVINGSTON Gill, et al
- Journal article citation:
- British Journal of Psychiatry, 205(6), 2014, pp.436-442.
- Publisher:
- Cambridge University Press
Background: Agitation in dementia is common, persistent and distressing and can lead to care breakdown. Medication is often ineffective and harmful. Aims: To systematically review randomised controlled trial evidence regarding non-pharmacological interventions. Method: The authors reviewed 33 studies fitting predetermined criteria, assessed their validity and calculated standardised effect sizes (SES). Results: Person-centred care, communication skills training and adapted dementia care mapping decreased symptomatic and severe agitation in care homes immediately (SES range 0.3-1.8) and for up to 6 months afterwards (SES range 0.2-2.2). Activities and music therapy by protocol (SES range 0.5-0.6) decreased overall agitation and sensory intervention decreased clinically significant agitation immediately. Aromatherapy and light therapy did not demonstrate efficacy. Conclusions: There are evidence-based strategies for care homes. Future interventions should focus on consistent and long-term implementation through staff training. Further research is needed for people living in their own homes. (Edited publisher abstract)
Care at the end of life for people with dementia living in a care home: a qualitative study of staff experience and attitudes
- Authors:
- LIVINGSTON Gill, et al
- Journal article citation:
- International Journal of Geriatric Psychiatry, 27(6), June 2012, pp.643-650.
- Publisher:
- Wiley
Despite many changes and improvements in end of life care, dementia is still seldom regards as a terminal illness. This study examined barriers and facilitators to care home staff delivering improved end-of-life care for this group of patients. Individual qualitative interviews were carried out with 58 staff in a 120-bed nursing home where the staff and the residents' religion differed. This was a Jewish Care home in London where the staff members were mostly Christian but from a wide range of countries; about 20% were Filipino. The staff felt warmly towards the residents and felt they could recognise when they were near death. Care staff, nurses and doctors did not see themselves as a team and communicated poorly with relatives about approaching death. The staff used opaque euphemisms and worried about being blamed. They were often unaware of or had concerns about the validity of advance care plans. They knew of the religious rituals around death but frequently misunderstood religious tradition. The authors conclude that there is a need for education and support about discussing and implementing plans around care at the end of life in dementia, and about cultural issues around death to improve practice. This needs to include communicating the complicated, unpredictable path of dementia near the time of death explicitly but sensitively.
Making decisions for people with dementia who lack capacity: qualitative study of family carers in UK
- Authors:
- LIVINGSTON Gill, et al
- Journal article citation:
- British Medical Journal, 4.9.10, 2010, p.494.
- Publisher:
- British Medical Association
The qualitative study aimed to identify common difficult decisions made by family carers on behalf of people with dementia, and the facilitators of and barriers to making these decisions. Focus groups were held with 43 family carers of people with dementia and individual interviews were also held with an 46 additional carers who had already been involved in making decisions for their relative. Five core problematic areas of decision making were identified: accessing dementia-related health and social services; care homes; legal-financial matters; non-dementia related health care; and making plans for the person with dementia if the carer became too ill to care for them. Strategies for dealing with these problems were also highlighted.
What trainees and trainers think about supervision
- Authors:
- SEMBHI Sati, LIVINGSTON Gill
- Journal article citation:
- Psychiatric Bulletin, 24(10), October 2000, pp.376-379.
- Publisher:
- Royal College of Psychiatrists
A confidential questionnaire was mailed to all trainers and trainees on the UCL/North London rotation, asking about the content and ways of improving supervision. Seventy-six per cent of trainees received regular, timetabled supervision. Ninety-four percent of trainees felt it was a good idea, but identified improvements, including more planning, setting an agenda and flexibility.
A nurse-coordinated educational initiative addressing primary care professionals' attitudes to and problem-solving in depression in older people - a pilot study
- Authors:
- LIVINGSTON Gill, et al
- Journal article citation:
- International Journal of Geriatric Psychiatry, 15(5), May 2000, pp.401-405.
- Publisher:
- Wiley
This study assessed the feasibility and efficacy of an intervention focusing on primary care professionals' attitudes to, problem-solving in and practice relating to depression in old age before and after a nurse-implemented educational intervention. The results of the study do not indicate that the evaluation of nurse-led educational interventions in primary care is feasible in the field of depression in old age. The belief that all that is needed is the provision of accessible education of professionals by experts in the field to change attitudes and practice has not been reinforced. The high refusal rate suggests that such interventions are unlikely in any case to be generally acceptable.
A qualitative study of adjustment to caring for an older spouse with psychiatric illness
- Authors:
- MURRAY Joanna, LIVINGSTON Gill
- Journal article citation:
- Ageing and Society, 18(6), November 1998, pp.659-671.
- Publisher:
- Cambridge University Press
An understanding of the ways in which older carers perceptions of their marital relationship and duty to their spouse underlie adjustment to care giving is required for the development of acceptable and efficacious services for spouse carers. With this aim the authors conducted qualitative interviews with spouses of older people with a mental illness identified in a representative community study. Those who still experience closeness in the relationship see themselves as coping and are reluctant to accept formal help. Others describe long term unhappiness in marriage and experience feeling of entrapment in role of the carer. They require early and comprehensive services. Hypotheses regarding these themes are proposed.