What works in reducing the use of anti-psychotic medication? How can staff help residents with dementia to eat and drink properly? What is the role of care home managers in creating safe and positive environments for residents and staff? What helps in supporting good end of life care for residents and families? What are the best ways of supporting residents with behaviours that challenge? What kind of GP input works best? These are just some of the questions which research has looked to address.
At a time of great pressure for care homes, it is really important to focus on the most effective and cost-effective ways of providing high-quality care. There are increasing demands from regulators, coupled with a changing profile of residents who have increasingly complex health and care needs that might previously have been met in hospital. As such, providing good, consistent care that meets the needs of individual residents, in a context of staffing and budget restraints, is very difficult. Each organisation and staff member has to make trade-offs to meet these competing demands. This is where research can play an important part in supporting these difficult decisions.
Advancing care through research
We did not always have good evidence for or about care homes. Most research was based in hospitals. However, interventions which work in hospitals are often not effective in care homes. In the last fifteen years, the National Institute of Health Research (NIHR) has invested in research and support for care homes. It is still quite a new area for research, but it’s encouraging how much progress has been made.
Advancing care, a report launched in July, provides an overview of NIHR’s research with care homes. It highlights 44 studies, from large, five-year research programmes to smaller projects. Some trials compare the effectiveness of different treatments. Other studies use interviews, focus groups and observations to understand more about the experience and acceptability of care.
These have been organised into three main areas – living well, ageing well and dying well – with overarching themes of research and working well.
Below are just some highlights and studies of interest to care home managers and staff. Many more feature in the full report.
A study involving over 300 residents with dementia found about half had a visual impairment and many impairments were uncorrected. This was a higher rate of eye problems, compared with others of similar age living outside of the care home environment, and higher than previous studies had found. About half of those with eye problems could be corrected by wearing glasses or cataract surgery.
The study showed wearing glasses was often difficult, with residents refusing to wear them or glasses going missing or breaking. Care staff and optometrists themselves often assumed people with dementia would not be able to be tested. But this study showed four out of five people with dementia could complete the sight test.
There was also a review of published research on how to reduce stress and anxiety for residents with dementia at mealtimes. It highlighted some approaches which seemed to help. Evidence to date suggests that playing music, such as quiet classical piano pieces, during mealtimes can be effective. These need to be played at a volume that can just be heard over the background noise.
Other helpful changes included replacing pre-plated meals with family-style meals, placing food on the table and serving people individually; promoting conversation during the meal; and increasing the lighting and maximising the contrast of the place settings, for example, by using black placemats on a white tablecloth.
All had a positive impact on behaviour, however, music was the most effective.
One research project into ageing well explored the use of anti-psychotic medication in people with dementia. A large trial of 16 care homes found that reviewing people’s anti-psychotic prescriptions, together with exercise and social interaction (for an hour a week) improved outcomes for residents. Outcomes included anti-psychotic use reducing by 50% due to the anti-psychotic review and the risk of death for residents reducing as a result of the review and social interaction.
While the medication review on its own reduced anti-psychotic prescribing, combining this with exercise and social interaction also improved quality of life and stopped symptoms from getting worse. Social interaction and increased exercise also had an effect in reducing levels of depression and apathy amongst people with dementia.
Another study into managing agitation in people with dementia found that teaching staff in care homes to communicate and consider the person with dementia’s needs, rather than focus on completing tasks with them was helpful for severe agitation, as were touch therapies. Pleasant activities and structured music therapy also helped to decrease agitation.
As 18% of people dying in England each year die in a care home, research into dying well is important. A research study followed 133 older people with dementia and observed the end of life experience for some, over an 18-month period. They found that there was great uncertainty for staff in knowing when someone was actively dying and how to interpret and manage symptoms and events. There was also uncertainty about the roles and responsibilities of care home and NHS staff and relatives at this time.
The second phase of this research developed resources to help deal with this uncertainty. This included a script for discussing end of life wishes with relatives and a tool to support discussions with emergency and out-of-hours services. When evaluated, this was shown to help in supporting a shift to better working between agencies.
Many studies in this review underline the complexity and co-ordination needed for various staff and agencies to work well together for care home residents.
One research study found that, on average, care homes accessed between 14 to 15 different NHS services – most often, district nurses, opticians, chiropodists, podiatrists, community psychiatric nurses and continence services. However, there was no single, recognisable way for these agencies to work together, and many arrangements appeared ad hoc.
A further study by the team identified the features and conditions for good joined-up care, including the importance of access to particular services, such as specialist dementia care settings, for both NHS and care staff.
The crucial role of the care home manager is underlined in many of these studies, although little research to-date has focused on the care home manager. One study concluded that the manager is central to creating a culture that ensures person-centred care in the home. Another study found that managers with an open attitude and a willingness to engage in research and service improvement is key to attempts to change services or raise standards.
Role of research in social care
Research won’t have all the answers, but it can help to tell us what works – and hasn’t worked – and introduce new approaches to try in your service.
There are real challenges in delivering relevant and meaningful research for care homes. One issue is the importance of context – the care home economy is so varied, ranging from chains to small, independent, family-run businesses. What is relevant in one context won’t necessarily apply in another.
Another challenge is that traditional research tries to standardise the intervention, so we can be sure everyone is getting the same treatment or service. However, in care homes, staff try to meet the needs of individuals through person-centred care. Some research study designs, like randomised controlled trials, just cannot address these differences in context or individual needs. Other approaches can be useful, though, including research which actively looks for best practice and tries to better understand what conditions are needed to make this happen.
What’s most important, is that those running and working in care homes need to be involved in setting the research agenda. This will ensure research addresses the real problems facing providers and engages them actively in the research.
If you come across areas of uncertainty where you think there is a need for new research, let the NIHR know. Also, there are networks like ENRICH (Enabling Research in Care Homes) which can help care homes to take part in research and to work in partnership with researchers.
The sector needs better research to help staff in their challenging and important work in care homes. Today’s promising intervention, when tested, could be tomorrow’s standard care.