No description available.

There are concerns about cognitively impaired older patients’ experiences of general hospital care. Nottingham University Hospital developed a medical and mental health unit (MMHU) as a demonstration model of best practice dementia care. This thesis describes a controlled clinical trial comparing patients’ experiences of care on the MMHU to standard care wards. Patient experience was measured using the structured non-participant observational tool Dementia Care Mapping. Observations lasted 6 hours during which a score was recorded every five minutes for the patient’s mood and engagement and activity, together with incidents of enhancing and detracting staff behaviours. Noise (alarms, background noise and co-patients calling out) was recorded. 90 (46 MMHU, 44 Standard care) patients were observed between March and December 2011. At admission, most characteristics of patients on MMHU and standard care were similar. However, patients observed on MMHU had more behaviour disturbance, more often were care home residents and were less disabled than those observed on standard care. Patients on MMHU experienced a median 11% (95% Confidence Interval (CI) 2%, 20%) improvement in the proportion of time in positive mood and engagement (79% versus 68%); a median 3 (95%CI 1, 5) more enhancers (4 versus 1); a median 13% (95%CI -17%, -7%) less time noise could be heard (79% versus 92%) but a median 15% (95%CI 1, 23%) increase in proportion of time co-patients called out (21% versus 6%). Patients on MMHU had a better experience of care than those on standard care wards in terms of their mood and engagement, number of enhancers and improved noise levels, but experienced more co-patients calling out. This is the first study measuring an intervention to improve cognitively impaired older patients’ experiences in the general hospital and the first study to use the Dementia Care Mapping tool to evaluate an intervention in this setting.

published_or_final_version / Paediatrics / Master / Master of Philosophy

Falls are a major cause of injury fear of falling and death affecting 24% of older people annually. Falls have a major impact on hospital services, are an important cause of carer strain and admission to long term care. Multifactorial interventions delivered to fallers are effective in reducing falls rates by 25%. However, no UK studies have evaluated the role of screening older people living in the community and offering those at high risk a falls prevention programme. This work describes two studies – the evaluation of a postal falls risk screening tool, and a randomised controlled trial assessing the benefits of offering a falls prevention programme to those identified as being at high risk. 335 older people were recruited into the screening study, using a modified version of the Falls Risk Assessment Tool. The sensitivity was 79%, specificity 58%, positive predictive value 50% and the negative predictive value 83%. In the RCT, 364 community-dwelling older people at high risk of falls were randomised into a pragmatic, multicentre trial evaluating falls prevention programmes. 181 were allocated to the control group and 183 to the intervention. The primary outcome was the rate of falls; the adjusted IRR was 0.73 (0.51-1.03), p=0.071. There were no significant differences between the groups in terms of the proportion of fallers, recurrent fallers, medically verified falls, injurious falls, time to first fall or time to second fall. Nor were there significant differences in terms of institutionalisation, mortality, basic or extended activities of daily living, or fear of falling. Further work on testing falls prevention interventions for acceptability is required, followed by a further adequately powered RCT to determine the clinical effectiveness of a systematic screening programme and intervention. At present, there is insufficient evidence for health care commissioners to recommend screening and intervention for falls.

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No description available.

Psychological factors have important implications for adjustment to chronic pain, which itself has a variety of emotional consequences. Mental imagery has historically been assumed to be closely connected to emotional responses, and some experimental and clinical evidence has supported this claim. Around two in five people with chronic pain spontaneously report having mind‟s-eye mental images of their pain, although this phenomenon has received only limited research attention. This study aimed to see whether, for people with chronic pain who report these images, evoking their pain images is different from describing their pain using only single descriptive words. It was hypothesised that evoking the images would result in a stronger negative emotional response, weaker positive emotional response and an increase in the perceived pain intensity. It was also hypothesised that, compared to baseline scores, emotional and pain intensity ratings would be higher under both experimental conditions. Thirty-six participants completed an experiment interview, which employed a repeated measures design. The dependent variables were visual analogue scale ratings of pain intensity and strength of emotional experience (fear, sadness, anger, disgust and happiness). Other measures completed assessed the nature of the imagery and level of overall psychological distress. The study found that evoking pain-related mental images resulted in a temporary increase in pain intensity, sadness, anger and disgust and a decrease in happiness. However, these emotional responses were no different from those experienced when participants described their pain in single words, although this verbal task did not result in the increase in pain intensity seen when images were evoked. These results suggest that for this group of people, pain imagery is no more closely connected to emotional responses than equivalent verbal representations. However, the fact that imagery evocation resulted in a temporary increase in pain intensity where the verbal condition did not perhaps suggests that this represents a qualitatively different kind of paying attention to pain. The next steps for this small but growing field of research are considered.

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No description available.

No description available.