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.

International Journal of Geriatric PsychiatryVolume 29, Issue 12 p. 1315-1317 Letter to the Editor Staff confidence, morale and attitudes in a specialist unit for general hospital patients with dementia and delirium—a qualitative study Karen Spencer, Karen Spencer Division of Rehabilitation and Ageing, University of Nottingham, Nottingham, UKSearch for more papers by this authorPippa E. R. Foster, Pippa E. R. Foster Division of Rehabilitation and Ageing, University of Nottingham, Nottingham, UKSearch for more papers by this authorKathy H. Whittamore, Kathy H. Whittamore Division of Rehabilitation and Ageing, University of Nottingham, Nottingham, UKSearch for more papers by this authorSarah E. Goldberg, Sarah E. Goldberg Division of Rehabilitation and Ageing, University of Nottingham, Nottingham, UKSearch for more papers by this authorRowan H. Harwood, Corresponding Author Rowan H. Harwood Division of Rehabilitation and Ageing, University of Nottingham, Nottingham, UK Health Care of Older People, Nottingham University Hospitals NHS Trust, Queen's Medical Centre, Nottingham, UKCorrespondence to: R. H. Harwood, E-mail: [email protected]Search for more papers by this author Karen Spencer, Karen Spencer Division of Rehabilitation and Ageing, University of Nottingham, Nottingham, UKSearch for more papers by this authorPippa E. R. Foster, Pippa E. R. Foster Division of Rehabilitation and Ageing, University of Nottingham, Nottingham, UKSearch for more papers by this authorKathy H. Whittamore, Kathy H. Whittamore Division of Rehabilitation and Ageing, University of Nottingham, Nottingham, UKSearch for more papers by this authorSarah E. Goldberg, Sarah E. Goldberg Division of Rehabilitation and Ageing, University of Nottingham, Nottingham, UKSearch for more papers by this authorRowan H. Harwood, Corresponding Author Rowan H. Harwood Division of Rehabilitation and Ageing, University of Nottingham, Nottingham, UK Health Care of Older People, Nottingham University Hospitals NHS Trust, Queen's Medical Centre, Nottingham, UKCorrespondence to: R. H. Harwood, E-mail: [email protected]Search for more papers by this author First published: 13 November 2014 https://doi.org/10.1002/gps.4178Citations: 8Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onEmailFacebookTwitterLinkedInRedditWechat References Goldberg, SE, Whittamore, K, Harwood, RH, et al. 2012. The prevalence of mental health problems amongst older adults admitted as an emergency to a general hospital. Age Ageing 41: 80–86. doi: 10.1093/ageing/afr106 Goldberg SE, Bradshaw LE, Kearney FC, et al. 2013. Comparison of a specialist Medical and Mental Health Unit with standard care for older people with cognitive impairment admitted to a general hospital: a randomised controlled trial (NIHR TEAM trial). BMJ 347: f4132. doi: 10.1136/bmj.f4132 Griffiths A, Knight, A, Harwood RH, Gladman JRFG. 2014. Preparation to care for confused older patients in general hospitals: a study of UK health professionals. Age Ageing 43: 521–527. doi: 10.1093/ageing/aft171 Srivastava A., Thomson SB. 2009. Framework analysis: a qualitative methodology for applied policy research. Journal of Administration & Governance 4(2): 72–79. http://www.joaag.com/uploads/06_Research_Note_Srivastava_and_Thomson_4_2_.pdf. Tadd W, Hillman A, Calnan S, et al. 2011. Right place—wrong person: dignity in the acute care of older people. Quality in Ageing and Older Adults 12(1): 33–43. Citing Literature Volume29, Issue12December 2014Pages 1315-1317 ReferencesRelatedInformation

Objectives To examine in depth carers’ views and experiences of the delivery of patient care for people with dementia or delirium in an acute general hospital, in order to evaluate a specialist Medical and Mental Health Unit (MMHU) compared with standard hospital wards. This qualitative study complemented the quantitative findings of a randomised controlled trial. Design Qualitative semistructured interviews were conducted with carers of patients with cognitive impairment admitted to hospital over a 4-month period. Setting A specialist MMHU was developed in an English National Health Service acute hospital aiming to deliver the best-practice care. Specialist mental health staff were integrated with the ward team. All staff received enhanced training in dementia, delirium and person-centred care. A programme of purposeful therapeutic and leisure activities was introduced. The ward environment was optimised to improve patient orientation and independence. A proactive and inclusive approach to family carers was encouraged. Participants 40 carers who had been recruited to a randomised controlled trial comparing the MMHU with standard wards. Results The main themes identified related closely to family carers’ met or unmet expectations and included activities and boredom, staff knowledge, dignity and fundamental care, the ward environment and communication between staff and carers. Carers from MMHU were aware of, and appreciated, improvements relating to activities, the ward environment and staff knowledge and skill in the appropriate management of dementia and delirium. However, communication and engagement of family carers were still perceived as insufficient. Conclusions Our data demonstrate the extent to which the MMHU succeeded in its goal of providing the best-practice care and improving carer experience, and where deficiencies remained. Neither setting was perceived as neither wholly good nor wholly bad; however, greater satisfaction (and less dissatisfaction) with care was experienced by carers from MMHU compared with standard care wards.

Objective To develop and evaluate a best practice model of general hospital acute medical care for older people with cognitive impairment. Design Randomised controlled trial, adapted to take account of constraints imposed by a busy acute medical admission system. Setting Large acute general hospital in the United Kingdom. Participants 600 patients aged over 65 admitted for acute medical care, identified as “confused” on admission. Interventions Participants were randomised to a specialist medical and mental health unit, designed to deliver best practice care for people with delirium or dementia, or to standard care (acute geriatric or general medical wards). Features of the specialist unit included joint staffing by medical and mental health professionals; enhanced staff training in delirium, dementia, and person centred dementia care; provision of organised purposeful activity; environmental modification to meet the needs of those with cognitive impairment; delirium prevention; and a proactive and inclusive approach to family carers. Main outcome measures Primary outcome: number of days spent at home over the 90 days after randomisation. Secondary outcomes: structured non-participant observations to ascertain patients’ experiences; satisfaction of family carers with hospital care. When possible, outcome assessment was blind to allocation. Results There was no significant difference in days spent at home between the specialist unit and standard care groups (median 51 v 45 days, 95% confidence interval for difference −12 to 24; P=0.3). Median index hospital stay was 11 versus 11 days, mortality 22% versus 25% (−9% to 4%), readmission 32% versus 35% (−10% to 5%), and new admission to care home 20% versus 28% (−16% to 0) for the specialist unit and standard care groups, respectively. Patients returning home spent a median of 70.5 versus 71.0 days at home (−6.0 to 6.5). Patients on the specialist unit spent significantly more time with positive mood or engagement (79% v 68%, 2% to 20%; P=0.03) and experienced more staff interactions that met emotional and psychological needs (median 4 v 1 per observation; P<0.001). More family carers were satisfied with care (overall 91% v 83%, 2% to 15%; P=0.004), and severe dissatisfaction was reduced (5% v 10%, −10% to 0%; P=0.05). Conclusions Specialist care for people with delirium and dementia improved the experience of patients and satisfaction of carers, but there were no convincing benefits in health status or service use. Patients’ experience and carers’ satisfaction might be more appropriate measures of success for frail older people approaching the end of life. Trial registration Clinical Trials NCT01136148