Purpose:To enable an understanding of the complexities involved in evaluating and improving the partnerships between organisations involved in integrated working.Theory: Network organisations provide a unique challenge to understanding and evaluating the processes and mechanisms through which organisations integrate.Through integrating research into this interface we propose a methodology for evaluation. Methods:A Grounded Theory study of partnership working in network organisations, with data analysis to build a theoretical model of the way that partnership works in complex organisational situations. Results and conclusions:Integrating care involves working across multiple organisations, creating complex environments for assessment and evaluation.We show that what happens in the 'spaces' between organisations involved in complex partnership arrangements is crucial and that current methods of partnership evaluation are inadequate for complex partnership situations, such as network organisations.Our model for integrating research into these interfaces between organisations involved in care enables these complexities to be better understood with the potential for real improvements in complex integrated care situations.In order to achieve this it is important that a theoretically-rooted, context-specific evaluative tool can be developed.This paper presents the Model of Network Partnership which the authors believe is a crucial stage in the process of development of such a tool with the potential to promote genuine improvements in integrated working.

Background Data from 12-week placebo-controlled trials have led to mounting concerns about increased mortality in patients with Alzheimer's disease (AD) who are prescribed antipsychotics; however, there are no mortality data from long-term placebo-controlled trials. We aimed to assess whether continued treatment with antipsychotics in people with AD is associated with an increased risk of mortality.Methods Between October, 2001, and December, 2004, patients with AD who resided in care facilities in the UK were enrolled into a randomised, placebo-controlled, parallel, two-group treatment discontinuation trial. Participants were randomly assigned to continue with their antipsychotic treatment (thioridazine, chlorpromazine, haloperidol, trifluoperazine, or risperidone) for 12 months or to switch their medication to an oral placebo. The primary outcome was mortality at 12 months. An additional follow-up telephone assessment was done to establish whether each participant was still alive 24 months after the enrolment of the last participant (range 24-54 months). Causes of death were obtained from death certificates. Analysis was by intention to treat (1717) and modified intention to treat (mITT). This trial is registered with the Cochrane Central Registry of Controlled Trials/National Research Register, number ISRCTN33368770.Findings 165 patients were randomised (83 to continue antipsychotic treatment and 82 to placebo), of whom 128 (78%) started treatment (64 continued with their treatment and 64 received placebo). There was a reduction in survival in the patients who continued to receive antipsychotics compared with those who received placebo. Cumulative probability of survival during the 12 months was 70% (95% Cl 58-80%) in the continue treatment group versus 77% (64-85%) in the placebo group for the mITT population. Kaplan-Meier estimates of mortality for the whole study period showed a significantly increased risk of mortality for patients who were allocated to continue antipsychotic treatment compared with those allocated to placebo (mITT log rank p=0.03; ITT p=0.02). The hazard ratio for the mITT group was 0.58 (95% CI 0.35 to 0.95) and 0.58 (0.36 to 0.92) for the ITT population. The more pronounced differences between groups during periods of follow up longer than 12 months were evident at specific timepoints (24-month survival 46% vs 71%; 36-month survival 30% vs 59%).Interpretation There is an increased long-term risk of mortality in patients with AD who are prescribed antipsychotic medication; these results further highlight the need to seek less harmful alternatives for the long-term treatment of neuropsychiatric symptoms in these patients.

BACKGROUND:Good practice guidelines state that a psychological intervention should usually precede pharmacotherapy, but there are no data evaluating the feasibility of psychological interventions used in this way. METHODS:At the first stage of a randomized blinded placebo-controlled trial, 318 patients with Alzheimer disease (AD) with clinically significant agitated behavior were treated in an open design with a psychological intervention (brief psychosocial therapy [BPST]) for 4 weeks, preceding randomization to pharmacotherapy. The therapy involved social interaction, personalized music, or removal of environmental triggers. RESULTS:Overall, 318 patients with AD completed BPST with an improvement of 5.6 points on the total Cohen-Mansfield Agitation Inventory (CMAI; mean [SD], 63.3 [16.0] to 57.7 [18.4], t = 4.8, df = 317, p < 0.0001). Therapy worksheets were completed in six of the eight centers, with the key elements of the intervention delivered according to the manual for >95% of patients. More detailed evaluation of outcome was completed for the 198 patients with AD from these centers, who experienced a mean improvement of 6.6 points on the total CMAI (mean [SD], 62.2 [14.3] to 55.6 [15.8], t = 6.5, df = 197, p < 0.0001). Overall, 43% of participants achieved a 30% improvement in their level of agitation. CONCLUSION:The specific attributable benefits of BPST cannot be determined from an open trial. However, the BPST therapy was feasible and was successfully delivered according to an operationalized manual. The encouraging outcome indicates the need for a randomized controlled trial of BPST.

A 3-year study tested the hypotheses that brushing each heifer for 5min per week in the weeks preceding calving (long term positive treatment: PT) while the heifers were unrestrained, is sufficient to improve subsequent parlour behaviour and production, and this could be influenced by the extent of the PT. Four intakes of commercial dairy heifers (total n148) managed under typical UK conditions were divided into treatment (T) and control (C) groups. The PT for the four treatment groups comprised of brushing each heifer for 5min per week in the weeks preceding calving for either 30min, 65, 155 or 245 in total for the different groups (equating to 6, 13, 31 and 49 weeks before calving). In the first 4 weeks after calving T heifers had 19% faster milk letdown (P<0.01) than C. Kicks in human presence accounted for 7.1% of the variation in milk yield (r2=0.071, P<0.001) and 46% of C's kicks were in human presence compared to 38% of T (P<0.05). In the first week after lactation T heifers who had received 30min of PT stamped 59% less at udder handling (P=0.017) compared to their respective C. The T heifers who had received 155min of PT during rearing displayed violent kicks 74% less than their C (P<0.10). Heifers who had received 65min PT had 75% less time spent on them during the milking routine (P<0.075). This was reflected in a significant difference in milker's score. Heifers appear to settle between Weeks 3 and 4 as there are no significant differences in behaviour of all heifers as a group. There was a treatment and week interaction for many variables and in Weeks 3 and 4 there are still differences in milking parlour variables between T and C at Week 4. This suggests that the PT quickened the T heifers’ acclimation to the milking routine. To conclude 30min of PT in the 6 weeks prior to calving appears sufficient to reduce subsequent fear response to humans in the parlour demonstrated through improved behaviour when being milked.

BACKGROUND:There have been increasing concerns regarding the safety and efficacy of neuroleptics in people with dementia, but there are very few long-term trials to inform clinical practice. The aim of this study was to determine the impact of long-term treatment with neuroleptic agents upon global cognitive decline and neuropsychiatric symptoms in patients with Alzheimer disease.METHODS AND FINDINGS:DESIGN:Randomised, blinded, placebo-controlled parallel two-group treatment discontinuation trial.SETTING:Oxfordshire, Newcastle and Gateshead, London and Edinburgh, United Kingdom.PARTICIPANTS:Patients currently prescribed the neuroleptics thioridazine, chlorpromazine, haloperidol trifluoperazine or risperidone for behavioural or psychiatric disturbance in dementia for at least 3 mo.INTERVENTIONS:Continue neuroleptic treatment for 12 mo or switch to an identical placebo.OUTCOME MEASURES:Primary outcome was total Severe Impairment Battery (SIB) score. Neuropsychiatric symptoms were evaluated with the Neuropsychiatric Inventory (NPI).RESULTS:165 patients were randomised (83 to continue treatment and 82 to placebo, i.e., discontinue treatment), of whom 128 (78%) commenced treatment (64 continue/64 placebo). Of those, 26 were lost to follow-up (13 per arm), resulting in 51 patients per arm analysed for the primary outcome. There was no significant difference between the continue treatment and placebo groups in the estimated mean change in SIB scores between baseline and 6 mo; estimated mean difference in deterioration (favouring placebo) -0.4 (95% confidence interval [CI] -6.4 to 5.5), adjusted for baseline value (p = 0.9). For neuropsychiatric symptoms, there was no significant difference between the continue treatment and placebo groups (n = 56 and 53, respectively) in the estimated mean change in NPI scores between baseline and 6 mo; estimated mean difference in deterioration (favouring continue treatment) -2.4 (95% CI -8.2 to 3.5), adjusted for baseline value (p = 0.4). Both results became more pronounced at 12 mo. There was some evidence to suggest that those patients with initial NPI >/= 15 benefited on neuropsychiatric symptoms from continuing treatment.CONCLUSIONS:For most patients with AD, withdrawal of neuroleptics had no overall detrimental effect on functional and cognitive status. Neuroleptics may have some value in the maintenance treatment of more severe neuropsychiatric symptoms, but this benefit must be weighed against the side effects of therapy.TRIAL REGISTRATION:Cochrane Central Registry of Controlled Trials/National Research Register (#ISRCTN33368770).

Objectives To determine the respective efficacy of quetiapine and rivastigmine for agitation in people with dementia in institutional care and to evaluate these treatments with respect to change in cognitive performance.Design Randomised double blind (clinician, patient, outcomes assessor) placebo controlled trial.Setting Care facilities in the north cast of England.Participants 93 patients with Alzheimer's disease, dementia, and clinically significant agitation.Intervention Atypical antipsychotic (quetiapine), cholinesterase inhibitor (rivastigmine), or placebo (double dummy).Main outcome measures Agitation (Cohen-Mansfield agitation inventory) and cognition (severe impairment battery) at baseline and at six weeks and 26 weeks. ne primary outcome was agitation inventory at six weeks.Results 31 patients were randomised to each group, and 80 (86%) started treatment (25 rivastigmine, 26 quetiapine, 29 placebo), of whom 71 (89%) tolerated the maximum protocol dose (22 rivastigmine, 23 quetiapine, 26 placebo). Compared with placebo, neither group showed significant differences in improvement on the agitation inventory either at six weeks or 26 weeks. Fifty six patients scored > 10 on the severe impairment battery at baseline, 46 (82%) of whom were included in the analysis at six week follow up (14 rivastigmine, 14 quetiapine, 18 placebo). For quetiapine the change in severe impairment battery score from baseline was estimated as an average of -14.6 points (95% confidence interval -25.3 to -4.0) lower (that is, worse) than m the placebo group at six weeks (P = 0.009) and -15.4 points (-27.0 to -3.8) lower at 26 weeks (P = 0.01). The corresponding changes with rivastigmine were -3.5 points (-13.1 to 6.2) lower at six weeks (P = 0.5) and -7.5 points (-21.0 to 6.0) lower at 26 weeks (P = 0.3).Conclusions Neither quetiapine nor rivastigmine is effective in the treatment of agitation in people with dementia in institutional care. Compared with placebo, quetiapine is associated with significantly greater cognitive decline.

Continuing the series on palliative care and dementia, the authors examine a wide range of psychological therapies, including traditional and some newer approaches.

It is increasingly recognised that pharmacological treatments for dementia should be used as a second-line approach and that non-pharmacological options should, in best practice, be pursued first. This review examines current non-pharmacological approaches. It highlights the more traditional treatments such as behavioural therapy, reality orientation and validation therapy, and also examines the potential of interesting new alternative options such as cognitive therapy, aromatherapy and multisensory therapies. The current literature is explored with particular reference to recent research, especially randomised controlled trials in the area. Although many non-pharmacological treatments have reported benefits in multiple research studies, there is a need for further reliable and valid data before the efficacy of these approaches is more widely recognised.