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Support at Home: Interventions to

Enhance Life in Dementia (SHIELD)

5 Year Research Programme

Funded by the National Institute of

Health Research

Professor Martin Orrell

Why?



• Number of older people with dementia in the UK

2008: Over 600,000

2026: 840,000

2050: 1.2 million

• Role of drug treatments and limitations

• Value of psychosocial interventions

• Increasingly emphasis on maintaining PWD at

home

Why?

 Impact of dementia in social health care

services and family carers

 National Service Framework :”Treatment in

dementia always needs to include non

pharmacological management strategies”

 National strategy for carers published in

1999 from the DoH have remained a high

priority.

Why?

 Need to identify useful and effective

interventions to reduce the social and

economic impact of dementia and

reduce its impact on PWD, carers and

society.

Aim:

 To provide essential evidence to clarify the

role of each of the interventions in:



. Helping to support people at home

. Reducing hospital admissions

. Improving quality of life of people

with dementia and carers

SHIELD

 Maintenance CST - improve cognition and quality of

life of people with dementia

 Reminiscence groups - for pwd/carers maintain quality

of life and improve relationships

 Expert carer programme - trains ex-carers to help new

carers of people with dementia

 Home treatment package - manage crises at home, and

prevent admission to hospital for people with dementia.

 Training manuals to help other services implement the

same approaches.

Cognitive Stimulation Therapy

Previous studies



2 RCT found that over 6 months CS

and CI in combination more effective

than CI alone

 RCT (Spector et al, 2003)

7 Week evidence based CST

201 People recruited

23 day centres (5) and care homes (18)

Greater London

Cognitive Stimulation Therapy

Previous studies

 MCST Pilot study (Orrell et al, 2005)

 Twice a week for 7 weeks

 Once a week for extra 16 weeks

 2 care homes treatment / 2 care homes control

group



Found significant improvement in cognitive function

What we know

 Beneficial for QoL and Cognition

 Cost effective

 Benefit similar to cholinesterase inhibitors

 Longer term MCST, significant

improvement in cognition over time

1.9 improvement on MMSE (EG)

0.7 decline on MMSE (CG)

What we do not know

 MCST Effects on a larger RCT

 MCST impact on care homes admissions

 Effectiveness of training

 CST practise evidence

 Different training models effects

What we’ll do

 Systematic literature review and meta

analysis

 Development of a MCST training package

 Piloting the package with 4 MCST groups

 Multicentre RCT of MCST vs. CST

CST/MCST

 Develop a training package based on the

previous CST manual for MCST

 Check package with 4 MCST groups

developing reliable measure of adherence to

competence

 Multicentre RCT of MCST vs. CST

RCT

CST/MCST

 230 people with dementia

=> 60/230 Alzheimer's type + Donezepil

 Ran CST Groups

5 to 8 per group

Twice a week

45 mins per session

7 Weeks

Randomised

Dementia other type

Alzheimers +

+ Alzheimers

Donezepil unsuitable

Donezepil

 Experimental Group

- 26 Weeks MCST

 Control Group Once a Week

- 26 Weeks TAU 45 Mins

People with dementia meeting

inclusion criteria for CST groups.

Screened and entered into CST groups

Subtype of dementia identified





Commence CST groups





Alzheimers disease plus 1) Non Alzheimers dementia OR

(1) currently on cholinesterase 2) Alzheimers but unwilling or

inhibitors (CHEIs) OR unsuitable to take cholinesterase

(2) willing and suitable for inhibitors.

cholinesterase inhibitors









IF (1) IF (2) Contact local clinical

Continue team suggest suitability for

with CHEIs

CHEIs







clinical clinical team

team starts does not start

CHEIs CHEIs





CST groups finish







Randomisation to either Randomisation to either

MCST plus CHEIs OR control plus CHEIs MCST OR control groups

Comparison Two training

packages

 Manual  Manual

 Workbook  Workbook

 DVD  DVD

 1 Day Training

Seminar

 Monthly follow up

support group for six

months

Analysis of the training

 Measure the impact of the training approach on

adherence to the training and competence .

 Impact of the two trainings in staff factors

 Therapist competency and adherence to the

manual using 60 videos of randomly selected

sessions (SRP)

 Post-RCT surveillance and monitoring study of

MCST in practice.

Reminiscence

 Taps into early memories and encourages

communication and well being

 Evidence showing that including carers and

people with dementia is more effective than

only carers

 Trial platform has developed a manual for

joint reminiscence indicating that improves

caring relationships and benefits both

Previous studies evidence

RYCT

What we know

 A previous study successfully developed a manual for joint

reminiscence (RYCT) and suggests that RYCT improves

the caring relationship and benefited both



- PWD had better autobiographical memory post treatment

but not at follow up

- Caregivers from YRCT perceived their relatives less

critical

- Carers after treatment groups showed reported less

depression.

RYCT

 10/12 Pairs of Person with dementia and

carers

 Weekly Meeting for 3 months

 Monthly meeting for 9 months

 300 people in total => 250

 15 RYCT/ 15 CG

Expert Carer Programme

 To train ex carers to be expert carers

 Evidence from previous studies (BECCA)

showing that ex carers are motivated to support

others at an earlier stage I their role as a family

carer through mentoring and teaching.

 65% befrienders were ex carers

 Feedback from BECCA groups found befrienders

would have preferred and expandable role.

What we’ll do

 Systematic Review on psychosocial approaches

for carers

 Consultation with voluntary organisations, carers

 Focus groups

 Scoping exercise including professionals

 Consensus conference including stakeholders

 Develop an Expert Carer Programme for ex carers

Expert Carer Programme

 Mentoring

 Training

CB

Stress Management

Behavioural Management

 Delivery to ex carers between

voluntary/health organisations

Expert Carer Programme: ECP

25 Expert Carers

 6 sessions (2 hour each)

 Selection of specific BECCA Modules adapted to

the needs of ex carers

 Modules:

Listening Skills

Coping Skills

Problem Solving

 DVD/Manual/Protocol/Diary

 Training plus support/ Diary Review fortnightly

Expert Carer Mentoring Role

 Fortnightly 2 hour support

 Coaching visits for 3 months including the

course

 Monthly support group run by expert carer

for 9 months

 Training for new carers: 4 Half Day

Sessions

What we’ll do

 Recruiting and training care workers in RYCT

 Exploratory trial

- Feasibility RYCT plus ECP

- Including the RYCT trial components and

ECP

 RCT, four arms, multicentre (5 Centres),

randomised (random allocation) controlled (stable

conditions) trial (stimulus-reaction)

Randomised Control Trial

 Total of 80 PWD/ 80 Carers

 20 in each group

RYCT

RYCT ECP UC Plus ECP



 Measures: Baseline/ 3 Months/ 6 Months

- QOL-AD

-GHQ-28

- Caregiver Mental Health

Intensive Home Support



• to help manage crisis at home and reduce

hospital admissions

• Previous research have found that 97% of social

services departments aimed to provided

community services but only 20 had intensive

care management.

What we’ll do

 Systematic review of the literature , looking at

care management and crisis resolution approaches

aimed at maintaining PWD at home

 Develop a HTP including:

- Professionals

- Academics

- Care Workers

- Voluntary Sectors

- Carers

- PWD

HTP

 Literature review will be summarised

 Scoping exercise including:

- Focus Groups

- Nominal Groups

- Postal Consultation

- Consensus Conference (including subgroups

working through a range of high risk case

examples using a draft of the HTP to articulate

best care practices and responses).

Function of HTP

 Advisory protocol/ care pathway including

a risk assessment/ care planning tool

 Development of a manual based on the

CANE

 Development of a training package

Survey 100 psychiatric

admissions

 Across 4 main study sites (NELMHT, Hull,

Manchester, Reading)

 Identify:

- Range of admissions

- Number of reasons for admissions

- Possible alternatives for admissions

- Time of admissions

 Depth analysis of cases and multidisciplinary

expert panel

What we’ll do

 Field testing of 100 people with dementia

identify as being at risk

 Development of a revised HTP

 Exploratory trial in CMHT in four centres

comparing HTP with TAU for 160 people

with dementia.

 National multicentre RCT of HTP in

dementia.

RCT HTO vs. UC

 Multicentre (4 main sites)

 Referred for home treatment because of high/very

high risk of requiring institutional/ hospital

admission

 Measures at 3/6/12 months

 Measures:

• CANE

• Number of psychiatric/ hospital admissions

• Number of Inpatient bed days

• QoL -AD

SHIELD Research questions



• How can we make services more clinically

effective/efficient?

• What is the best way to support community

services/reduce admissions?

• What will work best for patients/carers and

referrers?

• How can we improve quality of life and

satisfaction and reduce unmet needs?