Current and past research projects in the area of Older People's Health

We are working on a range of research projects in the area of Older People's Health.

Click on the project titles below to find out more about the research and the staff involved in each project:

Better health for care homes
Optimal NHS service delivery to care homes: a realist evaluation of the features and mechanisms that support effective working for the continuing care of older people in residential settings (The Optimal Study)
Researchers from the University of Hertfordshire, undertook a research project looking at the way in which the delivery of existing NHS services to care homes can be optimised. This study, which uses a research approach called realist evaluation, was funded by the National Institute for Health Research.
Twelve care homes across three areas in England took part in the study. The locations were selected for the different ways healthcare was delivered to care homes.
The study found four key factors for supporting effective working between healthcare services and care home staff:
1. investment in care home-specific work that legitimises and values work with care homes;
2. relational working which over time builds trust between practitioners;
3. care which ‘wraps around’ care homes;
4. access to specialist care for older people with dementia.
Where there were opportunities and interest from healthcare staff and care home staff to work together, this supported optimal healthcare provision in care homes.

View the summary of the project findings
Collaboration with: University of Nottingham
University of Hertfordshire staff:
- Professor Claire Goodman
- Sue Davis
- Dr Melanie Handley
Contact
Professor Claire Goodman
Changing practice in end of life care
Changing practice in dementia care in the community: developing and testing evidence-based interventions from timely diagnosis to end of life (EVIDEM- EOL)
It is often difficult for care home staff, family members and visiting health professions to know when a person with dementia is nearing ‘end-of-life’. EVIDEM EoL was a four-year study, carried out in two phases that aimed to understand the dying trajectory for this group and test a context sensitive end of life care intervention for people dying with and from dementia. The study recruited 133 older people with dementia from six care homes.
Phase one included tracking of care received by participants over an 18 month period, a medication review and an economic evaluation.
In Phase two a co-design approach (Appreciative Inquiry- AI) was used with three of the care homes to address Phase one findings about what was likely to support integrated working between care home and visiting health care staff. The intervention built on existing relationships, strengths and achievements and, when appropriate, end-of-life care tools and frameworks. AI was the impetus for care home and NHS staff to plan and implement change in how they could negotiate uncertainty across organisations and between practitioners.
The study found that end-of-life care for people with dementia was characterised by three types of uncertainty. These were:
1. pathway uncertainty related to difficulties with prognostication and knowing how to interpret and manage key events and symptoms,
2. relational uncertainty related to roles, responsibilities and relationships among all those involved in end-of-life care,
3. service uncertainty which emerged when it was unclear if services had the capacity or expertise to provide end-of-life care to people with dementia.
See End of life care interventions for people with dementia in care homes: addressing uncertainty within a framework for service delivery and evaluation. The intervention supported a shift in care home culture that could mitigate uncertainties inherent to end-of life care of older people with dementia and embed different ways of working between NHS and care home staff.
In conclusion
Even with access to end-of-life care tools, there was a need for participants to find ways of working together to review and “hold” the different types of uncertainty encountered when providing end of life care to people dying with and from dementia. The AI intervention provided an approach that could be incorporated into the everyday routines and meetings of the care home.
CRIPACC Research team:
- EVIDEM-EOL
- Professor Claire Goodman
- Sarah Amador
- Dr Elspeth Mathie
Full Report
Changing practice in dementia care in the community: developing and testing evidence-based interventions, from timely diagnosis to end of life (EVIDEM)
Links to papers
Older People's Health
Communities of practice for Dementia Champions
Creating a Community of Practice for Dementia Champions
The expected rise in numbers of people living with dementia requires a joined up, system wide approach to dementia care across health and social care services. Dementia Champions are seen as playing a key role in the transfer and dissemination of knowledge within and across agencies, but such roles are variously defined. Some organisations define all health care professionals as Dementia Champions, whereas others identify key clinicians or create salaried posts designated to lead on dementia linked activities within an organisation.
This study, funded by Health Education East of England, aimed to support the process of establishing and implementing a variety of Dementia Champion roles in the East of England. It involved creating a shared focus for Dementia Champions, addressing their training and development needs, and creating an infrastructure that can support the achievement of dementia strategy linked implementation targets (including the Commissioning for Quality and Innovation Payment Framework) across Hertfordshire NHS and Local Authority providers.
The development and implementation of the newly created role of Dementia Champions, requires an infrastructure through which to implement strategies that support Dementia Champion roles in relation to agreed job descriptions and programmes of education and training. For such initiatives to be sustainable they need to be strategically placed within networks that can bring together service providers, educators and commissioners.
University of Hertfordshire staff
- Professor Claire Goodman
- Dr Andrea Mayrhofer
- Dr Cheryl Holman
- Mr Nigel Smeeton
Contact
Dr Andrea Mayrhofer
Community engagement for people living with dementia
How we mobilise our communities into action to improve life for people affected by dementia is a key policy priority.
Researchers from the University of Hertfordshire worked with the Alzheimer’s Society, to identify how initiatives to promote community engagement can ensure that people living with dementia feel understood, valued and able to contribute to their community.
The aim of the study was to understand how community engagement (CE) for people affected by dementia is perceived to work, how this is expressed in different CE activities and how the impact of these initiatives is measured.
We used a research approach called realist synthesis to examine approaches to CE both in the UK and globally.
The study identified four key factors for CE
1. A language of inclusion
2. A clear identify for people living with dementia that is separate from those who provide support and care
3. An expectation that the person with dementia should and could participate and that their contribution is valued
4. Space, time and support for people to articulate their views and choices
For more information: Community Engagement Evidence Synthesis: a final report for Alzheimer's Society
CRIPACC staff:
- Professor Claire Goodman
- Professor Frances Bunn
- Dr Marina Buswell
- Bridget Russell
Contact
Professor Claire Goodman
Comorbidity and dementia
Research shows poorer access to health care for people living with dementia and comorbid health conditions
Researchers in CRIPACC have published a report exploring how having dementia alongside a long-term condition, such as diabetes, stroke or vision impairment affects access to care.
The study, funded by the National Institute for Health Research Health Services and Delivery Research Programme, found that people living with dementia may have poorer access to health services than those without dementia. Although family carers often play a significant part in managing and coordinating care, current systems are not designed to involve them in decision-making. In addition, there is a lack of guidance for health care professionals when they are making decisions about care.
Professor Frances Bunn who led the study said ‘whilst we know that the prevalence of comorbidity amongst people with dementia is high our findings suggest that there is currently little planning or provision for the way a diagnosis of dementia impacts on the management of existing long-term conditions such as diabetes. The authors conclude that services need to rethink the organisation of care for people living with dementia and comorbidity; including routine involvement of family carers and sensitivity to the changing needs of people living with dementia and their family carers.
YouTube video: Improving healthcare for people with dementia and comorbidity (CoDem study)
Read the full report here: Comorbidity and dementia: a mixed method study on improving health care for people with dementia (CoDem)
Read more about the findings from the qualitative study here: Healthcare organisation and delivery for people with dementia and comorbidity: a qualitative study exploring the views of patients, carers and professionals
CRIPACC staff:
- Professor Frances Bunn
- Professor Claire Goodman
- Dr Anne Marie Burn
Contact:
Professor Frances Bunn | Follow Frances Bunn on Twitter
Dementia education and training
Dementia Education and Training in Hertfordshire and Bedfordshire: An organisational audit
People living with dementia may require care in a variety of settings including at home, in care homes and in hospitals. This has implications for the current and future workforce in health and social care. To inform regional workforce development planning in dementia care, Health Education East of England commissioned the University of Hertfordshire to conduct an organisational audit of current dementia training at NHS Trusts, and in social care, across Hertfordshire and Bedfordshire.
The audit included NHS Trusts, local authorities, clinical commissioning groups, and health and social care organisations involved in commissioning and providing dementia education and training in the two counties. Results of the audit show that whilst there was considerable investment in dementia awareness training, learning was not targeted, assessed or structured to ensure on-going professional development. This has implications for workforce development and career-progression for staff responsible for the care of older people with dementia. The authors conclude that if a future workforce is expected to lead, coordinate, support and provide dementia care across health and social care, accreditation of learning could play a critical part in ensuring quality and consistency of approach and provision. This study makes a timely contribution to discussions on the skills and competencies needed to equip the future workforce for dementia care across health and social care.
Funded by
Health Education East of England
University of Hertfordshire staff
- Professor Claire Goodman
- Dr Andrea Mayrhofer
- Ms Rachel Sharpe
- Ms Helen Dye
Contact:
Dr Andrea Mayrhofer
Falls in mental health settings
Falls in acute mental health settings caring for older people
Researchers in CRIPACC worked with colleagues from Oxford Health NHS Foundation Trust and Brunel University have recently completed a study exploring how fall risk, prevention and management is understood and experienced in everyday practice by patients, family carers and staff, in inpatient mental health settings providing care for older people.
The study, funded by the National Institute for Health Research, Research for Patient Benefit, found that of patients experiencing a fall, almost half had a mental health problem other than dementia. We found most falls were in bedrooms (42%), and only 27% were directly observed by staff. Fall patterns were influenced by ward routines.
Dr Angela Dickinson who led the study said ‘despite falls being the main patient safety concern for older people being cared for in mental health settings, this is the first study to explore falls in these settings. For those experiencing falls we found many had diagnoses of both physical and mental health conditions and staff found balancing patient independence and risk of falling challenging’. The authors explained that understanding the patterns of falls could help in planning care and staffing levels in order to reduce falls, but patterns are specific to each clinical setting. Staff have to balance the risk of falls due to patient’s fluctuating mental health condition and physical health (and associated polypharmacy) with maintaining function and independence.
More information
- Falling in Acute Mental Health Settings for Older People: Who falls, where, when and why?
- Preventing falls among older people with mental health problems: a systematic review
Research staff:
Dr Angela Dickinson
- Dr Charles Simpson
Contact
Dr Angela Dickinson | Follow Angela Dickinson on Twitter
Integrated working between primary
A study to develop integrated working between primary health care services and care homes (Approach)
Older people in care homes have their everyday care and support needs met by care home staff, but often need access to a range of health care services. It is thought that closer integration between health care services and care homes will help to reduce inefficiency, improve residents’ quality of life and control costs. The aim of this study was to establish how care homes and health care services achieve integrated working to promote the health of older people.
The study included a systematic review of integrated working between health services and care homes, a national survey with 195 English care homes to establish current practice and a case study involving six care homes in three geographical regions.
Key findings
- Multiple NHS services visit care homes. These include initiatives to improve access to health care, reduce unplanned hospital admissions and work with care homes as providers of intermediate and end of life care. Models of service delivery to care homes however, are erratic, ill-defined and focus almost exclusively on the individual resident/patient encounter.
- Care home residents do not have universally high levels of health service use or uniformly close involvement of primary care staff.
- Financial incentives, governance processes or the use of shared protocols and assessments supported integrated working only when care home staff assimilated NHS priorities and patterns of working.
- There is a need to adjust patterns of working in the care home to ensure that health care is not ‘delivered’ to individuals in care homes but organised to support the facilitation of care delivery, review and discussion of residents’ priorities and preoccupations, with the older person, their preferred representatives and care home staff.
Conclusion
There is not a particular model of health care provision that supports integrated working with care homes. There is a tension when NHS services favour models of care that focus on diagnosis treatment and episodic involvement whilst care home providers prioritise support and relationships that foster a continuous review.
Contact
Professor Claire Goodman | Follow Claire Goodman on Twitter
Managing behaviour changes in people with dementia
Strategies for managing behavioural and psychological symptoms in dementia (BPSD) for community dwelling older people: Evidence into practice
Researchers from the University of Hertfordshire, University College London, King’s College London, University of Surrey and Hertfordshire Partnership University NHS Foundation Trust have recently completed a research project around the management of BPSD for people with dementia and their carers living at home. Many experience distressing symptoms such as aggression, wandering, agitation, emotional problems, known as behavioural and psychological symptoms of dementia which result in poor outcomes for both people with dementia and their carers.
The project, funded by the National Institute for Health Research, Research for Patient Benefit was an integrated review in collaboration with users and practitioners through stakeholder events. It synthesised research evidence on management of BPSD that supports people with dementia living at home and their carers as well as the evidence around views and experiences of carers in managing these symptoms.
Dr Daksha Trivedi who led the study said “whilst carers report that BPSD has a huge impact on the person with dementia and carer strain, there is currently little support on identifying these symptoms early and clear signposting for appropriate services.’ The findings suggest that accessible and appropriate training and education programmes for carers to help people with dementia needing care, including identifying triggers before symptoms become worse and carers reach a ‘tipping point’ would be helpful. Involvement of carers, person with dementia and professionals is important throughout the trajectory in meeting needs as symptoms change.
Funded by: NIHR Research for Patient Benefit (RfPB)
University of Hertfordshire staff:
- Dr Daksha Trivedi
- Professor Claire Goodman
- Dr Angela Dickinson
- Dr Andreas Braun
Collaborators:
- Professor Steve Iliffe, University College London
- Dr Ashaye Kunle, Hertfordshire Partnership NHS Foundation Trust
- Professor Heather Gage, University of Surrey
- Professor Jill Manthorpe, King’s College London
Contact
Dr Daksha Trivedi
Managing diabetes in people with dementia
Researchers looked at how to support people living with dementia and diabetes
Researchers from the University of Hertfordshire, Bangor University and University College London have completed a research project looking at how health and social care services can support people who are living with both dementia and diabetes. The study, which uses a research approach called realist synthesis, was funded by the National Institute for Health Research, Health Technology Assessment Programme.
The full report can be found here: Managing diabetes in people with dementia: a realistic review
Dementia and diabetes
Dementia and diabetes are both common in older people and many people may be living with both conditions. People living with dementia can find it more difficult to manage their diabetes. They are at increased risk of diabetes-related problems such as low blood sugar. Family members often help them to manage their diabetes.
In this study, evidence about the management of diabetes in people living with dementia was reviewed to find out what might work, how, why and in what contexts.
Professor Frances Bunn who led the study said ‘the findings from our study indicate that services for people living with dementia and diabetes should prioritise quality of life, independence and patient and carer priorities over a more biomedical target-driven approach”
Funded by
NIHR HTA
Research staff:
- Professor Frances Bunn
- Professor Claire Goodman
- Dr Daksha Trivedi
- Ms Bridget Russell
More information
- Managing diabetes in people with dementia: a realist synthesis (DIaMonD)
- Managing diabetes in people with dementia: protocol for a realist review
Contact
Professor Frances Bunn | Follow Frances Bunn on Twitter
Managing faecal incontinence in people with dementia
Managing Faecal Incontinence in people with advanced dementia resident in Care Homes (FINCH study)
View the HTA project page
Managing Faecal Incontinence in people with advanced dementia resident in Care Homes (FINCH study)
A third of people living with dementia are care home residents, many of whom experience faecal incontinence (FI). A study funded by the National Institute of Health Research, and led by Professor Goodman at the University of Hertfordshire, had looked at ways to improve continence care for people with dementia living in care homes. The study, which used an evidence review method called realist synthesis.
The review found that, as the majority of care home residents with FI also have urinary incontinence, there is limited value in focusing only on FI or one possible cause of FI such as constipation. Additionally, much research into incontinence in care homes has not considered how living with dementia specifically affects continence and a person’s ability to benefit from particular interventions.
Findings highlight how staff knowledge, support for person centred approaches to care and clinician involvement in assessing and diagnosing possible causes of FI are important in preventing and managing FI. A key factor, is how staff can act on their knowledge and training and whether an intervention “fits” with the everyday work of a care home. Valuing the intimate and personal care work that care home staff provide to people living with dementia, and the recognition of the challenges that arise when providing continence care is important. This needs to be prioritised within the organisation, supported with clinician input and be incorporated into future research designs and practice development.
More information
- Managing Faecal Incontinence in people with advanced dementia resident in Care Homes (FINCH study)
- What Works to Improve and Manage Fecal Incontinence in Care Home Residents Living with Dementia? A Realistic Synthesis of the Evidence
CRIPACC Staff:
- Professor Claire Goodman
- Professor Frances Bunn
- Dr Marina Buswell
- Ms Bridget Russell
Contact
Professor Claire Goodman | Follow Claire Goodman on Twitter
Peer to peer end of life care education in care homes
Evaluation of the End-of-Life Care Train the Trainer Education Model
Care home residents have multiple health needs that are often complicated by the presence of dementia. This means that they rely on a range of health and social care staff as well as family members to provide care and make decisions on their behalf. End of Life (EoL) care training aims to ensure that older people can receive appropriate care within the care home.
This project, funded by Health Education East of England, evaluated an educational EoL care intervention in 17 care homes. The intervention used a blended learning approach (clinical facilitators, online teaching and small group work) to cascade knowledge and skills in EoL care to care home staff. The study found that the intervention impacted positively on relationships between care home staff, residents, family and clinical professionals. This was conceptualised as a reduction of relational uncertainty when discussing a residents’ wishes and preferences. The EoL care training programme was also perceived to have reduced pathway uncertainty, which refers to the ability of an EoL care intervention to recognise different dying trajectories and support decision making on treatment and symptom management. However, the programme had less impact on the coordination and management of the input of health and social care services.
The authors conclude that care homes without on-site nursing support should be targeted for training in End of Life Care ahead of care homes with on-site nursing.
Funded by
Health Education East of England
University of Hertfordshire staff:
- Professor Claire Goodman
- Dr Andrea Mayrhofer
- Mr Nigel Smeeton
- Dr Melanie Handley
- Dr Sarah Amador
- Ms Susan Davies
Related links
End of life care interventions for people with dementia in care homes: addressing uncertainty within a framework for service delivery and evaluation
Contact
Professor Claire Goodman | Follow Claire Goodman on Twitter
Psychosocial experiences of dementia diagnosis
An exploration of patient experiences around diagnosis and treatment of dementia: a systematic review and evaluation of implications for service development
This study was done to better understand the experiences and attitudes of patients and their carers surrounding dementia diagnosis. The researchers conducted a systematic search for published qualitative research studies that reported on the experience, beliefs, feelings, and attitudes surrounding dementia diagnosis. They identified and reviewed 102 such studies.
Key findings
The complexity and variety of responses to a diagnosis of dementia means that making the diagnosis and conveying it to patients and carers is challenging. Negative connotations associated with dementia, inconsistent symptoms, and not knowing enough about the signs and symptoms were commonly reported barriers to early diagnosis. It was often the carer who initiated the search for help from a doctor, and among patients, willingness and readiness to receive a diagnosis varied. Being told one had dementia had a big impact on a patient’s identity and often caused feelings of loss, anger, fear, and frustration. Spouses had to adjust to increasingly unequal relationships and the transition to a role as carer.
Adjusting to a dementia diagnosis is a complex process. Initially, most patients and carers experienced conflicts, for example, between autonomy and safety, between recognizing the need for help but reluctance to accept it, or between living in the present and dealing with anxiety about and preparing for the future. As these were resolved and as the disease progressed, the attitudes of patients and carers towards dementia often became more balanced and accepting. Many patients and their families adopted strategies to cope with the impact of dementia on their lives in order to manage the disease and maintain some sort of normal life. These included practical strategies involving reminders, social strategies such as relying on family support, and emotional strategies such as using humour.
The studies also pointed to an urgent need for support from outside the family, both right after diagnosis and subsequently. General practitioners and family physicians have important roles in helping patients and carers to get access to information, social and psychological support, and community care. The need for information was reported to be ongoing and varied, and meeting it required a variety of sources and formats.
Funded by
National Institute for Health Research (NIHR)
Research for Patient Benefit
More information
Visit PLOS Medicine: Psychosocial Factors That Shape Patient and Carer Experiences of Dementia Diagnosis and Treatment: A Systematic Review of Qualitative Studies
CRIPACC research team:
- Professor Frances Bunn
- Professor Claire Goodman
Contact
Professor Frances Bunn | Follow Frances Bunn on Twitter
Shared decision making
Supporting shared decision making for older people with multiple health and social care needs: a realist synthesis to inform emerging models of health and social care
Professor Frances Bunn from the University of Hertfordshire led a study looking at how we can improve the way we involve older people, and their family carers, in decisions about their health and social care. We call this approach shared decision making (SDM). In particular, we wanted to find out how SDM can work in community settings where many different health and social care workers (such as GPs, nurses, social carers) may be involved in caring for the older person.
The study, was funded by the National Institute for Health Research.
We used a research approach called realist synthesis. In realist synthesis the views of stakeholders (for example patients, carers, practitioners and policy makers) are very important in helping to guide the review process and as part of the review process we consulted with a wide range of experts.
A summary of the project finding can be found here: Support share decision making for older people with multiple health and social care needs: a realist synthesis to inform emerging models of health and social care
Research team:
- Professor Frances Bunn (University of Hertfordshire)
- Professor Claire Goodman (University of Hertfordshire)
- Dr Paul Millac (University of Hertfordshire)
- Dr Isabel Hodkinson (Tower Hamlets CCG)
- Professor Jill Manthorpe (Kings College London)
- Dr Greta Rait (UCL)
- Professor Paricia Wilson, (University of Kent)
Funded by
National Institute for Health Research (NIHR), HS&DR
Contact
Professor Frances Bunn | Follow Frances Bunn on Twitter
Young onset dementia
Care pathways for individuals diagnosed with Young onset Dementia (YoD)
In the UK approximately 5% of people living with dementia have been diagnosed with young-onset dementia. This refers to people who are under the age of 65 when diagnosed. There is some evidence that their support needs are significantly different from those of people living with dementia who are older, and general dementia services for older people are not always suitable. However, there is not sufficient evidence in the literature to inform service design and delivery that is relevant to this group.
This study aims to answer questions around current availability, cost and effectiveness of services for people diagnosed with YoD. The project is informed by Public and Patient Involvement (PPI) and supported by the Alzheimer’s Society.
Funded by
CLAHRC East of England
Research staff at the University of Hertfordshire:
- Dr Andrea Mayrhofer
- Dr Elspeth Mathie
- Professor Claire Goodman
Collaborators
- Dr Jane McKeown, University of Sheffield and CLAHRC Yorkshire/Humber
- Lisa Irvine, UEA and CLAHRC East of England
- Dr M Walker, Hertfordshire Partnership University NHS Foundation Trust
Contact
Dr Andrea Mayrhofer
Dementia-friendly healthcare in hospitals
Understanding what supports hospital staff to provide dementia-friendly healthcare and with what outcomes for patients with dementia: A realist evaluation
There is a growing awareness among NHS Trusts and policymakers of the need to improve hospital care for people with dementia. However, there is limited understanding of how to achieve this. This study, funded by the Alzheimer’s Society, aimed to explain factors that influence the way staff use resources from interventions, such as training and This is me booklets, to modify their care for patients with dementia and how this impacts patient outcomes.
Using a research approach called realist evaluation, a literature review of current evidence and stakeholder views informed a theory of what works, for whom, in what circumstances. This theory was tested and refined from data collected in two case study sites in the East of England.
Six connected propositions set out the features that support hospital staff to provide dementia sensitive healthcare:
1. Staff have knowledge in dementia care and are able to use this to influence care activities appropriate to patient needs
2. Staff receive training that can be applied in their role and have access to ward-based development opportunities
3. Clinical experts and senior ward staff promote the use of care practices that are person-centred
4. Staff are supported to recognise and engage with opportunities for enhancing care when spending time with patients
5. Patient safety and risk management strategies are understood as an opportunity for promoting patient choice and person-centred care
6. Dementia care is valued as skilled work that is everyone’s responsibility
Going forward, addressing contextual factors in ways that will support ward staff to recognise dementia care as skilled work that is a fundamental part of their role could help embed best practices for dementia care in hospital settings.
For more information: Dementia-friendly interventions to improve the care of people living with dementia admitted to hospitals: a realist review
CRIPACC staff
Contact
Dr Melanie Handley | Follow Melanie Handley on Twitter
Dementia case-finding in acute hospitals
Dementia case-finding in acute hospitals
When someone aged 75 years or older is admitted into hospital as an emergency, it is government policy that there should be an assessment on their memory and the patient’s GP is informed of the results. This initiative (called dementia case-finding) aims to improve the recognition of dementia amongst older hospital patients so that earlier recognition may lead to timely treatment and enable better planning of appropriate care.
The CASCADE study has explored how hospitals are carrying out dementia case-finding and whether this initiative is working as planned. This is the first study to explore the views and experiences of healthcare professionals, patients and their carers regarding dementia case-finding to understand what impacts these assessments may have on patient care.
For more information:
Dementia case-finding in hospitals: a qualitative study exploring the views of healthcare professionals in English primary and secondary care
Collaboration with: University of Cambridge
Funded by: NIHR CLAHRC East of England
Contact:
Dr Anne-Marie Burn | Follow Anne-Marie Burn on Twitter