Dr Ramin Nilforooshan
Academic and research departmentsFaculty of Health and Medical Sciences.
Objectives Traditional healthcare education, delivered through a series of time-limited clinical placements, often fails to deliver an understanding of the experiences of those with long-term conditions, a growing issue for healthcare systems. Responses include longitudinal integrated clerkships and senior mentor programmes allowing students' longer placements, continuity of contact and opportunities to learn about chronic illness and patient experience. We review their development and delivery in dementia and present the Time for Dementia (TFD) Programme, a novel 2-year interdisciplinary educational programme.
Design The study design involves a scoping review of enhanced placements in dementia for healthcare professionals in training including longitudinal integrated clerkships and senior mentor programmes and a case study of the development of TFD and its evaluation.
Results Eight enhanced programmes in dementia were identified and seven in the USA. None were compulsory and all lasted 12 months. All reported positive impact from case study designs but data quality was weak. Building on these, TFD was developed in partnership between the Alzheimer's Society, universities and NHS and made a core part of the curriculum for medical, nursing and paramedic students. Students visit a person with dementia and their family in pairs for 2 h every 3 months for 2 years. They follow a semi-structured interaction guide focusing on experiences of illness and services and complete reflective appraisals.
Conclusions We need interprofessional undergraduate healthcare education that enables future healthcare professionals to be able to understand and manage the people with the long-term conditions who current systems often fail. TFD is designed to help address this need.
Early or timely recognition of dementia is a key policy goal of the National Dementia Strategy. However, older people who are homeless are not considered in this policy and practice imperative, despite their high risk of developing dementia.
Objectives and study design
This 24-month study was designed to (1) determine the prevalence of memory problems among hostel-dwelling homeless older people and the extent to which staff are aware of these problems; (2) identify help and support received, current care and support pathways; (3) explore quality of life among older homeless people with memory problems; (4) investigate service costs for older homeless people with memory problems, compared with services costs for those without; and (5) identify unmet needs or gaps in services.
Following two literature reviews to help study development, we recruited eight hostels ? four in London and four in North England. From these, we first interviewed 62 older homeless people, exploring current health, lifestyle and memory. Memory assessment was also conducted with these participants. Of these participants, 47 were included in the case study groups ? 23 had ?memory problems?, 17 had ?no memory problems? and 7 were ?borderline?. We interviewed 43 hostel staff who were participants? key workers. We went back 3 and 6 months later to ask further about residents? support, service costs and any unmet needs.
Overall, the general system of memory assessment for this group was found to be difficult to access and not patient-centred. Older people living in hostels are likely to have several long-term conditions including mental health needs, which remain largely unacknowledged. Participants frequently reported experiences of declining abilities and hostel staff were often undertaking substantial care for residents.
The hostels that were accessed were mainly in urban areas, and the needs of homeless people in rural areas were not specifically captured. For many residents, we were unable to access NHS data. Many hostel staff referred to this study as ?dementia? focused when introducing it to residents, which may have deterred recruitment.
To the best of our knowledge, no other study and no policy acknowledges hostels as ?dementia communities? or questions the appropriateness of hostel accommodation for people with dementia. Given the declining number of hostels in England, the limits of NHS engagement with this sector and growing homelessness, this group of people with dementia are under-recognised and excluded from other initiatives.
A longitudinal study could follow hostel dwellers and outcomes. Ways of improving clinical assessment, record-keeping and treatment could be investigated. A dementia diagnosis could trigger sustained care co-ordination for this vulnerable group.
RATIONALE: Paper spray offers a rapid screening test without the need for sample preparation. The incomplete extraction of paper spray allows for further testing using more robust, selective and sensitive techniques such as liquid chromatography mass spectrometry (LC-MS). Here we develop a two-step process of paper spray followed by LC-MS to (1) rapidly screen a large number of samples and (2) confirm any disputed results. This demonstrates the applicability for testing medication adherence from a fingerprint.
METHODS: Following paper spray analysis, drugs of abuse samples were analysed using LC-MS. All analyses were completed using a Q Exactive" Plus Orbitrap" mass spectrometer. This two-step procedure was applied to fingerprints collected from patients on a maintained dose of the antipsychotic drug quetiapine.
RESULTS: The extraction efficiency of paper spray for two drugs of abuse and metabolites was found to be between 15-35% (analyte dependent). For short acquisition times, the extraction efficiency was found to vary between replicates by less than 30%, enabling subsequent analysis by LC-MS. This two-step process was then applied to fingerprints collected from two patients taking the antipsychotic drug quetiapine, which demonstrates how a negative screening result from paper spray can be resolved using LC-MS.
CONCLUSIONS: We have shown for the first time the sequential analysis of the same sample using paper spray and LC-MS, as well as the detection of an antipsychotic drug from a fingerprint. We propose that this workflow may also be applied to any type of sample compatible with paper spray, and will be especially convenient where only one sample is available for analysis.