Objective To identify common difficult decisions made by family carers on behalf of people with dementia, and facilitators of and barriers to such decisions, in order to produce information for family carers about overcoming barriers.Design Qualitative study to delineate decision areas through focus groups and complexity of decision making in individual interviews. Setting Community settings in London.Participants 43 family carers of people with dementia in focus groups and 46 carers who had already made such decisions in individual interviews.Results Family carers identified five core problematic areas of decision making: accessing dementia related health and social services; care homes; legal-financial matters; non-dementia related health care; and making plans for the person with dementia if the carer became too ill to care for them. They highlighted the difficulties in making proxy decisions, especially against active resistance, and their altered role of patient manager while still a family member. Families devised strategies to gain agreement in order to ensure that the person with dementia retained dignity. ConclusionsThe following strategies helped with implementation of decisions: introducing change slowly; organising legal changes for the carer as well as the patient; involving a professional to persuade the patient to accept services; and emphasising that services optimised, not impeded, independence. To access services, carers made patients' general practice appointments, accompanied them to the surgery, pointed out symptoms, gained permission to receive confidential information, asked for referral to specialist services, and used professionals' authority to gain patients' agreement. End of life decisions were particularly difficult. They were helped by knowledge of the person with dementia's previous views, clear prognostic information, and family support. Information sheets to help carers to overcome barriers to proxy decision making have been developed; their impact in practice has yet to be evaluated.

Primary cultures of rabbit-kidney epithelial cells derived from purified proximal tubules were maintained without fibroblast overgrowth in a hormone-supplemented serumfree medium (Medium RK-1). A hormone-deletion study indicated that the primary cultures derived from purified rabbit proximal tubules required all of the three supplements in Medium RK-1 (insulin, transferrin, and hydrocortisone) for optimal growth but did not grow in response to EGF and Ta. In contrast, the epithelial cells in primary cultures derived from an unpurified preparation of rabbit kidney tubules and glomeruli grew in response to EGF and Ta, as well as insulin, transferrin, and hydrocortisone. These observations suggest that kidney epithelial cells derived from different segments of the nephron grow differently in response to hormones and growth factors.Differentiated functions of the primary cultures derived from proximal tubules were examined. Multicellular domes were observed, indicative of transepithelial solute transport by the monolayers. The proximal tubule cultures also accumulated a-methylglucoside (a-MG) against a concentration gradient. However, little or no a-MG accumulation was observed in the absence of Na ÷. Metabolic inhibitor studies also indicated that a-MG uptake by the primaries is an energy-dependent process, and depends upon the activity of the Na+/K ÷ ATPase. Phlorizin at 0.1 mM significantly inhibited 1 mM c~-MG uptake whereas 0.1 mM phloretin did not have a significant inhibitory effect. Similar observations have been made concerning the Na+-dependent sugar-transport system located on the lumenal side of the proximal tubule, whereas the Na÷-independent sugar transporter on the peritubular side is more sensitive to inhibition by phloretin than phlorizin. The cultures also exhibited PTH-sensitive cyclic AMP synthesis and brush-border enzymes typical of proximal cells. However, the activities of the enzymes leucine aminopeptidase, alkaline phosphatase, and y-glutamyl-transpeptidase were lower in the cultures than in purified proximal-tubule preparations from which they are derived.Primary kidney-cell culture is valuable for studying renal functions in vitro (1). Although several established kidney-ceU lines have been used to study the mechanism of transepithelial solute transport by the kidney (2, 3,4,5,6), investigations using such cell lines have several limitations. First, the available cell lines may 0nly resemble particular kidney-cell types to a limited extent. Secondly, only a limited number of established kidney-ceU lines are available for study. Consequently, culture systems are also needed that closely resemble cells in a number of nephron segments (7). Primary kidney-cell culture provides an excellent means to resolve these problems (8).Previous studies with primary-kidney cultures have been, however, impeded by the presence of serum in the tissueculture medium (9). The transporting epithelial cells in primary-kidney cultures maintained in serum-supplemented medium, have been overgrown by fibrobl...

BackgroundAgitation is reportedly the most common neuropsychiatric symptom in care home residents with dementia.AimsTo report, in a large care home survey, prevalence and determinants of agitation in residents with dementia.MethodWe interviewed staff from 86 care homes between 13 January 2014 and 12 November 2015 about residents with dementia with respect to agitation (Cohen-Mansfield Agitation Inventory (CMAI)), quality of life (DEMQOL-proxy) and dementia severity (Clinical Dementia Rating). We also interviewed residents and their relatives. We used random effects models adjusted for resident age, gender, dementia severity and care home type with CMAI as a continuous score.ResultsOut of 3053 (86.2%) residents who had dementia, 1489 (52.7%) eligible residents participated. Fifteen per cent of residents with very mild dementia had clinically significant agitation compared with 33% with mild (odds ratios (ORs)=4.49 95% confidence interval (CI)=2.30) and 45% with moderate or severe dementia (OR=6.95 95% CI=3.63, 13.31 and OR=6.23 95% CI=3.25, 11.94, respectively). More agitation was associated with lower quality of life (regression coefficient (rc)=−0.53; 95% CI=−0.61, −0.46) but not with staffing or resident ratio (rc=0.03; 95% CI=−0.04, 0.11), level of residents’ engagement in home activities (rc=3.21; 95% CI=−0.82, 7.21) or family visit numbers (rc=−0.03; 95% CI=−0.15, 0.08). It was correlated with antipsychotic use (rc=6.45; 95% CI=3.98, 8.91).ConclusionsCare home residents with dementia and agitation have lower quality of life. More staffing time and activities as currently provided are not associated with lower agitation levels. New approaches to develop staff skills in understanding and responding to the underlying reasons for individual resident’s agitation require development and testing.Declaration of interestNone.Copyright and usage© The Royal College of Psychiatrists 2017. This is an open access article distributed under the terms of the Creative Commons Non-Commercial, No Derivatives (CC BY-NC-ND) license.

BackgroundThere are widespread concerns about abuse of care home residents. We report, in the largest care home survey, prevalence of staff anonymously-reported, perpetrated/witnessed abusive behaviours towards care home residents over 3 months. We also report positive care behaviours.Methods1544 staff in 92 English care home units completed the revised Modified Conflict Tactics Scale and Maslach Burnout Inventory.OutcomesMost staff reported positive care behaviours, but specific person-centred activities were sometimes infrequent. Many care home staff were never or almost never aware of a resident being taken out of the home for their enjoyment (34%, n = 520); or an activity planned around a resident’s interests (15%, n = 234). 763 (51%; 95% Confidence Interval (CI) 47% to 54%) of care home staff reported carrying out or observing potentially abusive or neglectful behaviours at least sometimes in the preceding 3 months; some abuse was reported as happening “at least sometimes” in 91/92 care homes. Neglect was most frequently reported: making a resident wait for care (n = 399, 26%), avoiding a resident with challenging behaviour (n = 391, 25%), giving residents insufficient time for food (n = 297, 19%), and taking insufficient care when moving residents (n = 169, 11%). 1.1% of staff reported physical and 5% verbal abuse. More staff reported abusive/neglectful behaviour in homes with higher staff burnout-depersonalisation scores (adjusted odds ratio 1.191, CI 1.052–1.349).InterpretationStaff anonymous reports of abusive behaviour and neglect could be used to monitor care quality, as cases currently reported are probably tip of the iceberg, and be an outcome in intervention studies.

Lack of resources, especially care worker time and knowledge about managing challenging behavior and dementia were judged to underlie much of the abuse described. We describe the first instrument designed to measure abuse by care home workers anonymously; field-testing is the logical next step.