People living with dementia at home that draw on adult social care for support and commissioners in Bristol wanted to find out what helps people living with dementia to stay in their own homes. 

They wanted to know what services or what interventions might help people with dementia to improve their quality of life or their wellbeing. And they were also interested in what might help to prevent unwanted moves to a care home or admission to hospital.

So, we looked for relevant systematic reviews published since 2019. We also looked for guidance published by the National Institute for Health and Care Excellence, NICE. We excluded technology-enabled care for people with dementia, because ConnectED colleagues had recently looked at this. 

And we found eight systematic reviews. Three looked at a range of interventions for people with dementia and their carers, and three were focused specifically at support for carers. One review focused on what happens for people with dementia during a crisis, and another looked at support designed to prevent hospital or nursing home admission. And we also found one relevant NICE guideline. 

Just to comment on the quality of the evidence, the studies involved in these reviews looked at many different kinds of support, which weren't always clearly described, which makes comparisons difficult. 

Some of the studies had quite small numbers of people involved, or didn't contain enough information about their characteristics, particularly the stage of their dementia to be confident that their findings can be widely applied. 

The NICE guideline makes recommendations in the areas where the most robust evidence is available, and we'll talk about that further later.

So, what the evidence suggests. Just to define what we found in the evidence about care coordination, the literature defines it as, um, support which begins with a thorough assessment of the needs of the person with dementia and their carer. A tailored support plan is then created with the person, which may include a range of  interventions, including care at home or respite care, or helping people to get out into places they want to go to in the community. 

The coordinator supports the person with dementia and their carer by connecting health and social care services, and making changes in response to changes in the person's needs. 

And the evidence suggests that care coordination can improve the quality of life of people living at home with dementia, and that it can reduce the stress experienced by the carers. 

Combining care coordination with regular monitoring means practitioners can notice and respond promptly to new or changing needs, and this might prevent issues becoming a crisis. Because of that responsiveness, the likelihood of people moving to a care home is reduced, meaning that it is a cost-effective option for social care. 

The evidence also looks at occupational therapy interventions, which focus on promoting people's independence through the use of meaningful activities, as well as making changes to the environment.

The evidence suggests that these interventions support people with dementia to carry out everyday activities, and that this improves their quality of life.

Occupational therapists also work with carers to develop strategies to support people with dementia with everyday tasks, and to create a supportive home environment. 

As well as reducing their own feelings of stress, carers reported seeing fewer behavioural and psychological symptoms of dementia following occupational therapy support.

So, looking at what the evidence suggests about supporting carers. It's clear in the evidence that carers of people with dementia often experience really high levels of stress, and that they might be continually balancing their caring role, alongside looking after their own needs.

Carers value emotional support and practical help, including support to get out to the community and access resources and care services. 

Over time, the behavioural and psychological symptoms of dementia increase, and carers need support that responds to their changing role.

The evidence suggests that providing accessible information about what to expect as a person's dementia progresses, and exploring the emotional impact of these changes, referred to as psychoeducation, can reduce the risk of carers experiencing depression. 

Training carers on how to care for someone with dementia can increase their feelings of mastery, which is their sense of being skilled in their role as a carer. 

While support for carers has a positive effect on carer wellbeing and reduces their sense of burden, it only has a small effect on reducing the risk of the person with dementia moving into a care home. 

So, looking at those unwanted moves, we looked at evidence which talks about preventing moves in a crisis. A crisis means an event where there's seen to be a high risk of harm, needing an immediate intervention or change. Things like medical issues, significant changes in behaviour, and high levels of carer stress can trigger a crisis for people with dementia. 

Care coordination, including robust support to carers, timely access to medical treatment, and psychosocial support are key to preventing unplanned moves to a care home or hospital admission.

This relies on really good comprehensive community support services being available.

There is evidence that other interventions that aren't directly delivered or commissioned by adult social care can have positive outcomes for people with dementia. These include cognitive stimulation therapy, reminiscence therapy, and biobehavioural interventions. 

These interventions may improve the behavioural symptoms for people with dementia, or their functional abilities or mood, but they don't appear to have a significant effect on reducing the rate of people moving out of their homes. 

So, we also looked at what the guidance suggests, and the NICE guidance recommends that people with dementia should have a named health or social care professional who's responsible for coordinating their care. 

In order to promote independence and wellbeing, the guidance recommends people with dementia should be offered a range of tailored activities, group cognitive stimulation therapy, reminiscence therapy, and occupational therapy interventions.

The guidance suggests that carers of people with dementia should be offered psychoeducation, which includes education about the progression of dementia, skills training, and support with strategies for how to provide care, including how to respond to changes in behaviour. 

The guidance highlights that interventions for carers are most likely to be effective when they're provided as group sessions. 

So, what does all of this mean for practice? Current evidence doesn't suggest a single intervention to promote people's wellbeing and prevent or delay hospital or nursing home admission. 

People living with dementia and their carers need tailored, coordinated support, planned and delivered by people who understand dementia and its progression. 

The other recommendation we made is that social care commissioners should work with mental health colleagues to make sure that therapeutic support, including psychoeducation, is available to carers of people with dementia.