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The second in a new series about mental health in old age, this article reviews policies and research evidence on services for people with dementia at the end of their lives, and looks at future commissioning priorities

Older people with dementia living in the community are most likely to be cared for by other older people, predominantly spouses, who will be at increased risk of stress‐related health problems themselves. Appropriate support of such carers is crucial if carer breakdown and consequent care‐receiver admission to residential homes is to be avoided. This paper examines the experience of older carers of frail older people with dementia and examines the kind of support that is provided to such carers. In practice, the sole source of professional support received by older people in this study was from community psychiatric nurses (CPNs). CPNs' role did not comprise hands‐on care‐giving and family carers carried out most personal/physical and healthcare tasks themselves, aided in some cases by care workers. The paper concludes by suggesting that lack of support for carers in these activities requires redress.

Design for dementia has, to date, focused on the internal, generally institutional environment of care homes and dementia care facilities. Yet the majority of older people with dementia live at home, around one third of these on their own. Unless outdoor environments are designed to help older people with dementia continue to use their local neighbourhoods they will become effectively housebound. This paper presents the findings of a three‐year research project conducted by the WISE (Wellbeing in Sustainable Environments) research unit of the Oxford Institute for Sustainable Development at Oxford Brookes University. The researchers were funded by the EPSRC EQUAL initiative to examine how the outside environment could be made dementia friendly. This unprecedented research investigated the perceptions, experiences and use of the outdoor environment by older people with dementia and identified design factors that influence their ability to successfully use and negotiate their local neighbourhoods. The research found that dementia‐friendly outdoor environments are places that are familiar, legible, distinctive, accessible, comfortable and safe. The findings have enabled the researchers to provide some preliminary recommendations for designers, at all scales from urban design to the design of street furniture, on the criteria to consider in developing dementia‐friendly urban areas.

Services for people with dementia in the UK have developed piecemeal in the context of wider agency agendas. Health and social care agencies located in rural areas face particular challenges if they are to be able to support people with dementia within their communities. This article describes a piece of work carried out in three rural counties in East Anglia designed to map services across the statutory, voluntary and private sectors, and to describe the ways in which national policy is being interpreted to meet local need. Examples of innovative practice, as well as gaps in service design and delivery, were identified through an examination of local policy documents and qualitative interviews with strategic managers, frontline managers and practitioners, and local carers of people with dementia. The findings confirm that services for older people with dementia are under‐developed in comparison with services for older people generally, and in comparison with mental health services for working age adults. There are particular gaps with respect to rarer types of dementia, services for people with learning difficulties, and services for people from minority ethnic groups. Historically, a lack of strategic planning has meant that service development has been patchy and unco‐ordinated. Carers have been affected by a shortage of joined‐up information, high eligibility criteria and a change to short‐term working by practitioners. Nevertheless, the potential for developing community‐based and inclusive services for people with dementia is apparent, and the adaptability required of rural areas may, subject to further evaluation, provide a template for service development elsewhere.

2009 should be seen as the year for making real progress in the development of services for older people with dementia, as well as services for older people with other mental health problems. It is also likely to herald the beginning of major challenges to ensure that resources are available to support that development. In our first article, Toby Williamson reports on the publication of the national dementia strategy for England, together with other important developments and the challenges. He also describes some initiatives that have important links to dementia care and the future of mental health services for older people.

The purpose of this paper is to use an assessment sheet clarifying the characteristics related to adaptation in order to support the relocation of older people to recovery phase rehabilitation wards (RPRW).

A survey was conducted with older people aged 70 and above two weeks after relocation. Nurses responsible for the older people were asked to complete the sheet. Of the 44 items on the sheet, the 38 items not directly related to basic attributes constituted the scale of the state of adaptation. A total of 336 valid response sheets were analyzed.

Higher scores on the scale represented higher levels of adaptation, and when scores were analyzed, results showed that there was a tendency for the scores of older people aged 80 and above and older people with dementia to be significantly lower. Items that showed differences according to the presence of dementia included those showing adaptive tasks, such as “Condition has deteriorated since the time of relocation” and “Experiencing difficulties when nurses are giving care.” The tendencies of older people to adapt to relocation depending on the presence of dementia were clarified through the items on the scale.

It is necessary to pay attention to older people's physical and social environmental factors, adaptive tasks, and coping skills when they relocate to RPRW. The authors suggest that an approach based on the results of this study could help older people adapt to their new environment.

The purpose of this paper is to outline learning and good practice across Europe on the deployment of asset based approaches for promoting active ageing and intergenerational solidarity.

The paper draws on a wide ranging review of good practice across Europe distilled from desktop analysis and two European roundtable sessions with key stakeholders.

The paper analyses the current level of volunteering by older people across Europe and the evidence for its benefits to the health and wellbeing of older people. It then goes on to provide analysis and good practice regarding area and individual based asset approaches, as well those relevant to addressing the social exclusion faced by people with dementia.

The analysis and good practice examples in the report provide resources for developing effective asset based approaches to promoting active ageing and intergenerational solidarity.

The review of European experience is particularly original. There has been little if any European review of asset based approaches to active ageing and intergenerational solidarity. Learning from practice elsewhere enables more confident initiatives to be taken up and developed.

The social exclusion of people with dementia is a problem. Older men with dementia in nursing homes are at considerable risk of social exclusion due to factors associated with age, gender, mental health status and this setting. It is not known whether older men in this situation experience it as social exclusion or not. Drawing on a detailed case study from a male participant involved in a larger study on social exclusion, this paper highlights and explores masculine experiences of, and responses to, nursing home life. In this single case study it was found that social exclusion was experienced in an economic, spatial and emotional sense, and the participant aligned himself with other men in the home and masculine behaviours, perhaps to deal with that. Implications for care home practice and research are discussed. The paper concludes that more attention needs to be paid to the influence of gender and, in particular, to the different needs and experiences of older men with dementia in receipt of care generally.

The purpose of this paper is to evaluate the impact of an bilaterally asymmetric gymnastics-based exercise programme on older people participating in a care home and day centre setting.

The research design comprised a small-scale pilot in two care homes and one day care centre in Cambridgeshire, England. The research was a qualitative evaluation that included observing sessions delivered; interviews with older people participating, their spouses, family members and friends; interviews with staff; and a review of the diary of each session written by the person delivering the exercise programme.

Older people participating in the programme showed a demonstrable improvement with aspects of their physical, emotional and cognitive ability. Older people with mild to advanced forms of dementia appeared to benefit most. The sessions were enjoyable and a real bond developed between the older people.

Future research will benefit from understanding whether the observed improvements are reflected in objective measures. The inclusion of a comparison group will be important to further add to the belief that the observed changes are caused by the programme. The inclusion of a large sample size covering different geographic areas will be needed to test more widely the viability of this programme.

This research is the first to investigate the impact of an asymmetric gymnastics-based exercise programme on older people, with varying levels of dementia, in a care home and day centre setting.

This article explores the benefits of green exercise and open spaces for people living with dementia. These benefits are set within the existing general evidence base concerning well‐being and connection with nature. The scale of the social, economic and demographic challenges are outlined to enable potential opportunities to be identified. The benefits of green exercise, contact and connection with nature and open spaces for people with dementia and the current research gaps are identified. A case study of Dementia Adventure is highlighted, as are implications for practice.