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Long-term improvements in dementia care were found in a new study. Care home staff reported benefits from a programme called MARQUE (Managing Agitation and Raising Quality of life) two years after it was introduced.

The MARQUE programme includes a range of techniques to help staff get to know residents' interests, address their agitation, and improve communication. In the original study, researchers introduced the programme into 10 care homes. 

In this study, researchers revisited 6 of the same care homes. They asked staff to look back at action plans they had drawn up two years earlier. The study found that all homes had continued with at least one intervention. Staff members felt their working lives and the culture of the home had improved as a result. Themes that emerged from interviews with staff were: improved communication, more respect for junior colleagues, and an increased willingness to try new strategies. They saw benefits both for themselves and for residents.

However, only one home was still using its full action plan. That may be because members of staff who were trained in MARQUE techniques had left. 

Many interventions have been designed to improve dementia care. But long-term assessments are rare. Most studies look at the effects of an intervention within a year. That may not be long enough to embed improvements in a care home’s culture.

This is a small study, but it suggests the MARQUE programme could be rolled out more widely.  

Further information about dementia and care homes can be found on the NHS website.

What’s the issue?

Half a million people with dementia are expected to be living in UK care homes by 2040. They have complex health and care needs. Despite this, care home staff often have little training. 

The MARQUE scheme includes training for staff in new techniques to manage agitation. Care home staff develop an action plan, based on strategies that have worked for them. Staff and the care home manager agree on the plan. 

MARQUE includes:

    • a game to get to know residents’ preferences and interests (Call-to-Mind)
    • a technique to investigate causes of residents’ agitation, propose solutions and record outcomes of those interventions (called Describe, Investigate, Create, Evaluate, or DICE)
    • a focus on introducing activities the residents enjoyed 
    • improved communication between staff
    • relaxation techniques for staff.

In the original study in 10 care homes, MARQUE improved residents’ quality of life in the short-term. It did not reduce agitation. The staff training cost money, but MARQUE reduced residents’ use of health services. Overall, it made savings and was considered cost-effective.  

The researchers wanted to know if these improvements were sustained long-term.

What’s new?

Two years after the original study, researchers revisited 6 of the same 10 care homes. They interviewed 25 staff in total, including carers, managers, nurses and activity coordinators.

They found that all homes were still using at least one of the MARQUE interventions. The game to get to know residents’ preferences (Call-to-Mind) was the most used intervention, and four of the six homes were still playing it.

But implementation of action plans was patchy; only one home was still using its full action plan. This was largely because of staff turnover; many staff members who were trained in the MARQUE technique had left. 

 Three main themes emerged from the interviews. 

  1. Communication

The action plan led to staff in all roles speaking at meetings and handovers. Staff still used the Call-to-Mind game to learn what residents enjoyed. And they continued to use MARQUE documents in training new staff. The DICE approach to addressing problems improved communication. It was used verbally and in written documents. In two homes, it was added to the electronic care planning system. 

One staff member said of DICE: "We don’t use it in the form manner, but we use it on a day-to-day really. It’s part and parcel of what we do."

2. Respect and understanding

Senior staff and external health and care workers respected the skill of junior colleagues, and had a better understanding of the challenges they faced. Staff were proud when they were able to reduce a resident’s distress. They understood that their role was not simply to keep residents safe but also to make life more pleasant. They planned more small activities, on top of the larger events run by activity coordinators. 

A manager said: "It was another level of respect for each other, some of the team members you just see them going, I didn’t know that they knew so much.. I’m like, oh really?"

3. Willingness to try new things

Staff reported that using the DICE technique allowed them to try new ways of dealing with situations. They did not feel they had failed if a strategy did not work; they could simply ‘throw the DICE again’. Leadership support was important, and lead staff could drive plans and keep up enthusiasm. 

Staff had come to see agitation not as the resident’s fault, but as their response to distress. A nurse said: "We used to wait for somebody coming from ..outside.. tell us to do 1,2,3. But now I think the studies have opened our minds to say, okay, you can do this yourself." 

However, when key staff left, the action plan was used less. Staff struggled to overcome barriers. For example, when a dog-patting service became unavailable, they did not consider alternatives.

Why is this important?

The study showed that MARQUE empowered staff at all levels to manage agitation and interact more successfully with care home residents. This is likely to improve quality of life not just for residents, but for the staff themselves. 

Parts of the original MARQUE programme were still being used in all care homes studied. But the researchers say that the four homes which did not take part in this study might have had a less positive experience. 

What’s next?

The intervention was originally intended to be tested across a wider group of care homes. The COVID-19 pandemic made this impossible. The research team hopes that, with the easing of COVID-19 restrictions, the planned roll-out can restart.

The MARQUE programme was delivered by psychology graduates in the original study. In future, it could be delivered by social care staff. This might improve its efficiency, especially if it became a routine part of training for new recruits. 

You may be interested to read

This NIHR Alert is based on: Laybourne A, and others. Long‐term implementation of the Managing Agitation and Raising QUality of lifE intervention in care homes: A qualitative study. International Journal of Geriatric Psychiatry 2021;36:8

The paper reporting the initial findings of the MARQUE intervention: Livingston G,  and others. Clinical and cost-effectiveness of the Managing Agitation and Raising QUality of LifE in dementia (MARQUE) intervention for agitation symptoms in people with dementia in care homes: a single-blind, cluster-randomised controlled trial. Lancet Psychiatry 2019;6:4  

A systematic review of how to successfully embed interventions in care homes: Rapaport P, and others. A systematic review of the effective components of  psychosocial interventions delivered by care home staff to people with dementia. BMJ Open 2017;7:e014177 


Funding: This research was co-funded by the NIHR and the Economic and Social Research Council (ESRC). The two year follow study was funded by the NIHR ARC North Thames

Conflicts of Interest: The study authors declare no conflicts of interest.

Disclaimer: NIHR Alerts are not a substitute for professional medical advice. They provide information about research which is funded or supported by the NIHR. Please note that views expressed in NIHR Alerts are those of the author(s) and reviewer(s) and not necessarily those of the NHS, the NIHR or the Department of Health and Social Care.

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Study author

It was gratifying that staff were able to say they were proud of things they were doing. Residents were having a better time and care homes were asking health teams for less support. 

Staff said they were complimented by health teams, which was really nice. They were starting to see people in a different way. They saw that agitation was distress and that it was their job to address it. We were delighted by the findings. 

I think this intervention would have a big impact on the way people feel about their jobs and capabilities. Things have been difficult during Covid. It gives people the feeling they are skilled and valued much more. They found it pleasurable. 

We didn’t measure quality of life in this study. But I think it must have improved for residents with staff trying to attend to their needs.

Gill Livingston, Professor of Psychiatry of Older People, Division of Psychiatry, University College London


MARQUE is impressive and should be considered for all care homes. It obviously affects both residents and care workers. Meeting the needs of residents allows for a greater quality of life for all concerned. The authors looked at people with dementia as individuals. Patient-centred care is so often spoken of but is rarely put into practice. MARQUE proves that it works, and more people need to know about it.

I care for elderly parents and, like many unpaid carers, can feel overwhelmed at times. There are elements in this research that I feel I can use. It would be good to see further research into how unpaid carers can use this sort of information.

Chandrika Kaviraj, Public Contributor, London 


Part of my day-to-day clinical work involves looking after older people with advanced dementia and behavioural problems. Some are very distressed or agitated. It can take a long time to find a care home willing to accept a patient with agitation related to dementia. The care strategy for staff in this paper might help reduce admissions to hospital. People may then have shorter stays in hospital as care homes may be more confident in managing them, and in accepting them earlier from hospitals. My own ward team might find some of the strategies helpful in managing agitated older patients.

Only a few components of MARQUE seemed to be in place after 20 months. A cost analysis would therefore be helpful to see if the money and time spent was worth it. It was also unclear whether using only some of the MARQUE interventions rather than the whole thing is effective. Although something rather than nothing could be gauged to be an improvement.

This well-written paper looks at a very under-researched area. It may lead to recommendations for MARQUE or other strategies to be funded in care homes. It could become part of the dementia registration process or the CQC (Care Quality Commission) assessment of care home.

Yoganathan Suthahar, Consultant Geriatrician, Mid and South Essex NHS Foundation Trust 

Family member 

My mother in law went for respite day care and we worried about what efforts were being made to engage with her. Knowing about this intervention, even if it wasn’t in place, would have given me the knowledge to ask the right questions. Families and patients will be interested to see what is possible. It could inform their relationship with, and expectations of, their loved one’s care home.

The study could help care home owners and managers understand the benefits of such interventions. It might be helpful if the benefits could be costed, as money is so often a deciding factor in social care.

The findings show that sustainability is possible after the initial research period. Many interventions are just evaluated during the life-time of a project. Once the researchers go away, so does the intervention. Interventions to reduce agitation and the use of antipsychotics are much needed. But as shown here, they don’t always achieve what they set out to do.

Sandra Barker, Public Contributor, Gainsborough 

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