An innovative approach to hydration for a patient with dementia.
Nurs Older People. 2017 Apr 28;29(4):26-29
Authors: Beales A
Nursing older people in acute settings involves the provision of complex care, including the maintenance of good hydration. Dehydration is a serious condition that may contribute to the development of pressure ulcers, urinary tract infections, acute kidney injury and venous thromboembolism. If oral hydration methods are not successful, the alternatives are intravenous (IV) or subcutaneous fluid hydration therapy. These are invasive methods and may not be tolerated by all patients. This article uses a case study to explore an innovative approach to oral hydration. The intervention was developed for Roy, a patient with advanced Alzheimer's disease, who had a reduced fluid intake and who became agitated when staff or family members attempted to assist him with nutrition and hydration. It involved consultation with Roy's family and the introduction of a flavoured drink to encourage the patient to drink. His weekly fluid intake doubled as a result and the intervention avoided the use of alternative invasive rehydration therapy. Although this was a local initiative developed for one patient, it is an example of how a person - entred, collaborative approach can have a positive effect for patients.
PMID: 28452274 [PubMed - indexed for MEDLINE]
The value of life story work for staff, people with dementia and family members.
Nurs Older People. 2017 May 31;29(5):25-29
Authors: McKinney A
Dementia is a term used to describe a collection of symptoms that include problems with memory, self-care, reasoning and communication. Care interventions that focus on preserving people's dignity and identity are therefore essential. Using Driscoll's reflective model to guide critical thinking, this article reflects on the use of one intervention, namely life story work, to promote person-centred care for people with dementia. It explores the value or effect of life story work for healthcare staff, the person with dementia and family members. It also highlights best practice guidelines that are useful to consider to promote its optimal success as an intervention in dementia care, for example, instigating it early in the dementia journey and embedding it in a supportive culture. It is important to highlight to nursing students the many positive aspects of incorporating life story work into practice.
PMID: 28560926 [PubMed - indexed for MEDLINE]
Mutations and mechanisms in congenital and age-related cataracts.
Exp Eye Res. 2017 Mar;156:95-102
Authors: Shiels A, Hejtmancik JF
The crystalline lens plays an important role in the refractive vision of vertebrates by facilitating variable fine focusing of light onto the retina. Loss of lens transparency, or cataract, is a frequently acquired cause of visual impairment in adults and may also present during childhood. Genetic studies have identified mutations in over 30 causative genes for congenital or other early-onset forms of cataract as well as several gene variants associated with age-related cataract. However, the pathogenic mechanisms resulting from genetic determinants of cataract are only just beginning to be understood. Here, we briefly summarize current concepts pointing to differences in the molecular mechanisms underlying congenital and age-related forms of cataract.
PMID: 27334249 [PubMed - indexed for MEDLINE]
Caring for patients with Parkinson's disease in general hospital settings.
Nurs Older People. 2017 May 31;29(5):30-37
Authors: Queen V
Parkinson's disease (PD) is a common progressive neurological condition. There are 127,000 people with the disease in the UK, that is, one in every 500 of the population. In 2014-15 there were 14,000 hospital admissions of people with PD in England. However, PD is often not the primary cause of admission. Urinary tract infections and pneumonia, for example, are frequent causes of hospital admission for people with PD. Therefore, nurses on general medical and surgical wards will often care for people with PD. This article aims to provide an update on PD and explore the nurse's role in assessment and provision of safe and effective care for patients with PD in acute hospital settings.
PMID: 28560917 [PubMed - indexed for MEDLINE]
Authors: McCarthy, S; Paul, L; & O’Connell, M.
Source: Irish Medical Journal
Better arthritis care: Patients' expectations and priorities, the competencies that community-based health professionals need to improve their care of people with arthritis?
Musculoskeletal Care. 2017 Jul 21;:
Authors: Erwin J, Edwards K, Woolf A, Whitcombe S, Kilty S
OBJECTIVE: The aim of the present study was to identify the competencies that patients think non-specialist community-based nurses and allied health professionals (AHPs) need to enable them to assess, care for and manage arthritis appropriately.
METHODS: Four face-to-face focus groups were held with a total of 16 women and nine men with arthritis, to discuss the care they received from community-based health professionals, the skills and knowledge they expected from community-based health professionals and what they prioritized.
RESULTS: People with arthritis wanted health providers to have an understanding of the difference between inflammatory arthritis (IA) and osteoarthritis (OA), of how serious OA can be, and of the unpredictability of IA and flares. They emphasized the need for nurses and AHPs to understand the psychosocial impact of arthritis on individuals, family and friends, and the psychological adjustment needed when diagnosed with IA. They wanted community-based health professionals to have some knowledge of the types of drug treatments that people with IA receive and the implications of taking immunosuppressive drugs. They also wanted them to understand the pain associated with arthritis, particularly OA, which participants felt was not taken seriously enough. They wanted nurses and AHPs in the community to be able to give basic advice on pacing and pain management, to make multidisciplinary referrals, to communicate effectively between referral points and to be able to signpost people to sources of help and good, reliable sources of education and information (especially for OA). They also wanted them to understand that patients who have had a diagnosis for a long time are the experts in their own disease. Other areas which were emphasized as being important were good communication skills and taking a holistic approach to caring for people with arthritis.
CONCLUSIONS: OA and IA differ significantly, both in their nature and their management. However, patients with arthritis want health professionals working in the community to be able to take a holistic approach to arthritis, with an understanding not just of the physical effects, but also their impact on the lives of patients, their family and their wider social circle, and on their ability to participate. People with OA want their condition to be taken seriously and to be offered appropriate management options, while people with IA want professionals to understand the unpredictability of their condition and to have a basic understanding of the drugs used for its treatment.
PMID: 28730727 [PubMed - as supplied by publisher]
The Experiences of People with Dementia and Their Caregivers in Dementia Diagnosis.
J Alzheimers Dis. 2017 Jul 17;:
Authors: Lian Y, Xiao LD, Zeng F, Wu X, Wang Z, Ren H
BACKGROUND: People can live well with dementia if they are diagnosed early and receive early interventions and appropriate dementia management and care. However, dementia is currently under-detected and under-diagnosed. The diagnosis rate is around 50% only in higher-income countries and 5-10% only in low- and middle-income countries. Studies on consumers' experiences in engaging in dementia diagnosis in a socio-cultural context are much needed in order to generate research evidence to inform person-centered dementia care and services.
OBJECTIVE: The aim of the study was to understand the experiences of people with dementia and their caregivers in engaging in dementia diagnosis.
METHODS: An interpretative study design informed by Gadamer's hermeneutic principles was applied to the present study to achieve the aim of the study. The study was strengthened by applying a social ecological framework to the study design. In total, 23 participants contributed to the interviews or focus group. Thematic analysis was applied to data analysis.
RESULTS: Four themes were determined from data and described as: capabilities to detect the memory loss in an early stage, perceptions and beliefs of dementia in the community, different journeys toward the diagnosis and expectations of a smooth journey for others. These findings illuminate a social ecological perspective of improving early detection and timely diagnosis of dementia in the community settings.
CONCLUSION: The findings of this study have implications for policy, resource, and practice development. Consumers expect that government subsidized dementia care services in primary care and specialist care settings are needed in order to enable consumer-driven timely diagnosis and dementia management in home care settings.
PMID: 28731450 [PubMed - as supplied by publisher]
The impact of community-based eHealth self-management intervention among elderly living alone with hypertension.
J Telemed Telecare. 2017 Jan;23(1):167-173
Authors: Jung H, Lee JE
Introduction This study intended to examine the effect of an eHealth self-management (eHSM) intervention on elderly Korean persons who live alone in a community. Methods A quasi-experimental study was designed, and a total of 64 elderly persons (intervention n = 31, control n = 33) with hypertension (a systolic blood pressure measurement of ≥140 and/or a diastolic blood pressure ≥90 mm Hg) or taking anti-hypertensive medication participated. The eHSM intervention consisted of a four-week, in-class educational phase, community-based eHealth monitoring, and monthly telephone counselling for 24 weeks. Results The primary outcome measurement of the study was BP, and secondary outcomes included psycho-behavioural variables. Specifically, the systolic BP among intervention group participants was 133.9 mm Hg at baseline and 122.5 mm Hg after 24 weeks of follow-up. Participants in the intervention group showed greater improvement in self-efficacy, self-care behaviour, and social support than did participants in the control group 24 weeks post-intervention. Discussion The results highlight the clinical efficacy of an eHSM intervention composed of a four-week education program, self-monitoring, and follow-up counselling. The eHSM intervention should be expanded to include community-dwelling elderly persons with hypertension to improve the self-management of hypertension and control of blood pressure.
PMID: 26678063 [PubMed - indexed for MEDLINE]
Improving prognosis for patients with hepatocellular carcinoma in Ireland 1994-2008.
Eur J Gastroenterol Hepatol. 2017 Feb;29(2):221-224
Authors: Gaynor C, Iqbal M, Comber H, Deady S, McCormick PA
OBJECTIVES: The incidence of hepatocellular carcinoma (HCC) is increasing in low-prevalence countries such as the USA, UK and Ireland. Over the past two decades, diagnostic techniques have improved and new treatments have been introduced. The aim of this study was to determine whether there has been an impact on hepatoma mortality in Ireland.
METHODS: Anonymized cancer registration data from the National Cancer Registry of Ireland were used to investigate patient characteristics and trends in treatment and survival for Irish patients diagnosed with histologically confirmed HCC between 1994 and 2008. Analyses were carried out according to sex, age, stage of disease treatment received and period of incidence.
RESULTS: The incidence of HCC in Ireland increased steadily from 1994 to 2008. The median overall survival was 580 days for the entire cohort, with 1, 2, 3 and 5-year survivals of 56, 46, 39 and 36%, respectively. One-year cause-specific survival improved from 38% during 1994-1998, to 51% during 1999-2002 and to 66% during 2003-2007. Five-year cause-specific survival also improved over time from 19 to 34 to 38%, respectively. Surgery was associated with 1, 2, 3 and 5-year survivals of 92, 82, 78 and 78%, respectively.
CONCLUSION: This is the first population-based report of incidence, treatment patterns and outcomes of HCC in Ireland. Prognosis improved over time in this biopsy-proven cohort of patients with HCC. This improvement in survival seemed to be largely because of the effect of surgical interventions.
PMID: 27832038 [PubMed - indexed for MEDLINE]
Technologies in older people's care.
Nurs Ethics. 2017 Mar;24(2):125-137
Authors: Andersson Marchesoni M, Axelsson K, Fältholm Y, Lindberg I
BACKGROUND: The tension between care-based and technology-based rationalities motivates studies concerning how technology can be used in the care sector to support the relational foundation of care.
OBJECTIVES: This study interprets values related to care and technologies connected to the practice of good care.
RESEARCH DESIGN: This research study was part of a development project aimed at developing innovative work practices through information and communication technology. Participants and research context: All staff (n = 18) working at two wards in a care facility for older people were asked to participate in interviews, and 12 accepted. We analysed the data using latent content analysis in combination with normative analysis. Ethical considerations: The caregivers were informed that participation was voluntary and that they could drop out at any time without providing any explanation.
FINDINGS: Four values were identified: 'presence', 'appreciation', 'competence' and 'trust'. Caregivers wanted to focus on care receivers as unique persons, a view that they thought was compromised by time-consuming and beeping electronic devices. Appraising from next-of-kin and been seen as someone who can contribute together with knowledge to handle different situations were other desires. The caregivers also desired positive feedback from next-of-kin, as they wanted to be seen as professionals who have the knowledge and skills to handle difficult situations. In addition, the caregivers wanted their employer to trust them, and they wanted to work in a calm environment.
DISCUSSION: Caregivers' desire for disturbance-free interactions, being valued for their skills and working in a trustful working environment were interpreted as their base for providing good care. The caregivers' arguments are based on caring rationality, and sometimes they felt the technological rationality interfered with their main mission, providing quality care.
CONCLUSION: Introducing new technology in caring should support the caring relationship. Although society's overall technology-based approach may have gained popularity as a problem solver, technology-based rationality may compromise a care-based rationality. A shift in attitudes towards care as a concept on all societal levels is needed.
PMID: 26208722 [PubMed - indexed for MEDLINE]
Maintenance immunosuppression for adults undergoing liver transplantation: a network meta-analysis.
Cochrane Database Syst Rev. 2017 Mar 31;3:CD011639
Authors: Rodríguez-Perálvarez M, Guerrero-Misas M, Thorburn D, Davidson BR, Tsochatzis E, Gurusamy KS
BACKGROUND: As part of liver transplantation, immunosuppression (suppressing the host immunity) is given to prevent graft rejections resulting from the immune response of the body against transplanted organ or tissues from a different person whose tissue antigens are not compatible with those of the recipient. The optimal maintenance immunosuppressive regimen after liver transplantation remains uncertain.
OBJECTIVES: To assess the comparative benefits and harms of different maintenance immunosuppressive regimens in adults undergoing liver transplantation through a network meta-analysis and to generate rankings of the different immunosuppressive regimens according to their safety and efficacy.
SEARCH METHODS: We searched CENTRAL, MEDLINE, Embase, Science Citation Index Expanded, World Health Organization International Clinical Trials Registry Platform, and trials registers until October 2016 to identify randomised clinical trials on immunosuppression for liver transplantation.
SELECTION CRITERIA: We included only randomised clinical trials (irrespective of language, blinding, or publication status) in adult participants undergoing liver transplantation (or liver retransplantation) for any reason. We excluded trials in which participants had undergone multivisceral transplantation or participants with established graft rejections. We considered any of the various maintenance immunosuppressive regimens compared with each other.
DATA COLLECTION AND ANALYSIS: We performed a network meta-analysis with OpenBUGS using Bayesian methods and calculated the odds ratio, rate ratio, and hazard ratio (HR) with 95% credible intervals (CrI) based on an available-case analysis, according to National Institute of Health and Care Excellence Decision Support Unit guidance.
MAIN RESULTS: We included a total of 26 trials (3842 participants) in the review, and 23 trials (3693 participants) were included in one or more outcomes in the review. The vast majority of the participants underwent primary liver transplantation. All of the trials were at high risk of bias, and all of the evidence was of low or very low quality. In addition, because of sparse data involving trials at high risk of bias, it is not possible to entirely rely on the results of the network meta-analysis. The trials included mainly participants undergoing primary liver transplantation of varied aetiologies. The follow-up in the trials ranged from 3 to 144 months. The most common maintenance immunosuppression used as a control was tacrolimus. There was no evidence of difference in mortality (21 trials; 3492 participants) or graft loss (15 trials; 2961 participants) at maximal follow-up between the different maintenance immunosuppressive regimens based on the network meta-analysis. In the direct comparison, based on a single trial including 222 participants, tacrolimus plus sirolimus had increased mortality (HR 2.76, 95% CrI 1.30 to 6.69) and graft loss (HR 2.34, 95% CrI 1.28 to 4.61) at maximal follow-up compared with tacrolimus. There was no evidence of differences in the proportion of people with serious adverse events (1 trial; 719 participants), proportion of people with any adverse events (2 trials; 940 participants), renal impairment (8 trials; 2233 participants), chronic kidney disease (1 trial; 100 participants), graft rejections (any) (16 trials; 2726 participants), and graft rejections requiring treatment (5 trials; 1025 participants) between the different immunosuppressive regimens. The network meta-analysis showed that the number of adverse events was lower with cyclosporine A than with many other immunosuppressive regimens (12 trials; 1748 participants), and the risk of retransplantation (13 trials; 1994 participants) was higher with cyclosporine A than with tacrolimus (HR 3.08, 95% CrI 1.13 to 9.90). None of the trials reported number of serious adverse events, health-related quality of life, or costs.
FUNDING: 14 trials were funded by pharmaceutical companies who would benefit from the results of the trial; two trials were funded by parties who had no vested interest in the results of the trial; and 10 trials did not report the source of funding.
AUTHORS' CONCLUSIONS: Based on low-quality evidence from a single small trial from direct comparison, tacrolimus plus sirolimus increases mortality and graft loss at maximal follow-up compared with tacrolimus. Based on very low-quality evidence from network meta-analysis, we found no evidence of difference between different immunosuppressive regimens. We found very low-quality evidence from network meta-analysis and low-quality evidence from direct comparison that cyclosporine A causes more retransplantation compared with tacrolimus. Future randomised clinical trials should be adequately powered; performed in people who are generally seen in the clinic rather than in highly selected participants; employ blinding; avoid postrandomisation dropouts or planned cross-overs; and use clinically important outcomes such as mortality, graft loss, renal impairment, chronic kidney disease, and retransplantation. Such trials should use tacrolimus as one of the control groups. Moreover, such trials ought to be designed in such a way as to ensure low risk of bias and low risks of random errors.
PMID: 28362060 [PubMed - indexed for MEDLINE]
The Effectiveness of EMLA as a Primary Dressing on Painful Chronic Leg Ulcers: A Pilot Randomized Controlled Trial.
Adv Skin Wound Care. 2017 Aug;30(8):354-363
Authors: Purcell A, Buckley T, Fethney J, King J, Moyle W, Marshall AP
OBJECTIVE: To evaluate the effectiveness of the eutectic mixture of local anesthetics (EMLA; Aspen Pharmacare, St. Leonards, New South Wales, Australia) as a primary dressing on painful chronic leg ulcers.
DESIGN: A pilot randomized controlled trial.
SETTING: The study was conducted across 6 community nursing procedure clinics located in a community nursing service in New South Wales, Australia.
PARTICIPANTS: Sixty participants with painful chronic leg ulcers of varied etiology were recruited into the study.
INTERVENTION: Participants were randomly assigned to an intervention (daily EMLA use for 4 weeks as a primary dressing) or a standard wound care group.
MAIN OUTCOME MEASURE: The effectiveness of EMLA on wound-related pain intensity before, during, and after dressing change.
MAIN RESULTS: Mean pain scores were similar between the 2 groups at baseline (P = .84). During dressing change, mean pain scores across the 4-week intervention period were significantly lower in the intervention compared with the control group (intervention group: mean, 3.39 [SD, 2.16]; control group: mean, 4.82 [SD, 2.27]; P = .02). Mean pain scores after dressing change were also significantly lower for the intervention group over the 4-week intervention period (intervention group: mean, 2.71 [SD, 1.94]; control group: mean, 3.92 [SD, 2.03]; P = .03).
CONCLUSIONS: Data from this pilot study suggest that EMLA as a primary dressing may be effective in reducing chronic leg ulcer pain during and after dressing change and warrant further evaluation.
PMID: 28727591 [PubMed - in process]
Objective Assessment of Adherence to Inhalers by Patients with Chronic Obstructive Pulmonary Disease.
Am J Respir Crit Care Med. 2017 May 15;195(10):1333-1343
Authors: Sulaiman I, Cushen B, Greene G, Seheult J, Seow D, Rawat F, MacHale E, Mokoka M, Moran CN, Sartini Bhreathnach A, MacHale P, Tappuni S, Deering B, Jackson M, McCarthy H, Mellon L, Doyle F, Boland F, Reilly RB, Costello RW
RATIONALE: Objective adherence to inhaled therapy by patients with chronic obstructive pulmonary disease (COPD) has not been reported.
OBJECTIVES: To objectively quantify adherence to preventer Diskus inhaler therapy by patients with COPD with an electronic audio recording device (INCA).
METHODS: This was a prospective observational study. On discharge from hospital patients were given a salmeterol/fluticasone inhaler with an INCA device attached. Analysis of this audio quantified the frequency and proficiency of inhaler use.
MEASUREMENTS AND MAIN RESULTS: Patients with COPD (n = 244) were recruited. The mean age was 71 years, mean FEV1 was 1.3 L, and 59% had evidence of mild/moderate cognitive impairment. By combining time of use, interval between doses, and critical technique errors, thus incorporating both intentional and unintentional nonadherence, a measure "actual adherence" was calculated. Mean actual adherence was 22.6% of that expected if the doses were taken correctly and on time. Six percent had an actual adherence greater than 80%. Hierarchical clustering found three equally sized well-separated clusters corresponding to distinct patterns. Cluster 1 (34%) had low inhaler use and high error rates. Cluster 2 (25%) had high inhaler use and high error rates. Cluster 3 (36%) had overall good adherence. Poor lung function and comorbidities were predictive of poor technique, whereas age and cognition with poor lung function distinguished those with poor adherence and frequent errors in technique.
CONCLUSIONS: These data may inform clinicians in understanding why a prescribed inhaler is not effective and to devise strategies to promote adherence in COPD.
PMID: 27409253 [PubMed - indexed for MEDLINE]
Effectiveness of a community-based program for suicide prevention among elders with early-stage dementia: A controlled observational study.
Geriatr Nurs. 2017 Mar - Apr;38(2):97-105
Authors: Kim JP, Yang J
The purpose of this study was to develop a small-group-focused suicide prevention program for elders with early-stage dementia and to assess its effects. This was a quasi-experimental study with a control group pretest-posttest design. A total of 62 elders diagnosed with early-stage dementia who were receiving care services at nine daycare centers in J City Korea participated in this study. The experimental group participated in the suicide prevention program twice a week for 5 weeks with a pretest and two posttests The developed suicide prevention program had a significant effect on the perceived health status, social support, depression, and suicidal ideation of elders with early-stage dementia. Nurses should integrate risk factors such as depression and protective factors such as health status and social support into a suicide prevention program. This community-based program in geriatric nursing practice can be effective in preventing suicide among elders with early-stage dementia.
PMID: 27594544 [PubMed - indexed for MEDLINE]
Secondary prevention lifestyle interventions initiated within 90 days after TIA or 'minor' stroke: a systematic review and meta-analysis of rehabilitation programmes.
Br J Gen Pract. 2017 Jan;67(654):e57-e66
Authors: Heron N, Kee F, Cardwell C, Tully MA, Donnelly M, Cupples ME
BACKGROUND: Strokes are often preceded by a transient ischaemic attack (TIA) or 'minor' stroke. The immediate period after a TIA/minor stroke is a crucial time to initiate secondary prevention. However, the optimal approach to prevention, including non-pharmacological measures, after TIA is not clear.
AIM: To systematically review evidence about the effectiveness of delivering secondary prevention, with lifestyle interventions, in comprehensive rehabilitation programmes, initiated within 90 days of a TIA/minor stroke. Also, to categorise the specific behaviour change techniques used.
DESIGN AND SETTING: The review identified randomised controlled trials by searching the Cochrane Library, Ovid MEDLINE, Ovid EMBASE, Web of Science, EBSCO CINAHL and Ovid PsycINFO.
METHOD: Two review authors independently screened titles and abstracts for eligibility (programmes initiated within 90 days of event; outcomes reported for TIA/minor stroke) and extracted relevant data from appraised studies; a meta-analysis was used to synthesise the results.
RESULTS: A total of 31 potentially eligible papers were identified and four studies, comprising 774 patients post-TIA or minor stroke, met the inclusion criteria; two had poor methodological quality. Individual studies reported increased aerobic capacity but meta-analysis found no significant change in resting and peak systolic blood pressure, resting heart rate, aerobic capacity, falls, or mortality. The main behaviour change techniques were goal setting and instructions about how to perform given behaviours.
CONCLUSION: There is limited evidence of the effectiveness of early post-TIA rehabilitation programmes with preventive lifestyle interventions. Further robust randomised controlled trials of comprehensive rehabilitation programmes that promote secondary prevention and lifestyle modification immediately after a TIA are needed.
PMID: 27919935 [PubMed - indexed for MEDLINE]
Improving Adherence to Long-term Opioid Therapy Guidelines to Reduce Opioid Misuse in Primary Care: A Cluster-Randomized Clinical Trial.
JAMA Intern Med. 2017 Jul 17;:
Authors: Liebschutz JM, Xuan Z, Shanahan CW, LaRochelle M, Keosaian J, Beers D, Guara G, O'Connor K, Alford DP, Parker V, Weiss RD, Samet JH, Crosson J, Cushman PA, Lasser KE
Importance: Prescription opioid misuse is a national crisis. Few interventions have improved adherence to opioid-prescribing guidelines.
Objective: To determine whether a multicomponent intervention, Transforming Opioid Prescribing in Primary Care (TOPCARE; http://mytopcare.org/), improves guideline adherence while decreasing opioid misuse risk.
Design, Setting, and Participants: Cluster-randomized clinical trial among 53 primary care clinicians (PCCs) and their 985 patients receiving long-term opioid therapy for pain. The study was conducted from January 2014 to March 2016 in 4 safety-net primary care practices.
Interventions: Intervention PCCs received nurse care management, an electronic registry, 1-on-1 academic detailing, and electronic decision tools for safe opioid prescribing. Control PCCs received electronic decision tools only.
Main Outcomes and Measures: Primary outcomes included documentation of guideline-concordant care (both a patient-PCC agreement in the electronic health record and at least 1 urine drug test [UDT]) over 12 months and 2 or more early opioid refills. Secondary outcomes included opioid dose reduction (ie, 10% decrease in morphine-equivalent daily dose [MEDD] at trial end) and opioid treatment discontinuation. Adjusted outcomes controlled for differing baseline patient characteristics: substance use diagnosis, mental health diagnoses, and language.
Results: Of the 985 participating patients, 519 were men, and 466 were women (mean [SD] patient age, 54.7 [11.5] years). Patients received a mean (SD) MEDD of 57.8 (78.5) mg. At 1 year, intervention patients were more likely than controls to receive guideline-concordant care (65.9% vs 37.8%; P < .001; adjusted odds ratio [AOR], 6.0; 95% CI, 3.6-10.2), to have a patient-PCC agreement (of the 376 without an agreement at baseline, 53.8% vs 6.0%; P < .001; AOR, 11.9; 95% CI, 4.4-32.2), and to undergo at least 1 UDT (74.6% vs 57.9%; P < .001; AOR, 3.0; 95% CI, 1.8-5.0). There was no difference in odds of early refill receipt between groups (20.7% vs 20.1%; AOR, 1.1; 95% CI, 0.7-1.8). Intervention patients were more likely than controls to have either a 10% dose reduction or opioid treatment discontinuation (AOR, 1.6; 95% CI, 1.3-2.1; P < .001). In adjusted analyses, intervention patients had a mean (SE) MEDD 6.8 (1.6) mg lower than controls (P < .001).
Conclusions and Relevance: A multicomponent intervention improved guideline-concordant care but did not decrease early opioid refills.
Trial Registration: clinicaltrials.gov Identifier: NCT01909076.
PMID: 28715535 [PubMed - as supplied by publisher]
Long-Term Outcomes and Longitudinal Changes of Neurogenic Bowel Management in Adults With Pediatric-Onset Spinal Cord Injury.
Arch Phys Med Rehabil. 2017 Feb;98(2):241-248
Authors: Hwang M, Zebracki K, Vogel LC
OBJECTIVES: To describe long-term outcomes of neurogenic bowel dysfunction (NBD), determine changes over time in the type of bowel program, and determine changes in psychosocial outcomes associated with NBD-related factors in adults with pediatric-onset spinal cord injury (SCI).
DESIGN: Longitudinal cohort survey. Follow-up occurred annually for a total of 466 interviews, with most participants (75%) contributing to at least 3 consecutive interviews.
PARTICIPANTS: Adults (N=131) who had sustained an SCI before the age of 19 years (men, 64.1%; tetraplegia, 58.8%; mean age ± SD, 33.4±6.1y; mean time since injury ± SD, 19.5±7.0y).
INTERVENTIONS: Not applicable.
MAIN OUTCOME MEASURES: Type and evacuation time of bowel management programs; standardized measures assessing life satisfaction, health perception, depressive symptoms, and participation. Generalized estimating equations were formulated to determine odds of change in outcomes over time.
RESULTS: At first interview, rectal suppository/enema use was most common (51%). Over time, the likelihood of using manual evacuation (odds ratio [OR]=1.077; 95% confidence interval [CI], 1.023-1.134; P=.005), oral laxatives (OR=1.052; 95% CI, 1.001-1.107; P=.047), and colostomy (OR=1.071; 95% CI, 1.001-1.147; P=.047) increased, whereas the odds of rectal suppository use decreased (OR=.933; 95% CI, .896-.973; P=.001). Bowel evacuation times were likely to decrease over time in participants using manual evacuation (OR=.499; 95% CI, .256-.974; P=.042) and digital rectal stimulation (OR=.490; 95% CI, .274-.881; P=.017), but increase for rectal suppository/enema use (OR=1.871; 95% CI, 1.264-2.771; P=.002). When the level of injury was controlled for, participants using manual evacuation and digital rectal stimulation were more likely to have increases in community participation scores (P<.05).
CONCLUSIONS: Changes in type of bowel program over time may be associated with the time required to complete bowel evacuation in this relatively young adult SCI population.
PMID: 27473299 [PubMed - indexed for MEDLINE]
Prevention of Incontinence-Associated Skin Damage in Nursing Homes.
West J Nurs Res. 2017 May;39(5):643-659
Authors: Bliss DZ, Gurvich OV, Mathiason MA, Eberly LE, Savik K, Harms S, Mueller C, Wyman JF, Virnig B
Racial/ethnic disparities in preventing health problems have been reported in nursing homes. Incontinence is common among nursing home residents and can result in inflammatory-type skin damage, referred to as incontinence-associated skin damage (IASD). Little is known about the prevention of IASD and whether there are racial/ethnic disparities in its prevention. This study assessed the proportion of older nursing home residents receiving IASD prevention after developing incontinence after admission ( n = 10,713) and whether there were racial/ethnic disparities in IASD prevention. Predictors of preventing IASD were also examined. Four national data sets provided potential predictors at multiple levels. Disparities were analyzed using the Peters-Belson method; predictors of preventing IASD were assessed using hierarchical logistic regression. Prevention of IASD was received by 0.12 of residents and no racial/ethnic disparities were found. Predictors of preventing IASD were primarily resident-level factors including limitations in activities of daily living, poor nutrition, and more oxygenation problems.
PMID: 27586441 [PubMed - indexed for MEDLINE]
Effect of Current Dietary Recommendations on Weight Loss and Cardiovascular Risk Factors.
J Am Coll Cardiol. 2017 Mar 07;69(9):1103-1112
Authors: Jenkins DJA, Boucher BA, Ashbury FD, Sloan M, Brown P, El-Sohemy A, Hanley AJ, Willett W, Paquette M, de Souza RJ, Ireland C, Kwan N, Jenkins A, Pichika SC, Kreiger N
BACKGROUND: Dietary recommendations emphasize increased consumption of fruit, vegetables, and whole grain cereals for prevention of chronic disease.
OBJECTIVES: This study assessed the effect of dietary advice and/or food provision on body weight and cardiovascular disease risk factors.
METHODS: Healthy overweight men (n = 209) and women (n = 710), mean age 44.7 years, body mass index [BMI] 32.4 kg/m(2), were randomized between November 2005 and August 2009 to receive Health Canada's food guide (control, n = 486) or 1 of 3 interventions: dietary advice consistent with both Dietary Approaches to Stop Hypertension (DASH) and dietary portfolio principles (n = 145); weekly food provision reflecting this advice (n = 148); or food delivery plus advice (n = 140). Interventions lasted 6 months with 12-month follow-up. Semiquantitative food frequency questionnaires and fasting blood, anthropometric and blood pressure measurements were obtained at baseline, 6 months, and 18 months.
RESULTS: Participant retention at 6 and 18 months was 91% and 81%, respectively, after food provision compared to 67% and 57% when no food was provided (p < 0.0001). Test and control treatments showed small reductions in body weight (-0.8 to -1.2 kg), waist circumference (-1.1 to -1.9 cm), and mean arterial pressure (0.0 to -1.1 mm Hg) at 6 months and Framingham coronary heart disease risk score at 18 months (-0.19 to -0.42%), which were significant overall. Outcomes did not differ among test and control groups.
CONCLUSIONS: Provision of foods increased retention but only modestly increased intake of recommended foods. Current dietary recommendations showed small overall benefits in coronary heart disease risk factors. Additional dietary strategies to maximize these benefits are required. (Fruits, Vegetables, and Whole Grains: A Community-based Intervention; NCT00516620).
PMID: 28254171 [PubMed - indexed for MEDLINE]
Authors: Akl EA, Kahale LA, Hakoum MB, Matar CF, Sperati F, Barba M, Yosuico VED, Terrenato I, Synnot A, Schünemann H.
Source: Cochrane Database of Systematic Reviews 2017, Issue 9. Art. No.: CD006652. DOI: 10.1002/14651858.CD006652.pub5.
Authors: Bhangu J, King-Kallimanis BL, Donoghue OA, Carroll L, Kenny RA
Source: PLoS ONE 12(7): e0180997. https://doi.org/10.1371/journal.pone.0180997
Authors: Briggs R., Kennelly S.P. & Kenny R.A.
Source: Int J Geriatr Psychiatry. 2017 Aug 2. doi: 10.1002/gps.4770. [Epub ahead of print]
Piloting the older adult financial exploitation measure in adult safeguarding services.
Arch Gerontol Geriatr. 2017 May - Jun;70:148-154
Authors: Phelan A, Fealy G, Downes C
Financial abuse is arguably the most complex form of elder abuse as it may occur remote to the older person and it is impacted by issues such as cultural values, perpetrator intent and family expectations. Financial abuse may not be recognised by either the older person or the perpetrator, thus, its prevention, early identification and amelioration are important. The (Irish) National Centre for the Protection of Older People undertook a study to determine the appropriateness of the Older Adult Financial Exploitation Measure for use by the national safeguarding older person services. Findings from a small pilot study involving 16 safeguarding staff's use of the Older Adult Financial Exploitation Measure with 52 community dwelling older people referred to their service demonstrate a higher suspicion of financial abuse as well as identifying multiple instances of possible financial exploitation in a single individual. Thus, the Older Adult Financial Exploitation Measure is considered appropriate to assist safeguarding personnel's assessment of older people related to a suspicion of financial abuse.
PMID: 28161691 [PubMed - indexed for MEDLINE]
Impact of coronary heart disease on cognitive decline in Alzheimer's disease: a prospective longitudinal cohort study in primary care.
Br J Gen Pract. 2017 Feb;67(655):e111-e117
Authors: Bleckwenn M, Kleineidam L, Wagner M, Jessen F, Weyerer S, Werle J, Wiese B, Lühmann D, Posselt T, König HH, Brettschneider C, Mösch E, Weeg D, Fuchs A, Pentzek M, Luck T, Riedel-Heller SG, Maier W, Scherer M
BACKGROUND: Arteriosclerotic disorders increase the risk of dementia. As they have common causes and risk factors, coronary heart disease (CHD) could influence the course of dementia.
AIM: To determine whether CHD increases the speed of cognitive decline in Alzheimer's disease, and to discuss the potential for secondary cardiovascular prevention to modify this decline.
DESIGN AND SETTING: Prospective multicentre cohort study in general practices in six cities in Germany.
METHOD: Participants were patients with probable mild-to-moderate Alzheimer's dementia or mixed dementia (n = 118; mean age 85.6 [±3.4] years, range 80-96 years). The authors assessed the presence of CHD according to the family physicians' diagnosis. Cognitive performance was measured during home visits for up to 3 years in intervals of 6 months, using Mini Mental State Examination (MMSE) and Clinical Dementia Rating Sum of Boxes (CDR-SoB). The authors also recorded whether patients died in the observation period.
RESULTS: At baseline, 65 patients (55%) had CHD and/or a heart condition following a myocardial infarction. The presence of CHD accelerated cognitive decline (MMSE, P<0.05) by about 66%, and reduced cognitive-functional ability (CDR-SoB, P<0.05) by about 83%, but had no impact on survival.
CONCLUSION: The study shows that CHD has a significant influence on cognitive decline in older patients with late-onset dementia. The dementia process might therefore be positively influenced by cardiovascular prevention, and this possible effect should be further investigated.
PMID: 27993897 [PubMed - indexed for MEDLINE]
Early learners as health coaches for older adults preparing for surgery.
J Surg Res. 2017 Mar;209:184-190
Authors: Kaplan JA, Brinson Z, Hofer R, O'Sullivan P, Chang A, Horvath H, Chang GJ, Finlayson E
BACKGROUND: Few opportunities exist for early learners to engage in authentic roles on health care teams. In a geriatric optimization clinic for frail high-risk surgical patients, first-year medical and nurse practitioner students were integrated into an interprofessional team as health coaches.
MATERIALS AND METHODS: Frail surgical patients with planned operations were referred to a new preoperative optimization clinic to see a geriatrician, occupational, and physical therapists and a nutritionist. A curriculum for health coaching by early learners was developed, implemented, and evaluated in this clinic. Students attended the clinic visit with their patient, reviewed the interdisciplinary care plan, and called patients twice weekly preoperatively and weekly in the first month after discharge. Students logged all calls, completed patient satisfaction surveys 1 wk before surgery and participated in feedback sessions with team members and medical school faculty. Call success rate was calculated, and team communications were recorded and analyzed.
RESULTS: Median call success rate was 69.2% and was lowest among medical students (P = 0.004). Students and research assistants contacted or facilitated patient contact with their medical team 84 times. Overall, patients were extremely satisfied with the health coach experience, felt better prepared for surgery, and would recommend the program to others.
CONCLUSIONS: Early medical and nurse practitioner students can serve the important function of health coaches for frail patients preparing for surgery. Motivated students benefited from a unique longitudinal experience and gained skills in communication and care coordination. Not all students demonstrated capacity to engage in health coaching this early in their education.
PMID: 28032558 [PubMed - indexed for MEDLINE]
Incidence of venous thromboembolism in care homes: a prospective cohort study.
Br J Gen Pract. 2017 Feb;67(655):e130-e137
Authors: Apenteng PN, Hobbs FR, Roalfe A, Muhammad U, Heneghan C, Fitzmaurice D
BACKGROUND: Care home residents have venous thromboembolism (VTE) risk profiles similar to medical inpatients; however, the epidemiology of VTE in care homes is unclear.
AIM: To determine the incidence of VTE in care homes.
DESIGN AND SETTING: Observational cohort study of 45 care homes in Birmingham and Oxford, UK.
METHOD: A consecutive sample of care home residents was enrolled and followed up for 12 months. Data were collected via case note reviews of care home and GP records; mortality information was supplemented with Health and Social Care Information Centre (now called NHS Digital) cause of death data. All potential VTE events were adjudicated by an independent committee according to three measures of diagnostic certainty: definite VTE (radiological evidence), probable VTE (high clinical indication but no radiological evidence), or possible VTE (VTE cannot be ruled out). (Study registration number: ISTCTN80889792.) RESULTS: There were 1011 participants enrolled, and the mean follow-up period was 312 days (standard deviation 98 days). The incidence rate was 0.71 per 100 person years of observation (95% confidence interval [CI] = 0.26 to 1.54) for definite VTE, 0.83 per 100 person years (95% CI = 0.33 to 1.70) for definite and probable VTE, and 2.48 per 100 person years (95% CI = 1.53 to 3.79) for definite, probable, and possible VTE.
CONCLUSION: The incidence of VTE in care homes in this study (0.71-2.48 per 100 person years) is substantial compared with that in the community (0.117 per 100 person years) and in people aged ≥70 years (0.44 per 100 person years). Further research regarding risk stratification and VTE prophylaxis in this population is needed.
PMID: 28093420 [PubMed - indexed for MEDLINE]
Post-operative recurrence of Crohn's disease after definitive stoma: an underestimated risk.
Int J Colorectal Dis. 2017 Apr;32(4):453-458
Authors: Koriche D, Gower-Rousseau C, Chater C, Duhamel A, Salleron J, Tavernier N, Colombel JF, Pariente B, Cortot A, Zerbib P
INTRODUCTION: Crohn's disease (CD) is a progressive inflammatory disease affecting the entire gastrointestinal tract. The need for a definitive stoma (DS) is considered as the ultimate phase of damage. It is often believed that the risk of further disease progression is small when a DS has been performed.
AIMS: The goals of the study were to establish the rate of CD recurrence above the DS and to identify predictive factors of CD recurrence at the time of DS.
METHODS: We retrospectively reviewed all medical records of consecutive CD patients having undergone DS between 1973 and 2010. We collected clinical data at diagnosis, CD phenotype, treatment, and surgery after DS and mortality. Stoma was considered as definitive when restoration of continuity was not possible due to proctectomy, rectitis, anoperineal lesions (APL), or fecal incontinence. Clinical recurrence (CR) was defined as the need for re-introduction or intensification of medical therapy, and surgical recurrence (SR) was defined as a need for a new intestinal resection.
RESULTS: Eighty-three patients (20 males, 63 females) with a median age of 34 years at CD diagnosis were included. The median time between diagnosis and DS was 9 years. The median follow-up after DS was 10 years. Thirty-five patients (42%) presented a CR after a median time of 28 months (2-211) and 32 patients (38%) presented a SR after a median time of 29 months (4-212). In a multivariate analysis, APL (HR = 5.1 (1.2-21.1), p = 0.03) and colostomy at time of DS (HR = 3.8 (1.9-7.3), p = 0.0001) were associated factors with the CR.
CONCLUSION: After DS for CD, the risk of clinical recurrence was high and synonymous with surgical recurrence, especially for patients with APL and colostomy.
PMID: 27885481 [PubMed - indexed for MEDLINE]
Urinary Incontinence in Older Women: The Role of Body Composition and Muscle Strength: From the Health, Aging, and Body Composition Study.
J Am Geriatr Soc. 2017 Jan;65(1):42-50
Authors: Suskind AM, Cawthon PM, Nakagawa S, Subak LL, Reinders I, Satterfield S, Cummings S, Cauley JA, Harris T, Huang AJ, Health ABC Study
OBJECTIVES: To evaluate prospective relationships between body composition and muscle strength with predominantly stress urinary incontinence (SUI) and urgency urinary incontinence (UUI) in older women.
DESIGN: Prospective community-dwelling observational cohort study (Health, Aging, and Body Composition study).
PARTICIPANTS: Women initially aged 70 to 79 recruited from Pittsburgh, Pennsylvania, and Memphis, Tennessee (N = 1,475).
MEASUREMENTS: Urinary incontinence was assessed using structured questionnaires. Body mass index (BMI), grip strength, quadriceps torque, and walking speed were assessed using physical examination and performance testing. Appendicular lean body mass (ALM) and whole-body fat mass were measured using dual-energy X-ray absorptiometry.
RESULTS: At baseline, 212 (14%) women reported at least monthly predominantly SUI and 233 (16%) at least monthly predominantly UUI. At 3 years, of 1,137 women, 164 (14%) had new or persistent SUI, and 320 (28%) had new or persistent UUI. Women had greater odds of new or persistent SUI if they demonstrated a 5% or greater decrease in grip strength, (adjusted odds ratio (AOR) = 1.60, P = .047) and lower odds of new or persistent SUI if they demonstrated a 5% or greater decrease in BMI (AOR = 0.46, P = .01), a 5% or greater increase in ALM corrected for BMI (AOR = 0.17, P = .004), or a 5% or greater decrease in fat mass (AOR = 0.53, P = .01). Only a 5% or greater increase in walking speed was associated with new or persistent UUI over 3 years (AOR = 1.54, P = .04).
CONCLUSION: In women aged 70 and older, changes in body composition and grip strength were associated with changes in SUI frequency over time. In contrast, changes in these factors did not influence UUI. Findings suggest that optimization of body composition and muscle strength is more likely to modify risk of SUI than of UUI in older women.
PMID: 27918084 [PubMed - indexed for MEDLINE]
Tailored educational supportive care programme on sleep quality and psychological distress in patients with heart failure: A randomised controlled trial.
Int J Nurs Stud. 2016 Sep;61:219-29
Authors: Chang YL, Chiou AF, Cheng SM, Lin KC
BACKGROUND: Up to 74% of patients with heart failure report poor sleep in Taiwan. Poor symptom management or sleep hygiene may affect patients' sleep quality. An effective educational programme was important to improve patients' sleep quality and psychological distress. However, research related to sleep disturbance in patients with heart failure is limited in Taiwan.
OBJECTIVES: To examine the effects of a tailored educational supportive care programme on sleep disturbance and psychological distress in patients with heart failure.
DESIGN: randomised controlled trial.
PARTICIPANTS AND SETTING: Eighty-four patients with heart failure were recruited from an outpatient department of a medical centre in Taipei, Taiwan. Patients were randomly assigned to the intervention group (n=43) or the control group (n=41).
METHODS: Patients in the intervention group received a 12-week tailored educational supportive care programme including individualised education on sleep hygiene, self-care, emotional support through a monthly nursing visit at home, and telephone follow-up counselling every 2 weeks. The control group received routine nursing care. Data were collected at baseline, the 4th, 8th, and 12th weeks after patients' enrollment. Outcome measures included sleep quality, daytime sleepiness, anxiety, and depression.
RESULTS: The intervention group exhibited significant improvement in the level of sleep quality and daytime sleepiness after 12 weeks of the supportive nursing care programme, whereas the control group exhibited no significant differences. Anxiety and depression scores were increased significantly in the control group at the 12th week (p<.001). However, anxiety and depression scores in the intervention group remained unchanged after 12 weeks of the supportive nursing care programme (p>.05). Compared with the control group, the intervention group had significantly greater improvement in sleep quality (β=-2.22, p<.001), daytime sleepiness (β=-4.23, p<.001), anxiety (β=-1.94, p<.001), and depression (β=-3.05, p<.001) after 12 weeks of the intervention.
CONCLUSION: This study confirmed that a supportive nursing care programme could effectively improve sleep quality and psychological distress in patients with heart failure. We suggested that this supportive nursing care programme should be applied to clinical practice in cardiovascular nursing.
PMID: 27400028 [PubMed - indexed for MEDLINE]
A Pilot Randomized Controlled Trial of the Effects of Chair Yoga on Pain and Physical Function Among Community-Dwelling Older Adults With Lower Extremity Osteoarthritis.
J Am Geriatr Soc. 2017 Mar;65(3):592-597
Authors: Park J, McCaffrey R, Newman D, Liehr P, Ouslander JG
OBJECTIVES: To determine effects of Sit 'N' Fit Chair Yoga, compared to a Health Education program (HEP), on pain and physical function in older adults with lower extremity osteoarthritis (OA) who could not participate in standing exercise.
DESIGN: Two-arm randomized controlled trial.
SETTING: One HUD senior housing facility and one day senior center in south Florida.
PARTICIPANTS: Community-dwelling older adults (N = 131) were randomly assigned to chair yoga (n = 66) or HEP (n = 65). Thirteen dropped after assignment but prior to the intervention; six dropped during the intervention; 106 of 112 completed at least 12 of 16 sessions (95% retention rate).
INTERVENTIONS: Participants attended either chair yoga or HEP. Both interventions consisted of twice-weekly 45-minute sessions for 8 weeks.
MEASUREMENTS: Primary: pain, pain interference; secondary: balance, gait speed, fatigue, functional ability measured at baseline, after 4 weeks of intervention, at the end of the 8-week intervention, and post-intervention (1 and 3 months).
RESULTS: The chair yoga group showed greater reduction in pain interference during the intervention (P = .01), sustained through 3 months (P = .022). WOMAC pain (P = .048), gait speed (P = .024), and fatigue (P = .037) were improved in the yoga group during the intervention (P = .048) but improvements were not sustained post intervention. Chair yoga had no effect on balance.
CONCLUSION: An 8-week chair yoga program was associated with reduction in pain, pain interference, and fatigue, and improvement in gait speed, but only the effects on pain interference were sustained 3 months post intervention. Chair yoga should be further explored as a nonpharmacologic intervention for older people with OA in the lower extremities.
TRIAL REGISTRATION: ClinicalTrials.gov: NCT02113410.
PMID: 28008603 [PubMed - indexed for MEDLINE]
Urinary catheter-related visits to the emergency department and implications for community services.
Br J Nurs. 2017 May 11;26(9):S4-S11
Authors: Ansell T, Harari D
Thousands of patients live with urinary catheters and the potential complications deriving from long-term use. Disjointed community services may result in patients attending the emergency department (ED) to manage catheter complications.
AIM: to conduct a service review of catheterised patients attending the ED of a large London hospital; to describe incidence, reasons for attendance and cost to inform future planning for out-of-hospital care.
METHOD: a catheter collaborative, consisting of multidisciplinary health professionals and patients, formulated survey questions. Patients were identified from the electronic patient record by searching for the code 'urological complaint'. One month of clinical records were retrospectively reviewed and analysed using descriptive statistics.
RESULTS: 287 patients attended the department with urological complaints: 41 (14%) had urinary catheter problems, of these 24 (59%) patients were discharged and 17 (41%) were admitted for further treatment. Stays in ED varied from 1 hour 13 minutes to 17 hours (mean = 4.8 hours). A total of 9 patients (38%) were sent home during antisocial hours (9 pm to 7 am), 4 patients were discharged between midnight and 2 am. Patients admitted had mean stays of 4.11 days. Most admissions were short term for intravenous (IV) treatments; 3 patients were hospitalised for 20 days. A total of 14 patients (34%) were diagnosed with catheter-related infections: 11 (79%) had bladder infections and 3 (21%) had septicaemia. All 14 patients (100%) had urine-culture-confirmed infections, mainly from coliform, proteus and pseudomonas species. A total of 20 patients (49%) received antibiotic treatment. The majority of patients received an initial IV dose followed, where required, by oral treatment on discharge.
CONCLUSIONS: many catheterised patients had complex needs with high rates of urinary infections and admissions for urosepsis. High attendance related less to old age but more to complexity of history, such as neurological conditions and disability. Only a proportion of these patients could be safely treated by district nurse teams. A significant proportion would require more responsive community services with several spells of short-term input (e.g. daily or more than once-daily visits) and access to diagnostics, microbiology, pharmaceutical input and IV treatments.
PMID: 28493774 [PubMed - indexed for MEDLINE]
Building COPD care on shaky ground: a mixed methods study from Swedish primary care professional perspective.
BMC Health Serv Res. 2017 Jul 10;17(1):467
Authors: Lundell S, Tistad M, Rehn B, Wiklund M, Holmner Å, Wadell K
BACKGROUND: Chronic obstructive pulmonary disease (COPD) is a public health problem. Interprofessional collaboration and health promotion interventions such as exercise training, education, and behaviour change are cost effective, have a good effect on health status, and are recommended in COPD treatment guidelines. There is a gap between the guidelines and the healthcare available to people with COPD. The aim of this study was to increase the understanding of what shapes the provision of primary care services to people with COPD and what healthcare is offered to them from the perspective of healthcare professionals and managers.
METHODS: The study was conducted in primary care in a Swedish county council during January to June 2015. A qualitatively driven mixed methods design was applied. Qualitative and quantitative findings were merged into a joint analysis. Interviews for the qualitative component were performed with healthcare professionals (n = 14) from two primary care centres and analysed with qualitative content analysis. Two questionnaires were used for the quantitative component; one was answered by senior managers or COPD nurses at primary care centres (n = 26) in the county council and the other was answered by healthcare professionals (n = 18) at two primary care centres. The questionnaire data were analysed with descriptive statistics.
RESULTS: The analysis gave rise to the overarching theme building COPD care on shaky ground. This represents professionals driven to build a supportive COPD care on 'shaky' organisational ground in a fragmented and non-compliant healthcare organisation. The shaky ground is further represented by uninformed patients with a complex disease, which is surrounded with shame. The professionals are autonomous and pragmatic, used to taking responsibility for their work, and with limited involvement of the management. They wish to provide high quality COPD care with interprofessional collaboration, but they lack competence and are hindered by inadequate routines and lack of resources.
CONCLUSIONS: There is a gap between COPD treatment guidelines and the healthcare that is provided in primary care. To facilitate implementation of the guidelines several actions are needed, such as further training for professionals, additional resources, and improved organisational structure for interprofessional collaboration and patient education.
PMID: 28693473 [PubMed - in process]
Informed Family Member Involvement to Improve the Quality of Dementia Care in Nursing Homes.
J Am Geriatr Soc. 2017 Jan;65(1):59-65
Authors: Tjia J, Lemay CA, Bonner A, Compher C, Paice K, Field T, Mazor K, Hunnicutt JN, Lapane KL, Gurwitz J
OBJECTIVES: To describe the extent to which nursing homes engaged families in antipsychotic initiation decisions in the year before surveyor guidance revisions were implemented.
DESIGN: Mixed-methods study based on semistructured interviews.
SETTING: U.S. nursing homes (N = 20) from five CMS regions (III, IV, VI, VIII, IX).
PARTICIPANTS: Family members of nursing home residents (N = 41).
MEASUREMENTS: Family member responses to closed- and open-ended questions regarding involvement in resident care and antipsychotic initiation. Two researchers used a content analytical approach to code open responses to themes of family involvement in behavior management, decision-making, knowledge of risks and benefits, and informed consent.
RESULTS: Fifty-four percent of family members felt highly involved in decisions about behavior management. Forty-two percent recalled being asked how to manage resident behavior without medication, and 17% recalled receipt of information about antipsychotic risks and benefits. Sixty-six percent felt highly involved in the process of initiating antipsychotic medication; 24% reported being asked for input into the antipsychotic initiation decision and knowing before the antipsychotic was started.
CONCLUSION: Under existing federal regulations but before guidance revisions were implemented in 2013, more than 40% of families reported being involved in nonpharmacological behavior management of family members, but fewer than one in four reported being involved throughout the entire antipsychotic prescribing process. Interventions that standardize family engagement and promote adherence to existing federal regulations are needed. This discussion builds on these findings to weigh the policy options of greater enforcement of existing regulations versus enactment of new legislation to address this challenging issue.
PMID: 27550398 [PubMed - indexed for MEDLINE]
External validation of the Vulnerable Elder's Survey for predicting mortality and emergency admission in older community-dwelling people: a prospective cohort study.
BMC Geriatr. 2017 Mar 20;17(1):69
Authors: Wallace E, McDowell R, Bennett K, Fahey T, Smith SM
BACKGROUND: Prospective external validation of the Vulnerable Elder's Survey (VES-13) in primary care remains limited. The aim of this study is to externally validate the VES-13 in predicting mortality and emergency admission in older community-dwelling adults.
METHODS: Design: Prospective cohort study with 2 years follow-up (2010-2012).
SETTING: 15 General Practices (GPs) in the Republic of Ireland.
PARTICIPANTS: n = 862, aged ≥70 years, community-dwellers Exposure: VES-13 calculated at baseline, where a score of ≥3 denoted high risk.
OUTCOMES: i) Mortality; ii) ≥1 Emergency admission and ≥1 ambulatory care sensitive (ACS) admission over 2 years.
STATISTICAL ANALYSIS: Descriptive statistics, model discrimination (c-statistic) and sensitivity/specificity.
RESULTS: Of 862 study participants, a total of 246 (38%) were classified as vulnerable at baseline. Fifty-three (6%) died during follow-up and 246 (29%) had an emergency admission. At the VES-13 cut-point of ≥3 denoting high-risk model discrimination was poor for mortality (c-statistic: 0.61 (95% CI 0.54, 0.67), ≥1 emergency admission (c-statistic: 0.59 (95% CI 0.56, 0.63) and ≥1 ACS emergency admission (c-statistic: 0.63 (95% CI 0.60, 0.67).
CONCLUSIONS: In this study the VES-13 demonstrated relatively limited predictive accuracy in predicting mortality and emergency admission. External validation studies examining the tool in different health settings and healthier populations are needed and represent an interesting area for future research.
PMID: 28320329 [PubMed - indexed for MEDLINE]
The challenges of dysphagia in treating motor neurone disease.
Br J Community Nurs. 2017 Jul 01;22(Sup7):S17-S21
Authors: Vesey S
Motor neurone disease (MND) is a relatively rare degenerative disorder. Its impacts are manifested in progressive loss of motor function and often accompanied by wider non-motor changes. Swallowing and speech abilities are frequently severely impaired. Effective management of dysphagia (swallowing difficulty) symptoms and nutritional care requires a holistic multidisciplinary approach. Care must be patient focused, facilitate patient decision making, and support planning towards end of life care. This article discusses the challenges of providing effective nutritional care to people living with motor neurone disease who have dysphagia.
PMID: 28686046 [PubMed - in process]
Perspectives on the risks for older adults living independently.
Br J Community Nurs. 2017 Jul 02;22(7):338-345
Authors: Verver D, Merten H, Robben P, Wagner C
Insight into risks concerning older adults living independently from their own perspective and their care provider's perspective is essential to address issues that may threaten their independent living. The most often mentioned perceived risks by older adults and their care providers in different regions in the Netherlands were: loneliness, falls, budget cuts in Dutch long-term care and not being able to call for help. The different perspectives of the respondents show a wide variety in risks, but also some similarities. The perspective of the frail older adults is required to gain insight into the priority of their perceived risks. An additional finding was the reluctance shown by the older adults to ask others in their social network for help. Results imply that possible preventive measures should not only focus on the medical or physical domain because older adults are likely to have other priorities to maintain self-reliance and live independently.
PMID: 28686099 [PubMed - in process]
Fear of falling reduced by a lay led home-based program in frail community-dwelling older adults: A randomised controlled trial.
Arch Gerontol Geriatr. 2017 Jan - Feb;68:25-32
Authors: Kapan A, Luger E, Haider S, Titze S, Schindler K, Lackinger C, Dorner TE
BACKGROUND: In older adults, fear of falling (FOF) leads to a decline in daily physical activity quality of life and an increased risk of falling. The aim of this randomised controlled trial was to assess the effects of a 12-week home-based intervention program carried out by lay volunteers on FOF in frail older adults.
METHODS: Thirty-nine participants were randomised to a physical training and nutrition (PTN) group and 41 participants to a social support (SOSU) group. In the PTN group, strength training and conversation about optimising nutrition were performed twice weekly, and the SOSU group received home visits without intervention. FOF and change of FOF were assessed using the Falls Efficacy Scale - International (FES-I). The Short Physical Performance Battery (SPPB), the Physical Activity Scale for the Elderly (PASE) and maximum handgrip strength and their changes were also assessed.
RESULTS: The mean FES-I score at baseline was 42.7 points and was significantly associated with the SPPB and PASE scores. The FES-I score significantly changed in the PTN group from 44.1 to 39.9 points over the course of the intervention. Twenty-seven percent of the participants showed a decreased FES-I score of at least 4 points. This decrease was associated with an increase in the SPPB score and an increase in handgrip strength CONCLUSION: A 12-week structured physical training and nutrition intervention carried out by lay volunteers, which leads to an increase in physical activity and improved physical performance, can reduce FOF by about 10%.
PMID: 27588891 [PubMed - indexed for MEDLINE]
Activity engagement and physical function in old age sample.
Arch Gerontol Geriatr. 2017 Mar - Apr;69:55-60
Authors: Shah KN, Lin FV, Yu F, McMahon JM
OBJECTIVES: To describe the patterns of engagement in mental, physical, and social activity (MA, PA, and SA) and to examine the relationship between combined activity engagement and physical function among community-dwelling older adults.
DESIGN: Cross-sectional correlational study.
SETTING: Multiple communities.
PARTICIPANTS: A total of 466 individuals aged 55 years or older.
MEASUREMENTS: Physical function was assessed using grip strength and gait speed. Engagement in PA, MA and SA was obtained from self-report questionnaires.
RESULTS: We identified four classes ("Active PA and MA", "Active MA", "Active PA", and "Inactive") that significantly differed in the frequency of engagement in MA and PA using latent class analysis. SA didn't differ across classes. Controlling for age, the "Active PA and MA", "Active MA", "Active PA" groups displayed similar grip strength that was superior to the "Inactive" group. "Active PA and MA" group had best gait speed relative to other groups, especially "Active MA" and "Inactive" group, while the "Active PA", "Active MA", and "Inactive" group were similar in gait speed.
CONCLUSION: Combined physical and mental activity engagement was associated with better physical function, especially in gait speed. Future interventional research should investigate the combination of both physical and cognitive training to prevent decline of physical function in older adults.
PMID: 27888736 [PubMed - indexed for MEDLINE]
Higher morale is associated with lower risk of depressive disorders five years later among very old people.
Arch Gerontol Geriatr. 2017 Mar - Apr;69:61-68
Authors: Niklasson J, Näsman M, Nyqvist F, Conradsson M, Olofsson B, Lövheim H, Gustafson Y
OBJECTIVE: The aim of this study was to investigate whether higher morale, i.e. future-oriented optimism, at baseline was associated with lower risk of depressive disorders five years later among very old people.Methods The Umeå85+/GErontological Regional Database, a population-based study with a longitudinal design, recruited participants in Sweden and Finland aged 85, 90 and ≥95 years. The sample in the present study included 647 individuals (89.1±4.4 years (Mean±SD), range 85-103). After five years, 216 were alive and agreed to a follow-up (92.6±3.4 years, range 90-104). The Philadelphia Geriatric Center Morale Scale (PGCMS) was used to assess morale. The depressive disorder diagnosis was determined according to DSM-IV based on medical records and interview data including assessment scales for depressive disorders. A number of sociodemographic, functional and health-related variables were analysed as possible confounders.Results For those with no depressive disorders at baseline, the only baseline variable significantly associated with depressive disorders five years later was the PGCMS score. A logistic regression model showed lower risk of depressive disorders five years later with higher baseline PGCMS scores (odds ratio 0.779 for one point increase in PGCMS, p<0.001). The association remained after adjusting for social isolation (p<0.1 association with depressive disorders five years later).Conclusion Our results indicate that the higher the morale, the lower the risk of depressive disorders five years later among very old people. The PGCMS seems to identify those very old individuals at increased risk of depressive disorders five years later. Preventive measures could befocused on this group.
PMID: 27889589 [PubMed - indexed for MEDLINE]
Developing a framework for a novel multi-disciplinary, multi-agency intervention(s), to improve medication management in community-dwelling older people on complex medication regimens (MEMORABLE)--a realist synthesis.
Syst Rev. 2017 Jul 03;6(1):125
Authors: Maidment I, Booth A, Mullan J, McKeown J, Bailey S, Wong G
BACKGROUND: Medication-related adverse events have been estimated to be responsible for 5700 deaths and cost the UK £750 million annually. This burden falls disproportionately on older people. Outcomes from interventions to optimise medication management are caused by multiple context-sensitive mechanisms. The MEdication Management in Older people: REalist Approaches BAsed on Literature and Evaluation (MEMORABLE) project uses realist synthesis to understand how, why, for whom and in what context interventions, to improve medication management in older people on complex medication regimes residing in the community, work.
METHOD: This realist synthesis uses secondary data and primary data from interviews to develop the programme theory. A realist logic of analysis will synthesise data both within and across the two data sources to inform the design of a complex intervention(s) to help improve medication management in older people. 1. Literature review The review (using realist synthesis) contains five stages to develop an initial programme theory to understand why processes are more or less successful and under which situations: focussing of the research question; developing the initial programme theory; developing the search strategy; selection and appraisal based on relevance and rigour; and data analysis/synthesis to develop and refine the programme theory and context, intervention and mechanism configurations. 2. Realist interviews Realist interviews will explore and refine our understanding of the programme theory developed from the realist synthesis. Up to 30 older people and their informal carers (15 older people with multi-morbidity, 10 informal carers and 5 older people with dementia), and 20 care staff will be interviewed. 3. Developing framework for the intervention(s) Data from the realist synthesis and interviews will be used to refine the programme theory for the intervention(s) to identify: the mechanisms that need to be 'triggered', and the contexts related to these mechanisms. Intervention strategies that change the contexts so the mechanisms are triggered to produce desired outcomes will be developed. Feedback on these strategies will be obtained.
DISCUSSION: This realist synthesis aims to develop a framework (underpinned by our programme theory) for a novel multi-disciplinary, multi-agency intervention(s), to improve medication management in community-dwelling older people on complex medication regimens.
SYSTEMATIC REVIEW REGISTRATION: PROSPERO CRD42016043506.
PMID: 28673335 [PubMed - in process]
Supporting carers to manage pain medication in cancer patients at the end of life: A feasibility trial.
Palliat Med. 2017 Jun 01;:269216317715197
Authors: Latter S, Hopkinson JB, Lowson E, Hughes JA, Hughes J, Duke S, Anstey S, Bennett MI, May C, Smith P, Richardson A
BACKGROUND: Carers of people with advanced cancer play a significant role in managing pain medication, yet they report insufficient information and support to do so confidently and competently. There is limited research evidence on the best ways for clinicians to help carers with medication management.
AIMS: To develop a pain medicines management intervention (Cancer Carers Medicines Management) for cancer patients' carers near the end of life and evaluate feasibility and acceptability to nurses and carers. To test the feasibility of trial research procedures and to inform decisions concerning a full-scale randomised controlled trial.
DESIGN: Phase I-II clinical trial. A systematic, evidence-informed participatory method was used to develop CCMM: a nurse-delivered structured conversational process. A two-arm, cluster randomised controlled feasibility trial of Cancer Carers Medicines Management was conducted, with an embedded qualitative study to evaluate participants' experiences of Cancer Carers Medicines Management and trial procedures.
SETTING: Community settings in two study sites.
PARTICIPANTS: Phase I comprises 57 carers, patients and healthcare professionals and Phase II comprises 12 nurses and 15 carers.
RESULTS: A novel intervention was developed. Nurses were recruited and randomised. Carer recruitment to the trial was problematic with fewer than predicted eligible participants, and nurses judged a high proportion unsuitable to recruit into the study. Attrition rates following recruitment were typical for the study population. Cancer Carers Medicines Management was acceptable to carers and nurses who took part, and some benefits were identified.
CONCLUSION: Cancer Carers Medicines Management is a robustly developed medicines management intervention which merits further research to test its effectiveness to improve carers' management of pain medicines with patients at the end of life. The study highlighted aspects of trial design that need to be considered in future research.
PMID: 28679073 [PubMed - as supplied by publisher]
Scaffolding behavioral health concepts from more simple to complex builds NP students' competence.
Nurse Educ Today. 2017 Apr;51:124-126
Authors: Lauerer J, Edlund BJ, Williams A, Donato A, Smith G
BACKGROUND: Behavioral health disorders (psychiatric illness and substance abuse disorders) represent a significant burden across the nation's health care system. About one half of the problems that present in primary health care settings are behavioral in nature. There is urgent need to improve the integration of behavioral health care services into primary care.
METHODS: The purpose of this paper is to describe how an asynchronous online graduate nurse practitioner program utilized a constructivist paradigm to creatively combine online problem based learning cases and on campus learning intensives to scaffold student learning.
RESULTS: Student E-value scores were high and comments reflected improved knowledge, skill and comfort managing behavioral health problems in a primary care setting.
CONCLUSION: This innovative model can serve as a template for other educational programs and improve student's ability to identify, manage and treat common behavioral health care problems that present in primary care settings.
PMID: 27567341 [PubMed - indexed for MEDLINE]
Weakness of Eye Closure with Central Facial Paralysis after Unilateral Hemispheric Stroke Predicts a Worse Outcome.
J Stroke Cerebrovasc Dis. 2017 Apr;26(4):834-841
Authors: Lin J, Chen Y, Wen H, Yang Z, Zeng J
BACKGROUND: Upper facial dysfunction is not generally considered a feature of central facial paralysis after unilateral hemispheric stroke; however, weakness of eye closure (WEC) has been observed in some cases. We aimed to investigate the frequency and characteristics of WEC in unilateral stroke and its association with stroke prognosis.
METHODS: Patients with unilateral stroke and central facial paralysis were prospectively recruited within 7 days of onset. Facial paralysis was evaluated via the fourth item in the National Institute of Health Stroke Scale (NIHSS-4) and the Japan Facial Score (JFS) on admission, and at days 7, 14, 21, and 30 after stroke. Eye closure strength was measured daily using an ergometer for 30 days after stroke. Primary outcome was assessed using the modified Rankin Scale (mRS) at 90 and 180 days. Univariate and multivariate analyses were performed to investigate risk factors of WEC.
RESULTS: WEC was identified in 16 of 242 patients (6.6%). Baseline characteristics, stroke risk factors, and lesion volume were not significantly different between patients with and patients without WEC. Patients with WEC featured higher NIHSS-4 scores and lower JFS between admission and at 21 days after stroke. Severe central facial paralysis (odds ratio [OR] = 8.1, 95% confidence interval [CI] = 2.3-28.6, P = .001) and right hemispheric stroke (OR = 13.7, 95% CI = 3.7-51.2, P < .001) were potential predictors of WEC. At 180 days after stroke, patients with WEC demonstrated a lower rate of functional independence (mRS = 0-2: 37.5% versus 72.1%, P < .001).
CONCLUSIONS: WEC, which predicts a worse functional outcome at 180 days after unilateral stroke, demonstrates an association with severe central facial paralysis and right hemispheric stroke.
PMID: 27986397 [PubMed - indexed for MEDLINE]
Hot Topics in Primary Care: Cardiovascular Safety of Medications for Type 2 Diabetes Mellitus.
J Fam Pract. 2017 Apr;66(4 Suppl):S16-S21
Authors: Butler J
Besides vascular events, which include myocardial infarction and stroke, patients with diabetes are at a high risk for developing heart failure and heart failure-related death, with a 15% increase in the risk of heart failure for every 1% increase in glycated hemoglobin (HbA1c) above 7.5%.
PMID: 28375403 [PubMed - indexed for MEDLINE]
Hot Topics in Primary Care: Role of the Microbiome in Disease: Implications for Treatment of Irritable Bowel Syndrome.
J Fam Pract. 2017 Apr;66(4 Suppl):S40-S45
Authors: Lacy BE
Dietary and some other treatments for IBS are supported by a growing body of evidence, much of which comes from programs such as the Human Microbiome Project and Human Gut Microbiome Initiative, which were intended to identify and characterize microorganisms found in association with both healthy and diseased humans. These programs used state-of-the-art technology to characterize the human microbiome from multiple body sites. This evidence indicates that the gut microbiome plays an important role in IBS and some other gastrointestinal (GI) disorders.
PMID: 28375407 [PubMed - indexed for MEDLINE]
Hot Topics in Primary Care: Medication Adherence in Type 2 Diabetes Mellitus: Real-World Strategies for Addressing a Common Problem.
J Fam Pract. 2017 Apr;66(4 Suppl):S46-S51
Authors: Brunton SA, Polonsky WH
The importance of treatment adherence is well established, as poor adherence contributes to disease progression and increased morbidity and mortality. Analysis of 11,272 veterans with T2DM with a mean follow-up of 5 years showed that for each 10% increase in the medication possession ratio, the mean glycated hemoglobin (HbA1c) decreased by 0.24%. Poor adherence also leads to increased health care resource utilization and costs, including more frequent hospitalizations. Conversely, while improved adherence increases medication costs, it can decrease overall health care resource utilization and costs. Improved medication adherence also contributes to improvement in diabetes-related quality of life.
PMID: 28375408 [PubMed - indexed for MEDLINE]
Cognitive impairment among patients with multiple sclerosis: associations with employment and quality of life.
Postgrad Med J. 2017 Mar;93(1097):143-147
Authors: Campbell J, Rashid W, Cercignani M, Langdon D
OBJECTIVES: To explore the relationship between cognitive impairment and conventional measures of disability in multiple sclerosis (MS), quality of life (QOL) and employment status using the brief international cognitive assessment for multiple sclerosis (BICAMS) in the routine outpatient clinic.
METHODS: 62 patients with MS were assessed on the BICAMS test battery for cognitive impairment. Data were obtained on employment status and a number of questionnaires completed including fatigue severity score, multiple sclerosis neuropsychological questionnaire, hospital anxiety and depression scale, the functional assessment of multiple sclerosis (FAMS) as well as on the EuroQOL five dimension questionnaire (EQ-5D). Other assessments include the patient activation measure and unidimensional self-efficacy scale for multiple sclerosis.
RESULTS: Cognitive assessment revealed 44 subjects (65%) had evidence of cognitive impairment on formal testing. In comparison with patients without evidence of cognitive impairment, cognitively impaired patients exhibited significantly higher rates of unemployment (p=0.009). The symbol digits modalities test was the most significant predictor of unemployment. Cognitive impairment was associated with lower QOL scores on the FAMS (p=0.001) and EQ-5D (p<0.001).
CONCLUSIONS: BICAMS provides a sensitive and easy to administer screening test for cognitive impairment within the outpatient setting. Cognitive impairment is common in our cohort of patients with MS attending outpatients and appears to be associated with increased rates of unemployment and lower measures of QOL.
PMID: 27512050 [PubMed - indexed for MEDLINE]
Factors Influencing Diabetes Self-Management Among Medically Underserved Patients With Type II Diabetes.
Glob Qual Nurs Res. 2017 Jan-Dec;4:2333393617713097
Authors: Reyes J, Tripp-Reimer T, Parker E, Muller B, Laroche H
In this study, researchers compare and contrast issues regarding diabetes self-management between persons in good versus poor glycemic control. The sample comprises low-income racially diverse adults with diabetes from four mid-western community health centers; 44 patients participated in eight focus groups divided by control status (HbA1c of > 9 [uncontrolled] or < 7 [controlled]). Themes common to both groups included the impact of dietary restrictions on social interactions, food cravings, the impact of mental health on self-management, and the importance of formal and informal (friends and family) support. Those in the uncontrolled groups described fear about being able to control their diabetes, confusion about self-management, and difficulty managing their diabetes while caring for family members. Although those in the controlled groups acknowledged difficulties, they discussed resisting cravings, making improvements with small changes, positive feelings about their ability to control their diabetes, and enjoying new foods and exercise. Interventions should include mental health support, incorporate formal and informal patient support structures, and address literacy issues. Health care providers and intervention personnel should be very concrete about how to do self-management tasks and guide patients on how to alter their diabetes regimens for social and other important life events.
PMID: 28660239 [PubMed - in process]
Reducing Off-Label Antipsychotic Use in Older Community-Dwelling Adults With Dementia: A Narrative Review.
J Am Osteopath Assoc. 2017 Jul 01;117(7):441-450
Authors: Bain KT, Schwartz EJ, Chan-Ting R
The off-label use of antipsychotics for the management of behavioral and psychologic symptoms of dementia (BPSD) in older adults (age ≥65 years) is common, despite evidence of modest benefits and serious risks. Although national initiatives aimed at reducing antipsychotic use among older adults with BPSD in nursing homes have been successful, similar initiatives are lacking for community-dwelling adults with dementia. As a result, older adults with BPSD residing in the community may be at an even greater risk of being negatively affected by antipsychotic use. Physicians should be knowledgeable of this issue and understand the alternatives to antipsychotics, as well as how to reduce antipsychotic use in patients with dementia who are already taking antipsychotics.
PMID: 28662557 [PubMed - in process]
Living with Multiple Myeloma: A Continuum-Based Approach to Cancer Survivorship.
Semin Oncol Nurs. 2017 Jun 27;:
Authors: Kurtin S
OBJECTIVES: To describe a tailored approach to survivorship care for health care providers (HCPs) involved in the care of patients and caregivers living with multiple myeloma (MM) and identify key transition points within the continuum of care with recommended adaptation to the survivorship care plan (SCP).
DATA SOURCES: Review of the literature, web-based resources.
CONCLUSION: The health care needs of cancer survivors will vary throughout the continuum of care. Effective patient self-management requires several key elements: consistent and clear communication that allows the patient to make informed decisions, reinforcement of key messages at each visit, adjustment of visit frequency to the specific phase of survivorship and health care needs, integration of community programs and resources, and development of mutually determined goals. The goal is to focus on living, maintaining or improving quality of life (QOL) in the MM survivor with consideration of the needs of caregivers.
IMPLICATIONS FOR NURSING PRACTICE: Implementation of a tailored survivorship care plan (SCP) based on individual disease- and treatment-related factors, personal preferences, and available resources, setting expectations, and continuing to communicate openly with the MM patients and their caregivers promotes health-self-management, reduces symptom burden, and improves QOL. Innovative strategies for survivorship care that promote communicative health literacy, engage the patient and their caregivers in health self-management, involve the survivor in developing the SCP, and clearly designate the roles of HCPs are needed.
PMID: 28663078 [PubMed - as supplied by publisher]
Hyponatraemia - presentations and management.
Clin Med (Lond). 2017 Jun;17(3):263-269
Authors: Dineen R, Thompson CJ, Sherlock M
Hyponatraemia is the most common electrolyte disturbance encountered in clinical practice. It is associated with -significant morbidity and mortality, thus appropriate investigation and treatment is essential. Hyponatraemia presents with a spectrum of clinical presentations ranging from no symptoms to life-threatening neurological sequelae. Hyponatraemia has multiple aetiologies and distinguishing the underlying aetiology facilitates appropriate treatment. This review provides an overview of the presentations and approaches to management of this common clinical condition.
PMID: 28572229 [PubMed - indexed for MEDLINE]
Effect of Perioperative Intravenous Lidocaine Infusion on Acute and Chronic Pain after Breast Surgery: A Meta-Analysis of Randomized Controlled Trials.
Pain Pract. 2017 Mar;17(3):336-343
Authors: Chang YC, Liu CL, Liu TP, Yang PS, Chen MJ, Cheng SP
OBJECTIVES: Intravenous lidocaine infusion has been shown to reduce postoperative pain among patients undergoing abdominal surgery. This study aimed to evaluate the effects of perioperative lidocaine administration in breast surgery.
METHODS: A meta-analysis of randomized controlled trials comparing lidocaine infusion vs. placebo/routine treatment was performed. Standardized mean difference (SMD) or risk ratio (RR) with 95% confidence intervals (CIs) was calculated from pooled data. Random-effects models were used, and heterogeneity was assessed.
RESULTS: A total of 4 reports (3 primary studies and 1 extension) with 84 patients randomized to the lidocaine group and 83 patients randomized to the control group were included. There was no difference in pain scores at rest or during activity between the 2 groups from postoperative 2 hours to 3 days. At postoperative 72 hours, the lidocaine group had fewer analgesics consumed (SMD, -0.479; 95% CI, -0.914 to -0.043; P = 0.031). Chronic pain was assessed 3 to 6 months after breast surgery in 51 patients of the lidocaine group and 46 patients of the control group. Patients in the lidocaine group had significantly lower risk for the development of chronic pain (RR, 0.332; 95% CI, 0.141 to 0.781; P = 0.012).
CONCLUSION: The results indicate no significant benefits of intravenous lidocaine infusion in terms of acute postoperative pain. Although lidocaine seems to attenuate the risk of chronic pain after breast surgery, there is insufficient evidence to conclude that lidocaine infusion is of proved benefit because the results were based on a limited number of small trials.
PMID: 26913591 [PubMed - indexed for MEDLINE]
Meals Enhancing Nutrition After Discharge: Findings from a Pilot Randomized Controlled Trial.
J Acad Nutr Diet. 2017 Apr;117(4):599-608
Authors: Buys DR, Campbell AD, Godfryd A, Flood K, Kitchin E, Kilgore ML, Allocca S, Locher JL
BACKGROUND: After older adults experience episodes of poor health or are hospitalized, they may not return to premorbid or prehospitalization eating behaviors. Furthermore, poor nutrition increases hospital readmission risk, but evidence-based interventions addressing these risks are limited.
OBJECTIVE: This pilot study's objective was to evaluate the feasibility of conducting a randomized controlled trial assessing a post-discharge home-delivered meal program's impact on older adults' nutritional intake and hospital readmissions and to assess patient acceptability and satisfaction with the program. The aims of the study were to evaluate successful recruitment, randomization, and retention of at least 80% of the 24 participants sought; to compare the outcomes of hospital readmission and total daily caloric intake between participants in the intervention and control groups; and to assess patient acceptability and satisfaction with the program.
DESIGN: This study used a two-arm randomized controlled trial design, and baseline data were collected at enrollment; three 24-hour food recalls were collected during the intervention period; and health services utilization and intervention satisfaction was evaluated 45 days post-discharge.
PARTICIPANTS/SETTING: Twenty-four patients from the University of Alabama at Birmingham Hospital's Acute Care for Elders (ACE) Unit were enrolled from May 2014 to June 2015. They were 65 years or older; at risk for malnutrition; cognitively intact; able to communicate; discharged to a place where the patient or family was responsible for preparing meals; and diagnosed with congestive heart failure, chronic obstructive pulmonary disease, acute myocardial infarction, or pneumonia. Final analysis included 21 participants.
INTERVENTION: The intervention group received 10 days of home-delivered meals and nutrition education; the control group received usual care and nutrition education.
MAIN OUTCOME MEASURES: The main outcome was intervention feasibility, measured by recruitment and retention goals. Hospital readmissions, caloric intake, and satisfaction with the intervention were also evaluated.
STATISTICAL ANALYSES PERFORMED: Univariate and bivariate parametric statistics were used to evaluate differences between groups. Goals for success were identified to assess feasibility of conducting a full-scale study and outcomes were measured against the goals.
RESULTS: Of the randomized participants, 87.5% were retained for final data collection, indicating that this intervention study is feasible. There were no significant differences between groups for hospital readmissions; however, caloric intake during the intervention period was greater for intervention vs control participants (1,595 vs 1,235; P=0.03). Participants were overwhelmingly satisfied (82% to 100% satisfied or very satisfied) with staff performance, meal quality, and delivery processes.
CONCLUSIONS: Conducting a randomized controlled trial to assess outcomes of providing home-delivered meals to older adults after hospital discharge in partnership with a small nonprofit organization is feasible and warrants future research.
PMID: 28065635 [PubMed - indexed for MEDLINE]
Bariatric Surgery and Long-term Durability of Weight Loss.
JAMA Surg. 2016 Nov 01;151(11):1046-1055
Authors: Maciejewski ML, Arterburn DE, Van Scoyoc L, Smith VA, Yancy WS, Weidenbacher HJ, Livingston EH, Olsen MK
Importance: Bariatric surgery induces significant weight loss for severely obese patients, but there is limited evidence of the durability of weight loss compared with nonsurgical matches and across bariatric procedures.
Objectives: To examine 10-year weight change in a large, multisite, clinical cohort of veterans who underwent Roux-en-Y gastric bypass (RYGB) compared with nonsurgical matches and the 4-year weight change in veterans who underwent RYGB, adjustable gastric banding (AGB), or sleeve gastrectomy (SG).
Design, Setting, and Participants: In this cohort study, differences in weight change up to 10 years after surgery were estimated in retrospective cohorts of 1787 veterans who underwent RYGB from January 1, 2000, through September 30, 2011 (573 of 700 eligible [81.9%] with 10-year follow-up), and 5305 nonsurgical matches (1274 of 1889 eligible [67.4%] with 10-year follow-up) in mixed-effects models. Differences in weight change up to 4 years were compared among veterans undergoing RYGB (n = 1785), SG (n = 379), and AGB (n = 246). Data analysis was performed from September 9, 2014, to February 12, 2016.
Exposures: Bariatric surgical procedures and usual care.
Main Outcomes and Measures: Weight change up to 10 years after surgery through December 31, 2014.
Results: The 1787 patients undergoing RYGB had a mean (SD) age of 52.1 (8.5) years and 5305 nonsurgical matches had a mean (SD) age of 52.2 (8.4) years. Patients undergoing RYGB and nonsurgical matches had a mean body mass index of 47.7 and 47.1, respectively, and were predominantly male (1306 [73.1%] and 3911 [73.7%], respectively). Patients undergoing RYGB lost 21% (95% CI, 11%-31%) more of their baseline weight at 10 years than nonsurgical matches. A total of 405 of 564 patients undergoing RYGB (71.8%) had more than 20% estimated weight loss, and 224 of 564 (39.7%) had more than 30% estimated weight loss at 10 years compared with 134 of 1247 (10.8%) and 48 of 1247 (3.9%), respectively, of nonsurgical matches. Only 19 of 564 patients undergoing RYGB (3.4%) regained weight back to within an estimated 5% of their baseline weight by 10 years. At 4 years, patients undergoing RYGB lost 27.5% (95% CI, 23.8%-31.2%) of their baseline weight, patients undergoing AGB lost 10.6% (95% CI, 0.6%-20.6%), and patients undergoing SG lost 17.8% (95% CI, 9.7%-25.9%). Patients undergoing RYGB lost 16.9% (95% CI, 6.2%-27.6%) more of their baseline weight than patients undergoing AGB and 9.7% (95% CI, 0.8%-18.6%) more than patients undergoing SG.
Conclusions and Relevance: Patients in the Veterans Administration health care system lost substantially more weight than nonsurgical matches and sustained most of this weight loss in the long term. Roux-en-Y gastric bypass induced significantly greater weight loss among veterans than SG or AGB at 4 years. These results provide further evidence of the beneficial association between surgery and long-term weight loss that has been demonstrated in shorter-term studies of younger, predominantly female populations.
PMID: 27579793 [PubMed - indexed for MEDLINE]
Risk of Carotid Stroke after Chiropractic Care: A Population-Based Case-Crossover Study.
J Stroke Cerebrovasc Dis. 2017 Apr;26(4):842-850
Authors: Cassidy JD, Boyle E, Côté P, Hogg-Johnson S, Bondy SJ, Haldeman S
BACKGROUND: Chiropractic manipulation is a popular treatment for neck pain and headache, but may increase the risk of cervical artery dissection and stroke. Patients with carotid artery dissection can present with neck pain and/or headache before experiencing a stroke. These are common symptoms seen by both chiropractors and primary care physicians (PCPs). We aimed to assess the risk of carotid artery stroke after chiropractic care by comparing association between chiropractic and PCP visits and subsequent stroke.
METHODS: A population-based, case-crossover study was undertaken in Ontario, Canada. All incident cases of carotid artery stroke admitted to hospitals over a 9-year period were identified. Cases served as their own controls. Exposures to chiropractic and PCP services were determined from health billing records.
RESULTS: We compared 15,523 cases to 62,092 control periods using exposure windows of 1, 3, 7, and 14 days prior to the stroke. Positive associations were found for both chiropractic and PCP visits and subsequent stroke in patients less than 45 years of age. These associations tended to increase when analyses were limited to visits for neck pain and headache-related diagnoses. There was no significant difference between chiropractic and PCP risk estimates. We found no association between chiropractic visits and stroke in those 45 years of age or older.
CONCLUSIONS: We found no excess risk of carotid artery stroke after chiropractic care. Associations between chiropractic and PCP visits and stroke were similar and likely due to patients with early dissection-related symptoms seeking care prior to developing their strokes.
PMID: 27884458 [PubMed - indexed for MEDLINE]
Authors: Puma, D. V., Pérez-Quílez, O., Roure, S., Martínez-Cuevas, O., Bocanegra, C., Feijoo-Cid, M. and Valerio, L. (2017)
Source: Public Health Nurs, 34: 112–117. doi:10.1111/phn.12279
A Comparison of Expectations of Physicians and Patients with Chronic Pain for Pain Clinic Visits.
Pain Pract. 2017 Mar;17(3):305-311
Authors: Calpin P, Imran A, Harmon D
BACKGROUND: The patient-physician encounter forms the cornerstone of every health service. However, optimal medical outcomes are often confounded by inadequate patient-physician communication. Chronic pain is estimated to affect over 25% of the population. Its effects are multifaceted with patients at increased risk of experiencing emotional and functional disturbances. Therefore, it is crucial to address all components of the patient's pain experience, including beliefs and expectations. It is our understanding that no other study to date has evaluated the expectations of physicians and compared them to those of patients for pain clinic visits. We sought to describe and compare expectations of chronic pain patients and their physicians during a clinic consultation.
METHODS: We performed a retrospective review on patients attending the pain clinic for the first time who were enrolled and completed a questionnaire asking their expectations for their clinic visit as well as outcomes that would satisfy and disappoint them. Pain physicians were also included. We compared physicians' to patients' responses and evaluated relationships between patient responses and age, gender, pain location, Pain Self-Efficacy, Pain Catastrophizing Scale, and the Hospital Anxiety and Depression Scale.
RESULTS: One hundred chronic pain patients and 10 pain physicians were surveyed. Patients' clinical expectations for visits focused primarily on some pain relief (34%), education on the cause of pain (24%), and a definitive diagnosis (18%). Physician's expectations included formulation and communication of a management plan (70%), patient assessment for cause of pain (50%), and the education of patients on the cause of pain (40%) as important aims. Pain relief would satisfy the majority of patients (74%) and physicians (70%). No improvement would cause greatest dissatisfaction for patients (52%), but causing more harm would be disappointing to physicians (50%). Gender, age, pain location, and sleep quality all significantly influenced patients' expectations and affective pain comorbidities.
CONCLUSION: We found some agreement and some discordance of clinical expectations between pain patients and physicians. Patient factors may also impact on expectations and comorbidities. Findings from this study will help doctors consider patients' expectations in planning pain clinic visits, improve patient-doctor communication and pain management, and may lead to further hypothesis-driven studies.
PMID: 26992011 [PubMed - indexed for MEDLINE]
Medical Care Activities Among Spouses of Older Adults With Functional Disability: Implications for Caregiving Difficulties and Gains.
Am J Geriatr Psychiatry. 2017 May 04;:
Authors: Polenick CA, Leggett AN, Kales HC
OBJECTIVES: Spouses of older adults with functional disability often provide help with their partner's medical care. Yet little is known about the implications of these activities for spouses' caregiving experiences. We examined how spouses' medical care activities are linked to both positive and negative aspects of caregiving (difficulties and gains), and whether these associations vary by their age, gender, or education.
DESIGN: Retrospective analysis of data from the 2011 National Health and Aging Trends Study and National Study of Caregiving cross-sectional studies.
SETTING: Caregivers and care recipients/proxies were interviewed by telephone at home.
PARTICIPANTS: Nationally representative U.S. sample of 345 spousal caregivers and their community-dwelling care recipients aged 65 years and older.
MEASUREMENTS: Caregivers' self-reported sociodemographics, care activities, health conditions, well-being, and support resources. Care recipients (or proxies) reported on their health conditions and dementia status.
RESULTS: A higher number of health system interaction tasks (e.g., making appointments) were significantly associated with greater emotional caregiving difficulties, whereas a higher number of medical/nursing tasks (e.g., giving shots/injections) were significantly linked to greater caregiving gains. A higher number of medical/nursing tasks were also significantly associated with greater physical difficulties for caregiving wives and spouses with less education.
CONCLUSIONS: Medical care activities may have both positive and negative consequences for spousal caregivers, which depend partly on sociodemographics. This study underscores the importance of ensuring that spouses have the resources and support needed to provide complex care to their partners.
PMID: 28652082 [PubMed - as supplied by publisher]
Multilingual Self-Management Resources for Prostate Cancer Survivors and Their Partners: Results of a Long-Term Academic-State Health Department Partnership to Promote Survivorship Care.
Urology. 2017 Jun 23;:
Authors: Skolarus TA, Ragnoni JA, Garlinghouse C, Schafenacker A, Webster D, Hager P, Wittmann D, Northouse L
INTRODUCTION: There is increasing need for innovative, sustainable ways to provide evidence-based self-management information and supportive care for prostate cancer survivors and their partners. For these reasons, we describe how an academic-public partnership facilitated the broad dissemination of evidence-based, multilingual survivorship educational materials via a state-managed prostate cancer website.
METHODS: We outline the steps of an academic-public partnership leading to dissemination of online, survivorship materials as a resource for prostate cancer survivors and their partners. We examined the 5-year utilization of the materials from January 2011 through December 2015 according to 14 content areas (e.g., urinary, bowel, and sexual problems, fatigue, communication, cancer stress) and across three languages (English, Spanish, Arabic).
RESULTS: The total number of prostate cancer survivorship materials downloaded from January 2011 through December 2015 was 89,348. The number of downloaded materials increased over time from 6,421 in 2011 to 17,496 in 2015. The most commonly downloaded content area was Urine Problems (27.5%), followed by Bowel Problems (23.4%) and Sexual Side Effects (16.2%). The majority of downloaded material was in English (86.3%), followed by Spanish (9.8%) and Arabic (3.9%).
CONCLUSIONS: The academic-public partnership facilitated broad dissemination of evidence-based informational materials for prostate cancer survivors and their partners via a state-managed website from 2011 through 2015. Given the increasing role of academic-public partnerships in funding and development of robust, sustainable prostate cancer survivorship resources, this work serves as an introduction to these evidence-based materials and highlights a successful model of engagement between practitioners, research scientists, and public health administration.
PMID: 28652166 [PubMed - as supplied by publisher]
Evaluation of the Feasibility of a Home-Based TeleYoga Intervention in Participants with Both Chronic Obstructive Pulmonary Disease and Heart Failure.
J Altern Complement Med. 2017 Jun 27;:
Authors: Donesky D, Selman L, McDermott K, Citron T, Howie-Esquivel J
OBJECTIVE: Test the feasibility and clinical outcomes of a home-based videoconferencing yoga intervention in participants diagnosed with both Chronic Obstructive Pulmonary Disease (COPD) and heart failure (HF).
BACKGROUND: Yoga has potential benefit for symptom relief in participants with COPD and with HF; however, functional impairment and transportation issues can hinder access to typical yoga classes.
METHODS: A controlled, nonrandomized trial was conducted of an 8-week TeleYoga intervention versus an educational control (information leaflets mailed to participants with one weekly phone call). One-hour TeleYoga classes were implemented twice weekly via multipoint videoconferencing, which connected participants to live classes via an Internet connection to their televisions.
RESULTS: Fourteen participants with COPD and HF took part in the pilot study (7 in the intervention group and 8 in the control). Intervention participants were adherent to classes, able to safely participate, and found the classes enjoyable after the 8-week program. Dyspnea after exercise improved in the intervention group.
CONCLUSIONS: Despite their frailty, patients diagnosed with both COPD and HF were able to perform yoga safely in the home setting. TeleYoga was acceptable and adherence was good; however, technical issues were an important hindrance to participation.
PMID: 28654302 [PubMed - as supplied by publisher]
Decreasing Opioid Utilization in Rehabilitation Patients Using a Clinical Nurse Specialist Pain Consultant Program.
Arch Phys Med Rehabil. 2017 Jun 28;:
Authors: Urton MS, Rohlik E, Farrell M, Ng W, Woodard EK
OBJECTIVE: To investigate whether access to a clinical nurse specialist (CNS) with expertise in pain management will result in more rapid decline in opioid use across the rehabilitation hospitalization.
DESIGN: Retrospective chart review of patients discharged during six months prior to and six months following introduction of the CNS role.
SETTING: Not-for-profit 98-bed community inpatient rehabilitation hospital.
PARTICIPANTS: Two population-based samples of adult, inpatient rehabilitation patients with daily opioid use ≥ 30 mg morphine equivalent dose (MED)/day on admission and length of stay ≥ 24 days.
INTERVENTIONS: Implementation of a CNS pain consult program.
MAIN OUTCOME MEASURES: Change in average daily opioid use (mg MED/day), measured at admission, Week 1, Week 2, and Week 3.
RESULTS: Linear Mixed Modeling was used to estimate individual and group-average opioid trajectories, including individual patient intercepts (opioid use at admission) and slopes (change in opioid use over time). There was a significant interaction between group and time, b= 5.75, t = 2.52, p < 0.01, indicating faster change in opioid use for the CNS group (quadratic slope= -5.91) compared to the No CNS group (quadratic slope=-0.16). Quadratic change in the CNS group reflected an initial increase in opioid use from Admission to Week 1, followed by a steady decline. Conversely, there was virtually no change in the No CNS group. Random effects revealed considerable variability in opioid trajectories across patients.
CONCLUSIONS: Addition of a clinical nurse specialist pain consultant program to an inpatient rehabilitation hospital supported a distinct pattern of opioid tapering that promoted more rapid titration of daily opioid use across the rehabilitation hospitalization. Key Words: Pain, Clinical Nurse Specialist, Rehabilitation, Consultation.
PMID: 28668543 [PubMed - as supplied by publisher]
Pilot randomized controlled trial of a mindfulness-based group intervention in adolescent girls at risk for type 2 diabetes with depressive symptoms.
Complement Ther Med. 2017 Jun;32:66-74
Authors: Shomaker LB, Bruggink S, Pivarunas B, Skoranski A, Foss J, Chaffin E, Dalager S, Annameier S, Quaglia J, Brown KW, Broderick P, Bell C
OBJECTIVE: (1) Evaluate feasibility and acceptability of a mindfulness-based group in adolescent girls at-risk for type 2 diabetes (T2D) with depressive symptoms, and (2) compare efficacy of a mindfulness-based versus cognitive-behavioral group for decreasing depressive symptoms and improving insulin resistance.
DESIGN AND SETTING: Parallel-group, randomized controlled pilot trial conducted at a university.
PARTICIPANTS: Thirty-three girls 12-17y with overweight/obesity, family history of diabetes, and elevated depressive symptoms were randomized to a six-week mindfulness-based (n=17) or cognitive-behavioral program (n=16).
INTERVENTIONS: Both interventions included six, one-hour weekly group sessions. The mindfulness-based program included guided mindfulness awareness practices. The cognitive-behavioral program involved cognitive restructuring and behavioral activation.
MAIN OUTCOME MEASURES: Adolescents were evaluated at baseline, post-intervention, and six-months. Feasibility/acceptability were measured by attendance and program ratings. Depressive symptoms were assessed by validated survey. Insulin resistance was determined from fasting insulin and glucose, and dual energy x-ray absorptiometry was used to assess body composition.
RESULTS: Most adolescents attended ≥80% sessions (mindfulness: 92% versus cognitive-behavioral: 87%, p=1.00). Acceptability ratings were strong. At post-treatment and six-months, adolescents in the mindfulness condition had greater decreases in depressive symptoms than adolescents in the cognitive-behavioral condition (ps<.05). Compared to the cognitive-behavioral condition, adolescents in the mindfulness-based intervention also had greater decreases in insulin resistance and fasting insulin at post-treatment, adjusting for fat mass and other covariates (ps<.05).
CONCLUSIONS: A mindfulness-based intervention shows feasibility and acceptability in girls at-risk for T2D with depressive symptoms. Compared to a cognitive-behavioral program, after the intervention, adolescents who received mindfulness showed greater reductions in depressive symptoms and better insulin resistance. ClinicalTrials.gov identifier: NCT02218138 clinicaltrials.gov.
PMID: 28619307 [PubMed - indexed for MEDLINE]
A Risk Score for Predicting Multiple Sclerosis.
PLoS One. 2016;11(11):e0164992
Authors: Dobson R, Ramagopalan S, Topping J, Smith P, Solanky B, Schmierer K, Chard D, Giovannoni G
OBJECTIVE: Multiple sclerosis (MS) develops as a result of environmental influences on the genetically susceptible. Siblings of people with MS have an increased risk of both MS and demonstrating asymptomatic changes in keeping with MS. We set out to develop an MS risk score integrating both genetic and environmental risk factors. We used this score to identify siblings at extremes of MS risk and attempted to validate the score using brain MRI.
METHODS: 78 probands with MS, 121 of their unaffected siblings and 103 healthy controls were studied. Personal history was taken, and serological and genetic analysis using the illumina immunochip was performed. Odds ratios for MS associated with each risk factor were derived from existing literature, and the log values of the odds ratios from each of the risk factors were combined in an additive model to provide an overall score. Scores were initially calculated using log odds ratio from the HLA-DRB1*1501 allele only, secondly using data from all MS-associated SNPs identified in the 2011 GWAS. Subjects with extreme risk scores underwent validation studies. MRI was performed on selected individuals.
RESULTS: There was a significant difference in the both risk scores between people with MS, their unaffected siblings and healthy controls (p<0.0005). Unaffected siblings had a risk score intermediate to people with MS and controls (p<0.0005). The best performing risk score generated an AUC of 0.82 (95%CI 0.75-0.88).
INTERPRETATIONS: The risk score demonstrates an AUC on the threshold for clinical utility. Our score enables the identification of a high-risk sibling group to inform pre-symptomatic longitudinal studies.
PMID: 27802296 [PubMed - indexed for MEDLINE]
Community-Based Care of the Fibromyalgia Patient: Strategies to Promote Self-Management.
Home Healthc Now. 2017 Jul/Aug;35(7):364-372
Authors: Davis K, Sargent L, Menzies V
Along with a variety of distressing symptoms, a diagnosis of fibromyalgia (FM) brings with it substantial physical, psychosocial, and financial costs. Research shows that self-management is an effective means to manage FM and can lead to fewer healthcare visits. Yet due to the complexity of this disorder, healthcare providers need to be able to tailor treatment to individual patients by understanding effective treatment interventions. Home healthcare nurses (HHNs) are in a unique position to assess and implement effective treatment recommendations in the home setting and as such could consider incorporating self-management strategies into the home visit with the FM patient. Therefore, the purpose of this article is to use a case study to describe the assessment of FM patient's functional ability and quality of life and how the HHN may integrate self-management teaching into the established home care visit. A review of the literature and discussion of self-management interventions for the FM patient is presented. A summary of the case study and proposed clinical implications is offered.
PMID: 28650366 [PubMed - in process]
Factors influencing older people's experiences of participation in autonomous decisions concerning their daily care in their own homes: a review of the literature.
Int J Older People Nurs. 2016 Dec;11(4):284-297
Authors: Fjordside S, Morville A
AIM: To review the literature on how older people perceive opportunities and limitations with regard to participation in autonomous decisions concerning their daily care in their own homes.
BACKGROUND: The perception of personal control plays a critical role in an older person's health and well-being. Little is known about factors that facilitate or hinder older people's autonomous decision-making in their own homes.
METHODS: The study has been carried out as a literature review. The following databases were used: CINAHL, PubMed, PsykInfo, Cochrane, SweMed, Embase. Research studies range from 2009 to 2014.
RESULTS: The review includes 12 publications. Four core themes are generated: older person's autonomy in their own home; autonomy and relationship; the balance between autonomy and dependency; older people's autonomy and the organisation of home care.
CONCLUSION: Older people have a strong inner drive to maintain autonomy in their own home. The autonomy is challenged when the person becomes increasingly dependent on help. The relationship with carers is of vital importance with regard to the person's ability to make autonomous decisions. The organisation of home care restricts older people' scope for autonomy.
IMPLICATIONS FOR PRACTICE: Older people's own perspectives on autonomous decisions can contribute to the ongoing debate about how nursing care can be developed with respect to their autonomy. Nursing care demands attention to an older person's desire for autonomy despite dependency. A framework for systematic ethical discussions among carers may improve awareness about factors that facilitate or hinder good personalised care. The organisation of nursing care needs to be shaped in line with best practice for older people.
PMID: 27019374 [PubMed - indexed for MEDLINE]
Measuring carer burden in informal carers of patients with long-term conditions.
Br J Community Nurs. 2017 May 02;22(5):230-236
Authors: Kudra A, Lees C, Morrell-Scott N
INTRODUCTION: The aim of this literature review is to identify the most common tools used to measure burden in carers of people with Parkinson's disease (PD), heart failure (HF), multiple sclerosis (MS) and chronic obstructive pulmonary disease (COPD).
METHOD: Databases such as Medline, PsycINFO, CINAHL and Academic Search Complete were searched. Studies in which carer burden was measured were included.
RESULTS: Zarit Burden Inventory and Caregiver Reaction Assessment were most commonly used to measure carer burden, regardless of the chronic condition. A wide range of other instruments were also used.
CONCLUSIONS: Even though a range of tools are available, further improvements are necessary in order to enable healthcare professionals to identify carers experiencing high burden.
PMID: 28467247 [PubMed - indexed for MEDLINE]
Emergency Department Visits Without Hospitalization Are Associated With Functional Decline in Older Persons.
Ann Emerg Med. 2017 Apr;69(4):426-433
Authors: Nagurney JM, Fleischman W, Han L, Leo-Summers L, Allore HG, Gill TM
STUDY OBJECTIVE: Among older persons, disability and functional decline are associated with increased mortality, institutionalization, and costs. The aim of the study was to determine whether illnesses and injuries leading to an emergency department (ED) visit but not hospitalization are associated with functional decline among community-living older persons.
METHODS: From a cohort of 754 community-living older persons who have been followed with monthly interviews for up to 14 years, we matched 813 ED visits without hospitalization (ED only) to 813 observations without an ED visit or hospitalization (control). We compared the course of disability during the following 6 months between the 2 matched groups. To establish a frame of reference, we also compared the ED-only group with an unmatched group who were hospitalized after an ED visit (ED-hospitalized). Disability scores (range 0 [lowest] to 13 [highest]) were compared using generalized linear models adjusted for relevant covariates. Admission to a nursing home and mortality were evaluated as secondary outcomes.
RESULTS: The ED-only and control groups were well matched. For both groups, the mean age was 84 years, and 69% were women. The baseline disability scores were 3.4 and 3.6 in the ED-only and control groups, respectively. During the 6-month follow-up period, the ED-only group had significantly higher disability scores than the control group, with an adjusted risk ratio of 1.14 (95% confidence interval [CI] 1.09 to 1.19). Compared with participants in the ED-only group, those who were hospitalized after an ED visit had disability scores that were significantly higher (risk ratio 1.17; 95% CI 1.12 to 1.22). Both nursing home admissions (hazard ratio 3.11; 95% CI 2.05 to 4.72) and mortality (hazard ratio 1.93; 95% CI 1.07 to 3.49) were higher in the ED-only group versus control group during the 6-month follow-up period.
CONCLUSION: Although not as debilitating as an acute hospitalization, illnesses and injuries leading to an ED visit without hospitalization were associated with a clinically meaningful decline in functional status during the following 6 months, suggesting that the period after an ED visit represents a vulnerable time for community-living older persons.
PMID: 28069299 [PubMed - indexed for MEDLINE]
The experience of receiving a kidney transplant from a deceased donor: Implications for renal services.
Psychol Health. 2017 Feb;32(2):204-220
Authors: Lonargáin DÓ, Brannigan D, Murray C
OBJECTIVE: The study aimed to explore the psychological experiences of receiving a kidney transplant from a deceased donor and to examine resulting implications for renal services.
DESIGN: A qualitative design was utilised within an interpretative phenomenological analysis (IPA) framework.
MAIN OUTCOME MEASURES: Semi-structured interviews were conducted with six adults (male = 5, mean age = 45 yrs) on their experiences of receiving a kidney transplant from a deceased donor. All participants had their transplant within the preceding 21 months. Data were analysed using IPA.
RESULTS: The four elicited themes incorporate recipients' positive feelings about receiving a transplant, mainly arising from the newfound freedom that this entails, in addition to strong feelings of gratitude towards their donors. They also capture challenges, such as the uncertainty of living with a transplanted kidney, and highlight the increased dependence on others throughout the transplant process.
CONCLUSION: The findings indicate a range of psychological, social and occupational experiences for participants. It is concluded that optimal care in renal services would incorporate a holistic approach to pre and post-transplant care; identifying and supporting the needs of transplant recipients. A biopsychosocial model of care may enhance service user well-being. Potential areas of future research are explored.
PMID: 27845569 [PubMed - indexed for MEDLINE]
Positive changes among patients with advanced colorectal cancer and their family caregivers: a qualitative analysis.
Psychol Health. 2017 Jan;32(1):94-109
Authors: Mosher CE, Adams RN, Helft PR, O'Neil BH, Shahda S, Rattray NA, Champion VL
OBJECTIVE: This study assessed positive changes in patients with advanced colorectal cancer and their family caregivers following diagnosis. We compared self-reported positive changes within patient-caregiver dyads as well as self-reports and patient reports of positive changes in caregivers.
DESIGN: Individual, semi-structured qualitative interviews were conducted with 23 patients with advanced colorectal cancer and 23 caregivers. A theoretical thematic analysis of interview transcripts was framed by posttraumatic growth theory.
RESULTS: Patients and caregivers described five positive changes: closer relationships with others, greater appreciation of life, clarifying life priorities, increased faith, and more empathy for others. Additionally, only caregivers reported better health habits following the cancer diagnosis, and a minority of patients and caregivers reported no positive changes. In about half of cases, patients reported at least one positive change that was identical to that of their caregiver. However, in most cases, patient and caregiver reports of the caregiver's positive change were discrepant.
CONCLUSION: Findings suggest that positive changes are a shared experience for many patient-caregiver dyads and obtaining both patient and caregiver reports of caregiver positive changes provides a more comprehensive understanding of their experience. Interventions may capitalise on positive changes to promote meaningful living in the context of advanced cancer.
PMID: 27775432 [PubMed - indexed for MEDLINE]
It hasn't gone away: the problem of glucocorticoid use in lupus remains.
Rheumatology (Oxford). 2017 Apr 01;56(suppl_1):i114-i122
Authors: Apostolopoulos D, Morand EF
The treatment of SLE remains complex, and management is constrained by a lack of safe, effective, targeted therapies. Physicians, also, are constrained by a lack of evidence-based approaches with existing agents, including glucocorticoids, utilized in the majority of patients. While Cushingoid side effects of glucocorticoids are widely recognized, emerging literature now suggests that glucocorticoid use actually contributes to harmful outcomes in SLE, over and above these effects. These studies provide a compelling case for a re-evaluation of the long-term use of glucocorticoids in SLE, focusing on minimizing glucocorticoid exposure as part of the strategy to improve long-term outcomes. In this article, we review the evidence for the harmful effects of glucocorticoids in SLE, and propose therapeutic options that reduce reliance on glucocorticoids. We propose that it is time for the lupus community to have a louder conversation about glucocorticoid use, and for any residual complacency about their risk-benefit ratio to be banished.
PMID: 28013208 [PubMed - indexed for MEDLINE]
The influence of day care centres designed for people with dementia on family caregivers - a qualitative study.
BMC Geriatr. 2017 Jan 05;17(1):5
Authors: Tretteteig S, Vatne S, Rokstad AM
BACKGROUND: Dementia is one of the most challenging age-related illnesses for family caregivers, whose care-related burden is well known. Research indicates that day care centres (DCCs) can reduce the caregiver burden and help family caregivers to cope with demands; however, the current body of knowledge is still tentative and inconsistent, and more research is recommended. The aim of this study is to provide an extended understanding of the situation of family caregivers and to examine to what extent DCCs can meet their need for support and respite.
METHODS: This study has a qualitative descriptive design using in-depth interviews with 17 family caregivers of people with dementia attending DCCs. The data analysis was undertaken using systematic text condensation.
RESULTS: Caregivers experience a complex role, with added responsibilities, new tasks, and emotional and relational challenges that are expressed through distressing emotions and demands for interaction. Additionally, the caregiving role leads to positive experiences, such as acceptance and adaptation, support and help, and positive changes in the relationship. Day care relieves family caregivers by meeting the person with dementia's needs for social community, nutrition, physical activity, and structure and variety in everyday life. Using a DCC led to a higher quality of time spent together and easier cooperation, but it also produced some hard feelings and challenging situations. DCCs gave the caregivers a feeling of freedom and increased the time available to be spent on their own needs, to be social and to work or do practical tasks undisturbed.
CONCLUSIONS: DCCs for people with dementia can give family caregivers support and relief and have a positive impact on the relationship between the family caregiver and the person with dementia. A more individualized program, in addition to flexible opening hours, would make DCCs even more effective as a respite service, positively influencing the family caregiver's motivation and ability to care and postponing the need for nursing home placement.
PMID: 28056843 [PubMed - indexed for MEDLINE]
High-level adherence to a Mediterranean diet beneficially impacts the gut microbiota and associated metabolome.
Gut. 2016 Nov;65(11):1812-1821
Authors: De Filippis F, Pellegrini N, Vannini L, Jeffery IB, La Storia A, Laghi L, Serrazanetti DI, Di Cagno R, Ferrocino I, Lazzi C, Turroni S, Cocolin L, Brigidi P, Neviani E, Gobbetti M, O'Toole PW, Ercolini D
OBJECTIVES: Habitual diet plays a major role in shaping the composition of the gut microbiota, and also determines the repertoire of microbial metabolites that can influence the host. The typical Western diet corresponds to that of an omnivore; however, the Mediterranean diet (MD), common in the Western Mediterranean culture, is to date a nutritionally recommended dietary pattern that includes high-level consumption of cereals, fruit, vegetables and legumes. To investigate the potential benefits of the MD in this cross-sectional survey, we assessed the gut microbiota and metabolome in a cohort of Italian individuals in relation to their habitual diets.
DESIGN AND RESULTS: We retrieved daily dietary information and assessed gut microbiota and metabolome in 153 individuals habitually following omnivore, vegetarian or vegan diets. The majority of vegan and vegetarian subjects and 30% of omnivore subjects had a high adherence to the MD. We were able to stratify individuals according to both diet type and adherence to the MD on the basis of their dietary patterns and associated microbiota. We detected significant associations between consumption of vegetable-based diets and increased levels of faecal short-chain fatty acids, Prevotella and some fibre-degrading Firmicutes, whose role in human gut warrants further research. Conversely, we detected higher urinary trimethylamine oxide levels in individuals with lower adherence to the MD.
CONCLUSIONS: High-level consumption of plant foodstuffs consistent with an MD is associated with beneficial microbiome-related metabolomic profiles in subjects ostensibly consuming a Western diet.
TRIAL REGISTRATION NUMBER: This study was registered at clinical trials.gov as NCT02118857.
PMID: 26416813 [PubMed - indexed for MEDLINE]
Understanding temporal relationships between depression, falls, and physical activity in a cohort of post-hospitalized older adults - a breakthrough or a conundrum?
Int Psychogeriatr. 2017 Jun 19;:1-12
Authors: Lee DA, Lalor AF, Russell G, Stolwyk R, Brown T, McDermott F, Haines TP
BACKGROUND: Clinical depression affects approximately 15% of community-dwelling older adults, of which half of these cases present in later life. Falls and depressive symptoms are thought to co-exist, while physical activity may protect an older adult from developing depressive symptoms. This study investigates the temporal relationships between depressive symptoms, falls, and participation in physical activities amongst older adults recently discharged following extended hospitalization.
METHODS: A prospective cohort study in which 311 older adults surveyed prior to hospital discharge were assessed monthly post-discharge for six months. N = 218 completed the six-month follow-up. Participants were recruited from hospitals in Melbourne, Australia. The survey instrument used was designed based on Fiske's behavioral model depicting onset and maintenance of depression. The baseline survey collected data on self-reported falls, physical activity levels, and depressive symptoms. The monthly follow-up surveys repeated measurement of these outcomes.
RESULTS: At any assessment point, falls were positively associated with depressive symptoms; depressive symptoms were negatively associated with physical activity levels; and, physical activity levels were negatively associated with falls. When compared with data in the subsequent assessment point, depressive symptoms were positively associated with falls reported over the next month (unadjusted OR: 1.20 (1.12, 1.28)), and physical activity levels were negatively associated with falls reported over the next month (unadjusted OR: 0.97 (0.96, 0.99) household and recreational), both indicating a temporal relationship.
CONCLUSION: Falls, physical activity, and depressive symptoms were inter-associated, and depressive symptoms and low physical activity levels preceded falls. Clear strategies for management of these interconnected problems remain elusive.
PMID: 28625203 [PubMed - as supplied by publisher]
Physical Activity in Older Adults in Relation to Place of Residence and Coexistent Chronic Diseases.
J Phys Act Health. 2017 Jan;14(1):20-28
Authors: Kostka J, Kostka T, Borowiak E
BACKGROUND: The goal of this study was to assess the physical activity (PA) and its determinants of older people living in the 3 different environments.
METHODS: Three equal (n = 693 each) groups of individuals aged ≥65 years living in urban, rural and institutional environments took part in this study. PA was measured by the Seven Day Recall PA Questionnaire (energy expenditure-PA-EE) and the Stanford Usual Activity Questionnaire (health-related behaviors-PA-HRB).
RESULTS: PA-EE was highest in the rural environment and lowest in nursing homes. PA-HRB were most common in urban area. Older age, lower education level, several concomitant diseases and the number of systematically used medications were consistently related to lower PA-EE and PA-HRB. Smoking habit, presence of hypertension, musculoskeletal and gastrointestinal disorders had different association to PA-EE and PA-HRB in the 3 environments.
CONCLUSIONS: Subpopulations of older people differ from the general population with regard to their level of PA and its association with sociodemographic data and concomitant diseases. Concomitant serious diseases significantly decrease the level of PA of older subjects. The relationship between PA and nondebilitating disorders may vary depending on the living environment or PA assessment methodology.
PMID: 27775473 [PubMed - indexed for MEDLINE]
Collaborative Falls Prevention: Interprofessional Team Formation, Implementation, and Evaluation.
J Contin Educ Nurs. 2016 Dec 01;47(12):545-550
Authors: Lasater K, Cotrell V, McKenzie G, Simonson W, Morgove MW, Long EE, Eckstrom E
As health care rapidly evolves to promote person-centered care, evidence-based practice, and team-structured environments, nurses must lead interprofessional (IP) teams to collaborate for optimal health of the populations and more cost-effective health care. Four professions-nursing, medicine, social work, and pharmacy-formed a teaching team to address fall prevention among older adults in Oregon using an IP approach. The teaching team developed training sessions that included interactive, evidence-based sessions, followed by individualized team coaching. This article describes how the IP teaching team came together to use a unique cross-training approach to teach each other. They then taught and coached IP teams from a variety of community practice settings to foster their integration of team-based falls-prevention strategies into practice. After coaching 25 teams for a year each, the authors present the lessons learned from the teaching team's formation and experiences, as well as feedback from practice team participants that can provide direction for other IP teams. J Contin Educ Nurs. 2016;47(12):545-550.
PMID: 27893917 [PubMed - indexed for MEDLINE]
Healthcare decision-making: past present and future, in light of a diagnosis of dementia.
Int J Palliat Nurs. 2017 Jan 02;23(1):4-11
Authors: Dening KH, King M, Jones L, Sampson EL
End-of-life care policy in the UK states that all people should identify their needs, priorities and preferences for end-of-life care in the form of advance care planning. Advance care planning in dementia is less well developed than in some other disease groups such as cancer and, arguably, may be more complex. A person with dementia may lose the capacity to make decisions associated with advance care planning early in the course of the disease, requiring more involvement of family carers. This study explores the 'lived' context to health care decision-making of dyads (the person with dementia and their carer) in respect of past, present and future healthcare decision-making.
PMID: 28132606 [PubMed - indexed for MEDLINE]
The Treatment of Dysmenorrhea.
Pediatr Clin North Am. 2017 Apr;64(2):331-342
Authors: Ryan SA
Menstrual disorders and abnormal uterine bleeding are common concerns of young women. Complaints include menses that are: too painful (dysmenorrhea), absent or occur irregularly (amenorrhea or oligoamenorrhea), or prolonged and heavy (menorrhagia, or excessive uterine bleeding). In providing optimal reproductive care, the medical provider must be able to distinguish between normal developmental patterns or symptoms requiring education and reassurance from pathologic conditions requiring prompt assessment and treatment. This article discusses the normal menstrual patterns seen in adolescent females and provides an evaluation and management approach to primary and secondary dysmenorrhea.
PMID: 28292449 [PubMed - indexed for MEDLINE]
Strategies for improving adherence to antiepileptic drug treatment in people with epilepsy.
Cochrane Database Syst Rev. 2017 02 03;2:CD008312
Authors: Al-Aqeel S, Gershuni O, Al-Sabhan J, Hiligsmann M
BACKGROUND: Poor adherence to antiepileptic medication is associated with increased mortality, morbidity and healthcare costs. In this review, we focus on interventions designed and tested in randomised controlled trials and quasi-randomised controlled trials to assist people with adherence to antiepileptic medication. This is an updated version of the original Cochrane review published in the Cochrane Library, Issue 1, 2010.
OBJECTIVES: To determine the effectiveness of interventions aimed at improving adherence to antiepileptic medication in adults and children with epilepsy.
SEARCH METHODS: For the latest update, on 4 February 2016 we searched the Cochrane Epilepsy Group Specialized Register, the Cochrane Central Register of Controlled Trials (CENTRAL) via the Cochrane Register of Studies Online (CRSO), MEDLINE (Ovid 1946 to 4 February 2016), CINAHL Plus (EBSCOhost 1937 to 4 February 2016), PsycINFO (EBSCOhost 1887 to 4 February 2016), ClinicalTrials.gov, and the WHO International Clinical Trials Registry Platform. We also searched the reference lists of relevant articles.
SELECTION CRITERIA: Randomised and quasi-randomised controlled trials of adherence-enhancing interventions aimed at people with a clinical diagnosis of epilepsy (as defined in individual studies), of any age and treated with antiepileptic drugs in a primary care, outpatient or other community setting.
DATA COLLECTION AND ANALYSIS: All review authors independently assessed lists of potentially relevant citations and abstracts. At least two review authors independently extracted data and performed quality assessment of each study according to the Cochrane tool for assessing risk of bias. We graded the level of evidence for each outcome according to the GRADE working group scale.The studies differed widely according to the type of intervention and measures of adherence; therefore combining data was not appropriate.
MAIN RESULTS: We included 12 studies reporting data on 1642 participants (intervention = 833, control = 809). Eight studies targeted adults with epilepsy, one study included participants of all ages, one study included participants older than two years, one study targeted caregivers of children with epilepsy, and one study targeted families of children with epilepsy. We identified six ongoing trials. Follow-up time was generally short in most trials, ranging from one to 12 months. The trials examined three main types of interventions: educational interventions, behavioural interventions and mixed interventions. All studies compared treatment versus usual care or 'no intervention', except for two studies. Due to heterogeneity between studies in terms of interventions, methods used to measure adherence and the way the studies were reported, we did not pool the results and these findings were inappropriate to be included in a meta-analysis. Education and counselling of participants with epilepsy resulted in mixed success (moderate-quality evidence). Behavioural interventions such as use of intensive reminders provided more favourable effects on adherence (moderate-quality evidence). The effect on adherence to antiepileptic drugs described by studies of mixed interventions showed improved adherence in the intervention groups compared to the control groups (high-quality evidence).
AUTHORS' CONCLUSIONS: Behavioural interventions such as intensive reminders and the use of mixed interventions demonstrate some positive results; however, we need more reliable evidence on their efficacy, derived from carefully-designed randomised controlled trials before we can draw a firm conclusion. Since the last version of this review, none of the new relevant studies have provided additional information that would lead to significant changes in our conclusions. This current update includes 12 studies, of which six came from the latest searches.
PMID: 28157274 [PubMed - indexed for MEDLINE]
Treating patients with venous leg ulcers in the acute setting: part 1.
Br J Nurs. 2017 Jun 22;26(12):S32-S41
Authors: Anderson I
Leg ulcers present with a variety of aetiologies, sometimes in combination. The most common aetiology is venous, with treament involving compression, elevation and exercise; the most common treatment setting is the community. However, people with leg ulcers do sometimes require admission to hospital for conditions and situations which may, or may not, be ulcer-related. There is a lack of contemporary evidence on the experience of inpatients and insufficient analysis of the impact on healing and complications to the lower limb when patients with leg ulcers and compression therapy are admitted to hospital. Admission to hospital presents an ideal opportunity for a focus on leg care and potentially enhancing healing rates of patients. The reality for patients with venous leg ulceration being treated with compression therapy is that this does not continue if they are admitted to hospital as inpatients-having been interrupted for MRSA screening and skin assessment, often no-one is available to reinstate the therapy. This article highlights key issues in the ongoing care of these patients and offers suggestions for basic management until a more acceptable and evidence-based solution can be found. Part 2 will deal with the preparation for discharge and options for the treatment of patients who are not already in the care of community services.
PMID: 28640730 [PubMed - in process]
Patient Perspectives on Accessing Acute Illness Care.
West J Emerg Med. 2017 Jun;18(4):569-576
Authors: Finta MK, Borkenhagen A, Werner NE, Duckles J, Sellers CR, Seshadri S, Lampo D, Shah MN
INTRODUCTION: Older adults use the emergency department (ED) at high rates, including for illnesses that could be managed by their primary care providers (PCP). Policymakers have implemented barriers and incentives, often financial, to try to modify use patterns but with limited success. This study aims to understand the factors that influence older adults' decision to obtain acute illness care from the ED rather than from their PCPs.
METHODS: We performed a qualitative study using a directed content analysis approach from February to October 2013. Fifteen community-dwelling older adults age≥65 years who presented to the ED of an academic medical center hospital for care and who were discharged home were enrolled. Semi-structured interviews were conducted initially in the ED and subsequently in patients' homes over the following six weeks. All interviews were audio-recorded, transcribed, verified, and coded. The study team jointly analyzed the data and identified themes that emerged from the interviews.
RESULTS: The average age of study participants was 74 years (standard deviation ±7.2 years); 53% were female; 80% were white. We found five themes that influenced participants' decisions to obtain acute illness care from the ED: limited availability of PCP-based care, variable interactions with healthcare providers and systems, limited availability of transportation for illness care, desire to avoid burdening friends and family, and previous experiences with illnesses.
CONCLUSION: Community-dwelling older adults integrate multiple factors when deciding to obtain care from an ED rather than their PCPs. These factors relate to personal and social considerations, practical issues, and individual perceptions based on previous experiences. If these findings are validated in confirmatory studies, policymakers wishing to modify where older adults receive care should consider person-centered interventions at the system and individual level, such as decision support, telemedicine, improved transport services, enhancing PCPs' capabilities, and enhancing EDs' resources to care for older patients.
PMID: 28611875 [PubMed - in process]
Family socioeconomic position in early life and onset of depressive symptoms and depression: a prospective cohort study.
Soc Psychiatry Psychiatr Epidemiol. 2017 Jan;52(1):95-103
Authors: Joinson C, Kounali D, Lewis G
PURPOSE: To investigate whether low parental socioeconomic position (SEP) at birth is associated only with early-onset depressive symptoms in offspring.
METHODS: This prospective cohort study used data on 9193 individuals (4768 females, 4425 males) from the Avon Longitudinal Study of Parents and Children. Depressive symptoms during three age periods (10-12, 12-16, 16-20 years) were assessed using the Short Mood and Feelings Questionnaire, and ICD-10 depression at age 18 was assessed using the Clinical Interview Schedule-Revised.
RESULTS: Low SEP was associated with increased incidence rates of depressive symptoms in all age periods, with indicators of low standard of living showing the strongest associations. For instance, incidence rate ratios for material hardship were 1.75 (95% CI [1.42-2.15]) at 10-12 years, 1.36 (1.16-1.61) at 12-16 years and 1.39 (1.21-1.59) at 16-20 years. Low SEP was also associated with increased odds of ICD-10 depression at 18 years, ranging from OR = 1.20 (95% CI [0.94-1.52]) for manual social class to 1.74 (1.35-2.24) for material hardship.
CONCLUSIONS: There was no evidence that depressive symptoms can be "subtyped" by the age of onset, because the association with low SEP was evident for early- and later-onset symptoms. If socioeconomic inequalities in early life have long-term adverse impacts on mental health, policies addressing these inequalities could benefit the mental health of the population.
PMID: 27837235 [PubMed - indexed for MEDLINE]
Managing risk during care transitions when approaching end of life: A qualitative study of patients' and health care professionals' decision making.
Palliat Med. 2017 Jul;31(7):617-624
Authors: Coombs MA, Parker R, de Vries K
BACKGROUND: Increasing importance is being placed on the coordination of services at the end of life.
AIM: To describe decision-making processes that influence transitions in care when approaching the end of life.
DESIGN: Qualitative study using field observations and longitudinal semi-structured interviews.
SETTING/PARTICIPANTS: Field observations were undertaken in three sites: a residential care home, a medical assessment unit and a general medical unit in New Zealand. The Supportive and Palliative Care Indicators Tool was used to identify participants with advanced and progressive illness. Patients and family members were interviewed on recruitment and 3-4 months later. Four weeks of fieldwork were conducted in each site. A total of 40 interviews were conducted: 29 initial interviews and 11 follow-up interviews. Thematic analysis was undertaken.
FINDINGS: Managing risk was an important factor that influenced transitions in care. Patients and health care staff held different perspectives on how such risks were managed. At home, patients tolerated increasing risk and used specific support measures to manage often escalating health and social problems. In contrast, decisions about discharge in hospital were driven by hospital staff who were risk-adverse. Availability of community and carer services supported risk management while a perceived need for early discharge decision making in hospital and making 'safe' discharge options informed hospital discharge decisions.
CONCLUSION: While managing risk is an important factor during care transitions, patients should be able to make choices on how to live with risk at the end of life. This requires reconsideration of transitional care and current discharge planning processes at the end of life.
PMID: 28618896 [PubMed - in process]