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Although both obesity and ageing are risk factors for cognitive impairment, there is no evidence in Chile on how obesity levels are associated with cognitive function. Therefore, the aim of the present study was to investigate the association between adiposity levels and cognitive impairment in older Chilean adults. This cross-sectional study includes 1384 participants, over 60 years of age, from the Chilean National Health Survey 2009–2010. Cognitive impairment was evaluated using the Mini-Mental State Examination. BMI and waist circumference (WC) were used as measures of adiposity. Compared with people with a normal BMI, the odds of cognitive impairment were higher in participants who were underweight (OR 4·44; 95 % CI 2·43, 6·45; P < 0·0001), overweight (OR 1·86; 95 % CI 1·06, 2·66; P = 0·031) and obese (OR 2·26; 95 % CI 1·31, 3·21; P = 0·003). The associations were robust after adjustment for confounding variables. Similar results were observed for WC. Low and high levels of adiposity are associated with an increased likelihood of cognitive impairment in older adults in Chile.
Application timing and environmental factors reportedly influence the efficacy of auxinic herbicides. In resistance-prone weed species such as Palmer amaranth (Amaranthus palmeri S. Watson), efficacy of auxinic herbicides recently adopted for use in resistant crops is of utmost importance to reduce selection pressure for herbicide-resistance traits. Growth chamber experiments were conducted comparing the interaction of different environmental effects with application time to determine the influence of these factors on visible phytotoxicity and hydrogen peroxide (H2O2) formation in A. palmeri. Temperature displayed a high degree of influence on 2,4-D and dicamba efficacy in general, with applications at the low-temperature treatment (31/20 C day/night) resulting in an increase in phytotoxicity compared with high-temperature treatments (41/30 C day/night). Application time across temperature treatments significantly affected 2,4-D–induced phytotoxicity, resulting in a ≥30% increase across rates with treatments at 4:00 PM compared with 8:00 AM. Temperature differential had a significant influence on dicamba efficacy based on visible phytotoxicity data, with a ≥46% increase with a high (37/20 C day/night) compared with a low differential (41/30 C day/night). Concentration of H2O2 in herbicide-treated plants was 34% higher under a high temperature differential compared with the low differential. Humidity treatments and application time interactions displayed undetected or inconsistent effects on visible phytotoxicity and H2O2 production. Overall, temperature-related influences seem to have the largest environmental effect on auxinic herbicides within conditions evaluated in this study. Leaf concentration of H2O2 appears to be generally correlated with phytotoxicity, providing a potentially useful tool in determining efficacy of auxinic herbicides in field settings.
Despite its long coastline, relatively little is known about mainland China’s intertidal communities compared to Europe and the United States, although more is known from Taiwan and Hong Kong. In general, northern areas are dominated by temperate species, with tropical species in the south and subtropical areas supporting a diversity of species from both regions. Studies of intertidal systems are in their infancy, developing since the 1930s and particularly after the 1960s with a primary focus on taxonomy and distribution patterns. While species lists and distributions have been available for mainland China since the 1930s, and more recently Taiwan and Hong Kong, many of these are outdated and recent approaches reveal many cryptic species complexes. Basic information of spatial and temporal patterns is available, but is focussed on few locations, while larger-scale or temporally replicated studies are rare, with Hong Kong being an exception. As a result, we know a lot about a few small areas, and have often used this to generalise much larger areas. This bias is even more true for studies investigating intertidal processes. Clearly, this is an under-studied region and, given the unprecedented anthropogenic pressures it faces, we may already be documenting a highly degraded intertidal system.
Background: Massive transfusion protocols (MTP) are widely used to rapidly deliver blood products to bleeding trauma patients. Every minute delay in blood product administration in bleeding trauma patients is associated with a 5% increased odds of death. In-situ simulation (ISS) is simulation that takes place in the actual clinical work environment. We used ISS as a novel, prospective and iterative quality improvement (QI) approach to identify and improve MTP steps that impact time to blood delivery (TTBD) during actual trauma resuscitations. Aim Statement: To reduce the TTBD for bleeding trauma patients by 20% over a 12-month ISS-based QI initiative. Measures & Design: We conducted twelve high-fidelity, interprofessional ISS sessions at a Level-1 trauma center in Toronto, Canada. We used clinician video review as well as extensive stakeholder involvement, including with nurses, porters, blood bank and human factors experts, to develop Plan-Do-Study-Act (PDSA) cycles for MTP improvement. Our three major PDSA cycles revolved around: 1) decreasing MTP activation time; 2) reducing the unpredictable and inefficient transport times for the blood itself; and 3) improving the notification of blood product arrival in the trauma bay. Each PDSA cycle was iteratively tested with ISS prior to implementation into clinical care. Outcome measure was the mean TTBD for trauma patients requiring MTP (in minutes, standard deviation [SD]). Process measures included time to MTP activation and porter transport times. Balancing measures included stakeholder satisfaction. Evaluation/Results: Our baseline TTBD for MTP patients was 11.58min (n = 41, SD 6.8). There were 54 trauma patients that had MTP during the ISS-based QI initiative, and their mean TTBD was 10.44min (SD 6.1). The TTBD after the QI initiative was 9.12min, sustained over 1 year (n = 50, SD 5.3; 21.2% relative reduction, p < 0.05). A run chart did not show special cause variation chronologically related to our interventions. Patients in each group were similar in demographic data, trauma characteristics and injury severity score. Discussion/Impact: We achieved a 21.2% reduction in TTBD for trauma patients requiring MTP with an ISS-based QI initiative. ISS represents a novel approach to the identification and iterative testing of process improvements within trauma care. This methodology can and should be included in QI projects in order to safely test and improve processes of care before they impact real patients.
To assess variability in antimicrobial use and associations with infection testing in pediatric ventilator-associated events (VAEs).
Descriptive retrospective cohort with nested case-control study.
Pediatric intensive care units (PICUs), cardiac intensive care units (CICUs), and neonatal intensive care units (NICUs) in 6 US hospitals.
Children≤18 years ventilated for≥1 calendar day.
We identified patients with pediatric ventilator-associated conditions (VACs), pediatric VACs with antimicrobial use for≥4 days (AVACs), and possible ventilator-associated pneumonia (PVAP, defined as pediatric AVAC with a positive respiratory diagnostic test) according to previously proposed criteria.
Among 9,025 ventilated children, we identified 192 VAC cases, 43 in CICUs, 70 in PICUs, and 79 in NICUs. AVAC criteria were met in 79 VAC cases (41%) (58% CICU; 51% PICU; and 23% NICU), and varied by hospital (CICU, 20–67%; PICU, 0–70%; and NICU, 0–43%). Type and duration of AVAC antimicrobials varied by ICU type. AVAC cases in CICUs and PICUs received broad-spectrum antimicrobials more often than those in NICUs. Among AVAC cases, 39% had respiratory infection diagnostic testing performed; PVAP was identified in 15 VAC cases. Also, among AVAC cases, 73% had no associated positive respiratory or nonrespiratory diagnostic test.
Antimicrobial use is common in pediatric VAC, with variability in spectrum and duration of antimicrobials within hospitals and across ICU types, while PVAP is uncommon. Prolonged antimicrobial use despite low rates of PVAP or positive laboratory testing for infection suggests that AVAC may provide a lever for antimicrobial stewardship programs to improve utilization.
Introduction: Online medical education resources are widely used in emergency medicine (EM), but strategies to assess quality remain elusive. We previously derived the Medical Education Translational Resources: Impact and Quality (METRIQ) 8 instrument to evaluate quality in medical education blog posts. Methods: As part of a subsequent validation study (The METRIQ Blog Study), a mixed-methods usability analysis was performed to obtain user feedback on the quality assessment instrument in order to improve its clarity and reliability. Participants in the METRIQ Study were first asked to rate five blog posts using the METRIQ-8 Score. They then evaluated the METRIQ-8 instruments ease of use and likelihood of being recommended to others using a 7-point Likert scale and free text comments. Participants were also asked to flag and comment on items within the score that they felt were unclear. Global usability ratings were summarized using median scores or percent rated unclear. We used ANOVA to test associations between ease of use and demographic factors. A thematic analysis was performed on the comments. Results: 309 EM medical students, residents, and attendings completed the survey. Global ratings were generally very favorable (median 2 [IQR 2-3], with 7 being the lowest score) for ease of use and likelihood of recommendation, and did not vary by participants country of origin, frequency of blog use, or learner level. Participants stated that the score was structured, systematic, and straightforward. They found it useful for junior learners and for guiding blog creation. Four questions in the score (questions 2, 4, 5, and 7) were identified by 10% of subjects to be unclear. Thematic analysis of comments identified suggested four main themes for improving the score: adding clearer definitions with marking rubrics; shortening the 7-point scale; adding items evaluating blog post presentation and utility; and, rephrasing the wording of certain questions for clarity. Conclusion: A mixed methods usability analysis of the METRIQ-8 instrument for assessing blog quality was globally well received by EM medical students, residents, and attendings. Qualitative analyses revealed multiple areas to improve the instruments clarity and usability. The METRIQ score is a promising instrument for evaluating the quality of blogs; further development and testing is needed to improve its utility.
Introduction: Hospital-based gun violence is devastatingly traumatic for everyone present and recent events in Cobourg, Ontario underscore that an active shooter inside the emergency department (ED) is an imminent threat. In June 2016, the Ontario Hospital Association (OHA) added Code Silver to the list of standardized emergency preparedness colour codes and advised member hospitals to develop policies and train staff on how best to respond. Given that EDs are particularly susceptible to opportunistic breach by an active shooter, the impact of a Code Silver on ED functioning and staff members may be particularly acute. We hypothesized that there may not be a simple, one-size-fits-all-hospital-staff solution about how best to prepare EDs to respond to Code Silver. In order to inform and support future staff training initiatives related to Code Silver and other disaster situations in hospitals, we sought to investigate staff perspectives and behaviour related to personal safety at work and, in particular, an active shooter. Methods: We undertook a qualitative interview study of multi-disciplinary ED staff (MDs, RNs, clericals, allied health, administrators) at a single tertiary care centre in Toronto. The primary methods for data collection were in-depth qualitative interviews and focus groups. Participants were recruited using stakeholder and maximum variation sampling strategies. Data collection and analysis were concurrent and standard thematic analysis techniques were employed. Results: Sixteen (16) staff members participated in interviews and 40 participated in small focus group discussions. Data analysis revealed workplace violence and personal health risks have been normalized as expected, acceptable features of everyday life at work in the ED given that patients are perceived to be sick people in need of help that ED staff are trained for and prepared to provide. In contrast, weapons and active shooters challenge the boundaries of professional responsibility and readiness to respond to Code Silver is perceived by staff as a fallacy. Conclusion: Knowledge from this study gives us crucial insight into important areas for targeted training and opportunities for knowledge translation on the topic of implementing Code Silver in EDs across the country. Future interventions must include how to overcome normalization of workplace violence in the ED setting and negotiating competing professional obligations during crisis situations. Attention to these are crucial if we are to truly keep our staff safe during these traumatic events.
The number of people living with dementia in sub-Saharan Africa (SSA) is expected to increase rapidly in the coming decades. However, our understanding of how best to reduce dementia risk in the population is very limited. As a first step in developing intervention strategies to manage dementia risk in this setting, we investigated rates of cognitive decline in a rural population in Tanzania and attempted to identify associated factors.
The study was conducted in the rural Hai district of northern Tanzania. In 2014, community-dwelling people aged 65 years and over living in six villages were invited to take part in a cognitive screening program. All participants from four of the six villages were followed-up at two years and cognitive function re-tested. At baseline and follow-up, participants were assessed for functional disability, hypertension, and grip strength (as a measure of frailty). At follow-up, additional assessments of visual acuity, hearing impairment, tobacco and alcohol consumption, and clinical assessment for stroke were completed.
Baseline and follow-up data were available for 327 people. Fifty people had significant cognitive decline at two-year follow-up. Having no formal education, low grip strength at baseline, being female and having depression at follow-up were independently associated with cognitive decline.
This is one of the first studies of cognitive decline conducted in SSA. Rates of decline at two years were relatively high. Future work should focus on identification of specific modifiable risk factors for cognitive decline with a view to developing culturally appropriate interventions.
This qualitative study investigates how the Electronic Patient-Reported Outcome (ePRO) mobile application and portal system, designed to capture patient-reported measures to support self-management, affected primary care provider workflows.
The Canadian health system is facing an ageing population that is living with chronic disease. Disruptive innovations like mobile health technologies can help to support health system transformation needed to better meet the multifaceted needs of the complex care patient. However, there are challenges with implementing these technologies in primary care settings, in particular the effect on primary care provider workflows.
Over a six-week period interdisciplinary primary care providers (n=6) and their complex care patients (n=12), used the ePRO mobile application and portal to collaboratively goal-set, manage care plans, and support self-management using patient-reported measures. Secondary thematic analysis of focus groups, training sessions, and issue tracker reports captured user experiences at a Toronto area Family Health Team from October 2014 to January 2015.
Key issues raised by providers included: liability concerns associated with remote monitoring, increased documentation activities due to a lack of interoperability between the app and the electronic patient record, increased provider anxiety with regard to the potential for the app to disrupt and infringe upon appointment time, and increased demands for patient engagement. Primary care providers reported the app helped to focus care plans and to begin a collaborative conversation on goal-setting. However, throughout our investigation we found a high level of provider resistance evidenced by consistent attempts to shift the app towards fitting with existing workflows rather than adapting much of their behaviour. As health systems seek innovative and disruptive models to better serve this complex patient population, provider change resistance will need to be addressed. New models and technologies cannot be disruptive in an environment that is resisting change.
W49 A is a star-forming region (SFR) found in the constellation of Aquila. It contains 3 active regions: W49 North (W49 N), W49 South West (W49 SW) and W49 South (W49 S). We present preliminary results from two epochs (e-)MERLIN observations of all ground-state OH masers towards the star-forming region (SFR) complex W49 A. The first epoch of observations was done in full-polarization mode with MERLIN in 2005 while the second epoch was obtained only in dual circular polarization during the test observations of the upgraded e-MERLIN in 2013. The overall maser spatial distributions in both epochs are in good agreement. We found several new high velocity maser features up to +34 km s−1 and −28 km s−1. The magnetic field strengths are between 1.1 to 10.8 mG. All three sources show evidence of magnetic field reversal.
Vegetable injury and yield loss has occurred when applying halosulfuron to low-density polyethylene mulch (LDPE) prior to transplanting. Research determined vegetable crop response to halosulfuron applied over LDPE mulch from 1 to 28 d prior to transplanting using (1) temperature effects in aqueous solution in laboratory experiments, (2) analytical evaluation of degradation from LDPE under field conditions, and (3) a field bioassay. Halosulfuron stability was evaluated on a thermal gradient table for temperatures at 10 to 42 C for 15 d. Half-life was inversely related to temperatures ranging from 38.5 d at 20 C to 3.2 d at 42 C, with little to no degradation at temperatures of 11 and 15 C. Analytical data indicated that the field half-life of halosulfuron at 26 or 52 g ha−1 applied to LDPE mulch under dry conditions was 2.6 and 2.8 d, respectively. Given the changes in the microclimate effects at the mulch surface by absorption of solar radiation, daily thermal energy quantified halosulfuron degradation (at the same rates) to be 51 and 55 MJ m−2, respectively. At 21 d after treatment (DAT), 90% of halosulfuron had dissipated from the mulch, with none detectable 35 DAT under dry conditions. When watermelon or yellow crookneck squash was transplanted into mulch previously treated with halosulfuron at 79 g ha−1, plant growth and development were equal to nontreated controls as long as there was a 14 d prior to transplant (DPT) interval accompanied by 13.5 cm of rain, or a 17 DPT interval accompanied by 6.2 cm of rain. However, at 79 g ha−1 applied at 9 or 1 DPT in 2013, and 1 DPT in 2014, halosulfuron injured yellow squash and reduced yield and fruit number. Halosulfuron at 79 g ha−1 applied 1 DPT significantly reduced watermelon yield in 2013, which was confirmed by vine length and plant biomass reductions in 2014. Halosulfuron POST controls Cyperus spp. in mulch vegetable production, but time and rainfall are required for dissipation to occur in order to prevent injury and yield loss.
The efficacy of WSSA Group 4 herbicides has been reported to vary with dependence on the time of day the application is made, which may affect the value of this mechanism of action as a control option and resistance management tool for Palmer amaranth. The objectives of this research were to evaluate the effect of time of day for application on 2,4-D and dicamba translocation and whether or not altering translocation affected any existing variation in phytotoxicity seen across application time of day. Maximum translocation (Tmax) of [14C]2,4-D and [14C]dicamba out of the treated leaf was significantly increased 52% and 29% to 34% in one of two repeated experiments for each herbicide, respectively, with application at 7:00 AM compared with applications at 2:00 PM and/or 12:00 AM. Applications at 7:00 AM increased [14C]2,4-D distribution to roots and increased [14C]dicamba distribution above the treated leaf compared with other application timings. In phytotoxicity experiments, dicamba application at 8 h after exposure to darkness (HAED) resulted in significantly lower dry root biomass than dicamba application at 8 h after exposure to light (HAEL). Contrasts indicated that injury resulting from dicamba application at 8 HAEL, corresponding to midday, was significantly reduced with a root treatment of 5-[N-(3,4-dimethoxyphenylethyl)methylamino]-2-(3,4-dimethoxyphenyl)-2-isopropylvaleronitrile hydrochloride (verapamil) compared with injury observed with dicamba application and a root treatment of verapamil at 8 HAED, which corresponded to dawn. Overall, time of application appears to potentially influence translocation of 2,4-D and dicamba. Furthermore, inhibition of translocation appears to somewhat influence variation in phytotoxicity across times of application. Therefore, translocation may be involved in the varying efficacy of WSSA Group 4 herbicides due to application time of day, which has implications for the use of this mechanism of action for effective control and resistance management of Palmer amaranth.
Introduction: Hospital shootings are rare events that pose extreme and immediate risk to staff, patients and visitors. In 2015, the Ontario Hospital Association mandated all hospitals devise an armed assailant Code Silver protocol, an alert issued to mitigate risk and manage casualties. We describe the design and implementation of ASSIST (Active Shooter Simulation In-Situ Training), an institutional, full-scale hybrid simulation exercise to test hospital-wide response and readiness for an active shooter event, and identify latent safety threats (LSTs) related to the high-stakes alert and transport of internal trauma patients. Methods: A hospital-wide in-situ simulation was conducted at a Level 1 trauma centre in downtown Toronto. The two-hour exercise tested a draft Code Silver policy created by the hospital’s disaster planning committee, to identify missing elements and challenges with protocol implementation. The scenario consisted of a shooting during a hospital meeting with three casualties: a manikin with life-threatening head and abdomen gunshot wounds (GSWs), a standardized patient (SP) with hypotension from an abdominal GSW, and a second SP with minor injuries and significant psychological distress. The exercise piloted the use of a novel emergency department (ED)-based medical exfiltration team to transport internal victims to the trauma bay. The on-call trauma team provided medical care. Ethnographic observation of response by municipal police, hospital security, logistics and medical personnel was completed. LSTs were evaluated and categorized using video framework analysis. Feasibility was measured through debriefings and impact on ED workflow. Results: Seventy-six multidisciplinary medical and logistical staff and learners participated in this exercise. Using a framework analysis, the following LSTs were identified: 1) Significant communication difficulties within the shooting area, 2) Safe access and transport for internal casualties, 3) Difficulty accessing hospital resources (blood bank) 4) Challenges coordinating response with external agencies (police, EMS) and 5) Delay in setting up an off-site command centre. Conclusion: In situ simulation represents a novel approach to the development of Code Silver alert processes. Findings from ethnographic observations and a video-based analysis form a framework to address safety, logistical and medical response considerations.
Introduction: Hospital-based gun violence is devastatingly traumatic for everyone present and quite tragically on the rise. The Ontario Hospital Association (OHA) has recently designated active shooter situations as “Code Silver” and advised member hospitals to develop policies and train health care workers on how best to respond. Given that emergency departments (ED) are particularly susceptible to opportunistic breach by an active shooter and staff members are likely to be called upon as first responders, the impact of a Code Silver on ED functioning and staff members may be particularly severe. We hypothesized that there may not be a simple, one-size-fits-all-hospital-staff solution about how best to prepare ED physicians and staff to respond to a Code Silver situation. Methods: In order to inform and support future staff training initiatives related to Code Silver and other disaster situations in hospitals, we conducted a robust qualitative study to investigate perspectives and behaviour related to personal safety at work and Code Silver in particular among the multi-disciplinary ED staff at a single tertiary care centre in Toronto, Ontario. Participants for in-depth interviews and focus groups were recruited using a combination of stakeholder and maximum variation sampling strategies. Data analysis occurred in conjunction with data collection and standard thematic analysis techniques were employed. Results: Initial data analysis has revealed the following thematic concepts: the ubiquitous banality of personal health risk as an expected, acceptable feature of everyday life at work for ED staff, the perception of active shooters as a transgressive threat that violates the boundaries of professional responsibility, and the perceived fallacy of “readiness” to respond to disastrous situations. A fulsome analysis will be ready for presentation in June. Conclusion: Knowledge from this study indicates that ED staff members have unique and specific training needs in relation to an active shooter situation, and gives us deeper insight into potential areas of focus for training and opportunities for knowledge translation on the topic of Code Silver for EDs across the country.
Introduction: Effective trauma resuscitation requires a coordinated team approach, yet there is a significant risk for error. These errors can manifest from sequential system-, team- and knowledge based failures, defined as latent safety threats (LSTs). In situ simulation (ISS), a point-of-care training strategy, provides a novel prospective approach to identify factors that impact patient safety. This study quantified and formulated a hierarchy of LSTs during risk-informed ISS trauma resuscitations. Methods: At a Level 1 trauma centre, we conducted 12 multi-disciplinary, unannounced ISSs to prospectively identify trauma-related LSTs. Four, risk-informed scenarios were developed based on 5 recurring themes found within the trauma program’s morbidity and mortality process. The actual, on-call trauma team participated in the study. Simulations were video recorded with 4 cameras, each positioned at a different angle. Using a framework analysis methodology, human factors experts transcribed and coded the videos. Thematic structure was established deductively based on existing literature and inductively based on observed ISS events. All LSTs were prioritized for future patient safety, systems and ergonomic interventions using the Healthcare Failure Mode and Effect Analysis (HFMEA) matrix. Results: We identified 893 LSTs from 12 simulations. LST analysis resulted in 8 themes subcategorized into 43 codes. Themes were associated with team-, knowledge- or system-related issues. The following themes emerged: situational awareness, provider safety, mental model alignment, team/individual responsibility, team resources, equipment considerations, workplace environment and clinical protocols. The HFMEA hazard scoring process identified 13 high priority codes that required urgent attention and intervention to mitigate negative patient outcomes. Conclusion: A prospective, video-based framework analysis represents a novel and robust approach to LST identification within trauma care. Patterns of LSTs within and between simulations provide a high degree of transparency and traceability for an inter-professional trauma program review. Hazard matrix scoring facilitates the classification and prioritization of human factors interventions intended to improve patient safety.
In the above article (Paddick, 2017) The corresponding author's details were previously listed incorrectly. The correct details are; contact number +44 191 293 2709 and email address William.email@example.com. The original article has been updated with the correct contact details. The publishers apologise for any inconvenience and confusion this error has caused.
The majority of older adults with dementia live in low- and middle-income countries (LMICs). Illiteracy and low educational background are common in older LMIC populations, particularly in rural areas, and cognitive screening tools developed for this setting must reflect this. This study aimed to review published validation studies of cognitive screening tools for dementia in low-literacy settings in order to determine the most appropriate tools for use.
A systematic search of major databases was conducted according to PRISMA guidelines. Validation studies of brief cognitive screening tests including illiterate participants or those with elementary education were eligible. Studies were quality assessed using the QUADAS-2 tool. Good or fair quality studies were included in a bivariate random-effects meta-analysis and a hierarchical summary receiver operating characteristic (HSROC) curve constructed.
Forty-five eligible studies were quality assessed. A significant proportion utilized a case–control design, resulting in spectrum bias. The area under the ROC (AUROC) curve was 0.937 for community/low prevalence studies, 0.881 for clinic based/higher prevalence studies, and 0.869 for illiterate populations. For the Mini-Mental State Examination (MMSE) (and adaptations), the AUROC curve was 0.853.
Numerous tools for assessment of cognitive impairment in low-literacy settings have been developed, and tools developed for use in high-income countries have also been validated in low-literacy settings. Most tools have been inadequately validated, with only MMSE, cognitive abilities screening instrument (CASI), Eurotest, and Fototest having more than one published good or fair quality study in an illiterate or low-literate setting. At present no screening test can be recommended.
Cognitive stimulation therapy (CST) is a psychosocial group-based intervention for dementia shown to improve cognition and quality of life with a similar efficacy to cholinesterase inhibitors. Since CST can be delivered by non-specialist healthcare workers, it has potential for use in low-resource environments, such as sub-Saharan Africa (SSA). We aimed to assess the feasibility and clinical effectiveness of CST in rural Tanzania using a stepped-wedge design.
Participants and their carers were recruited through a community dementia screening program. Inclusion criteria were DSM-IV diagnosis of dementia of mild/moderate severity following detailed assessment. No participant had a previous diagnosis of dementia and none were taking a cholinesterase inhibitor. Primary outcomes related to the feasibility of conducting CST in this setting. Key clinical outcomes were changes in quality of life and cognition. The assessing team was blind to treatment group membership.
Thirty four participants with mild/moderate dementia were allocated to four CST groups. Attendance rates were high (85%) and we were able to complete all 14 sessions for each group within the seven week timeframe. Substantial improvements in cognition, anxiety, and behavioral symptoms were noted following CST, with smaller improvements in quality of life measures. The number needed to treat was two for a four-point cognitive (adapted Alzheimer's Disease Assessment Scale-Cognitive) improvement.
This intervention has the potential to be low-cost, sustainable, and adaptable to other settings across SSA, particularly if it can be delivered by non-specialist health workers.