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To develop a staff training intervention for agitation in people with severe dementia, reaching end-of-life, residing in nursing homes (NHs), test feasibility, acceptability, and whether a trial is warranted.
Feasibility study with pre- and post-intervention data collection, qualitative interviews, and focus groups.
Three NHs in South East England with dementia units, diverse in terms of size, ownership status, and location.
Residents with a dementia diagnosis or scoring ≥2 on the Noticeable Problems Checklist, rated as “severe” on Clinical Dementia Rating Scale, family carers, and staff (healthcare assistants and nurses).
Manualized training, delivered by nonclinical psychology graduates focusing on agitation in severe dementia, underpinned by a palliative care framework.
Main outcomes were feasibility of recruitment, data collection, follow-up, and intervention acceptability. We collected resident, family carer, and staff demographics. Staff provided data on resident’s agitation, pain, quality of life, and service receipt. Staff reported their sense of competence in dementia care. Family carers reported on satisfaction with end-of-life care. In qualitative interviews, we explored staff and family carers’ views on the intervention.
The target three NHs participated: 28 (49%) residents, 53 (74%) staff, and 11 (85%) family carers who were eligible to participate consented. Eight-four percent of staff attended ≥3 sessions, and we achieved 93% follow-up. We were able to complete quantitative interviews. Staff and family carers reported the intervention and delivery were acceptable and helpful.
The intervention was feasible and acceptable indicating a larger trial for effectiveness may be warranted.
The START (STrAtegies for RelaTives) intervention reduced depressive and anxiety symptoms of family carers of relatives with dementia at home over 2 years and was cost-effective.
To assess the clinical effectiveness over 6 years and the impact on costs and care home admission.
We conducted a randomised, parallel group, superiority trial recruiting from 4 November 2009 to 8 June 2011 with 6-year follow-up (trial registration: ISCTRN 70017938). A total of 260 self-identified family carers of people with dementia were randomised 2:1 to START, an eight-session manual-based coping intervention delivered by supervised psychology graduates, or to treatment as usual (TAU). The primary outcome was affective symptoms (Hospital Anxiety and Depression Scale, total score (HADS-T)). Secondary outcomes included patient and carer service costs and care home admission.
In total, 222 (85.4%) of 173 carers randomised to START and 87 to TAU were included in the 6-year clinical efficacy analysis. Over 72 months, compared with TAU, the intervention group had improved scores on HADS-T (adjusted mean difference −2.00 points, 95% CI −3.38 to −0.63). Patient-related costs (START versus TAU, respectively: median £5759 v. £16 964 in the final year; P = 0.07) and carer-related costs (median £377 v. £274 in the final year) were not significantly different between groups nor were group differences in time until care home (intensity ratio START:TAU was 0.88, 95% CI 0.58–1.35).
START is clinically effective and this effect lasts for 6 years without increasing costs. This is the first intervention with such a long-term clinical and possible economic benefit and has potential to make a difference to individual carers.
Declarations of interest
G.L., Z.W. and C.C. are supported by the UCLH National Institute for Health Research (NIHR) Biomedical Research Centre. G.L. and P.R. were in part supported by the National Institute for Health Research (NIHR) Collaboration for Leadership in Applied Health Research and Care (CLAHRC) North Thames at Bart's Health NHS Trust. The views expressed are those of the author(s) and not necessarily those of the NHS, the NIHR or the Department of Health. Z.W. reports during the conduct of the study; personal fees from GE Healthcare, grants from GE Healthcare, grants from Lundbeck, other from GE Healthcare, outside the submitted work.
40% of people with dementia have disturbed sleep but there are currently no known effective treatments. Studies of sleep hygiene and light therapy have not been powered to indicate feasibility and acceptability and have shown 40–50% retention. We tested the feasibility and acceptability of a six-session manualized evidence-based non-pharmacological therapy; Dementia RElAted Manual for Sleep; STrAtegies for RelaTives (DREAMS-START) for sleep disturbance in people with dementia.
We conducted a parallel, two-armed, single-blind randomized trial and randomized 2:1 to intervention: Treatment as Usual. Eligible participants had dementia and sleep disturbances (scoring ≥4 on one Sleep Disorders Inventory item) and a family carer and were recruited from two London memory services and Join Dementia Research. Participants wore an actiwatch for two weeks pre-randomization. Trained, clinically supervised psychology graduates delivered DREAMS-START to carers randomized to intervention; covering Understanding sleep and dementia; Making a plan (incorporating actiwatch information, light exposure using a light box); Daytime activity and routine; Difficult night-time behaviors; Taking care of your own (carer's) sleep; and What works? Strategies for the future. Carers kept their manual, light box, and relaxation recordings post-intervention. Outcome assessment was masked to allocation. The co-primary outcomes were feasibility (≥50% eligible people consenting to the study) and acceptability (≥75% of intervention group attending ≥4 intervention sessions).
In total, 63out of 95 (66%; 95% CI: 56–76%) eligible referrals consented between 04/08/2016 and 24/03/2017; 62 (65%; 95% CI: 55–75%) were randomized, and 37 out of 42 (88%; 95% CI: 75–96%) adhered to the intervention.
DREAM-START for sleep disorders in dementia is feasible and acceptable.
Agitation is reportedly the most common neuropsychiatric symptom in care home residents with dementia.
To report, in a large care home survey, prevalence and determinants of agitation in residents with dementia.
We interviewed staff from 86 care homes between 13 January 2014 and 12 November 2015 about residents with dementia with respect to agitation (Cohen-Mansfield Agitation Inventory (CMAI)), quality of life (DEMQOL-proxy) and dementia severity (Clinical Dementia Rating). We also interviewed residents and their relatives. We used random effects models adjusted for resident age, gender, dementia severity and care home type with CMAI as a continuous score.
Out of 3053 (86.2%) residents who had dementia, 1489 (52.7%) eligible residents participated. Fifteen per cent of residents with very mild dementia had clinically significant agitation compared with 33% with mild (odds ratios (ORs)=4.49 95% confidence interval (CI)=2.30) and 45% with moderate or severe dementia (OR=6.95 95% CI=3.63, 13.31 and OR=6.23 95% CI=3.25, 11.94, respectively). More agitation was associated with lower quality of life (regression coefficient (rc)=-0.53; 95% CI=-0.61, -0.46) but not with staffing or resident ratio (rc=0.03; 95% CI=-0.04, 0.11), level of residents' engagement in home activities (rc=3.21; 95% CI=-0.82, 7.21) or family visit numbers (rc=-0.03; 95% CI=-0.15, 0.08). It was correlated with antipsychotic use (rc=6.45; 95% CI=3.98, 8.91).
Care home residents with dementia and agitation have lower quality of life. More staffing time and activities as currently provided are not associated with lower agitation levels. New approaches to develop staff skills in understanding and responding to the underlying reasons for individual resident's agitation require development and testing.
Family carers of people with dementia frequently report acting abusively toward them and carer psychological morbidity predicts this. We investigated whether START (STrAtegies for RelaTives), a psychological intervention which reduces depression and anxiety in family carers also reduces abusive behavior in carers of people living in their own homes. We also explored the longitudinal course of carer abusive behavior over two year.
We included self-identified family carers who gave support at least weekly to people with dementia referred in the previous year to three UK mental health services and a neurological dementia service. We randomly assigned these carers to START, an eight-session, manual-based coping intervention, or treatment as usual (TAU). Carer abusive behavior (Modified Conflict Tactic Scale (MCTS) score ≥2 representing significant abuse) was assessed at baseline, 4, 8, 12, and 24 months.
We recruited 260 carers, 173 to START and 87 to TAU. There was no evidence that abusive behavior levels differed between randomization groups or changed over time. A quarter of carers still reported significant abuse after two years, but those not acting abusively at baseline did not become abusive.
There was no evidence that START, which reduced carer anxiety and depression, reduced carer abusive behavior. For ethical reasons, we frequently intervened to manage concerning abuse reported in both groups, which may have disguised an intervention effect. Future dementia research should include elder abuse as an outcome, and consider carefully how to manage detected abuse.
The role of explosions and patient transport vehicles as sources and vectors of Gram-negative, multidrug-resistant organisms (MDROs) that predominate infections following lengthy evacuations after disasters due to natural hazards and in current war-trauma patients is unknown.
Damaged or heavily-used vehicles could be sources of the MDROs subsequently linked to nosocomial infections.
From January through May 2008 in Iraq, inside surfaces of heavily-used, tactical vehicles (Experimental Group) were sampled with sterile, pre-moistened swabs. Swabs, along with positive and negative controls, were shipped to the reference laboratory in Washington, DC, where they underwent culture, identification and susceptibility testing, and pulsed-field gel electrophoresis. Multidrug-resistant organisms were defined according to the standard Centers for Disease Control and Prevention definitions. High risk organisms (HROs) were defined as susceptible E. coli, A. baumannii, P. aeruginosa, Enterobacter spp, or Klebsiella spp. Concurrently, new counterparts (Control Group) were similarly surveyed in a storage lot in Georgia, USA. Groups were compared using the Chi-squared test.
One hundred thirty-nine consecutive vehicles including all available ambulances were sampled, yielding 153 swabs. Nineteen were lost or damaged during shipping. Seventy-nine swabs yielded growth of one or more Gram-negative bacteria. The amount and genotype of MDROs in heavily-used vehicles, including those involved in roadside bombings, were compared to control vehicles and to strains isolated from wounds and environmental surfaces at the base hospital. Predominant organisms included P. agglomerans (34%), S. flexneri (8%), E. vulneris (6%), Pseudomonas sp. (6%), and K. pneumonia (6%). No MDROs were isolated. Thirteen vehicles (eight of 94 experimental and five of 45 control) yielded HRO. There was no difference in contamination rates (P = .63). No HROs were isolated from ambulances. No clonal association existed between vehicle and hospital strains.
Given the implications that this knowledge gap has on military and civilian prehospital reservoirs of infection, further study is warranted to confirm these findings and identify targets for preventive intervention throughout civilian disaster and military casualty evacuation chains.
LeshoE, AkeJ, HuangX, CashDM, NikolichM, BarberM, RobensK, GarnettE, LindlerL, ScottP. Amount of Usage and Involvement in Explosions Not Associated with Increased Contamination of Prehospital Vehicles with Multi-drug-resistant Organisms. Prehosp Disaster Med. 2013;28(2):1-3..
To investigate potential sources of gram-negative multidrug-resistant organisms (MDROs) in a deployed US military healthcare facility.
Swab sampling of patients, hospital personnel, and environmental surfaces was performed before the opening of a new medical treatment facility in Iraq and then serially for the next 6 months. Multidrug resistant isolates were genotypically characterized using pulsed-field gel electrophoresis (PFGE). Univariate and multivariate analysis were performed to evaluate associations between patient characteristics and MDRO carriage.
Deployed US military medical facility.
A total of 1,348 samples were obtained, yielding 654 isolates, 42 of which were MDROs. One hundred fifty-eight patients were sampled; swabs from 18 patients yielded 29 MDR isolates. Host nation patients comprised 89% of patients with MDROs and 37% of patients without MDROs (P < .001 ). Host nation patient status was also significantly associated with MDRO carriage in multivariate logistic regression analysis (adjusted odds ratio, 2.9; confidence interval, 1.3-6.3; P = .009). Bacteria with PFGE patterns matching those recovered from host nation patients were later isolated from environmental surfaces including recovery room patient monitors and the trauma bay floor.
At this facility, MDRO isolation was predominantly obtained from newly admitted host nation patients,,which may reflect baseline colonization with MDROs in the community. Patient MDRO carriage was linked to subsequent environmental contamination. These findings support intensive infection control efforts in forward deployed facilities.
Obesity is a serious problem that affects children from diverse ethnic backgrounds in both industrialised and developing countries. Worldwide, an estimated twenty-two million children <5 years of age were overweight in 2007. In the UK if current trends continue an estimated one-quarter of all children <16 years of age will be obese by 2050. Recent evidence suggests that most obesity is established during the preschool years, and because one in five obese 4 year olds will become obese adults this situation has major implications for public health. The causes of obesity in preschool children are complex and multifactorial. Although 30–50% of the predisposition towards obesity in preschool children can be explained by genetic factors, environmental influences also play a crucial role. The preschool period in particular is a pivotal time during which long-term dietary and physical activity habits are established, with potential lifelong effects on health. However, research in this age-group is limited. Previous studies have aimed to improve diet, increase physical activity and achieve behavioural change. However, few of these studies have been successful and there is an urgent need, therefore, for the development of evidence-based interventions aimed at the prevention of preschool obesity.
Breast cancer is a multifactorial disease that is triggered by gene–environment interactions. Epidemiological research has identified alcohol consumption as a significant non-hormonal-related and consistent risk factor, and is thus a preventable cause of breast cancer. The reasons why alcohol drinking increase breast cancer risk are unclear, and several hypotheses exist. The perturbation of estrogen metabolism and response appears to one mechanism underlying the association. Alcohol consumption also increases breast density in postmenopausal women and affects sex steroid levels. Other plausible mechanisms include: (1) mutagenesis by acetaldehyde, which is a metabolite of ethanol; (2) by enhancing the susceptibility of the mammary gland to carcinogenesis by affecting DNA repair, stimulating cell proliferation or altering mammary gland structural development; (3) influencing the disposition and function of essential nutrients or dietary factors considered cancer protective (e.g. affecting folate and one-carbon metabolism pathways); (4) inducing genome instability and DNA damage; and (5) inducing oxidative damage via ethanol or estrogen metabolism. To better understand the etiological nature of the effect of alcohol on breast carcinogenesis, further studies at the cellular and molecular levels on the interaction between ethanol and other risk factors, estrogen, carcinogens are needed.
Because Dioryctria amatella (Hulst) is a key pest in loblolly pine, Pinus taeda L. (Pinaceae), seed orchards in the southeastern United States, improved timing of insecticide applications would be valuable for its control. To time two fenvalerate (Pydrin® 2.4 EC) applications we tested four variations of a degree-day model that was developed to predicted when various proportions of D. amatella eggs would hatch during the spring generation. We compared reductions in Dioryctria spp. cone damage to unsprayed checks and a standard operational spray regime of four monthly applications of fenvalerate. In addition, we examined seeds from healthy cones to determine if sprays to control D. amatella also reduced seed damage caused by Leptoglossus corculus Say (Heteroptera: Coreidae) and Tetyra bipunctata (Herrich-Schäffer) (Heteroptera: Scutelleridae). Trials were conducted from 1984 to 1986 in two orchards in South Carolina and one in Alabama. Degree-day accumulations (threshold = 11 °C) were begun on the day when the cumulative number of male D. amatella equaled or exceeded five captured in 15 Pherocon 1C® traps baited with 100 μg of Z-11-hexadecenyl acetate. One application per year was insufficient to control D. amatella or reduced seed-bug damage. Two sprays based on D. amatella phenology significantly reduced coneworm and seed bug damage, and were as effective as four sprays applied monthly. None of the treatments reduce spring cone losses, which are primarily caused by Dioryctria merkeli Mutuura and Monroe. Several variations of the model performed well, but we suggest that the best, based on efficacy and ease of use, was when sprays were applied immediately after five males were caught (degree-day = 0) and again when the model predicted 50% of the spring generation eggs had hatched.
Many factors influence the type and quantity of services received by patients and, thus, the total cost of care. Knowledge of these factors can aid budgetary and service-planning decisions.
To investigate factors that influence the cost of caring for patients with severe psychotic illness.
Univariate and multivariate analyses were used to examine associations between baseline characteristics and subsequent 2-year total direct costs in 667 patients from the UK700 case management trial.
Significantly more money was spent on younger patients, those with longer duration of illness, those who had spent less time living independently and those who had spent longer in hospital for psychiatric reasons.
Total costs of caring for patients with severe psychotic illness appear to be influenced to a large extent by age, duration of illness and past levels of dependence on statutory services. The strength of these relationships is greater than the impact of illness severity.
Intensive case management is commonly advocated for the care of the severely mentally ill, but evidence of its cost-effectiveness is lacking.
To investigate the cost-effectiveness of intensive compared with standard case management for patients with severe psychosis.
708 patients with psychosis and a history of repeated hospital admissions were randomly allocated to standard (case-loads 30–35) or intensive (case-loads 10–15) case management. Clinical and resource use data were assessed over two years.
No statistically significant difference was found between intensive and standard case management in the total two-year costs of care per patient (means £24 550 and £22 700, respectively, difference £1850, 95% Cl – £1600 to £5300). There was no evidence of differential effects in African–Caribbean patients or in the most disabled. Psychiatric in-patient hospital stay accounted for 47% of the total costs, but neither such hospitalisation nor other clinical outcomes differed between the randomised groups.
Reduced case-loads have no clear beneficial effect on costs, clinical outcome or cost-effectiveness. The policy of advocating intensive case management for patients with severe psychosis is not supported by these results.
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