A patient's experience in dementia care: Using the "lived experience" to improve care

OBJECTIVE

To give FPs an understanding of the "lived experience" of dementia via the words of a person with dementia (PWD)- Faye Forbes, a 64-year-old Anglican priest with Alzheimer disease who provides her perspectives on living with dementia-and to use these thoughts to improve care and outcomes.

SOURCES OF INFORMATION

Ovid MEDLINE was searched from January 2005 to February 2015 using subject headings for dementia, caregiver, perspectives, and quality of health care. Articles geared toward FPs were selected. Relevant review articles and original research articles were used when appropriate and if they were applicable to PWDs and their caregivers.

MAIN MESSAGE

There are several frameworks that organize the main experiences described by patients and caregivers. We used a review of the qualitative literature to provide the framework to summarize Faye's experience under the following headings: seeking a diagnosis, accessing supports and services, information needs, disease management, and communication and attitudes.

CONCLUSION

Physicians should consider these themes when developing a management plan for PWDs. Trying to understand the experiences and perspectives of PWDs and their caregivers is important in providing optimal care.

[Ocriplasmin as a treatment option for symptomatic vitreomacular traction with and without macular hole. First clinical experiences]

PURPOSE

To evaluate the resolution rate in patients with symptomatic vitreomacular traction (≤ 1500 μm) with or without macular holes (≤ 400 μm) after therapy with intravitreal ocriplasmin (Jetrea®) injection in a clinical setting.

METHODS

Until now we have prospectively examined 21 eyes of 21 consecutive patients with symptomatic vitreomacular traction with or without macular holes who underwent intravitreal operative injection of 0.1 ml ocriplasmin. The best corrected visual acuity and high-resolution optical coherence tomography (SD-OCT) ultrastructural parameters were measured before injection and again 1, 3 and 4 months after treatment. The numbers of resolved vitreomacular traction and closed macular holes were documented.

RESULTS

Vitreomacular traction was resolved in 15 out of 21 (71 %) eyes. Of the five eyes which initially presented with vitreomacular traction with macular holes, all showed resolution of vitreomacular traction but only two of the macular holes were closed. The average best corrected visual acuity was 0.38 logMAR (± 0.23) at baseline and 0.43 logMAR (± 0.28), 0.38 logMAR (± 0.27) and 0.36 logMAR (± 0.24) 1, 3 and 4 months after injection, respectively. The average foveal thickness was 355.95 μm (± 114.53 μm) at baseline, reducing to 304.61 μm (± 100.91 μm), 308.00 μm (±76.17 μm) and 277.50 μm (± 26.24 μm) after 1, 3 and 4 months, respectively.

CONCLUSION

In this ongoing study there was a high percentage of resolution of vitreomacular traction (71 %) 1 month after intravitreal operative injection of Jetrea® and closure of two out of five macular holes. This was further associated with stabilization of visual acuity and reduction of foveal thickness. Further investigations are necessary to document the effectiveness of the pharmacological vitreolysis in a clinical setting.

[Therapeutic Options in Vitreomacular Traction With or Without a Macular Hole]

Treatment is usually indicated for symptomatic vitreomacular traction (VMT) with or without a full thickness macular hole (FTMH) and without spontaneous resolution. Ultrastructural parameters are evaluated by SD-OCT, in order to classify the vitreoretinal interface and to estimate the success rate of treatment. The resolution rate after therapy with intravitreal Jetrea® (Ocriplasmin) is high (up to 70 %) in patients with symptomatic focal vitreomacular traction (≤ 1500 µm) with or without a macular hole (≤ 250 µm) and with no epiretinal membrane (ERM), but depends on the exact baseline analysis. All other patients with idiopathic traction retinopathy should be treated by minimal invasive pars plana vitrectomy (MIVI). Vitreoretinal surgery effectively removes traction and gives a high closure rate of a full thickness macular hole (FTMH, 90 to 100 %). It is now a very safe procedure with few side effects. Despite a low risk profile (cataract, retinal tear etc.) the indication for surgery needs to take the safety profile into account. Therefore vitrectomy is only indicated in symptomatic patients complaining of blurred vision, VA reduction and metamorphopsia. Vitrectomy is also indicated in patients whose treatment by pharmacologic vitreolysis has failed.

Pre-Clerkship Observerships to Increase Early Exposure to Geriatric Medicine

Background and Purpose

To foster interest in geriatric care, the Queen’s Geriatrics Interest Group (QGIG) collaborated with the Division of Geriatric Medicine to arrange a Geriatrics Pre-Clerkship Observership Program.

Methods

Forty-two pre-clerkship medical students participated in the program between October 2013 and May 2014. Participants were paired with a resident and/or attending physician for a four-hour weekend observership on an inpatient geriatric rehabilitation unit. The program was assessed using: (1) internally developed Likert scales assessing student’s experiences and interest in geriatric medicine before and after the observership; (2) University of California Los Angeles–Geriatric Attitudes Scale (UCLA-GAS); and (3) narrative feedback.

Results

All participants found the process of setting up the observership easy. Some 72.7% described the observership experience as leading to positive changes in their attitude toward geriatric medicine and 54.5% felt that it stimulated their interest in the specialty. No statistically significant change in UCLA–GAS scores was detected (mean score pre- versus post-observership: 3.5 ± 0.5 versus 3.7 ± 0.4; p=.35). All participants agreed that the program should continue, and 90% stated that they would participate again.

Conclusions

The observership program was positively received by students. Structured pre-clerkship observerships may be a feasible method for increasing exposure to geriatric medicine.

Models of primary care for frail patients

OBJECTIVE

To discuss models of care for frail seniors provided in primary care settings and those developed by Canadian FPs.

SOURCES OF INFORMATION

Ovid MEDLINE and the Cochrane database were searched from 2010 to January 2014 using the terms models of care, family medicine, elderly, and geriatrics.

MAIN MESSAGE

New models of funding for primary care have opened opportunities for ways of caring for complex frail older patients. Severity of frailty is an important factor, and more severe frailty should prompt consideration of using an alternate model of care for a senior. In Canada, models in use include integrated care systems, shared care models, home-based care models, and family medicine specialty clinics. No one model should take precedence but FPs should be involved in developing and implementing strategies that meet the needs of individual patients and communities. Organizational and remunerative supports will need to be put in place to achieve widespread uptake of such models.

CONCLUSION

Given the increased numbers of frail seniors and the decrease in access to hospital beds, prioritized care models should include ones focused on optimizing health, decreasing frailty, and helping to avoid hospitalization of frail and well seniors alike. The Health Care of the Elderly Program Committee at the College of Family Physicians of Canada is hosting a repository for models of care used by FPs and is asking physicians to submit their ideas for how to best care for frail seniors.

Adverse events in nursing: A retrospective study of reports of patient and relative experiences

BACKGROUND

Patient safety is an important global issue. While it is well known that patients can suffer from adverse events in nursing care, there is a lack of knowledge as to how they experience them.

AIM

To examine adverse events in nursing care as they are experienced by patients and relatives.

METHODS

This was a retrospective study taking both a qualitative and a quantitative approach. It was based on data regarding 242 adverse events in nursing care, as reported by patients and relatives to Sweden's Medical Responsibility Board, content analysis was used to analyse the reports.

RESULTS

Patients' and relatives' experiences were analysed into four categories of adverse events, as concerning participation, clinical judgement, nursing intervention and the essentials of care.

LIMITATIONS

The reports were classified by the Medical Responsibility Board, without a standardized system. The adverse events reported were few in number and were reported by patients and relatives only.

CONCLUSION

Lack of participation has negative consequences and contributes to adverse events. Adverse events occur through missed care as well as through carer errors.

IMPLICATIONS ON NURSING AND HEALTH PRACTICE

Nurses need to improve their skills that support patient participation. Patient participation needs to be incorporated into nurses' duties.

IMPLICATIONS FOR NURSING AND HEALTH POLICY

Resources for patients to participate in their own care needs to be a priority underpinning policy-making in health systems. Nursing education systems need to teach students about the value and benefits of involving patients in their care.

Improving End-of-Life Communication and Decision Making: The Development of a Conceptual Framework and Quality Indicators

CONTEXT

The goal of end-of-life (EOL) communication and decision making is to create a shared understanding about a person's values and treatment preferences that will lead to a plan of care that is consistent with these values and preferences. Improvements in communication and decision making at the EOL have been identified as a high priority from a patient and family point of view.

OBJECTIVES

The purpose of this study was to develop quality indicators related to EOL communication and decision making.

METHODS

We convened a multidisciplinary panel of experts to develop definitions, a conceptual framework of EOL communication and decision making, and quality indicators using a modified Delphi method. We generated a list of potential items based on literature review and input from panel members. Panel members rated the items using a seven-point Likert scale (1 = very little importance to 7 = extremely important) over four rounds of review until consensus was achieved.

RESULTS

About 24 of the 28 panel members participated in all four rounds of the Delphi process. The final list of quality indicators comprised 34 items, divided into the four categories of our conceptual framework: Advance care planning (eight items), Goals of care discussions (13 items), Documentation (five items), and Organization/System aspects (eight items). Eleven items were rated "extremely important" (median score). All items had a median score of five (moderately important) or greater.

CONCLUSION

We have developed definitions, a conceptual framework, and quality indicators that researchers and health care decision makers can use to evaluate and improve the quality of EOL communication and decision making.

Humanities and geriatric education: a strategy for recruitment?

Ageing is a common subject in arts and literature as it is a universal experience. The use of the humanities in medical education may have a positive effect on trainees' attitude to caring for seniors and on geriatrics as a career choice. This paper summarizes the role of humanities in medical education and provides some examples and thoughts on how humanities curriculum can be used in geriatric teaching.

Developing physician consensus on the reporting of patients with mild cognitive impairment and mild dementia to transportation authorities in a region with mandatory reporting legislation

OBJECTIVE

To establish consensus among dementia experts about which patients with mild cognitive impairment (MCI) or mild dementia should be reported to transportation authorities.

METHODS

We conducted a literature review of predictors of driving safety in patients with dementia and combined these into 26 case scenarios. Using a modified Delphi technique, case scenarios were reviewed by 38 dementia experts (geriatric psychiatrists, geriatricians, cognitive neurologists and family physicians with expertise in elder care) who indicated whether or not they would report the patient in each scenario to regional transportation authorities and recommend a specialized on-road driving test. Scenarios were presented up to five times to achieve consensus, defined as 85% agreement, and discrepancies were discussed anonymously online.

RESULTS

By the end of the fifth iteration, there was cumulative consensus on 18 scenarios (69%). The strongest predictors of decision to report were the combination of caregiver concern about the patient's driving and abnormal Clock Drawing Test, which accounted for 62% of the variance in decision to report at the same time as or without a road test (p <0.01). Based on these data, an algorithm was developed to guide physician decision-making about reporting patients with MCI or mild dementia to transportation authorities.

CONCLUSION

This study supports existing international guidelines that recommend specialized on-road testing when driving safety is uncertain for patients with MCI and emphasizes the importance of assessing executive dysfunction and caregiver concern about driving.

Genetic or pharmacologic disruption of the calcineurin-nuclear factor of activated T-cells axis prevents social stress-induced voiding dysfunction in a murine model

OBJECTIVE

Social stress can suppress the voiding reflex, with resultant diminished voiding frequency and increased volumes. The calcineurin-NFAT (nuclear factor of activated T cells) pathway is important in memory development. It was hypothesized that interruption of the calcineurin-NFAT pathway might prevent social stress-induced voiding dysfunction.

METHODS

Mice were subjected to social stress in an established resident-intruder model for 1 h, followed by 23 h of barrier separation. NFATc3, NFATc4 knockout (KO) and wild-type (WT) mice were studied. At two weeks, voiding patterns were collected; this was followed by sacrifice. Corticotropin-releasing factor (CRF) mRNA expression in Barrington's nucleus (BN) was determined by in-situ hybridization.

RESULTS

Social stress decreased voiding frequency and increased voided volumes in WT strains. At baseline, NFATc3 KO mice showed decreased voids and increased volumes, while the NFATc4 KO mice resisted social stress. However, CRF mRNA increased in WT mice following social stress and was increased at baseline in NFATc3 KO mice. It was found that CRF mRNA did not increase following social stress in NFATc4 KO mice. The administration of CsA to WT mice normalized voiding patterns following social stress, albeit with no effect on CRF mRNA in BN.

CONCLUSION

Disrupting the calcineurin-NFAT axis by either genetic or pharmacologic approaches confers resistance to the development of social stress-induced voiding and dysfunction.

Results of surveillance for infections with Shiga toxin-producing Escherichia coli (STEC) of serotype O104:H4 after the large outbreak in Germany, July to December 2011

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Pharmacologic treatment of depression in the elderly

OBJECTIVE

To discuss pharmacologic treatment of depression in the elderly, including choice of antidepressants, titration of dose, monitoring of response and side effects, and treatment of unresponsive cases.

SOURCES OF INFORMATION

The 2006 Canadian Coalition for Seniors' Mental Health guideline on the assessment and treatment of depression was used as a primary source. To identify articles published since the guideline, MEDLINE was searched from 2007 to 2012 using the terms depression, treatment, drug therapy, and elderly.

MAIN MESSAGE

The goal of treatment should be remission of symptoms. Improvement of symptoms can be monitored by identifying patient goals or by use of a clinical tool such as the Patient Health Questionnaire-9. Treatment should be considered in 3 phases: an acute treatment phase to achieve remission of symptoms, a continuation phase to prevent recurrence of the same episode of illness (relapse), and a maintenance (prophylaxis) phase to prevent future episodes (recurrence). Initial dosing should be half of the usual adult starting dose and be titrated regularly until the patient responds, until the maximum dose is reached, or until side effects limit further increases. Common side effects of medications include falls, nausea, dizziness, headaches, and, less commonly, hyponatremia and QT interval changes. Strategies for switching or augmenting antidepressants are discussed. Older patients should be treated for at least a year from when clinical improvement is noted, and those with recurrent depression or severe symptoms should continue treatment indefinitely. Treatment of specific situations such as severe depression or depression with psychosis is discussed, including the use of electroconvulsive therapy. Criteria for referral to geriatric psychiatry are provided; however, many family physicians do not have easy access to this resource or to other nonpharmacologic clinical strategies.

CONCLUSION

The effectiveness of pharmacologic treatment of depression is not substantially affected by age. Identification of depression, choice of appropriate treatment, titration of medications, monitoring of side effects, and adequate duration of treatment will improve outcomes for older patients.

Autochthonous dengue virus infection in Japan imported into Germany, September 2013

In September 2013, dengue virus (DENV) infection was diagnosed in a German traveller returning from Japan. DENV-specific IgM and IgG and DENV NS1 antigen were detected in the patient’s blood, as were DENV serotype 2-specific antibodies. Public health authorities should be aware that autochthonous transmission of this emerging virus may occur in Japan. Our findings also highlight the importance of taking a full travel history, even from travellers not returning from tropical countries, to assess potential infection risks of patients.

An outbreak of Salmonella Newport associated with mung bean sprouts in Germany and the Netherlands, October to November 2011

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[The 2011 HUS epidemic in Germany. Challenges for disease control: what should be improved?]

From May to July 2011 [corrected] the world's largest outbreak of hemolytic uremic syndrome (HUS) occurred in northern Germany with dramatic consequences for the population, the health care system and the food industry. In the following we examine the detection of the outbreak, epidemic management and related public communication aspects based on scientific publications, media reports as well as own and new data analyses. The subsequent 17 recommendations concern issues such as participation in and implementation of existing and new surveillance systems particularly with respect to physicians, broad application of finely tuned microbiological typing, improved personnel capacity and crisis management structures within the public health service and evidence-based communication by administrations and scientific associations. Outbreaks of similar dimensions can inevitably occur again and result in costs which will far exceed investments needed for early detection and control. This societal balance should be taken into account in spite of limited resources in the public health sector.

DISC1-ATF4 transcriptional repression complex: dual regulation of the cAMP-PDE4 cascade by DISC1

Disrupted-In-Schizophrenia 1 (DISC1), a risk factor for major mental illnesses, has been studied extensively in the context of neurodevelopment. However, the role of DISC1 in neuronal signaling, particularly in conjunction with intracellular cascades that occur in response to dopamine, a neurotransmitter implicated in numerous psychiatric disorders, remains elusive. Previous data suggest that DISC1 interacts with numerous proteins that impact neuronal function, including activating transcription factor 4 (ATF4). In this study, we identify a novel DISC1 and ATF4 binding region in the genomic locus of phosphodiesterase 4D (PDE4D), a gene implicated in psychiatric disorders. We found that the loss of function of either DISC1 or ATF4 increases PDE4D9 transcription, and that the association of DISC1 with the PDE4D9 locus requires ATF4. We also show that PDE4D9 is increased by D1-type dopamine receptor dopaminergic stimulation. We demonstrate that the mechanism for this increase is due to DISC1 dissociation from the PDE4D locus in mouse brain. We further characterize the interaction of DISC1 with ATF4 to show that it is regulated via protein kinase A-mediated phosphorylation of DISC1 serine-58. Our results suggest that the release of DISC1-mediated transcriptional repression of PDE4D9 acts as feedback inhibition to regulate dopaminergic signaling. Furthermore, as DISC1 loss-of-function leads to a specific increase in PDE4D9, PDE4D9 itself may represent an attractive target for therapeutic approaches in psychiatric disorders.

Design of a synthetic simulator for pediatric lumbar spine pathologies

OBJECT

Simulation has become an important tool in neurosurgical education as part of the complex process of improving residents' technical expertise while preserving patient safety. Although different simulators have already been designed for a variety of neurosurgical procedures, spine simulators are still in their infancy and, at present, there is no available simulator for lumbar spine pathologies in pediatric neurosurgery. In this paper the authors describe the peculiarities and challenges involved in developing a synthetic simulator for pediatric lumbar spine pathologies, including tethered spinal cord syndrome and open neural tube defects.

METHODS

The Department of Neurosurgery of the University of Illinois at Peoria, in a joint program with the Mechanical Engineering Department of Bradley University, designed and developed a general synthetic model for simulating pediatric neurosurgical interventions on the lumbar spine. The model was designed to be composed of several sequential layers, so that each layer might closely mimic the tensile properties of the natural tissues under simulation. Additionally, a system for pressure monitoring was developed to enable precise measurements of the degree of manipulation of the spinal cord.

RESULTS

The designed prototype successfully simulated several scenarios commonly found in pediatric neurosurgery, such as tethered spinal cord, retethered spinal cord, and fatty terminal filum, as well as meningocele, myelomeningocele, and lipomyelomeningocele. Additionally, the formulated grading system was able to account for several variables involved in the qualitative evaluation of the technical performance during the training sessions and, in association with an expert qualitative analysis of the recorded sessions, proved to be a useful feedback tool for the trainees.

CONCLUSIONS

Designing and building a synthetic simulator for pediatric lumbar spine pathologies poses a wide variety of unique challenges. According to the authors' experience, a modular system composed of separable layers that can be independently replaced significantly enhances the applicability of such a model, enabling its individualization to distinctive but interrelated pathologies. Moreover, the design of a system for pressure monitoring (as well as a general score that may be able to account for the overall technical quality of the trainee's performance) may further enhance the educational applications of a simulator of this kind so that it can be further incorporated into the neurosurgical residency curriculum for training and evaluation purposes.