Evaluation of latent tuberculosis infection surveillance in Peel region, Ontario, 2010-2014

BACKGROUND

In Canada, identification and treatment of individuals with latent tuberculosis infection (LTBI) is a key component in preventing the progression of LTBI to active tuberculosis (TB). In Peel region, a large municipality in Ontario where half of the population is foreign-born, LTBI surveillance data are also critical to understanding the local epidemiology of TB.

OBJECTIVE

To evaluate LTBI surveillance data collected through the integrated Public Health Information System (iPHIS) from 2010 to 2014 by assessing data quality and usefulness and to provide recommendations to improve surveillance for Peel region.

METHODS

Using the European Centre for Disease Prevention and Control framework for surveillance evaluation, data quality was assessed based on completeness and validity of key variables in the iPHIS database. Usefulness of surveillance data in informing program decisions was assessed through interviews with stakeholders from Peel Public Health.

RESULTS

Of 6,576 iPHIS records evaluated, data for gender and date of birth were greater than 99% complete, while more than half of the risk factor fields were blank or 'unknown'. A comparison of 192 paper charts to the corresponding iPHIS record identified coding errors in over 40% of iPHIS risk factor fields. Treatment completion documented in iPHIS (20%) was lower than data obtained from a follow-up telephone survey of cases (50%). Stakeholders found surveillance data to be useful (100%), however, recommendations were made for improvement of data collection and analysis.

CONCLUSION

Evaluating LTBI surveillance to improve data quality and usefulness for program planning is essential in an era of TB elimination. This evaluation resulted in standardization of data entry processes and continuation of direct follow-up with LTBI clients to confirm treatment completion. Work to understand barriers to treatment initiation and completion is currently underway.

Review of Association Between Delirium and Dementia in Elderly People

Delirium is a neuropsychiatric syndrome, characterized by an acute change in mental status with a fluctuating course of symptoms, that affects almost 50% of people aged 65 years or older, admitted to hospital. Delirium is associated with negative outcomes, including increased risk of mortality, cognitive and functional decline. In 50% of the cases, the cause of delirium is multifactorial, resulting from a complex inter-relationship between several predisposing factors (e.g. advanced age, dementia) in highly vulnerable patients that are exposed to precipitating factors (e.g. infections). In this context, cognitive impairment and dementia are important risk factors for delirium, increasing its risk by two to five times, associated with worse outcomes. The underlying brain vulnerability of these patients with dementia may predispose to the development of delirium, as a consequence of insults related to the acute medical disease, medication or environmental factors. On the other hand, delirium may cause permanent neuronal damage, which may lead to the development or worsening of a pre-existing dementia. As a result, delirium and dementia frequently coexist and overlap, challenging differential diagnosis.

The identification of risk factors for delirium, specifically pre-existing cognitive impairment or dementia, in elderly people admitted to hospital is essential to the implementation of preventive strategies that may contribute to the decrease of delirium rates. The present literature review aims to highlight the association between delirium and dementia in elderly people, focusing on diagnosis, pathophysiology, prevention, and management.

Disclosure of interest

The authors have not supplied their declaration of competing interest.

Psychotropic Use in Elderly with Cognitive Impairment Living in Nursing Homes

Introduction

Elderly patients in nursing homes (NH) are often prescribed medications for many physical and mental health problems, with polypharmacy. There is a considerable number of studies documenting this extensive prescription of psychotropic medication, despite the raised concerns about their overuse/misuse, due to serious adverse effects, including increased rate of cognitive decline associated with antipsychotics.

Aims

To characterize the prescription of psychotropics in elderly sample with cognitive impairment living in NH.

Methods

Elderly living in three Portuguese NH were included in this cross-sectional study. All residents were eligible, unless they were unwilling or unresponsive. Participants’ medication was obtained from medical records. Guidelines of ATC were used to categorize the drugs. Participants were assessed with MMSE and GDS.

Results

The sample included 172 elderly, mostly women (90%), with average of 81(sd = 10) years and median lengths of stay of 3 years. Overall, 79.1% used ≥ 1 nervous system-acting drugs. Anxiolytics (54.7%), antidepressants (29.1%) and antipsychotics (23.3%) were the most frequent. The majority (58%) presented cognitive impairment (MMSE). Among those, 46.2% presented depression (GDS) and 79.6% took at least one drug for the CNS and 41.9% ≥ 3. Antipsychotics were received by 26.5%, while 57.1% used anxiolytics, 31.6% antidepressants and 16.3% anti-dementia drugs. No significant relation between GDS and antidepressants was found.

Conclusion

This study confirms the high usage of CNS drugs in patients with cognitive impairment in NH. These rates were comparable with previous studies. Antidepressants appear to be under-used, which can be related to the under-recognition of depression. Also, potential harmful psychotropic drugs such as anxiolytics and antipsychotics are overused.

Disclosure of interest

The authors have not supplied their declaration of competing interest.

Behavioral and Psychological Symptoms: A Contribution for their Understanding Based on the Unmet Needs Model

Introduction

Behavioural and psychological symptoms (BPSD) are frequent in dementia and their contribution to poor health outcomes is well recognized. Four major frameworks attempt an explanation their aetiology: biological, behavioural, environmental vulnerability and unmet needs models. The latter states that BPSD are symptoms of needs that are not being met due to patients’ decreased ability to communicate/fulfil them. This model also implies that if needs were met, BPSD would improve.

Aims

To explore the relation between needs and BPSD, and describe which unmet needs were contributing to BPSD in an elderly sample.

Methods

A cross-sectional study was conducted in three Portuguese nursing homes. All residents were considered eligible. However, those unwilling or unable to participate were excluded. For each elderly patient, needs were assessed with camberwell assessment of need for the elderly/cane and BPSD with European Portuguese neuropsychiatric inventory/NPI.

Results

The final sample included 166 elderly with an average of 80.9(sd = 10.2) years. Significant correlations between NPI and unmet and global needs were found (rs = 0.181,P = 0.020; rs = 0.254,P = 0.001, respectively). Additionally, the unmet needs of daytime activities (P = 0.019), company (P = 0.028) and behaviour (P = 0.001), presented significant correlations with NPI.

Conclusion

In this sample, a high number of unmet needs were found. The absence of daytime activities, company and behaviour contributed to the identified BPSD, which is in line with other studies also highlighting the importance of these needs in nursing homes. This not only provides a framework for understanding BPSD, but also points to the identification of unmet needs as pivotal in prevention and treatment of these symptoms.

Disclosure of interest

The authors have not supplied their declaration of competing interest.

Clinical algorithms to aid osteoarthritis guideline dissemination

BACKGROUND

Numerous scientific organisations have developed evidence-based recommendations aiming to optimise the management of osteoarthritis (OA). Uptake, however, has been suboptimal. The purpose of this exercise was to harmonize the recent recommendations and develop a user-friendly treatment algorithm to facilitate translation of evidence into practice.

METHODS

We updated a previous systematic review on clinical practice guidelines (CPGs) for OA management. The guidelines were assessed using the Appraisal of Guidelines for Research and Evaluation for quality and the standards for developing trustworthy CPGs as established by the National Academy of Medicine (NAM). Four case scenarios and algorithms were developed by consensus of a multidisciplinary panel.

RESULTS

Sixteen guidelines were included in the systematic review. Most recommendations were directed toward physicians and allied health professionals, and most had multi-disciplinary input. Analysis for trustworthiness suggests that many guidelines still present a lack of transparency. A treatment algorithm was developed for each case scenario advised by recommendations from guidelines and based on panel consensus.

CONCLUSION

Strategies to facilitate the implementation of guidelines in clinical practice are necessary. The algorithms proposed are examples of how to apply recommendations in the clinical context, helping the clinician to visualise the patient flow and timing of different treatment modalities.

The role of locus of control in nyaope addiction treatment

Background: Nyaope addiction is a significant health and social problem affecting some South African communities. With reported nyaope rehabilitation success rates of less than 3% and estimated dropout rates of 40%, improvement in the rehabilitation rates is essential. As locus of control (LOC) is a recognised predictive factor in the onset of substance use and rehabilitation outcomes, a rehabilitation programme aligned to the LOC orientation of the user could result in improved recovery outcomes. This study aimed to determine the LOC of nyaope users.Methods: Consenting adult male and female nyaope users voluntary participated in this quantitative study. After convenient sampling, 115 nyaope users admitted to drug rehabilitation centres registered and funded by the Gauteng Department of Social Development and 106 nyaope users from the streets of urban areas of Tshwane completed a self-administered validated questionnaire. LOC orientation was determined by giving participants 13 statements from which they had to choose the option that best described their situation in relation to drug addiction.Results: A total of 24.5% (47/192) of the respondents could be classified as having an external LOC orientation while 75.5% (145/192) were classified as having an internal LOC orientation.Conclusions: By determining the LOC orientation of a nyaope user, rehabilitation programmes could be aligned to suit the personality of the user leading to a better chance of successful recovery with fewer cases of readmission.

Delirium related distress in family: A non-systematic review

Introduction

Delirium is a common neuropsychiatric syndrome, particularly in elderly hospitalized patients, and is associated with an increase in morbidity and mortality. Although these negative consequences are well documented, only a few studies describe the experience of delirium from the families’ perspective.

Aims

To analyze studies regarding the experience and distress caused by delirium in the families/caregivers of adult/elderly hospitalized patients.

Methods

A non-systematic review of published articles until October 2015 in the database PubMed was carried out. The keyword “Delirium” was combined with: “experience”, “distress”, “anxiety” and “family”, “carer” and “relatives”. Inclusion criteria were: standardized diagnosis of delirium, systematic/prospective assessment of distress level. Clinical cases were excluded.

Results

Sixteen studies met the inclusion criteria for analysis. In most of them, family members (mostly younger) showed high levels of distress, even higher than health care professionals and patients. Several predictors of family distress were found, including poor functional status, psychomotor agitation, delusions, emotional lability, incoherent speech, inattention and disorientation. Higher distress was associated with long-term consequences (e.g. generalized anxiety). In the qualitative research, family members interpreted delirium as a sign of approaching death, result of pain/discomfort or an effect of medication. In addition, distress was associated with rapid and unexpected changes or unable to recognize the loved ones.

Conclusions

Delirium in patients was associated with significant distress in family members. These findings underline the importance of providing information and the development of appropriate supportive and psychoeducational interventions in order to help families throughout this process and reduce the associated distress. This work is supported by FCT (SFRH/BPD/103306/2014).

Disclosure of interest

The authors have not supplied their declaration of competing interest.

Tuning the Stoichiometry of Ag2S Thin Films for Resistive Switching Applications

In this work silver-rich and sulfur-rich silver sulfide (Ag2S) thin films were fabricated using a diversified set of experimental methods, namely ion beam deposition and atmosphere- and solution-based sulfurizations. The composition of the Ag2S thin films was studied using X-ray diffraction, Raman spectroscopy, scanning electron microscopy and energy dispersive X-ray spectroscopy. We found that it strongly depends on the fabrication conditions, such as sulfurization time and temperature. These conditions, in turn, affect the electrical characteristics of the thin films, namely the resistivity and resistive switching. We were able to control the Ag2S stoichiometry and infer its dependence on the fabrication parameters for all the followed methods.

Dementia severity among institutionalized elderly: Are there more unmet needs?

Introduction

The ageing population and the resulting increase in chronic diseases, including dementia, make the evaluation of their emergent needs a crucial step in psychogeriatric care. Unmet needs are found to be important clinical targets that should be followed by active management in order to improve health status and survival.

Objectives

To analyze the relation between unmet needs and cognition, and explore the nature of these needs across dementia severity stages.

Methods

A cross-sectional study was conducted in three nursing homes. Residents were excluded if they were terminally ill, unresponsive or presented delirium. All participants were assessed by Mini-Mental State Examination/MMSE (cognition) and Camberwell Assessment of Need for the Elderly/CANE (needs). Additionally, cognitive decline was staged as: absent (MMSE = 30), questionable (26–29), mild (21–25), moderate (11–20) and severe (≤ 10).

Results

The study included 175 elderly with a mean age of 80.6 (SD = 10.1) years, of which 58.7% presented cognitive decline. For these, the mean number of unmet needs was greater than for those without (4 vs 3, P < 0.001), and they differed significantly in the domains of daytime activities (P < 0.001), memory (P < 0.001) and psychotic symptoms (P = 0.005). A significant negative correlation was found between MMSE and number of unmet needs (rs = −0.369, P < 0.001). Considering the severity stages, unmet needs also differed: more needs in early stages in daytime activities (73.3%), and in advanced ones in memory (63.9%) and psychotic symptoms (23%).

Conclusions

Greater cognitive decline was related with more unmet needs, which agree with previous studies. The different nature of needs across severity stages also suggests that interventions should be tailored comprising this specificity and complexity, when effective care is planned.

Disclosure of interest

The authors have not supplied their declaration of competing interest.