Managing diabetes in people with dementia: protocol for a realist review

Interprofessional Teams Supporting Care Transitions from Hospital to Community: A Scoping Review

Introduction

Poor outcomes following the transition from hospital back to community living are common, especially for older adults with complex health and social care needs. Some health care systems now have multiple interprofessional teams (in hospital and community) to support care transitions. These teams will need to be well coordinated to improve care transition outcomes.

Methods

We conducted a scoping review to identify and map peer-reviewed literature on how interprofessional teams are working together to support older adults transitioning from hospital back to the community. We used the six-stage framework developed by Levac and colleagues (2010). Procedures were guided by the Joanna Briggs Institute scoping review guidelines.

Results

Our structured search and screening process resulted in 70 articles, published between 2000 and 2022, from 14 counties. Within these articles, 26 programs were described that used interprofessional teams in both the hospital and community.

Discussion

The qualitative articles suggested that effective teamwork is very important for promoting care transition quality, but the quantitative research did not report on team-related outcomes. Quantitative research has described, but not evaluated, strategies for promoting interprofessional collaboration.

Conclusion

Future research should focus on evaluating processes used to promote effective interprofessional teamwork in care transition interventions.

Novel insights into non-alcoholic fatty liver disease and dementia: insulin resistance, hyperammonemia, gut dysbiosis, vascular impairment, and inflammation

Non-alcoholic fatty liver disease (NAFLD) is a metabolic disease characterized by multiple pathologies. The progression of dementia with NAFLD may be affected by various risk factors, including brain insulin resistance, cerebrovascular dysfunction, gut dysbiosis, and neuroinflammation. Many recent studies have focused on the increasing prevalence of dementia in patients with NAFLD. Dementia is characterized by cognitive and memory deficits and has diverse subtypes, including vascular dementia, Alzheimer’s dementia, and diabetes mellitus-induced dementia. Considering the common pathological features of NAFLD and dementia, further studies on the association between them are needed to find appropriate therapeutic solutions for diseases. This review summarizes the common pathological characteristics and mechanisms of NAFLD and dementia. Additionally, it describes recent evidence on association between NAFLD and dementia progression and provides novel perspectives with regard to the treatment of patients with dementia secondary to NAFLD.

The mental health and well-being of internally displaced female Yazidis in the Kurdistan Region of Iraq: a realist review of psychosocial interventions and the impact of COVID-19

BACKGROUND

Yazidis in the Kurdistan Region of Iraq have been exposed to recurrent traumatic experiences associated with genocide and gender-based violence (GBV). In 2014, ISIS perpetrated another genocide against the Yazidi community of Sinjar. Women and girls were held captive, raped and beaten. Many have been forced into displacement. Rates of post-traumatic stress disorder (PTSD) and suicide are high. Limited research has evaluated interventions delivered to this population.

METHODS

This review explores how the global evidence on psychosocial interventions for female survivors of conflict-related sexual violence applies to the context of the female Yazidi population. We used a realist review to explore mechanisms underpinning complex psychosocial interventions delivered to internally displaced, conflict-affected females. Findings were cross-referenced with eight realist, semi-structured interviews with stakeholders who deliver interventions to female Yazidis in the Kurdistan Region of Iraq. Interviews also allowed us to explore the impact of COVID-19 on effectiveness of interventions.

RESULTS

Seven mechanisms underpinned positive mental health outcomes (reduced PTSD, depression, anxiety, suicidal ideation): safe spaces, a strong therapeutic relationship, social connection, mental health literacy, cultural-competency, gender-matching and empowerment. Interviews confirmed relevance and applicability of mechanisms to the displaced female Yazidi population. Interviews also reported increased PTSD, depression, suicide and flashbacks since the start of the COVID-19 pandemic, with significant disruptions to interventions.

CONCLUSION

COVID-19 is just one of many challenges in the implementation and delivery of interventions. Responding to the mental health needs of female Yazidis exposed to chronic collective violence requires recognition of their sociocultural context and everyday experiences.

Motivation as a mechanism underpinning exercise-based falls prevention programmes for older adults with cognitive impairment: a realist review

OBJECTIVES

This review aimed to identify mechanisms underlying participation in falls prevention interventions, in older adults with cognitive impairment. In particular we studied the role of motivation.

DESIGN

A realist review of the literature.

DATA SOURCES

EMBASE, MEDLINE, CINAHL, the Cochrane Library, PsycINFO and PEDRO.

ELIGIBILITY CRITERIA

Publications reporting exercise-based interventions for people with cognitive impairment, including dementia, living in the community.

DATA EXTRACTION AND SYNTHESIS

A 'rough programme theory' (a preliminary model of how an intervention works) was developed, tested against findings from the published literature and refined. Data were collected according to elements of the programme theory and not isolated to outcomes. Motivation emerged as a key element, and was prioritised for further study.

RESULTS

An individual will access mechanisms to support participation when they think that exercise will be beneficial to them. Supportive mechanisms include having a 'gate-keeper', such as a carer or therapist, who shares responsibility for the perception of exercise as beneficial. Lack of access to support decreases adherence and participation in exercise. Motivational mechanisms were particularly relevant for older adults with mild-to-moderate dementia, where the exercise intervention was multicomponent, in a preferred setting, at the correct intensity and level of progression, correctly supported and considered, and flexibly delivered.

CONCLUSION

Motivation is a key element enabling participation in exercise-based interventions for people with cognitive impairment. Many of the mechanisms identified in this review have parallels in motivational theory. Clinically relevant recommendations were derived and will be used to further develop and test a motivationally considered exercise-based falls intervention for people with mild dementia.

PROSPERO REGISTRATION NUMBER

CRD42015030169.

Traumatic brain injury associated with dementia risk among people with type 1 diabetes

OBJECTIVE

To examine the association between traumatic brain injury (TBI) and dementia risk among a cohort of middle-aged and elderly individuals with type 1 diabetes (T1D).

METHODS

We evaluated 4,049 members of an integrated health care system with T1D ≥50 years old between January 1, 1996, and September 30, 2015. Dementia and TBI diagnoses throughout the study period were abstracted from medical records. Cox proportional hazards models estimated associations between time-dependent TBI and dementia adjusting for demographics, HbA1c, nephropathy, neuropathy, stroke, peripheral artery disease, depression, and dysglycemic events. Fine and Gray regression models evaluated the association between baseline TBI and dementia risk accounting for competing risk of death.

RESULTS

A total of 178 individuals (4.4%) experienced a TBI and 212 (5.2%) developed dementia. In fully adjusted models, TBI was associated with 3.6 times the dementia risk (hazard ratio [HR] 3.64; 95% confidence interval [CI] 2.34, 5.68). When accounting for the competing risk of death, TBI was associated with almost 3 times the risk of dementia (HR 2.91; 95% CI 1.29, 5.68).

CONCLUSION

This study demonstrates a marked increase in risk of dementia associated with TBI among middle-aged and elderly people with T1D. Given the complexity of self-care for individuals with T1D, and the comorbidities that predispose them to trauma and falls, future work is needed on interventions protecting brain health in this vulnerable population, which is now living to old age.

Royal College of Psychiatrists Liaison Faculty & Joint British Diabetes Societies (JBDS): guidelines for the management of diabetes in adults and children with psychiatric disorders in inpatient settings

The Royal College of Psychiatrists Liaison Faculty & Joint British Diabetes Societies (JBDS) for Inpatient Care guidelines for the management of diabetes in adults and children with psychiatric disorders in inpatient settings are available in full at: www.diabetes.org.uk/joint-british-diabetes-society and https://abcd.care/joint-british-diabetes-societies-jbds-inpatient-care-group. This article summarizes the guidelines and recommendations. Commissioners are urged to ensure that the needs of people with diabetes and severe mental illness are specifically addressed in contracts with providers of inpatient care, and to avoid financial or other barriers to cross-organizational working and to ensure that patient-structured education is commissioned to meets the complex needs of people with diabetes and severe mental illness. Acute trusts are asked to develop joint pathways with mental health providers and facilitate multidisciplinary working and to screen for mental ill health in those admitted with acute complications of diabetes whose aetiology is unclear or not medically explained. Mental health trusts should create a diabetes register, screen for diabetes, particularly in those prescribed second-generation antipsychotics and ensure that staff are trained in managing and avoiding hypoglycaemia, and the safe use of insulin. Finally, clinical teams should ensure that all staff can access training in diabetes and mental health to support them to care for people with both diabetes and severe mental illness, develop local pathways for joint working and ensure best practice tariff criteria are met for diabetic ketoacidosis and hypoglycaemia, and for children and young people with diabetes.

Managing diabetes in people with dementia: a realist review

BACKGROUND

Dementia and diabetes mellitus are common long-term conditions that coexist in a large number of older people. People living with dementia and diabetes may be at increased risk of complications such as hypoglycaemic episodes because they are less able to manage their diabetes.

OBJECTIVES

To identify the key features or mechanisms of programmes that aim to improve the management of diabetes in people with dementia and to identify areas needing further research.

DESIGN

Realist review, using an iterative, stakeholder-driven, four-stage approach. This involved scoping the literature and conducting stakeholder interviews to develop initial programme theories, systematic searches of the evidence to test and develop the theories, and the validation of programme theories with a purposive sample of stakeholders.

PARTICIPANTS

Twenty-six stakeholders (user/patient representatives, dementia care providers, clinicians specialising in dementia or diabetes and researchers) took part in interviews and 24 participated in a consensus conference.

DATA SOURCES

The following databases were searched from 1990 to March 2016: MEDLINE (PubMed), Cumulative Index to Nursing and Allied Health Literature, Scopus, The Cochrane Library (including the Cochrane Database of Systematic Reviews), Database of Abstracts of Reviews of Effects, the Health Technology Assessment (HTA) database, NHS Economic Evaluation Database, AgeInfo (Centre for Policy on Ageing - UK), Social Care Online, the National Institute for Health Research (NIHR) portfolio database, NHS Evidence, Google (Google Inc., Mountain View, CA, USA) and Google Scholar (Google Inc., Mountain View, CA, USA).

RESULTS

We included 89 papers. Ten papers focused directly on people living with dementia and diabetes, and the rest related to people with dementia or diabetes or other long-term conditions. We identified six context-mechanism-outcome (CMO) configurations that provide an explanatory account of how interventions might work to improve the management of diabetes in people living with dementia. This includes embedding positive attitudes towards people living with dementia, person-centred approaches to care planning, developing skills to provide tailored and flexible care, regular contact, family engagement and usability of assistive devices. A general metamechanism that emerges concerns the synergy between an intervention strategy, the dementia trajectory and social and environmental factors, especially family involvement. A flexible service model for people with dementia and diabetes would enable this synergy in a way that would lead to the improved management of diabetes in people living with dementia.

LIMITATIONS

There is little evidence relating to the management of diabetes in people living with dementia, although including a wider literature provided opportunities for transferable learning. The outcomes in our CMOs are largely experiential rather than clinical. This reflects the evidence available. Outcomes such as increased engagement in self-management are potential surrogates for better clinical management of diabetes, but this is not proven.

CONCLUSIONS

This review suggests that there is a need to prioritise quality of life, independence and patient and carer priorities over a more biomedical, target-driven approach. Much current research, particularly that specific to people living with dementia and diabetes, identifies deficiencies in, and problems with, current systems. Although we have highlighted the need for personalised care, continuity and family-centred approaches, there is much evidence to suggest that this is not currently happening. Future research on the management of diabetes in older people with complex health needs, including those with dementia, needs to look at how organisational structures and workforce development can be better aligned to the needs of people living with dementia and diabetes.

STUDY REGISTRATION

This study is registered as PROSPERO CRD42015020625.

FUNDING

The NIHR HTA programme.

Development of programme theory for integration of service user and caregiver involvement in mental health system strengthening: protocol for realist systematic review

Background

There is international recognition of the need for service user and caregiver involvement in mental health system strengthening. However, little is known about how best to integrate this approach into the mental healthcare system; what works to advance involvement, under what conditions, how and when does involvement bring added value, and how can it work in resource-poor settings in low and middle-income countries.

Objective

To describe the methodology for a realist systematic review protocol to synthesise the evidence to explain the contexts, outcomes, and underlying mechanisms for involvement of service users with severe mental health problems and their caregivers in mental healthcare policy-making and planning, advocacy, service development, monitoring and improvement.

Methods/designs

The proposed realist systematic review will involve five steps: (i) clarifying the review scope, (ii) a systematic search for evidence, (iii) evidence appraisal and data extraction, (iv) data analysis, (v) synthesis of evidence and formation of revised programme theory. Inputs from a formative qualitative study, consultative Theory of Change meetings with key stakeholder groups, and scoping reviews will be used to identify candidate theory/theories that will guide the selection, appraisal and analysis of studies, and refine the Theory of Change model that will be piloted and evaluated. Synthesis of data will be undertaken using realist logic, constant comparison and thematic analysis. In a consultative meeting with stakeholders the Theory of Change model will then be situated with respect to relevant programme theories and adapted to incorporate the synthesized evidence of relevance to the local context. The finalized Theory of Change model will be piloted and evaluated in a primary health care setting in rural Ethiopia.

Discussion

Realist review methodology has not been applied to the area of mental health service user involvement in low- and middle-income country settings. In this protocol, we describe how this contextualized approach will be applied to identify and refine a theory-driven and transferable model of involvement of service users, embedded in ongoing work in Ethiopia.Systematic review registration PROSPERO CRD42018084595.

Diabetes in a Large Dementia Cohort: Clinical Characteristics and Treatment From the Swedish Dementia Registry

OBJECTIVE

We aimed to investigate the differences in clinical characteristics and pharmacological treatment associated with the presence of diabetes in a large cohort of patients with dementia.

RESEARCH DESIGN AND METHODS

A cross-sectional registry-based study was conducted using data from the Swedish Dementia Registry (SveDem). Data on dementia diagnosis, dementia type, and demographic determinants were extracted from SveDem. Data from the Swedish Patient Register and Prescribed Drug Register were combined for the diagnosis of diabetes. Data on antidiabetic, dementia, cardiovascular, and psychotropic medications were extracted from the Swedish Prescribed Drug Register. Logistic regression was used to determine whether the variables were associated with diabetes after adjustment for confounders. In total, 29,630 patients were included in the study, and 4,881 (16.5%) of them received a diagnosis of diabetes.

RESULTS

In the fully adjusted model, diabetes was associated with lower age at dementia diagnosis (odds ratio [OR] 0.97 [99% CI 0.97-0.98]), male sex (1.41 [1.27-1.55]), vascular dementia (1.17 [1.01-1.36]), and mixed dementia (1.21 [1.06-1.39]). Dementia with Lewy bodies (0.64 [0.44-0.94]), Parkinson disease dementia (0.46 [0.28-0.75]), and treatment with antidepressants (0.85 [0.77-0.95]) were less common among patients with diabetes. Patients with diabetes who had Alzheimer disease obtained significantly less treatment with cholinesterase inhibitors (0.78 [0.63-0.95]) and memantine (0.68 [0.54-0.85]).

CONCLUSIONS

Patients with diabetes were younger at dementia diagnosis and obtained less dementia medication for Alzheimer disease, suggesting less optimal dementia treatment. Future research should evaluate survival and differences in metabolic profile in patients with diabetes and different dementia disorders.

What works for whom in the management of diabetes in people living with dementia: a realist review

BACKGROUND

Dementia and diabetes mellitus are common long-term conditions and co-exist in a large number of older people. People living with dementia (PLWD) may be less able to manage their diabetes, putting them at increased risk of complications such as hypoglycaemia. The aim of this review was to identify key mechanisms within different interventions that are likely to improve diabetes outcomes in PLWD.

METHODS

This is a realist review involving scoping of the literature and stakeholder interviews to develop theoretical explanations of how interventions might work, systematic searches of the evidence to test and develop the theories and their validation with a purposive sample of stakeholders. Twenty-six stakeholders - user/patient representatives, dementia care providers, clinicians specialising in diabetes or dementia and researchers - took part in interviews, and 24 participated in a consensus conference.

RESULTS

We included 89 papers. Ten focused on PLWD and diabetes, and the remainder related to people with either dementia, diabetes or other long-term conditions. We identified six context-mechanism-outcome configurations which provide an explanatory account of how interventions might work to improve the management of diabetes in PLWD. This includes embedding positive attitudes towards PLWD, person-centred approaches to care planning, developing skills to provide tailored and flexible care, regular contact, family engagement and usability of assistive devices. An overarching contingency emerged concerning the synergy between an intervention strategy, the dementia trajectory and social and environmental factors, especially family involvement.

CONCLUSIONS

Evidence highlighted the need for personalised care, continuity and family-centred approaches, although there was limited evidence that this happens routinely. This review suggests there is a need for a flexible service model that prioritises quality of life, independence and patient and carer priorities. Future research on the management of diabetes in older people with complex health needs, including those with dementia, needs to look at how organisational structures and workforce development can be better aligned to their needs.

TRIAL REGISTRATION

PROSPERO, CRD42015020625. Registered on 18 May 2015.