The Delivery of Person-Centered Care for People Living With Dementia in Residential Aged Care: A Systematic Review and Meta-Analysis

BACKGROUND AND OBJECTIVES

Person-centered care is the gold standard of care for people living with dementia, yet few systematic reviews have detailed how it is delivered in practice. This mixed-methods review aimed to examine the delivery of person-centered care, and its effectiveness, for people living with dementia in residential aged care.

RESEARCH DESIGN AND METHODS

A systematic review and meta-analysis. Eligible studies were identified across 4 databases. Quantitative and qualitative studies containing data on person-centered care delivered to people with dementia living in residential aged care were included. Meta-analysis using a random-effects model was conducted where more than 3 studies measured the same outcome. A narrative meta-synthesis approach was undertaken to categorize verbatim participant quotes into representative themes. Risk of bias was undertaken using quality appraisal tools from the Joanna Briggs Institute.

RESULTS

41 studies were identified for inclusion. There were 34 person-centered care initiatives delivered, targeting 14 person-centered care outcomes. 3 outcomes could be pooled. Meta-analyses demonstrated no reduction in agitation (standardized mean difference -0.27, 95% confidence interval [CI], -0.58, 0.03), improvement in quality of life (standardized mean difference -0.63, 95% CI: -1.95, 0.70), or reduced neuropsychiatric symptoms (mean difference -1.06, 95% CI: -2.16, 0.05). Narrative meta-synthesis revealed barriers (e.g., time constraints) and enablers (e.g., staff collaboration) to providing person-centered care from a staff perspective.

DISCUSSION AND IMPLICATIONS

The effectiveness of person-centered care initiatives delivered to people with dementia in residential aged care is conflicting. Further high-quality research over an extended time is required to identify how person-centered care can be best implemented to improve resident outcomes.

The feeding of heather (Calluna vulgaris) to Teladorsagia circumcincta infected lambs reduces parasitism but can detrimentally impact performance

Gastrointestinal nematode (GIN) infections impact small ruminant health, welfare, and production across farming systems. Rising anthelmintic resistance and regulation of synthetic drug use in organic farming is driving research and development of sustainable alternatives for GIN control. One alternative is the feeding of plants that contain secondary metabolites (PSMs) e.g., proanthocyanidins (PA, syn. condensed tannins) that have shown anthelmintic potential. However, PSMs can potentially impair performance, arising from reduced palatability and thus intake, digestibility or even toxicity effects. In this study, we tested the trade-off between the antiparasitic and anti-nutritional effects of heather consumption by lambs. The impact of additional feeding of a nematophagous fungus (Duddingtonia flagrans) on larval development was also explored. Lambs infected with Teladorsagia circumcincta or uninfected controls, were offered ad libitum heather, or a control chopped hay for 22 days during the infection patent period. Eight days into the patent period, parasitised lambs were supplemented (or remained unsupplemented) with D. flagrans for a 5-day period. Performance and infection metrics were recorded, and polyphenol levels in the heather and control hay were measured to investigate their association with activity. The lambs consumed heather at approximately 20% of their dry matter intake, which was sufficient to exhibit significant anthelmintic effects via a reduction in total egg output (P = 0.007), compared to hay-fed lambs; the magnitude of the reduction over time in heather fed lambs was almost 10-fold compared to control lambs. Negative effects on production were shown, as heather-fed lambs weighed 6% less than hay-fed lambs (P < 0.001), even though dry matter intake (DMI) of heather increased over time. D. flagrans supplementation lowered larval recovery in the faeces of infected lambs by 31.8% (P = 0.003), although no interactions between feeding heather and D. flagrans were observed (P = 0.337). There was no significant correlation between PA, or other polyphenol subgroups in the diet and egg output, which suggests that any association between heather feeding and anthelmintic effect is not simply and directly attributable to the measured polyphenols. The level of heather intake in this study showed no antagonistic effects on D. flagrans, demonstrating the methods can be used in combination, but provide no additive effect on overall anthelmintic efficacies. In conclusion, heather feeding can assist to reduce egg outputs in infected sheep, but at 20% of DMI negative effects on lamb performance can be expected which may outweigh any antiparasitic benefits.

Methane emissions and rumen metabolite concentrations in cattle fed two different silages

In this study, 18 animals were fed two forage-based diets: red clover (RC) and grass silage (GS), in a crossover-design experiment in which methane (CH₄) emissions were recorded in respiration chambers. Rumen samples obtained through naso-gastric sampling tubes were analysed by NMR. Methane yield (g/kg DM) was significantly lower from animals fed RC (17.8 ± 3.17) compared to GS (21.2 ± 4.61) p = 0.008. In total 42 metabolites were identified, 6 showing significant differences between diets (acetate, propionate, butyrate, valerate, 3-phenylopropionate, and 2-hydroxyvalerate). Partial least squares discriminant analysis (PLS-DA) was used to assess which metabolites were more important to distinguish between diets and partial least squares (PLS) regressions were used to assess which metabolites were more strongly associated with the variation in CH₄ emissions. Acetate, butyrate and propionate along with dimethylamine were important for the distinction between diets according to the PLS-DA results. PLS regression revealed that diet and dry matter intake are key factors to explain CH₄ variation when included in the model. Additionally, PLS was conducted within diet, revealing that the association between metabolites and CH₄ emissions can be conditioned by diet. These results provide new insights into the methylotrophic methanogenic pathway, confirming that metabolite profiles change according to diet composition, with consequences for CH₄ emissions.

Nuclear Magnetic Resonance to Detect Rumen Metabolites Associated with Enteric Methane Emissions from Beef Cattle

This study presents the application of metabolomics to evaluate changes in the rumen metabolites of beef cattle fed with three different diet types: forage-rich, mixed and concentrate-rich. Rumen fluid samples were analysed by ¹H-NMR spectroscopy and the resulting spectra were used to characterise and compare metabolomic profiles between diet types and assess the potential for NMR metabolite signals to be used as proxies of methane emissions (CH₄ in g/kg DMI). The dataset available consisted of 128 measurements taken from 4 experiments with CH₄ measurements taken in respiration chambers. Predictive modelling of CH₄ was conducted by partial least squares (PLS) regression, fitting calibration models either using metabolite signals only as predictors or using metabolite signals as well as other diet and animal covariates (DMI, ME, weight, BW^0.75, DMI/BW^0.75). Cross-validated R² were 0.57 and 0.70 for the two models respectively. The cattle offered the concentrate-rich diet showed increases in alanine, valerate, propionate, glucose, tyrosine, proline and isoleucine. Lower methane yield was associated with the concentrate-rich diet (p < 0.001). The results provided new insight into the relationship between rumen metabolites, CH₄ production and diets, as well as showing that metabolites alone have an acceptable association with the variation in CH₄ production from beef cattle.

A pilot randomised controlled trial of brief versus twice weekly versus standard supervised consumption in patients on opiate maintenance treatment

INTRODUCTION AND AIMS

Methadone maintenance remains the mainstay of treatment for opiate dependence in Scotland. Guidelines recommend supervised self-administration for at least 3 months, yet this is often interpreted as long-term supervision. However, there is no evidence base for deciding the optimal period of supervision. We tested the feasibility of conducting a randomised controlled trial (RCT) of different supervision models.

DESIGN AND METHODS

Three armed pilot RCT, set in three Scottish treatment areas, recruited opiate-dependent patients who had received methadone treatment for 3 months. Participants were randomised to: (i) no supervision; (ii) twice weekly supervision; or (iii) daily supervision for further 3 months. As a pilot, key process measures were: recruitment rates, follow-up rates and treatment fidelity. We also wanted to estimate effect sizes of two co-primary outcomes for a full RCT: treatment retention and illicit heroin use. The recruitment target was 60 participants.

RESULTS

One hundred and two eligible patients were identified, 60 (59%) participated, and 46 followed up (77%). Study fidelity was good with two participants moving group. Those randomised to no supervision were significantly happier with their group allocation. No significant differences were found in primary outcomes, although retention decreased with increased supervision, while illicit heroin use was least in those most supervised.

DISCUSSION AND CONCLUSIONS

It is possible to recruit and randomise participants to an RCT comparing different forms of supervised consumption. Pilot data suggest increased supervision may reduce illicit heroin use, but may decrease retention. This should now be tested in a large-scale multicentre RCT.

Increased expression of keratinase and other peptidases by Candida parapsilosis mutants

Keratinases are enzymes of great importance involved in pathogenic processes of some fungi. They also have a widespread ecological role since they are responsible for the degradation and recycling of keratin. On the one hand, studying them furthers our knowledge of pathogenicity mechanisms, which has important implications for human health, and on the other hand, understanding their ecological role in keratin recycling has biotechnological potential. Here, a wild-type keratinolytic Candida parapsilosis strain isolated from a poultry farm was treated with ethyl methanesulfonate in order to generate mutants with increased keratinase activity. Mutants were then cultured on media with keratin extracted from chicken feathers as the sole source of nitrogen and carbon. Approximately 500 mutants were screened and compared with the described keratinolytic wild type. Three strains, H36, I7 and J5, showed enhanced keratinase activity. The wild-type strain produced 80 U/mL of keratinolytic activity, strain H36 produced 110 U/mL, strain I7, 130 U/mL, and strain J5, 140 U/mL. A 70% increase in enzyme activity was recorded for strain J5. Enzymatic activity was evaluated by zymograms with proteic substrates. A peptidase migrating at 100 kDa was detected with keratin, bovine serum albumin and casein. In addition, a peptidase with a molecular mass of 50 kDa was observed with casein in the wild-type strain and in mutants H36 and J5. Gelatinase activity was detected at 60 kDa. A single band of 35 kDa was found in wild-type C. parapsilosis and in mutants with hemoglobin substrate.

Who responds to aripiprazole in clinical practice? An observational study of combination versus monotherapy

We aimed to study aripiprazole, as monotherapy and combined with other antipsychotics, in routine clinical practice, to identify patients who had a favourable clinical response. We retrospectively identified all secondary care psychiatric patient records started on aripiprazole (n = 85). We assigned Clinical Global Impression scores to measure effectiveness. We examined demographic and clinical correlates of patients who improved (CGI Improvement scores < 5) versus those who did not improve (CGI > or = 5). 56 patients (66%) received aripiprazole as monotherapy, 29 patients (34%) in combination with other antipsychotics. 52 patients (62%) received a CGI 1-4 (minimally to very much improved), 32 patients (38%) a CGI > or = 5 (no change to very much worse). Patients who improved were less likely to have had previous or subsequent treatment with clozapine (p = 0.04). Discontinuation was due to agitation (35%), inefficacy (21%), nausea (18%) and worsening psychosis (12%). Combination with other antipsychotics resulted in less discontinuation and a lower maximum dose of aripiprazole. Aripiprazole was combined with other regular additional antipsychotics in 1/3rd of patients. Combination and monotherapy were clinically effective in around 60% of patients. Favourable response was associated with lack of treatment resistance. Agitation was the commonest reason for discontinuation.

Atrazine sorption and fate in a Ultisol from humid tropical Brazil

This study combined laboratory based microcosm systems as well as field experiments to evaluate the mobility of atrazine on a Ultisol under humid tropical conditions in Brazil. Results from sorption experiments fit to the Freundlich isotherm model [K(f) 0.99 mg kg(-1)/(mg l(-1))(1/n)], and indicate a low sorption capacity for atrazine in this soil and consequently large potential for movement by leaching and runoff. Microcosm systems using (14)C-atrazine to trace the fate of the applied herbicide, showed that 0.33% of the atrazine was volatilized, 0.25% mineralized and 6.89% was recorded in the leachate. After 60 d in the microcosms, 75% of the (14)C remained in the upper 5 cm soil layer indicating atrazine or its metabolites remained close to the soil surface. In field experiments, after 60 d, only 5% of the atrazine applied was recovered in the upper soil layers. In the field experiments atrazine was detected at a depth of 50 cm indicating leaching. Simulating tropical rain in field experiments resulted in 2.1% loss of atrazine in runoff of which 0.5% was adsorbed onto transported soil particles and 1.6% was in solution. Atrazine runoff was greatest two days after herbicide application and decreased 10 fold after 15 d. The use of atrazine on Ultisols, in the humid tropics, constitutes a threat to water quality, causing surface water and ground water pollution.

New group-specific 16S rDNA primers for monitoring foaming mycolata during saline waste-water treatment

Newly designed group-specific PCR primers for denaturing gradient gel electrophoresis (DGGE) were used to investigate foaming mycolata from a bioreactor treating an industrial saline waste-water. Genetic profiles on DGGE gels were different with NaCl at 1.65 and 8.24 g l(-1), demonstrating that mycolata community was affected by salinity. A semi-nested PCR strategy resulted in more bands in community genetic profiles than direct amplification. DNA sequencing of bands confirmed the efficacy of the novel primers with sequences recovered being most similar to foam producing mycolata. The new group-specific primers/DGGE approach is a new step toward a more complete understanding of functionally important groups of bacteria involved in biological treatment of waste-water.

An outbreak of subacute fasciolosis in Soay sheep: Ultrasonographic biochemical and histological studies

A naturally occurring outbreak of subacute fasciolosis in a group of 17 seven-month-old Soay ram lambs was studied following the sudden death of two sheep. In addition to standard biochemical investigations, ultrasound examination of the liver and cranial abdominal cavity was undertaken. There was a significant positive linear correlation between liver weight and ultrasonographic determination of liver size (R=0.72, P<0.05). Ultrasonographic examination of the liver revealed multiple hyperechoic dots in the parenchyma giving a granular appearance to the hepatic texture in three sheep corresponding to the most advanced histopathological changes as determined by the size of the abscesses and their relatively mature fibrous capsules, and areas of hepatic necrosis. No distension of the bile duct system was noted nor was the gall bladder imaged. While serum concentrations of albumin, globulin and certain liver enzymes assisted in the diagnosis of subacute fasciolosis in sheep, only glutamate dehydrogenase, and gammaglutamyl transferase remained elevated four weeks after triclabendazole treatment.

Premonitory symptoms in migraine: an electronic diary study

BACKGROUND

Migraine is frequently associated with nonheadache symptoms before, during, and after the headache. Premonitory symptoms occurring before the attack have not been rigorously studied. Should these symptoms accurately predict headache, there are considerable implications for the pathophysiology and management of migraine.

METHODS

Electronic diaries were used in a 3-month multicenter study to record nonheadache symptoms before, during, and after migraine. The authors recruited subjects who reported nonheadache symptoms in at least two of three attacks that they believed predicted headache. Symptoms were entered in the diaries by patient initiation and through prompted entries at random times daily. Entries could not be altered retrospectively. Data recorded included nonheadache symptoms occurring during all three phases of the migraine, prediction of the attack from premonitory symptoms, general state of health, and action taken to prevent the headache.

RESULTS

One hundred twenty patients were recruited: 97 provided usable data. Patients correctly predicted migraine headaches from 72% of diary entries with premonitory symptoms. A range of cognitive and physical symptoms was reported at a similar rate through all three phases of the migraine. The most common premonitory symptoms were feeling tired and weary (72% of attacks with warning features), having difficulty concentrating (51%), and a stiff neck (50%). Subjects who functioned poorly in the premonitory phase were the most likely to correctly predict headache.

CONCLUSIONS

Using an electronic diary system, the authors show that migraineurs who report premonitory symptoms can accurately predict the full-blown headache.

Use of rpoB and 16S rRNA genes to analyse bacterial diversity of a tropical soil using PCR and DGGE

AIM

To evaluate the rpoB gene as a biomarker for PCR-DGGE microbial analyses using soil DNA from the Cerrado, Brazil.

METHODS

DNA extraction from soil was followed by Polymerase Chain Reaction (PCR) amplification of rpoB and 16S rRNA genes. PCR products were compared by Denaturing Gradient Gel Electrophoresis (DGGE) to compare gene/community profiles.

RESULTS

The rpoB DGGE profiles comprised fewer bands than the 16S rDNA profiles and were easier to delineate and therefore to analyse. Comparison of the community profiles revealed that the methods were complementary.

CONCLUSIONS, SIGNIFICANCE AND IMPACT OF THE STUDY

The gene for the beta subunit of the RNA polymerase, rpoB, is a single copy gene unlike 16S rDNA. Multiple copies of 16S rRNA genes in bacterial genomes complicate diversity assessments made from DGGE profiles. Using the rpoB gene offers a better alternative to the commonly used 16S rRNA gene for microbial community analyses based on DGGE.

Novel bacterial diversity recovered from the rhizosphere of oilseed rape (Brassica napus) determined by the analysis of 16S ribosomal DNA

Soil was sampled to a distance of 2.5 mm beneath a root mat of oilseed rape (Brassica napus) in a model rhizosphere system. DNA was extracted and the 16S rDNA amplified, cloned and sequenced. Phylogenetic analysis of these sequences with those held on-line, revealed that 37% of the clones fell within the Holophaga /Acidobacterium phylum, 17% were within the proteobacteria, 14% of the clones were close relatives of Bacillus megaterium and 5% were related to Verrucomicrobium spinosum. An additional eleven clones (21%) could not be assigned to any known phylum and may represent novel bacterial lineages. This study highlights the diverse nature of rhizosphere soils and reinforces the role that molecular approaches play in unravelling such diversity.

Small is beautiful: comparative genomics with the pufferfish (Fugu rubripes)

As the Human Genome Project advances, it is clear that the emphasis will switch from accumulation of data to their interpretation. Comparative genomics provides a powerful way in which to analyse sequence data. Indeed, there is already a long list of 'model' organisms, which allow comparative analyses in a variety of ways. The very small vertebrate genome of the pufferfish provides a simple and economical way of comparing sequence data from mammals and fish, representing a large evolutionary divergence and so permitting the identification of essential elements that are still present in both species. These elements include genes and the associated machinery that controls their expression; elements that, in many cases, have survived the test of time.

The prevalence of eating disorders in thyroid disease: a pilot study

The aim of this study was to determine the prevalence of eating disorders and partial syndromes in women with thyroid disease. Female patients between the ages of 18 and 45 who attended a specialist thyroid clinic, in 1990, were asked to complete two self-report questionnaires (Bulimic Investigatory Test, Edinburgh, BITE and General Health Questionnaire, GHQ). High scoring patients were invited to attend for a research interview. The case notes of non-responders were examined. Seventy-three patients were entered into the study and 50 subjects returned their questionnaires (69%). Eleven patients scored highly on the BITE, nine of these patients also scoring highly on the GHQ, as did a further 12 patients. Ten patients were interviewed; of these, three patients (4%) met DSM111R criteria for bulimia nervosa and three patients met criteria for an eating disorder not otherwise specified. These results suggest that there is an increased prevalence of eating disorders in women thyroid patients.

Characterization of the pufferfish (Fugu) genome as a compact model vertebrate genome

Cloning and sequencing techniques now allow us to characterize genes directly instead of having to deduce their properties from their effects. This new genetics reaches its apotheosis in the plan to obtain the complete DNA sequence of the human genome, but this is far beyond the capacity of present sequencing methods. Small 'model' genomes, 'such as those of Escherichia coli (4.7 megabases (Mb) and yeast (14 Mb), or even those of Caenorhabditis elegans (100 Mb) and Drosophila (165 Mb), are better scaled to existing technology. The yeast genome will contain genes with functions common to all eukaryotic cells, and those of simple multicellular organisms may throw light on the genetic specification of more complex functions. However, vertebrates differ in their morphology and development, so the ideal model would be a vertebrate genome of minimum size and complexity but with maximum homology to the human genome. Here we report the characterization of the small genome (400 Mb) of the tetraodontoid fish, Fugu rubripes. A random sequencing approach supported by gene probing shows that the haploid genome contains 400 Mb of DNA, of which more that 90% is unique. This genome is 7.5 times smaller than the human genome and because it has a similar gene repertoire it is the best model genome for the discovery of human genes.

Pituitary adenylate cyclase activating polypeptide is a potent vasodilator in humans

The vasodilator effect of the novel peptide pituitary adenylate cyclase activating polypeptide (PACAP) was investigated in humans. Forearm blood flow was measured in six healthy men by venous occlusion plethysmography. Infusion of PACAP into the brachial artery at 0.01, 0.1, 1, 3, and 10 pmol/min produced a dose-related increase in forearm blood flow in the cannulated arm from 2.8 +/- 0.6 to 8.6 +/- 2.4 ml/100 ml/min at the highest dose (mean +/- SEM, p less than 0.05). In a subsequent experiment, where the highest dose of PACAP was repeated after a 36 min interval, there was no tachyphylaxis of the forearm blood flow response, with the forearm blood flow increasing by 129 +/- 9% during the first infusion and 128 +/- 31% during the second infusion (N.S.). In further experiments, microvascular blood flow was measured by a laser-Doppler flow probe to compare the effects of intradermally injected PACAP, vasoactive intestinal polypeptide (VIP), and calcitonin gene-related peptide (CGRP). When injected into the skin of normal volunteers at 10(-12) to 10(-11) mol/site, each peptide caused a rapid flare lasting 2-3 min, which became erythematous after 5 min. At 10(-12) mol/site, intradermally injected PACAP and VIP caused a maximum increase in skin blood flow at 15 min of 379 +/- 96 and 307 +/- 121% (% increase above basal +/- SEM), respectively, and these responses were not significantly affected by oral aspirin (600 mg) taken 1.5 h beforehand. The vasodilation induced by PACAP at 10(-12) mol/site lasted approximately 6 h, whereas the effect of the same dose of CGRP and VIP lasted less than 2 h. These data suggest that PACAP is a potent and long-lasting vasodilator in humans.

Adult day care for people with human immunodeficiency virus

The human immunodeficiency virus (HIV) adult day care ADC) center is an important component in the continuum of care for the HIV ill client, providing therapeutic advantages to the client and administrative advantages to the community as it copes with the growing HIV epidemic. The HIV ADC center was designed using several models of adult day programs for developmental, psychosocial, geriatric and neuropsychiatric treatment. The HIV ADC client is typically in a non-acute phase of a chronic disability resulting from some combination of primary HIV pathology and secondary illnesses associated with the Acquired Immune Deficiency Syndrome (AIDS) and is in need of some level of rehabilitation. The HIV ADC client is. typicall a gay or bisexual male, a man or woman who is or has been adbicted to intravenously injected drugs, or the sexual partner of someone in these groups. Programming addresses the psychosocial needs and daily reallties of these populations. This article describes occupational therapy intervention focused on maintaining, restoring, or adapting functional skills, with special attention to the daily activities most affected by cognitive/ perceptual dysfunction.

Ambulatory ST segment monitoring in the assessment of patients following PTCA

In this article we discuss the place of ambulatory ST-segment monitoring in the investigation of the patient following coronary angioplasty. Particular attention is focused on the relationship between the results of exercise testing (the standard technique in the evaluation of the post-angioplasty patient) and ambulatory ST-segment monitoring, in order to assess whether ST-segment monitoring might contribute further information in the identification of residual or recurrent ischaemia.