Effects of an individualised exercise programme plus Behavioural Change Enhancement (BCE) strategies for managing fatigue in frail older adults: a cluster randomised controlled trial

BACKGROUND

To the best of our knowledge, although ageing-induced fatigue could cause adverse outcomes such as frailty, there is currently no intervention for it. This study evaluated the effects of an individualised exercise programme with/without BCE strategies on reducing fatigue in older adults.

METHODS

A three-armed cluster-randomised controlled trial (RCT) was conducted with 184 participants (mean age: 79.1 ± 6.4; mean frailty score: 2.8 + 0.8) from 21 community centres (ClinicalTrials.gov: NCT03394495). They were randomised into either: the COMB group (n = 64), receiving 16 weeks of exercise training plus the BCE programme; the EXER group (n = 65), receiving exercise training and health talks; or the control group (n = 55), receiving only health talks. Fatigue was assessed using the Multi-dimensional Fatigue Inventory (range: 20 to 100, with higher scores indicating higher fatigue levels) at baseline, and immediately, 6 months, and 12 months post-intervention.

RESULTS

The GEE analyses showed significant interaction (time x group) between the COMB and control groups immediately (p < 0.001), 6 months (p < 0.001), and 12 months (p < 0.001) post-intervention. Comparing the COMB and EXER groups, there was a significant interaction immediately (p = 0.013) and at 12 months post-intervention (p = 0.007). However, no significant difference was seen between the EXER group and control group at any time point.

CONCLUSIONS

The COMB intervention showed better immediate and sustainable effects (i.e., 12 months after the intervention) on reducing fatigue in frail older adults than exercise training or health education alone.

TRIAL REGISTRATION

ClinicalTrials.gov (NCT03394495), registered on 09/01/2018.

"How are You Doing?" on the Healthy Aging of the Community-Dwelling Oldest-Old in the Shadow of the COVID-19 Pandemic

OBJECTIVE

Globally, the oldest-old population is growing rapidly. Little is known about the perceived well-being of the community-dwelling oldest-old, especially during the COVID-19 pandemic. This study examined the oldest-old's perceptions of aging well and the COVID-related impacts on them.

METHODS

Semi-structured in-depth interviews with 22 adults aged 85 or above were conducted with purposive sampling methods. Transcripts were analyzed using thematic analysis.

RESULTS

Four main themes emerged: 1) sustaining functional ability; 2) staying active with a positive attitude; 3) feeling grateful for support from society and family; 4) COVID-19-related anxieties and policies destabilizing their well-being.

DISCUSSION

This study provides direct evidence from the oldest-old on how they maintained their well-being. While they valued support from society and family, COVID-19-related measures disturbed their routines and prevented them from self-attaining well-being. The findings should be considered when developing interventions for this vulnerable group.

Magnitude, Temporal Trends, and Inequalities in the DALYs and YLDs of Nutritional Deficiency among Older Adults in the Western Pacific Region: Findings from the Global Burden of Disease Study 1990-2019

The population in the Western Pacific region is aging rapidly. Nutritional deficiency is prevalent in older adults; however, information regarding nutritional deficiency in this population is scarce. Using the 2019 Global Burden of Disease (GBD) results, the age-standardized disability-adjusted life years (DALYs) and years of healthy life lost due to disability (YLDs) from nutritional deficiency were estimated between 1990 and 2019 for this population. Average annual percentage change (AAPC) was used to assess temporal trends, and linear mixed-effects models were used to examine socioeconomic and sex inequalities. From 1990 to 2019, the age-standardized DALYs of nutritional deficiency in this population decreased from 697.95 to 290.95 per 100,000, and their age-standardized YLDs decreased from 459.03 to 195.65 per 100,000, with the greatest declines seen in South Korea (AAPCs < −5.0). Tonga had the least decline in DALYs (AAPC = −0.8), whereas Fiji experienced an increase in YLDs (AAPC = 0.1). Being female and having a lower sociodemographic index score was significantly associated with higher age-standardized DALYs and YLDs. The magnitude and temporal trends of the nutritional deficiency burden among older adults varied across countries and sex in the region, indicating that health policies on nutritional deficiency among older adults must be crafted to local conditions.

Enhancing the Physical Activity Levels of Frail Older Adults with a Wearable Activity Tracker-Based Exercise Intervention: A Pilot Cluster Randomized Controlled Trial

A wearable activity tracker (WAT) incorporated with behavioral change techniques (BCTs) increases physical activity in younger adults; however, its effectiveness with frail older adults is unknown. The feasibility and preliminary effects of a WAT-based exercise intervention to increase physical activity levels in frail older adults was investigated in this pilot study involving 40 community-dwelling frail older adults. The experimental group received a 14-week WAT-based group exercise intervention and a 3-month follow-up, while the control group only received similar physical training and all BCTs. The recruitment rate was 93%, and the average attendance rate was 85.2% and 82.2% in the WAT and control groups, respectively, establishing feasibility. Adherence to wearing the WAT was 94.2% and 92% during the intervention and follow-up periods, respectively. A significant interaction effect between time and group was found in all physical assessments, possibly lasting for 3 months post-intervention. However, no significant difference between groups was observed in any daily activity level by the ActiGraph measurement. The majority of the WAT group's ActiGraph measurements reverted to baseline levels at the 1-month follow-up. Thus, the WAT-based exercise program has potential for employment among community-dwelling frail older adults, but sustaining the effects after the intervention remains a major challenge.

Effects of a Modified Mindfulness-Based Cognitive Therapy for Family Caregivers of People With Dementia: A Randomized Clinical Trial

BACKGROUND AND OBJECTIVES

Family caregivers of people with dementia (PWD) experience high levels of stress resulting from caregiving. This study aimed to investigate the effects of a modified of Mindfulness-Based Cognitive Therapy (MBCT) for dementia caregiving.

RESEARCH DESIGN AND METHODS

113 family caregivers of PWD were randomized to either the intervention group, receiving the 7-session modified MBCT for a period of 10 weeks with telephone follow-up or the control group, receiving the brief education on dementia care and usual care. The caregiving stress (primary outcome) and various psychological outcomes of caregivers and the behavioral and psychological symptoms of dementia (BPSD) in the care recipients were assessed and compared at baseline (T0), postintervention (T1), and at the 6-month follow-up (T2).

RESULTS

At both T1 and T2, the intervention group had a statistically greater improvement in stress (p = .02 and .03), depression (p = .001 and .04), anxiety (p = .007 and .03), and BPSD-related caregivers' distress (p = .003 and p = .04). A significant greater improvement was also demonstrated in mental health-related quality of life at T2 (p = .001) and BPSD of the care recipients at T1 (p = .04). The increased caregivers' level of mindfulness was significantly correlated with the improvement of various psychological outcomes at T1 and T2 with a correlation coefficient -0.64 to 0.43.

DISCUSSION AND IMPLICATIONS

The modified MBCT enhanced the level of mindfulness in the caregivers and was effective to reduce the caregivers' stress and promote their psychological well-being during a 6-month follow-up. Future research is recommended to further examine its effects on the varieties of psychological and behavioral outcomes of both caregivers and care recipients and their dyadic relationships, as well as explore its mechanism of action in facilitating dementia caregiving.

CLINICAL TRIALS REGISTRATION NUMBER

NCT03354819.

Effects of an Individualized Exercise Program Plus Behavioral Change Enhancement Strategies for Managing Fatigue in Older People Who Are Frail: Protocol for a Cluster Randomized Controlled Trial

BACKGROUND

Although the evidence suggests that general fatigue is a strong indicator of rapid aging, frailty, and disability, general fatigue is undertreated in gerontological care.

OBJECTIVE

The aim of this study is to investigate whether an individualized exercise program with and without behavioral change enhancement (BCE) strategies for older people who are frail and have general fatigue will reduce their fatigue and symptoms of frailty.

DESIGN

A 3-arm, single-blind, cluster randomized controlled trial registered with ClinicalTrials.gov (NCT03394495) will be conducted.

SETTING

The study will be conducted in a community setting.

PARTICIPANTS

Two hundred eighty-five community-dwelling older people with general fatigue will be recruited from 12 district community health centers.

INTERVENTION

People from each center will be randomized to one of three groups. The combined group will receive a 16-week combined intervention consisting of individualized exercise training and the BCE program, plus two booster sessions at 2 and 6 months after the program. The exercise group will receive exercise training and health talks only. The control group will receive health talks only.

MEASUREMENTS

Outcome measures will be collected at baseline, at the midpoint (week 8) of the program, and then at 1 week, 6 months, and 12 months after the end of the program. The primary outcome---level of fatigue---will be measured using the Multidimensional Fatigue Inventory. Secondary outcomes will include the participants' frailty status, strength, mobility, exercise self-efficacy, and habitual physical activity.

LIMITATIONS

A self-reported level of fatigue will be used.

CONCLUSIONS

The effect of exercise and BCE strategies on general fatigue among older people who are frail is not known. This study will be a pioneering interventional study on how general fatigue among older people who are frail can be managed and how fatigue-related frailty can be prevented or minimized.

"I Sometimes Ask Patients to Consider Spiritual Care": Health Literacy and Culture in Mental Health Nursing Practice

While health literacy influences better outcomes of mental health patients, sociocultural factors shape the nature of the relationship. On this matter, little is known about how sociocultural factors affect health literacy practices of nurses, especially in low-income countries. This paper examines how local precepts, within culture and language, shape mental health nurses’ (MHNs) practice and understanding of patients’ health literacy level in Ghana. The study used a qualitative descriptive design involving 43 MHNs from two psychiatric hospitals. Conventional content analysis was used to analyze the data. Although the MHNs acknowledged the importance of health literacy associated with patients’ health outcomes, their practice was strongly attributed to patients’ substantial reliance on cultural practices and beliefs that led to misinterpretation and non- compliance to treatments. MHNs shared similar sociocultural ideas with patients and admitted that these directed their health literacy practice. Additionally, numerous health system barriers influenced the adoption of health literacy screening tools, as well as the MHNs’ low health literacy skills. These findings suggest MHNs’ direct attention to the broader social determinants of health to enhance the understanding of culture and its impact on health literacy practice.

Spatiotemporal dynamics of PDGFRβ expression in pericytes and glial scar formation in penetrating brain injuries in adults

Aims

Understanding the spatiotemporal dynamics of reactive cell types following brain injury is important for future therapeutic interventions. We have previously used penetrating cortical injuries following intracranial recordings as a brain repair model to study scar‐forming nestin‐expressing cells. We now explore the relationship between nestin‐expressing cells, PDGFRβ⁺ pericytes and Olig2⁺ glia, including their proliferation and functional maturation.

Methods

In 32 cases, ranging from 3 to 461 days post injury (dpi), immunohistochemistry for PDGFRβ, nestin, GFAP, Olig2, MCM2, Aquaporin 4 (Aq4), Glutamine Synthetase (GS) and Connexin 43 (Cx43) was quantified for cell densities, labelling index (LI) and cellular co‐expression at the injury site compared to control regions.

Results

PDGFRβ labelling highlighted both pericytes and multipolar parenchymal cells. PDGFRβ LI and PDGFRβ⁺/MCM2⁺ cells significantly increased in injury Zones at 10–13 dpi with migration of pericytes away from vessels with increased co‐localization of PDGRFβ with nestin compared to control regions (P < 0.005). Olig2⁺/MCM2⁺ cell populations peaked at 13 dpi with significantly higher cell densities at injury sites than in control regions (P < 0.01) and decreasing with dpi (P < 0.05). Cx43 LI was reduced in acute injuries but increased with dpi (P < 0.05) showing significant cellular co‐localization with nestin and GFAP (P < 0.005 and P < 0.0001) but not PDGFRβ.

Conclusions

These findings indicate that PDGFRβ⁺ and Olig2⁺ cells contribute to the proliferative fraction following penetrating brain injuries, with evidence of pericyte migration. Dynamic changes in Cx43 in glial cell types with dpi suggest functional alterations during temporal stages of brain repair.

Frailty and its association with the Mediterranean diet, life-space, and social participation in community-dwelling older people

Frailty is a common and vulnerable state in older people, which leads to a higher risk of adverse health outcomes. This cross-sectional study examined the association between frailty and its phenotypic components with the Mediterranean diet, life-space, and social participation in community-dwelling older people. 263 community-dwelling older people recruited from three community centers in Hong Kong completed the study (robust = 85, pre-frail = 120, frail = 58). The results showed that the Mediterranean diet (OR = 0.29), life-space (OR = 0.32), and social participation (OR = 0.31) were associated with frailty. All factors were preferentially associated with slowness. The Mediterranean diet and social participation were additionally associated with weakness and low activity, respectively. To reduce the risk of frailty among diverse populations of older people in community settings, eliminating foods considered detrimental in the Mediterranean diet is advocated. Older people's satisfaction with social participation should be taken into consideration. Environmental designs should accommodate slow-walking older people to maximize their life-space.

Improving health literacy and medication compliance through comic books: a quasi-experimental study of Chinese community-dwelling older adults

Background:

This study aims to investigate the effect of two interventions (verbal advice and comic books) on health literacy and medication compliance among older adults living in 15 public estates in Hong Kong.

Methods:

This is a two-phase multi-site quasi-experimental study with a pre-and-post design with four measurement points (T1–T4). In both phases, the two interventions were conducted by trained medical/nursing/pharmacy students. Two home visits were carried out in each phase. After the baseline measurement at Time 1 (T1), students verbally advised the older adult participants on how to read, understand, and interpret information on drug labels and how to store drugs properly. A post-assessment was conducted at T2. One year later, another pre-assessment was conducted at T3, and then students used a comic book to educate the older adults. A post-assessment was carried out at T4 after the use of the comic book. Health literacy was measured using the 24-item Chinese Health Literacy Scale for Chronic Care and medication compliance was measured using the Medication Compliance, Knowledge and Storage scale. Generalised Linear Mixed Models were used.

Results:

A total of 165 subjects were included. The majority (60.6%) were female, aged from 67 to 96. About half (47.3%) had received no formal education. Controlling for age and cognition, there was a significant increase in health literacy after the use of the comic book (coefficient = 2.742, p = 0.001). There was also a significant improvement in medication compliance (total score) (coefficient = −1.018, p < 0.001), reduced knowledge deficiency (coefficient = −0.236, p < 0.05), and reduced storage problems (coefficient = −0.293, p = 0.001) after using comic books.

Conclusion:

Comic books are a good strategy to improve the health literacy level and medication compliance of community-dwelling older adults.

A comparative study of the dentate gyrus in hippocampal sclerosis in epilepsy and dementia

Aims:

Hippocampal sclerosis (HS) is long-recognized in association with epilepsy (HS_E) and more recently in the context of cognitive decline or dementia in the elderly (HS_D), in some cases as a component of neurodegenerative diseases, including Alzheimer's disease (AD) and fronto-temporal lobe dementia (FTLD). There is an increased risk of seizures in AD and spontaneous epileptiform discharges in the dentate gyrus of transgenic AD models; epilepsy can be associated with an age-accelerated increase in AD-type pathology and cognitive decline. The convergence between these disease processes could be related to hippocampal pathology. HS_E typically shows re-organization of both excitatory and inhibitory neuronal networks in the dentate gyrus, and is considered to be relevant to hippocampal excitability. We sought to compare the pathology of HS_E and HS_D, focusing on re-organization in the dentate gyrus. Methods: In nine post mortem cases with HS_E and bilateral damage, 18 HS_D and 11 controls we carried out immunostaining for mossy fibres (dynorphin), and interneuronal networks (NPY, calbindin and calretinin) on sections from the mid-hippocampal body. Fibre sprouting (FS) or loss of expression in the dentate gyrus was semi-quantitatively graded from grade 0 (normal) to grade 3 (marked alteration). Results: Significantly more re-organization was seen with all four markers in the HS_E than HS_D group (P < 0.01). Mild alterations were noted in HS_D group with dynorphin (FS in 3 cases), calretinin (FS in 6 cases), NPY (FS in 11 cases) and calbindin (loss in 10 cases). In eight HS_D cases, alteration was seen with more than one antibody but in no cases were the highest grades seen. We also noted NPY and, to a lesser extent, calretinin labelling of Hirano bodies in CA1 of AD cases and some older controls, but not in HS_E. Conclusion: Reorganization of excitatory and inhibitory networks in the dentate gyrus is more typical of HS_E. Subtle alterations in HS_D may be a result of increased hippocampal excitability, including unrecognized seizure activity. An unexpected finding was the identification of NPY-positive Hirano bodies in HS_D but not HS_E, which may be a consequence of the relative vulnerabilities of interneurons in these conditions.

Exploring nursing assistants' roles in the process of pain management for cognitively impaired nursing home residents: a qualitative study

AIM

To explore nursing assistants' roles during the actual process of pain management (assessment, reporting, implementation of pain-relieving interventions and re-assessment) for cognitively impaired home residents with pain.

BACKGROUND

Nursing assistants provide most of the direct care to residents and represent the major taskforce in nursing homes. They may develop specialized knowledge of residents' pain experience that enables them to play both a pivotal role in pain assessment and possibly a supporting role in pain treatment. Currently, there is a lack of research into nursing assistants' functions in pain management.

DESIGN

This is a descriptive, exploratory qualitative study.

METHODS

Forty-nine nursing assistants were recruited from 12 nursing homes, 12 of them participating in semi-structured individual interviews and 37 in 8 semi-structured focus groups. All interviews were carried out from May to September 2010. Data collected via both data collection methods were transcribed verbatim and analysed by content analysis.

RESULTS

Nursing assistants were found to play four roles in the pain management process: (1) pain assessor; (2) reporter; (3) subordinate implementing prescribed medications; and (4) instigator implementing non-pharmacological interventions.

CONCLUSIONS

This study highlights the importance of nursing assistants in successful pain assessment and identifies their possible supporting roles in other aspects of pain management. However, nursing assistants' scope of practice resulted in their functions in pain management being continually undervalued by other healthcare professionals. Continuous in-service training, the use of a standardized pain management protocol and strategies for building coherent work teams in nursing homes are suggested to improve this situation.

Attitudes in the management of patients with dementia: comparison in doctors with and without special training

OBJECTIVE

To explore by postal survey the different attitudes towards management of patients with dementia in physicians with and without dementia training.

METHODS

A questionnaire was sent to 7669 members of the Hong Kong Medical Association, which represents 61% of all locally registered medical practitioners.

RESULTS

In all, 448 questionnaires were returned (response rate: 6%). Among these, there were 34 questionnaires with missing data or the respondents indicated that they were either retired or not in practice. Therefore, only 414 questionnaires were used in analysis. Among these, 82 (20%) had received dementia training, 310 (75%) had not, and 22 (5%) did not indicate their choice. Twelve statements were used to explore various attitudes about dementia care. Exploratory factor analysis showed that there were 2 strong factors: confidence and negative views. The mean scores of these 2 factors were significantly different in physicians with and without dementia training. With respect to management of patients with dementia, dementia-trained physicians had significantly greater confidence (mean [standard deviation (SD)] = 5.21 [1.34]) than those who were non-trained (mean [SD] = 3.57 [1.40]; p < 0.001). Conversely, non-trained physicians had significantly stronger negative views (mean [SD] = 3.89 [1.24]) on dementia care than those who were trained (mean [SD] = 3.12 [1.36]; p < 0.001).

DISCUSSION

These findings suggest that providing a certain level of dementia care training for physicians is an effective way to improve confidence in managing patients with dementia, and thereby decrease possible negative attitudes towards such care.

The psychometric qualities of four observational pain tools (OPTs) for the assessment of pain in elderly people with osteoarthritic pain

CONTEXT

Pain in cognitively impaired elderly people (CIEP) often goes unrecognized. Observational pain tools (OPTs) have been designed, but with limited evidence to support their psychometric qualities.

OBJECTIVES

This study compared four OPTs (the Pain Assessment IN Advanced Dementia [PAINAD], Abbey Pain Scale [Abbey PS], Pain Assessment Checklist for Seniors with Limited Ability to Communicate [PACSLAC], and Discomfort Scale--Dementia of Alzheimer Type [DS-DAT]), two self-report scales, and two proxy-report scales in assessing osteoarthritic (OA) pain among CIEP.

METHODS

Participants (n=124) were divided into two groups: cognitively intact and impaired. They were observed by two raters simultaneously at rest and during a standardized exercise program. Besides reliabilities, the correlation between the OPTs and the self-report/proxy-report scores was evaluated. The OPT scores collected during different activity levels were compared to establish the convergent and discriminant validity. Confirmatory factor analysis was used to evaluate the construct validity.

RESULTS

Similar and accepted patterns of reliability/validity were obtained for all OPTs, in which better levels of psychometric properties were consistently obtained during exercise. However, a single construct (OA pain) appeared only in the PAINAD and Abbey PS after deletion of the "breathing" and "physiological change" indicators, respectively. This showed that OPTs were better used to detect OA pain when pain was triggered by movement (i.e., an exercise program).

CONCLUSION

The PAINAD and Abbey PS appeared to be more reliable and valid for assessing OA pain while using an exercise program among elderly people, regardless of their cognitive ability.

The psychometric properties of Chinese pain intensity verbal rating scale

BACKGROUND

This study investigates the validity and reliability of the Chinese pain intensity verbal rating scale (C-PIVRS).

METHODS

This is a correlational comparative study. Fifty Chinese adults were recruited by convenience. A pain source generator (precision pain source, PPS-3) was used to produce four levels of mechanical pain stimuli (350, 550, 750 and 950 g). The pain stimuli were applied to subjects' interphalangeal joints in random sequences to stimulate sensation of pain. The subjects then rated their pain intensity using both the C-PIVRS and the visual analog scale (VAS) for each stimulus. The pain scores obtained from the C-PIVRS were compared with the VAS for satisfactory level of reliability and validity. Test and re-test were applied to verify consistency between the two pain scales.

RESULTS

The test/re-test correlation coefficients between the two pain scales were r = 0.92 (P < 0.001) and r = 0.91 (P < 0.001), respectively. This showed a good positive correlation. The intra-class correlation (ICC) ranged from 0.78 to 0.90, which indicated good reliability. In the factor analysis, a single factor emerged in each analysis. The first eigen values of each matrix were 3.42, 3.24, 3.17 and 3.29 for each level of pain stimulation. This indicated that both pain scales were assessing the same pain dimension.

CONCLUSIONS

The two pain scales have a comparable level of reliability and validity for assessing pain intensity in Chinese adults.