Estimated prevalence of frailty and prefrailty in patients undergoing coronary artery or valvular surgeries/procedures: A systematic review and proportional meta-analysis

BACKGROUND

The aging population has led to an increasing number of older patients undergoing cardiac surgeries/procedures. Frailty and prefrailty have emerged as important prognostic indicators among these patients. This proportional meta-analysis estimated the prevalence of frailty and prefrailty among patients undergoing cardiac surgery.

METHODS

We searched seven electronic databases for observational studies that used validated measure(s) of frailty and reported prevalence data on frailty and/or prefrailty in older patients undergoing coronary artery or valvular surgeries or transcatheter procedures. Meta-analyses were performed using a random-effects model.

RESULTS

One hundred and one articles involving 626,863 patients were included. The pooled prevalence rates of frailty and prefrailty were 28% (95% confidence interval [CI]: 23%-33%) and 40% (95% CI: 31%-50%), respectively, for patients scheduled for open-heart surgeries and 40% (95% CI: 36%-45%) and 43% (95% CI: 34%-53%), respectively, for patients undergoing transcatheter procedures. Frailty measured using a multidimensional approach identified a higher proportion of frail patients when compared with measures solely focused on physical frailty. Older age, female sex, and lower body mass index and hemoglobin concentrations were significantly associated with higher frailty prevalence. Moreover, countries with higher gross domestic product spent on healthcare exhibited a higher frailty prevalence.

CONCLUSION

Frailty represents a considerable health challenge among patients undergoing cardiac surgeries/procedures. Routine screening for frailty should be considered during perioperative care planning.

Empowerment-based cognitive behavioural therapy for insomnia in persons with mild cognitive impairment: A sequential explanatory mixed-method pilot study

Insomnia is an emerging risk factor for the onset of mild cognitive impairment (MCI) and its progression to dementia. Impaired cognition and neuropsychiatric symptoms create challenges for persons with MCI to participate actively in non-pharmacological interventions. This study examined the feasibility and preliminary effects of empowerment-based cognitive-behavioural therapy for insomnia (CBT-I) on sleep, cognitive function, and health-related quality of life (HRQoL) in persons with MCI and sleep problems. Sixty participants were randomly allocated to the intervention or control group to receive empowerment-based CBT-I or usual care, respectively. The 12 week intervention comprised all core CBT-I techniques delivered through a group and individualised face-to-face approach. An empowerment approach with interactive teaching methods, goal setting, and action planning was used to deliver the intervention. Outcome measures included subjective and objective sleep quality and pattern, and a battery of neuropsychological tests and the 12-item Short Form Survey were administered 3 months (T1) and 6 months post-randomisation (T2). This intervention is feasible and highly acceptable for persons with MCI. The intervention group showed significant improvements in subjective and objective sleep-related outcomes compared with the control group. Moreover, the intervention group showed greater improvements in global cognition, processing speed, attention, and mental flexibility than the control group at T1 and/or T2. No significant between-group differences were observed in memory or HRQoL scores. The qualitative data converged with the quantitative data. In conclusion, empowerment-based CBT-I was well received by persons with MCI and had potential positive effects on improving sleep and cognition in this cohort.

Theory-based cognitive-narrative intervention versus didactic education for promoting prompt care-seeking for acute myocardial infarction: A multisite mixed-methods randomized controlled trial

BACKGROUND

Prolonged delays by patients in making care-seeking decisions remain a significant obstacle to the effective management of acute myocardial infarction.

OBJECTIVES

This study aimed to compare the effects of a theory-based cognitive-narrative intervention with those of didactic education over a 24-month period on the participants' attitudes, beliefs, and knowledge regarding acute myocardial infarction, prehospital delay time, and the use of an ambulance. We also explored participants' engagement in the intervention.

DESIGN

This study adopted a sequential mixed-methods design comprising a multisite randomized controlled trial and a qualitative study.

METHODS

Community-dwelling adult patients with a prior history of acute myocardial infarction in the past year were recruited from four hospitals in Hong Kong. They were randomly assigned to an 8-week theory-based cognitive-narrative intervention that involved a vivid experience of complex decision-making or didactic education. The Acute Coronary Syndrome Response Index questionnaire was administered at baseline (T0) and at 3- (T1), 12- (T2), and 24-month (T3) follow-up time points. Prehospital delay time and the use of an ambulance were evaluated for those participants who had recurrent acute myocardial infarction attacks during the study period.

RESULTS

A total of 608 participants were randomly assigned to the theory-based cognitive-narrative intervention group (n = 304) or the didactic education group (n = 304). The intervention group reported greater improvements than the control group in their attitudes (β = -1.053, p = 0.002) and beliefs (β = -0.686, p = 0.041) regarding acute myocardial infarction and care-seeking at T1. These effects were sustained at T2 [attitudes (β = -0.797, p = 0.018); beliefs (β = -0.692, p = 0.047)] and T3 [attitudes (β = -0.717, p = 0.024); beliefs (β = -0.701, p = 0.032)]. Sixty-three participants experienced another acute myocardial infarction event by T2. The median delay times for the intervention and control groups were 3.13 h (interquartile range (IQR: 1.15-6.48)) and 4.82 h (IQR: 2.23-9.02), respectively. The prehospital delay time was significantly reduced in the intervention group compared with the control group (β = -0.07, p = 0.011). The qualitative findings echoed the quantitative findings, as participants indicated that the intervention helped them to understand the variable nature of the disease presentation, which enabled them to recognize the symptoms more readily.

CONCLUSION

The novel cognitive-narrative intervention used in this study effectively improved the participants' attitudes and beliefs regarding acute myocardial infarction and reduced the prehospital delay time.

TRIAL REGISTRATION

This study was registered with the International Clinical Trials Registry Platform of the World Health Organization (ChiCTR-IIC-17010576) on February 2, 2017; the first participant was recruited on January 11, 2018.

Combined exercise and cognitive interventions for adults with mild cognitive impairment and dementia: A systematic review and network meta-analysis

BACKGROUND

Exercise and cognitive interventions are beneficial for adults with preclinical and clinical dementia, but it is unclear whether the combination of these two components could generate synergistic benefits and what intervention designs would optimize this effect.

OBJECTIVES

This review aims to compare the effects of combined exercise and cognitive interventions on cognitive, psychological, functional outcomes, and health-related quality of life with the corresponding single approach and control groups in adults with mild cognitive impairment and dementia. It also aims to identify the optimal intervention design and factors affecting treatment effects.

METHODS

A comprehensive search was conducted in ten databases from inception to 23rd November 2022. The methodological quality of studies was evaluated by the Cochrane risk of bias tool. Pairwise meta-analyses were performed to assess the effects of combined interventions relative to the single type of intervention and control groups, with further subgroup analysis to explore the factors affecting treatment effects. Network meta-analyses were used to identify the optimal intervention components.

RESULTS

Twenty-nine randomized controlled trials involving 2910 participants were included. The results of pairwise meta-analyses indicated that combined interventions were superior to exercise in improving response inhibition, working memory, and delayed recall, but were not superior to cognitive interventions in all outcomes. Combined interventions were superior to active/passive controls in improving global cognition, response inhibition, immediate recall, delayed recall, category fluency, processing speed, and visuospatial ability. Influences of the clinical severity of dementia (mild cognitive impairment vs dementia), combination format (sequential vs simultaneous combination), mode of delivery (group-based vs individual-based vs mixed), training duration (short: ≤12 weeks vs medium: 13-24 weeks vs long: >24 weeks), and types of control (active vs passive control) were not detected. The network meta-analysis results indicated that the optimal intervention components varied across different outcomes, with multimodal exercise combining cognitive training demonstrated the greatest effects among all other combined or single component interventions in improving global cognition.

CONCLUSIONS

This review suggests the advantage of combined interventions over exercise with comparable effects when compared with cognitive interventions in the population with mild cognitive impairment and dementia. Full scale multi-arm randomized controlled trials to compare the effects of combined interventions with cognitive interventions are warranted.

Nurse-led multi-component behavioural activation programme to improve health outcomes in patients with atrial fibrillation: a mixed-methods study and feasibility analysis

AIMS

Patients with atrial fibrillation (AF) play passive roles in disease management. This study aimed to examine the feasibility and preliminary effects of an empowerment-based care model, titled 'the nurse-led multi-component behavioural activation (N-MBA) programme', on health-related quality of life, AF knowledge, psychological outcomes, medication adherence, and treatment decision-making in patients with AF.

METHODS AND RESULTS

This mixed-methods study comprised a pilot randomized controlled trial and a qualitative study. Patients with AF who had a moderate-to-high risk of stroke but were not prescribed oral anticoagulants were recruited. Forty participants were recruited and randomized in a 1:1 ratio to receive either the N-MBA programme or standard care. The 13-week programme comprised care components that prepared patients for shared decision-making, an empowerment-based educational module on AF self-care, and continuous support through telephone calls. The programme was feasible, and the overall attendance rate was 82.5%. The participants gave excellent ratings in the satisfaction survey. The N-MBA group showed greater improvements in health-related quality of life (HRQoL) and AF knowledge than the standard care group at the immediate post intervention and 6-month follow-up time points. No significant between-group changes in medication adherence, anxiety, and depression were detected. Participants in the N-MBA group actively raised concerns about AF and its treatment with their attending doctors. The qualitative data were consistent with the quantitative data, indicating that the programme built a comprehensive knowledge base of AF and self-care behaviours.

CONCLUSION

The N-MBA programme is feasible and acceptable to patients with AF. It improved patients' AF knowledge, treatment-related decision-making, and HRQoL.

REGISTRATION

ClinicalTrials.gov NCT03924739.

The prognostic impacts of frailty on clinical and patient-reported outcomes in patients undergoing coronary artery or valvular surgeries/procedures: A systematic review and meta-analysis

BACKGROUND

Frailty is emerging as an important prognostic indicator for patients undergoing cardiac surgeries/procedures. We sought to evaluate the prognostic and differential impacts of frailty on patients undergoing coronary artery or valvular surgical procedures of different levels of invasiveness, and to explore the differential predictability of various frailty measurement models.

METHODS

Eight databases were searched for prospective cohort studies that have adopted validated measure(s) of frailty and reported clinical, healthcare service utilization, or patient-reported outcomes in patients undergoing coronary artery or valvular surgeries/procedures.

RESULTS

Sixty-two articles were included (N = 16,679). Frailty significantly predicted mortality (short-term [≤ 30 days]: odds ratio [OR]: 2.33, 95% confidence interval [CI]: 1.28-4.26; midterm [6 months to 1 year]: OR: 3.93, 95%CI: 2.65-5.83; long-term [>1 year]: HR: 2.23, 95%CI: 1.60-3.11), postoperative complications (ORs: 2.54-3.57), discharge to care facilities (OR: 5.52, 95%CI: 3.84-7.94), hospital readmission (OR: 2.00, 95%CI: 1.15-3.50), and reduced health-related quality of life (HRQoL; standardized mean difference: -0.74, 95%CI: -1.30 to -0.18). Subgroup analyses showed that frailty exerted a greater impact on short-term mortality in patients undergoing open-heart surgeries than those receiving transcatheter procedures. Multidimensional and physical-aspect-focused frailty measurements performed equally in predicting mortality, but multidimensional measurements were more predictive of hospital readmission than physical-aspect-focused measurements.

CONCLUSION

Frailty was predictive of postoperative mortality, complications, increased healthcare service utilization, and reduced HRQoL. The impact of frailty on short-term mortality was more prominent in patients undergoing open-heart surgeries than those receiving transcatheter procedures. Multidimensional measures of frailty enhanced prognostic risk estimation, especially for hospital readmission.

Peer-supported exercise intervention for persons with mild cognitive impairment: a waitlist randomised controlled trial (the BRAin Vitality Enhancement trial)

BACKGROUND

motivating older people with cognitive impairment to remain physically active is challenging.

OBJECTIVE

this study aimed to examine the effects of a peer-supported exercise intervention on the cognitive function and health-related quality of life (HRQoL) of persons with mild cognitive impairment (MCI).

DESIGN

a two-arm randomised controlled trial.

SETTING AND PARTICIPANTS

community-dwelling persons with MCI were recruited from community centres for older adults in Hong Kong.

METHODS

participants randomised to the intervention group received an 8-week group-based peer-supported multicomponent exercise intervention, while the waitlist control group received usual care. A battery of neuropsychological tests and the Short Form-36 were administered at baseline, immediately post-intervention and 3 months post-intervention.

RESULTS

two hundred and twenty-nine participants were randomised to the intervention (n = 116) or control (n = 113) group. Compared with the control group, participants in the intervention group showed significantly greater improvements in processing speed and attention measured by the Colour Trails Test 1 (β = 7.213, 95% confidence interval [CI] = 2.870-11.557, P = 0.001) and working memory measured by the Digit Span Backward Test (β = 0.540, 95% CI = 0.199-0.881, P = 0.002) immediately post-intervention. The effects were sustained at 3 months post-intervention. Similarly, significantly greater improvements in sequencing and mental flexibility measured by the Colour Trails Test 2 were observed in the intervention group 3 months post-intervention (β = 6.979, 95% CI = 3.375-10.584, P < 0.001). Changes in global cognition, short-term memory and HRQoL were not significant.

CONCLUSION

the peer-supported exercise intervention was effective at sustaining improvements in executive function, attention and working memory in persons with MCI.

Effects of a Narrative-Based Psychoeducational Intervention to Prepare Patients for Responding to Acute Myocardial Infarction: A Randomized Clinical Trial

IMPORTANCE

Despite decades of educational efforts, patients' prolonged delays in seeking care for symptoms of acute myocardial infarction (AMI) remain the greatest obstacle to successful management of the condition.

OBJECTIVE

To compare the effects of a narrative-based psychoeducational intervention with a didactic educative approach on AMI survivors' intention to seek care for AMI symptoms and on AMI knowledge.

DESIGN, SETTING, AND PARTICIPANTS

A multisite randomized clinical trial recruited community-dwelling patients aged 18 years or older with a history of AMI from 4 hospitals in Hong Kong from January 1, 2018, to January 22, 2021, and followed up participants for 1 year.

INTERVENTIONS

An 8-week narrative-based psychoeducational intervention aimed to create a vivid cognitive experience of complex decision-making and modeled desirable behavioral changes through nurse-led, interactive video sessions using model patients. The control group received 4 nurse-led sessions comprising education about AMI and care seeking delivered using a didactic approach.

MAIN OUTCOMES AND MEASURES

The primary outcome was the behavioral intention between the 2 groups, reflected by participants' attitudes and beliefs about care seeking for AMI measured using the Acute Coronary Syndrome Response Index-Chinese version. The secondary outcome was AMI knowledge.

RESULTS

Six hundred and eight participants (mean [SD] age, 67.2 [8.3] years; 469 [77.1%] male) were randomized to either the narrative-based psychoeducation group (n = 304) or the didactic education group (n = 304). The psychoeducational intervention group reported greater positive changes than the control group in their attitudes (β = -1.053 [95% CI, -1.714 to -0.391]; P < .001) and beliefs (β = -0.686 [95% CI, -1.354 to -0.180]; P = .04) toward care seeking at the 3-month follow-up, and the difference was sustained at 12 months for both attitudes (β = -0.797 [95% CI, -1.477 to -0.117]; P = .02) and beliefs (β = -0.692 [95% CI, -1.309 to -0.012]; P = .047). There were no significant differences in AMI knowledge between the 2 study groups at the 3-month and 12-month time points.

CONCLUSIONS AND RELEVANCE

The results of this randomized clinical trial found that a novel approach of narrative-based psychoeducation was effective in improving patients' behavioral intention to seek care for AMI symptoms. Longer-term follow-up to evaluate actual care-seeking behavior and clinical outcomes in patients with AMI is warranted to determine the sustained effects of this intervention.

TRIAL REGISTRATION

ChiCTR Identifier: ChiCTR-IIC-17010576.

Lived experience of neuropsychiatric symptoms among females with mild cognitive impairment: A phenomenological study

AIMS

To explore the lived experience of neuropsychiatric symptoms (NPS) among females with mild cognitive impairment (MCI).

DESIGN

A phenomenological study using individual, semi-structured, telephone-based interviews was conducted to explore how the NPS are aroused, evolve, and affect the overall well-being, illness perception and the corresponding coping responses adopted by females with MCI.

METHODS

Twenty-nine participants with MCI were recruited from the community setting in Hong Kong between March and October 2020. Interviews were audio-recorded, transcribed verbatim, and analysed using an interpretative phenomenological analysis approach and constant comparison strategy.

RESULTS

Three themes were identified: (1) living vigilant lives with threats and uncertainty, (2) snowballing into further negative emotions and (3) seeking outlets for negative emotions. Our findings suggested that the participants' cognitive, functional and social challenges aroused intense emotional responses such as depression, agitation and anxiety. These noting negative emotions were further perpetuated by maladaptive coping responses, unrealistic expectations from coping strategies and overwhelming disease burden. Various internal and external strategies were adopted to enhance emotional adaptation, of which adopting a positive attitude appeared to be the most promising strategy.

CONCLUSION

This study shed light on the challenging experience of MCI. The cognitive afflictions and the resultant impacts on various life domains evoked a cluster of NPS. Support services need to enhance emotional adjustment through alleviating the various life stressors and strengthening the coping resources.

IMPACT

Elucidating the lived experience of NPS provides important insights into the development of a more effective, comprehensive and person-centred care planning for the population with MCI. Holistic care planning should extend beyond cognitive health optimization into enhancing disease knowledge, improve emotional coping, rebuild self-identity and bolstering social supports among this preclinical cohort.

Visual art therapy and cognition: Effects on people with mild cognitive impairment and low education level

OBJECTIVES

The aim of this study was to examine the effects of visual art therapy (VAT) on cognition, psychological and functional ability of people with mild cognitive impairment (MCI) and low education.

METHOD

A single-blinded randomized controlled trial was conducted among 127 older adults with MCI, mean age 73.6 years and level of education in years, (median (range)) = 0 (0 - 9). The intervention group received 12 VAT sessions over six weeks. The control group received six health education sessions. The outcomes measures at baseline, immediately after intervention, at three-months and six-month follow up included global cognitive functions, depression, mental wellbeing and instrumental activities of daily living functions.

RESULTS

The intervention group demonstrated greater improvement than the control group in global cognition (β =2.56, (95% CI =1.16, 3.97), p< .001, standardized mean difference (SMD) = 0.75), and depression (β =-2.01, (95% CI =-3.09, -0.93), p< .001, SMD = -0.93) immediately post intervention. The effects on cognitive functions were sustained at three and six-months follow ups. The differential effect of VAT on mental wellbeing and functional ability compared to health education were undetectable.

DISCUSSION

Visual art therapy can improve cognitive functions and mood status of older adults with MCI who have no or low education.

The Lived Experience of Patients and Family Caregivers in Managing Pneumoconiosis

The daily challenges of patients with pneumoconiosis and their caregivers in living with and providing care for this disease remain unexplored. As guided by the interpretive description, we found that pneumoconiosis patients suffered from highly anxiety-provoking symptoms and physical debilitation, which evoked high levels of distress and sense of impending death. The reduced functional capacity disrupted patients' role functioning and self-esteem. The perceived stigma of the embarrassing symptoms and treatments further disrupted their self-concept and social lives. Providing care for pneumoconiosis patients was demanding and burdensome, which jeopardized family caregivers' physical, emotional, and social well-being, and the relationship strain with the patients added further frustration to them. The perceived caregiving gain supported them to fully engage in daily caregiving. To improve the well-being of pneumoconiosis patients, a comprehensive empowerment-based dyadic care model is required to optimize adaptive behavioral changes and self-esteem, and improve self-efficacy in disease management for this cohort.

An empowerment-psycho-behavioral program on neuropsychiatric symptoms in persons with mild cognitive impairment: Study protocol of a randomized controlled trial

AIMS

Neuropsychiatric symptoms (NPS) are highly prevalent among persons with mild cognitive impairment (PwMCI). However, the mainstay of treatments only focuses on cognitive training. This study develops an empowerment-psycho-behavioural programme to improve the NPS and other health outcomes of this preclinical cohort. The empirical effects and the participants' perception and experience of the programme will be explored.

DESIGN

This sequential mixed-method study comprises a single-blind randomized controlled trial and a qualitative study.

METHODS

This study will recruit 250 PwMCI from the community and randomize them to either the intervention group to receive a 13-week empowerment-psycho-behavioural programme which focuses on promoting cognitive coping and stress adaptation, or the control group to receive a health education programme which serves as an attention placebo with content unrelated to dementia. The primary outcome is NPS, and the secondary outcomes include cognitive function, subjective memory complaints and health-related quality of life. These outcomes will be measured at baseline, upon completing the programme and 4 weeks thereafter. A purposive sample of 30 participants from the intervention group will be interviewed for their engagement experience in the programme. This study received funding support in July 2020.

DISCUSSION

Given the high prevalence and detrimental effects of NPS on disease progression, effective management is yet to be determined. Underpinned by the Progressively Lowered Stress Threshold (PLST) Model, the empowerment-psycho-behavioural programme is designed. Results on the outcome-based evaluation and the patients' experience can advance the science in this under-addressed area.

IMPACT

This study enhances our understanding of the PLST Model in explaining the manifestations of NPS by the stress-coping disequilibrium at the early disease stage. It will shed important insight into the care management of MCI to attend both cognition function and psychological well-being in research and clinical context.

TRIAL REGISTRATION

This study is registered in the ClinicalTrials.gov (NCT04723667) and the HKU Clinical Trials Registry (HKUCTR-2915).

Accuracy of the Montreal Cognitive Assessment in Detecting Mild Cognitive Impairment and Dementia in the Rural African Population

OBJECTIVE

The incidence of dementia in the sub-Saharan Africa is rising. However, screening tools for cognitive decline that fits their linguistic and cultural context are lacking. The aim of this study was to determine the accuracy of the Kiswahili version of Montreal Cognitive Assessment (K-MoCA) to detect mild cognitive impairment or dementia among older adults in the rural Tanzania.

METHODS

We recruited 259 community-dwelling older adults in Chamwino district, Tanzania. The concurrent validity and discriminatory power of K-MoCA were examined by comparing its score with IDEA cognitive screening and psychiatrist's diagnosis using DSM-V, respectively. All the questionnaires were administered in face-to-face interview.

RESULTS

K-MoCA demonstrated acceptable reliability (Cronbach's alpha = 0.780). Concurrent validity was evident by its significant correlation with the IDEA screening test (Pearson's r = 0.651, p < 0.001). Using the psychiatrist's rating as the reference, the optimal cut-off score for MCI and dementia was 19 and 15, respectively, which yielded the sensitivity of 70% and specificity of 60% for MCI, and sensitivity of 72% and specificity of 60% for dementia. Further analysis indicated that education and age influence performance on K-MoCA.

CONCLUSION

Overall, the K-MoCA is a reliable and valid tool for measuring cognitive decline. However, its limited discriminatory power for MCI and dementia may be compromised by the cultural irrelevance of some items.

An empowerment-based cognitive behavioural therapy for persons with mild cognitive impairment and insomnia: Protocol for a mixed-method pilot study

AIM

This study aims to examine the feasibility and effects of an empowerment-based cognitive behavioural therapy for insomnia on sleep, cognitive outcomes, and health-related quality of life in persons with mild cognitive impairment and insomnia.

STUDY DESIGN

This mixed-methods study comprises a pilot randomized controlled trial and an exploratory qualitative study.

METHODS

A total of 60 community-dwelling patients aged ≥50 years with mild cognitive impairment and self-reported sleep complaints will be recruited from the community centres for older people operated by two non-governmental organizations in Hong Kong. The participants will be randomly allocated to intervention or control groups, which will receive the empowerment-based cognitive behavioural therapy for insomnia and usual care respectively. We hypothesize that the cognitive behavioural therapy for insomnia intervention featuring an empowerment-based approach can improve sleep and cognitive function among patients with mild cognitive impairment. A subsample of 10 participants from the intervention group will be invited to take part in a qualitative interview to obtain more in-depth comments about the feasibility and acceptability of the intervention. Ethical approval was obtained on 2 November 2020. This study is supported by the Seed Fund for Basic Research from the University of Hong Kong on 4 September 2020.

DISCUSSION

This study will address a neglected risk factor for cognitive decline in persons with mild cognitive impairment. The theoretical integration of empowerment and cognitive model of behavioural changes may inform a wider and more successful application of cognitive behavioural therapy techniques for people with compromised cognitive ability and insomnia.

IMPACT

This study will also advance our knowledge on the role of sleep on persons with mild cognitive impairment and generate relevant empirical evidence to inform the care of this vulnerable cohort to affect a worldwide reduction in social, economic and healthcare burdens associated with cognitive impairment.

CLINICAL TRIAL REGISTRATION

This study has been registered at ClinicalTrials.gov (NCT04635085).

Can Visual Art Therapy Be Implemented With Illiterate Older Adults With Mild Cognitive Impairment? A Pilot Mixed-Method Randomized Controlled Trial

Older adults with mild cognitive impairment (MCI) with no literacy are at increased risk of progression to dementia. Whether it is feasible to engage this population in visual art therapy (VAT) and yield effects on cognition and depression remained unclear. A pilot mixed-method single-blinded randomized controlled trial was conducted in a sample of community-dwelling older adults with MCI. The experimental group (n = 21) was assigned to 12 sessions of VAT over 6 weeks, and the control group (n = 18) was assigned to 6 weekly health education (HE) on nonbrain health topics. Participants were evaluated at baseline using Montreal Cognitive Assessment-5-minute protocol (MoCA-5-min) and Geriatric Depression Scale Short Form (GDS-SF). A focus group discussion (FGD) was also conducted to the experimental group to explore their experiences of participating in the VAT. Findings indicated that both VAT and HE groups had significant improvement in MoCA-5-min scores and depressed mood over time; however, the significant group × time interaction effect was noted only for the psychological outcome. Findings from the FGD indicated that participants had challenging experiences at the beginning of the therapy, but later, they were able to cope and found that the VAT was relevant and beneficial for their cognitive and psychosocial health. This pilot study provided initial evidence about the potential benefit of VAT in improving cognitive and psychological well-being of older adults with MCI and low literacy and provided insights on how to better engage them in this cognitive stimulating intervention. A full-scale trial is recommended for a stringent evaluation.

Psychometrics and diagnostic properties of the Montreal Cognitive Assessment 5-min protocol in screening for Mild Cognitive Impairment and dementia among older adults in Tanzania: A validation study

BACKGROUND

The prevalence of dementia in Tanzania, as in other developing countries, is progressively increasing. Yet international screening instruments for mild cognitive impairment are lacking.

OBJECTIVES

The aim of this study was to determine the psychometrics and the diagnostic ability of the Montreal Cognitive Assessment 5 minutes protocol (MoCA-5-min) among older adults in the rural Tanzania.

METHODS

The MoCA-5-min and the Identification and Intervention for Dementia in Elderly Africans (IDEA) cognitive screening were concurrently administered through face to face to 202 community-dwelling older adults in Chamwino district. Exploratory factor analysis (EFA) using principal component method and oblique rotation was performed to determine the underlying factor structure of the scale. The concurrent and construct as well as predictive validities of the MoCA-5-min were examined by comparing its score with IDEA cognitive screening and psychiatrist's diagnosis using DSM-V criteria, respectively.

RESULTS

The EFA found that all the MoCA-5-min items highly loaded into one component, with factor loading ranging from 0.550 to 0.879. The intraclass correlation coefficient for 6 weeks test-retest reliability was 0.85. Its strong significant correlation with the IDEA screening (Pearson's r = 0.614, p < 0.001) demonstrated a good concurrent validity. Using the psychiatrist's rating as the gold standard, MoCA-5-min demonstrated the optimal cut-off score for MCI at 22, which yielded the sensitivity of 80% and specificity of 74%; and dementia at score of 16 giving a sensitivity of 90% and specificity of 80%. Upon stratifying the sample into different age groups, the optimal cut-off scores tended to decrease with the increase in age.

CONCLUSION

The MoCA-5-min is reliable and provides a valid and accurate measure of cognitive decline among older population in the rural settings of Tanzania. The use of varying cut-off scores across age groups may ensure more precise discriminatory power of the MoCA-5-min.

IMPLICATIONS FOR PRACTICE

Availability of the MoCA-5-min in Tanzania will facilitate clinicians to timely detect dementia at both pre-clinical and clinical stages. Its availability will also encourage further research and international collaborations in dementia prevention programs.

Role of depressive symptoms in subjective memory complaint in older adults with mild cognitive impairment

AIMS

To explore the independent relationship between depressive symptoms and subjective memory complaint (SMC) amongst older adults with mild cognitive impairment (MCI) after adjusting for objective cognitive function and other important confounding factors.

BACKGROUND

subjective memory complaint is a core symptom of MCI and is often the primary reason for older adults with MCI to seek for medical help. Improving subjective memory amongst older adults with MCI is important to enhance their quality of life and potentially delay further cognitive decline. Depressive symptoms, which are highly prevalent neuropsychiatric symptoms amongst older adults with MCI, may be one of the reasons that affect an individual's self-perception of memory function. However, there is a dearth of studies to provide a thorough evaluation of the independent relationship between depressive symptoms and SMC amongst older adults with MCI.

DESIGN

A descriptive correlational study.

METHODS

A consecutive sample (N = 154) of adults aged over 60 years was recruited from a community healthcare centre between June and September 2016. MCI was detected using the Montreal Cognitive Assessment. Depressive symptoms and subjective memory were measured using the Geriatric Depression Scale and Memory Inventory for the Chinese, respectively. Hierarchical regression was performed to explore the relationship between SMC and depressive symptoms, with control over objective cognitive function, socio-demographic and health-related confounding factors.

RESULTS

After controlling objective cognitive function and other confounding factors, SMC was independently associated with depressive symptoms (standardised β = 0.336, p < .001). This psychological status even explained for a greater variance (R²  = 8.8%) for SMC compared with objective cognitive function (R²  = 2.4%).

CONCLUSION

subjective memory complaint was independently associated with depressive symptoms in older adults with MCI. Early detection and management of depressive symptoms are highly important amongst this clinical cohort.

IMPLICATIONS FOR PRACTICE

Early detection and prompt treatment of depressive symptoms is a highly prioritised care agenda in managing SMC in older adults with MCI.

The experience of patients and family caregivers in managing pneumoconiosis in the family context: A study protocol

AIM

This study aims to explore the illness experience and needs of patients with pneumoconiosis and the caregiving experience of their respective family caregivers.

DESIGN

This is an exploratory qualitative study.

METHODS

Participants will be recruited during the annual patient interview with purposive sampling. Those with a confirmed diagnosis of pneumoconiosis for at least 1 year will be eligible. Patients with different levels of physical dependency will be recruited. The respective family caregivers of these patients, who are ≥21 years of age, assuming the role as primary caregivers of a pneumoconiosis patient will also be invited to join. In-depth interviews will be conducted in patients' home separately for patients and their caregivers and a home environment assessment will also be undertaken. The interview data will be transcribed verbatim, managed with the software NVivo 11 and analysed with content analysis. The ethical approval has obtained, and this study is supported by a research grant from the Pneumoconiosis Compensation Fund Board of Hong Kong on 14 August 2018.

DISCUSSION

This study will advance the knowledge on how pneumoconiosis patients and their family caregivers manage the disease in the family context. The findings of this study can inform the development of a family-oriented care model to support the pneumoconiosis patients and their family caregivers to manage this condition better.

IMPACT STATEMENT

Pneumoconiosis is the most common type of occupational lung disease in the Chinese population. These patients require long-term comprehensive services and support to assist their disease self-management. However, little is known about how these patients and their family caregivers manage the disease in the family context. The current study addresses this gap by exploring patients' illness experience and their family members' caregiving experience, which is timely to inform the design of family-oriented model of care to support this clinical cohort.

CLINICAL TRIAL REGISTRATION

This study has been registered at ClinicalTrials.gov (NCT04022902).

Brain Vitality Enhancement (BRAVE) program to promote brain health among persons with mild cognitive impairment: A study protocol

AIM

This study aims to evaluate the effects of a community-based program entitled 'Brain Vitality Enhancement (BRAVE)' on the cognitive function, physical and mental well-being of persons with mild cognitive impairment.

STUDY DESIGN

This is a parallel wait list randomized controlled trial.

METHODS

The BRAVE program consists of two phases. Phase 1 is an empowerment workshop for training 50 peer mentors to be the exercise ambassadors, while Phase 2 is a supervised exercise program for 250 persons with mild cognitive impairment. They will be randomly allocated to intervention or wait list control groups. For the intervention group, the peer mentors and mentees will be matched according to gender and residential areas to form mentor-mentee groups to attend an 8-week supervised exercise training. The mentor-mentee groups will continue to participate mentor-directed exercise sessions in the community thereafter. A mobile application will be developed for self-directed learning. We hypothesize that persons with mild cognitive impairment receiving the BRAVE program will demonstrate better cognitive function and health-related quality of life than the control group who receive usual care. This study is funded by a grant from the Food and Health Bureau of the Government of Hong Kong Special Administrative Region in April 2018.

DISCUSSION

This study will empower a group of golden-aged adults to be the ambassadors to promote brain health in the community and persons with mild cognitive impairment to integrate moderate-intensity exercise into their lifestyle to achieve long-term beneficial effects on their cognition and well-being.

IMPACT

Given the population with mild cognitive impairment is growing rapidly and expected to keep escalating in coming decades and limited treatment options for cognitive decline and its significant burden on the health and social care system, this study is timely to promote active ageing in the society and reduce the burden associated with cognitive decline.

A nurse-coordinated integrated care model to support decision-making and self-care in patients with atrial fibrillation: A study protocol

AIM

This study aims to evaluate the effects of a nurse-coordinated, empowerment-based integrated care model on self-care behaviours and psychosocial outcomes in patients with atrial fibrillation and to explore how this intervention affects patients' self-care behaviours and quality of life.

DESIGN

This mixed-methods study comprises a randomized controlled trial and an exploratory qualitative study.

METHODS

A total of 392 community-dwelling patients aged ≥65 years with a confirmed diagnosis of atrial fibrillation, a high stroke risk and no oral anticoagulants treatment will be recruited from the medical outpatient clinics of a university-affiliated hospital. The patients will be randomly allocated to intervention or control groups, which will receive treatment via the nurse-coordinated integrated care model or standard care, respectively. We hypothesize that compared with patients receiving standard care, atrial fibrillation patients exposed to the nurse-coordinated care model will be more likely to achieve compatible patient and physician decisions regarding the use of oral anticoagulants, better changes in medication adherence, anxiety, depression and health-related quality of life after the intervention. A subsample of 30 participants in the intervention group will also participate in a qualitative interview to provide their views and perceptions about the intervention. The ethical approval has obtained on 5 July 2018. This study is supported by a grant from the Research Grants Council of the Hong Kong Special Administrative Region on 29 June 2018.

DISCUSSION

This study will uniquely adopt an empowerment-based approach to equip patients as active agents in atrial fibrillation management through a nurse-coordinated integrated care model that comprehensively addresses their needs.

IMPACT

Patients with atrial fibrillation are currently receiving inadequate guideline-recommended care. This study will address this important evidence-practice gap by optimizing oral anticoagulant prescription and therapeutic effects and promotes effective patient self-care, so as to achieve worldwide reductions in atrial fibrillation-related morbidity, mortality, and healthcare burdens.

CLINICAL TRIAL REGISTRATION

This study has been registered at ClinicalTrials.gov (NCT03924739).

The effectiveness of physical exercise on cognitive and psychological outcomes in individuals with mild cognitive impairment: A systematic review and meta-analysis

OBJECTIVE

Individuals with mild cognitive impairment (MCI) are at high risk for developing dementia. Physical exercise is a promising intervention for cognitive decline. Systematic reviews regarding the effects of physical exercise on cognitive and psychological outcomes among MCI patients are limited, and a systematic review exploring the effects of exercise modalities on the results has not been conducted. This study evaluated the effects of physical exercise on cognitive and psychological outcomes for MCI patients and attempted to identify which specific modality of exercise is more effective.

DESIGN

Systematic review and meta-analysis.

DATA SOURCES

A systematic search of Medline, CINAHL, EMBASE, PsycINFO, SPORTDiscus, and the China National Knowledge Infrastructure was performed.

REVIEW METHODS

Two reviewers independently assessed the study quality using the Effective Public Health Practice Project Quality Assessment Tool. Meta-analysis was conducted when data were available, with further subgroup analyses for exercise types. A series of sensitivity analyses were conducted to explore the influence of study quality and control types on the primary outcome. A narrative analysis was performed when statistical synthesis was inappropriate.

RESULTS

Eleven studies met the inclusion criteria. The exercise interventions can be classified into three types: (a) aerobic exercise, (b) resistance exercise, and (c) multi-modal exercise. Results showed that physical exercise had beneficial effects for global cognition [standard mean difference (SMD) = 0.30, 95% confidence interval (CI): 0.10-0.49, p = 0.002]. Further subgroup analysis demonstrated that aerobic exercise programmes are consistently associated with medium effect size (SMD: 0.54-0.58). However, the effects of physical exercise on domain-specific cognitive function and psychological outcomes in MCI patients remain inconclusive. Results of sensitivity analysis indicated that types of control exert influence on the outcomes.

CONCLUSIONS

Physical exercise, aerobic exercise in particular, benefits global cognition in MCI patients. The evidence of physical exercise on domain-specific cognitive function and psychological outcomes remains unclear, more trials with rigorous study design are necessary to provide the evidence.

Factors in the prioritization of information needs among Hong Kong Chinese breast cancer patients

Objective:

The study aims to examine the prioritization of information needs in breast cancer patients, using the Information Needs Questionnaire (INQ); and to identify the demographic and clinical characteristics associated with that prioritization.

Methods:

A cross-sectional exploratory study was conducted, by means of consecutive sampling. The INQ was used to examine participants’ preferences on information needs. Their demographic and clinical characteristics were collected by means of a structured questionnaire and review of medical records. Backward multivariable logistic regression analysis was performed to examine the association between prioritization of patients’ information needs and their demographic and clinical characteristics.

Results:

A total of 275 breast cancer patients took part in the analysis. Of the nine INQ items, most participants ranked as their top four needs information about the likelihood of a cure (79%), extent of the disease (76%), treatment options (55%), and family risk of developing breast cancer (51%). Certain demographic and clinical characteristics-religious belief, whether living alone or not, household income, educational level, and time since cancer diagnosis-influenced patients’ prioritization of information needs.

Conclusion:

Understanding and meeting the information needs of breast cancer patients are crucial to improving their quality of care. Different patients are likely to have different priorities in information needs according to their demographic and clinical characteristics. An awareness of these associated factors will allow better tailor-made educational interventions to be provided to meet patients’ individual needs in a more adequate way.

Psychometric evaluation of the Perceived Barriers to Health Care-seeking Decision in Chinese patients with acute coronary syndromes

OBJECTIVES

This study aimed to develop the Chinese version of the Perceived Barriers to Health Care-seeking Decision (PBHSD-C) and evaluate its psychometric properties in Chinese patients with acute coronary syndromes (ACS).

BACKGROUND

The assessment of the level of perceived barriers in the care-seeking trajectory of ACS patients is important for the understanding of its impact on pre-hospital delay in seeking care.

METHODS

The psychometric properties of PBHSD-C were evaluated among 114 ACS patients in the cardiac unit of two major hospitals in Hong Kong.

RESULTS

The Content Validity Indexes were ranged from .88 to 1. The Cronbach's alpha of the PBHSD-C was .74. The intraclass correlation coefficients of all items were above .80. The convergent validity of the PBHSD-C was also supported.

CONCLUSION

The PBHSD-C is reliable and valid to be used to assess the level of perceived barriers in the care-seeking of Chinese patients with ACS.

Consistency in paired comparisons of Information Needs Questionnaires (INQ) among Hong Kong Chinese breast cancer patients

PURPOSE

This study examines the consistency of Hong Kong Chinese breast cancer patients in prioritizing the information needs using the Chinese version of the Information Needs Questionnaire and identifies the demographics and clinical characteristics associated with inconsistency of prioritizing their information needs.

METHODS

Inconsistency in prioritizing information needs was assessed by the number of circular triads in making paired comparison judgements. The chi-square test for the coefficient of agreement was used to test the hypothesis of random allocation of preferences. Stepwise multivariable regression analyses were performed to examine the association between the number of circular triads and participants' demographic and clinical characteristics.

RESULTS

362 Hong Kong Chinese breast cancer patients completed the questionnaire in 2008. A moderate amount of agreement among the participants was reported (coefficient of agreement = 0.31). The results of the chi-square test indicated that prioritizing information needs were not done randomly. Forward multivariable regression analyses revealed that breast cancer patients who were older, had lower educational levels or were unsure about their family history of cancer, on average, committed more circular triads. However, participants with longer interval since original diagnosis of cancer, on average, made fewer circular triads.

CONCLUSION

Exclusion of responses from inadequately consistent patients may be necessary when assessing the priority of information needs in breast cancer patients using the Chinese version of Information Needs Questionnaire, which could then more appropriately reflect the actual priority. Attention should be paid to patients' particular characteristics when assessing the priority of information needs by means of the instrument.