Older persons' experiences of care encounters in their home: A multiple-case study

AIM

To explore and describe older persons' unique experiences of care encounters with home care nurses in a real-life context.

BACKGROUND

The increasing number of older persons in society contributes to increases in age-related impairments compromising their quality of life. Future care consists of "hospitals at home" where care encounters occur in a person's private domain, partly becoming a clinical workplace. Scant research has focused on how older persons experience care encounters with home care nurses and needs to be highlighted.

DESIGN

Multiple-case study.

METHODS

The cases relied on replication logic and five purposive sampled older persons were interviewed. Data were analysed using qualitative content analysis and differences within and between cases were explored and findings across the cases were replicated.

FINDINGS

The cross-analysis emerged in three categories: "Nursing routine rules the care encounters", "Lack of knowledge and information" and "Dependency on support from others".

CONCLUSIONS

Our research has found that older persons face challenges while receiving home care, including limited engagement in their care and the need for enhanced support. Implementing person-centred care in homes poses ethical challenges that require careful consideration. Home care nurses should prioritise understanding each patient individually, recognising them beyond their patient role, which necessitates more thorough and time-sensitive care encounters.

REPORTING METHOD

Findings were reported using COREQ guidelines.

PATIENT OR PUBLIC CONTRIBUTION

Patients were interviewed and contributed with data for this study.

IMPLICATIONS FOR THE PROFESSION AND PATIENT CARE

This study emphasises the need to prioritise individualised care in home settings and listen to the voices of older individuals to enhance quality.

Chronic social and psychological stress impact select neuropathologies in the PS19 mouse model of tauopathy

OBJECTIVE

Despite advances toward understanding the etiology of Alzheimer's disease (AD), it remains unclear which aspects of this disease are affected by environmental factors. Chronic life stress increases risk for aging-related diseases including AD. The impact of stress on tauopathies remains understudied. We examined the effects of stress elicited by social (chronic subordination stress, CSS) or psychological/physical (chronic restraint stress, CRS) factors - on the PS19 mouse model of tauopathy.

METHODS

Male PS19 mice (average age 6.3 months) were randomized to receive CSS, CRS, or to remain as singly-housed controls. Behavioral tests were used to assess anxiety-like behaviors and cognitive functions. Immunofluorescence staining and western blotting analysis were used to measure levels of astrogliosis, microgliosis and tau burden. Immunohistochemistry was used to assess glucocorticoid receptor expression.

RESULTS

PS19 mice exhibit neuroinflammation (GFAP, t-tests; p = 0.0297; Iba1, t-tests; p = 0.006) and tau hyperphosphorylation (t-test, p = 0.0446) in the hippocampus, reduced anxiety (post hoc, p = 0.046), and cognitive deficits, when compared to wild type mice. Surprisingly, CRS reduced hippocampal levels of both total tau and phospho-tauS404 (t-test, p = 0.0116), and attenuated some aspects of both astrogliosis and microgliosis in PS19 mice (t-tests, p = 0.068 to p = 0.0003); however, this was not associated with significant changes in neurodegeneration or cognitive function. Anxiety-like behaviors were increased by CRS (post hoc, p = 0.046). Conversely, CSS impaired spatial learning in Barnes Maze without impacting tau phosphorylation or neurodegeneration and having a minimal impact on gliosis.

CONCLUSIONS

Our results demonstrate that social or psychological stress can differentially impact anxiety-like behavior, select cognitive functions, and some aspects of tau-dependent pathology in PS19 male mice, providing entry points for the development of experimental approaches designed to slow AD progression.

Structural and health system determinants of health outcomes in systemic lupus erythematosus: Understanding the mechanisms underlying health disparities

Chronic diseases are increasingly responsible for the burden of health outcomes across the world. However, there is also increasing recognition that patterns of chronic disease outcomes (e.g., mortality, quality of life, etc.) have inequities across race, gender, and socioeconomic groups that cannot be solely attributed to these determinants. There is a need for an organizing framework which centers fundamental causes of health disparities that may better guide future work in centering these mechanisms and moving beyond acknowledgment of health disparities. In this paper, we synthesize several concepts from health disparities literature into a conceptual framework for understanding the interplay of patients' lived experiences, the health care system and structural determinants. Our framework suggests that (1) structural factors influence the health care system, the patient, the health care provider, and the provider-patient relationship through process of subordination and (2) that structurally competent actions are critical to reducing health inequities. The addition of subordination to theoretical frameworks involving health equity and social determinants of health, along with engagement with concepts of structural competency suggest several systems level changes to improve health outcomes.

The stigma system: How sociopolitical domination, scapegoating, and stigma shape public health

Stigma is a fundamental driver of adverse health outcomes. Although stigma is often studied at the individual level to focus on how stigma influences the mental and physical health of the stigmatized, considerable research has shown that stigma is multilevel and structural. This paper proposes a theoretical approach that synthesizes the literature on stigma with the literature on scapegoating and divide-and-rule as strategies that the wealthy and powerful use to maintain their power and wealth; the literatures on racial, gender, and other subordination; the literature on ideology and organization in sociopolitical systems; and the literature on resistance and rebellion against stigma, oppression and other forms of subordination. we develop a model of the "stigma system" as a dialectic of interacting and conflicting structures and processes. Understanding this system can help public health reorient stigma interventions to address the sources of stigma as well as the individual problems that stigma creates. On a broader level, this model can help those opposing stigma and its effects to develop alliances and strategies with which to oppose stigma and the processes that create it.

Sir Isaac Newton Stranger in a Strange Land

The theme of this essay is that the time of dominance of Newton's world view in science is drawing to a close. The harbinger of its demise was the work of Poincaré on the three-body problem and its culmination into what is now called chaos theory. The signature of chaos is the sensitive dependence on initial conditions resulting in the unpredictability of single particle trajectories. Classical determinism has become increasingly rare with the advent of chaos, being replaced by erratic stochastic processes. However, even the probability calculus could not withstand the non-Newtonian assault from the social and life sciences. The ordinary partial differential equations that traditionally determined the evolution of probability density functions (PDFs) in phase space are replaced with their fractional counterparts. Allometry relation is proven to result from a system's complexity using exact solutions for the PDF of the Fractional Kinetic Theory (FKT). Complexity theory is shown to be incompatible with Newton's unquestioning reliance on an absolute space and time upon which he built his discrete calculus.

Skellam Type Processes of Order k and Beyond

In this article, we introduce the Skellam process of order k and its running average. We also discuss the time-changed Skellam process of order k. In particular, we discuss the space-fractional Skellam process and tempered space-fractional Skellam process via time changes in Skellam process by independent stable subordinator and tempered stable subordinator, respectively. We derive the marginal probabilities, Lévy measures, governing difference-differential equations of the introduced processes. Our results generalize the Skellam process and running average of Poisson process in several directions.

Signaling context modulates social function of silent bared-teeth displays in rhesus macaques (Macaca mulatta)

The signaling context has been found to change the meaning of the silent bared-teeth display (SBT) in pigtail macaques (Macaca nemestrina) such that the SBT in apparently peaceful contexts communicates subordination, a long-term pattern of behavior, whereas in conflict contexts it communicates immediate submission (PNAS, 104: 1581-1586). However, the context dependent nature of the SBT has not yet been explored in other species. We investigated SBT usage with respect to grooming, severe aggression, and signaler-receiver sex, rank difference, and body size in seven captive groups of rhesus macaques. Peaceful SBTs were given most often to male receivers by male and female signalers whereas conflict SBTs were given to both male and female receivers primarily by female signalers. Male signalers rarely gave SBTs (peaceful or conflict) to female receivers. Unlike pigtail macaques, peaceful SBTs in rhesus were often accompanied by withdrawal behavior (referred to as peaceful SBT-leave), which influenced grooming, but not aggression, at the dyadic level. Severe aggression was less frequent among dyads using peaceful SBTs (regardless of withdrawal behavior) than those using conflict SBTs. In contrast, grooming was more frequent among dyads using peaceful SBT-stay signals than those using peaceful SBT-leave signals or conflict SBTs. In total, our results indicate that peaceful SBTs are a functionally different signal from conflict SBTs in rhesus macaques.

High rates of pregnancy loss by subordinates leads to high reproductive skew in wild golden lion tamarins (Leontopithecus rosalia)

Across taxa, cooperative breeding has been associated with high reproductive skew. Cooperatively breeding golden lion tamarins (Leontopithecus rosalia) were long thought to have a monogynous mating system in which reproduction was limited to a single dominant female. Subordinates with few reproductive opportunities delayed dispersal and remained in the natal group to provide alloparental care to siblings, thus allowing dominant reproductive females to meet the energetic needs associated with high rates of reproduction and successful infant rearing. The goal of this study was to re-assess monogyny in wild golden lion tamarin groups based upon pregnancy diagnoses that used non-invasive enzyme immunoassay for progesterone and cortisol, combined with weekly data on individual weight gain, bi-annual physical examinations noting pregnancy and lactation status and daily behavioral observations. We established quantitative and qualitative criteria to detect and determine the timing of pregnancies that did not result in the birth of infants. Pregnancy polygyny occurred in 83% of golden lion tamarin groups studied. The loss of 64% of subordinate pregnancies compared to only 15% by dominant females limited reproductive success mainly to dominant females, thus maintaining high reproductive skew in female golden lion tamarins. Pregnancy loss by subordinate adults did not appear to result from dominant interference in subordinate hormonal mechanisms, but more likely resulted from subordinate abandonment of newborn infants to mitigate dominant aggression.

FRACTIONAL WAVE EQUATIONS WITH ATTENUATION

Fractional wave equations with attenuation have been proposed by Caputo [5], Szabo [27], Chen and Holm [7], and Kelly et al. [11]. These equations capture the power-law attenuation with frequency observed in many experimental settings when sound waves travel through inhomogeneous media. In particular, these models are useful for medical ultrasound. This paper develops stochastic solutions and weak solutions to the power law wave equation of Kelly et al. [11].

Effects of Chronic Social Stress on Obesity

The prevalence of overweight and obesity has markedly increased during the past few decades. Stress has been suggested as one environmental factor that may contribute to the development of obesity. In this review, we discuss the role that exposure to chronic stress may play in the development of obesity, with particular attention to the effects of chronic psychosocial stress. Of particular importance is the effect that social stress has on dietary preference, food consumption, and regional distribution of adipose tissue. We present evidence from human and animal studies that links sympathetic nervous system and hypothalamic-pituitary-adrenal axis hyperactivity with visceral obesity, and that stress tends to alter the pattern of food consumption, and promotes craving of nutrient-dense "comfort foods." Lastly, we discuss the visible burrow system, a model of chronic social stress used in our laboratory to assess the effects of social subordination on behavioral and metabolic profile.

Estradiol effects on behavior and serum oxytocin are modified by social status and polymorphisms in the serotonin transporter gene in female rhesus monkeys

Despite the well-documented relation between estradiol (E2) and behavior, exposure to stressors may modify sensitivity to E2. The effects of E2 on behavior are, in part, likely related to their modulation of the serotonin (5HT) and oxytocin systems. The short allele (s-variant) polymorphism found in the promoter region of the SLC6A4 gene that encodes the 5HT transporter (5HTT) modulates responsivity to stressors. The current study used ovariectomized adult female rhesus monkeys to evaluate how exposure to the psychosocial stressor of social subordination and polymorphisms in the gene encoding 5HTT influence the behavioral effects of E2 and immunoreactive serum oxytocin. Dominant females had higher levels of oxytocin than subordinate animals even though E2 increased immunoreactive serum oxytocin in all females. E2 increased affiliative behaviors in all animals, with even more of these prosocial behaviors directed at dominant females. S-variant females, regardless of social status, were more aggressive toward more subordinate cage mates and these behaviors too were increased by E2. Subordinate s-variant females are most often involved in agonistic behavior, less affiliative behavior, and were less responsive to the anxiolytic action of E2. The results show that the short allele of the 5HTT gene synergizes with psychosocial stress exposure to affect the behavioral efficacy of E2 while confirming the actions of E2 for producing generalized behavioral arousal in females. Whether differences in the central action of 5HT and/or oxytocin are responsible for this effect requires further study.

Gonadal hormones modulate the display of conditioned defeat in male Syrian hamsters

It has been widely reported that gonadal hormones influence the display of aggression in Syrian hamsters; conversely, much less is known about whether gonadal hormones modulate submissive/defensive behaviors in these animals. Following social defeat, male hamsters no longer display normal territorial aggression but instead display submissive/defensive behavior in the presence of a smaller opponent, a phenomenon we have termed conditioned defeat (CD). The purpose of the present study was to examine the effect of gonadal hormones on the display of CD in male hamsters. In Experiment 1, males were castrated or sham-operated. The castrated males were significantly more submissive following social defeat relative to their intact counterparts. The increased submissive behavior in the castrated males during CD testing was particularly surprising, given the fact that they were attacked significantly less during CD training. In Experiment 2a, males were castrated and given hormone replacement. Castrated males treated with testosterone or dihydrotestosterone displayed significantly less submissive behavior following social defeat than did those treated with cholesterol or estradiol. Finally, in Experiment 2b, there was no effect of hormone replacement on aggressive behavior in non-defeated hamsters suggesting that the decrease in submissive behavior in males treated with dihydrotestosterone or testosterone is specific to being previously defeated. Taken together the data indicate that the presence of androgens reduces the display of submission in defeated male hamsters. More importantly, these findings suggest that androgens may have a protective effect against the development of depression-like or anxiety-like behaviors following exposure to an ethologically relevant stressor.

Reproductive skew in female common marmosets: what can proximate mechanisms tell us about ultimate causes?

Common marmosets are cooperatively breeding monkeys that exhibit high reproductive skew: most subordinate females fail to reproduce, while others attempt to breed but produce very few surviving infants. An extensive dataset on the mechanisms limiting reproduction in laboratory-housed and free living subordinate females provides unique insights into the causes of reproductive skew. Non-breeding adult females undergo suppression of ovulation and inhibition of sexual behaviour; however, they receive little or no aggression or mating interference by dominants and do not exhibit behavioural or physiological signs of stress. Breeding subordinate females receive comparable amounts of aggression to non-breeding females but are able to conceive, gestate and lactate normally. In groups containing two breeding females,however, both dominant and subordinate breeders kill one another's infants. These findings suggest that preconception reproductive suppression is not imposed on subordinate females by dominants, at a proximate level, but is instead self-imposed by most subordinates, consistent with restraint models of reproductive skew. In contrast to restraint models, however, this self-suppression probably evolved not in response to the threat of eviction by dominant females but in response to the threat of infanticide. Thus,reproductive skew in this species appears to be generated predominantly by subordinate self-restraint, in a proximate sense, but ultimately by dominant control over subordinates' reproductive attempts.

Social stress, therapeutics and drug abuse: preclinical models of escalated and depressed intake

The impact of ostensibly aversive social stresses on triggering, amplifying and prolonging intensely rewarding drug taking is an apparent contradiction in need of resolution. Social stress encompasses various types of significant life events ranging from maternal separation stress, brief episodes of social confrontations in adolescence and adulthood, to continuous subordination stress, each with its own behavioral and physiological profile. The neural circuit comprising the VTA-accumbens-PFC-amygdala is activated by brief episodes of social stress, which is critical for the DA-mediated behavioral sensitization and increased stimulant consumption. A second neural circuit comprising the raphe-PFC-hippocampus is activated by continuous subordination stress and other types of uncontrollable stress. In terms of the development of therapeutics, brief maternal separation stress has proven useful in characterizing compounds acting on subtypes of GABA, glutamate, serotonin and opioid receptors with anxiolytic potential. While large increases in alcohol and cocaine intake during adulthood have been seen after prolonged maternal separation experiences during the first two weeks of rodent life, these effects may be modulated by additional yet to be identified factors. Brief episodes of defeat stress can engender behavioral sensitization that is relevant to escalated and prolonged self-administration of stimulants and possibly opioids, whereas continuous subordination stress leads to anhedonia-like effects. Understanding the intracellular cascade of events for the transition from episodic to continuous social stress in infancy and adulthood may provide insight into the modulation of basic reward processes that are critical for addictive and affective disorders.

Context modulates signal meaning in primate communication

A central issue in the evolution of social complexity and the evolution of communication concerns the capacity to communicate about increasingly abstract objects and concepts. Many animals can communicate about immediate behavior, but to date, none have been reported to communicate about behavior during future interactions. In this study, we show that a special, unidirectional, cost-free dominance-related signal used by monkeys (pigtailed macaques: Macaca nemestrina) means submission (immediate behavior) or subordination (pattern of behavior) depending on the context of usage. We hypothesize that to decrease receiver uncertainty that the signal object is subordination, senders shift contextual usage from the conflict context, where the signal evolved, to a peaceful one, in which submission is unwarranted. We predict and find that deceasing receiver uncertainty through peaceful signal exchange facilitates the development of higher quality social relationships: Individuals exchanging the peaceful variant groom and reconcile more frequently and fight less frequently than individuals exchanging signals only in the conflict context or no signals. We rule out alternative hypotheses, including an underlying reciprocity rule, temperament, and proximity effects. Our results suggest that primates can communicate about behavioral patterns when these concern relationship rules. The invention of signals decreasing uncertainty about relationship state is likely to have been critical for the evolution of social complexity and to the emergence of robust power structures that feed down to influence rapidly changing individual behavior.