Care dependency of nursing home patients with dementia: assessment from European perspective

In an international, study psychometric properties of the Care Dependency Scale (in Dutch shortened as: ZAS) were examined by analysing data gathered in nursing homes in Germany, Finland, Italy, The Netherlands, Norway and Wales (UK). For that purpose, from these countries a convenience sample was developed consisting of 832 patients with dementia. The English, Finnish, German, Italian and Norwegian research instruments were translations of the original Dutch ZAS. Psychometric evaluations of the ZAS were carried out for each country separately as well as for the countries combined. High alpha coefficients between 0.93 and 0.97 were calculated. Subsequent interrater and test-retest reliability revealed moderate to substantial kappa values. Factor analysis resulted in a one-factor solution. One of the main outcomes of the cross-cultural comparison was that the findings in the six countries show more similarities than differences, so that the scale can be used appropriately in nursing home practice and for international comparison of care dependency.     

Whether or not to treat pneumonia curatively in (demented) psychogeriatric patients: evaluation of a guideline for nursing home physicians

A guideline was developed to support decision-making about whether or not to treat pneumonia curatively in psychogeriatric (demented) nursing home patients. This guideline was developed as a 'checklist of considerations', primarily of the ethical and legal aspects of decision-making. Nursing home physicians used and evaluated the list. The list's acceptance was assessed by measuring the frequency of the list's use, and judgements of the list's contents and 'usefulness'. The list was used in 50 out of 58 participating nursing homes, in 47% of the 489 psychogeriatric patients in whom pneumonia occurred. The list was found somewhat to very useful to support decision-making in 47% of 107 individual patients. For the targeted patient category as a whole, 85% of 48 physicians who were asked retrospectively (one physician per home) found the list somewhat to very useful. The content of the list was judged favourably. In conclusion, the nursing home physicians accepted the considerations of the checklist as a basis for decision-making on whether or not to treat pneumonia curatively in psychogeriatric patients. In the future, the format of the list can be adapted for use in diverse clinical situations. Suggestions are provided to increase user friendliness and usefulness.     

Preparing physicians to utilize the emerging genetic toolbox: an approach for medical biochemistry

New genetic information is accumulating so rapidly that even the most current material given to first or second year medical students about any specific genetic disease may be incomplete if not obsolete before they obtain the M.D. degree. Therefore, medical education must emphasize the principles of molecular biology and genetics while providing students with the skills to independently obtain up-to-date genetic information following graduation. An assignment that requires students to acquire details about a particular genetic disease from various on-line resources is one method being used to accomplish the latter goal.     

Spinal and sacroiliac assessment and treatment techniques used by osteopathic physicians in the United States

Background

Without systematic exposure to biomedical research concepts or applications, osteopathic medical students may be generally under-prepared to efficiently consume and effectively apply research and evidence-based medicine information in patient care. The academic literature suggests that although medical residents are increasingly expected to conduct research in their post graduate training specialties, they generally have limited understanding of research concepts. With grant support from the National Center for Complementary and Alternative Medicine, and a grant from the Osteopathic Heritage Foundation, the University of North Texas Health Science Center (UNTHSC) is incorporating research education in the osteopathic medical school curriculum. The first phase of this research education project involved a baseline assessment of students' understanding of targeted research concepts. This paper reports the results of that assessment and discusses implications for research education during medical school.

Methods

Using a novel set of research competencies supported by the literature as needed for understanding research information, we created a questionnaire to measure students' confidence and understanding of selected research concepts. Three matriculating medical school classes completed the on-line questionnaire. Data were analyzed for differences between groups using analysis of variance and t-tests. Correlation coefficients were computed for the confidence and applied understanding measures. We performed a principle component factor analysis of the confidence items, and used multiple regression analyses to explore how confidence might be related to the applied understanding.

Results

Of 496 total incoming, first, and second year medical students, 354 (71.4%) completed the questionnaire. Incoming students expressed significantly more confidence than first or second year students (F = 7.198, df = 2, 351, P = 0.001) in their ability to understand the research concepts. Factor analyses of the confidence items yielded conceptually coherent groupings. Regression analysis confirmed a relationship between confidence and applied understanding referred to as knowledge. Confidence scores were important in explaining variability in knowledge scores of the respondents.

Conclusion

Medical students with limited understanding of research concepts may struggle to understand the medical literature. Assessing medical students' confidence to understand and objectively measured ability to interpret basic research concepts can be used to incorporate competency based research material into the existing curriculum.     

Understanding the expanding role of primary care physicians (PCPs) to primary psychiatric care physicians (PPCPs): enhancing the assessment and treatment of psychiatric conditions

Aim In the current healthcare system primary care physicians (PCPs) have, in effect, become the primary psychiatric care physicians (PPCPs) for many of their patients. Being the PPCP in an already busy and stressful medical industry presents additional time management and treatment challenges to successfully manage patients' medical and psychiatric needs. The aim of the study was to ascertain PCPs' psychiatric assessment and treatment practices and to determine the extent to which PCPs have a need for using a structured psychiatric assessment tool.Method We sent 300 PCPs a survey to examine their psychiatric assessment and treatment practices. A one-page questionnaire was used to inquire about PCPs' psychiatric care practice habits including types of conditions treated, psychiatric medications prescribed, assessment methods used, interest in using a structured assessment tool and referral sources used. Sixty-eight usable surveys (23%) were returned.Results PCPs identify approximately one-third of their patients as mental health patients. They are treating a wide range of psychiatric conditions and prescribing a variety of psychiatric medications. The vast majority are using traditional clinical interviewing as their primary method of psychiatric assessment. However, the majority were willing to use a structured psychiatric assessment tool.Conclusion PCPs are serving a useful role in providing psychiatric treatment to many of their patients. Using a more structured psychiatric assessment method in practice could ultimately strengthen the assessment and treatment of psychiatric conditions in primary care settings.     

Exemplary family physicians and consultants: empirical definition of contemporary medical practice.

To identify the characteristics of exemplary family physicians and consultants, we interviewed 25 family physicians and 25 consultants (5 each in the specialties of internal medicine, obstetrics and gynecology, pediatrics, psychiatry and surgery) selected by their peers as being exemplary in their own practice setting. The results indicated that the participants had well-formulated concepts of exemplary practitioners, defining five main categories of performance: clinical competence, relationship with patients, availability, family physician-consultant relationship and a fifth category that included organizational ability and personality attributes. The family physicians and the consultants placed different values on these categories and indicated that these values might change under different clinical circumstances. Their concepts appear to be compatible with, but not restricted to, a model of contemporary medical practice based on an ethic specific to medicine.     

Risk of death and hospital admission for major medical events after initiation of psychotropic medications in older adults admitted to nursing homes

Background

Despite safety-related concerns, psychotropic medications are frequently prescribed to manage behavioural symptoms in older adults, particularly those with dementia. We assessed the comparative safety of different classes of psychotropic medications used in nursing home residents.

Methods

We identified a cohort of patients who were aged 65 years or older and had initiated treatment with psychotropics after admission to a nursing home in British Columbia between 1996 and 2006. We used proportional hazards models to compare rates of death and rates of hospital admissions for medical events within 180 days after treatment initiation. We used propensity-score adjustments to control for confounders.

Results

Of 10 900 patients admitted to nursing homes, atypical antipsychotics were initiated by 1942, conventional antipsychotics by 1902, antidepressants by 2169 and benzodiazepines by 4887. Compared with users of atypical antipsychotics, users of conventional antipsychotics and antidepressants had an increased risk of death (rate ratio [RR] 1.47, 95% confidence interval [CI] 1.14–1.91 for conventional antipsychotics and RR 1.20, 95% CI 0.96–1.50 for antidepressants), and an increased risk of femur fracture (RR 1.61, 95% CI 1.03–2.51 for conventional antipsychotics and RR 1.29, 95% CI 0.86–1.94 for antidepressants). Users of benzodiazepines had a higher risk of death (RR 1.28, 95% CI 1.04–1.58) compared with users of atypical antipsychotics. The RR for heart failure was 1.54 (95% CI 0.89–2.67), and for pneumonia it was 0.85 (95% CI 0.56–1.31).

Interpretation

Among older patients admitted to nursing homes, the risks of death and femur fracture associated with conventional antipsychotics, antidepressants and benzodiazepines are comparable to or greater than the risks associated with atypical antipsychotics. Clinicians should weigh these risks against the potential benefits when making prescribing decisions.Despite concerns about their safety, psychotropic medications are used frequently to manage behavioural symptoms in older adults, particularly in those who have dementia. These medications tend to be used because the effectiveness of psychosocial and behavioural interventions remains unclear, and because implementation of those alternate interventions is often hampered by a lack of resources.¹ In nursing homes, psychotropic agents are given to up to two-thirds of dementia patients.^2–5The safety of antipsychotic medications in older adults has been called into question. The United States Food and Drug Administration and Health Canada have issued advisories stating that certain atypical antipsychotics (risperidone, olanzapine and aripiprazole) have been associated with an increased risk of stroke and transient ischemic events, and both atypical and conventional antipsychotics have been associated with an increased risk of death.^6–11 Given this problematic safety record, physicians may increasingly resort to alternative psychotropic agents for management of behavioural symptoms in older adults.^1,12,13 However, comparative studies of the safety of other classes of psychotropic medications in such patients have not been conducted.In the absence of randomized controlled trials, pharmacoepidemiologic studies using large databases are the best option available for defining the comparative safety of the psychopharmacologic treatment regimens used to manage behavioural symptoms in older adults with dementia. Rigorous methodologic approaches need to be applied to ensure that epidemiologic studies are unbiased by the selective prescribing that occurs in nonrandomized studies.¹ We aimed to examine the association between various classes of psychotropic medications and a range of unintended health outcomes among older adults admitted to nursing homes. We focused on patients in nursing homes because use of psychotropic medication is known to be extensive in this setting,^2–5 and medication safety is of particular concern given the complex array of medical illnesses among these patients.     

Neuronal death in primary retinal cultures is related to nitric oxide production, and is inhibited by erythropoietin in a glucose-sensitive manner

The aim of this work was to investigate the interrelated effects of glucose, nitric oxide (NO) and erythropoietin on neuronal survival in retinal cultures, thereby exploring the mechanism of neuronal death in the diabetic retina. Rat retinal cells were cultured in low (5 mM) or high (15 mM) glucose concentrations. After 9 days, cell viability was assessed by (3,4,5-dimethylthiazol-2-yl)-2,5-diphenyl tetrazolium bromide (MTT) assay and NO production was determined by the Griess reaction. Immunohistochemistry was used to quantify GABA-labelled neurones and cells staining for DNA breakdown. High or low glucose concentrations had no effect on basal NO production or the survival of neurones in culture, but treatment with N-nitro-L-arginine methyl ester reduced extracellular levels of NO and increased neuronal survival at both concentrations of glucose. Erythropoietin decreased cell death and NO levels, but only in cultures grown in low concentrations of glucose. It is concluded that erythropoietin's neurotrophic function in the retina is attenuated at glucose concentrations similar to those which occur in diabetes.     

Prenosological approach to attaining the objectives of aviation medical expert assessment

Early diagnosis of diseases and conditions undesirable in terms of flight safety in senior pilots is tightly linked with the evaluation of disease risks. Prenosological diagnostics is focused on borderline states that may pass from health to disease (prenosology and premorbidity) and, vice versa, from disease to recovery (post-nosology). Regarding health as a vital adaptation reserve, prenosology diagnostics is concerned with the ability of the body to adapt to the environment rather than develop a disease. A constant drain of adaptation reserves may become the reason for increased risks of disease. Heart rate variability analysis is one of the instruments of prenosological diagnostics. The paper discusses the applicability of the space-medicine oriented probabilistic approach to the evaluation of adaptation risks by medical expert assessment boards certifying civil pilots. The results of two series of investigations showed increased adaptation risks and reduced functional reserves in pilots found unfit to continue their careers.     

Prevention and treatment of osteoporosis in short stay departments of nursing homes: a nursing home physician's task

This research shows that nursing home physicians might play an important part in the diagnostics and treatment of vitamin-D deficiency. 96 rehabilitating elderly who had undergone a hip operation were investigated. 36% had a vitamin-D deficiency (vitamin-D < 30 nmol/l). Vitamin-D deficiency was 53 % in the fracture group and 26% in the arthritis group. Deficiencies were treated with vitamin-D medication. After the patient's discharge the general practitioner was sent a questionnaire. The results show that general practitioners agree to nursing home physicians' investigating vitamin-D deficiencies and to nursing home physicians' initiating vitamin-D medication in case of a deficiency. The general practitioners themselves do not often investigate vitamin-D deficiency.     

Nursing home rehabilitation, functional independence and quality of life: a pilot study of somatic nursing home rehabilitation patients

In a pilot study of 18 patients the relation between nursing home rehabilitation, functional independence and quality of life was examined. Furthermore, measurement instruments and study design were evaluated. Nursing home rehabilitation proved to be associated with (partially significant) improvement in functional independence and quality of life. Provided the inclusion of a control group and an observation period of adequate duration, study design and measurement instruments seemed to be appropriate for application in a multicenter study.