The "CHROME criteria": Tool to optimize and audit prescription quality of psychotropic medications in institutionalized people with dementia.

OBJECTIVE: Describe and validate the CHROME (CHemical Restraints avOidance MEthodology) criteria. DESIGN: Observational prospective longitudinal study. SETTING: Single nursing home in Las Palmas de Gran Canaria, Spain. PARTICIPANTS: 288 residents; mean age: 81.6 (SD 10.6). 77.4% had dementia. INTERVENTION: Multicomponent training and consultancy program to eliminate physical and chemical restraints and promote overall quality care. Clinicians were trained in stringent diagnostic criteria of neuropsychiatric syndromes and adequate psychotropic prescription. MEASUREMENTS: Psychotropic prescription (primary study target), neuropsychiatric syndromes, physical restraints, falls, and emergency room visits were semi-annually collected from December 2015 to December 2017. Results are presented for all residents and for those who had dementia and participated in the five study waves (completer analysis, n=107). RESULTS: For the study completers, atypical neuroleptic prescription dropped from 42.7% to 18.7%, long half-life benzodiazepines dropped from 25.2% to 6.5%, and hypnotic medications from 47.7% to 12.1% (p<0.0005). Any kind of fall evolved from 67.3 to 32.7 (number of falls by 100 residents per year). Physicians' diagnostic confidence increased, while the frequency of diagnoses of neuropsychiatric syndromes decreased (p<0.0005). CONCLUSIONS: Implementing the CHROME criteria reduced the prescription of the most dangerous medications in institutionalized people with dementia. Two independent audits found no physical or chemical restraint and confirmed prescription quality of psychotropic drugs. Adequate diagnosis and independent audits appear to be the keys to help and motivate professionals to optimize and reduce the use of psychotropic medication. The CHROME criteria unify, in a single compendium, neuropsychiatric diagnostic criteria, prescription guidelines, independent audit methodology, and minimum legal standards. These criteria can be easily adapted to other countries.

A Smart Band for Automatic Supervision of Restrained Patients in a Hospital Environment.

Mechanical contention (MC) is a restrictive, vital but controversial measure, prescribed in the majority of EU countries to handle patients with psycho-motor agitation that do not respond to other types of intervention, with an imminent risk of physical violence and aggression involved. This last resort approach implies risks for the somatic health of the contained individual that go from trauma injuries to, in some extreme cases, sudden death. Despite these risks, somatic supervision and the monitoring of patients under MC is limited, being periodically and manually carried out by nursing personnel with portable equipment. In this context, ensuring continuous monitoring using fully automated equipment is an uncovered yet urgent need. There are several devices already in the market capable of monitoring vital signs, but they are not specifically designed for these type of patients and they can be expensive and/or difficult to integrate with other systems from a software perspective. The work described in this paper gives answers to these necessities with the introduction of a low-cost system, targeted at psychiatric patients, for the acquisition and wireless transmission in real-time of physiological parameters, making use of micro-controllers for collecting and processing sensor data, and WiFi technology to upload the information to the server where a patient's profile with all the relevant vital parameters resides. In addition to data collection and processing, an application aimed at use by nursing staff has also been developed to raise alerts in case any critical condition is detected.

Psychosocial Predictors of Anxiety in Nursing Home Staff.

OBJECTIVES: Although research shows that nursing home staff experience significant levels of stress and burnout, studies analyzing the relationship of psychosocial variables on their feelings of anxiety are scarce. This study aims to analyze the relationship between psychosocial variables and levels of anxiety among staff. METHOD: Participants were 101 nursing home professionals. In addition to anxiety, socio-demographic variables, depersonalization, burden, relationship with families of the residents, and guilt about the care offered to the residents were assessed. A hierarchical regression analysis was carried out to analyze the contribution of the assessed variables to staff anxiety levels. RESULTS: The obtained model explained 57% of the variance in anxious symptomatology. Guilt about the care offered and poor quality of the relationship with residents' family were associated with anxiety. Further, working at nursing homes where the staff report higher levels of anxiety symptoms, the presence of depersonalization and burden were also associated with anxiety. CONCLUSION: The findings suggest that in addition to work-related variables (burden and burnout), problems with family members and guilt about the care offered are relevant variables for understanding staff's anxious symptomatology. CLINICAL IMPLICATIONS: Interventions that address issues of guilt about the quality of care, and problematic relationships with family members of residents, may have potential to reduce staff anxiety and promote their well-being.

Syndrome-Based Prescription to Optimize Psychotropics: Are CHROME Criteria a Game Changer?

A variety of medical and social factors have contributed over the last decades to the overuse of psychotropic drugs in people with dementia. One social factor is probably the frequent failure to provide adequate person-centered care, be it in the community or in institutional settings. This unfortunate reality has been reacted upon with numerous guidelines to reduce prescriptions of the most dangerous drugs (e.g., neuroleptics). Each psychotropic drug prescription can in principle be assessed around three dimensions: (a) adequate, (b) inadequate, and (c) chemical restraint. The CHemical Restraints avOidance MEthodology (CHROME) defined chemical restraint as any prescription based on organizational convenience, rather than justified with medical diagnosis. Two validation studies revealed that one of the main medical reasons of over- and miss-prescriptions was symptom-based prescription. By switching to syndrome-based prescription, a large proportion of drugs could be de-prescribed and some re-adjusted or kept. Paucity of research and weakness of data are not conclusive about the adequacy of specific drugs for the myriad of cases presented by patients with dementia and comorbid conditions. Clinical practice, however, leads us to believe that even under optimal care conditions, psychotropics might still contribute to quality of life if based on an adequate diagnosis. This article explains the rationale that underlies a syndromic approach aimed at optimizing psychotropic treatment in people with dementia whose significant suffering derives from their thought, affective, or behavioral problems. The results of previous validation studies of this new methodology will be discussed and conclusions for future results will be drawn.

CHROME Criteria and Quality of Life: A Pilot Study from Maria Wolff-Albertia.

BACKGROUND: Over- and potentially inappropriate prescribing of psychotropic medications is a major public health concern among people with dementia. OBJECTIVE: Describe the CHemical Restraints avOidance MEthodology (CHROME) criteria and evaluate its effects on psychotropic prescribing and quality of life (QoL). METHODS: Observational, prospective, two-wave study conducted in two nursing homes. A multicomponent program to eliminate chemical restraints and attain quality prescription of psychotropic medications was implemented. CHROME's diagnostic criteria comprise constellations of behavioral and psychological symptoms of dementia under six primary syndromic diagnoses. Since pharmacologic treatment is aimed at only one syndrome, polypharmacy is avoided. Psychotropic prescription, QoL, neuropsychiatric symptoms (NPS), and other clinical measurements were collected before and one year after the intervention. Results are presented for all residents (n = 171) and for completer subjects (n = 115). RESULTS: Mean age (SD) of the residents was 87.8 (5.7), 78.9% were women, and 68.5% suffered advanced dementia. Psychotropic prescriptions decreased from 1.9 (1.1) to 0.9 (1.0) (p < 0.0005). Substantive reduction in prescribing frequency was observed for antidepressants (76.9% pre-intervention, 33.8% post-intervention) and for atypical neuroleptics (38.8% pre-intervention, 15.1% post-intervention). There was improvement in patient's response to surroundings (p < 0.0005) and total NPS (p < 0.01), but small worsening occurred in social interaction (p < 0.02, completer subjects). Safety measurements remained stable. CONCLUSION: CHROME criteria appear to optimize psychotropic prescriptions, avoid chemical restraints, and allow external verification of quality prescriptions. Extensive use seems feasible, related to substantial reduction of prescriptions, and of benefit for people with dementia as de-prescriptions are not associated to increased NPS or QoL loss.

Nonpharmacological therapies in Alzheimer's disease: a systematic review of efficacy.

INTRODUCTION: Nonpharmacological therapies (NPTs) can improve the quality of life (QoL) of people with Alzheimer's disease (AD) and their carers. The objective of this study was to evaluate the best evidence on the effects of NPTs in AD and related disorders (ADRD) by performing a systematic review and meta-analysis of the entire field. METHODS: Existing reviews and major electronic databases were searched for randomized controlled trials (RCTs). The deadline for study inclusion was September 15, 2008. Intervention categories and outcome domains were predefined by consensus. Two researchers working together detected 1,313 candidate studies of which 179 RCTs belonging to 26 intervention categories were selected. Cognitive deterioration had to be documented in all participants, and degenerative etiology (indicating dementia) had to be present or presumed in at least 80% of the subjects. Evidence tables, meta-analysis and summaries of results were elaborated by the first author and reviewed by author subgroups. Methods for rating level of evidence and grading practice recommendations were adapted from the Oxford Center for Evidence-Based Medicine. RESULTS: Grade A treatment recommendation was achieved for institutionalization delay (multicomponent interventions for the caregiver, CG). Grade B recommendation was reached for the person with dementia (PWD) for: improvement in cognition (cognitive training, cognitive stimulation, multicomponent interventions for the PWD); activities of daily living (ADL) (ADL training, multicomponent interventions for the PWD); behavior (cognitive stimulation, multicomponent interventions for the PWD, behavioral interventions, professional CG training); mood (multicomponent interventions for the PWD); QoL (multicomponent interventions for PWD and CG) and restraint prevention (professional CG training); for the CG, grade B was also reached for: CG mood (CG education, CG support, multicomponent interventions for the CG); CG psychological well-being (cognitive stimulation, multicomponent interventions for the CG); CG QoL (multicomponent interventions for PWD and CG). CONCLUSION: NPTs emerge as a useful, versatile and potentially cost-effective approach to improve outcomes and QoL in ADRD for both the PWD and CG.

How did the surgeons treat neonates with imperforate anus in the eighteenth century?

Anorectal malformations (ARMS) are one of those challenging topics of pediatric surgery. The developments in assessing and approaching patients with these anomalies have been made in the last decades and the methods described in older textbooks functioned as a guide in planning these attempts (Kiely and Peña in Pediatric surgery, Mosby, Missouri, pp 1425-1449, 1998; Grosfeld in Anorectal malformations in children, Springer-Verlag, Berlin, pp 3-15, 2006). The aim of this study is to present the attitude of a surgeon of eighteenth century to the treatment of anorectal malformations, and the evolution in the history of the anomaly. The part about imperforate anus in a textbook of surgery, found in a second-hand bookstore, was translated. The description and the classification of the anomaly, the methods of approaching these cases together with some case reports were presented and compared with today's practice. The historical background of the anomaly was evaluated not only with regard to the book of Heister specifically but also to the other data obtained in the literature. The anomaly was reported to be "not rarely" observed. The obstetricians were warned to examine a newborn baby completely for early diagnosis. The classification of the anomaly was made according to the properties of the membrane covering the anus but prompt treatment, initiating with its simple excision, was suggested in all types. Better results in cases whose anus was covered with a thin, delicate membrane were reported. The results show that routine neonatal examination for all babies was recommended in this Textbook of Surgery which had been published 260 years ago. The physical deterioration due to delay was well described. A broad classification of imperforate anus was made and successful outcome in low-type anomalies of today was reported with some case samples. It is clear that all the efforts starting from Soranus until today improved the understanding of the anomaly. Combining previous information with today's practice in the meetings focused totally on anorectal malformations, where the leading surgeons shared their experiences and re-evaluated the problems encountered, enlightened the future status of this interesting topic of pediatric surgery.

Thermal and Chemical Treatments To Reduce Salmonella on Alfalfa (Medicago sativa) and Broccoli (Brassica oleracea var. italica) Seeds before and during the Sprouting Process: A Hurdle Approach.

Sprouts are vehicles of foodborne diseases caused by pathogens such as Salmonella. The aim of this study was to evaluate thermal and chemical treatments applied as a hurdle approach to reduce Salmonella in alfalfa (Medicago sativa) and broccoli (Brassica oleracea var. italica) seeds before and during their germination. Seeds, inoculated and then dried at 55°C for 48 h, were subjected to a chemical treatment and a thermal shock with (i) 75 mM caprylic acid at 70°C for 5 s, (ii) 0.04% CaO at 70°C for 5 s, or (iii) 1% H2O2 at 70°C for 5 s. After each treatment, seeds were immersed in water at 3°C for 5 s. Next, the imbibition process was carried out with 0.016% H2O2 at pH 3.0. Finally, the seeds were transferred to a rotary drum-type germinator and were sprayed with the same chemical solution that was applied before the imbibition process, for 20 s at intervals of 5 min for 40 min at 3 rpm. All chemical treatments reduced Salmonella at least 5 log CFU/g on both seeds. Germination rates between 90 and 93% were obtained after application of thermal and chemical treatments. Salmonella was not detected after the imbibition stage when caprylic acid and H2O2 treatments were applied. However, during the germination process of both seeds, Salmonella counts of >6 log CFU/g were obtained despite all treatments being applied at different stages of the sprouting process. These results demonstrated that thermal and chemical treatments used as a hurdle approach to control Salmonella on alfalfa and broccoli seeds significantly reduced the pathogen concentration on seeds >5 log but were ineffective to eliminate Salmonella and to control its growth during the sprouting process. The production of safe sprouts continues to be a major challenge for industry.

Reducing Physical Restraints in Nursing Homes: A Report From Maria Wolff and Sanitas.

OBJECTIVE: Physical restraints are associated with severe side effects and suffering. A comprehensive, person-centered, methodology was implemented in 41 Spanish nursing homes to safely eliminate restraints. METHODS: Data were collected in 2 waves: September 2011 (at the beginning of the intervention, n = 4361) and September 2014 (n = 5051). Use of 10 different types of physical restraints was recorded, as well as frequency of psychotropic medication prescription, falls, and mortality. RESULTS: Mean age was 83.4 (SD 8.5) and 63.5% of the residents had dementia. Frequency (95% confidence interval) of people having at least 1 restraint was reduced from 18.1% (17.0-19.3) to 1.6% (1.3-2.0). Use of benzodiazepines was also reduced, with no significant changes in other psychotropic medications and mortality. The rate of total falls increased from 13.1% (12.1-14.1) to 16.1% (15.1-17.1), with no significant increase in injurious falls. CONCLUSION: Physical restraints can almost completely be eliminated with reasonable levels of safety.

Cognitive-motor intervention in Alzheimer's disease: long-term results from the Maria Wolff trial.

BACKGROUND: Little is known about the long-term acceptance and effects of cognitive and motor stimulation interventions (CMSI) in Alzheimer's disease (AD). OBJECTIVE: To evaluate a replicable CMSI program for mild cognitive impairment (MCI) and mild-to-moderate AD persons. METHODS: Eighty-four non-institutionalized subjects with AD were randomized to receive either CMSI, administered by a single care provider, or standard support. Cognition, activities of daily living (ADL), mood, and study partner's subjective burden were assessed by blinded raters. Data on institutionalization, psychiatric medications, and demise were collected by the study physicians. Random effects model and survival analyses were conducted, after 2 and 3 years of study. RESULTS: Three-year assessments could be performed by the physician in 85% and by the blinded rater in 66% of subjects. Significant benefits were observed in basic ADL at the 2- and 3-year assessments, whereas instrumental ADL showed benefits only up to the second year of intervention (p < 0.05). CONCLUSION: Long-term cognitive-motor stimulation is well accepted and produces functional benefits in subjects with AD, with no extra subjective burden in the partner.

Psychotropic medications and falls in nursing homes: a cross-sectional study.

BACKGROUND: Psychotropic medications are very frequently used in nursing homes and have been associated with falls. Little is known on the potential differences between types and subtypes of these medications, and also regarding different prescription patterns. METHODS: Data from 4502 residents living in 41 nursing homes belonging to a Spanish private chain were collected during a study period of 1 month and analyzed. Frequency of injurious and noninjurious falls were investigated for the following groups of psychotropic medications: typical neuroleptics; atypical neuroleptics; antidepressants; short and middle half-life benzodiazepines (BZD); long half-life BZD; BZD (of any type) administered only if needed; other hypnotic, sedative or anxiolytic drugs; cholinesterase inhibitors, and memantine. OR (95% CI) were calculated using regression analysis adjusted for age, sex, number of medications, physical restraint, and cognitive performance. RESULTS: Mean age (SD) was 84.3 (8.6) and 73.4% of the subjects were female. Psychotropic medication was prescribed to 2987 residents (66.3%), and there were 490 falls. Total falls were associated with use of atypical neuroleptics (OR 1.50, CI 1.17‒1.94), antidepressants (OR 1.36, CI 1.03‒1.78), short and middle half-life BZD (OR 1.27, CI 1.00‒1.60), long half-life BZD (OR 1.65, CI 1.14‒2.38), cholinesterase inhibitors (OR 1.42, CI 1.05‒1.92), and memantine (OR 1.90, CI 1.32‒2.74). Injurious falls were associated with typical neuroleptics (OR 1.77, CI 0.99‒3.17), atypical neuroleptics (OR 1.64, CI 1.11‒2.44), and long half-life BZD (OR 2.57, CI 1.56‒4.25). The use of 2 or more psychotropics in combination was also associated with a significant increase of total falls and injurious falls. CONCLUSIONS: Psychotropic medications were highly prescribed in the studied sample and were associated with falls. The most unsafe profile was detected for long half-life BZD, neuroleptics, and psychotropics in combination.

The comparison of cognitive and functional performance in children and Alzheimer's disease supports the retrogenesis model.

The retrogenesis model states that the progression of brain aging and Alzheimer's disease (AD) deterioration proceeds inversely to human ontogenic acquisition patterns. Our aim was to assess if the progressive decline of cognitive abilities and functional capacity in AD follows an inverse sequence of acquisition compared to normal developmental patterns. One hundred eighty one children ranging in age from 4 to 12 years and 148 adults (cognitively normal, subjects with mild cognitive impairment, and mild-moderately severe AD) were assessed with the same cognitive and functional tools. The statistical analyses showed a progressive and inverse distribution on cognitive, functional, and mental age scores when comparing results of children classified by chronological age and patients by dementia staging. The pattern of cognitive acquisition in children showed a progressive development of overall cognitive function along all age ranges, in addition to a simultaneous acquisition of instrumental and basic daily living activities in the functional domain. AD patients showed a progressive decline in cognitive and functional domains, which concurs with the sequence of impairment reported in this dementia. Our findings provide support to the inverse and progressive pattern of functional and cognitive decline observed in AD patients compared to the developmental acquisition of these capacities in children, as stated by the retrogenesis model. Nonetheless, certain differences should be considered when comparing the sequence of acquisition during ontogenic development with that of progressive loss during the course of AD. Retrogenesis may account for the progressive loss of neocortical-related functions in AD.

Quality of life (QoL) in community-dwelling and institutionalized Alzheimer's disease (AD) patients.

The purpose of this study was to describe and compare QoL and its determinants in two groups of patients with AD that differed in place of residence: community or nursing home. This study covered 200 patients with AD (mean age 79.3 ± 8.2 years, 74% female). Fifty-four per cent of the subjects were living in a nursing home and 46% lived at home. QoL was measured using the Alzheimer's Disease Related Quality of Life Scale (ADRQL). The ADRQL was answered by the family caregiver (community group) or the professional caregiver (nursing home group). Descriptive statistics, Chi-square test, Mann-Whitney test and multiple regression analysis were used to compare sociodemographic and clinical variables between the two study groups. The institutionalized patients were predominantly women (87.0% vs. 58.7%, p<0.001), were older (84 years vs. 74 years, p<0.001), and had more advanced dementia (Global Deterioration Scale (GDS)>5 79.6% vs. 19.6%, p<0.001). ADRQL total score was higher (i.e., better QoL) for patients living at home than for institutionalized patients (72.6 ± 19.9 vs. 64.8 ± 18.2, p<0.01). Neuropsychiatric symptoms, severity of dementia, depression and functional dependence were significant predictors of worst QoL. Once those variables were controlled a marginal effect of setting on QoL was found, which favored the nursing home (ß=0.20, p<0.05).

Caregivers' estimation of patients' quality of life (QoL) in Alzheimer's disease (AD): an approach using the ADRQL.

The purpose of this study was to describe the QoL of patients with AD (PAD) as perceived by family caregivers, and to analyze the correlates of such QoL. This study covered 92 PAD enrolled in a cognitive-motor stimulation study. The severity of cognitive impairment ranged from mild cognitive impairment to severe dementia. QoL was measured using the AD-related quality of life (ADRQL) scale. Social and clinical variables (for both PAD and caregiver) as well as other variables relating to cognition, activities of daily living (ADL), behavior, mood and caregiver burden were recorded. Spearman correlation coefficients and multivariate linear regression analysis were used to analyze the correlates of ADRQL (global score and subscores). Behavior and basic ADL were the best predictors of global QoL (coefficient of determination R(2)=0.57, p<0.0005). Cognition contributed marginally to global QoL (R(2)=0.03, p<0.05). The following variables were specifically associated with ADRQL subscores: household income (lower response to surroundings, R(2)=0.11), instrumental ADL (less awareness of self, R(2)=0.09), mood (better feelings and mood, R(2)=0.04), caregiver caring for another dependent person (higher social interaction, R(2)=0.04), and caregiver burden (worse feelings and mood, R(2)=0.03). In conclusion, the main determinants of QoL in PAD are functional capacities and behavior. Other medical, psychological and social variables could also be contributing to specific aspects of QoL on an individual basis.