Organisation and integrated healthcare approaches for people living with HIV, multimorbidity, or both: a systematic review.

BACKGROUND: Universal recommendation for antiretroviral drugs and their effectiveness has put forward the challenge of assuring a chronic and continued care approach to PLHIV (People Living with HIV), pressured by aging and multimorbidity. Integrated approaches are emerging which are more responsive to that reality. Studying those approaches, and their relation to the what of delivery arrangements and the how of implementation processes, may support future strategies to attain more effective organizational responses. METHODS: We reviewed empirical studies on either HIV, multimorbidity, or both. The studies were published between 2011 and 2020, describing integrated approaches, their design, implementation, and evaluation strategy. Quantitative, qualitative, or mixed methods were included. Electronic databases reviewed cover PubMed, SCOPUS, and Web of Science. A narrative analysis was conducted on each study, and data extraction was accomplished according to the Effective Practice and Organisation of Care taxonomy of health systems interventions. RESULTS: A total of 30 studies, reporting 22 different interventions, were analysed. In general, interventions were grounded and guided by models and frameworks, and focused on specific subpopulations, or priority groups at increased risk of poorer outcomes. Interventions mixed multiple integrated components. Delivery arrangements targeted more frequently clinical integration (n = 13), and care in proximity, community or online-telephone based (n = 15). Interventions reported investments in the role of users, through self-management support (n = 16), and in coordination, through multidisciplinary teams (n = 9) and continuity of care (n = 8). Implementation strategies targeted educational and training activities (n = 12), and less often, mechanisms of iterative improvement (n = 3). At the level of organizational design and governance, interventions mobilised users and communities through representation, at boards and committees, and through consultancy, along different phases of the design process (n = 11). CONCLUSION: The data advance important lessons and considerations to take steps forward from disease-focused care to integrated care at two critical levels: design and implementation. Multidisciplinary work, continuity of care, and meaningful engagement of users seem crucial to attain care that is comprehensive and more proximal, within or cross organizations, or sectors. Promising practices are advanced at the level of design, implementation, and evaluation, that set integration as a continued process of improvement and value professionals and users' knowledge as assets along those phases. TRIAL REGISTRATION: PROSPERO number CRD42020194117.

The Utilisation of Payment Models Across the HIV Continuum of Care: Systematic Review of Evidence.

The increasing chronicity and multimorbidities associated with people living with HIV have posed important challenges to health systems across the world. In this context, payment models hold the potential to improve care across a spectrum of clinical conditions. This study aims to systematically review the evidence of HIV performance-based payments models. Literature searches were conducted in March 2020 using multiple databases and manual searches of relevant papers. Papers were limited to any study design that considers the real-world utilisation of performance-based payment models applied to the HIV domain. A total of 23 full-text papers were included. Due to the heterogeneity of study designs, the multiple types of interventions and its implementation across distinct areas of HIV care, direct comparisons between studies were deemed unsuitable. Most evidence focused on healthcare users (83%), seeking to directly affect patients' behaviour based on principles of behavioural economics. Despite the variability between interventions, the implementation of performance-based payment models led to either a neutral or positive impact throughout the HIV care continuum. Moreover, this improvement was likely to be cost-effective or, at least, did not compromise the healthcare system's financial sustainability. However, more research is needed to assess the durability of incentives and its appropriate relative magnitude.

RESUMEN: La creciente cronicidad y multimorbilidades asociadas con las personas que viven con el VIH han planteado importantes desafíos para los sistemas de salud en todo el mundo. En este contexto, los modelos de pago tienen el potencial de mejorar la atención en un espectro de condiciones clínicas. Este estudio tiene como objetivo revisar sistemáticamente la evidencia de los modelos de pagos basados ​​en el desempeño aplicados al dominio del VIH. Las búsquedas bibliográficas se realizaron en marzo de 2020 utilizando múltiples bases de datos y búsquedas manuales de artículos relevantes. Los artículos se limitaron a cualquier diseño de estudio que considere la utilización en el mundo real de modelos de pago basados ​​en el desempeño aplicados al dominio del VIH. Se incluyeron un total de 23 artículos de texto completo. Debido a la heterogeneidad de los diseños de los estudios, los múltiples tipos de intervenciones y su implementación en distintas áreas de la atención del VIH, las comparaciones directas entre diferentes estudios se consideraron inadecuadas. La mayoría de la evidencia se centró en los usuarios de la salud (83%), buscando afectar directamente el comportamiento de los pacientes basándose en los principios de la economía del comportamiento. A pesar de la variabilidad entre las intervenciones, la implementación de modelos de pago basados ​​en el desempeño generó un impacto neutral o positivo en todo el proceso de atención del VIH. Además, es probable que esta mejora sea costo-efectiva o, al menos, no comprometa la sostenibilidad financiera del sistema de salud. Sin embargo, se necesita más investigación para evaluar la durabilidad de los incentivos y su magnitud relativa apropiada.

Resilience in Very Advanced Ages: A Study With Centenarians.

This study intends to assess the relationship between resilience in extremely long-lived individuals and sociodemographic, cognitive and health status variables, and significant life events. A selected sample of 48 centenarians (mean age = 100.8 years, SD = 1.2; 83.3% female) from two centenarian studies was considered. A resilience score covering five items (aging and usefulness, hopefulness, worryness, loneliness, and control) was considered. Multivariable linear regression analyses were conducted in order to identify predictors of resilience. No significant differences in the resilience score regarding sociodemographic variables or typology of significant life events were found. Our findings underscore that health perception (better) and pain (less frequent) were associated with higher levels of resilience. In being present in extremely long-lived individuals, resilience should be object of interest in further research.

Psychiatric disorders as main discharge diagnosis by the Portuguese oldest old from 2000 to 2014: exploring national acute inpatient admissions.

ABSTRACTBackground:Mental health problems have been reported as one of the principal causes of incapacity and morbidity. According to the World Health Organization approximately 15% of adults aged 60+ and over suffer from a mental disorder. In the oldest old population, a higher deterioration in the mental state is expected, which is ought to increase the risk of incidence of mental problems and use of healthcare services. The aim of this study is to examine inpatient episodes with a mental disorder coded as primary discharge diagnosis between 2000 and 2014 by patients aged 80+ in Portugal mainland. METHOD: Exploratory descriptive analyses of data regarding the number of episodes and coded diagnosis on admission were performed. RESULTS: From a total of 1,837,613 inpatient episodes, 16,430 (0.9%) correspond to episodes having a psychiatric disorder as a primary discharge diagnosis. Delirium, dementia and amnestic and other cognitive disorders (60.1%), alcohol-related disorders (17.7%) and mood disorders (8.6%) were the most common diagnosis. An analysis by age group revealed that among octogenarians and nonagenarians delirium, dementia, and amnestic and other cognitive disorders were the most common diagnosis; in the centenarian group; however, these were outweighed by alcohol-related disorders. CONCLUSIONS: Findings from this study document the importance of neurocognitive disorders as a primary reason for hospitalization in the oldest old, but also highlights the need of paying attention to other mental disorders among this age group. Further studies should examine the prevalence of medical comorbidities in patients with mental disorders.

Caring for a centenarian parent: an exploratory study on role strains and psychological distress.

OBJECTIVES: This study examined the main sources of strain and the presence of psychological distress in a sample of centenarians' children who assumed the role of primary caregivers. METHOD: A sample of 43 children (M age = 67.10 ± 6.67 years; 90.7% female) caring for a centenarian parent was interviewed and asked about their overall caregiving experience. Information on caregiving burden (Zarit Burden Interview) and psychological distress (Hospital Anxiety and Depression Scale) was also obtained. Several characteristics of the caregiving dyads (e.g. age, co-residence) were tested to compare caregivers with and without anxiety and depressive symptoms. Qualitative data from the interviews were analysed for recurrent themes using thematic analysis. RESULTS: Main caregiving impacts concern social and leisure dimensions (role captivity), with important personal mid-life and late-life plans needing to be changed or postponed. Centenarians' children present higher levels of anxiety (M = 6.95 ± 4.7) than depression (M = 6.0 ± 4.1), and psychological distress was found to be significantly associated with high subjective burden, low life satisfaction, poorer perceived health, and perceived income inadequacy. CONCLUSION: The significant levels of psychological distress, along with the loss of autonomy and incapacity to prosecute plans for retirement, reinforce the psychological demands of late-life caregiving. Paying attention to these relationships is imperative to promote adequate responses for these caregivers.

Health Status, Living Arrangements, and Service Use at 100: Findings From the Oporto Centenarian Study.

This paper describes the sociodemographic characteristics, health status, and service use of centenarians living in the community and centenarians residing in an elder care facility/nursing home and examines their main differences. Participants were 140 centenarians from the population-based Oporto Centenarian Study (Mage = 101.2; SD = 1.6). Main findings revealed that the majority of the centenarians lived at home with their family members (57.9%). Increased health care needs, living alone, and family caregiving constraints were the most common reasons for entering a nursing home. Community-dwelling centenarians were cared for mostly by their children and were less dependent and in better cognitive health than those who resided in a nursing home. Differences were found in the pattern of health service use according to the centenarians' residence, ability to pay medical expenses, and dependency level. Findings highlight the need for an accurate assessment of caregiving support systems, particularly family intergenerational duties, and of the factors constraining the access and use of health and social services. Policy makers may be guided by the insights gained from this research and work toward improvement of support options and removal of barriers to service access.

[Montessori method applied to dementia - literature review]. / Método de Montessori aplicado à demência - revisão da literatura.

The Montessori method was initially applied to children, but now it has also been applied to people with dementia. The purpose of this study is to systematically review the research on the effectiveness of this method using Medical Literature Analysis and Retrieval System Online (Medline) with the keywords dementia and Montessori method. We selected lo studies, in which there were significant improvements in participation and constructive engagement, and reduction of negative affects and passive engagement. Nevertheless, systematic reviews about this non-pharmacological intervention in dementia rate this method as weak in terms of effectiveness. This apparent discrepancy can be explained because the Montessori method may have, in fact, a small influence on dimensions such as behavioral problems, or because there is no research about this method with high levels of control, such as the presence of several control groups or a double-blind study.

Health care utilization in very advanced ages: A study on predisposing, enabling and need factors.

This study aims to examine the effects of predisposing, enabling, and need factors on healthcare utilization in advanced age. Data from a sample of 270 Portuguese community-dwelling persons aged ≥80 years was used. Face-to-face interviews were conducted and included the application of a research protocol addressing a set of sociodemographic and health-related variables that expressed the Andersen Behavioral model (i.e., predisposing, enabling, and need factors). Predictors of visits to general practitioners (GP) and specialist physicians, as well as emergency department (ED) use and hospitalizations were investigated. Multivariate linear and logistic regression analyzes were used to model the effects of predictor factors specified in the Andersen Behavioral model. Our findings underscore that younger age and having multimorbidity were significantly associated with having GP visits. Specialist physician visits were associated with younger age and a higher number of daily medications. ED use was associated with being male, having formal social support and a higher number of daily medications. Hospitalizations were associated with being younger, being male and having multimorbidity. Our findings revealed that need and predisposing factors determined the most healthcare use.

The Modified Caregiver Strain Index: Portuguese version.

The Modified Caregiver Strain Index is a widely used tool to screen for caregiver strain in family caregivers. This study presents the Portuguese version of the Modified Caregiver Strain Index and explores its psychometric properties in a sample of 347 informal caregivers of older dependent individuals. Factor analysis revealed a two-factor structure and indicated satisfactory internal consistency. Criterion-related validity was supported by positive significant correlations with the emotional health of the caregiver (psychological distress). The findings show evidence of reliability and validity of the Portuguese version of the Modified Caregiver Strain Index encouraging its use in clinical and research fields.

Perceived risk of institutionalization, hospitalization, and death in oldest old primary care patients.

OBJECTIVES: This study aims to analyze the accuracy and predictive ability of the Risk Instrument for Screening in the Community (RISC) scored by general practitioners (GPs) in a sample of primary care patients aged 80+ with perceived mental health concerns. METHOD: GPs ranked the perceived risk of the three adverse outcomes (hospitalization, institutionalization and death) at 1 year in a five Likert scale (RISC score), where 1 is the lowest risk and 5 is the highest. Follow up contacts were conducted after 1 year of assessment in order to collect data on the three outcomes. RESULTS: The 1-year proportion of institutionalization, hospitalization and death were 12.1 %, 25.2 % and 19.0 % respectively. Based upon the sensitivity and specificity from the Receiver Operating Characteristic (ROC) curves, we found an optimal cut-off point of ≥4 for the RISC. The RISC had fair accuracy for 1-year risk of institutionalization (Area Under the ROC curve (AUC) = 0.75, 95% CI 0.43-0.68) and hospitalization (AUC = 0.65, 95% CI 0.52-0.78), but not for death (AUC = 0.55, 95% CI 0.43-0.68). CONCLUSIONS: The RISC as a short global subjective assessment is to be considered a reliable tool for use by GPs. Our results showed that RISC seems to be a good instrument to triage very old people at risk for institutionalization but with poor accuracy at predicting hospitalization and limited predictive ability for death, suggesting further research and caution on this instrument's use.

Positive aspects of care in informal caregivers of community-dwelling dementia patients.

WHAT IS KNOWN ON THE SUBJECT?: Positive aspects of care are considered an essential part of caregiving research. They have been related to a wide range of dimensions of the caregiving circumstances, but there are few valid, reliable and brief measures to assess them. One of the most frequently used internationally is the Positive Aspects of Caregiving (PAC) scale, whose psychometric properties have received little attention. WHAT THE PAPER ADDS TO EXISTING KNOWLEDGE?: The present study analyses the psychometric properties of the Portuguese version of the PAC scale in a sample of informal caregivers of someone with dementia and further explores the association of different factors (e.g. caregiver health, sociodemographic variables) with the PAC. The Portuguese version of PAC scale presented good psychometric characteristics, and the factor analysis revealed the presence of two factors: affirming self and enriching life. Our study also verified that higher levels of PAC are more likely to be associated with better caregiver health perception, lower levels of psychological distress and burden, the care recipient's older age, providing care to more than one care recipient, not receiving social support services and not considering institutionalizing the care recipient. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: Findings from this study can assist professionals, including mental health nurses, to develop and implement effective interventions that help dementia caregivers to maintain their emotional health by identifying and focusing specific positive aspects of care. The study stresses the Portuguese version of the PAC scale as a reliable and valid measure for practice. ABSTRACT: Introduction Positive aspects of care refer to the psychosocial benefits of caregiving. The Positive Aspects of Caregiving (PAC) scale is one of the instruments most frequently used internationally, but its psychometric properties and correlates within the caregiving experience have received limited attention. Aim To examine the factorial structure of the Portuguese version of PAC scale and to analyse background and contextual factors that are more likely to be associated with higher levels of PAC. Method The PAC scale, a sociodemographic questionnaire and measures assessing burden and physical and mental health were administered to 204 informal caregivers of dementia patients. Results Exploratory factor analysis revealed a two-factor structure; internal consistency was adequate. Higher scores were negatively correlated with caregiver burden and distress. Better health perception, care recipient's older age, providing care to more than one care recipient and overall self-reliance were correlated with higher levels of PAC. Discussion The PAC scale was found to be a reliable and valid measure. Dementia caregiving circumstances and caregivers' and care receivers' characteristics play an important role for the presence of PAC, but relate distinctively with its dimensions. Implications for Practice Findings can help mental health nurses to recognize distinctive relations between PAC and caregiving variables.

Regional differences in morbidity profiles and health care use in the oldest old: Findings from two Centenarian Studies in Portugal.

BACKGROUND: The worldwide increase of human life expectancy and the rapid aging of the population will contribute to an increasing prevalence of chronic illness. Even so, individuals who reach very advanced ages often postpone or escape age-related diseases that are common causes of death. OBJECTIVE: This article aims to examine health-related characteristics of two distinct samples of Portuguese centenarians (one predominantly rural - PR vs. one predominantly urban - PU), and explore potential dissimilarities in their morbidity profiles and use of health care services. METHODS: A total of 241 centenarians were considered. Sociodemographic characteristics, health status, and use of health care services were assessed by semi-structured interviews with the centenarians and their proxies (family or formal caregiver). RESULTS: A higher average of 4.80 self-reported illnesses (sd = 2.01) were found in the PU sample (vs. 2.96; sd = 1.77 in the PR sample); in overall the PR sample presented a better health condition with lower levels of physical and mental impairments, and a greater number of centenarians who did not succumb to the three most common lethal diseases (heart disease, non-skin cancer and stroke) in the elderly population (85.4% vs. 60% in the PU sample). CONCLUSIONS: Portuguese centenarians experienced a substantial number of illnesses, but an overall better health status was found in centenarians from the PR area. By providing distinctive health-related profiles, our findings suggest the importance of contextual factors in shaping how very advanced ages may be achieved.

Functional, Sensorial, Mobility and Communication Difficulties in the Portuguese Oldest Old (80+).

INTRODUCTION: The ageing of populations is evident in most developed countries, and the oldest old group is one of the segments with the fastest growing. The aim of this paper is to examine sociodemographic and health related characteristics of the portuguese oldest old, using a census-based approach. MATERIAL AND METHODS: A descriptive study considering all residents aged 80 years and older at the time of the 2011 Census (n = 532 219) was conducted. Information on sociodemographic characteristics, sensory functions (seeing, hearing), functional status (walking/climbing stairs, bathing/dressing alone), cognition (memory/concentration), and communication (understanding others/being understood) as assessed by the Portuguese census official questionnaires were analyzed. RESULTS: Findings revealed that most of the oldest old are women (64.5%), widowed (53.9%), illiterate (46.1%) and live in private households (88.8%). Walking/climbing stairs (57.1%), vision (39.1%) and hearing (35.1%) were the dimensions where the oldest old presented major constrains. In parallel, understanding others/being understood (25.9%) and memory/concentration (34.4%) were the dimensions with lower percentages of difficulties. Significant differences were found between octogenarians/nonagenarians and centenarians for vision, walk/climb stairs, and bathing/dressing alone, with centenarians presenting a higher percentage of difficulties. DISCUSSION: Portuguese oldest old showed significant difficulties in activities of daily living, nevertheless cognitive and communication capacities seem to be commonly maintained. Taken together, these findings suggest the need for functional assistance, which can be ultimately managed by the older person him/herself. CONCLUSION: Based on the observed differences between centenarians and younger oldest old, specific interventions should be equated to better respond to their potentially distinctive needs.

Introdução: O envelhecimento da população é evidente na maioria dos países desenvolvidos, e o grupo dos muito idosos é um dos segmentos da população com mais rápido crescimento. O objetivo deste estudo é analisar as características sociodemográficas e de saúde dos muito idosos portugueses, usando uma abordagem baseada nos dados dos censos populacionais. Material e Métodos: Foi conduzido um estudo descritivo considerando todos os residentes com 80 ou mais anos à data dos Censos 2011 (n = 532 219). Os dados dos questionários dos Censos acerca das características sociodemográficas, funções sensoriais (visão, audição), estado funcional (andar/subir degraus, tomar banho/vestir-se sozinho), cognição (memória/concentração) e comunicação (compreender os outros/fazer-se entender) foram analisados. Resultados: Os resultados revelaram que a maioria dos muito idosos são mulheres (64,5%), viúvos (53,9%), analfabetos (46,1%) e vivem em contexto domiciliar (88,8%). Andar/subir degraus (57,1%), visão (39,1%) e audição (35,1%) foram as dimensões onde os muito idosos apresentavam maiores constrangimentos. Em paralelo, compreender os outros/fazer-se entender (25,9%) e memória/ concentração (34,4%) foram as dimensões com percentagens mais baixas de dificuldade. Foram encontradas diferenças significativas entre a população octogenária/nonagenária e a população centenária para a visão, andar/subir escadas, e tomar banho/vestir-se sozinho, com os centenários a apresentarem uma maior percentagem de dificuldade. Discussão: Os muito idosos portugueses apresentam dificuldades significativas nas atividades de vida diária, contudo, as capacidades cognitivas e de comunicação parecem ser comummente mantidas. Em conjunto, estes resultados sugerem a necessidade de assistência funcional, mas que pode ser, em última instância, gerida pelo próprio idoso. Conclusão: Considerando as diferenças observadas entre os centenários e os idosos mais jovens, devem ser equacionadas intervenções capazes de responder às necessidades potencialmente específicas de cada grupo.

Pathways after inpatient admission in very advanced age: A Portuguese nationwide study.

INTRODUCTION: Oldest old patients often have complex and multiple medical conditions, which are associated with higher rates of use of healthcare services, and a higher risk of experiencing adverse outcomes, such as mortality. This study investigated (a) the in-hospital mortality rate and predictors in patients aged 80+; (b) the destination patients have after hospital discharge. METHODS: Nationwide study. All inpatient admissions by individuals aged 80 years and older between 2011 and 2014 in Portugal were considered. Exploratory descriptive analyses of data regarding in-hospital mortality and destination after discharge were performed; multivariate logistic regression analyses were conducted to identify predictors of in-hospital mortality. RESULTS: A total of 614,807 episodes of hospital admissions were analysed. A mortality rate of 15.4% was observed. In the majority of episodes, patients returned home (78.6%). Increased age, male gender, increased length of stay, unplanned attendance, medical DRG type, increased severity of illness and mortality risk, and comorbidities were significant predictors of in-hospital mortality. DISCUSSION: This study strengthens the importance of implementing health policies specifically to the oldest old, namely with the promotion of the use of primary care services. That would expectably concur to a better management of the most common medical conditions in this population, and a decrease in hospital unplanned attendances.

Hospital admissions by the oldest old: Past trends in one of the most ageing countries in the world.

AIM: To examine discharges of octogenarians, nonagenarians and centenarians from Portuguese public hospitals, namely admission type, principal diagnoses, comorbidities and length of stay. METHODS: The present study used administrative data from public acute care hospitals in the Portuguese National Health Service. All discharges of persons aged ≥80 years between 2000 and 2014 were analyzed. HCUP Clinical Classifications Software was considered to aggregate principal diagnosis, and comorbidities were assessed using the Charlson Comorbidity Index computed using International Classification of Diseases 9th Revision Clinical Modification codes. RESULTS: A total of 2 494 924 discharges of persons aged 80 years or older were registered. Most (73.7%) referred to inpatient episodes, of which 73% were unplanned and medical (non-surgical). Pneumonia (12.2%), acute cerebrovascular disease (7.1%) and non-hypertensive cardiac heart failure (5.3%) were the most common principal diagnoses among inpatient episodes. Congestive heart failure and diabetes without chronic complications were the two most frequent comorbidities (16.6%), and discharge diagnoses with higher median length of stay were tuberculosis, burns, and infective arthritis and osteomyelitis. CONCLUSIONS: The number of hospitalizations of the oldest old has suffered a significant increase in the past few years, reinforcing the need for healthcare services being prepared to the specificities of the oldest old population. Geriatr Gerontol Int 2017; 17: 2255-2265.

ß-Adrenergic modulation of cancer cell proliferation: available evidence and clinical perspectives.

PURPOSE: In this review, we aimed to present and discuss the available preclinical and epidemiological evidences regarding the modulation of cancer cell proliferation by ß-adrenoceptors (ß-AR), with a specific focus on the putative effects of ß-blockers according to their pharmacological properties. METHODS: A comprehensive review of the published literature was conducted, and the evidences concerning the involvement of ß-AR in cancer as well as the possible role of ß-blockers were selected and discussed. RESULTS: The majority of reviewed studies show that: (1) All the cancer types express both ß1- and ß2-AR, with the exception of neuroblastoma only seeming to express ß2-AR; (2) adrenergic agonists are able to increase proliferation of several types of cancers; (3) the proliferative effect seems to be mediated by both ß1- and ß2-AR; (4) binding to ß-AR results in a cAMP transient flux which activates two major downstream effector systems: protein kinase A and EPAC and (5) ß-blockers might be putative adjuvants for cancer treatment. CONCLUSIONS: Overall, the reviewed studies show strong evidences that ß-AR activation, through several intracellular mechanisms, modulate tumor cell proliferation suggesting ß-blockers can be a feasible therapeutic approach to antagonize ß-adrenergic response or have a protective effect per se. This review highlight the need for intensifying the research not only on the molecular mechanisms underlying the ß-adrenergic influence in cancer, but also on the implications of biased agonism of ß-blockers as potential antitumor agents.

Vibrating Platform Training Improves Respiratory Muscle Strength, Quality of Life, and Inspiratory Capacity in the Elderly Adults: A Randomized Controlled Trial.

BACKGROUND: Aging affects respiratory strength that could cause reduction in functional capacity and quality of life, playing a fundamental role in healthy aging and survival. To prevent these declines, the whole body vibration (WBV) has been proposed to increase strength and functional capacity. The aim of the study was to evaluate the effects of WBV on respiratory muscle strength, thoracoabdominal ventilation, and quality of life in the elderly adults. METHODS: This study was a controlled, randomized double-blind clinical trial. The study included 28 elderly adults randomized into three groups: Resistance (n = 9), WBV (n = 9), or WBV + resistance exercises (n = 10), performing training, sham, or double training for 3 months, twice per week. The variables of the study were as follows: maximal inspiratory and expiratory pressures (MIP and MEP), distribution of thoracoabdominal volumes variation in optoelectronic plethysmography (pulmonary rib cage-VRCp, abdominal rib cage-VRCa, and abdomen-VAB), and quality of life. RESULTS: After training, WBV and WBV + resistance groups increased MIP and MEP (p < .001). During inspiratory capacity maneuver, WBV groups had incremental increases in chest wall total volume (p < .001), showing a rise in pulmonary rib cage (p = .03) and abdominal rib cage (p = .04). Furthermore, WBV groups improved SF-36 scores in functional capacity, physical aspects, energy, pain, and general heath domains. CONCLUSIONS: The WBV is a training that could improve respiratory muscle strength and quality of life and promote different ventilatory strategies in chest wall and thoracoabdominal compartments in healthy elderly adults.

Underuse and Unawareness of Residential Respite Care Services in Dementia Caregiving: Constraining the Need for Relief.

This article describes an analysis of the use of residential respite care services and the factors that influence the use of such services among informal caregivers of people with dementia. The authors studied a sample of 223 caregivers participating in a community-based intervention project in northern Portugal. Participants provided information on their overall caregiving situation and on their use or willingness to use respite care services. Results showed that fewer than 6 percent of caregivers accessed the services and that although most caregivers were not familiar with these services, they recognized their importance and strongly considered the possibility of using them. Part-time care, lower levels of gratification, higher burden, and the care receiver's attendance of day center supported the willingness to use residential respite services. The limited offer, not knowing about the services, and cultural issues related to the family duties within the caregiving role can explain the low use of these services. Social work professionals have an important role in promoting residential respite care services, and thereby helping to reduce caregiving overload.

The Manual Diaphragm Release Technique improves diaphragmatic mobility, inspiratory capacity and exercise capacity in people with chronic obstructive pulmonary disease: a randomised trial.

QUESTIONS: In people with chronic obstructive pulmonary disease, does the Manual Diaphragm Release Technique improve diaphragmatic mobility after a single treatment, or cumulatively? Does the technique also improve exercise capacity, maximal respiratory pressures, and kinematics of the chest wall and abdomen? DESIGN: Randomised, controlled trial with concealed allocation, intention-to-treat analysis, and blinding of participants and assessors. PARTICIPANTS: Twenty adults aged over 60 years with clinically stable chronic obstructive pulmonary disease. INTERVENTION: The experimental group received six treatments with the Manual Diaphragm Release Technique on non-consecutive days within a 2-week period. The control group received sham treatments following the same regimen. OUTCOME MEASURES: The primary outcome was diaphragmatic mobility, which was analysed using ultrasonography. The secondary outcomes were: the 6-minute walk test; maximal respiratory pressures; and abdominal and chest wall kinematics measured by optoelectronic plethysmography. Outcomes were measured before and after the first and sixth treatments. RESULTS: The Manual Diaphragm Release Technique significantly improved diaphragmatic mobility over the course of treatments, with a between-group difference in cumulative improvement of 18mm (95% CI 8 to 28). The technique also significantly improved the 6-minute walk distance over the treatment course, with a between-group difference in improvement of 22 m (95% CI 11 to 32). Maximal expiratory pressure and sniff nasal inspiratory pressure both showed significant acute benefits from the technique during the first and sixth treatments, but no cumulative benefit. Inspiratory capacity estimated by optoelectronic plethysmography showed significant cumulative benefit of 330ml (95% CI 100 to 560). The effects on other outcomes were non-significant or small. CONCLUSION: The Manual Diaphragm Release Technique improves diaphragmatic mobility, exercise capacity and inspiratory capacity in people with chronic obstructive pulmonary disease. This technique could be considered in the management of people with chronic obstructive pulmonary disease. TRIAL REGISTRATION: NCT02212184.