Combining robot-assisted therapy with virtual reality or using it alone? A systematic review on health-related quality of life in neurological patients.

BACKGROUND: In the field of neurorehabilitation, robot-assisted therapy (RAT) and virtual reality (VR) have so far shown promising evidence on multiple motor and functional outcomes. The related effectiveness on patients' health-related quality of life (HRQoL) has been investigated across neurological populations but still remains unclear. The present study aimed to systematically review the studies investigating the effects of RAT alone and with VR on HRQoL in patients with different neurological diseases. METHODS: A systematic review of the studies evaluating the impact of RAT alone and combined with VR on HRQoL in patients affected by neurological diseases (i.e., stroke, multiple sclerosis, spinal cord injury, Parkinson's Disease) was conducted according to PRISMA guidelines. Electronic searches of PubMed, Web of Science, Cochrane Library, CINAHL, Embase, and PsychINFO (2000-2022) were performed. Risk of bias was evaluated through the National Institute of Health Quality Assessment Tool. Descriptive data regarding the study design, participants, intervention, rehabilitation outcomes, robotic device typology, HRQoL measures, non-motor factors concurrently investigated, and main results were extracted and meta-synthetized. RESULTS: The searches identified 3025 studies, of which 70 met the inclusion criteria. An overall heterogeneous configuration was found regarding the study design adopted, intervention procedures and technological devices implemented, rehabilitation outcomes (i.e., related to both upper and lower limb impairment), HRQoL measures administered, and main evidence. Most of the studies reported significant effects of both RAT and RAT plus VR on patients HRQoL, whether they adopted generic or disease-specific HRQoL measures. Significant post-intervention within-group changes were mainly found across neurological populations, while fewer studies reported significant between-group comparisons, and then, mostly in patients with stroke. Longitudinal investigations were also observed (up to 36 months), but significant longitudinal effects were exclusively found in patients with stroke or multiple sclerosis. Finally, concurrent evaluations on non-motor outcomes beside HRQoL included cognitive (i.e., memory, attention, executive functions) and psychological (i.e., mood, satisfaction with the treatment, device usability, fear of falling, motivation, self-efficacy, coping, and well-being) variables. CONCLUSIONS: Despite the heterogeneity observed among the studies included, promising evidence was found on the effectiveness of RAT and RAT plus VR on HRQoL. However, further targeted short- and long-term investigations, are strongly recommended for specific HRQoL subcomponents and neurological populations, through the adoption of defined intervention procedures and disease-specific assessment methodology.

Technology Assisted Rehabilitation Patient Perception Questionnaire (TARPP-Q): development and implementation of an instrument to evaluate patients' perception during training.

BACKGROUND: The introduction of technology-assisted rehabilitation (TAR) uncovers promising challenges for the treatment of motor disorders, particularly if combined with exergaming. Patients with neurological diseases have proved to benefit from TAR, improving their performance in several activities. However, the subjective perception of the device has never been fully addressed, being a conditioning factor for its use. The aims of the study were: (a) to develop a questionnaire on patients' personal experience with TAR and exergames in a real-world clinical setting; (b) to administer the questionnaire to a pilot group of neurologic patients to assess its feasibility and statistical properties. METHODS: A self-administrable and close-ended questionnaire, Technology Assisted Rehabilitation Patient Perception Questionnaire (TARPP-Q), designed by a multidisciplinary team, was developed in Italian through a Delphi procedure. An English translation has been developed with consensus, for understandability purposes. The ultimate version of the questionnaire was constituted of 10 questions (5 with multiple answers), totalling 29 items, exploring the patient's performance and personal experience with TAR with Augmented Performance Feedback. TARPP-Q was then administered pre-post training in an observational, feasible, multi-centric study. The study involved in-patients aged between 18 and 85 with neurological diseases, admitted for rehabilitation with TAR (upper limb or gait). FIM scale was run to control functional performance. RESULTS: Forty-four patients were included in the study. All patients answered the TARPP-Q autonomously. There were no unaccounted answers. Exploratory factor analyses identified 4 factors: Positive attitude, Usability, Hindrance perception, and Distress. Internal consistency was measured at T0. The values of Cronbach's alpha ranged from 0.72 (Distress) to 0.92 (Positive attitude). Functional Independence Measure (FIM®) scores and all TARPP-Q factors (Positive attitude, Usability, Hindrance perception, except for Distress (p = 0.11), significantly improved at the end of the treatment. A significant positive correlation between Positive attitude and Usability was also recorded. CONCLUSIONS: The TARPP-Q highlights the importance of patients' personal experience with TAR and exergaming. Large-scale applications of this questionnaire may clarify the role of patients' perception of training effectiveness, helping to customize devices and interventions.

Positive affect as a predictor of non-pharmacological adherence in older Chronic Heart Failure (CHF) patients undergoing cardiac rehabilitation.

In Chronic Heart Failure (CHF) patients, psychological and cognitive variables and their association with treatment adherence have been extensively reported in the literature, but few are the investigations in older people. The present study aimed to evaluate the psychological, cognitive, and adherence to treatment profile of older (>65 years) CHF patients, the interrelation between these variables, and identify possible independent predictors of self-reported treatment adherence. CHF inpatients undergoing cardiac rehabilitation were assessed for: anxiety, depression, cognitive impairment, positive and negative affect, and self-reported adherence (adherence antecedents, pharmacological adherence, and non-pharmacological adherence). 100 CHF inpatients (mean age: 74.9 ± 7.1 years) were recruited. 16% of patients showed anxiety and 24.5% depressive symptoms; 4% presented cognitive decline. Cognitive functioning negatively correlated to depression, anxiety, and negative affect (p < 0.01). The adherence antecedents (disease acceptance, adaptation, knowledge, and socio-familiar support) negatively correlated to anxiety (p < 0.05), depression (p < 0.001), and negative affect (p < 0.05), while they positively correlated to positive affect (p < 0.01). Pharmacological adherence negatively correlated to anxiety and negative affect (p < 0.05). Conversely, non-pharmacological adherence and positive affect positively correlated (p < 0.05). Furthermore, depression and anxiety negatively predicted adherence antecedents (ß = -0.162, p = 0.037) and pharmacological adherence (ß = -0.171, p = 0.036), respectively. Finally, positive affect was found as an independent predictor of non-pharmacological adherence (ß = 0.133, p = 0.004). In cardiac rehabilitation, a specific psychological assessment focused on anxiety, depression, and affect can provide useful information to manage CHF older patients' care related to treatment adherence. In particular, positive affect should be targeted in future interventions to foster patients' non-pharmacological adherence.

A systematic review on the usability of robotic and virtual reality devices in neuromotor rehabilitation: patients' and healthcare professionals' perspective.

BACKGROUND: The application of virtual reality (VR) and robotic devices in neuromotor rehabilitation has provided promising evidence in terms of efficacy, so far. Usability evaluations of these technologies have been conducted extensively, but no overviews on this topic have been reported yet. METHODS: A systematic review of the studies on patients' and healthcare professionals' perspective through searching of PubMed, Medline, Scopus, Web of Science, CINAHL, and PsychINFO (2000 to 2021) was conducted. Descriptive data regarding the study design, participants, technological devices, interventions, and quantitative and qualitative usability evaluations were extracted and meta-synthetized. RESULTS: Sixty-eight studies were included. VR devices were perceived as having good usability and as a tool promoting patients' engagement and motivation during the treatment, as well as providing strong potential for customized rehabilitation sessions. By contrast, they suffered from the effect of learnability and were judged as potentially requiring more mental effort. Robotics implementation received positive feedback along with high satisfaction and perceived safety throughout the treatment. Robot-assisted rehabilitation was considered useful as it supported increased treatment intensity and contributed to improved patients' physical independence and psychosocial well-being. Technical and design-related issues may limit the applicability making the treatment difficult and physically straining. Moreover, cognitive and communication deficits were remarked as potential barriers. CONCLUSIONS: Overall, VR and robotic devices have been perceived usable so far, reflecting good acceptance in neuromotor rehabilitation programs. The limitations raised by the participants should be considered to further improve devices applicability and maximise technological rehabilitation effectiveness. TRIAL REGISTRATION: PROSPERO registration ref. CRD42021224141 .

Hidden biases in clinical decision-making: potential solutions, challenges, and perspectives.

Every day, we must make decisions that range from simple and risk-free to difficult and risky. Our cognitive sources' limitations, as well as the need for speed, can frequently impair the quality and accuracy of our reasoning processes. Indeed, cognitive shortcuts lead us to solutions that are sufficiently satisfying to allow us to make quick decisions. Unfortunately, heuristics frequently misguide us, and we fall victim to biases and systematic distortions of our perceptions and judgments. Because suboptimal diagnostic reasoning processes can have dramatic consequences, the clinical setting is an ideal setting for developing targeted interventions to reduce the rates and magnitude of biases. There are several approaches to bias mitigation, some of which may be impractical. Furthermore, advances in information technology have given us powerful tools for addressing and preventing errors in health care. Recognizing and accepting the role of biases is only the first and unavoidable step toward any effective intervention proposal. As a result, our narrative review aims to present some insights on this contentious topic based on both medical and psychological literature.

A journey through roses and thorns: becoming a physician by learning from patients with life-threatening illnesses. A qualitative study with international medical students.

The medical students' well-being may be threatened by various stressors associated with providing care to different kinds of patients. This study aims to explore students' clinical experiences with patients who suffer from life-threatening illnesses, focusing on potential risk and protective factors. Audio-recorded and face-to-face interviews were conducted and transcribed verbatim. The "Interpretive Description" approach was used to analyse data. Overall, ten medical students with a mean age of 28 years old were interviewed. Well-being promoting factors were the following: therapeutic relationships, work-life balance, social support and communication, perception of improvement in knowledge and availability of advanced directives. Whilst factors that may reduce well-being included death exposure, managing emotions, communication difficulties, internal conflicts and disagreements, lack of knowledge and subjective concerns. These findings shed light on facets that are inherent parts of clinical experience with patients suffering from a life-threatening illness and that may turn in risk or protective factors for the medical students. Understanding the students' subjective experiences may aid in the improvement of the current educational programs, as well as in the development of tailored supportive and preventative interventions to promote well-being and professional competencies among this kind of students.

Lesson learned from an international training program on patients medication adherence for healthcare professionals.

SUMMARY: Objective. Healthcare professionals play a crucial role for promoting medication adherence in older adults. This research aimed to assess changes in professionals' opinions about medication adherence after attending a course, collecting suggestions for future educational programs. Method. A one-week course on medication adherence in older adults was held involving 32 healthcare professionals and students from Italy, Portugal and Poland as part of the Erasmus+ Skills4Adherence Project. Prior to and at the end of the course, participants provided three keyword answers through a Google Form. Responses were collectively discussed and commented on. Results. At the end of the course a general tendency to put more attention on patient's beliefs and engagement was revealed. The caregivers' role was also underlined. As to suggestions for education, three keywords were considered not enough to characterize adherence issues. Conversely, professionals considered collective discussions and roleplaying to be effective for increasing awareness on this theme. Discussion and conclusion. Several changes in healthcare professionals' opinions regarding determinants of medicationadherence were revealed after this dedicated course. Overall, multidisciplinary and practical training programs should be proposed for increasing healthcare professionals' awareness of factors impacting on medication adherence in older adults.

SMiLE to Life: Meaning in life in healthcare professionals working in palliative care and rehabilitation medicine.

BACKGROUND: In the healthcare landscape, various protective factors are identified, such as meaning in life (MiL), namely what gives sense to life events. However, little is known about this construct in the healthcare population. OBJECTIVES: To describe MiL among healthcare professionals employed in palliative care and neuro-rehabilitation medicine, unveiling possible differences related to medical specialty and socio-demographic characteristics. METHODS: In this cross-sectional and multicentre study, palliative care and neuro-rehabilitation professionals were recruited. MiL was evaluated with the Schedule for Meaning in Life Evaluation (SMiLE), which provides a list of meaningful areas, as well as related overall indexes of satisfaction (IoS), weighting (IoW), weighted satisfaction (IoWS). Descriptive statistics, t-test, chi-square, linear and binary logistic regressions were performed. RESULTS: Overall, 297healthcare professionals (palliative care=89, neuro-rehabilitation medicine=208, 47% of participants ≤ 40 years old) completed the evaluation. The sample was intra- and inter-groups heterogeneous, in particular concerning age and professional role. Conversely, no significant group differences emerged in MiL indexes comparisons, nor in the number of MiL listed areas. As for MiL areas, the category "family" increased the IoWS index, while terms related to "finances" contributed to decrease it. Comparing specialties, palliative care professionals were more likely to report areas like "partnership", "social commitment", and "satisfaction". Nurses (n=116), nurse aides (n=47), and therapists (n=67) were more likely to mention health-related terms (e.g. health, physical wellbeing) than physicians and psychologists (n=65). CONCLUSION: This study highlighted MiL areas among professionals employed in palliative care and neurorehabilitation specialties, providing informative suggestions for tailored health prevention programs which should pay particular attention to social and family relationships, socio-economic status, and health.

Resilience in palliative healthcare professionals: a systematic review.

PURPOSE: Exposure to end-of-life and chronic illness on a daily basis may put palliative healthcare professionals' well-being at risk. Resilience may represent a protective factor against stressful and demanding challenges. Therefore, the aim is to systematically review the quantitative studies on resilience in healthcare professionals providing palliative care to adult patients. METHODS: A literature search on PubMed, Scopus, Web of Science and PsycINFO databases was performed. The review process has followed the international PRISMA statement guidelines. RESULTS: At the initial search, a total of 381 records were identified. Twelve articles were assessed for eligibility and, finally, 6 studies met all the inclusion criteria. Of these, four researches were observational and two interventional pilot studies. From the systematic synthesis, palliative care providers' resilience revealed to be related to other psychological constructs, including secondary traumatic stress, vicarious posttraumatic growth, death anxiety, burnout, compassion satisfaction, hope and perspective taking. CONCLUSIONS: The current systematic review reported informative data leading to consider resilience as a process modulator and facilitator among palliative care professionals. A model on palliative healthcare providers' experience and the role of resilience was proposed. Further studies may lead to its validation and implementation in assessment and intervention contributing to foster palliative healthcare professionals' well-being.

Back to the future: five forgotten lessons for the healthcare managers of today.

Nowadays, political, economic and technological upheavals require the rediscovery of some elapsed soft skills by healthcare managers. These abilities are values grounded in the past and somewhat nebulous in the present. We suggest five forgotten lessons highlighting the importance of a stronger human and self-conscious approach in today's and tomorrow's healthcare managers.

The Need to Develop Standard Measures of Patient Adherence for Big Data: Viewpoint.

Despite half a century of dedicated studies, medication adherence remains far from perfect, with many patients not taking their medications as prescribed. The magnitude of this problem is rising, jeopardizing the effectiveness of evidence-based therapies. An important reason for this is the unprecedented demographic change at the beginning of the 21st century. Aging leads to multimorbidity and complex therapeutic regimens that create a fertile ground for nonadherence. As this scenario is a global problem, it needs a worldwide answer. Could this answer be provided, given the new opportunities created by the digitization of health care? Daily, health-related information is being collected in electronic health records, pharmacy dispensing databases, health insurance systems, and national health system records. These big data repositories offer a unique chance to study adherence both retrospectively and prospectively at the population level, as well as its related factors. In order to make full use of this opportunity, there is a need to develop standardized measures of adherence, which can be applied globally to big data and will inform scientific research, clinical practice, and public health. These standardized measures may also enable a better understanding of the relationship between adherence and clinical outcomes, and allow for fair benchmarking of the effectiveness and cost-effectiveness of adherence-targeting interventions. Unfortunately, despite this obvious need, such standards are still lacking. Therefore, the aim of this paper is to call for a consensus on global standards for measuring adherence with big data. More specifically, sound standards of formatting and analyzing big data are needed in order to assess, uniformly present, and compare patterns of medication adherence across studies. Wide use of these standards may improve adherence and make health care systems more effective and sustainable.

Healthcare professionals' perceptions about the Italian law on advance directives.

BACKGROUND: In the variegated legislative framework on advance directives, the first specific regulation in Italy on this issue came into force only in 2018. RESEARCH OBJECTIVE: This qualitative study aimed to investigate the implications of the new Italian law on advance directives in clinical practice from the perspective of those who deal with this delicate ethical issue on an everyday basis, that is, Italian healthcare professionals. RESEARCH DESIGN: A qualitative research design using semi-structured audio-recorded interviews was adopted. The data collection and analysis were performed according to the Grounded Theory approach. PARTICIPANTS: Nineteen healthcare professionals (16 nurses, 3 physicians) working in a palliative care unit of a research and clinical institute in Italy. ETHICAL CONSIDERATIONS: The study is part of the WeDistress HELL Project (WEllness and DISTRESS in HEalth care professionals dealing with end of Life and bioethicaL issues) approved by the Ethical Committee of ICS Maugeri - Institute of Pavia (Italy). FINDINGS: The authors identified a main overall category, 'Pros and Cons of the Italian law on advance directives', composed of six constituent categories: Positive welcome, Self-determination and protection, Prompts for future betterment, Uncertainties, Lack of knowledge, and Neutrality and no suggestions. DISCUSSION: The Italian law n. 219/2017 on advance directives was seen as a legal instrument possessing both strengths and weaknesses, but able to guarantee the patient's self-determination and support healthcare professionals in providing care according to patients' wishes. CONCLUSION: An understanding of the healthcare providers' perspective may support the discussion on advance directives and bridge the gaps that currently persist in handling ethical issues.

Dealing with ethical issues in rehabilitation medicine: The relationship between managerial support and emotional exhaustion is mediated by moral distress and enhanced by positive affectivity and resilience.

AIMS: To analyse whether managerial support and ethical vision of patient care would be related to emotional exhaustion directly or through moral distress and whether these relationships would be conditional on individual levels of positive affectivity and resilience. BACKGROUND: Although some studies described the effects of ethical climate, moral distress, resilience and positive affectivity on emotional exhaustion, there are no attempts of explicative models containing these variables. METHODS: A total of 222 Italian professionals employed in neuro-rehabilitation medicine units participated in this cross-sectional study. Descriptive statistics, mediation and moderated mediation analyses were conducted using SPSS. RESULTS: Managerial support and ethical vision of patient care were negatively related to emotional exhaustion, directly and through moral distress. Professionals high in resilience and positive affectivity benefited more from the protective effect of managerial support on emotional exhaustion through moral distress. CONCLUSION: Ethical climate represents a protective factor against moral distress and emotional exhaustion. Moreover, individual levels of positive affectivity and resilience may increase the beneficial effects deriving from managerial support in dealing with ethical issues. IMPLICATION FOR NURSING MANAGEMENT: Health organisations may consider developing strategies to improve ethical climate, enhance managers' ability to support team in dealing with ethical issues and foster employees' positive affectivity and resilience.

[Linking the ICF codes to clinical real-life assessments: the challenge of the transition from theory to practice]. / Misure di valutazione e abbinamento dei codici ICF in medicina riabilitativa: la sfida del passaggio dalla teoria alla pratica.

SUMMARY: According to the latest WHO guidelines, the ICD-ICF joint use currently represents the most agreed method to portray a patient's Care Pathway during a hospitalization. On this note, ICS Maugeri carried out an internal project aiming to identify the ICF codes that better describe the rehabilitation pathways in its Italian Institutes. 2 main goals so far have been achieved: 1. To re-conceptualize the Care Pathways thought the lenses of the ICD-ICF frameworks; 2. To link, whenever possible and by means of the WHO-ICF linking rules, each pertinent ICF code to the most appropriate assessment method, harmonizing its outputs to the 0-4 ICF Likert scale. The current project represents a first attempt towards the creation of a standard functioning assessment methodology to be implemented in rehabilitation settings. Despite being referred to the Maugeri group only, the ICD-ICF procedure described could hopefully be extended to other settings, representing a support for health information technologies.

[Towards a baseline ontology for information technology in rehabilitation medicine: the nomenclator of the rehabilitation procedures]. / Verso un'ontologia di riferimento per i sistemi informativi in medicina riabilitativa: il nomenclatore delle prestazioni riabilitative.

SUMMARY: One of the main aims of Healthcare Information Technology is the safe and efficient management of significant amounts of clinical data. Now more than ever, such goal requires the creation of common semantics to ontologically organize knowledge enclosed in databases. By means of the application of the WHO ICD-ICF frameworks, the ensemble of rehabilitative activities lead in all the Maugeri institutes in Italy, has been formally standardized to create a Nomenclator, with the aim to: a) support clinicians in the definition of the individualized Care Pathway; b) program, optimize and maximize patient's rehabilitation activities, according to clinical and organizational requirements; c) qualitatively and quantitatively report the daily health-care professionals' workflows; d) provide a structured and detailed medical record meeting appropriateness requirements. In this regard, the application of the ICD-ICF framework as a baseline ontology, paves the path to an ongoing tracking of the rehabilitation processes, leading to a more accurate description of patient's functioning profile. The upcoming challenge for rehabilitation is the ultimate overcoming of a solely epidemiological perspective, in order to embrace a holistic approach, fostered by ontologically-based information technologies.

Living with Parkinson's-past, present and future: a qualitative study of the subjective perspective.

BACKGROUND: the social impact of Parkinson's is difficult to capture in quantitative research given the condition's variable presentation, so qualitative research is needed to support a person-centred approach. AIMS: to describe how people with Parkinson's experience living with their condition over time. METHODS: 27 audio-recorded verbatim-transcribed interviews were analysed through the grounded theory method. FINDINGS: past, present and future were the core categories that emerged. Past is the dimension of regretted memories of past life overturned by the communication of diagnosis. Present is the time dimension in which patients concretely experience the hindrances associated with the condition (loss of autonomy, submissive acceptance and social embarrassment), and the resources (search for autonomy, serene or in-progress acceptance, and social support). Future is characterised by both positive visions of tomorrow and negative ones (worry, resignation, denial). CONCLUSION: these results, highlighting what living with Parkinson's means over time, may contribute to a better tailoring of nursing practice to the person's needs and rhythm, in a perspective of continuous adaptation.

[Digitalisation and clinical care pathways in rehabilitation medicine: a possible integration from the goal-planning and the rehabilitation programme design to the evaluation of clinical outcomes.] / ICF, digitalizzazione e percorsi clinico-assistenziali in medicina riabilitativa: una integrazione possibile dalla definizione degli obiettivi alla stesura del programma riabilitativo, alla valutazione dei risultati.

OBJECTIVES: In the light of the growing complexity featuring the contemporary world, a future challenge is represented by the maintenance of the humanization of healthcare, along with the necessity of a high specificity personalized treatment, in a growing emergency of lack of resources. Furthermore, the ongoing digital revolution spreading in every productive sector involves the health-care system as well, playing a crucial role for the goals of the specialized care-related prevention-treatment-rehabilitation approach of the Rehabilitation Medicine. However, the digitalization of clinical data is not to be considered as a mere tout-court necessity, but it deserves to be planned and carried out with consistent awareness: the digital transformation calls for a theoretical paradigm which, together with a shared language, will be able to embrace its multilevel complexity, taking into account the patient needs, the clinical care pathways and the administrative requests. METHODS: In the present work the potentialities of the WHO ICF model (International Classification of Functioning, Disability and Health) will be described. In particular, will be discussed the role of the ICF in representing the keystone able to connect the ICD-9-CM classification, the clinical care pathways, the individualized rehabilitation project and program and their digital implementation. RESULTS: Hence, each step of the process that led the implementation of the biopsychosocial model in the ICF Maugeri workflows will be presented, as well as the critical issues related to the digitalisation process and the strengths in safeguarding the patients' wellbeing.

Chlorine Para-Substitution of 1-Phenylethanol: Resonant Photoionization Spectroscopy and Quantum Chemical Calculations of Hydrated and Diastereomeric Complexes.

The conformational landscape of (S)-1-(4-chlorophenyl)ethanol, its monohydrated complex, and its diastereomeric adducts with R- and S-butan-2-ol, have been investigated by resonant two-photon ionization (R2PI) spectroscopy coupled with time-of-flight mass spectrometry. Theoretical calculations at the D-B3LYP/6-31++G** level of theory have been performed to assist in the interpretation of the spectra and in the assignment of the structures. The R2PI spectra and the predicted structures have been compared with those obtained on the analogous non-halogenated and fluorinated systems, i.e., (R)-1-phenylethanol and (S)-1-(4-fluorophenyl)ethanol, respectively. It appears that the presence of chlorine atom in the para position of the aromatic ring does not influence the overall geometry of bare molecule and its complexes with respect to the non-halogenated analogous systems. Anyway, it affects the electron density in the π system, and in turn the strength of OH···π and CH···π interactions. A spectral chiral discrimination is evident from the R2PI spectra of the diastereomeric adducts of (S)-1-(4-chlorophenyl)ethanol with the two enantiomers of butan-2-ol.

Toward appropriate criteria in medication adherence assessment in older persons: Position Paper.

Nonadherence to medication regimens is a worldwide challenge; adherence rates range from 38 to 57 % in older populations with an average rate of less than 45 % and nonadherence contributes to adverse drug events, increased emergency visits and hospitalisations. Accurate measurement of medication adherence is important in terms of both research and clinical practice. However, the identification of an objective approach to measure nonadherence is still an ongoing challenge. The aim of this Position Paper is to describe the advantages and disadvantages of the known medication adherence tools (self-report, pill count, medication event monitoring system (MEMS) and electronic monitoring devices, therapeutic drug monitoring, pharmacy records based on pharmacy refill and pharmacy claims databases) to provide the appropriate criteria to assess medication adherence in older persons. To the best of our knowledge, no gold standard has been identified in adherence measurement and no single method is sufficiently reliable and accurate. A combination of methods appears to be the most suitable. Secondly, adherence assessment should always consider tools enabling polypharmacy adherence assessment. Moreover, it is increasingly evident that adherence, as a process, has to be assessed over time and not just at one evaluation time point (drug discontinuation). When cognitive deficits or functional impairments may impair reliability of adherence assessment, a comprehensive geriatric assessment should be performed and the caregiver involved. Finally, studies considering the possible implementation in clinical practice of adherence assessment tools validated in research are needed.

ICF, quality of life, and depression in breast cancer: perceived disability in disease-free women 6 months after mastectomy.

GOAL OF WORK: Aim of the present observational study is to focus on health-related quality of life (HRQL), mood and everyday life of breast cancer affected women disease-free 6 months after mastectomy, paying particular attention to the International Classification of Functioning, Disability and Health (ICF) framework contribution. MATERIALS AND METHODS: Sixty-five breast cancer-affected women disease-free 6 months after mastectomy hospitalized for reconstructive surgery (mean age 46.3 ± 7.3) were enrolled. Their depressive symptoms (Beck Depression Inventory-BDI-II), HRQL, and every day life functioning/barriers and facilitators (ICF) were assessed. RESULTS: At the BDI-II, 6 patients (9.2 %) reported mild depression and 6 (9.2 %) severe depression; when the subscales were considered, 7 (10.8%) resulted depressed at the somatic-affective factor and 16 (24.6 %) at the cognitive factor. Compared to normative data no differences emerged at the HRQL Physical Component Summary (46.4 ± 9.3 vs 49.1 ± 10.1), whereas patients reported lower scores at the Mental HRQL Component Summary (45.9 ± 10.1 vs 51.5 ± 9.1; p = 0.00001 t = -4.3). As for the activity and participation domain, 11 of the 42 categories investigated were compromised in at least 20% of the sample: lifting and carrying objects (d430), acquisition of goods and services (d620), doing housework (d640), remunerative employment (d850), and many categories relating to interpersonal relationships; moreover the caregiver seems to be perceived as an important and positive modulator of disability. CONCLUSIONS: The addition of the ICF evaluation to the usual psychological assessment gives a more complete picture, enabling a broader perspective of the psychological-clinical implications. Mainly, the women that we have evaluated continue to function in their everyday lives, thanks in part to their ability to accept help from their own families. However, they inevitably carry signs of their disease which some translating into problems with interpersonal relationships, depressive thoughts and negative ideation. Only the synergistic use of all these assessment instruments can one truly perceive all the nuances relating to the social and psychological conditions of the assessed patients' life, overcoming a binomial vision of well-being and ill-being.