A before and after study of a nurse led comprehensive delirium management programme (DemDel) for older acute care inpatients with cognitive impairment.

BACKGROUND: Studies estimate that approximately one-third of episodes of delirium are preventable and that delirium prevention and management are often suboptimal in practice. While there is no doubt that prevention is desirable, the evidence of the benefits of early intervention and treatment for older hospitalised patients with dementia is unclear. AIM: To determine the effects of DemDel, a comprehensive delirium management programme, in inpatient acute care elders with cognitive impairment. DESIGN AND METHODS: This paper reports the quantitative part of a mixed methods study, comparing an intervention with treatment as usual using validated outcome measures. After training, ward nurses and physicians administered the intervention based on the DemDel algorithm that focused on delirium prevention, including an intensive systematic screening schedule for cognitive impairment and delirium, as well as comprehensive delirium management. The delirium management regimen included timely administration of pro re nata medication. SETTINGS: The study was conducted within four medical wards of an acute care university hospital in urban Switzerland. PARTICIPANTS: A total of 268 patients with cognitive impairment participated in the pre/post comparison study. The intervention and treatment as usual groups consisted of 138 and 130 patients, respectively. RESULTS: Eighty-seven (32.5%) out of 268 patients developed delirium, of whom 51 (58.6%) were of mixed, 10 (11.5%) hyperactive and 26 (29.9%) hypoactive delirium subtypes. Delirium appeared within the first five days after admission in 81.6% of cases. The 44 (31.9%) patients with delirium in the intervention group with systematic delirium management had less severe episodes of delirium and required medication for management than the 43 (33.1%) delirious patients in the control group. Intervention compliance was good on three of the four units. CONCLUSIONS: The DemDel programme was effective with regard to improvement of outcomes associated with delirium in patients with cognitive impairment. The intervention was feasible and possible to be embedded within routine practice on four busy general medical wards.

SolCos model-based individual reminiscence for older adults with mild to moderate dementia in nursing homes: a randomized controlled intervention study.

WHAT IS KNOWN ON THE SUBJECT?: To stimulate reminiscence of older adults with dementia performed individually or through group sessions is a well-known practice in nursing homes resulting in effects on behaviour and well-being as an alternative for medication. Robust scientific proof of the effectiveness of individual reminiscence therapy performed in nursing homes is sparse. WHAT THIS PAPER ADDS TO EXISTING KNOWLEDGE?: We have provided individual standardized reminiscence therapy to residents with dementia. The therapy was developed and tested in a previous study and performed in this study by trained nursing home volunteers. In comparison with a control group who received usual care, residents who received the reminiscence therapy showed significant less depressive symptoms. Moreover, residents were, in general, attentive, open and collaborative during the sessions and volunteers experienced the sessions as useful and pleasant. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: Individual reminiscence therapy can be learned and used by nursing home volunteers to improve care in nursing homes. ABSTRACT: Aim To investigate the effect of a standardized individualized intervention based on the SolCos transformational reminiscence model on depressive symptoms (primary outcome), cognition and behaviour (secondary outcomes) for older people with mild to moderate dementia, performed by trained nursing home volunteers as facilitators. Background Because of limited pharmacological treatment options for older adults with dementia relevant physical, sensory, psychological or social interventions offer alternative opportunities. Method Randomized controlled trial (ISRCTN74355073) was set up in two nursing homes with 29 and 31 residents in the intervention and the control groups respectively. Eighteen nursing home volunteers were trained to perform the reminiscence therapy. Various assessment scales were measured pre- and post-sessions. Results Linear regression analysis showed an impact on depressive symptoms. However, no impact was identified on cognition and behaviour. Facilitators experienced the sessions as useful and pleasant, and study participants were, in general, attentive, open and collaborative. Discussion Study results showed that organizing standardized individual reminiscence therapy with nursing home volunteers was feasible and study participants' attention and participation were overall good. Further study initiatives to explore the potential of individual reminiscence therapy within a person-centred framework are recommended in order to improve care in nursing homes.

Procyclin: an unusual immunodominant glycoprotein surface antigen from the procyclic stage of African trypanosomes.

An immunodominant species-specific surface glycoprotein antigen was purified from procyclic culture forms of Trypanosoma brucei rhodesiense using lectin affinity chromatography and a monoclonal antibody immunoadsorbent. The purified molecule appears on a 10% polyacrylamide gel as a wide, dark silver staining band having an apparent molecular mass of between 30 and 40 kDa, identical to that revealed by immunoblotting using anti-procyclic lysates. The molecule, which we have named procyclin, was shown by immunofluorescence and immunoelectron microscopy to be exposed on the surface of procyclic trypanosomes. Gas-phase protein microsequencing and micro-amino acid analysis revealed an unusual acidic polypeptide with an amino-terminal amino acid sequence which matched portions of previously published sequences predicted from two different cDNAs obtained using mRNA from procyclic trypanosomes. The procyclin molecules contained a large glutamic acid-proline repeat and the form we isolated was highly water soluble. Ten different monoclonal antibodies were used in ELISA with synthetic peptides to localize parasite surface epitopes to various portions of procyclin. The results showed that surface epitopes were spread throughout most of the procyclin molecule, including the glutamic acid-proline repeat portion. Procyclin is distributed over the surface of both culture form and tsetse fly midgut form procyclic trypanosomes, is developmentally regulated and is immunologically species-specific.

The immunochemical structure and surface arrangement of Leishmania donovani lipophosphoglycan determined using monoclonal antibodies.

Using intact Leishmania donovani promastigotes or purified L. donovani lipophosphoglycan (LPG) as immunogens, we have derived four LPG-specific monoclonal antibodies (MAbs). Two of these MAbs recognize an epitope consisting of the repeating phosphorylated galactose beta-1,4-mannose disaccharide portion of the molecule and cross-reacted with LPG from Leishmania major. These MAbs bound to the surface of living promastigotes of both species. The two other MAbs bound to the phosphosaccharide core structure of LPG and did not bind to the surface of living parasites, presumably due to masking of the core region. Experiments using all four MAbs with an LPG-deficient promastigote mutant indicated that both the repeat epitope and phosphosaccharide core were present in these cells, suggesting that incomplete assembly was responsible for the absence of intact LPG.

Lipophosphoglycan expression and virulence in ricin-resistant variants of Leishmania major.

Lipophosphoglycan (LPG) of Leishmania is a polymorphic molecule comprising an alkylglycerol anchor, a conserved oligosaccharide core and a species-specific polymer of oligosaccharide repeats jointed by phosphodiester bonds. This molecule, together with the membrane polypeptide gp63, has been implicated as a parasite receptor for host macrophages. To examine the role of LPG in parasite infectivity glycosylation variants of Leishmania major were generated by chemical mutagenesis of a virulent cloned line V121 and variants with modified LPG selected using the galactose-specific lectin Ricinus communis II (RCA II). Twenty RCA II-resistant primary clones were generated. Analysis of LPG profile by immunoblotting using LPG-specific monoclonal and polyclonal antibodies revealed that some of the clones were LPG-deficient. Three clones that did not bind any LPG-specific antibodies but expressed normal levels of the Mr 63,000 glycoprotein (gp63), a second parasite receptor for host, were chosen for detailed studies. All three clones expressed, at least to some extent, a surface molecule which could be labeled by mild periodate oxidation and sodium borotritide and behaved like LPG by hydrophobic interaction chromatography. All clones also bound a well-characterized monoclonal antibody L157 directed to the core oligosaccharide of LPG, but did not bind another monoclonal antibody, CA7AE, to an epitope on a repeating unit shared by Leishmania donovani and L. major LPG. A third monoclonal antibody, 5E6, recognizing LPG on the surface of wild-type V121 promastigotes bound only to RCA II-resistant clone 3A2-C3 and was restricted to an internal structure. The LPG molecule that this clone expressed was a form of LPG by its chromatographic behavior and by its monosaccharide and alkylglycerol composition. Clone 3A2-C3 was the only one to infect mice in vivo and survive in macrophages in vitro, albeit at a much reduced rate compared to wild-type V121 promastigotes. The data suggest that some form of LPG may be necessary to ensure parasite infectivity.

Archaeosomes as novel antigen delivery systems.

The humoral immune response mounted in BALB/c mice against bovine serum albumin or cholera toxin B subunit was compared when the antigens were associated with liposomes composed of either archaeal ether lipids or conventional lipids. Antibody titres in sera from mice immunised intraperitoneally were elevated to an extent comparable to those achieved with Freund's adjuvant by encapsulating bovine serum albumin in archaeal lipid vesicles (archaeosomes) of about 200 nm diameter. Comparison among six archaeosome and three conventional liposome compositions established that archaeosomes were generally much superior in potentiating an immune response. Further, only two immunisations, at the most, were needed to achieve close to the maximum antibody titre, as shown with archaeosomes composed of the polar lipids from Methanobrevibacter smithii, an inhabitant of the human colon. A similar positive response to presenting the more immunogenic cholera B subunit protein to the immune system of mice was shown for M. smithii archaeosomes. Encapsulation of the antigen in the archaeosome was necessary to achieve the full humoral response. This represents the first study to our knowledge where archaeosomes have been evaluated in vivo as possible antigen carriers.

The analysis of basic and acidic compounds using non-aqueous CE and non-aqueous CE-MS.

It has been shown that non-aqueous capillary electrophoresis (NACE) can provide improved separations in comparison to those obtained using conventional CE under aqueous conditions (ACE). Previous work carried out in our laboratories involving initial investigations into the technique have been reported. Based on the findings of that work it was possible to separate a variety of basic pharmaceuticals from selected impurities and to obtain the successful separation of some hydrophobic sulphonic acids. The successful coupling of NACE to mass spectrometry (NACE-MS) has also been demonstrated.

Student pilots referred to the neuropsychiatry branch, USAFSAM 1968-78: implications for selection.

The case records of 76 student aviators referred to the Neuropsychiatry Branch of the USAF School of Aerospace Medicine during the period 1968-78 are reviewed. Demographic and diagnostic data are provided including source of recruitment, age, marital status, aircraft flown, flying hours, and diagnostic categories. Psychophysiological categories are particularly scrutinized and cameo case histories provided. Implications for pilot selection are discussed.

Listening in the care environment--chaos or clarity for the hearing-impaired elderly person.

The reported study evaluates listening circumstances within long-stay wards in an attempt to understand the nature of the environment and so develop and subsequently evaluate a programme of nursing intervention for hearing-impaired residents. Evidence is presented which indicates that improvement of the residents' listening environment, promotes adaptation to hearing aids and enhances residents' quality of life. It is recommended that attending to the listening environment becomes a concern of nurses working within continuing care facilities for elderly people.

Gerontological nursing. 1: Challenges nursing older people in acute care.

This article, the first in a series of five, will briefly trace the emergence of gerontological nursing and highlight some of the tensions that currently exist in the context of acute care environments. The next two articles will consider the prospects and challenges for nurses working with older people in community and nursing home environments, while the fourth article uses hearing impairment across a range of care contexts as a case study to summarize the ways in which the nursing contribution to the health needs of older people could be significantly improved. The series will conclude with an article drawing together the challenges that gerontological nursing faces in the new millennium.

Gerontological nursing. 3: Valuing nursing homes and valuing staff.

This, the third of five articles considering the future of gerontological nursing, focuses on practice within nursing homes. The important contribution of such environments is highlighted and it is argued that work within long-term care settings must be recognized and valued if the quality of care provided is to improve.

Gerontological nursing. 4: Age-related hearing explored.

In the previous three articles in this series (Vol 9(1): 39-42; Vol 9(2): 103-6; Vol 9(3): 157-60), nurses have been challenged to reconsider their approach towards the care of older people. To facilitate this it is helpful to provide specific examples of how expert practice might be achieved. Using one of the most prevalent but neglected problems of old age, hearing disability, the authors describe how nurses can contribute to the health of older people and maximize the therapeutic component within gerontological nursing.

Gerontological nursing. 5: Realizing the future potential.

In this, the final article in the series, the authors consider the prospect for the future of gerontological nursing with a special focus on philosophy of care, expert gerontological nurses and evidence-based practice. The article highlights the need for more research and education in gerontological nursing if quality of care is to improve and gerontological nursing is to consolidate its place in the future of nursing practice.

Hearing impairment in elderly hospital residents.

Seventy per cent of the sample residents had significant hearing impairment (> or = 40 dBHL). Forty-seven per cent of the sample residents wanted further help with their hearing but this had not been offered. Screening for hearing impairment on the study wards was haphazard. Less than 10% of residents owned and used a hearing aid. The listening environment was potentially disabling on all of the wards. Nursing staff were inadequately prepared to meet the care needs of the hearing-impaired elderly hospital resident. Nursing and medical care policies are not sensitive towards the needs of the hearing-impaired elderly hospital resident. Hearing impairment is a neglected area of healthcare on long-stay wards for elderly people.

Gerontological nursing. 2: Refocusing the community agenda.

This, the second in a series of articles considering potential developments in gerontological nursing, focuses on a community setting. It highlights current trends in policy which emphasizes the promotion of independence and outlines implications for community nurses. The authors argue that if new roles are to emerge then the educational preparation of community nurses must reflect more fully future policy initiatives.

The nurse's role in assessing alcohol use by older people.

Nurses have the potential to carry out health promotion activity related to alcohol use in a range of settings where older people receive care. The majority of the literature on alcohol use in later life has focused on abuse, especially on the more common risk of drug-alcohol interactions. In order to work effectively with older people in health prevention and education, nurses need to be knowledgeable about older people's patterns of drinking, the effects of alcohol on medication and the current evidence on the harm and benefits of alcohol to health. In carrying out assessments, a skillful approach needs to be adopted in questioning older clients on what some might regard as a sensitive issue. Screening tools for the detection of alcohol abuse in the general adult population may not be valid for use with older clients. Tools specific to the detection of alcohol abuse by older people will be considered.

Hearing impairment in elderly hospital residents.

The provision of high quality nursing care for dependent elderly people is a daunting challenge to the profession. This survey focuses on the frequently neglected area of impaired hearing among elderly hospital residents and evaluates the service provided by one health board.

Research, ethics and the data protection legislation.

As nursing research becomes more common, so does the issue of whether or not patients should be involved and, if so, to what extent. This article examines how the data protection legislation helps to protect patients, and whether they have the capability to decide to participate, or not.