Usability and acceptability of internet-based interventions for family carers of people living with dementia: systematic review.

Objectives: Internet-based interventions can help carers of people living with dementia to cope with care-related challenges and can help improve their wellbeing. This systematic review aimed at investigating the criteria of usability and acceptability of self-guided internet-based interventions for family carers of people living with dementia. Method: Searches were conducted on PubMed, Virtual Health Library Regional Portal (Americas), MEDLINE, PsycINFO, Scopus, and Cochrane. Studies published up to December 2019, in English, Portuguese, or Spanish, were eligible. We followed the definition/criteria from ISO ISO-9241-11 for usability (efficiency, effectiveness, and satisfaction) and acceptability (barriers for using and utility). Methodological quality was evaluated using specific tools according to each study design. Results: Ten studies were included, all of which had high methodological quality. Carers of people living with dementia indicated that internet-based interventions were mostly effective, efficient, and satisfactory. They considered these to be informative, relevant, and functional, highlighting the utility and intention of using the resource in the future. The high heterogeneity in the terms and methods used to evaluate usability and acceptability hindered cross-study comparisons, however internet-based interventions were considered useful and acceptable by most carers. Conclusion: Future research should consider expanding the criteria of usability and acceptability to better reflect the needs of this population.

Symptoms of mood disorders in family carers of older people with dementia who experience caregiver burden: a network approach.

BACKGROUND: informal carers of people with dementia are at greater risk of anxiety and depressive disorders if they find caregiving to be a burden. The aim of this study was to use a network analysis of cross-sectional data to investigate the relationships between anxiety and depressive symptoms in family carers of older people with dementia who experience burden. METHODS: sixty family carers exhibiting high levels of burden using the Zarit Burden Interview were included in the study. Participants completed the Hospital Anxiety and Depression Scale. The network analysis identified the depression and anxiety symptom network using features including a topological graph, network centrality metrics and community analysis. The network was estimated through the graphical LASSO technique in combination with a walktrap algorithm to obtain the clusters within the network and the connections between the nodes (symptoms). A directed acyclic graph was generated to model symptom interactions. RESULTS: the resulting network architecture shows important bridges between depression and anxiety symptoms. Lack of pleasure and loss of enjoyment were identified as potential gateway symptoms to other anxiety and depression symptoms and represent possible therapeutic targets for psychosocial interventions. Fear and loss of optimism were highly central symptoms, indicating their importance as warning signs of more generalised anxiety and depression. CONCLUSIONS: this network analysis of depressive and anxiety symptoms in overburdened family carers provides important insights as to what symptoms may be the most important targets for behavioural interventions.

Comparing knowledge and attitudes to dementia care in Brazilian and UK GPs to guide future decisions about educational interventions.

Background: Dementia training for Brazilian general practitioners (GPs) is underdeveloped. We investigated knowledge and attitudes to dementia management among Brazilian GPs and compared these with previous UK findings to inform future decisions about how training is structured.Methods: A total of 115 Brazilian GPs were asked to complete a Portuguese translation of a questionnaire previously used in the UK. This comprised a 14-item multiple-choice knowledge quiz, and a 5-point Likert-scale questionnaire assessing attitudes across 10 dementia management domains. Exploratory factorial analysis was conducted for attitudes.Results: Attitudes toward dementia demonstrated the same underlying factor structure, "heartsink" and "heartfelt" factors, in Brazil as in previous UK studies, explaining 61.6% of variance in responses. Knowledge scores were negatively correlated with heartfelt and heartsink factors.Conclusions: Greater knowledge about dementia was associated with some pessimism about dementia care. The similarity in the structure of attitudes toward dementia management between Brazilian and UK GPs provides a starting point for shared educational approaches targeting attitudes.

Effectiveness of probiotics on the occurrence of infections in older people: systematic review and meta-analysis.

BACKGROUND: infectious diseases in older people are associated with higher mortality rates and probiotics have been hypothesised to reduce the occurrence of infection. OBJECTIVES: to assess the effectiveness and safety of probiotics in the occurrence of infections in older adults in comparison to placebo. METHODS: a systematic review and meta-analysis of randomised placebo-controlled trials were conducted on 30 December 2016 using Medline, Embase, CENTRAL, Web of Science and LILACS databases. Efficacy outcomes were: occurrence of infection, quality of life, mortality and mean duration of infection per episode. Safety outcomes were adverse events. Data were analysed using relative risk ratios with 95% confidence intervals. Relative risk ratios were pooled where more than three estimates were available. RESULTS: fifteen articles were included, with a total of 5,916 participants with a mean age of 75.21 years. The effect of probiotics was not significantly different from that reported for placebo on the occurrence of infection, adverse events, mortality or mean duration of infection episodes (relative risk (RR) 0.90, 95% confidence interval (CI) 0.76 to 1.08; RR 1.01, 95% CI 0.91 to 1.12; RR 1.09, 95% CI 0.70 to 1.72; MD -0.35, 95% CI -1.57 to 0.87, respectively). CONCLUSION: the current low-quality evidence does not support the use of probiotics for the reduction in the occurrence of infection in older adults, however, the safety outcomes were similar between probiotics and placebo. Further research is required to confirm these findings.PROSPERO: CRD42014013707.

Why medical schools are tolerant of unethical behavior.

The exposure to unethical and unprofessional behavior is thought to play a major role in the declining empathy experienced by medical students during their training. We reflect on the reasons why medical schools are tolerant of unethical behavior of faculty. First, there are barriers to reporting unprofessional behavior within medical schools including fear of retaliation and lack of mechanisms to ensure anonymity. Second, deans and directors do not want to look for unethical behavior in their colleagues. Third, most of us have learned to take disrespectful circumstances in health care institutions for granted. Fourth, the accreditation of medical schools around the world does not usually cover the processes or outcomes associated with fostering ethical behavior in students. Several initiatives promise to change that picture.

Suggested instruments for General Practitioners in countries with low schooling to screen for cognitive impairment in the elderly.

BACKGROUND: General Practitioners (GPs) from underdeveloped countries apply cognitive impairment (CI) assessment tools translated and adapted to cultural setting from other idioms, mainly English. As schooling in elderly from underdeveloped countries tends to be relatively heterogeneous, it is necessary to establish normative and cut-off scores for these CI instruments that are based on studies conducted locally. Some CI screening instruments frequently used by Brazilian specialists in dementia were analyzed to determine which could be most useful to GPs in their working sets. METHOD: Two hundred forty-eight patients aged 65 years or older that had been assisted by GPs in a tertiary hospital in Brazil were evaluated. Based on the MMSE and/or Short-IQCODE scores, 52 probable cases were identified on the basis of clinical data, performances on the neuropsychological tests and questionnaires (Functional Assessment Questionnaire/FAQ, Category Verbal Fluency/CVF, Clock Drawing Test/CDT) and blood tests and brain CT. RESULTS: The combination of a functional questionnaire with a cognitive instrument had higher sensitivity and specificity than using the instruments alone. A FAQ cut-off of 3 in conjunction with a CDT cut-off of 6 proved optimal (93% sensitivity and 92.5% specificity). A higher specificity (93.5%) was attained using a combination of the FAQ (cut-off of 3) with the CVF (cut-off of 10). CONCLUSIONS: For low schooling elderly, the combination of the FAQ and CVF represented a very simple method of increasing the chances of correct screening. For those with higher schooling, the combination of the FAQ and CDT was more suitable.

Behavioral and psychological symptoms of dementia in the long-term care setting: assessment of aged adults and intervention for caregivers.

Due to the progressive need for care, older adults with dementia are at risk of becoming institutionalized. Caregivers of these patients are tasked with the challenge of controlling behavioral and psychological symptoms without sufficient knowledge and are therefore at greater risk of developing physical and mental health problems. In this context, psychoeducational interventions can help greatly toward improving caregiver well-being. Objective: to investigate the prevalence of behavioral and psychological symptoms of dementia (BPSD) in aged residents of long-term care facilities (LTCFs), to determine the prevalence of burden and common mental disorders in caregivers, and to assess the effects of a psychoeducational intervention. Methods: an intervention study was performed at LTCFs for aged people. The following instruments were used: Self-Reporting Questionnaire and Zarit Burden Interview for caregivers; and the MMSE, Katz Index, Clinical Dementia Rating scale and Neuropsychiatry Inventory-Questionnaire for older adults. Results: Of the 72 aged residents assessed, 52 (72.2%) were female and mean age was 82.3 (±8.14) years. The most prevalent neuropsychiatric symptoms were euphoria and elation (74%), followed by agitation and aggression (74%). Of the 54 caregivers, 49 (90.7%) were women and mean age was 33.9 (±10.8) years. Overall, 33.3% screened positive for common mental disorder and 36.1% for burden/overload. A statistically significant association was found between burden and working in philanthropic institutions (p=0.003) and also between burden and presence of common mental disorder or otherwise (p=0.001). After the psychoeducational intervention, 42.8% reported reduced burden. Conclusion: The residents presented neuropsychiatric symptoms. Caregivers showed burden and common mental disorders, especially in philanthropic institutions. It was observed a reduction in burden of caregivers with psychoeducational intervention, showing the importance of this strategy.

Em razão do aumento progressivo da necessidade de cuidados, idosos com demência apresentam risco de institucionalização. Os cuidadores desses pacientes são desafiados a controlar os sintomas comportamentais e psicológicos da demência sem o conhecimento adequado e, como resultado, estão em maior risco de adoecimento físico e emocional. Nesse contexto, a intervenção psicoeducacional contribui significativamente para a melhoria do bem-estar do cuidador. Objetivo: Investigar a prevalência de sintomas comportamentais e psicológicos na demência em idosos de instituições de longa permanência, verificar a prevalência de sobrecarga e transtorno mental comum nos cuidadores e avaliar os efeitos de uma intervenção psicoeducacional. Métodos: Estudo de intervenção realizado em instituições de longa permanência para idosos. Os instrumentos utilizados foram: Self-Reporting Questionnaire e Zarit Burden Interview para os cuidadores e o Miniexame do Estado Mental, Katz Index, Clinical Dementia Rating e Neuropsychiatry Inventory-Questionnaire para os idosos. Resultados: Dos 72 idosos, 52 (72,2%) eram mulheres, com média de idade de 82,3 (±8,14) anos. Os sintomas neuropsiquiátricos mais prevalentes foram: euforia e elação (74%) e agitação e agressividade (74%). Dos 54 cuidadores, 49 (90,7%) eram mulheres, com média de idade de 33,9 (±10,8) anos. Apresentaram rastreio positivo para transtorno mental comum 33,3% e para sobrecarga 36,1%. Foi encontrada associação estatisticamente significativa entre sobrecarga e trabalhar em instituições filantrópicas (p=0,003), assim como entre a sobrecarga e ter ou não transtorno mental comum (p=0,001). Após a intervenção psicoeducacional, 42,8% apresentaram redução da sobrecarga. Conclusão: Os residentes apresentaram sintomas neuropsiquiátricos. Os resultados dos cuidadores indicaram a presença de sobrecarga e outras manifestações em saúde mental, principalmente em instituições filantrópicas, além de demonstrar a importância de intervenções psicoeducativas voltadas aos cuidadores, considerando que foram observados efeitos na redução da sobrecarga para o grupo intervenção.

Association among inflammaging, body composition, physical activity, and physical function tests in physically active women.

Background: Inflammaging is a phenomenon that has been associated with the development and progression of sarcopenia and frailty syndrome. According to the literature, on the one side, the increase in body fat is associated with a systemic pro-inflammatory status, which consequently favors inflammaging, and on the other side, the regular practice of physical exercise can mitigate the development of this scenario. Therefore, here, we aimed to evaluate the association between inflammaging and physical factors, both body and functional, in a group of physically active older women. Methods: Seventy older women (mean age 72.66 ± 6.17 years) participated in this observational cross-sectional and were separated into the eutrophic, overweight, and obese groups. It was assessed: by bioimpedance-body fat percentage (Fat%) and total (Fat kg), skeletal muscle mass (muscle), and free fat mass both in percentage (FFM%) and total (FFMkg); by the International Physical Activity Questionnaire (IPAQ)-the time of moderate-intensity physical activity per week; by physical tests-handgrip (HG), sit-up-stand-on-the-chair in 5 repetitions (Sit-up) and vertical squat jump test (SJ); in addition to the determination of serum cytokine concentration (IL-6, TNF-α, IL-10, and IL-8), and also body mass index (BMI) and calf circumference (Calf). Results: Higher FFM% and lower body fat (both kg and %) were found in the eutrophic group than in the other groups. The eutrophic group also performed more weekly physical activity, jumped higher, and presented not only higher serum IL-6 concentration but also an increased ratio of IL-10/IL-6, IL-10/TNF-α, IL-10/IL-8 as compared to the values found in the overweight group. The obese group presented higher body fat (kg and %) and lower FFM% than the other groups and also higher serum IL-6 concentration than the overweight group. Interestingly, several significant negative and positive correlations between body composition, physical tests, and serum cytokine concentrations were found in the eutrophic and obese groups. Conclusion: While the eutrophic older women group showed a remarkable regulation of the systemic inflammatory status with positive associations in the physical parameters assessed, the overweight and obese groups presented impairment regulations of the inflammaging, which could be related to less weekly physical activity and higher body fat.

Impact of long-term care facilities' size on adherence to COVID-19' infection prevention guidance. / Impacto do tamanho das instituições de longa permanência na adesão às orientações de prevenção de infecções por COVID-19.

OBJECTIVE: to evaluate the adherence of Brazilian long-term care facilities to the World Health Organization Infection Prevention and Control guidance, and assess the association of their size with the adherence to these recommendations. METHOD: cross-sectional study conducted with facilities' managers. Authors developed a 20-item questionnaire based on this guidance, and a global score of adherence, based on the adoption of these recommendations. Adherence was classified as (1) excellent for those who attended ≥14 out of 20 recommendations; (2) good for 10 to 13 items; and (3) low for those with less than ten items. Facilities' sizes were established as small, intermediate, and large according to a two-step cluster analysis. Descriptive statistics and chi-square tests were used at a 5% significance level. RESULTS: among 362 included facilities, 308 (85.1%) adhered to 14 or more recommendations. Regarding its size, adherence to screening COVID-19 symptoms of visitors (p=0.037) and isolating patients until they have had two negative laboratory tests (p=0.032) were lower on larger ones compared to medium and small facilities. CONCLUSION: adherence to COVID-19 mitigation measures in Brazilian facilities was considered excellent for most of the recommendations, regardless of the size of the units.

Measurement properties of self-report instruments to assess health literacy in older adults: a systematic review.

BACKGROUND: High health literacy (HL) is important to optimise health outcomes, particularly for older people (who are substantial consumers of health services) and their adult caregivers. The aim of this systematic review was to evaluate measurement properties of HL instruments tested with these population groups. MATERIALS AND METHODS: Six databases (MEDLINE (OVID); CINAHL; EMBASE (OVID); PsycInfo; Scopus; Cochrane Library) were searched for studies evaluating eight measurement properties of HL tools administered to older people or their caregivers. Only studies evaluating multi-domain self-report HL tools were included in analyses, using the COSMIN methodology. RESULTS: From 4261 unique papers located, 11 met inclusion criteria; six reported measurement properties of three HL self-report tools administered to older people (HLQ, eHEALS, and HeLMS) so are reported in this review, none involved caregiver samples. The HLQ and HeLMS were rated "moderate," and eHEALS "low" for tool development. The HLQ, examined in four included studies, had the highest ratings and quality of evidence across the three measurement properties investigated in included papers. CONCLUSION: The HLQ was the most highly rated self-report HL tool of just three tested with older people. Further studies evaluating measurement properties of self-report HL tools used with older people and/or their caregivers are needed.Implications for rehabilitationHealth literacy is important to optimise health outcomes of interventions for older people and their adult caregivers.Few studies have evaluated measurement properties of self-report / multi-domain health literacy tools for this population.The Health Literacy Questionnaire (HLQ) had the highest ratings and quality of evidence across the three measurement properties investigated in included studies, and is recommended for use in rehabilitation settings.

Knowledge and attitudes in dementia held by general practitioners in the primary care setting of Botucatu, São Paulo, Brazil.

BACKGROUND: Alzheimer's disease (AD) is the leading cause of dementia worldwide. Despite alarming evidence on dementia prevalence, the condition is still underdiagnosed by general practitioners (GPs) in primary care. Early detection of the disease is beneficial for patients and relatives, who should be provided comprehensive guidance on dealing with dementia complications, covering medical, family and social aspects, thereby providing an opportunity to plan for the future. OBJECTIVE: The objective of this study was to assess the knowledge of and attitudes toward dementia held by GPs from a city in the interior of São Paulo State, Brazil. METHODS: A non-randomized intervention study was conducted involving six lectures about dementia. Before and after the intervention, the participating physicians completed two quizzes about knowledge of and attitudes towards dementia. The study was carried out in the primary care services of the town and a total of 34 GPs participated in the study. RESULTS: The mean age of the sample was 33.9 (±10.2) years and the majority (76.5%) of the sample had not undertaken medical residency training. The mean number of correct answers on the Knowledge Quiz about dementia before and after the training intervention was 59.6 and 71.2% (p<0.001), respectively. The comparison of the mean responses on the Attitude Quiz revealed no statistically significant difference between the two applications of the instrument, before and after intervention (p=0.059). CONCLUSIONS: More training for GPs on dementia should be provided.

Association between baseline Mini-Mental State Examination score and dementia incidence in a cohort of oldest old.

BACKGROUND: The Brazilian population has aged rapidly. The oldest old, defined as persons aged 80 years or older, is the fastest growing segment of the Brazilian population. Several instruments have been used to assess the cognitive performance of the older people and predict dementia. One of the most commonly used is the Mini-Mental State Examination (MMSE). OBJECTIVE: The aim of this study was to investigate the relationship between baseline MMSE score and the incidence of dementia in a Brazilian cohort of independent oldest old. METHODS: Sociodemographic data and serial cognitive assessment of 248 older adults were analyzed. RESULTS: Mean follow-up time of subjects was 4.0(±1.9) years, 71.4% were women, and mean MMSE score at entry was 25(±3.5). Mean MMSE scores at baseline were significantly higher (p=0.001) in the cognitively intact group than in those who developed dementia. The logistic regression showed that for a one point increase in MMSE score at baseline there was a 10% reduction in the probability of dementia. CONCLUSIONS: In the Brazilian scenario of a rapidly growing population of oldest old, the extensive use of the MMSE gives rise to the need not only to determine its effectiveness for screening dementia, but also to interpret its score in terms of future conversion to dementia.

Influence of overcommitment on the quality of life and on climacteric symptoms in nursing professionals.

OBJECTIVE: To describe the general characteristics of nursing professionals and assess the influence of overcommitment on perceived climacteric symptoms and on the quality of life of nursing professionals. METHOD: A cross-sectional, analytical study of 152 nursing auxiliaries and assistants aged 40 years or older was conducted at 3 hospitals in the interior of São Paulo state. Sociodemographic data were collected and the Blatt-Kupperman Menopausal Index, Women´s Health Questionnaire, Medical Outcome Study 36-item Short Form Health Survey and Effort-Reward Imbalance were applied in 2017. A descriptive analysis was performed and network analysis was carried out. RESULTS: Participants had a mean age of 50.23 years (SD ±7.1). Group 1 comprising 61 (40.1%) women with overcommitment had poorer quality of life as well as more severe climacteric symptoms. CONCLUSIONS: Presence of overcommitment seems to influence the negative perception of climacteric symptomatology and quality of life.

Mapping Research Conducted on Long-Term Care Facilities for Older People in Brazil: A Scoping Review.

This scoping review aimed to explore the characteristics, strengths, and gaps in research conducted in Brazilian long-term care facilities (LTCFs) for older adults. Electronic searches investigating the residents (≥60 years old), their families, and the LTCF workforce in Brazil were conducted in Medline, EMBASE, LILACS, and Google Scholar, within the timescale of 1999 to 2018, limited to English, Portuguese, or Spanish. The reference lists were hand searched for additional papers. The Mixed Methods Appraisal Tool (MMAT) was used for critical appraisal of evidence. Data were reported descriptively considering the study design, using content analysis: 327 studies were included (n = 159 quantitative non-randomized, n = 82 quantitative descriptive, n = 67 qualitative, n = 11 mixed methods, n = 6 randomized controlled trials, and n = 2 translation of assessment tools). Regardless of the study design, most were conducted in a single LTCF (45.8%), in urban locations (84.3%), and in non-profit settings (38.7%). The randomized trials and descriptive studies presented the lowest methodological quality based on the MMAT. This is the first review to provide an overview of research on LTCFs for older people in Brazil. It illustrates an excess of small-scale, predominantly qualitative papers, many of which are reported in ways that do not allow the quality of the work to be assured.

Older adults with dementia: knowledge and attitudes of physicians in health units.

OBJECTIVE: To describe the knowledge and attitudes of general practitioners of the basic health network of the city of São Paulo in relation to patients with dementia and identify patterns of attitudes. METHODS: A total of 10% of the basic health units in the city of São Paulo (n = 45) were randomly distributed into six regional health coordination centers. Up to two general practitioners were interviewed in each unit, with a total of 81 physicians interviewed. They answered the translated and cross-culturally adapted version for Brazil of two British questionnaires, the knowledge quiz (knowledge about dementias) and the attitude quiz (attitude towards the patient afflicted with dementia), as well as a sociodemographic and occupational questionnaire to understand the profile of general practitioners working in primary care. Descriptive data analysis, factor analysis of the main components of the attitude quiz and study of association between attitudes and knowledge were performed, in addition to the multiple linear regression test to determine the relationship between occupational profile and knowledge about attitude patterns in dementia. RESULTS: The physicians interviewed had a median of five-year graduation time; 35.8% worked exclusively with primary care, and less than 40% had completed, or were attending, medical residency or specialization. Physicians showed a lower knowledge about the diagnosis of dementia than about the epidemiology of the disease and its therapeutic management. Their attitudes towards patients afflicted with dementia resulted in four factors: proactive optimism, delegated optimism, implicit dismay, and explicit dismay. The regression study showed that the attitude of explicit dismay decreases the longer the weekly working hours of the physician in the units, and that the delegated optimistic attitude of the physician decreases in the same situation. CONCLUSION: Investment in training is essential to improve physicians' performance in the field of dementia in primary care.

Assessment of functional health literacy in Brazilian carers of older people.

Individuals with low health literacy have less knowledge of their own health condition. Carers play a key role in older people's activities of daily living. OBJECTIVE: to evaluate the performance of carers of older people using the S-TOFHLA (Short Test of Functional Health Literacy in Adults) and to identify caregiver characteristics associated with low functional health literacy. METHODS: a cross-sectional study was conducted. The S-TOFHLA, a sociodemographic instrument, the Mini-Mental State Exam and the Patient Health Questionnaire-2 were applied to 80 carers of older patients routinely followed by doctors from the Primary Health Care Sector of the City of Botucatu, São Paulo. The multivariate analysis used an ordinal logistic regression model with test (S-TOFHLA) scores as the dependent variable. The level of statistical significance adopted was 0.05. RESULTS: the individuals had a mean age of 54.6 (± 11.7); 27% of the carers evaluated had inadequate levels of health literacy (S-TOFHLA ≥54). A higher proportion of individuals with low education had inadequate or marginal health literacy (p<0.001). CONCLUSION: nearly 1/3 of the carers had marginal or inadequate levels of health literacy. These results highlight the difficulties of many carers in understanding health information.

Indivíduos com baixo alfabetismo em saúde têm menos conhecimento sobre sua própria condição de saúde. Cuidadores desempenham um papel fundamental nas atividades de vida diária dos idosos. OBJETIVO: avaliar o desempenho de cuidadores de pessoas idosas usando o "S-TOFHLA (Short Test of Functional Health Literacy in Adults)" e identificar características do cuidador associadas ao baixa alfabetismo em saúde. MÉTODOS: um estudo transversal foi conduzido. O S-TOFHLA, um instrumento sociodemográfico, o Miniexame do Estado Mental e o "Patient Health Questionnaire - 2" foram aplicados a 80 cuidadores de pacientes idosos rotineiramente acompanhados por médicos do Setor de Atenção Primária à Saúde da cidade de Botucatu, São Paulo. A análise multivariada utilizou um modelo de regressão logística ordinal com os escores do S-TOFHLA como variável dependente. O nível de significância estatística adotado foi de 0,05. RESULTADOS: os indivíduos tiveram idade média de 54,6 (± 11,7) anos; 27% dos cuidadores avaliados apresentavam níveis inadequados de alfabetização em saúde. Uma proporção maior de indivíduos com baixa escolaridade apresentou alfabetização em saúde inadequada e limítrofe (p<0,001). CONCLUSÃO: aproximadamente 1/3 dos cuidadores apresentaram níveis limítrofes e inadequados de alfabetização em saúde. Esses resultados destacam as dificuldades de muitos cuidadores em compreender informações sobre saúde.

Evaluation of the Interrater Reliability of End-of-Life Medical Orders in the Physician Orders for Life-Sustaining Treatment Form.

Importance: Despite its spread in much of the United States and increased international interest, the Physician Orders for Life-Sustaining Treatment (POLST) paradigm still lacks supporting evidence. The interrater reliability of the POLST form to translate patients' values and preferences into medical orders for care at the end of life remains to be studied. Objective: To assess the interrater reliability of the medical orders documented in POLST forms. Design, Setting, and Participants: This cross-sectional study was conducted in a public university hospital in southeastern Brazil. Two independent researchers interviewed the same patients or decision-making surrogates (n = 64) during a single episode of hospitalization within a time frame of 1 to 7 days. Eligible participants were hospitalized adults aged 21 years or older who were expected to remain hospitalized for at least 4 days and whose attending physician responded no to the question, Would I be surprised if this patient died in the next year? Data collection occurred between November 1, 2015, and September 20, 2016, and first data analyses were performed on October 3, 2016. Main Outcomes and Measures: Interrater reliability as measured by κ statistics. Results: Of the 64 participants interviewed in the study, 53 (83%) were patients and 11 (17%) were surrogates. Patients' mean (SD) age was 64 (14) years, and 35 patients (55%) and 8 surrogates (73%) were women. Overall, in 5 cases (8%), disagreement in at least 1 medical order for life-sustaining treatment was found in the POLST form, changing from the first interview to the second interview. The κ statistic for cardiopulmonary resuscitation was 0.92 (95% CI, 0.80-1.00); for level of medical intervention, 0.89 (95% CI, 0.76-1.00); and for artificially administered nutrition, 0.92 (95% CI, 0.83-1.00). Conclusions and Relevance: The high interrater reliability of the medical orders in POLST forms appears to offer further support for this advance care planning paradigm; in addition, the finding that this interrater reliability was not 100% underscores the need to ensure that patients or their surrogates have decision-making capacity and to confirm that the content of POLST forms accurately reflects patients' current treatment preferences.

Behavioral and psychological symptoms of dementia in the long-term care setting: assessment of aged adults and intervention for caregivers / Sintomas comportamentais e psicológicos na demência no contexto da longa permanência: avaliação de idosos e intervenção para cuidadores

ABSTRACT Due to the progressive need for care, older adults with dementia are at risk of becoming institutionalized. Caregivers of these patients are tasked with the challenge of controlling behavioral and psychological symptoms without sufficient knowledge and are therefore at greater risk of developing physical and mental health problems. In this context, psychoeducational interventions can help greatly toward improving caregiver well-being. Objective: to investigate the prevalence of behavioral and psychological symptoms of dementia (BPSD) in aged residents of long-term care facilities (LTCFs), to determine the prevalence of burden and common mental disorders in caregivers, and to assess the effects of a psychoeducational intervention. Methods: an intervention study was performed at LTCFs for aged people. The following instruments were used: Self-Reporting Questionnaire and Zarit Burden Interview for caregivers; and the MMSE, Katz Index, Clinical Dementia Rating scale and Neuropsychiatry Inventory-Questionnaire for older adults. Results: Of the 72 aged residents assessed, 52 (72.2%) were female and mean age was 82.3 (±8.14) years. The most prevalent neuropsychiatric symptoms were euphoria and elation (74%), followed by agitation and aggression (74%). Of the 54 caregivers, 49 (90.7%) were women and mean age was 33.9 (±10.8) years. Overall, 33.3% screened positive for common mental disorder and 36.1% for burden/overload. A statistically significant association was found between burden and working in philanthropic institutions (p=0.003) and also between burden and presence of common mental disorder or otherwise (p=0.001). After the psychoeducational intervention, 42.8% reported reduced burden. Conclusion: The residents presented neuropsychiatric symptoms. Caregivers showed burden and common mental disorders, especially in philanthropic institutions. It was observed a reduction in burden of caregivers with psychoeducational intervention, showing the importance of this strategy.

RESUMO Em razão do aumento progressivo da necessidade de cuidados, idosos com demência apresentam risco de institucionalização. Os cuidadores desses pacientes são desafiados a controlar os sintomas comportamentais e psicológicos da demência sem o conhecimento adequado e, como resultado, estão em maior risco de adoecimento físico e emocional. Nesse contexto, a intervenção psicoeducacional contribui significativamente para a melhoria do bem-estar do cuidador. Objetivo: Investigar a prevalência de sintomas comportamentais e psicológicos na demência em idosos de instituições de longa permanência, verificar a prevalência de sobrecarga e transtorno mental comum nos cuidadores e avaliar os efeitos de uma intervenção psicoeducacional. Métodos: Estudo de intervenção realizado em instituições de longa permanência para idosos. Os instrumentos utilizados foram: Self-Reporting Questionnaire e Zarit Burden Interview para os cuidadores e o Miniexame do Estado Mental, Katz Index, Clinical Dementia Rating e Neuropsychiatry Inventory-Questionnaire para os idosos. Resultados: Dos 72 idosos, 52 (72,2%) eram mulheres, com média de idade de 82,3 (±8,14) anos. Os sintomas neuropsiquiátricos mais prevalentes foram: euforia e elação (74%) e agitação e agressividade (74%). Dos 54 cuidadores, 49 (90,7%) eram mulheres, com média de idade de 33,9 (±10,8) anos. Apresentaram rastreio positivo para transtorno mental comum 33,3% e para sobrecarga 36,1%. Foi encontrada associação estatisticamente significativa entre sobrecarga e trabalhar em instituições filantrópicas (p=0,003), assim como entre a sobrecarga e ter ou não transtorno mental comum (p=0,001). Após a intervenção psicoeducacional, 42,8% apresentaram redução da sobrecarga. Conclusão: Os residentes apresentaram sintomas neuropsiquiátricos. Os resultados dos cuidadores indicaram a presença de sobrecarga e outras manifestações em saúde mental, principalmente em instituições filantrópicas, além de demonstrar a importância de intervenções psicoeducativas voltadas aos cuidadores, considerando que foram observados efeitos na redução da sobrecarga para o grupo intervenção.

Validity and reliability of the Brazilian Portuguese version of the Australian National University - Alzheimer's Disease Risk Index (ANU-ADRI).

The ANU-ADRI is a self-report tool that assesses risk for Alzheimer's Disease (AD). OBJECTIVE: To validate an adapted Portuguese version of this instrument and to carry out the reliability Test-Retest of the ANU-ADRI in Brazil. METHODS: In this longitudinal study, the sample was formed (n=100) by two groups (A and B): each comprising 50 patients assisted by GPs (general practitioners) or specialists in dementia. All participants were cognitively healthy upon screening using the MMSE. The ANU-ADRI was applied at baseline (Test) and again within 1 week of the test (Retest). RESULTS: There was a correlation between the mean scores of the ANU-ADRI Test and Retest (r=0.918, P<0.001). Group A had higher ANU-ADRI scores than those of group B (P<0.05). There was a moderate negative linear relation between the ANU-ADRI and MMSE scores (r= -0.353, P<0.001). CONCLUSION: The ANU-ADRI is a valid and reliable instrument to assess whether community-dwelling Brazilians are at greater risk for AD. Low levels of education were associated with higher risk scores on the ANU-ADRI.

O Índice de Risco da Doença de Alzheimer da "Australian National University" (ANU-ADRI) é uma ferramenta baseada em auto-relato que avalia o risco para Doença de Alzheimer (DA). OBJETIVO: Validar uma versão adaptada em português deste instrumento e realizar a confiabilidade Teste-Reteste do ANU-ADRI no Brasil. MÉTODOS: Neste estudo longitudinal, a amostra foi composta (n=100) por 2 grupos (A e B): cada um com 50 pacientes assistidos por clínicos gerais ou especialistas em demência. Todos os participantes eram cognitivamente normais após o rastreio usando o MEEM. O ANU-ADRI foi aplicado no início (Teste) e até uma semana após o teste (Reteste). RESULTADOS: Houve uma correlação entre a média de pontuações do ANU-ADRI no Teste e Reteste (r=0,918, P<0,001). O grupo A teve pontuações maiores no ANU-ADRI que as do grupo B (P<0,05). Houve uma relação moderada linear entre as pontuações do ANU-ADRI e MEEM (r= -0,353, P<0,001). CONCLUSÃO: ANU-ADRI é um instrumento válido e confiável para avaliar se brasileiros que vivem na comunidade estão à risco maior para DA. Baixos níveis de escolaridade foram relacionados às pontuações mais altas do ANU-ADRI.

Cross-cultural adaptation to Brazilian Portuguese of the Dementia Knowledge Assessment Tool Version Two: DKAT2.

OBJECTIVES: The Dementia Knowledge Assessment Tool Version Two (DKAT2) was developed to measure caregivers' knowledge about the trajectory of dementia and assess changes in the knowledge before and after educational programs. The DKAT2 is a 21-item tool with questions about several aspects of dementia. The possible answers for each question are "yes", "no" or "don't know". The maximum score is 21. The aim of the study was to cross-culturally adapt the DKAT2 to Brazilian Portuguese. METHODS: The essential steps to cross-culturally adapt were conducted and the final version administered to 30 caregivers of older people with dementia, sampled by convenience. RESULTS: In the sample assessed, the mean age was 55.7 (± 12.5) years, 93.3% were female, 56.7% were sons/daughters and 23.3% were spouses of the older adults with dementia. The mean time caring for the elder was 4.7 (± 3.3) years and 70% of the caregivers had some level of burden. The mean age of the older people was 82.4 (± 6.7) years, 19 (63.3%) had a diagnosis of Alzheimer's disease, 100% were dependent for instrumental activities of daily living and 70% had some degree of dependence for basic activities of daily living. The mean score for the caregivers' knowledge level was 15.0 (± 2.5) correct answers. CONCLUSIONS: The Brazilian Portuguese version was developed and the final version is suitable for use in Brazil.