The STAIR OF KNOWLEDGE-a codesigned intervention to prevent pressure ulcers, malnutrition, poor oral health and falls among older persons in nursing homes in Sweden: development of a complex intervention.

OBJECTIVES: To describe the development of a codesigned complex intervention intended to prevent the risks of pressure ulcers, malnutrition, poor oral health and falls among older persons in nursing homes. DESIGN: A complex intervention development study. The development of the intervention was conducted in three phases. We established contact with stakeholders in the municipality, updated us of current status of the literature in this area and conducted studies in the local context (1). We codesigned the intervention in workshops together with end users (2). We codesigned the final outline of the intervention in an iterative process with stakeholders (3).Setting: Nursing homes in the municipality in southern Sweden. PARTICIPANTS: End users (n=16) in nursing homes (n=4) codesigned the intervention together with the research group in workshops (n=4) in March-April 2022. Additionally, stakeholders (n=17) who were considered to play an important role in developing the intervention participated throughout this process. Data were analysed using reflexive thematic analysis. RESULTS: Four workshops were conducted with end users (n=16) and 13 meetings with stakeholders (n=12) were held during the development process. The intervention aims to bridge the evidence-practice gap regarding the preventive care process of the risks of pressure ulcers, malnutrition, poor oral health and falls among older persons in nursing homes. The intervention is aimed at end users, lasts for 3 weeks and is divided into two parts. First, end users obtain knowledge on their own by following written instructions. Second, they meet, interact and discuss the knowledge acquired during part 1. CONCLUSION: The intervention is robustly developed and thoroughly described. The study highlights the extensive process that is necessary for developing tailored complex interventions. The description of the entire development process may enhance the replicability of this intervention. The intervention needs to be tested and evaluated in an upcoming feasibility study. TRIAL REGISTRATION NUMBER: NCT05308862.

Prevalence of risk for pressure ulcers, malnutrition, poor oral health and falls - a register study among older persons receiving municipal health care in southern Sweden.

BACKGROUND: Although pressure ulcers, malnutrition, poor oral health and falls are common among older persons, causing deteriorated health status, they have not been studied altogether among older persons receiving different types of municipal health care. The aim of this study was to determine the prevalence of risk for pressure ulcers, malnutrition, poor oral health and falls among older persons aged ≥65 years receiving municipal health care in southern Sweden. METHODS: A retrospective cross-sectional study (n = 12,518 persons aged ≥65 years) using data from the national quality registry Senior Alert was conducted. The prevalence of risk for pressure ulcers, malnutrition, poor oral health and falls was calculated based on categorical data from the instruments available in Senior Alert. T-tests, chi-square test, the Mantel- Haenszel test and logistic regression models were performed. RESULTS: The prevalence of risk for pressure ulcers, malnutrition, poor oral health and falls was 27.9, 56.3, 34.2 and 74.5% respectively. Almost 90% of the older persons had at least one health risk. The prevalence of risk for pressure ulcers, poor oral health and falls was significantly higher in dementia care units compared to short term nursing care, home health care and nursing homes. The prevalence of risk for malnutrition was significantly higher among older persons staying in short term nursing care compared to other types of housing. The odds of having a risk for malnutrition were higher in short term nursing care compared to other types of housing. The oldest age group of 95-106 years had the highest odds of having a risk for falls. The presence of multiple health risks in one subject were more common in dementia homes compared to nursing homes and home health care but not compared to short term nursing care. CONCLUSION: The prevalence of risk for pressure ulcers, malnutrition, poor oral health and falls was high, implying that these health risks are a great concern for older persons receiving municipal health care. A comprehensive supporting preventive process to prevent all the investigated health risks among older persons receiving municipal health care is recommended.

Prevention of pressure ulcers, malnutrition, poor oral health and falls in nursing homes: A focus group study with nurse aides, registered nurses and managers.

Background: Despite available knowledge how to prevent the risk of pressure ulcers, malnutrition, poor oral health and falls among older persons in nursing homes, these risks still frequently occur and cause a major burden for older persons; furthermore, for the health care system, they are extremely costly. One way to combat these risks is to register the prevention process in quality registries. However, the increasing older population worldwide is going to put high demands on those working with this group of people. Objective: To explore how nurse aides, registered nurses and managers in nursing homes experience working with the prevention of pressure ulcers, malnutrition, poor oral health and falls in general and according to the quality register Senior Alert care process. Methods: A qualitative study was conducted in nursing homes in a municipality in southern Sweden. We purposively sampled nurse aides, registered nurses and managers (n = 21) working in nursing homes registered in the quality register Senior Alert, who then participated in one of five focus group semistructured digital interviews held between February and April 2020. The interviews were audio recorded. Data were analysed using reflexive thematic analysis. Results: Our findings explore how nurse aides, registered nurses and managers experience working with the prevention of pressure ulcers, malnutrition, poor oral health and falls in nursing homes both in general and according to Senior Alert. The following four themes were generated during the analysis: (1) is included in the everyday work, (2) requires team effort, (3) requires handling many challenges and (4) requires finding strategies. Conclusion: The prevention of pressure ulcers, malnutrition, poor oral health and falls among older persons in nursing homes is complex. There is a commitment and responsibility among nurse aides, registered nurses and managers regarding preventive work and team effort, and finding useful strategies is necessary for the work to be successful. However, challenges, both at the individual and organizational levels, are involved, which implies that smoother organizational routines facilitating this preventive work are needed. Although nurse aides, registered nurses and managers are good at finding strategies that facilitate this work, one of the main challenges seems to lie in the variety of knowledge found among those working in nursing homes, particularly among nurse aides. This challenge was voiced by all the professionals, which suggests the need for a tailored educational intervention aimed at increasing the related knowledge among those working in nursing homes to enhance preventive work.

Myeloid blood dendritic cells and monocyte-derived dendritic cells differ in their endocytosing capability.

Human dendritic cells (DCs) constitute a heterogeneous population of antigen-presenting cells characterized by a unique capacity to stimulate naïve T cells. The functions of DCs depend on the particular subset and in this study we compare two types of myeloid DCs: freshly isolated blood mDCs and in vitro generated monocyte-derived DCs (MoDCs), in their ability to accomplish endocytosis. In our hands, these two DC subtypes showed similarities in the expression of surface markers, but displayed clear differences in endocytic capacity. Freshly isolated blood mDCs showed a high propensity to capture and endocytose particles compared to in vitro generated MoDCs. The blood mDCs also showed a clear receptor-enhanced endocytosis when zeolite particles were co-adsorbed with IgG. On the other hand, the MoDCs differed remarkably compared to blood mDCs in the capture of ovalbumin and immune complexes. Interestingly, the MoDCs showed low endocytosis of IgG-coated particles but an efficient capture of immune complexes. The MoDCs also showed a high capacity to capture ovalbumin although with a relatively low degree of internalization. These data indicate distinct differences in the early process of endocytosis featured by mDCs and MoDCs, which is important to consider when choosing DC populations for future functional or clinical applications.

Ligand surface density is important for efficient capture of immunoglobulin and phosphatidylcholine coated particles by human peripheral dendritic cells.

A unique property of dealuminated zeolite particles is the exceptional ability to bind both hydrophilic and hydrophobic biomolecules without any covalent linkages. By adsorbing phospholipids onto the particle surface, capture of particles by human peripheral myeloid dendritic cells (mDCs) was observed. Capture of zeolite particles was only seen when a low density of phosphatidylcholine was present on the particles, indicating a specific recognition of the structural features realised by phosphatidylcholine after adsorption on the particle. Adsorbing IgG on the particles revealed capture by mDCs that was dependent upon the density of the IgG molecules. To obtain a smaller particle exposing a high density of IgG molecules, immune complexes (ICs) were formed and both mDCs and pDCs (peripheral plasmacytoid DCs) captured immune complexes, although the mDCs showed a more efficient capture of ICs. As expected, mDCs captured and internalized ICs, whereas pDCs captured ICs but showed no internalization of ICs.

Receptor-mediated endocytosis of particles by peripheral dendritic cells.

Human peripheral dendritic cells (DCs) are antigen-presenting cells with the ability to internalize antigen and present antigen-derived peptides to T cells. Human DCs express several receptors on the surface for endocytosis and other recognition receptors that bind to microbes or microbial products, which are internalized and processed. Here, we report the use of nanometer-size zeolite particles as a tool to study receptor-mediated endocytosis by the two subsets of immature DCs, myeloid (mDC) and plasmacytoid (pDC) dendritic cells. A major difference in receptor-mediated endocytosis was observed between the two populations of peripheral DCs. The pDC population demonstrated an almost complete lack of receptor-mediated endocytosis of zeolite particles, whereas the mDC population demonstrated a clear receptor-mediated endocytosis. Fc receptors are expressed by both peripheral DC populations and lipoteichoic acid (LTA) and lipopolysaccharide (LPS) are known ligands of the Toll-like receptor (TLR)-2 and TLR4, respectively, both TLRs expressed by human mDCs. An efficient receptor-mediated endocytosis of immunoglobulin G-, LTA-, and LPS-coated zeolite particles was observed by the mDC population and their endocytosing capacity depended strongly on the density of the ligand adsorbed onto the zeolite particles. In conclusion, an efficient receptor-mediated endocytosis was observed from the mDC population, whereas the pDCs demonstrated an almost complete lack of receptor-mediated endocytosis and nanometer-size dealuminated zeolite particles were a useful tool for studying receptor-mediated endocytosis in human peripheral DCs.

Early activation markers of human peripheral dendritic cells.

Two major populations of dendritic cells (DCs), myeloid and plasmacytoid, can be isolated from human peripheral blood, and are distinguished by differential expression of the cell surface markers CD11c and CD123. These two populations of DCs also are different in their expression of Toll-like receptor (TLRs), which are involved in their activation. To investigate the early events during activation of peripheral DCs, the cells were stimulated in vitro with ligands for TLR-4 (as in lipopolysaccharides [LPS]) or TLR-9 (CpG-containing oligonucleotide [CpG]). The earliest change in protein expression detected after stimulating peripheral DCs with lipopolysaccharide (LPS) or CpG was increased production of the chemokine interleukin (IL)-8. Enhanced production of IL-8 occurred already within 2 hours of stimulation in both myeloid dendritic cells (M-DCs) and plasmacytoid dendritic cells (P-DCs), and preceded expression of the well established activation marker CD40. Although both populations of DCs secreted IL-8 upon activation, the levels of IL-8 produced was several times higher within the M-DCs compared with the P-DCs population. Before activation, both subsets of DCs expressed the IL-8 receptor type B (CD128b); but after stimulation the IL-8 receptor was down-regulated in both populations of DCs. Increased expression of MHC class II molecules is generally regarded as an early activation marker of DCs. However, only the P-DCs showed a significant up-regulation of MHC class II after stimulation. The M-DC population up-regulated MHC class II without any prior activation; thus care should be taken using increased expression of MHC class II molecules as an early activation marker of peripheral M-DCs after activation in vitro. In conclusion, we propose that during activation of human DCs the production of IL-8 and loss of CD128b are the earliest signs of activation preceding both MHC class II, CD40, CD80, and CD86 expression.