Availability and quality of assessment instruments on patient-centredness in older adults with multimorbidity: a systematic review.

OBJECTIVE: Patient-centredness (PC) is central to the health care of older adults with multimorbidity, but knowledge about the psychometric quality of instruments measuring it in this group is scarce. Based on an integrative model of PC, we aimed to identify assessment instruments of PC for this particular group and evaluate their psychometric properties. METHODS: We systematically searched six electronic databases (MEDLINE, CINAHL, EMBASE, PsycINFO, Web of Science and PSYNDEX), initially covering research published up to 2018 and updated later to include work up to July 2022. In evaluating the psychometric properties of identified instruments, we followed the COSMIN methodology. RESULTS: We identified 12 studies reporting on 10 instruments measuring PC in the health care of older adults with multimorbidity. For these instruments, structural validity and internal consistency were the psychometric properties reported most often. Based on the COSMIN criteria, eight instruments received favourable ratings for internal consistency with respect to methodological quality ('very good'), measurement property ('sufficient') and overall quality of evidence ('moderate'). Ratings of structural validity varied more largely, with three to seven instruments showing at least adequate methodological quality, sufficient structural validity or moderate quality of evidence. CONCLUSIONS: Similar to comparable previous reviews, evidence on the psychometric properties of instruments assessing PC in the health care of older adults with multimorbidity was rather limited. Informed by comprehensive models of PC, further research should aim at developing measures of PC that stand out on a broader range of psychometric properties.

Patient-centeredness in the multimorbid elderly: a focus group study.

BACKGROUND: Patient-centeredness (PC) aims to adapt health care to the individual needs and preferences of patients. An existing integrative model of PC comprises several dimensions of PC which have not yet been investigated from the patients' perspective. Older patients with multimorbidity represent a target group for patient-centered care, as their care needs are particularly complex and should be addressed individually. We aimed to assess the perspective that older patients with multimorbidity have of patient-centered care and to examine the transferability of the integrative model of PC to this specific population. METHOD: We performed 4 guided focus group interviews with a total of 20 older individuals with multimorbidity. The focus group interviews were audio-recorded and transcribed verbatim. Patients' statements were content-analyzed applying an a priori designed system of categories that included the dimensions of PC from the integrative model and the additional category 'prognosis and life expectancy', which had emerged from an initial literature search on aspects of PC specific to the multimorbid elderly. RESULTS: The new category 'prognosis and life expectancy' was confirmed and expanded to 'individual care needs related to aging and chronic disesase'. All dimensions of our integrative PC model were confirmed for older patients with multimorbidity. Among these, we found that eight dimensions (individual care needs related to aging and chronic disease, biopsychosocial perspective, clinician-patient communication, essential characteristics of the clinician, clinician-patient-relationship, involvement of family and friends, coordination and continuity of care, access to care) were complemented by aspects specific to this target population. CONCLUSIONS: The integrative PC model is applicable to the population of older patients with multimorbidity. For a population-specific adaptation, it might be complemented by the dimension 'individual care needs in aging and chronic disease', in conjunction with age-specific aspects within existing dimensions. Together with corresponding results from a Delphi survey, our adapted PC model will serve as the basis for a subsequent systematic review of instruments measuring PC in older patients with multimorbidity. TRIAL REGISTRATION: PROSPERO ( https://www.crd.york.ac.uk/prospero; CRD42018084057; 2018/02/01), German Clinical Trials Register ( www.drks.de ; DRKS00013309; 2018/01/23).

Patient-Centeredness in Older Adults With Multimorbidity: Results of an Online Expert Delphi Study.

BACKGROUND AND OBJECTIVES: Older adults suffering from multimorbidity represent a priority target group for patient-centeredness (PC). We aimed to investigate the transferability of an existing integrated model of PC comprising 15 dimensions on the care of older adults with multimorbidity from an expert perspective. RESEARCH DESIGN AND METHODS: A total of 242 experts were invited to participate in a 2-round online Delphi study. In round 1, they were asked to (a) individually rate relevance and clarity of the dimensions, (b) add missing dimensions, and (c) prioritize the dimensions. In round 2, experts received results of round 1 and were asked to rerate their ratings. RESULTS: Forty-eight experts participated in round 1 and 39 in round 2. Ten dimensions were rated as sufficiently relevant and clear, including one new dimension ("prognosis and life expectancy, burden of treatment"). Four dimensions were rated as relevant but insufficiently clear. One dimension failed to reach our validation threshold on both criteria. The 5 dimensions rated as most important were: "patient as a unique person," "clinician-patient communication," "patient involvement in care," "physical, cognitive, and emotional support," and "involvement of family and friends." DISCUSSION AND IMPLICATIONS: The experts' ratings were higher regarding relevance than regarding clarity, which emphasizes the still existing conceptual uncertainty of PC. Our results give further directions regarding the operationalization of PC in older adults with multimorbidity, which is essential for its implementation in routine care. Further refined using focus groups with geriatric patients, our adapted model serves as a basis for a systematic review of assessment instruments.

Availability and Quality of Assessment Instruments on Patient-Centredness in the Multimorbid Elderly (AQuA-PCE): a study protocol of a systematic review.

INTRODUCTION: Elderly, multimorbid patients are a primary target group for patient-centred care, and fostering patient-centredness (PC) in this group has been associated with different healthcare aims such as safety and quality of healthcare. However, evidence on effects of patient-centred interventions is still limited and mixed. In part, the lack of consistent evidence has its roots in a conceptual uncertainty of the term 'PC', which also hampers the development of assessment tools for PC. Consequently, reviews on assessment instruments of PC reveal problems regarding the quality of identified assessment instruments and regarding their comparability. Some of these reviews focus on the elderly. However, while the concept of multimorbidity is partly inherent, this focus is not explicit in any of the reviews.The aim of this systematic review is to identify assessment instruments of PC in the multimorbid elderly, using a subgroup-specific definition of PC ('subgroup-specific integrative model of PC') as the conceptual underpinning, and to provide a critical quality appraisal of their psychometric properties. METHODS AND ANALYSIS: A comprehensive systematic literature search for assessment tools on PC will be conducted in the MEDLINE, CINAHL, EMBASE, PsycINFO, Web of Science and PSYNDEX electronic databases. The search strategy will be informed by the subgroup-specific integrative model of PC. The electronic literature search will be complemented by a hand-search combining citation tracking, search in project databases, and contacting authors from relevant studies/reviews. The literature search (systematic and hand-search) will cover the period from November, 2018 to December 2019.The retrieval of relevant studies will be conducted via title screening, abstract screening, and full-text eligibility assessment applying defined inclusion criteria. Full texts will be independently assessed by two team members. Data from the included articles will be extracted using a standardised extraction form and evaluated based on the COSMIN methodology for systematic reviews of patient-reported outcome measures, which focuses on the methodological quality of included studies as well as on the measurement properties of the assessment instruments. Data extraction and quality assessment will be conducted by two independent reviewers. ETHICS AND DISSEMINATION: The study has received approval from the Ethics Committee of the University of Freiburg (reference number 587/17). The results of the project will be disseminated via scientific oral presentations at national and international conferences and will be published in scientific journals. TRIAL REGISTRATION NUMBERS: CRD42018084057; DRKS00013309.

Effects of mindfulness and psychoeducation on working memory in adult ADHD: A randomised, controlled fMRI study.

Adult attention-deficit/hyperactivity disorder (ADHD) is a serious mental disorder associated with impaired neurocognitive performance related to working memory function. Recent clinical trials have suggested that mindfulness is a promising intervention in adults with ADHD. We performed a randomised controlled clinical trial to investigate working memory (WM) with an n-back task in adults with ADHD during fMRI before and after an 8-week mindfulness intervention (MAP) compared with psychoeducation (PE). ADHD symptoms were assessed using the self- and observer-rated Conners Adult ADHD Rating Scales (CAARS). The complete pre-post data of 21 MAP and 19 PE participants were analysed. We found no group difference in ADHD symptoms or task performance at the pre-measurement, but there was a significant decrease in ADHD symptoms and significant improvement in task performance in both groups at the post-measurement. Furthermore, we found a significant increase in task-related activation in the right parietal lobe, with no difference between groups. Exploratory two-sample paired t-tests revealed significant increased brain activation after MAP in the bilateral inferior parietal lobule, right posterior insula and right precuneus. A decrease in self-rated 'Inattention/Memory Problems' after MAP compared to baseline was associated with stronger activation in parts of the left putamen, globus pallidus and thalamus.

Inattention Predicts Increased Thickness of Left Occipital Cortex in Men with Attention-Deficit/Hyperactivity Disorder.

BACKGROUND: Attention-deficit/hyperactivity disorder (ADHD) in adulthood is a serious and frequent psychiatric disorder with the core symptoms inattention, impulsivity, and hyperactivity. The principal aim of this study was to investigate associations between brain morphology, i.e., cortical thickness and volumes of subcortical gray matter, and individual symptom severity in adult ADHD. METHODS: Surface-based brain morphometry was performed in 35 women and 29 men with ADHD using FreeSurfer. Linear regressions were calculated between cortical thickness and the volumes of subcortical gray matter and the inattention, hyperactivity, and impulsivity subscales of the Conners Adult ADHD Rating Scales (CAARS). Two separate analyses were performed. For the first analysis, age was included as additional regressor. For the second analysis, both age and severity of depression were included as additional regressors. Study participants were recruited between June 2012 and January 2014. RESULTS: Linear regression identified an area in the left occipital cortex of men, covering parts of the middle occipital sulcus and gyrus, in which the score on the CAARS inattention subscale predicted increased mean cortical thickness [F(1,27) = 26.27, p < 0.001, adjusted R2 = 0.4744]. No significant associations were found between cortical thickness and the scores on CAARS subscales in women. No significant associations were found between the volumes of subcortical gray matter and the scores on CAARS subscales, neither in men nor in women. These results remained stable when severity of depression was included as additional regressor, together with age. CONCLUSION: Increased cortical thickness in the left occipital cortex may represent a mechanism to compensate for dysfunctional attentional networks in male adult ADHD patients.

Oxytocin Modulates Amygdala Reactivity to Masked Fearful Eyes.

The amygdala reveals enhanced reactivity to fearful eye whites, even when they are backwardly masked by a neutral face and therefore processed with limited visual awareness. In our fMRI study, we investigated whether this effect is indeed associated with fear detection within the eyes of the neutral face mask, or more generally, with reactivity to any salient increase in eye white area. In addition, we examined whether a single dose of intranasal oxytocin would modulate amygdala responses to masked fearful eye whites via a double-blind, placebo-controlled pharmacological protocol. We found that increased amygdala responses to salient changes within a face's eye region occurred specifically for masked fearful eyes but not for similar increases in white area as induced by nonsocial control stimuli. Administration of oxytocin attenuated amygdala responses to masked fearful eye whites. Our results suggest that the amygdala is particularly tuned to potential threat signals from the eye region. The dampening effects of oxytocin on early amygdala reactivity may reflect reduced vigilance for facial threat cues at a preconscious level. Future studies may investigate whether this early modulation accounts for the beneficial effects of oxytocin on social cognition in anxiety-related disorders, as suggested by previous studies.

Oxytocin attenuates neural reactivity to masked threat cues from the eyes.

The neuropeptide oxytocin has recently been shown to modulate covert attention shifts to emotional face cues and to improve discrimination of masked facial emotions. These results suggest that oxytocin modulates facial emotion processing at early perceptual stages prior to full evaluation of the emotional expression. Here, we used functional magnetic resonance imaging to examine whether oxytocin alters neural responses to backwardly masked angry and happy faces while controlling for attention to the eye vs the mouth region. Intranasal oxytocin administration reduced amygdala reactivity to masked emotions when attending to salient facial features, ie, the eyes of angry faces and the mouth of happy faces. In addition, oxytocin decreased neural responses within the fusiform gyrus and brain stem areas, as well as functional coupling between the amygdala and the fusiform gyrus specifically for threat cues from the eyes. Effects of oxytocin on brain activity were not attributable to differences in behavioral performance, as oxytocin had no impact on mere emotion detection. Our results suggest that oxytocin attenuates neural correlates of early arousal by threat signals from the eye region. As reduced threat sensitivity may increase the likelihood of engaging in social interactions, our findings may have important implications for clinical states of social anxiety.

Oxytocin and the social brain: neural mechanisms and perspectives in human research.

The present paper summarizes functional imaging studies investigating the effects of intranasal oxytocin (OT) on brain responses to social stimuli. We aim to integrate previous research, point to unresolved issues and highlight perspectives for future studies. The studies so far have focused on identifying neural circuits underlying social information processing which are particularly sensitive to modulations by exogenous OT. Most consistently, stimulus-related responses of the amygdala and associated areas within the prefrontal and temporal cortices have been found to be modulated by OT administration. However, there are a number of unresolved issues related to the possible role of sex differences and hormonal status, genetic variability, and individual differences in socio-cognitive functioning. Future studies focusing on these open questions are expected to contribute to a more nuanced understanding of the role of the central OT system in humans and may provide the basis for novel treatment approaches for mental disorders characterized by social deficits. This article is part of a Special Issue entitled Oxytocin and Social Behav.