[Sleep disturbance in elderly patients with dementia at home and the factors associated with its identification: An observational study].

AIMS: The purpose of this study was to objectively quantify the sleep of elderly patients with dementia at home using a device and to investigate the factors associated with its identification. METHODS: Sixteen patients (6 males [37.5%], 84.1±4.7 years old; and 10 patients with mild dementia [62.5%]) and their family caregivers who were using outpatient memory clinics and home-visiting nursing station in Japan were included. Demographic and clinical data of the patients and their family caregivers, subjective perceptions of patients' sleep, family caregivers' Zarit care burden, and whether or not they were aware of patients' sleep problems were determined. Nighttime sleep parameters were collected for one week using a non-wearable actigraph. Sleep parameters were compared with patients' subjective views and family caregivers' observations to investigate factors indicative of sleep disturbance. RESULTS: Nighttime sleep parameters for 1 week (mean) were follows: sleep efficiency, 77.2%±9.3%; asleep time, 442.3±99.9 minutes; sleep latency, 18.2±15.8 minutes; awake time, 105.1±69.7 minutes; and number of times leaving the bed, 4.6±3.8 (maximum of 29/night). A significant positive correlation was found between sleep efficiency and duration of dementia (r=0.53, p=0.046), while no correlation was found with dementia severity or Zarit care burden score. The agreement between the patients' complaints about sleep and sleep efficiency (75%) was 30.7%, and family caregivers' awareness of patients' nighttime awakening and bed-leaving was significantly associated with patients' incontinence (p=0.024) and a greater dementia severity (p=0.027). CONCLUSIONS: Elderly dementia patients experienced sleep disturbance at home, such as nighttime awakening and associated bed-leaving; however, it might be difficult to identify these patients at an early stage based on their own complaints and observations by family caregivers. Identifying sleep problems at an early stage may thus require the use of objective measurement devices.

Using a Non-Wearable Actigraphy in Nursing Care for Dementia With Lewy Bodies.

People who have dementia with Lewy bodies often have sleep disorders. We used non-wearable devices to record and categorize the sleep patterns of patients with Lewy body dementia. Individual sleep data at a dementia-care unit in Japan were recorded using non-wearables. One week's worth of data from 18 patients was analyzed. Median metrics for all participants were the following: sleep efficiency, 68% (23-89); sleep duration at night, 6.8 hours (1.6-11.1); times getting out of bed at night, 3.5 (0-13). We identified three types of abnormal sleep: extremely short sleep duration, excessive sleep duration at night, and excessive number of times getting out of bed at night. Sleep disturbances in Lewy body dementia patients are treated using various practices; staff must choose the most effective plan for each patient's situation. Monitoring patient sleep using non-wearable provides more objective data that can help staff better personalize nursing care.

Association between respiratory and heart rate fluctuations and death occurrence in dying cancer patients: continuous measurement with a non-wearable monitor.

BACKGROUND: The present study aimed to explore the association between impending death and continual changes in respiratory and heart rates measured using a non-wearable monitor every minute for the final 2 weeks of life in dying cancer patients. METHODS: In this longitudinal study, we enrolled patients in a palliative care unit and continuously measured their respiratory and heart rates via a monitor and additionally captured their other vital signs and clinical status from medical records. RESULT: A dataset was created comprising every 24-h data collected from every-minute raw data, including information from 240 days prior to death from 24 patients (345,600 data); each patient's data were measured for 3-14 days until death. After confirming the associations between the respiratory and heat rate values on the day of death (n = 24) or other days (2-14 days before death, n = 216) and the mean, maximum, minimum, and variance of respiratory and heart rates every 24 h by univariate analyses, we conducted a repeated-measures logistic regression analysis using a generalized estimating equation. Finally, the maximum respiratory rate and mean heart rate were significantly associated with death occurring within the following 3 days (0-24 h, 0-48 h, and 0-72 h), except for the maximum respiratory rate that occurs within 0-24 h. CONCLUSION: The maximum respiratory rate and mean heart rate measured every minute using a monitor can warn family caregivers and care staff, with the support of palliative care professionals, of imminent death among dying patients at home or other facilities.

Nonwearable actigraphy to assess changes in motor activity before and after rescue analgesia in terminally ill patients with cancer: A pilot study.

AIMS: This study aimed to investigate the usefulness of nonwearable actigraphy to assess changes in motor activity before and after rescue analgesic administration in terminally ill cancer patients. BACKGROUND: Evaluating pain in terminally ill cancer patients is difficult; pain assessment tools are needed. METHODS: This was an exploratory descriptive study conducted within a palliative care unit. A nonwearable actigraph was used to measure the activity score and movement index of terminally ill patients with weeks-long prognosis and pain. The actigraph and medical data were integrated, and data were compared 6 h before and after rescue analgesic administration. RESULTS: Among 10 patients (age: 75.8 ± 12.3 years; six men), we evaluated 28 pain episodes (mean activity score: 130.9 ± 180.5 counts per minute; movement index: 68.8%). When pain was relieved at night following rescue analgesic administration, activity score and movement index decreased significantly (6 h before vs. 6 h after analgesics, respectively: 113.1 to 69.7 counts per minute; 64.3% to 41.8%; both p < 0.0001). With no relief after rescue analgesic administration, activity score did not differ significantly 6 h before and after analgesics: 147.3 to 137.7 counts per minute. CONCLUSION: Pain in terminally ill cancer patients could be assessed using a nonwearable actigraph to capture motor activity and improve pain assessment.

[Seasonal changes in blood pressure and related factors among older patients receiving home medical care].

AIM: We investigated seasonal variations in blood pressure (BP) and factors related to these variations among older patients receiving home medical care. METHOD: A total 57 patients ≥ 65 years old receiving home medical care who participated in the Osaka Home Care REgistry study (OHCARE), a prospective cohort study, were included. We investigated the seasonal patient characteristics and variations in the BP. In addition, to determine the influence of seasonal variations in the systolic blood pressure (SBP) on the occurrence of clinical events (hospitalization, falls and death), we classified patients into larger- and smaller- change groups based on the median seasonal variations in SBP. RESULT: About 60% of subjects were very frail or bedridden. The mean BP was higher in winter than in summer (124.7±11/69.5±7 vs.120.5±12/66.9±8 mmHg) (P< 0.01). On comparing the characteristics of the two groups with larger and smaller changes in the SBP, the group with large BP changes had a significantly lower BP in summer than the group with small BP changes. In addition, the incidence of "hospitalization" was significantly higher in the group with large BP changes than in the group with small BP changes (P = 0.03). CONCLUSION: The present study revealed that there were seasonal changes in the BP in older patients receiving home medical care. It was also suggested that seasonal changes in the BP might be associated with the risk of hospitalization events. Given these BP variations, doctors and visiting nurses should be alert for systemic abnormalities, especially in frail patients receinving home medical care.

The change over time of vital signs with consideration for opioid use in the last 2 weeks of life among cancer patients in a palliative care unit: Continuous measurement of vital signs using a non-wearable monitor.

OBJECTIVES: The aim of this study was to examine the following by using a non-wearable monitor: (ⅰ) the trajectory of vital signs (VS) in the last 2 weeks of life among cancer patients, and (ⅱ) the difference in change over time of VS between cancer patients with and without opioid use. METHODS: We conducted a longitudinal study involving cancer patients in a palliative care unit (PCU) from April 2018 to October 2019. VS were collected continuously using a non-wearable monitor, and we calculated the means of respiratory rate (RR) and heart rate (HR) per hour, and counts of apnea per hour as outcome variables. Explanatory variables were time (subtracting time of death from measurement time of VS, divided by 36) and opioid use. Mean difference (MD) of time represented the slope per hour of VS values. First, we analyzed the associations between VS per hour and time using a linear mixed model (LMM) with random intercepts and slope over time. Second, we analyzed the associations between VS and interaction term between time and opioid use. RESULTS: We analyzed 26 cancer patients. RR (MD: 0.27 beats/min [95% CI: 0.27-0.28]), HR (MD: 1.51 beats/min [95% CI: 1.50-1.52]), and apnea (MD: 0.71 count/hour [95% CI: 0.70-0.72]) significantly increased hourly. In addition, RR was significantly associated with interaction term (MD: -1.59 beats/min [95% CI: -3.11 to -0.07]), which indicates that there is a difference in the slope of RR between opioid users and non-users. CONCLUSIONS: We have successfully described the trajectory of VS in high-resolution under conditions of a natural end of life in PCU.

Associations of blood pressure levels with clinical events in older patients receiving home medical care.

Some studies reported that excessive blood pressure (BP) control was not appropriate for older people, especially from the viewpoint of quality of life and maintaining sufficient blood flow for tissue perfusion. However, the lower limit of the target BP is still unclear, and there has not yet been a sufficient consensus. Therefore, we investigated the associations of BP levels with clinical events in older patients ~85 years old receiving home medical care. A total of 144 patients were included, who were followed for longer than 3 months in the Osaka Home Care Registry study, a prospective cohort study targeting older patients receiving home medical care in Japan. BP levels were divided into lower and higher groups based on the average systolic blood pressure (SBP). The main outcomes were clinical events, including hospitalizations, falls, and deaths during follow-up. As a result, the hospitalization rate in the SBP below 124 mmHg group was significantly higher than that in the SBP over 124 mmHg group. When comparing the clinical events between the two groups only in participants with hypertension, the same results were obtained. Furthermore, in Cox proportional hazards regression models adjusted by age, sex, and current diseases, the SBP below 124 mmHg group showed a significantly higher rate of required hospitalization (hazard ratio: 7.25, 95% confidence interval: 1.79-29.45). Thus, in older and very frail patients requiring home medical care, an SBP level below 124 mmHg could be a predictive marker of clinical events leading to hospitalization.

Factors associated with changes of care needs level in disabled older adults receiving home medical care: Prospective observational study by Osaka Home Care Registry (OHCARE).

AIM: To clarify factors associated with changes in care needs level and mortality among disabled older people receiving home medical care over a period of 2.5 years. METHODS: The study included 179 participants, aged ≥65 years, receiving home medical care, who consented to join the Osaka Home Care Registry study. The main outcome was changes in the care needs level of participants eligible for the long-term care insurance system. We investigated the association of changes in care needs level with basic characteristics and care-receiving status. RESULTS: At the 2.5-year follow up, 20.0% of participants showed deteriorated levels, and 41.8% of participants died. In multiple logistic regression, age (odds ratio [OR] 1.10, 95% confidence interval [CI] 1.00-1.21; P = 0.051) and bone joint diseases (OR 0.34, CI 0.09-1.22; P = 0.098) were possible risks associated with deterioration of the care needs level. Male sex (OR 3.28, CI 0.91-11.74; P = 0.068) was a possible risk factor for mortality, and lower serum albumin (OR 0.22, CI 0.07-0.73) was a significant risk factor for mortality. CONCLUSIONS: We clarified the different factors associated with deterioration of the care needs level and mortality among disabled older people. Old age and bone joint diseases might be predictive factors for the further deterioration of independence of physical activity, and a low serum albumin level is considered to be strongly associated with increased mortality. Geriatr Gerontol Int 2019; 19: 1198-1205.

[Factors associated with behavioral and psychological symptoms in patients with dementia who received home medical treatment: A cross-sectional study (OHCARE study)].

AIM: The present study investigated the behavioral and psychological symptoms of dementia (BPSD) and pharmacological therapy among elderly people with dementia who received home medical treatment. METHODS: This study was part of the Osaka Home Care Registry study (OHCARE-study). Participants were >65 years old with dementia. Demographic and medical data, BPSD, and the LTCI [long-term care insurance] care-need level were collected. A multiple logistic regression analysis was performed in order to clarify the factors associated with BPSD. RESULTS: Among 110 subjects (82.0±11.3 years old), 64.6% had a diagnosis of dementia, most commonly Alzheimer's dementia. Aside from home medical treatment, 58.1% had a nurse visit, 48.1% received home care, and 40.0% used a day service. The prevalence of BPSD was 53.0%. Those with BPSD most frequently had an LTCI care-need level of 3, and the prevalence of BPSD declined as the level increased after 3. Psychotropic drugs were prescribed in 61.5% of those with BPSD. Antipsychotic drugs were used significantly more frequently in those with nursing care resistance, assault and delusions than in others (all, p <0.005). A multivariate analysis showed that the positive predictor of BPSD was antipsychotic drug use, while negative predictors were an LTCI care-need level and the use of visiting rehabilitation. CONCLUSION: The BPSD in elderly dementia patients receiving home medical treatment were clarified. The LTCI care-need level is an independent predictor of BPSD after adjusting for the activities of daily life. Further longitudinal investigations including the BPSD severity and frequency are needed.

Prevalence of incontinence among cognitively impaired older residents in long-term care facilities in East Asia: A cross-sectional study.

AIM: The current study was an international cross-sectional study comparing the prevalence of incontinence among cognitively impaired older residents in long-term care facilities in East Asia, including Japan, Korea, China, Taiwan and Thailand between 2015 and 2016. METHODS: Participants were cognitively impaired older residents in long-term care facilities. Demographic data were collected. The Clinical Dementia Rating scale was used to assess dementia severity, and the Barthel Index was used as a surrogate measure of incontinence and toilet use dependence. The prevalence of urinary incontinence and fecal incontinence were examined. Multiple logistic regression analysis was used to predict incontinence and toilet use dependence. RESULTS: We analyzed data from 662 participants (age 82.6 ± 9.9 years, 57.6% women). The prevalence of urinary incontinence ranged from 10.1% in Taiwan to 71.0% in Korea. The prevalence of fecal incontinence varied from 4.0% in Taiwan to 57.0% in Korea. A higher Clinical Dementia Rating score was a significant predictor of urinary and fecal incontinence and toilet use dependence (P < 0.0001). CONCLUSIONS: The current survey showed a high prevalence of incontinence in long-term care residents in East Asia, and identified challenges for future studies. Development of clinical guidelines for incontinence care in cognitively impaired older persons is urgently required. Geriatr Gerontol Int 2019; 19: 444-450.

Healthcare professionals' competence in digitalisation: A systematic review.

AIMS AND OBJECTIVES: To identify key areas of competence for digitalisation in healthcare settings, describe healthcare professionals' competencies in these areas and identify factors related to their competence. BACKGROUND: Digitalisation requires changes in healthcare practices, policies and actions to revise job expectations and workflows. The aspects of patient safety and integration of digitalisation into the professional context necessitate an assessment of healthcare professionals' competencies in digitalisation. DESIGN: Systematic review. METHODS: A systematic review was conducted following Center of Reviews and Dissemination guidelines, including application of a PRISMA statement. Four databases-CINAHL (EBSCO), MEDLINE (Ovid), Web of Science and Academic Search Premiere (EBSCO)-were searched for relevant original peer-reviewed studies published between 2012-2017. Twelve were chosen for final analysis: five quantitative studies and seven qualitative studies, which were, respectively, subjected to narrative and thematic synthesis. RESULTS: Key competence areas regarding digitalisation from a healthcare perspective identified encompass knowledge of digital technology and the digital skills required to provide good patient care, including associated social and communication skills, and ethical considerations of digitalisation in patient care. Healthcare professionals need the motivation and willingness to acquire experience of digitalisation in their professional context. Collegial and organisational support appear to be essential factors for building positive experiences of digitalisation for healthcare professionals. CONCLUSION: Healthcare organisations should both pay attention to the social environment of a workplace and create a positive atmosphere if they want to improve the response to digitalisation. The successful implementation of new technology requires organisational and collegial support. RELEVANCE TO CLINICAL PRACTICE: Recommendations for clinical practice include the following: development of competence in digitalisation by healthcare professionals when using technological equipment to minimise errors; provision of sufficient resources, equipment and room for technology usage; and provision of regular education that considers the participants' competencies.

High frequency of getting out of bed in patients with Alzheimer's disease monitored by non-wearable actigraphy.

AIM: Sleep disturbances in patients with Alzheimer's disease have not been systematically evaluated, because sleep monitoring has proved difficult. Our goal was to quantitatively characterize sleep disturbances in patients with Alzheimer's disease. METHODS: The present study was a cross-sectional descriptive study, carried out in dementia care units in Japan. Participants were 63 patients with Alzheimer's disease (mean age 77.6 ± 8.0 years) with severe behavioral and psychological symptoms of dementia. A non-wearable actigraphy device placed under patient mattresses was used to measure sleep parameters: sleep time, time in bed, number of wakings and number of times they left the bed. Cut-off points for sleep parameters were based on the interquartile range of the data. RESULTS: Median nocturnal sleep time was 6.2 h (interquartile range 2.7 h). Median frequency of waking was eight times (5)/night. Median frequency of leaving the bed was five times (6), with a maximum of 31/night. We identified three types of sleep disturbance: frequent bed leaving, short sleep time and excessive sleep time. Multiple linear regression showed that duration of dementia was a significant predictor of frequent bed leaving at night (P = 0.042). CONCLUSIONS: Frequent bed leaving at night reflects severe sleep deprivation in patients with mild-to-severe Alzheimer's disease. Safety measures are required to prevent accidents related to sleep disturbances, regardless of dementia severity. Geriatr Gerontol Int 2019; 19: 130-134.

Potential underreporting of medication errors in a psychiatric general hospital in Japan.

The purpose of this study was to explore a pattern of underreporting within a psychiatric general hospital in Japan. All the medication errors reported online in 2010 were analysed. This research was approved by the university and the study hospital. There were 651 incidents related to medication errors. Medication error rate per 1000 patient days was 2.14 (range: 0.45-6.05). Medication error rates between two acute care wards with comparable case and staff mix differed. A low proportion of intercepted near-misses and low medication error rates around mealtime in acute care 1 were suggestive of under-reporting. Two dementia care wards with low medication error rates had no report of intercepted errors, which was also suggestive of underreporting. Ward-specific medication error rates and patterns are useful to identify wards with potential underreporting of medication error within the hospital.

Caring for early-onset dementia with excessive wandering of over 30 kilometres per day: a case report.

Excessive wandering in people in dementia is associated with a severe care burden. However, the quantification of excessive wandering has not been described, and its cause and treatment have not been evaluated with objective measurements to date. The purpose of this study was to evaluate pharmacological treatments and non-pharmacological interventions to reduce excessive wandering in an early-onset Alzheimer disease patient with objective indicators. Wandering was quantified using an integrated circuit monitoring system that measured the distance moved and the location of the patient. Monitoring was conducted in the dementia ward of a general hospital in 2012. Sleep quality was measured by non-wear actigraphy. The study was approved by the ethics committees of the Osaka University School of Allied Health Science, and of the study hospital. The case involved a 62-year-old woman diagnosed with early-onset Alzheimer disease and hospitalized in 2012 because of irritability and agitation; her Mini-Mental State Examination score was 5/30 and her Clinical Dementia Rating score was 3. When olanzapine (2.5 mg) was prescribed, she developed insomnia, and her wandering movements increased from 10 to 20 km/day. On some days, it exceeded 30 km/day, and she walked most of the night. She did not experience weight loss or physical exhaustion, but she sustained a minor injury in her left sole. Olanzapine was increased to 7.5 mg, but these problems persisted. Nursing staff discovered triggers for wandering and insomnia, including high sensitivity to odour and noise in the living room or her room. When the environment was changed to meet her needs, the distance moved per day decreased to <15 km and the sleep disturbances disappeared. This case demonstrated the difficulty in assessing the degree of ambulation and sleep disorder. Objective indicators are essential in evaluating the effectiveness of pharmacological and non-pharmacological interventions.

Pattern of underreporting falls in a general psychiatric hospital in Japan.

PURPOSE: To examine the pattern of underreporting of fall incidents in a general psychiatric hospital in Japan. DESIGN AND METHODS: All fall incidents were analyzed and stratified by ward. FINDINGS: A discrepancy in fall rates was found in acute psychiatric and dementia wards. The following indicators were suggestive of underreporting: "zero fall/1,000 patient-days," "proportion of falls without injury," and "proportion of falls identified as occurring in the bedroom as a fall location during certain time periods." PRACTICE IMPLICATIONS: Ward-specific fall rates, with further stratifications by time and location of the fall, were useful for identifying a pattern of underreporting.