Associated factors of suicidal ideation among older persons with dementia living at home in eight European countries.

OBJECTIVES: This study aimed to investigate the occurrence of suicidal ideation and associated factors in older persons with dementia living at home in eight European countries, and its association with quality of life. Furthermore, changes in suicidal ideation over time were investigated. METHODS: This cohort study (n = 1,223) was part of the European "RightTimePlaceCare" project conducted in 2010-2013. Participating countries were Estonia, Finland, France, Germany, the Netherlands, Spain, Sweden and the United Kingdom. Baseline and follow-up data were analysed using bivariate and multivariate logistic regression. RESULTS: The occurrence of suicidal ideation in the participating countries varied between 6% and 24%. Factors significantly (p < 0.0018) associated with suicidal ideation using bivariate analysis were: nationality, depressive symptoms, delusions, hallucinations, agitation, anxiety, apathy, disinhibition, irritability, night-time behaviour disturbances, anxiolytics and anti-dementia medication. In the multivariate regression analysis, country of origin, moderate stage of the dementia, depressive and delusional symptoms, and anti-dementia medication were significantly associated with suicidal ideation (p < 0.05). Over time, suicidal ideation decreased from severe to mild or became absent in 54% of the persons with dementia. CONCLUSION: It is essential that professionals identify older persons with dementia and suicidal ideation and depressive and other psychological symptoms in order to give them appropriate treatment and provide relief for their informal caregivers. We emphasize the importance of identifying suicidal ideation, irrespective of depressive symptoms, and specifically of paying attention to persons with moderate dementia. Living with the informal caregiver seems to be associated with staying stable without suicidal ideation.

Psychological Resilience and Health-Related Quality of Life in Swedish Women with Newly Diagnosed Breast Cancer.

PURPOSE: Psychological resilience appears to be an important influencing factor in various aspects of health-related quality of life (HRQoL) in a context of adversity, eg, being informed of a cancer diagnosis. The purpose was to investigate psychological resilience and HRQoL in Swedish women with newly diagnosed breast cancer in relation to demographic and clinicopathological characteristics. METHODS: A population-based cross-sectional study was conducted including 517 women with breast cancer in the South Swedish Health Care Region. Participants were enrolled at the time of consultation for the diagnosis. Psychological resilience was assessed with the Connor-Davidson Resilience Scale 25 (CD-RISC25), and HRQoL was assessed with the Short Form Health Survey. The participants responded to questions regarding demographic variables. Clinicopathological data were collected from the Swedish National Quality Register for Breast Cancer. RESULTS: The mean score for psychological resilience was 70.6, identifying 15% of included patients with a score lower than 58 (-1 standard deviation). The study cohort had significantly lower mean scores for several aspects of HRQoL compared with Swedish normative data. Regression analyses demonstrated that psychological resilience was significantly associated with all domains of HRQoL after adjustment for demographic and clinicopathological factors. CONCLUSION: Higher levels of psychological resilience were significantly related to higher levels of HRQoL in Swedish women with newly diagnosed breast cancer and no modifying factor was identified. The assessment of psychological resilience at the time of breast cancer diagnosis might allow for early identification of women in need of more intense psychosocial support. Future studies are needed to identify a clinically relevant threshold of the CD-RISC25.

Psychometric properties of the Connor-Davidson Resilience Scale (CD-RISC) in a non-clinical population in Sweden.

BACKGROUND: The Connor-Davidson Resilience Scale (CD-RISC) is the most widely used scale which assesses psychological resilience. Although it is recommended to be applied as a unidimensional scale, its factor structure, reliability, as well as discriminant and predictive validity need to be assessed when used in a new context. Moreover, the original five-factor structure has not been replicated in previous investigations. This study aimed to explore psychometric properties of the scale in a Swedish context. METHODS: Construct validity of the five-factor model of CD-RISC was assessed using Exploratory and Confirmatory Factor Analyses. Its discriminant validity was assessed in relation to a measure of emotion regulation (Brief Version of the Difficulties in Emotion Regulation Scale) using a Confirmatory Factor Analysis. Predictive validity of CD-RISC was assessed in relation to measures of physical and mental health-related quality of life (The 12-Item Short Form Survey) using hierarchical multiple regression analyses. A population based sample cohort was employed (N = 2599). RESULTS: Exploratory and Confirmatory Factor Analyses suggested a 22-item unidimensional model of CD-RISC. Psychological resilience was found to be independent from the measure of emotion regulation. It was shown to predict both physical and mental health-related quality of life, being especially strongly associated with mental health aspects. CONCLUSIONS: The study showed that the Swedish version of CD-RISC is an instrument with high discriminant and predictive validity, although the original factor structure does not apply in this context. CD-RISC can thus be used to identify individuals with a higher need of psychosocial support, especially relating to mental health needs.

Persons with Dementia Living at Home or in Nursing Homes in Nine Swedish Urban or Rural Municipalities.

The methodology from the "RightTimePlaceCare" study of dementia care was tested locally in terms of relevance, acceptability and attrition. Comparing persons with dementia (PwDs) receiving home care (HC) with PwDs living in nursing homes (NHs), in urban versus rural areas, regarding their health conditions and informal caregiver burden was also done. Standardized measurements regarding sociodemographic, and physical and mental health was used. Questions related to legal guardianship were added. Interviews were conducted with PwDs and their caregivers in HC (n = 88) and in NHs (n = 58). Bivariate and multivariate logistic regression analysis was used. The attrition rate was higher in HC. In the bivariate regression model, for HC and NH, living at home was significantly associated with more severe neuropsychiatric symptoms (p ≤ 0.001) and being cared by a spouse (p = 0.008). In NH, the informal caregivers were significantly younger (p = 0.003) and living in rural areas (p = 0.007) and more often in paid work (p ≤ 0.001). In the multivariate regression model, informal caregivers were significantly younger (p = 0.007) when caring for a PwD in an NH and caregiver burden was significantly higher in HC and in urban areas (p = 0.043). Legal guardianship was very low. Professionals should acknowledge that PwDs in HC have more behavioural problems and caregivers in urban areas report higher caregiver burden.

Prevalence of dementia diagnoses not otherwise specified in eight European countries: a cross-sectional cohort study.

BACKGROUND: Dementia is a syndrome, with a wide range of symptoms. It is important to have a timely diagnosis during the disease course to reduce the risk of medication errors, enable future care planning for the patient and their relatives thereby optimizing quality of life (QoL). For this reason, it is important to avoid a diagnosis of dementia not otherwise specified (DNOS) and instead obtain a diagnosis that reflects the underlying pathology. The aim of this study was to investigate the prevalence and associated factors of DNOS in persons with dementia living at home or in a nursing home. METHODS: This is a cross-sectional cohort study performed in eight European countries. Persons with dementia aged ≥65 years living at home (n = 1223) or in a nursing home (n = 790) were included. Data were collected through personal interviews with questionnaires based on standardised instruments. Specific factors investigated were sociodemographic factors, cognitive function, and mental health, physical health, QoL, resource utilization and medication. Bivariate and backward stepwise multivariate regression analyses were performed. RESULTS: The prevalence of DNOS in the eight participating European countries was 16% (range 1-30%) in persons living at home and 21% (range 1-43%) in persons living in a nursing home. These people are more often older compared to those with a specific dementia diagnosis. In both persons living at home and persons living in a nursing home, DNOS was associated with more severe neuropsychiatric symptoms and less use of anti-dementia medication. In addition, persons with DNOS living at home had more symptoms of depression and less use of antidepressant medication. CONCLUSIONS: The prevalence of DNOS diagnosis is common and seems to vary between European countries. People with DNOS are more often older with more severe neuropsychiatric symptoms and receive fewer anti-dementia medication, anxiolytics and antidepressants. This would support the suggestion that a proper and specific diagnosis of dementia could help the management of their disease.

Inter-rater agreement of the Quality of Life-Alzheimer's Disease (QoL-AD) self-rating and proxy rating scale: secondary analysis of RightTimePlaceCare data.

BACKGROUND: To assess the quality of life of people with dementia, measures are required for self-rating by the person with dementia, and for proxy rating by others. The Quality of Life in Alzheimer's Disease scale (QoL-AD) is available in two versions, QoL-AD-SR (self-rating) and QoL-AD-PR (proxy rating). The aim of our study was to analyse the inter-rater agreement between self- and proxy ratings, in terms of both the total score and the items, including an analysis specific to care setting, and to identify factors associated with this agreement. METHODS: Cross-sectional QoL-AD data from the 7th Framework European RightTimePlaceCare study were analysed. A total of 1330 cases were included: n = 854 receiving home care and n = 476 receiving institutional long-term nursing care. The proxy raters were informal carers (home care) and best-informed professional carers (institutional long-term nursing care). Inter-rater agreement was investigated using Bland-Altman plots for the QoL-AD total score and by weighted kappa statistics for single items. Associations were investigated by regression analysis. RESULTS: The overall QoL-AD assessment of those with dementia revealed a mean value of 33.2 points, and the proxy ratings revealed a mean value of 29.8 points. The Bland-Altman plots revealed a poor agreement between self- and proxy ratings for the overall sample and for both care settings. With one exception (item 'Marriage' weighted kappa 0.26), the weighted kappa values for the single QoL-AD items were below 0.20, indicating poor agreement. Home care setting, dementia-related behavioural and psychological symptoms, and the functional status of the person with dementia, along with the caregiver burden, were associated with the level of agreement. Only the home care setting was associated with an increase larger than the predefined acceptable difference between self- and proxy ratings. CONCLUSIONS: Proxy quality of life ratings from professional and informal carers appear to be lower than the self-ratings of those with dementia. QoL-AD-SR and QoL-AD-PR are therefore not interchangeable, as the inter-rater agreement differs distinctly. Thus, a proxy rating should be judged as a complementary perspective for a self-assessment of quality of life by those with dementia, rather than as a valid substitute.

Potentially inappropriate medication among people with dementia in eight European countries.

Objectives: to evaluate the frequency of potentially inappropriate medication (PIM) prescription among older people with dementia (PwD) from eight countries participating in the European study 'RightTimePlaceCare', and to evaluate factors and adverse outcomes associated with PIM prescription. Methods: survey of 2,004 PwD including a baseline assessment and follow-up after 3 months. Interviewers gathered data on age, sex, prescription of medication, cognitive status, functional status, comorbidity, setting and admission to hospital, fall-related injuries and mortality in the time between baseline and follow-up. The European Union(7)-PIM list was used to evaluate PIM prescription. Multivariate regression analysis was used to investigate factors and adverse outcomes associated with PIM prescription. Results: overall, 60% of the participants had at least one PIM prescription and 26.4% at least two. The PIM therapeutic subgroups most frequently prescribed were psycholeptics (26% of all PIM prescriptions) and 'drugs for acid-related disorders' (21%). PwD who were 80 years and older, lived in institutional long-term care settings, had higher comorbidity and were more functionally impaired were at higher risk of being prescribed two PIM or more. The prescription of two or more PIM was associated with higher chance of suffering from at least one fall-related injury and at least one episode of hospitalisation in the time between baseline and follow-up. Conclusions: PIM use among PwD is frequent and is associated with institutional long-term care, age, advanced morbidity and functional impairment. It also appears to be associated with adverse outcomes. Special attention should be paid to psycholeptics and drugs for acid-related disorders.

Trends in treatment with antipsychotic medication in relation to national directives, in people with dementia - a review of the Swedish context.

BACKGROUND: The aim of this study was to explore trends in treatment with antipsychotic medication in Swedish dementia care in nursing homes as reported in the most recent empirical studies on the topic, and to relate these trends to directives from the national authorities. METHODS: The study included two scoping review studies based on searches of electronic databases as well as the Swedish directives in the field. RESULTS: During the past decade, directives have been developed for antipsychotic medication in Sweden. These directives were generic at first, but have become increasingly specific and restrictive with time. The scoping review showed that treatment with antipsychotic drugs varied between 6% and 38%, and was higher in younger older persons and in those with moderate cognitive impairment and living in nursing homes for people with dementia. A decreasing trend in antipsychotic use has been seen over the last 15 years. CONCLUSIONS: Directives from the authorities in Sweden may have had an impact on treatment with antipsychotic medication for people with dementia. Treatment with antipsychotic medication has decreased, while treatment with combinations of psychotropic medications is common. National directives may possibly be even more effective, if applied in combination with systematic follow-ups.

The association between positive-negative reactions of informal caregivers of people with dementia and health outcomes in eight European countries: a cross-sectional study.

AIM: To describe the associations between positive and negative reactions of informal caregivers of people with dementia and health outcomes across eight European Countries. BACKGROUND: Caring for someone with dementia may have implications for the caregiver's own health and for the care recipient. These consequences could be associated with caregivers' reactions to the process of care. DESIGN: Association study based on cross-sectional data. METHODS: Participants were people with dementia and their informal caregivers living at home or in long-term care institutions. Data were collected between November 2010-April 2012 using the Caregiver Reaction Assessment (with dimensions of self-esteem, lack of family support, financial problems, disrupted schedule and health problems) and associations were sought with informal caregiver burden, quality of life and psychological well-being and with dementia sufferers' neuropsychiatric symptoms, comorbidity and dependency in activities of daily living using correlation coefficients. RESULTS: Data from 2014 participants were used. Variability across countries was noted, as well as differences between care at home and in long-term care institutions. In general, self-esteem and lack of family support correlated with caregiver burden and psychological well-being. Associations were also found between disrupted schedule and caregiver burden, psychological well-being and quality of life. Health problems were clearly associated with caregiver burden, psychological well-being and quality of life. CONCLUSION: Study results support links between the reactions of informal caregivers of people with dementia and health outcomes. These may have implications in terms of how services are addressed.

The long-term experience of living with peripheral arterial disease and the recovery following revascularisation: a qualitative study.

BACKGROUND: The long-term experience of living with peripheral arterial disease (PAD) and the durability of improvements after revascularisation are sparsely described in the literature. The primary goals of medical treatment and nursing care for PAD are to provide relief of symptoms, improve quality of life, and prevent the progression of arterial disease and cardiovascular complications. The majority of patients are elderly with a significantly increased risk of myocardial infarction, stroke, and cardiovascular death. Which can limit mobility and functional status even in the absence of ischaemic claudication, rest pain, or ulceration after a successful revascularisation. OBJECTIVES: To illuminate the long-term experience of living with PAD and the recovery following revascularisation. METHODS: Fourteen patients were interviewed 6 months and 212 years after revascularisation. The transcribed texts were analysed using manifest and latent content analysis. RESULTS: The long-term experience of living with PAD meant gradually becoming aware of having a chronic disease. This was interpreted through the following themes, representing the transition from being in an acute phase of PAD to the recovery after revascularisation and entering a chronic phase of PAD: (I) 'becoming better but not cured'; (II) 'recapturing control over life'; (III) 'reappraising meaning in life'. CONCLUSIONS: Becoming aware of having a chronic disease results in a need to adapt to and accept permanent restrictions in daily life. The findings showed that revascularisations offer several benefits. However, when PAD symptoms were relieved, other ailments became discernable, which reflects the complex course of PAD and atherosclerotic disease. Moreover, several critical points and events such as other concurrent diseases, unrealistic hopes for recovery, and the complex course of PAD and atherosclerotic disease complicated the transition process towards health and well-being.

Icelandic cancer patients receiving chemotherapy or radiotherapy: does distance from treatment center influence distress and coping?

The aim was to investigate psychologic distress and coping strategies in cancer patients during the time of chemotherapy or radiotherapy treatment and to compare those who lived close to the treatment center and those who had to stay away from home for treatment. Participants were 22 to 91 years old, 57% female patients, from 3 oncology outpatient clinics in Iceland. They were assessed with the Brief Symptom Inventory (BSI 18) and The Ways of Coping-Cancer Version (WOC-CA). Significantly higher scores were only found in somatic symptoms for patients who lived close to the treatment center than those who did not. Women had significantly higher scores on overall psychologic distress, depression, anxiety, social support, and behavioral and cognitive escape-avoidance compared with men. Significantly more depression and anxiety was found in the age group 22-45 years than the age group older than 70 years. Living alone, stress (WOC-CA), behavioral escape-avoidance, and distancing were shown to be significantly associated with psychologic distress. Having to stay away from home for treatment does not seem to affect cancer patients' psychologic well-being or the way they cope, whereas type of treatment has. Psychological distress is higher in female cancer patients than male and in younger patients (22-45 years) compared with older ones (>70 years). Also, findings indicate that coping strategies can influence distress.

Pain management in elderly persons who require assistance with activities of daily living: a comparison of those living at home with those in special accommodations.

OBJECTIVES: To describe and compare the methods of pain management used by elderly individuals with chronic pain and requiring assistance with activities of daily living, depending on whether they live alone, with someone, at home or in special accommodations. METHODS: This study comprised 294 people aged 76-100 years, identified as having chronic pain and requiring assistance with activities of daily living. Pain and pain management methods were compared using the Multidimensional Pain Inventory, Swedish version, and the Pain Management Inventory. RESULTS: Those living in special accommodations reported more pain than those living at home. Those living with someone reported more pain and interference in daily life than those living alone, despite using more pain-relief methods and having greater social support. The median number of pain-relieving methods used was 3.0 (75th-25th percentile: 5-2). Some (3.8%) did not use any method to relieve their pain. The most frequently used methods were prescribed medicine (20%), rest (20%) and distraction (15%). The methods rated most effective were using cold, exercise, hot bath/shower and consuming alcohol. CONCLUSION: Participants had only a small repertoire of pain management methods and these were mostly conventional in nature. Few non-pharmacological methods were used. The findings suggest the importance of thorough assessment, and the need to fully discuss pain management options with the elderly.

Oral health and nutritional status in a group of geriatric rehabilitation patients.

The aims of this study were to evaluate the oral health status and nutritional status in a group of geriatric rehabilitation patients, and to analyse the relationship between these two parameters. Nurses at the ward performed structured assessments of oral and nutritional status using the Revised Oral Assessment Guide and the Subjective Global Assessment form in 223 newly admitted patients. Most oral health problems were found among patients who stayed longer at the hospital and were more dependent on help as compared with the healthier patients. Thirty-four per cent of the patients were either severely undernourished, at risk or suspected to be undernourished (UN). Oral health problems were more common among UN patients (p < 0.0005) compared with well-nourished patients. The most frequent oral health problem was found on teeth or dentures (48%). Problems related to the tongue and lips were also common among UN patients (56 and 44%, respectively). Oral health status was correlated (r = 0.32) to nutritional status. Problems with swallowing had the strongest association to the nutritional status (OR 6.05; 95% CI 2.41-15.18). This study demonstrated that poor oral health status was related to undernourishment.