Training of attention and memory deficits in children with acquired brain injury.

UNLABELLED: This pilot study concerns cognitive rehabilitation of children with acquired brain injury (ABI). AIM: The aim is threefold; to determine (1) whether the Amsterdam Memory and Attention Training for Children (AMAT-C) programme for children with ABI can be integrated in the child's school, (2) whether supervision in the school-setting maintains the child's motivation throughout the training programme and (3) whether positive changes in memory, attention and executive functions are found with this implementation of the training method. METHODS: Seven children with memory and/or attention deficits after ABI were trained with AMAT-C. Measures used were programme evaluation questions, neuropsychological tests and a questionnaire concerning executive functions. RESULTS: Overall, children, parents and trainers were satisfied with the programme and the children were motivated throughout the programme. The children showed significant improvements in neuropsychological subtests, primarily in tests of learning and memory. No overall change in executive functions was noted. CONCLUSION: Provision of AMAT-C training and supervision at the child's school appears to ensure (1) satisfaction with the programme, (2) sustaining of motivation and (3) improvements in learning and memory.

Underweight, weight loss and related risk factors among older adults in sheltered housing--a Swedish follow-up study.

BACKGROUND: Underweight and weight loss are important factors in detecting malnutrition. OBJECTIVE: To describe underweight, weight loss and related nutritional factors after 12 months among individuals 75 years or older and living in sheltered housing. A further aim was to identify possible risk factors associated with underweight and weight loss. DESIGN: This is a part of a cross-sectional follow-up study from a county in Sweden, examining the disabilities, resources and needs of 719 older adults in sheltered housing units. Data were collected twice, with a 12-month interval using the Resident Assessment Instrument. RESULTS: Among the 503 remaining chronically ill individuals with cognitive and functional disabilities, 35% were classified as underweight at the initial assessment and 38% at the second, a non-significant difference. A further analysis showed 39% had decreased weight, 27% remained stable and 28% gained weight. A weight loss of 5% occurred in 27% of the older adults and a loss of 10% occurred in 14%. Risk factors associated with being underweight and weight loss, using scales derived from the instrument were cognitive and functional decline. Dementia and Parkinson's disease, eating dependencies and constipation were the strongest risk factors when analyzed as single items. CONCLUSION: A high percentage was underweight or exhibited weight loss and several risk factors were identified. Ensuring adequate nutritional status in individuals with a variety of diseases and declining health status is challenging. Increased combined efforts using a wide range of measures, nutritional programs and routines need to be regularly implemented.

Intellectual function late after open-heart operation.

Cerebral emboli are not uncommon complications after valve replacements. We investigated the hypothesis that there are emboli that are clinically unnoticeable but that may affect the intellectual function of the brain. One hundred sixty-five patients were studied with a battery of psychometric tests before and after operation, two months postoperatively, and 2 to 8 years after operation. Ten patients sustained late cerebral infarction or hemorrhage. Their late intellectual function was low, indicating an impairment in brain performance. The remaining 155 patients had had no cerebral complications postoperatively. Eighty-three had had valve replacement (Björk-Shiley valves); 51, aortocoronary bypass operations; and 21, closure of an atrial septal defect (all adult patients). Late intellectual function was significantly lower in the patients with a valve prosthesis than in the other two groups. However, this difference could be traced back to the operation. Thus, we have not been able to confirm our hypothesis that late intellectual function in patients with a heart valve prosthesis deteriorates as a result of clinically silent emboli. On the contrary, patients who have undergone aortocoronary bypass operation sustain more deterioration in late intellectual function than the other groups. Late intellectual function in this study population clearly was influenced by events during the operation. Because cerebral injury can be shown almost regularly after open-heart operation, this investigation provides an incentive for further efforts to improve the quality of open-heart surgery with the aim of keeping brain function as intact as possible.

Rehabilitation after aortic valve replacement with autologous fascia lata: a sociomedical study.

In a series of 50 patients who underwent aortic valve replacement with frame-supported fascia lata, 32 were seen for a combined medical and psychosocial examination 10 to 33 months postoperatively. The investigation included a psychometric test battery and an interview concerning the patient's social and psychological situation at the time of the operation and at follow-up. Twenty-seven patients had improved in their New York Heart Association Functional Classification at the time of follow-up. In most instances NYHA classification correlated well with the patients' subjective opinion on their recovery. Those who for various reasons were not able to return to work did not consider themselves recovered. The employment rate after operation was 66%. There is a great need for more information and support to families as well as for more intensive rehabilitation efforts, especially vocational, for the postoperative patient.

A descriptive study of childbirth education provided by midwives in Sweden.

OBJECTIVE: to describe the content, modes of working and reaction/interaction of childbirth education provided by midwives in Sweden. DESIGN: qualitative, using non-participant observation to collect the data. Grounded theory approach was used. SETTING: antenatal classes provided in the community in Sweden. PARTICIPANTS: twelve midwives with varying lengths of experience in teaching antenatal classes, and the prospective parents who attended these classes. MEASUREMENTS AND FINDINGS: three perspectives on the content and three modes of working were found. Combinations of the differing perspectives and working modes provided differing interactions within the classes. KEY CONCLUSIONS: the confirming/mixed model resulted in dialogue in the classes. It was assumed that this model would contribute to an increased understanding of the coming experience of giving birth. IMPLICATIONS FOR PRACTICE: the findings provide midwives with a basis for reflection on their experiences as leaders in the childbirth preparation part of education for parenthood.

Women's perceptions of childbirth and childbirth education before and after education and birth.

OBJECTIVE: to illuminate women's perceptions of childbirth and childbirth education before and after education and birth. DESIGN: qualitative, using tape-recorded interviews to collect data. Interpretation was performed from Antonovsky's concept sense of coherence. SETTING: childbirth education, a part of parent education in Sweden. PARTICIPANTS: eleven women expecting their first child, where the pregnancy was planned and normal MEASUREMENTS AND FINDINGS: the development of perceptions of childbirth and childbirth education was described. The women adopted the content of the education in different ways. Fear as well as unreflected knowledge seemed to block acquisition of new knowledge. Factors which contributed to a childbirth experience worse than expected were lack of or inconsistent information. Increased knowledge about childbirth and experiences of confirmation during childbirth contributed to a good or better experience than expected. KEY CONCLUSION: any model of childbirth education which does not take into consideration the individual woman's perceptions of childbirth and childbirth education seems to be inadequate. IMPLICATIONS FOR PRACTICE: the findings stress the importance of individual assessment of expectations of and experiences of childbirth education. Consistency in information given before and during childbirth supports a sense of comprehensibility, manageability and meaningfulness.

Swedish fathers' involvement in and experiences of childbirth preparation and childbirth.

OBJECTIVE: To discover the expectations and experiences of childbirth preparation and childbirth of Swedish men in order to contribute to a basis of reflections in the midwifery profession. DESIGN: Three tape-recorded interviews were performed: before and after childbirth preparation, and between one and three weeks after the baby was born. SETTING: Swedish maternity care. PARTICIPANTS: Eleven men who participated with their partners in antenatal classes. MEASUREMENTS AND FINDINGS: The interviews were analysed in several steps and included co-assessments by co-workers. Finally, an interpretation based on the concept 'vital involvement' was undertaken. Indications of vital involvement as well as various levels of involvement or distance were found. The participation in childbirth was more demanding than expected for the eleven men. They felt unprepared for an unpredictable process, the experience of time and pain, the woman's action, and their own reactions. The men who were regarded by the authors as vitally involved seemed to manage overwhelming feelings of helplessness during childbirth, to support the women, and experience the meeting with the baby positively. KEY CONCLUSION: It seems important for midwives to meet men individually, design childbirth preparation from men's perspective, follow up interpretations of the content, discuss expectations with regard to the men's role, and assess their experiences during the birth process.

Patient life stories and current situation as told by carers in nursing home wards.

Knowing a patient's life story is important for good nursing care of frail and vulnerable elderly people with cognitive impairments. The aim of the study was to compare patients' life stories and current situations as told by carers before and after 1 year of supervision, in which the Resident Assessment Instrument was used as a basis for individualized nursing care. Qualitative content analysis was used to disclose changes and to enable descriptions of patterns. After the intervention, two overall perspectives emerged from the analysis: the patient as a unique person with resources and abilities, despite limitations, and the carers' awareness of their own professional approach. It seemed as if the supervision and the use of a comprehensive and detailed assessment tool contributed to increased knowledge about the patients and to efforts to see them as real persons behind the dementia surface.

Dinner music for demented patients: analysis of video-recorded observations.

At a nursing home ward for demented patients, selections of dinner music were played during three periods of 2 weeks. At the end of the study was a control period. The reactions of five patients to three different types of music were registered by video observations. This study showed that the patients were affected by music, particularly soothing music. For example, it was found that when music was played one of the study's restless patients became unusually calm whereas another fed herself more than usual. The patients spent more time with dinner when music was played. Dinner music made the patients eat more calmly. Music as a nursing tool is an intervention that is simple to realize and worth trying. A tentative conclusion of this study is that music can beneficially affect restless and agitated demented patients.

Probable reasons for expressed agitation in persons with dementia.

Nursing home patients with dementia were videotaped in three previous studies. Sixty sequences of nine patients exhibiting agitated behaviors were examined to identify the most probable antecedents to agitation. Probable reasons were interpreted and applied to the Progressively Lowered Stress Threshold model, which suggests that agitation is stress related. Analysis suggests that agitation often serves as a form of communication. Two underlying reasons seem to be that the patient had loss of control over the situation and deficient autonomy. The most common causes for expressed agitation were interpreted as discomfort, a wish to be served immediately, conflict between patients or with nursing staff, reactions to environmental noises or sound, and invasion of personal space. It is recommended that nursing staff promote autonomy and independency for this group of patients whenever possible. By evaluating probable reasons for expressed agitation, the nursing staff can take steps to prevent or alleviate agitation.

Nurse-patient interaction after training in integrity promoting care at a long-term ward: analysis of video-recorded morning care sessions.

Morning care is a complex and problematic task for the demented patient, who has problems in understanding and coping with the situation. A training programme of integrity promoting care was given to the staff of a long-term ward and improvements of care were implemented during a 3 month intervention period. To evaluate possible effects, different parameters were used and compared with the data of a control ward. This report describes how caregivers behaved towards demented patients during morning care, before and after the training, and how patients' behaviour changed. The results are based on behaviour samples from 10 patients and 10 caregivers during 99 video-recorded morning care sessions, "double blindly" analysed. The number of coding schemes was 483, each consisting of 93 questions. The most prominent differences observed after the intervention were the increased number of opportunities to take part in decisions and activities given to the patients by the caregivers, more co-operation from patients, and finally an increase in verbal contact initiated both by patients and caregivers. It seems reasonable to suggest that when the environment was made more adequate and the demented patients could cope with it, they could use latent abilities that were not manifest in a less adequate environment.

[Effects of the training in integrity-promoting care on the interactions in a long-term ward]. / Auswirkungen der Schulung in integritätsfördernder Pflege auf die zwischenmenschlichen Beziehungsabläufe auf einer Langzeitabteilung.

A training programme in integrity-promoting care was given the staff of a long-term ward and practised during a three months intervention period. The effects were analysed in different parameters and compared with a control ward. This report describes analysis of video-recorded interactions (12 hs) during social activities between demented patients and caregivers and changes induced by the programme. The video-recorded episodes, containing mainly music and coffee sessions were interpreted from a model on interaction with demented patients suggested by Athlin and Norberg. The results indicate that the training programme and the guidance during the intervention resulted in increased understanding of demented patients' situation among the staff. They became more sensitive, adapted their cues and made the environment easier to interpret for the patients. This in turn led to the fact that the patients appeared more sensitive and clear in their cues. A positive circle developed.

Prehospital triage, discrepancy in priority-setting between emergency medical dispatch centre and ambulance crews.

BACKGROUND: The timely provision of emergency medical services might be influenced by discrepancies in triage-setting between emergency medical dispatch centre and ambulance crews (ACR) on the scene resulting in overloaded emergency departments (ED) and ambulance activities. The aim of this study was to identify such discrepancies by reviewing ambulance transports within a metropolitan city in the western region of Sweden. METHODS: All data regarding ambulance transports in Gothenburg, Sweden, during a 6-month period were obtained and analyzed by reviewing the available registry. RESULTS: There was a discrepancy between emergency medical dispatch centre and ACR in priority setting, which may result in a number of unnecessary transports to the hospital with consequent overloading of ED and a negative impact on ambulance availability. CONCLUSION: Appropriate ambulance use is one important part of emergency preparedness. Overuse results in decreased emergency medical services (EMS) availability and ED-overcrowding. Several factors, such as an imprecise triage system and increased public demands, may influence such overutilization. Improving the triage system and comprehensive public education on appropriate use of ambulances are two important steps toward a better use of national EMS resources.

Music and other strategies to improve the care of agitated patients with dementia. Interviews with experienced staff.

Many patients with dementia symptoms display forms of agitation such as the repeating of words, restlessness and aggression. These forms of behaviour may inflict strain on the co-patients and the caregivers. In this study, 17 experienced formal caregivers from nursing homes and collective residential units were interviewed about their experiences of agitated patients with dementia and strategies to improve their care. The questions were open except for specific questions about sound, music, and opinions about pharmacological treatment. A calm atmosphere and a slow pace emerged as important strategies to control agitation. Fixed routines could develop this. The mixing of lucid and agitated dementia patients appeared as a major problem, because some lucid patients became angry when patients with dementia displayed agitation. Irritability in one patient could trigger agitation in other patients but was possible to stop at an early stage. Several responders had successfully used music to calm individual agitated patients. Music seemed to be an underestimated nursing intervention to control agitation in daily life, but uncontrolled sound could cause agitation in the patients and stress in the nursing staff.

Cerebral protection during open heart surgery. A comparison between a disk oxygenator and two bubble oxygenators.

A disk oxygenator (Björk-AGA HLM) with a moderate hemodilution prime and two bubble oygenators (Harvey H 800 and Galen Optiflo 42-201) with a clear fluid prime are compared in regard to their effect upon postoperative intellectual function as measured by psychometric tests. There was no difference between the two bubble oxygenators. There was a marked, statistically significant difference between the bubble oxygenators and the disk oxygenator, the disk oxygenator yields considerably worse results. The reason for this is obscure but probably lies in the different microembolic output. The literature, however is not consistent on this question. At the present time, only bubble oxygenators are used in our unit.

Violation of the patient's integrity, seen by staff in long-term care.

The aim of the study was to describe the views held by staff (n = 233) in long-term care on what they regard as a violation of patient's integrity and to define the concept "integrity" in simple terms. The design of the investigation was inductive. The answers were coded into 775 items. Agreement was reached between the authors on 770 of the items when sorted into 13 categories: the unique personality, autonomous self, personal opinions, secret self, personal competence, professional self, family self, cultural self, information self, personal properties, private territory, corporal self, and ridiculing. The number of categories shows a great variation in the ordinary language definitions given by staff. It was also shown in two other ways: the difference in the level of abstraction in the items, and the fact that integrity referred to the patient, directly or indirectly. Our conclusion is that integrity by the staff reflects an ethical value and not a personal trait. If the staff have to violate the patient's integrity, because other vital values are involved, it is absolutely essential that they consider the ethical aspects of the situation carefully. Such violation demands that they preserve their respect for the patient to the greatest extent possible. It seems important in the training of different staff groups to show the complexity in the concept "integrity" and the ethical dilemmas that arise, especially in the interaction with vulnerable patients who are not able to protect and maintain their own integrity.