Empowerment-based cognitive behavioural therapy for insomnia in persons with mild cognitive impairment: A sequential explanatory mixed-method pilot study.

Insomnia is an emerging risk factor for the onset of mild cognitive impairment (MCI) and its progression to dementia. Impaired cognition and neuropsychiatric symptoms create challenges for persons with MCI to participate actively in non-pharmacological interventions. This study examined the feasibility and preliminary effects of empowerment-based cognitive-behavioural therapy for insomnia (CBT-I) on sleep, cognitive function, and health-related quality of life (HRQoL) in persons with MCI and sleep problems. Sixty participants were randomly allocated to the intervention or control group to receive empowerment-based CBT-I or usual care, respectively. The 12 week intervention comprised all core CBT-I techniques delivered through a group and individualised face-to-face approach. An empowerment approach with interactive teaching methods, goal setting, and action planning was used to deliver the intervention. Outcome measures included subjective and objective sleep quality and pattern, and a battery of neuropsychological tests and the 12-item Short Form Survey were administered 3 months (T1) and 6 months post-randomisation (T2). This intervention is feasible and highly acceptable for persons with MCI. The intervention group showed significant improvements in subjective and objective sleep-related outcomes compared with the control group. Moreover, the intervention group showed greater improvements in global cognition, processing speed, attention, and mental flexibility than the control group at T1 and/or T2. No significant between-group differences were observed in memory or HRQoL scores. The qualitative data converged with the quantitative data. In conclusion, empowerment-based CBT-I was well received by persons with MCI and had potential positive effects on improving sleep and cognition in this cohort.

Psychometric Validation of the Chinese Version of the Atrial Fibrillation Knowledge Scale in Chinese Patients With Atrial Fibrillation.

BACKGROUND: Assessment of patients' knowledge on atrial fibrillation (AF) and its management is important for evaluating their learning needs. However, a validated and comprehensive instrument to be used among Chinese patients is yet to be developed. OBJECTIVES: The aim of this study was to develop and validate the Chinese version of the Atrial Fibrillation Knowledge Scale (AFKS-C) in Chinese patients. METHODS: The 11-item AFKS was translated, and then content and face validations were conducted by an expert panel and patients with AF. A sample of 255 patients with AF was recruited from a university-affiliated hospital to evaluate its psychometric properties. The internal consistency and test-retest reliability were evaluated using the Kuder-Richardson formula 20 and κ statistics. Item analysis determined the item difficulty index and item discrimination coefficients. Factorial and discriminant validity were evaluated using exploratory factor analysis and the known-groups method. RESULTS: The content validity index of the AFKS-C was 0.94, and the Kuder-Richardson formula 20 value was 0.60. The difficulty indices of the items ranged from 0.36 to 0.89, and the point-biserial coefficients of the items ranged from 0.122 to 0.255, indicating sufficient discriminatory ability. The test-retest reliability was acceptable, because the κ values ranged from 0.234 to 0.710. The principal axis factoring analysis indicated a 3-factor structure that explained 50.4% of the total variance. The AFKS-C also demonstrated satisfactory discriminant validity, having yielded significantly different scores between patients with newly diagnosed and established AF. CONCLUSION: The AFKS-C has acceptable psychometric properties and can be used to measure the knowledge of patients and evaluate the effects of patient education programs.

Peer-supported exercise intervention for persons with mild cognitive impairment: a waitlist randomised controlled trial (the BRAin Vitality Enhancement trial).

BACKGROUND: motivating older people with cognitive impairment to remain physically active is challenging. OBJECTIVE: this study aimed to examine the effects of a peer-supported exercise intervention on the cognitive function and health-related quality of life (HRQoL) of persons with mild cognitive impairment (MCI). DESIGN: a two-arm randomised controlled trial. SETTING AND PARTICIPANTS: community-dwelling persons with MCI were recruited from community centres for older adults in Hong Kong. METHODS: participants randomised to the intervention group received an 8-week group-based peer-supported multicomponent exercise intervention, while the waitlist control group received usual care. A battery of neuropsychological tests and the Short Form-36 were administered at baseline, immediately post-intervention and 3 months post-intervention. RESULTS: two hundred and twenty-nine participants were randomised to the intervention (n = 116) or control (n = 113) group. Compared with the control group, participants in the intervention group showed significantly greater improvements in processing speed and attention measured by the Colour Trails Test 1 (ß = 7.213, 95% confidence interval [CI] = 2.870-11.557, P = 0.001) and working memory measured by the Digit Span Backward Test (ß = 0.540, 95% CI = 0.199-0.881, P = 0.002) immediately post-intervention. The effects were sustained at 3 months post-intervention. Similarly, significantly greater improvements in sequencing and mental flexibility measured by the Colour Trails Test 2 were observed in the intervention group 3 months post-intervention (ß = 6.979, 95% CI = 3.375-10.584, P < 0.001). Changes in global cognition, short-term memory and HRQoL were not significant. CONCLUSION: the peer-supported exercise intervention was effective at sustaining improvements in executive function, attention and working memory in persons with MCI.

Lived experience of neuropsychiatric symptoms among females with mild cognitive impairment: A phenomenological study.

AIMS: To explore the lived experience of neuropsychiatric symptoms (NPS) among females with mild cognitive impairment (MCI). DESIGN: A phenomenological study using individual, semi-structured, telephone-based interviews was conducted to explore how the NPS are aroused, evolve, and affect the overall well-being, illness perception and the corresponding coping responses adopted by females with MCI. METHODS: Twenty-nine participants with MCI were recruited from the community setting in Hong Kong between March and October 2020. Interviews were audio-recorded, transcribed verbatim, and analysed using an interpretative phenomenological analysis approach and constant comparison strategy. RESULTS: Three themes were identified: (1) living vigilant lives with threats and uncertainty, (2) snowballing into further negative emotions and (3) seeking outlets for negative emotions. Our findings suggested that the participants' cognitive, functional and social challenges aroused intense emotional responses such as depression, agitation and anxiety. These noting negative emotions were further perpetuated by maladaptive coping responses, unrealistic expectations from coping strategies and overwhelming disease burden. Various internal and external strategies were adopted to enhance emotional adaptation, of which adopting a positive attitude appeared to be the most promising strategy. CONCLUSION: This study shed light on the challenging experience of MCI. The cognitive afflictions and the resultant impacts on various life domains evoked a cluster of NPS. Support services need to enhance emotional adjustment through alleviating the various life stressors and strengthening the coping resources. IMPACT: Elucidating the lived experience of NPS provides important insights into the development of a more effective, comprehensive and person-centred care planning for the population with MCI. Holistic care planning should extend beyond cognitive health optimization into enhancing disease knowledge, improve emotional coping, rebuild self-identity and bolstering social supports among this preclinical cohort.

Can Visual Art Therapy Be Implemented With Illiterate Older Adults With Mild Cognitive Impairment? A Pilot Mixed-Method Randomized Controlled Trial.

Older adults with mild cognitive impairment (MCI) with no literacy are at increased risk of progression to dementia. Whether it is feasible to engage this population in visual art therapy (VAT) and yield effects on cognition and depression remained unclear. A pilot mixed-method single-blinded randomized controlled trial was conducted in a sample of community-dwelling older adults with MCI. The experimental group (n = 21) was assigned to 12 sessions of VAT over 6 weeks, and the control group (n = 18) was assigned to 6 weekly health education (HE) on nonbrain health topics. Participants were evaluated at baseline using Montreal Cognitive Assessment-5-minute protocol (MoCA-5-min) and Geriatric Depression Scale Short Form (GDS-SF). A focus group discussion (FGD) was also conducted to the experimental group to explore their experiences of participating in the VAT. Findings indicated that both VAT and HE groups had significant improvement in MoCA-5-min scores and depressed mood over time; however, the significant group × time interaction effect was noted only for the psychological outcome. Findings from the FGD indicated that participants had challenging experiences at the beginning of the therapy, but later, they were able to cope and found that the VAT was relevant and beneficial for their cognitive and psychosocial health. This pilot study provided initial evidence about the potential benefit of VAT in improving cognitive and psychological well-being of older adults with MCI and low literacy and provided insights on how to better engage them in this cognitive stimulating intervention. A full-scale trial is recommended for a stringent evaluation.

Psychometric Validation of the Chinese Version of Atrial Fibrillation Effect on Quality-of-Life Questionnaire Among Chinese Patients.

BACKGROUND: The Atrial Fibrillation Effect on Quality-of-Life Questionnaire (AFEQT) is a psychometrically sound instrument for measuring disease-specific health-related quality of life in atrial fibrillation populations. OBJECTIVE: In this study we aimed to validate the Chinese version of AFEQT (AFEQT-C) among Chinese patients with atrial fibrillation. METHODS: The AFEQT was translated into Chinese according to Brislin's model. The psychometric properties of internal consistency, stability, and concurrent and factorial validity were examined in a convenience sample. RESULTS: A total of 200 participants (mean age, 69.8 ± 5.2 years) were recruited. The Cronbach's α of the AFEQT-C was 0.94, and item-to-total correlations ranged from 0.44 to 0.80. The test-retest reliability was supported by good to excellent intraclass correlation coefficients, which ranged from 0.68 to 0.92. The AFEQT-C scores significantly correlated with the EuroQoL 5-Dimensional Questionnaire score to support concurrent validity. Confirmatory factor analysis demonstrated a 3-factor structure and all items loaded strongly onto their respective factors. CONCLUSIONS: The AFEQT-C is a reliable and valid measure of health-related quality of life in Chinese patients with atrial fibrillation.

An empowerment-based cognitive behavioural therapy for persons with mild cognitive impairment and insomnia: Protocol for a mixed-method pilot study.

AIM: This study aims to examine the feasibility and effects of an empowerment-based cognitive behavioural therapy for insomnia on sleep, cognitive outcomes, and health-related quality of life in persons with mild cognitive impairment and insomnia. STUDY DESIGN: This mixed-methods study comprises a pilot randomized controlled trial and an exploratory qualitative study. METHODS: A total of 60 community-dwelling patients aged ≥50 years with mild cognitive impairment and self-reported sleep complaints will be recruited from the community centres for older people operated by two non-governmental organizations in Hong Kong. The participants will be randomly allocated to intervention or control groups, which will receive the empowerment-based cognitive behavioural therapy for insomnia and usual care respectively. We hypothesize that the cognitive behavioural therapy for insomnia intervention featuring an empowerment-based approach can improve sleep and cognitive function among patients with mild cognitive impairment. A subsample of 10 participants from the intervention group will be invited to take part in a qualitative interview to obtain more in-depth comments about the feasibility and acceptability of the intervention. Ethical approval was obtained on 2 November 2020. This study is supported by the Seed Fund for Basic Research from the University of Hong Kong on 4 September 2020. DISCUSSION: This study will address a neglected risk factor for cognitive decline in persons with mild cognitive impairment. The theoretical integration of empowerment and cognitive model of behavioural changes may inform a wider and more successful application of cognitive behavioural therapy techniques for people with compromised cognitive ability and insomnia. IMPACT: This study will also advance our knowledge on the role of sleep on persons with mild cognitive impairment and generate relevant empirical evidence to inform the care of this vulnerable cohort to affect a worldwide reduction in social, economic and healthcare burdens associated with cognitive impairment. CLINICAL TRIAL REGISTRATION: This study has been registered at ClinicalTrials.gov (NCT04635085).

An empowerment-psycho-behavioral program on neuropsychiatric symptoms in persons with mild cognitive impairment: Study protocol of a randomized controlled trial.

AIMS: Neuropsychiatric symptoms (NPS) are highly prevalent among persons with mild cognitive impairment (PwMCI). However, the mainstay of treatments only focuses on cognitive training. This study develops an empowerment-psycho-behavioural programme to improve the NPS and other health outcomes of this preclinical cohort. The empirical effects and the participants' perception and experience of the programme will be explored. DESIGN: This sequential mixed-method study comprises a single-blind randomized controlled trial and a qualitative study. METHODS: This study will recruit 250 PwMCI from the community and randomize them to either the intervention group to receive a 13-week empowerment-psycho-behavioural programme which focuses on promoting cognitive coping and stress adaptation, or the control group to receive a health education programme which serves as an attention placebo with content unrelated to dementia. The primary outcome is NPS, and the secondary outcomes include cognitive function, subjective memory complaints and health-related quality of life. These outcomes will be measured at baseline, upon completing the programme and 4 weeks thereafter. A purposive sample of 30 participants from the intervention group will be interviewed for their engagement experience in the programme. This study received funding support in July 2020. DISCUSSION: Given the high prevalence and detrimental effects of NPS on disease progression, effective management is yet to be determined. Underpinned by the Progressively Lowered Stress Threshold (PLST) Model, the empowerment-psycho-behavioural programme is designed. Results on the outcome-based evaluation and the patients' experience can advance the science in this under-addressed area. IMPACT: This study enhances our understanding of the PLST Model in explaining the manifestations of NPS by the stress-coping disequilibrium at the early disease stage. It will shed important insight into the care management of MCI to attend both cognition function and psychological well-being in research and clinical context. TRIAL REGISTRATION: This study is registered in the ClinicalTrials.gov (NCT04723667) and the HKU Clinical Trials Registry (HKUCTR-2915).

The Lived Experience of Patients and Family Caregivers in Managing Pneumoconiosis.

The daily challenges of patients with pneumoconiosis and their caregivers in living with and providing care for this disease remain unexplored. As guided by the interpretive description, we found that pneumoconiosis patients suffered from highly anxiety-provoking symptoms and physical debilitation, which evoked high levels of distress and sense of impending death. The reduced functional capacity disrupted patients' role functioning and self-esteem. The perceived stigma of the embarrassing symptoms and treatments further disrupted their self-concept and social lives. Providing care for pneumoconiosis patients was demanding and burdensome, which jeopardized family caregivers' physical, emotional, and social well-being, and the relationship strain with the patients added further frustration to them. The perceived caregiving gain supported them to fully engage in daily caregiving. To improve the well-being of pneumoconiosis patients, a comprehensive empowerment-based dyadic care model is required to optimize adaptive behavioral changes and self-esteem, and improve self-efficacy in disease management for this cohort.

A Systematic Review on the Effects of Nonpharmacological Sleep Interventions on Cardiometabolic Risk or Disease Outcomes.

BACKGROUND: Many authors of epidemiological studies have documented the detrimental effects of insufficient or poor sleep on cardiometabolic health. However, little is known about the effects of sleep interventions on the individuals with cardiometabolic risks/diseases. OBJECTIVES: This systematic review aimed to evaluate the mediating effects of nonpharmacological sleep interventions, which were defined as interventions not involving the use of medications or invasive methods to alter sleep, on cardiometabolic outcomes among adults with cardiometabolic risks/diseases. METHODS: A systematic search of randomized controlled trials was conducted in 5 electronic databases from inception to November 2019. The Population, Intervention, Comparison and Outcomes of this review was the effects of nonpharmacological sleep interventions on sleep and cardiometabolic outcomes among the adults with cardiometabolic risks/diseases as compared with any control methods. Two reviewers independently assessed eligibility for inclusion and methodological quality. Narrative analysis was performed when meta-analysis was not appropriate. RESULTS: Nine studies met the inclusion criteria. These studies included exercise-based, sleep hygiene, and cognitive behavioral therapy interventions to improve sleep among adults who are overweight or obese and patients with type 2 diabetes and hypertension. All of the exercise-based interventions were effective in improving sleep, but not to an extent that can positively influence cardiometabolic health. The mediating effects on cardiometabolic risks were more apparent for the sleep hygiene and cognitive behavioral therapy interventions, despite the small number of pilot-scale studies in this area. CONCLUSION: The mediating effects of sleep improvement on cardiometabolic risk/disease control were inconclusive. More research to examine the effect of sleep-related risk-factor modification on cardiovascular health is warranted.

Visual art therapy as a treatment option for cognitive decline among older adults. A systematic review and meta-analysis.

AIMS: To investigate the effects of visual art therapy (VAT) on cognitive and psychological outcomes and explore the crucial design characteristics of VAT that might be associated with greater cognitive benefits among older adults. DESIGN: Systematic review and meta-analysis. DATA SOURCES: Peer reviewed articles were searched from Medline, EMBASE, Global Health, Cochrane Library, Ovid Nursing database, PsycINFO, British Nursing Index, and CINAHL Complete from inception of the databases to September 2019. REVIEW METHODS: This review and meta-analysis was conducted and reported according to preferred reporting items for systematic reviews and meta-analyses guidelines. The Cochrane risk of bias tool was used to examine the risk of bias of the studies. Narrative synthesis and quantitative meta-analysis were performed. RESULT: Twelve articles published between 2004-2019 involving 831 participants were identified. VAT significantly improved global cognitive function compared with different control groups (Hedges' g = 0.348 [95% CI = 0.026-0.671], p = .034, I2  = 66.570%). VAT also demonstrated psychological benefits in reducing depressive symptoms and anxiety. By systematic comparison of the intervention designs, it seems that those with greater cognitive benefit involved a higher level of creativity and optimized the use of essential components including art education, reminiscence, art processing, cognitive evaluation, art crafts/modelling, and socialization. CONCLUSION: Visual art therapy could be effective in improving cognitive functions and the associated psychological symptoms. Therefore, it can be adopted as an effective non-pharmacological intervention for preventing cognitive decline and dementia. IMPACT: This review answers the key question about the pooled effect of VAT as nonpharmacological therapy on preventing or managing dementia. In addition, it informs on the design characteristics of an effective VAT for implementing among older adults. This research will have an impact on the gerontological care and support the evidence about non-pharmacological approaches to prevent and manage dementia.

Brain Vitality Enhancement (BRAVE) program to promote brain health among persons with mild cognitive impairment: A study protocol.

AIM: This study aims to evaluate the effects of a community-based program entitled 'Brain Vitality Enhancement (BRAVE)' on the cognitive function, physical and mental well-being of persons with mild cognitive impairment. STUDY DESIGN: This is a parallel wait list randomized controlled trial. METHODS: The BRAVE program consists of two phases. Phase 1 is an empowerment workshop for training 50 peer mentors to be the exercise ambassadors, while Phase 2 is a supervised exercise program for 250 persons with mild cognitive impairment. They will be randomly allocated to intervention or wait list control groups. For the intervention group, the peer mentors and mentees will be matched according to gender and residential areas to form mentor-mentee groups to attend an 8-week supervised exercise training. The mentor-mentee groups will continue to participate mentor-directed exercise sessions in the community thereafter. A mobile application will be developed for self-directed learning. We hypothesize that persons with mild cognitive impairment receiving the BRAVE program will demonstrate better cognitive function and health-related quality of life than the control group who receive usual care. This study is funded by a grant from the Food and Health Bureau of the Government of Hong Kong Special Administrative Region in April 2018. DISCUSSION: This study will empower a group of golden-aged adults to be the ambassadors to promote brain health in the community and persons with mild cognitive impairment to integrate moderate-intensity exercise into their lifestyle to achieve long-term beneficial effects on their cognition and well-being. IMPACT: Given the population with mild cognitive impairment is growing rapidly and expected to keep escalating in coming decades and limited treatment options for cognitive decline and its significant burden on the health and social care system, this study is timely to promote active ageing in the society and reduce the burden associated with cognitive decline.

The experience of patients and family caregivers in managing pneumoconiosis in the family context: A study protocol.

AIM: This study aims to explore the illness experience and needs of patients with pneumoconiosis and the caregiving experience of their respective family caregivers. DESIGN: This is an exploratory qualitative study. METHODS: Participants will be recruited during the annual patient interview with purposive sampling. Those with a confirmed diagnosis of pneumoconiosis for at least 1 year will be eligible. Patients with different levels of physical dependency will be recruited. The respective family caregivers of these patients, who are ≥21 years of age, assuming the role as primary caregivers of a pneumoconiosis patient will also be invited to join. In-depth interviews will be conducted in patients' home separately for patients and their caregivers and a home environment assessment will also be undertaken. The interview data will be transcribed verbatim, managed with the software NVivo 11 and analysed with content analysis. The ethical approval has obtained, and this study is supported by a research grant from the Pneumoconiosis Compensation Fund Board of Hong Kong on 14 August 2018. DISCUSSION: This study will advance the knowledge on how pneumoconiosis patients and their family caregivers manage the disease in the family context. The findings of this study can inform the development of a family-oriented care model to support the pneumoconiosis patients and their family caregivers to manage this condition better. IMPACT STATEMENT: Pneumoconiosis is the most common type of occupational lung disease in the Chinese population. These patients require long-term comprehensive services and support to assist their disease self-management. However, little is known about how these patients and their family caregivers manage the disease in the family context. The current study addresses this gap by exploring patients' illness experience and their family members' caregiving experience, which is timely to inform the design of family-oriented model of care to support this clinical cohort. CLINICAL TRIAL REGISTRATION: This study has been registered at ClinicalTrials.gov (NCT04022902).

A nurse-coordinated integrated care model to support decision-making and self-care in patients with atrial fibrillation: A study protocol.

AIM: This study aims to evaluate the effects of a nurse-coordinated, empowerment-based integrated care model on self-care behaviours and psychosocial outcomes in patients with atrial fibrillation and to explore how this intervention affects patients' self-care behaviours and quality of life. DESIGN: This mixed-methods study comprises a randomized controlled trial and an exploratory qualitative study. METHODS: A total of 392 community-dwelling patients aged ≥65 years with a confirmed diagnosis of atrial fibrillation, a high stroke risk and no oral anticoagulants treatment will be recruited from the medical outpatient clinics of a university-affiliated hospital. The patients will be randomly allocated to intervention or control groups, which will receive treatment via the nurse-coordinated integrated care model or standard care, respectively. We hypothesize that compared with patients receiving standard care, atrial fibrillation patients exposed to the nurse-coordinated care model will be more likely to achieve compatible patient and physician decisions regarding the use of oral anticoagulants, better changes in medication adherence, anxiety, depression and health-related quality of life after the intervention. A subsample of 30 participants in the intervention group will also participate in a qualitative interview to provide their views and perceptions about the intervention. The ethical approval has obtained on 5 July 2018. This study is supported by a grant from the Research Grants Council of the Hong Kong Special Administrative Region on 29 June 2018. DISCUSSION: This study will uniquely adopt an empowerment-based approach to equip patients as active agents in atrial fibrillation management through a nurse-coordinated integrated care model that comprehensively addresses their needs. IMPACT: Patients with atrial fibrillation are currently receiving inadequate guideline-recommended care. This study will address this important evidence-practice gap by optimizing oral anticoagulant prescription and therapeutic effects and promotes effective patient self-care, so as to achieve worldwide reductions in atrial fibrillation-related morbidity, mortality, and healthcare burdens. CLINICAL TRIAL REGISTRATION: This study has been registered at ClinicalTrials.gov (NCT03924739).

The effects and cost-effectiveness of an empowerment-based self-care programme in patients with chronic heart failure: A study protocol.

AIM: This study aims to evaluate the effects of a 12-week empowerment-based self-care programme on the cognitive, psychological and behavioural aspects of self-care, health-related quality of life and unplanned hospital service use of chronic heart failure patients and to estimate its cost-effectiveness in reducing unplanned service use. STUDY DESIGN: Randomized controlled trial with cost-effectiveness analysis. METHODS: The study will recruit 236 community-dwelling Chinese patients with chronic heart failure from regional hospitals in Hong Kong. Patients will be randomized in blocks to attend either the 12-week empowerment-based self-care programme or a didactic education programme. Central to the empowerment-based model is that the patients are the primary decision makers in self-care and act autonomously to manage the disease. Collaborative approach and interactive teaching strategies are used to optimize patients' engagement and knowledge translation to real-life practice. Outcome evaluation on self-care maintenance and management, symptom perception, self-care confidence, self-care knowledge, health-related quality of life and health service use will take place at baseline, on completion of the programme and at 12 weeks thereafter. Generalized estimating equations and Cox regression examine the intervention effects. Bootstrapping technique will be conducted to examine the cost-effectiveness of the intervention. The study is formally funded in December 2016. DISCUSSION: Chronic heart failure is associated with high level of hospital admissions, of which 40% is avoidable through effective self-care. Although self-care confidence is known to improve self-care, no structured educative method has been developed to enhance this attribute. This study addresses this research gap with a stringent application of theory and research design. IMPACT: The study illustrates the application of the empowerment model for self-care enhancement in patients with chronic heart failure. The findings will inform the ways and values of this care model to enhance the disease management of this expanding clinical cohort.

Testing a Model to Reveal the Predictive Mechanism of Care-Seeking Decisions Among Patients With Acute Myocardial Infarction.

BACKGROUND: Extensive research has been conducted to examine the factors affecting care-seeking decisions in patients with acute myocardial infarction (AMI). Such a decision-making process is multifactorial, and its underlying mechanism is yet to be determined. OBJECTIVES: Our aim was to test a theoretically integrated model to identify the mechanisms underlying patients' care-seeking decisions in the context of AMI. METHODS: On the basis of both empirical and theoretical evidence, we proposed that patients' care-seeking decisions are driven by 2 sequential perceptual-cognitive processes concerned with illness labeling and interpretation, as well as the contextual influences of perceived barriers to care seeking and cues from others. A sample of 301 patients was recruited to test this model using structural equation modeling. RESULTS: The model testing revealed good fit with the data (χ = 38.48, df = 30, P = .72; root-mean-square error of approximation = 0.03, normed fit index = 0.96, nonnormed fit index = 0.98, and comparative fit index = 0.99) and explained 46% of the variance in AMI care-seeking delay. Successful action relied on whether patients could correctly attribute the symptom experience to AMI, were aware of their own susceptibility to the condition, and had a good understanding of how the disease manifested itself. Lowering perceived barriers and positive cues from others in advising care seeking played favorable roles to promote care-seeking behaviors. CONCLUSIONS: This integrative theoretical model is shown to be valid in explaining care-seeking delay among AMI patients and can guide the development of interventions to promote appropriate care-seeking behaviors among high-risk individuals.

Recognition of Atypical Symptoms of Acute Myocardial Infarction: Development and Validation of a Risk Scoring System.

BACKGROUND: Atypical symptom presentation in patients with acute myocardial infarction (AMI) is associated with longer delay in care seeking and poorer prognosis. Symptom recognition in these patients is a challenging task. OBJECTIVES: Our purpose in this risk prediction model development study was to develop and validate a risk scoring system for estimating cumulative risk for atypical AMI presentation. METHODS: A consecutive sample was recruited for the developmental (n = 300) and validation (n = 97) cohorts. Symptom experience was measured with the validated Chinese version of the Symptoms of Acute Coronary Syndromes Inventory. Potential predictors were identified from the literature. Multivariable logistic regression was performed to identify significant predictors. A risk scoring system was then constructed by assigning weights to each significant predictor according to their b coefficients. RESULTS: Five independent predictors for atypical symptom presentation were older age (≥75 years), female gender, diabetes mellitus, history of AMI, and absence of hyperlipidemia. The Hosmer and Lemeshow test (χ6 = 4.47, P = .62) indicated that this predictive model was adequate to predict the outcome. Acceptable discrimination was demonstrated, with area under the receiver operating characteristic curve as 0.74 (95% confidence interval, 0.67-0.82) (P < .001). The predictive power of this risk scoring system was confirmed in the validation cohort. CONCLUSIONS: Atypical AMI presentation is common. A simple risk scoring system developed on the basis of the 5 identified predictors can raise awareness of atypical AMI presentation and promote symptom recognition by estimating the cumulative risk for an individual to present with atypical AMI symptoms.

Estimated prevalence of frailty and prefrailty in patients undergoing coronary artery or valvular surgeries/procedures: A systematic review and proportional meta-analysis.

BACKGROUND: The aging population has led to an increasing number of older patients undergoing cardiac surgeries/procedures. Frailty and prefrailty have emerged as important prognostic indicators among these patients. This proportional meta-analysis estimated the prevalence of frailty and prefrailty among patients undergoing cardiac surgery. METHODS: We searched seven electronic databases for observational studies that used validated measure(s) of frailty and reported prevalence data on frailty and/or prefrailty in older patients undergoing coronary artery or valvular surgeries or transcatheter procedures. Meta-analyses were performed using a random-effects model. RESULTS: One hundred and one articles involving 626,863 patients were included. The pooled prevalence rates of frailty and prefrailty were 28% (95% confidence interval [CI]: 23%-33%) and 40% (95% CI: 31%-50%), respectively, for patients scheduled for open-heart surgeries and 40% (95% CI: 36%-45%) and 43% (95% CI: 34%-53%), respectively, for patients undergoing transcatheter procedures. Frailty measured using a multidimensional approach identified a higher proportion of frail patients when compared with measures solely focused on physical frailty. Older age, female sex, and lower body mass index and hemoglobin concentrations were significantly associated with higher frailty prevalence. Moreover, countries with higher gross domestic product spent on healthcare exhibited a higher frailty prevalence. CONCLUSION: Frailty represents a considerable health challenge among patients undergoing cardiac surgeries/procedures. Routine screening for frailty should be considered during perioperative care planning.

Nurse-led multi-component behavioural activation programme to improve health outcomes in patients with atrial fibrillation: a mixed-methods study and feasibility analysis.

AIMS: Patients with atrial fibrillation (AF) play passive roles in disease management. This study aimed to examine the feasibility and preliminary effects of an empowerment-based care model, titled 'the nurse-led multi-component behavioural activation (N-MBA) programme', on health-related quality of life, AF knowledge, psychological outcomes, medication adherence, and treatment decision-making in patients with AF. METHODS AND RESULTS: This mixed-methods study comprised a pilot randomized controlled trial and a qualitative study. Patients with AF who had a moderate-to-high risk of stroke but were not prescribed oral anticoagulants were recruited. Forty participants were recruited and randomized in a 1:1 ratio to receive either the N-MBA programme or standard care. The 13-week programme comprised care components that prepared patients for shared decision-making, an empowerment-based educational module on AF self-care, and continuous support through telephone calls. The programme was feasible, and the overall attendance rate was 82.5%. The participants gave excellent ratings in the satisfaction survey. The N-MBA group showed greater improvements in health-related quality of life (HRQoL) and AF knowledge than the standard care group at the immediate post intervention and 6-month follow-up time points. No significant between-group changes in medication adherence, anxiety, and depression were detected. Participants in the N-MBA group actively raised concerns about AF and its treatment with their attending doctors. The qualitative data were consistent with the quantitative data, indicating that the programme built a comprehensive knowledge base of AF and self-care behaviours. CONCLUSION: The N-MBA programme is feasible and acceptable to patients with AF. It improved patients' AF knowledge, treatment-related decision-making, and HRQoL. REGISTRATION: ClinicalTrials.gov NCT03924739.