Study protocol: older people in retirement villages. A survey and randomised trial of a multi-disciplinary invention designed to avoid adverse outcomes.

BACKGROUND: There is increasing interest among older people in moving into retirement villages (RVs), an attractive option for those seeking a supportive community as they age, while still maintaining independence. Currently in New Zealand there is limited knowledge of the medical, service supports, social status and needs of RV residents. The objective of this study is to explore RV facilities and services, the health and functional status of RV residents, prospectively study their healthcare trajectories and to implement a multidisciplinary team intervention to potentially decrease dependency and impact healthcare utilization. METHODS: All RVs located in two large district health boards in Auckland, New Zealand were eligible to participate. This three-year project comprised three phases: The survey phase provided a description of RVs, residents' characteristics and health and functional status. RV managers completed a survey of size, facilities and recreational and healthcare services provided in the village. Residents were surveyed to establish reasons for entry to the village and underwent a Gerontology Nurse Specialist (GNS) assessment providing details of demographics, social engagement, health and functional status. The cohort study phase examines residents' healthcare trajectories and adverse outcomes, over three years. The final phase is a randomised controlled trial of a multidisciplinary team intervention aimed to improve health outcomes for more vulnerable residents. Residents who triggered potential unmet health needs during the assessment in the survey phase were randomised to intervention or usual care groups. Multidisciplinary team meetings included the resident and support person, a geriatrician or gerontology nurse practitioner, GNS, pharmacist and General Practitioner. The primary outcome of the randomised controlled trial will be first acute hospitalization. Secondary outcomes include all acute hospitalizations, long-term care admissions, and all-cause mortality. DISCUSSION: This paper describes the study protocol of this complex study. The study aims to inform policies and practices around health care services for residents in retirement villages. The results of this trial are expected early 2020 with publication subsequently. TRIAL REGISTRATION: Australia and New Zealand Clinical Trials Registry: ACTRN12616000685415 . Registered 25.5.2016. Universal Trial Number (UTN): U111-1173-6083.

Use of antipsychotic medications in patients with Parkinson's disease at Auckland City Hospital.

BACKGROUND: The American Academy of Neurology considers clozapine first line treatment for psychosis in Parkinson's disease (PD). In practice, patients are typically treated with quetiapine initially despite only level C evidence for use due to concern about side-effects, and changed to clozapine if they fail this. AIM: To review the use of antipsychotics in patients with PD and the demographics of PD patients who develop psychosis. METHODS: Patients with PD on antipsychotic medications were identified by the Movement Disorder Nurse Specialist database and by reviewing patients admitted to Auckland City Hospital from January 2006 until March 2008. The demographic data, details of PD and antipsychotic use and comorbidities were recorded. RESULTS: Sixty-six patients with PD on antipsychotics were identified. The mean age was 75 years and 48 (73%) were in residential care. Patients admitted on antipsychotics had longer disease duration (P < 0.001) and were more likely to have cognitive impairment (P= 0.02) than those admitted not on antipsychotics. The most common indication for use was hallucinations. Patients on clozapine were younger (P < 0.005) and had less comorbidity (P= 0.04) than those on quetiapine. Fifty per cent (6/12) of patients on clozapine had previously failed quetiapine. CONCLUSION: Quetiapine has a good efficacy rate with minimal side-effects. This study lends support to the assumption that quetiapine is a useful medication. However, clozapine also was well tolerated and could be considered for use more frequently than it is.

Alcohol consumption and attitudes towards banning alcohol sales on campus among European university students.

OBJECTIVES: The European Commission's new health strategy for improving health at the European Union (EU) level includes tackling alcohol consumption. This study aimed to assess the prevalence of alcohol consumption and problem drinking, as well as students' attitudes towards banning the sale of alcohol on campus. STUDY DESIGN: In total, 5826 students from universities in seven European countries (Denmark, Germany, Spain, Lithuania, Poland, Bulgaria and Turkey) took part in this cross-sectional study. METHODS: A self-administered questionnaire assessed sociodemographic information, frequency of alcohol consumption, problem drinking and attitudes towards banning the sale of alcohol on campus. RESULTS: The highest prevalence of drinking alcohol more than once per week was reported in Bulgarian (males 46%, females 64%) and Spanish students (males 59%, females 64%). Among those students who drank alcohol (n=3170), problem drinking (CAGE score >1) was found in 24% of males and 13% of females. Male gender, depressive moods and a low importance of good grades at university were risk factors for drinking alcohol more than once per week as well as for problem drinking. There were substantial country differences in the proportion of students who would support a ban of alcohol sales on campus (23% in Denmark, 88% in Poland). Support for a ban was higher among female students and among students who drank alcohol once or less per week. CONCLUSIONS: Problem drinking is a concern among students in many European countries, especially among males. Students' support for banning the sale of alcohol on campus varies between countries and should be considered in developing EU policy.

Reducing emergency presentations from long-term care: A before-and-after study of a multidisciplinary team intervention.

INTRODUCTION: The complexity of care required by many older people living in long-term care (LTC) facilities poses challenges that can lead to potentially avoidable referrals to a hospital emergency department (ED). The Aged Residential Care Intervention Project (ARCHIP) ran an implementation study to evaluate a multidisciplinary team (MDT) intervention supporting LTC facility staff to decrease potentially avoidable ED presentations by residents. METHODS: ARCHIP (conducted in 21 facilities [1,296 beds] with previously noted high ED referral rates) comprised clinical coaching for LTC facility staff by a gerontology nurse specialist (GNS) and an MDT (facility senior nurse, resident's general practitioner, GNS, geriatrician, pharmacist) review of selected high-risk residents' care-plans. A before-after repeated measures analysis was conducted for 9 months before and 9 months after intervention commencement (a 29-month period because of staggered facility enrolment). Modelling was adjusted for time trend, seasonality, facility size, and cluster effect. RESULTS: ED admission rate ratio post- versus pre-intervention was 0.75 (95% C.I. 0.63, 0.89, p-value = 0.0008), a 25% reduction in ED presentations post-intervention. A sensitivity model used a shorter, staggered time period centred on intervention start (9 months pre-intervention and 9 months post-intervention) for each facility, and a four-level categorical intervention variable testing intervention effect over time. The sensitivity test showed a 24% reduction in ED presentations in months 1-3 post-intervention (p-value = 0.07), a 34% reduction in months 4-6 (p-value = 0.01), and a 32% reduction in ED presentations in months 7-9 (p-value = 0.03). However, when the higher ED referral rates for 3 months immediately pre-intervention were modelled, the impact of the intervention on ED presentation rates reverted almost to previous levels. KEY CONCLUSIONS: A GNS-led MDT outreach intervention, targeted at selected conditions, decreases avoidable ED admissions of high-risk residents from selected facilities.

Prevalence of alcohol use and the association between onset of use and alcohol-related problems in a general population sample in Germany.

AIMS: This paper examines the prevalence of alcohol use, alcohol-related problems and onset of regular alcohol use, including its association with the prevalence of CAGE symptoms. DESIGN AND PARTICIPANTS: Data come from three nationally representative samples of the non-institutionalized German general population aged 18-59 years which were conducted annually between 1994 and 1996. Subjects (n = 7501) were surveyed through telephone interviews. FINDINGS: Overall, men were more likely to drink alcohol, to be heavier drinkers and to experience more alcohol problems than women. Prevalence of 12-month use was constant across age among males, but decreased with age among women. Prevalence of heavier drinking, however, increased with age in both sexes. While for both sexes the median age of onset decreased towards younger cohorts, the prevalence of regular use at younger ages increased more strongly among females compared to males. In all cohorts of both sexes, an association between early age of onset and negative consequences measured by the CAGE questionnaire could be observed. Odds ratios were significantly lower for life-time experience of at least two CAGE symptoms among respondents if they had started regular alcohol use later than their peers. CONCLUSIONS: The results indicate a narrowing of the gender gap due to an increasing prevalence of regular alcohol use for females across cohorts. Gender differences with regard to heavier drinking are still prominent. The findings confirm those of related studies in which early age of onset of regular alcohol use was found to be a significant predictor for life-time alcohol-related problems.

A comparison of alcohol consumption between lesbians and heterosexual women in an urban population.

An elevated rate of alcohol problems is believed to exist in the gay and lesbian community. However, prevalence estimates suggesting this have generally been based on convenience samples which have over-represented bar patrons and clinical sources. Recent epidemiological studies examining risk factors for AIDS have gathered information on alcohol consumption as well as sexual orientation. Data based on improved sampling methods are now available for estimating drinking rates of lesbians and gay men. This study compares the drinking patterns of heterosexual women and lesbian/bisexual women who were recruited through a random sampling design in San Francisco, CA. Contrary to previous research, no statistically significant differences in alcohol consumption and drinking patterns between these two groups were found.

[The construction of an empirically based social status index through optimal scaling as illustrated by Germany]. / Die Konstruktion eines empirisch bestimmten Sozialschichtindexes mittels optimaler Skalierung am Beispiel von Deutschland.

Numerous epidemiological studies have shown an association between social status and disease. In alcohol research, socio-economic status (SES) has been associated with drinking patterns, misuse and alcohol problems. SES is a construct which is usually built by using the indicators education, occupation or income separately or combined as a summary score. However, either approach involves theoretical assumptions about the explanatory value of a chosen indicator before the data have been analysed. In this study we have created a gender-specific metric social status indicator for Germany by using all three single SES-indicators (education, occupation, income). We used national representative data from a postal survey from 2000. The age range was restricted to 25 - 59 years. To construct the indicator we used optimal scaling (categorical principal components analysis). Therefore no theoretical assumptions were necessary about the hierarchical order of educational or occupational categories. The optimal-scaling approach allows variables to be scaled on different levels. We used education and occupation as the original categorical data and income (equivalent income) as continuous data. The result of the scaling is a two-dimensional solution. The first dimension explains that variance which could be described by status consistencies (corresponding levels for education, occupation and income). The second dimension of the indicator results from the low correlation between education and income for some individuals (status inconsistencies). The two-dimensional indicator yields differentiated results which would not be visible using a one-dimensional SES-indicator such as education or a summary score. With regard to drinking patterns there are clear differences between middle or low-educated women or men with higher incomes and other social groups. Middle or low-educated men or women with a high income are more likely to be heavy episodic drinkers than people in other social status groups.

West German drinking patterns in 1984 and 1990.

Basic drinking patterns are examined with regard to sociodemographic correlates for the years 1984/1986 and 1990/1992 by a secondary analysis of data from representative samples of the former West German general population. Data come from the National Health Survey of the German Cardiovascular Prevention Study in which the former West German non-institutionalized general population aged 25-69 years was sampled through multistage probability methods. In 1984, 91% of West Germans were drinkers, 16% were daily drinkers, and 8% consumed a mean of 60 g or more of ethanol per day. These figures decreased slightly but significantly by 1990. Despite a downward trend in consumption between 1984 and 1990, Germany remains a 'wet' culture.

[Reducing income inequity and boosting social capital: new responsibilities in social epidemiological research]. / Verringerung der Einkommens-Ungleichheit und Verstärkung des sozialen Kapitals: Neue Aufgaben der sozial-epidemiologischen Forschung.

This paper focuses on the fact that there are not only large inequalities in health between but also within countries. The question is raised as to whether these two types of health inequalities are caused by similar processes, and whether understanding these processes could lead to new strategies for reducing such differences. Many studies in Germany have demonstrated that mortality and morbidity are much higher for low-status as compared to high-status population groups. These health inequalities are usually explained by differences in working and living conditions, in health behaviour and in health services utilisation. For some years there has been an extensive discussion in the international Public Health community on health inequalities between countries and on how they can be explained by income inequalities, with the term "social capital" becoming a central issue. This debate has been largely neglected in Germany, but such groundwork now offers an important opportunity for a more comprehensive discussion in this country as well.

[Trends in alcohol consumption and predictors for increased alcohol consumption in former East Germany--analysis of the 1st and 2nd stages of the German Cardiovascular Prevention Study]. / Trends im Alkoholkonsum und Prädiktoren für erhöhten Alkoholkonsum in der ehemaligen BRD--Analyse der ersten und zweiten Welle der Deutschen Herz-Kreislauf-Präventionsstudie.

In comparison to other European and western countries, the social epidemiology of alcohol consumption and alcohol abuse in the general population remains under-researched in Germany. In an attempt to begin to fill this gap, data sets from the German Cardiovascular Prevention Study (DHP), now available as public use files, are analysed. The goals of the present study are: (1) to investigate the data sets from the first and second stages of the DHP (1984, 1987) for possible trends in drinking patterns in the German general population, and (2) through use of logistic regression, to identify sociodemographic correlates of heavy drinking. The frequency of consumption of various types of alcoholic beverages declined slightly to moderately among both men and women between 1984 and 1987. The percentage of persons who drank alcohol also declined. Mean consumption of alcohol remained basically unchanged between the two points: about 30 g per day for men and about 13 g per day for women. The second goal of the research was to identify sociodemographic correlates of heavy drinking. It was found that women of a particular age group, 30-39 years, are inclined to be heavy drinkers in comparison to women of other ages. Also among women, higher socioeconomic status showed a positive relationship to heavy drinking: however, income showed a negative influence. Only through the interactions with age and with level of secondary education was income positively related to heavy drinking. Among men, those with four children or more showed greater odds to be heavy drinkers. But the odds for heavy drinking decline among older men who live with their partners, while the odds for heavy drinking are higher for older men who live alone. The chances of being a heavy drinker are also considerably higher for employed men in comparison to men not employed; however, employed men of higher socioeconomic status have reduced odds of being heavy drinkers. These findings suggest that the research results from other countries with regard to predictors of heavy drinking may not be entirely applicable to the German general population. In any case, more detailed research into the social epidemiology of alcohol consumption in Germany is warranted. New and more specific knowledge can then be used to help develop public health measures for certain population subgroups who are identified as being at risk for alcohol abuse or alcohol problems on account of their heavy alcohol consumption.

[Realm and goals of social epidemiology. A contribution to determining current status in relation to German language discussion]. / Inhalte und Ziele der Sozial-Epidemiologie. Beitrag zur Standortbestimmung der deutschsprachigen Diskussion.

A first approach to the word "social epidemiology" is provided by the two components social and epidemiology. They suggest that the social dimension of the distribution of morbidity and mortality should be analysed by means of epidemiological methods. The interest in this topic has risen considerably in recent years, but it is difficult to exactly specify the questions "social-epidemiologists" are analysing or should be analysing. That is why the "Social Epidemiology Working Group" is now reviewing the state of the art of social epidemiology discussions in the German-speaking countries. The overview shows the broad spectrum of social epidemiology topics, but also the difficulties in providing a clear definition. In a brief description of the Anglo-American discussion it is pointed out that social epidemiology have to deal with similar problems there, and that they classify their work as epidemiology rather than social epidemiology. The paper concludes with recommendations by the Working Group concerning the main topics and objectives of current socio-epidemiological research.

[The influence of regional differences in drinking style on hazardous use, excessive drinking, abuse and dependence]. / Der Einfluss regionaler Unterschiede im Trinkstil auf riskanten Konsum, exzessives Trinken, Missbrauch und Abhängigkeit.

INTRODUCTION: Previous research in Germany identified a "north-south" gradient in the hazardous use of alcoholic drinks, but this had methodological limitations. The present study estimates the hazardous use of alcohol more reliably. In addition, regional differences in drinking style and their relation to indicators of problematic alcohol use are examined. METHODS: Data are from 1995 and 1997 representative samples of the non-institutionalised German general population aged 18 to 59 years. Based on 15,017 complete observations prevalence rates for abstinence, hazardous consumption (>30 g ethanol per day for men; >20 g ethanol per day for women), two or more CAGE-symptoms, and heavy episodic drinking (5+ drinks consumed in a day) were calculated and a cluster analysis was performed with regard to the 16 German federal states. RESULTS: Regional differences exist in the prevalence of abstinence and hazardous drinking, but a "north-south" gradient was not evident. However, cluster analysis results suggest a "north-south" difference in drinking style, i.e. the quantity-frequency pattern of beer, wine, and spirits consumption. Compared with the northern German federal states, those in the south experienced more beer and less wine and spirits consumption in combination with a lower frequency of drinking beer and spirits. No cluster difference was found for hazardous drinking, lifetime prevalence of 2+ CAGE items or consumption of 5+ drinks in a day. Yet, mean consumption of ethanol was significantly higher in the north. CONCLUSIONS: Research suggesting more hazardous consumption in southern Germany must be tempered by these findings that found no 'north-south' gradient in several different indicators of problematic alcohol use. Different drinking styles in northern and southern states do not result in differences concerning prevalence of binge drinking nor alcohol-related problems. Drinking style only made a difference in the mean consumption of ethanol. Methodological differences between the reported studies are discussed.

Expression and localization of thioredoxin during early implantation in the marmoset monkey.

Thioredoxin is a powerful redox protein expressed in invasive cytotrophoblasts and essential for blastocyst implantation in mice. Isolated marmoset thioredoxin cDNA showed that the deduced amino acid sequence differed from the human sequence by four amino acids. The close homology of thioredoxin in the two species enabled us to use monoclonal antibodies against human thioredoxin to detect marmoset thioredoxin in implantation sites, blastocysts and culture medium. Immunocytochemistry on marmoset implantation sites, on pregnancy days 12 and 15, showed that thioredoxin is highly expressed in uterine luminal epithelium, glands and in some endometrial stromal cells. In attached blastocysts, thioredoxin staining was detected in mural and polar trophoblast cells and both visceral and parietal endoderm, whereas no staining was present in the inner cell mass. A similar pattern of thioredoxin expression was detected in hatched blastocysts attached to Matrigel in tissue culture. Trophoblastic vesicles derived from blastocysts expressed thioredoxin in inner endoderm-like cells and outer trophoblast-like cells and secreted thioredoxin into the culture medium. These experiments have demonstrated thioredoxin expression during early stages of embryo-maternal interaction. We propose that thioredoxin protects the early placenta from oxidative damage and that the marmoset is a valuable model for studying thioredoxin regulation and function during implantation and blastocyst differentiation.