Rationale for a Multi-Factorial Approach for the Reversal of Cognitive Decline in Alzheimer's Disease and MCI: A Review.

Alzheimer's disease (AD) is a multifactorial, progressive, neurodegenerative disease typically characterized by memory loss, personality changes, and a decline in overall cognitive function. Usually manifesting in individuals over the age of 60, this is the most prevalent type of dementia and remains the fifth leading cause of death among Americans aged 65 and older. While the development of effective treatment and prevention for AD is a major healthcare goal, unfortunately, therapeutic approaches to date have yet to find a treatment plan that produces long-term cognitive improvement. Drugs that may be able to slow down the progression rate of AD are being introduced to the market; however, there has been no previous solution for preventing or reversing the disease-associated cognitive decline. Recent studies have identified several factors that contribute to the progression and severity of the disease: diet, lifestyle, stress, sleep, nutrient deficiencies, mental health, socialization, and toxins. Thus, increasing evidence supports dietary and other lifestyle changes as potentially effective ways to prevent, slow, or reverse AD progression. Studies also have demonstrated that a personalized, multi-therapeutic approach is needed to improve metabolic abnormalities and AD-associated cognitive decline. These studies suggest the effects of abnormalities, such as insulin resistance, chronic inflammation, hypovitaminosis D, hormonal deficiencies, and hyperhomocysteinemia, in the AD process. Therefore a personalized, multi-therapeutic program based on an individual's genetics and biochemistry may be preferable over a single-drug/mono-therapeutic approach. This article reviews these multi-therapeutic strategies that identify and attenuate all the risk factors specific to each affected individual. This article systematically reviews studies that have incorporated multiple strategies that target numerous factors simultaneously to reverse or treat cognitive decline. We included high-quality clinical trials and observational studies that focused on the cognitive effects of programs comprising lifestyle, physical, and mental activity, as well as nutritional aspects. Articles from PubMed Central, Scopus, and Google Scholar databases were collected, and abstracts were reviewed for relevance to the subject matter. Epidemiological, pathological, toxicological, genetic, and biochemical studies have all concluded that AD represents a complex network insufficiency. The research studies explored in this manuscript confirm the need for a multifactorial approach to target the various risk factors of AD. A single-drug approach may delay the progression of memory loss but, to date, has not prevented or reversed it. Diet, physical activity, sleep, stress, and environment all contribute to the progression of the disease, and, therefore, a multi-factorial optimization of network support and function offers a rational therapeutic strategy. Thus, a multi-therapeutic program that simultaneously targets multiple factors underlying the AD network may be more effective than a mono-therapeutic approach.

An examination of the prevalence of acute pain for hospitalised adult patients: a systematic review.

AIMS AND OBJECTIVE: Aims of the review were to establish the prevalence of acute pain for adults in hospital, to identify the amount of severe or unacceptable pain reported and to examine the prevalence of acute pain within medical units. BACKGROUND: Acute Pain Services have been established in the United Kingdom (UK) to improve pain management within surgical settings. Acute pain is a common symptom across all hospital settings. However, medical settings have traditionally been considered low risk for acute pain and have therefore not always been included in the provision provided by APS. As a result 82% of APS surveyed in the UK felt that pain management was suboptimal on medical units. DESIGN AND METHOD: This review follows the process of a systematic review. RESULTS: Hospital-wide pain prevalence obtained ranged from 37·7-84%, severe pain prevalence ranged from 9-36%. The papers reviewed were of variable quality and heterogeneous resulting in the wide range of pain prevalence. Higher prevalence of pain was found for surgical patients compared to medical patients, although up to 55% of medical patients' reported pain. CONCLUSION: It is difficult to determine a definite prevalence of pain for adults in hospital due to the variability of the studies examined. However, pain does remain a significant symptom with up to 35% of patients reporting severe pain and approximately 50% of medical patient reported pain. RELEVANCE TO CLINICAL PRACTICE: Awareness of the extent of pain as a problem for patients is the first step to improving practice. This review has demonstrated that there is a need for similar Acute Pain Teams and services for the staff and patients admitted to all areas of the hospital, including medical units to help clinicians assess and treat pain in all areas of a hospital setting.

The complexity of pain assessment in older people.

Pain is common in older people and its assessment is an important part of the nurse's role. Asking people about their pain is considered the most accurate and reliable assessment because of the subjective nature of pain. A number of simple and easy-to-administer self-rating scales are available to measure pain intensity. To rate their pain, however, people need to understand the request, as well as recall and interpret the painful signal. Observing specific behaviours associated with pain is advocated when communication and cognitive function are impaired, for example, in people with advanced dementia. A number of pain assessment tools have been developed that involve observation of some or all of the behaviours. The aim of this article is to highlight the importance of pain assessment, discuss the various pain assessment scales and tools available and identify some of the factors that can make comprehensive assessment of pain in older people and those with cognitive impairment complex.

'Getting to Know Me': the development and evaluation of a training programme for enhancing skills in the care of people with dementia in general hospital settings.

OBJECTIVE: The aims of the study were to report on the development and evaluation of a staff training intervention in dementia care designed for use in the general hospital setting: the 'Getting to Know Me' training programme. The study also aimed to undertake initial psychometric analysis on two new outcome scales designed to measure knowledge and confidence in dementia care. METHODS: The study comprised two phases. The first phase comprised the design of two questionnaires which are shared within this paper: Confidence in Dementia (CODE) Scale and Knowledge in Dementia (KIDE) Scale. In phase two, staff undertook the 'Getting to Know Me' training programme (n=71). The impact of the programme was evaluated using a pre-post design which explored: (1) changes in confidence in dementia; (2) changes in knowledge in dementia; and (3) changes in beliefs about challenging behaviour. RESULTS: The psychometric properties of the CODE and KIDE scales are reported. Statistically significant change was identified pre-post training on all outcome measures. Clinically meaningful change was demonstrated on the CODE scale. CONCLUSIONS: The 'Getting to Know Me' programme was well received and had a significant impact on staff knowledge and confidence. Our findings add to a growing evidence base which will be strengthened by further robust studies, the exploration of the impact of staff training on direct patient outcomes, and further identification of ways in which to transfer principles of care from specialist dementia environments into general hospital settings.

Understanding the communication skills that support nurses to provide person-centred care.

Communication is a process of sharing information and developing relationships through interaction. It is essential for nursing care, providing a basis for nurses to establish therapeutic relationships and trust with patients and their families. It is often assumed that nurses can intuitively communicate well; as a result, traditionally there has been a lack of formal training in this area. However, communication is a skill that can be developed and enhanced. This article explains the elements of communication and discusses the skills required by nurses to communicate effectively and provide compassionate, person-centred care. The author outlines two communication models to demonstrate how nurses can use these skills to deliver bad news and support people in distress.

Observing pain management practice on a medical unit following changes arising from an action research study.

AIM: To describe pain assessment practice within a medical unit, to identify factors that may affect the assessment of pain and evaluate changes in practice. BACKGROUND: Pain is a problem for patients in all areas of a hospital, but its assessment and management on medical units had not been investigated. An initial assessment of practice found that pain was not consistently assessed and managed on the unit. A variety of activities have been employed during an action research study to change pain management practice. METHOD: Naturalistic unstructured participant observation of nurses and structured patient interviews were conducted. RESULTS: The need to communicate with many people led to interruptions, multi-tasking and practical problems were observed which appeared to affect the provision of nursing care, in particular, the administration of medications. These factors also prevented a comprehensive assessment of pain, although the assessment of pain intensity appeared to have increased. DISCUSSION: The constant activity and interruptions observed may make it difficult for patients to discuss their experience of pain in detail. These accepted, every day and taken-for-granted aspects of nursing observed appeared to reduce opportunities for comprehensive pain assessment. CONCLUSION: Pain assessment is one of a number of nursing activities, obtaining a pain score appears to have become routine practice. Nursing takes place in a complex environment, which may disrupt the provision of nursing care and impede communication. RELEVANCE TO PRACTICE: To increase nurses awareness of the complexity of every day practice, the numerous tasks required, interruptions to the provision of care and the resultant effect on pain assessment and management. They need to then identify and reflect on these factors prior to attempting to change their practice.

Neuroprotective Herbs for the Management of Alzheimer's Disease.

Background-Alzheimer's disease (AD) is a multifactorial, progressive, neurodegenerative disease that is characterized by memory loss, personality changes, and a decline in cognitive function. While the exact cause of AD is still unclear, recent studies point to lifestyle, diet, environmental, and genetic factors as contributors to disease progression. The pharmaceutical approaches developed to date do not alter disease progression. More than two hundred promising drug candidates have failed clinical trials in the past decade, suggesting that the disease and its causes may be highly complex. Medicinal plants and herbal remedies are now gaining more interest as complementary and alternative interventions and are a valuable source for developing drug candidates for AD. Indeed, several scientific studies have described the use of various medicinal plants and their principal phytochemicals for the treatment of AD. This article reviews a subset of herbs for their anti-inflammatory, antioxidant, and cognitive-enhancing effects. Methods-This article systematically reviews recent studies that have investigated the role of neuroprotective herbs and their bioactive compounds for dementia associated with Alzheimer's disease and pre-Alzheimer's disease. PubMed Central, Scopus, and Google Scholar databases of articles were collected, and abstracts were reviewed for relevance to the subject matter. Conclusions-Medicinal plants have great potential as part of an overall program in the prevention and treatment of cognitive decline associated with AD. It is hoped that these medicinal plants can be used in drug discovery programs for identifying safe and efficacious small molecules for AD.

ReCODE: A Personalized, Targeted, Multi-Factorial Therapeutic Program for Reversal of Cognitive Decline.

BACKGROUND: Alzheimer's disease (AD) is the major cause of age-associated cognitive decline, and in the absence of effective therapeutics is progressive and ultimately fatal, creating a dire need for successful prevention and treatment strategies. We recently reported results of a successful proof-of-concept trial, using a personalized, precision medicine protocol, but whether such an approach is readily scalable is unknown. OBJECTIVE: In the case of AD, there is not a single therapeutic that exerts anything beyond a marginal, unsustained, symptomatic effect. This suggests that the monotherapeutic approach of drug development for AD may not be an optimal one, at least when used alone. Using a novel, comprehensive, and personalized therapeutic system called ReCODE (reversal of cognitive decline), which proved successful in a small, proof-of-concept trial, we sought to determine whether the program could be scaled to improve cognitive and metabolic function in individuals diagnosed with subjective cognitive impairment, mild cognitive impairment, and early-stage AD. METHODS: 255 individuals submitted blood samples, took the Montreal Cognitive Assessment (MoCA) test, and answered intake questions. Individuals who enrolled in the ReCODE program had consultations with clinical practitioners, and explanations of the program were provided. Participants had follow-up visits that included education regarding diet, lifestyle choices, medications, supplements, repeat blood sample analysis, and MoCA testing between 2 and 12 months after participating in the ReCODE program. Pre- and post-treatment measures were compared using the non-parametric Wilcoxon signed rank test. RESULTS AND CONCLUSIONS: By comparing baseline to follow-up testing, we observed that MoCA scores either significantly improved or stabilized in the entire participant pool-results that were not as successful as those in the proof-of-concept trial, but more successful than anti-amyloid therapies-and other risk factors including blood glucose, high-sensitivity C-reactive protein, HOMA-IR, and vitamin D significantly improved in the participant pool. Our findings provide evidence that a multi-factorial, comprehensive, and personalized therapeutic program designed to mitigate AD risk factors can improve risk factor scores and stabilize or reverse the decline in cognitive function. Since superior results were obtained in the proof-of-concept trial, which was conducted by a small group of highly trained and experienced physicians, it is possible that results from the use of this personalized approach would be enhanced by further training and experience of the practicing physicians. Nonetheless, the current results provide further support indicating the potential of such an approach for the prevention and reversal of cognitive decline.

Holistic pain assessment in older people and older people living with dementia.

Pain occurs in a wide range of diseases and long-term conditions associated with ageing and can affect every aspect of an individual's life, reducing their ability to recover, their independence and their quality of life. The assessment of pain is an important aspect of nurses' role and requires them to obtain detailed information on how the older person experiences pain and how pain is affecting their life. However, there are many challenges to effective pain assessment in older people, including challenges concerning communication and cognition. This article provides an overview of pain assessment in older people, particularly those living with dementia, based on the author's expertise and on relevant literature, notably the recently revised UK national guidelines on the assessment of pain in older people.

Use of pain scales and observational pain assessment tools in hospital settings.

Pain is a personal, individual and subjective experience. The complex and dynamic nature of pain makes its assessment and management challenging for healthcare professionals. Various pain scales are available that can assist in identifying the patient's experience of pain; however, these tend to reduce this experience to a measure of pain intensity. The use of pain scales also requires patients to communicate and describe their pain; when this is not possible, it is necessary for healthcare professionals to observe patient behaviours that may indicate pain. Various observational pain assessment tools have been developed to assist in recognising and assessing pain. This article discusses the various pain scales and observational pain assessment tools that are available, and the evidence to support their use.

Using nitrous oxide and oxygen to control pain in primary care.

Improving pain control is an area where nurses have the clinical expertise to make a significant difference to the quality of patient care. The inhaled analgesic 50% nitrous oxide and 50% oxygen is ideal for use when undertaking short, potentially painful procedures as it is a safe and effective method of pain relief. Many patients in the community require procedures that can be extremely painful. This article describes how this analgesic has been successfully introduced throughout a PCT, through collaborative working between acute pain nurses based in the hospital setting and community nurses.

'Getting to Know Me': The second phase roll-out of a staff training programme for supporting people with dementia in general hospitals.

Objectives The aims were to evaluate a second phase roll-out of a dementia care training programme for general hospital staff and to further develop two outcome scales: the Confidence in Dementia scale for measuring confidence in working with people with dementia and the Knowledge in Dementia scale for measuring knowledge in dementia. Method Following a 'training the trainers' phase, the study involved the delivery of the 'Getting to Know Me' training programme to a large number of staff (n = 517) across three National Health Service (NHS) Trusts situated in North-West England. The impact of the programme was evaluated using a pre-post design which explored: (i) changes in confidence in dementia, (ii) changes in knowledge in dementia, and (iii) changes in beliefs about behaviours that challenge. Results Statistically significant change was identified between pre-post training on all outcome measures (Confidence in Dementia: eight point increase, p < 0.001; Knowledge in Dementia: two point increase p < 0.001; controllability beliefs scale: four point decrease, p < 0.001). Medium to large effect sizes were demonstrated on all outcome measures. The psychometric properties of the Confidence in Dementia and Knowledge in Dementia scales are reported. Conclusion Staff knowledge in dementia and confidence in working with people with dementia significantly increased following attendance at the training sessions. The findings are consistent with preliminary findings and strengthen current knowledge about the impact of dementia care training in general hospitals. The Confidence in Dementia and Knowledge in Dementia scales continue to demonstrate psychometrically sound properties and demonstrate utility in the field of dementia research.

Initial testing of a behavioural pain assessment tool within trauma units.

Pain is common in trauma patients who may be older and also may have cognitive impairment leading to reduced communication about their pain. A number of observational pain assessment tools are available and have been found to have limited clinical usefulness. The Bolton Pain Assessment Tool (BPAT) was developed following a trial of three established tools and includes a section to involve family and/or close carers in the pain assessment process. The aim of this paper is to present the findings of initial testing of BPAT. BPAT was used and evaluated by clinical staff in four trauma units in the UK. Forty-six staff evaluations were completed and 98% indicated it was easy to use; it took between one and two minutes to complete by 69.5% and led to pain management interventions by 93.5% of the respondents. It was rated highly by the clinical staff, but the involvement of families and close carers in the assessment process was different at each unit, with one unit not involving the family/close carer. There remains the need for a simple and practical way of assessing pain. This initial testing of the clinical feasibility of BPAT suggests that it is easy to use and helps to identify pain, but further testing of its reliability and validity is required.

The assessment and management of pain in an orthopaedic out-patient setting: A case study.

The management of pain is an important aspect of an orthopaedic nurse's role. The aim of this paper is to use an individual case study to demonstrate the role of an out-patient orthopaedic nurse in the identification, assessment and management of pain. This paper describes how pain was identified and managed for a patient in the orthopaedic outpatient department, highlighting that pain and its management are not isolated to the in-patient setting. The case study illustrates the importance of recognising pain and taking into account the numerous factors that can influence pain perception. The assessment of an individual patient's pain led to obtaining help from the Acute Pain Team which led to improvement in the patient's pain management and quality of life. The nursing team reflected and discussed the issues identified by this case study which led to changes in practice being introduced. This has resulted in an increased knowledge of and confidence in pain management within the nursing team and development and improvement of pain management practice within the orthopaedic out-patient department.

Multi-disciplinary interpretations of pain in older patients on medical units.

The aim of this study was to assess the knowledge and attitudes of the health care team caring for older patients on acute medical wards. Pain is probably the most distressing symptom experienced by hospital patients. Pain management has traditionally been seen as part of the anaesthetist's role, within the UK, establishment of acute pain teams was a response to the report 'pain after surgery' which cemented the link between pain and surgery. However, in 2004-2005, 63% of admissions to general medicine in the UK were individuals in the 60+ age group suggesting that older people are significant users of general medicine services. Treatment of pain is multi-disciplinary and effective pain management should be a universal response by health care professionals and non-professionals. A questionnaire was distributed to all nurses; registered and non-registered, junior doctors who worked on the acute medical wards, all physiotherapists and all pharmacists in the hospital. There were varying levels of pain management education identified across the professional groups and, whilst there is a reasonable level of pain knowledge both general and specific to the older person, there is still a need to improve the knowledge and attitudes of all health care professional groups caring for older patients in pain on acute medical wards.