Application of the European quality indicators for psychosocial dementia care in long-term care facilities in the Asia-Pacific region: a pilot study.

OBJECTIVES: An Asia-Pacific regional collaboration group conducted its first multi-country research project to determine whether or not European quality indicators (QIs) for psychosocial care in dementia could be implemented as a valid tool in residential aged care across seven Asia-Pacific sites (Australia, Hong Kong Special Administrative Region, Mainland China, Malaysia, Singapore, South Korea, and Thailand). METHOD: Following the European QI protocol, auditing and data extraction of medical records of consenting residents with dementia were conducted by trained auditors with relevant health care backgrounds. Detailed field notes by the auditors were also obtained to describe the characteristics of the participating care facilities, as well as key issues and challenges encountered, for each of the 12 QIs. RESULTS: Sixteen residential care facilities in the seven Asia-Pacific sites participated in this study. Data from 275 residents' records revealed each of the 12 Qis' endorsement varied widely within and between the study sites (0%-100%). Quality of the medical records, family and cultural differences, definitions and scoring of certain indicators, and time-consuming nature of the QI administration were main concerns for implementation. CONCLUSION: Several items in the European QIs in the current format were deemed problematic when used to measure the quality of psychosocial care in the residential aged care settings in participating Asia-Pacific countries. We propose refinements of the European QIs for the Asian-Pacific context, taking into account multiple factors identified in this study. Our findings provide crucial insights for future research and implementation of psychosocial dementia care QIs in this region.

Light-atom influences on the electronic structures of iron-sulfur clusters.

Ligand K-edge X-ray absorption spectroscopy was used to study dimeric and tetrameric Cl-terminated Fe-S clusters with variable numbers of S(2-) substituted by N(t)Bu(2-) (N(t)Bu(2-) = tertbutylimido) ligands to gain insights into the functional role of the interstitial light atom in the iron-molybdenum cofactor (FeMoco) of nitrogenase. These studies are complemented by time-dependent density functional theory analysis to quantify the relative effects on Fe-S and Fe-Cl bonding. The results show that N(t)Bu(2-) substitution dramatically affects the electronic structure of dimeric clusters, while the impact on tetrameric clusters is small. Strong agreement between experiment and theory merited extension of this analysis to hypothetical clusters with S(2-) substituted by N and C-atom donor ligands as well as FeMoco itself. These results show that very strong electron donors are required to appreciably modulate the electronic structure of tetrameric (or larger) iron sulfur clusters, pointing to a possible role of the central C(4-) in FeMoco.

Kinetics and mechanistic analysis of an extremely rapid carbon dioxide fixation reaction.

Carbon dioxide may react with free or metal-bound hydroxide to afford products containing bicarbonate or carbonate, often captured as ligands bridging two or three metal sites. We report the kinetics and probable mechanism of an extremely rapid fixation reaction mediated by a planar nickel complex [Ni(II)(NNN)(OH)](1-) containing a tridentate 2,6-pyridinedicarboxamidate pincer ligand and a terminal hydroxide ligand. The minimal generalized reaction is M-OH + CO(2) → M-OCO(2)H; with variant M, previous rate constants are ≲10(3) M(-1) s(-1) in aqueous solution. For the present bimolecular reaction, the (extrapolated) rate constant is 9.5 × 10(5) M(-1) s(-1) in N,N'-dimethylformamide at 298 K, a value within the range of k(cat)/K(M)≈10(5)-10(8) M(-1) s(-1) for carbonic anhydrase, the most efficient catalyst of CO(2) fixation reactions. The enthalpy profile of the fixation reaction was calculated by density functional theory. The initial event is the formation of a weak precursor complex between the Ni-OH group and CO(2), followed by insertion of a CO(2) oxygen atom into the Ni-OH bond to generate a four center Ni(η(2)-OCO(2)H) transition state similar to that at the zinc site in carbonic anhydrase. Thereafter, the Ni-OH bond detaches to afford the Ni(η(1)-OCO(2)H) fragment, after which the molecule passes through a second, lower energy transition state as the bicarbonate ligand rearranges to a conformation very similar to that in the crystalline product. Theoretical values of metric parameters and activation enthalpy are in good agreement with experimental values [ΔH(‡) = 3.2(5) kcal/mol].

Structural Analysis of Cubane-Type Iron Clusters.

The generalized cluster type [M4(µ3-Q)4L n ] x contains the cubane-type [M4Q4] z core unit that can approach, but typically deviates from, perfect Td symmetry. The geometric properties of this structure have been analyzed with reference to Td symmetry by a new protocol. Using coordinates of M and Q atoms, expressions have been derived for interatomic separations, bond angles, and volumes of tetrahedral core units (M4, Q4) and the total [M4Q4] core (as a tetracapped M4 tetrahedron). Values for structural parameters have been calculated from observed average values for a given cluster type. Comparison of calculated and observed values measures the extent of deviation of a given parameter from that required in an exact tetrahedral structure. The procedure has been applied to the structures of over 130 clusters containing [Fe4Q4] (Q = S2-, Se2-, Te2-, [NPR3]-, [NR]2-) units, of which synthetic and biological sulfide-bridged clusters constitute the largest subset. General structural features and trends in structural parameters are identified and summarized. An extensive database of structural properties (distances, angles, volumes) has been compiled in Supporting Information.

Fast carbon dioxide fixation by 2,6-pyridinedicarboxamidato-nickel(II)-hydroxide complexes: influence of changes in reactive site environment on reaction rates.

The planar complexes [Ni(II)(pyN(2)(R2))(OH)](-), containing a terminal hydroxo group, are readily prepared from N,N'-(2,6-C(6)H(3)R(2))-2,6-pyridinedicarboxamidate(2-) tridentate pincer ligands (R(4)N)(OH), and Ni(OTf)(2). These complexes react cleanly and completely with carbon dioxide in DMF solution in a process of CO(2) fixation with formation of the bicarbonate product complexes [Ni(II)(pyN(2)(R2))(HCO(3))](-) having η(1)-OCO(2)H ligation. Fixation reactions follow second-order kinetics (rate = k(2)'[Ni(II)-OH][CO(2)]) with negative activation entropies (-17 to -28 eu). Reactions were monitored by growth and decay of metal-to-ligand charge-transfer (MLCT) bands at 350-450 nm. The rate order R = Me > macro > Et > Pr(i) > Bu(i) > Ph at 298 K (macro = macrocylic pincer ligand) reflects increasing steric hindrance at the reactive site. The inherent highly reactive nature of these complexes follows from k(2)' ≈ 10(6) M(-1) s(-1) for the R = Me system that is attenuated by only 100-fold in the R = Ph complex. A reaction mechanism is proposed based on computation of the enthalpic reaction profile for the R = Pr(i) system by DFT methods. The R = Et, Pr(i), and Bu(i) systems display biphasic kinetics in which the initial fast process is followed by a slower first order process currently of uncertain origin.

Family Caregiver Perspectives on Suffering of Persons With Severe Dementia: A Qualitative Study.

CONTEXT: Dementia involves suffering. Assessing the experience of suffering among persons with severe dementia is instrumental to delivering quality end-of-life care to them and their caregivers. OBJECTIVES: We aimed to assess dimensions of suffering from the perspective of family caregivers and the resulting impact on their decisions for the care of persons with severe dementia. METHODS: Between July 2018 and February 2019, we conducted qualitative in-depth interviews with 27 family caregivers of community-dwelling persons with severe dementia with Functional Assessment Staging Test staging 7. We asked caregivers if they perceived persons with severe dementia to be suffering and explored reasons for their perceptions. We analyzed data using principles of reflexive thematic analysis. RESULTS: We conceptualized five dimensions of suffering among persons with severe dementia from the perspective of their caregivers: 1) untreated physical or behavioral symptoms, 2) emotional pain, 3) loss of agency, 4) loss of engagement with society, and 5) loss of personhood. Suffering among persons with severe dementia influences their caregivers' expression of a wish for their death and caregivers' decision regarding the use of life-prolonging interventions for them. CONCLUSION: Findings suggest that suffering among persons with severe dementia can occur independent of physical symptoms and requires provision of person-centered care. The study adds to the understanding of end-of-life care in persons with severe dementia and their caregivers.

A Prospective Longitudinal Study of Caregivers of Community Dwelling Persons with Severe Dementia (PISCES): Study Protocol.

Although many persons with severe dementia (PWSDs) are cared for at home by their family caregivers, few studies have assessed end of life (EOL) care experiences of PWSDs. We present the protocol for the PISCES study (Panel study Investigating Status of Cognitively impaired Elderly in Singapore) which aims to describe the clinical course, health care utilization, and expenditures for community-dwelling PWSDs; and perceived burden, coping, resilience, anticipatory and prolonged grief among their caregivers. This ongoing multi-center prospective longitudinal study is recruiting primary informal caregivers of 250 PWSDs from major restructured public hospitals, community hospitals, home care foundations, and hospices in Singapore. Caregivers are surveyed every four months for two years or until the PWSD passes away and then at eight weeks and six months post-death to assess the bereavement of the caregiver. Survey questionnaires included validated tools to assess PWSDs' quality of life, suffering, behaviors, functional status, resource utilization; and caregiver's satisfaction with care, awareness of prognosis, care preferences, resilience, coping, perceived burden, distress, positive aspects of caregiving, anticipatory grief, and bereavement adjustment. We also conduct qualitative in-depth interviews with a sub-sample of caregivers. The survey data is being linked with medical and billing records of PWSDs. The study has been approved by an ethics board. Results from the study will be disseminated through publications and presentations targeting researchers, policy makers and clinicians interested in understanding and improving EOL care for PWSDs and their caregivers.

A cross-sectional study of burnout and its associations with learning environment and learner factors among psychiatry residents within a National Psychiatry Residency Programme.

BACKGROUND: Multiple studies have reported high burnout rates among residents, including psychiatry. There is a paucity of studies examining the relationship between burnout and learning context, stress levels, resilience, stigma in healthcare providers and coping methods concurrently within the same cohort. OBJECTIVE: We examined the rate of burnout among our psychiatry residents in a cross-sectional study and hypothesised that burnout is associated with poorer perception of learning environment, greater perceived stress, stigma levels, lower resilience and specific coping strategies during training. METHODS: Ninety-three out of 104 psychiatry residents (89.4%) within our National Psychiatry Residency Programme participated in the study from June 2016 to June 2018. Relevant scales were administered to assess the perception of learning environment, burnout, stress, resilience, stigma levels and coping methods, respectively. We performed comparisons of the above measures between groups (burnout vs no burnout) and within-group correlations for these same measures. RESULTS: Overall, 54.8% of the sample met criteria for burnout. Residents with burnout had poorer perception of the learning environment, greater stress levels (both p<0.001), were less willing to disclose/seek help and employed greater active-avoidance coping strategies. Within the burnout group, greater perceived stress was correlated with poorer perception of learning environment (rs=-0.549) and greater use of active-avoidance coping (rs=0.450) versus additional use of problem-focussed coping within the non-burnout group. CONCLUSIONS: Burnout was related to both environment and learner factors. These findings viewed within the transactional, sequential and imbalance models of burnout suggest the need to address stressors, beef up coping, provide continual support and develop resilience among our learners.

Prevalence of Dementia in People Aged 60 Years and Above: Results from the WiSE Study.

BACKGROUND: The challenge of an aging population with its expected attendant problem of an increase in the number of people with dementia is a growing concern across the world. OBJECTIVE: The aims of this study were to establish the prevalence and risk factors of dementia in Singapore among the elderly resident population (aged 60 years and above). METHODS: The WiSE study was a comprehensive single phase, cross-sectional, epidemiological survey that adapted the 10/66 protocol to establish the 10/66 and the Diagnostic and Statistical Manual of mental disorders -fourth edition (DSM-IV) diagnosis of dementia. 10/66 and DSM-IV dementia diagnosis as established by the survey questionnaires was validated by comparing against a gold standard of clinical assessment. RESULTS: A total of 2,565 respondents completed the study giving a response rate of 65.6%. The validity of 10/66 dementia was higher (sensitivity = 95.6%, specificity = 81.8%) than that of DSM-IV dementia (sensitivity = 75.6%, specificity = 88.6%) when compared against the clinical gold standard. The study found that the prevalence of 10/66 dementia was 10% in the older adult population while the prevalence of DSM-IV dementia was 4.6%. Older age (75 years and above); no formal education, or completed primary education (versus higher education); homemaker and retired status (versus employed); and a history of stroke were associated with a higher risk of 10/66 dementia. CONCLUSION: The establishment of accurate data on the number of people with dementia is essential in the planning of services and initiatives.

First presentation psychosis among the elderly in Singapore.

INTRODUCTION: In tandem with our ageing population, it is observed there is a growing trend of elderly patients presenting for the first time with psychotic symptoms. Clinical experience suggests differences in the phenomenology of late-onset psychosis in our Asian context compared to studies done in the West. This study aimed to analyse the characteristics and psychopathology of first presentation psychosis in our local elderly and to determine the treatment outcome over a 12-month period. METHODS: A total of 64 subjects with first presentation psychosis were consecutively recruited. Those with a non-affective, non-organic psychotic disorder were evaluated using the Positive and Negative Symptoms Scale, the Clinical Global Impression Scale, Mini-Mental State Examination and the Beck's Depression Inventory. RESULTS: Of the 64 subjects recruited, 55 were enrolled in the study. 59.3% (n = 32) of the subjects were diagnosed to be suffering from very-late-onset schizophrenia-like psychosis, followed by delusional disorder in 31.5% (n = 17). The remaining 11.1% (n = 6) were diagnosed to have late-onset schizophrenia. The sample showed a high preponderance of women, with 88.9% reporting persecutory-type delusions. The majority of them were married and 80% of the subjects were living with relatives. Treatment was effective in ameliorating symptoms, but there was a high loss to follow-up of male subjects (81.8%). CONCLUSION: This descriptive study found sociodemographic and phenomenological similarities to other studies of late-onset psychosis in the West, except that social isolation and partition delusions were not prominent.

Severity of depression and suicidal ideations among elderly people in Singapore.

INTRODUCTION: Studies in the West have concluded that the severity of depression is the strongest predictor of the course of suicidal ideations among the elderly. However, Asian culture tends to be more reserved and this may impact on the reporting of suicidal ideations. This study aims to determine the prevalence of suicidal ideation among depressed elderly people in Singapore and attempts to investigate the relationship between severity of depression and suicidality. METHOD: Eighty consecutive depressed patients were recruited and severity of depressive symptoms rated with Beck's Depression Inventory (BDI). Suicidality was assessed using the Beck's Hopelessness Scale (BHS) and Beck's Suicide Intent Scale (BSS). Suicidal ideation was defined as any thought of wanting to kill oneself over the past seven days and not just a passive wish to die. RESULTS: 53.8% verbalized thoughts of wanting to kill themselves. Males were three times more likely to report suicidal thoughts. Severity of depression did not significantly influence the presence of suicidal thinking. The association of depression severity and suicidal ideations is not strongly supported. CONCLUSIONS: Elderly males were more likely to report suicidal ideations when depressed. Elderly patients who reported suicidal ideations were likely to be more severely depressed. However, in a depressed elderly person, the absence of suicidal ideations would not infer that the episode of depression was less severe.

The impact of neuropsychiatric symptoms of dementia on distress in family and professional caregivers in Singapore.

BACKGROUND: Behavioral and psychological symptoms of dementia (BPSD) are a source of distress and burden for caregivers. This study attempts to determine the neuropsychiatric symptoms, demographic characteristics, and referral patterns of outpatients with dementia compared with patients admitted to the acute psychogeriatric wards of Woodbridge Hospital. We also assessed the impact of neuropsychiatric symptoms on distress in family and professional caregivers. METHOD: Eighty-five consecutive patients with a first-time diagnosis of dementia were recruited. They were assessed using the Neuropsychiatric Inventory Caregiver Distress Scale (NPI-D). The professional caregiver distress questions were rephrased to assess the "occupational disruptiveness" of behaviors in the nursing home version (NPI-NH). RESULTS: Neuropsychiatric symptoms were common and were positively correlated with caregiver distress. Family caregivers were significantly more distressed than professional caregivers over the delusion, agitation, depression and aberrant motor domains, although the severity of the behavioral disturbances reported was not higher in the sample. The median NPI scores for the agitation and disinhibition domains were significantly higher in the inpatient group, contrasting with a higher score for the depression domain among the outpatient group. CONCLUSIONS: This study highlights the prevalence of neuropsychiatric symptoms in dementia and illustrates the strong correlation between the severity of behavioral disturbances and caregiver distress.