Observations of community-based multidisciplinary team meetings in health and social care for older people with long term conditions in England.

BACKGROUND: Community-based multi-disciplinary teams (MDTs) are the most common means to encourage health and social care service integration in England yet are rarely studied or directly observed. This paper reports on two rounds of non-participant observations of community-based multi-disciplinary team (MDT) meetings in two localities, as part of an evaluation of the Integrated Care and Support Pioneers Programme. We sought to understand how MDT meetings coordinate care and identify their 'added value' over bilateral discussions. METHODS: Two rounds of structured non-participant observations of 11 MDTs (28 meetings) in an inner city and mixed urban-rural area in England (June 2019-February 2020), using a group analysis approach. RESULTS: Despite diverse settings, attendance and caseloads, MDTs adopted similar processes of case management: presentation; information seeking/sharing; narrative construction; solution seeking; decision-making and task allocation. Patient-centredness was evident but scope to strengthen 'patient-voice' exists. MDTs were hampered by information governance rules and lack of interoperability between patient databases. Meetings were characterised by mutual respect and collegiality with little challenge. Decision-making appeared non-hierarchical, often involving dyads or triads of professionals. 'Added value' lay in: rapid patient information sharing; better understanding of contributing agencies' services; planning strategies for patients that providers had struggled to find the right way to engage satisfactorily; and managing risk and providing mutual support in stressful cases. CONCLUSIONS: More attention needs to be given to removing barriers to information sharing, creating scope for constructive challenge between staff and deciding when to remove cases from the caseload.

Comparison of the impact of two national health and social care integration programmes on emergency hospital admissions.

BACKGROUND: Policy-makers expect that integration of health and social care will improve user and carer experience and reduce avoidable hospital use. [We] evaluate the impact on emergency hospital admissions of two large nationally-initiated service integration programmes in England: the Pioneer (November 2013 to March 2018) and Vanguard (January 2015 to March 2018) programmes. The latter had far greater financial and expert support from central agencies. METHODS: Of the 206 Clinical Commissioning Groups (CCGs) in England, 51(25%) were involved in the Pioneer programme only, 22(11%) were involved in the Vanguard programme only and 13(6%) were involved in both programmes. We used quasi-experimental methods to compare monthly counts of emergency admissions between four groups of CCGs, before and after the introduction of the two programmes. RESULTS: CCGs involved in the programmes had higher monthly hospital emergency admission rates than non-participants prior to their introduction [7.9 (95% CI:7.8-8.1) versus 7.5 (CI: 7.4-7.6) per 1000 population]. From 2013 to 2018, there was a 12% (95% CI:9.5-13.6%) increase in emergency admissions in CCGs not involved in either programme while emergency admissions in CCGs in the Pioneer and Vanguard programmes increased by 6.4% (95% CI: 3.8-9.0%) and 8.8% (95% CI:4.5-13.1%), respectively. CCGs involved in both initiatives experienced a smaller increase of 3.5% (95% CI:-0.3-7.2%). The slowdown largely occurred in the final year of both programmes. CONCLUSIONS: Health and social care integration programmes can mitigate but not prevent rises in emergency admissions over the longer-term. Greater financial and expert support from national agencies and involvement in multiple integration initiatives can have cumulative effects.

Do the posterior midline cortices belong to the electrophysiological default-mode network?

The default-mode network (DMN) and its principal core hubs in the posterior midline cortices (PMC), i.e., the precuneus and the posterior cingulate cortex, play a critical role in the human brain structural and functional architecture. Because of their centrality, they are affected by a wide spectrum of brain disorders, e.g., Alzheimer's disease. Non-invasive electrophysiological techniques such as magnetoencephalography (MEG) are crucial to the investigation of the neurophysiology of the DMN and its alteration by brain disorders. However, MEG studies relying on band-limited power envelope correlation diverge in their ability to identify the PMC as a part of the DMN in healthy subjects at rest. Since these works were based on different MEG recording systems and different source reconstruction pipelines, we compared DMN functional connectivity estimated with two distinct MEG systems (Elekta, now MEGIN, and CTF) and two widely used reconstruction algorithms (Minimum Norm Estimation and linearly constrained minimum variance Beamformer). Our results identified the reconstruction method as the critical factor influencing PMC functional connectivity, which was significantly dampened by the Beamformer. On this basis, we recommend that future electrophysiological studies on the DMN should rely on Minimum Norm Estimation (or close variants) rather than on the classical Beamformer. Crucially, based on analytic knowledge about these two reconstruction algorithms, we demonstrated with simulations that this empirical observation could be explained by the existence of a spontaneous linear, approximately zero-lag synchronization structure between areas of the DMN or among multiple sources within the PMC. This finding highlights a novel property of the neural dynamics and functional architecture of a core human brain network at rest.

Synchrony, metastability, dynamic integration, and competition in the spontaneous functional connectivity of the human brain.

The human brain is functionally organized into large-scale neural networks that are dynamically interconnected. Multiple short-lived states of resting-state functional connectivity (rsFC) identified transiently synchronized networks and cross-network integration. However, little is known about the way brain couplings covary as rsFC states wax and wane. In this magnetoencephalography study, we explore the synchronization structure among the spontaneous interactions of well-known resting-state networks (RSNs). To do so, we extracted modes of dynamic coupling that reflect rsFC synchrony and analyzed their spatio-temporal features. These modes identified transient, sporadic rsFC changes characterized by the widespread integration of RSNs across the brain, most prominently in the ß band. This is in line with the metastable rsFC state model of resting-state dynamics, wherein our modes fit as state transition processes. Furthermore, the default-mode network (DMN) stood out as being structured into competitive cross-network couplings with widespread DMN-RSN interactions, especially among the ß-band modes. These results substantiate the theory that the DMN is a core network enabling dynamic global brain integration in the ß band.

The recovery experience of people who were sex trafficked: the thwarted journey towards goal pursuit.

BACKGROUND: In 2010, a shelter programme was established in the Netherlands to provide social and health services for trafficked people. This article describes how service users in this programme conceptualized and experienced their own process of recovery. METHODS: In 2012, 14 people of non-Dutch nationality who had been trafficked for the purpose of sexual exploitation were interviewed at all three shelters of the programme. Data analysis followed a grounded theory approach. RESULTS: Participants felt a strong need to turn over a new leaf in life, leaving negative experiences of the past behind and moving towards a life with a job, a family and friends. In contrast with their willingness to work towards realizing that future, they experienced a lack of autonomy and a thwarted sense of agency in redressing their present situation. Together with the ostracized nature of their place in Dutch society this left them 'in limbo': a feeling of standing still, while wanting to move forward. This led participants to find it more difficult to deal with problems related to their pasts and futures. They particularly appreciated Dutch language training, vocational skills training and opportunities for volunteer work. CONCLUSIONS: Participants exhibited a strong desire to fulfil the basic psychological needs of competence, relatedness and autonomy, but were thwarted in pursuing these goals. Seemingly against all odds, while faced with several external regulators that limited their agency to change their situation, participants found ways to pursue these goals, through their enthusiasm for activities that helped them get closer to their envisioned futures (language and skills training and volunteer work). Identifying pathways toward attaining their goals allowed them to hope for a better future. That hope and pursuing their goals helped them to cope with the problems of their past and their worries about the future. Therefore, to facilitate service users' recovery in a post-trafficking setting, there is a need to provide them with opportunities to hope for, pursue and attain their personal goals within the structural boundaries of their situation. A future-orientated, strengths-based approach towards service provision and responsive and supportive environments help to do this.

Health Technology Agency insights: informing modification of a qualitative benefit risk framework for Health Technology Reassessment of prescription medications.

OBJECTIVES: This study's intent was to determine if a qualitative benefit risk framework could be used or modified to further enable Health Technology Reassessment (HTR) of prescription medicine recommendations. The purpose of this research was to understand Canadian Health Technology Agency assessors past experiences and insights to inform any modifications to the Universal Methodology for Benefit-Risk Assessment (UMBRA) qualitative framework. The UMBRA framework consists of an eight-step process, used during the assessment phase, to aid in decision making and dissemination. METHODS: A qualitative descriptive study was conducted and included a purposeful, criterion-based sample of eight assessors who had participated in Health Technology Assessment (HTA) or HTR for prescription medicines or in qualitative decision-making frameworks. RESULTS: Participant interviews lead to four common themes: "adoption of a qualitative benefit risk framework," "data (either too much or not enough)," "importance of incorporating stakeholder values," and "feasibility of the UMBRA framework." Methodological challenges with HTR were highlighted including the lack of clinical outcome data and the ability to compare clinically relevant meaningful differences. The implementation of a ranking or weighing process found within the UMBRA framework was not favored by half of the participants. CONCLUSIONS: Research participants did not consider all steps of the UMBRA framework to be transferable to the assessment phase of HTR given the need for simplicity, resource efficiency, and stakeholder input throughout the process. The assessor experiences and insights and the resultant key themes can be used in future research to aid in the development of a qualitative recommendation framework for HTR.

Resting-state Functional Connectivity is an Age-dependent Predictor of Motor Learning Abilities.

This magnetoencephalography study investigates how ageing modulates the relationship between pre-learning resting-state functional connectivity (rsFC) and subsequent learning. Neuromagnetic resting-state activity was recorded 5 min before motor sequence learning in 14 young (19-30 years) and 14 old (66-70 years) participants. We used a seed-based beta-band power envelope correlation approach to estimate rsFC maps, with the seed located in the right primary sensorimotor cortex. In each age group, the relation between individual rsFC and learning performance was investigated using Pearson's correlation analyses. Our results show that rsFC is predictive of subsequent motor sequence learning but involves different cross-network interactions in the two age groups. In young adults, decreased coupling between the sensorimotor network and the cortico-striato-cerebellar network is associated with better motor learning, whereas a similar relation is found in old adults between the sensorimotor, the dorsal-attentional and the DMNs. Additionally, age-related correlational differences were found in the dorsolateral prefrontal cortex, known to subtend attentional and controlled processes. These findings suggest that motor skill learning depends-in an age-dependent manner-on subtle interactions between resting-state networks subtending motor activity on the one hand, and controlled and attentional processes on the other hand.

Comorbidities and the referral pathway to access joint replacement surgery: an exploratory qualitative study.

BACKGROUND: Variation in access to joint replacement surgery has been widely reported but less attention has been given to the impact of comorbidities on the patient journey to joint replacement surgery. There is a lack of consensus amongst healthcare professionals and commissioners about how patients with comorbidities should be referred or selected for joint replacement surgery. It is therefore important to understand the views of healthcare professionals on the management, referral and selection of patients with comorbidities for joint replacement surgery. METHODS: An exploratory qualitative study involving semi-structured interviews with 20 healthcare professionals in England across the referral pathway to joint replacement surgery. They were asked to talk about their experiences of referring and selecting patients with comorbidities for joint replacement surgery. The interviews were audio-recorded and transcribed verbatim. Data analysis followed a thematic analysis approach based on the principles of grounded theory. RESULTS: In general, the presence of comorbidities was not seen as a barrier to being referred or selected for joint replacement but was seen as a challenge to manage the patients' journey across the referral pathway. Each professional group, concentrated on different aspects of the patients' condition which appeared to affect how they managed patients with comorbidities. This implied there was a disagreement about roles and responsibilities in the management of patients with comorbidities. None of the professionals believed it was their responsibility to address comorbidities in preparation for surgery. This disagreement was identified as a reason why some patients seem to 'get lost' in the referral system when they were considered to be unprepared for surgery. Patients were then potentially left to manage their own comorbidities before being reconsidered for joint replacement. CONCLUSIONS: At the clinician-level, comorbidities were not perceived as a barrier to accessing joint replacement surgery but at the pathway-level, it may create an implicit barrier such that patients with comorbidities may get 'lost' to the system. Further study is needed to explore the roles and responsibilities of professionals across the current orthopaedic referral pathway which may be less suitable for patients with comorbidities.

Supporting ALL victims of violence, abuse, neglect or exploitation: guidance for health providers.

Smaller groups of victims of violence, abuse, neglect or exploitation - such as male victims of intimate partner violence (IPV), victims of elder abuse, victims of abuse by carers, victims of parent abuse, victims of human trafficking, girls and boys below 18 years engaging in sex work, victims of sexual exploitation by gangs or groups and victims of honour based violence (such as forced marriages and female genital mutilation) - are often in contact with the health care system without being identified as such and frequently do not receive appropriate treatment. To address this problem, two things need to happen: 1) that ALL groups of victims of violence, abuse, neglect or exploitation are explicitly listed in policies and protocols, and 2) that both the similarities as well as the differences between the groups with regard to identification, support and referral - described in this article - are explained, so that health providers are appropriately supported in this important function.

Age-related differences in practice-dependent resting-state functional connectivity related to motor sequence learning.

Decreased neural plasticity is observed with healthy ageing in the primary sensorimotor (SM1) cortex thought to participate in motor learning and memory consolidation processes. In the present magnetoencephalography study, the post-training reorganization of resting-state functional connectivity (rsFC) and its relation with motor learning and early consolidation in 14 young (19-30 years) and 14 old (66-70 years) healthy participants were investigated. At the behavioral level, participants were trained on a motor sequence learning task then retested 20-30 min later for transient offline gains in performance. Using a sensorimotor seed-based approach, rsFC relying on beta band power envelope correlation was estimated immediately before and 10 min after the learning episode. Post-training changes in rsFC (from before to after learning) were correlated with motor learning performance and with the offline improvement in performance within the hour after learning. Young and old participants exhibited differential patterns of sensorimotor-related rsFC, bearing specific relationships with motor learning and consolidation. Our findings suggest that rsFC changes following learning reflect the offline processing of the new motor skill and contribute to the early memory consolidation within the hour after learning. Furthermore, differences in post-training changes in rsFC between young and old participants support the hypothesis that ageing modulates the neural circuits underlying the learning of a new motor skill and the early subsequent consolidation stages. Hum Brain Mapp 38:923-937, 2017. © 2016 Wiley Periodicals, Inc.

Auditory Magnetoencephalographic Frequency-Tagged Responses Mirror the Ongoing Segmentation Processes Underlying Statistical Learning.

Humans are highly sensitive to statistical regularities in their environment. This phenomenon, usually referred as statistical learning, is most often assessed using post-learning behavioural measures that are limited by a lack of sensibility and do not monitor the temporal dynamics of learning. In the present study, we used magnetoencephalographic frequency-tagged responses to investigate the neural sources and temporal development of the ongoing brain activity that supports the detection of regularities embedded in auditory streams. Participants passively listened to statistical streams in which tones were grouped as triplets, and to random streams in which tones were randomly presented. Results show that during exposure to statistical (vs. random) streams, tritone frequency-related responses reflecting the learning of regularities embedded in the stream increased in the left supplementary motor area and left posterior superior temporal sulcus (pSTS), whereas tone frequency-related responses decreased in the right angular gyrus and right pSTS. Tritone frequency-related responses rapidly developed to reach significance after 3 min of exposure. These results suggest that the incidental extraction of novel regularities is subtended by a gradual shift from rhythmic activity reflecting individual tone succession toward rhythmic activity synchronised with triplet presentation, and that these rhythmic processes are subtended by distinct neural sources.

The Public Health Responsibility Deal: making the workplace healthier?

Background: The Public Health Responsibility Deal (RD) in England is a public-private partnership which aims to improve public health by addressing issues such as health at work. This paper analyses the RD health at work pledges in terms of their likely effectiveness and added value. Methods: A review of evidence on the effectiveness of the RD 'health at work' pledges to improve health in the workplace; analysis of publically available data on signatory organizations' plans and progress towards achieving the pledges; and assessment of the likelihood that workplace activities pledged by signatories were brought about by participating in the RD. Results: The 'health at work' pledges mostly consist of information sharing activities, and could be more effective if made part of integrated environmental change at the workplace. The evaluation of organizations' plans and progress suggests that very few actions (7%) were motivated by participation in the RD, with most organizations likely (57%) or probably (36%) already engaged in the activities they listed before joining the RD. Conclusions: The RD's 'health at work' pledges are likely to contribute little to improving workplace health as they stand but could contribute more if they were incorporated into broader, coherent workplace health strategies.

DRUG DISINVESTMENT FRAMEWORKS: COMPONENTS, CHALLENGES, AND SOLUTIONS.

OBJECTIVES: Value assessments of marketed drug technologies have been developed through disinvestment frameworks. Components of these frameworks are varied and implementation challenges are prevalent. The objective of this systematic literature review was to describe disinvestment framework process components for drugs and to report on framework components, challenges, and solutions. METHODS: A systematic literature search was conducted using the terms: reassessment, reallocation, reinvestment, disinvestment, delist, decommission or obsolescence in MEDLINE, EMBASE, NLM PubMed, the Cochrane Library, and CINAHL from January 1, 2000, until November 14, 2015. Additional citations were identified through a gray literature search of Health Technology Assessment international (HTAi) and the International Network of Agencies for Health Technology Assessment (INAHTA) member Web sites and from bibliographies of full-text reviewed manuscripts. RESULTS: Sixty-three articles underwent full text review and forty were included in the qualitative analysis. Framework components including disinvestment terms and definitions, identification and prioritization criteria and methods, assessment processes, stakeholders and dissemination strategies, challenges, and solutions were compiled. This review finds that stakeholders lack the political, administrative, and clinical will to support disinvestment and that there is not one disinvestment framework that is considered best practice. CONCLUSIONS: Drug technology disinvestment components and processes vary and challenges are numerous. Future research should focus on lessening value assessment challenges. This could include adopting more neutral framework terminology, setting fixed reassessment timelines, conducting therapeutic reviews, and modifying current qualitative decision-making assessment frameworks.

Aging reduces experience-induced sensorimotor plasticity. A magnetoencephalographic study.

Modulation of the mu-alpha and mu-beta spontaneous rhythms reflects plastic neural changes within the primary sensorimotor cortex (SM1). Using magnetoencephalography (MEG), we investigated how aging modifies experience-induced plasticity after learning a motor sequence, looking at post- vs. pre-learning changes in the modulation of mu rhythms during the execution of simple hand movements. Fifteen young (18-30 years) and fourteen older (65-75 years) right-handed healthy participants performed auditory-cued key presses using all four left fingers simultaneously (Simple Movement task - SMT) during two separate sessions. Following both SMT sessions, they repeatedly practiced a 5-elements sequential finger-tapping task (FTT). Mu power calculated during SMT was averaged across 18 gradiometers covering the right sensorimotor region and compared before vs. after sequence learning in the alpha (9/10/11Hz) and the beta (18/20/22Hz) bands separately. Source power maps in the mu-alpha and mu-beta bands were localized using Dynamic Statistical Parametric Mapping (dSPM). The FTT sequence was performed faster at retest than at the end of the learning session, indicating an offline boost in performance. Analyses conducted on SMT sessions revealed enhanced rebound after learning in the right SM1, 3000-3500ms after the initiation of movement, in young as compared to older participants. Source reconstruction indicated that mu-beta is located in the precentral gyrus (motor processes) and mu-alpha is located in the postcentral gyrus (somatosensory processes) in both groups. The enhanced post-movement rebound in young subjects potentially reflects post-training plastic changes in SM1. Age-related decreases in post-training modulatory effects suggest reduced experience-dependent plasticity in the aging brain.

A geometric correction scheme for spatial leakage effects in MEG/EEG seed-based functional connectivity mapping.

Spatial leakage effects are particularly confounding for seed-based investigations of brain networks using source-level electroencephalography (EEG) or magnetoencephalography (MEG). Various methods designed to avoid this issue have been introduced but are limited to particular assumptions about its temporal characteristics. Here, we investigate the usefulness of a model-based geometric correction scheme (GCS) to suppress spatial leakage emanating from the seed location. We analyze its properties theoretically and then assess potential advantages and limitations with simulated and experimental MEG data (resting state and auditory-motor task). To do so, we apply Minimum Norm Estimation (MNE) for source reconstruction and use variation of error parameters, statistical gauging of spatial leakage correction and comparison with signal orthogonalization. Results show that the GCS has a local (i.e., near the seed) effect only, in line with the geometry of MNE spatial leakage, and is able to map spatially all types of brain interactions, including linear correlations eliminated after signal orthogonalization. Furthermore, it is robust against the introduction of forward model errors. On the other hand, the GCS can be affected by local overcorrection effects and seed mislocation. These issues arise with signal orthogonalization too, although significantly less extensively, so the two approaches complement each other. The GCS thus appears to be a valuable addition to the spatial leakage correction toolkits for seed-based FC analyses in source-projected MEG/EEG data.

Sleep and memory consolidation: motor performance and proactive interference effects in sequence learning.

That post-training sleep supports the consolidation of sequential motor skills remains debated. Performance improvement and sensitivity to proactive interference are both putative measures of long-term memory consolidation. We tested sleep-dependent memory consolidation for visuo-motor sequence learning using a proactive interference paradigm. Thirty-three young adults were trained on sequence A on Day 1, then had Regular Sleep (RS) or were Sleep Deprived (SD) on the night after learning. After two recovery nights, they were tested on the same sequence A, then had to learn a novel, potentially competing sequence B. We hypothesized that proactive interference effects on sequence B due to the prior learning of sequence A would be higher in the RS condition, considering that proactive interference is an indirect marker of the robustness of sequence A, which should be better consolidated over post-training sleep. Results highlighted sleep-dependent improvement for sequence A, with faster RTs overnight for RS participants only. Moreover, the beneficial impact of sleep was specific to the consolidation of motor but not sequential skills. Proactive interference effects on learning a new material at Day 4 were similar between RS and SD participants. These results suggest that post-training sleep contributes to optimizing motor but not sequential components of performance in visuo-motor sequence learning.

Inter- and intra-subject variability of neuromagnetic resting state networks.

Functional connectivity studies conducted at the group level using magnetoencephalography (MEG) suggest that resting state networks (RSNs) emerge from the large-scale envelope correlation structure within spontaneous oscillatory brain activity. However, little is known about the consistency of MEG RSNs at the individual level. This paper investigates the inter- and intra-subject variability of three MEG RSNs (sensorimotor, auditory and visual) using seed-based source space envelope correlation analysis applied to 5 min of resting state MEG data acquired from a 306-channel whole-scalp neuromagnetometer (Elekta Oy, Helsinki, Finland) and source projected with minimum norm estimation. The main finding is that these three MEG RSNs exhibit substantial variability at the single-subject level across and within individuals, which depends on the RSN type, but can be reduced after averaging over subjects or sessions. Over- and under-estimations of true RSNs variability are respectively obtained using template seeds, which are potentially mislocated due to inter-subject variations, and a seed optimization method minimizing variability. In particular, bounds on the minimal number of subjects or sessions required to obtain highly consistent between- or within-subject averages of MEG RSNs are derived. Furthermore, MEG RSN topography positively correlates with their mean connectivity at the inter-subject level. These results indicate that MEG RSNs associated with primary cortices can be robustly extracted from seed-based envelope correlation and adequate averaging. MEG thus appears to be a valid technique to compare RSNs across subjects or conditions, at least when using the current methods.

'They treat us like machines': migrant workers' conceptual framework of labour exploitation for health research and policy.

BACKGROUND: The exploitation of migrant workers ranks high on global political agendas including the Sustainable Development Goals. Research on exploited workers, using assessment tools where exploitation is defined by professional experts, indicates serious health concerns and needs. Yet, migrant workers are rarely asked about their understanding of a phenomenon they may experience. Our study aimed to conceptualise 'labour exploitation' from the perspective of migrant workers employed in manual low-skilled jobs. METHODS: Twenty-seven Latin Americans working in London (UK) participated in Group Concept Mapping; a participatory mixed-method where qualitative data are collected to define a concept's content and then analysed using quantitative methods to generate a structured conceptual framework. Participants generated statements describing the concept content during brainstorming sessions, and structured them during sorting-rating exercises. Multi-Dimensional Scaling and Cluster Analysis were performed, generating a conceptual framework that clarified the dimensions, subdimensions and constituent statements of the concept of labour exploitation from migrant workers' perspectives. RESULTS: Three key dimensions were identified: 'poor employment conditions and lack of protection', covering contractual arrangements and employment relations; 'disposability and abuse of power' (or 'dehumanisation') covering mechanisms or means which make migrant workers feel disposable and abused; and 'health and safety and psychosocial hazards' encompassing issues from physical and psychosocial hazards to a lack of health and social protection. 'Dehumanisation' has not been included in mainstream tools assessing exploitation, despite its importance for study participants who also described harsh situations at work including sexual, physical and verbal abuse. CONCLUSION: Our study provides a conceptual framework of labour exploitation that gives voice to migrant workers and can be operationalised into a measure of migrant labour exploitation. It also calls for the dimension 'dehumanisation' and structural forms of coercion to be integrated into mainstream conceptualisations, and their workplace hazards to be urgently addressed.

The Public Health Responsibility Deal: how should such a complex public health policy be evaluated?

BACKGROUND: The Public Health Responsibility Deal (RD) in England was launched in 2011 as a public-private partnership which aims to 'tap into the potential for businesses and other influential organisations to make a significant contribution to improving public health by helping us to create this environment'. It has come under criticism from public health advocates and others, who have suggested that it will be ineffective or perhaps even harmful. Like many public health policies, there have also been demands to know whether it 'works'. METHODS: We conducted a scoping review and used this, supplemented with interviews with stakeholders, to develop a detailed logic model of the RD (presented here) to help understand its likely outcomes and the pathways by which these may be achieved as a basis for planning an evaluation. CONCLUSIONS: Evaluations of complex interventions require not just assessment of effects (including outcomes), but also a clear conceptualization of the intervention and its processes. The way the RD and the pledges made by participant organizations has been presented makes it difficult at this stage to evaluate whether the RD 'works' in terms of improving health. Instead, any evaluation needs to put together a jigsaw of evidence about processes, mechanisms and potential future health and non-health impacts, in part using the current scientific evidence. This task is ongoing.

Effect of cognitive reserve on the association between slow wave sleep and cognition in community-dwelling older adults.

Sleep, especially slow wave sleep (SWS), is essential for cognitive functioning and is reduced in aging. The impact of sleep quality on cognition is variable, especially in aging. Cognitive reserve (CR) may be an important modulator of these effects. We aimed at investigating this question to better identify individuals in whom sleep disturbances might have greater behavioral consequences. Polysomnography and neuropsychological assessments were performed in 135 cognitively intact older adults (mean age ± SD: 69.4 ± 3.8y) from the Age-Well randomized controlled trial (baseline data). Two measures of cognitive engagement throughout life were used as CR proxies. Linear regression analyses were performed between the proportion of SWS, and executive function and episodic memory composite scores. Then, interaction analyses between SWS and CR proxies on cognition were conducted to assess the possible impact of CR on these links. SWS was positively associated with episodic memory, but not with executive function. CR proxies modulated the associations between SWS and both executive and episodic memory performance. Specifically, individuals with higher CR were able to maintain cognitive performance despite low amounts of SWS. This study provides the first evidence that CR may protect against the deleterious effects of age-related sleep changes on cognition.