Effectiveness of cognitive-behavioural family intervention in reducing the burden of care in carers of patients with Alzheimer's disease

BACKGROUND

The majority of patients with Alzheimer's disease live outside institutions and there is considerable serious psychological morbidity among their carers.

AIMS

To evaluate whether family intervention reduces the subjective burden of care in carers of patients with Alzheimer's disease and produces clinical benefits in the patients.

METHOD

A prospective single-blind randomised controlled trial with three-month follow-up in which the experimental group received family intervention and was compared with two control groups.

RESULTS

There were significant reductions in distress and depression in the intervention group compared with control groups at post-treatment and follow-up. There were significant reductions in behavioural disturbance at post-treatment and an increase in activities at three months in patients in the intervention group. Based on an improvement on the General Health Questionnaire resulting in a carer converting from a case to a non-case, the number to treat was three immediately post-treatment and two at follow-up.

CONCLUSIONS

Family intervention can have significant benefits in carers of patients with Alzheimer's disease and has a positive impact on patient behaviour.

Development of a district Cord Blood Bank: a model for cord blood banking in the National Health Service

The Bristol Cord Blood Bank was established as a pilot project within existing health services to establish cost-effective recruitment, collection and processing suitable for use in the NHS should cord blood become a routine source of haemopoietic stem cells for transplantation in the UK. An important aim of the project was to evaluate the feasibility of establishing a midwifery-based collection network, thus utilising expertise already in place. Collection was performed on the delivery suite immediately after the placenta was delivered. The clinical experience of the midwife collector/counsellors allowed rapid pre-collection assessment of the condition of the cord and placenta. This prevented collection attempts from diseased or otherwise damaged placentas, leading to conservation of resources by preventing collection of most small volume donations. The bank was established within the National Blood Service, Bristol Centre to achieve Good Manufacturing Practice standards and ensure that processing was subject to the same stringency required for other sources of haemopoietic stem cells. Cord blood is an expensive resource. By utilising existing expertise in district Obstetric and National Blood Services, the Bristol Cord Blood Bank may serve as a model for health economic evaluation of cord blood banking of volunteer donations within the NHS.

Who answers 'willingness to pay' questions?

OBJECTIVES

The objectives of this study were twofold. The first was to compare characteristics of responders and non-responders to a survey of women attending a bone mineral density screening service in Aberdeen concerned with the screening process which contained questions on attenders' willingness to pay (WTP) and willingness to wait (WTW) for screening. The second objective was to compare the characteristics of those responding to either the WTP or the WTW questions relative to those who responded to both.

METHODS

After receiving a scan, women completed the questionnaire at the clinic or returned it by post. Logistic regression analysis was used to compare the characteristics of the responders and non-responders.

RESULTS

Those who smoked were less likely to return the questionnaire, whilst those who drank alcohol were more likely to return it. The majority of respondents answered both WTP and WTW questions. The proportions responding to the WTW and WTP questions were 93.2% and 81.5% for the two questions, respectively (95% confidence interval of difference = 9.4% to 13.9%). The only result which was statistically significant at the 1% level showed that, relative to those who answered the WTW but not the WTP questions, those who answered both were more likely to be older when they left full-time education. A weaker statistical association (at the 5% level) revealed that those who were older when leaving full-time education were more likely to answer a WTP question than not.

CONCLUSIONS

WTP questions seem to be less acceptable to those who leave full-time education earlier. Analysts may need to account for this in future studies. Whether such results can be replicated and reasons for non-response should be investigated.

Serotonin infusions inhibit sensory input from the dural vasculature

Intravenous infusions of serotonin (5-hydroxtryptamine creatinine sulphate, 5HT, 50-300 microg/kg/min) in cats reversibly inhibited the responses of cervical spinal cord neurons to electrical stimulation of the superior sagittal sinus. Inhibition developed over 20-30 min and resolved over the same time course, suggesting a dependence on accumulation of 5HT in the central nervous system. Inhibition was suppressed by prior intravenous injection of the 5HT antagonists methysergide (1 mg/kg) and methiothepin (1 mg/kg). Infusions of 5HT (50 microg/kg/min) caused a rise in whole blood levels of 5HT by a factor of 1.5 of control values. 5HT levels in platelet-free plasma rose by a factor of 50. Levels of 5HT and 5 hydroxyindole acetic acid released into the cerebrospinal fluid rose significantly. The results suggest that earlier clinical observations that 5HT infusions can ameliorate the pain of migraine may not have been due to cranial vasoconstriction alone, but could have involved a central action of 5HT.

Burden of Alzheimer's disease: helping the patient and caregiver

The burden associated with caring for a patient with dementia is well documented. There are many conflicting data on the factors that cause caregiver burden. Historically, studies in this area have tended to focus on deficits in the patient and the burden and distress they cause the caregiver. More recently, it has been acknowledged that caregivers' own characteristics may play a major role in determining how burdensome and stressful they find their role. These characteristics include such things as gender, availability of support systems, and relationship to patient, as well as the way the caregiver perceives the patient's symptoms (whether illness related or deliberate) and his or her attitude and behavior toward the patient. Understanding the origins of caregiver burden has broad implications both in terms of the well-being of caregivers and the quality of support that patients receive. The Manchester Carer's Project, which is described here, seeks to identify the origins and management of caregiver burden.

Valuing the benefits of publicly-provided health care: does 'ability to pay' preclude the use of 'willingness to pay'?

The case against the use of willingness to pay (WTP) methods to value the benefits of publicly-provided health care is often made on the basis that WTP is associated with ability to pay. In this paper, it is demonstrated that this argument is not so straightforward, depending on two criteria: (a) the association of people's preferences with ability to pay and (b) the disparities of WTP for given options within categories of ability to pay. A method of dealing with ability to pay, based on these criteria, is proposed and illustrated through the use of data from a case study.

Impact of obstetric factors on cord blood donation for transplantation

Recent reports have shown that low nucleated cell dose significantly decreases survival after cord blood transplantation. Prior to starting clinical cord blood banking we investigated the impact of obstetric factors on cell dose and volume of cord blood donations. Cord blood was obtained from 114 normal full-term deliveries. Mean volume collected was 93.5 ml, mean total nucleated cell count (TNC) was 13.1 x 108. Statistical analysis was by backwards stepwise regression. Significant factors affecting nucleated cell yield were volume of blood collected (P < 0.001), length of gestation (P < 0. 0001), time from delivery of the infant to cord clamping (P = 0.018) and total length of labour (P = 0.002). In clinical cord blood banking we have successfully used these findings for pre-collection assessment of placentae. Out of 476 cord blood donations subsequently collected for banking, only 29 (6.1%) have been discarded due to low volume. The mean TNC of the 409 banked units following volume reduction was 10.1 x 108. Despite careful optimization of collection, processing and storage techniques, cell dose still limits cord blood transplantation to smaller recipients.

Different behaviour of fresh and cultured CD34+ cells during immunomagnetic separation

In-vitro expansion of human cord blood (CB) cells could enhance peripheral blood recovery and ensure long-term engraftment of larger recipients in the clinical transplant setting. Enrichment of CD34+ cells using the MiniMACS column has been evaluated for the preparation of CB CD34+ cells before and after expansion culture. Repurification of CD34+ cells after culture would assist accurate phenotypic and functional analysis. When fresh CB mononuclear cells (MNC) were separated, the MACS positive (CD34+) fraction (90.1% pure) contained a mean (+/- SD, n = 5) of 93.0 +/- 8.0% of the eluted CD34+ cells, 99.6 +/- 0.7% of the CFU-GM and all of the eluted long-term culture-initiating cells (LTC-IC). Cord blood CD34+ cells were then cultured for 14 d with IL-3, IL-6, SCF, G-CSF and GM-CSF, each at 10 ng/ml. The total cell expansion was 2490 +/- 200-fold and the CD34+ cell expansion was 49 +/- 17-fold. The percentage of CD34+ cells present after expansion culture was 1.2 +/- 0.85%. When these cells were repurified on the MiniMACS column, the MACS positive fraction only contained 40.3 +/- 13.4% of the eluted CD34+ cells which was enriched for the mature CD34+ CD38+ subset, 24.4 +/- 8.8% of the eluted CFU-GM and 79.5 +/- 11.0% of the LTC-IC. The remaining cells were eluted in the MACS negative fraction. In conclusion, repurification of cultured CD34+ cells does not yield a representative population and many progenitors are lost in the MACS negative fraction. This can give misleading phenotypic and functional data. Cell losses may be important in the clinical setting if cultured cells were repurified for purging.

Recent advances in the methods of cost-benefit analysis in healthcare. Matching the art to the science

This paper outlines recent advances in the methods of cost-benefit analysis (CBA). Economic evaluations in healthcare can be criticised for, amongst other things, the inappropriate use of incremental cost-effectiveness ratios and the reporting of benefits in terms of cost savings, such as treatment costs averted. Many such economic evaluations are, according to the 'scientific' definition, CBAs. The 'balance-sheet' (or opportunity cost) approach is a form of CBA which can be used to identify who bears the costs and who reaps the benefits from any change. Whilst the next stage in a CBA, as defined in health economics, would require that all costs and benefits be valued in monetary terms, the balance-sheet approach, however, advocates that available monetary values can be augmented by other measures of cost and benefit. As such, this approach, which has a theoretical basis, is proposed as a practical prescription for CBA and highlights the notion that unquantified benefits are important and can be included within CBAs even when monetarisation is not possible. Recent methodological developments in monetary valuation for use in CBA are the development of the technique of willingness to pay, the use of conjoint analysis (CA) to elicit willingness-to-pay (WTP) values and advances in the debate on the inclusion of production gains in CBAs. Whilst acknowledging that there have been developments in each of these areas, it is claimed there has also been progress in using CBA as a framework for evaluation, as reflected by the balance-sheet approach. The paper concludes by stating that almost all types of economic evaluation have an element of the 'cost-benefit' approach in them. The important issue is to focus on the policy question to be addressed and to outline the relevant costs and benefits in a manner which assists the evaluation of welfare changes resulting from changes in healthcare delivery. The focus should not be on moulding a question to fit a hybrid definition of an analytical technique.

Therapeutic efficacy of zeta-cypermethrin pour-on for the treatment of biting and sucking lice in cattle under field conditions

OBJECTIVE

To assess the efficacy of zeta-cypermethrin pour-on to control cattle lice.

DESIGN

Five field trials in south-eastern Australia.

PROCEDURE

Zeta-cypermethrin pour-on, deltamethrin pour-on and pour-on vehicle were applied to groups of 10 cattle. Lice were counted before treatment and 14, 28, 42 and 56 days after treatment.

RESULTS

Zeta-cypermethrin pour-on given at 2.5 mg/kg was equivalent to, or marginally more effective than a deltamethrin pour-on at 0.75 mg/kg. It eliminated B bovis and H eurysternus and gave good control of L vituli and S capillatus. Zeta-cypermethrin at 1 mg/kg gave good control of B bovis and H eurysternus but was not satisfactory against L vituli and S capillatus.

CONCLUSION

Zeta-cypermethrin pour-on, given at 2.5 mg/kg, is an effective treatment for cattle lice control. Zeta-cypermethrin, and other synthetic pyrethroid pour-ons, are the treatment of choice to control B bovis.

Educate ICU assistive personnel

Many institutions use assistive personnel in intensive care units (ICUs) to provide more cost-effective nursing care. One ICU uses a comprehensive, competency-based orientation program to help fulfill the assistive personnel's unique orientation needs.

Economic evaluation of open versus laparoscopic hernia repair: some pragmatic considerations for the measurement of costs

Laparoscopic hernia repair costs more than open repair. This increase in cost largely is because of the use of disposables. Indirect cost benefits of laparoscopic procedure because of a more rapid return to normal activity are different to calculate but may be present for select groups of patients.

Determinants of carer stress in Alzheimer's disease

OBJECTIVES

To explore the impact of subgroups and individual symptoms of non-cognitive disturbance on the carers of Alzheimer's disease patients.

DESIGN

Cross-sectional study using clinically valid scales to assess patient symptomatology and self-report questionnaires to measure carer variables.

SETTING

Old age psychiatry outreach services in South and Central Manchester.

SUBJECTS

100 patients with Alzheimer's disease living at home and their carers.

MAIN OUTCOME MEASURES

Subjective burden and distress in carers.

RESULTS

Separate statistical analyses were performed for subgroups and individual symptoms of non-cognitive disturbance. For subgroups, multivariate analyses identified depression and behavioural disturbances in patients as significant predictors of subjective burden in carers. Carer distress was predicted by depression, psychosis and cognitive impairments in patients and carer gender. For individual symptoms of non-cognitive disturbance, three features of depression in patients (mood-related signs, physical signs and behaviour changes), walking disruptions and the patient-carer relationship predicted of subjective burden in carers. Variance in the level of carer distress was accounted for by sleep disruptions, hallucinations and mood-related depressive features in patients and carer gender.

CONCLUSION

The findings confirm that the non-cognitive features of Alzheimer's disease are stressful for carers and indicate specific relationships between mood-related and behavioural signs of depression, walking and sleep disruptions and hallucinations in patients and adverse carer outcomes. Patient depression and the mood-related signs of depression in particular were the most consistent and powerful predictors of psychological morbidity in carers. Intervention strategies need to identify and target troublesome behaviours in patients and aim to either change these behaviours or alter the way carers respond to them. Thus, interventions need to be symptoms-rather than service-led and are likely to require multidisciplinary and multi-agency approaches.

Intimacy as a determinant of expressed emotion in carers of people with Alzheimer's disease

BACKGROUND

Although high expressed emotion (EE) has been found to be an important predictor of poor prognosis in a wide range of conditions such as schizophrenia, anorexia and depression no complete explanation exists for individual differences in EE responses. The aim of this paper is to investigate the role of intimacy in determining the level of EE in carers of people with dementia.

METHODS

Ninety-nine carers of people with dementia who presented to Old Age Psychiatry Services in South and Central Manchester completed questionnaires to ascertain past and current levels of intimacy. Camberwell Family Interviews (CFIs) were carried out to ascertain levels of EE.

RESULTS

Current intimacy was found to be strongly related to EE such that low current intimacy was associated with high EE and there was a significant difference between high and low intimacy groups on measures of criticism and hostility, though not warmth.

CONCLUSIONS

The association found between intimacy and EE indicates that high EE may be a characteristic of low intimacy relationships between the carer and the cared-for-person. Since the assessment of EE is time intensive, perhaps a measure of intimacy will provide a short-hand screen for identifying critical and hostile caring environments.

Surgery versus radiation therapy as single-modality treatment of tonsillar fossa carcinoma: the Roswell Park Cancer Institute experience (1971-1991)

OBJECTIVE

To compare the efficacy and treatment outcomes in patients with tonsillar fossa cancer using surgery or radiation as a single modality therapy.

METHODS

From 1971 to 1991 239 patients with oral pharyngeal cancer were treated at Roswell Park Cancer Institute. Of these patients 90 had tonsillar carcinoma. Seventy-six of these patients received either surgery (SA) (n = 56) or radiation therapy (RA) (n = 20) as single-modality therapy and are the subject of this review. All patients in the radiation arm of this review were surgical candidates who declined primary surgical therapy.

RESULTS

Sixty-three percent of the SA and 80% of the RA treatment groups presented with either stage III or stage IV disease (P < or = .05). Forty-seven percent of the SA group and 52% of the RA patients had clinically positive regional disease at initial presentation. There was a predictable pattern of nodal presentation, with level II the most frequently involved region. The rate of occult metastasis was 27% and was evenly distributed between T1 and T4 disease. The overall local control rate in the SA group was 75%, compared with 60% in the RA group (P value was not significant). The disease-specific survival (all stages) was 61% in the SA group and 37% in the RA group (P < or = .05). The disease-free survival for stage III and stage IV disease in the SA group was 47% and in the RA group 27% (P < or = .05). Survival measured against clinical response to radiation therapy, in complete responders (all stages) was 83%; by contrast there were no survivors past 24 months in the partial response group (P < or = .001).

CONCLUSION

The results from this study suggest that for early disease (stage I/II), surgery or radiation therapy as single-modality treatment is equally effective. For advanced disease radiation therapy is inferior to surgery as a single-modality treatment, as measured by ultimate survival and the local control of disease. There is, however, a subset of patients with advanced disease who respond to radiation therapy and whose survival is equivalent to our surgical cohort of patients.

Economic evaluation in dentistry: an ethical imperative?

In this paper a case is made for the use of principles and techniques of economic evaluation to aid the planning of oral health services. The reader is taken through a case study, which highlights not only the importance of economic principles but also the challenges involved in carrying out economic evaluations in dentistry. These challenges need to be faced if oral health services are to be planned in a way that is of maximum benefit to the community.

Evaluating innovation in general practice: a pragmatic framework using programme budgeting and marginal analysis

BACKGROUND

Innovation in primary care in the UK, in terms of new service developments, is occurring at a fast pace. However, little information is available on the costs and benefits of these changes.

OBJECTIVES

We aimed to illustrate the use of programme budgeting and marginal analysis (PBMA) as a framework for evaluating innovation in primary care, using an example of practice-based diabetes care. The aim was to examine changes in the use of practice resources and the changes in benefits to patients, following the introduction of a diabetes clinic.

METHODS

PBMA is a form of pragmatic economic evaluation combining practice data for the 'before' period and data from the literature to model the 'after' period.

RESULTS

In 1995/6, the total amount of resources devoted to diabetes care in the two practices was 145813 pound sterling (634 pound sterling per patient). Of this sum, 62% was allocated to out-patient visits, 28% to prescribing, 5% to hospital admissions, 2% to GP consultations and 2% to tests. The literature suggests that a nurse-run diabetes clinic would result in similar health outcomes and better access for patients. The introduction of such a clinic could potentially save each practice between 2000 pound sterling and 16000 pound sterling per year. This result takes into account a wide range of assumptions about changes in resource use, but does depend on the findings of previous studies.

CONCLUSIONS

The results of this study show that PBMA is a useful framework for helping practices be accountable and make 'evidence-based' decisions about service innovations in primary care.

Determinants of carer stress in Alzheimer's disease

OBJECTIVES

To explore the impact of subgroups and individual symptoms of non-cognitive disturbance on the carers of Alzheimer's disease patients.

DESIGN

Cross-sectional study using clinically valid scales to assess patient symptomatology and self-report questionnaires to measure carer variables.

SETTING

Old age psychiatry outreach services in South and Central Manchester.

SUBJECTS

100 patients with Alzheimer's disease living at home and their carers.

MAIN OUTCOME MEASURES

Subjective burden and distress in carers.

RESULTS

Separate statistical analyses were performed for subgroups and individual symptoms of non-cognitive disturbance. For subgroups, multivariate analyses identified depression and behavioural disturbances in patients as significant predictors of subjective burden in carers. Carer distress was predicted by depression, psychosis and cognitive impairments in patients and carer gender. For individual symptoms of non-cognitive disturbance, three features of depression in patients (mood-related signs, physical signs and behaviour changes), walking disruptions and the patient-carer relationship predicted of subjective burden in carers. Variance in the level of carer distress was accounted for by sleep disruptions, hallucinations and mood-related depressive features in patients and carer gender.

CONCLUSION

The findings confirm that the non-cognitive features of Alzheimer's disease are stressful for carers and indicate specific relationships between mood-related and behavioural signs of depression, walking and sleep disruptions and hallucinations in patients and adverse carer outcomes. Patient depression and the mood-related signs of depression in particular were the most consistent and powerful predictors of psychological morbidity in carers. Intervention strategies need to identify and target troublesome behaviours in patients and aim to either change these behaviours or alter the way carers respond to them. Thus, interventions need to be symptoms-rather than service-led and are likely to require multidisciplinary and multi-agency approaches.

The (near) equivalence of cost-effectiveness and cost-benefit analyses. Fact or fallacy?

There has been much recent debate in the health economics literature as to the (near) equivalence of cost-benefit analysis (CBA) and cost-effectiveness analysis (CEA). The aim of this paper is to demonstrate that whether such a (near) equivalence exists depends on whether one defines economic evaluations as 'CBA' or 'CEA' on the basis of either what is measured or what question the analyst is seeking to answer. The former basis of definition is popular within the 'decision science' approach to economic evaluation, but does not seem to have any theoretical support. If the latter, more theoretically correct, basis is accepted, there is no longer a case for the (near) equivalence of CBA and CEA.

Willingness to pay: a method for measuring preferences for maternity care?

BACKGROUND

The aim of this study was to assess the feasibility of the use of "willingness to pay" as a measure of the benefits of intrapartum care.

METHODS

A questionnaire was mailed to 150 pregnant women booking at Aberdeen Maternity Hospital in the northeast of Scotland, giving information on options for intrapartum care compiled from a recent randomized trial of care in a midwife-managed delivery unit versus care in a consultant-led labor ward. Women were asked which type of care they preferred and what would be their maximum willingness to pay for their preferred option. Data were also collected on demographic and clinical characteristics.

RESULTS

Most women (55%) expressed a preference for care in a midwives unit. However, strength of preference, as reflected in willingness to pay, was greater among those in the smaller group, who expressed a preference for care in a consultant-led labor ward. The willingness-to-pay results were not associated with ability to pay.

CONCLUSIONS

These data should be used together with cost data to decide on provision of care. Given the strength of preference of the minority group, and if the cost implications are not too great, a flexible service that takes account of women's wishes should be provided, even if this goes against the trend for care of those at low risk. By analyzing choice of care by income groups and social class groupings, it is possible to examine whether willingness-to-pay results are associated with indicators of ability to pay. In this case, they were not. Willingness to pay has an advantage in allowing respondents to account for more than just health gain when valuing different types of care.