Effects and feasibility of an Integrative Medicine program for geriatric patients-a cluster-randomized pilot study

Community based complex interventions to sustain independence in older people: systematic review and network meta-analysis

OBJECTIVE

To synthesise evidence of the effectiveness of community based complex interventions, grouped according to their intervention components, to sustain independence for older people.

DESIGN

Systematic review and network meta-analysis.

DATA SOURCES

Medline, Embase, CINAHL, PsycINFO, CENTRAL, clinicaltrials.gov, and International Clinical Trials Registry Platform from inception to 9 August 2021 and reference lists of included studies.

ELIGIBILITY CRITERIA

Randomised controlled trials or cluster randomised controlled trials with ≥24 weeks' follow-up studying community based complex interventions for sustaining independence in older people (mean age ≥65 years) living at home, with usual care, placebo, or another complex intervention as comparators.

MAIN OUTCOMES

Living at home, activities of daily living (personal/instrumental), care home placement, and service/economic outcomes at 12 months.

DATA SYNTHESIS

Interventions were grouped according to a specifically developed typology. Random effects network meta-analysis estimated comparative effects; Cochrane's revised tool (RoB 2) structured risk of bias assessment. Grading of recommendations assessment, development and evaluation (GRADE) network meta-analysis structured certainty assessment.

RESULTS

The review included 129 studies (74 946 participants). Nineteen intervention components, including "multifactorial action from individualised care planning" (a process of multidomain assessment and management leading to tailored actions), were identified in 63 combinations. For living at home, compared with no intervention/placebo, evidence favoured multifactorial action from individualised care planning including medication review and regular follow-ups (routine review) (odds ratio 1.22, 95% confidence interval 0.93 to 1.59; moderate certainty); multifactorial action from individualised care planning including medication review without regular follow-ups (2.55, 0.61 to 10.60; low certainty); combined cognitive training, medication review, nutritional support, and exercise (1.93, 0.79 to 4.77; low certainty); and combined activities of daily living training, nutritional support, and exercise (1.79, 0.67 to 4.76; low certainty). Risk screening or the addition of education and self-management strategies to multifactorial action from individualised care planning and routine review with medication review may reduce odds of living at home. For instrumental activities of daily living, evidence favoured multifactorial action from individualised care planning and routine review with medication review (standardised mean difference 0.11, 95% confidence interval 0.00 to 0.21; moderate certainty). Two interventions may reduce instrumental activities of daily living: combined activities of daily living training, aids, and exercise; and combined activities of daily living training, aids, education, exercise, and multifactorial action from individualised care planning and routine review with medication review and self-management strategies. For personal activities of daily living, evidence favoured combined exercise, multifactorial action from individualised care planning, and routine review with medication review and self-management strategies (0.16, -0.51 to 0.82; low certainty). For homecare recipients, evidence favoured addition of multifactorial action from individualised care planning and routine review with medication review (0.60, 0.32 to 0.88; low certainty). High risk of bias and imprecise estimates meant that most evidence was low or very low certainty. Few studies contributed to each comparison, impeding evaluation of inconsistency and frailty.

CONCLUSIONS

The intervention most likely to sustain independence is individualised care planning including medicines optimisation and regular follow-up reviews resulting in multifactorial action. Homecare recipients may particularly benefit from this intervention. Unexpectedly, some combinations may reduce independence. Further research is needed to investigate which combinations of interventions work best for different participants and contexts.

REGISTRATION

PROSPERO CRD42019162195.

Lifestyle medicine for depression: A meta-analysis of randomized controlled trials

BACKGROUND

The treatment effect of multi-component LM interventions on depressive symptoms has not yet been examined.

METHODS

We systematically searched six databases from inception to February 2020 to identify randomized controlled trials (RCTs) involving any multi-component LM interventions (physical activity, nutritional advice, sleep management, and/or stress management) on depressive symptoms relative to care as usual (CAU), waitlist (WL), no intervention (NI), or attention control (AC) comparisons.

RESULTS

Fifty studies with 8,479 participants were included. Multi-component LM interventions reduced depressive symptoms significantly relative to the CAU (p >.001; d = 0.20) and WL/NI (p > .01; d = 0.22) comparisons at immediate posttreatment. However, no significant difference was found when compared with AC. The intervention effects were maintained in the short-term (1- to 3-month follow-up) relative to the CAU comparison (p > .05; d = 0.25), but not in the medium- and long-term. The moderator analyses examining the effect of multi-component LM interventions compared with CAU suggested that the number of lifestyle factors adopted was a significant moderator. Although disease type was not a significant moderator, there was a tendency that the clinical effect of multi-component LM interventions was stronger (d = 0.45) in those diagnosed with major depression. No publication bias was detected.

LIMITATIONS

Low number of RCTs available in some subgroup analyses prevented from finding meaningful effects. Results may not be extended to major depression, because data on secondary depression were captured.

CONCLUSION

Multi-component LM interventions appeared to be effective in mitigating depressive symptoms; however, the magnitude of the clinical effect was small. Future research is needed to assess more comprehensive and individualized LM interventions which have a greater emphasis on motivational and compliance aspects and focus solely on individuals with depression.

The State of the Evidence for Whole-System, Multi-Modality Naturopathic Medicine: A Systematic Scoping Review

Objective: To summarize the current state of the research evidence for whole-system, multi-modality naturopathic medicine.

Design: A systematic search for research articles from around the world was undertaken using MEDLINE, Embase, CINAHL, AMED, and WHO regional indexes. Naturopathic journals and gray literature were hand searched. No language restrictions were imposed.

Interventions: All human research evaluating the effectiveness of naturopathic medicine, where two or more naturopathic modalities are delivered by naturopathic clinicians, were included in the review. Case studies of five or more cases were included.

Results: Thirty-three published studies (n = 9859) met inclusion criteria (11 American; 4 Canadian; 6 German; 7 Indian; 3 Australian; 1 United Kingdom; and 1 Japanese) across a range of mainly chronic clinical conditions. The studies predominantly showed evidence for the efficacy of naturopathic medicine for the conditions and settings in which they were based.

Conclusions: To date, research in whole-system, multi-modality naturopathic medicine shows that it is effective for treating cardiovascular disease, musculoskeletal pain, type 2 diabetes, polycystic ovary syndrome, depression, anxiety, and a range of complex chronic conditions.

[Health promotion in nursing homes]

Specific environmental conditions in long-term care facilities for very old chronically ill and multi-morbid residents raise issues regarding health promotion in nursing and the care of this highly vulnerable target group. Too much prioritisation of medical and nursing care, combined with (personnel-related) structural deficits, may be an obstacle to consistent resource-oriented thinking and behaviour in these settings. This may be additionally compounded by a lack of appropriate strategies to support sustained integration of health-promoting activities into the facilities' daily routines.This article advocates for a holistic approach that looks beyond care provision and integrates a health promotion perspective. It encourages reflection on and modification of socio-spatial conditions in care settings so that residents are empowered to take more responsibility for their own health related behaviour. Encouraging residents to participate and providing guidance, support and motivation are key tasks for nursing staff in this context. The aim is to develop and stimulate the residents' own strengths and resources related to their health.Against this background, the "activating care" concept should be elaborated with much greater emphasis on health promotion in order to maximise the potential of a theory that sees skills and resource development as an integral aspect of care.

Structural validity and internal consistency of the Qualidem in people with severe dementia

BACKGROUND

Since its development, the Qualidem has had items that were considered unsuited for people with very severe dementia. This study attempted to investigate the applicability of all Qualidem items in people with all stages of dementia severity.

METHODS

Four data sets that contained Qualidem observations on people with dementia were combined. Dementia severity was categorized based on the Global Deterioration Scale (GDS), with a dichotomization of very severe dementia (GDS 7) and others (GDS 1-6). Unidimensional latent-trait models (Mokken scaling) were estimated to fit the Qualidem responses in the overall sample and the dichotomized groups. Scalability was assessed using coefficients of homogeneity (Loevinger's H), while reliability was assessed with Cronbach's α and ρ.

RESULTS

Combining the four databases resulted in 4,354 Qualidem measurements. The scalability of all scales was considered acceptable in the overall sample, as well is in the subgroups (all H > 0.3). Additionally, the reliability was good-excellent in the scales: "positive affect," "positive self-image," "care relationship," and "negative affect." Reliability was questionable-acceptable for "feeling at home," "social relations," "social isolation," and "restless tense behavior." Reliability was poor for "having something to do."

CONCLUSIONS

Statistical considerations allow using all Qualidem items in all dementia stages. Future research should determine balance of statistical- versus conceptual-based reasoning in this academic debate.

Patients' Preference for Integrating Homoeopathy Services within the Secondary Health Care Settings in India: The Part 3 (PPIH-3) Study

Indian patients' preference for integrated homoeopathy services remains underresearched. Two earlier surveys revealed favorable attitude toward and satisfaction from integrated services. The objectives of this study were to examine knowledge, attitudes, and practice of homoeopathy and to evaluate preference toward its integration into secondary-level health care. A cross-sectional survey was conducted during May to October 2015 among 659 adult patients visiting randomly selected secondary-level conventional health care setups in Kolkata, Mumbai, Kottayam, and New Delhi (India) using a self-administered 24-item questionnaire in 4 local vernaculars (Bengali, Marathi, Malayalam, and Hindi). Knowledge and practice scores were compromised; attitude scores toward integration and legal regulation were high. Respondents were uncertain regarding side effects of homoeopathy and concurrent use and interactions with conventional medicines. A total of 82.40% (95% confidence interval = 79.23, 85.19) of the participants were in favor of integrating homoeopathy services. Preference was significantly higher in Delhi and lower in Kottayam. Probable strategic measures for further development of integrated models are discussed.

How big should the pilot study for my cluster randomised trial be?

There is currently a lot of interest in pilot studies conducted in preparation for randomised controlled trials. This paper focuses on sample size requirements for external pilot studies for cluster randomised trials. We consider how large an external pilot study needs to be to assess key parameters for input to the main trial sample size calculation when the primary outcome is continuous, and to estimate rates, for example recruitment rates, with reasonable precision. We used simulation to provide the distribution of the expected number of clusters for the main trial under different assumptions about the natural cluster size, intra-cluster correlation, eventual cluster size in the main trial, and various decisions made at the piloting stage. We chose intra-cluster correlation values and pilot study size to reflect those commonly reported in the literature. Our results show that estimates of sample size required for the main trial are likely to be biased downwards and very imprecise unless the pilot study includes large numbers of clusters and individual participants. We conclude that pilot studies will usually be too small to estimate parameters required for estimating a sample size for a main cluster randomised trial (e.g. the intra-cluster correlation coefficient) with sufficient precision and too small to provide reliable estimates of rates for process measures such as recruitment or follow-up rates.

Homeopathy and integrative medicine: keeping an open mind

Some physicians have incorporated some forms of complementary and alternative medicine (CAM) or related medicinal products in their clinical practices, suggesting that an unconventional treatment approach might be seen as an integration rather than as an alternative to standard medical practice. Among the various CAMs, homeopathy enjoys growing popularity with the lay population, but it is not acknowledged by academia or included in medical guidelines. The major problem is to establish the effectiveness of this clinical approach using the strict criteria of evidence-based medicine. This issue of the Journal of Medicine and the Person collects contributions from some of the most prestigious centers and research groups working in the field of homeopathy and integrative medicine. These contributions are not specialized information but are of general interest, focusing on this discipline as one of the emerging fields of personalized medical treatment.