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Tan ZS, Qureshi N, Spivack E, Rhinehart D, Gatmaitan D, Guinto A, Kremen S, Sicotte NL. Pragmatic implementation of comprehensive dementia care management: The Cedars-Sinai C.A.R.E.S. Program preliminary data. J Am Geriatr Soc 2024; 72:2532-2543. [PMID: 38526042 DOI: 10.1111/jgs.18891] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2023] [Revised: 02/15/2024] [Accepted: 03/05/2024] [Indexed: 03/26/2024]
Abstract
BACKGROUND The United States faces a growing challenge with over 6.5 million people living with dementia (PLwD). PLwD and their caregivers struggle with cognitive, functional, behavioral, and psychosocial issues. As dementia care shifts to home settings, caregivers receive inadequate support but bear increasing responsibilities, leading to higher healthcare costs. In response, the Centers for Medicare & Medicaid Services (CMS) introduced the Guiding an Improving Dementia Experience (GUIDE) Model. The study explores the real-world implementation of the Cedars-Sinai C.A.R.E.S. Program, a pragmatic dementia care model, detailing its recruitment process and initial outcomes. METHODS The Cedars-Sinai C.A.R.E.S. Program was integrated into the Epic electronic health record system and focused on proactive patient identification, engagement, interdisciplinary collaboration, care transitions, and ongoing care management. Eligible patients with a dementia diagnosis were identified through electronic health record and invited to join the program. Nurse practitioners with specialized training in dementia care performed comprehensive assessments using the CEDARS-6 tool, leading to personalized care plans developed in consultation with primary care providers. Patients benefited from a multidisciplinary team and support from care navigators. RESULTS Of the 781 eligible patients identified, 431 were enrolled in the C.A.R.E.S. PROGRAM Enrollees were racially diverse, with lower caregiver strain and patient behavioral and psychological symptoms of dementia (BPSD) severity compared to other programs dementia care programs. Healthcare utilization, including hospitalizations, emergency department (ED) admissions, and urgent care visits showed a downward trend over time. Completion of advanced directives and Physician Order of Life-Sustaining Treatment (POLST) increased after enrollment. CONCLUSION The Cedars-Sinai C.A.R.E.S. Program offers a promising approach to dementia care. Its real-world implementation demonstrates the feasibility of enrolling a diverse population and achieving positive outcomes for PLwD and their caregivers, supporting the goals of national dementia care initiatives.
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Affiliation(s)
- Zaldy S Tan
- Department of Neurology, Cedars-Sinai Medical Center, Los Angeles, California, USA
- Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Nabeel Qureshi
- Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, California, USA
- RAND Corporation, Santa Monica, California, USA
| | - Erica Spivack
- Department of Neurology, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Deana Rhinehart
- Department of Neurology, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Dyane Gatmaitan
- Department of Neurology, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Augustine Guinto
- Department of Neurology, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Sarah Kremen
- Department of Neurology, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Nancy L Sicotte
- Department of Neurology, Cedars-Sinai Medical Center, Los Angeles, California, USA
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White J, Norton G, Pond D, Khaing K, Dolja-Gore X, Byles J, Carey M. General practitioner and practice nurses perspectives on implementation of the 75+ health assessment: Implications for dementia care and well-being. J Adv Nurs 2024. [PMID: 39073187 DOI: 10.1111/jan.16354] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2023] [Revised: 07/04/2024] [Accepted: 07/14/2024] [Indexed: 07/30/2024]
Abstract
BACKGROUND The uptake of the health assessment for persons aged 75 years and older (75 + HA) remains low. Repeat assessments provide an opportunity to identify areas of change in cognitive function which may mark the onset of dementia. We aimed to explore general practitioner (GP) and practice nurse experiences of implementing the 75 + HA with a focus on clinical considerations for dementia care. METHODS An interpretative qualitative study involving interviews with 15 GPs (female = 11, male = 4) and 5 practice nurses (all female). Data were analysed using an inductive thematic approach. RESULTS The majority of GPs (n = 11) worked in metropolitan settings and four GPs worked in regional settings across NSW. All participants worked in separate clinics, except for two GPs and one practice nurse who worked within the same metropolitan clinic. Distinct themes emerged regarding participants experiences of implementing the 75 + HA for patients with dementia: (1) negotiating aged care is complex and facilitated by a comprehensive assessment; (2) implementing work practices that support the 75 + HA in patients with cognitive decline; and (3) variations in follow up of findings and implications for care. DISCUSSION The 75 + HA provides an opportunity for monitoring and acting on emergent physical and cognitive health changes. Increased engagement and support towards implementing the 75 + HA, particularly in the context of dementia, may facilitate the instigation of interventions. While some participants in this study were confident with identifying and managing cognitive decline, the majority relied on geriatricians to confirm dementia diagnosis and refer to community support services. We suggest the need for greater initiatives and clinical guidelines to assist GPs in the identification and management of cognitive decline. IMPLICATIONS FOR THE PROFESSION From a nursing perspective, this study highlights the valuable role of nurses towards assessment and management of issues raised in the health assessment for persons aged 75 years and older. However, more resources are needed to enable nurse time for adequate follow-up care.
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Affiliation(s)
- Jennifer White
- Hunter Medical Research Institute, New Lambton Heights, New South Wales, Australia
- School of Medicine and Public Health, College of Health Medicine and Wellbeing, University of Newcastle, Callaghan, New South Wales, Australia
- Centre for Women's Health Research, College of Health Medicine and Wellbeing, University of Newcastle, Callaghan, New South Wales, Australia
| | - Grace Norton
- Hunter Medical Research Institute, New Lambton Heights, New South Wales, Australia
- School of Medicine and Public Health, College of Health Medicine and Wellbeing, University of Newcastle, Callaghan, New South Wales, Australia
- Centre for Women's Health Research, College of Health Medicine and Wellbeing, University of Newcastle, Callaghan, New South Wales, Australia
| | - Dimity Pond
- School of Medicine and Public Health, College of Health Medicine and Wellbeing, University of Newcastle, Callaghan, New South Wales, Australia
| | - Kay Khaing
- Centre for Women's Health Research, College of Health Medicine and Wellbeing, University of Newcastle, Callaghan, New South Wales, Australia
| | - Xenia Dolja-Gore
- Hunter Medical Research Institute, New Lambton Heights, New South Wales, Australia
- School of Medicine and Public Health, College of Health Medicine and Wellbeing, University of Newcastle, Callaghan, New South Wales, Australia
- Centre for Women's Health Research, College of Health Medicine and Wellbeing, University of Newcastle, Callaghan, New South Wales, Australia
| | - Julie Byles
- Hunter Medical Research Institute, New Lambton Heights, New South Wales, Australia
- School of Medicine and Public Health, College of Health Medicine and Wellbeing, University of Newcastle, Callaghan, New South Wales, Australia
- Centre for Women's Health Research, College of Health Medicine and Wellbeing, University of Newcastle, Callaghan, New South Wales, Australia
| | - Mariko Carey
- Hunter Medical Research Institute, New Lambton Heights, New South Wales, Australia
- School of Medicine and Public Health, College of Health Medicine and Wellbeing, University of Newcastle, Callaghan, New South Wales, Australia
- Centre for Women's Health Research, College of Health Medicine and Wellbeing, University of Newcastle, Callaghan, New South Wales, Australia
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Teano AL, Scott A, Gipson C, Albert M, Pettigrew C. Social Media Programs for Outreach and Recruitment Supporting Aging and Alzheimer Disease and Related Dementias Research: Longitudinal Descriptive Study. JMIR Aging 2024; 7:e51520. [PMID: 38981112 PMCID: PMC11267090 DOI: 10.2196/51520] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2023] [Revised: 01/29/2024] [Accepted: 05/06/2024] [Indexed: 07/11/2024] Open
Abstract
BACKGROUND Social media may be a useful method for research centers to deliver health messages, increase their visibility in the local community, and recruit study participants. Sharing examples of social media-based community outreach and educational programs, and evaluating their outcomes in this setting, is important for understanding whether these efforts have a measurable impact. OBJECTIVE The aim of this study is to describe one center's social media activities for community education on topics related to aging, memory loss, and Alzheimer disease and related dementias, and provide metrics related to recruitment into clinical research studies. METHODS Several social media platforms were used, including Facebook, X (formerly Twitter), and YouTube. Objective assessments quantified monthly, based on each platform's native dashboard, included the number of followers, number of posts, post reach and engagement, post impressions, and video views. The number of participants volunteering for research during this period was additionally tracked using a secure database. Educational material posted to social media most frequently included content developed by center staff, content from partner organizations, and news articles or resources featuring center researchers. Multiple educational programs were developed, including social media series, web-based talks, Twitter chats, and webinars. In more recent years, Facebook content was occasionally boosted to increase visibility in the local geographical region. RESULTS Up to 4 years of page metrics demonstrated continuing growth in reaching social media audiences, as indicated by increases over time in the numbers of likes or followers on Facebook and X/Twitter and views of YouTube videos (growth trajectories). While Facebook reach and X/Twitter impression rates were reasonable, Facebook engagement rates were more modest. Months that included boosted Facebook posts resulted in a greater change in page followers and page likes, and higher reach and engagement rates (all P≤.002). Recruitment of participants into center-affiliated research studies increased during this time frame, particularly in response to boosted Facebook posts. CONCLUSIONS These data demonstrate that social media activities can provide meaningful community educational opportunities focused on Alzheimer disease and related dementias and have a measurable impact on the recruitment of participants into research studies. Additionally, this study highlights the importance of tracking outreach program outcomes for evaluating return on investment.
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Affiliation(s)
- Anthony L Teano
- Department of Geriatric Medicine and Gerontology, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Ashley Scott
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Cassandra Gipson
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Marilyn Albert
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Corinne Pettigrew
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, United States
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Brown P, Cooper C, Dening KH, Hoe J, Burton A. An exploration of how specialist dementia nurses perceive and maintain the skills and competencies that frame their specialism: A qualitative survey. Heliyon 2024; 10:e27856. [PMID: 38596077 PMCID: PMC11001773 DOI: 10.1016/j.heliyon.2024.e27856] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2023] [Revised: 03/04/2024] [Accepted: 03/07/2024] [Indexed: 04/11/2024] Open
Abstract
Background UK policy for complex and long-term health conditions including dementia has recommended that specialist nursing intervention is offered across the trajectory of the condition, but there is a lack of agreement regarding the skills and competencies that specialist nurses are expected to possess. Admiral Nurses are the largest UK group of specialist dementia nurses. Objective To explore how Admiral Nurses met and were supported to meet competencies as defined in the Admiral Nurse Competency Framework, and to develop and maintain skills as dementia specialists. Design Cross-sectional, semi-structured survey. Setting Online national survey. Participants Admiral (specialist dementia) Nurses. Methods We co-designed our survey with Admiral Nurses; then invited Admiral Nurses to complete it in 2022-23 Data were analysed thematically. Results 68 (20% of all Admiral Nurses) completed the survey; most were female (85.2%), from a white ethnic group (88.2%); they reported on average 24 years of nursing experience. We identified three themes in responses: 1.Having time and skills for meaningful support, explored how participants were resourced with time and skills to understand and address family carer client needs by active listening, tailoring person-centred support, and "walking alongside" families. 2.Partnering family carers, concerned how they co-designed interventions with family carers, learning from these collaborative partnerships where expertise was shared. 3.Practice and peer-based learning, explored how participants took responsibility for using available training, peer learning and self-reflection to develop their practice. Conclusions Admiral Nurse roles enabled respondents to develop as autonomous practitioners and to access resources that supported them to build and sustain their dementia specialist practice. Learning was practice based, through partnerships with family carer clients, peer support and self-directed learning. Specialist nursing models may help address the global health workforce emergency, through enabling creative practice development and valued roles that support retention of experienced nurses.
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Affiliation(s)
- Pat Brown
- Division of Psychiatry, University College London, London, UK & Dementia UK, London, UK
| | - Claudia Cooper
- Centre for Psychiatry and Mental Health, Wolfson Institute of Population Health, Queen Mary University of London, London, UK, And East London NHS Foundation Trust
| | - Karen Harrison Dening
- School of Health & Life Sciences, De Montfort University, Leicester, Leicestershire & Dementia UK, London, UK
| | - Juanita Hoe
- Geller Institute of Ageing and Memory (GIAM), University of West London, London, UK
| | - Alexandra Burton
- Department of Behavioural Science and Health, University College London, London, UK
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Nishimura M, Harrison Dening K, Sampson EL, Vidal EIDO, Nakanishi M, Davies N, Abreu W, Kaasalainen S, Eisenmann Y, Dempsey L, Moore KJ, Bolt SR, Meijers JMM, Dekker NL, Miyashita M, Nakayama T, van der Steen JT. A palliative care goals model for people with dementia and their family: Consensus achieved in an international Delphi study. Palliat Med 2024; 38:457-470. [PMID: 38634232 PMCID: PMC11025301 DOI: 10.1177/02692163241234579] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/19/2024]
Abstract
BACKGROUND Advance care planning in dementia includes supporting the person and their family to consider important goals of care. International research reports the importance of psycho-social-spiritual aspects towards end of life. AIM To develop a multidimensional international palliative care goals model in dementia for use in practice. DESIGN International Delphi study integrating consensus and evidence from a meta-qualitative study. The Delphi panel rated statements about the model on a 5-point agreement scale. The criteria for consensus were pre-specified. SETTING/PARTICIPANTS Seventeen researchers from eight countries developed an initial model, and 169 candidate panellists were invited to the international online Delphi study. RESULTS Panellists (107; response 63.3%) resided in 33 countries. The model comprised four main care goals: (1) Comfort ensured; (2) Control over function maintained; (3) Identity protected and personhood respected and (4) Coping with grief and loss-person and caregiver supported. The model reflects how needs and care goals change over time with the progression of dementia, concluding with bereavement support. The first version of the model achieved a consensus after which it was slightly refined based on feedback. We did not achieve a consensus on adding a goal of life prolongation, and on use of the model by people with dementia and family themselves. CONCLUSION A new palliative care goals model for people with dementia and their families includes relationship aspects for use by professionals and achieved a consensus among a panel with diverse cultural background. The position of life prolongation in relation to palliative care goals needs further research.
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Affiliation(s)
- Mayumi Nishimura
- Department of Health Informatics, School of Public Health, Graduate School of Medicine, Kyoto University, Kyoto, Kyoto Prefecture, Japan
| | | | - Elizabeth L Sampson
- Royal London Hospital and Centre for Psychiatry and Mental health, East London NHS Foundation Trust, London, UK
- Wolfson Institute of Population Health, Queen Mary University London, London, UK
| | | | - Miharu Nakanishi
- Department of Psychiatric Nursing, Tohoku University Graduate School of Medicine, Sendai, Miyagi, Japan
| | - Nathan Davies
- Research Department of Primary Care and Population Health, University College London, London, UK
| | - Wilson Abreu
- Center for Health Technology and Ser- vices Research, University of Porto (ESEP/CINTESIS), Porto, Portugal
| | | | - Yvonne Eisenmann
- Department of Palliative Medicine, University Hospital of Cologne, Cologne, North Rhine-Westphalia, Germany
| | - Laura Dempsey
- Department of Nursing and Healthcare, Technological University of the Shannon: Midlands Midwest, Athlone, Ireland
| | - Kirsten J Moore
- National Ageing Research Institute, Parkville, VIC, Australia
- Medicine-Royal Melbourne Hospital, The University of Melbourne, Melbourne, VIC, Australia
| | - Sascha R Bolt
- Tilburg School of Social and Behavioral Sciences, Tilburg University, Tilburg, North Brabant, The Netherlands
| | - Judith MM Meijers
- Department of Health Services Research, CAPHRI School for Public Health and Primary Care, Maastricht University, Maastricht, Limburg, The Netherlands
- Living Lab in Ageing and Long-Term Care, Maastricht, The Netherlands
- Zuyderland Care, Zuyderland Medical Center, Sittard-Geleen, The Netherlands
| | - Natashe Lemos Dekker
- Institute of Cultural Anthropology and Development Sociology, Leiden University, Leiden, South Holland, The Netherlands
| | - Mitsunori Miyashita
- Department of Palliative Nursing, Health Sciences, Tohoku University Graduate School of Medicine, Sendai, Miyagi, Japan
| | - Takeo Nakayama
- Department of Health Informatics, School of Public Health, Graduate School of Medicine, Kyoto University, Kyoto, Kyoto Prefecture, Japan
| | - Jenny T van der Steen
- Department of Public Health and Primary Care, Leiden University Medical Center, Leiden, South Holland, The Netherlands
- Department of Primary and Community Care, Radboud University, Nijmegen, The Netherlands
- Cicely Saunders Institute, King’s College London, UK
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Villarejo-Galende A, García-Arcelay E, Piñol-Ripoll G, del Olmo-Rodríguez A, Viñuela F, Boada M, Franco-Macías E, Ibañez de la Peña A, Riverol M, Puig-Pijoan A, Abizanda-Soler P, Arroyo R, Baquero-Toledo M, Feria-Vilar I, Balasa M, Berbel Á, Rodríguez-Rodríguez E, Vieira-Campos A, Garcia-Ribas G, Rodrigo-Herrero S, Lleó A, Maurino J. Medical help-seeking intentions among patients with early Alzheimer's disease. Front Psychiatry 2023; 14:1290002. [PMID: 38173708 PMCID: PMC10762795 DOI: 10.3389/fpsyt.2023.1290002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2023] [Accepted: 12/01/2023] [Indexed: 01/05/2024] Open
Abstract
Background Limited information is available on the active process of seeking medical help in patients with Alzheimer's disease (AD) at early stages. The aim of this study was to assess the phenomenon of medical help-seeking in early AD and to identify associated factors. Methods A multicenter, non-interventional study was conducted including patients of 50-90 years of age with prodromal or mild AD (National Institute on Aging/Alzheimer's Association criteria), a Mini-Mental State Examination (MMSE) score ≥ 22, and a Clinical Dementia Rating-Global score (CDR-GS) of 0.5-1.0. A multivariate logistic regression analysis was conducted. Results A total of 149 patients were included. Mean age (SD) was 72.3 (7.0) years, 50.3% were female, and 87.2% had a CDR-GS score of 0.5. Mean disease duration was 1.4 (1.8) years. Ninety-four (63.1%) patients sought medical help, mostly from neurologists. Patients with help-seeking intentions were mostly female (60.6%) with a CDR-GS score of 0.5 (91.5%) and had a greater awareness of diagnosis, poorer quality of life, more depressive symptoms, and a more severe perception of their condition than their counterparts. Lack of help-seeking intentions was associated with male sex (p = 0.003), fewer years of education (p = 0.005), a low awareness of diagnosis (p = 0.005), and a low emotional consequence of the condition (p = 0.016). Conclusion Understanding the phenomenon of active medical help-seeking may facilitate the design of specific strategies to improve the detection of cognitive impairment, especially in patients with a lower level of educational attainment and poor awareness of their condition.
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Affiliation(s)
- Alberto Villarejo-Galende
- Department of Neurology, Hospital Universitario 12 de Octubre, Instituto de Investigación Imas12, Universidad Complutense de Madrid, Madrid, Spain
| | | | - Gerard Piñol-Ripoll
- Cognitive Disorders Unit, Hospital Universitari Santa Maria de Lleida, Lleida, Spain
| | | | - Félix Viñuela
- Cognitive Impairment Unit, Hospital Universitario Virgen Macarena, Seville, Spain
| | - Mercè Boada
- Ace Alzheimer Center Barcelona, Barcelona, Spain
| | - Emilio Franco-Macías
- Dementia Unit, Department of Neurology, Hospital Universitario Virgen del Rocío, Seville, Spain
| | | | - Mario Riverol
- Department of Neurology, Clínica Universidad de Navarra, University of Navarre, Pamplona, Spain
| | - Albert Puig-Pijoan
- Cognitive Impairment and Movement Disorders Unit, Department of Neurology, Hospital del Mar, Barcelona, Spain
| | - Pedro Abizanda-Soler
- Department of Geriatrics, Complejo Hospitalario Universitario de Albacete, Albacete, Spain
| | - Rafael Arroyo
- Department of Neurology, Hospital Universitario Quirónsalud, Madrid, Spain
| | - Miquel Baquero-Toledo
- Grup d'Investigació en Malaltia d'Alzheimer, Department of Neurology, Hospital Universitari i Politècnic La Fe, Valencia, Spain
| | - Inmaculada Feria-Vilar
- Department of Neurology, Complejo Hospitalario Universitario de Albacete, Albacete, Spain
| | - Mircea Balasa
- Unit of Alzheimer's Disease and Other Cognitive Disorders, Hospital Clínic, Barcelona, Spain
| | - Ángel Berbel
- Department of Neurology, Hospital Central de la Cruz Roja, Madrid, Spain
| | - Eloy Rodríguez-Rodríguez
- Department of Neurology, Hospital Universitario de Marqués de Valdecilla, IDIVAL, University of Cantabria, Santander, Spain
| | - Alba Vieira-Campos
- Department of Neurology, Hospital Universitario de La Princesa, Madrid, Spain
| | | | - Silvia Rodrigo-Herrero
- Memory Unit, Department of Neurology, Hospital Universitario Juan Ramón Jiménez, Huelva, Spain
| | - Alberto Lleó
- Department of Neurology, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
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Zhu EM, Buljac-Samardžić M, Ahaus K, Sevdalis N, Huijsman R. Implementation and dissemination of home- and community-based interventions for informal caregivers of people living with dementia: a systematic scoping review. Implement Sci 2023; 18:60. [PMID: 37940960 PMCID: PMC10631024 DOI: 10.1186/s13012-023-01314-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2022] [Accepted: 10/08/2023] [Indexed: 11/10/2023] Open
Abstract
BACKGROUND Informal caregivers of people with dementia (PwD) living at home are often the primary source of care, and, in their role, they often experience loss of quality of life. Implementation science knowledge is needed to optimize the real-world outcomes of evidence-based interventions (EBIs) for informal caregivers. This scoping review aims to systematically synthesize the literature that reports implementation strategies employed to deliver home- and community-based EBIs for informal caregivers of PwD, implementation outcomes, and the barriers and facilitators to implementation of these EBIs. METHODS Embase, MEDLINE, Web of Science, and Cochrane Library were searched from inception to March 2021; included studies focused on "implementation science," "home- and community-based interventions," and "informal caregivers of people with dementia." Titles and abstracts were screened using ASReview (an innovative AI-based tool for evidence reviews), and data extraction was guided by the ERIC taxonomy, the Implementation Outcome Framework, and the Consolidated Framework for Implementation Science Research; each framework was used to examine a unique element of implementation. RESULTS Sixty-seven studies were included in the review. Multicomponent (26.9%) and eHealth (22.3%) interventions were most commonly reported, and 31.3% of included studies were guided by an implementation science framework. Training and education-related strategies and provision of interactive assistance were the implementation strategy clusters of the ERIC taxonomy where most implementation strategies were reported across the reviewed studies. Acceptability (82.1%), penetration (77.6%), and appropriateness (73.1%) were the most frequently reported implementation outcomes. Design quality and packaging (intervention component suitability) and cosmopolitanism (partnerships) constructs, and patient's needs and resources and available resources (infrastructure) constructs as per the CFIR framework, reflected the most frequently reported barriers and facilitators to implementation. CONCLUSION Included studies focused largely on intervention outcomes rather than implementation outcomes and lacked detailed insights on inner and outer setting determinants of implementation success or failure. Recent publications suggest implementation science in dementia research is developing but remains in nascent stages, requiring future studies to apply implementation science knowledge to obtain more contextually relevant findings and to structurally examine the mechanisms through which implementation partners can strategically leverage existing resources and regional networks to streamline local implementation. Mapping local evidence ecosystems will facilitate structured implementation planning and support implementation-focused theory building. TRIAL REGISTRATION Not applicable.
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Affiliation(s)
- Eden Meng Zhu
- Erasmus School of Health Policy & Management, PO Box 1738, 3000 DR, Rotterdam, The Netherlands.
| | | | - Kees Ahaus
- Erasmus School of Health Policy & Management, PO Box 1738, 3000 DR, Rotterdam, The Netherlands
| | - Nick Sevdalis
- Centre for Behavioural and Implementation Science Interventions, National University of Singapore, Singapore, Singapore
| | - Robbert Huijsman
- Erasmus School of Health Policy & Management, PO Box 1738, 3000 DR, Rotterdam, The Netherlands
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Moermans VRA, Hamers JPH, Verbeek H, de Casterlé BD, Milisen K, Bleijlevens MHC. District nurses' experiences with involuntary treatment in dementia care at home: a qualitative descriptive study. BMC Nurs 2023; 22:394. [PMID: 37853344 PMCID: PMC10585764 DOI: 10.1186/s12912-023-01553-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2023] [Accepted: 10/05/2023] [Indexed: 10/20/2023] Open
Abstract
BACKGROUND Research shows that half of person(s) living with dementia (PLWD) receive care which they resist and/or have not given consent to, defined as involuntary treatment. District nurses play a key role in providing this care. Knowledge about how district nurses experience involuntary treatment is lacking. Therefore, the aim of this study was to describe the experiences of district nurses who used involuntary treatment for PLWD at home. METHODS A qualitative descriptive design using semi-structured interviews. Sixteen district nurses with experience in involuntary treatment for PLWD were recruited through purposive sampling. Data were analysed using the Qualitative Analysis Guide of Leuven. RESULTS District nurses' experiences with involuntary treatment were influenced by their involvement in the decision-making process. When they were involved, they considered involuntary treatment use to be appropriate care. However, at the moment that involuntary treatment use was started, district nurses were worried that its use was unjust since they wished to respect the wishes of the PLWD. Eventually, district nurses found, from a professional perspective, that involuntary treatment use was necessary, and that safety outweighed the autonomy of the PLWD. District nurses experienced dealing with this dilemma as stressful, due to conflicting values. If district nurses were not involved in the decision-making process regarding the use of involuntary treatment, family caregivers generally decided on its use. Often, district nurses perceived this request as inappropriate dementia care and they first tried to create a dialogue with the family caregivers to reach a compromise. However, in most cases, family caregivers stood by their request and the district nurse still provided involuntary treatment and found this difficult to tolerate. CONCLUSIONS Our results show that district nurses experience involuntary treatment use as stressful due to dealing with obverse values of safety versus autonomy. To prevent involuntary treatment use and obverse values, we need to increase their ethical awareness, communication skills, knowledge and skills with person-centred care so they can deal with situations that can evolve into involuntary treatment use in a person-centred manner.
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Affiliation(s)
- Vincent R A Moermans
- Department of Health Services Research, Care and Public Health Research Institute, Faculty of Health Medicine and Life Sciences, Maastricht University, Duboisdomein 30, Maastricht, 6229 GT, The Netherlands.
- Department of Nursing, White Yellow Cross Limburg, Genk, Belgium.
- Living Lab in Ageing and Long-Term Care, Maastricht, the Netherlands.
| | - Jan P H Hamers
- Department of Health Services Research, Care and Public Health Research Institute, Faculty of Health Medicine and Life Sciences, Maastricht University, Duboisdomein 30, Maastricht, 6229 GT, The Netherlands
- Living Lab in Ageing and Long-Term Care, Maastricht, the Netherlands
| | - Hilde Verbeek
- Department of Health Services Research, Care and Public Health Research Institute, Faculty of Health Medicine and Life Sciences, Maastricht University, Duboisdomein 30, Maastricht, 6229 GT, The Netherlands
- Living Lab in Ageing and Long-Term Care, Maastricht, the Netherlands
| | | | - Koen Milisen
- Department of Public Health and Primary Care, Academic Centre for Nursing and Midwifery, KU Leuven, Leuven, Belgium
- Department of Geriatric Medicine, University Hospitals Leuven, Leuven, Belgium
| | - Michel H C Bleijlevens
- Department of Health Services Research, Care and Public Health Research Institute, Faculty of Health Medicine and Life Sciences, Maastricht University, Duboisdomein 30, Maastricht, 6229 GT, The Netherlands
- Living Lab in Ageing and Long-Term Care, Maastricht, the Netherlands
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Zolnoori M, Barrón Y, Song J, Noble J, Burgdorf J, Ryvicker M, Topaz M. HomeADScreen: Developing Alzheimer's disease and related dementia risk identification model in home healthcare. Int J Med Inform 2023; 177:105146. [PMID: 37454558 PMCID: PMC10529395 DOI: 10.1016/j.ijmedinf.2023.105146] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2023] [Revised: 06/22/2023] [Accepted: 07/07/2023] [Indexed: 07/18/2023]
Abstract
BACKGROUND More than 50 % of patients with Alzheimer's disease and related dementia (ADRD) remain undiagnosed. This is specifically the case for home healthcare (HHC) patients. OBJECTIVES This study aimed at developing HomeADScreen, an ADRD risk screening model built on the combination of HHC patients' structured data and information extracted from HHC clinical notes. METHODS The study's sample included 15,973 HHC patients with no diagnosis of ADRD and 8,901 patients diagnosed with ADRD across four follow-up time windows. First, we applied two natural language processing methods, Word2Vec and topic modeling methods, to extract ADRD risk factors from clinical notes. Next, we built the risk identification model on the combination of the Outcome and Assessment Information Set (OASIS-structured data collected in the HHC setting) and clinical notes-risk factors across the four-time windows. RESULTS The top-performing machine learning algorithm attained an Area under the Curve = 0.76 for a four-year risk prediction time window. After optimizing the cut-off value for screening patients with ADRD (cut-off-value = 0.31), we achieved sensitivity = 0.75 and an F1-score = 0.63. For the first-year time window, adding clinical note-derived risk factors to OASIS data improved the overall performance of the risk identification model by 60 %. We observed a similar trend of increasing the model's overall performance across other time windows. Variables associated with increased risk of ADRD were "hearing impairment" and "impaired patient ability in the use of telephone." On the other hand, being "non-Hispanic White" and the "absence of impairment with prior daily functioning" were associated with a lower risk of ADRD. CONCLUSION HomeADScreen has a strong potential to be translated into clinical practice and assist HHC clinicians in assessing patients' cognitive function and referring them for further neurological assessment.
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Affiliation(s)
- Maryam Zolnoori
- Columbia University Irving Medical Center, New York, NY, USA; Center for Home Care Policy & Research, VNS Health, New York, NY, USA; School of Nursing, Columbia University, USA.
| | - Yolanda Barrón
- Center for Home Care Policy & Research, VNS Health, New York, NY, USA
| | | | - James Noble
- Columbia University Irving Medical Center, New York, NY, USA
| | - Julia Burgdorf
- Center for Home Care Policy & Research, VNS Health, New York, NY, USA
| | - Miriam Ryvicker
- Center for Home Care Policy & Research, VNS Health, New York, NY, USA
| | - Maxim Topaz
- Center for Home Care Policy & Research, VNS Health, New York, NY, USA; School of Nursing, Columbia University, USA
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Fahsold A, Roes M, Holle B, Kuliga S. Methods for the involvement of people living with dementia in research focused on the built environment: a protocol for a scoping review. BMJ Open 2023; 13:e075350. [PMID: 37620266 PMCID: PMC10450054 DOI: 10.1136/bmjopen-2023-075350] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2023] [Accepted: 08/08/2023] [Indexed: 08/26/2023] Open
Abstract
INTRODUCTION The positive influence of a well-designed built environment in dementia-specific care has been known for several years. Many studies focusing on the built environment have captured the perspectives of people living with dementia. However, it remains unclear to what degree and with which methods these individuals have been actively involved in research especially when attempting to understand their perspective. The planned scoping review aims to (1) synthesise methods and results from research about the built environment according to active involvement of people living with dementia and (2) describe facilitators and barriers to this active involvement to capture their perspectives in research. METHODS AND ANALYSIS We will use four search strategies: (1) searches in academic databases MEDLINE via PubMed, CINAHL and APA PsycINFO via EBSCO, and Scopus; (2) grey literature searches via Google Scholar; (3) handsearches of non-academic environmental planning and design journals and (4) identifying other publications of key authors in the field. Additionally, backward and forward citation tracking will be performed via reference lists and Google Scholar, respectively. Relevant literature published between 2013 and 2023 will be identified for data extraction and synthesis. One researcher will perform each strategy. Title-abstract/full text-screening will be conducted using Covidence by two researchers. Results will be displayed in a table and through figures illustrating identified facilitators and barriers. ETHICS AND DISSEMINATION We raised no ethical concerns for the planned scoping review. We will prepare the findings including the identified barriers with long-term care practitioners from our network to identify how changes in practical application methods can be addressed. This dialogue can serve as a basis for including people living with dementia to discuss highlighted barriers when researching their perspectives on the built environment. The scoping review results will be reported in both academic and non-academic journals and at academic conferences.
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Affiliation(s)
- Anne Fahsold
- Deutsches Zentrum für Neurodegenerative Erkrankungen, Standort Witten, Witten, Germany
- School of Nursing Science, Faculty of Health, Witten/Herdecke University, Witten, Germany
| | - Martina Roes
- Deutsches Zentrum für Neurodegenerative Erkrankungen, Standort Witten, Witten, Germany
- School of Nursing Science, Faculty of Health, Witten/Herdecke University, Witten, Germany
| | - Bernhard Holle
- Deutsches Zentrum für Neurodegenerative Erkrankungen, Standort Witten, Witten, Germany
- School of Nursing Science, Faculty of Health, Witten/Herdecke University, Witten, Germany
| | - Saskia Kuliga
- Deutsches Zentrum für Neurodegenerative Erkrankungen, Standort Witten, Witten, Germany
- Faculty of Health, Witten/Herdecke University, Witten, Germany
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11
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Raghunandan R, Howard K, Ilomaki J, Hilmer SN, Gnjidic D, Bell JS. Preferences for deprescribing antihypertensive medications amongst clinicians, carers and people living with dementia: a discrete choice experiment. Age Ageing 2023; 52:afad153. [PMID: 37596920 PMCID: PMC10439526 DOI: 10.1093/ageing/afad153] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2022] [Indexed: 08/21/2023] Open
Abstract
BACKGROUND Optimal management of hypertension in people with dementia may involve deprescribing antihypertensives. Understanding differing treatment priorities is important to enable patient-centred care. This study explored preferences for antihypertensive deprescribing amongst people living with dementia, carers and clinicians. METHODS Discrete choice experiments (DCEs) are a stated preference survey method, underpinned by economic theory. A DCE was conducted, and respondents completed 12 labelled choice-questions, each presenting a status quo (continuing antihypertensives) and antihypertensive deprescribing option. The questions included six attributes, including pill burden, and event risks for stroke, myocardial infarction, increased blood pressure, cognitive decline, falls. RESULTS Overall, 112 respondents (33 carers, 19 people living with dementia, and 60 clinicians) completed the survey. For people with dementia, lower pill burden increased preferences for deprescribing (odds ratio (OR) 1.95, 95% confidence interval (95% CI) 1.08-3.52). Increased stroke risk (for each additional person out of 100 having a stroke) decreased the likelihood of deprescribing for geriatricians (OR 0.71, 95% CI 0.55-0.92) and non-geriatrician clinicians (OR 0.62, 95% CI 0.45-0.86), and carers (OR 0.71, 95% CI 0.58-0.88). Increased myocardial infarction risk decreased preferences for deprescribing for non-geriatricians (OR 0.81, 95% CI 0.69-0.95) and carers (OR 0.84, 95% CI 0.73-0.98). Avoiding cognitive decline increased preferences for deprescribing for geriatricians (OR 1.17, 95% CI 1.03-1.33) and carers (OR 1.27, 95% CI 1.09-1.48). Avoiding falls increased preferences for deprescribing for clinicians (geriatricians (OR 1.20, 95% CI 1.11-1.29); non-geriatricians (OR 1.16, 95% CI 1.07-1.25)). Other attributes did not significantly influence respondent preferences. CONCLUSIONS Antihypertensive deprescribing preferences differ amongst people with dementia, carers and clinicians. The study emphasises the importance of shared decision-making within the deprescribing process.
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Affiliation(s)
- Rakhee Raghunandan
- Menzies Centre for Health Policy and Economics, School of Public Health, Faculty of Medicine and Health, University of Sydney, Camperdown, NSW, Australia
| | - Kirsten Howard
- Menzies Centre for Health Policy and Economics, School of Public Health, Faculty of Medicine and Health, University of Sydney, Camperdown, NSW, Australia
| | - Jenni Ilomaki
- Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Clayton, VIC, Australia
| | - Sarah N Hilmer
- Kolling Institute of Medical Research, Royal North Shore Hospital and University of Sydney, St Leonards, NSW, Australia
- Departments of Clinical Pharmacology and Aged Care, Royal North Shore Hospital, St Leonards, NSW, Australia
- Northern Clinical School, Faculty of Medicine and Health, University of Sydney, Camperdown, NSW, Australia
| | - Danijela Gnjidic
- School of Pharmacy, Faculty of Medicine and Health, and Charles Perkins Centre, University of Sydney, Camperdown, NSW, Australia
| | - J Simon Bell
- Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Clayton, VIC, Australia
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Mohr W, Rädke A, Afi A, Weber N, Platen M, Mühlichen F, Scharf A, Michalowsky B, Hoffmann W. Do They Align? Congruence Between Patient Preferences of People Living with Cognitive Impairments and Physicians' Judgements for Person-Centered Care: An Analytic Hierarchy Process Study. J Alzheimers Dis 2023; 91:727-741. [PMID: 36502324 PMCID: PMC9912726 DOI: 10.3233/jad-220753] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Person-centered care (PCC) requires knowledge about patient preferences. Among people living with cognitive impairments (PlwCI), evidence on quantitative, choice-based preferences, which allow to quantify, weigh, and rank care elements, is limited. Furthermore, data on the congruence of patient preferences with physicians' judgements for PCC are missing. Such information is expected to support the implementation of PCC; state-of-the-art medical care aligned with patients' preferences. OBJECTIVE To elicit patient preferences and physicians' judgements for PCC and their congruence. METHODS Data from the mixed-methods PreDemCare study, including a cross-sectional, paper-and-pencil, interviewer-assisted analytic hierarchy process (AHP) survey conducted with n = 50 community-dwelling PlwCI and n = 25 physicians. Individual AHP weights (preferences/judgements) were calculated with the principal eigenvector method and aggregated per group by aggregation of individual priorities mode. Individual consistency ratios (CRs) were calculated and aggregated per group. Group differences in preferences/judgements were investigated descriptively by means and standard deviations (SDs) of AHP weights, resulting ranks, and boxplots. Additionally, differences between groups were investigated with independent paired t-test/Mann Whitney U-test. Sensitivity of AHP results was tested by inclusion/exclusion of inconsistent respondents, with an accepted threshold at CR≤0.3 for patients, and CR≤0.2 for physicians, due to better cognitive fitness of the latter group. RESULTS Patient preferences and physicians' judgements did not differ significantly, except for the criterion Memory Exercises (AHP weights (mean (SD)): 0.135 (0.066) versus 0.099 (0.068), p = 0.01). We did not see rank-reversals of criteria after exclusion of inconsistent participants. Mean CR for patients at the criteria level was 0.261, and 0.181 for physicians. CONCLUSION Physicians' judgements in our setting aligned well with patients' preferences. Our findings may be used to guide the implementation of preference-based PCC.
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Affiliation(s)
- Wiebke Mohr
- German Center for Neurodegenerative Diseases e.V. (DZNE), Site Rostock/Greifswald, Germany,Correspondence to: Wiebke Mohr, German Center for Neurodegenerative Diseases e.V., Ellernholzstraße 1-2, 17487 Greifswald, Germany. Tel.: +49 3834 86 8537; E-mail:
| | - Anika Rädke
- German Center for Neurodegenerative Diseases e.V. (DZNE), Site Rostock/Greifswald, Germany
| | - Adel Afi
- German Center for Neurodegenerative Diseases e.V. (DZNE), Site Rostock/Greifswald, Germany
| | - Niklas Weber
- German Center for Neurodegenerative Diseases e.V. (DZNE), Site Rostock/Greifswald, Germany
| | - Moritz Platen
- German Center for Neurodegenerative Diseases e.V. (DZNE), Site Rostock/Greifswald, Germany
| | - Franka Mühlichen
- German Center for Neurodegenerative Diseases e.V. (DZNE), Site Rostock/Greifswald, Germany
| | - Annelie Scharf
- German Center for Neurodegenerative Diseases e.V. (DZNE), Site Rostock/Greifswald, Germany
| | - Bernhard Michalowsky
- German Center for Neurodegenerative Diseases e.V. (DZNE), Site Rostock/Greifswald, Germany
| | - Wolfgang Hoffmann
- German Center for Neurodegenerative Diseases e.V. (DZNE), Site Rostock/Greifswald, Germany,
Institute for Community Medicine, Section Epidemiology of Health Care and Community Health, University Medicine Greifswald, Germany
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Creavin ST, Fish M, Lawton M, Cullum S, Bayer A, Purdy S, Ben-Shlomo Y. A Diagnostic Test Accuracy Study Investigating General Practitioner Clinical Impression and Brief Cognitive Assessments for Dementia in Primary Care, Compared to Specialized Assessment. J Alzheimers Dis 2023; 95:1189-1200. [PMID: 37694368 PMCID: PMC7615275 DOI: 10.3233/jad-230320] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/12/2023]
Abstract
BACKGROUND Many health systems are interested in increasing the number of uncomplicated and typical dementia diagnoses that are made in primary care, but the comparative accuracy of tests is unknown. OBJECTIVE Calculate diagnostic accuracy of brief cognitive tests in primary care. METHODS We did a diagnostic test accuracy study in general practice, in people over 70 years who had consulted their GP with cognitive symptoms but had no prior diagnosis of dementia. The reference standard was specialist assessment, adjudicated for difficult cases, according to ICD-10. We assessed 16 index tests at a research clinic, and additionally analyzed referring GPs clinical judgement. RESULTS 240 participants had a median age of 80 years, of whom 126 were men and 132 had dementia. Sensitivity of individual tests at the recommended thresholds ranged from 56% for GP judgement (specificity 89%) to 100% for MoCA (specificity 16%). Specificity of individual tests ranged from 4% for Sniffin' sticks (sensitivity 100%) to 91% for Timed Up and Go (sensitivity 23%). The 95% centile of test duration in people with dementia ranged from 3 minutes for 6CIT and Time and Change, to 16 minutes for MoCA. Combining tests with GP judgement increased test specificity and decreased sensitivity: e.g., MoCA with GP Judgement had specificity 87% and sensitivity 55%. CONCLUSIONS Using GP judgement to inform selection of tests was an efficient strategy. Using IQCODE in people who GPs judge as having dementia and 6CIT in people who GPs judge as having no dementia, would be a time-efficient and accurate diagnostic assessment.The original protocol for the study is available at https://bmcfampract.biomedcentral.com/articles/10.1186/s12875-016-0475-2.
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Affiliation(s)
- Samuel Thomas Creavin
- Population Health Sciences, University of Bristol, Canynge Hall, 39 Whatley Road, Bristol BS8 2PS
| | | | - Michael Lawton
- Population Health Sciences, University of Bristol, Canynge Hall, 39 Whatley Road, Bristol BS8 2PS
| | - Sarah Cullum
- Faculty of Medical and Health Sciences, The University of Auckland, Building 507, 22-30 Park Avenue, Grafton, Auckland 1142, New Zealand
| | - Antony Bayer
- Division of Population Medicine, Cardiff University, Cardiff, CF64 2XX
| | - Sarah Purdy
- Population Health Sciences, University of Bristol, Canynge Hall, 39 Whatley Road, Bristol BS8 2PS
| | - Yoav Ben-Shlomo
- Population Health Sciences, University of Bristol, Canynge Hall, 39 Whatley Road, Bristol BS8 2PS
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14
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O'Caoimh R. Informant-Administered Cognitive Screening as a Component of Memory Clinic Assessment: Overcoming Ethical and Practical Challenges. J Alzheimers Dis 2022; 90:1433-1436. [PMID: 36404552 DOI: 10.3233/jad-220989] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Possin and Rosen provide a robust commentary exploring the challenges of using caregivers as cognitive testers. Informants have an important and often overlooked role in diagnosing cognitive impairment. O'Caoimh et al. show they can support cognitive screening in advance of clinic, suggesting new research avenues including the potential for home-monitoring. Although concerns testing may engender bias, introduce practice effects, and impact patient autonomy are valid and require examination, these should be viewed in light of patient preference, clinical need, and the broader ethics of assessing dementia. The importance of distinguishing concerns over accuracy and ethical appropriateness is also discussed.
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Affiliation(s)
- Rónán O'Caoimh
- Department of Geriatric Medicine, Mercy University Hospital, Grenville Place, Cork City, Ireland.,Health Research Board Clinical Research Facility, University College Cork, Cork City, Ireland
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15
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Dupont C, Smets T, Monnet F, Eneslätt M, Tishelman C, Van den Block L. The cultural adaptation of the go wish card game for use in Flanders, Belgium: a public health tool to identify and discuss end-of-life preferences. BMC Public Health 2022; 22:2110. [PMID: 36397020 PMCID: PMC9672613 DOI: 10.1186/s12889-022-14523-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2022] [Accepted: 11/02/2022] [Indexed: 11/19/2022] Open
Abstract
Background Public health tools like the Go Wish card game from the US, have been found useful to support people in reflecting on their end-of-life preferences, but a cultural adaptation is essential for their success. In the present study, we explore the necessary cultural adaptations to the Go Wish cards by applying an extensive, systematic, and community-engaging negotiating procedure to facilitate the use of the cards in the general population of Flanders, Belgium. Methods We used an iterative cultural adaptation process with repeated discussions with various community organizations and representatives of minority and religious groups. After that, the cards were evaluated by 12 healthcare professionals in relation to: linguistic equivalence to the original version, applicability, comprehensibility, and relevance per card. Additional testing with potential users preceded final adjustments. Results We found that stakeholders were keen to engage throughout the process of cultural adaptation and we were able to make a range of cultural adaptations for the use of the cards in Flanders. All original statements were rephrased from passive to more active statements. Sixteen out of 36 cards were adjusted to make them more culturally appropriate for use in Flanders, e.g., “to meet with clergy or a chaplain” to “having a spiritual counselor as support.” Three new cards were added: two with statements appropriate to the Belgian patient rights and euthanasia legislation and one extra Wild Card. Potential users (n = 33) felt that the cards supported conversations about end-of-life preferences. Conclusion By making community engagement a cornerstone of our adaption process, we developed a card set that potential end-users considered a supportive public health tool for reflecting and discussing end-of-life values and preferences. The described process is particularly valuable for culturally adapt interventions, especially given that community engagement in adapting interventions is essential to creating grounded interventions. Supplementary Information The online version contains supplementary material available at 10.1186/s12889-022-14523-9.
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Villarejo-Galende A, García-Arcelay E, Piñol-Ripoll G, del Olmo-Rodríguez A, Viñuela F, Boada M, Franco-Macías E, Ibañez de la Peña A, Riverol M, Puig-Pijoan A, Abizanda-Soler P, Arroyo R, Baquero-Toledo M, Feria-Vilar I, Balasa M, Berbel Á, Rodríguez-Rodríguez E, Vieira-Campos A, García-Ribas G, Rodrigo-Herrero S, Terrancle Á, Prefasi D, Lleó A, Maurino J. Quality of Life and the Experience of Living with Early-Stage Alzheimer’s Disease. J Alzheimers Dis 2022; 90:719-726. [DOI: 10.3233/jad-220696] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Background: There is a need to better understand the experience of patients living with Alzheimer's disease (AD) in the early stages. Objective: The aim of the study was to evaluate the perception of quality of life in patients with early-stage AD. Methods: A multicenter, non-interventional study was conducted including patients of 50–90 years of age with prodromal or mild AD, a Mini-Mental State Examination (MMSE) score ≥22, and a Clinical Dementia Rating-Global score (CDR-GS) of 0.5.–1.0. The Quality of Life in Alzheimer ’s Disease (QoL-AD) questionnaire was used to assess health-related quality of life. A battery of self-report instruments was used to evaluate different psychological and behavioral domains. Associations between the QoL-AD and other outcome measures were analyzed using Spearman’s rank correlations. Results: A total of 149 patients were included. Mean age (SD) was 72.3 (7.0) years and mean disease duration was 1.4 (1.8) years. Mean MMSE score was 24.6 (2.1). The mean QoL-AD score was 37.9 (4.5). Eighty-three percent (n = 124) of patients had moderate-to-severe hopelessness, 22.1% (n = 33) had depressive symptoms, and 36.9% (n = 55) felt stigmatized. The quality of life showed a significant positive correlation with self-efficacy and negative correlations with depression, emotional and practical consequences, stigma, and hopelessness. Conclusion: Stigma, depressive symptoms, and hopelessness are frequent scenarios in AD negatively impacting quality of life, even in a population with short disease duration and minimal cognitive impairment.
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Affiliation(s)
- Alberto Villarejo-Galende
- Department of Neurology, Hospital Universitario 12 de Octubre, Instituto de Investigación Hospital 12 de Octubre (I+12), Madrid, Spain
- Networking Research Center on Neurodegenerative Diseases (CIBERNED), Instituto de Salud Carlos III, Madrid, Spain
| | | | - Gerard Piñol-Ripoll
- Cognitive Disorders Unit, Hospital Universitari Santa Maria de Lleida, Institut de Recerca Biomédica de Lleida (IRBLLeida), Lleida, Spain
| | | | - Félix Viñuela
- Instituto Neurológico Andaluz, Hospital Victoria Eugenia, Unidad Deterioro Cognitivo, Hospital Universitario Virgen Macarena, Sevilla, Spain
| | - Mercè Boada
- Networking Research Center on Neurodegenerative Diseases (CIBERNED), Instituto de Salud Carlos III, Madrid, Spain
- Ace Alzheimer Center Barcelona, Universitat Internacional de Catalunya, Barcelona, Spain
| | - Emilio Franco-Macías
- Dementia Unit, Department of Neurology, Hospital Universitario Virgen del Rocío, Instituto de Biomedicina de Sevilla (IBiS), Sevilla, Spain
| | | | - Mario Riverol
- Department of Neurology, Clínica Universidad de Navarra, Universidad de Navarra, Pamplona, Spain
| | - Albert Puig-Pijoan
- Cognitive Impairment and Movement Disorders Unit, Department of Neurology, Hospital del Mar, Hospital Del Mar Medical Research Institute (IMIM), Barcelona, Spain
| | - Pedro Abizanda-Soler
- Department of Geriatrics, Complejo Hospitalario Universitario de Albacete, Albacete, Spain
| | - Rafael Arroyo
- Department of Neurology, Hospital Universitario Quirónsalud, Madrid, Spain
| | - Miquel Baquero-Toledo
- Grup d’Investigació en Malaltia d’Alzheimer, Department of Neurology, Hospital Universitari i Politècnic La Fe, Institut d’Investigació Sanitaria La Fe, Valencia, Spain
| | - Inmaculada Feria-Vilar
- Department of Neurology, Complejo Hospitalario Universitario de Albacete, Albacete, Spain
| | - Mircea Balasa
- Alzheimer’s Disease and other Cognitive Disorders Unit, Hospital Clínic, Institut d’Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - Ángel Berbel
- Department of Neurology, Hospital Central de la Cruz Roja, Madrid, Spain
| | - Eloy Rodríguez-Rodríguez
- Networking Research Center on Neurodegenerative Diseases (CIBERNED), Instituto de Salud Carlos III, Madrid, Spain
- Department of Neurology, Hospital Universitario de Marqués de Valdecilla, Instituto de Investigación Sanitaria Valdecilla (IDIVAL), Universidad de Cantabria, Santander, Spain
| | - Alba Vieira-Campos
- Department of Neurology, Hospital Universitario de La Princesa, Madrid, Spain
| | - Guillermo García-Ribas
- Department of Neurology, Hospital Universitario 12 de Octubre, Instituto de Investigación Hospital 12 de Octubre (I+12), Madrid, Spain
| | - Silvia Rodrigo-Herrero
- Department of Neurology, Hospital Universitario 12 de Octubre, Instituto de Investigación Hospital 12 de Octubre (I+12), Madrid, Spain
| | | | | | - Alberto Lleó
- Networking Research Center on Neurodegenerative Diseases (CIBERNED), Instituto de Salud Carlos III, Madrid, Spain
- Department of Neurology, Hospital Universitario 12 de Octubre, Instituto de Investigación Hospital 12 de Octubre (I+12), Madrid, Spain
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Mohr W, Rädke A, Afi A, Mühlichen F, Platen M, Scharf A, Michalowsky B, Hoffmann W. Development of a Quantitative Preference Instrument for Person-Centered Dementia Care—Stage 2: Insights from a Formative Qualitative Study to Design and Pretest a Dementia-Friendly Analytic Hierarchy Process Survey. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:ijerph19148554. [PMID: 35886406 PMCID: PMC9321359 DOI: 10.3390/ijerph19148554] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/28/2022] [Revised: 07/04/2022] [Accepted: 07/11/2022] [Indexed: 02/05/2023]
Abstract
Person-centered care (PCC) requires knowledge about patient preferences. An analytic hierarchy process (AHP) is one approach to quantify, weigh and rank patient preferences suitable for People living with Dementia (PlwD), due to simple pairwise comparisons of individual criteria from a complex decision problem. The objective of the present study was to design and pretest a dementia-friendly AHP survey. Methods: Two expert panels consisting of n = 4 Dementia Care Managers and n = 4 physicians to ensure content-validity, and “thinking-aloud” interviews with n = 11 PlwD and n = 3 family caregivers to ensure the face validity of the AHP survey. Following a semi-structured interview guide, PlwD were asked to assess appropriateness and comprehensibility. Data, field notes and partial interview transcripts were analyzed with a constant comparative approach, and feedback was incorporated continuously until PlwD had no further comments or struggles with survey completion. Consistency ratios (CRs) were calculated with Microsoft® Excel and ExpertChoice Comparion®. Results: Three main categories with sub-categories emerged: (1) Content: clear task introduction, (sub)criteria description, criteria homogeneity, (sub)criteria appropriateness, retest questions and sociodemography for heterogeneity; (2) Format: survey structure, pairwise comparison sequence, survey length, graphical design (incl. AHP scale), survey procedure explanation, survey assistance and response perspective; and (3) Layout: easy wording, short sentences and visual aids. Individual CRs ranged from 0.08 to 0.859, and the consolidated CR was 0.37 (0.038). Conclusions: Our formative qualitative study provides initial data for the design of a dementia-friendly AHP survey. Consideration of our findings may contribute to face and content validity in future quantitative preference research in dementia.
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Affiliation(s)
- Wiebke Mohr
- German Center for Neurodegenerative Diseases e.V. (DZNE), Site Rostock/Greifswald, Ellernholzstrasse 1-2, D-17487 Greifswald, Germany; (A.R.); (A.A.); (F.M.); (M.P.); (A.S.); (B.M.); (W.H.)
- Correspondence: ; Tel.: +49-3834-8685-37
| | - Anika Rädke
- German Center for Neurodegenerative Diseases e.V. (DZNE), Site Rostock/Greifswald, Ellernholzstrasse 1-2, D-17487 Greifswald, Germany; (A.R.); (A.A.); (F.M.); (M.P.); (A.S.); (B.M.); (W.H.)
| | - Adel Afi
- German Center for Neurodegenerative Diseases e.V. (DZNE), Site Rostock/Greifswald, Ellernholzstrasse 1-2, D-17487 Greifswald, Germany; (A.R.); (A.A.); (F.M.); (M.P.); (A.S.); (B.M.); (W.H.)
| | - Franka Mühlichen
- German Center for Neurodegenerative Diseases e.V. (DZNE), Site Rostock/Greifswald, Ellernholzstrasse 1-2, D-17487 Greifswald, Germany; (A.R.); (A.A.); (F.M.); (M.P.); (A.S.); (B.M.); (W.H.)
| | - Moritz Platen
- German Center for Neurodegenerative Diseases e.V. (DZNE), Site Rostock/Greifswald, Ellernholzstrasse 1-2, D-17487 Greifswald, Germany; (A.R.); (A.A.); (F.M.); (M.P.); (A.S.); (B.M.); (W.H.)
| | - Annelie Scharf
- German Center for Neurodegenerative Diseases e.V. (DZNE), Site Rostock/Greifswald, Ellernholzstrasse 1-2, D-17487 Greifswald, Germany; (A.R.); (A.A.); (F.M.); (M.P.); (A.S.); (B.M.); (W.H.)
| | - Bernhard Michalowsky
- German Center for Neurodegenerative Diseases e.V. (DZNE), Site Rostock/Greifswald, Ellernholzstrasse 1-2, D-17487 Greifswald, Germany; (A.R.); (A.A.); (F.M.); (M.P.); (A.S.); (B.M.); (W.H.)
| | - Wolfgang Hoffmann
- German Center for Neurodegenerative Diseases e.V. (DZNE), Site Rostock/Greifswald, Ellernholzstrasse 1-2, D-17487 Greifswald, Germany; (A.R.); (A.A.); (F.M.); (M.P.); (A.S.); (B.M.); (W.H.)
- Institute for Community Medicine, Section Epidemiology of Health Care and Community Health, University Medicine Greifswald, Ellernholzstrasse 1-2, D-17487 Greifswald, Germany
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Mohr W, Rädke A, Michalowsky B, Hoffmann W. Elicitation of quantitative, choice-based preferences for Person-Centered Care among People living with Dementia in comparison to physicians' judgements in Germany: study protocol for the mixed-methods PreDemCare-study. BMC Geriatr 2022; 22:567. [PMID: 35804302 PMCID: PMC9264751 DOI: 10.1186/s12877-022-03238-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2021] [Accepted: 06/22/2022] [Indexed: 12/27/2022] Open
Abstract
Background Person-Centered-Care (PCC) requires knowledge about patient preferences. Among People-living-with-Dementia (PlwD) data on quantitative, choice-based preferences, which would allow to quantify, weigh and rank patient-relevant elements of dementia-care, and identify most/least preferred choices, are limited. The Analytic-Hierarchy-Process (AHP) may be one approach to elicit quantitative, choice-based preferences with PlwD, due to simple pairwise comparisons of individual criteria from a complex decision-problem, e.g. health care decisions. Furthermore, data on congruence of patient preferences with physicians’ judgements for PCC are missing. If patient preferences and physicians’ judgements differ, provision of PCC becomes unlikely. An understanding of patient preferences compared to physician’s judgements will support the implementation of truly PCC, i.e. state of the art dementia-care aligned with patient preferences. Methods This mixed-methods-study will be based on the results from a previous systematic review and conducted in three phases: (I) literature-based key intervention-categories of PCC will be investigated during qualitative interviews with Dementia-Care-Managers (DCMs) and PlwD to identify actually patient-relevant (sub) criteria of PCC; (II) based on findings from phase I, an AHP-survey will be designed and pre-tested for face- and content-validity, and consistency during face-to-face “thinking-aloud”-interviews with PlwD and two expert panels (DCMs and physicians); (III) the developed survey will elicit patient preferences and physicians’ judgements for PCC. To assess individual importance weights for (sub) criteria in both groups, the Principal-Eigenvector-Method will be applied. Weights will be aggregated per group by Aggregation-of-Individual-Priorities-mode. Descriptive and interferential statistical analyses will be conducted to assess congruence of importance-weights between groups. Subgroup-analyses shall investigate participant-heterogeneities, sensitivity of AHP-results shall be tested by inclusion/exclusion of inconsistent respondents. Discussion Little research is published on quantitative, choice-based preferences in dementia care. We expect that (1) PlwD have preferences and can express these, (2) that the AHP is a suitable technique to elicit quantitative, choice-based preferences among PlwD, and (3) to identify a divergence between patient preferences and physicians’ judgements for PCC. With the help of the AHP-technique, which supports systematic decision-making including multiple criteria, it may be possible to involve PlwD in future care decisions (patient participation) and ensure implementation of truly Person-Centered-Dementia-Care. Trial registration Approval of the study was granted by the Ethics Committee at the University Medicine Greifswald the 09Apr2021 (Reg.-Nr.: BB 018–21, BB 018-21a, BB 018-21b).
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Affiliation(s)
- Wiebke Mohr
- German Center for Neurodegenerative Diseases e.V. (DZNE), Site Rostock / Greifswald, Ellernholzstraße 1-2, 17487, Greifswald, Germany.
| | - Anika Rädke
- German Center for Neurodegenerative Diseases e.V. (DZNE), Site Rostock / Greifswald, Ellernholzstraße 1-2, 17487, Greifswald, Germany
| | - Bernhard Michalowsky
- German Center for Neurodegenerative Diseases e.V. (DZNE), Site Rostock / Greifswald, Ellernholzstraße 1-2, 17487, Greifswald, Germany
| | - Wolfgang Hoffmann
- German Center for Neurodegenerative Diseases e.V. (DZNE), Site Rostock / Greifswald, Ellernholzstraße 1-2, 17487, Greifswald, Germany.,Institute for Community Medicine, University Medicine Greifswald (UMG), Greifswald, Germany
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Development of a Quantitative Instrument to Elicit Patient Preferences for Person-Centered Dementia Care Stage 1: A Formative Qualitative Study to Identify Patient Relevant Criteria for Experimental Design of an Analytic Hierarchy Process. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:ijerph19137629. [PMID: 35805286 PMCID: PMC9266267 DOI: 10.3390/ijerph19137629] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/17/2022] [Revised: 06/15/2022] [Accepted: 06/17/2022] [Indexed: 01/19/2023]
Abstract
Background: Person-centered care (PCC) requires knowledge about patient preferences. This formative qualitative study aimed to identify (sub)criteria of PCC for the design of a quantitative, choice-based instrument to elicit patient preferences for person-centered dementia care. Method: Interviews were conducted with n = 2 dementia care managers, n = 10 People living with Dementia (PlwD), and n = 3 caregivers (CGs), which followed a semi-structured interview guide including a card game with PCC criteria identified from the literature. Criteria cards were shown to explore the PlwD’s conception. PlwD were asked to rank the cards to identify patient-relevant criteria of PCC. Audios were verbatim-transcribed and analyzed with qualitative content analysis. Card game results were coded on a 10-point-scale, and sums and means for criteria were calculated. Results: Six criteria with two sub-criteria emerged from the analysis; social relationships (indirect contact, direct contact), cognitive training (passive, active), organization of care (decentralized structures and no shared decision making, centralized structures and shared decision making), assistance with daily activities (professional, family member), characteristics of care professionals (empathy, education and work experience) and physical activities (alone, group). Dementia-sensitive wording and balance between comprehensibility vs. completeness of the (sub)criteria emerged as additional themes. Conclusions: Our formative study provides initial data about patient-relevant criteria of PCC to design a quantitative patient preference instrument. Future research may want to consider the balance between (sub)criteria comprehensibility vs. completeness.
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Villarejo-Galende A, García-Arcelay E, Piñol-Ripoll G, Del Olmo-Rodríguez A, Viñuela F, Boada M, Franco-Macías E, de la Peña AI, Riverol M, Puig-Pijoan A, Abizanda-Soler P, Arroyo R, Baquero-Toledo M, Feria-Vilar I, Balasa M, Berbel Á, Rodríguez-Rodríguez E, Vieira-Campos A, García-Ribas G, Rodrigo-Herrero S, Lleó A, Maurino J. Awareness of Diagnosis in Persons with Early-Stage Alzheimer's Disease: An Observational Study in Spain. Neurol Ther 2022; 11:1183-1192. [PMID: 35648383 PMCID: PMC9338197 DOI: 10.1007/s40120-022-00367-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2022] [Accepted: 05/13/2022] [Indexed: 01/01/2023] Open
Abstract
Introduction Limited information is available on people’s experiences of living with Alzheimer’s disease (AD) at earlier stages. This study assessed awareness of diagnosis among people with early-stage AD and its impact on different person-centered outcome measures. Methods We conducted an observational, cross-sectional study in 21 memory clinics in Spain. Persons aged 50–90 years, diagnosed with prodromal or mild AD (NIA/AA criteria), a Mini Mental State Examination (MMSE) score ≥ 22, and a Clinical Dementia Rating-Global score (CDR-GS) of 0.5 or 1.0 were recruited. The Representations and Adjustment to Dementia Index (RADIX) was used to assess participants’ beliefs about their condition and its consequences. Results A total of 149 persons with early-stage AD were studied. Mean (SD) age was 72.3 (7.0) years and 50.3% were female. Mean duration of AD was 1.4 (1.8) years. Mean MMSE score was 24.6 (2.1) and 87.2% had a CDR-GS score of 0.5. Most participants (n = 84, 57.5%) used a descriptive term related to specific AD symptoms (e.g., memory difficulties) when asked what they called their condition. Participants aware of their diagnosis using the term AD (n = 66, 45.2%) were younger, had more depressive symptoms, and poorer life satisfaction and quality of life compared to those without awareness of their specific diagnosis. Practical and emotional consequences RADIX scores showed a significant negative correlation with Quality of Life in Alzheimer’s Disease score (rho = − 0.389 and − 0.413, respectively; p < 0.0001). Years of education was the only predictor of awareness of AD diagnosis [OR = 1.04 (95% CI 1.00–1.08); p = 0.029]. Conclusions Awareness of diagnosis was a common phenomenon in persons with early-stage AD negatively impacting their quality of life. Understanding illness representations in earlier stages may facilitate implementing optimized care that supports improved quality of life and well-being.
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Affiliation(s)
- Alberto Villarejo-Galende
- Department of Neurology, Hospital Universitario 12 de Octubre, Instituto de Investigación Hospital 12 de Octubre (I+12), CIBERNED, Madrid, Spain
| | | | - Gerard Piñol-Ripoll
- Unitat Trastorns Cognitius, Hospital Universitari de Santa Maria, Institut de Recerca Biomèdica de Lleida (IRBLLeida), Lleida, Spain
| | | | - Félix Viñuela
- Instituto Neurológico Andaluz, Hospital Victoria Eugenia, Unidad de Deterioro Cognitivo, Hospital Universitario Virgen Macarena, Sevilla, Spain
| | - Mercè Boada
- Ace Alzheimer Center Barcelona, Universitat Internacional de Catalunya, CIBERNED, Barcelona, Spain
| | - Emilio Franco-Macías
- Dementia Unit, Department of Neurology, Hospital Universitario Virgen del Rocío, Instituto de Biomedicina de Sevilla (IBiS), Sevilla, Spain
| | | | - Mario Riverol
- Department of Neurology, Clínica Universidad de Navarra, Pamplona, Spain
| | - Albert Puig-Pijoan
- Cognitive Impairment and Movement Disorders Unit, Department of Neurology, Hospital Del Mar Medical Research Institute (IMIM), Barcelona, Spain
| | - Pedro Abizanda-Soler
- Department of Geriatrics, Complejo Hospitalario Universitario de Albacete, Albacete, Spain
| | - Rafael Arroyo
- Department of Neurology, Hospital Universitario Quirónsalud, Madrid, Spain
| | - Miquel Baquero-Toledo
- Department of Neurology, Hospital Universitari i Politècnic La Fe, Institut d'Investigació Sanitaria La Fe, Valencia, Spain
| | - Inmaculada Feria-Vilar
- Department of Neurology, Complejo Hospitalario Universitario de Albacete, Albacete, Spain
| | - Mircea Balasa
- Alzheimer's Disease and Other Cognitive Disorders Unit, Hospital Clínic, Institut d'Investigacions Biomèdiques August Pi I Sunyer (IDIBAPS), Barcelona, Spain
| | - Ángel Berbel
- Department of Neurology, Hospital Central de la Cruz Roja, Madrid, Spain
| | - Eloy Rodríguez-Rodríguez
- Department of Neurology, Hospital Universitario Marqués de Valdecilla, Instituto de Investigación Sanitaria Valdecilla (IDIVAL), Santander, Spain
| | - Alba Vieira-Campos
- Department of Neurology, Hospital Universitario de La Princesa, Madrid, Spain
| | | | | | - Albert Lleó
- Memory Unit, Department of Neurology, Hospital de La Santa Creu i Sant Pau, Biomedical Research Institute Sant Pau, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Jorge Maurino
- Medical Department, Roche Farma, Ribera del Loira 50, 28042, Madrid, Spain.
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