The 4AT, a rapid delirium detection tool for use in hospice inpatient units: Findings from a validation study

BACKGROUND

Delirium is a serious neuropsychiatric syndrome with adverse outcomes, which is common but often undiagnosed in terminally ill people. The 4 'A's test or 4AT (www.the4AT.com), a brief delirium detection tool, is widely used in general settings, but validation studies in terminally ill people are lacking.

AIM

To determine the diagnostic accuracy of the 4AT in detecting delirium in terminally ill people, who are hospice inpatients.

DESIGN

A diagnostic test accuracy study in which participants underwent the 4AT and a reference standard based on the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders. The reference standard was informed by Delirium Rating Scale Revised-98 and tests assessing arousal and attention. Assessments were conducted in random order by pairs of independent raters, blinded to the results of the other assessment.

SETTING/PARTICIPANTS

Two hospice inpatient units in Scotland, UK. Participants were 148 hospice inpatients aged ⩾18 years.

RESULTS

A total of 137 participants completed both assessments. Three participants had an indeterminate reference standard diagnosis and were excluded, yielding a final sample of 134. Mean age was 70.3 (SD = 10.6) years. About 33% (44/134) had reference standard delirium. The 4AT had a sensitivity of 89% (95% CI 79%-98%) and a specificity of 94% (95% CI 90%-99%). The area under the receiver operating characteristic curve was 0.97 (95% CI 0.94-1).

CONCLUSION

The results of this validation study support use of the 4AT as a delirium detection tool in hospice inpatients, and add to the literature evaluating methods of delirium detection in palliative care settings.

TRIAL REGISTRY

ISCRTN 97417474.

Acceptance and Commitment Therapy (ACT) for people with advanced progressive illness, their caregivers and staff involved in their care: A scoping review

BACKGROUND

People with an advanced progressive illness and their caregivers frequently experience anxiety, uncertainty and anticipatory grief. Traditional approaches to address psychological concerns aim to modify dysfunctional thinking; however, this is limited in palliative care, as often concerns area valid and thought modification is unrealistic. Acceptance and Commitment Therapy is a mindfulness-based behavioural therapy aimed at promoting acceptance and valued living even in difficult circumstances. Evidence on its value in palliative care is emerging.

AIMS

To scope the evidence regarding Acceptance and Commitment Therapy for people with advanced progressive illness, their caregivers and staff involved in their care.

DESIGN

Systematic scoping review using four databases (Medline, PsychInfo, CINAHL and AMED), with relevant MeSH terms and keywords from January 1999 to May 2023.

RESULTS

1,373 papers were identified and 26 were eligible for inclusion. These involved people with advanced progressive illness (n = 14), informal caregivers (n = 4), palliative care staff (n = 3), bereaved carers (n = 3), and mixed groups (n = 2). Intervention studies (n = 15) showed that Acceptance and Commitment Therapy is acceptable and may have positive effects on anxiety, depression, distress, and sleep in palliative care populations. Observational studies (n = 11) revealed positive relationships between acceptance and adjustment to loss and physical function.

CONCLUSION

Acceptance and Commitment Therapy is acceptable and feasible in palliative care, and may improve anxiety, depression, and distress. Full scale mixed-method evaluation studies are now needed to demonstrate effectiveness and cost-effectiveness amongst patients; while further intervention development and feasibility studies are warranted to explore its value for bereaved carers and staff.

Inpatient hospice admissions. Who is admitted and why: a mixed-method prospective study

Background

Over the next two decades, the numbers of people who will need palliative care in the United Kingdom and Ireland is projected to increase. Hospices play a vital role supporting people who require specialist palliative care input through community-based and inpatient palliative care services. Evidence is needed to understand the role of these different services to inform future service development.

Objectives

To describe the reasons for admission, and outcomes at the end of the stay, for patients admitted to two hospice inpatient units (IPUs).

Design

This was a mixed-methods study using a convergent, parallel mixed-methods design.

Methods

We reviewed the case notes of all patients admitted to two hospice inpatient units from July to November 2019; conducted semi-structured interviews with patients and families; as well as brief structured interviews with inpatient unit staff.

Results

Two hundred fifty-nine patients were admitted to a hospice IPU, accounting for 276 admissions in total. Overall, 53% were female; median age was 71 years (range: 26-95 years). Most patients (95%) were White British or Scottish, and 95% had a cancer diagnosis. Most patients were admitted from the community, under one-third were admitted from hospital. Most (85%) had previous palliative care involvement. Nearly, half had district nurse support (48%). Worry and anxiety was frequently reported as a reason for admission, alongside physical concerns. Median length of stay was 12 days, and 68% died during their stay. Hospice was recorded as the preferred place of care for 56% of those who died there.

Conclusions

Sustained efforts to promote the hospice as place of care for people with conditions other than cancer are needed alongside greater clarity regarding of the role of the hospice IPU, and who would benefit most from IPU support.

Feasibility of RESTORE: An online Acceptance and Commitment Therapy intervention to improve palliative care staff wellbeing

BACKGROUND

Acceptance and Commitment Therapy is a form of Cognitive Behavioural Therapy which uses behavioural psychology, values, acceptance and mindfulness techniques to improve mental health and wellbeing. Acceptance and Commitment Therapy is efficacious in treating stress, anxiety and depression in a broad range of settings including occupational contexts where emotional labour is high. This approach could help palliative care staff to manage work-related stress and promote wellbeing.

AIM

To develop, and feasibility test, an online Acceptance and Commitment Therapy intervention to improve wellbeing of palliative care staff.

DESIGN

A single-arm feasibility trial of an 8-week Acceptance and Commitment Therapy based intervention for staff, consisting of three online facilitated group workshops and five online individual self-directed learning modules. Data was collected via online questionnaire at four time-points and online focus groups at follow-up.

SETTING/PARTICIPANTS

Participants were recruited from Marie Curie hospice and nursing services in Scotland.

RESULTS

Twenty five staff commenced and 23 completed the intervention (93%). Fifteen participated in focus groups. Twelve (48%) completed questionnaires at follow-up. Participants found the intervention enjoyable, informative and beneficial. There was preliminary evidence for improvements in psychological flexibility (Cohen's d = 0.7) and mental wellbeing (Cohen's d = 0.49) between baseline and follow-up, but minimal change in perceived stress, burnout or compassion satisfaction.

CONCLUSION

Online Acceptance and Commitment Therapy for wellbeing is acceptable to palliative care staff and feasible to implement using Microsoft Teams in a palliative care setting. Incorporating ways to promote long-term maintenance of behaviour changes, and strategies to optimise data collection at follow-up are key considerations for future intervention refinement and evaluation.

'There's something about admitting that you are lonely' - prevalence, impact and solutions to loneliness in terminal illness: An explanatory sequential multi-methods study

BACKGROUND

Loneliness is a prevalent societal issue and can impact on a person's physical and mental health. It is unclear how loneliness impacts on end of life experiences or how such feelings can be alleviated.

AIM

To explore the perceived prevalence, impact and possible solutions to loneliness among people who are terminally ill and their carers in Northern Ireland through the lens of health and social care professionals.

DESIGN

An explanatory multi-method study.

SETTING/PARTICIPANTS

An online survey (n = 68, response rate 30%) followed by three online focus groups with palliative and end of life care health and social care professionals (n = 14). Data were analysed using descriptive statistics and thematic analysis.

RESULTS

Loneliness was perceived by professionals as highly prevalent for people with a terminal illness (92.6%) and their carers (86.8%). Loneliness was considered a taboo subject and impacts on symptoms including pain and breathlessness and overall wellbeing at end of life. Social support was viewed as central towards alleviating feelings of loneliness and promoting connectedness at end of life. Four themes were identified: (1) the stigma of loneliness, (2) COVID-19: The loneliness pandemic (3) impact of loneliness across physical and mental health domains and (4) the power of social networks.

CONCLUSION

There is a need for greater investment for social support initiatives to tackle experiences of loneliness at end of life. These services must be co-produced with people impacted by terminal illness to ensure they meet the needs of this population.

Exploration of delirium assessment and management in a hospice inpatient unit

Background: Delirium is common across all palliative care settings. Guidelines exist to support the care of terminally ill people who develop delirium; yet the evidence base is limited. Recent surveys of palliative care specialists have suggested clinical practice is variable. Aim: To explore delirium assessment and management in a hospice inpatient setting. Methods: A mixed-methods study comprising a retrospective case note review of 21 patients admitted to a hospice inpatient unit and semi-structured interviews with seven hospice inpatient doctors and nurses. Results: A total of 62% of patients were screened for delirium on admission using the 4 As tool (4AT). The period prevalence of delirium was 76% during the 2-week study period. The term ‘delirium’ was documented infrequently in case notes, compared to other more ambiguous terms. Interview data suggested that nurses were unfamiliar with delirium screening tools. Conclusion: Lack of awareness about delirium screening tools and the infrequent use of the term ‘delirium’ may suggest that delirium goes under-recognised and under-treated. Further education and research are required to support the care of terminally ill people with delirium.

Communication of palliative care needs in discharge letters from hospice providers to primary care: a multisite sequential explanatory mixed methods study

Background

The provision of palliative care is increasing, with many people dying in community-based settings. It is essential that communication is effective if and when patients transition from hospice to community palliative care. Past research has indicated that communication issues are prevalent during hospital discharges, but little is known about hospice discharges.

Methods

An explanatory sequential mixed methods study consisting of a retrospective review of hospice discharge letters, followed by hospice focus groups, to explore patterns in communication of palliative care needs of discharged patients and describe why these patients were being discharged. Discharge letters were extracted for key content information using a standardised form. Letters were then examined for language patterns using a linguistic methodology termed corpus linguistics. Thematic analysis was used to analyse the focus group transcripts. Findings were triangulated to develop an explanatory understanding of discharge communication from hospice care.

Results

We sampled 250 discharge letters from five UK hospices whereby patients had been discharged to primary care. Twenty-five staff took part in focus groups. The main reasons for discharge extracted from the letters were symptoms “managed/resolved” (75.2%), and/or the “patient wishes to die/for care at home” (37.2%). Most patients had some form of physical needs documented on the letters (98.4%) but spiritual needs were rarely documented (2.4%). Psychological/emotional needs and social needs were documented in 46.4 and 35.6% of letters respectively. There was sometimes ambiguity in “who” will be following up “what” in the discharge letters, and whether described patients’ needs were resolved or ongoing for managing in the community setting. The extent to which patients received a copy of their discharge letter varied. Focus groups conveyed a lack of consensus on what constitutes “complexity” and “complex pain”.

Conclusions

The content and structure of discharge letters varied between hospices, although generally focused on physical needs. Our study provides insights into patterns associated with those discharged from hospice, and how policy and guidance in this area may be improved, such as greater consistency of sharing letters with patients. A patient-centred set of hospice-specific discharge letter principles could help improve future practice.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12904-022-01038-8.

An analysis of the construct validity and responsiveness of the ICECAP-SCM capability wellbeing measure in a palliative care hospice setting

BACKGROUND

For outcome measures to be useful in health and care decision-making, they need to have certain psychometric properties. The ICECAP-Supportive Care Measure (ICECAP-SCM), a seven attribute measure (1. Choice, 2. Love and affection, 3. Physical suffering, 4. Emotional suffering, 5. Dignity, 6. Being supported, 7. Preparation) developed for use in economic evaluation of end-of-life interventions, has face validity and is feasible to use. This study aimed to assess the construct validity and responsiveness of the ICECAP-SCM in hospice inpatient and outpatient settings.

METHODS

A secondary analysis of data collated from two studies, one focusing on palliative care day services and the other on constipation management, undertaken in the same national hospice organisation across three UK hospices, was conducted. Other quality of life and wellbeing outcome measures used were the EQ-5D-5L, McGill Quality of Life Questionnaire - Expanded (MQOL-E), Patient Health Questionnaire-2 (PHQ-2) and Palliative Outcomes Scale Symptom list (POS-S). The construct validity of the ICECAP-SCM was assessed, following hypotheses generation, by calculating correlations between: (i) its domains and the domains of other outcome measures, (ii) its summary score and the other measures' domains, (iii) its summary score and the summary scores of the other measures. The responsiveness of the ICECAP-SCM was assessed using anchor-based methods to understand change over time. Statistical analysis consisted of Spearman and Pearson correlations for construct validity and paired t-tests for the responsiveness analysis.

RESULTS

Sixty-eight participants were included in the baseline analysis. Five strong correlations were found with ICECAP-SCM attributes and items on the other measures: four with the Emotional suffering attribute (Anxiety/depression on EQ-5D-5L, Psychological and Burden on MQOL-E and Feeling down, depressed or hopeless on PHQ-2), and one with Physical suffering (Weakness or lack of energy on POS-S). ICECAP-SCM attributes and scores were most strongly associated with the MQOL-E measure (0.73 correlation coefficient between summary scores). The responsiveness analysis (n = 36) showed the ICECAP-SCM score was responsive to change when anchored to changes on the MQOL-E over time (p < 0.05).

CONCLUSIONS

This study provides initial evidence of construct validity and responsiveness of the ICECAP-SCM in hospice settings and suggests its potential for use in end-of-life care research.

Changes in mortality patterns and place of death during the COVID-19 pandemic: A descriptive analysis of mortality data across four nations

BACKGROUND

Understanding patterns of mortality and place of death during the COVID-19 pandemic is important to help provide appropriate services and resources.

AIMS

To analyse patterns of mortality including place of death in the United Kingdom (UK) (England, Wales, Scotland and Northern Ireland) during the COVID-19 pandemic to date.

DESIGN

Descriptive analysis of UK mortality data between March 2020 and March 2021. Weekly number of deaths was described by place of death, using the following definitions: (1) expected deaths: average expected deaths estimated using historical data (2015-19); (2) COVID-19 deaths: where COVID-19 is mentioned on the death certificate; (3) additional non-COVID-19 deaths: above expected but not attributed to COVID-19; (4) baseline deaths: up to and including expected deaths but excluding COVID-19 deaths.

RESULTS

During the analysis period, 798,643 deaths were registered in the UK, of which 147,282 were COVID-19 deaths and 17,672 were additional non-COVID-19 deaths. While numbers of people who died in care homes and hospitals increased above expected only during the pandemic waves, the numbers of people who died at home remained above expected both during and between the pandemic waves, with an overall increase of 41%.

CONCLUSIONS

Where people died changed during the COVID-19 pandemic, with an increase in deaths at home during and between pandemic waves. This has implications for planning and organisation of palliative care and community services. The extent to which these changes will persist longer term remains unclear. Further research could investigate whether this is reflected in other countries with high COVID-19 mortality.

Brief Engagement and Acceptance Coaching for Hospice Settings (the BEACHeS study): results from a Phase I study of acceptability and initial effectiveness in people with non-curative cancer

Objectives

Transitioning into palliative care is psychologically demanding for people with advanced cancer, and there is a need for acceptable and effective interventions to support this. We aimed to develop and pilot test a brief Acceptance and Commitment Therapy (ACT) based intervention to improve quality of life and distress.

Methods

Our mixed-method design included: (i) quantitative effectiveness testing using Single Case Experimental Design (SCED), (ii) qualitative interviews with participants, and (iii) focus groups with hospice staff. The five-session, in-person intervention was delivered to 10 participants; five completed at least 80%.

Results

At baseline, participants reported poor quality of life but low distress. Most experienced substantial physical health deterioration during the study. SCED analysis methods did not show conclusively significant effects, but there was some indication that outcome improvement followed changes in expected intervention processes variables. Quantitative and qualitative data together demonstrates acceptability, perceived effectiveness and safety of the intervention. Qualitative interviews and focus groups were also used to gain feedback on intervention content and to make design recommendations to maximise success of later feasibility trials.

Conclusions

This study adds to the growing evidence base for ACT in people with advanced cancer. A number of potential intervention mechanisms, for example a distress-buffering hypothesis, are raised by our data and these should be addressed in future research using randomised controlled trial designs. Our methodological recommendations—including recruiting non-cancer diagnoses, and earlier in the treatment trajectory—likely apply more broadly to the delivery of psychological intervention in the palliative care setting.

This study was pre-registered on the Open Science Framework (Ref: 46,033) and retrospectively registered on the ISRCTN registry (Ref: ISRCTN12084782).

Validation of the 4AT tool for delirium assessment in specialist palliative care settings: protocol of a prospective diagnostic test accuracy study [version 1; peer review: 2 approved]

BACKGROUND

Delirium is a serious and distressing neuropsychiatric condition, which is prevalent across all palliative care settings. Hypoactive delirium is particularly common, but difficult to recognize, partly due to overlapping symptoms with depression and dementia. Delirium screening tools can lead to earlier identification and hence better management of patients. The 4AT (4 'A's Test) is a brief tool for delirium detection, designed for use in clinical practice. It has been validated in 17 studies in over 3,700 patients. The test is currently used in specialist palliative care units, but has not been validated in this setting. The aim of the study is to determine the diagnostic accuracy of the 4AT for delirium detection against a reference standard, in hospice inpatients.

METHODS

240 participants will be recruited from the inpatient units of two hospices in Scotland. If a patient lacks capacity to consent, agreement will be sought from a legal proxy. Each participant will complete the 4AT and a reference standard assessment based on the diagnostic delirium criteria in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). This will be supplemented by tests of cognition and attention, including reverse days of the week, counting down from 20 to 1, Vigilance 'A', the Observational Scale for Level of Arousal, the modified Richmond Agitation Sedation Scale and the Delirium Rating Scale-Revised-98. The assessments will be conducted in a randomized order by two independent clinicians, who will be blinded to the results until both are complete. Primary outcomes will be the sensitivity and specificity of the 4AT in detecting delirium.

DISCUSSION

The findings will inform clinical practice regarding delirium assessment in palliative care settings.

TRIAL REGISTRATION

ISRCTN ISRCTN97417474 (21/02/2020).

Digital health interventions in palliative care: a systematic meta-review

Digital health interventions (DHIs) have the potential to improve the accessibility and effectiveness of palliative care but heterogeneity amongst existing systematic reviews presents a challenge for evidence synthesis. This meta-review applied a structured search of ten databases from 2006 to 2020, revealing 21 relevant systematic reviews, encompassing 332 publications. Interventions delivered via videoconferencing (17%), electronic healthcare records (16%) and phone (13%) were most frequently described in studies within reviews. DHIs were typically used in palliative care for education (20%), symptom management (15%), decision-making (13%), information provision or management (13%) and communication (9%). Across all reviews, mostly positive impacts were reported on education, information sharing, decision-making, communication and costs. Impacts on quality of life and physical and psychological symptoms were inconclusive. Applying AMSTAR 2 criteria, most reviews were judged as low quality as they lacked a protocol or did not consider risk of bias, so findings need to be interpreted with caution.

How many people will need palliative care in Scotland by 2040? A mixed-method study of projected palliative care need and recommendations for service delivery

OBJECTIVE

To estimate future palliative care need and complexity of need in Scotland, and to identify priorities for future service delivery.

DESIGN

We estimated the prevalence of palliative care need by analysing the proportion of deaths from defined chronic progressive illnesses. We described linear projections up to 2040 using national death registry data and official mortality forecasts. An expert consultation and subsequent online consensus survey generated recommendations on meeting future palliative care need.

SETTING

Scotland, population of 5.4 million.

PARTICIPANTS

All decedents in Scotland over 11 years (2007 to 2017). The consultation had 34 participants; 24 completed the consensus survey.

PRIMARY AND SECONDARY OUTCOMES

Estimates of past and future palliative care need in Scotland from 2007 up to 2040. Multimorbidity was operationalised as two or more registered causes of death from different disease groups (cancer, organ failure, dementia, other). Consultation and survey data were analysed descriptively.

RESULTS

We project that by 2040, the number of people requiring palliative care will increase by at least 14%; and by 20% if we factor in multimorbidity. The number of people dying from multiple diseases associated with different disease groups is projected to increase from 27% of all deaths in 2017 to 43% by 2040. To address increased need and complexity, experts prioritised sustained investment in a national digital platform, roll-out of integrated electronic health and social care records; and approaches that remain person-centred.

CONCLUSIONS

By 2040 more people in Scotland are projected to die with palliative care needs, and the complexity of need will increase markedly. Service delivery models must adapt to serve growing demand and complexity associated with dying from multiple diseases from different disease groups. We need sustained investment in secure, accessible, integrated and person-centred health and social care digital systems, to improve care coordination and optimise palliative care for people across care settings.

Shared electronic care coordination systems following referral to hospice

In Scotland, the Key Information Summary (KIS) enables health providers to access key patient information to guide decision-making out-of-hours. KISs are generated in primary care and rely on information from other teams, such as community specialist palliative care teams (CSPCTs), to keep them up-to-date. This study involved a service evaluation consisting of case note reviews of new referrals to a CSPCT and semi-structured interviews with palliative care community nurse specialists (CNSs) regarding their perspectives on KISs. Some 44 case notes were examined, and 77% of patients had a KIS on CSPCT referral. One-month post-referral, all those re-examined (n=17) had a KIS, and 59% KISs had been updated following CNS assessments. CNSs cited anticipatory care planning (ACP) as the most useful aspect of KIS, and the majority of CNSs said they would appreciate KIS editing access. A system allowing CNSs to update KISs would be acceptable to CNSs, as it could facilitate care co-ordination and potentially improve comprehensiveness of ACP information held in KISs.

What makes palliative care needs "complex"? A multisite sequential explanatory mixed methods study of patients referred for specialist palliative care

BACKGROUND

Specialist palliative care (SPC) providers tend to use the term 'complex' to refer to the needs of patients who require SPC. However, little is known about complex needs on first referral to a SPC service. We examined which needs are present and sought the perspectives of healthcare professionals on the complexity of need on referral to a hospice service.

METHODS

Multi-site sequential explanatory mixed method study consisting of a case-note review and focus groups with healthcare professionals in four UK hospices.

RESULTS

Documentation relating to 239 new patient referrals to hospice was reviewed; and focus groups involving 22 healthcare professionals conducted. Most patients had two or more needs documented on referral (96%); and needs were recorded across two or more domains for 62%. Physical needs were recorded for 91% of patients; psychological needs were recorded for 59%. Spiritual needs were rarely documented. Referral forms were considered limited for capturing complex needs. Referrals were perceived to be influenced by the experience and confidence of the referrer and the local resource available to meet palliative care needs directly.

CONCLUSIONS

Complexity was hard to detail or to objectively define on referral documentation alone. It appeared to be a term used to describe patients whom primary or secondary care providers felt needed SPC knowledge or support to meet their needs. Hospices need to provide greater clarity regarding who should be referred, when and for what purpose. Education and training in palliative care for primary care nurses and doctors and hospital clinicians could reduce the need for referral and help ensure that hospices are available to those most in need of SPC input.

Unscheduled and out-of-hours care for people in their last year of life: a retrospective cohort analysis of national datasets

OBJECTIVES

To analyse patterns of use and costs of unscheduled National Health Service (NHS) services for people in the last year of life.

DESIGN

Retrospective cohort analysis of national datasets with application of standard UK costings.

PARTICIPANTS AND SETTING

All people who died in Scotland in 2016 aged 18 or older (N=56 407).

MAIN OUTCOME MEASURES

Frequency of use of the five unscheduled NHS services in the last 12 months of life by underlying cause of death, patient demographics, Continuous Unscheduled Pathways (CUPs) followed by patients during each care episode, total NHS and per-patient costs.

RESULTS

53 509 patients (94.9%) had at least one contact with an unscheduled care service during their last year of life (472 360 contacts), with 34.2% in the last month of life. By linking patient contacts during each episode of care, we identified 206 841 CUPs, with 133 980 (64.8%) starting out-of-hours. People with cancer were more likely to contact the NHS telephone advice line (63%) (χ² (4)=1004, p<0.001) or primary care out-of-hours (62%) (χ² (4)=1924,p<0.001) and have hospital admissions (88%) (χ² (4)=2644, p<0.001). People with organ failure (79%) contacted the ambulance service most frequently (χ² (4)=584, p<0.001). Demographic factors associated with more unscheduled care were older age, social deprivation, living in own home and dying of cancer. People dying with organ failure formed the largest group in the cohort and had the highest NHS costs as a group. The cost of providing services in the community was estimated at 3.9% of total unscheduled care costs despite handling most out-of-hours calls.

CONCLUSIONS

Over 90% of people used NHS unscheduled care in their last year of life. Different underlying causes of death and demographic factors impacted on initial access and subsequent pathways of care. Managing more unscheduled care episodes in the community has the potential to reduce hospital admissions and overall costs.

Changing patterns of mortality during the COVID-19 pandemic: Population-based modelling to understand palliative care implications

BACKGROUND

COVID-19 has directly and indirectly caused high mortality worldwide.

AIM

To explore patterns of mortality during the COVID-19 pandemic and implications for palliative care, service planning and research.

DESIGN

Descriptive analysis and population-based modelling of routine data.

PARTICIPANTS AND SETTING

All deaths registered in England and Wales between 7 March and 15 May 2020. We described the following mortality categories by age, gender and place of death: (1) baseline deaths (deaths that would typically occur in a given period); (2) COVID-19 deaths and (3) additional deaths not directly attributed to COVID-19. We estimated the proportion of people who died from COVID-19 who might have been in their last year of life in the absence of the pandemic using simple modelling with explicit assumptions.

RESULTS

During the first 10 weeks of the pandemic, there were 101,614 baseline deaths, 41,105 COVID-19 deaths and 14,520 additional deaths. Deaths in care homes increased by 220%, while home and hospital deaths increased by 77% and 90%, respectively. Hospice deaths fell by 20%. Additional deaths were among older people (86% aged ⩾ 75 years), and most occurred in care homes (56%) and at home (43%). We estimate that 22% (13%-31%) of COVID-19 deaths occurred among people who might have been in their last year of life in the absence of the pandemic.

CONCLUSION

The COVID-19 pandemic has led to a surge in palliative care needs. Health and social care systems must ensure availability of palliative care to support people with severe COVID-19, particularly in care homes.

Exploring the costs, consequences and efficiency of three types of palliative care day services in the UK: a pragmatic before-and-after descriptive cohort study

Background

Palliative Care Day Services (PCDS) offer supportive care to people with advanced, progressive illness who may be approaching the end of life. Despite the growth of PCDS in recent years, evidence of their costs and effects is scarce. It is important to establish the value of such services so that health and care decision-makers can make evidence-based resource allocation decisions. This study examines and estimates the costs and effects of PCDS with different service configurations in three centres across the UK in England, Scotland and Northern Ireland.

Methods

People who had been referred to PCDS were recruited between June 2017 and September 2018. A pragmatic before-and-after descriptive cohort study design analysed data on costs and outcomes. Data on costs were collected on health and care use in the 4 weeks preceding PCDS attendance using adapted versions of the Client Service Receipt Inventory (CSRI). Outcomes, cost per attendee/day and volunteer contribution to PCDS were also estimated. Outcomes included quality of life (MQOL-E), health status (EQ-5D-5L) and capability wellbeing (ICECAP-SCM).

Results

Thirty-eight attendees were recruited and provided data at baseline and 4 weeks (centre 1: n = 8; centre 2: n = 8, centre 3: n = 22). The cost per attendee/day ranged from £121–£190 (excluding volunteer contribution) to £172–£264 (including volunteer contribution) across the three sites. Volunteering constituted between 28 and 38% of the total cost of PCDS provision. There was no significant mean change at 4 week follow-up from baseline for health and care costs (centre 1: £570, centre 2: -£1127, centre 3: £65), or outcomes: MQOL-E (centre 1: − 0.48, centre 2: 0.01, centre 3: 0.24); EQ-5D-5L (centre 1: 0.05, centre 2: 0.03, centre 3: − 0.03) and ICECAP-SCM (centre 1:0.00, centre 2: − 0.01, centre 3: 0.03). Centre costs variation is almost double per attendee when attendance rates are held constant in scenario analysis.

Conclusions

This study highlights the contribution made by volunteers to PCDS provision. There is insufficient evidence on whether outcomes improved, or costs were reduced, in the three different service configurations for PCDS. We suggest how future research may overcome some of the challenges we encountered, to better address questions of cost-effectiveness in PCDS.

Drug therapy for delirium in terminally ill adults

BACKGROUND

Delirium is a syndrome characterised by an acute disturbance of attention and awareness which develops over a short time period and fluctuates in severity over the course of the day. It is commonly experienced during inpatient admission in the terminal phase of illness. It can cause symptoms such as agitation and hallucinations and is distressing for terminally ill people, their families and staff. Delirium may arise from any number of causes and treatment should aim to address these causes. When this is not possible, or treatment is unsuccessful, drug therapy to manage the symptoms may become necessary. This is the second update of the review first published in 2004.

OBJECTIVES

To evaluate the effectiveness and safety of drug therapies to manage delirium symptoms in terminally ill adults.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, CINAHL and PsycINFO from inception to July 2019, reference lists of retrieved papers, and online trial registries.

SELECTION CRITERIA

We included randomised controlled trials of drug therapies in any dose by any route, compared to another drug therapy, a non-pharmacological approach, placebo, standard care or wait-list control, for the management of delirium symptoms in terminally ill adults (18 years or older).

DATA COLLECTION AND ANALYSIS

We independently screened citations, extracted data and assessed risk of bias. Primary outcomes were delirium symptoms; agitation score; adverse events. Secondary outcomes were: use of rescue medication; cognitive status; survival. We applied the GRADE approach to assess the overall quality of the evidence for each outcome and we include eight 'Summary of findings' tables.

MAIN RESULTS

We included four studies (three new to this update), with 399 participants. Most participants had advanced cancer or advanced AIDS, and mild- to moderate-severity delirium. Meta-analysis was not possible because no two studies examined the same comparison. Each study was at high risk of bias for at least one criterion. Most evidence was low to very low quality, downgraded due to very serious study limitations, imprecision or because there were so few data. Most studies reported delirium symptoms; two reported agitation scores; three reported adverse events with data on extrapyramidal effects; and none reported serious adverse events. 1. Haloperidol versus placebo There may be little to no difference between placebo and haloperidol in delirium symptoms within 24 hours (mean difference (MD) 0.34, 95% confidence interval (CI) -0.07 to 0.75; 133 participants). Haloperidol may slightly worsen delirium symptoms compared with placebo at 48 hours (MD 0.49, 95% CI 0.10 to 0.88; 123 participants with mild- to moderate-severity delirium). Haloperidol may reduce agitation slightly compared with placebo between 24 and 48 hours (MD -0.14, 95% -0.28 to -0.00; 123 participants with mild- to moderate-severity delirium). Haloperidol probably increases extrapyramidal adverse effects compared with placebo (MD 0.79, 95% CI 0.17 to 1.41; 123 participants with mild- to moderate-severity delirium). 2. Haloperidol versus risperidone There may be little to no difference in delirium symptoms with haloperidol compared with risperidone within 24 hours (MD -0.42, 95% CI -0.90 to 0.06; 126 participants) or 48 hours (MD -0.36, 95% CI -0.92 to 0.20; 106 participants with mild- to moderate-severity delirium). Agitation scores and adverse events were not reported for this comparison. 3. Haloperidol versus olanzapine We are uncertain whether haloperidol reduces delirium symptoms compared with olanzapine within 24 hours (MD 2.36, 95% CI -0.75 to 5.47; 28 participants) or 48 hours (MD 1.90, 95% CI -1.50 to 5.30, 24 participants). Agitation scores and adverse events were not reported for this comparison. 4. Risperidone versus placebo Risperidone may slightly worsen delirium symptoms compared with placebo within 24 hours (MD 0.76, 95% CI 0.30 to 1.22; 129 participants); and at 48 hours (MD 0.85, 95% CI 0.32 to 1.38; 111 participants with mild- to moderate-severity delirium). There may be little to no difference in agitation with risperidone compared with placebo between 24 and 48 hours (MD -0.05, 95% CI -0.19 to 0.09; 111 participants with mild- to moderate-severity delirium). Risperidone may increase extrapyramidal adverse effects compared with placebo (MD 0.73 95% CI 0.09 to 1.37; 111 participants with mild- to moderate-severity delirium). 5. Lorazepam plus haloperidol versus placebo plus haloperidol We are uncertain whether lorazepam plus haloperidol compared with placebo plus haloperidol improves delirium symptoms within 24 hours (MD 2.10, 95% CI -1.00 to 5.20; 50 participants with moderate to severe delirium), reduces agitation within 24 hours (MD 1.90, 95% CI 0.90 to 2.80; 52 participants), or increases adverse events (RR 0.70, 95% CI -0.19 to 2.63; 31 participants with moderate to severe delirium). 6. Haloperidol versus chlorpromazine We are uncertain whether haloperidol reduces delirium symptoms compared with chlorpromazine at 48 hours (MD 0.37, 95% CI -4.58 to 5.32; 24 participants). Agitation scores were not reported. We are uncertain whether haloperidol increases adverse events compared with chlorpromazine (MD 0.46, 95% CI -4.22 to 5.14; 24 participants). 7. Haloperidol versus lorazepam We are uncertain whether haloperidol reduces delirium symptoms compared with lorazepam at 48 hours (MD -4.88, 95% CI -9.70 to 0.06; 17 participants). Agitation scores were not reported. We are uncertain whether haloperidol increases adverse events compared with lorazepam (MD -6.66, 95% CI -14.85 to 1.53; 17 participants). 8. Lorazepam versus chlorpromazine We are uncertain whether lorazepam reduces delirium symptoms compared with chlorpromazine at 48 hours (MD 5.25, 95% CI 0.38 to 10.12; 19 participants), or increases adverse events (MD 7.12, 95% CI 1.08 to 15.32; 18 participants). Agitation scores were not reported.

SECONDARY OUTCOMES

use of rescue medication, cognitive impairment, survival There were insufficient data to draw conclusions or assess GRADE.

AUTHORS' CONCLUSIONS

We found no high-quality evidence to support or refute the use of drug therapy for delirium symptoms in terminally ill adults. We found low-quality evidence that risperidone or haloperidol may slightly worsen delirium symptoms of mild to moderate severity for terminally ill people compared with placebo. We found moderate- to low-quality evidence that haloperidol and risperidone may slightly increase extrapyramidal adverse events for people with mild- to moderate-severity delirium. Given the small number of studies and participants on which current evidence is based, further research is essential.

The impact of population ageing on end-of-life care in Scotland: projections of place of death and recommendations for future service provision

BACKGROUND

Global annual deaths are rising. It is essential to examine where future deaths may occur to facilitate decisions regarding future service provision and resource allocation.

AIMS

To project where people will die from 2017 to 2040 in an ageing country with advanced integrated palliative care, and to prioritise recommendations based on these trends.

METHODS

Population-based trend analysis of place of death for people that died in Scotland (2004-2016) and projections using simple linear modelling (2017-2040); Transparent Expert Consultation to prioritise recommendations in response to projections.

RESULTS

Deaths are projected to increase by 15.9% from 56,728 in 2016 (32.8% aged 85+ years) to 65,757 deaths in 2040 (45% aged 85+ years). Between 2004 and 2016, proportions of home and care home deaths increased (19.8-23.4% and 14.5-18.8%), while the proportion of hospital deaths declined (58.0-50.1%). If current trends continue, the numbers of deaths at home and in care homes will increase, and two-thirds will die outside hospital by 2040. To sustain current trends, priorities include: 1) to increase and upskill a community health and social care workforce through education, training and valuing of care work; 2) to build community care capacity through informal carer support and community engagement; 3) to stimulate a realistic public debate on death, dying and sustainable funding.

CONCLUSION

To sustain current trends, health and social care provision in the community needs to grow to support nearly 60% more people at the end-of-life by 2040; otherwise hospital deaths will increase.

17 Key information summary (KIS) generation for people who died in scotland in 2017: a mixed methods study

Introduction

The percentage of people with a key information summary (KIS) or an anticipatory care plan (ACP) at the time of death can act as an indicator of access to palliative care. Key information summaries (KIS) introduced throughout Scotland in 2013, are shared electronic patient records which contain essential information relevant to a patient’s care including palliative care. There is now a need to examine current levels of KIS generation and ACP documentation in the last months of life to assess progress and review barriers and facilitators to sharing patient information across settings and to inform out-of-hours care.

Aims

To estimate the extent and timing of KIS and ACP generation for people who die with an advanced progressive condition and to compare with our previous study (Tapsfield et al. 2016).

To explore GP experiences of commencing and updating a KIS; and their perspectives on what works well and what can be improved in supporting this process.

Methods

A mixed methods study consisting of a retrospective review of the electronic records of all patients who died in 16 Scottish general practices in 2017 and semi-structured interviews with 16 GPs.

Results

Quantitative and qualitative data collection is in progress.

Conclusion

Findings will describe current levels of KIS and ACP documentation for people who die in Scotland. We will synthesize GP experiences of KIS use and describe the essential components of an ACP that need to be documented to enable good palliative care across settings including emergency and out-of-hours care.

Reference

. Tapsfield J, Hall C, Lunan C, McCutheon H, McLoughlin P, Rhee J, Rus A, Spiller J, Finucane AM, Murray SA. Many people in Scotland now benefit from anticipatory care before they die: An after death analysis and interviews with general practitioners. BMJ Supportive and Palliative Care2016. doi:10.1136/bmjspcare-2015-001014

15 Triggers for the pharmacological management of delirium in palliative care: a mixed methods study

Introduction

Delirium is a serious neurocognitive disorder with a high prevalence in palliative care and debate regarding its management is ongoing.

Aims

To describe how delirium and its symptoms is documented in patient records

To determine the use of delirium screening tools and how these are viewed by staff

To identify triggers for pharmacological intervention in delirium management in a terminally ill population.

Methods

A retrospective case-note review concerning all patients admitted to a hospice inpatient setting between 1–17th August 2017 and semi-structured interviews with 7 hospice doctors and nurses.

Results

21 patients were reviewed. 62% were screened for delirium using the 4AT on admission. 76% had documented symptoms of delirium and of these 81% died without delirium resolution. There were inconsistencies in the documentation of delirium and the term itself was used infrequently. Non-pharmacological measures were poorly documented. Midazolam was the most commonly used medication. Triggers for pharmacological intervention included failure of non-pharmacological measures distress agitation and risk of patient harm. Nursing staff recognised delirium in its severe form but were less likely to do so in milder cases.

Conclusions

Triggers for pharmacological intervention are in-keeping with guidelines however the level of understanding of delirium’s presentation varied between participants. This along with the high prevalence of delirium frequent use of midazolam and limited awareness and documentation of non-pharmacological measures (e.g. structured family support) highlights the need for further training and research.

Palliative and end-of-life care research in Scotland 2006-2015: a systematic scoping review

Background

The Scottish Government set out its 5-year vision to improve palliative care in its Strategic Framework for Action 2016–2021. This includes a commitment to strengthening research and evidence based knowledge exchange across Scotland. A comprehensive scoping review of Scottish palliative care research was considered an important first step. The aim of the review was to quantify and map palliative care research in Scotland over the ten-year period preceding the new strategy (2006–15).

Methods

A systematic scoping review was undertaken. Palliative care research involving at least one co-author from a Scottish institution was eligible for inclusion. Five databases were searched with relevant MeSH terms and keywords; additional papers authored by members of the Scottish Palliative and End of Life Care Research Forum were added.

Results

In total, 1919 papers were screened, 496 underwent full text review and 308 were retained in the final set. 73% were descriptive studies and 10% were interventions or feasibility studies. The top three areas of research focus were services and settings; experiences and/or needs; and physical symptoms. 58 papers were concerned with palliative care for people with conditions other than cancer – nearly one fifth of all papers published. Few studies focused on ehealth, health economics, out-of-hours and public health. Nearly half of all papers described unfunded research or did not acknowledge a funder (46%).

Conclusions

There was a steady increase in Scottish palliative care research during the decade under review. Research output was strong compared with that reported in an earlier Scottish review (1990–2005) and a similar review of Irish palliative care research (2002–2012). A large amount of descriptive evidence exists on living and dying with chronic progressive illness in Scotland; intervention studies now need to be prioritised. Areas highlighted for future research include palliative interventions for people with non-malignant illness and multi-morbidity; physical and psychological symptom assessment and management; interventions to support carers; and bereavement support. Knowledge exchange activities are required to disseminate research findings to research users and a follow-up review to examine future research progress is recommended.

Electronic supplementary material

The online version of this article (10.1186/s12904-017-0266-0) contains supplementary material, which is available to authorized users.

Experience of emotion in frail older people towards the end of life: A secondary data analysis

People are living longer, but with increased age comes greater frailty and multi-morbidity. This secondary data analysis examines transcripts from interviews with 11 frail older people and 6 informal carers to explore emotion in relation to frailty and deteriorating health. Anger and frustration were frequently experienced with declining functional ability; sadness occurred with social isolation, loss of autonomy and independence; anxiety was evident when transition to a care home was discussed; and contentment was described when connecting with others. Reluctant acceptance emerged as a coping strategy. Insights gained from analysing emotion may inform communications training courses for community nurses, though further research is required.

The experiences of caregivers of patients with delirium, and their role in its management in palliative care settings: an integrative literature review

OBJECTIVES

To explore the experiences of caregivers of terminally ill patients with delirium, to determine the potential role of caregivers in the management of delirium at the end of life, to identify the support required to improve caregiver experience and to help the caregiver support the patient.

METHODS

Four electronic databases were searched-PsychInfo, Medline, Cinahl and Scopus from January 2000 to July 2015 using the terms 'delirium', 'terminal restlessness' or 'agitated restlessness' combined with 'carer' or 'caregiver' or 'family' or 'families'. Thirty-three papers met the inclusion criteria and remained in the final review.

RESULTS

Papers focused on (i) caregiver experience-distress, deteriorating relationships, balancing the need to relieve suffering with desire to communicate and helplessness versus control; (ii) the caregiver role-detection and prevention of delirium, symptom monitoring and acting as a patient advocate; and (iii) caregiver support-information needs, advice on how to respond to the patient, interventions to improve caregiver outcomes and interventions delivered by caregivers to improve patient outcomes.

CONCLUSION

High levels of distress are experienced by caregivers of patients with delirium. Distress is heightened because of the potential irreversibility of delirium in palliative care settings and uncertainty around whether the caregiver-patient relationship can be re-established before death. Caregivers can contribute to the management of patient delirium. Additional intervention studies with informational, emotional and behavioural components are required to improve support for caregivers and to help the caregiver support the patient. Reducing caregiver distress should be a goal of any future intervention.© 2016 The Authors. Psycho-Oncology Published by John Wiley & Sons Ltd.

Anticipatory prescribing at the end of life in Lothian care homes

Common symptoms at the end of life include pain, breathlessness, anxiety, respiratory secretions and nausea. National end-of-life care strategies advocate anticipatory prescribing for timely management of these symptoms to enhance patient care by preventing unnecessary distress. This study investigated the extent to which residents in eight Lothian care homes had anticipatory medications prescribed prior to death. Data were collected as part of a service development project to improve palliative care in nursing care homes in Edinburgh. Of the 77 residents who died in the care homes, 54% had anticipatory medicines prescribed. Only 15% had prescriptions for all four nationally recommended anticipatory medications. Many care home residents do not have the recommended anticipatory medications in place in the last days of life and thus may experience inadequate symptom control. Interventions that increase the availability of anticipatory medicines to manage common symptoms at the end of life for care home residents are required.

Is the patient satisfaction questionnaire an acceptable tool for use in a hospice inpatient setting? A pilot study

Background

The Patient Satisfaction Questionnaire (PSQ) is an assessment tool used to evaluate patients’ perspectives of their doctor’s communication and interpersonal skills. The present pilot study investigated whether the PSQ could be administered successfully in a hospice inpatient setting and if it is an acceptable tool for completion by patients and relatives in this context.

Methods

The study was conducted in two phases. A first phase was undertaken to establish the process of PSQ administration in a hospice inpatient ward. A second phase of questionnaire administration followed by semi-structured interviews explored inpatient experiences of the questionnaire process.

Results

Overall, 30 inpatients and one relative were invited to complete the PSQ across both phases of data collection, representing 53% of all inpatients at the time of data collection. The remaining 47% were deemed unsuitable to ask due to a diagnosis of dying (24%), confusion (17%), distress (3%) or lack of availability (2%). The average response rate across both phases of data collection was 87%. Qualitative interview data suggested that the PSQ was considered clear, easy to understand and not burdensome in terms of time or effort for this population.

Conclusions

The PSQ appears an acceptable tool to use in a hospice inpatient setting. Many patients welcomed the opportunity to be involved and give feedback. Using a greater proportion of relatives as an alternative source of feedback could be considered in future studies.

Discussing preferred place of death with patients: staff experiences in a UK specialist palliative care setting

BACKGROUND

National end-of-life care policies propose that health professionals regularly discuss matters such as preferred place of death (PPD) with patients.

AIM

To explore clinician experiences of discussing PPD with palliative care patients.

METHOD

Six clinicians from a Scottish hospice each participated in a semi-structured interview. Interview data was analysed using interpretative phenomenological analysis.

RESULTS

Four themes were integral to the participants' accounts: the importance of discussing preferences at the end of life (staff recognise the value of discussing patients' final wishes), identifying how and when to discuss PPD (discussions are tailored to the individual), reflecting on the emotional aspects of discussing PPD (discussing PPD is challenging but rewarding), and a journey from expectations to experience (discussing PPD becomes easier with time).

CONCLUSION

Although potentially difficult, the participants believed that advance care planning is important and beneficial. With time, they had developed communication strategies enabling them to discuss PPD in an effective, patient-centred way.

Improving end-of-life care in nursing homes: implementation and evaluation of an intervention to sustain quality of care

BACKGROUND

Internationally, policy calls for care homes to provide reliably good end-of-life care. We undertook a 20-month project to sustain palliative care improvements achieved by a previous intervention.

AIM

To sustain a high standard of palliative care in seven UK nursing care homes using a lower level of support than employed during the original project and to evaluate the effectiveness of this intervention.

DESIGN

Two palliative care nurse specialists each spent one day per week providing support and training to seven care homes in Scotland, United Kingdom; after death audit data were collected each month and analysed.

RESULTS

During the sustainability project, 132 residents died. In comparison with the initial intervention, there were increases in (a) the proportion of deceased residents with an anticipatory care plan in place (b) the proportion of those with Do Not Attempt Cardiopulmonary Resuscitation documentation in place and (c) the proportion of those who were on the Liverpool Care Pathway when they died. Furthermore, there was a reduction in inappropriate hospital deaths of frail and elderly residents with dementia. However, overall hospital deaths increased.

CONCLUSIONS

A lower level of nursing support managed to sustain and build on the initial outcomes. However, despite increased adoption of key end-of-life care tools, hospital deaths were higher during the sustainability project. While good support from palliative care nurse specialists and GPs can help ensure that key processes remain in place, stable management and key champions are vital to ensure that a palliative care approach becomes embedded within the culture of the care home.

Preferred place of death for patients referred to a specialist palliative care service

Objectives

Understanding patients’ preferences for place of death and supporting patients to achieve their wishes has become a priority. This study aims to: (1) examine preferences of patients referred to a specialist palliative care service; (2) determine whether preferences of those who have been admitted as hospice inpatients differ from those who have not; (3) identify reasons why preferred place of death (PPD) is sometimes not recorded; and (iv) investigate whether nominating a PPD relates to actual place of death.

Method

PPD information was collected as part of standard care for all patients referred to a specialist palliative care service. Case notes were reviewed retrospectively for 1127 patients who died under the care of the service.

Results

Seventy-seven percent of the patients expressed a PPD, a further 21% of patients had documented reasons for PPD remaining unknown. Eighty percent of patients who had never been admitted to the hospice wanted to die at home. In contrast, 79% of those with at least one hospice inpatient admission wanted to die in the hospice. Patients who had an unknown PPD were three times more likely to die in hospital.

Conclusions

Most patients in a specialist palliative care setting are willing to express a PPD. Preferences differ for patients who had never been admitted as hospice inpatients from those who have had at least one inpatient stay. Routine and ongoing assessment of PPD are recommended to support patients’ wishes at the end of life.

Basic emotion profiles in healthy, chronic pain, depressed and PTSD individuals

OBJECTIVES

To compare self-reports of five basic emotions across four samples: healthy, chronic pain, depressed and post-traumatic stress disorder (PTSD), and to investigate the extent to which basic emotion reports discriminate between individuals in healthy or clinical groups.

METHODS

In total, 439 participants took part in this study: healthy (n = 131), chronic pain (n = 220), depressed (n = 24) and PTSD (n = 64). The participants completed the trait version of the Basic Emotion Scale. Basic emotion profiles were compared both within each group and between the healthy group and each of the three other groups. Discriminant analysis was used to assess the extent to which basic emotions can be used to classify the participants as belonging to the healthy group or one of the clinical groups.

RESULTS

In the healthy group, happiness was experienced more than any other basic emotion. This was not found in the clinical groups. In comparison to the healthy participants, the chronic pain group experienced more fear, anger and sadness, the depressed group reported more sadness and the PTSD group experienced all of the negative emotions more frequently. Discriminant analysis revealed that happiness was the most important variable in determining whether an individual belonged to the healthy group or one of the clinical groups. Anger was found to further discriminate between depressed and chronic pain individuals.

CONCLUSION

The findings demonstrate that basic emotion profile analysis can provide a useful foundation for the exploration of emotional experience both within and between healthy and clinical groups. 

The effect of happiness and sadness on alerting, orienting, and executive attention

OBJECTIVE

According to the attention network approach, attention is best understood in terms of three functionally and neuroanatomically distinct networks-alerting, orienting, and executive attention. An important question is whether the experience of emotion differentially influences the efficiency of these networks.

METHOD

This study examines 180 participants were randomly assigned to a happy, sad, or control condition and undertook a modified version of the Attention Network Test.

RESULTS

The results showed no effect of happiness or sadness on alerting, orienting, or executive attention. However, sad participants showed reduced intrinsic alertness.

CONCLUSION

This suggests that sadness reduces general alertness rather than impairing the efficiency of specific attention networks.

The effect of fear on attentional processing in a sample of healthy females

The present experiment examines the effect of fear on efficiency of three attention networks: executive attention, orienting and alerting, in a healthy female sample. International Affective Picture System (IAPS) images were used to elicit both a fear response and a non-emotional response in 100 participants. During the emotion manipulation, participants performed a modified version of the Attention Network Test (ANT). Results showed enhanced executive attention in the fear condition compared to the control condition. Specifically, during a fear experience participants were better able to inhibit irrelevant information resulting in faster response times to a target. There was no effect of fear on orienting while the effect of fear on alerting was inconclusive. It is suggested that enhanced executive attention in fear-eliciting situations may function to focus attention on a potentially threat-related target, thus facilitating subsequent rapid responding.

A footswitch evaluation of the gait of elderly fallers with and without a diagnosis of orthostatic hypotension and healthy elderly controls

Gait abnormalities are a recognised risk factor for falling in the elderly and variability in gait has been shown to be a measurable predictor of falls. We carried out a footswitch evaluation of the temporal parameters of gait of elderly fallers with a primary diagnosis of Orthostatic Hypotension, elderly fallers without a diagnosis of Orthostatic Hypotension and a control group of healthy elderly non-fallers. We hypothesized that elderly persons with Orthostatic Hypotension are falling purely as a consequence of their vascular abnormalities and are not falling for the same reasons as regular elderly fallers, including biomechanical irregularities. Therefore it was assumed that their gait pattern would not be similar to that of regular elderly fallers but instead would resemble that of healthy elderly non-fallers. Results show that elderly fallers with or without a diagnosis of Orthostatic Hypotension tend to spend more time in the stance phase of gait, possibly due to a fear of falling. Elderly fallers with a diagnosis of Orthostatic Hypotension have similar levels of gait variability as healthy elderly Controls. These are significantly less than elderly fallers without Orthostatic Hypotension. Therefore elderly fallers with a diagnosis of Orthostatic Hypotension may not be falling for the same reasons as regular elderly fallers.

Accelerometer versus footswitch evaluation of gait unsteadiness and temporal characteristics of gait in two elderly patient groups

We examined anterior-posterior and medio-lateral head and trunk movements during gait using accelerometers, and a footswitch evaluation of temporal gait parameters of elderly fallers with a primary diagnosis of Orthostatic Hypotension, elderly fallers without Orthostatic Hypotension, and a control group of healthy elderly non-fallers. We wanted to evaluate whether both sets of measures can be used to differentiate between patient groups. We were able to significantly differentiate between the three elderly groups to the same extent using both sets of measures.