Interventions at Hospital Discharge to Guide Caregivers in Medication Management for People Living with Dementia: a Systematic Review

BackgroundHospital discharge has a significant impact on the continuity of care for people living with dementia. Clear guidance on medication management should be provided to caregivers of people living with dementia to ensure appropriate use of medications post-discharge.AimIdentify and appraise the impact of interventions at hospital discharge to guide caregivers in the medication management for people living with dementia.MethodA systematic search of original studies was performed in Medline, Embase, PsycINFO, and CINAHL. Articles published in English that reported on interventions to guide caregivers in medication management for people living with dementia were included. Two authors independently reviewed titles and abstract. Full-text articles were assessed for eligibility and quality assessment was conducted by two authors.ResultsA total of five studies were included with a range of interventions that were typically delivered post-discharge by a multidisciplinary team and most targeted administration of medications by caregivers. Overall, three types of discharge interventions were identified including a pre-discharge caregiver educational intervention, a post-discharge multidisciplinary team intervention, and discharge summary documentation intervention at transitions of care. Of these, a pre-discharge caregiver education led to shorter hospital stay (25 days vs. 31 days, p = 0.005). A post-discharge intervention that included follow-up visits resulted in lower use of high-risk medications (19% vs. 40%), and reduction in 30-day re-hospitalization rates (11% vs. 20%). In contrast, in another post-discharge intervention study, no difference in one-month re-hospitalization rates (8.4% vs. 8.0%, p = 0.82) was demonstrated. In another study, a post-discharge hospital educational program provided to caregivers  led to significantly reduced caregiver burden (31.7 ± 17.6 (SD) pre-intervention to 27.7 ± 16.9 (SD) post-intervention (p = 0.037)).DiscussionCurrent findings suggest there is a need for well-designed interventions to guide caregivers in all aspects of medication management for people living with dementia, and should include support for caregivers in care coordination.Supplementary InformationThe online version contains supplementary material available at 10.1007/s11606-020-06442-5.KEY WORDS: dementia, caregivers, hospitalization, discharge planning, transitions of care, medication safety     

Family Support Groups within a Research Project on Dementia

This is a report of three different support groups for caregivers of patients with senile dementia who were participating in a larger study of Alzheimer disease. One group consisted of structural, open-ended sessions while the other two were closed, time-limited groups. For this sample the most cohesive and supportive group was one which was unstuctured and time-limited. It also consisted of caregivers whose relationships to the patients were similar (i.e., spouses). Recommendations for research and practice are made.     

Dementia: a neuroendocrine perspective

The etiology of Alzheimer's disease (AD) has not been as yet completely defined. Genetic, environmental and neurophysiological aspects should all be taken into account. The disease has also neuroendocrine implications, some of which are discussed in this review. It is known that stress and glucocorticoids may affect neurone survival. On the contrary, some data indicate that DHEA and DHEAS exert a neuroprotective action. In AD, changes in hypothalamic-pituitary-adrenal axis function have been reported. Experimental and clinical evidence indicates that glucocorticoid hypersecretion and DHEAS levels decrement may add to hippocampal dysfunction in aging and in AD. Glucocorticoid and beta-amyloid concur in the mechanism of neurone damage, as well as excitatory amino acids (EAA), Ca++ and reactive oxygen species (ROS). The neuroprotective effects exerted by IGFs are also hindered in aging and even more in AD. Production and biological actions of IGFs are negatively influenced by cortisol hypersecretion and DHEAS decrease in patients with AD.     

Dementia: case ascertainment in a community survey

The three-stage East Baltimore Mental Health Survey, conducted in 1981 as part of the Epidemiological Catchment Area Program, provided an opportunity to assess the prevalence of dementia and specific dementing disorders in a community-based, cross-sectional sample of the population. From the 3,841 households originally sampled, 810 individuals were selected for clinical psychiatric evaluation. Forty-one individuals were given a provisional diagnosis and referred to Stage 3 for differential diagnosis, with 32 individuals completing this evaluation. Thorough clinical evaluation of these cases resulted in an overall prevalence of dementia of 4.5% in those 65 years of age and older. The prevalence of specific dementing disorders was Alzheimer's disease (AD) (2.0%), Multi-Infarct Dementia (MID) (2.0%) and Mixed Dementia (MD) (0.5%). Prevalence increased with age for all dementias: Non-Whites had higher rates of dementia than Whites; females had higher rates of AD while males had higher rates of MID; and the prevalence of AD increased with increasing education, whereas the prevalence of MID decreased with increased education. Although this study includes only a small number of cases, necessitating some caution in interpreting the results, these figures do represent an estimate of the prevalence of severe dementing disorders and provide a basis for further community study.     

Challenging pancreatic cancer-prone pedigrees: a nosologic dilemma

OBJECTIVES: Our objective is to describe 11 pancreatic cancer (PC)-prone families, none of which are consonant with known hereditary cancer syndromes, in an attempt to portray familial aggregations of this disease that might be encountered in a clinical practice setting. METHODS: We selected 11 families containing two or more first- and/or second-degree relatives affected with PC from a registry of 200 PC-prone kindreds. Each proband and/or key relative(s) was interviewed and completed a detailed family history questionnaire (after providing informed consent) that allowed us to extend the pedigree as far as possible with retrieval of primary medical and pathology documents, whenever available. RESULTS: All of the 11 families show PC features that merit clinical attention and raise questions as to whether this familial clustering could be due to "chance" alone, exposure to certain common environmental factors, such as cigarette smoking, and/or polygenic, multifactorial, or Mendelian inherited factors. CONCLUSIONS: It is estimated that about 5% of PC may have a primary hereditary etiology. Because of early death, reduced penetrance, and often profuse phenotypic and genotypic heterogeneity, particularly with respect to variable age of onset and association with diverse patterns of cancer at different anatomic sites, the pedigrees require extension for ultimate diagnosis. Physician knowledge about PC's natural history and syndrome delineation should ultimately foster earlier diagnoses and possibly prevention of this disease. These high-risk patients may provide a source of DNA for formal linkage analysis in the search for culprit cancer-prone susceptibility loci.     

A Unique Support Model for Dementia Patients and Their Families in a Tertiary Hospital Setting: Description and Preliminary Data

Dementia is a disease of great concern, as the deficit in memory and other cognitive functions that characterize this condition leads to a loss of independent function, which in turn has serious impact on individuals, families, and health care systems. Hospitals and clinics in general do not have “support” programs to assist dementia patients and their families. The day-to-day coping with the disease, care planning, and safety of dementia patients is often left to the families or other support networks, with minimal professional assistance. This article profiles the rationale, emergence, and process of a unique dementia support program based on a continuum of care model, started at Stanford University Medical Center under the Aging Adult Services Program. Each patient and family/caregiver is offered (a) comprehensive information, (b) identification of problem areas, (c) discussion about symptom management and interventions via home visits or family meetings, and (d) linkages to resources, legal/financial planning, and community/specialist services. The number of interactions with patient and family can vary and is customized to the patient/family needs. The dementia support program is recognized as a resource and is a part of a set of recommendations routinely sent to families by Stanford's Neurology Department (http://scmd.stanford.edu/) once the diagnosis of dementia has been made. To date, 237 families have been helped since the program's inception in September 2008, and 85 families agreed to participate in a survey to elicit preliminary data about the usefulness of the dementia support program.     

Dementia with Lewy bodies: a review

The dementia with Lewy bodies (DLB) is the second major type of senile, degenerative dementia, after the Alzheimer disease (AD). It is characterized by the presence of cytoplasmic inclusions of alpha-synuclein in the cerebral cortex and in the nuclei of the brain stem. DLB patients frequently have complex visual hallucinations, depressive symptoms, Parkinsonian manifestations and cognitive deficits, showing important associations with the Parkinson disease and the AD. The DLB should be differentiated from atypical Parkinsonisms, but the differential diagnosis often remains difficult and unsafe. Clinical and neuropathological findings, as well as neuroimaging are valuable tools in establishing specific diagnosis of DLB. Acetylcholinesterase inhibitors, dopamine-agonists, benzodiazepines of short or medium half-life, and antidepressants may be useful in the treatment of DLB, depending on the dominant symptoms of the given patients.     

Autoimmune Pancreatitis: Updated Concepts of a Challenging Diagnosis

Autoimmune pancreatitis is a benign process characterized by inflammation and fibrosis. It is now known that cases of “autoimmune pancreatitis” actually consist of two distinct pathologic entities. Type 1 autoimmune pancreatitis is a manifestation of a systemic process, immunoglobulin G subclass 4 (IgG4)-related disease. IgG4-related disease can affect virtually every organ system in the body. Type 1 affects older patients and is characterized by an elevated serum IgG4 level and sites of extrapancreatic disease. Type 2 autoimmune pancreatitis is a disease process confined to the pancreas. It affects younger patients and is associated with inflammatory bowel disease. Type 2 is not associated with elevated IgG4 levels or extrapancreatic disease. Both subtypes can mimic malignancy, particularly pancreatic cancer. Awareness of the clinical and imaging features of the subtypes of autoimmune pancreatitis is important to avoid an incorrect diagnosis of malignancy.     

Pancreatic Cancer: Proteomic Approaches to a Challenging Disease

Purpose of Review: To describe progress in the application of proteomic approaches to advance our understanding of the biology of pancreatic cancer as well as contribute potential protein biomarkers for this disease. Recent Findings: Here we review proteomic studies relating to pancreatic cancer that have been published in the past 12 months. We describe novel techniques for the simplification of complex protein samples, focusing particularly on emerging methods for reducing the complexity of blood. We provide examples, where possible, of the application of these novel technologies to pancreatic cancer research. Summary: Both the range of proteomic-based approaches and their sensitivities for the detection of low-abundance proteins has increased. This provides promise that further research will yield insight into pancreatic cancer, including valuable information on proteins that may ultimately serve as biomarkers for pancreatic cancer.     

Adverse Events During Apheresis Procedures: Audit at a Tertiary Hospital

Apheretic platelets are better quality blood components which reduce donor exposure and chances of TTIs to transfusion recipients when compared to the whole blood derived components. Though safe, these apheretic donations are associated with donor adverse events. We evaluated the incidence of such adverse events associated with the modern apheresis procedures that would provide an insight as well as help formulating preventive steps to avoid frequent occurrences of such events. This prospective audit-based observational study was conducted over 1 year. Donors for plateletpheresis were selected as per the standard operating procedure of the Apheresis Lab. The apheresis procedures were done on the MCS+ (Haemonetics Corp.), Trima Accel (Terumo BCT) and COM.TEC (Fresenius Kabi AG). 1740 apheresis procedures were performed, out of which 1708 were plateletpheresis and 32 therapeutic plasma exchange (TPE) procedures for 7 patients. A total of 102 adverse events were noted; of which, 80 (78.43 %) events were associated with donors, 15 (14.71 %) were owed to equipment related problems and 7 (6.86 %) were technical aberrations. All the events associated with donors were mild. No adverse events were reported with any of the 32 TPEs. Apheresis procedures are associated with adverse events which can be reduced by meticulous donor-vigilance, superior training modules for the technical personnel and continued supervision of experienced transfusion medicine specialists. Continued efforts towards making the donor’s experience with apheresis more pleasant give a forward thrust to the noble vision of preparing a voluntary apheresis donor pool in India.     

Increasing Autopsy Rates at a Public Hospital

Despite the acknowledged value of autopsies, autopsy rates are low in American hospitals. We developed an extensive intervention to increase the autopsy rate on the medical service of our urban teaching hospital and to identify obstacles to obtaining permission for autopsy. The 6-month intervention increased the autopsy rate from 7.5% during the previous 2 years to 16.8%, but this effect disappeared after the intervention. Among patients for whom permission for autopsy was not obtained, physicians failed to request permission for 31% and families refused permission for 69%.
KEY WORDS: autopsy; autopsy rate; permission for autopsy; public hospitals.     

Challenging scenarios in a travel clinic: advising the complex traveler

With adequate preparation and in consultation with a travel medicine expert, most travelers today can travel safely regardless of their age and health status. The few instances when it is prudent to alter travel plans or postpone travel altogether are not to be taken lightly. For the most part, however, most complex travelers can enjoy a healthy and rewarding travel experience.     

Rubella outbreak in Thailand 1983-1984: a study at Siriraj Hospital

The recent rubella epidemic in Thailand prevailed from September 1983 to August 1984 with its peak in March. Throughout the outbreak, approximately 70% of the cases diagnosed clinical rubella were laboratory proved. In the middle of the outbreak, accuracy of the clinical diagnosis was 75-87%, while it was 25-33% at the beginning and the end. Concerning the clinical findings in rubella, maculopapular rash may be generalized or localized, and lymphadenopathy occurred only in 40% of the clinical cases. Lymphadenopathy and respiratory symptoms appeared 3 times more frequent than those in the non-rubella cases. Rubella inapparent infection occurred in 5.14% of the contact cases. Acquisition of the disease after contact did not depend on the degree of close relationship between the index cases and the contact cases. Outcome of pregnancy and congenital rubella infection after the outbreak have to be further investigated.