Reconciling conceptualizations of relationships and person‐centred care for older people with cognitive impairment in acute care settings

Relationships are central to enacting person‐centred care of the older person with cognitive impairment. A fuller understanding of relationships and the role they play facilitating wellness and preserving personhood is critical if we are to unleash the productive potential of nursing research and person‐centred care. In this article, we target the acute care setting because much of the work about relationships and older people with cognitive impairment has tended to focus on relationships in long‐term care. The acute care setting is characterized by archetypal constraints which differentiate it from long‐term care, in terms of acuity and haste, task‐orientated work patterns and influence from “the rule of medicine,” all of which can privilege particular types of relating. In this article, we drew on existing conceptualizations of relationships from theory and practice by tapping in to the intellectual resources provided by nurse researchers, the philosophy of Martin Buber and ANT scholars. This involved recounting two examples of dyadic and networked relationships which were re‐interpreted using two complementary theoretical approaches to provide deeper and more comprehensive conceptualizations of these relationships. By re‐presenting key tenets from the work of key scholars on the topic relationships, we hope to hasten socialization of these ideas into nursing into the acute care setting. First, by enabling nurses to reflect on how they might work toward cultivating relationships that are more salutogenic and consistent with the preservation of personhood. Second, by stimulating two distinct but related lines of research enquiry which focus on dyadic and networked relationships with the older person with cognitive impairment in the acute care setting. We also hope to reconcile the schism that has emerged in the literature between preferred approaches to care of the older person with cognitive impairment, that is person‐centred care versus relationship‐centred care by arguing that these are complementary rather than mutually exclusive and can be brought together in one theoretical framework acknowledging personhood as relational in essence.     

天津市社区老年人MCI患病及影响因素分析

  目的  了解天津市社区老年人血脂水平与轻度认知障碍（MCI）发生的关系,为采取MCI相应的预防措施提供参考依据。  方法  采用以社区为基础1 : 1匹配的病例对照研究方法,于2016年3月在天津市王顶堤街道辖区内随机选取4个社区卫生服务中心,将体检时诊断为MCI的210例 ≥ 65岁老年人作为病例组,按病例组同性别、年龄（ ± 1岁）匹配210名认知正常老年人作为对照组,两组进行问卷调查和实验室检测,《精神障碍诊断和统计手册 – V》（DSM-V）用于诊断MCI,采用多因素条件logistic回归模型分析社区老年人血脂水平与MCI发生的关系。  结果  天津市病例组MCI社区老年人和对照组认知正常社区老年人的总胆固醇（TC）、低密度脂蛋白胆固醇（LDL-C）、高密度脂蛋白胆固醇（HDL-C）、LDL-C/HDL-C水平分别为186.50（160.75,215.00）mg/dL和195.50（168.00,217.25）mg/dL、101.00（77.75,121.00）mg/dL和100.00（79.75,123.00）mg/dL、58.50（46.75,71.25）mg/dL和58.00（47.00,70.00）mg/dL、1.71（1.30,2.35）和1.66（1.31,2.26）,2组老年人TC、LDL-C、HDL-C、LDL-C/HDL-C水平差异均无统计学意义（均P > 0.05）;在调整了文化程度及是否患高血压、糖尿病、心脏病、脑卒中等混杂因素后,多因素条件logistic回归分析结果显示,天津市TC为200 ~ 240 mg/dL社区老年人发生MCI的风险为 < 200 mg/dL社区老年人的0.52倍（OR = 0.52,95 % CI = 0.27 ~ 0.99）,HDL-C为 > 40 mg/dL社区老年人发生MCI的风险为 ≤ 40 mg/dL社区老年人的0.30倍（OR = 0.30,95 % CI = 0.14 ~ 0.67）,LDL-C为100 ~ 130 mg/dL、130 ~ 160 mg/dL和 > 160 mg/dL社区老年人发生MCI的风险分别为 < 100 mg/dL社区老年人的2.37倍（OR = 2.37,95 % CI = 1.21 ~ 4.65）、3.22倍（OR = 3.22,95 % CI = 1.09 ~ 9.49）和9.33倍（OR = 9.33,95 % CI = 1.59 ~ 54.61）,LDL-C/HDL-C为 > 2.30社区老年人发生MCI的风险为 < 1.31社区老年人的0.37倍（OR = 0.37,95 % CI = 0.16 ~ 0.88）。  结论  高水平的LDL-C为天津市社区老年人MCI发生的危险因素,而高水平的HDL-C和LDL-C/HDL-C比值及中等水平的TC则为天津市社区老年人MCI发生的保护因素。     

Association of diet quality score with the risk of mild cognitive impairment in the elderly

BACKGROUND/OBJECTIVESAlthough adherence to a higher diet quality may help prevent cognitive decline in older adults, literature for this in a Korean population is limited. Thus, the aim of this study was to examine the association between diet quality indices and the risk of mild cognitive impairment (MCI) in Korean older adults.SUBJECTS/METHODSThis cross-sectional study included 806 community-dwelling people aged 60 yrs and over in Korea. Diet quality was assessed via the revised Recommended Food Score (RFS) and alternate Mediterranean Diet Score (aMDS). Cognitive function was measured using a Korean version of the Mini-Mental State Examination (MMSE-KC). Associations between diet quality indices and MMSE-KC score were assessed with a general linear model after adjusting for covariates. Logistic regression was used to determine the association between diet quality indices and the risk of MCI.RESULTSThe prevalence of MCI was 35.3%. There were no significant trends between MMSE-KC scores and RFS and aMDS after adjusting for age, gender, education, exercise, living status, social activity, and alcohol drinking. Among total subjects, RFS was inversely associated with the risk of MCI after adjusting for covariates (Q5 vs. Q1; odds ratio [OR], 0.49; 95% confidence interval [CI], 0.28–0.83). Among total subjects and men, aMDS was inversely related to the risk of MCI after adjusting for covariates (Q5 vs. Q1; OR, 0.51; 95% CI, 0.29–0.89 for total subjects; Q5 vs. Q1; OR, 0.36; 95% CI, 0.15–0.83 for men).CONCLUSIONSOur results demonstrate that high diet quality evaluated by RFS and aMDS is inversely associated with the risk of MCI. Thus, high quality diet may reduce or retard cognitive decline in the old population. Longitudinal studies are needed to determine the causal relationship between diet quality and the risk of MCI in the elderly.     

老年轻度认知功能障碍患者认知评分变化3年前瞻性研究

目的 探讨社区老年轻度认知功能障碍(MCI)患者认知评分变化及其在阿尔茨海默病(AD)预测中的价值.方法 采用多级整群抽样方法选择对象,对贵阳市社区老年人开展3年前瞻性研究,将基线MCI患者前后简易智能状态检查(MMSE)总分及各领域得分变化进行对比分析,并对MCI患者不同转归结局MMSE前后得分进行比较,采用logistic回归分析方法对其在AD发病的危险性进行估计.结果 MCI患者基线和随访对认知功能总分及各领域得分差异有统计学意义(P＜0.05).结局为痴呆者基线MMSE得分低于保持MCI和转为正常者(P＜0.05).Logistic回归分析显示定向力下降的MCI患者转化为AD的危险性较高(OR=1.730,95％CI=1.283～2.332).结论 MCI患者各领域得分及MMSE总分较低者更容易转化为AD.在MCI转归为痴呆的过程中,定向力得分下降可能是其中一个重要的预测因子.     

Reconciling concepts of space and person‐centred care of the older person with cognitive impairment in the acute care setting

Although a large body of literature exists propounding the importance of space in aged care and care of the older person with dementia, there is, however, only limited exploration of the ‘acute care space’ as a particular type of space with archetypal constraints that maybe unfavourable to older people with cognitive impairment and nurses wanting to provide care that is person‐centred. In this article, we explore concepts of space and examine the implications of these for the delivery of care to older people who are cognitively impaired. Our exploration is grounded in theorisations of space offered by key geographers and phenomenologists, but also draws on how space has been constructed within the nursing literature that refers specifically to acute care. We argue that space, once created, can be created and that nursing has a significant role to play in the process of its recreation in the pursuit of care that is person‐centred. We conclude by introducing an alternative logic of space aimed at promoting the creation of more salutogenic spaces that invokes a sense of sanctuary, safeness, and inclusion, all of which are essential if the care provided to the older person with cognitive impairment is apposite to their needs. The concept of ‘person‐centred space’ helps to crystallize the relationship between space and person‐centred care and implies more intentional manipulation of space that is more conducive to caring and healing. Significantly, it marks a return to Nightingale's wisdom, that is, to put the person in the best possible conditions for nature to act upon them.     

孤独感对社区老年人轻度认知障碍的影响

目的了解重庆市社区老年人孤独感与轻度认知障碍(mild cognitive impairment, MCI)的现状,探讨孤独感对老年人MCI的影响。方法采用多阶段随机抽样方法,选取重庆市9个社区的1 375例老年人作为研究对象,采用UCLA孤独量表和蒙特利尔认知评估量表(MoCA)调查社区老年人的孤独感和MCI状况。结果社区老年人孤独感得分为36.36±7.67分,中等及以上水平孤独感者占43.78%。老年人MoCA总分为24.65±3.78分,MCI的检出率为28.44%。不同水平孤独感老年人的MoCA总分及其各维度得分均具有统计学差异(P<0.05)。Logistic回归分析显示,中等水平孤独感(OR=1.476,95%CI:1.047～2.079)和高水平孤独感(OR=1.731,95%CI:1.026～2.921)是社区老年人MCI的危险因素。结论社区老年人孤独感和MCI的检出率较高,且孤独感水平越高,MCI的检出率越高。社区工作人员应采取措施减轻老年人的孤独状况,从而延缓其认知功能的下降,改善老年人的生活质量。     

中国四省55岁及以上人群睡眠时长与轻度认知功能障碍的关联性

目的 探索中老年人睡眠时长与轻度认知功能障碍(mild cognitive impairment,MCI)的关联性.方法 采用多阶段分层整群随机抽样的方法,于2018年5-8月份抽取河北、浙江、陕西、湖南4个省32个县中5334名55岁及以上居民[男性2362人,女性2972人,年龄(67.43±7.48)岁],通过问...     

Reconciling concepts of time and person‐centred care of the older person with cognitive impairment in the acute care setting

The aim of this analysis was to examine the concept of time to rejuvenate and extend existing narratives of time within the nursing literature. In particular, we hope to promote a new trajectory in nursing research and practice which focuses on time and person‐centred care, specifically of older people with cognitive impairment hospitalized in the acute care setting. We consider the explanatory power of concepts such as clock time, process time, fast care, slow care and time debt for elucidating the relationship between ‘good care’ and ‘time use’. We conclude by offering two additional concepts of time, plurotemporality and person‐centred time (PCT) which we propose will help advance of nursing knowledge and practice. Nurse clinicians and researchers can use these alternative concepts of time to explore and describe different temporal structures that honour the patient's values and preferences using experiential, observation‐based nursing research approaches.     

轻度认知功能障碍及其影响因素的研究进展

目前,早期发现和干预仍是控制老年期痴呆的主要措施。随着对治疗方法的深入研究,正常衰老和痴呆中间的病理状态—轻度认知功能障碍(mild cognitive impairment,MCI)的提出为老年期痴呆的早期治疗和干预提供了新的靶点,其影响因素的研究也得到研究者的重视。大量研究发现,心血管疾病、吸烟、中年期肥胖、中年期高胆固醇血症、糖尿病及代谢综合征等是该疾病的主要影响因素。本文通过文献复习,对这些因素进行了综述。以期为后续研究提供参考借鉴。     

老年人血管性认知功能障碍影响因素分析

目的 探讨老年人血管性认知功能障碍（VCI）的影响因素,为采取有效的干预措施提供参考依据。方法 收集2013年3月-2017年3月牡丹江医学院红旗医院收治的200例年龄>60岁老年脑梗塞或者脑出血患者,根据认知功能评定结果将其分为VCI组（79例）和非VCI组（121例）,采用多因素非条件logistic回归分析方法分析VCI发生的影响因素。结果 VCI组和非VCI组患者在年龄、文化程度、婚姻状况、睡眠状况、食用肉类情况、饮茶情况及有无高血压、糖尿病、冠心病方面差异均有统计学意义（均P<0.05）;VCI组患者在同型半胱氨酸（Hcy）和超敏C反应蛋白（hs-CRP）分别为（20.18±3.62）μmol/L和（6.80±1.13）mg/L,均高于非VCI组患者的（12.72±1.59）μmol/L和（2.31±1.02）mg/L,血管内皮生长因子（VEGF）为（180.26±21.37）pg/mL,低于非VCI组患者的（226.53±24.28）pg/mL,差异均有统计学意义（均P<0.001）;多因素非条件logistic回归分析结果显示,年龄≥70岁、高血压、Hcy和hs-CRP水平较高是老年人VCI发生的危险因素,初中及以上文化程度、每天饮茶和VEGF水平较高是老年人VCI发生的保护因素。结论 年龄、文化程度、饮茶情况、有无高血压及Hcy、VEGF、hs-CRP水平是老年人VCI发生的主要影响因素。     

Reconciling conceptualisations of the body and person‐centred care of the older person with cognitive impairment in the acute care setting

In this article, we sought reconciliation between the “body‐as‐representation” and the “body‐as‐experience,” that is, how the body is represented in discourse and how the body of older people with cognitive impairment is experienced. We identified four contemporary “technologies” and gave examples of these to show how they influence how older people with cognitive impairment are often represented in acute care settings. We argued that these technologies may be mediated further by discourses of ageism and ableism which can potentiate either the repressive or productive tendencies of these technologies resulting in either positive or negative care experiences for the older person and/or their carer, including nurses. We then provided examples from research of embodied experiences of older people with dementia and of how nurses and other professionals utilized their inter‐bodily experiences to inform acts of caring. The specificity and individuality of these experiences were more conducive to positive care experiences. We conclude the article by proposing that the act of caring is one way nurses seek to reconcile the “body‐as‐representation” with the “body‐as‐experience” to mitigate the repressive effects of negative ageism and ableism. The act of caring, we argue, is the essence of caring enacted through the provision of person‐centred care which evokes nurses to respond appropriately to the older person's “otherness,” their “variation of being” while enabling them to enact a continuation of themselves and their own version of normality.     

Reconciling conceptualizations of ethical conduct and person‐centred care of older people with cognitive impairment in acute care settings

Key commentators on person‐centred care have described it as a “new ethic of care” which they link inextricably to notions of individual autonomy, action, change and improvement. Two key points are addressed in this article. The first is that few discussions about ethics and person‐centred are underscored by any particular ethical theory. The second point is that despite the espoused benefits of person‐centred care, delivery within the acute care setting remains largely aspirational. Choices nurses make about their practice tend to comply more often with prevailing norms than those championed by person‐centred care. We draw on elements of work by moral philosopher Løgstrup and Foucault to provide insight into nurses’ ethical conduct and ask why nurses would want to act otherwise , when what they think and do is viewed as normal, or think and act otherwise if doing so is seen within the organization as transgressive? To address these more specific questions, we discuss them in relation to the following constructs: the ethical demand , sovereign expressions of life and parrhêsia . We conclude by arguing that a ethical theoretical framework enables nurses to increase their perceptibility and appreciation of the ethical demand particularly those emanating from incommensurability between organizational norms and the norms invoked by person‐centred care. We argue that nurses’ responses to the ethical demand by way of parrhêsia can be an important feature of intra‐organizational reflexivity and its transformation towards the delivery care that is more person‐centred, particularly for older people with cognitive impairment. We conclude the article by highlighting the implications of this for nursing education and research.     

The association between cognitive impairment and community service use patterns in older people living in Australia

Family plays a vital role in supporting individuals with dementia to reside in the community, thus delaying institutionalisation. Existing research indicates that the burden of care‐giving is particularly high for those caring for a person with dementia. Yet, little is known about the uptake of community services by people with a diagnosis of dementia. Therefore, this study aims to better understand the relationship between cognitive impairment and the receipt of community care services. In order to examine the relationship, secondary data collected across Queensland, Australia, from 59,352 home‐care clients aged 65 and over during 2007–2008 are analysed. This cross‐sectional study uses regression analyses to estimate the relationship between cognitive impairment and service mix, while controlling for socio‐demographic characteristics. The dependent variables include formal services, informal care and total home‐care service hours during a 12‐month period. The findings of this study demonstrate that cognitive impairment is associated with accessing more hours of respite and day centre care but fewer hours of other formal care services. Additionally, the likelihood of support from an informal caregiver increases when a client becomes cognitively impaired. Therefore, this study demonstrates that there is an increased need for respite programmes to support informal caregivers in the future, as the population of people living with dementia increases. These findings support the need for investigations of new and innovative respite models in the future.     

老年轻度认知功能障碍者人格特征分析

目的探讨老年轻度认知功解障碍者人格特征,为采取有效的预防措施提供科学依据。方法2008年,采用整群随机抽样方法在山西省太原市选取9个社区的老年人群中轻度认知功能障碍者(MCI)232例,按年龄、性别、文化程度进行1∶1配对的病例对照研究。采用Epi-Data和SPSS13.0软件进行单因素和多因素条件Logistic回归分析。结果单因素条件Logistic回归分析发现,卡特尔16种人格因素问卷(16PF)中的乐群(A)(χ2=2.826,P=0.003)、恃强(E)(χ2=11.581,P=0.000)、忧虑(O)(χ2=2.409,P=0.001)、独立(Q2)(χ2=0.351,P=0.046)、自律(Q3)(χ2=0.173,P=0.001)在MCI组与对照组之间差异有统计学意义。多因素条件Logistic回归分析结果显示,16PF中恃强(E)(χ2=34.920,P=0.000)、独立(Q2)(χ2=4.168,P=0.041)、自律(Q3)(χ2=6.560,P=0.010)在MCI组与对照组之间差异有统计学意义,并且16PF中的独立(Q2)(OR=0.050,95%CI=0.005~0.515)、自律(Q3)(OR=0.057,95%CI=0.009~0.407)是MCI的保护性因素,且独立并自律是轻度认知功能障碍的保护性因素(OR=0.059,95%CI=0.011~0.298)。结论16PF中恃强性是MCI的危险性因素。高独立性及高自律性为MCI的保护性因素,且高独立性并高自律性对MCI的影响分别存在主效应及联合作用效应。     

心理护理在血管性认知障碍康复中的作用

目的探讨心理护理在血管性认知障碍康复中的作用。方法将90例血管性认知障碍的患者随机分成2组,2组均采用常规药物以及康复干预治疗,心理护理组在此基础上予以心理护理,分别在治疗前及治疗后2个月进行MOCA量表测评,并比较结果。结果心理护理组患者MOCA量表各子项目评分较常规治疗组患者有明显提高,差异有统计学意义(P<0.01)。结论心理护理联合药物及康复干预,能明显改善患者认知功能的各个主要方面。     

武汉市社区老年人轻度认知功能障碍患病现状及其影响因素分析

目的 了解湖北省武汉市社区老年人轻度认知功能障碍（MCI）的患病现状及其影响因素,为采取相应的干预措施提供参考依据。方法 于2014年7-8月采用随机整群抽样方法对在武汉市6个街道抽取的1 218名老年人进行面访调查。结果 武汉市社区1 218名老年人中,MCI患病者340例,MCI患病率为27.91%;多因素非条件logistic回归分析结果显示,年龄≥70岁和文化程度为中学是武汉市社区老年人MCI患病的危险因素,进行体育锻炼是武汉市社区老年人MCI患病的保护因素。结论 武汉市社区老年人MCI患病率较高;年龄、文化程度和是否进行体育锻炼是武汉市社区老年人MCI患病的主要影响因素。     

开封市社区老年人群轻度认知功能障碍患病率及危险因素研究

目的 调查开封市社区老年人轻度认知障碍(mild cognitive impairment,MCI)的患病率及潜在风险因素,为当地科学制定预防措施提供依据。方法 2018年5—11月,基于分层整群随机抽样方法选取开封市6个社区680名≥60岁老年人作为调查对象,使用中文版“简明精神状态量表”进行认知功能评估。结果 680名调查对象中,发现MCI患者153例,患病率22.50%。单因素分析显示,不同年龄、性别、文化教育程度和患有慢性病对MCI患病率差异有统计学意义(P＜0.05);多元logistic回归分析结果表明,控制混杂因素后,女性是老年人MCI的危险因素(OR=1.806,95%CI:1.088～2.998)。而年龄＜80岁(OR=0.736,95%CI:0.561～0.967)、小学文化程度(OR=0.680,95%CI:0.483～0.956)、初中文化程度(OR=0.396,95%CI:0.266～0.588)、高中及以上教育(OR=0.284,95%CI:0.115～0.700)是MCI的保护因素。结论 开封市老年人MCI患病率较高,女性、高龄、受教育程度低的老年人可能是MCI的高危人群,也是未来MCI防控的重点人群。     

膳食因素与老年人认知功能障碍相关性研究进展

膳食因素与老年人认知功能障碍的发生关系密切,膳食多种营养成分如碳水化合物和脂类摄入过量与认知功能障碍的发生有关,而某些膳食成分如微量元素对认知功能障碍的发生具有一定的预防作用。本文就膳食中多种因素与老年人认知功能障碍的关系及其具体作用机制作一综述。     

Improved evaluation and management of cognitive impairment: results of a comprehensive intervention in long-term care

OBJECTIVES: Although as many as 50% of patients in long-term care have dementia, it is often not diagnosed and therefore, undertreated. We determined whether an intervention could improve the diagnosis and management of patients with cognitive impairment (CI) in long-term care. DESIGN, SETTING, AND PARTICIPANTS: The assessment phase consisted of a record review of 60 consecutively admitted patients to the San Francisco VA Nursing Home Care Unit (NHCU). Cognitive impairment was determined by admission MMSE < or = 24, indication of cognitive problem on MDS, or chart diagnosis of dementia. The evaluation consisted of a repeat chart review of 60 additional consecutively admitted patients. INTERVENTION: The intervention consisted of low-cost and easy-to-implement educational activities (training, focus groups), strategies to document cognitive status, and consultation with dementia experts. MEASUREMENTS/RESULTS: The 2 cohorts of 60 patients did not differ on demographics or on other characteristics (P > .25 for all). Prior to the intervention, of the 23 patients with CI, 52% had an identified etiology, 35% had a physician management plan, and 22% had a multidisciplinary care plan. Postintervention, of the 22 patients with CI, 91% had an identified etiology (P = .007), 86% had a physician plan (P = .001), and 59% had a multidisciplinary plan (P = .016). CONCLUSIONS: Initial results confirmed the underdiagnosis and undertreatment of CI in our long-term care facility. Our intervention with educational programs, increased documentation of cognitive status, and consultation resulted in increased identification of etiology and improved plans for management of patients with CI.