Dietary and lifestyle interventions for weight management in adults from minority ethnic/non‐White groups: a systematic review

Minority ethnic/non‐White populations are more prone to weight gain and more susceptible to obesity‐related complications. The objective of this study was to systematically review dietary and lifestyle interventions for weight management in minority ethnic groups. Electronic databases and reference lists of original studies and reviews were searched for studies on dietary and lifestyle weight management interventions published. Randomized clinical trials with ≥6‐month duration were included. Nineteen studies met the inclusion criteria. Fourteen studies involved African–Americans, one in non‐White Hispanics, one in Japanese Americans and three in both African–Americans and non‐White Hispanics. Most of the interventions proved relatively effective. However, significant drawbacks were noted for several of these studies, such as small sample size, high attrition rates and lack of follow‐up data. Better quality and long‐term trials are required in order to investigate in detail the effectiveness of lifestyle changes for weight management in these populations and eventually support evidence‐based recommendations.     

Mortality risk and prospective medicare expenditures for persons with dementia

OBJECTIVES: To determine whether an index that stratifies dementia patients into high- and low-mortality-risk groups can be effective in prospectively identifying persons with high and low expenditures. DESIGN: A mortality risk index developed for persons with dementia was used to stratify persons into groups at high and low risk of 12-month mortality. Expenditures were compiled from Medicare claims for 12 months after the predicted mortality classification. SETTING: The Medicare Alzheimer's Disease Demonstration Evaluation (MADDE) operated in eight sites across the United States. Subjects were living in a community setting at time of their mortality risk classification. PARTICIPANTS: Participants (N=2,255) were volunteer enrollees in MADDE; all had a diagnosis of irreversible dementia and two or more limitations in activities of daily living (ADLs). MEASUREMENTS: Outcomes were Medicare Part A expenditures. Risk factors included age, sex, ADL limitations, selected chronic conditions, prior year hospital stays, and relationship to caregiver. RESULTS: Patients predicted as at high risk of death had higher average monthly Medicare expenditures than those predicted to be at low risk of death. At the 50th sensitivity percentile for mortality, differences in average expenditures exceeded 700 dollars per month. CONCLUSION: It is not known whether it is possible to achieve reductions in expenditures for patients with advanced dementia at high risk of mortality, but study findings support consideration of an advanced illness model that would attempt to generate acute services savings and use these savings for palliative services that might improve patients' and caregivers' quality of life.     

Oral feeding options for people with dementia: a systematic review

To review the benefits of oral feeding options in people with dementia. DESIGN: Systematic literature search with review of potentially eligible studies by two independent investigators. SETTING: PubMed/MEDLINE, EMBASE, the Cochrane Library, CINAHL, and PsychINFO literature indices between January 1990 and October 2009. PARTICIPANTS: Clinical trials with random or nonrandom control groups were included if they reported on clinical outcomes of oral feeding interventions for people with dementia. MEASUREMENTS: Investigators abstracted data from included studies using a structured instrument. Studies were graded on quality and potential bias, and overall strength of evidence was summarized. RESULTS: Thirteen controlled trials provided data on use of supplements for people with dementia, and 12 controlled trials tested assisted feeding or other interventions. Studies provide moderate‐strength evidence for high‐calorie supplements, and low‐strength evidence for appetite stimulants, assisted feeding, and modified foods to promote weight gain in people with dementia. The few studies measuring function or survival showed no difference. CONCLUSION: High‐calorie supplements and other oral feeding options can help people with dementia with feeding problems to gain weight; they are unlikely to improve other outcomes. These treatments can be offered alone or in combination as an alternative to tube feeding.     

A systematic review and meta-analysis of placebo-controlled antidepressant studies in people with depression and dementia

OBJECTIVES: To determine the efficacy of antidepressants in people with depression and dementia. DESIGN: A systematic review and meta‐analysis based on a literature search of Medline and Cochrane Trials Registry for acute‐phase, double‐blind, placebo‐controlled, parallel‐design, random‐assignment trials of antidepressants marketed in the United States. SETTING: Outpatient clinics, inpatient units, residential settings. PARTICIPANTS: People with criterion‐based diagnoses of dementia and depression. MEASUREMENTS: Numbers of participants randomized; baseline and end point depression scale scores; and response, remission, and discontinuation rates were extracted. Random‐effects meta‐analyses were performed for response and remission rates, change scores using standardized mean differences, and discontinuation rates. Sensitivity analyses were planned to examine effects of depression diagnosis, severity, and trial duration. RESULTS: Seven trials with 330 participants met selection criteria. The odds ratio (OR) for six trials reporting response rates with antidepressant and placebo was 2.12 (95% confidence interval (CI)=0.95–4.70; Z=1.84, P=.07). The OR for five trials reporting remission rates was 1.97 (95% CI=0.85–4.55; Z=1.59, P=.11). Both analyses demonstrated heterogeneity. The standardized mean difference in trials was 0.29 (95% CI=0.02–0.60, Z=1.86, P=.06). This analysis did not demonstrate significant heterogeneity. Adverse event discontinuation rates (9.0%) were not significantly higher with drug than placebo (6.0%), and were low. CONCLUSION: The evidence for antidepressant treatment of people with depression and dementia, although suggestive, does not confirm efficacy. All of the trials were significantly underpowered to detect differences, resulting in inconclusive findings. Variable trial methods, comorbid conditions, and differences in antidepressants employed further confounded findings.     

Racial,ethnic and neighborhood socioeconomic differences in incidence of dementia: A regional retrospective cohort study

Background

Evidence on the effects of neighborhood socioeconomic disadvantage on dementia risk in racially and ethically diverse populations is limited. Our objective was to evaluate the relative extent to which neighborhood disadvantage accounts for racial/ethnic variation in dementia incidence rates. Secondarily, we evaluated the spatial relationship between neighborhood disadvantage and dementia risk.

Methods

In this retrospective study using electronic health records (EHR) at two regional health systems in Northeast Ohio, participants included 253,421 patients aged >60 years who had an outpatient primary care visit between January 1, 2005 and December 31, 2015. The date of the first qualifying visit served as the study baseline. Cumulative incidence of composite dementia outcome, defined as EHR-documented dementia diagnosis or dementia-related death, stratified by neighborhood socioeconomic deprivation (as measured by Area Deprivation Index) was determined by competing-risk regression analysis, with non-dementia-related death as the competing risk. Fine-Gray sub-distribution hazard ratios were determined for neighborhood socioeconomic deprivation, race/ethnicity, and clinical risk factors. The degree to which neighborhood socioeconomic position accounted for racial/ethnic disparities in the incidence of composite dementia outcome was evaluated via mediation analysis with Poisson rate models.

Results

Increasing neighborhood disadvantage was associated with increased risk of EHR-documented dementia diagnosis or dementia-related death (most vs. least disadvantaged ADI quintile HR = 1.76, 95% confidence interval = 1.69–1.84) after adjusting for age and sex. The effect of neighborhood disadvantage on this composite dementia outcome remained after accounting for known medical risk factors of dementia. Mediation analysis indicated that neighborhood disadvantage accounted for 34% and 29% of the elevated risk for composite dementia outcome in Hispanic and Black patients compared to White patients, respectively.

Conclusion

Neighborhood disadvantage is related to the risk of EHR-documented dementia diagnosis or dementia-related death and accounts for a portion of racial/ethnic differences in dementia burden, even after adjustment for clinically important confounders.     

The global challenge of type 2 diabetes and the strategies for response in ethnic minority groups

Ethnic minorities living in high‐income countries usually exhibit a greater risk of developing diabetes along with higher morbidity and mortality rates. We evaluated the effectiveness of interventions to improve glycaemic control in ethnic minority groups. Results of major controlled trials, systematic reviews and meta‐analyses were included in the review. Only 1/47 studies addressing diet and exercise interventions reported details on the ethnicity of the studied population. Self‐management education was successful if associated with increased self‐efficacy; delivered over a longer period; of high intensity; culturally tailored; and when using community educators. Strategies adopted in community‐gathering places, family‐based, multifaceted, and those tackling the social context were likely to be more effective. A positive relationship was found between social support and self‐management behaviour as well as quality of life, but there is little evidence about the impact of organizational changes within health‐care services on diabetes control. More research is needed to strengthen the evidence on effective strategies for response to diabetes in ethnic minorities. Also, there is a need to take into account diabetes beliefs and communication difficulties, as well as potential protective factors. Globally, many health‐care systems are inadequately equipped to improve diabetes prevention and disease outcomes in these communities. Copyright © 2010 John Wiley & Sons, Ltd.     

Special care facility compared with traditional environments for dementia care: a longitudinal study of quality of life

OBJECTIVES: To compare the effect of a specialized care facility (SCF) on quality of life (QoL) for residents with middle- to late-stage dementia over a 1-year period with residence in traditional institutional facilities. DESIGN: A prospective, matched-group design with assessments of QoL every 3 months for 1 year. SETTING: Twenty-four long-term care centers and four designated assisted living environments in an urban center in western Canada. PARTICIPANTS: One hundred eighty-five residents with Global Deterioration Scores of 5 or greater were enrolled: 62 in the intervention SCF group and 123 in the traditional institutional facilities groups. INTERVENTION: The SCF is a 60-bed purpose-built facility with 10 people living in six bungalows. The facility followed an ecologic model of care that is responsive to the unique interplay of each person and the environment. This model encompasses a vision of long-term care that is more comfortable, more like home, and offers more choice, meaningful activity, and privacy than traditional settings. MEASUREMENTS: QoL outcomes were assessed using the Brief Cognitive Rating Scale, Functional Assessment Staging, Cohen-Mansfield Agitation Inventory, Pleasant Events Scale-Alzheimer's disease, Multidimensional Observation Scale of Elderly Subjects, and Apparent Affect Rating Scale. RESULTS: The intervening SCF group demonstrated less decline in activities of daily living, more sustained interest in the environment, and less negative affect than residents in the traditional institutional facilities. There were no differences between groups in concentration, memory, orientation, depression, or social withdrawal. CONCLUSION: The present study suggests that QoL for adults with middle- to late-stage dementia is the same or better in a purpose-built and staffed SCF than in traditional institutional settings.     

Factors influencing quality of life of elderly people with dementia and care implications: A systematic review

BackgroundIdentifying factors associated with Quality of Life (QoL) of elderly people with dementia could contribute to finding pathways to improve QoL for elderly people in dementia.AimThis paper systematically reviews all possible factors that influence QoL of elderly people with dementia, identifies how these factors are different by different stages of dementia and living settings, and explores how the influencing factors could be perceive differently by elderly people with dementia, family members, and caregivers.MethodPubMed, PsycINFO, Web of Science and DelphiS searches from 2000 to 2015 and hand searches of publication lists, reference lists and citations were used to identify primary studies on ‘quality of life’ and ‘dementia’ elderly people.ResultsThe results suggest that there are a complex variety of factors influencing QoL of elderly people with dementia, and the factors cover demographic, physical, psychological, social, and religious aspects. And the factors influencing QoL of elderly people with dementia are different in different living settings (care institutions and communities) as well as different people’s perspectives (elderly people with dementia, family members and care staff). Environmental factors and quality of care are important for elderly people in care institutions; while religious seem to only affect QoL of those living in communities. However, this review fails to comprehensively identify unique or common factors associated QoL in dementia across three stages. Further study should pay more attention to comparing factors associated with QoL in dementia across three stages of dementia.     

Honoring Choices Minnesota: Preliminary Data from a Community‐Wide Advance Care Planning Model

Advance care planning (ACP) increases the likelihood that individuals who are dying receive the care that they prefer. It also reduces depression and anxiety in family members and increases family satisfaction with the process of care. Honoring Choices Minnesota is an ACP program based on the Respecting Choices model of La Crosse, Wisconsin. The objective of this report is to describe the process, which began in 2008, of implementing Honoring Choices Minnesota in a large, diverse metropolitan area. All eight large healthcare systems in the metropolitan area agreed to participate in the project, and as of April 30, 2013, the proportion of hospitalized individuals 65 and older with advance care directives in the electronic medical record was 12.1% to 65.6%. The proportion of outpatients aged 65 and older was 11.6% to 31.7%. Organizations that had sponsored recruitment initiatives had the highest proportions of records containing healthcare directives. It was concluded that it is possible to reduce redundancy by recruiting all healthcare systems in a metropolitan area to endorse the same ACP model, although significantly increasing the proportion of individuals with a healthcare directive in their medical record requires a campaign with recruitment of organizations and individuals.