Factors associated with behavioral and psychological symptoms of dementia

Most people with dementia suffer behavioral and psychological symptoms (BPSD). These symptoms add to caregiver stress and accelerate cognitive decline. The etiology of BPSD is complex, with multiple factors influencing symptom manifestation. The ability to accommodate and communicate needs decreases with cognitive deterioration. Unmet needs may explain why some individuals, despite having the same diagnosis and degree of cognitive impairment, have more severe BPSD. BPSD is treated with both atypical and typical antipsychotics (APD). Numerous studies demonstrated that APD treatment in individuals with dementia might cause major side effects, including death. The purpose of this Thesis is to examine factors associated with BPSD in a large group of individuals with dementia. The Thesis covers four cross-sectional investigations using data from five Swedish registries: The Swedish registry for cognitive/dementia disorders (SveDem), the Swedish Behavioral and psychological symptoms of dementia Registry (BPSD registry), the Swedish Prescribed Drug Registry (SPDR), the Swedish Cause of Death Registry (CODR), and the Swedish National Patient Registry (NPR). Six types of diagnoses were included in the studies: Alzheimer’s disease (AD), vascular dementia (VaD), mixed (Mixed) dementia, Parkinson’s disease dementia (PDD), dementia with Lewy bodies (DLB), frontotemporal dementia (FTD) and unspecified dementia (UNS). In Study 1, we discovered that 75% of individuals with dementia exhibited at least one clinically significant BPSD, the most prevalent being aberrant motor behavior, agitation/aggression and irritability. In comparison to AD, we found a lower risk of delusions (in FTD, UNS), hallucinations (FTD), agitation (VaD, PDD, UNS), elation/euphoria (DLB), anxiety (Mixed, VaD, unspecified dementia), disinhibition (in PDD); irritability (in DLB, FTD, UNS), aberrant motor behavior (Mixed, VaD, UNS), sleep and night-time behavior changes (UNS). Higher risk of delusions (DLB), hallucinations (DLB, PDD), apathy (VaD, FTD), disinhibition (FTD) and appetite and eating abnormalities (FTD) were also found in comparison to AD. In Study 2, pain was the most prevalent unmet need, followed by sleeping disturbances, impaired hearing and impaired vision. Additionally, we found that the risk of BPSD increases with unmet physical or psychological needs in dementia. In Study 3, APD use at the time of dementia diagnosis was associated with increased mortality risk across the cohort and by dementia subtype. In Study 4, we found that out of 53,384 individuals with dementia, 1,823 owned a firearm and 419 were unfit owners. Owners of firearms were mostly male, younger, living alone and without homecare support. Living with another person, frontotemporal dementia, APD and hypnotics prescription, being diagnosed in a memory/cognitive clinic, female gender, and mild and moderate dementia were the most important predictors of being reported to the police. In conclusion, individuals with dementia who live in long-term care facilities frequently develop BPSD. Additionally, unmet needs are significantly associated with BPSD in each dementia type. Individuals with dementia receive both typical and atypical APDs, however, their use is associated with an increased risk of death. Finally, we found that the decision to withdraw the firearm is based on a variety of clinical factors associated with dementia

Investigating the use of Action Research and Activity Theory to Promote the Professional Development of Teachers in Iceland

The thesis is for a joint award of Doctor of Philosophy in Education from the University of Exeter and the University of Iceland. A co-tutelle agreement was made between the two universities regarding this joint award.ABSTRACT This thesis investigates the use of action research and activity theory to promote the professional development of teachers in an Icelandic upper secondary school. The purpose of the research was to develop a new model to foster professional development through enhancing the participants’ agency to transform their practice. It was carried out with an action research group of twenty-one school professionals and an outside consultant. The group’s aim was to find ways to increase students’ sense of responsibility for their studies. The project combined the ideas behind the Change Laboratory, one of the methods of developmental work research established by Engeström and action research as elaborated by McNiff. I termed our approach the Change Room. There activity theory and the theory of expansive learning provided the participants with a conceptual framework, historical analysis and tools to analyse what changes might be appropriate in our classroom practice. The action research provided the participants with the method and tools to guide the participants when carrying out and evaluating these changes. The research focus was on tensions the participants experienced in their classroom practice. Through creative resolutions of these tensions the intention was to develop better practices and contribute to school development. The research used both action research and case study methodology. The research tools were documentary analysis, interviews, surveys, research diary and observations. The findings were analysed using deductive process based on activity theory. The teachers experienced tensions in their classroom practice between students’ active and passive learning, didactic and dialogic teaching methods, and the requirement to cover the syllabus and to promote deep learning. To resolve these tensions the teachers have developed teaching practices that enhanced active student learning and given more weight to the students’ voices. Participation in the action research group enhanced both individual and collective learning of the school professionals. Their agency to change practice was increased and they also developed more cross curriculum agency. The combination of activity theory and action research in the Change Room provides a new model for enhancing teachers’ professional development and collaboration that has potential to transform classroom practice

MODUL PEMBELAJARAN EVALUASI PROGRAM PENDIDIKAN

Mata Kuliah Evaluasi Program Pendidikan ini memberikan wawasan kepada mahasiswa tentang konsep Evaluasi Program sebagai riset dan menjadi dasar pengetahuan untuk menyusun proposal penelitian Evaluasi

Measuring Nutritional Status, Hydration and Body Composition Changes in Acute Stroke

Background: Dysphagia and cognitive problems, both common after stoke, may affect dietary intake increasing the risk of malnutrition. Malnutrition has adverse effects on body composition especially in conditions that escalate the stress response in the body and may be associated with immobility such as stroke. Study objective: The objective of my study was to understand the prognosis of malnutrition on post cardiovascular disease (CV) outcomes, understand body composition changes after stroke assessed using multi-frequency bioelectrical impedance analysis (MF-BIA) methods, examine the utility of MF-BIA in diagnosing dehydration in stroke patients, and validate MF-BIA selected body composition estimates against the reference method Dual X-ray absorptiometry (DEXA). Methodology: To understand the prognosis of malnutrition on post CVD outcomes I carried out a systematic review and meta-analysis examining the association between selected markers of malnutrition on outcomes. The systematic review is presented in Chapter 2 of this thesis. Chapter 3 presents an observational longitudinal study that describes body composition changes after ischaemic stroke and their prognosis on outcomes. Ischaemic stroke patients admitted to an acute unit were prospectively recruited between January-July 2011. Body composition variables (BioScan 920-2, Maltron International Ltd, Essex, United Kingdom) were measured on admission and discharge. Results were descriptively presented stratified by type of feeding regimen, type of stroke and stroke severity. Validated follow up questionnaire were sent to participants by post to understand body composition changes association with their health and quality of life. In chapter 4 the diagnostic accuracy of MF-BIA BioScan 920-2 in diagnosing dehydration after stroke was examined for several diagnostic cut offs of current and impending dehydration. In chapter 5 external validation of MF-BIA BioScan 920-2 fat free mass and fat mass estimates against reference method DEXA was examined using ten participants data. Bland and Altman analysis for understanding the agreement between two methods of clinical measurement was carried out. Results: Undernutrition (assessed using nutrition assessment tools) were associated with mortality post cardiovascular event. Other findings are presented in Chapter 2. Fat free mass loss, and fat mass gain, protein mass loss, muscle mass loss, and body cell mass loss were observed in patients on modified diet (soft/mashed diet, pureed diet, nilby- mouth feeding regimen). Sample size was small to generalize a conclusion on the association between body composition changes in acute stay and outcomes. MF-BIA BioScan 920-2 did not show diagnostic accuracy in diagnosing dehydration in stroke patients. MF-BIA BioScan 920-2 fat free mass and fat mass estimates were in agreement with their corresponding estimate from the reference methods DEXA. Conclusion: My study was novel as it provided new information with regard to body composition changes in acute stroke while utilizing new validated equipment in estimating body composition component of fat free mass and fat mass. My study also aimed to investigate new non-invasive methods to diagnose dehydration in stroke patients. It contributed new knowledge that can be useful in future research, sample size calculation, and can help researchers in the field to determine minimally clinically significant differences for similar research and targeted intervention clinical trials