Population Health Solutions for Assessing Cognitive Impairment in Geriatric Patients.

In December 2017, the National Academy of Neuropsychology convened an interorganizational Summit on Population Health Solutions for Assessing Cognitive Impairment in Geriatric Patients in Denver, Colorado. The Summit brought together representatives of a broad range of stakeholders invested in the care of older adults to focus on the topic of cognitive health and aging. Summit participants specifically examined questions of who should be screened for cognitive impairment and how they should be screened in medical settings. This is important in the context of an acute illness given that the presence of cognitive impairment can have significant implications for care and for the management of concomitant diseases as well as pose a major risk factor for dementia. Participants arrived at general principles to guide future screening approaches in medical populations and identified knowledge gaps to direct future research. Key learning points of the summit included: recognizing the importance of educating patients and healthcare providers about the value of assessing current and baseline cognition;emphasizing that any screening tool must be appropriately normalized and validated in the population in which it is used to obtain accurate information, including considerations of language, cultural factors, and education; andrecognizing the great potential, with appropriate caveats, of electronic health records to augment cognitive screening and tracking of changes in cognitive health over time

Assessment of trauma symptomatology in adults with intellectual disabilities: validation of the Lancaster and Northgate Trauma Scales

Background and Aims There is evidence that people with intellectual disabilities experience a higher rate of traumatic life events. However, attempts to research the presence of posttraumatic stress disorder (PTSD) symptomatology have been hampered by the absence of a validated and suitable assessment tool. The aim of this study, therefore, was to further examine the psychometric properties of a recently developed measure, the Lancaster and Northgate Trauma Scales (LANTS; Wigham, Hatton & Taylor, 2011b). Method Using a correlational design, 40 individuals (23 female, 17 male) with a mild intellectual disability (Mean FSIQ = 60.68; SD = 6.13) completed the LANTS and measures of anxiety and depression, along with a measure of general intellectual functioning. Two assessment tools developed for this study were also administered: the Impact of Events Scale – Intellectual Disabilities (IES-ID), a version of the Impact of Events Scale Revised (IES-R; Weiss & Marmar, 1997) adapted specifically for people with intellectual disabilities; and the Trauma Information Form (TIF) which is a selfreport assessment of trauma experiences in line with current DSM-IV-TR criteria (2000). Results Both trauma scales had high internal and test-retest reliability, although the IESID subscales were less reliable than the total severity score. Convergent validity was also good with the LANTS and IES-ID both positively correlated with each other, and iii measures of anxiety and depression. However, unlike the IES-ID, the LANTS failed to correlate with the number of traumas. No differences on trauma or demographic factors were found between a high and low PTSD group. Intellectual functioning was not related to the extent of trauma symptomatology. Conclusions The LANTS and IES-ID are promising trauma assessment tools, and therefore both may have clinical utility for the identification of PTSD symptomatology in people with intellectual disabilities. While the findings should be extended to a larger sample, they clearly provide a basis for more research into this under-researched but burgeoning area

National evaluation of Partnerships for Older People Projects

Executive Summary The Partnership for Older People Projects (POPP) were funded by the Department of Health to develop services for older people, aimed at promoting their health, well-being and independence and preventing or delaying their need for higher intensity or institutional care. The evaluation found that a wide range of projects resulted in improved quality of life for participants and considerable savings, as well as better local working relationships. • Twenty-nine local authorities were involved as pilot sites, working with health and voluntary sector partners to develop services, with funding of £60m • Those projects developed ranged from low level services, such as lunch-clubs, to more formal preventive initiatives, such as hospital discharge and rapid response services • Over a quarter of a million people (264,637) used one or more of these services • The reduction in hospital emergency bed days resulted in considerable savings, to the extent that for every extra £1 spent on the POPP services, there has been approximately a £1.20 additional benefit in savings on emergency bed days. This is the headline estimate drawn from a statistically valid range of £0.80 to £1.60 saving on emergency bed days for every extra £1 spent on the projects. • Overnight hospital stays were seemingly reduced by 47% and use of Accident & Emergency departments by 29%. Reductions were also seen in physiotherapy/occupational therapy and clinic or outpatient appointments with a total cost reduction of £2,166 per person • A practical example of what works is pro-active case coordination services, where visits to A&E departments fell by 60%, hospital overnight stays were reduced by 48%, phone calls to GPs fell by 28%, visits to practice nurses reduced by 25% and GP appointments reduced by 10% • Efficiency gains in health service use appear to have been achieved without any adverse impact on the use of social care resources • The overwhelming majority of the POPP projects have been sustained, with only 3% being closed – either because they did not deliver the intended outcomes or because local strategic priorities had changed • PCTs have contributed to the sustainability of the POPP projects within all 29 pilot sites. Moreover, within almost half of the sites, one or more of the projects are being entirely sustained through PCT funding – a total of 20% of POPP projects. There are a further 14% of projects for which PCTs are providing at least half of the necessary ongoing funding • POPP services appear to have improved users’ quality of life, varying with the nature of individual projects; those providing services to individuals with complex needs were particularly successful, but low-level preventive projects also had an impact • All local projects involved older people in their design and management, although to varying degrees, including as members of steering or programme boards, in staff recruitment panels, as volunteers or in the evaluation • Improved relationships with health agencies and the voluntary sector in the locality were generally reported as a result of partnership working, although there were some difficulties securing the involvement of GP

Prevalence and treatment of health anxiety in genitourinary medicine

The concepts of hypochondriasis and health anxiety are described in historical and modern contexts and justification given for the preferred usage of health anxiety, with the condition better classified with the anxiety disorders. The prevalence of hypochondriasis is reviewed and it is noted that most of the data are in primary care with only one paper from genitourinary medicine. The treatments for health anxiety and hypochondriasis are reviewed and noted, until recently, to be relatively limited in efficacy. A prevalence study of health anxiety in genitourinary medicine in two centres found that 8‐ 11% of attenders had significant health anxiety recorded by the Health Anxiety Inventory; that symptoms persisted over a 9 month period, and were associated with higher numbers of medical consultations. This was followed by a randomised controlled trial in a genitourinary medicine clinic in which an adapted form of cognitive behaviour therapy was given by me as a medical practitioner, and compared with a single explanatory interview in a control group. Assessments of clinical symptoms, social functioning and costs were made at baseline, 3, 6 and 12 months after randomisation. In 49 patients allocated, greater improvement was seen for the primary outcome of Health Anxiety Inventory (HAI) scores in patients treated with CBT (n=23) than in the control group (n=26) (P=0.001). Similar but less marked differences were found for the secondary outcomes of generalised anxiety, depression and social function, and there were fewer health service consultations. These differences were maintained in the six months after treatment was completed. The treatment costs were only partly offset by the savings in clinic appointments and for every unit reduction in HAI score there was an incremental cost of £33. It is concluded that the treatment, given in this manner, has the potential to be generalised

Using a Community-Based Participatory Research Approach to Address Individual and Community Health in Charleston, MS. The Initial Step: A Formative Needs Assessment

The purpose of this formative study was to use a Community-Based Participatory Research (CBPR) approach to conduct a comprehensive health needs assessment (CHNA) in Charleston, Mississippi (MS) to determine perceived needs of the community and identify priority health issues. A second purpose was to provide methodological and scholarly contributions to the existing literature regarding CBPR and CHNAs. The target population was residents living in Charleston, MS (N=2,193). Eighty-five residents participated in the study. This was a five-part study including: (1) Key informant interviews (n=11), (2) Focus groups (n=8), (3) Assessment of the built environment, (4) Assessment of the nutrition environment, and (5) Assessment of policy. Findings of the needs assessment revealed the priority health concerns in the community: obesity, diabetes, hypertension, asthma, stroke, cancer, stress, depression, prescription drug non-compliance, heart disease, limited access to health care, limited access to healthy foods, and limited health knowledge. The greatest social concerns identified were high school drop out rate, teen pregnancy, poverty, domestic violence, poor housing, alcohol abuse, drugs, smoking, limited jobs, limited education, illiteracy, and few social opportunities. Findings revealed the environmental concerns were chemicals from farming, smoking, the water supply system, and the lack of recycling available in the community. The assessment of the nutrition environment shothat residents have limited options available for purchasing healthy food. The assessment of the built environment shothe community is not physical activity friendly and residents have limited resources for physical activity. The assessment of policies revealed a need for policies to support health. Findings also identified assets, resources, and organizations in the community contributing to health and wellness. To improve health and wellness in the community there is need for a community recreation facility, worksite and community wellness programs, community health education, after school programs, group fitness classes, a farmers market, outdoor recreation facilities, increased job opportunity, recycling, and policy changes. Findings of the needs assessment describe and identify the priority health issues, needs, and service gaps and will be used to inform future planning, development, implementation, and evaluation of programs to improve health

Aligning Investments to Improve Population Health: A Statewide Strategy to Address the Social Determinants of Health

In this report, authors Michael Swack, Sarah Boege, and Kevin Barnett discuss the initiative to develop a statewide strategy to address the social determinants of health in New Hampshire. Launched in 2020, this project is a collaboration between the Center for Impact Finance at the Carsey School of Public Policy at UNH, the Center to Advance Community Health and Equity (CACHE) at the Public Health Institute, the Institute for Health Policy and Practice at UNH, and the New Hampshire Hospital Association/Foundation for Healthy Communities. Michael Swack, director of the Center for Impact Finance at the Carsey School, serves as the co-principal investigator of the project, along with Kevin Barnett of the Public Health Institute

Risk factors associated with Mild Cognitive Impairment in ageing UK Military veterans

BackgroundThe exploration of adverse health outcomes and chronic health conditions in military veterans is essential in occupational epidemiology to identify gaps in public health needs. Recent demographic reports in the UK showed a higher proportion of military veterans were in the 65 years and over category than non-veterans. Additionally given that military veterans are at risk of mental and physical ill-health and lifestyle-related factors (including depression, post-traumatic stress disorder, traumatic brain injury (TBI), diabetes, heart disease, high cholesterol, high blood pressure, stroke, obesity, cigarette smoking, frequent alcohol consumption, and being physically inactive), the risk of Mild Cognitive Impairment (MCI) is probable and warrants further exploration. Previous research has investigated the association between the aforementioned mental and physical health disorders, lifestyle-related factors, and dementia in the military and non-veteran populations in the UK. Although research is yet to compare the risk of MCI in UK military veterans and non-veterans using data from a single study which is essential for making direct comparisons.AimsThis thesis aimed to address this gap by using data from a single UK-based study to investigate the association between mental and physical ill-health status, lifestyle-related factors, and MCI. This was done in three main analysis: (a) comparing the risk of MCI in individuals with or without the aforementioned risk factors in the overall sample, (b) comparing the risk of MCI only in military veterans and non-veterans with the aforementioned risk factors, (c) comparing the risk of MCI in military veterans with or without the aforementioned risk factors.MethodsA series of epidemiological analyses was conducted to address the aim of this thesis. A systematic review and meta-analysis explored the association between the aforementioned health risk factors and MCI and dementia in military veterans. Based on the findings from the systematic review and meta-analysis, a deep dive analysis was conducted utilising data from the PROTECT study, a cohort study exploring healthy brain ageing, cognitive decline, and MCI in middle-aged and older adults (≥40 years) in the UK. This included analysis from two prospective cohort studies and a cross-sectional study investigating the association between MCI and (1) depression, (2) cardiovascular health (CVH) and lifestyle-related risk factors, and (3) lifetime TBI.ResultsFindings from the systematic review and meta-analysis, which included 25 peer-reviewed articles, showed over two-thirds of existing research were based on dementia in military veterans. Depression, TBI, and obesity were significantly associated with cognitive decline in military veterans. The meta-analysis showed depression (OR = 2.45, 95% CI 1.37-4.36), PTSD (OR=1.86, 95% CI 1.56-2.21) and TBI (OR=2.05, 95% CI 1.68-2.50) significantly increased the risk of dementia in military veterans.A prospective cohort analysis was conducted using data from the PROTECT study which comprised of military veterans and non-veterans. Depression significantly increased the risk of MCI (HR=2.45, 95% CI 2.03-3.01) in the overall sample. There was no significant difference in the risk of MCI between military veterans and non-veterans with depression (HR=0.56, 95% CI 0.24-1.30) and between military veterans with or without depression (HR=1.85, 95% CI 0.67-5.12).The next prospective cohort analysis explored the association between nine CVH and lifestyle-related risk factors and MCI in a sample of military veterans and non-veterans. The risk of MCI significantly reduced in military veterans who were obese (HR=0.21, 95% CI 0.07-0.65), frequent alcohol consumers (HR=0.53, 95% CI 0.38-0.74), or physically inactive (HR=0.46, 95% CI 0.25-0.85) compared to non-veterans. There was a significant difference in the risk of MCI between military veterans with diabetes (HR=2.22, 95% CI 1.04-4.75) or high cholesterol (HR=3.11, 95% CI 1.64-5.87) compared to military veterans without diabetes or high cholesterol.A cross-sectional analysis was conducted which comprised of military veterans and non-veterans. TBI significantly increased the risk of MCI (OR=1.21, 95% CI 1.11-1.31) in the overall sample. There was no significant difference in the risk of MCI between military veterans and non-veterans with TBI (OR=1.19, 95% CI 0.98-1.45) and between military veterans with or without TBI (OR=1.21, 95% CI 0.83-1.74).ConclusionIn summary, the risk of MCI was driven by mental and physical health and lifestyle-related risk factors and not by military veteran status except for obesity, alcohol consumption and physical inactivity. Within the military veteran sample, diabetes and high cholesterol increased the risk of MCI. This thesis highlighted the importance of understanding risk factors associated with MCI in UK military veterans. These findings have clinical, social, occupational and research implications. Future research is needed to explore other health risk factors, subtypes of MCI and the military job profile of military veterans.</div

Asylum in Ireland - a public health perspective

This report has two elements, first a review of the literature on refugees and asylum seekrs, with particular to the legal and practical situation in Ireland, and secondly a report of a survey of refugees and asylum seekers carried out in part fulfillment of the requirments for the MPH. The survey had two elements, one a quantitaitve stuy carried out in Dublin and Ennis, and the second a series of focus groups

Hancock County and Statewide Needs, Resources, and Readiness Assessment on Older Adult Alcohol Abuse

Alcohol and drug abuse remains to be a serious health issue among 17 percent of adults aged 60 or older. This assessment was conducted in order to determine and fully understand the needs, resources, and readiness necessary to address the issue of substance abuse throughout the state of Maine. It involved a four-part study focused in the Hancock County region. Twelve focus groups were held with the target groups being professionals, caregivers, and older adults. Surveys and interviews were distributed statewide to evaluate substance abuse. Secondary data analysis was included as well in order to analyze arrests, hospital admissions, treatment, payment sources, and comparisons of geographical location and age. Through all aspects of this study, it was concluded that there is very limited treatment and prevention options for substance abuse in Maine. The issue of community denial is a barrier to addressing and treating substance abuse in older adults. Thus, it is crucial to debunk myths, educate the communities, and provide support in order to effectively assist the elderly population in Maine