Exploring ways to enhance pain management for older people with dementia in acute care settings using a Participatory Action Research approach

BACKGROUND: Dementia is a progressive condition that leads to reduced cognition, deteriorating communication and is a risk factor for other acute and chronic health problems. The rise in the prevalence of dementia means untreated pain is becoming increasingly common with healthcare staff being challenged to provide optimal pain management. This negatively impacts the person living with dementia and their carers. There is minimal evidence that explores the pain management experience of patients as they move through acute care settings. OBJECTIVE: To understand the complexities of managing the pain of older people with dementia as they progress through acute care settings, with the view of assisting staff to improve practice. METHOD: A Participatory Action Research approach, guided by the Promoting Action Research in Health Services framework, was used. Three Action Cycles were completed comprising of an exploratory audit and two case studies (Action Cycle One), three focus groups with a total of 14 participants (Action Cycle Two) and the development and implementation of immediate and long‐term actions (Action Cycle Three). RESULTS: Thematic analysis identified four themes that affected pain management practices. These were not knowing the patient; balancing competing priorities; knowledge and understanding of pain and dementia and not assimilating available information. CONCLUSION: Pain management practices for patient living with dementia, across acute care settings, was influenced by shared ways of thinking and working. Not knowing the patient, fragmentation of information and having insufficient knowledge of the subtleties of dementia led participants to deliver task‐focused, target and policy‐driven care that was not person‐centred in its approach. Facilitated reflection enabled acute care teams to actively participate in identifying problems and finding solutions to enhance practice

Preserving the Past: An Early Interview Improves Delayed Event Memory in Children With Intellectual Disabilities.

The influence of an early interview on children's (N = 194) later recall of an experienced event was examined in children with mild and moderate intellectual disabilities (CWID; 7-12 years) and typically developing (TD) children matched for chronological (7-12 years) or mental (4-9 years) age. Children previously interviewed were more informative, more accurate, and less suggestible. CWID (mild) recalled as much information as TD mental age matches, and were as accurate as TD chronological age matches. CWID (moderate) recalled less than TD mental age matches but were as accurate. Interviewers should elicit CWID's recall as early as possible and consider developmental level and severity of impairments when evaluating eyewitness testimony.This research was supported by a grant from the Economic and Social Research Council, UK RES-­‐000-­‐23-­‐0949 to Charlie Lewis, Deirdre Brown and Michael Lamb, and in part by a Postdoctoral Fellowship from the Foundation for Research, Science and Technology, NZ (LANC0201) to Deirdre Brown.This is the final version of the article. It first appeared from Wiley via http://dx.doi.org/10.1111/cdev.1236

Confirming nasogastric tube position with electromagnetic tracking versus pH or X-ray and tube radio-opacity

Recent evidence suggests official statistics greatly underestimate the occurrence of complications from misplaced nasogastric (NG) tubes, even when detected. Current methods of confirming tube position do not provide adequate protection from misplacement. In addition, some tubes are inadequately radio-opaque. We prospectively audited placement of Cortrak polyurethane tubes (PUTs) to determine: accuracy of the electromagnetic (EM) trace in confirming tube position, radio-opacity of PUTs compared with previously placed polyvinylchloride (PVC) Ryles tubes and whether 12 French PUTs can be used to aspirate gastric residual volumes (GRVs). A total of 127 PUTs were placed in 113 patients. EM traces accurately confirmed tube position compared with X-ray (100% agreement). A 'gastric' EM trace has been defined for future use by other operators. PUTs were adequately radio-opaque with good agreement between interpreters (>98%) whereas PVC Ryles tubes were insufficiently radio-opaque (57-73%), invisible in 23% of cases and with poor agreement between interpreters leaving risk of error. The alternative of using pH confirmation was not possible in 44%. In these cases subsequent X-ray incurred a 2-hour delay to feed and medicines. In addition, neither post-placement pH testing nor X-ray warn of lung placement and potential trauma, whereas the EM trace warned of lung placement prior to damage in 7% of placements. 12 French, single-port PUTs appear adequate to aspirate large GRVs. EM tracing may be considered a standalone method of confirming NG tube position. Corflo (Cortrak) PUTs are adequately radio-opaque. Use of PVC Ryles and other inadequately radio-opaque tubes should stop

Ion Transport Processes of Crustacean Epithelial Cells

Epithelial cells of the gut, antennal glands, integument, and gills of crustaceans regulate the movements of ions into and across these structures and thereby influence the concentrations of ions in the hemolymph. Specific transport proteins serving cations and anions are found on apical and basolateral cell membranes of epithelia in these tissues. In recent years, a considerable research effort has been directed at elucidating their physiological and molecular properties and relating these characteristics to the overall biology of the organisms. Efforts to describe ion transport in crustaceans have focused on the membrane transfer properties of Na1/H1 exchange, calcium uptake as it relates to the molt cycle, heavy metal sequestration and detoxification, and anion movements into and across epithelial cells. In addition to defining the properties and mechanisms of cation movements across specific cell borders, work over the past 5 yr has also centered on defining the molecular nature of certain transport proteins such as the Na1/H1 exchanger in gill and gut tissues. Monovalent anion transport proteins of the gills and gut have received attention as they relate to osmotic and ionic balance in euryhaline species. Divalent anion secretion events of the gut have been defined relative to potential roles they may have in hyporegulation of the blood and in hepatopancreatic detoxification events involving complexation with cationic metals

The role of immunosuppression in long-term graft hepatitis and fibrosis after paediatric liver transplant comparison of two treatment protocols:comparison of two treatment protocols

Background and aims: We have previously demonstrated high rates of chronic allograft hepatitis and fibrosis in liver transplant patients on long-term cyclosporine monotherapy. We subsequently changed practice to add low-dose prednisolone to maintenance treatment with tacrolimus post-transplant. The aim of the study was to assess the impact of the immunosuppression change on graft histopathology.Methods: Patients treated in this era (Tac + Pred, 2000–2009, N = 128) were compared to a historical cohort, who had been maintained on a steroid-free, cyclosporine-based regime (CSA-Only, 1985–1996, N = 129). Protocol liver biopsies and laboratory tests were performed five- and ten-years post-transplant in both groups.Results: Compared to CSA-Only, the Tac + Pred cohort had significantly lower rates of chronic hepatitis (CH) at five (20% vs. 44%, p Conclusion: Increased immunosuppression effectively reduced chronic allograft hepatitis and fibrosis at five years, suggesting it is an immunologically driven variant of rejection. However, there was no significant reduction in the degree of fibrosis at ten years, indicating a multifactorial origin for long term graft fibrosis

Narrative skill and testimonial accuracy in typically developing children and those with intellectual disabilities

Children must describe maltreatment coherently for their testimony to be influential in court. We know little about how well children with intellectual disabilities (CWID) describe their experiences relative to typically developing (TD) children, despite CWID’s vulnerability to maltreatment. We investigated children’s reports of an experienced event and compared coherence in CWID (mild to moderate impairment: 7-11 years) with TD children matched for mental (4-10 years) or chronological age (7-11 years). All children included important markers of narrative coherence in their reports. Children with lower mental ages, particularly those with an intellectual disability, included fewer markers of narrative coherence in their reports than children with higher mental ages. Individual markers of narrative coherence, particularly recall of content, predicted accuracy of testimony and resistance to suggestion even when disability and mental age were taken into account. These findings highlight the importance of helping children to describe their experiences coherently