Enabling Social Inclusion and Urban Citizenship of Older Adults through eHealth: The iZi Project in the Hague

While the elderly constitute a significant proportion of urban population, they are often not included in the decision-making processes concerning their health requirements. These exclusionary practices could be viewed as reflecting deficits in urban citizenship as well as a denial of what the French sociologist Henri Lefebvre defined in 1968 as the ‘right to the city’ (Lefebvre, 1968). This article is concerned with promoting the social inclusion of the elderly in urban spaces. It focuses on the potential of eHealth to facilitate their independent living in their own homes, an expressed priority of the elderly. It discusses a pilot project pioneered by the Municipality of The Hague where attention and space was given for the elderly to express their physical and emotional needs in different fora with relevant stakeholders, and reflect on ways in which eHealth could be of help to them. These ideas were important in creating the iZi Experience Home project, which also served as an important tool for creating awareness, enthusiasm and information about the possibilities of technology. The article examines the different processes involved in the development of eHealth applications, including the nature of the deliberations, the devices evolved and tried out in the homes of the elderly. Such methods also raised understanding regarding the challenges of using eHealth, such as the barriers faced by service providers, the costs associated with the gadgets and the resistance of caregivers to these techniques. The project demonstrated that traditional eHealth applications were indeed important in supporting the elderly through increased mobility, security and ability to remain in their homes. But these need to be complemented by community generation, spaces for sharing experiences and physical face-to-face interactions to bring about more comprehensive well-being and happiness. There is therefore the need to broaden the concept of eHealth to move beyond technical solutions only but to include the ideas of the patients, in this case the elderly, in policies, discussions with stakeholders, innovations and practices. In these ways, the elderly are supported to claim their rights to the city. The discussion contributes to understanding the challenges of exercising urban enacted citizenship amongst the elderly, and the need to include inclusion and democratic participation as rights and norms of ‘age-friendly’ cities

T cell receptor alpha-chain gene rearrangements in B-precursor leukemia are in contrast to the findings in T cell acute lymphoblastic leukemia. Comparative study of T cell receptor gene rearrangement in childhood leukemia.

We have analyzed T cell receptor alpha-chain gene configuration using three genomic joining (J) region probes in 64 children with acute lymphoblastic leukemia (ALL). 11 out of 18 T-ALLs were T3 positive; alpha-chain gene rearrangements were demonstrated in only two of 18, indicating that the majority of T-ALLs would have rearrangements involving J alpha segments located upstream of these probes. In contrast, 15 out of 46 B-precursor ALLs showed rearrangements of the alpha-chain gene and J alpha segments located approximately 20-30 kb upstream of the constant region were involved in 13 of these patients. Nine of 15 B-precursor ALLs with rearranged alpha-chain genes had rearrangements of both gamma- and beta-chain genes, whereas the remaining six had no rearrangements of gamma- and beta-chain genes. These findings indicated that alpha-chain gene rearrangement is not specific for T lineage cells and gamma- and/or beta-chain gene rearrangement does not appear essential for alpha-chain gene rearrangement, at least in B-precursor leukemic cells

Autoamplification of NFATc1 expression determines its essential role in bone homeostasis

NFATc1 and NFATc2 are functionally redundant in the immune system, but it was suggested that NFATc1 is required exclusively for differentiation of osteoclasts in the skeletal system. Here we provide genetic evidence that NFATc1 is essential for osteoclast differentiation in vivo by adoptive transfer of NFATc1−/− hematopoietic stem cells to osteoclast-deficient Fos−/− mice, and by Fos−/− blastocyst complementation, thus avoiding the embryonic lethality of NFATc1−/− mice. However, in vitro osteoclastogenesis in NFATc1-deficient cells was rescued by ectopic expression of NFATc2. The discrepancy between the in vivo essential role of NFATc1 and the in vitro effect of NFATc2 was attributed to selective autoregulation of the NFATc1 gene by NFAT through its promoter region. This suggested that an epigenetic mechanism contributes to the essential function of NFATc1 in cell lineage commitment. Thus, this study establishes that NFATc1 represents a potential therapeutic target for bone disease and reveals a mechanism that underlies the essential role of NFATc1 in bone homeostasis

Less Medication Use in Inpatients With Severe Mental Illness Receiving a Multidisciplinary Lifestyle Enhancing Treatment. The MULTI Study III

Besides having an unhealthy lifestyle contributing to premature mortality, inpatients with severe mental illness (SMI) use high dosages of medication. Previous research has shown improved health after lifestyle improvements in SMI. In addition, we aimed to retrospectively study whether a multidisciplinary lifestyle enhancing treatment (MULTI) was associated with changes in medication use after 18 months, as compared with patients that continued treatment as usual (TAU) and explored mediation by a change in physical activity. We conducted an observational study within a cohort of inpatients with SMI, who received MULTI (N = 65) or continued TAU (N = 49). Data on their somatic and psychotropic medications were collected, converted into defined daily dose (DDD), and analyzed using linear multilevel regression, correcting for baseline value and differences between groups in age, diagnosis, and illness severity. Compared with TAU, the DDD for psychotropic medication significantly decreased with MULTI (B = −0.55, P = 0.02). Changes in total activity did not mediate this association, suggesting that multiple components of MULTI contributed. Corrected between-group analyses for subgroups of medication were not possible due to lack of power and skewed distributions. Within-group data showed a decreased proportion of users as well as median DDD in both groups for almost all medications. In addition to previously reported health improvements after 18 months of MULTI, we observed a significant decrease in dose of psychotropic medication in MULTI compared to TAU. This first study evaluating a wide range of medications indicates a possible effect of lifestyle improvements on medication use in inpatients with SMI. Findings need to be confirmed in future controlled studies, however

Does improved functional performance help to reduce urinary incontinence in institutionalized older women? a multicenter randomized clinical trial

<p>Abstract</p> <p>Background</p> <p>Urinary incontinence (UI) is a major problem in older women. Management is usually restricted to dealing with the consequences instead of treating underlying causes such as bladder dysfunction or reduced mobility.</p> <p>The aim of this multicenter randomized controlled trial was to compare a group-based behavioral exercise program to prevent or reduce UI, with usual care. The exercise program aimed to improve functional performance of pelvic floor muscle (PFM), bladder and physical performance of women living in homes for the elderly.</p> <p>Methods</p> <p>Twenty participating Dutch homes were matched and randomized into intervention or control homes using a random number generator. Homes recruited 6–10 older women, with or without UI, with sufficient cognitive and physical function to participate in the program comprising behavioral aspects of continence and physical exercises to improve PFM, bladder and physical performance. The program consisted of a weekly group training session and homework exercises and ran for 6 months during which time the control group participants received care as usual. Primary outcome measures after 6 months were presence or absence of UI, frequency of episodes (measured by participants and caregivers (not blinded) using a 3-day bladder diary) and the Physical Performance Test (blinded). Linear and logistic regression analysis based on the Intention to Treat (ITT) principle using an imputed data set and per protocol analysis including all participants who completed the study and intervention (minimal attendance of 14 sessions).</p> <p>Results</p> <p>102 participants were allocated to the program and 90 to care as usual. ITT analysis (n = 85 intervention, n = 70 control) showed improvement of physical performance (intervention +8%; control −7%) and no differences on other primary and secondary outcome measures. Per protocol analysis (n = 51 intervention, n = 60 control) showed a reduction of participants with UI (intervention −40%; control −28%) and in frequency of episodes (intervention −51%; control −42%) in both groups; improvement of physical performance (intervention + 13%; control −4%) was related to participation in the exercise program.</p> <p>Conclusions</p> <p>This study shows that improving physical performance is feasible in institutionalized older women by exercise. Observed reductions in UI were not related to the intervention. [Current Controlled Trials ISRCTN63368283]</p

Effect of running therapy on depression (EFFORT-D). Design of a randomised controlled trial in adult patients [ISRCTN 1894]

<p>Abstract</p> <p>Background</p> <p>The societal and personal burden of depressive illness is considerable. Despite the developments in treatment strategies, the effectiveness of both medication and psychotherapy is not ideal. Physical activity, including exercise, is a relatively cheap and non-harmful lifestyle intervention which lacks the side-effects of medication and does not require the introspective ability necessary for most psychotherapies. Several cohort studies and randomised controlled trials (RCTs) have been performed to establish the effect of physical activity on prevention and remission of depressive illness. However, recent meta-analysis's of all RCTs in this area showed conflicting results. The objective of the present article is to describe the design of a RCT examining the effect of exercise on depressive patients.</p> <p>Methods/Design</p> <p>The EFFect Of Running Therapy on Depression in adults (EFFORT-D) is a RCT, studying the effectiveness of exercise therapy (running therapy (RT) or Nordic walking (NW)) on depression in adults, in addition to usual care. The study population consists of patients with depressive disorder, Hamilton Rating Scale for Depression (HRSD) ≥ 14, recruited from specialised mental health care. The experimental group receives the exercise intervention besides treatment as usual, the control group receives treatment as usual. The intervention program is a group-based, 1 h session, two times a week for 6 months and of increasing intensity. The control group only performs low intensive non-aerobic exercises. Measurements are performed at inclusion and at 3,6 and 12 months.</p> <p>Primary outcome measure is reduction in depressive symptoms measured by the HRSD. Cardio-respiratory fitness is measured using a sub maximal cycling test, biometric information is gathered and blood samples are collected for metabolic parameters. Also, co-morbidity with pain, anxiety and personality traits is studied, as well as quality of life and cost-effectiveness.</p> <p>Discussion</p> <p>Exercise in depression can be used as a standalone or as an add-on intervention. In specialised mental health care, chronic forms of depression, co-morbid anxiety or physical complaints and treatment resistance are common. An add-on strategy therefore seems the best choice. This is the first high quality large trial into the effectiveness of exercise as an add-on treatment for depression in adult patients in specialised mental health care.</p> <p>Trial registration</p> <p>Netherlands Trial Register (NTR): <a href="http://www.trialregister.nl/trialreg/admin/rctview.asp?TC=1894">NTR1894</a></p

Development and validation of the observation list for early signs of dementia (OLD)

Objective: Development and validation of a short Observation List of possible early signs of Dementia (OLD) for use in general practice. Design: Stepwise development using reviews of publications and expert consensus. Field study for evaluation of reliability. Validation study (interviews, family forms) using existing valid and reliable measures. Use of data reduction techniques to construct a short version. Setting of field study: Twenty-two GPs in 19 Dutch practices. Participants: The first two patients seen on 15 working days (n=470) were observed. Inclusion: age > 75, without a known diagnosis of dementia. Exclusion: psychiatric treatment, severe depression, acute illness with confusion. Division of patients into three groups with no, intermediate, and the most signs (total of interviewed patients, n=60; family forms, n=39). Outcome measures: Reliability (Cronbach's alpha and factor-analysis). Convergent validity using the Cognitive Screening Test (CST), the Word Learning Test (WLT, total and retention), the Informant Questionnaire on Cognitive Decline in the Elderly (IQCODE), the Groningen Activities Restriction Scale (GARS), and an IADL scale. Discriminant validity using the geriatric depression scale (GDS). Construct validity using a Principal Component Analysis (PRINCALS). Incremental validity using the intuitive opinion of the GP (McNemar test). Results: Reliability in the total group 0.88, first factor explained variance 42.5%. Convergent validity (two-way ANOVA) results: CST (p=0.00), WLT-total (p=0.001), WLT retention (p=0.00), IQCODE (p=0.09). No statistically significant differences for GARS and IADL. GDS (p=0.30) not different. PRINCALS first factor explained 48% of variance. The OLD added to the GP opinion (McNemar p=0.00). Reliability short version 0.89 (interviewed group), 0.86 (total group). Conclusion: The OLD is a valid and reliable method to detect early signs of dementia in general practice that can indicate when it may be useful to employ existing screening instruments

The effects of an exercise program for older adults with osteoarthritis of the hip

Objective. Evaluation of an 8-week exercise program with strength training and lifestyle advice for older adults with osteoarthritis (OA) of the hip. Outcome measures were pain, hip function, disability, quality of life (QOL), and body mass index (BMI). Methods. Inclusion criteria for this randomized controlled trial were: age a 55 years, clinical diagnosis of OA according to American College of Rheumatology criteria, and living independently. Interview and physical data were collected at baseline, post-test, and followup (3 mo) by trained interviewers and physical therapists with validated instruments: Harris Hip Score, Sickness Impact Profile, Groningen Activity Restriction Scale, functional tests (walking, timed Up & Go, ascending and descending stairs, and toe reaching), and visual analog scales (pain and QOL). Data were analyzed on an intention-to-treat basis. Effect sizes were calculated. Results. There were 109 participants (55 experimental, 54 controls). The 15 participants who dropped out were characterized by less tolerance to pain and younger age. The program had a positive effect on pain (moderate effect at post-test and small effect at followup), hip function (small effect at post-test), self-reported disability (small effect at followup), and the timed Up & Go test (small effect at followup). It did not affect QOL, other measures of observed disability, or BMI. Conclusion. The exercise program had positive effects on pain and hip function, which are important mediators of disability. This study fulfilled a need for older adults with hip OA and provides evidence of the benefit of exercise in the management of hip OA

EFFORT-D study process evaluation: Challenges in conducting a trial into the effects of running therapy in patients with major depressive disorder

Background: Exercise is currently seen as an effective treatment for major depressive disorder (MDD). However, existing studies have focused mainly on mild-to-moderate depression. The moderate positive effect of exercise found in meta-analyses concerning these studies differs, however, from the harsh daily clinical practice, when trying to implement exercise as an adjunctive treatment. We aimed to evaluate the feasibility of aerobic exercise in MDD and identify future problems for implementation. Methods: The EFFect Of Running Therapy on Depression (EFFORT-D) study was a randomized clinical trial examining the effectiveness of running therapy or Nordic walking in inpatients and outpatients with MDD. We conducted a process evaluation based on the method of Linnan and Steckler. Participant inclusion, dropout and no show were registered qualitatively and quantitatively. Results: The inclusion and delivered dose of the exercise interventions were limited (60 and 75%, respectively), leading to 80% less inclusion than foreseen. Motivational doubts were the main reason not to participate in the study. The unexpected high dropout rates (40% after 3 months and 80% after 12 months) were frequently related to lack of motivation due to disease characteristics and severity. The duration of the intervention, longer than 3 months was another underlying factor for poor adherence. Conclusions: Depression severity appeared to be the key factor determining dropout, followed by the duration of exercise intervention, expressed by a pre- and post-inclusion lack of motivation. Both running therapy and Nordic walking were apparently unsuitable for most patients with MDD in the current format. Emphasis on motivational issues is necessary from the early start of the intervention in these patients with MDD. Also a tailored and stepped-care approach is advised for future implementation