Clients\u27 Internal Representations of Their Therapists

Thirteen adults in long-term individual psychotherapy were interviewed regarding their internal representations (defined as bringing to awareness the internalized image ) of their therapists. Results indicated that in the context of a good therapeutic relationship, clients\u27 internal representations combined auditory, visual, and kinesthetic (i.e., felt presence) modalities; were triggered when clients thought about past or future sessions, or when distressed; occurred in diverse locations; and varied in frequency, duration, and intensity. Clients felt positively about their representations and used them to introspect or influence therapy within sessions, beyond sessions, or both. The frequency of, comfort with, and use of clients\u27 internal representations increased over the course of therapy, and the representations benefited the therapy and therapeutic relationship. Therapists tended not to take a deliberate role in creating clients\u27 internal representations, and few clients discussed their internal representations with their therapists

Carers for older people with co-morbid cognitive impairment in general hospital: characteristics and psychological well-being

OBJECTIVE: This analysis sought to describe the characteristics and well-being of carers of older people with mental health problems admitted to a general hospital. METHODS: General medical and trauma orthopaedic patients aged 70 years or older admitted to an acute general teaching hospital were screened for mental health problems. Those screened positive, together with a carer, were invited to undergo further assessment with a battery of health status measurements. Carers were interviewed to ascertain strain (caregiver strain index (CSI)), psychological distress (12-item General Health Questionnaire) and quality of life (EQ-5D). RESULTS: We recruited 250 patients to the study, of whom 180 were cognitively impaired and had carers willing to take part. After 6 months, 57 patients (32%) had died, and we followed up 100 carers. Carers' own health, in terms of mobility, usual activities, and anxiety, was poor in a third of cases. At the time of admission, high carer strain was common (42% with CSI ≥ 7), particularly among co-resident carers (55%). High levels of behavioural and psychiatric symptoms at baseline were associated with more carer strain and distress. At follow-up, carer strain and distress had reduced only slightly, with no difference in outcomes for carers of patients who moved from the community to a care home. CONCLUSION: Hospital staff should be alert to sources of carer strain and offer carers practical advice and emotional support. Interventions are required to prevent and manage behavioural and psychiatric symptoms at the time of acute physical illness or to alleviate their effects on carers

Caring for cognitively impaired older patients in the general hospital: A qualitative analysis of similarities and differences between a specialist Medical and Mental Health Unit and standard care wards

Background: Around half of people aged over 70 admitted as an emergency to general hospital have dementia, delirium or both. Dissatisfaction is often expressed about the quality of hospital care. A medical and mental health unit was developed to provide best practice care to cognitively impaired older patients. The Unit was evaluated by randomised controlled trial compared to standard care wards. Part of this evaluation involved structured non-participant observations of a random sub-sample of participants and the recording of field notes. Objectives: The aim of this paper is to compare and contrast the behaviours of staff and patients on the Medical and Mental Health Unit and standard care wards and to provide a narrative account that helps to explain the link between structure, process and reported outcomes. Design: Field notes were analysed using the constant comparison method. Setting: A large hospital within the East Midlands region of the United Kingdom. Participants: Patient participants were aged over 65, and identified by Admissions Unit physicians as being ‘confused’. Most patients had delirium or dementia. Results: Sixty observations (360 hours) were made between March and December 2011. Cognitively impaired older patients had high physical and psychological needs, and were cared for in environments which were crowded, noisy and lacked privacy. Staff mostly prioritised physical over psychological needs. Person-centred care on the Medical and Mental Health Unit was mostly delivered during activity sessions or meal times by activities coordinators. Patients on this unit were able to walk around more freely than on other wards. Mental health needs were addressed more often on the Medical and Mental Health Unit than on standard care wards but most staff time was still taken up delivering physical care. More patients called out repetitively on the Unit and staff were not always able to meet the high needs of these patients. Conclusion: Care provided on the Medical and Mental Health Unit was distinctly different from standard care wards. Improvements were worthwhile, but care remained challenging and consistent good practice was difficult to maintain. Disruptive vocalisation may have been provoked by concentrating cognitively impaired patients on one ward

‘Socialised care futility’ in the care of older people in hospital who call out repetitively: an ethnographic study

BackgroundPeople living with dementia may call out repetitively, sometimes called disruptive vocalisation, or verbal agitation. In literature and policy, patients who call out repetitively are assumed to be expressing an unmet need, which should be met. Yet there has been little systematic study of this patient group in an acute hospital setting.ObjectivesTo better understand patients who call out repetitively and to identify what care looks like in an acute hospital setting.DesignEthnography.SettingsTen acute geriatric medical wards in two hospitals.Participants30 cognitively impaired patients who were calling out repetitively, and 15 members of hospital staff.MethodsSemi-structured interviews with hospital staff, 150 hours of ward observations and informal conversations with staff, scrutiny of medical and nursing documentation, and measures of patient health status.ResultsPatients who called out were moderately or severely cognitively impaired, often had delirium, were very physically disabled, and many were approaching the end of life. Most hospital staff were found to hold contradictory views: that calling out represents distress or unmet need, but that nothing can be done to alleviate the calling out. During informal conversations, most staff also tended to say that they intuitively recognised when intervening was likely to alleviate calling out. During observations, many staff appeared to and spoke of the ability to ‘block’ calling out. As a result we argue that social, emotional and physical needs may get overlooked. We argue that some calling out of a need, represents a need that is unmeetable. We also found that while staff would talk about strategies for identifying need, observations and hospital documentation did not support evidence of systematic attempts to identify potential need.ConclusionCalling out repetitively within a hospital setting is difficult for staff to understand and to respond to. This is because many of these patients are severely cognitively impaired, while also bed-bound and dependent on their professional carers. We argue that a form of socialised care futility gets communicated between staff and is used to rationalise becoming unresponsive to calling-out. We explain this phenomenon as resulting from two protective mechanisms: defence of staff's professional identity as competent practitioners; and defence of staff as having personal morality. Socialised care futility risks good quality care, therefore systematic strategies to assess and manage possible need should be developed, even if calling out remains irresolvable in some cases

Rehabilitation potential in older people living with frailty: a systematic mapping review

BackgroundFollowing periods of acute ill-health and injury, older people are frequently assessed and provided with rehabilitation services. Healthcare practitioners are required to make nuanced decisions about which patients are likely to benefit from and respond to rehabilitation. The clinical currency in which these decisions are transacted is through the term “rehabilitation potential”. The aim of this study was to explore information about rehabilitation potential in older people to inform the development of an evidence-based assessment tool.MethodsA systematic mapping review was completed to describe the extent of research and the concepts underpinning rehabilitation potential. We searched Medline, CINHAL, EMBASE, AMED, PsycINFO, PEDro, Cochrane Library, Web of Science, ProQuest, Trip and EThOS from inception to December 2020. We included studies which focused on rehabilitation potential and/or assessing for rehabilitation interventions for older people with comorbidities in the hospital and community setting. Reviewer pairs independently screened articles and extracted data against the inclusion criteria. A descriptive narrative approach to analysis was taken.Results13,484 papers were identified and 49 included in the review. Rehabilitation potential was found to encompass two different but interrelated concepts of prognostication and outcome measurement. 1. Rehabilitation potential for prognostication involved the prediction of what could be achieved in programmes of rehabilitation. 2. Rehabilitation potential as an outcome measure retrospectively considered what had been achieved as a result of rehabilitation interventions. Assessments of rehabilitation potential included key domains which were largely assessed by members of the multi-disciplinary team at single time points. Limited evidence was identified which specifically considered rehabilitation potential amongst older people living with frailty.ConclusionsCurrent approaches to rehabilitation potential provide a snapshot of an individual’s abilities and conditions which fail to capture the dynamic nature and fluctuations associated with frailty and rehabilitation. New approaches to measures and abilities over time are required which allow for the prognostication of outcomes and potential benefits of rehabilitation interventions for older people living with frailty

Double jeopardy: the influence of excessive daytime sleepiness and impaired cognition on health‐related quality of life in adults with heart failure

Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/106066/1/ejhfhfs054.pd

Examining the Relationship Between Word Reading Efficiency and Oral Reading Rate in Predicting Comprehension Among Different Types of Readers

To further explore contextual reading rate, an important aspect of reading fluency, we examined the relationship between word reading efficiency (WRE) and contextual oral reading rate (ORR), the degree to which they overlap across different comprehension measures, whether oral language (semantics and syntax) predicts ORR beyond contributions of word-level skills, and whether the WRE–ORR relationship varies based on different reader profiles. Assessing reading and language of average readers, poor decoders, and poor comprehenders, ages 10 to 14, ORR was the strongest predictor of comprehension across various formats; WRE contributed no unique variance after taking ORR into account. Findings indicated that semantics, not syntax, contributed to ORR. Poor comprehenders performed below average on measures of ORR, despite average WRE, expanding previous findings suggesting specific weaknesses in ORR for this group. Together, findings suggest that ORR draws upon skills beyond those captured by WRE and suggests a role for oral language (semantics) in ORR

Effect of Progression From Impaired Glucose Tolerance to Diabetes on Cardiovascular Risk Factors and Its Amelioration by Lifestyle and Metformin Intervention: The Diabetes Prevention Program randomized trial by the Diabetes Prevention Program Research Group*

OBJECTIVE Although subjects with diabetes have increased risk for cardiovascular disease (CVD), the evolution of this increased risk as pre-diabetic individuals progress to diabetes is not understood. This study examines the longitudinal relationship between selected CVD risk factors (blood pressure, triglycerides, HDL and LDL cholesterol, and LDL peak particle density [PPD]) and glycemia in the three treatment groups of the Diabetes Prevention Program. RESEARCH DESIGN AND METHODS A total of 3,234 participants with impaired glucose tolerance (IGT) were followed for a mean of 3.2 years after randomization to intensive lifestyle intervention (ILS), metformin, or placebo. Using repeated-measures models, adjusted mean levels of risk factors were estimated for an annual change in glycemic status. Tests were also conducted to assess the risk factor trends with improvement or worsening of glycemic status. RESULTS CVD risk factor values and changes from baseline became more unfavorable as glucose tolerance status deteriorated but improved with reversion to normal glucose tolerance (NGT), especially in the ILS intervention group (trend test P < 0.001 for all risk factors except for LDL PPD [P = 0.02] in ILS and HDL cholesterol [P = 0.02] in placebo). Although there were few significant differences in the transition from IGT to diabetes, there were strong relationships between risk factors and continuous measures of glycemia. CONCLUSIONS Progression from IGT to diabetes is associated with mild deterioration, whereas reversion to NGT is associated with improvement in risk factors. Early intervention with ILS, but less so with metformin, in participants at high risk for diabetes improves the cardiovascular risk and glucose tolerance profile simultaneously

The VOICE study – a before and after study of a dementia communication skills training course

Background A quarter of acute hospital beds are occupied by persons living with dementia, many of whom have communication problems. Healthcare professionals lack confidence in dementia communication skills, but there are no evidence-based communication skills training approaches appropriate for professionals working in this context. We aimed to develop and pilot a dementia communication skills training course that was acceptable and useful to healthcare professionals, hospital patients and their relatives. Methods The course was developed using conversation analytic findings from video recordings of healthcare professionals talking to patients living with dementia in the acute hospital, together with systematic review evidence of dementia communication skills training and taking account of expert and service-user opinion. The two-day course was based on experiential learning theory, and included simulation and video workshops, reflective diaries and didactic teaching. Actors were trained to portray patients living with dementia for the simulation exercises. Six courses were run between January and May 2017. 44/45 healthcare professionals attended both days of the course. Evaluation entailed: questionnaires on confidence in dementia communication; a dementia communication knowledge test; and participants’ satisfaction. Video-recorded, simulated assessments were used to measure changes in communication behaviour. Results Healthcare professionals increased their knowledge of dementia communication (mean improvement 1.5/10; 95% confidence interval 1.0–2.0; p<0.001). Confidence in dementia communication also increased (mean improvement 5.5/45; 95% confidence interval 4.1–6.9; p<0.001) and the course was well-received. One month later participants reported using the skills learned in clinical practice. Blind-ratings of simulated patient encounters demonstrated behaviour change in taught communication behaviours to close an encounter, consistent with the training, but not in requesting behaviours. Conclusion We have developed an innovative, evidence-based dementia communication skills training course which healthcare professionals found useful and after which they demonstrated improved dementia communication knowledge, confidence and behaviour