Insomnia symptoms in elderly persons - assessment, associated factors and non-pharmacological nursing interventions

The aim of this thesis was to test a tool for assessing insomnia symptoms in elderly persons and to investigate late-life insomnia in terms of associated factors and evidence of non-pharmacological interventions in healthcare settings. Data were collected by means of a systematic literature search (Study I), questionnaires (Studies II-III), interviews and observations (Study IV). The results from Study I are based on nine studies and six non-pharmacological interventions were found. Evidence for the interventions was limited. However, massage, acupunctural stimulation and listening to music/natural sounds or watching an instrumental music video showed a moderate to large effect on several sleep outcomes. In Study II, the measurement properties of the Minimal Insomnia Symptom scale (MISS) were tested on 497 elderly pesons. Corrected item-total correlations were 0.64-0.70, floor/ceiling effects were 6.6/0.6% and reliability 0.81. Using a cut-off score of ≥7 points, sensitivity and specificity were 93/84%. MISS was found to be feasible as a screening tool for insomnia in the elderly. An investigation of associations between leisure activities and sleep disturbances (Study III) showed that gardening, strolling in the country, home maintenance, repairing cars/machines and playing chess/cards were associated with fewer sleep disturbances in elderly persons. Adjusting for age, gender, general health, functional ability and mood, only playing chess/cards remained statistically significant. After interactions between gender and leisure activities were added to the model, only home maintenance was statistically significant. The ability to pursue home maintenance seemed to be particularly important for women. Investigating sleep and everyday activities at residential care facilities (RCFs) revealed that the punctual scheduling of meals and coffee times helped to maintain a regular rhythm and limit daytime sleep (Study IV). Several residents perceived their sleep to be longer and more regular since moving in. Less mobile residents would spend most of the day in the day room, with less activity and without the possibility of withdrawing. Slumbering in the day room was common. Residents who were mobile spent more time in the privacy of their apartments, pursuing activities on their own. In conclusion, evidence for non-pharmacological sleep interventions is limited. Socio-intellectual activities, such as playing chess/cards or doing home maintenance, were associated with fewer sleep disturbances. Less dependent pesons benefitted from the structured day at the RCF, they performed solitary activities to a large extent and they felt their sleep had improved. MISS was found to be a reliable tool for initial screening of insomnia in the elderly, and could be useful in clinical practice

Communication about medication management during patient-physician consultations in primary care: a participant observation study

Objective - To explore communication about medication management during annual consultations in primary care. Design: passive participant observations of primary care consultations. Setting - Two primary care centres in southern Sweden. Participants - Consultations between 18 patients (over the age of 60 years) with chronic diseases and 10 general practitioners (GPs) were observed, audio-recorded, transcribed and analysed using content analysis. Results - Four categories emerged: communication barriers, striving for a shared understanding of medication management, evaluation of the current medication treatment and the plan ahead and behavioural changes in relation to medication management. Misunderstandings in communication, failure to report changes in the medication treatment and use of generic substitutes complicated mutual understanding and agreement on continued treatment. The need for behavioural changes to reduce the need for medication treatment was recognised but should be explored further. Conclusion - Several pitfalls, including miscommunication and inaccurate medication lists, for safe medication management were identified. The purpose of annual consultations should be clarified, individual treatment plans could be used more actively during primary care consultations and efforts are needed to improve verbal communication and information continuity

Measurement properties of the Minimal Insomnia Symptom Scale (MISS) in an elderly population in Sweden

<p>Abstract</p> <p>Background</p> <p>Insomnia is common among elderly people and associated with poor health. The Minimal Insomnia Symptom Scale (MISS) is a three item screening instrument that has been found to be psychometrically sound and capable of identifying insomnia in the general population (20-64 years). However, its measurement properties have not been studied in an elderly population. Our aim was to test the measurement properties of the MISS among people aged 65 + in Sweden, by replicating the original study in an elderly sample.</p> <p>Methods</p> <p>Data from a cross-sectional survey of 548 elderly individuals were analysed in terms of assumptions of summation of items, floor/ceiling effects, reliability and optimal cut-off score by means of ROC-curve analysis and compared with self-reported insomnia criteria.</p> <p>Results</p> <p>Corrected item-total correlations ranged between 0.64-0.70, floor/ceiling effects were 6.6/0.6% and reliability was 0.81. ROC analysis identified the optimal cut-off score as ≥7 (sensitivity, 0.93; specificity, 0.84; positive/negative predictive values, 0.256/0.995). Using this cut-off score, the prevalence of insomnia in the study sample was 21.7% and most frequent among women and the oldest old.</p> <p>Conclusions</p> <p>Data support the measurement properties of the MISS as a possible insomnia screening instrument for elderly persons. This study make evident that the MISS is useful for identifying elderly people with insomnia-like sleep problems. Further studies are needed to assess its usefulness in identifying clinically defined insomnia.</p

Toxicological and bioactivity evaluation of blackcurrant press cake, sea buckthorn leaves and bark from Scots pine and Norway spruce extracts under a green integrated approach

Aqueous extracts from blackcurrant press cake (BC), Norway spruce bark (NS), Scots pine bark (SP), and sea buckthorn leaves (SB) were obtained using maceration and pressurized hot water and tested for their bioactivities. Maceration provided the extraction of higher dry matter contents, including total phenolics (TPC), anthocyanins, and condensed tannins, which also impacted higher antioxidant activity. NS and SB extracts presented the highest mean values of TPC and antioxidant activity. Individually, NS extract presented high contents of proanthocyanidins, resveratrol, and some phenolic acids. In contrast, SB contained a high concentration of ellagitannins, ellagic acid, and quercetin, explaining the antioxidant activity and antibacterial effects. SP and BC extracts had the lowest TPC and antioxidant activity. However, BC had strong antiviral efficacy, whereas SP can be considered a potential ingredient to inhibit α-amylase. Except for BC, the other extracts decreased reactive oxygen species (ROS) generation in HCT8 and A549 cells. Extracts did not inhibit the production of TNF-alpha in lipopolysaccharide-stimulated THP-1 macrophages but inhibited the ROS generation during the THP-1 cell respiratory burst. The recovery of antioxidant compounds from these by-products is incentivized for high value-added applications.</p

An original phylogenetic approach identified mitochondrial haplogroup T1a1 as inversely associated with breast cancer risk in BRCA2 mutation carriers

Introduction: Individuals carrying pathogenic mutations in the BRCA1 and BRCA2 genes have a high lifetime risk of breast cancer. BRCA1 and BRCA2 are involved in DNA double-strand break repair, DNA alterations that can be caused by exposure to reactive oxygen species, a main source of which are mitochondria. Mitochondrial genome variations affect electron transport chain efficiency and reactive oxygen species production. Individuals with different mitochondrial haplogroups differ in their metabolism and sensitivity to oxidative stress. Variability in mitochondrial genetic background can alter reactive oxygen species production, leading to cancer risk. In the present study, we tested the hypothesis that mitochondrial haplogroups modify breast cancer risk in BRCA1/2 mutation carriers. Methods: We genotyped 22,214 (11,421 affected, 10,793 unaffected) mutation carriers belonging to the Consortium of Investigators of Modifiers of BRCA1/2 for 129 mitochondrial polymorphisms using the iCOGS array. Haplogroup inference and association detection were performed using a phylogenetic approach. ALTree was applied to explore the reference mitochondrial evolutionary tree and detect subclades enriched in affected or unaffected individuals. Results: We discovered that subclade T1a1 was depleted in affected BRCA2 mutation carriers compared with the rest of clade T (hazard ratio (HR) = 0.55; 95% confidence interval (CI), 0.34 to 0.88; P = 0.01). Compared with the most frequent haplogroup in the general population (that is, H and T clades), the T1a1 haplogroup has a HR of 0.62 (95% CI, 0.40 to 0.95; P = 0.03). We also identified three potential susceptibility loci, including G13708A/rs28359178, which has demonstrated an inverse association with familial breast cancer risk. Conclusions: This study illustrates how original approaches such as the phylogeny-based method we used can empower classical molecular epidemiological studies aimed at identifying association or risk modification effects.Peer reviewe

31st Annual Meeting and Associated Programs of the Society for Immunotherapy of Cancer (SITC 2016) : part two

Background The immunological escape of tumors represents one of the main ob- stacles to the treatment of malignancies. The blockade of PD-1 or CTLA-4 receptors represented a milestone in the history of immunotherapy. However, immune checkpoint inhibitors seem to be effective in specific cohorts of patients. It has been proposed that their efficacy relies on the presence of an immunological response. Thus, we hypothesized that disruption of the PD-L1/PD-1 axis would synergize with our oncolytic vaccine platform PeptiCRAd. Methods We used murine B16OVA in vivo tumor models and flow cytometry analysis to investigate the immunological background. Results First, we found that high-burden B16OVA tumors were refractory to combination immunotherapy. However, with a more aggressive schedule, tumors with a lower burden were more susceptible to the combination of PeptiCRAd and PD-L1 blockade. The therapy signifi- cantly increased the median survival of mice (Fig. 7). Interestingly, the reduced growth of contralaterally injected B16F10 cells sug- gested the presence of a long lasting immunological memory also against non-targeted antigens. Concerning the functional state of tumor infiltrating lymphocytes (TILs), we found that all the immune therapies would enhance the percentage of activated (PD-1pos TIM- 3neg) T lymphocytes and reduce the amount of exhausted (PD-1pos TIM-3pos) cells compared to placebo. As expected, we found that PeptiCRAd monotherapy could increase the number of antigen spe- cific CD8+ T cells compared to other treatments. However, only the combination with PD-L1 blockade could significantly increase the ra- tio between activated and exhausted pentamer positive cells (p= 0.0058), suggesting that by disrupting the PD-1/PD-L1 axis we could decrease the amount of dysfunctional antigen specific T cells. We ob- served that the anatomical location deeply influenced the state of CD4+ and CD8+ T lymphocytes. In fact, TIM-3 expression was in- creased by 2 fold on TILs compared to splenic and lymphoid T cells. In the CD8+ compartment, the expression of PD-1 on the surface seemed to be restricted to the tumor micro-environment, while CD4 + T cells had a high expression of PD-1 also in lymphoid organs. Interestingly, we found that the levels of PD-1 were significantly higher on CD8+ T cells than on CD4+ T cells into the tumor micro- environment (p < 0.0001). Conclusions In conclusion, we demonstrated that the efficacy of immune check- point inhibitors might be strongly enhanced by their combination with cancer vaccines. PeptiCRAd was able to increase the number of antigen-specific T cells and PD-L1 blockade prevented their exhaus- tion, resulting in long-lasting immunological memory and increased median survival

Association between Sleep Disturbances and Leisure Activities in the Elderly : A Comparison between Men and Women.

It has been suggested that physical or social activity is associated with fewer sleep disturbances among elderly people. Women report more sleep disturbances than men, which could indicate a variation in activity patterns between the genders. The aim of this study was to investigate associations between sleep disturbances and leisure activities in men and women (n = 945) aged ≥60 years in a Swedish population. Sleep disturbances were measured using eight dichotomous questions and seventeen variables, covering a wide range of leisure activities. Few leisure activities were found to be associated with sleep disturbances and their importance decreased when the models were adjusted for confounders and gender interactions. After clustering the leisure activities and investigating individual activities, socio-intellectual activities were shown to be significant for sleep. However, following adjustment for confounders and gender interactions, home maintenance was the only activity significant for sleep. Being a female increased the effect of home maintenance. Besides those leisure activities, poor/fair self-rated health (OR 7.50, CI: 4.27-11.81) and being female (OR 4.86, CI: 2.75-8.61) were found to have the highest association with poor sleep. Leisure activities pursued by elderly people should focus on activities of a socio-intellectual nature, especially among women, to promote sleep.Open access journal</p

Association between Sleep Disturbances and Leisure Activities in the Elderly: A Comparison between Men and Women.

It has been suggested that physical or social activity is associated with fewer sleep disturbances among elderly people. Women report more sleep disturbances than men, which could indicate a variation in activity patterns between the genders. The aim of this study was to investigate associations between sleep disturbances and leisure activities in men and women (n = 945) aged ≥60 years in a Swedish population. Sleep disturbances were measured using eight dichotomous questions and seventeen variables, covering a wide range of leisure activities. Few leisure activities were found to be associated with sleep disturbances and their importance decreased when the models were adjusted for confounders and gender interactions. After clustering the leisure activities and investigating individual activities, socio-intellectual activities were shown to be significant for sleep. However, following adjustment for confounders and gender interactions, home maintenance was the only activity significant for sleep. Being a female increased the effect of home maintenance. Besides those leisure activities, poor/fair self-rated health (OR 7.50, CI: 4.27-11.81) and being female (OR 4.86, CI: 2.75-8.61) were found to have the highest association with poor sleep. Leisure activities pursued by elderly people should focus on activities of a socio-intellectual nature, especially among women, to promote sleep

Det omorganiserade personalarbetet : Linjechefernas uppfattning av en centraliserad HR-funktion

Syftet med denna studie var att undersöka samt analysera hur linjechefer uppfattar en centraliserad HR-funktion, då tidigare forskning påvisar att en HR-transformation kan innebära utmaningar. Det har tidigare konstaterats att samspelet mellan linjechefer och HR-funktionen påverkas av omorganiseringen och aktörerna måste inta nya roller samt förvärva nya kunskaper. Tidigare forskning belyser även att det som förefaller effektivt på en övergripande nivå inte alltid upplevs som effektivt för linjecheferna och därmed behöver linjechefernas åsikter beaktas. Studien bidrar till att synliggöra utvecklingsmöjligheter och förhoppningen har varit att HR-center inom en offentlig organisation ska kunna använda resultatet för att generera ett ändamålsenligt stöd. Studien har genomförts inom Falu kommun som nyligen har genomgått en HR-transformation. För att uppnå syftet har en kvalitativ fallstudie med åtta semistrukturerade intervjuer genomförts. Resultatet från intervjuerna har sedan analyserats utifrån tidigare forskning inom ämnet för att kunna förstå vad empirin säger i förhållande till teori. Resultatet visar på att en centraliserad HR-funktion skapar en större styrka till organisationen, genom att HR-specialisterna kan utbyta kunskaper med varandra. HR-transformationen medför dock nya tillvägagångssätt för att hantera personalfrågor och linjecheferna saknar den personliga kontakten. Den nya shared service-organisationen som innebär att linecheferna ska kunna söka ett mer specialiserat stöd hos olika HR-funktioner, leder till att linjecheferna har många olika HR-handläggare i olika ärenden. Respondenterna är överens om att detta är en av baksidorna med HR-transformationen och efterfrågar kontakt med en specifik HR-medarbetare. Linjechefernas anställningstid har betydelse för hur omorganiseringen uppfattas. De linjechefer som varit med under HR-transformationen saknar i större utsträckning en HR-medarbetare på plats. För att HR-funktionen ska få en förståelse för linjechefernas arbete behöver de vara mer närvarande ute i organisationen. Till skillnad från tidigare forskning förefaller det dock finnas en tydlig arbetsfördelning och linjecheferna ser personalansvaret som positivt. Sammanfattningsvis uppfattar linjecheferna den centraliserade HR-funktionen som positiv, HR-medarbetarna är kunniga och stöttande i alla personalärenden. Det finns dock utvecklingsmöjligheter att ta i beaktande för att HR-transformationen ska skapa värde och effektivitet för såväl linjechefer som för HR-funktionen.The purpose of this study was to investigate and analyze how line managers perceive a centralized HR function, as previous research shows that an HR transformation can pose challenges. It has previously been found that the interaction between line managers and the HR function is influenced by the reorganization and the operators must take on new roles and acquire new knowledge. Earlier research also highlights that what seems to be effective at an overall level is not always perceived as effective for the line managers and thus the line managers' views need to be considered. The study contributes to highlighting development opportunities and the hope has been that HR centers within a public organization should be able to use the results to generate appropriate support. The study has been carried out within Falu commune which has recently undergone an HR transformation. To achieve the purpose, a qualitative case study with eight semi-structured interviews has been conducted. The results of the interviews have then been analyzed based on previous research in the subject in order to understand what the empiricism says in relation to theory. The result shows that a centralized HR function creates a greater strength for the organization, because the HR specialists can exchange knowledge with each other. The HR transformation, however, entails new approaches to managing personnel issues and the line managers lack the personal contact. The personal contact does not necessarily mean that there is an HR employee out in the administrations. The new shared service organization, which means that the line managers should be able to apply for a more specialized support from different HR functions, leads to the line managers having many different HR managers in different cases. The respondents agree that this is one of the back sides to the HR transformation and asks for contact with a specific HR employee. The line managers' employment period is important for how the reorganization is perceived. The line managers who participated in the HR transformation lack a HR employee on site to a greater extent. For the HR function to gain an understanding of the work of the line managers, they need to be more present in the organization. However, unlike previous research, it seems that there is a clear division of labor and the line managers see personnel responsibility as positive. To sum up, the line managers perceive the centralized HR function as positive, the HR employees are knowledgeable and supportive in all staff matters. However, there are development opportunities to consider in order for the HR transformation to create value and efficiency for both line managers and for the HR function