Proactive Ethical Design for Neuroengineering, Assistive and Rehabilitation Technologies: the Cybathlon Lesson.

Rapid advancements in rehabilitation science and the widespread application of engineering techniques are opening the prospect of a new phase of clinical and commercial maturity for Neuroengineering, Assistive and Rehabilitation Technologies (NARTs). As the field enters this new phase, there is an urgent need to address and anticipate the ethical implications associated with novel technological opportunities, clinical solutions, and social applications. In this paper we review possible approaches to the ethics of NART, and propose a framework for ethical design and development, which we call the Proactive Ethical Design (PED) framework. A viable ethical framework for neuroengineering, assistive and rehabilitation technology should be characterized by the convergence of user-centered and value-sensitive approaches to product design through a proactive mode of ethical evaluation. We propose four basic normative requirements for the realization of this framework: minimization of power imbalances, compliance with biomedical ethics, translationality and social awareness. The aims and values of the CYBATHLON competition provide an operative model of this ethical framework and could drive an ethical shift in neuroengineering and rehabilitation

Osteoporosis drug treatment: duration and management after discontinuation. A position statement from the SVGO/ASCO.

Antiosteoporotic drugs are recommended in patients with fragility fractures and in patients considered to be at high fracture risk on the basis of clinical risk factors and/or low bone mineral density. As first-line treatment most patients are started with an antiresorptive treatment, i.e. drugs that inhibit osteoclast development and/or function (bisphosphonates, denosumab, oestrogens or selective oestrogen receptor modulators). In the balance between benefits and risks of antiresorptive treatment, uncertainties remain regarding the optimal treatment duration and the management of patients after drug discontinuation. Based on the available evidence, this position statement will focus on the long-term management of osteoporosis therapy, formulating decision criteria for clinical practice

Swiss Frailty Network and Repository: protocol of a Swiss Personalized Health Network's driver project observational study.

Early identification of frailty by clinical instruments or accumulation of deficit indexes can contribute to improve healthcare for older adults, including the prevention of negative outcomes in acute care. However, conflicting evidence exists on how to best capture frailty in this setting. Simultaneously, the increasing utilisation of electronic health records (EHRs) opens up new possibilities for research and patient care, including frailty. The Swiss Frailty Network and Repository (SFNR) primarily aims to develop an electronic Frailty Index (eFI) from routinely available EHR data in order to investigate its predictive value against length of stay and in-hospital mortality as two important clinical outcomes in a study sample of 1000-1500 hospital patients aged 65 years and older. In addition, we will examine the correlation between the eFI and a test-based clinical Frailty Instrument to compare both concepts in Swiss older adults in acute care settings. As a Swiss Personalized Health Network (SPHN) driver project, our study will report on the characteristics and usability of the first nationwide eFI in Switzerland connecting all five Swiss University Hospitals' Geriatric Departments with a representative sample of patients aged 65 years and older admitted to acute care. The study protocol was approved by the competent ethics committee of the Canton of Zurich (BASEC-ID 2019-00445). All acquired data will be handled according to SPHN's ethical framework for responsible data processing in personalised health research. Analyses will be performed within the secure BioMedIT environment, a national infrastructure to enable secure biomedical data processing, an integral part of SPHN. NCT04516642

Instrumental and non-instrumental evaluation of 4-meter walking speed in older individuals

Background: Manual measurement of 4-meter gait speed by a stopwatch is the gold standard test for functional assessment in older adults. However, the accuracy of this technique may be biased by several factors, including intra- and inter-operator variability. Instrumental techniques of measurement using accelerometers may have a higher accuracy. Studies addressing the concordance between these two techniques are missing. The aim of the present community-based observational study was to compare manual and instrumental measurements of 4-meter gait speed in older individuals and to assess their relationship with other indicators of physical performance. Methods: One-hundred seventy-two (69 men, 103 women) non-disabled community-dwellers aged \ue2\u89\ua565 years were enrolled. They underwent a comprehensive geriatric assessment including physical function by Short Physical Performance Battery (SPPB), hand grip strength, and 6-minute walking test (6MWT). Timed usual walking speed on a 4-meter course was assessed by using both a stopwatch (4-meter manual measurement, 4-MM) and a tri-axial accelerometer (4-meter automatic measurement, 4-MA). Correlations between these performance measures were evaluated separately in men and women by partial correlation coefficients. Results: In both genders, 4-MA was associated with 4-MM (men r = 0.62, p<0.001; women r = 0.73, p<0.001), handgrip strength (men r = 0.40, p = 0.005; women r = 0.29, p = 0.001) and 6MWT (men r = 0.50, p = 0.0004; women r = 0.22, p = 0.048). 4-MM was associated with handgrip strength and 6MWT in both men and women. Considering gait speed <0.6 m/s as diagnostic of dismobility syndrome, the two methods of assessment disagreed, with a different categorization of subjects, in 19% of men and 23% of women. The use of accelerometer resulted in 29 (13 M, 16 F) additional diagnoses of dismobility, compared with the 4-MM. Conclusions: In an older population, the concordance of gait speeds manually or instrumentally assessed is not optimal. The results suggest that manual measures might lead to misclassification of a substantial number of subjects. However, longitudinal studies using standardized and validated procedures aimed at the comparison of different techniques are needed before recommending the use of accelerometers in comprehensive geriatric assessment

Use it or lose it! Cognitive activity as a protec-tive factor for cognitive decline associated with Alzheimer's disease.

Because of the worldwide aging of populations, Alzheimer's disease and other dementias constitute a devastating experience for patients and families as well as a major social and economic burden for both healthcare systems and society. Multiple potentially modifiable cardiovascular and lifestyle risk factors have been associated with this disease. Thus, modifying these risk factors and identifying protective factors represent important strategies to prevent and delay disease onset and to decrease the social burden. Based on the cognitive reserve hypothesis, evidence from epidemiological studies shows that low education and cognitive inactivity constitute major risk factors for dementia. This indicates that a cognitively active lifestyle may protect against cognitive decline or delay the onset of dementia. We describe a newly developed preventive programme, based on this evidence, to stimulate and increase cognitive activity in older adults at risk for cognitive decline. This programme, called "BrainCoach", includes the technique of "motivational interviewing" to foster behaviour change. If the planned feasibility study is successful, we propose to add BrainCoach as a module to the already existing "Health Coaching" programme, a Swiss preventive programme to address multiple risk factors in primary care

Prevalence and incidence of iron deficiency in European community-dwelling older adults: an observational analysis of the DO-HEALTH trial

Background and aim Iron deficiency is associated with increased morbidity and mortality in older adults. However, data on its prevalence and incidence among older adults is limited. The aim of this study was to investigate the prevalence and incidence of iron deficiency in European community-dwelling older adults aged ≥ 70 years. Methods Secondary analysis of the DO-HEALTH trial, a 3-year clinical trial including 2157 community-dwelling adults aged ≥ 70 years from Austria, France, Germany, Portugal and Switzerland. Iron deficiency was defined as soluble transferrin receptor (sTfR) > 28.1 nmol/L. Prevalence and incidence rate (IR) of iron deficiency per 100 person-years were examined overall and stratified by sex, age group, and country. Sensitivity analysis for three commonly used definitions of iron deficiency (ferritin  1.5) were also performed. Results Out of 2157 participants, 2141 had sTfR measured at baseline (mean age 74.9 years; 61.5% women). The prevalence of iron deficiency at baseline was 26.8%, and did not differ by sex, but by age (35.6% in age group ≥ 80, 29.3% in age group 75–79, 23.2% in age group 70–74); P  1.5. Occurrences of iron deficiency were observed with IR per 100 person-years of 9.2 (95% CI 8.3–10.1) and did not significantly differ by sex or age group. The highest IR per 100 person-years was observed in Austria (20.8, 95% CI 16.1–26.9), the lowest in Germany (6.1, 95% CI 4.7–8.0). Regarding the other definitions of iron deficiency, the IR per 100 person-years was 4.5 (95% CI 4.0–4.9) for ferritin  1.5. Conclusions Iron deficiency is frequent among relatively healthy European older adults, with people aged ≥ 80 years and residence in Austria and Portugal associated with the highest risk

Ethical Design of Intelligent Assistive Technologies for Dementia: A Descriptive Review.

The use of Intelligent Assistive Technology (IAT) in dementia care opens the prospects of reducing the global burden of dementia and enabling novel opportunities to improve the lives of dementia patients. However, with current adoption rates being reportedly low, the potential of IATs might remain under-expressed as long as the reasons for suboptimal adoption remain unaddressed. Among these, ethical and social considerations are critical. This article reviews the spectrum of IATs for dementia and investigates the prevalence of ethical considerations in the design of current IATs. Our screening shows that a significant portion of current IATs is designed in the absence of explicit ethical considerations. These results suggest that the lack of ethical consideration might be a codeterminant of current structural limitations in the translation of IATs from designing labs to bedside. Based on these data, we call for a coordinated effort to proactively incorporate ethical considerations early in the design and development of new products

A before and after study of a nurse led comprehensive delirium management programme (DemDel) for older acute care inpatients with cognitive impairment

Studies estimate that approximately one-third of episodes of delirium are preventable and that delirium prevention and management are often suboptimal in practice. While there is no doubt that prevention is desirable, the evidence of the benefits of early intervention and treatment for older hospitalised patients with dementia is unclear.; To determine the effects of DemDel, a comprehensive delirium management programme, in inpatient acute care elders with cognitive impairment.; This paper reports the quantitative part of a mixed methods study, comparing an intervention with treatment as usual using validated outcome measures. After training, ward nurses and physicians administered the intervention based on the DemDel algorithm that focused on delirium prevention, including an intensive systematic screening schedule for cognitive impairment and delirium, as well as comprehensive delirium management. The delirium management regimen included timely administration of pro re nata medication.; The study was conducted within four medical wards of an acute care university hospital in urban Switzerland.; A total of 268 patients with cognitive impairment participated in the pre/post comparison study. The intervention and treatment as usual groups consisted of 138 and 130 patients, respectively.; Eighty-seven (32.5%) out of 268 patients developed delirium, of whom 51 (58.6%) were of mixed, 10 (11.5%) hyperactive and 26 (29.9%) hypoactive delirium subtypes. Delirium appeared within the first five days after admission in 81.6% of cases. The 44 (31.9%) patients with delirium in the intervention group with systematic delirium management had less severe episodes of delirium and required medication for management than the 43 (33.1%) delirious patients in the control group. Intervention compliance was good on three of the four units.; The DemDel programme was effective with regard to improvement of outcomes associated with delirium in patients with cognitive impairment. The intervention was feasible and possible to be embedded within routine practice on four busy general medical wards