Challenges in dementia care: Comparing key issues from Brazil and the United Kingdom

The United Kingdom-Brazil Dementia Workshop took place in July 2019 in the city of Belo Horizonte, MG, Brazil, with an interdisciplinary group of health and care professionals from the United Kingdom and from Brazil to address challenges in diagnosis, public perception and care of dementia. The aim of this article is to present the results identified in relation to challenges in the care of dementia, including recommendations that could potentially guide local and State/Municipal authorities and care services for people with dementia in the future. Four key issues were prioritised to identify challenges and generate possible solutions in Brazil and the United Kingdom: I) limitations of current health systems; II) continuous and long-term support for family carers (pre-diagnosis, mourning); III) support for people with advanced dementia and end-of-life care; IV) support for people with young-onset dementia. In both countries, carers feel left without post-diagnostic support; information on the progression of dementia is lacking and some people do not even have a specific diagnosis; encouraging and providing training for carers best manage some of the symptoms is imperative; preparation for end of life care and support carers after the death of their loved ones remains highly needed; strengthening services and qualification of health professionals, also creating protocols to guide dementia-related services represent a common challenge to overcome. The authors outline recommendations according to the issues identified to assist future formulation of adequate policies and services for people with dementia and carers

Human herpesvirus infections and dementia or mild cognitive impairment: a systematic review and meta-analysis.

Interest is growing in the role of infectious agents in the pathogenesis of dementia, but current evidence is limited. We conducted a systematic review and meta-analysis to investigate the effect of any of eight human herpesviruses on development of dementia or mild cognitive impairment (MCI). We searched the Cochrane Library, Embase, Global Health, Medline, PsycINFO, Scopus, Web of Science, clinical trials registers and grey literature sources from inception to December 2017 for observational studies with cohort, case control or self-controlled designs, or randomised controlled trials of interventions against herpesviruses. Pooled effect estimates and 95% confidence intervals (CIs) were generated through random effects meta-analyses across studies with the same design, outcome, and virus type, method and site of measurement. We included 57 studies across various geographic settings. Past infection with herpesviruses, measured by IgG seropositivity, was generally not associated with dementia risk. A single cohort study rated moderate quality showed an association between varicella zoster virus reactivation (ophthalmic zoster) and incident dementia (HR 2.97; 95%CI, 1.89 to 4.66). Recent infection with, or reactivation of, herpes simplex virus type 1 or type 1/2 unspecified, cytomegalovirus and human herpes virus-6 measured by serum IgM, high titre IgG or clinical disease may be associated with dementia or MCI, though results were inconsistent across studies and overall evidence rated very low quality. Longitudinal population studies with robust repeated virus measurements taken sufficiently proximal to dementia onset are needed to establish whether, when and among whom herpesviruses affect dementia risk

Reducing antipsychotic prescriptions in primary care : a healthcare perspective

Purpose: One in 14 people over 65 years suffer from dementia in the UK. Over 25 per cent are receiving antipsychotics, which cause increases in mortality and cerebrovascular events. The need for a reduction and the use of alternative supportive strategies has been advocated. Risperidone at six-week intervals is the only antipsychotic licensed for treatment with regular review. The majority of management occurs at primary care level and in care homes. The purpose of this paper is to investigate antipsychotic prescribing practices and patient review in these settings. Design/methodology/approach: In total, two surveys comprising questions addressing prescribing practices were developed and distributed electronically to all GP practices and care homes in Coventry and Warwickshire, West Midlands, England. Findings: The majority of GPs (75 per cent) reported only “occasional” discontinuation of antipsychotics due to concerns at reducing drugs on their own, expectations of regulation from secondary care and resistance from care home staff. Poor reduction levels were reported in care homes, attributing low numbers to reluctance among GPs. History of cardiovascular risk factors did not appear to influence withdrawal. Only 40 per cent of GP practices maintained sole use of risperidone. At least six-monthly reviews were reported by 63 per cent of GPs and 64 per cent of care homes, with very few conducting reviews at least three-monthly. The importance of non-pharmacological alternatives was emphasized, yet access was limited and highly resource-dependent. Originality/value: This study reveals the perspectives of staff delivering healthcare for people with dementia and behavioural and psychological symptoms of dementia (BPSD). Potentially inappropriate antipsychotic principles were reported. A lack of communication and uncertainty of roles was evident. The development of understandable guidelines for healthcare workers and care home staff managing behavioural issues in patients with dementia is necessary

Prevalences of dementia and cognitive impairment among older people in sub-Saharan Africa : a systematic review

Objective: To perform a systematic review of the literature on the prevalence of cognitive impairment and dementia in sub-Saharan Africa. Methods: Five electronic databases were searched for relevant abstracts and to identify papers eligible for full-text review. A study was included if two authors agreed that it had a cohort, case–control or cross-sectional design and reported population-level data; was limited to black African adults older than 50 years or described as “elderly” or “old”; reported data for individuals residing in sub-Saharan Africa; and reported at least one measure of cognitive impairment or clinical outcomes relevant to cognitive decline. References of papers included in our study were searched to identify additional candidate publications. Disagreements about inclusion were adjudicated during discussions involving all authors. Data were extracted independently by two authors, using a form developed by the authors and tested on a sample of papers. Findings: A total of 2320 unique papers was found; the full text of 87 was reviewed. Nineteen papers featuring 11 cross-sectional studies were included; all were published during 1995–2011. Studies occurred in Benin, Botswana, the Central African Republic, the Congo and Nigeria and enrolled approximately 10 500 participants. The prevalence of dementia ranged from 0%, in Nigeria, to 10.1% (95% confidence interval, CI: 8.6–11.8), also in Nigeria. The prevalence of cognitive impairment ranged from 6.3%, in Nigeria, to 25% (95% CI: 21.2–29.0), in the Central African Republic. Conclusion: Prevalences of dementia and cognitive impairment in sub-Saharan Africa varied widely, with few published studies revealed by the literature search

Transcendental meditation for the primary prevention of cardiovascular disease (protocol)

BACKGROUND: A major determinant in cardiovascular disease (CVD) is stress. As transcendental meditation (TM) is thought to help in lowering negative stress indicators, it may be a beneficial strategy for the primary prevention of CVD. OBJECTIVES: To determine the effectiveness of TM for the primary prevention of CVD. SEARCH METHODS: We searched the following electronic databases: the Cochrane Central Register of Controlled Trials (CENTRAL) (2013, Issue 10); MEDLINE (Ovid) (1946 to week three November 2013); EMBASE Classic and EMBASE (Ovid) (1947 to week 48 2013); ISI Web of Science (1970 to 28 November 2013); and Database of Abstracts of Reviews of Effects (DARE) and Health Technology Assessment Database and Health Economics Evaluations Database (November 2013). We also searched the Allied and complementary Medicine Database (AMED) (inception to January 2014) and IndMed (inception to January 2014). We handsearched trial registers and reference lists of reviews and articles and contacted experts in the field. We applied no language restrictions. SELECTION CRITERIA: We included randomised controlled trials (RCTs) of at least three months' duration involving healthy adults or adults at high risk of CVD. Trials examined TM only and the comparison group was no intervention or minimal intervention. We excluded trials that involved multi-factorial interventions. Outcomes of interest were clinical CVD events (cardiovascular mortality, all-cause mortality and non-fatal events) and major CVD risk factors (e.g. blood pressure and blood lipids, occurrence of type 2 diabetes, quality of life, adverse events and costs). DATA COLLECTION AND ANALYSIS: Two authors independently selected trials for inclusion, extracted data and assessed the risk of bias. MAIN RESULTS: We identified four trials (four papers) (430 participants) for inclusion in this review. We identified no ongoing studies. The included trials were small, short term (three months) and at risk of bias. In all studies, TM was practised for 15 to 20 minutes twice a day.None of the included studies reported all-cause mortality, cardiovascular mortality or non-fatal endpoints as trials were short term, but one study reported survival rate three years after the trial was completed. In view of the considerable statistical heterogeneity between the results of the studies for the only outcomes reported, systolic blood pressure (I(2) = 72%) and diastolic blood pressure (I(2) = 66%), we decided not to undertake a meta-analysis. None of the four trials reported blood lipids, occurrence of type 2 diabetes, adverse events, costs or quality of life. AUTHORS' CONCLUSIONS: Currently, there are few trials with limited outcomes examining the effectiveness of TM for the primary prevention of CVD. Due to the limited evidence to date, we could draw no conclusions as to the effectiveness of TM for the primary prevention of CVD. There was considerable heterogeneity between trials and the included studies were small, short term and at overall serious risk of bias. More and larger long-term, high-quality trials are needed

Levels of vitamin D and cardiometabolic disorders: systematic review and meta-analysis

Cardiometabolic disorders and vitamin D deficiency are becoming increasingly more prevalent across multiple populations. Different studies have suggested a potential association between abnormal vitamin D levels and multiple pathological conditions including cardiovascular diseases and diabetes. We aimed to evaluate the association between vitamin D levels, using 25-hydroxy vitamin D (25OHD) as an indicator of vitamin D status, and the presence of cardiometabolic disorders including cardiovascular disease, diabetes and metabolic syndrome. We performed a systematic review of the current literature on vitamin D and cardiometabolic disorders using the PubMed and Web of Knowledge databases in September 2009. Studies in adults looking at the effect of vitamin D levels on outcomes relating to cardiometabolic disorders were selected. We performed a mesa-analysis to assess the risk of developing cardiometabolic disorders comparing the highest and lowest groups of serum 25OHD. From 6130 references we identified 28 studies that met our inclusion criteria, including 99,745 participants. There was moderate variation between the studies in their grouping of 25OHD levels, design and analytical approach. We found that the highest levels of serum 25OHD were associated with a 43% reduction in cardiometabolic disorders [OR 0.57,95% (CI 0.48-0.68)]. Similar levels were observed, irrespective of the individual cardiometabolic outcome evaluated or study design. High levels of vitamin D among middle-age and elderly populations are associated with a substantial decrease in cardiovascular disease, type 2 diabetes and metabolic syndrome. If the relationship proves to be causal, interventions targeting vitamin D deficiency in adult populations could potentially slow the current epidemics of cardiometabolic disorders. (C) 2009 Elsevier Ireland Ltd. All rights reserve

Is vitamin K consumption associated with cardio-metabolic disorders? A systematic review

Associations have been found between various micronutrients and cardio-metabolic outcomes. Vitamin K deficiency has been associated with increased calcification of the main arteries and with insulin resistance. The present study aimed to examine the association between vitamin K intake and cardiometabolic outcomes including cardiovascular disease, type 2 diabetes and the metabolic syndrome. A systematic review of the literature was performed in January 2010. Nine electronic databases, and trial registers, reference lists of retrieved articles and citations were searched. Intervention, cohort, case-control or cross-sectional studies in adults were included if they examined the association between vitamin K levels (dietary intake, biomarkers, supplements) on clinical outcomes relevant to cardiometabolic disease. Five studies met the inclusion criteria (1 trial, 4 cohort studies). Heterogeneity of designs, exposures/interventions and outcomes meant that meta-analysis was not possible. No associations were found between vitamin K1 intake and coronary heart disease (CHD) (4 cohorts) or stroke (2 cohorts) in multivariate analyses. No differences were seen in the prevalence of diabetes in a trial of vitamin K1 supplementation. Two cohorts examined the effects of vitamin K2 intake on the incidence of CHD; both found significant associations where higher vitamin K2 intake was associated with fewer CHD events. Few studies have examined the effects of vitamin K intake on clinical outcomes relevant to cardiometabolic disorders. None of the studies used biomarkers. Currently there is no evidence for an effect of vitamin K1, but results for vitamin K2 look promising. Further prospective studies are required to confirm these findings. (C) 2010 Elsevier Ireland Ltd. All rights reserved