The effectiveness and cost-effectiveness of assistive technology and telecare for independent living in dementia: a randomised controlled trial

OBJECTIVES: The use of assistive technology and telecare (ATT) has been promoted to manage risks associated with independent living in people with dementia but with little evidence for effectiveness. METHODS: Participants were randomly assigned to receive an ATT assessment followed by installation of all appropriate ATT devices or limited control of appropriate ATT. The primary outcomes were time to institutionalisation and cost-effectiveness. Key secondary outcomes were number of incidents involving risks to safety, burden and stress in family caregivers and quality of life. RESULTS: Participants were assigned to receive full ATT (248 participants) or the limited control (247 participants). After adjusting for baseline imbalance of activities of daily living score, HR for median pre-institutionalisation survival was 0.84; 95% CI, 0.63 to 1.12; P = 0.20. There were no significant differences between arms in health and social care (mean -£909; 95% CI, -£5,336 to £3,345, P = 0.678) and societal costs (mean -£3,545; 95% CI, -£13,914 to £6,581, P = 0.499). ATT group members had reduced participant-rated quality-adjusted life years (QALYs) at 104 weeks (mean - 0.105; 95% CI, -0.204 to -0.007, P = 0.037) but did not differ in QALYs derived from proxy-reported EQ-5D. DISCUSSION: Fidelity of the intervention was low in terms of matching ATT assessment, recommendations and installation. This, however, reflects current practice within adult social care in England. CONCLUSIONS: Time living independently outside a care home was not significantly longer in participants who received full ATT and ATT was not cost-effective. Participants with full ATT attained fewer QALYs based on participant-reported EQ-5D than controls at 104 weeks

The impact of assistive technology on burden and psychological well-being in informal caregivers of people with dementia (ATTILA Study)

INTRODUCTION: Assistive technology and telecare (ATT) may alleviate psychological burden in informal caregivers of people with dementia. This study assessed the impact of ATT on informal caregivers’ burden and psychological well‐being. METHODS: Individuals with dementia and their informal caregivers were recruited to a randomized‐controlled trial assessing effectiveness of ATT. Caregivers were allocated to two groups according to their cared‐for person's randomization to a full or basic package of ATT and were assessed on caregiver burden, state anxiety, and depression. Caregivers’ data from three assessments over 6 months of the trial were analyzed. RESULTS: No significant between‐ or within‐group differences at any time point on caregivers’ burden, anxiety, and depression levels were found. DISCUSSION: Full ATT for people with dementia did not impact caregivers’ psychological outcomes compared to basic ATT. The length of follow up was restricted to 6 months

Hazardous explosive eruptions of a recharging multi-cyclic island arc caldera

Caldera-forming eruptions of silicic volcanic systems are among the most devastating events on Earth. By contrast, post-collapse volcanic activity initiating new caldera cycles is generally considered less hazardous. Formed after Santorini’s latest caldera-forming eruption of ~1600 bce, the Kameni Volcano in the southern Aegean Sea enables the eruptive evolution of a recharging multi-cyclic caldera to be reconstructed. Santorini’s eruptive record has been documented by onshore products and historical descriptions of mainly effusive eruptions dating back to 197 bce. Here we combine high-resolution seismic reflection data with cored lithologies from International Ocean Discovery Program Expedition 398 at four sites to determine the submarine architecture and volcanic history of intra-caldera deposits from Kameni. Our shore-crossing analysis reveals the deposits of a submarine explosive eruption that produced up to 3.1 km3 of pumice and ash, which we relate to a historical eruption in 726 ce. The estimated volcanic explosivity index of magnitude 5 exceeds previously considered worst-case eruptive scenarios for Santorini. Our finding that the Santorini caldera is capable of producing large explosive eruptions at an early stage in the caldera cycle implies an elevated hazard potential for the eastern Mediterranean region, and potentially for other recharging silicic calderas

The effectiveness and cost-effectiveness of assistive technology and telecare for independent living in dementia: a randomised controlled trial.

OBJECTIVES: The use of assistive technology and telecare (ATT) has been promoted to manage risks associated with independent living in people with dementia but with little evidence for effectiveness. METHODS: Participants were randomly assigned to receive an ATT assessment followed by installation of all appropriate ATT devices or limited control of appropriate ATT. The primary outcomes were time to institutionalisation and cost-effectiveness. Key secondary outcomes were number of incidents involving risks to safety, burden and stress in family caregivers and quality of life. RESULTS: Participants were assigned to receive full ATT (248 participants) or the limited control (247 participants). After adjusting for baseline imbalance of activities of daily living score, HR for median pre-institutionalisation survival was 0.84; 95% CI, 0.63 to 1.12; P = 0.20. There were no significant differences between arms in health and social care (mean -£909; 95% CI, -£5,336 to £3,345, P = 0.678) and societal costs (mean -£3,545; 95% CI, -£13,914 to £6,581, P = 0.499). ATT group members had reduced participant-rated quality-adjusted life years (QALYs) at 104 weeks (mean - 0.105; 95% CI, -0.204 to -0.007, P = 0.037) but did not differ in QALYs derived from proxy-reported EQ-5D. DISCUSSION: Fidelity of the intervention was low in terms of matching ATT assessment, recommendations and installation. This, however, reflects current practice within adult social care in England. CONCLUSIONS: Time living independently outside a care home was not significantly longer in participants who received full ATT and ATT was not cost-effective. Participants with full ATT attained fewer QALYs based on participant-reported EQ-5D than controls at 104 weeks

Assistive technology and telecare to maintain independent living at home for people with dementia: the ATTILA RCT

BACKGROUND: Assistive technology and telecare have been promoted to manage the risks associated with independent living for people with dementia, but there is limited evidence of their effectiveness. OBJECTIVES: This trial aimed to establish whether or not assistive technology and telecare assessments and interventions extend the time that people with dementia can continue to live independently at home and whether or not they are cost-effective. Caregiver burden, the quality of life of caregivers and of people with dementia and whether or not assistive technology and telecare reduce safety risks were also investigated. DESIGN: This was a pragmatic, randomised controlled trial. Blinding was not undertaken as it was not feasible to do so. All consenting participants were included in an intention-to-treat analysis. SETTING: This trial was set in 12 councils in England with adult social services responsibilities. PARTICIPANTS: Participants were people with dementia living in the community who had an identified need that might benefit from assistive technology and telecare. INTERVENTIONS: Participants were randomly assigned to receive either assistive technology and telecare recommended by a health or social care professional to meet their assessed needs (a full assistive technology and telecare package) or a pendant alarm, non-monitored smoke and carbon monoxide detectors and a key safe (a basic assistive technology and telecare package). MAIN OUTCOME MEASURES: The primary outcomes were time to admission to care and cost-effectiveness. Secondary outcomes assessed caregivers using the 10-item Center for Epidemiological Studies Depression Scale, the State-Trait Anxiety Inventory 6-item scale and the Zarit Burden Interview. RESULTS: Of 495 participants, 248 were randomised to receive full assistive technology and telecare and 247 received the limited control. Comparing the assistive technology and telecare group with the control group, the hazard ratio for institutionalisation was 0.76 (95% confidence interval 0.58 to 1.01; p = 0.054). After adjusting for an imbalance in the baseline activities of daily living score between trial arms, the hazard ratio was 0.84 (95% confidence interval 0.63 to 1.12; p = 0.20). At 104 weeks, there were no significant differences between groups in health and social care resource use costs (intervention group - control group difference: mean -£909, 95% confidence interval -£5336 to £3345) or in societal costs (intervention group - control group difference: mean -£3545; 95% confidence interval -£13,914 to £6581). At 104 weeks, based on quality-adjusted life-years derived from the participant-rated EuroQol-5 Dimensions questionnaire, the intervention group had 0.105 (95% confidence interval -0.204 to -0.007) fewer quality-adjusted life-years than the control group. The number of quality-adjusted life-years derived from the proxy-rated EuroQol-5 Dimensions questionnaire did not differ between groups. Caregiver outcomes did not differ between groups over 24 weeks. LIMITATIONS: Compliance with the assigned trial arm was variable, as was the quality of assistive technology and telecare needs assessments. Attrition from assessments led to data loss additional to that attributable to care home admission and censoring events. CONCLUSIONS: A full package of assistive technology and telecare did not increase the length of time that participants with dementia remained in the community, and nor did it decrease caregiver burden, depression or anxiety, relative to a basic package of assistive technology and telecare. Use of the full assistive technology and telecare package did not increase participants' health and social care or societal costs. Quality-adjusted life-years based on participants' EuroQol-5 Dimensions questionnaire responses were reduced in the intervention group compared with the control group; groups did not differ in the number of quality-adjusted life-years based on the proxy-rated EuroQol-5 Dimensions questionnaire. FUTURE WORK: Future work could examine whether or not improved assessment that is more personalised to an individual is beneficial. TRIAL REGISTRATION: Current Controlled Trials ISRCTN86537017. FUNDING: This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 25, No. 19. See the NIHR Journals Library website for further project information

Effects of Anacetrapib in Patients with Atherosclerotic Vascular Disease

BACKGROUND: Patients with atherosclerotic vascular disease remain at high risk for cardiovascular events despite effective statin-based treatment of low-density lipoprotein (LDL) cholesterol levels. The inhibition of cholesteryl ester transfer protein (CETP) by anacetrapib reduces LDL cholesterol levels and increases high-density lipoprotein (HDL) cholesterol levels. However, trials of other CETP inhibitors have shown neutral or adverse effects on cardiovascular outcomes. METHODS: We conducted a randomized, double-blind, placebo-controlled trial involving 30,449 adults with atherosclerotic vascular disease who were receiving intensive atorvastatin therapy and who had a mean LDL cholesterol level of 61 mg per deciliter (1.58 mmol per liter), a mean non-HDL cholesterol level of 92 mg per deciliter (2.38 mmol per liter), and a mean HDL cholesterol level of 40 mg per deciliter (1.03 mmol per liter). The patients were assigned to receive either 100 mg of anacetrapib once daily (15,225 patients) or matching placebo (15,224 patients). The primary outcome was the first major coronary event, a composite of coronary death, myocardial infarction, or coronary revascularization. RESULTS: During the median follow-up period of 4.1 years, the primary outcome occurred in significantly fewer patients in the anacetrapib group than in the placebo group (1640 of 15,225 patients [10.8%] vs. 1803 of 15,224 patients [11.8%]; rate ratio, 0.91; 95% confidence interval, 0.85 to 0.97; P=0.004). The relative difference in risk was similar across multiple prespecified subgroups. At the trial midpoint, the mean level of HDL cholesterol was higher by 43 mg per deciliter (1.12 mmol per liter) in the anacetrapib group than in the placebo group (a relative difference of 104%), and the mean level of non-HDL cholesterol was lower by 17 mg per deciliter (0.44 mmol per liter), a relative difference of -18%. There were no significant between-group differences in the risk of death, cancer, or other serious adverse events. CONCLUSIONS: Among patients with atherosclerotic vascular disease who were receiving intensive statin therapy, the use of anacetrapib resulted in a lower incidence of major coronary events than the use of placebo. (Funded by Merck and others; Current Controlled Trials number, ISRCTN48678192 ; ClinicalTrials.gov number, NCT01252953 ; and EudraCT number, 2010-023467-18 .)

Data report: marine tephra compositions in proximal and distal drill cores, IODP Expeditions 375, 372, and 329, ODP Leg 181, and DSDP Leg 90, offshore New Zealand, Southwest Pacific

We report on a total of 1005 samples analyzed for major and trace element compositions from marine sediments drilled along the Hikurangi subduction zone and within the incoming Pacific plate. The samples are from International Ocean Discovery Program Expeditions 375 and 372; Integrated Ocean Drilling Program Expedition 329; Ocean Drilling Program Leg 181; and Deep Sea Drilling Project Leg 90. All 1005 samples, resulting in a total number of ~20,200 individual measurements, were analyzed for major element compositions with the electron microprobe. A subset of 419 samples, resulting in a total number of ~1820 individual glass shard analyses, were analyzed for trace element compositions using the laser ablation-inductively coupled plasma-mass spectrometer. In total, ~640 samples were identified as primary ash layers based on their homogeneous geochemistry, visual appearance in the core pictures, and high amount of volcanic glass. Based on the biostratigraphy presented in the cruise reports and subsequent work, we can distinguish between Quaternary- and Neogene-derived tephras. The tephra layers of Quaternary age are mostly of rhyolitic composition with occasional andesitic, dacitic, and trachytic glass shards. The Neogene tephras are mostly of basaltic andesite, andesitic, and rhyolitic composition, with a few basaltic and trachytic tephras. Tephras of both age groups follow the calc-alkaline series trend with a tendency to shift into the high-K calc-alkaline series for tephras with >70 wt% SiO2

Data report: chemical compositions of marine tephra layers in the Indian Ocean, IODP Expeditions 353 and 362

We report on a total of 310 samples from marine sediments drilled in the Indian Ocean that were analyzed for glass shard compositions. Samples are mainly from International Ocean Discovery Program Expeditions 353 and 362 but are complemented by samples from Expedition 354; Ocean Drilling Program Legs 183, 121, 120, 119, 116, and 115; and Deep Sea Drilling Project Leg 22. We performed 4327 successful single glass shard analyses with the electron microprobe for major element compositions and conducted 937 successful single analyses with laser ablation-inductively coupled plasma-mass spectrometry (LA-ICP-MS) for trace element compositions on individual glass shards previously measured with the electron microprobe. In total, we were able to measure glass compositions for 254 samples. Of all the samples, 235 can be classified as tephra layers containing pyroclasts as the predominant component in their clast inventory between the 63 and 125 µm grain size fraction, often exceeding 90 vol%. The compositions of the Indian Ocean marine tephras range from basalt to rhyolite and from basaltic trachyandesite to trachyte and fall into the calc-alkaline, K-rich calc-alkaline, and shoshonitic magmatic series

Advances in New Zealand's Tephrochronostratigraphy Using Marine Drill Sites: The Neogene

Three volcanic arcs have been the source of New Zealand's volcanic activity since the Neogene: Northland arc, Coromandel Volcanic Zone (CVZ) and Taupō Volcanic Zone (TVZ). The eruption chronology for the Quaternary, sourced by the TVZ, is well studied and established, whereas the volcanic evolution of the precursor arc systems, like the CVZ (central activity c. 18 to 2 Ma), is poorly known due to limited accessibility to, or identification of, onshore volcanic deposits and their sources. Here, we investigate the marine tephra record of the Neogene, mostly sourced by the CVZ, of cores from IODP Exp. 375 (Sites U1520 and U1526), ODP Leg 181 (Sites 1123, 1124 and 1125), IODP Leg 329 (Site U1371) and DSDP Leg 90 (Site 594) offshore of New Zealand. In total, we identify 306 primary tephra layers in the marine sediments. Multi-approach age models (e.g. biostratigraphy, zircon ages) are used in combination with geochemical fingerprinting (major and trace element compositions) and the stratigraphic context of each marine tephra layer to establish 168 tie-lines between marine tephra layers from different holes and sites. Following this approach, we identify 208 explosive volcanic events in the Neogene between c. 17.5 and 2.6 Ma. This is the first comprehensive study of New Zealand's Neogene explosive volcanism established from tephrochronostratigraphic studies, which reveals continuous volcanic activity between c. 12 and 2.6 Ma with an abrupt compositional change at c. 4.5 Ma, potentially associated with the transition from CVZ to TVZ. Key Points New Zealand's Neogene explosive volcanism based on the marine tephra record Geochemical fingerprinting of marine tephra layers across the study area to establish volcanic events Insights into geochemical variations with time, repose times and spatiotemporal distributio