A European study investigating patterns of transition from home care towards institutional dementia care: the protocol of a RightTimePlaceCare study

<p>Abstract</p> <p>Background</p> <p>Health care policies in many countries aim to enable people with dementia to live in their own homes as long as possible. However, at some point during the disease the needs of a significant number of people with dementia cannot be appropriately met at home and institutional care is required. Evidence as to best practice strategies enabling people with dementia to live at home as long as possible and also identifying the right time to trigger admission to a long-term nursing care facility is therefore urgently required. The current paper presents the rationale and methods of a study generating primary data for best-practice development in the transition from home towards institutional nursing care for people with dementia and their informal caregivers. The study has two main objectives: 1) investigate country-specific factors influencing institutionalization and 2) investigate the circumstances of people with dementia and their informal caregivers in eight European countries. Additionally, data for economic evaluation purposes are being collected.</p> <p>Methods/design</p> <p>This paper describes a prospective study, conducted in eight European countries (Estonia, Finland, France, Germany, Netherlands, Sweden, Spain, United Kingdom). A baseline assessment and follow-up measurement after 3 months will be performed. Two groups of people with dementia and their informal caregivers will be included: 1) newly admitted to institutional long-term nursing care facilities; and 2) receiving professional long-term home care, and being at risk for institutionalization. Data will be collected on outcomes for people with dementia (e.g. quality of life, quality of care), informal caregivers (e.g. caregiver burden, quality of life) and costs (e.g. resource utilization). Statistical analyses consist of descriptive and multivariate regression techniques and cross-country comparisons.</p> <p>Discussion</p> <p>The current study, which is part of a large European project 'RightTimePlaceCare', generates primary data on outcomes and costs of long-term nursing care for people with dementia and their informal caregivers, specifically focusing on the transition from home towards institutional care. Together with data collected in three other work packages, knowledge gathered in this study will be used to inform and empower patients, professionals, policy and related decision makers to manage and improve health and social dementia care services.</p

Violent aggression predicted by multiple pre-adult environmental hits

Early exposure to negative environmental impact shapes individual behavior and potentially contributes to any mental disease. We reported previously that accumulated environmental risk markedly decreases age at schizophrenia onset. Follow-up of matched extreme group individuals (≤1 vs. ≥3 risks) unexpectedly revealed that high-risk subjects had >5 times greater probability of forensic hospitalization. In line with longstanding sociological theories, we hypothesized that risk accumulation before adulthood induces violent aggression and criminal conduct, independent of mental illness. We determined in 6 independent cohorts (4 schizophrenia and 2 general population samples) pre-adult risk exposure, comprising urbanicity, migration, physical and sexual abuse as primary, and cannabis or alcohol as secondary hits. All single hits by themselves were marginally associated with higher violent aggression. Most strikingly, however, their accumulation strongly predicted violent aggression (odds ratio 10.5). An epigenome-wide association scan to detect differential methylation of blood-derived DNA of selected extreme group individuals yielded overall negative results. Conversely, determination in peripheral blood mononuclear cells of histone-deacetylase1 mRNA as 'umbrella mediator' of epigenetic processes revealed an increase in the high-risk group, suggesting lasting epigenetic alterations. Together, we provide sound evidence of a disease-independent unfortunate relationship between well-defined pre-adult environmental hits and violent aggression, calling for more efficient prevention

Density-Dependent Differentiation of Bacteria in Spatially Structured Open Systems

Bacterial quorum sensing is usually studied in well-mixed populations residing within closed systems. The latter do not exchange mass with their surroundings; however, in their natural environment, such as the rhizosphere, bacteria live in spatially structured open systems. Here, we tested the hypothesis that trapping of bacteria within microscopic pockets of an open system triggers density-dependent differentiation. We designed a microfluidic device that trapped swimming bacteria within microscopic compartments. The geometry of the traps controlled their diffusive coupling to fluid flow that played a dual role as nutrient source and autoinducer sink. Bacillus subtilis differentiates into a state of competence in response to quorum sensing and nutrient limitation. Using a mutant strain with a high differentiation rate and fluorescent reporters for competence, we found that the cell density required for differentiation was 100-fold higher than that required in closed systems. A direct comparison of strongly and moderately coupled reservoirs showed that strong coupling supported early differentiation but required a higher number of bacteria for its initiation. Weak coupling resulted in retardation of growth and differentiation. We conclude that spatial heterogeneity can promote density-dependent differentiation in open systems, and propose that the minimal quorum is determined by diffusive coupling to the environment through a trade-off between retaining autoinducers and accessing nutrients

The relationship between pressure ulcers and skin blood flow response after a local cold provocation

Objective: To study the relationship between an impaired blood flow response after a local cold stimulus, testing nerve regulation of the local blood flow response, and an increased risk of developing pressure ulcers. Design: An observational, longitudinal, prospective study. Setting: Dutch nursing home. Patients: Eighty-two newly admitted somatic nursing home patients, age 60 years and older. Intervention: A local cold stimulus (17°C) applied to the trochanter major. Main Outcome Measures: On admission, blood flow response to a local cold stimulus. As the stimulus was withdrawn, the temperature measured at the skin increased asymptotically toward the final temperature, TfThe velocity of this rise was characterized by the time constant, τ, of the process. On admission, and weekly during a 4-week follow-up period, the presence or absence of pressure ulcers was verified. Results: The blood flow response time correlated significantly with the risk of developing pressure ulcers. The patients who developed pressure ulcers during the follow-up period had a significantly longer response time than the patients who did not. Conclusions: Malfunction of the nervous regulatory mechanisms of the local blood flow is partially responsible for an increased susceptibility to pressure ulcer formation

Fitness Trade-Offs in Competence Differentiation of Bacillus subtilis

In the stationary phase, Bacillus subtilis differentiates stochastically and transiently into the state of competence for transformation (K-state). The latter is associated with growth arrest, and it is unclear how the ability to develop competence is stably maintained, despite its cost. To quantify the effect differentiation has on the competitive fitness of B. subtilis, we characterized the competition dynamics between strains with different probabilities of entering the K-state. The relative fitness decreased with increasing differentiation probability both during the stationary phase and during outgrowth. When exposed to antibiotics inhibiting cell wall synthesis, transcription, and translation, cells that differentiated into the K-state showed a selective advantage compared to differentiation-deficient bacteria; this benefit did not require transformation. Although beneficial, the K-state was not induced by sub-MIC concentrations of antibiotics. Increasing the differentiation probability beyond the wt level did not significantly affect the competition dynamics with transient antibiotic exposure. We conclude that the competition dynamics are very sensitive to the fraction of competent cells under benign conditions but less sensitive during antibiotic exposure, supporting the picture of stochastic differentiation as a fitness trade-off

Role of Cyclic Di-GMP and Exopolysaccharide in Type IV Pilus Dynamics

For Pseudomonas aeruginosa, levels of cyclic di-GMP (c-di-GMP) govern the transition from the planktonic state to biofilm formation. Type IV pili (T4P) are crucial determinants of biofilm structure and dynamics, but it is unknown how levels of c-di-GMP affect pilus dynamics. Here, we scrutinized how c-di-GMP affects molecular motor properties and adhesive behavior of T4P. By means of retraction, T4P generated forces of similar to 30 pN. Deletion mutants in the proteins with known roles in biofilm formation, swarming motility, and exopolysaccharide (EPS) production (specifically, the diguanylate cyclases sadC and roeA or the c-di-GMP phosphodiesterase bifA) showed only modest effects on velocity or force of T4P retraction. At high levels of c-di-GMP, the production of exopolysaccharides, particularly of Pel, is upregu-lated. We found that Pel production strongly enhances T4P-mediated surface adhesion of P. aeruginosa, suggesting that T4P-matrix interactions may be involved in biofilm formation by P. aeruginosa. Finally, our data support the previously proposed model of slingshot-like twitching motility of P. aeruginosa. IMPORTANCE Type IV pili (T4P) play various important roles in the transition of bacteria from the planktonic state to the biofilm state, including surface attachment and surface sensing. Here, we investigate adhesion, dynamics, and force generation of T4P after bacteria engage a surface. Our studies showed that two critical components of biofilm formation by Pseudomonas aeruginosa, T4P and exopolysaccharides, contribute to enhanced T4P-mediated force generation by attached bacteria. These data indicate a crucial role for the coordinated impact of multiple biofilm-promoting factors during the early stages of attachment to a surface. Our data are also consistent with a previous model explaining why pilus-mediated motility in P. aeruginosa results in characteristic twitching behavior

Depressie en pijn: Een ongelukkig huwelikj

Depression and pain are common disorders among nursing home residents. Residents with depression report more pain than residents without depression and residents with pain more frequently suffer from depression than residents without pain. More severe depression is associated with more pain and more severe pain is associated with more depression. Presence of pain hinders the recognition of depression and negatively effects treatment of depression. Presence of depression in turn negatively effects the treatment of pain. The high prevalence of pain, of depression and of the unhappy marriage of pain and depression among nursing home residents, asks for a systematical screening of these residents on depression and pain

Incidence and outcome of depressive symptoms in nursing home patients in the Netherlands

Objectives: To assess incidence and outcome of depressive symptoms among nursing home (NH) patients and to identify clinical characteristics predicting onset and persistence of depressive symptoms. Methods: Depressive symptoms (GDS>10) and relevant correlates were assessed at baseline and at follow-up (6 months) in 350 NH-patients of 14 Dutch NH's with the Geriatric Depression Scale (GDS). Predictors of onset and persistence were studied using chi-square statistics and multiple logistic regression analyses. Results: The prevalence of depressive symptoms decreased from 41.3% to 28.9% during six months follow-up. The onset of depressive symptoms in those without depressive symptoms at baseline was 4.7%, while the rate of persistence was 63-3%. Persistence of depressive symptoms was more frequent in patients with higher GDS-scores (18-30) at baseline. No baseline characteristics were associated with onset of depressive symptoms. Persistence of depressive symptoms was only associated with more years of education. Conclusions: Pre-admission factors and transition may largely be responsible for depressive symptoms among nursing home patients. The observed substantial decrease in prevalence of depressive symptoms over six months is largely due to remission of depressive symptoms present at baseline. Adaptation of nursing home patients to pre-admission factors, facilitated by the nursing home environment, may explain this observed decrease of depressive symptoms. Future studies should evaluate interventions targeted at patients with higher GDS-scores (18-30)