Assessment, diagnosis, care and support for people with dementia and their carers: a national clinical guideline.

This guideline provides recommendations based on current evidence for best practice in the assessment, care and support of adults with dementia. The guideline applies to all settings, including home, long-term care, care homes, hospital, hospice, day-care centres and primary care. Personcentred care should be the focus of the implementation of this guideline. The focus for this guideline is adults living with dementia. Older people with dementia represent the majority of people living with dementia in Scotland, however young-onset dementia in adults is also included. The guideline covers the adult population, as a true dementia in children (ie an incident, progressive, neurodegenerative disorder) is extremely rare. There are specific subgroups of the dementia population and types of dementia that have highly specialist needs, and the guideline development group agreed that covering these groups in this guideline would not provide the in-depth information required to support such groups. Two examples are dementia in people with learning disabilities and those with alcohol-related dementia. Sources of further information about dementia in people with learning disabilities are listed in section 9.4. Prevention of dementia is a rapidly evolving area and would need its own guidance to do justice to the field, and as such was also considered by the guideline development group to be out of scope. Perspectives were sought from stakeholders across Scotland, including people living with dementia and their carers, on the remit of the guideline. Taking these into account the guideline development group agreed to prioritise areas where specific guidance was needed for Scotland

The role of ENT surgeons in snoring assessment : some prospective preliminary evidence

Objectives: To determine (i) the prevalence of unsuspected upper aerodigestive tract disease in snorers, (ii) the diagnostic yield of routine flexible endoscopy and (iii) the relationship between symptoms of upper aerodigestive tract disease and examination findings in snorers. Design: Prospective analytical cohort study. Setting: Snoring clinic in Secondary Care Otolaryngologycentre. Participants: Ninety-three patients referred with disruptive snoring.Main outcome measures: A structured history ofupper aerodigestive tract symptoms was obtained byclinic interview. All patients underwent detailed ENTexamination. Univariate analysis was undertaken on data collected. Results: The prevalence of oropharyngeal and laryngealpathology in the cohort was 3%. No unsuspected upper aerodigestive tract pathology was found on routineflexible endoscopy. A history of Hard Nasal Symptoms was an accurate predictor of underlying nasal pathology. Conclusion: The authors propose that the detailed examination of snorers by ENT specialists is unnecessary in the absence of Hard Nasal Symptoms, hoarseness orpain. We propose that a system of triage based on patient history could help identify the minority of snorers who require specialist assessment

The pain of low status: the relationship between subjective socio-economic status and analgesic prescriptions in a Scottish community sample

There is a strong positive relationship between objective measures of socioeconomic status (OSS) and general health. However, there is an increasing interest in the relationship between health and subjective socioeconomic status (SSS), which describes one’s perceived rank in relation to the rest of society, based on factors such as income, occupation, and education. While the relationship between SSS and general health is well2established, the relationship between SSS and pain has received little attention. Gathering both self2report questionnaire data and General Practitioner medical data from a large representative community sample in Scotland between 2012 and 2013 ( N = 1824), we investigated the relationship between SSS and prescriptions for analgesic drugs. We found that higher levels of SSS significantly predicted lower odds of participants having been prescribed at least one analgesic drug in the previous six months. We obtained this result even after controlling for OSS2related variables (education, occupational status, and geographical location) and demographic variables (age and gender). This suggests that, just like the relationship between SSS and general health, SSS has important effects on pain that go beyond the influence of OSS

Predictors of Cardiac Rehabilitation Utilization in England: Results From the National Audit

Background-—Cardiac rehabilitation (CR) is grossly underused, with major inequities in access. However, use of CR and predictors of initiation in England where CR contracting is available is unknown. The aims were (1) to investigate CR utilization rates in England, and (2) to determine sociodemographic and clinical factors associated with CR initiation including social deprivation. Methods and Results-—Data from the National Audit of CR, between January 2012 and November 2015, were used. Utilization rates overall and by deprivation quintile were derived. Logistic regression was performed to identify predictors of initiation among enrollees,using the Huber–White–sandwich estimator robust standard errors method to account for the nested nature of the data. Of the 234 736 (81.5%) patients referred to CR, 141 648 enrolled, 97 406 initiated CR, and of those initiating, 37.2% completed a program of ≥8 weeks duration. The significant characteristics associated with CR initiation were younger age (odds ratio [OR] 0.98, 95% CI 0.98–0.99), having a partner (OR 1.31, 95% CI 1.17–1.48), not being employed (OR 0.86, 95% CI 0.77–0.96), not having diabetes mellitus (OR 0.84, 95% CI 0.77–0.92), greater anxiety (OR 1.02, 95% CI 1.003–1.04), not being a medically managed myocardial infarction patient (OR 0.57, 95% CI 0.42–0.76), and having had coronary artery bypass graft surgery (OR 1.64, 95% CI 1.09–2.47). Conclusions-—CR enrollment does not meet English National Health Service targets; however it compares with that in other countries. Evidence-based approaches increasing CR enrollment and initiation should be applied, focusing on the identified characteristics associated with CR initiation, specifically older, single, employed individuals with diabetes mellitus and those not revascularized

Guideline summary: assessment, diagnosis, care and support for people with dementia and their carers [Scottish Intercollegiate Guidelines Network SIGN Guideline 168].

The Scottish Intercollegiate Guidelines Network (SIGN) have recently published their guideline SIGN168 on 'Assessment, Diagnosis, Care, and Support for People with Dementia and their Carers'. The guideline makes evidence-based recommendations for best practice in the assessment, care and support of adults living with dementia. Topics featured in this guideline are limited to those prioritised by stakeholders, especially people with lived and living experience, and those not well covered under pre-existing guidance. We summarise the guideline recommendations related to identification and diagnosis of dementia, investigative procedures, postdiagnostic support living with dementia, including non-pharmacological approaches for distressed behaviours, using technology to support people with dementia, grief and dementia and changing needs of people with dementia. The guideline content is summarised as officially published, with additional commentary in the final section

Exploring the implementation of cognitive behaviour therapy for psychosis using the Normalization Process Theory framework

Objective: Evidence suggests that only a minority of service users experiencing psychosis have access to Cognitive Behavioural Therapy for psychosis (CBTp). Normalisation Process Theory (NPT) is a theoretical framework which focuses on processes by which interventions are implemented and normalised in clinical practice. This study explored the views and experiences of mental health professionals regarding the implementation of CBTp. Barriers and facilitators to implementation were explored using the NPT framework. Design: A qualitative methodology was adopted involving semi-structured focus groups and individual interviews. Methods: A total of 14 members of staff working in the community and crisis mental health teams were recruited. Thematic analysis was used to generate initial themes. The Framework approach was utilised to map initial themes to the NPT framework. Results: Inductive coding generated five overarching themes consisting of 15 individual subthemes which captured the perceived barriers to engagement; contextual barriers to implementation; optimisation of implementation; positive attitudes towards implementation; and expectations of implementing CBTp. All but two subthemes mapped on to the NPT framework. The deductive analysis suggested that difficulties in making sense of CBTp among professionals were reflected as service level barriers which impeded wider implementation. Conclusion: The results of this study suggested a mixture of barriers and facilitators to CBTp implementation. Interpreting our findings within an NPT framework indicates the importance of strong clinical leadership to address difficulties in sense-making and service investment in CBTp

Individuals with filaggrin-related eczema and asthma have increased long-term medication and hospital admission costs

Background Eczema and asthma are chronic diseases with onset usually before the age of 5 years. More than 50% of individuals with eczema will develop asthma and/or other allergic diseases. Several loss‐of‐function mutations in filaggrin (FLG) have been identified in patients with eczema. However, the association of FLG with healthcare use is unknown. Objectives To determine whether FLG mutations are associated with increased prescribing for eczema and asthma and whether increased prescribing is associated with increased healthcare costs. Methods A secondary analysis of BREATHE, a cross‐sectional study of gene–environment associations with asthma severity, was undertaken. BREATHE data was collected for 1100 participants with asthma, in Tayside and Fife, Scotland during the period 2003–2005. Through collaboration with the Health Informatics Centre in Dundee, BREATHE was linked to accident and emergency, community prescribing and Scottish morbidity records. The data linkage allowed longitudinal exploration of associations between genetic variation and prescribing. Results An association was found between FLG mutations and increased prescribing for mild and moderate eczema, asthma‐reliever medicine and asthma exacerbations. A strong association was found between FLG mutations and prescribing of emollients [incidence rate ratio (IRR) 2·19, 95% confidence interval (CI) 1·36–3·52], treatment for severe eczema (IRR 2·18, 95% CI 1·22–3·91) and a combination of a long‐acting β2‐agonist and corticosteroids (IRR 3·29, 95% CI 1·68–6·43). Conclusions The presence of FLG mutations in this cohort is associated with increased prescribing for eczema and asthma. Randomized controlled trials are required to determine if these individuals could benefit from management strategies to reduce morbidity and treatment costs