The Characteristics and Outcomes of People with Dementia in Inpatient Mental Health Care: A Review

Objectives: Inpatient mental health beds for people with dementia are a limited resource. Practitioners need an understanding of this population to provide high-quality care and design services. This review examines the characteristics, care, and outcomes of people with dementia admitted to inpatient mental health services. Methods: Systematic searches of key databases were undertaken up to November 2021. Findings were grouped into categories and then synthesized into a narrative review. Results: The review identified 36 international papers, the majority of which were retrospective audits. The literature describes significant psychiatric and medical comorbidity and significant risk of change in residence and death associated with admission. Conclusions: We found a limited literature describing the characteristics, care, and outcomes of people with dementia in inpatient mental health services. The lack of research is striking given the complexity and vulnerability of this client group. More research is needed to describe the needs of this group, current and best practice to optimize care. Clinical Implications: Professionals working in inpatient mental health services need to be aware of the evidence base available, consider how they evaluate patient outcomes, review their staffing and skills mix, and seek the views of patients and relatives in improving services

Single-qubit unitary gates by graph scattering

We consider the effects of plane-wave states scattering off finite graphs, as an approach to implementing single-qubit unitary operations within the continuous-time quantum walk framework of universal quantum computation. Four semi-infinite tails are attached at arbitrary points of a given graph, representing the input and output registers of a single qubit. For a range of momentum eigenstates, we enumerate all of the graphs with up to $n=9$ vertices for which the scattering implements a single-qubit gate. As $n$ increases, the number of new unitary operations increases exponentially, and for $n>6$ the majority correspond to rotations about axes distributed roughly uniformly across the Bloch sphere. Rotations by both rational and irrational multiples of $\pi$ are found.Comment: 8 pages, 7 figure

Huntington's Disease: Mechanisms of Pathogenesis and Therapeutic Strategies.

Huntington's disease is a late-onset neurodegenerative disease caused by a CAG trinucleotide repeat in the gene encoding the huntingtin protein. Despite its well-defined genetic origin, the molecular and cellular mechanisms underlying the disease are unclear and complex. Here, we review some of the currently known functions of the wild-type huntingtin protein and discuss the deleterious effects that arise from the expansion of the CAG repeats, which are translated into an abnormally long polyglutamine tract. Finally, we outline some of the therapeutic strategies that are currently being pursued to slow down the disease

Association between lithium use and the incidence of dementia and its subtypes: A retrospective cohort study.

BACKGROUND: Dementia is the leading cause of death in elderly Western populations. Preventative interventions that could delay dementia onset even modestly would provide a major public health impact. There are no disease-modifying treatments currently available. Lithium has been proposed as a potential treatment. We assessed the association between lithium use and the incidence of dementia and its subtypes. METHODS AND FINDINGS: We conducted a retrospective cohort study comparing patients treated between January 1, 2005 and December 31, 2019, using data from electronic clinical records of secondary care mental health (MH) services in Cambridgeshire and Peterborough NHS Foundation Trust (CPFT), United Kingdom (catchment area population approximately 0.86 million). Eligible patients were those aged 50 years or over at baseline and who had at least 1 year follow-up, excluding patients with a diagnosis of mild cognitive impairment (MCI) or dementia before, or less than 1 year after, their start date. The intervention was the use of lithium. The main outcomes were dementia and its subtypes, diagnosed and classified according to the International Classification of Diseases-10th Revision (ICD-10). In this cohort, 29,618 patients (of whom 548 were exposed to lithium) were included. Their mean age was 73.9 years. A total of 40.2% were male, 33.3% were married or in a civil partnership, and 71.0% were of white ethnicity. Lithium-exposed patients were more likely to be married, cohabiting or in a civil partnership, to be a current/former smoker, to have used antipsychotics, and to have comorbid depression, mania/bipolar affective disorder (BPAD), hypertension, central vascular disease, diabetes mellitus, or hyperlipidemias. No significant difference between the 2 groups was observed for other characteristics, including age, sex, and alcohol-related disorders. In the exposed cohort, 53 (9.7%) patients were diagnosed with dementia, including 36 (6.8%) with Alzheimer disease (AD) and 13 (2.6%) with vascular dementia (VD). In the unexposed cohort, corresponding numbers were the following: dementia 3,244 (11.2%), AD 2,276 (8.1%), and VD 698 (2.6%). After controlling for sociodemographic factors, smoking status, other medications, other mental comorbidities, and physical comorbidities, lithium use was associated with a lower risk of dementia (hazard ratio [HR] 0.56, 95% confidence interval [CI] 0.40 to 0.78), including AD (HR 0.55, 95% CI 0.37 to 0.82) and VD (HR 0.36, 95% CI 0.19 to 0.69). Lithium appeared protective in short-term (≤1-year exposure) and long-term lithium users (>5-year exposure); a lack of difference for intermediate durations was likely due to lack of power, but there was some evidence for additional benefit with longer exposure durations. The main limitation was the handling of BPAD, the most common reason for lithium prescription but also a risk factor for dementia. This potential confounder would most likely cause an increase in dementia in the exposed group, whereas we found the opposite, and the sensitivity analysis confirmed the primary results. However, the specific nature of the group of patients exposed to lithium means that caution is needed in extending these findings to the general population. Another limitation is that our sample size of patients using lithium was small, reflected in the wide CIs for results relating to some durations of lithium exposure, although again sensitivity analyses remained consistent with our primary findings. CONCLUSIONS: We observed an association between lithium use and a decreased risk of developing dementia. This lends further support to the idea that lithium may be a disease-modifying treatment for dementia and that this is a promising treatment to take forwards to larger randomised controlled trials (RCTs) for this indication

Trends in Gender and Racial/Ethnic Disparities in Physical Disability and Social Support Among U.S. Older Adults With Cognitive Impairment Living Alone, 2000-2018

BACKGROUND AND OBJECTIVES: Informal care is the primary source of support for older adults with cognitive impairment, yet is less available to those who live alone. We examined trends in the prevalence of physical disability and social support among older adults with cognitive impairment living alone in the United States. RESEARCH DESIGN AND METHODS: We analyzed 10 waves of data from the U.S. Health and Retirement Survey spanning 2000-2018. Eligible people were those aged ≥65, having cognitive impairment, and living alone. Physical disability and social support were measured via basic and instrumental activities of daily living (BADLs, IADLs). We estimated linear temporal trends for binary/integer outcomes via logistic/Poisson regression, respectively. RESULTS: A total of 20 070 participants were included. Among those reporting BADL/IADL disability, the proportion unsupported for BADLs decreased significantly over time (odds ratio [OR] 0.98, 95% confidence interval [CI] 0.97-0.99), and the proportion unsupported for IADLs increased (OR = 1.02, CI 1.01-1.04). Among those receiving IADL support, the number of unmet IADL support needs increased significantly over time (relative risk [RR] 1.04, CI 1.03-1.05). No gender disparities were found for these trends. Over time, Black respondents had a relatively increasing trend of being BADL-unsupported (OR = 1.03, CI 1.0-1.05) and Hispanic and Black respondents had a relatively increasing trend in the number of unmet BADL needs (RR = 1.02, CI 1.00-1.03; RR = 1.01, CI 1.00-1.02, respectively), compared to the corresponding trends in White respondents. DISCUSSION AND IMPLICATIONS: Among lone-dwelling U.S. older adults with cognitive impairment, fewer people received IADL support over time, and the extent of unmet IADL support needs increased. Racial/ethnic disparities were seen both in the prevalence of reported BADL/IADL disability and unmet BADL/IADL support needs; some but not all were compatible with a reduction in disparity over time. This evidence could prompt interventions to reduce disparities and unmet support needs

Simulating a Community Mental Health Service During the COVID-19 Pandemic: Effects of Clinician-Clinician Encounters, Clinician-Patient-Family Encounters, Symptom-Triggered Protective Behaviour, and Household Clustering.

Objectives: Face-to-face healthcare, including psychiatric provision, must continue despite reduced interpersonal contact during the COVID-19 (SARS-CoV-2 coronavirus) pandemic. Community-based services might use domiciliary visits, consultations in healthcare settings, or remote consultations. Services might also alter direct contact between clinicians. We examined the effects of appointment types and clinician-clinician encounters upon infection rates. Design: Computer simulation. Methods: We modelled a COVID-19-like disease in a hypothetical community healthcare team, their patients, and patients' household contacts (family). In one condition, clinicians met patients and briefly met family (e.g., home visit or collateral history). In another, patients attended alone (e.g., clinic visit), segregated from each other. In another, face-to-face contact was eliminated (e.g., videoconferencing). We also varied clinician-clinician contact; baseline and ongoing "external" infection rates; whether overt symptoms reduced transmission risk behaviourally (e.g., via personal protective equipment, PPE); and household clustering. Results: Service organisation had minimal effects on whole-population infection under our assumptions but materially affected clinician infection. Appointment type and inter-clinician contact had greater effects at low external infection rates and without a behavioural symptom response. Clustering magnified the effect of appointment type. We discuss infection control and other factors affecting appointment choice and team organisation. Conclusions: Distancing between clinicians can have significant effects on team infection. Loss of clinicians to infection likely has an adverse impact on care, not modelled here. Appointments must account for clinical necessity as well as infection control. Interventions to reduce transmission risk can synergize, arguing for maximal distancing and behavioural measures (e.g., PPE) consistent with safe care

Risk factors for excess deaths during lockdown among older users of secondary care mental health services without confirmed COVID‐19: A retrospective cohort study

Funder: UK National Institute for Health Research (NIHR) Cambridge Biomedical Research CentreFunder: NIHR Applied Research Collaboration East of EnglandAbstract: Objective: To investigate factors contributing to excess deaths of older patients during the initial 2020 lockdown beyond those attributable to confirmed COVID‐19. Methods: Retrospective cohort study comparing patients treated between 23 March 2020 and 14 June 2020, deemed exposed to the pandemic/lockdown, to patients treated between 18 December 2019 and 10 March 2020, deemed to be unexposed. Data came from electronic clinical records from secondary care mental health services in Cambridgeshire and Peterborough NHS Foundation Trust (CPFT), UK (catchment area population ∼0.86 million). Eligible patients were aged 65 years or over at baseline with at least 14 days' follow‐up, excluding patients diagnosed with confirmed or suspected SARS‐CoV‐2 infection. The primary outcome was all‐cause mortality. Findings: In the two cohorts, 3,073 subjects were exposed to lockdown and 4,372 subjects were unexposed; the cohorts were followed up for an average of 74 and 78 days, respectively. After controlling for confounding by sociodemographic factors, smoking status, mental comorbidities, and physical comorbidities, patients with dementia suffered an additional 53% risk of death (HR = 1.53, 95% CI = 1.02–2.31), and patients with severe mental illness suffered an additional 123% risk of death (HR = 2.23, 95% CI = 1.42–3.49). No significant additional mortality risks were identified from physical comorbidities, potentially due to low statistical power in that respect. Conclusion: During lockdown people with dementia or severe mental illness had a higher risk of death without confirmed COVID‐19. These data could inform future health service responses and policymaking to help prevent avoidable excess death during future outbreaks of this or a similar infectious disease

Antioxidants can inhibit basal autophagy and enhance neurodegeneration in models of polyglutamine disease.

Many neurodegenerative diseases exhibit protein accumulation and increased oxidative stress. Therapeutic strategies include clearing aggregate-prone proteins by enhancing autophagy or decreasing oxidative stress with antioxidants. Many autophagy-inducing stimuli increase reactive oxygen species (ROS), raising concerns that the benefits of autophagy up-regulation may be counterbalanced by ROS toxicity. Here we show that not all autophagy inducers significantly increase ROS. However, many antioxidants inhibit both basal and induced autophagy. By blocking autophagy, antioxidant drugs can increase the levels of aggregate-prone proteins associated with neurodegenerative disease. In fly and zebrafish models of Huntington's disease, antioxidants exacerbate the disease phenotype and abrogate the rescue seen with autophagy-inducing agents. Thus, the potential benefits in neurodegenerative diseases of some classes of antioxidants may be compromised by their autophagy-blocking properties

Surgical resident experience with common bile duct exploration and assessment of performance and autonomy with formative feedback

Background Common bile duct exploration (CBDE) is safe and effective for managing choledocholithiasis, but most US general surgeons have limited experience with CBDE and are uncomfortable performing this procedure in practice. Surgical trainee exposure to CBDE is limited, and their learning curve for achieving autonomous, practice-ready performance has not been previously described. This study tests the hypothesis that receipt of one or more prior CBDE operative performance assessments, combined with formative feedback, is associated with greater resident operative performance and autonomy. Methods Resident and attending assessments of resident operative performance and autonomy were obtained for 189 laparoscopic or open CBDEs performed at 28 institutions. Performance and autonomy were graded along validated ordinal scales. Cases in which the resident had one or more prior CBDE case evaluations (n = 48) were compared with cases in which the resident had no prior evaluations (n = 141). Results Compared with cases in which the resident had no prior CBDE case evaluations, cases with a prior evaluation had greater proportions of practice-ready or exceptional performance ratings according to both residents (27% vs. 11%, p = .009) and attendings (58% vs. 19%, p < .001) and had greater proportions of passive help or supervision only autonomy ratings according to both residents (17% vs. 4%, p = .009) and attendings (69% vs. 32%, p < .01). Conclusions Residents with at least one prior CBDE evaluation and formative feedback demonstrated better operative performance and received greater autonomy than residents without prior evaluations, underscoring the propensity of feedback to help residents achieve autonomous, practice-ready performance for rare operations