Apathy and its response to antipsychotic review and non-pharmacological interventions in people with dementia living in nursing homes : WHELD, A factorial cluster randomised controlled trial

Objectives: Apathy is common, impactful, and difficult to manage in people with dementia. We evaluated the efficacy of non-pharmacological interventions, exercise and social interaction, in combination with antipsychotic review, to reduce apathy in people with dementia living in nursing homes in a cluster randomised controlled trial (RCT). Methods: Well-being and health for people with dementia (WHELD) programme included a 2X2X2 factorial cluster RCT involving people with dementia living in 16 nursing homes in UK. All homes received training in person-centred care, and were randomised to receive antipsychotic review, social interaction, and exercise, either alone or in combinations. Apathy was one of the secondary outcomes of the WHELD trial, and it was measured by the Neuropsychiatric Inventory-nursing home version at baseline and nine months (N=273). We employed multilevel mixed effects linear regression models to assess the impact of the interventions on apathy. Results: Prevalence of apathy was 44.0% (n=120; 95% CI 38.1-49.9%) at baseline. Severity of apathy had significant positive correlations with dementia severity, neuropsychiatric symptoms, depressive symptoms, agitation, and the needs of the people with dementia (p<0.001). Antipsychotic review reduced antipsychotic use, but it significantly increased apathy (β=5.37; SE=0.91; p<0.001). However, antipsychotic review in combination with either social interaction (β=-5.84; SE=1.15; p<0.001) or exercise (β=-7.54; SE=0.93; p<0.001) significantly reduced apathy. Conclusions: Antipsychotic review can play a significant role in improving apathy in people with dementia living in nursing homes, when combined with psychosocial interventions such as social interaction and exercise. Guidance must be adapted to reflect this subtlety in care

UK sustainable drainage systems: past, present and future

Urban drainage has developed from an engineering discipline, concerned principally with public health and safety outcomes, into a multifaceted vision linking drainage with environmental and wider social and economic imperatives to deliver multifunctional outcomes. UK attention is too often focused on surface water as ‘a problem’, despite international progress and initiatives showing that an ‘opportunity-centred’ approach needs to be taken. Sustainable drainage systems, or ‘Suds’, can, when they are part of an integrated approach to water management, cost-effectively provide many benefits beyond management of water quality and quantity. New tools are available that can design Suds for maximum value to society but this requires greater collaboration across disciplines to seize all of the opportunities available. This paper introduces those tools and a roadmap for their use, including guidance, design objectives and criteria for maximising benefits. These new supporting tools and guidance can help to provide a business case for greater use of Suds in future

Integrating Integrated Water Management

© 2014, Thomas Telford Services Ltd. All rights reserved. The water cycle is a contiguous system interconnected with human activities. Management has tended to be fragmented across anthropocentrically defined disciplines, potentially generating unintended negative consequences. The ecosystem approach and the ecosystem services framework emphasise interlinked, albeit often overlooked, benefits that the natural environment provides for people. This enables recognition and avoidance of potential ‘negative externalities’, identification of solutions optimising benefits across multiple services, and participation of wider constituencies of stakeholders. Systemic, outcome-based approaches are inherently economically efficient, yielding greater cumulative benefits for lower transaction costs by working with natural processes. The ecosystem approach establishes geographical and socio-economic contexts for management ecosystem service outcomes, providing a broader context in which to nest established water resource management methods. The ecosystem approach can also be applied at different scales and to diverse societal activities, internalising into them the value of natural processes. It is amenable to integration into catchment-scale considerations, yet does not present these activities as subsidiary to river basin planning. The addition of ecosystem services for options appraisal in preexisting decision-support tools adapts them to better address multi-benefit goals. Shifts are required in the policy and economic environment, but engineers have an important role in promoting, applying and innovating multibenefit solutions

Preferências da população de diferentes estratos sociais no manejo das águas pluviais urbanas

Resumo Muitos municípios brasileiros possuem legislação específica voltada para o manejo das águas pluviais no meio urbano, tendo como principal objetivo a redução do escoamento superficial. Entre as medidas promovidas se encontra a obrigatoriedade de implantação de diferentes dispositivos nos lotes que funcionem armazenando ou infiltrando o excesso do escoamento superficial causado pela urbanização, de forma a compensar o impacto desta. Esse tipo de prática é conhecido como técnica compensatória (TC). Diante das diferentes TC que podem ser escolhidas, neste artigo são apresentadas as preferências e principais percepções da população de três diferentes estratos socioeconômicos a respeito das TCs. O estudo foi conduzido na cidade de Santa Maria, RS, que como outros municípios brasileiros de médio porte, ainda deverá adotar algum tipo de política pública voltada para a gestão das águas pluviais no meio urbano. Foram entrevistadas 518 residências em bairros representativos da baixa classe alta, alta classe média e baixa classe média, que possuem a mesma diretriz para ocupação do solo. Os resultados revelaram importantes aspectos a respeito do entendimento dos entrevistados no que se refere ao manejo das águas pluviais em meio urbano e evidenciaram que a preferência por TC de armazenamento ou infiltração pode ser influenciada pela classe socioeconômica. Ainda, a entrevista permitiu identificar que em mais de 90% dos domicílios entrevistados já existe conhecimento sobre esse tipo de política pública

Packages of Care for Dementia in Low- and Middle-Income Countries

In the fifth in a series of six articles on packages of care for mental disorders in low- and middle-income countries, Martin Prince and colleagues discuss the treatment of dementia

Perceptual Load-Dependent Neural Correlates of Distractor Interference Inhibition

The load theory of selective attention hypothesizes that distractor interference is suppressed after perceptual processing (i.e., in the later stage of central processing) at low perceptual load of the central task, but in the early stage of perceptual processing at high perceptual load. Consistently, studies on the neural correlates of attention have found a smaller distractor-related activation in the sensory cortex at high relative to low perceptual load. However, it is not clear whether the distractor-related activation in brain regions linked to later stages of central processing (e.g., in the frontostriatal circuits) is also smaller at high rather than low perceptual load, as might be predicted based on the load theory.We studied 24 healthy participants using functional magnetic resonance imaging (fMRI) during a visual target identification task with two perceptual loads (low vs. high). Participants showed distractor-related increases in activation in the midbrain, striatum, occipital and medial and lateral prefrontal cortices at low load, but distractor-related decreases in activation in the midbrain ventral tegmental area and substantia nigra (VTA/SN), striatum, thalamus, and extensive sensory cortices at high load.Multiple levels of central processing involving midbrain and frontostriatal circuits participate in suppressing distractor interference at either low or high perceptual load. For suppressing distractor interference, the processing of sensory inputs in both early and late stages of central processing are enhanced at low load but inhibited at high load

Urban futures and the code for sustainable homes

Copyright © 2012 ICE Publishing Ltd. Permission is granted by ICE Publishing to print one copy for personal use. Any other use of these PDF files is subject to reprint fees.A 6?6 ha (66 000 m2) regeneration site, commonly referred to as Luneside East, is to be turned from a run down, economically under-achieving area of Lancaster, UK, into a new, distinctive, vibrant, sustainable quarter of the city. As a result several aspects of water planning for 350 new homes and 8000 m2 of workspace needed to be considered before any infrastructure investment was undertaken. This included assessment of the future capacity requirements (i.e. inflows and outflows) for water infrastructure (i.e. mains water supply, wastewater disposal, rainwater storage and stormwater disposal) much of which will be located underground. This paper looks at the implications of various water management strategies on the Luneside East site (e.g. water-efficient appliances, greywater recycling and rainwater harvesting) in line with current policy measures that focus on technology changes alone (e.g. the code for sustainable homes). Based on these findings this paper outlines some basic implications for technological resilience discussed in the context of four ‘world views’ – that is, the urban futures scenarios considered in this special issue. Conclusions are drawn as to how far this can take engineers, planners and developers in understanding and planning for resilient water infrastructure within a development like Luneside East

Core outcome measures for interventions to prevent or slow the progress of dementia for people living with mild to moderate dementia: Systematic review and consensus recommendations.

BACKGROUND: There are no disease-modifying treatments for dementia. There is also no consensus on disease modifying outcomes. We aimed to produce the first evidence-based consensus on core outcome measures for trials of disease modification in mild-to-moderate dementia. METHODS AND FINDINGS: We defined disease-modification interventions as those aiming to change the underlying pathology. We systematically searched electronic databases and previous systematic reviews for published and ongoing trials of disease-modifying treatments in mild-to-moderate dementia. We included 149/22,918 of the references found; with 81 outcome measures from 125 trials. Trials involved participants with Alzheimer's disease (AD) alone (n = 111), or AD and mild cognitive impairment (n = 8) and three vascular dementia. We divided outcomes by the domain measured (cognition, activities of daily living, biological markers, neuropsychiatric symptoms, quality of life, global). We calculated the number of trials and of participants using each outcome. We detailed psychometric properties of each outcome. We sought the views of people living with dementia and family carers in three cities through Alzheimer's society focus groups. Attendees at a consensus conference (experts in dementia research, disease-modification and harmonisation measures) decided on the core set of outcomes using these results. Recommended core outcomes were cognition as the fundamental deficit in dementia and to indicate disease modification, serial structural MRIs. Cognition should be measured by Mini Mental State Examination or Alzheimer's Disease Assessment Scale-Cognitive Subscale. MRIs would be optional for patients. We also made recommendations for measuring important, but non-core domains which may not change despite disease modification. LIMITATIONS: Most trials were about AD. Specific instruments may be superseded. We searched one database for psychometric properties. INTERPRETATION: This is the first review to identify the 81 outcome measures the research community uses for disease-modifying trials in mild-to-moderate dementia. Our recommendations will facilitate designing, comparing and meta-analysing disease modification trials in mild-to-moderate dementia, increasing their value. TRIAL REGISTRATION: PROSPERO no. CRD42015027346.GL was (in part) supported by the National Institute for Health Research (NIHR) Collaboration for Leadership in Applied Health Research and Care (CLAHRC) North Thames at Bart’s Health NHS Trust. The views expressed are those of the authors and not necessarily those of the NHS, the NIHR or the Department of Health. JTC is funded by the National Institute for Health Research (NIHR) Collaboration for Leadership in Applied Health Research and Care South West Peninsula. The views expressed are those of the authors and not necessarily those of the NHS, the NIHR or the Department of Health

Sustainable drainage system site assessment method using urban ecosystem services

The United Kingdom's recently updated approach to sustainable drainage enhanced biodiversity and amenity objectives by incorporating the ecosystem approach and the ecosystem services concept. However, cost-effective and reliable methods to appraise the biodiversity and amenity values of potential sustainable drainage system (SuDS)sites and their surrounding areas are still lacking, as is a method to enable designers to distinguish and link the amenity and biodiversity benefits that SuDS schemes can offer. In this paper, therefore, the authors propose two ecosystem services- and disservices-based methods (i.e. vegetation structure cover-abundance examination and cultural ecosystem services and disservices variables appraisal) to aid SuDS designers to distinguish and link amenity and biodiversity benefits, and allow initial site assessments to be performed in a cost-effective and reliable fashion. Forty-nine representative sites within Greater Manchester were selected to test the two methods. Amenity and biodiversity were successfully assessed and habitat for species, carbon sequestration, recreation and education ecosystem services scores were produced,which will support SuDS retrofit design decision-making. Large vegetated SuDS sites with permanent aquatic features were found to be most capable of enhancing biodiversity- and amenity-related ecosystem services. Habitat for species and recreation ecosystem services were also found to be positively linked to each other. Finally, waste bins on site were found to help reduce dog faeces and litter coverage. Overall, the findings presented here enable future SuDS retrofit designs to be more wildlife friendly and socially inclusive