Preparatory review of studies of withdrawal of anti-hypertensive medication in older people

Introduction: Since 2012 we have undertaken a programme of research into the management of hypertension in people with dementia. As part of this we are studying the feasibility of withdrawing antihypertensive drugs in people with dementia and well-controlled hypertension, with the aim of them remaining normotensive but avoiding some of the burdens and side-effects of antihypertensive medications. We decided to undertake a preliminary examination of the literature to examine the evidence and safety of antihypertensive withdrawal (not restricted to those with dementia) to determine whether this has already been extensively reviewed, to provide an approximate estimate of the likelihood of success of antihypertensive withdrawal, and to prepare for a systematic review of this literature if required and feasible. Method: For this rapid review, we undertook a search for existing reviews and examined the relevant papers identified, and briefly updated the search once we found that the most recent review was in 2008. Results: One appropriate review (from 2008) yielding seven relevant articles, and one further article were identified, giving eight articles which were examined. Seven of the eight were published more than ten years ago. Six of the eight studies had follow-up data for 1 year or longer. Successful long term (1 year or more) withdrawal of antihypertensive medication was reported in 20-52% of patients. Conclusion: Our review indicates that 22-50% of patients whose blood pressures are currently adequately controlled might be able to withdraw medication without return of long term hypertension. The rapid review approach we took may have missed articles of relevance and so we propose that a systematic review of withdrawal is undertaken. Because much of the data will be old, it should seek data not only on the proportions of patients who remained normotensive at long term follow up using the standards of the day, but should seek data on findings relevant to current guidelines. Only data reporting long term follow up (≥ 1 year) should be included. Data referring to old or discontinued medications should be distinguished

Interventions for preventing delirium in hospitalised non-ICU patients

BACKGROUND: Delirium is a common mental disorder, which is distressing and has serious adverse outcomes in hospitalised patients. Prevention of delirium is desirable from the perspective of patients and carers, and healthcare providers. It is currently unclear, however, whether interventions for preventing delirium are effective. OBJECTIVES: To assess the effectiveness of interventions for preventing delirium in hospitalised non-Intensive Care Unit (ICU) patients. SEARCH METHODS: We searched ALOIS - the Cochrane Dementia and Cognitive Improvement Group's Specialized Register on 4 December 2015 for all randomised studies on preventing delirium. We also searched MEDLINE (Ovid SP), EMBASE (Ovid SP), PsycINFO (Ovid SP), Central (The Cochrane Library), CINAHL (EBSCOhost), LILACS (BIREME), Web of Science core collection (ISI Web of Science), ClinicalTrials.gov and the WHO meta register of trials, ICTRP. SELECTION CRITERIA: We included randomised controlled trials (RCTs) of single and multi- component non-pharmacological and pharmacological interventions for preventing delirium in hospitalised non-ICU patients. DATA COLLECTION AND ANALYSIS: Two review authors examined titles and abstracts of citations identified by the search for eligibility and extracted data independently, with any disagreements settled by consensus. The primary outcome was incidence of delirium; secondary outcomes included duration and severity of delirium, institutional care at discharge, quality of life and healthcare costs. We used risk ratios (RRs) as measures of treatment effect for dichotomous outcomes; and between group mean differences and standard deviations for continuous outcomes. MAIN RESULTS: We included 39 trials that recruited 16,082 participants, assessing 22 different interventions or comparisons. Fourteen trials were placebo-controlled, 15 evaluated a delirium prevention intervention against usual care, and 10 compared two different interventions. Thirty-two studies were conducted in patients undergoing surgery, the majority in orthopaedic settings. Seven studies were conducted in general medical or geriatric medicine settings.We found multi-component interventions reduced the incidence of delirium compared to usual care (RR 0.69, 95% CI 0.59 to 0.81; seven studies; 1950 participants; moderate-quality evidence). Effect sizes were similar in medical (RR 0.63, 95% CI 0.43 to 0.92; four studies; 1365 participants) and surgical settings (RR 0.71, 95% CI 0.59 to 0.85; three studies; 585 participants). In the subgroup of patients with pre-existing dementia, the effect of multi-component interventions remains uncertain (RR 0.90, 95% CI 0.59 to 1.36; one study, 50 participants; low-quality evidence).There is no clear evidence that cholinesterase inhibitors are effective in preventing delirium compared to placebo (RR 0.68, 95% CI, 0.17 to 2.62; two studies, 113 participants; very low-quality evidence).Three trials provide no clear evidence of an effect of antipsychotic medications as a group on the incidence of delirium (RR 0.73, 95% CI, 0.33 to 1.59; 916 participants; very low-quality evidence). In a pre-planned subgroup analysis there was no evidence for effectiveness of a typical antipsychotic (haloperidol) (RR 1.05, 95% CI 0.69 to 1.60; two studies; 516 participants, low-quality evidence). However, delirium incidence was lower (RR 0.36, 95% CI 0.24 to 0.52; one study; 400 participants, moderate-quality evidence) for patients treated with an atypical antipsychotic (olanzapine) compared to placebo (moderate-quality evidence).There is no clear evidence that melatonin or melatonin agonists reduce delirium incidence compared to placebo (RR 0.41, 95% CI 0.09 to 1.89; three studies, 529 participants; low-quality evidence).There is moderate-quality evidence that Bispectral Index (BIS)-guided anaesthesia reduces the incidence of delirium compared to BIS-blinded anaesthesia or clinical judgement (RR 0.71, 95% CI 0.60 to 0.85; two studies; 2057 participants).It is not possible to generate robust evidence statements for a range of additional pharmacological and anaesthetic interventions due to small numbers of trials, of variable methodological quality. AUTHORS' CONCLUSIONS: There is strong evidence supporting multi-component interventions to prevent delirium in hospitalised patients. There is no clear evidence that cholinesterase inhibitors, antipsychotic medication or melatonin reduce the incidence of delirium. Using the Bispectral Index to monitor and control depth of anaesthesia reduces the incidence of postoperative delirium. The role of drugs and other anaesthetic techniques to prevent delirium remains uncertain

Appropriateness of unscheduled hospital admissions from care homes

Unscheduled hospital admissions from care homes are common and potentially avoidable but little guidance is available as to what constitutes an appropriate hospital admission. We surveyed healthcare professionals’ opinions on a range of common scenarios affecting care-home residents. We developed seven clinical vignettes and an accompanying questionnaire. We used purposive sampling to obtain opinions from relevant primary care and secondary care teams. We asked assessors to comment on whether they would favour hospital admission and to justify their response using pre-selected options and/or free text. Admission to hospital was judged inappropriate in 54.6% of responses. Opinion on admission varied according to the case, with fewer than half of respondents agreeing for three of the seven cases. Recurring themes were uncertainty around services available to care homes and anticipatory care planning. The lack of consensus suggests that concepts surrounding inappropriate care-home admission are not shared by staff who provide care for this patient group

Articulating the Unique Competencies of Admiral Nurse Practice

Purpose: This article describes the process of developing a contemporary competency framework for Admiral Nurses in dementia care. Design/methodology/approach: Information and evidence was gathered from research and policy literature regarding competencies to deliver advanced practice within dementia care. An online survey completed by 75 Admiral Nurses with follow-up interviews clarified current practice across the range of service contexts in which they work. A focus group of people living with dementia and family carers, and a reference group of practitioners helped to develop a competency framework which was refined through focus groups with Admiral Nurses working in different areas. Findings: The literature review, survey and interviews provided a framework grounded in up-to-date evidence and contemporary practice. There was broad agreement in the literature and the practitioners’ priorities regarding the core competencies of advanced practice, with constructive suggestions for making the framework useable in practice. This resulted in a robust framework articulating the competencies of Admiral Nurses which could be used for continuous professional development. Research limitations/implications: Practical implications: Social Implications: Originality/value: Engaging the Admiral Nurses ensured the competencies were contemporary, succinct and applicable within practice, and also cultivated a sense of ownership. Developing the competency framework with the Admiral Nurses not for them provides an approach which may have value for professionals undertaking a similar process in their specialist area. It is anticipated the competency framework will provide further evidence of the benefits of specialist nurse support for families affected by dementia

New institutionalisation following acute hospital admission: a retrospective cohort study

Background: institutionalisation following acute hospital admission is common and yet poorly described, with policy documents advising against this transition. Objective: to characterise the individuals admitted to a care home on discharge from an acute hospital admission and to describe their assessment. Design and setting: a retrospective cohort study of people admitted to a single large Scottish teaching hospital. Subjects: 100 individuals admitted to the acute hospital from home and discharged to a care home. Methods: a single researcher extracted data from ward-based case notes. Results: people discharged to care homes were predominantly female (62%), widowed (52%) older adults (mean 83.6 years) who lived alone (67%). About 95% had a diagnosed cognitive disorder or evidence of cognitive impairment. One-third of cases of delirium were unrecognised. Hospital stays were long (median 78.5 days; range 14–231 days) and transfers between settings were common. Family request, dementia, mobility, falls risk and behavioural concerns were the commonest reasons for the decision to admit to a care home. About 55% were in the acute hospital when the decision for a care home was made and 44% of that group were discharged directly from the acute hospital. Conclusions: care home admission from hospital is common and yet there are no established standards to support best practice. Decisions should involve the whole multidisciplinary team in partnership with patients and families. Documentation of assessment in the case notes is variable. We advocate the development of interdisciplinary standards to support the assessment of this vulnerable and complex group of patients

Recruitment of people with dementia in primary care –experiences from the HIND study

OBJECTIVES: A purpose of the Hypertension in Dementia feasibility study was to explore recruitment of people with dementia and essential hypertension in primary care practices to prepare a withdrawal study of their antihypertensive medication. METHODS: Primary care practices were invited by phone to support the study, which would entail screening their databases to identify people with diagnoses of both dementia and essential hypertension, and sending out letters to these people asking them to indicate their willingness participate in the feasibility withdrawal study. Practice managers or GPs from practices that declined to support the study were asked to give their reasons. RESULTS: All primary care practices in Nottingham and Nottinghamshire were contacted (n=145). Of those, 12 (8%) practices agreed to support the study. Between them they identified and sent out a total of 249 letters to potential participants. Of these 19 (7%) people responded and only 6 (2%) met the eligibility criteria for withdrawing antihypertensive medication. 80/133 (60%) non responding practices gave reasons for why they did not support the study: the most common responses were that 31 (39%) were ‘too busy’, staff changes or short staffed were cited in 11 (14%) and “too time consuming” was cited in 7 (9%). CONCLUSIONS: Recruitment of a sufficiently large and representative population for a larger trial would not be feasible in primary care practices using these methods, due to the high workload in UK primary care

Assessment of the Effects of 6 Standard Rodent Diets on Binge-Like and Voluntary Ethanol Consumption in Male C57BL/6J Mice

In recent years much attention has been given to the lack of reproducibility in biomedical research, particularly in pre-clinical animal studies. This is a problem that also plagues the alcohol research field, particularly in consistent consumption in animal models of alcohol use disorders. One often overlooked factor that could affect reproducibility is the maintenance diet used in pre-clinical studies

The global oscillation network group site survey. II. Results

The Global Oscillation Network Group (GONG) Project will place a network of instruments around the world to observe solar oscillations as continuously as possible for three years. The Project has now chosen the six network sites based on analysis of survey data from fifteen sites around the world. The chosen sites are: Big Bear Solar Observatory, California; Mauna Loa Solar Observatory, Hawaii; Learmonth Solar Observatory, Australia; Udaipur Solar Observatory, India; Observatorio del Teide, Tenerife; and Cerro Tololo Interamerican Observatory, Chile. Total solar intensity at each site yields information on local cloud cover, extinction coefficient, and transparency fluctuations. In addition, the performance of 192 reasonable components analysis. An accompanying paper describes the analysis methods in detail; here we present the results of both the network and individual site analyses. The selected network has a duty cycle of 93.3%, in good agreement with numerical simulations. The power spectrum of the network observing window shows a first diurnal sidelobe height of 3 × 10⁻⁴ with respect to the central component, an improvement of a factor of 1300 over a single site. The background level of the network spectrum is lower by a factor of 50 compared to a single-site spectrum

Flavor Physics in an SO(10) Grand Unified Model

In supersymmetric grand-unified models, the lepton mixing matrix can possibly affect flavor-changing transitions in the quark sector. We present a detailed analysis of a model proposed by Chang, Masiero and Murayama, in which the near-maximal atmospheric neutrino mixing angle governs large new b -> s transitions. Relating the supersymmetric low-energy parameters to seven new parameters of this SO(10) GUT model, we perform a correlated study of several flavor-changing neutral current (FCNC) processes. We find the current bound on B(tau -> mu gamma) more constraining than B(B -> X_s gamma). The LEP limit on the lightest Higgs boson mass implies an important lower bound on tan beta, which in turn limits the size of the new FCNC transitions. Remarkably, the combined analysis does not rule out large effects in B_s-B_s-bar mixing and we can easily accomodate the large CP phase in the B_s-B_s-bar system which has recently been inferred from a global analysis of CDF and DO data. The model predicts a particle spectrum which is different from the popular Constrained Minimal Supersymmetric Standard Model (CMSSM). B(tau -> mu gamma) enforces heavy masses, typically above 1 TeV, for the sfermions of the degenerate first two generations. However, the ratio of the third-generation and first-generation sfermion masses is smaller than in the CMSSM and a (dominantly right-handed) stop with mass below 500 GeV is possible.Comment: 44 pages, 5 figures. Footnote and references added, minor changes, Fig. 2 corrected; journal versio

Predicting discharge to institutional long-term care after stroke: a systematic review & meta-analysis

Background/Objectives: Stroke is a leading cause of disability worldwide, and a significant proportion of stroke survivors require long-term institutional care. Understanding who cannot be discharged home is important for health and social care planning. Our aim was to establish predictive factors for discharge to institutional care after hospitalization for stroke. Design: We registered and conducted a systematic review and meta-analysis (PROSPERO: CRD42015023497) of observational studies. We searched MEDLINE, EMBASE, and CINAHL Plus to February 2017. Quantitative synthesis was performed where data allowed. Setting: Acute and rehabilitation hospitals. Participants: Adults hospitalized for stroke who were newly admitted directly to long-term institutional care at the time of hospital discharge. Measurements: Factors associated with new institutionalization. Results: From 10,420 records, we included 18 studies (n = 32,139 participants). The studies were heterogeneous and conducted in Europe, North America, and East Asia. Eight studies were at high risk of selection bias. The proportion of those surviving to discharge who were newly discharged to long-term care varied from 7% to 39% (median 17%, interquartile range 12%), and the model of care received in the long-term care setting was not defined. Older age and greater stroke severity had a consistently positive association with the need for long-term care admission. Individuals who had a severe stroke were 26 times as likely to be admitted to long-term care than those who had a minor stroke. Individuals aged 65 and older had a risk of stroke that was three times as great as that of younger individuals. Potentially modifiable factors were rarely examined. Conclusion: Age and stroke severity are important predictors of institutional long-term care admission directly from the hospital after an acute stroke. Potentially modifiable factors should be the target of future research. Stroke outcome studies should report discharge destination, defining the model of care provided in the long-term care setting