[Application of dementia care mapping (DCM) for one year in a geriatric health services facility: Effects of developmental evaluation based on collaboration by medical and welfare staff aimed at person-centred care].

PURPOSE: This study aimed to clarify the effects of dementia care mapping (DCM) for one year in a healthcare center for older adults. DCM was conducted between September 2016 and August 2017. The care staff include nurses and caregivers in a narrow sense, medical staff, such as a physician, physical therapists, and occupational therapists worked on DCM as care staff in this study. RESULTS: There were 24 participants, with an average work experience of 7.21 (±4.74) years. In comparison to the baseline evaluation, the final assessment of self-efficacy through person-centred care showed significant improvement in 'Forecasting and Problem Solving on the Job' within 'Perceived Job Competence of Care Workers'. Six main categories of content were extracted from focus group interviews: 'Awareness,' 'Change of Elderly People under the Care of Staff throughout the Development of Mapping', 'Affirmative Feelings of Care Staff for Mapping', 'Negative Feelings for Mapping', 'Need for the Efficacy and Efficiency of the Mapping', and 'Mapping Based on the Age of the Participant and Future Prospects for Mapping'. The results of person-centred care showed that both the older patients and the staff noticed changes through the development of mapping. CONCLUSION: The developmental evaluation, based on collaboration by medical and welfare staff can improve self-efficacy through the practice of person-centred care and improves the ability to solve problems during the provision of care.

[Effects of a fall intervention program for elderly patients with dementia based on person-centered care on care staff].

AIM: This study aimed to clarify the effects of a fall prevention intervention that focused on the characteristics of falls among elderly patients with dementia and was based on person-centered care in geriatric facilities on care staff. METHODS: This study was conducted between May 2016 and January 2017, and the subjects were classified into two groups: the intervention group, consisting of members who had participated in a three-month education training program, and the control group, consisting of members who provided the usual care. The study period was nine months divided as follows: training period (three months), fall prevention practice (three months), and follow-up period (three months). The quality of care was measured using the Nursing Quality Indicator for Preventing Falls (NQIPFD), and the assessment scale of health care professionals' recognition of the successful Interdisciplinary Team Approach in Health Care Facilities for the Elderly was also used. In total, the care staff members were evaluated four times: once to obtain baseline values before training, and again after the training period, after the fall prevention practice, and after the follow-up period. The results were analyzed using an analysis of variance (fixed factors = group and time, random factor = subjects, and covariance = years of experience working at the geriatric facility and type of job). RESULTS: There were 50 care staff subjects in the intervention group and 69 people in the control group. The results of the analysis of variance indicated that there was a significant difference in the NQIPFD between baseline 68.60 (±9.09) and follow-up 70.02 (±9.88) in the intervention group. With regard to the differences by intervention, the effect size of the dementia knowledge scale scores was 0.243 higher than the others, which was significant (p<0.01). CONCLUSIONS: The results showed that the participation of care staff in a fall intervention program to support elderly patients with dementia based on person-centered care significantly improved the NQIPFD and other measured factors. These findings suggest that the program fostered positive effects among the care staff.

[Utility of a Life-trouble Scale-based care planning tool for elderly patients living in a long-term care health facility: Effects of an intervention based on person-centered care].

PURPOSE: This study aimed to clarify the utility of the Life-trouble Scale-based care planning tool for elderly patients with dementia (Life-trouble Scale, viewpoints, and care points of the elderly with dementia suffering from life troubles) in order to develop an appropriate care plan and practices in a long-term care health facility. METHOD: Participants were elderly patients with dementia who were evaluated by care staff using the abovementioned scale at baseline and after intervention (one month later) from September to December 2017. The patients were divided into an intervention group, which received care based on the Life-Trouble Inclusion Scale, and the control group, which received the usual care. The outcomes of these two groups were compared. RESULTS: The intervention and control groups comprised 14 and 12 elderly patients with dementia, respectively. More than 60% of the care staff worked with both groups. Scores on the agitation sub-scale of the NPI [please define abbreviation] and "life-trouble associated with irritation and confusion" sub-scale of the Life-Trouble Scale improved significantly in the intervention group. Among the care staff, self-efficacy related to caring for elderly patients with dementia and scores on the Emotional Exhaustion and Depersonalization sub-scales of the Japanese version of the Maslach Burnout Inventory improved significantly. CONCLUSION: The present findings suggest that care intervention using the Life-trouble Scale-based care planning tool was beneficial for both elderly patients with dementia and their care staff.

[An analysis of the reliability and validity of the Life-trouble Scale for elderly patients living in geriatric facilities].

PURPOSE: The purpose of this study was to develop the Life-trouble Scale for elderly people with dementia to concretely determine their life troubles in geriatric facilities. RESULTS: The subjects of this study were elderly people living in geriatric health services facilities whose degree of life independence was evaluated as ≥II, who had a diagnosis of dementia, and who agreed to participate in this study.The study population included 191 subjects (male, n=144, 75.4%; female, n=47, 24.6%). The average age was 85.72 (±6.96) years, the mean degree of need for nursing care was 3.73 (±1.22), and the mean MMSE score was 9.11 (±8.80).Based on the factor analysis of the Life-trouble Scale, the first factor was named, "Basic Life Behavior and Life Trouble with Communication." The second factor was named, "Life Trouble Associated with Irritation and Confusion". The third factor was named, "Trouble with Human Relations Associated with Feelings and Changes in Consciousness". The fourth factor was named, "Life Trouble Associated with Changes in Consciousness and Repeated Behavior". The Cronbach's α of the 4 factors was 0.884, and the NPI and Crichton rating scales were significantly correlated with the 4 factors. CONCLUSION: The results showed that the Life-trouble Scale had reliability and validity, and that it was useful for solving problems in geriatric health services facilities.

The effects of quality of life on behavioral and psychological symptoms in elderly people with dementia residing at long-term care facilities.

PURPOSE: The purpose of the present study was to clarify how quality of life (QOL) affects the behavioral and psychological symptoms of dementia (BPSDs) among elderly individuals with dementia within long-term care facilities (e.g., long-term healthcare facilities, sanatorium-type medical facilities, and special nursing homes for the elderly). METHODS: Elderly individuals with dementia were evaluated to determine their activities of daily living (ADL; Katz), Mini-mental State Examination (MMSE), Neuropsychiatric Inventory (NPI), and Quality of life inventory for the elderly with dementia (QOLD) scores. RESULTS: The subjects were recruited from intermediate welfare facilities (n = 226, 43.7%), hospitals with supportive care (n=91, 17.6%), and intermediate care facilities (n = 200, 38.7%). The mean age of the subjects was 85.18±7.13 years. The NPI scores revealed that Agitation/Aggression was high among subjects who resided in healthcare health facilities and sanatorium-type medical facilities, while Apathy/Indifference was high in those who resided in special nursing homes. Additionally, a multiple regression analysis found that most of the NPI items, when set as independent variables, displayed a significant association with the same subscale of the QOLD. CONCLUSION: When each item of the NPI was set as a dependent variable in a multiple regression analysis, the scores were significantly related to both subscales of the QOLD. It is suggested that QOL should be maintained or improved in an effort to reduce the incidence of the associated BPSDs in long-term care facilities.

Repeated provocation of time- and ATP-induced early pulmonary vein reconnections after pulmonary vein isolation: eliminating paroxysmal atrial fibrillation in a single procedure.

BACKGROUND: Recurrence of atrial fibrillation (AF) after successful pulmonary vein isolation (PVI) occurs mainly due to the reconnection of the once isolated PV. Although provocation and elimination of the early pulmonary vein reconnection (EPVR) soon after PVI has been widely performed to improve the outcome, AF recurrence due to subsequent PV reconnections still occurs. In this study, we repeatedly provoked and eliminated the EPVR to determine the appropriate procedural end point. METHODS AND RESULTS: Seventy-five patients with paroxysmal AF underwent PVI. EPVR was provoked by both time and ATP induction every 30 minutes until 90 minutes after the individual isolation of all PVs. The number of reconnected atrio-PV gaps were evaluated and reablated at each provocation step. Although both time- and ATP-dependent EPVR was induced most frequently at 30 minutes after PVI (75 and 76 gaps, respectively), the prevalence of induced EPVR at 60 minutes was still high (64 and 36 gaps induced by time and ATP, respectively). Only a small number of EPVR appeared at 90 minutes after the elimination of all EPVR by 60 minutes (8 gaps, P<0.01). During the mean follow-up period of 370 days, 92% of cases were free from AF without antiarrhythmic drugs. CONCLUSIONS: Provocation and elimination of time- and ATP-induced EPVR not only at 30 minutes but also at 60 minutes is recommended after PVI to improve its efficacy.

Dormant pulmonary vein conduction induced by adenosine in patients with atrial fibrillation who underwent catheter ablation.

BACKGROUND: intravenous administration of adenosine triphosphate (ATP) is used to induce transient pulmonary vein (PV) reconduction (dormant PV conduction) following PV isolation. This study investigated the detailed characteristics of dormant PV conduction in patients with atrial fibrillation (AF) who underwent catheter ablation. METHODS: two hundred sixty consecutive patients (235 men; mean age, 54 ± 10 years) who underwent catheter ablation of their AF were included in this study. ATP was injected following PV isolation to induce dormant PV conduction, which was then eliminated by radiofrequency application. RESULTS: dormant PV conduction was induced by ATP in 60.4% (157/260) of the patients and in 25.3% (258/1,021) of the isolated PVs. This transient PV reconduction was more frequently observed in the left superior PV in comparison with other PVs (P < .0001). There was no significant difference in the prevalence of the dormant PV conduction among patients with paroxysmal AF, persistent AF, and long-lasting AF (62%, 66%, and 48%, respectively; P = .13). During the follow-up period, repeat AF ablation was performed in 70 patients with recurrent AF. The dormant PV conduction was less frequently induced in the repeat procedure than in the initial procedure (60.4% vs 31.4%, P < .0001). CONCLUSIONS: dormant PV conduction was evenly induced among AF types. The repeat PV isolation led to the decrease in incidence of the ATP-induced acute transient pharmacological PV reconduction.

Comparison of the clinical outcome after pulmonary vein isolation based on the appearance of adenosine-induced dormant pulmonary vein conduction.

BACKGROUND: The elimination of transient pulmonary vein (PV) reconduction (dormant PV conduction) revealed by adenosine in addition to PV isolation reduced the atrial fibrillation (AF) recurrence after catheter ablation. The dormant PV conduction is induced in approximately half of the AF patients that undergo PV isolation. The present study compared the clinical outcome of AF ablation in patients whose dormant PV conduction was eliminated by additional radiofrequency applications with the outcome in patients without dormant conduction. METHODS: A total of 233 consecutive patients (206 male, 54.2 +/- 10.1 years) that underwent AF ablation were included in the present study. Dormant PV conduction was induced by the administration of adenosine triphosphate after PV isolation and was eliminated by supplemental radiofrequency application. All patients were followed up for >12 months (mean 903 days) after the first ablation. RESULTS: Following PV isolation, dormant PV conduction was induced in 139 (59.7%) of 233 patients and was successfully eliminated in 98% (223/228) of those in the first ablation procedure. After the first procedure, 63.9% (149/233) of patients were free from AF recurrence events. The success rates of a single or final AF ablation in patients with the appearance of the dormant PV conduction were similar to those of patients without dormant conduction (P = .69 and P = .69, respectively). CONCLUSIONS: Dormant PV conduction was induced in over half of the patients with AF. After the elimination of adenosine triphosphate-induced reconnection, the clinical outcome of patients with the dormant PV conduction was equivalent to that of patients without conduction.

Prospective randomized comparison of a steerable versus a non-steerable sheath for typical atrial flutter ablation.

AIMS: Although cavotricuspid isthmus (CTI) ablation can cure typical atrial flutter (AFL), it might be difficult to achieve a bidirectional conduction block in the isthmus in some patients. We investigated the usefulness of a steerable sheath for CTI ablation in patients with typical AFL or atrial fibrillation. METHODS AND RESULTS: A total of 40 consecutive patients (36 males; mean age 55.2 +/- 10.0 years) undergoing CTI ablation were randomized to one of the following two groups: group S (using a steerable long sheath) or group NS (using a non-steerable long sheath). Ablation was performed using an 8 mm tip catheter. The anatomy of the CTI was evaluated by a dual-source computed tomography scan prior to the procedure. The procedural endpoint was the achievement of a bidirectional isthmus conduction block. Bidirectional block in the CTI was achieved in all patients with 485.3 +/- 416.4 s of radiofrequency (RF) application. The CTI anatomy, including the length, depth, and morphology, was similar between the two groups. The duration and total amount of RF energy delivery were significantly shorter and smaller in group S than in group NS (310 +/- 193 vs. 661 +/- 504 s, P = 0.006, and 12,197 +/- 7306 vs. 26,906 +/- 21,238 J, P = 0.006, respectively). CONCLUSION: The use of a steerable sheath reduced the time and amount of energy needed to achieve a bidirectional conduction block in the CTI. For patients in whom the establishment of a conduction block is difficult, a steerable sheath should be considered as a therapeutic option for typical AFL ablation.

Impact of pulmonary vein isolation on the autonomic modulation in patients with paroxysmal atrial fibrillation and prolonged sinus pauses.

AIMS: The efficacy of catheter-based pulmonary vein isolation (PVI) for paroxysmal atrial fibrillation (AF) and prolonged sinus pauses [bradycardia-tachycardia syndrome (BTS)] has been already described. However, the effects of PVI on autonomic modulation in BTS patients remain to be determined. We, therefore, examined the alteration in the autonomic modulation through the PVI procedure by using a heart rate variability (HRV) analysis of 24 h ambulatory monitoring. METHODS AND RESULTS: This study consisted of 26 symptomatic paroxysmal AF patients either with prolonged sinus pauses on termination of AF (>3.0 s, BTS group, n = 11) or without any evidence of sinus node dysfunction (control group, matched for sex and age, n = 15) who underwent PVI. All 11 BTS patients became free from both AF and prolonged sinus pauses without pacemaker implantation (23 +/- 14 months of observation). The mean heart rate significantly increased in the control group (P < 0.05), but not in the BTS group after the PVI procedure, although the HRV parameters of root-mean-square successive differences in the adjacent NN intervals, standard deviation of the NN intervals, and high frequency did significantly decrease in both groups (P < 0.05). CONCLUSION: Although the parasympathetic modulation was significantly attenuated after the PVI procedure, the mean heart rate did not increase in the BTS patients, probably due to the pre-existing sinus node dysfunction.

The dormant epicardial reconnection of pulmonary vein: an unusual cause of recurrent atrial fibrillation after pulmonary vein isolation.

The case of a 65-year-old man with recurrent atrial fibrillation after undergoing segmental pulmonary vein isolation caused by the reconnection of previously isolated pulmonary veins is herein reported. Interestingly, frequent ectopic firings in the left superior pulmonary vein conducted to the left atrium, not through its ostium but through the supposed epicardial pathway at the region of the Marshall ligament, which had been absent during the first treatment session. The reisolation of the left superior pulmonary vein by radiofrequency application in the left atrial appendage thus successfully eliminated the occurrence of atrial fibrillation.

Atrial septal pacing to resynchronize atrial contraction and improve atrial transport function.

OBJECTIVES: Atrial septal pacing via a trans-septal breakthrough site within the right atrial septum can shorten global atrial activation time, resulting in significant reduction of recurrence of atrial fibrillation events. This study examined whether this pacing method will lead to resynchronization of atrial contraction and its benefit on hemodynamic function can be maintained for 24 months. METHODS: Thirty patients with atrial fibrillation and delayed atrial conduction were enrolled (17 males, 13 females, mean age 73 +/- 7 years). Trans-septal breakthrough site within the right atrial septum was identified through pacing from the dorsal left atrium. Continuous atrial septal pacing at the trans-septal breakthrough site was performed for 24 months. Time difference (TD) between right and left atrial contractions was measured during atrial septal pacing and sinus rhythm by pulse Doppler echocardiography of the trans-tricuspid (P-At) and mitral (P-Am) blood flows (TD = P-Am - P-At). RESULTS: The atrial lead was screwed near the fossa ovalis in 29 of 30 patients. Atrial septal pacing yielded significantly shorter P wave duration (101.9 +/- 10.4 vs 139.6 +/- 14.7 msec, p < 0.001), leading to significant reduction of TD in atrial contraction (-8.8 +/- 10.0 vs 29.8 +/- 13.6 msec, p < 0.001)as compared to sinus rhythm. Both shorter P wave duration and reduced TD during atrial septal pacing remained statistically significant during the follow-up period as compared to sinus rhythm. Both left atrial diameter and A to E ratio of filling waves at mitral valve were significantly decreased at 12 months and remained decreased at 24 months. CONCLUSIONS: Atrial septal pacing at the trans-septal breakthrough site can resynchronize atrial contraction and results in improved hemodynamic effects during 24 months of follow-up.

Focal source of atrial fibrillation arising from the ostium of the inferior vena cava.

A patient presented with paroxysmal atrial fibrillation (AF) caused by focal rapid discharges arising from the ostium of the inferior vena cava (IVC). Surface ECG showed typical features of AF and flutter when rapid activation at the IVC ostium was conducted to the right atrium in a 1-to-1 and 2-to-1 fashion, respectively. Discrete radiofrequency energy applications at the medial ostium of the IVC completely eliminated the atrial tachyarrhythmias.

A focal source of atrial fibrillation in the superior vena cava: isolation and elimination by radiofrequency ablation with the guide of basket catheter mapping.

Although it has been reported that pulmonary veins sometimes act as a focal driver of atrial fibrillation (AF), little has been reported concerning the contribution of the superior vena cava (SVC) to the maintenance of AF. Here we report a patient with sustained AF due to focal discharges inside the SVC after pulmonary vein isolation procedure. Stepwise radiofrequency current applications with the guide of multielectrode basket catheter mapping first disconnected the arrhythmogenic SVC from the right atrium and then eliminated the tachycardia.

Various routes of septal propagation in common atrial flutter.

INTRODUCTION: Although in the treatment of common atrial flutter, the isthmus between the tricuspid valve annulus and the eustachian ridge is often chosen as the site for conduction block by radiofrequency ablation, the precise path of the flutter circuit remains unknown. We therefore investigated the propagation of the atrial flutter wave front around the coronary sinus ostium and how its path is altered by application of radiofrequency current. METHODS AND RESULTS: To assess activation pattern, activation in the region surrounding the coronary sinus ostium was mapped using a deflectable decapolar catheter under basal conditions and while applying radiofrequency current to the septal isthmus, between the tricuspid valve annulus and the eustachian ridge. In five of eleven patients studied, the eustachian ridge side, below the coronary sinus ostium, was activated earlier, and the flutter wave exited from either the tricuspid valve annulus side or the eustachian ridge side, above the coronary sinus ostium. In four patients, a partial line of block created by applying radiofrequency current between the tricuspid valve annulus and the coronary sinus ostium or between the coronary sinus ostium and the eustachian ridge led to a shift in the direction of propagation of the flutter wave front from anterior to posterior or from posterior to anterior of the coronary sinus ostium, and prolongation of the cycle length. CONCLUSION: Application of radiofrequency current to the septal isthmus, between the tricuspid valve annulus and the eustachian ridge, can shift both the anterior and posterior propagation of flutter around the coronary sinus ostium.