A short staff training system for behavioural and psychological symptoms of dementia in care facilities, based on functional analysis and positive behaviour support: a single-arm pre- and post-comparative study.

BACKGROUND: Work schedules can make it challenging for professional care workers to participate in long-term training programs on managing behavioural and psychological symptoms of dementia (BPSD). Simultaneously, it is necessary to prevent caregivers' negative responses to BPSD, provide a positive environment for people with dementia, and create a system for new management plans, since the initial one is often unsuccessful. Therefore, we developed a short manual-based training system for functional analysis including positive behaviour support and strategies when management plans do not function well. This study aimed to preliminarily examine the usefulness of this system. METHODS: Thirty-five staff members from 12 care facilities participated in the training. For each facility, off-the-job training was performed in two 120-min sessions held over 2 days. Then, care plans were implemented by staff members for a month, during which on-the-job training was provided. The study included 14 people with dementia and BPSD. This was a single-arm study without a control group. Pre- and post-tests were conducted to examine the effects of the training system using the Neuropsychiatric Inventory-Nursing Home Version. RESULTS: The results of the pre- and post-tests for the total scores on severity and occupational disruptiveness significantly improved, with large effect sizes. Regarding symptom domains, delusions, agitation/aggression, and aberrant motor behaviour significantly improved in both severity and occupational disruptiveness. Depression/dysphoria and anxiety significantly improved in severity; however, there were trends of improvement in occupational disruptiveness. In addition, the effect sizes for severity and occupational disruptiveness of delusions and agitation/aggression were large. CONCLUSIONS: This preliminary study suggests that the training system is promising. A randomised controlled trial with a larger sample size is necessary to confirm the findings.

Cross-sectional survey of the replacement of the Japanese term for dementia: Did it reduce discomfort in family members?

OBJECTIVES: Decreasing discrimination and stigma of dementia is an international issue. In 2004, the Japanese government changed the previous Japanese stigmatic term of dementia ("Chiho") to the present one ("Ninchi-sho") a meaning near "neurocognitive disorder." This study aimed to examine cross-sectionally if the present term functioned well or not from the viewpoint of families of people with dementia (PWD), and to discover variables influencing their feelings of the term: the feelings about people surrounding PWD, and the family members' and PWD's attributes. METHODS: Questions regarding the feelings about the present Japanese term and people surrounding PWD were asked to 155 family members accompanying PWD who visited three hospitals. For analyses, the degree of the discomfort about the present Japanese term was shown descriptively. The relationship of constructs of the feelings extracted by exploratory factor analysis (EFA) and the attributes was analyzed using structural equation modeling (SEM). RESULTS: 71.6% agreed that the present term discomforted them less than the previous one. Only 13.2% thought that the present term was discriminatory. However, about one third of the participants felt discomfort when they used even the present term. Using the constructs extracted by EFA, the analysis of SEM revealed that the negative feelings of the terminology were affected by hesitation to disclose to surrounding people that their family member had dementia, which the attributes of younger family members, wives, husbands, and siblings influenced. Moreover, because of disclosing the dementia, the feelings of support from people alleviated the feelings of hesitation, influenced by sex (female). CONCLUSIONS: It was suggested that overall, the present term successfully reduced discomfort in families, compared with the result of the previous term surveyed by the Ministry of Health, Labour, and Welfare. However, unignorable numbers of family members still feel stigma. New policies are necessary considering the influencing factors.

Reliability and validity of the Japanese version of a self-report (DEMQOL) and carer proxy (DEMQOL-PROXY) measure of health-related quality of life in people with dementia.

AIM: The DEMQOL is a self-report measure of subjective quality of life of people with dementia, and the DEMQOL-PROXY is a carer proxy version. The study aimed to develop Japanese versions of the DEMQOL and DEMQOL-PROXY, and test their reliability and validity. METHODS: Translation, reverse translation and equivalency evaluation by the original author were used to develop Japanese versions of the DEMQOL (DEMQOL-J) and DEMQOL-PROXY (DEMQOL-PROXY-J). Interviews were carried out with 90 pairs of people with dementia and their carers to assess their quality of life using the DEMQOL-J, DEMQOL-PROXY-J and other quality of life scales. Internal consistency was evaluated using Cronbach's alpha. Test-retest reliabilities were evaluated using intraclass correlation coefficients. Criterion validity was determined using Pearson's correlation coefficient. RESULTS: Data from 87 pairs who completed the interviews were analyzed. Cronbach's alphas for the DEMQOL-J and DEMQOL-PROXY-J were 0.930 and 0.927, respectively. For 27 pairs who were re-interviewed, the intraclass correlation coefficients for the DEMQOL-J and DEMQOL-PROXY-J were 0.942 (P < 0.001) and 0.942 (P < 0.001), respectively. Both the DEMQOL-J and DEMQOL-PROXY-J correlated significantly with other quality of life scales (the Quality of Life - Alzheimer's Disease instrument, the EuroQol-5D-3L and the World Health Organization Well-Being Index-5-J; P < 0.001). There was also a significant correlation between the DEMQOL-J and the DEMQOL-PROXY-J (r = 0.645, P ≤ 0.001). CONCLUSIONS: The DEMQOL-J and DEMQOL-PROXY-J are reliable and valid measures of dementia-specific quality of life. Geriatr Gerontol Int 2019; 19: 487-491.

Reliability and validity of the Japanese version of the Alzheimer's Disease Knowledge Scale.

Concerned with the importance of prevailing knowledge about dementia in supporting those with dementia, large-scale educational programs have been implemented in some countries. Although Japan is one of those few countries, the experience from Japanese programs has been rarely shared because of the lack of a standardized measurement for assessing knowledge about dementia. This study aims to develop a Japanese version of the Alzheimer's Disease Knowledge Scale (JADKS) and to examine its reliability and validity. The JADKS was developed through a translation-back-translation process and was distributed to 837 people including university students, community-dwelling older people, health and welfare professionals, and family caregivers. Using data from the 566 participants who fully completed the questionnaire, test-retest reliability, internal consistency, and concurrent validity were evaluated. The results indicate that the JADKS has acceptable psychometric properties. The JADKS may be useful in assessing knowledge about dementia and could help compare effectiveness of educational programs.

Increased dosage of donepezil for the management of behavioural and psychological symptoms of dementia in dementia with Lewy bodies.

BACKGROUND: As with other types of dementia, the behavioral and psychological symptoms of dementia (BPSD) can make caregiving difficult for patients with dementia with Lewy bodies (DLB). We hypothesized that administration of donepezil at an increased dose of 10 mg/day might dose-dependently improve BPSD in DLB patients with relapse, after their symptoms had been controlled initially by donepezil therapy at the standard dose. METHODS: The present study was as an open-label trial. We enrolled 24 patients with DLB (diagnosed according to the Consortium on Dementia with Lewy Bodies Guideline-Revised) who experienced a relapse of BPSD despite treatment with donepezil at the standard dose (5 mg/day). The donepezil dose for these patients was increased to 10 mg/day, and we evaluated the efficacy and safety of this dose escalation strategy. RESULTS: The Neuropsychiatric Inventory (NPI) scores for BPSD showed statistically significant improvements as a result of the increased dosage, except those for anxiety and euphoria, disinhibition, irritability/lability. High-dose donepezil therapy caused gastrointestinal symptoms in 4 patients, but there were no life-threatening adverse events, such as arrhythmias, or no exacerbation of parkinsonian symptoms. CONCLUSIONS: We found that donepezil dose-dependently improved relapsing BPSD in these patients. Therefore, increasing the dosage of donepezil is a safe and effective treatment for patients with DLB who experience a relapse of BPSD.

Moraxella lacunata infection associated with septicemia, endocarditis, and bilateral septic arthritis in a patient undergoing hemodialysis: a case report and review of the literature.

We report the first case of both endocarditis and bilateral septic arthritis in a patient caused by Moraxella lacunata and successful management of the infection with antimicrobial therapy. The route of entry leading to bacteremia may have been the oral cavity given the poor oral hygiene of the patient as evidenced by bleeding gums. We hypothesize that the bacteremia led to septic arthritis and mitral valve infective endocarditis. In this case report, we also review the literature on M. lacunata infections and conclude that this organism should be considered in bilateral septic arthritis in a patient with underlying heart abnormalities and/or with renal failure.

Care staff training in residential homes for managing behavioural and psychological symptoms of dementia based on differential reinforcement procedures of applied behaviour analysis: a process research.

Previous studies of care staff training programmes for managing behavioural and psychological symptoms of dementia (BPSD) based on the antecedent-behaviour-consequence analysis of applied behaviour analysis have not included definite intervention strategies. This case study examined the effects of such a programme when combined with differential reinforcement procedures. We examined two female care home residents with dementia of Alzheimer's type. One resident (C) exhibited difficulty in sitting in her seat and made frequent visits to the restroom. The other resident (D) avoided contact with others and insisted on staying in her room. These residents were cared for by 10 care staff trainees. Using an original workbook, we trained the staff regarding the antecedent-behaviour-consequence analysis with differential reinforcement procedures. On the basis of their training, the staff implemented individual care plans for these residents. This study comprised a baseline phase and an intervention phase (IN) to assess the effectiveness of this approach as a process research. One month after IN ended, data for the follow-up phase were collected. In both residents, the overall frequency of the target behaviour of BPSD decreased, whereas the overall rate of engaging in leisure activities as an alternative behaviour increased more during IN than during the baseline phase. In addition, the overall rate of staff actions to support residents' activities increased more during IN than during the baseline phase. However, the frequency of the target behaviour of BPSD gradually increased during IN and the follow-up phase in both residents. Simultaneously, the rate of engaging in leisure activities and the staff's treatment integrity gradually decreased for C. The training programme was effective in decreasing BPSD and increasing prosocial behaviours in these two cases. However, continuous support for the staff is essential for maintaining effects.

The level of agreement regarding patient disposition between emergency physicians and consultants in the emergency department.

BACKGROUND: Consultation is a common and important aspect of emergency medicine practice. We examined the frequency of consultations, the level of agreement and factors of disagreement with regard to the disposition of patients who visited two emergency departments (EDs) of tertiary care hospitals in Japan. FINDINGS: We analyzed 3,503 consecutive patients who visited two EDs in Japan during a 3-month period. The initial diagnosis in the ED, the presence of consultation, and the patient disposition following the ED visit were recorded. At least one consultation was requested in 34.7% of the patients (1,215/3,503), and 88% of these patients were admitted to the hospital (1,063/1,215). Consultants and emergency physicians (EPs) agreed on patient disposition 95% of the time (1,153/1,215), with κ = 0.76 (95% CI 0.70-0.82). Opinions about disposition were discordant in 5% of the patients consulted upon. In 63% of those cases, patients were not diagnosed in the ED. CONCLUSION: Consultants and EPs agreed on patient disposition in most cases. In more than half of the cases in which disagreements arose between EPs and consultants, the EPs were not able to reach an initial diagnosis. Further studies are needed to examine the association between disagreements in disposition and adverse outcomes.

Effects of cognitive stimulation therapy Japanese version (CST-J) for people with dementia: a single-blind, controlled clinical trial.

OBJECTIVES: Cognitive stimulation therapy (CST) has shown to have significant benefits in improving the cognitive function and quality of life (QOL) in people with mild-to-moderate dementia in a UK randomized controlled trial (RCT). We developed and examined the Japanese version of group CST (CST-J) in a single-blind, controlled clinical trial. METHOD: CST-J consisting of 14 sessions was administered to a treatment group (n = 26) twice a week for 7 weeks. The treatment group was compared with a control group (n = 30). Based on single-blindness, cognition was evaluated by a researcher, and QOL and mood were rated by the participants themselves. Additionally, QOL and mood of participants were rated by care workers who were not blind but who observed them most directly in their daily life (important for social validity). RESULTS: A linear mixed model was used for analyses of cognition and QOL. There were significant improvements in cognition [COGNISTAT (Neurobehavioral Cognitive Status Examination) and MMSE (Mini-Mental State Examination)] for the treatment group compared with the control group (p < 0.01). Regarding QOL, the EQ-5D was significant (p = 0.019) and the QoL-AD (Quality of Life - Alzheimer's Disease) showed a positive trend (p = 0.06) when rated by care workers, although not when rated by the participants themselves. Using a nonparametrical analysis, there were significant improvements in the face scale for mood when rated by both the participants (p < 0.01) and the care workers (p = 0.017). CONCLUSION: The CST-J shows promising improvements in cognition, mood, and aspects of QOL for people with dementia in Japanese care settings. A large RCT is now needed.

[Problems impeding the introduction of care services under the long-term care insurance system].

OBJECTIVE: To identify problems currently impeding the introduction of care services to seniors who are not yet taking advantage of such services despite the need for some kind of in-home care, and to examine effective solutions by creating a model that clarifies relationships among these problems based on covariance structural analysis. METHODS: An anecdotal self-completion questionnaire was sent by mail to public health nurses who provide consultations to seniors in 657 locations throughout the mainland Japan, Honshu. The cases targeted in this survey were seniors for whom the introduction of care services was perceived to be difficult. Respondents were asked to relate one particularly memorable case encountered since April 2000 in which intervention assistance was provided through home visits. The survey consisted of 43 questions, including demographic information, basic case data, the outcome of intervention assistance in the case cited, and obstacles to introducing nursing services. We analyzed the 311 valid responses received (valid response rate: 47.3%). After performing factor analysis on the problems that were considered to impede the introduction of care services, we examined the relationships among these problems using covariance structural analysis and selected the model that best fit the data. RESULTS: 1) Problems that were considered to impede the introduction of care services were extracted from the results of an item analysis and factor analysis as follows. Factor 1: "Resistance to changing lifestyle." Factor 2: "Relative's lack of understanding or cooperation." Factor 3: "Lack of ability to handle procedures and contracts." Factor 4: "Lack of informal support." Factor 5: "Resistance to undergoing medical exams." 2) We performed a covariance structural analysis using the five factors derived from the factor analysis as the latent variables, and selected the best-fitting model, in which GFI = 0.929, AGFI = 0.901, and CFI = 0.950. The model showed that factors 3, 4, and 5 overlapped with factors 1 and 2 in impeding the introduction of nursing services, thus impeding the introduction of care services. CONCLUSION: The relationships among the problems impeding the introduction of care services were clarified using an anecdotal survey administered to public health nurses. To provide adequate support to these seniors, efforts must be made to examine community-based methods of providing intervention assistance tailored to the needs of individuals, as well as to examine systems of identifying and accommodating seniors who require assistance because they lack the ability to handle bureaucratic procedures themselves and also lack other sources of support.

Reliability and validity of the Japanese version of the Agitated Behaviour in Dementia Scale in Alzheimer's disease: three dimensions of agitated behaviour in dementia.

BACKGROUND: Agitation in dementia seriously affects not only patients' quality of life (QOL), but also caregivers' QOL. Thus, an appropriate assessment of agitated behaviour in dementia is needed for clinical management. We developed the Japanese version of the Agitated Behaviour in Dementia scale (ABID), examined its reliability and validity, and carried out its factor analysis to elucidate its factor structure. METHODS: The Japanese version of the ABID was given caregivers of 149 Japanese patients with Alzheimer's disease (AD). The internal-consistency, test-retest reliability and concurrent validity of the Japanese version of the ABID were then examined. A factor analysis was used to examine the agitated behavioural dimensions underlying ABID. RESULTS: The Japanese version of the ABID showed an excellent internal reliability for both frequency ratings (Cronbach's α= 0.89) and reaction ratings (Cronbach's α= 0.92), and an excellent test-retest reliability for both frequency ratings and reaction ratings. The total score for the frequency ratings of the ABID was significantly associated with the Cohen-Mansfield Agitation Inventory (CMAI), and the total score for the reaction ratings of the ABID was significantly associated with the Zarit Burden Interview. The factor analysis showed three subtypes: physically agitated behaviour, verbally agitated behaviour and psychosis symptoms. CONCLUSIONS: The Japanese version of the ABID promises to be useful for assessing agitated behaviour in patients with AD. Importantly, understanding these subtypes of agitated behaviour might have implications for individualized treatment plans.

A case of sepsis and meningitis caused by probable travel-related Neisseria meningitidis serogroup B infection: the first report of N. meningitidis ST-4893 in Japan.

Herein we present a case of Neisseria meningitidis-related sepsis and meningitis in a 60-year-old woman. The N. meningitidis strain was identified as serogroup B and sequence type (ST)-4893 by multilocus sequence typing (MLST). The patient in this case had visited France prior to development of symptoms. No meningococcal isolate belonging to ST-4893 has been identified in Japan previously, whereas an ST-4893 strain from France has been reported in the MLST database. These results strongly suggest that this case is likely to have been imported from France.

Disappearance of memory fragments in patients with Alzheimer's disease: evidence from a longitudinal study of visual priming.

Previous studies suggested that perceptual memory as indexed by visual priming is normal in patients with Alzheimer's disease (AD). However, these studies did not specifically test the long-term effects of visual priming, which may differ significantly between Alzheimer's patients and normal subjects. To test this possibility, we examined long-term visual priming in AD patients, 1 hour, 1 month, and 3 months after training. Our results indicated a significant difference in visual priming between AD patients and normal subjects after 3 months, but not 1 month. For AD patients, there was a strong positive correlation between the 3-month priming effect and the Mini-Mental State Examination (MMSE) scores-severely demented patients were less likely to exhibit priming after 3 months. It appears that severe cortical degeneration may render AD patients unable to consolidate their perceptual memories. Our results suggest that lack of visual priming in AD patients is linked to the inability to maintain fragmented perceptual memories.

Comparison of neurocognitive results after coronary artery bypass grafting and thoracic aortic surgery using retrograde cerebral perfusion.

OBJECTIVE: Retrograde cerebral perfusion (RCP) is used as an adjunctive method to hypothermic circulatory arrest to enhance cerebral protection in patients undergoing thoracic aortic surgery. It remains unclear whether RCP provides improved neurological and neuropsychological outcome. METHODS: Forty-six patients undergoing thoracic aortic surgery using RCP, and 28 undergoing coronary artery bypass grafting (CABG; n = 28) with CPB, were enrolled in the study. Patients receiving RCP were subdivided into two groups, those with less than 60 min of RCP (S-RCP; n = 27) and with 60 min or more (L-RCP; n = 19). The patients' neurocognitive state was assessed by the revised Wechsler Adult Intelligence Scale a few days before operation, at 2-3 weeks and 4-6 months after operation. RESULTS: There were no stroke, seizure, and hospital mortality in either group. Significant decline between baseline and early scores were seen in three subtests (digit span, arithmetic, and picture completion) for S-RCP and four (digit span, arithmetic, picture completion, and picture arrangement) for L-RCP. Significant decline between baseline and late scores were seen in one subtest (arithmetic) for S-RCP, four (digit span, arithmetic, picture completion, and picture arrangement) for L-RCP, and one (object assembly) for CABG. The mean change of scores for one late test (digit symbol) was significantly lower in S-RCP than in CABG. The mean change of scores for three early tests (digit span, vocabulary, and picture arrangement) and four late tests (information, digit span, picture completion, and picture arrangement) were significantly lower in L-RCP than in CABG. Stepwise logistic regression analysis disclosed that, after considering the other variables, significant difference in test score changes were observed between CABG and L-RCP for two early tests (picture completion and digit symbol) as well as for three late tests (digit span, similarities, and picture completion). None of test score changes showed significant difference between CABG and S-RCP. CONCLUSIONS: The neurocognitive outcome in patients undergoing RCP less than 60 min were comparable with patients undergoing CABG without circulatory arrest. Prolonged RCP of 60 min or more in patients undergoing surgery of the thoracic aorta was associated with postoperative neurocognitive impairment.

Deficits in long-term retention of learned motor skills in patients with cortical or subcortical degeneration.

We investigated the acquisition and long-term retention of new skills in patients with cortical (Alzheimer's disease, AD) and subcortical (progressive supranuclear palsy, PSP; Parkinson's disease, PD) degeneration. The motor skill task performance of the PD and PSP patients improved with training, but the improvement disappeared within a few months, whereas AD patients retained learned skills for 3-18 months. The results of our experiments show that subcortical dysfunction induces a retention deficit for newly learned motor skills. Our present study suggests that a normal striatum is necessary for the formation of long-lasting motor skills, and that the striatum plays an important role as a motor skill consolidation system.

Neurocognitive outcome after retrograde cerebral perfusion.

BACKGROUND: Neurocognitive outcome in patients undergoing thoracic aortic surgery using retrograde cerebral perfusion (RCP) remains uncertain. METHODS: Forty-two patients undergoing thoracic aortic surgery using RCP were enrolled in the study. The patients' neurocognitive state was assessed by the revised Wechsler Adult Intelligence Scale (WAIS-R) a few days before operation, at 2 to 3 weeks, and at 4 to 6 months after operation. RESULTS: There were no stroke, seizure, and hospital death. Significant performance deterioration was observed in digit span, arithmetic, and picture completion of the WAIS-R subtests. Bivariate comparison showed that older age (late vocabulary, late similarities, and late object assembly), longer RCP time (early picture arrangement, and early block design), later awake time (early and late picture arrangement, and early block design), longer respirator use (early and late digit span, late picture arrangement), longer ICU time (late picture completion, early and late picture arrangement, and early block design), and longer hospital stay (early picture arrangement) were significantly associated with the decline in neurocognitive performance. Stepwise logistic regression analysis disclosed that older age (late similarities and late object assembly), later awake time (late picture arrangement), and longer respirator use (early and late digit span, and late picture arrangement) were most predictive for the decline in neurocognitive performance. CONCLUSIONS: On average, digit span, arithmetic, and picture completion tests were most sensitive in detecting the decline in neurocognitive performance. The relationship between the duration of RCP and neurocognitive test results was not significant.

Pharmacokinetics of lopinavir after administration of Kaletra in healthy Japanese volunteers.

The pharmacokinetic parameters of lopinavir (LPV) were examined by administering Kaletra (LPV+ritonavir) to 8 healthy Japanese volunteers both in the fasting and postprandial conditions. LPV showed a biphasic decline, which was slower in the initial phase and became more rapid in the later phase. The behavior of LPV in the initial phase could be modeled using a one-compartment model with first-order absorption. In the fasting study, calculations based on the pharmacokinetic model revealed that the time to reach the maximum concentration (T(max)), maximum concentration (C(max)), half-life (T(1/2)), lag time, apparent volume of distribution (Vd/F) and oral clearance (Cl/F) were 3.2+/-1.0 h, 6.9+/-1.9 microg/ml, 10.0+/-3.7 h, 0.71+/-0.32 h, 51.0+/-12.4 l and 4.2+/-2.6 l/h, respectively. On the other hand, in the postprandial study, the calculated T(max), C(max), T(1/2), lag time, Vd/F and Cl/F were 5.6+/-2.0 h, 7.6+/-1.8 microg/ml, 16.7+/-7.0 h, 2.35+/-0.78 h, 48.0+/-15.9 l and 2.1+/-0.6 l/h, respectively. The values for the area under the curve for data collected over a 24-h period (AUC(24 h)) in the fasting and postprandial studies were 86.0+/-27.7 and 102.1+/-31.0 microg.h/ml, respectively. The T(1/2) had a tendency to be prolonged after food intake, but there were 2 cases with shortened T(1/2). Food intake prolonged the lag time 3-fold and as a result, the postprandial T(max) was 2 times longer.