Development and evaluation of an aged care specific Advance Care Plan.

OBJECTIVES: To report on the quality of advance care planning (ACP) documents in use in residential aged care facilities (RACF) in areas of Victoria Australia prior to a systematic intervention; to report on the development and performance of an aged care specific Advance Care Plan template used during the intervention. DESIGN: An audit of the quality of pre-existing documentation used to record resident treatment preferences and end-of-life wishes at participating RACFs; development and pilot of an aged care specific Advance Care Plan template; an audit of the completeness and quality of Advance Care Plans completed on the new template during a systematic ACP intervention. PARTICIPANTS AND SETTING: 19 selected RACFs (managed by 12 aged care organisations) in metropolitan and regional areas of Victoria. RESULTS: Documentation in use at facilities prior to the ACP intervention most commonly recorded preferences regarding hospital transfer, life prolonging treatment and personal/cultural/religious wishes. However, 7 of 12 document sets failed to adequately and clearly specify the resident's preferences as regards life prolonging medical treatment. The newly developed aged care specific Advance Care Plan template was met with approval by participating RACFs. Of 203 Advance Care Plans completed on the template throughout the project period, 49% included the appointment of a Medical Enduring Power of Attorney. Requests concerning medical treatment were specified in almost all completed documents (97%), with 73% nominating the option of refusal of life-prolonging treatment. Over 90% of plans included information concerning residents' values and beliefs, and future health situations that the resident would find to be unacceptable were specified in 78% of completed plans. CONCLUSIONS: Standardised procedures and documentation are needed to improve the quality of processes, documents and outcomes of ACP in the residential aged care sector.

Quality of advance care planning policy and practice in residential aged care facilities in Australia.

OBJECTIVES: To assess existing advance care planning (ACP) practices in residential aged care facilities (RACFs) in Victoria, Australia before a systematic intervention; to assess RACF staff experience, understanding of and attitudes towards ACP. DESIGN: Surveys of participating organisations concerning ACP-related policies and procedures, review of existing ACP-related documentation, and pre-intervention survey of RACF staff covering their role, experiences and attitudes towards ACP-related procedures. SETTING: 19 selected RACFs in Victoria. PARTICIPANTS: 12 aged care organisations (representing 19 RACFs) who provided existing ACP-related documentation for review, 12 RACFs who completed an organisational survey and 45 staff (from 19 RACFs) who completed a pre-intervention survey of knowledge, attitudes and behaviour. RESULTS: Findings suggested that some ACP-related practices were already occurring in RACFs; however, these activities were inconsistent and variable in quality. Six of the 12 responding RACFs had written policies and procedures for ACP; however, none of the ACP-related documents submitted covered all information required to meet ACP best practice. Surveyed staff had limited experience of ACP, and discrepancies between self reported comfort, and levels of knowledge and confidence to undertake ACP-related activities, indicated a need for training and ongoing organisational support. CONCLUSIONS: Surveyed organisations â policies and procedures related to ACP were limited and the quality of existing documentation was poor. RACF staff had relatively limited experience in developing advance care plans with facility residents, although attitudes were positive. A systematic approach to the implementation of ACP in residential aged care settings is required to ensure best practice is implemented and sustained.

Trauma at the hands of another: longitudinal study of differences in the posttraumatic stress disorder symptom profile following interpersonal compared with noninterpersonal trauma.

OBJECTIVE: Survivors of traumatic events of an interpersonal nature typically have higher rates of posttraumatic stress disorder (PTSD) than survivors of noninterpersonal traumatic events. Little is known about potential differences in the nature or trajectory of PTSD symptoms in survivors of these different types of traumatic events. The current study aimed to identify the specific symptom profile of survivors of interpersonal and noninterpersonal trauma, and to examine changes in differences in the symptom profile over time. METHOD: The study examined PTSD symptom data from 715 traumatic injury survivors admitted to the hospital between April 2004 and February 2006, who were assessed 3, 12, and 24 months after injury using the Clinician-Administered PTSD Scale (primary outcome measure). Multivariate analyses of variance were used to investigate differences in PTSD symptom profile over time between interpersonal and noninterpersonal trauma. RESULTS: Multivariate analyses of variance revealed significant differences between the 2 groups in overall severity of PTSD symptoms at each of the 3 time points: 3 months, F(17,696) = 5.86, P < .001; 12 months, F(17,696) = 3.62, P < .001; 24 months, F(17,696) = 3.09, P < .001. Survivors of interpersonal trauma demonstrated significantly (P < .01) higher scores on 14 PTSD symptoms at 3 months after injury but on only 6 symptoms by 24 months. Symptoms on which differences persisted were the PTSD unique symptoms more associated with fear and threat. CONCLUSIONS: Interpersonal trauma results in more severe PTSD symptoms in the early aftermath of trauma. Over the course of time, the distinctive persisting symptoms following interpersonal trauma involve fear-based symptoms, which suggest fear conditioning may be instrumental in persistent interpersonal PTSD.

Successful aging: development and testing of a multidimensional model using data from a large sample of older australians.

OBJECTIVES: To develop a multidimensional statistical model that could assess the contribution of, and interrelationships between, measures likely to contribute to an individual's successful aging, defined as aging well across a number of dimensions. DESIGN: Cross-sectional. SETTING: Data collected from 8,841 Australians aged 16 to 85 during the 2007 National Survey of Mental Health and Well-Being conducted by the Australian Bureau of Statistics. PARTICIPANTS: Two thousand two hundred eighty-six survey participants aged 61 to 85. MEASUREMENTS: Self-assessed physical and mental health, quality of life, and cognition constitute the outcome factor: successful aging. Attributes measuring past and current mental and physical health, social measures, and health behaviors were considered for inclusion as predictor measures. Results of the final model allowed calculation of individual weighted successful aging scores. RESULTS: The final model closely fitted responses from participants and men and women separately. Factors measuring mental and physical health and social support contributed significantly and independently to successful aging. Health behaviors, measuring extent of physical exercise and not smoking, contributed to successful aging in addition to their association with physical health. On average, those scoring in the highest decile of the successful aging measure reported having two chronic health conditions, indicating that such conditions do not necessarily preclude high levels of well-being in older individuals. CONCLUSION: This model developed from a large sample of older individuals identified factors worth targeting in future social and health policy initiatives for this age group. It also indicates that chronic illness is not necessarily a barrier to successful aging.

The general practitioner's role in providing mental health services to Australians, 1997 and 2007: findings from the national surveys of mental health and wellbeing.

OBJECTIVES: To compare the findings of the 1997 and 2007 Australian national surveys of mental health and wellbeing (NSMHWBs) with respect to the role of general practitioners in providing mental health services. DESIGN, SETTING AND PARTICIPANTS: There were 10,641 participants Australia-wide in the 1997 survey and 8841 in the 2007 survey. Data were gathered through face-to-face interviews using a written questionnaire. MAIN OUTCOME MEASURES: Rates of use of GPs and other health care providers for treatment of mental health problems; levels of met and unmet need for mental health services reported by those accessing GP services. RESULTS: Between 1997 and 2007, the proportion of people accessing any mental health care service within the previous 12 months increased significantly, from 12.4% to 21.4% (P < 0.01), although the proportion accessing GP care for mental health problems did not increase. In both surveys, nearly 60% of individuals with self-assessed mental health problems sought no professional help for their problems, although about 80% of these non-users had seen GPs about other matters. The proportions of participants who reported receiving sufficient information, medication and/or therapy for their mental health problem increased significantly over the 10-year period. However, unmet need for information also increased. In both surveys, over 90% of participants aged 60 years or over with self-assessed mental health problems reported obtaining no help for their mental health problem despite seeing a GP for other reasons. CONCLUSION: Despite a significant rise in the use of mental health services, the role of GPs in providing such services has not increased.

Is telomere length a biomarker of aging? A review.

Telomeres, the DNA-protein structures located at the ends of chromosomes, have been proposed to act as a biomarker of aging. In this review, the human evidence that telomere length is a biomarker of aging is evaluated. Although telomere length is implicated in cellular aging, the evidence suggesting telomere length is a biomarker of aging in humans is equivocal. More studies examining the relationships between telomere length and mortality and with measures that decline with "normal" aging in community samples are required. These studies would benefit from longitudinal measures of both telomere length and aging-related parameters.

Attachment style in the prediction of recovery following group treatment of combat veterans with post-traumatic stress disorder.

Post-traumatic stress disorder (PTSD) can be difficult to treat, with gains often particularly modest in combat veterans. Although group-based treatments are commonly delivered for veterans, little is known about factors influencing their outcomes. Attachment style is known to be associated with psychopathology after trauma and is critical to group-based interventions, but has not yet been investigated in relation to treatment outcome. A better understanding of factors that influence outcome is critical in optimizing the effectiveness of such interventions. This study investigated attachment style as a predictor of outcome for 103 veterans attending group-based treatment for combat-related PTSD. Measures included the Clinician Administered PTSD Scale, PTSD Checklist, and Relationship Styles Questionnaire. Path analyses indicated preoccupied attachment style strongly negatively predicted outcome following treatment. The preoccupied attachment style impedes recovery in group-based treatment for veterans with PTSD. Potential mechanisms underlying this finding are discussed. The results suggest that greater attention should be paid at initial assessment to attachment style of veterans before entering PTSD treatment, particularly group-based interventions.

Longitudinal analyses of family functioning in veterans and their partners across treatment.

OBJECTIVE: This study evaluated the relations between posttraumatic stress disorder (PTSD) symptoms and poor family functioning in veterans and their partners. METHOD: Data were collected from Caucasian veterans with PTSD (N = 1,822) and their partners (N = 702); mean age = 53.9 years, SD = 7.36. Veterans completed the Posttraumatic Checklist Military Version (PCL-M) and, along with their partners, completed the McMaster Family Assessment Device (FAD-12). Assessments were conducted at intake into a treatment program at 3 months and 9 months posttreatment. RESULTS: Structural equation models (SEMs) were developed for veterans as well as for veterans and their partners. Poor family functioning for veterans at intake predicted intrusion (ß = .08), hyperarousal (ß = .07), and avoidance (ß = .09) at 3 months posttreatment. At 3 months posttreatment, family functioning predicted hyperarousal (ß = .09) and avoidance (ß = .10) at 9 months. For veterans and their partners, family functioning at intake predicted avoidance (ß = .07) at 3 months, and poor family functioning at 3 months predicted intrusion (ß = .09) and hyperarousal (ß = .14) at 9 months. The reverse pathways, with PTSD symptoms predicting poor family functioning, were only evident with avoidance (ß = .06). CONCLUSION: Family functioning may play a role in treatment for veterans.

Combined pharmacotherapy and psychological therapies for post traumatic stress disorder (PTSD).

BACKGROUND: PTSD is an anxiety disorder related to exposure to a severe psychological trauma. Symptoms include re-experiencing the event, avoidance and arousal as well as distress and impairment resulting from these symptoms.Guidelines suggest a combination of both psychological therapy and pharmacotherapy may enhance treatment response, especially in those with more severe PTSD or in those who have not responded to either intervention alone. OBJECTIVES: To assess whether the combination of psychological therapy and pharmacotherapy provides a more efficacious treatment for PTSD than either of these interventions delivered separately. SEARCH STRATEGY: Searches were conducted on the trial registers kept by the CCDAN group (CCDANCTR-Studies and CCDANCTR-References) to June 2010. The reference sections of included studies and several conference abstracts were also scanned. SELECTION CRITERIA: Patients of any age or gender, with chronic or recent onset PTSD arising from any type of event relevant to the diagnostic criteria were included. A combination of any psychological therapy and pharmacotherapy was included and compared to wait list, placebo, standard treatment or either intervention alone. The primary outcome was change in total PTSD symptom severity. Other outcomes included changes in functioning, depression and anxiety symptoms, suicide attempts, substance use, withdrawal and cost. DATA COLLECTION AND ANALYSIS: Two or three review authors independently selected trials, assessed their 'risk of bias' and extracted trial and outcome data. We used a fixed-effect model for meta-analysis. The relative risk was used to summarise dichotomous outcomes and the mean difference and standardised mean difference were used to summarise continuous measures. MAIN RESULTS: Four trials were eligible for inclusion, one of these trials (n =24) was on children and adolescents. All used an SSRI and prolonged exposure or a cognitive behavioural intervention. Two trials compared combination treatment with pharmacological treatment and two compared combination treatment with psychological treatment. Only two trials reported a total PTSD symptom score and these data could not be combined. There was no strong evidence to show if there were differences between the group receiving combined interventions compared to the group receiving psychological therapy (mean difference 2.44, 95% CI -2.87, 7.35 one study, n=65) or pharmacotherapy (mean difference -4.70, 95% CI -10.84 to 1.44; one study, n = 25). Trialists reported no significant differences between combination and single intervention groups in the other two studies. There were very little data reported for other outcomes, and in no case were significant differences reported. AUTHORS' CONCLUSIONS: There is not enough evidence available to support or refute the effectiveness of combined psychological therapy and pharmacotherapy compared to either of these interventions alone. Further large randomised controlled trials are urgently required.

A longitudinal analysis of posttraumatic stress disorder symptoms and their relationship with Fear and Anxious-Misery disorders: implications for DSM-V.

This paper examined the hypothesis that PTSD-unique symptom clusters of re-experiencing, active avoidance and hyperarousal were more related to the fear/phobic disorders, while shared PTSD symptoms of dysphoria were more closely related to Anxious-Misery disorders (MDD/GAD). Confirmatory factor and correlation analyses examining PTSD, anxiety and mood disorder data from 714 injury survivors interviewed 3, 12 and 24-months following their injury supported this hypothesis with these relationships remaining robust from 3-24 months posttrauma. Of the nine unique fear-oriented PTSD symptoms, only one is currently required for a DSM-IV diagnosis. Increasing emphasis on PTSD fear symptoms in DSM-V, such as proposed DSM-V changes to mandate active avoidance, is critical to improve specificity, ensure inclusion of dimensionally distinct features and facilitate tailoring of treatment.

Differences in older people's responses to CIDI's depression screening and diagnostic questions may point to age-related bias.

BACKGROUND: Psychiatric surveys based on the Composite International Diagnostic Interview (CIDI) report very low rates of affective disorder in older people, perhaps because CIDI's long, convoluted screening questions present a special challenge to aged respondents. We have shown previously that inconsistencies in responses to CIDI's two screening questions about dysphoria and anhedonia rose in frequency with age. By contrast, responses to the short, simple K-10 and GHQ-12 mental health scales showed much less change over the lifespan. As a check on age-related bias, we now compare responses to CIDI's depression screening questions with responses to subsequent, simpler questions about other depressive symptoms. METHODS: Secondary analysis of an Australian national survey in which CIDI was administered to 10,641 adults by trained lay interviewers. RESULTS: Rates of positive responses to both CIDI screening questions fell from 11% in age-group 18-34 years to 3% in respondents aged > or = 65 years. Responses to simpler CIDI items about other depressive symptoms and help-seeking behaviour showed much less change with age. CONCLUSION: Older respondents may deny symptoms when subjected to complex batteries of questions concerning severity, time frame, attribution and consequences. CIDI diagnoses need to be validated across the full age spectrum. LIMITATIONS: Residents of aged care facilities and those with low cognitive scores were excluded.

Mental health scales and psychiatric diagnoses: responses to GHQ-12, K-10 and CIDI across the lifespan.

BACKGROUND: Surveys based on complex interviews like CIDI report very low rates of affective disorder in older people, perhaps because the lengthy, convoluted questions present a special challenge to aged respondents. By contrast, mental health scales like the GHQ-12 and K-10 show much less change in score with age. Before concluding that scales present a fairer picture of aged mental health, it is important to check if scores are inflated by items that might reflect normal involutional changes in cognition, energy and social role. METHODS: Secondary analysis of an Australian national survey of 10,641 adults. RESULTS: GHQ-12 and K-10 scores declined with age to a relatively minor degree. When scores were bisected, the proportion of respondents scoring above the cutpoints fell with age but to a lesser degree than with ICD-10 diagnoses. Scores on GHQ-12 and K-10 items relating to cognition, energy and social role rose with age but, on factor analysis, these items loaded similarly in a two-factor model. CONCLUSION: No evidence emerged of age-related bias in either GHQ-12 or K-10. Items concerning cognition, energy and social role were associated with affect in older people, just as they were in younger ones. It seems unlikely therefore that the different trajectories over the lifespan of CIDI diagnoses and scores on GHQ-12 and K-10 are due to limitations within the scales. The possibility that CIDI minimizes affective disorder in older age-groups cannot be discounted. LIMITATIONS: Residents of aged care facilities and those with low cognitive scores were excluded.

A predictive screening index for posttraumatic stress disorder and depression following traumatic injury.

Posttraumatic stress disorder (PTSD) and major depressive episode (MDE) are frequent and disabling consequences of surviving severe injury. The majority of those who develop these problems are not identified or treated. The aim of this study was to develop and validate a screening instrument that identifies, during hospitalization, adults at high risk for developing PTSD and/or MDE. Hospitalized injury patients (n = 527) completed a pool of questions that represented 13 constructs of vulnerability. They were followed up at 12 months and assessed for PTSD and MDE. The resulting database was split into 2 subsamples. A principal-axis factor analysis and then a confirmatory factor analysis were conducted on the 1st subsample, resulting in a 5-factor solution. Two questions were selected from each factor, resulting in a 10-item scale. The final model was cross-validated with the 2nd subsample. Receiver-operating characteristic curves were then created. The resulting Posttraumatic Adjustment Scale had a sensitivity of .82 and a specificity of .84 when predicting PTSD and a sensitivity of .72 and a specificity of .75 in predicting posttraumatic MDE. This 10-item screening index represents a clinically useful instrument to identify trauma survivors at risk for the later development of PTSD and/or MDE.

Naturalistic comparison of models of programmatic interventions for combat-related post-traumatic stress disorder.

OBJECTIVES: Post-traumatic stress disorder (PTSD) is a difficult-to-treat sequel of combat. Data on effectiveness of alternate treatment structures are important for planning veterans' psychiatric services. The present study compared clinical presentations and treatment outcomes for Australian veterans with PTSD who participated in a range of models of group-based treatment. METHOD: Participants consisted of 4339 veterans with combat-related PTSD who participated in one of five types of group-based cognitive behavioural programmes of different intensities and settings. Data were gathered at baseline (intake), as well as at 3 and 9 month follow up, on measures of PTSD, anxiety, depression and alcohol misuse. Analyses of variance and effect size analyses were used to investigate differences at intake and over time by programme type. RESULTS: Small baseline differences by programme intensity were identified. Although significant improvements in symptoms were evident over time for each programme type, no significant differences in outcome were evident between programmes. When PTSD severity was considered, veterans with severe PTSD performed less well in the low-intensity programmes than in the moderate- or high-intensity programmes. Veterans with mild PTSD improved less in high-intensity programmes than in moderate- or low-intensity programmes. CONCLUSION: Comparable outcomes are evident across programme types. Outcomes may be maximized when veterans participate in programme intensity types that match their level of PTSD severity. When such matching is not feasible, moderate-intensity programmes appear to offer the most consistent outcomes. For regionally based veterans, delivering treatment in their local environment does not detract from, and may even enhance, outcomes. These findings have implications for the planning and purchasing of mental health services for sufferers of PTSD, particularly for veterans of more recent combat or peacekeeping deployments.

Trauma exposure and posttraumatic stress disorder in the elderly: a community prevalence study.

OBJECTIVE: Little prevalence data exist on trauma exposure and posttraumatic stress disorder (PTSD) in the elderly. The authors examined lifetime exposure to trauma and 12-month PTSD in a large community sample. METHOD: Data were drawn from the Australian National Survey of Mental Health. Of the total 10,641 participants, 1,792 were over the age of 65. The Composite International Diagnostic Interview provided trauma exposure and diagnostic status. RESULTS: A curvilinear pattern of lifetime exposure to trauma across the lifespan was obtained for women, whereas men showed a linear increase. This difference was explained by combat exposure. PTSD prevalence reduced with age and participants over 65 reported negligible rates. Around 10% of the elderly reported reexperiencing symptoms. CONCLUSIONS: PTSD rates are lower in older age cohorts, although reasons for this are unclear. With 10% reporting reexperiencing symptoms associated with past events, however, greater awareness of treatments that target traumatic memories may be beneficial.

Mechanisms of anger and treatment outcome in combat veterans with posttraumatic stress disorder.

Research has identified anger as prominent in, and an influence on, treatment outcome for military veterans with posttraumatic stress disorder (PTSD). This study examined factors influencing the relationship between anger and outcome to improve treatment effectiveness. Participants comprised 103 veterans attending PTSD treatment. Measures of PTSD and comorbidity were obtained at intake and 9-month follow-up. Measures also included potential mediators of therapeutic alliance, social support, problematic/undermining relationships and fear of emotion. Path analyses supported anger as a predictor of treatment outcome, with only fear of anger and alcohol comorbidity accounting for the variance between anger and outcome. To improve treatment effectiveness, clinicians need to assess veterans' anger, aggression, and alcohol use, as well as their current fear of anger and elucidate the relationship between these factors.

Effectiveness of complementary and self-help treatments for anxiety in children and adolescents.

OBJECTIVE: To review the evidence for the effectiveness of complementary and self-help treatments for anxiety disorders and situational anxiety in children and adolescents. DATA SOURCES: Systematic literature search using PubMed, PsycINFO and the Cochrane Library for 111 treatments up to February 2006. STUDY SELECTION: There were 11 treatments for which intervention studies had been undertaken and reported. DATA EXTRACTION: Studies on each treatment were reviewed by one author and checked by a second. A consensus was reached for level of evidence. DATA SYNTHESIS: Relevant evidence was available for bibliotherapy, dance and movement therapy, distraction techniques, humour, massage, melatonin, relaxation training, autogenic training, avoiding marijuana, a mineral-vitamin supplement (EMPower +) and music therapy. Findings from case-control studies, individual cohort studies or low quality randomised controlled trials indicated that several treatments may have potential to reduce anxiety, including bibliotherapy, massage, melatonin, and relaxation training. CONCLUSIONS: Although some complementary and self-help treatments might be useful for children and adolescents with anxiety, they need to be tested adequately through randomised controlled trials before they could be recommended.

Pretrauma and posttrauma neurocognitive functioning and PTSD symptoms in a community sample of young adults.

OBJECTIVE: The authors sought to assess whether neurocognitive deficits in people with the posttraumatic stress disorder (PTSD) symptoms of reexperiencing and arousal are a consequence of these symptoms or represent a preexisting vulnerability factor for developing these symptoms after exposure to a traumatic event. METHOD: A random sample of 2,097 young adults who participated in a longitudinal epidemiological study in 1999 and 2000 were reinterviewed in 2003 and 2004 after a major natural disaster (a widespread fire) had occurred in the region. At both interviews, participants completed a number of neurocognitive tests covering immediate and delayed word recall, digit span, coding speed, and vocabulary. Five pre- and posttrauma neurocognitive measures for 1,599 participants who were exposed to the fire were examined to assess the extent to which development of the PTSD symptoms of reexperiencing and arousal was associated with change in neurocognitive skills. Analyses adjusted for a number of potential confounding factors. RESULTS: Higher levels of fire-related reexperiencing and arousal symptoms were associated with less improvement in word recall ability at the second interview. However, levels of these symptoms were more consistently associated with having poorer pretrauma scores on all five neurocognitive measures available for this study. CONCLUSIONS: The presence of the PTSD symptoms of reexperiencing and arousal may result in a relative decline in some measures of verbal memory over time. The more robust finding from this study is that poorer performance on some neurocognitive tests may be a vulnerability factor for developing symptoms of PTSD, not only an outcome of PTSD symptoms.

The brain reserve hypothesis, brain atrophy and aging.

BACKGROUND: Researchers have used the concept of brain reserve to explain the dissociation between pathological brain damage and cognitive and functional performance. A variety of brain reserve hypotheses exist, and different empirical strategies have been employed to investigate these variants. OBJECTIVE: The study investigates (i) the relationship between measures of brain burden (atrophy, white matter hyperintensities (WMH)) and measures of reserve (education, creativity, and intelligence); (ii) the relationship between cognitive decline and reserve; (iii) whether measures of reserve mediate the effect of atrophy on estimated cognitive change, and (iv) the association between brain risk factors, education and atrophy. METHODS: A cross-sectional study of a sample of 446 individuals 60-64 years of age who underwent MRI scans as part of a large epidemiological study. Measures were taken of education, intelligence, creativity, cognitive speed, brain volume, WMH, estimated cognitive decline from earlier in life and brain atrophy. RESULTS: No association was found between estimated cognitive decline and brain burden (atrophy, WMH). Risk factors for brain insult were not associated with greater brain atrophy in the less well educated. Neither education, nor any other measure including intelligence or creativity, provided a buffer for cognitive decline in individuals with high levels of brain atrophy. CONCLUSION: Little support was found for the brain reserve hypothesis.