Access to community care for people with dementia and their informal carers : Case vignettes for a European comparison of structures and common pathways to formal care.

BACKGROUND: People with dementia and their informal carers often do not receive appropriate professional support or it is not received at the right time. OBJECTIVES: Description and comparison of common pathways to formal community dementia care in eight European countries as a part of the transnational Actifcare project. MATERIALS AND METHODS: The German team was responsible for creating an individual case scenario as a starting point. The research teams in Ireland, Italy, the Netherlands, Norway, Portugal, Sweden, and the United Kingdom were then asked to describe a common pathway to formal dementia care by writing their own vignette using the provided individual case scenario. RESULTS: A transnational qualitative content analysis was used to identify the following categories as being the most important: involved professionals, dementia-specific and team-based approaches, proactive roles, and financial aspects. General practitioners (GPs) are described as being the most important profession supporting the access to formal care in all the involved countries. In some countries other professionals take over responsibility for the access procedure. Dementia-specific approaches are rarely part of standard care; team-based approaches have differing significances in each of the countries. Informal carers are mainly proactive in seeking formal care. The Nordic countries demonstrate how financial support enhances access to the professional system. CONCLUSION: Enhanced cooperation between GPs and other professions might optimize access to formal dementia care. Team-based approaches focusing on dementia care should be developed further. Informal carers should be supported and relieved in their role. Financial barriers remain which should be further investigated and reduced.

Life weariness and suicidal thoughts in late life: a national study in Sweden.

OBJECTIVES: This study aimed at investigating the point prevalence of life weariness and suicidal thoughts and their relationship with socio-demographic characteristics in a population of older adults in Sweden. METHOD: Data from 7913 individuals aged 60 years and older were drawn from the Swedish National Study on Aging and Care, a collaborative study in Sweden. Life weariness and suicidal thoughts were measured by one item derived from the Montgomery-Åsberg Depression Rating Scale. A multinomial regression model was used to investigate the relationships of socio-demographic characteristics with life weariness and suicidal thoughts. RESULTS: Living in urban and semi-urban areas, being of advanced age, being divorced and having lower educational levels were related to life weariness. Living in a residential care facility, being widowed or unmarried, being born in a non-Nordic European country and experiencing financial difficulties were related to both life weariness and suicidal thoughts. Sex was found to be unrelated to either life weariness or suicidal thoughts. CONCLUSION: This study found that several socio-demographic variables were associated with life weariness and suicidal thoughts among older adults. Specific attention to older individuals with these characteristics may be warranted as they might be more vulnerable to life weariness and suicidal thoughts.

Formal and Informal Care of Community-Living Older People: A Population-Based Study from the Swedish National Study on Aging and Care.

OBJECTIVES: Study formal and informal care of community-living older people in the Swedish National study of Aging and Care (SNAC). DESIGN: Cross-sectional, population based cohort. SETTING: Three areas in Sweden: Municipality of Nordanstig, Stockholm and Skåne County. PARTICIPANTS: 3,338 persons ≥72 years. MEASUREMENTS: Patterns and amounts of informal and formal care by cognition and area of residence. RESULTS: 73% received no care; 14% formal care; and 17% informal care (7% received both). In the whole study population, including those who used no care, individuals in small municipalities received 9.6 hours of informal care/month; in mid-size municipalities, 6.6; and in urban areas, 5.6. Users of informal care received 33.1 hours of informal care/month in small municipalities, 54.6 in mid-size municipalities and 36.1 in urban areas. Individuals with cognitive impairment received 14.1 hours of informal care/month, 2.7 times more than people with no/slight impairment. In the whole study population, individuals in small municipalities received an average of 3.2 hours of formal care/month; in mid-size municipalities 1.4; and in urban areas, 2.6. Corresponding figures for formal care users were 29.4 hours in small municipalities, 13.6 in mid-size municipalities and 16.7 in urban areas. Formal care users received 7.1 hours, and informal care users, 5.9 hours for each hour/month received by people in the study population as a whole. CONCLUSIONS: More informal than formal care was provided. Informal care is more frequent in small municipalities than urban areas and for those with than without cognitive impairment. The relationship between data on the whole population and the data on users or care indicates that population-based data are needed to avoid overestimates of care.

Incremental patterns in the amount of informal and formal care among non-demented and demented elderly persons: results from a 3-year follow-up population-based study.

OBJECTIVE: Elderly care includes complex interactions between formal services, informal care, morbidity and disabilities. Studies of the incremental effects of formal and informal care are rare and thus the objective was to describe the longitudinal patterns in formal and informal care given to non-demented and demented persons living in a rural area in Sweden. METHODS: Transitions in the Kungsholmen-Nordanstig Project (n=919) was followed up 3 years later (n=579), presented as different combinations of informal and formal care, institutionalization and mortality. Number of hours spent on care was examined by the Resource Utilization in Dementia instrument (RUD). Bootstrapped descriptive statistics and regression models were applied. RESULTS: The overall mortality during follow-up was 34%, and 15% had been institutionalized. Of those who lived at home, those receiving only formal care had been institutionalized to the greatest extent (29%; p<0.05). In terms of hours, informal care decreased amongst demented. The ratio between demented and non-demented was greater at baseline, both regarding informal care (10:1 and 3:1, respectively) and formal care (5:1 and 4:1, respectively). People with mild cognitive decline and no home support at baseline had a great risk of being receiver of care (formal or informal) or dead at follow-up. CONCLUSIONS: The amount of informal care was lower for demented persons still living at home at follow-up than at baseline, probably due to selection effects (institutionalization and mortality). Mild cognitive decline of non-users of care at baseline was strongly associated with receiving care or being dead at follow-up.

Patients' pretreatment beliefs about recovery influence outcome of a pain rehabilitation program.

AIM: The aim of this study was to monitor the outcome of a five-week cognitive-behavioral interdisciplinary rehabilitation program for patients disabled by chronic pain, utilizing data collected for a national quality registry. METHODS: The study included 255 consecutive patients from a university hospital setting. Demographic data and patient beliefs about recovery recorded on a five-category scale were collected before the program. Pain intensity (VAS), Disability Rating Index (DRI) and life satisfaction (LiSat-11) were collected before, immediately after and one year after the program. Partial respondents and non-respondents were excluded;168 patients remained. RESULTS: Pain intensity decreased (''pain now''; Friedman's test, P<0.0001) by 13 mm (median) after the program, (Dunn's test; P<0.001) and by 5 mm after one year (P<0.05). Only one of twelve DRI items (activity), ''participating in exercise/sports'' improved significantly after rehabilitation (Wilcoxon's test; P=0.0009), and remained improved one year later (P=0.0144). Life satisfaction in the physical and psychological domains increased after the program. A clinically meaningful reduction in pain intensity (10 mm) was reported by 43% of patients at the one-year follow-up. This group had significant increases in life satisfaction. Only patients with positive beliefs about recovery before rehabilitation showed a decrease in pain intensity at the one-year follow-up (P<0.028). CONCLUSIONS: The program influenced the pain, life satisfaction and, to a small extent, activity. A clinically relevant pain reduction and an increase in life satisfaction were related. Patients' pretreatment beliefs about recovery influenced the long-term decrease of pain intensity, indicating that more attention should be focused on patients' pretreatment beliefs.

Walking training of patients with hemiparesis at an early stage after stroke: a comparison of walking training on a treadmill with body weight support and walking training on the ground.

OBJECTIVE: To compare the effect of walking training on a treadmill with body weight support (BWS) and walking training on the ground at an early stage of rehabilitation in patients with hemiparesis after stroke. DESIGN: Randomized controlled experimental study. SETTING: Multicentre design; three departments of rehabilitation medicine. SUBJECTS: Seventy-three consecutive first stroke patients admitted to a rehabilitation clinic were randomized into a treatment group and a control group. INTERVENTIONS: The treatment group received walking training on a treadmill with BWS for 30 minutes, 5 days a week. The control group received walking training according to the Motor Relearning Programme (MRP) on the ground for 30 minutes 5 days a week, not including treadmill training. During the time in the rehabilitation department (about two months), all patients in the study also received professional stroke rehabilitation besides the walking training in the two groups. MAIN OUTCOME MEASURES: Functional Independence Measure (FIM), walking velocity for 10 m, Functional Ambulation Classification (FAC), Fugl-Meyer Stroke Assessment and Berg's Balance Scale. The assessments were performed at admission, at discharge and at 10-month follow-up. RESULTS: There were no statistically significant differences between the groups at discharge or at the 10-month follow-up with regard to FIM, walking velocity, FAC, Fugl-Meyer Stroke Assessment, and Berg's Balance Scale. Patients in both groups improved in these variables from admission to the 10-month follow-up. CONCLUSIONS: Treadmill training with BWS at an early stage of rehabilitation after stroke is a comparable choice to walking training on the ground.

Acupuncture for chronic low back pain: a randomized placebo-controlled study with long-term follow-up.

OBJECTIVE: The authors sought to determine whether a series of needle acupuncture treatments produced long-term relief of chronic low back pain. DESIGN: A blinded placebo-controlled study with an independent observer. The patients were randomized to receive manual acupuncture, electroacupuncture, or active placebo (mock transcutaneous electrical nerve stimulation). Subjects were examined and monitored by an investigator who was blinded to the treatment given. SETTING: A tertiary-level pain clinic at a Swedish university hospital. PATIENTS: Fifty consecutive patients (33 women, 17 men; mean age, 49.8 years) with chronic low back pain (mean pain duration, 9.5 years) and without rhizopathy or history of acupuncture treatment were included in the study. INTERVENTIONS: Treatments were given once per week for 8 weeks. Two further treatments were given during the follow-up assessment period of 6 months or longer. OUTCOME MEASURES: The independent observer made a global assessment of the patients 1, 3, and 6 months after treatment. The patients kept pain diaries to score pain intensity twice daily, analgesic intake, and quality of sleep daily, and activity level weekly. RESULTS: At the 1-month independent assessment, 16 of 34 patients in the acupuncture groups and 2 of 16 patients in the placebo group showed improvement (p <0.05). At the 6-month follow-up assessment, 14 of 34 patients in the acupuncture groups and 2 of 16 patients in the placebo group showed improvement (p <0.05). A significant decrease in pain intensities occurred at 1 and 3 months in the acupuncture groups compared with the placebo group. There was a significant improvement in return to work, quality of sleep, and analgesic intake in subjects treated with acupuncture. CONCLUSIONS: The authors found a long-term pain-relieving effect of needle acupuncture compared with true placebo in some patients with chronic nociceptive low back pain.

Pressure pain thresholds and electromyographically defined muscular fatigue induced by a muscular endurance test in normal women.

OBJECTIVE: This study was undertaken to examine the relation between muscular tenderness measured as pressure pain thresholds (PPTs) and electromyographic (EMG) signs of fatigue before and after a local standardized static muscle contraction. DESIGN: Pressure pain thresholds were measured in the shoulder region before, immediately after, and 10 minutes after a standardized static endurance test while monitoring the EMG signs of local muscular fatigue and its recovery. The study did not address local biochemical issues. SETTING: The study was conducted at the Department of Rehabilitation, Lund University Hospital, Lund, Sweden. SUBJECTS: Twenty-five healthy female volunteers without musculoskeletal problems participated in this study. INTERVENTION: A static endurance test was performed, which consisted of a submaximal unilateral activation of the right trapezius and deltoid muscles for as long as possible. OUTCOME MEASURES: Bilateral PPTs over the trapezius and deltoid muscles were measured with an electronic pressure algometer. Established surface EMG parameters of local muscular fatigue were assessed. The Borg Rating of Perceived Exertion scale was used. RESULTS: The average endurance time was 330 seconds. Immediately after the test, significant bilateral increases in the normalized PPTs over both muscles were found, although the increase was more pronounced on the test side: over the right trapezius muscle by 13% (p <0.001), over the right deltoid muscle by 23% (p <0.001), and over the left trapezius and deltoid muscles by 6% (p = 0.04) and (p = 0.009), respectively. These increases persisted 10 minutes after the end of the test. The subjects developed significant signs of fatigue as defined by EMG criteria in both muscles on the right side during the test. The recovery from fatigue was approximately half complete 15 seconds after the end of the test and complete or almost complete 10 minutes thereafter. CONCLUSIONS: Pressure pain thresholds over shoulder muscles remained elevated up to 10 minutes after a unilateral static endurance test. This time course was completely different from that of EMG-defined muscle fatigue, which showed a fast recovery. These findings indicate that the mechanisms of recovery from fatigue and nociception are independent of each other. The bilateral PPT increases might be explained by central antinociceptive mechanisms activated by static muscle work.

Rehabilitation of long-term sick-listed patients in Sweden through techniques of sports medicine.

Sweden has seen a sharp increase in sick-listing recently. A new rehabilitation programme was tested for patients with musculoskeletal pain applying the experiences from sports injury rehabilitation. In this programme, the danger of inactivity was emphasised, and the staff accepted that the process of restoring physical fitness may be accompanied by a temporary increase in pain. During an 11 month period, 101 patients began a 4-week rehabilitation programme. This programme was in action 5 days a week from 9AM to 4PM. Six patients broke off the programme. The remainder were called back for a follow-up 6 months later, a total of 83 patients attending. This follow-up showed that only 22% benefit. Significantly more men than women returned to work. After rehabilitation the patients perceived better health and their living habits normalized. In patients sick-listed for long periods, an intensive period of exercise based largely on sports medicine can lead to return-to-work, also in Sweden.

Electrophysiological evidence for an antinociceptive effect of ketamine in the rat spinal cord.

BACKGROUND: The dissociative anesthetic ketamine also has antinociceptive effects. The mechanism and the site of action of such effect of ketamine have been, however, elusive and controversial. The present study was conducted to examine the effect of systemically administered ketamine on spinal nociceptive transmission. METHODS: We investigated and compared the effects of ketamine (0.25-8 mg/kg) on the hamstring flexor reflex in intact, lightly anesthetized rats and spinally transected rats. The opioid receptor antagonist naloxone was used to examine the involvement of opioid receptors in the actions of ketamine. Finally, the effects of ketamine on dorsal horn neuronal activity to electrical stimulation of peripheral nerves were also studied. RESULTS: Ketamine caused similar dose-dependent depression of the hamstring flexor reflex recorded from spinally intact rats and from spinalized rats. Even the highest dose of ketamine failed to influence the monosynaptic reflex. The depressive effect of ketamine on the flexor reflex was not reversed by naloxone. Ketamine i.v. also exerted a relatively selective inhibition of the responses of dorsal horn wide-dynamic-range neurons to C-fiber input of electrical stimulation of the plantar nerve. CONCLUSIONS: Our present results support the notion that ketamine can exert a direct antinociceptive effect in rat spinal cord. Moreover, the data indicated that the spinal antinociceptive effect of ketamine does not involve naloxone-sensitive opioidergic mechanisms.

Capsaicin-evoked release of pituitary adenylate cyclase activating peptide (PACAP) and calcitonin gene-related peptide (CGRP) from rat spinal cord in vivo.

Capsaicin-evoked release of pituitary adenylate cyclase activating peptide (PACAP)-like immunoreactivity (LI) from rat spinal cord was examined in vivo. In anaesthetized rats, a catheter was inserted through the atlanto-occipital membrane into the subarachnoid space at the level of the sacral spinal cord for infusion of artificial cerebrospinal fluid. Another catheter was placed in the cisternal opening for outflow. Blood pressure was monitored and kept stable during the experiment. Perfusion samples were analyzed for PACAP and calcitonin gene-related peptide (CGRP) by radioimmunoassay. The addition of capsaicin (10 microM) to the perfusate elevated the concentrations of PACAP-27-LI in the artificial cerebrospinal fluid by 177%, PACAP-38-LI by 93% and CGRP-LI by 692%. In view of the presence of PACAP-immunoreactive nerve fibres in the superficial layers of the dorsal horn and the expression of PACAP in the small sized neurons in the dorsal root ganglia, the findings suggest that PACAP is released into the artificial cerebrospinal fluid from C-fibres in the spinal cord. PACAP conceivably plays a modulating role in nociception.

The effect of pituitary adenylate cyclase activating peptide (PACAP) on the nociceptive formalin test.

Recent studies have suggested that pituitary adenylate cyclase activating peptide (PACAP) may be involved in nociceptive transmission. The present study examined the effect of low-dose PACAP-27 on nociceptive behavior using the formalin test. PACAP-27 was administered intrathecally. Twenty minutes later, formalin (50 microliters, 5%) was injected subcutaneously into the dorsal surface of the right hind paw. Intrathecal PACAP-27 at 0.6 pmol suppressed the second phase response to formalin, while 5 pmol depressed both phases. PACAP-27 at 5 pmol did not impair motor function. Hence, the data suggest that the effect of PACAP-27 on formalin-induced pain-related behavior is specific. The findings may lead to a better understanding of the role of PACAP in nociceptive transmission.

Laser-evoked cerebral potentials and sensory function in patients with central pain.

Central pain syndromes (CPS) could be caused by disinhibition of spinothalamic excitability or by other central nervous system (CNS) changes caused by reduced spinothalamic function. To examine these possibilities, we studied 11 patients (ages 51-82 years) with unilateral central pain and with reproducible cerebral evoked vertex potentials in response to cutaneous stimulation of the normal side with pulses from an infra-red CO2 laser. All patients had normal tactile and kinesthetic sensation; one had slightly decreased vibratory sense bilaterally. All showed, from the unaffected (asymptomatic) side, laser evoked potentials (LEPs) with negative (N) components ranging from 208 to 280 msec peak latency (av: 240 +/- 6 SE msec) and peak amplitudes of 1-7 microV (av: 2.9 +/- 0.5 SE microV), followed, in all but 1 patient, by positive (P) potentials ranging from 288 to 370 msec peak latency (av: 319 +/- 7.7 SE msec) with peak amplitudes of 1-7 microV (2.8 +/- 0.5 SE microV). Laser stimulation of the affected (symptomatic) side in 5 patients evoked LEPs with N-P interpeak amplitudes that were within 20% of those evoked from the normal side. All but one of these patients had thresholds for warm, heat pain, and deep pain that were normal in comparison with the unaffected side. The excepted patient had the largest N-P interpeak amplitude asymmetry (18.5%) of this group. Ratings of laser pulse intensity were either symmetrical (n = 2) or increased on the affected side (n = 3) in these patients. In contrast, laser stimulation of the affected side failed to evoke either N or P potentials in 6 patients, all of whom had lateralized increased thresholds for warm, heat pain, or deep pain, or reduced ratings of laser pulse sensation. Although 1 patient had increased ratings of laser pulse sensation, the amplitude of the LEP was always reduced on the side of increased pain or heat threshold in these CPS patients (Fisher exact test: P = 0.015). These results reflect primarily a deficit in spinothalamic tract function and do not suggest excessive CNS responses to synchronous activation of cutaneous heat nociceptors in patients with CPS.

Nerve blocks with local anesthetics and corticosteroids in chronic pain: a clinical follow-up study.

During 4 years, 45 patients with various chronic pain conditions were treated with nerve blocks in our clinic. The blocks consisted of injections of local anesthetic and a corticosteroid on one or several occasions. At the end of this time period, the patients' pain was classified from their records as nociceptive, neurogenic, or unknown, according to International Association for the Study of Pain (IASP) criteria. The long-term treatment results were evaluated retrospectively with a questionnaire. Twenty-nine patients had neurogenic pain, 11 patients had nociceptive pain, and, in the remaining 5 patients, the type of pain could not be determined. Only 6 of the 45 patients had pain relief for longer than 1 month. It is concluded that treatment with nerve blocks alone is not very effective as a long-term treatment for chronic pain. Further experimental and systematic clinical studies are necessary to define the ultimate place for nerve blocks in the treatment of chronic nonmalignant pain.

Favorable Long-term Results with the End-to-Side Jejunoileal Bypass.

BACKGROUND: Although jejunoileal bypass (JIB) causes long-standing weight loss, it is no longer recommended as a surgical treatment of morbid obesity due to adverse effects. METHODS: JIB was performed on 87 morbidly obese subjects with a mean age of 35 years. Complete follow-up on 95% of the patients included monitoring weight, metabolic parameters and liver biopsies up to 25 years postoperatively. RESULTS: The mean (+/- SD) Body Mass Index (BMI) was reduced from 41.5 +/- 5.8 kg m(2) preoperative, to 26.7 +/- 3.8 kg m(2) at 2 years and 29.7 +/- 3.9 kg m(2) at 16 years follow-up. More than 60% loss of initial excess weight was achieved by 88% of the patients at four years and by 75% at 16 years follow-up. Reversal of the bypass was performed in 3% of the patients and revisions in 8% of the patients. There was no 30-day hospital mortality but there was one (1 %) late bypass-related death. Complications included urinary calculi in 39% of the patients, electrolyte disturbances in 25% and transient liver failure in 5.5%. Liver biopsies taken more than 13 years postoperatively in 44 patients revealed no cirrhosis. All patients were normoglycemic and normolipemic at follow-up. CONCLUSIONS: The majority of the patients have an acceptable weight reduction, few serious adverse effects but several beneficial effects after more than 16 years. The JIB deserves a reconsideration as an alternative in obesity surgery.