Deconstructing dementia and delirium hospital practice: using cultural historical activity theory to inform education approaches.

Older patients with dementia and delirium receive suboptimal hospital care. Policy calls for more effective education to address this though there is little consensus on what this entails. The purpose of this clarification study is to explore how practice gaps are constructed in relation to managing the confused hospitalised older patient. The intent is to inform educational processes in the work-place beyond traditional approaches such as training. Adopting grounded theory as a research method and working within a social constructionist paradigm we explored the practice gaps of 15 healthcare professionals by interview and conducted five focus groups with patients, carers and Liaison mental health professionals. Data were thematically analysed by constant comparison and theoretical sampling was undertaken until saturation reached. Categories were identified and pragmatic concepts developed grounded within the data. Findings were then further analysed using cultural historical activity theory as a deductive lens. Practice gaps in relation to managing the confused older patient are determined by factors operating at individual (knowledge and skill gaps, personal philosophy, task based practice), team (leadership, time and ward environmental factors) and organisational (power relationships, dominance of medical model, fragmentation of care services) levels. Conceptually, practice appeared to be influenced by socio-cultural ward factors and compounded by a failure to join up existing "patient" knowledge amongst professionals. Applying cultural historical activity theory to further illuminate the findings, the central object is defined as learning about the patient and the mediating artifacts are the care relationships. The overarching medical dominance emerges as an important cultural historical factor at play and staff rules and divisions of labour are exposed. Lastly key contradictions and tensions in the system that work against learning about the patient are identified. Cultural historical activity theory can be used to advance understanding of practice gaps in order to develop a broader transformative approach to dementia and delirium practice and education. Structural changes at an individual, team and systems level resulting from this novel understanding of practice complexity are proposed. Contradictions can be used as foci for expansive learning. Lastly, interprofessional education (formal and informal) is advocated to further knotwork and improve the care of the older confused patient.

Learning about the patient: an innovative interprofessional dementia and delirium education programme.

BACKGROUND: Patients with confusion (delirium and dementia) in the general hospital environment are more likely to have negative health outcomes compared with other patients. Poor team and individual practice is partly responsible for this, and a training gap has been described. We report an innovative interprofessional teaching intervention that is founded on robust medical education research findings, and has the potential to improve staff practice. INNOVATION: A 2-day programme is described that seeks to address previously identified learning needs in relation to managing the confused older patient. The programme is underpinned theoretically by learning from patients and carers, action learning and matching of teaching methods to aims (e.g. by the use of mindmaps to differentiate between dementia, delirium and depression). The programme has been implemented in Northumbria, England. Patients with confusion in the general hospital environment are more likely to have negative health outcomes RESULTS: In total 48 health care professionals, representing 12 different professional groups, attended three courses. Findings suggest that the programme significantly increases confidence across six core domains towards managing the confused older patient (p < 0.001, Mann-Whitney U-test). Furthermore, the course addresses negative attitudes and empowers staff to introduce relevant practice change. IMPLICATIONS: These results are pertinent given the findings of the Francis Inquiry, which identified significant care deficits within a culture of failing to practice in a patient-centred manner. As the core material focuses on learning about the patient, rather than the disease process, this programme may help address these gaps. Arguably our findings are of relevance to other innovators seeking to teach effectively in the hospital setting and improve patient care.

Systemic folate status, rectal mucosal folate concentration and dietary intake in patients at differential risk of bowel cancer (The FAB2 Study).

BACKGROUND/OBJECTIVES: Folate has been strongly implicated in the aetiology of colorectal cancer. However, the relationship between dietary folate intake, rectal mucosal folate status and colorectal cancer risk is uncertain. The study aimed to estimate nutrient intakes and measure systemic folate status and rectal mucosal folate concentration in people at differential risk of developing colorectal cancer. METHODS: Two hundred and twenty-eight individuals were recruited from gastroenterology clinics and subdivided into three patient groups: untreated colorectal cancer (n = 43), adenomatous polyps (n = 90) or normal bowel (n = 95). Biopsies from macroscopically normal rectal mucosa and blood were collected and used for the measurement of rectal mucosal 5-methyltetrahydrofolate (5-MeTHF) and systemic markers of folate status, respectively. Nutrient intake was estimated using a validated food frequency questionnaire. RESULTS: Dietary intake variables, plasma 5-MeTHF and red cell folate and plasma homocysteine concentrations were similar in all three subject groups and 95% CI fell within normal range for each variable. Rectal mucosal 5-MeTHF concentration was higher in the normal mucosa of adenomatous polyp patients than in normal subjects (P = 0.055). Rectal mucosal 5-MeTHF was associated significantly with plasma folate (P < 0.001, r = 0.294), red cell folate (P = 0.014, r = 0.305), plasma homocysteine (P = 0.017, r = -0.163) and dietary folate intake (P = 0.036, r = 0.152). CONCLUSIONS: This study demonstrates adequate folate status of patients attending gastroenterology clinics for the investigation of bowel symptoms, with no significant difference in dietary intakes or systemic folate status indices according to diagnosis. Rectal mucosal 5-MeTHF concentrations were elevated in adenomatous polyp patients, but failed to reach significance. Further studies are required to determine the biological significance of this observation.

Reconceptualizing models of delirium education: findings of a Grounded Theory study.

BACKGROUND: Effectiveness of educational interventions targeted at improving delirium care is limited by implementation barriers. Studying factors which shape learning needs can overcome these knowledge transfer barriers. This in-depth qualitative study explores learning needs of hospital staff relating to care needs of the confused older patients. METHODS: Fifteen research participants from across the healthcare spectrum working within an acute care setting were interviewed. Five focus groups were undertaken with patients, carers, and mental health specialists. A Grounded Theory methodology was adopted and data were analyzed thematically in parallel to collection until theoretical saturation was reached. RESULTS: Eight categories of practice gap emerged: ownership of the confused patient, negative attitudes, lack of understanding of how frightened the patient is in hospital, carer partnerships, person-centered care, communication, recognition of cognitive impairment and specific clinical needs (e.g. capacity assessments). Conceptually, the learning needs were found to be hierarchically related. Moreover, a vicious circle relating to the core learning needs of ownership, attitudes and patient's fear emerged. A patient with delirium may be frightened in an alien environment and then negatively labeled by staff who subsequently wish for their removal, thereby worsening the patient's fear. DISCUSSION: These findings reconceptualize delirium education approaches suggesting a need to focus interventions on core level practice gaps. This fresh perspective on education, away from disease-based delirium knowledge toward work-based patient, team and practice knowledge, could lead to more effective educational strategies to improve delirium care.

Developing effective educational approaches for Liaison Old Age Psychiatry teams: a literature review of the learning needs of hospital staff in relation to managing the confused older patient.

BACKGROUND: Deficiencies in the knowledge, skills and attitudes of all healthcare professionals working within the general hospital contribute towards the suboptimal care of older hospitalized patients with confusion. In the U.K., policy dictates that Liaison Old Age Psychiatry teams deliver effective education to general hospital clinical staff. The purpose of this paper is to review the literature concerning the learning needs of healthcare professionals in relation to managing confusion in the older patient in order to inform effective educational approaches for Liaison Old Age Psychiatry teams. METHODS: A broad range of medical and educational databases were searched. Identified English language studies were selected for further analysis if they had a specific educational focus in the hospital setting and then further subdivided into intervention and naturalistic studies. The impact of intervention studies was evaluated by Kirkpatrick's system. Learning needs, as determined from the naturalistic studies, were mapped to identify themes. RESULTS: 13 intervention studies were identified. Despite a high level of effectiveness for educational interventions, it was unclear what the active components were. A further 23 naturalistic studies were identified; their findings focused on knowledge gaps, diagnostic behaviors and experiences, attitudes and training issues. Few studies specifically researched learning needs or the educational role of liaison teams. Conspicuous by its absence was reference to relevant educational theories. CONCLUSIONS: The findings of this review can be incorporated in the planning of local curricula by Liaison Teams in order to design educational strategies. There is a need for further research, especially studies exploring the learning needs of all healthcare professionals.

Responses of biomarkers of folate and riboflavin status to folate and riboflavin supplementation in healthy and colorectal polyp patients (the FAB2 Study).

Epidemiologic data suggest that increasing folate intake may protect against colorectal cancer. Riboflavin may interact with folate to modulate the effect. A double-blind randomized placebo-controlled intervention study (the FAB2 Study) was carried out in healthy controls and patients with colorectal polyps (adenomatous and hyperplastic) to examine effects of folic acid and riboflavin supplements on biomarkers of nutrient status and on putative biomarkers of colorectal cancer risk (DNA methylation and DNA damage; to be reported elsewhere). Ninety-eight healthy controls and 106 patients with colorectal polyps were stratified for the thermolabile variant of methylene tetrahydrofolate reductase, MTHFR C677T, and were randomized to receive 400 microg of folic acid, 1,200 microg of folic acid, or 400 microg of folic acid plus 5 mg of riboflavin or placebo for 6 to 8 weeks. Blood samples and colon biopsy samples were collected for the measurement of biomarkers of folate and riboflavin status. Supplementation with folic acid elicited a significant increase in mucosal 5-methyl tetrahydrofolate, and a marked increase in RBC and plasma, with a dose-response. Measures of riboflavin status improved in response to riboflavin supplementation. Riboflavin supplement enhanced the response to low-dose folate in people carrying at least one T allele and having polyps. The magnitude of the response in mucosal folate was positively related to the increase in plasma 5-methyl tetrahydrofolate but was not different between the healthy group and polyp patients. Colorectal mucosal folate concentration responds to folic acid supplementation to an extent comparable to that seen in plasma, but with a suggestion of an upper limit.

The identification of topics for research that are important to people with ulcerative colitis.

OBJECTIVES: To identify topics for research that are important to people with ulcerative colitis, and to provide a framework by which their research priorities can be analysed. METHODS: This is a qualitative study using focus groups and interviews. Forty people with ulcerative colitis participated. Topics for research of importance to participants were identified and analysed using the Framework method. RESULTS: Topics were grouped into nine main categories: finding the cause of colitis, cure of colitis, prevention of colitis, living with colitis, treatment (conventional, complementary and surgical) and its complications, control of particular symptoms, information provision, communicating with health professionals and methods of service delivery. An initial framework to classify the research priorities of people with colitis is provided. CONCLUSIONS: This study suggests the potential to utilize patients' views to generate research topics that are rarely researched and to involve them in setting the research agenda. People with ulcerative colitis are able to identify many different areas of research that they feel are important to them. This may help to ensure that research is relevant to patients' needs.

Safety on elective: a survey on safety advice and adverse events during electives.

The risk of students contracting HIV on electives has received much coverage. Few data exist, however, on risks of other adverse events. Medical schools gave comprehensive advice on infectious disease but little on personal safety. There were no reported parenteral infections or deaths from infection, despite cases of malaria and one needle-stick injury. Accidents were responsible for six deaths and three serious injuries from just nine medical schools. A further student committed suicide after return to the UK. Personal violence and events related to the political situation of the elected country were also reported. This paper is based on a retrospective survey of elective convenors from UK medical schools examining advice given and adverse events. Accidents appear to pose significant risk to medical students on elective and there appears to be a lack of advice on personal safety issues. Further research should examine behaviours that put students at risk of accidents, and strategies that could prevent such events.

Factors associated with the development of post-infectious functional gastrointestinal diseases: does smoking play a role?

OBJECTIVES: Irritable bowel syndrome (IBS) is associated with psychological stress, alterations in gut motor function and/or visceral perception. Previous studies suggest 7-32% of people develop IBS after bacterial gastroenteritis but the exact mechanisms underlying post-infectious IBS are not clear. The present study's aim was to examine the role of possible causative factors in the development of post-infectious functional gastro-intestinal disorders (FGIDs), including IBS. METHODS: A prospective cohort study where 122 people without a prior FGID under study and with stool-positive bacterial gastroenteritis consented to participate. The presence or not of IBS, functional dyspepsia or functional diarrhoea was diagnosed at the start and on 6-month follow-up using self-complete Rome II modular questionnaires. Demographic data, smoking, alcohol use, anxiety and depression (using the Hospital Anxiety and Depression Scale), and life events and impact (using the Life Events Survey) were collected at the start of the study. RESULTS: One hundred and seven questionnaires were returned with 25 participants (23.4%) developing a FGID and 16 participants presenting symptoms consistent with IBS (15%). Smoking was significantly associated with the development of a post-infectious FGID (odds ratio = 4.8, 95% confidence interval = 1.5-15.2) on regression analysis. CONCLUSIONS: Post-infectious FGIDs appear to be associated with smoking. Smoking is known to moderate gut immunity in other disorders such as ulcerative colitis and Crohn's disease. This study adds to increasing evidence for an organic basis to post-infectious FGIDs, perhaps moderated via inflammatory pathways.

Predictors of quality of life in ulcerative colitis: the importance of symptoms and illness representations.

BACKGROUND: Establishing predictors of quality of life (QoL) in individuals with inflammatory bowel disease could help to identify those patients who are most likely to experience poor QoL and to target therapeutic interventions appropriately. We aimed to investigate how disease-specific QoL depends on demographic, diseaserelated, and physiological markers of disease activity, cognitive representations of illness, and perceived general health status. METHODS: A total of 111 individuals completed the Inflammatory Bowel Disease Questionnaire (IBDQ), the Medical Outcomes Study 36-Item Short-Form Health Survey (SF-36), and the Illness Perception Questionnaire (IPQ). The extent of disease was determined from records, and disease activity was determined by a symptom index. Bivariate analyses and multivariate regression models were used to identify predictors of disease-specific QoL. RESULTS: Bivariate analyses showed that symptom-related disease activity, elements of illness representation measured by the IPQ, and elements of physical and mental health measured by the SF-36 were the only variables that were strongly or moderately correlated with disease-specific QoL. Multivariate regression modeling showed that disease activity was the major explanatory variable for each of the 4 domains and for the total score on the IBDQ. CONCLUSION: This study highlights the strong relationship between individuals' symptoms and all domains of their health-related QoL, but shows little association with age, gender, physiological markers of disease activity, or anatomic disease extent. Perceptions of the condition were relatively weak predictors of self-reported QoL. The best strategy for improving QoL among individuals with ulcerative colitis may be to find ways to reduce their symptoms.

Quality improvement programme to achieve acceptable colonoscopy completion rates: prospective before and after study.

PROBLEM: A large audit of colonoscopy in the United Kingdom showed that the unadjusted completion rate was 57% when stringent criteria for identifying the caecum were applied. The caecum should be reached 90% of the time. Little information is available on what units or operators need to do to improve to acceptable levels. DESIGN: Quality improvement programme using two completed cycles of audit. SETTING: Endoscopy department in a university linked general hospital in northeast England. KEY MEASURES FOR IMPROVEMENT: Colonoscopy completion rate. STRATEGY FOR CHANGE: Two audit cycles were completed between 1999 and 2002. Changes to practice were based on results of audit and took into account the opinions of relevant staff. Lack of time for each colonoscopy, poor bowel preparation, especially in frail patients, and a mismatch between number of colonoscopies done and completion rate for individual operators were responsible for failed colonoscopies. Appropriate changes were made. EFFECTS OF CHANGE: The initial crude colonoscopy completion rate was 60%, improving to 71% after the first round of audit and 88% after the second round, which approximates to the agreed audit standard of 90%. The final adjusted completion rate was 94%. LESSONS LEARNT: Achievement of the national targets in a UK general hospital is possible by lengthening appointments, admitting frail patients for bowel preparation to one ward, and allocating colonoscopies to the most successful operators.

Dietary beliefs of people with ulcerative colitis and their effect on relapse and nutrient intake.

BACKGROUND & AIMS: Ulcerative colitis usually follows a relapsing and remitting course. Patients believe that dietary factors are important. We wished to determine the nature of and reasons for patients' dietary beliefs and their effect on relapse and nutrient intake. METHODS: In a 1-year prospective cohort study, patients' nutrient intake and disease activity were measured with a validated food frequency questionnaire and disease activity index. Food beliefs, demographics and disease characteristics were recorded. The influence of beliefs on the risk of relapse and nutrient intake were examined using chi-squared and Mann-Whitney U-tests. RESULTS: One hundred and eighty-three patients were studied and 52% relapsed. Sixty-eight per cent held dietary beliefs and reported modifying their intake accordingly. The most common reported behaviour was the avoidance of milk and dairy products. Food beliefs were more common amongst those who had received dietary advice. No reported behaviour reduced the risk of relapse, but patients who avoided dairy products had a significantly lower intake of calcium. Folate intake was below UK recommended levels in 13% of patients. CONCLUSIONS: Patients with ulcerative colitis believe that many foods are harmful or helpful to their disease activity. Commonly held beliefs do not modify the risk of relapse, but do adversely affect nutrient intake.

Illness perceptions in people with acute bacterial gastro-enteritis.

Functional gastro-intestinal disorders (FGID) like irritable bowel syndrome (IBS) are common and can develop after gastro-enteritis. Illness representations may be important influences on the development of post-infectious FGIDs. Here, we studied both the relationship between prior chronic symptoms (FGIDs) and illness perception during an acute illness (bacterial gastro-enteritis) as well as the relationship between illness perception during an acute illness (bacterial gastro-enteritis) and the subsequent development of chronic abdominal symptoms. Two hundred and seventeen people with recent gastro-enteritis completed a questionnaire asking about gut symptoms consistent with a diagnosis of IBS, functional dyspepsia or functional diarrhoea and the Illness Perception Questionnaire. Those without a prior FGID were followed up and completed a similar gut questionnaire at six months. People with a prior FGID had significantly more symptoms and scored significantly higher on the timeline and consequence scores than those without. People who developed a FGID had a non-significantly higher number of symptoms and higher consequence and timeline scores than those who did not. Neither comparative group differed in the control/cure scores or causation scores. The implications of the findings are discussed.

Does bacterial gastroenteritis predispose people to functional gastrointestinal disorders? A prospective, community-based, case-control study.

OBJECTIVES: Irritable bowel syndrome (IBS) might develop after gastroenteritis. Most previous studies of this relationship have been uncontrolled, and little is known regarding other functional gastrointestinal disorders (FGIDs) after gastroenteritis. The primary aim of this study was to determine the frequency of IBS, functional dyspepsia, or functional diarrhea 6 months after bacterial gastroenteritis. METHODS: This was a prospective, community-based, case-control study. Cases had proven bacterial gastroenteritis, and controls were community-based. FGIDs were diagnosed with the use of self-completed Rome II modular questionnaires administered at baseline, 3, and 6 months. Subjects with prior FGIDs were excluded. The primary endpoint was the presence of one of the three specific FGIDs at 6 months. RESULTS: A total of 500 cases and 705 controls were identified. Of the 500 cases, 265 (53%) consented, but only 128 cases and 219 community controls who consented were eligible. At 6 months, 108 cases and 206 controls returned the questionnaire. FGIDs were diagnosed in significantly more cases (n = 27, 25%) than controls (n = 6, 2.9%) (OR = 11.11, 95% CI = 4.42-27.92). IBS was diagnosed in 18 cases (16.7%) and four controls (1.9%) (OR = 10.1, 95% CI = 3.32-30.69); functional diarrhea in six cases (5.6%) and no controls. Functional dyspepsia was uncommon in both cases and controls. Similar findings were found at 3 months, with 29% of cases and 2.9% of controls having an FGID. CONCLUSIONS: Symptoms consistent with IBS and functional diarrhea occur more frequently in people after bacterial gastroenteritis compared with controls, even after careful exclusion of people with pre-existing FGIDs. The frequency is similar at 3 and 6 months. Our findings support the existence of postinfectious IBS and give an accurate estimate of its frequency.

Is irritable bowel syndrome more common in patients presenting with bacterial gastroenteritis? A community-based, case-control study.

OBJECTIVE: Irritable bowel syndrome (IBS) has been reported to follow infectious diarrhea. Food-borne infections affect 76 million people in the United States and 9.4 million in England per year; of these, only a small percentage of patients see their doctor, and even fewer will have stool culture confirmation. We hypothesized that patients who present to their doctor with gastroenteritis and have positive stool samples may be different from the normal population with regard to their pre-existing bowel symptoms. Our aim was to determine if patients with bacterial gastroenteritis were more likely to have prior IBS, functional dyspepsia, or functional diarrhea, compared with a control population. METHODS: Between January, 2000 and January, 2001, subjects with stool positive bacterial gastroenteritis and control subjects from the same primary care practice were invited to participate. The main outcome measure was the presence of IBS, functional dyspepsia, or functional diarrhea diagnosed using self-report Rome II modular questionnaires. RESULTS: A total of 217 people with recent bacterial gastroenteritis and 265 community controls consented to participate in the study. Of these, 89/217 cases and 46/265 controls had one of the functional GI disorders (OR = 3.3; 95% CI = 2.17-5.00). IBS was present in 67 cases (31%) and 26 controls (10%) (OR = 4.1; 95% CI = 2.49-6.72). There was no statistically significant difference in the presence of prior functional dyspepsia or functional diarrhea. CONCLUSIONS: IBS is more frequent before diagnosis in people with bacterial gastroenteritis presenting to their primary care physician than in community controls. Studies that examine the rate of IBS after bacterial gastroenteritis need to carefully exclude people with prior IBS in a systematic way.

Is lactose intolerance implicated in the development of post-infectious irritable bowel syndrome or functional diarrhoea in previously asymptomatic people?

OBJECTIVE: The relationship between lactose intolerance and post-infectious irritable bowel syndrome (IBS) in adults is uncertain. Bowel symptoms may persist after bacterial gastroenteritis and as post-infectious IBS. Acquired lactose intolerance may follow viral enteric infections in children. We compared the frequency of lactose intolerance after bacterial gastroenteritis in adults with and without symptoms of IBS or functional diarrhoea at 3-6-months' follow-up. DESIGN: A prospective cohort study was conducted. METHODS: All subjects with bacterial gastroenteritis confirmed by stool culture from the microbiology laboratory and without prior IBS or functional diarrhoea were eligible to participate. IBS and functional diarrhoea were diagnosed via self-completed Rome II modular questionnaires. Lactose intolerance was determined from a rise in breath hydrogen and plasma glucose and symptoms. RESULTS: One hundred and twenty-eight subjects with bacterial gastroenteritis were followed prospectively, from which a smaller cohort of 42 subjects took part in this study. The cohort was comprised of 24/25 subjects who developed post-infectious IBS (n = 16) or functional diarrhoea (n = 8) (9 male, 15 female) and 18 random controls (8 male, 10 female) chosen from the group without IBS or functional diarrhoea. The mean age of the subjects was 44.4 years (range 25-76 years). In the group with functional diarrhoea or IBS, four subjects had failure of the plasma glucose to rise but none had abnormal glucose hydrogen breath tests. In the control subjects, one had a positive combined test and six had failure of plasma glucose to rise alone. No subject developed symptoms during the test. CONCLUSIONS: Bacterial gastroenteritis did not cause persistent lactose intolerance in our study population. Lactose intolerance does not appear to be implicated in the aetiology of post-infectious bowel symptoms, including IBS. Advice to avoid dairy products in patients presenting with post-infectious IBS on the basis that they may have lactose intolerance appears unnecessary in patients from northern England.

Push enteroscopy in a UK district general hospital: experience of 51 cases over 2 years.

OBJECTIVES: To determine the number of patients referred for enteroscopy in a district general hospital (DGH), the indication, enteroscopic +/- histological diagnosis, and to compare findings with other series from tertiary referral centres or outside the UK. DESIGN: Retrospective case series over a 2-year period. RESULTS: In the 2-year period, 52 patients were referred for enteroscopy. All except one underwent enteroscopy. The mean age of the patients was 60 years (range 31-84 years). The main indications for enteroscopy were obscure gastrointestinal haemorrhage in 31 (61%) patients (19 with acute and 12 with chronic bleeding) and 7 (14%) patients with arteriovenous malformations (AVMs) on initial oesophagogastroduodenoscopy (OGD). Other indications included clinical deterioration in known coeliac disease in four (8%) patients and abnormal small-bowel follow-through in five (10%) patients. More than half (51%) of the enteroscopies were reported as abnormal, but 10 (38%) had pathology in the stomach or first part of the duodenum (D1) not diagnosed on initial OGD. Diagnoses of two T-cell lymphomas and one of pre-lymphomatous monoclonal T-cell proliferation were made in the refractory coeliac disease group. CONCLUSIONS: Indications (obscure gastrointestinal bleeding), most frequent findings (small-bowel AVMs), and 'missed' lesions within reach of a gastroscope (20%) were in keeping with other series. Enteroscopy is a useful tool in investigating patients with refractory coeliac disease. Its value in investigating patients with abnormal small-bowel radiology was not confirmed. The current need for push enteroscopy in a DGH is small (approximately 1 per 8000 population per year), but it would take only small changes in referral practice to escalate. Criteria for enteroscopy should be developed and refined with improving knowledge of the diagnostic yield for each indication and clinical outcome.