Intervention research in psychosis: prevention trials.
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Prevention trials have not been a central focus in mental health research in general and in the psychoses in particular. In this article we provide the basis for development of a model for prevention trials, define the parameters of the model, and provide some illustrative examples. The article expands upon traditional approaches to prevention by incorporating perspectives from the fields of treatment and services research. Approaches to prevention are based upon models of etiology, pathophysiology, and risk. A number of barriers to the development of a major emphasis on prevention are identified, and those that are embedded in the infrastructure of the field are highlighted. (+info)
Priorities in care and services for elderly people: a path without guidelines?
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The growing gap between demands and resources is putting immense pressure on all government spending in Sweden. The gap is especially apparent in care and services for elderly people in light of the rapid aging of the population. The article considers the decisions and priorities concerning resource allocation in the welfare sector in general and in elderly care in particular. The aim is to describe the political and administrative setting and to provide a conceptual structure that outlines the nature of the problem. Various levels of decision making are identified and discussed in the context of political accountability. Current transitions in elderly care are described with respect to service provision, marketisation, coverage rates, and eligibility standards. Basic principles of distribution are highlighted in order to clarify some central concepts of efficiency and justice, and a number of strategies for actual prioritising are identified. The article concludes with an endorsement of more conscious decisions in resource allocation. Existing knowledge and information concerning the effects of various strategies must be utilised, and the values and assumptions used for setting priorities must be made explicit. (+info)
PTEVAL: a computerized home-based physical therapy intervention instrument.
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The determination of physical therapy treatment protocols, based on an in-home evaluation of a patient, is a complex task. The specific rules for treatment indications are individually simple, but numerous and hence time-consuming and prone to error using pencil-and-paper methods. This paper describes PTEVAL, a computerized Point-of-Care instrument designed to support the intervention protocols of an ongoing clinical trial. With appropriate modifications and extensions, PTEVAL can be a model for instruments used in clinical practice. (+info)
Complex service evaluation.
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Services represent the practical manifestation of the synthesis of research knowledge and real world factors. In order to develop the evaluation of complex services, there needs to be a consensus about what a complex service is. I suggest that it is a system for the supplying of a public need. Whilst there is strong academic and policy support for a systems-based approach, there is only limited understanding in the clinical and managerial community and limited skills within the health and social care research community on systems methodologies. Evaluation of complex systems will probably need an integration of existing evaluative methods with a soft systems approach. (+info)
The combination of bedside swallowing assessment and oxygen saturation monitoring of swallowing in acute stroke: a safe and humane screening tool.
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BACKGROUND: dysphagia is common in acute stroke. Accurate detection of the presence or absence of aspiration by bedside swallowing assessment is difficult without objective methods, tending to over-diagnose aspiration. As a result, some patients suffer restricted oral intake unnecessarily. OBJECTIVE: we examined the predictive values of pulse oximetry and speech and language therapy bedside swallowing assessment in the detection of aspiration compared with videofluoroscopy. DESIGN: a double-blind observational study. SETTING: two university teaching hospitals. SUBJECTS: we studied 53 patients whose acute strokes were confirmed by computed tomography scan. METHODS: Each subject had initial standard bedside swallowing assessment, closely followed by simultaneous and mutually blinded pulse oximetry, swallowing assessment and videofluoroscopy. RESULTS: 15 of 53 subjects aspirated. Bedside swallowing assessment and saturation assessment at > or = 2% desaturation gave good sensitivity (80% and 87% respectively), but low positive predictive values (50% and 36% respectively). Both assessments mistook laryngeal penetration for aspiration. Re-analysis with aspiration +/- penetration as a new endpoint improved bedside swallowing assessment positive predictive values to 83% (chi2 =3.59, P=0.032). Sensitivity of saturation assessment was maintained at 86%, positive predictive values of saturation assessment improved to 69% (chi2=6.74, P=0.009). The combination of bedside swallowing assessment and saturation assessment versus aspiration + penetration gave a positive predictive value of 95%. CONCLUSIONS: screening by saturation assessments detects 86% of aspirators/penetrators and should be followed immediately by bedside swallowing assessment, as the combination of the two assessments gives the best positive predictive value. For patients with acute stroke, we advocate a 10 ml water-swallow screening test with simultaneous pulse oximetry by suitably trained medical and nursing staff. Use of this screening test would improve dysphagia detection whilst minimizing unnecessary restriction of oral intake in stroke patients. (+info)
Assessing needs from patient, carer and professional perspectives: the Camberwell Assessment of need for Elderly people in primary care.
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BACKGROUND: despite evidence that needs assessment of older people can improve survival and function when linked to effective long-term management, there is no structured needs assessment tool in widespread use. The Camberwell Assessment of Need for the Elderly is a new tool not previously evaluated in primary care. It includes the views of patients, carers and health professionals, enabling a direct comparison of their perspectives. AIM: to conduct a feasibility study of Camberwell Assessment of Need for the Elderly in primary care and to compare the needs identified by patients, carers and health professionals. METHODS: we selected a random sample of 1:20 of all people aged 75 and over from four general practices in inner-city and suburban north-west London. We interviewed the patients, their informal carers and lead health professionals using the Camberwell Assessment of Need for the Elderly schedule. RESULTS: 55 (65.5%) of 84 patients, 15 (88.2%) of 17 carers and all of 55 health professionals completed interviews. The patients' three most frequently identified unmet needs were with 'eyesight/hearing', 'psychological distress' and 'incontinence'. The carers' three most frequently identified unmet needs were with 'mobility', 'eyesight/hearing' and 'accommodation' and the health professionals' were with 'daytime activities', 'accommodation' and 'mobility'. Kappa tests comparing patient and health professional assessments showed poor or fair agreement with 18 of the 24 variables and moderate or good agreement with six. None showed very good agreement. CONCLUSION: the Camberwell Assessment of Need for the Elderly schedule is feasible to use in primary care and can identify perceived needs not previously known about by health professionals. A shorter version of Camberwell Assessment of Need for the Elderly focusing on areas of poor agreement and high levels of need might be useful in the assessment of needs in older people in primary care. (+info)
Development and validation of a brief observer-rated screening scale for depression in elderly medical patients.
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OBJECTIVE: to develop a depression screening scale that does not rely on verbal communication. SETTING: an acute geriatric unit in a teaching hospital. SUBJECTS: 96 patients (mean age 81 years, range 68-92, 59 women); 40% of the initial study group of 50 and 22% of the validation group of 46 were diagnosed as depressed. METHODS: we devised a scale using nine items which could be rated by an observer; we determined inter-rater reliability, sensitivity, specificity and predictive values for each item compared with a Geriatric Mental State-AGECAT diagnosis of depression; we validated a final scale of six items. RESULTS: inter-rater reliability was poor for two items (irritability and sleep disturbance) while two items (sleep disturbance and night sedation) had poor sensitivity; we omitted these items in a revised scale. Re-analysis of data from the initial study showed that a cut-off of > or = 3 on the revised scale gave a sensitivity of 83%, a specificity of 95%, a positive predictive value of 0.89 and a negative predictive value of 0.90. Spearman's correlation coefficient between the six-item questionnaire and the Hamilton rating scale was 0.79. In the validation study, the cut-off score of > or = 3 on the revised six-item scale had a sensitivity of 90%, specificity of 72%, a positive predictive value of 0.69 and a negative predictive value of 0.96. CONCLUSIONS: this simple, short, observation-based screening scale completed by nurses is sensitive and specific in identifying depression in elderly medically ill patients, and may be a useful addition to clinical practice. (+info)
Mental ability age 11 years and health status age 77 years.
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OBJECTIVES: to measure the effects of childhood mental ability on health in old age. DESIGN: longitudinal cohort study. SETTING: community-based. PARTICIPANTS: survivors of the 1932 Scottish Mental Survey cohort randomly selected from the Community Health Index in North East Scotland. MEASUREMENTS: (i) presence of disease by diagnostic category; (ii) cardiovascular, respiratory, anthropomorphic, sensory and locomotor physiological variables; (iii) Barthel index of functional independence; (iv) socio-demographic and socio-economic variables as health status predictors; and (v) score on the Moray House Test in 1932. RESULTS: There was no significant difference in Moray House Test score in 1932 between those with (mean 39.7, S.D. 13.8) and without (mean 40.1, S.D. 12.1) current disease (F = 0.04, P = 0.84). Physiological health status was predicted by demi-span (F = 6.87, P< 0.001), sex (F = 3.69, P = 0.001), deprivation category (F = 1.45, P = 0.05) and the interaction between sex and deprivation category (F = 2.01, P = 0.002). Moray House Test score in 1932 correlated significantly and positively with Barthel score (r = 0.24, P < 0.001). No additional general linear models added any other significant socio-economic variable once Moray House Test Score in 1932 was entered. Moray House Test score in 1932 remained significant (beta = 0.16, P = 0.024) after Mini Mental State Examination score was entered and found to be significant (beta = 0.21, P = 0.003). CONCLUSION: socio-economic and socio-environmental factors are important determinants of some aspects of inequalities in health in old age in this cohort. Pre-morbid mental ability was an important independent predictor of late-life functional independence. (+info)