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BMJ (Clinical Research Ed.) Mar 2021To describe the comparative efficacy of drug and non-drug interventions for reducing symptoms of depression in people with dementia who experience depression as a... (Comparative Study)
Comparative Study Meta-Analysis
OBJECTIVE
To describe the comparative efficacy of drug and non-drug interventions for reducing symptoms of depression in people with dementia who experience depression as a neuropsychiatric symptom of dementia or have a diagnosis of a major depressive disorder.
DESIGN
Systematic review and meta-analysis.
DATA SOURCES
Medline, Embase, the Cochrane Library, CINAHL, PsycINFO, and grey literature between inception and 15 October 2020.
ELIGIBILITY CRITERIA FOR STUDY SELECTION
Randomised trials comparing drug or non-drug interventions with usual care or any other intervention targeting symptoms of depression in people with dementia.
MAIN OUTCOME MEASURES
Pairs of reviewers screened studies, abstracted aggregate level data, and appraised risk of bias with the Cochrane risk of bias tool, which facilitated the derivation of standardised mean differences and back transformed mean differences (on the Cornell scale for depression in dementia) from bayesian random effects network meta-analyses and pairwise meta-analyses.
RESULTS
Of 22 138 citations screened, 256 studies (28 483 people with dementia) were included. Missing data posed the greatest risk to review findings. In the network meta-analysis of studies including people with dementia without a diagnosis of a major depressive disorder who were experiencing symptoms of depression (213 studies; 25 177 people with dementia; between study variance 0.23), seven interventions were associated with a greater reduction in symptoms of depression compared with usual care: cognitive stimulation (mean difference -2.93, 95% credible interval -4.35 to -1.52), cognitive stimulation combined with a cholinesterase inhibitor (-11.39, -18.38 to -3.93), massage and touch therapy (-9.03, -12.28 to -5.88), multidisciplinary care (-1.98, -3.80 to -0.16), occupational therapy (-2.59, -4.70 to -0.40), exercise combined with social interaction and cognitive stimulation (-12.37, -19.01 to -5.36), and reminiscence therapy (-2.30, -3.68 to -0.93). Except for massage and touch therapy, cognitive stimulation combined with a cholinesterase inhibitor, and cognitive stimulation combined with exercise and social interaction, which were more efficacious than some drug interventions, no statistically significant difference was found in the comparative efficacy of drug and non-drug interventions for reducing symptoms of depression in people with dementia without a diagnosis of a major depressive disorder. Clinical and methodological heterogeneity precluded network meta-analysis of studies comparing the efficacy of interventions specifically for reducing symptoms of depression in people with dementia and a major depressive disorder (22 studies; 1829 patients).
CONCLUSIONS
In this systematic review, non-drug interventions were found to be more efficacious than drug interventions for reducing symptoms of depression in people with dementia without a major depressive disorder.
SYSTEMATIC REVIEW REGISTRATION
PROSPERO CRD42017050130.
Topics: Antidepressive Agents; Cognitive Behavioral Therapy; Combined Modality Therapy; Dementia; Depression; Exercise Therapy; Humans; Network Meta-Analysis; Social Support; Therapy, Soft Tissue
PubMed: 33762262
DOI: 10.1136/bmj.n532 -
Palliative Medicine Apr 2021Delirium is a distressing neuropsychiatric disorder affecting patients in palliative care. Although many delirium screening tools exist, their utility, and validation...
BACKGROUND
Delirium is a distressing neuropsychiatric disorder affecting patients in palliative care. Although many delirium screening tools exist, their utility, and validation within palliative care settings has not undergone systematic review.
AIM
To systematically review studies that validate delirium screening tools conducted in palliative care settings.
DESIGN
Systematic review with narrative synthesis (PROSPERO ID: CRD42019125481). A risk of bias assessment via Quality Assessment Tool for Diagnostic Accuracy Studies-2 was performed.
DATA SOURCES
Five electronic databases were systematically searched (January 1, 1982-May 3, 2020). Quantitative studies validating a screening tool in adult palliative care patient populations were included. Studies involving alcohol withdrawal, critical or perioperative care were excluded.
RESULTS
Dual-reviewer screening of 3749 unique titles and abstracts identified 95 studies for full-text review and of these, 17 studies of 14 screening tools were included ( = 3496 patients). Data analyses revealed substantial heterogeneity in patient demographics and variability in screening and diagnostic practices that limited generalizability between study populations and care settings. A risk of bias assessment revealed methodological and reporting deficits, with only 3/17 studies at low risk of bias.
CONCLUSIONS
The processes of selecting a delirium screening tool and determining optimal screening practices in palliative care are complex. One tool is unlikely to fit the needs of the entire palliative care population across all palliative care settings. Further research should be directed at evaluating and/or adapting screening tools and practices to fit the needs of specific palliative care settings and populations.
Topics: Adult; Delirium; Hospice and Palliative Care Nursing; Humans; Mass Screening; Palliative Care
PubMed: 33588640
DOI: 10.1177/0269216321994730 -
Journal of Global Health Dec 2020Rapid increase in life expectancy in low- and middle-income countries including the World Health Organization's Southeast Asia Region (SEAR) has resulted in an increase...
BACKGROUND
Rapid increase in life expectancy in low- and middle-income countries including the World Health Organization's Southeast Asia Region (SEAR) has resulted in an increase in the global burden of dementia, which is expected to become a leading cause of morbidity. Accurate burden estimates are key for informing policy and planning. Given the paucity of data, estimates were developed using both a Bayesian methodology and as well as a traditional frequentist approach to gain better insights into methodological approaches for disease burden estimates.
METHODS
Seven databases were searched for studies published between 2010-2018 regarding dementia prevalence in SEAR, generating 8 relevant articles. A random-effects model (REM) and a Bayesian normal-normal hierarchical model (NNHM) were used to obtain the pooled prevalence estimate of dementia for people aged 60 and above in SEAR. The latter model was also developed to estimate age-specific dementia prevalence. Using UN population estimates for SEAR, total and age-specific projections of the burden of dementia in 2015, 2020 and 2030 were calculated.
RESULTS
The prevalence of dementia in SEAR was found to be 3% (95% confidence interval (CI) = 2-6%) in those above age 60 based on REM, and 3.1% (95% credible interval = 1.5-5.0%) based on the NNHM. The estimated prevalence varies with age, increasing from 1.6% (95% credible interval = 0.8-2.5%) in people aged 60-69 to 12.4% (95% credible interval = 5.6-20%) in people above the age of 80. The risk of developing dementia increased exponentially with age. The number of people living with dementia in SEAR in 2015 was estimated at 5.51 million (95% credible interval = 2.66-8.82), with projections of 6.66 million (95% credible interval = 3.21-10.7) in 2020 and 9.6 million (95% credible interval = 4.62-15.36) in 2030.
CONCLUSION
The burden of dementia in SEAR is substantial and will continue to increase rapidly by 2030. The lack of research focusing on dementia in SEAR points to a significant under-recognition of this disease. The projected rise in dementia cases in the future should prompt urgent governmental response to address this growing public health issue. We also argue that given the overall paucity of data for the region, the Bayesian approach offers a promising methodology for improved estimates of disease prevalence and burden and should continue to be explored.
Topics: Aged; Aged, 80 and over; Asia, Southeastern; Bayes Theorem; Cost of Illness; Cross-Sectional Studies; Dementia; Humans; Middle Aged; Prevalence; World Health Organization
PubMed: 33282225
DOI: 10.7189/jogh.10.020701 -
Proceedings. Biological Sciences Aug 2020Combinations of intense non-pharmaceutical interventions (lockdowns) were introduced worldwide to reduce SARS-CoV-2 transmission. Many governments have begun to...
Combinations of intense non-pharmaceutical interventions (lockdowns) were introduced worldwide to reduce SARS-CoV-2 transmission. Many governments have begun to implement exit strategies that relax restrictions while attempting to control the risk of a surge in cases. Mathematical modelling has played a central role in guiding interventions, but the challenge of designing optimal exit strategies in the face of ongoing transmission is unprecedented. Here, we report discussions from the Isaac Newton Institute 'Models for an exit strategy' workshop (11-15 May 2020). A diverse community of modellers who are providing evidence to governments worldwide were asked to identify the main questions that, if answered, would allow for more accurate predictions of the effects of different exit strategies. Based on these questions, we propose a roadmap to facilitate the development of reliable models to guide exit strategies. This roadmap requires a global collaborative effort from the scientific community and policymakers, and has three parts: (i) improve estimation of key epidemiological parameters; (ii) understand sources of heterogeneity in populations; and (iii) focus on requirements for data collection, particularly in low-to-middle-income countries. This will provide important information for planning exit strategies that balance socio-economic benefits with public health.
Topics: COVID-19; Child; Coronavirus Infections; Disease Eradication; Family Characteristics; Humans; Immunity, Herd; Models, Theoretical; Pandemics; Pneumonia, Viral; Schools; Seroepidemiologic Studies
PubMed: 32781946
DOI: 10.1098/rspb.2020.1405 -
BMC Psychiatry Jul 2020Broadening our knowledge of the longitudinal course of mood symptoms is cardinal to providing effective long-term treatments. Research indicates that patients with...
BACKGROUND
Broadening our knowledge of the longitudinal course of mood symptoms is cardinal to providing effective long-term treatments. Research indicates that patients with mental illness are willing to engage in the use of telemonitoring and mobile technology to assess and monitor their mood states. However, without the provision of distant support, adverse outcomes and events may be difficult to prevent and manage through self-monitoring. Understanding patient perspectives is important to achieving the best balance of self-monitoring, patient empowerment, and distant supporter involvement.
METHODS
This systematic review synthesises quantitative and qualitative evidence of the effectiveness and feasibility of daily/weekly/monthly remote mood monitoring that includes distant support in participants with mood disorders. Inclusion criteria comprised mood monitoring of mood disorder patients as main intervention, study design, method of monitoring, and presence of psychotherapy and psychoeducation. Effectiveness was defined by the change in depression and/or mania scores. Feasibility was determined on participant feedback and completion/attrition rates. Studies were assessed for quality using the Mixed Methods Appraisal Tool version 2018.
RESULTS
Nine studies of acceptable quality met the inclusion criteria. Distant mood monitoring was effective in improving depression scores but not mania scores. Feasibility, as measured through compliance and completion rates and participant feedback, varied.
CONCLUSION
Distant mood monitoring with support may be a useful, acceptable, and feasible intervention for diverse groups of patients in terms of age and ethnicity. Further, it may be effective in improving symptoms of depression, increasing treatment adherence, and facilitating the prevention and management of adverse outcomes. As a task-shifting intervention, distant mood monitoring may help to alleviate the burden on mental health providers in developing countries.
Topics: Affect; Bipolar Disorder; Humans; Mental Health; Mood Disorders; Psychotherapy
PubMed: 32698802
DOI: 10.1186/s12888-020-02782-y -
Frontiers in Pediatrics 2020This study aimed to identify alterations in pharmacokinetics in children on extracorporeal membrane oxygenation (ECMO), identify knowledge gaps, and inform future...
This study aimed to identify alterations in pharmacokinetics in children on extracorporeal membrane oxygenation (ECMO), identify knowledge gaps, and inform future pharmacology studies. We systematically searched the databases MEDLINE, CINAHL, and Embase from earliest publication until November 2018 using a controlled vocabulary and keywords related to "ECMO" and "pharmacokinetics," "pharmacology," "drug disposition," "dosing," and "pediatrics." Inclusion criteria were as follows: study population aged <18 years, supported on ECMO for any indications, received any medications while on ECMO, and reported pharmacokinetic data. Clearance and/or volume of distribution values were extracted from included studies. Forty-one studies (total patients = 574) evaluating 23 drugs met the inclusion criteria. The most common drugs studied were antimicrobials ( = 13) and anticonvulsants ( = 3). Twenty-eight studies (68%) were conducted in children <1 year of age. Thirty-three studies (80%) were conducted without intra-study comparisons to non-ECMO controls. Increase in volume of distribution attributable to ECMO was demonstrated for nine (56%) drugs: cefotaxime, gentamicin, piperacillin/tazobactam, fluconazole, micafungin, levetiracetam, clonidine, midazolam, and sildenafil (range: 23-345% increase relative to non-ECMO controls), which may suggest the need for higher initial dosing. Decreased volume of distribution was reported for two drugs: acyclovir and ribavirin (50 and 69%, respectively). Decreased clearance was reported for gentamicin, ticarcillin/clavulanate, bumetanide, and ranitidine (range: 26-95% decrease relative to non-ECMO controls). Increased clearance was reported for caspofungin, micafungin, clonidine, midazolam, morphine, and sildenafil (range: 25-455% increase relative to non-ECMO controls). There were substantial pharmacokinetic alterations in 70% of drugs studied in children on ECMO. However, studies evaluating pharmacokinetic changes of many drug classes and those that allow direct comparisons between ECMO and non-ECMO patients are still lacking. Systematic evaluations of pharmacokinetic alterations of drugs on ECMO that incorporate multidrug opportunistic trials, physiologically based pharmacokinetic modeling, and other methods are necessary for definitive dose recommendations. : CRD42019114881.
PubMed: 32670992
DOI: 10.3389/fped.2020.00260 -
Transplant International : Official... Oct 2020Several factors mediate intestinal microbiome (IM) alterations in transplant recipients, including immunosuppressive (IS) and antimicrobial drugs. Studies on the... (Review)
Review
Several factors mediate intestinal microbiome (IM) alterations in transplant recipients, including immunosuppressive (IS) and antimicrobial drugs. Studies on the structure and function of the IM in the post-transplant scenario and its role in the development of metabolic abnormalities, infection, and cancer are limited. We conducted a systematic review to study the taxonomic changes in liver (LT) and kidney (KT) transplantation, and their potential contribution to post-transplant complications. The review also includes pre-transplant taxa, which may play a critical role in microbial alterations post-transplant. Two reviewers independently screened articles, and assessed risk of bias. The review identified 13 clinical studies, which focused on adult kidney and liver transplant recipients. Patient characteristics and methodologies varied widely between studies. Ten studies reported increased an abundance of opportunistic pathogens (Enterobacteriaceae, Enterococcaceae, Fusobacteriaceae, and Streptococcaceae) followed by butyrate-producing bacteria (Lachnospiraceae and Ruminococcaceae) in nine studies in post-transplant conditions. The current evidence is mostly based on observational data and studies with no proof of causality. Therefore, further studies exploring the bacterial gene functions rather than taxonomic changes alone are in demand to better understand the potential contribution of the IM in post-transplant complications.
Topics: Adult; Dysbiosis; Humans; Immunosuppressive Agents; Kidney Transplantation; Liver; Transplant Recipients
PubMed: 32640109
DOI: 10.1111/tri.13696 -
Sensors (Basel, Switzerland) Jun 2020Wireless power transfer (WPT) systems have become increasingly suitable solutions for the electrical powering of advanced multifunctional micro-electronic devices such...
Wireless power transfer (WPT) systems have become increasingly suitable solutions for the electrical powering of advanced multifunctional micro-electronic devices such as those found in current biomedical implants. The design and implementation of high power transfer efficiency WPT systems are, however, challenging. The size of the WPT system, the separation distance between the outside environment and location of the implanted medical device inside the body, the operating frequency and tissue safety due to power dissipation are key parameters to consider in the design of WPT systems. This article provides a systematic review of the wide range of WPT systems that have been investigated over the last two decades to improve overall system performance. The various strategies implemented to transfer wireless power in implantable medical devices (IMDs) were reviewed, which includes capacitive coupling, inductive coupling, magnetic resonance coupling and, more recently, acoustic and optical powering methods. The strengths and limitations of all these techniques are benchmarked against each other and particular emphasis is placed on comparing the implanted receiver size, the WPT distance, power transfer efficiency and tissue safety presented by the resulting systems. Necessary improvements and trends of each WPT techniques are also indicated per specific IMD.
Topics: Electric Power Supplies; Electronics; Prostheses and Implants; Wireless Technology
PubMed: 32575663
DOI: 10.3390/s20123487 -
BMC Geriatrics Jun 2020Prescribing trends suggest that pharmacologic alternatives to antipsychotics are gaining in popularity, but randomized trial (RCT) data of their comparative safety is... (Meta-Analysis)
Meta-Analysis
BACKGROUND
Prescribing trends suggest that pharmacologic alternatives to antipsychotics are gaining in popularity, but randomized trial (RCT) data of their comparative safety is scarce. Our objective was to describe the comparative safety of pharmacologic interventions for treating neuropsychiatric symptoms in dementia.
METHODS
We searched MEDLINE, EMBASE, CENTRAL, CINAHL, and PsycINFO, from inception to May 28, 2019, for studies of pharmacologic interventions used to treat neuropsychiatric symptoms in dementia. Dementia care partners selected fracture risk as our primary outcome. Pairs of reviewers, working independently, conducted all study screening, data abstraction, and risk of bias appraisal. We conducted Bayesian random-effects network meta-analyses (NMAs) using data from RCTs to derive odds ratios (ORs). In secondary analyses, we conducted frequentist random-effects NMAs using data from RCTs and Bayesian three-level hierarchical random-effects NMAs incorporating data from RCTs and non-randomized studies.
RESULTS
Our systematic review included 209 randomized and non-randomized studies (889,378 persons with dementia). In NMAs of data from randomized trials, there were no increased odds of fracture associated with any intervention in primary analyses; however, data were sparse. We found increased odds of cerebrovascular events associated with antipsychotics (odds ratio [OR] 2.12, 95% credible interval [CrI] 1.29 to 3.62; number needed to harm [NNH] = 99) and increased odds of falls associated with dextromethorphan-quinidine (OR 4.16, 95% CrI 1.47 to 14.22; NNH = 55) compared to placebo in persons with dementia. In a subgroup of persons with Alzheimer disease, antipsychotics were associated with increased odds of fracture compared to anticonvulsants (OR 54.1, 95% CrI 1.15 to 38,300; NNH = 18). In older persons (mean age ≥ 80 years) with dementia, anticonvulsants were associated with increased odds of death compared to placebo (OR 8.36, 95% CrI 1.17 to 203.4; NNH = 35) and antipsychotics were associated with increased odds of death compared to antidepressants (OR 5.28, 95% CrI 1.06 to 3.51; NNH = 47).
CONCLUSION
Although antipsychotics were associated with greater harm than antidepressants and anticonvulsants in subgroups of persons with dementia, medications used in lieu of antipsychotics for treating neuropsychiatric symptoms in dementia, such as anticonvulsants and dextromethorphan-quinidine, were also associated with harm. Decision-making concerning treatments prescribed in lieu of antipsychotics should include potential harms.
PROSPERO REGISTRATION
CRD42017050130.
Topics: Aged; Aged, 80 and over; Antidepressive Agents; Antipsychotic Agents; Bayes Theorem; Dementia; Humans; Network Meta-Analysis
PubMed: 32546202
DOI: 10.1186/s12877-020-01607-7 -
Palliative Medicine Jun 2020Despite being a terminal neurodegenerative disease, the role of palliative care is less recognised for motor neurone disease than for other life-limiting conditions....
BACKGROUND
Despite being a terminal neurodegenerative disease, the role of palliative care is less recognised for motor neurone disease than for other life-limiting conditions. Understanding the experiences of, and need for, palliative care for patients and carers is key to configuring optimal policy and healthcare services.
AIM
To explore the experiences of, and need for, palliative care of people with motor neurone disease and their informal carers across the disease trajectory.
DESIGN
A systematic review of qualitative research conducted using Thematic Synthesis - PROSPERO registration CRD42017075311.
DATA SOURCES
Four electronic databases were searched (MEDLINE, CINAHL, PsycINFO, Social Science Citation Index) using terms for motor neurone disease, amyotrophic lateral sclerosis, palliative care, and qualitative research, from inception to November 2018. Included papers were data extracted and assessed for quality.
RESULTS
A total of 41 papers were included, representing the experiences of 358 people with motor neurone disease and 369 caregivers. Analytical themes were developed detailing patients' and carers' experiences of living with motor neurone disease and of palliative care through its trajectory including response to diagnosis, maintaining control, decision-making during deterioration, engaging with professionals, planning for end-of-life care, bereavement.
CONCLUSION
The review identified a considerable literature exploring the care needs of people with motor neurone disease and their carers; however, descriptions of palliative care were associated with the last days of life. Across the disease trajectory, clear points were identified where palliative care input could enhance patient and carer experience of the disease, particularly at times of significant physical change.
Topics: Caregivers; Hospice Care; Humans; Motor Neuron Disease; Palliative Care; Qualitative Research
PubMed: 32286157
DOI: 10.1177/0269216320908775