Philipe de Souto Barreto

A multicentric individually-tailored controlled trial of education and professional support to nursing home staff: research protocol and baseline data of the IQUARE study.

BackgroundWhilst the number of people living in nursing homes (NH) is expected to rise, research on NH quality is scarce. The purpose of this article is to describe the research protocol of the IQUARE study and to present its baseline data.Methods and designIQUARE is a 18-month multicentric individually-tailored controlled trial of education and professional support to NH staff. The main purposes of IQUARE are to improve the quality of the health care provided in NHs and to reduce the risk of functional decline among residents. Data on internal organisation and residents’ health for the 175 participating NHs were recorded by NH staff at baseline. NHs were allocated to either a light intervention group (LIG, n = 90 NHs, totalising 3 258 participants) or a strong intervention group (SIG, n = 85 NHs, totalising 3 017 participants). Intervention for LIG consisted at delivering to NH staff descriptive statistics on indicators of quality regarding their NH and the NHs from their sub-region of health and region; whereas for SIG, NH staff received the same information that LIG, but quality indicators were discussed by a cooperative work (two half-day meetings) between a hospital geriatrician and NH staff. Strategies for overcoming NH’s weaknesses were then traced; the efficacy of strategies is evaluated at a 6-month period.ResultsBaseline data showed high levels of dependence, comorbidities, psychological disturbances and medication’s consumption among NH residents. Large discrepancies among NHs were observed.ConclusionsIQUARE is one of the largest controlled trials in NHs developed in France. Results from IQUARE may constitute the basis for the development of new work modalities within the French health system, and serve as a model of a feasible research approach in NHs.

Potential underuse of analgesics for recognized pain in nursing home residents with dementia: a cross-sectional study.

Summary Dementia decreases the likelihood of taking analgesics for treating a recognized condition of pain independent of the use of other pain relievers. Abstract The expression of pain is altered in people with dementia (PWD), increasing the risk of undertreatment in that population. The objective of this study was to determine whether dementia and the absence of pain assessment in the patients’ medical chart reduced the probability of analgesic use in a large sample of nursing home (NH) residents. This is a cross‐sectional study using data from 6275 residents (mean age 86 ± 8.2 years; 73.7% women) from 175 NHs located in France. Information on residents’ health status (including dementia and pain assessment) and NHs’ structure and organisation were recorded by the NH staff. The NH staff sent to the research team drug prescriptions participants were taking. They were screened for the use of analgesics (dependent variable) and other medications potentially used for pain management. The prevalence of analgesic use was 46.8% (42.3% for PWD and 52% for people with no dementia). A binary logistic regression showed that PWD (odds ratio 0.75; 95% confidence interval 0.66–0.85) and those who had no pain assessment records (odds ratio 0.64; 95% confidence interval 0.53–0.79) had significant lower probabilities of taking analgesics; these results were independent of pain complaints. Results remained fairly unchanged after performing several sensitivity analyses. Our results suggest that improvements are needed in pain management in NHs, particularly for PWD. Implementing systematic evaluations of pain in NHs’ routine would contribute to a better management of pain, which can lead to important benefits for residents.

Exercise training for managing behavioral and psychological symptoms in people with dementia: A systematic review and meta-analysis

This systematic review and meta-analysis of randomized controlled trials assessed the effects of exercise on behavioral and psychological symptoms of dementia (BPSD, including depression) in people with dementia (PWD). Secondary outcomes for the effects of exercise were mortality and antipsychotic use. Twenty studies were included in this review (n=18 in the meta-analysis). Most studies used a multicomponent exercise training (n=13) as intervention; the control group was often a usual care (n=10) or a socially-active (n=8) group. Exercise did not reduce global levels of BPSD (n=4. Weighted mean difference -3.884; 95% CI -8.969-1.201; I(2)=69.4%). Exercise significantly reduced depression levels in PWD (n=7). Standardized mean difference -0.306; 95% CI -0.571 to -0.041; I(2)=46.8%); similar patterns were obtained in sensitivity analysis performed among studies with: institutionalized people (p=0.038), multicomponent training (p=0.056), social control group (p=0.08), and low risk of attrition bias (p=0.11). Exploratory analysis showed that the principal BPSD (other than depression) positively affected by exercise was aberrant motor behavior. Exercise had no effect on mortality. Data on antipsychotics were scarce. In conclusion, exercise reduces depression levels in PWD. Future studies should examine whether exercise reduces the use (and doses) of antipsychotics and other drugs often used to manage BPSD.

How much exercise are older adults living in nursing homes doing in daily life? A cross-sectional study

Abstract Information on the amount of exercise practised by nursing home (NH) residents is scarce. This study aimed at describing NH residents’ participation in exercise classes, as well as to examine whether the presence of a professional exercise instructor in the facilities is associated with residents’ exercise habits. The cross-sectional data of 5402 residents (median age = 88 years; mostly women (75.2%)) from 163 NHs in France were analysed. Adjusted logistic and linear regressions were performed to examine whether the presence of a professional exercise instructor in the NH was associated with exercise habits: exercise participation, frequency, duration, and levels. From the 5402 participants, 1914 were participating in exercise classes provided in the NH. Most of them had an exercise frequency of 1x/week or less. Median duration of exercise sessions was 45 min. Exercise levels were rated as: highly active (n = 487), intermediately active (n = 1096), and poorly active (n = 331). The presence of a professional exercise instructor working in the facility was significantly associated with exercise participation and with higher exercise frequencies and levels, and session duration. In conclusion, the presence of professional exercise instructors is associated with better exercise habits in NH residents. Improved exercise habits may potentially be translated into better health in this population.

Participation bias in postal surveys among older adults: The role played by self-reported health, physical functional decline and frailty

Postal survey is a simple and efficient way to collect information in large study samples. The purpose of this study was to find out differences between older adults who responded to a postal survey on health outcomes and those who did not, and to examine the importance of frailty, physical functional decline and poor self-reported health in determining non-response. We mailed out a questionnaire on general health twice at a years interval to 1000 individuals ≥60 years, and members of the medical insurance scheme of the French national education system. At Year1, 535 persons responded to the questionnaire (65% women, 70.9 ± 8.4 years). A year later (Year2), we obtained 384 responses (63.3% women, 70.5 ± 7.8 years). Compared to respondents, non-respondents at Year2 were more frequently categorized as frail, reported more often to be in bad health, and had more physical functional declines. Frailty, physical functional decline and poor self-reported health increased the likelihood of not responding to Year2 questionnaire, with poor self-reported health weakening the association of physical functional decline and non-response. Respondents of this postal survey are fitter and healthier than non-respondents. This participation bias precludes the generalization of postal surveys results.

Time to Challenge Public Health Guidelines on Physical Activity

There is striking evidence in support of physical activity (PA) as a very strong factor in health promotion and disease prevention. Since the mid-1990s, public health guidelines on PA have established PA recommendations to promote health and prevent several non-communicable diseases (NCDs). However, it is not clear that there is universal agreement on the validity of all aspects of these recommendations. Indeed, a growing body of evidence has accumulated over the last 20 years showing that less than 150 min/week of moderate PA, i.e. the minimum PA level currently recommended, promotes health and prevents NCDs. Moreover, when determining whether someone achieves the minimum PA recommendations, the quantities of PA undertaken are added together regardless of what domain of PA they represent, i.e. leisure-time, occupational, transport or housework. However, while convincing evidence exists to show that leisure-time and transport PA are important factors for promoting health, the evidence for occupational PA and housework is mixed. Therefore, the purpose of this article is to discuss two major issues relating to public health guidelines on PA for adults and older adults: the minimum volumes of PA required and the importance of PA domains in health promotion. A proposal on how to tackle these issues and ultimately strengthen PA recommendations is also presented.

Direct and indirect relationships between physical activity and happiness levels among older adults: a cross-sectional study.

Objectives: The purposes of this study were to examine if physical activity (PA) is associated to happiness and to investigate if social functioning and health status mediate this association.Method: Participants of this cross-sectional study were 323 men and women, age 60 or over, who were covered by the medical insurance of the French National Education System, France. They received by mail a self-report questionnaire that asked for information about general health, PA, and happiness.Results: In multinomial logistic regressions, the total volume of PA was associated to higher levels of happiness, but this association disappeared in the presence of social functioning. A structural equation modelling (SEM) showed an indirect association between PA and happiness, which was mediated by participants’ health status and social functioning; in this SEM model, social functioning was the only variable directly associated to happiness.Conclusion: Complex associations among PA, health status, and social functioning...Objectives: The purposes of this study were to examine if physical activity (PA) is associated to happiness and to investigate if social functioning and health status mediate this association. Method: Participants of this cross-sectional study were 323 men and women, age 60 or over, who were covered by the medical insurance of the French National Education System, France. They received by mail a self-report questionnaire that asked for information about general health, PA, and happiness. Results: In multinomial logistic regressions, the total volume of PA was associated to higher levels of happiness, but this association disappeared in the presence of social functioning. A structural equation modelling (SEM) showed an indirect association between PA and happiness, which was mediated by participants’ health status and social functioning; in this SEM model, social functioning was the only variable directly associated to happiness. Conclusion: Complex associations among PA, health status, and social functioning appear to determine happiness levels in older adults.

Static or dynamic predictors of physical activity (PA)? A tracking study based on 12- and 38-month follow-ups in older adults

Studies that investigated stability of PA in older populations are scarce. Moreover, no studies used dynamic indicators to predict PA trajectories. The purpose of the present study were to investigate PA stability overtime, and to examine if changes in self-reported physical function (dynamic indicator) are better predictors of trajectories of PA than baseline measures of physical function (static indicator). This is a prospective postal survey with two time-point follow-ups: 12 and 38 months. Participants were older adults aged ≥ 60 years, and members of the medical insurance scheme of the French national education system. They responded to a self-report questionnaire on PA and general health status at three different times: baseline, 12- and 38-month follow-ups (n=243 for the 12-month follow-up; n=164 for the 38-month follow-up). Overtime analyses of PA showed a moderate-to-good stability with regard to both duration and volume of PA; however, a decrease in stability for vigorous PA was found between 12- and 38-month follow-ups. Both baseline measure and changes in physical function predicted PA trajectories, but magnitudes of associations were stronger for the dynamic indicator. Moreover, change in physical function was the only predictor of both becoming active compared with Inactive (reduced probability) and becoming inactive compared to Active (increased probability). In conclusion, a dynamic indicator of physical function is a better predictor of PA variation than static indicators.

Happiness and unhappiness have no direct effect on mortality

822 www.thelancet.com Vol 387 February 27, 2016 What defi nes a good life? If in answering this question you included happiness in your list, you are not alone. Indeed, the pursuit and enjoyment of happiness is a common goal and desire in life for most people. Adults of all ages, including those in old age, frequently report the experience of happiness as a determinant of a good life. Since both happiness and health are crucial aspects of quality of life, medical work about the potential positive eff ects of happiness on a person’s health and longevity is a growing area that has received increasing attention in the past decade. In The Lancet, Bette Liu and colleagues use data from a cohort of women in the UK Million Women Study, mean age 60 years, to examine whether happiness was associated with good health and with reduced mortality risk after an average follow-up of about 10 years. The strongest correlates of unhappiness were treatment for depression and anxiety (odds ratio [OR] 0·224 [99% group-specifi c CI 0·218–0·229]) and self-reported poor health (OR 0·298 [0·293–0·303]). In crude analyses of 719 671 women without chronic health disorders from the cohort, unhappiness was signifi cantly associated with an increased risk of all-cause mortality (age-adjusted rate ratio [RR] 1·29, 95% CI 1·25–1·33). However, in multivariate regression models adjusted for age, personal characteristics, treatment for illnesses, and self-reported health (the key factor) there was no signifi cant association (0·98, 0·94–1·01). Other researchers have found that hedonic wellbeing (ie, a viewpoint that defi nes wellbeing through experiences of pleasure vs displeasure and that can be roughly summarised as happiness) is not a good predictor of mortality in women, when baseline levels of health and health behaviours had been taken into account. A Japanese cohort study (n=88 175) showed that high levels of enjoyment in life appeared to protect against cardiovascular mortality in men but not in women aged 40–69 years. However, another study with 97 253 women from the USA aged 50–79 years showed that high levels of optimism were associated with reduced mortality risk. Reviews and a meta-analysis on the associations between happiness (hedonic wellbeing, subjective wellbeing, or positive psychological wellbeing) and longevity support the notion that happy people live longer. Although most studies on this topic did not adjust their analyses for self-reported health, they suggest that the associations between happiness and longevity are strongest among healthy individuals. Liu and colleagues’ main fi nding does not support this association, since no signifi cant relation was shown between happiness and mortality risk within the subgroup of people reporting good or excellent health (indeed, Liu and colleagues’ analysis of only people reporting excellent health showed all-cause mortality risk to be slightly higher in the unhappiest individuals compared with the happiest). The happiness–mortality association seems to be, to some extent, sex-specifi c, with higher positive eff ects reported in men than in women. Previous research shows diff erent profi les of psychological wellbeing according to sex; for instance, women’s wellbeing would rely more on positive interpersonal relations than men’s. Moreover, in older adults, the diff erence between men and women on reported wellbeing and happiness increases with advancing age. Therefore, men and women probably defi ne happiness diff erently, which might explain, at least partially, sex-specifi c diff erences for the associations between happiness and medical outcomes, including mortality. Further qualitative research that allows separate content analysis for men and women about happiness across diff erent age ranges is needed to improve understanding of the complex concept of happiness. Although mortality is one of the most well documented outcomes in reports on happiness, happiness has also been shown to be associated with other medical disorders, particularly a reduced risk of both incident cardiovascular diseases and disability levels (see Diener and Chan for a review). Research about happiness of older adults should focus on medical outcomes other than mortality, particularly the incidence and prognostic value of disabling diseases and disability, the most important clinical issues faced by elderly populations. For example, an important gap exists in knowledge about the potential associations of happiness with the incidence of cognitive decline and dementia; indeed, happiness is associated with healthy lifestyles, such as exercise and abstinence from smoking, which, in turn, are protective factors against dementia. Therefore, it is plausible to suggest that happiness could be associated with a reduced risk of incident dementia. Moreover, further research from a Happiness and unhappiness have no direct eff ect on mortality

Prescription of physical activity

We also acknowledged that higher mortality rates in the low fi tness category might be the outcome of subclinical disease, and not low fi tness per se. To account for this, we took several steps, including the exclusion of patients who died within the fi rst 2 years of follow-up, and repeated the analyses. The fi tness-mortality risk association remained, and the risk reduction did not change substantially.Finally, we diff er with Gobulic and Ray’s interpretation of our fi ndings. It was fi tness (not statins) that had a diff erential benefi t across statin strata. Our statements are based on the fi ndings derived from acceptable and robust statistical procedures, and within the limitations of epidemiological data. The observational nature of the study alone should not constitute the basis for the dismissal of our fi ndings.