Rabih Chattat

A European consensus on outcome measures for psychosocial intervention research in dementia care

Psychosocial intervention makes a vital contribution to dementia care. However, the lack of consensus about which outcome measures to use to evaluate effectiveness prevents meaningful comparisons between different studies and interventions. This study used an iterative collaborative, evidence-based approach to identify the best of currently available outcome measures for European psychosocial intervention research. This included consensus workshops, a web-based pan-European consultation and a systematic literature review and a rigorous evaluation against agreed criteria looking at utility across Europe, feasibility and psychometric properties. For people with dementia the measures covered the domains of quality of life, mood, global function, behaviour and daily living skills. Family carer domains included mood and burden, which incorporated coping with behaviour and quality of life. The only specific staff domain identified was morale, but this included satisfaction and coping with behaviour. In conclusion twenty-two measures across nine domains were recommended in order to improve the comparability of intervention studies in Europe. Areas were identified where improved outcome measures for psychosocial intervention research studies are required.

Risk factors and incidence of postoperative delirium in elderly patients after elective and emergency surgery.

This study evaluated the incidence of postoperative delirium (POD) in elderly patients undergoing general surgery, the risk factors associated with POD, and its impact on hospital stay and mortality.

Hypothalamic-pituitary-adrenal axis activity and its relationship to the autonomic nervous system in women with visceral and subcutaneous obesity: effects of the corticotropin-releasing factor/arginine-vasopressin test and of stress.

In a previous study, we demonstrated that premenopausal women with visceral obesity have hyperactivity of the hypothalamic-pituitary-adrenal (HPA) axis, characterized by an exaggerated hormone response to corticotropin-releasing factor (CRF) and corticotropin (ACTH) stimulation. The hypothalamic peptide flow that stimulates the pituitary, particularly after a physiological stress challenge, involves not only CRF, but also arginine-vasopressin (AVP), which synergizes the CRF capacity to stimulate pituitary hormone secretion. Previous studies in humans have demonstrated that combining AVP with CRF permits maximal stimulation of the pituitary, providing a more appropriate method of assessing pituitary hormone reserve. We therefore investigated the response of the HPA axis to combined CRF and AVP stimuli in obese women with different obesity phenotypes. Moreover, we examined hormonal and cardiovascular responses to several mental stress tasks, according to previously standardized procedures. Two groups of age-matched premenopausal eumenorrheic obese women with visceral (V-BFD) or subcutaneous (S-BFD) body fat distribution and a group of normal-weight healthy controls were investigated. All women randomly underwent the following protocol: (1) a combined CRF/AVP test (100 micrograms plus 0.3 IU intravenously [IV], respectively); (2) a standardized stress test, which consisted of completing two puzzles and a mental arithmetic test; and (3) a control saline test. Blood samples for ACTH and cortisol determinations were obtained before and during each test, and measurements of arterial blood pressure and pulse rate were made at regular intervals during the stress test. After combined CRF/AVP administration, ACTH and cortisol were significantly higher in V-BFD than in the other two groups. In contrast, no significant hormonal variation was found in either group during stress tasks. During the stress test, pulse rate (but not arterial blood pressure) significantly increased after 8 and 15 minutes in the V-BFD group, whereas no significant variation was found in S-BFD and control women. A significant correlation was present between the pulse rate and change in cortisol level during the stress test at minutes 8 (r=.54, P<.05) and 15 (r=.57, p<.01) in all women considered together. Subjective emotional involvement during stressful tasks was measured by a two-dimensional short verbal scale, which revealed that the stress section had a more significant impact in obese V-BFD than in S-BFD and control women. These data therefore confirm that women with visceral obesity have hyperactivity of the HPA axis, and that the combined CRF/AVP stimulation may offer a good tool for investigating pituitary reserve in this obesity phenotype. Moreover, the results indicate that these women probably have a hyperreactive sympathetic response to acute stress that seems interrelated to that of the HPA axis.

Fibromyalgic Syndrome: Depression and Abnormal Illness Behavior

This study reports psychological symptoms assessed in 327 patients with fibromyalgia (FS) in a multicenter investigation. Two self-report scales, in their validated Italian translations, were used for screening: the CES-D (the Center of Epidemiologic Studies-Depression) developed at the NIMH for measuring depression and the Illness Behavior Questionnaire (IBQ) developed by Pilowsky and Spence. The cutoff point of 23 in the CES-D scores revealed about 49% of the fibromyalgic patients as depressed. In analyzing patterns of illness behavior patients with FS showed a high score on IBQ scales of disease conviction, psychological versus somatic focusing and denial. CES-D scores showed significant correlations with illness behavior scales. These results and their implications for the treatment of fibromyalgic patients are discussed.

Illness behavior, affective disturbance and intestinal transit time in idiopathic constipation

Patients with constipation differ not only from healthy subjects but can also be categorized into two groups: slow transit constipation (STC) and normal transit constipation (NTC) using measures of total intestinal transit time (TITT). We investigated the role of illness behavior and affective state in 45 NTC and 29 STC patients as compared with 20 healthy subjects. All subjects completed the Illness Behavior Questionnaire (IBQ), the Symptom Questionnaire (SQ), and the CES-D to assess illness behavior, psychological distress, and depression. The constipated patients reported more psychological distress than healthy subjects. Within the constipated group, the NTC subjects had significantly higher scores on the IBQ dimensions of hypochondriasis and disease affirmation. Our results suggest that even among constipated patients psychological distress is prominent and that measures of illness behavior help to discriminate among different pathophysiological groups.

Benign Joint Hypermobility Syndrome: Psychological Features and Psychopathological Symptoms in a Sample Pain-Free at Evaluation

30 subjects with BJHS (Hypermobile) (M age = 32.3 yr., SD = 10.4) and two control groups, 25 healthy subjects (Healthy) (M age = 33.9 yr., SD = 93) and 30 fibromyalgic patients (Fibromyalgic) (M age = 32.2 yr., SD = 9.4), were given the Symptom Checklist-90-R, the Illness Behavior Questionnaire, the Female Functional Symptoms Frequency (FFF) and the Male Functional Symptoms Frequency (MFF), derived from the DSM-III–R, evaluating functional somatic disturbances and their intensity, and the Symptom Questionnaire. The mean scores for the Hypermobile group showed significant psychological distress and increased frequency and intensity of somatic symptoms. Scores on Anxiety and Somatic Symptoms, General Hypochondriasis, Disease Conviction, Affective Disturbance, Denial, and Irritability were significantly higher in the Hypermobile than in the Healthy group. Elevated scores were found for the Fibromyalgic group on the Illness Behavior Questionnaire subscales for Psychological vs Somatic Focus, Disease Affirmation, and Discriminating Factors when compared with the Hypermobile group. Considerable emotional symptoms were detected which should not be underestimated by physicians when establishing an integrated biopsychosocial therapy.

Pre-Operative, High-IL-6 Blood Level is a Risk Factor of Post-Operative Delirium Onset in Old Patients

Background: Post-operative delirium (POD) is a common complication in elderly patients undergoing surgery, but the underpinning causes are not clear. We hypothesized that inflammaging, the subclinical low and chronic grade inflammation characteristic of old people, can contribute to POD onset. Accordingly, we investigated the association of pre-operative and circulating cytokines in elderly patients (>65 years), admitted for elective and emergency surgery. Methods: This is a secondary analysis of a sub-cohort of patients belonging to a previous large case–control study, where 351 patients were clinically and cognitively thoroughly characterized, together with the assessment of POD (47 patients) by confusion assessment method and delirium rating scale. Seventy-four pre-operative plasma samples were selected from a larger bio-bank and they included 37 subjects with POD and 37 without POD. Inflammaging related cytokines, i.e., IL-1β, IL-2, IL-6, IL-8, IL-10, and TNF-α, were assayed by ELISA in pre-operative blood samples; univariate and multivariable analyses have been applied to identify cytokines independently associated to POD. Associations of cytokine levels with functional status, cognitive decline, intra-hospital mortality, and comorbidity were also analyzed independently of POD onset. Results: High IL-6 and low-IL-2 levels were significantly associated with POD. After adjustment for potential confounders in multivariate analysis, high level of pre-operative IL-6 was confirmed to be significantly associated with risk of POD onset. High level of IL-6 was also associated with several baseline features (including poor functional status, cognitive impairment, emergency admission, and higher comorbidity burden) and intra-hospital mortality. Conclusion: Pre-operative, high-plasma level of IL-6 (≥9 pg/mL) was significantly associated with POD onset. We propose IL-6 as an additional risk factor of POD onset together with the previously identified factors. Discovery of all risk factors contributing to POD onset will permit to improve hospitalized patient management and the decrease of healthcare cost.

The Italian version of the Zarit Burden Interview: a validation study

BACKGROUND Caregiving experiences in dementia may have adverse effects on the caregivers own physical and mental health. The Zarit Burden Interview (ZBI) is the most widely used instrument for assessing family carer burden and the purpose of the present study was to evaluate the psychometric properties of the Italian version of the ZBI (I-ZBI). METHODS I-ZBI was administered to a non-randomized sample of 273 caregivers related to consecutively attending outpatients with a previously established primary diagnosis of dementia, according to DSM-IV criteria. Measurements used for the construct validity of the instrument were the General Health Questionnaire (GHQ-12), Hospital Anxiety and Depression Scale (HADS) and the Symptom Checklist-90-Revised (SCL-90-R). Validity and reliability were evaluated, as well as the factor structure of the instrument. RESULTS Most caregivers were children (65%), female (72%) and living with the patient (53%), with quite a high level of burden. The I-ZBI demonstrates good reliability with high internal consistency (α = 0.90) and split-half correlation of 0.78, and good concurrent validity with other assessment tools. A five-factor solution was obtained for the I-ZBI and the original bi-factorial structure of the ZBI was not confirmed. CONCLUSIONS The Italian version of the Zarit Burden Interview is valid, reliable and useful for use in clinical contexts and in future studies that could lead to a better understanding of carer burden in dementia. Clarifying the factorial structure of the ZBI would help to further the understanding of the large body of research using it and would also help to advance the understanding of subjective burden.

Social health and dementia: a European consensus on the operationalization of the concept and directions for research and practice

ABSTRACT Background: Because the pattern of illnesses changes in an aging population and many people manage to live well with chronic diseases, a group of health care professionals recently proposed reformulating the static WHO definition of health towards a dynamic one based on the ability to physically, mentally and socially adapt and self-manage. This paper is the result of a collaborative action of the INTERDEM Social Health Taskforce to operationalize this new health concept for people with dementia, more specifically the social domain, and to formulate directions for research and practice to promote social health in dementia. Method: Based on the expertise of the Social Health Taskforce members (N = 54) three groups were formed that worked on operationalizing the three social health dimensions described by Huber et al.: (1) capacity to fulfil potential and obligations; (2) ability to manage life with some degree of independence; (3) participation in social activities. For each dimension also influencing factors, effective interventions and knowledge gaps were inventoried. After a consensus meeting, the operationalizations of the dimensions were reviewed by the European Working Group of People with Dementia (EWGPWD). Results: The social health dimensions could be well operationalized for people with dementia and are assessed as very relevant according to the Social Health Taskforce and EWGPWD. Personal (e.g. sense of coherence, competencies), disease-related (e.g. severity of cognitive impairments, comorbidity), social (support from network, stigma) and environmental factors (e.g. enabling design, accessibility) that can influence the person with dementias social health and many interventions promoting social health were identified. Conclusion: A consensus-based operationalization of social health in dementia is proposed, and factors that can influence, and interventions that improve, social health in dementia identified. Recommendations are made for research and practice.

Alzheimer Europe's position on involving people with dementia in research through PPI (patient and public involvement)

ABSTRACT This paper reflects Alzheimer Europes position on PPI (patient and public involvement) in the context of dementia research and highlights some of the challenges and potential risks and benefits associated with such meaningful involvement. The paper was drafted by Alzheimer Europe in collaboration with members of INTERDEM and the European Working Group of People with Dementia. It has been formally adopted by the Board of Alzheimer Europe and endorsed by the Board of INTERDEM and by the JPND working group ‘Dementia Outcome Measures - Charting New Territory’. Alzheimer Europe is keen to promote the involvement of people with dementia in research, not only as participants but also in the context of PPI, by generating ideas for research, advising researchers, being involved in consultations and being directly involved in research activities. This position paper is in keeping with this objective. Topics covered include, amongst others, planning involvement, establishing roles and responsibilities, training and support, managing information and input from PPI, recognising the contribution of people with dementia involved in research in this way, promoting and protecting the rights and well-being of people with dementia, training and support, and promoting an inclusive approach and the necessary infrastructure for PPI in dementia research.