S. Martins

Delirium in elderly people: a review

The present review aims to highlight this intricate syndrome, regarding diagnosis, pathophysiology, etiology, prevention, and management in elderly people. The diagnosis of delirium is based on clinical observations, cognitive assessment, physical, and neurological examination. Clinically, delirium occurs in hyperactive, hypoactive, or mixed forms, based on psychomotor behavior. As an acute confusional state, it is characterized by a rapid onset of symptoms, fluctuating course and an altered level of consciousness, global disturbance of cognition or perceptual abnormalities, and evidence of a physical cause. Although pathophysiological mechanisms of delirium remain unclear, current evidence suggests that disruption of neurotransmission, inflammation, or acute stress responses might all contribute to the development of this ailment. It usually occurs as a result of a complex interaction of multiple risk factors, such as cognitive impairment/dementia and current medical or surgical disorder. Despite all of the above, delirium is frequently under-recognized and often misdiagnosed by health professionals. In particular, this happens due to its fluctuating nature, its overlap with dementia and the scarcity of routine formal cognitive assessment in general hospitals. It is also associated with multiple adverse outcomes that have been well documented, such as increased hospital stay, function/cognitive decline, institutionalization and mortality. In this context, the early identification of delirium is essential. Timely and optimal management of people with delirium should be performed with identification of any possible underlying causes, dealing with a suitable care environment and improving education of health professionals. All these can be important factors, which contribute to a decrease in adverse outcomes associated with delirium.

Control of allergic rhinitis and asthma test – a formal approach to the development of a measuring tool

BackgroundThe concurrent management of allergic rhinitis and asthma (ARA) has been recommended by Allergic Rhinitis and its Impact on Asthma (ARIA) guidelines. However, a tool capable of assessing simultaneously the control of upper and lower airways diseases is lacking.AimTo describe the studies conducted to design the control of ARA test (CARAT) questionnaire.MethodsWe performed a literature review to generate a list of potentially important items for the assessment of control of ARA. A formal consensus development process, that used an innovative web-based application, was designed – 111 experts in ARA and 60 patients participated. At the final consensus meeting, 25 primary and secondary care physicians formulated the questions and response options. A qualitative feasibility study (n = 31 patients) was conducted to evaluate the comprehensibility of the questionnaire while testing two different designs.ResultsThirty-four potentially important items were identified. All the steps of the consensus process were completed in 2.5 months. The opinions of experts and patients lead to the formulation of 17 questions. At the feasibility study the instructions and wording problems were corrected and a semi-tabular format was chosen.ConclusionA tool to measure the control of allergic rhinitis and asthma was developed using a comprehensive set of methodological steps ensuring the design quality and the face and content validity. Additional validation studies to assess the psychometric properties of the questionnaire have started.

Association of anxiety with asthma: subjective and objective outcome measures.

Background The relationship between anxiety and asthma is currently being intensively studied. Objective The authors examined anxiety that influences and is influenced by this complex disease. Method The authors conducted a cross-sectional study of adults with asthma at a hospital outpatient department, excluding known psychiatric patients. A sample of 195 patients, mostly middle-aged women with moderate/severe asthma, underwent pulmonary function and airway-inflammation tests and were given anxiety rating questionnaires. Results A high level of anxiety was present in 70% of the patients. Anxiety was associated with worse subjective asthma outcomes and increased use of medication/healthcare services, but with decreased airway inflammation, and was not associated with lung function. Conclusion Anxiety seems to influence patients’ perception/awareness of asthma symptoms.

Functional characterization of Arabidopsis thaliana transthyretin-like protein

BackgroundArabidopsis thaliana transthyretin-like (TTL) protein is a potential substrate in the brassinosteroid signalling cascade, having a role that moderates plant growth. Moreover, sequence homology revealed two sequence domains similar to 2-oxo-4-hydroxy-4-carboxy-5-ureidoimidazoline (OHCU) decarboxylase (N-terminal domain) and 5-hydroxyisourate (5-HIU) hydrolase (C-terminal domain). TTL is a member of the transthyretin-related protein family (TRP), which comprises a number of proteins with sequence homology to transthyretin (TTR) and the characteristic C-terminal sequence motif Tyr-Arg-Gly-Ser. TRPs are single domain proteins that form tetrameric structures with 5-HIU hydrolase activity. Experimental evidence is fundamental for knowing if TTL is a tetrameric protein, formed by the association of the 5-HIU hydrolase domains and, in this case, if the structural arrangement allows for OHCU decarboxylase activity. This work reports about the biochemical and functional characterization of TTL.ResultsThe TTL gene was cloned and the protein expressed and purified for biochemical and functional characterization. The results show that TTL is composed of four subunits, with a moderately elongated shape. We also found evidence for 5-HIU hydrolase and OHCU decarboxylase activities in vitro, in the full-length protein.ConclusionsThe Arabidopsis thaliana transthyretin-like (TTL) protein is a tetrameric bifunctional enzyme, since it has 5-HIU hydrolase and OHCU decarboxylase activities, which were simultaneously observed in vitro.

O Impacto Traumático de Experiências de Vergonha: Estudo das propriedades psicométricas da versão portuguesa da Impact of Event Scale - Revised

Experiencias precoces de vergonha tem sido apontadas como possiveis experiencias traumaticas, constituindo-se como memorias traumaticas com implicacoes na vulnerabilidade para a psicopatologia. O presente estudo explora as propriedades psicometricas da versao portuguesa da Escala do Impacto do Acontecimento- Revista (Impact of Event Scale-Revised, IES-R; Weiss & Marmar, 1997) numa amostra de 811 sujeitos da populacao geral. Especificamente, examina a estrutura factorial, a consistencia interna, a validade convergente e divergente deste instrumento de auto-resposta. A escala original (IES-R) foi traduzida para portugues e a comparabilidade do conteudo foi verificada atraves de traducao-retroversao. A validade de constructo foi analisada atraves de uma Analise em Componentes Principais, cujos resultados apoiaram a estrutura de uma dimensao subjacente a IES-R, que explica 55.4% da variância. Foram encontradas correlacoes item-total moderadas a elevadas (>.56) e um alfa de Cronbach elevado (α=.96), indicadores de excelente consistencia interna. A validade convergente e divergente da escala foi comprovada atraves das correlacoes elevadas encontradas com a Escala de Centralidade do Acontecimento e das correlacoes moderadas encontradas com as subescalas Depressao, Ansiedade e Stress. A IES-R mostrou ser um instrumento fiavel e valido para avaliar reaccoes de stress traumatico, com caracteristicas de intrusao, evitamento e hiperactivacao, em relacao a experiencias de vergonha.

Delirium Recognition by Family: European Portuguese Validation Study of the Family Confusion Assessment Method

To present the validation study of the European Portuguese version of the Family Confusion Assessment Method (FAM‐CAM) and to assess the level of psychological distress in families and caregivers of elderly hospitalized adults with delirium.

Validity and Reliability of the European Portuguese Version of Neuropsychiatric Inventory in an Institutionalized Sample

Background Neuropsychiatric symptoms are very common in dementia and have been associated with patient and caregiver distress, increased risk of institutionalization and higher costs of care. In this context, the neuropsychiatric inventory (NPI) is the most widely used comprehensive tool designed to measure neuropsychiatric Symptoms in geriatric patients with dementia. The aim of this study was to present the validity and reliability of the European Portuguese version of NPI. Methods A cross-sectional study was carried out with a convenience sample of institutionalized patients (≥ 50 years old) in three nursing homes in Portugal. All patients were also assessed with mini-mental state examination (MMSE) (cognition), geriatric depression scale (GDS) (depression) and adults and older adults functional assessment inventory (IAFAI) (functionality). NPI was administered to a formal caregiver, usually from the clinical staff. Inter-rater and test-retest reliability were assessed in a subsample of 25 randomly selected subjects. Results The sample included 166 elderly, with a mean age of 80.9 (standard deviation: 10.2) years. Three out of the NPI behavioral items had negative correlations with MMSE: delusions (rs = -0.177, P = 0.024), disinhibition (rs = -0.174, P = 0.026) and aberrant motor activity (rs = -0.182, P = 0.020). The NPI subsection of depression/dysphoria correlated positively with GDS total score (rs = 0.166, P = 0.038). NPI showed good internal consistency (overall α = 0.766; frequency α = 0.737; severity α = 0.734). The inter-rater reliability was excellent (intraclass correlation coefficient (ICC): 1.00, 95% confidence interval (CI) 1.00 - 1.00), as well as test-retest reliability (ICC: 0.91, 95% CI 0.80 - 0.96). Conclusion The results found for convergent validity, inter-rater and test-retest reliability, showed that this version appears to be a valid and reliable instrument for evaluation of neuropsychiatric symptoms in institutionalized elderly.

Delirium in elderly patients: association with educational attainment.

Objective Among cognitive reserve markers, educational attainment is the most widely studied, with several studies establishing a strong association with risk of dementia. However, it has not yet been fully examined in delirium. This study aims to analyse the relationship between educational attainment and delirium. Methods The study included elderly hospitalised patients admitted (≥48 h) into an intermediate care unit (IMCU) of Intensive Care Medicine Service. Exclusion criteria were as follows: Glasgow Coma Scale (total≤11), blindness/deafness, inability to communicate or to speak Portuguese. The European Portuguese Version of the Confusion Assessment Method (CAM) was used for delirium assessment. Results The final sample (n=157) had a mean age of 78.8 (SD=7.6) the majority being female (52.2%), married (51.5%) and with low educational level (49%). According to CAM, 21% of the patients had delirium. The delirium group presented the fewest years of education (median 1 vs. 4), with statistical significance (p=0.003). Delirium was more frequent among male patients [odds ratio (OR) 0.32; 95% confidence interval (CI) 0.12–0.86; p=0.023], as well as those patients with lower education (OR 0.76; 95% CI 0.62–0.95; p=0.016), and with respiratory disease (OR 3.35; 95% CI 1.20–9.33; p=0.020), after controlling for age and medication. Conclusion Similar to previous studies, these findings point to a negative correlation between education and delirium. This study appears as an attempt to contribute to the knowledge about the role of cognitive reserve in risk of delirium, particularly because is the first one that has been carried out in an IMCU, with lower educated elderly patients. Further studies are needed to clarify this relationship considering other markers (e.g. cognitive activities), which can contribute to the definition of preventive strategies.

Short Sleep Duration and Circadian Rhythms: Association with Suicidal Behaviour

The current lifestyles in modern societies promote a behaviourally-induced sleep deprivation and circadian rhythm alterations. Some sleep disorders influence the development of suicidal behaviours. This study aims to review the literature exploring the association of both short sleep duration and sleep circadian rhythms with suicidal behaviours. A review was conducted in the PubMed database, using the query (“circadian rhythms” OR “sleep” OR “sleep disorders”) AND (“suicide” OR “suicidal behaviour” OR “suicidality”). The results were filtered for the last 10 years, with 522 results. Studies relating sleep disorders or circadian rhythms with suicidal behaviours, using a well-defined index for sleep disorders, and any measure of suicidal behaviour, were included. After the selection criteria, 48 studies were selected for qualitative analysis. An association between short sleep duration and an increased risk of suicidal behaviour was found in most of the studies with children/adolescents and adults. Particularly, studies measuring weekend vs. weekday sleep duration suggest a concrete role of behaviourally-induced sleep deprivation in this increased risk. Contrastingly, in studies with the elderly, that association was not significant. For sleep circadian rhythms, the studies point to an association between an evening-type chronotype and suicidal behaviours. The results suggest a significant association of short sleep duration and evening-type chronotype with suicidal behaviours, for youth and adults. Both sleep disorders could be connected through a behaviourally-induced sleep deprivation. These associations can provide possible fields of intervention to prevent suicide.

Needs in Elderly in Residential Care and Their Relationship to Dependency

Introduction The worlds population is aging rapidly. Along with age, other challenges, like increased levels of dependency and new, complex and often expensive needs of an aged population are rising. Since unmet needs are associated with key prognostic outcomes such as excess disability or premature institutionalization, they are major health concerns. Objectives To study the relationship between levels of dependency and needs presented by an elderly sample. Methods A cross-sectional study with an institutionalized sample (≥50years) from three Portuguese residential homes was carried out. All permanent residents were eligible. However, those with delirium, who were terminally ill, unable to communicate or who refused to participate were not included. Participants were assessed with the Adults and Older Adults Functional Assessment Inventory/IAFAI and the Camberwell Assessment of Need for the Elderly/CANE. Each resident and a respective staff carer were interviewed for residents’ current needs. Results The sample included 175 elderly, with a mean age of 81 (sd=10). The majority were female (90%) and widowed (50%) with low educational level (86%, 0-4 years). The mean functional impairment (IAFAI score) was 43.45% (sd=23.52) and the number of global needs was 12 (sd=4). A significant correlation between the IAFAI score and the total of met (r s =0.642, p s =0.505, p s =0.796, p Conclusions In this sample higher levels of dependency were related with more met/unmet needs. Despite the cross-sectional nature of the study, the findings convey an important message regarding the influence of functional disability on unmet needs.