Evidently Cochrane: By Sarah Chapman // December 4, 2015
In the UK, 9.9 million people are aged over 65 and it has been estimated that around 6.6% have dementia; in the over 85s, this may be as high as 50%. Dementia has been identified as a national priority in health and social care and recent guidelines have emphasized early diagnosis to help with planning and management, though ‘screening’ for dementia remains the subject of debate.
A questionnaire to identify possible dementia
Currently, less than half those with dementia will be diagnosed as having it. There are lots of different ways of assessing people for possible dementia and no clear agreement about the best way to do it. One approach is to ask someone who knows the person about changes they’ve observed and a questionnaire that is commonly used for this purpose is the Informant Questionnaire on Cognitive Decline in the Elderly (IQCODE).
A team led by Dr Terry Quinn at the Cochrane Dementia and Cognitive Improvement Group has conducted a series of Cochrane reviews to find out what research can tell us about the accuracy of the IQCODE, used in different settings, for identifying possible dementia. A diagnosis of dementia can’t be made using the IQCODE alone, but this questionnaire can be used to flag up the need for further assessment or to help with a diagnosis along with other investigations.
The reviewers found that although the accuracy of the IQCODE is in a range that many would consider reasonable, in this population its use is likely to result in a large number of people being wrongly assessed as likely to have dementia and a large number of people who do have dementia being missed.
So out of a population of 100, it’s wrong for 15 of them.
In the latest edition of Health Matters, John Newton and Kevin Fenton focus on one of the most significant threats to public health in England – antimicrobial resistance.
Antibiotic consumption has risen by 6.5% over the past 4 years in England. We know that a large proportion of this prescribing is for sore throats, ear infections, and coughs and colds that can get better without the need for antibiotics.
This edition of Health Matters sets out the scale of the problem and how healthcare professionals, and those working in local authorities, can bring down levels of antibiotic prescribing.
Objective: To summarise the findings of an updated Cochrane review of interventions aimed at improving the appropriate use of polypharmacy in older people.
Design: Cochrane systematic review. Multiple electronic databases were searched including MEDLINE, EMBASE and the Cochrane Central Register of Controlled Trials (from inception to November 2013). Hand searching of references was also performed. Randomised controlled trials (RCTs), controlled clinical trials, controlled before-and-after studies and interrupted time series analyses reporting on interventions targeting appropriate polypharmacy in older people in any healthcare setting were included if they used a validated measure of prescribing appropriateness. Evidence quality was assessed using the Cochrane risk of bias tool and GRADE (Grades of Recommendation, Assessment, Development and Evaluation).
Setting: All healthcare settings.
Participants: Older people (≥65 years) with ≥1 long-term condition who were receiving polypharmacy (≥4 regular medicines).
Primary and secondary outcome measures: Primary outcomes were the change in prevalence of appropriate polypharmacy and hospital admissions. Medication-related problems (eg, adverse drug reactions), medication adherence and quality of life were included as secondary outcomes.
Results: 12 studies were included: 8 RCTs, 2 cluster RCTs and 2 controlled before-and-after studies. 1 study involved computerised decision support and 11 comprised pharmaceutical care approaches across various settings. Appropriateness was measured using validated tools, including the Medication Appropriateness Index, Beers’ criteria and Screening Tool of Older Person’s Prescriptions (STOPP)/ Screening Tool to Alert doctors to Right Treatment (START). The interventions demonstrated a reduction in inappropriate prescribing. Evidence of effect on hospital admissions and medication-related problems was conflicting. No differences in health-related quality of life were reported.
Conclusions: The included interventions demonstrated improvements in appropriate polypharmacy based on reductions in inappropriate prescribing. However, it remains unclear if interventions resulted in clinically significant improvements (eg, in terms of hospital admissions). Future intervention studies would benefit from available guidance on intervention development, evaluation and reporting to facilitate replication in clinical practice.
An analysis of trends in inpatient surveys in NHS acute trusts in England 2005-13 from the King’s fund
Patient surveys – recognised internationally as a key marker of the quality of care, and an important tool for improvement in the NHS – provide a unique perspective, complementing the wealth of other data on hospital performance gathered by trusts and regulators. Now, for the first time, The King’s Fund and Picker Institute Europe have analysed longitudinal inpatient survey data for acute trusts over a nine-year period (2005 to 2013).
The survey questions that were analysed (20 of a much larger number) were grouped into five aspects of care that matter most to patients: access and waiting; safe, high-quality co-ordinated care; better information, more choice; building better relationships; and a clean, comfortable and friendly place.
Objectives: To determine the diagnostic accuracy of the Whooley questions in the identification of depression; and, to examine the effect of an additional ‘help’ question.
Design: Systematic review with random effects bivariate diagnostic meta-analysis. Search strategies included electronic databases, examination of reference lists, and forward citation searches.
Inclusion criteria: Studies were included that provided sufficient data to calculate the diagnostic accuracy of the Whooley questions against a gold standard diagnosis of major depression.
Data extraction: Descriptive information, methodological quality criteria, and 2×2 contingency tables were extracted.
Results: Ten studies met inclusion criteria. Pooled sensitivity was 0.95 (95% CI 0.88 to 0.97) and pooled specificity was 0.65 (95% CI 0.56 to 0.74). Heterogeneity was low (I2=24.1%). Primary care subgroup analysis gave broadly similar results. Four of the ten studies provided information on the effect of an additional help question. The addition of this question did not consistently improve specificity while retaining high sensitivity as reported in the original validation study.
Conclusions: The two-item Whooley questions have high sensitivity and modest specificity in the detection of depression. The current evidence for the use of an additional help question is not consistent and there is, as yet, insufficient data to recommend its use for screening or case finding.
If experience at Southern Health NHS Foundation Trust is anything to go by, there is plenty of scope for progress. According to a report by Mazars, and commissioned by NHS England, examining deaths at this trust in particular, the NHS failed to investigate thoroughly the unexpected deaths of over 1,000 mental health and learning-disability patients between April 2011 and March 2015.
Mehta, N. et al. The British Journal of Psychiatry Nov 2015, 207 (5) 377-384.
Most research on interventions to counter stigma and discrimination has focused on short-term outcomes and has been conducted in high-income settings.
To synthesise what is known globally about effective interventions to reduce mental illness-based stigma and discrimination, in relation first to effectiveness in the medium and long term (minimum 4 weeks), and second to interventions in low- and middle-income countries (LMICs).
We searched six databases from 1980 to 2013 and conducted a multi-language Google search for quantitative studies addressing the research questions. Effect sizes were calculated from eligible studies where possible, and narrative syntheses conducted. Subgroup analysis compared interventions with and without social contact.
Eighty studies (n = 422 653) were included in the review. For studies with medium or long-term follow-up (72, of which 21 had calculable effect sizes) median standardised mean differences were 0.54 for knowledge and −0.26 for stigmatising attitudes. Those containing social contact (direct or indirect) were not more effective than those without. The 11 LMIC studies were all from middle-income countries. Effect sizes were rarely calculable for behavioural outcomes or in LMIC studies.
There is modest evidence for the effectiveness of anti-stigma interventions beyond 4 weeks follow-up in terms of increasing knowledge and reducing stigmatising attitudes. Evidence does not support the view that social contact is the more effective type of intervention for improving attitudes in the medium to long term. Methodologically strong research is needed on which to base decisions on investment in stigma-reducing interventions.
The size of portions, packages, and tableware has increased over the past 50 years. A recent Cochrane review shows that people consistently consume more food or non-alcoholic drinks when offered larger sized portions or packages. In this BMJ article, Theresa Marteau and colleagues suggest ways to reduce portion size, availability, and appeal.
Portion size matters: Click here to see an infographic showing the impact of portion size, and how policies can be developed in response.
In her latest annual report, ‘Health of the 51%: women’, the Chief Medical Officer (CMO) Professor Dame Sally Davies makes recommendations on a wide range of health issues, most notably obesity, ovarian cancer and ‘taboo problems’ such as incontinence and the menopause.
The report highlights obesity as one of the biggest risks to women’s health, affecting all aspects of a woman’s life from birth, family planning, pregnancy and right through to menopause and later life.
In England, 56% of women aged 35 to 44 and 62% of women aged 45 to 54 were classified as overweight or obese in 2013. Dame Sally says that the growing obesity problem is so serious that the government needs to make tackling obesity in the whole population a national priority.
The report encourages women not to suffer in silence about some of the problems they find embarrassing to talk about, such as incontinence or the menopause.
Urinary and faecal incontinence affects more than 5 million women in the UK and, along with prolapse, costs the NHS more than £200 million a year in treatment and support. Six weeks after pregnancy, 33% of women report urinary incontinence and 10% report faecal incontinence.
The CMO’s report also examines women’s cancers, particularly ovarian cancer. This is the second most common gynaecological cancer and the most lethal, with 6,483 women in England diagnosed with ovarian cancer in 2012 and 3,988 deaths in 2013. Survival in England and the UK is among the lowest in the OECD nations, with 5-year survival rates around 36%.