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.