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  • Jun 09 / 2021
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Current Affairs, David McMahon

Delirium or dementia and does it matter?

Delirium and dementia are both conditions which result in a persons altered conscious. Delirium is a short term and sudden onset (hours or days) disturbance in cognition, with usually treatable causes. It is often linked to infections such as chest infections, urine infections or dehydration. This contrasts with dementia which has a slow and insidious onset (several months to years) and sadly to date has no proven cure.

So why would it be important for both researchers and health professionals to not be confused themselves about why a patient is confused?

The truth is by being clear ourselves about what an aetiology or process is, we are creating a research environment with the correct nomenclature, discourse, and standards to meaningfully make contributions to research, and communicate with fellow researchers in the field. The ultimate aim being to push our knowledge of the processes and pathophysiology forward. This is a real and present need in both delirium research and dementia research[1] [2].

As part of my MD, I looked at how delirium and dementia are clinically assessed in real healthcare settings by reviewing the current international clinical practice guidelines (CPGs) on this.  To do this we performed a systematic review of the literature and had pre-defined criteria for data extraction which yielded our CPGs to analysis. The current field had a relatively small number of CPGs addressing these important topics, and many drew on expert opinion rather than higher standards of evidence for their recommendations to clinicians.

Apart from the intrinsic value that research itself has, and the duty of clinicians to improve upon, and offer the best care, there are also compelling demographic and socio-economic reasons which I’ll discuss below.

Person/patient benefits:

While it is true that there are no current cures available for dementia, it is nonetheless still worth identifying. Diagnosing the disease or risk of disease early is still valuable, as it means that the individual and their carers have time to make choices and plan for the future, and allows access to treatments that can help manage symptoms such as the pharmacological intervention for depression, or agents designed to retard the dementias progression  [7]. It can also enable vital support for their carers.

Specifically, the detection of delirium (an acute disturbance in cognition) on its own, or superimposed with the others, allows a treatable condition (i.e., infection), or iatrogenic effect to be addressed.  This is critical, as for every 48 hours of delirium that pass, there is an 11% increase in mortality. This also enhances the likelihood a person returning to their prior functioning [8].

Demographically:

There is a rising ageing population (i.e., those adults aged 65 years old and above) in Scotland, the rest of UK, and internationally [3]. This rise is fuelling escalating rates of dementia globally, in a linear fashion in high income countries and exponentially in low and middle income countries [4]. Equally, although delirium can affect anyone it primarily affects older patients [2].

Socio-health economics:

The costs to society, and not just to the person with dementia, is stark. The total estimated worldwide costs of dementia were US$604 billion in 2010. Roughly 70% of the costs occurred in western Europe and North America. Within high-income regions, costs of informal care and the direct costs of social care contribute similar proportions of total costs with direct medical costs accounting for a much smaller share. On the other hand, in low- and middle-income countries, informal care accounts for the majority of total costs with direct social care costs being negligible [5]. What these economic costs do not factor in is the huge human costs of caring for a relative or friend with dementia.

The same review went on to say that “Despite first being described more than 2500 years ago, delirium remains frequently unrecognised and poorly understood”. In 2011 delirium “affect[ed as many] as 50% of elderly people (i.e., those aged 65 years or older) in hospital, and cost more than US$164 billion per year in the USA and more than $182 billion per year in 18 European countries combined.”.  Again, the metrics are glaring – delirium presents a huge financial challenge to healthcare systems.

Methods and Results:

Given its importance in these conditions, clinicians look to guidelines to inform the care they offer which should be drawn from evidence-based medicine​ (i.e., research). Below details the methods we use to search the relevant literature and the quality score the results before combining those results into a synthesis:

The stacked polar chart shows which CPGs scored on which domains of the AGREE quality tool (generally Scottish & UK guidelines scored well, whereas the Royal College of Physicians CPG did not):

Results-AGREE scored CPGs:  

Below is  a table of all the guidelines – what they recommend to do, broken up by how to use the recommendations into 3 categories and the grade of the evidence used to make that recommendation i.e green high, yellow moderate and red poor quality CPG. This is presented for delirium in table 1 and for dementia in table 2.

Table 1: CPG synthesis for delirium

Key:

Table 2: CPG synthesis for dementia

Conclusion:
– Answers to key clinical questions vague or not addressed
– Quality of evidence for recommendation predominantly expert opinion
– Discord between number dementia CPGs v importance of disease/prevalence & healthcare burden
– Limited geographic spread of dementia CPGs V delirium CPGs

Looking at the conclusions of our work, there are not many CPGs around how to assess cognition in dementia compared to delirium despite this huge global health burden; policy makers and public involvement in research priorities needed. There is a lack of primary research to base most recommendations on, and CPGs are not standard operating procedures for doctors to follow.    

References:

1.  The search for a cure for dementia is not going well but behavioural changes can reduce the risk of developing it: The Economist; 2020 [cited 2021 18/05/2021]; Aug 29th 2020 edition:[Available from: https://www.economist.com/special-report/2020/08/27/the-search-for-a-cure-for-dementia-is-not-going-well

2.  Delirium is prevalent in older hospital inpatients and associated with adverse outcomes: results of a prospective multi-centre study on World Delirium Awareness Day. BMC medicine. 2019;17:1-11.

3.  Economic UNDo, Affairs S. World Population Prospects: The 2010 Revision, Volume II-Demographic Profiles. UN; 2013.

4.  Nichols E, Szoeke CE, Vollset SE, et al. Global, regional, and national burden of Alzheimer’s disease and other dementias, 1990–2016: a systematic analysis for the Global Burden of Disease Study 2016. The Lancet Neurology. 2019;18(1):88-106.

5.  Wimo A, Jönsson L, Bond J, et al. The worldwide economic impact of dementia 2010. Alzheimers Dement. 2013 Jan;9(1):1-11.e3.

6. Inouye SK, Westendorp RG, Saczynski JS. Delirium in elderly people. Lancet. 2014 Mar 8;383(9920):911-22.

7. Rasmussen J, Langerman H. Alzheimer’s Disease – Why We Need Early Diagnosis. Degenerative neurological and neuromuscular disease. 2019;9:123-130.

8.  González M, Martínez G, Calderón J, et al. Impact of delirium on short-term mortality in elderly inpatients: a prospective cohort study. Psychosomatics. 2009 May-Jun;50(3):234-8.

  • Jun 04 / 2021
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Current Research, Dr Emily Long

A place-based and relational perspective on loneliness and social isolation

Dr Emily Long, MRC/CSO Social and Public Health Sciences Unit

Loneliness and social isolation are pressing concerns for population wellbeing within the UK, with their relevance particularly acknowledged since the onset of Covid-19. Loneliness is defined as the subjective emotional experience of an absence of desired social relationships, while social isolation refers to the objective quantity of social relationships and frequency of contact. Both loneliness and isolation have known associations with physical health, use of health care services, and confer an early mortality risk comparable to that from obesity or smoking. 

But what causes someone to be lonely or socially isolated? And are the risk factors different dependent on where someone lives? Rural areas, for example, face specific challenges related to loneliness and social isolation, including limited public transportation, digital access and exclusion, and practical constraints on facilitating relationships between people who live more remotely.  

Based within a social ecological framework, loneliness and social isolation are the product of multiple, interdependent domains of influence (e.g., individual, interpersonal, community, societal), wherein factors within different spheres mutually influence each other. Aspects of rural life that may have particular implications for loneliness and isolation are evaluated alongside a complex set of social ecological factors. In this way, differences in factors that drive loneliness or social isolation can be compared across rural and urban settings, while recognising that individual circumstances may mitigate or exacerbate place-based differences.  

Moreover, social network characteristics are known to relate to loneliness and isolation. Grounded in sociology and social network theory, social network analysis (SNA) captures the relational ties (known as ‘alters’) of an individual (known as an ‘ego’), including the ties between alters (i.e., network density), relational characteristics (e.g., supportiveness), and attributes (e.g., age) of those who comprise the social network. By incorporating these characteristics into statistical models, SNA can identify specific dimensions of relationships that relate to loneliness or isolation.  

Despite this potential, social network data have not been collected in large-scale surveys in the UK, limiting understanding of the dynamics between social networks and loneliness to generalizations from the US. As such, the extent to which the social networks of those experiencing loneliness differ from non-lonely individuals is unknown. Similarly, although rural communities face a unique social environment, it is unclear whether this translates to differences in social networks, and how this may relate to loneliness or isolation. 

Efforts to reduce loneliness and social isolation that fail to account for the impact of place, and the interconnections between place-based influences and personal circumstances, including social networks, risk ignoring critical avenues for prevention. Recent policy initiatives acknowledge this and urge for a place-based investigation of loneliness and isolation, explicitly highlighting the need for research in rural areas, including an assessment of differing risk factors compared to urban locations.  

In response, we are currently collecting data on social relationships and wellbeing among Scottish adults living in either Glasgow or the rural Highlands. This data will allow us to investigate place-based differences in loneliness and social isolation across the life span, examine links with mental health, and elucidate the patterns through which social connections impact loneliness. Stay tuned for our results. 

See further details on our study: http://bit.ly/connectionsstudy 

See the following references for further research on these topics. 

1. Department for Digital, Culture, Media & Sport (2018). 2.Valtorta, N. Heart (2016). 3.Valtorta, N. American Journal of Public Health (2018). 4. Holt-Lunstad, J. Perspectives of Psychological Science (2015). 5. Henning-Smith, Policy Brief (2018). 6. Santini, Z. Lancet Public Health (2020). 7. Bhavsar, V. PloS one (2019). 8. Department for Environment, Food & Rural Affairs (2019). 9. Scottish Government (2020). 10. Public Health England (2017). 11. Victor, C. BMC Public Health (2020). 

  • Apr 27 / 2021
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Authors, Rita Ibrahim

3MT Final 2021- MVLS- Diet and Genes: One Size Does Not Fit All

We are currently facing a global nutrition crisis whereby diseases such as obesity and Type 2 Diabetes are drastically increasing in prevalence. Diet plays a huge role in those diseases; however, currently there is no universal diet that provides the same benefit for everyone. My project aims to tackle the question of why we all respond to diets differently. One source of this variation is our DNA! I aim to look at how DNA, in different compartments of our cell: the nucleus and the mitochondria, communicate with each other and decide the health-outcome of a diet. I will be using fruit flies to conduct my experiments because humans share 75% of their disease-related genes with them. By understanding the interaction between the nucleus and mitochondria, we will have a better understanding of nutrition-related diseases such as type 2 diabetes and obesity. This will not only help us minimise the risk of those diseases in us but also in our children and generations to come.

Link to the video: 3MT Final 2021- Rita Ibrahim- MVLS- Diet and Genes: One Size Does Not Fit All

Source: Researcher Development University of Glasgow Youtube Page

  • Apr 06 / 2021
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Current Affairs, Sophie Westrop

The health inequalities experienced by women with intellectual disabilities: A need for more research.

I was asked to contribute to the IHAWKES special on “Women” as my PhD relates to gender differences in the physical activity and sedentary behaviour of adults with intellectual disabilities. However, I want to take this special as an opportunity to raise awareness of the health inequalities experienced by women with intellectual disabilities and express a need for more researchers to address this issue.

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  • Mar 31 / 2021
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Cara Richardson, Current Affairs

Understanding Suicide Risk in Men

Suicides in men outnumber women in almost every country in the world (Naghavi, 2019), with the exception of the 15-19 year age group. In Scotland males accounted for almost 75% of all suicide deaths in 2019 (ScotPHO, 2020). Each life lost to suicide is a preventable tragedy and more needs to be done to understand the risk factors in individuals who take their own life.

A well-known theory in this field is the Gender Paradox of Suicide (Canetto & Sakinofsky, 1998) where women are more likely to attempt suicide, but men are more likely to die by suicide. Due to this increased risk in men we need to understand which risk factors are particularly relevant in this group. Recent reviews (Franklin et al., 2017; O’Connor & Nock, 2014; Turecki & Brent, 2016; Turecki et al., 2019) have highlighted advances in our understanding of risk factors for suicide in men and women, yet our ability to predict suicide remains no better than chance.

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  • Mar 03 / 2021
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Current Affairs, Emily Tweed

NEW SUSTAINABLE TRAVEL GUIDANCE LAUNCHED: REFLECTIONS FROM A STEERING GROUP MEMBER

Almost exactly a year ago, I sat in Stirling train station on a brief break between meetings in Dundee and Glasgow, perched on a freezing metal bench and balancing my laptop, a headset, my mobile phone, and a cup of soup as I attempted to join a meeting of the Sustainable Business Travel working group. The topic? How we could encourage University of Glasgow colleagues to use Zoom as an alternative to in-person meetings.

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  • Dec 18 / 2020
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Alexandra Rose, Current Research, Uncategorized

RESEARCHER SHOWCASE: Alexandra Rose and The assessment of mood after severe brain injury

Alexandra Rose (CPsychol) is a Principal Clinical Psychologist based in a London hospital, working with patients with brain injury. Her research is focused on understanding the assessment of mood, depression and distress after severe brain injury. She is supervised by Professor Jonathan Evans and Dr Breda Cullen. Alex is in the 2nd year of pursuing her PhD in Psychological Medicine. She is studying remotely whilst continuing her clinical work and is being assisted financially by a Francis Newman Foundation grant.  The following is part of her project exploring the assessment of mood after severe brain injury.

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  • Dec 17 / 2020
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Current Research, Warut Aunjitsakul

RESEARCHER SHOWCASE: Warut Aunjitsakul and maintenance mechanisms of social anxiety disorder in people with psychosis

Warut Aunjitsakul is a psychiatrist and clinical instructor from Prince of Songkla University, Thailand and very keen to develop theoretical understanding and improve psychological intervention in people with psychosis. He is now pursuing his PhD in Psychological Medicine.  

The following is part of Warut’s PhD project aiming to understand the maintenance mechanisms of social anxiety disorder in people with psychosis. 

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