Development and Application of Medication Appropriateness Indicators for Persons with Advanced Dementia: A Feasibility Study

Background: No studies have been conducted in the UK context to date that categorise medications in terms of appropriateness for patients with advanced dementia, or that examine medication use in these vulnerable patients.

Objectives: The objectives of this study were to categorise the appropriateness of a comprehensive list of medications and medication classes for use in patients with advanced dementia; examine the feasibility of conducting a longitudinal prospective cohort study to collect clinical and medication use data; and determine the appropriateness of prescribing for nursing home residents with advanced dementia in Northern Ireland (NI), using the categories developed.

Methods: A three-round Delphi consensus panel survey of expert clinicians was used to categorise the appropriateness of medications for patients with advanced dementia [defined as having Functional Assessment Staging (FAST) scores ranging from 6E to 7F]. This was followed by a longitudinal prospective cohort feasibility study that was conducted in three nursing homes in NI. Clinical and medication use for participating residents with advanced dementia (FAST scores ranging from 6E to 7F) were collected and a short test of dementia severity administered. These data were collected at baseline and every 3 months for up to 9 months or until death. For those residents who died during the study period, data were also collected within 14 days of death. The appropriateness ratings from the consensus panel survey were retrospectively applied to residents’ medication data at each data collection timepoint to determine the appropriateness of medications prescribed for these residents.

Results: Consensus was achieved for 87 (90 %) of the 97 medications and medication classes included in the survey. Fifteen residents were recruited to participate in the longitudinal prospective cohort feasibility study, four of whom died during the data collection period. Mean numbers of medications prescribed per resident were 16.2 at baseline, 19.6 at 3 months, 17.4 at 6 months and 16.1 at 9 months. Fourteen residents at baseline were taking at least one medication considered by the consensus panel to be never appropriate, and approximately 25 % of medications prescribed were considered to be never appropriate. Post-death data collection indicated a decrease in the proportion of never appropriate medications and an increase in the proportion of always appropriate medications for those residents who died.

Conclusions: This study is the first to develop and apply medication appropriateness indicators for patients with advanced dementia in the UK setting. The Delphi consensus panel survey of expert clinicians was a suitable method of developing such indicators. It is feasible to collect information on quality of life, functional performance, physical comfort, neuropsychiatric symptoms and cognitive function for this subpopulation of nursing home residents with advanced dementia.

Energy and environmental forensic analysis for public buildings.

This paper outlines a forensic method for analysing the energy, environmental and comfort performance of a building. The method has been applied to a recently developed event space in an Irish public building, which was evaluated using on-site field studies, data analysis, building simulation and occupant surveying. The method allows for consideration of both the technological and anthropological aspects of the building in use and for the identification of unsustainable operational practice and emerging problems. The forensic analysis identified energy savings of up to 50%, enabling a more sustainable, lower-energy operational future for the building. The building forensic analysis method presented in this paper is now planned for use in other public and commercial buildings.

Evidential event inference in transport video surveillance

This paper presents a new framework for multi-subject event inference in surveillance video, where measurements produced by low-level vision analytics usually are noisy, incomplete or incorrect. Our goal is to infer the composite events undertaken by each subject from noise observations. To achieve this, we consider the temporal characteristics of event relations and propose a method to correctly associate the detected events with individual subjects. The Dempster–Shafer (DS) theory of belief functions is used to infer events of interest from the results of our vision analytics and to measure conflicts occurring during the event association. Our system is evaluated against a number of videos that present passenger behaviours on a public transport platform namely buses at different levels of complexity. The experimental results demonstrate that by reasoning with spatio-temporal correlations, the proposed method achieves a satisfying performance when associating atomic events and recognising composite events involving multiple subjects in dynamic environments.

Experimental investigation of thermal inertia properties in hemp-lime concrete walls

Hemp-lime concrete is a sustainable alternative to standard building wall materials, with low associated embodied energy. It exhibits good hygric, acoustic and thermal properties, making it an exciting, sustainable building envelope material. When cast in temporary shuttering around a timber frame, it exhibits lower thermal conductivity than concrete, and consequently achieves low U-values in a primarily mono-material wall construction. Although cast relatively thick hemp-lime walls do not generally achieve the low U-values stipulated in building regulations. However assessment of its thermal performance through evaluation of its resistance to thermal transfer alone, underestimates its true thermal quality. The thermal inertia, or reluctance of the wall to change its temperature when exposed to changing environmental temperatures, also has a significant impact on the thermal quality of the wall, the thermal comfort of the interior space and energy consumption due to space heating. With a focus on energy reduction in buildings, regulations emphasise thermal resistance to heat transfer with only less focus on thermal inertia or storage benefits due to thermal mass. This paper investigates dynamic thermal responsiveness in hemp-lime concrete walls. It reports the influence of thermal conductivity, density and specific heat through analysis of steady state and transient heat transfer, in the walls. A novel hot-box design which isolates the conductive heat flow is used, and compared with tests in standard hot-boxes. Thermal diffusivity and effusivity are evaluated, using experimentally measured conductivity, based on analytical relationships. Experimental results evident that hemp-lime exhibits high thermal inertia. They show the thermal inertia characteristics compensate for any limitations in the thermal resistance of the construction material. When viewed together the thermal resistance and mass characteristics of hemp-lime are appropriate to maintain comfortable thermal indoor conditions and low energy operation.

Assessment of the impact speed and angle conditions for the EN1317 barrier tests

Roadside safety barriers designs are tested with passenger cars in Europe using standard EN1317 in which the impact angle for normal, high and very high containment level tests is 20°. In comparison to EN1317, the US standard MASH has higher impact angles for cars and pickups (25°) and different vehicle masses. Studies in Europe (RISER) and the US have shown values for the 90th percentile impact angle of 30°–34°. Thus, the limited evidence available suggests that the 20° angle applied in EN 1317 may be too low.
The first goal of this paper is to use the US NCHRP database (Project NCHRP 17–22) to assess the distribution of impact angle and collision speed in recent ROR accidents. Second, based on the findings of the statistical analysis and on analysis of impact angles and speeds in the literature, an LS-DYNA finite element analysis was carried out to evaluate the normal containment level of concrete barriers in non-standard collisions. The FE model was validated against a crash test of a portable concrete barrier carried out at the UK Transport Research Laboratory (TRL).
The accident data analysis for run-off road accidents indicates that a substantial proportion of accidents have an impact angle in excess of 20°. The baseline LS-DYNA model showed good comparison with experimental acceleration severity index (ASI) data and the parametric analysis indicates a very significant influence of impact angle on ASI. Accordingly, a review of European run-off road accidents and the configuration of EN 1317 should be performed.

Predicting impact damage, residual strength and crashworthiness of composite structures

The development of the latest generation of wide-body carbon-fibre composite passenger aircraft has heralded a new era in the utilisation of these materials. The premise of superior specific strength and stiffness, corrosion and fatigue resistance, is tempered by high development costs, slow production rates and lengthy and expensive certification programmes. Substantial effort is currently being directed towards the development of new modelling and simulation tools, at all levels of the development cycle, to mitigate these shortcomings. One of the primary challenges is to reduce the extent of physical testing, in the certification process, by adopting a ‘certification by simulation’ approach. In essence, this aspirational objective requires the ability to reliably predict the evolution and progression of damage in composites. The aerospace industry has been at the forefront of developing advanced composites modelling tools. As the automotive industry transitions towards the increased use of composites in mass-produced vehicles, similar challenges in the modelling of composites will need to be addressed, particularly in the reliable prediction of crashworthiness. While thermoset composites have dominated the aerospace industry, thermoplastics composites are likely to emerge as the preferred solution for meeting the high-volume production demands of passenger road vehicles. This keynote presentation will outline recent progress and current challenges in the development of finite-element-based predictive modelling tools for capturing impact damage, residual strength and energy absorption capacity of thermoset and thermoplastic composites for crashworthiness assessments.