The cognitive impact of anticholinergics:a clinical review

Context: The cognitive side effects of medications with anticholinergic activity have been documented among older adults in a variety of clinical settings. However, there has been no systematic confirmation that acute or chronic prescribing of such medications lead to transient or permanent adverse cognitive outcomes. Objective: Evaluate the existing evidence regarding the effects of anticholinergic medications on cognition in older adults. Data sources: We searched the MEDLINE, OVID, and CINAHL databases from January, 1966 to January, 2008 for eligible studies. Study selection: Studies were included if the anticholinergic activity was systematically measured and correlated with standard measurements of cognitive performance. Studies were excluded if they reported case studies, case series, editorials, and review articles. Data extraction: We extracted the method used to determine anticholinergic activity of medications and its association with cognitive outcomes. Results: Twenty-seven studies met our inclusion criteria. Serum anticholinergic assay was the main method used to determine anticholinergic activity. All but two studies found an association between the anticholinergic activity of medications and either delirium, cognitive impairment or dementia. Conclusions: Medications with anticholinergic activity negatively affect the cognitive performance of older adults. Recognizing the anticholinergic activity of certain medications may represent a potential tool to improve cognition.

Model evaluation and case series data

We discuss aggregation of data from neuropsychological patients and the process of evaluating models using data from a series of patients. We argue that aggregation can be misleading but not aggregating can also result in information loss. The basis for combining data needs to be theoretically defined, and the particular method of aggregation depends on the theoretical question and characteristics of the data. We present examples, often drawn from our own research, to illustrate these points. We also argue that statistical models and formal methods of model selection are a useful way to test theoretical accounts using data from several patients in multiple-case studies or case series. Statistical models can often measure fit in a way that explicitly captures what a theory allows; the parameter values that result from model fitting often measure theoretically important dimensions and can lead to more constrained theories or new predictions; and model selection allows the strength of evidence for models to be quantified without forcing this into the artificial binary choice that characterizes hypothesis testing methods. Methods that aggregate and then formally model patient data, however, are not automatically preferred to other methods. Which method is preferred depends on the question to be addressed, characteristics of the data, and practical issues like availability of suitable patients, but case series, multiple-case studies, single-case studies, statistical models, and process models should be complementary methods when guided by theory development.

Beyond maternal death: improving the quality of maternal care through national studies of ‘near-miss’ maternal morbidity

Knight M, Acosta C, Brocklehurst P, Cheshire A, Fitzpatrick K, Hinton L, Jokinen M, Kemp B, Kurinczuk JJ, Lewis G, Lindquist A, Locock L, Nair M, Patel N, Quigley M, Ridge D, Rivero-Arias O, Sellers S, Shah A on behalf of the UKNeS coapplicant group. Background Studies of maternal mortality have been shown to result in important improvements to women’s health. It is now recognised that in countries such as the UK, where maternal deaths are rare, the study of near-miss severe maternal morbidity provides additional information to aid disease prevention, treatment and service provision. Objectives To (1) estimate the incidence of specific near-miss morbidities; (2) assess the contribution of existing risk factors to incidence; (3) describe different interventions and their impact on outcomes and costs; (4) identify any groups in which outcomes differ; (5) investigate factors associated with maternal death; (6) compare an external confidential enquiry or a local review approach for investigating quality of care for affected women; and (7) assess the longer-term impacts. Methods Mixed quantitative and qualitative methods including primary national observational studies, database analyses, surveys and case studies overseen by a user advisory group. Setting Maternity units in all four countries of the UK. Participants Women with near-miss maternal morbidities, their partners and comparison women without severe morbidity. Main outcome measures The incidence, risk factors, management and outcomes of uterine rupture, placenta accreta, haemolysis, elevated liver enzymes and low platelets (HELLP) syndrome, severe sepsis, amniotic fluid embolism and pregnancy at advanced maternal age (≥ 48 years at completion of pregnancy); factors associated with progression from severe morbidity to death; associations between severe maternal morbidity and ethnicity and socioeconomic status; lessons for care identified by local and external review; economic evaluation of interventions for management of postpartum haemorrhage (PPH); women’s experiences of near-miss maternal morbidity; long-term outcomes; and models of maternity care commissioned through experience-led and standard approaches. Results Women and their partners reported long-term impacts of near-miss maternal morbidities on their physical and mental health. Older maternal age and caesarean delivery are associated with severe maternal morbidity in both current and future pregnancies. Antibiotic prescription for pregnant or postpartum women with suspected infection does not necessarily prevent progression to severe sepsis, which may be rapidly progressive. Delay in delivery, of up to 48 hours, may be safely undertaken in women with HELLP syndrome in whom there is no fetal compromise. Uterine compression sutures are a cost-effective second-line therapy for PPH. Medical comorbidities are associated with a fivefold increase in the odds of maternal death from direct pregnancy complications. External reviews identified more specific clinical messages for care than local reviews. Experience-led commissioning may be used as a way to commission maternity services. Limitations This programme used observational studies, some with limited sample size, and the possibility of uncontrolled confounding cannot be excluded. Conclusions Implementation of the findings of this research could prevent both future severe pregnancy complications as well as improving the outcome of pregnancy for women. One of the clearest findings relates to the population of women with other medical and mental health problems in pregnancy and their risk of severe morbidity. Further research into models of pre-pregnancy, pregnancy and postnatal care is clearly needed.

Terapia de aceptación y compromiso en un caso de tras¬torno mixto de ansiedad y depresión en una paciente con cáncer

This paper introduces the case of a woman with breast cancer who had developed a mixed depressive-anxiety disorder with avoidance behaviors. The patient presented depressive symptoms like listlessness, insomnia, weeping, food disorders and hopelessness though. Also, she exhibited physiological arousal and restlessness feelings. Additionally, the patient had an avoidance patron behavior in relation with all stimulus she believed could hurt her. Based on the Acceptance and Commitment Therapy (ACT) the intervention planted the following objectives: the patient will learn to accept her illness and the emotional distress that she was experiencing, also, the patient will recover the other areas of her life that she had abandoned. The treatment was developed in 14 sessions. The therapist used these techniques: creative hopelessness, disabling verbal functions, values clarification and loss of control over private events. In the results, it was observed a positive change in the behavior of the patient as well as a decrease in emotional distress that was his reason for initial consultation

Intervenção psicomotora em saúde mental em contexto hospitalar : Centro Hospitalar Trás-os-Montes e Alto Douro, EPE

O presente relatório descreve as atividades de estágio desenvolvidas no âmbito do Mestrado em Reabilitação Psicomotora, Ramo de Aprofundamento de Competências Profissionais, da Faculdade de Motricidade Humana, realizado no Centro Hospitalar Trás-os-Montes e Alto Douro, EPE. O estágio profissionalizante desenvolveu-se em 3 áreas, o Internamento de Agudos, a Psiquiatria e a Psiquiatria da Infância e Adolescência existindo avaliações psicomotoras, bem como intervenções com crianças, adolescentes e adultos, na área da saúde mental. O relatório expõe dois estudos-caso, demonstrando o trabalho desenvolvido, somando um enquadramento teórico, legal e institucional atual, bem como uma reflexão acerca da experiência de estágio. O primeiro estudo-caso remete para uma utente com Doença de Coreia de Huntington e o segundo estudo-caso refere-se a uma criança com atraso global do desenvolvimento psicomotor. Para cada estudo-caso é descrito todo o processo de avaliação, objetivos, programa terapêutico, resultados e conclusões. Da mencionada intervenção foi possível verificar melhorias, tanto a nível psicomotor, como cognitivo e sócio-emocional, demonstrando a importância da terapia psicomotora no contexto de saúde mental. As intervenções delineadas são elaboradas em equipa multidisciplinar para uma melhor compreensão do indivíduo. No final é realizado uma crítica a todos os níveis.

Depresión en pacientes con epilepsia: Revisión sistemática de la literatura

Esta revisión sistemática de la literatura tuvo como objetivo investigar sobre la depresión en personas con epilepsia en la última década (2005-2015), enfocándose en identificar en el paciente con epilepsia: características sociodemográficas, prevalencia de la depresión, tipos de intervención para el manejo de la depresión, factores asociados con la aparición y el mantenimiento de la depresión y por último, identificar las tendencias en investigación en el estudio de la depresión en pacientes con epilepsia. Se revisaron 103 artículos publicados entre 2005 y 2015 en bases de datos especializadas. Los resultados revelaron que la prevalencia de depresión en pacientes con epilepsia es diversa y oscila en un rango amplio entre 3 y 70 %, por otro lado, que las principales características sociodemográficas asociadas a la depresión está el ser mujer, tener un estado civil soltero y tener una edad comprendida entre los 25 y los 45 años. A esto se añade, que los tratamientos conformados por terapia psicológica y fármacos, son la mejor opción para garantizar la eficacia en los resultados del manejo de la depresión en los pacientes con epilepsia. Con respecto a los factores asociados a la aparición de la depresión en pacientes con epilepsia, se identificaron causas tanto neurobiológicas como psicosociales, asimismo los factores principales asociados al mantenimiento fueron una percepción de baja calidad de vida y una baja auto-eficacia. Y finalmente los tipos de investigación más comunes son de tipo aplicado, de carácter descriptivo, transversales y de medición cuantitativa.

Business Process Redesign in Information Technology Incident Management: A teaching case

This paper consists of a detailed case narrative on how a leading Australian Finance organisation has utilised contemporary Business Process Management (BPM) concepts for improving the IT incident management processes within the whole organisation. The target audience includes practitioners who are interested in BPM case studies and Academics who may be seeking case studies for innovative teaching practices.

IT service desk process improvement : a narrative style case study

This paper is a detailed case narrative on how a Faculty of a leading Australian University conducted a rigorous process improvement project, applying fundamental Business Process Management (BPM) concepts. The key goal was to increase the efficiency of the faculty’s service desk. The decrease of available funds due to reducing student numbers and the ever increasing costs associated with service desk prompted this project. The outcomes of the project presented a set of recommendations which leads to organizational innovation having information technology as an enabler for change. The target audience includes general BPM practitioners or academics who are interested in BPM related case studies, and specific organisations who might be interested in conducting BPM within their service desk processes.

Case study of collaborative learning in two contexts : what do English language learners gain?

This chapter describes the use of collaborative learning as an approach to enhance English language learning by students from non-English speaking backgrounds. Communicative Language Teaching (CLT) principles were applied to two case studies, one comprising of undergraduate English as Foreign Language Learners in Turkey and the other involved English as Second Language learners in Australia. Social constructivism inspired communicative language teaching using collaborative learning activities such as team work, interactive peer-based learning, and iterative stages of learning matrix were incorporated to enhance students' learning outcomes. Data collected after the CLT intervention was made up of field notes, reflective logs and focus group interviews which revealed complementarities, as well as subtle differences between the two cases. The findings were summarized as learning dispositions; speaking fluency and confidence; learning diagnostics and completion deficiencies; task engagement, flow theory and higher order thinking skills; in addition to self efficacy and development of student identity. CLT has the potential to provide a more inclusive and dynamic education for diverse learners through vital outcomes and benefits which resonate with the real world.

Application of cognitive-behavioural family intervention for schizophrenia in multidisciplinary teams : what can the matter be?

Surveyed 45 therapists who had participated in a family intervention for schizophrenia training program to examine the difficulties they had encountered, their recall of the intervention strategies, and the extent that they thought the approach had become integrated in their everyday work. Between 6 mo and 3 yrs after the family training, Ss reported the number of families they had systematically treated, and the difficulties they had encountered. Allowance of time to undertake the intervention, afterhours scheduling, and illness or holidays presented particular difficulties. Only 4% reported that their knowledge of behavioral techniques was a problem, but in a written test most therapists did not display minimum recall of the material of cognitive therapy, social skills training, or behavioral strategies. The study demonstrated significant problems in disseminating cognitive-behavioral approaches to multidisciplinary settings.

An evaluation framework for educational reform projects for teacher quality improvements in developing countries : a case study of Egyptian education reform

The role of the evaluation for Official Development Assistance (ODA) enterprises including educational development has become critical after increasing “aid fatigue” experienced by the international community in the 1990s. To date, however, monitoring and evaluating outcomes of the projects has been limited to the project life. Consequently these have been mainly through the international aid agencies. Furthermore, the monitoring and evaluation led by international aid agencies have paid little attention to aspects of the sustainability of technical cooperation in educational development. To sustain the impact of technical cooperation, the reinforcement of evaluation has drawn increasing attention in light of the emerging modalities in international development. Therefore this research was inspired to investigate alternative evaluation frameworks for an educational reform project for teacher quality improvement that may increase possibilities for long term sustainability. Importantly, the new modalities in international development and educational issues provide new options. In addition, the research reviewed theoretical and practical issues surrounding evaluation in general, and highlighted the evaluation of education reform projects. The research reported explored via case studies, the evaluation processes employed by the Egyptian education reform projects implemented by the Japan International Cooperation Agency (JICA) and the United Nations Children’s Fund (UNICEF). The case studies used three data sources (archival and relevant documents, a survey questionnaire and interviews) to illuminate the contextually-embedded evaluation processes. The research found that process evaluation is a potential alternative method since it is likely to be locally institutionalised, which may yield long-term sustainability of the projects.

Creativity, culture and tourism : the case of Istanbul and London film industries

During the last decade many cities have sought to promote creativity as a driver for economic growth. They have done this by encouraging specific sectors of creative industries. This paper focuses on the film industry as one of these sectors which also has a high level of interaction with place. Film industry, has had an important role in incubating the creativity potential. It can be a powerful magnet for creative people, fostering indigenous creativity and attracting outside talent, and might thus contribute to the formation of creative cities. This recent research suggests that the film industry has positively effect on tourism by increasing place recognition through the locations used in films and for cities that host film festivals. Film festivals provide events, workshops and experiences that allow visitors to express themselves through interaction with the place and its living culture. This paper examines the importance of creative industries for both urban development and sustainable tourism. To explore the relation between creative tourism, culture and the film industry and its effect on successful tourism planning this paper presents the preliminary findings of case studies of the film industry in Beyo

Printmaking as an expanding field in contemporary art practice : a case study of Japan, Australia and Thailand

This thesis proposes that contemporary printmaking, at its most significant, marks the present through reconstructing pasts and anticipating futures. It argues this through examples in the field, occurring in contexts beyond the Euramerican (Europe and North America). The arguments revolve around how the practice of a number of significant artists in Japan, Australia and Thailand has generated conceptual and formal innovations in printmaking that transcend local histories and conventions, whilst paradoxically, also building upon them and creating new meanings. The arguments do not portray the relations between contemporary and traditional art as necessarily antagonistic but rather, as productively dialectical. Furthermore, the case studies demonstrate that, in the 1980s and 1990s particularly, the studio practice of these printmakers was informed by other visual arts disciplines and reflected postmodern concerns. Departures from convention witnessed in these countries within the Asia-Pacific region shifted the field of the print into a heterogeneous and hybrid realm. The practitioners concerned (especially in Thailand) produced work that was more readily equated with performance and installation art than with printmaking per se. In Japan, the incursion of photography interrupted the decorative cast of printmaking and delivered it from a straightforward, craft-based aesthetic. In Australia, fixed notions of national identity were challenged by print practitioners through deliberate cultural rapprochements and technical contradictions (speaking across old and new languages).However time-honoured print methods were not jettisoned by any case study artists. Their re-alignment of the fundamental attributes of printmaking, in line with materialist formalism, is a core consideration of my arguments. The artists selected for in-depth analysis from these three countries are all innovators whose geographical circumstances and creative praxis drew on local traditions whilst absorbing international trends. In their radical revisionism, they acknowledged the specificity of history and place, conditions of contingency and forces of globalisation. The transformational nature of their work during the late twentieth century connects it to the postmodern ethos and to a broader artistic and cultural nexus than has hitherto been recognised in literature on the print. Emerging from former guild-based practices, they ambitiously conceived their work to be part of a continually evolving visual arts vocabulary. I argue in this thesis that artists from the Asia-Pacific region have historically broken with the hermetic and Euramerican focus that has generally characterised the field. Inadequate documentation and access to print activity outside the dominant centres of critical discourse imply that readings of postmodernism have been too limited in their scope of inquiry. Other locations offer complexities of artistic practice where re-alignments of customary boundaries are often the norm. By addressing innovative activity in Japan, Australia and Thailand, this thesis exposes the need for a more inclusive theoretical framework and wider global reach than currently exists for ‘printmaking’.

Resolving painful emotional experience during psychodrama

Unresolved painful emotional experiences such as bereavement, trauma and disturbances in core relationships, are common presenting problems for clients of psychodrama or psychotherapy more generally. Emotional pain is experienced as a shattering of the sense of self and disconnection from others and, when unresolved, produces avoidant responses which inhibit the healing process. There is agreement across therapeutic modalities that exposure to emotional experience can increase the efficacy of therapeutic interventions. Moreno proposes that the activation of spontaneity is the primary curative factor in psychodrama and that healing occurs when the protagonist (client) engages with his or her wider social system and develops greater flexibility in response to that system. An extensive case-report literature describes the application of the psychodrama method in healing unresolved painful emotional experiences, but there is limited empirical research to verify the efficacy of the method or to identify the processes that are linked to therapeutic change. The purpose of this current research was to construct a model of protagonist change processes that could extend psychodrama theory, inform practitioners’ therapeutic decisions and contribute to understanding the common factors in therapeutic change. Four studies investigated protagonist processes linked to in-session resolution of painful emotional experiences. Significant therapeutic events were analysed using recordings and transcripts of psychodrama enactments, protagonist and director recall interviews and a range of process and outcome measures. A preliminary study (3 cases) identified four themes that were associated with helpful therapeutic events: enactment, the working alliance with the director and with group members, emotional release or relief and social atom repair. The second study (7 cases) used Comprehensive Process Analysis (CPA) to construct a model of protagonists’ processes linked to in-session resolution. This model was then validated across four more cases in Study 3. Five meta-processes were identified: (i) a readiness to engage in the psychodrama process; (ii) re-experiencing and insight; (iii) activating resourcefulness; (iv) social atom repair with emotional release and (v) integration. Social atom repair with emotional release involved deeply experiencing a wished-for interpersonal experience accompanied by a free flowing release of previously restricted emotion and was most clearly linked to protagonists’ reports of reaching resolution and to post session improvements in interpersonal relationships and sense of self. Acceptance of self in the moment increased protagonists’ capacity to generate new responses within each meta-process and, in resolved cases, there was evidence of spontaneity developing over time. The fourth study tested Greenberg’s allowing and accepting painful emotional experience model as an alternative explanation of protagonist change. The findings of this study suggested that while the process of allowing emotional pain was present in resolved cases, Greenberg’s model was not sufficient to explain the processes that lead to in-session resolution. The protagonist’s readiness to engage and activation of resourcefulness appear to facilitate the transition from problem identification to emotional release. Furthermore, experiencing a reparative relationship was found to be central to the healing process. This research verifies that there can be in-session resolution of painful emotional experience during psychodrama and protagonists’ reports suggest that in-session resolution can heal the damage to the sense of self and the interpersonal disconnection that are associated with unresolved emotional pain. A model of protagonist change processes has been constructed that challenges the view of psychodrama as a primarily cathartic therapy, by locating the therapeutic experience of emotional release within the development of new role relationships. The five meta-processes which are described within the model suggest broad change principles which can assist practitioners to make sense of events as they unfold and guide their clinical decision making in the moment. Each meta-process was linked to specific post-session changes, so that the model can inform the development of therapeutic plans for individual clients and can aid communication for practitioners when a psychodrama intervention is used for a specific therapeutic purpose within a comprehensive program of therapy.