Advance care planning for people living with dementia: An umbrella review of effectiveness and experiences

© 2020 The Author(s). This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).Abstract Background: End of life care is often inadequate for people with dementia. Advanced care planning (ACP) has the potential to improve outcomes for people with dementia. The aim of this review is to establish the strength of the evidence and provide decision makers with a clear understanding of what is known about ACP for people living with dementia.Design: Evidence synthesis including systematic reviews and primary studies. PROSPERO registration: CRD42018107718. Data sources: PubMed, CINAHL Plus, SCOPUS, Social Care Online and Cochrane Library were searched (July 2018). No year limit applied. To be included, reviews had to evaluate effectiveness of ACP for people with dementia or report on views and experiences of ACP from the perspective of people with dementia, carers, or health and care professionals. Additional searches (September 2018) were conducted to identify recent primary studies not included in the reviews.Review methods: Data extraction was undertaken by one reviewer and checked by a second. Methodological quality was assessed using AMSTAR-2 and Joanna Briggs Institute instruments by two authors independently. Outcomes were categorized and tabulated to assess effectiveness. Qualitative data was analysed using thematic synthesis.Results: Nineteen reviews (163 unique studies) and 11 primary articles with a range of advance care planning definitions and of variable quality were included. Advance care planning was associated with decreased hospitalizations, increased concordance between care received and prior wishes and increased completion of advance care planning documents but quality of primary research was variable. Views of ACP for people with dementia can be clustered around six themes; 1) timing and tailoring, 2) willingness to engage, 3) roles and responsibilities of healthcare professionals, 4) relationships, 5) training and 6) resources needed. The diminishing decision-making capacity over time is a key overarching feature.Conclusions: Advance care planning is acceptable for people with dementia and their carers and is associated with improved outcomes. Guidelines on which outcomes and which definition to use are necessary, as is research to test different approaches to ACP. Education on topics related to diminishing decision-making capacity is key to optimize advance care planning for people with dementia and their carers.Peer reviewe

Palliative care for people with dementia living at home: a systematic review of interventions

Background: The European Association for Palliative Care White Paper defined optimal palliative care in dementia based on evidence and expert consensus. Yet, we know little on how to achieve this for people with dementia living and dying at home. Aims: To examine evidence on home palliative care interventions in dementia, in terms of their effectiveness on end-of-life care outcomes, factors influencing implementation, the extent to which they address the European Association for Palliative Care palliative care domains and evidence gaps. Design: A systematic review of home palliative care interventions in dementia. Data sources: The review adhered to the PRISMA guidelines and the protocol was registered with PROSPERO (CRD42018093607). We searched four electronic databases up to April 2018 (PubMed, Scopus, Cochrane library and CINAHL) and conducted lateral searches. Results: We retrieved eight relevant studies, none of which was of high quality. The evidence, albeit of generally weak quality, showed the potential benefits of the interventions in improving end-of-life care outcomes, for example, behavioural disturbances. The interventions most commonly focused on optimal symptom management, continuity of care and psychosocial support. Other European Association for Palliative Care domains identified as important in palliative care for people with dementia, for example, prognostication of dying or avoidance of burdensome interventions were under-reported. No direct evidence on facilitators and barriers to implementation was found. Conclusions: The review highlights the paucity of high-quality dementia-specific research in this area and recommends key areas for future work, for example, the need for process evaluation to identify facilitators and barriers to implementing interventions.Peer reviewedFinal Published versio

Corporate Social Responsibility: A Cross Sectional Examination of Incentivization

This study examined corporate social responsibility and the most effective ways to incentivize environmentally proactive behavior among federal production contractors. The goal was to isolate factors which have the greatest potential for encouraging corporate environmental responsibility and to use the knowledge gained to construct incentives which can be incorporated into federal contracts. Relying on the concepts developed in organizational theory, four theories were presented to provide support that organizational behavior can be influenced. Previous incentive techniques used by the government were also investigated. From the initial research, a model was developed to describe the relationship between incentives and environmental responsibility. Personal interviews with individuals involved in the acquisition process and review of various contract documents were conducted. An informal interview guide was used to interview government contracting officers, environmental engineers, and contractors associated with two System Project Offices. Interviews with high level policy makers were also conducted. Analysis of the data suggest that incentives do work; however, based on the theories of Transaction Cost Economics, policy incentives appear to be more effective than contract incentives at producing the kind of organizational environmental awareness the government is looking for from its contractors

Writing Across Campus: Using Authentic Writing Experiences to Help Pre-Service Teachers Learn to Teach Writing

This study demonstrates the impact asynchronous discussion boards had on cross-college preservice teachers writing and writing instruction understanding. Participants from two universities in writing methods courses participated in discussion boards to learn about writing instruction. Students in the groups not only asked higher-level depth of knowledge questions to each other, but they also began to focus their responses and comments about their future teaching and instructional practices. Students built a stronger community of writers than students in previous courses that read, responded, and replied to peers

Die funktionelle Rolle von Diaphanous verwandten Forminen in der Zellmigration

To characterize the role of mDia2/Drf3 in mammalian cells, an EGFP-tagged active Drf3 variant, lacking the C-terminal DAD-domain (Drf3ΔDAD), was generated. Expression of EGFP-Drf3ΔDAD in B16-F1 mouse melanoma cells strongly induced the formation of filopodia tipped by the formin. Interestingly, Drf3ΔDAD–containing filopodia frequently thickened at their tips after protruding beyond the cell periphery. Yet, actin filament spacing in these filopodia was largely independent of filopodial width, as determined by electron microscopy. In addition to that, Drf3ΔDAD levels and F-actin amounts showed a linear correlation in these filopodia tips. Thus, thickening of Drf3ΔDAD-induced filopodia tips occurs through de novo actin filament nucleation. This indicates nucleation of actin filaments to be the predominant mechanism of actin filament generation in filopodia, rather than simple elongation of pre-existing lamellipodial filaments. FMNL2 emerged as potential additional regulator of filopodia, but also lamellipodia formation. Active EGFP-tagged FMNL2 was strongly enriched at the tips of protruding lamellipodia and filopodia in B16-F1 cells. FMNL2 interacted with active Cdc42 and Rac1 in vitro. Interestingly, co-expression of Cdc42, but not Rac, was sufficient to mediate accumulation of EGFP-tagged FMNL2 at the tips of lamellipodia and filopodia. In addition, FMNL2 appeared to be regulated by N-terminal myristoylation. Although myristoylation was not essential for interaction of the formin with Cdc42 and proper subcellular targeting, both the lipid modification and active Cdc42 contribute to localisation and activation by counteracting autoinhibition. In vitro polymerisation assays indicated that FMNL2 does not promote actin filament nucleation, but instead elongation powered by profilin. In vivo the presence of FMNL2 was relevant for efficient cell motility, significantly expanding the repertoire of Cdc42 effectors directly promoting actin filament assembly in migration.Filopodien sind protrusive Strukturen, die aus Bündeln von unverzweigten Aktinfilamenten bestehen. Um die funktionelle Rolle des Diaphanous verwandten Formins Drf3 in der Filopodienbildung genauer zu charakterisieren wurde durch Deletion der DAD-Domäne ein konstitutiv aktives Drf3 (Drf3ΔDAD) hergestellt. Expression von Drf3ΔDAD in B16-F1 Mausmelanomzellen induzierte die Bildung von Filopodien, an deren Spitze das Formin angereichert war. In einigen Fällen konnte beobachtet werden, dass sich Drf3ΔDAD induzierte Filopodien verdickten, nachdem sie das umgebende Aktinnetzwerk verlassen hatten. Elektronenmikroskopische Untersuchungen ergaben, dass dieses auf eine erhöhte Anzahl an Aktinfilamenten in der Spitze der Filopodien zurückzuführen war, wobei die Packdichte konstant blieb. Außerdem bestand eine lineare Korrelation von F-Aktin zu Drf3ΔDAD. Zusammengenommen zeigt dieses, dass das Verdicken der Filopodien durch de novo Nukleation von Aktinfilamenten zu erklären ist. Zusätzlich zu Drf3 ist das Formin FMNL2 ein potentieller Kandidat, der zur Bildung von Filopodien aber auch Lamellipodien betragen könnte. In B16-F1 Zellen lokalisiert ein aktives EGFP-getaggtes FMNL2 an der Spitze von Filopodien und Lamellipodien. In Vitro interagiert FMNL2 mit aktivem Cdc42 und aktivem Rac1, aber nur die Koexpression von aktivem Cdc42 ist ausreichend, um die Anreicherung des Formins im Lamellipodium zu vermitteln. Des Weiteren trägt eine N-terminale Myristoylierung zur Regulation von FMNL2 bei. Obwohl diese Lipidmodifikation weder für die Lokalisation im Lamellipodium noch für die Interaktion mit Cdc42 essentiell ist, tragen die Myristoylierung und Cdc42 vermutlich durch Aufheben der Autoinhibition zur Lokalisation von FMNL2 bei. In Vitro Aktinpolymerisationsassays zeigten, dass FMNL2 nicht als Aktinnukleator fungiert, sondern im Zusammenspiel mit Profilin die Elongation von bestehenden Aktinfilamenten unterstützt. In Vivo kontrolliert FMNL2 die effiziente Zellmigration